June 24, 2016

Gut check

The story

The USPSTF has been working overtime this year on a range of complex issues. This week they updated their recs on colon cancer screening.

The recommendations

We last heard from the USPSTF on colon cancer screening in 2008, and the overall story sounds similar this time around. Screen asymptomatic, average risk adults aged 50 - 75 for colon cancer to detect early-stage cancers and prevent cancer-related deaths. The updated recs allow for several new screening options.

Dealer's choice

The agency says four colon cancer screening strategies result in similar life expectancy gains and consumption of health care resources: (1) colonoscopy once every 10 years, (2) annual screening with fecal immunochemical testing (FIT), (3) annual screening with FIT combined with flexible sigmoidoscopy every 10 years, and (4) computed tomography colonography ("virtual colonoscopy") every 5 years. Screening with yearly guaiac-based fecal occult blood testing or solo sigmoidoscopy is less effective, but better than nothing.

The rationale

A complex model predicts lives saved vs. resources used. For most of the strategies, expect to prevent about 20 cancer-related deaths for every 1000 adults screened. Abnormal screening tests prompt evaluation with colonoscopy, and complications from colonoscopy account for most of the harms from screening. This chart projects the benefits and harms of different screening strategies.

The takeaway

The USPSTF has bought in big on the something-is-better-than-nothing approach to colon cancer screening, calling screening procedures "substantially underused". Mix individual preferences with the tools available at your clinic to get your patients checked.

Say it on rounds

When your diabetic patient offers fries and a sip of Coke

Remain calm, and think about therapy. Diabetes is a leading risk factor for development of nonalcoholic fatty liver disease (NAFLD). An RCT of pioglitazone in biopsy-proven NAFLD showed a reduction in fatty liver disease activity scores in 58% of patients, a treatment difference of 41% vs. placebo. Pioglitazone patients also had significant reductions in liver fibrosis, hepatocellular carcinoma, and premature mortality at 3-year follow-up.

When patients pass for unknown reasons

Mystery is a tough pill to swallow. An analysis of sudden cardiac deaths in children and young adults found that coronary artery disease and inherited cardiomyopathies explained about 40% of deaths, while another 40% of deaths were deemed unexplained. Of the unexplained deaths, 27% were found to have clinically relevant cardiac gene mutations upon genetic testing.

When the colonoscopy clerk gives you a crooked look

If your patients are consistently cited for poor bowel prep, try some new tools. A meta-analysis of eight randomized trials with over 3,700 patients found that enhanced instructions in the form of pamphlets, visual aids, smart phone apps, and others improved the quality of pre-procedural bowel prep compared to standard instructions.
Gastrointest Endosc

When your cheekbones could use a little extra oomph

Researchers removed facial bones from Yucatán minipigs and replaced them with bone grown in image-guided 3D scaffolds immersed in a mixture of stem cells and nutrient solution. The new bone did not prompt rejection, and successfully integrated with native pig bone within 6 months.
Sci Transl Med

Brush up

How it works

Traditional transvenous implantable cardioverter-defibrillators (ICDs) use ventricular leads to detect arrhythmias. Antitachycardia pacing (ATP) is used to correct ventricular tachycardia, and direct-current shock is used to correct ventricular fibrillation. Newer subcutaenous ICDs may be a good fit for patients at increased risk for transvenous lead complications, though they don't have ATP or pacemaker functionality.

What's the evidence

For AICDs in symptomatic congestive heart failure? 2005's SCD-HeFT showed a 23% reduction in all-cause mortality over 5 years for shock-only ICD therapy compared to conventional therapy or amiodarone in an RCT of 2,500 patients. Participants had an ejection fraction of < 35% and NYHA class II or III symptoms.

Summer days

The Scope team is taking a break next week to celebrate Uncle Sam and put the finishing touches on fellowship applications. We'll see you back in your inbox on July 8th.

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