May 10, 2019

Without a trace

The story

Leave it to residency to raise the stakes when you're starting to feel comfortable. But just like you'll be moving up this summer, in HIV, the undetectable = untransmittable (U=U) paradigm keeps clearing hurdles.

The background

While you've spent years honing in on which of your co-residents are secretly dating, experts have been gathering confidence that appropriately treated HIV infection is just about impossible to spread. In 2011 the landmark HPTN 052 trial found that antiretroviral therapy (ART) markedly reduced viral transmission among serodifferent (one partner HIV positive, one not) heterosexual couples counseled to use condoms. Queue caveats: no one uses condoms (or at least few couples use them perfectly), and the event rate of HIV transmission is ~20 times higher for unprotected receptive anal sex compared to unprotected vaginal sex.

The study

PARTNER2 evaluated 780 serodifferent gay couples at 75 sites in Europe over median follow-up of 2 years. Participants were assessed with regular HIV testing (HIV-negative partner) and viral load testing, and upon seroconversion of a negative partner, phylogenetic analysis was performed to identify linked (partner's virus) transmission. Couples reported 76,000 episodes of condomless anal sex with a total of zero (0!) linked transmissions. A total of 15 unlinked transmissions were detected.  

The takeaway

The findings put major heft behind U=U, with many calling it a done deal. They add to the urgency to get untreated HIV infections under control.

Say it on rounds

When you're already counting down to signout

Why the rush? Standard approaches to medical thrombolysis in stroke limit use of alteplase (tPA) to within 4.5 hours after onset. EXTEND compared use of alteplase between 4.5 and 9 hours after stroke onset to placebo in 225 patients with stroke and imaging evidence of salvageable brain tissue. Alteplase patients were more likely to have minimal or no deficits at 90 days (35% vs. 29%), though the trial was stopped early due to changes in the field's standard of care. More patients in the alteplase group experienced symptomatic intracerebral hemorrhage.

When clinical documentation pages you about a note from 2 years ago

Some hospital teams are a bit behind the ball, but leave that out of the ED: a retrospective cohort of 10,800 ED patients with sepsis found that each hour delay in door-to-antibiotic time was linked to a 10% increase in mortality at 1 year. The difference was significant even among patients who survived to hospital discharge. Patients treated within 3 hours of arrival were more likely to survive than those treated after 3 hours, though a mortality benefit was not found for treatment within 1 hour. Median door-to-antibiotic time was 166 minutes.

When you worry about your Coke habit

A mammoth analysis of 100,000 patients in two large cohorts found associations between consumption of sugar-sweetened beverages (SSBs) and artificially sweetened beverages (ASBs) and mortality. SSBs were associated with mortality in a dose-dependent fashion, with excess harm seen beginning at 2 - 6 drinks / week and greatest for ≥ 2 drinks / day (pooled HR 1.21). ASBs were associated with modestly increased mortality (pooled HR 1.04) at a dose of ≥ 2 / day. Both findings were largely driven by increases in cardiovascular disease.

Brush up


Old age + obesity is a recipe for osteoarthritis (OA), so it's safe to say worldwide incidence is rising. Look for a chief complaint of joint pain, and use factors like morning stiffness, reduced range of motion, crepitus, and joint instability to help differentiate OA from other causes. The knee is the most common site of disease followed by the hips and hands. First-line treatment is the stuff you're telling your patients in clinic every day: education, self-management of activity and sleep, exercise, and weight loss for obese or overweight patients.

What's the evidence

For total knee replacement (TKR) in OA? A 2015 study of 100 participants with moderate to severe knee arthritis found that TKR followed by 12 weeks of nonsurgical treatment produced greater improvement in pain scores than conservative management. Experts recommend referral of end-stage (joint pain that reduces walking distance, disrupts sleeping patterns and restricts daily activity) osteoarthritis for surgery after all conservative management options have been unsuccessful over the course of 6 months.

What your Tom's Natural Deodorant friends are talking about

Denver voters passed a resolution to decriminalize possession of psychedelic mushrooms by razor-thin margins. The city is the first in the United States to decriminalize psilocybin.

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