geoffrey modest medical blogs

A recent article found that long-term exposure to air pollution was significantly associated with increasing emphysema, as assessed using quantitative CT imaging and lung function (see  air pollution and copd jama2019  in dropbox, or doi:10.1001/jama.2019.10255) Details: -- 7071 participants in the Multi-Ethnic Study of Atherosclerosis (MESA study) from 6 US metropolitan areas (Winston-Salem, NC; New York City; Baltimore, MD; St. Paul, MN, Chicago, IL; Los Angeles, CA), from 2000-2018 -- age at recruitment 60, 47% men; others varied by site (eg 10% white/37% Chinese/12% black in LA, 50% white/50% black in Baltimore, 20% white/35% black/45% Hispanic in NY), some college in 60%, never smoker 45%/former smoker 40%/current 15%, BMI <30 in 70% -- pollutant exposures measured: ground-level ozone (O 3 ), PM 2.5  (fine particular matter < 2.5 microns), NO x  (nitrogen oxides) and black carbon     --baseline: O 3  15-25 parts per billion, PM 2.5  13-18 mcg/m

From: Rebecca Perkins [mailto: Rbperkin@bu.edu ] Sent: Tuesday, August 20, 2019 8:43 AM To: Geoff A. Modest, M.D. Subject: Re: CDC recommends HPV vaccine to age 26, and more Thanks for highlighting HPV and your great work! And thank you for largely focusing your article on the benefits for the pediatric population.  I did want to add that the risk benefit vaccination ratio for adults is very different from kids. The estimated reduction is 193 HPV-related cancer cases per year if the entire adult population is vaccinated, compared to 25,000 cases averted per year if the entire pediatric and adolescent population is vaccinated. Vaccination of adults in the US will also cause a worldwide shortage of HPV vaccine, delaying cervical cancer reduction efforts in low resource countries which have the majority of cervical cancer burden. So thanks for helping to keep the focus where it will make the most difference--vaccinating kids! These comments are from Rebecca Perkins, wh

The CDC formally adopted the recommendations that all should be vaccinated with the HPV vaccine until age 26 and that those 27-45 may be vaccinated through shared decision-making (see https://www.cdc.gov/mmwr/volumes/68/wr/mm6832a3.htm These guidelines follow the ACIP recommendation of 2018 ( http://gmodestmedblogs.blogspot.com/2019/07/acip-new-recommendations-for-hpv-and.html ) Details: --HPV infections are remarkably common, typically acquired in adolescents and young adults soon after their first sexual activity, though can be acquired at any later time there is a new sex partner --HPV is associated with a variety of cancers: cervical, anal, penile, vaginal, vulvar, and oropharyngeal     --there are approx 33,700 HPV-related cancers per year: 12,900 oropharyngeal cancers in men and women (though many more cases in men than women), 10,800 cervical cancers in women, 6000 anal cancers in men and women, and smaller numbers of the other ones; all typically decades after i

a recent systematic review/meta- analysis assessed the value of statins in depression, finding signficant benefit (see  statin depression review jaffectdisord2019  in dropbox, or doi.org/10.1016/j.jad.2019.07.002 Received 15 April 2019). Details: --10 articles were included, all randomized controlled trials: 3 were in patients with clinical depression, 7 in non-depressed people --total sample size 2517 (1348 on statins and 1169 placebo) --patients were followed from 4 weeks to 4 years --in the depressed group, statins were add-on therapies (vs placebo) to antidepressants (eg citalopram, fluoxetine) --statins used: simvastatin in 4, lovastatin in 3, atorvastatin 2, and pravastatin 1 study Results: --overall: statins were significantly more effective than placebo in decreasing depressive symptoms, standardized mean difference (SMD) of -0.309 (-0.525 to -0.094), p=0.005 [small effect size] --subgroup analysis:     --depressed population: SMD -0.796 (-1.107 to -0.486)

a really poignant article/set of cartoons points to one of the many absurdities in our current health care system: see  https://www.latimes.com/opinion/story/2019-08-09/financial-toxicitiy-cancer-care-graphic  , written by a woman whose husband died from cancer, financially ruined by the costs of treatment, who then went to medical school and became an academic oncologist researching the way medical costs affect people this was sent to me by an old friend living in LA, who made the comment: "Living in a visual age, it really captures the poignancy and horror of the US health system  in a way that it might take a writer many pages to convey, and still not as powerfully. Most importantly, people will read those cartoons. They probably would never read a couple pages of prose  anymore." geoff

ray martin emailed me back as below, raising the unfortunately common issue of PEP (post-exposure prophylaxis)  for needlesticks and the recommendation to use raltegravir (and INSTI which may actually be more likely to have an effect on folate) as opposed to dolutegravir in "persons who are pregnant or are of childbearing potential", per UpToDate raises suggestion that women of childbearing potential might be advised to try to avoid pregnancy during the time taking PEP...  and, if possibly very early pregnancy, checking pregnancy test and discussing pros/cons of INSTI-based regimen geoff From:  Ray Martin Sent:  Monday, August 12, 2019 8:29 AM To:  Geoff A. Modest, M.D. < GModest@uphams.org > Subject:  Re: WHO: Dolutegravir is best drug in pregnancy Hi Geoff, Thanks for this.  Working in employee health I write Rx's for PEP following high-risk needle sticks and have been prescribing raltegravir for pregnant women instead of dolutegravir