A Rash Decision. The Hazards of the Wrongful Use of Adrenaline

Anaphylaxis is life-threatening and should be addressed urgently. Its treatment is not without side effects and an accurate diagnosis must be made to prevent potential harm by the wrongful use of medication. A 46-year-old woman with hypertension treated with angiotensin converting enzyme inhibitor (ACEI) presented to the emergency department with non-pitting oedema of the face and limbs. A hasty diagnosis of anaphylaxis was made and intravenous adrenaline administered. The patient developed a myocardial infarction caused by coronary artery spasm that required invasive intervention. The initial clinical picture was resolved when the ACEI was discontinued unmasking a case of ACEI-induced angioedema. The correct differentiation of these two apparently similar clinical entities is of utmost importance in the management of emergency department patients.info:eu-repo/semantics/publishedVersio

The Role of Hyperbaric Oxygen Therapy in Pneumatosis Cystoides Intestinalis—A Scoping Review

Pneumatosis cystoides intestinalis (PCI) is characterized by gas-filled cysts within gastrointestinal tract wall from esophagus to rectum, with preferential involvement of large and small intestine. PCI is rare with an estimated incidence of 0.03 to 0-2% in general population. PCI can be distinguished into idiopathic (15%) or secondary (85%) and the clinical picture ranges from completely asymptomatic to life-threatening intraabdominal complications. Although etiology of PCI appears to be multifactorial, the exact pathophysiology is poorly understood and two main theories have been proposed (mechanical and bacterial). Over the last decades, an enormous therapeutic armamentarium was considered in PCI's management, including hyperbaric oxygen therapy (HBOT). Treatment comprises conservative treatment in mild cases to surgery in highly symptomatic and complicated PCI. In the late 70s, HBOT started to be used in selected cases of PCI not responding to conservative measures. Since then, several case reports, case series, and reviews have been published in the literature with variable outcomes. The overall response rate and complete response were 92.1% (n = 82/89) and 65.2% (n = 58/89), respectively, with a median follow-up of 7 months. Furthermore, HBOT is extremely safe, with few reported complications in the literature when used for PCI. Nevertheless, a randomized, controlled, and double-blind clinical trial is unlikely to occur given the rarity of PCI, logistical issues of HBOT, and methodological considerations related to adequate blinding with a sham-controlled group. HBOT in combination with personalized diet and antibiotics may be beneficial for moderate to severe PCI in patients with no indication for emergency exploratory laparotomy. The purpose of this article is to synthesize the existing data, analyse results of previous studies, identify gaps in knowledge, and discuss PCI' management, including the proposal of an algorithm, with a special focus on HBOT.info:eu-repo/semantics/publishedVersio

A Rash Decision. The Hazards of the Wrongful Use of Adrenaline

Anaphylaxis is life-threatening and should be addressed urgently. Its treatment is not without side effects and an accurate diagnosis must be made to prevent potential harm by the wrongful use of medication. A 46-year-old woman with hypertension treated with angiotensin converting enzyme inhibitor (ACEI) presented to the emergency department with non-pitting oedema of the face and limbs. A hasty diagnosis of anaphylaxis was made and intravenous adrenaline administered. The patient developed a myocardial infarction caused by coronary artery spasm that required invasive intervention. The initial clinical picture was resolved when the ACEI was discontinued unmasking a case of ACEI-induced angioedema. The correct differentiation of these two apparently similar clinical entities is of utmost importance in the management of emergency department patients.info:eu-repo/semantics/publishedVersio

Optimizing diagnosis of obstructive coronary artery disease by CT angiography: RCT's final results and 12-months follow-up

Abstract Aim In patients (pts) with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) may improve pt selection for invasive coronary angiography (ICA) as alternative to functional testing. However. the role of CTA in symptomatic pts after abnormal functional test (FT) is incompletely defined. Methods and results This randomized clinical trial conducted in single academic tertiary center selected 218 symptomatic pts with mild to moderately abnormal FT referred to ICA to receive either the originally intended ICA (n=103) or CTA (n=115). CTA interpretation and subsequent care decisions were made by the clinical team. Pts with high risk features on FT, previous acute coronary syndrome, previously documented CAD, chronic kidney disease (GFR&amp;lt;60ml/min/1.73m2) or persistent atrial fibrillation were excluded. The primary endpoint was the percentage of ICA with no significant obstructive CAD (no stenosis ≥50%) in each group. Diagnostic (DY) and revascularization (RY) yields of ICA in either group were also assessed. Pts were followed up for at least 1 year for the primary safety endpoint of all cause death/ nonfatal myocardial infarction/ stroke. Unplanned revascularization (UP) and symptomatic status (SS) were also evaluated. Pts averaged 68±9 years of age, 60% were male, 29% were diabetic. Nuclear perfusion stress test was used in 33.9% in CTA group and 31.1% in control group (p=0.655). Mean post (functional) test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 32.1%. In the CTA group, ICA was cancelled by referring physicians in 83 of the pts (72.2%) after receiving CTA results. For those undergoing ICA, non-obstructive CAD was found in 5 pts (15.6%) in the CTA-guided arm and 60 (58.3%) in the usual care arm (p&amp;lt;0.001 Mean cumulative radiation exposure related to diagnostic work up was similar in both groups (6±14 vs 5±14mSv, p=0.152). Both DY (84.4% vs 41.7, p&amp;lt;0.001) and RY (71.9% vs 38.8%, p=0.001) yields were significantly higher for CTA-guided ICA as compared to standard FT-guided ICA. The rate of the primary safety endpoint was similar between both groups (1.9% vs 0%, p=0.244), as well as the rates of UP (0.9% vs 0.9%, p=1.000) and SS (persistent angina: 29.6% vs 24.8%, p=0.425). Conclusions In pts with suspected CAD and mild to moderately abnormal ischemia test, a diagnostic strategy including CTA as gatekeeper is safe, effective and significantly improves diagnostic and revascularization yields of ICA. Funding Acknowledgement Type of funding source: None </jats:sec

P2722Optimizing diagnosis of obstrutive coronary artery disease by CT angiography and ischemia test: a randomized clinical trial

Abstract Aim In patients with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) may improve patient selection for invasive coronary angiography (ICA) as alternative to functional testing. However, the role of CTA in symptomatic patients after abnormal functional test is incompletely defined. Methods and results This randomized clinical trial conducted in single academic tertiary center selected 218 symptomatic patients (pts) with mild to moderately abnormal functional test referred to invasive coronary to receive either the originally intended ICA (n=103) or CTA (n=115). CTA interpretation and subsequent care decisions were made by the clinical team. Patients with high risk features on functional tests, previous acute coronary syndrome, previously documented CAD, chronic kidney disease (GFR &lt;60 ml/min/1.73m2) or persistent atrial fibrillation were excluded. The primary endpoint was the percentage of ICA with no significant obstructive CAD (no stenosis ≥50%) in each group. Diagnostic and revascularization yields of ICA in either group were also assessed. Subjects averaged 68±9 years of age, 60% were male, 29% were diabetic. Nuclear perfusion stress test was used in 33.9% in CTA group and 31.1% in control group (p=0.655). Mean post (functional) test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 32.1%. In the CTA group, ICA angiography was cancelled by referring physicians in 83 of the pts (72.2%) after receiving CTA results. For those undergoing ICA, nonobstructive CAD was found in 5 pts (15.6%) in the CTA-guided arm and 60 (58.3%) in the usual care arm (P&lt;0.001). Mean cumulative radiation exposure related to diagnostic work up was similar in both groups (6±14 vs 5±14mSv, P=0.152), but a greater cumulative contrast dose in the CTA-guided group (87.5±21 vs 77±40, p=0.026) was observed. Both diagnostic (84.4% vs 41.7, p&lt;0.001) and revascularization (71.9% vs 38.8%, p=0.001) yields were significantly higher for CTA-guided ICA as compared to standard functional test-guided ICA. Conclusions In patients with suspected CAD and mild to moderately abnormal functional test, a diagnostic strategy including computed tomographic angiography as gatekeeper is effective and significantly improves diagnostic and revascularization yields of invasive coronary angiography. </jats:sec