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Sep 16, 2016

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The story

Some residents think watchful waiting is a good way to do nothing while the intern finishes all of the work. The term takes on a different meaning in prostate cancer, where new research compares the strategy to more aggressive options.

The basics

Early-stage prostate cancer grows slowly, and few tumors metastasize. About 40-50% percent of men in the US choose to monitor their disease with prostate-specific antigen (PSA) screening rather than pursue radical prostatectomy or radiation therapy. Aggressive treatment options can have significant side effects, but the consequences of metastasis are severe. 

The evidence

ProtecT compared treatment strategies for early-stage, localized prostate cancer in 1,600 patients over a median follow-up of ten years. An active monitoring arm, in which patients had their PSA tracked over time, was more likely to progress to metastatic disease than a surgery arm and a radiation therapy arm, but no mortality difference was seen between the groups. The incidence of metastatic disease was small, with 3 cases per 1,000 person-years in the treatment arms and 6.3 per 1,000 person-years in the active monitoring arm. 
NEJM

The commentary

Some think the ProtecT data supports treating early prostate cancer rather than waiting, and argue that the trial's 10-year follow-up was too short to detect differences in mortality between groups. Others point to the low 10-year mortality rate in all arms of the trial as evidence that deferring treatment is a reasonable option if consistent with patient preferences. Note that the trial's early stage cancers were found through PSA screening, which the USPSTF no longer recommends

The takeaway

In the complex world of early-stage prostate cancer, data is as important as anything. ProtecT offers more precise answers to questions on risks and benefits. 

Say it on rounds

When you spend all day trying to go to the bathroom

That's called a busy shift. But patients with chronic severe constipation have a maximum of two spontaneous bowel movements a week despite abdominal discomfort and straining at stool. An RCT sponsored by the Chinese government found that 8 weeks of acupuncture with electrical stimulation doubled the number of weekly bowel movements compared to sham acupuncture in constipated patients. The authors think the procedure increases gut motility by activating parasympathetic nerves.
Annals

When you schedule an add-on to the already overbooked cath lab

What's good for business may also be good for patients. Researchers tapped into 400,000 patients in the MINAP registry to look for changes in cardiac mortality from 2003 – 2013. They found a 30% decrease in mortality from acute coronary syndrome despite an increase in the prevalence of comorbidities like diabetes and hypertension. Data analysis attributed the changes to increased use of invasive coronary strategies, including a 20% increase in the use of stents.
JAMA

When the last lunch time cookie tumbles to the floor

Be bold and be daring, but be aware that the 5-second rule doesn't hold up at the benchtop. A new study found that Enterobacter can jump on your food in less than one second, shattering the dreams of little brothers everywhere. Watermelon was a favorite snack for the bacteria, while gummy worms were considerably less attractive. 
Appl Environ Microbiol
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Brush up

Asthma

Genes and environment combine to produce a worldwide asthma prevalence of 5-16%. Allergic inflammation is key to most cases, and research increasingly points to a protective role for early microbial exposure. Inhaled corticosteroids remain the mainstay of treatment, while long-acting beta agonists (LABAs) or leukotriene receptor antagonists are added in hard-to-control or poorly adherent patients.

What's the evidence

For anti-IgE therapy in uncontrolled asthma? 2011's EXTRA trial found that the monoclonal anti-IgE antibody omalizumab decreased exacerbation rates by 25% relative to placebo in 850 uncontrolled asthmatics from urban areas. Adverse affects were minimal, but medication cost is a significant barrier. 

Special interests

Thousands of documents show that a sugar trade group paid Harvard scientists to implicate fat as the culprit in coronary heart disease (CHD) in a 1967 review article, shifting blame away from sugar's role in CHD for decades.

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