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May 4, 2018

En masse

The story

We’ve all had that attending who yells about things until they happen, but sometimes a heavy-handed approach works best. Mass eradication programs are gaining ground against malaria. 

The plague

Gripe as you wish about your Malarone copay when you travel abroad, but one-third of the world's population lives in areas at-risk for malaria. In particular distress is the Greater Mekong region of southeast Asia, where treatment efforts, bolstered by a WHO initiative to eliminate disease, are hindered by emerging resistance to the first-line antimalarial artemesinin. It's the kind of cyclical pattern that calls for a break-the-wheel-style fix. 

The intervention

Stopping the spread of malaria hinges on early treatment of disease and eliminating high-prevalence reservoirs. A Gates Foundation-funded initiative in remote malaria hotspots (prevalence > 40%) in Myanmar tackled both issues. Health workers were dispatched to early diagnosis posts where ultrasensitive PCR-based testing was used to identify infection. Villages were also given monthly mass administration of antimalarials. The early treatment posts decreased malaria incidence by roughly 20% in an observational study, while mass drug administration decreased incidence by 80%. 
Lancet

The takeaway

Some argue that mass drug administration is expensive and leaves room for malaria to return in the future. But the study's supporters say that rapidly decreasing disease burden unloads health-workers, freeing them to cast a broader net and reach more patients.

Say it on rounds

When your med school laptop finally runs out of steam

Time for an upgrade. You know alteplase as the bread-and-butter TPA you give during acute stroke, but the newer tenecteplase is a genetically-modified cousin designed to better open blocked arteries. In a phase 2 study of 200 patients with ischemic stroke eligible for thrombectomy, infusion of tenecteplase doubled the rate of vascular reperfusion compared to alteplase (22% vs. 10%) and improved 90-day functional outcomes. There were no differences in rates of intracerebral hemorrhage.
NEJM

When you spot a little gray in your colleague's beard

The more the better. An observational study of elderly Medicare beneficiaries undergoing major surgery found that older surgeons produced lower operative mortality than their younger counterparts. The effect size was small – 6.6% for surgeons younger than 40 vs. 6.3% for surgeons older than 60 – but was consistent across all age ranges studied. No operative mortality difference was seen between gender, though female surgeons in their 50s were the top performing group according to study metrics.
BMJ

When your college friends might have been on to something

Give credit where it's due. There are few effective treatment options for post-traumatic stress disorder (PTSD), but a look at MDMA (ecstasy or 'Molly') combined with psychotherapy for 26 patients with PTSD found that the drug improved disease severity scores at one-year follow-up. Some patients no longer met diagnostic criteria for PTSD at the study's end. Per supporters, MDMA evokes trust and feelings of well-being, which allows survivors to examine traumatic memories during therapy. The FDA has given the drug breakthrough therapy status and approval could come soon.
Lancet Psychiatry

Brush up

Chronic Hep B

Like your off-service rotating intern, hepatitis B may not get much attention but can cause a lot of trouble if ignored. The infection is uncommon in the United States, but prevalence in parts of East Asia and sub-saharan Africa reaches > 8%. Screen patients from high-risk countries as well as people who are pregnant or work in healthcare to prevent long-term complications. HBV-positive patients need frequent monitoring to check for worsening liver function and progression to cirrhosis.

What's the evidence

For newer antiviral agents in chronic Hep B? The decision to treat depends on the presence of cirrhosis, LFTs, and HBV viral load. First-line regimens include the nucleoside / nucleotide analogues entecavir and tenofovir because of high efficacy and low rates of resistance. Tenofovir's approval is based in part on a 2008 RCT that found that tenofovir disoproxil fumarate increased rates of HBV DNA suppression compared to older drug adefovir in patients with chronic Hep B. 

What your baseball friends are talking about

Doctors are known to beat themselves up over small things, but Houston Astros closer Ken Giles punched himself in the face after giving up a home run to Yankees catcher Gary Sanchez. Coming to an ER near you?

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