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Jun 8, 2018

Stoppage time

The story

Like running the list 3 times a day or social work rounds, ECMO probably helps patients, but it'd be nice to see some evidence. Here's why a trial comparing ECMO to mechanical ventilation was stopped early.

The basics

You get stiff when your attending talks about your dating life in front of the entire clinic staff, but it's nothing like lungs in the acute respiratory distress syndrome (ARDS). Strategies like low-tidal volume, prone positioning, and paralysis have helped to reduce the overdistention that is thought to further damage injured lungs in severe disease. But reducing vent trauma is different than removing it altogether, and venovenous extracorporeal membrane oxygenation (ECMO) – in which gas exchange is moved via circuit to a membrane outside the body – was an odds-on bet to improve outcomes.

The study

After previous ECMO trials had critical flaws, EOLIA was designed to test routine ECMO in severe ARDS against modern best vent management practices. The 250-patient trial gave treating docs the option for crossover to ECMO in the ventilation arm. In what has ballooned into a messy controversy, the trial was stopped early after the ECMO arm just barely met a predefined measure of futility. When the whistle blew, the ECMO arm had a non-significant 60-day mortality advantage (35% vs. 46%), and almost 30% of the vent group had crossed over to ECMO. These very sick patients helped blur a possible benefit for ECMO in the final study analysis. Safe to say, people in the field are frustrated.
NEJM

The takeaway

We won't see a similarly large trial on ECMO soon. In the meantime, ECMO will likely remain a rescue maneuver, rather than routine care, for severe ARDS patients.

Say it on rounds

When your patient’s MELD is higher than her urine output

Some situations scream for albumin, but its use in chronic decompensated cirrhosis has never been clear. The 440-patient open-label ANSWER trial compared weekly albumin infusions with standard medical therapy in cirrhosis patients with ascites. The albumin group had higher 18-month survival (77% vs. 66%), less frequent paracentesis (54% reduction), a lower incidence of SBP and hepatorenal syndrome, and improved quality of life. Experts say the cost of albumin and many of the trial's screening criteria may serve as a barrier to wider use. 
Lancet

When you chart-stalk your patients one last time before bed

Whatever helps you sleep at night. Oncologists can rest easy after the 10,000-patient TAILORx trial found no benefit for adjuvant chemotherapy in patients with intermediate scores on the 21-gene Oncotype DX assay. The assay is widely used after resection of early hormone-positive breast cancers to recommend for or against chemo, but the majority of patients fell into a gray zone that left clinicians unsure of what to do. The new results showed that these patients – about 60,000 women a year in the US – had similar recurrence-free survival with or without chemo.
NEJM

When the DJ in the resident lounge is way too into the new Kanye album

Think about earplugs if it's before lunch. A group of Swedish studies linked low volume ambient music with healthy food choices. In a Stockholm café, diners chose unhealthy menu items 52% of the time when music volume was high vs. 42% of the time when volume was low, while healthy items were chosen 42% of the time with low music vs. 31% of the time with high music. Music genre did not play a role. The authors suggest that soft music promotes relaxation and more mindful choices.
J Acad Mark Sci

Brush up

Calciphylaxis

No matter how painful your 4-hour family meeting was, it's not nearly as bad as the deposition of calcium and phosphate in small blood vessels. Calciphylaxis is a rare, life-threatening condition that causes excruciating skin lesions (see examples here). ESRD patients are at highest risk, though the disorder is also linked to CKD, AKI, and coumadin use. Pain may precede observable skin lesions. Prognosis is poor, as average survival is less than 1 year.

What's the evidence

For treatment of calciphylaxis? There are no approved therapies, and management should focus on analgesia and wound management. The antioxidant sodium thiosulfate, which blocks vascular smooth muscle calcification, is being evaluated in clinical trials after retrospective data found that about 26% of ESRD patients treated with the drug during HD sessions achieved complete resolution of lesions.

What your ID friends are talking about

Fresh off the heels of an Ebola outbreak in the Congo in April, the Nipah virus is threatening to spark an epidemic in Kerala, India. The brain-damaging virus is thought to have spread through contact with fruit bats and has killed 17 of 18 infected persons thus far.

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