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Dec 2, 2016

AI

The story

If prerounding on a full list each morning has you feeling like a robot, you may be on to something. Researchers are taking huge steps towards making artificial intelligence a part of clinical care.

Screen time

Diabetic retinopathy affects almost 30% of diabetics in the United States. Guidelines recommend annual screening for retinopathy in patients without disease and a repeat examination 6 months later for patients with moderate disease. Since diabetes has a prevalence of about 9% in the US, that's roughly 30 million recommended screening visits per year to your pals in the resident ophthalmology clinic. It sure would be nice if a computer could help.

Rise of the machines

Enter deep learning algorithms, which use large data sets to learn how to identify images. Essentially, you show a computer a large set of pictures that do and do not have diabetic retinopathy, and the machine learns on its own how to pick disease from non-disease. Researchers applied a deep learning algorithm to two large retina image sets and were able to determine retinopathy with a sensitivity greater than 98% in both cases.
JAMA

Up next

We're quick to bristle at tech hubris, but give your computer buddies credit where it's due. Deep learning algorithms are designed by data scientists, rather than clinicians, and look like they can play a useful role if able to hold up in prospective studies. Many hope similar technology can be applied to radiology images.

Say it on rounds

When you can hear your patient wheeze from outside the room

Some asthmatics definitely need inhaled corticosteroids (ICS), but for others it may be tough to tell. Guidelines recommend using ICS in patients with symptoms > 2 days a week. A post-hoc analysis of the 7,100 patient START trial, originally designed to test the long-term effect of ICS in patients with mild asthma, found that daily budesonide reduced the time to first hospitalization in those with symptoms < 2 days a week. The magnitude of benefit was small, and RCTs would likely be needed to confirm the findings before any changes to current guidelines.
Lancet

When you want to rewind to your fourth year of med school

It's no sin to want to turn back the clock. Cardiologists and their patients with coronary artery disease feel the same way, and for years have searched for medicines to reduce coronary plaque burden. The GLAGOV trial evaluated the effect of the PCSK9 inhibitor evolocumab (Repatha) on coronary atheroma burden as measured by intravascular ultrasound over 76 weeks in patients already on statins. LDL-C was much lower in the evolocumab group relative to placebo (37 vs 93 mg/dL), and plaque regression was seen in a greater percentage of patients (64% vs 47%).
JAMA

When sleep deprivation has you feeling trippy

You can always go to bed early, or try taking a nap. But cancer patients have a difficult time finding relief from diagnosis-related depression and anxiety. Two small studies found that psilocybin, a compound in hallucinogenic mushrooms, can help. About 80% of trial participants had significant reductions in anxiety and depression symptoms, and for many the effects were sustained seven months after a single dose. Researchers hope the striking results can encourage larger trials.
J Psychopharmacol I and II

Brush up

Von Willebrand's Disease

Like scheduled blood draws at a New York City hospital, platelets in von Willebrand’s disease don't always work as intended. The defect lies in von Willebrand's factor (vWF) and factor VIII, which both help platelets aggregate and adhere to sites of vascular injury. Though most cases follow an autosomal inheritance pattern, women present with symptoms more frequently because of menorrhagia. Diagnose with a clinical history of bleeding and laboratory tests that demonstrate a lack of vWF or factor VIII. Most minor bleeding responds to desmopressin, which can also be given to patients prior to surgical procedures or dental work.

What's the evidence

For infusion of vWF to control bleeding in von Willebrand's disease? Trials are small but promising. A 2015 prospective trial of 11 patients with severe disease refractory to desmopressin found that prophylaxis with concentrated vWF infusions safely decreased bleeding episodes. The same was shown in menorrhagia, typically managed with oral contraceptives or the levonorgestrel IUD. For those who fail, vWF factor infusion was effective in a literature review of 88 women with bleeding refractory to first line management.

What your public health friends are talking about

As you jump into the holiday spirit, take a look at the Access to Medicine Index's annual list of the pharmaceutical companies best at getting their drugs and vaccines to the world's poorest countries. 

Spread the word

Send your interns something to look forward to.

  

We're off for Fellowship Match Day next week and will be back on December 16th. Big ups to all residents participating in the Match – you are stars and any program would be lucky to have you.

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