geoffrey modest medical blogs

Given the emergence of methicillin-resistant Staphylococcus aureus (MRSA), there are concerns about what empiric therapy to prescribe for skin infections, including cellulitis. A recent article in JAMA assessed the utility of adding trimethoprim-sulfamethoxazole (TMP-SMX) to cephalexin in treating uncomplicated cellulitis (see  cellulitis cephalex vs cephalex tmpsmx jama2017  in dropbox, or doi:10.1001/jama.2017.5653) . Details: -- 5 US emergency departments participated in an outpatient double-blind study of 500 patients >12 years old with cellulitis but without wound, purulent drainage, or abscess, seen from 2009-2012. -- Median age 40, 58% male, 57% white/35% black/1% Asian, symptom duration 3 days, 20% with a history of fever in the week prior to enrollment, 56% of infections were in the lower extremity/24% upper extremity/9% trunk abdomen or back/6% head or neck/4% groin or buttocks, 11% diabetics; mean length and width of erythema was 13 x 10 cm -- Bedside ultrasound was

A recent article in JAMA found that regular injections of intra-articular steroids was associated with decreased knee cartilage volume and no real improvement in pain in patients with knee osteoarthritis (see  knee pain steroids not help JAMA2017  in dropbox, or doi:10.1001/jama.2017.5283). ​Details: --140 patients with symptomatic knee osteoarthritis as well as synovitis by ultrasound (evidence of effusion synovitis, with suprapatellar pouch depth >2mm) were randomized to receiving intra-articular 1cc triamcinolone 40mg vs 1cc saline every 3 months for 2 years, both without local anesthetic --mean age 58, 54% women, BMI 31, 65% white, mean hemoglobin A1c=6%, CRP 0.5 --all patients had radiographic evidence of Kellgren-Lawrence knee OA grade 2 or 3 (grade 2= definite osteophytes and possible joint space narrowing on anteroposterior weight-bearing radiograph; grade 3= multiple osteophytes, definite joint space narrowing, sclerosis, possible bony deformity) --knee MRI wa

The BMJ just published a systematic review comparing knee arthroscopy versus conservative management in patients with degenerative knee disease ( see knee DJD not do arthroscopy bmj2017  in dropbox, or doi:10.1136/bmjopen-2017- 016114), an update of a prior review, adding ten new studies. Details: -- 13 RCTs and 12 observational studies were included -- studies were diverse: the analysis included those with symptomatic degenerative knee disease, defined as persistent knee symptoms that affect quality of life and does not respond to conservative treatment, but with or without osteoarthritis and, in those getting arthroscopic surgery, “including any or all of debridement and/or partial  meniscectomy”.  Those with acute trauma were excluded. Results: -- knee arthroscopy led to a very small reduction in pain in the first three months (mean difference 5.4 on 100 point scale), and very small or no pain reduction up to two years (mean difference of 3.1), high-certainty evidence

A recent article in JAMA, which made it into the popular press (see  http://gizmodo.com/a-third-of-new-drugs-have-adverse-effects-after-fda-app-1795048377 ​ ),  assessed post-market safety events of new drugs approved by the FDA between 2001 and 2010, finding a large number of serious adverse events  after  the drugs were approved and on the market ( pharma postmarket safety JAMA2017​  in dropbox, or Downing NS. JAMA 2017; 317(18): 1854). Details : -- all new drugs and biologics approved by the FDA between 2001 and the end of 2010 were assessed, excluding diagnostic agents, sunscreens, and drugs not intended for use in the United States, with follow-up through February 28, 2017. They did not include labeling changes and dosage form discontinuations. -- 222 novel therapeutics were approved, 183 pharmaceuticals and 39 biologics.     -- 47 (21.2%) were for cancer treatment and hematology     -- 37 (16.7%) for infectious diseases     -- 26 (11.7%) for cardiovascular disease

The American College of Physicians just updated their clinical practice guideline on the treatment of low bone density/osteoporosis to prevent fractures in women and men (s ee  osteoporosis treatment clinical guide AIM2017  in  dropbox , or doi:10.7326/M15-1361). Details: --treatment options     --bisphosphonates: high quality evidence that they reduce vertebral, nonvertebral and hip fractures in postmenopausal osteoporotic women (specifically shown with alendronate, risedronate, and zolendronic acid; ibandronate shown to reduce radiologic vertebral fractures; zoledronic acid reduces vertebral fractures in osteoporotic men). [BUT, these differences in bisphosphonates probably reflects the studies that have been done and may not indicate true differences between these meds. eg, we tend to assume that all ACE inhibitors are similar without specific studies showing true equivalence. Though it may not be true.....]. Adverse events: low-quality evidence that they can be associated

The  Fleischner  Society guidelines for the management of incidental pulmonary nodules found on CT scans was just updated, involving international input from radiologists, pulmonologists, surgeons, pathologists (see  pulm  nodule incidental guidelines radiol2017  in  dropbox , or doi:10.1148/radiol.2017161659​). Details: --the guidelines refer to incidental pulmonary nodules found by CT scan in those >35yo, not for patients at high risk ( eg  in those with cancer who might have mets , or those getting CTs for screening purposes) --the minimum threshold size leading to  recommendation for nodule follow-up is if the estimated cancer risk is >1% (arbitrarily chosen) --follow-up CTs should use low-radiation techniques, no more than 3  mGy  in a standard sized person, in order to reduce radiation exposure,  esp  in patients likely to receive many of them.  -- Single solid nodules    -- <6 mm (a larger size than prior guidelines): no further follow-up studies (grade