Published April 1, 2023
Morning Report — Not Your Typical Medical Newsletter
March Madness may have captivated our attention last month, but Match Madness captivated our hearts. We hope the med students reading this saw those two life-changing words: “YOU MATCHED!” With a historic 40,375 certified positions matched this year, the future of healthcare is in good hands. Please enjoy this med student’s Match Day reaction. We’re not crying; you’re crying.
CDC Hopes New Screening Strategy Is a Checkmate on HBV
GUIDELINE GUIDANCE
The old way wasn’t working. The CDC’s (and USPSTF’s) risk-based screening strategy for hepatitis B virus (HBV) has left us staring at the same abysmal US prevalence rates since 1999. Time for a new approach? The CDC in the equivalent of taking its queen out early has opted for an aggressive new strategy: HBV screening across the board.
Specifically, the CDC’s 2023 guidelines put the following pieces in place:
- One-time universal screening of all adults ≥18 years
- Periodic screening of individuals at high risk (see expanded list) AND for anyone who wants it—no questions asked
- Screening of all pregnant women in the first trimester, regardless of vaccination status
- Initial screening performed with the triple panel (HBsAg, anti-HBs, total anti-HBc)
Key takeaway
Up to 2.4 million people live with HBV in the United States, and an estimated two-thirds are blind to their condition. The CDC believes these new guidelines will position frontline clinicians to better identify those elusive infections and finally curtail the spread of this potentially deadly disease. The agency further hopes that the combination tactic of universal screening plus vaccination of all adults aged 19 to 59 years will keep new infections in check and ultimately turn HBV on its side. Your move, USPSTF …
Throwing Stones at Hydrochlorothiazide
GI GIST
Hydrochlorothiazide has held its ground as the bedrock pharmacologic agent in the prevention of recurrent kidney stones for 50-plus years—a Rolling Stones-level of staying power. But a new study published in NEJM threatens hydrochlorothiazide’s therapeutic longevity—at least for this purpose.
NOSTONE trial rocks the boat
In a double-blind study of >400 people with recurrent calcium-containing kidney stones, various doses of hydrochlorothiazide showed no significant superiority over placebo during a three-year follow-up, even in patients with hypercalciuria. All doses of hydrochlorothiazide did, however, confer a higher risk of hypokalemia, gout, skin allergy, new-onset diabetes mellitus, etc.
Trial left stones unturned
Should we now discard a half century of medical practice? Not yet. Experts argue the trial was underpowered and note the conspicuous absence of urinary calcium excretion as an inclusion criterion. “This is a very well-conducted trial, but horribly conceived,” summarized expert urologist Dr. Mantu Gupta, keeping his comments as real as a Keith Richards interview.
Key takeaway
Some patients would give their left kidney to avoid the agony of a stone recurrence, so it’s dismaying to read that the reigning preventive medication failed to provide a protective effect—and links to weighty side effects. But before medical societies etch guideline updates in stone, we’ll need better-conceived studies. This trial is merely a stepping stone, one that spurs you to consider the risks and benefits of this preventive therapy to individual patients. Ideally, we would prefer interventions that fully eliminate kidney stones, without inducing adverse effects. But as is often the case in medicine, you can’t always get what you want.
Study Gets Behind Termination of the DRE for Prostate Cancer Screening
MEN’S HEALTH MUSINGS
What was once a compulsory part of the wellness visit for male patients is progressively going the way of cursive writing and voice messages. Another study points to the unimpressive yield of the digital rectal exam (DRE) for prostate cancer screening and suggests the DRE has officially lost its job to prostate-specific antigen (PSA) and MRI testing.
This large study, presented at the European Association of Urology Congress, found the DRE ineffective as a standalone prostate cancer screening tool in middle-aged men. Researchers gave the manual screening method this shoddy performance review:
- Only 1% of the DREs in the study raised suspicion for prostate cancer
- Of the 57 patients in whom DRE did raise a red flag, only three had cancer (low-grade)
- A DRE cannot literally reach approximately 18% of tumors located in the prostate
- The cancer detection rate via PSA is four times higher than that of the DRE
Key takeaway
"Our study suggests that the DRE is simply not sensitive enough to detect those early stage cancers,” said one study author. Clearly, the DRE is not doing the job it was hired to do—detecting cancer early. Cutting it from the payroll could eliminate unnecessary testing and lead more men back into the exam room. The authors speculate that DREs may be “one reason why people don’t come to screening visits—the examination probably puts a lot of men off.” It’s certainly why Fletch—we mean, Mr. Babar stopped going.
Rapid-Fire COVID-19 Updates
COVID QUICK HITS
- Effect of higher-dose ivermectin for 6 days vs placebo on time to sustained recovery in outpatients with COVID-19: a randomized clinical trial
- Treating long-COVID brain fog with ME/CFS guidelines
- Outpatient treatment of COVID-19 and the development of long COVID over 10 months: a multi-center, quadruple-blind, parallel group randomized phase 3 trial
Exercise for Severe Depression Passes the Bar
CARDIO CORNER
We don’t typically get our clinical pearls from Legally Blonde, but Elle Woods nailed it: “Exercise gives you endorphins. Endorphins make you happy.” On first blush (or lip gloss), prescribing exercise may seem like an obvious—yet perhaps inadequate—approach to managing symptoms of depression, but impressive new findings remind us how potent exercise can be.
A new study has shown that exercise can be just as effective, if not more so, than standard drugs or psychotherapy for treating severe depression. The systematic review analyzed data from 41 studies involving >2,000 people with depression and found that almost any type of exercise can reduce depression symptoms. Researchers noted particularly beneficial effects in studies involving individuals with major depressive disorder and in studies with supervised exercise interventions. But the real highlight here is the number needed to treat (NNT) at a promising two (lower, even, than the number of Legally Blonde installments).
Key takeaway
The authors conclude that recommending exercise is an evidence-based approach to treating depression; however, you may want to consider the small sample sizes of many trials and high heterogeneity in methods when interpreting the results. Still, we can’t deny our excitement over the exceptionally low NNT for a nonpharmacologic intervention, so we’re celebrating like it’s Harvard Law graduation day.
Continue encouraging patients to engage in physical activity for their mental health and consider promoting supervised and group exercise with moderate intensity and aerobic regimens. Maybe draw the line at suggesting the “bend and snap” as an exercise modality. We object!
Interested in more healthcare news? Here are some other articles we don’t want you to miss:
- Paving the way for the world's first RSV vaccine, FDA advisers recommend two different shots
- Worsening spread of Candida auris in the United States, 2019 to 2021
- MOXIE significantly reduces cardiovascular events in high-risk chronic disease patients
- Drug combo may extend the lives of women with advanced endometrial cancer
- Salt sensitivity of blood pressure in women
- Marathon running does not increase arthritis risk: survey
- Fast-acting nasal spray for migraine snags FDA approval
- Appraisal of the causal effect of plasma caffeine on adiposity, type 2 diabetes, and cardiovascular disease: two sample mendelian randomization study
Morning Report is written by:
- Alissa Scott, Author
- Aylin Madore, MD, MEd, Editor
- Eleni Scott, MD, Editor
- Emily Ruge, Author & Editor
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Please note that the summaries in Morning Report are intended to provide clinicians with a brief overview of an article, and while we do our best to select the most salient points, we ask that you please read the full article linked in each summary for clarification before making any practice-changing decisions.
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