Clinical management and outcome of major bleeding in patients on treatment with vitamin K antagonists.

BACKGROUND: The optimal management of major bleeding associated with vitamin K antagonists remains unclear. OBJECTIVES: The aim of the study was to assess the determinants of outcome of vitamin K antagonists-associated major bleeding and the outcome of bleeding in relation with the therapeutic management. METHODS: Patients hospitalized for major bleeding while on vitamin K antagonists were included in a prospective, cohort study. Major bleeding was defined according to the criteria of the International Society of Thrombosis Haemostasis. The primary study outcome was death at 30days from major bleeding. RESULTS: 544 patients were included in this study, of which 282 with intracranial hemorrhage. Prothrombin complex concentrates were used in 51% and in 23% of patients with intracranial hemorrhage or non-intracranial major bleeding, respectively (p<0.001); fresh frozen plasma was used in 7% and in 17% of patients with intracranial hemorrhage or non-intracranial major bleeding (p<0.001). Death at 30days occurred in 100 patients (18%), 72 patients with intracranial hemorrhage and 28 patients with non-intracranial major bleeding. Age over 85years, low Glasgow Coma Scale score and shock were independent predictors of death at 30days. Invasive procedures were associated with decreased risk of death. CONCLUSIONS: Among the patients hospitalized for major bleeding while on vitamin K antagonists, the risk for death is substantial. The risk for death is associated with the clinical severity of major bleeding as assessed by the GCS score and by the presence of shock more than with the initial localization of major bleeding (ICH vs other sites).

[Road traffic crashes, alcohol, meals, sleep and work hours: a case-crossover study at the Emergency Room of Udine, Italy]. / Incidenti stradali, alcol, pasti, sonno e ore di lavoro: uno stu- dio di case-crossover presso il Pronto Soccorso di Udine.

In case-crossover studies, useful for assessing the effect of acute transient exposures, each case acts as his/her own control, therefore, interpersonal confounding is controlled for by study. We used such design for studying the effect of the acute consumption of alcohol and meals, and of sleep and work hours on the risk of road traffic crashes. Subjects, enrolled at the Emergency Room (ER) of Udine from 12/3/2007 to 11/3/2008, were a sample of the drivers who arrived alive at the ER after a crash. They were interviewed by trained interviewers, who systematically covered predefined shifts, using a semi-structured questionnaire. The questionnaire collected information on the subjects, vehicles, and crashes, and contained a hourly diary of the exposure to driving, sleeping, working in the 48 hours before the crash and to alcohol and meals 24 hours before the crash. The statistical analysis was based on the matched pair interval approach. The exposures in the hours immediately before the crash (case window) were compared with those in previous hours (control window). Different window durations were chosen for different exposures. The relative risk (RR) of having a crash and 95% confidence intervals (95% CI) were estimated with conditional logistic regression, adjusting for potential confounders such as day of the week and time. We observed a statistically significant two-fold increase in the RR for drivers who had consumed alcohol (even small amounts) and a four-fold increase for those who had worked > 12 ore. The RR was increased by 10 times for drivers who had been awake for at least 16 hours. Meals were not associated with the risk of crash; the findings regarding sleep amount were controversial. In conclusion, the study confirms an increased risk of road crashes after consuming alcohol, even for amounts below the legal limit, and suggests that extended work hours and prolonged wakefulness may increase the risk of crashes.

Epidemiology and survival rate of out-of-hospital cardiac arrest in north-east Italy: The F.A.C.S. study. Friuli Venezia Giulia Cardiac Arrest Cooperative Study.

The results of the first epidemiological, prospective, multicentric study on cardiac arrest in a geographical Italian region are reported. On 708 consecutive cardiac arrests, 438 underwent cardiopulmonary resuscitation (CPR). Of these, 344 were identified of cardiac aetiology. The underlying initial rhythm was: 166 asystole (48.3%), 104 ventricular fibrillation (30.2%), 74 pulseless electrical activity (21.5%). The best outcome occurred in patients whose cardiac arrest was witnessed by the EMS (49% return of spontaneous circulation (ROSC), 21% hospital discharge). When cardiac arrest was witnessed by lay people, 20.5% had ROSC and 4.4% were discharged alive from the hospital. When it was unwitnessed ROSC and hospital discharge were 8.6 and 1.7%, respectively. Ventricular fibrillation was highly predictive of outcome. Both ROSC and hospital discharge correlated inversely with the delay of the first defibrillation. Overall, the highest probability of survival was achieved when CPR interventions were started within the first minutes after collapse. Basic Life Support (BLS) manoeuvres began after 9 min of untreated cardiac arrest were still followed by a ROSC, but none of these patients survived. The incidence of prehospital cardiac arrest in our population was estimated to be in proportion of 0.95/1000 per year with a survival rate of 6.7%.

The possible value of platelet aggregation studies in patients with increased platelet number.

ADP, adrenalin and collagen platelet aggregation studies were performed in 54 patients with elevated platelet counts: 38 patients showed primary thrombocythemia and 16 secondary thrombocytosis. Patients with primary thrombocythemia (78.7%) showed a decrease aggregation pattern while in patients with secondary thrombocytosis platelet aggregation response was entirely normal. An increase in platelet aggregation was obtained in four patients with primary thrombocythemia. The platelet aggregation response did not appear to be related to circulating platelet number. A relationship between increased platelet aggregation and the occurrence of thrombosis was demonstrated. Similarly, a correction between impaired platelet aggregation and bleeding was also present. These results emphasize the diagnostic value of platelet aggregation studies in patients with elevated platelet number.