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1.
MMW Fortschr Med ; 161(Suppl 6): 15-23, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31587168

RESUMO

BACKGROUND: Non-vitamin K-dependent oral anticoagulants (NOAC) have changed the management of patients with oral anticoagulation. This raises the question of which patients should preferably be anticoagulated with NOAC and which preferably with vitamin K antagonists (VKA). This discussion has so far been insufficiently conducted and often decided on a flat-rate basis in favor of the NOAC. METHOD: To clarify the question owhich form of anticoagulation - NOAC or VKA - is the best choice for patients with atrial fibrillation, an interdisciplinary team of experts met. RESULTS AND CONCLUSIONS: The experts discussed essential practical aspects of NOAC and VKA therapy. Based on typical clinical scenarios, they developed assistance, comments and tips on the differentiated use of oral anticoagulants in patients with atrial fibrillation. A criteria served amongst others practicability in daily medical practice, contraindications, side effects and interactions, but also the patient's desire. The advantages and disadvantages of therapy with VKA and NOAC were summarized in a table.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial , Vitamina K/antagonistas & inibidores , Administração Oral , Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Fibrinolíticos , Humanos , Modalidades de Fisioterapia
2.
Medicine (Baltimore) ; 98(40): e17421, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31577757

RESUMO

Regional citrate anticoagulation (RCA) was recommended as the first treatment option for adults by the Kidney Disease Improving Global Outcomes Kidney Foundation in 2012, for the characteristic of sufficient anticoagulation in vitro, but almost no anticoagulation in vivo. Traditionally, the substitute for RCA is calcium-free. This study investigated a simplified protocol of RCA for continuous hemofiltration (CHF) in children using a commercially available substitute containing calcium.An analytical, observational, retrospective study assessed 59 pediatric patients with 106 sessions and 3580 hours of CHF. Values before and after treatment were compared, including Na, ionic calcium (iCa) and HCO3 concentrations, pH, and the ratio of total calcium to iCa (T/iCa). In addition, in vivo and in vitro iCa, treatment time, sessions with continuous transmembrane pressure >200 mm Hg, and sessions with clotting and bleeding were recorded.The average treatment time was 33.8 ±â€Š10.1 hours. In vitro, 88.5% of iCa achieved the target (0.25-0.35 mmol/L), and in vivo, 95.4% of iCa achieved the target (1.0-1.35 mmol/L). There were 8 sessions with a transmembrane pressure >200 mm Hg and 3 sessions with filters clotted. After treatment, there were 2, 1, and 2 sessions with T/iCa > 2.5 (implying citrate accumulation), iCa < 0.9 mmol/L, and iCa > 1.35 mmol/L. No sodium disorders were recorded. There were fewer cases of acidemia and more cases of alkalemia after treatment compared to before.RCA-CHF with a substitute containing calcium and close monitoring could be a safe and effective treatment for children. In addition, the calcium test site in vitro and the adjustment of citrate should be given strict attention.


Assuntos
Lesão Renal Aguda/metabolismo , Lesão Renal Aguda/terapia , Anticoagulantes/farmacocinética , Cálcio/farmacocinética , Ácido Cítrico/farmacocinética , Hemofiltração , Lesão Renal Aguda/etiologia , Anticoagulantes/administração & dosagem , Cálcio/administração & dosagem , Criança , Pré-Escolar , Ácido Cítrico/administração & dosagem , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos
3.
Pan Afr Med J ; 33: 160, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31565122

RESUMO

Intra-alveolar bleeding is a rare and severe medical emergency due to numerous causes. We report the clinical case of a patient who could contribute to extend the literature on this subject. The study included a 62-year old man, with a history of a trial fibrillation, under anti-vitamins K antagonist admitted with dyspnoea of sudden onset associated with haemoptysis and practising self-medication using non-steroidal anti-inflammatory drugs. X-rays and chest scan showed diffuse bilateral alveolar opacities. Haemostatic screening tests on admission showed non-coagulable INR. The diagnosis of intra-alveolar bleeding was clinically and radiologically suspected and then confirmed by bronchial endoscopy with broncho-alveolar lavage (BAL) which detected uniformly hemorrhagic liquid. Previous studies of similar complications occurring after anti-vitamins K antagonists assumption are rare. In conclusion, it seems very important to emphasize the interest of strict and optimal clinico-biological monitoring of patients treated in anti-vitamins K antagonists to avoid an overdose which could contribute to a life-threatening severe haemorrhagic event.


Assuntos
Acenocumarol/efeitos adversos , Anticoagulantes/efeitos adversos , Hemorragia/induzido quimicamente , Alvéolos Pulmonares/patologia , Acenocumarol/administração & dosagem , Anticoagulantes/administração & dosagem , Dispneia/induzido quimicamente , Hemoptise/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Vitamina K/antagonistas & inibidores
4.
Khirurgiia (Mosk) ; (10): 75-81, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31626243

RESUMO

Postoperative complications in vascular surgery may be partly provoked by suture material. Analysis of the mechanisms of these complications may be useful for their prevention. Mechanisms of suture-induced thrombosis and neointimal hyperplasia, possible strategies for prevention of postoperative complications including those allowing drug deliveries directly to the vascular anastomosis area are discussed in the article. According to the literature data, heparin is the most optimal drug for modifying suture material and prevention of thrombosis and neointimal hyperplasia. Heparin delivery to the vascular anastomosis site will reduce the risk of thrombosis by inhibiting the activity of thrombin. Complex of heparin and antithrombin III increases inhibitory effect of antithrombin against thrombin. In addition, heparin is able to reduce proliferation of vascular smooth muscle cells through inhibition of the synthesis of extracellular matrix proteases involved in migration and proliferation of cells. Thus, heparin delivery to the vascular injury site may be used to prevent thrombosis and myoproliferative response. Moreover, this strategy prevents complications associated with systemic administration of anticoagulants.


Assuntos
Suturas/efeitos adversos , Trombose/prevenção & controle , Doenças Vasculares/prevenção & controle , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Anticoagulantes/administração & dosagem , Heparina/administração & dosagem , Humanos , Hiperplasia/etiologia , Hiperplasia/patologia , Hiperplasia/prevenção & controle , Neointima/patologia , Trombose/etiologia , Doenças Vasculares/etiologia
5.
Am Surg ; 85(8): 821-829, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560301

RESUMO

Anticoagulated older adults suffering ground-level falls are a specialty trauma population at risk for intracranial hemorrhage (ICH). Delays in diagnosis or initiation of anticoagulation reversal can lead to increased morbidity/mortality. A novel "Headstrike" protocol was implemented to improve the treatment efficacy and disposition of these patients. The study objective was to determine effectiveness of the "Headstrike" protocol in providing these patients with timely treatment and disposition, while maintaining positive outcomes. A trauma performance improvement database was queried for all "Headstrike" activations for a 12-month period after implementation. Demographics, patient care, and health data were collected. Descriptive statistics were used for cohort analysis. Five hundred fifteen patients were activated as a "Headstrike" during the study period. Thirty eight patients were diagnosed with ICH (7.4%), 35 of whom were identified on initial imaging. Anticoagulation reversal was ordered for 84.6 per cent of these patients. Of the patients with negative initial CT, only three patients (0.8%) were found to have a delayed ICH on routine follow-up imaging. No anticoagulant/antiplatelet agent was associated with a significantly higher risk of ICH. Implementation of the "Headstrike" protocol resulted in trauma service line resources being used more efficiently, while ensuring high-quality, expeditious care to this population.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Anticoagulantes/administração & dosagem , Protocolos Clínicos , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/terapia , Idoso , Feminino , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Masculino , Melhoria de Qualidade , Estudos Retrospectivos , Centros de Traumatologia , Resultado do Tratamento
6.
Am Surg ; 85(8): 861-864, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560304

RESUMO

Traumatic brain injuries in patients on antithrombotic agents carry significant morbidity. Initial therapy is centered around reversal of these agents. The thromboelastogram (TEG) maps the clotting cascade to guide reversal. A retrospective chart review was conducted for 118 patients presenting with a traumatic brain injury while on antithrombotics. Patients were divided between those who received a TEG on arrival and those who did not. The primary endpoint was overall mortality. Secondary endpoints included blood product utilization, and outcomes associated with specific novel anticoagulants. Mortality in the control group was 20.3 per cent compared with 18.5 per cent in the TEG group (P = 0.81). For less severe injuries, the control group mortality was 3.8 per cent and the TEG group mortality was 8.7 per cent (P = 0.64). For more severe injuries, mortality in the control versus TEG groups were 31.6 per cent and 25.8 per cent, respectively (P = 0.73). Blood product utilization was significantly lower in the TEG group (P = 0.002). Overall mortality was not significantly different between the groups. However, when stratified by severity of injury, mortality was reduced in the TEG-guided group in severely injured patients. Blood product utilization was significantly reduced with TEG-guided reversal. Trauma centers can improve the utilization of blood products in reversal of antithrombotics with the use of TEG.


Assuntos
Anticoagulantes/administração & dosagem , Lesões Encefálicas Traumáticas/sangue , Hemorragias Intracranianas/sangue , Ressuscitação/métodos , Tromboelastografia , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Lesões Encefálicas Traumáticas/mortalidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/mortalidade , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento
7.
Am Surg ; 85(8): 871-876, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560306

RESUMO

The aim of this study was to evaluate the impact of prehospital antiplatelet and/or anticoagulant (APAC) use on treatment and outcomes in patients with severe blunt chest injury. Patients with three or more rib fractures and a hospital length of stay (LOS) > three days admitted from 2014 to 2015 were included. Demographics, mortality, complications, injuries, hospital and ICU LOS, use of blood products, and thoracostomy were studied. Of 383 patients, 27.4 per cent were on APAC medication. Patients on APAC were older (P < 0.0001), had higher Glasgow Coma Score (P < 0.0001), and had lower Injury Severity Score (P < 0.0001) and total number of fractures (P = 0.0013) than the non-APAC group. APAC was not a predictor of mortality with or without age adjustment. In multiple linear regressions, APAC did not predict an increased LOS. APAC patients did not demonstrate an increase in admission diagnosis or complication of hemothorax, blood transfusions, tube thoracostomy, tracheostomy, LOS, or mortality rates. Similar findings are present in the subgroup of patients studied with high kinetic energy mechanism of injury. Our study does not support the perceived morbidity of APAC therapy in patients with severe blunt chest injury.


Assuntos
Anticoagulantes/administração & dosagem , Hemorragia/etiologia , Inibidores da Agregação de Plaquetas/administração & dosagem , Fraturas das Costelas/complicações , Ferimentos não Penetrantes/complicações , Fatores Etários , Idoso , Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fraturas das Costelas/sangue , Fraturas das Costelas/terapia , Ferimentos não Penetrantes/sangue , Ferimentos não Penetrantes/terapia
8.
Zhonghua Shao Shang Za Zhi ; 35(8): 568-573, 2019 Aug 20.
Artigo em Chinês | MEDLINE | ID: mdl-31474035

RESUMO

Objective: To explore the effects of citric acid on patients with severe burn complicated with acute renal injury treated by continuous renal replacement therapy (CRRT). Methods: Medical records of 83 patients with large area of burn complicated with acute renal injury admitted to intensive care unit (ICU) of our department from January 2015 to December 2018 and meeting the inclusion criteria were analyzed retrospectively. The patients were divided into heparin group [n=43, 25 males and 18 females, aged (35.0±2.5) years] and citric acid group [n=40, 22 males and 18 females, aged (37.0±6.6) years] according to different anticoagulation methods. After admission, routine support treatment and CRRT were performed after being diagnosed with acute renal injury in patients in 2 groups. Patients in heparin group were treated with low molecular weight heparin for anticoagulation with first dosage of 20 U/kg and an increase of 2.5 to 5.0 U per hour, and patients in citric acid group were given citric acid of 0.02 g/mL with dosage of 150~200 mL/h for anticoagulation. The use time of blood filter, recovery time of urine volume, and time of staying in ICU, and platelet count, activated partial thromboplastin time (APTT), prothrombin time (PT), and serum creatinine, urea nitrogen, cystatin C, procalcitonin, C-reactive protein, and neutrophil, leukocyte count, blood sugar, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and heart rate, body temperature, and mean arterial pressure before treatment and post treatment hour (PTH) 24 were recorded. Besides, occurrence of hemorrhage, hypocalcemia, metabolic acidosis, metabolic alkalosis, and death within 28 days post injury were recorded. Data were processed with t test and chi-square test. Results: The use time of blood filter of patients in citric acid group was (28.7±3.2)h, significantly longer than (19.4±2.6) h in heparin group (t=14.139, P<0.01). The recovery time of urine volume and time of staying in ICU of patients in citric acid group were respectively (7.6±0.9) and (9.6±1.3) d, significantly shorter than (9.2±1.5) and (11.2±1.8) d in heparin group (t=5.516, 4.697, P<0.01). Before treatment, there were no statistically significant differences in platelet count, APTT, and PT of patients in 2 groups (t=1.235, 0.515, 1.279, P>0.05). At PTH 24, the platelet count of patients in citric acid group was significantly higher than that in heparin group (t=10.947, P<0.01), and APTT and PT of patients in citric acid group were significantly shorter than those in heparin group (t=7.069, 9.142, P<0.01). Before treatment, there were no statistically significant differences in serum creatinine, urea nitrogen, and cystatin C of patients in 2 groups (t=1.684, 1.878, 1.472, P>0.05). At PTH 24, the serum creatinine, urea nitrogen, and cystatin C of patients in citric acid group were significantly lower than those in heparin group (t=7.778, 9.776, 5.117, P<0.01). Before treatment, there were no statistically significant differences in serum procalcitonin and C-reactive protein of patients in 2 groups (t=1.413, 0.898, P>0.05). At PTH 24, the serum procalcitonin and C-reactive protein of patients in citric acid group were significantly lower than those in heparin group (t=2.635, 2.297, P<0.05). Before treatment, there were no statistically significant differences in neutrophil, leukocyte count, blood sugar, AST, and ALT of patients in 2 groups (t=0.555, 0.816, 0.470, 1.896, 0.982, P>0.05). At PTH 24, the neutrophil, leukocyte count, blood sugar, AST, and ALT of patients in citric acid group were significantly lower than those in heparin group (t=2.054, 3.314, 7.185, 2.151, 3.013, P<0.05 or P<0.01). Before treatment, there were no statistically significant differences in heart rate, body temperature, and mean arterial pressure of patients in 2 groups (t=1.406, 0.474, 0.720, P>0.05). At PTH 24, the heart rate, body temperature, and mean arterial pressure of patients in citric acid group were significantly lower than those in heparin group (t=2.307, 4.498, 2.056, P<0.05 or P<0.01). The incidence of hemorrhage of patients in citric acid group while in hospital was significantly lower than that in heparin group (χ(2)=4.949, P<0.05). There were no statistically significant differences in incidence of hypocalcemia, metabolic acidosis, metabolic alkalosis, and death rate within 28 days post injury of patients in 2 groups while in hospital (χ(2)=3.346, 0.884, 0.297, 0.324, P>0.05). Conclusions: Citric acid has significant anticoagulant effect on patients with large area of burn complicated with acute renal injury treated by CRRT, which can prolong the use time of the blood filter, shorten the recovery time of urine volume and time of staying in ICU, improve renal function indexes, blood biochemical indexes, and inflammation indexes, maintain the stability of internal environment, and reduce the risk of hemorrhage.


Assuntos
Lesão Renal Aguda/complicações , Lesão Renal Aguda/terapia , Queimaduras/complicações , Ácido Cítrico/administração & dosagem , Terapia de Substituição Renal , Adulto , Anticoagulantes/administração & dosagem , Feminino , Humanos , Masculino , Estudos Retrospectivos
9.
Zhonghua Jie He He Hu Xi Za Zhi ; 42(9): 694-699, 2019 Sep 12.
Artigo em Chinês | MEDLINE | ID: mdl-31484244

RESUMO

Objective: To investigate the incidence of venous thromboembolism (VTE) in lung transplant (LT) recipients. Methods: The clinical data on 124 consecutive patients who underwent lung transplant at Lung Transplantation Center of China-Japan Friendship Hospital from March 2017 to September 2018 were retrospectively collected. Deep venous thrombosis (DVT) was ascertained by vascular ultrasound. Pulmonary embolism (PE) was diagnosed by either chest computed tomography pulmonary angiogram or ventilation/perfusion scan. The risk factors in those patients with postoperative VTE were studied. Results: A total of 124 lung transplant recipients including 78 single lung transplant recipients (62.9%) and 46 bilateral lung transplant recipients(37.1%) were enrolled. Preoperative and postoperative prophylactic anticoagulant was used in 52 patients(52/124, 41.9%) and 69 patients(69/124, 55.6%) respectively. Thirty-two patients developed postoperative VTE among 124 consecutive patients. The overall incidence rate of VTE among 124 LT recipients was 25.8%. The median time to VTE episode following lung transplant was 22.5 days (range 4-295 days). The percentage of DVT in VTE was 93.8%(30/32), involving 1-8 (2.83±1.86) veins. And 60.0% of DVT was from lower extremities and 56.7% located in upper extremities (P>0.05). Four patients (4/32,12.5%) had PE episodes, and half of them suffered from only PE without DVT. The use of extracorporeal membrane oxygenation (ECMO) in 32 patients with VTE was 90.6% (29/32), which was significantly higher than that without VTE (64/92,69.6%, P=0.033). However, there was no difference in the use of peripherally inserted central catheter (PICC) between two groups (96.9% vs 81.5%, P=0.067). Resolution of VTE was successfully accomplished by anticoagulant therapy with long-term use of low molecular weight heparin in 30 patients (93.7%) and followed by oral warfarin in 2 patients (6.3%). Three months follow-up data after anticoagulant therapy showed that total and partial vascular recanalization rate was 65.6%(21/32) and 34.4%(11/32), respectively. Despite anticoagulation-related bleeding complications in three patients, no serious consequences occurred. Conclusions: VTE was frequent in LT recipients. It was speculated that ECMO utilization may be a major risk factor for high incidence of VTE in LT recipients. Aggressive VTE screening/treatment protocols were suggested to be implemented in LT recipients.


Assuntos
Transplante de Pulmão/efeitos adversos , Complicações Pós-Operatórias , Tromboembolia Venosa/epidemiologia , Adulto , Anticoagulantes/administração & dosagem , China/epidemiologia , Humanos , Incidência , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia
11.
JAMA ; 322(9): 834-842, 2019 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-31479138

RESUMO

Importance: The optimal international normalized ratio (INR) to prevent venous thromboembolism (VTE) in warfarin-treated patients with recent arthroplasty is unknown. Objective: To determine the safety and efficacy of a target INR of 1.8 vs 2.5 for VTE prophylaxis after orthopedic surgery. Design, Setting, and Participants: The randomized Genetic Informatics Trial (GIFT) of Warfarin to Prevent Deep Vein Thrombosis enrolled 1650 patients aged 65 years or older initiating warfarin for elective hip or knee arthroplasty at 6 US medical centers. Enrollment began in April 2011 and follow-up concluded in October 2016. Interventions: In a 2 × 2 factorial design, participants were randomized to a target INR of 1.8 (n = 823) or 2.5 (n = 827) and to either genotype-guided or clinically guided warfarin dosing. For the first 11 days of therapy, open-label warfarin dosing was guided by a web application. Main Outcomes and Measures: The primary outcome was the composite of VTE (within 60 days) or death (within 30 days). Participants underwent screening duplex ultrasound postoperatively. The hypothesis was that an INR target of 1.8 would be noninferior to an INR target of 2.5, using a noninferiority margin of 3% for the absolute risk of VTE. Secondary end points were bleeding and INR values of 4 or more. Results: Among 1650 patients who were randomized (mean age, 72.1 years; 1049 women [63.6%]; 1502 white [91.0%]), 1597 (96.8%) received at least 1 dose of warfarin and were included in the primary analysis. The rate of the primary composite outcome of VTE or death was 5.1% (41 of 804) in the low-intensity-warfarin group (INR target, 1.8) vs 3.8% (30 of 793) in the standard-treatment-warfarin group (INR target, 2.5), for a difference of 1.3% (1-sided 95% CI, -∞ to 3.05%, P = .06 for noninferiority). Major bleeding occurred in 0.4% of patients in the low-intensity group and 0.9% of patients in the standard-intensity group, for a difference of -0.5% (95% CI, -1.6% to 0.4%). The INR values of 4 or more occurred in 4.5% of patients in the low-intensity group and 12.2% of the standard-intensity group, for a difference of -7.8% (95% CI, -10.5% to -5.1%). Conclusions and Relevance: Among older patients undergoing hip or knee arthroplasty and receiving warfarin prophylaxis, an international normalized ratio goal of 1.8 compared with 2.5 did not meet the criterion for noninferiority for risk of the composite outcome of VTE or death. However, the trial may have been underpowered to meet this criterion and further research may be warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT01006733.


Assuntos
Anticoagulantes/administração & dosagem , Artroplastia de Quadril , Artroplastia do Joelho , Coeficiente Internacional Normatizado , Tromboembolia Venosa/prevenção & controle , Varfarina/administração & dosagem , Idoso , Anticoagulantes/efeitos adversos , Feminino , Seguimentos , Hemorragia/induzido quimicamente , Humanos , Estimativa de Kaplan-Meier , Masculino , Modelos de Riscos Proporcionais , Tromboembolia Venosa/mortalidade , Varfarina/efeitos adversos
12.
Arch Esp Urol ; 72(7): 629-632, 2019 Sep.
Artigo em Espanhol | MEDLINE | ID: mdl-31475671

RESUMO

Sr Director:Desde que la FDA (Food and Drug Administration) aprobó el uso de los nuevos fármacos  anticoagulantes orales (NACOs) para la fibrilación auricular en octubre de 2010, ha habido un  aumento exponencial en la prescripción de estos medicamentos, de forma que gradualmente están reemplazando a los tradicionales antagonistas de la vitamina K (AVK) como un nuevo estándar enanticoagulación oral (1).


Assuntos
Anticoagulantes/uso terapêutico , Próstata/patologia , Administração Oral , Anticoagulantes/administração & dosagem , Biópsia , Humanos , Masculino , Estados Unidos
13.
Hautarzt ; 70(11): 850-853, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31560079

RESUMO

Current guidelines generally recommend continuation of blood thinning drugs in dermatologic surgery and the previously used "bridging" with subcutaneous or intravenous heparin is obsolete. While the guidelines are increasingly implemented in daily practice, there is still uncertainty concerning the use of the novel direct oral anticoagulants (NOAC = DOAC). In this review, we analyze current developments and formulate concise recommendations for continuation during skin surgery under consideration of individual risk.


Assuntos
Anticoagulantes/administração & dosagem , Dabigatrana/administração & dosagem , Procedimentos Cirúrgicos Dermatológicos/métodos , Hemorragia Pós-Operatória/induzido quimicamente , Guias de Prática Clínica como Assunto , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Rivaroxabana/administração & dosagem , Administração Oral , Anticoagulantes/uso terapêutico , Humanos , Hemorragia Pós-Operatória/terapia , Medição de Risco
14.
Harefuah ; 158(8): 499-502, 2019 Aug.
Artigo em Hebraico | MEDLINE | ID: mdl-31407535

RESUMO

BACKGROUND: The use of direct oral anticoagulants (DOACs) provides immediate and useful anticoagulation without the need of monitoring. The recent expansion in use of DOACs might change the therapeutic approaches in venous thromboembolism (VTE). OBJECTIVES: To evaluate the treatment of VTE as well as the 90-days compliance with anticoagulants in the pre-DOACs era. METHODS: A retrospective study was conducted at Beilinson Hospital, Rabin Medical Center. Inclusion criteria entailed: patients >18 years old; new lower extremities deep vein thrombosis or pulmonary embolism, diagnosed at ER between May, 2014 and May, 2015. Patients with previous diagnosis; upper extremities or inner organs thrombosis or with missing data were excluded. Data collected included: gender and age, comorbidity with active malignancy, provoked/unprovoked events, hospitalization and length of stay, anticoagulation treatment during hospitalization and discharge, recommendations for duration of treatment or further hematologist's evaluation and 90-days compliance with anticoagulation treatment. RESULTS: The study group included 208 patients, 29% with active malignancy. All were hospitalized. In 54% of the subjects without active malignancy the event was provoked, whereas in 46% unprovoked. This detail was not discussed in any of the cases. The average length of stay tended to be longer in patients with a complete switch to warfarin than in ones on DOACs (10.3+7.5 vs. 6.4+5.2 days, p=0.09). Recommendations for the length of treatment or the need for further evaluation by a hematologist were not found in the majority. The overall 90-days compliance with anticoagulants was 47%. CONCLUSIONS: Most of the therapeutic approach errors might be resolved during the expanded use of DOACs, along with the simplicity of the recommendations at discharge. The study was supported by an educational grant from Pfizer, Inc.


Assuntos
Anticoagulantes/uso terapêutico , Tromboembolia Venosa/tratamento farmacológico , Administração Oral , Adolescente , Anticoagulantes/administração & dosagem , Humanos , Estudos Retrospectivos , Centros de Atenção Terciária
15.
Medicine (Baltimore) ; 98(31): e16585, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31374026

RESUMO

RATIONALE: Hypercoagulability can lead to thromboembolic events that are a life-threatening complication of nephrotic syndrome (NS). Conventional anticoagulants are first-line treatment in the presence of demonstrated thrombosis in NS. Direct-acting oral anticoagulants (DOACs) have provided useful alternatives for the prevention and treatment of thromboembolic events. PATIENT CONCERNS: A 59-year-old male developed lower limbs deep vein thrombosis (DVT) during the early course of NS but presented poor response to oral therapeutic doses of rivaroxaban. The decision was made to switch from rivaroxaban to heparin and subsequently bridged to warfarin. The patient presented significant clinical symptom improvement. DIAGNOSIS: NS with Lower limbs DVT. INTERVENTIONS: Rivaroxaban was discontinued and switch to heparin and subsequently bridged to warfarin. OUTCOMES: Venography result of both lower limb vein showed the venous wall was smooth without obvious stenosis or obstruction. Edema of the patient's lower limbs gradually improved and disappeared. LESSONS: The existing published data on the application of DOACs in NS are limited. DOACs have an immediate anticoagulant effect and have demonstrated safety and efficacy and required no routine monitoring, however, application of these agents in NS likely requires further investigation before widespread adoption.


Assuntos
Anticoagulantes/uso terapêutico , Síndrome Nefrótica/complicações , Rivaroxabana/uso terapêutico , Trombose Venosa/tratamento farmacológico , Trombose Venosa/etiologia , Varfarina/uso terapêutico , Anticoagulantes/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome Nefrótica/tratamento farmacológico , Rivaroxabana/administração & dosagem , Trombofilia/tratamento farmacológico , Trombofilia/etiologia , Varfarina/administração & dosagem
17.
Z Gastroenterol ; 57(8): 983-996, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31398770

RESUMO

Portal hypertension in patients with liver cirrhosis can be improved, not only by surgical or interventional shunt placements, but also by drug-only treatment. Many recent studies addressed the question whether any of these substances can improve survival of patients with liver cirrhosis when administered continuously for months and years. Non-selective beta-blockers (NSBB), statins, antibiotics, enoxaparin and albumin have been shown to possess many beneficial effects in the pathophysiology of portal hypertension or on events leading to decompensation of liver cirrhosis. Accordingly, they represent candidate drugs for long-term treatment to improve patient survival. In contrast to NSBB, antibiotics and albumin, which have clearly defined indications in the treatment of complications related to portal hypertension, the role of statins and anticoagulants in the management of these patients remains to be further elucidated. Recent studies came to opposing results when a permanent treatment was tested to improve patient prognosis or to prevent liver decompensation. At present, there is no reason to change our everyday practice beyond established management proposals published in practice guidelines. This paper gives an overview of present and future indications for treatment with NSBB, antibiotics, statins, anticoagulants and albumin with special reference to studies aiming at improving prognosis of patients with liver cirrhosis.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Hipertensão Portal/complicações , Cirrose Hepática/tratamento farmacológico , Anticoagulantes/administração & dosagem , Humanos , Prognóstico
18.
Gastroenterology ; 157(2): 403-412, Aug., 2019. tabela, grafico
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1022748

RESUMO

BACKGROUND & AIMS: Antiplatelets and anticoagulants are associated with increased upper gastrointestinal bleeding. We evaluated whether proton pump inhibitor therapy could reduce this risk. METHODS: We performed a 3 × 2 partial factorial double-blind trial of 17,598 participants with stable cardiovascular disease and peripheral artery disease. Participants were randomly assigned to groups given pantoprazole 40 mg daily or placebo, as well as rivaroxaban 2.5 mg twice daily with aspirin 100 mg once daily, rivaroxaban 5 mg twice daily, or aspirin 100 mg alone. The primary outcome was time to first upper gastrointestinal event, defined as a composite of overt bleeding, upper gastrointestinal bleeding from a gastroduodenal lesion or of unknown origin, occult bleeding, symptomatic gastroduodenal ulcer or ≥5 erosions, upper gastrointestinal obstruction, or perforation. RESULTS: There was no significant difference in upper gastrointestinal events between the pantoprazole group (102 of 8791 events) and the placebo group (116 of 8807 events) (hazard ratio, 0.88; 95% confidence interval [CI], 0.67-1.15). Pantoprazole significantly reduced bleeding of gastroduodenal lesions (hazard ratio, 0.52; 95% confidence interval, 0.28-0.94; P = .03); this reduction was greater when we used a post-hoc definition of bleeding gastroduodenal lesion (hazard ratio, 0.45; 95% confidence interval, 0.27-0.74), although the number needed to treat still was high (n = 982; 95% confidence interval, 609-2528).CONCLUSIONS: In a randomized placebo-controlled trial, we found that routine use of proton pump inhibitors in patients receiving low-dose anticoagulation and/or aspirin for stable cardiovascular disease does not reduce upper gastrointestinal events, but may reduce bleeding from gastroduodenal lesions. ClinicalTrials. (AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Doenças Cardiovasculares/prevenção & controle , Aspirina/administração & dosagem , Método Duplo-Cego , Relação Dose-Resposta a Droga , Hemorragia Gastrointestinal/prevenção & controle , Anticoagulantes/administração & dosagem
19.
Vasc Health Risk Manag ; 15: 175-186, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31417269

RESUMO

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in patients with cancer. Compared with the general population, cancer patients with VTE have higher rates of both VTE recurrence and bleeding. While low molecular weight heparin (LMWH) has been the mainstay of treatment for cancer-associated VTE for over a decade, direct oral anticoagulants (DOACs) have recently emerged as a new therapeutic option due to their ease of administration and because they do not require laboratory monitoring. Several large randomized clinical trials have been performed or are ongoing at the time of writing, comparing DOACs with LMWH in this population. Three of these trials have thus far been published and suggest that DOACs are a reasonable alternative to LMWH for management of cancer-associated VTE. Despite the advantages offered by DOACs, these agents may not be appropriate for certain patient groups owing to increased risk of bleeding, organ compromise, extremes of weight, and other issues. Finally, data are emerging suggesting that DOACs may be useful for primary thromboprophylaxis in cancer patients in conjunction with validated risk assessment scores. In this evidence-based review, data for the use of DOACs to treat cancer-associated VTE will be examined, focusing on efficacy, safety, and timing of treatment. Guidance on choosing the optimal anticoagulant for a given patient is also offered.


Assuntos
Anticoagulantes/administração & dosagem , Coagulação Sanguínea/efeitos dos fármacos , Neoplasias/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle , Administração Oral , Anticoagulantes/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Neoplasias/sangue , Neoplasias/diagnóstico , Neoplasias/mortalidade , Recidiva , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade
20.
BMC Health Serv Res ; 19(1): 539, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31370840

RESUMO

BACKGROUND: In Germany, patients receiving oral anticoagulation (OAC) are often treated by general practitioners (GPs), and large proportions of patients receive vitamin K antagonists (VKAs). The quality of OAC in German GP practices, differences between various practices, and improvement potential through implementation of case management, have not yet been investigated satisfactorily. Based on results of a cluster-randomized controlled trial, we aimed to assess whether OAC quality can be improved, any variations between practices exist and determine practice- and patient-level factors. METHODS: The PICANT trial (2012-2015) was performed in 52 GP practices in Hesse, Germany. Adult patients with long-term indication for OAC received best practice case management in the intervention group. International normalized ratio (INR) values were recorded from anticoagulation passes. The Rosendaal method was used to calculate Time in Therapeutic Range (TTR) at patient level, and mean pooling to obtain center-specific TTR (cTTR) at practice level. The quality of OAC was assessed by TTR and cTTR. Linear model analyses were used to investigate associations between practice-/ patient-level factors and TTR. RESULTS: Inclusion of 736 patients (49.6% intervention and 50.4% control patients); 690 (93.8%) received phenprocoumon. Within 24 months, the TTR was 75.1% (SD 17.6) in the intervention versus 74.3% (SD 17.8) in the control group (p = 0.670). The cTTR averaged 75.1% (SD 6.5, range: 60.4 to 86.7%) in the intervention versus 74.3% (SD 7.2, range: 52.7 to 85.7%) in the control group (p = 0.668). At practice level, the TTR was significantly lower in practices with a male physician and certification in quality management. At patient level, the TTR was significantly higher in patients with moderate to high compliance, in men, and in patients that performed self-management. The TTR was significantly lower in patients with certain comorbidities, and who were hospitalized. CONCLUSIONS: The intervention did not effectively improve OAC quality compared to routine care. Quality of INR control was generally good, but considerable variation existed between GP practices. The variability indicates optimization potential in some practices. The demonstrated association between patient-level factors and TTR highlights the importance of considering patient characteristics that may impede achieving high quality therapeutic outcomes. TRIAL REGISTRATION: ISRCTN registry, ISRCTN41847489 , registered 27 February 2012.


Assuntos
Anticoagulantes/administração & dosagem , Medicina Geral , Qualidade da Assistência à Saúde/estatística & dados numéricos , Terapia Trombolítica , Vitamina K/antagonistas & inibidores , Administração Oral , Adulto , Feminino , Fibrinolíticos/uso terapêutico , Alemanha , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde
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