Knee pain is a common clinical complaint with a broad differential diagnosis. In critically ill patients, acute monoarticular pain and swelling typically raise concern for septic arthritis. However, alternative etiologies such as crystal-induced arthritis, trauma, and hemarthrosis must also be considered.

This report presents a rare case of spontaneous hemarthrosis in a patient receiving prophylactic enoxaparin. Although uncommon, spontaneous hemarthrosis is a significant complication of anticoagulation therapy, particularly with low molecular weight heparins (LMWH) like enoxaparin.

Stroke remains a major cause of death and disability, highlighting the intimate relationship between cardiovascular and cerebrovascular disease. Despite substantial advances in diagnosis and treatment, marked disparities in access to care and clinical outcomes continue to exist. As such, stroke remains a shared challenge for primary care physicians, cardiologists, and neurologists, emphasizing the need for effective prevention, timely intervention, structured rehabilitation, and optimal secondary prevention. In this issue, we feature the Executive Summary of the 2024 Clinical Practice Guidelines on the Management of Acute Ischemic Stroke and Intracerebral Hemorrhage in the Philippines, an important resource for promoting evidence-based, patient-centered care and improving stroke outcomes.

INTRODUCTION

Stroke is the leading cause of disability worldwide and remains a major cause of death among Filipinos. Despite being the most common neurological disease, wide variations in management persist among clinicians. This CPG aims to provide evidence-based recommendations for the diagnosis and management of acute stroke.

A systematic synthesis of evidence was conducted to address the diagnosis and management of both acute hemorrhagic and ischemic stroke. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was followed. The process included: (1) generation of critical questions and outcomes (2) retrieval of current and relevant evidence, (3) synthesis and appraisal of the evidence base, (4) formulation of draft recommendations, (5) deliberation by a multi-sectoral stakeholder panel on feasibility, values and preferences to assess the strength of recommendations and (6) planning for dissemination, implementation, impact evaluation and updating.

Sixteen clinical questions were addressed leading to 21 recommendations. Most were strong recommendations supported by moderate to high certainty of evidence. The recommendations span the spectrum of acute stroke care, including early diagnosis with imaging, admission to stroke units, reperfusion therapies, surgical options, prevention of complications and the role of adjunctive treatments.

The recommendations in this CPG are intended to guide clinicians and other stakeholders in the diagnosis and management of acute stroke. They are meant to supplement, not replace, the sound clinical judgment of healthcare providers.

INTRODUCTION

Dual antiplatelet therapy (DAPT) with aspirin plus P2Y12 receptor inhibitor has become a cornerstone in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI) for the prevention of stent thrombosis. However, aspirin intolerance poses a problem in the lack of guideline-based alternatives with proven benefit. In this study, we aim to determine the efficacy and safety of cilostazol-based DAPT as an alternative treatment for aspirin among patients undergoing PCI.

A comprehensive literature search was performed. All studies that investigated cilostazol as an alternative to aspirin on top of P2Y12 inhibitors for patients undergoing PCI were included. Outcomes of interest in this meta-analysis were reduction of major adverse cardiovascular events (MACE) and bleeding.

Three cohort studies including 1,227 patients on cilostazol and 1,480 on aspirin, both with a P2Y12 inhibitor were analyzed. Pooled estimates showed no significant difference in MACE (OR 1.32, 95% CI 0.79–2.23; p = 0.29) or acute myocardial infarction (OR 0.94, 95% CI 0.46–1.89; p = 0.85) between groups. However, cilostazol-based DAPT was associated with significantly less bleeding (OR 0.52, 95% CI 0.27–0.99; p = 0.05). All outcomes were statistically homogeneous (p>0.1, I²CONCLUSION

Cilostazol compared to aspirin, both on top of a P2Y12 receptor inhibitor, is as efficient in the reduction of MACE and acute myocardial infarction; and even safer in terms of bleeding. Cilostazol-based DAPT may serve as an alternative to standard DAPT among aspirin-intolerant patients undergoing PCI.

Stroke remains a major cause of death and disability, highlighting the intimate relationship between cardiovascular and cerebrovascular disease. Despite substantial advances in diagnosis and treatment, marked disparities in access to care and clinical outcomes continue to exist. As such, stroke remains a shared challenge for primary care physicians, cardiologists, and neurologists, emphasizing the need for effective prevention, timely intervention, structured rehabilitation, and optimal secondary prevention. In this issue, we feature the Executive Summary of the 2024 Clinical Practice Guidelines on the Management of Acute Ischemic Stroke and Intracerebral Hemorrhage in the Philippines, an important resource for promoting evidence-based, patient-centered care and improving stroke outcomes.

INTRODUCTION

Stroke is the leading cause of disability worldwide and remains a major cause of death among Filipinos. Despite being the most common neurological disease, wide variations in management persist among clinicians. This CPG aims to provide evidence-based recommendations for the diagnosis and management of acute stroke.

A systematic synthesis of evidence was conducted to address the diagnosis and management of both acute hemorrhagic and ischemic stroke. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was followed. The process included: (1) generation of critical questions and outcomes (2) retrieval of current and relevant evidence, (3) synthesis and appraisal of the evidence base, (4) formulation of draft recommendations, (5) deliberation by a multi-sectoral stakeholder panel on feasibility, values and preferences to assess the strength of recommendations and (6) planning for dissemination, implementation, impact evaluation and updating.

Sixteen clinical questions were addressed leading to 21 recommendations. Most were strong recommendations supported by moderate to high certainty of evidence. The recommendations span the spectrum of acute stroke care, including early diagnosis with imaging, admission to stroke units, reperfusion therapies, surgical options, prevention of complications and the role of adjunctive treatments.

The recommendations in this CPG are intended to guide clinicians and other stakeholders in the diagnosis and management of acute stroke. They are meant to supplement, not replace, the sound clinical judgment of healthcare providers.

INTRODUCTION

Dual antiplatelet therapy (DAPT) with aspirin plus P2Y12 receptor inhibitor has become a cornerstone in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI) for the prevention of stent thrombosis. However, aspirin intolerance poses a problem in the lack of guideline-based alternatives with proven benefit. In this study, we aim to determine the efficacy and safety of cilostazol-based DAPT as an alternative treatment for aspirin among patients undergoing PCI.

A comprehensive literature search was performed. All studies that investigated cilostazol as an alternative to aspirin on top of P2Y12 inhibitors for patients undergoing PCI were included. Outcomes of interest in this meta-analysis were reduction of major adverse cardiovascular events (MACE) and bleeding.

Three cohort studies including 1,227 patients on cilostazol and 1,480 on aspirin, both with a P2Y12 inhibitor were analyzed. Pooled estimates showed no significant difference in MACE (OR 1.32, 95% CI 0.79–2.23; p = 0.29) or acute myocardial infarction (OR 0.94, 95% CI 0.46–1.89; p = 0.85) between groups. However, cilostazol-based DAPT was associated with significantly less bleeding (OR 0.52, 95% CI 0.27–0.99; p = 0.05). All outcomes were statistically homogeneous (p>0.1, I²CONCLUSION

Cilostazol compared to aspirin, both on top of a P2Y12 receptor inhibitor, is as efficient in the reduction of MACE and acute myocardial infarction; and even safer in terms of bleeding. Cilostazol-based DAPT may serve as an alternative to standard DAPT among aspirin-intolerant patients undergoing PCI.

RATIONALE/OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) may be associated with meteorologic factors in temperate countries. The authors aimed to investigate the relationship between meteorologic factors and aSAH admissions in the Philippines, a tropical country with two seasons: rainy and dry.

A census review of aSAH admissions from 2015 to 2019 at a tertiary hospital was performed. Meteorologic data were collected for the same time period, and statistical analysis was performed.

A total of 660 patients were admitted for aSAH, 275 and 385 during the rainy and dry seasons, respectively. August and October had the greatest number of mean admissions (13.2) while February had the least (6.2). There was a moderate positive correlation between aSAH admissions and mean temperature. Negligible to weak negative correlations were seen between aSAH admissions and humidity, barometric pressure and precipitation. However, there was no correlation on regression analysis.

There were no significant differences in aSAH admissions between rainy and dry seasons. The authors found an increase in aSAH admissions during months with higher temperatures and HI, and weak to negligible negative correlations between aSAH admissions and humidity, barometric pressure, and precipitation. These findings may inform health care facilities in terms of readiness for aSAH admissions.

Systemic Lupus erythematosus (SLE) is a multiorgan autoimmune disease that affects 20-150 per 100,000 women. It is a mutagenic disease which causes formation of autoantibodies immune complexes that leads to inflammation in different organs leading to organ damage. We present a case of a young female who was newly diagnosed to have SLE. She presented with an elevated ANA, low C3 and elevated Anti-DS DNA. She first manifested with epistaxis and subsequently experienced the various complications of SLE such as infection, thrombosis, bleeding, ascites, etc. The initial presentation of normochromic, normocytic anemia and thrombocytopenia together with further work-ups supported another concomitant autoimmune disease, namely Evan’s syndrome. Evan’s syndrome is a rare manifestation of SLE, and is observed in only 2.73% of the population. In addition, the patient manifested with sudden onset of right-sided body weakness with Cranial CT scan findings of areas of focal infarction in the frontal lobe with concomitant acute intracranial hemorrhages. The evidence of both thrombosis and hemorrhage provided conflicting management strategies for this patient. The use of hydroxychloroquine, which is the cornerstone of lupus therapy, provided beneficial antithrombotic effects. A multidisciplinary approach to management and prudent choice of medications were vital in the success of treatment on such a complicated case.

The introduction of non-vitamin K antagonist oral anticoagulant (NOAC) into clinical use heralds a new age for anticoagulation therapy in patients with atrial fibrillation (AF).However,anticoagulation-related bleeding is currently a major challenge in the anticoagulation process.Assessing the risk of anticoagulation-related bleeding is an important part for the management of patients with AF.Clinical risk factor scores have moderate ability to predict the risk of anticoagulation-related bleeding.To improve the anticoagulation safety of NOACs,additional clinical and biological markers and genetic polymorphisms should be considered to enhance the predictive capability for anticoagulation-related bleeding.This review summarizes the challenges in the management of anticoagulation therapy,with emphases on the bleeding risk scores,biomarkers,clinical indicators,and genetic loci currently used to guide the risk assessment of anticoagulation-related bleeding in AF patients.This review is expected to provide research insights and reference frameworks for predicting and evaluating the bleeding risk associated with NOACs.
Humans ; Atrial Fibrillation/drug therapy* ; Anticoagulants/therapeutic use* ; Hemorrhage/chemically induced* ; Risk Assessment ; Administration, Oral ; Risk Factors