Is cervical spinal manipulation dangerous?

OBJECTIVE: Concern about cerebrovascular accidents after cervical manipulation is common. We report a case of cerebrovascular infarction without sequelae. CLINICAL FEATURES: A 39-year-old man with nonspecific neck pain was treated by his general practitioner with cervical manipulation. INTERVENTION AND OUTCOME: This immediately elicited severe headache and neurologic symptoms that disappeared completely within 3 months despite permanent signs of a complete left-sided cerebellar infarction on computed tomography and magnetic resonance imaging. At 7-year follow-up the patient was fully employed, and repeated magnetic resonance imaging still showed infarction of the left cerebellar hemisphere. However, the patient remained completely free of neurologic symptoms, and color duplex ultrasonography showed normal cervical vessels, including patent vertebral arteries. CONCLUSION: It appears that the risk of cerebrovascular accidents after cervical manipulation is low, considering the enormous number of treatments given each year, and very much lower than the risk of serious complications associated with generally accepted surgery. Provided there is a solid indication for cervical manipulation, we believe that the risk involved is acceptably low and that the fear of serious complications is greatly exaggerated.     

Is there a role for melatonin in the ICU?

Summary In the last decade, there have been significant developments in the understanding of the hormone melatonin in terms of its physiology, regulatory role and potential utility in various domains of clinical medicine. Melatonin’s purported properties include, among others, regulation of mitochondrial function, anti-inflammatory, anti-oxidative and neuro-protective effects, sleep promotion and immune enhancement. As such, its role has been explored specifically in the critical care setting in terms of many of these properties. This review addresses the physiological basis for considering melatonin in the critical care setting as well as the current evidence pertaining to its potential utility Contributions of the study This review examines and discusses the role of melatonin in the intensive care unit in terms of sleep, delirium and sepsis, both the physiology and as a therapy.     

Is there a role for statins in fungal infections?

It has been hypothesized that statins, HMG-CoA reductase inhibitors, may be used to treat fungal infections. Here we review data on antifungal properties of statins, effects on the host inflammatory response as well as available clinical evidence. We conclude that: statins exhibit antifungal properties in vitro although at supraphysiological concentrations; statins appear to have anti-inflammatory effects on host cells in vitro; statins have effects on fungal physiology beyond direct growth inhibition; clinical studies are scarce (n = 5), and their design is retrospective and observational, which is associated with a high risk of bias. Given the limited evidence for a beneficial effect of statins in fungal infection, randomized and controlled trials are highly warranted in this field.     

Is there a role for higher education in preparing nurses?

Nurse education is now almost wholly situated within universities internationally. However, issues such as the necessity of higher education for what is seen as a practical occupation and the question of whether or not nursing is a profession arise. Newman viewed universities as places where training was given but character was also formed and self-awareness was developed through exposure to a wide range of disciplines and this type of education has helped to shape other professions. If nursing fulfills the criteria for a profession then it requires nurses to be properly educated in higher education. Poor media images of nursing, opposition from within and outside of the profession and poor funding for research, especially in the UK, where most nurses still do not enter the register with a degree, mean that the place of nursing in higher education remains on the periphery. Nurses must be competent to practice and higher education is not incompatible with the development of competent practitioners. However, higher education should take competent practitioners to a higher level whereby they become capable: able to respond appropriately in unfamiliar situations and to unfamiliar events. This paper argues for the role of higher education for nurses in terms of developing capability.     

Is there a role for transversus abdominis in lumbo-pelvic stability?

There has been considerable interest in the literature regarding the function of transversus abdominis, the deepest of the abdominal muscles, and the clinical approach to training this muscle. With the development of techniques for the investigation of this muscle involving the insertion of fine-wire electromyographic electrodes under the guidance of ultrasound imaging it has been possible to test the hypotheses related to its normal function and function in people with low back pain. The purpose of this review is to provide an appraisal of the current evidence for the role of transversus abdominis in spinal stability, to develop a model of how the contribution of this muscle differs from the other abdominal muscles and to interpret these findings in terms of the consequences of changes in this function.     

Is there a role for screening asymptomatic patients with diabetes?

Coronary artery disease (CAD) remains a leading cause of death among patients with diabetes mellitus. However, many patients with diabetes and CAD are asymptomatic and may sustain a myocardial infarction as their presenting symptom of CAD. Non-invasive cardiovascular imaging offers an opportunity to detect the presence and severity of CAD, or its hemodynamic consequences. The Detection of Ischemia in Asymptomatic Diabetics study and the FACTOR-64 study examined the utility of non-invasive imaging tests to evaluate asymptomatic individuals with diabetes mellitus. The results of these trials may have been negative with regard to promoting CAD screening of asymptomatic diabetic patients, but they do strengthen the position of optimal medical management in reducing cardiovascular events. However, performing a trial to include true high-risk patients who have CAD and are more likely to have silent ischemia could lead to prognostically beneficial coronary revascularizations.     

Slow-release potassium overdose: Is there a role for magnesium?

Slow-release potassium overdose is rare and often fatal. Recommended treatment is derived from that of other, more common, causes of hyperkalaemia and from the general principles of overdose management. We present a patient who survived after a massive slow-release potassium (Slow-K^®) ingestion resulting in a peak potassium concentration of 12 mmol/L, the highest yet reported. A review of previously reported cases of potassium overdose and a summary of recommended therapies for the treatment of hyperkalaemia are presented. Laboratory and current clinical evidence support the addition of magnesium to standard therapy for potassium overdose, particularly where there is concern about increasing doses of calcium; this suggestion requires further clinical research.     

Is there a role for fish oil in inflammatory bowel disease?

A number of animal and human studies suggest omega 3-fatty acids are anti-inflammatory. As a result they may have a therapeutic role in inflammatory bowel disease (IBD). The aim of this review is to briefly assess the literature about the utility of poly-unsaturated fatty acids (PUFAs) in the management of IBD. Taken together, almost all studies suggest some beneficial effects of n-3 PUFAs in IBD but the mechanism remains controversial. In addition, clinical benefit seems to be largely confined to ulcerative colitis. However all studies have concluded that these compounds have no potential for a steroid/aminosalicylic acid sparing effect or to maintain remission. Now the question arises as to whether this treatment is of real value to IBD patients? Clearly they have some therapeutic potential but further work is needed.     

Is there a role for remote ischaemic postconditioning in cardiopulmonary resuscitation?

Cardiac arrest causes whole body ischaemic injury and cellular death. Successful cardiopulmonary resuscitation (CPR) can subsequently lead to a global reperfusion phenomenon with a paradoxically increased rate of cellular death. Interventions that decrease the ischaemia-reperfusion injury may be useful in the treatment of these patients. Remote ischaemic postconditioning with transient limb ischaemia is feasible in cardiac arrest patients. This article discusses the concept of ischaemic pre- and postconditioning and its potential use in patients during CPR and after return of a spontaneous circulation.     

Is there a role for dehydroepiandrosterone replacement in the intensive care population?

Intensive Care Medicine -