Risk of hemorrhage in patients with chronic liver disease and coagulopathy receiving pharmacologic venous thromboembolism prophylaxis.

STUDY OBJECTIVE: To evaluate the impact of pharmacologic venous thromboembolism (VTE) prophylaxis on risk of hemorrhage while hospitalized in patients with chronic liver disease (CLD) and concurrent coagulopathy. DESIGN: Retrospective, multicenter chart review. SETTING: Five hospital, university-affiliated network in eastern Pennsylvania. PATIENTS: Patients admitted to the network from January 1, 2012, until December 31, 2012, with ICD-9 code consistent with CLD and elevated international normalized ratio of 1.5 or greater not secondary to anticoagulation. MEASUREMENTS AND MAIN RESULTS: Two hundred fifty-six patients met criteria for analysis, with 80 having received pharmacologic VTE prophylaxis and 176 having received no pharmacologic VTE prophylaxis. Differences were observed in the primary outcome of overall hemorrhage (composite of major and minor hemorrhage) for patients receiving VTE prophylaxis versus no VTE prophylaxis (17.5% vs 7.4%, p=0.02). Logistic regression revealed covariates independently associated with increased hemorrhage risk were pharmacologic VTE prophylaxis use (adjusted odds ratio [AOR] 3.64, p=0.004), increasing international normalized ratio (AOR 1.31, p=0.007), and decreasing platelet count (AOR 0.99, p=0.03). CONCLUSIONS: Patients with CLD and concurrent coagulopathy receiving pharmacologic VTE prophylaxis are at an increased risk of overall hemorrhage. Clinical implications remain unclear secondary to the difference in rate of overall hemorrhage being driven primarily by a difference in minor hemorrhage. In addition, no difference was demonstrated in many assessed clinically relevant markers.

Risk factors for mesh extrusion after prolapse surgery: a case-control study.

OBJECTIVES: To identify risk factors for mesh extrusion in women undergoing pelvic organ prolapse repair by abdominal sacral colpopexy (ASC) or vaginal mesh procedure (VMP). METHODS: A multicenter case-control study of patients who underwent ASC or VMP from 2006 to 2009 identified using diagnosis and procedure coding. Cases were defined as women who underwent eligible index procedure with synthetic mesh and had mesh visible through the vaginal epithelium at postoperative evaluation; controls were matched in an approximate 1:3 ratio by date and type of procedure. Two conditional logistic regression models were constructed to assess variables associated with mesh extrusion among women who underwent ASC and among women who underwent VMP. RESULTS: Eighty-four cases were identified (43 cases after ASC and 41 cases after VMP), and 252 patients were matched as controls (147 patients who underwent ASC and 105 patients who underwent VMP). Concomitant hysterectomy was positively associated with mesh extrusion) among women who underwent ASC (adjusted odds ratio, 3.18; 95% confidence interval, 1.27-7.93; P = 0.01) and VMP (adjusted odds ratio, 3.72, 95% confidence interval, 1.20-11.54; P = 0.02). Age, race, type of vaginal incision, menopausal status, medical comorbidities, and smoking were not significantly associated with extrusion in either group. CONCLUSIONS: Concomitant hysterectomy is a risk factor for mesh extrusion after ASC and VMPs. This information may be helpful during informed preoperative counseling and planning.