Jun 9, 2017

Crystal ball

The story

Your so-close-to-being-done-it-hurts team of PGY-3 writers will miss the luxury of being able to say ‘let me check with my attending’. But who's to say the boss is right, anyway? New research explores if doctors can predict prognosis in the ICU. 

The background

A well-worn ICU challenge is deciding how hard to push. Even if patients are able to survive critical illness, they may suffer permanent cognitive deficits or severe declines in functional status. Goals of care becomes crucial. And while much research has focused on helping families improve the quality of their decision making, little has focused on how to give families accurate prognostic info from which to base decisions.

The results

ICU physicians and nurses are good at predicting mortality but less skilled at predicting functional outcomes, says a prospective cohort study of 300 critically ill patients across 5 ICUs. Predictions were made between ICU days 3 and 6 and later compared to actual outcomes at 6 months. Physicians were best at predicting 6-month mortality, and though they predicted functional outcomes like independent toileting, return to original residence, and cognition better than chance, the margins were slight. Confidence was key: all predictions were more accurate when physicians felt confident, and when docs and nurses were both confident accuracy was even higher.

The takeaway

Physicians and nurses were better able to predict outcomes than common critical illness severity scores. But giving families info on what functional status to expect for their loved ones remains a challenge.

Say it on rounds

When the ED calls about hemoptysis, but red Gatorade is sitting at bedside

With pulmonary embolism (PE), it's just so hard to tell. A prospective cohort study of 3,500 patients with suspected PE found that the YEARS algorithm safely excluded PE at 3-month follow-up. YEARS simplifies the Well's criteria to 3 items – presence of hemoptysis, clinical signs of DVT, and the presence of PE as the most likely diagnosis – and hitches the results to D-dimer values irrespective of patient age. The algorithm reduced unnecessary CT scans by 15% compared to current standard-of-care.  

When you haven't peed once during your 12-hour shift

Your renin-angiotensin system is working just fine, but that may not be the case in your septic patients. A 320-patient international RCT evaluated synthetic angiotensin II as a vasopressor and found that the compound increased mean arterial pressure compared to placebo in patients with vasodilatory shock who were already on high doses of norepinephrine. After 48 hours, the angiotensin II group had lower SOFA scores than the control group, though the trial was not powered to detect a mortality benefit.

When all of your AM labs are drawn promptly and result on time

Everyone likes unexpected good news. Here's some for pregnancy after breast cancer: despite concerns that pregnancy could lead to increased risk of recurrence in women with prior hormone receptor-positive breast cancer, a prospective multicenter cohort study found no difference in disease-free survival between breast cancer survivors who became pregnant and those who did not at up to 5 years after diagnosis. Next up: ongoing studies investigating the safety of temporary interruption of adjuvant hormone-blocking therapy to allow pregnancy.
ASCO Abstracts

Brush up

IgG4-related disease

Get familiar with IgG4-related disease, which since its discovery in 2003 has gained a reputation for popping up in any organ system. Common presentations include autoimmune pancreatitis, sialadenitis and retroperitoneal fibrosis, but be sure to include the disease in the differential for any new mass or unexplained organ enlargement. Common labs won't guide you towards diagnosis, so maintain a low threshold to order serum IgG subclasses. Tissue biopsy and staining are used to confirm disease activity.

What's the evidence

For treatment with rituximab in IgG4-related disease? While optimal treatment has yet to be established, growing evidence suggests that rituximab is safe and efficacious. A 2015 prospective open-label pilot trial of 30 patients found that 97% percent of patients responded to rituximab treatment. Three-quarters of participants achieved decreases in disease severity index scores and were able to be taken off of steroids.

What your Silicon Valley friends are talking about

Unmet market needs. Birth control app Nurx is taking it's birth control delivery service deep into the 'contraceptive deserts' of Texas, where only one clinic exists for every 1,000 or more women in need.

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