Invasive methods are well accepted, but there is increasing evidence that these methods are neither accurate nor effective in guiding therapy
An accurate and non-invasive measurement of CO is the best method of cardiovascular assessment
Although large efforts are spent for creating fistula as the primary access, use of Hemodialysis Vascular catheters are still the major access on the first Hemodialysis session and after 4 month whether we would like it or not.
"USRDS 2013"
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
Although large efforts are spent for creating fistula as the primary access, use of Hemodialysis Vascular catheters are still the major access on the first Hemodialysis session and after 4 month whether we would like it or not.
"USRDS 2013"
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
Mechanical ventilation ppt including airway, ventilator, tubings and connections, nursing management, trouble shooting common problems and issues, suctioning etc.
Assessment of haemodynamics a critically ill patient and its management has always been a matter if debate. Over time a lot of studies and therapeutic interventions have been carried out. This presentation is a review of such interventions and their impact on the outcome.
fluid optimization concept based on dynamic parameters of hemodynamic monitoringSurendra Patel
Recent advances in hemodynamic monitoring to assess fluid responsiveness of patients in acute circulatory failure is based on dynamic parameters like SPV, PPV, SVV and PVI. These parameters are more accurate than static but needs advanced and sensitive monitoring tools.
Bronchial Thermoplasty (BT) Novel Treatment for Patients with Severe AsthmaBassel Ericsoussi, MD
Do our Asthma Patients Know What They Are Missing?Now, A Revolutionary Procedure Can Help Them Lead A Fuller Life.
Bronchial Thermoplasty (BT) Novel Treatment For Patients With Severe Asthma
Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...Bassel Ericsoussi, MD
EBUS-TBNA, EUS-FNA or their combination have finally gained acceptance as the tests of first choice in mediastinal staging. In suspected non-small cell lung cancer, endobronchial ultrasound may be preferred in the histologic sampling of paratracheal and subcarinal mediastinal adenopathy because the diagnostic yield can surpass mediastinoscopy
THE VENTILATOR CIRCUIT AND VENTILATOR-ASSOCIATED PNEUMONIA (VAP) Bassel Ericsoussi, MD
THE VENTILATOR CIRCUIT APPEARS TO HAVE ONLY A SMALL EFFECT ON THE DEVELOPMENT OF VAP. This contradicts the widely held belief that the ventilator circuit is an important contributor to the development of VAP
New technology called Electromagnetic Navigation Bronchoscopy® (ENB) that uses virtual bronchoscopy and real time 3-dimensional CT images that enable me to localize these peripheral lung nodules for diagnosis and treatment. This outpatient procedure is minimally invasive and therefore has a small risk of pneumothorax (2-3%) and its published diagnostic yield rates range from 67% - 86%
The Role Of Corticosteroids In The Perioperative Management Of Endobronchial ...Bassel Ericsoussi, MD
FBs, particularly those with high oil content may cause severe mucosal inflammation with formation of bulky granulation tissue. When a FB is completely encased in bulky and bleeding granulation tissue, extraction can be very difficult or impossible. A short course of corticosteroids may reduce the inflammatory process and enhance recovery pre or post extraction and in some cases may facilitate removal of the FB.
Whole-lung lavage is a large-volume BAL that is performed mainly in the treatment of PAP. In brief, it involves the induction of general anesthesia followed by isolation of the two lungs with a double-lumen endotracheal tube and performance of single-lung ventilation while large volume lavages are performed on the nonventilated lung. Warmed normal saline solution in 1-L aliquots (total volumes up to 20 L) is instilled into the lung, chest physiotherapy is performed, then the proteinaceous effluent is drained with the aid of postural positioning. The sequence of events is repeated until such time as the effluent, which is initially milky and opaque, becomes clear. This procedure results in significant clinical and radiographic improvement secondary to the washing out of the proteinaceous material from the alveoli. The whole-lung lavage video details all aspects of the procedure, including case selection, patient preparation and equipment, a step-by-step review of the procedure, and postoperative considerations.
Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, An...Bassel Ericsoussi, MD
Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, And Excessive Dynamic Airway Collapse: Classification, Diagnosis, and Treatment
Deep Venous Thrombosis and Pulmonary Embolism : Diagnostic Approach and Curre...Bassel Ericsoussi, MD
Acute pulmonary embolism: Overview, Diagnosis, Treatment
DVT/PE in pregnancy
Prevalence of PE in COPD exacerbations
Diagnostic vascular ultrasonography
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
HEMODYNAMICS MONITORING IN CRITICALLY ILL PATIENTS: ASSESSMENT OF FLUID STATUS AND MEASURES OF VOLUME RESPONSIVENESS
1. HEMODYNAMICS MONITORING IN CRITICALLY ILL
PATIENTS: ASSESSMENT OF FLUID STATUS AND
MEASURES OF VOLUME RESPONSIVENESS
Bassel Ericsoussi, MD
Pulmonary & Critical Care Specialist
2. Measuring Cardiac Output
• The function of the heart is to transport blood
to deliver oxygen to the cells of the body to
ensure their survival and proper function and
to remove the cellular wastes
– Cardiac Output (CO) = SV × HR
– Ejection Fraction (EF) = (SV / EDV) × 100%
– Stroke Volume (SV) = EDV – ESV
– Cardiac Index (CI) = CO / Body Surface Area (BSA)
3. Measuring Cardiac Output
Invasive methods are well accepted, but there is
increasing evidence that these methods are
neither accurate nor effective in guiding therapy
An accurate and non-invasive measurement of
CO is the best method of cardiovascular
assessment
4. Measuring Cardiac Output
The Fick Principle
• First described by Adolf Fick in 1870
• The rate at which oxygen is consumed is a
function of the rate of blood flows and the
rate of oxygen picked up by the red blood cells
• VO2 = CO x (CA – CV)
• CO = VO2 / (CA – CV)
– (CA – CV) Arteriovenous oxygen difference
5. Measuring Cardiac Output
The Fick Principle
• VO2 = CO x (CA – CV)
• CO = VO2 / (CA – CV)
– (CA – CV) Arteriovenous oxygen difference
• VO2 calculated using an assumed oxygen
consumption
• CaO2 = Hb x 1.34 x SaO2 + 0.003 PaO2
• CvO2 = Hb x 1.34 x SvO2 + 0.003 PvO2
6. Measuring Cardiac Output
The Fick Principle
• Invasive
• Requires time for the sample analysis
• Accurate oxygen consumption samples are
difficult to acquire
7. Measuring Cardiac Output
Pulmonary Artery Thermodilution
• Injection of 10 ml of cold glucose into the pulmonary
artery and measuring the temperature distally using
the same catheter with temperature sensors set apart
at a known distance 6–10 cm
• Calculate the Cardiac Output from a measured
time/temperature curve (The "thermodilution curve")
– low CO registers temperature change slowly
– high CO registers temperature change rapidly
– The degree of change in temperature is directly
proportional to the CO
• 3-4 passes are usually averaged to improve accuracy
8. Measuring Cardiac Output
Pulmonary Artery Thermodilution
• The Swan - Ganz catheter or PAC, was
introduced to clinical practice in 1970
• Due to hospital acquired infection, we don’t
use continuous invasive cardiac monitoring in
the Intensive Care Unit.
• Use of the PAC is still useful in right heart
study in the cardiac catheterization laboratory
today.
9. Measuring Cardiac Output
Pulmonary Artery Thermodilution
• PAC use is complicated by
– arrhythmias
– infection
– pulmonary artery rupture
– right heart valve damage
• Recent studies in patients with critical
illness, sepsis, acute respiratory failure and
heart failure suggest use of the PAC does not
improve patient outcomes
10. CVP AS A MARKER OF INTRAVASCULAR
VOLUME STATUS AND RESPONSE TO FLUIDS
• CVP is NOT RELIABLE for judging intravascular volume status
• A low CVP generally can be relied upon as supporting positive
response to fluid loading
• Target CVP 8–12 mmHg
• Higher target CVP of 12-15 mmHg should be achieved
–
–
–
–
Mechanically ventilated patients
Decreased ventricular compliance
Pulmonary artery hypertension
Increased abdominal pressure
11.
12. Assessment of Fluid Status and Measures of
Volume Responsiveness
Passive Leg Raising and Artery Peak Velocity
• Doppler evaluation of arterial peak velocity
variation
In the responder patient, passive leg raising
induced an increase of arterial peak velocity by
15%
13.
14.
15. Assessment of Fluid Status and
Measures of Volume Responsiveness
IVC Diameter Variation
• Measure proximal IVC AP diameter 3 cm from the RA
• Spontaneous breathing
> 50% decrease in the IVC diameter with inspiration
predicts responsiveness to volume expansion
• Positive pressure ventilation
> 12% increase in the IVC diameter with inspiration
predicts responsiveness to volume expansion
Max D – min D / average D > 12%
Max D - min D / min D > 18%
20. Assessment of Fluid Status and
Measures of Volume Responsiveness
Pulse pressure variation
21. LIMITATIONS OF IVC AND PULSE
PRESSURE VARIATIONS
• All patients must be:
– Passively ventilated – heavily sedated
– Large tidal volume 10-12 ml/kg
– Off vasopressors
– Sinus rhythm
– Absence of increased abdominal pressure
• Good luck finding these patient
Bassel Ericsoussi, MD
21
22. Assessment of Fluid Status and
Measures of Volume Responsiveness
Passive Leg Raising and Stroke
Volume Variation
• Straight leg raising test: Can be done on any patient
– Sinus or irregular rhythm
– Spontaneous breathing or on ventilator
– On pressors or off pressors
• Use apical 5 chamber view and measure the aortic blood flow (stroke
volume)
• Raise legs to 45 degree (you have just given a “blood bolus” 500 ml blood
in legs returned to the heart)
• Wait 30-60-90 sec (highest values within 90 sec)
• Recheck the stroke volume
– SVV > 12%
Bassel Ericsoussi, MD
22
23. Statistical Analysis Of Arterial Pressure
Flotrac/Vigileo
• By analyzing the shape of the arterial pressure
waveform, the effect of vascular tone is
assessed allowing calculation of SV.
• Cardiac Output (Q) is then derived utilizing the
equation Q=HR*SV.
• While these invasive arterial monitors do not
require intracardiac catheterisation from a
pulmonary artery catheter, they do require an
arterial line and are invasive.
24. Statistical Analysis Of Arterial Pressure
Flotrac/Vigileo
• Disadvantages
– Inability to provide data regarding right-sided heart
pressures, or mixed venous oxygen saturation
– The measurement of pressure in the artery to
calculate the flow in the heart is irrational and of
questionable accuracy
– Arterial pressure monitoring is limited in patients off
ventilation, in atrial fibrillation, in patients on
vasopressors and in patients with a dynamic
autonomic system such as in sepsis