Aug 25, 2017

Summer fever

The story

Just because you use a fax machine for parts of your core job responsibilities doesn't mean that all of development has passed you by. New research shows you're largely protected from rheumatic heart disease, while the developing world has a lot of catching up to do.

The background

Thanks to penicillin G and improvements in living conditions, most of the developed world waved goodbye to rheumatic heart disease in the 1980's. And while your medical students are way more likely to be pimped about rheumatic fever than to see an actual patient with complications, the disease remains a scourge of the developing world, where it is responsible for the bulk of cardiac morbidity in young people. The public health burden is strong, since upfront treatment of the disease is cheap, but managing long-term cardiac complications is expensive. 

The burden

Data from 2015's mammoth Global Burden of Disease study found that worldwide rates of fatal and nonfatal rheumatic heart disease dropped by almost half between 1990 and 2015. Benefits were dramatically stacked in favor of the developed world. A heat map of affected areas looks a lot like the usual victims of public health shortages, with the highest rates of disease observed in Oceania, South Asia, and central sub-Saharan Africa. The study estimates that rheumatic heart disease causes 320,000 deaths annually, but the true impact of the disease may be much greater. Subclinical rheumatic heart disease, an entity thought to have a prevalence 3 to 10 times greater than clinical disease, was not captured in study estimates. 

The takeaway

Rheumatic heart disease is an underrecognized cause of global mortality, and disease-related spending vastly trails efforts to contain better known public health problems like HIV, TB, and malaria. Public education and promoting universal access to early antibiotic therapy could be cheap and efficacious first steps.

Say it on rounds

When the next available GI appointment is in 2020

Sometimes you have to take matters into your own hands. Hepatitis C (HCV) treatment has to date fallen largely in the purview of specialists in hepatology and infectious disease, leaving large swaths of infected patients without access to treatment. An open-label clinical trial evaluated treatment outcomes in 600 HCV patients under the care of specialists, primary care physicians, or nurse practitioners in underserved communities. Overall, 86% of trial patients achieved sustained virologic response, and there was no statistical difference between prescriber groups. Many hope the findings will help bridge the gap between a prevalent disease and a lack of specialists to treat it.

When your post-call celebrations have you asking yourself CAGE questions

Maybe it's time to kick the habit. Speaking of habits, a longitudinal, multi-center study of smokers found that a $1 increase in cigarette prices was associated with a 7% reduction in the risk of heavy smoking ( > 10 cigarettes per day) and a 20% increase in the likelihood of smoking cessation. The results were independent of newly implemented bar or restaurant smoking bans in certain regions, and highlight taxation as a key driver of tobacco reduction in the US.

When your night float intern has no time for scut

Getting 30 pages about sleep medication is enough for one intern to handle, so cut your overnight colleagues a break on managing contrast protocols. Patients with prior allergic reactions to IV contrast typically receive a 13-hour oral steroid premedication protocol. A retrospective noninferiority cohort study of 200 ED patients found that an accelerated 5-hour IV steroid premedication regimen prevented breakthrough allergic reactions at rates comparable to the 13-hour treatment group (97.5% vs. 97.9%, respectively). The 5-hour protocol used a lower overall steroid dose. 

Brush up


Despite a prevalence of up to 25% among women in their late 30's, migraines are clinically underdiagnosed. Don't get lost in details: classic signs like aura, photophobia, nausea, and debilitating pain point to migraines regardless of other headache characteristics. Once an accurate diagnosis is established, screen for exacerbating factors. Lifestyle factors include stress, irregular sleep and caffeine habits, and skipped meals. Medications to keep an eye on include SSRIs, proton-pump inhibitors, and hormone therapies like OCPs and postmenopausal estrogen.

Get meta

With migraine treatment options and efficacy. A review of migraine meds by the American Headache Society found that triptans are the most frequently successful treatment, providing relief for up to 51% of patients within 2 hours of administration. Prophylaxis agents like beta-blockers, candesartan, tricyclic antidepressants, and anticonvulsants help some patients, but have shown only marginal benefit in clinical trials. Consider using these meds if migraines occur at least once per week or on 4 or more days per month.

What your bro friends are talking about

The conversation gets a bit awkward when it turns to sperm. But a new study says that dudes throughout the Western world have seen their average sperm count drop 50% between 1973 and 2011. We'll leave guesses why up to you, the Internet, and, well, science.

Spread the word

One week later, we remain indebted to Heather Heyer and the protestors in Charlottesville who served as a first line of defense against bigotry in the United States. Here's how you can donate to help the victims of domestic terror and their families.


We're off for Labor Day and will return on September 8th. We're back in the Twitter game, so follow @MedicineScope or like our Facebook page for updates while we're gone.

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