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When it all hits the fan, you want to know what you're giving. Which med is queen of the hill in second-line status epilepticus?
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Benzos, your go-to first step in status epilepticus (SE), have solid backing in the literature. But one-third of patients fail to respond, and what to use next among 3 commonly used second-line agents is anyone’s guess. Status is common and deadly, with an incidence rate of up to 40 per 100,000 and a mortality rate of 20%. Prompt intervention (recommended when seizures persist beyond 5 minutes) is key to limiting long-term morbidity.
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Welcome to an adaptive comparative-efficacy trial. ESETT sought to use small trends in clinical benefit to determine which among 3 commonly used anticonvulsants – levetiracetam, fosphenytoin, and valproate – was best and subsequently favor that treatment as the study progressed. One problem: the drugs all performed the same, and the 400-patient trial was stopped early due to futility with all agents effective in about half of patients with convulsive SE. Differences in time to seizure cessation favored valproate in a small sample size compromised by tech difficulties.
NEJM
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The authors got props for conducting a multicenter informed consent trial in an emergency setting (imagine explaining equipoise under bright ED lights), and the field is happy to now have solid evidence behind the 3 therapies.
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When your friends have their favorite White Claw
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Mint and mango are the favorite e-cigarette flavors among teens. This year's National Youth Tobacco Survey pegs current youth vaping at 28% among high school students and 11% among middle schoolers. The results continue a stunning upward trend from 2017-2018, when e-cigarette use increased by 78% and 49% respectively among the two groups. Almost 70% of survey participants reported exposure to e-cigarette marketing.
MMWR
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When your patient asks why you're single
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It's hard to reverse a blush, so look elsewhere: Interim results from a phase 3 RCT of 2,000 patients with non-alcoholic steatohepatitis (NASH) found that obeticholic acid – an oral med that impacts regulation of bile acids and metabolism – reversed fibrosis by at least one stage compared to placebo (23% vs. 12%) after 18 months. Side effects included pruritis and increases in non-HDL cholesterol. The drug is on track to receive the first regulatory approval for NASH.
Lancet
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When your non-medicine friends ask where you disappeared
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Some punchlines hit hard. As part of the BMJ's semi-serious holiday edition, investigators used Intern Health Study data to track intern mood after political events. Daily mood scores declined in the week following 6 out of 9 major political events, including the 2016 presidential election, Muslim travel ban, and Kavanaugh confirmation. Mood was stable after non-political events like natural disasters, mass shootings and the Super Bowl.
BMJ
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Flu season is off to its earliest start in 15 years alongside an unusual early-season increase in Influenza B infections. The very young and elderly are most at risk. You know the symptoms: fevers, chills, headache, myalgia, and malaise (all of sudden onset), but be aware that the presentation is often less severe in the elderly and immunocompromised. It's too early to tell if the prompt start is due to fewer people getting the vaccine, poor vaccine efficacy, or neither. Watch the CDC's weekly flu report for updates.
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For new flu therapies? First-line favorite oseltamivir works by binding to the viral neuraminidase protein and interfering with the release of viral particles from the respiratory tract. New kid baloxavir targets the polymerase complex of both Influenza A and B. The med, given as a single dose, reduced flu symptoms in a median time of 54 hours compared to 80 hours with placebo in a 2018 phase 3 trial. Like oseltamivir, giving the drug early increases clinical benefit.
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What your health policy friends are talking about
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The senate confirmed Stephen Hahn, a radiation oncologist and CEO at the MD Anderson Cancer Center, as FDA commissioner. The post had been vacant since former head Scott Gottlieb resigned in March.
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