AMA morning rounds report.
Good morning. Here are today's top stories. December 18, 2019 Leading the NewsSustained weight loss tied to breast cancer risk reduction, research suggestsTIME (12/17, Ducharme) reports new research “provides encouraging evidence that, for women 50 and older, virtually any amount of sustained weight loss translates to a reduction in breast cancer risk.” The findingspublished in the Journal of the National Cancer Institute were based on data from 180,000 women over 50 years of age in the U.S., Australia, and Asia. The study showed “among women not using hormone therapy (which is sometimes used to replace hormones lost during menopause, and has been linked to breast cancer risk), losing about 4.5 pounds—and keeping it off—seemed to be enough to drive risk down by around 18%, compared to a woman of similar starting weight who did not lose any.” Moreover, “sustained weight loss of 20 pounds and up corresponded to a roughly 32% lower risk.” NBC News (12/17) reports that the research does not prove cause and effect, but only indicates “an association between weight loss and reduced risk of breast cancer.” Meanwhile, “outside experts say the results are important, and give physicians science to back up common-sense health advice for their patients to lose excess weight when possible.” Reuters (12/17, Carroll) reports, “Even among those who lost 20 pounds or more and gained some of it back, there was still a lower risk of breast cancer compared to those whose weight remained stable.”
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Reuters (10/21, Rapaport) reports on a research review finding that “women who breastfeed may be less likely to develop diabetes and high blood pressure.” The review included “data from four previous studies looking at the connection between lactation and diabetes in a total of about 206,000 women.” They found that “mothers who breastfed for more than 12 months were 30% less likely to develop diabetes and 13% less likely to develop high blood pressure than women who didn’t nurse babies that long.” The review was published at JAMA Network Open.
Individuals with breast implants have a risk of developing breast implant-associated anaplastic large cell lymphoma, or BIA-ALCL. BIA-ALCL is not breast cancer—it is a type of non-Hodgkin’s lymphoma (cancer of the immune system). In most cases, BIA-ALCL is found in the scar tissue and fluid near the implant, but in some cases, it can spread throughout the body. Precise risks are difficult to determine due to lack of information about how many patients have received breast implants in the US and worldwide.
BackgroundIn 2011, the FDA identified a possible association between breast implants and the development of anaplastic large cell lymphoma (ALCL). At that time, the FDA knew of so few cases of ALCL that it was not possible to determine what factors increased a patient’s risk. In a reportsummarizing the Agency's findings, we emphasized the need to gather additional information to better characterize ALCL in individuals (cis- and trans-gender women and men) with breast implants. Over time, we have strengthened our understanding of this condition. In 2016, the World Health Organizationdesignated breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) as a T-cell lymphoma that can develop following breast implants. The exact number of cases remains difficult to determine due to significant limitations in world-wide reporting and lack of global breast implant sales data. At this time, most data suggest that BIA-ALCL occurs more frequently following implantation of breast implants with textured surfaces rather than those with smooth surfaces. FDA ActionsWe continue to collect and evaluate information about ALCL in individuals with breast implants. On an ongoing basis, we:
Current StatusSince 2016, there have been several advances in the description of the disease and treatment recommendations. These are summarized below:
Of the 660 total BIA-ALCL related MDRs the FDA received, many MDRs were identified as duplicate reports, including additional follow-up reports that were submitted to the FDA. The FDA has carefully reviewed the 660 MDRs to provide a more accurate analysis and to only provide unique BIA-ALCL reports. The resulting data reflected a total of 457 unique MDRs for BIA-ALCL. While the MDR reports provide information regarding the implant at the time of BIA-ALCL diagnosis, they do not typically give information about a patient’s history of breast implants. It is important to note that at the time of diagnosis, patients may have their original breast implants or they may have had one or more replacements. The MDR system is a valuable source of information. However, it depends on accurate reporting, and therefore may contain incomplete, inaccurate, untimely, unverified, or biased data. Over time, we may gather more information about a report and thus the numbers listed above may change. In addition, it is difficult to determine the total number of cases or estimate risk from the MDR reporting system due to potential under-reporting of events, possible duplicate reporting, and lack of data about the exact number of breast implants. Medical LiteratureA significant body of medical literaturehas been published since our 2011 report, including additional case histories and comprehensive reviews of the natural history and long-term outcomes of the disease. Most of the cases reported in the literature describe individuals who have had textured implants. Several recent journal articles explore possible risk factors for developing BIA-ALCL, including the methods used to create the textured surface and the role of biofilm. Most of the published information about treatment describes removal of the implant and the capsule surrounding the implant, and in some patients, treatment with chemotherapy and radiation. Several recent publications have estimated the risk of developing BIA-ALCL in individuals with textured breast implants. Current literature reported various estimates that BIA-ALCL may develop in 1 in between 3,817 to 30,000 women with textured breast implants (Clemens et al,2017; Loch-Wilkinson et al, 2017; De Boer et al, 2018). RecommendationsHealth Care Providers:If you have patients with breast implants, you should continue to provide them routine care and support. BIA-ALCL has been identified most frequently in patients undergoing implant revision operations for late onset, persistent seroma (fluid collection around the implant). Because BIA-ALCL has generally only been identified in patients with late onset of symptoms such as pain, lumps, swelling, or breast asymmetry, prophylactic breast implant removal in patients without signs or symptoms is not recommended. Current recommendations from the Plastic Surgery Foundation and the NCCN include the steps below.
BIA-ALCL appears to develop more frequently in individuals with textured implants than in people with smooth-surfaced implants. Before getting breast implants, make sure to talk to your health care provider about the benefits and risks of both textured-surface and smooth-surfaced implants. If you have breast implants, there is no need to change your routine medical care and follow-up.You should expect swelling and pain immediately after surgery. If you notice changes in the way your breast looks or feels after you recover from surgery—including swelling or pain around the implant—be sure to talk to your health care provider about the possibility of BIA-ALCL. Although not specific to BIA-ALCL, you should follow standard medical recommendations including:
We will continue to report on significant findings as new information and analyses become available. The AP (9/26, Stobbe) reports about 80,000 Americans died of the flu and related complications this past winter – “the disease’s highest death toll in at least four decades” – according to CDC Director Robert Redfield, M.D. Dr. Redfield said, “I’d like to see more people get vaccinated. ... We lost 80,000 people last year to the flu.” Daniel Jernigan, M.D., “a CDC flu expert,” explained that while the flu detected this year appears to be a less aggressive strain, officials still “don’t know what’s going to happen, but we’re seeing more encouraging signs than we were early last year.” The AP adds that in recent years, “flu-related deaths have ranged from about 12,000 to – in the worst year – 56,000, according to the CDC.”
Fortune (9/26, Shoot) reports the flu vaccine “turned out to not be very effective” last year, which contributed to “the sudden increase in flu-related deaths.” After the last flu season, “the CDC began using a new methodology for ranking severity of flu seasons,” classifying the 2017-2018 winter as “a high severity season across all age groups,” the only season to receive a high severity classification. Obesity rate for American adults grows to nearly 40 percentThe New York Times (3/23, Richtel, Jacobs, Subscription Publication) reports that data published in the Journal of the American Medical Association indicate that “nearly 40 percent of” American adults “were obese in 2015 and 2016, a sharp increase from a decade earlier.” The data also indicate that “7.7 percent of American adults were severely obese in the same period.”
Meanwhile, HealthDay (3/23, Thompson) reported that approximately “18.5 percent of kids were obese in 2015-2016, compared with 17 percent in 2007-2008.” Physician's First Watch
David G. Fairchild, MD, MPH, Editor-in-Chief In This Issue: February 16, 2018 Flu Vaccine Effectiveness Estimated at 36% Anticoagulants for Patients with Afib and Kidney Disease? Study Yields Mixed Findings Your NEJM Group Today: Treating Physical & Mental Public Health / Oral Prednisolone for Wheeze in Young Kids? / Boston-Area IM Opportunity Polio Transmission Threat Still Global Public Emergency Researchers Probe What Happened to American Diplomats in Cuba FDA Expands Window That Clot Retrieval Device Can Be Used Presidents' Day on Monday Flu Vaccine Effectiveness Estimated at 36% By Amy Orciari Herman Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS The overall effectiveness of this season's influenza vaccine has been estimated at 36%, according to an analysis in MMWR. Researchers examined data on nearly 4600 patients who sought outpatient care for acute respiratory illness with cough within 7 days of symptom onset between November 2017 and February 2018. Some 38% tested positive for influenza on reverse-transcription polymerase chain reaction. Roughly 43% of those with influenza had been vaccinated. Vaccine effectiveness was estimated for each virus type as follows:
The report's authors write, "Even with current vaccine effectiveness estimates, vaccination will still prevent influenza illness, including thousands of hospitalizations and deaths. Persons aged ≥6 months who have not yet been vaccinated this season should be vaccinated." In a news conference on Thursday, the CDC's Dr. Anne Schuchat noted that three out of four children who've died from flu this season were not vaccinated.
ACP Calls for Less-Intensive Blood Glucose Control in Type 2 DiabetesBy the Editors The American College of Physicians now recommends that most patients with type 2 diabetes aim for a hemoglobin A1c level between 7% and 8%. This represents a loosening of the group's 2007 recommendation, which said less than 7% was "a reasonable goal" for many patients. In a guideline update published in the Annals of Internal Medicine, the ACP cites evidence that treating to targets of 7% or lower rather than 8% does not reduce the risk for death or macrovascular events over 5–10 years — but does result in "substantial harms," such as hypoglycemia. In NEJM Journal Watch General Medicine, Dr. Daniel Dressler reviews the rest of the ACP's new recommendations and explains why "a more aggressive approach might be appropriate in younger patients with few comorbid conditions." CDC: Flu season has peaked but still widespread in 45 statesABC World News Tonight (3/2, story 10, 0:15, Muir) reported the US Centers for Disease Control and Prevention recently released data showing that nationally, 17 more children have died due to flu-related illnesses this season, bringing the total to 114. ABC added, “More than the past two years, and we’re still in this.” The CBS Evening News (3/2, story 6, 0:20, Glor) reported that by comparison, there were 40 pediatric deaths “at this time last year.” So far, the flu is still “widespread in 45 states, down from 48 last week.” According to the CBS Weekend News (3/3, story 7, 0:20, Ninan), “The CDC says the worst of the flu season is finally behind us.”
The Washington Post (3/2, Sun) reported that although the season has peaked, “increasing numbers of people are being infected by a secondary strain of the respiratory virus that could lead to a late-season bump,” federal officials announced Friday. They predicted the flu season could continue until mid-April. The Post said “the intensity of illness has made it the worst since the swine flu pandemic of 2009-2010.” CDC spokeswoman Kristen Nordlund explained, “Today’s flu data show activity is down significantly for the second consecutive week, which means we peaked in early February.” -AMA Morning Rounds |
AuthorDr. Wang is happy to share some of the latest news and research articles with you to keep you informed on the latest advances in medicine Archives
December 2019
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