May 18, 2018

As needed

The story

Just like your physical exam is way more thorough when someone else is watching, patients with asthma are more likely to use their meds when they have symptoms. Can PRN inhalers match up with maintenance meds?

The background

Patients don't want to take twice-daily meds when they're feeling just fine, so adherence to inhaled steroids in mild persistent asthma is poor. Affected patients have symptoms twice a week or more but not every day. They remain prone to exacerbations, which can be especially harmful to the long-term lung function of young adults. Since avoiding hospitalizations is key, many have questioned whether inhaled steroids are needed all the time or only when patients are symptomatic and the early signs of exacerbation are underway.

The evidence

SYGMA-2 upped the ante on symptomatic treatment by looking at whether a combined PRN inhaler featuring a beta-agonist and a steroid (budesonide–formoterol, Symbicort) could keep pace with maintenance inhaled steroid therapy and a PRN beta-agonist. The 4,000 patient trial found no difference in exacerbation rate or time to first exacerbation between the two groups, though the maintenance therapy group did report improvements in quality-of-life. Use of inhaled steroids was 75% lower in the PRN group.

The takeaway

Combined inhalers prevent exacerbations – a heavy driver of asthma costs – in non-adherent patients and spare steroid exposure. Patients who comply can keep the status quo. 

Say it on rounds

When it hurts to refuse antibiotic requests

You could be sparing future pain. The prevalence of kidney stones has increased 70% in the last 30 years, and many wonder if changes to the microbiome are responsible. A case-control study matched 26,000 adults and children with kidney stones to 260,000 controls. Antibiotic exposure was far more prevalent in the kidney stone group, with sulfa drugs (Bactrim), cephalosporins, and fluoroquinolones associated with the highest risk. Recent exposure and young age were associated with greater odds of forming stones.
J Am Soc Nephrol

When your pulse is faint and you're going on hour 30

Radial blood flow: overrated. Using ever-trendy patient level analysis techniques, researchers pooled outcomes from 1,000 patients on 6 trials to find whether radial-artery or saphenous-vein grafts performed better in coronary-artery bypass surgery (CABG). Radial artery patients had fewer cardiac events, a lower rate of occlusion, and a lower incidence of repeat revascularization. Death from any cause was similar between groups.

When your morning routine is set to the minute

Timing is everything. A cross-sectional study of over 90,000 participants found that disruption of normal circadian rhythms was associated with an increased risk of depression and bipolar disorder, higher loneliness scores, and slower reaction times. Data was collected using wrist-worn biofeedback devices similar to FitBits. The findings aren't exactly new, but the study used fancier tech for sleep measurement and a larger sample size than predecessors. 
Lancet Psychiatry

Brush up

Essential tremor

Your intern's feeling a little shaky about moving up the ranks? Could be something else. Essential tremor (ET) affects 1% of the world's population. Patients have isolated bilateral action tremor for a duration of at least 3 years, and tremor can be present in other areas like the head, lower limbs, or even the larynx / voice. Check labs to rule out kidney or thyroid dysfunction, and make sure to perform a full neuro exam. Use propranolol or primidone for initial treatment.

What's the evidence

For interventional treatment of refractory ET? Deep brain stimulation and unilateral thalamotomy have long been known to help with difficult to control symptoms. More recently, a 2016 RCT of 76 patients with refractory ET found that MRI-guided ultrasound ablation of causative thalamic tissue improved tremor symptoms by about 50% from baseline compared to sham procedure. The treatment is now FDA-approved.

What your GI friends are talking about

Spray everywhere and hope it stops has never been a popular strategy in GI training programs. But with the FDA-approval of Hemospray you may find the approach in an endoscopy suite near you. This video shows the spray in action.

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