Hospital Chronicles (E-Journal)
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Should All Patients With Atrial Fibrillation Receive an Oral Anticoagulant in the Era of Non-Vitamin K Anticoagulants?
Full text linkOral anticoagulants (OAC) decrease the thromboembolic risk of non-valvular atrial fibrillation (AF) at the expense of increased bleeding. Over the years, several risk stratification schemes for both stroke and bleeding risk have been devised, among which lately the respective CHA2DS2-VASc and HAS-BLED scores predominate. However, even when the bleeding risk score is high, the guidelines recommend not to withhold OAC at least for patients with high stroke risk, but to attempt to concomitantly modify the conditions contributing to the high bleeding risk. The CHA2DS2-VASc score has been considered more reliable than other scores in identifying “truly low-risk†patients who do not require OAC, in whom the risk of bleeding may negate the protective effect of OAC. Some have suggested more complex schemes to better identify very low risk patients, but these schemes may lead to more extensive and costly assessments to decide on a relatively simple question, i.e. the need or not for anticoagulation therapy. In the era of non-vitamin K oral anticoagulants (NOACs), this may not be necessary any more, and a simple recommendation of providing every AF patient with OAC therapy may turn out to be a more practical and realistic approach, as long as these newer agents remain safe and effective
Nasal High Flow Oxygen in Respiratory Failure
Full text linkHigh flow nasal cannula system or nasal high flow oxygen is an oxygen delivery device which administers heated, humidified high flow oxygen with concentrations from 21% to 100% and with a flow rate up to 60 L/min in adults. It generates many physiologic effects to respiratory system with a lot of clinical applications. Indeed, greater comfort and tolerance, more effective oxygenation, and improved breathing pattern with increased tidal volume and decreased respiratory rate and dyspnea has constantly been detected. Therefore, it can be used to improve cardiogenic pulmonary edema and hypoxemic respiratory failure of any cause, postoperatively, during post-extubation, as well as for palliative car
The Current Role of Glycoprotein IIb/IIIa Inhibitors in Percutaneous Coronary Intervention
Full text linkThe central role of platelets in acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI) is well appreciated. The various platelet activation mechanisms finally lead to the expression and activation of surface glycoprotein IIb/IIIa receptors that mediate platelet aggregation and thrombus formation. Glycoprotein IIb/IIIa inhibitors (GPIs) are the most potent antiplatelent agents and their role in ACS treatment and PCI has been dominant in the recent past. The advent of stents and thienopyridines minimized ischemic complications and in parallel the role of GPIs in low risk PCI. Despite being effective in decreasing PCI-related ischemic complications, the major drawback of GPI use is a relative increase of hemorrhagic complications that can unfavorably affect prognosis. The availability of bivalirudin, which is regarded as an equally effective but safer antithrombotic agent when compared to the combination of heparin and GPIs, despite an ongoing controversy, has also led to a decrease of GPI use in PCI for ACS. Finally the advent of novel potent antiplatelet agents (prasugrel, ticagrelor and soon cangrelor) further contained GPI use in patients with ischemic – thrombotic risk that clearly exceeds bleeding risk and mainly for bail-out in case of a thrombotic event during PCI. A concise overview of accumulated data regarding optimal use of GPIs as determined by large clinical trials and recent guidelines is herein attempted
Lu177-DOTA-octreotate therapy on neuroendocrine tumour management: A case report and literature review
No full textFavourable outcomes of peptide receptor radiotherapy of neuroendocrine tumors have been reported during the last years. This case report refers to a patient with a non-functional neuroendocrine carcinoma of pancreas with liver metastases and abdominal lymph nodes involvement. He underwent fractionated treatment with 4 cycles of Lu177-DOTA-octreoate (7.400MBq) after the failure of treatment with chemotherapy regiments. We conclude that fractionated therapy with Lu177-DOTA-octreotate should be considered a treatment option in the management of patients for symptomatic improvement in inoperable or metastasized neuroendocrine tumors, and for patients with large tumors and high somatostatin receptor expression
You Are What You Eat, Hence Curtail Saturated and Trans Fats, Free Sugars and Salt
Full text linkThe new Dietary Guidelines for Americans 2015-2020 focus on healthy eating patterns and exercise. They recommend 3 different healthy eating patterns: the Healthy US Style, the Healthy Mediterranean Style, and the Healthy Vegetarian Style eating pattern, accommodating a variety of cultural and individual preferences, but sharing many common food based features. A healthy eating pattern includes a variety of vegetables, fruits, grains, low-fat dairy products, protein foods, and oils. Specific recommendations have been made for particular dietary components to reduce: saturated fat (< 10% of calories); sodium (< 2.3 g/day); and added sugars (< 10% of calories). Interestingly, these guidelines do not make a recommendation for a quantitative limit for dietary cholesterol indicating the lack of adequate evidence for such recommendation. However, they state that there is evidence showing that eating patterns that include lower intake of dietary cholesterol (~100 - 300 mg/d) are associated with reduced risk of cardiovascular disease, and risk of obesity. Finally the new guidelines emphasize the importance of physical activity and exercise to promote health
An Underexpanded Stent Does not Forgive
Full text linkResistant coronary lesions regularly challenge physicians performing percutaneous coronary interventions (PCI) and specific techniques may be required to achieve procedural success. Underestimation of a resistant lesion may result in implanting an underexpanded stent due to insufficient plaque modification. Stent underexpansion is a risk factor for stent thrombosis and particularly difficult to treat. We present herein a case of a resistant right coronary artery lesion, insufficiently modified before stenting and finally treated with an underexpanded stent which could not be expanded by balloon post-dilatation at the initial intervention. Two inferior wall myocardial infarctions ensued one and three years later, both due to stent thrombosis despite intensive dual antiplatelet therapy and both treated by primary PCI. The stent could only be expanded by aggressive non-compliant balloon dilatation at the last procedure. The case presentation is followed by a brief discussion concerning techniques to successfully treat resistant coronary lesions and underexpanded stents
Paroxysmal Nocturnal Hemoglobinuria Testing by Flow Cytometry: Brief Overview for Clinicians
Full text linkParoxysmal Nocturnal Hemoglobinuria (PNH) is a rare, acquired hematopoietic stem cell disorder, caused by a somatic mutation in the PIG-A gene. This mutation is responsible for the synthesis of glycophosphatidylinositol (GPI) anchor that attaches a number of proteins to the cell surface. The mutant gene leads to partial deficiency or absence of all proteins normally linked to the cell membrane by GPI anchor. The primary clinical manifestations of PNH are complement mediated hemolytic anemia, thrombosis in atypical locations and blood cytopenias. Flow cytometry has become the gold standard method for PNH clone detection due to its high sensitivity and specificity and due to the ability to examine multiple GPI-linked proteins on red and white blood cells surface. It is the method of choice for the detection of very small PNH clones in subclinical PNH that often accompanies aplastic anemia and other bone marrow disorders. PNH clone detection traditionally involves the analysis of CD55 and CD59 on red and white blood cells. Other markers such as CD14, CD16, CD24, CD66b and CD157 are suitable to detect GPI-linked proteins in the surface of granulocytes and monocytes. The most useful reagent to assess white blood cell PNH clones is Fluorescent Aerolysin (FLAER) which is a mutated form of proaerolysin conjugated with a fluorochrome. Its advantage in PNH clones detection is due to the ability to bind directly to the glycan portion of the GPI anchor. Flow cytometry is a sophisticated method and a useful tool for clinical cell analysis. However, PNH is a clinical diagnosis and flow cytometric results should always be interpreted with respect to clinical manifestations and other laboratory findings
The Implementation of Global Asthma Management Guidelines in Two General Respiratory Outpatient Clinics in Greece
No full textBACKGROUND: The implementation of global guidelines for asthma management aims at asthma control. The aim of this study was to investigate the implementation of asthma management guidelines by both patients and physicians in two general pulmonary outpatient clinics in Greece.METHODS: Two questionnaires were administered to pulmonologists (n=43) and patients (n=181) separately. Asthma control was assessed by Asthma Control Test.RESULTS: All physicians informed their patients about asthma and suggested regular visits. The vast majority educated their patients to recognize symptom deterioration (n=42, 97.7%) and asthma triggers (n=41, 95.3%), to readjust treatment (n=41, 95.3%) and use correctly the inhaler devices (n=40, 93%). Greek pulmonologists suggested physical activity (n=40, 93%), peak flow meter use (n=13, 30.2%) and asthma physiotherapy (n=10, 23.3%), while 13 (30.2%) provided a written action plan. Among 181 participants with asthma, 41 (22.7%) had hyperventilation, while 117 (64.6%), mostly young men, had controlled asthma with high FEV1% predicted and without hyperventilation. Only 21 (11.6%) visited the emergency room in the past 6 months, while 98 (54.1%) had regular follow-up. They had developed a partnership with their physician (n=151, 83.4%) and confirmed their response to education on asthma triggers (n=156, 86.2%), symptom deterioration (n=171, 94.5%), inhaler medication technique (n=168, 92.8%) and peak flow meter use (n=40, 22.1%). Moreover, 118 (65.2%) patients recognized medication categories and 34 (18.8%) had a written action plan. They complied with physical activity suggestion (n=141, 77.9%), while 11 (6.1%) have performed breathing exercises.CONCLUSION: The recommendations for asthma management are significantly integrated into clinical practice in Greece, leading to high prevalence of asthma control.Â
Management of Major Bleeding with the Non-Vitamin K Oral Anticoagulants: the Role of Antidotes
Full text linkOver the recent years, new oral anticoagulant agents have been developed and entered the clinical arena, the non-vtamin K or direct oral anticoagulants (NOACs). Although more expensive, these agents have been proven as equivalent or superior to vitamin K antagonists in the treatment of non-valvular atrial fibrillation (AF) and venous thrombo-embolism with a lower incidence of intracerebral hemorrhage. Nevertheless, occurrence of major or life-threatening bleeding events is still quite possible. Thus, there is a major concern regarding the lack of a specific antidote and rapid reversal agent in such disastrous situations. Fortunately, the development of effective specific NOAC antidotes has recently made great advances, which are herein briefly reviewed