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This week the USPTF got down and dirty with breast cancer screening.
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In 2009, the USPTF made a splash when they recommended against routine mammography screening for women between 40 - 49. Remember: the USPTF is a big deal, and the government takes their recs seriously. Their new recommendations endorse screening as an individual choice for women under 50. They give the recommendation a C grade.
Annals
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US law basically requires private insurers to pay for the USPTF's A and B grade recommendations, so in theory a C grade leaves women vulnerable to a lapse in coverage for mammograms under age 50. Cue ensuing outrage from cancer advocacy groups and breast cancer survivors when the draft recommendations were released in April. A lot of the crisis is avoided though, since congress passed a law in December that extends coverage of screening mammography indefinitely. But even the committee notes they felt a lot of pressure to put politics above science in their latest review.
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The sweet spot for mammogram screening is the 60 - 69 age range, with an estimated 21 deaths saved per 10,000 women undergoing screening over 10 years. As you move further away from the bullseye, the benefit of screening decreases. In women aged 40 - 49, mammography prevents 3 deaths per 10,000 women over 10 years. Young women also have higher rates of overdiagnosis, which the USPTF says produces hard to quantify psychological and treatment related effects. And researchers note that recent advances in breast cancer treatment probably dilute some of the known survival benefit.
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Women with dense breast tissue (roughly one sixth of patients) remain especially tricky, since they have higher rates of both undetected breast cancer and false positive diagnoses. Imaging with ultrasound and MRI helps find more cancers in these women, but no mortality data exists for these additional screening measures.
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Whew. Mammography is complicated and emotionally charged. For now, continue to screen women aged 50 - 75 every two years. For women between 40 - 49, make like Kanye and T Swift and have a conversation.
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WHEN YOU WANT TO GET YOUR FREAK ON
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Be thankful you don't have low T. Testosterone levels dip as men age, but the benefits of supplementation have been unclear aside from late night infomercials. Men older than 65 who had low T were randomized to placebo vs. testosterone gel for one year. Three arms were studied: sexual function, "physical function" (umm walking), and "vitality" (self reported energy). Those undergoing 'T' treatment had improved libido and mood, but no difference was seen in physical function or energy levels. See this sexy Quick Take video for more.
NEJM
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WHEN YOU THINK YOUR PATIENT'S SNIFFLE IS MORE THAN JUST A URI
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Acute HIV can hide from conventional HIV tests, since the body has not had time to produce antibodies against the virus. In patients in high prevalence populations, HIV antigen antibody combination screening after a negative rapid test detected more than 80% of acute HIV infections found by the gold standard, pooled RNA HIV tests. A disproportionate number of HIV cases are transmitted during the acute infection phase, so knowing who has the virus is critical.
JAMA
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WHEN YOU FORGET TO TELL YOUR SIGNIFICANT OTHER YOU SIGNED UP TO MOONLIGHT ON VALENTINE'S DAY
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You've got a problem. Also a problem: hepatorenal syndrome. When given with albumin, the systemic vasoconstrictor terlipressin produced a greater improvement in renal function than albumin alone in patients with cirrhosis and type 1 hepatorenal syndrome. Transplant free survival, overall survival and number of adverse events were similar between groups. The drug, which is similar mechanistically to vasopressin, is mainly used in Europe and Australia.
Gastroenterology
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WHEN YOU'RE POST-STROKE PATIENT GUILTS YOU INTO GRABBING HIM A MOUTAIN DEW
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Make him a little more insulin sensitive. Insulin resistance is a known risk factor for stroke and heart attacks. Non-diabetic patients with a recent stroke or TIA who took piaglitazone – a diabetes drug that increases insulin sensitivity – were 24% less likely to have a stroke or heart attack at 5 years. They were half as likely to develop diabetes, but had a higher risk of weight gain, edema, and broken bones.
NEJM
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Is a clinical diagnosis. Look for jaundice, anorexia, fever, and tender hepatomegaly in chronic alcoholics. Check liver function tests for mild transaminase elevation and an AST/ALT ratio greater than 2. Severe disease is defined by the presence of hepatic encephalopathy or a Maddrey score >32.
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For steroids in alcoholic hepatitis? AASLD guidelines recommend 4 weeks of prednisolone for severe alcoholic hepatitis, and suggest pentoxifylline if steroids are contraindicated. But the recommendations are controversial. 2015's STOPAH trial showed a non-statistically significant decrease in 28-day mortality in patient's treated with prednisolone, while pentoxifylline showed no mortality benefit.
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WHAT YOUR EPIDEMIOLOGY FRIENDS ARE TALKING ABOUT
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Watch out for proton pump inhibitors and dementia. Researchers looked up insurance diagnoses for PPIs and dementia in the largest German insurance registry. After adjusting for a bunch of factors, PPI prescriptions were associated with a 44% increased risk of a dementia diagnosis. The finding come on the heels of a lot of recent questions about PPI safety.
JAMA Neurology
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