Inhospital management of AIS slides'19.pptxAbushuMohammed
The main goals in the initial phase of acute stroke management are to ensure medical stability, to quickly reverse conditions that are contributing to the patient's problem, to determine if patients with acute ischemic stroke are candidates for reperfusion therapy, and to begin to uncover the pathophysiologic basis of the neurologic symptoms.
Austin Spine is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Spine.
The journal aims to promote latest information and provide a forum for doctors, researchers, physicians, and healthcare professionals to find most recent advances in the areas of Spine. Austin Spine accepts research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of Spine.
Austin Spine strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Inhospital management of AIS slides'19.pptxAbushuMohammed
The main goals in the initial phase of acute stroke management are to ensure medical stability, to quickly reverse conditions that are contributing to the patient's problem, to determine if patients with acute ischemic stroke are candidates for reperfusion therapy, and to begin to uncover the pathophysiologic basis of the neurologic symptoms.
Austin Spine is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Spine.
The journal aims to promote latest information and provide a forum for doctors, researchers, physicians, and healthcare professionals to find most recent advances in the areas of Spine. Austin Spine accepts research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of Spine.
Austin Spine strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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.
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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
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
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4. Terminologies
Classes Of Study
Class 1
Good Quality randomize control Trials
(RCT)
Class 2
Moderate RCT and Good Quality
cohort/Case Control Study
Class 3
Low Quality RCT or Moderate to low
Cohort/Case control Study
Levels Of Recommendation
Level 1
High Quality of body of evidence
Level II A
Moderate Quality of body of evidence
Level II B & III
Low quality of body of evidence
5. Types of Traumatic Brain Injury(TBI)
Epidural Hematoma
Sub Dural Hematoma
Diffuse axonal injury
Cortical Contusions
6. Decompressive craniotomy
Cerebral edema Raised ICP Cerebral Herniation
Decompressive craniotomy Improvement in outcome in specific TBI patient
Data Randomized Control Trials (RCTs)
Variation in surgical technique , Timing and patient populations
7. Summary Of Evidence
31 relevant studies reviewed
Question addressed
1) DC vs Medical Management
2) DC of different sizes in term of their effect on patient mortality and function
3) Comparison OF DC TO Craniotomy
4) Use of DC earlier or later in the course of treatment
➢ Q 1&2 addressed by class 2 evidence
➢ Q 3&4 addressed by class 3 evidence
8. Recommendation
Level 1 Insufficient evidence
Level 2 Bifrontal DC is not recommended
Large Frontotemporoparoietal DC Recommended Over Small
9. Prophylactic Hypothermia
Standard of care for neuroprotection after cardiac arrest from acute coronary
syndromes.
Well known for its ability to reduce intracranial pressure.
Risks, including coagulopathy and immunosuppression, and profound
hypothermia bears the additional risk of cardiac dysrhythmia and death
Prophylactic Vs therapeutic Hypothermia
10. Summary of Evidence
14 Potentially relevant Studies reviewed
Question Addressed
1) hypothermia versus normothermia (7 RCTs, Clifton 1993,2001)
2) shorter versus longer periods of cooling (1 RCTs, Jiang 2006)
3) head-only versus systemic cooling (1RCTs, Liu 2006)
11. Prophylactic Hypothermia
Recommendations
Level I and II A
• There was insufficient evidence to support a Level I or II A recommendation for
this topic.
Level II B
• Early (within 2.5 hours), short-term (48 hours post-injury) prophylactic
hypothermia is not recommended to improve outcomes in patients with diffuse
injury
12. Hyperosmolar Therapy
Monoro, Kellie
Weed and McKibben
Mannitol and hypertonic saline
Brains dehydration
Improve micro circulatory flow
Constriction of pial arteriols
13. Hyperosmolar Therapy
Summary Of Evidence
8 new studies reviewed.
includedclass 2 study, Data Collected from 22 Trauma Center
Comparative effectiveness of different hyperosmolar agent studied
Quality of evidence –Insufficient
Recommendations
Level I, II, and III
• Although hyperosmolar therapy may lower intracranial pressure, there was
insufficient evidenceabout effects on clinical outcomes to support a specific
recommendation, or to support use of any specific hyperosmolar agent, for patients
with severe traumatic brain injury.
14. Cerebrospinal Fluid Drainage
External ventricular drainage (EVD) _Controversial Topic
Closed position – monitoring of ICP
Open position –Drainage of CSF
Key Variable- Patient age
Pediatric population-continuous CSF drainage
Adult Population-three pattern of practice
15. Cerebrospinal Fluid Drainage
Summary of evidence
12 new studied reviewed
2 question addressed
(1) whether continuous or intermittent CSF drainage is superior at reducing ICP2
(2) whether use of CSF drainage is associated with lower mortality
Quality of evidence -No
Recommendation
Level I and II
•There was insufficient evidence to support a Level I or II recommendation for this topic.
Level III
• An EVD system zeroed at the midbrain with continuous drainage of CSF may be considered to
lower ICP burden more effectively than intermittent use. • Use of CSF drainage to lower ICP in
patients with an initial Glasgow Coma Scale (GCS)
16. Ventilation therapies
Definite Airways protection
Transient hyperventilation for treatment of imminent herniation
Normal ventilation is goal
PaCO2 most powerful determinant of CBF(20-80mmHg)
17. Ventilation therapies
Quality of evidence
Four study reviewed
1 RCT – Low quality of evidence
Recommendations
Level I and II A
• There was insufficient evidence to support a Level I or II A recommendation for
this topic.
Level II B
• Prolonged prophylactic hyperventilation with partial pressure of carbon
dioxide in arterial blood (PaCO2) of 25 mm Hg or less is not recommended
18. Anesthetics, Analgesic, and sedatives
Commonly used for prophylaxis or control of ICH and seizures
Barbiturates
Decrease CMRO2
Improved coupling of regional blood flow – decrease CBV
Inhibit oxygen radical per oxidation
S.E hypotension, decrease COP
, increase intra pulmonary shunting
19. Anesthetics, Analgesic, and sedatives
Summary Of Evidence
9 Studied reviewed
3 questions address
(1) Does the prophylactic use of barbiturates improve outcomes,
(2) can barbiturates be used to reduce intracranial hypertension
(3) does the use of sedatives improve outcomes?
Class 2 Studies – Level of evidence low
20. Anesthetics, Analgesic, and sedatives
RECOMMENDATIONS
Level I and II A •
There was insufficient evidence to support a Level I or Level IIA recommendation for
this topic
Level II B
•Administration of barbiturates to induce burst suppression measured by EEG as
prophylaxis against the development of intracranial hypertension is not
recommended.
• High-dose barbiturate administrationis recommended to control elevated ICP
refractory to maximum standard medical and surgical treatment. Hemodynamic
stability is essential before and during barbiturate therapy.
• Although propofol is recommendedfor the control of ICP, it is not recommended for
improvement in mortality or 6-month outcomes. Caution is required as high-dose
propofol can produce significant morbidity
21. Steroids
Introduce in early 1960s as treatment of brain edema
Useful in
Restoration of altered vascular permeability
Reduction of CSF production
Attenuation of free radicals production
Glucocorticoids useful in patient with brain tumor
22. Steroids
Summary of evidence
4 new studies reviewed
Land mark study
Crash Trial
RECOMMENDATIONS
Level I
• The use of steroids is not recommended for improving outcome or reducing
ICP
. In patients with severe TBI, high-dose methylprednisolone was associated
with increased mortality and is contraindicated
23. Nutrition
RECOMMENDATIONS
Level I
• There was insufficient evidence to support a Level I recommendation for this
topic. 85
Level II A
• Feeding patients to attain basal caloric replacement at least by the fifth day
and, at most, by the seventh day post-injury is recommended to decrease
mortality.
Level II B
• Transgastric jejunal feeding is recommended to reduce the incidence of
ventilatorassociated pneumonia.
24. Infection Prophylaxis
RECOMMENDATIONS
Level I
• There was insufficient evidence to support a Level I recommendation for this topic.
Level II A
• Early tracheostomy is recommended to reduce mechanical ventilation days when the overall
benefit is felt to outweigh the complications associated with such a procedure. However, there is
no evidence that early tracheostomy reduces mortality or the rate of nosocomial pneumonia.
• The use of povidone-iodine (PI) oral care is not recommended to reduce ventilatorassociated
pneumonia and may cause an increased risk of acute respiratory distress syndrome.
Level III
• Antimicrobial-impregnated catheters may be considered to prevent catheter-related infections
during EVD
25. Deep Vein Thrombosis prophylaxis
RECOMMENDATIONS
Level I and II
• There was insufficient evidence to support a Level I or II recommendation for
treatment of deep vein thrombosis (DVT) in severe TBI patients.
Level III
• Low molecular weight heparin (LMWH) or low-dose unfractioned heparin may
be used in combination with mechanical prophylaxis. However, there is an
increased risk for expansion of intracranial hemorrhage
26. Seizure prophylaxis
RECOMMENDATIONS
Level I
• There was insufficient evidence to support a Level I recommendation for this
topic.
Level II A
• Prophylactic use of phenytoin or valproate is not recommended for preventing
late PTS.
• Phenytoin is recommended to decrease the incidence of early PTS (within 7
days of injury), when the overall benefit is felt to outweigh the complications
associated with such treatment. However, early PTS have not been associated
with worse outcomes
27. Intracranial Pressure (Monitoring)
RECOMMENDATIONS
Level I and II A
• There was insufficient evidence to support a Level I or II A recommendation for
this topic. 133
Level II B
• Management of severe TBI patients using information from ICP monitoring is
recommended to reduce in-hospital and 2-week post-injury mortality
28. Cerebral Perfusion Pressure (Monitoring)
RECOMMENDATIONS
Level I
• There was insufficient evidence to support a Level I recommendation for this
topic.
Level II B
• Management of severe TBI patients using guidelines-based recommendations
for CPP monitoring is recommended to decrease 2-week mortality
29. Advanced Cerebral Monitoring
RECOMMENDATIONS
Level I and II
• There was insufficient evidence to support a Level I or II recommendation for
this topic. 152 (Although patients with desaturations identified with advanced
cerebral monitoring have poorer outcomes,Level II evidence showed no
improvement in outcomes for monitored patients.) Level III
• Jugular bulb monitoring of arteriovenous oxygen content difference (AVDO2),
as a source of information for management decisions, may be considered to
reduce mortality and improve outcomes at 3 and 6 months post-injury
30. Blood Pressure (Thresholds)
RECOMMENDATIONS
Level I and II
• There was insufficient evidence to support a Level I or II recommendation for
this topic.
Level III
• Maintaining SBP at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm
Hg or above for patients 15 to 49 or over 70 years old may be considered to
decrease mortality and improve outcomes.
31. Intracranial Pressure Thresholds
RECOMMENDATIONS*
Level I and II A
• There was insufficient evidence to support a Level I or II A recommendation for
this topic.
Level II B
• Treating ICP above 22 mm Hg is recommended because values above this level
are associated with increased mortality
32. Cerebral Perfusion Pressure
RECOMMENDATIONS
Level I and II A
• There was insufficient evidence to support a Level I or II A recommendation for
this topic.
Level II B
• The recommended target cerebral perfusion pressure (CPP) value for survival
and favorable outcomes is between 60 and 70 mm Hg. Whether 60 or 70 mm Hg
is the 182 minimum optimal CPP threshold is unclear and may depend upon the
patient’s autoregulatory status.
Level III
• Avoiding aggressive attempts to maintain CPP above 70 mm Hg with fluids and
pressor may be considered because of the risk of adult respiratory failure.
33. Advanced Cerebral Monitoring
RECOMMENDATIONS
Level I and II
• There was insufficient evidence to support Level I or II recommendation for
this topic. 192
Level III
• Jugular bulb monitoring of arteriovenous oxygen content difference (AVDO2),
as a source of information for management decisions, may be considered to
reduce mortality and improve outcomes at 3 and 6 months post-injury