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1.
Zhonghua Xin Xue Guan Bing Za Zhi ; 47(8): 602-607, 2019 Aug 24.
Artigo em Chinês | MEDLINE | ID: mdl-31434430

RESUMO

Objective: Differences in the activated coagulation time (ACT) during ablation and adequate heparin dosing were observed among atrial fibrillation (AF) patients undergoing AF catheter ablation receiving different anticoagulation therapies and the suitable heparin dosing during ablation among patients treated with different anticoagulation therapies was explored. Methods: Patients who received warfarin (n=100), low-molecular-weight heparin (n=100), dabigatran etexilate (n=98, 110 mg, Bid) and rivaroxaban (n=48, 20 mg, Qd) were included. All of them underwent the first AF ablation during January 2016 to December 2017 and patients with hepatic and renal dysfunction were excluded. Initial bolus heparin (100 U/kg, intravenous) was applied to all patients. Additional heparin dosage was added according to the ACT, which was measured in 15-minute interval to maintain the ACT within 250-350 seconds until the end of ablation. Patient characteristics, ACT and complications were compared among various groups. Results: The baseline general characteristics among patients were similar. The baseline ACTs in the dabigatran groups were significantly longer than those in the rivaroxaban group ((133±36) seconds vs. (113±22) seconds, P<0.05). The 15 min ACT in the warfarin group was longer than in the dabigatran group ((259±56) seconds vs. (243±43) seconds, P<0.05). The 15-minute ACTs were significantly longer in the warfarin ((259±56) seconds) and dabigatran ((243±43) seconds) groups compare with low-molecular-weight heparin group ((224±40) seconds) and rivaroxaban group ((226±32) seconds) (all P<0.05). The same trend was also observed in the rate of reaching ACT goal after initial-standard-dosage of heparin (warfarin (53%, 53/100), dabigatran (45%,44/98), low-molecular-weight heparin (28%,28/100), rivaroxaban (23%,11/48), P<0.05). The 1 hour ACT in the warfarin group ((254±49) seconds) was significantly longer than the other three groups (dabigatran (233±33) seconds, low-molecular-weight heparin (226±34) seconds, rivaroxaban (231±30) seconds, all P<0.01). The rate of reaching ACT goal at 1 hour were significantly higher in the warfarin group (66%,35/53) than in the dabigatran group (41%,18/44), and rivaroxaban group (27%,3/11) (all P<0.05). The total heparin required was significantly higher in rivaroxaban group than in the dabigatran and warfarin groups (all P<0.05). During the perioperative period, no patient exhibited any thromboembolic complications, and only a few minor bleeding complications was observed among patients, which was similar between the four groups (P>0.05). Conclusion: Higher dosage of heparin is required during AF ablation to achieve the satisfactory anticoagulant intensity for AF patients under dabigatran etexilate (110 mg, Bid), low-molecular-weight heparin and rivaroxaban (20 mg, Qd) anticoagulation therapy before AF ablation.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial , Ablação por Cateter , Heparina/uso terapêutico , Fibrilação Atrial/terapia , Benzimidazóis , Dabigatrana , Humanos , Resultado do Tratamento
2.
J Stroke Cerebrovasc Dis ; 28(8): e116-e118, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31171457

RESUMO

We describe a 45-year-old man who presented with nausea, vomiting, and strong occipital headache on the right side. Although no abnormalities on neurological examination or computed tomography imaging were found on admission, peripheral blood cell counts showed polycythemia (hemoglobin 20.6 g/dL) and electrocardiography demonstrated atrial fibrillation. Therefore, anticoagulant treatment with heparin was started immediately. On the following day, the occipital headache continued. Brain T2*-weighted (T2*WI) magnetic resonance imaging (MRI) and, to a lesser extent, susceptibility-weighted imaging showed dilation of numerous cortical veins, suggesting the possibility of cerebral venous thrombosis (CVT). MR venography (MRV) showed a deficit of the right transverse sinus. Contrast-enhanced MRI revealed partial defects of the right transverse sinus, and led to the definite diagnosis of CVT, and the anticoagulation therapy was continued. On day 7 the headache disappeared, and MRV on day 16 showed the recanalization of the right transverse sinus. There were no complications subsequent to the CVT. On day 25, the patient was discharged with no after-effect. We speculate that the dilation of cortical veins on T2*WI is a helpful sign in detecting acute-phase CVT.


Assuntos
Veias Cerebrais/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Trombose dos Seios Intracranianos/diagnóstico por imagem , Anticoagulantes/uso terapêutico , Angiografia Cerebral/métodos , Veias Cerebrais/patologia , Dilatação Patológica , Heparina/uso terapêutico , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Flebografia/métodos , Valor Preditivo dos Testes , Trombose dos Seios Intracranianos/tratamento farmacológico , Trombose dos Seios Intracranianos/patologia , Resultado do Tratamento
3.
Rinsho Ketsueki ; 60(4): 281-285, 2019.
Artigo em Japonês | MEDLINE | ID: mdl-31068556

RESUMO

Pregnancy with paroxysmal nocturnal hemoglobinuria (PNH) poses a high risk of thrombosis, maternal death, miscarriage, and premature infants. Eculizumab lowers complications for pregnancy with PNH. A proposed protocol for the management of pregnancy in women with PNH by The National Research Group on Idiopathic Bone Marrow Failure Syndrome (the Japanese Guideline) recommends patients to start eculizumab at an early stage of pregnancy if they have not been treated with eculizumab or continue eculizumab during pregnancy. A 31-year-old female with PNH who was transfusion-independent but had occasional hemolysis was treated with eculizumab after a missed abortion and soon conceived. During pregnancy, the patient had neither hemolysis nor thrombosis and gave birth to a healthy child without using heparin. Heparin was initiated soon after delivery and continued for six weeks because of the known high postpartum risk of thrombosis. No postpartum complications were observed. PNH is a rare disease with fewer cases of pregnancy reported. Hence, it is essential to accumulate cases of PNH with pregnancy to establish the validity of the Japanese Guideline.


Assuntos
Aborto Retido , Anticorpos Monoclonais Humanizados/uso terapêutico , Hemoglobinúria Paroxística/complicações , Trombose/prevenção & controle , Adulto , Feminino , Heparina/uso terapêutico , Humanos , Gravidez , Resultado da Gravidez
5.
Int. j. cardiovasc. sci. (Impr.) ; 32(3): 227-237, may.-june. 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1005940

RESUMO

Background: The knowledge on the management of patients with acute coronary syndrome (ACS) is essential to reduce the gap between evidence and practice. Objective: To describe a simulation training strategy for emergency healthcare professionals and provide preliminary data on knowledge acquisition, learners' confidence and prescription of medications after training. Methods: The training was part of the implementation of two myocardial infarction systems of care. It comprehended lectures and simulation-based learning using high and low-fidelity mannequins and actors. It was tested in two phases: the first one in Belo Horizonte and the second one in Montes Claros, both in the state of Minas Gerais. A test was applied before and after training to assess knowledge acquisition. Confidence to perform thrombolysis in ST-elevation myocardial infarction (STEMI) patients was assessed using a questionnaire, and the impact on medication prescription analyzed STEMI patients admitted to hospitals in Montes Claros. Results: In the first phase, 156 professionals answered both tests: 70% of them improved their results and the median number of right answers increased (6, interquartile range [IQR] 5-7; vs 7 ([IQR] 6-9; p < 0.05). In the second phase, 242 professionals answered both tests: 58% of the physicians and 83% of the nurses obtained better test scores. Participants referred a positive impact on their clinical practice, 95% reported feeling very secure when perform fibrinolysis after the training, and there was also an impact on medication prescription. Conclusions: There was an impact on the learners' knowledge acquisition and confidence using our two-phase training model , with evidence of impact on performance


Assuntos
Humanos , Masculino , Feminino , Indicadores de Qualidade em Assistência à Saúde , Serviço Hospitalar de Emergência/tendências , Síndrome Coronariana Aguda/mortalidade , Prescrições de Medicamentos , Heparina/uso terapêutico , Reperfusão Miocárdica/métodos , Análise Estatística , Telemedicina/métodos , Assistência Centrada no Paciente/métodos , Educação Médica Continuada/métodos , Eletrocardiografia/métodos , Serviços Médicos de Emergência/métodos , Infarto do Miocárdio
6.
Int J Lab Hematol ; 41 Suppl 1: 15-25, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31069988

RESUMO

Heparin-induced thrombocytopenia (HIT) is a clinical-pathological disorder; thus, laboratory testing for the pathogenic platelet-activating antiplatelet factor 4 (PF4)/heparin antibodies is central for diagnosis. The "iceberg" model summarizes the inter-relationship between platelet activation assays and PF4-dependent immunoassays, with platelet-activating antibodies comprising a subset of anti-PF4/heparin antibodies. The platelet serotonin-release assay (SRA), performed by reference laboratories, has high sensitivity and specificity for HIT (~95% each), and is especially suited for detecting highly pathogenic HIT sera containing both heparin-dependent and heparin-independent platelet-activating antibodies; this latter subgroup of antibodies explains "autoimmune HIT" disorders (delayed-onset, persisting, spontaneous, heparin "flush," fondaparinux-associated). Recently, SRA-negative HIT has become recognized, in which serum from some HIT patients contains subthreshold levels of platelet-activating antibodies (by SRA) that become detectable using a PF4-enhanced platelet activation assay. Unusual immunologic features of HIT include early antibody detectability (at onset of platelet count fall) and antibody transience (seroreversion). Widely available PF4-dependent enzyme immunoassays (EIAs) have high sensitivity but poor specificity for HIT, although specificity is enhanced with IgG-specific EIAs and strong positive results; unfortunately, EIA results are usually not available in real time. Automated rapid immunoassays, such as the chemiluminescence immunoassay (CLIA) and latex immunoturbidimetric assay (LIA), facilitate real-time laboratory diagnosis. Recently available likelihood ratio (LR) data for positive (LR+) and negative (LR-) test results allow clinicians to adjust their pretest probabilities for HIT, using Bayesian analysis, into real-time posttest probabilities that are dramatically increased (test positive) or decreased (test negative). Moreover, (semi-)quantitative CLIA- and LIA-positive results (weak, moderate, strong positive) can further refine the posttest probability of HIT.


Assuntos
Anticoagulantes/efeitos adversos , Heparina/efeitos adversos , Púrpura Trombocitopênica Idiopática/induzido quimicamente , Púrpura Trombocitopênica Idiopática/diagnóstico , Anticoagulantes/uso terapêutico , Autoanticorpos/imunologia , Técnicas de Laboratório Clínico , Heparina/uso terapêutico , Humanos , Ativação Plaquetária/efeitos dos fármacos , Ativação Plaquetária/imunologia , Fator Plaquetário 4/antagonistas & inibidores , Fator Plaquetário 4/imunologia , Púrpura Trombocitopênica Idiopática/imunologia
7.
Discov Med ; 27(147): 101-109, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30939294

RESUMO

Acute pancreatitis (AP) is a common and destructive inflammatory condition of the pancreas. Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) has become the second major cause of AP. Although the association between HTG and AP is well established, HTG as a risk factor of AP in the general population is not well identified. In this review, we summarize recent progress in our understanding of the pathogenesis of HTG-AP and clinical management of this disease. The mechanism responsible for HTG-AP is related to high-level free fatty acid (FFA), microcirculatory disorder, oxidative stress, Ca2+ overload, and genetic polymorphism. Heparin and insulin therapy in diabetic patients with HTG can dramatically reduce triglyceride levels. Use of plasmapheresis is still experimental and better-designed studies are needed to evaluate the promise in the management of HTG-AP. Dietary intervention, lifestyle changes, and control of secondary causes are critical to the management and treatment of HTG-AP.


Assuntos
Pancreatite , Doença Aguda , Heparina/uso terapêutico , Humanos , Hipertrigliceridemia/sangue , Hipertrigliceridemia/complicações , Hipertrigliceridemia/tratamento farmacológico , Hipertrigliceridemia/genética , Insulina/uso terapêutico , Pancreatite/sangue , Pancreatite/tratamento farmacológico , Pancreatite/etiologia , Pancreatite/genética
8.
BMJ Case Rep ; 12(4)2019 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-30954959

RESUMO

Idiopathic intracranial hypertension (IIH) is a challenging disease with unclear pathophysiology. Recognition of venous sinus stenting to improve intracranial pressure is increasing.We present a 56-year-old man diagnosed with IIH. A parasagittal meningioma abutting the sagittal sinus causing venous compression was found. Venous sinus stenting via endovascular approach using a WALLSTENT was performed. Intravascular pressures recorded after stenting demonstrated resolution of the pressure gradient.The patient had no complications from the procedure and reported substantial symptomatic improvement. Subsequent ophthalmologic exam demonstrated resolution of the bilateral papilledema noted prior to stenting. Endovascular treatment of venous sinus stenosis in the treatment of IIH is an emerging technique. Treatment of venous compromise due to a mass lesion with stenting is a rarely described concept. For our patient, endovascular stenting was the primary treatment modality, allowing the tumour to be followed with serial imaging.


Assuntos
Constrição Patológica/cirurgia , Meningioma/diagnóstico , Procedimentos Neurocirúrgicos/métodos , Seio Sagital Superior/patologia , Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Procedimentos Endovasculares , Fibrinolíticos/uso terapêutico , Heparina/uso terapêutico , Humanos , Pressão Intracraniana , Masculino , Meningioma/complicações , Meningioma/cirurgia , Pessoa de Meia-Idade , Stents , Resultado do Tratamento
9.
BMJ Case Rep ; 12(4)2019 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-30967446

RESUMO

A man in his late 50s presented to the emergency room with a 1-month history of severe abdominal pain and an endoscopic fishbone retrieval from his rectum. Serial CT scans revealed a fishbone located in the patient's upper abdomen, which had migrated through the stomach wall, into the periportal space, causing a contained gastric perforation, development of a porta hepatis abscess and secondary portal vein thrombosis. Furthermore, the sharp tip of the fishbone lay 5 mm from the patient's hepatic artery. He was transferred to a hepatobiliary centre where he underwent urgent exploratory laparotomy, with surgical exploration of the porta, drainage of the abscess and retrieval of the fishbone. Postoperatively, he received further treatment with antibiotics and anticoagulation and recovered without further sequelae.


Assuntos
Abscesso Abdominal/etiologia , Migração de Corpo Estranho/complicações , Veia Porta , Trombose/etiologia , Abscesso Abdominal/diagnóstico por imagem , Abscesso Abdominal/cirurgia , Dor Abdominal , Idoso , Anticoagulantes/uso terapêutico , Diagnóstico Diferencial , Infecções por Enterobacteriaceae/tratamento farmacológico , Infecções por Enterobacteriaceae/etiologia , Migração de Corpo Estranho/diagnóstico , Heparina/uso terapêutico , Humanos , Masculino , Combinação Piperacilina e Tazobactam/uso terapêutico , Veia Porta/diagnóstico por imagem , Infecções Estreptocócicas/tratamento farmacológico , Infecções Estreptocócicas/etiologia , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológico , Trombose/cirurgia , Tomografia Computadorizada por Raios X
10.
Gastroenterology ; 157(1): 34-43.e1, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30986390

RESUMO

DESCRIPTION: This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership. The intent is to evaluate the current data on mechanism of altered coagulation in patients with cirrhosis, provide guidance on the use of currently available testing of the coagulation cascade, and help practitioners use anticoagulation and pro-coagulants appropriately in patients with cirrhosis. METHODS: This review is framed around the best practice points, which were derived from the most impactful publications in the area of coagulation in cirrhosis and agreed to by all authors. BEST PRACTICE ADVICE 1: Global tests of clot formation, such as rotational thromboelastometry, thromboelastography, sonorheometry, and thrombin generation, may eventually have a role in the evaluation of clotting in patients with cirrhosis, but currently lack validated target levels. BEST PRACTICE ADVICE 2: In general, clinicians should not routinely correct thrombocytopenia and coagulopathy before low-risk therapeutic paracentesis, thoracentesis, and routine upper endoscopy for variceal ligation in patients with hepatic synthetic dysfunction-induced coagulation abnormalities. BEST PRACTICE ADVICE 3: Blood products should be used sparingly because they increase portal pressure and carry a risk of transfusion-associated circulatory overload, transfusion-related acute lung injury, infection transmission, alloimmunization, and/or transfusion reactions. BEST PRACTICE ADVICE 4: The following transfusion thresholds for management of active bleeding or high-risk procedures may optimize clot formation in advanced liver disease: hematocrit ≥25%, platelet count >50,000, and fibrinogen >120 mg/dL. Commonly utilized thresholds for international normalized ratio correction are not supported by evidence. BEST PRACTICE ADVICE 5: Thrombopoietin agonists are a good alternative to platelet transfusion, but require time (about 10 days) to elevate platelet levels. BEST PRACTICE ADVICE 6: The large volume of fresh frozen plasma required to reach an arbitrary international normalized ratio target, limitations of the usual target, minimal effect on thrombin generation, and adverse effects on portal pressure limit the utility of this agent significantly. BEST PRACTICE ADVICE 7: The 4-factor prothrombin complex concentrate contains both pro- and anticoagulant factors that offer an attractive low-volume therapeutic to rebalance a disturbed hemostatic system. However, dosage is, in part, based on international normalized ratio, which is problematic in cirrhosis, and published experience in liver disease is limited. BEST PRACTICE ADVICE 8: Anti-fibrinolytic therapy may be considered in patients with persistent bleeding from mucosal oozing or puncture wound bleeding consistent with impaired clot integrity. Both ε-aminocaproic acid and tranexamic acid inhibit clot dissolution. Neither is believed to generate a hypercoagulable state, although both may exacerbate pre-existing thrombi. BEST PRACTICE ADVICE 9: Desmopressin releases von Willebrand factor as its primary hemostatic mechanism. As this factor is usually elevated in cirrhosis, the agent lacks a sound evidence-based foundation, but may be useful in patients with concomitant renal failure. BEST PRACTICE ADVICE 10: Systemic heparin infusion is recommended for symptomatic deep vein thrombosis and portal and mesenteric vein thrombosis, but there are unresolved issues regarding monitoring with both the anti-Xa assay and the partial thromboplastin time due to cirrhosis-related antithrombin deficiency (heparin cofactor). BEST PRACTICE ADVICE 11: Treatment of incidental portal and mesenteric vein thrombosis depends on estimated impact on transplantation surgical complexity vs risks of bleeding and falls. Therapy with low-molecular-weight heparin, vitamin K antagonists, and direct-acting anticoagulants improve portal vein repermeation vs observation alone. BEST PRACTICE ADVICE 12: Direct-acting anticoagulants, such as the factor Xa and thrombin inhibitors, are relatively safe and effective in stable cirrhotic patients, but are in need of further study in patients with more advanced liver disease.


Assuntos
Transtornos da Coagulação Sanguínea/terapia , Transfusão de Sangue/métodos , Cirrose Hepática/sangue , Trombofilia/terapia , Trombose Venosa/terapia , Anticoagulantes/uso terapêutico , Antifibrinolíticos/uso terapêutico , Antitrombinas/uso terapêutico , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/complicações , Fatores de Coagulação Sanguínea/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Fibrinogênio/metabolismo , Hematócrito , Heparina/uso terapêutico , Humanos , Coeficiente Internacional Normatizado , Cirrose Hepática/complicações , Plasma , Contagem de Plaquetas , Veia Porta , Tromboelastografia , Trombocitopenia , Trombofilia/sangue , Trombofilia/complicações , Trombopoetina/agonistas , Reação Transfusional , Trombose Venosa/sangue , Trombose Venosa/complicações
13.
Clin Appl Thromb Hemost ; 25: 1076029619833480, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30841720

RESUMO

Unfractionated heparin dosing is unpredictable and subject to numerous pharmacokinetic changes including distribution and metabolic changes associated with obesity and age. Weight-based dosing is commonly used to better predict the dose for a patient when targeting a therapeutic range. A dosing equation that adjusts weight-based doses for age and body mass index may improve therapeutic dose prediction. We conducted a 2-phase observational study with a derivation and validation period to develop an equation to adjust weight-based unfractionated heparin for age and body mass index to target a therapeutic activated partial thromboplastin time of 60 to 80 seconds. The first phase retrospectively identified patients who acheived therapeutic anticoagulation and utilized linear regression to determine a predictive equation for weight-based dosing that adjusts for age and body mass index. The second phase prospectively identified patients in an observational manner and compared the dose of unfractionated heparin on which they became therapeutic against both the weight-based dose and the predicted dose adjusted for age and body mass index. The correlation between predictive age and body mass index adjusted dose and actual therapeutic dose was 0.703 compared to the correlation between the empiric weight-based dose and actual therapeutic dose which was 0.532 ( P = .05). Age and body mass index adjusted weight-based dosing significantly improved therapeutic dose prediction for unfractionated heparin. Further study in a prospective, randomized trial is warranted for validation of this approach in a real world setting.


Assuntos
Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Tromboembolia Venosa/tratamento farmacológico , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/farmacologia , Índice de Massa Corporal , Peso Corporal , Feminino , Heparina/administração & dosagem , Heparina/farmacologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tromboembolia Venosa/patologia
14.
Medicine (Baltimore) ; 98(12): e14821, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30896626

RESUMO

RATIONALE: The efficacy of direct oral anticoagulants (DOACs) in the treatment and prophylaxis of cancer-related venous thromboembolism (VTE) is reportedly similar to that of heparin. However, the effect of DOACs on the prophylaxis of cancer-related arterial thromboembolism (ATE) remains unclear. To our knowledge, we present the 1st case where cerebral ATE was encountered during edoxaban administration for VTE in a patient with lung adenocarcinoma. PATIENT CONCERNS: In March 2017, a 63-year-old female was diagnosed with lung adenocarcinoma (cT2aN3M1b stage IVa) along with having asymptomatic VTE; thus, 60 mg/day edoxaban administration was initiated. In addition, 1st-line chemotherapy generated a partial antitumoral response. However, owing to lung cancer progression, a secondary treatment with pembrolizumab administration was initiated. The patient suddenly experienced aphasia 11 days after pembrolizumab administration. DIAGNOSIS: The patient was diagnosed as multiple cerebral ATE using brain magnetic resonance imaging. However, VTE recurrence was not observed. Based on the findings of lung cancer progression and increased coagulation, cerebral ATE was diagnosed as Trousseau syndrome. INTERVENTIONS: DOAC administration was switched to heparin administration. OUTCOMES: Coagulation profile normalized and aphasia improved without any further disease symptoms. LESSONS: We considered that DOACs are effective for the treatment and prophylaxis of VTE but may be insufficient for ATE prevention. Therefore, DOACs should be replaced with heparin to prevent ATE when cancer and coagulation become uncontrollable with DOAC.


Assuntos
Adenocarcinoma/complicações , Inibidores do Fator Xa/efeitos adversos , Embolia Intracraniana/induzido quimicamente , Neoplasias Pulmonares/complicações , Piridinas/efeitos adversos , Tiazóis/efeitos adversos , Tromboembolia Venosa/complicações , Adenocarcinoma/tratamento farmacológico , Antineoplásicos/uso terapêutico , Progressão da Doença , Inibidores do Fator Xa/administração & dosagem , Feminino , Fibrinolíticos/uso terapêutico , Heparina/uso terapêutico , Humanos , Embolia Intracraniana/tratamento farmacológico , Pessoa de Meia-Idade , Piridinas/administração & dosagem , Tiazóis/administração & dosagem , Tromboembolia Venosa/prevenção & controle
15.
Thromb Haemost ; 119(4): 618-632, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30791055

RESUMO

Unfractionated heparin (UFH) and their low-molecular-weight derivatives are sourced almost exclusively from porcine mucosa (HPI); however, a worldwide introduction of UFH from bovine mucosa (HBI) has been recommended to reinforce the currently unsteady supply chain of heparin products. Although HBI has different chemical composition and about half of the anticoagulant potency of HPI (∼100 and ∼180 international unit [IU]/mg, respectively), they have been employed as interchangeable UFHs in some countries since the 1990s. However, their use as a single drug provoked several bleeding incidents in Brazil, which precipitated the publication of the first monographs exclusive for HBI and HPI by the Brazilian Pharmacopoeia. Nevertheless, we succeed in producing with high-resolution anion-exchange chromatography a novel HBI derivative with anticoagulant potency (200 IU/mg), disaccharide composition (enriched in N,6-disulfated α-glucosamine) and safety profile (bleeding and heparin-induced thrombocytopaenia potentials and protamine neutralization) similar to those seen in the gold standard HPI. Therefore, we show that it is possible to equalize the composition and pharmacological characteristics of these distinct UFHs by employing an easily implementable improvement in the HBI manufacturing.


Assuntos
Anticoagulantes/química , Heparina/química , Mucosa Intestinal/metabolismo , Tromboembolia/tratamento farmacológico , Tromboembolia/prevenção & controle , Animais , Ânions , Anticoagulantes/uso terapêutico , Bovinos , Cromatografia por Troca Iônica , Composição de Medicamentos/métodos , Fator Xa/química , Heparina/uso terapêutico , Heparina de Baixo Peso Molecular/química , Humanos , Tempo de Tromboplastina Parcial , Ligação Proteica , Protrombina/química , Suínos , Equivalência Terapêutica
16.
Thromb Res ; 175: 53-58, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30708169

RESUMO

BACKGROUND: No study supports the use of either aPTT or anti-Xa activity for heparin monitoring in critical care patients. There are no strong data on the agreement between aPTT and anti-Xa. The aims of this study were to: 1. Analyse the agreement between aPTT and anti-Xa in a large population of critically ill patients under unfractionated heparin therapy (UFH), 2. Identify clinical and biological factors associated to agreement or disagreement, and 3. Analyse the impact of anti-Xa availability on the use of aPTT and UFH therapy. METHODS: Retrospective study in a 35 beds mixed-ICU population between 2006 and 2016 in a University teaching hospital. INCLUSION CRITERIA: delivery of a UFH dose >15,000 U/24 h during at least one day with one anti-Xa determination. DATA: demographic variables, aPTT, anti-Xa, laboratory variables, presence of extracorporeal devices (ECD). Pairs of simultaneously dosed aPTT and anti-Xa [aPTT:anti-Xa] were analysed on the basis of their agreement within the sub-therapeutic, therapeutic (aPTT 50-80″, anti-Xa 0.3-0.7 U/ml) or supra-therapeutic ranges. RESULTS: 2283 patient admissions (2085 patients) were analysed. 35,595 [aPTT:anti-Xa] pairs were found. The overall [aPTT:anti-Xa] agreement was 59.6% and lowest (54.3%) in presence of ECD compared to non-ECD patients (61.6%; p < 0.001). Sixteen demographic and biological variables were analysed and were not predictive of [aPTT:anti-Xa] agreement. No significant difference in administered UFH dose was observed after anti-Xa introduction. CONCLUSION: In this large cohort, the [aPTT:anti-Xa] agreement is <60% and significantly lower in patients with ECD. None of the variables identified as potentially affecting the agreement were predictive. Availability of anti-Xa had neither effect on aPTT use nor on UFH-dose. These results call for a prospective study to determine the optimal UFH-therapy monitoring tool.


Assuntos
Anticoagulantes/sangue , Inibidores do Fator Xa/uso terapêutico , Heparina/sangue , Tempo de Tromboplastina Parcial/métodos , Anticoagulantes/farmacologia , Anticoagulantes/uso terapêutico , Estudos de Coortes , Estado Terminal , Inibidores do Fator Xa/farmacologia , Feminino , Heparina/farmacologia , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
17.
N Engl J Med ; 380(14): 1305-1315, 2019 04 04.
Artigo em Inglês | MEDLINE | ID: mdl-30779530

RESUMO

BACKGROUND: Whether adjunctive intermittent pneumatic compression in critically ill patients receiving pharmacologic thromboprophylaxis would result in a lower incidence of deep-vein thrombosis than pharmacologic thromboprophylaxis alone is uncertain. METHODS: We randomly assigned patients who were considered adults according to the local standards at the participating sites (≥14, ≥16, or ≥18 years of age) within 48 hours after admission to an intensive care unit (ICU) to receive either intermittent pneumatic compression for at least 18 hours each day in addition to pharmacologic thromboprophylaxis with unfractionated or low-molecular-weight heparin (pneumatic compression group) or pharmacologic thromboprophylaxis alone (control group). The primary outcome was incident (i.e., new) proximal lower-limb deep-vein thrombosis, as detected on twice-weekly lower-limb ultrasonography after the third calendar day since randomization until ICU discharge, death, attainment of full mobility, or trial day 28, whichever occurred first. RESULTS: A total of 2003 patients underwent randomization - 991 were assigned to the pneumatic compression group and 1012 to the control group. Intermittent pneumatic compression was applied for a median of 22 hours (interquartile range, 21 to 23) daily for a median of 7 days (interquartile range, 4 to 13). The primary outcome occurred in 37 of 957 patients (3.9%) in the pneumatic compression group and in 41 of 985 patients (4.2%) in the control group (relative risk, 0.93; 95% confidence interval [CI], 0.60 to 1.44; P = 0.74). Venous thromboembolism (pulmonary embolism or any lower-limb deep-vein thrombosis) occurred in 103 of 991 patients (10.4%) in the pneumatic compression group and in 95 of 1012 patients (9.4%) in the control group (relative risk, 1.11; 95% CI, 0.85 to 1.44), and death from any cause at 90 days occurred in 258 of 990 patients (26.1%) and 270 of 1011 patients (26.7%), respectively (relative risk, 0.98; 95% CI, 0.84 to 1.13). CONCLUSIONS: Among critically ill patients who were receiving pharmacologic thromboprophylaxis, adjunctive intermittent pneumatic compression did not result in a significantly lower incidence of proximal lower-limb deep-vein thrombosis than pharmacologic thromboprophylaxis alone. (Funded by King Abdulaziz City for Science and Technology and King Abdullah International Medical Research Center; PREVENT ClinicalTrials.gov number, NCT02040103; Current Controlled Trials number, ISRCTN44653506.).


Assuntos
Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Dispositivos de Compressão Pneumática Intermitente , Trombose Venosa/prevenção & controle , Adolescente , Adulto , Anticoagulantes/efeitos adversos , Terapia Combinada , Feminino , Heparina/efeitos adversos , Heparina de Baixo Peso Molecular/uso terapêutico , Mortalidade Hospitalar , Humanos , Incidência , Unidades de Terapia Intensiva , Dispositivos de Compressão Pneumática Intermitente/efeitos adversos , Estimativa de Kaplan-Meier , Extremidade Inferior/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Ultrassonografia , Tromboembolia Venosa , Trombose Venosa/epidemiologia
18.
J Med Case Rep ; 13(1): 36, 2019 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-30773142

RESUMO

INTRODUCTION: Cerebral venous thrombosis is relatively rare and characterized by a wide spectrum of clinical features. It is more common in young adults with women affected more than men. The diagnosis of cerebral venous thrombosis is easier nowadays due to easy access to advanced neuroimaging techniques. Abnormalities in thrombophilic profile are associated with enhanced risk of cerebral venous thrombosis. It has varied etiologies such as hypercoagulable states, infection, dehydration, pregnancy, and substance abuse. Hyperhomocysteinemia is found to be closely associated with an enhanced risk of cerebral venous thrombosis. CASE PRESENTATION: Here we report a case of cerebral venous thrombosis secondary to hyperhomocysteinemia caused by vitamin B12 deficiency in a 32-year-old Indo-Aryan man. A detailed coagulation workup led us to find the etiology of cerebral venous thrombosis in this patient who followed a strict vegetarian diet and had vitamin B12 deficiency leading to hyperhomocysteinemia. CONCLUSION: There are conflicting reports in the literature about the association of hyperhomocysteinemia, B12 deficiency, and cerebral venous thrombosis but some reports point to a significant association. We conclude that further studies with a large sample size are required to analyze the effect of hyperhomocysteinemia and low vitamin B12 on the risk of cerebral venous thrombosis.


Assuntos
Hiper-Homocisteinemia/etiologia , Trombose Intracraniana/etiologia , Deficiência de Vitamina B 12/complicações , Adulto , Anticoagulantes/uso terapêutico , Anticonvulsivantes/uso terapêutico , Encéfalo/diagnóstico por imagem , Diuréticos Osmóticos/uso terapêutico , Glicerol/uso terapêutico , Heparina/uso terapêutico , Humanos , Hiper-Homocisteinemia/sangue , Hiper-Homocisteinemia/tratamento farmacológico , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/tratamento farmacológico , Imagem por Ressonância Magnética , Masculino , Manitol/uso terapêutico , Convulsões/complicações , Convulsões/tratamento farmacológico , Ácido Valproico/uso terapêutico , Vitamina B 12/análogos & derivados , Vitamina B 12/uso terapêutico , Deficiência de Vitamina B 12/sangue , Deficiência de Vitamina B 12/tratamento farmacológico , Complexo Vitamínico B/uso terapêutico , Varfarina/uso terapêutico
20.
J Med Case Rep ; 13(1): 14, 2019 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-30651128

RESUMO

BACKGROUND: Acquired thrombophilia is a potential sequela of malignancy, chronic inflammation, and conditions characterized by severe protein deficiency (for example, nephrotic syndrome, protein-losing enteropathy). As such, venous thrombosis is often a feature, and occasionally a presenting sign, of systemic disease. Ménétrier's disease is a rare hyperplastic gastropathy that may lead to gastrointestinal protein loss and hypoalbuminemia. To date, reports of venous thrombosis associated with Ménétrier's disease are exceedingly scarce. CASE PRESENTATION: We report the case of a 40-year-old white man who presented with unprovoked deep venous thrombosis, pulmonary embolism, and renal vein thrombosis. Upon receiving therapeutic anticoagulation, he developed severe gastrointestinal bleeding, and endoscopic evaluation led to a diagnosis of Ménétrier's disease. A laboratory workup revealed deficiency of protein C, protein S, and antithrombin III, as well as markedly elevated levels of factor VIII. He was determined to have an acquired thrombophilia as a direct result of Ménétrier's disease. CONCLUSIONS: This case describes an acquired thrombophilic state in a patient with Ménétrier's disease and profound hypoalbuminemia. Although this association is rarely described, we discuss the probable mechanisms leading to our patient's thrombosis. Specifically, we posit that his gastrointestinal protein loss led to a deficiency of several anticoagulant proteins and a compensatory elevation in factor VIII, as occurs in nephrotic syndrome and inflammatory bowel disease. Of note, this patient's recurrent venous thrombosis was the initial clinical sign of his gastrointestinal pathology.


Assuntos
Antiulcerosos/uso terapêutico , Anticoagulantes/uso terapêutico , Gastrite Hipertrófica/diagnóstico , Heparina/uso terapêutico , Pantoprazol/uso terapêutico , Embolia Pulmonar/diagnóstico , Trombose Venosa/diagnóstico , Adulto , Diagnóstico Diferencial , Endoscopia , Gastrite Hipertrófica/complicações , Gastrite Hipertrófica/tratamento farmacológico , Humanos , Masculino , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/etiologia , Radiografia Abdominal , Resultado do Tratamento , Trombose Venosa/tratamento farmacológico , Trombose Venosa/etiologia
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