- Modality Selection for the Revascularization of Left Main Disease. [Review]
- CJCan J Cardiol 2018 Dec 15
- The management of severe left main (LM) disease remains controversial and continues to evolve as new evidence emerges. Patient selection for coronary artery bypass grafting (CABG) or percutaneous cor…
The management of severe left main (LM) disease remains controversial and continues to evolve as new evidence emerges. Patient selection for coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) relies on both predicting mortality with CABG from clinical characteristics using the Society of Thoracic Surgeons (STS) risk score and anatomical complexity, using the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score. LM stenting techniques continue to evolve; for bifurcation lesions, the use of the double-kiss crush technique may reduce the incidence of late target vessel revascularization. In patients with acute coronary syndrome (ACS) complicated by cardiogenic shock, PCI is likely the first-line option in those with anatomically amenable disease, whereas all other stable non-ST-elevated ACS should be treated similar to stable ischemic heart disease. Outcomes comparing CABG and PCI have been recently examined in 2 large randomized clinical trials. In general, early outcomes of periprocedural myocardial infarction and stroke favoured PCI or were not different from outcomes with CABG. However, the conclusions of both trials are at present discordant with respect to late major adverse cardiac and cerebral events; additional follow-up of the trial patients is important for informed patient decision making. The appropriate mode of revascularization should be selected according to patient clinical characteristics and the complexity of the coronary lesions according to European and American guidelines. In those with low or intermediate SYNTAX scores, particularly with high surgical risk, PCI may be preferred to CABG in most other scenarios. A multidisciplinary heart team is recommended to help individualize revascularization decisions.
- Compartment Syndrome of the Foot: An Evidence-Based Review. [Review]
- JFJ Foot Ankle Surg 2019; 58(4):632-640
- Compartment syndrome of the foot (CSF) is a surgical emergency, with high risk of morbidity and poor outcome, including persistent neurologic deficits or amputation. Uncertainty remains regarding sur…
Compartment syndrome of the foot (CSF) is a surgical emergency, with high risk of morbidity and poor outcome, including persistent neurologic deficits or amputation. Uncertainty remains regarding surgical approaches, pressure monitoring values, and the extent of surgical treatment. This review provides a summary of the current knowledge and reports evidence-based diagnostic and therapeutic management options for CSF. Articles describing CSF were identified from MEDLINE, PubMed, and Cochrane databases up until February 2018. Experimental and original articles, systematic and nonsystematic reviews, case reports, and book chapters, independent of their level of evidence, were included. Crush injuries are the leading cause of CSF, but CSF can present after fractures of the tarsal or metatarsal bones and dislocations of the Lisfranc or Chopart joints. CSF is often associated with persistent neurologic deficits, claw toes, amputations, and skin healing problems. Diagnosis is made after accurate clinical evaluation combined with intracompartmental pressure monitoring. A threshold value of <20 mmHg difference between the diastolic blood pressure and the intracompartmental pressure is considered diagnostic. Management consists of surgery, whereby 2 dorsal incisions are combined with a medioplantar incision to the calcaneal compartment. The calcaneal compartment can serve as an "indicator compartment," as the highest-pressure values can regularly be measured within this compartment. Appropriately powered studies of CSF are necessary to further evaluate and compare diagnostic and therapeutic options.
- Science and fiction in critical care: established concepts with or without evidence? [Review]
- CCCrit Care 2019 Jun 14; 23(Suppl 1):125
- In the absence of evidence, therapies are often based on intuition, belief, common sense or gut feeling. Over the years, some treatment strategies may become dogmas that are eventually considered as …
In the absence of evidence, therapies are often based on intuition, belief, common sense or gut feeling. Over the years, some treatment strategies may become dogmas that are eventually considered as state-of-the-art and not questioned any longer. This might be a reason why there are many examples of "strange" treatments in medical history that have been applied in the absence of evidence and later abandoned for good reasons.In this article, five dogmas relevant to critical care medicine are discussed and reviewed in the light of the available evidence. Dogma #1 relates to the treatment of oliguria with fluids, diuretics, and vasopressors. In this context, it should be considered that oliguria is a symptom rather than a disease. Thus, once hypovolaemia can be excluded as the underlying reason, there is no justification for giving fluids, which may do more harm than good in euvolaemic or hypervolaemic patients. Similarly, there is no solid evidence for forcing diuresis by administering vasopressors and loop diuretics. Dogma #2 addresses the treatment of crush syndrome patients with aggressive fluid therapy using NaCl 0.9%. In fact, this treatment may aggravate renal injury by iatrogenic metabolic acidosis and subsequent renal hypoperfusion. Dogma #3 concerns the administration of NaCl 0.9% to patients undergoing kidney transplantation. Since these patients are usually characterised by hyperkalaemia, the potassium-free solution NaCl 0.9%, containing exclusively 154 mmol/l of sodium and chloride ions each, is often considered as the fluid of choice. However, large volumes of chloride-rich solutions cause hyperchloraemic acidosis in a dose-dependent manner and induce a potassium shift to the extracellular space, thereby increasing serum potassium levels. Thus, balanced electrolyte solutions are to be preferred in this setting. Dogma #4 relates to the fact that enteral nutrition is often withheld for patients with high residual gastric volume due to the theoretical risk of gastro-oesophageal reflux, potentially resulting in aspiration pneumonitis. Despite controversial discussions, there is no clinical data supporting that residual gastric volume should be generally measured, especially not in patients without a gastro-intestinal surgery and/or motility disorders. Clinical evidence rather suggests that abandoning residual gastric volume monitoring does not increase the incidence of pneumonia, but may benefit patients by facilitating adequate enteral feeding. Finally, dogma #5 is about sedating all mechanically ventilated patients because "fighting" against the respirator may cause insufficient ventilation. This concern needs to be balanced against the unwanted consequences of sedation, such as prolonged mechanical ventilation and intensive care unit length of stay as well as increased risk of delirium. Modern concepts based on adequate analgesia and moderate to no sedation appear to be more suitable.In conclusion, dogmas are still common in clinical practice. Since science rather than fiction should govern our actions in intensive care medicine, it is important to remain critical and challenge long established concepts, especially when the underlying evidence is weak or non-existing.
- Put Your Lights On: Electrocution As a Cause of an Unexplained Fall and Loss of Consciousness. [Journal Article]
- EJEur J Case Rep Intern Med 2019; 6(5):001084
- Electrical accidents are not reported very frequently, and may occur undetected as the signs are often manifold and not very specific. We report the case of a 43-year-old woman admitted to hospital d…
Electrical accidents are not reported very frequently, and may occur undetected as the signs are often manifold and not very specific. We report the case of a 43-year-old woman admitted to hospital due to a fall of unclear cause, with loss of consciousness, partial amnesia, paresis of both legs and crush syndrome. Only by thorough and repeated history-taking, and a careful physical examination that revealed burns typical of electrical current injuries, was the case resolved. With this case presentation, we would like to make the reader aware of electrocution as a possible cause of bruises and unconsciousness of unclear origin.
- Osteopathic manipulative treatment in pudendal neuralgia: A case report. [Journal Article]
- JBJ Bodyw Mov Ther 2019; 23(2):247-250
- Pudendal neuralgia is characterised by pain in the pudendal dermatome. It could be due to a stenosis of the pudendal canal, a compression along its pathway, or a pelvic trauma. Pudendal nerve entrapm…
Pudendal neuralgia is characterised by pain in the pudendal dermatome. It could be due to a stenosis of the pudendal canal, a compression along its pathway, or a pelvic trauma. Pudendal nerve entrapment (PNE) syndrome is frequently involved in pudendal neuralgia onset. This case report describes the osteopathic manipulative treatment (OMT) of a patient with functional PNE. A 40-year-old female presented with a 12-month history of intense pelvic pain resistant to 3 months of pharmacologic treatment that arose after three proctological surgeries. A perineal retracted painful scar was visible upon examination. PNE syndrome diagnosis was based on Nantes criteria. The electromyogram of the nerve showed an increased motor response latency of the left pudendal nerve. Visual analogue scale (VAS), female National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), Oswestry Disability Index (ODI) and Tampa scale of kinesiophobia (TSK) were used to assess patient's symptoms at baseline (T0), after pharmacologic treatment (T1), after OMT (T2), and at 6-month follow-up. Five treatments, including direct and indirect techniques, were performed over 1 month. OMT reduced pelvic neuralgia and disability indexes without any complications, maintaining a positive outcome at 6-month follow-up (VAS: T0 = 10, T1 = 10, T2 = 1.8, T3 = 1.5), (NIH-CPSI: T0 = 34, T1 = 30, T2 = 7, T3 = 6), (ODI: T0 = 48, T1 = 29, T2 = 9, T3 = 5) and (TSK: T0 = 51, T1 = 41, T2 = 20, T3 = 17). This is the first report of a patient diagnosed with functional PNE managed with OMT. A link between PNE, scar and pelvic somatic dysfunctions could suggest double crush syndrome.
- Loading with Oral P2Y12 Receptor Inhibitors: To Crush or Not to Crush? [Journal Article]
- THThromb Haemost 2019; 119(7):1037-1047
- Oral P2Y12 receptor inhibitors represent a mainstay treatment in patients with acute coronary syndrome and those undergoing percutaneous coronary intervention. In the setting of ST-elevation myocardi…
Oral P2Y12 receptor inhibitors represent a mainstay treatment in patients with acute coronary syndrome and those undergoing percutaneous coronary intervention. In the setting of ST-elevation myocardial infarction, when early platelet inhibition is highly desirable, the onset of action of oral P2Y12 receptor inhibitors is, however, delayed, likely due to delayed drug absorption. Crushing the tablets, which are to be used for patient loading with an oral P2Y12 receptor inhibitor, has been shown to provide earlier platelet inhibition than standard, integral tablets administration. Chewed ticagrelor tablets may also result in a similar effect. Such findings should be interpreted with caution, mainly due to the small number of patients enrolled and the nature (pharmacodynamic/pharmacokinetic) of the respective studies. Furthermore, in patients with out-of-hospital cardiac arrest, who remain comatose, crushing tablets is commonly applied in clinical practice for platelet P2Y12 receptor inhibition. In this review, we focus on current evidence regarding the role of crushed P2Y12 receptor inhibitor pills, analyzing clinical scenarios where most of the promise exists along with future expectations from this type of formulation. Large randomized studies are needed to draw firm conclusions regarding the clinical benefit of 'crushing' over the usual 'not-crushing' practice.
- Damage control orthopedics applied in an 8-year-old child with life-threatening multiple injuries: A CARE-compliant case report. [Case Reports]
- MMedicine (Baltimore) 2019; 98(16):e15294
- CONCLUSIONS: We emphasize the importance of damage control principles when managing polytraumatized children.
- Elevated Plasma Levels of Drebrin in Glaucoma Patients With Neurodegeneration. [Journal Article]
- FNFront Neurosci 2019; 13:326
- Glaucoma is an optic neuropathy characterized by progressive degeneration of retinal ganglion cells (RGCs). Aberrations in several cytoskeletal proteins, such as tau have been implicated in the patho…
Glaucoma is an optic neuropathy characterized by progressive degeneration of retinal ganglion cells (RGCs). Aberrations in several cytoskeletal proteins, such as tau have been implicated in the pathogenesis of neurodegenerative diseases, could be initiating factors in glaucoma progression and occurring prior to axon degeneration. Developmentally regulated brain protein (Drebrin or DBN1) is an evolutionarily conserved actin-binding protein playing a prominent role in neurons and is implicated in neurodegenerative diseases. However, the relationship between circulating DBN1 levels and RGC degeneration in glaucoma patients remains unclear. In our preliminary study, we detected drebrin protein in the plasma of glaucoma patients using proteomic analysis. Subsequently, we recruited a total of 232 patients including primary angle-closure glaucoma (PACG), primary open-angle glaucoma (POAG) and Posner-Schlossman syndrome (PS) and measured its DBN1 plasma levels. We observed elevated DBN1 plasma levels in patients with primary glaucoma but not in patients with PS compared to nonaxonopathic controls. Interestingly, in contrast to tau plasma levels increased in all groups of patients, elevated drebrin plasma levels correlated with retinal nerve fiber layer defect (RNFLD) in glaucoma patients. To further explore the expression of DBN1 in neurodegeneration, we conducted experiment of optic nerve crush (ONC) models, and observed increased expression of DBN1 in the serum as well as in the retina and then decreased after ONC. This result reinforces the potentiality of circulating DBN1 levels are increased in glaucoma patients with neurodegeneration. Taken together, our findings suggest that circulating DBN1 levels correlated with RNFLD and may reflect the severity of RGCs injury in glaucoma patients. Combining measurement of circulating drebrin and tau levels may be a useful indicator for monitoring progression of neurodegenerative diseases.
- Acute Compartment Syndrome of the Hand from a Parrot Bite. [Case Reports]
- CCureus 2019 Jan 08; 11(1):e3845
- Acute compartment syndrome (ACS) of the hand is uncommon, especially secondary to exotic animal bites. In this case, we describe a patient who developed ACS of the hand after being bitten by her pet,…
Acute compartment syndrome (ACS) of the hand is uncommon, especially secondary to exotic animal bites. In this case, we describe a patient who developed ACS of the hand after being bitten by her pet, an African grey parrot. The patient required emergent fasciotomy that resulted in symptom improvement. Furthermore, the patient developed an abscess leading to the consideration of antibiotic coverage for bird bites. This case provoked the consideration of compartment syndrome on the differential for minor crush or unusual injuries. It is also important to recognize that compartment syndrome may occur in any fascial compartment. As bird-related injuries are uncommon, we have briefly discussed antibiotic coverage for bird bites and associated zoonoses. We believe this is the first reported case of compartment syndrome of the hand from a parrot bite.
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- Validity and reliability of the Turkish version of the Cold Intolerance Symptom Severity Questionnaire [Journal Article]
- TJTurk J Med Sci 2019 Mar 14; 49(2)
- CONCLUSIONS: As a result, the CISS-T is a valid and reliable instrument to assess the severity of cold intolerance.