Episode 60 - Variety of Topics

Episode 60: Variety of Topics.  Gabrielle Robinson (MS3) discusses with Dr Arreaza these topics: IsoPSA, 3HP for LTBI, shingles vaccine, and DELC.Introduction: You will hear a conversation between Gabrielle Robinson, a 3rd year medical student, and Hector Arreaza. They discussed 4 articles about topics that are relevant to current clinical practice in family medicine.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.Variety of Topics. By Gabrielle Robinson, MS3, Ross University School of Medicine, and Hector Arreaza, MD.  The IsoPSA testH: Cleveland Clinic published this article in July 2020[1]. G: According to that article, the IsoPSA test is a new clinically relevant screen for prostate cancer. The data suggests that ISoPSA can potentially decrease unnecessary prostate biopsies by 45%. The IsoPSA evaluates changes in the structure of PSA rather than measuring the concentration of PSA.  G: IsoPSA is meant to be used in patients who are over 50 years old with PSA > 4ng/mL that have not had a previous diagnosis for prostate cancer or are under surveillance.H: Is PSA a bad screening test?G: Measuring the concentration of PSA has proven to be a less sensitive screening tool because PSA is specific for tissues and nonspecific for cancer. This means that a high PSA does not necessarily mean cancer is present.  The PSA can be elevated due to a multitude of reasons including but not limited to prostatitis, benign prostatic hyperplasia, etc.  Unfortunately, this has led to the overdiagnosis of low-grade cancers that were in fact benign conditions. However, PSA is an effective tool for monitoring of recurrence of prostate cancer and it reduces the need for treatment of metastatic disease.H: As a reminder, screening for prostate cancer in asymptomatic individuals by using PSA is a grade D recommendation from the USPSTF. D means “Do not do it!” However, IsoPSA is not included in that recommendation. We’ll see if evidence suggests IsoPSA as an alternative in the future.  3HP for latent TB infection treatmentH: This information was published by CDC on June 28, 2018. G: Previously, the treatment for latent TB included 3–9 months of DAILY Isoniazid (INH) or Rifampin (RIF), either alone or combined.  Now, new data according to CDC recommends that INH-RPT (isoniazid-rifaPENtine) treatment once a week for 12 weeks (AKA 3HP regimen) is adequate in controlling the reactivation of latent TB[2].H: RifaPEntine is not Rifampin.G: It is also worth mentioning that this treatment is also approved for patients 2-11 years of age as well as patients who have HIV/AIDS who are currently taking anti-retroviral.H: Currently, the regimens for LTBI treatment are: -Monotherapy with INH for 6-9 months-Monotherapy with Rifampin daily for 4 months-Combinations: INH-Rifampin daily for 3 months (3HR therapy), and INH-RifaPENTINE weekly for 3 months (3HP therapy). Shingles vaccine may reduce risk of strokeG: Why do we think having shingles increases risk of stroke in the first place? The mechanism is not well understood but there is a strong index of suspicion that the inflammation resulting from the outbreak plays a significant role.  H: So, you read a study, a chart review published by the American Heart Association, tell us about it.In this study, patients who received the shingles vaccine (live vaccine) were compared to patient who did NOT receive the vaccine. The results showed that getting the shingles vaccine decreased the risk of stroke by 16%.  The types of strokes that were decreased included hemorrhagic stroke which was decreased by 12% and ischemic stroke that was decreased by 18%.  The age range for which this was most effective is 66 to 79 years of age and is worth mentioning that patients under 80 years of age had a decreased risk in stoke by 20% while the patients over 80 years old were decreased by about 10%[3]. Diagonal Ear Lobe Crease: An Association with CADH: Last week we got this information from Dr Cobos, a Kern Medical hematologist. G: Diagonal Ear Lobe Crease (DELC) also known as Frank’s sign, is a crease in the ear lobe that is associated with increased risk of coronary artery disease, peripheral vascular disease, and cerebrovascular disease. Although the pathophysiology of this sign is not yet understood, there has been a grading system set in place that is linked to the incidence of cardiovascular events based on length, depth, bilateralism, and inclination according to Stanford Medicine. The classifications are as follows:Unilateral incomplete – least severeUnilateral completeBilateral complete – Most severe Other classification (not associated with increased cardiovascular events):Grade 1 – wrinklingGrade 2a – Superficial crease (floor of sulcus visible)Grade 2b – crease greater than 50% across earlobeGrade 3 – deep cleft across whole earlobe (floor of sulcus not visible) H: As a curious fact, Steven Spielberg and Mel Gibson have the DELC.  Conclusion: Now we conclude our episode number 60 “Variety of Topics.” Future Dr Robinson presented a summary of four interesting articles she read. She explained that IsoPSA may be an alternative for screening for prostate cancer in the future, and she reminded us of the weekly treatment of latent tuberculosis infection with INH and rifaPENtine (also known as 3HP treatment for LTBI). There was a decrease in stroke risk in patients who received shingles vaccine, according to a study published by the American Heart Association in 2020, and the Diagonal Ear Lobe Crease sign was mentioned as a possible association with cardiovascular risk. Even without trying, every night you go to bed being a little wiser. Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza and Gabrielle Robinson. Audio edition: Suraj Amrutia. See you next week! ____________________________References:  The IsoPSA Test Is Available, and It Could Change the Diagnostic Paradigm for Prostate Cancer, Consult QD, Cleveland Clinic, Jul 7, 2020, https://consultqd.clevelandclinic.org/the-isopsa-test-is-available-and-it-could-change-the-diagnostic-paradigm-for-prostate-cancer/ CDC Releases Updated Recommendations for Treatment of Latent TB Infection, Centers for Disease Control and Prevention, June 28, 2018, https://www.cdc.gov/nchhstp/newsroom/2018/treatment-of-latent-TB-infection.html Shingles vaccine may also reduce stroke risk, American Heart Association, February 12, 2020, https://newsroom.heart.org/news/shingles-vaccine-may-also-reduce-stroke-risk Frank's Sign - Diagonal earlobe crease (DELC), Stanford Medicine 25, July 2, 2015, https://stanfordmedicine25.stanford.edu/blog/archive/2015/what-is-the-name-of-this-sign.html  Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!