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

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

Miconazole and nystatin used as topical antifungal drugs interact equally strongly with warfarin.

WHAT IS KNOWN AND OBJECTIVE: Medline search disclosed 10 case reports of interactions between oral anticoagulants and miconazole oral gel, but none so far between nystatin solution and anticoagulants. We report on change in anticoagulant activity with use of different topical antifungal drugs, miconazole oral gel and vaginal suppositories, and nystatin solution. METHODS: We conducted a retrospective study that included 43 patients on stable anticoagulation before the introduction of topical antifungal drugs. Miconazole oral gel was prescribed for 32 patients, nystatin solution for eight patients and miconazole vaginal suppositories for three patients. RESULTS AND DISCUSSION: Nineteen (44·2%) of the patients reported bleeding complications and some of these were severe. Fifteen of 32 who used miconazole oral gel and four of 8 of those who used nystatin solution were affected. Before use of the antifungal drugs, the mean weekly warfarin dose in the nystatin group was 14·5 mg, and after antifungal drugs, 9 mg, P = 0·038, while the mean international normalized ratio (INR) before antifungal drugs was 2·5 (range 1·9-3·5) and afterwards it was 10·6 (range 4·5-19·3), P = 0·0001. In the miconazole oral gel group the mean weekly warfarin dose was 15·7 mg, and after 10·8 mg, P = 0·008, while the mean INR before antifungal drugs was 2·44 (range 1·92-3·18) and afterwards it was 8·8 (range 4·9-16·9), P < 0·0001. WHAT IS NEW AND CONCLUSION: Miconazole oral gel and topically applied nystatin solution have equally strong effects on warfarin activity and can provoke major bleeding. Prospective evaluation of this effect is called for. However, based on our results the warfarin dose adjustment appears necessary when the anticoagulant is used concomitantly with those topical antifungals.

Thrombophilia in women with pregnancy-associated complications: fetal loss and pregnancy-related venous thromboembolism.

BACKGROUND/AIMS: Existing data regarding the prevalence of thrombophilia in women with pregnancy complications are conflicting. METHODS: To investigate the relationship between pregnancy-associated complications and the presence of thrombophilia, we studied the records of 453 women with pregnancy-associated complications. In 55 women, intrauterine fetal death (fetus mortus in utero, FMU) after 20 weeks of gestation was recorded, in 231 two or more consecutive recurrent fetal losses (RFL) were recorded, while 167 had a venous thromboembolism (VTE) during one of their pregnancies. The control group consisted of 128 healthy women, with no previous history of thrombotic events or miscarriages. RESULTS: In the FMU group we found 54.5% of women had thrombophilia, in the RFL group 38%, and in the VTE group 52.7%. The most frequent thrombophilia in the VTE group was the FV Leiden (OR 17.9, 95% CI 4.2-75.9). The most frequent thrombophilia in the FMU group was the FII G20210A (OR 7.09, 95% CI 1.8-27.9). Statistical difference between RFL and the control group was observed only for FV Leiden (OR 6.8, 95% CI 1.6-29.7). CONCLUSION: Thrombophilia was found to be considerably more common in women with pregnancy-associated complications in comparison with the women with normal pregnancies, most frequently in patients with VTE or FMU.

Monte Carlo simulations and laser Doppler flow measurements with high penetration depth in biological tissuelike head phantoms.

Laser Doppler flow measurements on biological tissuelike phantoms have shown that penetration depths of 30 mm could be obtained, thus exceeding the penetration depth of commercial instruments for the measurement of skin perfusion by more than an order of magnitude. Monte Carlo simulations were performed and compared with measurement results obtained on a headlike tissue model to quantify the influence of perfusion of the scalp on the cortex perfusion results. We found Doppler frequency spectra to be independent of the mean scattering angle and could be fitted with a sum of Gaussian functions, using a simple analytical model.

Time-gated transillumination of biological tissues and tissuelike phantoms.

The applicability and limits of time-resolved transillumination to determine the internal details of biological tissues are investigated by phantom experiments. By means of line scans across a sharp edge, the spatial resolution (Δx) and its dependence on the time-gate width (Δt) can be determined. Additionally, measurements of completely absorbing bead pairs embedded in a turbid medium demonstrate the physical resolution in a more realistic case. The benefit of time resolution is especially high for a turbid medium with a comparatively small reduced scattering coefficient of approximately µ(s)' = 0.12 mm(-1). Investigations with partially absorbing beads and filled plastic tubes demonstrate the high sensitivity of time-resolving techniques with respect to spatial variations in scattering or absorption coefficients that are due to the embedded disturber. In particular, it is shown that time gating is sensitive to variations in scattering coefficients.