Jan 11, 2019

Mere myths

The story

Being old doesn't mean you can't get the job done, just ask your attending. Here's how tried and true hydroxyurea performed in sickle cell patients in sub-Saharan Africa.

The background

Hydroxyurea has been a pillar of care in sickle cell disease (SCD) for over 20 years, but use in sub-Saharan Africa, where the burden of SCD is highest, has lagged. Beyond expense – drug costs are roughly $1.20 / day – skeptics point to high rates of malaria and malnutrition as reasons why the drug, essentially a mild chemotherapy, may be ineffective or cause excess toxicity in African patients. So while the recommended age to start hydroxyurea in SCD patients is 9 months in the US, sub-Saharan SCD screening and specialized treatment programs are sparse.

The study

REACH evaluated hydroxyurea use in 600 children with SCD in 4 sub-Saharan countries. Results from the phase 1-2 trial were similar to US-based studies: hydroxyurea increased hemoglobin and fetal hemoglobin levels, cut pain crises by over 50%, and decreased rates of transfusion and death compared to the pretreatment period. The incidence of malaria, a prominent cause of premature mortality, was 50% lower in trial participants. With a retention rate of 94% at 3 years, REACH dispelled myths that long-term medication trials can't be run in Africa.

The takeaway

A staggering 50 - 90% of children with SCD in Africa will die before age 5. Newborn screening for disease and early use of hydroxyurea will be critical for reducing disease-related mortality. 

Say it on rounds

When your patient crashes right after you sign out your list

Not what you intended. The same can be said for 2012's Hospital Readmissions Reduction Program (HRRP), which penalizes institutions for 30-day readmissions for common diseases. A retrospective cohort of 8 million Medicare patients found an increase in 30-day mortality for heart failure and pneumonia in the period following HRRP initiation. The findings add to other program headwinds, including a recent Medicare Advisory review that linked apparent readmissions reductions to discharges from the ED or observation units rather than improvements in transitional care.

When night float started every antibiotic

Time to peel back. Data and common sense support narrowing antibiotics when cultures are positive, but managing negative cultures is tricky. A single-center retrospective study of 280 patients with culture-negative nosocomial pneumonia found that de-escalating anti-MRSA agents within 4 days of diagnosis did not change 28-day mortality. Compared with continuing anti-MRSA coverage for 5 days, de-escalation was associated with fewer hospital days (15 vs. 20), fewer ICU days (10 vs. 13), and a lower incidence of acute kidney injury (36% vs. 50%).  

When your senior resident is allergic to work

Be skeptical. A survey of 40,000 adults that examined food allergies and subsequent ED visits found that only about 60% of allergies were real. On the whole, prevalence of convincing allergies was 11% compared to a self-reported prevalence of 19%. The most common allergies were shellfish, milk and peanuts. Among real allergies, 38% of patients had at least one related lifetime ED visit. 
JAMA Netw Open

Brush up

Inflight medical emergencies

About 1 in every 600 flights has an inflight medical emergency, which in real terms translates to just about every time you set off on vacation. When offering to help, make sure to sync up with other volunteers to discuss role and relevant clinical experience. Domestic flights must have an automated defibrillator, and flight attendants will relay information to a ground-based medical support team that will help guide management. Legal liability is minimal – no physician has every been successfully sued in the US for air assistance.

Get meta

With common causes of inflight medical emergencies. An analysis of 14 epidemiology studies found syncope (33%) to be the most common inflight emergency, followed by GI (15%), respiratory (10%), and cardiovascular (7%) symptoms. In general you'll want to start with a focused history and physical, and use the FAA-mandated inflight medical kit (contents here) to take vitals. Here's a cheat sheet with symptom-based inflight assessments.

What your blood bank friends are talking about

You have blood bank friends? Check out the worldwide race to find donors for a 2-year old with a rare blood type battling neuroblastoma.

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