Acute vascular endothelial dysfunction is a central event in the pathogenesis of sepsis, increasing vascular permeability, promoting activation of the coagulation cascade, tissue edema and compromising perfusion of vital organs. Aging and chronic diseases (hypertension, dyslipidaemia, diabetes mellitus, chronic kidney disease, cardiovascular disease, cerebrovascular disease, chronic pulmonary disease, liver disease, or cancer) are recognized risk factors for sepsis. In this article we review the features of endothelial dysfunction shared by sepsis, aging and the chronic conditions preceding this disease. Clinical studies and review articles on endothelial dysfunction in sepsis, aging and chronic diseases available in PubMed were considered. The main features of endothelial dysfunction shared by sepsis, aging and chronic diseases were: (1) increased oxidative stress and systemic inflammation, (2) glycocalyx degradation and shedding, (3) disassembly of intercellular junctions, endothelial cell death, blood-tissue barrier disruption, (4) enhanced leukocyte adhesion and extravasation, (5) induction of a pro-coagulant and anti-fibrinolytic state. In addition, chronic diseases impair the mechanisms of endothelial reparation. In conclusion, sepsis, aging and chronic diseases induce similar features of endothelial dysfunction. The potential contribution of pre-existent endothelial dysfunction to sepsis pathogenesis deserves to be further investigated.
Hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tPA). In contrast, when shock and hypoperfusion occur, activation of the protein C pathway and endothelial tPA release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. Both thrombotic and bleeding phenotypes are associated with increased mortality and are influenced by the extent and severity of tissue injury and degree of hemorrhagic shock. Response to trauma is a complex, dynamic process in which risk can shift from bleeding to thrombosis depending on the injury pattern, hemostatic treatment, individual responses, genetic predisposition, and comorbidities. Based on this body of knowledge, we will review and consider future directions for the management of severely injured trauma patients.
Forensic entomology is a scientific tool applied to the study of insect or arthropod succession at the scene of a crime or that associated with an accident or natural death. Interpreting this succession provides information to determine minimum and maximum limits of the Postmortem Interval (PMI), that is, the time between death and the discovery of the body. This study was carried out during the rainy season, from 27 October to 12 December 2002 in an urban area of the city of Medellín, Colombia. Three domestic pigs were used as animal models. The results showed that both the aforementioned species as well as the physical characteristics of the carcass determined the indicator species of the postmortem interval in urban areas of the city. In total, 11,937 individuals were collected and identified, belonging to 12 orders, 29 families and 42 genera. Diptera were the most abundant order (90%) represented mainly by Calliphoridae (80%). Coleoptera were scarcely present, representing only 2.8% of the total collected. Based on information obtained of eggs and larvae reared to adult of this successional study, an occurrence matrix was elaborated for determining of the PMI. From the same study area and under the same conditions, a list of arthropods associated with carrion is presented in this manuscript.
It is the first study to detect increasing levels of endotoxemia following multiple trauma. Shock and early surgery predict the development of endotoxemia; endotoxemia is particularly associated with cardiovascular dysfunction. However, Gram-negative infections are uncommon in these patients, suggesting that the gastrointestinal tract is the dominant reservoir of endotoxin. Endotoxin may be an appropriate therapeutic target in patients who have sustained severe multiple trauma.
Sirs, Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is currently the most common therapeutic surgical procedure for patients with advanced ParkinsonÕs disease (PD) and motor complications, not controlled by the pharmacological treatment. The success of the post-operative clinical outcome depends on careful patient selection and an optimal targeting of the STN. To improve the location accuracy of this nucleus, intraoperative microrecordings are performed in most centres. The standard procedure of electrodes implantation is usually carried out under local anaesthesia [1]. Experience in intraoperative microrecording of STN under general anaesthesia is scarce [2], and neuronal firing patterns are not well typified.We describe the intraoperative microrecording results obtained from a patient with advanced PD who underwent implantation of DBS electrodes in the STN under general anaesthesia using Bispectral Analysis of the Electroencephalogram (BIS). This technique allows hypnotic titration over the complete range of cortical activity. A BIS value of 65-85 is recommended for sedation and 40-65 for general anaesthesia [3]. BIS values correspond linearly to the hypnotic dose of intravenous or volatile agents [4] and, therefore, it allows changing the level of sedation and analgesia rapidly to accommodate specific requirements such as intraoperative microrecording.A 59-year-old man with a 7-year history of PD complicated with motor fluctuations and dyskinesias was scheduled for DBS of STN. General anaesthesia was used during the surgical procedure because the patient experienced a severe painful cervical dystonia which prevented positioning the stereotactic frame.Propofol 200 mg, fentanyl 150 lg and cisatracurium 10 mg were administered, then target propofol and remifentanyl concentrations were adjusted to achieve a BIS value of 60-65 during microrecordings, the lightest level of a general anaesthesia.
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