Factors influencing postoperative bleeding after dental extraction in older adult patients receiving anticoagulation therapy

OBJECTIVES

To investigate factors influencing postoperative bleeding occurrence after dental extraction in older patients receiving anticoagulation therapy.

MATERIALS AND METHODS

This retrospective study included patients aged ≥ 65 years receiving one of the following anticoagulants: apixaban, edoxaban, rivaroxaban, and warfarin. Patients who underwent one to multiple tooth extractions in the geriatric dentistry clinic at Tokyo Medical and Dental University Hospital between August 1, 2016, and November 30, 2020, were included. The outcome variable was postoperative bleeding occurrence. Logistic regression analysis was performed with the following ten factors as explanatory variables: age, sex, maximum systolic blood pressure during the extraction, type of local anesthesia, vertical incision, osteotomy, usage of surgical splints, the mesiodistal width of the extracted tooth on a radiograph, use of antiplatelet agents, and history of diabetes requiring medication.

RESULTS

Among 395 participants (mean age, 82.3 ± 6.5 years) included in this study, 75 patients experienced postoperative bleeding after tooth extraction. Logistic regression analysis revealed that the odds ratios for the vertical incision (18.400, p < 0.001), osteotomy (3.630, p = 0.00558), usage of surgical splints (1.860, p = 0.0395), and the mesiodistal width of the extracted tooth on a radiograph (1.060, p = 0.0261) were statistically significant.

CONCLUSIONS

For dental extraction in older patients receiving anticoagulants, postoperative bleeding is more likely to occur in patients with vertical incision, osteotomy, and posterior or multiple tooth extractions.

CLINICAL RELEVANCE

Dentists should consider suturing and adjunctive hemostatic procedures for patients undergoing vertical incision, osteotomy, and multiple tooth extractions while receiving anticoagulation therapy to minimize the risk of postoperative bleeding.

Frequency of prothrombin time-international normalized ratio monitoring and the long-term prognosis in patients with mechanical valve replacement

BACKGROUND

The study aimed to assess the correlation between the monitoring frequency of PT-INR and the long-term prognosis in patients with mechanical heart valve (MHV) replacement after discharge.

METHODS

This single-center, observational study enrolled patients who underwent MHV replacement and discharged from June 2015 to May 2018. Patients or their corresponding family members were followed with a telephone questionnaire survey in July-October 2020. Based on monitoring intervals, patients were divided into frequent monitoring (FM) group (≤ 1 month) and less frequent monitoring (LFM) group (> 1 month). The primary endpoint was the composite of thromboembolic event, major bleeding or all-cause death. The secondary endpoints were thromboembolic event, major bleeding or all-cause death, respectively.

RESULTS

A total of 188 patients were included in the final analysis. The median follow-up duration was 3.6 years (Interquartile range: 2.6 to 4.4 years). 104 (55.3%) patients and 84 (44.7%) patients were classified into the FM group and the LFM group, respectively. The FM group had a significantly lower incidence of the primary endpoint than the LFM group (3.74 vs. 1.16 per 100 patient-years, adjusted HR: 3.31 [95% CI 1.05-10.42, P = 0.041]). Secondary analysis revealed that the risk of thromboembolic events and all-cause death were also reduced in the FM group.

CONCLUSIONS

The management of warfarin treatment in patients after MHV replacement remains challenging. Patients with less frequent monitoring of PT-INR might have worse clinical prognosis than those with frequent PT-INR monitoring.

Pharmacist-physician collaborative care for outpatients with left ventricular assist devices using a cloud-based home medical management information-sharing system: a case report

Background

The standard anticoagulation therapy for patients implanted with left ventricular assist devices (LVADs) includes warfarin therapy. We developed a cloud-based home medical management information-sharing system named as LVAD@home. The LVAD@home system is an application designed to be used on iPad tablet computers. This system enables the sharing of daily information between a patient and care providers in real time. In this study, we reported cases of outpatients with LVADs using this system to manage anticoagulation therapy.

Case presentation

The patient, a man in his 40s with end-stage heart failure owing to non-ischemic dilated cardiomyopathy, underwent LVAD implantation and warfarin was started on postoperative day 1. He started to use LVAD@home to manage warfarin therapy after discharge (postoperative day 47). He sent his data to care providers daily. By using this system, the pharmacist observed his signs of reduced dietary intake 179 days after discharge, and after consulting the physician, told the patient to change the timing of the next measurement earlier than usual. On the next day, the prothrombin time-international normalized ratio increased from 2.0 to 3.0, and thus the dose was decreased by 0.5 mg. Four patients used this system to monitor warfarin therapy from October 2015 to March 2018. In these patients, the time in therapeutic range was 90.1 ± 1.3, which was higher than that observed in previous studies. Additionally, there were no thromboembolic events or bleeding events.

Conclusions

The cloud-based home management system can be applied to share real-time patient information of factors, including dietary intake that interact with warfarin. It can help to improve long-term anticoagulation outcomes in patients implanted with LVAD.

Factors influencing the effectiveness of recombinant human soluble thrombomodulin on disseminated intravascular coagulation: a retrospective study

Background

Although recombinant human soluble thrombomodulin (rTM) has been widely used to treat disseminated intravascular coagulation (DIC) in Japan, there is no consensus regarding rTM efficacy. Therefore, if the factors influencing rTM efficacy is revealed, it may be possible to demonstrate the effectiveness of rTM by limiting the patients who use rTM. This study investigated the factors of rTM treatment which influence DIC status.

Methods

This retrospective case-control study enrolled hospitalized adult patients treated with rTM from October 2010 to May 2020. Among these patients, 227 who were diagnosed with DIC according to the Japanese Association for Acute Medicine DIC scoring system were assessed. The primary endpoint was the 28-day mortality after rTM treatment. For Cox-proportional hazards model, explanatory factors determined using univariate analysis with p <  0.1 were used. In addition, some factors considered to affect DIC-related mortality such as age ≥ 75 years, rTM dose ≥380 U/kg, antithrombin III treatment, and diseases with a poor prognosis (sepsis, solid tumors, and trauma) were added as covariates.

Results

Univariate analyses suggested that male sex (p = 0.029), treatment in intensive care unit (p = 0.061), and prothrombin time-international normalized ratio (PT-INR) (p <  0.001) were the factors influencing DIC-related 28-day mortality after rTM treatment. According to Cox-proportional hazard analysis, the adjusted odds ratio for DIC-related 28-day mortality in patients with PT-INR ≥ 1.67 was 2.23 (95% confidence interval: 1.451–3.433, p <  0.001), age ≥ 75 years was 1.57 (95% confidence interval: 1.009–2.439, p = 0.046), and male sex was 1.66 (95% confidence interval: 1.065–2.573, p = 0.025), respectively. As life-threatening bleeding events were not observed, prolonged PT-INR might directly or indirectly affect DIC-related mortality caused by rTM treatment.

Conclusion

rTM treatment for DIC was less effective in male patients with PT-INR ≥ 1.67 and age ≥ 75 years.

Investigation of the Safety of Injection Laryngoplasty under Antithrombotic Therapy

BACKGROUND

Glottic insufficiency negatively affects phonation and swallowing function. Injection laryngoplasty is a convenient and minimally invasive treatment for glottic insufficiency. This study assessed whether injection laryngoplasty is safe under continued administration of antithrombotic drugs, and aimed to establish measurable laboratory values under which such a procedure can be safely performed.

METHOD

This retrospective medical record review covered the period from November 2012 to June 2018. We examined 17 patients who underwent injection laryngoplasty (47 injections) under continued administration of antithrombotic drugs at the University of Tokyo Hospital. We analyzed clinical and demographic profiles, complications, and blood test values. Statistical analyses were performed regarding the risks of complications due to injection side, route of administration, and number of antithrombotic drugs.

RESULTS

No patients exhibited airway narrowing or dyspnea; however, bleeding after injection laryngoplasty was observed in 3 patients. All patients exhibited values within the optimal treatment range. There were no significant differences regarding the risks of complications due to injection side, route of administration, or number of antithrombotic drugs.

CONCLUSIONS

When the platelet count, prothrombin time-international normalized ratio, and activated partial thromboplastin time were within the optimal range prior to treatment, injection laryngoplasty could safely be performed, regardless of the administration of antithrombotic drugs.

Exacerbation of prothrombin time-international normalized ratio before second polymyxin B cartridge hemoperfusion predicts poor outcome of patients with severe sepsis and/or septic shock

BACKGROUND

Although polymyxin B cartridge hemoperfusion (PMX) has an important place in the treatment of patients with severe sepsis and/or septic shock (SS), there are few rigid indications for performing PMX a second time.The objective of the study was to investigate the clinicolaboratory characteristics (CCs) showing the most significant change from the first to the second PMX and associated with 28-d mortality in patients with SS.

METHODS

Between April 2006 and March 2008, 78 patients with SS who had received two sessions of PMX in a prospectively collected multicenter collaboration study were enrolled. Univariate and multivariate analyses using the differences in the values of individual CCs (Δ-CCs) were performed to assess the CCs showing the most significant change in value associated with 28-d mortality. The Δ-CC was defined as: Δ2nd-1st-CC = value of the CC just before the second PMX - value of the CC just before the first PMX.

RESULTS

Among 28 Δ2nd-1st-CCs, 10 Δ2nd-1st-CCs were selected by using receiver operating characteristic (ROC) curve analyses. The results of multivariate analysis using adequate 8 Δ2nd-1st-CCs that had been selected by univariate analyses revealed that only Δ2nd-1st-prothrombin time-international normalized ratio (PT-INR) (≤0.16/>0.16; hazard ratio = 6.562; 95% CI = 1.525-28.23; P = 0.012) was associated with 28-d mortality. Survival curve analysis demonstrated a significant difference in 28-d mortality between patients with a lower (≤0.16) and a higher (>0.16) Δ2nd-1st-PT-INR (P < 0.001).

CONCLUSIONS

Patients with exacerbation of PT-INR (>0.16) after initial PMX are unlikely to benefit clinically from a second PMX for treatment of SS.