Harefuah
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Review
[Neutrophil gelatinase-associated lipocalin (NAGL): a novel biomarker for acute kidney injury].
The incidence of both acute and chronic kidney diseases is persistently increasing and is reaching epidemic proportions. Early therapeutic intervention may significantly decrease the morbidity and mortality rates among these patients. However, the lack of early non-invasive biomarkers has hampered our ability to diagnose kidney diseases as early as possible, and subsequently, to initiate timely, effective, and appropriate treatment. ⋯ In the last few years various specific biomarkers for kidney diseases were discovered and the most reliable representative is neutrophil gelatinase-associated lipocalin (NGAL), which is the focus of this review. Several studies have demonstrated that plasma and urinary NGAL levels increase two hours after the induction of acute kidney injury (AKI) in several clinical situations such as cardiac surgery, radiocontrast nephropathy, kidney transplantation, hemolytic uremic syndrome and critically ill patients in intensive care unit. Serum and urine concentrations of NGAL increase before those of creatinine, making this biomarker a powerful tool for early detection of renal disease, thus hopefully to reduce the high mortality rate among patients with AKI.
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With raised life expectancy, there is a constant elevation in the percentage of elderly people in the general population. Consequently, the age of the surgical patient increases. This progressive process results in operating on patients who were considered 'too old for surgery' a decade ago. ⋯ As a result, the elderly surgical patients have higher rates of peri-operative morbidity and mortality. Anesthesia and peri-operative care should be customized to this population. Practicing management of older patients undergoing surgery will increase the experience of all caregivers and, in time, improve outcome.
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Uncontrolled bleeding is a major cause for early death in both military and civilian trauma. The process of massive bleeding which begins as "surgical bleed" from injured vessels may rapidly evolve into a complex coagulopathy that can be detected early, sometimes within minutes of injury. The magnitude of coagulopathy is directly related to the severity of the injury and its presence is also an independent predictor of early mortality. ⋯ An important breakthrough was the understanding that abnormal coagulation tests early in the process of trauma are not the consequences of disseminated intravascular coagulation (DIC). Supported by these new data, an aggressive approach to hemostatic resuscitation was developed which is based on the following principles: permissive hypotension to avoid "dilutional" coagulopathy, awareness of the prevention of hypothermia and acidosis and the use of hemostatic agents such as rFVIIa, fibrinogen concentrate and tranexamic acid early in the course of trauma. Importantly, the common practice of blood component therapy was revised and it is recommended that RBC, FFP and platelets will be transfused early and preferably in 1:1:1 ratio.
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Somatoform disorders among children and adolescents may cause impairment in educational and social functioning and generate a great deal of psychosocial distress. The diagnosis of such disorders is complex due to the fact that they may appear as medical conditions. Hence, most of somatoform patients do not seek psychiatric assistance. ⋯ SSRI'S are effective in somatoform disorders that have co-morbidity with anxiety and depression as well as in body dysmorphic disorder and hypochondriasis. Conversion disorder is usually treated with benzodiazepines and pain disorder with light analgesics, tricyclics and tegretol. In terms of psychotherapy, treatments most effective for somatoform disorders have been found to be cognitive-behavioral therapy, hypnosis and biofeedback.
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The current article revolves upon the challenge of diagnosing free peritoneal air in an abdominal X-ray. We present an 80 year old lady who was admitted due to abdominal pain and vomiting. On an acute abdomen XR series, a small amount of free air was suspected, but this was inconclusive. ⋯ It is advised to have the patient stand or lie in the left decubitus position for 10-15 minutes before the X-rays are conducted. Use of high resolution monitors to enhance the visual acuity and consulting an expert radiologist can help when in doubt. If one is still not sure, it is recommended to perform a CT scan, which is the gold standard for detecting free peritoneal air.