Hospital Chronicles (E-Journal)
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Very Late Thrombosis of an Undersized Bare-Metal Stent
Get PDFA 52-year-old gentleman was admitted with anterior non ST elevation myocardial infarction. He had a history of stenting of the left anterior descending (LAD) – first diagonal (D1) bifurcation with two bare-metal stents (BMS) according to the provisional T-technique ten years earlier. He was also submitted to a simple balloon angioplasty for focal LAD in-stent restenosis 14 months ago. The urgent coronary angiography this time showed a very late stent thrombosis of the LAD BMS fortunately with preserved distal flow. He was initially treated successfully with aspiration thrombectomy combined to few days of aspirin, prasugrel and enoxaparin to enable complete thrombus dissolution. Five days later the LAD stent was examined with optical coherence tomography (OCT) which revealed severe malapposition proximally to the D1 due to initial BMS undersizing. The stent was expanded and a kissing-balloon inflation was performed at the LAD – D1 bifurcation with appropriately sized balloons. Finally, after verifying the correct stent expansion and apposition by OCT, a drug-eluting balloon inflation was performed in-stent in order to minimize the risk of restenosis. Subsequent clinical course was uneventful. Details and images concerning these procedures are presented and discussed herein
Sinotubular Junction Remodeling with Aortic Cusp repair. An alternative to Bentall operation for Ascending Aortic aneurysm with Aortic Valve Regurgitation.
Get PDFWe present a 72-year-old female patient with ascending aortic aneurysm and aortic valve regurgitation, who was referred for surgery. Preoperative echocardiography demonstrated a dilated sinutubular junction (STJ), preserved sinus dimensions and moderate to severe aortic valve insufficiency with central regurgitant jet. During surgery, comprehensive visual assessment of aortic cusp configuration revealed prolapse of the non-coronary cusp, which was repaired by appropriate techniques. Ascending aorta pathology was corrected with sinutubular junction remodelling (STJR). The combination of STJR and cusp repair is an excellent alternative to root replacement with no prosthesis-related long term complications
Serotonin Toxicity Syndrome in Pregnancy: Could the Values of Blood Gases be Affected?
Get PDFSerotonin toxicity syndrome is a potentially life-threatening condition caused by excessive serotonergic activity in the nervous system. It is characterized by mental status changes, autonomic instability, and neuromuscular hyperactivity. Critically ill patients may require neuromuscular paralysis, sedation, and intubation. If serotonin syndrome is recognized and complications are managed appropriately, the prognosis is favorable. In the presented case clinical presentation and outcome of the serotonin syndrome which was developed in a 30-year-old pregnant woman with a medical history of depression managed by selective serotonin-noradrenaline reuptake inhibitors is discussed. This case is presented to inform physicians about our observations regarding the results of blood gases and to discuss our possible explanation
Diseases of the Eye with Systemic Involvement and /or Acute Presentation
Get PDFOpticneuritis is defined as an inflammation of the optic nerve, which is mostlyidiopathic. However, it can be associated with variable causes: demyelinatinglesions, autoimmune disorders, infectious conditions, compressive, toxic,metabolic and hereditary conditions. It is divided intoarteritic, which is commonly seen in temporal arteritis/polymyalgia rheumaticaand non arteritic, which is associated with advanced age, atherosclerosis,hypertension and hyperlipidemia. Among demyelinating disorders, multiplesclerosis is the most common cause. The term optic neuritis is indicated bysub-acute unilateral painful visual loss mostly in a young healthy female andby excluding glaucoma. The clinical diagnosis of optic neuritis consists of theclassic triad of visual loss, periocular pain and dyschromatopsia whichrequires careful ophthalmic, neurologic and systemic examinations todistinguish between typical and atypical optic neuritis. In neuromyelitis optica,optic neuritis is initially misdiagnosed as optic neuritis in multiplesclerosis or other conditions such as ischemic optic neuritis and Leber’sdisease. Therefore, differential diagnosis is necessary to make a propertreatment plan. According to Optic Neuritis Treatment Trial, the first line oftreatment is intravenous methylprednisolone with faster recovery and lesschance of recurrence of optic neuritis and conversion to multiple sclerosis.Apart from optic neuritis of various causes, loss of vision could be due toglaucoma or uveitis. Glaucoma is optic nerve damage due to an interruption ofthe production and/or abduction of vitreous gel of the eye. Uveitis refers to a group of heterogeneous diseasesthat share the features of intraocular inflammation, but whose etiologies includeidiopathic autoimmune disease, infections and masquerade syndromes. Acute retinal necrosis and detachment may have a debilitatingeffect on vision and must be rapidly diagnosed and confronted, too. Theabove-mentioned clinical entities, their etiologies and current therapies arebriefly discussed in this review.Key-words: optic neuritis; multiple sclerosis; age-relatedmacular degeneration; diabetic retinopathy; glaucoma; uveitisAbbreviations: AMD (age-related macular degeneration); DR (diabeticretinopathy); DME (diabetic macular edema); AGEs (advanced end glycationproducts
Cardiorenal Syndrome: A Glimpse Into Some Intricate Interactions
Get PDFIt is well known that heart and kidney functions are interdependent; primary disorders of one organ have been shown to affect the other organ (organ cross-talk). Over the last decade, growing interest and attention has been drawn to this interaction; the term cardiorenal syndrome (CRS) has been coined and 5 types of CRS have been recognized, whereby a vicious cycle is proposed of acute or chronic dysfunction of either the kidney or the heart which can trigger and aggravate dysfunction of the other organ. This interrelation in which one system negatively influences the other system calls for a closer examination of its pathophysiology, a more systematic approach for the diagnosis and treatment of this syndrome, and more intensive investigation for potential preventive measures. An overview of these complex interactions is herein attempted
Aortic Isthmus Pseudoaneurysm After Coarctation Repair as a Source of Thromboembolism
Get PDFA 60 year old male, smoker with a past medical history of moderate hypertension, hypercholesterolemia, bronchial asthma and surgically corrected aortic coarctation with interposition grafting at the age of 17, was presented with four episodes of post-exercise lower limb thromboembolism within a period of two years. The electrocardiogram was normal and multiple Holter recordings showed no rhythm abnormalities. The cardiac transthoracic echocardiogram showed normal left ventricular dimensions and systolic function, normal right ventricle, bicuspid aortic valve with moderate insufficiency and mild stenosis, ascending aorta with a diameter of 46mm, and a pressure gradient across the aortic isthmus of 20mmHg. The cardiac transesophageal echocardiogram revealed no intracardiac thrombi or shunts and in addition neither dissection nor thrombus in the descending thoracic aorta was detected. Although the patient was subjected to multiple diagnostic imaging examinations, it was the Dual Source Computed Tomography with three-dimensional image reconstruction of the aorta that disclosed the detachment of the graft’s wall inner surface at the site of its proximal anastomosis with the descending thoracic aorta, just distal to the origin of the left subclavian artery, that resulted in the formation of a pseudoaneurysm which served as the source of distally embolizing thrombi. Moreover, in the distal thoracic aorta just after the graft’s distal anastomosis, a mild stenosis occurred due to intense intramural calcification. Although various therapeutic approaches were considered, the patient was finally taken to the operating theatre, where, via a left lateral thoracotomy, the preoperative findings were confirmed and the lesions successfully repaired
Treatment of Catecholaminergic Polymorphic Ventricular Tachycardia: Lessons from One Case
Get PDFWe report a case of a 27-year-old female with catecholaminergic polymorphic ventricular tachycardia, presenting with syncope during emotional stress. β-Blockade alone was ineffective, whereas the addition of amiodarone prevented arrhythmia-relapses for 28 months. In view of planned pregnancy, the latter was substituted with flecainide, coupled with defibrillator-implantation. Fourteen months later, the patient had 3 appropriate, followed by 3 inappropriate shocks. This case highlights the short-comings of pharmacological treatment and the limitations of device-therapy; the high rate of inefficacious shocks, along with the proarrhythmic potential, point towards the judicious use of defibrillators, aiming at shock-delivery only for ventricular fibrillation
The Role of Music to Promote Relaxation in Intensive Care Unit Patients
Get PDFBACKGROUND: The intensive care unit (ICU) is one of the most stressful environments for patients among various clinical settings in a hospital. ICU patients are not only compromised by illness but also faced with a wide range of stressors. Most of the time, pharmacological therapies are commonly used to control the distress, but are expensive and lead to high hospital care costs. It is thought that music can act as a nursing intervention to relieve both physiological and psychological responses and increase comfort of patients. OBJECTIVE: The aim of the study was to identify, review and evaluate the literature regarding the role of music listening to promote relaxation for patients in the ICU together with considerations for future research. METHODS: MEDLINE, PubMed, CINAHL, AMED and PsycINFO databases were searched for the terms “music therapyâ€, “music medicine†and “music listeningâ€. In addition, an internet search using Google Scholar was performed. RESULTS: Literature research shows that music can influence a wide range of physiological and psychological effects and is effective in decreasing stress and facilitating relaxation responses. Different types of music and music preference of the individual patient may have a different effect. Moreover, live music is considered more important than pre-recorded music. CONCLUSION: Music therapy has been widely used in a variety of cultures for centuries to decrease patients’ perception of pain, anxiety and depression, and boost their feelings of relaxation. Music can be used as a safe and inexpensive non-pharmacologic antianxiety intervention to enhance relaxation and decrease stress in ICU patients. The key implication is to educate doctors and nurses on modern aspects of music therapy
A Lyophilized Form of Saccharomyces Boulardii Enhances the Helicobacter pylori Eradication Rates of Omeprazole-Triple Therapy in Patients With Peptic Ulcer Disease or Functional Dyspepsia
Get PDFBackground: Saccharomyces boulardii prevents antibiotic-induced diarrhea and exerts anti-H.pylori effects in vitro and in vivo. Aim: To assess whether S. boulardii enhances the efficacy of classic triple therapy in eradicating H. pylori. Methods: Seventy patients with peptic ulcer or functional dyspepsia according to Rome III criteria and H. pylori infection were treated with omeprazole 20 mg bid, clarithromycin 500 mg bid and amoxicillin 1 g bid for 14 days. A total of 36 out of 70 (51%) patients were randomized to S. boulardii [Ultralevure®, two capsules tid for 14 days (group A) and 34 (49%) on no intervention (group B). H. pylori eradication was assessed by a 13C-Urea Breath Test. Results: At baseline there were no significant differences between the two groups in any patient or disease characteristics. H. pylori was eradicated in 30/36 (83.4%) patients in group A vs 20/34 (58.8%) in group B (P=0.034, 95% CI 4.4% to 43.6%). Seven patients in group B (20.6%) and 1 patient in group A stopped treatment because of diarrhea (95% CI 3.3% to 32.7%, P=0.026). Multi-factorial analysis did not reveal any patient or disease related parameter linked to treatment outcome except for the use of the probiotic. Conclusion: S. boulardii enhanced the effect of classic triple therapy mainly by preventing antibiotic- and/or proton pump inhibitor-induced diarrhea
The Effectiveness of Inspiratory Muscle Training in Weaning Critically Ill Patients from Mechanical Ventilation
Get PDFBACKGROUND: Inspiratory muscle weakness is a consequence of mechanical ventilation that contributes to weaning failure in critical ill patients. Since 1980, case reports of inspiratory muscle training (IMT) in ventilated, difficult to be weaned patients have proposed that this training strategy is associated with successful weaning. OBJECTIVE: We evaluated the efficacy of the inspiratory muscle training on the weaning process. METHODS: We conducted a literature search in the following databases: PubMed, EMBASE, Scopus and Google scholar. Selected keywords included inspiratory/ respiratory muscle training, weaning/failure, mechanical ventilation, critically ill, threshold load, intubated/ tracheostomy. RESULTS: In our analysis we included three randomized control trials involving 150 patients. The studies used different devices of training and training protocols. Inspiratory muscle training significantly increased inspiratory muscle strength in relation to sham or no training. CONCLUSION: Although IMT leads to significant increase of respiratory muscle strength, it has not yet been clearly demonstrated that this also leads to successful weaning. Further large randomized studies are needed to determine the beneficial effect of IMT in weaning patients from ventilatory support