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Oct 13, 2017

Off trend

The story

Like efforts to boost your social life in residency, much of modern medicine is about stopping the damage. And while your nights and weekends are gone for good, new therapy offers hope that disabled multiple sclerosis patients can recover.

The background

Diurese to dry weight, stabilize plaque, slow hair loss. Multiple sclerosis (MS) has long followed the medical trend of modifying disease rather than reversing it. Patients are all too familiar: 15 disease-modifying meds are approved for MS therapy, but none promote repair of damaged nerve tissue. These drugs are generally anti-inflammatory and act to tone down the immune system. They work best in early disease, leaving preexisting disability untouched.

The study

The phase 2 ReBUILD trial looked at the use of the antihistamine clemastine fumarate in 50 patients with relapsing MS, mild disability, and chronic optic neuropathy. Patients given clemastine saw improvements relative to placebo in 2 laboratory measurements of MS-associated visual disability. The benefits of clemastine – to date used as an over-the-counter anti-allergy med – were modest, but this is the first evidence that medications can repair optic nerve damage. It's also an important example of repurposing old drugs for new tricks. Unlike novel therapeutics, clemastine has a known safety profile.
Lancet

The takeaway

Further testing is up next, and whether clemastine can generate true clinical benefit remains unclear. But many are hopeful that the drug is the first of many for central nervous system repair.

Say it on rounds

When your patient tells you one thing and the attending the exact opposite

Broken trust is better than broken bones. The anti-sclerostin antibody romosozumab ("romo") prevents fractures in osteoporosis, but how does it stack up against standard-of-care bisphosphonates? The ARCH trial compared romo with alendronate in 4,000 postmenopausal women with osteoporosis and found that romo cut the risk of vertebral fracture in half during 2-year follow-up. Romo also increased bone density, a key metric for next-generation osteoporosis therapies. But sit tight before considering romo a new standard-of-care: the trial found an unexpected increase in serious cardiovascular events compared to alendronate, a finding that will need further study before the drug is ready for mainstream use.
NEJM

When your attending always calls you by your co-resident's name

You and your patients prefer personalized treatment. A French RCT of 300 surgical patients found that targeting an intraoperative systolic blood pressure (SBP) within 10% of the patient's resting blood pressure led to fewer episodes of post-op organ dysfunction and sepsis than targeting standard parameters of SBP > 80 mm Hg or within 40% of the patient's resting blood pressure. The study's patient population was deemed high risk and underwent major surgeries where fluid shifts and intraoperative hypotension were common. Differences in organ dysfunction were seen at 30 days, though there was no difference between groups in 30-day mortality. 
JAMA

When you spend all day caring for patients, but haven't been to a doctor in years

For now, the data is still in your favor, but unchecked hypertension can be a problem later on. For women, hypertension in their 40s was associated with a 65% percent increased risk of dementia in later life independent of other risk factors like smoking and obesity. The association did not hold for women with hypertension in their 30s. The findings are from a 5,500 patient study that tracked participants from 1964 to 2015. Male participants had more time to control their blood pressure, as hypertension was tied to dementia beginning at age 50.
Neurology

Brush up

Schistosomiasis

The parasitic adult fluke worms that cause schistosomiasis colonize just about every resident in endemic regions beginning in childhood. The worms enter through blood vessels and evade the immune system for years as they shed eggs. Morbidity stems from the immune response to trapped eggs in the intestines, liver, or genitals. Treatment focuses on the anti-parasite agent praziquantel, which cures disease and reduces egg output. The drug is given to children every 1 - 2 years in affected areas to control disease spread.

What's the evidence

For co-infection with schistosomiasis and HIV? Population-based studies show a 3 - 4 times increased risk of HIV infection in women with genital schistosomiasis, likely from damage to epithelial tissue that allows for easier disease spread during sex. Men are also at risk: a study of T-cells in the peripheral blood found that the T-cells of men with active schistosomiasis infections expressed more HIV co-receptors – gateways for the HIV virus to infect cells – than men with cured infections.

Wildfire

There's movie stunts, and then there's real life. Check out hospital staff in Napa escorting patients to safety in a background of roaring flames. Two hospitals were evacuated as wildfires continue to rage in Northern California.

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