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General Reviews

Current treatment of venous thrombembolism

Ionuţ Munteanu
Spitalul Clinic Sanador
Current treatment of venous thrombembolism. Deep vein thrombosis and pulmonary embolism, considered to be different manifestations of the same disease - venous thromboembolism, have few differences regarding the anticoagulant treatment. However, there are some issues which will be discussed.
The therapy objectives in patients with venous thromboembolism include: prevention of death by pulmonary embolism, relieving symptoms in the affected leg, preventing morbidity and prevention of recurrent thromboembolism or postthrombotic syndrome, or minimize symptoms of post-thrombotic syndrome. For most patients, treatment goals are achieved using appropriate anticoagulant therapy, reducing the risk of recurrence in the first three months after diagnosis from over 25% to under 4%. Using of compression socks, providing a gradient of 30-40 mmHg at the ankle for 2 years after the diagnosis, reduce the risk of postthrombotic syndrome. Thrombolysis, applied either systemic or directly by catheter, is indicated in selected cases to prevent onset of post-thrombotic syndrome or remove quickly the symptoms due to high venous obstruction.
Thrombolytic therapy should be continued with anticoagulant therapy to prevent recurrence of venous thromboembolism. The use of an inferior vena cava filter is indicated for prevention of death by pulmonary embolism in patients who have contraindications to anticoagulant therapy, or anticoagulant treatment that was properly administered remains inefficient. Surgical treatment is recommended in case of chronic pulmonary hypertension, due to thromboembolic disease.
Keywords: venous thrombembolism, anticoagulant treatment, thrombolysis, inferior vena cava filter, surgical treatment

A “newborn” completed the anticholinergics family

Florin Mihălţan1
1. Institutul de Pneumologie „Marius Nasta” Bucureşti

A "newborn" completed the anticholinergics family. Emergence of a new ultra-long acting anticholinergic as glycopyrronium can bring a change of attitude in the life of practicioner. In this article I try to correctly position the new representative of the anticholinergics class, looking at all the evidence in vitro and in vivo, benefits, tolerability and safety of this product. Finally, on scientific evidence-based medicine I positioned this product in the new GOLD 2011 classification.

Keywords: glycopyrronium, COPD, treatment, GOLD 2011  

Immediate and delayed hypersensitivity reactions to intravascular iodine based radiocontrast media – an update

Roxana Silvia Bumbăcea, Brîndușa Petruţescu, Dragos Bumbăcea, Irina Strâmbu
1. Dermatology and Allergology Dept., Elias Emergency Hospital, Bucharest; 2. “Carol Davila” University of Medicine and Pharmacy, Bucharest; 3. Pulmonology Dept, Elias Emergency Hospital, Bucharest; 4. Pulmonology Dept, “Marius Nasta” Institute of Pulmonology, Bucharest

Used since 1929 in medical practice, nowadays four chemical varieties of intravascular iodine based radiocontrast media (I-RCM) are available: ionic monomers with high osmolarity, ionic dimers with low osmolarity, non-ionic monomers with low osmolarity and non-ionic iso-osmolar dimers. Increasing prescription of I-RCMs augments the number of reported hypersensitivity reactions. I-RCM induced hypersensitivity reactions can be clasified in two types: immediate hypersensitivity reactions (IHRs - occurring within the first hour) and delayed hypersensitivity reactions (DHRs - occurring between 1 hour and 7 days).

IHRs usually present as urticaria and angioedema but may associate severe respiratory and cardiovascular symptoms. Risk factors for an IHRs include a prior immediate reaction, personal history of atopic diseases (mainly asthma) and treatment with beta blocking agents. Diagnostic tests for IHRs include blood tests (serum tryptase) and skin tests (prick and intradermal) performed 2 to 6 months after IHR. High osmolarity of the I-RCM is the factor most strongly associated with IHRs. Primary prevention of IHRs involves the use of non-ionic low-osmolar or iso-osmolar agents for all intravascular procedures. DHRs are usually mild to moderate in severity, transient and self-limiting, presenting as maculopapular rash in more than 50% of cases.

As with IHRs, the most important risk factor for DHRs is a previous reaction to I-RCM. Assessment of DHRs includes skin prick tests, intradermal and patch tests. Due to extensive cross-reactivity between I-RCM, a change of product is no guarantee against a repeated reaction. Current premedication procedures in patients with previous severe reactions can reduce symptoms, but may not prevent recurrent reactions.

Keywords: iodine, radiocontrast media, osmolarity, hypersensitivity reactions, skin tests, premedication

Smoking, snoring and obstructive sleep apnea

Mihaela Trenchea, Oana Deleanu, Maria Suţa, Oana Cristina Arghir
1. Medstar Medical Center, Constanţa‚ 2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, 3. Faculty of Medicine, “Ovidius” University, Constanţa, România

Obstructive sleep apnea (OSA), with an apnea/hypopnea index (AHI) ≥5 events per hour , is recognized as an important cause of medical morbidity and mortality, being associated with a wide range of significant medical consequences, including arterial hypertension, cardiovascular diseases, metabolic diseases, neurological diseases and psychological effects. Tobacco smoking is considered a predisposing factor for pulmonary and cardiovasculary diseases and a risk factor for developing OSA. Since snoring is frequent in smokers and a common symptom, even a preclinical form of OSA, it is reasonable to speculate that smoking is an independent risk factor for snoring and may be associated with OSA. Current studies have observed there is a synergistic effect between smoking and OSA, both increasing the risk of cardiovascular disease through oxidative stress, endothelial dysfunction and abnormal inflammatory response. OSA, itself, could be responsible for nicotine addiction.

Keywords: obstructive sleep apnea, tobacco smoking, risk factor, snoring