Jul 27, 2018

Summer rush

The story

Time wasn't an issue when you were living the high life as a 4th-year med student, but in trauma it's a big deal. New research examines how urgent plasma delivery changes outcomes.

Need for speed

We totally get that it's an emergency when you don't get your coffee within 30 minutes of waking up, but hemorraghic shock is, like, the ultimate: most deaths occur within 2 hours of injury and disproportionately affect young people, meaning tons of lost productivity. Minimizing crystalloids and maximizing resuscitation with RBCs, plasma, and platelets – so-called "damage-control resuscitation" – has improved outcomes once patients arrive on scene at the trauma center. But the clock starts ticking after the initial injury.

Air it out

PAMPer randomized injured patients at risk for hemorrhagic shock (SBP < 90 mm Hg) undergoing air transport to a trauma center to receive standard-of-care resuscitation or 2 units of thawed plasma. Survival curves separated within 3 hours in favor of the plasma group, and plasma recipients saw a 10% drop in 30-day mortality (23% vs. 33%). Plasma patients also had a lower INR, which investigators think signals less coagulopathy from massive blood loss. Transfusion reactions were minimal, and there were no episodes of transfusion-associated lung injury.

The takeaway

With a number needed to treat of 10 and no clear evidence of harm, thawed plasma is a no-brainer. But logistics are challenging: the product has a shelf life of 5 days and is tough to keep available on medical planes. Other options like whole blood (21 day shelf life) and never frozen liquid plasma (26 days) are under exploration.

Say it on rounds

When there are 5 scrub sizes, and none fit you

Pills aren't much different. An individual patient analysis of over 100,000 patients drawn mostly from primary prevention trials found that low-dose aspirin (< 100 mg/day) prevented CV events only in patients with body weight < 70 kg. Heavier patients benefitted from higher aspirin doses (> 300 mg/day). Baby aspirin was almost twice as effective in the lower weight group (23% vs. 12% reduction in CV events) than in the general population. Weight-based dosing also affected the risk of colon cancer and major GI bleeding, and may explain aspirin's superior prevention track record in women compared to men.

When July nights on the liver service are already harrowing enough

Deaths from cirrhosis increased by 65% between the years 1999 - 2016, largely driven by increased rates of alcoholic cirrhosis in adults aged 25 - 34. Annual deaths from hepatocellular carcinoma doubled during the same time period. Though no one can say for sure, many think alcoholism related to unemployment during the Great Recession may be responsible, as death rates across states and many ethnic groups spiked after 2008.   

When your hair was perfect until you put on an N95 mask

There’s a lot of fallout from the BCG vaccine, but not all of it is bad. Eight-year follow-up from a 2012 proof-of-concept study in patients with type 1 diabetes found that the BCG vaccine was associated with sustained reductions in hemoglobin A1c of roughly 10% compared to a placebo and reference group. The study was small (9 vaccinated patients), but the durable drop in A1c when diabetes generally worsens over time has generated buzz for immune modulation as a therapeutic pathway in this disease.
npj Vaccines

Brush up

Numbers game

Rest assured: you're not the only one ordering Lasix. There are over 1 million hospital discharges for heart failure annually at a total cost of over $30 billion. Adults have a lifetime risk of > 20%, and mortality within 5 years of diagnosis approaches 50%. Coronary artery disease, hypertension, obesity, smoking, and diabetes contribute to more than half of all cases. Oh, and if your attending asks as much as ours does, the number of affected adults is around 6.5 million.

Get meta

With hypertension and heart failure. An analysis of 600,000 patients in over 100 studies found a 28% reduction in heart failure incidence and a 13% reduction in all-cause mortality for each 10 mmHg reduction in blood pressure in hypertensive patients. Unsurprisingly, diuretics were superior to other drug classes for heart failure prevention.

What your radiology friends are talking about

The last place you want to see CT scanners is on vacation, but the machines have made an appearance at New York's JFK International Airport. The new tech will scan luggage in 3D, and may soon allow you to leave your laptop in your bag.
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