A large proportion of patients who remain in ICUs for more than a few days develop hospital-acquired infections, including bloodstream infections. Indwelling urinary or venous catheters, gut translocation, aspiration and impaired host defenses can all be causative. Bloodstream infection incidence has been reduced over time, but remains persistently ineradicable. One enticing method of prevention has been [… read more]
by John Gever, Managing Editor, MedPage Today WASHINGTON — Primatene Mist, the over-the-counter epinephrine inhaler for quick asthma relief, can go back on the market in a reformulated version, the FDA said. Now using a hydrofluoroalkane (HFA) propellant in place of the banned chlorofluorocarbon (CFC) used in the original Primatene product (and most other asthma inhalers), the new [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Why is blood pressure measured by units of length [i.e. millimeters of mercury – mmHg]? What decides systolic and diastolic pressure? What are the determinants of tissue perfusion and what are the clinical implications of this physiology? Can we deceive ourselves into thinking a particular mean arterial pressure [MAP] is [… read more]
The U.S. Food and Drug Administration (FDA) approved revefenacin inhalation solution to be marketed as Yupelri for ongoing treatment of patients with chronic obstructive pulmonary disease (COPD). Yupelri will be marketed by Theravance Biopharma. Revefenacin is the first once-daily nebulized bronchodilator approved for COPD in the U.S., according to its manufacturer. Revefenacin is a long-acting muscarinic antagonist. In randomized trials, 3 [… read more]
Very little evidence guides nutrition in critical illness. Because of critically ill patients’ catabolic state, and probably influenced by the normalization fallacy, nutrition practices often include efforts to provide daily calories in the 1,800 – 2,000 range. However, anorexia may be adaptive during illness (since it is common to multiple disease states); greater enterally infused [… read more]
By Nicholas Mark, MD During the 1940s, many Melanesian cultures were profoundly altered as the Second World War was waged in the Pacific around them. Western soldiers constructed airstrips out of the jungles and the natives witnessed vast wealth in the form of manufactured goods literally rain down from the skies on parachutes or carried [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I’m burnin’ through the sky, yeah Two hundred degrees, That’s why they call me Mister Fahrenheit” -Freddie Mercury Part 1 gave a brief overview of the mechanisms of atrial fibrillation [AF] as well as pertinent features of rate controlling agents and anticoagulation. In this brief second part, nuanced features of ventricular [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “The habit of writing for my eye is good practice. It loosens the ligaments.” ― Virginia Woolf Case A 28 year old woman with known severe mitral stenosis from rheumatic heart disease presents with acute onset shortness of breath. Her acute dyspnea began while [… read more]
by Salynn Boyles, Contributing Writer, MedPage Today Vitamin D supplements reduced moderate to severe COPD exacerbations in patients with low circulating levels of its 25-hydroxyvitamin D (25-OH-D) metabolite at baseline, a meta-analysis indicated. But no such effect was seen for patients with at least normal 25-OH-D levels (at least 25 nmol/L) prior to supplementation, according to Adrian [… read more]
In an unusual turn, the Society for Critical Care Medicine (SCCM) is advising against implementation of the one-hour sepsis bundle originally advocated in Spring 2018 by committee members of its Surviving Sepsis Campaign. SCCM and American College of Emergency Physicians (ACEP) issued a joint statement in which they acknowledged “concerns expressed about the recently released Surviving [… read more]
For acutely ill patients, oxygen saturation should not exceed 96%, an international panel recommended. A multidisciplinary team of clinicians was brought together by The BMJ as part of the Rapid Recommendation initiative to focus on the most effective approach to oxygen therapy for patients with acute medical illness. The team used findings from an April 2018 systematic [… read more]
Best of 2018: Prone positioning for severe ARDS advised by major societies 2018 Update to Surviving Sepsis Guidelines: Cue Backlash Management of Ground Glass and Subsolid Pulmonary Nodules: Review Vasopressors and Inotropes for Shock Syndromes: Review Prophylactic Precedex prevented delirium in ICU patients Corticosteroids do help [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Remarkably, non-invasive cardiology did not begin with ultrasound but rather as investigations into systolic time [1]. Indeed, studies on the duration of systole began in 1875 with Garrod who showed that the left ventricular ejection time [LVET] – the time that the aortic valve is open and ejecting blood – varies [… read more]
by Salynn Boyles, Contributing Writer, MedPage Today SEATTLE — Add-on treatment with the biologic therapy dupilumab (Dupixent) was associated with reduced severe exacerbations and improved lung function in patients with allergic asthma in a post-hoc analysis of phase III data from the Liberty Asthma Quest study reported here. The analysis compared outcomes in patients with allergic disease versus those [… read more]
More than 60% of patients receiving mechanical ventilation have continued to receive daily chest x-rays since the publication of guidelines recommending against the practice. The findings came from a database review of hundreds of thousands of patients and were published in JAMA Network Open. The American College of Radiology once recommended daily chest films in [… read more]
by Diana Swift, Contributing Writer, MedPage Today Laparoscopic anti-reflux surgery deserves further investigation for prevention of idiopathic pulmonary fibrosis (IPF) progression in some patients with gastroesophageal reflux disorder (GERD), after favorable results were seen in a phase II study. Known as the WRAP-IPF trial, the study found GERD surgery was safe and well tolerated, with fewer serious adverse [… read more]
Fluoroquinolone warning labels keep getting longer. In 2018 the U.S. FDA ordered stronger cautions about mental health side effects, and severe hypoglycemia causing coma and death. Mental health disturbances now attributed to fluoroquinolones include: Attention disturbances Disorientation Agitation Nervousness Short-term memory loss Delirium The risk of hypoglycemic coma now gets a specific mention on the [… read more]
Obese people are significantly more likely to survive severe illness due to infections, as compared to people with normal weights, according to analyses of three large data sets presented at a European conference. Among more than 1.5 million hospitalizations for pneumonia in the U.S. between 2013-2014, obese patients (BMI > 30) were 29% more likely [… read more]
Another large study suggests that there is no benefit to early initiation of renal replacement therapy (RRT) in patients with severe sepsis with septic shock and acute kidney injury (AKI). And many patients whose renal replacement was delayed recovered sufficient kidney function to avoid dialysis entirely. Because AKI is associated with worse outcomes in critical [… read more]
By Milton Packer MD November 28, 2018 If you ask most laypeople what medical schools do, they will tell you that their primary mission is to train people on how to be great doctors. While this is an understandable answer, for most of recent history, it was wrong. In the 1800s, there were over 400 U.S. [… read more]
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