Swiss medical weekly
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Elevation of the mean pulmonary arterial pressure to ≥25 mm Hg within the low-pressure system of the pulmonary circulation is defined as pulmonary hypertension. Pulmonary hypertension may be the consequence of various clinical and pathophysiological entities. ⋯ Remodelling is arguably the most important factor: its complex pathogenesis is not completely understood and no specific treatment directly targets vascular remodelling. This article aims to review the current understanding of the pathogenesis of pulmonary hypertension and to give insights in future developments in this evolving field.
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Swiss medical weekly · Jan 2015
ReviewBiomarker-guided personalised emergency medicine for all - hope for another hype?
Polymorbid patients, diverse diagnostic and therapeutic options, more complex hospital structures, financial incentives, benchmarking, as well as perceptional and societal changes put pressure on medical doctors, specifically if medical errors surface. This is particularly true for the emergency department setting, where patients face delayed or erroneous initial diagnostic or therapeutic measures and costly hospital stays due to sub-optimal triage. A "biomarker" is any laboratory tool with the potential better to detect and characterise diseases, to simplify complex clinical algorithms and to improve clinical problem solving in routine care. ⋯ The rational for the use of all these biomarkers, first, tackle diagnostic ambiguity and consecutive defensive medicine, second, delayed and sub-optimal therapeutic decisions, and third, prognostic uncertainty with misguided triage and site-of-care decisions all contributing to the waste of our limited health care resources. A multifaceted approach for a more targeted management of medical patients from emergency admission to discharge including biomarkers, will translate into better resource use, shorter length of hospital stay, reduced overall costs, improved patients satisfaction and outcomes in terms of mortality and re-hospitalisation. Hopefully, the concepts outlined in this review will help the reader to improve their diagnostic skills and become more parsimonious laboratory test requesters.
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Swiss medical weekly · Jan 2015
Review"The obesity paradox" in disease--is the protective effect of obesity true?
Although obesity and the associated metabolic syndrome negatively impact on health outcomes, a paradoxical relationship between obesity and mortality has been reported for specific patient populations - the "obesity paradox". However, underlying mechanisms remain unclear and several possible explanations are being discussed. ⋯ Second, a statistical bias is possible, owing to confounding, selection bias, performance bias and measurement bias of most observational studies reporting the obesity paradox. Within this article, we summarise current concepts regarding the underlying pathophysiology and possible explanation for the obesity paradox, and discuss open questions such as whether age is an effect modifier on the relationship of obesity and mortality.
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Swiss medical weekly · Jan 2015
Pulseless electrical activity cardiac arrest: time to amend the mnemonic "4H&4T"?
Pulseless electrical activity (PEA) cardiac arrest is characterised by a residual organised electrical activity. PEA is frequently induced by reversible conditions. The mnemonic "4H&4T" was proposed as a reminder to assess for Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia, Hypothermia, Thrombosis, cardiac Tamponade, Toxins, and Tension pneumothorax. Other potential aetiologies have been identified, but their respective probability and frequencies are unclear. The aim of this study was to analyse the aetiologies of PEA out-of-hospital cardiac arrests and to evaluate their relative frequencies. ⋯ Intracranial haemorrhage and nonischaemic cardiac disorders represent significant causes of PEA, with a prevalence equalling or exceeding the frequency of classical 4H&4T aetiologies. These conditions are potentially accessible to simple diagnostic procedures (computed tomography or echocardiography).