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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


What Your Doctor Is Reading What Your Doctor Is Reading
 

Update From the Medical Journals: April 2013


April 26, 2013

By Mary Pickett M.D.

Harvard Medical School

What's the latest news in the medical journals this month? Find out what your doctor is reading.

  • Medical Group Has Advice for Doctors and Patients About the PSA Test
  • Financial Burden of Dementia Is Huge  
  • Brain Scans Can "See" Pain
  • More News in Brief: Heart Drug Amiodarone May Increase Cancer Risk; Colic in Infants May Be Related to Childhood Migraines; Pain After Stroke is Common; and Taking Seizure Drug Depakote in Pregnancy Raises Autism Risk

Medical Group Has Advice for Doctors and Patients About the PSA Test

A year ago, the U.S. Preventive Services Task Force (USPSTF) recommended that we stop screening men for prostate cancer with  the PSA (prostate specific antigen) test if they don't have any symptoms. Why? Overall, research shows that having the test causes  more harm than good.

Now, the American College of Physicians (ACP) has issued its own guideline on this subject. It was published online April 9 by the Annals of Internal Medicine. In large part, the ACP guideline agrees that most men are better off without the test. But men from age 50 to 69 should share in this decision-making with their doctors, says the ACP. Some men in this age range, the guidelines point out, may have a strong emotional need to know that they are  "cancer free"  This may make some men willing to take on the risks that can follow PSA testing.
Doctors should make sure patients understand  these 10 "talking points" from the ACP before doing the test:

  1. PSA is a controversial screening test.
  2. The harm from screening (and from tests and treatments that follow) outweighs the benefits.
  3. Most men with prostate cancer do not die of prostate cancer because it is so slow-growing.
  4. Without screening, most men won't ever be diagnosed with prostate cancer. They will die of other causes.
  5. Men who choose a PSA test are more likely to be diagnosed with prostate cancer.
  6. A mildly high PSA (one that is no higher than 10μg/L) can lead to a cancer diagnosis, but it can't tell us  how likely the cancer is to spread or how serious it is. This is the result for most men who are diagnosed with prostate cancer after screening. PSA levels above 10μg/L (seen in only a small number of screened men) can predict a cancer that is more likely to be serious, and more likely to benefit from treatment.
  7. Testing prevents at most 1 death for every 1,000 men tested, if we watch these men for 11 years.
  8. The most important potential harms from screening are the result of treatments that can follow a positive test: a small risk of death from surgery (about 1 out of 200 men), loss of sexual function (one out of three treated men), or lasting problems with leaking urine (1 out of 10 men).
  9.  A doctor should not order this test unless the patient decides for himself that it's right for him.
  10.  A man can change his screening plan at any time, and new science may change our advice in coming years.

 Financial Burden of Dementia Is Huge

Dementia—losing the ability to think and reason— is a devastating problem. A study funded by the National Institute on Aging included 856 people who were 70 years or older. Researchers gave them a 3- to 4- hour-long memory and reasoning test. They diagnosed 126 people (14.7%) with dementia. Based on this, they estimate that 1 out of every 7 Americans over age 70 has dementia, whether or not it has been formally diagnosed.

Dementia is expensive, because patients who have it eventually need assistance with dressing, bathing and other personal care. They also need supervision to stay safe. Family members provide most of the care; they are not paid for this care. The researchers also looked at a group of 11,000 patients with dementia. They added up payments to nursing homes, doctors, hospitals, nurses, home aides and caregivers. Then they estimated lost salary for family members caring for a relative with dementia.

The researchers used a much larger group of almost 11,000 patients, and reviewed payments made in a year. They added up what was paid to nursing homes, doctors and hospitals, nurse care and paid home aides and caregivers for people with dementia. Then they estimated lost salary for family members who could not work because of a relative's needs in the home. They found that the total cost of dementia (expenses plus lost potential income for U.S. families) to be somewhere between $157 billion and $215 billion—more than heart disease or cancer care. Medicare paid approximately $11 billion of this cost. State-based Medicaid paid for some long-term care. But most of the money spent and all of the lost income came out of the pockets of patients and family members.

The New England Journal of Medicine published the study April 4.

 Brain Scans Can "See" Pain

A type of brain scan called a functional MRI might be able to "see" when patients are experiencing physical pain. One hundred and fourteen volunteers agreed to have their arms touched by a heating element. It was hot enough to cause very uncomfortable burning feeling. Functional MRIs scans showed no special pattern when the heating element was warm but not hot. But when it was hot enough to cause pain, a pattern that the researchers have described as a "pain signature" appeared on the MRI scan. Patients who thought about an emotionally painful event (they were shown photographs of recent romantic partners, with whom they had had a break-up) had a similar "pain signature." But it was different enough that researchers could tell it apart from physical pain. When treatment for pain was provided, the signature pattern became less visible.

It is not clear how this type of testing may be used in the future. Doctors do not need to second-guess patients when they report pain. But this testing may help doctors care for patients who are not able to communicate pain  (those in a coma, who have paralysis or who are recovering from stroke). The New England Journal of Medicine published the study results April 11.

More News In Brief

 

  • Heart Drug Amiodarone May Increase Cancer Risk. Amiodarone (Cordarone, Pacerone) helps suppress abnormal heart rhythms. The journal Cancer published a study online April 8 that concluded amidarone might increase the risk for a variety of cancers. Researchers tracked 6,418 people taking the drug for two and a half years. During that time, 280 people developed cancer. This was more people than expected. The risk was highest for men and people taking a high dose of the drug. This link to cancer will make people even more cautious about the drug.
  • Colic in Infants May Be Related to Childhood Migraines. Infants with colic cry nonstop and are difficult to console. The crying may be a response to pain. An interesting study in the April 17 issue of the Journal of the American Medical Association (JAMA) suggests a connection between infant colic and migraine headaches in childhood years. Almost three out of four children and adolescents aged 6 to 18 years who had childhood migraines also had a history of colic as infants. Only 1 out of every 4 children without migraines had infant colic. It is unknown why these two problems are related. Maybe colic is a kind of migraine, or maybe colic shows a sensitivity to pain that can also contribute to a migraine experience. It is possible that this connection might lead to better treatments for colic.
  • Pain After Stroke is Common. Out of 15,000 stroke survivors, 10.6% had chronic pain after stroke, according to a study published in the journal Stroke on April 4. This study has surprised doctors, because this means pain is a more frequent complication than they thought. Pain after stroke can be nerve pain ("neuropathic pain"), such as a burning or shooting pain in a limb. A stroke can also cause sensitivity to touch, making light touch feel unpleasant and painful. Many people who have had a stroke have cramps or spasticity in muscles on the side that was weakened by the stroke. Shoulder aching is common when stroke causes arm weakness.
  • Seizure Drug Depakote in Pregnancy Raises Risk For Autism. Control of seizures during pregnancy sometimes requires taking drugs. These drugs have been linked to some birth defects. A study in Denmark looked at 508 children who were exposed to valproate (Depakote, Depakene) during their mother's pregnancy. It found that the rate of autism in these children was at least 2.5 times higher than expected. The study was published in the April 24 issue of JAMA.

 

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