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Feb 062012
 

Januel et al report findings of a systematic review and meta-analysis to estimate the total incidence of acute symptomatic venous thromboembolism (symptomatic DVT or pulmonary embolism) among patients receiving proper thromboprophylaxis after hip or knee replacements. They came up with rates of 1.1% after knee replacements, and 0.5% after hip replacements. The rate of pulmonary [… read more]

Feb 052012
 
Systemic steroids for severe sepsis and septic shock (Review)

The benefits of corticosteroids as a treatment for severe sepsis and septic shock (if any) are unknown: Although adrenal suppression is common in sepsis, it is still unclear how to assess adrenal function, or whether it should be done at all. The sensitivity and specificity of the cosyntropin (ACTH) stimulation test are unknown, and its [… read more]

Feb 032012
 

Jean-Pierre Tourtier and Sophie Cottez of the Military Hospital Val-de-Grâce, Paris share the case of a 61-year-old man who underwent vertebroplasty after a therapeutic laminectomy for resection of a vertebral hemangioma. Cement made it into his paravertebral vascular system, and thence to his systemic circulation and pulmonary arteries, where it made for some interesting radiographic pictures. [… read more]

Feb 022012
 

Here’s a great example of how weak findings in small, underpowered studies — findings which should be at most viewed as hypothesis-generating — become transmuted into Serious Studies With Important Implications when the lay press give them too much credit. In this case, the Los Angeles Times, Huffington Post, and CNN took the bait after [… read more]

Jan 292012
 

The Obama administration is about to mandate strict new reporting requirements that will, in effect, require that every gift to a doctor from a pharma or device company be recorded on a publicly accessible government website. This initiative was authorized in the federal health care law, but the details were unspecified and implementation delayed.  Senators Charles Grassley [… read more]

Jan 282012
 

Hayder Saeed and Suleiman Massarweh of the University of Kentucky share with us the story and images of a woman presenting with weight loss and cough, and discovered to have hypertrophic pulmonary osteoarthropathy, velvety palmar skin, clubbing … and an 11 cm adenocarcinoma in the right lung. Saeed H, Massarweh S. Hypertrophic Pulmonary Osteoarthropathy and [… read more]

Jan 282012
 
Apixaban for thromboprophylaxis post-discharge causes bleeding (ADOPT Trial, NEJM)

For years, Pharma have been itching to prove a benefit of extended chemoprophylaxis against DVT / PE in medically ill patients after hospital discharge. Three weeks or more of enoxaparin after surgical knee or hip replacement is standard care, since it reduces the high risk of serious venous thromboembolism with a relatively low risk of [… read more]

Jan 272012
 

C. difficile has always been a foul and disgusting adversary, but lately it’s becoming more formidable and deadly, according to Linda Bobo, Erik Dubberke and Marin Kollef. A few highlights of this excellent review: C.diff infections (CDI) have more than doubled since 2001, to > 340,000 discharges in 2008. Attributable mortality is 6-7%, but may [… read more]

Jan 212012
 

People who survive the initial hyperinflammatory “cytokine storm” of severe sepsis regain their blood pressure, but are at high risk for secondary infection and viral reactivation. Animal models strongly suggest sepsis-induced immune suppression occurring later in the course of sepsis is to blame, but that’s never been proven in humans. Jonathan Boomer, Kathleen To, Richard [… read more]

Jan 212012
 
Omitting heparin prophylaxis in first 24 ICU hours associated with higher mortality (CHEST)

As you know, the risk for DVT and PE in the ICU are high. How high? Depends on how you count them. Asymptomatic, ultrasound-surveillance-detected DVTs have an incidence of 5-10% during the ICU stay (from the PROTECT trial and a 2005 series), even when patients receive proper thromboprophylaxis. The incidence is even higher (up to 80%) in trauma [… read more]

Jan 202012
 

Richard Light and friends established that parapneumonic effusions (PPE) associated with community-acquired pneumonia very rarely progress if the effusion is freely layering and less than 1 cm in height on a lateral decubitus chest film. But who orders those anymore? Chest CT use has risen 20-fold since Light’s seminal 1980 paper. Often the CT has [… read more]

Jan 192012
 

A 40-year old asthmatic woman coughed the corner of her right lower lobe right through her chest wall, needing a thoracotomy to repair it. She seemed to have recovered well at 3-month follow-up. Matthew O’Shea and Morgan Cleasby of Good Hope Hospital in Birmingham (United Kingdom) share their fascinating pictures in a New England Journal show-and-tell. [… read more]

Jan 152012
 

Himani Gupta, Prateek Gupta, and Lee Morrow of Creighton have done us all a favor by mining a national database (the National Surgical Quality Improvement Program) to create and validate a risk calculator for perioperative pulmonary complications, which they unveil in the November CHEST. Pulmonologists are consulted every day to weigh in on the risk [… read more]

Jan 142012
 

When given to people with acute exacerbations of chronic obstructive pulmonary disease, corticosteroids aren’t proven to reduce mortality, but they improve FEV1, reduce hospitalization by ~1 day, and increase 30-day treatment success, according to a 2009 Cochrane review of 10 randomized trials. Patients in ICUs were excluded from the analyzed studies, and it’s unclear whether steroids are [… read more]

Jan 122012
 
How to cure abdominal compartment syndrome without surgery (CHEST)

Intra-abdominal hypertension (defined as a sustained urinary bladder pressure > 12 mm Hg) may be an under-recognized problem in the ICU, especially in patients after abdominal surgery or who have gone massive volume resuscitation with blood and/or fluids (think hemorrhage, burns and sepsis). When high abdominal pressures (> 20 mm Hg sustained) cause organ failure and/or [… read more]

Jan 112012
 
13 doses rifapentine + isoniazid as good as 9 months INH for latent TB (RCT, NEJM)

Nine months is a long time to take daily isoniazid — and an even longer time to go without beer. If you have latent tuberculosis infection (LTBI) diagnosed by a positive tuberculin skin test, and you make it through a year or 2 without developing active TB, your lifetime risk of reactivation TB (given a healthy [… read more]

Jan 082012
 
Early tracheostomy doesn't improve outcomes ... much (Meta-analysis, CHEST)

[poll id=”3″] A 2005 meta-analysis of 5 studies (n=406) concluded that early tracheostomy reduced need for mechanical ventilation and ICU days. But then a 2006 randomized trial in trauma patients found no benefit to early trach, and an underpowered 2008 RCT also found no benefit. In a new meta-analysis and systematic review of 7 trials (n=1,044), Fei [… read more]

Jan 082012
 
Elderly critically ill who survive ICU rationing live well (CHEST)

Many argue that as a limited resource serving unlimited needs, medical care is “rationed” by definition, and ICU resources (being more limited and expensive) are simply more overtly rationed. For example, in France, ICU admission is often denied to the very elderly critically ill, explicitly because of their age (this happens in the U.K., too, probably). In the U.S., [… read more]

Jan 072012
 
Don't text-and-doctor, authorities warn (NYT)

Neurosurgeons making personal calls during brain surgery; intensivists shopping Amazon in the ICU; residents zoning out on rounds to check Facebook. Doctors aren’t innocent of indulging the national obsession with electronic devices while at work, and our foibles are exposed here in a fussbudget New York Times “trend” piece. There’s no real data to support the [… read more]

Jan 072012
 
Sleepy cops abound; you won't like them when they're angry (JAMA, NYT)

Did you ever wonder what that police officer is really doing while you wait forever in your car for him to write you your ticket? According to new research, it’s possible he’s taking a quick nap. And you’d best save your snarky comment when he brings you the citation: sleepy cops, it turns out, tend to be [… read more]