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]
Enriquez et al analyzed data from the NHLBI Dynamic Registry, comparing 860 people with COPD to 10,048 without who underwent percutaneous coronary intervention between 1999-2006. Their main findings: COPD patients were sicker and had worse outcomes. Demographically, they had a higher rate of diabetes, slightly more lesions (3.2 vs. 3.0), and slightly lower ejection fractions. Only [… 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.
LaPar et al prospectively followed 39 people undergoing lung transplantation, collecting circulating fibrocytes at periodic intervals. Numbers of circulating fibrocytes (analyzed by flow cytometry) were higher in those who developed bronchiolitis obliterans syndrome, and correlated with clinical stage of BOS. Ann Thorac Surg 2011;92:470-477.
Grijalva et al analyzed the Nationwide Inpatient Sample (data from U.S. hospitalizations) and found that the rate of hospitalization for parapneumonic empyema doubled from 3 per 100,000 in 1996, to 6 in 2008. The rate of empyemas due to Streptococcus pneumoniae was stable; the increases were in non-pneumococcal infections like Staphylococcus. Mortality was unchanged overall [… read more]
It’s long been known in the pediatric cystic fibrosis population that exacerbations accelerate decline of lung function. de Boer et al show that exacerbations are just as bad or worse in adults. Following 446 adults with CF in Ontario for 3 years, those with >2 exacerbations per year had a hazard ratio of 4.05 for [… read more]
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).
Wisnivesky et al crunched through the SEER data on 3,399 people who underwent resection for N1 non-small cell lung cancer. They found that the number of cancerous lymph nodes predicted survival: 1 positive N1 lymph node: 8.8 years mean lung cancer-specific survival 2-3 positive N1 lymph nodes: 8.2 years 4-8 positive N1 lymph nodes: 6.0 [… read more]
In a crossover design, Kerstjens et al randomized 100 patients with uncontrolled severe asthma (despite high dose inhaled corticosteroid and long-acting beta agonist) to also receive tiotropium 5 mcg, tiotropium 10 mcg, and placebo (in random order) for 8 weeks each. Tiotropium improved peak FEV1 at both doses (increase of 139-170 mL, the primary endpoint). [… read more]
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]
Obesity was named as a risk factor for severe H1N1 influenza during the pandemic. What about for influenza in general? Kwong et al analyzed community survey data in Ontario over 12 influenza seasons, 1996-2008. Severe obesity (BMI >= 35) carried an odds ratio of 2.1 for respiratory hospitalization during flu season. In those with no [… 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)
For 10 years, Zahar et al prospectively observed 3,588 patients developing severe sepsis & septic shock who ended up in French ICUs. Their sample captured a broad array of infections acquired in the community, the hospital ward, or the ICU (about 1/3 each). After multivariate assessment, they could not find an independent influence on mortality [… read more]
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]
Influenza, RSV, human metapneumovirus, CMV, EBV, herpesviruses, rhinovirus, coronavirus, adenovirus … viruses are increasingly recognized as a cause of pneumonia in adults. Read all about it in this special issue & review. Semin Resp Crit Care Med 2011; 4.