[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. / Überbrückende Antikoagulation bei Patienten unter Vitamin-K-Antagonisten : Eine Bestandsaufnahme.

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

[Dyspnea. Profile of the most important diagnostic tests]. / Dyspnoe. Profile der wichtigsten diagnostischen Tests.

The diagnostic pathway for the evaluation of patients with dyspnea requires a thorough history taking and physical examination. Based on the results of these basic steps a broad variety of additional diagnostic tests are available. Each test can contribute valuable information when correctly indicated and performed. Among these are electrocardiography (ECG), laboratory parameters, X-ray examination, echocardiography, spirometry and whole body plethysmography and finally spiroergometry. This article presents a focused review of what each of these diagnostic modalities can contribute to the diagnostic process for dyspnea.

[Treatment of deep vein thrombosis and pulmonary embolism]. / Therapie der Beinvenenthrombose und der Lungenembolie.

Deep vein thrombosis and pulmonary embolism may be considered as different manifestations of the same disease: venous thromboembolism. Under the condition of entirely stable hemodynamics, treatment follows exactly the same principles. The phase of initial therapy has a duration of 5-10 days and has remained so far a domain of parenteral anticoagulants (low molecular weight heparin, fondaparinux). The phase of early maintenance therapy is instituted with an overlap and has a duration of 3-6 months; vitamin K antagonists with a target INR of 2.0-3.0 are the standard. Patients with a high risk of recurrence and a low risk of bleeding will enter a phase of prolonged or even indefinite maintenance therapy. Again, vitamin K antagonists with a target INR of 2.0-3.0 are the standard. A target INR of 1.5-2.0 may be considered an alternative for patients in whom a very stable anticoagulation with less frequent INR testing is desirable. Clear recommendations can be made for venous thromboembolism treatment in pregnancy, in the post partum and lactation periods, as well as for patients with severe renal impairment. New anticoagulants (thrombin inhibitors, factor Xa inhibitors) have made significant progress in their clinical development and will soon become available as an alternative for all three phases of therapy.

[Bridging, interruption and switching of anticoagulants in trauma surgery]. / Überbrückung, Pausieren und Wechsel von Antikoagulanzien in der Unfallchirurgie.

Patients under long-term administration of vitamin K antagonists may require temporary interruption of anticoagulation therapy for invasive procedures or trauma surgery. Due to the long half-life of these substances bridging therapy with anticoagulants having a shorter half-life may become necessary. In this situation the risk of bleeding due to the intervention and the risk of thromboembolism due the underlying disease must be assessed. Low molecular weight heparins (LMWHs) are considered to be the medication of choice for bridging anticoagulation, mainly due to practical reasons and as they do not require coagulation monitoring and dose adjustment out of hospital treatment is feasible. Low molecular weight heparins are not authorized for the indication of bridging anticoagulation, however, on the basis of recent studies on large patient cohorts, the evidence of efficacy and safety is significantly better for LMWHs than for unfractionated heparin. New oral anticoagulants will soon become available for stroke prevention in patients with atrial fibrillation and for treatment of venous thromboembolism. Due to the shorter half-lives these compounds will no longer require bridging anticoagulation. However, the trauma surgeon should be familiar with the dosing regimens for different indications in order to adequately decide about the preoperative cessation and the perioperative pause of these anticoagulants.

[A huge malignant degenerating neurofibroma of the lower leg coexistent with type 1 Recklinghausen disease]. / Monströses, maligne entartetes Neurofibrom am Unterschenkel bei Morbus Recklinghausen.

HISTORY: A 65-year-old man had noted a tumor of the right lower leg that had progressively grown over the last twenty years. He had a dyspnoea on insignificant movement and was relatively immobile because of the extent of the tumor. The tumor had been diagnosed as a Klippel-Trenaunay syndrome. INVESTIGATIONS: Laboratory investigations suggested a hypochromic and microcytic anaemia and an inflammatory constellation. The tumor had no av-fistulas on ultrasonography and angiography, but there were many pathological arteries and tumor nodes. The tumor nodes had been seen also on MRI-biopsy suggested a neurogenic sarcoma. DIAGNOSIS AND TREATMENT: Amputation of the leg was necessary. The histological diagnosis was neurofibrosarcoma with extensive necrotic areas and Recklinghausen disease. Investigation did not reveal any metastasis. Postoperatively the anaemia regressed and the patient learned to walk with a prosthesis. CONCLUSIONS: This history shows the problem of separating clearly the two hereditary diseases. Often there is a different clinical picture in everyday life. One must consider the definitely higher risk of malignant tumors of patients with neurofibromatosis. Ultrasonography is a non-invasive method that can provide morphological information on soft parts and pathology of the vessels. It facilitates the classification of such.