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Apr 5, 2019

Waiting game

The story

Patients get all kinds of sick while waiting for heart and lung transplants. Can hep C donors increase the organ supply?

The background

While the family behind OxyContin faces lawsuits over its role in the opioid crisis, a surge in deaths from drug overdoses has fueled a 20% increase in organ transplants in recent years. But supply is still inadequate: over 110,000 patients sit on US transplant waiting lists, and 12,000 people died while waiting for an organ in 2018. Hepatitis C infection – overrepresented in drug overdose deaths – prompts many otherwise viable organs to be discarded. Modern anti-viral treatment could make these organs safe for use.

The study

DONATE-HCV evaluated heart and lung transplant outcomes for 44 HCV-mismatched (donor positive, recipient negative) patients at a single-center. All recipients were preemptively treated with 4 weeks of sofosbuvir–velpatasvir, a pangenotypic direct-acting antiviral regimen. While 95% of patients had a detectable HCV load after transplant, all patients who completed 6 month follow-up had excellent graft function and an undetectable viral load following treatment. Recipients had a shorter length of stay in the ICU than typical transplant patients, which experts tie to shorter time on the transplant waitlist.  
NEJM

The takeaway

There's a lot left to do to prove that HCV mismatched organs are safe in the long run, but these early results are encouraging. In some areas, HCV donors could boost available organs by a third.

Say it on rounds

When you want to know which co-resident got you sick

Check a respiratory PCR. But if you want to know who's spreading HIV, look to an updated model from the CDC that traces transmission along the continuum of care. Transmission rates were highest among individuals who were acutely infected but unaware of their status (16 per 100 person-years), while infected individuals who were aware of their status but not in care were the leading group responsible for overall transmission (43%). No transmission occurred among patients who achieved viral suppression with antiretroviral therapy.
MMWR

When you have the day's third wet vs. dry debate

Clinical ambiguity is widespread in the hospital, and pre-eclampsia is no exception. Diagnosis hinges on clinical findings that are often subjective or nonspecific. A RCT of 1,000 women with suspected pre-eclampsia found that measurement of placental growth factor (PGF) levels reduced time to diagnosis from 4 days with usual care to an average of 2. Earlier diagnosis led to a small but statistically significant reduction in severe maternal adverse outcomes (5% to 4%) when PGF levels were acted upon according to a pre-determined algorithm.  
Lancet

When the ED smells like a college basement

Sobering centers offer an alternative destination for the short-term care of alcohol intoxication and are generally focused on providing support for the uninsured and the homeless. A single-center retrospective study designed to establish the safety of a San Francisco sobering center found that only 4% of patients required secondary transfer to an ED, most often for tachycardia or concern for alcohol withdrawal. Initial triage to the sobering center did not result in any deaths over 3-year follow-up.
Ann Emerg Med
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Brush up

H. pylori infection

Most Helicobacter pylori infections are asymptomatic, though the bacteria is a frequent cause of dyspepsia and peptic ulcer disease (PUD) worldwide and has been labeled a grade I carcinogen by the WHO for its association with gastric cancer. Consider screening patients with active PUD, dyspepsia, MALToma, unexplained anemia, and those on long-term aspirin or NSAIDs. Office-based stool antigen or urea breath tests are both sensitive and specific for infection.

What's the evidence

For quadruple therapy for H pylori infection? A 2016 RCT of 1,600 patients in Taiwan found that 10-day bismuth quadruple therapy with bismuth, lansoprazole, amoxicillin, and metronidazole increased eradication rates compared to 10-day concomitant therapy and 14-day triple therapy (lansoprazole, amoxicillin, clarithromycin). Eradication failure is common, so it is essential to document clearance of infection after treatment. Treated patients also remain at risk for reinfection.

What your Coachella friends are talking about

Don't bother with bug repellant at the Sahara Tent. Dubstep – specifically Skrillex's "Scary Monsters and Nice Sprites” – decreased host attacks, blood feeding, and reproduction when played for Aedes aegypti (yellow fever / dengue) mosquitos.

Spread the word

Send your interns something to look forward to

  

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