July 8, 2016

Antiplatelet action

The story

There may be more antiplatelet agents than answers about how to use them after acute stroke. Researchers are looking for solutions on a trial-by-trial basis.

Take a chance

The CHANCE trial made a splash in 2013 when it showed that combination aspirin and clopidogrel (dual antiplatelet therapy, or DAPT) reduced stroke recurrence vs. aspirin alone in the first 90 days following minor stroke and transient ischemic attack (TIA) in 5,000 Chinese patients. Many use this data to recommend DAPT in all patients with evidence of symptomatic intracranial large artery stenosis, a common cause of stroke in the Chinese population. A large RCT evaluating DAPT in non-Chinese patients is ongoing

Get personal

Cardiologists have known since 2009 that genetic clopidogrel resistance prompted worse outcomes in patients treated with clopidogrel in the setting of acute myocardial infarction and percutaneous coronary intervention. The CHANCE investigators genotyped their participants and found that the benefits of DAPT in the original trial were seen only in the 40% of patients without genetic clopidogrel resistance.

What else?

New results from the 13,000 patient SOCRATES trial found that ticagrelor (Brilinta) – your preferred antiplatelet agent for non-ST elevation ACS – did not significantly reduce rates of stroke, MI or death within 90 days when compared to aspirin in patients with stroke and high-risk TIA.

The takeaway

Appropriate antiplatelet therapy following acute stroke is complex and still largely unsettled. While we wait for the dominoes to fall from ongoing trials, watch for a role for personalized medicine in future guidelines.

Say it on rounds

When you worry that the tech revolution has passed you by

Turns out there's no escape. The Silicon Valley-engineered I-SPY 2 trial aims to drop the time and cost of bringing new drugs to market by comparing multiple drugs at once in highly targeted settings. The trial uses a technique called adaptive randomization to increase the likelihood of patient assignment to a given drug therapy as evidence of the therapy's efficacy builds, all in an effort to quickly estimate which drugs are likely to succeed in larger trials. New results predict that two breast cancer targeted therapies – veliparib, a polymerase inhibitor, and neratinib, a tyrosine kinase inhibitor – would likely succeed in phase 3 trials.

When you feel the stress of a tough family meeting

Imagine the effects on caregivers. A multi-center RCT found no difference in anxiety and depression scores in caregivers of ICU patients following structured palliative care-led meetings compared to routine, ICU team-led meetings. Caregivers exposed to the palliative care-led intervention, in which there was an emphasis on sharing prognostic data, were more likely to experience posttraumatic stress disorder (PTSD) symptoms at 3 months. An accompanying editorial sorts through the complexities of these results.

When your new intern's orders just don't smell right

Relax. What could go wrong? But when your patient's stool smells after beginning antibiotics, that's trouble. A retrospective study of over 200 patients found a lower incidence of recurrent C. difficile infection in hospitalized patients on systemic antibiotic therapy treated with oral vancomycin prophylaxis (OVP) compared to patients treated with antibiotics who did not receive OVP (4.2% vs 26.6%, respectively). Prospective studies are an obvious next step.
Clin Infect Dis

Brush up

Ankylosing spondylitis (AS)

Is hard to spell and harder to diagnose, since no single clinical feature, lab test, or imaging finding is necessary or sufficient for diagnosis. Consider the disease in those with insidious back pain, morning stiffness lasting greater than 30 minutes, and pain that diminishes with activity. Formal diagnosis requires at least 3 months of back pain before age 45, radiographic sacroiliitis, and one other clinical feature. When pain precedes radiographic changes, a positive HLA-B27 (seen in up to 89% of patients) serves as an important clue.

What's the evidence

For treatment of AS? NSAIDs are first-line treatment for disease-related pain and stiffness. Tumor necrosis factor (TNF) inhibitors are recommended next for uncontrolled symptoms, with response rates of roughly 60%. A 2015 RCT of patients with AS refractory to TNF inhibitor therapy found that the anti-interleukin 17A monoclonal antibody secukinumab (Cosentyx) produced a 61% disease response rate at 16 weeks.

What your dermatology friends are talking about

It's a bit racy for our tastes, but a nationwide survey on pubic hair grooming trends has received a lot of buzz.

Spread the word


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