June 10, 2016


The story

In 1999 the CDC said the US was on the verge of stamping out syphilis for good. Now the USPSTF recommends routine screening for anyone at risk for infection. What gives?

The comeback

Syphilis, the great imitator, was thought to be so under control that the CDC launched a national plan to eliminate the disease in 1999. In the 2000s the disease reached a historic nadir of 4 cases per 100,000 people, but that number increased to 6.3 cases per 100,000 people in 2014. Men account for over 90% of new cases.

Who's at risk?

The USPSTF recommends screening for all patients at 'increased risk' of infection, and asks clinicians to understand the prevalence of infection in their communities. High prevalence groups include men who have sex with men, women with HIV, those with a history of incarceration or commercial sex work, certain ethnic groups including African Americans, Hispanics and Native Americans, residents of certain geographic areas (southern US, western US and metropolitan areas), and men under age 29.

Test then treat

Start with a sensitive screening test (nontreponemal VDRL or RPR), and if positive move to a specific confirmatory test (treponemal antibodies: FTA-ABS or TP-PA). Confirmed syphilis remains broadly sensitive to penicillin G, which can often be given in a single dose. The USPSTF concedes that the optimal screening interval is not well established.

The takeaway

The USPSTF gives their new recommendations an A rating and notes that the negative impact of screening is minimal. Think of the guidance as a renewed call for syphilis awareness, and look to screen young men in metropolitan areas.

Say it on rounds

When you mistake your ICU patient for Buzz Lightyear

Blame it on sleep debt or technology, but it's definitely not your fault. A single-center RCT of 83 patients with acute respiratory distress syndrome found that patients who used a transparent helmet for non-invasive positive pressure ventilation (NIPPV) had more ventilator-free days, a lower intubation rate, and lower 90-day mortality than patients who used nasal NIPPV. Adverse effects were similar between groups.

When you and your friends compare inappropriate pages

There are big differences among things that might otherwise appear similar. Investigators looked at mutational drivers of acute myeloid leukemia (AML) in over 1500 patients in three large trials. They classified the disease into 11 subgroups based on combinations of driver gene mutations present in tumor samples. The authors say that breaking the clinically heterogeneous disease into genomic subtypes will help with prognostic stratification and the development of more specific clinical trials.

When you sign out your pager but stick around to wrap up errands

Some issues are murky. The dipeptidyl peptidase-4 (DPP-4) inhibitors saxaglitpan and sitagliptan help control blood glucose in diabetes but have been implicated as a possible cause of heart failure. A retrospective, population-based study compared over 300,000 DPP-4 users to patients taking a diverse group of other diabetes drugs and found no increased risk for hospitalized heart failure in the DPP-4 group.

Brush up

Irritable bowel syndrome (IBS)

You don't feel great after eating hospital cafeteria soft-serve for dinner, so imagine the plight of the 11% of the world's population with IBS. Diagnose the disorder with the Rome criteria: recurrent abdominal pain or discomfort at least 3 days per month combined with two or more of improvement with defecation, onset with a change in stool frequency, or onset with a change in stool form. Exclude organic GI disease, and guide therapy by subtyping IBS according to the predominant bowel habit.

What's the evidence

For treatment agents in IBS with diarrhea? Two agents are FDA-approved and have been shown to reduce abdominal pain and improve stool consistency. Rifaximin (Xifaxan), a non-systemic antibiotic, improved symptoms in roughly 40% of participants up to 10 weeks after drug administration in a 2011 RCT. A 2016 trial of eluxadoline (Viberzi), a mixed opioid receptor binder, found that the drug improved symptoms in 32% of patients after 6 months of follow-up.

The pay gap

A cross sectional survey in the BMJ found that white male physicians earned substantially more income than their black male counterparts from 2000 - 2013. Male physicians earned more than female physicians, regardless of race.

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