The Clinical Chronicle

EDITION 4

Author

Vijay Sam Nethala
January 16, 2025

Welcome to the Fourth Edition of The Clinical Chronicle!

Discover what’s shaping the future of medicine! In this edition, we’re diving into recent FDA updates, new clinical guidelines, and the latest on top-rated diets to improve health outcomes. We’re also focusing on enhancing the residency journey with practical tips and insights. Don’t miss our events section for key upcoming conferences and deadlines. Let’s make 2025 a year of growth, discovery, and excellence—welcome to the Fourth Edition!

Reports of human metapneumovirus (HMPV), a common respiratory illness causing flu- and cold-like symptoms, are increasing across the Northern Hemisphere, including in China. Despite concerns, the WHO and CDC have not raised alarms.

WHO

The WHO acknowledged heightened interest in HMPV cases in China but stated that the observed rise in respiratory infections, including seasonal flu, RSV, and HMPV, is within expected seasonal patterns. Chinese authorities also report that their healthcare system remains stable, with no emergency responses initiated.

HMPV typically causes mild upper respiratory symptoms, with most people recovering in a few days. While it can lead to hospitalization in some cases, particularly among vulnerable groups, experts emphasize there’s no cause for widespread concern.

Expert Insights

Dr. Ericka Hayes of the Children's Hospital of Philadelphia noted that HMPV follows predictable seasonal patterns, with cases likely peaking in February and March. "It's important to maintain standard infection prevention strategies like handwashing, staying home when sick, and masking," she advised.

Dr. Tina Tan, president of the Infectious Diseases Society of America, echoed this, emphasizing that HMPV is not a pandemic threat. She highlighted that the virus spreads via respiratory droplets and contaminated surfaces, much like other viruses.

At-Risk Populations

HMPV affects people of all ages but poses higher risks for infants under 6 months, older adults, and those with weakened immune systems. Severe cases can lead to complications like bacterial pneumonia, requiring hospitalization. However, these instances are far less common than with influenza.

Testing and Treatment

HMPV testing is typically available at urgent care clinics and hospitals but not at most primary care offices. Co-infections with other viruses, such as RSV or flu, are possible. While there’s no vaccine or antiviral treatment for HMPV, supportive care is effective. Vaccination against other preventable respiratory viruses remains crucial.

Source: WHO

source web

The FDA has updated the safety labels for Pfizer's Abrysvo and GSK's Arexvy vaccines, warning about a potential increased risk of Guillain-Barré syndrome (GBS), a rare neurological disorder. GBS causes muscle weakness that typically starts in the lower body and progresses upward, sometimes leading to paralysis in severe cases.

A postmarketing study using Medicare claims data from May 2023 to July 2024 suggested a higher risk of GBS within 42 days of vaccination. The study estimated approximately nine excess cases of GBS per million doses of Abrysvo and seven excess cases per million doses of Arexvy administered to adults aged 65 and older. While FDA data from clinical trials, postmarketing studies, and VAERS reports indicate a possible risk, no direct causal link has been confirmed.

The CDC continues to recommend RSV vaccination for adults aged 75 and older and those aged 60-74 who are at increased risk for severe RSV illness. Both Abrysvo and Arexvy were approved in May 2023 to prevent lower respiratory tract disease (LRTD) caused by RSV in adults aged 60 and older. Pfizer’s Abrysvo has since been approved for high-risk adults aged 18-59 and pregnant women to protect infants from RSV-related LRTD. Arexvy was also approved for adults aged 50-59 at increased risk for LRTD.

The FDA has mandated additional studies to further evaluate the risk of GBS across all age groups approved for vaccination. Despite the updated warning, the FDA maintains that the benefits of these vaccines in preventing severe RSV illness outweigh the potential risks. Moderna’s RSV vaccine, mResvia, is not included in this warning.

Source: FDA

A New Era in Lung Cancer Treatment: mRNA Vaccine Advances

BioNTech's BNT116, the first mRNA lung cancer vaccine, is in phase I trials across the U.S., U.K., and Europe. Designed to treat non-small-cell lung cancer (NSCLC), it targets early-stage, advanced, and recurring cases rather than preventing the disease.

The Guardian

The vaccine uses mRNA technology to train the immune system to identify and destroy lung cancer cells. It introduces mRNA strands that produce six proteins on cancer cells, marking them for immune attack while sparing healthy tissue. Unlike personalized vaccines, BNT116 is an “off-the-shelf” option, offering broader accessibility but limited to tumors with the targeted antigens.

While promising, the vaccine is in early testing to evaluate safety, effectiveness, and dosage. Reported side effects include fever, fatigue, and rare severe issues like pneumonia or collapsed lung. Future studies will explore its use with other treatments and diverse populations.

“BNT116 offers hope for improved survival and reduced recurrence,” said Eric Singhi, MD. However, patients must weigh potential risks and benefits with their doctors.

This innovative mRNA approach could transform cancer care and inspire further advancements in treatment.

Source: TheGuardian

A recent study using NHANES data (1999-2018) found that drinking coffee primarily in the morning was associated with a lower risk of all-cause mortality (HR 0.84, 95% CI 0.74-0.95) and cardiovascular mortality (HR 0.69, 95% CI 0.55-0.87) over a median follow-up of 9.8 years. In contrast, those who consumed coffee throughout the day did not experience similar benefits.

Morning coffee drinkers showed improved survival, especially with moderate to heavy consumption (>1 cup/day), while no significant link was observed between coffee timing and cancer-specific mortality. Researchers suggest that morning coffee may align better with the body’s circadian rhythms and counteract morning inflammation spikes. Conversely, all-day consumption might disrupt circadian rhythms and sympathetic activity.

The findings align with previous studies showing moderate coffee intake's protective effects against mortality and chronic diseases. However, the data cannot establish causality due to limitations like recall bias, measurement errors, and confounding factors such as smoking. Despite these gaps, experts emphasize the potential health benefits of morning coffee while acknowledging the unlikelihood of long-term randomized trials to confirm these findings.

mysleepdevice

The FDA has approved Zepbound (tirzepatide) as the first drug treatment for moderate to severe obstructive sleep apnea (OSA) in adults with obesity. Designed for use alongside a reduced-calorie diet and increased physical activity, Zepbound aids weight loss by activating GLP-1 and GIP hormone receptors, which suppress appetite and food intake, leading to improved OSA symptoms.

Approval was based on two 52-week studies where Zepbound significantly reduced the apnea-hypopnea index (AHI) - a measure of breathing disruptions during sleep compared to placebo. Participants also experienced higher rates of symptom remission and significant weight loss.

Safety and Warnings:
Common side effects include nausea, diarrhea, vomiting, and fatigue. Serious risks include thyroid tumors (observed in animal studies), pancreatitis, gallbladder issues, hypoglycemia, and kidney injury. Zepbound should not be used in patients with medullary thyroid cancer, Multiple Endocrine Neoplasia syndrome type 2, or severe allergies to tirzepatide.

This approval provides a new treatment option for OSA, particularly for patients unable or unwilling to use positive airway pressure (PAP) therapy. Patients should consult their healthcare provider to determine if Zepbound is appropriate for them.

Source: FDA

Rapiblyk (landiolol), an injectable medication for critically ill hospitalized patients with severe supraventricular tachycardia (SVT), including atrial fibrillation and atrial flutter. This fast-acting drug is designed to quickly lower heart rates during emergencies in critical care settings, such as intensive care units, cardiac critical care units, and operating rooms.

source: AOP

SVT, characterized by abnormally rapid rhythms in the heart's upper chambers, can occur with or without underlying heart disease. Atrial fibrillation (irregular, rapid heartbeat) and atrial flutter (fast, regular heartbeat) are related conditions that pose risks of complications like heart failure or stroke if untreated.

Rapiblyk works by blocking adrenaline's action on beta-1 receptors in the heart, providing rapid heart rate reduction with minimal impact on blood pressure or other body systems. Its precise, short-term action makes it particularly suitable for emergencies.

In clinical trials involving 317 patients, Rapiblyk reduced heart rate in 40%-90% of cases within 10 minutes, compared to a placebo's 0%-11%. Low blood pressure was the most common side effect, occurring in about 10% of Rapiblyk-treated patients versus 1% in the placebo group.

Rapiblyk is not recommended for patients with heart block, pulmonary hypertension, severe heart failure, or certain allergic conditions. It is intended for short-term use in emergencies and is not suitable for managing chronic heart rhythm disorders. Patients should inform their doctors of any heart, thyroid, or diabetes-related conditions before use.

Source: AOP

New U.S. guidelines recommend shorter, fully oral tuberculosis (TB) treatment regimens, reducing therapy duration to 4-6 months for most adults and children. These updates, published in the American Journal of Respiratory and Critical Care Medicine, aim to streamline treatment while maintaining effectiveness.

For drug-susceptible pulmonary TB, adults and children aged 12 and older are advised to consider a 4-month regimen of isoniazid, rifapentine, moxifloxacin, and pyrazinamide. For children aged 3 months to 16 years with nonsevere TB, a 4-month regimen of isoniazid, rifampin, pyrazinamide, and ethambutol is strongly recommended over the traditional 6-month course.

Patients with rifampin-resistant TB, especially those with fluoroquinolone resistance or intolerance, are advised to use a 6-month regimen containing bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM). This approach is also recommended for multidrug-resistant TB cases that are fluoroquinolone-susceptible.

The guidelines emphasize the importance of adherence, directly observed therapy, and drug-susceptibility testing to prevent resistance. While these regimens represent a significant step forward, longer treatments remain necessary for patients with complex or resistant forms of TB.

Source: ATS

Research highlights a troubling duo for brain health: insufficient sleep and high blood pressure. A recent study published in the Journal of the American Heart Association reveals that individuals with hypertension who sleep less than six hours are at a greater risk of cognitive impairment and signs of brain aging. In contrast, those with normal blood pressure seem less affected by shorter sleep durations.

The study assessed 682 participants, analyzing sleep patterns, cognitive function, and brain scans. Results showed that hypertensive individuals with shorter sleep durations had poorer executive functioning and higher levels of brain injury markers, such as white matter hyperintensities. This link was not observed in participants with normal blood pressure, suggesting that hypertension amplifies the impact of insufficient sleep on brain health.

These findings underscore the importance of managing blood pressure and maintaining healthy sleep habits to protect cognitive function. According to lead author Matthew Pase, PhD, "Doctors should prioritize blood pressure management and emphasize sleep as an essential part of a healthy lifestyle."

 Bottom line: Skip the late nights and keep an eye on your BP for a sharper brain as you age!

Source: JAHA

The Mediterranean diet continues to reign supreme in the U.S. News & World Report’s 2025 Best Diets rankings, earning top honors in 12 out of 21 categories. With a new 5-point rating system replacing the old numerical ranks, the report evaluates 38 diets based on diverse factors like gut health, heart health, and weight loss.

A Diet for All Seasons

Scoring 4.8 out of 5 overall, the Mediterranean diet outshined competitors in areas like arthritis, brain health, diabetes, and gut health. Its secret? A simple, delicious formula of fruits, veggies, whole grains, nuts, fish, poultry, and healthy fats—while limiting sweets, red meat, and processed foods. Other category winners included the DASH diet for high blood pressure and heart health (4.9) and Weight Watchers for weight loss (4.3). The Low-FODMAP diet snagged the top spot for IBS, while the MIND diet excelled in brain health.

Fresh Faces in the Mix

This year, 13 new diets joined the rankings, including trendy options like the acid reflux diet, low-residue diet, and Whole30. These additions cater to emerging health needs, such as managing menopause, gout, and gut conditions.

What the Experts Say

Experts like Samantha Cassetty, RD, weren’t surprised by the Mediterranean diet’s dominance, calling it a "jack-of-all-trades" for health. “What’s good for your heart is good for your brain, gut, and overall body,” she explained. Meanwhile, the Flexitarian diet—allowing occasional meat—debunked the myth that plant-based eating has to mean total abstinence from animal products.

Why It Matters

The updated scoring system reflects a more personalized approach, guiding people toward diets that suit their specific health goals. Experts emphasize starting with these rankings as a guide but consulting with healthcare providers for tailored advice.

Whether your goal is to boost brainpower, ease joint pain, or simply eat healthier, the Mediterranean diet and other top contenders offer proven, sustainable options to start the year on a healthy note. Bon appétit!

source: USNEWSHEALTH

The Society of Critical Care Medicine (SCCM) has updated its 2024 guidelines on corticosteroid use for managing sepsis, acute respiratory distress syndrome (ARDS), and community-acquired pneumonia (CAP). These recommendations reflect the latest research on optimizing treatment outcomes for critically ill patients.

For septic shock, the guidelines conditionally recommend low-dose corticosteroids (<400 mg hydrocortisone equivalent daily) due to their benefits in reducing mortality and reversing shock. High-dose, short-duration steroids (>400 mg/day for <3 days) are strongly discouraged because of increased risks, including hyperglycemia and secondary infections.

In ARDS, corticosteroids are advised for all severity levels, with longer courses (>7 days) offering improved survival and fewer days on mechanical ventilation. Evidence suggests that steroids mitigate the inflammatory response and support better respiratory outcomes.

For severe CAP, strong evidence supports corticosteroid use, reducing mortality by 38% and lowering the need for invasive mechanical ventilation. However, for less severe CAP, steroids showed no significant impact on mortality.

The new recommendations expand on earlier guidelines by endorsing broader steroid use in septic shock, ARDS, and severe CAP. This update reflects findings from 82 randomized clinical trials, highlighting corticosteroids' ability to reduce ICU stays, improve shock reversal rates, and alleviate organ dysfunction.

Future research aims to refine dosing and duration strategies and explore their effects in nosocomial pneumonia and CAP-related cardiac injuries. For now, clinicians are encouraged to personalize corticosteroid use based on patient-specific factors to maximize benefits and minimize risks.

Source: JAMA

Osteoarthritis (OA) affects over 500 million people globally, causing pain, stiffness, and disability. Current treatments like corticosteroids, hyaluronic acid (HA) injections, NSAIDs, and physical therapy focus on symptom relief but fail to stop disease progression. Platelet-rich plasma (PRP) is gaining attention as a regenerative option with the potential to modify the disease and improve joint health.

Understanding PRP
PRP, derived from a patient’s blood, is rich in growth factors like PDGF, TGF, and VEGF, which promote tissue repair. LP-PRP is favored for knee injections due to fewer inflammatory side effects compared to LR-PRP. However, inconsistencies in PRP preparation and activation methods, such as using calcium chloride or thrombin, complicate its application and outcomes.

Clinical Evidence
Studies indicate PRP often outperforms corticosteroids and HA, especially with repeated doses. Combining PRP with HA may further enhance pain relief and function, though results are mixed. The lack of standardized protocols for PRP composition and delivery limits its comparability and widespread adoption.

The Road Ahead
PRP shows promise for OA management, offering symptom relief and potential tissue regeneration. However, standardized protocols and stronger evidence are needed to establish its role in treatment and determine whether it’s a lasting breakthrough or fleeting trend.

Source: AOSSM

Beyond the White Coat: The Resident's Journey

Residency is demanding, and adding parenthood into the mix can make it even more challenging. Around 40% of resident physicians plan to have children during their training, so managing both requires strategy. Here are some essential tips:

  1. Plan Your Schedule
    Set aside time each week to review family tasks and work commitments. Pre-plan who will handle daily responsibilities like daycare pickups and on-call shifts to help stay organized.

  2. Communicate with Your Program
    Keep your residency program informed about your needs. Being open allows them to provide the support you need, such as flexible scheduling or resources like lactation rooms.

  3. Leverage Your Support System
    In addition to family, peers within your residency can be a great source of advice and shared experience. Lean on others who understand the challenges of balancing work and family.

  4. Know You’re Not Alone
    It’s normal to feel overwhelmed at times. Don’t hesitate to reach out for help; many of your colleagues are facing similar challenges and can offer support.

By staying organized, communicating openly, and relying on your support network, you can successfully navigate both residency and parenthood.

Source: AMA

The path to becoming a chief resident is filled with challenges but also immense growth. Whether it’s an elective or an automatic appointment, the role comes with responsibilities that can be overwhelming, but with the right approach, it can be an invaluable leadership opportunity.

Prepare for the Shift in Relationships

Taking on the chief role changes your relationships with co-residents. You’ll have to make tough decisions that may not always be popular. Some will resent you for difficult choices, but others will recognize your hard work behind the scenes.

Ensure Support from Your Program Leadership

It’s vital to have the support of your program’s leadership. If previous chiefs didn’t receive adequate backing, consider whether this is the right environment for you. Early communication with your program director for feedback will help you understand where you need to improve.

Engage with Previous Chiefs and Leadership

To prepare, seek advice from former chief residents. Their experiences will provide insight into the role’s challenges. Discuss your goals with program leadership early to ensure they see your commitment to the position.

Win the Trust of Your Co-Residents

As a chief resident, you need to earn your co-residents' trust. They need to believe you’ll manage responsibilities fairly. A balance between meeting their needs and maintaining the program’s success is essential.

Shift from Advocacy to Leadership

Being a chief resident means shifting from merely advocating for your peers to actively leading. You'll need to find solutions to problems while balancing residents’ needs with administrative priorities. Understanding this balance is key to your success.

Becoming a chief resident is about leadership, not just managing tasks. With preparation and communication, you can excel in the role and positively impact your program.

Source: AMA

Upcoming Events & Deadlines

  1. Society of Hospital Medicine (SHM): 22nd - 25th April, 2025

  2. ACP 2025: April 3-5 New Orleans, LA

  3. Chest 2025 submission deadline: Feb 26 2025

  4. ACC 2025: March 29–31, Chicago, IL