1. Annual FIT home stool test effective for colon cancer screening
Increased use of FIT could improve CRC screening rates, especially among vulnerable populations
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2390 Editorial: http://annals.org/aim/article/doi/10.7326/M19-0301 URLs go live when the embargo lifts
Fecal immunochemical tests (FITs) are effective for screening for colorectal cancer (CRC) when used annually by average risk asymptomatic adults. Because these at-home tests are easy-to-use, non-invasive, and inexpensive, adopting their use could improve lagging CRC screening rates, especially among vulnerable populations. Findings from a meta-analysis are published in Annals of Internal Medicine.
The U.S. Preventive Services Task Force currently recommends CRC screening for adults aged 50 to age 75, without preferentially recommending one specific screening test over another. Colonoscopy is considered to be the gold standard in the U.S., but several other countries use annual or biennial stool blood tests. Despite colonoscopy effectiveness and cost-effectiveness, only about 65 percent of eligible U.S. adults get tested. Adopting a FIT screening strategy could increase screening rates, but more information is needed about FIT performance for CRC detection.
Researchers from the Regenstrief Institute and Indiana University School of Medicine reviewed 31 studies involving 120,255 patients to summarize FIT performance for CRC, quantify FIT performance characteristics for colon polyps, and to identify factors affecting those characteristics. They found that single-application FITs have moderate to high sensitivity and specificity for CRC, depending on the positivity threshold. At a high specificity, FITs are moderately sensitive for CRC. Although FITs are much less sensitive for advanced adenomas, these lesions rarely transition to cancer, suggesting an opportunity to detect this lesion with programmatic screening before they become cancer.
James Allison, MD, from the University of California, San Francisco and Kaiser Permanente Northern California Division of Research laments the designation of colonoscopy as the "best/gold standard" screening test when there exists a paucity of research supporting that assertion or comparing colonoscopy to less invasive, cheaper tests. He notes that some U.S. primary care physicians and many of their patients may be unaware that FITs are noninvasive, easy to prepare, and inexpensive and have effectiveness similar to that of colonoscopy when used in a consistent programmatic fashion to screen for CRC. This is because the media and health systems continue to promote colonoscopy as the best test for CRC, even though U.S. CRC screening guidelines no longer promote this idea. Dr. Allison suggests that physicians in the U.S. be educated about the advantages of FITs as screening tests for CRC and educate and advocate to increase screening rates. He also suggests that changes to insurance coverage that could lead to many more of our vulnerable populations being successfully screened.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Thomas F. Imperiale, MD, please contact Cindy Aisen at caisen@iupui.edu. To reach the editorialist, James Allison, MD, please contact Janet Byron at Janet.L.Byron@kp.org.
2. Sertraline and talk therapy nearly equally effective for treating depression in dialysis patients
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2229
Editorial: http://annals.org/aim/article/doi/10.7326/M19-0526
URLs go live when the embargo liftsCognitive behavioral therapy (CBT) and drug treatment with sertraline were both found to be effective for treating depression in patients undergoing dialysis for end-stage renal disease. At 12 weeks, depression scores were slightly better with sertraline, but patients also experienced more side effects. A conversation with a therapist had no effect on patients' willingness to start depression treatment. Findings from a randomized controlled trial are published in Annals of Internal Medicine.
Major depression is a common problem among patients receiving maintenance dialysis for end-stage renal disease, yet most do not seek treatment. Patients with depression have difficulty adhering to diet, medications, and treatment schedules and in navigating care transitions, and they have greater health care use and mortality rates. Both CBT and medications are proven effective for treating depression, but data on patients' acceptance of treatment and on the comparative efficacy of various therapies for this population are limited.
Researchers from UW Medicine/Kidney Research Institute in Seattle, University of New Mexico, and University of Texas Southwestern tested two hypotheses among patients receiving maintenance dialysis who had major depressive disorder or dysthymia. In phase one of the study, the investigators sought to determine if an engagement interview with a therapist would increase the frequency of depression treatment. In phase two, the researchers compared the efficacy of CBT with that of sertraline over 12 weeks among 184 kidney-failure patients at 41 dialysis facilities in three U.S. metropolitan areas. First, they found that an engagement interview did not increase willingness to undergo therapy. Second, the researchers found that sertraline was slightly more effective than CBT, but both treatments seemed to work. The researcher suggest that physicians should select the treatment that is available and acceptable to the patient, recognizing that each comes with its own burdens.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Rajnish Mehrotra, MD, MS, please contact Brian Donohue, at bdonohue@uw.edu.
3. Sex-specific models successfully predict bleeding risk with aspirin therapy
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2808
Editorial: http://annals.org/aim/article/doi/10.7326/M19-0416
URLs go live when the embargo lifts
Sex-specific prognostic bleeding risk models successfully estimate the absolute bleeding harms of aspirin among persons in whom aspirin is being considered for the primary prevention of cardiovascular disease (CVD). Findings from a cohort study are published in Annals of Internal Medicine.
Many prognostic models for cardiovascular risk can be used to estimate aspirin's absolute benefits, but few bleeding risk models are available to estimate its likely harms. An accurate risk prediction tool is needed.
Researchers from the University of Auckland, New Zealand sought to develop a prognostic bleeding risk model for persons in whom aspirin might be considered for the primary prevention of CVD. The 385,191 participants were automatically recruited into the cohort after their first CVD risk assessment and their data was entered into PREDICT, a web-based decision support program integrated with New Zealand's electronic health records. The sex-specific models showed that established risk factors for bleeding were associated with an increased risk for bleeding in men and women. Although older age, smoking, and diabetes were associated with increased bleeding risk in both sexes, no association was observed between bleeding risk and other established CVD risk factors. According to the researchers, these models could help identify people for whom the benefits of aspirin are likely to outweigh its harms in primary prevention. A tool using the prognostic bleeding risk models described by the authors will identify such people and is currently under development.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org.To interview the lead author, Vanessa Selak, PhD, please contact her directly at v.selak@auckland.ac.nz.
4. Bloodletting may lower triglyceride levels in patients with severe hypertriglyceridemia
Abstract: http://annals.org/aim/article/doi/10.7326/L18-0706
URLs go live when the embargo liftsPlasmapheresis may be necessary but insufficient, to treat some cases of severe hypertriglyceridemia. A case report detailed in Annals of Internal Medicine describes a case in which bloodletting was helpful.
Clinicians from University Hospital of Cologne saw a 39-year-old man with nausea, vomiting, malaise, headache, and slowly deteriorating alertness. He had very high levels of triglycerides and cholesterol, as well as elevated hemoglobin A1C. The researchers hypothesized that the patient's extreme hypertriglyceridemia with hyperviscosity syndrome was caused by a combination of insulin resistance, obesity, inappropriate diet, and insufficiently treated diabetes. They gave the patient intravenous fluids and vasopressor for hypovolemic shock. The patient was then admitted to the intensive care unit with severe ketoacidosis and treated with insulin therapy combined with fibrate and omega-3 fatty acids. Because the hypertriglyceridemia was still present and severe, the clinicians employed bloodletting to prevent pancreatitis. The patient improved in both serum levels and neurological function. According to the authors, theirs is the first report to describe using bloodletting to treat hypertriglyceridemia.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Matthias Kochanek, please contact him directly at matthias.kochanek@uk-koeln.de or the co-author at philipp.koehler@uk-koeln.de.
Also New in this issue:
Health Care in 2030: Will Artificial Intelligence Replace Physicians?
Nirav R. Shah, MD, MPH
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M19-0344
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Journal
Annals of Internal Medicine