Biomarkers in Emergency Medicine: Katrin Hruska
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Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine. All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality. In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease. A biomarker, in its broadest sense, is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001). This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time). If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance. As Katrin explains, over testing and over diagnosis have serious consequences. Not only for patients but also for the healthcare system. In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing. This increases testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardised workup for a certain symptom, primary care centres and emergency telephone services will refer patients to the Emergency Department for testing, even when the pretest probability is low. Katrin contends this bias is not an inherent problem of biomarkers themselves, but of the decision-making process of clinicians. The human brain fears uncertainty. Anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of over testing in settings where medico-legal risks for the clinicians are low. There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty.
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In simple terms delirium leads to poor outcomes and death.
Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness.
So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated.
The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer?
Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play.
Scott stresses with analgesia first, the sedation needed is less. He explains how he achieves this in practice in detail. He then provides some clinical examples and how he would approach them including which specific medications he uses in practice.
Scott’s main points are simple. Control the pain and very few patients will need a lot of sedation.
In addition, if you adequately control the pain, very few patients will have delirium in the Emergency Department.
Join Scott as he passionately discusses post-intubation sedation.
For more like this, head to our podcast page. #CodaPodcast
The Problem with Hospital Systems: Alex Psirides
Alex Psirides discusses the problem with major hospitals and the systems that they use.
Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system.
As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches.
The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world.
Many staff lack acute medical skills.
Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs.
Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.
Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care.
Unfortunately, junior doctors often call for help when it is too late.
Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better ‘back in the day.’
The Problem with Hospital Systems: Alex Psirides
For more like this, head to our podcast page. #CodaPodcast
How to Spot the Sick Child in the Emergency Department
Ffion Davies gives her take on how to spot the sick child in the Emergency Department.
Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.
So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well.
Ffion breaks her thinking into two main areas: physiology and psychology.
Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child.
Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease.
Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true.
Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem.
Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.
Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department.
Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations.
For more like this, head to our podcast page. #CodaPodcast
Paed-Iconoclasm: Breaking the Myths without Breaking Your Patient
Myths and medical dogma fill the gap between what we know and what we don’t know. Learn “Defense Against the Dark Arts” and how not to let this gap hurt some of our most vulnerable patients -- children.
Emergency management of agitation: Reuben Strayer
Rueben Strayer provides a masterclass in droperidol for emergency management of agitation. He discusses sedation in three patient groups.
Agitated but cooperative
If the patient is agitated but cooperative there is no concern for a dangerous condition. They respond well to some company and a sandwich. Drug therapy in this group is relatively straightforward.
Disruptive without danger
You can converse and engage with this group; however, they are not responsive to suggestion. They are loud and disruptive and need to be sedated. You can do a history and exam and be fairly confident that there is no dangerous underlying condition.
There is no threat to themselves or others. They can be managed by observation in an unmonitored bed. So, you can sacrifice speed of sedation to ensure safety. Simple and well worn, tried and tested methods of mixed medical sedation are fine in this situation. And Reuben stresses this… it is fine. To be better than fine, consider a single agent - droperidol. Droperidol is the most effective and safest agent for undifferentiated agitation.
If droperidol is unavailable the next best choice is midazolam intramuscularly. Be careful. Dosage is trickier in this situation. You need to monitor for respiratory depression and ne prepared to manage it. It works quickly but has a narrow therapeutic window. As such, for unmonitored patients, Reuben combines drugs to get away with smaller doses. Listen in to learn how!
Excited delirium
This patient is rare. But this is a dangerous situation. A few clues are the patients who are thrashing, angry, incoherent, un-engageable. They may have a fluctuating level of consciousness. Have a low threshold if you are not sure – err on the side of caution and treat as excited delirium.
How do you treat this person? Five strong people are needed (not including those administering care), one for each limb plus one at the head. Administer high flow oxygen via a mask immediately. Do not wait for sats or vitals. This stops spit and provides oxygen! Get the patient out of dangerous positions such as the “hogtie” position and ensure no one is applying pressure to the chest or neck.
Next chemical restraint – IM shot as soon as possible. This is as opposed to any mechanical restraints. The priority is immediate control. This allows you time to properly assess and treat the patient whilst ensuring their safety and the safety of the treating team.
Join Reuben for a no nonsense run through of managing the agitated patient.
Critical Care: No place for a woman?
This document discusses gender bias and challenges faced by women in critical care medicine. It notes that while the majority of critically ill patients are women, women make up a smaller percentage of ICU trainees, consultants, editorial boards, and faculty positions. Female speakers also represent a lower percentage than male speakers at some critical care conferences. The document suggests women face biases such as being seen as less competent or committed if they are mothers, or being hired and promoted based on past accomplishments rather than potential. It calls for addressing gender bias and advocating for critical care to be a welcoming field for women.
Burnout in Healthcare: Peter Brindley
Peter Brindley explains how burnout affects us all. It affects the cost, quality of care, organisational culture, performance and patient outcomes.
Burnout is fatigue, loss of ideals, purposelessness, presentism and the sense of being under-appreciated. It is not tiredness, exhaustion, boredom, mid-life crisis, depression, PTSD, perfectionism or narcissism.
Moreover, burnout involves the 4 C's: cutting corners, cynicism, callousness, and contempt.
Peter explains when and why, and to whom a burnout occurs. A major reason for burnout is the difference between expectations and reality. This drives the thought, “this is not what I signed up for.”
Furthermore, he presents the 12 steps which lead to a burnout. It begins by the need to prove yourself by working harder, neglecting your needs, avoiding issues, and losing friends or hobbies. This leads to denial, withdrawal, behavioural changes, depersonalisation, inner emptiness, depression and finally burnout.
Peter suggests a few things that we can do to prevent burnout. He recommends purposeful imbalance and dividing career into thirds: learning, earning, and returning.
Evidently, burnout is a chronic condition, and although it cannot be cured, it is manageable. It might take years to manifest and hence, we must always be on the lookout for the signs.
Finally, for more like this head to our podcast page. #CodaPodcast
Learning from excellence in critical care
Adrian Plunkett describes how to learn from excellence in critical care. Learning from excellence is an initiative which began at Birmingham Children’s Hospital.
Firstly, Adrian shares an anecdote regarding how the initiative begun. He sent a letter to the CEO of a hospital appreciating one of the doctors who treated him for cancer. The doctor unfortunately never received it. This caused Adrian to ask - is appreciation and gratitude undervalued?
Evidently, noticing excellence will lead to two things: learning new insights and increasing staff morale.
Adrian raises the question, why we do we not focus on the good things? We spend all our time improving safety and quality even though accidents and disasters are only a small percentage of what we do.
Moreover, Adrian claims that people inherently have negative biases. This is evident in healthcare, so how can we combat this?
The solution is to focus on excellent care. This led to the formation of a reporting system called Learning from Excellence (LfE), where people answer two questions: Who did something excellent? What did they do?
LfE is a formal system for reporting and providing positive feedback and appreciation to the healthcare workers. It is a beneficial and constructive way of learning from excellence.
Finally, Adrian explains, “Saying ‘thank you’ or ‘well done’ is the easiest quality improvement intervention of all.”
Learning from excellence in critical care by Adrian Plunkett
For more like this head to our podcast page. #CodaPodcast
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
Simon Finfer argues that the transfusion threshold should be 70 g/L. Simon first raises the Choosing Wisely Guidelines for Critical Care.
These state that one should not transfuse red blood cells in haemodynamically stable patients with a haemoglobin concentration of greater than 70g/L.
He continues to discuss the application of this specifically to patients with an acute brain injury. In doing so he will talk about evidence generally and how one must approach the use of evidence in specific patient subgroups.
Simon continues by raising further research to justify his position.
Oli Flower on the other hand will take the position that the transfusion trigger should be 90g/L. He makes the point that this is the easy position to take. Essentially, he is just explaining why the critical care community does what it does!
As Oli explains, haemoglobin plays a pivotal role in providing oxygen to tissue. In the case of a brain injury, to prevent further injury, one must ensure continued supply of oxygen to said tissue.
Oli will lean on animal studies, human studies as well as trial data to support his position. The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives critical care professionals mad.
So surely there must be a “right” number. Unfortunately, there is not, which is where understanding all the relevant aspects to the argument becomes important.
Join Oli and Simon as they debate on this important issue.
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
For more like this, head to our podcast page. #CodaPodcast
ICU year in review - Paul Young and Flavia Machado
This tweet lists two Twitter accounts, @DogICUma and @FlaviaSepsis, that discuss critical care trials and sepsis. It suggests following these accounts to stay informed on recent important clinical research findings in critical care and sepsis.
Controversies in Brain Death
The document discusses the history and controversies surrounding the concept of brain death. It notes that while brain death was formalized in the 1960s to facilitate organ donation, debates continue around defining the precise criteria. Specifically, opinions differ on whether brain death requires the irreversible loss of whole brain or just brainstem functions, and how to properly determine irreversibility through clinical examinations and ancillary tests. However, the document argues that the clinical diagnosis of brain death is robust when performed by skilled examiners, and that uniform international standards could help address some of the ongoing controversies.
The Risks of Surgery: John Carlisle
John Carlisle asks the big question – what is the risk of surgery? It is a big question that holds implications for everyone involved in caring for patients. Like John, patients want to live a long and happy life. They would like to know whether the chances of living a long and happy life are enhanced by having surgery or not. They do not generally care whether they will be alive in 30 days or not. John explored whether or not we can accurately answer the question – what are the risks of a given surgery?
Prognostic models based on a single surgical cohort are very vulnerable to chance and variation. This is even the case with large cohorts. The reason is that mortality is not that common. Therefore, the range of uncertainty in any one model is big.
John explores this concept in the context of surgical intervention for abdominal aortic aneurysms. He highlights the perils prognosticating by describing the trials that influences the treatment guidelines for abdominal aortic aneurysms. John describes the current data, and the flaws in the recommendations currently being offered.
John then describes a tool he has developed relating to this particular question. The tool also explains how one piece of research has been misunderstood, a misunderstanding that has resulted in two general mistakes: surgeons operating on aneurysms when they should not; surgeons not operating on aneurysms when they should.
For more like this, head to our podcast page. #CodaPodcast
Debate: The ICU is no place for the elderly
The document discusses whether the intensive care unit (ICU) is an appropriate place for elderly patients. It notes that the average age of patients who arrest in the ICU is 70 years old, suggesting closer monitoring is needed for older patients. Studies show 29% of Medicare beneficiaries spend their last month of life in the hospital receiving curative care, despite the likelihood of benefit being low. The ICU is a very dangerous place, with fatality risks higher than many industries. The document argues that hospitals may not be the best place for aging, chronically ill patients, and that treatment is often costly and ineffective for this group. Palliative care options with a "plan B" are preferable to ICU admission for many elderly patients. Discrimination
A Young Person's Experience of Critical Illness
Natalie May & Roisin McNamara discuss a young person’s experience of critical illness.
They are joined by Ema, an 11-year-old girl who had a scary time when she was diagnosed with tracheitis. Experiencing critical illness is scary for anyone. However, when you are a young person, this terrifying experience is amplified.
Natalie and Roisin tell us what we as clinicians can do or think about differently to provide a better patient experience.
Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better.
The main take away boils down to clear communication. Medical professionals often think they are explaining things thoroughly. However, the words they use, and the speed of the delivery of those words, leaves a patient feeling confused and scared.
On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate.
Bringing one’s awareness to this can assist when we are deciding how and when to discuss the ongoing treatment.
Ema’s mother also provides insights into the experience of the family. The broad themes include the feelings of isolation, fear, and overwhelming concern.
Encouragingly, there are simple things that clinicians can do to alleviate these feelings. Whilst the fear and concern for one’s young child will never abate, simply taking the time to listen to all worries and ensuring understanding can go a long way towards improving the experience for both the patient and their family.
Similarly, ongoing communication regarding the tests, procedures, and treatments that are planned to be undertaken is highlighted as critical in eliciting the support and buy in of the family.
Critical illness in a young person will never be easy for the patient or their families. Listen in to this discussion to discover how to make it more bearable.
For more like this, head to our podcast page. #CodaPodcast
Is Emergency Medicine a Failed Paradigm
Scott presents the argument that whilst Emergency Physicians are amazing, as it stands, Emergency Medicine is failing.
Scott presents the system as it should be.
This involves stabilising the critically ill before admission to the ICU, seeing sick patients in appropriate time and seeing the less sick patients as you can.
The issue as it stands, is when this system breaks down. He talks about the ‘boxes’ which now includes the ‘not sick at all’ patient. This leads to Emergency Physician’s not doing what they are trained to do.
Scott discusses the issues with the outcome measurements of Emergency Departments. Hospitals measure patient satisfaction and wait times.
Moreover, Scott argues that a trip to the ED should be the worst day in a patient’s life and measuring their satisfaction is misleading.
A good medical outcome should be the indication of success.
Scott also discusses the issue of Emergency Physicians not dealing with emergencies for most of their practice. This, in Scott’s eyes, leads to cognitive dissonance, where ED doctors are not doing what they are trained to do.
Simon argues that Emergency Medicine is not a failed paradigm. Emergency Physicians are trained to help people, when people feel that they need to be treated.
He claims that doctors in this speciality want to treat a wide variety of people across a wide spectrum of disease.
Evidently, Simon discusses a ‘revolution’ in Emergency Medicine. An increasing number of people are attending Emergency Departments across the world. The generalist approach of Emergency Medicine is critical in triaging, treating, and helping these people in their moment of need.
The skills, breadth of knowledge and wisdom and ability to work across a range of specialties and in uncertainty is what makes Emergency Medicine and the physicians who work in it special.
Join in the debate as Scott and Simon argue for and against the place of Emergency Medicine.
Finally, for more like this head to our podcast page. #CodaPodcast
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Nikki Black provides an insight into critical care in humanitarian emergencies.
Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.
She shares these from the SMACC stage.
Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.
Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.
Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.
Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!
On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.
Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.
Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.
She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Finally, for more like this, head to our podcast page. #CodaPodcast
The Role of Love in Critical Care Leadership: Liz Crowe
The Role of Love in Critical Care Leadership by Liz Crowe.
There are times when this job can leave you heartbroken and love gets you through.
Meditation Performance and Critical Care: Scott Weingart
The document discusses the results of a study on the impact of COVID-19 lockdowns on air pollution. Researchers found that lockdowns led to significant short-term reductions in nitrogen dioxide and fine particulate matter pollution globally as economic activities slowed. However, the impacts on greenhouse gases and long-term air quality improvements remain uncertain without permanent behavior and economic changes.
Rethinking Adrenaline in Cardiac Arrest
The use of adrenaline in cardiac arrest resuscitation has been advocated since the 1960s. Laboratory studies and anecdotal experience showed improved rates of return of spontaneous circulation (ROSC) with the use of adrenaline at a dosage of approximately 0.01 mg/kg. This led to the widespread adoption of adrenaline administration during cardiac arrest into every resuscitation guideline for decades to come. Extensive laboratory studies characterized the beneficial physiological effects of adrenaline during cardiac arrest and closed-chest cardiopulmonary resuscitation (CC-CPR). Adrenaline administered during CC-CPR results in peripheral arterial vasoconstriction that raises the aortic pressure, particularly during the relaxation phase of CC-CPR. This increase in aortic pressure results in an increased aortic to right atrial pressure gradient that drives blood flow to the myocardium during CC-CPR. This pressure gradient is known as the coronary perfusion pressure (CPP) and has been shown to correlate with ROSC in both laboratory investigations and clinical studies. During the 1990s, the use of “high-dose” adrenaline showed increased rates of ROSC compared to “standard-dose” adrenaline. However, it was subsequently recognized that larger doses of adrenaline did not result in improved survival. Furthermore, questions have been raised as to whether or not “standard-dose” adrenaline improves survival from cardiac arrest. Recent meta-analyses have raised serious questions about the value of adrenaline, showing a benefit for achieving ROSC but no clear evidence of improved long-term survival. Controlled clinical trials to address this question are now underway. However, there is another important issue that needs to be addressed: the “route” of administration. With the growing interest in endovascular resuscitation, the use of intra-aortic adrenaline titration offers a means of rapidly and effectively delivering adrenaline to peripheral arterial effector sites while providing arterial pressure and CPP monitoring to guide titration of adrenaline doses to achieve an optimal hemodynamic effects while avoiding excessive adrenaline doses.
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Bad Blood
Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human. When they run riot or the fine balance between pro- and anti-inflammatory states is shifted however there can be significant morbidity and mortality. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients.
Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications.
Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic hemolytic anemia (MAHA) will also be described including the role of ADAMST13.
HIT is an uncommon but important conditions which is difficult to diagnose in a critically ill patient. An approach to HIT is discussed.
Have you always wondered about NETs (neutrophil extracellular traps) and their importance?
If so this whistle-stop tour of non-malignant hematology in the ICU is for you!
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The current study was a cross-sectional study with a sample size of 117 patients with sepsis. Various hematological parameters of all the patients were obtained on day of admission (day 1) and seventh day (day 7) using hemogram reports and the difference of their statistical mean and standard deviation was estimated.There was a significant statistical difference in the mean and standard deviation of neutrophil lymphocyte count ratio (NLCR), red cell distribution width standard deviation (RDW SD), Platelet count (PLT) and Platelet crit (PCT) whereas Mean platelet volume (MPV), Platelet distribution width (PDW) and Platelet large cell ratio (PLCR) showed no significant changes on day 1 and day 7 of observation in patients taken for the study.
Nov journal watch
This document provides a summary of the November 2014 issue of the UTSW Internal Medicine Journal Watch. It includes summaries of articles on topics such as assessing acid-base disturbances, managing Staphylococcus aureus bacteremia, community acquired pneumonia, predicting hepatocellular carcinoma in hepatitis C patients, and guidelines for prioritizing patients for new hepatitis C treatments. It also reviews articles related to infectious diseases, critical care, nephrology, cardiology, and more.
Curb 65 thorax-2003-lim-377-82
This document describes a study that derived and validated a new severity assessment model called CURB-65 for stratifying patients with community acquired pneumonia (CAP) into different risk groups upon hospital admission. The study combined data from previous CAP studies involving over 1000 patients. Using logistic regression, factors independently associated with 30-day mortality were identified as age over 65, albumin level under 30 g/dl, and CURB score over 2 (which evaluates confusion, urea, respiratory rate, blood pressure). These factors were used to create the CURB-65 score, which stratifies patients into risk groups from 0.7% to 57% 30-day mortality risk based on their score. The validation cohort confirmed similar mortality risks based on
Triple low
This study examined the relationship between a "triple low" state of low mean arterial pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia with hospital length of stay and 30-day mortality in 24,120 patients. The study found that the occurrence of a triple low state was associated with significantly increased length of stay and mortality risk compared to patients without a triple low. Mortality risk increased progressively with longer durations spent in the triple low state.
Beyond Framingham
This document discusses moving beyond the traditional Framingham Risk Score for assessing individual coronary heart disease risk. It outlines three areas showing promise: (1) biomarkers like hsCRP and LpPLA2 that can identify pre-clinical disease, (2) vascular imaging like CIMT and CACS that provide more direct measures of atherosclerosis, and (3) genomics though the effects of common gene variants on risk are small and replication has been difficult. Biomarkers and imaging allow refining risk assessment, especially for those at intermediate Framingham risk, while challenges remain in applying genetics to individual risk prediction.
What is epidemiology?.pdf
This document provides an introduction to the field of epidemiology. It defines epidemiology as the study of disease occurrence and distribution in human populations and the factors that influence these. Key points made include that epidemiological studies examine disease outcomes in relation to the population at risk, draw conclusions by making comparisons between groups, and aim to identify risk factors and monitor disease trends over time. However, the text stresses the importance of ensuring comparisons are not biased by unequal ascertainment of cases or exposures.
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This document reviews recent advances in the management of pulmonary embolism (PE). Risk-adapted treatment and follow-up has led to more favorable outcomes for PE patients. Age-adjusted D-dimer cutoff levels can decrease overuse of imaging tests by increasing the specificity of D-dimer. New oral anticoagulants are effective alternatives to standard treatments. However, areas that require more research include the implications of subsegmental PE, diagnosing PE in pregnant patients, and the efficacy of new oral anticoagulants in cancer patients. Improving guideline implementation will further optimize PE management.
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This study evaluated shock index (SI), defined as heart rate divided by systolic blood pressure, as a predictor of morbidity and mortality in pediatric trauma patients. The study used data from the 2010 National Trauma Data Bank and found that an elevated age-adjusted SI was strongly associated with mortality, need for blood transfusion, ventilation, procedures, and ICU stay. Compared to hypotension alone, elevated SI had improved sensitivity for predicting negative outcomes while maintaining high specificity. The findings support using SI as a simple tool to identify pediatric trauma patients at risk of shock-related complications.
Acute pancreatitis
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Number of Pages 4 (Double Spaced)Number of sources 8Writi.docx
Number of Pages: 4 (Double Spaced)
Number of sources: 8
Writing Style: APA
Type of document: Coursework
Category: Healthcare
Order Instructions:
Comprehensive Article Review
Caverly, T.J., Fagerlin, A, & Wiener, R.S. (2018, January 22). Comparison of observed harms and expected mortality benefit for persons in the Veterans Health Affairs Lung Cancer Screening Demonstration Project. JAMA Internal Medicine.
1. What research questions are addressed in this study and what is their purpose (5 points)?
2. What type of research design was used (experimental, quasi-experimental, correlational) in this study and what led you to your decision (5 points)?
3. Are the instruments in this study valid and reliable, why or why not (10 points)?
4. Discuss the specific results of each of the ANCOVAs (analysis of covariance) done in this study. What was the purpose of"each" of the ANCOVAs? What was the covariate in each and why did they do an ANCOVA in each case (5 points)?
5. In the Tables, results are presented, Please explain the tables and summarize the results (15 points).
6. Explain, in simple language, any significant results of this study (25 points)?
7. Identify and discuss any threats to internal and/or external validity in this study (10 points).
8. If you could redesign this study correcting anything you have found wrong with the research, what would you correct and how would you do it (20 points)?
Opinion
EDITORIAL
Reducing Harms in Lung Cancer Screening
Bach to the Future
Michael ln cze, MD, MSEd: Rita F. Redberg, MD, MSc
TbeUS PreventativeServices Task Force cmrcntly recom mends si:;ree ning (grade Brecommendation)for lung canc er witha nnuallow-dose computed tomo graph}' for high-risk in dividuals ages55 to 80 years, defined as those having greate r
gLblefor LCS using the Bach risk tool,11 a vaJidatcd risk model usingsex,age, smokingduration, durationof abstinence from smoking and number of cigarettes smoked per day as inpu ts.
The asto undingly high ratesof false-pos itiveresults in the low
=Related attid e
than a 30 pack-year cumula tivesmoking historyand h av• ing quit with in the past 15 years.1 The evide nce to sup
est risk quintiles (eg, 2221false-positive resul ts per lung ca n cer death averted and a NNS of nearly 5600 in quintile1), as well as extremelylow ratesoflungcancerincidencein the low est-risk groups, confirm trends illustrated in previous stud
port thisrecommendation overwhelminglycomes rrom the Na
tional Lung CancerScreenfngTrial(NL ST). While3 other large randomized clinical trials failed to show any mortality ben efit tolung cancer screening (LCS), the NLST demonstrateda 20% reduction in lungcan ce r mortality,a lo ng with a 6.7% re duction in .ill-ca use mortality, when compared with an an nual chest radiograph, witb a number needed toscreen (NNS} of256to prevent I lung-cancerassociated death over3years.-2 5 Real-worldapplication ofLCS has been particularly .
Pathophysiology Of Heart Failure
This document discusses support vector machines (SVM), a machine learning technique used for classification and regression analysis. SVM works by finding optimal hyperplanes in a multidimensional space that maximize the margin between examples of different classes. It can handle both continuous and categorical variables. The algorithm finds this optimal hyperplane by minimizing an error function during training. Depending on the type of error function used, there are four main types of SVM models: C-SVM classification, nu-SVM classification, epsilon-SVM regression, and nu-SVM regression.
PROCALCITONINA
This study evaluated the validity of procalcitonin (PCT) for diagnosing bacterial infections in elderly patients aged 75 years or older. 161 patients were included in the study and divided into two groups: 95 patients with probable bacterial infections and 66 patients without infections. PCT levels above 0.5 ng/mL were found in 72% of patients with probable bacterial infections and 8% of patients without infections. The study found that PCT has a sensitivity of 72% and specificity of 92% for diagnosing bacterial infections in elderly patients using a cutoff of 0.5 ng/mL. The researchers concluded that PCT can be reliably used to diagnose bacterial infections in elderly patients due to its good sensitivity and high specificity.
Sepsis.pptx
This document summarizes information about sepsis in surgical patients, biomarkers for sepsis detection, and the Surviving Sepsis Campaign 2021 guidelines. It discusses definitions of sepsis, SIRS criteria, qSOFA and SOFA scores. Key points include the importance of early source control, the role of lactate and C-reactive protein as biomarkers, and the need for a multidisciplinary approach involving surgeons, infectious disease specialists and others to determine the best source control strategy for each patient.
Postgrad med j 2015-pflug-77-82
This study evaluated the performance of three pneumonia severity scores - CURB-65, CRB-65, and CURB-age - in predicting 30-day mortality in 559 adult inpatients with community-acquired pneumonia. The study found that CURB-age stratified patients into risk groups that were most closely associated with mortality outcomes. Specifically, CURB-age identified more low-risk patients who had lower mortality than CRB-65, and sorted more patients who died within 30 days into the high-risk group compared to the other scores. Analysis of receiver operating characteristics further indicated CURB-age had better ability to predict 30-day mortality compared to the other scores. The study concludes CURB-age may provide
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This document provides a summary of articles across various medical specialties discussed in the April 2015 edition of the UTSW Journal Watch. In the Hepatology section, an article is summarized that finds corticosteroids may be safely used in patients with severe alcoholic hepatitis who present with an upper GI bleed after bleeding is controlled. In Pulmonary/Critical Care, a summary is provided of a trial finding no difference in mortality between early goal-directed therapy and usual care for treating septic shock. The study suggests protocols for goals of care are less important than early antibiotics and fluids. In Nephrology, a meta-analysis summary indicates preoperative use of renin-angiotensin system inhibitors may be linked to
EPC_June-15_pp.52-55 (EPC Industry Advisor) (1)
The document discusses the challenges surrounding diagnosing and predicting the future of patients with variant Creutzfelt-Jakob disease (vCJD). Current diagnostic tools can only confirm the disease post-mortem and late in progression, providing little useful information for patients. New diagnostic techniques including nasal sampling and blood tests show promise but are still only effective for symptomatic patients. Wide-scale population testing raises ethical issues as many carriers may never develop symptoms but would suffer psychologically from a positive diagnosis. There are no treatments for vCJD, so early diagnosis remains a priority but challenges remain due to the properties of prions and low levels in the body.
journal 2 Coronary artery stenosis.pptx
1) The study analyzed the correlation between serum levels of homocysteine (Hcy), cystatin C (Cys C), and uric acid (UA) and the severity of coronary artery stenosis in 1412 patients diagnosed with acute coronary syndrome.
2) The results showed significantly higher levels of Hcy, Cys C, and UA in the 765 patients with confirmed coronary heart disease compared to the 647 patients without obstructive stenosis.
3) Detection of combined Hcy and Cys C levels with UA levels was found to effectively assess the severity of coronary artery stenosis and provide predictive value for diagnosing coronary heart disease in a manner that is cheap, safe, and effective.
Procalcitonin
Procalcitonin is a peptide marker that is useful for differentiating between bacterial and viral infections. It begins to rise more quickly than C-reactive protein after an inflammatory insult and its levels correlate with the severity of infection or sepsis. Clinical situations where measuring procalcitonin may be helpful include determining the need for and length of antibiotic therapy for respiratory infections, diagnosing and monitoring sepsis, and distinguishing between bacterial and viral causes of meningitis or pneumonia. While elevated in response to bacterial infection, procalcitonin levels may also increase in response to certain non-infectious conditions like trauma or transplantation. It is a more reliable indicator of sepsis than C-reactive protein or other markers.
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Management of-pulmonary-embolism--a 2016-journal-of-the-american-college-of-
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Number of Pages 4 (Double Spaced)Number of sources 8Writi.docx
Number of Pages 4 (Double Spaced)Number of sources 8Writi.docx
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Precision Medicine in Acute Brain Injury
Systematic review of 26 studies with 55,792 patients found that dedicated neurocritical care (NCC) was associated with decreased risk of mortality (17% relative risk reduction) and decreased risk of poor functional outcomes (17% relative risk reduction) in critically ill brain-injured adults. A survey of Australian ICUs found limited availability of NCC, with only 4 centers specializing in it and 9 employing an intensivist subspecializing in NCC. Continuous EEG monitoring was found to have higher sensitivity for detecting nonconvulsive seizures than routine EEG monitoring, and was associated with reduced in-hospital mortality, though barriers to its universal use include infrastructure and personnel requirements.
CSD by Jeffcote Coda 22.pdf
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Subdural Haemorrhage and MMA embolisation
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
The BONANZA Trial and PbTO2 Monitoring
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
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Dilating the Dogma of Vasospasm
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
EVD Tips and Tricks
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Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories work
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
TBI: when to stop and when to give time
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
Ketamine in Brain Injury by Toby Jeffcote
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
Managing Complications of Chronic SCI by Bonne Lee
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia
Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
Keywords
SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI
EEG and Status Eplilepticus by Tania Farrar
Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
So why do we do cEEGs for patients with suspected SE?
To confirm the diagnosis
To see if patient just post ictal or still seizing
To establish that the clinical and electric seizures have stopped
To see if burst suppression is achieved
To exclude other differential diagnoses
She makes a good argument for why cEEG is such an important tool in managing SE.
In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.
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Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
Paediatric Stroke by Shree Basu
Shree Basu is a Paediatirc Intensivist in Sydney. These slides from the Brain Symposium 2023 accompany the talk she gave. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
Hypertensing Spinal Cord Injury - gold standard or wacky?
This document discusses the concept of maintaining higher blood pressure levels, known as hypertension, after a spinal cord injury to improve spinal cord perfusion pressure and reduce secondary injury. It notes that while animal studies and some human trials have shown improved neurological outcomes, the evidence is still limited. It calls for larger randomized controlled trials in humans that also incorporate multi-modal monitoring and standardized outcome measures to further evaluate if inducing hypertension after spinal cord injury should be considered the gold standard of care.
Optimal Cerebral Perfusion Pressure
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.
The Power of Words - Death and Language.ppt
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Undertreatment of sepsis can lead to mortality, while overdiagnosis and overtreatment can increase future risk of antimicrobial resistance. Antimicrobial stewardship aims to balance these risks by prioritizing patient safety and appropriate antimicrobial use. Data shows variability in appropriateness of antimicrobial prescribing between different types of hospitals. Embedding antimicrobial stewardship principles throughout sepsis diagnosis and treatment, from initial microbiology testing to post-treatment review, can help standardize care and optimize outcomes.
Brain injury outcomes and predictors
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
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Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort. Pharmacology of Prostaglandins, Thromboxanes and Leukotrienes
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Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
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Endocrine Therapy
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Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
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One of the basic concepts of gene therapy is to transform viruses into genetic shuttles, which will deliver the gene of interest into the target cells.
Safe methods have been devised to do this, using several viral and non-viral vectors.
In the future, this technique may allow doctors to treat a disorder by inserting a gene into a patient's cells instead of using drugs or surgery.
The biggest hurdle faced by medical research in gene therapy is the availability of effective gene-carrying vectors that meet all of the following criteria:
Protection of transgene or genetic cargo from degradative action of systemic and endonucleases,
Delivery of genetic material to the target site, i.e., either cell cytoplasm or nucleus,
Low potential of triggering unwanted immune responses or genotoxicity,
Economical and feasible availability for patients .
Viruses are naturally evolved vehicles that efficiently transfer their genes into host cells.
Choice of viral vector is dependent on gene transfer efficiency, capacity to carry foreign genes, toxicity, stability, immune responses towards viral antigens and potential viral recombination.
There are a wide variety of vectors used to deliver DNA or oligo nucleotides into mammalian cells, either in vitro or in vivo.
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Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
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Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
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Biomarkers in Emergency Medicine: Katrin Hruska
- 1. Bringing sexy back? biomarkers - useful or useless? Katrin Hruska
- 4. N Engl J Med 2015; 373:1916-1925November 12,
- 5. ”in the near future, high suPAR levels probably will inform physician-patient conversations about preventing kidney disease"
- 6. ”rigorous NEJM study is a significant breakthrough in preventive medicine"
- 8. Groundbreaking blood test predicts kidney disease FIVE YEARS BEFORE symptoms appear
- 9. ”Trisaq's product strategy has been designed to yield early proof-of- concept as well as commercialization opportunities” ”Conservatively estimated, Trisaq's current pipeline of products can benefit about 15-25% of all CKD patients and their combined sales potential well exceeds $1 billion.
- 10. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
- 12. Novel Blood Biomarker May Predict CKD Risk Outcomes studies necessary to prove clinical efficacy
- 13. suPAR: Strong and independent predictor of survival
- 16. Rather young and healthy than old and sick
- 18. The primary endpoint was to create an accurate prognostication score of death by combining APACHE II score and serum suPAR.
- 19. 💀 14 ng/mL 3-70 ng/mL 1-65 ng/mL 😀 9 ng/mL suPAR levels and survival in sepsis range:
- 20. Copyright ©2012 Giamarellos-Bourboulis et al.; licensee BioMed Central Ltd. Crit Care. 2012; 16(4): R149.
- 21. suPAR Copyright ©2012 Giamarellos-Bourboulis et al.; licensee BioMed Central Ltd. Crit Care. 2012; 16(4): R149.
- 22. APACHE II
- 23. Copyright ©2012 Giamarellos-Bourboulis et al.; licensee BioMed Central Ltd. Crit Care. 2012; 16(4): R149.
- 24. Copyright ©2012 Giamarellos-Bourboulis et al.; licensee BioMed Central Ltd. Crit Care. 2012; 16(4): R149.
- 25. Mortality% 0 10 20 30 40 i ii iii iv Apache II<17 Apache II≥17 suPAR ≥12 suPAR ≥12 ”validated” in a Swedish cohort
- 26. Mortality% 0 10 20 30 40 i ii iii iv suPAR ≥12 suPAR ≥12 the high mortality in stratum (ii) may be due to small number of patients in this group (n = 21) and chance variations in mortality. Apart from that aberration, the findings validate those from the larger Greek study ”validated” in a Swedish cohort
- 27. ”this strong discriminative prognostic score developed in Greek patients was validated in a cohort of Swedish patients” ”There is no doubt that suPAR has strong prognostic value in ICU patients. However, in many cases this knowledge may not lead to lifesaving interventions, as limited treatment options are efficient in severely ill sepsis patients”
- 28. Prediction of 30 day mortality compared to Danish Emergency Process Triage
- 30. Agreement in 55% of cases ”additional biomarkers other than CT are needed" ”we acknowledge the editorial and statistical contribution of Leslie S. Prichep, PhD”
- 31. ”we acknowledge the editorial and statistical contribution of Leslie S. Prichep, PhD”
- 32. A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic responses to a therapeutic intervention
- 33. A clinical endpoint is a characteristic or variable that reflects how a patient feels, functions or survives A surrogate endpoint is a biomarker that is intended to substitute for a clinical endpoint
- 34. A clinical endpoint is a characteristic or variable that reflects how a patient feels, functions or survives A surrogate endpoint is a biomarker that is intended to substitute for a critical endpoint
- 36. photo: Michele di Trani So you think you’re in pain?