Discover and read the best of Twitter Threads about #rantorial
Most recents (9)
a fresh review article on pancreatitis in the Lancet is some hot garbage. as Eduardo rightly pointed out π, the bit on fluid resuscitation is nuts. but there are more errors, which merit a short #rantorial... 1/4
one RCT showed that delayed feeding was OK... in a population with mostly *mild* illness. the authors wrongly extrapolate this to *all* patients. esp for an intubated patient, there is no reason to delay feeding for 72 hours! #rantorial 2/4
emcrit.org/ibcc/pancreatiβ¦
emcrit.org/ibcc/pancreatiβ¦
regarding analgesia, the authors suggest that opioids could be used to avoid non-opioids! π€¬π€¬ this is backwards. the goal is generally to use non-opioids to reduce the opioid dose, and thereby *avoid* opioid-induced side effects (especially illeus). #3/4
emcrit.org/ibcc/pain/
emcrit.org/ibcc/pain/
the remdesivir story continues to unfold in a genuinely weird way. before going further, let's not forget the "compassionate use" trial in NEJM which claimed success because everyone didn't die (which, in retrospect, is *definitely* hot garbage) (rant 1/4)
the NIH guidelines now recommend remdesivir for anyone with COVID-19 who is hospitalized with a saturation <94%. these recommendations are broader than the NIAID trial inclusion criteria- so even if the trial is very positive, this still seems like an over-reach (#rantorial 2/4)
the SCCM just released a statement promoting remdesivir, even though the NIAID trial remains unpublished. never mind about RCTs! the new approach to evaluating drugs is really good retrospective data sharing. cool, cool, cool. (#3/4)
(sccm.org/Blog/May-2020/β¦)
(sccm.org/Blog/May-2020/β¦)
finally read this article on "acute severe hypertension" in NEJM and it's even worse than I was expecting... π€― (#rantorial 1/4)
the NEJM article directly contradicts established guidelines & practice regarding hypertensive urgency (#rantorial 2/4)
for a review which is consistent with guidelines & not awful, take a look at the @iBookCC chapter (#rantorial 3/4)
emcrit.org/ibcc/hypertensβ¦
emcrit.org/ibcc/hypertensβ¦
recent study suggests that post-arrest patients with lactate >12 mM might benefit from TTM33 (as opposed to TTM36). some folks on twitter are getting excited about this, but the study has very weak methodology (#rantorial 1/4)
(study: ncbi.nlm.nih.gov/pubmed/31745738)
(study: ncbi.nlm.nih.gov/pubmed/31745738)
the post-hoc study stratifies post-arrest patients on the basis of lactate level (<7, 7-12, >12). TTM33 vs. TTM36 doesn't make a difference in *any* of three strata. the p-values aren't anywhere close to statistical significance (#rantorial 2/4)
a multivariable model is used to massage the p-value in the lactate >12mm sub-groups from 0.42 down to 0.005. that's an 85-fold decrease! I'm no statistician, but this seems pretty shady (how can you get p=0.005 from a small raw sample size of 4/31 patients?) (#rantorial 3/4)
this fresh review article in NEJM on acute upper airway obstruction is the most horrifically wrong & dangerous piece of literature I've encountered in a while π³ (#rantorial 1/6)
nejm.org/doi/full/10.10β¦
nejm.org/doi/full/10.10β¦
the authors recommend a *generic* algorithm for airway management. this strategy is often unwise for a patient with suspected upper airway obstruction (there is no mention of awake fiberoptic intubation... or a double-setup ?!?)(#rantorial 2/6)
there is an oddly generic & opinionated discussion of direct laryngoscopy versus video laryngoscopy... I'm just including this to rile up the twittersphere...π (#rantorial 3/6)
a fresh meta-analysis of steroids shows that they increase GI bleeds! sounds scary, but let's look into this further... (#rantorial 1/7)
the meta-analysis detected a barely significant increase in "clinically significant bleeding" in patients treated with steroid. there was *no* difference in bleeding of any severity. why this discrepancy? let's dig deeper...(2/7)
ncbi.nlm.nih.gov/pubmed/31501997
ncbi.nlm.nih.gov/pubmed/31501997
the primary endpoint ("clinically significant" bleeding) was only reported in 25 trials. most are small. nearly *half* of the power in this analysis comes from a single trial, Roberts 2004... what was going on here? (#rantorial 3/7)
A new study in JAMA-IM suggests that a care bundle for pneumonia patients including oral steroid, rapid transition to PO antibiotics, and early mobilization caused harm (increased GI ulceration). Yikesπ± Run for the hills! (#rantorial 1/5)
jamanetwork.com/journals/jamaiβ¦
jamanetwork.com/journals/jamaiβ¦
Here are the main results. Every outcome was negative except for GI bleeding. Due to the rarity of GI bleeding, this was analyzed using adjusted analysis with a regression model (#rantorial 2/5)
However, the fragility of this effect on GI bleeding is zero. If we perform an unadjusted Fisher exact test, the p-value is 0.09 (#rantorial 3/5)
Currently there is a debate raging in the US about the role of government to mandate sepsis protocols. Given the current state of our government, this is probably a bad idea⦠(#rantorial 1/9)
A fresh study in JAMA attempts to associate the implementation of mandated sepsis protocols in New York State in 2013 with reduced mortality. The key word being *associate,* which I suppose sounds better than βcorrelateβ (#rantorial 2/9) jamanetwork.com/journals/jama/β¦
The study compares sepsis mortality in New York with three other states before/after the mandates. In all cases, mortality decreased over time in a similar fashion. This suggests mortality reductions have *nothing* to do with the mandates⦠(#rantorial 3/9)
Fresh RCT on IVC filters! 240 trauma patients with initial contraindication to DVT prophylaxis randomized to IVC filter vs no filter. Primary endpoint was a composite of symptomatic PE or death. The first evident problem is *power*β¦ (#rantorial, 1/7...)
nejm.org/doi/full/10.10β¦
nejm.org/doi/full/10.10β¦
Study was powered based a 25-year-old data showing a 9% risk of PE in patients with *no* DVT prophylaxis. But, advances in trauma care, pneumatic compression devices, & initiation of chemical prophylaxis ASAP have reduced this rate, leaving the study underpowered (2/7).
The primary endpoint is a composite of death or symptomatic PE. Since PE is uncommon & most deaths arenβt due to PE, the composite endpoint is overall driven simply by death. As would be expected, there is no difference (3/7).
