Oct 26, 2018

Shot selection

The story

Like lugging the defibrillator up 10 flights to an arrest, treating latent tuberculosis (TB) with months of antibiotics makes you think there has to be a better way. A new vaccine shows promise.   

The background

Your top worldwide infectious disease killer isn’t HIV or malaria, it’s TB. Many cite the massive latent viral reservoir  – a quarter of the world’s population is infected – as the reason why disease incidence has barely budged despite progress in diagnosis and treatment. The right vaccine could help, though the use of old-standby BCG is controversial in the non-infected and the vaccine doesn’t offer substantive protection against activation of latent disease. 

A new result

A phase 2b trial of the M72/AS01E vaccine found a 54% protection rate against progression to active pulmonary disease in patients with confirmed latent TB in Kenya, Zambia, and South Africa. The vaccine combines two TB antigens with an adjuvant system that revs up the immune system to bolster response. Across 3,500 HIV-negative adults aged 18 - 50, 10 patients who received the vaccine converted to active disease vs. 22 who received placebo during mean follow-up of 2.3 years. Protective rates were higher in younger patients (age < 25), a group that experts view as key to stopping the global epidemic. 

The takeaway

For all its size and complexity, the trial mostly establishes proof of principle given the low event rates in both groups. Alongside longer follow-up, cost and durability of response will be important metrics to keep an eye on.

Say it on rounds

When your med student follows you to the bathroom

Setting boundaries can be a headache. Antibodies targeting CGRP have improved symptoms for patients with chronic migraine, though patients who failed multiple lines of treatment were largely excluded from previous trials. A 250-patient phase 3 RCT found that the anti-CRGP antibody erenumab improved symptoms in heavily pretreated patients with episodic migraine. Thirty percent of patients in the erenumab group achieved the primary outcome – a reduction of 50% or greater in the baseline number of monthly migraine days – compared with 14% who received sham therapy.

When 1 overnight intern covers 40 liver patients

It’s probably safe. And so is transcatheter aortic valve replacement (TAVR) in patients at low-risk for surgical mortality. The Low Risk TAVR trial prospectively compared TAVR in 200 patients to a retrospective cohort of matched controls. At 30 days, there was zero all-cause mortality in the TAVR group compared to 1.7% mortality in controls, though the authors caution that some surgical patients underwent additional procedures like CABG at the time of valve repair. Overall, the 30-day findings offer a reassuring safety signal while we wait for data from larger RCTs.  

When there’s no produce in the overnight vending machine

If you need another excuse to swing by the farmer's market, know that a prospective cohort of 70,000 French volunteers found that those who self-reported the highest intake of organic foods had a 25% lower risk of incident cancer diagnosis compared to those with the lowest intake over a follow-up period of 5 years. Overall cancer incidence was low. Another recent study from the same cohort found a lower level of urinary pesticides after organic food interventions.
JAMA Int Med

Brush up

Medical marijuana in chronic pain

You can make a strong case for or against medical marijuana for chronic pain. Beyond effects like moderate analgesia, reduced allodynia, and muscle relaxation, supporters point to a role for cannabis in stress reduction and mood control. Detractors point to a so-so efficacy record in the literature and side effects like sedation, dysphoria, appetite stimulation, and short-term memory loss that can interfere or disrupt established treatments like psychological therapies and rehab.

Get meta

With marijuana use in symptom control. An analysis of 79 trials found low-quality evidence that marijuana reduced nausea and vomiting following chemotherapy and moderate-quality evidence that marijuana reduced pain symptoms in chronic pain compared to placebo. The analysis also tied marijuana to a reduction in spasticity. Somnolence, euphoria, loss of balance, and hallucinations were among commonly reported adverse events.

What your urgent care friends are talking about

Flu season started early in 2018, but new drugs should be available soon. The FDA approved the first new drug for flu in nearly 20 years this week. Baloxavir (trade name Xofluza) is expected to have efficacy against drug-resistant strains.


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  1. Average savings calculated based on single loans of DO and MD degree holders refinanced from 9/2013 to 12/2017 where borrowers’ previous rates were disclosed. Assumes same loan terms for previous and refinanced loans, and payments made to maturity with no prepayments. Actual savings for individual loans vary based on loan balance, interest rates, and other factors.
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