Mar 22, 2019

Wired up

The story

Checked-out third-years notwithstanding, you’re supposed to up your game as time goes by. Here’s how transcatheter aortic valve replacement (TAVR) has held up its end of the bargain.

The background

You've cracked enough ribs to know that recovery from surgical aortic valve replacement (SAVR) takes time. TAVR gets patients out of the hospital faster, and has surpassed SAVR as the most frequent aortic valve replacement procedure. Since the first large TAVR trials for high-risk patients were published in 2010, improved valve technology and operator expertise have made the procedure safer. And after TAVR was shown to be non-inferior to SAVR in patients at intermediate surgical risk in 2016, researchers set their sights on low-risk patients.

The valves

There are two styles of TVAR valves, and both shined in large trials. PARTNER 3 compared TAVR with a ballon-expandable valve to SAVR in 1,000 patients with severe aortic stenosis (AS) at low surgical risk. TAVR produced a lower rate of death, stroke, or rehospitalization at 1 year (8.5% vs. 15%), with much of the benefit seen within 30 days. EVOLUT compared TAVR with self-expanding valves to SAVR in 1,400 low-risk AS patients and found a lower estimated incidence of death or disabling stroke at 2 years (5.3 vs. 6.7%) favoring TAVR.

The takeaway

These results surpassed expectations, but long-term outcomes are pending and will be watched closely. For now, candidate patients should receive a full heart valve evaluation (surgeons and cardiologists) before choosing a procedure.

Say it on rounds

When you end every night shift with an omelette

Never change. But be aware that a pooled prospective cohort study of 30,000 US adults found a dose-dependent link between eggs and mortality. Over an average follow-up of 17 years, each additional half-egg per day (~90 mg of cholesterol) was associated with a 6% increase in cardiovascular disease and an 8% increase in all-cause mortality. International studies in this oft-researched topic have failed to find similar risk, and the authors suggest that the American diet – already heavy in animal fat – may be more sensitive to extra dietary cholesterol. 

When a month in the ICU is all you can handle

At-risk patients feel the same way about treatment. Even though tuberculosis (TB) is the leading cause of death for HIV patients, preventative therapy with isoniazid (INH) remains underused in part due to prolonged treatment courses. A randomized trial of 3,000 patients with HIV in high-prevalence TB areas found that 1 month of rifapentine plus INH produced greater treatment compliance rates (97% vs. 90%) and fewer serious side effects than 9 months of INH alone. Preventative efficacy was similar between groups.

When you need AI to translate paper charts

Maybe someday. Finding polyps is the name of the game in colonoscopy, and it's just the kind of task where image-based artificial intelligence (AI) could help. A RCT of 1,050 patients undergoing colonoscopy at a single center in China found that colonoscopy assisted by an AI polyp-detection system increased adenoma detection rate by 50% compared to standard care. The difference was driven almost entirely by detection of diminutive polyps, and whether the technology can impact clinical outcomes remains unclear.

What exactly happens when you refinance your student loans?

Refinancing allows you to trade in your existing loans for a new loan at a lower interest rate and/or at different terms. You get a better deal on your new loan because it is based on your current income, payment history, and education.

Click here to check your rate.

Plus, medical students who’ve matched to a residency program can refinance their medical school loans and pay only $100 per month during training and up to six months into their professional practice!¹

Don’t forget, as a Scope reader, you’ll receive a $300 bonus2 when you refinance with Laurel Road. 

Brush up

Out in space

Commercial spaceflight is approaching, in case your next vacation isn't booked. Space medicine challenges vary based on time spent in space and distance travelled. Motion sickness (zero gravity can wreak havoc on your neurovestibular system) and headaches from intravascular fluid shifts are common in the first few days of spaceflight, while exposure to space radiation, deconditioning, and even spaceflight-associated neuro-ocular syndrome (SANS) are associated with lengthy trips to the outer reaches.

What's the evidence

For who's ready for launch? Commercial passengers won't be as fit as Apollo astronauts. A 2012 study subjected 77 untrained adult volunteers to centrifuge-simulated suborbital spaceflight. Peak heart rate during simulation correlated with post-simulation imbalance, but on the whole participants tolerated high G-forces well, including patients with common medical comorbidities. Motion sickness was among subjects' most frequent symptoms.

What your health policy friends are talking about

Does insulin need to be so expensive? Dr. Elizabeth Rosenthal explores how pharma companies pump up the US price of insulin, leaving patients and taxpayers on the hook for big dollars.

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¹We may agree under certain circumstances to allow a borrower to make $100/month payments immediately after loan disbursement if the borrower is employed full‐time as an intern, resident, fellow, or similar postgraduate trainee at the time of loan disbursement. These payments may not be enough to cover all of the interest that accrues on the loan. Unpaid accrued interest will be added to your loan and monthly payments of principal and interest will begin when the post‐graduate training program ends.

2$300 bonus subject to eligibility. Offer cannot be combined with other offers, including the Referral Program.

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