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Jan 19, 2018

Seek and find

The story

It may seem like the whole world visits the ED when you're on call, but a ton of sick patients never make it to the waiting room. New research looks at how to find tuberculosis patients before they seek medical care.

The trend

Tuberculosis (TB) causes more worldwide deaths than HIV or malaria. And while public health efforts have led to the widespread availability of treatment, disease incidence has barely budged. Stopping disease means stopping transmission in asymptomatic patients, and the old paradigm of treating whoever shows up hasn't performed as expected. Over a third of new cases each year do not seek treatment, and those who do are often lost to follow-up in what researchers call the downward cascade of care

The study

Actively following household contacts of infected patients more than doubled the rate of TB detection compared to standard passive detection, says a cluster RCT of 25,000 household contacts in Vietnam. Clinic workers in the active group invited close contacts of infected patients for chest X-ray, sputum smear, and physical exam at regular intervals for two years after initial diagnosis. The approach led to a 2.5x greater likelihood of registering new cases than waiting for patients to present to clinic. 
NEJM

The takeaway

Finding and treating asymptomatic TB patients could have a powerful impact on disease spread. Many are hopeful that the study, which used existing district health workers for its active approach, can be used as a blueprint for similar efforts in other high-prevalence areas.

Say it on rounds

When Gen Med has your New Years resolutions on the ropes

Time for an intervention. The same is true for patients with refractory morbid obesity, as a retrospective cohort of 33,000 patients found that nonsurgical obese patients faced double the risk of mortality as patients who underwent bariatric surgery via bypass, sleeve gastrectomy or gastric sleeve. Median follow-up was 4.5 years, and no mortality difference was found between the three surgical modalities. The study adds to growing evidence for bariatric surgery's long-term benefits. 
JAMA

When walk-in clinic is a pain in the butt

At least it's not a fistula. About 25 - 40% of patients with Crohn's disease develop debilitating fistulas that are often refractory to standard therapy. A Phase III RCT of 212 patients found that a single injection of adipose-derived stem cells called Cx601 improved fistula remission rates by nearly 50% compared to placebo. Remission was sustained for over one year, and there was no difference in adverse events between groups. 
Gastroenterology

When you want to predict how many admissions you'll get

Take a quick scroll through who's in the ED. And if you want to predict outcomes in pulmonary arterial hypertension (PAH), try following brain natriuretic peptide (BNP). An observational study of 1,400 patients with primary PAH found that high BNP levels (> 340 pg/mL) at enrollment were associated with a 3.6x greater risk of mortality at 5 years. But it's not all bad news: improvement of BNP at 1-year post-enrollment was associated with a decreased risk of mortality.
Chest

Brush up

Parkinson's disease

Neurodegenerative symptoms – resting tremor, rigidity, akinesia, and postural instability – define classic Parkinson's disease. But non-motor symptoms like cognitive impairment, olfactory issues, sleep disorder, and constipation are increasingly recognized as an early disease prodrome. Understanding of disease pathology is limited, but the loss of dopaminergic neurons in the basal ganglia serves as the basis for treatment. Current meds focus on increasing dopamine activity. They treat disease symptoms but do not stop disease progression.

What's the evidence

For deep brain stimulation (DBS) in Parkinson's disease? The invasive approach is usually performed in late-stage disease, when adverse medication effects become disabling. But 2013’s EARLYSTIM trial found that early use of DBS for patients with early motor complications improved quality-of-life and disability scores compared to optimal medical therapy.

World's finest

We take it for granted in NYC, but colorful accents and colleagues from around the globe make our hospital days so much more fun. We're glad Tom Brokaw agrees.

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