Minerva medica
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This is a review of the management of septic shock that suggests an approach to treatment (ABCDEF: Airway, Breathing, Circulation, Drugs, Evaluate the source of sepsis, Fix the source of sepsis) for clinicians. The incidence of septic shock is increasing and mortality ranges from 30% to 70%. The commonest sources of infection are lung (25%), abdomen (25%), and other sources. ⋯ There was no difference in mortality (39.2% hydrocortisone vs 36.1%) or organ dysfunction. Several randomized controlled trials of intensive insulin versus conventional insulin in the critically ill have yielded conflicting results and do not support the routine use of intensive insulin in the ancillary management of septic shock. A recent randomized controlled trial of intensive versus less intensive renal support in patients who had acute kidney injury found no difference in mortality (53.6% vs 51.5% respectively), duration of renal support, or rates of recovery of renal and non-renal organ dysfunction.
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Acute coronary syndromes (ACS) encompasses a spectrum of coronary heart diseases, ranging in severity from unstable angina to ST-elevation myocardial infarction (STEMI). Early diagnosis and risk stratification are needed in order to address correctly hospitalization and treatment. Although the diagnosis of STEMI in the presence of typical electrocardiogram (ECG) changes and symptoms is easy and does not require the use of biomarkers, cardiac biomarkers are particularly important in the Emergency Department (ED), where about 25% of patients admitted are affected by ACS but clinical presentation is often atypical and ECG alterations may be absent. ⋯ Classic cardiac biomarkers, like myoglobin, cardiac troponin T or I and creatine kinase-MB, have a poor sensitivity, dependent on the time past from the onset of symptoms to presentation, the duration of ischemia and the amount of myocardial tissue involved. Although the serial testing of these cardiac biomarkers can improve the detection of myocardial necrosis, there is still a need for the development of early markers that can reliably rule out ACS from the ED at presentation and also detect myocardial ischemia in the absence of irreversible myocyte injury. There are several markers which represent the different features of ACS pathogenesis and that can be divided into three major groups: markers of cardiac ischemia and necrosis, markers of inflammation and coronary plaque instability and marker of cardiac function.
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Carotid artery stenosis is one of many risk factors of stroke and transient ischaemic attack. Asymptomatic and symptomatic carotid stenoses behave differently and they should be considered as different disease entities. This review provides an up-to-date overview of the evidence base for the management of patients with asymptomatic and symptomatic carotid stenosis. ⋯ Early trials of endovascular treatment suggested that endovascular treatment may be equally effective as surgery, but subsequent trials have shown very mixed results and offering carotid stenting routinely is not recommended. In patients with asymptomatic carotid stenosis, two landmark trials have shown benefit of surgery over medical treatment particularly in young men. Again it has to be kept in mind that medical treatment has much improved since the surgery trials were conducted.
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Some authors have proposed an updating of the therapeutic recommendations for some kinds of pain, such as musculoskeletal, post-traumatic and post-surgical pain for which a multimodal approach is being increasingly considered. With regard to this, an association of analgesics belonging to different pharmacological classes becomes an important option, given that analgesic efficacy can be ensured using lower dosages of single components, improving the tolerability of the drugs. The fixed combination of paracetamol (325 mg) and tramadol (37.5 mg) has a precisely dose ratio to obtain an additive analgesic effect, improving both the analgesic efficacy, which is more stronger and complete, and the duration of the action, guaranteeing a quick analgesic effect over time. ⋯ Rigorous studies were conducted also for chronic pain; in the 6 studies considered the duration of treatment was 4-13 weeks and a total of 1 890 patients, affected by chronic musculoskeletal pain, were admitted. The mean daily dose of paracetamol/tramadol was between 3.5 and 4.2 tablets/day, showing itself to be constant and independent of the disease considered. In conclusion, the fixed association paracetamol/tramadol is a new therapeutic option, particularly useful in mild-moderate pain where paracetamol is inadequate.