Adherencija i propisivanje statina u primarnoj prevenciji unutar primarne zdravstvene zaštite

Uz slabo dijagnosticiranu porodičnu hiperkolesterolemiju, sekundarna hiperkolesterolemija vrlo je čest i zanemaren problem u svakodnevnoj kliničkoj praksi. Cilj ove studije je prikazati stvarno stanje korištenja statinske terapije u praksi jedne ordinacije primarne zdravstvene zaštite te istražiti razloge zbog kojih bolesnici ne koriste statine u primarnoj kardiovaskularnoj prevenciji. Analizirani su rezultati laboratorijskih nalaza LDL-k, non-HDL kolesterola u serumu, koncentracija triglicerida te kreatinina u serumu 1608 pacijenata jedne od ordinacija u sklopu Doma zdravlja Zagreb – Zapad kroz lipanj 2019. godine. Ukoliko je bolesnik koristio statinsku terapiju prilikom uzimanja uzoraka krvi, dobivena laboratorijska koncentracija serumskog kolesterola množila se s odgovarajućim korekcijskim faktorom za vrstu i dozu statina. Uključeni su bolesnici čije su vrijednosti LDL-k izvornom ili korigiranom vrijednošću prelazile 5 mmol/L. Bubrežna funkcija izračunata je po CKD-EPI formuli. Isključeni su svi bolesnici sa svim jetrenim i/ili bubrežnim bolestima kao i oni s nereguliranim vrijednostima glukoze u plazmi, perifernom arterijskom bolesti te preboljelim srčanim ili moždanim infarktom u osobnoj anamnezi. Od 1608 pacijenata ordinacije, njih 40 (26 žena i 14 muškaraca, ukupno 2,5%) imalo je vrijednosti LDL kolesterola iznad 5 mmol/L (max 10,2 mmol/L). Razlika između spolova nije bilo. 38 pacijenata (95%) bili su hipertoničari te 8 (20%) dijabetičari s dobro reguliranim vrijednostima glukoze u plazmi. Unatoč vrijednostima LDL kolesterola, samo 10 pacijenata imalo je propisanu statinsku terapiju (25%). Vrijednosti non-HDL kolesterola u ovih bolesnika varirale su između 5,3 i 12,1 mmol/L. U 13 pacijenata postojali su dokazi u prilog miješane hiperlipidemije. Starost bolesnika je iznosila između 52 i 89 godina. Unatoč normalnom padu bubrežne funkcije sa starenjem (Spearman r=–0,71, p<0,01), vrijednosti LDL i non-HDL kolesterola nisu pokazale korelaciju s njome. Ukupno 13 bolesnika bilo je starije od 70 godina. Hiperkolesterolemija u primarnoj prevenciji kao jedan od neovisnih rizičnih čimbenika za razvoj kardiovaskularnih bolesti i dalje je vrlo podcijenjen problem. Usprkos čvrstim dokazima te visokim vrijednostima kolesterola u serumu, sumnjičavost liječnika u učinkovitost statinske terapije i slaba suradljivost bolesnika dovode do razočaravajućih rezultata u korištenju hipolipemičkih lijekova u primarnoj prevenciji kardiovaskularnih bolesti

Intestinal injury due to sodium polystyrene sulfonate (SPS) treatment in a heart transplant patient

Sodium polystyrene sulphonate (SPS) is a cation exchange resin widely used to treat hyperkalemia in patients with renal failure. Although infrequent, one of its most severe side effects is a gastrointestinal mucosal injury that is most commonly located in the colon. The injury can range from mild superficial injury to wall necrosis and perforation. The causative mechanisms are still unclear. The risk factors include end- stage renal disease, hemodynamic instability, solid organ transplantation, postoperative status and gastrointestinal motility disorders, including opioid usage. CASE REPORT One month after a successful heart transplantation the patient presented with sudden hematochezia and hemorrhagic shock. Emergency laparotomy, right hemicolectomy, and end ileostomy were performed. Histopathological analysis of the resected colon revealed mucosal injury with the presence of crystals of Kayexalate in the necrotic regions. We later found out that several days before this event, the patient received SPS for the treatment of hyperkalemia owing to mild deterioration of chronic kidney disease. The patient fully recovered and was discharged from the hospital. CONCLUSION Acute lower gastointestinal bleeding has many causes, but SPS-related mucosal injury and intestinal perforation is unusual. Since our patient had several predisposing factors for this serious side effect it is important to use SPS only when necessary, especially in the postoperative patients and in those with gastrointestinal motility disorders. Although similar cases of intestinal injury after SPS therapy in solid organ transplant patients have alredy been reported this is, to our knowledge, the first reported case in a patient who underwent a heart transplantation

Risk of inappropriate use of antibiotics in newborn

Antibiotici su danas nedvojbeno najkorišteniji lijekovi u jedinicama za intenzivno liječenje novorođenčadi (NICU). Primarni razlog primjene antibiotika kod novorođenčadi je liječenje i prevencija novorođenačke sepse. Novorođenačka sepsa dijeli se na ranu i na kasnu, tako da se čimbenici koji pogoduju nastanku kao i uzročnici ove dvije vrste sepse razlikuju. Nedonoščad spada u posebno rizičnu skupinu kada je u pitanju razvoj sepse. Značajan problem leži u ispravnom postavljanju dijagnoze zbog nespecifičnosti kliničke slike. Danas su najkorištenije dijagnostičke metode za dijagnozu sepse kompletna krvna slika, CRP (C-reaktivni protein), prokalcitonin, hemokulture dok se neke novije metode presepsin, PCR (polymerase chain reaction) još istražuju. Ampicilin i gentamicin danas su najčešće propisivani antibiotici u NICU. Propisivanje antibiotika vrlo je varijabilno te se razlikuje od ustanove do ustanove. U kriterije za započinjanje terapije spadaju evaluacija čimbenika rizika za razvoj sepse koji čine klinički znakovi, porođajna masa, stupanj prematuriteta, kolonizacija majke streptokokom grupe B (GBS), trajanje rupture plodovih ovoja te intrapartalna antibiotička profilaksa majke. Terapija se u pravilu prekida nakon laboratorijskog praćenja smirivanja upalnih parametara. Štetne posljedice neadekvatnog korištenja antibiotika najoportunije bi bilo podijeliti na neposredne i odgođene. Vjeruje se da većina štetnih posljedica antibiotske terapije proizlazi iz njihovog učinka na razvoj fiziološke flore. U neposredne posljedice spada stvaranje rezistentnih sojeva, povećani rizik za razvoj nekrotizirajućeg enterokolitisa, bronhopulmonalne displazije, retinopatije pa čak i povećana smrtnost. Pod odgođene štetne posljedice misli se napose na poremećaje u dobivanju tjelesne mase i astmu. Programi pojačanog nadzora nad ordiniranjem antibiotika i naglašavanje važnosti dojenja otvaraju mogućnost za smanjenje izlaganja novorođenčadi štetnim učincima antibiotske terapije.Antibiotics are clearly most prescribed drugs in neonatal intensive care units (NICU) today. The primary reason behind antibiotic use is the treatment and prevention of sepsis in infants. Sepsis in infants is divided into two categories - early onset sepsis (EOS) and late onset sepsis (LOS), and there exists a difference in terms of the risk factors and the causative agents related to these two sepsis groups. Preterm infants show especially high risk for development of sepsis. Correctly diagnosing sepsis is a relevant issue due to the unspecificity of its clinical signs. The most commonly used diagnostic methods currently include complete blood count, CRP (C-reactice protein), procalcitonin and hemocultures while some less common methods such as presepsin and PCR (polymerase chain reaction) are also being reserached. Ampicilin and gentamicin are the most commonly prescribed antibiotics in NICUs. Antibiotic prescription is very variable and it differs from medical institution to medical institution. Criteria used for assessing whether to commence antibiotic therapy include evaluation of risk factors which consist of: clinical presentation, weight at birth, degree of prematurity, group B streptococci (GBS) colonisation of the mother, duration of membrane rupture and maternal intrapartal antibiotic prophylaxis. The treatment is generally discontinued after laboratory results demonstrate a calming of inflammation markers. Harmful effects of antibiotics are best divided into those that are immediate and those that are delayed. It is belived that the majority of the harmful consequences of antibiotic treatment comes from their effect on the development of physiological flora. Antimicrobial resistance, increased risk of necrotising enterocolitis (NEC), bronchopulmonary dysplasia, retinopathy and even increased mortality all fall under immediate consequences of antibiotic overtreatment. The most important delayed consequences are the disruption of normal weight gain and asthma. Antibiotic stewardship programs and emphasizing the role of breastfeeding are considered to be important for the decrease of newborn infant exposure to the harmful effects of antibiotic treatment

Risk of inappropriate use of antibiotics in newborn

Antibiotici su danas nedvojbeno najkorišteniji lijekovi u jedinicama za intenzivno liječenje novorođenčadi (NICU). Primarni razlog primjene antibiotika kod novorođenčadi je liječenje i prevencija novorođenačke sepse. Novorođenačka sepsa dijeli se na ranu i na kasnu, tako da se čimbenici koji pogoduju nastanku kao i uzročnici ove dvije vrste sepse razlikuju. Nedonoščad spada u posebno rizičnu skupinu kada je u pitanju razvoj sepse. Značajan problem leži u ispravnom postavljanju dijagnoze zbog nespecifičnosti kliničke slike. Danas su najkorištenije dijagnostičke metode za dijagnozu sepse kompletna krvna slika, CRP (C-reaktivni protein), prokalcitonin, hemokulture dok se neke novije metode presepsin, PCR (polymerase chain reaction) još istražuju. Ampicilin i gentamicin danas su najčešće propisivani antibiotici u NICU. Propisivanje antibiotika vrlo je varijabilno te se razlikuje od ustanove do ustanove. U kriterije za započinjanje terapije spadaju evaluacija čimbenika rizika za razvoj sepse koji čine klinički znakovi, porođajna masa, stupanj prematuriteta, kolonizacija majke streptokokom grupe B (GBS), trajanje rupture plodovih ovoja te intrapartalna antibiotička profilaksa majke. Terapija se u pravilu prekida nakon laboratorijskog praćenja smirivanja upalnih parametara. Štetne posljedice neadekvatnog korištenja antibiotika najoportunije bi bilo podijeliti na neposredne i odgođene. Vjeruje se da većina štetnih posljedica antibiotske terapije proizlazi iz njihovog učinka na razvoj fiziološke flore. U neposredne posljedice spada stvaranje rezistentnih sojeva, povećani rizik za razvoj nekrotizirajućeg enterokolitisa, bronhopulmonalne displazije, retinopatije pa čak i povećana smrtnost. Pod odgođene štetne posljedice misli se napose na poremećaje u dobivanju tjelesne mase i astmu. Programi pojačanog nadzora nad ordiniranjem antibiotika i naglašavanje važnosti dojenja otvaraju mogućnost za smanjenje izlaganja novorođenčadi štetnim učincima antibiotske terapije.Antibiotics are clearly most prescribed drugs in neonatal intensive care units (NICU) today. The primary reason behind antibiotic use is the treatment and prevention of sepsis in infants. Sepsis in infants is divided into two categories - early onset sepsis (EOS) and late onset sepsis (LOS), and there exists a difference in terms of the risk factors and the causative agents related to these two sepsis groups. Preterm infants show especially high risk for development of sepsis. Correctly diagnosing sepsis is a relevant issue due to the unspecificity of its clinical signs. The most commonly used diagnostic methods currently include complete blood count, CRP (C-reactice protein), procalcitonin and hemocultures while some less common methods such as presepsin and PCR (polymerase chain reaction) are also being reserached. Ampicilin and gentamicin are the most commonly prescribed antibiotics in NICUs. Antibiotic prescription is very variable and it differs from medical institution to medical institution. Criteria used for assessing whether to commence antibiotic therapy include evaluation of risk factors which consist of: clinical presentation, weight at birth, degree of prematurity, group B streptococci (GBS) colonisation of the mother, duration of membrane rupture and maternal intrapartal antibiotic prophylaxis. The treatment is generally discontinued after laboratory results demonstrate a calming of inflammation markers. Harmful effects of antibiotics are best divided into those that are immediate and those that are delayed. It is belived that the majority of the harmful consequences of antibiotic treatment comes from their effect on the development of physiological flora. Antimicrobial resistance, increased risk of necrotising enterocolitis (NEC), bronchopulmonary dysplasia, retinopathy and even increased mortality all fall under immediate consequences of antibiotic overtreatment. The most important delayed consequences are the disruption of normal weight gain and asthma. Antibiotic stewardship programs and emphasizing the role of breastfeeding are considered to be important for the decrease of newborn infant exposure to the harmful effects of antibiotic treatment

Risk of inappropriate use of antibiotics in newborn

Antibiotici su danas nedvojbeno najkorišteniji lijekovi u jedinicama za intenzivno liječenje novorođenčadi (NICU). Primarni razlog primjene antibiotika kod novorođenčadi je liječenje i prevencija novorođenačke sepse. Novorođenačka sepsa dijeli se na ranu i na kasnu, tako da se čimbenici koji pogoduju nastanku kao i uzročnici ove dvije vrste sepse razlikuju. Nedonoščad spada u posebno rizičnu skupinu kada je u pitanju razvoj sepse. Značajan problem leži u ispravnom postavljanju dijagnoze zbog nespecifičnosti kliničke slike. Danas su najkorištenije dijagnostičke metode za dijagnozu sepse kompletna krvna slika, CRP (C-reaktivni protein), prokalcitonin, hemokulture dok se neke novije metode presepsin, PCR (polymerase chain reaction) još istražuju. Ampicilin i gentamicin danas su najčešće propisivani antibiotici u NICU. Propisivanje antibiotika vrlo je varijabilno te se razlikuje od ustanove do ustanove. U kriterije za započinjanje terapije spadaju evaluacija čimbenika rizika za razvoj sepse koji čine klinički znakovi, porođajna masa, stupanj prematuriteta, kolonizacija majke streptokokom grupe B (GBS), trajanje rupture plodovih ovoja te intrapartalna antibiotička profilaksa majke. Terapija se u pravilu prekida nakon laboratorijskog praćenja smirivanja upalnih parametara. Štetne posljedice neadekvatnog korištenja antibiotika najoportunije bi bilo podijeliti na neposredne i odgođene. Vjeruje se da većina štetnih posljedica antibiotske terapije proizlazi iz njihovog učinka na razvoj fiziološke flore. U neposredne posljedice spada stvaranje rezistentnih sojeva, povećani rizik za razvoj nekrotizirajućeg enterokolitisa, bronhopulmonalne displazije, retinopatije pa čak i povećana smrtnost. Pod odgođene štetne posljedice misli se napose na poremećaje u dobivanju tjelesne mase i astmu. Programi pojačanog nadzora nad ordiniranjem antibiotika i naglašavanje važnosti dojenja otvaraju mogućnost za smanjenje izlaganja novorođenčadi štetnim učincima antibiotske terapije.Antibiotics are clearly most prescribed drugs in neonatal intensive care units (NICU) today. The primary reason behind antibiotic use is the treatment and prevention of sepsis in infants. Sepsis in infants is divided into two categories - early onset sepsis (EOS) and late onset sepsis (LOS), and there exists a difference in terms of the risk factors and the causative agents related to these two sepsis groups. Preterm infants show especially high risk for development of sepsis. Correctly diagnosing sepsis is a relevant issue due to the unspecificity of its clinical signs. The most commonly used diagnostic methods currently include complete blood count, CRP (C-reactice protein), procalcitonin and hemocultures while some less common methods such as presepsin and PCR (polymerase chain reaction) are also being reserached. Ampicilin and gentamicin are the most commonly prescribed antibiotics in NICUs. Antibiotic prescription is very variable and it differs from medical institution to medical institution. Criteria used for assessing whether to commence antibiotic therapy include evaluation of risk factors which consist of: clinical presentation, weight at birth, degree of prematurity, group B streptococci (GBS) colonisation of the mother, duration of membrane rupture and maternal intrapartal antibiotic prophylaxis. The treatment is generally discontinued after laboratory results demonstrate a calming of inflammation markers. Harmful effects of antibiotics are best divided into those that are immediate and those that are delayed. It is belived that the majority of the harmful consequences of antibiotic treatment comes from their effect on the development of physiological flora. Antimicrobial resistance, increased risk of necrotising enterocolitis (NEC), bronchopulmonary dysplasia, retinopathy and even increased mortality all fall under immediate consequences of antibiotic overtreatment. The most important delayed consequences are the disruption of normal weight gain and asthma. Antibiotic stewardship programs and emphasizing the role of breastfeeding are considered to be important for the decrease of newborn infant exposure to the harmful effects of antibiotic treatment

Intestinal injury due to sodium polystyrene sulfonate (SPS) treatment in a heart transplant patient

Sodium polystyrene sulphonate (SPS) is a cation exchange resin widely used to treat hyperkalemia in patients with renal failure. Although infrequent, one of its most severe side effects is a gastrointestinal mucosal injury that is most commonly located in the colon. The injury can range from mild superficial injury to wall necrosis and perforation. The causative mechanisms are still unclear. The risk factors include end- stage renal disease, hemodynamic instability, solid organ transplantation, postoperative status and gastrointestinal motility disorders, including opioid usage. CASE REPORT One month after a successful heart transplantation the patient presented with sudden hematochezia and hemorrhagic shock. Emergency laparotomy, right hemicolectomy, and end ileostomy were performed. Histopathological analysis of the resected colon revealed mucosal injury with the presence of crystals of Kayexalate in the necrotic regions. We later found out that several days before this event, the patient received SPS for the treatment of hyperkalemia owing to mild deterioration of chronic kidney disease. The patient fully recovered and was discharged from the hospital. CONCLUSION Acute lower gastointestinal bleeding has many causes, but SPS-related mucosal injury and intestinal perforation is unusual. Since our patient had several predisposing factors for this serious side effect it is important to use SPS only when necessary, especially in the postoperative patients and in those with gastrointestinal motility disorders. Although similar cases of intestinal injury after SPS therapy in solid organ transplant patients have alredy been reported this is, to our knowledge, the first reported case in a patient who underwent a heart transplantation