February 12, 2021

Background: Publication of the RECOVERY trial results on Dexamethasone were game changing - the drug had a clear reduction in mortality in patients requiring oxygen. Since then, we have had little to celebrate in terms of therapeutics in those with moderate to severe disease. The beneficial effects of corticosteroids in COVID-19 patients with hypoxic lung damage suggests other, more specific immunomodulatory agents may provide additional patient-oriented improvements.

Enter Tocilizumab.  This is a recombinant anti-IL6 receptor monoclonal antibody that inhibits binding of IL-6 to receptors that signal inflammation.  The results of tocilizumab from randomized trials thus far have shown mixed results for benefit.  Many of the trials not showing benefit were smaller, however the larger REMAP-CAP trial [2] did report benefit in patients requiring organ support. Further data is clearly needed to guide clinicians.

February 11, 2021

Background: The recently published CODA trial (Link is HERE) comparing antibiotics vs laparoscopic appendectomy for acute uncomplicated appendicitis demonstrated  an antibiotic 1st strategy was non-inferior to laparoscopic appendectomy. However, there were nearly 3 in 10 patient who had undergone appendectomy by 90 days and 2x more complications in the antibiotics 1st strategy.  Furthermore, patients with an appendicolith were at much higher risk of complications indicating a surgery 1st strategy for these patients.  These results mirror what was seen in the APPAC study. In the original APPAC trial at 5 year follow up 61% of 256 patients with uncomplicated acute appendicitis were successfully treated with antibiotics and those who developed recurrent appendicitis had no adverse outcomes related to delays in appendectomy [2]. One of the big issues with previous studies is the requirement of IV antibiotics before transitioning to oral antibiotics.  The ability to initiate oral antibiotic therapy and avoid hospital admission could further decrease cost, improve patient satisfaction, and even improve quality of life.

January 28, 2021

Background: Anyone who has had a corneal abrasion knows how painful it can be.   Unfortunately, traditional analgesic agents (ibuprofen, acetaminophen, opiates etc) are ineffective in relieving pain. Topical anesthetic drops can be diagnostic of superficial eye pathology and are routinely used prior to slit-lamp examination.  They provide immediate relief in the emergency department and have been shown to be effective and safe (Limited evidence has not shown significant adverse events) as short-term outpatient therapy (REBEL EM).  The biggest concern with the use of topical anesthetic agents as outpatient therapy is delayed healing, which is what most evidence has focused on.  This may occur with long-term use, but not been seen in studies of short-term use of topical anesthetics (REBEL EM). Use of short-term topical anesthetics further has the potential to reduce the use of opioids for analgesia for this indication. Recent published literature on topical anesthetic for this indication have focused on harms. There is scant literature detailing their benefit.

January 22, 2021

Background: Facilities around the world have seen surges of COVID-19 pneumonia  patients who have required protracted hospitalizations leading to overwhelmed hospital systems. Awake proning is a practice that was adopted early in the pandemic as a means to avoid, or at least delay, endotracheal intubation to lessen the burden of ICU care.  Proning helps improve lung recruitment, reduce ventilation/perfusion mismatch, and reduces alveolar strain in intubated patients.  Numerous small trials and anecdotes of awake proning have shown improvements in oxygenation and respiratory rate.However, whether these surrogate physiological endpoint improvements translate to better clinical outcomes (i.e. intubation and mortality) is still largely unknown.

January 11, 2021

Background: Current trauma resuscitation prioritizes control of bleeding and uses massive transfusion protocols to prevent and treat coagulopathy. This is typically done in the form of massive transfusion protocols delivered in proportions that approach the composition of whole blood. Two strategies to help guide this replacement of blood products are conventional coagulation tests and viscoelastic hemostatic assays.