This document discusses subarachnoid hemorrhage (SAH) and vasospasm, which is a common complication of SAH. It provides an overview of the pathophysiology of SAH and vasospasm, involving factors such as nitric oxide, endothelin-1, and oxidative stress. Current standard therapies aim to prevent rebleeding and improve cerebral blood flow, but have limitations. Emerging therapies are being investigated to more effectively treat and prevent vasospasm.
Acute management of patients with stroke is to stabilize the patient and to complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival.
Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention.
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
Acute management of patients with stroke is to stabilize the patient and to complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival.
Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention.
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
Celia Bradford talks about prevention and management of vasospasm after subarachnoid haemorrhage. This talk was recorded at Bedside Critical Care Conference 4.
Consulting at The Business Relationship Specialists (2)LuisSoaresCosta
The Business Relationship Specialists is a Global Network of Executive Coaches, Behaviour Modelling Trainers, Change Management and Cultural Transformation Consultants and Facilitators
Parkinsonism Puzzle - Case
Saya banyak belajar dari kasus ini, bersyukur mendapat kesempatan belajar dari kasus ini.
Menanti advis dan kesempatan berdiskusi dengan rekan sejawat & pembaca.
*Semoga selalu yang terbaik untuk pasien kita!
note: cerita lengkapnya di [https://neurobsession.wordpress.com/2015/02/05/parkinsonian-dementia-chapter1-organic-vs-psychogenic-the-debate/]
Kapan aneurysma yang belum ruptur memerlukan intervensi?
"In the decision-making process, the PHASES score may be considered for predicting a patient’s risk of aneurysm rupture."
Keunikan anatomi small vessel of the brain dan neurovascular unit, kontroversi peran stganasi vena dalam patofisiologi, klasifikasi small vessel disease, variasi kriteria diagnostik, pitfall dalam neuroimaging, pilihan antiplatelet untuk prevensi sekundar, dampaknya bagi outcome pasien, hubungannya dengan gangguan fungsi kognitif.
Hmm, apa lagi nih yang baru?
Hypertension Emergencies and their managementpptxUzomaBende
This Presentation talks about Hyprtension, the mode of presentation of hypertensive crisis and the effective management of hypertensive crisis to prevent case fatalities.
"Navigating Neurologic and Neurosurgical Emergencies: A Guide for Nursing Students"
🌟 Greetings, nursing students! Dr. Ganesh here, and today, we're embarking on a crucial journey into the realm of neurologic and neurosurgical emergencies. Whether you're on the path to becoming a registered nurse, nurse practitioner, or simply seeking foundational knowledge, this discussion is crafted to empower you in emergency care scenarios.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
3. Case
Scenario
• A
45
year
old
woman,
who
frequently
presents
with
migraine
reports
her
"worst
migraine
ever"
and
on
specific
ques9oning
reports
a
sudden
onset
occipital
headache
now
generalised
with
associated
vomi9ng.
She
requests
analgesia
and
an
an9eme9c
so
that
she
can
"sleep
it
off
at
home"
and
has
brought
her
son
to
drive
her
home.
4. Clinical
Features
• Sudden
onset
HA
that
lasts
1-‐2
weeks
(74%)
• Vomi9ng
(77%)
• Decreased
LOC
(53%)
• Nuchal
rigidity
(35%)
• Focal
deficit
(15%)
• Seizures
(7%)
5. • Missed
because
sudden,
severe
headache
is
not
present
in
25%
of
pa9ents
• 1
in
10
with
sudden
headache,
SAH
is
the
cause
• Missed
in
20-‐50%
of
pa9ents
at
first
presenta9on
6. Diagnosis
• CT
scan
AND
lumbar
puncture
if
scan
is
nega9ve
• If
SAH
is
found,
it
is
usually
followed
with
catheter
cerebral
angio
or
MR/CT
angio
to
document
the
anatomic
features
• CT
scan
detects
93-‐98%
of
SAH
10. Subarachnoid
Hemorrhage
• Common
and
devasta9ng
condi9on
affec9ng
younger
pa9ents
• Accounts
for
3-‐8%
of
all
strokes
• Responsible
for
25%
of
years
lost
due
to
stroke
• 7-‐20
per
100,000
people
annually
11. SAH
• Outcomes
are
poor
• Mortality,
50%
from
SAH
• Morbidity,
15%
severely
disabled
• Only
20-‐35%
of
pa9ents
will
have
moderate
to
good
recovery
12. SAH
• Incidence
stable
over
last
4
decades
• Incidence
increases
with
age
(mean
50
years)
• Females
more
than
males
(1.6
x)
• Black
North
Americans
higher
risk
than
white
13. Risk
factors
• HTN
• Heavy
alcohol
use
• Smoking
• Sympathomime9c
drugs
(cocaine)
• Previous
ruptured
aneurysm
• Congenital
– PCKD
– Ehlers
Danlos
type
IV
14. Preopera9ve
care
• Blood
pressure
should
be
monitored
and
controlled
–
balance
of
CPP
vs
HTN
induced
rebleed
• SBP
<
160
-‐
one
study
in
2001
(Ohkuma
et
al)
found
rebleeding
was
more
common
in
those
with
a
systolic
blood
pressure
160
mm
Hg
16. Vasospasm
• Common
post-‐opera9ve
complica9on:
– 3-‐5
days
post
SAH
– Resolu9on
over
2-‐4
weeks
– Radiographically
in
70%
of
pa9ents
– Clinically
apparent
in
20-‐30%
of
pa9ents
– 50%
of
symptoma9c
pts
will
progress
to
infarct
– 15-‐20%
will
have
a
disabling
stroke
or
die
of
ischemia
20. Nitric
oxide
• NO
is
a
potent
vasodilator
• NO
ac9vates
guanylyl
cyclase
to
ac9vate
cGMP-‐dependent
protein
kinases
• Dephosphoryla9on
of
myosin,
ac9va9on
of
K+
channels
and
closure
of
voltage-‐dependent
Ca2+
channels
=
smooth
muscle
relaxa9on
• Low
levels
in
SAH
–
free
Hb
mops
up
NO
21. Nitric
Oxide
• SAH
inhibi9on
of
NO
synthase
• ADMA,
endogenous
inhibitor
of
eNOS,
high
with
vasospasm
• NO
may
reverse
vasocontrictor
ET-‐1
effects
22. Endothelin-‐1
• ET-‐1
cleaved
by
endothelin
conver9ng
enzyme
to
ac9ve
form
• Potent
vasoconstrictor
(ETA
)
via
G-‐protein
secondary
messenger
• ET-‐1
produced
by
endothelial
cells
by
ischemia,
high
in
SAH
• Lower
levels
in
absence
of
vasospasm
23. Vasospasm
• Goals
of
management:
– Reduce
the
threat
of
ischemic
damage
• Control
ICP
• Decreasing
brain
metabolic
rate
• Improving
CBF
24. Standard
Therapy
• Preven9on
of
rebleed:
– by
securing
intracranial
aneurysm
within
24-‐48h
• Can
allow
SBP
to
rise
to
200
mmHg
• Avoid:
– hypovolemia,
hypotension,
anemia,
fever
and
increased
ICP
• Nimodipine
60
mg
Q4h
PO
for
21
days
– IV
form
in
Europe
but
no
difference
in
clinical
effect
[Kronvall
2009]
25. Standard
therapy
• Nimodipine
• Predominant
effect
is
not
through
a
decrease
in
angiographic
vasospasm
• Probably
acts
through
effects
on
microcircula9on
and
neuroprotec9on
• Nicardipine
does
reduce
vasospasm
but
did
not
affect
outcome
(Haley
1993)
27. Triple
H
Therapy
• Hypervolemia/
Hemodilu9on/
Hypertension
• At
first
sign
of
clinical
vasospasm:
– Hypervolemic
hemodilu9on
goal
hematocrit
33-‐38%
– CVP
10-‐12
mmHg
(PAWP
15-‐18
mmHg)
– SBP
160-‐200
mmHg
in
clipped
aneurysms
• Cohort
compared
to
literature
standards
28. Triple
H
Therapy
• Side
effects:
– Pulmonary
edema
– Cardiac
arrythmia
– Increased
risk
in
elderly
pa9ents
with
poor
cardiac
reserve
29. Triple
H
Therapy
• 1
randomized
trial
of
pa9ents
to
Hypervolemia
versus
normovolemia
post
clipping
• No
effect
on
CBF
or
vasospasm
30. Triple
H
Therapy
• Cochrane
review
in
2004
confirmed
as
no
solid
evidence
for
volume
expansion
31. Triple
H
Therapy
• Started
with
interven9ons
on
pig
model
and
then
took
protocol
to
pa9ents
post
SAH
32. • In
pigs
with
intact
BBB,
neither
HTN
or
hypervolemia
had
an
effect
on
ICP,
CBF
or
brain
oxygena9on
• BUT
in
pa9ents,
induced
HTN
(MAP
>130)
resulted
in
inc.
CBF
and
brain
oxygena9on
• Hypervolemia
had
minimal
to
no
effect
• HHH
combo
reversed
HTN
effects
on
brain
oxygena9on
33. Triple
H
Therapy
• “Standard
triple
H
therapy”
should
be
modified
– HTN
with
careful
volume
expansion
should
be
the
new
standard
35. Sta9ns
and
SAH
• Sta9ns
not
only
func9on
to
lower
cholesterol
but
are
also
potent
NO
inducers
and
down-‐
regulators
of
inflamma9on
• Observa9onal
studies
of
sta9n
use
in
pa9ents
were
encouraging
36.
37. Sta9ns
and
SAH
• 12-‐fold
increase
in
odds
of
surviving
SAH
if
previously
on
sta9ns
38. “Statin treatment reduces need for traditional rescue
therapy, and improved outcome in physical and
psychosocial function at 6 months”
39. “vasospasm morbidity and mortality
reduced by 83 and 75%, respectively”
“incidence and severity were reduced by 32%”
“duration of vasospasm was shortened by 0.8 days”
40. BUT…..
• Various
groups
added
the
therapy
into
their
“standard
care”
• Now
star9ng
to
get
reports
of
their
outcome
analyses
41. “All patients were started on a statin on
admission and no clinical difference was noted”
42. Sta9ns
• So
what
does
this
mean
for
the
use
of
Sta9ns:
– They
don’t
appear
to
be
a
good
rescue
tool
– But
if
you
were
on
it
for
>1
month
prior
to
event
there
is
an
11-‐fold
harm
reduc9on
43. Magnesium
• Calcium
antagonist
• Good
safety
profile
• Comparable
to
nimodipine
alone
• No
studies
adding
to
nimodipine
44. Magnesium
• 34%
Reduc9on
in
delayed
cerebral
ischemia
• 23%
Reduc9on
in
poor
outcome
at
3
months
45. Clazosentan
• ETA
antagonist
in
Phase
II
trial
• CONSCIOUS-‐1
study
• Decreased
incidence
of
vasospasm,
DIND,
and
infarcts
on
CT
in
dose-‐dependent
manner
• BUT,
no
reduc9on
in
mortality
(underpowered)
• CONSCIOUS-‐2,
currently
enrolling
46. NO
donors
• Gene
therapy
–
way
too
experimental
• Intraventricular
administra9on
of
sodium
nitroprusside
tried
in
10
pa9ents
with
medically
refractory
vasospasm
–
3
pts
had
excellent
outcome
• More
to
come
47. EPO
• May
be
“neuroprotec9ve”
• May
prevent
vasospasm
by
increasing
ac9va9on
of
eNOS
–
NO
donor
• S9ll
preliminary
48. Conclusion
• SAH
is
a
devasta9ng
problem
affec9ng
younger
popula9on
• Vasospasm
is
a
known
poten9ally
modifiable
problem
with
significant
morbidity
and
mortality
49. Conclusion
• Preven9on
of
vasospasm:
– Oral
nimodipine
is
of
proven
benefit
– Star9ng
a
sta9n
–
jury
s9ll
out
– If
a
pa9ent
is
on
a
sta9n,
con9nue
it
ASAP
• Rescue
therapy
for
vasospasm
is
beuer
coined
as
“Hypertensive
therapy”
with
judicious
volume
maintenance
50. Conclusion
• Magnesium
therapy
may
be
of
benefit
if
added
to
nimodipine
or
if
nimodipine
is
contraindicated
• There
are
specific
targets
s9ll
under
inves9ga9on
and
therapies
in
the
pipeline
but
not
ready
for
prime-‐9me