geoffrey modest medical blogs

There was a new guideline from the American Heart Association on the management of congenital heart disease in pregnancy (see  pregnancy and congenital heart disease circ2017  in  dropbox , or DOI: 10.1161/CIR.0000000000000458, or go to URL:  http://circ.ahajournals.org/content/early/2017/01/12/CIR.0000000000000458?sid=3d46cd93-3125-4db0-8f6c-a1002093e09d   ). Given that this is not a common primary care issue, i will broadly review their approach and defer to the article itself for the specifics  in (very) brief, this article has sections on: --physiology of pregnancy and its effects on the heart/lungs (eg increased blood volume, increased cardiac output, decreased oncotic pressure, increased heart rate,  increased B-type natriuretic peptide,  vascular tree remodeling to accommodate the increased blood volume, increased pulmonary tidal volume/minute ventilation) --preconception counseling/diagnostic evaluation --estimating maternal and fetal risk, including some risk strati

A recent Canadian study evaluated patients with physician-diagnosed asthma to see if they could be tapered off medications, and whether subsequent testing confirmed the diagnosis of asthma  (see  asthma diagnosis error jama2017  in dropbox, or Aaron SD. JAMA.2017;317(3):269) ​. Details: -- 701 patients who had physician-diagnosed asthma within the last five years were enrolled in a prospective multicenter study in 10 Canadian cities from 2012 to 2016. 613 people completed the study -- Mean age 51, 67% women, 90% white, BMI 30, 70% college-educated, 29% current smokers, mean age of asthma diagnosis was 45, spirometry or serial peak flow testing was done in the community in 56%, 18% had an urgent visit to healthcare facility for asthma in the past year, 90% using current asthma medications (49% using asthma controlling medications daily, 44% inhaled corticosteroids with or without long-acting beta-agonists, 7% leukotriene antagonists only), FEV1 pre-bronchodilator was 88% of pre

This blog will not shock you: when Texas closed abortion facilities, decreasing access and making women travel further distances to get an abortion, there was a substantial decrease in the number of abortions done with a small increase in out-of-state abortions (see  abortion  dec  with  dec  access jama2017  in  dropbox , ordoi:10.1001/jama.2016.17026). Details: -- in 2013 Texas enacted a restrictive abortion law which was partially reversed by the Supreme Court in 2016 as being unconstitutional -- after passage of the law, the number of abortion facilities declined, with the following changes:     --2012 (prior to the law): 66,098 abortions done in Texas, 97 done out-of-state. 41 abortion facilities in 17 counties in Texas     --2014: 53,882 abortions done in Texas, 254 done out-of-state. 21 abortion facilities in 6 counties in Texas -- the median distance to a facility increased by 51 miles. There was a clear, consistent trend between the decrease in abortions and the

And, perhaps the last blog on exercise, at least for now… A Norwegian study assessed the relationship between physical activity, sedentary lifestyle, and DSM-IV defined major depressive disorder (MDD) in kids aged 6 to 10 years old (see  physical activity and depression in kids peds2017  in dropbox, or DOI: 10.1542/peds.2016-1711​). Details: -- community sample of 6-year-old children (n=795) in Trondheim, Norway were followed-up at 8 and 10 years of age. -- Physical activity was recorded by accelerometry – wearing an accelerometer for 7 consecutive days, 24 hours a day, and only removing when bathing or showering; they assessed the time period of 6 AM till midnight and excluded periods of time where there were greater than 20 minutes of 0 counts (suggesting they were not wearing the unit); sedentary activity was <100 counts per minute; and moderate-to-vigorous physical activity, MVPA, was  >2296 counts per minute ). Major depression was assessed through semistructure

The SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) compared aggressive medical management of patients with intracranial stenosis and a non-disabling stroke/TIA, versus stenting plus aggressive medical management, finding that aggressive medical management was superior  (see  stroke prevention exercise neurology2016  in dropbox, or doi 10.1212/WNL.0000000000003534​). ​  In a prespecified analysis, they looked at the relationship between risk factor control during follow-up and outcomes in the aggressive medical arm. Details: -- 227 patients were analyzed, with risk factors recorded at baseline, 30 days, 4 months, and then every 4 months for up to 32 months. -- aggressive medical therapy included aspirin 325 mg per day along with clopidogrel 75 mg daily for the first 90 days, as well as treating the systolic blood pressure and LDL cholesterol to target (see below). Secondary risk factors included the non-HDL c

There have been a plethora of articles in the past year on the beneficial effects of exercise. I will use the next several blogs to sample some of these. One article looked at the beneficial effects of leisure-time physical activity on 26 cancer types   (see  exercise and cancer jamaintmed2016  in dropbox, or doi:10.1001/jamainternmed.2016 ). Details: -- 1.44 million participants from 12 prospective US and European cohorts had self-reported leisure-time physical activity at baseline (1987 to 2004). Leisure-time physical activity levels were assessed as cohort-specific percentiles on a continuous basis. Hazard ratios are based on high v s  low activity  levels (comparing the 90 th  versus  10 th  percentiles of activity) -- median age 59 years, 57% females, BMI 26. -- 186,932 participants with cancer were included in the analysis -- moderate activity in general was defined as intensity of >=3 more METS; vigorous activity as >=6 METS (see below for a definition for

This blog will bring up 2 recent studies suggesting the lack of efficacy of mammography screening coupled with significant overdiagnosis. 1. An article a couple of years ago looked at screening mammography in the US, with 10 year follow-up of breast cancer incidence and mortality (see  mammog nonbenefit US jamaintmed2015  in dropbox, or Harding C. JAMA Intern Med 2015; 175: 1483). Details: -- this was an ecological study of 16,120,349 women 40 years of older who resided in 547 counties reporting in the Surveillance, Epidemiology, and End Results (SEER) cancer registries during the year 2000. -- 53,207 had a diagnosis of breast cancer and were followed for 10 years. -- The researchers looked at the extent of the screening in each county, and the results of both breast cancer incidence and mortality (the latter being defined as women diagnosed with breast cancer in the year 2000 who had died from the disease during the 10 year follow-up period). Overall, In the 547 countie