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.

February 10, 2021

Take Home Points
  • Consider ruptured AAA in patients (especially those > 50 years of age) with unexplained hypotension, back or abdominal pain
  • All ruptured AAAs should be considered unstable regardless of vital signs as rapid deterioration is common
  • A ruptured AAA is 100% fatal without surgical or endovascular intervention. Mobilize your surgical colleagues early

February 8, 2021

Background: What if we lived in a world where we didn’t call “STEMI alerts”, but instead paged out “OMI alerts”? In the Reperfusion Era of the late 20th century, many large trials showed the benefits of emergent reperfusion therapy, with even greater benefit in the subgroup of patients with undefined ST elevation. As the best idea available, the STEMI-NSTEMI paradigm replaced the Q-wave vs. non-Q-wave MI paradigm in 2000. STEMI-NSTEMI has been a primary determinant of cath lab activations, hospital metrics, and many other patient factors and outcomes. However, the STEMI criteria fail us frequently, missing upwards of 30% of acute coronary occlusion. Additionally, the STEMI/NSTEMI paradigm is dependent on ST segment elevation defined by millimeter criteria, however many occlusion myocardial infarctions (OMI), have no ST segment elevation at all.  To many of us, this idea is not new; we are often taught about STEMI equivalents and “subtle STEMI” that also deserve aggressive management. Over the last 15 years, there has been increased interest in identifying which patients would benefit most from emergent reperfusion therapy. Occlusion myocardial infarction (OMI) vs non-occlusion myocardial infarction (NOMI) is a new paradigm that emerged a few years ago (courtesy of Dr. Stephen Smith, Dr. Pendell Myers, and Dr. Scott Weingart) that might change the way we think about acute myocardial infarction. Their OMI Manifesto is an incredible document (which I highly recommend you read) outlining the historical, clinical, and academic perspectives of why the STEMI-NSTEMI paradigm should be replaced by the OMI-NOMI paradigm. OMI is defined as acute coronary occlusion or near occlusion with insufficient collateral circulation where without emergent catheterization and reperfusion myocardium will undergo necrosis. Patients with OMI are the only ones who benefit from emergent reperfusion therapy, and these patients can present with or without ST elevation on ECG.

February 4, 2021

What do Warren Buffet, Tim Cook, Michelle Obama, Oprah Winfrey, and Jack Dorsey have in common? They are all highly successful people with a penchant for rising early. Two additional people I find incredibly motivating, Jocko Willink and Eric Thomas, are also early risers. Jocko infamously posts inspirational photos of his wristwatch to social media at 3:30 AM.