External Ventricular Drains After Subarachnoid Hemorrhage: Is Less More?

External ventricular drains (EVD) are essential in the early management of hydrocephalus and elevated intracranial pressure after subarachnoid hemorrhage (SAH). Once in place, management of the EVD is thought to influence long-term patient outcomes, rates of ventriculitis, incidence of delayed cerebral ischemia, need for a ventriculoperitoneal shunt, and intensive care unit (ICU) and hospital length of stay. The available evidence supports adopting early clamp trials and intermittent cerebrospinal fluid (CSF) drainage. However, a recent survey demonstrated that most neurological ICUs employ the opposite approach of continuously open EVDs and gradual weaning. In this article, we review the literature and arguments for and against the different EVD approaches. We conclude that an early clamp trial and intermittent CSF drainage can be safe and result in fewer EVD complications and shorter length of stay. Given the discrepancy between the available evidence and current practice, more studies on the optimal management of EVDs are warranted with the greatest need for multicenter prospective studies.     

How Well Can We Control Dyslipidemias Through Lifestyle Modifications?

The role for lifestyle modifications to correct dyslipidemia(s) is reviewed. Dietary composition is crucial. Replacing saturated fat with MUFA or n-6 PUFA lowers plasma low-density lipoproteins (LDL) cholesterol and ameliorates the LDL/HDL ratio. Replacing saturated fat with carbohydrates has diverging effects due to the heterogeneity of carbohydrate foods. Diets rich in refined carbohydrates increase fasting and postprandial triglycerides, whereas the consumption of fiber-rich, low GI foods lowers LDL cholesterol with no detrimental effects on triglycerides. The role of polyphenols is debated: available evidence suggests a lowering effect of polyphenol-rich foods on postprandial triglycerides. As for functional foods, health claims on a cholesterol lowering effect of psyllium, beta-glucans and phytosterols are accepted by regulatory agencies. The importance of alcohol intake, weight reduction, and physical activity is discussed. In conclusion, there is evidence that lifestyle affects plasma lipid. A multifactorial approach including multiple changes with additive effects is the best option. This may also ensure feasibility and durability. The traditional Mediterranean way of life can represent a useful model.     

State of the Art of Combined Heart-Lung Transplantation for Advanced Cardiac and Pulmonary Dysfunction

Over the last several decades, significant advances and improvements in care of transplant patients have resulted in markedly improved outcomes. A number of options are available for patients with advanced cardiopulmonary dysfunction requiring transplantation. There is a debate about when isolated heart or isolated lung transplantation is no longer possible or advisable and combined heart-lung transplantation is justified. Organ availability and allocation severely limit the latter option to very few well-selected patients. We review practice patterns, trends, and outcomes after triple-organ heart-lung transplant (HLTx) worldwide, as well as our own experience with heart-lung transplant in the modern era.     

Clinical Perspectives and Pearls from the 2015 ESC NSTE-ACS Guidelines

Four years after the latest edition, the 2015 non-ST-segment elevation acute coronary syndromes guidelines of the European Society of Cardiology have been published. Novel aspects include a new diagnostic algorithm for non-ST-segment elevation myocardial infarction using high-sensitivity cardiac troponins as well as guidance on cardiac rhythm monitoring duration. A large section is dedicated to antiplatelet therapy including initiation and duration of dual-antiplatelet therapy as well as the management of patients requiring, at the same time, long-term oral anticoagulation. New sections include the management of antiplatelet agent in patients requiring coronary artery bypass surgery and of acute bleeding events related to antiplatelet agents, vitamin K antagonist (VKA), and non-VKA oral anticoagulant drugs. Current evidence supports the radial access over the femoral one for coronary angiography and percutaneous revascularization.     

Who Benefits from Oncoplastic Surgical Techniques?

Breast-conserving therapy, which includes wide local excision of the tumor followed by irradiation, has become a standard treatment option for women with early-stage invasive breast cancer. The potential advantages of conservative breast surgery include the minor outpatient nature of the procedures, lower incidence of post-operative pain and complications, preservation of the breast and nipple areolar complex, and shorter delay to adjuvant therapy. However, not all patients are optimal candidates for breast-conserving procedures. Oncoplastic techniques combine the removal of breast cancer tumors in combination with either local volume replacement techniques to correct small defects, or by immediate reconstruction of larger defects using techniques of plastic surgery with or without contralateral breast procedures for symmetry. Therefore, oncoplastic techniques offer the potential to perform a wider excision of the tumor with an improved cosmetic result, thus potentially increasing the eligible pool for breast conservation.