From Brexit to TRexit: Transperineal biopsies pose a challenge to the traditional transrectal biopsy method

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By now most of us are familiar with Brexit, the UK’s pending divorce with the European Union. But in a play on that term, British doctors are also moving towards an exit they’ve dubbed “TRexit” from the most common sort of prostate biopsy: the transrectal ultrasound guided biopsy, or TRUS.

Men who test positive on the PSA cancer screening test will usually have a prostate biopsy that’s performed in either of two ways. With a TRUS, doctors guided by an ultrasound machine can sample the prostate using a biopsy needle inserted through the rectum. Alternatively, the biopsy needle can be inserted (also under ultrasound guidance) through the perineum, the patch of skin located between the anus and the scrotum. Since it’s traditionally been easier to perform, and less painful for the patient, the TRUS method is preferred globally, accounting for 99% of the estimated one million prostate biopsies performed every year in the United States.

But now, UK doctors want to abandon the TRUS for the transperineal method. Why? In short, because TRUS biopsies have been associated with a growing risk of hard-to-treat infections. According to Michael Gross, a researcher in the department of urology at Weill Cornell Medical College in New York, “up to 25% of all men carry antibiotic-resistant strains of E. coli bacteria at biopsy, and those rates are increasing across the country and across the world.”

During a TRUS procedure, E. coli and other fecal strains can glom onto the biopsy needle and enter the prostate. Up to 5% of TRUS-biopsied men develop sepsis, and many of them require costly hospitalizations. But since transperineal biopsies bypass the rectum and its associated bacteria altogether, the risks of infection are negligible by comparison.

Fewer threats from drug-resistant bacteria

At the 2019 annual meeting of the American Urological Association last May, a British team from Guy’s Hospital, London, reported results from a feasibility study with 678 men who were given a transperineal biopsy (58% of them under local anesthesia) for either suspected or diagnosed prostate cancer. The complication rates were low, and the incidence of sepsis requiring treatment among the men was 0.16%.

Doctors have mostly avoided transperineal biopsies because of the perceived need for general anesthesia, which is expensive and potentially risky for certain patients. Unlike the rectum, which has few nerve endings in regions close to the prostate, the perineum is highly innervated and sensitive to pain. But according to Gross, local nerve blockers can effectively limit pain from the transperineal biopsy, and recent published evidence shows some men actually prefer it to TRUS.

Studies have shown that, when combined with magnetic resonance imaging scans that focus on regions of the prostate that look suspicious for cancer, both sorts of biopsies detect clinically significant tumors with comparable accuracy.

Will doctors here take TRexit’s lead in abandoning TRUS for the transperineal approach? That remains to be seen, and depends on more access to training opportunities. “The doctor’s experience and comfort level with a transperineal biopsy is very important,” says Dr. David Crawford, a urologist at the University of California, San Diego. The American Urological Association gave its first course on transperineal office-based biopsy this year.

Gross and his colleagues say transperineal biopsies performed under local anesthesia in a doctor’s office offer a viable alternative as threats from antibiotic-resistant bacterial strains steadily increase. But in what’s becoming a more widespread practice, doctors who perform TRUS biopsies can also swab the rectum for bacteria days prior to conducting the procedure, and then give antibiotics targeted at the specific species they find. Dr. Jim Hu at Weill Cornell Medical College is currently putting together a multi-institutional study designed to compare infection rates between transperineal biopsies and TRUS biopsies preceded by a rectal swab.

“As with any procedure, the physician performing the biopsy must feel comfortable and familiar with it,” says Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of “Future research is needed compare quality of the biopsies obtained by either approach, as well as their associated complication rates and overall patient satisfaction, before the transperineal biopsies procedure displaces the more traditional TRUS method here.”

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HPV vaccine: A vaccine that works, and one all children should get

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Human papillomavirus, or HPV, is the most common sexually transmitted infection. Most of the time, the body clears it without problems. But when it doesn’t, it can lead to cancer. HPV is the leading cause of cervical cancer, and it can also lead to cancers of the vagina, vulva, penis, anus, and mouth. Every year, there are more than 40,000 cases of cancer caused by HPV.

The HPV vaccine can prevent most of them.

Research shows the HPV vaccine is effective

A study published in the journal Pediatrics underlined just how effective the vaccine is. Researchers studied women ages 13 to 26 between 2006 and 2017, looking at their protection against different strains of HPV. They studied women because initially the vaccine was given only to women, so we have the longest data about its effects in women. What they found was really encouraging. Not only did the vaccine seem to protect against the strains covered by the vaccine, but women who got it were less likely to be infected by other strains, showing that the vaccine has cross-reactivity against other strains of HPV.

What was even more encouraging was that over the 10-year period, even women who didn’t get the vaccine became less likely to be infected with HPV. This is called herd immunity. By making the infection less common, those who are vaccinated help protect other people.

All of this is great news — and yet only about half of US teens are fully vaccinated against HPV. For comparison, 94% of US children have had both doses of MMR when they start kindergarten.

What makes some families hesitate about the HPV vaccine?

For some families, the fact that the vaccine prevents a sexually transmitted infection makes parents squeamish. While it’s understandable that parents of 11- and 12-year-olds (when vaccination usually begins, although it can be given as early as 9) might not think that their child needs to be protected against a sexually transmitted infection, vaccinating early makes sense. The vaccine works best if vaccination is complete well before they start having sex — and being realistic, not only is it hard to predict exactly when that will happen, but once teens get older it’s not always as easy to be sure they go to the doctor and get vaccinated. Doing it early ensures their protection.

And for parents who worry that giving the vaccine could somehow be perceived as permission to have sex, and might make teens more likely to do so, research shows that this doesn’t happen.

Parents also worry about the safety of the HPV vaccine. We have now had many years of experience with the vaccine, with many thousands of doses. The vast majority of side effects are mild, such as fever or muscle pain, and last only a day or two. Some teens feel faint after getting it, which is why it’s recommended that they sit or lie down for about 15 minutes afterward. While unexpected allergic reactions can always occur, lots of very careful research has not shown any serious side effects from the vaccine.

The bottom line

The bottom line: the HPV is a safe, effective vaccine that helps to prevent cancer. Whenever we are given a chance to prevent cancer, we should take it.

Follow me on Twitter@drClaire

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The DASH diet: A great way to eat foods that are healthy AND delicious

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The Dietary Approaches to Stop Hypertension (DASH) diet is an eating plan based on eating plenty of fresh fruits and vegetables, and choosing lean proteins, low-fat dairy, beans, nuts, and vegetable oils, while limiting sweets and foods high in saturated fats.

A recent study published the American Journal of Preventive Medicine found that men and women younger than 75 who most closely followed the DASH diet had a significantly lower risk of heart failure compared to study participants who did not follow the DASH diet. Currently, about 5.7 million adults in the United States have heart failure, and about half of those who develop heart failure die within five years of diagnosis.

The DASH diet and heart health

This latest study adds to established research linking the DASH diet with heart health. For example, the original DASH trial, published in the New England Journal of Medicine in 1997, found that the DASH diet reduced blood pressure in adults with borderline high blood pressure (hypertension). Importantly, the DASH trial represented a broad spectrum of men and women, including racial and ethnic minorities from a variety of socioeconomic levels.

In a second study, researchers added a low-sodium modification to the DASH diet. In this trial, participants following a DASH diet were randomized to receive 3,000, 2,300, or 1,500 milligrams (mg) of sodium per day. The study found that the low-sodium (1,500 mg/day) DASH diet was as effective for lowering blood pressure as a first-line blood pressure-lowering medication. This is significant because, according to the American Heart Association, an estimated 103 million adults in the United States have high blood pressure, defined as a reading of 130/80 mm Hg or greater.

Why does the DASH diet work?

The DASH diet

is low in saturated fat and dietary cholesterol is low in sodium (if following the low-sodium version) is rich in potassium, magnesium, calcium, protein, and fiber emphasizes fruits, vegetables, and low-fat dairy includes whole grains, fish, poultry, and nuts limits red meat, sweets, and sugary beverages.

These components seem to work synergistically to reduce risk factors for heart disease.

Getting started on the DASH diet

If you’d like to try the DASH diet, follow these guidelines, which are based on a 2,000 calorie per day diet.

Food group Daily servings Examples of one serving Whole grains 6–8 1 slice bread; 1/2 cup cooked rice; pasta; 1 ounce dry cereal Vegetables 4–5 1 cup raw, leafy vegetables; 1/2 cup cooked vegetable Fruit 4–5 1 medium apple; 1 cup melon Low-fat/fat-free dairy 2–3 1 cup milk or yogurt; 1 1/2 ounces cheese Lean meat, poultry, fish 6 or less 1 ounce cooked lean meat, fish, poultry; 1 egg Nuts, legumes, seeds 4–5 per week 1/3 cup nuts; 2 tablespoons peanut butter; 1/2 cup cooked legumes Fats and oils 2–3 1 teaspoon healthy oil (olive); 2 tablespoons salad dressing Sweets 5 or less per week 1 tablespoon sugar; 1 cup soda; 1/2 cup sorbet Adapted from the National Heart, Lung, and Blood Institute, National Institutes of Health

Here are some tips for incorporating the DASH diet throughout your day.

Fruits and vegetables

Start loading up on fruits and vegetables with your first meal of the day. Try an egg white omelet, cooked in olive oil. Add spinach, mushrooms, and yellow and orange peppers. Or make a quick smoothie using strawberries, blueberries, greens, and low-fat yogurt or low-fat milk. Assemble a marvelous salad for lunch with fresh salad greens, your favorite fruits and veggies, a healthy protein like beans, tuna, chicken, or tofu, a sprinkling of nuts or seeds, some whole grains like farro or quinoa, and a drizzle of olive oil and lemon. Make a stir-fry for dinner. Start with a healthy oil (olive or peanut), add some garlic, and load up with onions, peppers, baby bok choy, broccoli, mushrooms, asparagus, and any other vegetables you may have. Frozen vegetables are fine too. Make a little space in the wok to cook some chicken, shrimp, or tofu. Don’t forget to add some spices for flavor!

Dairy and whole grains

Try a whole-grain cold cereal with low-fat milk or old-fashioned oats prepared using milk. Use low-fat cottage cheese and add some fresh chives. Serve on a few whole-grain crackers. Make a whole-wheat pasta and add some low-fat feta or goat cheese. Include a few peas and cherry tomatoes. Top with some extra virgin olive oil or a little pesto.

Healthy fats

For a healthy dressing, mix 2/3 cup extra virgin olive oil to 1/3 cup vinegar, add a teaspoon of Dijon mustard, a dash of salt, and some ground pepper. Use olive oil when preparing roasted, stir-fried, or grilled vegetables. Try avocado toast — a slice of whole-grain bread with 1/2 an avocado sliced thin. Squeeze some fresh lemon over, and top with a teaspoon of sesame seeds.

Nuts, legumes, and seeds

Add some nuts to your oatmeal or plain yogurt. Add pumpkin or sunflower seeds to salads. Have a small package of nuts or seeds on hand as a late afternoon snack. Make a vegetarian chili with black or red beans, chopped onions, canned tomatoes, minced garlic, cumin, and chili powder. If you use canned beans, rinse and drain them or buy the low-sodium version.

Fish, poultry, or lean meat

Use lean protein as a part of the meal, not as the focus or the only food on your plate. Add chicken, fish, and occasionally lean meat to soups and salads where vegetables, whole grains, herbs, and nuts can take center stage. Try fish or chicken kabobs on the grill with chunks of red onion, portobello mushrooms, and yellow, red, and green peppers.

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