Coronary intravascular brachytherapy for in-stent restenosis: A review of the contemporary literature.

Intracoronary stent restenosis (ISR) is a clinically relevant challenge in the modern era. Heterogeneity in patient- and lesion-specific factors can further compound this clinical challenge. Coronary intravascular brachytherapy (IVBT) was the standard therapeutic approach for ISR prior to the advent of drug-eluting stents (DES). Despite prospective data describing the superiority of DES over IVBT for treating de novo ISR, IVBT remains a treatment option for patients with complex disease. The purpose of this review is to evaluate the historical and contemporary literature surrounding IVBT in order to elucidate its role in modern cardiac care and to describe opportunities for future investigations to improve patient selection. Herein, we provide a review of the contemporary literature describing IVBT as a safe and effective treatment option for patients with recurrent, refractory ISR after multilayer DES and no good surgical or mechanical option. Combination therapy with emerging technologies such as DCBs may further increase efficacy.

Elderly suicide with and without a history of suicidal behavior: implications for suicide prevention and management.

This study examined the impact of a history of suicidal behavior on suicide among elderly people in Singapore. In this coroner register-based study, characteristics of 409 elderly people who died of suicide in Singapore between 2000 and 2004 were examined. Sixty-five people were classified with a history of previous suicidal behavior and 344 people without a history of suicidal behavior. Elderly people who died of suicide and had a past history of suicidal behavior were more likely to suffer from major psychiatric disorders (26.2% vs 10.2%, p = 0.001), encounter social problems in life (33.9% vs 21.5%, p = 0.038), have alcohol detected in the blood toxicology report at autopsy (23.1% vs. 12.8%, p = 0.036), receive psychiatric treatment in the past (60% vs. 37.5%, p < 0.001), have antidepressant detected in the blood toxicology report at autopsy (16.9% vs. 8.1%, p = 0.037), and be admitted to a mental hospital under the mental health legislation (36.9% vs. 11.6%, p < 0.001). Conversely, those without a past history of suicidal behavior were more likely to have a pre-suicidal plan for the fatal suicide act (11.1% vs. 1.5%, p = 0.011) and have received medical or surgical treatment in the past (22.1% vs. 9.2%, p = 0.018). For suicide prevention in Asians, psychiatrists should aggressively treat major psychiatric disorders, engage social services to resolve social problems in elderly people with a history of suicidal behavior, and reduce access to alcohol. Clinicians working in medical or surgical departments should routinely screen for suicide plans in elderly patients without a past history of suicidal behavior.

Pulmonary hypertension in first episode infective endocarditis among intravenous buprenorphine users: case report.

BACKGROUND: Since the Food and Drug Administration (FDA) approved the use of buprenorphine hydrochloride (Subutex) for the treatment of opiate dependence in 2002, there has been a global trend of its IV abuse which led to life-threatening medical complications such as infective endocarditis (IE), cardiac failure, and death. METHODS: First episode IE were identified in 14 patients (prevalence of 10.8%) among 130 IV buprenorphine abusers who presented to the National University Hospital, Singapore between 2004 to 2006. The variables that were examined in the present study included age, gender, ethnicities, duration of symptoms, types of valves, laboratory, microbiology, echocardiographic features, types of antibiotics given, duration of hospitalization, and the mortality rate. RESULTS: While the majority of these patients presented predominantly with pleuropneumonic symptoms and had tricuspid-valve vegetations with Staphylococcus aureus being the commonest causative organism as reported in other IV drug abusers, pulmonary arterial hypertension (PHT) seemed peculiarly common (79%), and the mortality (21%) was higher in our patients compared to previously reported series (5-10%). Univariate linear regression revealed no relationship between PHT and the presence of septic pulmonary emboli (p =.284) and pulmonary embolism (p =.777). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: PHT may contribute to morbidity and mortality amongst IV buprenorphine abusers. A high index of suspicion of PHT is required in treating IV buprenorphine abusers who presented with pleuropneumonic symptoms. The absence of a relationship between PHT and pulmonary embolism underscores the possibility of the contribution of buprenorphine to PHT, which have been demonstrated in a number of animal studies.

Cutaneous complications among i.v. buprenorphine users.

i.v. buprenorphine hydrochloride (Subutex) misuse has been creating a number of medical complications, and cutaneous manifestations such as soft tissue infection are one of the commonest consequences. Between January 2004 and December 2006, amongst 130 i.v. buprenorphine abusers who presented to the National University Hospital, Singapore, cutaneous complications were identified in 45 patients (prevalence, 31%) with cellulitis and skin abscess being the commonest complications. Tissue and blood culture were positive in 19 (42%) patients and Methicillin-sensitive Staphylococcus aureus was the commonest microbiological isolate (20%). Univariate linear regression revealed significant relationships between body temperature (P = 0.03), heart rate (P = 0.02), respiratory rate (P < 0.001), total peripheral white cell count (P = 0.011), absolute neutrophil count (P < 0.001) and serum C-reactive protein (CRP) level (P < 0.001) on admission and through the duration of hospitalization. In multivariate analysis, respiratory rate on admission remained significantly associated with longer duration of hospitalization (P = 0.01). i.v. cloxacillin, i.v. crystallized penicillin and oral cloxacillin were the most commonly prescribed antibiotics while 11 (24%) patients required surgical treatment. The mean duration of hospitalization was 8 +/- 11 days and repeated cutaneous complications occurred in eight (18%) patients. In conclusion, cutaneous complications are common among i.v. buprenorphine users. Respiratory rates on admission predict duration of hospital stay. A high index of suspicion coupled with a correct choice of antibiotics based on local bacteriological surveillance is necessary in an attempt to reduce cutaneous complications and length of hospitalization.