Hot Medicine Topics – 5/23/17

HOT MEDICINE TOPICS:  23 MAY 2017

This was a great month for actual practice-changing studies!  Read on!

 

  • Should we screen extensively for occult cancer after an unprovoked DVT?  Khan, et al. BMJ 2017 22 March.

 

    1. Current knowledge:  Previously reported incidences of cancer in this population was around 10%.  In practice, many patients with unprovoked DVT are extensively screened (i.e., with CT imaging, endoscopy, etc) though there is limited evidence to support this aggressive approach.
    2. New knowledge:  Two large, high-quality RCTs found rather that the incidence of malignancy is closer to 4%.  The authors of this study suggest that CT should NOT be used in most patients since the yield is low.  Thorough H&P, basic labs (CBC, CMP) and age-specific cancer screening (if not done) should be the initial approach.

 

  • The Danish Mammogram Study.  JØrgenson, et al. Annals of Internal Medicine, 7 March 2017.

 

      1. Current knowledge:  A good screening test should (a) detect early-stage disease that will harm the patient and (b) prevent advanced disease – it is not clear whether mammography does this.  This study looked at a q 2 year screening protocol in women ages 50-69yo between 1980-2010, so pretty reflective of a USPSTF-style practice.
      2. New knowledge:  Authors compared incidence of advanced (>20mm) and non-advanced (<20mm) cancers in women (1) in screened vs non-screened regions of Denmark and (2) across age cohorts to measure overdiagnosis rates (i.e., early-stage cancers that would not advance) and prevention of advanced cancers.  
        1. Screening was not associated with a lower rate of advanced tumors (fails criterion b above).
        2. Screening found more non-advanced tumors compared to not screening.  Region-to-region comparisons:  overdiagnosis rate of 24% (including DCIS) and 14% (excluding DCIS).  Age group comparisons: overdiagnosis rate of 48% (excluding DCIS) and 38% (including DCIS) (fails criterion a above).
        3. Summary:  At best, around a quarter of “early” lesions on mammography would never harm the woman, but of course lead to harms of overdiagnosis.  Mammography does not appear to prevent advanced cancers.  This study, predictably, caused the American Cancer Society and other groups to throw fits in the US.

 

 

 

  • Thyroid Hormone Therapy for Older Adults with Subclinical Hypothyroidism.  Stott, et al. New Engl J Med 3 April 2017.

 

      1. Current knowledge:  Treatment of subclinical hypothyroidism (asymptomatic pt with elevated TSH, normal FT4) is controversial, especially in the elderly who have an increased risk of complications from overtreatment.
      2. New knowledge:  This study was a double-blind RCT of 737 adults ≥65yo with subclinical hypothyroidism randomized to treatment (start 50 mcg, or 25 mcg if low body weight, titrated to normal TSH) vs no treatment (placebo with mock dose adjustment).  Primary outcomes were validated symptoms scores (tiredness, function, etc).  Secondary outcomes were many: grip strength, BP, cardiovascular events, etc.
      3. The punchline:  Levothyroxine treatment made NO difference in anything!
      4. Conclusion:  We probably shouldn’t be treating asymptomatic subclinical hypothyroidism in the elderly.  Treat the patient, not the numbers.

 

 

 

  • Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients with Knee Osteoarthritis.  McAlindon, et al.  JAMA 16 May 2017.

 

    1. Current Knowledge:  We do a ton of them – every three months, patients get steroid injections in their arthritic knees.  Does it help?  Does it harm?  This study looked at our common practice – triamcinolone 40mg IA q 3 mos vs saline (placebo).
    2. New Knowledge:  Study involved 140 patients (mean, 58yo, 54% women, 85% completed study) with symptomatic knee OA based on validated ACR scores and with U/S evidence of synovitis.  Followed for 2 years.  All underwent annual MRI-based measurement of cartilage volume.  
      1. Triamcinolone resulted in (a) significantly greater cartilage volume loss and (b) no difference in pain compared to saline.
    3. This is a big deal.  It’s a well-done study showing HARM with regular knee steroid injections for OA, and no benefit in pain control!  We should stop doing this (jury is still out on shoulders and other joints, but probably not great).  Re-double our efforts on weight loss, physical therapy, APAP, NSAIDs (where tolerated), topical treatments, acupuncture, consider IA opioids (in clinic?!).  Remember:  Hyaluronic acid doesn’t work either, so don’t resort to that.
      1. There goes half of Procedure Clinic.
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