Current opinion in critical care
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Curr Opin Crit Care · Oct 2012
ReviewPathophysiology of acute brain dysfunction: what's the cause of all this confusion?
To survey the recent medical literature examining the pathophysiology of acute brain dysfunction (delirium and coma) in the ICU. ⋯ The multifactorial pathophysiology of acute brain dysfunction remains incompletely understood. Multiple clinical risk factors have been identified and numerous pathophysiologic pathways have been hypothesized. Future research is required to investigate the roles of these pathways on differing clinical presentations, potential therapeutic options, and patient outcomes.
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This review summarizes the approach to and recent developments in the evaluation and treatment of acute right heart failure in the ICU. Right heart failure, defined as failure of the right ventricle to provide sufficient blood flow through the pulmonary circulation at normal central venous pressure, is a common problem caused by a combination of increased right-ventricular afterload and right-ventricular contractile dysfunction. ⋯ Right heart failure causes venous congestion and systemic hypoperfusion. Once right heart failure is identified, the primary goal is to alleviate any reversible cause of excessive load or right-ventricular contractile failure. When the underlying abnormalities cannot be alleviated, trials of diuretic, vasodilator, or inotropic therapy may be required. Invasive monitoring helps guide therapy. Medically refractory right heart failure may potentially be treated with right-ventricular assist devices.
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To summarize is to review recent progress in 'genomic' science and how this may be applied to the perioperative environment. Although investigations that relate genetic variation to perioperative outcomes continue, it is increasingly apparent that epigenetic mechanisms may contribute to much of the observed variation in complex outcomes not otherwise explained by differences in genetic sequence. ⋯ Enhancing our understanding of the way in which patients as genomic organisms interact with the perioperative environment requires a more sophisticated appreciation of the factors governing gene expression than has been the case to date. Epigenetic mechanisms are sure to play a pivotal role in what is essentially an acquired phenotype.
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This review describes recent findings related to molecular-based methods of potential application in the diagnosis of bacterial hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP). It focuses on methods capable of providing organism identification and keys of bacterial resistance necessary in clinical and epidemiological management of patients and on their ability to provide quantitative results. ⋯ Despite some limitations, current molecular diagnostic methods have a great potential to include bacterial targets useful in the identification of microorganisms and antimicrobial resistance, to analyze directly unprocessed samples and to obtain quantitative results in bacterial HAP/VAP, an entity of complex microbiological diagnosis due to the features of the pathogens commonly implicated.