dr. Erwin Kurniawan

Selasa, 20 Mei 2014

Early Goal-Directed Therapy in Sepsis

In hypotension persists despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl), goals in the first 6 hours of resuscitation include:

CVP of 8-12 mmHg. Mechanical ventilation, increased abdominal pressure, and preexisting impaired ventricular compliance may require higher CVP targets of 12-15 mmHg^[5]

Superior vena oxygen saturation (ScvO2) of > 70% OR mixed venous oxygen saturation (SvO2) of > 65%. If initial fluid resuscitation fails to achieve adequate oxygen saturation additional options include dobutamine infusion (maximum 20 µg/kg/min) or transfusion of packed red blood cells to a hematocrit ≥ 30%. If a ScvO2 is unavailable, lactate normalization may be used as a surrogate marker. A reduction in lactate by ≥ 10% is noninferior to achieving a ScvO2 of ≥ 70% ^[6]

Achieve MAP ≥ 65mmHg^[5] The presence of atherosclerosis or pre-existing uncontrolled hypertension may necessitate a higher MAP target.
Achieve Urine output ≥ 0.5 mL/kg/h^[5]

Successful targeting the above goals in the first 6-hour period results in a 15.9% absolute reduction in 28-day mortality rate.

Senin, 19 November 2012

Brodmann areas

http://en.wikipedia.org/wiki/Brodmann_area

Brodmann areas for human & non-human primates

Areas 3, 1 & 2 - Primary Somatosensory Cortex (frequently referred to as Areas 3, 1, 2 by convention)
Area 4 - Primary Motor Cortex
Area 5 - Somatosensory Association Cortex
Area 6 - Premotor cortex and Supplementary Motor Cortex (Secondary Motor Cortex)(Supplementary motor area)
Area 7 - Somatosensory Association Cortex
Area 8 - Includes Frontal eye fields
Area 9 - Dorsolateral prefrontal cortex
Area 10 - Anterior prefrontal cortex (most rostral part of superior and middle frontal gyri)
Area 11 - Orbitofrontal area (orbital and rectus gyri, plus part of the rostral part of the superior frontal gyrus)
Area 12 - Orbitofrontal area (used to be part of BA11, refers to the area between the superior frontal gyrus and the inferior rostral sulcus)
Area 13 and Area 14^* - Insular cortex
Area 15^* - Anterior Temporal Lobe
Area 17 - Primary visual cortex (V1)
Area 18 - Secondary visual cortex (V2)
Area 19 - Associative visual cortex (V3,V4,V5)
Area 20 - Inferior temporal gyrus
Area 21 - Middle temporal gyrus
Area 22 - Superior temporal gyrus, of which the caudal part is usually considered to contain the Wernicke's area
Area 23 - Ventral Posterior cingulate cortex
Area 24 - Ventral Anterior cingulate cortex.
Area 25 - Subgenual cortex (part of the Ventromedial prefrontal cortex)^[4]
Area 26 - Ectosplenial portion of the retrosplenial region of the cerebral cortex
Area 27* - Piriform cortex
Area 28 - Posterior Entorhinal Cortex
Area 29 - Retrosplenial cingulate cortex
Area 30 - Part of cingulate cortex
Area 31 - Dorsal Posterior cingulate cortex
Area 32 - Dorsal anterior cingulate cortex
Area 33 - Part of anterior cingulate cortex
Area 34 - Anterior Entorhinal Cortex (on the Parahippocampal gyrus)
Area 35 - Perirhinal cortex (on the Parahippocampal gyrus)
Area 36 - Parahippocampal cortex (on the Parahippocampal gyrus)
Area 37 - Fusiform gyrus
Area 38 - Temporopolar area (most rostral part of the superior and middle temporal gyri)
Area 39 - Angular gyrus, considered by some to be part of Wernicke's area
Area 40 - Supramarginal gyrus considered by some to be part of Wernicke's area
Areas 41 & 42 - Primary and Auditory Association Cortex
Area 43 - Primary gustatory cortex
Area 44 - pars opercularis, part of Broca's area
Area 45 - pars triangularis Broca's area
Area 46 - Dorsolateral prefrontal cortex
Area 47 - Inferior prefontal gyrus
Area 48 - Retrosubicular area (a small part of the medial surface of the temporal lobe)
Area 49 - Parasubiculum area in a rodent
Area 52 - Parainsular area (at the junction of the temporal lobe and the insula)

(*) Area only found in non-human primates.

Medial view


Lateral view

Rabu, 19 September 2012

Antibiotic Use in Infants Ups Risk for Childhood Obesity

Clinical Implications

Exposure to antibiotic use in children younger than 6 months is associated with elevated body mass scores at ages 10 months, 20 months, and 38 months and overweight at age 38 months. However, such exposure is not linked with overweight or obesity at age 7 years.

http://www.medscape.org/viewarticle/769506?src=cmemp

Does a Healthy Diet Prevent Chronic Disease?

Clinical Implications

The DASH and Mediterranean diets are examples of healthy eating patterns that have been shown to have beneficial effects on a number of chronic health outcomes.

Table 1. DASH Diet Food Group Servings for a 2000-Calories-Per-Day Diet

Food Group	Target Serving	Examples of 1 Serving
Low-fat dairy	2-3/day	1 cup milk or yogurt
Grains (mostly whole)	6-8/day	1 slice bread 1 oz dry cereal 1/2 cup cooked rice, pasta, or cereal
Lean meats, poultry, fish	≤6/day	1 oz cooked lean meat, poultry, or fish 1 egg
Nuts/seeds/legumes	4-5/week	1/3 cup or 1 1/2 oz nuts 2 Tbsp peanut butter 2 Tbsp or 1/2 oz seeds 1/2 cup cooked legumes
Fruits	4-5/day	1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit 1/2 cup fruit juice
Vegetables	4-5/day	1 cup raw leafy vegetables 1/2 cup cut-up raw or cooked vegetables

Adapted from the 2010 Dietary Guidelines for Americans

Table 2. Mediterranean Diet

High in fresh fruits and vegetables, olive oil, legumes, unrefined grains

Moderate in low-fat dairy

Low in meat

Moderate to high in fish

Moderate alcohol intake

http://www.medscape.org/viewarticle/769479?src=cmemp

Can Long-Acting Beta-Agonists, ICS Cut Asthma Exacerbations?

Clinical Implications

It did not differ significantly in children receiving Long Acting Beta Agonists (LABAs) plus Inhaled Corticosteroid) ICS vs children receiving higher doses of ICS.
Compared with children receiving higher ICS doses, those receiving LABAs plus ICS had significantly higher PEF, less use of rescue medication, and greater short-term growth. Adverse events were not significantly different between the groups.

http://www.medscape.org/viewarticle/770166?src=cmemp

Does Adding Clopidogrel to Aspirin Reduce Stroke Risk?

Clinical Implications

Among patients with recent lacunar strokes, adding clopidogrel to aspirin did not significantly lower the risk for recurrent stroke.
Among patients with recent lacunar strokes, adding clopidogrel to aspirin did significantly increase the risk for hemorrhage and death.

http://www.medscape.org/viewarticle/770170?src=cmemp