An Australian experience of retrievable inferior vena cava filters in patients with increased risk of thromboembolic disease

AIM

Pulmonary embolism (PE) is a common cause of death and morbidity. Anticoagulant therapy reduces the risk of PE but is associated with bleeding. Inferior vena caval (IVC) filters protect against PE but have an increased long term risk of deep vein thrombosis (DVT). Temporary IVC filters allow protection against PE during high risk situations and may be later removed avoiding the need for long term anticoagulation.

METHODS

We present our experience with the Recovery (Bard, Tempe, AZ) and Tulip (Cook, Bloomington, IN) optionally retrievable filters.

RESULTS

Retrievable filters were planned for 121 patients. Mean age: 58.8 years; 72 male. The indications included: Established venous thromboembolism (VTE) and contraindication to anticoagulation; high risk of VTE and need for surgery with high risk of bleeding; VTE extension despite anti-coagulation. A retrievable filter was placed without significant incident in 113 patients. There were two proven cases of PE. In total there were 27 deaths of patients during the period of their follow up. There was 1 death related to confirmed filter migration. There was 1 sudden unexplained death in a patient with suspected malignancy. Filter removal was attempted in 58 cases at a mean of 44 days and was performed successfully in 52. Thromboembolus was found in the retrieved filter in 30 cases but did not prevent removal in 29.

CONCLUSION

Retrievable IVC Filters are safe and effective in preventing PE in high risk patients. We have demonstrated success in retrieving filters up to 182 days following insertion, avoiding the need for long term anticoagulation.

Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach

There is poor agreement on definitions of different phenotypes of preschool wheezing disorders. The present Task Force proposes to use the terms episodic (viral) wheeze to describe children who wheeze intermittently and are well between episodes, and multiple-trigger wheeze for children who wheeze both during and outside discrete episodes. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting beta(2)-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitisation has been established. Maintenance treatment with inhaled corticosteroids is recommended for multiple-trigger wheeze; benefits are often small. Montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Large well-designed randomised controlled trials with clear descriptions of patients are needed to improve the present recommendations on the treatment of these common syndromes.

Awareness of risk factors amongst first degree relative patients with colorectal cancer

BACKGROUND

The association between family history of colorectal cancer (CRC) in first degree relatives (FDRs) and the risk of developing the disease has been well established. However, little is known about the degree of awareness of CRC risk factors amongst FDRs. This study examined awareness of familial, dietary and lifestyle risk amongst FDRs.

METHOD

Consent to approach relatives was obtained from CRC patients who attended outpatients following surgery for CRC. A study specific questionnaire was sent by post to their FDRs. The dietary and lifestyle risk factors tested in the questionnaire were those promoted in CRC educational material.

RESULTS

One hundred and four questionnaires were returned out of 137 sent (76%). Fifty-nine per cent (n = 61) of FDRs were aware of their increased risk. Fifty-five per cent (n = 57) were aware of the link between CRC and smoking; however, knowledge of association of CRC with excessive alcohol consumption (32%) and lack of exercise (40%) was less well appreciated. Higher awareness scores were obtained by those with a university education (P < 0.001). Ninety four per cent believed that relatives of CRC patients were not provided with enough information as to their being at risk and risk factors.

CONCLUSIONS

This study provides an initial assessment of the awareness of CRC risk factors in a population at increased risk. It demonstrates a poor level of knowledge. Improved education strategies allowing FDRs to make dietary and lifestyle modifications that could reduce their lifetime risk of developing CRC are necessary.

Evidence supporting nutritional interventions for persons in early stage Alzheimer's disease (AD)

The purpose of this paper is to grade research evidence supporting nutritional interventions for persons with early stage dementias and to report the recommendations of a consensus panel. Thirty four studies were reviewed in the areas of dietary restriction, antioxidants, and Mediterranean diet with strong support from epidemiological studies found in all three areas. The body of evidence to support nutritional interventions in the prevention and treatment of AD is growing and has potential as a treatment modality following translational studies.

Chronic exposure to schistosome eggs reduces serum cholesterol but has no effect on atherosclerotic lesion development

Previous studies have shown that people infected with schistosomiasis have lower levels of serum cholesterol than uninfected controls. To better understand the impact of this parasitic infection on serum cholesterol levels and on atherosclerotic lesion development induced by hypercholesterolemia, apolipoprotein E (ApoE)-deficient mice were chronically exposed to the eggs of Schistosoma mansoni over a period of 16 weeks. Total serum cholesterol and low-density lipoprotein (LDL) were reduced in egg-exposed ApoE-deficient mice fed a diet high in cholesterol compared to unexposed controls. However, exposure to eggs had no effect on atherosclerotic lesion size or progression in ApoE-deficient mice. Macrophages isolated from egg-exposed mice had an enhanced ability to take up LDL but not acetylated LDL (acLDL). This study suggests that schistosome eggs alone may alter serum lipid profiles through enhancing LDL uptake by macrophages, but these changes do not ultimately affect atherosclerotic lesion development.

Cyclooxygenase-2 expression and its association with increased angiogenesis in human abdominal aortic aneurysms

Although the mechanism whereby non-steroidal anti-inflammatory drugs may reduce abdominal aortic aneurysm (AAA) development is unknown, one potential route is via inhibition of the cyclooxygenase (COX) enzyme. Despite the fact that evidence from animal models suggests a role for the COX-2 isoform in promotion of AAA development, only very limited data exist on COX-2 expression in human AAAs. Semiquantitative immunohistochemistry for COX-2 was performed on a series of formalin-fixed, paraffin-embedded human AAAs (n = 49). Associated clinicopathological data, including the degree of inflammatory cell infiltration and neorevascularization, were obtained. COX-2 protein was detected in 46 of 49 (94%) human AAAs. Expression of COX-2 protein varied widely between AAAs. COX-2 protein localized to cells in the inflammatory infiltrate with a morphology characteristic of macrophages. COX-2 expression increased with the extent of inflammatory cell infiltration (P < 0.001) and with the degree of AAA neorevascularization (P < 0.001). Logistic regression analysis identified neorevascularization (P < 0.001) as the only significant independent predictor of COX-2 positivity in human AAAs. COX-2 protein is present at increased levels in the majority of human AAAs and is expressed by mononuclear cells in the inflammatory cell infiltrate. Promotion of angiogenesis by COX-2 may play a role in AAA development.

Monitoring change in diabetes care using diabetes registers--experience from divisions of general practice

BACKGROUND

The quality of care for patients with type 2 diabetes has been the subject of a number of government initiatives over the past decade. General practice has an especially important role in diabetes care.

METHODS

The National Integrated Diabetes Program was introduced in 2001. Changes in the frequency of assessment and the physiological markers of diabetic control were assessed in a cohort of 2731 patients with type 2 diabetes from 16 general practice diabetes registers during 2000-2002.

RESULTS

Frequency of assessment was better in patients living in low socioeconomic postcodes but did not change significantly over the 3 years. There were improvements in intermediate outcomes (HbA1c, systolic and diastolic blood pressure, lipid levels) over the period.

DISCUSSION

These data provide a benchmark for improvement in the quality of diabetes care in general practice.

Faecal corticosteroid levels as an indicator of well-being in the tammar wallaby, Macropus eugenii

Faecal corticosteroid levels were measured in five female tammar wallabies, Macropus eugenii, at Macquarie University, NSW, Australia, to assess their reliability as indicators of well-being in this species. Animals were challenged with a change in conditions over the course of approximately 1 week, comprising movement from group yards to isolation in individual yards, in order to impose a disturbance to homeostasis ("stress"). Faecal samples were collected in 24-h intervals during the study period and analysed for corticosteroid concentration. The use of enzyme immunoassay for the measurement of corticosteroids in marsupial faecal pellets was validated. We observed a significant increase in faecal corticosteroids upon isolation and movement. Faecal corticosteroids remained above initial levels in all five animals throughout the study period, suggesting that faecal corticosteroid concentrations may be a useful indicator of a change in animal well-being. Faecal corticosteroid levels did not correlate with serum cortisol levels, implying that the use of noninvasive methods in a representative marsupial, the tammar wallaby, has the potential to provide information that is not readily apparent using blood-based protocols. Faecal corticosteroid analysis therefore has the potential for application in monitoring the well-being of captive and managed marsupial populations, as part of an integrated system of measures of animal health and well-being.

Are serum cortisol levels a reliable indicator of wellbeing in the tammar wallaby, Macropus eugenii?

Serum corticosteroid levels were measured in six female tammar wallabies (Macropus eugenii) at Macquarie University, NSW, Australia, to assess their reliability as indicators of wellbeing in this species. Animals were challenged with a change in conditions over the course of approximately 3 weeks, comprising (i) isolation and movement; (ii) altered feeding routine, in order to impose a disturbance to homeostasis ("stress"). Blood samples were collected five times during the study period, and analysed for corticosteroid concentration and a number of haematological and biochemical measures. The use of enzyme immunoassay for the measurement of corticosteroids in marsupial serum was validated. We found that there was no significant change in serum corticosteroid concentrations in response to either of the changed conditions suggesting that serum corticosteroid concentrations are not reflective of a change in wellbeing. Cortisol was the dominant serum corticosteroid, with concentrations up to 50 times higher than corticosterone. Significant differences were observed in aspartate amino-transferase, alanine amino-transferase, haemoglobin, total erythrocyte count and mean corpuscular haemoglobin concentration over the period of study. However, no significant correlations emerged to justify any of these measures, or serum corticosteroid levels, as reliable indicators of compromised wellbeing in the tammar wallaby.

Dornase alfa in the treatment of cystic fibrosis in Europe: a report from the Epidemiologic Registry of Cystic Fibrosis

Dornase alfa (Pulmozyme) treatment for patients with cystic fibrosis (CF) has been shown to improve pulmonary function and reduce exacerbations of infection in a number of placebo-controlled double-blind studies. Data in the Epidemiologic Registry of Cystic Fibrosis (ERCF) in November 1998 were used to assess the long-term effectiveness in routine clinical practice of dornase alfa in terms of pulmonary function and frequency of acute pulmonary exacerbations in CF. At that time, the ERCF contained data on 13,684 CF patients, with a mean observation period of 2.3 years. To be included in the analysis, patients had to have 2 years of data in the Registry in appropriate detail. Overall, untreated patients showed a decline in forced expiratory volume in 1 sec over a 2-year period of -2.3% predicted, but treated patients were stable, showing a change of 0.3% predicted, i.e., a treatment benefit of 2.5%. Compared to untreated patients, there were 25 fewer exacerbations per 100 treated patients per year. The analysis suggested that younger patients were likely to benefit more from treatment. The findings of randomized clinical trials were supported by the data collected in routine clinical practice.

Dynamics of hematopoiesis in paroxysmal nocturnal hemoglobinuria (PNH): no evidence for intrinsic growth advantage of PNH clones

PNH is characterized by expansion of one or more stem cell clones with a PIG-A mutation, which causes a severe deficiency in the expression of glycosylphosphatidylinositol (GPI)-anchored proteins. There is evidence that the expansion of PIG-A mutant clones is concomitant with negative selection against PIG-A wild-type stem cells by an aplastic marrow environment. We studied 36 patients longitudinally by serial flow cytometry, and we determined the proportion of PNH red cells and granulocytes over a period of 1-6 years. We observed expansion of the PNH blood cell population(s) (at a rate of over 5% per year) in 12 out of 36 patients; in all other patients the PNH cell population either regressed or remained stable. The dynamics of the PNH cell population could not be predicted by clinical or hematologic parameters at presentation. These data indicate that in most cases the PNH cell expansion has already run its course by the time of diagnosis. In addition, since in most cases no further expansion takes place, we can infer that the tendency to overgrow normal cells is not an intrinsic property of the PNH clone.