Mar 13 2008
I have steadily endeavored to keep my mind free so as to give up any hypothesis, however much beloved (and I cannot resist forming one on every subject), as soon as the facts are shown to be opposed to it.
— Charles R. Darwin
I’m getting old: 50, almost 51, and that’s over 350 in dog years. As a result of my advancing age there are things I do not get: tattoo’s, hip hop, visible undergarments, and those rectangular, square plastic glasses that seem so popular and look hideous on everyone. It gets harder to change.
I have been able to stick MD after my name for almost a quarter century now (175 dog years for those keeping track), and it does give a sense of perspective to the ebb and flow of medical therapies. Medicine for the last hundred years has been all about change. Dogma from last century is nonsense this century, all due to that damn science. It gets so tiresome having to learn something new.
Last month’s New England Journal of Medicine was another in a seemingly endless series of plus ça change, plus c’est la même chose moments.4 They published the results of the CORTICUS study, a trial that looked at the use of corticosteroids in septic shock. For background, septic shock occurs when a severe infection shuts down most important organs and the patient cannot maintain their blood pressure. Mortality is high and, depending on the patient, the infection and the infecting organism, mortality ranges from 30 to 110%. People can die several times during their admission and be temporarily brought back, at least from the sloppy definitions of the near death experience proponents (shameless plug for Quackcast 23). Sepsis is a Bad Disease. Patients in septic shock often have lower levels of cortisol in their blood than they should. So maybe giving replacement cortisol, in the form of hydrocortisone or prednisone, would decrease the death rates.
The results of the CORTICUS (I so want to be involved in a study that has an obscene acronym) suggests steroids are not effective. When compared to placebo, physiologic hydrocortisone (i.e. giving enough hydrocortisone to replace the deficit) was no better at preventing mortality. It didn’t work. Or didn’t it. Or did it? Which one?