Background: Cavernous Sinus Thrombosis (CST) is a rare and life-threatening condition with antibiotics as the mainstay of therapy for those due to infection. While controversy exists, recent retrospective reviews using anticoagulation reveal potential mortality reduction with a low risk of adverse events such as intracranial hemorrhage (ICH). The optimal timing and duration of treatment are unknown. The Case: We report a 32-year-old female who presented with fever, headache, complete bilateral ophthalmoplegia, cellulitis, and a cranial MRV diagnostic of CST. She received antibiotics targeted to MRSA organisms isolated from eye and blood specimen. Further, into the course, the patient had an onset of aphasia and right-sided hemiplegia. Workup revealed multiple cranial infarcts with narrowing of the left internal carotid artery, likely representing thrombus as the source of embolism. The decision to anticoagulate was reevaluated and subsequently started. The patient was reassessed clinically after two months to have improved motor strength and speech return; thus, anticoagulation was discontinued. Discussion: Although data are lacking, most recent reports favor the use of anticoagulation. Some authors recommend initiation in patients with deteriorating neurologic status despite antibiotics and hydration. The higher frequency of ICH in anticoagulated CST patients with CNS infection is a basis for some authors to withhold treatment. The treatment duration varies with different studies, generally ranging from several weeks to three months or more. Conclusion Further studies are needed to define the exact role of anticoagulation, particularly its timing and duration. Nevertheless, timely identification of the condition and constant re-evaluation are critical to early patient recovery.
Duration of Therapy

Background and Objective: Physician adherence to the recommended management of patients with heart failure with reduced ejection fraction (HFrEF) at the outpatient setting is crucial to reduce the burden of subsequent rehospitalization, morbidity, and mortality. Recently updated guidelines recommend early and rapid titration to optimal doses of medications in the first 2 to 6 weeks of discharge. In the absence of local data, our study evaluates physician adherence to guideline-recommended treatment in this setting. Methods: This is a retrospective cross-sectional study among post-discharge HFrEF patients at the outpatient department from December 2022 to May 2023 with a follow-up within three months. Clinical profile and treatment were extracted from medical records. Adherence to the 2021 ESC Guidelines Class I recommendations, among eligible patients, is measured as quality indicators. Data are presented using descriptive statistics. Results: A total of 99 patients were included in the study. Overall, adherence to prescription of beta-blockers (94.8%), ACEI/ARNI/ARBs (88.5%), and diuretics (100%) were high. Prescription of mineralocorticoid receptor antagonists (MRA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) were 67% and 57.3%, respectively. Over three months of follow-up, improvement in the quality of care was demonstrated with ACEI/ARNI/ARBs (81.8% to 90.9%), MRA (68.7 to 81.2%), and SGLT2i (58% to 67.7%). Beta-blocker use is consistently high at 97%. In the 3rd month post-discharge, titration to optimal doses was achieved in only 26.4%, 15%, and 6.25% for those on beta-blockers, ACEI/ARNI/ARB, and MRA, respectively. For non-pharmacologic management, referral to HF specialty was made in 30% and cardiac rehabilitation in 22.2%. Conclusion Among patients with HFrEF seen at the outpatient, there is good physician adherence to betablockers, ACEI/ARNI/ARBs, and diuretics. MRA and SGLT2i prescription, referral to HF specialty and cardiac rehabilitation, and up-titration to optimal doses of oral medications for HF need improvement. Hospital pathway development and regular performance evaluation will improve initiation, maintenance, and up-titration of appropriate treatment.
Human ; outpatients