---was Vanderbilt University Medical Center. Quackademic medicine goes against Vandy's traditions. VUMC was a leader in the biomedical sciences. It was always a place where new ideas were welcome but where nutty ideas were just nutty ideas. I was aware that woo got its foot in the door of VUMC a year or so ago with the opening of the Center for Integrative Health. At the time though I thought it was mainly soft woo. Then the other day I found this:
Early in the video I was mildly encouraged that at least scientific plausibility was preserved with the mention of endorphin and serotonin release but about 1:39 in when he started talking about blocked chi it was all over. This is pure woo. If it can find a place at Vanderbilt it can find a place anywhere. The infiltration is nearly complete.
Tuesday, December 14, 2010
Rescue therapies for severe ARDS
Severe ARDS can be defined in various ways, usually by the lung injury score. In general it means you can't ventilate the patient with reasonable airway pressures and fractions of inspired oxygen.
Rescue therapies are modalities considered unproven in that they haven't been validated by high level evidence. As measures of last resort for the patient who cannot be managed by other means, however, they may offer the only hope for survival. Rescue therapies were reviewed in a recent issue of Critical Care Medicine and include recruitment maneuvers, high PEEP, high frequency oscillation, inhaled nitric oxide, prone positioning, corticosteroids and extracorporeal life support.
Rescue therapies are modalities considered unproven in that they haven't been validated by high level evidence. As measures of last resort for the patient who cannot be managed by other means, however, they may offer the only hope for survival. Rescue therapies were reviewed in a recent issue of Critical Care Medicine and include recruitment maneuvers, high PEEP, high frequency oscillation, inhaled nitric oxide, prone positioning, corticosteroids and extracorporeal life support.
Anxiety and COPD outcomes
From Thorax:
I don't have the full text of this paper, and I wonder if they controlled for continued smoking. Nicotine is a powerful anxiolytic for some COPD patients.
Via Clinical Cases and Images.
Results COPD was associated with a greater risk of anxiety in multivariable analysis (OR 1.85; 95% CI 1.072 to 3.18). Among patients with COPD, anxiety was related to poorer health outcomes including worse submaximal exercise performance (less distance walked during the 6-min walk test: −66.3 feet for anxious vs non-anxious groups; 95% CI −127.3 to −5.36) and a greater risk of self-reported functional limitations (OR 2.41; 95% CI 1.71 to 3.41). Subjects with COPD with anxiety had a higher longitudinal risk of COPD exacerbation in Cox proportional hazards analysis after controlling for covariates (HR 1.39; 95% CI 1.007 to 1.90).
I don't have the full text of this paper, and I wonder if they controlled for continued smoking. Nicotine is a powerful anxiolytic for some COPD patients.
Via Clinical Cases and Images.
Monday, December 13, 2010
"It is not the effect on individuals that is presently at issue -- it is the authority of Congress to compel anyone to purchase health insurance"
---said a federal judge today in a ruling upholding Virginia's challenge to Obamacare.
Right ventricular infarction---clues from the standard 12 lead
This electrocardiogram was presented in a case discussion at the Prehospital 12-Lead ECG blog. This patient had changes of acute inferior STEMI. Generally, right sided precordial leads are used to diagnose RV MI. However, clues suggesting the diagnosis are present in this standard 12 lead, one being the minimal ST elevation in lead V1, the other being the fact that the greatest magnitude of ST elevation occurs in lead III, the inferior lead which most reflects changes in the right ventricle.
Hematologic toxicity of linezolid
This study was based on a medical record review from an academic VA medical center:
Patients. Four hundred forty-four patients (mean age 63.7 yrs) who received 544 courses of linezolid from 2004–2007.
Measurements and Main Results
The frequencies of grade 1–2 and grade 3–4 thrombocytopenia were 7.6% and 5.2%, respectively. Grade 3–4 anemia developed in 18.8% of courses; each of the patients had baseline grade 1–2 anemia. Linezolid was discontinued because of toxicity in 35 (6.4%) of the 544 courses. Independent variables associated with grade 3–4 thrombocytopenia included a baseline hemoglobin level of less than 10.5 g/dl, presence of immunosuppression, and a baseline platelet count of 50–99.9 × 103/mm3. Independent variables associated with development of grade 3–4 anemia included presence of a cardiovascular condition, urologic condition, immunosuppression, and a baseline platelet count of 50–99.9 × 103/mm3. Other toxicities reported with linezolid included diarrhea (6.6% of courses), followed by nausea (4.4%) and vomiting (4.0%).
Conclusion. The overall rates of thrombocytopenia and anemia for patients receiving linezolid were found to be higher than those in phase III clinical trials.
Evaluation of the patient with hypokalemia---a systematic approach
This review is part of the American Journal of Kidney Disease Acid-base and electrolyte teaching case series.
Friday, December 10, 2010
Does early goal directed therapy matter? A point-counterpoint
In response to a study published in Chest showing a disturbing low rate of adherence to early goal directed therapy (EGDT) at a large medical center, editorials expressing opposing views were presented in the same issue.
First Dr. Emanuel Rivers, principal investigator in the landmark EGDT study published almost a decade ago, defended the protocol. He cited the very strong basic science rationale that had been developed long before the EGDT trial. He also noted, as I have many times before in this blog, the many studies over the ensuing years after the trial that replicated its findings.
The counterpoint editorial was written by Dr. Gary Schmidt from the pulmonary-critical care section at the University of Iowa. His was largely and argumentum ad populum: adherence to EGDT is low; this must reflect informed skepticism; therefore EGDT is not validated. He did point out evidence that lactate guided therapy may be a surrogate for serial measurement of ScvO2. At least one study, however, found that lactate levels were complementary to the measurement of ScvO2. Finally, he noted three trials in progress which are examining various components of EGDT:
The results of multiple studies which replicate Rivers' original findings are compelling and I doubt that these three trials will negate EGDT in any way. More likely, by examining individual components of EGDT they will provide better understanding and insight, and perhaps some tweaks that will refine early hemodynamic resuscitation of septic patients.
Dr. Rivers offered a rebuttal in which he questioned the equipoise of continued trials. Dr. Schmidt countered once again.
First Dr. Emanuel Rivers, principal investigator in the landmark EGDT study published almost a decade ago, defended the protocol. He cited the very strong basic science rationale that had been developed long before the EGDT trial. He also noted, as I have many times before in this blog, the many studies over the ensuing years after the trial that replicated its findings.
The counterpoint editorial was written by Dr. Gary Schmidt from the pulmonary-critical care section at the University of Iowa. His was largely and argumentum ad populum: adherence to EGDT is low; this must reflect informed skepticism; therefore EGDT is not validated. He did point out evidence that lactate guided therapy may be a surrogate for serial measurement of ScvO2. At least one study, however, found that lactate levels were complementary to the measurement of ScvO2. Finally, he noted three trials in progress which are examining various components of EGDT:
These include the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial (1,600 subjects), the Protocolized Care for Early Septic Shock (ProCESS) trial centered in Pittsburgh (1,935 subjects), and the Protocolised Management of Sepsis (ProMISe) trial in the United Kingdom (1,260 subjects).
The results of multiple studies which replicate Rivers' original findings are compelling and I doubt that these three trials will negate EGDT in any way. More likely, by examining individual components of EGDT they will provide better understanding and insight, and perhaps some tweaks that will refine early hemodynamic resuscitation of septic patients.
Dr. Rivers offered a rebuttal in which he questioned the equipoise of continued trials. Dr. Schmidt countered once again.
Combination antibiotics in early septic shock---synergistic effect?
In hospital medicine there exists a dialectical tension between the idea of “antimicrobial stewardship,” which encourages restricted use of antibiotics, and that of “adequately broad spectrum therapy” in which combinations of antibiotics are advocated for a variety of reasons.
The best discussion I've found on the purported reasons for combinations of antibiotics (some of which are better clinically validated than others) is in Mandell's ID textbook, Part I Chapter 18. Reasons for combination therapy include coverage of the likely spectrum when the pathogen and/or its antimicrobial sensitivity is unknown. The most time honored and clinically accepted example of this is meningitis. Sepsis and pneumonia are emerging as increasingly important examples in this category, given recent data that mortality is reduced when the spectrum is covered at the initiation of therapy as opposed to adding drugs later in the course as microbiologic data become available. (Shoot first, ask questions later). Another reason for combination therapy is prevention of emergent resistance. The best validated example is treatment of tuberculosis. A third reason is antimicrobial synergy. The most universally accepted example of this is the treatment of enterococcal endocarditis.
So the title of an article in the September issue of Critical Care Medicine is a little deceiving: Early combination antibiotic therapy yields improved survival compared with monotherapy in septic shock: A propensity-matched analysis. My first reaction was that this is something we already knew based on the reason cited above. But that's not what this study was about. It compared monotherapy with an agent to which the offending pathogen was proven to be susceptible to double coverage by agents having different mechanisms of action, to which the pathogen was susceptible. From the paper:
So now there are two reasons to use combination antibiotic therapy with the initiation of treatment of septic shock: adequacy of coverage and synergy.
A related editorial discussed general issues related to combination antibiotic therapy in a variety of settings. The editorial cites a lot of data and deserves a careful read.
The best discussion I've found on the purported reasons for combinations of antibiotics (some of which are better clinically validated than others) is in Mandell's ID textbook, Part I Chapter 18. Reasons for combination therapy include coverage of the likely spectrum when the pathogen and/or its antimicrobial sensitivity is unknown. The most time honored and clinically accepted example of this is meningitis. Sepsis and pneumonia are emerging as increasingly important examples in this category, given recent data that mortality is reduced when the spectrum is covered at the initiation of therapy as opposed to adding drugs later in the course as microbiologic data become available. (Shoot first, ask questions later). Another reason for combination therapy is prevention of emergent resistance. The best validated example is treatment of tuberculosis. A third reason is antimicrobial synergy. The most universally accepted example of this is the treatment of enterococcal endocarditis.
So the title of an article in the September issue of Critical Care Medicine is a little deceiving: Early combination antibiotic therapy yields improved survival compared with monotherapy in septic shock: A propensity-matched analysis. My first reaction was that this is something we already knew based on the reason cited above. But that's not what this study was about. It compared monotherapy with an agent to which the offending pathogen was proven to be susceptible to double coverage by agents having different mechanisms of action, to which the pathogen was susceptible. From the paper:
Using a Cox proportional hazards model, combination therapy was associated with decreased 28-day mortality (444 of 1223 [36.3%] vs. 355 of 1223 [29.0%]; hazard ratio, 0.77; 95% confidence interval, 0.67-0.88; p = .0002). The beneficial impact of combination therapy applied to both Gram-positive and Gram-negative infections but was restricted to patients treated with β-lactams in combination with aminoglycosides, fluoroquinolones, or macrolides/clindamycin. Combination therapy was also associated with significant reductions in intensive care unit (437 of 1223 [35.7%] vs. 352 of 1223 [28.8%]; odds ratio, 0.75; 95% confidence interval, 0.63-0.92; p = .0006) and hospital mortality (584 of 1223 [47.8%] vs. 457 of 1223 [37.4%]; odds ratio, 0.69; 95% confidence interval, 0.59-0.81; p less than .0001). The use of combination therapy was associated with increased ventilator (median and [interquartile range], 10 [0-25] vs. 17 [0-26];p = .008) and pressor/inotrope-free days (median and [interquartile range], 23 [0-28] vs. 25 [0-28]; p = .007) up to 30 days.
So now there are two reasons to use combination antibiotic therapy with the initiation of treatment of septic shock: adequacy of coverage and synergy.
A related editorial discussed general issues related to combination antibiotic therapy in a variety of settings. The editorial cites a lot of data and deserves a careful read.
Thursday, December 09, 2010
Renal tubular function
This is from the American Journal of Kidney Disease Core Curriculum series. Free full text. Not light reading.
Gurgling and hospital acquired pneumonia
Gurgling during speech or quiet breathing noted at any time during hospitalization was a powerful predictor in this study.
The myth of 98,000 patients
It's been just over a decade since the Institute of Medicine (IOM) dropped a bomb with the publication of its patient safety report To Err is Human. Many believe the report to be a scholarly scientific work. After all, the IOM is a subsidiary of the National Academy of Sciences. In reality it was a massive publicity stunt. Head on over and check out my guest post at Kevin MD (and the interesting comment thread there) where I argue that the report may have done more harm than good for the cause of patient safety.
Wednesday, December 08, 2010
Pneumococcal vaccination for adults: Is it time to switch?
To the conjugate vaccine, that is, especially now that the 13-valent vaccine is available. It is much more effective in preventing pneumococcal disease than its weak sister the polysaccharide vaccine, whose major role is the enhancement of hospital report cards. If you really want to impact pneumococcal disease what should you do? Give the conjugate vaccine off label? A recent article in Chest discusses the ins and outs.
Emergency treatment of COPD: high flow oxygen and mortality
A recent BMJ paper reported:
In their discussion section the authors concluded:
The more is better oxygen culture may be driven in part by overconfidence in pulse oximetry. COPD patients who are decompensated may have respiratory acidosis which shifts the oxy-hemoglobin dissociation curve to the right due to the Bohr effect. This causes hemoglobin to unload oxygen to tissues more readily, resulting in a lower saturation for a given PO2. Knee jerk reactions to such low saturations, however well intended, may have adverse consequences.
Interventions High flow oxygen treatment compared with titrated oxygen treatment in the prehospital (ambulance/paramedic) setting...
Results In an intention to treat analysis, the risk of death was significantly lower in the titrated oxygen arm compared with the high flow oxygen arm for all patients (high flow oxygen n=226; titrated oxygen n=179) and for the subgroup of patients with confirmed chronic obstructive pulmonary disease (high flow n=117; titrated n=97). Overall mortality was 9% (21 deaths) in the high flow oxygen arm compared with 4% (7 deaths) in the titrated oxygen arm; mortality in the subgroup with confirmed chronic obstructive pulmonary disease was 9% (11 deaths) in the high flow arm compared with 2% (2 deaths) in the titrated oxygen arm. Titrated oxygen treatment reduced mortality compared with high flow oxygen by 58% for all patients (relative risk 0.42, 95% confidence interval 0.20 to 0.89; P=0.02) and by 78% for the patients with confirmed chronic obstructive pulmonary disease (0.22, 0.05 to 0.91; P=0.04). Patients with chronic obstructive pulmonary disease who received titrated oxygen according to the protocol were significantly less likely to have respiratory acidosis (mean difference in pH 0.12 (SE 0.05); P=0.01; n=28) or hypercapnia (mean difference in arterial carbon dioxide pressure −33.6 (16.3) mm Hg; P=0.02; n=29) than were patients who received high flow oxygen.
In their discussion section the authors concluded:
However, resources for an aggressive campaign of education will still be needed to change the “more is better” oxygen culture that may ignore the potential dangers of hyperoxia.
The more is better oxygen culture may be driven in part by overconfidence in pulse oximetry. COPD patients who are decompensated may have respiratory acidosis which shifts the oxy-hemoglobin dissociation curve to the right due to the Bohr effect. This causes hemoglobin to unload oxygen to tissues more readily, resulting in a lower saturation for a given PO2. Knee jerk reactions to such low saturations, however well intended, may have adverse consequences.
Tuesday, December 07, 2010
Antiplatelet therapy after intracerebral hemorrhage
Patients who have recovered from ICH may have indications for antiplatelet therapy. How often is this done? Is it safe, weeks or months later? These questions were addressed in a recent study published in Stroke.
Results—There were 417 ICH patients who survived to discharge. Of these, 120 patients were prescribed subsequent antiplatelet medicines (28.8%). The median time from discharge to antiplatelet use was 14.8 months (range, 2 days–7.5 years). Among all survivors, there were 14 recurrent ICH (rate, 9.7 per 1000 patient-years; 95% confidence interval [CI], 5.3–16.4), 29 subsequent ischemic strokes (rate, 20.6; 95% CI, 13.8–29.6), and 40 subsequent ischemic strokes or myocardial infarctions (rate, 28.7; 95% CI, 20.5–39.0). Hazard ratios associated with antiplatelet exposure were 1.07 (95% CI, 0.24–4.84) for recurrent ICH, 0.23 (95% CI, 0.03–1.68) for ischemic stroke, and 0.72 (95% CI, 0.25–2.02) for ischemic strokes or myocardial infarction.
Conclusions—Antiplatelet prescribing was common after ICH. Subsequent ischemic strokes or myocardial infarctions were more common than recurrent ICH. Antiplatelet prescribing did not appear to have a clinically significant impact on outcomes measured. Despite being contraindicated, antiplatelet use wasnot a major hazard for recurrent ICH.
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