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PulmCCM Roundup #5
The PulmCCM Roundup gathers all the best in pulmonary and critical care from around the web. Browse all the PulmCCM Roundups.
Statins Fail for COPD, ARDS
Statins have been optimistically tested as a tonic for everything from diabetes to dementia -- so far, without success. That consistency was maintained in 2 recent trials showing statins' failure to improve outcomes in either ARDS or COPD; both trials were stopped early for safety concerns or futility.
In the ARDSNet (NIH-funded) SAILS trial, rosuvastatin failed to improve outcomes among people with sepsis-related acute respiratory distress syndrome (ARDS); there was a trend toward harm in the statin-treated patients.
Statins also failed to reduce rates of COPD exacerbations among 885 patients in the STATCOPE study funded by the U.S. NIH and its Canadian counterpart (the CIHR), reported in the same NEJM issue. The disappointing results come in the wake of the STATIN-VAP trial, which was (wait for it) also stopped early for futility after statins seemingly increased mortality risk in patients with ventilator-associated pneumonia (VAP). If this keeps up, one might be tempted to conclude that statins only work for their original indication, secondary prevention of cardiovascular events. But wait, there's more: significant evidence suggests statins might prevent pulmonary embolism and DVT. A huge phase 3 randomized trial testing rosuvastatin for prevention of recurrent PE in 3,000 people was posted to clinicaltrials.gov, but is currently on hold.
"Brain Dead" Jahi McMath Is Still Alive
Jahi McMath is reportedly alive more than 6 months after her diagnosis of brain death and her release (or her body's, depending on your point of view) from the San Francisco area hospital where she was originally treated for anoxic brain injury. She was legally considered a cadaver, issued a death certificate, and her body (on a ventilator) released to her family. Apparently, she was then transported to New Jersey, one of the few states that allow a family to overrule a doctor's diagnosis of brain death. Her exact location and clinical status is a secret, but apparently, she has not died. Her family's lawyer says she is following commands and "improving." Was this a misdiagnosis of brain death (since we all were taught that rapidly progressive organ failure would inevitably lead to asystole after brain death)? Or were we MDs effectively duped in our training on brain death, based on what was (by today's standards) anecdotal evidence from 1960s and 70s-era care and research, and with self-fulfilling prophecies precluding any further investigation of the matter since then? Consider this 1998 Neurology article, entitled "Chronic Brain Death." Excerpt: "The tendency to asystole in brain death can be transient ... If brain death is to be equated with death, it must be on some basis more plausible than loss of somatic integrative unity." If you missed this lively discussion on PulmCCM, it's worth checking out.
Azithromycin for COPD and Pneumonia
A review article in JAMA recommends macrolide (e.g. azithromycin) maintenance therapy for prevention of COPD exacerbations in many patients. Authors downplay the still mostly-unknown (but low) risks of sudden cardiac death from the weak pro-arrhythmogenic effects of azithromycin. In a retrospective analysis of data at U.S. veterans' hospitals reported in JAMA, pneumonia regimens including azithromycin were associated with an absolute 5% reduction in death at 90 days. If this had been a randomized trial (which it was not), that would be a very impressive number needed to treat of only 20 to save a life. There was also a slightly increased risk of myocardial infarction. They noted no increased incidence of arrhythmias. PulmCCM reviewed azithromycin for prevention of COPD exacerbations recently as well.
Authors of a NEJM review article declare "Palliative care in the ICU has come of age" and walk us through the messy emotional terrain of caring for dying patients in the ICU. But the sterilized advice for "shared decision making" and "providing valid prognostic information" can only partially neuter the often-dark psychological morass of these situations, familiar to anyone who's struggled through a few. The permeating existential fear, desperate survival instincts, guilt, and exorcism of family demons, not to mention physicians' own angst from processing all of the above while coping with the impossibility of confident prognosis in most cases, deserve a Tolstoy novel, not just a review article ... but this is a good one anyway.
Sepsis and Septic Shock
Absolute mortality from severe sepsis and septic shock fell by half in Australia and New Zealand between 2000 and 2012, from 35% to 17%, according to a large database review in JAMA. Pretty impressive, mate. The findings were probably due to improved care, and possibly selection bias by identifying more people with sepsis, early.
Recent Review Articles
Early management of severe sepsis (Paul Marik in Chest)
Obliterative bronchiolitis (NEJM)
Occupational asthma (NEJM)
Intracerebral hemorrhage (NEJM)
Pertussis (Whooping Cough) (Chest)