November 2011 Critical Care Journal Club

Reference as: Robbins RA. November 2011 Critical Care Journal Club. Southwest J Pulm Crit Care 2011;3:172. (Click here for PDF version of journal club)

Raschke RA, Garcia-Orr R. Hemophagocytic lymphohistiocytosis: a potentially underrecognized association with systemic inflammatory response syndrome, severe sepsis, and septic shock in adults. Chest 2011;140:933-8. (Click here for abstract)

I was asked to do Critical Care Journal Club for November and have taken the opportunity to review an article authored by Roaxanne Garciaorr and Robert Raschke, the Critical Care Journal Club editor who normally writes this journal club.

Hemophagocytic lymphohistiocytosis (HLH) was originally described as a genetic disorder of immune regulation in neonates with protracted fever, hepatosplenomegaly, and cytopenia. A secondary form of HLH, triggered by serious infections, was subsequently described in adults. This manuscript reports three adult patients who presented with systemic inflammatory response syndrome and features consistent with severe sepsis and septic shock, who subsequently received a diagnosis of secondary HLH.  The hyperinflammatory pathophysiologic characteristics of HLH and septic shock are closely intertwined. Clinical and laboratory features of HLH and septic shock overlap in some patients, making the syndromes difficult to distinguish. In the authors experience and review, progressive pancytopenia was the feature most likely to suggest secondary HLH in the adult patient with presumed (or definite) septic shock. Use of other HLH-2004 diagnostic criteria is hindered by the poor operating characteristics of these tests in critically ill adults. Bone marrow aspiration is the most useful diagnostic test, but may yield an initial false-negative result. Treatment by aggressive immunosuppressive therapy with dexamethasone, etoposide, cyclosporine, and IV immunoglobulin should not be delayed.

This manuscript describes an entity which is underrecognized and treatable. It emphasizes awareness and is well worth reading those unfamiliar with HLH.

Paulos JA. Bigger plates, more food--or is it the other way around? Scientific American 2011;305:20.

Another article was brought to our attention by Clement Singarajah. This single page article describes when dealing with weakly correlated quantities, spurious trends and associations can be created by artfully defining the size of categories. The author uses an example of plate size and ounces of food consumed at a buffet. He shows that either large or small plates can be shown to lead to increased food consumption depending on how large or small plates are defined. This article will increase the awareness of how these manipulations can be used by the unscrupulous or the naïve to support a preconceived conclusion.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care