Anticoagulation risk assessment for patients with non-valvular atrial fibrillation and venous thromboembolism: A clinical review.

Non-valvular atrial fibrillation and venous thromboembolism anticoagulation risk assessment tools have been increasingly utilized to guide implementation and duration of anticoagulant therapy. Anticoagulation significantly reduces stroke and recurrent venous thromboembolism risk, but comes at the cost of increased risk of major and clinically relevant non-major bleeding. The decision for anticoagulation in high-risk patients is complicated by the fact that many risk factors associated with increased thromboembolic risk are simultaneously associated with increased bleeding risk. Traditional risk assessment tools rely heavily on age, sex, and presence of cardiovascular comorbidities, with newer tools additionally taking into account changes in risk factors over time and novel biomarkers to facilitate more personalized risk assessment. These tools may help counsel and inform patients about the risks and benefits of starting or continuing anticoagulant therapy and can identify patients who may benefit from more careful management. Although the ability to predict anticoagulant-associated hemorrhagic risk is modest, ischemic and bleeding risk scores have been shown to add significant value to therapeutic management decisions. Ultimately, further work is needed to optimally implement accurate and actionable risk stratification into clinical practice.

Cerebrospinal fluid TNF-α, IL-6, and IL-8 in children with bacterial meningitis.

OBJECTIVE: We evaluated the levels of cerebrospinal fluid concentrations of tumor necrosis factor-α, interleukin-6, and interleukin-8 in bacterial meningitis in children. METHODS: The study included children up to 14 years of age admitted to a pediatric ward with fever, headache, vomiting, and seizures. The diagnosis of bacterial meningitis was based on clinical features: physical examination, blood and cerebrospinal fluid cytochemical findings, Gram stain, and bacterial culture. The cerebrospinal fluid levels of tumor necrosis factor-α, interleukin-6, and interleukin-8 were measured in 57 children with bacterial meningitis, 15 with viral meningitis, and 15 controls by enzyme-linked immunosorbent assay methods. RESULTS: The mean concentrations of cerebrospinal fluid, tumor necrosis factor-α, interleukin-6, and interleukin-8 were 1108 ± 183, 652 ± 287, and 442 ± 120 pg/mL, respectively, in children with bacterial meningitis and were significantly increased in those in the viral meningitis group (tumor necrosis factor-α : 711 ± 105, IL-6 : 272 ± 161, IL-8 : 175 ± 62 pg/mL; P < 0.001) or control (390 ± 37, 59 ± 17, 19 ± 13 pg/mL, respectively, P < 0.001). At optimum cutoff level based on the receiver operating characteristic curve, cerebrospinal fluid cytokines (tumor necrosis factor-α, interleukin-6, and interleukin-8) showed sensitivity and specificity of 100% for the diagnosis of bacterial meningitis. For differentiation of bacterial from viral meningitis, cerebrospinal fluid level of tumor necrosis factor-α, IL-6, and IL-8 showed sensitivity and specificity of 94.7% and 86.7%, 80.7% and 53.3%, and 89.5% and 86.7%, respectively. CONCLUSION: The increased concentration of cerebrospinal fluid tumor necrosis factor-α, interleukin-6, and interleukin-8 in children with meningitis suggests a role in the pathogenesis of bacterial meningitis and these levels might prove to be useful in children whose diagnosis is in question.

Serum procalcitonin in septic meningitis.

OBJECTIVE: To evaluate the role of serum procalcitonin (PCT) in diagnosis of septic meningitis in children and its efficacy in differential diagnosis. METHODS: The study included 40 children of septic meningitis admitted in pediatric ward with fever, headache, vomiting and seizure, up to 14 y of age. The diagnosis of septic meningitis was based on clinical features; physical examination, blood and cerebrospinal fluid (CSF) cytochemical findings, gram's stain and bacterial culture. Fifteen cases of aseptic meningitis admitted during same period were also included in the study, and 15 children with normal CSF were taken as control. Serum PCT was measured by ELISA Kit. RESULTS: Serum PCT level was significantly higher in children with septic meningitis than those with aseptic meningitis or in controls (p < 0.001). In culture and gram's stain positive 7 cases, serum procalcitonin was significantly elevated (24,768.21 ± 6,567.45 pg/mL) than aseptic meningitis(14,451.24 ± 4,266.15 pg/mL) (p < 0.001). Further its level was found significantly elevated in partially treated septic meningitis as compared to aseptic meningitis cases (p < 0.001). At optimum cut off value of ≥ 5,000 pg/mL, based on area under ROC curve, PCT showed sensitivity, specificity, positive predictive value and negative predictive value of 98.5 %, 93.5 %, 98.6 % and 93.3 % respectively. Serum PCT with cut off level of 15,000 pg/ml showed sensitivity, specificity, PPV and NPV of 92 %, 67 %, 91.4 % and 71.4 % respectively for the differentiation of septic from aseptic meningitis. CONCLUSIONS: Serum PCT may be used as diagnostic marker for septic meningitis and its differentiation from aseptic meningitis.