Dec 21, 2018

Trim down

The story

Hard-to-reach populations become more accessible when you bring the clinic to them. Can blood pressure be managed at the barbershop?

The background

It takes trust to let someone cut your hair every 2 weeks for a decade. That’s the kind of relationship the average participant had with his barber at the start of an innovative hypertension project designed to improve blood pressure control in black men, a high-risk group with a lukewarm-at-best relationship with the doctor's office. Organizers planned to leverage the community feel of black-owned barbershops in LA to promote health awareness while using onsite pharmacists to counsel patients and prescribe meds. Six-month results were stunning, prompting investigators to extend the trial.

The study

The pharmacist / barbershop combo reduced systolic blood pressure (SBP) by an average of 29 mmHg over the course of 1-year follow-up. Of 320 participants with a baseline mean SBP of 150 mmHg, 68% of men in the intervention arm achieved a BP of <130/80 mmHg compared to 11% in an education-only control group. While efficacy showed no signs of slowing down during the extension – results were indistinguishable from 6-month data – pharmacist visits decreased from a mean of 7 in the first 6 months to 4 afterwards. The frequent upfront visits allowed pharmacists to adjust regimens that were ineffective or causing problems.

The takeaway

This level of blood pressure control could do wonders for primary prevention if implemented on a broader scale. A key next test is whether the authors can implement their approach outside of their well-developed LA network.

Say it on rounds

When you can't read your attending's paper notes

She's old school, and so is SCPG-4. The Scandanavian trial of 700 men with localized prostate cancer launched in 1989, just before the introduction of widespread PSA screening. After 29-year follow-up, patients randomized to surgery vs. observation gained a 3-year survival advantage with radical prostatectomy, though benefits were mostly seen in patients with markers of aggressive disease. Researchers are curious to see if results from later trials – where PSA screening is implicated in the overdiagnosis of indolent cancers – will show similar benefit.

When you buy Monster in bulk but won't touch Red Bull

Are they really that different? Biosimilars – 'close enough' copies of expensive biologic drugs – are easy to like but tough to prescribe, since no one wants to be on the hook if something goes wrong. In the latest comparative equivalence trial, CT-P13, a biosimilar to the anti-TNF agent infliximab, produced similar rates of disease-related surgery, hospitalization, and death when compared to infliximab in a French cohort study of 5,000 patients with Crohn's disease. The agent has to date seen only modest uptake in clinical practice.

When you're struggling after last night's holiday party 

At least you know the root cause. A Danish cohort study linked severe childhood infections with mental disorders using diagnosis codes from a nationwide registry. Children with infections requiring hospitalization were almost twice as likely (HR 1.8) to receive a diagnosis of a mental disorder later in life and 40% more likely to use a psychotropic medication. Behavioral disorders (i.e. ADHD, OCD) were associated with the highest post-infection risk. Though the findings in no way prove causality, the authors speculate that immune-mediated effects or microbiome disturbances may be at play.
JAMA Psych

Brush up

DAPT after stroke

Balancing bleeding risk and stroke prevention is a fickle business, and trials for dual antiplatelet therapy (DAPT) after acute stroke have been all over the map. To maximize benefit, choose your patients carefully: consider high-risk TIA (ABCD2 score ≥ 4) or mild ischemic stroke (NIHSS score ≤ 3) patients for aspirin and clopidogrel (Plavix) for 10 - 21 days. Patients with major stroke are at increased risk of bleeding and may not be appropriate. Start DAPT within 24 hours of the event, as risk of stroke is highest in the short term. Bleeding complications are more likely to arise with longer use. 

Get meta

With DAPT after minor ischemic stroke and high-risk TIA. An analysis of 10,000 patients across 3 trials found a 2% absolute risk reduction in non-fatal recurrent stroke for DAPT compared to aspirin monotherapy. Benefits were confined to the first 10 days after the initial event, and no benefit was seen for therapy beyond 3 weeks. Increased risk of moderate-to-severe bleeding was roughly 2 events per 1,000 patients. 

What your public health friends are talking about

There are better uses for drones than shutting down airports. UNICEF sent a vaccine-packed drone (see video) to a remote area of the Pacific island Vanuatu that is otherwise too treacherous to supply.

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We're off for the holidays and will return on January 11th. Thanks for an awesome 2018 – we're looking forward to more fun next year.

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