Heparin-induced thrombocytopenia: principles for early recognition and management

Heparin-induced thrombocytopenia (HIT) is a potentially devastating complication of therapy with either unfractionated or low-molecular-weight heparin. Thrombocytopenia is no longer essential for the diagnosis of HIT, since a 50% drop in the platelet count may be a more specific indicator. Once HIT is clinically suspected, heparin should be stopped immediately and direct thrombin inhibitor therapy started; waiting for laboratory confirmation may be catastrophic.     

Positron emission tomography demonstrates radiation-induced changes to nonirradiated lungs in lung cancer patients treated with radiation and chemotherapy

STUDY OBJECTIVES: To determine whether acute changes in shielded lungs can be detected by positron emission tomography (PET) after radiation therapy. DESIGN: Retrospective cohort study. SETTING: University-affiliated medical center. PATIENTS: Sixteen patients undergoing radiation therapy for lung cancer who had PET scans after receiving treatment. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Thirteen of 16 patients (81.2%) showed increased (18)fluoro-2-deoxyglucose uptake in shielded nonirradiated lung in the following four distinct patterns: (1) contralateral peripheral pleural uptake in 5 of 16 patients (31.2%); (2) ipsilateral peripheral pleural uptake in 5 of 16 patients (31.2%); (3) bilateral peripheral pleural uptake in 1 of 16 patients (6.2%); and (4) bilateral diffuse background uptake in 1 of 16 patients (6.2%). This last patient developed clinically evident radiation pneumonitis. CONCLUSIONS: Increased lung metabolic activity can be demonstrated in the nonirradiated lung in patients who have undergone radiation therapy for lung cancer and can be detected by PET scanning. PET scanning of lungs in irradiated patients may provide an early demonstrable barometer of pulmonary toxicity. If verified, this imaging tool could prove to be useful in monitoring patients receiving radiation therapy for thoracic malignancies and may have predictive value for subsequent fibrosis. PET scanning may also be an important tool in future studies to further elucidate the pathogenetic mechanism of radiation-induced lung injury.     

Acute myocardial ischemia following accidental intravenous administration of epinephrine in high concentration

Inadvertent and accidental epinephrine overdose might result in potentially lethal complications. We present a case of acute epinephrine toxicity resulting in acute myocardial ischemia in a young boy with combined variable immunodeficiency syndrome who developed severe allergic reaction to intravenous immunoglobulin, and was subsequently given epinephrine by mistake intravenously rather than subcutaneously. He developed significant ischemic changes in standard 12-lead electrocardiogram, transiently raised cardiac enzymes, reduced left ventricular systolic function, pulmonary edema and pulmonary hemorrhage. It is suggested that special precautionary measures should be taken regarding the dose and the route while administering epinephrine to avoid mishaps.     

Elevated plasma osteoprotegerin levels are associated with venous thrombosis and bleeding in patients with polycythemia vera

Patients with polycythemia vera (PV) have an increased risk for the development of thrombohemorrhagic complications. The pathogenesis of these complications is still unclear. An important role in vascular disease has recently been attributed to osteoprotegerin (OPG). It has been shown that various tissues of the cardiovascular system produce OPG, and there is growing evidence of an association between elevated serum OPG levels and cardiovascular morbidity. We evaluated if OPG was associated with an increased risk of venous thrombosis or bleeding complications in a cohort of 114 PV patients. The analysis consisted of a retrospective and a prospective part. In the retrospective univariate analysis, a one unit change in OPG caused the odds of venous thrombosis to increase by 40% (p=0.005) and the odds of bleeding to increase by 52% (p=0.001). Multivariate analysis only slightly attenuated the association to 33% (p=0.03) and 37% (p=0.013) for venous thrombosis and bleeding, respectively. OPG was also related to the development of the combined outcome of venous thrombosis and bleeding in the prospective analysis (log-rank-test: p=0.017). This is the first report that links the occurrence of venous thrombosis or bleeding to elevated OPG levels.     

Metastatic carcinoid to the conducting system-is it a rare or merely unrecognized manifestation of carcinoid cardiopathy?

We report a unique case of carcinoid cardiopathy. The patient, a 59-year-old white woman with a known carcinoid tumor of the terminal ileum, presented with complete heart block and subsequently died. Because of her clinical presentation, we examined the conducting system at autopsy. The atrioventricular node was heavily infiltrated by metastatic carcinoid. The tumor was also seen in the surrounding atrial myocardium. No other metastatic lesions were seen in the heart. Carcinoid cardiopathy in the form of right-sided endocardial and valvular thickening has been well documented in the literature, and we found these features in our case as well. To our knowledge, carcinoid has never been documented in the cardiac conducting system until now. We found 2 cases of possible involvement of the conducting system reported in the literature. Unfortunately, the conducting system was not examined postmortem in either of these cases. If conducting system involvement is not unique to the present case, patients with metastatic carcinoid and cardiac problems may require different management. We hope that this case will stimulate further postmortem study of the conducting system in patients with metastatic carcinoid tumor.     

Occurrence of Microplastics and Heavy Metals in Aquatic and Agroecosystem: A Case Study

Bulletin of Environmental Contamination and Toxicology - A case study was conducted to evaluate the microplastics and heavy metals distribution in Pakistani farmland. Wastewater, soil, and...