Apr 28, 2017

Bloody truth

The story

When you mistake a patient's daughter for his wife, there's no real way to stop the bleeding. But for postpartum hemorrhage? You have a few tools at your disposal.

The background

Like boredom on teaching rounds that go way past noon, deaths during pregnancy and childbirth are largely preventable. Postpartum hemorrhage (PPH) is a big culprit: it prompts 100,000 deaths annually, mostly in resource-poor countries in Africa and Asia. In 2012 the WHO recommended tranexamic acid, an inhibitor of fibrin and fibrinogen breakdown, for use in PPH when uterine contraction agents fail, but data on efficacy was lacking.     

The study

The aptly named WOMAN trial looked at PPH in 20,000 women in an international RCT that included countries with some of the highest global rates of maternal deaths. Administration of tranexamic acid reduced postpartum bleeding deaths by 19%, a benefit that increased to 31% when the medication was dosed within 3 hours of delivery. Significant reductions were also seen in the need for laparotomy to control bleeding.

The takeaway

The Gates Foundation-funded WOMAN trial showed impressive results for tranexamic acid in PPH. Up next: making sure that the drug is available in resource-poor settings.

Say it on rounds

When the 1 train is forever under weekend contruction

Now you have two excuses to bike to work. A prospective population-based study from the UK compared outcomes in cyclists and walkers to non-active commuters. While walking was associated with reduced cardiovascular disease incidence and mortality compared to non-active commutes, cycling had similar heart-healthy benefits but was also associated with reduced all cause mortality, cancer incidence and cancer mortality. Longer distances conferred increased benefits in all forms of active commuting.

When you're thinking virus, but your patient is thinking antibiotics

The TOAST Trial – unrelated to the risks and benefits of drinking champagne – examined symptom relief following dexamethasone in 560 patients who presented to outpatient clinics with sore throat. At 48 hours, patients who received a single dose of oral dexamethasone were 30% more likely to report complete resolution of symptoms than those given placebo (35% vs. 27%, respectively). Consider the med when caught between persistent patients who demand treatment and the canons of antibiotic stewardship.

When your resident salary stretches only so far

Cheap and durable work well for more than just work outfits. An RCT from Niger found that a low-cost, heat-stable oral rotavirus vaccine reduced episodes of severe rotavirus gastroenteritis (GE) in infants by 67% when compared to placebo without apparent side effects. Rotavirus is the leading cause of GE in young children, and since existing vaccines need to be refrigerated, the new vaccine should be much more accessible. 

Brush up

Sickle cell disease

Old tricks go a long way toward extending life-expectancy in sickle cell disease. Use penicillin prophylaxis to reduce infections in young children. Prevent strokes with regular blood transfusions and transcranial Doppler screening. Dose hydroxyurea, time-tested and inexpensive, to reduce pain crises and episodes of acute chest syndrome.

What's the evidence

For the malaria hypothesis in sickle cell disease? Sickle cell trait confers substantial protection against malaria, and a sophisticated 2010 geostatistical analysis tied population-level sickle cell allele frequency to historically endemic areas. Researchers found a robust association between sickle cell trait and malaria in sub-Saharan Africa, though the relationship between the two in India, where sickle cell disease is also highly prevalent, was less clear. 

What your family planning friends are talking about

A new synthetic uterus successfully brought premature lambs to term in what could one day be a game-changing therapy for premature babies. But don't write off the $1 billion-plus commercial surrogacy industry: the artificial wombs can't yet support a full pregnancy.

Spread the word

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