Principles Of Patient Management Research Articles

6574 Pheochromocytoma In A Patient With ESRD; Clinical Challenges And Lessons From A Successful Evaluation

Abstract Disclosure: S. Younes: None. A. Sayed: None. K. Selk: None. L.A. Willard: None. Introduction: Pheochromocytomas are rare tumors that arise from the chromaffin cells in the adrenal medulla, that secrete norepinephrine, epinephrine and dopamine. Common presentations include resistant hypertension (HTN) and adrenergic spells with headaches, sweating and tachycardia. The literature has few cases of pheochromocytoma in the setting of end stage renal disease (ESRD). Case: A 46-year-old male with a history of resistant HTN on amlodipine, lisinopril, and labetalol, complicated by ESRD on hemodialysis (HD) and secondary hyperparathyroidism initially presented with gross hematuria. The patient reported sporadic, intermittent headaches associated with palpitations and sweating. A renal ultrasound revealed a left-sided complex renal cystic mass. CT abdomen/pelvis demonstrated an enhancing left adrenal lesion and MRI abdomen/pelvis confirmed an enhancing 4.6 x 2.8 cm adrenal mass. Laboratory studies revealed elevated normetanephrine of 1186 pg/mL (ref <149 pg/mL), elevated metanephrine at 139 pg/mL (ref <57 pg/mL) and elevated epinephrine at 128 pg/mL (ref <95 pg/mL). Given the laboratory and imaging findings in conjunction with clinical presentation, an excision of the adrenal mass was set. Two weeks prior to the surgery, alpha blockade was started with doxazosin 1mg daily with a goal blood pressure <130/80. He was admitted to the hospital with a goal to keep him 1-1.5kg above his dry weight. His dry weight was 81.5kg close to admission weight, so he was started on gentle IV hydration. He had a left robotic assisted adrenalectomy and was given stress dose steroids and a steroid taper given no preoperative Cushing’s screen was completed. No postoperative complications reported, and doxazosin was discontinued. 2 weeks later, he reported his adrenergic spells had resolved. Surgical pathology confirmed pheochromocytoma and he was referred for genetic consultation. Conclusion: Although there is little in the literature regarding management of a pheochromocytoma in patients with ESRD, similar principles of management in patients with normal renal function apply, including blood pressure control, alpha blockade, and establishment of euvolemia with recommendation of a high-sodium diet and 1-2 liters of saline the day prior to the procedure. This case highlights successful perioperative management with traditional use of alpha blockade but also incorporated maintaining the patient 1-1.5 kg above their dry weight for surgery to limit postoperative hypotension. Presentation: 6/3/2024

Pulmonary arterial hypertension related to congenital heart disease with a left-to-right shunt: phenotypic spectrum and approach to management.

Patients with pulmonary hypertension associated with a left-right shunt include a wide spectrum of pathophysiological substrates, ranging from those characterized by pulmonary over-circulation to those with advanced pulmonary vascular disease. The former group may benefit from shunt repair in carefully selected cases but, when advanced pulmonary vascular disease has developed, defect closure should be avoided, and pulmonary vasodilators may be used to improve effort tolerance and hemodynamics. There is a paucity of evidence, however, to support decision-making in the care of these patients. We discuss the principles of management in patients with pulmonary hypertension and a predominant left-right shunt. The recommendations and statements made in this paper are based on pathophysiological considerations and expert opinion.

Drug-induced nephropathy: a brief overview of prevention, diagnosis, treatment

Drug-induced nephropathy (DN) is a common cause of kidney injury in outpatients and hospitalized patients, affecting approximately 20% of the adult population. DN occurs especially often when patients are treated with antibiotics, antiviral, antitumor drugs and nonsteroidal anti-inflammatory drugs. A detailed collection of pharmacological and allergological history and assessment of potential risk factors for drug nephrotoxicity are key to DN prevention and diagnosis. The article briefly covers the mechanisms of development and clinical phenotypes of DN, criteria for diagnosis, principles of patient management, including general prevention of DN and prevention of kidney injury associated with certain medications.

Topical therapy of otitis media in children: A review

Various types of otitis are common in the pediatric population. The use of otoscopy techniques by primary care doctors (pediatricians, family, and general practitioners) has significantly expanded the diagnostic capabilities of the primary examination of the child. However, it requires many specialists to know the principles of patient management with various types of otitis media. The article addresses the principles of routing and drug therapy for patients with various types of otitis media. The focus is on ear drops (formulation, indications for using specific drugs, safety, and age-related aspects).

Management of patients with transcatheter implantable aortic valve

Valvular heart disease remains one of the causes of cardiovascular morbidity and mortality worldwide. Aortic stenosis is the most common valvular pathology requiring cardiac surgery. For elderly and senile patients with high risks of volumetric cardiac surgery, a new type of biological prosthesis, a transcatheter implantable aortic valve, has become a solution to the problem. Over the past decade catheter interventions for severe valvular heart disease have evolved from balloon dilatation of native stenotic valves to replacement and reconstructive intervention of diseased valves. Transcatheter aortic valve implantation, which is widespread in the USA and Europe, has also begun to be performed in our country, primarily in comorbid groups of patients. Rapid technological advances in device design are likely to improve immediate and long-term outcomes of surgery and expand the current indications for transcatheter aortic valve implantation. The article analyzes the indications for the procedure in accordance with the latest recommendations of 2021, possible complications of the transcatheter aortic valve implantation, as well as the principles of patient management after the procedure, including the principles of drug therapy in this group of patients. Separately, the topic of aortic regurgitation and the possibility of transcatheter aortic valve implantation are touched upon, since this pathology is a new indication that has appeared only in the latest recommendations of the European Society of Cardiology. In this review, we want to acquaint physicians with the indications for transcatheter aortic valve implantation, the main complications, and the principles of managing patients in the perioperative period. The complication rate after transcatheter aortic valve implantation is decreasing due to technical advances and experience of interventional surgeons. In-depth knowledge of potential complications and their prevention plays a key role in improving the immediate and long-term results of surgery.

Acute kidney injury in patients with COVID-19: Epidemiology, pathogenesis and treatment.

Acute kidney injury occurs in about 30% of patients hospitalized with coronavirus disease 2019 (COVID-19) and is one of the most common extrapulmonary complications of this disease. The highest risk of acute kidney injury is found in hospitalized patients who require mechanical ventilation. The pathogenesis of acute kidney injury in COVID-19 is multifactorial and seems to not be fully understood. Both direct and indirect mechanisms of kidney injury caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) should be considered. The histological picture of kidney specimens obtained from patients with acute kidney injury in the course of COVID-19 is dominated by acute tubular necrosis. Some patients also have acute interstitial nephritis, blood clots in the kidney vessels and focal segmental glomerulosclerosis (the variant with collapsing vascular loops). Acute kidney injury in COVID-19 is primarily caused not by direct viral effect, but by indirect pathophysiological mechanisms. The histopathological findings in these patients does not differ from the majority of the other patients with acute kidney injury. The main pathophysiological mechanisms underlying acute kidney injury in COVID-19 are: hemodynamic abnormalities, hypoxia and cytokine storm. The methods of treating the underlying disease, i.e., COVID-19 in patients with acute kidney injury and those without acute kidney injury are similar. However, it should be stressed that in the treatment of COVID-19 accompanied by acute kidney injury, the contraindication to remdesivir is estimated using glomerular filtration rate (eGFR) <30 mL/min/1.73 m2. The general principles of management in patients with both, COVID-19 and acute kidney injury do not differ from the principles of management in patients with acute kidney injury due to the other causes.

Principles of management for patients with oral cancer during the COVID-19 pandemic

The outbreak of coronavirus disease 2019 (COVID-19) affects the world. It is highly contagious and spreads quickly. COVID-19 severely increases the medical burden and interferes with our normal work. This article introduces our experience on treat oral cancer patients during the epidemic. The negative impact can be minimized through reasonable and orderly arrangement.

Lumbar puncture in patients on anticoagulants

Lumbar puncture is an important invasive procedure often used in the diagnosis of neurological disorders. Generally, lumbar puncture is a safe procedure, with a very low incidence of serious complications, the risk of which, however, may increase in the group of patients on anticoagulant therapy (anticoagulants and platelet anti-aggregation agents). This applies to both the risk of haemorrhagic complications and the risk of thrombotic events during temporary discontinuation of anticoagulants. This paper presents the current knowledge on the management in patients receiving anticoagulants (vitamin K antagonists, new anticoagulants, heparins, fondaparinux) and platelet anti-aggregation agents (P2Y12 platelet receptor antagonists, glycoprotein IIb/IIIa inhibitors, acetylsalicylic acid) who require lumbar puncture. Furthermore, we present the issue of bridging therapy in patients at a high risk of thrombotic complications. In the case of neurological indications for a lumbar puncture in a patient on anticoagulants or anti-aggregation therapy, the urgency of the procedure and the risk of adverse effects should be assessed and other diagnostic methods should be considered in the first place. If there is a need for an urgent lumbar puncture, treatment modification or the use of drugs to reverse the anticoagulant or anti-aggregation effect may be necessary. Each case must be treated individually, considering medical and family history, comorbidities and other medications taken by the patient. Most of the available recommendations related to the presented problem have been developed by anaesthetic associations. There is a need to popularise the principles of management in patients on anticoagulants who require lumbar puncture due to neurological disorders.

Ulcerative colitis in the practice of a medical assistant

Ulcerative colitis (UC) is a chronic nonspecific inflammatory disease caused by immune disorders, mental disorders, genetics, and other factors. Its main clinical manifestations are accompanied by abdominal pain, diarrhea, bloody stools, weight loss, etc. A distinctive feature of nonspecific ulcerative colitis from Crohn's disease is its limitation by the large intestine, as well as the limited inflammation of the mucous membrane [1]. The disease affects various age groups from infants to the elderly, with a maximum incidence rate between the ages of 15 to 30 years and between 50 and 70 years. UC seriously affects human health and quality of life because of its long duration and repeated attacks, and also there is a risk of developing colorectal cancer. The disease violates the quality of life and leads to disability [2]. The article presents the causes of ulcerative colitis and describes the mechanisms for the development of pathological changes in the intestine. The principles of patient management, taking into account the severity of the disease, and the tactics of rational drug therapy are presented.

Established and Emerging Treatments for Patients with Inborn Errors of Metabolism.

Inborn errors of metabolism (IEMs) are inherited defects in a metabolic pathway resulting in clinical disease. The overall goal of therapy is to restore metabolic homeostasis while minimizing the deleterious effects of the interruption. Conventional treatments focus on decreasing substrate, providing product, and replacing deficient enzyme or cofactor. We discuss examples of established, novel, and emerging therapies to provide a framework for understanding the principles of management for patients with IEMs.

Diffuse Hair Loss and Thinning: a Modern Perspective on the Problem and Approaches to Therapy

Hair condition is an indicator of health. By the nature of the violation of hair growth, somatic, infectious, endocrinological and other diseases can be identified in the early stages. From a practical point of view, it is very important to know the differences in changes in the condition of hair during loss or thinning. Diffuse alopecia is the most common form of hair growth disorders (up to 80 %) in people aged 30–50. The biological role of iron (Fe) in the human body is great - it provides oxygen transport and oxidative processes in tissues, and its deficiency leads to the development of iron deficiency anemia and associated trophic and metabolic disorders, especially hair growth and development. Spectrum of drugs that have the ability to compensate for these disorders is narrow enough. Relatively recently, a new Gf-based product appeared on the Ukrainian pharmaceutical market – a dietary supplement Richter FerroBio (Gedeon Richter, Hungary), specially designed for those cases when food does not manage to achieve a sufficient level of Fe or the need for it significantly increases. The article describes the distinctive features of diffuse thinning and hair loss. The principles of patient management are generalized and the possibilities of strengthening hair growth using heme iron preparations are shown.

Современные принципы ведения больных с описторхозом

Современные принципы ведения больных с описторхозом

Psoriatic arthritis: pathogenetic features and innovative therapies

The paper considers the modern concepts of the etiology and pathogenesis of psoriatic arthritis (PsA). The latter is currently indicated as a T-cell-mediated disease that is based on the activation of cellular immunity, followed by the hyperproduction and imbalance of key pro- and anti-inflammatory cytokines, such as tumor necrosis factor-α (TNF- α), interleukin-1β (IL-1β), IL-6, IL-12/23, and IL-17. The paper presents the basic principles of diagnosis and clinical manifestations of the disease and notes the importance of screening questionnaires, the use of which allows specialists to diagnose PsA early, by actively identifying articular complaints, the characteristic clinical and radiological signs of damage to the joint, spine, and entheses. It is pointed out that the key target of pharmacotherapy for PsA is to achieve remission or minimal activity of the main clinical manifestations of the disease, to slow down or prevent its radiographic progression, to increase the length and quality of life in patients, and to reduce the risk of comorbidities. The authors characterize the major groups of used drugs: nonsteroidal anti-inflammatory drugs, conventional and targeted synthetic disease-modifying antirheumatic drugs, and biological drugs (inhibitors of TNF-α, IL-12/23, and IL-17). The key Treat-to-target principles of patient management are considered; it is noted that strict control over disease activity and treatment results provides suppression of all major clinical manifestations of PsA. The paper also shows the basic principles of the creation and further development of the All-Russian Registry of PsA patients, which makes it possible to optimize management decision-making on the provision of high-tech medical care and drugs for this cohort of patients.

A cross-sectional study of dentists about the need for a practice management course in undergraduate dental program.

Objective:To evaluate dentists’ opinions about the need for a practice management course in the undergraduate dental program.Materials and Methods:This cross-sectional study was conducted in 2017 on practicing dentists in Lahore, Pakistan. A self-administered pilot-tested questionnaire was distributed among 588 dentists using a convenience sampling method to obtain their responses about the need for a practice management course. Descriptive statistics and bivariate and multivariate logistic regression analyses were performed.Results:About 83.8% of 588 dentists completed the questionnaires. There were 36.7% of males and 63.3% of females (mean age 26.22 ± 4.8 years). The principles of patient management (94.1%), time management skills (90.3%), and teamwork (89.2%) were the most commonly agreed topics of the practice management course. The least agreed topics included office design (59.2%), health-care systems (60.9%), and inventory systems (69%). Most participants (74.4%) thought that a practice management course is required to successfully manage a dental practice, and 63% recommended to include the course in the dental curriculum. Multivariate logistic regression showed that dentists working in private clinic (odds ratio (OR): 3.35, P = 0.001), dentists with graduation within ≤ past 5 years (OR: 3.64, P = 0.001), and dentists who attended a practice management course (OR: 3.12, P = 0.001) were more likely to agree to the need of a practice management course to successfully run a dental office.Conclusion:Most dentists believed that a practice management course is required for a successful dental practice. The development and implementation of such a course should be based on the feedback from dentists to ensure evidence-based approaches.

European principles of inhibitor management in patients with haemophilia

BackgroundIn spite of recent major advances in the understanding and treatment of inhibitor development in patients with haemophilia, multidisciplinary management of many of these patients remains suboptimal and highly heterogenous across Europe.MethodsFollowing a series of multidisciplinary meetings and a review of the literature, the European haemophilia community of health professionals and patients jointly defined practical optimum standards for ensuring and harmonizing treatment and care for patients with an inhibitor.ResultsTen complementary principles for the management of inhibitors in haemophilia have been developed, emphasizing the importance and benefits of a centralized, multidisciplinary, expert and holistic approach.ConclusionsThis document will serve as a benchmark to improve the multidisciplinary and practical management of patients with inhibitor. Implementation and adherence to each of these principles should have a major positive impact on the management and outcomes of patients developing an inhibitor.

Intrauterine sinechia: features of surgical treatment and prevention of recurrence

The article is devoted to the issues of surgical treatment and prevention of recurrence of intrauterine sinechia (IUS) and its severe condition Asherman syndrome. The topicality of the IUS is characterized by a high incidence of infertility, common miscarriage, amenorrhea and hypomenstrual syndrome. The article describes the principles for management of patients with IUS, the features of surgical treatment and the prevention of recurrence of the disease. The authors present their own clinical data summarizing the experience in treating 64 women with IUS. All patients underwent a hysteroscopic adhesiolysis. In the postoperative period, 48 women (group 1) received an adhesion barrier based on hyaluronic acid and carboxymethylcellulose – Antiadhesin injected into the cavity of the uterus. 16 women (control group 2) did not receive Antiadgesin. The study showed that significantly fewer relapses and a significant increase in commenced pregnancy were detected among patients in group 1. As can be seen from the above, not only the careful and complete dissection of the adhesions, but also the active postoperative rehabilitation period, which includes the prevention of relapsing adhesiogenesis using intrauterine injections of adhesion barriers, is crucial for the comprehensive treatment of patients with IUS.

Community-Acquired Pneumonia Visualized on CT Scans but Not Chest Radiographs: Pathogens, Severity, and Clinical Outcomes

BackgroundThe clinical significance of pneumonia visualized on CT scan in the setting of a normal chest radiograph is uncertain.MethodsIn a multicenter prospective surveillance study of adults hospitalized with community-acquired pneumonia (CAP), we compared the presenting clinical features, pathogens present, and outcomes of patients with pneumonia visualized on a CT scan but not on a concurrent chest radiograph (CT-only pneumonia) and those with pneumonia visualized on a chest radiograph. All patients underwent chest radiography; the decision to obtain CT imaging was determined by the treating clinicians. Chest radiographs and CT images were interpreted by study-dedicated thoracic radiologists blinded to the clinical data.ResultsThe study population included 2,251 adults with CAP; 2,185 patients (97%) had pneumonia visualized on chest radiography, whereas 66 patients (3%) had pneumonia visualized on CT scan but not on concurrent chest radiography. Overall, these patients with CT-only pneumonia had a clinical profile similar to those with pneumonia visualized on chest radiography, including comorbidities, vital signs, hospital length of stay, prevalence of viral (30% vs 26%) and bacterial (12% vs 14%) pathogens, ICU admission (23% vs 21%), use of mechanical ventilation (6% vs 5%), septic shock (5% vs 4%), and inhospital mortality (0 vs 2%).ConclusionsAdults hospitalized with CAP who had radiological evidence of pneumonia on CT scan but not on concurrent chest radiograph had pathogens, disease severity, and outcomes similar to patients who had signs of pneumonia on chest radiography. These findings support using the same management principles for patients with CT-only pneumonia and those with pneumonia seen on chest radiography.

MANAGEMENT TACTICS FOR PATIENTS WITH URINARY INFECTION

Modern approaches to diagnosis, management and prevention of complicated urinary infections are presented in the paper. The clinical example was used to describe the main principles of management in patients with pyelonephritis in conditions of polyclinic, aimed at timely diagnosis of disease and reduction of risk for development of possible complications.

Applications of gait analysis in pediatric orthopaedics

Computerized motion analysis, through innovation in technology and data interpretation, can be used as an important clinical tool. Gait deviations commonly occur in the pediatric population, some of which require a comprehensive approach to evaluation and treatment. This article provides an overview of the clinical application of gait analysis in pediatric orthopedics. The patient populations that may benefit from gait analysis and common gait abnormalities are presented as well as a systematic approach to observational gait analysis. The application of gait analysis in quantitatively identifying gait deviations and assisting with clinical decision-making are reviewed. Major components of the testing protocol such as physical examination, three-dimensional kinematics and kinetics, foot pressure, electromyography, energy consumption, are described. Principles of patient management and the utilization of gait analysis in various stages of clinical evaluation and treatment planning (baseline, follow-up, pre-intervention and post-interventions) are discussed. Two example cases (in-toeing and cerebral palsy) are illustrated to demonstrate the use of gait analysis in forming a therapeutic plan and measuring the treatment outcome quantitatively. Supplemental video files are included to illustrate important components of computerized gait analysis, demonstrate abnormal gait patterns, and present preoperative and postoperative gait videos of the case studies.

Long-term outcomes of secondary atrial fibrillation in the community: the Framingham Heart Study.

Guidelines have proposed that atrial fibrillation (AF) can occur as an isolated event, particularly when precipitated by a secondary, or reversible, condition. However, knowledge of long-term AF outcomes after diagnosis during a secondary precipitant is limited. In 1409 Framingham Heart Study participants with new-onset AF, we examined associations between first-detected AF episodes occurring with and without a secondary precipitant and both long-term AF recurrence and morbidity. We selected secondary precipitants based on guidelines (surgery, infection, acute myocardial infarction, thyrotoxicosis, acute alcohol consumption, acute pericardial disease, pulmonary embolism, or other acute pulmonary disease). Among 439 patients (31%) with AF diagnosed during a secondary precipitant, cardiothoracic surgery (n=131 [30%]), infection (n=102 [23%]), noncardiothoracic surgery (n=87 [20%]), and acute myocardial infarction (n=78 [18%]) were most common. AF recurred in 544 of 846 eligible individuals without permanent AF (5-, 10-, and 15-year recurrences of 42%, 56%, and 62% with versus 59%, 69%, and 71% without secondary precipitants; multivariable-adjusted hazard ratio, 0.65 [95% confidence interval, 0.54-0.78]). Stroke risk (n=209/1262 at risk; hazard ratio, 1.13 [95% confidence interval, 0.82-1.57]) and mortality (n=1098/1409 at risk; hazard ratio, 1.00 [95% confidence interval, 0.87-1.15]) were similar between those with and without secondary precipitants, although heart failure risk was reduced (n=294/1107 at risk; hazard ratio, 0.74 [95% confidence interval, 0.56-0.97]). AF recurs in most individuals, including those diagnosed with secondary precipitants. Long-term AF-related stroke and mortality risks were similar between individuals with and without secondary AF precipitants. Future studies may determine whether increased arrhythmia surveillance or adherence to general AF management principles in patients with reversible AF precipitants will reduce morbidity.