Anticoagulants for the treatment of acute coronary syndrome in the era of new oral agents

Acute coronary syndromes (ACS) cause cessation of myocardial blood flow leading to coronary ischemia. The standard medical treatment includes heparin or low molecular weight heparin in the hospital, antiplatelet agents in the hospital and long term, and occasionally warfarin long term. All of these therapies are associated with bleeding complications. Furthermore, warfarin, with its narrow therapeutic window and need for frequent laboratory monitoring, poses several disadvantages. The development of novel oral factor Xa inhibitors and oral direct thrombin inhibitors may provide an alternative to warfarin. In this review, we discuss the new agents, rivaroxaban, apixaban, and dabigatran, for the potential treatment of ACS. We also review the relevant clinical trials evaluating their effects in ACS. These novel anticoagulants allow convenience of use with no requirement for laboratory monitoring and limited drug interactions, which may provide multifaceted treatment options for ACS and anticoagulation in the future.     

Diabetic retinal neurodegeneration as a form of diabetic retinopathy

Purpose

To review the evidence supporting diabetic retinal neurodegeneration (DRN) as a form of diabetic retinopathy.

Method

Review of literature.

Results

DRN is recognized to be a part of retinopathy in patients with diabetes mellitus (DM), in addition to the well-established diabetic retinal vasculopathy (DRV). DRN has been noted in the early stages of DM, before the onset of clinically evident diabetic retinopathy. The occurrence of DRN has been confirmed in animal models of DM, histopathological examination of donor’s eyes from diabetic individuals and assessment of neural structure and function in humans. DRN involves alterations in retinal ganglion cells, photoreceptors, amacrine cells and bipolar cells, and is thought to be driven by glutamate, oxidative stress and dysregulation of neuroprotective factors in the retina. Potential therapeutic options for DRN are under evaluation.

Conclusions

Literature is divided on the temporal relation between DRN and DRV, with evidence of both precedence and simultaneous occurrence. The relationship between DRN and multi-system neuropathy in DM is yet to be evaluated critically.

     

Osteomas of the craniofacial region: A case series and review of literature

Objective:

To discuss the clinical presentation, diagnosis and management of osteomas involving the craniomaxillofacial region.

Materials and Methods:

This study was conducted from June 2004 to March 2012 at our institute. A total of 12 cases between the ages of 10 and 50 years were managed with surgical excision and reconstruction. The criteria used to diagnose osteoma included radiographic and clinical features and histological confirmation of the specimen. The total follow-up period ranged from 6 to 24 months.

Results:

Out of 12 osteomas, 10 were peripheral and 2 were centrally located. Mandible involvement was seen in six patients, four involved the orbit, one the frontal bone and one the frontal bone with the skull base. All patients undergoing excision and reconstruction had a favourable aesthetic and functional outcome. There were no recurrences and no post-operative complications.

Conclusion:

Osteomas affect all age groups with no sex predilection and are usually clinically asymptomatic till they become large in size. Surgical excision and appropriate reconstruction is the mainstay of management. Surgery is indicated when lesion is symptomatic or actively growing and the surgical approach for exposure of the lesion should be case specific.KEY WORDS: Craniofacial, osteoma, reconstruction     

The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases

Objective:

This report details our experience with the use of the temporoparietal fascia flap in different scenarios of reconstruction and to discuss our technique of harvest, clinical applications, and review of literature of this versatile flap.

Materials and Methods:

A retrospective study of 82 cases of temporoparietal fascia flap in 71 patients, operated over a period of 10 years was conducted. Patients were grouped based on various clinical indications. The follow up period ranged from a minimum of 1 to a maximum of 10 years (Mean-four and a half years). All patients were analyzed for functional and aesthetic outcome using preoperative and postoperative photographs.

Results:

No significant complications were seen in our series. Only 2 out of 82 flaps had partial necrosis of flap (2.44%). Two patients who were operated for release of submucous fibrosis developed recurrence due to continued use of tobacco. The final outcome in one patient of ear reconstruction was unsatisfactory due to flap failure. The remaining patients had satisfactory functional and aesthetic outcomes (95.77%). None had other complications like temporal branch of facial nerve injury or alopecia along the scar line.

Conclusion:

The TPFF is one of the most reliable and versatile flap in the head and neck region. It can also be reliably used as free fascial flap. When its advantages are combined with the surgeon''s resourcefulness, various defects can be successfully reconstructed using the temporoparietal facia flap with satisfactory aesthetic and functional outcome.KEY WORDS: Head and neck reconstruction, temporoparietal fascia flap, TPFF     

Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing

Introduction

Rivaroxaban is the first licensed oral direct inhibitor of factor Xa. Recent studies from the RECORD trials suggest rivaroxaban has superior efficacy compared to enoxaparin in preventing venous thromboembolism (VTE) with no significant increase in the major bleeding risk. Concerns remain regarding the incidence of minor bleeding, consequent delayed wound healing and subsequent risk of infection. The aim of this observational study was to assess the incidence of post-operative complications in patients receiving either rivaroxaban or enoxaparin thromboprophylaxis following elective hip and knee arthroplasty.

Methods

A total of 258 patients undergoing elective total hip or knee arthroplasty within one NHS Trust were included. A total of 202 subjects (mean age, 70.7 years ± 10.0, 43 % men) received a daily dose of 10 mg of oral rivaroxaban and 56 (mean age, 70.9 years ± 9.8, 39 % men) had a daily subcutaneous injection of 40 mg of enoxaparin as thromboprophylaxis. Endpoints included VTE (deep vein thrombosis and pulmonary embolism), haemorrhagic wound complications, hospital re-admission, requirement for blood transfusion, minor and major bleeding and death.

Results

There were no significant differences in the incidence of VTE, requirement for blood transfusion and readmission rate between rivaroxaban and enoxaparin-treated patients. The incidence of minor bleeding (2.0 vs. 0 %) and haemorrhagic wound complications (5.0 vs. 1.8 %) were non-significantly higher in the rivaroxaban-treated group. There were no cases of pulmonary embolism, major bleeding or death in either group.

Conclusion

Our experience with rivaroxaban in elective hip and knee arthroplasty showed no significant difference in the incidence of VTE or major bleeding. There was, however, a tendency to greater risk of minor bleeding and wound complications that were largely haemorrhagic in nature, which may have reached significance in a larger study.