geoffrey modest medical blogs

One somewhat confusing issue is whether to anti-coagulate a patient with a symptomatic calf  deep vein thrombosis. A recent article addressed this issue (see  dvt calf not treat lancethem2016 in dropbox, or doi.org/10.1016/ S2352-3026(16)30131-4 ).  Details: -- randomized double-blind controlled study of low-risk outpatients (no active cancer or previous thromboembolic disease), with a 1 st symptomatic DVT in the calf -- 259 patients from 23 centers in Canada, France, and Switzerland were randomized to low molecular weight heparin (LMWH, in this case nadroparin which is not available in the US) vs. subcutaneous placebo, and treated for 6 weeks. All patients were prescribed 30 mmHg compression stockings and followed for 90 days. -- 50% women, mean age 52, 45% of the DVTs were in the posterior tibial or peroneal vein, 55% gastrocnemius or soleus. 6% were on daily low-dose aspirin, and 6% were on NSAIDs -- risk fac...

A recent systematic review/meta-analysis assessed the association between prediabetes by different definitions and all-cause/cardiovascular mortality (see  dm prediabetes lower defn bmj2016  in dropbox, or doi.org/10.1136/bmj.i5953) Details: -- 53 prospective cohort studies with 1,611,339 individuals were followed a median of 9.5 years. -- The researchers assessed different criteria for defining glucose intolerance:     --impaired fasting glucose         -- IFG – ADA (American Diabetes Association): 100 to 126 mg/dL         -- IFG – WHO (World Health Organization): 110 to 126 mg/dL     -- impaired glucose tolerance: 140 to 200 mg/dL, which is consistent across guidelines, based on 2-hour plasma glucose during an oral glucose tolerance test     -- raised hemoglobin A1c:    ...

The FDA just extended the indication for the diabetes drug empagliflozin (Jardiance) to include reducing cardiovascular mortality in those with diabetes and cardiovascular disease. Their press release (see  http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm531517.htm ​ ) states that they looked at postmarketing data, though their original approval 2 years ago indicated that they requested 5 years of post-marketing data. ---------------------------------------------------------------------------------------------------------------------------- below is my prior blog on the original study/critique on empagliflozin (sent out on 12/9/2015): A recent study looked at the SGLT2 inhibitor (sodium-glucose cotransporter 2) empagliflozin and cardiovascular outcomes/mortality in patients with type 2 diabetes (see  dm empagliflozin cv outcomes nejm2015  in dropbox, or N Engl J Med 2015;373:2117​). The SGLTs are involved in acti...

a recent article looked at the demographics and epidemiology of sudden death in young athletes from the United States National Registry from 1982-2011 (see athlete sudden death etiology ajm2016 in dropbox, or Maron BJ. Am J Med (2016) 129, 1170). Details: -- 2406 athlete deaths were reported to the registry, of whom 842 had confirmed cardiovascular causes associated with exercise, and with autopsy examination. Results: -- Mean age 18, 89% male, 46% white/43% African-American or other minority. 25% of deaths were during competition, 39% during practice, 17% during recreational activity, 18% unassociated with physical activity. 66% were junior high or high school, 19% in college. 35% playing basketball, 30% football. -- Mortality rate in males exceeded females by 6.5-fold (1:121,691 and 1:787,392 athlete-years, respectively; p <0.001) -- cause of sudden death:    -- hypertrophic cardiomyopathy (HCM): 302 athletes (292 males, 10 females), 36% of cas...

The American College of Physicians just released guidelines on the management of gout (see  gout management guidelines AIM2016 in dropbox, or doi:10.7326/M16-0570 ), sponsored by the Agency for Healthcare Research and Quality (AHRQ).  Details: -- risk factors for gout include overweight/obesity, hypertension, alcohol, diuretics, a diet rich in meat/seafood/high fructose foods and drinks, and renal failure -- recommended acute gout therapies     -- lifestyle changes: although there is evidence that vitamin C supplementation reduces serum urate level, there are no data on symptomatic outcomes. Low-quality evidence from one study found that reducing the intake of red meat, shellfish, and yeast-rich foods as well as increasing the intake of low-fat dairy, vegetables, and cherries is no more effective than general dietary counseling (weight loss, decreasing alcohol) for reducing urate levels.     -- colchicine: hi...

it is unclear from the literature what the goal blood pressure should be in patients with atrial fibrillation, and this is not addressed by any of the guidelines. A post hoc analysis of the AFFIRM trial (Atrial Fibrillation Follow-up Investigation of Rhythm Management, a prospective trial assessing the strategy of rate versus rhythm control) looked retroactively at the relationship of achieved blood pressure and outcomes (see  afib optimal bp amjcardiol2014 in dropbox, or Badheka AO. Am J Cardiol 2014; 114: 727)). Details: -- 3947 patients in the trial were followed 6 years, noting their systolic and diastolic blood pressures (recorded after sitting quietly for at least five minutes) at baseline and at follow-up, divided into 10-mm Hg increments. The follow-up blood pressure was defined as the average of all available blood pressure measurements during each post-baseline visit -- mean age 69, and the following were significantly (and much) more frequent in...

A recent article looked at the relationship between achieved LDL cholesterol levels and changes in coronary artery atherosclerosis progression, as determined by coronary CT angiography, CTA (see  lipids intensive LDL lowering dec CAD progression JACC2016 in dropbox, or doi.org/10.1016/j.jcmg.2016.04.013).  Details: -- 147 patients with evident atherosclerotic plaques on CTA had quantitative plaque size measured both at baseline and at follow-up CTA two years later (median 3.2 years) -- baseline characteristics: mean age 62, 57% male, 65% with hypertension, 33% diabetes, 20% active smoking, 27% dyslipidemia (defined as total cholesterol >240 mg/dL, LDL >130, HDL <40, triglycerides >150, and/or treatment with lipid-lowering agents), cardiac risk score by both the ATP III and Framingham risks:  60% low risk (<10% over 10 years),  30% intermediate (10 to 20%), and  10% high risk (>20%). Number risk factors = 1.6 -- mul...

On 10/19/16, the CDC recommended that 9 to 14 year olds receive only 2 doses of the 9-valent HPV vaccine at least 6 months apart, instead of the prior recommendation for 3 doses.  But those who started the series between ages of 15 through 26 continue to need 3 shots (see http://www.cdc.gov/media/releases/2016/p1020-hpv-shots.html for the press release). Here is the article it was based on (see  hpv vaccine 2-dose jama2016  in dropbox, or doi:10.1001/jama.2016.17615). details: -- open-label, non-inferiority study done in 52 ambulatory sites in 15 countries, with 5 cohorts:                 -- girls aged 9 to 14, getting 2 doses 6 months apart (n= 301)                 -- boys aged 9 to 14, getting 2 doses 6 months apart (n= 301)         ...