Symptomatic venous thromboembolism in Asian major trauma patients: incidence, presentation and risk factors

Background

Trauma patients are known to be at increased risk of venous thromboembolism (VTE), and pulmonary embolism (PE) is one of the preventable causes of mortality in trauma patients. The incidence of VTE in Asian populations was believed to be lower than in Caucasians, but the recent literature suggests that this is not the case. The purpose of this study was to assess the incidence of VTE in Asian major trauma patients and to examine the manner of presentation, use of prophylaxis and risk factors for VTE. While other studies of VTE have addressed general and high-risk populations within Asia, our study is one of the few to examine Asian major trauma patients.

Methods

Data for all patients with VTE were extracted from the Singapore General Hospital trauma database over a 10-year period from 1998 to 2007. Patient profiles and clinical factors were compared to patients without a diagnosis of VTE admitted with injuries in the same time period.

Results

There were 8,615 patients entered into our database in this 10-year period. Thirty-four patients had VTE, with an overall incidence of 0.39 %. Thirteen patients had pulmonary embolism, an incidence of 0.15 %. Of note, 30 % of patients with deep vein thrombosis (DVT) presented with fever alone without limb symptoms. Almost all 34 patients who developed VTE had either head injury, a spinal cord injury or a pelvic/extremity injury. Eighteen patients had head injury, 22 patients sustained pelvic or extremity injury, and three patients had spinal cord injury with paraplegia. Head injury and spinal cord injury with neurologic sequelae were statistically significant risk factors for VTE (p < 0.05).

Conclusion

The incidence of symptomatic VTE in the Asian trauma population is no lower than in the West. The incidence found in this study is similar to the incidence of VTE according to a study using data from the American national trauma data bank using similar study methods and with a similar study population. It is also higher than the incidence in the literature for general post-surgical Asian patients. Fever was the presenting factor in some patients and screening for VTE should not be forgotten when assessing fever in the trauma patient. The strong association between head injury, spinal cord injury and VTE confirms that we should pay special attention to VTE prophylaxis for our patients with these injuries.     

Periocular Cutaneous Anaplastic Large Cell Lymphoma Clearance with Brentuximab Vedotin

The treatment options for primary cutaneous anaplastic large cell lymphoma are numerous, including excision, external beam radiation, methotrexate, and chemotherapy. In patients with recalcitrant tumors, alternative options may be necessary. The authors report a 60-year-old man with a 6cm primary cutaneous anaplastic large cell lymphoma located on the right cheek, near the eye. After failing four months of methotrexate, and due to concern for ocular radiation toxicity, the patient started brentuximab vedotin, an anti-CD30 antibody-drug conjugate. With two cycles of brentuximab vedotin, he had a complete response that was histologically confirmed. Six months after a total of four cycles, he remains clear. He experienced no side effects other than a mild infusion reaction. Brentuximab vedotin may be an effective option for primary cutaneous anaplastic large cell lymphoma in patients with large tumors in cosmetically sensitive areas, those who have not responded to conventional therapy, or those who have contraindications to radiation therapy. Optimal dosing for primary cutaneous anaplastic large cell lymphoma and long-term outcomes are not currently known.Primary cutaneous anaplastic large cell lymphomaa (pcALCL) is a subtype of cutaneous T-cell lymphoma (CTCL) histologically characterized by large, highly typical CD30+ T-cells that clinically presents as a solitary tumor. The authors report a case of a large pcALCL arising on the face with periorbital extension. The size and periorbital location were relative contraindications to radiation therapy and surgery. Oral weekly methotrexate was initiated, but the tumor enlarged in size and the growth extended near the eye despite generally adequate doses. After brief treatment with brentuximab vedotin, the tumor resolved completely.     

Comparison of assessment tools to score recovery of function after repair of traumatic lesions of the median nerve

In this paper the recovery after repair of the median nerve has been used to compare different assessment tools for evaluation of peripheral nerve function: touch (moving 2-point discrimination (2PD); Semmes-Weinstein (SW) monofilament, motor (Medical Research Council (MRC) scale), combined motor and sensory (Dellon modification of the Moberg pick up test; Moberg Recognition test), and pain (visual analogue scale; pinprick-test). The mean (SD) age of our 28 patients was 28 (12) years. The mean (SD) follow-up period was 5 years, 2 months (2 years, 8 months). On the operated side three patients (11%) had a moving 2PD of less than 4 mm. The results of the moving 2PD were compared with those of the SW monofilaments, but with a poor correlation. The MRC score correlated well with opposition movement of the thumb and muscle wasting (p<0.01). We recommend a number of tests to evaluate (the chronological return of) peripheral nerve function.     

Double edge: CDK2AP1 in cell-cycle regulation and epigenetic regulation

Cancer research has been devoted toward an understanding of the molecular regulation and functional significance of cell-cycle regulators in the pathogenesis and development of cancers. Cyclin-dependent Kinase 2-associated Protein 1 (CDK2AP1) is one such cell-cycle regulator, originally identified as a growth suppressor and a prognostic marker for human oral/head and neck cancers. Functional importance and the molecular mechanism of CDK2AP1-mediated cell-cycle regulation have been documented over the years. Recent progress has shown that CDK2AP1 is a competency factor in embryonic stem cell differentiation. Deletion of CDK2AP1 leads to early embryonic lethality, potentially through altered differentiation capability of embryonic stem cells. More intriguingly, CDK2AP1 exerts its effect on stem cell maintenance/differentiation through epigenetic regulation. Cancer cells and stem cells share common cellular characteristics, most prominently in maintaining high proliferative potential through an unconventional cell-cycle regulatory mechanism. Cross-talk between cellular processes and molecular signaling pathways is frequent in any biological system. Currently, it remains largely elusive how cell-cycle regulation is mechanistically linked to epigenetic control. Understanding the molecular mechanism underlying CDK2AP1-mediated cell-cycle regulation and epigenetic control will set an example for establishing a novel and effective molecular link between these two important regulatory mechanisms.     

Confocal laser scanning microscopy and ultrastructural study of VGLUT2 thalamic input to striatal projection neurons in rats

We examined thalamic input to striatum in rats using immunolabeling for the vesicular glutamate transporter (VGLUT2). Double immunofluorescence viewed with confocal laser scanning microscopy (CLSM) revealed that VGLUT2+ terminals are distinct from VGLUT1+ terminals. CLSM of Phaseolus vulgaris‐leucoagglutinin (PHAL)‐labeled cortical or thalamic terminals revealed that VGLUT2 is rare in corticostriatal terminals but nearly always present in thalamostriatal terminals. Electron microscopy revealed that VGLUT2+ terminals made up 39.4% of excitatory terminals in striatum (with VGLUT1+ corticostriatal terminals constituting the rest), and 66.8% of VGLUT2+ terminals synapsed on spines and the remainder on dendrites. VGLUT2+ axospinous terminals had a mean diameter of 0.624 μm, while VGLUT2+ axodendritic terminals a mean diameter of 0.698 μm. In tissue in which we simultaneously immunolabeled thalamostriatal terminals for VGLUT2 and striatal neurons for D1 (with about half of spines immunolabeled for D1), 54.6% of VGLUT2+ terminals targeted D1+ spines (i.e., direct pathway striatal neurons), and 37.3% of D1+ spines received VGLUT2+ synaptic contacts. By contrast, 45.4% of VGLUT2+ terminals targeted D1‐negative spines (i.e., indirect pathway striatal neurons), and only 25.8% of D1‐negative spines received VGLUT2+ synaptic contacts. Similarly, among VGLUT2+ axodendritic synaptic terminals, 59.1% contacted D1+ dendrites, and 40.9% contacted D1‐negative dendrites. VGLUT2+ terminals on D1+ spines and dendrites tended to be slightly smaller than those on D1‐negative spines and dendrites. Thus, thalamostriatal terminals contact both direct and indirect pathway striatal neurons, with a slight preference for direct. These results are consistent with physiological studies indicating slightly different effects of thalamic input on the two types of striatal projection neurons. J. Comp. Neurol., 521:1354–1377, 2013. © 2012 Wiley Periodicals, Inc.     

Cost analysis of risperidone long-acting injection in the treatment of schizophrenia and schizoaffective disorders in Hong Kong: An approach using generalised estimating equations

Schizophrenia is one of the most expensive psychiatric illnesses. This study compared retrospectively health-care resources consumed 12 months before and 24 months after risperidone long-acting injection (RLAI) treatment in Hong Kong. A mirror-image analysis was conducted using data (N=191) from three public hospitals in Hong Kong from 2003 to 2007. The main outcome measure was hospitalisation cost. Other secondary outcomes such as hospitalisation episodes, outpatient visits and adverse events were also compared. A predictive model was established using linear regression based on generalised estimating equations. Analysis showed that RLAI was associated with a reduction in hospitalisation cost by HK$10,001,390 (24.7%) (HK$40,418,694 vs. HK$30,417,303; P-value <0.05). Days of hospitalisation were reduced by 1538 days (10.1%) (15,271 vs. 13,733; P-value <0.05). The predictive model estimated that the hospitalisation cost of patients using RLAI was only 11.1% (3.1–3.93%, 95% confidence interval (CI)) compared to those receiving conventional antipsychotics combined with oral risperidone. Cost of hospitalisation was significantly reduced after RLAI therapy. However, results should be considered as indicative or suggestive only, due to potential channelling bias where certain drug regimens are preferentially prescribed to patients with particular conditions. The findings from our study may be useful in health-care decision making considering treatment options for schizophrenia in resource-limited settings.     

When nouns and verbs degrade: Facilitating communication in semantic dementia

Background: Little is known about how to maintain communicative effectiveness in semantic dementia as the disease progresses from impairment in word retrieval to a loss of conceptual knowledge.

Aim: The purpose of this study is twofold. The first objective is to characterise communicative effectiveness using a modified framework derived from Chapman and Ulatowska (1997 Chapman, S. B. and Ulatowska, H. K. 1997. “Discourse in dementia: Consideration of consciousness.”. In Language structure, discourse and the access to consciousness, Edited by: Stamenov, M. I. 155–188. Philadelphia: John Benjamin Publishing Company.  [Google Scholar]) that integrates two components: codification of ideas (falling on a continuum from verbal to nonverbal and generative to automatic forms) and functions of communication (imaginative, heuristic, informative, personal, interactional, regulatory, and instrumental). The second objective is to outline principles of a discourse intervention that focuses on communicative effectiveness.

Method & Procedures: The participant was Mr Bobby V, a man with semantic dementia. His communication abilities were characterised at diagnosis and 24 months later using the framework of communicative effectiveness, based on discourse samples, clinical observation, and caregiver report. From the time of diagnosis, Bobby V received discourse intervention, which focused on maintaining his communication abilities using all available communication resources. We outline principles of discourse intervention in semantic dementia based on our experience of delivering individual and group intervention to Bobby V.

Outcomes and Results: The communicative effectiveness framework described here could be used to characterise communication skills, set therapy goals, and monitor progress in semantic dementia. Discourse intervention likely facilitated Bobby V's continued success in maintaining communication despite progressive loss of nouns and verbs.

Conclusions: Targeting conversational effectiveness in terms of communicative functions offers a promising and ecologically valuable intervention for people with semantic dementia, as it allows individuals with this form of dementia to connect meaningfully with people in their immediate surroundings well into the later stages of the disease.     

Surgical treatment of complex spinal cord lipomas

Purpose

This paper shows the long-term benefits of total/near-total resection of complex spinal cord lipomas and meticulous reconstruction of the neural placode, and specifically, its advantage over partial resection, and over non-surgical treatment for the subset of children with asymptomatic virgin lipomas.

Methods

The technique of total resection and placode reconstruction, together with technical nuances, are described in detail. We added 77 patients with complex lipomas to our original lipoma series published in 2009 and 2010, to a total of 315 patients who had had total or near-total resection and followed for a span of 20 years. Long-term outcome is measured by overall progression-free survival (PFS) with the Kaplan–Meier analysis, and by subgroup Cox proportional recurrence hazard analysis for the influence on outcome of 4 predictor variables of lipoma type, presence of symptoms, prior surgery, and post-operative cord–sac ratio. These results are compared to an age-matched, lesion-matched series of 116 patients who underwent partial lipoma resection over 11 years. The results for total resection is also compared to two large published series of asymptomatic lipomas followed without surgery over 9 to 10 years, to determine whether prophylactic total resection confers better long-term protection over conservative treatment for children with asymptomatic lipomas..

Results

The PFS after total resection for all lipoma types and clinical subgroups is 88.1 % over 20 years versus 34.6 % for partial resection at 10.5 years (p?<?0.0001). Culling only the asymptomatic patients with virgin (previously unoperated) lipomas, the PFS for prophylactic total resection for this subgroup rose to 98.8 % over 20 years, versus 67 % at 9 years for one group of non-surgical treatment and 60 % at 10 years for another group of conservative treatment. Our own as well as other published results of partial resection also compare poorly to non-surgical treatment for the subset of asymptomatic virgin lipomas. Multivariate subgroup analyses show that cord–sac ratio is the only independent variable that predicts outcome, with a 96.9 % PFS for ratio <30 % (loosest sac), 86.2 % for ratio between 30 and 50 %, and 78.3 % for ratio >50 % (tightest sac), and a threefold increase in recurrence hazard for high ratios (p?=?0.0009). Pre-operative patient profiling using multiple correspondence analysis shows the ideal patient for total resection is a child less than 2 years old with a virgin asymptomatic lipoma, who, with a PFS of 99.2 %, is virtually cured by total resection.

Conclusion

Total/near-total resection of complex lipomas and complete reconstruction of the neural placode achieves far better long-term protection against symptomatic recurrence than partial resection for all lesions; and for the subset of asymptomatic virgin lipomas, also better than non-surgical treatment. Partial resection in many cases produces worse outcome than conservative treatment for asymptomatic lesions.