Emergency care of patients receiving non-vitamin K antagonist oral anticoagulants.

Non-vitamin K antagonist oral anticoagulants (NOACs), which inhibit thrombin (dabigatran) and factor Xa (rivaroxaban, apixaban, edoxaban) have been introduced in several clinical indications. Although NOACs have a favourable benefit-risk profile and can be used without routine laboratory monitoring, they are associated-as any anticoagulant-with a risk of bleeding. In addition, treatment may need to be interrupted in patients who need surgery or other procedures. The objective of this article, developed by a multidisciplinary panel of experts in thrombosis and haemostasis, is to provide an update on the management of NOAC-treated patients who experience a bleeding episode or require an urgent procedure. Recent advances in the development of targeted reversal agents are expected to help streamline the management of NOAC-treated patients in whom rapid reversal of anticoagulation is required.

Primary and secondary prophylaxis of venous thromboembolism with low-molecular-weight heparins: prolonged thromboprophylaxis, an alternative to vitamin K antagonists.

Low-molecular-weight heparins (LMWHs) are used widely in the treatment and prevention of venous thromboembolism (VTE). The LMWHs dalteparin and enoxaparin reduce the rate of VTE by at least 50% if administered for 4-5 weeks following major orthopedic surgery, compared with in-hospital prophylaxis for 7-15 days. Meta-analyses have confirmed that the size of the reduction is similar for both clinical and asymptomatic VTE. Vitamin K antagonists (VKAs) have been shown to be associated with significantly higher bleeding rates compared with LMWH when used as prolonged prophylaxis against VTE following major orthopedic surgery. Patients with cancer are a recognized group at high risk of VTE, and those undergoing major surgery for their malignancy are at particular risk. Evidence from clinical trials is amassing to show that prolonged prophylaxis with LMWH (dalteparin, enoxaparin) in these patients can significantly reduce the rate of postoperative VTE. In cancer patients with acute VTE, the traditional approach is to initiate acute treatment with unfractionated heparin or LMWH followed by long-term treatment with VKA to prevent recurrence. However, clinical trial data have confirmed that the LMWH dalteparin, when administered for 6 months, is significantly more effective than VKA in preventing recurrence, cutting the rate of VTE by 52% without increasing the risk of bleeding. A new and intriguing area of interest is whether LMWH can enhance survival in patients with cancer. Preliminary data suggest that a biological effect of LMWH may act to prolong survival in patients with cancer.

A rare cause of steatohepatitis.

We present a rare case of steatohepatitis due to neutral lipid storage disorder in a 1.5-year-old male presenting with intermittent fever, hepatomegaly and dark-coloured urine. On examination, there was ichthyosis involving both the limbs. Liver biopsy showed steatohepatitis. The peripheral blood smear revealed fat vacuoles in the cytoplasm of leucocytes, characteristic of the Dorfman-Chanarin syndrome. Awareness of this condition helps in prompt diagnosis and avoids unnecessary further investigations.

Low-molecular-weight heparins: weeks or months instead of days of treatment.

Low-molecular-weight heparins (LMWHs) have been used for more than a decade in the prophylaxis and treatment of venous thromboembolism and recently in coronary artery disease. During the past few years, the duration of treatment has been increased in several pathologic conditions. A number of clinical studies provided evidence that the duration of prophylaxis after hip replacement should be prolonged up to 35 days after surgery. Several clinical trials concluded that LMWHs provide an effective and safe alternative to oral anticoagulants in the secondary prevention of deep vein thrombosis. A recent trial showed that extended dalteparin treatment is useful for protection against further complications while patients are waiting for invasive procedures. Finally, LMWHs seem to be safe during pregnancy.

Critical appraisal of current antithrombotic trials in patients undergoing total hip replacement.

Patients undergoing total hip replacement are at high risk of developing venous thromboembolism. The 6th ACCP Consensus Conference on Antithrombotic Therapy identified two effective prophylactic methods; low molecular weight heparins (LMWH) and oral anticoagulants. However, two key issues remain controversial. The relative efficacy and safety of prophylaxis initiated pre operatively and post operatively and the optimum duration of prophylaxis. Clinical practice has diverged in North America and Europe as to the appropriate time to administer prophylaxis. This treatment is given pre-operatively in Europe and post-operatively in North America. A number of recent studies have demonstrated that an effective antithrombotic agent administered either immediately before or after surgery may be more effective than current practice. The use of LMWH for extended thromboprophylaxis is supported by convincing data. Clinical trials have demonstrated a significant benefit of pentasaccharide in the prevention of venous thromboembolism in major orthopaedic surgery. A direct thrombin inhibitor given sc. followed by oral administration was found to be as effective and safe as LMWH for the prophylaxis of deep vein thrombosis (DVT) following major hip or knee surgery.

Efficacy of a modified Ultra Fast Papanicolaou (UFP) stain for breast aspirates.

The chief limitation of Ultra Fast Papanicolaou (UFP) stain, suggested by Yang and Alvarez (1995), is that, Richard Allan Haematoxylin (RA-H) and Richard Allan Cytostain (RA-C), used in the staining procedure are not universally available. It has not been established so far, whether, changes in the reagents and their proportions depending on the local availability, influence the performance of the stain. The objective of this study was to assess the feasibility and applicability of a modified UFP stain to suit our local laboratory supplies of chemical dyes, as applied to the permanent smears prepared from Fine Needle Aspiration (FNA) of breast lumps. In the present study, smears from FNA from 100 breast lumps were stained by the modified UFP stain. The modification consisted of following two changes: use of Gill's Haematoxylin instead of RAH and omission of Orange G from cytostain. Eighty Six breast aspirates were adequate for interpretation. Smears showed transparent cells with crisp nuclear features, equal to and even better than the conventional Papanicolaou stain, in a blood free background. There was an increase in total staining time by 40 seconds. We recommend the use of this modified UFP stain, only if similar reagents are being used in other laboratories. Otherwise situation specific modifications may be needed. If the UFP stain is to be used for tissues where the chances of cytoplasmic keratinization are negligible, then the use of Orange G component of the stain may become redundant.

Efficacy of fine needle capillary sampling in the diagnosis of stage III and IV cervical carcinoma.

OBJECTIVE: To test the sensitivity of fine needle capillary sampling (FNCS) as compared to scrape cytology in cervical carcinoma, stage III and IV, and to study the quality of material obtained by FNCS. STUDY DESIGN: Prospective. In 48 cases of cervical carcinoma, clinically stage III and IV, FNCS was done along with scrape cytology. The results were compared, considering histopathology as the gold standard. The quality of material obtained by both methods was compared using the parameters background, cellularity and cellular preservation. RESULTS: FNCS had a sensitivity of 87.5% as against 62.5% for scrape cytology. Material obtained by FNCS had a cleaner background and better cellularity and morphologic preservation. CONCLUSION: FNCS is superior to scrape cytology for the diagnosis of stage III and IV cervical carcinoma.

Evaluation of fine needle capillary sampling in superficial and deep-seated lesions. An analysis of 670 cases.

OBJECTIVE: To study the efficacy and merits of a simplified cytologic technique of fine needle capillary (FNC) sampling in 670 cases. STUDY DESIGN: FNC sampling was tested on a consecutive series of 600 superficial palpable masses and 70 deep-seated lesions during the period January 1993-September 1993. Among superficial masses, sampling was done on 380 lymph nodes, 88 breast lesions, 56 thyroids, 12 salivary glands and 64 miscellaneous sites. Fifty-five lung lesions were sampled using 8 computed tomography, while 15 abdominal masses were sampled using ultrasonography. Cell samples were assessed as diagnostically adequate or inadequate. RESULTS: The diagnostic adequacy in lymph node, breast and thyroid lesions was 95%, 91.07% and 90.09%, respectively. The diagnostic adequacy for deep-seated lesions was 91.42%. CONCLUSION: The procedure gives a better perception of tumor consistency and control of the hand. FNC resulted in a high yield of good-quality material with retention of cellular architecture. It is recommended that the operator become familiar with the macroscopic slide appearance of a cellular smear. Doubts persist with respect to fibrotic and cystic lesions.

Seroprevalence of hepatitis A virus in Mumbai, and immunogenicity and safety of hepatitis A vaccine.

OBJECTIVES: Since epidemiologic trends of hepatitis A are changing worldwide, we studied its seroprevalence in Mumbai, which is thought to be a high-endemicity area. The immunogenicity and safety of a hepatitis A vaccine were also studied. METHODS: Six hundred and seventy subjects (456 men; age range 6 mo-60 y) answered a questionnaire on social and medical history. Qualitative analysis of total anti-HAV was performed in all subjects by ELISA. One hundred and seven of 147 anti-HAV negative subjects received hepatitis A vaccine at months 0, 1 and 6. Subjects were followed up (months 1, 2, 6, 7) to look for side-effects and seroconversion. RESULTS: The seroprevalence of HAV was 523/670 (78%); 38% of children < 5 years were anti-HAV negative. Seroprevalence rates of 80% were reached by 15 years. Prevalence was lower in the higher socio-economic group (151/234; 64.5%) compared with the lower socio-economic group (372/436; 85%) (p < 0.001). One month after doses 1, 2 and 3 of the hepatitis A vaccine, seropositivity was 92%, 99% and 100%, respectively. Minor self-limited side-effects occurred in 19.5% of subjects; there were no major side-effects. CONCLUSIONS: The seroprevalence of anti-HAV is high in Mumbai. Seroprevalence is lower in the higher socio-economic groups. The hepatitis A vaccine is safe and immunogenic.

PIP: Prevention of hepatitis A virus (HAV) can be achieved through improved hygiene and living conditions, access to clean drinking water, and passive and active immunization. The present study assessed the age-related seroprevalence of HAV in Mumbai, India, in 1995-96 and the immunogenicity and safety of a newly developed inactivated HAV vaccine. 670 children and adults were recruited from 2 sites: a private hospital serving a predominantly middle- and upper-class population and a public hospital with low-income patients. Overall, 523 subjects (78%) were positive for anti-HAV. This rate was higher among low-income patients (85.3%) than those of higher socioeconomic status (64.5%). 38% of children under 5 years of age and 80% of those 11-15 years old were seropositive. 107 patients seronegative for anti-HAV were offered the vaccine. Anti-HAV antibody appeared 1 month after the first injection in 92.4% of vaccine recipients and 1 month after the second injection in 99%. Side effects were mild and self-limited. These findings confirm both the safety and the immunogenicity of the inactivated hepatitis A vaccine in high endemicity areas. However, universal immunization remains too costly in India. Further epidemiologic studies are needed to identify specific risk groups and regions that should be targeted for hepatitis A vaccine.

Significance of serum ferritin and lactate dehydrogenase in benign and malignant disease of breast.

Serum ferritin (SF) and lactate dehydrogenase (LDH) was estimated in 117 patients presenting with a breast lump and in 40 controls. Both pre and post treatment values were determined. Both the values were significantly higher in breast malignancies (p = 0.00) and also corresponded with the clinical stage and bulk of the tumour. The fall in post treatment values was proportional to the response to therapy. Persistent rise in values in the post treatment period was indicative of local recurrence of metastasis.

Florid melanocytic colonization in a metastasis of breast carcinoma. A case report.

BACKGROUND: Melanocytic colonization in breast carcinoma with skin invasion is an unusual entity. Very rarely does florid colonization by melanocytes simulate melanoma. This phenomenon requires recognition. The cytomorphology of this lesion is reported below for the first time. CASE: A 45-year-female operated on for breast carcinoma developed a recurrent nodule on the mastectomy scar and another circumscribed, depigmented nodule on the back. Fine needle aspiration cytology smears from the recurrent nodule showed features of lobular carcinoma of the breast, whereas the nodule on the back showed cytomorphologic features simulating melanoma along with cells simulating lobular carcinoma of the breast. CONCLUSION: We report for the first time the cytologic finding of melanocytic colonization in subcutaneous secondary breast carcinoma.

Supernumerary limbs: a case report of a rare congenital anomaly.

We report a case of an 18-month-old female who presented with three supernumerary upper limbs of varying lengths on the right side. Each limb had a proximal, middle, and distal segment, and an intercalated elbow and wrist joint. A single digit was present in the superior limb, three digits in the middle limb, and two digits in the caudal-most limb. Right plagiocephaly, congenital torticollis, scoliosis involving the upper and mid thoracic region, and a hypoplastic right pectoralis major were the other abnormal features noted. Radiography showed two scapulae, humerus, a single forearm bone in each limb, and rudimentary metacarpals and phalanges. Limb duplication may rarely be encountered in parasitic conjoined twins. The role of mutagens, drugs, cellular contributions, and morphogens in the growth and differentiation of limbs has been studied in animals. It is rather difficult to deduce the time of action of the factors responsible for such a malformation.

Cytodiagnosis of lower respiratory tract lesions by transthoracic needle aspiration.

A comprehensive prospective and retrospective study of 130 cases was carried out to evaluate the safety, adequacy and diagnostic accuracy of Transthoracic Needle Aspiration (TTNA) in various pulmonary lesions. Using both guided and unguided TTNA diagnostic material was procured in 86.15% cases. Rotex II, Chiba, lumber puncture and ordinary needles were used depending upon the type of lesion. Overall diagnostic accuracy of the procedure was 79.46 percent. Complication after the procedure were transient and self limiting. Haemoptysis was noted in 3.84 percent cases and pneumothorax in a single case. Thus TTNA can be safely included in the investigative protocol of lung lesions.

Spondylocostal dysostosis.

Spondylocostal dysostosis is a rare condition characterized by short stature due to a short trunk, multiple morphological abnormalities of the vertebrae and ribs due to malsegmentation of the axial skeleton. Radiological features include reduced number of vertebrae and ribs, hemivertebrae, fused or sagitally cleft vertebrae or multiple rib fusions. Three distinct clinical entities are described. We report nine cases of this syndrome, seven were infants and presented with an abnormal shape of the thorax. Two of them had a meningocoele, and one succumbed to the CNS anomalies on the third day of life. The other two cases were two and eight years of age. Cardiac lesion was detected in one case and renal malformations in three cases. Reduction in the rib number was present in all cases, and rib fusion in seven cases. Thoracic vertebral dysegmentation was noted in all, lumbar in three and cervical in one case. This is the first large series from India. No clear single etiology was established.