Thomas Mätzsch

Recurrent thromboembolism in pregnancy and puerperium. Is there a need for thromboprophylaxis

By sending a questionnaire (response rate 93%) to 321 women with a history of venous thromboembolism and previous coagulation tests, 72 patients were identified who had a total of 87 pregnancies after the thromboembolic episode. The main aim of the study was to analyze the influence of prophylaxis during pregnancy and delivery on the development of further thromboembolic complications. During pregnancy there was no difference in frequency of thromboses between the group given prophylaxis (n = 20) and the group not receiving it (n = 67). At delivery the frequency of thrombosis was 5.3% among the 57 women given prophylaxis and 11.1% among the 30 without prophylaxis, a difference that is not significant. The implication of these findings is discussed both concerning the indications for giving prophylaxis and concerning the problem of designing relevant prophylactic trials.

Low molecular weight heparin for thromboprophylaxis and epidural/spinal anaesthesia--is there a risk?

This article reviews the problem of bleeding in connection with epidural/spinal anaesthesia, with special emphasis on the use of low molecular weight heparins for thromboprophylaxis. There are methodological difficulties to studying the problem in a scientifically correct way because of the rarity of the complication. However, from the data in the literature there are no indications of an increased risk in using the combination of low molecular weight heparin in prophylactic doses and epidural/spinal anaesthesia. So far, there is only a single case report, of spinal haematoma, although low molecular weight heparins have been used in combination with epidural/spinal anaesthesia in at least 1000000 patients. In controlled studies, at least 10000 patients have been given the combination without complications.

Accuracy of duplex sonography before carotid endarterectomy--a comparison with angiography

OBJECTIVES The aim of this prospective study was to contribute to the evaluation of the reliability of Duplex sonography (DS) before carotid endarterectomy (CEA). DESIGN The study was performed prospectively in a university hospital setting. METHODS Eighty-one consecutive patients aged 49-83 years were examined with DS and carotid angiography (CAG) before CEA. The results of the DS were judged as either confident, or CAG was assessed to be necessary preoperatively. The results from the DS and the CAG were then compared. RESULTS DS was judged as confident in 148 of the 162 arteries examined. In none of these 148 arteries did CAG change patient management in any way, and the agreement between DS and CAG was good. In the remaining 14 arteries CAG was judged necessary, in 11 arteries because DS assessed the internal carotid artery (ICA) as occluded, which was confirmed by CAG in 10 arteries. In three arteries the reason was poor quality of the DS, however these three arteries were correctly assessed as severely diseased. CONCLUSIONS This study confirms that DS alone is sufficient in the preoperative evaluation before CEA, provided that CAG is performed whenever DS shows occlusion of the ICA, or when the quality of the DS is poor.

Abdominal injuries in children: an analysis of 348 cases

Three hundred and forty-eight children from Skaraborg County, Sweden, admitted to hospital with abdominal injuries over a 30-year period (1951-1980), have been analysed and compared with all patients with abdominal injury (1407) admitted to hospital from the same area during the same period. The number of children admitted in the second half of the period was greater than during the first but the proportion of children compared with adults was considerably reduced. During the period abdominal injuries due to car accidents increased in adults but not in children. The most frequent cause of abdominal injury in children was a bicycle accident. Abdominal injury due to sport also increased over the period. Mortality decreased, with no deaths in the past 10 years, compared with 8.6 per cent mortality in the first 10 years of the period.

Late symptoms after pregnancy‐related deep vein thrombosis

Summary. Thromboembolism during pregnancy is a rare complication with a potential fatal outcome. Very little is known about long‐term effects and therefore 104 women with thrombosis during pregnancy or puerperium were identified and their subjective complaints were assessed in a questionnaire. All had their thrombosis diagnosed by objective methods and the median follow‐up time was 11 years. In spite of anticoagulant treatment only 22% were without complaints; 4% had ulceration, all occurring in the group with thrombosis during pregnancy. Significantly more women who had had their thrombosis during pregnancy used compression bandages than those who had their thrombosis during puerperium. The severity of the symptoms increased with the increasing number of thromboses. Anticoagulant therapy of the acute episode does not appear to alter the degree of long‐term handicap in the lower limbs.

Pharmacokinetics of a low molecular weight heparin, Logiparin, after intravenous and subcutaneous administration to healthy volunteers

In six healthy volunteers we have estimated the pharmacokinetic parameters of the anti factor Xa (AXa) and anti factor IIa (AIIa) activities of a LMW heparin, Logiparin. For the AXa the following parameters were estimated in a 1-compartment model (mean and 95% confidence limits in brackets): elimination half life 82 minutes (60-127 min), absorption half life (s.c. inj.) 200 minutes (137-368 min), bioavailability 90% (24-156%), and apparent volume of distribution 3.9 l (3.1-5.2 l). The plasma activity was linearly correlated to the dose given and to the body weight of the volunteer. For the AIIa the parameters estimated in a 1-compartment model were: elimination half life 71 minutes (52-115 min), absorption half life 257 minutes (133-3442 min), bioavailability 67% (44-90%), and apparent volume of distribution 10.1 l (7.2-16.7 l). The plasma activity was dependent on dose and body weight but it also seemed to be influenced by individual factors. This study shows that the absorption rate is the rate limiting factor and the explanation for the long lasting effect of this LMW heparin after subcutaneous injection. The slow absorption rate and the high bioavailability are probably the major advantages of LMW heparins compared to conventional heparin.

Interleukin-1 receptor antagonist is detectable in human carotid artery plaques and is related to triglyceride levels and Chlamydia pneumoniae IgA antibodies.

Abstract. Gottsäter A, Forsblad J, Mätzsch T, Persson K, Ljungcrantz I, Ohlsson K, Lindgärde F (Malmö University Hospital, University of Lund, Malmö, Sweden). Interleukin‐1 receptor antagonist is detectable in human carotid artery plaques and is related to triglyceride levels and Chlamydia pneumoniae IgA‐antibodies. J Intern Med 2002; 251: 61–68.

Carotid artery entrapment by the hyoid bone

We report a patient with a transient ischemic attack presumably caused by an entrapment of the internal carotid artery by the hyoid bone and without a significant carotid artery stenosis. The patient was operated on, with a release of the right internal and external carotid artery and resection of the right greater cornu of the hyoid bone. One year after treatment, the patient has not experienced any further neurologic symptoms, and a color duplex scan showed no stenosis of the right carotid artery. The hyoid bone is a potential cause of damage to the carotid vessels, depending on the individuals anatomy. Provocative maneuvers can be performed in patients with cerebrovascular symptoms who are not demonstrated to have significant anatomic stenosis with carotid imaging.

Cost/benefit aspects on thromboprophylaxis.

Several studies have shown thromboprophylaxis of any kind to be more cost-effective than no prophylaxis or general diagnostic surveillance and selective treatment. Little has been written on low molecular weight heparins from the cost-effectiveness point of view. This preliminary study shows low molecular weight heparin to be more cost-effective than standard low-dose heparin in most situations of prophylaxis.

Abdominal trauma during thirty years: analysis of a large case series

Studies have been made in 1407 patients of the causes, the organs involved and the outcome of injury to the abdomen in patients needing admission to hospital in an area of Southern Sweden, between 1950 and the end of 1979. The proportion of female patients and those aged over 60 increased significantly. The seasonal distribution of the injuries showed significant change, with a drop in the initially high frequency sustained during the summer months. Penetrating injuries were rare, but increased in the 1970s. Road traffic accidents as the cause of abdominal injuries rose to a maximum of 56 per cent in the late 1960s. The numbers of injured organs and the frequency of other associated injuries rose gradually until the mid-1970s, after which there was a slight decrease. The spleen, liver and large blood vessels were the organs which were increasingly often injured. The annual incidence of various visceral injuries per 100 000 population was calculated. The number of patients with a delay of at least 24 hours before operation fell significantly and there was a tendency to shorter hospital stay. The mortality curve showed a peak in the late 1960s.