Extending Screening in “Elderly” Patients: Should We Consider a Selective Approach?

BackgroundBreast cancer screening has been shown to reduce breast cancer-associated mortality. However, screening is limited to the targeted age group of 45 to 69 years in New Zealand despite the recognized increased risk with age. This study aims to compare the outcomes of women aged over 70 years with screen-detected and clinically detected cancers.Patients and MethodsA retrospective review was performed of prospectively collected data from June 2000 to May 2013 by the Auckland Breast Cancer Register. Demographic and tumor characteristics of women with invasive cancer and ductal carcinoma in situ diagnosis aged 70 years and over were compared between those screened and clinically detected. Five-year disease-free and overall survival outcomes were reviewed.ResultsA total of 2128 women aged 70 years and over were diagnosed with breast cancer (median, 77 years; interquartile range [IQR], 74-84 years). Of these, 416 (19.5%) were diagnosed through mammography screening, with a median age of 74 years (IQR, 71-77 years) compared with 79 years (IQR, 74-85 years) for those with clinical detected cancer diagnosis. Screen-detected cancers accounted for a significantly higher proportion of diagnoses in those aged 70 to 74 years compared with older patients (P < .001). Screen-detected cancers were of lower T and N stages. Disease-specific survival was significantly longer in screen-detected cancers versus other cancers (5-year survival, 93.7% vs. 81.9%; P < .001), as was overall survival (5-year survival, 84.7% vs. 57.4%; P < .001).ConclusionScreening in those aged 70 years and over continues to identify breast cancer at early stages and with improved survival. Although aware of the potential for lead-time bias and the healthy volunteer effect, there should still be consideration to extend breast cancer screening to patients aged to up 74 years after appropriate assessment of comorbidities and functional status.     

Management and prevention of imported malaria in children. Update of the French guidelines

Since the 2007 French guidelines on imported Falciparum malaria, the epidemiology, treatment, and prevention of malaria have changed considerably requiring guidelines for all Plasmodium species to be updated. Over the past decade, the incidence of imported malaria has decreased in all age groups, reflecting the decrease in the incidence of malaria in endemic areas. The rates of severe pediatric cases have increased as in adults, but fatalities are rare. The parasitological diagnosis requires a thick blood smear (or a rapid immunochromatographic test) and a thin blood film. Alternatively, a rapid antigen detection test can be paired with a thin blood film. Thrombocytopenia in children presenting with fever is highly predictive of malaria following travel to a malaria-endemic area and, when detected, malaria should be strongly considered. The first-line treatment of uncomplicated P. falciparum malaria is now an artemisinin-based combination therapy (ACT), either artemether-lumefantrine or artenimol-piperaquine, as recommended by the World Health Organization in endemic areas. Uncomplicated presentations of non-falciparum malaria should be treated either with chloroquine or ACT. The first-line treatment of severe malaria is now intravenous artesunate which is more effective than quinine in endemic areas. Quinine is restricted to cases where artesunate is contraindicated or unavailable. Prevention of malaria in pediatric travelers consists of nocturnal personal protection against mosquitoes (especially insecticide-treated nets) combined with chemoprophylaxis according to the risk level.     

An Internally Validated Nomogram for Predicting the Likelihood of Improvement of Clinical Global Impression in Patients With Lifelong Premature Ejaculation Treated With Dapoxetine

BackgroundAlthough the introduction of dapoxetine has ushered in a new era in the treatment of premature ejaculation, many patients with lifelong premature ejaculation (LPE) exhibit an unimproved clinical global impression even after treatment with dapoxetine.AimTo investigate independent predictors of the improvement of Clinical Global Impression (iCGI) in patients with LPE treated with dapoxetine and develop a nomogram to predict a patient's likelihood of achieving iCGI.MethodsData of 243 patients with LPE diagnosed at Xijing Hospital (Xi'an, China) and Northwest Women's and Children's Hospital (Xi'an, China) from January 2019 to May 2020 were analyzed. Independent predictors of iCGI were identified, and a nomogram was developed using R software based on a multivariate logistic regression model. The predictive accuracy of the nomogram was measured using the area under the receiver operating characteristic curve. The nomogram was calibrated by comparing predictions with observations.Main Outcome MeasuresThe primary outcome was the patient-rated Clinical Global Impression of Change scale score after a 4-week course of dapoxetine treatment, which was collected via an online questionnaire. A Clinical Global Impression of Change score of ≥1 was defined as iCGI in this study.ResultsPatients with LPE with at least a bachelor's degree, a self-reported intravaginal ejaculation latency time of >1 minute, and an International Index of Erectile Function question 5 score of ≥3 were independent factors associated with achieving iCGI, whereas a Premature Ejaculation Diagnostic Tool question 1 score of ≥2 was an independent factor negatively associated with achieving iCGI. The predictive accuracy of the nomogram, which was developed by integrating all variables with independent predictive significance, was 0.710 (95% confidence interval: 0.702–0.718). In addition, the calibration plot demonstrated excellent agreement between predictions and observations.Clinical ImplicationsIf the predictive performance of our nomogram is further proven in multiple external validations, it can be used to select suitable patients for dapoxetine treatment, thereby reducing the number of patients discontinuing treatment.Strengths & LimitationsThis study developed the first nomogram for predicting the likelihood of achieving iCGI in patients with LPE treated with dapoxetine. However, our nomogram was not externally validated using independent cohorts from other institutions.ConclusionThis study identified several independent predictors of iCGI in patients with LPE treated with dapoxetine. An effective nomogram was developed to predict their likelihood of achieving iCGI. External validations using data of Western patients with LPE are required to test the broader applicability of this Chinese patient-based tool.Hou G, Gao M, Zhang L, et al. An Internally Validated Nomogram for Predicting the Likelihood of Improvement of Clinical Global Impression in Patients With Lifelong Premature Ejaculation Treated With Dapoxetine. J Sex Med 2020;17:2341–2350.     

新型冠状病毒(COVID-19)感染性肺炎现代中医诊疗建议方案与探讨

自2019年12月以来,以我国湖北武汉地区为中心,以人群集散辐射传播为特点,全国各地病例陆续出现增加。疫情发源地罹患患者早期以身热不扬、干咳气促、身楚乏力为主要症状,以脉濡缓、舌苔厚腻、胸部X线检查显示炎性反应性改变为特征的新型冠状病毒(COVID-19)感染性肺炎为主的新型传染病。疫情传入地的患者早期症状由于地域的不同,有所差异。各地传统中医、现代医学先后集体或个人出台了相关诊疗方法和建议方案。作为现代中医,按照习近平主席:“遵循中医发展规律,传承精华,守正创新”和“中西并重”的指示精神。为规范这一新型传染病“瘟疫”的认知和诊疗,综合相关资料,根据疫情演变规律,结合个人经验与体会,特此探讨COVID-19感染性肺炎的诊疗建议方案。     

Guía de práctica clínica 2021 para la detección temprana,el diagnóstico,el tratamiento y el seguimiento de los pacientes con espondiloartritis axial. Asociación Colombiana de Reumatología

BackgroundAxial spondyloarthritis is a rheumatic condition affecting young patients with social and occupational consequences. Diagnosis delay is associated with functional impairment and impact on quality of life, requiring a multidisciplinary approach.ObjectiveTo develop a set of recommendations based on the best available evidence for the early detection, diagnosis, treatment, and monitoring of adult patients with axial spondyloarthritis.MethodsA working group was established, questions were developed, outcomes were graded, and a systematic search for evidence was conducted. A multidisciplinary panel of members was established (including patient representatives), minimizing bias in relation to conflicts of interest. The GRADE approach Grading of Recommendations Assessment, Development and Evaluation was used to assess the quality of the evidence as well as the direction and strength of recommendations. In total, 11 recommendations on diagnosis (n=2), pharmacological treatment (n=6), non-pharmacological treatment (n=2) and monitoring (n=1) are presented.ResultsSacroiliac joint radiography as the first diagnostic method, and the use of disease activity scales for patient monitoring (ASDAS or BASDAI), are recommended. Nonsteroidal anti-inflammatory drugs are the first treatment option; in case of intolerance or residual pain, acetaminophen or opioids are recommended. In patients with axial involvement, it is recommended not to use conventional disease-modifying antirheumatic drugs or systemic or local glucocorticoids. In patients with failure to non-steroidal anti-inflammatory drugs, anti-TNF or anti-IL17A is recommended. In those patients presenting with anti-TNF failure, starting an anti-IL17A is recommended. Exercise, physical and occupational therapy are recommended as part of treatment. It is recommended not to use unconventional therapies as the only treatment option.ConclusionsThis set of recommendations provides an updated guideline for the diagnosis, treatment, and monitoring of patients with axial spondyloarthritis.     

小儿宝泰康颗粒治疗小儿急性上呼吸道感染的临床研究

目的:研究观察小儿宝泰康颗粒治疗小儿急性上呼吸道感染的临床疗效及安全性评价。方法:选取2018年1月至2019年1月山东省立医院儿科门诊收治的急性上呼吸道感染患儿86例作为研究对象,按照就诊先后顺序编号分为对照组和观察组,每组43例。对照组给予小儿豉翘清热颗粒治疗,观察组给予小儿宝泰康颗粒治疗。对2组患儿的临床疗效、症状消退时间、血清炎性反应因子水平、不良反应发生率等进行统计比较。结果:治疗后观察组总有效率高于对照组,差异有统计学意义(P<0.05),且观察组痊愈率高于对照组,差异有统计学意义(P<0.05),显效率低于对照组,差异有统计学意义(P<0.05);有效率2组较为相近,差异无统计学意义(P>0.05),无效率低于对照组,差异有统计学意义(P<0.05)。治疗后观察组发热、咳嗽、鼻塞流涕、咽喉肿痛、脘腹胀满、食欲不振等症状消退时间均短于对照组,组间比较,差异有统计学意义(P<0.05)。治疗后2组患儿的血清白细胞介素-6(IL-6)、血清白细胞介素-18(IL-18)、肿瘤坏死因子-α(TNF-α)、C反应蛋白(CRP)水平均有显著降低,差异有统计学意义(P<0.05),且观察组各项指标水平均低于对照组,差异有统计学意义(P<0.05)。对照组发生水样便腹泻2例,腹痛1例,观察组未出现不良反应,组间比较,差异无统计学意义(P>0.05)。结论:小儿宝泰康颗粒治疗小儿急性上呼吸道感染的临床疗效显著,能够缩短患儿的症状消退时间,降低患儿自身的炎性反应水平,治疗安全性良好,值得临床推荐。     

颅内深静脉血栓形成的临床诊治

目的　探讨颅内深静脉血栓形成（deep cerebral venous thrombosis，DCVT）的临床诊断与治疗策略。 方法　回顾性分析10年来影像学诊断为DCVT的5例患者的临床表现、影像学特征、治疗及预后情况。 结果　DCVT最常累及Rosenthal基底静脉、大脑内静脉、Galen静脉和直窦，其临床表现不典型，常见有头痛、意识障碍、复视、偏瘫等，常见诱发因素有口服避孕药、产褥期、妊娠期等。丘脑水肿为DCVT患者最常见的影像学征象。肝素抗凝治疗简单有效，大脑深静脉可恢复再通，临床症状缓解。 结论　DCVT患者临床症状缺乏特异性，早期诊断困难，特殊成像技术和特定影像学特征有助于其明确诊断，及时正确的抗凝治疗可获得良好的预后。