May 20, 2016

Lung screen

The story

The USPSTF earns its pay through easy-to-understand health recommendations for large populations. Lung cancer screening may not be so simple.

The basics

USPSTF recs call for annual lung cancer screening with low-dose CT (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. The guidance is based on 2011's National Lung Cancer Screening Trial, which found that annual LDCT decreased lung cancer mortality by 20% compared to chest X-ray. Not a bad place to start, but the number needed to screen (NNS) to prevent one lung cancer death was 320.

The model

Investigators tossed the one-size-fits-all approach of the USPSTF and instead applied a complex risk assessment model to each patient. Model-based screening, which calculated individual risk based on recorded outcomes in major lung cancer screening trials, dropped the NNS by 17% compared to USPSTF recs. Many of the benefits came from replacing low-risk patients who fit the current USPSTF guidelines with current smokers, low-intensity smokers, and high-intensity former smokers who quit a long time ago.

The takeaway

Cancer screening recommendations are always controversial, and the complexity of the model in question means it may not be ready for prime time. But with so much data available on lung cancer outcomes, a personalized approach is a good place to start.

Say it on rounds

When the hospital menu makes your stomach turn

Another choice always helps. COPD guidelines recommend combined therapy with a long-acting beta-agonist (LABA) and an inhaled glucocorticoid or long-acting muscarinic antagonist (LAMA) for high-risk patients. In a multicenter RCT, the LABA-LAMA regimen of indacaterol-glycopyrronium (brand name Ultibro) decreased COPD exacerbations by 11% compared to the LABA-inhaled glucocorticoid regimen of salmeterol-fluticasone. The Ultibro group also saw improvements in lung function and quality of life.

When you're wrist-deep in a post-call bucket of curly fries

Maybe skip to the next paragraph. An analysis of three large prospective cohort studies found that high self-reported intake of potatoes or French fries was associated with an increased risk of new-onset hypertension. In a substitution analysis, replacing one daily serving of potatoes with one serving of non-starchy vegetables was associated with a lower risk of hypertension.

When your significant other asks why you came home late from work

It's hard to get going, if you don't know where to start. The same applies to the ICU, where it's never clear when to initiate hemodialysis (HD). Researchers randomized over 600 patients to early HD at the time of randomization versus delayed HD following onset of a strict dialysis indication. There was no mortality difference between the two groups, but the delayed HD group experienced fewer line-associated infections and earlier recovery of kidney function. Note that only 30% of the study's patients were on continuous veno-venous hemofiltration (CVVH), which has become the standard of care in many ICUs.

When you fight to get your floor patient the last ICU bed

The right lab work can help build your case. A multicenter prospective study of over 1700 patients with community acquired pneumonia found that high serum procalcitonin levels were associated with a need for ICU-level care (invasive respiratory support or pressors) within 72 hours. The highest levels of procalcitonin were associated with a 22% risk of need for invasive support, compared to a 4% risk for those with undetectable levels. 

Brush up


Graves' disease is the most common cause of hyperthyrodisim, followed by toxic nodular goiter. Look for clinical symptoms like weight loss, heat intolerance, tremor, and palpitations. Consider antithyroid medications, surgery, or radioactive iodine ablation for treatment of Graves' disease, but drugs won't work for long-term treatment of toxic nodular goiter.

What's the evidence

For duration of antithyroid medication treatment in Graves' disease? Patients with Graves' face a high risk of relapse with drug therapy. A 2010 Cochrane review of 26 RCTs found that patients treated for 12 months saw fewer relapses than those treated for 6 months, while treatment beyond 18 months did not show benefit.

Bioengineering update

From America's first successful penis transplant to the use of human acellular vessels for hemodialysis access, it's a big week in medical reconstruction.

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