Deep insight into the complex mechanisms of myocardial ischemia-reperfusion injury has been attained in the past years. Minocycline is a second-generation tetracycline with US FDA approval for clinical use in various infections. Lately, several noninfectious cytoprotective activities of minocycline have been discovered as well. There now exists encouraging evidence of its protective role in cardiovascular pathology and its activity against myocardial ischemia-reperfusion injury. In this article, an overview of the major mechanisms involved in myocardial ischemia-reperfusion injury is presented. This is followed by an analysis of the mechanisms by which minocycline exerts its cytoprotective role and of studies that have been conducted in order to analyze minocycline, along with a review of the scope and limitations of its role as a cytoprotective agent.
Cardiac and renal dysfunction often coexist, and one begets the other. The association is referred to as cardiorenal syndrome. One subtype, acute cardiorenal syndrome, is often described as a clinical scenario in which acute worsening of cardiac function leads to acute kidney injury. Though this definition covers the basic pathophysiologic framework, a robust clinical definition is still lacking. Acute cardiorenal syndrome is common and often leads to emergency room visits and hospitalization. Our understanding of the hemodynamic mechanisms of acute cardiorenal syndrome is advancing. Correction of hypervolemia is the mainstay of therapy.
An 82-year-old man with a history of end-stage renal disease presented with progressively worsening confusion and somnolence for the past 4-5 days. The patient was diagnosed with herpes zoster by his primary care physician 5 days ago and was started on a course of valacyclovir 1 g three times a day (dose not adjusted for renal impairment).A lumbar puncture was performed and cerebrospinal fluid (CSF) studies revealed 37 white blood cells (WBCs)/hpf (100% monocytes), protein 64 mg/dL and glucose 52 mg/dL. He was started on ceftriaxone, ampicillin and acyclovir. MRI of the brain was done and was unremarkable. Acyclovir-induced encephalopathy was high on differential, but his CSF findings were concerning for viral encephalitis. Nonetheless, all antimicrobials were discontinued and he was scheduled for a 5-hour dialysis session. The very next day, he showed immense improvement and eventually recovered completely. CSF PCR tests for both herpes simplex virus and varicella zoster virus came back negative.
Extracorporeal membrane oxygenation (ECMO) may be used in extreme circumstances for patients with a mediastinal mass and respiratory failure. We report on a young man with primary mediastinal B‐cell lymphoma invading into the trachea, requiring a 40‐day ECMO run who underwent fluorodeoxyglucose positron emission tomography (FDG‐PET) imaging and treatment with concurrent mediastinal irradiation and continuous infusion chemotherapy while on this life‐saving technology. This case illustrates that oncology patients may be managed by multidisciplinary teams for extended periods in extraordinary circumstances using multimodality therapies. Additionally, to our knowledge this is the first case to demonstrate the feasibility of FDG‐PET imaging while on ECMO.
Administration of fluid is a cornerstone of supportive care for sepsis. Current guidelines suggest a protocolized approach to fluid resuscitation in sepsis despite a lack of strong physiological or clinical evidence to support it. Both initial and ongoing fluid resuscitation requires careful consideration, as fluid overload has been shown to be associated with increased risk for mortality. Initial fluid resuscitation should favor balanced crystalloids over isotonic saline, as the former is associated with decreased risk of renal dysfunction. Traditionally selected resuscitation targets, such as lactate elevation, are fraught with limitations. For developing or established septic shock, a focused hemodynamic assessment is needed to determine if fluid is likely to be beneficial. When initial fluid therapy is unable to achieve the blood pressure goal, initiation of early vasopressors and admission to intensive care should be favored over repetitive administration of fluid.
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