geoffrey modest medical blogs

A recent real-world study reported on the results of the implementation of the low-dose CT (LDCT) lung cancer screening in smokers at 8 VA hospitals (see  lung cancer CT at VA jamaintmed2017  in dropbox, or  doi:10.1001/jamainternmed.2016.9022 ​). Details: --93,033 primary care patients assessed: 4246 met criteria for screening, 2452 [57.7%, a pretty low number…] agreed to be screened: 96% men, mean age 65, --of note, there was a large variation in the number of positive LDCT screens by site, varying from 31% to 85%. [this raises the issue of lack of consistency in radiologist interpretation of LDCTs, which is also found in mammography evaluation and for several other xrays] Results: --1257 (60%) had lung nodules, of whom 1184 (56%) required tracking (solid nodules <8mm without suspicious features (irregular or speculated borders) and not known to be new or growing based on prior imaging, ground glass nodules >5mm, or mixed solid and round glass nodules of any size

The American College of Physicians and the American Academy of Family Physicians just published guidelines on the pharmacologic treatment of hypertension in adults over 60 yo, with both a systematic review and meta-analysis (see  htn elderly ACP guidelines AIM217  in dropbox, or doi:10.7326/M16-1785), and a clinical practice guideline (see  http://annals.org/aim/article/2598413/pharmacologic-treatment-hypertension-adults-aged-60-years-older-higher-versus  ) Results: -- they analyzed 46 publications representing 21 randomized controlled trials and 3 cohort studies -- 9 trials show that intensive blood pressure treatment substantially improved outcomes in patients with moderate to severe hypertension, with SBP >160 mmHg. The data on lower systolic blood pressures also showed benefit but the results were less consistent. -- Overall studies of patients achieving SBP <140 mmHg were similar to those that achieved 140, although   t he reduction in stroke risk was  more consis

A recent Danish study found that vitamin B12 deficiency was associated with diabetic cardiovascular autonomic neuropathy, CAN (see  dm b12  def  and  autonom   neurop  jdiabcomplic2017  in  dropbox , or Hansen CS. J Diabetes  Complic . 2017; 31(1); 202) ​Details: -- 469 type II diabetic patients were screened for CAN by several measures, as well as for peripheral neuropathy. -- Mean age 59, 60% male, diabetes duration 10 years, 5% excessive alcohol consumption, 12% smokers, BMI 32, blood pressure 132/82, 6% on vitamin B12 supplementation (though 16% in those in the highest B12 quartile), 80% on lipid-lowering drugs, 75% on metformin, 4% on PPIs alone and 10% on the combination with metformin, 40% on insulin --CAN was measured after a 5-minute supine resting period:     -- heart rate variability (HRV)     -- 3 tests assessing cardiovascular autonomic reflexes:         -- lying-to-standing test         -- deep breathing test (E/I ratio), a measure of heart rate varia

Two important articles were just published in NEJM which I think should stimulate a change in clinical practice regarding prescribed opiates. ------------------------------------------------------------------------------------ One article assessed the relative importance of physician prescribed opiates and the subsequent development of opioid use disorders in the elderly (see  opiate prescribing in elderly and dependence nejm2017  in dropbox, or Barnett ML. N Engl J Med 2017; 376: 663). Details: -- retrospective analysis of a random 20% sample of continuously-enrolled Medicare beneficiaries who had an emergency department (ED) visit from 2008-2011, and had not received opioid prescription for the prior six months -- mean age 69, 65% female, 76% white, 50% also on Medicaid, 37% disabled, mean of 3.5 chronic conditions (most commonly hypertension in 78%, hyperlipidemia in 70%, acute MI in 50%, depression 40%, diabetes 38%, COPD 28%), with 38% from the South/24% Midwest/2

2 recent articles looked at US cervical cancer mortality and hpv infections in men. 1. The New York Times reported a huge racial gap in cervical cancer deaths in the United States (see  https://www.nytimes.com/2017/01/23/health/cervical-cancer-united-states-death-toll.html?_r=0  ). They referred to an article which calculated a much higher death rate from cervical cancer overall in the US than previously found, with an increased disparity between black and white women (see  cervical ca inc mortality cancer2017  in dropbox, or DOI: 10.1002/cncr.30507 ). Details: -- the age-standardized rate for cervical cancer death reported by the National Center for Health Statistics from 2000-2012 was 3.2/ 100K  in white women and 5.7/100K in black women -- however, these results  were not corrected for the prevalence of hysterectomies , and given that hysterectomies are significantly more common in black women, the above statistics understated the cervical cancer death rates (since thes