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Feb 10, 2017

Pumps and pipes

The story

You may worry from time to time that residency is turning your heart into frosted metal. And while we’d normally tell you to get more sleep and plan a tropical vacation, new research suggests there are worse ways to pump blood.

The background

Advanced heart failure is on the rise, and the number or organs available for transplant can’t keep up. Almost a third of patients designated for transplant will use a ventricular assist device (VAD) for over 2 years, and almost half of patients listed for transplant will be taken off the list before a new heart comes their way. 

The implant

Despite debuting in the 1960s, VADs remain a work in progress. The devices improve survival and quality of life in patients with advanced heart failure, but benefits are tempered by an increased risk of infection, bleeding, stroke, and pump thrombosis. Engineers are continually trying to minimize pump thrombosis with VAD designs that reduce device friction, and a new VAD, the HeartMate 3, uses magnetic force to allow rotor parts to essentially float while pumping blood.

The study

MOMENTUM 3 looked at device implantation either as a bridge to transplant or as destination therapy in 300 patients with advanced heart failure. Patients who received the HeartMate 3 had superior 6-month stroke-free survival compared to patients who received the standard-of-care HeartMate II (86% vs. 77%). And while 10% of patients in the HeartMate II group had suspected or confirmed pump thrombosis, no patients experienced this complication in the HeartMate 3 group. Functional status and quality of life were similar between the two groups, as were rates of bleeding. 
NEJM

The takeaway

Pack your bags for destination VAD. Experts in the field say the new developments are a step in the right direction, but we’re still in the early stages of a long innovation game.

Say it on rounds

When it's Valentine's Day, and the air is thick with romance

Better than cigarette smoke. A cross-sectional study of about 180 active and former smokers measured levels of smoking-related carcinogens in long-term users of standard cigarettes, e-cigarettes, and nicotine replacement therapy (NRT). While nicotine levels in all subjects were similar, levels of known tobacco-related toxins and carcinogens were significantly lower in the e-cigarette and NRT groups.
Annals

When you stumble into a dark call room, only to find it's already occupied

Just because you can't see something doesn't mean it's not there. Standard-of-care calls for 24-hour monitoring for atrial fibrillation after ischemic stroke, but some wonder if that's enough time to find an arrhythmia. A 400-patient RCT found an absolute increase in a fib detection (14% vs. 5%) in post-stroke patients who underwent prolonged Holter monitoring (30 days divided among 3 periods) relative to those who received 24-hour monitoring. Given a number needed to screen of 11, many are hopeful that enhanced monitoring will reduce recurrent stroke rates in future studies.
Lancet Neurol

When a snowstorm shuts the subway

It's okay to miss pre-rounds every once in a while. But you can't miss giant cell arteritis (GCA) in a patient with headaches. A prospective study of 140 patients found that normal findings on an MRI protocol designed to evaluate scalp arteries correlated strongly with negative temporal artery biopsies. MRI had a sensitivity of 93% and a negative predictive value of 98% when temporal artery biopsy was used as a reference test. The authors suggest that MRI can be used as a first step in GCA diagnosis, with temporal artery biopsy reserved for patients with abnormal MRI findings.
Arthritis Rheumatol

Brush up

Myasthenia gravis

Try not to be spooked if your eyelids droop at the end of every shift. Because while you’re just tired, patients with myasthenia gravis (MG) with disease confined to ocular activity for over 2 years have an excellent prognosis. Look for diplopia and ptosis as key symptoms in the clinical history. Diagnose with a combo of clinical history and a positive test for disease-related autoantibodies. Pyridostigmine, an acteylcholinesterase inhibitor, is the preferred drug for symptom management. Patients who fail are given prednisone and azathioprine as first-line immunosuppressive treatment.

What's the evidence

For thymectomy in MG? Thymectomy has long been the standard of care for the 10% of patients with thymoma in MG, but was only recently confirmed as effective in an RCT. A trial of 126 patients with early-onset or late-onset myasthenia gravis confirmed that early thymectomy reduced symptoms in young patients with recent onset generalized disease refractory to acetylcholinesterase inhibitors. Patients also experienced fewer immunosuppressive drug treatments and exacerbations during 3 years of observation.

Monkey business

A non-surgical, reversible form of male birth control to replace vasectomy strikes this team of writers as a golden opportunity. But the project has drawn little interest from pharma companies, leaving a non-profit to push the idea to market. Now, an injectable male contraceptive gel has passed the monkey test.

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