May 31, 2019

Blockade revisited

The story

There are times on the wards when you wouldn't mind a little Valium, but paralysis probably isn't your cup of tea. Here's how routine neuromuscular blockade shakes out in acute respiratory distress syndrome (ARDS). 

Times gone by

Critical care trials are notoriously hard to implement, so positive results tend to stick. Yet the French ACURASYS trial of 2010, which found a mortality benefit for early neuromuscular blockade (NMB) and deep sedation in ARDS, has been met with controversy since publication. Benefits like decreased barotrauma were unexpected and ultimately attributed to improved ventilator synchrony. On the harmful side, NMB can cause prolonged weakness and exacerbate ICU PTSD.

Fresh new look

ROSE randomized 1,000 patients with moderate-to-severe ARDS to receive NMB agent cisatracurium and deep sedation or usual care with lighter sedation targets. The trial was stopped for futility after 90-day mortality was virtually identical in the 2 groups (42.5% vs. 42.8%) at the second interim analysis. As for the difference in trial outcomes, some experts think that deep sedation in the control group in ACURASYS prompted unrecognized breath stacking that was absent in the less heavily sedated control arm of ROSE. 

The takeaway

ROSE is a large and well-run trial that argues against the routine use of NMB in ARDS patients. Consider NMB in patients with breath stacking or any predisposition to ventilator-induced lung injury despite optimal vent settings and sedation.

Say it on rounds

When you thought med school thickened your coronaries

Quite the opposite, in fact. Cardiovascular disease disproportionately affects the uneducated, and an analysis of data from the UK Biobank found that each additional 3.6 years of education was associated with a 13% decrease in coronary heart disease (CHD) through observational analysis and a 37% decrease through genetic analysis (Mendelian randomization). Modifiable risk factors like obesity, hypertension, and smoking accounted for about 40% of education's impact on CHD.

When you hit send on a risky text

What's done is done. The same could be said for low-risk patients following unexplained syncope. A propensity score analysis of 2,500 elderly adults who presented to the ED with unexplained syncope found no difference in the rate of serious adverse events after 30 days in patients who were admitted to the hospital versus those who were discharged directly from the ED when upfront risk scores were taken into account. Admission did confer a non-significant trend towards benefit in these patients, which should be of comfort when they are inevitably admitted to your service.
Ann Emerg Med

When insurance won't cover a BID PPI but will cover twice the daily dose

You're used to getting creative with pharmacy, and using progesterone for smoking cessation is no exception. Women have higher quit rates than men and are more likely to quit in the luteal phase (high progesterone) of the menstrual cycle. A RCT of smoking cessation in 216 patients of both genders found that women randomized to progesterone were twice as likely to be abstinent at 4 weeks than those given placebo (35% vs. 17%) and had a longer time to first relapse. Men in the study saw no benefit.

A mortgage is more in reach than you think

Thinking about buying a place? Check physician mortgage rates with LeverageRx. They understand your credit profile – student loans, an attending's salary somewhere at the end of training – and can match you with mortgage options with low or no down payments and relaxed debt to income ratios. Get quotes from a wide range of lenders in 3 easy steps online.

Brush up

Acute alcoholic hepatitis

Suspect alcoholic hepatitis in patients with longstanding alcohol abuse who present with jaundice and AST:ALT elevation in a ratio of at least 2:1. Rule out infection, biliary obstruction, drug-induced liver injury, and ischemic hepatitis, and consider liver biopsy to confirm the diagnosis. Maddrey's discriminant function (DF) can be used to evaluate prognosis and guide use of steroids. Cessation of alcohol consumption is critical for affected patients.

What's the evidence

For G-CSF in severe alcoholic hepatitis (SAH)? A 2019 single-center RCT of 430 patients with histologically proven SAH refractory to one week of steroids found that those who received G-CSF had lower MELD, DF, and 90-day mortality compared to those who received placebo. G-CSF is thought to promote hepatic regeneration through bone marrow mobilization of stem cells. 

What your public health friends are talking about

Everyone likes a 90's party, but 90's-style outbreaks should go the way of the VCR. US measles cases have now reached a total not seen since 1992 with no signs of slowing down.

Spread the word

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