1
|
Nourouzpour N, Jen TTH, Bailey J, Jobin PG, Sutherland JM, Ho CM, Prabhakar C, Ke JXC. Association between anesthesia technique and death after hip fracture repair for patients with COVID-19. Can J Anaesth 2024; 71:367-377. [PMID: 38129357 DOI: 10.1007/s12630-023-02673-2] [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: 06/27/2023] [Revised: 08/26/2023] [Accepted: 09/18/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Patients with COVID-19 undergoing hip fracture surgeries have a 30-day mortality of up to 34%. We aimed to evaluate the association between anesthesia technique and 30-day mortality after hip fracture surgery in patients with COVID-19. METHODS After ethics approval, we performed a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program data set from January to December 2021. Inclusion criteria were age ≥ 19 yr, laboratory-confirmed SARS-CoV-2 infection within 14 days preoperatively, and hip fracture surgery under general anesthesia (GA) or spinal anesthesia (SA). Exclusion criteria were American Society of Anesthesiologists Physical Status V, ventilator dependence, international normalized ratio ≥ 1.5, partial thromboplastin time > 35 sec, and platelet count < 80 × 109 L-1. The primary outcome was all-cause 30-day mortality. The adjusted association between anesthetic technique and 30-day mortality was analyzed using multivariable logistic regression. RESULTS Of 23,045 patients undergoing hip fracture surgery, 331 patients met the study criteria. The median [interquartile range] age was 82 [74-88] yr, and 32.3% were male. The 30-day mortality rate was 10.0% (33/331) for the cohort (10.7%, 29/272 for GA vs 6.8%, 4/59 for SA; P = 0.51; standardized mean difference, 0.138). The use of SA, compared with GA, was not associated with decreased mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.21 to 1.8; E-value, 2.49). CONCLUSION Anesthesia technique was not associated with mortality in patients with COVID-19 undergoing hip fracture surgery. The findings were limited by a small sample size. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT05133648); registered 24 November 2021.
Collapse
Affiliation(s)
- Nilufer Nourouzpour
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
| | - Tim T H Jen
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, St. Paul's Hospital, Providence Health Care, Vancouver, BC, Canada
| | - Jonathan Bailey
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Parker G Jobin
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Jason M Sutherland
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
| | - Chun-Man Ho
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Christopher Prabhakar
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, St. Paul's Hospital, Providence Health Care, Vancouver, BC, Canada
| | - Janny X C Ke
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada.
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
- Department of Anesthesia, St. Paul's Hospital, Providence Health Care, Third Floor, Providence Building, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| |
Collapse
|
2
|
Giannubilo SR, Marzioni D, Tossetta G, Ciavattini A. HELLP Syndrome and Differential Diagnosis with Other Thrombotic Microangiopathies in Pregnancy. Diagnostics (Basel) 2024; 14:352. [PMID: 38396391 PMCID: PMC10887663 DOI: 10.3390/diagnostics14040352] [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: 12/31/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/25/2024] Open
Abstract
Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic-functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces "mechanical" (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy.
Collapse
Affiliation(s)
| | - Daniela Marzioni
- Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Via Tronto 10/a, 60126 Ancona, Italy; (D.M.); (G.T.)
| | - Giovanni Tossetta
- Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Via Tronto 10/a, 60126 Ancona, Italy; (D.M.); (G.T.)
| | - Andrea Ciavattini
- Department of Clinical Sciences, Polytechnic University of Marche, Via Corridoni 11, 60123 Ancona, Italy;
| |
Collapse
|
3
|
Kozak M, Hallan DR, Stoltzfus M, Rizk E. Lumbar Puncture in Thrombocytopenia: The Floor Is Not Firm. Cureus 2023; 15:e42019. [PMID: 37593278 PMCID: PMC10430889 DOI: 10.7759/cureus.42019] [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: 05/22/2023] [Accepted: 07/16/2023] [Indexed: 08/19/2023] Open
Abstract
Objective Lumbar puncture (LP) is a diagnostic procedure that accesses the spinal subarachnoid space to measure the opening pressure of the cerebrospinal fluid (CSF) and obtain samples of CSF for analysis. Although commonly performed, LPs are associated with the risk of morbidity and mortality. In addition, thrombocytopenia is thought to increase the risk of LP complications, particularly spinal bleeds. This study compares rates of complications among patients who received LPs with and without thrombocytopenia in hopes of establishing more evidence-based platelet thresholds for an LP. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent LPs - those with thrombocytopenia (defined as a platelet level of 10,000-50,000 platelets {plts}/μL) and those without thrombocytopenia. The outcomes of interest were the new occurrence of subdural hematoma, epidural hematoma, subarachnoid hemorrhage, receipt of a blood patch, new onset of paralysis, and requirement of spinal decompression. Results The risk of developing a spinal bleed following an LP was 1.496% (42 of 2,808) for the cohort with thrombocytopenia versus 1.09% (31 of 2,843) for the cohort without thrombocytopenia. The risk difference, risk ratio, and odds ratio of patients from these two cohorts experiencing a spinal bleed following an LP were insignificant at 0.05. The risk of receiving a blood patch following an LP was 7.844% for those with thrombocytopenia compared to 1.421% for those without thrombocytopenia. The odds ratio of receiving a blood patch between the two cohorts was 5.906, significant to the 0.05 level (95% CI: 4.213-8.279). There was no significant difference in the cohorts' risk of developing paralysis or requiring spinal decompression following an LP. Conclusion In support of recent findings against conventional platelet count thresholds prior to LP, it was observed in the present study that the incidence of post-LP spinal bleeding in the 30 days after LP is not associated with platelet counts below the guideline threshold of 50,000 plts/μL. Patients with thrombocytopenia are also not significantly more likely to require spinal decompression or develop new onset paralysis. However, thrombocytopenia is associated with a significantly increased likelihood of receiving a blood patch following an LP.
Collapse
Affiliation(s)
- Michael Kozak
- Neurosurgery, Penn State College of Medicine, Hershey, USA
| | - David R Hallan
- Neurosurgery, Penn State College of Medicine, Hershey, USA
| | | | - Elias Rizk
- Neurosurgery, Penn State College of Medicine, Hershey, USA
| |
Collapse
|
4
|
EKİCİ H, ÖKMEN F, SARITAŞ DG, İMAMOĞLU M, EKER T, ERGENOĞLU AM. Primary autoimmune thrombocytopenia in pregnancy: maternal and neonatal outcomes. EGE TIP DERGISI 2023. [DOI: 10.19161/etd.1262496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Aim: To evaluate clinical characteristics, maternal and neonatal outcomes among pregnant women with primary autoimmune thrombocytopenia (ITP).
Materials and methods: All pregnant women with ITP who had undergone antenatal follow-up and delivery at the Department of Obstetrics and Gynecology at a referral center, between 2011 and 2021, were retrospectively investigated. Patients were evaluated in three groups according to antenatal
treatment modality.
Results: 42 pregnant women with ITP were included in the study. A total of 29 (%69) pregnant womenhad been diagnosed with ITP before pregnancy and 13(%31) were diagnosed during pregnancy. 17 (%41) pregnant women did not receive any antenatal treatment, and 25 (%59) pregnant women receieved treatment. Postpartum haemorrhage (%50) was reported more frequently in the
steroids+IVIG group. A total of 42 pregnancies, 43 babies (one twin pregnancy, 41 singletons) were liveborn. Three neonates (%7) had thrombocytopenia and one of them had intracranial haemorrhage.
Conclusions: In pregnancies complicated with ITP, the platelet count is moderately or severely low, which can have adverse maternal and neonatal outcomes. Postpartum haemorrhage is a significant cause of maternal morbidity in cases with ITP. Therefore, pregnant women with ITP should be delivered in facilities that can adequately manage postpartum haemorrhage.
Collapse
Affiliation(s)
| | - Fırat ÖKMEN
- Buca Seyfi Demirsoy Training and Research Hospital, Izmir, Türkiye
| | | | - Metehan İMAMOĞLU
- Department of Obstetrics and Gynecology, Bridgeport Hospital / Yale New Haven Health, Bridgeport, CT, United States
| | | | | |
Collapse
|
5
|
Jordan A, Jain AG, Koipallil GK, Reddy M, Chakkoli S, Midha S, Phuoc V, Eatrides J, Erhardt C, Patel AK, Rico J, Visweshar N, Mhaskar R, Parikh N, Laber D, Jaglal M. Can we lower the platelet threshold of ≥ 50 × 10 9/L for performing a lumbar puncture safely in patients with hematological malignancies? Ann Hematol 2023; 102:663-668. [PMID: 36534146 DOI: 10.1007/s00277-022-05073-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
Lumbar punctures (LP) are routinely used to administer intrathecal chemotherapy for children and adults with hematologic malignancies. The current guidelines suggest a platelet threshold of ≥ 50 × 109/L prior to LP for intrathecal chemotherapy (ITC). This can be challenging in patients with hematological malignancies who are thrombocytopenic. We conducted a retrospective chart review of 900 LPs for ITC and compared adverse events in patients with a platelet count of ≥ 50 × 109/L and < 50 × 109/L. Cohort 1 included 682 LPs (75.8%) with a pre-procedure platelet count ≥ 50 × 109/L, and cohort 2 included 218 LPs (24.2%) with a pre-procedure platelet count < 50 × 109/L. Cohort 2 was further subdivided into pre-procedure platelet counts of 41 × 109/L-49 × 109/L (n = 43), 31 × 109/L-40 × 109/L (n = 77), 21 × 109/L-30 × 109/L (n = 84), and 11 × 109/L-20 × 109/L (n = 14). Among 900 LP procedures, a pre-procedure platelet count < 50 × 109/L did not demonstrate a higher rate of post-procedure adverse events (6.5% vs 6.8%, p = 0.8237). When cohort 2 was further stratified, the cohort with a pre-procedure platelet count of 21 × 109/L-30 × 109/L had the highest percentage of complications from LP (9.5%) and the highest rates of traumatic taps with observed LP RBC count > 200 (35.7%, p = 0.0015). The rate of red blood cells (RBC) in the CSF was significantly higher in the group with platelets < 50 × 109/L with observed LP RBC count ≥ 200 (31.2% vs 20.5%, p = 0.0016), ≥ 500 (27.1% vs 14.6%, p < 0.0001), and ≥ 1000 (23% vs 11.6%, p < 0.0001). No instances of epidural hematomas were seen. We found no significant difference in bleeding complications between patients undergoing LPs for ITC with a platelet count above or below 50 × 109/L.
Collapse
Affiliation(s)
- Aryanna Jordan
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA.
| | - Akriti G Jain
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Meghana Reddy
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Sanjay Chakkoli
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Shonali Midha
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Vania Phuoc
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jennifer Eatrides
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Crystal Erhardt
- H. Lee Moffitt Center and Research Institute, Tampa, FL, USA
| | - Ankita K Patel
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Juan Rico
- Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Nathan Visweshar
- Department of Internal Medicine, Division of Hematology and Oncology, University of South Florida, Tampa, FL, USA
| | - Rahul Mhaskar
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Nainesh Parikh
- H. Lee Moffitt Center and Research Institute, Tampa, FL, USA
| | - Damian Laber
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Michael Jaglal
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| |
Collapse
|
6
|
Lyons HS, Ramalingam S, Mitchell JL, Yiangou A, Thaller M, Sinclair AJ, Mollan SP. Multiple lumbar punctures aiming to relieve headache results in iatrogenic spinal hematoma: a case report. J Med Case Rep 2022; 16:464. [PMID: 36514112 DOI: 10.1186/s13256-022-03687-y] [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: 04/27/2022] [Accepted: 11/10/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Multiple lumbar punctures have historically been a strategy to relieve headaches associated with idiopathic intracranial hypertension despite limited clinical evidence of long-term efficacy. Lumbar puncture is typically a straightforward procedure with minimal complications reported, however, serious complications can occur. Lumbar-puncture-related spinal hematomas are rare but can lead to irreversible paralysis. CASE PRESENTATION We report a case of a 28-year-old Caucasian woman who was treated with multiple lumbar punctures to manage headache, thought to be attributed to idiopathic intracranial hypertension. The patient developed a lumbosacral epidural hematoma following a lumbar puncture, which led to incomplete cauda equina syndrome. Multiple lumbar punctures had been the long-term management for the patient's chronic headaches associated with her diagnosis of idiopathic intracranial hypertension. She had no risks of an underlying coagulopathy. Following a lumbar puncture, she re-presented with lower back pain and bilateral paresthesia. Over the subsequent 48 hours, this progressed to urinary incontinence and saddle paresthesia. Imaging revealed an epidural hematoma, which was conservatively managed. She continued to report saddle paresthesia and urinary incontinence 7 months following the lumbar puncture. Between 1974 to 2022, our literature search found 41 case reports detailing lumbar-puncture-related spinal hematomas. It is an established but rare complication of lumbar puncture and there are limited studies looking at the incidence of its occurrence. Whilst coagulopathy has been found to be a risk factor, it is unclear if the gauge of the needle is relevant. Case evidence suggests there may be no significant difference in outcomes between surgical and conservative management of spinal hematomas. This case highlights that lumbar punctures can be invasive, with potentially serious complications. A lumbar puncture should therefore only be performed when clinically justified. CONCLUSIONS This case highlights a rare complication of lumbar puncture and emphasizes the importance of a risk-benefit discussion for each procedure. Spinal hematoma following lumbar puncture is a rare complication but with potentially devastating consequences. Within the setting of idiopathic intracranial hypertension, the evidence base for the long-term benefit of headache relief by repeat lumbar puncture is low.
Collapse
Affiliation(s)
- Hannah S Lyons
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
| | - Satheesh Ramalingam
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
| | - James L Mitchell
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Andreas Yiangou
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK. .,Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| |
Collapse
|
7
|
Habas E, Rayani A, Alfitori G, Eldin Ahmed G, Elzouki ANY. Gestational Thrombocytopenia: A Review on Recent Updates. Cureus 2022; 14:e23204. [PMID: 35444886 PMCID: PMC9010930 DOI: 10.7759/cureus.23204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/08/2022] Open
Abstract
Thrombocytopenia is a condition in which the blood platelet count is low. It is well established that the mild thrombocytopenia frequency is higher in normal pregnancy. This type of thrombocytopenia was named pregnancy-induced thrombocytopenia. However, recently, it has been widely known as gestational thrombocytopenia (GT). The rate is higher in women with a prior GT history and multiple pregnancies. However, it appears that GT is a physiological response to the pregnancy; placenta's peculiar structure and its unique blood flow pattern play major roles in GT development. There are no specific, precise, or known underlying pathophysiological mechanisms of GT, and no new specific management strategies are published yet. Therefore, we decided to do a non-systematic review of any recent updates that had been published in PubMed, EMBASE, and Web of Science about the pathophysiology of GT, its treatment, and other related topics.
Collapse
|
8
|
Ke JXC, Flexman AM, Schwarz SKW, MacDonald S, Prabhakar C. OUP accepted manuscript. BJS Open 2022; 6:6601280. [PMID: 35657135 PMCID: PMC9164863 DOI: 10.1093/bjsopen/zrac061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background The relationship between anaesthetic technique and graft patency after open lower limb revascularization is unclear. The aim of this study was to evaluate the association between 30-day graft patency after elective infrainguinal bypass and anaesthetic technique (regional anaesthesia (RA, i.e. neuraxial and/or peripheral nerve blockade) compared with general anaesthesia (GA)). Methods Patients who underwent elective infrainguinal bypass in the 2014–2019 National Surgical Quality Improvement Program Vascular Procedure Targeted Lower Extremity Open data set were included. Excluded patients were those under 18 years old, those who did not receive RA or GA, and/or had an international normalized ratio of 1.5 of greater, a partial thromboplastin time more than 35 s, or a platelet count less than 80 × 109/L. The primary outcome was primary graft patency without reintervention. The relationship between anaesthetic technique and patency was analysed with multivariable logistic regression. Results Included were 8893 patients with a mean(s.d.) age of 68(11) years and 31.5 per cent female. Within the cohort, 7.7 per cent (n = 688) patients received RA only, 90.4 per cent (n = 8039) GA only, and 1.9 per cent (n = 166) both GA and RA. In the RA-only group, 91.7 per cent (631 of 688) received neuraxial anaesthesia. The primary patency rate was 93.2 per cent (573 of 615) for RA only, and 91.5 per cent (6390 of 6983) for GA only (standardized mean difference, 0.063). RA was not associated with a higher rate of patency compared with GA (adjusted OR, 1.16; 95 per cent c.i., 0.83 to 1.63; P = 0.378). Conclusion There was no association between anaesthetic technique and 30-day graft patency after elective infrainguinal bypass surgery. Further prospective studies would be useful to study the impact of anaesthesia technique on important patient-centred outcomes such as long-term patency and non-home discharge.
Collapse
Affiliation(s)
- Janny Xue Chen Ke
- Correspondence to: Janny Xue Chen Ke, 1081 Burrard Street, Vancouver, British Columbia V6Z1Y6, Canada (e-mail: ; @jannyke
| | - Alana M. Flexman
- Department of Anesthesia, St. Paul’s Hospital, Providence Health Care, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephan K. W. Schwarz
- Department of Anesthesia, St. Paul’s Hospital, Providence Health Care, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shaun MacDonald
- Division of Vascular Surgery, St. Paul’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | | |
Collapse
|
9
|
Lo CYF, Le S, Kim E. Sphenopalatine Ganglion Block for Postdural Puncture Headaches in a Thrombocytopenic Adolescent Young Adult: A Case Report. J Pediatr Hematol Oncol 2022; 44:e299-e301. [PMID: 34986135 DOI: 10.1097/mph.0000000000002280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Abstract
The epidural blood patch is the gold-standard therapy to treat postdural puncture headaches from dural puncture when conservative therapies fail. However, an epidural blood patch is contraindicated in patients with coagulopathy and thrombocytopenia (platelet count of 60,000/µL) due to concerns of an epidural hematoma. We present a case of an adolescent with acute lymphocytic leukemia, thrombocytopenia, and persistent postdural puncture headaches. The patient was successfully treated with a sphenopalatine ganglion nerve block at the bedside without any side effects and complications.
Collapse
|
10
|
Early Surgery with Neuraxial Anaesthesia in Patients on Chronic Antiplatelet Therapy with a Proximal Femur Fracture: Multicentric Randomised Clinical Trial. J Clin Med 2021; 10:jcm10225371. [PMID: 34830654 PMCID: PMC8624584 DOI: 10.3390/jcm10225371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. Methods: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. Results: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5–3.7) days for the experimental group and 4.9 (4.4–5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.
Collapse
|
11
|
Abstract
Platelets are commonly transfused either therapeutically or prophylactically to maintain hemostasis. Most platelet transfusions are used to manage patients with hematologic malignancies. Although platelet transfusion guidelines have been published, platelet transfusion practices are still heterogeneous. Platelet transfusion guidelines partly lack recommendations or differ in the platelet threshold recommendations in some clinical situations. This article reviews platelet transfusions focusing on transfusion guidelines and platelet thresholds in different clinical settings.
Collapse
Affiliation(s)
- Shan Yuan
- Division of Transfusion Medicine, Department of Pathology, City of Hope National Medical Center, Duarte, CA 91010-3000, USA
| | - Zaher K Otrock
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, Henry Ford Hospital, K6, 2799 West Grand Boulevard, Detroit, MI 48202, USA; Department of Pathology, Wayne State University School of Medicine, Detroit, MI, USA.
| |
Collapse
|
12
|
Karlström C, Gryfelt G, Schmied L, Meinke S, Höglund P. Platelet transfusion improves clot formation and platelet function in severely thrombocytopenic haematology patients. Br J Haematol 2021; 196:224-233. [PMID: 34528253 DOI: 10.1111/bjh.17820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/16/2022]
Abstract
Prophylactic platelet (PLT) transfusion is a common practice in severely thrombocytopenic patients that reduces mortality, but responses to platelet transfusions are variable and difficult to predict in individual patients. In this prospective study, we evaluated the outcome of PLT transfusions in 40 patients with haematological malignancies, linking corrected count increment (CCI) to clot formation and agonist-induced platelet activation after transfusion. The CCI was highly variable between patients and 34% showed no response (1-h CCI < 7,5). Short time since the last PLT transfusion and extended storage time of the PLT product were linked to poor transfusion response, while patient sex, C-reactive protein or the number of chemotherapy cycles prior to transfusion did not influence transfusion outcome. High CCI and good PLT responsiveness to agonist stimulation predicted efficient clot formation in rotational thromboelastometry, but transfusion did not restore poor PLT function in patients to the level of healthy controls. Our study provides new insights into factors affecting PLT transfusion outcome in haematology patients with severe thrombocytopenia, and suggests that the thrombocytopenic environment, or disease-associated factors, may hamper platelet responsiveness.
Collapse
Affiliation(s)
- Cecilia Karlström
- Department of Medicine Huddinge, Center for Haematology and Regenerative Medicine (HERM), Karolinska Institutet, Stockholm, Sweden.,Medical Unit Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Gunilla Gryfelt
- Medical Unit Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Laurent Schmied
- Department of Medicine Huddinge, Center for Haematology and Regenerative Medicine (HERM), Karolinska Institutet, Stockholm, Sweden
| | - Stephan Meinke
- Department of Medicine Huddinge, Center for Haematology and Regenerative Medicine (HERM), Karolinska Institutet, Stockholm, Sweden
| | - Petter Höglund
- Department of Medicine Huddinge, Center for Haematology and Regenerative Medicine (HERM), Karolinska Institutet, Stockholm, Sweden.,Medical Unit Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
13
|
Sanders-Davis LJ, Ritchie J. Appendicitis with concurrent COVID-19 infection in a patient during the third trimester of pregnancy. BMJ Case Rep 2021; 14:e242651. [PMID: 34162616 PMCID: PMC8230971 DOI: 10.1136/bcr-2021-242651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2021] [Indexed: 12/15/2022] Open
Abstract
This article presents an unusual case of appendicitis in pregnancy complicated by the novel coronavirus (SARS-CoV-2). The novel coronavirus has affected the way medicine is practised across most parts of the world with over 160 000 000 global cases to date. Tackling management of these cases is more complex when other pathological processes are ongoing. Appendicitis is a common occurrence in pregnancy, with most obstetric centres seeing about one or two cases a year. Though maternal morbidity and mortality are relatively unimpacted by this event, fetal loss and preterm labour are common sequelae. This case involves a 35-year-old woman presenting in her third trimester with abdominal pain and who went on to be diagnosed with concurrent appendicitis and SARS-CoV-2 infection. Although spinal anaesthesia would be most appropriate as it avoids aerosol generation, general anaesthetic techniques were indicated due to thrombocytopenia in this case. She underwent a successful appendicectomy, although preterm delivery was indicated as a result of maternal and fetal concerns.
Collapse
Affiliation(s)
| | - Joanne Ritchie
- Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust Maternity Services, Telford, UK
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW In this review, we discuss recent developments and trends in the perioperative management of thrombocytopenia. RECENT FINDINGS Large contemporary data base studies show that preoperative thrombocytopenia is present in about 8% of asymptomatic patients, and is associated with increased risks for bleeding and 30-day mortality. Traditionally specific threshold platelet counts were recommended for specific procedures. However, the risk of bleeding may not correlate well with platelet counts and varies with platelet function depending on the underlying etiology. Evidence to support prophylactic platelet transfusion is limited and refractoriness to platelet transfusion is common. A number of options exist to optimize platelet counts prior to procedures, which include steroids, intravenous immunoglobulin, thrombopoietin receptor agonists, and monoclonal antibodies. In addition, intraoperative alternatives and adjuncts to transfusion should be considered. It appears reasonable to use prophylactic desmopressin and antifibrinolytic agents, whereas activated recombinant factor VII could be considered in severe bleeding. Other options include enhancing thrombin generation with prothrombin complex concentrate or increasing fibrinogen levels with fibrinogen concentrate or cryoprecipitate. SUMMARY Given the lack of good quality evidence, much research remains to be done. However, with a multidisciplinary multimodal perioperative strategy, the risk of bleeding can be decreased effectively.
Collapse
|
15
|
Peterson W, Tse B, Martin R, Fralick M, Sholzberg M. Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review. Res Pract Thromb Haemost 2021; 5:e12491. [PMID: 33977207 PMCID: PMC8105160 DOI: 10.1002/rth2.12491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/29/2020] [Accepted: 01/01/2021] [Indexed: 11/08/2022] Open
Abstract
Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.
Collapse
Affiliation(s)
- Wynn Peterson
- Division of Medicine University of Toronto Toronto ON Canada
| | - Brandon Tse
- Faculty of Medicine University of Toronto Toronto ON Canada
| | - Rachel Martin
- Department of Anesthesia St. Michael's Hospital Toronto ON Canada
| | - Michael Fralick
- Sinai Health System and the Department of Medicine University of Toronto Toronto ON Canada
| | - Michelle Sholzberg
- Division of Hematology Department of Medicine and Department of Laboratory Medicine and Pathobiology St. Michael's Hospital Toronto ON Canada
| |
Collapse
|
16
|
Ahsan MJ, Lateef N, Latif A, Malik SU, Batool SS, Fazeel HM, Ahsan MZ, Faizi Z, Thandra A, Mirza M, Kabach A, Core MD. A systematic review and meta-analysis of impact of baseline thrombocytopenia on cardiovascular outcomes and mortality in patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 97:E778-E788. [PMID: 33232562 DOI: 10.1002/ccd.29405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/04/2020] [Accepted: 11/14/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Thrombocytopenia (TP) is associated with higher incidence of bleeding in the setting of percutaneous coronary intervention (PCI) leading to increased morbidity and mortality. Herein, we report a meta-analysis evaluating the effects of baseline thrombocytopenia (bTP) on cardiovascular outcomes in patients undergoing PCI. METHODS Literature search was performed using PubMed, Embase, Cochrane library and clinicaltrials.gov from inception till October 2019. Patients were divided into two groups: Patients with (a) no Thrombocytopenia (nTP) (b) bTP before PCI. Primary endpoints were in-hospital, and all-cause mortality rates at the longest follow-up. The main summary estimate was random effects risk ratio (RR) with 95% confidence intervals (CIs). RESULTS A total of 6,51,543 patients from 10 retrospective studies were included. There was increased in-hospital all-cause mortality (RR 2.58 [1.7-3.8], p < .001) and bleeding (RR 2.37 [1.41-3.98], p < .005), in the bTP group compared to the nTP group. There was no difference for in-hopsital major adverse cardiovascular outcomes (MACE) (RR 1.38 [0.94-2.0], p < .10), post-PCI MI (RR 1.17 [0.9-1.5], p = .19) and TVR (RR 1.65 [0.8-3.6], p = .21), respectively. Outcomes at longest follow-up showed increased incidence of all-cause mortality (RR 1.86 [1.2-2.9], p < .006) and bleeding (RR 1.72 [1.1-2.9], p = .04) in bTP group, while there was no significant difference for post-PCI MI (RR 1.07 [0.91-1.3], p = .42), MACE (RR 1.86 [0.69-1.8], p = .68) and TVR (RR 1.1 [0.9-1.2], p = .93) between both groups. CONCLUSIONS bTP in patients undergoing PCI is associated with increased mortality and predicts risk of bleeding.
Collapse
Affiliation(s)
- Muhammad J Ahsan
- Department of Internal Medicine, Creighton University Medical Center, Omaha, Nebraska, USA
| | - Noman Lateef
- Department of Internal Medicine, Creighton University Medical Center, Omaha, Nebraska, USA
| | - Azka Latif
- Department of Internal Medicine, Creighton University Medical Center, Omaha, Nebraska, USA
| | - Saad U Malik
- Department of Internal Medicine, University of Arizona, Tucson, Arizona, USA
| | - Syeda S Batool
- Department of Internal Medicine, University of Alabama, Huntsville, Alabama, USA
| | - Hafiz M Fazeel
- Department of Internal Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Mohammad Z Ahsan
- Department of Internal Medicine, Fatima Memorial Hospital, Lahore, Pakistan
| | - Zaheer Faizi
- Department of Surgery, Crozer Chester Medical Center, Upland, Pennsylvania, USA
| | - Abhishek Thandra
- Division of Cardiovascular Medicine, Creighton University Medical Center, Omaha, Nebraska, USA
| | - Mohsin Mirza
- Department of Internal Medicine, Creighton University Medical Center, Omaha, Nebraska, USA
| | - Amjad Kabach
- Division of Cardiovascular Medicine, Creighton University Medical Center, Omaha, Nebraska, USA
| | - Michael Del Core
- Division of Cardiovascular Medicine, Creighton University Medical Center, Omaha, Nebraska, USA
| |
Collapse
|
17
|
Matar CF, Bou-Fakhredin R, Russo R, Andolfo I, Iolascon A, Taher AT. Recommendations for pregnancy in Fanconi anemia. Expert Opin Biol Ther 2021; 21:1403-1409. [PMID: 33798394 DOI: 10.1080/14712598.2021.1913119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Fanconi anemia (FA) is a rare congenital disease that belongs to the family of congenital trilinear bone marrow failure. Most FA patients will suffer bone marrow failure and the main treatment relies on supportive measures or more recently on the use of hematopoietic stem cell transplant. The improvements seen in the management of FA has led women to reach childbearing age and have successful pregnancies. However, these pregnancies are associated with increased complications such as preterm delivery, cesarean delivery, eclampsia and others.Areas covered: This review highlights on the outcome of pregnancies in FA patients reported in the literature along with practical recommendations.Expert opinion: Multidisciplinary efforts are required to optimize the management of pregnancy in FA patients. Moreover, the development of a set of recommendations to optimize the treatment is highly necessary.
Collapse
Affiliation(s)
- Charbel F Matar
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Roberta Russo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy.,CEINGE Advanced Biotechnology, Naples, Italy
| | - Immacolata Andolfo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy.,CEINGE Advanced Biotechnology, Naples, Italy
| | - Achille Iolascon
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy.,CEINGE Advanced Biotechnology, Naples, Italy
| | - Ali T Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
18
|
Are Tpo agonists an option for ITP in pregnancy? Blood 2021; 136:2971-2972. [PMID: 33367548 DOI: 10.1182/blood.2020008637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
19
|
Sheyn D, Darvish R, Nayak L, Myer S, Claridge C, Bretschneider CE. Perioperative outcomes for benign hysterectomy among women with thrombocytopenia. Int J Gynaecol Obstet 2021; 154:233-240. [PMID: 33420719 DOI: 10.1002/ijgo.13582] [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: 06/24/2020] [Revised: 09/28/2020] [Accepted: 01/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine whether mild or moderate thrombocytopenia is associated with postoperative complications after benign hysterectomy. METHODS A retrospective study of data from women who underwent benign hysterectomy included in the American College of Surgeons National Surgical Quality Improvement Project Database. The data were stratified by normal platelet count, mild thrombocytopenia (100-149 × 103 platelets/µl), and moderate thrombocytopenia (50-99 × 103 platelets/µl). Multivariable logistic regression was used to determine the relationship between mild or moderate thrombocytopenia and the main outcome measures. RESULTS Moderate thrombocytopenia was associated with an increased risk of perioperative transfusion (adjusted odds ratio [aOR], 2.87; 95% confidence interval [CI], 1.96-4.21) and reoperation (aOR, 4.03; 95% CI, 1.94-17.33), but mild thrombocytopenia was not. There was an increased risk of infection among women with both mild (aOR, 1.38; 95% CI, 1.12-1.69) and moderate (aOR, 2.00; 95% CI,1.23-3.22) thrombocytopenia. There was no association between either mild or moderate thrombocytopenia and readmission, prolonged hospital stay, or longer surgical time. CONCLUSION Thrombocytopenia was found to be associated with increased infectious morbidity after hysterectomy, and moderate thrombocytopenia was associated with an increased risk of perioperative transfusion and reoperation.
Collapse
Affiliation(s)
- David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.,Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.,Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ryan Darvish
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.,Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lalitha Nayak
- Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Hematology & Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sara Myer
- Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Caitlin Claridge
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.,Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - C Emi Bretschneider
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
| |
Collapse
|
20
|
Anaya R, Rodriguez M, Gil JM, Vilalta N, Merchan-Galvis A, Moral V, Mateo J, Martinez-Zapata MJ. Correlation between PlateletWorks ® and PFA-100 ® for Measuring Platelet Function before Urgent Surgery in Patients with Chronic Antiplatelet Therapy. J Clin Med 2021; 10:jcm10020255. [PMID: 33445597 PMCID: PMC7827156 DOI: 10.3390/jcm10020255] [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: 12/07/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 11/16/2022] Open
Abstract
Hemostasis is crucial for reducing bleeding during surgical procedures. The points-of-care based on the platelet function test could be useful to minimize the complications related to chronic antiplatelet therapy during surgery. The present study is aimed at comparing two point-of-care platelet function devices-Platelet Function Analyzer PFA-100® (Siemens Canada, Mississauga, ON, Canada) and Plateletworks®(Helena Laboratories, Beaumont, TX, USA). Our objective is to evaluate if they provide comparable and useful information to manage anti-aggregate patients before surgery. We included patients with a femoral fracture receiving chronic antiplatelet therapy and a median age of 89 years (range from 70 to 98). A platelet function evaluation was performed on all patients before surgery using both devices-Plateletworks® and PFA-100®. The correlation between Plateletworks® and PFA-100® was performed using Cohen's Kappa coefficient. Twenty consecutive patients participated in the trial; 16 patients were under treatment with 75 mg/day of clopidogrel, three with >300 mg/day of acetylsalicylic acid (ASA), and only one was in treatment with both antiplatelet agents. Cohen's Kappa coefficient was 0.327 comparing PFA-100®-ADP (adenosine diphosphate) and Plateletworks® and, 0.200 comparing PFA-100®-EPI (epinephrine) and Plateletworks®. In conclusion, we found a weak concordance comparing PFA-100® and Plateletworks®. This could partially be due to the advanced age of the included patients. However, given the limited sample size, more studies are necessary to confirm these results.
Collapse
Affiliation(s)
- Rafael Anaya
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (R.A.); (M.R.); (J.M.G.); (N.V.); (V.M.)
| | - Mireia Rodriguez
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (R.A.); (M.R.); (J.M.G.); (N.V.); (V.M.)
| | - José María Gil
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (R.A.); (M.R.); (J.M.G.); (N.V.); (V.M.)
| | - Noelia Vilalta
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (R.A.); (M.R.); (J.M.G.); (N.V.); (V.M.)
| | - Angela Merchan-Galvis
- Iberoamerican Cochrane Centre-Public Health and Clinical Epidemiology, IIBSant Pau, 08025 Barcelona, Spain;
- Departamento de Medicina Social y Salud Familiar, Universidad del Cauca, 190003 Popayán, Colombia
| | - Victoria Moral
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (R.A.); (M.R.); (J.M.G.); (N.V.); (V.M.)
| | - José Mateo
- Thrombosis and Hemostasis Unit, Hematology Department, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain;
| | - María José Martinez-Zapata
- Iberoamerican Cochrane Centre-Public Health and Clinical Epidemiology, IIBSant Pau, 08025 Barcelona, Spain;
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 08025 Barcelona, Spain
- Correspondence:
| |
Collapse
|
21
|
Eslick R, Cutts B, Merriman E, McLintock C, McDonnell N, Shand A, Clarke L, Ng S, Kando I, Curnow J. HOW Collaborative position paper on the management of thrombocytopenia in pregnancy. Aust N Z J Obstet Gynaecol 2021; 61:195-204. [PMID: 33438201 DOI: 10.1111/ajo.13303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/09/2020] [Accepted: 11/24/2020] [Indexed: 12/23/2022]
Abstract
Thrombocytopenia in pregnancy is a common occurrence, affecting up to 10% of women by the time of birth. These recommendations aim to provide pragmatic guidance on the investigation, diagnosis and management of thrombocytopenia in pregnancy; including safety of neuraxial anaesthesia and precautions required for birth. Management of neonatal thrombocytopenia is also addressed. The authors are clinicians representing haematology, obstetric medicine, maternal-fetal medicine, and anaesthesia. Each author conducted a detailed literature review then worked collaboratively to produce a series of unanimous recommendations. The recommendation strength is limited by the lack of high-quality clinical trial data, and represents level C evidence.
Collapse
Affiliation(s)
- Renee Eslick
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Briony Cutts
- Royal Women's Hospital, Melbourne, Victoria, Australia.,Joan Kirner Women's and Children's at Sunshine Hospital, Melbourne, Victoria, Australia
| | | | | | - Nolan McDonnell
- King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Antonia Shand
- Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Lisa Clarke
- Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Sara Ng
- Southern Highlands Haematology, Sydney, New South Wales, Australia
| | - Ian Kando
- National Women's Hospital, Auckland, New Zealand
| | | |
Collapse
|
22
|
Mishra B, Vishnu VY. Lumbar Puncture: Indications, Challenges and Recent Advances. Neurology 2021. [DOI: 10.17925/usn.2021.17.1.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
23
|
Livingston AJ, Laing B, Zwagerman NT, Harris MS. Lumbar drains: Practical understanding and application for the otolaryngologist. Am J Otolaryngol 2020; 41:102740. [PMID: 32979671 DOI: 10.1016/j.amjoto.2020.102740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/13/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Lumbar drains are frequently used in patients with otolaryngologic concerns. These can be used therapeutically or prophylactically with the primary purpose being to modulate CSF pressure. Within otolaryngology, lumbar drains are most frequently used for cerebrospinal fluid leaks - either due to cerebrospinal fluid fistulas or in skull base surgery as these allow for potential healing of the defect. While not typically placed by otolaryngologists, a basic understanding of lumbar drains is beneficial in the context of patient management. MANAGEMENT A lumbar drain is inserted into the intrathecal space in a patient's lumbar spine. Though considered to be a benign procedure, complications are relatively frequent, and adjustment or replacement of the drain may be required. Complications include infection, epidural bleeding, retained hardware, sequelae of relative immobility, or may relate to over-drainage, ranging from mild headache to cranial neuropathies, altered mental status, pneumocephalus, intracranial hemorrhage, and death. While in place, neurologic exams should be performed routinely and should include motor and sensory exams of the lower extremities. A patient should be monitored for fevers, nuchal rigidity, and other signs of infection or meningitis. The CSF fluid should be grossly examined to identify changes, but routine laboratory tests are not typically run on the fluid itself. Drainage rates will vary usually between 5 and 20 mL per hour and must be frequently reassessed and adjusted based upon signs of intracranial hypotension. Drains should be removed when appropriate and should not be left in more than 5 days due to the increased infectious risk. CONCLUSION Lumbar drains are important tools used in patients with otolaryngologic pathologies. Otolaryngologists and otolaryngology residents should be familiar with these catheters to determine if they are working correctly and to identify adverse effects as early as possible.
Collapse
Affiliation(s)
| | - Brandon Laing
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Nathan T Zwagerman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States of America; Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Michael S Harris
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States of America; Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States of America
| |
Collapse
|
24
|
McCormick M, Delaney M. Transfusion support: Considerations in pediatric populations. Semin Hematol 2020; 57:65-72. [PMID: 32892845 DOI: 10.1053/j.seminhematol.2020.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Indexed: 01/19/2023]
Abstract
Over 400,000 units of blood and blood products are transfused to pediatric patients annually, yet only sparse high-quality data exist to guide the preparation and administration of blood products in this population. The direct application of data from studies in adult patients should be undertaken with caution, as there are dissimilarities in the pathology and physiology between adult and pediatric patients. We provide an overview of available evidence in the field of pediatric transfusion medicine, summarizing indications for blood product transfusion, thresholds for transfusion and indications for blood product modifications.
Collapse
Affiliation(s)
- Meghan McCormick
- Division of Hematology-Oncology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children's National Medical Center, Washington, DC, USA; Departments of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC, USA.
| |
Collapse
|
25
|
Fonseca NM, Pontes JPJ, Perez MV, Alves RR, Fonseca GG. [SBA 2020: Regional anesthesia guideline for using anticoagulants update]. Rev Bras Anestesiol 2020; 70:364-387. [PMID: 32660771 DOI: 10.1016/j.bjan.2020.02.006] [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: 11/22/2019] [Revised: 02/10/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022] Open
Abstract
The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.
Collapse
Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de Ensino e Treinamento (CET), Uberlândia, MG, Brasil; Comissão de Normas Técnicas da Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil.
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care, European Society of Anaesthesiology, Bruxelas, Bélgica
| | - Marcelo Vaz Perez
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Conselho Editorial da Revista Brasileira de Anestesiologia, São Paulo, SP, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Gabriel Gondim Fonseca
- Irmandade da Santa Casa de Misericórdia de São Paulo, Anesthesiology Specialization, São Paulo, SP, Brasil
| |
Collapse
|
26
|
Fonseca NM, Pontes JPJ, Perez MV, Alves RR, Fonseca GG. SBA 2020: Regional anesthesia guideline for using anticoagulants update. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32660771 PMCID: PMC9373103 DOI: 10.1016/j.bjane.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de Ensino e Treinamento (CET), Uberlândia, MG, Brasil; Comissão de Normas Técnicas da Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil.
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care, European Society of Anaesthesiology, Bruxelas, Bélgica
| | - Marcelo Vaz Perez
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Conselho Editorial da Revista Brasileira de Anestesiologia, São Paulo, SP, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Gabriel Gondim Fonseca
- Irmandade da Santa Casa de Misericórdia de São Paulo, Anesthesiology Specialization, São Paulo, SP, Brasil
| |
Collapse
|
27
|
|
28
|
Spinal needle size and traumatic neonatal lumbar puncture: an observational study (neo-LP). Eur J Pediatr 2020; 179:939-945. [PMID: 32002614 DOI: 10.1007/s00431-020-03580-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/30/2019] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
Abstract
The incidence of 'traumatic' lumbar puncture (LP; CSF red cells > 500/mm) has been reported to be 35-46% in the neonatal period. A traumatic LP incurs challenges in diagnosis and management of the underlying condition and increases the risk of complications. We aimed to assess the benefits of a smaller outer diameter, larger gauge 25G needle in reducing the incidence of traumatic LPs compared with the standard 22G LP needle. This prospective observational study compared data from two consecutive epochs. Epoch 1 (Control, April 2016-October 2016), 22G needle for LP as standard practice. Epoch 2 (Intervention, November 2016-October 2017) 25G needle used for LP. Primary outcome was the incidence of traumatic LP. Multiple logistic regression analyses were conducted adjusting for corrected gestational age (CGA) at LP, proceduralist experience and need for ventilation as an indicator of illness. There were 240 LPs during the study period involving 361 attempts (22G, n = 228; 25G, n = 133). Median gestation at birth (P = 0.617) and CGA at LP (P = 0.163) were comparable. Multivariate analysis revealed lower incidence of traumatic LP using 25G needle (P < 0.001). Incidence of obtaining a successful CSF sample was similar between groups (P = 0.944). Proceduralist experience (P = 0.189) and neonatal illness (P = 0.801) were not significant factors.Conclusion: Our results showed that traumatic LPs were ~ 50% less common with 25G vs 22G needles while retaining a comparable success rate. Dry taps were more likely among the 25G group.What is Known:• The incidence of neonatal 'traumatic' lumbar puncture (CSF red cells > 500/mm) has been reported to be 35-46%.• A traumatic lumbar puncture incurs challenges in diagnosis and management of the underlying condition and increases the risk of complications.What is New:• Multivariate analysis revealed lower incidence of traumatic lumbar puncture using 25G needle (vs 22G).• Incidence of obtaining a successful CSF sample was similar between groups.
Collapse
|
29
|
Pesce A, Palmieri M, Armocida D, Frati A, Santoro A. Letter: Neurosurgery and Coronavirus (COVID-19) Epidemic: Doing our Part. Neurosurgery 2020; 87:E48-E49. [PMID: 32293677 PMCID: PMC7184435 DOI: 10.1093/neuros/nyaa115] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Alessandro Pesce
- IRCCS - "Neuromed" Pozzilli (IS), Italy.,A.U.O. "Policlinico Umberto I" Neurosurgery Division Sapienza University, Rome Human Neurosciences Department Roma, Italy
| | - Mauro Palmieri
- A.U.O. "Policlinico Umberto I" Neurosurgery Division Sapienza University, Rome Human Neurosciences Department Roma, Italy
| | - Daniele Armocida
- A.U.O. "Policlinico Umberto I" Neurosurgery Division Sapienza University, Rome Human Neurosciences Department Roma, Italy
| | | | - Antonio Santoro
- A.U.O. "Policlinico Umberto I" Neurosurgery Division Sapienza University, Rome Human Neurosciences Department Roma, Italy
| |
Collapse
|
30
|
Abstract
Importance Immune thrombocytopenia purpura (ITP), an autoimmune disease characterized by destruction of platelets, is a hematological disorder that can present in both pregnant and nonpregnant patients. Although thrombocytopenia in pregnancy can be caused by more common pathologies such as gestational thrombocytopenia and preeclampsia, ITP can present initially during pregnancy, further complicating diagnosis. Management must be considerate of both the pregnancy itself and the fetus. Objective Review the diagnosis, treatment, and management of ITP in pregnancy based on current recommendations. Evidence Acquisition Review articles, original research, and case studies were utilized. Results Throughout pregnancy, patients are screened for a variety of conditions or disorders of pregnancy. Thrombocytopenia is a common pathology of pregnancy, but ITP is a rare condition that a provider needs to be aware of. After ruling out secondary causes of thrombocytopenia or more common causes such as gestational thrombocytopenia or preeclampsia, ITP should be considered. After diagnosis, treatment options should be discussed and initiated to provide safety for both the mother and fetus. Conclusions After reading this article, the reader will understand the current recommendations regarding the diagnosis, treatment, and management of ITP in pregnancy. Relevance The practitioner will be comfortable treating this condition during pregnancy.
Collapse
|
31
|
Rodeghiero F, Marranconi E. Management of immune thrombocytopenia in women: current standards and special considerations. Expert Rev Hematol 2020; 13:175-185. [PMID: 31903814 DOI: 10.1080/17474086.2020.1711729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Immune thrombocytopenia (ITP) is an acquired autoimmune disorder, with an incidence rate of 20-40/million adults/year and an estimated prevalence in women of childbearing age of 24.5/million.Areas covered: Authors discuss management of ITP in pregnancy, treatment-related toxicity, delivery, neonatal thrombocytopenia and breastfeeding, and other women's specific issues. The search of papers published between January 1990 and December 2019 was done on PubMed using combinations of the keywords below. The distinction between ITP and other thrombocytopenias in pregnancy is of paramount importance. The current belief (at variance with the past) that ITP is a relatively benign disease pregnancy is emphasized.Expert opinion: The lack of randomized, prospective, controlled studies hampers evidence-based statements. Remarkably, ITP diagnosis is still one of exclusion, there are no clinical or laboratory criteria for prognosis and we still need more solid data on the risks related to neonatal thrombocytopenia. Corticosteroids and IVIG remain the mainstay of treatment, since rituximab, thrombopoietin-receptor agonists, fostamatinib may be toxic in pregnancy. Safety and efficacy of recombinant-human-thrombopoietin, available in China, require confirmation studies. Quality of life and women-related toxicity of treatments in young girls, adults, and elders are still an orphan area of investigation.
Collapse
Affiliation(s)
- Francesco Rodeghiero
- Hematology Project Foundation and Department of Hematology, S. Bortolo Hospital, Vicenza, Italy
| | - Ettore Marranconi
- Hematology Project Foundation and Department of Hematology, S. Bortolo Hospital, Vicenza, Italy.,Graduate School in Hospital Pharmacy, Pisa University, Pisa, Italy
| |
Collapse
|
32
|
Abstract
Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.
Collapse
|
33
|
Affiliation(s)
- Renee Eslick
- Clinical and Laboratory Haematologist, Haematology Department, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Claire McLintock
- Clinical and Laboratory Haematologist, Obstetric Physician, National Women’s Health, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
34
|
Bailey LJ, Shehata N, De France B, Carvalho JCA, Malinowski AK. Obstetric neuraxial anesthesia at low platelet counts in the context of immune thrombocytopenia: a systematic review and meta-analysis. Can J Anaesth 2019; 66:1396-1414. [DOI: 10.1007/s12630-019-01420-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 02/08/2023] Open
|
35
|
Rodriguez-Merchan EC. Risks and patient outcomes of surgical intervention for hemophilic arthropathy. Expert Rev Hematol 2019; 12:325-333. [DOI: 10.1080/17474086.2019.1602035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
36
|
|
37
|
Costerus JM, Brouwer MC, van de Beek D. Technological advances and changing indications for lumbar puncture in neurological disorders. Lancet Neurol 2019; 17:268-278. [PMID: 29452686 DOI: 10.1016/s1474-4422(18)30033-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/24/2017] [Accepted: 11/28/2017] [Indexed: 01/12/2023]
Abstract
Technological advances have changed the indications for and the way in which lumbar puncture is done. Suspected CNS infection remains the most common indication for lumbar puncture, but new molecular techniques have broadened CSF analysis indications, such as the determination of neuronal autoantibodies in autoimmune encephalitis. New screening techniques have increased sensitvity for pathogen detection and can be used to identify pathogens that were previously unknown to cause CNS infections. Evidence suggests that potential treatments for neurodegenerative diseases, such as Alzheimer's disease, will rely on early detection of the disease with the use of CSF biomarkers. In addition to being used as a diagnostic tool, lumbar puncture can also be used to administer intrathecal treatments as shown by studies of antisense oligonucleotides in patients with spinal muscular atrophy. Lumbar puncture is generally a safe procedure but complications can occur, ranging from minor (eg, back pain) to potentially devastating (eg, cerebral herniation). Evidence that an atraumatic needle tip design reduces complications of lumbar puncture is compelling, and reinforces the need to change clinical practice.
Collapse
Affiliation(s)
- Joost M Costerus
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands.
| |
Collapse
|
38
|
How low can you go: What is the safe threshold for platelet transfusions in patients with hematologic malignancy in sub-Saharan Africa. PLoS One 2019; 14:e0211648. [PMID: 30726290 PMCID: PMC6364911 DOI: 10.1371/journal.pone.0211648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/17/2019] [Indexed: 01/19/2023] Open
Abstract
Background Despite the importance of platelet transfusions in treatment of hematologic cancer patients, the optimal platelet count threshold for prophylactic transfusion is unknown in sub-Saharan Africa. Methods We followed patients admitted to the Uganda Cancer Institute with a hematological malignancy in 3 sequential 4-month time-periods using incrementally lower thresholds for prophylactic platelet transfusion: platelet counts ≤ 30 x 109/L in period 1, ≤ 20 x 109/L in period 2, and ≤ 10 x 109/L in period 3. Clinically significant bleeding was defined as WHO grade ≥ 2 bleeding. We used generalized estimating equations (GEE) to compare the frequency of clinically significant bleeding and platelet transfusions by study period, adjusting for age, sex, cancer type, chemotherapy, baseline platelet count, and baseline hemoglobin. Results Overall, 188 patients were enrolled. The median age was 22 years (range 1–80). Platelet transfusions were given to 42% of patients in period 1, 55% in period 2, and 45% in period 3. These transfusions occurred on 8% of days in period 1, 12% in period 2, and 8% in period 3. In adjusted models, period 3 had significantly fewer transfusions than period 1 (RR = 0.6, 95% CI 0.4–0.9; p = 0.01) and period 2 (RR = 0.5, 95% CI 0.4–0.7; p<0.001). Eighteen patients (30%) had clinically significant bleeding on at least one day in period 1, 23 (30%) in period 2, and 15 (23%) in period 3. Clinically significant bleeding occurred on 8% of patient-days in period 1, 9% in period 2, and 5% in period 3 (adjusted p = 0.41). Thirteen (21%) patients died in period 1, 15 (22%) in period 2, and 11 (19%) in period 3 (adjusted p = 0.96). Conclusion Lowering the threshold for platelet transfusion led to fewer transfusions and did not change the incidence of clinically significant bleeding or mortality, suggesting that a threshold of 10 x 109/L platelets, used in resource-rich countries, may be implemented as a safe level for transfusions in sub-Saharan Africa.
Collapse
|
39
|
Affiliation(s)
- Siobhan Perry
- CT3 Anaesthetics Trainee, Department of Anaesthesia, Great Western Hospital, Swindon SN3 6BB
| | - Jonathan Barnes
- CT3 Anaesthetics Trainee, Department of Anaesthesia, Great Western Hospital, Swindon
| | - Anthony Allan
- Consultant Anaesthetist, Department of Anaesthesia, Great Western Hospital, Swindon
| |
Collapse
|
40
|
Navarrete SB, Worrall EF, Lahaye LA, Scott MJ. Epidural hematoma after intrathecal chemotherapy in a pediatric patient - The value of early diagnosis by anesthesia follow-up. J Clin Anesth 2018; 52:19-20. [PMID: 30153537 DOI: 10.1016/j.jclinane.2018.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/04/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Sergio B Navarrete
- Virginia Commonwealth University Health System, Richmond, VA, United States of America.
| | - Eric F Worrall
- Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Laura A Lahaye
- Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Michael J Scott
- Virginia Commonwealth University Health System, Richmond, VA, United States of America
| |
Collapse
|
41
|
Dodd KC, Emsley HCA, Desborough MJR, Chhetri SK. Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline. Pract Neurol 2018; 18:436-446. [DOI: 10.1136/practneurol-2017-001820] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 11/04/2022]
Abstract
Lumbar puncture (LP) is an important and frequently performed invasive procedure for the diagnosis and management of neurological conditions. There is little in the neurological literature on the topic of periprocedural management of antithrombotics in patients undergoing LP. Current practice is therefore largely extrapolated from guidelines produced by anaesthetic bodies on neuraxial anaesthesia, haematology groups advising on periprocedural management of antiplatelet agents and anticoagulants, and by neuroradiology on imaging-guided spinal procedures. This paper summarises the existing literature on the topic and offers recommendations to guide periprocedural antithrombotic management for LP, based on the consolidation of the best available evidence.
Collapse
|
42
|
Tharp WG, Farhang B. Thromboelastography Before Epidural Placement in a Thrombocytopenic Parturient With Gaucher Disease Treated With Imiglucerase: A Case Report. A A Pract 2018; 11:16-18. [PMID: 29634566 DOI: 10.1213/xaa.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Gaucher disease is a common inborn error of metabolism leading to widespread chronic inflammation and often thrombocytopenia. Here we discuss assessment of coagulation in a parturient with Gaucher disease treated with imiglucerase, who presented with thrombocytopenia and requested epidural analgesia for planned vaginal delivery. We used thromboelastography to determine the safety of placing an epidural catheter and to plan for potential peripartum bleeding. The patient had a normal coagulation profile by thromboelastography and had uncomplicated epidural analgesia for a successful spontaneous vaginal delivery.
Collapse
Affiliation(s)
- William G Tharp
- From the Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, Vermont
| | | |
Collapse
|
43
|
The Role of the Anesthesiologist in Preventing Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol 2018; 61:372-386. [DOI: 10.1097/grf.0000000000000350] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
44
|
Estcourt LJ, Malouf R, Hopewell S, Doree C, Van Veen J. Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Cochrane Database Syst Rev 2018; 4:CD011980. [PMID: 29709077 PMCID: PMC5957267 DOI: 10.1002/14651858.cd011980.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND People with a low platelet count (thrombocytopenia) often require lumbar punctures or an epidural anaesthetic. Lumbar punctures can be diagnostic (haematological malignancies, subarachnoid haematoma, meningitis) or therapeutic (spinal anaesthetic, administration of chemotherapy). Epidural catheters are placed for administration of epidural anaesthetic. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to lumbar punctures and epidural anaesthesia, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to these procedures varies significantly from country to country. This indicates significant uncertainty among clinicians regarding the correct management of these patients. The risk of bleeding appears to be low, but if bleeding occurs it can be very serious (spinal haematoma). Consequently, people may be exposed to the risks of a platelet transfusion without any obvious clinical benefit.This is an update of a Cochrane Review first published in 2016. OBJECTIVES To assess the effects of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthesia in people with thrombocytopenia (low platelet count). SEARCH METHODS We searched for randomised controlled trials (RCTs), non-randomised controlled trials (nRCTs), controlled before-after studies (CBAs), interrupted time series studies (ITSs), and cohort studies in CENTRAL (the Cochrane Library 2018, Issue 1), MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 13 February 2018. SELECTION CRITERIA We included RCTs, nRCTs, CBAs, ITSs, and cohort studies involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter.The original review only included RCTs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane for including RCTs, nRCTs, CBAs, and ITSs. Two review authors independently assessed studies for eligibility and risk of bias and extracted data. Results were only expressed narratively. MAIN RESULTS We identified no completed or ongoing RCTs, nRCTs, CBAs, or ITSs. No studies included people undergoing an epidural procedure. No studies compared different platelet count thresholds prior to a procedure.In this update we identified three retrospective cohort studies that contained participants who did and did not receive platelet transfusions prior to lumbar puncture procedures. All three studies were carried out in people with cancer, most of whom had a haematological malignancy. Two studies were in children, and one was in adults.The number of participants receiving platelet transfusions prior to the lumbar puncture procedures was not reported in one study. We therefore only summarised in a narrative form the relevant outcomes from two studies (150 participants; 129 children and 21 adults), in which the number of participants who received the transfusion was given.We judged the overall risk of bias for all reported outcomes for both studies as 'serious' based on the ROBINS-I tool.No procedure-related major bleeding occurred in the two studies that reported this outcome (2 studies, 150 participants, no cases, very low-quality evidence).There was no evidence of a difference in the risk of minor bleeding (traumatic tap) in participants who received platelet transfusions before a lumbar puncture and those who did not receive a platelet transfusion before the procedure (2 studies, 150 participants, very low-quality evidence). One of the 14 adults who received a platelet transfusion experienced minor bleeding (traumatic tap; defined as at least 500 x 106/L red blood cells in the cerebrospinal fluid); none of the seven adults who did not receive a platelet transfusion experienced this event. Ten children experienced minor bleeding (traumatic taps; defined as at least 100 x 106/L red blood cells in the cerebrospinal fluid), six out of the 57 children who received a platelet transfusion and four out of the 72 children who did not receive a platelet transfusion.No serious adverse events occurred in the one study that reported this outcome (1 study, 21 participants, very low-quality evidence).We found no studies that evaluated all-cause mortality within 30 days from the lumbar puncture procedure, length of hospital stay, proportion of participants who received platelet transfusions, or quality of life. AUTHORS' CONCLUSIONS We found no evidence from RCTs or non-randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter. There are no ongoing registered RCTs assessing the effects of different platelet transfusion thresholds prior to the insertion of a lumbar puncture or epidural anaesthesia in people with thrombocytopenia. Any future study would need to be very large to detect a difference in the risk of bleeding. A study would need to be designed with at least 47,030 participants to be able to detect an increase in the number of people who had major procedure-related bleeding from 1 in 1000 to 2 in 1000. The use of a central data collection register or routinely collected electronic records (big data) is likely to be the only method to systematically gather data relevant to this population.
Collapse
Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Reem Malouf
- University of OxfordNational Perinatal Epidemiology Unit (NPEU)Old Road CampusOxfordUKOX3 7LF
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Joost Van Veen
- Sheffield Teaching Hospitals NHS Foundation TrustDepartment of HaematologyGlossop RoadRoom H101D, H floorSheffieldUKS10 2JF
| | | |
Collapse
|
45
|
Efficacy of treatment immune thrombocytopenic purpura in pregnancy with corticosteroids and intravenous immunoglobulin. Blood Coagul Fibrinolysis 2018; 29:141-147. [DOI: 10.1097/mbc.0000000000000683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
46
|
Riveros-Perez E, Hermesch AC, Barbour LA, Hawkins JL. Aplastic anemia during pregnancy: a review of obstetric and anesthetic considerations. Int J Womens Health 2018; 10:117-125. [PMID: 29535558 PMCID: PMC5836687 DOI: 10.2147/ijwh.s149683] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aplastic anemia is a hematologic condition occasionally presenting during pregnancy. This pathological process is associated with significant maternal and neonatal morbidity and mortality. Obstetric and anesthetic management is challenging, and treatment requires a coordinated effort by an interdisciplinary team, in order to provide safe care to these patients. In this review, we describe the current state of the literature as it applies to the complexity of aplastic anemia in pregnancy, focusing on pathophysiologic aspects of the disease in pregnancy, as well as relevant obstetric and anesthetic considerations necessary to treat this challenging problem. A multidisciplinary-team approach to the management of aplastic anemia in pregnancy is necessary to coordinate prenatal care, optimize maternofetal outcomes, and plan peripartum interventions. Conservative transfusion management is critical to prevent alloimmunization. Although a safe threshold-platelet count for neuraxial anesthesia has not been established, selection of anesthetic technique must be evaluated on a case-to-case basis.
Collapse
Affiliation(s)
- Efrain Riveros-Perez
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA
| | | | | | - Joy L Hawkins
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
47
|
Cines DB, Levine LD. Thrombocytopenia in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:144-151. [PMID: 29222249 PMCID: PMC6142617 DOI: 10.1182/asheducation-2017.1.144] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/12/2017] [Indexed: 05/31/2023]
Abstract
Thrombocytopenia develops in 5% to 10% of women during pregnancy or in the immediate postpartum period. A low platelet count is often an incidental feature, but it might also provide a biomarker of a coexisting systemic or gestational disorder and a potential reason for a maternal intervention or treatment that might pose harm to the fetus. This chapter reflects our approach to these issues with an emphasis on advances made over the past 5 to 10 years in understanding and managing the more common causes of thrombocytopenia in pregnancy. Recent trends in the management of immune thrombocytopenia translate into more women contemplating pregnancy while on treatment with thrombopoietin receptor agonists, rituximab, or mycophenylate, which pose known or unknown risks to the fetus. New criteria to diagnose preeclampsia, judicious reliance on measurement of ADAMTS13 to make management decisions in suspected thrombotic thrombocytopenic purpura, new evidence supporting the efficacy and safety of anticomplement therapy for atypical hemolytic uremic syndrome during pregnancy, and implications of thrombotic microangiopathies for subsequent pregnancies are evolving rapidly. The goals of the chapter are to help the hematology consultant work through the differential diagnosis of thrombocytopenia in pregnancy based on trimester of presentation, severity of thrombocytopenia, and coincident clinical and laboratory manifestations, and to provide guidance for dealing with some of the more common and difficult diagnostic and management decisions.
Collapse
Affiliation(s)
- Douglas B. Cines
- Department of Pathology and Laboratory Medicine
- Department of Medicine, and
| | - Lisa D. Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
48
|
Safe Use of Low-Molecular-weight Heparin in Pediatric Acute Lymphoblastic Leukemia and Lymphoma Around Lumbar Punctures. J Pediatr Hematol Oncol 2017; 39:596-601. [PMID: 28991127 DOI: 10.1097/mph.0000000000000988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children with acute lymphoblastic leukemia or lymphoma (ALL) undergo multiple lumbar punctures (LPs) and frequently require low-molecular-weight heparin (LMWH) for thromboembolic complications. We evaluated if withholding LMWH 24 hours before and after LPs prevented bleeding complications. Children (n=133) with ALL from who were: (1) treated at St. Jude Children's Research Hospital, (2) received LMWH (2×/day of ~1 mg/kg) between January 2004 until December 2012, and (3) underwent a LP were analyzed. Spinal hematoma was defined as a clinical suspicion leading to diagnostic imaging. Traumatic LP was defined as ≥10 red blood cells per microliter of cerebrospinal fluid. In 1708 LPs, no hematomas occurred. For each child treated with LMWH, the probability of experiencing a spinal hematoma during the entire ALL treatment course was 0% (95% confidence interval [CI], 0.0%-2.7%), and in each LP, assuming no intrapatient correlation, the probability of spinal hematoma was 0% (95% CI, 0.0%-0.2%). Traumatic LPs were more common when performed when children were not receiving LMWH therapy (odds ratio [OR], 1.5; 95% CI, 1.1-2.2) which may be explained by clinician optimization of known risk factors for traumatic cerebrospinal fluid before the procedures. Withholding LMWH for 24 hours before and after LPs in children being treated for ALL is safe.
Collapse
|
49
|
Coagulation after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a retrospective cohort analysis. Can J Anaesth 2017; 64:1144-1152. [DOI: 10.1007/s12630-017-0952-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 07/17/2017] [Accepted: 08/14/2017] [Indexed: 10/19/2022] Open
|
50
|
Wan Sulaiman WA, Inche Mat LN, Hashim HZ, Hoo FK, Ching SM, Vasudevan R, Mohamed MH, Basri H. Acute disseminated encephalomyelitis in dengue viral infection. J Clin Neurosci 2017. [PMID: 28625589 DOI: 10.1016/j.jocn.2017.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Dengue is the most common arboviral disease affecting many countries worldwide. An RNA virus from the flaviviridae family, dengue has four antigenically distinct serotypes (DEN-1-DEN-4). Neurological involvement in dengue can be classified into dengue encephalopathy immune-mediated syndromes, encephalitis, neuromuscular or dengue muscle dysfunction and neuro-ophthalmic involvement. Acute disseminated encephalomyelitis (ADEM) is an immune mediated acute demyelinating disorder of the central nervous system following recent infection or vaccination. This monophasic illness is characterised by multifocal white matter involvement. Many dengue studies and case reports have linked ADEM with dengue virus infection but the association is still not clear. Therefore, this article is to review and discuss concerning ADEM in dengue as an immune-medicated neurological complication; and the management strategy required based on recent literature.
Collapse
Affiliation(s)
- Wan Aliaa Wan Sulaiman
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia; Institute of Gerontology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.
| | - Liyana Najwa Inche Mat
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia; Institute of Gerontology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Hasnur Zaman Hashim
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
| | - Fan Kee Hoo
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia; Institute of Gerontology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Siew Mooi Ching
- Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia; Institute of Gerontology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | | | - Mohd Hazmi Mohamed
- Department of Surgery, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
| | - Hamidon Basri
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
| |
Collapse
|