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Phillips A, Bradley C, Cash J, Sangiovanni R, Wingerson C. Effect of low- versus high-dose 4-factor prothrombin complex concentrate in factor Xa inhibitor-associated bleeding: A qualitative systematic review. Am J Health Syst Pharm 2024; 81:e274-e282. [PMID: 38430127 DOI: 10.1093/ajhp/zxae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Indexed: 03/03/2024] Open
Abstract
PURPOSE The purpose of this review is to evaluate current literature on the treatment of factor Xa inhibitor-associated bleeds with 4-factor prothrombin complex concentrate (4F-PCC), with a focus on the effect of low versus high dosing of 4F-PCC on hemostatic efficacy and safety outcomes. SUMMARY A search of PubMed and EBSCOhost was performed to identify studies evaluating patients with a factor Xa inhibitor-bleed treated with 4F-PCC at either low or high doses. Studies of patients receiving alternative reversal agents such as fresh frozen plasma and andexanet alfa or where no comparator group was evaluated were excluded from the analysis. To assess the effect of these 4F-PCC dosing strategies, the primary outcome of interest was hemostatic efficacy. Four studies meeting inclusion criteria were included in this review. In each of the included studies, similar rates of hemostatic efficacy, hospital mortality, and venous thromboembolism were observed in the low- and high-dose cohorts. CONCLUSION These results suggest low- and high-dose 4F-PCC may confer similar clinical effectiveness and safety; however, these findings should be evaluated and confirmed with future prospective studies.
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Affiliation(s)
- Anna Phillips
- Presbyterian College School of Pharmacy, Clinton, SC, USA
| | - Colby Bradley
- Presbyterian College School of Pharmacy, Clinton, SC, USA
| | - Julie Cash
- Presbyterian College School of Pharmacy, Clinton, SC, USA
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2
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Alwakeal A, Maas MB, Naidech AM, Jahromi BS, Potts MB. Fixed- Versus Variable-Dose Prothrombin Complex Concentrate for the Emergent Reversal of Vitamin K Antagonists: A Systematic Review and Meta-Analysis. Crit Care Med 2024; 52:811-820. [PMID: 38353592 PMCID: PMC11008445 DOI: 10.1097/ccm.0000000000006212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Four-factor prothrombin complex concentrate (4-PCC) is recommended for rapid reversal of vitamin K antagonists (VKAs) such as warfarin, yet optimal dosing remains uncertain. DATA SOURCES A systematic review was conducted of PubMed, Embase, and Ovid MEDLINE (Wolters Kluwer) databases from January 2000 to August 2023 for clinical studies comparing fixed- vs. variable-dose 4-PCC for emergent VKA reversal with at least one reported clinical outcome. STUDY SELECTION Abstracts and full texts were assessed independently and in duplicate by two reviewers. DATA EXTRACTION Data were extracted independently and in duplicate by two reviewers using predefined extraction forms. DATA SYNTHESIS The analysis comprised three randomized trials and 16 cohort studies comprising a total of 323 participants in randomized trials (161 in fixed dosage and 162 in variable dosage) and 1912 patients in cohort studies (858 in fixed-dose and 1054 in variable dose). Extracranial bleeding was the predominant indication, while intracranial hemorrhage varied. Overall, a fixed-dose regimen may be associated with a lower dose of 4-PCC and results in a reduction in 4-PCC administration time compared with a variable-dose regimen. A fixed-dose regimen also likely results in increased clinical hemostasis. While there is no clear difference between the two regimens in terms of achieving a goal international normalized ratio (INR) less than 2, a fixed-dose regimen is less likely to achieve a goal INR less than 1.5. High certainty evidence indicates that the fixed-dose regimen reduces both mortality and the occurrence of thromboembolic events. Additional subgroup analyses provides exploratory data to guide future studies. CONCLUSIONS A fixed-dose regimen for 4-PCC administration provides benefits over a variable-dose regimen in terms of dose reduction, faster administration time, improved clinical hemostasis, and reduced mortality and thromboembolic events. Further studies are warranted to better refine the optimal fixed-dose regimen.
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Affiliation(s)
- Amr Alwakeal
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Matthew B Maas
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew M Naidech
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Sylvester KW, Grandoni J, Rhoten M, Coakley L, Matiello-Lyons E, Frankel K, Fortin B, Jolley K, Park HS, Freedman RY, Mehra MR, Givertz MM, Connors JM. Assessment of Temporary Warfarin Reversal in Patients With Left Ventricular Assist Devices: the KVAD Study. J Card Fail 2024:S1071-9164(24)00087-3. [PMID: 38521486 DOI: 10.1016/j.cardfail.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Patients with left ventricular assist devices (LVADs) require interruption of warfarin for invasive procedures, but parenteral bridging is associated with many complications. Four-factor prothrombin complex concentrate (4F-PCC) can temporarily restore hemostasis in patients undergoing anticoagulation with warfarin. OBJECTIVES This pilot study evaluated the strategy of using variable-dose 4F-PCC to immediately and temporarily reverse warfarin before invasive procedures without holding warfarin in patients with LVADs. The duration of effect of 4F-PCC on factor levels and time to reestablish therapeutic anticoagulation post procedure were assessed. METHODS Adult patients with LVADs and planned invasive procedures were enrolled from a single center. Warfarin was continued uninterrupted. The 4F-PCC dose administered immediately pre-procedure was based on study protocol. International normalized ratio (INR)- and vitamin K-dependent factor levels were collected before and during the 48 hours after 4F-PCC administration. The use of parenteral bridging, International Society for Thrombosis and Haemostasis major and clinically relevant nonmajor bleeding (CRNMB) and thromboembolic events at 7 and 30 days were collected. RESULTS In 21 episodes of 4F-PCC reversal, median baseline INR was 2.7 (IQR 2.2-3.2). The median dosage of 4F-PCC administered was 1794 units (IQR 1536-2130). At 24 and 48 hours post 4F-PCC administration, median INRs were 1.8 (IQR 1.7-2.0) and 2.0 (IQR 1.9-2.4). Two patients required postoperative bridging. One patient experienced major bleeding within 72 hours, and 2 experienced CRNMB within 30 days. There were no thromboembolic events. Baseline and post 4F-PCC vitamin K-dependent factor levels corresponded with changes in INR values. The median time to achieve therapeutic INR post-procedure was 2.5 days (IQR, 1-4). CONCLUSION Administration of 4F-PCC for temporary reversal of warfarin for invasive procedures in patients with LVADs allowed for continued warfarin dosing with minimal use of post-intervention bridging, limited bleeding and no thromboembolic events.
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Affiliation(s)
- Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA. https://twitter.com/KatelynSylvester4
| | - Jessica Grandoni
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Megan Rhoten
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Lara Coakley
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA
| | | | - Katie Frankel
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA
| | - Brooke Fortin
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Kate Jolley
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Hae Soo Park
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | | | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA. https://twitter.com/MRMehraMD
| | - Michael M Givertz
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA. https://twitter.com/GivertzMichael
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Boston, MA.
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Fabbro M, Patel PA, Henderson RA, Bolliger D, Tanaka KA, Mazzeffi MA. Coagulation and Transfusion Updates From 2021. J Cardiothorac Vasc Anesth 2022; 36:3447-3458. [PMID: 35750604 PMCID: PMC8986228 DOI: 10.1053/j.jvca.2022.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/02/2022]
Abstract
2021 and the COVID 19 pandemic have brought unprecedented blood shortages worldwide. These deficits have propelled national efforts to reduce blood usage, including limiting elective services and accelerating Patient Blood Management (PBM) initiatives. A host of research dedicated to blood usage and management within cardiac surgery has continued to emerge. The intent of this review is to highlight this past year's research pertaining to PBM and COVID-19-related coagulation changes.
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Navarro-Oviedo M, Marta-Enguita J, Roncal C, Rodriguez JA, Zandio B, Lecumberri R, Hermida J, Oyarzabal J, Pineda-Lucena A, Paramo JA, Muñoz R, Orbe J. CM-352 EFFICACY IN A MOUSE MODEL OF ANTICOAGULANT-ASSOCIATED INTRACRANIAL HAEMORRHAGE. Thromb Haemost 2022; 122:1314-1325. [PMID: 35114692 PMCID: PMC9393087 DOI: 10.1055/a-1759-9962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Intracranial haemorrhage (ICH) is one of the major devastating complications of anticoagulation. Matrix metalloproteinases (MMPs) inhibition has been proposed as a novel pharmacological approach for ICH treatment. OBJECTIVES We evaluated the effects of CM-352 (MMPs-fibrinolysis inhibitor) in an experimental ICH model associated with oral anticoagulants as compared with clinically used prothrombin concentrate complex (PCC). METHODS ICH was induced by collagenase injection into the striatum of WT (C57BL/6J) anticoagulated mice (warfarin or rivaroxaban) and Mmp10 -/- mice. Hematoma volume and neurological deficits were measured 24h later by diaminobenzidine staining and different behavioural test. Circulating plasminogen activator inhibitor-1 (PAI-1) activity and interleukin-6 (IL-6) were measured in plasma samples and local inflammation was assessed by neutrophil infiltration. Finally, fibrinolytic effects of MMP-10 and rivaroxaban were evaluated by thromboelastometry and thrombin-activatable fibrinolysis inhibitor (TAFI) activation assays. RESULTS Only PCC reduced haemorrhage volume and improved functional outcome in warfarin-ICH, but both, PCC and CM-352 treatments, diminished haemorrhage volume (46%, p<0.01 and 64%, p<0.001, respectively) and ameliorated functional outcome in rivaroxaban-ICH. We further demonstrated that CM-352, but not PCC decreased neutrophil infiltration in the haemorrhage area at 24h. The effect of CM-352 could be related to MMP-10 inhibition since Mmp10-/- mice showed lower haemorrhage volume, better neurological score, reduced IL-6 levels and neutrophil infiltration, and increased PAI-1 after experimental ICH. Finally, we found that CM-352 reduced MMP-10 and rivaroxaban-related fibrinolytic effects in thromboelastometry and TAFI activation. CONCLUSIONS CM-352 treatment, by diminishing MMPs and rivaroxaban-associated fibrinolytic effects, might be a novel antihaemorrhagic strategy for rivaroxaban-associated ICH.
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Affiliation(s)
- Manuel Navarro-Oviedo
- Atherosclerosis Research Laboratory, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
| | - Juan Marta-Enguita
- Atherosclerosis Research Laboratory, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain.,Neurology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Carmen Roncal
- Atherosclerosis Research Laboratory, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain.,CIBER Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Jose A Rodriguez
- CIBER Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Atherosclerosis Research Laboratory, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
| | - Beatriz Zandio
- Neurology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Ramón Lecumberri
- CIBER Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Jose Hermida
- CIBER Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Atherosclerosis Research Laboratory, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, PAmplona, Spain
| | - Julen Oyarzabal
- Small Molecules Platform, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
| | - Antonio Pineda-Lucena
- Small Molecules Platform, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
| | - Jose A Paramo
- CIBER Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Atherosclerosis Research Laboratory, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain.,Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Roberto Muñoz
- Red de Investigación Cooperativa de Enfermedades Vasculares Cerebrales (INVICTUS PLUS), Madrid, Spain.,Neurology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Josune Orbe
- CIBER Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Atherosclerosis Research Laboratory, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
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Bahramian B, Afshari A, Kiani B, Sani MA, Hashemi M. The prevalence of foodborne parasites in raw vegetables in Iran: a comprehensive systematic review and meta-analysis. JOURNAL OF ENVIRONMENTAL HEALTH SCIENCE & ENGINEERING 2021; 19:2027-2045. [PMID: 34900321 PMCID: PMC8617144 DOI: 10.1007/s40201-021-00714-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/10/2021] [Indexed: 06/14/2023]
Abstract
UNLABELLED Foodborne parasites in raw vegetables could cause parasitic infections in humans. An effective approach to the reduction of pathogenic microorganisms in vegetables involves identifying the main sources of contamination and the ecology of the involved microorganisms. This review aimed to evaluate the prevalence of foodborne parasites in raw vegetables in Iran. According to the reviewed studies, the prevalence rate of Ascaris spp., Giardia spp., Toxocara spp., Fasciola, Trichuris, Cryptosporidium, Dicrocoeliasis, Taenia spp., and Entamoeba histolytica was 6 % (95 % CI: 5-8 %), 6 % (95 % CI: 5-7 %), 6 % (95 % CI: 4-7 %), 2 % (95 % CI: 1-2 %), 1 % (95 % CI: 1-2 %), 10 % (95 % CI: 6-15 %), 2 % (95 % CI: 1-3 %), 5 % (95 % CI: 4-6 %), and 3 % (95 % CI: 2-4 %), respectively. According to the standard deviation map, Ilam province was one of the high-risk areas in terms of food-borne parasites in raw vegetables (3 SD < prevalence < 4 SD). Given the key role of raw vegetables in human parasitic contamination, governments must implement more stringent programs for effective wastewater treatment, preventing domestic and wild animals from entering farms, not using human and animal manure on farms, using ready-to-eat packaged vegetables, food safety training for households, implementation of GMP and HACCP in the factory vegetable packaging are required in this regard, especially in the high-risk areas of Iran, such as Ilam province. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s40201-021-00714-w.
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Affiliation(s)
- Behnam Bahramian
- Medical Toxicology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Asma Afshari
- Medical Toxicology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behzad Kiani
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahmood Alizadeh Sani
- Division of Food Safety and Hygiene, Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hashemi
- Medical Toxicology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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7
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Mohammadi K, Alizadeh Sani M, Nattagh‐Eshtivani E, Yaribash S, Rahmani J, Shokrollahi Yancheshmeh B, Julian McClements D. A systematic review and meta-analysis of the impact of cornelian cherry consumption on blood lipid profiles. Food Sci Nutr 2021; 9:4629-4638. [PMID: 34401109 PMCID: PMC8358377 DOI: 10.1002/fsn3.2416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 01/13/2023] Open
Abstract
Polyphenolic and flavonoid compounds are claimed to improve blood lipid profiles and to provide protective effects against cardiovascular disease. For this reason, we conducted a systematic review and meta-analysis of studies that comprehensively investigated the effects of cornelian cherry supplementation on lipid profiles in rat models. Up to December 2020, 855 articles were screened, and finally, seven articles were selected as eligible for the meta-analysis. This meta-analysis revealed that cornelian cherry supplementation significantly decreased low-density lipoprotein (LDL) (WMD = -6.38 mg/dl; 95% CI, -9.93 to-2.84; p < .001), triglyceride (TG) (WMD = -52.36 mg/dl; 95% CI, -80.50 to -24.22; p < .005), and cholesterol level (WMD = -37.16 mg/dl; 95% CI, -51.19 to -23.13; p < .005) in treated rats compared with control groups. A nonsignificant increase in high-density lipoprotein (HDL) level was observed (WMD = 4.21 mg/dl; 95% CI, -3.25 to 11.66; p = .268). These results suggest that cherry supplementation may have health effects by modifying lipid profiles. However, there is a need for more well-controlled human clinical trials to make more definitive conclusions about the potential health benefits of cherry supplementation.
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Affiliation(s)
- Keyhan Mohammadi
- Department of Clinical PharmacyFaculty of PharmacyTehran University of Medical SciencesTehranIran
| | - Mahmood Alizadeh Sani
- Division of Food Safety and HygieneSchool of Public HealthTehran University of Medical SciencesTehranIran
| | | | - Shakila Yaribash
- Faculty of PharmacyTehran University of Medical SciencesTehranIran
| | - Jamal Rahmani
- Student Research CommitteeDepartment of Clinical Nutrition and DieteticsFaculty of Nutrition and Food TechnologyShahid Beheshti University of Medical SciencesTehranIran
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