Treatment Of Reversible Causes Research Articles

A - 3 The Relationship between Memory and Depression In an Elderly Chinese Cohort: a Baseline Analysis

Abstract Objective Explore the relationship between depression and memory aged 60 years and older while controlling for age, gender, and education. Method This study utilized data from the Characterization of Dementia in Asian-Pacific Islanders study by Bruce Miller, M.D., and Howie Rosen, M.D., at the Memory and Aging Center at UCSF. Inclusion criteria included participants age 60+ who completed the Benson Figure Test, GDS-30, and the Chinese Version Verbal Learning Test (CVVLT) in English, Cantonese, or Mandarin. Exclusion criteria included participants under age 60 and or experience history of neurological strokes or injuries, and disabilities related to memory. The final sample yielded 136 participants, including 41 (30.1%) males, 95 (69.9%) females, 120 (88.2%) right-handed, 3 (2.2%) left-handed, and 7 (5.1%) ambidextrous. Average age of participants was 71.46 (SD = 7.26). A memory composite score was computed based on average of performances on the Benson Figure Task delay and the CVVLT 10-minute delay. Raw GDS-30 scores represented depression. Results There was a weak positive correlation between memory composite scores, gender, and education, and a weak negative correlation between memory composite scores, age, and GDS-30 scores. Conclusions Findings indicate some evidence for a relationship between depression and memory in elderly Chinese populations. However, the sample was skewed, and consisted of less depressed and higher memory functioning participants. Despite these limitations, it is pertinent to explore how healthcare providers may outreach to this population to monitor risk factors, improve timeliness of dementia diagnosis, and maximize treatment of reversible causes, adherence to treatment plans, and help families care plan.

Memory complaint in a middle-income country: a four-year longitudinal study in a cohort with low-education

Abstract Background Memory complaints are frequent in older adults and are associated with higher risk of cognitive decline. Objective To investigate the functional outcome of individuals with memory complaints followed up at primary care centers. Methods Data were collected between 2016 e 2020 in primary health care centers in Brazil. Patients underwent the Brief Cognitive Screening Battery, and the Functional Activities Questionnaire. Results The initial sample (2016) comprised 91 individuals classified into those with subjective cognitive decline (SCD, n = 15), mild cognitive impairment (MCI, n = 45), or dementia (n = 31). During follow-up, 8 individuals (8.8% of the initial sample) died and 26 (28.5% of the initial sample) were not found. Fifty-seven participants underwent clinical reassessment. Of 15 individuals with SCD, 7 were not found (46.7%), 4 (26.7%) progressed to MCI, and 4 (26.7%) remained stable. Of 45 individuals with MCI, 11 were not found (24.4%), 2 (4.4%) died, 6 (13.4%) progressed to dementia, 12 (26.7%) regressed to SCD, and 14 (31.1%) remained stable. Of 31 individuals with dementia, 8 were not found (25.8%), 6 (19.4%) died, 2 (6.5%) regressed to SCD, 7 (22.6%) regressed to MCI, and 8 remained stable (25.8%). Clinical improvement was due to the treatment of reversible causes, such as B12 hypovitaminosis and mood disorders. Older age, lower Mini-Mental State Examination, and higher scores of memory complaint, but not the use of benzodiazepines and of proton pump inhibitors, were predictors of functional status. Conclusion Despite their limits (short sample size, missing data), these results support the idea that adequate screening, follow-up, and treatment of reversible causes of dementia in primary care are essential.

Management of acute colonic pseudo-obstruction: opportunities to improve care?

Acute colonic pseudo-obstruction (ACPO) is a functional bowel obstruction characterised by colonic dilatation in the absence of mechanical obstruction on imaging. Complications include bowel ischaemia, perforation and death. The aim of this study was to explore outcomes for patients treated for ACPO and to assess adherence to current ACPO treatment guidelines. This is a retrospective service evaluation and included patients with a diagnosis of ACPO between 1 March 2018 and 31 March 2023. Process measures were identified following discussion with the clinical team from published guidance. Patients were identified using clinical coding and radiological text reports. Cases were eligible for inclusion if they had radiologically confirmed ACPO. Data were collected following review of patient notes into Microsoft Excel. Descriptive analysis was performed with no formal statistical assessment. A total of 45 patients were identified, of whom 13 were admitted under general surgery. All patients received admission bloods (n=45). Nearly all patients had computed tomography imaging (43/45, 96%). Only 3/45 (6.7%) of the patients received optimal conservative management (intravenous infusion, nil by mouth, flatus tube, treatment of reversible causes). In all, 11/45 (24%) required further treatment, of whom 7 received this within 72 h. The leading (11/45) complication following diagnosis of ACPO was hospital-acquired pneumonia. Mortality was seen in 9/45. ACPO is often managed remotely by general surgeons. This may impact on the quality of conservative management, and timeliness of endoscopic or pharmacological intervention. Further work is needed to optimise management.

Traumatic cardiac arrest.

This review considers the latest evidence relating to the epidemiology and outcomes, treatment guidelines, diagnostic and therapeutic interventions in traumatic cardiac arrest. There is variation in the incidence and outcomes of traumatic cardiac arrest which is influenced in part by case definitions. Irrespective of case definitions outcomes from traumatic cardiac arrest are typically worse than those seen from cardiac arrest due to medical causes but not so poor as to consider that treatment is futile. Clinical guidelines focus on the prompt treatment of reversible causes, although evidence that this improves outcomes is limited. Point of care ultrasound to assist with the identification of reversible causes should be limited to experienced operators where there is thought to be a high likelihood of a reversible cause being present. Care should be taken to minimize interruptions in chest compressions during scanning. There is little recent evidence to support specific therapeutic interventions. The role of Resuscitative Endovascular Balloon Occlusion of the Aorta during traumatic cardiac arrest remains to be determined in on-going research. Trauma related cardiac arrest differs from cardiac arrest due to medical causes. Whilst the core principles of treatment are similar, a higher priority is placed on identifying and treating reversible causes.

Impact of the 2015 European guidelines for resuscitation on traumatic cardiac arrest outcomes and prehospital management: A French nationwide interrupted time-series analysis

AimTo evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on patient outcomes following traumatic cardiac arrest (TCA) and on advanced life support interventions carried out by physician-staffed ambulances. MethodsData of TCA patients aged ≥18 years were extracted from the French nationwide cardiac arrest registry. A pre- (2011–2015) and a post-publication period (2016–2020) were defined. In the guidelines, a specific TCA management algorithm was introduced to prioritise the treatment of reversible causes. Its impact was evaluated using adjusted interrupted time series analysis. Results4,980 patients were treated (2,145 during the pre-publication period and 2,739 during the post-publication period). There was no significant change in the rates of prehospital ROSC (22.4% vs. 20.2%, p = 0.07 in the pre- and post- intervention respectively), survival (1.4% vs. 1.4%, p = 0.87) or good neurological outcome (71.4% vs. 66.7%, p = 0.93) or in the incidence of organ donation (1.6% vs. 1.3%, p = 0.50). There were nonsignificant changes in the adjusted temporal trend for ROSC (aOR 0.88; 95% CI [0.77; 1.00]), survival (aOR 1.34; 95% CI [0.83;2.17]), good neurological outcome (aOR 1.57; 95% CI [0.82;3.05]), and organ donation (aOR 1.06; 95% CI [0.71;1.60]). The use of intraosseous catheters (13.0% vs. 19.2%, p < 0.001), external haemorrhage control measures (23.9% vs. 64.8%, p < 0.001), bilateral chest decompression (13.7% vs. 16.5%, p = 0.009), and packed red cell transfusion (2.7% vs. 6.5%, p < 0.001) increased in the post-publication period. ConclusionsDespite the increased frequency of trauma rescue interventions performed by on-scene physicians, no change in patient-centred outcomes was associated with the publication of the 2015 ERC guidelines in France.

Extracorporeal resuscitation-criteria, prerequisites, outcome : A reality check

Für ausgewählte Patienten, in denen die konventionelle kardiopulmonale Reanimation (cCPR) erfolglos bleibt, sprechen die europäischen Leitlinien zur Reanimation 2021 erstmals eine Empfehlung zur extrakorporalen Reanimation (eCPR) als mögliche Rettungstherapie aus. Die eCPR wird im therapierefraktären Kreislaufstillstand etabliert, um Diagnostik und Therapie reversibler Ursachen, wie Herzinfarkt, Lungenembolie, akzidentielle Hypothermie, Intoxikationen mit herzwirksamen Substanzen und akute Hypoxie, zu ermöglichen. Selektionskriterien für eCPR umfassen prognostische Reanimationsfaktoren, wie beobachteter Kreislaufstillstand, Start von Reanimationsmaßnahmen in < 5 min, schockbarer Erstrhythmus, Zeichen effektiver cCPR wie Lebenszeichen während der Reanimation, anhaltendes Kammerflimmern, intermittierende Phasen von Spontankreislauf oder anhaltendes endtidales CO2 > 10 mm Hg, Patientenalter und Gesundheitszustand. Die Zeitspanne vom Kreislaufstillstand bis zur eCPR ist eine der wichtigsten Determinanten für neurologisch gutes Überleben und sollte < 60 min liegen. Für die Einhaltung dieser Zielvorgabe muss eine entschlossene „Load-and-Go“-Strategie mit frühzeitiger Patientenselektion und raschem Transport unter mechanischer cCPR in ein eCPR-Zentrum verfolgt werden, oder es wird versucht, die eCPR präklinisch zum Einsatz zu bringen. Zwei randomisierte kontrollierte eCPR-Studien demonstrierten Überlebensraten von 43 % bzw. 31,5 % bei Patienten mit anhaltendem Kammerflimmern bzw. kardialem Kreislaufstillstand. Ob diese Ergebnisse außerhalb einzelner hochspezialisierter Zentren anwendbar sind, ist wie die Frage nach der besten präklinischen und innerklinischen Strategie Gegenstand zukünftiger Studien.

Prehospital Cardiac Arrest Airway Management: An NAEMSP Position Statement and Resource Document

Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. Multiple cardiac arrest airway management techniques are available to EMS clinicians including bag-valve-mask (BVM) ventilation, supraglottic airways (SGAs), and endotracheal intubation (ETI). Important goals include achieving optimal oxygenation and ventilation while minimizing negative effects on physiology and interference with other resuscitation interventions. NAEMSP recommends: Based on the skill of the clinician and available resources, BVM, SGA, or ETI may be considered as airway management strategies in OHCA. Airway management should not interfere with other key resuscitation interventions such as high-quality chest compressions, rapid defibrillation, and treatment of reversible causes of the cardiac arrest. EMS clinicians should take measures to avoid hyperventilation during cardiac arrest resuscitation. Where available for clinician use, capnography should be used to guide ventilation and chest compressions, confirm and monitor advanced airway placement, identify return of spontaneous circulation (ROSC), and assist in the decision to terminate resuscitation.

Prevalence of Severe Neurocognitive Impairment and Its Association with Socio-Demographics and Functionality Among Ugandan Older Persons: A Hospital-Based Study.

BackgroundThe prevalence of neurocognitive disorders, especially dementia, is rising due to an increase in longevity. Early detection and diagnosis of neurocognitive impairments are important for early interventions and appropriate management of reversible causes, especially by the primary health workers. However, this study aimed to determine the prevalence and associated factors of severe neurocognitive impairment among elderly persons attending a tertiary hospital in Uganda.MethodsThis cross-sectional survey was conducted in a Ugandan hospital setting, where older adults go for treatment for their chronic health problems. Following the inclusion criteria, interviews were conducted, where information about socio-demographics was collected, whereas neurocognitive impairment and functionality were assessed by Mini-Mental State Examination and Barthel Index, respectively. Chi-square test, Pearson correlation test, and logistic regression were performed to determine the factors associated with severe neurocognitive impairment.ResultsA total of 507 elderly persons aged 60 years and above were enrolled in this study (mean age 68.62 ±7.95 years), and the prevalence of severe neurocognitive impairment was 28.01%. Advanced age, female gender, lower education level, and functional dependency were significantly associated with severe neurocognitive impairment.ConclusionSevere neurocognitive impairment is prevalent among Ugandan hospital attending elderlies with functional dependency. This suggests a need to routinely screen cognitive disorders among older persons who visit the healthcare facilities with other physical complaints to enable early detection and treatment of reversible causes of neurocognitive impairment, such as depression and delirium to enable better functionality.

Preporuke za sprovođenje mera napredne podrške života Evropskog resuscitacionog saveta Izmene u odnosu na preporuke iz 2015. godine

Adult advanced life support guidelines 2021 provided by the European Resuscitation Council in its largest extent do not differ significantly from equivalent guidelines published six years ago. However, some important points were further emphasized, and some protocols show new additions and structural changes. According to the new guidelines, there is a greater recognition that patients with both in-hospital and out-of-hospital cardiac arrest have premonitory signs, and that many of these arrests may be preventable. High-quality chest compressions with minimal interruption, early defibrillation, and treatment of reversible causes remained high priority steps in resuscitation process. New guidelines also recommend that, if an advanced airway is required, rescuers with a high tracheal intubation success rate should use this technique. With regard to using diagnostic procedures, medications, and special methods of cardiopulmonary resuscitation, newest guidelines also made new suggestions. According to these guidelines, when adrenaline is used, it should be used as soon as possible when the cardiac arrest rhythm is non-shockable, and after three defibrillation attempts for a shockable cardiac arrest rhythm. The guidelines recognise the increasing role of point-of-care ultrasound in peri-arrest care for diagnosis, but emphasis that it requires a skilled operator, and the need to minimise interruptions during chest compression. Additionally, 2015 guidelines suggested use of point-of-care ultrasound in diagnosing several various conditions with potential of causing cardiac arrest. However, 2021 guidelines limited indications in diagnosing only cardiac causes, such as tamponade or pneumothorax. The guidelines also reflect the increasing evidence for extracorporeal cardiopulmonary resuscitation as a rescue therapy for selected patients with cardiac arrest when conventional advanced life support measures are failing or to facilitate specific interventions. Additionally, newest guidelines made significant changes in the order of steps used in the In/hospital resuscitation algorithm, as well as changes in several very important steps of treating tachycardias and high heart rate associated arrhythmias.

High-quality chest compressions are possible during intra-hospital transport, but depend on provider position: A manikin study.

Treatment of reversible causes of cardiac arrest often requires intrahospital transportation during ongoing resuscitation. But high-quality chest compression with minimal interruption is the most essential prerequisite for an optimal outcome after cardiac resuscitation. We aimed to evaluate chest compression quality according to the provider position during intrahospital transportation. Manikin observational study. German Tertiary Care Hospital. A total of 20 paramedics (eight female, 12 male); average professional experience 4.8 ± 3.1 years since their initial enrolment for training. Participants performed chest compressions during simulated intrahospital transportation in four groups: provider kneeling beside manikin on the floor (control group), walking next to the bed (group 1), kneeling on the bed beside the manikin (group 2), kneeling astride the manikin on the bed (group 3). Quality metrics as European Resuscitation Council Guidelines 2015. Subsequently, the participants were asked to assess their own subjective feelings of safety, comfort and strain, and to recommend one position. The quality of chest compression in the control group and groups 2 and 3 did not differ significantly. Group 1 performed significantly worse in terms of the correct hand placement on the chest (P = 0.044 vs. control group) and compression depth (P = 0.004 vs. control group, P = 0.035 vs. group 2, P = 0.006 vs. group 3). Transport speed was faster in groups 2 and 3 vs. group 1 (P < 0.05 vs. group 1, P < 0.05 vs. group 2). The majority of participants rated position 1 as unsafe (90%), unpleasant (100%) and exhausting (100%). They predominantly favoured position 3 (70%). Performing guideline-compliant chest compressions during intra-hospital transportation is feasible with an appropriate provider position. Our results suggest, kneeling beside or astride the patient on the bed enables high-quality chest compressions, faster transport and is perceived by the providers as more pleasant. 'Walking next to the bed' while performing chest compressions should be avoided.

Out-of-Hospital Cardiopulmonary Resuscitation

With an incidence of 50 - 70 resuscitations attempted per 100000 inhabitants and year Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death in adults in the developed world. Thus, cardiac arrest is a common emergency situation attended by emergency medical services (EMS). Due to the pathophysiology it is one of the most time-critical emergencies: after 3 - 5 minutes of cardiac arrest without resuscitation efforts the likelihood of neurological impairments is significantly increased once the patient survives the initial event. Therefore, the immediate start of basic life support (BLS) with high quality chest compressions is paramount. Advanced life support comprises defibrillation, if indicated, airway management, the application of selected drugs and the treatment of reversible causes. After return of spontaneous circulation (ROSC) a structured post-resuscitation care in EMS and in dedicated hospitals is essential to achieve the best neurological outcome for the patient. The universal resuscitation algorithm has to be adapted for special circumstances of OHCA (e. g. a traumatic cause, cardiac arrest in pregnancy, …).

Atrial fibrillation in acute heart failure: A position statement from the Acute Cardiovascular Care Association and European Heart Rhythm Association of the European Society of Cardiology.

Atrial fibrillation and acute heart failure frequently co-exist and can exacerbate each other. Their combination leads to increased morbidity and mortality. However, the prevalence and significance, as well as the treatment, of atrial fibrillation in acute heart failure are not well studied. Management of atrial fibrillation in acute heart failure requires a multidisciplinary team approach. Treatment of underlying disease(s), identification and treatment of potentially correctable causes and precipitating factors and anticoagulation are crucial. In this article, current evidence on atrial fibrillation in the setting of acute heart failure is summarised. The recommendations on management of atrial fibrillation in the prehospital stage, the treatment of reversible causes, when and how to use rate or rhythm control, maintenance of sinus rhythm, catheter ablation and pacing, anticoagulation, as well as measures on prevention of atrial fibrillation are provided.

Metabolic encephalopathy secondary to diabetic ketoacidosis: a case report

IntroductionMetabolic encephalopathy is a rare but potentially devastating complication of diabetic ketoacidosis (DKA). This case highlights the dramatic cognitive decline of a young man due to metabolic encephalopathy complicating DKA. The aims of this case report are to highlight metabolic encephalopathy as a complication of DKA and to explore the current research in diabetic related brain injury. The importance of investigation and treatment of reversible causes of encephalopathy is also demonstrated.Case presentationA 35-year-old man with a background of type 1 diabetes mellitus (T1DM) and relapsing remitting multiple sclerosis (RRMS) presented to the emergency department (ED) in a confused and agitated state. Prior to admission he worked as a caretaker in a school, smoked ten cigarettes per day, took excess alcohol and smoked cannabis twice per week.Following initial investigations, he was found to be in DKA. Despite timely and appropriate management his neurological symptoms and behavioural disturbance persisted. Neuroimaging revealed temporal lobe abnormalities consistent with an encephalopathic process. The patient underwent extensive investigation looking for evidence of autoimmune, infective, metabolic, toxic and paraneoplastic encephalopathy, with no obvious cause demonstrated.Due to persistent radiological abnormalities a temporal lobe biopsy was performed which showed marked astrocytic gliosis without evidence of vasculitis, inflammation, infarction or neoplasia. A diagnosis of metabolic encephalopathy secondary to DKA was reached. The patient’s cognitive function remained impaired up to 18 months post presentation and he ultimately required residential care.ConclusionsMetabolic encephalopathy has been associated with acute insults such as DKA, but importantly, the risk of cerebral injury is also related to chronic hyperglycaemia. Mechanisms of cerebral injury in diabetes mellitus continue to be investigated. DKA poses a serious and significant neurological risk to patients with diabetes mellitus. To our knowledge this is the second case report describing this acute complication.

Updates in Management and Timing of Dialysis in Acute Kidney Injury

Acute kidney injury (AKI) is a common complication in hospitalized patients and is associated with mortality, prolonged hospital length of stay, and increased healthcare costs. This paper reviews several areas of controversy in the identification and management of AKI. Serum creatinine and urine output are used to identify and stage AKI by severity. Although standardized definitions of AKI are used in research settings, these definitions do not account for individual patient factors or clinical context which are necessary components in the assessment of AKI. After treatment of reversible causes of AKI, patients with AKI should receive adequate volume resuscitation with crystalloid solutions. Balanced crystalloid solutions generally prevent severe hyperchloremia and could potentially reduce the risk of AKI, but additional studies are needed to demonstrate a clinical benefit. Intravenous albumin may be beneficial in patients with chronic liver disease either to prevent or attenuate the severity of AKI; otherwise, the use of albumin or other colloids (eg, hydroxyethyl starch) is not recommended. Diuretics should be used to treat volume overload, but they do not facilitate AKI recovery or reduce mortality. Nutrition consultation may be helpful to ensure that patients receive adequate, but not excessive, dietary protein intake, as the latter can lead to azotemia and electrolyte disturbances disproportionate to the patient's kidney failure. The optimal timing of dialysis initiation in AKI remains controversial, with conflicting results from two randomized controlled trials.

A review of tinnitus

Tinnitus is one of the most common otological symptoms. In recent times our understanding of tinnitus has significantly progressed. Tinnitus may be defined as conscious awareness of a sound in the absence of an external auditory stimulus. People with tinnitus almost always seek the attention of their general practitioner, who is best placed to assess, investigate and provide appropriate counselling. The aim of this article is to define and provide guidelines on causes, assessment, appropriate investigation and management of tinnitus. Tinnitus may be categorised as subjective, objective, primary or secondary. The assessment of tinnitus begins by determining which of these types with the patient presents with. All patients with tinnitus warrant formal audiometric assessment, and a proportion will warrant further imaging. Management requires treatment of reversible causes. Those with subjective, bothersome chronic tinnitus require tinnitus-specific therapies.

Management of electrical storm of unstable ventricular tachycardia in post myocardial infarction patients: A single centre experience

ObjectiveThis is a case series of consecutive patients with past myocardial infarction presenting with Electrical Storm (ES) of unstable ventricular tachycardia (VT) treated by a protocol directed algorithm. MethodsManagement protocol involved treatment of reversible causes, ventilatory & hemodynamic support, administration of antiarrhythmic drugs (AAD) & maximally tolerated doses of beta-blockers, stellate ganglionectomy and Radiofrequency ablation (RFA) guided by Electro Anatomic Mapping (EAM). Patients were followed up periodically with review of device data logs. ResultsThere were 12 patients (mean age=61.38±6.48years & mean LVEF=31.92±4.23%). Presentation was recurrent ICD shocks (n=5) or VT (n=7). All were mechanically ventilated. Reversible causes were identified in 4 patients and appropriately addressed. Totally 8 patients underwent endocardial substrate modification by EAM & RFA. Endocardial LV Voltage mapping demonstrated a mean scar area of 70.04±17.63 sq.cm (27.04±6.20% of mapped area). The electrograms targeted for ablation included late potentials, fractionated electrograms, double potentials and channels within the scar. Two patients had stellate ganglionectomy in addition. Ten patients (83.3%) survived to discharge, all of whom are alive at a follow up of 30.12±19months free of ES. VT free survival at end of follow up was 80%. No patient had hospitalization related to VT. Single episode of VT recurrence was seen in 2 patients at 7 months and 1year of follow up respectively. ConclusionIn post myocardial infarction patients presenting with ES and unstable VT, a protocol driven approach involving substrate modification targeting abnormal electrograms improves outcomes.

Clinical cardiac imaging in cardiac arrest and periarrest.

Echocardiography during preresuscitation care, cardiopulmonary resuscitation and postresuscitation is suggested to be an important tool in critical care medicine. At present a structured process integrating advanced life support and transtoracic echocardiography is not included in guidelines of cardiac resuscitation. However identification and treatment of reversible causes or complicating factors during cardiopulmonary resuscitation is rational and aimed to improve the outcomes. Furthermore, echocardiography has the potential to define the efficiency of the chest compressions and the optimal duration of the resuscitation maneuvers and/or the right time to switch to extracorporeal resuscitation.

Cardiopulmonary resuscitation in cardiac arrest following trauma

For decades, survival rates of cardiac arrest following trauma were reported between 0 and 2 %. Since 2005, survival rates have increased with awide range up to 39 % and good neurological recovery in every second person injured for unknown reasons. Especially in children, high survival rates with good neurologic outcomes are published. Resuscitation following traumatic cardiac arrest differs significantly from nontraumatic causes. Paramount is treatment of reversible causes, which include massive bleeding, hypoxia, tension pneumothorax, and pericardial tamponade. Treatment of reversible causes should be simultaneous. Chest compression is inferior following traumatic cardiac arrest and should never delay treatment of reversible causes of the traumatic cardiac arrest. In massive bleeding, bleeding control has priority. Damage control resuscitation with permissive hypotension, aggressive coagulation therapy, and damage control surgery represent the pillars of initial treatment. Cardiac arrest due to hypoxia should be resolved by airway management and ventilation. Tension pneumothorax should be decompressed by finger thoracostomy, pericardial tamponade by resuscitative thoracotomy. In addition, resuscitative thoracotomy allows direct and indirect bleeding control. Untreated impact brain apnea may rapidly lead to cardiac arrest and requires quick opening of the airway and effective oxygenation. Established algorithms for treatment of cardiac arrest following trauma enable asafe, structured, and effective management.

The role of palliative care

The aim of palliative care is the improvement of quality of life of patients with life limiting disease and their relatives through symptom control, psychosocial and spiritual care. Thorough assessment, treatment of reversible causes and drug therapy supported by other therapeutic measures are essential for symptom relief. Honest, respectful and empathic communication is crucial for the care of patients. In the terminal phase, symptom control, reduction of unnecessary diagnostic and therapeutic measures, as well as care for the relatives are most important. Palliative care should be provided to all patients with advanced disease irrespective of diagnosis and prognosis. Most patients can be seen in generalist palliative care. Specialist palliative care should be offered to patients with complex symptoms and needs through specialist palliative home care, on palliative care units and hospital support teams.

Identification and prereferral care for patients with chronic kidney disease by Nigerian family medicine trainee

Background: The family physician is usually the first contact between patients and the health care system at the tertiary level, and they play an important role in the screening for chronic kidney disease (CKD), treatment of reversible causes, and timely referral to the nephrologist. We do not know if the future family physician in Nigeria is prepared for this important role, prompting us to carry out this study. Materials and Methods: Self-administered questionnaires were given to family medicine trainees attending a nationally organized revision course. Results: Two hundred questionnaires were distributed and 172 were returned Guidelines for the management of CKD were correctly identified by only 18% of the participants. The screening methods that were identified for CKD included urinalysis (43.6%), serum creatinine alone (72.7%), estimation of glomerular filtration rate (70.3%), and renal ultrasound (30.5%). Less than 50% were aware of the recommended frequency of screening for diabetic and elderly patients while less than 25% were aware of coronary artery disease and stroke as complications of CKD. After a diagnosis of CKD, 40.4% would refer immediately to the nephrologist, while 33%, 13%, and 2% would use the serum creatinine level alone, estimated glomerular filtration rate (GFR), and clinical features, respectively, as guides in taking decisions on referral. Conclusion: A good number of the participants had poor knowledge in the aspects of identification of patients with CKD, initial evaluation of such patients and eventual referral to nephrologists. Concerted efforts are needed to improve this knowledge in the family physician trainees of Nigeria.