geoffrey modest medical blogs

There was extended followup of ACCORD-Lipid study for 5 years after the study ended, which confirmed the original conclusions that adding fenofibrate to simvastatin in diabetic patients did not improve cardiovascular outcomes, and that the assessment of prespecified outcomes also found that the subgroup with low HDL/high triglycerides did better with fenofibrate, but women overall did worse (see  lipids fenofibrate not help diabet jamacardiol2016  in dropbox, or doi:10.1001/jamacardio.2016.4828 ) Details: --4644 patients (90% of surviving participants) agreed to the 5-year followup of the ACCORD-lipid trial, after the fenofibrate vs placebo intervention was finished (all patients received simvastatin) --this cohort was similar to the original study (these are the pre-trial baselines): 31% women, 66% white/14% black/7% Hispanic, 35% previous cardiovascular event, 4% heart failure, 14% current smoker/46% former, BMI 32, 11 year duration of diabetes, A1c=8.25, LDL 100, HDL 42 in

A recent meta-analysis found that vitamin D supplementation, especially in those who were quite deficient, led to lower risk of acute respiratory infections (see  vit  d  dec   uri  bmj2017   in  dropbox , or doi.org/10.1136/bmj.i6583).   Details: -- 25 eligible RCTs were found, with a total of 10,933 patients, aged 0-95. The researchers were able to access individual participant data from the studies. Outcome data was obtained for those participants experiencing at least one acute respiratory tract infection. The trials were from 14 countries on 4 continents. All studies supplied oral vitamin D3 to those in the intervention arm. This was given as bolus doses every month to every 3 months in 7 studies, weekly doses in 3 studies, and daily doses in 12 studies. Study duration range from 7 weeks to 1.5 years. --overall demographics: 50-50 male/female, 50% < 1yo/15% 1-16yo/28% 16-65yo/10% >65yo, 5% baseline 25(OH) level of <25 nmol/L, 33% >25 nmol/L, 62% not recorded

Another observational study, this one using data-mining of large patient databases, found that concurrent use of prescription opiates and benzodiazepines was associated with increased ER visits and hospital admissions for opiate overdoses ( see opiates and benzos mortality bmj2017  in chronic pain folder in dropbox, or doi.org/10.1136/bmj.j760). Details: --315,428 privately insured patients aged 18-64, continuously enrolled in a health plan with medical and drug benefits from 2001 til 2013 --about 40% men, comorbid conditions included: heart failure, peripheral vascular disease, hypertension, COPD, diabetes, CKD, cerebrovascular disease, dementia, MI, liver disease, alcohol "abuse" (??not clear how defined), drug "abuse" (also not defined), psychosis, and depression --the principle search was for patients on opiates who had at least one day of overlapping prescriptions for a benzo Results: --9% of opiate users also had a benzo in 2001, increasing to

A recent Korean multicenter observational study found that patients with coronary artery disease who achieved an LDL <70 mg/dl had very significantly decreased atherosclerotic plaque progression than those with higher LDL, further supporting the concept of treating-to-target to specific LDL levels ( see lipids intensive LDL lowering dec CAD progression JACC2016  , or doi.org/10.1016/j.jcmg.2016.04.013). Details: --147 patients with visible plaques on coronary CT angiography (CTA) who had another CTA at least 2 years later (median 3.2 years), as well as lab values within 1 month of both the baseline and followup CTAs -- mean age 62, 57% male, BMI 25, hypertension 65%, diabetes 33%, active smoker 20%, NCEP ATPIII risk score <10 in 55%/10-20 in 32%/>20 in 13%, Framingham risk score <10 in 63%/10-20 in 29%/>20 in 9%. Of note, those who achieved an LDL<70 were sicker: 1.95 vs 1.54 cardiac risk factors, 54% vs 26% with diabetes. though overall not a high risk group

T he annual update of the American Diabetes Assn Standards of Medical Care in Diabetes had a few changes over last year's (​see  dm diabetes care fulltext2017 in dropbox, or Diabetes Care, Janurary 2017; 40, suppl 1).  I  will highlight those changes (see the text for the overall recommendations). promoting health and reducing disparities in populations  (a major update):  --they acknowledge (finally) that psychosocial care is important in the overall care of diabetics, including self-management, mental health, communication, and life-stage considerations.  --specific recommendations to look at the patients' social context  (including assessing food insecurity, housing stability and financial barriers)  and make use of local community resources and support for self-management​ classification and diagnosis of diabetes :  --having a baby ≥ 9 pounds was bumped from the list as an independent risk factor for development of prediabetes or Type II diabetes. and for wom

A recent article in the BMJ challenged the long-held belief that ACE inhibitor/ARB related increases in creatinine were actually renoprotective (see  RAS blockade inc creat cardiorenal risk bmj2017  in dropbox, or Schmidt M. BMJ 2017;356:j791). Details: -- observational study of 122,363 patients starting treatment with ACE inhibitor (ACE-I) or ARB from 1997 to 2014 -- they assessed the rates of end-stage renal disease, myocardial infarction, heart failure, and all-cause death among patients whose creatinine increased 30% or more after starting treatment, and also assessed the effect of each 10% increase in creatinine above the patient's baseline. Results: -- 2078 patients (1.7%) had a creatinine increase of 30% or more. -- Comparing those with a creatinine increase of > 30%, vs those with < 30%:     -- 56% female vs 46%     -- median age 68 vs 63     -- myocardial infarction in 10.5 vs 4.5%     -- heart failure in 19 vs 4.8%     -- arrhythmia in 17.