Gastrointestinal

NEJM Resident eBulletin – Elevated PSA

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Teaching Topic

Elevated PSA

Case Records of the Massachusetts General Hospital

Case 9-2012: A 67-Year-Old Man with a Persistently Elevated PSA Level

D.S. Kaufman and Others

CME Exam

At least 30% of clinically important prostate cancers may be missed during transrectal ultrasound-guided biopsy, and the results are not improved if more than 12 cores are taken (so-called “saturation biopsies”).

Clinical Pearls

Clinical Pearl  What is a Gleason score?

The Gleason score is the sum of the two most common histologic grades in a prostate-gland tumor, each of which is rated on a scale of 1 to 5, with 5 being the most cytologically aggressive. It correlates with prognosis. A higher score is more likely to be seen with disease that is not confined to the prostate, and is also correlated with poorer response to treatment of localized disease.

Clinical Pearl  What are the criteria for active surveillance in prostate cancer?

The authors report that criteria for active surveillance for prostate cancer include a PSA level less than 10 ng per milliliter. While the decision to carry out active surveillance is one that must be individualized, in general, in addition to having a relatively low PSA, patients with early clinical disease stage and a Gleason score indicating well or moderately differentiated tumor may be considered for active surveillance.

Morning Report Questions

Q. What is transperineal template-guided mapping biopsy (TTMB) of the prostate?

A. Traditional transrectal ultrasound-guided needle biopsy of the prostate allows excellent and convenient sampling of the posterior aspect of the prostate gland, where prostate cancers most commonly originate. On occasion, however, the cancer may arise either centrally or anteriorly and may be beyond the reach of a biopsy needle inserted through the rectum. However, the anterior gland can be reached through a perineal approach, a technique that is used to insert radioactive seeds into the prostate gland for the purpose of treatment (brachytherapy). Precision is needed to ensure that the needles are placed correctly. To achieve this, transrectal ultrasonography is used to visualize the needles, and the needles themselves are passed through holes in a template (grid) that is secured against the perineum. The perforations ensure that the needles are inserted in parallel and with a known relationship to one another. The “repurposing” of this brachytherapy technique for prostate biopsy is known as TTMB, or “grid” biopsy, and the template may be used to insert biopsy needles precisely to any location in the prostate gland.

Figure 3. Transperineal Template-Guided Mapping Biopsy of the Prostate.

Q. What are the indications for consideration of TTMB?

A. A PSA level higher than expected for the size of the gland should prompt consideration of TTMB for better sampling of the prostate. Biopsies performed with the use of templates are important for carefully selected patients in whom there is an unexplained discordance between PSA readings and findings on examination of biopsy specimens obtained via transrectal approach. One quarter of patients who undergo TTMB after at least one negative specimen obtained by transrectal ultrasound-guided biopsy will have positive results on TTMB. Up to half of these patients have cancers with a Gleason score of 7 or higher. In patients with two or more negative specimens from transrectal ultrasound-guided biopsies, the most common finding in specimens obtained by TTMB was cancer in the anterior lobes. The morbidity associated with TTMB is greater than that associated with transrectal ultrasound-guided biopsies; there is a higher incidence of acute urinary obstruction. Overall, the costs associated with TTMB (e.g., the costs of general anesthesia, the operating room, and the processing of a large number of tissue cores) render it far more expensive than transrectal ultrasound-guided biopsies.

Pink Slime – You Want Fries With That?

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Similar to a previous dissection they had performed on hot dogs, the researchers discovered waste and by-products including connective tissue, nerve tissue, cartilage, bone, and in a quarter of the samples, Sarcocystis parasites. But surely these “fillers” were the minority, right? Unfortunately not. After crunching the numbers, the researchers found that the amount of actual meat (muscle flesh) in the burgers ranged from 2.1 percent to 14.8 percent.

via Michael Greger, M.D.: Pink Slime: All About the Green.

NEJM Resident e-Bulletin Teaching Topics 11.03.11

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The next time you get asked by a sales professional why you rated her client for ulcerative colitis pull out this cheat sheet for talking points.

Q. What is the risk of cancer in patients with ulcerative colitis?

A. On the basis of data from referral centers, the cumulative risk of colorectal cancer among patients with chronic ulcerative colitis may reach 20 to 30% at 30 years, but the incidence rate is much lower in population-based series (approximately 2%). Risk factors for cancer include a long duration of disease, regardless of clinical activity; extensive involvement; a young age at onset; severe inflammation; the presence of primary sclerosing cholangitis; and a family history of colorectal cancer.

One Veggie Burrito with Salmonella Please

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I had a burrito with guacamole and salsa for lunch today.  Serious!

Medical News: Salsa, Guacamole Among Top Causes of Foodborne Illness – in Infectious Disease, Public Health from MedPage Today

The incidents accounted for 4.1% of all restaurant-related food borne illnesses from 1998 to 2008, more than double the 1.6% incidence from 1984 to 1997.

Of the 5,560 salsa or guacamole-related illnesses reported, 33% were attributed to Salmonella, 18% to Norovirus, 15% to Shigella, 10% to other infections, and 24% due to unknown causes. The infections resulted in a combined 145 hospitalizations and three deaths.

Of the outbreaks, 95 were traced to salsa and 36 to guacamole. Reported reasons for contamination included improper storage time or temperature (30%), contamination by food handlers and preparers (20%), and contaminated equipment or cross-contamination.

The raw ingredients used to make the popular condiments — including tomatoes, hot peppers, and cilantro — have also been implicated in past outbreaks of foodborne illnesses, Kendall noted.

The study concluded that training materials should be devised for the healthy preparation and storage of salsa and guacamole.

The CDC began collecting data on foodborne illnesses in 1973, but the first recorded incidents related to salsa and guacamole occurred in 1984.

Combination Therapy for Crohn’s

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Better Treatment Found for Crohn’s Disease – BusinessWeek

The international trial included 508 people with Crohn’s disease who had never been treated with immunosuppressive drugs. One-third were given infliximab alone, one-third received only azathioprine and one-third were treated with both. The trial was funded by Centocor Ortho Biotech, which markets infliximab, and Schering-Plough.

After 26 weeks, 56.8 percent of those getting combination therapy had complete remission of symptoms, compared to 44.4 percent of those getting only infliximab and 30 percent of those getting only azathioprine.