How to effectively manage the refractory coronary thrombus? A systemic mini-review

The main management principle for patients with coronary thrombus should be “more removal and less implantation”. Routine thrombus aspiration(TA) is ineffective for intracoronary thrombus or high residual thrombus burden after TA and may result in a refractory coronary thrombus. It is unwise to implant a stent in the vessel with high residual thrombus, which is associated with no-reflow, impaired microvascular perfusion, and consequently worse clinical outcomes. Therefore, increasing the efficie...     

Gastrointestinal stromal tumor of the stomach: How to manage?

Gastrointestinal stromal tumor (GIST) is one of the most common malignant mesenchymal tumors of the stomach. Prognosis of this disease is related to tumor size and mitotic activity and early diagnosis is the only way to improve it. Diagnosis of GIST always requires histological and immunohistochemical confirmation as no imaging modalities can diagnose it conclusively. Endoscopic forceps biopsy results are frequently negative. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a technique which allows tissue samples to be obtained with minimal risks and is accurate in the diagnosis of GIST. From the point of view of the endoscopist, aggressive use of EUS-FNA is the only promising way to allow early diagnosis and early treatment of this disease.     

How to manage postmenopausal osteoporosis?

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased fracture risk. Several therapeutic agents are now available to treat postmenopausal osteoporosis and prevent fractures. Combined calcium and vitamin D supplementation reduce the relative risk of non-vertebral fractures by about 18%. Hormone replacement therapy (HRT) should not be prescribed for osteoporosis in women who do not experience menopausal symptoms. The marked benefits of raloxifene on the reduction in invasive breast cancer and vertebral fracture risk are partially counterbalanced by a lack of effect on non-vertebral fracture risk, and an increased risk of venous thromboembolism and stroke. All four bisphosphonates available in Belgium, except ibandronate, have been shown to reduce the risk of vertebral, non-vertebral and hip fractures in prospective, placebo-controlled trials. Globally, the incidence of vertebral fractures is reduced by 41%-70%, and the incidence of non-vertebral fractures by 25%-39%. The anti-fracture efficacy of weekly or monthly doses of oral bisphosphonates has not been directly shown but is assumed from bridging studies based on BMD changes. To date, the various bisphosphonates have not been studied in head-to-head comparative trials with fracture endpoints. There are potential concerns that long-term suppression of bone turnover associated with bisphosphonate treatment may eventually lead to adverse effects, especially atypical femoral fractures and osteonecrosis of the jaw, but these cases are extremely rare. Teri-paratide (recombinant human 1-34 PTH) administered by daily subcutaneous injections decreases by 65% the relative risk of new vertebral fractures in patients with severe osteoporosis. Pivotal trials with strontium ranelate have shown a 41% reduction in new vertebral fractures and a 16% reduction in non-vertebral fractures over 3 years. Denosumab is a fully human monoclonal antibody to RANK Ligand that is administered as a 60-mg subcutaneous injection every 6 months. In the pivotal phase III trial, there was a 68% reduction in the incidence of new vertebral fractures, whereas the incidence of non-vertebral fractures was reduced by 20%. Several new approaches are being explored, including antibodies to sclerostin, cathepsin K inhibitors, src kinase inhibitors, and drugs that act on calcium sensing receptors.     

How to manage difficult anatomic conditions affecting transradial approach coronary procedures?

The adoption of transradial approach for percutaneous coronary diagnostic and interventional procedures is known to reduce access-site complications. However, anatomic variants of brachial-radial axis, axillary-subclavian-anonymous axis and aortic arch may obstacle successful completion of transradial procedures. In the present paper, we discuss how to diagnose and manage the possible obstacles occurring at the different steps of transradial diagnostic and interventional procedures.     

Opinion: How to manage subepithelial lesions of the upper gastrointestinal tract?

Subepithelial lesions (SELs) in the upper gastrointestinal (GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound (EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor (GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration (EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions (size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.     

The coronary slow flow phenomenon: a new cardiac "Y" syndrome?

The coronary slow flow phenomenon (CSFP) is an angiographic finding that is characterised by delayed progression of the contrast medium during coronary angiography. The mechanism of this phenomenon remains unknown. In the present paper, we revise the current evidence regarding this phenomenon and discuss recent findings from our group reporting increased resting resistances in patients with the CSFP. We report that these patients had preserved blood flow responses to the intracoronary infusion of the vasodilator papaverine, demonstrating that the CSFP is not necessarily associated with an abnormal coronary flow reserve.Based on these findings and on the review of the current literature, we concur with the concept proposed by Beltrame et al. that the CSFP should be considered a separate clinical entity. Further studies are necessary to describe the clinical characteristics, including the prognosis, of these patients and to identify potential treatments.     

How should we manage the patient?

The patient with HCV infection may present with a variety of problems and range from the asymptomatic patient with mild liver damage to a patient presenting with complications of cirrhosis or hepatocellular carcinoma. The diagnosis of hepatitis C may be a complete surprise to the patient or be an expected diagnosis in someone with known risk factors. Similarly the physician may be faced with a patient who knows very little about hepatitis C or someone who has read extensively on the subject. The initial consultation is useful for gaining information on the patient's background, physical examination may give useful clinical clues on the stage of the liver disease. The consultation gives the physician a chance to educate the patient on the current thinking on hepatitis C and to organize confirmatory and other investigations that will help decide on the next line of management, i.e. whether the patient is a candidate for combination therapy of interferon and ribavirin.     

How to manage patients with cardiopulmonary disease?

Systemic lupus erythematosus (SLE) is a connective tissue disease characterized by the formation of autoantibodies and immune complexes. The heart and lungs are among the organ systems commonly affected in SLE. Pericarditis, premature coronary atherosclerosis, pleuritis and pulmonary infections are the most prevalent cardiopulmonary manifestations. Other rare associations include myocarditis, coronary arteritis, acute lupus pneumonitis/pulmonary haemorrhage, acute reversible hypoxaemia and 'shrinking lung' syndrome. Current imaging modalities may provide earlier detection of subclinical disease, which may aid in preventing these potentially fatal complications. The response to treatment varies, depending on the presentation of disease. In this chapter we address the frequency, diagnosis and monitoring, and treatment regimens of cardiac and pulmonary involvement in patients with SLE.     

How to manage an isolated elevated PTH?

The aim of this article is to discuss the diagnostic approach of an increased serum PTH concentration in a normocalcemic, normophosphatemic patient. Detection of this biological presentation is frequent in routine practice all the more that PTH reference values established in vitamin D replete subjects with a normal renal function are used by the clinical laboratories. The first step in this diagnostic approach will be to rule out a cause of secondary hyperparathyroidism (SHPT). Among these, the most frequent are vitamin D deficiency, very low calcium intake, impaired renal function, malabsorptions, drugs interfering with calcium/bone metabolism, such as lithium salts and antiresorptive osteoporosis therapies, hypercalciuria due to a renal calcium leak. If no cause of SHPT are evidenced, the diagnosis of normocalcemic primary hyperparathyroidism (PHPT) should be considered. A calcium load test is a very useful tool for this diagnosis if it shows that serum PTH is not sufficiently decreased when calcemia rises frankly above the upper normal limit. In a normocalcemic patient with hypercalciuria and a high serum PTH concentration, a thiazide challenge test may help to differentiate SHPT due to a renal calcium leak from normocalcemic PHPT. Beyond the discussion of this diagnostic flowchart, we also discuss some points about the merits and the difficulties of measuring and interpreting ionized calcemia and 24-h calciuria.     

How to assess coronary lesion, reperfusion quality, and PCI result?

During High Tech congress 2004, different questions have been discussed concerning the assessment of cardiac ischemia, quality of reperfusion and result of angioplasty. Coronary angiogram alone is not enough to decide the optimal therapeutic strategy. Ischemia-driven decision is a much better option. How should we assess the more accurately the need for ischemia-driven revascularization? Angiographic success (TIMI 3 flow grade) after angioplasty is near 95%, but is not sufficient to assess precisely the quality of myocardial reperfusion. Which more efficient tools are available? At last, which angiographic or clinical criteria should we use to assess the result of angioplasty?     

How to manage musculoskeletal conditions: when is 'rehabilitation' appropriate?

Multidisciplinary rehabilitation has established efficacy in few musculoskeletal conditions. It is likely to be effective in the context of chronic back pain and possibly other types of chronic pain, and in frail older people with hip fractures. The principles of multidisciplinary rehabilitation, which include time-limited and goal-directed interventions, can be used in other musculoskeletal interventions but there have not yet been sufficient randomized trials to determine its effectiveness. Multidisciplinary rehabilitation is relatively costly and therefore is not likely to be cost effective unless it achieves return to work in people in the working-age group, or averts the need for residential care in frail older people.     

Is prophylaxis the best use of the ICD? Response to the letter to the editor (Sharma et al.).

We thank Dr. Sharma and his colleagues for their interest inour article and wish to respond to the issues they have raised.¹ Regarding ß-blocker use in the MADIT study,² Mosshas shown that the ICD benefit "...remained significant after adjustment for ß-blocker use".³The Multicenter UnSustained Tachycardia Trial (MUSTT)—withpatients nearly identical in profile to     

How to manage splenic rupture during major liver resection?

Spontaneous splenic rupture is a rare but life threatening complication of major liver resection with only five reported cases during major liver resection under hepatic vascular occlusion. We report two cases of splenic rupture during liver resection including the first case during portal triad clamping. In both patients, the hemorrhage was stopped by removing the vascular clamp. A splenectomy was performed in both patients and liver resection was completed under vascular clamping without complications. Although very rare, physicians should be aware of the possibility of splenic rupture during liver resection because instead of increasing vascular occlusion, clamp removal usually stops the hemorrhage.