Dec 16, 2016

Tis the season

The story

Feeling ready to discuss Zika with your relatives at the holiday dinner table? Us neither. Here's the latest on Zika's role in birth defects to get you started, for that uncle that thinks med school teaches you everything about human health.

The registry

Rest assured: pregnant women who develop symptoms of Zika infection after the first trimester are unlikely to give birth to infants with Zika-associated birth defects. Or so would suggest preliminary data from the US Zika Pregnancy Registry, run by the CDC. The study looked at 442 completed pregnancies in women with PCR or antibody evidence of Zika infection and found no birth defects in women infected in the second or third trimesters. Women with both asymptomatic and symptomatic infections were included, and similar rates of birth defects (about 6% of pregnancies) were found in both groups.

The rash

A study of 125 Zika infected women in Rio de Janeiro found opposite results. The authors screened women based on the appearance of a characteristic rash during pregnancy, and included only those with PCR evidence of Zika infection. Adverse outcomes, including structural defects like microcephaly and abnormal findings on neuroimaging, were found in 46% of births, including 55% of women infected in the first trimester, 52% infected in the second, and 29% in the third. Since 80% of infections are thought to be asymptomatic, some suggest that women with rash represent a particularly severe subset of disease.

The takeaway

Whether second or third trimester fetuses are vulnerable or not, pregnant women and their partners should do their best to avoid Zika hot spots until the outbreak resolves or a vaccine emerges.

Say it on rounds

When you find out you're working way more weekend days than your colleagues

Residency: no one's beacon of fairness. But uneven hospital outcomes are a bit more unsettling. Researchers looked at hospital level data for over 22 million admissions and found a two-fold difference in mortality for acute myocardial infarction between the best performing hospitals and the worst. Adverse events like line infections were up to 13 times more common in the worst-performing hospitals nationally. By comparing individual hospitals, researchers were able uncover detail often missed when hospitals are compared by county or region.
PLoS One

When you nail the blood draw but the sample gets lost in lab

Painful, but a lot easier to bear than a vaso-occlusive crisis. For sickle cell patients, hydroxyurea has been the only effective preventative therapy to date. Enter crizanlizumab, an antibody against the p-selectin molecule responsible for the adhesion of sickle RBCs to vascular endothelium. A 200-patient phase 2 RCT found a 45% lower annual rate of pain crises in patients treated with crizanlizumab compared to placebo. The medication appeared to act synergistically with hydroxyurea, and many think monthly IV dosing could boost adherence. 

When winter calls for scrubs and long johns

Some things are obvious pairs. Researchers matched bedside ultrasound in the ED with the Well's criteria to better screen for pulmonary emboli (PE). The combo increased the sensitivity (70% vs 58%) and specificity (88% vs 68%) of PE detection compared to the Well's criteria alone in 450 patients in Italy. The authors promote ultrasound, which was used to look for pulmonary infarcts and DVT, as cheap and easy to learn, and predict that broader use at the bedside could spare CT angiography in many patients.
Acad Emerg Med

Brush up

Crohn's disease

Your time in residency is going down, but the worldwide incidence of Crohn's disease is rising. The classic patient presents with abdominal pain, chronic diarrhea, weight loss, and fatigue. Endoscopy remains the gold standard for diagnosis and can help track disease activity along with laboratory markers like CRP and fecal calprotectin. Therapy is increasingly focused on achieving deep and long lasting remission, which means treating beyond clinical symptoms.

What's the evidence

For anti-TNF therapy in Crohn's disease? 2010's SONIC trial found that combination azathioprine and the TNF-α inhibitor infliximab produced a 57% steroid-free remission rate at 26 weeks in patients with moderate to severe Crohn's disease naive to immunosuppressive or biologic therapy. The rate was significantly higher than remission rates from each individual therapy and established combination therapy as first-line treatment for these patients. 

What your lawyer friends are talking about

White collar crime. As in pharmaceutical company executives fixing drug prices to make generic meds more expensive. The Justice Department filed its first charges this week following a two-year investigation into rising drug costs. 

Spread the word

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