Routine podiatry assessment as a potential preventive tool for atrial fibrillation screening in diabetics

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Atrial fibrillation (AF) is a common heart arrhythmia predominantly in advanced age patients and in diabetic’s type II (DMPII). Even if the risk of stroke in AF in DMPII is relative high, 25% of AF patients remains undiagnosed and also cryptogenic AF is very common in the diabetic population. During a 12-month study project, podiatrists and podologists performed foot pulse-checks in their routine podiatry assessment, when encountering visual symptoms that suggest an underlying circulatory disorder in diabetics. This simple non-invasive method aims to increase screening and diagnosis of AF from allied health professionals, in order to reveal patients with previously undiagnosed AF and patients with cryptogenic Af, challenging the potential reduction of AF complications and mainly of stroke.

Purpose 

Early detection of AF in diabetics from allied health professionals during routine podiatry assessment. Revealing of previously undiagnosed AF contributes to stroke and other AF complications incidence reduction in the diabetics population.

Methods 

During a 12-month study, 2 podiatrists and 6 podologists performed foot pulse-checks on diabetics, during their annual foot screening appointments, since they have been trained from medical doctors to spot rhythm abnormalities during pulse palpation of the foot arteries. They have been also trained to confirm their pulse palpation evidence thought Doppler ultrasound wave assessments during evaluation of arterial blood supply (anterior-posterior tibial arteries and ramifications) of the diabetic foot. During the study 300 diabetics (mean age 60 years old, 180 males, 120 females) had their feet pulse-tested. Spss statistical software had been used. 

Results 

17% of diabetics during foot pulse-checks presents undiagnosed AF. There was no statistically significant difference (p < 0.05) between sex  (males and females AF screening percents were similar). 

Conclusion(s) 

Early detection and properly managed during AF screening reduces AF complications and specifically stroke incidence. Opportunistic podiatric detection of previously undiagnosed and cryptogenic AF from allied professionals is a non invasive, safe, fast and economic method with potential contributions in this direction. More studies must be designed in order to support the routine podiatry assessment, as a useful Screening diagnostic tool of AF for reducing cardiovascular complications incidence in diabetics but also in the general population.

The impact of nationwide lockdown on acute coronary syndromes hospitalization rate in the Western Macedonia regional hospital of Greece

Funding Acknowledgements

Type of funding sources: None.

Introduction

 World Health Organization declared the Covid-19 outbreak a global pandemic on March 11, 2020. The pandemic is associated with more than 75 million cases and more than 1.5 million deaths worldwide. Greece implemented a nationwide lockdown on March 23, 2020, to control the pandemic wave and prevent reducing morbidity and mortality due to Covid-19. During this period, acute coronary syndromes (ACS) hospitalization in the cardiology department was reduced. In addition, the second pandemic wave also led to a new national lockdown on November 7, 2020, although it was implemented 15 days earlier in the relative regional hospital area due to high viral load.

Purpose

 Our study evaluated the number of hospitalized patients with ACS during the nationwide lockdown period, comparing them with the previous years (period 2018 and 2019).

Material and Methods

 Data recordings regarding ACS (unstable angina, NSTEMI, STEMI) hospitalization rates in the Cardiology department were collected from the hospital"s register. Each year"s data analysis interval included the periods of the nationwide lockdown of 2020; March 23 to May 3 and October 14 to December 10. Statistical analysis was performed between periodic groups using the chi-square test (IBM SPSS Statistics software, version 23.0).

Results

 During 2018, the number of patients hospitalized for ACS was 81 and consisted of 39,1% of the total hospitalizations in the Cardiology Department. In 2019 the number of patients hospitalized for ACS was 62 and consisted the 48,8% of the total hospitalizations, while in 2020, the number of patients hospitalized for ACS was 30 and consisted the 27,5% of the total hospitalizations. Furthermore, there was a statistically significant difference (p < 0,05) regarding ACS event hospitalization rate between the period of lockdown (March to May and October-December 2020) and the COVID-19-free period of the previous year (March to May and October to December 2019). There was no statistically significant difference (p > 0,05) regarding ACS event hospitalization rate between the period of lockdown (March to May and October to December 2020) and the COVID-19-free period of the year 2018 (March to May and October to December). Finally, there was no statistically significant difference (p > 0,05) in ACS event hospitalization rate between March to May and October to December regarding the years 2018 and 2019.

Conclusion

 Our results are in compliance with the ESC"s comparative survey regarding the observed worldwide reduction of hospitalizations for ACS during the COVID-19 lockdown era, suggesting a potential impact of lockdown in both non-environmental and environmental risk factors for cardiovascular disease. Factors of the relative epidemiological reduction are complexed and puzzled, while morbidity and mortality of ACS remained relatively stable even after the lockdown, so future studies are necessary to further investigate them.

Anemia and stroke: Where do we stand?

Anemia seems to have a clear relationship with cerebrovascular events (CVEs), as there is a direct connection between central nervous system, blood supply, and tissue oxygen delivery. Anemia is considered a hyperkinetic state which disturbs endothelial adhesion molecule genes that may lead to thrombus formation. Furthermore, blood flow augmentation and turbulence may result in the migration of this thrombus, thus producing artery-to-artery embolism. It is for this reason that anemia is characterized as "the fifth cardiovascular risk factor." Anemia is consistently present in patients with acute stroke, ranging from 15% to 29%, while the mortality rate was significantly higher in patients suffering from anemia at the time of admission. Different types of anemia (sickle cell disease, beta thalassemia, iron deficiency anemia [IDA]) have been associated with increased cardiovascular and CVE risk. The relation between hemoglobin level and stroke would require further investigation. Unfortunately, treatment of anemia in cardiovascular and cerebrovascular disease still lacks clear targets and specific therapy has not developed. However, packed red blood cell transfusion is generally reserved for therapy in patients with CVEs. What is more, treatment of IDA prevents thrombosis and the occurrence of stroke; although iron levels should be checked, chronic administration favors thrombosis. Regarding erythropoietin (EPO), as there is lack of studies in anemic stroke patients, it would be desirable to utilize both neuroprotective and hematopoietic properties of EPO in anemic stroke patients. This review aims to clarify the poorly investigated and defined issues concerning the relation of anemia and CVEs.

Is management of hyperglycaemia in acute phase stroke still a dilemma?

INTRODUCTION

Close monitoring of blood glucose levels during the immediate post-acute stroke phase is of great clinical value, as there is evidence that the risk of neurological deterioration is associated with both hyper- and hypoglycaemia. The aim of this review paper is to summarise the evidence on post-stroke blood glucose management and its impact on clinical outcomes, during the early post-acute stage.

FINDINGS

Post-stroke hyperglycaemia has been associated with increased cerebral oedema, haemorrhagic transformation, lower likelihood of recanalisation and deteriorating neurological state. Thus, hyperglycaemia during an acute stroke may result in poorer clinical outcomes, infarct progression, poor functional recovery and increased mortality rates. Although hypoglycaemia may also lead to poorer outcomes via further brain injury, it can be readily reversed by glucose administration. In most patients, the goal of regular treatment is euglycaemia and for acute-stroke patients, a reasonable approach is to target control of glucose level at 100-150 mg/dL.

CONCLUSION

Both hypoglycaemia and hyperglycaemia may lead to further brain injury and clinical deterioration; that is the reason these conditions should be avoided after stroke. Yet, when correcting hyperglycaemia, great care should be taken not to switch the patient into hypoglycaemia, and subsequently aggressive insulin administration treatment should be avoided. Early identification and prompt management of hyperglycaemia, especially in acute ischaemic stroke, is recommended. Although the appropriate level of blood glucose during acute stroke is still debated, a reasonable approach is to keep the patient in a mildly hyperglycaemic state, rather than risking hypoglycaemia, using continuous glucose monitoring.

Simultaneous manifestation of pleural effusion and acute renal failure associated with dasatinib: a case report

WHAT IS KNOWN AND OBJECTIVE

Dasatinib is a novel second-generation inhibitor of multiple tyrosine kinases, indicated for the treatment for Philadelphia chromosome-positive (Ph+) chronic myeloid leukaemia (CML), acute lymphoblastic leukaemia (ALL) and lymphoid blast CML with resistance or intolerance to prior therapy. Although dasatinib is a potent, efficacious and generally well-tolerated drug, patients are also subject to various adverse effects. The most common pulmonary-related side effect is pleural effusion (PE). Renal failure has been reported rarely as a side effect of dasatinib treatment. We report the first case of a patient with imatinib-resistant CML who developed PE and acute renal failure (ARF) simultaneously, after being placed on dasatinib therapy.

CASE SUMMARY

We report a 58-year-old female dasatinib-treated patient with Ph+ chronic phase CML who was admitted to our hospital due to persisted dyspnoea and fever. After reviewing the laboratory and clinical findings, we determined our patient as having simultaneously ARF and PE related to dasatinib therapy. Dasatinib was discontinued, and after 10 days of treatment with ampicillin-sulbactam, allopurinol, amlodipine, furosemide and methylprednisolone, she was discharged home effusion free and with ameliorated renal function.

WHAT IS NEW AND CONCLUSION

PE is the most common extra-haematological toxicity observed during dasatinib treatment whose pathogenesis is still unclear. A possible role of cytokines, such as platelet-derived growth factor receptor (PDGFR)-β and vascular endothelial growth factor (VEGF), in causing endothelial permeability has been suggested. The aetiology of renal failure is also unclear in these patients, but two different possible mechanisms have been suggested such as tumour lysis syndrome and toxic tubular damage. In conclusion, here we describe the first case of simultaneous manifestation of PE and ARF associated with dasatinib. Thus, in patients treated with tyrosine kinase inhibitors, especially those with predisposing nephrological or haematological factors, serum creatinine levels should be monitored routinely.

Amiodarone: pharmacological profile, animal-model experimental data and clinical use. How important is the vasodilating effect?

Amiodarone, the major representative of class III antiarrhythmic agents, is widely used in the treatment of ventricular and hyperventricular arrhythmias, being specifically useful in the therapy of patients suffering from life threatening ventricular arrhythmias. The combination of antianginal and antiarrthythmic actions of amiodarone is an extremely significant advantage regarding the treatment of patients with chronic atherosclerotic cardiopathy, as heart rate disorders are frequently fatal in coronary heart disease and, reversely, a high percentage of cardiac arrhythmias are caused by coronary heart disease. Since 1980s, several experimental in vitro and in vivo data, as well as clinical studies, regarding both systematic and coronary circulation, support the vasodilative effects of amiodarone. We have previously showed that amiodarone in vitro exerts a vasodilator effect in isolated vessel tissue, mainly via the activation of intracellular calcium binding mechanisms, a fact that differentiates this agent from other coronary vasodilative drugs, such as calcium channel blockers, that affect extracellular calcium ions entrance. Thus, the vasodilative, antianginal and antiarrhythmic actions of amiodarone may be further enhanced by the simultaneous supplementation of calcium channel blockers via synergistic mechanisms, supporting the clinical use of such drug combinations. Finally, as amiodarone and noradrenaline have been reported to exert antagonistic actions, the application of amiodarone is particularly indicated in pathologic conditions characterized by the stimulation of sympathetic nervous system (sympathicotonia).

Standardized arrangement for a guideline-driven treatment of the metabolic syndrome: the SAGE-METS study

AIM

To substantially increase awareness, treatment and effective control of the metabolic syndrome (MetS) and its components.

SUBJECTS AND METHODS

This is a pilot best practice implementation enhancement programme to reduce the estimated cardiovascular disease (CVD) risk in 628 MetS patients with or without diabetes or CVD by improving quality of care. A baseline visit was followed by action to improve adherence to lifestyle advice and drug treatment for CVD risk factors by physicians specifically trained to implement guidelines. Finally, after 6 months, a single-page form was completed, showing if patients were at CVD risk factor target. If not, there was an analysis of the reason why.

RESULTS

The programme was effective in improving utilization of evidence-based treatment in 628 MetS patients. There was a substantially greater patient perception of MetS, an enhancement in compliance with lifestyle advice and increased prescription of evidence-based medication, leading to a 48% (p < 0.0001) improvement in estimated CVD risk. There was a substantial increase in the number of subjects on target for specific CVD risk factors.

CONCLUSIONS

This is the first study to increase adherence to multiple interventions for all MetS components on an outpatient basis, in both primary care and teaching hospital settings. Physician and patient education, distribution of printed guidelines and brochures, and completion of a single-page form motivated both physicians and patients to achieve multiple CVD risk factor guideline goals. The absence of a control group is a limitation of this study. Further work is also needed to establish if the improvements observed are sustained on a long-term basis.

The neuroprotective role of erythropoietin in the management of acute ischaemic stroke: from bench to bedside

Recombinant human erythropoietin was produced soon after the discovery of the erythropoietin gene in 1985 and since then, it is used in various clinical conditions such as chronic renal failure. Moreover, experimental studies have shown that erythropoietin exerts neuroprotective action as well. Recently, a clinical trial yielded promising results concerning the use of erythropoietin in stroke management. In this review, we summarize the main data which suggest that recombinant human erythropoietin and its analogues may indeed have a role in stroke treatment.

Stroke and conditions that mimic it: a protocol secures a safe early recognition

OBJECTIVE

Certain disorders may be falsely diagnosed as stroke. We examined the efficacy of the diagnostic protocol that is followed in our stroke unit and was designed in order to early differentiate more efficiently between stroke and conditions that mimic it. METHODS-PATIENTS: Three hundred sixty-two elderly patients (196 male, 166 female with average age 74.56 years), who were hospitalized at our stroke center between January of 2005 and June of 2007 and diagnosed at admission as stroke patients, were retrospectively studied in order to investigate if the final diagnosis agreed with the initial diagnosis of stroke on admission.Our diagnostic protocol included medical history of the patient, assessment of state of consciousness, blood pressure, electrocardiogram, complete blood cell count (hematocrit/hemoglobin, leukocytes, platelets), clotting mechanism (prothrombin time, activated partial thromboplastin time), glucose, electrolytes (Na, K, Ca), renal (blood urea nitrogen, creatinine) and liver function (SGOT, SGPT), as well as imaging methods like chest X-Ray and brain CT scan.

RESULTS

In 95% of patients, the final diagnosis agreed with the initial diagnosis of stroke at admission. According to final diagnosis, 344 (95%) of them had stroke -either hemorrhagic or ischemic-, while from the rest 18 (5%), 12 (66.7%) were found to have metastatic neoplasm of brain, 3 (18.7%) had primal tumour of brain, whereas 3 (18.7%) suffered from other diseases (respiratory infection, meningoencephalitis, thyrotoxicosis). The principal symptoms of the conditions that mimicked a stroke were: aphasic disturbances (27.3%), dizziness/fainting (27.3%), headache/diplopia (11.1%), dysarthria (11.1%), hiccup and/or swallow disturbances (5.6%).

CONCLUSION

Our diagnostic protocol seems to ensure a high degree of differential diagnosis between stroke and conditions that mimic it.

Parathyroid crisis as first manifestation of primary hyperparathyroidism

We report the case of a 61-year-old woman who suffered a parathyroid crisis due to a parathyroid adenoma. The patient presented with the typical clinical symptoms of hypercalcemia. Ca(+2) and PTH were markedly increased. Initially, she was treated conservatively until Ca(+2) returned to normal levels. Then, she underwent surgical excision of a newly diagnosed parathyroid adenoma. Parathyroid crisis (PC), also known as parathyroid storm or acute primary hyperparathyroidism, is a rare and serious complication of primary hyperparathyroidism (PH). Fewer than 200 cases have been described in the literature. Prognosis is poor: mortality is 100% in non-operable cases and 20% in cases in which parathyroidectomy is performed. We emphasize the importance of early diagnosis and aggressive treatment.