Breast Cancer Screening Guidelines

Given the data from randomized trials, which consistently show a 14 to 32% reduction in mortality from breast cancer with annual or biennial mammography in women 50 to 69 years of age, screening mammography should be recommended for women in this age group provided that their life expectancy is 5 years or more. For women 70 years of age or older, data from randomized trials are lacking, and the decision about screening should therefore be individualized on the basis of life expectancy and the patient's preference.

As for women in their 40s, there's not great consensus, and the decision should be individualized, with the recognition that the probability of a benefit is greater for women at higher risk.  For a woman in her 40s without risk factors, her chance of having invasive breast cancer over the next 8 years is about 1 in 80, and her chance of dying from it is about 1 in 400.

Mammographic screening every 2 years will detect two out of three cancers in women in their 40s and will reduce the risk of death from breast cancer by 15%. However, there is about a 40% chance that she will be called back for further imaging tests and a 3% chance that she will undergo biopsy, with a benign finding. Lifestyle modifications (e.g., weight control and avoidance of excessive alcohol consumption) that might lower her risk should also be discussed.

Reference: http://www.nejm.org/doi/full/10.1056/NEJMcp1101540

Case: Neck Swelling in an Adolescent

A previously healthy 13-year-old girl presents to the emergency department with a 2-week history of worsening sore throat and a 4-day history of left neck swelling, pain, and fever. Results of evaluation by a prior clinician at the onset of symptoms included a negative rapid streptococcal antigen test and a positive heterophile antibody test, prompting treatment with oral corticosteroids for 5 days as an anti-inflammatory medication. The girl now reports pain with swallowing, decreased oral intake, and left-sided head tilt for the past 24 hours.

On physical examination, the girl has a temperature of 38.4°C and appears to be in no acute distress. In addition, her heart rate is 91 beats/min, respiratory rate is 20 breaths/min, and blood pressure is 119/69 mm Hg. She has a warm, very tender, firm, anterior, left-sided 1.5-cm mass at the level of the thyroid gland. The mass moves when she swallows. Findings on the rest of her physical examination are normal.

Laboratory investigation reveals a white blood cell count of 17.2×10³/μL (17.2×10⁹/L) with 74% neutrophils and 14% lymphocytes, hemoglobin of 13 g/dL (130 g/L), and platelet count of 423×10³/μL (423×10⁹/L). C-reactive protein (CRP) measurement is elevated at 1.6 mg/dL (normal, 0.3 to 1.0 mg/dL). 

Images from a computed tomography (CT) scan of her neck with intravenous contrast enhancement are shown below.

What's the diagnosis?

***See first comment for answer.

MKSAP Question - Neurology

A 50-year-old man is evaluated for a 12-year history of slowly progressive left leg weakness and trouble ambulating. There is no history of transient neurologic symptoms. He has a history of hypertension, coronary artery disease, and chronic low back pain. Current medications are sublingual nitroglycerin, atenolol, aspirin, and occasional NSAIDs.

On physical examination, vital signs are normal. The patient has moderately severe spastic paraparesis that is worse on the left, with prominent circumduction of the left leg during ambulation. He requires a cane to ambulate 100 meters.

Cerebrospinal fluid analysis reveals the presence of oligoclonal bands.  MRIs of the brain and spine show lesions consistent with chronic multiple sclerosis.

Which of the following is the most appropriate treatment for this patient?

A) Glatiramer acetate

B) Interferon beta-1a

C) Natalizumab

D) Physical therapy


See first comment for correct answer with explanation.

UTI in Febrile Infants: Updated AAP Guidelines

A revised AAP clinical practice guideline on the diagnosis and management of the initial urinary tract infection (UTI) in febrile infants and young children is markedly different from the previous practice parameter published in 1999.  New data have become available in the past five years, with the findings prompting a reexamination of the older studies.  The notable changes are highlighted below:

1. Diagnosis: The criteria for diagnosis now include an abnormal urinalysis as well as a positive culture containing ≥ 50,000 colony forming units/milliliter of a urinary pathogen. The abnormal urinalysis helps distinguish true UTI from asymptomatic bacteriuria. Guidance also is provided regarding assessment of the likelihood of UTI to help determine which febrile infants clinicians should evaluate for UTI.
2. Treatment: Oral therapy is recognized as effective as parenteral therapy.
3. Imaging: Renal-bladder ultrasonography (RBUS) should be performed, but voiding cystourethrography (VCUG) no longer is recommended routinely after the first febrile UTI. Indications for VCUG include findings on RBUS that suggest the presence of high grade vesicoureteral reflux or the recurrence of a febrile UTI.
4. Follow-up: Emphasis should be on counseling families to seek medical evaluation promptly for UTI during future febrile illnesses.

The rationale for the biggest change — discouraging the routine performance of VCUGs — stems from analysis of the six recent randomized controlled trials of prophylaxis vs. no prophylaxis in young infants following a febrile UTI.

Prophylaxis was not demonstrated to be superior to no prophylaxis in preventing recurrence of febrile UTI in infants without reflux or in those with grades I-IV reflux. (In the studies, only five infants with grade V reflux were included, so the effectiveness of prophylaxis for infants with this grade of reflux is not known, but less than 1% of febrile infants with UTI have grade V reflux.)

Recurrent febrile UTI is less common among infants without high grade reflux, so waiting for the second UTI reduces the number of VCUGs performed by 90% and has a higher yield of infants with grades IV and V reflux. Studies of renal scarring suggest that waiting for the second UTI is acceptable and does not offset the benefit of sparing 90% of febrile infants with UTI the radiation, discomfort and cost of VCUG.

The figures in this updated guideline are worth scanning, including factors influencing the likelihood of UTI in febrile male & female infants; choices for parenteral and oral treatment of UTIs; sensitivity & specificity of diagnostic tests for UTI in infants; and a clinical practice guideline algorithm.

Reference: http://pediatrics.aappublications.org/content/128/3/595