Cerebral thrombosis in patients with β-thalassemia: a systematic review

A hypercoagulable state has been documented in patients with β-thalassemia. It could result in thromboembolic events in several organs including brain involvement, which deserves particular attention. We summarized the prevalence of cerebral involvement in patients with β-thalassemia worldwide. We conducted an electronic search on PUBMED (MEDLINE), SCOPUS, and Google Scholar databases up to January 2011. Overall 152 thalassemic patients with cerebral thromboembolic events and a proportion of 1.13% (134 of 11770) were recorded. From all patients with cerebral thromboembolic events, 74 (48%) were splenectomized. Cerebral thromboembolic events were reported after transfusion in six β-thalassemia major, and two β-thalassemia intermedia patients. Three β-thalassemia major patients had irregular transfusion and 22 β-thalassemia intermedia patients were not transfused. Thrombocytosis were determined in 11 β-thalassemia major, and 15 β-thalassemia intermedia patients. Cardiomyopathy was present in 13 β-thalassemia major and four β-thalassemia intermedia patients. Also, nine β-thalassemia major patients had diabetes. Activated protein C resistant, decreased protein C or protein S or plasminogen level was detected in eight β-thalassemia major patients. Cerebral involvement appears to be associated with increasing age, transfusion naivety, splenectomy, thrombocytosis, intensive transfusion, decreased protein C level, and having risk factors for cerebrovascular accident such as cardiomyopathy, and diabetes. In light of these findings, diagnostic MRI is recommended in high-risk groups to screen for early asymptomatic brain damage. If brain ischemia is found, the administration of antiplatelet aggregants or blood transfusion is likely to be beneficial. In addition, in thalassemic patients who complicated with a thromboembolic event, secondary prophylaxis could be helpful to prevent cerebral thromboembolic events.     

Effect of bivalirudin compared with unfractionated heparin plus abciximab on infarct size and myocardial recovery after primary percutaneous coronary intervention: the horizons-AMI CMRI substudy

Background : Myocardial infarct size is a strong independent predictor of mortality in patients with ST‐elevation myocardial infarction (STEMI). In the Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction (HORIZONS‐AMI) trial, bivalirudin compared with unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor reduced cardiac mortality in STEMI patients, which was attributed to reduced major bleeding. Whether a possible reduction in infarct size with bivalirudin may have contributed to the enhanced survival with this agent is unknown. Methods : Cardiac magnetic resonance imaging was performed within 7 days and after 6 months in 51 randomized patients from a single center in HORIZONS‐AMI trial (N = 28 bivalirudin, N = 23 heparin plus abciximab). Infarct size, microvascular obstruction (MVO), left ventricular ejection fraction (LVEF), and LV end‐diastolic and end‐systolic volume indices were evaluated. Results : Infarct size was not significantly different after treatment with bivalirudin compared with heparin plus abciximab either within 7 days (median 9.3% [interquartile range 4.9%, 26.6%] vs. 20.0% [5.9%, 28.2%], P = 0.28) or at 6 months 6.7% [3.8%, 20.0%] vs. 8.2% [1.8%, 16.5%], P = 0.73). MVO was present in 28.6% versus 34.8% of patients respectively (P = 0.63). LVEF and LV volume indices also did not significantly differ between the two groups at either time period, nor were differences in myocardial recovery evident. Conclusions : In conclusion, in the HORIZONS‐AMI Cardiac magnetic resonance imaging (CMRI) substudy, cardiac magnetic resonance imaging within 7 days and at 6 months after primary percutaneous coronary intervention (PCI) did not demonstrate significant differences in infarct size, MVO, LVEF, or LV volume indices in patients treated with bivalirudin compared with unfractionated heparin plus abciximab. © 2011 Wiley Periodicals, Inc.     

Fourth ventricle rosette-forming glioneuronal tumour in children: an unusual presentation in an 8-year-old patient, discussion and review of the literature

Introduction

Rosette-forming glioneuronal tumour of the fourth ventricle is a rarely described entity. While usually having an indolent course and hence classified as a WHO grade 1 tumour, the precise characteristics and risk of recurrence of this tumour are still unknown. In addition, the preferred treatment modality remains unclear.

Discussion

We present a case of an 8-year old with an early recurrence of 9 months after undergoing a sub-total resection of her tumour. Following further resection, there was no tumour present on the 3-month follow-up. In order to better characterise this tumour entity, we performed a review of the available literature on the subject. We found that it mainly affected young adults and had a female predominance. While initially these tumours were described in the fourth ventricle, the current literature suggests that they may be found in a larger variety of sites within the brain and spinal cord. There are several reports of recurrence occurring between 9 months and 10 years following surgery. There is as yet no feature of the tumour that appears to predict the risk of recurrence.

Conclusion

This phenomenon warrants further examination to discover if there is a sub-section of tumours that is likely to recur, and until this is established, all patients should be followed up at regular intervals.     

Gender differences on benefits and risks associated with oral antithrombotic medications for coronary artery disease

Introduction: Despite the significant advances in the pharmacological and interventional management of patients with cardiovascular disease (CVD) over the last decades, cardiovascular mortality remains the leading cause of death. Large randomized clinical trials have investigated the efficacy and safety of different antithrombotic medications in patients with CVD. Although female gender is generally underrepresented in these clinical trials, most analyses clearly indicate that both men and women may accrue therapeutic benefits from antithrombotic management strategies.

Areas covered: This review aims to provide a comprehensive and focused update on gender-related comparative clinical studies of antithrombotic therapies in patients suffering from CVD.

Expert opinion: Current evidence supports the understanding of a similar therapeutic effect between genders with signals of an increased risk of bleeding in women. However, important gaps in evidence exist due to the overall limited percentage of women that have been enrolled in randomized controlled trials. A greater awareness of gender-related issues in antithrombotic therapy should be promoted among physicians and further evidence from large clinical trials looking at the safety and efficacy balance of different antithrombotic strategies in women is warranted.     

Therapeutic agents in perioperative third molar surgical procedures

Surgical extraction of third molars is one of the most common of all surgical procedures. The outcome of third molar surgery includes pain, trismus, edema, nausea, infection, and alveolar osteitis. The intent of this article is to provide a literature review and analysis of the various chemotherapeutic agents used to control, minimize, or eliminate these outcomes. Unfortunately, comparison of the published studies represents a tremendous challenge because of the variability in parameters and methods used for each study. A trend does exist among many of the current researchers, who realize that randomized, controlled, evidence-based research rather than personal experience is necessary to develop appropriate guidelines for using chemotherapeutic agents.