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Steroid Replacement in Critical Care

    • The relative contribution of genomic and nongenomic mechanisms to corticosteroids’ therapeutic effects varies with the dose administered; the higher the dose, the greater the contribution of nongenomic effects.
    • Steroid replacement may be associated with survival benefit in adults with sepsis or septic shock, acute respiratory distress syndrome, or community-acquired pneumonia.
    • In sepsis, corticosteroids are best administered within the first 24 hours of management and for at least 3 days at full dose.

Central Nervous System Infections

    • Serogroup B meningococcal vaccines. The incidence of community-acquired bacterial meningitis has declined over the past 30 years, in part due to the advancement and implementation of vaccination programs (Haemophilus influenzae type b [1987], Streptococcus pneumoniae or pneumococcal [2000], and Neisseria meningitidis or meningococcal [2005] vaccines) in the United States and western Europe
    • Use of steroids for bacterial meningitis. In patients with bacterial meningitis, dexamethasone delivered prior to (or simultaneously with) the initial empirical antibiotics and continued 4 days thereafter was associated with a significant reduction in the composite end point of death or significant neurologic disability and death at the 2-month follow-up compared with placebo
    • Development of molecular diagnostics (e.g., 16S polymerase chain reaction [PCR]) for identifying pathogens. Broad-range bacterial PCR amplifies species-specific gene coding for 16S ribosomal RNA of common pathogens; the sensitivity depending on the pathogen is 61 to 88% with specificities greater than 95%

Strategies of Hemodialysis Access

    • The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, MN) is an innovative approach to obtain permanent AV access in patients with subclavian and internal jugular venous occlusions not amenable to open or endovascular means of recanalization.
    • In 2016, data from the United States Renal Data System (USRDS) showed that 124,675 new patients began therapy for ESRD, whereas the prevalent dialysis population reached 726,331. Of note, after a continuous rise in ESRD patients between 1980 and 2010, for the first time a plateau or even slight decline was seen between 2010 and 2016.
    • A common tradeoff for the higher long-term patency rates associated with autogenous AV access is failure of maturation of the outflow vein, leading to inadequate venous dilation and either inability to successfully use the AV access for dialysis or early AV access failure. Initial success rates leading to a functional AV access range from 55 to 97%.

Strategies of Hemodialysis Access

    • The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, MN) is an innovative approach to obtain permanent AV access in patients with subclavian and internal jugular venous occlusions not amenable to open or endovascular means of recanalization.
    • In 2016, data from the United States Renal Data System (USRDS) showed that 124,675 new patients began therapy for ESRD, whereas the prevalent dialysis population reached 726,331. Of note, after a continuous rise in ESRD patients between 1980 and 2010, for the first time a plateau or even slight decline was seen between 2010 and 2016.
    • A common tradeoff for the higher long-term patency rates associated with autogenous AV access is failure of maturation of the outflow vein, leading to inadequate venous dilation and either inability to successfully use the AV access for dialysis or early AV access failure. Initial success rates leading to a functional AV access range from 55 to 97%.

Strategies of Hemodialysis Access

    • The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, MN) is an innovative approach to obtain permanent AV access in patients with subclavian and internal jugular venous occlusions not amenable to open or endovascular means of recanalization.
    • In 2016, data from the United States Renal Data System (USRDS) showed that 124,675 new patients began therapy for ESRD, whereas the prevalent dialysis population reached 726,331. Of note, after a continuous rise in ESRD patients between 1980 and 2010, for the first time a plateau or even slight decline was seen between 2010 and 2016.
    • A common tradeoff for the higher long-term patency rates associated with autogenous AV access is failure of maturation of the outflow vein, leading to inadequate venous dilation and either inability to successfully use the AV access for dialysis or early AV access failure. Initial success rates leading to a functional AV access range from 55 to 97%.

Neuroimaging for the Clinician

    • Advances in CT technology have led to the development of multidetector scanners, which can be used to obtain  dynamic images of blood flow, thus noninvasively approximating the data obtained from catheter-based angiography. Selective vessel angiography is not yet possible with this technique because contrast administration is intravenous.
    • Functional MRI allows for anatomic localization of neurons activated during specific tasks by measuring the hemodynamic response coupled to increased brain activity. Functional MRI can assist in localization of the primary and supplementary motor cortices, somatosensory cortices, visual cortices, Broca and Wernicke areas, and other brain regions. 
    • The conventional angiographic technique used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) compared lumen caliber at the point of maximal stenosis (often at or near the carotid bifurcation) with lumen caliber within a superior nonstenotic segment of the internal carotid artery to calculate  the percentage of stenosis. This approach could have greater spatial resolution than the more currently used  CT or MR angiography techniques.

Neuroimaging for the Clinician

    • Advances in CT technology have led to the development of multidetector scanners, which can be used to obtain  dynamic images of blood flow, thus noninvasively approximating the data obtained from catheter-based angiography. Selective vessel angiography is not yet possible with this technique because contrast administration is intravenous.
    • Functional MRI allows for anatomic localization of neurons activated during specific tasks by measuring the hemodynamic response coupled to increased brain activity. Functional MRI can assist in localization of the primary and supplementary motor cortices, somatosensory cortices, visual cortices, Broca and Wernicke areas, and other brain regions. 
    • The conventional angiographic technique used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) compared lumen caliber at the point of maximal stenosis (often at or near the carotid bifurcation) with lumen caliber within a superior nonstenotic segment of the internal carotid artery to calculate  the percentage of stenosis. This approach could have greater spatial resolution than the more currently used  CT or MR angiography techniques.

Neuroimaging for the Clinician

    • Advances in CT technology have led to the development of multidetector scanners, which can be used to obtain  dynamic images of blood flow, thus noninvasively approximating the data obtained from catheter-based angiography. Selective vessel angiography is not yet possible with this technique because contrast administration is intravenous.
    • Functional MRI allows for anatomic localization of neurons activated during specific tasks by measuring the hemodynamic response coupled to increased brain activity. Functional MRI can assist in localization of the primary and supplementary motor cortices, somatosensory cortices, visual cortices, Broca and Wernicke areas, and other brain regions. 
    • The conventional angiographic technique used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) compared lumen caliber at the point of maximal stenosis (often at or near the carotid bifurcation) with lumen caliber within a superior nonstenotic segment of the internal carotid artery to calculate  the percentage of stenosis. This approach could have greater spatial resolution than the more currently used  CT or MR angiography techniques.
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