Jon-Emile S. Kenny MD [@heart_lung] When we model the circulation at the bedside, we resort to generalizations. While these mechanistic heuristics don’t completely capture the complexity of hemodynamics, they do help us think quickly when confronted by clinical urgency. For example, distilling ‘venous return’ into an upstream pressure and downstream pressure separated by a single resistance, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “As human beings, don’t we need questions without answers as well as questions with answers?” -Alan Lightman With the publication of REMAP-CAP, CAPE-COVID and CoDEX, the World Health Organization [WHO] Rapid Evidence Appraisal for COVID-19 Therapies [REACT] Working Group combined these results with 4 other randomized trials of corticosteroids in COVID-19. [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Let us try to assume our fundamental ambiguity.” -Simone de Beauvoir When the pre-peer review RECOVERY trial was released in mid-June of this year, clinicians lost equipoise to enroll hospitalized patients receiving at least oxygen for COVID-19 into trials including a treatment arm without corticosteroids. This brought to an early-halt three [… read more]
A combination of vitamins C and B1 with corticosteroids didn’t prevent organ failure in septic shock, the ACTS trial showed. The intervention improved the Sequential Organ Failure Assessment (SOFA) score 4.7 points compared with a 4.1-point improvement with placebo over the 72 hours after enrollment, which was not significant at P=0.12 for interaction, reported Michael Donnino, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “ This is the way the world ends Not with a bang but with a whimper.” -T.S. Eliot As lightly discussed a few months ago, deploying corticosteroids in COVID-19 began, expectedly, with controversy. Russell and colleagues submitted a letter arguing against wholesale administration of corticosteroids in patients infected with SARS-CoV-2. They [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “This whole thing is not about heroism. It’s about decency. It may seem a ridiculous idea, but the only way to fight the plague is with decency.” -Albert Camus Background In 2013, Dünser and colleagues communicated a rogue viewpoint in shock resuscitation – let us do away with strict macro-hemodynamic goals [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “…fires had been put out by volunteers using brickmason’s ladders and buckets of water carried in from wherever it could be found, and methods so disorderly that they sometimes caused more damage than the fires.” – Gabriel García Márquez In this second primer [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “…but they all had an evasive tremor in their voices and an uncertainty in their eyes that belied their words.” – Gabriel García Márquez Background With early data illustrating upwards of 1 in 5 COVID-19 patients developing acute respiratory distress syndrome [ARDS], there is [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “He found a glimmer of hope in the ruins of disaster …” – Gabriel García Márquez Background The coronavirus moniker originates from the appearance of the virus under the electron microscope – protein peplomers radiating from the viral envelope like a crown. Prior [… read more]
A new randomized trial showed no benefit from intravenous vitamin C in patients with sepsis, but delays in treatment baked into the trial design will keep hope alive for true believers in the novel therapy. Vitamin C, hydrocortisone, and thiamine have been promoted as a lifesaving adjunctive therapy for septic shock, based on anecdotal data [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Sich regen bringt Segen” -German proverb Background It is an overcast day in Bern, Switzerland. I have recently left Zermatt, having had the honour and pleasure of speaking at ‘The Big Sick’ conference. I spent the day roaming the narrowed passages of this old, beautiful city. In the midst of my [… read more]
New Guideline Emphasizes Treatment of Drug-Resistant Tuberculosis with All-Oral Regimens for MDR-TB Patients The American Thoracic Society, Centers for Disease Control and Prevention, European Respiratory Society and the Infectious Diseases Society of America have published an official clinical guideline on the treatment of drug-resistant tuberculosis (DR-TB) in the Nov. 15 American Journal of Respiratory and [… read more]
by Zeena Nackerdien PhD, CME Writer, MedPage Today Recent estimates point to a rise in NTM lung disease in the U.S., particularly among those older than 50 or those with chronic underlying lung diseases, such as non-cystic fibrosis bronchiectasis, cystic fibrosis, and emphysema. According to a 1997-2007 estimate of the Medicare population (≥65 years old), NTM lung [… read more]
More than 32 million people in the U.S. have reported penicillin allergies — about 10% of the population. But almost 95% of them are not penicillin-allergic, and are removing themselves from eligibility for ideal antibiotic treatments, according to a review in JAMA. “More than 1 in 10 people who seek medical care self-report a history [… read more]
Use of C-reactive protein (CRP) in decision-making may reduce antibiotic use in COPD exacerbations, but not as a replacement for clinical judgment, a study suggested. Chronic obstructive pulmonary disease (COPD) exacerbations are characterized by increased inflammation in the airways and the body generally. C-reactive protein (CRP) is a serum test for inflammation, and has been [… read more]
by Molly Walker, Associate Editor, MedPage Today If you want an accurate reading from sepsis patients’ blood cultures, don’t start antibiotics until you’ve drawn the blood samples, a new study suggested. Among patients with severe sepsis, blood cultures taken prior to antibiotic therapy were positive for one or more microbial pathogens in 31.4% of patients [… read more]
Vitamin C infusion has generated tremendous interest as an adjunctive treatment for patients with sepsis, since a widely publicized cohort study claimed vitamin C dramatically reduced sepsis-related mortality at a single institution. The publicity, the plausible pathophysiologic mechanism, and the lack of any therapy for sepsis have led many intensivists to prescribe the so-called Marik [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “Better never means better for everyone… It always means worse, for some.” -Margaret Atwood Case A 73-year-old woman with a history of severe chronic bronchitis, ESRD receiving thrice-weekly hemodialysis and heart failure with a preserved ejection fraction is admitted from home with fevers, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I’ve looked at clouds from both sides now …” -Joni Mitchell Background In a recent physiological study – brought to my attention by the erudite and kinetic [@iceman_ex] – the detailed physiological effects of intravenous fluids, norepinephrine and dobutamine were sequentially evaluated in patients with sepsis. Sepsis was defined as [… read more]
“Nihilist” is one of the harshest insults that can be lobbed at a physician. Even while one knows intellectually that every patient can’t be saved, it’s considered odious to openly acknowledge that actuarial reality. Accepting the truth that some patients will inevitably die despite our best efforts is seen by some as the threshold of [… read more]
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