geoffrey modest medical blogs

The USPSTF just came out with their lipid screening recommendations for children and adolescents (see  lipid screening kids USPSTF2016 jama​  in dropbox, or JAMA 2016; 316(6): 625), giving them an "I" rating (current evidence insufficient to recommend screening). F or full supporting documents of the USPSTF recommendations, see  lipid screening kids USPSTF full paper jama2016  in dropbox or   JAMA 2016; 316(6): 645​).  t heir points: --they consider both dyslipidemia from genetic heterozygous familial hypercholesterolemia, FH, (1 in 200-500 people in North America and Europe), where there are really high cholesterol levels (LDL>190 mg/dl, often 2-3x that of unaffected people) and evidence of increased cardiovascular risk (though not typically until age 30: 1 in 6 men and 1 in 10 women have ischemic heart disease by age 40, 25% of women and 50% of men by age 50), as well as multifactorial dyslipidemia, MD, (may have genetic component as well as environmental, esp obesi

A recent research letter suggested that there was significant overtreatment of patients with subsegmental pulmonary emboli, and a pretty strikingly high risk of serious adverse events (see  dvt   subsegmental  PE overtreatment jamaintmed2018  in dropbox, or  doi:10.1001/jamainternmed.2018.2971  ) Details: -- retrospective review of all CT pulmonary angiograms (CTPAs) in 1 Canadian tertiary care hospital, from 2014 to 2016 -- 223 PEs were classified as proximal, lobar, segmental, or subsegmental pulmonary emboli, based on the most proximal embolus -- mean age 68, 38% with cancer -- Doppler ultrasounds of the leg veins when done were performed within 2 weeks of the CTPA   Results: -- 79 (36%) of the PEs were subsegmental     -- 32 of these (41%) had a Doppler ultrasound done, and 8 (25%) were positive for DVT     -- 62 of 71 (87%) were systemically anticoagulated [excluding the 8 with DVT who were appropriately anticoagulated] vs 135 of 143 (94%) of those wi

The American Heart Association Obesity Committee of the Council on Lifestyle and Cardiometabolic Health just provided an updated perspective on sedentary behaviors (and particularly screen time ), with recommendations on the prevention and management of childhood obesity (see  obesity inc screen time in kids AHAadvisory2018 in dropbox, or  https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000591   ). In particular children 8 to 18 spend on average more than 7 hours daily on screens for recreational purposes. Details: -- a 2012 review of prospective studies found that physical inactivity was the 4 th highest risk factor for mortality worldwide, and is associated with excess morbidity and mortality in adults -- physical inactivity reflects a low involvement in activity, whereas sedentary behaviors reflect being seated with low energy expenditure, as per television watching, reading, and motorized transport -- prior data supports the association between recreational

Tianeptine is an atypical tricyclic antidepressant used in Europe, Asia (it was developed in the USSR in the 1960s), and Latin America. It also has  μ -opioid receptor agonist activity. It is not approved for use in the US. see  https://www.cdc.gov/mmwr/volumes/67/wr/mm6730a2.htm?s_cid=mm6730a2_w  ​ Details: --the CDC analyzed poison control center calls for tianeptine during 2000-2017, a total of 218 calls, 52% being for tianeptine-only exposure --from 2000-2013, there were a total of 11 calls, which then increased from 5 in 2014, to 38 in 2015, to 83 in 2016, and 81 in 2017 --91% of the calls were from health care providers Results: --55% of people had intentional exposure, 84% by ingestion/7% parenteral/2%inhalation --57% of the calls were for those 21-40 yo --most common problems were: neurologic (48%; mostly agitation, drowsiness, confusion), cardiovascular (33%; mostly tachycardia, high blood pressure), and GI (11%; mostly nausea); also some effects mimicked

​ A recent meta-analysis of lipid-lowering shows that remarkably low levels of LDL cholesterol provide clinical cardiovascular benefit with no clear  increased harm  (see  lipids very low LDL benefit JAMAcardiol2018  in dropbox, or doi:10.1001/jamacardio.2018.2258). Details: -- 4 trials were looked at:     -- the Cholesterol Treatment Trialists Collaboration (CTTC), a meta-analysis of several RCTs that compared different LDLs achieved through statins, median follow-up of 4.9 years, 1922 vascular events     -- 3 RCTs evaluated non-statin LDL lowering therapies:         -- IMPROVE-IT study with ezetimibe (n= 18,144), median follow-up 6.0 years, 5104 vascular events         -- FOURIER study with the PCSK9 inhibitor evolocumab (n=2,034), median follow-up 2.1 years, 184 vascular events         -- REVEAL study with the cholesteryl ester transfer protein (CETP) inhibitor anacetrapib (n=30,449), median follow-up 4.1 years, 4282 vascular events Results: -- statin ther