Hemarthroses complicating anticoagulant therapy (heparin, oral anticoagulants)]

Three patients with hemarthrosis complicating anticoagulant therapy are described. Two had acute hemarthrosis of the knee joint occurring during long term oral anticoagulant therapy for cardiovascular disorders. Joint symptoms disappeared rapidly after arthrocentesis and diminution of the dose of oral anticoagulant medication. The third patient has been on chronic hemodialysis for the last three years. After 2 years of this therapy he developed periarthritis of the right shoulder, followed suddenly by hemarthrosis of the right shoulder which remained symptomatic for 9 months in spite of several joint aspirations and reduction in the dosage of heparin administered during hemodialysis. Resolution of the hemarthrosis of the right shoulder occurred only when the vascular access for the dialysis sessions was displaced from the right to the left forearm. It is assumed that there was communication in the venous draining territories of the arterio-venous fistula and the shoulder articulation.     

Acute sciatic neuropathy complicating living donor renal transplantation

The surface structures of the eggs of house fly (M. domestica vicina) were examined by SEM. A layer of membranaous structure with small holes in clusters covering the whole egg was seen. The membranous structure is supported by large amount of tissue masses of different sizes. The submembranous tissue is dotted with numerous concave-holes. A hatching crack with a layer of very thin and vulnerable membrane runs lengthwise across the concave surface of the egg.     

Femoral neuropathy: unusual presentation for recurrent large-bowel cancer

OBJECTIVE: There is evidence from animal studies that fluoxetine may enhance the concentrations of neuroactive steroids. Therefore, the authors investigated whether clinically effective treatment with antidepressants may alter the concentrations of neuroactive steroids in patients suffering from a major depressive episode. METHOD: In the first study, eight drug-naive outpatients with major depression were studied during treatment with fluoxetine. In a complementary study, 11 inpatients with major depression were studied during a severe depressive episode and after recovery following treatment with different antidepressants. Plasma samples were quantified for neuroactive steroids by means of a highly sensitive and specific combined gas chromatography/mass spectrometry analysis. RESULTS: During depression, there was a significant decrease in 3 alpha, 5 alpha-tetrahydroprogesterone (3 alpha, 5 alpha-THP) and 3 alpha, 5 beta-THP concentrations, both of which are positive modulators of the gamma-aminobutyric acidA receptor, and a concomitant increase in 3 beta, 5 alpha-THP levels. This dysequilibrium of neuroactive steroids could be corrected by treatment with different antidepressants. CONCLUSIONS: These results provide the first clinical evidence of a possible role of neuroactive steroids in successful antidepressant therapy.     

Thrombophilia, anticoagulant therapy and pregnancy

Thromboembolic complications during pregnancy are the most common causes of maternal death. Here we report on thromboembolic prophylaxis of 60 pregnancies of 32 pregnant women with familial thrombophilia. Long-term Fraxiparine (Sanofi-Chinoin) as thromboprophylaxis was applied in 26 cases throughout pregnancy. UFH (Heparin-Ca inj.) was used in 11 cases, and there were 23 pregnancies without thromboembolic prophylaxis in our patient's case histories. Artificial abortions were not included in this paper. The ratio of successful pregnancies were: with Fraxiparine: 24/26 (92.3%), with UFH (Heparin-Ca): 8/11 (72.7%), without prophylaxis: 4/23 (17.4%). In the patient group treated with Fraxiparine there were no foetopathy, thrombocytopenia or bleeding complication. LMWH is recommended for pregnant women with familial thrombophilia. According to literature data and our own experiences the doses of LMWH in patients with familial thrombophilia, and -antiphospholipid syndrome, and -artificial heart value are suggested.     

Topical corticosteroid therapy complicating congenital glaucoma

A 4-month-old infant with congenital glaucoma had been treated with a topical antibiotic-corticosteroid for three months. This fact complicated initial management, delaying definitive diagnosis and therapy. Topical steroid therapy in infants can produce a condition simulating congenital glaucoma. Since there is little rationale for using topical steroids to treat most infantile external disease processes, they are best avoided. When steroids are used for a prolonged period, some strategy for detecting glaucoma should be adopted.     

Monitoring of oral anticoagulant therapy in lupus anticoagulant positive patients with the anti-phospholipid syndrome

Introduction of the International Normalized Ratio (INR) has improved the standardization of laboratory control of oral anticoagulant therapy (OAT). However, it has been reported that misleading INR results can be obtained from OAT patients with lupus anticoagulant (LA). To investigate this claim, we studied 35 OAT patients, 14 of whom had anti-phospholipid syndrome (APS) with a documented LA. Attainment of anticoagulation was confirmed by chromogenic assay of factor VII and factor X. Prothrombin times were performed using eight thromboplastins (five derived from rabbit brain, two recombinant human tissue factor and one made from human placenta) with an International Sensitivity Index (ISI) of <1.40. When using the thromboplastin manufacturers' ISI there was a significant difference (ANOVA, P<0.0001) between INR results obtained with the eight reagents for both APS (average CV = 12.4%) and non-APS (average CV = 12.5%) patient groups. Variation using the eight thromboplastins was assessed by calculating the CV for each sample; these values were then pooled for each patient group to give the average CV for all samples with all reagents for the two patient groups. Results for both patient groups exhibited markedly reduced variation (APS group average CV = 6.5%, non-APS group average CV = 5.8%) when locally assigned ISI values were employed in the calculation of INRs. Our data does not support the suggestion that the INR may not reflect the true level of anticoagulation in the long-term warfarin-treated patient, in whom lupus anticoagulant was detected. However, there was strong evidence that thromboplastin use should be restricted to those clot detection systems for which the reagent's manufacturer has assigned an ISI, or local ISI assignment must be undertaken. The inappropriate use of a generic (i.e. optical or mechanical clot detection system without regard to specific analyser type) ISI value can lead to ambiguous results.     

Treatment of the patient receiving Coumadin anticoagulant therapy

Minimizing the risk of bleeding as well as the risk of thromboembolism in dental patients being treated with anticoagulants is a common challenge for practitioners. This article features tips on evaluating and managing these patients.     

Adrenal hemorrhage complicating ACTH therapy in Crohn's disease

Huge dose ACTH therapy is used in some severely ill patients with inflammatory bowel disease. We report a teenage girl with Crohn's disease who developed an acute abdomen following ACTH therapy. CT revealed the mass to be a hemorrhagic adrenal gland; the opposite adrenal gland was hypertrophied but without signs of hemorrhage.     

Response to therapy in demyelinating motor neuropathy

We reviewed results of immunotherapy in patients with demyelinating motor neuropathy (DMN), and found that patients over 50 years of age at onset responded poorly, and younger patients responded variably to intervention. We suggest that patients with DMN be given a guarded prognosis, particularly if >50 years of age at onset.     

Potential neuroprotective therapy for glaucomatous optic neuropathy

Although mexiletine, an antiarrhythmic with local anesthetic properties, has been reported to relieve discomfort in diabetic neuropathy, its usefulness in the treatment of HIV-related painful peripheral neuropathy (PPN) has not been determined. The tolerance and effectiveness of mexiletine in HIV-related PPN were assessed in 22 patients who were randomized to receive mexiletine (maximum dose, 600 mg/day) or placebo for 6 weeks, followed by the alternative intervention for 6 weeks after a 1-week washout period. The daily pain response was assessed using a visual analogue scale card in 19 patients who received at least 2 weeks of the drug, 16 of whom were crossed-over to receive the alternate agent. No statistically significant difference was found between the mean daily pain scores for patients receiving mexiletine versus placebo, irrespective of the order in which the agents were received. Comparing the mean individual daily pain scores for each phase of study, 5 patients (31%) had significantly less pain while receiving mexiletine compared with their response to placebo, 5 patients (31%) had significantly less pain while receiving placebo, and no difference was noted in 6 patients (38%). Crossover and multivariate analyses for repeated measures showed no apparent difference in the response to mexiletine versus placebo. Dose-limiting adverse events occurred in 39% of those receiving mexiletine, but only 1 patient (5%) discontinued placebo. Mexiletine was only modestly well tolerated despite its relatively brief period of administration, and no evidence was found to support its benefit in HIV-related PPN. Although a first-drug effect was not demonstrated, a powerful placebo effect was seen in some patients.     

Spinal para-medullary conduction anesthesia in therapy with anticoagulant drugs]

Epidural and spinal blocks can lead to iatrogenic bleeding in the spinal canal. Incidence of this severe complication is considered low, but the risk of irreversible neurological defects for the patient requires increased attention by the anaesthetist. The perioperative risk is higher in patients under anticoagulant therapy. The different pharmacodynamics and pharmacokinetics of practically relevant anticoagulants are discussed and recommendations for the performance of centroneuraxis blocks in patients under anticoagulant therapy are given.