Feb 23, 2018

No vacancy

The story

You’ll hear some choice things when you call the ICU resident in the middle of the night, but "wheel them up, we have tons of beds" is not one of them. Does a jammed ICU hurt patients in the ED?

The strain

Patient demand exceeds bed supply in ICUs around the country. And while the literature applies the euphemism "complex decision making” to explain who's accepted and who's declined, the real world ramifications are that textbook ICU admission criteria are thrown out the window and patients have to prove their merit on a case-by-case basis. The strain on the system increased ED boarding time for critically ill patients by over 30% between 2001 - 2009, leaving many to wonder how the extra time affects outcomes.

The study

Longer time in the ED after ICU triage was associated with increased mortality and persistent organ dysfunction, says a retrospective cohort study of 850 critically ill patients in a New York City tertiary care ED.  Patients denied ICU entry had a median ED boarding time that was almost 3x the length of accepted patients, possibly due to a re-triaging process. Outcomes were similar for patients accepted to their intended ICU vs. overflow ICUs (think MICU vs. SICU, NICU, etc.), but an inability to get overflow patients to other ICUs contributed to increased waiting time.
Crit Care Med

The takeaway

Getting patients out of the ED and into the ICU improves care. Taking advantage of overflow beds in other units looks like an important first step.

Say it on rounds

When only your subway commute separates you from sleep

You'd probably prefer a taxi, just like patients with cancer-associated venous thromboembolism (Ca-VTE) would prefer pills to daily injections. A 1000-patient RCT compared the oral factor Xa inhibitor edoxaban to standard-of-care low molecular weight heparin (LMWH) in the treatment of Ca-VTE and found edoxaban to be non-inferior to LMWH for the study's composite outcome of recurrent VTE or major bleeding. Experts think edoxaban is ready for prime-time use in this setting. Trial results for other factor Xa inhibitors are pending.

When your stomach growl interrupts rounds

Don't ignore hypoglycemia, especially in insulin-dependent diabetics. An RCT of 150 type 1 diabetics on multiple daily insulin injections compared real-time continuous glucose monitoring (rtCGM) to self-monitoring. rtCGM patients saw a 68% reduction in monthly hypoglycemic events with less glycemic variability and less severe hypoglycemia. rtCGM also produced mild improvements in hemoglobin A1c, meaning these results don't come at the expense of glycemic control.

When lunch was two Cokes and a day-old cookie

It happens. In a prospective cohort that examined the dietary habits of 100,000 adults, French researchers linked ultra-processed foods to an increased risk of cancer. A 10% increase in the consumption of foods like sugary drinks and snacks was associated with a 12% increase in overall cancer risk. The association held despite controlling for obesity, a known risk factor, leading the the authors of the study to speculate that additives in processed foods may have carcinogenic activity. 

Brush up


Like correcting your attending on rounds, there's a fine line in transplant between help and harm. Post-transplant lymphoproliferative disorders (PTLD) are lymphomas that arise in the setting of immunosuppression and the Epstein-Barr virus (EBV). The disease is rare in renal transplant patients and others who require low level immunosuppression, but prevalence increases with more extensive immune blockade. Early identification and treatment improves outcomes.

What's the evidence

For chemotherapy in the treatment of PTLD? Treatment starts by cutting the dose of cyclosporine and tacrolimus in half, though the response in PTLD lesions is highly variable. For those who fail to respond to immunosuppression reduction, a 2012 study of 70 PTLD patients found that chemotherapy combined with rituximab produced a complete or partial response in 90% of treated patients.

What your football friends are talking about

If they're from Philly, you're probably still hearing more than you can handle about the Eagles. But among other notable news this offseason is the FDA approval of a blood test that can detect concussions.

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