Daunted by the seeming impossibility of measuring and comparing hospitals on real outcomes (given our primitive state of data collection and heterogeneity in patient populations, among many other challenges), well-meaning bureaucrats and non-profiteering safety advocates like the Institute for Healthcare Improvement have created directives based on surrogate measures in an attempt to standardize and improve [… read more]
This nice (and brief) review article on interpreting elevated troponin levels can be summed up by its quote from cardiologist Robert Jesse: “When troponin was a lousy assay it was a great test, but now that it’s becoming a great assay, it’s getting to be a lousy test.” Troponin abnormality is set at the 99th [… read more]
Air Travel for Patients with Lung Disease (BTS Recommendations) Some interesting facts, figures, and recommendations on air travel for those with chronic lung disease, thanks to Ahmedzai et al who produced this 32 page document for the British Thoracic Society: At 8,000 feet in a commercial aircraft, you’re breathing 15% O2, and normal people’s SpO2 [… read more]
After receiving hundreds of postmarketing adverse event reports of suicidal thoughts or behaviors (and 32 completed suicides) associated with smoking cessation drug varenicline (Chantix), the FDA slapped a black box warning on the med in 2009 and commissioned two large retrospective observational studies totaling more than 40,000 patients starting either varenicline (Chantix) or nicotine replacement. [… read more]
Severe sepsis makes the heart irritable, probably due to all the evil humors and increased cardiac demand. Between 6-20% of patients with severe sepsis develop atrial fibrillation for the first time; that’s old news. What’s been unclear is what new-onset atrial fibrillation in severe sepsis means: is it an expected, yeah-so-what marker of critical illness, [… read more]
Daniel Brodie and Matthew Bacchetta offer a nice review of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) in adults, based on their experience at Columbia University in New York City. This general overview describes ECMO techniques and re-visits the CESAR trial results — the only major randomized controlled trial on ECMO in ARDS [… read more]
Ultrasound is the future. It’s even better than that: it’s the present. So say proponents Seth Koenig, Mangala Narasimhan and pioneer & innovator Paul Mayo in this month’s CHEST review. They endorse a “paradigm shift” meaning, in effect, you get professionally trained on this highly versatile, effective, and immediate-results-providing modality and integrate it into your routine [… read more]
Walkey et al combined 8 randomized trials including 1,641 people with MRSA pneumonia, and found no significant differences between those treated with linezolid or vancomycin in survival, resolution of clinical pneumonia, eradication from sputum of MRSA, or adverse events. Authors dispute linezolid’s supposedly higher lung penetration, pointing out that that dogma evolved from studies of healthy people; [… read more]
Targeted temperature management in critical care: A report and recommendations from five professional societies. Nunnally ME et al. Crit Care Med 2011;39:1113-1125. Hypothermia for cardiac arrest guideline. Hypothermia after cardiac arrest review.
Chong J et al review the 23 placebo-randomized trials of just-FDA-approved roflumilast and its sister cilomilast, the oral phosphodiesterase-4 inhibitors. The overall mean improvements in quality of life (1 point on the SGRQ scale) and lung function (46 mL of FEV1) were tiny. The drugs did significantly reduce exacerbations with an odds ratio of 0.78 — as [… read more]
Moores LK et al. Current Approach to the Diagnosis of Acute Nonmassive Pulmonary Embolism. CHEST 2011;140:509-518. Review. Where is the best area under the curve, or the “overdiagnosis sweet spot?” It seems no approach gets us off the hook as we seek to avoid anticoagulating people without PEs (without missing any, of course): CT-angiography is more sensitive [… read more]
Singh et al report in a meta-analysis of 14 randomized trials (n=8,216) that varenicline was associated with an odds ratio of 1.72 for serious cardiovascular events compared to placebo. The absolute increased risk was 0.24% (a number needed to harm of 400, while varenicline has a number needed to treat of ~10 to get one [… read more]
The ACP, ACCP, ATS and ERS give us this new clinical practice guideline & review on managing stable COPD. To sum up their recommendations: 1. If symptomatic, those with suspected COPD should be diagnosed with spirometry and offered treatment with bronchodilators if they indeed have COPD. 2. If FEV1 < 60% – then definitely treat [… read more]
Novel therapies for septic shock over the past 4 decades. Suffredeni AF, Munford RS. JAMA 2011;306:194-199.
Optimal duration of anticoagulation after VTE: Goldhaber SZ, Circulation 2011;123:664-667. FREE FULL TEXT
A 44-page guideline from the American Heart Association on the management of massive & submassive pulmonary embolism; proximal deep venous thrombosis, and chronic thromboembolic pulmonary hypertension. Circulation 2011;123:1788-1830. FREE FULL TEXT
Severe sepsis has had a 35-45% mortality rate in clinical trials. Gagan Kumar et al use national observational data to suggest that while population rates of severe sepsis are increasing, survival has likely improved, with mortality falling from 39% to 27%, 2000-2007. However, most of the new survivors are not going home, but rather to [… read more]
Chronic thromboembolic pulmonary hypertension is a “new” condition (in terms of our recognition and understanding of it), whose true prevalence, natural history, and response to therapies continue to be elucidated. Meanwhile, specialized surgical centers continually make thromboendarterectomy safer, providing definitive cures that are nothing short of miraculous for those affected by this otherwise usually fatal [… read more]
Intracranial hemorrhage is a subject neuro-intensivists spend years learning about and refining their knowledge and skills on. A few key points: Myocardial “stunning” with depressed ejection fraction and pulmonary edema should be expected, due to a form of tako-tsubo cardiomyopathy, most commonly in subarachnoid hemorrhage. It’s not due to ischemia and gets better over weeks. [… read more]
Obesity may impose extra burdens on critical care staff (think turning, transport, intubation and central line placement), but reviews suggest people with “ordinary” obesity (BMI 30-39) with have the same mortality from critical illness as overweight or healthy-weight people. In fact, obese people may have a survival advantage, despite possible longer durations of mechanical ventilation and ICU stays. But what about extreme obesity (BMI > [… read more]
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