What’s New in Scientific American™ Medicine:

  • Approach to the Patient with Shock
  • Cardiac Arrest and Resuscitation
  • Pacemaker Therapy
  • Chorea: Classification, Differential Diagnosis, and Treatment
  • Toxic Gases
  • Toxic Plants and Mushrooms
  • Transplant Immunology: Basic Immunology and Clinical Practice
  • Clinical Trial Design and Statistics


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Pulmonary & Critical Care Medicine

Approach to the Patient with Shock

DAVID C. MACKENZIE, MD, CM
Director of Emergency Ultrasound, Maine Medicine Medical Center, Portland ME, Assistant Professor of Emergency Medicine, Tufts University School of Medicine, Boston, MA

The Categories of Shock

There are four main categories of shock: hypovolemic, distributive, cardiogenic, and obstructive. Although the main end point (i.e., inadequate delivery of oxygenated blood to the body’s tissues and organs) of each of these categories of shock is the same, the pathophysiologic mechanisms differ. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with shock.

 


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Pulmonary & Critical Care Medicine

Cardiac Arrest and Resuscitation

JENNIFER L. MARTINDALE, MD
Emergency Medicine, SUNY Downstate Medical Center/Kings County Hospital, Brooklyn, NY
CHARLES N. POZNER, MD
Neil and Elise Wallace STRATUS Center for Medical Simulation, Brigham and Women’s Hospital; Medicine and Emergency Medicine, Harvard Medical School, Boston, MA

Interest in supraglottic devices grew as a result of concerns regarding complications associated with endotracheal tube placement, including failed attempts, unrecognized tube misplacement, and interrupted compressions. In contrast to endotracheal intubation, supraglottic devices, which include the laryngeal mask airway, the esophagotracheal tube, and the laryngeal tube airway, can be placed quickly with minimal interruption in compressions and used with minimal training. Recent observational studies have shown lower rates of return of spontaneous circulation and slightly lower or no difference in neurologically favorable survival rates associated with supraglottic airway devices compared with endotracheal intubation. In the patient with return of spontaneous circulation, these temporary airway devices should be replaced with an endotracheal tube if airway maintenance and ventilatory support are still necessary.

 


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Cardiovascular Medicine

Pacemaker Therapy

SHAMAI A. GROSSMAN, MD, MS
Associate Professor of Emergency Medicine, Harvard Medical School, Vice Chair for Health Care Quality, Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, MA

Pacemaker Support

The number of permanent pacemakers implanted per year increased by 55.6% between 1993 and 2009, and is continuing to rise. Accordingly, the number of patients treated in the emergency department who have permanent pacemakers is increasing, and it is important for physicians in the emergency department to be familiar with the operation and potential complications of these devices.

 


Neurology

Chorea: Classification, Differential Diagnosis, and Treatment

JAMES P. BATTISTA, MD
Movement Disorders Division, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
RUTH H. WALKER, MD, ChB, PhD
Movement Disorders Clinic, Department of Neurology, James J. Peters VAMC, Bronx, NY; Movement Disorders Division, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY

Treatment Plan for Chorea

The ideal treatment plan for chorea is a multidisciplinary, holistic approach, incorporating a variety of nonmedical aspects of therapy, including physical, occupational, and speech therapists, in addition to psychologists, nurses, and social workers. If there is a reversible cause of chorea, such as a metabolic abnormality, an autoimmune process, or a causative medication, this should be addressed initially and may result in the resolution of the movement disorder. The management of chorea and other aspects of basal ganglia neurodegenerative disorders is extrapolated predominantly from experience in Huntington disease; however, there is as yet no evidence that any agent slows disease progression in this or in other neurodegenerative disorders. At present, treatment is focused on symptomatic management.

 


Toxic Gases

STEPHANIE T. WEISS, MD, PhD
Associate Director, Emergency Medicine, Morton Hospital and Medical Center, Taunton, MA
KATHRYN W. WEIBRECHT, MD, PhD
Associate Director, Emergency Medicine, Morton Hospital and Medical Center, Taunton, MA

Treatments for Toxic Gases

Normobaric oxygen and hyperbaric oxygen are the two main treatments for carbon monoxide, although studies have been inconclusive in regards to the effectiveness of hyperbaric oxygen. The Cyanokit (containing hydroxocobalamin) is considered to be more effective for hydrogen cyanide when compared with the Cyanide Antidote Kit due to the former’s low toxicity and high effectiveness. Hydrogen sulfide is often used as a suicide agent, the mortality of which is close to 100%.

 


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Toxic Plants and Mushrooms

MARIE KING, MD, PhD
Emergency Physician, Harrington Hospital, Southbridge, MA
RICHARD CHURCH, MD
Assistant Professor, Emergency Medicine and Toxicology, University of Massachusetts, Worcester, MA

Knowing Your Flora and Fungi

Many species of plants and mushrooms exist that, when consumed, can induce poisoning in individuals, causing a range of side effects. As the toxins do not always correspond to an antidote, it is important to have the ability to identify each harmful species to determine the appropriate treatment.

 


Transplant Immunology: Basic Immunology and Clinical Practice

LUNG-YI LEE, MD
DAVID P. FOLEY, MD
Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

Belatacept Treatment

Belatacept, a human fusion protein that combines a modified extracellular portion of CTLA-4 with the constant region fragment (Fc) of human IgG1, is a novel agent that was approved by the US Food and Drug Administration in June 2011 to be used to prevent acute rejection in renal transplant patients. Belatacept confers better renal function compared with cyclosporine, with a comparable safety profile, and no differences have been found between belatacept and calcineurin inhibitors in the prevention of acute rejection, graft loss, and death. However, belatacept treatment is associated with less chronic kidney scarring and better renal transplant function.

 


Clinical Trial Design and Statistics

SAMANTHA M. THOMAS, MS
Department of Biostatistics & Bioinformatics, Duke Cancer Institute, Durham, NC
APRIL K. S. SALAMA, MD
Division of Medical Oncology, Duke University School of Medicine, Durham, NC
JULIE ANN SOSA, MD, MA, FACS
Endocrine Neoplasia Diseases Group, Duke Cancer Institute and Duke Clinical Research Institute, Durham, NC

Fast-Track Therapy and the FDA Safety and Innovation Act

Because of the complex nature of clinical trial design, significant resources and infrastructure are invested in drug development. Many drugs fail to progress beyond the phase I/II stage, and many phase III trials take years to accrue and publish results, leading to a delay in Food and Drug Administration (FDA) approval for diseases that desperately need better therapeutic options. The relatively recent FDA Safety and Innovation Act has allowed for the creation of priority and expedited review for drugs and biologics in serious conditions and where there is an unmet medical need. The designation of fast-track or breakthrough therapy may be granted when there is preclinical or clinical evidence to suggest that the intervention may result in a substantial improvement over currently available therapies.

 


SAM-CTA

Written By

decker

The Decker Team