Mar 9, 2018

Fat stores

The story

A therapy that selectively melts away fat seems too good to be true, even if the primary site of action is the liver. Here's the latest on a novel treatment for advanced fatty liver disease.

The background

You see hypertension, obesity, and diabetes on every clinic day, but non-alcoholic steatohepatitis (NASH), the liver's manifestation of the metabolic syndrome, is hard to recognize. Affected patients experience progressive inflammation and fibrosis that predispose to cirrhosis and hepatocellular carcinoma. While no FDA-approved treatment exists for the disease, experts project that NASH will cause cirrhosis in 2% of US adults in their lifetime and will be the most common cause of liver transplant by 2020.

The study

If excess fat is driving inflammation in the liver, then decreasing fat synthesis should help slow disease progression. In a Phase 2 study of 80 patients with NASH, therapy with the experimental compound NGM282 decreased hepatic lipid content by 5% or more in 70% of treated patients in just 12 weeks. Elevated liver enzymes also improved on treatment. For most cases, hepatic fat returned after completion of therapy, and side effects like diarrhea and abdominal pain were common. 

The takeaway

Innovative therapies like NGM282 are needed to combat an under-recognized liver epidemic. Look for Phase 3 studies next.

Say it on rounds

When the line for sign out is out the door

Waiting is the hardest part. The wait for kidney transplant averages 3 - 5 years, but over 500 organs are discarded annually because of hepatitis C (HCV) infection. A pilot study of 10 HCV negative patients awaiting transplant found that pre- and post-transplant HCV treatment allowed for safe transplant of HCV positive kidneys. There were no documented HCV infections or adverse events in the recipients. The findings could provide a much-needed boost to available organs.

When your hypoxic patient gets the last ICU bed

Breathe easy. An RCT of 1,800 adolescents and adults prone to asthma exacerbation found a benefit for self-directed therapy at early signs of attack. The experimental group quadrupled their home dose of inhaled steroids at the first sign of worsening symptoms and saw a lower rate of exacerbations (45% vs 52%) compared to usual care at one year. While gains were modest, the intervention is inexpensive and easy to implement.

When post-call leaves you too weak to clean your room

No one is going to throw out last night’s pizza boxes, but activated charcoal can help mop up antibiotics before they wreak havoc in the colon. A 30-patient RCT found that a modified oral activated charcoal designed to target the distal ileum was able to soak up > 99% of oral moxifloxacin from stool without compromising serum drug concentrations. With t.i.d. dosing, charcoal prevented detrimental changes to the microbiome and quickened gut flora recovery time.
J Infect Dis

Brush up

Thyroid nodules

Two-thirds of the general population have thyroid nodules that can be found on physical exam or with ultrasound. Most have no clinical significance. Be on the lookout for nodules that could be malignant, cause compression, or cause thyroid dysfunction. Your first job is to assess for compressive symptoms like globus sensation, dysphagia, or hoarseness. Check thyroid hormone levels to see if the nodule is functional, and order fine needle aspiration if suspicious findings are seen on ultrasound. 

What's the evidence

For differentiation of benign vs. suspicious findings on thyroid ultrasound? A 2008 retrospective study of 800 thyroid nodules found that the presence of at least one malignant ultrasound finding – taller-than-wide shape, irregular margins, hypoechogenicity, and calcifications – had a sensitivity of 83% and specificity of 74% for thyroid malignancy. Nodules with spongiform appearance and isoechogenicity were highly likely to be benign. 

What your do-it-yourself friends are talking about

Taking care of others is hard, but caring for yourself? Read about a nurse who diagnosed and treated his own heart attack alone in the Australian outback.

Spread the word

Send your interns something to look forward to


We're off next week and will return on March 23rd.
Thanks to everyone fighting for gender equity on International Women's Day, and best of luck to all of the med students matching next week.

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