Articles: function.
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Dtsch. Med. Wochenschr. · Jan 2001
[Myocardial infarction and coronary artery ventricular fistulas due to blunt chest trauma]
An 18-year-old previously healthy, cigarette smoking man with no other risk factors for ischaemic heart disease, was admitted to hospital after being kicked in the chest by a horse. On arrival he complained about pain in the lower mediastinum. INVESTIGATIONS: The ECG showed sinus rhythm, right bundle branch block and convex bowed ST elevation in leads V1-V3. Sixty minutes after the incident the cardiac enzymes (creatinekinase-MB fraction, troponin I) were significantly raised. Despite an only slightly reduced left ventricular function documented by transthoracic echocardiography, SPECT-thallium scan showed large scintigraphic defects. Coronary heart disease was excluded by coronary angiography. Four small coronary-ventricular fistulas were identified. Laevocardiography showed a hypokinesia in the antero-septal region. DIAGNOSIS, TREATMENT AND COURSE: We assumed traumatic myocardial infarction of the anterior wall and rupture of multiple small coronary vessels, leading to coronary-ventricular fistulas. No interventional or surgical therapy was performed. Later on the left ventricular function became normal. Echocardiography merely outlined an akinetic scar in the middle of the septum. At exercise ECG test sixteen months later, the patient remained asymptomatic and was able to exercise without any signs of ischaemia up to a work load of 175 W. Furthermore, the fistulas could be seen by echocardiography. ⋯ Cardiac involvement should be considered in all cases of blunt chest trauma. In addition to a traumatic myocardial infarction fistulas may also, though rarely, occur. Myocardial scintigraphy after cardiac contusion is not suitable for diagnosing myocardial ischaemia or vitability.
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To review the recent pharmacokinetic and pharmacodynamic reports of some of the commonly used antibiotics in critically ill patients and recommend alterations in their administration to improve their efficacy. ⋯ Applying pharmacokinetic and pharmacodynamic principles to critically ill patients will lead to better antibiotic use and hopefully a better outcome.
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In past years, cerebral monitoring was mostly focused around global cerebral perfusion and metabolism monitoring, with the use of transcranial Doppler recordings, jugular bulb oximetry and near-infrared spectroscopy. Most of the recently introduced cerebral monitoring modalities, such as brain tissue partial oxygen tension monitoring and cerebral microdialysis, offer new opportunities by providing regional information on the specific brain area in which the probe is inserted. ⋯ In this case, the combination of global and regional cerebral monitoring might offer the best information on which to base patient management. Also, the introduction of more clinically useful, functional neuroimaging techniques may be a valuable adjunct to future neurological critical care management.
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Internal disc disruption is a common cause of disabling low back pain in a substantial number of young, healthy adults. A clinical diagnosis of internal disruption, in absence of objective clinical findings, is convincingly established only by means of provocation discography. Intradiscal electrothermal therapy has been shown to be effective in managing chronic disabling discogenic pain. ⋯ Further, the assessment of functional status showed significant improvement with standing and walking, whereas sitting also demonstrated significant improvement in 62% of the patients, though it was not statistically significant. No complications were noted in the perioperative period or during the follow-up period. In conclusion, intradiscal electrothermal therapy is a safe and effective procedure in patients suffering with chronic functionally limiting discogenic pain who fail to respond to aggressive conservative modalities of treatments as well as interventional therapy with injections.
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The somatosensory system of preterms and newborns differs substantially from adults. These differences are of considerable preclinical and clinical interest. Maturation of A- and C-fibre synaptic connections in the dorsal horn and development of descending inhibition from the brainstem all take place postnatally in the rat. In early stages of development there is no definite spatial separation in the dorsal horn between the nociceptive and the non-nociceptive system. In preterms but not in adults non-noxious stimuli can induce central sensitization. Many neurotransmitters and signalling molecules involved in pain pathways are expressed early in the developing nervous system but do not reach adult levels for a considerable period. More important, receptors are frequently transiently overexpressed or expressed in areas during development where they are not seen in the adult and may have a different functional profile. The descending pain inhibitory system that provides an important protection against central sensitization develops later than the ascending nociceptive system. Thus, during a critical period of time the immature nociceptive system is highly vulnerable. For example, neonatal circumcision in the absence of analgesia results in increased pain responses during subsequent routine vaccination months later. ⋯ In view of the changing nature of neonatal somatosensory and pain pathways and the vulnerability of the developing nervous system to alterations in sensory stimulation it is important that preterms and newborns need the care of a specialist for prevention and treatment of pain to avoid suffer and long-term changes in the nervous system.