Changes in right ventricular dimensions, function, and pulmonary circulation loading according to the degree of interdialytic weight gain in maintenance hemodialysis patients

INTRODUCTION

The aim of this study was to investigate changes in echocardiographic right ventricular (RV) indices in relation to the degree of fluid accumulation between hemodialysis sessions, evaluated according to the recommended threshold of interdialytic-weight-gain corrected for dry weight (IDWG%).

METHODS

A post-hoc analysis was performed using data from 41 maintenance hemodialysis patients. Patients were divided into a higher (>4.5%) and a lower (<4.5%) IDWG% group and underwent an echocardiographic assessment at the start and the end of the 3-day and the 2-day interdialytic interval.

RESULTS

RV systolic pressure (RVSP) increments were more pronounced in the higher compared to the lower IDWG% group (16.43 ± 5.37 vs. 14.11 ± 13.38 mm Hg respectively, p = 0.015) over the 3-day interval, while changes in RV filling pressures, did not differ significantly between the groups (p = 0.84).

CONCLUSIONS

During the 3-day interdialytic interval, pulmonary circulation is particularly overloaded in patients with fluid accumulation higher than the recommended thresholds, as evidenced by higher RVSP elevations.

Different Interdialytic Intervals and Cardiorespiratory Fitness in Patients Undergoing Hemodialysis

Key Points

Background

Long interdialytic interval in thrice-weekly hemodialysis is associated with excess cardiovascular and all-cause mortality risk. Impaired cardiorespiratory fitness is a strong predictor of mortality in hemodialysis. This study investigated differences in cardiorespiratory fitness assessed with cardiopulmonary exercise testing (CPET) between the end of the 2-day and the 3-day interdialytic interval.

Methods

A total of 28 hemodialysis patients, randomized in two different sequences of evaluation, underwent CPET and spirometry examination at the end of the 2-day and the 3-day intervals. The primary outcome was the difference in oxygen uptake at peak exercise (VO2peak [ml/kg per minute]) assessed with CPET. Volume status was assessed with interdialytic weight gain, lung ultrasound, bioimpedance spectroscopy, and inferior vena cava measurements. A total of 14 age-matched and sex-matched controls were also evaluated. Comparisons of changes in parameters of interest were performed with paired or independent t-tests or relevant nonparametric tests, as appropriate. Bivariate correlation analyses and generalized linear mixed models were used to examine associations between changes in CPET parameters and volume indices.

Results

Hemodialysis patients at the end of both 2-day and 3-day intervals presented lower values in all major CPET parameters than controls. VO2peak (ml/kg per minute) was significantly higher at the end of the 2-day than the 3-day interval (15.2±4.2 versus 13.6±2.8; P < 0.001); the results were similar for VO2peak (ml/min) (1188±257 versus 1074±224; P < 0.001) and VO2peak (% predicted) (58.9±9.2 versus 52.3±8.6; P < 0.001). Numerical but no statistically significant differences were detected in VO2 anaerobic threshold (ml/kg per minute) and VO2 anaerobic threshold (ml/min) between the two time points. Maximal work load (90.1±23.2 versus 79.3±25.1; P < 0.001), exercise duration, heart rate at peak exercise, and oxygen pulse also showed lower values at the end of the 3-day interval. Forced expiratory volume in 1-second levels were similar between the two evaluations. Generalized linear mixed model analysis, including interdialytic weight gain as random covariate, attenuated the observed differences in VO2peak (ml/kg per minute). Changes in bioimpedance spectroscopy–derived overhydration indexes were moderately correlated with changes of VO2peak (ml/kg per minute).

Conclusions

The 3-day interval was associated with further impairment of VO2 at peak exercise. This effect was predominantly driven by excess fluid accumulation during the extra interdialytic day.

Post-Operative Thoracic Epidural Analgesia and Incidence of Major Complications according to Specific Safety Standardized Documentation: A Large Retrospective Dual Center Experience

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications.

Cardiorespiratory fitness assessed with cardiopulmonary exercise testing in patients with juvenile idiopathic arthritis: a systematic review and meta-analysis

OBJECTIVES

JIA is the most common type of arthritis in children and adolescents, causing joint damage, chronic pain and disability. Deconditioning is also prevalent in patients with JIA due to both inactivity and the disease progression, resulting in reduced cardiorespiratory fitness (CRF). We aimed to evaluate CRF of patients with JIA compared with healthy controls.

METHODS

This is a systematic review and meta-analysis of studies using cardiopulmonary exercise testing (CPET) to examine differences in determinants of CRF between patients with JIA vs healthy controls. The primary outcome was peak oxygen uptake (VO2peak). Literature search involved PubMed, Web of Science and Scopus databases, manual search of article references and grey literature. Quality assessment was undertaken with Newcastle-Ottawa Scale.

RESULTS

From 480 literature records initially retrieved, eight studies (538 participants) were included in final meta-analysis. VO2peak was significantly lower in patients with JIA compared with controls [weighted mean difference (WMD): -5.95 ml/kg/min (95% CI -9.26, -2.65)]. Exercise duration and VO2peak (% predicted) were found to be significantly impaired in patients with JIA compared with controls [standardized mean difference: -0.67 (95% CI -1.04, -0.29) and WMD: -11.31% (95% CI -20.09, -2.53), respectively], while no significant differences were found in maximum heart rate.

CONCLUSION

VO2peak and other CPET variables were lower in patients with JIA compared with controls, indicating reduced CRF in the former. Overall, exercise programs for patients with JIA should be promoted as part of their treatment to improve physical fitness and reduce muscle atrophy.

PROSPERO REGISTRATION

CRD42022380833.

Efficacy and Safety of Nintedanib in Patients with Connective Tissue Disease-Interstitial Lung Disease (CTD-ILD): A Real-World Single Center Experience

Connective Tissue Disease-Interstitial Lung Disease (CTD-ILD) is a severe and fatal manifestation of systemic autoimmune disorders. Therapies rely on immunomodulators but their efficacy in ILD progression remains uncertain. Nintedanib, an antifibrotic agent that slows pulmonary function decline, has been approved for CTD-ILD treatment. The aim of this study was to assess the effectiveness and safety of nintedanib in CTD-ILD patients in a real-world data setting. A single-center, retrospective, and descriptive analysis of CTD-ILD patients treated with nintedanib from June 2019 to November 2022 was performed. The assessment of nintedanib treatment's efficacy was judged solely on the evolution of pulmonary function tests (PFTs), which were evaluated before and after treatment. Twenty-one patients (67% females, median age 64 years (IQR = 9) with CTD-ILD (systemic sclerosis n = 9, rheumatoid arthritis n = 5, dermatomyositis n = 4, juvenile rheumatoid arthritis n = 1, undifferentiated CTD n = 1, interstitial pneumonia with autoimmune features n = 1), 18 of whom were on concomitant immunosuppressives, had a median follow-up period of 10 months (IQR = 5). PFTs before and after treatment did not significantly differ. The mean FVC% difference was +0.9 (sd = 7.6) and the mean DLco% difference was +3.4 (sd = 12.6), suggesting numerical improvement of PFTs. The average percentage change was -0.3% and +7.6% for FVC% and DLco%, respectively, indicating stabilization of lung function. Our real-world data across a broad spectrum of CTD-ILD suggest that nintedanib could be beneficial in combination with immunosuppressives in slowing the rate of lung function decline.

Effect of kidney transplantation on indices of cardiorespiratory fitness assessed with cardiopulmonary exercise testing: a systematic review and meta-analysis

BACKGROUND

Patients with kidney failure often present with reduced cardiovascular reserve. Kidney transplantation (KT) is the optimal treatment for patients with end-stage kidney disease as it is associated with longer survival and improved quality of life compared to dialysis.

METHODS

This is a systematic review and meta-analysis of studies using cardiopulmonary-exercise-testing to examine the cardiorespiratory fitness of patients with kidney failure before and after KT. The primary outcome was difference in pre- and post-transplantation values of peak oxygen uptake (VO2peak). Literature search involved three databases (PubMed-Web of Science-Scopus), manual search, and grey literature.

RESULTS

From 379 records initially retrieved, six studies were included in final meta-analysis. A marginal, but not significant, improvement was observed in VO2peak after KT compared to pre-transplantation values (SMD: 0.32, 95%CI -0.02; 0.67). Oxygen consumption at anaerobic threshold was significantly improved after KT (WMD: 2.30 ml/kg/min, 95%CI 0.50; 4.09). Consistent results were shown between preemptive and after-dialysis-initiation transplantation and a trend for improvement in VO2peak was observed at least 3 months post-transplantation, but not earlier.

CONCLUSION

Several major indices of cardiorespiratory fitness tend to improve after KT. This finding may represent another modifiable factor contributing to better survival rates of kidney transplant recipients compared to patients undergoing dialysis.

The role of cardiopulmonary exercise testing in risk stratification and prognosis of atrial fibrillation: a scoping review of the literature

BACKGROUND

Cardiopulmonary exercise testing (CPET) is a significant tool for evaluating exercise capacity in healthy individuals and in various pulmonary and cardiovascular conditions, quantifying symptoms and predicting outcomes. Atrial fibrillation (AF) poses a significant burden on patients and health systems; a research marathon is ongoing for discovering the pathophysiologic substrate, natural history, prognostic tools and optimal treatment strategies for AF. Among the plethora of variables measured during CPET, there is a series of parameters of interest concerning AF.

METHODS

We conducted a scoping review aiming to identify significant CPET-related parameters linked to AF, as well as indicate the impact of other cardiac disease-related variables. We searched PubMed from its inception to 12 January 2022 for reports underlining the contribution of CPET in the assessment of patients with AF. Only clinical trials, observational studies and systematic reviews were included, while narrative reviews, expert opinions and other forms of manuscripts were excluded.

RESULTS

In our scoping review, we report a group of heterogeneous, thus noteworthy parameters relevant to the potential contribution of CPET in AF. CPET helps phenotype AF populations, evaluates exercise capacity after cardioversion or catheter ablation, and assesses heart rate response to exercise; peak VO₂ and VE/VCO₂, commonly measured indices during CPET, also serve as prognostic tools in patients with AF and heart failure.

CONCLUSIONS

CPET seems to hold a clinically important predictive value for future cardiovascular events both in patients with pre-existing cardiac conditions and in healthy individuals. CPET variables may play a fundamental role in the prediction of future AF-related events.

Cardiopulmonary exercise testing in patients with end-stage kidney disease: principles, methodology and clinical applications of the optimal tool for exercise tolerance evaluation

Chronic kidney disease (CKD), especially end-stage kidney disease (ESKD), is associated with an increased risk for cardiovascular events and all-cause mortality. Exercise intolerance as well as reduced cardiovascular reserve is extremely common in patients with CKD. Cardiopulmonary exercise testing (CPET) is a non-invasive, dynamic technique that provides an integrative evaluation of cardiovascular, pulmonary, neuropsychological and metabolic function during maximal or submaximal exercise, allowing the evaluation of functional reserves of these systems. This assessment is based on the principle that system failure typically occurs when the system is under stress and thus CPET is currently considered to be the gold standard for identifying exercise limitation and differentiating its causes. It has been widely used in several medical fields for risk stratification, clinical evaluation and other applications, but its use in everyday practice for CKD patients is scarce. This article describes the basic principles and methodology of CPET and provides an overview of important studies that utilized CPET in patients with ESKD, in an effort to increase awareness of CPET capabilities among practicing nephrologists.

Right Ventricular Myocardial Work Characterization in Patients With Pulmonary Hypertension and Relation to Invasive Hemodynamic Parameters and Outcomes

Noninvasive evaluation of indexes of right ventricular (RV) myocardial work (RVMW) derived from RV pressure-strain loops may provide novel insights into RV function in precapillary pulmonary hypertension. This study was designed to evaluate the association between the indexes of RVMW and invasive parameters of right heart catheterization and all-cause mortality. Noninvasive analysis of RVMW was completed in 51 patients (mean age 58.1 ± 12.7 years, 31% men) with group I or group IV pulmonary hypertension. RV global work index (RVGWI), RV global constructive work (RVGCW), RV global wasted work (RVGWW), and RV global work efficiency (RVGWE) were compared with parameters derived invasively during right heart catheterization. Patients were followed-up for the occurrence of all-cause death. The median RVGWI, RVGCW, RVGWW, and RVGWE were 620 mm Hg%, 830 mm Hg%, 105 mm Hg% and 87%, respectively. Compared with conventional echocardiographic parameters of RV systolic function, RVGCW and RVGWI correlated more closely with invasively derived RV stroke work index (R = 0.63, p <0.001 and R = 0.60, p <0.001, respectively). Invasively derived pulmonary vascular resistance correlated with RVGWW (R = 0.63, p <0.001), RVGWE (R = 0.48, p <0.001), and RV global longitudinal strain (R = 0.58, p <0.001). RVGCW (hazard ratio 1.42 per 100 mm Hg% <900 mm Hg%, 95% confidence interval 1.12 to 1.81, p = 0.004) and RVGWI (hazard ratio 1.46 per 100 mm Hg% <650 mm Hg%, 95% confidence interval 1.09 to 1.94, p = 0.010) were significantly associated with all-cause mortality, whereas RV global longitudinal strain, RVGWE, and RVGWW were not. In conclusion, indexes of RVMW were more closely correlated with invasively derived RV stroke work index and peripheral vascular resistance than conventional echocardiographic parameters of RV systolic function. Decreased values of RVGCW and RVGWI were associated with all-cause mortality, whereas conventional echocardiographic parameters of RV function were not.

The impact of cardiovascular comorbidities associated with risk for left heart disease on idiopathic pulmonary arterial hypertension: Data from the Hellenic Pulmonary Hypertension Registry (HOPE)

Whereas younger female patients were diagnosed with idiopathic pulmonary arterial hypertension (IPAH) in 1980s, it is now frequently encountered in elderly patients with cardiovascular comorbidities (CVCs) associated with increased risk for left heart disease. We present data until November 2019 regarding specific features and clinical outcomes of IPAH population from the Hellenic Pulmonary Hypertension Registry (HOPE). Patients were divided into two groups based on the presence of ≥ or <3 CVCs, arterial hypertension, diabetes mellitus, obesity, presence of coronary artery disease, or atrial fibrillation. Overall, 77 patients with IPAH (55.1 [interquartile range, IQR: 24.1] years, 62.8% women) have been recorded. Fifteen patients (19.2%) had ≥3 CVCs, while 25 (32%) were over 65 years old. Patients with ≥3 CVCs were older, presented an almost equal female to male ratio, walked less in 6‐min walk test, and had lower mean arterial pulmonary pressure and pulmonary vascular resistance at baseline than patients with less CVCs. Fewer patients with ≥3 CVCs received PAH‐specific treatment compared to patients with less comorbidities (n = 11 [73.3%] versus n = 58 [95.5%], p = 0.02). During a median follow‐up period of 3.8 (IQR: 2.7) years, 18 patients died (all‐cause mortality 24.3%). Male sex and older age were independent predictors of mortality and/or lung transplantation, while CVCs did not have a significant impact on clinical outcomes. In this nationwide, register‐based study, the epidemiology of IPAH involves older patients with CVCs, who seem to have less hemodynamic compromise, but worse functional impairment and are treated less aggressively with PAH pharmacotherapy.

Cardiotoxicity of azithromycin in COVID-19: an overall proportion meta-analysis

INTRODUCTION

To explore the incidence of pro-arrhythmic effects such as corrected QT interval (QTc) prolongation, arrhythmic events and myocardial injury of azithromycin as administered for the treatment of COVID-19.

MATERIAL AND METHODS

We searched PubMed, the Cochrane Library and Web of Science databases from inception to 18 January 2021, as well as the medRχiv preprint database from 1 August 2020 to 18 January 2021, for studies exploring the cardiotoxicity effects of azithromycin, with or without concomitant use of hydroxychloroquine, in the context of Covid19. We performed a random effects single-arm meta-analysis of studies to calculate pooled proportion estimates for pro-arrhythmic effects. Meta-regression analyses were conducted to explain between-study heterogeneity.

RESULTS

Thirty-four studies with a total of 3088 patients were included. Among 12 studies, the incidence of > 60ms QTc prolongation from baseline was 13% (95% CI 9%-18%, I² = 73%), whereas, among 28 studies, the incidence of QTc ≥ 500 ms at follow-up was 8% (95% CI 6%-11%, I² = 78%). Still, the discontinuation rate due to QTc prolongation was only 3% (95% CI 2%-5%, I² = 55%). The absolute risk of Torsade de pointes and ventricular tachycardia was 0.2% and 0.8%, respectively. Increased age, male sex, presence of hypertension or diabetes mellitus, use of QTc prolonging medication, prolonged baseline QTc interval and indicators of disease severity such as death explained between-study heterogeneity.

CONCLUSIONS

Azithromycin, with or without hydroxychloroquine, leads to a significant risk for critical QTc prolongation in patients with Covid19. Due to its cardiotoxicity effects and its unproven efficacy in Covid19, azithromycin use should be limited to cases of bacterial co-infection.

Multiple Extrapulmonary Tuberculous Abscesses Developed Postpartum in a Non-HIV Patient Under Anti-tuberculosis Chemotherapy

Although abscess formation constitutes a recognized complication of tuberculous lymphadenitis, the concomitant development of multiple tuberculous abscesses in the course of tuberculous lymphadenitis has rarely been described in the literature among HIV-negative patients under appropriate chemotherapy. Adherence and sensitivity to the administered anti-tuberculosis chemotherapy have to be verified in such patients. We report a case of deteriorating tuberculous lymphadenitis, presenting with the development of multiple extrapulmonary abscesses (cervical, psoas, and retroperitoneal) in an HIV-negative patient who had complied with appropriate anti-tuberculosis chemotherapy for four months. Mycobacterium tuberculosis was the identified pathogen in specimens from the abscesses. Continuation of anti-tuberculosis medications and concurrent administration of antibiotics, along with CT-guided percutaneous drainage of the psoas abscess, resulted in gradual resolution of the patient's lesions. Interestingly, our patient had recent childbirth, indicating a potential association between the immunomodulatory processes during the postpartum period and the development of the so-called paradoxical reaction. Awareness of such complications should be raised, as a timely recognition and subsequent therapeutical treatment are essential for a favorable outcome.

Right ventricular myocardial work characterisation in patients with pulmonary hypertension: association with invasive haemodynamic parameters

Background

Non-invasive evaluation of indices of right ventricular (RV) myocardial work derived from RV pressure-strain loops may provide novel insights into RV function in pre-capillary pulmonary hypertension.

Purpose

This study was designed to evaluate the association between the indices of RV myocardial work and invasive haemodynamic parameters in a patient cohort with pulmonary arterial hypertension (Group I) or chronic thromboembolism pulmonary hypertension (Group IV).

Methods

The non-invasive analysis of echocardiography-derived RV myocardial work (Figure 1, upper panel) was completed in 51 patients (mean age 58.1±12.7 years, 31% male) with Group I (78%) or Group IV (22%) pulmonary hypertension. Conventional echocardiographic measurements of RV systolic function, RV global work index (RV GWI), RV global constructive work (RV GCW), RV global wasted work (RV GWW) and RV global work efficiency (RV GWE) were compared with parameters derived invasively during right heart catheterisation (RHC).

Results

The median RV GWI, RV GCW, RV GWW and RV GWE were 620 (443 to 857) mmHg%, 830 (650 to 1206) mmHg%, 105 (54 to 169) mmHg% and 87 (82 to 93)%, respectively. Compared to pulmonary artery systolic pressure and conventional echocardiographic parameters of RV systolic function (RV global longitudinal strain [GLS], tricuspid annular plane systolic excursion and RV fractional area change), RV GCW and RV GWI correlated more closely with invasively-derived RV stroke work index (R=0.63, P&lt;0.001 and R=0.60, P&lt;0.001, respectively) (Figure 1, lower panels). Invasively-derived pulmonary vascular resistance (PVR) correlated with RV GWW (R=0.63, P&lt;0.001), RV GWE (R=0.48, P&lt;0.001) and RV GLS (R=0.58, P&lt;0.001). RV GLS correlated more closely with invasively-derived stroke volume index (R=−0.57, P&lt;0.001) than RV GCW, RV GWI and RV GWE (R=0.34, P=0.016, R=0.48, P&lt;0.001 and R=0.47, P&lt;0.001, respectively).

Conclusions

In a patient cohort with Group I and Group IV pulmonary hypertension, indices of RV myocardial work were more closely correlated with invasively-derived RV stroke work index and PVR than conventional echocardiographic parameters of RV systolic function.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Method and correlations

Epidemiological characteristics and outcomes from 187 patients with COVID-19 admitted to 6 reference centers in Greece: an observational study during the first wave of the COVID-19 pandemic

INTRODUCTION

Epidemiological data from patients with COVID-19 has been recently published in several countries. Nationwide data of hospitalized patients with COVID-19 in Greece remain scarce.

MATERIAL AND METHODS

This was an observational, retrospective study from 6 reference centers between February 26 and May 15, 2020.

RESULTS

The patients were mostly males (65.7%) and never smokers (57.2%) of median age 60 (95% CI: 57.6-64) years. The majority of the subjects (98%) were treated with the standard-of-care therapeutic regimen at that time, including hydroxychlo-roquine and azithromycin. Median time of hospitalization was 10 days (95% CI: 10-12). Twenty-five (13.3%) individuals were intubated and 8 died (4.2%). The patients with high neutrophil-to-lymphocyte ratio (NLR) ( > 3.58) exhibited more severe disease as indicated by significantly increased World Health Organization (WHO) R&D ordinal scale (4; 95% CI: 4-4 vs 3; 95% CI: 3-4, p = 0.0001) and MaxFiO2% (50; 95% CI: 38.2-50 vs 29.5; 95% CI: 21-31, p < 0.0001). The patients with increased lactate dehydrogenase (LDH) levels ( > 270 IU/ml) also exhibited more advanced disease compared to the low LDH group ( < 270 IU/ml) as indicated by both WHO R&D ordinal scale (4; 95% CI: 4-4 vs 4; 95% CI: 3-4, p = 0.0001) and MaxFiO2% (50; 95% CI: 35-60 vs 28; 95% CI: 21-31, p < 0.0001).

CONCLUSION

We present the first epidemiological report from a low-incidence and mortality COVID-19 country. NLR and LDH may represent reliable disease prognosticators leading to timely treatment decisions.

Cardiorespiratory fitness assessed by cardiopulmonary exercise testing between different stages of pre-dialysis chronic kidney disease: A systematic review and meta-analysis

AIM

The burden of several cardiovascular risk factors increases in parallel to renal function decline. Exercise intolerance is common in patients with chronic kidney disease (CKD) and has been associated with increased risk of adverse outcomes. Whether indices of cardiorespiratory capacity deteriorate with advancing CKD stages is unknown.

METHODS

We conducted a systematic review and meta-analysis of studies assessing cardiorespiratory capacity in adult patients with pre-dialysis CKD using cardiopulmonary exercise testing (CPET) and reporting data for different stages. Our primary outcome was differences in peak oxygen uptake (VO₂ peak) between patients with CKD Stages 2-3a and those with Stages 3b-5(pre-dialysis). Literature search was undertaken in PubMed, Web of Science and Scopus databases, and abstract books of relevant meetings. Quality assessment was undertaken with Newcastle-Ottawa-Scale.

RESULTS

From 4944 records initially retrieved, six studies with 512 participants fulfilling our inclusion criteria were included in the primary meta-analysis. Peak oxygen uptake (VO₂ peak) was significantly higher in patients with CKD Stages 2-3a versus those with Stages 3b-5(pre-dialysis) [weighted-mean-difference, WMD: 2.46, 95% CI (1.15, 3.78)]. Oxygen consumption at ventilatory threshold (VO₂ VT) was higher in Stages 2-3a compared with those in Stages 3b-5(pre-dialysis) [standardized-mean-difference, SMD: 0.59, 95% CI (0.06, 1.1)], while no differences were observed for maximum workload and respiratory-exchange-ratio. A secondary analysis comparing patients with CKD Stages 2-3b and Stages 4-5(pre-dialysis), yielded similar results [WMD: 1.78, 95% CI (1.34, 2.22)]. Sensitivity analysis confirmed the robustness of these findings.

CONCLUSION

VO₂ peak and VO₂ VT assessed with CPET are significantly lower in patients in CKD Stages 3b-5 compared with Stages 2-3a. Reduced cardiorespiratory fitness may be another factor contributing to cardiovascular risk increase with advancing CKD.

Diagnosis and management of combined post- and precapillary pulmonary hypertension in a patient with multiple comorbidities

Diagnosis of pulmonary hypertension requires a laborious investigation that must be performed in accordance with international guidelines. Right-heart catheterization is the gold standard examination to assess the degree of hemodynamic impairment of post- or precapillary origin, guiding management. The presence of comorbidities is becoming rather frequent in real-life pulmonary hypertension cases, thus creating diagnostic and therapeutic complexity. We present a case of combined post- and precapillary pulmonary hypertension in a patient with ischemic heart disease and combined pulmonary fibrosis and emphysema, in order to describe the diagnostic algorithm for pulmonary hypertension and elucidate the problematic aspects of managing this debilitating disease in a patient with several comorbidities. Current guidelines do not support the use of specific vasodilator treatment in group II - due to heart disease and group III-due to lung disease pulmonary hypertension, unless the patient presents with severe pulmonary hypertension (mean pulmonary artery pressure > 35 mm Hg or cardiac index < 2.0 L/min) with right ventricular dysfunction and is treated in an expert center and preferably in the context of a randomized control trial. In the case presented, therapeutic management focused, firstly, on treatment of the underlying heart and lung disease and, subsequently, on specific vasoactive therapy, due to severe hemodynamic deterioration.

MO611CARDIOPULMONARY RESERVE EXAMINED WITH CARDIOPULMONARY EXERCISE TESTING IN INDIVIDUALS WITH AND WITHOUT CHRONIC KIDNEY DISEASE; A SYSTEMATIC REVIEW AND META-ANALYSIS

Background and Aims

Patients with chronic kidney disease (CKD) often present with reduced physical activity and exercise performance due to a number of factors relevant to co-existing disturbances of the cardiac, nervous and muscular systems. Cardiopulmonary exercise testing (CPET) is widely applied in daily clinical practice used for clinical evaluation of exercise intolerance and related symptoms (i.e. dyspnea, fatigue), as well risk stratification, and other applications in several medical fields.

Method

This is a systematic review and meta-analysis of studies which used CPET technology in adult patients with CKD to examine cardiopulmonary reserve in individuals with versus individuals without CKD. The primary outcome was peak oxygen uptake (VO2peak). Literature search involved PubMed, Web of Science and Scopus databases; manual search of article references and of grey literature was also performed. Newcastle-Ottawa Scale was applied to evaluate the quality of retrieved studies.

Results

From an initial 4944 literature records, we identified 29 studies fulfilling the inclusion criteria; of these, 25 studies with complete data including 2213 participants were included in final meta-analysis. Peak oxygen uptake (VO2peak) was significantly lower in CKD patients compared to controls without CKD (standardized-mean-difference, SMD:-1.40, 95%CI[-1.68, -1.13]) (Figure). Oxygen consumption at anaerobic threshold (VO2AT) (SMD:-1.06, 95%CI[-1.34, -0.79]), maximum workload (weighted-mean-difference, WMD:-58.26, 95%CI[-74.14, -42.38]) and respiratory exchange ratio (RER) (WMD:-0.02, 95%CI[-0.05, 0.01]) were also impaired in CKD patients compared to non-CKD individuals. In 3 studies comparing patients with CKD versus patients with heart failure without CKD VO2peak was higher in the former (WMD:6.60, 95%CI[3.02, 10.18]). Sensitivity analyses confirmed the robustness of these findings.

Conclusion

VO2peak and other commonly analyzed CPET variables were lower in CKD patients compared to controls, indicating reduced functional cardiopulmonary reserve in the former. In contrast, CKD patients performed better when compared patients with heart failure.

Haemodynamic effects of PAH-targeted therapies in pulmonary hypertension due to lung disease: A systematic review and meta-analysis

BACKGROUND

Pulmonary hypertension (PH) is a negative predictor in patients with lung disease and/or hypoxia (group 3 PH). Current guidelines do not endorse the use of targeted therapies for pulmonary arterial hypertension (PAH) in patients with group 3 PH, due to lack of strong evidence. However, a variety of studies have examined the effect of PAH-targeted therapies in group 3 PH with mixed methods and conflicting results.

OBJECTIVE

To evaluate the effect of PAH-targeted therapies on haemodynamic parameters as assessed by right heart catheterization in patients with group 3 PH.

METHODS

Search strategy included PubMed and CENTRAL databases for randomized controlled trials from inception until Jan 30, 2020. We hand searched review articles, clinical trial registries and reference lists of retrieved articles. The primary outcome was the effect of PAH-targeted therapies on haemodynamic parameters [mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), cardiac index (CI) and right atrial pressure (RAP)] in patients with group 3 PH, while secondary outcomes were 6-min walking distance (6MWD), brain natriuretic peptide (BNP) and quality of life (QoL).

RESULTS

Five studies with a total of 140 patients were included. PAH-targeted therapies improved significantly mPAP [mean difference (MD) -4.02 mmHg, 95% CI -7.95;-0.09], and PVR [standardized mean difference (SMD) -0.29, 95% CI -0.50;-0.07], but not CI (SMD 0.23, 95% CI -0.23; 0.70) or RAP (MD 0.26 mmHg, 95% CI -18.75; 19.27). PAH-targeted therapies significantly increased the 6MWD by 38.5 m (95% CI 17.6; 59.4), while they did not manage to improve QoL (SMD -3.42, 95% CI -14.74; 7.91) or BNP values. There was no effect of oxygenation by the PAH-targeted therapies compared to placebo.

CONCLUSION

PAH-targeted therapies slightly improved mPAP and PVR in group 3 PH, without affecting CI. Larger RCTs targeted in specific subpopulations are needed to extract more robust conclusions.

PROTOCOL REGISTRATION

Open Science Framework 10.17605/OSF.IO/56FDW.

Assessment of Exercise Intolerance in Patients with Pre-Dialysis CKD with Cardiopulmonary Function Testing: Translation to Everyday Practice

BACKGROUND

Chronic kidney disease (CKD) is often characterized by increased prevalence of cardiovascular risk factors and increased incidence of cardiovascular events and death. Reduced cardiovascular reserve and exercise intolerance are common in patients with CKD and are associated with adverse outcomes.

SUMMARY

The gold standard for identifying exercise limitation is cardiopulmonary exercise testing (CPET). CPET provides an integrative evaluation of cardiovascular, pulmonary, hematopoietic, neuropsychological, and metabolic function during maximal or submaximal exercise. It is useful in clinical setting for differentiation of the causes of exercise intolerance, risk stratification, and assessment of response to relevant treatments. A number of recent studies have used CPET in patients with pre-dialysis CKD, aiming to assess the cardiovascular reserve of these individuals, as well as the effect of interventions such as exercise training programs on their functional capacity. This review provides an in-depth description of CPET methodology and an overview of studies that utilized CPET technology to assess cardiovascular reserve in patients with pre-dialysis CKD. Key Messages: CPET can delineate multisystem changes and offer comprehensive phenotyping of factors determining overall cardiovascular risk. Potential clinical applications of CPET in CKD patients range from objective diagnosis of exercise intolerance to preoperative and long-term risk stratification and providing intermediate endpoints for clinical trials. Future studies should delineate the association of CPET indexes, with cardiovascular and respiratory alterations and hard outcomes in CKD patients, to enhance its diagnostic and prognostic utility in this population.

Peripheral microangiopathy in Eisenmenger syndrome: A nailfold video capillaroscopy study

BACKGROUND

Eisenmenger syndrome (ES) comprises a severe phenotype of pulmonary arterial hypertension characterized by angiopathy of the lung circulation. The aim of the present study was to demonstrate the presence of systemic microvascular abnormalities in patients with ES using nailfold video-capillaroscopy (NVC) and to identify potential correlations of nailfold capillaroscopic characteristics with non-invasive markers of systemic organ function.

METHODS

Α cross-sectional NVC study was performed in 17 consecutive patients with ES and 17 healthy controls matched for age and sex. NVC quantitative (capillary density, capillary dimensions, haemorrhages, thrombi, shape abnormalities) and qualitative (normal, non-specific or scleroderma pattern) parameters were evaluated.

RESULTS

Patients with ES [median age 40 (18-65) years, 11 women] presented reduced capillary density [8.8 (7.2-10.2) loops/mm vs. 9.9 (8.3-10.9) loops/mm, p = .004] and increased loop width [15.9 (10.3-21.7) μm vs. 12.3 (7.6-15.2) μm, p < .001], while they had significantly more abnormal capillaries than healthy controls [2.5 (0.9-5.4) abnormal loops/mm vs. 1.0 (0.0-1.7) abnormal loops/mm, p < .001]. NVC shape abnormalities in ES were positively correlated with NT-proBNP (r = 0.52, p = .03) and were negatively associated with estimated glomerular filtration rate (r = -0.60, p = .02). Additionally, capillary loop diameter was positively correlated with increased haemoglobin levels (r = 0.55, p = .03) and negatively correlated with reduced peripheral oxygen saturation (r = - 0.56, p = .02).

CONCLUSIONS

This study supports the hypothesis of peripheral microvascular involvement in ES parallel to pulmonary microangiopathy detected by NVC. Further longitudinal studies are needed to confirm our preliminary results.

Non-Invasive Assessment of Endothelial Dysfunction in Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is characterised by an increased pressure in the pulmonary arterial circulation, resulting in the elevation of pulmonary vascular resistance. Pulmonary endothelial dysfunction and inflammation, triggered by shear stress and hypoxia, constitute the hallmarks of pulmonary vasculopathy by promoting endothelial and smooth muscle cells proliferation, vasoconstriction, and thrombosis. While research was predominantly focused on pulmonary vasculature, the investigation of peripheral endothelial damage in different vascular beds has attracted the interest over the last years. As a result, effective non-invasive methods that can assess the endothelial function and the architectural integrity have been utilized for the evaluation of pulmonary and peripheral vasculature. Non-invasive plethysmography, pulmonary flow reserve, nailfold videocapillaroscopy, near-infrared spectroscopy, and imaging techniques such as magnetic resonance angiography and perfusion imaging coupled by a number of biomarkers can be used for the assessment of peripheral vascular function in PAH individuals. In this review, we summarise and critically approach the current evidence of more systemic derangement of vascular function in PAH defined by novel, non-invasive methods employed for functional and morphological assessment of endothelium and microcirculation.

Prediction of long-term survival in patients with transfusion-dependent hemoglobinopathies: Insights from cardiac imaging and ferritin

AIMS

The current study evaluated the association of echocardiography, cardiac magnetic resonance (CMR), and ferritin data with 10-year survival in thalassemia patients.

METHODS

Demographics, ferritin, echocardiography, and CMR parameters of stable consecutive thalassemia patients were prospectively collected.

RESULTS

In total, 75 patients (mean age 37 ± 11 years, 45% male) with thalassemia were included and dichotomized based on their survival status after a median follow-up period of 10.3 [9.6-10.9] years. Older age (HR: 1.071, p = 0.001), ferritin ≥2000 ng/ml (HR: 4.682, p = 0.007) and ≥1700 ng/ml (HR: 7.817, p = 0.002), elevated LV end-diastolic pressure (HR: 1.019, p = 0.044), TR Vmax >2.8 m/s (HR: 6.845, p = 0.005), and CMR T2∗ ≤20 msec (HR: 3.602, p = 0.043) and ≤34 msec (HR: 5.854, p = 0.026) were associated with increased all-cause mortality (primary endpoint). A baseline model including age was created and became more predictive of worse survival by adding TR Vmax >2.8 m/s instead of elevated LV end-diastolic pressure (C index 0.767 vs. 0.760, respectively), ferritin ≥1700 ng/ml instead of ≥2000 ng/ml (C index 0.890 vs. 0.807, respectively), or CMR T2∗≤34 msec instead of ≤20 msec (C index 0.845 vs. 0.839, respectively). Parameters associated with the combined endpoint of cardiac mortality/cardiac hospitalization (secondary endpoint) after adjusting for age were ferritin ≥1700 ng/ml (HR 3.770, p = 0.014), ratio E/A wave >2 (HR 3.565, p = 0.04), TR Vmax >2.8 m/s (HR 4.541, p = 0.049), CMR T2∗ ≤20 ms (HR 9.462, p = 0.001), and CMR T2∗ ≤34 ms (HR 11.735, p = 0.002). The model including age and T2∗ ≤34 ms instead of T2∗ ≤20 ms was more predictive of the secondary endpoint (C-index 0.844 vs 0.838, respectively).

CONCLUSIONS

In thalassemia patients, TR Vmax >2.8 m/s, ferritin ≥2000 ng/ml, and CMR T2∗ ≤20 ms were associated with worse long-term survival. In the current era of advanced chelation therapy, aiming for ferritin ≤1700 ng/ml and CMR T2∗ ≥34 ms may improve their prognosis.

Left Atrial Strain Identifies Increased Atrial Ectopy in Patients with Beta-Thalassemia Major

Patients with beta-thalassemia major (β-ΤΜ) may develop cardiac arrhythmias through a multifactorial mechanism. The current study evaluated the association of cardiac structure and function on echocardiography with atrial ectopic burden on 24-hour tape recording in β-ΤΜ patients. This prospective study included consecutive β-ΤΜ patients. Demographic, laboratory, echocardiographic, cardiac magnetic resonance (CMR) T2* and 24-hour tape recording data were prospectively collected. The patients were classified according to the median value of premature atrial contractions (PACs) on 24-hour tape. In total, 50 β-TM patients (37.6 ± 9.1 years old, 50% male) were divided in 2 groups; PACs ≤ 24/day and > 24/day. Patients with PACs > 24/day were treated with blood transfusion for a longer period of time (39.0 ± 8.6 vs. 32.0 ± 8.9 years, p < 0.007), compared to their counterparts. Older age (OR: 1.121, 95% CI: 1.032–1.217, p = 0.007), longer duration of blood transfusion (OR:1.101, 95% CI:1.019–1.188, p = 0.014), larger LV end-diastolic diameter (OR: 4.522, 95% CI:1.009–20.280, p = 0.049), higher values of LA peak systolic strain (OR: 0.869, 95% CI: 0.783–0.964, p = 0.008), higher MV E/E′ average (OR: 1.407, 95% CI: 1.028–1.926, p = 0.033) and higher right ventricular systolic pressure (OR: 1.147, 95% CI: 1.039–1.266, p = 0.006) were univariably associated with PACs > 24/day. LA peak systolic strain remained significantly associated with PACs > 24/day after adjusting for the duration of blood transfusions or for CMR T2*. The multivariable model including blood transfusion duration and LA peak systolic strain was the most closely associated with PACs > 24/day. Receiver operating characteristic curve analysis identified a left atrial peak systolic strain of 31.5%, as the best cut-off value (83% sensitivity, 68% specificity) for prediction of PACs > 24/day. In β-TM patients, LA peak systolic strain was associated with the atrial arrhythmia burden independently to the duration of blood transfusions and CMR T2*.

Burnout syndrome among emergency medicine physicians: an update on its prevalence and risk factors

OBJECTIVE

Training in and practising emergency medicine are very stressful conditions that pose a significant emotional burden on physicians, placing them at high risk of developing burnout. The purpose of the current manuscript is to review the published literature on burnout prevalence among emergency medicine physicians and to identify the risk factors associated with its occurrence.

MATERIALS AND METHODS

A search of MEDLINE (January 1980-March 2019) was conducted using the terms "burnout", "emergency", "physicians", "emotional exhaustion", "depersonalization" in various combinations. All studies, which assessed burnout prevalence (as primary or secondary outcome) among emergency medicine physicians and were published as full-text articles in English, were included in the review.

RESULTS

Twenty-seven studies met eligibility criteria. Although the prevalence of burnout among emergency medicine physicians is high, the exact incidence widely varies ranging between 25% and 77.8%, because of the unique characteristics of each population under study, and also due to the different definitions, tools, and cut-offs used for burnout diagnosis. Several work-related parameters (heavy work-load, low job satisfaction, a problematic co-workers relationship, and difficulty in balancing personal with professional life), personality traits and stress-copying methods, life-style parameters, and other mental disorders (such as stress and sleep disorders) are associated with the establishment of burnout.

CONCLUSIONS

Emergency medicine physicians are of a high risk of burnout, although further agreement is needed regarding the use of the Maslach Burnout Inventory as a diagnostic tool. Furthermore, the identification of the potential risk factors for this disorder is crucial so that high-risk groups could be early identified and properly addressed.

An evaluation of selexipag for the treatment of pulmonary hypertension

INTRODUCTION

Selexipag is a first-in-class, oral, long-acting, selective, non-prostanoid agonist of the prostacyclin receptor (IP receptor), indicated for the treatment of symptomatic adult pulmonary arterial hypertension (PAH). It was designed with the objective to surpass the inconveniences associated with standard prostanoid therapy, presenting fewer adverse effects and comparable hemodynamic benefits.

AREAS COVERED

This review describes the pharmacologic properties of selexipag and presents the clinical trials that have been completed or are currently ongoing regarding its clinical efficacy, safety, and tolerability. The pivotal GRIPHON study is extensively presented.

EXPERT OPINION

Selexipag is the first IP receptor to reduce the morbidity/mortality composite endpoint of the GRIPHON study, a large, randomized, placebo-controlled study. The TRITON study failed to demonstrate a clear benefit of initial triple oral therapy including selexipag compared to initial double oral therapy. Current guidelines do not provide definitive recommendations regarding the place of selexipag in the treatment algorithm of PAH. Finally, the possibility of transition between the several drugs acting in the prostacyclin pathway, and the potential role of selexipag in chronic thromboembolic pulmonary hypertension and pediatric PAH is currently being examined, possibly expanding its future use.

Rifampicin-moxifloxacin interaction in tuberculosis treatment: a real-life study

SETTING

Rifampicin (RMP) has been reported to reduce moxifloxacin (MFX) levels, which may interfere with the effectiveness of MFX in treating tuberculosis (TB).

OBJECTIVE

To study the MFX-RMP interaction in patients receiving MFX with or without RMP as part of their anti-tuberculosis treatment regimen.

DESIGN

Patients with pulmonary TB followed up by the Tuberculosis Out-patient Clinic of the Pulmonary Department, Aristotle University of Thessaloniki, Greece, who underwent treatment with MFX during the periods 1 May 2012-30 April 2014 and 1 January-31 March 2015, were included in the study. MFX levels were compared between 12 patients who were receiving RMP (Group 1) and 10 who were not (Group 2).

RESULTS

The participants did not significantly differ in body mass index, days of MFX treatment or MFX dose/kg. Neither the peak concentration (Cmax) nor the 24 h area under the curve (AUC24) differed significantly between the two groups (Group 1, Cmax median 3.9 [range 1.9-4.5] mg/l; AUC24 29.1 [10-47.4] mg·h/l and Group 2, Cmax 4.1 [2-6.4] mg/l; AUC24 36.5 [14.6-54.2] mg·h/l).

CONCLUSION

Although a decrease in MFX exposure was observed in the RMP-treated group, the effect was lower than previously reported in a real-life setting. The large variability observed in MFX pharmacokinetics in both groups may suggest the need for dose readjustment in some patients, regardless of RMP co-administration.

Endobronchial ultrasound: morphological predictors of benign disease

The objective of this study was to assess the utility of endobronchial ultrasound (EBUS) morphology of lymph nodes in predicting benign cytology of transbronchial needle aspirates in a prospective observational study. Five ultrasonic morphological characteristics of mediastinal and hilar lymph nodes were recorded: size, shape, margins, echogenic appearance and the presence of a central blood vessel. These characteristics were correlated with the final diagnosis. A total of 402 consecutive patients (237 males and 165 females) undergoing EBUS were studied. The final diagnosis was malignant disease in 244 (60.6%) and benign disease in 153 (38.05%) subjects. Out of 740 sampled nodes, in 463 (62.6%) malignant cells were identified, whereas in 270 (36.5%) nodes, no malignant cells were identified. On univariate analysis small size, triangular shape and the presence of a central vessel were predictive of a benign aetiology. In the final multivariate model, a predictive probability of 0.811 (95% CI 0.72-0.91) for benign disease was found if lymph node size was <10 mm and a central vessel was present. Sonographic appearances of lymph nodes improve the predictive probability of EBUS for benign aetiologies, and may reduce the number of nodes requiring sampling and the need for further invasive investigations.

Chronic thromboembolic pulmonary hypertension: do not miss the chance for an early diagnosis

BACKGROUND

Chronic thromboembolic pulmonary hypertension most often results from obstruction of the pulmonary vascular bed by nonresolving thromboemboli. Misdiagnosis of the disease is common because patients often present with subtle or nonspecific symptoms. Furthermore, some features in chest imaging may mimic parenchymal lung disease. The most clinically important mimic in high-resolution chest tomography is air trapping, which can be seen in a variety of small airway diseases.

CASE REPORT

We present the case of a 45-year-old woman with a long history of dyspnea and exercise intolerance, misdiagnosed with allergic alveolitis. The diagnosis of CTEPH was finally established with computed tomography (CT) angiography and hemodynamics.

CONCLUSIONS

Chronic thromboembolism is under-diagnosed and also frequently misdiagnosed in clinical practice. The present report aims to increase the awareness of clinicians towards an accurate diagnosis of the disease, which is necessary for the early referral of CTEPH patients for operability.

Repeated episodes of respiratory failure due to bilateral vocal cord paralysis

BACKGROUND

Bilateral vocal cord paralysis can produce severe airway obstruction, leading to acute respiratory failure. Discriminating the pathology of the upper airway from chronic obstructive diseases of the lower airways often presents a challenge for clinicians in the Emergency Department.

OBJECTIVES

To underlie the value of clinical examination and flow-volume loops in the establishment of diagnosis of upper airway obstruction.

CASE REPORT

We describe the case of a 55-year-old female ex-smoker who presented with a long history of hoarseness and progressive exertional dyspnea. The patient developed repeated episodes of acute respiratory failure and was supported with noninvasive ventilation. The diagnosis of bilateral vocal cord paralysis was finally established by patient's symptoms and flow-volume loops demonstrating variable extrathoracic obstruction.

CONCLUSION

Vocal cord paralysis is a rare and often neglected condition, contributing to repeated episodes of acute respiratory failure. Flow-volume loop is a useful tool when symptoms are suggestive of upper airway obstruction.

A case of pulmonary veno-occlusive disease: diagnostic dilemmas and therapeutic challenges

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary hypertension (PH). Misdiagnosis of the disease is common since PVOD presents with clinical and radiographic features mimicking idiopathic pulmonary arterial hypertension or even PH due to interstitial lung disease. Vasodilators may not be efficacious in PVOD and may in fact worsen hemodynamic status with the development of pulmonary edema. Lung transplantation represents the best treatment option. In the present report we describe the challenging diagnosis of PVOD in a patient with PH referred to our department. Final diagnosis was established by surgical lung biopsy. The patient was offered sequential combination therapy under close monitoring and maintained remarkable clinical stabilization while being on the waiting list for lung transplantation.

Lemierre's syndrome presenting to the ED: rapidly fatal sepsis caused by methicillin-susceptible Staphylococcus aureus Staphylococcus protein A type t044

We describe the case of a fatal septic illness in a previously healthy young man caused by community-acquired methicillin-susceptible Staphylococcus aureus of Staphylococcus protein A (spa) type t044. The patient developed a devastating Lemierre-like syndrome with extensive thrombosis of inferior vena cava and iliac veins with multiple metastatic septic emboli of the lungs. He presented to the emergency department with rapidly progressing sepsis followed by multiple organ dysfunction syndrome. Recognition of such virulent community-acquired strains is of great importance because they could prove to be emerging pathogens for life-threatening diseases.

Haemarthrosis after superwarfarin poisoning

INTRODUCTION

Superwarfarins are widely used as rodenticides. They are similar to warfarin, but they are more potent and act longer. In case of poisoning, they cause severe bleeding, usually from multiple sites.

CASE REPORT

A 67-yr-old man was admitted with melaena, epistaxis and haemarthrosis in his left knee. PT, INR and aPTT were markedly increased. Initially, the patient was treated with blood and fresh frozen plasma (FFP) transfusions. However at the second day, PT, INR and aPTT were even worse. The combination of persistent coagulopathy, normal mixing studies, normal liver function tests and absence of hepatic failure or malabsorption syndromes lead to the suspicion of vitK dependent clotting factors deficiency due to superwarfarin poisoning. Indeed, the patient admitted a suicide attempt with rodenticide, although he had previously denied it. Psychiatric evaluation revealed a disturbed personality. Melaena stopped after 7 d. Then, the patient was administered 30 mg of vitK daily for a total period of 4 months.

CONCLUSIONS

Superwarfarin poisoning leads to severe bleeding, usually from multiple sites. Prolonged treatment with high doses of vitK is necessary. Haemarthrosis, as a complication of superwarfarin poisoning, is presented here for the first time in literature.