Minerva medica
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Electrical storm is the clustering of hemodynamically destabilizing ventricular tachycardia or ventricular fibrillation that typically requires multiple electrical cardioversions or defibrillations within a 24-hour period. Electrical storm is frequently seen in the acute phase of myocardial infarction, in patients with the genetic arrhythmia syndromes, and in patients with implanted cardioverters-defibrillators. ⋯ In this review we present the most common conditions associated with electrical storm, therapeutic options for suppression of electrical storm, and new investigational techniques emerging for the treatment of electrical storm in refractory cases. The management of this life threatening arrhythmia typically requires the coordinated efforts of emergency medicine, critical care, cardiology, cardiac electrophysiology, and pacemaker experts.
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Natural history of patients with acute myocardial infarction has significantly improved in the last 20 years. The main reason for this progress was the introduction of effective reperfusion strategies. It has been clearly documented that the speed, extension, and duration of reperfusion are key prognostic factors. Mechanical reperfusion during primary percutaneous coronary interventions has been shown to be superior to fibrinolysis in order to achieve these ⋯ All the techniques able to positively interact with the ischemia-reperfusion process and that have been evaluated so far (stent, adjunctive pharmacological therapy, anti-embolic devices, etc.) will be discussed.
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Over the last decades, there has been a significant increase in incidence and prevalence of heart failure, a major cause of cardiac morbidity and mortality. Measurements of neurohormones, in particular B-type natriuretic peptide (BNP), can significantly improve diagnostic accuracy, and also correlate with long-term morbidity and mortality in patients with chronic heart failure presenting to the emergency department. ⋯ BNP is the first biomarker to prove its clinical value for the diagnosis of left ventricular systolic and diastolic dysfunction but also for the right ventricular dysfunction, guiding prognosis and therapy management. Emerging clinical data will help further refine biomarker-guided therapeutic and monitoring strategies involving BNP.
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Diagnosis of indeterminate mediastinal masses and staging of lung cancer poses a significant challenge. Options for tissue diagnoses include computed tomography (CT)-guided percutaneous biopsy, transbronchial fine-needle aspiration, mediastinoscopy/mediastinotomy or thoracoscopy, but these investigations have limitations in terms of tissue yield, safety profile and cost. Trans-esophageal endoscopic ultrasound scanning (EUS) is a new minimal invasive method that provides high resolution imaging of the mediastinum using high frequency ultrasound probes attached to the tip of a flexible endoscope and offers in addition the facility of fine needle aspiration (EUS-FNA) or tru-cut biopsy (TCB) under real-time ultrasound guidance. ⋯ Recently, endobronchial ultrasound guided transbronchial needle aspiration Biopsy (EBUS-TBNA) has been developed and several publications have now documented high diagnostic values with sensitivities of more than 90% in the staging of NSCLC. A recent publication from our group has documented a sensitivity and specificity of 100% when EUS-FNA and EBUS-TBNA is used in combination for staging of the mediastinum. It seems therefore logical to assume that the combination of EUS-FNA and EBUS-TBNA will replace more invasive methods such as mediastinoscopy for diagnosis and staging of lung cancers in the near future.
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Accurate cancer staging allows the most favorable therapy and prognosis of a neoplastic process, and allows consistency when performing clinical trials for different stages of tumors. In the case of non small-cell lung cancer (NSCLC), the most important parameters for optimal treatment and prognosis are the presence of cancer spread to the lymph nodes within the mediastinum, and to distant organs. ⋯ The capability of performing fine needle aspiration (FNA) has greatly improved the accuracy and popularity of EUS for lung cancer staging. This review will outline the basic principals of lung cancer staging, EUS-FNA techniques, and role of EUS-FNA in lung cancer staging.