Jan 18, 2019

Start over

The story

Like restarting your laptop when it's acting weird, rebooting the immune system can work wonders in auto-immune disease. Here's a look at stem cell transplant in MS.

The background

Relapsing-remitting multiple sclerosis (RRMS) is a tale of the immune system gone haywire: recurrent attacks to the central nervous system build up over time to cause cumulative disability. But while conventional approaches like disease-modifying therapy (DMT) aim to tone down the immune system, autologous stem cell transplant (auto-HSCT) offers a total reset. During transplant, immune stem cells are removed from the patient before chemotherapy wipes out what's left. The stem cells are then reintroduced into a non-inflammatory environment without co-stimulating signals, promoting tolerance.

The study

Auto-HSCT improved disability scores and reduced relapses compared to DMT in a trial of 110 RRMS patients with highly active disease. At 1 year, disease progression occurred in 3 transplant patients and 34 DMT patients, and the wide between-group differential held through preliminary 5-year results. The authors note that the study, launched in 2005, did not include modern DMT agents, though it is unlikely that newer meds would elevate DMT outcomes to be on par with auto-HSCT.

The takeaway

Auto-transplant is fraught with complications – upfront hazards include cost, chemotherapy toxicity, and the need for transplant-specific expertise – but on the whole this treatment offers tremendous promise for young patients with aggressive disease.

Say it on rounds

When you snooze your alarm for the sixth time

Those extra REM cycles count. In the largest effort of its kind, analysis from the 4,000 patient PESA study linked poor sleep to subclinical atherosclerosis. Objective sleep data from activity monitors found that patients who slept fewer than 6 hours nightly were 27% more likely to have atherosclerosis on 3D ultrasound than those who slept 7 - 8 hours, and those with highly fragmented sleep were 34% more likely to have atherosclerosis than sound sleepers. No differences were seen between groups on CT coronary calcium scoring.

When the hospital furnace has you hot under the collar

You don't know the half of it. Hormone replacement therapy (HRT) relieves menopausal symptoms like hot flashes but increases the risk of venous thromboembolism (VTE). A case-control study of two UK primary research databases spanning almost 20 years found that while oral HRT increased the risk of VTE by about 60% compared to controls, transdermal HRT patches were not associated with excess risk. Since only about 15% of women who use HRT use patches, there's plenty of room to get patients to switch.

When the Saints are on, and you're not leaving the couch

Up to you, but know that a trial of 160 sedentary participants over age 55 with evidence of cognitive impairment found that aerobic exercise 3x per week improved executive function compared to usual behavior. The 2x2 factorial trial also randomized patients to the DASH diet or usual eating habits. While the participants at baseline had executive function scores equivalent to a 90-year-old, the combined diet and exercise group achieved a 9-year improvement compared to a slight worsening in the control group.

Brush up

Non-alcoholic fatty liver disease (NAFLD)

NAFLD is the leading cause of liver disease in the USA, and as much as 40% of the population is affected. The disease is most common among patients with the metabolic syndrome and is usually found through hepatic steatosis seen on imaging or incidentally-noted abnormal LFTs. Diagnosis requires confirmatory imaging and the exclusion of other common causes of liver disease. Left untreated, NAFLD can progress to non-alcoholic steatohepatitis (NASH) and cirrhosis.

What's the evidence

For weight loss in NAFLD? Prospective lifestyle modification studies found that among participants who achieved a 10% reduction in body weight, 97% saw resolution of NAFLD and 90% saw resolution of NASH. These patients also saw improvement in liver fibrosis. Consider bariatric surgery for NAFLD patients who are unable to lose weight. 

What your adolescent medicine friends are talking about

You've heard whispers linking cannabis use in adolescents to schizophrenia. As marijuana becomes more popular (and more legal), here's a summary of what researchers do and don't know.

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