Muhammad umer khan

and 3 more

INTRODUCTION: Paroxetine is an antidepressant belonging to the class of SSRI. It is used in multiple psychiatric disorders including depression, anxiety and obsessive-compulsive disorder. Apart from being very efficacious, it causes some adverse effects too and hyponatremia is one of them. The association between the two is not well established, which makes this case worth of attention. CASE PRESENTATION: A 52 years old male hypertensive patient was brought to the ER after having an episode of seizure. Hyponatremia due to an unknown cause was made a provisional diagnosis. He was then referred to the psychiatric department for further assessment, where his detailed history was taken and mental state examination was performed. The patient was found to be suffering from chronic depression. The patient has been taking a combination of antipsychotics and antidepressants for this condition. Paroxetine, Olanzapine and Quetiapine were prescribed to him by his psychiatrist 10 years back, and since then he was taking it daily. His current medication was then immediately altered and paroxetine was replaced by mirtazapine. DISCUSSION/ CONCLUSION: Numerous studies have been done on the effects of SSRIs, but very few of them mentioned their association with hyponatremia. Electrolyte imbalances are common with many medications including antiepileptic and antidepressant drugs as well. Although some literature has shown the link between the two, drug induced hyponatremia remained one of the rarest adverse effect. In summary, paroxetine is very effective in the management of depression but its long-term use could result in an electrolyte imbalance in hypertensive patients

Sandhya Kumari

and 1 more

Title Page:Title : Letter To the Editor: Outcomes of Preoperative Antiplatelet Therapy in Patients With Acute Type A Aortic DissectionArticle Type : Letter To The EditorCorrespondence : 1. Sandhya KumariContact no: +92-3321346164 Email: [email protected]: Ziauddin University KarachiAddress: Bungalow Number 7/2, 26th Street, Tauheed Commercial Area, Phase 5 Defence Karachi.ORCID: 0000-0001-8842-8738Co-Author : 2. Roomi RajaContact No: +92-3342946940 Email: [email protected]: Ziauddin University KarachiAddress: Hemilton Courts Block G-1 Flat 408 Near Teen Talwar Clifton KarachiORCID: 0000-0001-9104-3644Word Count : 340Conflict of interest : NoneAcknowledgement : NoneDeclaration : NoneDisclosure : NoneFunding : NoneDear Editor,We have, in recent times, read with great interest the article entitled “ Outcomes of Preoperative Antiplatelet Therapy in Patients With Acute Type A Aortic Dissection” by Xuan Jiang MD et al.1 We highly appreciate the author’s efforts towards this highly sensitive topic and it needs to be applauded by the readers.We acknowledge the primary conclusion of the article that patients receiving antiplatelet therapy before having surgery for acute type A aortic dissection is associated with increased mortality and increased need for blood transfusions. However, some concerns appear, disturbing the validity of the study.Even though the authors have highlighted the use of multiple different antiplatelet drugs before the surgery such as ticagrelor, clopidogrel and aspirin, there remains some factors that made an impact on the findings. Firstly, the authors should have considered the patients who are on Dual antiplatelet therapy because mortality and blood transfusion rate in patients using dual antiplatelet therapy is higher as compared to a single antiplatelet drug user.2 Secondly, the authors should have widened their inclusion criteria and could have included patients with preoperative characteristic such as cardiac tamponade and lower systolic blood pressure, like the study of 2014 included these two as variables and found increased prevalence of mortality associated with these variables.3Thirdly, the authors should have classified the patients using Debakey class 1,2 and Penn class A,B,C classifications. For example, a study in 2019 stated that the patients who experienced major bleeding were associated with Debakey class 1 and higher Penn class.4 Lastly, the authors should have taken into consideration some measures while transferring a patient to the ICU to minimize the mortality rate. For example, a study of 2022 stated that patients on new oral anticoagulants required norepinephrine and other inotropic agents while transferring to ICU as compared to patients taking warfarin (Coumadin).5In last, additional new studies should be conducted on patients receiving antiplatelet therapy before undergoing mitral valve surgery so that incidents leading to mortality goes down and prognosis becomes better.References:1- Jiang X, Khan F, Shi E, Fan R, Qian X, Zhang H, Gu T. Outcomes of preoperativeantiplatelet therapy in patients with acute type A aortic dissection. J Card Surg. 2022Jan;37(1):53-61. doi: 10.1111/jocs.16080. Epub 2021 Oct 17. PMID: 34657299.2- Chemtob RA, Moeller-Soerensen H, Holmvang L, Olsen PS, Ravn HB. OutcomeAfter Surgery for Acute Aortic Dissection: Influence of Preoperative AntiplateletTherapy on Prognosis. J Cardiothorac Vasc Anesth. 2017 Apr;31(2):569-574. doi:10.1053/j.jvca.2016.10.007. Epub 2016 Oct 11. PMID: 28017673.3- Hansson EC, Dellborg M, Lepore V, Jeppsson A. Prevalence, indications andappropriateness of antiplatelet therapy in patients operated for acute aortic dissection:associations with bleeding complications and mortality. Heart. 2013 Jan;99(2):116-21. doi: 10.1136/heartjnl-2012-302717. Epub 2012 Oct 9. PMID: 23048167.4- Hansson EC, Geirsson A, Hjortdal V, Mennander A, Olsson C, Gunn J, et al.Preoperative dual antiplatelet therapy increases bleeding and transfusions but notmortality in acute aortic dissection type a repair [Internet]. OUP Academic. OxfordUniversity Press; 2019: doi: org/10.1093/ejctz/ezy469. Epub 2019 january 16.5- Sromicki J, Van Hemelrijck M, Schmiady MO, Krüger B, Morjan M, Bettex D, VogtPR, Carrel TP, Mestres CA. Prior intake of new oral anticoagulants adversely affectsoutcome following surgery for acute type A aortic dissection. Interact CardiovascThorac Surg. 2022 Jun 15;35(1):ivac037. doi: 10.1093/icvts/ivac037. PMID:35258082; PMCID: PMC9252133.