Neurologist

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New Medical Findings In Realation To Neurology

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Lupus Anticoagulant Increases Risk of Stroke, MI In Young Women

NEW YORK — September 29, 2009 — A study published online first and in the November edition of The Lancet Neurology shows that women with a particular subtype of antibody called lupus anticoagulant (LA) have a more than 40-fold increased risk of stroke and 5-fold increased risk of myocardial infarction (MI) compared with the general population. In addition, smoking and oral contraceptive use increase the risk of these events even more.

Although it is known that antiphospholipid syndrome causes thrombosis, bleeding, and repeat miscarriage in women, the extent of the increased risk for stroke and MI was unknown before this study.

Rolf Urbanus, MD, and Philip de Groot, MD, of the University Medical Centre Utrecht, Utrecht, the Netherlands, together with colleagues from the Leiden University Medical Centre, and colleagues used data from the Risk of Arterial Thrombosis In Relation to Oral Contraceptives (RATIO) study for their analysis.

A total of 1,006 women aged under 50 years were enrolled between 1990 and 2001. Questionnaires were used to assess the prevalence of various risk factors, with blood samples taken to measure various phospholipid antibodies, including LA. The patient pool included women who had had a stroke (175) or MI (203), and healthy controls (628).

LA was found in 30 (17%) patients with stroke, 6 (3%) patients with MI, and in 4 (0.7%) healthy controls. Based on the observation that 4 of 628 healthy controls had LA, the prevalence in women in the general population is estimated by the authors to be 7 in 1000, or 0.7%; previous studies have made higher estimates.

LA increased the risk of stroke 43-fold compared with healthy controls; in women with LA who smoked, the risk was raised 87-fold; and in women with LA who used oral contraceptives, the risk was increased more than 200-fold.

LA also increased with risk of MI 5-fold compared with healthy controls; LA plus smoking increased the risk 34-fold, and LA plus oral contraceptives increased the risk 22-fold. Smoking and oral contraceptive use enhance the action of LA, explaining these increased risks.

“Our results suggest that lupus anticoagulant is a major risk factor for arterial thrombotic events in young women, and the presence of other cardiovascular risk factors increases this risk even further…Screening for lupus anticoagulant in young women with ischaemic stroke seems to be warranted,” the authors wrote.

SOURCE: The Lancet Neurology

Secondary abscess arising in a craniopharyngioma;

An abscess arising in a craniopharyngioma is rare, but has potentially high mortality and morbidity. Diagnosis is difficult because clinical and neuroradiological characteristics are not clearly defined. We report a patient with a pituitary abscess concomitant with a craniopharyngioma and discuss the pathophysiological mechanism. We discuss the previous five reports and suggest that abscesses with craniopharyngioma remain challenging clinical entities. We speculate that inflammation is a response to components of the ruptured epithelium of the cyst, thereby providing an explanation of the mechanism of abscess formation.

Hyperhomocysteinemia in epileptic patients on new antiepileptic drugs;

Summary Purpose: Older enzyme-inducing antiepileptic drugs (AEDs) may induce supraphysiologic plasma concentrations of total (t) homocysteine (Hcy). The aim of the present study was to investigate the effect of new AEDs on plasma tHcy levels. Methods: Patients 18-50 years of age, on AEDs monotherapy, with no other known cause of hyper-tHcy were enrolled. Plasma tHcy, folate, vitamin B(12), and AEDs levels were determined by standard high-performance liquid chromatography (HPLC) methods. Methylenetetrahydrofolate-reductase (MTHFR) polymorphisms were checked using Puregene genomic DNA purification system (Gentra, Celbio, Italy). A group of healthy volunteers matched for age and sex was taken as control. Results: Two hundred fifty-nine patients (151 on newer and 108 on older AEDs) and 231 controls were enrolled. Plasma tHcy levels were significantly higher [mean values, standard error (SE) 16.8, 0.4 vs. 9.1, 0.2 mum; physiologic range 5-13 mum] and folate lower (6.3, 0.1 vs. 9.3, 0.1 nm; normal>6.8 nm) in patients compared to controls. Patients treated with oxcarbazepine, topiramate, carbamazepine, and phenobarbital exhibited mean plasma tHcy levels above the physiologic range [mean values (SE) 16 (0.8), 19.1 (0.8), 20.5 (1.0), and 18.5 (1.5) mum, respectively]. Conversely, normal tHcy concentrations were observed in the lamotrigine and levetiracetam groups [both 11.1 (0.5) mum]. Discussion: Oxcarbazepine and topiramate might cause hyper-tHcy, most likely because of the capacity of these agents to induce the hepatic enzymes. Because literature data suggest that hyper-tHcy may contribute to the development of cerebrovascular diseases and brain atrophy, a supplement of folate can be considered in these patients to normalize plasma tHcy.

Should anterior pituitary function be tested during follow-up of all patients presenting at the emergency department because of traumatic brain injury

Context: A wide range (15-56%) of prevalences of anterior pituitary insufficiency is reported in patients after traumatic brain injury (TBI). However, different study populations, study designs, and diagnostic procedures were used. No data is available on emergency-department-based cohorts of TBI patients. Objective: To assess the prevalence of pituitary dysfunction in an emergency-department-based cohort of TBI patients, using strict endocrinological diagnostic criteria. Methods: Of all patients presenting in the emergency department with TBI over a two-year period, 516 matched the inclusion criteria. 107 patients (77 mild TBI, 30 moderate/severe TBI) agreed to participate. They were screened for anterior pituitary insufficiency by GHRH-arginin testing, evaluation of fasting morning hormone levels (cortisol, TSH, free thyroxine, FSH, LH, and 17beta-estradiol or testosterone), and menstrual history 3-30 months after TBI. Abnormal screening results were defined as low peak GH to GHRH-arginin, or low levels of any of the end-organ hormones with low or normal pituitary hormone levels. Patients with abnormal screening results were extensively evaluated, including additional hormone provocation tests (insulin tolerance test, ACTH-stimulation test, repeated GHRH-arginin test) and assessment of free testosterone levels. Results: Screening results were abnormal in 15 of 107 patients. Subsequent extensive endocrine evaluation diagnosed anterior pituitary dysfunction in 1 patient only (partial hypocortisolism). Conclusion: Applying strict diagnostic criteria to an emergency-department-based cohort of TBI patients showed that anterior pituitary dysfunction is rare (<1%). Routine pituitary screening in unselected patients after TBI is unlikely to be cost-effective.

Palliation of dyspnoea in advanced COPD: revisiting a role for opioids;

Chronic obstructive pulmonary disease (COPD) will be the third leading cause of death worldwide by 2020. The burdens of this increasingly prevalent illness borne by patients, their family caregivers and the healthcare system are substantial. Dyspnoea as the predominant symptom becomes increasingly difficult to palliate as COPD progresses through advanced stages and, for 50% of patients, can become refractory to conventional treatment. This narrative review focuses on the potential role for carefully initiated and titrated opioids in the management of dyspnoea for patients with advanced COPD who are not yet in a terminal stage, yet struggle with symptoms that reflect underlying mechanisms of dyspnoea that lend themselves to this approach. The many barriers that currently exist to the provision of opioids in this setting are addressed, and recommendations are provided for an approach that should engender confidence among patients, their caregivers and the physicians who treat them.

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October 29, 2009 - Posted by | 1

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