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January 22nd, 2015

KNOW YOUR GENES

THE STORY

Investigators are pushing personalized genomic medicine forward with new gene markers to determine cancer therapy and prognostication.

THE COLON

Lose your keys. Lose your pager. But don't lose CDX2. The 4% of colon cancers where the gene was absent carried a worse prognosis than tumors where it was detectable. The good news is that CDX2 negative tumors were responsive to chemotherapy, which helps clear up the mystery of who needs adjuvant chemo after colon cancer surgery. This robot can tell you more, if you have 2 minutes and like monotone.
NEJM

THE BLOOD

In AML, knowing the risk of relapse is high priority when considering who gets stem cell transplant after chemo. It turns out that the presence of NPM1, a leukemia-specific molecular marker, predicts that risk, as well as long-term survival. Patients with undetectable NPM1 mutations after second-cycle chemotherapy are 5 times less likely to relapse within 3 years.
NEJM

THE LUNG

A French cancer group evaluated whether tumor gene sequencing impacted treatment and outcomes in lung cancer. About half of the Frenchies had an actionable gene mutation, and half of those patients were able to go on targeted therapy trials. The investigators say their data shows that nationwide molecular profiling is logistically feasible and has clinical benefit. 
Lancet

THE TAKEAWAY

Genes are the other four letter words. And they’re bringing personalization to oncology clinic, fast.

SAY IT ON ROUNDS

WHEN YOU'RE SURE NO ONE IN THE WHOLE WORLD ADMITS MORE ICU PATIENTS ON THEIR CALL SHIFT

Being right can sting. A retrospective study found that the US had double the rate of end of life ICU admissions as 6 other 'developed' countries (read: Canada plus some Euros). Uncle Sam had the 2nd highest rate of in-hospital deaths, and the third highest end of life expenditures. Germany had one fifth the rate of ICU admissions as the US, and at least triple the number of residents at Oktoberfest.
JAMA

WHEN IT'S DARK, AND YOUR 80 YEAR OLD PATIENT CLUTCHES HER CHEST

Turn the lights on in the cath lab. A Norwegian RCT found that patients older than 80 with NSTEMI or unstable angina benefitted from cardiac catheterization over medical treatment alone. They had lower rates of MI, stroke, and death, though the benefits decreased with age. Bleeding rates were similar in the two groups.
Lancet

WHEN YOUR UNCLE COMPLAINS ABOUT HIS BOWELS AT THE DINNER TABLE

Think prune juice, tried and true. But for long-term IBS sufferers eluxadoline decreased abdominal pain and improved stool consistency when compared to placebo at 3 and 6 months. The oral drug, which acts through a mixed opioid effect, caused pancreatitis in a small number of patients. Look for it to cost a pretty penny once it hits the market.
NEJM

A GOOD CLEAN RINSE

May be better than surgery for perforated diverticulitis with purulent peritonitis. The disease is typically treated with the Hartmann procedure – open colon resection with colostomy. A small RCT showed that laparoscopic lavage led to fewer re-operations, fewer readmissions, and decreased length of hospital stay.
Annals

BRUSH UP

TO PREVENT FRACTURES IN OSTEOPOROSIS

First figure out who's high risk. DEXA at age 65 is useful to look at bone mineral density, as is the FRAX score. Tell affected patients to exercise, stop smoking, and take calcium and vitamin D. Bisphosphonates are first-line treatment. They can be stopped after 5 years if a repeat DEXA checks out.

WHAT'S THE EVIDENCE

For Colace? Not much. The discharge stocking stuffer is less effective for constipation than osmotics (think Miralax or milk of magnesia) or stimulant laxatives (bisacodyl and senna).

GET META

With gender and atrial fibrillation. A look at 30 cohort studies with 4 million plus patients found that women with a fib had higher all cause mortality than their male counterparts. They had more strokes and cardiac events, too. No cause was identified. 
BMJ

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