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February 12th, 2016

NOTHING BUT A NUMBER

THE STORY

Getting old is hard – on residents carrying the admitting pager. Weakness and cognitive impairment pack hospital beds, especially in winter. But new studies show a substantial reduction in the incidence of dementia in the elderly, and some hope that physical activity may decrease frailty.

HOLD ON TO YOUR MARBLES

Baby-boomers have reached their golden years, so what's happening with dementia? The Framingham study, the epidemiology powerhouse known for cardiovascular risk calculators, shows that the incidence of dementia in the elderly has decreased over 40% from the late 1970's to the early 2010's. Decreased rates of vascular dementia from stroke and appropriate treatment of afib can explain some, but not all, of the change. 
NEJM

HOLD ON TO YOUR STRENGTH

Frailty and falls are common in the elderly, but to date there's no easy cure. A large study of sedentary adults aged 70-89 years showed a trend towards decreased fall related fractures and hospital admissions in men following a structured physical activity program, though this finding was outside the study's prespecified analyses. On the whole, the structured physical activity program did not reduce the risk of serious fall injuries compared to health education programs for both sexes, but the authors note that the study may have been underpowered to detect a difference. 
BMJ

THE TAKEAWAY

The plight of the elderly is increasingly a nationwide crisis. So its nice to see some more golden years for all those lucky enough to avoid heart disease and cancer, even if a lot of work remains.

SAY IT ON ROUNDS

WHEN YOU'RE WONDERING IF YOUR RESEARCH POSTER WILL COMMAND ATTENTION

If you picked Zika, kudos. The virus's link to microcephaly in infants has to date stemmed from an epidemiological association in Brazil. But an autopsy of a microcephalic fetus from an infected mother recovered the full Zika genome in the fetal brain and eyes. Immunofluorescence studies showed that neurons may harbor the virus. The findings don't directly prove that Zika causes microcephaly, but it makes the evidence a whole lot stronger.  
NEJM

WHEN YOU GET CALLED ON WHILE ASLEEP IN PATHOPHYSIOLOGY CONFERENCE

It's good to know nuts and bolts, in a pinch. In thrombotic thrombocytopenic purpura (TTP), von Willebrand factors (vWF) aggregate because the enzyme ADAMTS13 is dysfunctional. The large vWF polymers attract and activate platelets, leaving the circulatory system with microthrombi that damage organs. Caplacizumab, a novel antibody, binds to vWF and prevents it from binding with platelets. When combined with plasma exchange, treatment with caplacizumab decreased time to resolution in TTP vs placebo in a phase II study. Patients in the treatment group trended toward less evidence of end organ damage, though the treatment did not improve TTP relapse rates.
NEJM

WHEN YOUR BARREL CHESTED PATIENT WON'T WALK WITH PT

It may be brain thing. A small case-control autopsy study showed that disease duration in COPD is negatively correlated with gray matter changes in the anterior cingulate cortex (ACC) – the region of the brain that processes dyspnea and fear – as well as other regions of gray matter. The changes may cause COPD patients to be more afraid of dyspnea and physical activity than healthy counterparts.
Chest

WHEN EVERY CLINIC PATIENT YOU SEE ASKS FOR ANTIBIOTICS FOR THEIR COLD

It can only be February. In US primary care clinics, acute respiratory tract infections account for the majority of inappropriate antibiotic prescriptions. A multicenter RCT showed that clinicians wrote for fewer inappropriate antibiotic prescriptions when prompted to justify their antibiotic choice. They also wrote for fewer inappropriate scripts when their antibiotic prescription rates were compared to their peers. 
JAMA

BRUSH UP

TO DIAGNOSE SEPSIS

Check off 2 or more of the following to get SIRS: fever or hypothermia, rapid heart rate, tachypnea or abnormal WBC (<4 or >12). Sprinkle a suspected or identified source of infection to get sepsis, and mix in a lactate or hypotension to get severe sepsis. If your patient's BP isn't getting better despite adequate fluids, he or she is officially in septic shock. Treatment is bundled into the first 6 hours, where adequate fluids, antibiotics and source control are key.

WHAT'S THE EVIDENCE

For steroids in septic shock? The Annane Trial in 2002 suggested that giving hydrocortisone and fludrocortisone to patients with septic shock and relative adrenal sufficiency increased survival. But 2008's CORTICUS showed that steroids did not improve septic shock survival compared to placebo, though patients in the treatment group had a quicker reversal of shock. Surviving Sepsis guidelines now recommend only using hydrocortisone if shock is refractory to fluids and pressors. 

GET META

With antibiotics and community acquired pneumonia. A mix of observational studies and RCTs showed relative reductions in mortality when antibiotics were initiated within 4-8 hours of arrival in the hospital. Data suggested that beta-lactam and macrolide combo therapy and fluoroquinolone mono therapy were more effective than beta-lactam monotherapy, though results were mixed and data was drawn from mostly low quality observational studies.
JAMA

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