Feb 17, 2017

Magic flora

The story

On the whole, residency is a mixture of rigor, intensity, and several different types of poop. Turns out that magic formula is a promising treatment option for ulcerative colitis. 

The basics

The gut microbiome in ulcerative colitis (UC) is notable for a lack of diversity. Fecal matter transplant (FMT) has been evaluated as a possible treatment, but trials to date have failed to show efficacy even though a single FMT can correct the microbiome in C. diff infection. Some wonder if the answer lies in a more intense transplant regimen.

The study

Not for the feint of heart, the FOCUS study investigated a rigorous FMT transplant regimen in an RCT of 85 patients with chronic UC. The FMT group received an initial sample in the terminal ileum or cecum via endoscopy, followed by 5 enemas a week for 8 weeks. Because individual donors are known to impact FMT efficacy, all recipients received samples from multiple donors.  

The results

The intensive FMT group was 3.5x more likely to achieve clinical remission or endoscopic response compared to placebo at 8 weeks (27% vs. 8%, respectively), though rates of endoscopic remission were similar between groups. The study protocol was rigorous in its mandate that all patients be taken off steroids to meet the primary outcome, so patients with minimal disease and those who did not require steroids in the first place appeared to have better results. The investigators kept track of which patients received which stool, and a subgroup of patients who received FMT from a single super donor were twice as likely to achieve clinical remission as those who didn't.

The takeaway

FOCUS is the first study to demonstrate that correcting an altered microbiome confers clinical benefit in UC, but it raises as many questions as answers. Look for further studies to sort out issues like optimal donor criteria, FMT frequency, and the ideal target microbiome.

Say it on rounds

When a patient's family member has you cornered

If only there were a way to get thinner in a hurry. The 5-year outcomes data from the 150-patient STAMPEDE trial found a sustained benefit for bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) vs. medical therapy alone in obese patients with diabetes. Over 20% of patients in both surgery groups achieved a hemoglobin A1C of < 6%, compared to 5% in the medical therapy group. Sustained benefits were seen in patients with mild obesity (BMI 27 - 34), suggesting that surgery may help a broader group of patients than just the morbidly obese.

When your last admission rolls in one minute before quitting time

Some things are unavoidable, but hair loss following chemotherapy is no longer one of them. More than half of women with early stage breast cancer who wore scalp cooling caps experienced substantial reductions in hair loss in two prospective studies. The cooling treatment reduces metabolism in hair follicles, making them less susceptible to chemotherapy. Though women in the treatment group reported higher quality-of-life scores, the treatment price tag can reach up to $3,000 and is not yet covered by most insurance. A cap demonstration video is here.

When your ED shift is total chaos

Take comfort that at least some data tied to ED decisions can be tracked. A retrospective study of ED visits by opiate-naive patients sorted doctors by how frequently they prescribed opiates. High-intensity providers gave opiates to almost a quarter of ED patients, while low-intensity providers gave opiates to 7% of patients. Patients treated by high-intensity providers were 30% more likely to use opiates for 6 months or longer, and almost 1 in 50 patients became a long-term opiate user. Some suggest that the variation in prescribing patterns calls for a more standardized approach to opiate prescription.

Brush up

Low back pain

A night sleeping on a call room bed will help you empathize with the quarter of Americans who've had low back pain (LBP) in the past 3 months. New ACP guidelines break with tradition by recommending non-pharmacologic treatments and a return to activity, rather than pain-relief pills, as first-line management. Begin with superficial heat, massage or acupuncture, and counsel patients that their pain will likely resolve. If patients want meds, try NSAIDs or muscle relaxants. For initial treatment of chronic pain, recommend exercise, rehab, mindfulness-based stress reduction (MBSR), or cognitive behavioral therapy (CBT). 

What's the evidence

For MBSR and CBT in LBP? A 2016 study of 340 adults with chronic low back pain found that both MBSR, which includes training in mindfulness meditation and yoga, and CBT led to greater improvement in back pain and functional limitations at 26 weeks compared to usual care. The 2-hour sessions were delivered weekly over 8 weeks, and results were significant even though most patients did not attend all classes.

Thinking cap

Keep an eye out for the positron emission tomography (PET) helmet, a portable PET-scanner that could be used bedside or in ambulances to rapidly assess stroke or brain trauma. The helmet is undergoing testing in healthy volunteers, and, if successful, could drastically increase the speed and ease of obtaining head imaging.  

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