geoffrey modest medical blogs

A recent study of older community-dwelling high-risk hypertensive patients looked at the relationship between their achieved blood pressure and cardiovascular outcomes ( see  htn automated office bp in ontario hypertension2016  in dropbox, or Myers MG Hypertension. 2016;68:866​). details: --6183 community-dwelling Ontario residents >65yo on antihypertensive therapy, followed mean of 4.6 years (the CHAP study: Cardiovascular Health Awareness Program) --blood pressure measured (as in the SPRINT trial) by AOBP (electronic automated office blood pressure). In Ontario, the protocol was that the person rest seated in a quiet place, undisturbed before and during the readings. The research staff did not speak to the subjects or interact with them. The patient did not wait 5 minutes, but the AOBP recorded the blood pressure each minute for 5 minutes and computed the mean value. The AOBP was recorded in community pharmacies, which a different study found to be similar to AOBP done in t

T here was an interesting subgroup analysis of the ACCORD blood pressure wing (Action to Control Cardiovascular Risk in Diabetes) which found that those with orthostatic hypotension (OH) had a significantly higher risk of mortality and heart failure events (see  hypotension orthostatic ACCORD hypertension2016  in dropbox, or Fleg JL, Hypertension. 2016;68:888 ). Details: -- the ACCORD trial had 10,251 high-risk patients with type 2 diabetes, hemoglobin A1c >7.5%, and were between 40 and 79 years old with cardiovascular disease or 55 to 79 years with anatomic evidence of subclinical atherosclerosis, albuminurea, LVH, or >= 2 additional cardiovascular risk factors. 4733 were randomly assigned to intensive vs standard blood pressure control in a non-blinded trial, with target systolic blood pressure (SBP) of <120 vs <140 mm Hg, and with no requirements as to what medications to give (clinicians' decisions) -- 4266 participants were involved in this analysis, with bl

 given the recent 2 articles on cervical cancer screening, I thought I would add (briefly) a third to the troika (s ee  pap in women with HPV vaccine jnci2016   in   dropbox , or  doi :  10.1093/ jnci /djw216). Funded by National Cancer Institute of the NIH and done by Harvard School of Public Health. details: --this is a mathematical modeling of the cost-effectiveness of different cervical cancer screening approaches in HPV-vaccinated women --they looked at different levels of cost-effectiveness thresholds: from $50K to $200K per quality-adjusted life-year (QALY) gained results: -- in women who were fully vaccinated with either the bivalent or quadrivalent HPV vaccine , optimal screening strategies involved either cytology or HPV screening alone every 5 years starting at age 25 or 30 (cost-effectiveness ratios ranging from $34,680 to $138,560 per QALY gained --in women vaccinated with the nonavalent vaccine (that being: 9 HPV genotypes), only HPV testing by itself was e

There was a recent systematic review and network meta-analysis of treatments of H Pylori infections in countries with high vs low clarithromycin resistance (see  hpylori rx network metaanal gut2016  in dropbox, or doi:10.1136/gutjnl-2016-311868). A network meta-analysis is helpful when there are not head-to-head comparisons of all of the therapies, using mathematical  assumptions/ manipulations to approximate results across studies in an attempt to approximate the likely results if there were such direct  comparisons .  There was another recent blog which did a similar analysis of H pylori treatments but was not stratified by clarithromycin sensitivity (see  http://gmodestmedblogs.blogspot.com/2015/08/h-pylori-regimens.html    from the BMJ in 2015). details of the current analysis: --117 trials with 32,852 patients analyzing 17 H pylori eradication regimens were included --mean age 48, trials ranged from 58 to 1463 patients, with mean of 281 --all had documented H pylori infec

The American Soc iety of Clinical Oncology just published guidelines for the secondary prevention of cervical cancer (see  pap guidelines ASCO2016  in dropbox, or doi:   10.1200/JGO.2016.006577 , or go to  http://jgo.ascopubs.org/content/early/2016/10/08/JGO.2016.006577.full.pdf+html   ) . These guidelines were unusual in that they stratified the screening approach based on the country's resources, reflecting a global initiative, and also had several differences from the current US guidelines. Details: -- HPV testing is recommended in all resource settings, though visual inspection with acetic acid may be used in countries with basic resources. -- frequency of testing:     -- for countries with maximal resources: should be from  age 25 to 65, every five years if negative .     -- for countries with enhanced resources: age 30 to 65. If two consecutive negative tests at five-year intervals, then every 10 years. Stop at age 65 if consistently negative results for the past 1

There have been several articles suggesting that allopurinol is associated with decreased cardiovascular events (for example ,  see  http://gmodestmedblogs.blogspot.com/2016/03/hyperuricemia-allopurinol-decreases.html    ).  This might be attributed to the cardiotoxic effects of hyperuricemia itself, or perhaps through its association with the metabolic syndrome (see the above allopurinol blog for more details, as well as  http://gmodestmedblogs.blogspot.com/2019/04/uric-acid-lowering-cardiovasc-benefit.html    for an evolutionary perspective).  However a recent study found that colchicine in patients with gout also seems to be associated with fewer cardiovascular events ( see  cad colchicine dec events annrheumdis2016  in  dropbox , or Solomon DH. Ann Rheum Dis 2015; doi: 10.1136/annrheumdis-2015-207984) . Details: -- all patients were identified with a diagnosis of gout in their electronic record in a large academic hospital (99% accurate diagnosis, on a sample of 100 records)