Wednesday, July 31, 2019

Blood stream infections: how long to treat? When is PO sufficient?

This review in the Journal of Hospital Medicine is an excellent resource.

Tuesday, July 30, 2019

Non invasive ventilation for acute hypoxemic respiratory failure: what’s the latest?


Noninvasive ventilation reduces the risk of intubation in subgroups of acute hypoxemic patients.

Immunosuppressed, acute pulmonary edema and pneumonia patients may benefit most from NIV.

Well designed randomized clinical trials are required to address the benefit in other populations.



Evaluate current recommendation for the use of noninvasive ventilation (Bi-level positive airway pressure- BiPAP modality) in hypoxemic acute respiratory failure, excluding chronic obstructive pulmonary disease.


Electronic searches in MEDLINE, Web of Science, Clinical Trials, and The Cochrane Central Register of Controlled Clinical Trials. We searched for randomized controlled trials comparing BiPAP to a control group in patients with hypoxemic acute respiratory failure. Endotracheal intubation and death were the assessed outcomes.


Of the 563 studies found, nine met the inclusion criteria for this systematic review. The pooled RR (95% CI) for intubation in patients with acute pulmonary edema (APE)/community acquired pneumonia (CAP) and in immunosuppressed patients (cancer and transplants) were 0.61 (0.39–0.84) and 0.77 (0.60–0.93), respectively. For Intensive Care Units (ICU) mortality, the RR (95% CI) in patients with APE/CAP was 0.51 (0.22–0.79). The heterogeneity was low in all comparisons.


NIV showed a significant protective effect for intubation in immunosuppressed patients (cancer and transplants) and in patients with APE/CAP. However, the benefits of NIV for other etiologies are not clear and more trials are needed to prove these effects.

Monday, July 29, 2019

Biomarkers in midlife may predict physical decline years later

Clinical Perspective

What Is New?

Lower levels of NT-proBNP (N-terminal pro-B-type natriuretic peptide) and interleukin-6 in middle-aged adults were independently associated with better physical capability (a key component of healthy aging) up to 9 years later.

Such associations were meaningfully stronger than those observed for conventional risk markers including lipids, blood pressure, and glycemia and were not explained by the onset of cardiovascular and kidney disease or diabetes mellitus.

What Are the Clinical Implications?

Elevated NT-proBNP and interleukin-6 in midlife could help identify (and thereby target) individuals set to have poor physical capability as they age.

Such findings may relate in part to such biomarkers capturing early end-organ damage, or cumulative stressor pathways that lead to physical decline.

Future trials targeting improvements in physical capability should include middle-aged as well as older adults and use measurements of cardio-renal biomarkers as intermediate outcomes.

Sunday, July 28, 2019

Adverse drug reactions in the elderly: a clinical vignette and a reminder of the Beers list

The free full text article is here. The newly revised Beers list can be accessed here.

Saturday, July 27, 2019

Antiplatelet therapy reduces mortality in sepsis


Antiplatelet drugs can reduce the mortality rate in patients with sepsis.

Aspirin can effectively reduce mortality in patients with sepsis.

Antiplatelet drugs reduce mortality regardless of the timing of administration.



Abnormal platelet activation plays an important role in the development of sepsis. The effect of antiplatelet drugs on the outcome of patients with sepsis remains unclear. This meta-analysis aimed to determine the effect of antiplatelet drugs on the prognosis of patients with sepsis.

Materials and methods

PubMed, Cochrane Library, CBM, and Embase were searched for all related articles published from inception to April 2018. The primary end point was mortality. Adjusted data were used and statistically analysed.


Ten cohort studies were included. The total number of patients with sepsis was 689,897. Data showed that the use of antiplatelet drugs could effectively reduce the mortality of patients with sepsis (odds ratio (OR) = 0.82, 95% CI: 0.81–0.83, p less than 0.05). Seven studies used aspirin for antiplatelet therapy, and subgroup analysis showed that aspirin effectively reduced ICU or hospital mortality in patients with sepsis (OR = 0.60, 95% CI: 0.53–0.68, p less than 0.05). A subgroup analysis on the timing of anti-platelet drug administration showed that antiplatelet drugs can reduce mortality when administered either before (OR = 0.78, 95% CI: 0.77–0.80) or after sepsis (OR = 0.59, 95% CI: 0.52–0.67).


Antiplatelet drugs, particularly aspirin, could be used to effectively reduce mortality in patients with sepsis.

Antithrombotic therapy for sepsis is not a new concept. The coagulation system is activated and accounts for some of the injury in sepsis. Activated protein C was found beneficial in selected septic patients and was approved as an adjunct in the treatment of sepsis with organ dysfunction in 2001. The company withdrew the product from the market in 2011.