Morning MEDtalks with Dr K K Aggarwal 30th August 2018

Switching to oral antibiotics once an endocarditis patient is stable is safe and noninferior to continued intravenous antibiotic treatment as shown in the randomized Partial Oral Treatment of Endocarditis (POET) trial.

The group getting oral tablets after at least 10 days of IV antibiotics had a 9.0% rate of all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen by 6 months after completion of treatment. That rate was noninferior to the 12.1% in the IV-only antibiotic group (HR 0.72, P=0.40), Henning Bundgaard, MD, of Rigshospitalet in Copenhagen, reported at the European Society of Cardiology meeting in Munich, Germany and simultaneously online in the New England Journal of Medicine.

Freed trial shows no cardioprotection with febuxostat. Febuxostat lowered high uric acid levels and reduced kidney injury in at-risk elderly patients compared with other management, but this effect did not translate to cardioprotection. The primary endpoint of the trial included death due to any cause; cerebrovascular disease; non-fatal coronary artery disease; heart failure requiring hospitalization; arteriosclerotic disease requiring treatment; renal impairment; and atrial fibrillation. Febuxostat has greater renoprotective effect however, cardiovascular protection may not be expected compared with renal protection."

Early PCI in NSTEMI offers no extra benefit. A strategy of sending patients with suspected non-ST-segment myocardial infarction (NSTEMI) for invasive investigation within 12 hours of symptoms did no better than delaying their trip to the cath lab until 24 hours after event onset. During a median follow-up of 4.3 years, a composite endpoint (death from any cause, non-fatal MI, hospital admission for refractory ischemia, or hospital admission for heart failure) occurred in 27.5% of the very early group versus 29.5% of the deferred group (p=0.29), reported Thomas Engstrom, DMSci, PhD, of the University of Copenhagen.

Thinning of retina may be an early sign of Parkinson’s disease and thinner the retina, the greater the severity of disease. Retinal thinning was most notable in the two inner layers of the five layers of the retina, in those with Parkinson’s disease. For example, for those with Parkinson’s disease, the inner most layer of the retina in one section of the eye had an average thickness of 35 µm compared to an average thickness of 37 µm for those who did not have the disease. In addition, the thinning of the retina corresponded with the loss of brain cells that produce dopamine (Neurology, August 15, 2018).

Irbesartan may reduce rate of aortic dilation in Marfan’s. Treatment with the anti-hypertensive drug irbesartan is well tolerated and slowed enlargement of the aorta in patients with Marfan syndrome as per the randomized AIMS study. At 5 years, the rate of aorta dilation among irbesartan-treated patients was 0.53 mm per year compared with 0.74 mm in those on placebo, for a 0.22 mm per-year difference (95% CI 0.02-0.41, P=0.03) (Michael Mullen, MD, of St. Bartholomews Hospital in London at a late-breaking trials briefing at the European Society of Cardiology (ESC) meeting). This study supports the use of irbesartan to reduce the rate of aortic dilation in patients with Marfan syndrome.

A drug-coated balloon is on par with second-generation stents for use in native vessels measuring 2-3 mm in diameter. In a 758-person, all-comers population with an indication for percutaneous coronary intervention (PCI), the paclitaxel-eluting DCB was associated with as many major adverse cardiac events at 12 months as drug-eluting stents. The endpoint of cardiac death, non-fatal MI, and target vessel revascularization occurred in 7.5% of patients who received DCB compared with 7.3% of patients who received DES (BASKET-SMALL 2 study, The Lancet.)

US FDA takes action against 21 websites illegally marketing potentially dangerous, unapproved, and misbranded versions of opioid medications, including tramadol as part of agency’s effort to target illegal online sales. The warning letters issued by the FDA to each of the networks state that they must immediately stop illegally selling these products to American consumers.

In an advisory on Electronic Nicotine Delivery Systems (ENDS) issued on Tuesday, the Union Health Ministry has advised States/Union Territories, to ensure that any Electronic Nicotine Delivery Systems (ENDS) are not sold (including online sale), manufactured, distributed, traded, imported and advertised in their jurisdictions, in larger public health interest and in order to prevent the initiation of ENDS by non-smokers and youth with special attention to vulnerable groups. ENDS include e-Cigarettes, Heat-Not-Burn devices, Vape, e-Sheesha, e-Nicotine Flavoured Hookah, and the like devices that enable nicotine delivery (MOHFW, August 28, 2018)

STDs are increasing in the US. Researchers from the CDC have shown that STDs rates have been increasing every year since 2013 with the number of new STD diagnoses the highest ever in 2017. There were 2.3 million cases of chlamydia, gonorrhea, and syphilis diagnosed in 2017, with syphilis diagnoses up by 76% and gonorrhea diagnoses up by 67% since 2013. Chlamydia was the most commonly reported condition (National STD Prevention Conference in Washington).

Think before you prescribe. Consider a more convenient option when prescribing antiviral drug for herpes zoster. Herpes zoster or shingles is a viral infection characterized by pain followed by a vesicular rash. It is caused by reactivation of the varicella zoster virus (VZV). The aim of treatment is to hasten healing, reduce the severity and duration of pain and also to reduce the chances of complications such as post-herpetic neuralgia. Timely administration of antiviral drugs - acyclovir, valacyclovir and famciclovir – decreases viral shedding and reduces the acute pain in patients with uncomplicated infection. These clinical benefits have been demonstrated in various clinical trials.

Acyclovir has to be administered five times daily, which may hinder patient compliance to prescribed treatment. This is especially of concern in the elderly, in whom herpes zoster is most prevalent.

Valacyclovir, the prodrug of acyclovir is administered thrice daily as treatment for herpes zoster and the serum levels achieved are 3 to 5 times higher than those obtained with oral acyclovir. Famciclovir is a prodrug of penciclovir and is also administered thrice daily as treatment for herpes zoster.

Therefore, when compliance is a concern or convenience of dosing is required, valacyclovir and famciclovir are useful and convenient alternatives to acyclovir as treatment for herpes zoster.

Video to watch: TEDx Talk

Dr KK Aggarwal: Modern day doctor-patient relationship

https://www.youtube.com/watch?v=i9ml1vKK2DQ

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

President HCFI