Wednesday, January 29, 2014

Does Investigating Delirium Make You Delirious? A Sober Look at Sedation and Analgesia in the ICU

Michael's Milk
I rarely use the Medical Evidence Blog to discuss review articles, but today's NEJM has one that I can't pass up about Sedation and Delirium in the Intensive Care Unit.  It is my opinion that we have gotten carried away by the torrent of articles, many in prominent journals, about delirium in the ICU and that while this is an important topic for research, it is extremely premature to try to translate the findings into practice, and moreover, that the approach to sedation suggested by the article is lacking in common sense.

As chronicled in the accompanying perspective article by D.S. Jones, delirium has been around as long as ICUs have, and the longer you're there, the more likely you will become delirious.  It's an exposure thing.  Thus, until somebody reports the results of a trial of delirium treatment or prevention that has important and undeniable effects on clinically relevant outcomes, I will continue to approach delirium as I always have - by going to great lengths to get patients out of bed, off the vent, and out of the ICU as fast as I possibly can - because these things benefit all patients regardless of whether they have an impact on delirium.

Thursday, January 23, 2014

White Noise: Trials of Pharmaceuticals for Alzheimer's Disease

"But we are not here concerned with hopes or fears, only with the truth as far as our reason allows us to discover it." - Charles Darwin

In yesterday's NEJM, the results of two trials of antiamyloid monoclonal antibodies (sonalezumab and bapeneuzumab)  for Alzheimer's Disease (AD) are published.  I became interested in the evidence for AD treatments after the recent trial of Vitamin E and Mematine for AD (the TEAM-AD VA Cooperative Trial) was published in JAMA earlier this month.  Regular readers know that I think that the prior probability that vitamins, minerals, and antioxidants are beneficial for any disease outside of deficiency states is very low.  The vitamin E trial was the impetus for some background investigation which I will summarize below.