Hospital Chronicles (E-Journal)
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Pulmonary Embolism: Clinical Features and Diagnosis
Get PDFPulmonary embolism is a lethal yet treatable disease. Given the significant overlap of symptoms and signs between the presentation of pulmonary embolism and acute coronary syndromes, it becomes clear that emergency room physicians must be familiar with the diagnosis of pulmonary embolism. A critical issue is always to consider pulmonary embolism in the differential diagnosis of chest pain. However, the clinical diagnosis of pulmonary embolism remains problematic due to the nonspecific presenting symptoms, signs, electrocardiographic abnormalities, arterial blood gas and chest X-ray findings. D-dimers are becoming a widely available useful laboratory tool in the diagnosis of suspected pulmonary embolism. In this concise overview, the diagnostic value of clinical assessment in patients with possible pulmonary embolism will be explored
Impact of Glutamine Supplemented Total Parenteral Nutrition in
Get PDFBACKGROUND: The importance of the metabolic role of glutamine has been demonstrated in several laboratory and clinical studies. A number of publications have addressed issues relevant to the benefits of the parenteral use of glutamine in patients with a variety of conditions. OBJECTIVE: To review published evidence of the relationship between glutamine supplemented total parenteral nutrition (TPN) and infection rates, length of hospital stay, nitrogen balance, total lymphocyte count and mortality in patients undergoing elective surgery. MATERIAL AND METHODS: 146 titles, abstracts, and articles were reviewed. Those primary studies were included that were randomized trials of surgical patients requiring TPN. The effect of glutamine enriched TPN (Gln-enriched TPN) regimen vs. standard TPN regimen on clinical and biological outcomes was evaluated. RESULTS: Eight randomized trials were found. When the results of these trials were analyzed with respect to infection, Gln-enriched TPN was associated with a relative risk ratio (RR) of 0.368 (95% CI, 0.162-0.832, p=0.016). Gln-enriched TPN was also associated with reduced length of hospital stay (1.191 days less; 95% CI 0.395- 1.986, p=0.004), better cumulative nitrogen balance (2.568gr; 95% CI 1.274-3.863, p=0.000), an increase in total lymphocyte count (2.246 /?¬L; 95% CI 0.416-4.076, p=0.017), and a reduction in mortality rate (RR 0.723; 95% CI 0.174-3.012, p=0.656). No side-effects were reported. CONCLUSION: There is strong evidence that a benefit from Gln-enriched TPN may exist for surgical patients in terms of length of hospital stay, infection rate, total lymphocyte count and cumulative nitrogen balance. The benefit from glutamine-enriched TPN on mortality was not found to be statistically significant
Erythrocyte and Liver Porphobilinogen Deaminase in Cirrhosis and Clinical or Experimental Cholestasis
Get PDFBACKGROUND? ? Porphobilinogen deaminase, the third enzyme in the haem synthetic process -mainly expressed in the erythrocytes and liver - has a key role in the pathogenesis of the acute porphyrias.DESIGN AND RESULTS We studied the effect of cirrhosis or cholestasis on this enzyme activity and found that:1. Erythrocyte porphobilinogen deaminase was significantly increased (p=0.0003) in 27 patients with non-alcoholic liver cirrhosis (19.89?±6.65 ??moles/h.l) and 24 patients with extrahepatic cholestasis (20.69?±11.17 ??moles/h.l) as compared to 30 controls (12.77?±4.76 ??moles/h.l). Its activity was positively correlated to the prothrombin time in both patient groups and negatively to the alkaline phosphatase in the cholestasis group.2. Erythrocyte porphobilinogen deaminase of controls significantly increased when their plasma was substituted by that of patients with cholestasis (p lt; 0.001) or cirrhosis (p=0.05), although it remained lower than that of the latter. No change was observed in samples from patients with cirrhosis or cholestasis when their plasma was substituted by that of controls.3. In 8 rabbits, cholestasis produced by ligation of the common bile duct significantly increased porphobilinogen deaminase both in the erythrocytes (from 30.26?±10.33 to 48.87?±15.82 nmoles/h.l, p=0.002) and the liver (from 13.27?±4.79 to 17.68?±5.42 nmoles/h.g, p=0.035). In 8 sham-operated rabbits erythrocyte porphobilinogen deaminase also increased (from 29.60?±9.85 to 33.32?±12.23 nmoles/h.l, p=0.016), but to a significantly lower degree than that of the ???cholestatic?? group (111.10?±10.95 % versus 167.96?±41.64% p=0.006) while the hepatic enzyme remained unchanged (from 13.40?±3.85 to 13.83?±7.21 nmoles/h.g, p=0.80).4. In 5 patients with cholestasis the mean hepatic PBG-D activity was higher than in the 5 controls (12.63?±3.24 versus 9.64?±1.17 nmoles/h.g), although not significantly higher (p=0.11).CONCLUSION PBG-D activity is considerably increased in liver cirrhosis and clinical or experimental cholestasis. It seems probable that plasma factors may play a role in this effect by inducing PBG-D activity
ECG Changes Associated With Right-Sided Pneumothorax
Get PDFVarius ECG changes have been described with pneumothorax, most often left-sided.We present a case of spontaneous right-sided pneumothorax, presenting with an ECG suggestive of an old myocardial infarction. A chest X-ray confirmed the diagnosis of pneumothorax, while an echocardiogram and serial cardiac enzyme testing excluded myocardial infarction (old or recent). ECG changes returned to normal after chest tube insertion and airdrainage. Physicians must be familiar with the ECG changes that can be caused by pneumothorax in order to avoid diagnostic and therapeutic pitfalls
ECG Changes and Voltage Attenuation in Congestive Heart Failure
Get PDFThe electrocardiogram (ECG) is invaluable in providing diagnosis, prognosis, and information for decision making in the management of patients with congestive heart failure (CHF). In addition to the traditional applications of the ECG, which are of importance in the management of patients with CHF, and include indeed the bulk of ECG derived information, a recently described association of peripheral edema with attenuated ECG voltage, provides an expanded dimension in diagnostics. These attenuations result in decreased amplitude of QRS complexes, P-waves, and shortened duration of QRS complexes and QT intervals, with significant diagnostic implications.Alleviation of peripheral edema in response to diuresis in patients with CHF reverses all above alterations
Cost Effectiveness of Drug Eluting Stents
Get PDFDrug eluting stents (DES) have ushered in a new era in non-surgical coronary revascularization with substantially reduced rates of restenosis, albeit at an increased expense for our health care system incurred by their higher cost compared to bare metal stents (BMS) and by a high demand of these devices by both physicians and patients. The risk of late thrombosis and other safety issues will need to be further investigated. The cost-effectiveness of DES depends on the features of the target population, the higher DES cost, any remaining safety issues and the specific treatment comparator (BMS, surgical or medical therapy). According to the data of economic analyses and clinical trials, DES will be reasonably cost-effective for a great percentage of patients and even cost saving for the subgroup of patients who are at high risk of clinical restenosis with the conventional PCI techniques. The main limitation of wider application of DES in the daily interventional practice remains their high price, which if lowered in the future will broaden their target population in interventional cardiology
Audit of parenteral nutrition: standard parenteral nutrition regimens -feast or famine?
Get PDFBackground: Adequate nutrition of patients at a surgical unit is of great importance since both over- and undernutrition can lead to serious morbidity and even mortality. Surgical patients are frequently unable to meet nutritional needs by the enteral route and the use of SPN regimens is a common practice. Compared with patient-specific prescriptions, SPN solutions require fewer nutritional calculations, are less expensive, more convenient and offer greater biochemical stability. However, the accuracy and consistency with which these regimens meet patients??? nutritional requirements remain unclear and are undefined in the literature. To examine whether patients at a surgical unit are adequately fed with SPN regimens, 13 surgical patients were prospectively followed- up and a comparison was made between the nutrients prescribed with the SPN solutions and the nutrients calculated individually for each patient. Mat erial and Methods: The exact amounts of macronutrients calculated and prescribed with the SPN regimens were collected. To calculate individualised nutritional requirement the Schofield equation was used with adjustment for activity and stress. Elia???s recommendation was used for protein requirements. Fat/carbohydrate calories were calculated. Anthropometry was used to estimate patients??? nutritional status. Prescribed and calculated energy, nitrogen, fat and carbohydrate were compared using Wilcoxon signed rank tests. Spearman???s rho correlations were calculated. Results : Statistically significant difference was found between fat (sig.=0,001), carbohydrate (sig.=0,05) and energy (sig.=0,03) provided by SPN regimens and the ones calculated. No statistically significant difference was found between delivered and calculated nitrogen. ConclusionS: For short-term feeding, the potential benefits of SPN regimens may outweigh the risks associated with carbohydrate deficit and fat and energy excess. However, for longer-term feeding these risks may become clinically significant. Some improvement of the quality of feeding can be established by calculating nutritional requirements and by assessing the patients??? nutritional status before commencing PN
Littoral cell angioma of the spleen accompanied by haemophagocytic syndrome in a dialysis patient suffering from aa amyloidosis
Get PDFLittoral cell angioma (LCA) is a rare form of vascular tumor unique to the spleen that arises from the specialized endothelial cells that line the splenic sinuses (littoral cells). Haemophagocytic syndrome (HS) is also a rare hematologic disorder that some times accompanies LCA. The authors describe a young dialysis patient with a history of familiar mediteranean fever and secondary amyloidosis who was found to have this rare association of AA amyloidosis with LCA and haemophagocytic syndrome
Aspirin and Clopidogrel: Lessons from PCI-CLARITY, COMMIT & CHARISMA
Get PDFPlatelet activation plays a critical role both in spontaneous coronary artery thrombosis due to atherosclerotic plaque rupture and in thrombotic complications following percutaneous coronary intervention (PCI) with coronary artery stenting. Aspirin use has been shown to safely reduce ischemic events throughout the spectrum of clinical conditions of coronary artery disease (CAD). Therefore, aspirin is part of the standard treatment given to patients with CAD, including those undergoing PCI. Despite the inhibition of cyclooxygenase by aspirin, however, platelet activation can still occur through thromboxane-independent pathways, leading to the aggregation of platelets and the formation of thrombin. For that reason, a more potent antiplatelet effect was sought by using other agents ??? thienopyridines (ticlopidine, clopidogrel) and glycoprotein IIb/IIIa (GpIIb/IIIa) inhibitors, usually in combination with aspirin. Indeed, depending on the clinical scenario and the concomitant anticoagulants used, regimens combining 2 or more of these antiplatelet agents have resulted in fewer ischemic events and sometimes more bleeding events compared with aspirin alone
Migraine Headaches: The Immunologist's View
Get PDFObjective: Review evidence supporting the role of mast cells in migraine pathophysiology.Background: Mast cells are known for their role in allergic reactions, but they are also important in immunity and inflammatory diseases, especially those precipitated or worsened by stress. Such are migraine headaches that are associated with spreading neuronal depression and neurogenic inflammation intracranially. Migraines are also comorbid with allergies and could precipitate acute coronary syndromes (ACS). Mast cells are located perivascularly, in close association with neurons, especially in the meninges. Mast cells can be activated by trigeminal nerve stimulation and by acute stress, leading to increased vascular permeability and neurogenic inflammation dependent on NK-1 receptors, but not necessarily on substance P (SP). Methods: We reviewed relevant literature and summarized our own findings.Results: Corticotropin-releasing hormone (CRH), a mediator of the stress response released from the hypothalamus, can activate CRH receptors either on the sensory nuclei of the trigeminal nerve or directly on the mast cells. They, then release proinflammatory, nociceptive and vasoactive mediators including histamine, tryptase and vascular endothelial growth factor (VEGF), thereby triggering migraine headaches.  Conclusions: These results indicate that there are several novel points of intervention for the development of therapeutic agents to help alleviate migraines. Preliminary clinical studies with brain mast cell blockers and CRH receptor antagonists suggest that they could be useful prophylactically