Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
•
3 likes•1,260 views
1. Critical illness is a highly stressful state driven by the underlying disease, treatments, and ICU environment. 2. Prolonged stress can lead to "allostatic overload" and decompensation of organ systems even if no structural damage is present. 3. There is a need to reduce stress in critically ill patients through minimizing stressful interventions, providing psychological support, optimizing the environment, and exploring pharmacological de-stressing therapies.
Report
Share
Report
Share
Download to read offline
Recommended
Gordon Lithgow at Health Extension Salon #7
Dr. Lithgow, from the Buck Institute, presents evidence from his lab that multiple age-related diseases share a common root in cellular aging processes, and furthermore that interventions designed to affect the aging process could prevent or delay such diseases.
The P4 Initiative: Personalized - Predictive - Preventive - Participatory Med...
An introduction to the new medical wholism pattern: The P4 Initiative (Personalized - Predictive - Preventive - Participatory Medicine) for the Management of Chronic Diseases' Epidemic
Dr. George Bellos, MD, PhD, MRCGP, MEPMA, MEURAC
Managing Director at Health Centre Koropi, Attica
Penyuluhan Lupus untuk pasien dan keluarganya
Sebuah edukasi pasien tentang lupus, meliputi berbagai aspek yang patut diketahui, agar pasien dan keluarganya tidak larut dalam fase denial dan bargaining yang berkepanjangan
Martin Borch Jensen - The Science of Aging 2019
Why do we experience an exponential increase in disease as we age? Are the underlying processes treatable? What are the recent breakthroughs in anti-aging science, and how are these moving from academia into biotech? The Science of Aging seminar focuses on all the previous questions and, most importantly, how can you get involved in anti-aging as an entrepreneur or investor.
Recommended
Gordon Lithgow at Health Extension Salon #7
Dr. Lithgow, from the Buck Institute, presents evidence from his lab that multiple age-related diseases share a common root in cellular aging processes, and furthermore that interventions designed to affect the aging process could prevent or delay such diseases.
The P4 Initiative: Personalized - Predictive - Preventive - Participatory Med...
An introduction to the new medical wholism pattern: The P4 Initiative (Personalized - Predictive - Preventive - Participatory Medicine) for the Management of Chronic Diseases' Epidemic
Dr. George Bellos, MD, PhD, MRCGP, MEPMA, MEURAC
Managing Director at Health Centre Koropi, Attica
Penyuluhan Lupus untuk pasien dan keluarganya
Sebuah edukasi pasien tentang lupus, meliputi berbagai aspek yang patut diketahui, agar pasien dan keluarganya tidak larut dalam fase denial dan bargaining yang berkepanjangan
Martin Borch Jensen - The Science of Aging 2019
Why do we experience an exponential increase in disease as we age? Are the underlying processes treatable? What are the recent breakthroughs in anti-aging science, and how are these moving from academia into biotech? The Science of Aging seminar focuses on all the previous questions and, most importantly, how can you get involved in anti-aging as an entrepreneur or investor.
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.
To enable screen reader support, press shortcut Ctrl+Alt+Z. To learn about keyboard shortcuts, press shortcut Ctrl+slash.
Cardiac Arrest and Oxygen: Stephen Bernard
Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients.
Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes.
This is especially true in hospitals where oxygen is used frequently and often without much thought.
Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea.
In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest.
Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge.
The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way.
Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury.
Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen.
Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest.
Biomarkers in Critical Care: Mervyn Singer
Mervyn Singer discusses the use of biomarkers in critical care.
Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED.
These biomarkers are numerous - lipids, progesterone, troponin, thyroid stimulating hormone, inflammatory cytokines, mitochondrial dysfunction… so on and so forth!
Prognostication can happen as early as the Emergency Department.
Studies from the States have found high levels of inflammatory cytokines can predict death, separately from clinical presentation. Therefore, we can predict when critically ill patients are destined to die. So, does this mean that we are just prolonging the life of those destined to die in critical care? Perhaps.
Mervyn discusses this being the possible reason for many failed ICU studies. Concurrently, the only progress in critical care in the past 20 years may be due only to less iatrogenic harm.
Furthermore, he explains his experiments with rats demonstrating the use of cardiovascular parameters, cytokines, troponins and even cholesterol being accurate prognostic biomarkers.
Then, Mervyn goes on to identify the use of steroids in sepsis. He talks about research that demonstrates a benefit to steroid use, but only in those patients predicted to die using the aforementioned biomarkers. This could be a key to selecting an appropriate patient group to allocate a specific treatment too.
Furthermore, we examine treating sepsis with beta blockers. Giving beta blockers to everyone has no effect at best and a harmful effect at worst. However, giving beta-blockers to those who were predicted to die conferred benefit!
In conclusion, we can predict outcome early in disease. This may allow better selection of patients for certain treatments! We thus need to adopt a completely different strategy for such patients predetermined to die. This also applies to trial design, especially where survival is the endpoint.
For more like this, head to our podcast page. #CodaPodcast
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
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.
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
ICU year in review - Paul Young and Flavia Machado
Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what’s new in critical care then this is the talk for you.
Bombing of Hospitals in Warzones: Kathleen Thomas
Kathleen Thomas describes her harrowing experience of a warzone whilst working in the ICU and ED of the Médecins Sans Frontières run Kunduz Trauma Centre (KTC) in northern Afghanistan.
Kathleen describes her work during a week where she found herself caught up in an eruption of war. The Taliban forcibly took control of Kunduz from the US backed Afghan Military.
This marked the beginning of a challenging week of heavy conflict in which the hospital was the only facility providing impartial medical care to war wounded civilians and soldiers from both sides of the conflict.
Despite the proximity of the rapidly changing front line, Kathleen believes that the hospital is the safest place. Both warring parties had agreed to respect the protection provided to us under International Humanitarian law.
Kathleen’s work in KTC came to a grinding halt when a US Gunship fired over 200 missiles into our hospital. This destroyed the main building and killed 42 people including 14 of her colleagues.
It was a scene of nightmarish horror that Kathleen will never forget.
More than 250 hospitals in Syria and 130 in Yemen have been attacked. This shows a growing disregard for the rules of war. Despite the condemnation by the UN, the attacks on medical facilities continue, unabated.
Following an eyewitness account of the attack on KTC, Kathleen asks some important questions: Is international humanitarian law no longer respected by warring parties?
Are we entering into a new paradigm of war where hospital attacks are a legitimate military tactic?
What does this mean for the future of critical care delivery in war zones across the world?
Bombing of Hospitals in Warzones: Kathleen Thomas
For more like this, head to our podcast page. #CodaPodcast
Geriatric Emergency Medicine
Sue Mason gives you her take on Geriatric Emergency Medicine. Sue’s bread and butter is managing the elderly in the Emergency Department. It is not a sexy topic and there are few gizmos and gadgets. Nevertheless, it is very important.
How big is the problem?
Patients over 65 years represent about a quarter of the patients that attend Sue’s Emergency Department. However, most of these patients arrive by ambulance and the vast majority of visits in this age group are deemed necessary. This culminates with 50% of these patients being admitted. Attendance and admissions in the elderly age group are both going up.
What are we doing about it?
Advances have been made in prehospital care. In Sue’s region, paramedics have been trained in assessing and managing elderly falls. This found a reduction in ED attendance by 25% and decreased admissions by 6%.
Approaching the management of the elderly with a multidisciplinary team has proved to be effective in a ward setting. This has not been replicated in the Emergency Department. Within the ED there is potential for the inclusion of a pharmacist to improve admission rates. However there has not been any other “in department” interventions involving a broader team.
The initiation of interventions from the ED to continue in the community has been looked at, although the evidence is mixed.
How can we do it better?
Sue explores the question of whether all Emergency physicians should be trained in Geriatric Medicine. Or whether there should be sub-specialists in Geriatric Emergency Medicine. She also explores other strategies. Simple things such as not putting elderly patients on beds/trolleys unless clinically indicated and ensuring they have fluids on board. Overriding all decisions should be the question – does this patient need this investigation, treatment, and admission.
For more like this, head to our podcast page. #CodaPodcast
Anderson - Never Ever Die
David Anderson is an intensivist and medical donation specialist at the Alfred Hospital Melbourne. From a 2016 ICN Victoria meeting he discusses the coming epidemic of dementia and how its coming to an intensive care near you.
Is Point of Care Ultrasound (POCUS) a problem?
Maxime Valois and John Christian Fox argue the role of POCUS in critical care.
Maxime makes the case for POCUS being a problem.
POCUS changes everything. It has helped physicians throughout the world to make easier, more accurate and faster diagnoses.
It has contributed to enhance the diagnostic possibilities in resource-scarce environments However, as it gains more widespread acceptance, its use is becoming more and more common.
Maxime contests that this poses a problem. No longer is ultrasound only in the domain of specialists and technology-eager early adopters of the technology. He proposes that this will lead to difficulties as non-specialists take up the technology.
Maxime warns against being hypnotised against the seductive nature of ultrasound. Research and use of fancier, new or more advanced applications are likely to help the global advancement of POCUS and even medicine in general. But as POCUS enters fully in its stage of normal science, this will inevitably induce some degree of scientific esotericism.
This has been the case of all past scientific revolutions.
Point-of-care ultrasound is already generating some important difficulties. If these go unattended, Maxime believe POCUS itself might rapidly be a problem.
John on the other hand claims in no way is POCUS a problem.
It is maybe only a problem for the radiologist holding down their turf in a small hospital that has been shielded from the world wide web.
John argues that POCUS is changing the way medicine is practiced for the better. John makes the point that ultrasound makes the clinician better, faster, and stronger. It does so without exposing patient to harmful radiation.
Furthermore, John contends that POCUS enables the physician to bridge the gap between patient and doctor in increasingly complex healthcare system. It allows him to spend more time at the bedside and in doing so deliver better care for his patients.
John makes his point with a range of clinical situations, driving his point home that POCUS certainly has a place in the future of medicine.
Is Point of Care Ultrasound (POCUS) a problem?
For more like this, head to our podcast page. #CodaPodcast
Haines- Developing puzzle icu outcomes
Kimberley Haines is a senior ICU physiotherapist and the Allied Health Research Lead at Western Health. Her academic research focusses on the long term progress of ICU survivors. Here she discusses the developing puzzle of ICU outcomes.
MIchael Parr on Post Cardiac Arrest ICU Care
Michael Parr speaks at Bedside Critical Care Conference 4 about how to best manage post cardiac arrest patients in the ICU. The audio for this great talk can be found at www.intensivecarenetwork.com
Debate: The ICU is no place for the elderly
Francesca Rubulotta argues in favour of the ICU being no place for the elderly.
She describes the ICU as a horrible monster, a very dangerous place. Furthermore, she suggests the ICU is on par with climbing a mountain in terms of risk and exposure to catastrophise.
She continues to make the point that once a person reaches adulthood, the healthcare system is a one size fits all model.
This extends to the type of treatment required – whether it be for an acute or chronic condition.
Whilst hospitals, and ICU specifically, may be suited to assist those with acute conditions, it is perhaps less appropriate to deal with chronic conditions that avail the elderly.
Francesca concludes that for the elderly, there needs to be a new model.
One reliable, dedicated to the older patient population and able to provide the dignity they deserve.
Karin Amrein provides a counter argument. She bases this initially through a personal story of her grandmother. This provides the basis for her argument that advanced age does not predetermine outcomes in healthcare.
‘Elderly’ is a large spectrum and age alone is a poor individual determinate for health. At an individual level, age cannot tell one how a person will fare in the ICU, and it can be an appropriate setting for the right ‘elderly’ patient.
Karin contends that all patients are worthy of care in all settings depending on their personal context. Whilst with elderly patient one might consider conditions such as sarcopenia or dementia, this should not render them unworthy of care.
Karin suggests this is discrimination.
For Karin, age is just a number, and it is the person that should be treated – including in the ICU if appropriate.
Join Francesca Rubulotta and Karin Amrein as they debate whether ICU is a place for the elderly.
For more like this, head to our podcast page. #CodaPodcast
CRM for EMS workshop
All rights reserved to respective authors or parties. This is a compilation of various materials from various sources.
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
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
The role of the endothelium as a mediator of critical illness
Endothelium was once thought to be an inert organ. However, it plays an important role in multiple functions. These include coagulation, inflammation and determination of vascular permeability.
He then gives a brief overview of the endothelial arrangement, function of the glycocalyx layer and how an injury causing a loss of the protective layer results in holes in the endothelium. The inflammatory cells enter via these holes and causes oedema in the affected organs leading to multiple pathologies.
Danny then explains the role of endothelium in controlling cell barrier function.
Activation of cortactin protein and the myosin light-chain kinase (MLCK) enzymes activate stress fibres resulting in pulling of endothelial cells thereby increasing its permeability.
Danny discusses the role of endothelial dysfunction in acute respiratory distress syndrome (ARDS) at macrovascular, microvascular and molecular levels. Macrovascular thrombosis is related to an increase in severity of ARDS, pulmonary hypertension, and mortality.
At a microvascular level there is a loss of vascularity and increased blood vessel thickness. At a microscopic level, endothelial cells appear swollen and damaged in ARDS. Endothelial dysfunction drives organ dysfunction and mortality. Changes in various endothelial markers like increased von Willebrand factor (vWF), decreased protein C and increased pulmonary dead space correlate with increased mortality.
Studies show that endothelial dysfunction is a more specific and sensitive method to predict mortality of critically ill patients when compared to SOFA score, SAPS 2 score and WCC. Danny discusses ventilator strategies for endothelial cells in ARDS patients. Lowering the tidal volume of ventilators and employing recruitment manoeuvres are such strategies.
Both of these cause a decrease in oedema by reducing endothelial permeability. He then shares the various potential pharmacological treatments for treating endothelial damage. These include statins and spingosine-1-phosphate (S1P). Different studies on the effect of statins in ARDS show contradicting result.
However, targeted therapies can be designed by studying the phenotypes and molecular basis of ARDS in each patient.
The role of the endothelium as a mediator of critical illness by Danny McAuley
Finally, for more like this, head to our podcast page. #CodaPodcast
Biomarkers in Emergency Medicine: Katrin Hruska
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.
More Related Content
Viewers also liked
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.
To enable screen reader support, press shortcut Ctrl+Alt+Z. To learn about keyboard shortcuts, press shortcut Ctrl+slash.
Cardiac Arrest and Oxygen: Stephen Bernard
Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients.
Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes.
This is especially true in hospitals where oxygen is used frequently and often without much thought.
Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea.
In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest.
Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge.
The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way.
Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury.
Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen.
Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest.
Biomarkers in Critical Care: Mervyn Singer
Mervyn Singer discusses the use of biomarkers in critical care.
Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED.
These biomarkers are numerous - lipids, progesterone, troponin, thyroid stimulating hormone, inflammatory cytokines, mitochondrial dysfunction… so on and so forth!
Prognostication can happen as early as the Emergency Department.
Studies from the States have found high levels of inflammatory cytokines can predict death, separately from clinical presentation. Therefore, we can predict when critically ill patients are destined to die. So, does this mean that we are just prolonging the life of those destined to die in critical care? Perhaps.
Mervyn discusses this being the possible reason for many failed ICU studies. Concurrently, the only progress in critical care in the past 20 years may be due only to less iatrogenic harm.
Furthermore, he explains his experiments with rats demonstrating the use of cardiovascular parameters, cytokines, troponins and even cholesterol being accurate prognostic biomarkers.
Then, Mervyn goes on to identify the use of steroids in sepsis. He talks about research that demonstrates a benefit to steroid use, but only in those patients predicted to die using the aforementioned biomarkers. This could be a key to selecting an appropriate patient group to allocate a specific treatment too.
Furthermore, we examine treating sepsis with beta blockers. Giving beta blockers to everyone has no effect at best and a harmful effect at worst. However, giving beta-blockers to those who were predicted to die conferred benefit!
In conclusion, we can predict outcome early in disease. This may allow better selection of patients for certain treatments! We thus need to adopt a completely different strategy for such patients predetermined to die. This also applies to trial design, especially where survival is the endpoint.
For more like this, head to our podcast page. #CodaPodcast
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
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.
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
ICU year in review - Paul Young and Flavia Machado
Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what’s new in critical care then this is the talk for you.
Bombing of Hospitals in Warzones: Kathleen Thomas
Kathleen Thomas describes her harrowing experience of a warzone whilst working in the ICU and ED of the Médecins Sans Frontières run Kunduz Trauma Centre (KTC) in northern Afghanistan.
Kathleen describes her work during a week where she found herself caught up in an eruption of war. The Taliban forcibly took control of Kunduz from the US backed Afghan Military.
This marked the beginning of a challenging week of heavy conflict in which the hospital was the only facility providing impartial medical care to war wounded civilians and soldiers from both sides of the conflict.
Despite the proximity of the rapidly changing front line, Kathleen believes that the hospital is the safest place. Both warring parties had agreed to respect the protection provided to us under International Humanitarian law.
Kathleen’s work in KTC came to a grinding halt when a US Gunship fired over 200 missiles into our hospital. This destroyed the main building and killed 42 people including 14 of her colleagues.
It was a scene of nightmarish horror that Kathleen will never forget.
More than 250 hospitals in Syria and 130 in Yemen have been attacked. This shows a growing disregard for the rules of war. Despite the condemnation by the UN, the attacks on medical facilities continue, unabated.
Following an eyewitness account of the attack on KTC, Kathleen asks some important questions: Is international humanitarian law no longer respected by warring parties?
Are we entering into a new paradigm of war where hospital attacks are a legitimate military tactic?
What does this mean for the future of critical care delivery in war zones across the world?
Bombing of Hospitals in Warzones: Kathleen Thomas
For more like this, head to our podcast page. #CodaPodcast
Geriatric Emergency Medicine
Sue Mason gives you her take on Geriatric Emergency Medicine. Sue’s bread and butter is managing the elderly in the Emergency Department. It is not a sexy topic and there are few gizmos and gadgets. Nevertheless, it is very important.
How big is the problem?
Patients over 65 years represent about a quarter of the patients that attend Sue’s Emergency Department. However, most of these patients arrive by ambulance and the vast majority of visits in this age group are deemed necessary. This culminates with 50% of these patients being admitted. Attendance and admissions in the elderly age group are both going up.
What are we doing about it?
Advances have been made in prehospital care. In Sue’s region, paramedics have been trained in assessing and managing elderly falls. This found a reduction in ED attendance by 25% and decreased admissions by 6%.
Approaching the management of the elderly with a multidisciplinary team has proved to be effective in a ward setting. This has not been replicated in the Emergency Department. Within the ED there is potential for the inclusion of a pharmacist to improve admission rates. However there has not been any other “in department” interventions involving a broader team.
The initiation of interventions from the ED to continue in the community has been looked at, although the evidence is mixed.
How can we do it better?
Sue explores the question of whether all Emergency physicians should be trained in Geriatric Medicine. Or whether there should be sub-specialists in Geriatric Emergency Medicine. She also explores other strategies. Simple things such as not putting elderly patients on beds/trolleys unless clinically indicated and ensuring they have fluids on board. Overriding all decisions should be the question – does this patient need this investigation, treatment, and admission.
For more like this, head to our podcast page. #CodaPodcast
Anderson - Never Ever Die
David Anderson is an intensivist and medical donation specialist at the Alfred Hospital Melbourne. From a 2016 ICN Victoria meeting he discusses the coming epidemic of dementia and how its coming to an intensive care near you.
Is Point of Care Ultrasound (POCUS) a problem?
Maxime Valois and John Christian Fox argue the role of POCUS in critical care.
Maxime makes the case for POCUS being a problem.
POCUS changes everything. It has helped physicians throughout the world to make easier, more accurate and faster diagnoses.
It has contributed to enhance the diagnostic possibilities in resource-scarce environments However, as it gains more widespread acceptance, its use is becoming more and more common.
Maxime contests that this poses a problem. No longer is ultrasound only in the domain of specialists and technology-eager early adopters of the technology. He proposes that this will lead to difficulties as non-specialists take up the technology.
Maxime warns against being hypnotised against the seductive nature of ultrasound. Research and use of fancier, new or more advanced applications are likely to help the global advancement of POCUS and even medicine in general. But as POCUS enters fully in its stage of normal science, this will inevitably induce some degree of scientific esotericism.
This has been the case of all past scientific revolutions.
Point-of-care ultrasound is already generating some important difficulties. If these go unattended, Maxime believe POCUS itself might rapidly be a problem.
John on the other hand claims in no way is POCUS a problem.
It is maybe only a problem for the radiologist holding down their turf in a small hospital that has been shielded from the world wide web.
John argues that POCUS is changing the way medicine is practiced for the better. John makes the point that ultrasound makes the clinician better, faster, and stronger. It does so without exposing patient to harmful radiation.
Furthermore, John contends that POCUS enables the physician to bridge the gap between patient and doctor in increasingly complex healthcare system. It allows him to spend more time at the bedside and in doing so deliver better care for his patients.
John makes his point with a range of clinical situations, driving his point home that POCUS certainly has a place in the future of medicine.
Is Point of Care Ultrasound (POCUS) a problem?
For more like this, head to our podcast page. #CodaPodcast
Haines- Developing puzzle icu outcomes
Kimberley Haines is a senior ICU physiotherapist and the Allied Health Research Lead at Western Health. Her academic research focusses on the long term progress of ICU survivors. Here she discusses the developing puzzle of ICU outcomes.
MIchael Parr on Post Cardiac Arrest ICU Care
Michael Parr speaks at Bedside Critical Care Conference 4 about how to best manage post cardiac arrest patients in the ICU. The audio for this great talk can be found at www.intensivecarenetwork.com
Debate: The ICU is no place for the elderly
Francesca Rubulotta argues in favour of the ICU being no place for the elderly.
She describes the ICU as a horrible monster, a very dangerous place. Furthermore, she suggests the ICU is on par with climbing a mountain in terms of risk and exposure to catastrophise.
She continues to make the point that once a person reaches adulthood, the healthcare system is a one size fits all model.
This extends to the type of treatment required – whether it be for an acute or chronic condition.
Whilst hospitals, and ICU specifically, may be suited to assist those with acute conditions, it is perhaps less appropriate to deal with chronic conditions that avail the elderly.
Francesca concludes that for the elderly, there needs to be a new model.
One reliable, dedicated to the older patient population and able to provide the dignity they deserve.
Karin Amrein provides a counter argument. She bases this initially through a personal story of her grandmother. This provides the basis for her argument that advanced age does not predetermine outcomes in healthcare.
‘Elderly’ is a large spectrum and age alone is a poor individual determinate for health. At an individual level, age cannot tell one how a person will fare in the ICU, and it can be an appropriate setting for the right ‘elderly’ patient.
Karin contends that all patients are worthy of care in all settings depending on their personal context. Whilst with elderly patient one might consider conditions such as sarcopenia or dementia, this should not render them unworthy of care.
Karin suggests this is discrimination.
For Karin, age is just a number, and it is the person that should be treated – including in the ICU if appropriate.
Join Francesca Rubulotta and Karin Amrein as they debate whether ICU is a place for the elderly.
For more like this, head to our podcast page. #CodaPodcast
CRM for EMS workshop
All rights reserved to respective authors or parties. This is a compilation of various materials from various sources.
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
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
The role of the endothelium as a mediator of critical illness
Endothelium was once thought to be an inert organ. However, it plays an important role in multiple functions. These include coagulation, inflammation and determination of vascular permeability.
He then gives a brief overview of the endothelial arrangement, function of the glycocalyx layer and how an injury causing a loss of the protective layer results in holes in the endothelium. The inflammatory cells enter via these holes and causes oedema in the affected organs leading to multiple pathologies.
Danny then explains the role of endothelium in controlling cell barrier function.
Activation of cortactin protein and the myosin light-chain kinase (MLCK) enzymes activate stress fibres resulting in pulling of endothelial cells thereby increasing its permeability.
Danny discusses the role of endothelial dysfunction in acute respiratory distress syndrome (ARDS) at macrovascular, microvascular and molecular levels. Macrovascular thrombosis is related to an increase in severity of ARDS, pulmonary hypertension, and mortality.
At a microvascular level there is a loss of vascularity and increased blood vessel thickness. At a microscopic level, endothelial cells appear swollen and damaged in ARDS. Endothelial dysfunction drives organ dysfunction and mortality. Changes in various endothelial markers like increased von Willebrand factor (vWF), decreased protein C and increased pulmonary dead space correlate with increased mortality.
Studies show that endothelial dysfunction is a more specific and sensitive method to predict mortality of critically ill patients when compared to SOFA score, SAPS 2 score and WCC. Danny discusses ventilator strategies for endothelial cells in ARDS patients. Lowering the tidal volume of ventilators and employing recruitment manoeuvres are such strategies.
Both of these cause a decrease in oedema by reducing endothelial permeability. He then shares the various potential pharmacological treatments for treating endothelial damage. These include statins and spingosine-1-phosphate (S1P). Different studies on the effect of statins in ARDS show contradicting result.
However, targeted therapies can be designed by studying the phenotypes and molecular basis of ARDS in each patient.
The role of the endothelium as a mediator of critical illness by Danny McAuley
Finally, for more like this, head to our podcast page. #CodaPodcast
Biomarkers in Emergency Medicine: Katrin Hruska
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.
Viewers also liked (20)
Paed-Iconoclasm: Breaking the Myths without Breaking Your Patient
Paed-Iconoclasm: Breaking the Myths without Breaking Your Patient
ICU year in review - Paul Young and Flavia Machado
ICU year in review - Paul Young and Flavia Machado
John Myburgh vs Anthony Holley - ICP Monitoring in TBI is So Last Season
John Myburgh vs Anthony Holley - ICP Monitoring in TBI is So Last Season
The role of the endothelium as a mediator of critical illness
The role of the endothelium as a mediator of critical illness
Similar to Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
SE Pendant - Scalar Energy, Negative Ions, Far Infrared, Germanium
Detailed presentation about why you need the SE Pendant. SE Pendant - Scalar Energy, Negative Ions, Far Infrared, Germanium
Introductory Psychology: Stress
lecture 27 from a college level introduction to psychology course taught Fall 2011 by Brian J. Piper, Ph.D. (psy391@gmail.com) at Willamette University, Seyle
Earthing the ultimate antioxidant
IT IS The Most Important Health Discovery Ever. Earthing ranks right up there with the discovery of penicillin. The Earth is an electrical planet and our bodies are bioelectrical beings. When we are physically in touch with the Earth, we absorb electrons (negatively charged) from the Earth’s surface. This help to neutralize the (positively charged) free radicals in our body that damage our cells. The destructive activity of free radicals in the body has been linked with many diseases and accelerated aging.
Future of Health : How We Can Avoid Aging?
Dr Aubrey de Grey, né le 20 avril 1963, à Londres, est un scientifique anglais, ancien informaticien à l’université de Cambridge et autodidacte en biogérontologie. Il vit actuellement à San Francisco. Lors de la conférence FUTUR DE LA SANTÉ tenue le 10 octobre 2017, il a présenté les avancées de la technologie combinées à la génomique permettant de développer un moyen de régénérer les tissus cellulaires pour rajeunir et allonger l’espérance de vie humaine.
neurobiology of brain and everyday behaviour
This is the final project for the course neurobiology of brain and behaviour. This consists analysis of the neurodegenerative disease- Amyotrophic lateral sclerosis (ASL)
Cell injury l1 medical sept 2018
Pathology lecture on cell injury part 1 for medical and dental students
Anti-aging supplements? Myths, reality and speculation
Talk given by Michael C Price to the H+UK meeting in Birkbeck College on 28th March 2010
MRS2000 - PEMF Discussion
Think of the MRS 2000 (Magnetic Resonance Stimulation) as a Whole Body Battery Recharger. This is LITERALLY true as the 70 trillion cells in your body are actually miniature batteries that store charge. A healthy cell has around 90+ millivolts of energy stored while a sick and diseased cell can drop below 30 millivolts.
So you see, health is really all about energy. The more energy you have, the healthier you feel. It really is that simple!
Neurological Disorders
Neurological Disorders; neurological disorders, disorder of development, degenerative disorder.
Author: Chinun Boonroungrut
ชื่อ-นามสกุล: ชินัณ บุญเรืองรัตน์
E-mail: b.chinun@gmail.com
Autoimmunity & disorders ppt by DR.C P. PRINCE
PPT prepared by :
DR.PRINCE C P
HOD & Associate Professor
Department of Microbiology,
Mother Theresa
Post Graduate & Research Institute of Health Sciences (Government of Puducherry Institution)
Pondicherry.
An autoimmune disorder is a condition that occurs when the immune system attacks and destroys healthy body tissue.
Graves’ disease
Hashimoto’s thyroiditis
Addison’s disease
Myasthenia gravis
SLE
Diabetes mellitus type
Similar to Stress Metabolism Adaptation & Critical Illness: Mervyn Singer (20)
SE Pendant - Scalar Energy, Negative Ions, Far Infrared, Germanium
SE Pendant - Scalar Energy, Negative Ions, Far Infrared, Germanium
Anti-aging supplements? Myths, reality and speculation
Anti-aging supplements? Myths, reality and speculation
Aubrey de grey why you're helpless now but not for long
Aubrey de grey why you're helpless now but not for long
More from SMACC Conference
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
More on BOOST3 here
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
By Catherine Bell and Andrew Udy
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.
Browne Neuro symposium.pptx
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?
After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference.
Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways.
Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions.
Hypertensive therapy is relatively safe and easy to implement but not without risk.
Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.
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
Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.
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.
More from SMACC Conference (20)
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill - More neuroanatomy pearls for neurocritical care
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
TBI Debate - Mild, moderate and severe categories work
TBI Debate - Mild, moderate and severe categories work
Managing Complications of Chronic SCI by Bonne Lee
Managing Complications of Chronic SCI by Bonne Lee
Hypertensing Spinal Cord Injury - gold standard or wacky?
Hypertensing Spinal Cord Injury - gold standard or wacky?
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Recently uploaded
Non-respiratory Functions of the Lungs.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS
PPT RELATED TO ARTHROLOGY ACCORDING TO NCISM AYURVEDA
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
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.
Follow us on: Pinterest
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
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Physiology of Special Chemical Sensation of Taste
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Gram Stain introduction, principle, Procedure
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
CDSCO and Phamacovigilance {Regulatory body in India}
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
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
NVBDCP.pptx Nation vector borne disease control program
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
KDIGO 2024 guidelines for diabetologists
KDIGO guidelines 2024 for evaluation and management of CKD, related to diabetes and management of diabetic kidney disease
Are There Any Natural Remedies To Treat Syphilis.pdf
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pharma Pcd Franchise in Jharkhand - Yodley Lifesciences
Join Monopoly Pharma PCD Franchise in Jharkhand :Ranchi, Jamshedpur, Dhanbad, Bokaro Steel City, Hazaribagh, Deoghar, Giridih, etc.
How to Give Better Lectures: Some Tips for Doctors
Talk given to Koronadal Internists Society, Marbel, South Cotabato as part of the Continuing Medical Education (CME) series.
New Drug Discovery and Development .....
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Knee anatomy and clinical tests 2024.pdf
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recently uploaded (20)
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
CDSCO and Phamacovigilance {Regulatory body in India}
CDSCO and Phamacovigilance {Regulatory body in India}
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
NVBDCP.pptx Nation vector borne disease control program
NVBDCP.pptx Nation vector borne disease control program
Are There Any Natural Remedies To Treat Syphilis.pdf
Are There Any Natural Remedies To Treat Syphilis.pdf
Pharma Pcd Franchise in Jharkhand - Yodley Lifesciences
Pharma Pcd Franchise in Jharkhand - Yodley Lifesciences
How to Give Better Lectures: Some Tips for Doctors
How to Give Better Lectures: Some Tips for Doctors
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
- 1. Should we de-stress the distressed? Mervyn Singer Bloomsbury Inst of Intensive Care Medicine University College London, UK
- 3. ORGANS LOOK NORMAL IN PATIENTS DYING OF MULTI-ORGAN FAILURE ... “.. no evidence of injury to cardiac myocytes in patients with sepsis who had myocardial depression.” “.. in patients with sepsis and acute renal failure only focal injury with preservation of normal glomeruli and tubules.” HOTCHKISS + KARL, NEJM 2003
- 4. FUNCTIONAL FAILURE NOT STRUCTURAL DAMAGE WHY????? COULD IT BE THAT SUCH PATIENTS ARE ??STRESSED OUT
- 5. WE HAVEN’T EVOLVED TO DEAL WITH ONGOING SEVERE STRESS …
- 6. .. ability to cope with blood loss and tissue trauma .. ability to heal quickly .. endogenous food reserves - “auto-cannabilization” .. a functioning immune system SURVIVAL DEPENDED ON ..
- 7. We’re now living much longer … .. far beyond what evolution ever intended Life expectancy at birth in England (1540-2011)
- 8. W E H AV E N ’ T E V O LV E D T O C O P E W I T H … old age multiple co-morbidities prolonged critical illness modern life-saving drugs and organ supports
- 9. sick, stressed patient stressful drugs stressful machines stressful environment
- 10. S T R E S S crucial coping mechanism to deal with stressors changes in behaviour autonomic & hormonal modulation of: inflammatory & immune systems cardiovascular, respiratory systems metabolic activity …. too much of a good thing becomes bad
- 11. “acute stress response” (1915) World War 1 - studied physiological effect of emotions threat -> sympathetic discharge -> primes for fight/flight generally adaptive & protective.. .. though noted nervous exhaustion -> ± manifest as physical illness Walter Cannon (1871-1945)
- 12. Hans Seyle (1936) - “General Adaptation Syndrome” Physiological systems protect & restore the body against stress .. but can also cause harm Stress —> ‘distress’ when body can no longer withstand insult —> functional compromise Various insults (cold, trauma, spinal cord transection, xs exercise, drugs) -> similar pathological findings
- 13. TA K O T S U B O C A R D I O M Y O PAT H Y • heart failure • first recognized in Japan in early 90s • follows emotional stress, e.g. argument, bereavement, public speaking .. • normal coronaries • related to excess catecholamine levels
- 14. physiological and behavioural changes generally adaptive in the short term allostatic load = physiological costs of chronic stress exposure allostatic overload - when serious pathophysiology may occur type 1 overload - when energy demand exceeds supply: • animal goes into survival mode that decreases allostatic load and regains positive energy balance • normal life cycle resumes when insult passes (Sterling & Eyer 1988) A L L O S TA S I S
- 15. Hibernation (extreme cold) • bears, mice… Estivation (extreme heat / drought) • reptiles, mammals, snails, • fish, trees Deep-sea diving (anoxia) • turtles Dormancy • bacteria (e.g. TB A L L O S TAT I C A D A P TAT I O N
- 16. .. protects against persisting hypoperfusion M Y O C A R D I A L H I B E R N AT I O N
- 17. abnormal in critical illness; many also early prognosticators
- 20. metabolism energy Chicken, egg .. or both? CRITICAL ILLNESS Type I allostatic overload??
- 22. physiological pharmacological psychological delirium & PTSD pro-thromboticmuscle loss/wasting arrhythmias, heart failure immunosuppressive CHRONIC CRITICAL ILLNESS B E I N G A N I C U PAT I E N T I S S T R E S S F U L
- 23. Singer M. Lancet 2007; 370: 636-7 obvious e.g. tachyarrhythmias, digital ischaemia stimulation of bacterial growth + virulence immunosuppression metabolic modulation, insulin resistance catabolism thrombogenic decreased bioenergetic efficiency increased cardiac work ventricular remodelling myocardial damage
- 24. failed organs .. yet usually structurally normal tissue PO2 high, i.e. O2 available but not utilized if patient survives, organs usually recover - even those that are poorly regenerative Is MOF an allostatic response to severe, prolonged inflammation?? However, does too extreme a phenotype become maladaptive?
- 25. good analgesia other drug approaches prevent hypoxia reduce/remove anxiety wake-sleep cycles quality sleep access to daylight & views communication aids mobilisation privacy music alleviate boredom noise reduction alternative therapies D E - S T R E S S I N G P R O C E D U R E S
- 29. C O M E T O T H I S A F T E R N O O N ’ S TA L K F O R S O M E L I F E - S AV I N G D E - S T R E S S I N G T H E R A P I E S … AT L E A S T I N R O D E N T S !
- 30. • Critical illness is a stressful event • Stress driven by underlying disease process, our treatments and the ICU environment • Excess stress -> decompensation (‘allostatic overload’) • Need to destress patients … • minimise stressful interventions • psychological supports • optimize environment • pharmacological de-stressing S U M M A RY