Presentation X-thorax of a 50-year old female after an incident of near drowning. After an easy intubation, her oxygen saturation increased significantly, but still remained low (<90%).
Presentation A 66-year-old man presented with acute respiratory disfunction a few days after he completed his 3 week antibiotic treatment for a Legionella pneumonia located in the right lung. An X-ray showed that the right lung was compressed (Figure 1).…
A 42-year old female patient presented with chronic pain and swelling on the backfoot.
Haemoglobin transports oxygen from the pulmonary capillaries to vital organs and other tissues. Acute anaemia, for example as a consequence of surgical blood loss, can lead to tissue hypoxia and organ damage. When haemoglobin concentration drops below critical levels, red blood cell (RBC) transfusion may be indicated and even lifesaving. However, RBC transfusion has also been associated with many complications, for instance transfusion reaction, infection transmission, and acute lung injury. Therefore, determining adequate transfusion triggers is of utmost importance.1 The prevailing Dutch transfusion guideline endorses the ‘4-5-6’ strategy, in which patient characteristics and clinical status influence the decision to apply RBC transfusion.2 In short, RBC transfusion is triggered by haemoglobin concentrations below 4 mmol/L in healthy adults, whereas this trigger is 6 mmol/L in cardiopulmonary restricted patients. Despite its simplicity, recent evidence suggests that the ‘4-5-6’ strategy does not benefit patient outcomes and that a more restrictive use of RBC transfusion might be beneficial. A recent, multicenter, randomized study comprising of more than five thousand cardiac surgery patients found no difference in clinical outcomes (stroke, renal failure, myocardial infarction and death) between a transfusion trigger of 4.5 and 6 mmol/L , respectively.3 Furthermore, a randomized study comprising of almost one thousand patients with acute upper gastrointestinal bleeding found an higher survival rate with a transfusion trigger of 4.3 compared to 5.5 mmol/L.1-4 Therefore, we expect that future guidelines will recommend restrictive use of RBC transfusion in critical care settings.
Area of expertise
Multiple Myeloma, Monoclonal gammopathy of undetermined significance (MGUS), Smouldering multiple myeloma and immunotherapy.
Many children with complaints of upper airway obstruction undergo a tonsillectomy. Dr. Sluder (1865-1928) first described this procedure in 1911, which includes the use of a blunt guillotine.1 He was able to remove both tonsils in less than 10 seconds. General anesthesia was extremely dangerous at the time. Therefore, this technique was performed in non-intubated children, mostly with the use of local anesthetics, and sometimes without any anesthetics.
Over many years, Sluder’s method made way for a nowadays daily used dissection technique in which intubation is necessary. In this procedure, a free airway is guaranteed throughout the whole operation. Moreover, the surgeon is able to perform the tonsillectomy more carefully, and as a result the hemostasis of the operational area can be monitored more precisely. However, this technique is more cumbersome and has an increased procedural time.
Sluder’s operation is still performed in some Dutch hospitals. Current guidelines recommend that his technique should only be performed in non-intubated children by competent anesthesiologists and ENT specialists.2 The airway is considered unsafe due to the possibility of aspiration of tissue and blood. Moreover, this very painful stimulus is performed during sub-anesthetic threshold values of volatile anesthetics, which may lead to acute laryngospasm, resulting in a ‘cannot ventilate’ situation in a patient without intravenous access. In addition, anesthesiologists lose their competence as this method disappears in their education. Thus, in our opinion, the classic dissection technique is ought to replace Sluder’s operation in non-intubated children.
High intelligence scores have been associated with positive outcomes, such as better behavioural, cognitive and emotional control in addition to good academic performance and improved mental and physical health and mortality.1 However, several studies have found high intelligence scores and superior school performance to correlate with a predisposition towards developing bipolar disorder, psychosis and schizophrenia.2-4 For attention-deficit hyperactivity disorder (ADHD) it is argued that high intelligence is inherently related to high activity levels, low impulse control, boredom, frustration and poor attention span. Although, it has also been stated that these problems are not characteristic for ADHD as they are non-pervasive and solely specific for situations that evoke boredom and frustration. Conversely, it is hypothesized that ADHD is underdiagnosed in highly intelligent individuals as high intellect may mask ADHD problems and cognitive deficits. These opposing hypotheses have been heavily debated and not studied methodically. For this Expert Opinion article, the methodology and relevance of the first large general population based study on the relation between intelligence and ADHD problems related to ADHD will be reviewed.