How to Avoid Bad Decisions
Reading Time: 9 minutes | September 8, 2022
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USPSTF Leans Conservative on Statin Use
GUIDELINE GUIDANCE
The United States Preventive Services Task Force (USPSTF) finalized its statement on the use of statins for primary prevention of cardiovascular disease (CVD) last week, polarizing the medical community like a partisan bill on the Senate floor.
The USPSTF based its recommendation on 23 clinical trials and three observational studies that assessed the head-to-head use of a statin with either placebo or no statin on CVD risk. True to brand, the task force erred on the side of caution and recommended a conservative approach.
USPSTF recommendations on prescribing statins for primary prevention of CVD:
Prescribe for adults 40-75 years with ≥1 CVD risk factor (ie, dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk of ≥10% (B recommendation)
Selectively offer to adults 40-75 years with ≥1 CVD risk factor (as above) and an estimated 10-year CVD risk of 7.5% to <10% (C recommendation)
Insufficient evidence to assess the risks vs benefits for primary prevention of CVD events and mortality in adults ≥76 years (I statement)
While these recommendations mirror much of the 2018 American College of Cardiology (ACC)/American Heart Association (AHA) multispecialty guidelines on blood cholesterol, they diverge enough to spark fierce debate and the penning of a quartet of critical editorials: one, two, three, four.
Those in Camp USPSTF may call these 2022 statin recommendations "sensible and practical," while those in Camp ACC/AHA may consider them "too conservative." With CVD accounting for one out of every four deaths in the United States, the stakes are high, and opinions are understandably strong. At this year's Thanksgiving dinner, you may want to avoid discussing statins and opt for a less contentious topic, like student loan forgiveness.
Is Mental Fatigue All in Our Heads?
NEURO NEWS
You know that feeling of mental fatigue that comes from working a long shift, studying for an exam, or assembling a piece of furniture from IKEA. After such an activity, do we really need a mental break to binge The Office for the fifth time, or is mental fatigue an illusion, as previous studies have suggested?
New research shows that a day of grueling mental activity leads to a greater accumulation of glutamate in the prefrontal cortex than does a less taxing day. That buildup of a potentially toxic byproduct alters our decision-making ability. To preserve brain functioning, we then downshift to activities that are easy on the brain and offer instant gratification, like downing Oreos while rewatching Jim and Pam's wedding.
So, what can patients (and you!) do to avoid brain overload from work? One solution is to win the lottery. Another is to get plenty of rest and sleep because, according to solid evidence, sleep can clean out glutamate from synapses. And most important, you may want to advise patients not to make any important decisions once cognitive fatigue sets in. That's how bad decisions happen, unless you're Michael Scott—in which case, bad decisions happen because you're Michael Scott.
The average 20 x 40−foot residential pool contains not only water and chlorine but also 2 gallons of urine. "Not the pool I'm in," we all say. Nonetheless, a little urine in the pool never hurt anyone, right?
Unfortunately, when urine combines with chlorine, bad things happen. That unmistakable "pool smell" is actually the scent of chemicals that develop when chlorine meets urine. One such chemical, cyanogen chloride, has been used as a chemical warfare agent, with the potential to harm a person's cardiovascular and pulmonary systems. Other byproducts, nitrosamines, have been linked with an increased risk of cancer.
Of course, patients should not avoid swimming pools, but if they do develop a reaction to pool water, this may help explain why.
This "Did You Know" was brought to you by frequent Morning Report contributor Debbie Downer. Don't even get her started on hot tubs.
Shocking Potential Treatment for Memory Loss
Electroconvulsive therapy is more than 80 years old—but like fellow octogenarians Dr. Anthony Fauci, William Shatner, and Barbra Streisand, it's continuing to reinvent itself. According to new research, this treatment for severe depression may one day provide protection against memory loss as well.
A small randomized, double-blind study suggests that administering mild electric shocks to an older adult's brain may confer either short- or long-term memory benefits, depending on the spatial location and frequency of the electrical stimulation. For four consecutive days, researchers delivered electric signals to participants' brains for 20 minutes while measuring their ability to recall five lists of 20 words. Those receiving the stimulation demonstrated a 50% to 60% improvement in memory performance over those in the sham group. Shockingly, the patients sustained these memory boosts through a one-month follow-up.
Now for the caveats: (1) Only 150 people participated in the study—we speculate that descriptions of a brain-zapping cap may have caused hesitancy. (2) None of the participants had a known neurologic disorder, so we can't speculate on the benefits to patients with dementia.
Before this therapy can truly send shock waves through the healthcare community, it'll need to show efficacy in larger studies and with patients with dementia. In the meantime, this research offers hope that electroconvulsive therapy can exploit the brain's plasticity, even at older ages. If this treatment proves effective and safe, the next hurdle will be to convince patients to try it, despite its historically negative depiction in media. Once you've seen One Flew Over the Cuckoo's Nest, you can't unsee it.
Rapid-Fire COVID-19 Updates
COVID QUICK HIT
Risk for myocardial infarction, stroke, and pulmonary embolism following COVID-19 vaccines in adults younger than 75 years in France
Physical activity and risk of infection, severity and mortality of COVID-19: a systematic review and non-linear dose–response meta-analysis of data from 1 853 610 adults
FDA authorizes first revamp of COVID vaccines to target omicron
Considerations in Cervical and Prostate Cancer Screening
CANCER CONCLUSIONS
Annual prostate cancer screening may be more beneficial for Black men
A large retrospective study comparing various intervals of prostate-specific antigen (PSA) screening among Black and White men revealed important findings. First, and less surprising, PSA screening at intervals >1 year resulted in similar prostate cancer-specific mortality reductions for both Black and White men. But when that screening cadence increased to annual, White men saw no additional benefit while Black men did. Annual screening, compared with less frequent screening, was associated with a 35% risk reduction in prostate cancer-specific mortality among Black men (number needed to treat = 11). The investigators posited an explanation: "These results may be biologically plausible because a shorter screening interval may be valuable for detecting aggressive disease, which is more common in Black men."
Both the American Cancer Society and the USPSTF recommend that clinicians engage patients in shared decision-making when it comes to PSA screening. During those discussions with your Black male patients, you may want to share this study's findings that annual screening may significantly lower their risk of prostate-specific mortality.
Distant stage cervical cancer on the rise
In another large retrospective study, researchers examined trends in cervical cancer stage IVA-B (distant stage) among Black and White women over the past two decades. Here is what they found:
Distant stage cervical cancer incidence is increasing annually by 1.3% across all races/ethnicities
Black women have disproportionately higher incidence rates than White women
White women aged 40-44 in the South have seen the greatest increase in incidence
White women have lower rates of screening and vaccination than Black women
An uptick in distant stage cervical cancer is disheartening, given the stage's 17% five-year survival rate. But we know that cervical cancer is preventable and—when caught early—treatable, so this study should serve as an important reminder to recommend screening and human papillomavirus (HPV) vaccination as appropriate. Please see the USPSTF and American Cancer Society recommendations for cervical cancer screening.
Interested in more healthcare news? Here are some other articles we don't want you to miss:
New drug candidate fights off more than 300 drug-resistant bacteria
Sleep loss leads to the withdrawal of human helping across individuals, groups, and large-scale societies
Personalized microbiome-driven effects of non-nutritive sweeteners on human glucose tolerance
Vitamin D supplementation seems to alleviate depressive symptoms in adults
Smoking and other risk factors cause almost half of cancer deaths, study finds
Morning Report is written by:
Alissa Scott, Author
Aylin Madore, MD, MEd, Editor
Eleni Scott, MD, Editor
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