Jun 1, 2018

Split decision

The story

You know from when you get sick-pulled for night shift after you've already fallen asleep that nothing in medicine is set in stone. Here's why the USPSTF dropped their recommendation against PSA screening.

Help or harm

Long before you were a doctor, prostate-specific antigen (PSA) reigned supreme as the go-to cancer screening test in men. But things changed in 2012, when the USPSTF recommended against routine prostate cancer screening. The problem? Risks – overdiagnosis and the harms of excess treatment – outweighed small to negligible benefits from early detection. Most prostate cancers grow slowly, and beyond psychological harm, treatments can cause long-term side effects like urinary incontinence and erectile dysfunction. The recs led to a 30% fall in new prostate cancer diagnoses in the first year after their release.

What's changed?

This year's recommendations reflect updated data. Some studies, like the ERSPC, found a greater mortality benefit for screening after longer follow-up, while others look biased in hindsight and have been discounted. All in all, the number needed to screen to prevent 1 prostate cancer death at 13-year follow-up is about 800. Separately, more men with slow-growing prostate cancers are choosing active surveillance rather than prostatectomy or radiation, mitigating some of the harms of overdiagnosis. 

Personal choice

The new Task Force recommendations no longer recommend against PSA screening. Instead, have a conversation with men aged 55 - 69 and make a decision based on their preferences. African American men and those with a family history are at greater risk for prostate cancer and may be more likely to benefit from screening. Don't screen men over age 70. 

Say it on rounds

When the numbers don't add up

Do some digging. While the Puerto Rican government reported an official death toll of 63 following Hurricane Maria, a boots-on-the-ground survey of 3,300 households found 38 deaths in 3 months following the storm. When extrapolated to a population level, researchers estimate a death count of 4,600, or more than 70x the official estimate. One third of the deaths were linked to healthcare interruptions, including inaccessible meds (15%), trouble with respiratory equipment (10%), and closed medical facilities or unavailable doctors.

When your temper is tied to whether you ate lunch

You're well aware that the brain and gut work together, and now researchers are catching up. A data review of 405 patients with inflammatory bowel disease (IBD) established a brain-gut bi-directionality by linking disease activity with alterations in mood. Increases in IBD activity spurred greater anxiety scores in patients with normal baselines, and increased periods of anxiety predicted future IBD flares. A natural next question: can anxiety treatment reduce IBD activity? 

When intern year is coming to a close

Congrats! But know that you remain at risk for some chores (pre-rounding, progress notes, etc.) through residency and beyond. The same is true for atrial fibrillation, where two retrospective cohorts found that patients with resolved disease remained at increased risk – roughly 60% greater than matched controls – for stroke or TIA. Since less than 20% of resolved patients were on anticoagulation, many wonder if part or all of this patient group would benefit from AC.

Brush up

Antiphospholipid syndrome

Keep antiphosholipid syndrome (APS) in mind when working up stroke, DVT, or recurrent miscarriages. Suspicious thrombotic events combined with the presence of antiphospholiopid antibodies form a rough diagnosis. About 20 - 30% of lupus patients will test positive for the disease, but APS is also prevalent in patients with unexpected pregnancy complications (6%) and young patients with stroke (17%). Management focuses on control of traditional cardiovascular risk factors and anticoagulation for patients with previous thromboses.

What's the evidence

For primary clot prevention in APS? The data is controversial at best. A 2014 meta-analysis of 11 primary studies with 1,200 patients found a protective effect for aspirin in retrospective studies that was not present in prospective studies. Experimental evidence also suggests that hydroxychloroquine may prevent thrombosis, and a 2009 retrospective study found a small but significant decrease in thrombotic events proportional to time on hydroxychloroquine treatment.

What your social media friends are talking about

There's too much racism in tweets, but what about in pills? Drugmaker Sanofi had to remind people that 'racism is not a known side effect' of any of its meds after Roseanne Barr blamed her now infamous tweets on Ambien. 

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