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Oct 7, 2016

Seven year itch

The story

You'll never feel itchier than the minute after you diagnose a patient with scabies, so you can imagine the plight of patients with severe eczema. Big changes are underway for patients with refractory disease.

The basics

Atopic dermatitis is more than just a rash: many of the 1.6 million Americans with severe disease suffer from intense itching, sleep deprivation, anxiety and depression, and poor quality of life. Moisturizers, topical steroids and calcineurin inhibitors serve as basic treatment, and all patients should be tested for co-existing allergies. Severe disease calls for phototherapy and systemic immunosuppressants, which can have toxic effects and be difficult to wean.

The breakthrough

Enter duplilumab, a monoclonal antibody against interleukin 13 and 4 signaling that basically cools off the body's response to allergic triggers. In paired RCTs of 670 patients with moderate to severe atopic dermatitis, duplilumab significantly improved disease severity scores vs. placebo at 16 weeks. About 40% of patients in the treatment group saw complete or almost complete resolution of skin rash. Patients reported improvement in all endpoints studied, including pruritis, anxiety and depression, and quality of life. 
NEJM

The takeaway

Dupilumab will give many disease sufferers a physical and psychological boost, though cost will likely be a barrier. The drug is expected to gain FDA approval in March.

Say it on rounds

When your eyes are baggy after a 5 AM wake-up

Don't take drastic action. The field of face transplantation has come a long way in recent years. A prospective study of 7 transplant recipients found that transplants had good functional outcomes after up to 9 years, but were complicated by frequent rejection episodes. Patients with self-inflicted injuries had worse outcomes. Here's a pic showing what the procedure has done for patients who have sustained difficult injuries. It's not John Travolta or Tom Cruise, but it's a start.
Lancet

When you know more about Zika than bread and butter medicine

Add some neuro to the fold. Zika and Guillain-Barre syndrome (GBS) have long been linked, but causality is notoriously difficult to prove. A prospective cohort study from Colombia searched for Zika in the body fluids of GBS patients and found evidence of active or past infection in over 80% of cases. If you're thinking there's not a lot of ICU space or access to intravenous immunoglobulin in some affected countries, then you're on the same page as some very worried public health advocates.
NEJM

When you mix up patients

Never good, but mixing registries can be fruitful. A mash-up of national prescription and psychiatric registries in Denmark showed a 40% increase in the use of antidepressants after patients initiated treatment with hormonal birth control. Progestin-only contraceptives and intrauterine IUDs were most strongly associated with subsequent antidepressant use. Depression was more common in adolescents, but like most things hormonal, the effect diminished with age.
JAMA Psych

Brush up

Kidney stones

These too shall pass, or so we hope. Flank pain is the most common symptom in renal colic, but dysuria, hematuria, nausea and vomiting are also often present. Men have roughy double the lifetime risk of women, and up to 80% of stones will pass spontaneously. Treatment begins with fluids and pain control, while expulsive therapy can help with large stones. If there's concern for obstruction (think sepsis or acute renal failure), you'll need to call urology or IR for urgent intervention.

What's the evidence

For ultrasound in the diagnosis of nephrolithiasis? The gold standard for diagnosis is non-contrast CT, but ultrasound may be a safer tool in the emergency department. A 2014 study of 2,800 ED patients found no difference in the rate of high-risk diagnoses between patients assessed with CT, point-of-care ultrasound, or radiology ultrasound, but ultrasound imaging was associated with a significantly lower radiation burden. Return ED visits, hospitalizations, and diagnostic accuracy did not differ between groups.

What your health policy friends are talking about

In case you missed it, HRC has big plans for health care. Here's her platform in her own words, as addressed to the medical community. Since political leanings vary by physician specialty, she may want to tailor future messages to psychiatrists or medicine docs.

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