Surgical management of cervical adenitis due to atypical mycobacteria in children.

JAMA

Spironolactone, a steroidal mineralocorticoid receptor antagonist (MRA), has been used to treat patients with heart failure (HF) for more than half a century. Spironolactone improved outcomes in patients with severely symptomatic HF with reduced ejection fraction, and later, eplerenone expanded the benefits to patients with mildly symptomatic HF with reduced ejection fraction and myocardial infarction complicated by HF. Spironolactone reduced HF events in some patients with HF with preserved ejection fraction, but the results were not generalizable to all patients with HF with preserved ejection fraction. More recently, the nonsteroidal MRA finerenone improved the HF outcomes of patients with HF with preserved ejection fraction, expanding the benefits previously seen among patients with diabetes and albuminuric chronic kidney disease. The use of MRAs has been limited due to excessive concern about hyperkalemia. Education about the limited true risk associated with hyperkalemia, and about how to predict, prevent, and manage hyperkalemia, may lead to wider acceptability and use of these agents. Several ongoing trials are testing steroidal and nonsteroidal MRAs in HF populations. In this review, we perform a critical appraisal of MRA use in HF populations and point toward future directions.

Mineralocorticoid Receptor Antagonists in Heart Failure: An Update.

Circulation. Heart Failure

The majority of patients with kidney failure requiring replacement therapy will need the support of hemodialysis during their journey with kidney failure. A reliable functioning vascular access is required to provide hemodialysis. This Core Curriculum reviews the major forms of vascular access (arteriovenous fistula, arteriovenous graft, and central venous catheter) as well as the planning, preparation, creation, use, and maintenance of vascular access, requiring a P-L-A-N (Patient ESKD Life-Plan first then Access Needs) for each patient. The end-stage kidney disease Patient Life-Plan focuses on a strategy for kidney replacement modalities, while the Access Needs are the corresponding dialysis access(es) and management plans. The Access Needs include a vessel preservation plan, creation plan, contingency (complications) plan, and access succession plan. Stenosis and thrombosis are common problems with arteriovenous accesses, and dysfunction and infection are common problems with central venous catheters. Underrecognized and underreported but potentially life-threatening situations include arteriovenous access rupture and high-output cardiac failure. Effective management of these and other vascular access problems requires a coordinated multidisciplinary effort that is patient centered while preserving vascular access.

Hemodialysis Vascular Access: Core Curriculum 2025.

American Journal of Kidney Diseases

The aim of this review is to summarize available data, including the most recent ones, to help develop the best possible strategy regarding the use of tracheostomy in ICU patients requiring prolonged mechanical ventilation or who experience loss of airway-protecting mechanisms.

Tracheostomy facilitates the weaning process by reducing the patient's work of breathing and increasing comfort. It thus allows for a reduction in sedation levels. It also helps with secretions clearance, facilitates disconnection from the ventilator, and enables earlier phonation, oral intake, and mobilization. Despite these advantages, tracheostomy does not reduce mortality and is associated with both early and late complications, particularly tracheal stenosis. The timing of tracheostomy remains a subject of debate, and only a personalized approach that considers each patient's specific characteristics can help find the best possible compromise between avoiding unnecessary delays and minimizing the risks of performing a needless invasive procedure. In the absence of contraindications, the percutaneous single dilator technique under fibroscopic guidance should be the first choice, but only if the team is properly trained.

A step-by-step individualized approach based on the available evidence allows identifying the best strategy regarding the use of tracheostomy in ICU patients.

Tracheostomy: update on why, when and how.

Current Opinion in Critical Care

Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase (COX)-2-specific inhibitors provide significant analgesic and opioid-sparing benefits. However, these analgesics are commonly avoided owing to concerns of potential adverse effects. The evidence for NSAID-related adverse effects is conflicting and of poor quality, and these analgesics are safer than what has been implied. Thus, it is imperative that NSAIDs or COX-2-specific inhibitors are administered routinely unless there are well-founded contraindications.

Nonsteroidal anti-inflammatory drugs in the perioperative period: current controversies and concerns.

British Journal of Anaesthesia

Activation of the renin-angiotensin-aldosterone system is the ultimate pathophysiological hallmark in heart failure. Though aldosterone primarily appears to regulate electrolyte homeostasis by acting on distal nephrons in the kidneys, its effects are far-reaching across the cardiovascular system as its receptors are also expressed in vascular smooth muscle cells, endothelial cells, macrophages and cardiomyocytes. Aldosterone excess leads to vascular stiffness, vasoconstriction, endothelial dysfunction, inflammation, oxidative stress, cardiac fibrosis and hypertrophy, atherogenesis and thrombosis. Hence, aldosterone antagonism is an attractive proposition for heart failure management. The first-generation non-selective mineralocorticoid receptor antagonist spironolactone produced a spectacular reduction of cardiovascular outcomes in the seminal RALES study, while the selective second-generation congener eplerenone boasts two positive studies: EPHESUS and EMPHASIS-HF. The TOPCAT trial indicated that a specific subgroup of patients with heart failure with preserved ejection fraction may benefit from targeted therapy of mineralocorticoid receptor antagonists. Newer-generation non-steroidal mineralocorticoid antagonists and aldosterone synthase inhibitors are being evaluated in randomised trials.

Evidence for Aldosterone Antagonism in Heart Failure.

Cardiac Failure Review

From 6% to 8% of patients who present with myocardial infarction have no evidence of obstructive coronary artery disease on angiography. This subgroup tends to be younger, and more of them are women. This review highlights a proposed algorithm to identify the underlying cause of myocardial infarction with nonobstructive coronary arteries (MINOCA). We emphasize the need for a collaborative approach in diagnosing and managing MINOCA to improve patient outcomes, advocating for a standardized diagnostic pathway that incorporates cardiac magnetic resonance imaging and comprehensive clinical evaluation to tailor treatments effectively.

Myocardial infarction with nonobstructive coronary arteries: Current management strategies.

Cleveland Clinic Journal of Medicine

Until recently, major bodies producing guidelines for the management of hypertension in patients with chronic kidney disease (CKD) disagreed in some key issues. In June 2023, the European Society of Hypertension (ESH) published the new 2023 ESH Guidelines for the management of arterial hypertension a document that was endorsed by the European Renal Association. Several novel recommendations relevant to the management of hypertension in patients with CKD appeared in these guidelines, which have been updated to reflect the latest evidence-based practices in managing hypertension in CKD patients. Most of these are in general agreement with the previous 2021 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines-some reflect different emphasis on some topics (i.e. detailed algorithms on antihypertensive agent use) while others reflect evolution of important evidence in recent years. The aim of the present review is to summarize and comment on key points and main areas of focus in patients with CKD, as well as to compare and highlight the main differences with the 2021 KDIGO Guidelines for the management of blood pressure in CKD.

Surgical management of cervical adenitis due to atypical mycobacteria in children.

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Surgical management of cervical adenitis due to atypical mycobacteria in children.

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