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Jan 27, 2017

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The story

In residency, patients you thought were all patched up have a nasty habit of coming back. The same holds true for C. diff and recurrent infections. New targeted therapies can help.

Active infection

C. Difficile is on the rise, and the numbers aren't pretty. Estimates from 2011 found 450,000 annual cases in the US contributing to 15,000 deaths, all at a cost to the healthcare system of $40 billion. Recurrence complicates up to 35% of cases, and relapsed infection is harder to treat and more dangerous.

Passive therapy

Patients with high levels of circulating antibodies against C. diff's two toxins, toxin A and toxin B, are less likely to relapse or even suffer infection in the first place. In the 2,600 patient MODIFY trials, researchers looked at whether passive immunity to C. diff through two monoclonal antibodies targeting toxin A and toxin B could prevent infection recurrence. Patients treated with standard-of-care antibiotics and a single infusion of bezlotoxumab, an antibody against toxin B, were 40% less likely to relapse compared to placebo (17% recurrence rate vs. 28%, respectively). Infusion of axtoxumab, which neutralizes toxin A, failed to improve recurrence rates. Combination therapy with both agents was no better than bezlotoxumab monotherapy. Side effects were minimal.
NEJM

The takeaway

The FDA has already approved bezlotoxumab, which could appear in your hospital formulary soon. Like any monoclonal antibody, cost will be a key factor in use and adaptation.

Say it on rounds

When noon conference doubles as naptime

We're pretty confident it's sleep deprivation, but ask your partner if they've noticed a snore. Lab-based polysomnography (PSG) is the gold standard for obstructive sleep apnea (OSA) diagnosis, but home sleep testing (HST) has emerged as a popular and less costly alternative. A randomized, non-inferiority study of 400 patients found that clinicians could still accurately diagnose and treat OSA when presented with stripped-down PSG data designed to mimic HST results. The results could spare many patients PSG sleepovers.
Annals

When you find an unmarked lab sample and can't tell what's inside

All bets are off. A large new study shows the same is true for undiagnosed pleural effusions (UPE), which are often assumed to be secondary to malignancy. An analysis of 782 consecutive patients with UPEs found that almost half were non-malignant. The non-malignant effusions were more dangerous when secondary to cardiac and renal dysfunction, as both groups had one-year mortality rates of almost 50%. 
CHEST

When your patients just aren't listening

Take a cue from viruses and find more clever ways to communicate. In a virology breakthrough, scientists found that viruses communicate with each other through protein-based methods that allow them to estimate the amount of virus in a host. The information can be used to decide whether to replicate and kill or lay dormant. Researchers hope the discovery can lead to novel anti-viral therapies.
Nature

Brush up

Supersize

Two-thirds of the US population is overweight or obese, and the health consequences are devastating. Excess adipose is associated with obstructive sleep apnea, osteoarthritis, reflux disease, non-alcoholic fatty liver disease, coronary artery disease, and diabetes. Your first prescription should be diet and exercise, but pharmacotherapy (see usage guidelines) or bariatric surgery can help when indicated. Moderate weight loss, defined as a 5 - 10% reduction from baseline, can significantly reduce disease risk.

What's the evidence

For bariatric surgery in obese adults with diabetes? A 150-patient RCT from 2012 found that bariatric surgery led to significantly lower hemoglobin A1C levels compared to intensive medical therapy alone.  At 1-year follow-up, 42% of gastric bypass patients had an A1C of < 6%, compared to 12% in the medical therapy group. Improvement was maintained at 3-year follow-up, but long-term data on micro and macrovascular outcomes is needed.

What your infectious disease friends are talking about

Source control. In a heroic and unprecedented move, Canadian surgeons removed the lungs of a cystic fibrosis patient with a certain-to-be-fatal multi-drug resistant pneumonia. After 6 days of ECMO followed by a successful lung transplant, the 32-year-old mother is recovering.

Share with us

We believe an active citizenry is key to the Democratic process, and we couldn’t be more proud of our colleagues who took part in the Women’s March on January 21st on behalf of physicians, scientists, and patients. We want your stories – send your best pics to share@medicinescope.com, and make sure to include your thoughts on how we can use protest to advocate for equality. We’ll post our favorites next week in a special web gallery dedicated to the physician-activist community.

  

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