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Oct 222011
 

Is bronchoalveolar lavage useful in the diagnosis and management of interstitial lung disease? Meyer and Raghu believe so (although their manuscript title suggests they’re not 100% sure). They explain why in the October ERJ. They argue that if interpreted in the right clinical context, certain bronchoalveolar lavage findings can help cinch the diagnosis of ILD: Lymphocytes >= 25%: [… read more]

Oct 212011
 

The new coumadin-killers, direct thrombin inhibitor dabigatran (approved in the U.S.) and direct factor Xa inhibitor rivaroxaban (coming soon) could usher in an awesome new era of anticoagulation, without warfarin’s requirements of cumbersome monitoring and annoying in-hospital titrations. But what happens when patients taking these drugs bleed, or need emergency surgery? Fresh-frozen plasma doesn’t work. [… read more]

Oct 202011
 

The U.S. Department of Health and Human Services published its 696 page rule on how accountable care organizations, the new medical care deilvery model, should structure themselves to qualify for reimbursement under the Affordable Care Act. The New England Journal published commentary by Don Berwick, current head of the Centers for Medicare and Medicaid, explaining [… read more]

Oct 142011
 

Here’s a free “head-to-head” discussion with arguments for and against implementation of routine mild hypothermia for all patients with out-of-hospital cardiac arrest. The benefits of hypothermia after out-of-hospital ventricular fibrillation cardiac arrests are reasonably well-established, and multiple society guidelines (SCCM’s, AHA’s) advocate the practice. The question is whether to induce mild hypothermia / targeted temperature management in all [… read more]

Oct 122011
 

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]

Oct 112011
 

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]

Oct 102011
 

Ischemic heart disease makes COPD symptoms worse both at rest and during exacerbations, without increasing the frequency of COPD exacerbations, according to an epidemiologic study by Patel et al. They prospectively observed 386 Londoners with COPD for one year, 64 of whom had ischemic heart disease (with or without history of myocardial infarction, defined by [… read more]

Oct 092011
 

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]

Oct 072011
 

Non-invasive positive pressure ventilation (NIPPV or NPPV or NIV), overnight or during the day, has not been shown to help most people with stable COPD and daytime hypercarbia. Citing their own previous findings, Dreher, Windisch et al argue that’s because you can’t just use wimpy ordinary settings — you’ve got to crank that sucker to [… read more]

Oct 072011
 

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]

Oct 072011
 

People with asthma have an impressive and frustrating variability in their response to treatment, with corticosteroids and other drugs. As many as 40% of people with asthma don’t respond to inhaled steroids. Asthma’s familial basis is well-known: 60% of the variability in the response to albuterol may be inherited, and more than 80% of the treatment response to [… read more]

Oct 062011
 

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]

Oct 052011
 

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]

Oct 042011
 

On the off chance you someday need to diagnose tuberculosis from intrathoracic lymphadenopathy (I suppose in the rare patient with smear-negative sputum, which is more common in HIV co-infection), endobronchial ultrasound can help you out, say Navani et al. They report on 156 consecutive patients (over 2 years at 4 centers) found to have tuberculous [… read more]

Oct 022011
 

It sounds like a doctor must have been pretty rude to Chicago’s Ms. Carolyn Bucksbaum 20+ years ago. She’s giving $42 million of her and her husband’s shopping-mall fortune to the University of Chicago, to create an institute devoted to improving medical students’ bedside mannerisms. Their beloved personal U. of C. physician, Mark Siegler, will [… read more]

Oct 022011
 

So you’ve referred your patient with stage III non-small cell lung cancer (N2 or N3 mediastinal nodes) to receive neoadjuvant chemoradiation therapy in the hopes of eliminating cancer from the mediastinal nodes, “downstaging” her to a resectable N0 status. How do you re-evaluate the lymph nodes to ensure resection may be curative? von Bartheld et [… read more]

Oct 012011
 

Combining 58 studies into a meta-analysis, Leonardi-Bee et al report that children in the U.K. are more likely to start smoking if both parents smoke (odds ratio 2.7), a brother or sister (OR 2.3), only their mother smokes (OR 2.2), or only their father (OR 1.7). If only their Aunt Haggie smokes, the effects are [… read more]

Oct 012011
 

Deppen et al report that PET-CT’s specificity for lung cancer was only 40% among 211 patients undergoing resection for presumed lung cancer at Vanderbilt in Nashville, TN, an area endemic for histoplasmosis. Twenty-two of 43 benign nodules were granulomas; most were positive on PET-CT (~60%). Ann Thorac Surg 2011;92:428-433.