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Apr 13, 2018

Against the spread

The story

Your friends aren't your patients, but that doesn't stop them from asking you gross medical questions. Here's our best answer for the friend who's worried about unprotected sex after trips to Zika hot spots. 

The worry

Remember Zika? The virus dropped libido across Dallas when the CDC reported the first US case of sexually transmitted infection in February, 2016. The agency has since published their recs on sexual transmission for travelers to and from at-risk areas. For couples trying to get pregnant, the CDC recommends that women use protection for at least 8 weeks after returning home. But Zika can last even longer in semen, leading the agency to recommend 6 months of barrier contraception for male travelers.

The evidence

Zika RNA can be detected in semen for up to 9 months in a small percentage of men, but the virus is rarely infectious. A prospective study of 180 men with confirmed infection found that only 4% of RNA positive semen samples were infectious, and no samples were found to be infectious after 30 days. On the whole, 33% of the study's men were found to have Zika shedding in their semen. Older age and less frequent ejaculation were markers for RNA persistence. 
NEJM

The takeaway

We're not here to advise you on your sex life, but these data suggest that 1 - 2 months of barrier contraception is a good target for returning travelers. Experts think we may have gotten ahead of ourselves with ultra-sensitive RNA tools that are detecting latent rather than active virus. 

Say it on rounds

When Facebook leaked all of your data 

Sorry? But if your sleep apnea patients can learn to trust the cloud again, CPAP manufacturers are getting in on the motivation game. A 130,000 patient study found that patients using active patient engagement (APE) technology – a web-based service in which patients get real-time feedback on therapy compliance and praise when goals are met – reached 87% adherence to nocturnal CPAP goals compared to 70% adherence in the usual care group. On average patients in the APE group used CPAP for an additional hour per night.
Chest

When all that's left at noon conference is chips and salsa

You weren't winning any diet awards anyway. A prospective cohort study of 1,500 patients from the Framingham Heart Study found that healthy eating and weight loss decreased liver fat accumulation and reduced risk for new-onset non-alcoholic fatty liver disease (NAFLD). The patients who most improved their diet over time (i.e. increased vegetables, nuts, legumes, and decreased red meat) saw 80% less liver fat accumulation than those whose diet quality declined. Since NAFLD therapies remain elusive, diet and exercise remain your patients' best bet.
Gastroenterology

When paracentesis fluid is everywhere, including your socks and sneakers

That's traumatic, but things can get way worse. Consider traumatic brain injury (TBI): a population-based observational cohort study from Denmark found that persons with a history of TBI of any severity faced a 25% increased risk of dementia compared to persons with no history of TBI. While the absolute risk of dementia remained low, persons with a single mild TBI (concussion) were 17% more likely to develop incipient dementia. The authors say the results call for better brain protection in contact sports.
Lancet Psychiatry

Brush up

Toxic alcohol ingestion

The toxic alcohols are hard to tell apart. Methanol poisoning is most often from automotive windshield-washer fluid and can affect vision. Ethylene glycol is found in antifreeze and is commonly used in suicide attempts. In stuporous patients, look for an elevated osmolal gap ( > 20 mOsm), anion gap, and lactic acidosis if you're worried about ingestion. All of the alcohols are absorbed rapidly from the digestive tract, so the goal of therapy is to prevent breakdown of the alcohols into their toxic metabolites.

What's the evidence

For fomepizole in toxic ingestion? A strong inhibitor of alcohol dehydrogenase, the drug is FDA-approved for treatment of ethylene glycol and methanol poisoning. A 2013 systematic review found that fomepizole decreased mortality from toxic alcohol ingestion compared to intravenous ethanol, a less potent alcohol dehydrogenase inhibitor. Adverse events were more common with ethanol.

What your Whole Foods friends are talking about

The Environmental Working Group's list of produce with the most pesticide exposure when farmed conventionally, the dirty dozen, may convince you to splurge on organic. Then again, there's always the clean fifteen

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