if you don't immediately know why this paper is garbage, then read this explanation (bit.ly/3klwkek). in short, time-to-intervention studies are retrospective correlational junk which continue to infest the scientific literature (rantorial #1/4)
the data from this study actually suggest that early antibiotics in pneumonia are *bad*, but early antibiotics in septic shock are *good*. this obviously isn't true -it merely serves as an illustration of what happens when you conflate correlation with causality (rantorial #2/4)
the study is funded and largely performed by Shionogi (a company producing - you guessed it - antibiotics!). this may explain their unbridled enthusiasm with the conclusion that early antibiotics will save the world (rantorial #3/4)
in fairness, I'm not suggesting that delaying antibiotic therapy is a good idea. but we should be intellectually honest about the lack of high-quality evidence in this area. repeated publication of time-to-intervention studies merely pollutes the scientific literature (#4/4)
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how to place a consult: you MUST understand the five stages of consultant grief.
once you can understand this painful and natural process, requesting consults will make a LOT more sense
buckle up, it can be a little rough…
🧵 1/6…
stage 1: denial
- You dont need a consult.
- You called the wrong service.
- 18 years old? consult pediatrics
- I’m not actually on call now
- Everything’s fine, just walk it off…
stage 2: anger
- you should have consulted us earlier/later
- you should have checked this test before calling us
- you’re a terrible doctor/student/human being
this is much better than MINDS (which contained ~90% hypoactive), but probably still not ideal.
(at this point, does anyone actually think that haloperidol helps with hypoactive delirium ??)
other than dilution of the patient population by patients with hypoactive delirium (who are unlikely to benefit & might conceivably be harmed by over-sedation), the methodology seems pretty solid.
I think it's time for a difficult discussion, folks.
Let's talk about CSF lactate 🫣
CSF lactate has been shown to be *superior* to traditional CSF studies in sorting out viral vs. bacterial meningitis in several studies & meta-analyses...
a subset of patients with viral meningitis will initially have a *neutrophilic* pleocytosis.
this can lead to unnecessary admissions & antibiotics
some patients are subjected to repeat LPs 😩
a low CSF lactate could avoid all of this, allowing patients to go home from the ED
CSF lactate measurement is recommended in guidelines from the United Kingdom, Europe, and France.
(it's not recommended in the ID society of America guidelines, but they're from *2004* and require revisions)