Garden of the Generalife in Granada

In his article in the Art at JAMA Cole presents the work of Théo van Rysselberghe who was born in Ghent and studied at the city’s Royal Academy of Fine Arts.  Van Rysselberghe was a frequent visitor to Spain and North Africa, and the Mediterranean region at large. In the course of his career as an artist, he was influenced by Paul Signac, Georges Seurat, and Henri de Toulouse-Lautrec among others.  In his painting of the Garden of the Generalife in Granada, he demonstrates how visual perception changes when an observer moves from the shade into bright sunlight.  The color and symmetry of the garden draw one’s attention, but on a hot summer day, lingering in the shade is so enjoyable as all people who live in hot climates know.

The estates and gardens at Generalife were built in the 14^th century and it was a favorite retreat of the Emirs of the Alhambra who stayed there when they in need of quiet time to reflect on state and personal issues. Its arcades enclosed formal gardens with fountains and reflecting pools, and the songs of birds such as nightingales were heard in its shady alcoves.

According to legend, a prince was raised in the comfort and seclusion of the Generalife to prevent him from falling in love until he reached a suitable age.  One day he rescued a dove from a hawk, and in return the dove told him of a princess in a secret garden surrounded by high walls. Soon the prince was off to find her, the implication being that a life of ease and beauty is no substitute for love.

JAMA. 2015;314(1):10-11

Courtesy of the Fine Arts Museums of San Francisco (https://www.famsf.org/), San Francisco, California; gift of B. Gerald Cantor, 1969

No need to print mammograms on films; FDA

An FDA communiqué to mammography facilities “said that printing breast images to hard-copy film is no longer necessary and can be performed at the discretion of individual centers”. 

Over the past 20 years, there has been significant evolution in mammography, with the shift from screen-film to digital imaging being the most prominent change.

A total of 39 million procedures were performed in the 8,737 mammographic facilities that were accredited by the FDA as of Nov 1, 2015.   Today fewer than 350 screen-film units remain in use in the U.S. The nearly universal availability of computers for viewing of digital images diminishes the need for a facility to maintain a printer.

Today, with many mammograms shared on computer media such as compact discs or via online access, the provision of printed hard copies is becoming obsolete.

Computer-Aided Detection did not improve Digital Screening Mammography's Diagnostic Accuracy

Lehman et al in a paper published by JAMAInternal Medicine report on their findings that suggest that computer-assisted detection (CAD) used in most mammograms added no benefit to breast cancer screening while it substantially increased costs.

The authors compared the accuracy of digital screening mammography interpreted with (n = 495 818) versus without (n = 129 807) CAD from 2003 through 2009 in 323 973 women.  271 radiologists in 66 facilities interpreted the mammographic studies.  They found 3159 breast cancers within 1 year of the screening.

Screening performance was not improved with CAD on any metric assessed. Mammography sensitivity was 85.3% with and 87.3% without CAD. Specificity was 91.6% with and 91.4% without CAD. There was no difference in cancer detection rate (4.1 in 1000 women screened with and without CAD). Computer-aided detection did not improve intra-radiologist performance. Sensitivity was significantly lower for mammograms interpreted with versus without CAD in the subset of radiologists who interpreted both with and without CAD.

The authors concluded CAD does not improve diagnostic accuracy of mammography. These results suggest that while insurers pay an additional $400 million a year for CAD, its addition to standard mammography had no beneficial impact to women.

American Cancer Society Updated Guidelines for Breast Cancer Screening

Breast cancer is a leading cause of premature mortality among US women.   Oeffinger at al report in JAMA the American Cancer Society (ACS) 2015 update regarding the frequency of screening mammography in women at average risk. 

The ACS recommends that women with an average risk of breast cancer should undergo annual screening mammography starting at age 45 years (strong recommendation).

Women 55 years and older should transition to biennial screening (strong recommendation).

Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation).

Women should have the opportunity to have annual screening between at the ages of 40-45 received a qualified recommendation.

The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).

These updated ACS guidelines provide evidence-based recommendations for breast cancer screening for women at average risk of breast cancer.   

Complications of Central Venous Catheterization by Insertion Site

Parienti et al report in NEJM the finds of a trial regarding complications from central venous catheters depending on the insertion site. 

In this multicenter trial, they randomly assigned non-tunneled central venous catheterization in patients in the intensive care unit to the subclavian, jugular, or femoral veins.

The primary outcome measure was catheter-related bloodstream infection and symptomatic deep-vein thrombosis.

A total of 3471 catheters were inserted in 3027 patients. In the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02). In pairwise comparisons, the risk of the primary outcome was significantly higher in the femoral group than in the subclavian group and in the jugular group than in the subclavian group, whereas the risk in the femoral group was similar to that in the jugular group. In the three-choice comparison, pneumothorax requiring chest-tube insertion occurred in 13 (1.5%) of the subclavian-vein insertions and 4 (0.5%) of the jugular-vein insertions.

The authors concluded that subclavian vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular vein or femoral vein catheterization.

N Engl J Med 2015; 373:1220-1229

Carotid Occlusion May Not Be Associated With High Risk For Stroke

Yang et al published on JAMA Neurology their retrospective analysis of patients who presented at two atherosclerosis clinics in Ontario with asymptomatic carotid artery stenoses that were followed for 20-years with carotid duplex scans.

Among the 3681 patients who had annual carotid ultrasound examinations, 316 (8.6%) were asymptomatic before an occlusion that occurred during observation period.

Of the new occlusions, 254 of 316 [80.4%] occurred before 2002, when medical therapy was less intensive; the frequency decreased by quartile of years (P < .001, χ2 test). Only 1 patient (0.3%) had a stroke at the time of the occlusion, and only 3 patients (0.9%) had an ipsilateral stroke during follow-up (all before 2005).

In Kaplan-Meier survival analyses, neither severity of stenosis nor contralateral occlusion predicted the risk of ipsilateral stroke or transient ischemic attack, death from stroke, or death from unknown cause at a mean follow-up of 2.56 years. In Cox proportional hazards regression analyses, only age (P = .02), sex (P = .01), and carotid plaque burden (P = .006) significantly predicted risk of those events.

The authors concluded that the risk of progression to carotid occlusion is well below the risk of carotid stenting or endarterectomy and has decreased markedly with more intensive medical therapy. Preventing carotid occlusion is not  a valid indication for intervention to prevent occlusion as the circle of Willis offers substantial protection.

JAMA Neurol. 2015.1843