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Oct 27, 2017

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The story

There are tons of people in the hospital that you'll work with once and then never see again. COPD patients aren't one of them. New research delves into how to cut down on exacerbations.

The background

It used to be that the tough part of your job was tagging shortness of breath as cardiac or pulmonary, but in 2017 that approach feels a bit impersonal. Even though guidelines for COPD have historically targeted all disease subtypes, about 40% of COPD patients fit into an eosinophilic phenotype that is more prone to exacerbations. Mepolizumab – an anti-IL-5 antibody that inactivates eosinophils – reduces exacerbations in patients with severe eosinophilic asthma. Can it help in COPD?

The study

Mepolizumab decreased exacerbation rates by almost 20% relative to placebo in patients with eosinophilic COPD who had recent exacerbations despite maximum standard therapy, says a planned subgroup analysis of the Phase 3 METREX study. The investigators defined eosinophilia as 2% or more eosinophils in the peripheral blood, and higher eosinophil counts were associated with favorable responses to therapy. Despite the reduction in exacerbations, there was no significant difference in symptoms or disease activity questionnaires. A 2-minute video has more. 
NEJM

The takeaway

METREX helps usher COPD into the era of precision medicine. And while many hoped the benefits of mepolizumab would be more substantial, dividing COPD into disease subtypes may be a key approach to novel therapies. 

Say it on rounds

When you spend the day transferring patients to the ICU

If only they weren't sick in the first place. The CANTOS trial found that canakinumab, an antibody against IL-1β that inhibits inflammation, decreased the rate of recurrent cardiovascular events in high-risk patients. The trial's participants were also followed for incident lung cancer, where inflammation is thought to be an important driver of growth and metastasis. In what is considered hypothesis-generating data, lung cancer incidence and mortality were both lower in the canakinumab group. Expect more studies soon. 
Lancet

When you move mountains to get a cardiac MRI

Sometimes fancy tests are worth it. Tabbing prognosis in acute myocarditis is notoriously difficult. A prospective cohort study of 670 patients with suspected myocarditis found that the MRI finding of late gadolinium enhancement in specific regions of the heart was associated with a more than 2-fold higher risk of major adverse cardiovascular events. Normal cardiac MRI (CMR) findings were associated with a low adverse event rate, pointing to CMR as a useful risk stratification tool.
JACC

When something's at the end of the tunnel, but it's not always clear what it is

Light is emerging as a powerful driver for mood, even if it's tough to catch sunshine during winter days on wards. A study of 43 patients with bipolar disorder and moderate depression found that mid-day administration of broad-spectrum bright light induced remission from depression symptoms in 68% of patients vs. 22% with dim red light after 6 weeks of therapy.  All of the patients were on stable doses of anti-manic medications. Larger studies are an obvious next step.
Am J Psychiatry

Brush up

Dengue fever

Before zika, dengue was (and still is) bad news. The disease has been rising in incidence globally and produces symptoms similar to zika and other mosquito-borne viral illnesses. Rash, body aches, and fever are common, and patients often develop a debilitating flu-like illness after an incubation period of 4 - 8 days. Secondary infections can lead to a massive immune response that triggers plasma leakage, bleeding, and hemorrhagic shock.

What's the evidence

For the role of dengue in zika infection? The two flaviviruses are closely related, and zika outbreak hot spots match closely with areas of prior dengue exposure. A theory that antibodies to dengue help the zika virus enter human cells was put to the test in a 2016 study of human plasma. Plasma immune to dengue infection showed substantial cross-reaction to the zika virus, which in turn led to more potent zika infection through a mechanism called antibody-dependent enhancement.

What your med tech friends are talking about

Fetoscopes. The evidence has favored prenatal surgery for spinal bifida since 2011, but a little reminder never hurts. Here's an account of the stakes involved when surgeons operate on the world's tiniest patients while they're still inside the womb.

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