Sickle-Cell Trait as a Risk Factor for an Unprovoked Venous Thromboembolism: A Case Report

In this case report, we examine the increased risk of venous thromboembolism (VTE) in patients with sickle-cell trait (SCT), illustrated by a patient with SCT who developed pulmonary embolism (PE) despite low scores on conventional risk assessment tools. The case prompts both a discussion of risk assessment and management strategies in this population.

Acute Cerebral Infarct and Saddle Pulmonary Embolism in a Post-COVID-19 Patient Treated With Thrombolytics

The coronavirus disease 2019 (COVID-19) has been associated with a prothrombotic state during active infection with the severe acute respiratory syndrome coronavirus (SARS-CoV-2). However, reports of delayed multisystemic COVID-19-associated thromboembolic sequelae are limited in the current literature. In addition, the initiation of prophylactic antithrombotic therapy in patients for the prevention of such events during and after infection remains controversial due to conflicting reports. Here, we present evidence to support that patients with comorbid conditions are at higher risk for multisystemic COVID-19-associated thromboembolic events and propose that beginning prophylactic therapy in this population could lead to more favorable outcomes. We describe a 67-year-old male who presented with left-sided weakness and worsening shortness of breath and was diagnosed with COVID-19 approximately one month prior. Initial computed tomography (CT) of the brain showed an age-indeterminate cerebellar infarct. On CT angiography (CTA) of the neck, a saddle embolus was incidentally found and was confirmed on an immediate follow-up chest CT. After consultation with neurology, a decision was made to administer thrombolytics at the standard recommended stroke dosing. The patient was admitted to the ICU and received mechanical thrombectomy two days later. At the time of hospital discharge, the patient still had left-sided weakness on examination and required no additional oxygen support. This report reviews the prevalence of delayed sequelae of COVID-19 and the benefit of prophylactic antithrombotic therapy during active and post-SARS-CoV-2 infection. It is important for emergency medicine physicians to recognize that patients who have recovered from COVID-19 are at high risk for delayed thromboembolic disease, even in the absence of personal or family history of coagulopathy. This underscores the necessity of obtaining imaging studies in high-risk patients who present with acute symptoms that cannot be explained by other probable causes. In addition, patients should be encouraged to follow up with their primary care providers to discuss prophylactic anticoagulation therapy as it could be beneficial during and post-COVID-19.

Incidence of sickle cell disease patients with pulmonary embolism admitted to the intensive care unit in Bahrain

OBJECTIVES

To describe the incidence of pulmonary embolism (PE) in sickle cell disease (SCD) patients admitted to the intensive care unit (ICU).

METHODS

A retrospective descriptive analysis was conducted with 124 SCD patients diagnosed with PE or suspected PE admitted to the ICU of Salmaniya Medical Complex, Manama, Bahrain between May 2017 and April 2018. A data collection form was used to obtain information on the history and demographics of PE patients.

RESULTS

A total of 124 patients diagnosed with SCD were admitted to the ICU during the study period. Male patients slightly outnumbered (n=75; 56.4%) female patients, and the average age was in the mid- thirties (mean=37.4 years). The main diagnosis leading to ICU admission was vaso-occlusive crisis. The average hemoglobin level was 8.6 mg/dl, hemoglobin S% was 55.8%, and the length of stay in the ICU was 5.3 days. A total of 5 patients were diagnosed with PE with an incidence rate of 3.8%. All PE patients were females, which resulted in a significant relationship between gender and the likelihood of developing PE. No statistical relationship existed between the likelihood of developing PE and patient age, hemoglobin, hemoglobin S%, length of stay in ICU, and mortality.

CONCLUSION

The demographic characteristics of the population included a male predominance, age in the mid-thirties, and vaso-occlusive crisis diagnosis upon admission to the ICU. The incidence of PE was significantly related to female gender. No significant relationship existed between the likelihood of developing PE and age, hemoglobin, hemoglobin S%, length of ICU stay, or mortality.

Risk factors for venous thromboembolism in endometrial cancer

Background

Venous thromboembolism (vte) in malignancy is associated with poor outcomes. We conducted a retrospective review of vte in patients with endometrial cancer to characterize the vte incidence, identify factors that contribute to vte risk, and compare survival outcomes in patients with and without vte.

Methods

A retrospective chart review identified 422 eligible patients who underwent surgery for endometrial cancer (1 January 2014 to 31 July 2016). The primary outcome was vte. Binary logistic regression identified risk factors for vte; significant risk factors were included in a multivariate analysis. Kaplan-Meier estimates are reported, and log rank tests were used to compare the Kaplan-Meier curves. Risk-adjusted estimates for overall survival based on vte were determined using a multivariate Cox proportional hazards model.

Results

The incidence of vte was 6.16% overall and 0.7% within 60 days postoperatively. Non-endometrioid histology, stages 3 and 4 disease, laparotomy, and age (p < 0.1) were identified as factors associated with vte and were included in a multivariate analysis. The overall death rate in patients with vte was 42% (9% without vte): hazard ratio, 5.63; 95% confidence interval, 2.86 to 11.08; p < 0.0001. Adjusting for age, stage of disease, and histology, risk of death remained significant for patients with a vte: hazard ratio, 2.20; 95% confidence interval, 1.09 to 4.42; p = 0.0271.

Conclusions

A method to identify patients with endometrial cancer who are at high risk for vte is important, given the implications of vte for patient outcomes and the frequency of endometrial cancer diagnoses. Factors identified in our study might assist in the recognition of such patients.

Performance Monitoring during Visual Priming

Repetitive performance of single-feature (efficient or pop-out) visual search improves RTs and accuracy. This phenomenon, known as priming of pop-out, has been demonstrated in both humans and macaque monkeys. We investigated the relationship between performance monitoring and priming of pop-out. Neuronal activity in the supplementary eye field (SEF) contributes to performance monitoring and to the generation of performance monitoring signals in the EEG. To determine whether priming depends on performance monitoring, we investigated spiking activity in SEF as well as the concurrent EEG of two monkeys performing a priming of pop-out task. We found that SEF spiking did not modulate with priming. Surprisingly, concurrent EEG did covary with priming. Together, these results suggest that performance monitoring contributes to priming of pop-out. However, this performance monitoring seems not mediated by SEF. This dissociation suggests that EEG indices of performance monitoring arise from multiple, functionally distinct neural generators.

Treating Venous Thromboembolism Post Intracranial Hemorrhage: A Case Report

Venous thromboembolism (VTE) is a significant issue occurring due to genetic, acquired and circumstantial risk factors. Treatment is according to the clinical situation and judgment for long term anticoagulation based on individual risk. Anticoagulation after a history of a hemorrhagic stroke poses a therapeutic dilemma. We present a case of a 68-year-old male who presented with right-sided chest pain and shortness of breath. Workup included a CT that was positive for multiple right-sided pulmonary emboli (PE). The patient has a past medical history of Factor V Leiden Mutation, recurrent PE, and deep vein thrombosis (DVT). Two months prior he was diagnosed with a 1.3-cm intracranial hemorrhage (ICH) from multiple cavernous angiomas. At that time his warfarin was discontinued and an inferior vena cave (IVC) filter was placed. Facing the recent ICH and now multiple and recurrent PE, it was decided to resume anticoagulation based on ICH location. ICH from a deep source is likely a better characteristic that favors a resumption of anticoagulation. Our case will highlight that IVC filters cannot be solely relied upon in patients that are at high risk for thrombotic events with underlying genetic thrombophilia.

Using Injury Severity Score and Abbreviated Injury Score to Determine Venous Thromboembolism Risk

Background

Venous thromboembolisms (VTEs) continue to be a leading cause of death among trauma patients. Predicting which patients will develop a VTE can be difficult. This study investigated whether the Injury Severity Score (ISS) could be used in conjunction with the Abbreviated Injury Score (AIS) to assess a trauma patient’s risk for subsequent VTE development.

Materials and Methods

Participants were found by querying a trauma center registry. There were 2,213 patients included for evaluation. The patients were categorized based on their ISS and the anatomical region with the greatest injury (determined by the AIS). Odds ratios for developing VTEs were calculated for each ISS category.

Results

The results showed that in most categories VTE risk increased as ISS increased. Patients with trauma to their head/neck, chest, or extremities with ISS values of 21 or greater were all at significantly increased risk for VTE development. Patients in these categories with an ISS less than 21 seemed to have little or only moderately increased odds of developing a VTE, although these values were not statistically significant. Patients with abdominal trauma were at increased risk even with ISS values of 11-21.

Conclusion

Trauma to the head/neck region, chest, and extremities (including pelvis) with ISS of 21 or higher had significantly increased odds of developing a VTE. Patients with abdominal trauma of any severity appeared to have increased odds of developing a VTE.

Submassive Pulmonary Embolism: A Re-evaluation of Hemodynamic Instability

Current medical management of pulmonary embolism (PE) is driven by risk stratification, with thrombolytic treatment reserved for patients with hemodynamic instability. We describe a case of a man with acute submassive bilateral pulmonary emboli and a right popliteal deep vein thrombosis (DVT), who had persistent shortness of breath, tachycardia, and hypoxemia but remained normotensive and was therefore not treated with thrombolytics until he suffered a fatal cardiac arrest on hospital day six. We examine the indications, risks, and potential benefits of thrombolytic treatment in patients with submassive PE who exhibit signs of instability but do not meet current indications for thrombolytic treatment with persistent hypotension or shock.

The Role of Serial Ultrasounds in Diagnosing Suspected Deep Venous Thrombosis

Venous thromboembolisms (VTE), which include deep venous thrombosis (DVT) and pulmonary embolism (PE), are a major cause of morbidity and mortality in the United States and globally. This often underdiagnosed medical condition has many known risk factors including pregnancy, malignancy, immobility, exogenous estrogen use, and hereditary factors. A significant portion of emergency department visits involves ruling out these diseases.

This case presents a woman with unilateral leg pain and swelling who initially had a negative emergency room workup including a negative lower extremity Doppler study. Upon a repeat visit, she was found to have extensive deep venous thrombosis and was diagnosed with B-cell lymphoma. This case highlights the importance of having patients return for repeat imaging if Dopplers are negative in the initial encounter.

AB041. Evolution of PDE5 inhibitors in Korea

After launching of Sildenafil Citrate, the last invention of 20^th century, in 1998, oral PDE5 inhibitor has been established as first line treatment of erectile dysfunction (ED) and shift new paradigm of diagnosis and treatment of ED. The big success of sildenafil in pharmaceutical R&D induced the consecutive development of the so-called ‘The second viagra’, e.g., Tadalafil and Vardenafil in 2003. Currently, these 3 kinds of PDE5 inhibitors are most famous and well-known PDE5 inhibitors worldwide. In Korea, another 3 kinds of PDE5 inhibitors, Udenafil (2005), Mirodenafil (2007) and Avanafil (2011) have been developed and 6 kinds of PDE5 inhibitors were used in the competitive market. In last 10 years, the evolution of PDE5 inhibitors competition has changed the dosage concept from on-demand to daily low-dose and applied for other indications beyond ED such as pulmonary hypertension in Sildenafil, and BPH/LUTS in Tadalafil and penile rehabilitation with daily low dose. For the preparations of PDE5 inhibitors, the termination of Korean patent of sildenafil in 2012 released 4 preparations of PDE5 inhibitors, tablet, oro-disposable film, granule and chewable of 60 generic Sildenafil from 49 companies. The oro-disposable film and chewable are favorable from patients. In Korea, patent of Cialis will be terminated in near future and the development of generic drugs like Viagra will go in the right way and as expected. The long half-life of Tadalafil enabled the approval for BPH/LUTS with daily low dose usage. In turn, the generic Cialis also will be developed as various preparations including oro-disposable film and as combination with antihypertensive for ED/HT, PDE5 inhibitor with alpha blockers for ED/LUTS and PDE5 inhibitor with antidepressant for ED/PE. The present lecture review the evolution of PDE5 inhibitors from the development of sildenafil citrate in 1998 to combination in 2015, Korea.

Diagnostic pitfalls of discriminating lymphoma-associated effusions

High serum lactate dehydrogenase (LDH) level, immunologic defects, enlarged mediastinal lymph nodes, and frequent hydration and diuresis in lymphoma patients may affect the development of pleural effusion (PE). The study was to assess the clinical utility of "Light criteria" and the "recommended algorithm for investigating PEs" in patients with lymphoma.The characteristics of 126 PEs of lymphoma patients who underwent diagnostic thoracentesis between January 1, 2003, and April 30, 2012, were reviewed. Using Light criteria, 29 (23%) PEs were incorrectly classified. The sensitivity for exudates in Light criteria was 88% and the specificity was only 44%. In 32 transudates, PE LDH correlated with blood LDH concentration (P < 0.001, r = 0.66). Nine transudates were misclassified as exudates (50%; 9/18) just due to PE LDH more than two-thirds the upper limits. Among the 56 bilateral PEs, 33 (59%) were exudates. Ten (63%) polymorphonuclear (PMN)-predominant exudative PEs were malignant. Infective PEs were often mononuclear (67%) rather than PMN predominant.When a patient has lymphoma with either unilateral or bilateral PE, thoracentesis for microbiological testing and cytology is imperative. Carefully clinical correlation in addition to the result from Light criteria and differential cell count is essential for prompt management.

Temporal changes in deep venous thrombosis risk after electrical injury

Previous work has used the National Burn Repository to examine deep venous thrombosis (DVT) after electrical injury. However, these studies were limited and could not examine when DVT occurs after electrical injury. In addition, the utility of risk assessment models for DVT risk stratification has not been examined in this patient population. The authors performed a retrospective chart review of electrically injured patients at a single, American Burn Association- and American College of Surgeons-verified burn center over a 9-year period. Risk factors were identified and used to calculate Caprini scores at baseline and time of discharge. Outcomes of interest included symptomatic DVT or pulmonary embolism and time to DVT or pulmonary embolism. A total of 77 electrically injured patients were identified. DVT incidence was 6.5%. Patients with DVT had significantly higher TBSA (27.8% vs 3.8%), mean number of operations (4.8 vs 0.3), central venous catheter insertion (100% vs 5.3%), ventilator days (16.2 vs 0.3), intensive care unit days (24.4 vs 0.9), and mean change in Caprini score (18.6 vs 1.3) during hospitalization. Baseline Caprini scores were low, and DVT events occurred only after multiple risk factors were present; the average time-to-event was hospital day 17. Among patients with Caprini score >8, DVT incidence increased to 62%. In our single-center experience, the Caprini score was able to quantify DVT risk after electrical injury. In our series of 77 patients, the overall incidence of DVT was 6.5%. However, among patients whose Caprini score reached >8 during hospitalization, DVT incidence increased to 62%.

Attention systems and the organization of the human parietal cortex

Event-related functional magnetic resonance imaging was used to compare activity in the human parietal cortex in two attention-switching paradigms. On each trial of the visual switching (VS) paradigm, subjects attended to one of two visual stimuli on the basis of either their color or shape. Trials were presented in blocks interleaved with cues instructing subjects to either continue attending to the currently relevant dimension or to switch to the other stimulus dimension. In the response switching (RS) paradigm, subjects made one of two manual responses to the single stimulus presented on each trial. The rules for stimulus-response mapping were reversed on different trials. Trials were presented in blocks interleaved with cues that instructed subjects to either switch stimulus-response mapping rules or to continue with the current rule. Brain activity at "switch" and "stay" events was compared. The results revealed distinct parietal areas concerned with visual attentional set shifts (VS) and visuomotor intentional set shifts (RS). In VS, activity was recorded in the lateral part of the intraparietal region. In RS, activity was recorded in the posterior medial intraparietal region and adjacent posterior superior and dorsomedial parietal cortex. The results also suggest that the basic functional organization of the intraparietal sulcus and surrounding regions is similar in both macaque and human species.

The expression and function of Notch pathway genes in the developing rat eye

The Notch gene plays a role in the development of disparate tissues in multiple organisms. Because the vertebrate eye is an excellent model system for both patterning and cell fate determination, two processes that can involve Notch, we examined the expression patterns of Notch 1 and Notch 2, and their ligands Delta and Jagged, in the developing rat eye. Notch 1 and Delta were found to be expressed in the neural retina during the period of cell fate determination and differentiation. Notch 2 was found to be expressed in the non-neuronal derivatives of the optic cup, including the pigment epithelium, optic stalk, and ciliary body. Jagged was expressed in distinct regions within the optic vesicle, ciliary body, and lens, with patterns that changed over time. The potential function of Notch 1 in cell-type specification and differentiation was examined by introducing a constitutively active form of Notch 1 in vivo using a replication-incompetent retrovirus. This form of Notch 1 was found to cause abnormal growth and interfere with the differentiation of multiple retinal cell types.