🚨BIG NEWS: In January, the unpublished VICTAS trial of vitamin C in #sepsis was stopped after enrolling just 501 of a planned 2000
Now data on clinicaltrials.gov shows why, and it doesn’t look good for #vitaminC. Is this the last🔩in⚰️of the ‘metabolic cure’?
A short🧵
1/
I’ve been hopeful but more than a little skeptical about the 🍹🍋 metabolic cocktail for sepsis (vitamin C + hydrocortisone + thiamine) since the original before/after case series.
I’ve followed this literature closely & have been waiting eagerly for the results of the RCTs.
2/
Thats’s why I was excited to see that VICTAS had posted results. bit.ly/3j3Iatl
The VICTAS trial is the largest (& arguably best) of the vitamin C RCTs: a placebo-controlled, Double-blind RCT done at 43 sites across the US. The 1° endpoint was vasopressor free days.
3/
The results are incomplete & we will need to wait for the actual publication to get the full picture.
But what we can see doesn’t look good:
* similar mortality rate in both arms
* more vasopressor free days in the control group
* some adverse events in the vitamin C arm 4/
Even with this limited data and some simple stats, we can see that there is no significant difference in all cause mortality:
- HAT 22.2% vs Placebo 24.1% (RR 0.92 95% CI 0.67 - 1.27; p = 0.67)
There also isn’t a difference in vasopressor free days:
- HAT 25 vs Placebo 26 5/
When we think about these results in the context of the other published studies it 🎨a consistent🖼:
- *not one* study has replicated the effect seen by Marik et al
See my updated Forrest Plot (full blog post soon): The more studies we do the smaller the overall effect. 6/
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Damn. Under Trump the White House Medical Unit was a pill-mill. Thousands of ambien & provigil per month.
Worse, for a clinic that doesn’t typically do procedures w/ moderate sedation they sure are they ordering prodigious quantities of morphine, fentanyl, versed, & ketamine…?
Honestly, this reminds me of Norman Ohler’s Blitzed.
The AG report was largely concerned with the enormous cost of prescribing these non-genetic meds.
It’s worth pointing out that dispensing prescription meds without documentation is malpractice. In the case of controlled substances it’s also likely a crime.
The long awaited #COVIDOUT RCT is now in @TheLancet:
- high risk adults randomized to either metformin (MET), ivermectin (IVM), fluvoxamine (FLV) or placebo.
- MET reduced the risk of long COVID (6.3% vs 10.4%; NNT = 24)
- no benefit with IVM or FLV
Pulmonary teaching case: you are called to the bedside of a 60yo man who was admitted for pneumonia a week ago. You were called because “he coughed and now his chest is PULSATING!”
This is what you see at the site of a previously removed chest drain:
EN is a rare complication of an infected pleural effusion where purulent fluid “escapes” the pleura and erodes into the chest wall, causing an extrapleural fluid collection that communicates with the pleural space.
Because Empyema necessitans communicates with the pleural space, fluid can move back & forth with respiration, as seen here:
With inspiration, negative intra-thoracic pressure pulls the fluid into the chest. With expiration, positive intra-thoracic pressure pushes fluid out. 3/ twitter.com/i/web/status/1…
Interesting RCT in @NEJM about platelet transfusions prior to CVC placement in people w/ thrombocytopenia (Plt 10-50k):
- higher rate of grade 2-4 bleeding w/o Plt transfusion: 11.9% vs 4.9%
- difference driven by much more bleeding w/ subclavian lines nejm.org/doi/full/10.10… 1/
This trial enrolled n=338 hospitalized people in 🇳🇱 with platelets between 10-50k, INR <1.5 (changed to 3.0). 57% were heme/onc patients & 43% were ICU patients.
Median Plt count was 30k
Most were getting a CVC for chemoTx. (Most weren’t exactly your “typical” ICU patient.) 2/
Importantly they placed the CVC within 1 hour or randomization. This means they probably didn’t transfuse then place a line, more like placed a line while transfusing.
(IMO this difference matters in situations where platelets are dysfunctional, like uremia) 3/