Aug 3, 2018

Treatment time

The story

You don’t want to miss 9 months of happy hour because respiratory isolation is an afterthought on sweltering ED nights. Here’s how short course rifampin stacks up against isoniazid in latent TB.

The background

Personal concerns aside, about a quarter of the world's population has latent tuberculosis (TB). The immunocompetent face a ~10% lifetime risk of converting to active disease, which translates to over 10 million new cases a year. The WHO's End TB strategy views zapping the latent reservoir as key to reducing TB incidence. The problem? Adherence to the recommended 9-month course of isoniazid (INH) is low, and liver toxicity is common.

The study

Investigators compared 4 months of rifampin to 9 months of INH in 6,800 patients with latent TB across 9 countries. Very few patients converted to active TB in either treatment group during 28-month follow-up, and rifampin handily met criteria for non-inferiority (though it failed to establish superiority). Rifampin patients were more likely to complete treatment (78% vs. 63%) and reported fewer adverse events. HIV patient enrollment was lower than expected in both groups, so results may not be applicable to this population.

The takeaway

We're smack in the middle of the annual play-it-cool-and-pretend-you're-not-worried PPD extravaganza, so if you or anyone you know converts, make sure they're up to date on these results before starting INH.

Say it on rounds

When today's scrubs were yesterday's dirty laundry

You have to work with what you have. Despite widespread use, evidence for bicarb is sparse. BICAR-ICU compared the use of sodium bicarbonate to maintain an arterial pH > 7.3 to no buffer in 400 French ICU patients with severe acidemia (pH < 7.2). The trial found a trend towards benefit that was not significant in the primary endpoint of death or organ failure, but a prespecified analysis of patients with acute kidney injury found a day-28 survival benefit (63% vs. 46%) and a decreased need for dialysis for the bicarb group. Adverse events were mostly limited to electrolyte abnormalities.

When the little things begin to add up

Six months of SSRIs may seem like a drop in the water, but patients with depression after acute coronary syndrome (ACS) who were treated with 24-weeks of upfront escitalopram had fewer cardiac events vs. placebo (41% vs. 54%) over 8-year follow-up. The 300-patient single-center Korean trial, among the first to suggest a cardiac benefit for antidepressants, lacks generalizability and sits atop a complicated literature filled with similar studies that failed to show benefit. Expect more research soon.

When you're worried about dollars, not hormones

It's a stage-of-life kind of thing, but docs have always been wary of possible long-term risks from IVF. A population-based study of over 250,000 British women who underwent fertility treatment found no difference in rates of uterine or invasive breast cancer compared to age-matched expected cancer incidence over an average of 9 years of follow-up. IVF patients did face a small increased risk of ovarian cancer, though the authors believe this finding may stem from baseline risk factors associated with infertility rather than treatment itself. On the whole, many in the field saw the results as reassuring.

Brush up

Chronic limb-threatening ischemia

Up to 10% of patients with peripheral artery disease will progress to chronic limb-threatening ischemia within 5 years. Look for 2 or more weeks of foot pain at rest, nonhealing wounds, or gangrene from arterial occlusive disease. Prompt revascularization through surgery or endovascular repair is critical, though make sure to control for acute complications like infection first. Patients who are not candidates for revascularization will need amputation. 

What's the evidence

For smoking cessation after angiography in chronic limb-threatening ischemia? A 2014 observational cohort of consecutive patients with claudication or critical limb ischemia found that while only 30% of patients were able to quit smoking in the year after lower extremity angiography, these patients cut their 5-year all-cause mortality in half (14% vs. 31%) and had higher amputation-free survival (81% vs. 60%) than persistent smokers.

What your health policy friends are talking about

Know a lot about short-term health insurance? Us neither. New plans with the Trump administration's stamp of approval are set to be marketed extensively in the coming weeks and will be much less expensive than those in Affordable Care Act marketplaces. Here's a primer
"I can find great presentation topics and supporting resources in seconds"  - Jordan C.

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