DYSPAREUNIA IN UNDIAGNOSED SJOGREN'S SYNDROME

SUMMARY A case of superficial dyspareunia in a 46-year-old women is described. Clinical suspicion, examination and investigations supported a diagnosis of Sjogren's syndrome.     

Proceedings of the 11th Annual AEM (Academic Emergency Medicine) Consensus Conference. June 2, 2010. Phoenix, Arizona, USA

This article is drawn from a report created for the American College of Emergency Physicians (ACEP) Emergency Department (ED) Categorization Task Force and also reflects the proceedings of a breakout session, “Beyond ED Categorization—Matching Networks to Patient Needs,” at the 2010 Academic Emergency Medicine consensus conference, “Beyond Regionalization: Integrated Networks of Emergency Care.” The authors describe a brief history of the significant national and state efforts at categorization and suggest reasons why many of these efforts failed to persevere or gain wider implementation. The history of efforts to categorize hospital (and ED) emergency services demonstrates recognition of the potential benefits of categorization, but reflects repeated failures to implement full categorization systems or limited excursions into categorization through licensing of EDs or designation of receiving and referral facilities. An understanding of the history of hospital and ED categorization could better inform current efforts to develop categorization schemes and processes. ACADEMIC EMERGENCY MEDICINE 2010; 17:e154–e160 © 2010 by the Society for Academic Emergency Medicine     

Evolving concept of dyssynchrony and its utility

The role of electromechanical dyssynchrony in heart failure gained prominence in literature with the results of trials of cardiac resynchronization therapy(CRT).CRT has shown to significantly decrease heart failure hospitalization and mortality in heart failure patients with dyssynchrony.Current guidelines recommend the use of electrical dyssynchrony based on a QRS>150 ms and a left bundle branch block pattern on surface electrocardiogram to identify dyssynchrony in patients who will benefit from CRT implantation.However,predicting response to CRT remains a challenge with nearly one-third of patients gaining no benefit from the device.Multiple echocardiographic measures of mechanical dyssynchrony have been studied over the past two decade.However,trials where mechanical dyssynchrony used as an additional or lone criteria for CRT failed to show any benefit in the response to CRT.This shows that a deeper understanding of cardiac mechanics should be applied in the assessment of dyssynchrony.This review discusses the evolving role of imaging techniques in assessing cardiac dyssynchrony and their application in patients considered for device therapy.     

Prevalence of metabolic syndrome in patients with angiographically proven coronary artery disease presenting to a tertiary care hospital in Delhi,India

BackgroundCoronary artery disease is fast emerging as the major concern for afflicting people across the globe. The Indian subcontinent is highly predisposed to this condition due to distinctive risk factor profile of this population. This fact has led to a condition where the current preventative and management protocols that have worked well in the non-Asian Indian Caucasian populations, have failed to bring about the anticipated control over the incidence and progression of CAD in Asian Indians. Metabolic syndrome has been identified as a major determinant of CAD in this population.Materials and methodsThe prevalence of metabolic syndrome was determined in 431 patients undergoing coronary angiography through various diagnostic algorithms. The Asian modified diagnostic criteria were also implemented to estimate the metabolic syndrome prevalence in patients with different levels of stenosis.ResultsWe observed a high incidence of metabolic syndrome in the patients with coronary artery disease. The prevalence of MS increased with increase in severity of coronary artery involvement. The IDF guideline with Asian modification was the most successful diagnostic algorithm.ConclusionsIt is now imperative to acknowledge the unique pattern of CAD and risk factor profile prevalent among South Asians. This will facilitate more focused and individualized management protocols directed to this population. Metabolic syndrome is a major syndrome prevalent in this population. Hence, effective control of MS may help in reducing the morbidity and mortality due to CAD in a great way.     

Urgent stenting of the M2 (superior) division of the middle cerebral artery after systemic thrombolysis in acute stroke

We report a case of a 54-year-old man who presented with a right middle cerebral artery territory infarct and was treated with systemic thrombolytics. He continued to fluctuate neurologically and, with the use of angiography, was found to have an occlusion of the right M2 artery (superior division). This occlusion was successfully revascularized with a coronary stent.     

Deployment of acute mechanical circulatory support devices via the axillary artery

Introduction: Use of acute mechanical circulatory support (MCS) devices for high-risk cardiac intervention, cardiogenic shock, and advanced heart failure is growing. Alternate vascular access options for these devices remains a clinical challenge. Building on experience from trans-aortic valve replacement procedures, the axillary artery is becoming a common access route for acute MCS and represents an important advance in the development of acute MCS technologies.

Areas covered: Authors review the clinical data and technical aspect of acute MCS deployment via the axillary artery. Axillary access is particularly useful for patients: 1) with severe peripheral vascular disease, 2) with hostile femoral access due to infection, indwelling endovascular devices, or obesity, and 3) to provide early mobility and ambulation. In this review, we discuss the deployment, technical issues and hemostasis regarding the use of intraaortic balloon pump, specifically, axillary intraaortic balloon pumps, trans-valvular left ventricular Impella pumps and arterial outflow of VA-ECMO.

Expert opinion: Vascular comorbidities or device design may limit the traditional iliofemoral access route for acute mechanical circulatory support devices. Large bore access for the deployment of these devices through the axillary artery is feasible and safe when appropriate vascular access and closure techniques are used.