New cervical cancer screening guidelines by American College of Obstetrics and Gynecology, US Preventive Health Task Force, American Cancer Society and American Society for Clinical Pathology were published yesterday March 15, 2012 and reviewed on noon conference today. Many web sites (including some pages on CDC) are not updated yet to reflect this.
The take home?
Screening starts at age 21 regardless of age of sexual initiation.
Screening ends at age 65 in patients for those who have had appropriate screening and who do not have cancer history even if new sexual partner.
Generally speaking, PAP screening is every 3 years NOT annually if no abnormality.
Given prevalence and latency, do not do HPV co-testing in women under 30.
For women 30-65, Pap screening may be reduced to every 5 years if paired with HPV co-testing. If HPV co-test is positive, any abnormality is sent to colposcopy. If the HPV co-test is negative then ASCUS may be followed up in a year by the PCP.
Studies show that half of women with cervical cancer never had a PAP, but many women are having too many Paps! So do enough, not too many.
Screening for women
ACOG/ ACS/ USPSTF Guidelines:
http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recommendations
What to do with HPV co-test results
http://www.cdc.gov/std/hpv/pap/#table2
ACOG STD Screening Recommendations 2009
Sexually active women aged 25 years or younger should be screened for chlamydia, and all sexually active adolescents should be screened for gonorrhea. Urine-based screening without a speculum examination is sufficient for such screening, according to ACOG. However, pelvic exam may be used to look for STD's, if appropriate. ACOG also says that all adolescents and women aged 19 to 64 years who are sexually active should be screened for HIV, although frequency is not specified.
USPSTF STD Screening Recommendations
http://www.uspreventiveservicestaskforce.org/uspstf08/methods/stinfections.htm
Data do not support pelvic exams for vulvar, vaginal, uterine or ovarian cancers.
A visible or palpable abnormality OR specific complaint initiates a diagnostic test not screening although appearance of condylomata alone do not indicate deviation from cervical cancer screening guidelines.
MODIFIABLE RISKS: About 100 women die in TN each year due to cervical cancer. Here is our state specific facts about cervical cancer and risk factors (diet, smoking, condom use etc):
http://hit.state.tn.us/Reports/SurveyReports/BRFSS_Factsheet/PAPsmear%20BRFSS%20FactSheets%20TN%202005.pdf
PREVENTION: Don't smoke, limit number of sexual contacts, use condoms. HPV vaccination.
Usual vaccination is around age 12, but catch up is outlined in this CDC document. Vaccination status does not alter screening guidelines.
http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-hpv-gardasil.pdf
ACCESS:For individuals you encounter who do not have access to breast and cervical cancer screening (due to insurance, SES), there is a been a federally funded program in place to help. Ours is at the Knox County Dept of Health. To search for sites throughout the country:
http://www.cdc.gov/cancer/nbccedp/screenings.htm
PATIENT INFORMATION ABOUT HPV AND CERVICAL CANCER, INCLUDING IMMUNIZATION AND MODIFIABLE RISK FACTORS:
http://www.cdc.gov/cancer/cervical/pdf/cervical_facts.pdf
Review of topics covered in morning report, M&m, and core conferences with links to supplemental reading material.
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Thursday, March 15, 2012
Wednesday, October 5, 2011
Oct 5 - Carotid Dissection
Unusual condition discussed today - spontaneous dissection of the carotid artery resulting in stroke in a young patient. Often precipitated by an innocuous trauma such as turning the head rapidly, painting a ceiling, extending the neck during hair care at a beauty shop, and chriopractic manipulation (risk probably less than 1 in 40,000 encounters).
Collagen vascular disease present in ~ 1/4 as a predisposing cause.
This article from NEJM is a comprehensive review of the topic and covers vertebrobasilar (which has a similar pathogenesis and treatment) dissection as well.
Treatment is anticoagulation with heparin followed by warfarin, and interventions such as stenting is generally reserved for those with unresolving neuro deficits or significant hemodynamic cerebral blood flow impairments.
Collagen vascular disease present in ~ 1/4 as a predisposing cause.
This article from NEJM is a comprehensive review of the topic and covers vertebrobasilar (which has a similar pathogenesis and treatment) dissection as well.
Treatment is anticoagulation with heparin followed by warfarin, and interventions such as stenting is generally reserved for those with unresolving neuro deficits or significant hemodynamic cerebral blood flow impairments.
Tuesday, October 4, 2011
Sep 30 MR - Hyperglycemia Potpourri
Hyperglycemic Crises in Diabetes - review article from the ADA with great references and resources, covers the topics discussed today. Read this and you will know enough for boards and most patient care scenarios. Read and know the rest and you will be an internist.
Two contrasting cases of significant hyperglycemia - classic DKA and hyperglycemic hyperosmolar nonketotic state (HHNS) also formerly known as hyperglycemic nonketotic coma and many other names.
HHNS is a condition seen in type 2 diabetics with uncontrolled disease that lose access to free water due to debility, restraints, or acute illness. Things rapidly spiral out of control as they lose fluids from osmotic diuresis and develope more and more concentrated serum.
This AFP article is a good review of the condition and its treatment. Primary focus should be on volume resuscitation as it is not a pure insulin deficiency state. Administering insulin before fluid resuscitation could precipitate hypotension.
Also, keep in mind that this syndrome can precipitate central pontine myelinolysis, even in the absence of hyponatremia, as this article and several other reports have demonstrated.
As for DKA this is a condition that some patients have so often it often breeds complacency in physicians caring for them. It is a life threatening emergency and bad management decisions can make things worse. Overcorrection of glucose, inadequate volume resuscitation, or mismanagement of electrolyte problems are all potential pitfalls. It is easy to get lost in the data and a flowchart is essential to ensure good management. This article from a pediatric diabetes journal summarizes concensus guidelines and includes tons of useful calculations and fomulas for various fluid and insulin regimens. Most of this generalizes to care of adult DKA patients.
Two contrasting cases of significant hyperglycemia - classic DKA and hyperglycemic hyperosmolar nonketotic state (HHNS) also formerly known as hyperglycemic nonketotic coma and many other names.
HHNS is a condition seen in type 2 diabetics with uncontrolled disease that lose access to free water due to debility, restraints, or acute illness. Things rapidly spiral out of control as they lose fluids from osmotic diuresis and develope more and more concentrated serum.
This AFP article is a good review of the condition and its treatment. Primary focus should be on volume resuscitation as it is not a pure insulin deficiency state. Administering insulin before fluid resuscitation could precipitate hypotension.
Also, keep in mind that this syndrome can precipitate central pontine myelinolysis, even in the absence of hyponatremia, as this article and several other reports have demonstrated.
As for DKA this is a condition that some patients have so often it often breeds complacency in physicians caring for them. It is a life threatening emergency and bad management decisions can make things worse. Overcorrection of glucose, inadequate volume resuscitation, or mismanagement of electrolyte problems are all potential pitfalls. It is easy to get lost in the data and a flowchart is essential to ensure good management. This article from a pediatric diabetes journal summarizes concensus guidelines and includes tons of useful calculations and fomulas for various fluid and insulin regimens. Most of this generalizes to care of adult DKA patients.
Wednesday, September 14, 2011
15 Sep - Annual Program Review
Below are articles mentioned in today's Annual Program Review
Internal Medicine Residency Redesign - AJM 2011
Comprehensive Residency Research Curriculum
Quality of Life, Burnout, and Medical Knowledge among IM Residents
Attractiveness of IM to Medical Students
ACGME Letter GME Funding
Costs of Failing to Fail
APDIM E Learning Links - Also added permanent link on cool sites column to right.
Internal Medicine Residency Redesign - AJM 2011
Comprehensive Residency Research Curriculum
Quality of Life, Burnout, and Medical Knowledge among IM Residents
Attractiveness of IM to Medical Students
ACGME Letter GME Funding
Costs of Failing to Fail
APDIM E Learning Links - Also added permanent link on cool sites column to right.
Thursday, September 8, 2011
8 Sep - Hepatorenal Syndrome
This case was of a gentleman with severe decompensated cirrhosis with refractory ascites. Management of ascites was discussed previously in this post.
A couple key articles to add:
Know the trail test - quick, easy, and evidence based way to monitor cirrhotics for early encephalopathy. This NEJM review from 1997 goes over the use of this test for early detection, as well as most interventions short of the newly used rifaximin.
As for use of TIPS - two traditional uses are to control variceal hemorrhage and to improve refractory ascites. A recent trail suggests that this technique should be used more early in patients at high risk for variceal bleeding, before they have had their first bleed.
Finally - know hepatorenal syndrome. This was well reviewed recently in NEJM. Type 1 hepatorenal is the rapidly progressive, more dramatic version with highest short term mortality. FENA <1 suggests hepatorenal syndrome in cirrhotics with kidney impairment. Accurate estimation of GFR in cirrhotics is difficult, and the CG equation performs more poorly than MDRD, and even that overestimates the actual renal function. The potential role of TIPS in this condition was mentioned, but definitive clinical data is lacking.
The cost of midodrine/octreotide/albumin therapy is ~$2000 per day in drug cost alone, and should primarily be considered a bridge to definitive treatment such as transplant.
A couple key articles to add:
Know the trail test - quick, easy, and evidence based way to monitor cirrhotics for early encephalopathy. This NEJM review from 1997 goes over the use of this test for early detection, as well as most interventions short of the newly used rifaximin.
As for use of TIPS - two traditional uses are to control variceal hemorrhage and to improve refractory ascites. A recent trail suggests that this technique should be used more early in patients at high risk for variceal bleeding, before they have had their first bleed.
Finally - know hepatorenal syndrome. This was well reviewed recently in NEJM. Type 1 hepatorenal is the rapidly progressive, more dramatic version with highest short term mortality. FENA <1 suggests hepatorenal syndrome in cirrhotics with kidney impairment. Accurate estimation of GFR in cirrhotics is difficult, and the CG equation performs more poorly than MDRD, and even that overestimates the actual renal function. The potential role of TIPS in this condition was mentioned, but definitive clinical data is lacking.
The cost of midodrine/octreotide/albumin therapy is ~$2000 per day in drug cost alone, and should primarily be considered a bridge to definitive treatment such as transplant.
7 Sep - Sepsis Guidelines
Discussion today focused primarily on the early management of sepsis. This is a condition for which the mortality has not really decreased much since the advent of antibiotic therapy. A few interventions have been shown to decrease mortality, and there are a core set of interventions that should be considered in all septic patients.
The Surviving Sepsis Campaign has papers and pocket cards that review the current interventions shown to improve mortality in septic shock. They focus their measures on two phases of care - the first 6 hours (primarily ED interventions) and the following 24 hours (primarily ICU interventions).
This Nov 2001 trial on early goal directed therapy for sepsis formed the basis for much of the recommendations in this guideline. The only part that gives me pause is the recommendation to transfuse above a HCT of 30 if patients have low SVO2 despite volume resuscitation. This somewhat conflicts with other studies that show trends for worse outcomes with higher transfusion targets.
As for steroid therapy in sepsis, the clinical trial data follows a roughly 11 year cycle that I think correlates with sunspot activity cycles. The most recent data from recent JAMA and NEJM trials is pessimistic, and argues that any benefit from steroids, if truly present, is likely small. This benefit comes with the clearly documened risks of steroid therapy, to include worsening immunosuppression and hyperglycemia. If you so choose to use them, current dogma is to not base the decision on a ACTH stim test and only use low doses of hydrocortisone.
One side discussion revolved around the impact of severe sepsis on cognitive decline in elderly survivors of sepsis. A recent trial published in Mayo Clinic Proceedings demonstrated significant persistent cognitive decline in elderly patients post-surgery. This corresponds with previous studies that have shown similar persistent declines in elderly patients after severe sepsis. The rate of significant permanent cognitive impairment in elderly sepsis survivors is high, and fundamentally alters independent living for many patients. These studies should help you set realistic expectations for families when dealing with elderly family members facing major surgeries or critical illness.
The Surviving Sepsis Campaign has papers and pocket cards that review the current interventions shown to improve mortality in septic shock. They focus their measures on two phases of care - the first 6 hours (primarily ED interventions) and the following 24 hours (primarily ICU interventions).
This Nov 2001 trial on early goal directed therapy for sepsis formed the basis for much of the recommendations in this guideline. The only part that gives me pause is the recommendation to transfuse above a HCT of 30 if patients have low SVO2 despite volume resuscitation. This somewhat conflicts with other studies that show trends for worse outcomes with higher transfusion targets.
As for steroid therapy in sepsis, the clinical trial data follows a roughly 11 year cycle that I think correlates with sunspot activity cycles. The most recent data from recent JAMA and NEJM trials is pessimistic, and argues that any benefit from steroids, if truly present, is likely small. This benefit comes with the clearly documened risks of steroid therapy, to include worsening immunosuppression and hyperglycemia. If you so choose to use them, current dogma is to not base the decision on a ACTH stim test and only use low doses of hydrocortisone.
One side discussion revolved around the impact of severe sepsis on cognitive decline in elderly survivors of sepsis. A recent trial published in Mayo Clinic Proceedings demonstrated significant persistent cognitive decline in elderly patients post-surgery. This corresponds with previous studies that have shown similar persistent declines in elderly patients after severe sepsis. The rate of significant permanent cognitive impairment in elderly sepsis survivors is high, and fundamentally alters independent living for many patients. These studies should help you set realistic expectations for families when dealing with elderly family members facing major surgeries or critical illness.
Friday, September 2, 2011
2 Sep Cavitary Lung Disease
This AM covered a case of long-standing progressive cavitary lung disease, due in this case to Mycobacterium avium. Cavitary diseases of the lung cover a broad range of infectious and non-infectious causes. Chronicity of the process, associated findings, and epidemiologic history are all necessary to narrow down the possibilities. If spontaneous sputum does not reveal the offending pathogen invasive diagnostics are often needed, usually starting with bronchoscopy, followed by CT guided needle biopsy, and ultimately VATS / open lung biopsy.
When you see cavitary lesions on XRay always consider TB, and err on the side of placing the patient in respiratory isolation precautions if you are ordering AFB smears. Don't wait until they are positive.
Further reading:
Clin Micro Review April 2008 - best review of the differential of cavitary lung lesions with many good images of representative radiographs for many possible causes.
This image from that article shows a MAI cavity very similar to that seen in our patient.
Treatment of non-TB mycobacterial lung disease is actually more complicated than treating TB itself, and takes longer to achieve cure. These guidelines from the ATS and IDSA cover the topic in depth.
When you see cavitary lesions on XRay always consider TB, and err on the side of placing the patient in respiratory isolation precautions if you are ordering AFB smears. Don't wait until they are positive.
Further reading:
Clin Micro Review April 2008 - best review of the differential of cavitary lung lesions with many good images of representative radiographs for many possible causes.
Treatment of non-TB mycobacterial lung disease is actually more complicated than treating TB itself, and takes longer to achieve cure. These guidelines from the ATS and IDSA cover the topic in depth.
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