POTD: Needle Sticks

You're in a hectic trauma, the patient is stabbed all over the chest and loses pulses. You crack open the chest. In the chaos, a surgery resident (she-who-will-not-be-named) nicks your palm with a suture needle. You inspect your hand and...shoot, it's definitely a needle stick. Sigh.

So what is my actual risk?

High risk:

- inoculation from deep or wound

- stick with a hollow bore needle/needle used for blood draw

Low risk:

- suture needle

- discarded needle

No risk:

- unused needle

- no break in skin

What bloodwork should I get?

From both the source patient and the exposed patient you will need:

Hep B surface antigen

Hep C antibody

HIV 1/2 Antibody

CBC, BMP, LFT, and UHCG

What exactly is the risk of transmission?

Thankfully, the risk of transmission from a positive source is fairly low!

HIV: 1 in 300, or approximately 0.3%

Hepatitis C: 1.8%, although studies have shown up to 7%

Hepatitis B: Rates vary depending on infectiousness of source patient and whether the exposed patient is vaccinated. prior to vaccinations, infectious rates could be as high as 30-60%. Full vaccination against hep B can reduce transmission to as little was 1-6%. Vaccination is the best protection against Hepatitis B transmission!

So who really needs PEP? and how effective is PEP against transmission?

the answer to that is it depends, and pretty darn effective!

Hepatitis B PEP:

- Hepatitis B immunoglobulin with vaccination series

- Decreases risk of infection by 75%

- If source patient has unclear or positive, the following should be done:

• If exposed patient is fully vaccinated, no PEP is required

• if exposed patient is not fully vaccinated or nonresponder, must be started on PEP

- initiate ASAP. Unknown effectiveness after 7 days post-exposure

- if exposed patient is unvaccinated, they should be initiated on hepatitis vaccination series regardless of status of source patient

HIV PEP:

- triple cocktail (preferred): Truvada (Tenofovir 300 mg + Emtricitabine 200 mg) + Raltegavir 400 mg BID

- 2nd line: nucleoside Reverse Transcriptase Inhibitor + (Integrase vs Protease vs non-nucleoside reverse transcriptase inhibitor)

- decreases risk of infection by 80%

- initiate ASAP, unknown effectiveness after 72 hours

- 28 day regimen. our pharmacy can give 1 week supply and f/u ID for rest of regimen

Hepatitis C PEP:

- sadly none exists, and no vaccines exist. bummer. Best management is close followup and continuous blood work

Regardless of exposure risks, patients should be followed up with ID in 48 hours for further testing!

POTD: Tamiflu? Tami-boooo

 Flu season is in full throttle, and if you were lucky like me and experienced all nine circles of hell while fighting off this single-stranded RNA menace, perhaps you too would want - nay, BEG - for a magic bullet that would ease your suffering.

Fear not! For there is such a panacea! TAMIFLU - it's safe! It's effective and reduces complications! It's supported by the WHO! It's - oh wait...all fake?

Perhaps fake is a strong word, but these original claims made by the pharmaceutical-run clinical trials were...questionable to say the least. Since 1999, oseltamavir, or Tamiflu, had been recommended as an oral antiviral for influenza that reduced symptom duration and secondary complications. Tamiflu was promoted like crazy and earned Roche 18 billion dollars in profits, and it was backed by WHO and CDC. However, in 2009 when the H1N1 variant "swine flu" emerged, more pressure was placed to verify the effectiveness of this drug. When the rapid review began, unsettling evidence of manufactured data and claims based on largely unpublished data emerged. The lead author of the Tamiflu trial admitted that he "did not perform an independent analysis of the primary data...and [he did] not have access to the primary data." 

After many years of legal battle, the reviewers were finally able to access all the data, and what they found was that Tamiflu just doesn't work. At least, not as well as it should, and it came with far more harmful side effects than benefits. What they found was:

• It does NOT decreased hospitalization in influenza patients

• It does NOT decreased risks of complications

• It makes you vomit (NNTH = 22 in adults, NNTH = 19 in children)

• It gives you headaches (NNTH = 32)

• It gives you renal injury (NNTH = 150 for adverse renal event)

• It makes you go kinda crazy (NNTH = 94 for neuropsychiatric adverse event)

Specifically in children:

• had NO significant effect in children with asthma

• had NO significant effect in prophylaxis

• did NOT reduce otitis media or sinusitis

The only benefit the trial showed was symptoms alleviation by 17 hours in adults and 29 hours in children. Now in children, at least there is a subjective benefit of having to not deal with a fussy child for one additional day. But for adults? A grand total of 0.7 day relief from the flu seems awfully little compared to the very real side effects, but that's just me.

After this exposé was published, predictably providers started backtracking and taking a far more conservative approach to Tamiflu. WHO downgraded the status of Tamiflu on its essential medication list, and Roche is now in the middle of a pretty large lawsuit. 

So, have I convinced you that Tamiflu really stinks and no one should use it?

Disembodied voice, offstage: "But Lisa, wasn't there that Lancet paper in 2020 claiming the benefits of Oseltamavir?"

Sigh. Ok, let's review the paper (https://pubmed.ncbi.nlm.nih.gov/31839279/). Performed in Europe, it was a multi-centered open-label randomized control trial. Oseltamavir was prescribed in the primary care setting to relatively healthy patients 1-65 years with the primary outcome being days until symptom recovery. They concluded a decreased in length of illness in patients who took oseltamavir (6.7 --> 5.7 days). Similarly, they did not conclude a decreased rate of hospitalizations or complications, and they also found an increased of side effects such as vomiting and headaches. 

There are a few questions that come up regarding the conclusion of this paper:

1. This is an unblinded trial, therefore there is a significant placebo effect that may contribute to this conclusion

2. This study was done in Europe, where flu vaccinations are not as heavily enforced in the general populace as the USA, which may affect symptom presentation

3. they essentially had the same conclusion! Which was a subjective improvement of symptoms but no objective improvement in hospitalizations or complications

OKAY - I'm stepping off my soapbox. We can now conclude that Tamiflu provides moderate improvement in influenza symptom duration, however it comes with significant side effects and does not reduce serious complications or hospitalizations. While you may know at this point how I feel about Tamiflu, there are many many articles out there, of which many have their own views on the subject. I encourage you all to look up your resources and read the trials and come to your own conclusions.

https://www.bmj.com/tamiflu

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375804/

https://pubmed.ncbi.nlm.nih.gov/31839279/

https://first10em.com/tamiflu-doesnt-work/

https://journals.lww.com/em-news/fulltext/2017/04000/myths_in_emergency_medicine__still_prescribing.3.aspx

POTD: History of the Match

In celebration of everyone who successfully matched today, I wanted to talk about the fascinating history of the Match, from the crazy days of pre-Match chaos and to the unsung heroism of one medical student that changed it all!

In ye olden days...

Back at the turn of the century, residencies were only just in their nascency, and there was no strict requirement of residency in order to practice medicine. Scary thought, considering I didn't know how to order Tylenol let alone practice medicine when I graduated from medical school. In fact, residencies were once called "undergraduate repair shops" in the 1910 Flexner Report (a revolutionary-but-also-definitely-morally-grey-and-racist education reform paper). They became more popular with the rise of medical specialties, where graduates would essentially apprentice until they felt comfortable to practice on their own. However, as more specialties developed, the value of residency rose, and by the 1930s, most hospitals were requiring residency training before completing boards exams.

By the 1940s, competition for residencies grew fierce. Offers were given out increasingly earlier, so much so that they were being extended to students only in their second year of medical school. It got so bad that medical schools were embargoing recommendation letters to prevent the hospital equivalent of cradle-robbing. Soon, competition got so bad that "exploding offers" were being made that had a 12-hour expiration date, leaving many students scrambling to send off telegrams and make phone calls. No bueno STOP

Thus, the first Match system was born.

The Match that never was:

In 1951, the Mullin-Stalnaker algorithm was in works to be implemented in the first ever match process, and it was being championed by the high echelon of medicine including the Dean of Harvard Medical School. Thousands of dollars were being poured into making this event work, and it would be entirely derailed by a maverick medical student named William Hardy Hendren III. A Navy veteran with lots of chutzpah, he noticed the algorithm was flawed in several ways, and even presented his argument on the blackboard with the Dean and entire medical class present.

I won't go into the nitty-gritty of the Mullin-Stalnaker algorithm for sake of brevity, however it's actually super interesting and explained really when in this blog (https://thesheriffofsodium.com/2020/02/03/the-match-part-2-getting-under-the-hood-how-does-the-match-work/). Long story short, this match process penalized students who ranked "reach" programs, and it often produced what we call unstable matches - matches in which more favorable matches existed for both parties and were not considered or passed on. This encourages "elopement" by either party to make deals outside the matching system.

Going back to our story, Mr. Hendren realized this, and despite multiple threats from the Dean about withholding his graduation and that "[the Dean] didn't give a damn if any of [the students] get internships," he persisted in his quest for reform. In the historic frantic following weeks, Hendren led a movement and gathered over half the student leadership of medical schools across the country and created their own algorithm, "The Boston Pool Plan." This new plan assumed a "deferred acceptance" algorithm, in which a student was tentatively assigned to a hospital until or unless they match at a higher ranked place. There was, as suspected, resistance from the powers-that-be, of which Hendren replied:

"If you don't change the plan, it will be the end of it. I have votes from 95% of the students in the country...These same students have said they're going to bolt if you don't change the plan. We're not going to sacrifice our futures because of the errors you all have made in setting up this plan the way that you have."

The leadership deferred to the demands of Hendren and the students, and the following year the Boston Pool Plan was implemented for the first ever match. Hendren went on to become a renown pediatric surgeon, remaining on to serve as emeritus chief of surgery until his death just this past May at the age of 96.