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Jul 13, 2018

Mix and match

The story

Like the option to phone into rounds when you're running late, an effective HIV vaccine would be a gamechanger. Here's what modern science has brought to the table.

The background

Born alongside the HIV epidemic was an ongoing push for a vaccine. If only the virus would cooperate: HIV's mechanisms of resistance, from genetic diversity across strains to rapid viral mutation, have to date evaded all efforts. The medical community last saw a candidate tested in humans in 2009, when an RCT of 16,000 Thai volunteers found that a recombinant vaccine + booster combo was 31% protective, an effect size considered too low for the drug to be developed for widespread use.

The mosaic

APPROACH tested 7 vaccine + booster combinations in 400 patients in east Africa, South Africa, Thailand, and the United States. The mosaic vaccines hitched a mix of HIV antigens to an adenovirus envelope to trigger a broad immune response. All 7 combos were found to be safe and well-tolerated in the phase 1/2a trial, and 2 met prespecified criteria to advance to a 2,600-patient phase 2b study. The winning, or most immunogenic, vaccine combination in humans produced a 67% rate of protection against the simian HIV virus in rhesus monkeys, who battled 6 intrarectal viral challenges. No one said science was easy.
Lancet

The takeaway

The mosaic will be the 6th HIV vaccine to be evaluated for efficacy in humans. A trial of a second candidate, based off of a modification to the 2009 Thai study, is also underway. Here's hoping these succeed where others have failed.

Say it on rounds

When you wear your heart on your sleeve

Bad for dating, but good for arrhythmias? Atrial fibrillation accounts for one third of strokes, and effective screening could help find undiagnosed disease. A wearable ECG patch designed to screen high-risk patients tripled the rate (6.7% vs. 2.6%) of A-fib detection at 1 year compared to routine care in matched controls. Patches were worn for 2 weeks at a time, 3 months apart. Patch-wearers were more likely to begin anticoagulation than controls, though they also had a higher rate of health care utilization.
JAMA

When the World Cup has you thinking global

Postpartum hemorrhage is the leading cause of mortality for moms worldwide. Yet oxytocin, an effective anti-hemorrhage tool, is unstable at room temperature. Enter carbetocin: the heat-stable analogue was non-inferior to oxytocin in the primary outcome of postpartum hemorrhage > 500mL in a WHO-led RCT involving 10 countries and 29,000 women. Carbetocin may be more effective than oxytocin in low-resource settings where refrigerators are absent, and could simplify supply chains by removing the need for cold storage during transport.
NEJM

When your overnight admission shows up obtunded without records

We don't have to tell you about the risks of interhospital transfers. Small VA centers often do not have access to in-house intensivists, so in some cases the agency provides telemedicine ICU (Tele-ICU) support. A retrospective study of over 500,000 patients in 117 rural acute care facilities found that patients in tele-ICU centers were 20% less likely to be transferred to another facility than matched controls. There were no changes in 30-day mortality. 
Chest

Brush up

Stomach churn

We're betting you're personally familiar with viral gastroenteritis, so you'll be as surprised as we were to learn that up to 50% of viral carriers are asymptomatic. Handwashing and cleanup following suspected cases are critical. Look for acute onset vomiting, watery diarrhea, abdominal cramping, and low-grade fever. Norovirus (all ages) and rotavirus (young children) are the two leading worldwide pathogens. Symptoms usually resolve after 2 - 5 days in the immuncompetent, so focus on supportive care and hydration in this group.

What's the evidence

For rotavirus vaccine efficacy? When the vaccine was introduced in the US in 2006, rotavirus infection caused up to 70,000 hospital admissions and 400,000 clinic visits for young children annually. In the 7 years after vaccine implementation, detected cases of rotavirus fell 60 - 90%. Routine vaccination of infants has been implemented in 95 countries globally as of April 2018.

What your dermatology friends are talking about

The Guinness World Record holder for longest fingernails used a powertool to end 66 years of uninterrupted growth. Gross.

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