Friday, June 29, 2012

Xigris Isn't Dead - Just Hibernating

Activated Protein C, also known as Xigris, which has had an infamous and circuitous career of sorts, is back.

After a short life of use in severe sepsis, the continued investigations into its efficacy have finally been unable to establish its benefit.  Although many expensive therapies without conclusive benefit are still in use in medicine, we'll score this one (belatedly) for the good guys.

This early animal research, published as a letter in Nature Medicine, reports on interventions targeting the aPC pathway to prevent lethal radiation injury to hematopoietic cells.  They say that starting infusions of aPC within 24 hours of lethal radiation exposure mitigated radiation mortality in mice.  Probably quite a long way off for real-world usage, but any potential treatment is better than none.

"Pharmacological targeting of the thrombomodulin–activated protein C pathway mitigates radiation toxicity"

Wednesday, June 27, 2012

Failings of Modern Medicine

A brilliant piece that eloquently states many of the ideas espoused on this blog, focusing on pulmonary embolism as the poster child for over-testing, over-diagnosis, and lack of sound evidence underlying treatment.

These authors, in the Archives of Internal Medicine, accurately describe the chimeric nature of pulmonary embolism - historically described as a dreaded disease, diagnosed clinically from the manifestations of pulmonary infarction, to the modern manifestation of filling defects noted on CTA during an episode of pleuritic chest pain.  They discuss the handful of patients who benefited from the first heparinization for treatment, and argue the disease for which anticoagulation is the treatment is not the disease we are diagnosing today.

This article covers so many excellent points, and ties the clinical problems so tightly into the underlying principles, that it's almost the sort of must-read article to which medical students should be exposed - in order to bring about that frightening moment of maturity in medicine in which you realize the emperor is distinctly lacking in clothes.

Lovely work!

"The Diagnosis and Treatment - of Pulmonary Embolism: A Metaphor for Medicine in the Evidence-Based Medicine Era"

Monday, June 25, 2012

Impaled in a Rowing Accident

This article I dredged up from the archives is mostly of sentimental value - although, I could claim it's related to Olympic sport-related trauma with the upcoming Games.

This is from the series "Case records of the Massachusetts General Hospital", which run the gamut all the way out to some of the most esoteric diagnoses possible.  This particular article describes the management and outcomes of a man impaled by a rowing shell while on the Charles River.  Eight-person rowing shells are ~17 meters in length, have a crewed weight of nearly 1,000 kg, and travel fast enough that a water skier may be towed behind.  There is a small rubber bumper affixed to the, otherwise sharp, wooden or carbon-fiber bow that is meant to reduce the potential for injury in event of a collision.  In this incident, the momentum of a head-on impact dislodged the bow ball and resulted in the unfortunate impalement incident described.  A fascinating little read.

Rowing collisions are uncommon, injuries are rare, and this is probably nearly unique.

"Case records of the Massachusetts General Hospital. Case 10-2007. A 55-year-old manimpaled in a rowing accident."