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Treatment of intracranial arterial disease
Published in Debabrata Mukherjee, Eric R. Bates, Marco Roffi, Richard A. Lange, David J. Moliterno, Nadia M. Whitehead, Cardiovascular Catheterization and Intervention, 2017
Alberto Maud, Gustavo J. Rodriguez
The WASID trial investigated the effects of oral vitamin K antagonist warfarin (with a target international normalized ratio of 2-3) vs. aspirin in patients with recent ischemic stroke or TIA attributed to 50%-99% stenosis of a major intracranial artery. Patient recruitment in WASID was prematurely stopped at 569 patients, owing to safety concerns of patients treated by warfarin. Warfarin and aspirin showed comparable effects in preventing the composite primary endpoint (ischemic stroke, brain hemorrhage, or vascular death) in a mean follow-up of 1.8 years (21.8% vs. 22.1%, P = 0.83). However, long-term usage of warfarin significantly increased the rates of major adverse events, including death (9.7% vs. 4.3%, P = 0.02) and major hemorrhage (8.3% vs. 3.2%, P = 0.01).21 Post-hoc subgroup analyses showed a beneficial effect of warfarin over aspirin (16% vs. 33%, P = 0.04) in preventing the primary endpoint in patients with stroke attributed to BA stenosis, but there was no significant difference in recurrent vertebrobasilar ischemic stroke between the two groups.28 The Fraxiparine in Ischemic Stroke (FISS-tris) study randomized 603 patients and compared the safety and efficacy of anticoagulation (subcutaneous low-molecular-weight heparin [LWMH, nadroparin calcium] for 10 days followed by aspirin for 6 months) vs. aspirin only for 6 months. Among the 353 patients who had large artery occlusive disease, 300 had ICAD only, 11 had extracranial disease only, and 42 had both.29 Post-hoc analysis indicated that the early use of LWMH in patients with large artery occlusive disease may reduce early neurological deterioration within 10 days after stroke, although the primary endpoint of the trial (favorable functional outcome at 6 months with a Barthel index e85) did not differ between the LWMH and aspirin groups. There was no significant difference in the risks of recurrent stroke from Day 10 to 6 months (4% vs. 5%, P = 0.74) or death within 6 months (5% vs. 5%, P = 0.88) in the two groups, either. Subgroup analyses suggested a more favorable functional outcome in patients with vertebrobasilar territory stroke treated with LWMH (OR 5.76, 95% CI 2-16.56; P = 0.001).30 Therefore, warfarin or short-term subcutaneous LWMH, are not superior to aspirin in preventing stroke in symptomatic ICAD.
Multiple organ failure and shock following acute alpha lipoic acid (ALA) intoxication
Published in Clinical Toxicology, 2019
Riccardo Moretti, Chiara Angeletti, Stefano Minora
We report a 70-year-old woman who was prescribed ALA, pantoprazole and LMWH (nadroparin calcium) following lumbar spine surgery. Due to a prescribing error, the woman accidentally ingested 4.5 g of ALA active principle from a preparation intended for industrial use instead of the commercially available preparation (Alpha-lipoic Acid, Farmalabor, Bitonto, Italy). ALA concentration in this product is 99.5% and is higher than OTC supplements, which provide a more gradual and predictable absorption after ingestion. As confirmed by the closest relatives, who presented with the box, the drug had been bought from a specialized website. She began having new onset, generalized, tonic-clonic seizures 30 minutes after the ingestion. The seizures were refractory to intravenous diazepam (0.3 mg/Kg), intravenous lorazepam (0.06 mg/Kg) and levetiracetam (7.7 mg/Kg).
Pregnancy in a patient with eosinophilic granulomatosis with polyangiitis
Published in Journal of Obstetrics and Gynaecology, 2019
George J. Daskalakis, Vasilios P. Pergialiotis, Mariana K. Theodora, Panagiotis G. Antsaklis, Mihail A. Sindos, Panagiotis G. Vlahogianopoulos, Kaliopi J. Pappa
On admission, the laboratory findings were: SO2: 94%, pCO2: 26 mmHg, pO2: 64 mmHg, pH: 7.48, haemoglobin: 10.4, haematocrit: 31.2%, white cell count: 16,900 (eosinophilia 35%), platelets: 409,000, urea: 17 mg/dlt, glucose: 85 mg/dlt, creatinine: 0.44 mg%, K: 4.3 mmol/lt, Na: 136 mmol/lt, C-reactive protein: 80.068 (normal values <5), d-dimers: 1.13, creatinine phosphokinase: 23 U/lt, aspartate aminotransferase: 65U/lt, alanine transaminase: 88U/lt. A chest radiograph showed there were multiple infiltrates at the bases of the lungs as interstitial pneumonitis. Her blood pressure was 110/70 mmHg and her temperature was 36.8°C. She was a nonsmoker. The treatment remained the same as was from the beginning of her pregnancy: methylprednisolone 4 mg twice daily, azathioprine 125 mg/day, salbutamol inhaler 200 mcg three times a day and fluticasone propionate inhaler 250 mcg twice per day. Moreover, nadroparin calcium at 0.3 mL× 2/day was given. An ultrasound scan was also performed which revealed an appropriately grown foetus (estimated foetal weight 955 g) with normal amniotic fluid and normal Doppler indices.
Recognition of pulmonary pathology in a patient presenting with shoulder pain
Published in Physiotherapy Theory and Practice, 2022
Fabrizio Brindisino, Valerio Passudetti, Denis Pennella, Giuseppe Giovannico, John D. Heick
The patient took the following medications postoperatively: prednisone; tiocolchioside (muscle relaxant); diclofenac (non-steroidal anti-inflammatory); omeprazole (proton pump inhibitor); and nadroparin calcium (low molecular weight heparin). The patient was discharged from the hospital one week after surgery and stated that from the onset of his abdominal symptoms, he lost about 11 kg. While at home, the patient had a difficult time with postural changes because of ongoing shoulder pain (4/10 NPRS -Numeric Pain Rating Scale- an eleven-point scale with 0 being no pain and 10 the worst pain imaginable) (Keele, 1948) and thoracic pain (2/10 NPRS) (Bodychart 1).