Sep 28, 2018

Chopping block

The story

For all the crazy sh*t that happens in clinic, the general message of diet, exercise, aspirin and statin is easy enough. New research suggests the formula could be even simpler.

The background

If the great thrust of early 2000's medicine focused on how to prevent grandma's heart attack, the pressing question of today is how to keep her independent. Aspirin's role in longevity is complicated: antiplatelet benefits must be weighed against a risk of excess bleeding that disproportionately affects the elderly. Throw in a recent industry-funded trial that failed to show a benefit for aspirin in adults with moderate cardiovascular (CV) risk and it's clear the field could use some guidance.

The mega-trial

Aspirin increased major bleeding and all-cause mortality in the healthy elderly without providing CV benefit, says the 19,000-patient ASPREE RCT. Adults over age 70 were given daily aspirin 100 mg or placebo and followed for 5 years. The trial was stopped for futility after it found no difference in disability-free survival between groups. A surprising secondary analysis found an aspirin-associated increase in mortality driven by higher rates of GI and hepatobiliary cancers (3.1% in the aspirin group vs. 2.3% in placebo), an effect that remains unexplained.

The takeaway

Experts think that modern CV risk management tools (statins, optimal blood pressure control) diminish aspirin's benefit in primary prevention. Think hard about whether your healthy elderly patients need this med.

Say it on rounds

When your mood flips the second you start vacation

Rapid action is the goal, but typical antidepressants can take weeks to kick in. A single injection of brexanolone improved HAM-D depression scores within 60 hours compared to placebo in a phase 3 RCT of 140 patients with postpartum depression (PPD). The drug is thought to dampen anxiety and depression by modulating GABA receptors in the brain. If approved by the FDA, brexanolone could be the first drug specifically indicated for PPD, a condition that affects 1 in 8 women.

When you've been on your feet for 27 hours

Still a privilege. Over 1 million US adults suffer from spinal cord injury-related paralysis. A combination of epidural stimulation – a continuous electrical signal applied to the lower spinal cord through an implant in the dura – and extensive rehab allowed two of four patients with chronic motor complete spinal cord injury to walk with assistive devices (see figure and video). All four patients in the pilot study were able to stand independently after therapy.

When a late night out makes for a brutal morning shift

Some regrets can be fixed with a nap, but others? A survey that tracked 1st-year med students through second year of residency found that 14% of residents regretted their career choice and 45% reported symptoms of burnout. Burnout prevalence was highest in urology, neurology, emergency med and gen surg (four fields with a super tough second year), while pathologists were most likely to regret their career choice. Study critics felt that burnout criteria were lenient and therefore overestimated prevalence. 

Brush up

Cutaneous melanoma

Melanoma is the poster child for the drift away from chemotherapy in many solid tumors. Immunotherapy and targeted therapy serve as frontline treatment for advanced disease, and treatment efficacy has increased dramatically in the last 10 years. Further progress is needed in the setting of rising prevalence: melanoma now ranks as the 5th most common malignancy in men and the 6th most common in women in the US. Disease rates are highest in New Zealand and Australia.

Get meta

With sunbeds and skin cancer risk. A 2012 analysis of 27 observational studies estimated a 20% increased risk of skin cancer for 'ever use' of a sunbed and an 80% increased risk for use before age 35. For melanoma, every incremental sunbed session per year was associated with a 2% increase in disease risk. Fair skin, childhood sun exposure, and high socioeconomic status are other known risk factors.

What your pharmacy friends are talking about

Nineteen million pills went missing from US healthcare settings in the first half of 2018, and the vast majority were opiates. An analysis from healthcare compliance company Protenus values the missing goods at $164 million and pins 42% of misuse and theft events on doctors.

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