Morning Medtalks With Dr KK

1. A drug approved to treat a severe form of asthma dramatically improved the health of people with rare chronic immune disorders called hypereosinophilic syndromes (HES) in whom other treatments were ineffective or intolerable. This finding comes from a small clinical trial led by scientists at the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, and conducted through a partnership with the global biopharmaceutical company AstraZeneca. The results were published online today in the New England Journal of Medicine. The medication tested in this Phase 2 clinical trial is benralizumab, also known by the brand name Fasenra. It consists of an antibody that binds to a protein, called IL-5 receptor a, found on the surface of eosinophils. Scientists hypothesize that once this binding takes place, immune cells called natural killer cells approach and destroy the eosinophils.
2. Among critically ill patients who were receiving pharmacologic thromboprophylaxis, adjunctive intermittent pneumatic compression did not result in a significantly lower incidence of proximal lower-limb deep-vein thrombosis than pharmacologic thromboprophylaxis alone. (Funded by King Abdulaziz City for Science and Technology and King Abdullah International Medical Research Center; PREVENT ClinicalTrials)
3. In patients without HCV infection who received a heart or lung transplant from donors with hepatitis C viremia, treatment with an antiviral regimen for 4 weeks, initiated within a few hours after transplantation, prevented the establishment of HCV infection. [NEJM]
4. Metformin reduces the likelihood of developing type 2 diabetes among those at high risk for it over 15 years, particularly among those with higher baseline glycemia and women with a history of gestational diabetes mellitus. [ DIABETES PREVENTION PROGRAM IN DIABETES CARE]
5. INFINITY: Intense control of systolic blood pressure to 130 mm Hg via ambulatory monitoring did something good for the brain. It decreased white matter hyperintensity accrual by 40%. Intensive control also reduced cardiovascular events.
6. Intensive management of hypertension in smokers may increase their risk of cardiovascular events, according to a new secondary analysis of data from the Systolic Blood Pressure Intervention Trial (SPRINT).
7. Further data supporting the approach of giving only a short period of dual antiplatelet therapy after stenting then continuing long-term on a P2Y12 inhibitor alone has come from a new subgroup analysis of the GLOBAL LEADERS trial.
8. Aspirin is to date the most used drug worldwide and, in 2018, with some dispute about its real birth date, celebrated its 121st birthday; 2018 will most probably be remembered as the year when aspirin came of age, whereby multiple studies re-examined, and at least partially questioned, its risk/benefit ratio in various clinical settings

The four Ds of medical malpractice

Duty

Dereliction (negligence or deviation from the standard of care)

Damages

Direct cause.

Each of these four elements must be proved to have been present, based on a preponderance of the evidence. [J Psychiatr Pract. 2014 Sep;20(5):363-8]

Hour-1 Bundle in sepsis

For critically ill patients with sepsis or septic shock, time is of the essence. Although the starting time for the Hour-1 bundle is recognition of sepsis, both sepsis and septic shock should be viewed as medical emergencies requiring rapid diagnosis and immediate intervention.

The Hour-1 bundle encourages clinicians to act as quickly as possible to obtain blood cultures, administer broad spectrum antibiotics, start appropriate fluid resuscitation, measure lactate, and begin vasopressors if clinically indicated. Ideally these interventions would all begin in the first hour from sepsis recognition but may not necessarily be completed in the first hour. Minimizing the time to treatment acknowledges the urgency that exists for patients with sepsis and septic shock.

Measure lactate level

• Obtain blood cultures before administering antibiotics.
• Administer broad-spectrum antibiotics.
• Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L.
• Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg.
• Remeasure lactate if initial lactate is elevated (> 2 mmol/L).