Internal and emergency medicine
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The interaction of ADP with its platelet receptor P2Y12 plays a crucial role in platelet activation and thrombogenesis. This article reviews the pharmacology and clinical trials of specific antagonists of P2Y12. Clopidogrel is a thienopyridine with proven antithrombotic efficacy, but it has some important drawbacks: (a) it is a pro-drug that needs to be metabolized to its active metabolite; (b) it has a delayed onset and offset of action and (c) there is high inter-individual variability in pharmacological response. ⋯ Cangrelor is not superior to clopidogrel in preventing thrombotic events in patients undergoing PCI. Ticagrelor is superior to clopidogrel in preventing major adverse cardiac events in ACS patients, but, like prasugrel, is associated with a higher frequency of non-CABG-related bleeding complications. A shorter period of drug discontinuation before surgery is necessary in ticagrelor-treated patients compared to clopiodgrel-treated patients to limit the severity of post-surgical bleeding.
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The treatment of polycythemia vera in young adults is challenging, requiring one to run a balance between the increased risk of vascular complications, if left untreated, versus the potential of promoting secondary leukemia/myelodysplasia or cancer, if actively managed with chemotherapy. We report the results of a 20-year retrospective analysis in a cohort of 30 young adults with PV (median age 37 years, range 19-45) treated exclusively with phlebotomy, aspirin and hydroxyurea only in case of vascular complications occurring in the presence of thrombocytosis (platelet count > 600 × 10(9)/L). With this approach, vascular complications were no higher than in other published series, and secondary leukemia/myelodysplasia or cancer was not observed during a follow-up of 14 years.
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Chronic headaches represent a significant burden for the affected individuals and for the society, and a major challenge for successful care. Among the various types of chronic headaches, those that are associated with medication overuse (medication-overuse headache, MOH) are of particular importance because of the large proportion of patients who complain of this condition and their poor outcome. Most patients with MOH had migraine as primary headache. ⋯ Although the pathophysiology of MOH is unknown, recent studies hypothesize that plastic changes in specific pain areas of the central nervous system are main contributors to establishing MOH. Not infrequently, drug overuse is associated with habituation and failure of previously effective medications. Finally, treatment of MOH is poorly evidence based and mostly relies on clinical experience and belief.
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Letter Case Reports
Emergency airway management using the Bonfils intubation fiberscope.