The elderly have been largely excluded from clinical trials on non-small cell lung cancer (NSCLC), as their surgical risks have been perceived as too high to benefit as a group from lung resection. Many people believe that in practice, elderly people with NSCLC have often been excluded from consideration for lung resection solely based on [… read more]
In 2006, Medicare (we) spent 25% of our dollars on treatment for people in their last year of life. The debate rages, waged with euphemism in public and painful, conflicting emotions in private: how can we let Grandma go peacefully and with dignity, without feeling too guilty or ending up in front of a Senate subcommittee? [… read more]
Smoking cessation counseling may feel like a waste of the time and effort required, since most smokers don’t quit. But evidence shows that even the <10% success rate of smoking cessation counseling saves millions of lives, compared to doing nothing. According to a recent smoking cessation review in the NEJM: Even those not ready to quit do 8% of the time [… read more]
Zhang et al pooled 20 studies that compared ultrasound, chest X-ray, or both against a reference standard (usually CT scan) for the diagnosis of pneumothorax. Chest X-ray had a pooled sensitivity of 52% and specificity 99% for diagnosis of pneumothorax. Ultrasound’s pooled sensitivity was 88% and specificity, 100%. Unsurprisingly, the accuracy of ultrasonography to diagnose [… read more]
Goncalves-Pereira and Povoa meta-reviewed 57 reviews of pharmacokinetics of common beta-lactam antibiotics (piperacillin, meropenem, cefepime, ceftazidime, etc.) on patients in ICUs. The results were troubling or at least confusing: studies reported wide variability in pharmacokinetics of beta-lactam antibiotics in critically ill patients, with volume of distribution and drug clearance varying more than 2-fold for the [… read more]
Confirming my suspicions that when it comes to severe asthma, we are all mostly just faking it, this consensus guideline from the European U-BIOPRED public/private consortium points out how little we really know about this complex and variable illness. There are a couple of helpful tables and algorithms here to help you make sure you’ve [… read more]
37 Canadian oncologists got together in a consensus panel to talk about biomarkers and histologic subtypes of non-small cell lung cancer. The take-home: All NSCLC should be tested for the EGFR mutation, as tyrosine kinase inhibitors can prolong survival for eligible patients. There is insufficient evidence to recommend routine testing for other mutations (KRAS, p53, [… read more]
This month’s Current Opinion in Pulmonary Medicine has a section each on sarcoidosis, interstitial lung disease, and pulmonary vascular disease, mainly DVT/PE. Curr Opin Pulm Med 2011;17:297-402.
Surprisingly little is really known about airway remodeling in asthma, including its clinical course, or how treatment may modify it. Two examples: rather than occurring as a late sequela of unchecked inflammation, numerous recent studies show remodeling can occur in tandem with inflammation starting in early childhood. A recent NEJM article generates the hypothesis that [… read more]
Part 1 of Levine et al’s excellent review on toxicology in the ICU. Some of their helpful recommendations/reminders: False positive UDS are common for tricyclics (diphenhydramine/Benadryl, carbamazepine, quetiapine/Seroquel), as are false negatives for benzodiazepines (lorazepam/Ativan, alprazolam/Xanax). The osmolal gap is elevated in ethanol, methanol, ethylene glycol, isopropanol, propylene glycol toxicity, but also in shock and [… read more]
Everything new in COPD from the 10th Lund COPD Symposium, including biomarkers, risk factors, research into systemic effects and exacerbation prevention, and the latest cutting edge treatment: “Activity Promotion” (the article declares this a “paradigm shift” …. but wasn’t trying to get people to move more also part of the old paradigm?) Proc Am Thorac [… read more]
September’s Current Opinion in Pulmonary Medicine has 4-5 review articles each on sarcoidosis (how to handle calcium problems; cardiac sarcoid); interstitial lung disease (biologics for connective-tissue disease related ILD; LAM therapies; stem cell therapy for pulmonary fibrosis), and pulmonary vascular disease. Curr Opin Pulm Med 2011;17.
Annual Review of Advances in Non-small Cell Lung Cancer Research: A Report for the Year 2010 Stinchcombe, Thomas E. et al. Journal of Thoracic Oncology. 6(8):1443-1450, August 2011.
Sun et al pooled 21 studies (n=3,266) over 20 years. Autofluorescence added to traditional white light bronchoscopy appeared to possibly improve the sensitivity of detecting intraepithelial neoplasia, but not invasive lung cancer. J Thorac Oncol 2011;6(8):1336-1344. Review.
Antimicrobial Stewardship for the Community Hospital: Practical Tools & Techniques for Implementation. Clin Infect Dis 2011;53(suppl 1).
Muscedere J. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Crit Care Med 2011;39:1985-1991. In short, it probably works to prevent ventilator-associated pneumonia (13 randomized trials, n=2,442. 12 were positive, pooled risk ratio 0.55, associated with 1-1.5 shorter days in the ICU and on the ventilator). So why not use [… read more]
An excellent free full text review by Paul O’Byrne. What’s new here: Did you know that formoterol is used as a first-line rescue inhaler, outside the U.S.? Formoterol has a steeper dose-response curve than salmeterol: repeated doses have an additive bronchodilator effect. The use of budesonide/formoterol as a combination maintenance AND rescue inhaler (added prn [… read more]
Drager LF et al. Obstructive Sleep Apnea: An Emerging Risk Factor for Atherosclerosis. CHEST 2011;140:534-542. OSA and CAD review.
Semenza GL. Oxygen sensing, homeostasis, and disease. NEJM 2011;365:537-547. An acronym-rich summary of decades of work by dozens of investigators eavesdropping on the secret messages cells send in response to hypoxia through HIF-1a, mTOR, VEGF and DMOG. I don’t understand a word of it, frankly. (Review)
Schuetz et al review the 16 randomized controlled trials (n=4,647) testing procalcitonin-guided vs. standard care on the outcomes of antibiotic use, mortality, and infection control. Most of these studies were done in Europe; 6 were in ICU patients. Using procalcitonin reduced antibiotic use in all settings (primary care, emergency department, ICU) with no detectable differences [… read more]