Primecuts – This Week In The Journals

March 2, 2015

By Akansha Chhabra, MD

Peer Reviewed

Blue and black or white and gold? This seems to be the most popular question across social media platforms over the last few days. And what is this all about? A dress. It all started when guitarist Caitlin McNeill posted a picture of this perplexing two-tone dress on her tumblr last week. Not an hour later it stirred up a heated debate among the masses. [1] Neuroscientist Bevil Conway stepped forward to explain the “dress phenomenon.” He reports, “what’s happening here is your visual system is looking at this thing, and you’re trying to discount the chromatic bias of the daylight axis. So people either discount the blue side, in which case they end up seeing white and gold, or discount the gold side, in which case they end up with blue and black.” [2] Nonetheless, many people, including big name celebrities such as Mindy Kaling, Julianne Moore, and James Franco, continue to remain loyal to their respective views. Whether the truth lies behind a conspiracy theory, or a scientific explanation of rods and cones, the world may forever remain divided on this ever so important question.

Now in medical news…

The role of corticosteroids in severe community-acquired pneumonia.

A study published by the Journal of the American Medical Association last week looked at the effect of methylprednisolone on treatment failure in patients with severe community-acquired pneumonia. In this multicenter, randomized, double blind, placebo-controlled trial, 120 patients with severe community acquired pneumonia and a C-reactive protein level of greater than 150mg/L at admission were randomized to receive an intravenous bolus of methylprednisolone or placebo every 12 hours for 5 days. It is important to note that although antimicrobial treatment was similar in both study groups (combination of ceftriaxone with levofloxacin and azithromycin) they were not all completely identical. The primary outcome of the study was divided into early and late treatment failure. Early treatment failure included development of shock, need for invasive mechanical ventilation, or death within 72 hours of treatment whereas late treatment failure included radiographic progression, persistent severe respiratory failure, development of shock, need for invasive mechanical ventilation, or death between 72 and 120 hours after the initiation of treatment. Results of the study revealed that overall there was a 13% treatment failure in the methylprednisolone group compared to 31% in the placebo group (p= 0.02). The methylprednisolone group also had less radiographic progression than the placebo group (2% versus 15%, p =0.007). The two groups did not differ in rate of invasive mechanical ventilation, septic shock, and in-hospital mortality. Although these findings could alter the way in which physicians treat patients with severe community-acquired pneumonia, it is important to take into account the adverse effects of intravenous corticosteroids including hyperglycemia, gastrointestinal bleeding, and risk of infection, which were all reported in this study.

Direct oral anticoagulants in cancer-associated venous thromboembolism.

Although direct oral anticoagulants (DOAs) have been studied extensively in treatment and prevention of venous thromboembolism (VTE) [4], there have been limited trials in the use of DOAs in cancer-associated VTE. Last week, Chest published a meta-analysis illustrating the efficacy of DOAs in patients with VTE and malignancy. [5] The study authors completed a systematic review of several randomized controlled trials that compared DOAs with vitamin K antagonists in cancer patients with VTE. They selected six studies to include in their meta-analysis and looked at VTE recurrence and bleeding events in these patients. There was a 3.9% VTE recurrence rate in cancer patients being treated with a DOA in comparison to a 6% recurrence rate in those being treated with conventional treatment (heparin followed by a vitamin K antagonist), which was not statistically significant (OR 0.63; 95% CI, 0.37-1.10). Major bleeding occurred in 3.2% of the patients treated with DOAs and 4.2% of the patients treated with conventional anticoagulation (OR 0.77, 95% CI 0.41-1.44), which was also noted to be statistically insignificant. This trial shows that direct oral anticoagulants seem to be as effective as vitamin K antagonists in prevention of VTE in cancer patients, along with the same risk of bleeding. In current practice, low molecular weight heparin (LMWH) is the standard of care for VTE treatment in patients with cancer but with the growing use of DOAs, this meta-analysis will hopefully set the path for future research that compares the safety and efficacy of DOAs versus LMWH.

The benefits and costs of supplemental ultrasound screening in women with dense breasts.

Breast cancer screening is a topic that has been long scrutinized in the medical literature with new and changing guidelines every few years. A recent study published by the Annals of Internal Medicine closely examined the costs and benefits of ultrasonography as a supplemental screening method. [6] The study population included women between ages 50 and 74 years undergoing biennial mammography screening- a secondary analysis was performed on a subset of women 40-84 years undergoing annual screening, which will not be discussed here. The subjects were further divided into 3 different screening strategies: those who received mammography alone, those who received mammography plus screening ultrasound after a negative mammogram result for women with extremely dense breast tissue, and mammography plus handheld screening ultrasound after a negative mammogram for women with extremely dense breast tissue. These groups were compared to no screening at all. The outcomes measured included averted breast cancer deaths, quality-adjusted life-years (QALYs) gained, cost, and biopsies recommended after a false positive ultrasound result. The study projected that for women aged 50-74 years with extremely dense breasts who were receiving supplemental ultrasound screening after negative mammography, there would be a gain of 1.7 QALYs per 1000 women with aversion of 0.36 breast cancer deaths. Ultrasonography in these patients also resulted in 354 biopsy recommendations per 1000 women secondary to a false-positive result on ultrasound compared to patients who received biennial mammography screening alone. Cost-effectiveness ratio was calculated to be $325,000 per QALY gained for supplemental ultrasonography relative to digital mammography screening alone. The authors of this study conclude that unless there is a more efficient and more economical way to incorporate supplemental ultrasonography with biennial mammography, the use of ultrasound in breast cancer screening may just not be worth the cost.

A little teaser for other interesting articles from the past week…

A study published in the Journal of the National Cancer Institute found that although women who had given birth had a 33% higher risk of estrogen receptor negative breast cancer and a 37% higher risk of triple-negative breast cancer than those who were nulliparous, these numbers were lower in women who had breastfed than those who had never breastfed. [7]

Lately, it seems that when at a loss, intravenous immunoglobulin (IVIG) use has been on the rise as a last resort of treatment in various diseases. Rheumatology briefs us on the multiple uses of IVIG in rheumatic diseases including Kawasaki’s disease, lupus, and ANCA-associated vasculitis. [8]

For most of us, melatonin is usually used to overcome jetlag or those long stretches of night shifts as a resident, but can it also have anti-malignant, anti-hyperglycemic, and cardioprotective effects? Take a look at this week’s Lancet for a brief correspondence on what may be the new partner to aspirin. [9]

We’ve always been told that exercise is a good thing, but is there such a thing as too much exercise? Circulation last week published a study on how much exercise is exactly needed to reduce vascular disease risk. [10]

Selective serotonin reuptake inhibitors have long been implicated in fracture risk and osteoporosis. Endocrine takes a look at exactly what dose, length of treatment, time of treatment, and sex/age leads to a fracture risk in patients taking SSRIs. [11]

Dr. Akansha Chhabra is a 2nd year medical resident at NYU Langone Medical Center

Peer reviewed by Anish B. Parikh, MD, 3rd year resident, Medicine, NYU Langone Medical Center

Image courtesy of Wikimedia Commons


1. Mahler J. (2015, February 27). A White and Gold (No, Blue and Black!) Dress Melts the Internet. New York Times. Retrieved from

2. Rogers A. (2015, February 26). The Science of Why No One Agrees on the Color of This Dress. Wired. Retrieved from

3. Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response. JAMA. 2015 Feb 17;313(7):677-86.

4. Schulman S, Kearon C, Kakkar AK, et al. RE-COVER Study Group. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361(24):2342-2352.

5. Vedovati MC, Germini F, Agnelli G et al. Direct oral anticoagulants in patients with VTE and cancer. Chest. 2015 Feb; 147 (2): 475-83.

6. Sprague BL, Stout NK, Schechter C, et al. Benefits, harms, and cost-effectiveness of supplemental ultrasonography screening for women with dense breasts. Annals of Internal Medicine. 2015; 162(3): 157-166.

7. Phipps AI, Li CI. Breastfeeding and triple-negative breast cancer: potential implications for racial/ethnic disparities. Journal of the National Cancer Institute. 2014; 106(10): 1-2.

8. Mulhearn B, Bruce IN. Indications for IVIG in rheumatic diseases. Rheumatology. 2015 Mar; 54(3): 383-391.

9. Opie L, Lecour S. Melatonin, the new partner to aspirin? The Lancet. 2015; 385(9970): 774.

10. Armstrong ME, Green J, Reeves GK et al. Frequent physical activity may not reduce vascular disease risk as much as moderate activity: large prospective study of women in the United Kingdom. Circulation. 2015; 131: 721-729.

11. Bruyere O, Reginster J. Ostepoosis in patients taking selective serotonin reuptake inhibitos: a focus on fracture outcome. Endocrine. 2015; 48(1): 65-68.