Fatal haemoptysis induced by invasive pulmonary aspergillosis in patients with acute leukaemia during bone marrow and clinical remission: report of two cases and review of the literature.

We describe two patients with acute leukaemia who died of massive haemoptysis caused by invasive pulmonary aspergillosis (IPA). The fatal event occurred during the period of bone marrow remission which followed chemotherapy-induced neutropenia. This is a rare complication. We were able to find additional 17 similar cases in the English literature, which we review. Clinically, the picture consisted of unremitting fever with profound and prolonged neutropenia, cough and dyspnoea. Both our patients were treated with broad-spectrum antibiotics, fluconazole and amphotericin B. An upper lobe infiltrate in one case, and a progressive pleural effusion in the other, were late findings on chest radiographs during the period of bone marrow recovery. Both patients succumbed to sudden massive haemoptysis during the period of bone marrow and clinical improvement. In conclusion, patients with acute non-lymphoid leukaemia are at significant risk for IPA-induced fatal haemoptysis during bone marrow and clinical remission. A high index of suspicion should be sustained throughout the entire clinical course. In view of the potential fatal outcome, aggressive diagnostic and treatment efforts are mandatory.

Adequacy of anticoagulation in patients with atrial fibrillation: effect of various parameters.

BACKGROUND: Despite reported evidence of the vital importance of appropriate anticoagulation in patients with chronic atrial fibrillation for stroke prevention, this treatment modality still lags behind optimal requirements. HYPOTHESIS: Our objectives were to evaluate various doctor or patient-related factors that influence quality of control and to assess the adequacy of anticoagulation provided by physicians in the community. METHODS: In a retrospective study, International Normalized Ratio (INR) values obtained immediately on admission to hospital were considered representative of previous long-term control. RESULTS: Only 42% of the relevant 385 patient population fell within the protective anticoagulation range of INR 1.91-4.1. The respective figures for patients with poor (INR < 1.5) or suboptimal (INR 1.51-1.9) control, as well as those whose INR values risked bleeding (INR > 4.1), were 28.3, 14.1, and 15.6%. Patient involvement in treatment positively influenced quality of control. By contrast, age 70-80 years or absence of congestive heart failure negatively affected quality of anticoagulation [p = 0.07, odds ratio (OR), 1.7 (95% confidence interval. 0.94-3.08), p = 0.014, OR, 2.06 (95% confidence interval, 1.15-3.7) respectively]. The percentage of patients admitted with stroke who had been adequately anticoagulated was significantly lower than that of patients who had no stroke (21 vs. 44.4%). Adequacy of anticoagulation in patients with cardiac prosthetic valves was superior compared with the rest of the patient population (56.7 vs. 42% with optimal, and only 14.5 vs. 28.3% with poor anticoagulation, respectively), indicating that under the same conditions a better quality of treatment could be achieved. CONCLUSIONS: Adequacy of anticoagulation in patients with atrial fibrillation lags behind actual recommendations. Better control is required and achievable.

Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission.

BACKGROUND AND PURPOSE: The value of warfarin in preventing stroke in patients with chronic atrial fibrillation is well established. However, the prevalence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfarin treatment. METHODS: Between 1990 and 1998, 1027 patients were discharged with chronic or persistent atrial fibrillation. This population was composed of (1) patients with cardiac prosthetic valves (n=48), (2) those with increased bleeding risks (n=152), (3) physically or mentally handicapped patients (n=317), and (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfarin use. RESULTS: The respective rates of warfarin use on discharge in the 4 groups were 93.7%, 30.9%, 17.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatment rates increased with each consecutive triennial period (29.7%, 53.6%, and 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, and being hospitalized in a given medical department emerged as independent variables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI 0.17 to 0.55); P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and availability of echocardiographic information, regardless of the findings, each increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0001, OR 3.52 [95% CI 2.16 to 5.72], respectively). CONCLUSIONS: Old age, language difficulties, insufficient doctor alertness to warfarin benefit, and patient disability produced reluctance to treat. Warfarin use still lags behind requirements.