Mar 1, 2019

Long game

The story

A monthlong shot of Red Bull would have its pitfalls, but long-acting injections can do some good. Here’s how extended-release buprenorphine (BUP-XR) zaps barriers to opiate abuse treatment.

The background

There's a two decade track record for buprenorphine in opiate use disorder, but the med has fallen out of favor as a series of myths and regulations have left many docs unable or unwilling to prescribe it. One issue at play is diversion: heroin users can use buprenorphine to ease withdrawal symptoms between doses, giving the drug a street value and abuse potential. Counteracting measures like minimizing prescribed doses, random pill counts, and urine tests are a headache for docs and patients. A med with fewer hassles could help.

The study

BUP-XR maintains steady state plasma concentrations for a month. A phase 3 RCT of adults with opiate use disorder seeking treatment found that monthly BUP-XR improved abstinence compared to placebo at 24 weeks (42% vs. 5%) as measured by urine tests and self-reports of illicit use. Treatment retention and medication satisfaction scores were high, and BUP-XR patients reported an increase in employment during the study period compared to a decrease for placebo.

The takeaway

BUP-XR is FDA-approved and will make buprenorphine more accessible to docs and patients. Whether the treatment can deter use of popular synthetic opioids like fentanyl remains to be determined. 

Say it on rounds

When hour 27 has you loopy

You'll be fine with a nap, but about half of patients who undergo major cardiac surgery (i.e. CABG) will experience post-op delirium that will lengthen their ICU stay. A trial of 120 patients who underwent cardiac surgery found that use of post-op IV acetaminophen (Tylenol) reduced delirium compared to placebo (10% vs. 28%) and shortened ICU stay by about 16 hours. Most think opioid sparing analgesia from acetaminophen contributed to the positive outcome.  

When you'd like a robot to write your progress notes

Maybe one day. For now you'll have to settle for insulin dosing in type 2 diabetes (T2D): d-NAV, a handheld device that optimizes insulin dose based on real-time glucose levels and glycemic patterns, reduced A1c compared to usual care in a RCT of 180 T2D patients. At 6 months, d-NAV patients saw a 1% drop in A1c compared to 0.3% with standard insulin dosing. There was no difference in hypoglycemic events. While automated insulin delivery systems are popular in T1D, this is among the first applications in T2D.

When your intern is desperate to place a line

Here's for early opportunity. A single-center phase 2 RCT of 310 patients examined the use of early low-dose norepinephrine (NE) vs. placebo at initial presentation of septic shock. More early NE patients achieved resolution of shock at 6 hours (76% vs. 48%), though the difference in 28-day mortality did not meet significance (16% vs. 22%). NE patients saw fewer episodes of cardiogenic pulmonary edema and arrhythmia, and NE did not affect the amount of IVF given. Further studies are up next.
Am J Respir Crit Care Med

Brush up


The second-largest Ebola virus outbreak in history is on the move in the Democratic Republic of the Congo (DRC). Infection spreads through body fluids and holds an incubation period of 2 - 21 days. The disease typically begins abruptly with high fever, malaise, fatigue, and body aches followed by a second phase of GI symptoms. Real-time RT-PCR is used for diagnosis. Some patients will recover spontaneously, though most will develop shock, organ failure, and hemorrhage.

What's the evidence

For prevention of Ebola with vaccines? Outbreaks from 2013 - 2016 rapidly accelerated vaccine testing and development. A phase 3 ring-vaccination trial in which close contacts of persons with confirmed infection were vaccinated with the rVSV-ZEBOV vaccine found no cases of Ebola in 2,100 patients who were immediately vaccinated compared to 7 cases in a delayed vaccination group. Though the magnitude of the vaccine's efficacy is still being studied, about 80,000 people have been vaccinated in the DRC thus far.

What your social media friends are talking about

Facebook is a key launchpad for anti-vaccine propaganda. The social network is taking early steps to curtail the spread of misinformation.

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