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Nov 30, 2018

Hive dreams

The story

You'll drink anything with traces of caffeine, but kids with allergies have a much different relationship to peanuts. Can oral desensitization help? 

The trace

Peanut allergies are on the rise among children in the US, and they usually persist into adulthood. And while associated deaths are rare, teenagers have enough to worry about beyond close encounters with a Snickers bar. Even micro-doses can prompt systemic reactions, making complete avoidance the go-to strategy to date. In 2012 a UK group was the first to prove that defatted peanut flour could induce desensitization. They called their flour 'oral immunotherapy', and sparked a race to bring a drug to market.

The flour

The phase 3 PALISADE trial randomized 550 patients with severe peanut allergy to AR101, a 12% defatted peanut flour, or placebo. The primary analysis of children aged 4 to 17 found that following desensitization with AR101 for 24 weeks, two-thirds of patients in the active treatment group could tolerate a dose of 600 mg of peanut (about two peanuts) compared to 4% in the placebo group. Desensitization required careful monitoring, and about 10% of patients had to withdraw due to side effects. Adults over 17 did not derive significant benefit. How long densitization will last in the absence of maintenance therapy remains unclear.
NEJM

The takeaway

AR101 is far from a cure, but it could help a lot of children put their peanut-brush-with-death fears aside. The drug has a breakthrough therapy designation from the FDA and should be up for approval soon. 

Say it on rounds

When autocorrect wrecks your medical jargon

You can't fix what you can't spell. Chikungunya emerged as a global threat during an outbreak in the Americas from 2013 - 2015, but there are no specific treatments or preventative measures available to decrease spread. A phase 2 RCT of a measles-vectored chikungunya (MV-CHIK) vaccine found that over 80% of patients who received multiple injections had high immunogenicity as measured by antibody titers. No serious adverse events were reported, and a phase 3 trial is now underway. 
Lancet

When the fellow says she never got your consult page

Sounds fishy. REDUCE-IT compared twice-daily icosapent ethyl, a fish-oil-derived omega-3 fatty acid, to placebo in 8,200 patients with sky-high cardiovascular risk and elevated triglycerides. At 5-year follow-up, 17% of patients in the treatment group experienced a major CV event compared to 22% of patients in the placebo group. The results surprised investigators: the 25% lower relative risk seen in the icosapent ethyl group was greater than expected based on changes in biomarkers like cholesterol, triglycerides, or CRP, while similar past trials have failed to show this degree of benefit. Expect more research soon.
NEJM

When you prick your pinky to stay awake

That's on you. But we doubt your patients are pleased with all the needles they see each day. An RCT of 480 hospitalized patients found that dripping lidocaine onto the skin immediately prior to subcutaneous injection reduced pain by 25% compared to usual care as measured by patient-reported pain scores. Benefits were mostly seen during PICC placement.
Chest

Brush up

Numbers game

Think of HIV in terms of spread and risk: there are about 2 million new infections each year worldwide including 40,000 in the United Stares. One in 8 HIV-positive Americans is unaware she is infected, and about half of the 1.2 million infected US adults are not on treatment. That’s where risk comes into play: transmission events per 10,000 HIV exposures is estimated to be 168 for unprotected receptive anal intercourse, 8 for unprotected vaginal intercourse, and 63 for needle sharing.

Get meta

With pre-exposure prophylaxis (PrEP) and HIV transmission. USPSTF draft recommendations advised physicians to offer PrEP to all patients at high risk of acquiring HIV with a Grade A rating. The task force reviewed 12 trials of PrEP vs. placebo and found that PrEP cut the risk of HIV transmission in half even with imperfect use. Transmission approaches zero with strict adherence. Once the rec is approved, private insurance plans will have to cover the medication for eligible patients under the Affordable Care Act.

What your lab friends are talking about

Genetically engineering mice makes your clothes smell, but genetically engineering humans is a wild breach of ethics. The scientific community reacted with outrage to a rogue scientist's purported use of CRISPR in human embryos.

Spread the word

Send your interns something to look forward to

  

Congrats to all of the residents who matched on Wednesday! Big ups to you – the end of the tunnel is in sight.

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