Commentary by Cara Litvin MD, Executive Editor, Clinical Correlations
Published in the NEJM this week was a study intended to conclusively determine whether corticosteroids are an effective adjunctive therapy in severe sepsis. Although corticosteroid use is a widely accepted therapy for the treatment of sepsis, prior evidence supporting this practice has been lacking. In this multicenter randomized double-blind trial (CORTICUS), ICU patients were randomized to receive a full course of hydrocortisone therapy versus placebo. Corticotropin stimulation tests were performed in all patients. The primary end point was mortality at 28 days in those who failed their stimulation tests. Some secondary end points included mortality in corticotropin responders as well as 1 year mortality and a reversal of organ failure (shock). There was no difference in mortality in either those who failed or passed their cort-stim tests. Although shock appeared to be reversed more quickly in the hydrocortisone group, this group also experienced more episodes of superinfection. The accompanying editorial points out that the trial was underpowered to detect a clinically important effect. Thus the jury remains undecided on corticosteroid use in the ICU and it is unlikely that the CORTICUS trial will change current practice.
Moving on to a study with more positive results, yet another compelling report on statins. In a prospective meta-analysis reported in the Lancet, all-cause mortality in diabetic patients decreased by 9% with every 1 mmol/L decrease in LDL. Major vascular events were reduced by 21% per mmol/L reduction in LDL. Among diabetics, the proportional effects of statin therapy were the same, irrespective of other baseline characteristics.
Meanwhile, making headlines in media circuits this week were the results of a survey by the federal Substance Abuse and Mental Health Services Administration reporting that rates of abuse of cough medicines amongst 12-25 year olds are comparable to rates of abuse of LSD, and even higher than rates of methamphetamine use in the same age group. An alarming 3.1 million young people have used cough medicines, particularly dextromethorphan, in an attempt to produce hallucinations or dissociative experiences.
And hitting close to home this week was a report in the NY Times detailing the financial crisis occurring at Grady Memorial Hospital in Atlanta. For those of us with Bellevue near and dear to our hearts, hearing about a public city hospital in peril is unnerving. Although Grady provides vital services to the Atlanta region, particularly for the uninsured and Medicaid patients, it may no longer have the financial resources necessary to sustain itself.
Finally, on a lighter (and sweeter) note, a report in the BMJ this week reminds us all of the dangers of…sugarless gum. The report includes two cases of severe weight loss and chronic diarrhea attributed to the consumption of large amounts (over 20 sticks) of sugar-free gum containing sorbitol. In both cases, patients with severe weight loss and diarrhea who were noted to previously consume large amounts of sorbitol (in the form of gum and other sugar-free sweets) were placed on sorbitol-free diets, curing them of their GI afflictions.