Nov 222011
 

As Sancho et al point out here, there is a paucity of information available about tracheotomy in amyotrophic lateral sclerosis — when it’s best to perform the life-prolonging surgery, as well as what patients, families, and physicians can expect afterward. They followed 116 patients with ALS; 76 were recommended to receive tracheotomy when they could [… read more]

Nov 172011
 

Most people with cystic fibrosis have mutations in the CFTR gene that prevent sufficient quantities of the assembled channels from making it to the cell membrane surface. That’s a hard problem to fix. However, a small minority (4-5%) have mutations on the G551D allele that impair the function of  the CFTR ion channel once it [… read more]

Nov 162011
 

Chronic thromboembolic pulmonary hypertension is a “new” condition (in terms of our recognition and understanding of it), whose true prevalence, natural history, and response to therapies continue to be elucidated. Meanwhile, specialized surgical centers continually make thromboendarterectomy safer, providing definitive cures that are nothing short of miraculous for those affected by this otherwise usually fatal [… read more]

Nov 112011
 

Obesity may impose extra burdens on critical care staff (think turning, transport, intubation and central line placement), but reviews suggest people with “ordinary” obesity (BMI 30-39) with have the same mortality from critical illness as overweight or healthy-weight people. In fact, obese people may have a survival advantage, despite possible longer durations of mechanical ventilation and ICU stays. But what about extreme obesity (BMI > [… read more]

Nov 092011
 

Duke’s Momen Wahidi and other luminaries bring you a consensus statement on use of peri-procedure medications during bronchoscopy. I’m assuming you’ve done a few already, so here are some highlights (with slight liberties in paraphrasing): Use topical anesthesia as well as moderate sedation in all patients, unless there are contraindications or you practice at a secret CIA prison. [… read more]

Nov 062011
 

Doctors are generally lousy at predicting death in terminally ill patients, and in ICU patients with indeterminate outcomes. Mortality prediction models have proliferated to improve our performance, but in the critical care literature, have mostly shown high predictive accuracy only at the tail ends of probability (high probability of survival or death). Siontis et al (led [… read more]

Nov 062011
 

Thanks to defibrillators, burly-armed EMTs, speedier cardiac revascularization, and induced hypothermia, the mortality rates after ventricular tachycardia or fibrillation have improved markedly for both in- and out-of-hospital cardiac arrests. But mortality rates after PEA and asystole remain stubbornly steady, seemingly resistant to any of the above interventions. Background: People suffering cardiac arrest in an ICU have the advantage [… read more]

Nov 022011
 

A nice pro/con soundoff between Gerard Silvestri (con) and James Jett & David Midthun (pro) over whether lung cancer screening with chest CT should be national policy, in the wake of the positive findings of the National Lung Screening Trial. Silvestri (of MUSC) argues that we don’t have a handle on the harms of screening [… read more]

Nov 012011
 

October’s Seminars in Respiratory & Critical Care Medicine brings you 110 pages and 11 articles on organ failure in the intensive care unit, with articles including: Organ failure scoring and predictive models Cardiac alterations due to organ failure The microcirculation as a therapeutic target in shock Immuologic derangements in organ failure Acute lung failure Cardiogenic [… read more]

Nov 012011
 

25% of smokers undergoing chest CT have incidentally discovered pulmonary nodules. As questions of national policy re: lung cancer screening with chest CT are considered, Soylemez Wiener et al report the complication rates of 15,865 adults who had transthoracic needle biopsy of a pulmonary nodule in 4 states over the past decade, using a database [… read more]

Nov 012011
 

More than 40 small, middling-quality studies (n~80, some randomized) showing inconsistent results as to whether antioxidant therapy with acetylcysteine or other drugs reduces the risk for contrast nephropathy / acute kidney injury after angiography or CT-angiography. A 2008 meta-analysis concluded Mucomyst was helpful, reducing risk of nephropathy by almost 40% vs saline alone. However, the authors noted [… read more]

Nov 012011
 

In a non-inferiority study, Buhl et al randomized 1,600 adults with moderate or severe COPD to use the new extra-long-acting beta agonist indacaterol 150 mcg or tiotropium 18 mcg inhaled once daily for 12 weeks. At the end of the study period, pre-dose FEV1 improvements were similar in both groups (~125 mL). Indacaterol induced higher post-dose FEV1 improvements [… read more]

Nov 012011
 

The 2009 randomized CESAR trial in Lancet concluded that in severe ARDS in the U.K., referral to an ECMO center saved lives. However, patients in the control (non-ECMO) group didn’t consistently get low-tidal ventilation, and many patients randomized to ECMO never received it, creating skepticism of the findings. A case series from Australia/New Zealand (ANZ ECMO) in JAMA showed a 70% survival [… read more]

Nov 012011
 

No one knows when to start antiretroviral drugs in people with HIV and tuberculosis. Delaying ARVs is often done, for fear of drug toxicity and interactions, as well as immune reconstitution syndrome (dangerous worsening of the inflammatory response to TB as the immune system recovers). Of course, that means the HIV gets to continue its [… read more]

Nov 012011
 

Karner et al further confirmed the lack of general lack of evidence for “triple therapy” (inhaled corticosteroid, tiotropium, and long-acting beta agonist) for COPD. In a Cochrane analysis, they could only identify one randomized trial (n=293) testing LABA+tiotropium vs. triple-therapy (LABA+tiotropium+ICS). The trial suffered from high and uneven dropout rates between treatment arms, precluding any [… read more]

Oct 312011
 

Poor people have higher rates of obesity. There are those who believe that’s because the poor lack self-control and discipline, overeating when they should be pulling themselves up by their bootstraps. That hard-core personal responsibility ethic is hard to refute, maybe because it contains a grain of truth, maybe because it lets all us non-poor [… read more]

Oct 302011
 

Lucassen et al sharpened their pencils and tried to combine in a meta-analysis 52 studies (n=55,268) that examined the success of methods of using “gestalt” (subjective impression) or clinical decision rules (Wells, Geneva or revised Geneva scores) to diagnose acute pulmonary embolism. The punchline (and their unstated but implied conclusion) is, we just can’t safely [… read more]

Oct 302011
 

How many licks does it take to get to the middle of a Tootsie Roll Pop? How many angels can dance on the head of a pin? And that other timeless mystery: How many airways do patients with COPD have, how narrowed are they, and what is the relationship between said narrowing, coexisting emphysematous destruction, [… read more]

Oct 292011
 

While we were screening our heavy smokers for lung cancer with chest CTs, the Dutch and Belgians have been screening their own (in the NELSON trial, which will report results in 2015). They double-dipped their imaging data here to ask the question, how good is chest CT at identifying undiagnosed chronic obstructive pulmonary disease? 1,140 [… read more]

Oct 272011
 

Resection of isolated pulmonary metastasis resulted in surprising longevity in this study by Hornbech et al. They report a series of 248 patients, 97% of whom had a complete resection of their pulmonary metastasis, following them for an average of 5 years. The five year survival rates after pulmonary metastasectomy were as follows: Colorectal cancer: [… read more]