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Fibrinolysis can become a reasonable option for some cases of ST-elevation myocardial infarction

MD-FM Thursday March 14, 2013





GENERIQUE
Carillon
 
Sarah:
MD FM — Medical News from around the world with Peter Goodwin.
 
P1

PETER:
Hello, and with me is Sarah Maxwell. To begin with, for patients with ST elevation myocardial infarction who aren’t able to get primary percutaneous coronary intervention within one hour of first medical contact — the guideline-mandated timing for intervention — fibrinolysis is an effective option, according to a study published in the New England Journal of Medicine…

SARAH:
Yes, and the data were presented at the American College of Cardiology meeting in San Francisco and showed that, coupling fibrinolysis with timely coronary angiography was as beneficial as primary PCI. There was a slightly higher risk of intracranial bleeding for older patients with fibrinolysis, but it was brought under control by halving the thrombolytic therapy dose. Co-author Anthony Gershlick:

Bob-Gershlick: “If you cannot achieve guideline-mandated times for primary PCI, then an option would be to do point of first medical contact thrombolysis, with a dose adjustment for the elderly, plus the adjunctive medication indicated in the protocol, and then take the patient to a PCI-capable hospital. What we found is that when patients arrive at the hospital there are many more of them who have their arteries opened, having been given thrombolysis, than if they were just going for primary PCI. And at the hospital, they should have an ECG 90 minutes after the thrombolytic has been given, and if the ECG has not settled to more than 50% of ST-segment elevation, they should go immediately to the cath lab. But if the ECG has settled, then they should have their angiogram proceeding on to angioplasty over the next 24 hours. And that allows us to have a much more controlled management of the infarct.”

SARAH:
That was Professor Anthony Gershlick, of the University of Leicester in the UK, speaking to MDFM from the meeting in San Francisco. He added that primary PCI does remain the first-line approach when it can be delivered within the guideline-mandated timing.

VIRGULE MUSICALE

P2

PETER:
And more news from the ACC meeting last weekend: For patients undergoing urgent or elective PCI, an investigational anti-platelet drug — Cangrelor — was much more effective at reducing ischemic and bleeding complications than clopidogrel…

SARAH:
Yes, 11,000 patients having PCI were randomized to receive either Cangrelor — an I/V adenosine diphosphate receptor antagonist — or the current standard of care, clopidogrel, in a study also published in the New England Journal of Medicine. Rates of death, myocardial infarction, ischemia-driven revascularization and stent thrombosis at 48 hours after randomization were all significantly lower with Cangrelor:
 
Bob-Smith: “The other important observation is that these patients had both stable angina and acute coronary syndrome --so we’re talking about a therapeutic approach that applies to a broad spectrum of patients. There had been questions about the use of clopidogrel and loading doses, even up to 600 mg, and this appears to offer a very nice alternative with improved outcomes. In this setting one would worry about an increase in bleeding, but in looking at the various different definitions for bleeding, there’s only one index --the acuity index --where there seemed to be a problem. So I would see this as a very attractive therapeutic option.”

SARAH:
That was doctor Sidney Smith from North Carolina, who did not participate in the study but added that the drug still has to be tested in other settings, such as in Asian patients who are known to have a greater tendency to bleed.

P3

PETER:
Also reported at the ACC meeting in San Francisco: People with borderline high cholesterol may be at greater cardiovascular risk during the winter months according to a study that followed 230,000 people. It showed that cholesterol levels fluctuate with season changes and these findings are in line with previous data we reported from the American Heart Association showing that heart-related deaths increase during the winter months.

VIRGULE MUSICALE
 
P4

PETER:
People with mental disorders are at a greater risk of being murdered than the rest of the population, according to a large Swedish cohort study reported in the British Medical Journal...

SARAH:
Yes, the data showed that, people with any mental illness’s were, overall, at five times greater risk of homicide than the general population. The risk was up to three-fold in those with personality disorders, depression, anxiety, or schizophrenia; but substance use disorders conferred the highest risk of all — nine times. Roger Webb, from Manchester University, wrote an editorial on the study:

bob-Webb-1: “So.. do they live in more dangerous neighborhoods than people who are not mentally ill? There’s also issues around the illnesses themselves: they can display symptoms that can provoke hostility in others: they may be irritable or they may be paranoid... They may have a reduced awareness of their personal safety.”
 
SARAH:
And Professor Webb had this recommendation for practitioners:

Bob-Webb-2: “Mental health professionals need to consider the issue of risks as broadly as they possibly can. In different specialties of mental health you tend to focus on particular types of risks: often adult mental health people are particularly interested in the risk of suicide, or if you look at forensic mental health services, the emphasis tends to be on reducing violence perpetration, if you look at child and adolescent mental health, a lot of the emphasis there is about reducing rates of self harm, antisocial behavior, substance misuse... Of all the different types of risks associated with mental illness, the risk of being a victim of violence is perhaps one of the ones that is overlooked”
 
SARAH:
Roger Webb from Manchester, in the UK who said an effort should also be made to promote a more accurate portrayal of patients with mental health problems, who are too often stigmatized as a threat to society rather than victims.

VIRGULE MUSICALE

P5

PETER:
Not getting enough sleep each night could lead to gaining weight — even to the level of obesity — according to findings published in PNAS that show sleep plays a key role in energy metabolism…
 
SARAH:
Yes, the study showed that people who slept only five hours a night for five days in a row, found it harder to refrain from eating and gained nearly a kilo in weight, compared to people who had a full nine hours sleep! Senior study author Kenneth Wright:
 
 Bob-Wright-1: “When people were not getting enough sleep, they actually ate a smaller breakfast but they ate a lot more in snacks after dinner --They ate 42% more at night compared to when they were getting sufficient sleep. So it’s a real big change in how their eating pattern is across the day”

SARAH:
Dr Kenneth Wright, from the University of Colorado, who said this reduced dietary restraint could be a physiological adaptation, to provide the extra energy needed to sustain additional wakefulness:
 
Bob-Wright-2: “People do spend more energy when they don’t get enough sleep on a nightly basis. The brain is recognizing that it’s sleep deprived and needs more energy and we think there is a central part of the brain that is actually causing an increase in food intake. People were telling us they were less hungry but yet they still overate!”

SARAH:
Kenneth Wright, from Boulder in Colorado, who noted that, since these experiments were conducted in a laboratory environment, they can’t be translated directly into real life settings.


VIRGULE MUSICALE


BREVE 1 Sur fond musical
 
PETER:
Finally, in brief: for patients with severe, treatment-refractory anorexia nervosa, deep brain stimulation in the sub-callosal cingulate led to improved and maintained body mass indexes at nine months. A pilot study — published in The Lancet — looked at the safety and efficacy of DBS in six patients and found half had an improvement in mood, anxiety and brain metabolism after the procedure.

And...
 
BREVE 2

Children who are physically active, are not only healthier, but can also better cope with stress, according to a cross-sectional study with 250 eight-year-olds — published in the Journal of Clinical Endocrinology & Metabolism. It showed that sedentary children had surges of the stress hormone cortisol, when they were exposed to everyday stressors; while the most active children had little or no increase in their cortisol levels. Yet another reason for kids to get off their computers and go out to play!

That's all from MDFM for now. Sarah Maxwell will be back with more next week, so until then from me Peter Goodwin, goodbye!
 
JINGLE FIN     
 

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