geoffrey modest medical blogs

A community health worker-led intervention in Argentina led to dramatic improvements in hypertension control (see doi:10.1001/jama.2017.11358 ). Details: --18 primary health care centers within the national public system, which provides free medications and health care to uninsured patients --1432 low-income patients with uncontrolled hypertension, recruited from 2013-15 and followed 18 months --9 centers (743 patients) were randomized to the intervention:     --community health worker-led multicomponent intervention, including health coaching on lifestyle modification, home BP monitoring and medication adherence, and BP audit and feedback; these workers generally functioned as case managers for the patients and their families. Initial 90-minute home visit when all family members were available, then 60-minute monthly or bimonthly follow-up visits, with tailored counseling, including strategies to help people lose weight, restrict dietary sodium, increase physical activity

A recent meta-analysis found that in a variety of anxiety disorders, the risk of relapse was high if antidepressants were discontinued within one year of therapy (see   doi.org/10.1136/bmj.j3927 . Details: --28 studies were included in the analysis (including 4 unpublished one) from 1995 to 2012, with 5233 patients who had anxiety disorder, obsessive-compulsive disorder, or PTSD; and summarized relapse rates in patients who had responded clinically to antidepressant use for their anxiety disorders and then were randomized to continuing the antidepressant vs switching to placebo, assessing:     --the prevalence of relapse per treatment group     --the risk of relapse or time to relapse between these groups     --and whether relapse risk was related to the type of anxiety disorder, type of antidepressant, mode of discontinuation (taper vs abrupt discontinuation), duration of previous treatment, duration of follow-up, whether concurrent psychotherapy was allowed, or whether s

And another vitamin D study. This one showing a relationship with multiple sclerosis (see doi:10.1212/WNL.0000000000004489). Details: --Prospective, nested-control study of women in the Finnish Maternity Cohort, where there were 1.8 million stored serum samples from over 800,000 pregnant women --age when  25(OH) D levels were collected: 28; 25(OH) D levels:  55% <30 nmol /L (12 ng/ml), 38% 30-50 nmol /L (12-20 ng/ml), 7% >50 nmol /L. --age of sample collection: 29; age when multiple sclerosis (MS) diagnosed: 37 --the  25(OH) D levels ​ had the expected seasonal variation average baseline: in this case average levels of 20-25 nmol /L in the winter and peaked at 45-50 nmol /L in August --1092 women developed multiple sclerosis (MS) between 1983 and 2009 --cases were matched to 2123 controls by date of birth and area of residence Results: --50 nmol /L (20 ng/ml) increase in 25(OH) D levels was associated with a 39% reduced risk of MS, RR 0.61 (0.44-0.85), p=0.003 --wom

A trial of monthly high-dose vitamin D in community-dwelling older adults found that there were meaningful benefits in bone mineral density in those who had a baseline low vitamin D level (s ee  doi : 10.1111/joim.12651 ). Details: -- a 2 year  substudy  of a trial in older community-dwelling adults in New Zealand assessed the influence of vitamin D on bone mineral density (BMD) overall, as well as in those with a low 25-OH vitamin D level -- 452 people were randomized to monthly high-dose vitamin D supplementation (100,000 IU of vitamin D3) vs placebo -- the primary endpoint was a change in the lumbar spine BMD, with exploratory analyses to see if there was a threshold of baseline 25-OH vitamin D level affecting the BMD Results: -- overall, vitamin D supplementation had no significant treatment effect on the lumbar spine or total body, but BMD loss at the hips was significantly attenuated by -1/2% over 2 years in the vitamin D group (?clinical significance of this 1/2% chang

A recent article in the Times of India noted that the cost of a new cancer drug is actually $648 million in R&D, a "small fraction of the $2.7 billion the industry claims is the average cost of drug discovery", leading to "a more than 10-fold higher revenue than R&D spending, a sum not seen in other sectors of the economy" [ see http://timesofindia.indiatimes.com/india/pharma-companies-inflating-rd-costs/articleshow/60505689.cms ; and thanks to Paul Susman for bringing this to my attention]. I will review the original article as it appeared in JAMA Internal Medicine (see  doi:10.1001/jamainternmed.2017.3601 ). Details: --the researchers make the above comment that a recent estimate of R&D spending is $2.7 billion in 2017 dollars, but "this analysis lacks transparency and independent replication": --they looked at US Securities and Exchange Commission filings for drug companies with no drugs on the US market that then received approval by t

​The NY Times and ProPublica today had an article highlighting how insurance companies/pharmacy benefits managers are exacerbating the opioid crisis  Details: --they analyzed Medicare prescription drug plans  covering  35.7 million people in the second quarter of 2017     --lidocaine patches require prior approval     --only 1/3 of plans cover topical buprenorphine (Butrans), which is much less risky than other opioids     --BUT, almost every plan covers more toxic opiates without a problem --they highlight a woman with chronic abdominal pain, on the topical buprenorphine which worked for her, but then UnitedHealthcare (the nation's largest insurer) stopped covering the drug: they suggested "switching to a 'lower cost alternative,' such as OxyContin or extended-release morphine". Her appeal was denied. She could not get the $324/month patch, but morphine was cheaper ($29 per month) and covered without any prior approval or obstacles. [the feds/DEA

 Laryngopharyngeal reflux (LPR) is quite common, has protean manifestations (eg, chronic dysphonia, excessive throat clearing, persistent cough, globus pharyngeus, dysphasia, and others) and historically has been treated with long-term high-dose PPIs. There may be a relationship between LPR and laryngeal and esophageal carcinomas, as well as with Barrett's. A new retrospective analysis suggests that alkaline water and a Mediterranean diet works at least as well as PPIs (s ee doi:10.1001/jamaoto.2017.1454 ). Details : -- retrospective chart review of 2 treatment cohorts:     -- 85 patients from 2010-12 treated with PPI (either esomeprazole or dexlansoprazole) and standard reflux precautions (prohibiting coffee, tea, chocolate, soda, greasy/fried/fatty/spicy foods, and alcohol)     -- 99 patients from 2013-15 were treated with alkaline water (pH >8.0), a 90% plant-based Mediterranean-style diet, and standard reflux precautions -- mean age of each cohort was 60 years, 60% wo

​​A new observational Swedish study found that alendronate was effective in preventing hip fractures in those >80 yo who had a prior hip fracture (see doi: 10.1111/joim.12678). a publicly-funded study.   Details: --90,795 men and women >80yo with history of prior fracture in a Swedish national database of people who had the standard fall risk assessment --7844 controls and 1961 alendronate-treated patients were propensity score-matched by age, sex, weight, height, rheumatoid arthritis, alcohol-related diseases, prior steroid treatment, the individual diseases causing secondary osteoporosis (eg, hyperthyroidism, hypogonadism, chronic liver disease), Charlson Comorbidity index (includes most of the chronic medical diseases), and fracture history (time since index fracture, number of fractures, prior fall injury and osteoporosis diagnosis) --mean age 86, 88% female,   0.4%  alcohol-related disease,  5%  RA,  25 %  prior “intense steroid use”,  4  yrs  since prior fracture