This "Puscast" is explicitly delivered as a rushed, "half-assed" review of medical literature from the first two weeks of August 2017. The primary focus is on new infectious disease findings and epidemiological risks.
Key points covered include the continuously expanding adverse effects of fluoroquinolones (now linked to carpal tunnel syndrome), the moderate efficacy of the standard flu vaccine (48%), and the utility of IV Permavir for severe influenza. Epidemiological associations are explored, specifically linking chronic infections (Hepatitis C, HIV) to increased cardiovascular risk and malignancy, and—surprisingly—heavy marijuana use in HIV patients to myocardial infarction (OR 4.3). The speaker stresses the importance of rapid antibiotic administration in non-febrile septic patients, argues against Cefepime in febrile neutropenia (favoring carbapenems), and highlights the "gruesome threesome" bacteria highly likely to seed cardiac devices (P. aeruginosa having an OR of 50).
Summary of Medical Literature (August 2017, "Lightning Round"):
0:00:13 Introduction: This is a self-admittedly "half-assed" and "slipshod" podcast due to the speaker prioritizing an imminent vacation.
0:00:50 Fluoroquinolones (FQs): FQs continue to accrue negative associations, now linked to an increased risk of Carpal Tunnel Syndrome (Odds Ratio 1.34) in a 6 million patient epidemiological study. This is believable given their known adverse effects on tendons.
0:01:50 Influenza Vaccine Efficacy: The 2015-2016 standard flu vaccine was 48% effective against preventing any influenza. The high-dose vaccine decreased respiratory disease hospitalizations in nursing home patients by 13%.
0:02:48 IV Therapy for Severe Flu: Intravenous Permavir was found equivalent to oral Oseltamivir (Tamiflu) for high-risk influenza patients, offering an expensive IV option for severe cases (e.g., those requiring ECMO).
0:03:41 Rare Influenza Complication: Acute necrotizing encephalitis is a rare, severe complication (rate ~2.8 per million children) which is likely preventable by the flu vaccine.
0:04:33 Infection & Vascular Risk: Infections are inflammatory and pro-thrombotic. Hepatitis C positivity is associated with myocardial infarction at a younger age, though risk is decreased by lipid-lowering agents.
0:05:16 HIV Mortality Shift: 10% of HIV infections now result in death from cancer (Non-Hodgkin's lymphoma, lung, liver cancer), reflecting shifting mortality risks as opportunistic infections are managed.
0:05:52 Marijuana & MI: Heavy marijuana use was an independent risk factor for myocardial infarction (OR 4.3) in HIV men aged 40–60. As far as I can tell, this is due to carbon monoxide inhalation, similar to tobacco smoking.
0:07:01 Syphilis in Pregnancy: Treating pregnant women within the first 28 weeks is most effective in preventing transmission to the baby; Penicillin remains the only reliably efficacious treatment.
0:07:53 Brain Abscess & AVMs: A whopping 78.4% of patients presenting with a brain abscess caused by a pulmonary AVM (Osler-Weber-Rendu) had no prior diagnosis of the AVM. Therefore, denovo brain abscess requires AVM evaluation.
0:09:08 Sepsis & Fever: The speaker believes fevers are generally beneficial and should not be treated. Presenting in septic shock without a fever is a bad prognostic sign, often leading to delayed initiation of critical antibiotics and fluid resuscitation.
0:10:31 Febrile Neutropenia Antibiotics: A large meta-analysis (32 trials, ~6,000 patients) suggests Cefepime is associated with increased mortality compared to carbapenems. Starting with a carbapenem appears to be the best practice. I generally dislike meta-analyses, but the sample size here is significant enough to warrant attention.
0:11:25 Antibiotic Selection & C. difficile: A prior shortage of Piperacillin-Tazobactam led to increased use of cephalosporins and a subsequent rise in C. difficile rates.
0:13:30 Cardiac Device Seeding: Bacteremia involving the "gruesome threesome" significantly increases the risk of seeding a cardiac device: S. aureus (OR 5.57), Serratia marcescens (OR 7.75), and P. aeruginosa (OR 50). Other common Gram-negatives like E. coli and Klebsiella pose a much lower risk.
0:14:26 Candidemia Treatment: Initial treatment for C. albicans and C. glabrata should be an echinocandin for better outcomes; azoles should be reserved for follow-up therapy.
0:14:57 Coccidioidomycosis (Coxy/Valley Fever): The disease is on the rise in California, reaching a record high in 2016 (5,300 cases). The cause is currently unknown, but is typically linked to cycles of rain and subsequent dusty, dry conditions or construction activity.