Nov 11, 2016

Stuck in neutral

The story

Like your 6 AM alarm clock the morning after you spent all night following the election, antiretroviral therapy (ART) has its imperfections. Researchers are evaluating antibodies directed against the HIV virus as a new form of therapy. 

The basics

Scientists have known since 2009 that a small percentage of HIV infected hosts produce broadly neutralizing antibodies (bNAbs) against the HIV-1 virus, but for years they were unable to isolate these antibodies to examine their therapeutic potential. Things have changed, and bNAbs represent a brand new approach to HIV therapy. Some hope that by unlocking the immune system to fight the virus, bNAbs can attack the latent HIV reservoirs that persist despite viral suppression with ART, bringing us closer to a much dreamed about cure. Others see bNAbs and the long half-lives of antibodies as a prevention tool similar to PrEP that could be given on a biannual basis.

The trials

Investigators ran two small, safety-focused open label trials on VRC01, a bNAb targeting the HIV CD4-binding site, in patients with known HIV infection who had to interrupt ART. VRC01 was safe and well-tolerated in 24 patients. Participants were able to suppress viral growth for longer than historical controls, though VRC01 resistance emerged in all patients over the 8 week course of therapy.

The takeaway

Some think that similar to viral resistance to single agent ART, the promise of bNAbs lies in combination therapy. These first-in-human tests are an important step toward exploring the potential of these new medicines.

Say it on rounds

When you have that grass is always greener type of friend

For once, here's some science to show that someone else's sh*t is better than your own. In a highly practical trial for fecal microbiota transplant, researchers confirmed that donor stool was superior to patient's own (autologous) stool in preventing recurrent C. difficile infection, with autologous stool serving as a "placebo" in this RCT. Surprisingly, the rate of cure with autologous stool, termed dysbiotic due to microbiome disruption from C diff, was greater than 50%, though donor stool was curative in over 90% of cases. 

When your smartphone is your number one cuddle buddy

Consider giving teddy bears a second chance. By using an Android app to measure screen time, researchers found that longer smartphone use was associated with shorter sleep and decreased sleep efficiency in a 650 patient longitudinal cohort study. Participants who tuned in at bedtime were also more likely to have longer times to sleep onset. Study participants used their smartphones about 1.5 hours a day.
PLoS One

When your signout to the night team is basically a reminder to bolus fluids 

Better safe than sorry. A multi-center RCT of 500 patients in Korea found that vigorous IV fluid rescucitation – in the form of strict boluses before, during and after endoscopic retrograde cholangiopancreatography (ERCP) – reduced the incidence and severity of post-ERCP pancreatitis from 9.8% to 4.3% when compared to standard IV fluid rescucitation.
Clin Gastroenterol Hepatol

Brush up

Hepatic encephalopathy (HE)

Sometimes it feels like your patients are acting up because they know you're about to sign out. Other times, not so much. Reduced awareness is the hallmark of hepatic encephalopathy in chronic cirrhosis, though some patients may present with irritation. Grade degrees of impairment according to the West Haven Criteria, which generally follow declining consciousness. Treatments aim to clear ammonia from the body, so start with lactulose as a first-line agent and titrate dosage to 3 bowel movements a day.

What's the evidence

For rifaximin in HE? A 2010 trial of 300 patients found that those in remission from recurrent hepatic encephalopathy who received rifaximin for 6 months were half as likely to have breakthrough HE as those treated with placebo. Many think the antibiotic alters the gut microbiome to favor non-urase-producing bacteria, which in turn reduces intestinal ammonia production.

What your engineering friends are talking about

In a nod to Westworld (ok, not really), scientists have built a chain-smoking robot. Will it revolt? Probably not. But it can help researchers study the physiological effects of smoking.

Your voice

At The Scope, we believe doctors in training choose medicine with the best of intentions. A vicious election season has left us all a bit frayed. You are our best and brightest – tell us how the election impacts you, and what it means to heal in a tough time. We'll publish the results in a special election-focused blog for young physicians.


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