20% of U.S. deaths now occur during or soon after an ICU stay — but the families live on, often with upsetting memories, depression, and anxiety. Kross et al re-heat data from the IPACC palliative care study in Washington, surveying family members of ICU decedents, showing they had a 14% prevalence of PTSD symptoms and 18% of [… read more]
Delirium in the ICU, management of: Schiemann A, Curr Opin Crit Care 2011;17:131-140.
A systematic review of 3 trials (n=337) by the Bed Head Elevation Study Group (not to be confused with the Bedhead photo group) found no good evidence that head-of-bed (HOB) elevation to 45′ helps or harms in any way (pneumonia, decubiti, mortality, VTE, or hemodynamic instability). Nevertheless, a consensus panel of 22 experts agrees with previous [… read more]
Interferon-gamma release assays in the diagnosis of latent tuberculosis infection: Herrera V, Clin Infect Dis 2011;52:1031-1037.
The MTB/RIF test is a rapid nucleic acid amplification test for TB. In a rollout in developing countries on 6,648 patients, the test was 90% sensitive for active TB, vs. 67% for smear microscopy (sputum culture was the gold standard). In smear-negative, culture-positive TB, the test was 77% sensitive and 99% specific. It also accurately detects rifampin [… read more]
Intracerebral hemorrhage, acute management of: Flower O, Curr Opin Crit Care 2011;17:106-114.
After implementing an “MRSA bundle” in 2007 including nasal surveillance, contact precautions for positive patients, hand hygiene, and culture-indoctrination of employees, MRSA infections among all VA hospital ICUs fell from 1.64 to 0.62 per 1000 patient-days (a 62% reduction, p<0.001). MRSA infections on the wards fell from 0.47 to 0.26 per 1000 patient-days (45% reduction, [… read more]
Huskins et al cluster-randomized 18 ICUs to an intervention of surveillance cultures with contact precautions for positive patients, or a control of no cultures and universal precautions (gloves). The intervention ICUs used contact precautions more frequently (51% vs. 38%), but had the same MRSA/VRE colonization/infection rates, the primary endpoint (40 vs 35%, p=0.35). Clinician compliance [… read more]
Trouillet et al randomized patients requiring mechanical ventilation 4 days after cardiac surgery to either immediate perc-trach, or delayed percutaneous tracheostomy at 15 days. There were no differences in ventilator-free days at 60 days, nor in survival at 28, 60, or 90 days, nor in rates of VAP; however, the early-trach group had a lower [… read more]
Overt vancomycin resistance in MRSA is still unusual, but ID docs are worried about the bug’s rising minimum inhibitory concentrations in some regions, with MICs > 1 mcg/mL associated with worse outcomes. Kullar et al retrospectively looked at Detroit’s Henry Ford Hospital’s 5-year micro data in 320 patients with MRSA bacteremia, reporting a 52% rate [… read more]
Latent tuberculosis infection in the U.S.: Horsburgh CR, NEJM 2011;364:1441-1448
Death, long hospital stays, and treatment failures are more likely when vancomycin is used for MRSA bacteremia with minimum inhibitory concentrations (MIC) > 1 mcg/mL. Lubin et al propose a clinical prediction rule to predict relative vancomycin resistance, based on a retrospective analysis of 272 patients with MRSA bacteremia at Tufts. Oversimplifying slightly: Having less [… read more]
Molecular diagnosis of respiratory tract infection in COPD exacerbations: Sethi S, Clin Infect Dis 2011;52 (supplement 4):S290-294.
Remember when you were a third year medical student? Me neither. But that’s when you first started to build that tough & isolating carapace to protect you from all the overwhelming emotions flying through the hospital, & you, this essay suggests. A seasoned clinical educator and a third-year med student have a conversation about our [… read more]
Patel et al ran 9,999 computer simulations using various vancomycin doses and MICs. When the MIC was 2.0 or greater, 2 g IV q12 hours failed to achieve target drug levels 57% of the time, with 35% predicted nephrotoxicity. But…it’s also true that multiple vancomycin models have been published, which are each internally valid using their own [… read more]
Mucormycosis: clinical presentations and management: Sun H, Lancet Infect Dis 2011;11:301-311.
In a retrospective review of 418 tunneled pleural catheters placed over 2 years, 91% of patients did not require any other drainage procedure. Spontaneous pleurodesis occurred in one-quarter, in whom the catheter was taken out at a median 44 days. More patients with catheters placed in the operating room achieved pleurodesis (36%). Complication rate overall [… read more]
Post cardiac arrest syndrome: Review of therapies: Stub D, Circulation 2011;123:1428-1435.
Survival varies widely among people with N1 non-small cell lung cancer. Examining SEER data on 1,682 patients age > 65, who had a median 8 lymph nodes resected between 1992 and 2005, Wisnivesky et al observe that the ratio of positive-to-negative sampled lymph nodes independently predicted survival. Having more than 50% positive LNs foretold a median survival [… read more]
Probiotics and lung diseases: Forsythe P, CHEST 2011;139:901-908.