Lawrence S. Zachary, M.D. from the University of Chicago presents on Fat Transfer to the upper and lower extremities in patients with Raynaud's Phenomenon.
1) Fluids are administered to increase venous return and subsequently stroke volume when cardiac reserve is present. This improves clinical characteristics through increased perfusion.
2) Studies show fluid resuscitation is associated with improvements in clinical signs like lactate levels and hemodynamics. However, fluids may have little effect on microcirculation or tissue perfusion.
3) Restricting or guiding fluids based on lactate levels is associated with better outcomes for surgical patients compared to more liberal fluid strategies. Small changes in lactate toward normal ranges, rather than clear decreases, may be sufficient with fluids alone.
11_Management Post operative Low Cardiac Output Syndrome.pdfAsokjayaraj
Low cardiac output syndrome (LCOS) is defined as cardiac index <2.2 L/min/m2 without relative hypovolemia secondary to left or right ventricular failure. It occurs in 3-5% of adult cardiac surgery patients and 25% of congenital cardiac surgery patients. Risk factors include age over 65, LVEF under 50%, on-pump CABG, recent MI, complex congenital surgery, diabetes, and CKD. Early detection through hemodynamic monitoring is important to prevent complications. Treatment involves optimizing preload through fluid administration or passive leg raises, and using inotropic medications or mechanical support like ECMO if needed. Perioperative goal-directed therapy protocols have been shown to reduce
Intraoperative oesophageal Doppler monitoring (ODM) guided fluid management was compared to standard central venous pressure (CVP) guided fluids in a randomized controlled trial of 128 colorectal surgery patients. ODM guided fluid optimization resulted in significantly shorter hospital length of stay, earlier return of gut function, fewer postoperative complications, and cost savings compared to CVP-guided fluids. ODM provided a more reliable assessment of intravascular volume status and cardiac preload than CVP alone.
Oesophageal Doppler Monitoring (ODM) provides a non-invasive assessment of stroke volume and cardiac output during surgery. A randomized controlled trial found that using ODM to guide intraoperative fluid management in colorectal surgery patients resulted in shorter hospital length of stay, earlier return of gut function, fewer complications, better hemodynamic measurements, and cost savings compared to managing fluids to maintain CVP between 12-15 mmHg. ODM may help optimize fluid management and improve recovery in complex and orthopedic surgeries.
This document discusses considerations for anesthesia during kidney transplantation. It covers preoperative risk evaluation focusing on systems impacted by renal failure. Important preoperative workup is outlined. Intraoperative concerns include general anesthesia, invasive monitoring, fluid management targeting dynamic indices rather than static pressures, and use of balanced crystalloids over normal saline. Postoperative pain management options emphasizing multimodal analgesia and regional techniques are reviewed. Maintaining normothermia and glycemic control are also noted as important intraoperative concerns. The conclusion emphasizes the challenges of perioperative kidney transplant management and the importance of optimization, pain control, fluid management, and hemodynamics for recovery.
This document discusses surgical closure of patent ductus arteriosus (PDA) in premature infants. It provides guidelines for when surgical referral is appropriate, such as when two courses of medication have failed to close a large PDA. The success rate of medication closure is 79% for infants over 1750g and lower for infants under 800g. The document outlines pre-operative testing and guidelines for the surgery including echocardiogram, bloodwork and discussions between medical teams. Potential complications are discussed such as hemorrhage, recurrent ductal patency and respiratory problems. Post-ligation cardiac syndrome is also summarized, which can involve low blood pressure, increased ventilation needs, and interventions like inotropic support.
Lawrence S. Zachary, M.D. from the University of Chicago presents on Fat Transfer to the upper and lower extremities in patients with Raynaud's Phenomenon.
1) Fluids are administered to increase venous return and subsequently stroke volume when cardiac reserve is present. This improves clinical characteristics through increased perfusion.
2) Studies show fluid resuscitation is associated with improvements in clinical signs like lactate levels and hemodynamics. However, fluids may have little effect on microcirculation or tissue perfusion.
3) Restricting or guiding fluids based on lactate levels is associated with better outcomes for surgical patients compared to more liberal fluid strategies. Small changes in lactate toward normal ranges, rather than clear decreases, may be sufficient with fluids alone.
11_Management Post operative Low Cardiac Output Syndrome.pdfAsokjayaraj
Low cardiac output syndrome (LCOS) is defined as cardiac index <2.2 L/min/m2 without relative hypovolemia secondary to left or right ventricular failure. It occurs in 3-5% of adult cardiac surgery patients and 25% of congenital cardiac surgery patients. Risk factors include age over 65, LVEF under 50%, on-pump CABG, recent MI, complex congenital surgery, diabetes, and CKD. Early detection through hemodynamic monitoring is important to prevent complications. Treatment involves optimizing preload through fluid administration or passive leg raises, and using inotropic medications or mechanical support like ECMO if needed. Perioperative goal-directed therapy protocols have been shown to reduce
Intraoperative oesophageal Doppler monitoring (ODM) guided fluid management was compared to standard central venous pressure (CVP) guided fluids in a randomized controlled trial of 128 colorectal surgery patients. ODM guided fluid optimization resulted in significantly shorter hospital length of stay, earlier return of gut function, fewer postoperative complications, and cost savings compared to CVP-guided fluids. ODM provided a more reliable assessment of intravascular volume status and cardiac preload than CVP alone.
Oesophageal Doppler Monitoring (ODM) provides a non-invasive assessment of stroke volume and cardiac output during surgery. A randomized controlled trial found that using ODM to guide intraoperative fluid management in colorectal surgery patients resulted in shorter hospital length of stay, earlier return of gut function, fewer complications, better hemodynamic measurements, and cost savings compared to managing fluids to maintain CVP between 12-15 mmHg. ODM may help optimize fluid management and improve recovery in complex and orthopedic surgeries.
This document discusses considerations for anesthesia during kidney transplantation. It covers preoperative risk evaluation focusing on systems impacted by renal failure. Important preoperative workup is outlined. Intraoperative concerns include general anesthesia, invasive monitoring, fluid management targeting dynamic indices rather than static pressures, and use of balanced crystalloids over normal saline. Postoperative pain management options emphasizing multimodal analgesia and regional techniques are reviewed. Maintaining normothermia and glycemic control are also noted as important intraoperative concerns. The conclusion emphasizes the challenges of perioperative kidney transplant management and the importance of optimization, pain control, fluid management, and hemodynamics for recovery.
This document discusses surgical closure of patent ductus arteriosus (PDA) in premature infants. It provides guidelines for when surgical referral is appropriate, such as when two courses of medication have failed to close a large PDA. The success rate of medication closure is 79% for infants over 1750g and lower for infants under 800g. The document outlines pre-operative testing and guidelines for the surgery including echocardiogram, bloodwork and discussions between medical teams. Potential complications are discussed such as hemorrhage, recurrent ductal patency and respiratory problems. Post-ligation cardiac syndrome is also summarized, which can involve low blood pressure, increased ventilation needs, and interventions like inotropic support.
Renal Denervation in Resistant Hypertension 23.pptxPrerna806536
This document summarizes renal artery denervation (RDN) as a treatment for resistant hypertension. It discusses evidence from clinical trials showing modest reductions in blood pressure with RDN. Ideal candidates for RDN are identified as patients with uncontrolled resistant hypertension on 3 or more medications including a diuretic. Open questions remain about long-term safety and identifying better responders to RDN. The document concludes that with good efficacy and safety data, RDN should be considered as a treatment option for resistant hypertension in appropriately selected patients.
This document provides an overview of deep vein thrombosis (DVT) and pulmonary embolism (PE). It covers the definition, epidemiology, risk factors, clinical features, investigations, management including prevention, treatment and anticoagulation. DVT occurs when a blood clot forms in a deep vein, usually in the legs, while PE is a complication that can occur when part of the clot breaks off and travels to the lungs. The document outlines Virchow's triad of factors that contribute to clot formation and discusses various diagnostic tests and therapeutic approaches for DVT and PE.
This document provides information on sepsis for EMS providers, including causes and risk factors, signs and symptoms, treatment guidelines, and case studies. Sepsis is a serious condition that can lead to septic shock and organ failure if not treated quickly. The guidelines describe identifying septic patients in the field using specific criteria and initiating fluid resuscitation and transport to the hospital for early goal directed therapy to improve outcomes. Case studies demonstrate application of the guidelines and emphasize importance of early recognition and treatment.
Novel oral Anticoagulants : Right decision , right choiceSYEDRAZA56411
This document discusses novel oral anticoagulants (NOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban. It provides guidance on using NOACs to treat conditions like non-valvular atrial fibrillation and deep vein thrombosis/pulmonary embolism. The document also discusses perioperative management of NOACs, reversal agents, and compares NOACs to warfarin. Overall, it emphasizes that while NOACs are an important advancement, their risks and appropriate use require careful assessment and management.
This document summarizes recent updates in understanding and treating scleroderma pulmonary hypertension. It discusses advances in defining and classifying PH in scleroderma patients based on recent guidelines. It covers updates in understanding the pathogenesis of scleroderma-associated PAH (SSc-PAH), including the vasculopathy, right ventricle involvement, and inflammation. It also summarizes risk stratification strategies and updated screening methods using tests like echocardiograms, pulmonary function tests, and blood biomarkers. Finally, it discusses current medical therapy approaches for SSc-PAH focusing on drugs targeting the nitric oxide pathway, endothelin receptors, and prostacyclins, as well as an emerging role for immunosuppression.
The recent definition, concept and terminologies of septic shock, surviving sepsis campaign, management techniques, SOFA score. Also includes antibiotics and supportive modalities.
The document discusses several studies on vascular complications in overweight patients undergoing percutaneous coronary interventions (PCI) and coronary angiography. The TROP study analyzed outcomes in 346 overweight patients undergoing PCI or angiography. It found the radial approach reduced complications compared to femoral. Other studies also found lower risks with radial access, especially in obese patients. Overall, obesity is a risk factor for cardiovascular disease and complications, and the radial approach may help reduce risks in overweight and obese patients undergoing coronary procedures.
XIII Reunión anual de la sección de Insuficiencia Cardiaca de la SEC
OVIEDO, 16-18 JUNIO 2016 HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS (HUCA)
http://secardiologia.es/insuficiencia/cientifico/ic-oviedo-2016
Simposio: Abordaje integral y multidisciplinar de la Insuficiencia Mitral
VIERNES, 17 DE JUNIO 12:45-14:00 SALA A
Posibilidades del tratamiento percutáneo
Xavi Freixa Rofastes, Barcelona
Carfilzomib is a next-generation proteasome inhibitor for the treatment of relapsed or refractory multiple myeloma. Studies showed carfilzomib had clinical benefit as a single agent even in heavily pretreated patients, with overall response rates of 22.9% and durable responses. Combination studies found carfilzomib with lenalidomide and dexamethasone improved progression-free survival compared to lenalidomide and dexamethasone alone, demonstrating carfilzomib is effective in relapsed multiple myeloma even in patients with prior therapies. Carfilzomib provides an important treatment option for patients with relapsed disease.
Peripheral vascular diseases (PVD), also known as peripheral artery occlusive disease, refers to obstruction or deterioration of arteries other than those supplying the heart or brain, primarily caused by atherosclerosis. PVD presents as either chronic arterial insufficiency or acute arterial occlusion. Management involves risk factor modification, exercise therapy for intermittent claudication, and endovascular or surgical revascularization depending on severity. For acute limb ischemia, the initial goals are to prevent thrombus propagation through anticoagulation and consider endovascular thrombolysis or surgical embolectomy to restore blood flow.
Peripheral vascular diseases (PVD), also known as peripheral artery occlusive disease, refers to obstruction or deterioration of arteries other than those supplying the heart or brain, primarily caused by atherosclerosis. PVD presents as either chronic arterial insufficiency or acute arterial occlusion. Management involves risk factor modification, endovascular or surgical revascularization techniques, and exercise therapy. For intermittent claudication, cilostazol is an effective pharmacotherapy that improves walking distance. Acute limb ischemia requires immediate anticoagulation and revascularization to prevent limb loss.
recommandations ESC 2012 sur les pathologies valvulaires cardiaquessiham h.
This document summarizes the results of the ACCESS-EUROPE study on the MitraClip procedure for treating mitral regurgitation. The study found that at 1 year follow up:
- Mitral regurgitation was reduced to ≤2+ in 79% of patients and NYHA functional class was I/II in 72% of patients.
- Quality of life scores improved significantly and 6-minute walk distance increased by an average of 59.5 meters.
- Adverse events rates were consistent with the high risk nature of the study patients, with death occurring in 17.3% of patients at 1 year.
Raynaud's phenomenon is characterized by episodic vasospasm and ischemia of the extremities in response to cold or stress. Attacks typically involve color changes from white to blue to red. Primary Raynaud's has no known cause, while secondary Raynaud's is associated with underlying conditions like scleroderma. Nifedipine is currently the only drug approved for treatment, though research continues on therapies like topical nitroglycerin and rho kinase inhibitors to promote vasodilation.
PERCUTANEOUS TREATMENT STRATEGIES OF VALVULAR HEART DISEASEPraveen Nagula
This document discusses various percutaneous treatment strategies for valvular heart disease, focusing on mitral valve repair techniques. It provides an overview of early balloon valvuloplasty procedures and more recent advances like the MitraClip device for mitral regurgitation repair. The document reviews clinical trials that demonstrated the safety and efficacy of the MitraClip, as well as its current FDA approval status. It also discusses alternative percutaneous mitral repair approaches like indirect annuloplasty via the coronary sinus.
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
This document provides guidelines for the management of ST-elevation myocardial infarction (STEMI) from the 2017 European Society of Cardiology. It outlines recommendations for emergency care, reperfusion strategies including primary percutaneous coronary intervention (PCI) and pharmacoinvasive strategies. It also discusses adjunctive therapies, imaging, long-term drug therapies, and new concepts in the 2017 version compared to 2012, including the management of myocardial infarction with non-obstructive coronary arteries (MINOCA). The guidelines emphasize short timelines for reperfusion and emphasize radial access and new generation drug-eluting stents for primary PCI.
1. Surgery continues to play an important role in the treatment of portal hypertension, both as primary and rescue therapy in select patients.
2. For good risk cirrhotic patients with refractory variceal bleeding, surgical shunts such as distal splenorenal shunt have better long-term outcomes compared to TIPS.
3. TIPS is preferred for poor risk cirrhotic patients, while surgical shunts or devascularization remain the standard treatment for non-cirrhotic portal hypertension. Surgery is not obsolete in managing portal hypertension.
Diabetes is a leading cause of blindness worldwide. It can cause diabetic retinopathy (DR) through changes in the retinal blood vessels. DR progresses through stages from mild nonproliferative DR to more severe proliferative DR. Treatment includes laser photocoagulation surgery, intravitreal injections of anti-VEGF drugs, and sometimes vitrectomy surgery. Tight control of blood glucose and blood pressure is important to prevent or slow the progression of DR. Regular eye screening is also needed according to guidelines based on type of diabetes and duration. A team-based approach is important for optimal diabetes and eye disease management.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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Renal Denervation in Resistant Hypertension 23.pptxPrerna806536
This document summarizes renal artery denervation (RDN) as a treatment for resistant hypertension. It discusses evidence from clinical trials showing modest reductions in blood pressure with RDN. Ideal candidates for RDN are identified as patients with uncontrolled resistant hypertension on 3 or more medications including a diuretic. Open questions remain about long-term safety and identifying better responders to RDN. The document concludes that with good efficacy and safety data, RDN should be considered as a treatment option for resistant hypertension in appropriately selected patients.
This document provides an overview of deep vein thrombosis (DVT) and pulmonary embolism (PE). It covers the definition, epidemiology, risk factors, clinical features, investigations, management including prevention, treatment and anticoagulation. DVT occurs when a blood clot forms in a deep vein, usually in the legs, while PE is a complication that can occur when part of the clot breaks off and travels to the lungs. The document outlines Virchow's triad of factors that contribute to clot formation and discusses various diagnostic tests and therapeutic approaches for DVT and PE.
This document provides information on sepsis for EMS providers, including causes and risk factors, signs and symptoms, treatment guidelines, and case studies. Sepsis is a serious condition that can lead to septic shock and organ failure if not treated quickly. The guidelines describe identifying septic patients in the field using specific criteria and initiating fluid resuscitation and transport to the hospital for early goal directed therapy to improve outcomes. Case studies demonstrate application of the guidelines and emphasize importance of early recognition and treatment.
Novel oral Anticoagulants : Right decision , right choiceSYEDRAZA56411
This document discusses novel oral anticoagulants (NOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban. It provides guidance on using NOACs to treat conditions like non-valvular atrial fibrillation and deep vein thrombosis/pulmonary embolism. The document also discusses perioperative management of NOACs, reversal agents, and compares NOACs to warfarin. Overall, it emphasizes that while NOACs are an important advancement, their risks and appropriate use require careful assessment and management.
This document summarizes recent updates in understanding and treating scleroderma pulmonary hypertension. It discusses advances in defining and classifying PH in scleroderma patients based on recent guidelines. It covers updates in understanding the pathogenesis of scleroderma-associated PAH (SSc-PAH), including the vasculopathy, right ventricle involvement, and inflammation. It also summarizes risk stratification strategies and updated screening methods using tests like echocardiograms, pulmonary function tests, and blood biomarkers. Finally, it discusses current medical therapy approaches for SSc-PAH focusing on drugs targeting the nitric oxide pathway, endothelin receptors, and prostacyclins, as well as an emerging role for immunosuppression.
The recent definition, concept and terminologies of septic shock, surviving sepsis campaign, management techniques, SOFA score. Also includes antibiotics and supportive modalities.
The document discusses several studies on vascular complications in overweight patients undergoing percutaneous coronary interventions (PCI) and coronary angiography. The TROP study analyzed outcomes in 346 overweight patients undergoing PCI or angiography. It found the radial approach reduced complications compared to femoral. Other studies also found lower risks with radial access, especially in obese patients. Overall, obesity is a risk factor for cardiovascular disease and complications, and the radial approach may help reduce risks in overweight and obese patients undergoing coronary procedures.
XIII Reunión anual de la sección de Insuficiencia Cardiaca de la SEC
OVIEDO, 16-18 JUNIO 2016 HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS (HUCA)
http://secardiologia.es/insuficiencia/cientifico/ic-oviedo-2016
Simposio: Abordaje integral y multidisciplinar de la Insuficiencia Mitral
VIERNES, 17 DE JUNIO 12:45-14:00 SALA A
Posibilidades del tratamiento percutáneo
Xavi Freixa Rofastes, Barcelona
Carfilzomib is a next-generation proteasome inhibitor for the treatment of relapsed or refractory multiple myeloma. Studies showed carfilzomib had clinical benefit as a single agent even in heavily pretreated patients, with overall response rates of 22.9% and durable responses. Combination studies found carfilzomib with lenalidomide and dexamethasone improved progression-free survival compared to lenalidomide and dexamethasone alone, demonstrating carfilzomib is effective in relapsed multiple myeloma even in patients with prior therapies. Carfilzomib provides an important treatment option for patients with relapsed disease.
Peripheral vascular diseases (PVD), also known as peripheral artery occlusive disease, refers to obstruction or deterioration of arteries other than those supplying the heart or brain, primarily caused by atherosclerosis. PVD presents as either chronic arterial insufficiency or acute arterial occlusion. Management involves risk factor modification, exercise therapy for intermittent claudication, and endovascular or surgical revascularization depending on severity. For acute limb ischemia, the initial goals are to prevent thrombus propagation through anticoagulation and consider endovascular thrombolysis or surgical embolectomy to restore blood flow.
Peripheral vascular diseases (PVD), also known as peripheral artery occlusive disease, refers to obstruction or deterioration of arteries other than those supplying the heart or brain, primarily caused by atherosclerosis. PVD presents as either chronic arterial insufficiency or acute arterial occlusion. Management involves risk factor modification, endovascular or surgical revascularization techniques, and exercise therapy. For intermittent claudication, cilostazol is an effective pharmacotherapy that improves walking distance. Acute limb ischemia requires immediate anticoagulation and revascularization to prevent limb loss.
recommandations ESC 2012 sur les pathologies valvulaires cardiaquessiham h.
This document summarizes the results of the ACCESS-EUROPE study on the MitraClip procedure for treating mitral regurgitation. The study found that at 1 year follow up:
- Mitral regurgitation was reduced to ≤2+ in 79% of patients and NYHA functional class was I/II in 72% of patients.
- Quality of life scores improved significantly and 6-minute walk distance increased by an average of 59.5 meters.
- Adverse events rates were consistent with the high risk nature of the study patients, with death occurring in 17.3% of patients at 1 year.
Raynaud's phenomenon is characterized by episodic vasospasm and ischemia of the extremities in response to cold or stress. Attacks typically involve color changes from white to blue to red. Primary Raynaud's has no known cause, while secondary Raynaud's is associated with underlying conditions like scleroderma. Nifedipine is currently the only drug approved for treatment, though research continues on therapies like topical nitroglycerin and rho kinase inhibitors to promote vasodilation.
PERCUTANEOUS TREATMENT STRATEGIES OF VALVULAR HEART DISEASEPraveen Nagula
This document discusses various percutaneous treatment strategies for valvular heart disease, focusing on mitral valve repair techniques. It provides an overview of early balloon valvuloplasty procedures and more recent advances like the MitraClip device for mitral regurgitation repair. The document reviews clinical trials that demonstrated the safety and efficacy of the MitraClip, as well as its current FDA approval status. It also discusses alternative percutaneous mitral repair approaches like indirect annuloplasty via the coronary sinus.
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
This document provides guidelines for the management of ST-elevation myocardial infarction (STEMI) from the 2017 European Society of Cardiology. It outlines recommendations for emergency care, reperfusion strategies including primary percutaneous coronary intervention (PCI) and pharmacoinvasive strategies. It also discusses adjunctive therapies, imaging, long-term drug therapies, and new concepts in the 2017 version compared to 2012, including the management of myocardial infarction with non-obstructive coronary arteries (MINOCA). The guidelines emphasize short timelines for reperfusion and emphasize radial access and new generation drug-eluting stents for primary PCI.
1. Surgery continues to play an important role in the treatment of portal hypertension, both as primary and rescue therapy in select patients.
2. For good risk cirrhotic patients with refractory variceal bleeding, surgical shunts such as distal splenorenal shunt have better long-term outcomes compared to TIPS.
3. TIPS is preferred for poor risk cirrhotic patients, while surgical shunts or devascularization remain the standard treatment for non-cirrhotic portal hypertension. Surgery is not obsolete in managing portal hypertension.
Diabetes is a leading cause of blindness worldwide. It can cause diabetic retinopathy (DR) through changes in the retinal blood vessels. DR progresses through stages from mild nonproliferative DR to more severe proliferative DR. Treatment includes laser photocoagulation surgery, intravitreal injections of anti-VEGF drugs, and sometimes vitrectomy surgery. Tight control of blood glucose and blood pressure is important to prevent or slow the progression of DR. Regular eye screening is also needed according to guidelines based on type of diabetes and duration. A team-based approach is important for optimal diabetes and eye disease management.
Similar to Fat Transfer to the Upper and Lower Extremities in Patients with Raynaud's Phenomenon (20)
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
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Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
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.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
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.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Fat Transfer to the Upper and Lower Extremities in Patients with Raynaud's Phenomenon
1. Fat Transfer to the Upper and Lower Extremities
in Patients With Raynaud’s Phenomenon –
A Novel Therapeutic Modality
Lawrence S. Zachary, MD
Section of Plastic and Reconstructive Surgery
Department of SurgeryNo disclosures
4. 4Fat Transfer in Raynaud’s
Treatment
Ca Channel
Blockers
ARB
Protective
Measures
Protective
Measures PDE-I
Clopidogrel
Endothelin
Receptor
Blockers
Alpha
Blockers
Topical
Nitrates
ACE-I
ASA
Prostanoids
5. 5Fat Transfer in Raynaud’s
Treatment
Ca Channel
Blockers
ARB
Protective
Measures
Protective
Measures
PDE-I
Clopidogrel
Endothelin
Receptor
Blockers
Alpha
Blockers
Topical
Nitrates
ACE-I
ASA
Prostanoids
Invasive
Modalities
Surgical
Sympathectomy
Neuro-
modulators
Fat TransferFat Transfer
6. • Clinical improvement – radiation dermatitis, burns
• Histological evidence – Sultan, PRS 2011
– Radiation dermatitis murine model fat injection
– Regression of hyperpigmentation, ulcers and fibrosis
– Improvements in the inflammatory, microvascular,
and fibrotic characteristics
• Mechanism unclear –
Restoration of depleted adipose-derived stem cells?
6Fat Transfer in Raynaud’s
Fat Transfer Rationale
Raynaud’s - different pathogenesis – similar end effect
7. 7Fat Transfer in Raynaud’s
Goal
as a means to delay progression of
Raynaud’s Phenomenon
after failure of medical management
as a means to delay progression of
Raynaud’s Phenomenon
after failure of medical management
Utilize fat graftingUtilize fat grafting
8. • Adaptation of rejuvenation of the hand by fat grafting
• Approximately 30 ml of decanted fat
• Abdominal depots
• Injected via blunt cannulae into the affected extremity
8Fat Transfer in Raynaud’s
Technique
9. 9Fat Transfer in Raynaud’s
Technique
10 ml - dorsum of hand
3 ml - snuff-box
2-3 ml - each dorsal webspace
6 ml - along palmar arch
1 ml - palmar webspaces 2-4
2 ml - first webspace
2 ml - ulnar border of small finger
11. 11
Results
Fat Transfer in Raynaud’s
Total patients 14
Total extremities 25
Hand 20
Feet 5
Mean follow up 12 months (4-17)
Female: Male 13:1
Primary: Secondary 8:6
Average fat injected 23.29 ml (10-30)
Concomitant digital sympathectomy 4
12. 12
Results
Overall improvement 92.5% of patients
Pain reduction 85.7% (7 2.6)
1 patient – no change
1 patient – increased pain
Cold attacks 78.5% decreased frequency
and severity
Ulcerations 66% improvement
Major complications 0
Minor complications 2
Subsequent neuromodulator 1
Subsequent sympathectomy 1
Fat Transfer in Raynaud’s
18. 18Fat Transfer in Raynaud’s
Hand Vascular Perfusion by Laser Doppler
Normal Moderate Severe
19. 19Fat Transfer in Raynaud’s
Hand Vascular Perfusion by Laser Doppler
20. 20Fat Transfer in Raynaud’s
Hand Vascular Perfusion by Laser Doppler
21. 21Fat Transfer in Raynaud’s
Preop Postop
200
150
100
50
Perfusionunits
Hand Vascular Perfusion by Laser Doppler
?QMRADASH
22. Durable clinical improvement in the majority of treated patients
Safe, relatively straightforward
Mechanism – to be elucidated (stem cell angiogenesis? padding?)
Role in treatment of advanced, refractory Raynaud’s Phenomenon
22
Conclusions
Fat Transfer in Raynaud’s
Raynaud’s phenomenon is a common affliction effecting 2% of the adult population,
More commonly in woman
It results from an imbalance between vasodilation and vasoconstriction
It can be divided in to primary raynaud, which usually exists in isolation from systemic disease
and in which the vasoconstriction results in cold attacks an pain, which can be severe and debilitating
Secondary raynauds typically occurs in the setting of autoimmune diseases such as systemic sclerosis (or scleroderma)
And manifests in fibrosis, scarring, contractures, ulcerations and even autoamputations
Clearly there is a continuum of disease manifestation
Initial treatment is preventative – with gloves and cold avoidance
But many patients progress to require medical treatment with calcium channel blockers and topical nitrates
And there is a whole host of other medications aimed at vasodilation and prevention of arterial thrombosis
Despite all of these options,
A portion of these patients develop severe, refractory symptoms
And this is where the hand surgeon comes in to play,
invoking invasive modalities
With injection of neuromodulators such as botulinum toxin – which has shown to be effective, but short lived, and can be an arduous undertaking for the patient and surgeon when done in the clinic setting
Another option would be surgical sympathectomy of the hands of affected feet –
this is not a trivial undertaking, with inherent procedural risks,
and requires somewhat specialized training
and my not be long-lived with the regrowth of the stripped adventitia
The intervention we propose he today is autologous fat grafting into the affected extremities
The rationale here stems from the clinical improvement witnessed in radiation dermatitis treated with fat injection, and to a certain extent in burn reconstruction
A published study from a murine model shower regression of hyperpigmentation, ulcers and fibrosis
With histological correlates
However, the mechanism is unknown, and thought to be related to repletion of adipose derived stems cells into the injured tissue
Recognizing that the pathophysiology in raynauds is differet, we contend that the end result at the tissue level is similar
We therefore set out to utilize fat grafting
As a means to treat patients with refractory cases of raynauds
We adapted a technique popularized by coleman for cosmetic rejuvenation of the hand by fat grafting
And inject approximately 30 ccs of decanted fat from abdominal sources,
Via blunt cannulae into the affcted extremity
The fat is dispersed subcutaneously and deeper, along the vessels as follows
10 cc dorsum of the hand
3 ml in the snuff box
2-3 in each dorsal webspace
6 cc along the palmar arch, the palmar webspaces and along the digital vessels
Here you can see the fat being injected while withdrawing the cannula
Over the past couple of years we performed this procedure on 14 patients
Or 25 extremities
Mainly in the hands
With a mean follow up of one year
Most of the patients severe females with primary raynauds
The average amount of fat was about 23 cc
And four had concomitant single digit sympathectomy for critical ischemia
All in all –
We some some levelof improvement in the vast majority of our patients
Primary in pain relief
Althou one patient reported no change
And would stated her pain was actually worse
In the patients that had ulcerations – two thirds were much improved or healed
Two patients required further interventions at a 3-6 month interval
It may be difficult to appreciate the subtle coloration improvement in this case
But here you can clearly see the healing of several ulcers
In the patient with severe scleroderma
With overall improvement suggested by here wearing her ring again
An example of fat transfer to the feet
We attempted to further quantify and monitor this intervention
With speckle laser doppler that gives an idea as to the perfusion to the studied area
And this is an example of a clinically improved patient with a correlating improvement in measured perfusion
However, not all of our outcomes were as encouraging
We really had a range of measured responses that did not directly correlate with our clinical obserations
And we are are still working out how to utilize this technology
And are in the process of using other objective measure sucha s the DASH score whch grades function
As well as quantitative MRA for a better assessment of tissue perfusion and longevity of the far grafts
5 showed LD improvement – 4/5 improved clinically, but the impovement was not sig in the LD
5 LD decrease – 4/5 improved symptoms
In conclusion we found fat transfer in patients with raynauds phenomenon of varying degrees
Provides a durable clinical improvement in the majority of treated patients
It appears to be safe and relatively straightforward
The precise mechanism has yet to be elucidated – and perhaps has to do with neoangiogenesis and decreased scar promoted by stem cells
Although I think in the scleroderma patients – even the small amount of fat that survives,
Provides a little bit of padding and cushioning to their severely sclerotic digits
So we think that there is definitely a role for fat transfer in advanced, refractory raynauds phenomenon
And look forward to collaborating with other surgeons on this project