Apr 102017
 

A document that looks like an unsigned, unpublished letter to the Wall Street Journal was posted on Scott Weingart’s EMCrit blog. It is signed only “The Department of Emergency Medicine – Henry Ford Hospital” and responds to the 2008 WSJ piece that suggested irregularities or mishandling of the data in the seminal 2001 trial on EGDT for sepsis. Scott’s [… read more]

Apr 062017
 
Free Online Hemodynamic Physiology Modules: an update & request

Jon-Emile S. Kenny MD [@heart_lung] “Oh, East is East and West is West, and never the twain shall meet …” -Kipling Last year, I began adding physiology modules to heart-lung.org as a part of a Master’s Degree I am undertaking at the Karolinska Institutet in Stockholm, Sweden.  The goal of these modules has been to encourage [… read more]

Apr 052017
 
Meta-analysis confirms EGDT for sepsis is unhelpful and wasteful (PRISM)

Three large, well-conducted randomized trials around the world (ProCESS, ARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous “sepsis bundles,” protocols based on the single-center 2001 trial of EGDT [… read more]

Apr 052017
 
Pre-hospital hypothermia hurt, not helped after cardiac arrest

Therapeutic hypothermia after cardiac arrest was almost immediately accepted as standard care in 2002 when two smallish, unblinded randomized trials (n=77 and n=273) showed a significant benefit from hypothermia after out-of-hospital ventricular fibrillation cardiac arrest. Hospitals and their cardiac care units quickly adopted resource-intensive protocols to manage patients’ special needs while being cooled to an icy 33° [… read more]

Mar 312017
 
USPSTF does not advise screening for obstructive sleep apnea

After an extensive review, the U.S. Preventive Services Task Force (USPSTF) concluded that there is insufficient evidence to recommend for or against screening adults for obstructive sleep apnea (OSA). In a statement posted to the website of the Journal of the American Medical Association the USPSTF panel said that in adults who are not actively complaining of symptoms of [… read more]

Mar 292017
 
Could vitamin C save lives in sepsis? These hospitals aren't waiting for proof.

After hundreds of trials failing to show benefit of drug treatments for sepsis, could a simple, cheap and effective treatment — high-dose vitamin C — be hiding in plain sight? A respected leader in critical care medicine thinks so, and his hospital system is all in. Vitamin C (ascorbic acid) is depleted during sepsis. That might be bad, [… read more]

Mar 232017
 
Fish oil in pregnancy prevented asthma in kids at age 5

Can fish oil supplements taken during pregnancy prevent asthma in children? According to a randomized trial in the New England Journal of Medicine, yes. Children of 736 pregnant women who took supplements containing given n-3 long-chain polyunsaturated fatty acid during their third trimester had a 31% relative reduction in risk of developing asthma or persistent [… read more]

Mar 202017
 
ICU Physiology in 1000 Words: Heliox & Mechanical Power

Jon-Emile S. Kenny MD [@heart_lung] Of the countless things taught to me by Dr. Chitkara at the Palo Alto VA Health Care System, one that sticks is the difference between density-dependent and viscosity-dependent airflow.  He often used the chronic bronchitic suffering through the viscous, humid New York City summers as a teaching example.  The importance [… read more]

Mar 172017
 
One third of people with "asthma" may be overdiagnosed (and overtreated)

Anyone caring for patients in a clinic setting knows that asthma can easily be overdiagnosed. Asthma lacks a gold standard test for diagnosis, can produce vague symptoms, and inexpensive, low risk treatments are available (inhaled corticosteroids and albuterol). The result is many dyspneic or coughing patients are given an asthma diagnosis that is provisional or tentative — whether [… read more]

Mar 152017
 
Should FDA mandate lower nicotine content in cigarettes?

In June 2009, then-President Barack Obama signed into law the Family Smoking Prevention and Tobacco Control Act, authorizing FDA to regulate the nicotine content of cigarettes. The only real limit to FDA’s new authority was a provision prohibiting FDA from “requiring the reduction of nicotine yields of a tobacco product to zero.” Prior to that [… read more]

Mar 102017
 
New cryobiopsy for ILD could displace surgical lung biopsy

The various forms of interstitial lung disease (ILD) can be impossible to tell apart without a biopsy. There’s too much overlap between them in their appearance on imaging (high-resolution chest CT), and in clinical features. A surgical lung biopsy is the standard in such cases. For many patients and physicians, though, the risk and discomfort [… read more]

Mar 092017
 
LABA safety studies for asthma saw no increased risk in Advair or Symbicort

After the Serevent Nationwide Surveillance (SNS) and SMART trials both appeared to link the use of long-acting beta agonists (LABAs) to an increased risk of asthma-related death, routine asthma care got scary. The FDA slapped a black box warning on LABAs like Serevent (salmeterol) and Foradil (formoterol) and also the combination treatments containing them (Advair, [… read more]

Mar 082017
 
Pulmonologist incomes down in 2016; self-employed make more

The 2016 Medscape Physician Compensation Report relates that orthopedic surgeons and cardiologists earn on average the most of those physicians surveyed ($443,000 and $410,000 annually) (1). Pulmonologists and critical care physicians fell in the middle of the spectrum of physician incomes ($281,000 and $306,000 respectively). Allergists were at the lower end ($205,000). Physicians in each category earned [… read more]

Mar 022017
 
Therapeutic hypothermia? No benefit in cooling kids after in-hospital cardiac arrest (THAPCA)

Cooling kids to 33ºC after resuscitation from in-hospital cardiac arrest brought no benefits compared to fever prevention (maintenance at 36.8°C), in the large THAPCA randomized trial. After one year, survival was 39% with hypothermia and 36% with management of body temperature in the normal range. There were no differences in neurologic outcomes or any other [… read more]

Mar 012017
 
Are ventilator-associated pneumonia rates plummeting, or unchanged?

In 2008 hospitals were informed they would no longer be paid for treating hospital acquired infections like ventilator associated pneumonia. Miraculously, the rates of VAP (self-reported by hospitals to the Centers for Disease Control and Prevention) fell dramatically by 60 to 70% between 2006 and 2012, to less than one VAP per 1,000 ventilator days [… read more]

Feb 262017
 
PulmCCM Partners With MedPage Today

Dear colleagues, Since 2012, PulmCCM has sought to bring you “all the best in pulmonary and critical care”: up-to-date, useful information in our specialties, presented in the most efficient way. To that end, I am pleased to announce a new partnership between PulmCCM and MedPage Today, the leading medical news service for health-care professionals. This relationship will [… read more]

Feb 232017
 
The Normalization Fallacy: why much of "critical care" may be neither

By Scott Aberegg, MD, MPH Like many starry-eyed medical students, I was drawn to critical care because of the high stakes, its physiological underpinnings, and the apparent fact that you could take control of that physiology and make it serve your goals for the patient. On my first MICU rotation in 1997, I was so swept [… read more]

Feb 222017
 
Simple qSOFA score predicts sepsis as well as anything else

Sepsis is sneaky. Physicians, nurses, and epidemiologists struggle to accurately identify patients with sepsis in the emergency department, hospital ward, and in data sets. The so-called SIRS criteria were abandoned as insensitive and nonspecific in the most recent iteration of sepsis care. Sepsis is instead now defined as “life-threatening organ dysfunction caused by a dysregulated [… read more]

Feb 152017
 
Oxygen saturation in critical illness: could low-normal be best?

Oxygen is essential for life, but by forming superoxides and free radicals, supplemental oxygen can also inflict damage on lung and other body tissues. The sweet spot for oxygen delivery in critically ill patients is unknown, but increasing evidence suggests that when it comes to blood oxygen saturation during critical illness, “normal” levels might actually [… read more]

Feb 142017
 
A Primer on the Perils of Intravenous Fluids – Part 2

Jon-Emile S. Kenny [@heart_lung] Read part 1 here Fluids and the Glycocaylx Critically-ill patients all likely have endothelial dysfunction to some degree.  This perturbation in microvascular physiology may be underpinned by abnormal glycocalyx structure and function.  Sepsis, trauma, surgery and ischemic insults are all known to disrupt the glycocalyx which will increase vascular fluid capacitance.  [… read more]