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Archive for October, 2014

Primary Care Corner with Geoffrey Modest MD: Whither the pelvic, again

29 Oct, 14 | by EBM

BMJ had a recent systemic review and meta-analysis of urinary screening for HPV (DOI: 10.1136/bmj.g5264), including 14 studies with 1443 women, comparing urine HPV DNA screen with cervical DNA screen.



–Urine detection of HPV had a pooled sensitivity of 87% (CI: 78-92%), and specificity of 94% (CI: 82-98%)

–Urine detection of high risk HPV (15 serotypes assessed) had a pooled sensitivity of 77% (CI: 68-84%), and specificity of 88% (CI: 58-97%)

–Urine detection of HPV 16/18 (the worst of the high-risk) had a pooled sensitivity of 73% (CI: 56-86%), and specificity of 98% (CI: 91-100%)

–Translation of above: the high specificity suggests that positive test results are 15 times more likely to occur in HPV positive women; the less-high sensitivity suggests that a negative test results would happen only 7 times more frequently in non-infected women. For those with HPV​ 16/18, positive test results are 37 times more likely to occur in HPV positive women and negative test results would happen only 4 times more frequently in non-infected women.

–Sensitivity for urinary HPV testing increased with first void urine, on meta-regression analysis

So, we have moved away from annual pelvic exams for pap smears and gc/ct (gonorrhea/chlamydia) screening of yore to much less frequent pap smears (beginning later, at age 21, and with frequency of every 3-5 years depending on age and HPV testing, and with several European countries currently assessing doing only HPV testing without cytology). And now perhaps we are moving to just doing urine testing for HPV in the future, maybe even as a sole initial screen. And we have transitioned from cervical gc/ct screening to urine gc/ct tests. In addition, women with vaginal discharges are often appropriately self-treating (eg for yeast) or getting medications for various infections without pelvic exams (eg, urine testing for trichomonas, or simply empiric therapy for bacterial vaginosis/BV). As a result, as clinicians we certainly are doing many fewer pelvic exams now as compared to a couple of years ago. Though, clearly, pelvic exams are invasive, uncomfortable procedures that many women would love to avoid, I do have one caveat. I have seen several episodes where a woman has potential PID and the clinician is comfortable with just sending a urine for GC/chlamydia. The issue here is that GC and chlamydia are not the only culprits (the data are a bit murky here, since there are so many potentially infectious pathogens in the vagina, but it is likely that PID is caused by mycoplasmas, ureoplasmas, BV, and, very often, mixed organisms – both aerobic and anaerobic). And there can be other causes of acute pelvic pain besides PID (eg, ovarian cysts, appendicitis, endometriosis, assorted GI problems including bowel obstruction and constipation…). Again, I think it is great that we clinicians need to do fewer pelvic exams. My concern is that this mind-set may lead to not doing one when it is clinically indicated.


Primary Care Corner with Geoffrey Modest MD: Men get paid more than women by big pharmacy companies

20 Oct, 14 | by EBM

I don’t want to shock you, but it seems that of the 300 top paid doctors by big pharmacy and medical device companies, 90% are men. No doubt for many reasons, including their predominance at the head of many of the highly paid specialty societies (as I plow through many of the guidelines generated by different specialty organizations, it is pretty remarkable how few women are on these committees).




Primary Care Corner with Geoffrey Modest MD: Alcohol Consumption and Atrial Fibrillation

14 Oct, 14 | by EBM


A prospective Swedish observational study assessed the level of alcohol consumption and the risk of atrial fibrillation (see DOI: org/10.1016/j.jacc.2014.03.048). In this study, 79,019 men and women from 2 large population-based cohorts (the Cohort of Swedish Men and the Swedish Mammography Cohort), initially free of atrial fibrillation (AKA afib), completed alcohol ingestion questionnaires (as part of 350-item questionnaire), followed for >12 years (with 860K person-years of followup).


–7245 incident cases of afib

–Compared with current drinkers of <1 drink/week (with 12 grams alcohol/drink), multivariate relative risks were:

–1-6 drinks/wk: RR=1.01 (0.94-1.09)

–7-14 drinks/wk: RR=1.07 (0.98-1.17)

–15-21 drinks/wk: RR=1.14 (1.01-1.28)

–>21 drinks/wk: RR=1.39 (1.22-1.58)

–No difference in association with alcohol by gender. Above RRs were similar if excluded binge drinkers (>5 drinks on single occasion)

–In their meta-analysis of 7 prior studies with 12554 incident cases of afib, they found relative risks:

–for 1 drink/day: RR=1.08 (1.06-1.10)

–for 2 drinks/day: RR=1.17 (1.13-1.21)

–for 3 drinks/day: RR=1.26 (1.19-1.33)

–for 4 drinks/day: RR=1.36 (1.27-1.46)

–for 5 drinks/day: RR=​1.47 (1.34-1.61)

So, pretty impressive association in both their study and the meta-analysis that moderate alcohol consumption is associated with the development of atrial fibrillation, and that this association is not just with binge drinking (“holiday heart”). However, on the other side, is the lower risk of coronary artery disease with moderate alcohol consumption (though there is argument that these studies showing benefit of alcohol are pretty biased). Seems reasonable to me (though untested) that people at high risk of developing afib (e.g., some combination of advanced age, systolic hypertension, heart failure, increased BMI, mitral valve disease, frequent PACs or increased PR interval) be advised to avoid alcohol on a regular basis.


Primary Care Corner with Geoffrey Modest MD: Benefit of fiber after MI

9 Oct, 14 | by EBM

BMJ with analysis of the Nurses Health Study (32 years of followup) and Health Professional Follow-up Study (22 years of followup), 2 large prospective US studies, found a beneficial role of fiber in patients surviving an MI (see DOI: 10.1136/bmj.g2659). they assessed covariates, such as other dietary components, medication use, medical history and lifestyle factors, though were unable to control for family history of MI, hypercholesterolemia, polyunsaturated fat intake, multivitamins, glycemic index, site of MI, ST elevation and initial creatinine level.

In this prospective cohort study, they found:

​–2258 women and 1840 men initially free of cardiovascular disease, stroke or cancer at the time of enrollment, then survived an MI in followup and completed food frequency questionnaires both before and after their MI

–Comparing the top fifth of post-MI fiber consumption to the lowest fifth: there was a 25% reduction in all-cause mortality–HR 0.75 (0.58-0.97). Those with highest intake of cereal fiber had a slightly lower mortality than with other fiber sources (fruit or vegetable fiber) –HR 0.73 (0.58-0.91).

–People who increased their fiber after the MI also with significant benefit –HR 0.69 (0.55-0.87)

–With fiber assessed as a continuous variable, the benefit was 15% for a 10g/day increment in fiber — HR 0.85(0.74-0.97)

–no difference if control for BMI, physical active, glycemic load, aspirin or lipid-lowering medication

In these types of studies, it is often hard to attribute a single intervention (high fiber foods) from more general changes (those who eat higher fiber foods may do other healthful behaviors, such as eating other healthy foods or exercising more). There may be some specific benefits of fiber itself (improved insulin sensitivity, improved glycemic control, increase in short chain fatty acid production, increased satiety, reduced systemic inflammation, reduced LDL, reduced lipid peroxidation, and beneficial gut microbiota environment) but the main point here is that healthy diets are beneficial. This benefit is on top of using statins post-MI. which really brings me to my major concern: there have been a few studies showing that prescribing statins lead to less healthy eating (since the statins work so well). Some of this may be because patients are happy with the lipid outcomes they see with the statins and that lifestyle changes are so much harder than taking a pill (and often with less dramatic results than the pill). But part of the problem may be that providers are less vigilant in promoting healthy lifestyles in patients who have such good-looking lipids.  And, this study reinforces that healthy lifestyle is an added benefit to statins in preventing all-cause mortality (and, to a lesser extent, cardiovascular mortality). And healthy lifestyle has additional benefits (preventing/helping treat diabetes, or obesity, or stress-related problems, or perhaps several different cancers, or alzheimers?, some data that Mediterranean diet is helpful).


Primary Care Corner with Geoffrey Modest MD: Soft Tissue Infection Guidelines

7 Oct, 14 | by EBM

​The Infectious Diseases Society of America just updated their 2005 guidelines for treatment of skin and soft tissue infections (see DOI: 10.1093/cid/ciu296). The guideline deals with minor infections and up to life threatening ones, but I will focus on ones seen/treated in primary care (there is also an algorithm for wound infections, which I will leave to you to investigate).

-Mild nonpurulent infections (cellulitis, erysipelas): Where mild infection is defined as skin infection without systemic signs of infection (>38 deg C, tachycardia >90, tachypnea >24,or WBC >12K or <400, or immunocompromized):

–Blood culture/biopsies etc. only if patient is immunocompromized (and these patients should be admitted/get IV antibiotics)

–Should use antibiotic with anti-strep activity for 5 days, then extend if necessary after further evaluation. They do note that many clinicians (which includes me) like to cover methicillin-sensitive staph (MSSA). Also, consider covering methicillin-resistant (MRSA) if severe infection, nasal colonization with MRSA, injection drug use.

–In lower extremity cellulitis, examine interdigital toe spaces to look for fissuring, scaling, maceration which could lead to recurrent cellulitis  (I’ve had a couple of patients with recurrent lower extremity cellulitis and bad fungal infections of toenails or interdigitally, who did not have further cellultitis when those were treated. I would also add that patients with venous insufficiency and recurrent cellulitis seem to do better with compression stockings.) Consider prophylactic antibiotics in patients with recurrent infections (3-4 episodes/yr) , e.g. with oral penicillin or erythromycin for 4-52 weeks or benzathine penicillin IM 2.4M units ​every 2-4 weeks.

–Dog/cat bites — give preemptive therapy for 3-5 days in those with more severe bites or immunocompromized (they note that patients with relatively minor dog bites, not involving the face, hand, or foot found a pretty low incidence of infection — 16% — and may not justify routine antibiotic administration, esp if there is good followup available.  Give amox-clavulanate 875/125 bid. for human bites, always give antibiotics). Give Td or Tdap if not given within past 10 years, consider rabies prophylaxis, do not generally close wounds except on face, and give azithro if concerned about cat scratch disease.

–In terms of general treatment, MRSA is unusual cause of cellulitis (study in cellulitis patients at a medical center with high incidence of other MRSA-related skin infections found that cefazolin or oxacillin was successful in 96% of the patients. Another recent study not referenced in this article found greater efficacy of cephalexin to TMP/SMX,  and, I would add, some of the agents used to treat MRSA, esp TMP-SMX and doxycycline, are less active against strep).

–Antibiotic recommendations: pen VK (I do not use this since by inspection cannot rule-out staph infection), cephalosporin, dicloxacillin, or clindamycin orally — see doses under impetigo/ecthyma

–Impetigo/ecthyma (ecthyma is deeper infection, lesions usually begin as vesicles which rupture, then get circular erythematous ulcer with adherent crusts, and typically leaves a scar

–Gram stain and culture pus or exudates to see if staph or strep, but treatment without this is reasonable in typical cases

–Bullous or nonbullous impetigo: can use oral therapy or topical, though oral therapy preferred if multiple lesions

–Therapies: topical — use either mupirocin or retapamulin bid for 5 days; oral — 7 days of therapy active against staph (unless culture shows strep alone), with MSSA agent (dicloxacillin 250 qid,  cephalexin 250 qid, though I usually use 500 bid with good effect, amox-clav 875/125 bid), or if MRSA suspected can use doxycycline 100 bid , clindamycin 300-400 qid, or TMP/SMX 1-2 DS tabs bid.

–Purulent skin infections/abscesses

–Gram stain and culture are recommended (though not for inflamed epidermoid cysts).

–I&D is recommended for inflamed epidermoid cysts, and abscesses (including carbuncles, large furuncles).

–Use of antibiotics should be based on presence or absence of systemic inflammatory response (T>38C or <36C, tachypnea>24, tachycardia >90, WBC>12000 or <400)

–Antibiotic for MRSA is recommended in those who fail initial antibiotic treatment or have impaired host defenses. Also for those with systemic symptoms as above.

–For those with recurrent abscesses, look for local causes (eg pilonidal cyst, hidradenitis or foreign body), drain and culture, then treat with 5 to 10 days of an active antibiotic. Consider 5-day decolonization regimen (e.g., intranasal mupirocin, daily chlorhexidene washes, daily decontamination of personal items) and evaluate for neutrophil disorders if recurrent abscesses began in childhood. They do mention bleach baths (1/4-1/2 cup of bleach per full bath) — see here for a previous blog that promots bleach baths and I have had a few people email me with very positive stories. Data is not great for the 5-day decolonization regimens they cite. I would also add that I have seen a patient with apparent recurrent abscesses on his hands, which turned out to be a herpetic whitlow.

​–Choice of antibiotics for empiric therapy: TMP/SMX 1-2 DS tabs bid or doxycycline/minocycline 100mg bid. For culture-guided therapy: dicloxacillin 500 qid or cephalexin 500 qid (they did not include clindamycin in the empiric therapy. Not sure why. I have certainly had much success with that and it covers strep if needed.)


Primary Care Corner with Geoffrey Modest: Electronic medical records

2 Oct, 14 | by EBM

Not-so-surprising article in NY times highlighting both the remarkably high cost of electronic records (largely supported by public monies) and their remarkably poor performance (specifically in their ability to exchange information across different electronic records).


To me, it was folly to have the feds fund all of the different private electronic medical records, which meet some baseline functionality, both because of their exorbitant costs and the obvious issues of intercommunicability, especially since there is the remarkably functional (and free) VA system available to all. In fact, I saw a recent throw-away med journal (I think it was Medical Economics), which rated the different electronic records based on provider feedback. Of the 30 or so records, the VA placed in the top 2, both for hospitals and clinic practices.

Another boondoggle which feeds into (instead of helping fix) a much-too-expensive and unconnected/non-coherent medical system….


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