Hippocratic concepts of acute and urgent respiratory diseases still relevant to contemporary medical thinking and practice: a scoping review.

BACKGROUND: The collected works of Hippocrates were searched for concepts on the diagnosis, prognosis, and treatment of acute and urgent respiratory diseases, with the objective to trace their origins in the Hippocratic Collection. METHODS: A scoping review was performed to map out key concepts of acute and severe respiratory diseases in the entire Hippocratic Collection. The digital library Thesaurus Lingua Graeca (TLG) was researched for references in the entire Hippocratic Collection regarding the epidemiology, pathophysiology, prognosis, diagnosis and treatment of acute respiratory diseases; then, the relevant texts were studied in their English translation by the Loeb Classical Library. RESULTS: Hippocratic physicians followed principles of treatment for pneumonia and pleurisy, still relevant, such as hydration, expectoration, analgesia and prompt mobilisation. Other approaches, including the inhalation of "vapours through tubes" in angina, can be considered as forerunners of modern medical practice. Thoracic empyema was diagnosed by shaking the patient and direct chest auscultation after "applying your ear to his sides". In case of an emergency from upper airway obstruction, urgent insertion of primitive airway equipment, such as a small pharyngeal tube, was applied. CONCLUSIONS: The main Hippocratic concepts on four still common acute and urgent respiratory diseases -pneumonia, pleurisy, thoracic empyema and upper airway obstruction- were identified and most of them were found to be in agreement with contemporary medical thinking and practice.

Preoperative Albuminuria and Intraoperative Chloride Load: Predictors of Acute Kidney Injury Following Major Abdominal Surgery.

BACKGROUND: Postoperative Acute Kidney Injury (AKI) is a common and serious complication associated with significant morbidity and mortality. While several pre- and intra-operative risk factors for AKI have been recognized in cardiac surgery patients, relatively few data are available regarding the incidence and risk factors for perioperative AKI in other surgical operations. The aim of the present study was to determine the risk factors for perioperative AKI in patients undergoing major abdominal surgery. METHODS: This was a prospective, observational study of patients undergoing major abdominal surgery in a tertiary care center. Postoperative AKI was diagnosed according to the Acute Kidney Injury Network criteria within 48 h after surgery. Patients with chronic kidney disease stage IV or V were excluded. Logistic regression analysis was used to evaluate the association between perioperative factors and the risk of developing postoperative AKI. RESULTS: Eleven out of 61 patients developed postoperative AKI. Four intra-operative variables were identified as predictors of AKI: intra-operative blood loss (p = 0.002), transfusion of fresh frozen plasma (p = 0.004) and red blood cells (p = 0.038), as well as high chloride load (p = 0.033, cut-off value > 500 mEq). Multivariate analysis demonstrated an independent association between AKI development and preoperative albuminuria, defined as a urinary Albumin to Creatinine ratio ≥ 30 mg·g-1 (OR = 6.88, 95% CI: 1.43⁻33.04, p = 0.016) as well as perioperative chloride load > 500 mEq (OR = 6.87, 95% CI: 1.46⁻32.4, p = 0.015). CONCLUSION: Preoperative albuminuria, as well as a high intraoperative chloride load, were identified as predictors of postoperative AKI in patients undergoing major abdominal surgery.

The relevance of the Hippocratic Oath to the ethical and moral values of contemporary medicine. Part II: interpretation of the Hippocratic Oath-today's perspective.

This is the second part of a paper on the relevance and significance of the Hippocratic Oath to modern medical ethical and moral values with the aim at answering questions on controversial issues related to the Oath. Part I argued that the general attributes and ethical values of the Oath are relevant to the modern world. Part II attempts to elucidate the interpretation of the specific injunctions of the Oath from today's perspective in relation to ethical values concerning the duties of physicians to patients and society. The objective is to prove that the Oath has established the general context of medical ethics of the physician-patient relationship, which reflects long-lasting moral values that still define the medical profession. The Oath has exemplified the fundamental modern ethical principles of beneficence, non-maleficence and confidentiality. Its foremost message focuses on patients' best interests and not on the prohibition of surgery, euthanasia or abortion, as is generally believed. Furthermore, the Oath as a code of professional identity has had a powerful impact on modem judicial opinions regarding medical ethics. In a lot of ways, it is as relevant of the values of contemporary medicine as it was for ancient medicine. These slides can be retrieved under Electronic Supplementary Material.

The value of the Modified Early Warning Score for unplanned Intensive Care Unit admissions of patients treated in hospital general wards.

AIM: To determine the value of the Modified Early Warning Score (MEWS) for general ward patients and its potential use as an alarm tool for ward nurses. METHODS: A combined prospective-retrospective observational study was conducted with 153 patients in a university hospital (2013-2014). All patients were admitted to the intensive care unit (ICU) from general wards. Parameters retrospectively studied were 5 MEWS values at 4 hourly intervals, up to 20 hours before ICU admission. Parameters prospectively studied were ICU length of stay, ICU mortality, and mortality after ICU discharge. RESULTS: Most frequent severe adverse events were acute respiratory failure (39.9%) and septic shock (20.3%). Modified Early Warning Score increased gradually during the last 20 hours, and most patients remained in the wards, above a cut-off point ≥7 recorded at 4 hours before admission. Significant associations between latest MEWS score and ICU mortality and ICU length of stay were found. MEWS score≥ 7 hours before admission was highly associated with increased ICU and hospital mortality. CONCLUSION: Patient deterioration in general wards can result in severe adverse events. Modified Early Warning Score is a strong predictor of outcome and may be used as a monitoring tool for potentially avoidable deaths and unplanned admissions to ICU.

The relevance of the Hippocratic Oath to the ethical and moral values of contemporary medicine. Part I: The Hippocratic Oath from antiquity to modern times.

The present paper discusses the relevance and significance of the Hippocratic Oath to contemporary medical ethical and moral values. It attempts to answer the questions about some controversial issues related to the Oath. The text is divided in two parts. Part I discusses the general attributes and ethical values of the Oath, while Part II presents a detailed analysis of each passage of the Oath with regard to perennial ethical principles and moral values. Part I starts with the contribution of Hippocrates and his School of Cos to medicine. It continues by examining the moral dilemmas concerning physicians and patients in the Classical Times and in the Modern World. It also investigates how the Hippocratic Oath stands nowadays, with regard to the remarkable and often revolutionary advancements in medical practice and the significant evolution in medical ethics. Further, it presents the debate and the criticism about the relevance of the general attributes and ethical values of the Oath to those of modern societies. Finally, it discusses the endurance of the ethical values of the Hippocratic Oath over the centuries until today with respect to the physicians' commitment to the practice of patient-oriented medicine. Part I concludes with the Oath's historic input in the Judgment delivered at the close of the Nuremberg "Doctors' Trial"; this Judgement has become legally binding for the discipline in the Western World and was the basis of the Nuremberg Code. The ethical code of the Oath turned out to be a fundamental part of western law not only on medical ethics but also on patients' rights regarding research.

Gastrointestinal motility following thoracic surgery: the effect of thoracic epidural analgesia. A randomised controlled trial.

BACKGROUNDS: Impairment of gastrointestinal (GI) motility is an undesirable but inevitable consequence of surgery. This prospective randomised controlled study tested the hypothesis that postoperative thoracic epidural analgesia (TEA) with ropivacaine or a combination of ropivacaine and morphine accelerates postoperative GI function and shortens the duration of postoperative ileus following major thoracic surgery compared to intravenous (IV) morphine. METHODS: Thirty patients scheduled for major thoracic surgery were randomised to three groups. All patients had bowel motility assessments 1 week preoperatively. All patients received general anaesthesia. Group Ep-R received TEA with ropivacaine; group Ep-RM received TEA with ropivacaine and morphine and group IV-M received IV morphine via patient controlled analgesia pump (PCA). Bowel motility was assessed by clinical examination in addition to oro-ceacal transit time (OCTT) on the first and third postoperative days and colonic transit time (CTT). RESULTS: Overall the OCTT demonstrated a 2.5-fold decrease in bowel motility on the first postoperative day. The OCTT test revealed statistically significant differences between all groups (Ep-R vs Ep-RM, p = 0.43/Ep-R vs IV-M, p = 0.039 / Ep-RM vs IV-M, p < 0.001). Also, very significant differences were found in the OCCT test between days (Ep-R vs Ep-RM, p < 0.001/Ep-R vs IV-M, p < 0.001 / Ep-RM vs IV-M, p = 0.014). There were no significant differences in the CTT test or the clinical signs between groups. However, 70% of the patients in the Ep-R group and 80% in the Ep-RM group defecated by the third day compared to only 10% in the IV-M group, (p = 0.004). CONCLUSIONS: Objective tests demonstrated the delayed motility of the whole GI system postoperatively following thoracic surgery. They also demonstrated that continuous epidural analgesia with or without morphine improved GI motility in comparison to intravenous morphine. These differences were more pronounced on the third postoperative day. TRIAL REGISTRATION: ISRCTN number: 11953159 , retrospectively registered on 20/03/2017.

The origins of oral medicine in the Hippocratic collected works.

The collected works of Hippocrates describe for the first time in a systematic way a large number of oral diseases, such as ulcers, inflammations, abscesses and tumours from the epiglottis, mouth, tongue, palate, uvula and the sublingual area. Several of these case reports are remarkable for the accurate observation of clinical symptoms and signs, the aetiology, the pathogenesis and their therapeutic approach in relation to prognosis. The Hippocratic authors report cases of aphthae as part of a polysystemic disease, described many centuries later by Behçet and Adamantiades, while they associate features of splenomegaly from endemic malaria with gingivitis (ulitis). Benign lip ulcers, caused by sharp teeth bites, were distinguished from the difficult to treat herpes labialis (herpes) and from the necrotising nomae. Although staphylitis and angina (kynanche) were attributed to phlegm accumulation, they were recognised as true emergencies when they were associated with a swollen tongue and uvula. Several cases of kynanche with forward displacement of the first cervical vertebrae, atrophy of the uvula and oedema of the jaws are illustrated. A fatal outcome was anticipated in cases of phagedaenic ulcers of the teeth, causing necrosis and abscess formation. The therapeutic approach of oral diseases proceeded step by step, starting with simple regimens and progressing to invasive techniques, such as phlebotomy, surgical incisions for fluid drainage, and cauterisation. With the aim to avoid adverse events, special attention was paid to the correct timing of surgery and the maintenance of a patent airway with the insertion of small pharyngeal tubes.

Emergencies and acute diseases in the collected works of Hippocrates: observation, examination, prognosis, therapy.

The collected works οf Hippocrates include a wealth of references to emergencies and acute conditions; if the physician could treat these, he would be considered superior to his colleagues. Works most relevant to current Emergency Medicine are presented. They indicate Hippocrates' remarkable insight and attention to the value of close observation, meticulous clinical examination, and prognosis. Hippocrates and his followers disdained mystery and were not satisfied until they had discovered a rational cause to diseases. They assigned great significance to distressing signs and symptoms - the famous Hippocratic face, the breathing pattern, pain, seizures, opisthotonus - pointing to a fatal outcome, which they reported to their patient. The principles of treatment of emergencies, such as angina, haemorrhage, empyema, ileus, shoulder dislocations and head injuries, are astonishingly similar to the ones used nowadays.

A survey of key opinion leaders on ethical resuscitation practices in 31 European Countries.

BACKGROUND: Europe is a patchwork of 47 countries with legal, cultural, religious, and economic differences. A prior study suggested variation in ethical resuscitation/end-of-life practices across Europe. This study aimed to determine whether this variation has evolved, and whether the application of ethical practices is associated with emergency care organisation. METHODS: A questionnaire covering four domains of resuscitation ethics was developed based on consensus: (A) Approaches to end-of-life care and family presence during cardiopulmonary resuscitation; (B) Determinants of access to best resuscitation and post-resuscitation care; (C) Diagnosis of death and organ donation (D) Emergency care organisation. The questionnaire was sent to representatives of 32 countries. Responses to 4-choice or 2-choice questions pertained to local legislation and common practice. Positive responses were graded by 1 and negative responses by 0; grades were reconfirmed/corrected by respondents from 31/32 countries (97%). For each resuscitation/end-of-life practice a subcomponent score was calculated by grades' summation. Subcomponent scores' summation resulted in domain total scores. RESULTS: Data from 31 countries were analysed. Domains A, B, and D total scores exhibited substantial variation (respective total score ranges, 1-41, 0-19 and 9-32), suggesting variable interpretation and application of bioethical principles, and particularly of autonomy. Linear regression revealed a significant association between domain A and D total scores (adjusted r(2)=0.42, P<0.001). CONCLUSIONS: According to key experts, ethical practices and emergency care still vary across Europe. There is need for harmonised legislation, and improved, education-based interpretation/application of bioethical principles. Better application of ethical practices may be associated with improved emergency care organisation.

Adding fentanyl to etomidate fails to reduce painful recall of external direct current cardioversion in adults: a randomised trial.

INTRODUCTION: External electrical cardioversion under hypnotics, even when combined with opioids, has been consistently described as distressing or painful. The main objective of the present study was to determine if adding an opioid to a hypnotic, in comparison to the same hypnotic alone, would decrease the incidence of unpleasant or painful recall during anaesthesia for external electrical cardioversion. METHODS: This was a single-centre, prospective, randomised, double-blinded clinical trial that took place from September 2011 to March 2012. Fifty-two adult patients with persistent atrial fibrillation, scheduled for external direct current cardioversion, were enrolled. Exclusion criteria were age >80 years, previous cardiac surgery, implanted pacemaker or defibrillator, and haemodynamic instability. Patients received intravenously either (group EF) fentanyl 50 g and after 60 s etomidate 0.1 mg/kg, or (group E) only etomidate 0.1 mg/kg. If the patients did not lose their eyelid reflex, repeated doses of etomidate 4 mg were given. Cardioversion was attempted with an extracardiac biphasic electrical shock from 200 to 300 J, at most three times. The primary endpoint was recall of something unpleasant or painful. Secondary outcome measures were predictors of the requirement for repeat doses of etomidate, and the number of shocks needed. RESULTS: Fifty-one patients (35 male, 16 female), aged 62.1 ± 10.2 years, completed the study. There were no differences between group EF and group E regarding recall (unpleasant recall 0 vs. 2 patients, p=0.235; painful recall 1 vs. 0 patients, p=0.510). The administration of etomidate alone was a significant predictor for subsequent repeated doses of etomidate (p=0.049, odds ratio 4.312, 95% confidence interval 1.007-18.460). The number of shocks needed to restore sinus rhythm did not differ between the groups (p=0.846). CONCLUSIONS: In the present study, the addition of fentanyl to etomidate did not diminish distressing or painful experience during anaesthesia for external cardioversion.

Molecular response of the human diaphragm on different modes of mechanical ventilation.

BACKGROUND: The mechanical stress that the human diaphragm is exposed to during mechanical ventilation affects a variety of processes, including signal transduction, gene expression, and angiogenesis. OBJECTIVES: The study aim was to assess the change in the production of major angiogenic regulators [vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF2), and transforming growth factor beta 1 (TGFB1)] on the human diaphragm before and after contraction/relaxation cycles during mechanical ventilation. METHODS: This observational study investigates the diaphragmatic mRNA expression of VEGF, FGF2, and TGFB1 in surgical patients receiving general anesthesia with controlled mechanical ventilation (CMV) with muscle relaxation (group A, n = 13), CMV without muscle relaxation (group B, n = 10), and pressure support of spontaneous breathing (group C, n = 9). Diaphragmatic samples were obtained from each patient at two time points: 30 min after the induction of anesthesia (t1) and 90 min after the first specimen collection (t2). RESULTS: No significant changes in the mRNA expression of VEGF, FGF2, and TGFB1 were documented in groups A and C between time points t1 and t2. In contrast, in group B, the mRNA levels of the above angiogenic factors were increased in time point t2 compared to t1, a finding which was statistically significant (pVEGF = 0.003, pFGF2 = 0.028, pTGFB1 = 0.001). CONCLUSIONS: These findings suggest that the molecular response of the human diaphragm before and after application of diverse modes of mechanical ventilation is different. Angiogenesis via the expression of VEGF, FGF2, and TGFB1 was only promoted in CMV without muscle relaxation, and this may have important clinical implications.

Anaesthesia for cardioversion: a prospective randomised comparison of propofol and etomidate combined with fentanyl.

INTRODUCTION: External electrical cardioversion is mostly performed solely under sedatives or hypnotics, although the procedure is painful. The aim of this prospective randomised study was to compare two anaesthetic protocols that included analgesia. METHODS: Patients with persistent atrial fibrillation were randomised to receive intravenously either fentanyl 50 µg and propofol 0.5 mg/kg (group P) or fentanyl 50 µg and etomidate 0.1 mg/kg (group E), while breathing spontaneously 100% oxygen. In the case of inadequate anaesthesia, repeated doses of 20 mg propofol (group P) or 4 mg etomidate (group E) were given as often as necessary until loss of eyelid reflex. Cardioversion was achieved with an extracardiac biphasic electrical shock ranging from 200 to 300 J, performed three times at most. RESULTS: Forty-six patients (25 in group P, 21 in group E), aged 64 ± 9 years, were enrolled in the study. There were no differences between the study groups concerning left ventricular ejection fraction, the dimension of the left atrium, the number of shocks needed or the number of unsuccessful cardioversions. Patients in group E had a shorter time from injection of the induction agents until loss of consciousness (49 vs. 118 s, p=0.003) and until the first shock was given (61 vs. 135 s, p=0.004). Systolic blood pressure decreased significantly (repeated measurements ANOVA with Bonferroni adjustment) in group P when the baseline value was compared to that after anaesthesia induction (mean decrease 15.2 mmHg, 95% CI 5.6-24.8 mmHg, p=0.001) and to the value after recovery (mean decrease 15.2 mmHg, 95% CI 4.8-25.7 mmHg, p=0.002). Manual ventilation was required in 7 and 9 patients in groups P and E, respectively (p=0.360). CONCLUSION: Both anaesthetic regimens provided excellent conditions for external electric cardioversion. In addition, etomidate in combination with fentanyl had a shorter induction time and ensured haemodynamic stability.

Antiemetic prophylaxis in thyroid surgery: a randomized, double-blind comparison of three 5-HT3 agents.

PURPOSE: The aim of this double-blind randomized study was to compare the antiemetic efficacy of three 5-hydroxytryptamine type 3 antagonists in terms of the incidence and intensity of postoperative nausea and vomiting (PONV) in a homogenous group of female patients undergoing thyroidectomy. METHODS: The study cohort consisted of 203 American Society of Anesthesiologists PS I-II female patients randomized into four groups to receive at induction of anesthesia an intravenous (IV) bolus of 5 ml solution of one of the following: normal saline (placebo), granisetron 3 mg, ondansetron 4 mg, or tropisetron 5 mg. Nausea and vomiting were evaluated at five time points: during the first hour in the postanesthesia care unit (PACU) and 6, 12, 18, and 24 h postoperatively. Nausea intensity was measured using a visual analogue scale score (0-10). RESULTS: Patients in the placebo group displayed a high incidence of nausea in the PACU and at 6, 12, and 18 h postoperatively (44, 60, 50, and 34%, respectively) and of vomiting (26, 42, 30 and 10%). The administration of granisetron reduced significantly the incidence of nausea at 6, 12, and 18 h (26, 18, and 2%, respectively) and vomiting at 6 and 12 h (10 and 6%, respectively). Ondansetron reduced significantly the incidence of nausea and vomiting only at 6 h postoperatively (28 and 12%, respectively). The administration of tropisetron did not affect the incidence of PONV compared to placebo. CONCLUSION: Among the female patients of this study undergoing thyroid surgery, granisetron 3 mg provided the best prophylaxis from PONV. Ondansetron 4 mg was equally effective, but its action lasted only 6 h, whereas tropisetron 5 mg was found ineffective.

Case report: subarachnoid anesthesia for kyphoplasty: is anesthesia adequate?

We performed a prospective pilot study of subarachnoid anesthesia for kyphoplasty in 11 nonrandomized patients. Subarachnoid anesthesia was administered at the level of the best palpable intervertebral space below L3. Patients received intrathecally either hyperbaric or plain bupivacaine with or without fentanyl. Five patients experienced pain during the surgical procedure and received supplemental IV analgesia. One patient felt pain from the pressure on the ribs while in the prone position. The remaining patients were comfortable. In no patient was respiratory compromise or deep sedation observed. We conclude that subarachnoid anesthesia may be an adequate technique for kyphoplasty.

Basic life support skill retention by medical students: a comparison of two teaching curricula.

AIM: In December 2005 the new guidelines for resuscitation were released and a new curriculum for the teaching of basic life support (BLS) was adopted. The aim of the present study was to investigate the effectiveness of the new guidelines and teaching curriculum on the BLS skill retention of medical students 1 year following their initial training. METHODS: The study was conducted in two consecutive academic years and compared BLS skill retention of two groups of medical students in their fourth year of medicine. The first group (group A) was taught the old guidelines with the old curriculum in the year 2005 and was re-assessed in 2006, and the second group (group B) was taught the new guidelines with the new curriculum in the year 2006 and was re-assessed in 2007. RESULTS: Significantly more students in group B assessed signs of life, located the compression area correctly and performed good quality chest compressions compared with the group taught the old guidelines with the old curriculum. CONCLUSIONS: The most important BLS skill, good quality chest compressions, was retained by significantly more students who were taught the new resuscitation guidelines according to the new curriculum.

Cranial trauma in ancient Greece: from Homer to classical authors.

This article presents literary evidence on traumatic cranio-cerebral injuries in ancient Greece from about 900 B.C. to 100 B.C. The main sources of information are epic and classic Greek texts of that period. Homer provides the first literary source of head trauma, which he portrayed in his epic poems The Iliad and The Odyssey. He describes 41 injuries of the head, face and cervical spine, of which all but two were fatal. Subsequently, other classical authors like Plato, Plutarch and others illustrate cases of cranial trauma that occurred mainly in the battlefields, during athletic games or in unusual accidents. They describe some interesting cases of head trauma in prominent men, such as the poet Aeschylos, the kings Pyrrhos and Kyros and Alexander the Great. Most of these descriptions show that the ancient Greeks possessed very good knowledge of the anatomy of the head and neck region and also of the pathophysiological consequences of trauma in the region.

References to anesthesia, pain, and analgesia in the Hippocratic Collection.

The Hippocratic Collection, containing 60 medical texts by Hippocrates and his pupils, was searched using the electronic database Thesaurus Lingua Graeca to identify the words "anaesthesia" and "analgesia," their derivatives and also words related to pain. Our purpose was to investigate the special use and meaning of these words and their significance in medical terms. The word "anaesthesia" appears 12 times in five Hippocratic texts to describe loss of sensation by a disease process. This observation reveals Hippocrates as the first Greek writer to use the word in a medical rather than a philosophical context. Hippocrates was also the first Greek physician to keep an airway open by bypassing a pharyngeal obstruction with the insertion of narrow tubes into the swollen throat of a patient with quinsy, thus facilitating the airflow into the lungs. In the Hippocratic texts, "analgesia" is related to "anaesthesia" for the first time, when it is pointed out that an unconscious patient is insensitive to pain. Hippocrates and his followers rationalized pain as a clinical variable and as a valuable diagnostic and prognostic tool. They used expressive and precise adjectives and well-defined characteristics of pain, such as location, duration, or relation to other symptoms, to elucidate a disease process. They also had a wide terminology for the various types of pain, still in use today. Many cures were described for the treatment of pain, including incisions, effusions, venesection, purges, cauterization and, most interestingly, the use of many plants, such as opium or the application of soporific substances. In particular, Hippocrates refers to opium poppy as "sleep inducing."