Predicting the risk of venous thromboembolism recurrence

Venous thromboembolism (VTE) is a chronic disease with a 30% ten-year recurrence rate. The highest incidence of recurrence is in the first 6 months. Active cancer significantly increases the hazard of early recurrence, and the proportions of time on standard heparin with an APTT ≥ 0.2 anti-X(a) U/mL, and on warfarin with an INR ≥ 2.0, significantly reduce the hazard. The acute treatment duration does not affect recurrence risk after treatment is stopped. Independent predictors of late recurrence include increasing patient age and body mass index, leg paresis, active cancer and other persistent VTE risk factors, idiopathic VTE, antiphospholipid antibody syndrome, antithrombin, protein C or protein S deficiency, hyperhomocysteinemia and a persistently increased plasma fibrin D-dimer. A recommendation for secondary prophylaxis should be individualized based on the risk for recurrent VTE (especially fatal pulmonary embolism) and bleeding. The appropriateness of secondary prophylaxis should be continuously reevaluated, and the prophylaxis stopped if the benefit no longer exceeds the risk.

The increase of neuron-specific enolase in cerebrospinal fluid and plasma as a marker of neuronal damage in patients with acute brain infarction

Our goal was to determine the neuron-specific enolase (NSE) concentration in cerebrospinal fluid (CSF) and plasma in patients with the acute brain infarction (BI) and analyze the correlation between the measured NSE concentration and infarct volume and the degree of neurological and functional deficit. The study included 55 patients aged 56-68 with BI in the acute phase. The control group consisted of 16 patients subjected to diagnostic radiculography. The results showed a significant increase of NSE concentration within the first seven days in patients compared to the controls (2.838 +/- 0.504 ng/ml CSF and 4.479 +/- 0.893 ng/ml plasma). A significant correlation was found between NSE concentration and infarction volume and the degree of neurological and functional deficit both in the CSF (r = 0.828, r = 0.735, r = 0.796; p < 0.001) and in plasma (r = 0.810, r = 0.681, r = 0.783; p < 0.001). The results suggest that an early determination of this marker in CSF and plasma in patients with BI could be a valuable diagnostic factor.

Origin of ICU acquired paresis determined by direct muscle stimulation

BACKGROUND

Acquired diffuse paresis in an intensive care unit (ICU) can result from critical illness myopathy or polyneuropathy. Clinical examination and conventional neurophysiological techniques may not distinguish between these entities.

OBJECTIVE

To assess the value of direct muscle stimulation (DMS) to differentiate myopathic from neuropathic process in critically ill patients with diffuse severe muscle weakness.

METHODS

30 consecutive patients with ICU acquired diffuse motor weakness were studied. Responses of the right deltoid and tibialis anterior muscles to DMS and to motor nerve stimulation (MNS) were studied and compared with results of conventional nerve conduction studies and concentric needle electromyography (EMG). An original algorithm was used for differential diagnosis, taking into account first the amplitude of the responses to DMS, then the MNS to DMS amplitude ratio, and finally the amplitude of the sensory nerve action potentials recorded at the lower limbs.

RESULTS

Evidence of neuropathy and myopathy was found in 57% and 83% of the patients, respectively. Pure or predominant myopathy was found in 19 patients. Other results were consistent with neuromyopathy (n = 5) and pure or predominant neuropathy (n = 2). Four patients had normal results with stimulation techniques, but spontaneous EMG activity and raised plasma creatine kinase suggesting necrotic myopathy.

CONCLUSIONS

A neurophysiological approach combining DMS and conventional techniques revealed myopathic processes in a majority of ICU patients. Reduced muscle fibre excitability may be a leading cause for this. The diagnosis of myopathy in ICU acquired paralysis can be established by a combination of DMS, needle EMG, and plasma creatine kinase.

Critical illness polyneuropathy and myopathy in patients with acute respiratory distress syndrome

OBJECTIVE

Critical illness polyneuropathy/myopathy (CIP/CIM) is frequently described in critically ill patients who survive severe sepsis. Clinically relevant paresis is major symptom of CIP/CIM. We aimed at determining risk factors and diagnostic value of electrophysiologic testing for CIP/CIM in patients with acute respiratory distress syndrome (ARDS).

DESIGN

Single-center, retrospective analysis, using charts.

SETTING

University medical center.

PATIENTS

Fifty consecutive ARDS patients in our intensive care unit.

INTERVENTIONS

Patient characteristics and clinical course were analyzed. All patients received early electrophysiologic testing. CIP/CIM was diagnosed by the presence of clinical relevant paresis.

MEASUREMENTS AND MAIN RESULTS

Clinically relevant paresis was confirmed in 27 ARDS patients (60%), whereas in 18 patients no paresis was determined (controls); five patients died before clinical assessment of paresis was feasible. Patients with paresis were older, had more days on mechanical ventilation, and had increased intensive care unit length of stay compared with controls. Patients who developed paresis had elevated daily peak blood glucose levels during 28 days of intensive care unit treatment: 166 (134, 200) mg/dL in CIP/CIM patients vs. 144 (132, 161) mg/dL in controls (median, quartiles). Twenty-five of 27 patients with paresis revealed reduced motor unit potentials, fibrillation potentials, or positive sharp waves on early electrophysiologic testing indicating CIP/CIM, whereas 16 of 18 control patients did not.

CONCLUSIONS

In ARDS patients, paresis is a frequent complication causing prolonged mechanical ventilation and intensive care unit length of stay. An association between hyperglycemia and CIP/CIM has been found. However, since this is a retrospective survey, a causal relation is not clearly supported. In this study, the use of early electrophysiologic testing in ARDS patients was a valuable diagnostic tool for detecting CIP/CIM.

Localized Reversible Reduction of Apparent Diffusion Coefficient in Transient Hypoglycemia-Induced Hemiparesis

BACKGROUND AND PURPOSE

The pathophysiology of hypoglycemia shares a common mechanism with cerebral ischemia, but so far, little is known regarding MRI of humans with hypoglycemia.

METHODS

We report a patient with left hemiparesis and dysarthria associated with a blood glucose level of 1.7 mmol/L. The patient recovered completely after glucose infusion.

RESULTS

The initial diffusion-weighted imaging (DWI) showed increased signal intensities and a reduction of apparent diffusion coefficient (ADC) values localized in the corpus callosum (splenium) and asymmetrically in the corona radiata. After 48 hours, follow-up revealed complete recovery of DWI and ADC signal abnormalities.

CONCLUSIONS

To our knowledge, this is the first presentation of a case with transient hypoglycemia-induced focal neurological deficits revealing completely reversible MRI changes in terms of disturbed DWI and ADC with a peculiar as yet undescribed topography.

Interaction between the levels of hormones and minerals in sera of healthy and sick cows

An interaction between blood levels of parathyroid hormone, calcitonin, 1.25-dihydroxycholecalciferol and levels of calcium, phosphorus and magnesium was examined in 85 cows, which included healthy cows and cows with ostemalacia, mastitis and paresis. Levels of parathyroid hormone (PTH) and calcitonin were determined in vitro using IMMULITE analyser (Diagnostic Products Corporation, USA), by means of immunometric assay. Levels of vitamin D were measured using the enzyme linked immunosorbent assay (ELISA). Levels of calcium, phosphorus and magnesium were determined using the automated Eos-Bravo analyser (Hospitex Diagnostics, Italy) with HOSPITEX reagents. The lowest blood levels of calcium (1.38 +/- 0.18 mmol/L) and phosphorus (0.65 +/- 0.12 mmol/L) were found in cows with parturient paresis. Decreased blood levels of phosphorus and magnesium were also determined in cows with osteomalacia. For cows with parturient paresis, which received a mineral supplement, the average serum level of calcium was by 20.7% higher than the level found in those which did not receive a supplement, and the level of phosphorus was by 23.6% higher, however, these levels remained low. The blood level of parathyroid hormone ranged from 3.47 to 5.20 pmol/L in healthy cows and from 3.95 to 15.21 pmol/L in sick cows. The highest and statistically significant increase in blood PTH level (up to 18.31 +/- 1.88 pmol/L) was found in cows with parturient paresis. The blood level of PTH correlated inversely with the level of calcium in cows with osteomaliacia (r = -0.89) and in cows with parturient paresis (r = -0.49 and r = -0.61, respectively). The serum level of calcitonin ranged from 1.46 pmol/L to 2.40 pmol/L in healthy and sick cows and the difference was not statistically significant. Lower serum levels of vitamin D were found in heifers-in-calf and in cows with mastitis. A clear correlation between levels of calcitonin, vitamin D and macronutrients was not found.

Paresis following mechanical ventilation

PURPOSE OF REVIEW

To review the medical literature on neuromuscular abnormalities acquired in the intensive care unit (ICU), particularly after mechanical ventilation, focusing on the most recent advances in this field.

RECENT FINDING

Using a simple bedside muscle strength score, significant clinical weakness is detected in one fourth of patients awakening in ICU after more than 1 week of mechanical ventilation. Weakness is associated with a longer time on mechanical ventilation, although the exact relationship between limb and respiratory neuromuscular involvement remains unclear. Muscle involvement is often combined with axonal involvement and can predominate or occur in isolation in some patients. Although prolonged severe weakness is unusual, milder abnormalities may persist for several months after discharge. In addition to severity and duration of initial organ failures, both neuromuscular inactivity and use of corticosteroids make an independent contribution of the neuromuscular abnormalities. Conversely, strict glycemic control may prevent neuromuscular abnormalities, although this needs to be confirmed in general ICU patients.

SUMMARY

Avoiding complete neuromuscular inactivity, using corticosteroids with greater discernment, and closely monitoring blood glucose levels might be worthwhile avenues for research in prevention of neuromuscular abnormalities acquired in the most severely ill ICU patients. Investigations of the severity of the respiratory neuromuscular involvement are also warranted.

Chronic active VZV infection manifesting as zoster sine herpete, zoster paresis and myelopathy

After lumbar-distribution zoster, an HTLV-1-seropositive woman developed chronic radicular sacral-distribution pain (zoster sine herpete), cervical-distribution zoster paresis and thoracic-distribution myelopathy. Detection of anti-varicella zoster virus (VZV) IgM and VZV IgG antibody in cerebrospinal fluid (CSF), with reduced serum/CSF ratios of anti-VZV IgG compared to normal serum/CSF ratios for albumin and total IgG, proved that VZV caused the protracted neurological complications. Diagnosis by antibody testing led to aggressive antiviral treatment and a favorable outcome.

Plasma concentrations of C-reactive protein and fibrinogen in ischaemic stroke

This study investigated how fibrinogen and C-reactive protein (CRP) levels change in response to neural damage occurring after ischaemia, and the relationship between the distribution of the arterial lesion, the disease prognosis and the levels of these substances. Fibrinogen and CRP levels were measured in blood samples obtained from 83 patients admitted to hospital within 72 h of a first ischaemic stroke. The patients were evaluated clinically with the Glasgow Outcome Scale (GOS), and results were compared with 43 age-matched controls. The fibrinogen and CRP levels in unconscious patients with hemiparesis or hemiplegia were higher than those in conscious hemiplegic patients. Also, the difference in GOS values between the unconscious patients with hemiparesis or hemiplegia and conscious patients with hemiparesis or hemiplegia was statistically significant. Patients with large infarcts in the median cerebral artery and anterior cerebral artery had higher fibrinogen and CRP concentrations than the control group. In conclusion, fibrinogen and CRP may be important measures for determining the prognosis and outcome in patients following ischaemic stroke.

Hemostatic alterations in patients with acute, unilateral vestibular paresis

OBJECTIVES

The etiopathogenesis of acute unilateral peripheral vestibulopathy (APV) still remains a matter of debate; ischemic changes in the circulation of the labyrinth may play a role. We consequently looked for possible hemostasis alterations in a group of patients with APV of an unknown nature.

METHODS

We evaluated blood parameters known to be involved in circulation disorders, including total and HDL cholesterol, triglycerides, apolipoprotein A and B, lipoprotein(a), homocysteine, folate, prothrombin time, activated partial thromboplastin time, fibrinogen, D-dimer, antithrombin III, protein C, protein S, activated protein C resistance, and anticardiolipin IgG and IgM antibodies. A series of 23 patients affected with APV were consecutively referred to our department, in the acute phase, before treatment, and in the follow-up phase after 4 to 6 weeks of pharmacologic washout. The aforementioned blood parameters were also measured in a series of 15 patients with Menière's disease.

RESULTS

The patients with APV in the acute phase compared with the patients with Menière's disease in the acute phase exhibited increased plasma levels of fibrinogen (mean, 338.3 +/- 135.9 SD vs 271.3 +/- 69.8 SD mg/dL, P = 0.05), increased plasma levels of D-dimer (mean, 320 +/- 207.8 SD vs 226.7 +/- 138.7 SD NG/mL), enhanced plasma levels of lipoprotein(a) (41.4 +/- 38.6 SD vs 16 +/- 18.2 SD mg/dL, F = 5.67, P = 0.02), high leukocyte count (9.1 +/- 2.7 SD vs 6.5 +/- 1.3 SD x 10(3)/microL; F = 8.42, P < 0.006), and low serum folate concentration (5.3 +/- 1.8 SD vs 7.1 +/- 2.7 NG/mg; F = 4.34, P = 0.04). During follow-up the prothrombin time was prolonged (F = 4.34, P = 0.04) and leukocyte count decreased (F = 7.39, P < 0.019) in the APV patients, whereas fibrinogen, D-dimer, lipoprotein(a), and folate were unchanged.

CONCLUSION

Our results provide evidence suggesting an involvement of the hemostatic system in APV.

Cortisol axis abnormalities early after stroke--relationships to cytokines and leptin

OBJECTIVE

To assess the relationships between circulating levels of proinflammatory cytokines and adrenocortical hormones and leptin early after stroke.

DESIGN

Blood samples were collected four times daily the first two days after stroke, twice daily the next 4 days and four times at day 7. Cognitive function and functional outcome was measured at admittance and at day 7.

SETTING

Consecutive inclusion of patients admitted to the stroke unit at Umeâ University Hospital.

SUBJECTS

Eight men and 4 women with acute stroke and 10 healthy volunteers.

MAIN OUTCOME MEASURES

Levels and diurnal variations of plasma proinflammatory cytokines interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-alpha), serum adrenocortical hormones (cortisol and DHEA) and leptin, and MMSE, SSS, and ADL scores.

RESULTS

A significant correlation was present between IL-6 and cortisol levels the first two days after stroke (P < 0.05). In patients with a disturbed diurnal rhythm of cortisol, cortisol and leptin levels were increased (68% and 81% increase, respectively), whilst DHEA levels were unaltered. Half of the patients displayed an abnormal diurnal rhythmicity of leptin at the end of the week. Median TNF-alpha levels for the first two days after stroke also correlated to median leptin levels at the end of the week (P < 0.05). Median IL-6 levels correlated to severity of paresis on days 1 and 7 and to MMSE scores on day 7 (P < 0.05).

CONCLUSIONS

Neuroendocrine disturbances are common and often profound early after stroke. Cytokines seem to be important modulators of these disturbances, including diurnal rhythmicity of cortisol and leptin.

Estrone and progesterone plasma levels of normal cows and cows with parturient paresis

Blood plasma concentrations of estrone and progesterone, calcium and inorganic phosphorus were measured in 22 cows (Swedish Red and White Breed) from 4 weeks prepartum up to 6 days post partum. Ten cows with parturient paresis had Ca levels below 6 mg/100 ml. Data from plasma analyses in individual cows were grouped in the following periods: 28–22, 21–15, 14–8, 7–6, 5–4, 3, 2, 1 day(s) before parturition and 1, 2, 3–6 days after parturition. Statistical comparisons of the levels of the hormones and the ratio progesterone/estrone did not reveal any significant differences between the paretic and normal cows at any time period. The results do not support the theories that high systemic levels of estrogens or an imbalance between estrogen and progesterone predispose towards parturient paresis.

Studies on parturient paresis in dairy cows. V. On the composition and calcium binding capacity of two bovine serum protein fractions, with special regard to parturient paresis

In healthy cows unaffected by imminent or recent calving the protein in serum can directly bind the overwhelming proportion of the bound calcium. In recent calvers this capacity is considerably less. When adding ammonium sulphate to blood serum to 62 % of total saturation a protein fraction precipitates which is mainly albumin. This fraction has a far greater calcium binding capacity than the soluble fraction, which contains most of the serum globulin, and the lowering of this capacity after calving is entirely referable to the former fraction. No difference has been found in these respects between normal cows after calving and cows with parturient paresis.

An analysis of 10 amino acids in the two protein fractions described above showed that the amino acid composition of both exhibits differences between recent calvers and cows outside the calving period, and likewise that each of the two fractions differs in composition between healthy cows after calving and cows with parturient paresis.