Risk of venous thromboembolism in people with epilepsy

Evidence for causal effects of neuropsychiatric conditions on risk of venous thromboembolism: A univariable and multivariable Mendelian randomization study

BACKGROUND

Substantial observational evidence suggests an association between neuropsychiatric conditions and venous thromboembolism (VTE). However, the causal relationship between these two conditions requires further investigation. Therefore, we used a two-sample Mendelian randomization (MR) approach to assess the bidirectional causal effects between four neuropsychiatric conditions and VTE, deep vein thrombosis, and pulmonary embolism (PE).

METHODS

Genetic variants associated with four neuropsychiatric conditions (ie, schizophrenia, major depressive disorder [MDD], bipolar disorder, and epilepsy) and VTE, deep vein thrombosis, and PE were selected. Bidirectional univariable and multivariable MR methods were applied to evaluate the causal relationships among these conditions. The primary causal estimates were obtained using the inverse variance weighted method with multiplicative random effects, supplemented by MR Egger regression, weighted median, simple mode, and weighted mode. Sensitivity analysis was conducted using the MR pleiotropy residual sum, funnel plots, and outlier (MR pleiotropy and residual sum and outlier) method.

RESULTS

Univariable MR results showed that genetic susceptibility to MDD increases the risk of VTE and PE (VTE: odds ratio [OR], 1.25; 95% confidence interval [CI], 1.08-1.46; P = .004; PE: OR, 1.36; 95% CI, 1.09-1.69; P = .006) and that PE has an adverse causal effect on MDD (OR, 1.02; 95% CI, 1.00-1.04; P = .026). Adjustment for confounders such as obesity, sleep duration, smoking, physical activity, and alcohol consumption revealed that increased genetic susceptibility to MDD is also associated with VTE and PE.

CONCLUSIONS

Our results suggest that genetic susceptibility to MDD might have an adverse causal effect on the risk of VTE and PE and that PE has a reverse causal effect on MDD. Prevention and early diagnosis of depression are crucial in the management of VTE and PE.

Photosensitive Peptide Enabling Molecular Recognition Tandem Covalent Biosensing for Evaluating and Preventing Venous Thromboembolism in Dravet Syndrome

Venous thromboembolism (VTE) is a complication of Dravet syndrome, accounting for many unexpected deaths. To control VTE more tightly and to prevent such tragedies, a reliable and low-cost risk evaluation assay is urgently needed, so that the daily routine of VTE risk evaluation can be established. In this work, we have developed such an assay combining the photocatalytic activity of Bengal red to trigger the target-specific self-splicing of a peptide probe and subsequent cross-linking with P-selectin. Following this protocol, a robust and one-step detection can be achieved, without using any costly enzymes, antibodies, or nanomaterials, but the same level of sensitivity and robustness can be attained. Specifically, the effect of epilepsy on elevating platelet P-selectin can be observed by using the proposed assay. This may in the near future promise a new method for evaluating the side effects of P-selectin through relatively noninvasive peripheral blood sampling.

The efficacy of direct oral anticoagulants in patients on concomitant treatment with levetiracetam

Guidelines do not support the combination of direct oral anticoagulants (DOACs) and the antiepileptic drug levetiracetam, due to potential relevant P-glycoprotein (P-gp) mediated interaction that might result in decreased DOACs concentrations and increased thromboembolic risk. However, there is no systematic data on the safety of this combination. The aim of this study was to find patients concurrently treated with levetiracetam and DOAC, assess their plasma concentrations of DOAC, and the incidence of thromboembolic events. From our registry of patients on anticoagulation drugs we identified 21 patients concomitantly treated with levetiracetam and DOAC, 19 patients with atrial fibrillation and two patients with venous thromboembolism. Eight patients received dabigatran, 9 apixaban and 4 rivaroxaban. For each subject blood samples were collected for determination of trough DOAC and trough levetiracetam concentrations. The average age was 75 ± 9 years, 84% were males, HAS-BLED score was 1.8 ± 0.8, and in patients with atrial fibrillation CHA₂DS₂-VASc score was 4.6 ± 2.0. The average trough concentration level of levetiracetam was 31.0 ± 34.5 mg/L. Median trough concentrations of DOACs were for dabigatran 72 (range 25-386) ng/mL, for rivaroxaban 47 (range 19-75) ng/mL, and for apixaban 139 (range 36-302) ng/mL. During the observation period of 1388 ± 994 days none of the patients suffered a thromboembolic event. Our results did not demonstrate a reduction in DOACs plasma levels during levetiracetam treatment, suggesting that levetiracetam could not be an important P-gp inducer in humans. DOAC in combination with levetiracetam remained effective therapy to protect against thromboembolic events.

Seizures as the first clinical manifestation of acute pulmonary embolism: an underestimate issue in neurocritical care

BACKGROUND

The aim of the present review is to analyze the clinical characteristics of patients with acute pulmonary embolism (PE) which seizures were the first clinical manifestation of the disease.

METHODS

After screening 258 articles in PubMed, Scopus, Cochrane Library, and Google Scholar databases, we identified 16 case reports meeting the inclusion criteria.

RESULTS

The mean age of the population was 48.4 ± 19.8 years (9 males and 7 females). About three of four patients (68.7%) were hemodynamically stable at admission, having a systolic blood pressure > 90 mmHg. Intriguingly, the doubt of acute PE was based on clinical suspicion or on instrumental findings in 62.5% and 18.7% of patients, respectively. In 3 subjects (18.7%), the acute cardiovascular disease was not suspected. Half of patients had an unremarkable previous medical history while neurological comorbidities were present in 4 patients (25.0%). During seizures, a transient loss of consciousness (TLOC) was reported in 6 cases. Seizures were retrospectively classified according to the 2017 ILAE classification, whenever possible. A focal and generalized onset was reported in 37.5% and 50% of cases, respectively, in 12.5% of patient's data that were insufficient to classify the events. The mean number of seizure episodes in the population enrolled was 2.0 ± 1.1. Mortality rate was 54.5% but one investigation did not report the patient's outcome.

CONCLUSIONS

The relationship between seizures and acute PE is probably underrecognized. Identifying patients that have a high probability of acute PE is fundamental to avoid any treatment delay and ameliorate their outcomes.

Venous thromboembolism following inpatient pediatric surgery: Analysis of 153,220 patients

PURPOSE

To evaluate venous thromboembolism (VTE) rates and risk factors following inpatient pediatric surgery.

METHODS

153,220 inpatient pediatric surgical patients were selected from the 2012-2015 NSQIP-P database. Demographic and perioperative variables were documented. Primary outcome was VTE requiring treatment within 30 postoperative days. Secondary outcomes included length of stay (LOS) and 30-day mortality. Prediction models were generated using logistic regression. Mortality and time to VTE were assessed using Kaplan-Meier survival analysis.

RESULTS

305 patients (0.20%) developed 296 venous thromboses and 12 pulmonary emboli (3 cooccurrences). Median time to VTE was 9 days. Most VTEs (81%) occurred predischarge. Subspecialties with highest VTE rates were cardiothoracic (0.72%) and general surgery (0.28%). No differences were seen for elective vs. urgent/emergent procedures (p = 0.106). All-cause mortality VTE patients was 1.2% vs. 0.2% in patients without VTE (p < 0.001). After stratifying by American Society of Anesthesiologists (ASA) class, no mortality differences remained when ASA < 3. Preoperative, postoperative, and total LOSs were longer for patients with VTE (p < 0.001 for each). ASA ≥ 3, preoperative sepsis, ventilator dependence, enteral/parenteral feeding, steroid use, preoperative blood transfusion, gastrointestinal disease, hematologic disorders, operative time, and age were independent predictors (C-statistic = 0.83).

CONCLUSIONS

Pediatric postsurgical patients have unique risk factors for developing VTE.

LEVEL OF EVIDENCE

Level II.

Safety in the epilepsy monitoring unit: A retrospective study of 524 consecutive admissions

The yield of monitoring patients at an epilepsy monitoring unit (EMU) depends on the recording of paroxysmal events in a timely fashion, however, increasing the risk of safety adverse events (AEs). We aimed to retrospectively study the frequency and risk factors for AE occurrences in all consecutive admissions to an adult EMU in a tertiary medical center. We also compared our findings with published data from other centers. Between January 2011 and June 2014, there were 524 consecutive admissions to the adult EMU at the Tel Aviv Sourasky Medical Center. Adverse events were recorded in 47 (9.0%) admissions. The most common AE was 4-hour seizure cluster (58.7% of AEs) and, in decreasing frequency, AEs related to antiepileptic drugs (AEDs, 11.1%), falls and traumatic injuries (9.5%), intravenous line complications (9.5%), electrode-related (4.8%), status epilepticus (SE, 3.2%), and cardiac (1.6%) and psychiatric (1.6%) complications. There were significantly more AEs among patients with a younger age at disease onset (p=0.005), a history of temporal lobe epilepsy (p=0.046), a history of focal seizures with altered consciousness (p=0.008), a history of SE (p=0.022), use of a vagal nerve stimulator (p=0.039), and intellectual disability (p=0.016) and when the indication for EMU monitoring was noninvasive or invasive presurgical evaluation (p=0.001). Adverse events occurred more frequently when patients had more events in the EMU (p=0.001) and among those administered carbamazepine (p=0.037), levetiracetam (p=0.004), clobazam (p=0.008), and sulthiame (p=0.016). Patients with a history of psychogenic nonepileptic seizures (PNESs) had significantly fewer AEs (p=0.013). Adverse events were not associated with the age, gender, duration of hospitalization or monitoring, AED withdrawal and renewal, seizure frequency by history, presence of major psychiatric comorbidities, abnormal neurological exam, or the presence of a lesion as on brain magnetic resonance imaging. In conclusion, this study reveals that AEs are not unusual in the EMU and that seizure clustering is the most common among them. Adverse events occur more frequently in patients with more severe epilepsy and intellectual disability and in patients undergoing presurgical evaluations and less frequently in patients with PNESs.