Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome

Background Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months. Results The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit–feedback program. This improvement remained unchanged until the end of the 12th month. Conclusions The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.

Percutaneous Transsplenic Balloon-Assisted Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Portal Vein Obliteration for Portal Vein Recanalization: Feasibility, Safety and Effectiveness

Purpose To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)–transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique. Materials and Methods In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR–TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose–area product (DAP) and air kerma (AK) were evaluated. Results Transsplenic PVR–TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy. Conclusions Transsplenic PVR–TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT.

Trends in the Degree of Control and Treatment of Cardiovascular Risk Factors in People With Type 2 Diabetes in a Primary Care Setting in Catalonia During 2007–2018

ObjectiveTo assess the trends in cardiovascular risk factor control and drug therapy from 2007 to 2018 in subjects with type 2 diabetes mellitus (T2DM).Materials and MethodsCross-sectional analysis using yearly clinical data and treatment obtained from the SIDIAP database. Patients aged ≥18 years with a diagnosis of T2DM seen in primary care in Catalonia, Spain. ResultsThe number of T2DM patients increased from 299,855 in 2007 to 394,266 in 2018. We also found an increasing prevalence of cardiovascular disease, heart failure, and chronic kidney disease (from 18.4 to 24.4%, from 4.5 to 7.3%, and from 20.2 to 31.3%, respectively). The achievement of glycemic targets (HbA1c<7%) scarcely changed (54.9% to 55.9%). Major improvements were seen in blood pressure (≤140/90 mmHg: from 55% to 71.8%), and in lipid control (low-density lipoprotein cholesterol <100 mg/dl: 33.4% to 48.4%), especially in people with established cardiovascular disease (48.8 to 69.7%). Simultaneous achievement of all three targets improved from 12.5% to 20.1% in the overall population and from 24.5% to 32.2% in those with cardiovascular disease but plateaued after 2013. There was an increase in the percentage of patients treated with any antidiabetic drug (70.1% to 81.0%), especially metformin (47.7% to 67.7%), and DPP4i (0 to 22.6%). The use of SGLT-2 and GLP-1ra increased over the years, but remained very low in 2018 (5.5% and 2.1% of subjects, respectively). There were also relevant increases in the use of statins (38.0% to 49.2%), renin-angiotensin system (RAS) drugs (52.5% to 57.2%), and beta-blockers (14.3% to 22.7%).ConclusionsDuring the 2007-2018 period, relevant improvements in blood pressure and lipid control occurred, especially in people with cardiovascular disease. Despite the increase in the use of antidiabetic and cardiovascular drugs, the proportion of patients in which the three objectives were simultaneously achieved is still insufficient and plateaued after 2013. The use of antidiabetic drugs with demonstrated cardio renal benefits (SGLT-2 and GLP-1ra) increased over the years, but their use remained quite low.

Angiosarcoma of the Scalp: A Case Report

Angiosarcomas also called hemangioendothelia, are rare and highly malignant vascular tumors of mesodermal origin, they represent 08-10% of cancers and can affect any part of the body.Angiosarcoma mainly affects the skin, the face is the preferred topography in adults, it remains exceptional in children, with a predilection for the mediastinum and pericardium,The angiogenesis of angiosarcomas is still poorly understood; However, chronic lymphedema and exposure to prolonged radiotherapy are blamed. Total surgical excision is the treatment of choice in localized forms, followed by chemotherapy. pre- and post-operative radiotherapy may be necessary.New studies have shown the effectiveness of beta blockers (propranolol) in the management of angiosarcomas.The prognosis depends on the age of the patient, the size of the tumor, the histological grade and the extent of tumor progression.

A spectrofluorimetric study of the limbal area in patients with primary open-angle glaucoma

Purpose: to evaluate hypoxic changes in the limbus area conjunctiva of patients with primary open-angle glaucoma (POAG) treated with prolonged instillations of prostaglandin (PG) analogs. Material and methods. A spectrofluorimetric study of the limbus zone was carried out in 202 patients aged 56–87 years with POAG in the developed and advanced stages, divided into 2 groups. Group 1 consisted of patients aged 69.4 ± 10.3 years who received beta-blockers (BB) and carbonic anhydrase inhibitors (ICA) for 5–10 months; of these, 39 (30.2 %) had a developed stage of POAG and 90 (69.7 %) had advanced POAG. Group 2, aged 72.3 ± 9.4, received PG analogs, in addition to BB and ICA, for 5–10 months. In this group, 21 (28.7 %) patients had developed POAG and 52 (71.23 %) had advanced POAG. Results. The patients who received PG instillations showed a significantly higher ratio of fluorescence intensity in the wavelength range of 410/520 nm NADH/FAD (0.352 ± 0.043) than those receiving no such therapy (0.319 ± 0.047), which can be interpreted as a hypoxic state of the limbus area. Conclusion. Spectrofluorimetric testing of POAG patients taking PG analogs can be useful for detecting ischemia in the limbus area, because this category of patients are very likely to form cicatricial changes in the area of the filtration cushion in the early postoperative period after antiglaucomatous interventions.