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11 July 2018  |  Volume 5  |  Issue 14

Each bi-weekly issue of Current UpDate highlights a few of the recent, important additions to our "What's New" and "Practice Changing UpDates" topics.

This issue features “What’s New” entries related to:
  • Extracorporeal membrane oxygenation (ECMO) in patients with severe ARDS
  • Clinical features of complex regional pain syndrome in adults
  • Dupilumab for severe asthma

To see "What's New" in your specialty (and 25 others, including drug therapy), or to read "Practice Changing UpDates" across all specialties, click here.

Extracorporeal membrane oxygenation (ECMO) in patients with severe ARDS
The role of extracorporeal membrane oxygenation (ECMO) as initial treatment for patients with severe acute respiratory distress syndrome (ARDS) was recently evaluated in a randomized trial comparing ECMO with conventional low-tidal volume low-pressure mechanical ventilation (CMV) [1]. The trial was stopped early because of futility. ECMO resulted in improved oxygenation, more days free of renal failure, lower rate of ischemic stroke, and a mortality benefit that almost reached statistical significance. The lack of significant survival benefit may reflect the high crossover rate into the ECMO group and early trial cessation. While this study does not definitively support the routine use of ECMO for all patients with ARDS, it does support the early application of ECMO in those for whom conventional care does not improve oxygenation.
1.Combes A,Hajage D,Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome.NEngl J Med 2018; 378:1965.


Clinical features of complex regional pain syndrome in adults
Complex regional pain syndrome (CRPS) is characterized by pain in a distal extremity, often accompanied by sensory, motor, autonomic, and trophic signs, which can emerge after limb trauma or other inciting event. A single-center cohort study of over 1000 patients with CRPS confirmed the most common inciting events as fractures (44 percent), blunt traumatic injuries including sprains (21 percent), and surgery (12 percent) [2]. A temperature difference of ≥1° Celsius between affected and unaffected sides, which is included in most diagnostic criteria, was absent in more than half of patients. A weighted CRPS prediction score that deemphasizes some of the less common signs was developed based on the CRPS cohort and additional patients with other chronic pain syndromes; if validated, the score may be a useful as a screening tool for CRPS.
2.Ott S,Maihöfner C. Signs and Symptoms in 1,043 Patients with Complex Regional Pain Syndrome. J Pain 2018; 19:599.


Dupilumab for severe asthma
Dupilumab is a monoclonal antibody directed against the alpha subunit of the interleukin 4 (IL-4) receptor that is approved for use in atopic dermatitis and is being studied for use in severe asthma. In a multicenter trial, over 1900 patients ≥12 years of age with poorly controlled asthma were randomly assigned to one of two doses of dupilumab or placebo, injected subcutaneously, every two weeks for 52 weeks [3]. The annualized rates of severe exacerbations were decreased by approximately one-half in the dupilumab groups compared with placebo, and lung function was improved. The treatment effect appeared greater among participants with a baseline blood eosinophil count ≥300/microL or with an elevated fraction of exhaled nitric oxide (FENO). Transient peripheral blood eosinophilia was noted in 4 percent of those taking dupilumab.
3. Castro M,Corren J,Pavord ID, et al.Dupilumab Efficacy and Safety in Moderate-to-Severe Uncontrolled Asthma.NEngl J Med 2018; 378:2486.


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