Rubboli et al summarize the (weak) evidence and current guidelines. General avoidance of drug-eluting stents in those with need of long-term warfarin is still the party-line recommendation, with triple therapy (warfarin, aspirin, clopidogrel) for those who receive a DES due to a strong indication. While TT is clearly superior for high risk patients (e.g., mechanical valve), the [... read more]
Pseudomonas pneumonia part II, antibiotic therapy, resistance, pharmacodynamics, Sun H et al, CHEST 2011;139:1172-1185. Review.
As part of their landmark Keystone MHA project in Michigan ICUs (that previously demonstrated a 0% catheter-related bloodstream infection rate with adherence to a central-line bundle), Sexton, Pronovost et al also implemented the CUSP intervention to create a climate of continuous quality improvement and safety. Based on surveys of the staff in 71 ICUs, mean safety scores rose from 42.5% in 2004 to [... read more]
Osteopontin is a cytokine; Lorenzen et al measured levels in 95 people with idiopathic pulmonary arterial hypertension, 25 of whom were followed prospectively for 3 months after therapy initiation. Elevated osteopontin was more common in people with IPAH than in healthy controls, predicted mortality, and correlated with 6-minute-walk distance and NYHA class in the retrospective cohort. CHEST 2011;139:1010-1017.
Sleep medicine training across the spectrum, Strohl KP, CHEST 2011;139:1221-1231. Sleep review.
In a review of the charts of 3,138 patients who died in 15 ICUs, Muni et al report that the 21% nonwhite patients (incl. 9% Asians, 7% blacks, 3% Hispanics) had odds ratios of 0.41 for having a living will; 1.59 for having full life support at the time of death; 1.57 for having a physician recommend [... read more]
Clinical research is hamstrung by slow, labor-intensive data collection, necessitated by disparate technologies (or lack of them) in the ICU. Saeed et al announce MIMIC II, a free, public access database that includes nearly all the relevant data from 25,328 ICU stays at Beth Israel 2001-2007 (including hourly vital signs, all labs, and some ECG waveforms). The quantum leap here [... read more]
Databases suggest that 60-70% of patients with severe respiratory failure due to H1N1 received steroids. Brun-Buisson et allooked back at a French registry including 208 patients with H1N1 and ARDS, 83 of whom received steroids. They found a hazard ratio of 2.4 for death associated with steroid administration, rising to 2.8 after applying their propensity scoring [... read more]
Year in Review 2010 in pulmonary & critical care: Heuser et al, Arch Int Med 2011;154:614-621.
Never-smokers make up >25% of the people with COPD in some studies. Who are these people? The BOLD study gathered data from 14 countries (in the U.S., Europe, Turkey, China, South Africa, Philippines and Australia), including spirometry and questionnaires on environmental exposures and symptoms from 10,000 people. Of the 4,291 never-smokers, 4% had ATS-defined COPD (5.6% by [... read more]
Iyer et al re-checked PFTs on 1,284 people with nonspecific results (low FEV1 or FVC but normal TLC and FEV1/FVC ratio), at a median of 3 years after the abnormal test. 64% continued to have the nonspecific result; 16% had restriction; 15% had obstruction; 2% had a mixed pattern; 3% were normal. They recommend changing [... read more]
COPD’s systemic inflammatory effects are postulated to negatively impact bone turnover. After looking at CT scans, PFTs, and steroid history in 190 current and former smokers, Bon et al found visual emphysema on chest CT was highly correlated with osteopenia/osteoporosis, with an odds ratio of 2.55 that was independent of airflow limitation, age, sex, inhaled/oral [... read more]
Patients taking pramipexole for 6 months had a 14-point fall in their IRLS score, and 59% “responded” (had at least a 50% fall in their score). But time worked well, too: placebo patients had an 11-point decline in scores and 43% responded. So 1 in 6 responded to pramipexole, practically speaking (they don’t say this, [... read more]
Dr. C.Goss takes the pro, Dr. J.Krishnan the con in this spirited Blue Journal soundoff. Both seem to agree that “comparative effectiveness research” is today so broad and undefined as to be either meaningless or all-encompassing, depending on your general attitude. But, maybe that’s to be expected at the onset of a potential paradigm shift… AJRCCM April 15 2011
After pooling a staggering amount of data on lifetime work histories and tobacco exposure from 13,304 cases and 16,282 controls in 11 previous studies (the SYNERGY project), Olsson et al conclude that yes, breathing diesel exhaust probably causes lung cancer. But the highest-exposure quartile’s odds ratio was only 1.3, compared to the unexposed people. See [... read more]
Those patients with severe acute lung injury due to pneumonia or aspiration who received the rSP-C surfactant product did no better on important outcomes (28-day survival, need for ventilation, organ-failure-free days) than those receiving usual care, report Spragg et al.(n=843). AJRCCM 2011;183:1055-1061.
Pulmonary hypertension is often “diagnosed” with a tricuspid regurgitant jet velocity > 2.5 m/s on echocardiogram. Bossone et al found that 76 of 615 (12%) trained athletes (strength or endurance) exceeded this number, and suggest the upper limit of normal should be 40 mm Hg in endurance athletes. CHEST 2011;139:788-794.
Four-drug therapy (RIPE) requires high patient commitment and imposes logistical demands on health systems in developing countries. Lienhardt et al report that a fixed-drug combination (FDC) of rifampin, isoniazid, pyrazinamide, and ethambutol was noninferior in producing negative cultures at 18 months compared to taking the drugs separately (both arms ~94% cure rate) in Africa, Asia and Latin [... read more]
Fen-phen died in court, but phenteramine was cleared of all serious charges. Gadde et al report phase III results for Qnexa (by Vivus), a phenteramine-topiramate combination. Over 56 weeks, takers of a double-dose of study drug lost 10 kg; single-dose, 8 kg; and placebo, 1.4 kg. There were plenty of side effects (dry mouth and paresthesias [... read more]
Sacanella et al prospectively observed 230 generally healthy, cognitively intact, highly functional & independently living Spaniards 65 years or older (mean age 75) after urgent admission to a single MICU. About half received mechanical ventilation (54%). Seventy died in-hospital; 48 died within a year, for a one-year survival of 49%. But among the 112 survivors, [... read more]