Summary. Background: The management of venous thromboembolism (VTE) requires an initial treatment with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH), followed by oral anticoagulants (OA) for at least 3 months. OA treatment however, requires laboratory monitoring of anticoagulation, carries a de®nite risk of bleeding, and may be contraindicated in some patients. As an alternative to vitamin K antagonists, subcutaneous LMWH has been proposed and evaluated in randomized clinical trials, but they are all small studies that lack the power to establish if these two treatment modalities are equivalent in ef®cacy or safety. Objectives: The objective of this review was to evaluate the ef®cacy (VTE recurrence) and safety (bleeds and deaths) of long-term treatment of VTE with LMWH compared with OA. A secondary endpoint was to evaluate the effect of LMWH on cancer mortality. Methods: Computerized searches of MedLine and EmBase were performed. In addition, randomized clinical trials were located through personal communication with colleagues, and through the manual scanning of meeting proceedings and reference lists of relevant studies. When necessary, the authors of the selected papers were called to obtain additional information. Two reviewers (AI and FG) reviewed and extracted data independently using a standard form. The primary analysis was performed for ef®cacy and safety endpoints on an intention-to-treat basis for the study period of randomized treatment. A meta-regression analysis was used to investigate the relationship between daily dose and clinical outcome. Results: Seven studies that ful®llled our prede®ned criteria were identi®ed, for a total of 1379 patients. When all studies were combined, a statistically non-signi®cant reduction in the risk of VTE (OR 0.66; 95% con®dence interval [CI] 0.41, 1.07) and in the risk of major bleeding (OR 0.45; 95% CI 0.18, 1.11) in favor of LMWH treatment was found. No difference in total mortality (OR 1.19; 95% CI 0.78, 1.83) or in cancer-related mortality was observed between the LMWH and the OA treatment. Conclusions: The results of this meta-analysis indicate that a 3-month course of LMWH is as effective and safe as a corresponding period of OA treatment, and may thus be considered as a valuable alternative option for patients in whom OA treatment appears contraindicated or problematic.

To cite this article: Guercini F, Acciarresi M, Agnelli G, Paciaroni M. Cryptogenic stroke: time to determine aetiology. J Thromb Haemost 2008; 6: 549-54.Summary. Strokes that remain without a definite cause even after extensive work-up are classified as cryptogenic. These constitute about 30-40% of all strokes. Stroke aetiology may remain undetermined for the following reasons: (i) the cause of stroke is transitory or reversible and the diagnostic work-out is not therefore performed at the appropriate time; (ii) all known causes of stroke are not fully investigated; (iii) some causes of stroke remain unknown. Recent studies have challenged the previous view that cryptogenic stroke is a relatively benign cerebrovascular event, and have shown that cryptogenic stroke is associated with a higher rate of recurrence and adverse outcome at long-term follow-up. The determination of stroke aetiology is a valuable procedure to avoid the risk of stroke recurrence, especially in young patients. In this review, we discuss new evidence on the aetiology of cryptogenic stroke, specifically focusing on patients with patent foramen ovale and atheroma of the aortic arch.Keywords: aortic arch atheroma, cryptogenic stroke, patent foramen ovale.Strokes of indefinite cause, even after an extensive work-up, are classified as cryptogenic [1,2]. Cryptogenic strokes account for about 30-40% of all strokes [1][2][3]. Up until the last decade, a cryptogenic stroke was seen as a relatively benign event, and patients with a stroke of unknown cause were considered to have a lower risk of recurrence than those with other types of stroke. However, the rate of recurrence after a cryptogenic stroke was recently reported to be about 30% during the first year after the index event [1]. This is in stark contrast with previous studies that found a 10-20% rate of stroke recurrence after 2 years [4,5].What makes a stroke cryptogenic?1. The cause of a stroke may be transitory or reversible, and so diagnostic work-out might not be undertaken at the appropriate time.(a) An example of a transitory or reversible cause is atrial fibrillation (AF), which accounts for about 10% of all strokes and 50% of the cardioembolic strokes [6,7]. Unfortunately, AF often remains underdiagnosed as it is frequently asymptomatic: up to 30% of AF patients are unaware of their arrhythmia [8], and about 25% of patients presenting with AF-associated stroke have had no prior diagnosis of AF [9,10]. Moreover, AF is intermittent in 30% of patients with stroke, and might not therefore be seen in a single ECG recording [11]. It was examined whether seven-day ambulatory ECG monitoring allowed further detection of AF in patients admitted with an acute stroke or transient ischemic attack (TIA) in whom standard ECG and 24-Holter show normal results [12]. AF was detected in 22 of 149 patients (14.8%) with an acute stroke or TIA by event-loop recording (ELR), a device designed to monitor the heart rhythm for one week or longer in ambulatory patients. Standard ECG identified such arrhythmia...

ISD is related to the presence of a more severe clinical picture and case history, but the most significant independent variables are the VLPP and MUCP.

INTRODUCTION AND OBJECTIVE:The relationship between bladder outlet obstruction (BOO) due to benign prostate hyperplasia and sexual dysfunction is of considerable current interest. The influence of surgical treatment of BOO on sexual dysfunction is uncertain and available evidence is conflicting. Transurethral resection of the prostate (TURP) is known to cause retrograde ejaculation, but its effect on erectile function is still discussed controversially. In our study we prospectively investigated the influence of TURP on erectile and ejaculatory function.METHODS: The presented data have been collected by the 'Outcome Association', a quality control instrument in the Swiss healthcare system. From January 2000 to August 2003 1190 patients scheduled for TURPin 10 hospitals in the Canton Zurich were prospectively assessed. A questionnaire including the sexual function domain of the Danish prostatic symptom score (DAN-PSS-Sex) and a question on general sexual activity was mailed out to the patients prior to their hospitalization as well as 4 months after surgery. DAN-PSS-Sex scores before and after TURP were compared using Wilcoxon signed ranks test (level of significance p<0.05).RESULTS: Preoperatively questionnaires of 839 patients were returned and deemed evaluable. Mean patient age was 69 years (range 43 to 91 years). 228 patients (27%) stated that they were still sexually active. Postoperatively 405 questionnaires were returned and evaluable for analysis. Therein I 06 patients (26%) declared that they were sexually active. In patients with 2 evaluable questionnaires the mean erectile function score increased (worsened) insignificantly from 0.853 to 0.911 (p=0.2). When this score was multiplied with the respective bother score, however, an almost significant decrease from 1.774 to 1.553 (p=0.05) resulted. Mean ejaculatory function scores increased from 1.063 to 2.239 (p

<b><i>Background:</i></b> In this randomized trial, currently utilized standard treatments were compared with enoxaparin for the prevention of venous thromboembolism (VTE) in patients with intracerebral hemorrhage (ICH). <b><i>Methods:</i></b> Enoxaparin (0.4 mg daily for 10 days) was started after 72 h from the onset of ICH. The primary outcome was symptomatic or asymptomatic deep venous thrombosis as assessed by ultrasound at the end of study treatment. The safety of enoxaparin was also assessed. We included the results of this study in a meta-analysis of all relevant studies comparing anticoagulants with standard treatments or placebo. <b><i>Results:</i></b> PREVENTIHS was prematurely stopped after the randomization of 73 patients, due to the low recruitment rate. The prevalence of any VTE at 10 days was 15.8% in the enoxaparin group and 20.0% in the control group (RR 0.79 [95% CI 0.29–2.12]); 2.6% of enoxaparin and 8.6% of standard therapy patients had severe bleedings (RR 0.31 [95% CI 0.03–2.82]). When these results were meta-analyzed with the results of the selected studies (4,609 patients; 194 from randomized trials), anticoagulants were associated with a nonsignificant reduction in any VTE (OR 0.81; 95% CI 0.43–1.51), in pulmonary embolism (OR 0.53; 95% CI, 0.17–1.60), and in mortality (OR 0.85; 95% CI 0.64–1.12) without increase in hematoma enlargement (OR 0.97; 95% CI, 0.31–3.04). <b><i>Conclusions:</i></b> In patients with acute ICH, the use of anticoagulants to prevent VTE was safe but the overall level of evidence was low due to the low number of patients included in randomized clinical trials.