IntroductionEosinophilic granulomatosis with polyangiitis is a rare and potentially fatal disease if not readily diagnosed. Cerebral involvement is extremely rare and clinical presentation as hemorrhagic stroke is even rarer.Case presentationA 58-year-old Caucasian man was admitted to our medical unit because of a computed tomography-diagnosed hemorrhagic stroke with right-sided hemiparesis and fever. A chest computed tomography scan also revealed multiple bilateral pulmonary infiltrates; coronary artery, and carotid and left vertebral artery calcifications were also observed. Empiric antimicrobial therapy with cephalosporins was promptly undertaken; low-molecular-weight heparin was introduced as prophylaxis for venous thromboembolism. Over the following days, magnetic resonance imaging scans showed a regression of the hemorrhagic framework, also revealing hypoxic areas consistent with acute ischemic lesions. With a computed tomography scan showing a worsening of his pulmonary framework, antimicrobial therapy was modified and corticosteroids were introduced. A new blood cell count revealed further increased leukocytosis (17.49×103μL), characterized by a surprising rise of eosinophilic cells (32.8%). Angiography of the coronary arteries found diffuse dilatations with severe signs of endothelial damage. Such an unexpected framework induced a strong suspicion that the stroke was the expression of a systemic vasculitis, which had triggered his cerebral, coronary, and pulmonary frameworks. The search for antineutrophil cytoplasmic antibody was positive for perinuclear antineutrophil cytoplasmic antibody, and eosinophilic granulomatosis with polyangiitis was diagnosed. Explaining to the patient the rarity of his disease, and what the most typical presentations of eosinophilic granulomatosis with polyangiitis were, he revealed that before admission he had had scalp injuries, in the nuchal region, and had taken corticosteroids as self-medication, with subsequent disappearance of the lesions. Therefore, high-dose corticosteroid treatment was started, and at discharge he was in good clinical condition with a slight right-sided hyposthenia.ConclusionsA diagnosis of eosinophilic granulomatosis with polyangiitis is often difficult, but we are convinced that intake of corticosteroids on a self-prescribed basis may have obscured the clinical presentation. Therefore, this case also suggests how the growing phenomenon of self-medication can be harmful, and that a careful investigation of clinical history is still an act of paramount importance.
Objectives:Recently, the SOHO, CATIE and CUTLASS studies showed that molecules which apparently showed the most side effects are not only the most effective but also tend to cause to the least frequent changes in treatment. Can we generalise this assertion ?Method:Review of the literature addressing comparing efficiency of treatments and cost efficacy studies. Result: Although we witness a profusion of publications about the efficiency of given molecules vs placebo, studies comparing molecules are scarce, and studies on cost efficacy in natural environments are even scarcer. The last few years’ efforts to completely minimise side effects seem to have resulted in a reduction of medication efficacy. Moreover, the previously held hypothesis suggesting that the fewer the side effects, the less the need to change treatment has been proven wrong. The duration of a treatment is more dependent upon its efficiency.Conclusion:Clinicians cannot use the absence of noxiousness of a molecule as their primary criterion of choice. They should carefully balance side effects and efficiency. There is a lack of studies about cost-efficacy and, in the interpretation of such studies it is essential that the limitations of the studies be taken into account, and their results should not be over-generalised. There is a danger that such misinterpretation of results may lead us to abandon the use of some of our most effective molecules, even though the data actually favours the use of Effective drugs with the appropriate monitoring of and dealing with side effects.
Heart failure, in its diverse forms based on the value of the ejection fraction, is associated to high mortality and the frequent need for hospitalization, with a consequent heavy burden on healthcare resources. For an appropriate treatment of heart failure with preserved ejection fraction (HFpEF), there are no specific drugs effective for this condition. Those indicated in HF with reduced EF (HFrEF) are of more benefit in that form of HF, according to the guidelines of the European Society of Cardiology of 2016: ACE-inhibitors, beta-blockers, anti-aldosterones are all indicated with a class of recommendation/level of evidence IA; therapy with loop diuretics is indicated in the case of clinical congestion (IB). Studies carried out with ACE-inhibitor (or angiotensin-receptor antagonist) or beta-blocker or anti-aldosterone to evaluate their efficacy also in HFpEF have substantially shown a benefit only on a reduction in the hospitalization rate. The same guidelines identify regular aerobic activity (IA) as more effective in the condition of HFpEF and indicate, appropriately, the need to treat comorbidities (IC) in the elderly (where they are more present and more numerous). They also recommend to avoid certain associations of drugs and, obviously, harmful (and contraindicated) medications that could worsen the clinical picture or might be potentially lethal.
RESUMENIntroducción: En la práctica de cirugía oral en los pacientes bajo terapia anti coagulante, el empleo de un sistema eficaz de acción hemostática es de extrema relevancia, porque puede evitar la alteración del régimen terapéutico anticoagulante y el riesgo de un exceso de sangrado. En el presente trabajo se investiga la capacidad hemostática de la cola de fibrina como presidio hemostático en los pacientes bajo terapia anticoagulante, exponiendo los resultados de la experimentación sobre la base de un Standard de referencia del trauma quirúrgico y de la intensidad de la terapia anticoagulante.Materiales y métodos: Han sido seleccionados 20 pacientes en terapia anticoagulante con una edad comprendida entre los 44 y 79 años, se han realizado, según las modalidades apropiadas, simples exodoncias o más complejas de dientes mono-, bi-y tri-radiculares. Tras la alveoloplastia se ha colocado una esponja de fibrina reabsorbible en forma de gel (Gingistat®)y se ha realizado la sutura. El trauma quirúrgico ha sido clasificado por medio de una escala cuantitativa que puede expresar de forma unívoca el grado de trauma. La categoría de trauma por cada paciente se establece por la suma de los valores obtenidos de cada uno de los procedimientos unitarios. Ha sido posible evaluar el coeficiente de relación entre la intensidad del efecto anticoagulante (medido por medio del lNR) y número de complicaciones hemorrágicas que se han verificado, además de entre el grado de trauma quirúrgico y el número de complicaciones que se han presentado.Resultados y Conclusiones: Se demuestra que el utilizo terapéutico de la cola de fibrina puede ser considerado como un válido soporte por la optimización de la hemostasis en los pacientes con alteraciones de la coagulación inducidas farmacológica mente.Palabras clave: Terapia anticoagulante, cola de fibrina, cirugía odontoestomatológica. SUMMARYAim of the work: The authors emphasize how an effective emostatic method is extremely important in patients treated with anticoagulating therapy during oral surgery: it can avoid the risk of an excessive emorrhage and the necessity to alter the anticoagu-lating therapeutic regimen. The present study examines the fibrin glue emostatic ability as emostatic support in patients treated with anticoagulating therapy. It expresses the experiment results,based on standards of reference of surgical trauma and considers the anticoagulating therapy intensity. Materials and methods: 20 patients with anticoagulation therapy have been selected within the age of 44 and 79. Following the appropriate techniques extractions of teeth with one, two or three roots have been practiced. After the alveoloplasty a reabsorbable sponge of fibrine is placed and the suture is done. The surgical trauma has been c1assified by means of a quantitative scale which can express it without inaccuracy. The category of trauma for each patient is established by the total of the values obtained from each of the single procedures. It has been possible to evaluate the coefficient of relationsh...
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