[TREATMENT OF MECHANICALLY VENTILATED PATIENTS IN AN INTERNAL MEDICINE DEPARTMENT - OVERVIEW 2013].

BACKGROUND: Over recent years the number of mechanically ventilated patients in internal medicine departments has grown. These patients are elderly, mostly disabled and suffer from many chronic illnesses. Most of them require prolonged mechanical ventilation. OBJECTIVES: The study aimed to evaluate the population of mechanically ventilated patients in an internal department, the treatment and outcomes, particularly the morbidity in hospitalization and to identify the prognostic causes of death. METHODS: A retrospective study was conducted to check the medical records of ventilated patients between the years 2012- 2013 in internal medicine departments including demographic information, chronic illnesses, cause of hospitalization and ventilation, complications and results of treatment. RESULTS: The study includes 97 patients over the age of 60, 50% of them disabled, average Apache score was 29.9; 65% of the patients required ventilation for over 3 days and 35% for over 10 days; 71% of the patients died. The most common causes of death were pneumonia, sepsis, cerebrovascular accident, cardiac event, worsening of heart failure, worsening of chronic obstructive pulmonary disease or a combination of these. The patients who died displayed an Apache score significantly higher at admittance to the hospital. Significant risk factors for mortality included chronic diabetes, sepsis, pneumonia and renal failure. CONCLUSIONS: The results raise the question of whether to increase the number of beds for internal intensive care. A discussion is required among medical personnel and laymen to define a group of patients who should not deteriorate to mechanical ventilation or any other invasive procedures.

[Etiology of severe pulmonary hypertension--possible role of metabolic syndrome].

BACKGROUND: In clinical practice the association between obesity and pulmonary hypertension (PH) is not rare. AIM: The aim of this study was to examine the prevalence of obesity and metabolic syndrome in patients with severe PH, especially cases without significant cardiac, pulmonary or vascular causes. METHODS: We retrospectively anaLyzed the records of 91 patients with severe PH in order to establish its causes. RESULTS: A total of 64% of the patients were women. The women were older than the men, 76.5 years vs 74.0. The BMI of the women was higher than the men, 37.0 vs 30.07. The most common causes of severe PH seen in an internal medicine ward are: severe heart failure (45.1%), chronic lung disease (16.5%) or a combination of both (12.1%). Overall, 11% of our study patients were morbidly obese without significant cardiac, pulmonary or vascular causes of PH. This group was characterized by high incidence of diabetes meLLitus, arterial hypertension, hyperlipidemia, atrial fibrillation and left ventricular (LV) diastolic dysfunction. CONCLUSION: Our results point to a possible association between metabolic syndrome and PH.

The influence of smoking cessation on hemodynamics and arterial compliance.

Cigarette smoking is associated with consistent changes in small arteries and arterioles. Recently, arterial compliance was determined in smokers; however, the effect of smoking cessation on arterial compliance has not yet been investigated. The objective of the study was to assess how smoking cessation, achieved with use of behavioral and pharmacologic therapy, influences vascular compliance and arterial stiffness in smokers. In an open-label study, 60 habitual smokers were treated for 2 months with buproprion 300 mg per day and personal and group conversations in order to facilitate smoking cessation. Hemodynamic variables, including vascular compliance and augmentation index (AI), were measured twice, at the beginning of the study and after 6 months. Of the 60 smokers, 35 stopped smoking and 25 failed at the end of the 2-month treatment period. Of the 35 who were initially successful, 12 went back to smoking, and thus only 23 remained nonsmokers at the end of 6 months. Smoking cessation was accompanied by significantly lower arterial pressure and heart rate but by weight gain. Among the 23 subjects who stopped smoking for 6 months capacitive compliance (C(1)) did not change but oscillatory compliance (C(2)) rose significantly (from 5.1 +/-2.3 to 6.3 +/-3.0 p<0.01), and AI decreased significantly (from 63.1 +/-22 to 50.6 +/-17 p<0.05), whereas in smokers who still smoked after this period, both C(1) and C(2) and augmentation index did not change significantly from their basal values. The authors conclude that smoking cessation improves arterial stiffness as assessed by the augmentation index, owing mainly to increasing the small artery compliance, which is known to be an early index of endothelial damage.

Effect of weight loss on blood pressure, arterial compliance, and insulin resistance in normotensive obese subjects.

BACKGROUND: Obesity is characterized by insulin resistance and hyperinsulinemia that may elevate arterial pressure due to sympathetic overactivity and volume overload. The aim of the study is to measure hemodynamic parameters and metabolic variables in obese normotensive subjects. METHODS: Twenty-four normotensive, overweight subjects from our medical staff were enrolled. They had personal and group meetings with a physician, dietician, and psychologist to improve their compliance with regard to physical activity and personal low-calorie diet. In addition, each subject was given orlistat 120 mg three times daily for 12 weeks. Noninvasive hemodynamic parameters including arterial compliance were measured using radial artery pulse wave analysis, at the beginning and 1 month after taking the last dose of Orlistat, and insulin resistance was calculated using HOMA score. RESULTS: At the end of the 3-month period, the average weight was reduced from 89.5 +/- 12 kg to 81.5 +/- 9 kg. The systolic arterial pressure was reduced from 128 +/- 12 mm Hg to 121 +/- 10 mm Hg and diastolic arterial pressure was reduced from 75.4 +/- 9 mm Hg to 69.6 +/- 7 mm Hg. Arterial compliance measurements showed significant improvement in large artery compliance from 13 +/- 4 to 15.8 +/- 3.6 while no change occurred in small arteries. The insulin sensitivity assessed by HOMA score improved significantly from 6.5 +/- 4.5 to 4.8 +/- 3.1 with weight reduction. CONCLUSIONS: Our data show that weight loss is accompanied by lowering of blood pressure, even in normotensive obese patients. This weight loss brings about an improvement in insulin resistance and a rise in large artery compliance, whereas no change occurs in small artery compliance.

Small artery compliance in cirrhotic patients during total paracentes.

BACKGROUND: Hemodynamic changes, including systemic vascular resistance, in cirrhotic patients during massive paracentesis have been reported, but large and small artery compliance has not yet been investigated. OBJECTIVE: To investigate hemodynamic variables, including small and large artery compliance, in cirrhotic patients during total paracentesis. METHODS: The study included 15 cirrhotic patients admitted for an episode of tense diuretic-resistant ascites. Hemodynamic variables including vascular compliance were measured using an HDI pulse wave cardiovascular profiling instrument CR-2000. The variables were measured in these patients before, immediately after, and 24 hours following large volume (mean 5.6 L) paracentesis. RESULTS: Cardiac output increased immediately after paracentesis due to increment in stroke volume, with no change in heart rate. However, 24 hours later the cardiac output decreased to below the basal level. The fluctuation was statistically significant (P < 0.05). There was no change in large artery compliance, but small artery compliance increased after paracentesis (P < 0.05) and partially retumed to the basal level after 24 hours. Systemic vascular resistance measurement showed the same pattern of change: vasodilatation occurred during paracentesis and was attenuated 24 hours later. CONCLUSIONS: Large volume paracentesis with albumin replacement caused an accentuation of the vasodilatation (small but not large artery) already present in these patients. This may be the first sign of enhanced vasodilatation due to large volume paracentesis before the clinical expression of impaired hemodynamics and deterioration of renal function.

Malignant pericardial effusion and cardiac tamponade as a late complication of endometrial carcinoma.

Malignant pericardial effusion, as a complication of gynecological cancer, is a rare occurrence. A review of the literature reveals only four cases of malignant pericardial effusion from endometrial carcinoma diagnosed during life. All of them were followed by cardiac tamponade a short time after being diagnosed and were associated with extensive myometrial invasion and multiple metastases. We describe a case of malignant pericardial effusion and cardiac tamponade due to recurrence of endometrial carcinoma characterized by the long period from diagnosis to clinical evidence of pericardial involvement. The causes of long-term disease-free interval are discussed.