geoffrey modest medical blogs

A recent case-control study of a large, comprehensive Danish database found a significant connection between patients prescribed hydrochlorothiazide (HCTZ) and the risk of malignant melanoma (see  htn hctz melanoma jamaintmed2018 in dropbox, or  doi:10.1001/jamainternmed.2018.1652 ). Details: -- 19,273 patients with histologically verified melanoma were compared to 192,730 population controls. -- All were without a prior history of cancer (except non-melanoma skin cancer), organ transplant, HIV infection, or azathioprine use Results: -- those who ever used HCTZ: 1958 melanoma cases vs 17,244 in controls; 17% increase with HCTZ (1.11-1.23), controlling for age, sex, history of nonmelanoma skin cancer, other comorbidity (diabetes, COPD, alcohol use disorder, chronic renal failure), Charlson Comorbidity Index score, highest level of the achieved education, and use of specific drugs (topical or oral retinoids, tetracycline, macrolides, aminoquinolones, amiodarone, methoxypsoralen,

​ A recent article found that taking probiotics led to a significant decrease in rehospitalization in patients who had severe manic disorder  (see  mania probiotics nutrition201 8​  in dropbox, or DOI: 10.1111/bdi.12652) . Details: -- 66 patients hospitalized for mania were randomized after discharge to a 24-week course of adjunctive probiotics (Lactobacillus rhamnosus strain GG and Bifidobacterium animalis subsp. lactis strain Bb12) vs placebo. -- Mean age 35, 65% female, 75% white/15% African-American, 40% current cigarette smokers, BMI 30, DSM-IV diagnosis: bipolar 1 manic (63%)/bipolar 1 mixed (15%)/schizoaffective disorder bipolar type 2 (2%), medications: typical antipsychotic 20%/atypical antipsychotic 80%/mood stabilizer 65%/lithium 35%/antidepressant 30% -- BPRS (Brief Psychiatric Rating Scale): 45; YMRS (Young Mania Rating Scale): 13; MADRS (Montgomery-Asberg Depression Rating Scale): 13; RBANS (Repeatable Battery for the Assessment of Neuropsychological Status) co

​In my humble attempt to go where angels rightfully fear to tread, I will review the new recommendations of PSA screening by the USPSTF ​(see  psa uspstf review jama2018 in dropbox, or doi:10.1001/jama.2018.3712 for their detailed evaluation, and  psa uspstf review jama2018  or doi:10.1001/jama.2018.3710​ for the recommendations) Background: -- prostate cancer is the most commonly diagnosed cancer in men in the US and the 2nd leading cause of cancer death. In 2018 approximately 165,000 men will be diagnosed and 29,000 will die from prostate cancer. -- The lifetime risk of being diagnosed with prostate cancer in the United States is 13% and the lifetime risk of dying is 2.5% -- Prostate cancer incidence is 74% greater in African-American men vs white men, and the lifetime risk of prostate cancer death is 4.2% for African-American men, 2.9% for Hispanic men, 2.3% for white men, and 2.1% for Asian/Pacific Islanders -- median age at death from prostate cancer is 80 years old.

Two drug company sponsored articles appeared in a recent New England Journal highlighting the benefit of as-needed budesonide/formoterol (brand name Symbicort), a combination inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) in patients with mild asthma. ----------------------------------------------------------------------------------------- The 1 st article compared as-needed ICS/LABA twice-daily with ICS maintenance twice-daily (see  asthma mild LABA-ics2 nejm2018 in dropbox, or DOI: 10.1056/NEJMoa1715275) Details: -- 4215 patients >12 years old with mild asthma who were appropriate for treatment with low-dose maintenance ICS. -- Mean age 41, 62% female, 3% current smokers, 8 years since diagnosis of asthma, ACQ–5 score (see below) 1.5, FEV1 pre-bronchodilator was 84% of predicted increasing to 96% after bronchodilator with 15% bronchodilator reversibility, number of severe exacerbations 12 months: 78% zero, 17% one, 5% more. -- Patients

​ A new and seemingly much better hepatitis B vaccine is in the pipeline (see  https://www.cdc.gov/mmwr/volumes/67/wr/mm6715a5.htm ), approved by the Advisory Committee on Immunization Practices on February 21, 2018. Details: --Current hepatitis B vaccines have a similar aluminum adjuvant. The new vaccine, Heplisav-B (HepB-CpG), has a purified HepB surface antigen (HBsAg) combined with small synthetic immunostimulatory cytidine-phosphate-guanosine oligodeoxynucleotide (CpG-ODN) motifs (1018 adjuvant). The 1018 adjuvant binds to Toll-like receptor 9 to stimulate a directed immune response to HBsAg. This vaccine contains no preservatives. --Data from 4 randomized controlled trials assessed its efficacy (using the surrogate marker of HBsAb levels >10 mIU/mL), and 6 studies assessed adverse events     --Seroprotective antibody levels were achieved in 90.0 to 100% of subjects after 2 doses, vs 70.5 to 90.2% of subjects receiving 3 doses of the older Engerix-B vaccine, deemed t

A recent retrospective cohort study found that the incidence of stroke in patients with atrial fibrillation was dependent on the percentage of time they were in afib (see  afib stroke risk inc with more afib jamacardiol2018 in dropbox, or doi:10.1001/jamacardio.2018.1176) Details: -- 1965 eligible adult patients, from the Kaiser Permanente Real-World Heart Monitoring Strategy Evaluation, Treatment Patterns, and Health Metrics in Atrial Fibrillation (KP-RHYTHM) database, who had paroxysmal atrial fibrillation during 14 days of continuous ambulatory EKG monitoring, from 2011 to 2016. None were on anticoagulation -- mean age 69, 45% women, 75% white/5% African-American/14% Asian, 20% diabetes/9% heart failure/62% hypertension/3% prior ischemic stroke/2.5% catheter ablation during the prior 12 months, 24% eGFR<60,1% had anticoagulants in the past 90 days, 39% anticoagulants in the 30 days post-monitoring -- mean CHA 2 DS 2 -VASc score 2.6, ATRIA (Anticoagulation and Risk Factors

The treatment for patients who have embolic strokes of an undetermined source ("cryptogenic strokes") in order to prevent recurrence is not clear. It is usually felt these are from an arterial source, though may be from paradoxical emboli from a DVT in the setting of a patent foramen ovale (PFO). A recent study found that rivaroxaban was not superior to aspirin but had more bleeding associated (see  stroke embolic  rivarox  not better than  asa  nejm2018  in dropbox, or DOI: 10.1056/NEJMoa1802686​ ), a drug company sponsored study. Details: -- 7213 people were enrolled at 459 international sites, from 2014 to 2017, with non-lacunar cryptogenic strokes -- mean age 67, 62% male, 72% white/20% Asian, BMI 27, blood pressure 135/79, 78% on statins, 77% hypertensive, 25% diabetic, 21% current tobacco use, 17% previous stroke/TIA, 17% on aspirin prior to a qualifying stroke, median NIH stroke scale 1 (range 0-42, higher scores reflecting worse neurologic deficits) -- all