Jul 14, 2017

Hard stop

The story

You can't reverse oversleeping your alarm clock and showing up to rounds an hour late. But for bleeding in patients on novel oral anticoagulants (NOACs)? That's a different story.

The background

If your coumadin clinic has a referral mechanism that predates cell phones, you're probably already comfortable with NOACs. For years doctors knocked the anticoagulants because, unlike warfarin, they couldn't be reversed in the event of major bleeding. But the state of affairs is changing: the humanized antibody idarucizumab (Praxbind) was approved in 2015 to reverse major bleeding in the direct thrombin inhibitor dabigatran (Pradaxa). For Factor Xa inhibitors apixaban (Eliquis) and rivaroxaban (Xarelto), andexanet alfa reverses bleeding, but the FDA is awaiting further data prior to approval.

The study

How does the dabigatran inhibitor idarucizumab hold up in life-threatening bleeds? A prospective evaluation of 500 patients on dabigatran (mostly for stroke prevention in a fib) found that idarucizumab led to bleeding cessation in a median of 2.5 hours in patients with uncontrolled GI bleeding, intracranial hemorrhage, or major trauma. A second group of patents was given the reversal agent for urgent procedures and was able to undergo surgery within 2 hours of administration with peri-procedural hemostasis in 93% of patients. Long-term rates of thrombosis and mortality were better than studies involving warfarin and vitamin K reversal in similar populations.

The takeaway

NOACs are here to stay, and while we wait for approval for reversal agents for Factor Xa inhibitors, consider using dabigatran for your patients at risk of falls or major bleeding.

Say it on rounds

When your desk has 3 empty coffee cups and you haven't had a sip of water

It's important to have your priorities straight. A prospective cohort study of over 500,000 patients in 10 European countries found that the highest quartile of coffee consumers (> 3 cups per day) had lower all-cause mortality than non-coffee drinkers over 15-year follow-up. Coffee drinkers had more favorable liver function tests and lower inflammatory biomarkers than non-coffee drinkers, and the findings held for decaf. The study is the largest to date on coffee consumption and mortality.

When even your toothbrush can't save you from morning breath after 27-hour call

Fresh is increasingly hard to find, and current US air pollution standards may not help. An open cohort study of 60 million Medicare beneficiaries found that increases in two air pollutants – fine particulate matter and ozone – were associated with an increased risk of death, even when pollutant concentrations were below the EPA's National Ambient Air Quality Standards. Men, blacks, and those eligible for Medicaid were at greatest risk. See this 2-minute video for more.

When your hospital ID becomes a student discount card

You can't change what you have, but you can tinker. In an attempt to outsmart resistant organisms, researchers chemically modified vancomycin to have activity against vancomycin-resistant enterococci (VRE). The super-drug is designed to maintain efficacy against projected future forms of bacterial resistance. While the modified antibiotic needs formal clinical testing, the project lends hope to the idea that old tools – vancomycin has been in use for over 50 years – can be used to fight multidrug-resistant bacteria.

Brush up

Something's crawling

Acute Lyme is on the rise, so keep a pair of tweezers handy this summer. Look for the all-important erythema migrans rash, notable for its bullseye appearance with red borders and central clearing, along with fevers and malaise 1 - 2 weeks after a tick bite. The diagnosis is clinical: serologies are positive in only 25 - 40% of acute cases, though sensitivity increases to 80 - 100% in disseminated disease. Cranial nerve palsy, aseptic meningitis, heart block, and arthritis are feared manifestations of dissemination. 

What's the evidence

For treating beyond Lyme in tick-borne illness? A 2014 analysis of 4,000+ blacklegged ticks in New York found that more than one-third of lyme carrying ticks also carried babesiosis or anaplasmosis. Overall, roughly 30% of ticks carried Borrelia burgdorferi, the bacterial pathogen in Lyme disease, while more than 10% of ticks carried more than one pathogen. Use oral doxycycline to treat Lyme and anaplasmosis. Mild babesiosis calls for treatment with azithromycin and atovaquone.

Survival guide: Part II

Thanks for tuning in to our lifestyle guide last week! This week, your fresh-from-residency Scope writers offer their favorite tips and tricks for navigating the hospital.

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