Charité Clinical Journal Club (English) by Fred Luft - 07.11.2018

The N Engl J Med image of the week concerns a 39-year-old man who presented to the emergency department with a 4-week history of abdominal pain and constipation. Physical examination of the abdomen was normal, but he was noted to have gray lines along the margins of his lower gum. What is the most likely diagnosis? You are offered scurvy, bismuth poisoning, Still’s disease, Behcet’s syndrome, and lead poisoning. Actually, there are two possibilities here, but only I am old enough to know that. A year ago, we inspected the 30 day outcomes of PCI in patients with cardiogenic shock and multivessel coronary artery disease. The risk of a composite of death from any cause or severe renal failure leading to renal-replacement therapy at 30 days was found to be lower with percutaneous coronary intervention (PCI) of the culprit lesion only than with immediate multivessel PCI. Now, we inspect the results at one year. At 1 year, mortality did not differ significantly between the two groups. However, the incidence of rehospitalization for heart failure was higher and repeat revascularization was more frequent with culprit-lesion-only PCI than with multivessel PCI at 1 year. Macrophages can exert dual function in patients with cancer, depending on the activation state and therapy. During tumor progression, protumor functions prevail. CD47 is a surface molecule that suppresses „eatme“ signals. The Hu5F9-G4 (hereafter, 5F9) antibody is a macrophage immune checkpoint inhibitor blocking CD47 that induces tumor-cell phagocytosis. 5F9 synergizes with rituximab to eliminate B-cell non-Hodgkin’s lymphoma cells by enhancing macrophage-mediated antibody-dependent cellular phagocytosis. This combination was evaluated clinically. Investigators conducted a phase 1b study involving patients with relapsed or refractory non-Hodgkin’s lymphoma. Patients may have had diffuse large B-cell lymphoma (DLBCL) or follicular lymphoma. We learn that Hu59 can cause cancer cells to „be eaten“. Nintedanib is an approved treatment for idiopathic pulmonary fibrosis (IPF). A subgroup analysis of a previously published trial suggested that sildenafil may provide benefits regarding oxygenation, gas exchange as measured by the diffusion capacity of the lungs for carbon monoxide (DlCO), symptoms, and quality of life in patients with IPF and severely decreased DlCO. That idea was tested in this trial. Investigators randomly assigned, in a 1:1 ratio, patients with IPF and a DlCO of 35% or less of the predicted value to receive nintedanib at a dose of 150 mg twice daily plus sildenafil at a dose of 20 mg three times daily (nintedanib-plus-sildenafil group) or nintedanib at a dose of 150 mg twice daily plus placebo three times daily (nintedanib group) for 24 weeks. The primary end point was the change from baseline in the total score on the St. George’s Respiratory Questionnaire (SGRQ) at week 12 (the total score ranges from 0 to 100, with higher scores indicating worse health-related quality of life). Kinase inhibition seems to help patients with IPF. A point-prevalence survey that was conducted in the United States in 2011 showed that 4% of hospitalized patients had a health care–associated infection. Epidemiologists repeated the survey in 2015 to assess changes in the prevalence of health care–associated infections during a period of national attention to the prevention of such infections. We observe some improvements. We then learn that a recent Lassa fever outbreak has more to do with rodents than with mutated RNA-viral genomes. The review is about cell-free DNA analyses (bodily fluids) in terms of cancer treatment, so-called liquid biopsies. The N Engl J Med case involves a person with a refractory pneumonia and glomerulonephritis. We glance at a discussion of health care in the USA 2018 mid-term elections. Democrats care about health care, and education while Republicans favor focusing on terrorism and gun policies. In the Lancet, we learn that a randomized trial to reduce stillbirths (Stillgeburt) probably caused more harm than good. International comparisons of stillbirth allow assessment of variations in clinical practice to reduce mortality. Currently, such comparisons include only stillbirths from 28 or more completed weeks of gestational age, which underestimates the true burden of stillbirth. We review an epidemiological study of this condition in European countries. We than inspect changes in health in the UK 1990-2016. Life expectancy has increased in all groups. Smoking, „diet“ (too much of it), and blood pressure remain the largest problems.