geoffrey modest medical blogs

​ The decline in the prescription of osteoporosis medications after a patient has had a hip fracture  has been an increasing , contrary to both recommendations and (i think) common sense (see  osteop hip fracture and later meds jama2018  in dropbox, or doi:10.1001/jamanetworkopen.2018.0826 ). Details: -- data from Truven MarketScan commercial claims, from employer-sponsored health insurance plans for employees and their dependents, as well as Medicare-eligible retirees with employer-sponsored Medicare supplemental plans, from 2004-2015 -- 97,169 patients >50 yo, not on anti-osteoporosis meds who had a hip fracture; median age 80, 66% women. -- assessed initial dispensing of osteoporosis medication within 180 days of hip fracture hospitalization (those already on osteoporosis treatment in the prior 6 months were excluded) -- those with hip fracture who were given osteoporosis medications were matched with 10 patients with hip fracture who were not given the meds -- primary e

The International Antiviral Society - USA Panel just published their 2018 recommendations for antiretroviral drugs in treatment and prevention of HIV infection in adults ( see  hiv 2018 treatment guidelines intl antiviral society jama2018  in dropbox or doi:10.1001/jama.2018.8431 or https://jamanetwork.com/journals/jama/fullarticle/2688574 ). Details: -- initiating antiretroviral therapy (ART):     -- start ART therapy as soon as possible after the diagnosis, but do not use an NNRTI because of concerns for drug resistance, or abacavir without 1 st testing for HLA –B*5701; some opportunistic infections may preclude starting ART right away, though it should be started within the 1 st 2 weeks after the diagnosis for most of them . Can be started right away with the diagnosis of malignancy     -- draw HIV viral load; CD4 count; HIV genotype for NRTI, NNRTI , PI resistance ; test for viral hepatitis, comprehensive metabolic panel . T hough treatment can be started prior to

just after I finished writing the blog on Novartis, I just found out that Sanofi will be dumping their anti-infectives research and development unit (see https://www.reactgroup.org/news-and-views/news-and-opinions/year-2018/despite-industry-amr-declaration-commitments-sanofi-quits-rd-on-anti-infectives/ ). thanks (again) to Paul Susman Details: -- as with Novartis, Sanofi signed the 2016 Davos agreement to help deal with increasing antimicrobial resistance, specifically to “invest in Research &  Development to meet public health needs of: diagnostics and treatment, reducing the development of antimicrobial resistance, improving access to high-quality antibiotics, vaccines and diagnostics, and reducing the environmental impact of manufacturing” -- Sanofi took a leading role in developing this antimicrobial resistance declaration and roadmap -- Sanofi will license more than 10 anti-infectives to Evotec, a German biotech company, which will receive a €60 million payout from San

​​ As mentioned in prior blogs, there are increasing numbers of increas ingly  antibiotic - resistant microbes. And, compounding this problem, is the hesitance of drug companies to develop new antibiotics, since these are much less profitable than drugs  f or chronic diseases (they tend to be prescribed for a limited time course, and typically after routine antibiotics have been tried) In this light, it is disturbing that Novartis AG has just announced that they are stopping their antibiotic development program, including stopping development of some very promising new antibiotics that are at later stages of development.  (s ee  http://www.cidrap.umn.edu/news-perspective/2018/07/novartis-drops-antibiotic-development-program  ). (thanks again to Paul Susman for bringing this to my attention) Details: -- Novartis was one of a few large drug companies doing active research and development for new antibacterial and antiviral drugs -- they were a signer of the Davos Declaration in

A recent international study found that a structured questionnaire, Duke Activity Status Index (DASI) outperformed other measures in predicting p re- operative risk for high risk patients undergoing major noncardiac surgery ( see  medical clearance for surgery lancet2018 in dropbox, or Wijeysundera DM. Lancet 2018; 391: 2631–40​ ). Details: -- 25 hospitals (5 in Canada, 7 in the UK, to Australia, 3 in New Zealand) with 1401 patients were included in this prospective cohort study, from 2013 to 2016 -- patients all had one or more risk factors for cardiac complications in surgery: history of heart failure, stroke, diabetes, or coronary artery disease -- median age 65 years, 39% female, 91% reclassified as American Society of Anesthesiologists Physical Status (ASA-PS) 2 or 3 (mild or severe systemic illness, but not one that is a constant threat to life) -- comorbidities: CAD 12%, diabetes 19%, hypertension 56%, current or recent smoker 15%, COPD 13%, significant arthritis

A recent review of individual data from 10 trials found that aspirin effectiveness for cardiovascular and colon cancer protection depends on the weight of the person (see  aspirin  dec vasc  risk if  nl   wt  lancet2018  in dropbox, or doi.org/10.1016/ S0140-6736(18)31307-2). Details: --10 RCTs on primary prevention of  cardiovasc  disease (9 with weight/height and accessible individual patient data, 7 on low dose 75-100mg aspirin, 2 on high dose  ≥ 325 mg), with 117,279 participants --body weight varied 4-fold, with median weight ranging from 60-81 kg --results validated in 5 trials of aspirin for secondary prevention of stroke (4 with individual patient data, one low-dose and 2 higher dose aspirin, and 1 comparing these 2 doses)  Results: --patients on 75-100 mg aspirin:     --25% decrease in cardiovascular events in those weighing 50-69 kg, HR 0.75 (0.65-0.85), p<0.0001.  Benefit was 32% in those weighing 50-69 kg , HR 0.68 (0.56-0.83), p=0.0001     -- no