Feb 9, 2018

Risk assessment

The story

If your head hurts every time a test you ordered 3 days ago still hasn't been done, it's probably just the mid-February doldrums. But for patients suffering from migraines, frequent headaches carry long-term risks.  

The background

Migraine prevalence pushes 15% in the general population, and women are disproportionately affected. According to 2016's Global Burden of Disease Study, migraine was the #2 worldwide cause of years lived with disability in 2016, trailing only low back pain. Debilitating headaches are just a start: migraines can be difficult to diagnose, and the disorder is increasingly tied to an elevated risk of stroke and heart disease. 

The study

A nationwide Danish population-based cohort study examined the risk of cardiovascular disease in patients with an acute care diagnosis of migraine. Over 19 years of follow-up, 50,000 migraine patients faced 1.5x the risk of myocardial infarction, 2x the risk of stroke, and an increased risk of blood clots and atrial fibrillation compared to matched controls. Associations were stronger for patients with aura than those without and in women compared to men.

The takeaway

The study is the largest to date linking migraines to cardiovascular disease. A logical next question is whether appropriate migraine treatment can reduce risk.

Say it on rounds

When you forget to sign over your pager before leaving work

We're all familiar with unintended consequences. A multi-regional cross-sectional study of first graders found that the prevalence of fetal alcohol spectrum disorders (FASDs) is much higher than previously estimated. Between 1.1 - 5.0% of 3,000 first-graders under evaluation were found to have features suggestive of FASDs, putting the disorder on par with autism in prevalence. The authors marked their estimate as conservative, since many parents in the study chose not to discuss their drinking habits while pregnant.

When the stock market downturn has your finance friends on edge

In medicine, past performance can actually predict future results. So it's no surprise that long-term follow up from a 50-patient phase I trial of CAR T cell therapy in B-cell acute lymphoblastic leukemia found that patients with low disease burden prior to therapy lived longer and had fewer side effects than patients with a high pretreatment burden of disease. Median survival for treated patients was 13 months, which compares favorably to the 8 months seen with current standard-of-care therapy.

When you were laser-focused at noon conference. Until you started snoring

You could use a boost. In a proof-of-concept study, researchers used direct brain stimulation to improve memory performance in epilepsy patients. Electrodes implanted to block seizures were instead used to stimulate the lateral temporal cortex to help encode memory. When the devices were switched on, participants saw a 15% boost in memory performance without adverse effects or knowledge that the device was in use. The authors are hopeful that the technique can be adapted to a non-invasive approach. 
Nature Commun

Brush up

Transplant immnuosuppression

Like dating during residency, immunosuppression after kidney transplantation can be precarious. The name of the game is to prevent graft rejection while minimizing the risk of infection and post-transplant malignancies. Conventional first-line regimens are a calcineurin inhibitor (usually cyclosporine or tacrolimus) combined with mycophenolate mofetil (MMF) and a prednisone taper. Steroid-sparing regimens withhold the prednisone taper but may increase the risk of graft rejection.

What's the evidence

For tacrolimus as a first-line agent in deceased donor kidney transplant? A 2001 RCT of over 200 patients found that when combined with MMF, treatment with tacrolimus decreased rates of allograft failure compared to cyclosporine. While tacro has grown in popularity over the years, the drug has been linked to an increased risk of diabetes and BK virus nephropathy.

What your tech friends are talking about

We're not quite sure what the point of this is, but Elon Musk just sent a red Tesla into space. Here's a video of the experience. Don't be fooled – the spaceman in the driver seat is a mannequin.

Spread the word

Sharing The Scope won't be the most sexy thing you do this Valentine's Day, but it also won't be the least. Especially if you're working.


We're off next week for President's Day weekend. We'll see you back in your inbox on February 23rd.

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