Use of ADHD drugs ‘increases by 50% in six years.

There has been a 50% rise in England in the use of drugs for attention deficit hyperactivity disorder in six years.

NHS prescriptions for methylphenidate drugs, including Ritalin, rose from 420,000 in 2007 to 657,000 last year, the Care Quality Commission said.

The watchdog warned health workers to “carefully monitor” their use as they have the potential to be “abused”.


The drugs are one of a number linked to the “smart-drug” craze, where students take medication to help them focus.

Methylphenidate is known as a psychostimulant.

While it is not completely clear how it works, it is thought to stimulate a part of the brain that changes mental and behavioural reactions.

The CQC report – its annual review of controlled drugs – said the number of prescriptions for both children and adults for such medications rose by 11% between 2011 and 2012.

Private prescribing also rose during the period going up from just under 2,000 in 2007 to just under 5,000 last year. But as the numbers of these are a small fraction of the NHS prescriptions the belief is that the rise has been driven by an increase in the number of ADHD diagnoses.

‘Worrying’ trend

The commission said: “As in previous years, we believe that this reflects increased diagnosis of, and prescribing for, the treatment of ADHD.

“We are also aware of the possibility that methylphenidate could be diverted and abused, and for this reason we recommend that its use should be monitored carefully.”

Consultant psychiatrist Professor Tim Kendall, who has compiled national guidelines on treating ADHD, told BBC Radio 4’s Today programme the increase in prescriptions was a worry.


He said: “I think it’s a real trend. I think it’s too big to be ignored.”

Asked if there are any dangers to people who take methylphenidate drugs over a long period, Prof Kendall said: “In children, without doubt. If you take Ritalin for a year, it’s likely to reduce your growth by about three-quarters of an inch.

“I think there’s also increasing evidence that it precipitates self-harming behaviour in children and in the long term we have absolutely no evidence that the use of of Ritalin reduces the long-term problems associated with ADHD.

“Having said that, if you’ve got a kid with severe ADHD, it’s very difficult to treat them psychologically without using Ritalin as well.”

Common symptoms of ADHD include inattentiveness, hyperactivity and impulsiveness. Symptoms tend to be first noticed at an early age and it is normally diagnosed between the ages of three and seven.

It is estimated that the condition affects 2% to 5% of school children and young people – although less than half of those have the severe form that requires medication. However, it can be a lifelong condition and many people continue to show symptoms in adulthood.

The CQC report also found there has been large increases in the use of other controlled drugs.

Methadone prescriptions in the NHS rose from 1.8m to 2.3m over six years, while buprenorphine, which like methadone is used as a pain relief, more than doubled to over 2.2m

However, use of temazepam, which is often used to sedate patients – the so-called chemical cosh, fell from 3.2m to 2.3m.

Source: BBC





President Bush’s unnecessary heart surgery.

Vinay Prasad is chief fellow of medical oncology at the National Cancer Institute and the National Institutes of Health. Adam Cifu is a professor of medicine at the University of Chicago.

Former president George W. Bush, widely regarded as a model of physical fitness, received a coronary artery stent on Tuesday. Few facts are known about the case, but what is known suggests the procedure was unnecessary.

Before he underwent his annual physical, Mr. Bush reportedly had no symptoms. Quite the opposite: His exercise tolerance was astonishing for his age, 67. He rode more than 30 miles in the heat on a bike ride for veterans injured in the wars in Iraq and Afghanistan.

If Mr. Bush had visited a general internist practicing sound, evidence-based care, he would not have had cardiac testing. Instead, the doctor would have had conducted age-appropriate cancer screening. For the former president, this would include only colon cancer screening. It no longer would include even prostate-specific antigen testing for cancer. The doctor would have screened for cholesterol, checked for hypertension and made sure the patient was up to date on age-appropriate vaccinations, including those for pneumococcal pneumonia and shingles. Presumably Mr. Bush got these things, and he got the cardiac test as well.

What value does a stress test add for an otherwise healthy 67-year-old?No study has shown that this examination improves outcomes. The trials that have been done for so-called routine stress testing examined higher-risk patients. They found that performing stress tests on people at high risk of cardiovascular disease may detect blockages but does not improve symptoms or survival. Routine stress testing does, however, increase the use of procedures such as coronary stenting.

Unfortunately, Mr. Bush, like many VIPs, may be paying the price of these in-depth investigations. His stress test revealed an abnormality, prompting another test: a CT angiogram. This study showed a blockage, which was stented open during an invasive procedure. It is worth noting that at least two large randomized trials show that stenting these sorts of lesions does not improve survival. Because Mr. Bush had no symptoms, it is impossible that he felt better after these procedures.

Instead, George W. Bush will have to take two blood thinners, aspirin and Plavix, for at least a month and probably a year. (The amount of time a blood thinner is needed depends on the type of stent placed). While he takes these medications, he will have a higher risk of bleeding complications with no real benefit.

Although this may seem like an issue important only to the former president, consider the following: Although the price of excessive screening of so-called VIPs is usually paid for privately, follow-up tests, only “necessary” because of the initial unnecessary screening test, are usually paid for by Medicare, further stressing our health-care system. The media coverage of interventions like Mr. Bush’s also leads patients to pressure their own doctors for unwarranted and excessive care.



Many Back Pain Treatments Are Ineffective and Unnecessary, and Here’s Why….

Story at-a-glance

  • Most cases of back pain are a result of mechanical problems, such as poor posture or improper movement that are best prevented and managed by regular exercise and strengthening your back and abdominal muscles
  • Well-established guidelines for the treatment of back pain require very conservative management ; in most cases, no more than aspirin or acetaminophen (Tylenol) and physical therapy
  • Recent research shows that many doctors do not follow these guidelines. Over the past decade, use of Tylenol and NSAID’s declined by about 50 percent, while prescriptions for opiates rose by more than 50 percent
  • One of the most effective strategies to prevent or address back pain is posture training like Foundation Training or Esther Gokhale.
  • Other alternatives include chiropractic and osteopathic adjustments, Neuro-structural integration technique (NST), non-exercise activities, and yoga

An estimated 80 percent of Americans will suffer from chronic back pain at some point in life. Nearly 30 percent may be struggling with persistent or chronic back pain right now,1 leading many to resort to prescription painkillers, expensive steroid shots or even surgery.

This despite the fact that, in most cases, back pain is a result of simple mechanical problems relating to poor posture or improper movement, which are best prevented and managed by regular exercise and strengthening your back and abdominal muscles.

It is estimated that back pain accounts for more than 10 percent of all primary care doctors visits each year, and the cost for treatment stacks up to $86 billion annually.2 According to recent research, much of this treatment is unnecessary, while simultaneously failing to successfully address the problem.


As reported by The New York Times:

“Well-established guidelines for the treatment of back pain require very conservative management — in most cases, no more than aspirin or acetaminophen (Tylenol) and physical therapy.

Advanced imaging procedures, narcotics and referrals to other physicians are recommended only for the most refractory cases or those with serious other symptoms. But a study published in JAMA Internal Medicine4suggests that doctors are not following the guidelines.”

Back Pain Is Often Over-Treated

The team reviewed more than 23,900 outpatient visits for back pain that was unrelated to more serious conditions (such as cancer) over a 12-year period (1999-2010), and found that during this time:5

  • Use of Tylenol and other NSAIDs declined by just over 50 percent
  • Prescriptions for opiates increased by 51 percent
  • CT and MRI scans also rose by 57 percent
  • Referrals to specialists increased by 106 percent
  • Use of physical therapy remained steady at about 20 percent

Needless to say, the trend shows that back pain is increasingly being treated with addictive drugs and diagnostic exams that expose patients to potentially unnecessary and dangerous levels of radiation. Back pain is actually one of the primary reasons why so many American adults get addicted to pain killers.

Furthermore, the existing treatments do not cure back pain—they only treat the symptoms. Senior author, Dr. Bruce E. Landon, a professor of health care policy at Harvard, told The New York Times6 that back pain actually tends to improve by itself in most cases, adding:

“It’s a long conversation for physicians to educate patients. Often it’s easier just to order a test or give a narcotic rather than having a conversation. It’s not always easy to do the right thing.”

Opiates are not the only dangerous drugs being pushed for back pain. One of the most egregious examples of Big Pharma disease mongering7 is the emergence of ads suggesting your back pain may be caused by ankylosing spondylitis, a chronic inflammatory disease of the axial skeleton, which includes the spine.

“Do you have back pain? Are you dismissing it as resulting from “lifting too much” at the gym or “bad posture”? one radio ad asks. “You might have ankylosing spondylitis.”

The drug advertised is Humira, which has a price tag of about $20,000 a year. It is reprehensible for drug companies to promote this expensive and dangerous drug for an exceedingly rare cause of low back pain, which likely is responsible for less than a tenth of a tenth of one percent of low back pain!

Side effects of the drug8 include tuberculosis, serious infections, increased risk of lymphoma and other cancers, hepatitis B infection in carriers of the virus, allergic reactions, nervous system problems, blood problems, heart failure, certain immune reactions including a lupus-like syndrome, liver problems, new or worsening psoriasis, and many more. Considering the fact that most cases of low back pain are not caused by inflammatory conditions, you probably do not need this drug, although your doctor may very well give it to you should you ask.

Don’t Settle for Band-Aids—Treat the Root Cause of Your Back Pain

With the exception of blunt force injuries, low back pain is commonly caused and exacerbated by:

Poor posture Poor physical conditioning facilitated by inactivity Internal disease, such as kidney stones, infections, blood clots
Obesity Psychological/emotional stress Osteoporosis (bone loss)


Since poor posture and/or improper movement is to blame for most cases of back pain, one of the best things you can do to prevent and manage back pain is to exercise regularly and keep your back and abdominal muscles strong. Foundation Training—an innovative method developed by Dr. Eric Goodman to treat his own chronic low back pain—is an excellent alternative to the Band Aid responses so many are given. The program is inexpensive and can be surprisingly helpful, as these exercises are designed to help you strengthen your entire core and move the way nature intended.

Many people fail to realize that many times back pain actually originates from tension and imbalance at a completely different place than where the pain is felt. For example, the very act of sitting for long periods of time ends up shortening the iliacus, psoas and quadratus lumborum muscles that connect from your lumbar region to the top of your femur and pelvis. When these muscles are chronically short, it can cause severe pain when you stand up as they will effectively pull your lower back (lumbar) forward.

The reality is that the imbalance among the anterior and posterior chains of muscles leads to many of the physical pains experienced daily. By rebalancing these muscles, you can remedy many pains and discomforts. Teaching your body to naturally support itself at the deepest level is going to be far more effective than strapping on an external back brace, which over time can lead to even weaker musculature.

Another option is Esther Gokhale who is a posture expert that I interviewed earlier this year. I’ll be running that interview shortly. Both of these strategies are far more effective than the typical conventional medical approach for low back pain. Additionally, chiropractic or osteopathic care as discussed below can also frequently be very valuable.

Most Body Pain Can Be Traced to Poor Postural Patterns

Besides having a weak core, another MAJOR cause of neck, back, and other areas of pain is due to the shortening of your suboccipital muscles in the back of your neck. This occurs when you sit and walk around with your head in a forward-tilted position, which is becoming symptomatic of the modern lifestyle where everything you attend to is right in front of you on one screen or another.

According to Dr. Goodman, back pain is just one possible result of this kind of postural imbalance. It can also result in shoulder pain, carpal tunnel syndrome, headaches, jaw pain, knee pain, IT band pain, and more. To address this, Dr. Goodman has expanded Foundation Training into a broader program he now calls “Modern Moveology.”

Chiropractic and Osteopathic Care May Also Be of Benefit

Seeing a qualified chiropractor is certainly a wise consideration if you suffer from back pain. I am an avid believer in thechiropractic philosophy, which places a strong emphasis on your body’s innate healing ability and far less reliance on band-aid responses like drugs and surgery.

A recent study published in the Annals of Internal Medicine9 even revealed that chiropractic care is often more effective than medication for treating musculoskeletal pain. After following 272 neck-pain patients for 12 weeks, researchers found that those who used a chiropractor or exercised were more than twice as likely to be pain free compared to those who took medication.

Another option is to consult a doctor of osteopathic medicine (DO). As many of you know, I am an osteopathic physician, which I chose because DOs practice a “whole person” approach to medicine, treating the entire person rather than just symptoms. DOs receive additional training in adjusting the musculoskeletal system, and osteopathic manipulation has also been found to reduce chronic low back pain. In one recent study10 involving 455 people, participants received eight weeks of either osteopathic manipulation, a sham treatment, or ultrasound therapy. Sixty-three percent of those who’d had osteopathic manipulation reported a moderate improvement in their pain while half said they had a substantial improvement.

That said, it’s been my experience that only a small percentage of DOs are truly skilled in this area, as many have instead chosen to follow a more conventional allopathic model. So if you choose to see a DO for osteopathic manipulation, make sure they provide this service and have ample experience.

Two Other Non-Invasive Treatment Options for Back Pain

Neuro-structural integration technique (NST) is yet another non-drug pain relief option. NST is a gentle, non-invasive technique that stimulates your body’s reflexes. Simple movements are done across muscles, nerves and connective tissue, which helps your neuromuscular system to reset all related tension levels, promoting natural healing. It is completely safe and appropriate for everyone from highly trained athletes, to newborns, pregnant women, and the elderly and infirm. To find an NST therapist near you, see our NST Therapists Page. You can also purchase a DVD set to learn more about this technique.

Last but not least, yoga, which is particularly useful for promoting flexibility and core muscles, has also been proven beneficial if you suffer with back pain. The Yoga Journal11 has an online page demonstrating specific poses that may be helpful. A recent study in the journal Evidence-Based Complementary and Alternative Medicine12 also found that once-weekly yoga classes appear to produce as much benefit for lower back pain sufferers as taking classes twice a week. According to one of the authors:13

“Given the similar improvement seen in once weekly yoga classes, and that once a week is more convenient and less expensive, we recommend patients suffering from lower back pain who want to pursue yoga attend a weekly therapeutic yoga class.”

Even More Tips to Beat Back Pain

Preventing back pain is surely easier than treating it. Besides the recommendations already covered above, which included getting chiropractic adjustments, Foundation Training, Egoscue exercises, and NST, below are several more tips for beating back pain. With this many alternatives available, there are few good reasons to turn to pharmaceutical or surgical band-aids that do nothing to treat the underlying causes of your pain, but might cause additional harm in the process:

  1. Exercise and physical activity will help strengthen the muscles of your spine. Make your exercise time count by includinghigh-intensity sessions. You probably only need this once or twice a week at the most. You’ll also want to include exercises that really challenge your body intensely along with those that promote muscle strength, balance and flexibility.
  2. If you spend many hours every day sitting down, pay careful attention to consciously sucking in your belly and rotating your pelvis slightly up. At the same time make sure your head is back with your ears over your shoulders and your shoulder blades pinched. This will help keep your spine in proper alignment. You can hold these muscles tight for several minutes and do this once every hour. The upcoming interview with Esther Gokhale will go into far more details.

Also, to combat the detrimental health ramifications of excessive sitting, make a point to stand up at least once every 10 minutes. In addition to regularly standing up, I also do a few squats while I’m at it. To learn more about the importance of regularly getting out of your chair, please see my interview with Dr. Joan Vernikos, former director of NASA’s Life Sciences Division and author of Sitting Kills, Moving Heals.

  1. Optimize your vitamin D and K2 levels to prevent the softening of the bones that can often lead to lower back pain.
  2. Ground yourself. Grounding yourself to the earth, also known as Earthing, decreases inflammation in your body, which can help quiet down back pain and other types of pain. Your immune system functions optimally when your body has an adequate supply of electrons, which are easily and naturally obtained by barefoot/bare skin contact with the earth. Research indicates the earth’s electrons are the ultimate antioxidants, acting as powerful anti-inflammatories. Whenever possible, take a moment to venture outside and plant your bare feet on the wet grass or sand.
  3. Address psychological factors. Few people want to be told that their pain is psychological or emotional in origin, but there’s quite a bit of evidence that backs this up.

Underlying emotional issues and unresolved trauma can have a massive influence on your health, particularly as it relates to physical pain. Dr. John Sarno,14 for example, used mind-body techniques to treat patients with severe low back pain and has authored a number of books on this topic. His specialty was those who have already had surgery for low back pain and did not get any relief. This is one tough group of patients, yet he had a greater than 80 percent success rate using techniques like the Emotional Freedom Technique (he has now retired from practice).

  1. Get regular massage therapy. Massage releases endorphins, which help induce relaxation and relieve pain.
  2. Keep your weight spread evenly on your feet when standing. Don’t slouch when standing or sitting to avoid putting stress on your back muscles.
  3. Always support your back, and avoid bending over awkwardly. Protect your back while lifting – this activity, along with carrying, puts the most stress on your back.
  4. Wear comfortable shoes. For the ladies, it would be good to not wear heels most of the time.
  5. Drink plenty of water to enhance the height of your intervertebral disks. And because your body is composed mostly of water, keeping yourself hydrated will keep you fluid and reduce stiffness.
  6. Quit smoking as it reduces blood flow to your lower spine and your spinal disks to degenerate.
  7. Pay attention to how—and how long—you sleep, because studies have linked insufficient sleep with increased back and neck problems. Pay attention to your sleep position. Sleep on your side to reduce curving of your spine, and stretch before getting out of bed. A firm bed is recommended.

Addressing the Root of Your Pain Might Save You More Than Dollars

Once you understand that back pain is typically the result of poor posture or improper movement, the remedy becomes clear. Certainly, addictive pain killers and surgery will not address these issues. So if you’re among those seeking medical care for persistent back pain, I’d advise you to consider your options before filling that prescription or going under the knife.

As shown in the featured research, the use of potent drugs and back surgeries are now becoming more the trend—not because they’re effective, but because many doctors simply do not take the time to educate their patients on the causes of the pain. And in fact, many doctors may still be under-educated on this issue as well.

While drug addiction and surgical interventions can have significant long-term ramifications and may in the long run lead to deteriorating health, most back pain can be prevented and treated by a variety of natural measures, including Foundation Training, osteopathic manipulation, chiropractic care, Earthing, yoga, EFT, and more.



Words prompt us to notice what our subconscious sees.

It’s a case of hear no object, see no object. Hearing the name of an object appears to influence whether or not we see it, suggesting that hearing and vision might be even more intertwined than previously thought.

Studies of how the brain files away concepts suggest that words and images are tightly coupled. What is not clear, says Gary Lupyan of the University of Wisconsin in Madison, is whether language and vision work together to help you interpret what you’re seeing, or whether words can actually change what you see.

Lupyan and Emily Ward of Yale University used a technique called continuous flash suppression (CFS) on 20 volunteers to test whether a spoken prompt could make them detect an image that they were not consciously aware they were seeing.

CFS works by displaying different images to the right and left eyes: one eye might be shown a simple shape or an animal, for example, while the other is shown visual “noise” in the form of bright, randomly flickering shapes. The noise monopolises the brain, leaving so little processing power for the other image that the person does not consciously register it, making it effectively invisible.

Wheels of perception

In a series of CFS experiments, the researchers asked volunteers whether or not they could see a specific object, such as a dog. Sometimes it was displayed, sometimes not. When it was not displayed or when the image was of another animal such as a zebra or kangaroo, the volunteers typically reported seeing nothing. But when a dog was displayed and the question mentioned a dog, the volunteers were significantly more likely to become aware of it. “If you hear a word, that greases the wheels of perception,” says Lupyan: the visual system becomes primed for anything to do with dogs.

In a similar experiment, the team found that volunteers were more likely to detect specific shapes if asked about them. For example, asking “Do you see a square?” made it more likely than that they would see a hidden square but not a hidden circle.

James McClelland of Stanford University in California, who was not involved in the work, thinks it is an important study. It suggests that sight and language are intertwined, he says.

Lupyan now wants to study how the language we speak influences the ability of certain terms to help us spot images. For instance, breeds might be categorised differently in different languages and might not all become visible when volunteers hear their language’s word for “dog”. He also thinks textures or smells linked to an image might have a similar effect on whether we perceive it as words.


Glucose Levels Predict Risk for Dementia.

Higher glucose levels within the nondiabetic range predicted higher risk for dementia.
Observational studies have established an association between diabetes and dementia. In this prospective study from Seattle’s Group Health Cooperative, researchers sought to determine whether average glucose levels in people without diabetes predict development of dementia. The study involved 2067 older adults (mean age 74; 11% with diabetes) who had no evidence of dementia at baseline and who were screened every 2 years using the Cognitive Abilities Screening Instrument. Average glucose levels were estimated using models that incorporated both serial glycosylated hemoglobin and blood glucose values.

During a median follow-up of 7 years, 25% of participants were diagnosed with dementia. Among participants who did not have diabetes, risk for developing dementia increased with increasing average glucose levels, after adjustment for potentially confounding variables. For example, in those whose average glucose level was 115 mg/dL, relative risk for dementia was 18% higher than in those whose average glucose level was 100 mg/dL. Among participants who had diabetes, relative risk for dementia was 40% higher in those whose average glucose level was 190 mg/dL compared with 160 mg/dL.


The prospective nature of this study, in which patients screened negative for dementia at baseline, is a strength. However, unmeasured confounders might have influenced the association between glycemia and dementia, and reverse causality is remotely possible (e.g., lifestyle changes in patients with early subclinical dementia might promote higher glucose levels). If higher blood glucose levels within the nondiabetic range do contribute to development of dementia, the mechanism is unclear.

Source: NEJM

2008–2010 Epidemic Keratoconjunctivitis Outbreaks Detailed.

An MMWR analysis of six outbreaks of adenovirus-associated epidemic keratoconjunctivitis from 2008 through 2010 provides lessons on infection control in healthcare settings. Epidemic keratoconjunctivitis is a severe form of viral conjunctivitis with symptoms that can last up to 21 days and may be associated with common ophthalmologic procedures.

The healthcare-associated outbreaks occurred in Florida, Illinois, Minnesota, and New Jersey. Healthcare providers were likely sources of transmission in four of the outbreaks, and infection control breaches occurred in all. Over 400 patients were infected.

MMWR‘s editors recommend the following infection-control measures:

  • Use strict hand hygiene.
  • Wear disposable gloves for potential contact with eye secretions.
  • Disinfect ophthalmologic instruments after every use, or use disposable instruments.
  • Ensure patients with suspected conjunctivitis have a separate waiting room, sign-in area, and exam room.
  • Bar from work any staff members with signs of epidemic keratoconjunctivitis.

In addition, the editors note, isopropyl alcohol is not sufficient for disinfecting ophthalmologic instruments that contact typically sterile body sites; rather, staff should follow equipment manufacturer’s instructions.

Source: MMWR article

Fluoroquinolone Labels Updated to Reflect Heightened Risk for Peripheral Neuropathy.

The FDA is requiring that the labels of fluoroquinolone antibiotics warn of the drugs’ increased risk for peripheral neuropathy.

The risk has been observed with oral and injectable fluoroquinolones, but not topical agents. Patients could experience peripheral neuropathy any time during their treatment, and it could persist for months or years or be permanent.

Patients should contact their healthcare providers if they develop symptoms consistent with peripheral neuropathy in the arms and legs, including pain, burning, numbness, or weakness; change in sensation to touch, pain, or temperature; or change in the sense of body position.

Patients who develop these symptoms should stop taking the antibiotic and receive alternative therapies unless the benefit of the fluoroquinolone outweighs the risk.

Source: FDA MedWatch safety alert

Fluoroquinolones Linked to Dysglycemia in Patients with Diabetes.

Fluoroquinolones are associated with increased risk for both hyperglycemia and hypoglycemia among patients with diabetes, compared with other antibiotics, according to a study in Clinical Infectious Diseases.

Researchers in Taiwan used national insurance claims data to identify roughly 78,000 outpatients with diabetes who received a new prescription for an oral antibiotic.

Within 30 days of starting the antibiotic, patients taking moxifloxacin, levofloxacin, or ciprofloxacin had 1.75 to 2.48 times the risk for hyperglycemia-related emergency department visits or hospitalizations, relative to patients taking macrolides. Risks were similarly elevated for episodes of hypoglycemia. Moxifloxacin was associated with the highest risk for dysglycemia.

The authors conclude: “Clinicians should consider these risks when treating patients with diabetes and prescribe fluoroquinolones cautiously.”

Source: Clinical Infectious Diseases article

Use of Therapeutic Plasma Exchange in the Burn Unit: A Review of the Literature.

Burn centers routinely treat a complex mix of patients with soft tissue injuries, including burn injuries, necrotizing soft tissue infections, and dermatologic conditions such as toxic epidermal necrolysis (TEN). In each of these conditions, fluid resuscitation, surgical interventions, and advances in critical care have improved survival significantly; however, there remains a subset of patients who do not respond to conventional means. It is because of these patients that we continue to seek means to “rescue” patients who are failing to respond to conventional care. Therapeutic plasma exchange (TPE) is an uncommon and underutilized treatment modality that has been used as a form of treatment “rescue.” We provide a review of the literature describing the use of TPE in TEN, burn shock, and sepsis. Our review of the literature over the past 30 years demonstrates persistent clinical benefits and reduced morbidity and mortality with use of TPE in TEN, burn shock, and sepsis. Many studies demonstrate significant improvement in morbidity and mortality with TPE in patients suffering from these conditions. However, future well-designed studies of the role of TPE in conditions commonly encountered in burn units are indicated. Improved awareness of TPE may lead to increased use of this uncommonly utilized modality and allow for potential future collaboration in a prospective, randomized, controlled trial with a larger number of subjects.


Characteristics and Outcomes of Patients With Vasoplegic Versus Tissue Dysoxic Septic Shock.


Background: The current consensus definition of septic shock requires hypotension after adequate fluid challenge or vasopressor requirement. Some patients with septic shock present with hypotension and hyperlactatemia greater than 2 mmol/L (tissue dysoxic shock), whereas others have hypotension alone with normal lactate (vasoplegic shock).

Objective: The objective of this study was to determine differences in outcomes of patients with tissue dysoxic versus vasoplegic septic shock.

Methods: This was a secondary analysis of a large, multicenter randomized controlled trial. Inclusion criteria were suspected infection, two or more systemic inflammatory response criteria, and systolic blood pressure less than 90 mmHg after a fluid bolus. Patients were categorized by presence of vasoplegic or tissue dysoxic shock. Demographics and Sequential Organ Failure Assessment scores were evaluated between the groups. The primary outcome was in-hospital mortality.

Results: A total of 247 patients were included, 90 patients with vasoplegic shock and 157 with tissue dysoxic shock. There were no significant differences in age, race, or sex between the vasoplegic and tissue dysoxic shock groups. The group with vasoplegic shock had a lower initial Sequential Organ Failure Assessment score than did the group with tissue dysoxic shock (5.5 vs. 7.0 points; P = 0.0002). The primary outcome of in-hospital mortality occurred in 8 (9%) of 90 patients with vasoplegic shock compared with 41 (26%) of 157 in the group with tissue dysoxic shock (proportion difference, 17%; 95% confidence interval, 7%–26%; P < 0.0001; log-rank test P = 0.02). After adjusting for confounders, tissue dysoxic shock remained an independent predictor of in-hospital mortality.

Conclusions: In this analysis of patients with septic shock, we found a significant difference in in-hospital mortality between patients with vasoplegic versus tissue dysoxic septic shock. These findings suggest a need to consider these differences when designing future studies of septic shock therapies.