Macrolides still look good for pneumonia

  • June 23, 2014

Azithromycin survival JAMACochranized in the past, macrolides (usually azithromycin) seem more convincingly beneficial regarding mortality and treatment failure in pneumonia (especially in the elderly). This large but retrospective VA registry analysis supports this suggestion. The finding of more MIs but fewer ‘cardiac events’ is confusing. First line for everyone, include it in the initial antimicrobials, continue it despite negative atypical screen, avoid in ischaemic heart disease – I don’t think we know yet.

Thrombolysis for which PE patients – time to decide?

  • June 23, 2014

PE chatterjeeChatterjee’s MA after the recent swathe of studies suggests using thrombolysis (full dose) in PE all-comers results in less mortality and fewer recurrences even though bleeding occurs much more frequently (NNH 18). Disability and quality of life might be revealing but is rarely reported (re bleeding but staying alive). If restricted to the under 65s then it’s safer. Time to make up your mind – particularly about the younger patients with signs of right heart compromise!

Degrees of death

  • June 19, 2014

Death pathway“Death is the permanent loss of capacity for consciousness and all brainstem functions”. C1-2 and N1-3 – the attempt to separate the often  inseparable circulatory and neurological elements of dying and death. This guideline development provides a good glossary and some reassuring common sense in amongst some more complicated detail.

More on predicting outcome after TTM

  • June 10, 2014

Hypoxic arrestA multimodal approach is intuitively best but what’s the minimum you need to include in a predictive model? This small-but-nice study suggests clinical examination PLUS electroencephalography reactivity PLUS serum neuron-specific would give near certain forecast of a dreadful outcome.

What honestly works for ARDS?

  • June 10, 2014

Picture1If you ‘umbrellanalyse’ (my term, but you can use it) 20,000 patients with ARDS, it seems we’re not sure of much more than: DON’T oscillate, DO prone, and DO use low a Vt strategy. All else is futile?

Get adrenaline in early at non-shockable in-hospital arrests

  • June 3, 2014

Adrenaline timing arrest‘Get with the guidelines’ latest registry analysis in the BMJ focusses on timing of adrenaline in non-shockable, in-hospital arrests. 12% of those given adrenaline at 1, 2 or 3 minutes survived to hospital discharge compared with 7% at 6 mins. Of note only 7% or 25,000 survived with favourable neurological outcome (moderate disability or better). Good Medscape analysis available.

ACEP epilepsy guidelines 2014

  • June 2, 2014

StatusACEP guidelines on epilepsy include a pragmatic section on status epilepticus. No drug clearly wins. Maybe stick to what you know. Benzodiazepine infusions probably best avoided?

Probiotics to prevent C.diff diarrhoea: flawed evidence but Cochrane folk recommend it!

  • June 1, 2014

c diff forrestA recent Cochrane review suggests probiotics (unspecified) reduce the incidence of C.diff diarrhoea (or symptomatic infection), but not C.diff infection per se. High heterogeneity, low quality of evidence, some counter-intuitive findings but somehow a moderate level recommendation that probiotics are good for patients on antibiotics. NB this was not an analysis of critically ill patients!