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Annals of Translational Medicine Sep 2018The hemodynamic effects of mechanical ventilation can be grouped into three clinically relevant concepts. First, since spontaneous ventilation is exercise. In patients... (Review)
Review
The hemodynamic effects of mechanical ventilation can be grouped into three clinically relevant concepts. First, since spontaneous ventilation is exercise. In patients increased work of breathing, initiation of mechanical ventilatory support may improve O delivery because the work of breathing is reduced. Second, changes in lung volume alter autonomic tone, pulmonary vascular resistance, and at high lung volumes compress the heart in the cardiac fossa similarly to cardiac tamponade. As lung volume increases so does the pressure difference between airway and pleural pressure. When this pressure difference exceeds pulmonary artery pressure, pulmonary vessels collapse as they pass form the pulmonary arteries into the alveolar space increasing pulmonary vascular resistance. Hyperinflation increases pulmonary vascular resistance impeding right ventricular ejection. Anything that over distends lung units will increase their vascular resistance, and if occurring globally throughout the lung, increase pulmonary vascular resistance. Decreases in end-expiratory lung volume cause alveolar collapse increases pulmonary vasomotor tone by the process of hypoxic pulmonary vasoconstriction. Recruitment maneuvers that restore alveolar oxygenation without over distention will reduce pulmonary artery pressure. Third, positive-pressure ventilation increases intrathoracic pressure. Since diaphragmatic descent increases intra-abdominal pressure, the decrease in the pressure gradient for venous return is less than would otherwise occur if the only change were an increase in right atrial pressure. However, in hypovolemic states, it can induce profound decreases in venous return. Increases in intrathoracic pressure decreases left ventricular afterload and will augment left ventricular ejection. In patients with hypervolemic heart failure, this afterload reducing effect can result in improved left ventricular ejection, increased cardiac output and reduced myocardial O demand. This brief review will focus primarily on mechanical ventilation and intrathoracic pressure as they affect right and left ventricular function and cardiac output.
PubMed: 30370276
DOI: 10.21037/atm.2018.04.29 -
Soins; La Revue de Reference Infirmiere 2020When medicine and humanities are dissociated and then reconciled, what is the meaning of "medical humanities" today? What are the strengths and weaknesses of the French...
When medicine and humanities are dissociated and then reconciled, what is the meaning of "medical humanities" today? What are the strengths and weaknesses of the French system? At a time when the link between the humanities and medicine seems more distended than ever, ten recommendations for developing and changing the way future doctors look at things are presented.
Topics: Education, Medical; France; Humanities; Humans; Schools, Medical
PubMed: 32245560
DOI: 10.1016/j.soin.2020.01.013 -
Journal of Obstetrics and Gynaecology... Jun 2016Congenital high airway obstruction syndrome (CHAOS) is a rare, usually lethal abnormality characterized by complete or near-complete intrinsic obstruction of the fetal...
INTRODUCTION
Congenital high airway obstruction syndrome (CHAOS) is a rare, usually lethal abnormality characterized by complete or near-complete intrinsic obstruction of the fetal airway. Laryngeal atresia is the most frequent cause, but other etiologies include laryngeal or tracheal webs, laryngeal cyst, subglottic stenosis or atresia, tracheal atresia and laryngeal or tracheal agenesis. When antenatal diagnosis of possible upper airway obstruction is made, specific type of obstruction is rarely determined making the term CHAOS introduced by Hedrick et al in 1994 more appropriate.
USG CHARACTERISTICS
Sonographic findings in CHAOS are characteristic and are secondary to high airway obstruction. The lungs are symmetrically enlarged, echogenic and homogenous. The distended lungs have mass effect on the diaphragm, which appears flattened or inverted, and the heart is displaced anteriorly in the midline. The heart often appears dwarfed by the surrounding enlarged lungs.
DISCUSSION
The primary abnormality is an intrinsic obstruction of the upper airway. Normal lung development involves a continuous efflux of fluid from the fetal lungs. Laryngeal atresia/CHAOS stops the efflux of this fluid, and this retained fluid distends the alveoli with fluid giving the lungs voluminous echogenic appearance and inverting the diaphragm. Isolated airway obstruction without hydrops has a relatively favorable prognosis. CHAOS with associated anomalies and with early presentation of hydrops is an ominous sign with a high rate of fetal demise and a poor survival rate even with the ex utero intrapartum treatment (EXIT) procedure.
PubMed: 27298534
DOI: 10.1007/s13224-016-0910-2 -
VideoGIE : An Official Video Journal of... Jan 2024Definitive peroral endoscopic treatment of pancreaticobiliary pathology in patients with surgically altered anatomy has recently been made more feasible by the use of... (Review)
Review
BACKGROUND AND AIMS
Definitive peroral endoscopic treatment of pancreaticobiliary pathology in patients with surgically altered anatomy has recently been made more feasible by the use of lumen-apposing metal stents (LAMS) to create bowel-to-bowel anastomoses. We aim to demonstrate 4 cases of non–gastric bypass Roux-en-Y anatomy for which an enteroenterostomy was created under EUS guidance to facilitate complex peroral ERCP.
METHODS
Akin to EUS-directed transgastric ERCP, the approach to EUS-directed transenteric ERCP involves identification and expansion of the target bowel before transmural puncture and stent placement. Bowel irrigation is used to opacify and distend the pancreaticobiliary limb in reasonable proximity to the papilla or biliary-enteric anastomosis, which facilitates enteroenterostomy creation via LAMS placement. Peroral ERCP can be performed through anastomosis, generally using a therapeutic gastroscope, once the transmural tract has matured.
RESULTS
In 4 cases of biliary obstruction, peroral ERCP was successfully performed after creation of an enteroenterostomy. In 3 of the 4 cases, target bowel opacification and distention were achieved by continuous irrigation through a previously placed percutaneous transhepatic cholangiography tube. In one case, a gastro-jejunostomy was created after irrigation of the target bowel loop via antegrade catheter advanced through a prior hepaticogastrostomy. No major adverse events occurred. In 2 of the 4 patients, the endoscopic objective (stone clearance) was met and the transenteric LAMS was removed. The other 2 patients are still undergoing serial ERCP.
CONCLUSIONS
EUS-guided enteroenterostomy permits safe and effective peroral ERCP, allowing for more efficient and effective treatment of pancreaticobiliary pathology in patients with surgically altered anatomy.
PubMed: 38239185
DOI: 10.1016/j.vgie.2023.09.007 -
Nuclear Medicine Communications Jun 2021Interpretation of gastrointestinal PET/computed tomography (PET/CT) is often complicated by anatomy including bowel folds, flexures, variant redundancy, decompressed...
Interpretation of gastrointestinal PET/computed tomography (PET/CT) is often complicated by anatomy including bowel folds, flexures, variant redundancy, decompressed bowel segments and physiological uptake. This makes it very difficult to identify both true positives and true negatives, compromising both sensitivity and specificity. CT enterography is increasingly being integrated into the field of nuclear medicine to address these issues. This technique uses the combination of negative/neutral contrast to distend the lumen of the gut and iodinated contrast to enhance the gastrointestinal wall and pathological findings. Apart from augmentation in the diagnostic performance, the technique also improves the quality of the imaging, confidence of the reporting physician and inter-rater agreement. Therefore, this technique has found favor among nuclear medicine physicians, in the imaging of chronic inflammatory disorders and malignancies in and of the gut. It is a feasible and easily executable procedure with minimal and manageable side-effects and should be routinely recommended in cases where interference from physiologic findings is expected.
Topics: Contrast Media; Humans; Positron Emission Tomography Computed Tomography; Retrospective Studies; Sensitivity and Specificity
PubMed: 33560721
DOI: 10.1097/MNM.0000000000001373 -
Current Treatment Options in... Mar 2017The current review will attempt to describe the important lessons learned from published randomized controlled trials (RCT) comparing water immersion (WI) or water... (Review)
Review
The current review will attempt to describe the important lessons learned from published randomized controlled trials (RCT) comparing water immersion (WI) or water exchange (WE) techniques with gas insufflation colonoscopy. Air insufflation (AI) to distend the colon to permit visualization and passage through the lumen was developed for diagnostic colonoscopy. When screening colonoscopy was adopted, the same AI method was used. Interval cancers, diagnosed within 3 to 5 years after an index screening colonoscopy, appeared to be linked to low adenoma detection rate (ADR). Conscious sedation was introduced to manage insertion pain a few decades ago, incurring moderate costs of nursing staff, space for recovery, patient burdens of escort requirement, and at home recovery time. Recent advancement to deep sedation entailed additional costs of anesthesia staff support. In the past decade, investigators worldwide evaluated the use of water-assisted methods as an adjunct or in lieu of gas insufflation during insertion to minimize discomfort and improve ease of insertion. For convenience, one approach embraced the removal of infused water during withdrawal (WI). A subsequent evolution entailed removal of infused water predominantly during insertion (WE), specifically designed to further minimize insertion pain. Results of RCT shed light on the impact of WI and WE on insertion pain (primary outcome) and adenoma detection (secondary outcome). Water immersion is easier to learn and apply than WE, but mastery of the WE technique appears to have two major advantages. Current RCT data suggest that both WI and WE decrease insertion pain and facilitate completion of difficult colonoscopy, with WE having a superior impact than WI. Water exchange was serendipitously associated with an increase in ADR; this has been repeatedly confirmed in follow-up studies. When it is unknown which patient's colonoscopy will be difficult, it would seem prudent for the average colonoscopist to optimize the chance of success and increase in ADR by using WE from the very start.
PubMed: 28205108
DOI: 10.1007/s11938-017-0119-1 -
World Journal of Gastroenterology Jan 2021In the United States, colorectal cancer (CRC) is the second leading cause of mortality in men and women. We are now seeing an increasing number of patients with...
In the United States, colorectal cancer (CRC) is the second leading cause of mortality in men and women. We are now seeing an increasing number of patients with advanced-stage diagnosis and mortality from colorectal cancer before 50 years of age, which requires earlier screening. With the increasing need for CRC screening through colonoscopy, and thus endoscopists, easier and simpler techniques are needed to train proficient endoscopists. The most widely used approach by endoscopists is air insufflation colonoscopy, where air distends the colon to allow visualization of the colonic mucosa. This technique is un-comfortable for patients and requires an anesthetist to administer sedation. In addition, patients commonly complain about discomfort post-op as air escapes into the small bowel and cannot be adequately removed. Current research into the use of water insufflation colonoscopies has proved promising in reducing the need for sedation, decreasing discomfort, and increasing the visibility of the colonic mucosa. Future direction into water insufflation colonoscopies which have shown to be simpler and easier to teach may increase the number of proficient endoscopists in training to serve our aging population.
Topics: Adenoma; Aged; Colonic Neoplasms; Colonic Polyps; Colonoscopy; Colorectal Neoplasms; Female; Humans; Insufflation; Male
PubMed: 33519138
DOI: 10.3748/wjg.v27.i3.233 -
Journal of Minimal Access Surgery 2021Suprahepatic gall bladder is rare, and torsion of the ectopic gall bladder is extremely rare. We report a patient of acute suprahepatic cholecystitis with torsion. A...
Suprahepatic gall bladder is rare, and torsion of the ectopic gall bladder is extremely rare. We report a patient of acute suprahepatic cholecystitis with torsion. A 69-year-old Korean male was admitted to our hospital for sudden-onset, severe epigastric pain. Abdominal computed tomography and ultrasonography showed a distended gall bladder with diffuse wall thickening and scanty pericholecystic fluid, which was located in ectopic suprahepatic position, accompanied by S4 hypotrophy of the liver without gallstones. Emergency laparoscopic cholecystectomy was performed, and intraoperative findings revealed a distended and ischaemic gall bladder that was located in the suprahepatic position and had twisted along the cystic duct and artery pedicle in a clockwise manner. Detorsion was done and the gall bladder was resected. Unfortunately, the pre-operative diagnosis of gall bladder torsion was missed, and a definite diagnosis was made at the time of surgery. The patient was discharged on the 4 post-operative day.
PubMed: 34045393
DOI: 10.4103/jmas.JMAS_171_20