Safety of Direct Oral Anticoagulants and Vitamin K Antagonists in Oldest Old Patients: A Prospective Study.

OBJECTIVE: The safety of direct oral anticoagulants (DOACs) in oldest old patients with nonvalvular atrial fibrillation (NVAF) in daily clinical practice has not been systematically assessed. This study examined the safety of DOACs and dicumarol (a vitamin K antagonist) in NVAF geriatric patients. DESIGN: Prospective study from January 2010 through June 2015, with follow-up through January 2016. SETTING: Geriatric medicine department at a tertiary hospital. PARTICIPANTS: A total of 554 outpatients, 75 years or older, diagnosed of NVAF and starting oral anticoagulation. MEASUREMENTS: The main outcome was bleeding, which was classified into major (including those life-threatening) and nonmajor episodes. Statistical analyses were performed with Cox regression. RESULTS: A total of 351 patients received DOACs and 193 dicumarol. Patients on DOACs were older, with more frequent comorbidities, mobility limitation and disability in activities of daily living, as well as higher mortality, than those treated with dicumarol. The incidence of any bleeding was 19.2/100 person-years among patients on DOACs and 13.7/100 person-years on dicumarol; corresponding figures for major bleeding were 5.2 for those on DOACs, and 3.3 for those on dicumarol. In crude analyses, hazard ratios (95% confidence intervals) for any bleeding, and for mayor bleeding in patients on DOACs vs dicumarol were 1.60 (1.04-2.44) and 2.22 (0.88-5.59), respectively. Excess risk of bleeding associated with DOACs vs dicumarol disappeared after adjustment for clinical characteristics, so that corresponding figures were 1.19 (0.68-2.08) and 1.01 (0.35-2.93). Results did not vary across subgroups of high-risk patients. CONCLUSION: In very old patients with NVAF, the higher risk of bleeding associated with DOACs vs dicumarol could be mostly explained by the worse clinical profile of patients receiving DOACs. Risk of bleeding was rather high, and warrants close clinical monitoring.

[Fournier's disease. Clinical case]. / La malattia di Fournier. Caso clinico.

Fournier's disease is a necrotizing fasciitis that prefers the male and which is located in the perineal area. In view of possible complications related to sepsis, systemic organ impairment and high mortality, is now considered a urological emergency. The main causes are infections of urethral and anorectal tract, immunodepression syndromes, diabetes mellitus and trauma. Infections are mixed with aerobic and anaerobic germs responsible of necrosis of tissue disorders due to the phenomena of necrotizing immunovasculitis disease. We present a case of Fournier's disease in perineal area, with gangrenosum necrotic evolution treated with antibiotic therapy, curettage of the necrotic tissue and local disinfection with saline and antiseptics solution. A total parenteral nutrition to ensure maximum perineal decontamination has been made. The extensive loss of substance scrotal was rebuilt in 25- day while the anal wound has healed spontaneously after complete surgical curettage.

Oclusiónes intestinales altas por hematomas yeyunales intramurales espontáneos en tratamiento dicumarínico / Small bowel obstruction due to intramural hematoma during anticoagulant therapy

Los accidentes oclusivos y suboclusivos en el inicio del uso de los tratamientos prolongados con anticoagulantes se cifraban entre el 1-2%, disminuyendo paulatinamente gracias al mejor conocimiento de los mecanismos de la hemostasia. La presencia de dolor abdominal y cuadro suboclusivo/oclusivo en pacientes bajo tratamiento anticoagulante con dicumarínicos representa un problema diagnóstico para el cirujano, al emular un abdomen quirúrgico. Hasta la aparición de la ecografía y sobre todo de la tomografía axial computerizada, fue difícil su diagnóstico y proporcionándonos éstas, datos precisos tanto para su estudio como por la información sobre su evolución. Su tratamiento inicialmente es médico y no requiriendo intervención quirúrgica, excepto en los casos de perforación. Presentamos dos casos que no requirieron intervención quirúrgica (AU)

Small bowel obstruction caused by intramural haemorrhage secondary to anti-coagulant therapy is estimated at 1-2%, gradually decreasing due to better understanding of the mechanisms of haemostasis. The presence of abdominal pain and occlusive box / occlusion in patients under anticoagulant therapy with Coumadin is a diagnostic problem for the surgeon, a surgical abdomen emulate. Until the advent of ultrasound and especially computerized tomography, it was difficult to diagnose and supplying them, so accurate data for study and for the information on its progress. Their initial treatment is medical and not requiring surgical intervention, except in cases of perforation. We present two cases treated conservatively (AU)

Skin necrosis during oral anticoagulant long-term treatment: an atypical side.

The effectiveness of anticoagulant therapy for venous thromboembolism, with regards to both acute phase and long term prophylaxis, in patients with recurrent deep venous thrombosis (DVT) and persistence of risk factors, has been confirmed by many studies. However, it is not free of complications such as hemorrhage or, more rarely, skin necrosis. The patient, observed by us since 1994, was treated with oral vitamin K antagonists: he was affected by post-thrombotic syndrome and deficiency of congenital procoagulant factors (factor II heterozygote and MTHFR positive heterozygote) and secondary deficiency of procoagulant factors due to the consumption of protein C, with appearance of skin necrosis that occurred after many years of oral anticoagulant treatment. The change of therapy from oral anticoagulant to low molecular weight heparin and the use of local dressing, led to the resolution of the clinical symptoms and on to healing.

Platelet-rich plasma treatment and hemostasis in patients with hemorrhagic risk.

AIM: Our research aimed to evaluate the risk of haemorrhage following oral surgical operations, in patients who were undergoing an anticoagulant therapy, and to test the usefulness of the autologous platelet gel in order to control haemostasis. METHODS: A total of 208 patients (84 males/124 females) undergoing an anticoagulant therapy and submitted to oral surgery, were divided at random into 4 groups (A, B, C, D) consisting of 52 patients each, using as criterion of differentiation the kind of treatment we adopted in order to get haemostasis. The patients belonging to the first 3 groups (A, B, C), underwent a surgical operation without discontinuing the dicumarol therapy. In order to get haemostasis, we used: platelet-rich plasma (PRP) and suture, in group A; PRP, haemostatic sponges and suture, in group B; haemostatic sponges, suture and compression by means of gauzes soaked in tranexamic acid in group C. Group D, instead, consisted of patients who underwent a surgical operation, before which the dicumarol therapy had been suspended and replaced by heparincalcium. RESULTS: Patients belonging to the groups A and B showed a very good haemostasis like the patients of group D (control group). As the coumarin therapy didn't need to be discontinued some days before the surgical operation, so the days of hospital stay were reduced and there wasn't the risk of thromboembolism. As to group C (19 males), 6 patients (i.e. 11.5%) showed a good haemostasis, both at once and in the long term, so that they could be discharged on day 2 after surgery. CONCLUSIONS: The results obtained during our research, highly encourage using PRP regularly when carrying out surgical treatments on patients who are undergoing a coumarin therapy.

[Recurrent hemoptysis secondary to an aortobronchial fistula]. / Hemoptisis recurrente secundaria a una fístula aortobronquial.

Aortobronchial fistula is a rare but serious cause of hemoptysis. It can develop from an aneurysm of the descending thoracic aorta in the context of infections or it may appear as a sequel of surgical repair of congenital heart defects. Presenting symptoms include mild bronchial hemorrhages and recurrent chest pain, culminating in a normally fatal massive hemorrhage. Diagnosis by imaging is not always conclusive and clinical suspicion based on medical history is essential. Surgical placement of an endovascular stent graft is the treatment of choice. Post-surgical prognosis is good although there is a risk of recurrence in the case of superinfection.

[Subarachnoid hemorrhage in a patient with corrected cyanotic congenital cardiopathy]. / Hemorragia subaracnoidea en un paciente con una cardiopatía congénita cianótica corregida.

A 19-year-old man with congenital cyanotic heart disease experienced subarachnoid bleeding from a ruptured cerebral aneurysm. Immediate rebleeding with disordered hemostasis caused by prophylactic anticoagulation treatment was the cause of death. Medical progress in repairing congenital heart disease or attenuating its effects has increased the life expectancy of such patients. Anesthesiologists who are not specialized in this area may find themselves assuming responsibility for these patients during non-cardiac surgery of greater or lesser extension.

Fulminant hepatic failure associated with dicoumarol therapy.

Coumarins have been associated with non-predictable hepatic injury. In the case of dicoumarol, there is no hard evidence in the literature of a causal connection with liver damage. We report the case of a 73-year-old woman who developed a fatal liver disease of a mixed hepatocellular-cholestatic type after 3 months of treatment with dicoumarol. A thorough diagnostic work-up did not reveal any other possible cause of the liver disease.

[Treatment of advanced Budd-Chiari syndrome by liver transplantation]. / Behandlung des fortgeschrittenen Budd-Chiari-Syndroms durch Lebertransplantation.

Budd-Chiari syndrome (BCS) with hepatic vein occlusion is a rare disorder that can effectively be treated in advanced stages with orthotopic liver transplantation. We report on 16 patients who received 18 liver grafts and were followed up for at least 2 years. In 7 patients a hematological disorder was confirmed by bone marrow biopsy. One patient died after 4 months due to cytomegalovirus pneumonia; another patient died after 2 years due to progressive liver failure after portal vein thrombosis. The actuarial 5-year survival rate is 87.5% compared to 85.3% in all other 710 orthotopic liver transplantations performed from September 1988 to December 1995 at our institution. Anticoagulation consisted of intravenous heparin and overlapping continuation with dicoumarin. Three patients received hydroxyurea for thrombocytosis, one patient for 1 week only early after the transplantation. Two postoperative abdominal hemorrhages required laparotomy. Two patients had to be retransplanted, one for thrombosis of the hepatic artery and portal vein after discontinuation of dicoumarin due to GI bleeding and one for hepatic vein thrombosis after insufficient dicoumarin intake. Terminal BCS represents a good indication for orthotopic liver transplantation; however, life-long, closely monitored anticoagulation is essential.

[Hematoma of the abdominal wall as differential diagnosis of cystic pelvic tumor]. / Bauchwandhämatom als Differentialdiagnose zu einem zystischen Unterbauchtumor.

In a woman patient aged 80 years under anticoagulation with dicumarol (Marcumar), abdominal pain suddenly occurred which was located on the right side as well as signs of acute bleeding. Preoperative sonography and computer scan showed a large, cystic tumour, most likely originating from the right ovary with infiltration of the abdominal wall. Intraoperative diagnosis was a large haematoma of the abdominal wall and the retroperitoneum penetrating into the free abdomen.

[Thrombophlebitis--basic principles of treatment]. / Phlebothrombose--Grundzüge der Behandlung.

Therapeutic strategies in deep vein thrombosis are yielding possible prevention of life-threatening pulmonary thromboembolism and extension of thrombosis. In order to prevent long term sequelae, i.e., the postthrombotic syndrome, recanalization is necessary before venous valves have been destroyed. Therapeutical guidelines comprise immobilization (except isolated calf vein thrombosis), compression therapy and anticoagulation. Thrombolysis may be performed in patients in whom extension and localization of thrombosis may result in a postthrombotic syndrome, if thrombosis is not older than 1-2 weeks, if there are no concomitant diseases which make it uncertain for the patient to experience postthrombotic syndrome, and in the absence of contraindications.

Dicumarol content in alcoholic herb elixirs: one of the factors at risk induced IVKD-I.

Nine medicinal plants known to be the ingredients of the traditional herbal medicinal elixir, and seven popular commercial alcoholic herb elixirs were investigated for the content of dicumarol by using high pressure liquid chromatography (HPLC) and thin layer chromatography (TLC) methods. Umbelliferae (Conioselinum Univittatum) were the only medicinal plants found to contain dicumarol 0.04 mg/dl. Dicumarol content was also found in three out of seven brands of commercial alcoholic herb elixirs with the concentration of 0.58, 1.86 and 6.00 mg/dl. These findings indicated that the traditional herbal medicinal elixirs containing dicumarol in varying amount may play a role in inducing bleeding diathesis in breast-fed infants of mothers known to consume the elixir.