Swiss medical weekly
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Invasive candidiasis is rare in the general population (about 8 episodes/100,000/year), but has a higher incidence in hospitalised patients (0.5/1000 admissions). It complicates about 10 per 1000 admissions in critical care, where it represents 10-15% of all nosocomial infections. ⋯ Prophylaxis of invasive candidiasis, which is very effective, is based on risk factor identification. However, prophylaxis must be restricted to carefully selected groups of patients, to avoid the emergence of resistant strains and a shift in the distribution of pathogens from albicans to non-albicans strains under the pressure of antifungal agents.
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Swiss medical weekly · Oct 2000
ReviewPathophysiology of brain insult. Therapeutic implications with the Lund Concept.
This paper describes some major implications of brain insult following trauma or intracerebral haemorrhage for the development of brain oedema and compromised microcirculation. Secondary insults such as an increase in intracranial pressure and development of contusion and penumbra zone areas, as well as their bearing on outcome, are discussed. A therapeutic protocol is presented which aims at keeping intracranial volume within acceptable limits by counteraction of interstitial brain oedema, reduction in intracerebral blood volume, and improvement of microcirculation around contusions. This ICP-targeted therapy, called the "Lund Concept", for treatment of severe head injury has resulted in marked reduction in mortality following brain trauma.
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In trauma patients it is mandatory to establish the exact reason for their hypotension. If hypovolaemia is most probably responsible for the hypotension, fluid resuscitation should be initiated. The therapy of choice is infusion of sugarless, isotonic crystalloids with a physiologic serum electrolyte composition. ⋯ Larger blood losses must be treated with blood components such as packed red cells, fresh frozen plasma and thrombocyte concentrates as indicated. There are no widely accepted values for laboratory or monitoring parameters in starting or stopping a given fluid therapy; these values are unquestionably influenced, among other things, by the patient history and the pattern of the injuries. Initial resuscitation (when to start, who should administer the fluid and how much) also remains a focus of heated controversy.
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In trauma patients restoration of intravascular volume in an attempt to achieve normal systemic pressure faces the risk of increasing blood loss and thereby potentially affecting mortality. Due to the lack of controlled clinical trials in this field, the growing evidence that hypotensive resuscitation results in improved long-term survival mainly stems from experimental studies in animals. The main differences between concepts for the reduction of blood loss in systemic hypotension are between "deliberate hypotension" (synonym "controlled hypotension", used intraoperatively), "delayed resuscitation" (where the hypotensive period is intentionally prolonged until operative intervention) and "permissive hypotension" (where restrictive fluid therapy increases systemic pressure without reaching normotension). In this review the concept of "permissive hypotension" is delineated on the basis of macro- and microcirculatory changes secondary to hypovolaemia and low driving pressure, and the potential indications and limitations are discussed.
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Swiss medical weekly · Oct 2000
Case Reports[Endemic and imported severe leptospirosis (Weil's disease) in southern Switzerland].
We report on 4 cases of severe icteric leptospirosis. Three patients developed renal failure requiring haemodialysis and one required mechanic ventilation for 10 days. On entry all patients presented with severe myalgia, particularly in the calves, jaundice, oligo-anuria and severe thrombocytopenia. ⋯ Three out of 4 patients were infected in southern Switzerland. This observation underscores the importance of wild and domestic animals as a leptospira reservoir. Patients presenting with acute renal failure and jaundice, but only mild-to-moderate elevation of transaminases, are suspect for leptospirosis regardless of travel to a tropical or subtropical country.