Dr.Proxy

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Final clinical trials are currently underway in the United States and Europe testing sugammadex, a member of a new class of reversal drugs, which may dramatically alter the practice of anesthesiology. Su refers to sugar and gammadex refers to the structural molecule, a modified cyclodextrin.

Mechanism of Action

The three-dimensional structure of sugammadex resembles a doughnut with a hydrophobic cavity and a hydrophilic exterior. Hydrophobic interactions trap the drug into the cyclodextrin cavity (the doughnut hole) forming a very tight complex at a 1:1 ratio with steroidal neuromuscular blocking drugs (rocuronium > vecuronium >> pancuronium) causing a rapid and long-acting reversal of neuromuscular blockade.

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Why EndNote?

EndNote is a leading bibliographic software product on the market. But will it be valuable for me?  Is it worth the time required to learn how to use it?  Perhaps a good way to evaluate these questions for yourself is to consider a few examples of how people can use EndNote.

Using EndNote to import citations from saved literature searches

Joan is a medical researcher who works for a state hospital. Her responsibilities include tracking the latest findings in medical literature and consulting with physicians. Joan searches PubMed and other databases for the latest information on the topics she is tracking and then saves her citations. She easily downloads references into her EndNote library, with hyperlinks that allow her to go directly from a reference to its location on the Web. Joan has designed her library so that she can easily sort her reference list by special criteria unique to her needs.

Developing a personal library of references

Donna is doing an historical research project about communities surrounding textile mills. Her resources include books, newspaper articles, photographs, correspondence, personal interviews, and government documents. She uses EndNote as a tool for cataloging and tracking the diverse information she collects. As she adds references to her EndNote library, she adds notes for each entry. This helps her remember what she wanted to use from each source when she writes her book.

Creating and formatting citations for papers and publications

Bill is a Public Health graduate student writing his PhD dissertation.  He uses EndNote to keep track of his ever-expanding group of source materials. As he writes, he inserts citations into his paper. They are automatically formatted according to the format style required by his university. He will also use EndNote to generate a properly formatted bibliography. Bill is writing some shorter papers that he wants to submit to several different journals. He uses the same EndNote library for these papers, and he will use Endnote to reformat the citations into whatever styles are required by the publishers.
These are a few examples of ways you can use EndNote. Endnote is flexible, so you can customize it to suit your needs. You may find that as you continue to add references to your library, EndNote becomes more and more essential to your work.


More  : http://www.endnote.com/

October 20, 2010 — Chest compressions should be the first step in addressing cardiac arrest. Therefore, the American Heart Association (AHA) now recommends that the A-B-Cs (Airway-Breathing-Compressions) of cardiopulmonary resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing).
The changes were documented in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in the November 2 supplemental issue of Circulation: Journal of the American Heart Association, and represent an update to previous guidelines issued in 2005.
"The 2010 AHA Guidelines for CPR and ECC [Emergency Cardiovascular Care] are based on the most current and comprehensive review of resuscitation literature ever published," note the authors in the executive summary. The new research includes information from "356 resuscitation experts from 29 countries who reviewed, analyzed, evaluated, debated, and discussed research and hypotheses through in-person meetings, teleconferences, and online sessions ('webinars') during the 36-month period before the 2010 Consensus Conference."
According to the AHA, chest compressions should be started immediately on anyone who is unresponsive and is not breathing normally. Oxygen will be present in the lungs and bloodstream within the first few minutes, so initiating chest compressions first will facilitate distribution of that oxygen into the brain and heart sooner. Previously, starting with "A" (airway) rather than "C" (compressions) caused significant delays of approximately 30 seconds.
"For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim's airway by tilting their head back, pinching the nose and breathing into the victim's mouth, and only then giving chest compressions," noted Michael R. Sayre, MD, coauthor and chairman of the AHA's Emergency Cardiovascular Care Committee, in an AHA written release. "This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body," he added.
The new guidelines also recommend that during CPR, rescuers increase the speed of chest compressions to a rate of at least 100 times a minute. In addition, compressions should be made more deeply into the chest, to a depth of at least 2 inches in adults and children and 1.5 inches in infants.
Persons performing CPR should also avoid leaning on the chest so that it can return to its starting position, and compression should be continued as long as possible without the use of excessive ventilation.
9-1-1 centers are now directed to deliver instructions assertively so that chest compressions can be started when cardiac arrest is suspected.
The new guidelines also recommend more strongly that dispatchers instruct untrained lay rescuers to provide Hands-Only CPR (chest compression only) for adults who are unresponsive, with no breathing or no normal breathing.
Other Key Recommendations
Other key recommendations for healthcare professionals performing CPR include the following:

• Effective teamwork techniques should be learned and practiced regularly.
• Quantitative waveform capnography, used to measure carbon dioxide output, should be used to confirm intubation and monitor CPR quality.
• Therapeutic hypothermia should be part of an overall interdisciplinary system of care after resuscitation from cardiac arrest.
• Atropine is no longer recommended for routine use in managing and treating pulseless electrical activity or asystole.

Pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of continuous CPR. The new guidelines also discuss resuscitation of infants and children with various congenital heart diseases and pulmonary hypertension.
The authors of the guidelines have disclosed no relevant financial relationships.
Circulation. 2010;122[suppl 3]:S640-S656.
Additional Resource
The 2010 AHA guidelines for CPR and emergency cardiovascular care are available on the AHA Web site.

Clinical Context

Study Highlights

• The AHA has rearranged the A-B-Cs (Airway-Breathing-Compressions) of CPR to C-A-B (Compressions-Airway-Breathing).
• Chest compressions are therefore the first step for lay and professional rescuers to revive an individual with sudden cardiac arrest.
• This change in CPR sequence applies to adults, children, and infants, but excludes newborns.
• "Look, Listen and Feel" has been removed from the basic life support algorithm.
• Other changes in CPR recommendations for basic life support include the following:
  • Rate of chest compressions should be at least 100 times a minute.
  • Rescuers should push deeper on the chest, resulting in compressions of at least 2 inches in adults and children and 1.5 inches in infants.
  • Between each compression, rescuers should avoid leaning on the chest so that it can return to the starting position.
  • Rescuers should avoid stopping chest compressions and avoid excessive ventilation.
  • All 9-1-1 centers should assertively give telephone instructions to start chest compressions (Hands-Only CPR) when cardiac arrest is suspected in adults who are unresponsive, with no breathing or no normal breathing.
• Dispatchers should provide instructions in conventional CPR for individuals who have presumably drowned or have had other likely asphyxial arrest.
• For attempted defibrillation with an automated external defibrillator of children 1 to 8 years old, the rescuer should use a pediatric dose-attenuator system if one is available, or a standard automated external defibrillator if the pediatric dose-attenuator system is not available.
• A manual defibrillator is preferred for infants younger than 1 year.
• Key guidelines recommendations for healthcare professionals include the following:
  • Effective teamwork techniques should be learned and practiced regularly.
  • To confirm intubation and monitor CPR quality, professional rescuers should use quantitative waveform capnography to measure and monitor carbon dioxide output.
  • Therapeutic hypothermia should be incorporated into the overall interdisciplinary system of care after resuscitation from cardiac arrest.
  • For management and treatment of pulseless electrical activity (asystole), atropine is no longer recommended for routine use.
• The new guidelines do not recommend routine use of cricoid pressure in cardiac arrest.
• For the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic wide-complex tachycardia, adenosine is recommended.
• Pediatric advanced life support guidelines offer new strategies for resuscitating infants and children with certain congenital heart diseases and pulmonary hypertension.
• The pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of uninterrupted CPR.

Clinical Implications

• In its latest guidelines, the AHA has rearranged the A-B-Cs of CPR to C-A-B. This change in CPR sequence applies to adults, children, and infants, but excludes newborns.
• Key guidelines recommendations for healthcare professionals include focus on effective teamwork techniques, use of quantitative waveform capnography, and incorporation of therapeutic hypothermia into the overall interdisciplinary system of care. Atropine is no longer recommended for routine use for management of pulseless electrical activity (asystole).

Author: Ian S deSouza, MD, Assistant Professor, Department of Emergency Medicine, Kings County Hospital/SUNY Downstate Medical Centers
Coauthor(s): Che' Damon Ward, MD, Staff Physician, Department of Emergency Medicine, State University of New York Health Science Center at Brooklyn

Introduction

Background

Ventricular tachycardia (VT) is a tachydysrhythmia originating from a ventricular ectopic focus, characterized by a rate typically greater than 120 beats per minute with wide QRS complexes. VT may be monomorphic (originating from a single focus with identical QRS complexes) or polymorphic (may appear as an irregular rhythm, with varying QRS amplitudes and morphology). Nonsustained VT is defined as a run of tachycardia of less than 30 seconds duration; longer runs are considered sustained VT.

No absolute ECG criteria exist for establishing the presence of VT. However, several factors suggest VT, including the following:

• Rate greater than 120 beats per minute (usually 150-200)
• Wide QRS complexes (>140 ms)
• Presence of atrioventricular (AV) dissociation
• Fusion beats
• Capture beats

Other historical factors suggesting VT are prior ischemic or structural heart disease. It may exist without cardiovascular collapse but when hemodynamic compromise occurs, it may deteriorate rapidly into a more malignant dysrhythmia: ventricular fibrillation (VF). Therefore, this tachydysrhythmia must be addressed swiftly to avoid morbidity or mortality.

Pathophysiology

Ventricular tachycardia (VT) is usually a consequence of structural or ischemic heart disease, with breakdown of normal conduction patterns. Abnormal automaticity (which tends to favor ectopic foci) or activation of reentrant pathways in the myocardium can exist to generate the dysrhythmia. Electrolyte disturbances, ischemia, and sympathomimetics may increase the likelihood of VT in the susceptible myocardium.

AV dissociation, shown in the image below, is apparent in approximately half of VT episodes, and when present, it is a hallmark characteristic of VT.¹ This occurs because the sinus node is depolarizing the atria at a rate that is slower than the pathologic, faster ventricular rate. P waves can be visualized at times in between or embedded in the QRS complexes, but the P waves and QRS complexes have their own independent rates.