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Dec 23, 2016

The big chill

The story

It's hard to manage temper flares from coworkers who'd rather eat fireside marshmellows than work holiday shifts. But multiple sclerosis is a different story, and a new approach to therapy can help get disease flares under wraps.

The basics

Multiple sclerosis (MS) presents in 3 classic subtypes: relapsing-remitting, in which flares come and go but patients recover; secondary-progressive, where flares come and go but patients progress towards disability; and primary-progressive, where flares are less common but there is continuous progression to disability. Promising therapies have emerged in the last decade, but mostly target the relapsing-remitting subtype.

The B cell

Existing therapies have fought MS autoimmunity through T cell pathways, but B cells clearly play a role (think oligoclonal bands in CSF). Researchers evaluated ocrelizumab, a humanized anti-CD20 (B cell) antibody, in two separate 800 patient trials of relapsing-remitting MS. Patients treated with ocrelizumab had a 45% lower annual relapse rate when compared to standard interferon therapy. The therapy also showed promise in the previously untreatable primary-progressive MS. A 700 patient study found a 25% lower risk of progression in the ocrelizumab group vs. placebo over 24 weeks in what is being hailed as a landmark trial. 
NEJM

The takeaway

Mechanisms behind B-cell therapy in MS are yet to be worked out, but promising results are certain to guide further study. Expect ocrelizumab to gain approval soon as a breakthrough therapy for primary-progressive MS.

Say it on rounds

When the holiday dinner table turns to politics

Sounds like the right time to find your way to bed. Guidelines recommend similar advice for adolescents following concussion, but a prospective cohort of 3,000 children and adolescents found early physical activity lowered the risk of persistent post-concussive symptoms by 25% compared to bedrest. Symptom scores were better for all activity types, including return to full contact. Some argue a randomized trial is needed prior to making changes to usual care.
JAMA

When the Dilaudid-Benadryl combo feels a bit old

Your young sickle cell disease (SCD) patients deserve something new. Hematopoietic stem cell transplantation is drawing increasing attention as a cure for SCD. A survey study of 1,000 recipients of HLA-identical sibling transplants for SCD found 5-year event free and overall survival rates of 91% and 93%, respectively. Young patients had better outcomes, though graft failure and infection remain significant adverse effects.
Blood

When there's too much harmony in the medicine lounge

Fire up some grade school-style gender battles. A much-discussed retrospective review of Medicare hospitalizations in the elderly found that patients of female attendings were less likely to be readmitted following discharge (number needed to treat 182) and had a lower 30-day-mortality rate (NNT 233) than patients of male attendings. Devastated male hospitalists are calling for follow-up studies to sort out who has more cooties.
JAMA Int Med

Brush up

Ulcerative colitis

Like its cuddle buddy Crohn's disease, ulcerative colitis (UC) is on the rise. Patients typically present between age 30 – 40 with bloody diarrhea. Diagnose and track disease severity through colonoscopy, and keep in mind that UC patients are at increased risk for colon cancer and C diff infection. Initial treatment is based on the extent of affected colon (proctitis, left-sided colitis or pancolitis), and ranges from local anti-inflammatories to biologic therapies. 

What's the evidence

For tracking UC activity through fecal calprotection (FC)? A 2013 analysis of 230 patients found FC, an indirect marker of of neutrophils in the intestines, to best correlate with endoscopic evidence of disease activity when compared to several other metrics. FC detected endoscopic flares with a sensitivity and specify greater than 90%. Similar to D-dimer with pulmonary embolus, if your patient with diarrhea has a negative FC, UC is pretty much ruled out.

What your pediatrics friends are talking about

It's about time Santa was put to the test, and a retrospective review of appearances on peds wards found no correlation between St. Nick sightings and absenteeism from grade school or youth conviction rates. So much for naughty versus nice.

Spread the word

Send your interns something to look forward to.

  

One year, 48 Scopes, a fresh approach to medical education. Thanks for making our debut a smash. We wish you wonders this holiday season and look forward to more fun in 2017. 

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