Articles: disease.
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Apoptosis is a highly regulated process of cell deletion and plays a fundamental role in the maintenance of tissue homeostasis in the adult organism. Numerous studies in recent years have revealed that apoptosis is a constitutive suicide programme expressed in most, if not all cells, and can be triggered by a variety of extrinsic and intrinsic signals. ⋯ In addition, defective macrophage engulfment and degradation of cell corpses may also contribute to a dysregulation of tissue homeostasis. An increased understanding of the signalling pathways that govern the execution of apoptosis and the subsequent clearance of dying cells may thus yield novel targets for therapeutic intervention in a wide range of human maladies.
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To evaluate the evidence regarding decisions made in the perioperative management of patients undergoing ambulatory surgery for the following: the elderly, hyper-reactive airways disease, coronary artery disease, diabetes, obesity, obstructive sleep apnea, the ex-premature infant and the child with an upper respiratory infection. ⋯ Evidence indicates that ambulatory anesthesia is currently very safe. Ambulatory surgery, however, is being offered to a population with increasing co-morbidity. As the population undergoing ambulatory surgery changes over time, the evidence regarding patient outcomes will need re-examination.
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The aim of this article is to review current practice of spinal anesthesia regarding technique and medication use; review recent applications of spinal anesthesia to subspecialty care in outpatient, cardiac, and obstetrical anesthesia; and update risk assessment associated with spinal anesthesia. ⋯ Innovations in technology, equipment, and needle design improved safety and decreased complication rates from spinal anesthesia. The increased popularity of ambulatory surgical procedures has resulted in more frequent use of spinal anesthesia. Intrathecal narcotic analgesia is used increasingly in fast-tracking cardiac surgical protocols. Modern anesthetic and analgesic techniques include resurgence of older agents (2-chloroprocaine) as well as new agents (levobupivacaine and ropivacaine) that are used in conjunction with adjuvant intrathecal medications (opioids, vasopressors, and alpha-2 adrenergic agonists). Surgical thromboprophylaxis and the increased use of anticoagulants in patients with cardiovascular disease have challenged anesthesiologists to update clinical guidelines to minimize the risk of hemorrhagic complications such as epidural hematoma. The risk/benefit ratio of spinal anesthesia should be individualized. The continued popularity of spinal anesthesia is due to the safety, effectiveness and efficiency of this technique.
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Analysis of recent data indicates a clear benefit of carotid endarterectomy for symptomatic patients with high-grade carotid artery stenosis, and a marginal benefit for asymptomatic patients. Despite myriad challenges presented by patients undergoing carotid endarterectomy, excellent outcomes have been achieved and many centers have shown the technique to be safe as an outpatient procedure for specific populations. Greater attention to comorbidities and their management in the perioperative period is increasingly important as older and more complex patients present for invasive treatment of carotid disease. Scientific study aimed at defining which characteristics merit our attention will only lead to improved outcomes and greater understanding of carotid disease, endarterectomy and anesthesia. While controversial, the efficacy, safety, and durability of stenting and angioplasty have improved in recent years. Potential advantages of stenting and angioplasty of the carotid artery include avoiding cranial nerve damage, wound hematoma, and general anesthesia. Staying abreast of the science regarding such endovascular therapies will be increasingly important. ⋯ Patients with significant comorbidities may be managed safely by a variety of anesthetic techniques. Maintaining hemodynamic stability and monitoring cerebral oxygen delivery remain important goals of perioperative management. Recent data regarding the durability and safety of stenting and angioplasty of the carotid artery suggest that outcomes may approach those of carotid endarterectomy.