Psychiatric Symptoms in Patients with Shiga Toxin-Producing E. coli O104:H4 Induced Haemolytic-Uraemic Syndrome

Background

In May 2011 an outbreak of Shiga toxin-producing enterohaemorrhagic E. coli (STEC) O104:H4 in Northern Germany led to a high number of in-patients, suffering from post-enteritis haemolytic-uraemic syndrome (HUS) and often severe affection of the central nervous system. To our knowledge so far only neurological manifestations have been described systematically in literature.

Aim

To examine psychiatric symptoms over time and search for specific symptom clusters in affected patients.

Methods

31 in-patients suffering from E. coli O104:H4 associated HUS, were examined and followed up a week during the acute hospital stay. Psychopathology was assessed by clinical interview based on the AMDP Scale, the Brief Symptom Inventory and the Clinical Global Impressions Scale.

Results

At baseline mental disorder due to known physiological condition (ICD-10 F06.8) was present in 58% of the examined patients. Patients suffered from various manifestations of cognitive impairment (n = 27) and hallucinations (n = 4). Disturbances of affect (n = 28) included severe panic attacks (n = 9). Psychiatric disorder was significantly associated with higher age (p<0.0001), higher levels of C-reactive protein (p<0.05), and positive family history of heart disease (p<0.05). Even within the acute hospital stay with a median follow up of 7 days, symptoms improved markedly over time (p <0.0001).

Conclusions

Aside from severe neurological symptoms the pathology in E.coli O104:H4 associated HUS frequently includes particular psychiatric disturbances. Long term follow up has to clarify whether or not these symptoms subside.     

Cyclophosphamide Therapy in the Nephrotic Syndrome in Childhood

Forty-six children with the nephrotic syndrome whose renal biopsy specimens showed minimal changes and whose response to corticosteroid therapy was unsatisfactory were treated with cyclophosphamide. Three patients were completely steroid-resistant from the outset and the remainder were steroid-dependent. In several patients steroids controlled the condition less effectively with time. Most patients showed signs of steroid toxicity, and growth retardation was striking.A moderate leucopenia was induced with cyclophosphamide, and treatment was maintained for three to four months in the majority of cases. Thirty-eight children (83%) have remained in complete remission off all treatment for periods of 3 to 23 months, 33 after one course of cyclophosphamide and five after a second course. Two other patients who remitted but relapsed later are still on treatment. In only six patients was full remission not obtained, and three of these were steroid-resistant from the start. Two died from pneumonia and adrenal failure and four continued to have proteinuria, though in one an impressive reduction occurred.The results indicate that cyclophosphamide therapy is an effective alternative for nephrotic children with normal glomeruli on light microscopy who develop steroid dependence or resistance, and who exhibit toxic effects of steroid therapy.     

Knowledge of Thrombolytic Therapy for Acute Ischemic Stroke among Community Residents in Western Urban China

Background and Purpose

Thrombolytic therapy rate for acute ischemic stroke remains low, and improving public awareness of thrombolytic therapy may be helpful to reduce delay and increase chances of thrombolytic therapy. Our purpose was to survey the level of knowledge about thrombolytic therapy for acute ischemic stroke among community residents in Yuzhong district, Chongqing, China.

Methods

In 2011, a population-based face-to-face interview survey was conducted in Yuzhong district, Chongqing. A total of 1500 potential participants aged ≥18 years old were selected using a multi-stage sampling method.

Results

A total of 1101 participants completed the survey. Only 23.3% (95% CI = 20.8 to 25.8) were aware of thrombolytic therapy for acute ischemic stroke, of whom 59.9% (95% CI = 53.9 to 65.9) knew the time window. Awareness of thrombolytic therapy was higher among young people, those with higher levels of education and household income, those with health insurance, and those who knew all 5 stroke warning signs, while awareness of the time window was higher among those aged 75 years or older. Multivariate logistic regression analysis showed that awareness of thrombolytic therapy was independently associated with age, education level, health insurance and knowledge of stroke warning signs (P<0.05).

Conclusions

In this population-based survey the community residents have poor awareness of thrombolytic therapy for acute ischemic stroke.     

Risks and Benefits of Early Antithrombotic Therapy after Thrombolytic Treatment in Patients with Acute Stroke

Background

Current guidelines recommend withholding antithrombotic therapy (ATT) for at least 24 h in patients with acute ischemic stroke treated with thrombolytic therapy. Herein, we report a retrospective analysis of a single-centre experience on the safety and efficacy of antithrombotic therapy (ATT) started before or after 24 h of intravenous thrombolysis in a cohort of acute ischemic stroke patients.

Methods

A total of 139 patients (Rapid ATT group) received antithrombotic therapy before 24 h of thrombolysis, and 33 patients (Standard ATT group) after 24 h. The brain parenchyma and vessel status were assessed using simple CT scan on admission, multimodal CT scan at the end of thrombolysis, and angio-CT/MRI scan at day 3. Functional outcome was scored using the modified Rankin Scale (mRS) at day 90.

Results

The two ATT groups had similar demographics, stroke subtypes, baseline NIHSS, thrombolytic strategies, vessel-patency rates at the end of thrombolysis, and incidence of bleeding complications at follow up. At day 3, the Rapid ATT group had a non-significant improved vessel-patency rate than the Standard ATT group. At day 90, a greater proportion of patients in the rapid ATT group had shifted down the mRS, and had improved in the NIHSS score.

Conclusions

ATT initiated before 24 h of intravenous thrombolytic therapy in acute stroke patients disclosed no safety concerns compared with a conventional antithrombotic therapy delay of 24 h and showed better functional outcome at follow up. The value of early initiation of ATT after thrombolysis deserves further assessment in randomized controlled trials.     

患肢加压溶栓治疗下肢深静脉血栓形成的临床疗效及护理效应

目的:探讨止血带结扎患肢,从足背浅静脉推注尿激酶治疗下肢深静脉血栓形成的临床疗效及护理效应。方法:对62例下肢深静脉血栓患者经患肢足背静脉穿刺,踝关节上用止血带阻断浅静脉后,推注中等剂量尿激酶.通过测量腿围和彩超结果来评价是否有效。并采用多种护理辅助手段辅助治疗。结果:临床症状迅速改善,有效率22.5%,显效率77.5%。结论:此方法操作简单,所用材料价格便宜,临床效果明显,值得推广应用。     

静脉溶栓时机对急性ST段抬高型心肌梗死患者溶栓效果及主要不良心脏事件发生率的影响

目的:探讨静脉溶栓时机对急性ST段抬高型心肌梗死患者溶栓效果及主要不良心脏事件发生率的影响。方法:将2016年1月至2017年12月我院接诊的314例急性ST段抬高型心肌梗死患者纳入本研究,按照溶栓治疗时间不同分为A组(发病至溶栓时间6 h)172例、B组(发病至溶栓时间为6～12 h)102例和C组(发病至溶栓时间12 h)40例,比较三组患者溶栓效果、溶栓后ST段回落情况以及住院期间主要不良心脏事件发生情况。结果:A组患者梗死冠脉溶通率、溶栓后ST段回落幅度高于B组和C组,且B组高于C组,差异均有统计学意义(P0.05)。A组患者治疗后ST段回落最大幅度所需时间、住院期间主要不良心脏事件总发生率低于B组和C组,且B组低于C组,差异均有统计学意义(P0.05)。结论:急性ST段抬高型心肌梗死患者发病后6 h内静脉溶栓治疗梗死冠脉溶通率更高、ST段回落效果更好,可降低住院期间主要不良心脏事件发生风险。     

Prothrombotic Effects of Thrombolytic Therapy in a Rat (Rattus norvegicus) Model of Venous Thrombolysis

The use of thrombolytic agents has greatly improved patient outcomes, but the prothrombotic response to these drugs in vivo is unknown. Approximately 24 h after we induced thrombosis in male Sprague–Dawley rats, we placed an infusion line in the inferior vena cava and administered either saline or a thrombolytic agent (tissue plasminogen activator [tPA] or plasmin) for 30 min. Blood was drawn immediately after infusion; rats were euthanized 24 h after infusion for collection of blood and tissue (inferior vena cava and thrombus). Thrombus size was decreased in the tPA-treated rats but not in those that received saline or plasmin; this change correlated with the significant rise in D-dimer levels noted immediately after infusion in the tPA-treated rats. Plasma soluble P-selectin, a prothrombotic marker, was elevated at 24 h in the plasmin group compared with the other treatment groups. There were no significant differences in plasma C3a, C5a, or C5b9 levels or in thrombus C3 levels between groups. According to ultrastructural analysis, thrombus structure and vein wall effects did not differ between groups. Local tPA did not induce a prothrombotic state during acute DVT or after thrombolytic therapy in a rodent model of venous thrombolysis. Conversely, levels of the prothrombotic marker plasma soluble P-selectin increased when plasmin was administered.Abbreviations: DVT, deep vein thrombosis; IVC, inferior vena cava; tPA, tissue plasminogen activatorDeep vein thrombosis (DVT) is part of a disease condition known as venous thromboembolism. Approximately 360,000 new cases of DVT occur annually^7,36 in the United States, and this number has not changed appreciably over the years.³³ DVT can lead to serious sequelae such as chronic venous insufficiency and postthrombotic syndrome,^4,13 and recurrence of thrombosis is a significant risk.¹² To prevent these complications, the goals of treatment are to restore vessel patency and prevent valvular damage.²⁴ Standard-of-care anticoagulants do not always meet both of these goals, and catheter-directed thrombolysis has arisen as an alternative treatment method.²⁴ This technique uses placement of a multiport catheter at the site of the thrombus, with subsequent infusion of a thrombolytic agent.²⁴ The thrombolytic agents most commonly used are plasminogen activators, such as tissue-plasminogen activator (tPA), urokinase plasminogen activator (uPA), and streptokinase. These agents work on the fibrinolytic system and catalyze the conversion of plasminogen to plasmin.⁶ Plasmin then binds to fibrin, which leads to breakdown of fibrin and initiates the formation of fibrin degradation products, such as D-dimer.^6,10 Recently, there has been increased interest in the use of plasmin,²⁰ due to its direct thrombolytic ability (already in the active form to break down fibrin) and enhanced safety profile when compared with plasminogen activators.²¹Inflammation plays an important role in the development and progression of DVT²⁷ and therefore has become a target for treatment of this disease. Soluble plasma P-selectin has been documented to be a biomarker of thrombosis, and increased concentrations are associated with a prothrombotic state.^2,25 Several components of the innate immune system, specifically the complement system, are upregulated in the presence of thrombolytics.^1,3 In addition, the presence of certain complement components (for example, C3) within the thrombus may lead to states of hypofibrinolysis.^14,16 Taken together, these factors may impede successful therapy via catheter-directed thrombolysis and lead to a poorer patient outcome.Therefore, we set out to determine whether thrombolytic agents create a prothrombotic environment during acute DVT, especially at the site of treatment with catheter-directed thrombolysis. Our hypothesis was that local and systemic prothrombotic indicators would be activated after therapy with thrombolytic agents with different mechanisms of action (indirect, recombinant tPA; direct thrombolytic, plasmin) in a rat model of venous thrombolysis.     

CT Permeability Imaging Predicts Clinical Outcomes in Acute Ischemic Stroke Patients Treated with Intra-arterial Thrombolytic Therapy

In this study, we determined whether a prediction of final infarct volume (FIV) and clinical outcomes in patients with an acute stroke is improved by using a contrast transfer coefficient (K ^trans) as a biomarker for blood–brain barrier (BBB) dysfunction. Here, consecutive patients admitted with signs and symptoms suggesting acute hemispheric stroke were included in this study. Ninety-eight participants with intra-arterial therapy were assessed (46 female). Definition of predicted FIV was performed using conventional perfusion CT (PCT-PIV) parameters alone and in combination with K ^trans (K ^trans-PIV). Multiple logistic regression analyses and linear regression modeling were conducted to determine independent predictors of the 90-day modified Rankin score (mRS) and FIV, respectively. We found that patients with favorable outcomes were younger and had lower National Institutes of Health Stroke Scale (NIHSS) score, smaller PCT-PIV, K ^trans-PIV, and smaller FIV (P?<?0.001). K ^trans-PIV showed good correlation with FIV (P?<?00.001, R ²?=?0.6997). In the regression analyses, K ^trans-PIV was the best predictor of clinical outcomes (P?=?0.009, odds ratio (OR)?=?1.960) and also the best predictor for FIV (F?=?75.590, P?<?0.0001). In conclusion, combining PCT and K ^trans maps derived from first-pass PCT can identify at-risk cerebral ischemic tissue more precisely than perfusion parameters alone. This provides improved accuracy in predicting FIV and clinical outcomes.     

Rubella Syndrome—Cardiovascular Manifestations and Surgical Therapy in Infants

Of nine patients under five months of age with cardiovascular manifestations of the rubella syndrome, six had patent ductus arteriosus. Three of these six also had pulmonary artery stenosis. One infant had bilateral isolated pulmonary artery stenosis. The significant clinical findings leading to the diagnosis of pulmonary artery stenosis were axillary murmurs in the presence of right ventricular hypertrophy. Demonstration of a gradient across the stenosis at the time of catheterization, together with cineangiography, established the diagnosis. In two cases ventricular septal defect was the only cardiac anomaly.Six babies under five months of age had interruption of a patent ductus arteriosus because of uncontrollable congestive heart failure or failure to thrive. Although growth failure was not necessarily due to heart disease, all were developing satisfactorily following operation.Diagnosis and therapy of the cardiac complications of the rubella syndrome is possible in the first few months of life. Early recognition of cardiac defects in the young infant with the rubella syndrome permits aggressive medical management and in selected instances surgical therapy.     

腔静脉滤器植入、溶栓及手术治疗下肢深静脉血栓形成

目的:探讨下肢深静脉血栓形成的有效治疗方法。方法:回顾性分析1988年4月-2006年10月间治疗的255例下肢深静脉血栓形成的临床资料。直接患肢深静脉溶栓74例,手术取栓12例,抗凝等治疗169例,下腔静脉滤器植入32例(均为永久性滤器)。结果:随访2～126个月,平均64个月。31只下腔静脉滤器均展开良好,有1例临时滤器移位至下腔静脉近心端,其他无移位。1例永久性滤器植入14个月后滤器中血栓形成。溶栓组显效52例,有效20例,无效2例。手术组显效10例,有效2例,无效0例。两种治疗方法比较,显效率有显著差别(P＜0．05),总有效率无显著差别。结论:腔静脉滤器植入能有效预防肺动脉栓塞,但应严格掌握适应证。手术治疗是提高疗效和预防后遗症的有效方法。