Bleeding and Thrombotic Risk in Low Dose Heparin Infusion as Compared to Standard Dose Heparin Infusion.

Intravenous unfractionated heparin (UFH) remains one of the most commonly used anticoagulants in the hospital setting. The optimal protocol for initiation and maintenance of UFH has been difficult to determine. Over the past two decades, weight-based nomogram protocols have gained favor. Herein, we present a retrospective study of 377 patients at a single tertiary academic center treated with low intensity (LI) and standard intensity (SI) UFH protocols for therapeutic anticoagulation. UFH levels are measured by anti-Xa assay activity with therapeutic levels of 0.30 to 0.70 IU/mL for SI and 0.25 to 0.35 IU/mL for LI.  Patients treated on the LI protocol were more likely to have had a previous history of bleeding and lower baseline hemoglobin. Incidence of new or worsening thrombus while on UFH was comparable between both protocols (odds ratio (OR) 0.93, 95% confidence interval (CI) 0.29-2.98, p=0.899). Patients on LI protocol had higher incidence of bleeding while on UFH (OR 1.21, 95% CI 0.51-2.89, p=0.667). Our study thus suggests that the LI protocol may have comparable efficacy to the SI protocol in treating venous thromboembolism (VTE) and that target anti-Xa levels of 0.25 to 0.35 IU/mL may be more optimal in high-risk patients.

Normalization of Diffuse ST-Depression with aVR Elevation After Rehydration in a Patient with Severe Aortic Stenosis.

BACKGROUND Isolated ST elevation in lead aVR in combination with global ST depression with normalization after rehydration is a unique electrocardiographic pattern that is associated with a broad range of diagnoses. Its association with left main coronary artery disease and other acute coronary syndromes suggest the need for early and aggressive cardiac evaluation. CASE REPORT A 53-year-old man presented with altered mental status and loss of consciousness. He was unresponsive, hypotensive, tachycardiac, and diaphoretic. An initial ECG showed diffuse ST depression with isolated ST elevation in lead aVR, and initial troponin levels were negative. After rehydration, a repeat ECG showed sinus rhythm without ischemic changes. An emergent echocardiogram showed severe aortic stenosis and global hypokinesis. Repeat troponin results were elevated. The patient had 2 subsequent cardiac arrests. Emergent cardiac catheterization showed an occluded right coronary artery with collaterals and complete occlusion of the LAD. Urgent intra-aortic balloon pump was placed, followed by coronary artery bypass graft, aortic valve replacement, and a placement of a left ventricular assist device. Despite maximal hemodynamic support, the patient died after cardiac arrest due to massive myocardial infarction. CONCLUSIONS Normalization of diffuse ST depression with isolated aVR ST elevation on electrocardiography with improvement in clinical and hemodynamic status through fluid resuscitation can mask a stuttering myocardial infarction given its association with left main coronary artery disease and partial right coronary artery occlusion.

Vibrio vulnificus septicemia and leg ulcer.

Vibrio vulnificus is a gram-negative bacteria that can cause septicemia, wound infection, or a self-limiting diarrhea. This infection typically presents as an extremely virulent infection in patients with underlying liver disease 1 to 2 days after exposure. We report a case of V vulnificus septicemia, cellulitis, and leg ulceration in a patient who had symptoms develop after exposure to brackish water (19 days before admission) or after ingestion of raw oysters (10 days before admission). The longest incubation period previously reported is 6 days. The diagnosis was made from identification of the bacteria from blood cultures. No organisms were seen or grown in culture from the skin biopsy specimen, which showed epidermal necrosis and dermal and subcutaneous neutrophilic abscess. We review 13 cases of V vulnificus septicemia and leg ulcers and their approximate incubation time.