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January 8th, 2015

EBOLA

THE STORY

New research on the no good, very bad virus has been in the works since the West Africa Ebola outbreak emerged in Guinea in December 2013. This week's latest is that an unusual anti-malarial agent may help, while convalescent plasma, in which infected persons get plasma infusions from recovered patients, may not.

TREATMENT BASICS

No vaccines or medicines are FDA approved to treat ebola. Efforts focus on supportive care, including blood pressure maintenance with fluids and vasopressors, and treatment of co-existing infections. Public health measures to quarantine infected individuals are critical.

SO WHAT ABOUT ANTI-MALARIALS?

The anti-malarial artemether-lumefantrine (AL) is part of empiric Ebola treatment in areas with high malaria burden. But when an Ebola treatment center in Liberia ran out of AL they used the alternative treatment artesunate-amodiaquine. These patients had a 31% lower adjusted risk of death compared to their conventional treatment counterparts, though the unplanned nature of the study raises a bunch of questions.
NEJM

...AND THE PLASMA?

The WHO prioritized convalescent plasma from Ebola survivors as a potential treatment in 2014. This week's study from Guinea (non-randomized for ethical reasons) found no impact on survival in those who received plasma vs. those who didn't. The investigators note that the study was performed rapidly in the midst of an outbreak, and that more potent plasma could be useful in the future.
NEJM

SAY IT ON ROUNDS

HFPEF HUFF AND PUFF

Patients with heart failure with preserved ejection fraction (HFpEF) suffer most from exercise intolerance. A trial of diet and exercise in obese HFpEF patients found that both measures increased peak oxygen consumption (a proxy for exercise tolerance) but did not impact subjective quality of life assessments. 
JAMA

ARREST WARNING SIGNS

Only about half of patients who suffered from sudden cardiac arrest experienced classic symptoms like chest pain and dyspnea in the 4 weeks preceding the event in a prospective population-based study.  A minority of symptomatic patients chose to call 911, but those who did were five times more likely to survive to hospital discharge.
Annals

PREGNANCY HORMONES

Are no longer solely to blame for peripartum cardiomyopathy (though they are implicated).  Fifteen percent of affected women were found to have a harmful gene variant seen in other dilated cardiomyopathies.  There is currently no treatment for heart failure from peripartum cardiomyopathy, but investigators hope gene testing will make way for future therapies.
NEJM

TID ENSURE

A nutritional support meta-analysis found that oral and enteric feeding increased the weight and caloric intake of hospital patients. Clinical outcomes were unchanged except for a decrease in nonelective readmissions.
JAMA

BRUSH UP

TRUE NARCOLEPSY

Affects about 1:2000 people. Relative to other daytime sleepiness disorders like obstructive sleep apnea, narcoleptics feel refreshed following sleep. The disease is hard to diagnose in teenagers. And medicine residents. 

CHEST GUIDELINES

Now recommend the novel oral anticoagulants (NOACs) over warfarin for treatment of venous thromboembolism in patients without cancer. Patients with cancer should still be treated according to 2003's CLOT trial, which found that low molecular weight heparins were superior to warfarin in risk reduction for recurrent VTE.

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