The risk of recurrent venous thromboembolism

Venous thromboembolism (VTE) is a chronic rather than acute disease. After withdrawal of secondary thromboprophylaxis, many patients will experience a subsequent episode of thrombosis. Of these patients, approximately 5% will die from pulmonary embolism. The risk of recurrent VTE depends on the number of risk factors and their severity. High-risk patients, i.e. those with a natural coagulation inhibitor deficiency, recurrent thrombosis, active cancer, the lupus anticoagulant or compound clotting defects most probably benefit from indefinite oral anticoagulation. In these patients the risk of bleeding due to anticoagulant treatment seems to be outweighed by the risk of VTE. Patients with hyperhomocysteinemia or high factor (F) VIII plasma levels are also at an increased risk of recurrence. The optimal duration of secondary thromboprophylaxis in these patients is currently under investigation. Patients with the heterozygous F V Leiden mutation or the G20210A mutation in the F II gene do not require extended anticoagulation since their risk of recurrence is similar as in patients without the aforementioned mutations. Patients with VTE secondary to surgery or trauma have a relatively low risk of recurrence. In these patients short-term secondary thromboprophylaxis (6 to 12 weeks) is justified whereas patients with a first episode of spontaneous VTE should be treated with oral anticoagulants for a longer period of time (3 to 6 months).     

Natural antibodies to oxidation‐specific epitopes: innate immune response and venous thromboembolic disease

Essentials

• Natural antibodies to oxidation‐specific epitopes have antithrombotic properties.
• We evaluated the relation between natural IgM and IgG antibodies and the venous thrombosis risk.
• Risk of recurrent thrombosis was higher in patients with low natural IgM antibody levels.
• The protective effect of high IgM levels suggests a role of innate immune response in thrombosis.

Summary

Background and objectives

Natural antibodies to oxidation‐specific epitopes protect from atherothrombotic events. Whether mechanisms of innate immunity are relevant in the pathogenesis of venous thromboembolism (VTE) is unknown.

Patients/Methods

We measured plasma levels of immunoglobulin M (IgM) antibodies to oxidized low‐density lipoproteins (OxLDL) and phosphocholine (PC) by enzyme linked immune assay in 663 patients with unprovoked VTE, who were prospectively followed after discontinuation of anticoagulation for a median of 8.8 years. The study endpoint was recurrent VTE.

Results

IgM antibody levels to OxLDL and PC were higher in patients without compared to those with recurrent VTE (n = 174, 26.2%). For each doubling of OxLDL‐IgM or PC‐IgM the hazard ratio (HR) of recurrence was 0.88 (95% confidence interval [CI], 0.77–1.01) and 0.82 (95% CI, 0.71–0.94), respectively. After 5 years the probability of recurrence in patients with PC‐IgM levels in the highest tertile (> 19.6 RLU/100 ms) was 13.0% (95% CI, 8.1–17.6%), compared with 21.1% (95% CI, 14.9–26.9%) in the middle tertile and 20.6% (95% CI, 14.7–26.0%) in the lowest tertile. The corresponding HR was 0.56 (0.39–0.82) for PC‐IgM levels in the highest compared with the lowest tertile. Neither immunoglobulin G IgG antibody levels to OxLDL nor those to PC were associated with risk of VTE.

Conclusion

Levels of natural IgM antibodies to oxidation‐specific epitopes are inversely related to the risk of VTE.     

Patient-Perceived Pressure from Clinicians for Labor Induction and Cesarean Delivery: A Population-Based Survey of U.S. Women

ObjectiveTo determine whether patient-perceived pressure from clinicians for labor induction or cesarean delivery is significantly associated with having these procedures.ConclusionsPatient-perceived pressure from clinicians significantly predicts labor induction and cesarean delivery. Efforts to reduce provider–patient miscommunication and minimize potentially unnecessary procedures may be warranted.     

Could neonatal disseminated herpes simplex virus infections be treated earlier?

INTRODUCTION: Neonatal disseminated herpes simplex virus (HSV) infection can cause rapidly progressive multiple organ failure with an 85% mortality if untreated. Early recognition and treatment may improve outcome [N Engl J Med 324(1991)450]. OBJECTIVES: (i) To determine the number and presentation of neonates with disseminated HSV admitted to an intensive care unit. (ii) To determine paediatric Specialist Registrar (SpR) awareness of the diagnosis and management of a typical potential case of neonatal disseminated HSV. METHODS: (i) A 10-year review of case notes of neonates admitted to the intensive care unit (ICU) at Great Ormond Street Hospital. (ii) A telephone questionnaire of 'on-call' Paediatric SpR's in the London area. RESULTS: Eight cases of confirmed disseminated HSV infection were identified. All died. Each case followed a similar clinical course with presentation between days 5-9 of life (median day 7). A short prodrome preceded the rapid development of disseminated intravascular coagulopathy (DIC), hepatitis and multiple organ failure. Only three cases received antiviral treatment in the first 24 h after hospital admission. None of the 30 registrars who were interviewed initially considered disseminated HSV in the differential diagnosis of a 7-day-old baby presenting with non-specific signs of sepsis. Only 4/30 referring unit protocols included disseminated HSV in the differential diagnosis of neonatal sepsis. CONCLUSIONS: HSV infection should be considered in the differential diagnosis of the acutely unwell neonate. This condition is rare but well documented in the literature. Effective antiviral therapies exist but are often not started early in the clinical course. Awareness of this condition needs to be increased.