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Jul 28, 2017

Brain bruise

The story

Seeing your discharge plan fall through at 5 pm may make you bang your head against the wall, but be careful: chronic traumatic encephalopathy remains poorly understood. A look into the brains of football players provides some answers.

The background

With symptoms of impulsive behavior, forgetfulness, and depression, chronic traumatic encephalopathy (CTE) looks a lot like being a resident at 5:30 in the morning. But while you'll feel better after a nap, CTE patients progress to violent behavior, suicidality, and dementia. Even the NFL now accepts that there is a clear link between CTE and repetitive head trauma. But in a world where up to 3.5 million Americans per year will have head injuries from contact sports, and over 40% of Americans will have concussions in their lifetime, who's at risk remains unclear.

The study

Researchers examined the brains of 202 deceased football players who donated their brains for study out of concern for CTE. The long-awaited results from Boston University's "brain bank" found different levels of CTE severity related to how long the participants played football. CTE was more prevalent and more severe in NFL players than college football players, and worse in college football players than high school football players. A whopping 110 out of 111 former NFL players had neuropathological evidence of disease.
JAMA

The takeaway

At over 4 times the size of the next largest study, this data set is the most comprehensive on the subject to date. More research is needed to establish the prevalence of the disease among athletes, but the results add to a clear set of warning signs surrounding head trauma in football.

Say it on rounds

When you walk into a full list. Again

There's no escaping the grind. Unless you're treating giant-cell arteritis (aka temporal arteritis), where for years the price of disease control was a long and drawn-out steroid taper with accompanying side effects like weight gain and diabetes. A 250-patient RCT found that treatment with IL-6 inhibitor tocilizumab led to steroid-free remission at one year in over 50% of patients vs. about 20% of patients on placebo. The tocilizumab group needed less than half of the cumulative prednisone dose of the placebo group over the 52-week study period. A two-minute video has more.
NEJM

When your 2 am chili fries feel better on the way down than when you wake up the next morning

Eat now, pay later works in more ways than one. A cohort analysis of 115,000 men and women tied weight gain between early and middle adulthood to an increased risk of diabetes, hypertension, cardiovascular disease, and certain cancers. A weight gain of 20 kg or more between ages 20 - 39 was also linked to higher mortality. While much research has focused on the long-term effects of childhood obesity, the findings highlight early and middle adulthood, a period when most people feel healthy, as a critical time to prevent obesity and associated chronic diseases.
JAMA

When you expect every supply closet to have on-demand graham crackers and ginger ale

Things don't really work that way, outside of the hospital. But on-demand PrEP can reduce the spread of HIV in those at high risk for infection. In an open-label extension of the original IPERGAY trial proving the efficacy of daily PrEP, 360 patients were offered on-demand PrEP for use with sex rather than as a daily medication. The on-demand group had a 97% relative reduction in HIV incidence compared to the original IPERGAY placebo group. Because on-demand PrEP has to be taken before and after sex to be effective, many think it adds a layer of complexity compared to daily medication use.
Lancet HIV

Brush up

Diverticulitis

Over half of adults over age 60 have asymptomatic diverticular disease. Think of acute diverticulitis in patients with left lower quadrant pain, change in bowel habits, and fever. Risk factors include obesity, smoking, and medications like NSAIDs and steroids. Look for leukocytosis and an elevated C-reactive protein on labs, and order an abdominal CT scan to confirm the diagnosis. Complications can include abscess, fistula or perforation. Treat advanced or recurrent cases with fluids, antibiotics and bowel rest, and make sure to call surgery or IR if an abscess is present.

What's the evidence

For withholding antibiotics in acute uncomplicated diverticulitis? A 2016 multi-center RCT in the Netherlands compared a 10-day course of amoxicillin-clavulanic acid (Augmentin) with placebo in 528 patients with mild left-sided disease. No significant differences were found in median time to recovery or secondary outcomes such as recurrence or all-cause mortality. Guidelines now recommend selective use of antibiotics in mild cases of acute diverticulitis.

What your health policy friends are talking about

We feel dizzy this week from all the headlines around 'repeal and replace' on Capital Hill. Here's a quick catch-up guide if you're too busy with actual patient care to keep up with Senate bluster.

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