Intensive Medical Treatment Research Articles

Blood pressure control in the general and high risk populations, longitudinal trends

Abstract Introduction Despite better control of high blood pressure (BP) in the general as well as high cardiovascular (CV) risk populations as a factor contributing to the decrease in CV mortality since 1990, the targets set by the guidelines may not have been reached. Purpose We analysed longitudinal trends in BP control in the general and high risk populations, to assess implementation of guidelines and to identify subpopulations with still unsatisfactory BP control. Methods Analysis of seven independent surveys of the general population (Czech MONICA and post-MONICA studies, 1985–2017) and five independent surveys of patients with stable manifest coronary heart disease (CHD) 1995–2017 (Czech samples of the EUROASPIRE I-V surveys). Results A total of 15 000 persons (Czech MONICA) and 2 098 patients (Czech EUROASPIRE) were investigated. In the 1985–2017 period, mean systolic BP decreased in the general population (MONICA) from 134 to 128 mmHg (p<0.001) and diastolic BP from 84 to 82.5 mmHg (p<0.01), hypertensive levels of BP (>140/90mmHg) were found in 45% in 1995 but only in 27.5% in 2017, and the prevalence of uncontrolled severe hypertension (BP>180/110 mmHg) decreased from 3 to 1%. The proportion of properly controlled hypertension increased from 13.2 to 53% (p<0.0001). In the 1995–2017 surveys of the high-risk population (EUROASPIRE) systolic BP decreased from 144.1 to 135.5 mmHg (p<0.001), diastolic BP from 87.5to 83.5mmHg (p<0.01), higher than recommended BP (>140/90mmHg, >140/85mmHg in diabetics) was found in 66.2% in 1995, still present as much as in 54.4% in 2017. Proportion of patients with very high BP (BP>180/110 mmHg) decreased from 18.4 to 1% only. Drugs with a potentially antihypertensive effect were used in 79.9 and 95.3% of patients in 1995 and 2017, respectively (p<0.0001). Population BP levels ceased to decline since 2000/01 survey, in the CHD population since the 2012/13 survey. This is obviously due to considerable increase in prevalence of obesity, and an increasing prevalence of diabetes, both in the general and high-risk populations. The more intensive medical high BP treatment seems to have a beneficial effect on hypertension control, even more in the general than in the high risk population. Conclusions The recent trend in BP levels, both in the general and high-risk populations, are far from satisfactory, with the main causative factor suggested to be the increasing prevalence of obesity and diabetes. While there has been progress in hypertension control, more in the general nad limited in high-risk population, truly effective BP control may be illusory without comprehensive CV risk factor control. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Agency for Medical Research, Ministry of Health of the Czech Republic

S3448 Percutaneous Endoscopic Gastrostomy Placement in Patients Infected with SARS-CoV-2, A Single Center Review

Introduction: Infection with SARS-CoV-2 can manifest with several gastrointestinal symptoms, specifically diarrhea, nausea, vomiting, gastrointestinal bleeding and loss of appetite. In patients requiring hospitalization, especially the critically ill, loss of appetite can quickly cause severe malnutrition, hindering the body’s ability to recover from illness. Severe disease also results in sequelae including prolonged mechanical ventilation and stroke, further limiting enteral nutrition and in many cases, creates a need for percutaneous endoscopic gastrostomy (PEG). We aim to characterize the demographics, timeline and severity of disease of patients with COVID-19 who required PEG placement at our institution. Methods: This was a single-center retrospective cohort study evaluating patients who tested positive for SARS-CoV-2 from March 2020 through January 2021, and had a percutaneous endoscopic gastrostomy (PEG) tube placed as an inpatient. Primary endpoints include the number of patients with COVID-19 requiring PEG, time from COVID-19 diagnosis to PEG placement, and severity of COVID-19 in those requiring PEG (measured by intensive care unit requirements, respiratory status, and medical treatment beyond supportive care). Secondary endpoints include demographics, past medical history of diabetes and stroke, and BMI. Results: 12,224 patients were COVID-19 positive from March 2020 - January 2021. 76 patients underwent inpatient PEG placement. 68/76 patients (89.5%) required ICU admission and 66/76 (86.8%) patients were considered to have severe or critical COVID infection. The average age of patients was 65, 46 were male, and 48.7% of patients were white. On average, PEG placement occurred 26.4 days after positive COVID test. Average BMI on admission was 30.5, serum protein on admission 6.7 and albumin 3.4. One third of patients had a history of DM, where 17% had a history of past or current stroke. Enteral access via nasogastric tube (NGT)/Dobhoff prior to PEG was noted in 71/76 patients. Conclusion: Our data suggests severity of COVID infection is the greatest predictor of patients that will require PEG placement. Nutritional status on admission, comorbidities, and demographic data is unlikely to help determine those that will require enteral access. As COVID-19 cases continue to present and patients recover, Gastroenterologists should be aware of the frequency and population in which PEGs were placed as management and decision for removal may fall in their purview.Figure 1.: Comparison made between those people who were admitted to the intensive care unit and underwent PEG placement and those that did not require the intensive care unit and received PEG placement.

Reacqua: A low-cost solar still system for the removal of antibiotics from contaminated effluents

The use of antibiotics in intensive animal production and human medical treatment can result in a significant discharge of those drugs and its transformation products in faeces and urine that contaminate water bodies. The effluents produced by poultry and pig production plants are often discharged without any treatment in the environment. These effluents can contain high levels of active drugs and several by-products. The contamination of water sources with these contaminants is of emerging concern for human health and the environment. The search for treatment processes capable of removing antibiotics from water is an urgent need, especially in rural zones that lack of wastewater treatment plants. A solar still system was used for removal and degradation of a mixture of several veterinary antibiotics widely used in poultry and pig intensive production. Water samples (10 L) containing enrofloxacin, oxytetracycline, sulfadimethoxine, sulfaquinoxaline, sulfamethazine, and sulfamethoxazole within the concentration range of 20–500 mg L−1 were processed in the system. The experiment was carried out in filed conditions in duplicate (Summer and Winter). The occurrence of transformation products was also investigated to elucidate the degradation pathways. The system was able to remove antibiotics in a range from 99.73% to more than 99.99%.

Predicting future left anterior descending artery events from non-culprit lesions: insights from the Lipid-Rich Plaque study.

The left anterior descending (LAD) artery is the most frequently affected site by coronary artery disease. The prospective Lipid Rich Plaque (LRP) study, which enrolled patients undergoing imaging of non-culprits followed over 2 years, reported the successful identification of coronary segments at risk of future events based on near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) lipid signals. We aimed to characterize the plaque events involving the LAD vs. non-LAD segments. LRP enrolled 1563 patients from 2014 to 2016. All adjudicated plaque events defined by the composite of cardiac death, cardiac arrest, non-fatal myocardial infarction, acute coronary syndrome, revascularization by coronary bypass or percutaneous coronary intervention, and rehospitalization for angina with >20% stenosis progression and reported as non-culprit lesion-related major adverse cardiac events (NC-MACE) were classified by NIRS-IVUS maxLCBI4 mm (maximum 4-mm Lipid Core Burden Index) ≤400 or >400 and association with high-risk-plaque characteristics, plaque burden ≥70%, and minimum lumen area (MLA) ≤4 mm2. Fifty-seven events were recorded with more lipid-rich plaques in the LAD vs. left circumflex and right coronary artery; 12.5% vs. 10.4% vs. 11.3%, P = 0.097. Unequivocally, a maxLCBI4 mm >400 in the LAD was more predictive of NC-MACE [hazard ratio (HR) 4.32, 95% confidence interval (CI) (1.93-9.69); P = 0.0004] vs. [HR 2.56, 95% CI (1.06-6.17); P = 0.0354] in non-LAD segments. MLA ≤4 mm2 within the maxLCBI4 mm was significantly higher in the LAD (34.1% vs. 25.9% vs. 13.7%, P < 0.001). Non-culprit lipid-rich segments in the LAD were more frequently associated with plaque-level events. LAD NIRS-IVUS screening may help identify patients requiring intensive surveillance and medical treatment.

Geriatric patients in the intensive care unit

Der Anteil geriatrischer Patienten auf der Intensivstation an allen dort behandelten Patienten beträgt bis zu 30 %. Das Alter per se ist jedoch kein Prognosekriterium für das therapeutische Outcome einer intensivmedizinischen Behandlung. Prognostisch wichtiger sind der funktionelle Status und geriatrische Syndrome. Hierbei sind die Gebrechlichkeit (Frailty) und das Delir von zentraler Bedeutung. Zum jeweiligen Screening sollten Clinical Frailty Scale (CFS) bzw. Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) zur Anwendung kommen. Darüber hinaus spielen altersphysiologische Organveränderungen sowie Multimorbidität und die damit assoziierte Polypharmazie eine wichtige Rolle. Letztere sollte bereits bei Aufnahme auf ihre absolute Notwendigkeit hin überprüft werden. Ein weiteres Ziel der intensivmedizinischen Behandlung von geriatrischen Patienten ist die Erhaltung und Verbesserung ihres Ernährungszustands. Zu seiner Erfassung sollte ein Screening mithilfe eines etablierten Tools (z. B. Nutritional Risk Screening [NRS] 2002) erfolgen. Bei der Behandlung von kritisch kranken geriatrischen Patienten mit Coronoaviruserkrankung 2019 (COVID-19) hat die Gebrechlichkeit ebenfalls eine entscheidende Bedeutung. Grundsätzlich ist bei jeder Therapieanwendung gerade auch bei geriatrischen Patienten die Frage nach der Sinnhaftigkeit der intensivmedizinischen Behandlung unter Beachtung des (mutmaßlichen) Patientenwillens und seiner Lebensperspektive zu klären. Dabei ist zu prüfen, ob ein angestrebtes Therapieziel erreicht werden kann und ob die Belastungen während der Behandlung gerechtfertigt ist. Weiterhin spielt bei der intensivmedizinischen Versorgung geriatrischer Patienten die sektorenübergreifende Zusammenarbeit eine wichtige Rolle.

Clinical Manifestations and Prognostic Factors of Fungal Keratitis: Analysis in Patients Over a 20-year Period

Purpose: To describe the clinical manifestations, causative organisms, treatment, and prognostic factors of fungal keratitis based on analysis of patients over the past 20 years. Methods: A total of 177 patients (177 eyes) with fungal keratitis, who were diagnosed by smears and cultures, were reviewed retrospectively. Sex, age, predisposing factors, causative organisms, clinical manifestations, treatment, and prognosis were evaluated. The patients were divided into three groups: only potassium hydroxide (KOH)-positive, only culture-positive, and KOH- and culture-positive. Logistic regression was performed to identify the factors associated with a poor clinical outcome. Results: The mean age of the patients was 67.4 ± 11.3 years; 107 (60.5%) patients were men. The most common predisposing factor was ocular trauma (57.6%), especially by plants (29.4%). The most prevalent filamentous fungi were Fusarium species (31.6%, 49 isolates), and the most prevalent yeasts were Candida species (11.0%, 17 isolates). In cases of bacterial and fungal keratitis, filamentous fungus with Gram-positive bacterial infection (70.7%, 29/41) was the most common presentation. Visual improvement after treatment was common in the KOH-positive group (79.2%, 19/24), while visual deterioration after treatment was common in the culture-positive group (40.4%, 36/89). Previous ocular disease (odds ratio [OR]: 3.744, p = 0.010), hypopyon (OR: 2.941, p = 0.030), and surgical treatment (OR: 24.482, p &lt; 0.001) were risk factors for a poor clinical outcome in the multivariate logistic regression model. Conclusions: Clinical prognosis was good in the KOH-positive only group, but poor in the culture-positive group. If fungal keratitis is suspected, diagnostic KOH staining and culture tests should be performed initially. Early intensive antifungal medical treatments are necessary for patients with risk factors for poor clinical outcomes.

Colonic adenocarcinoma resulting in recurrent colic and hematochezia in an Arabian stallion

A fourteen-year-old Arabian stallion was presented with general weakness and hematochezia. Clinical examination showed tachycardia but the rest of the physical parameters were within normal limits. Transcutaneous abdominal ultrasonography showed distended small intestinal loops with normal motility but increased mural thickness. Gastroscopic examination revealed small focal lesions in the non-glandular part of the stomach around the margo plicatus of the greater curvature, with a score of II/IV Equine Gastric Ulcer Syndrome. Blood analysis revealed anemia, hypoproteinemia and neutrophilia. Treatment was palliative and was determined based on the initial findings. Despite intensive medical treatment, the horse was euthanized due to progressive deterioration of its condition. Post-mortem necropsy and histopathology revealed an adenocarcinoma with osseous metaplasia within the left dorsal colon.

Malassezia otitis unresponsive to primary care: outcome in 59 dogs.

Otitis externa (OE) is a common disorder in dogs. Infection by the commensal yeast, Malassezia pachydermatis, may result in chronic disease that does not respond to standard primary care. Chronic infectious OE may be associated with otitis media (OM). To report medical management, clinical outcomes and frequency of middle ear involvement, in dogs with Malassezia otitis unresponsive to primary care. Fifty-nine dogs from one referral veterinary hospital from January 2007 to September 2018. Retrospective analysis of medical records of dogs referred with chronic otitis and treated for Malassezia otitis at a referral veterinary hospital. Chronic Malassezia OE was treated successfully in 91% of ears, in 87% of these cases with one ear flush intervention. Median time-to-resolution was 27days after ear flush intervention. Neither duration of otitis, presence of neutrophils in aural discharge nor administration of oral itraconazole affected clinical outcome. Malassezia OM occurred concurrently in 17% of ears. These findings assist clinicians and carers of affected dogs in decision-making, by documenting that most cases of canine Malassezia otitis that have not resolved with standard primary care, can be treated successfully with a well-staged and intense medical treatment plan. Malassezia OM should be suspected to occur concurrently in around a fifth of affected ears.

High-Intensity End-of-Life Care of Allogeneic Hematopoietic Cell Transplantation Recipients (HCT) — a Population-Based Study

BACKGROUNDIntensity of end-of-life care has received much attention in oncology due to concerns that high intensity care is likely expensive and may be inconsistent with patient goals. For these reasons, the National Quality Forum endorsed quality measures around intensity of end-of-life care for oncology patients and many studies have examined rates of and disparities in intensity of end-of-life care in this population treated with conventional therapy. However, little is known about intensity of end-of-life care in allogeneic HCT recipients, a population that is at very high risk for morbidity and mortality. METHODSUsing the California Office of Statewide Health Planning and Development administrative discharge database linked to death certificates, we performed a population-based analysis of allogeneic HCT recipients who died between 2000-2011 and had received their transplant within one year of death. Previously-defined and validated end-of-life care intensity indicators were used and included an intense medical intervention (CPR, intubation, ICU admission, or hemodialysis) within 30 days of death, discharge and subsequent readmission within 30 days of death, and hospital death. A patient was considered to have a given indicator if it was coded during an admission that took place entirely within 30 days of death and/or coded during a terminal admission. Multivariable logistic regression models were used to evaluate associations between clinical and sociodemographic characteristics and: i) hospital death, ii) any medically-intense intervention, iii) ≥2 intensity indicators, iv) readmission within 30 days of death. Regression analyses were done for the whole group and then stratified by age at death (pediatrics: 0-21y; adolescent and young adult [AYA]: 22-39y; adult: 40+y). Sociodemographic and clinical characteristics were considered associated with high intensity care if they were associated with an intensity indicator in at least 2 of the 4 regression analyses. Estimated costs incurred in the last year of life were calculated using each hospital's charge-to-cost ratio adjusted for 2016 dollars. RESULTSA total of 1978 patients were included in the analysis (390 pediatric, 439 AYA, and 1149 adult) with a median age at death of 40 years old; 57% were non-Hispanic white and 28% were Hispanic; 58% were male; 94% had an oncologic diagnosis (AML [38%]; ALL [22%] were most common). Eighty-four percent of the population died in the hospital, 71% of the patients had ≥2 intensity indicators and 52% had a medically-intense intervention. During their terminal admission or admission within 30 days of death, 48% of the cohort was admitted to the ICU, 44% was intubated, 21% received hemodialysis, and 8% received CPR. Entire Cohort: patient age (15-21y, 30-39y, and 40-49y; referent grp: age >60y) and presence of comorbidities at HCT were associated with a medically-intense intervention, ≥2 interventions, and hospital death. Pediatric Cohort: Presence of ≥2 comorbidities during the admission for HCT was associated with high-intensity end-of-life care (a medically-intense intervention, ≥2 interventions, and hospital death). AYA Cohort: Presence of ≥2 comorbidities during the admission for HCT was associated with high-intensity end-of-life care (a medically-intense intervention, ≥2 interventions, and hospital death). Older Adult Cohort: Patient age (40-49y; referent grp: age >60y) and presence of ≥2 comorbidities at HCT were associated with a medically-intense intervention and >2 intensity indicators. Cost of Care: HCT recipients in this study were admitted a median of 106 days during their last year of life, costing the system $558,136 in inpatient expenses per patient. CONCLUSIONSAllogeneic HCT recipients who die within a year of transplantation frequently receive a number of intensive end-of-life care interventions, as evidenced by the fact that 84% of the patients die in the hospital and 48% are admitted to the ICU at the end-of-life. Further work is needed to determine if these rates are consistent with patients' goals and whether interventions like earlier end-of-life conversations and/or palliative care consults may decrease intensity of care in this population as in non-HCT oncology patients. DisclosuresNo relevant conflicts of interest to declare.

Medical and surgical interventions and outcomes for infants with trisomy 18 (T18) or trisomy 13 (T13) at children's hospitals neonatal intensive care units (NICUs).

ObjectivesTo examine characteristics and outcomes of T18 and T13 infants receiving intensive surgical and medical treatment compared to those receiving non-intensive treatment in NICUs.Study designRetrospective cohort of infants in the Children’s Hospitals National Consortium (CHNC) from 2010 to 2016 categorized into three groups by treatment received: surgical, intensive medical, or non-intensive.ResultsAmong 467 infants admitted, 62% received intensive medical treatment; 27% received surgical treatment. The most common surgery was a gastrostomy tube. Survival in infants who received surgeries was 51%; intensive medical treatment was 30%, and non-intensive treatment was 72%. Infants receiving surgeries spent more time in the NICU and were more likely to receive oxygen and feeding support at discharge.ConclusionsInfants with T13 or T18 at CHNC NICUs represent a select group for whom parents may have desired more intensive treatment. Survival to NICU discharge was possible, and surviving infants had a longer hospital stay and needed more discharge supports.

INFECTIOUS AND INFLAMMATORY COMPLICATIONSIN OPHTHALMOLOGYAMID COVID-19

Inflammatory complications of the organ of vision in the time of COVID-19 can be manifested as conjunctivitis, scleritis, episcleritis, keratitis, uveitis and optic neuritis. It is essential to collect anamnesis, examine the blood for the presence of COVID 19 and treat these patients with the help of infectious disease specialists. Correct diagnosis of inflammatory ocular complications in the presence of COVID 19 makes it possible to prevent ocular complications, such as: ulcers and corneal penetration; fusion and overgrowth of the pupil,which leadto secondary glaucoma; endoophthalmitis, panophthalmitis and optic nerve atrophy. Timely intensive medical care and adequate treatment of these complications lead to a decrease in disability in this category of patients.Keywords:Ophthalmology, COVID-19,complications, ulcers, endoophthalmitis, panophthalmitis, gastrointestinal tract, cavernous sinus thrombosis

Toxicity after chimeric antigen receptor T-cell therapy : Overview and management of early and late onset side effects

The transfusion of chimeric antigen receptor (CAR) T‑cells has become established as anew treatment option in oncology; however, this is regularly associated with immune-mediated side effects, which can also run asevere course and necessitate aspecific treatment and intensive medical treatment. A literature review was carried out on CART-cell therapy, toxicities and the management of side effects. The cytokine release syndrome (CRS) and the immune effector cell-associated neurotoxicity syndrome (ICANS) regularly occur shortly after CART-cell treatment. The symptoms of CRS can range from mild flu-like symptoms to multiorgan failure. In addition to mild symptoms, such as disorientation and aphasia, ICANS can also lead to convulsive seizures and brain edema. The management of CRS and ICANS is based on the severity according to the grading of the American Society for Transplantation and Cellular Therapy (ASTCT). Tocilizumab and corticosteroids are recommended for CRS and corticosteroids are used for ICANS. In the further course persisting hypogammaglobulinemia and cytopenia are frequent even months after the initial treatment and promote infections even months after CAR T‑cell therapy. Potentially severe complications regularly occur after CART-cell therapy. An interdisciplinary cooperation between intensive care physicians, hematologists, neurologists and specialists in other disciplines is of decisive importance for the optimal care of patients after CAR T‑cell therapy.

Special pathologies of pregnant patients in intensive care medicine

Da die Inzidenz intensivtherapiepflichtiger Erkrankungen in Schwangerschaft oder Puerperium sehr niedrig ist, werden Intensivmediziner bei der Behandlung dieser Patientinnen vor eine Vielzahl von ungewohnten Herausforderungen gestellt. Die physiologischen und pathophysiologischen Veränderungen während einer Schwangerschaft bedingen einige Besonderheiten bezüglich der intensivmedizinischen Behandlung schwangerer oder kürzlich entbundener Patientinnen. Nachdem im ersten Beitrag dieser CME-Reihe die wichtigsten Prinzipien und aktuellen Empfehlungen zur Versorgung intensivtherapiebedürftiger schwangerer oder frisch entbundener Patientinnen behandelt wurden, fokussiert der zweite Beitrag auf Diagnostik und Therapie spezieller, ausgewählter Krankheitsbilder.

Principles of intensive medical care in pregnant patients

As the incidence of diseases during pregnancy or in the puerperium necessitating intensive medical care is very low, intensive care physicians are faced with a multitude of unfamiliar challenges in the treatment of this patient collective. The physiological and pathophysiological alterations during pregnancy induce some specific features with respect to the intensive medical treatment of pregnant or postpartum patients. Therefore, the first article in this CME series summarizes the most important principles and current recommendations on the care of pregnant or postpartum patients who need intensive medical treatment, always under consideration of the well-being of mother and child. The second article describes the diagnostics and treatment of special selected pathologies.

Fatal myopericarditis complicated with coronary vein perforation under the triple antithrombotic therapy: a case report

Background Acute pericarditis generally follows a mild clinical course and is rarely fatal. Coronary vein involvement is rarely reported.Case summary We report an autopsy case of cardiac tamponade from idiopathic myopericarditis due to coronary venous perforation under the triple antithrombotic therapy. A 69-year-old man was admitted to our hospital with abnormal findings on electrocardiography, bloody pericardial effusion, and mild elevation of troponin I. Oral anti-inflammatories were started and the patient followed a benign course. However, on hospital Day 5, he suddenly suffered cardiogenic shock with pulseless electric activity due to cardiac tamponade under the combination use of the dual antiplatelet drugs and an anticoagulant drug. He died despite intense medical treatment. Autopsy revealed cardiac tamponade caused by perforation in the coronary venous wall. To the best of our knowledge, this is the first description of fatal myopericarditis as a complication of coronary venous perforation.Discussion The aetiology and mechanism remain unknown; however, we should take care for this rare complication in patients with acute myopericarditis and bloody effusion under the triple antithrombotic therapy.

Challenge in diagnosis of late onset necrotizing enterocolitis in a term infant: a case report

BackgroundNecrotizing enterocolitis (NEC) is a common devastating inflammatory gastrointestinal disease and frequently occurs in premature infants. Here, we reported a case of late-onset NEC in a term neonate with good outcome after surgery for long-term follow-up.Case presentationTen-week-old male came to emergency unit due to prolonged diarrhea and abdominal distention. He was born at gestational age of 40 weeks with birth weight and Apgar score of 2800 g and 7/8, respectively. He had no history of formula feeding. Two weeks before admitted to the hospital, the patient had frequent diarrhea with fever. He was found lethargic with abdominal distention, absence of bowel sounds and abdominal tenderness. Plain abdominal x-ray and CT scan showed gastric and intestinal dilatation and gasless colon, suggesting a small bowel obstruction, and bowel wall thickening indicating peritonitis, without any free subdiaphragmatic air (pneumoperitoneum). Moreover, the patient did not have a congenital heart disease. While in intensive medical treatment, he showed a continuous clinical deterioration. All findings were suggestive of intestinal inflammation with clinical deterioration, and we decided to perform an emergency exploratory laparotomy and found an ischemia along the jejunoileal with a perforation at 25 cm above the ileocecal valve. Subsequently, we performed a double-barrel ileostomy through a separate incision from the laparotomy. Histopathological findings confirmed the diagnosis of NEC. We closed the stoma at postoperative day 43. The patient was discharged uneventfully a month after stoma closure.ConclusionAbdominal CT scan might be useful to establish an early recognition of late-onset NEC; thus, immediate surgical intervention might be performed to decrease its morbidity and mortality. Moreover, late-onset NEC in term neonates might occur without any risk factors or significant co-morbidities.

Long-term cognitive and multimodal imaging outcomes after carotid artery stenting vs intensive medication alone for severe asymptomatic carotid stenosis

Severe carotid stenosis is associated with cognitive impairment, which may be attributed to asymptomatic microembolism and/or chronic hypoperfusion. We aim to evaluate the long-term cognitive and brain connectivity outcomes of carotid artery stenting (CAS) for asymptomatic ≥70% stenosis of the extracranial internal carotid artery (ICA). We conducted a non-randomized controlled study to compare intensive medical therapy alone (Med) or in combination with carotid artery stenting for the composite vascular events, neuropsychological, and multimodal magnetic resonance perfusion imaging and diffusion tensor imaging outcomes. Sixty-nine patients were followed for a mean of 2.3 years (31 Med, 38 CAS) and 11 patients had composite vascular events of all-cause death, ischemic stroke, or myocardial infarction (6 Med vs 5 CAS). Forty-six asymptomatic subjects completed neuropsychological and multimodality imaging follow-ups (23 Med, 23 CAS). Compared to the Med group, the CAS group had a modest improvement of 12-item delayed verbal memory (8.9±2.4 to 9.8±2.7 vs 9.0±2.1 to 8.9±2.3, p=0.04), but not in global cognition, attention or executive function, which was associated with increased structural connectivity of fractional anisotropy at the ipsilateral deep white matter. Importantly, the memory improvement was correlated with the perfusion increment at the ipsilateral middle cerebral artery territory. For asymptomatic extracranial carotid steno-occlusion, successful carotid revascularization in addition to intensive medical treatment may potentially benefit cognitive reserve and connectivity strength which are partly attributed to restoration of non-critical hypoperfusion.

Cardiomyopathy in Pregnancy: A Review Literature

BACKGROUND: Pregnancy is an experience that many women can achieve. Pregnancy is generally well tolerated in asymptomatic patients with cardiomyopathies but in restrictive form cardiomyopathy, pregnancy cannot be tolerated because of poor prognosis. Prior cardiac events, poor functional class (New York Heart Association class III or IV), or advanced left ventricular systolic dysfunction are present, the risk of maternal cardiac complications during pregnancy are markedly increased. Worsening of the clinical condition can occur during pregnancy, despite intensive medical treatment. Although the incident of cardiovascular disease is present 0.5-4% in developed countries, our knowledge about various of cardiomyopathy and pregnancy should be updateable. CONCLUSION: Our literature provide three types of cardiomyopathy in pregnancy with an example condition for each type that relevant during pregnancy. Peripartum cardiomyopathy is the most common form of cardiomyopathy occured in pregnancy therefore a thorough review is needed to give best outcome for pregnancy. Arryhtmia is the commonnest form in hypertrophic cardiomyopathy which need to be regularly monitored and measure should be taken if the arryhtmia is life threatening for mother and the child. Cardiac amyloidosis is the common form of restrictive cardiomyopathy in pregnancy.

Rationale, Design, and Implementation of Intensive Risk Factor Treatment in the CREST2 Trial

A subanalysis of patients entered in the CREST2 trial (carotid revascularization and medical management for asymptomatic carotid stenosis) from 2014 to March 23, 2020 was performed. Interim risk factor data were gathered for 1618 patients at baseline and follow-up through 24 months analyzing intensive medical management alone compared with intensive medical management plus carotid endarterectomy or transfemoral carotid artery stenting for preventing stroke or death. The mean baseline low-density lipoprotein level was 80 mg/dL, which had significantly improved to 67 mg/dL after intensive medical treatment. The mean baseline systolic blood pressure of 140 mm Hg had significantly improved to 130 mm Hg. A rigorous approach to intensive stroke risk factor management in CREST2 resulted in significant improvements in risk factor control.

Prioritization of intensive medical treatment places - Concept proposal

In der Situation des Beatmungsbettenmangels sind ethisch begründbare, transparente und nachvollziehbare Entscheidungen zu treffen. Dieses Konzept sieht vor, dass zunächst alle Patienten nach Notwendigkeit intubiert und dann von einem Triage-Team beurteilt werden. Dabei stehen neu aufgenommene COVID-Patienten mit neu aufgenommenen Nicht-COVID-Patienten und bereits intensivmedizinisch behandelte Patienten in Konkurrenz um ein Beatmungsgerät. Die Kombination der kurz- und langfristigen Prognose soll dem interprofessionellen Triage-Team ermöglichen, nachvollziehbare Entscheidungen zu treffen. Ziel des Priorisierungskonzeptes ist es, möglichst viele Menschenleben zu retten und die Behandlungsteams von der schwierigen Entscheidung der Priorisierung zu entlasten.