Drug-induced aseptic meningitis

Drug-induced aseptic meningitis is a rare but serious condition that should be suspected in patients with meningitis who test negative for a microbiological agent. The medical history is presented here of a woman with recurrent urinary tract infections where meningitis symptoms arose after repeated exposure to a frequently prescribed drug.

Association between clinical frailty, illness severity and post-discharge survival: a prospective cohort study of older medical inpatients in Norway

Aim

To assess impact of frailty screening and two markers of illness severity on survival following discharge from the hospital.

Findings

Independently of age, ward (acute geriatric and general medical) and comorbidity, both higher degree of frailty and illness severity associated with reduced survival probability following discharge. The impact of frailty on survival was higher in those experiencing high clinical and laboratory illness severity.

Message

The prognostic value of frailty screening increased when performed in conjunction with two markers of illness severity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00555-8.

Purpose

Study associations between frailty, illness severity and post-discharge survival in older adults admitted to medical wards with acute clinical conditions.

Methods

Prospective cohort study of 195 individuals (mean age 86; 63% females) admitted to two medical wards with acute illness, followed up for all-cause mortality for 20 months after discharge. Ward physicians screened for frailty and quantified its degree from one to eight using Clinical Frailty Scale (CFS), while clinical illness severity was estimated by New Early Warning Score 2 (NEWS2) and laboratory illness severity was calculated by a frailty index (FI-lab) using routine blood tests.

Results

CFS, NEWS2 and FI-lab scores were independently associated with post-discharge survival in an adjusted Cox proportional hazards model with age, ward category (acute geriatric and general medical) and comorbidity as covariates. Adjusted hazard ratios and 95% confidence intervals were 1.54 (1.24–1.91) for CFS, 1.12 (1.03–1.23) for NEWS2, and 1.02 (1.00–1.05) for FI-lab. A frailty × illness severity category interaction effect (p = 0.003), suggested that the impact of frailty on survival was greater in those experiencing higher levels of illness severity. Among patients with at least moderate frailty (CFS six to eight) and high illness severity according to both NEWS2 and FI-lab, two (13%) were alive at follow-up.

Conclusion

Frailty screening aided prognostication of survival following discharge in older acutely ill persons admitted to medical wards. The prognostic value of frailty increased when combined with readily available illness severity markers acquired during admission.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00555-8.

Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial

BACKGROUND

Conventional anticoagulant treatment for acute deep vein thrombosis (DVT) effectively prevents thrombus extension and recurrence, but does not dissolve the clot, and many patients develop post-thrombotic syndrome (PTS). We aimed to examine whether additional treatment with catheter-directed thrombolysis (CDT) using alteplase reduced development of PTS.

METHODS

Participants in this open-label, randomised controlled trial were recruited from 20 hospitals in the Norwegian southeastern health region. Patients aged 18-75 years with a first-time iliofemoral DVT were included within 21 days from symptom onset. Patients were randomly assigned (1:1) by picking lowest number of sealed envelopes to conventional treatment alone or additional CDT. Randomisation was stratified for involvement of the pelvic veins with blocks of six. We assessed two co-primary outcomes: frequency of PTS as assessed by Villalta score at 24 months, and iliofemoral patency after 6 months. Analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00251771.

FINDINGS

209 patients were randomly assigned to treatment groups (108 control, 101 CDT). At completion of 24 months' follow-up, data for clinical status were available for 189 patients (90%; 99 control, 90 CDT). At 24 months, 37 (41·1%, 95% CI 31·5-51·4) patients allocated additional CDT presented with PTS compared with 55 (55·6%, 95% CI 45·7-65·0) in the control group (p=0·047). The difference in PTS corresponds to an absolute risk reduction of 14·4% (95% CI 0·2-27·9), and the number needed to treat was 7 (95% CI 4-502). Iliofemoral patency after 6 months was reported in 58 patients (65·9%, 95% CI 55·5-75·0) on CDT versus 45 (47·4%, 37·6-57·3) on control (p=0·012). 20 bleeding complications related to CDT included three major and five clinically relevant bleeds.

INTERPRETATION

Additional CDT should be considered in patients with a high proximal DVT and low risk of bleeding.

FUNDING

South-Eastern Norway Regional Health Authority; Research Council of Norway; University of Oslo; Oslo University Hospital.

Mortality and recurrence after treatment of VTE: long term follow-up of patients with good life-expectancy

INTRODUCTION

After completed anticoagulant treatment for acute VTE, both the subsequent mortality and risk of recurrent VTE are high, probably related to the frequent presence of serious disease in these patients. The aim of the study was to determine survival and recurrence in selected patients with good life-expectancy, and to evaluate risk factors.

METHODS

The 323 patients were followed for median 7.4 years (range 4.1-11.9) after cessation of anticoagulation. Survival analysis and Cox-regression were used for univariate and multivariate analysis.

RESULTS

The cumulative incidence of survival after 5 years was 93.4%. Standardised mortality ratio was 1.42 for men and 1.28 for women. Patients without a transient risk factor prior to the index VTE were associated with higher risk of mortality compared to risk of mortality in patients with a transient risk factor (hazard ratio (HR) 2.81; 95% CI 1.40-5.62). Recurrence of VTE after 5 years was 19.0%. A persistent risk factor or a spontaneous VTE was associated with higher risk of recurrence compared to a transient risk factor (HR 2.39; 95% CI 1.44-3.95). Elevated D-dimer levels increased the risk, and immobilisation prior to the index VTE reduced the risk of recurrence. Sex, age and thrombophilia were not independent risk factors for recurrence.

CONCLUSIONS

Despite a low mortality rate in this selected cohort, the recurrence rate and risk factors for recurrence were similar to findings reported in unselected populations. VTE unrelated to a transient risk factor was associated with increased mortality compared to mortality in patients with a transient risk factor.

Catheter-directed thrombolysis vs. anticoagulant therapy alone in deep vein thrombosis: results of an open randomized, controlled trial reporting on short-term patency

BACKGROUND

Approximately one in four patients with acute proximal deep vein thrombosis (DVT) given anticoagulation and compression therapy develop post-thrombotic syndrome (PTS). Accelerated removal of thrombus by thrombolytic agents may increase patency and prevent PTS.

OBJECTIVES

To assess short-term efficacy of additional catheter-directed thrombolysis (CDT) compared with standard treatment alone.

PATIENTS AND METHODS

Open, multicenter, randomized, controlled trial. Patients (18-75 years) with iliofemoral DVT and symptoms < 21 days were randomized to receive additional CDT or standard treatment alone. After 6 months, iliofemoral patency was investigated using duplex ultrasound and air-plethysmography assessed by an investigator blinded to previous treatment.

RESULTS

One hundred and three patients (64 men, mean age 52 years) were allocated additional CDT (n = 50) or standard treatment alone (n = 53). After CDT, grade III (complete) lysis was achieved in 24 and grade II (50%-90%) lysis in 20 patients. One patient suffered major bleeding and two had clinically relevant bleeding related to the CDT procedure. After 6 months, iliofemoral patency was found in 32 (64.0%) in the CDT group vs. 19 (35.8%) controls, corresponding to an absolute risk reduction (RR) of 28.2% (95% CI: 9.7%-46.7%; P = 0.004). Venous obstruction was found in 10 (20.0%) in the CDT group vs. 26 (49.1%) controls; absolute RR 29.1% (95% CI: 20.0%-38.0%; P = 0.004). Femoral venous insufficiency did not differ between the two groups.

CONCLUSIONS

After 6 months, additional CDT increased iliofemoral patency from 36% to 64%. The ongoing long-term follow-up of this study will document whether patency is related to improved functional outcome.

Gains and losses of warfarin therapy as performed in an anticoagulation clinic

BACKGROUND

Knowledge of the net benefit of warfarin therapy in routine care is needed to define realistic management recommendations, but lack of randomized controls precludes conventional risk-benefit analysis.

OBJECTIVE

Assess risk and benefit of routine warfarin therapy in an anticoagulation clinic.

DESIGN

Retrospective observational analysis.

PATIENTS

A total of 1435 outpatients on warfarin for a total of 1613 patient years, treated to prevent the target events recurrent venous thromboembolism (VTE) or myocardial infarction (MI), and stroke in patients with atrial fibrillation (AF) or mechanical heart valves.

MEASUREMENTS

Major bleeding and thromboembolic (TE) events and all deaths.

CALCULATIONS

Expected annual target event rates without warfarin were from published data. Differences between combined major events observed with warfarin, and expected without warfarin were calculated.

RESULTS

In the total material, annual rates were 3.0% major TE events, 1.1% major bleeding events, 0.12% fatal bleeding, and a benefit/risk ratio of 3.8. The net gain, expressed in reduced combined bleeding and target TE annual event rate, was 9.9% in secondary prophylaxis in AF, 4.4% in VTE patients, 2.7% in post-MI patients, 2.4% in primary prophylaxis in AF and 0.6 in patients with mechanical heart valves. The apparent benefit/risk ratio was 3.9 in VTE patients, 5.8 in AF patients and 1.1 in patients with mechanical heart valves.

CONCLUSION

Net effects of prolonged warfarin therapy in patients with VTE and AF performed in an anticoagulation clinic have an acceptable risk/benefit ratio, comparable with what has been obtained in elective clinical trials.

[Catheter-directed thrombolysis of iliofemoral venous thrombosis]

BACKGROUND

Although a success rate of 80% has been reported in patients with iliofemoral venous thrombosis treated with catheter-based thrombolysis, the possible long-term benefit of this treatment is not known.

MATERIAL AND METHOD

28 consecutive patients referred for catheter-based thrombolysis of iliofemoral venous thrombosis were treated with infusion of alteplase into the thrombus for two to five days. Following thrombolysis, warfarin was given for at least one year. All patients were examined every six months with colour duplex scanning and air pletysmography.

RESULTS

100% thrombolysis was achieved in eight patients, 75-99% in ten, 50-74% in nine and < 50% in one patient. Angioplasty (four) or stent implantation (four) was successful in eight out of twelve patients with stenosis of the left common iliac vein. Early recurrence of thrombosis (< 7 days) occurred in three patients, pulmonary embolism in one, and bleeding at the insertion site in six. After a mean follow-up of 2.5 years, 17 patients were free of symptoms, seven had a mild degree and four a moderate degree of postthrombotic syndrome. Eighteen patients had normal venous physiology, nine deep venous reflux, and three functional obstruction of deep veins. Postthrombotic syndrome was associated with deep venous reflux and/or functional obstruction of the iliofemoral segment.

INTERPRETATION

Catheter-based thrombolysis is a safe and effective treatment of proximal deep venous thrombosis and might reduce the occurrence of postthrombotic syndrome compared to treatment with anticoagulation alone.