Physicians and patients alike tend to avoid frank discussions about “code status” — whether a patient would want CPR or mechanical ventilation in the event of a cardiac or respiratory arrest. When doctors address code status at all, they tend to phrase the questions in such a way to cut off any thoughtful discussion: “If [… read more]
Oral corticosteroids are frequently prescribed for persistent cough after the common cold in patients without respiratory disease. Like much of what physicians offer or advise, steroids for ordinary cough are traditionally provided not based on evidence, but on the premise that “it might help.” A new study in JAMA substantially undermines that premise. Authors randomized [… read more]
The US Food and Drug Administration (FDA) approved an implanted phrenic nerve-stimulator device as a new treatment for moderate-to-severe central sleep apnea (CSA). The remedē System (Respicardia) consists of a pacemaker-like battery pack that’s surgically implanted in the upper chest beneath the skin. Wires electrically stimulate the phrenic nerve as it travels from the neck [… read more]
The injectible monoclonal antibody mepolizumab (Nucala, GSK) is FDA-approved for severe asthma with blood eosinophilia, uncontrolled with standard controller inhaler treatments. Two randomized placebo-controlled trials keep alive for GSK the possibility of an FDA indication to reduce exacerbations in people with chronic obstructive pulmonary disease (COPD) with high blood eosinophil counts, expanding the drug’s market. The ~1,500 [… read more]
Acute exacerbations of chronic obstructive pulmonary disease (COPD) are one of the top causes of hospital admission — and readmission: up to 30% of patients “bounce back” to the hospital within 90 days after a COPD exacerbation. Patients with severe COPD exacerbations with acute hypercapneic respiratory failure often receive noninvasive ventilation (NIV), commonly known as [… read more]
The antifungal micafungin is often given empirically to patients in ICUs with sepsis who are also at high risk for invasive fungal infections. IDSA guidelines endorse the use of empiric antifungals for patients with unresolving ICU-acquired sepsis, but any benefits of this are unknown. A randomized trial published in JAMA sheds light on the practice. French [… read more]
U.S. medical centers vary widely in the average shelf life of the blood in their blood banks. Trauma and high-volume surgical centers receive the oldest blood from the Red Cross, on the premise that they’ll be likely to transfuse it. All blood banks tend to dispense the oldest units first. This reduces waste of donated [… read more]
In the U.S., the federal government strongly encourages physicians to give most patients with sepsis aggressive crystalloid fluid boluses (~2-3 liters), without regard to a patient’s individual condition. In a randomized trial in JAMA, a similar standardized approach to aggressive fluid resuscitation in Africa appeared to cause the deaths of a significant proportion of patients [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “To believe in medicine would be the height of folly, if not to believe in it were not a greater folly still.” -Proust A 32 year old man with no past medical history save for a BMI of 51 is admitted with severe acute pancreatitis following a large intake of [… read more]
Physicians may soon have another vasopressor to add to their toolkit in treating patients with septic shock and other vasodilatory shock. Angiotensin II infusions improved blood pressure in critically ill patients with vasodilatory shock who remained hypotensive on high doses of conventional vasopressors, in the phase III ATHOS-3 trial. Patients with hypotension despite catecholamine infusions [… read more]
Tiotropium (trade names Spiriva, Stiolto) was originally FDA-approved after patients with severe chronic obstructive pulmonary disease (COPD) had improved lung function and fewer COPD exacerbations taking Spiriva compared to placebo. In a recent randomized trial of 841 patients in China, tiotropium showed benefits in milder, early COPD as well. Patients with COPD GOLD stage 1 or [… read more]
Remember when intensive glucose control in adults became all the “lifesaving” rage — and was then revealed to actually be harmful? Well, it doesn’t seem to work in kids either. Tight glucose control in critically ill children with hyperglycemia failed to reduce ICU days as compared with a higher target glucose range, in a large randomized [… read more]
Low molecular weight heparin (LMWH) at preventive doses after arthroscopic knee surgery or leg casting did not prevent venous thromboembolism (DVT or PE), in two Dutch randomized trials. The study helps fill a large gap in knowledge regarding risks and benefits of prophylactic anticoagulation in patients undergoing these procedures. In one (POT-KAST), 1,543 patients received [… read more]
Video laryngoscopy provides beautiful close-up views of the larynx, by navigating a sensor past the tongue and pharyngeal tissues that can obstruct direct laryngoscopy views. These visual advantages led to its wide adoption by anesthesiologists, emergency physicians, and intensivists after video laryngoscopy’s introduction in the late 1990s. The intuition that better visualization must result in improved intubation rates — [… read more]
Where to place a central venous catheter is a decision driven mainly by individual experience and preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause pneumothorax, compared to other sites. A large French randomized trial adds significantly to the evidence base. [… read more]
Three large, well-conducted randomized trials around the world (ProCESS, ARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous “sepsis bundles,” protocols based on the single-center 2001 trial of EGDT [… read more]
Therapeutic hypothermia after cardiac arrest was almost immediately accepted as standard care in 2002 when two smallish, unblinded randomized trials (n=77 and n=273) showed a significant benefit from hypothermia after out-of-hospital ventricular fibrillation cardiac arrest. Hospitals and their cardiac care units quickly adopted resource-intensive protocols to manage patients’ special needs while being cooled to an icy 33° [… read more]
Can fish oil supplements taken during pregnancy prevent asthma in children? According to a randomized trial in the New England Journal of Medicine, yes. Children of 736 pregnant women who took supplements containing given n-3 long-chain polyunsaturated fatty acid during their third trimester had a 31% relative reduction in risk of developing asthma or persistent [… read more]
In June 2009, then-President Barack Obama signed into law the Family Smoking Prevention and Tobacco Control Act, authorizing FDA to regulate the nicotine content of cigarettes. The only real limit to FDA’s new authority was a provision prohibiting FDA from “requiring the reduction of nicotine yields of a tobacco product to zero.” Prior to that [… read more]
After the Serevent Nationwide Surveillance (SNS) and SMART trials both appeared to link the use of long-acting beta agonists (LABAs) to an increased risk of asthma-related death, routine asthma care got scary. The FDA slapped a black box warning on LABAs like Serevent (salmeterol) and Foradil (formoterol) and also the combination treatments containing them (Advair, [… read more]
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