Dec 1, 2017

Top down

The story

If you think the jolt of your alarm before sunrise is a tough pill to swallow, then trust us, there's worse. New research sheds light on fecal matter capsules for recurrent C. diff.

The background

Like changing rotations when you start to get bored in the hospital, the best approach to recurrent C. difficile infection (CDI) is to mix it up. Fecal matter transplant (FMT) injects healthy stool into antibiotic-weakened intestines to restore normal gut flora and eliminate dominant C. diff strains. FMT delivered through colonoscopy achieves cure rates in about 90% of cases. But as any sharp doctor knows, there's more than one way to reach the colon. 

The pill

FMT via oral capsule (think: poop pill) produced similar cure rates to FMT via colonoscopy, says a randomized, non-inferiority trial of 115 patients with at least 3 prior episodes of CDI. All patients completed a course of PO vancomycin until diarrhea symptoms improved and then underwent a full bowel prep prior to FMT. Both regimens prevented recurrent CDI in 96% of patients at 12 weeks, though there were fewer adverse events in the capsule group. The trial used a larger capsule dose than previous studies that failed to show the same magnitude of benefit, suggesting a role for dose-dependence.

The takeaway

FMT via colonoscopy is limited by time, donor coordination, and expense. Fecal matter capsules could dramatically broaden access to an important therapy.

Say it on rounds

When you just want some quiet time in the dark

You need some time away from your pager, but the stakes are higher for chronic migraine sufferers. Elevated levels of calcitonin-gene related peptide (CGRP) play an important role in migraine pain and vascular activity. Infusion of fremanezumab, an anti-CGRP monoclonal antibody, reduced the number of headache days per month relative to placebo in 1,100 patients with chronic migraines. About 40% of patients in the treatment group reported a decrease in migraine frequency of 50% or greater. See this 2-minute video for more. 

When it's almost 5 pm, and you still have an open admitting spot

It's tough to watch and wait. A randomized, open-label study in New Zealand compared expectant management (EM) with intrauterine insemination (IUI) in 200 women with unexplained infertility. Both groups received ovarian stimulation therapy. The IUI group had a higher rate of livebirths (31% vs. 9%) than the EM group, with no difference in pregnancy-related adverse events. Experts say the study is the most robust evidence to date that IUI is an effective fertility tactic. 

When you're the first to a code, and find the patient brushing her teeth 

Tele arrests are a good reason to defer CPR, but there are few excuses for arrests outside the hospital. An analysis of 19,000 public cardiac arrests found that men were more likely to receive bystander CPR than women. CPR was initiated on 45% of men vs. 39% of women, which translated to a 23% greater likelihood of survival in men. No gender difference was found in CPR initiation for arrests inside the home. 
AHA News

Brush up

Diuretics in heart failure

Lasix dosing is straightforward, until it isn't. In your complex frequent flyers, you're likely to encounter diuretic resistance. Look for gut edema, low renal blood flow, chronic kidney disease, NSAID use, and low serum protein as resistance markers. While the evidence for specific strategies is thin, begin with loop diuretics and look to add a thiazide diuretic early in patients who do not meet urine output goals. Here's a step-up guide to diuretic dosing.

What's the evidence

For bolus vs. continuous infusion in acute decompensated heart failure? 2011's DOSE trial famously found no difference between the two dosing strategies in patients' global assessment of symptoms or serum creatinine. Critics point out that the initial dose of Lasix drips used in the trial was lower than recommended and that no bolus was given before drips were started. 

What your journalism friends are talking about

Charlie Rose, Matt Lauer and probably more to come. You don't need us to tell you that sexual harassment is not an industry-specific problem. Here's a look at the worldwide prevalence of women who've faced sexual harassment. Stats are broken down by region.

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