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Dho-Nagy EA, Brassai A, Lechsner P, Ureche C, Bán EG. COVID-19 and Antipsychotic Therapy: Unraveling the Thrombosis Risk. Int J Mol Sci 2024; 25:818. [PMID: 38255892 PMCID: PMC10815664 DOI: 10.3390/ijms25020818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/04/2024] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
In the context of the COVID-19 pandemic, this study investigates the potential correlation between the increased use of antipsychotic medications and the rising incidence of venous thromboembolism (VTE). As psychiatric disorders surged, the consequential escalation in antipsychotic drug use raised concerns about thrombotic risks. We conducted a comprehensive literature review using PubMed, focusing on articles that intersected COVID-19, antipsychotic medication, and thrombosis. This approach allowed for a nuanced examination of the historical and recent data on antipsychotic drugs and their association with thrombotic events. Our findings reveal a notable link between the use of antipsychotic medications, particularly second-generation antipsychotics, and an increased risk of VTE, including pulmonary embolism and deep vein thrombosis. This association was evident, despite variations in study designs and populations. The study underscores the need for cautious medication management in psychiatric care, especially during pandemic conditions like COVID-19, to mitigate thrombotic risks. It advocates a personalized approach to prescribing antipsychotics, considering individual patient factors and comorbidities, to balance the benefits against potential thrombotic complications.
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Affiliation(s)
- Eszter-Anna Dho-Nagy
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine in English, Preclinical Research Laboratory, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Attila Brassai
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine in English, Preclinical Research Laboratory, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Patrick Lechsner
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine in English, Preclinical Research Laboratory, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Corina Ureche
- Department of Internal Medicine, Faculty of Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Erika-Gyöngyi Bán
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine in English, Preclinical Research Laboratory, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
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Mohseni Afshar Z, Babazadeh A, Janbakhsh A, Afsharian M, Saleki K, Barary M, Ebrahimpour S. Vaccine-induced immune thrombotic thrombocytopenia after vaccination against Covid-19: A clinical dilemma for clinicians and patients. Rev Med Virol 2021; 32:e2273. [PMID: 34197678 PMCID: PMC8420499 DOI: 10.1002/rmv.2273] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Abstract
The coronavirus disease 2019 (Covid-19) pandemic has had devastating effects on public health worldwide, but the deployment of vaccines for Covid-19 protection has helped control the spread of SARS Coronavirus 2 (SARS-CoV-2) infection where they are available. The common side effects reported following Covid-19 vaccination were mostly self-restricted local reactions that resolved quickly. Nevertheless, rare vaccine-induced immune thrombotic thrombocytopenia (VITT) cases have been reported in some people being vaccinated against Covid-19. This review summarizes the thromboembolic events after Covid-19 vaccination and discusses its molecular mechanism, incidence rate, clinical manifestations and differential diagnosis. Then, a step-by-step algorithm for diagnosing such events, along with a management plan, are presented. In conclusion, considering the likeliness of acquiring severe SARS-CoV-2 infection and its subsequent morbidity and mortality, the benefits of vaccination outweigh its risks. Hence, if not already initiated, all governments should begin an effective and fast public vaccination plan to overcome this pandemic.
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Affiliation(s)
- Zeinab Mohseni Afshar
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Arefeh Babazadeh
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Alireza Janbakhsh
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mandana Afsharian
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kiarash Saleki
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran.,USERN Office, Babol University of Medical Sciences, Babol, Iran
| | - Mohammad Barary
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran.,USERN Office, Babol University of Medical Sciences, Babol, Iran
| | - Soheil Ebrahimpour
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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Jönsson AK, Schill J, Olsson H, Spigset O, Hägg S. Venous Thromboembolism During Treatment with Antipsychotics: A Review of Current Evidence. CNS Drugs 2018; 32:47-64. [PMID: 29423659 PMCID: PMC5843694 DOI: 10.1007/s40263-018-0495-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This article summarises the current evidence on the risk of venous thromboembolism (VTE) with the use of antipsychotics. An increasing number of observational studies indicate an elevated risk of VTE in antipsychotic drug users. Although the use of certain antipsychotics has been associated with VTE, current data can neither conclusively verify differences in occurrence rates of VTE between first- and second-generation antipsychotics or between individual compounds, nor identify which antipsychotic drugs have the lowest risk of VTE. The biological mechanisms involved in the pathogenesis of this adverse drug reaction are still to be clarified but hypotheses such as drug-induced sedation, obesity, increased levels of antiphospholipid antibodies, enhanced platelet aggregation, hyperhomocysteinaemia and hyperprolactinaemia have been suggested. Risk factors associated with the underlying psychiatric disorder may at least partly explain the increased risk. Physicians should be aware of this potentially serious and even sometimes fatal adverse drug reaction and should consider discontinuing or switching the antipsychotic treatment in patients experiencing a VTE. Even though supporting evidence is limited, prophylactic antithrombotic treatment should be considered in risk situations for VTE.
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Affiliation(s)
- Anna K Jönsson
- Department of Drug Research, Section of Clinical Pharmacology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Chemistry, National Board of Forensic Medicine, Linköping, Sweden
| | - Johan Schill
- Department of Psychiatry, Region Jönköping County, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Hans Olsson
- Department of Psychiatry, Region Jönköping County, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Staffan Hägg
- Futurum, Region Jönköping County, Department of Medical and Health Sciences, Linköping University, Sweden.
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Chow V, Reddel C, Pennings G, Scott E, Pasqualon T, Ng ACC, Yeoh T, Curnow J, Kritharides L. Global hypercoagulability in patients with schizophrenia receiving long-term antipsychotic therapy. Schizophr Res 2015; 162:175-82. [PMID: 25634682 DOI: 10.1016/j.schres.2014.12.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 12/04/2014] [Accepted: 12/06/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with schizophrenia are at increased risk of venous thromboembolism. The mechanisms underlying this association are poorly understood. AIMS We investigated whether there is a global hypercoagulable state in patients with schizophrenia utilising the overall haemostatic potential (OHP) assay which assesses overall coagulation potential (OCP), haemostatic potential (OHP) and fibrinolytic potential (OFP). METHOD Citrated plasma was collected for OHP assays from patients with schizophrenia on long-term antipsychotic treatment and compared with healthy age- and sex-matched controls. Time courses of fibrin formation and degradation were measured by spectrophotometry (absorption of 405nm) after the addition of tissue factor and tissue plasminogen activator to plasma. RESULTS Ninety patients with schizophrenia (antipsychotic treatment-15.9±9.7years) and 30 controls were recruited. Patients with schizophrenia had higher rates of smoking and levels of inflammatory markers (high-sensitivity C-reactive protein and neutrophil-to-lymphocyte ratio) than controls. Whilst D-dimer, fibrinogen and platelet count did not differ between patients with schizophrenia and controls, the OCP (54.0±12.6 vs 45.9±9.1, p=0.002) and OHP (12.6±5.8 vs 7.2±3.7, p<0.001) were higher, and OFP was lower (76.6±9.8% vs 84.9±6.4%, p<0.001) in patients with schizophrenia, implying both a hypercoagulable and hypofibrinolytic state in these patients. Importantly, abnormalities in overall coagulation were independently predicted by levels of plasminogen-activator-inhibitor-1, fibrinogen, platelet count, inflammatory markers and plasma triglycerides, suggesting a multifactorial aetiology. CONCLUSION Patients with schizophrenia have evidence of a global hypercoagulable and hypofibrinolytic state which may contribute to their increased risk of venous thromboembolism.
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Affiliation(s)
- Vincent Chow
- ANZAC Research Institute, Sydney, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, Australia; University of Sydney, Australia
| | - Caroline Reddel
- ANZAC Research Institute, Sydney, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, Australia; University of Sydney, Australia
| | - Gabrielle Pennings
- ANZAC Research Institute, Sydney, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, Australia; University of Sydney, Australia
| | - Elizabeth Scott
- Brain & Mind Research Institute, University of Sydney, Australia
| | - Tundra Pasqualon
- Department of Psychiatry, Croydon Health Centre, Sydney, Australia
| | - Austin C C Ng
- Department of Cardiology, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, Australia; University of Sydney, Australia
| | - Thomas Yeoh
- Department of Cardiology, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, Australia
| | - Jennifer Curnow
- ANZAC Research Institute, Sydney, Australia; University of Sydney, Australia; Department of Haematology, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, Australia
| | - Leonard Kritharides
- ANZAC Research Institute, Sydney, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, Australia; University of Sydney, Australia.
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Abstract
Since preliminary case reports suggesting a possible association between first generation of antipsychotics and venous thromboembolism (VTE), consistent epidemiological data is now available suggesting a moderate association between antipsychotics and VTE. However, despite several hypotheses, the underlying mechanisms remain unknown or uncertain. In addition, if the association between antipsychotics and VTE is plausible, the intensity of this risk and the dose effect relationship do not have yet been determined. Prospective data is therefore needed in order to confirm and to quantify this association. Because of the level of uncertainty, the clinical impact on the prevention and the treatment of VTE in patients with a psychiatric illness appears to be low.
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Affiliation(s)
- Cécile Tromeur
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, EA 3878, Department of Internal Medicine and Chest Diseases, Brest, France
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Gallerani M, Imberti D, Mari E, Marra A, Manfredini R. Risperidone and pulmonary embolism: a harmful association? Case series and review of the literature. Acta Neuropsychiatr 2012; 24:361-8. [PMID: 25287179 DOI: 10.1111/j.1601-5215.2012.00641.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Gallerani M, Imberti D, Mari E, Marra A, Manfredini R. Risperidone and pulmonary embolism: a harmful association? Case series and review of the literature.Objective: Risperidone is an atypical antipsychotic drug used to treat a number of psychiatric diseases, such as schizophrenia, schizoaffective and bipolar disorders and irritability in children with autism. Moreover, it is also often administered for short-term treatment of persistent aggression in people with moderate-to-severe Alzheimer's dementia. A possible association between risperidone and venous thromboembolism (VTE) has been described. We intended to verify the dimension of the problem in our hospital setting.Methods: We considered all consecutive patients hospitalised in our Internal Medicine Department from January 2004 to December 2010, who were treated with risperidone and presented pulmonary embolism (PE).Results: Four cases of patients, apparently free from the well-known major risk factors for VTE (i.e. cancer, prolonged immobilisation, acute cardiac and respiratory failure, infections), who presented PE associated with risperidone therapy, were reported in details.Conclusions: A review of the available literature, discussing the possible different pathogenic reasons for this increased risk of VTE, is provided.
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Affiliation(s)
- Massimo Gallerani
- Internal Medicine, Az. Ospedaliera Universitaria "St. Anna", Ferrara, Italy
| | - Davide Imberti
- Internal Medicine, Az. Ospedaliera Universitaria "St. Anna", Ferrara, Italy
| | - Elisa Mari
- Internal Medicine, Az. Ospedaliera Universitaria "St. Anna", Ferrara, Italy
| | - Anna Marra
- Pharmaceutical Department, Az. Ospedaliera Universitaria "St. Anna", Ferrara, Italy
| | - Roberto Manfredini
- Department of Clinical and Experimental Medicine, Clinica Medica and Vascular Diseases Center, University of Ferrara, Ferrara, Italy
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Association between antipsychotic medication and venous thromboembolism. Ir J Psychol Med 2010; 27:22-26. [PMID: 30282291 DOI: 10.1017/s0790966700000884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study aims to identify and review available evidence in the literature to determine the strength of association between antipsychotic medications and thromboembolism as an adverse effect. METHOD Electronic databases were searched for evidence. RESULTS A total of 15 case reports, 14 case series, two observational studies and three case-control studies were found in the literature. Two case control studies found significantly increased risk of venous thromboembolism (OR 13.3 and 7.1 respectively). The risk was high for low potency antipsychotics. Studies were critically appraised to determine the strength of evidence. CONCLUSION The studies reviewed indicate a significant association between antipsychotics and venous thromboembolism. Patients using the antipsychotics and those who prescribe them should be aware of this association.
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Lacut K, Le Gal G, Couturaud F, Cornily G, Leroyer C, Mottier D, Oger E. Association between antipsychotic drugs, antidepressant drugs and venous thromboembolism: results from the EDITH case-control study. Fundam Clin Pharmacol 2008; 21:643-50. [PMID: 18034665 DOI: 10.1111/j.1472-8206.2007.00515.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cohort studies suggest that exposure to antipsychotic agents may be associated with an increased risk of venous thromboembolism (VTE). Few data concerning antidepressant drugs are available. Using a different methodological approach, the aim of this study was to estimate the association between neuroleptic and antidepressant drug use and the risk of VTE. We report the results of a case-control study designed to evaluate interactions between acquired and inherited risk factors of VTE. We included 677 cases hospitalized with deep vein thrombosis and or pulmonary embolism with no major acquired risk factor for VTE, and 677 controls matched for gender and age. Drug exposure was defined as current use of drugs at admission. Neuroleptic exposure was associated with an increased risk of VTE (OR = 2.1, 95% CI 1.4-3.2). Among neuroleptics, antipsychotic agent use was associated with a 3.5-fold increased risk of VTE (OR = 3.5, 95% CI 2.0-6.2). No association was found between antidepressant drug exposure and the risk of VTE (OR = 1.1, 95% CI 0.9-1.5). In this hospital-based case-control study, exposure to antipsychotic drugs was associated with an increased risk of VTE. These results, added to previous results, suggest that clinicians should consider antipsychotic drug exposure as a potential risk factor of VTE. More studies are needed in order to further elucidate this adverse effect, and to determine the possible predisposing factors and the biological mechanisms involved.
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Affiliation(s)
- K Lacut
- EPI-PHARM G.E.T.B.O., Equipe d'accueil 3878, Department of Internal Medicine and Chest Diseases, Hôpital de la Cavale Blanche, 29609 Brest Cedex, France.
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Abstract
Psychiatric disorders themselves and treatment with conventional antipsychotic medications have in a number of early studies been associated with venous thromboembolism. In general, information on the relationship between antipsychotics and this possible adverse effect is in the form of case reports and open cross-sectional studies. However, recently the association between conventional antipsychotics and venous thrombosis has been strengthened as a result of the publication of a large, nested, case-control study. In this study, low-potency antipsychotic drugs were more strongly associated with venous thrombosis than high-potency drugs. In addition, recent epidemiological data support an association between the atypical antipsychotic agent clozapine and venous thromboembolism. The risk for venous thromboembolism seems to be highest during the initial months of treatment with antipsychotics. The biological mechanisms responsible for this possible adverse drug reaction are unknown, but a number of hypotheses have been suggested. The increased risk may be the result of drug-induced sedation, obesity, hyperleptinaemia, antiphospholipid antibodies and increased activity in the coagulation system. The association could also be related to underlying risk factors present in patients with psychosis such as smoking. Despite the limitations of present knowledge, clinicians should be aware of this possible adverse drug reaction and should consider interrupting or changing the antipsychotic regimen in patients in whom this reaction is suspected. More studies are needed in order to further elucidate this adverse effect, particularly to determine the incidence rate, possible predisposing factors and the biological mechanisms involved.
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Affiliation(s)
- Staffan Hägg
- Department of Psychiatry, Sahlgrenska Hospital/Sahlgrenska, Göteborg, Sweden.
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Zornberg GL, Jick H. Antipsychotic drug use and risk of first-time idiopathic venous thromboembolism: a case-control study. Lancet 2000; 356:1219-23. [PMID: 11072939 DOI: 10.1016/s0140-6736(00)02784-7] [Citation(s) in RCA: 157] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Antipsychotic drugs have been associated with an increased risk of adverse events such as venous thromboembolism. Our aim was to assess this risk in users of conventional antipsychotic drugs who had been diagnosed with first-time, idiopathic venous thromboembolism. METHODS From a baseline population of 29,952 recipients of conventional and atypical antipsychotic drugs aged younger than 60 years, we identified 42 individuals with idiopathic venous thromboembolism and 172 matched controls. We compared risk of current and recent use of antipsychotic drugs with non-use before the index date in cases and controls. FINDINGS Current exposure to conventional antipsychotic drugs was associated with a significantly increased risk of idiopathic venous thromboembolism compared with non-use (adjusted odds ratio 7.1 [95% CI 2.3-21.97]). Although we found no difference between phenothiazines, thioxanthenes, or other conventional antipsychotic drugs, low potency antipsychotic drugs drugs such as chlorpromazine and thioridazine were more strongly associated with venous thromboembolism (odds ratio 24.1 [3.3-172.7]) than were high potency antipsychotic drugs such as haloperidol (3.3 [0.8-13.2]). The risk for venous thrombosis was highest during the first few months of conventional antipsychotic drug use. INTERPRETATION Current exposure to conventional antipsychotic drugs significantly increases the risk of idiopathic venous thromboembolism in men and women younger than 60 years of age.
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Affiliation(s)
- G L Zornberg
- Boston Collaborative Drug Surveillance Program, Boston University School of Medicine, Lexington, MA 02421, USA.
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Affiliation(s)
- V F Tapson
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Fujita MQ, Zhu BL, Quan L, Ishida K, Oritani S, Maeda H. Pulmonary embolism: a case of sudden unexpected death in a psychiatric hospital. Leg Med (Tokyo) 1999; 1:176-9. [PMID: 12935491 DOI: 10.1016/s1344-6223(99)80033-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a case of suspected fatal physical abuse in which the cause of death was proved to be pulmonary embolism. A patient with mental retardation presenting aggressive behavior was admitted to a psychiatric hospital and was treated with major tranquilizers. She suddenly died subsequent to an angina-like attack. For several days before her death, she had been confined to her bed because of very low physical and mental activity. Bruises and abrasions were observed on the extremities, suggesting the recent restraints. There was no positive evidence of physical abuse. At autopsy, the cause of death was elucidated to be pulmonary embolism originating from thrombi in the left popliteal vein. This case indicates the risk of pulmonary embolism in immobilized patients in psychiatric hospitals.
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Affiliation(s)
- M Q Fujita
- Department of Legal Medicine, Osaka City University Medical School, Osaka 545-8585, Japan
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