Heart failure with preserved ejection fraction.

This is an interesting topic. The ejection fraction is a measurement of left heart function obtained during echocardiography. The question is how does the heart fail when the measured EF is normal? 

Heart failure is an important cause of shortness of breath which has to be differentiated from lung causes of shortness of breath.  Often the distinction between the two conditions is not obvious clinically without further investigations. Relevant investigations include ECG, NT proBNP (blood test), echocardiography, chest x-ray and coronary angiography.  

Heart failure with preserved ejection fraction is a type of heart failure with normal or near normal ejection fraction and objective evidence of diastolic dysfunction.  

More than half of heart failure patients have heart failure with a maintained ejection fraction. The illness primarily affects the elderly, accounting for 4.9 percent of the population over the age of 60. It appears to be more common in women, and it is projected to become more widespread as people live longer. 

Link to this interesting article which I have read:

Heart failure with preserved ejection fraction | Radiology Reference Article | Radiopaedia.org

Feger, J., Worsley, C. Heart failure with preserved ejection fraction. Reference article, Radiopaedia.org. (accessed on 24 Mar 2022) https://doi.org/10.53347/rID-93980

Tracheostomy for Ventilated Patient

Doctors struggle to accurately predict which patients will require prolonged mechanical ventilation.  Doctors need a clear understanding of the nature and typical course of chronic critical illness.

Communication about chronic critical illness should begin before its onset and, ideally, as early as the initiation of mechanical ventilation (or even at decision-making about whether to initiate ventilation).  Doctors should inform not only of the risk of death in the ICU, but also the chance the patient might survive but remain dependent on the ventilator and other intensive therapies for a prolonged period. 

These initial discussions allow a longer time for doctors to “cultivate prognostic awareness” i.e. the capacity to understand prognosis and the likely illness trajectory and help patients and families prepare psychologically and practically for further developments.

Based on the available evidence, routine placement of tracheostomy prior to day 10 of mechanical ventilation is not indicated. General consensus is that a tracheostomy should be placed after day 10 if the patient is likely to require more than a few additional days of ventilation i.e. the patient will neither be liberated from the ventilator nor die in the near future i.e. the patient is chronically critically ill.

Benefits of tracheostomy include:

Improved patient comfort

Easier oral care and suctioning

Reduced need for sedation or analgesia

Reduced accidental extubation

Improved weaning from mechanical ventilation

Easier facilitation of rehabilitation

Earlier communication and oral nutrition

Facilitated transfer to lower level of care

Early Complications:

Bleeding

Air leak causing subcutaneous emphysema, pneumothorax, pneumomediastinum

 

Damage to the swallowing tube (esophagus)

 

Injury to the nerve of the vocal cords (recurrent laryngeal nerve)

 

Tracheostomy tube can be blocked by blood clots, mucus, or pressure of the airway walls.

Late Complications:

Accidental removal of the tracheostomy tube

 

Infection in the trachea and around the tracheostomy tube

 

Trachea may be damaged by pressure from the tube resulting in bacterial infections and scar tissue formation

Delayed Complications:

Thinning of the trachea from the tube rubbing against it (tracheomalacia)

Ipoh Founded by Hakka Made Vibrant by Cantonese

This presentation is by Dr Richard Ng who is an Ipoh City Councilor.  

There are several facts which I find very interesting:

• Paloh Ku Miu was the Chinese Temple located near the Kinta River Jetty where the Chinese immigrants arrived.  The deity was brought from Penang to Ipoh by Leong Fee.  Leong Fee came to Malaya during the 1st wave of Chinese Migration.
• The table on Chinese ethnicity in the late 1800's and early 1900's showed that the Cantonese outnumber the Hakkas in Ipoh.
• The Hakkas were mainly tin miners whereas the Cantonese were mainly traders. 
• In the early days the Ipoh settlement was mainly located on one side of the Kinta River.  On the other side of the river the Chinese reared pigs.  The pig styes produced an overwhelming offensive stench for the settlement depending on the direction of blowing wind.  The British relocated the pig styes far away from the settlement and Yau Tet Shin bought up the land to build houses.  This was the beginning of the New Town of Ipoh across the other side of the Kinta River. 
• The Cantonese Trail has many interesting heritage sites. Very importantly it also included many business sites in the City.  These sites will be of great interest to the people of Guangzhou who are also Cantonese.  They will be willing to explore Ipoh to find out why their clansmen migrated to this place in the early days.  

The presentation is rather long but I am sure it will be worth your time going through the whole presentation.