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Wang Q, Liang P, Xu Y, Yuan B, Lan C, Yan X, Li L. Serum trough concentration threshold and risk factors of cefoperazone-induced coagulopathy in critically ill patients: A retrospective case-control study. Eur J Clin Pharmacol 2024; 80:737-746. [PMID: 38353692 PMCID: PMC11001783 DOI: 10.1007/s00228-024-03634-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/22/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE To analyze the risk factors influencing the development of cefoperazone-induced coagulopathy in critically ill patients and determine the threshold of serum trough concentration. METHODS A retrospective case-control study was conducted in the intensive care unit patients treated with cefoperazone, and it was approved by the Ethical Committee of Drum Tower Hospital affiliated with the Medical School of Nanjing University (NO.2023-158-01). Patients were divided into the normal group and coagulopathy group based on prothrombin time. The clinical characteristics of the two groups were compared using univariate analysis. The serum concentration threshold and influencing factors of cefoperazone-induced coagulopathy in critically ill patients were analyzed using the receiver operating characteristic curve and multivariate logistic regression analysis. RESULTS A total of 113 patients were included, and cefoperazone-induced coagulopathy occurred in 39 patients, with an incidence of 34.5%. These patients experienced significant prothrombin time prolongation around day 6 (median) after cefoperazone application. The serum trough concentration threshold of cefoperazone-induced coagulopathy in critically ill patients was 87.765 mg/l. Multivariate logistic regression analysis revealed that the APACHE II score (p = 0.034), prophylactic use of vitamin K1 (p < 0.001), hepatic impairment (p = 0.014), and Cmin ≥ 87.765 mg/l (p = 0.005) were associated with cefoperazone-induced coagulopathy. CONCLUSION Cefoperazone-induced coagulopathy usually occurs on the 6th day of cefoperazone use in critically ill patients. The risk will increase in patients with an APACHE II score > 25, hepatic impairment, and cefoperazone Cmin ≥ 87.765 mg/l. Vitamin K1 is effective in preventing this adverse reaction.
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Affiliation(s)
- Qian Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Pei Liang
- Department of Pharmacy, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Ying Xu
- Intensive Care Unit, Drum Tower Hospital Affiliated to Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Binbin Yuan
- Intensive Care Unit, Drum Tower Hospital Affiliated to Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Chen Lan
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Xiaodi Yan
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Li Li
- Department of Pharmacy, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, Jiangsu, China.
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Valenzuela-Mencia J, Serrera-Figallo MÁ, Torres-Lagares D, Machuca-Portillo G, Sánchez-Fernández E, Valmaseda-Castellón E, Peñarrocha-Diago M, Fernández-Mosteirín N, Somoza-Martin JM, Pérez-Jardón A, Chamorro-Petronacci CM, García-García A. Clinical practice guideline of the spanish society of oral surgery for oral surgery in patients with coagulation disorders. Med Oral Patol Oral Cir Bucal 2024; 29:e58-e66. [PMID: 37330959 PMCID: PMC10765342 DOI: 10.4317/medoral.26063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND The number of patients treated with coagulation disorders, and more specifically with anticoagulant therapy, has increased worldwide in recent years due to increased life expectancy in developed countries. The protocols for managing this type of patient in oral surgery has varied over recent years, especially after the appearance of new direct-acting oral anticoagulants (DOACs). The assessment of risk of bleeding in this type of patient when undergoing a surgical procedure continues to be a controversial issue for patients, dentists and general practitioners. The objective of this document is to offer recommendations, based on evidence, for decision making for patients with coagulopathies who require dental surgical intervention. MATERIAL AND METHODS Based on the indications of the "Preparation of Clinical Practice guidelines in the National Health System. Methodological manual", we gathered a group of experts who agreed on 15 PICO questions based on managing patients with coagulation disorders in dental surgical procedures, such as fitting of implants or dental extractions. RESULTS The 15 PICO questions were answered based on the available evidence, being limited in most cases due to the lack of a control group. Two of the PICO questions were answered by the experts with a grade C recommendation, while the rest were answered with grade D. CONCLUSIONS The results of this review highlight the need to undertake well designed clinical trials with control groups and with a representative sample size.
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Ni J, Chen M, Su Y, Gao Q, Liu L, Lu X. Right femoral vein and right dorsal artery thrombosis in childhood acute myeloid leukemia: A case report. Medicine (Baltimore) 2023; 102:e35121. [PMID: 37832057 PMCID: PMC10578772 DOI: 10.1097/md.0000000000035121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND It is rare for newly diagnosed (de novo) or newly treated acute myeloid leukemia (AML) complicated with thrombotic complications, especially combined arterial and venous thrombosis. METHODS We reported a 13-year-old boy diagnosed with AML and leukocytosis, who developed right femoral vein and right dorsal artery thrombosis during chemotherapy. After treatment with low molecular weight heparin, diosmin, and alprostadil, symptoms were relieved. Unfortunately, the child suffered from coagulopathy afterward, which was unexpectedly caused by vitamin K deficiency. RESULTS After supplementation with vitamin K and prothrombin complex concentrate, coagulation function recovered. CONCLUSION For childhood AML patients with high thrombotic risks, close monitoring during anticoagulant treatment was necessary. Concomitantly, we should be alert to past medication history and combined medication use, especially those that may lead to vitamin K deficiency, secondary bleeding, and coagulation disorders. Rational use of antibiotics, anticoagulants, and antitumor drugs must be guaranteed.
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Affiliation(s)
- Jiaqi Ni
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Min Chen
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yali Su
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Qianqian Gao
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingjun Liu
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaoxi Lu
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
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Nielsen VG. Novel Toxicodynamic Model of Subcutaneous Envenomation to Characterize Snake Venom Coagulopathies and Assess the Efficacy of Site-Directed Inorganic Antivenoms. Int J Mol Sci 2023; 24:13939. [PMID: 37762243 PMCID: PMC10530349 DOI: 10.3390/ijms241813939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 08/31/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
Venomous snake bite adversely affects millions of people yearly, but few animal models allow for the determination of toxicodynamic timelines with hemotoxic venoms to characterize the onset and severity of coagulopathy or assess novel, site-directed antivenom strategies. Thus, the goals of this investigation were to create a rabbit model of subcutaneous envenomation to assess venom toxicodynamics and efficacy of ruthenium-based antivenom administration. New Zealand White rabbits were sedated with midazolam via the ear vein and had viscoelastic measurements of whole blood and/or plasmatic coagulation kinetics obtained from ear artery samples. Venoms derived from Crotalus scutulatus scutulatus, Bothrops moojeni, or Calloselasma rhodostoma were injected subcutaneously, and changes in coagulation were determined over three hours and compared to samples obtained prior to envenomation. Other rabbits had ruthenium-based antivenoms injected five minutes after venom injection. Viscoelastic analyses demonstrated diverse toxicodynamic patterns of coagulopathy consistent with the molecular composition of the proteomes of the venoms tested. The antivenoms tested attenuated venom-mediated coagulopathy. A novel rabbit model can be used to characterize the onset and severity of envenomation by diverse proteomes and to assess site-directed antivenoms. Future investigation is planned involving other medically important venoms and antivenom development.
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Affiliation(s)
- Vance G Nielsen
- Department of Anesthesiology, The University of Arizona College of Medicine, Tucson, AZ 85724, USA
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Groeneveld DJ, Poole LG, Bouck EG, Schulte A, Wei Z, Williams KJ, Watson VE, Lisman T, Wolberg AS, Luyendyk JP. Robust coagulation activation and coagulopathy in mice with experimental acetaminophen-induced liver failure. J Thromb Haemost 2023; 21:2430-2440. [PMID: 37054919 PMCID: PMC10524846 DOI: 10.1016/j.jtha.2023.03.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/07/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Patients with acetaminophen (APAP)-induced acute liver failure (ALF) display both hyper- and hypocoagulable changes not necessarily recapitulated by standard hepatotoxic doses of APAP used in mice (eg, 300 mg/kg). OBJECTIVES We sought to examine coagulation activation in vivo and plasma coagulation potential ex vivo in experimental settings of APAP-induced hepatotoxicity and repair (300-450 mg/kg) and APAP-induced ALF (600 mg/kg) in mice. RESULTS APAP-induced ALF was associated with increased plasma thrombin-antithrombin complexes, decreased plasma prothrombin, and a dramatic reduction in plasma fibrinogen compared with lower APAP doses. Hepatic fibrin(ogen) deposits increased independent of APAP dose, whereas plasma fibrin(ogen) degradation products markedly increased in mice with experimental ALF. Early pharmacologic anticoagulation (+2 hours after 600 mg/kg APAP) limited coagulation activation and reduced hepatic necrosis. The marked coagulation activation evident in mice with APAP-induced ALF was associated with a coagulopathy detectable ex vivo in plasma. Specifically, prolongation of the prothrombin time and inhibition of tissue factor-initiated clot formation were evident even after restoration of physiological fibrinogen concentrations. Plasma endogenous thrombin potential was similarly reduced at all APAP doses. Interestingly, in the presence of ample fibrinogen, ∼10 times more thrombin was required to clot plasma from mice with APAP-induced ALF compared with plasma from mice with simple hepatotoxicity. CONCLUSION The results indicate that robust pathologic coagulation cascade activation in vivo and suppressed coagulation ex vivo are evident in mice with APAP-induced ALF. This unique experimental setting may fill an unmet need as a model to uncover mechanistic aspects of the complex coagulopathy of ALF.
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Affiliation(s)
- Dafna J Groeneveld
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Lauren G Poole
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Emma G Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anthony Schulte
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Zimu Wei
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Kurt J Williams
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Victoria E Watson
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation and Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - James P Luyendyk
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA; Department of Pharmacology & Toxicology, Michigan State University, East Lansing, Michigan, USA.
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Boster JM, Adams MA, Moore HB. Commentary on "Robust coagulation activation and coagulopathy in mice with experimental acetaminophen-induced liver failure". J Thromb Haemost 2023; 21:2365-2366. [PMID: 37597895 DOI: 10.1016/j.jtha.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Julia M Boster
- Division of Hepatology, Department of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Megan A Adams
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hunter B Moore
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA.
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Beckmann L, Lennartz M, Poch A, Holstein K, Bokemeyer C, Langer F. Expression and Release of Tumor Cell Tissue Factor Triggers Recurrent Thromboembolism in a Patient with Endometrial Cancer. Hamostaseologie 2023; 43:289-296. [PMID: 36863395 DOI: 10.1055/a-2010-6484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Although cancer-associated thrombosis (CAT) is a frequent complication in patients with malignancies, its treatment remains a challenge in daily practice. Here, we report the clinical course of a 51-year-old woman presenting with a highly thrombogenic paraneoplastic coagulopathy. Despite therapeutic anticoagulation with various agents, including rivaroxaban, fondaparinux, and low-molecular-weight heparin, the patient suffered from recurrent venous and arterial thromboembolism. Locally advanced endometrial cancer was identified. Tumor cells showed strong expression of tissue factor (TF), and significant concentrations of TF-bearing microvesicles were detected in patient plasma. Coagulopathy was controlled only by continuous intravenous anticoagulation with the direct thrombin inhibitor, argatroban. Multimodal antineoplastic treatment, including neoadjuvant chemotherapy followed by surgery and postoperative radiotherapy, resulted in clinical cancer remission, which was paralleled by normalization of tumor markers, CA125 and CA19-9, D-dimer levels, and TF-bearing microvesicles. In summary, continuous anticoagulation with argatroban and multimodal anticancer treatment may be necessary to control TF-driven coagulation activation with recurrent CAT in endometrial cancer.
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Affiliation(s)
- Lennart Beckmann
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | | | - Annika Poch
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Katharina Holstein
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
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Dodhiawala PB, Pribyl K, Larson J, Vakayil V, Chandrashekar M, Lord A, Welbig J, Zantek ND, Martin D, Harmon JV. Outcomes of 4-factor Prothrombin Complex Concentrate in Patients With Liver Disease and Nonvitamin K Antagonist-Related Coagulopathy: A Retrospective Study. Clin Appl Thromb Hemost 2023; 29:10760296231198038. [PMID: 37649304 PMCID: PMC10475228 DOI: 10.1177/10760296231198038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 09/01/2023] Open
Abstract
The administration of 4-factor prothrombin complex concentrate (4F-PCC) has expanded beyond its Food and Drug Administration (FDA)-approved indication for the emergent reversal of vitamin K antagonists (VKAs). Therefore, this study aimed to evaluate the risks and benefits associated with the expanded use of 4F-PCC. We conducted a single-center retrospective review of 4F-PCC administrations at our university hospital. Of the 159 patients who received 4F-PCC, 76% (n = 121) and 24% (n = 38) received it for the FDA-approved indication in the vitamin K-related coagulopathy (VKA) group and for expanded use in the nonvitamin K-related coagulopathy (nVKA) group, respectively. The expanded use of 4F-PCC was associated with a less robust reduction in the international normalized ratio (INR) (INR of -0.7 ± 1.3 vs INR of -1.6 ± 1.8, P = .002), and fewer patients in the nVKA group achieved a postadministration INR of less than1.5 (11% vs 79%, P = .001) than those in the VKA group. Furthermore, the 30-day mortality rate was significantly higher in the nVKA cohort than in the VKA cohort (42% vs 20%, P = .04). Notably, based on our data, underlying differences in the patient's comorbidities, particularly advanced liver disease, may have contributed to the observed outcome variations, including mortality rate. Therefore, factors, including comorbidities and the underlying etiology of coagulopathy, should be considered when deciding on the expanded use of 4F-PCC. Further research is needed to better understand the potential risks and benefits of 4F-PCC in expanded use scenarios, and the clinical decision to use 4F-PCC outside its FDA-approved indication should be made carefully, considering this information.
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Affiliation(s)
- Paarth B. Dodhiawala
- Medical Scientist Training Program, University of Minnesota, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kyle Pribyl
- Department of Anesthesia, University of Minnesota, Minneapolis, MN, USA
| | - Jared Larson
- Department of Pharmacy, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Amanda Lord
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Julie Welbig
- Laboratory Administration, Fairview Health Services, St. Paul, MN, USA
| | - Nicole D. Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - David Martin
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - James V. Harmon
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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Watson CJ, Simpson MD, Whitledge JD, Patterson A, Burns MM. Warfarin Overdose in an Adolescent Not Dependent on Anticoagulation: Reversal Strategy and Kinetics. J Med Toxicol 2022; 18:334-339. [PMID: 36066724 PMCID: PMC9492822 DOI: 10.1007/s13181-022-00907-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Warfarin induces coagulopathy. Guidelines protocolize reversal of supratherapeutic international normalized ratio (INR) in patients dependent on anticoagulation, but practices vary for reversing warfarin-induced coagulopathy after overdose in non-warfarin-dependent patients. CASE REPORT This is the report of a 15-year-old female who ingested her father's warfarin (100-200 mg) in a self-harm attempt. At hour 24 post-ingestion, her INR was 2.00 and she was admitted for monitoring. Reversal of coagulopathy was initially deferred pending the INR trend. The INR was 5.10 at hour 60 and 2.5 mg oral vitamin K1 (VK1) was given. At hour 85, the INR peaked at 6.67 and she received a second oral dose of 2.5 mg VK1. On day 8, she was medically cleared with an INR of 1.31. On day 11, she developed lower abdominal pain and diarrhea. Imaging revealed a duodenal hematoma, and symptoms improved spontaneously. She was again medically cleared 13 days post-ingestion. Her serum warfarin concentration peaked at 19 mcg/mL at hour 46. Serial warfarin concentrations were obtained, demonstrating first-order elimination kinetics and a 30-hour half-life. CONCLUSION A restrictive approach to coagulopathy reversal in non-warfarin-dependent patients with intentional warfarin overdose may result in worsening coagulopathy, bleeding, and lengthy hospital stay. Given the risk for significant, prolonged coagulopathy, these patients should be treated early with VK1, with subsequent serial INR monitoring and probable additional VK1 dosing. Delayed peak warfarin concentrations support consideration of gastrointestinal decontamination in late presenters.
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Affiliation(s)
- C James Watson
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA.
| | - Michael D Simpson
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3025, Boston, MA, 02115, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - James D Whitledge
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3025, Boston, MA, 02115, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Al Patterson
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, USA
| | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3025, Boston, MA, 02115, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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10
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Noni M, Koukou DM, Tritzali M, Kanaka-Gantenbein C, Michos A, Spoulou V. Coagulation Abnormalities and Management in Hospitalized Pediatric Patients With COVID-19. Pediatr Infect Dis J 2022; 41:570-574. [PMID: 35389967 PMCID: PMC9177125 DOI: 10.1097/inf.0000000000003545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence and severity of coagulation abnormalities have not been extensively studied in pediatric populations with coronavirus disease 2019 (COVID-19). Moreover, their association with an increased risk for thromboembolic events remains unclear, and there is a lack of evidence for optimal prophylactic antithrombotic management. The aim of our study was to present our experience in evaluation, management, and long-term outcomes of coagulation abnormalities in pediatric hospitalized patients with COVID-19. METHODS A prospective study was performed in all children hospitalized for COVID-19 during a 6-month period focusing on patients' coagulation abnormalities, the normalization of the coagulation profile with or without anticoagulation prophylaxis and the clinical outcome of the disease. RESULTS Two hundred twenty-three patients (median age: 11.4 months) were enrolled in the study. Coagulation abnormalities were detected in 92.4% of patients with increased D-dimer levels to be the most common abnormality detected in 84.3% of patients. Prophylactic anticoagulation was initiated only in 7 (3.1%) selected patients with severe COVID-19 and at least 2 risk factors for venous thromboembolism (VTE) and in all patients with previous history of VTE. Follow-up coagulation profile in 85 patients showed that changes over time had a tendency towards normalization irrespectively of the initiation of anticoagulant thromboprophylaxis. No thrombotic complications were observed 3 months upon discharge. CONCLUSIONS Although abnormal findings in coagulation profile were very common, they were not associated with risk for VTE even in severe cases. A trend of normalization early in the course of the disease was observed regardless of the use of anticoagulant thromboprophylaxis.
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Affiliation(s)
- Maria Noni
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Dimitra-Maria Koukou
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Maroula Tritzali
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Christina Kanaka-Gantenbein
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Athanasios Michos
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Vana Spoulou
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
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11
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Post DS, van der Veer A, Schijns OEMG, Klinkenberg S, Rijkers K, Wagner GL, van Kranen-Mastenbroek VHJM, Willems PCPH, Verhezen PWM, Beckers EAM, Heubel-Moenen FCJI, Henskens YMC. Assessment of need for hemostatic evaluation in patients taking valproic acid: A retrospective cross-sectional study. PLoS One 2022; 17:e0264351. [PMID: 35213601 PMCID: PMC8880909 DOI: 10.1371/journal.pone.0264351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Valproic acid (VPA) is a frequently prescribed anti-epileptic drug. Since its introduction side effects on hemostasis are reported. However, studies show conflicting results, and the clinical relevance is questioned. We aimed to determine the coagulopathies induced by VPA in patients who undergo high-risk surgery. The study results warrant attention to this issue, which might contribute to reducing bleeding complications in future patients. METHODS Between January 2012 and August 2020, 73 consecutive patients using VPA were retrospectively included. Extensive laboratory hemostatic assessment (including platelet function tests) was performed before elective high-risk surgery. Patient characteristics, details of VPA treatment, and laboratory results were extracted from medical records. RESULTS 46.6% of the patients using VPA (n = 73) showed coagulopathy. Mainly, platelet function disorder was found (36.4%). Thrombocytopenia was seen in 9.6% of the patients. Data suggested that the incidence of coagulopathies was almost twice as high in children as compared to adults and hypofibrinogenemia was only demonstrated in children. No association was found between the incidence of coagulopathies and VPA dosage (mg/kg/day). CONCLUSION A considerable number of patients using VPA were diagnosed with coagulopathy, especially platelet function disorder. Further prospective studies are needed to confirm the need for comprehensive laboratory testing before elective high-risk surgery in these patients.
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Affiliation(s)
- Demi S. Post
- Department of Pediatric Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Arian van der Veer
- Department of Pediatric Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Pediatric Hematology, Amalia children’s hospital, RadboudUMC, Nijmegen, The Netherlands
- * E-mail:
| | - Olaf E. M. G. Schijns
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Academic Center for Epileptology, Maastricht University Medical Center and Kempenhaeghe, Maastricht–Heeze, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (UM), Maastricht, The Netherlands
| | - Sylvia Klinkenberg
- Department of Pediatric Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kim Rijkers
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Academic Center for Epileptology, Maastricht University Medical Center and Kempenhaeghe, Maastricht–Heeze, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (UM), Maastricht, The Netherlands
| | - G. Louis Wagner
- Academic Center for Epileptology, Maastricht University Medical Center and Kempenhaeghe, Maastricht–Heeze, The Netherlands
| | - Vivianne H. J. M. van Kranen-Mastenbroek
- Academic Center for Epileptology, Maastricht University Medical Center and Kempenhaeghe, Maastricht–Heeze, The Netherlands
- Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paul C. P. H. Willems
- Department of Orthopedic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paul W. M. Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Erik A. M. Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Yvonne M. C. Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
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Jagdish RK, Maras JS, Sarin SK. Albumin in Advanced Liver Diseases: The Good and Bad of a Drug! Hepatology 2021; 74:2848-2862. [PMID: 33772846 DOI: 10.1002/hep.31836] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 02/13/2021] [Accepted: 03/17/2021] [Indexed: 12/13/2022]
Abstract
Human serum albumin is the most abundant plasma protein, and it regulates diverse body functions. In patients with advanced and decompensated cirrhosis, serum albumin levels are low because of a reduction in the hepatocyte mass due to disease per se and multiple therapeutic interventions. Because of their oncotic and nononcotic properties, administration of human albumin solutions (HAS) have been found to be beneficial in patients undergoing large-volume paracentesis or who have hepatorenal syndrome or spontaneous bacterial peritonitis. Albumin also improves the functionality of the immune cells and mitigates the severity and risk of infections in advanced cirrhosis. Its long-term administration can modify the course of decompensated cirrhosis patients by reducing the onset of new complications, improving the quality of life, and probably providing survival benefits. There is, however, a need to rationalize the dose, duration, and frequency of albumin therapy in different liver diseases and stages of cirrhosis. In patients with acute-on-chronic liver failure, potentially toxic oxidized isoforms of albumin increase substantially, especially human nonmercaptalbumin and 2, and nitrosoalbumin. The role of administration of HAS in such patients is unclear. Determining whether removal of the pathological and dysfunctional albumin forms in these patients by "albumin dialysis" is helpful, requires additional studies. Use of albumin is not without adverse events. These mainly include allergic and transfusion reactions, volume overload, antibody formation and coagulation derangements. Considering their cost, limited availability, need for a health care setting for their administration, and potential adverse effects, judicious use of HAS in liver diseases is advocated. There is a need for new albumin molecules and economic alternatives in hepatologic practice.
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Affiliation(s)
- Rakesh Kumar Jagdish
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jaswinder Singh Maras
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
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Abstract
Acute intoxication with a vitamin K antagonist may cause serious coagulopathy. We report the accidental ingestion of a high dose of acenocoumarol in a young child. Two intravenous administrations of 5 mg of vitamin K, in combination with fast and repeated administration of activated charcoal and sodium sulfate, were sufficient to prevent coagulopathy and related symptoms, despite a confirmed elevated blood acenocoumarol concentration (260 µg/L).
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Affiliation(s)
| | - Jelmer Sytema
- Clinical Pharmacy and Toxicology, Martini Hospital, Groningen, The Netherlands
| | - Marinus van Hulst
- Clinical Pharmacy and Toxicology, Martini Hospital, Groningen, The Netherlands
- Department of Health Sciences, University Medical Centre Groningen, Groningen, The Netherlands
| | - Arvid Wa Kamps
- Paediatrics, Martini Hospital, Groningen, The Netherlands
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Lu YQ. Coagulation disorders following an accidental ingestion of cerium dioxide nanoparticles. Environ Toxicol Pharmacol 2021; 82:103560. [PMID: 33290874 DOI: 10.1016/j.etap.2020.103560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 06/12/2023]
Abstract
Clinically, acute cerium dioxide poisoning or damage is very rare. Here, the investigator reported a case about the patient who accidental ingested cerium dioxide nanoparticles during work shift. The patient recovered well after the treatment with removal of cerium and restoring coagulation factor activity. The author also reviewed relative literatures to discuss the potential mechanism of coagulation disorders following cerium dioxide nanoparticles ingestion. This case is the first report in the world about acute oral poisoning due to cerium dioxide nanoparticles, with the exact exposure concentration.
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Affiliation(s)
- Yuan-Qiang Lu
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, Zhejiang, People's Republic of China; Zhejiang Provincial Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases, Hangzhou, 310003, Zhejiang, People's Republic of China.
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Affiliation(s)
- Eleonora Camilleri
- Center for Atherothrombotic Disease, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Niccolò Maggini
- Center for Atherothrombotic Disease, Careggi University Hospital, Florence, Italy
| | - Matteo Piccica
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Annarita Botta
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Daniela Poli
- Center for Atherothrombotic Disease, Careggi University Hospital, Florence, Italy.
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Abstract
A 30-year-old man presented with altered sensorium following Russell's viper bite, which was found to be secondary to intracranial hemorrhage secondary to venom-induced consumptive coagulopathy. He was managed conservatively with blood component transfusion and antivenom injection, and successfully discharged.
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Abstract
BACKGROUND The success of digital replantation is highly dependent on the patency of the repaired vessels after microvascular anastomosis. Antithrombotic agents are frequently used for preventing vascular occlusion. Low molecular weight heparin (LMWH) has been reported to be as effective as unfractionated heparin (UFH) in peripheral vascular surgery, but with fewer adverse effects. Its benefit in microvascular surgery such as digital replantation is unclear. This is an update of the review first published in 2013. OBJECTIVES To assess if treatment with subcutaneous LMWH improves the salvage rate of the digits in patients with digital replantation after traumatic amputation. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 17 March 2020. The authors searched PubMed, China National Knowledge Infrastructure (CNKI) and Chinese Electronic Periodical Services (CEPS) on 17 March 2020 and sought additional trials from reference lists of relevant publications. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials comparing treatment with LMWH versus any other treatment in participants who received digital replantation following traumatic digital amputation. DATA COLLECTION AND ANALYSIS Two review authors (PL, CC) independently extracted data and assessed the risk of bias of the included trials using Cochrane's 'Risk of bias' tool. Disagreements were resolved by discussion. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included two new randomised trials in this update, bringing the total number of included trials to four. They included a total of 258 participants, with at least 273 digits, from hospitals in China. Three studies compared LMWH versus UFH, and one compared LMWH versus no LMWH. The mean age of participants ranged from 24.5 to 37.6 years. In the studies reporting the sex of participants, there were a total of 145 men and 59 women. The certainty of the evidence was downgraded to low or very low because all studies were at high risk of performance or reporting bias (or both) and there was imprecision in the results due to the small numbers of participants. The three studies comparing LMWH versus UFH reported the success rate of replantation using different units of analysis (participant or digit), so we were unable to combine data from all three studies (one study reported results for both participants and digits). No evidence of a benefit in success of replantation was seen in the LMWH group when compared with UFH, regardless of whether the outcomes were reported by number of participants (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.87 to 1.10; 130 participants, 2 studies; very low-certainty evidence); or by number of digits (RR 0.97, 95% CI 0.90 to 1.04; 200 digits, 2 studies; low-certainty evidence). No studies reported the incidence of compromised microcirculation requiring surgical or non-surgical therapy, or any systemic/other causes of microvascular insufficiency. There was no evidence of a clear difference between the LMWH and UFH groups in occurrence of arterial occlusion (RR 1.08, 95% CI 0.16 to 7.10; 54 participants, 1 study; very low-certainty evidence) or venous occlusion (RR 0.81, 95% CI 0.20 to 3.27; 54 participants, 1 study; very low-certainty evidence). Two studies reported adverse effects. The LMWH and UFH groups showed no evidence of a difference in wound bleeding (RR 0.53, 95% CI 0.23 to 1.23; 130 participants, 2 studies; low-certainty evidence), haematuria (RR 0.43, 95% CI 0.09 to 2.11; 130 participants, 2 studies; very low-certainty evidence), ecchymoses (RR 0.82, 95% CI 0.21 to 3.19; 130 participants, 2 studies; very low-certainty evidence), epistaxis (RR 0.27, 95% CI 0.03 to 2.32; 130 participants, 2 studies; very low-certainty evidence), gingival bleeding (RR 0.18, 95% CI 0.02 to 1.43; 130 participants, 2 studies; very low-certainty evidence), and faecal occult blood (RR 0.27, 95% CI 0.03 to 2.31; 130 participants, 2 studies; very low-certainty evidence). We could not pool data on coagulation abnormalities as varying definitions and tests were used in the three studies. One study compared LMWH versus no LMWH. The success rate of replantation, when analysed by digits, was reported as 91.2% success in the LMWH group and 82.1% in the control group (RR 1.11, 95% CI 0.93 to 1.33; 73 digits, 1 study; very low-certainty evidence). Compromised microcirculation requiring surgical re-exploration, analysed by digits, was 11.8% in the LMWH group and 17.9% in the control group (RR 0.86, 95% CI 0.21 to 3.58; 73 digits, 1 study; very low-certainty evidence). Compromised microcirculation requiring incision occurred in five out of 34 digits (14.7%) in the LMWH group and eight out of 39 digits (20.5%) in the control group (RR 0.72, 95% CI 0.26 to 1.98; 73 digits; very low-certainty evidence). Microvascular insufficiency due to arterial occlusion, analysed by digits, was 11.8% in the LMWH group and 17.9% in the control group (RR 0.66, 95% CI 0.21 to 2.05; 73 digits, 1 study; very low-certainty evidence), and venous occlusion was 14.7% in the LMWH group and 20.5% in the control (RR 0.72, 95% CI 0.26 to 1.98; 73 digits, 1 study; very low-certainty evidence). The study did not report complications or adverse effects. AUTHORS' CONCLUSIONS There is currently low to very low-certainty evidence, based on four RCTs, suggesting no evidence of a benefit from LMWH when compared to UFH on the success rates of replantation or affect microvascular insufficiency due to vessel occlusion (analysed by digit or participant). LMWH had similar success rates of replantation; and the incidence rate of venous and arterial microvascular insufficiency showed no evidence of a difference between groups when LMWH was compared to no LMWH (analysed by digit). Similar rates of complications and adverse effects were seen between UFH and LMWH. There was insufficient evidence to draw conclusions on any effect on coagulation when comparing LMWH to UFH or no LMWH. The certainty of the evidence was downgraded due to performance and reporting bias, as well as imprecision in the results. Further adequately powered studies are warranted to provide high-certainty evidence.
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Affiliation(s)
- Pei‐Tzu Lin
- Chang Gung Memorial Hospital, ChiayiDepartment of Pharmacy6, Sec West, Chia‐Pu RdPuzihChiayiTaiwan61363
- Chang Gung University of Science and TechnologyDepartment of Nursing2, Sec West, Chia‐Pu RdPuzihChiayiTaiwan61363
| | - Shu‐Hui Wang
- Far Eastern Memorial HospitalDepartment of Dermatology21, Sec 2, Nanya S RdBanciao DistrictNew TaipeiTaiwan22060
- Fu Jen Catholic UniversityGraduate Institute of Applied Science and Engineering, College of Science and Engineering510, Zhongzheng RdXinzhuang DistNew TaipeiTaiwan24205
| | - Ching‐Chi Chi
- Chang Gung UniversityCollege of MedicineTaoyuanTaiwan
- Chang Gung Memorial Hospital, LinkouDepartment of Dermatology5, Fuxing StGuishan DistTaoyuanTaiwan33305
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Abstract
Patients with major burn injury undergo a series of pathophysiologic changes that begin with a systemic inflammatory response and coagulation abnormalities, similar to those experienced by patients with sepsis or severe trauma. Coagulation changes in patients with burns are generally characterized by procoagulant abnormalities, but alterations in fibrinolysis and anticoagulation factors have also been observed. Around 40% of patients with major burn show changes on standard coagulation tests, and these have been related to the severity of the lesions, smoke inhalation, and administration of intensive fluid resuscitation therapy. Current surgical techniques for debridement of burn lesions are aggressive and associated with considerable blood loss. A fast-acting selective enzymatic debriding agent based on bromelain has been recently developed. NexoBrid is indicated for removing eschar in adults with deep partial- and full-thickness thermal burns. A potential effect of oral bromelain on hemostasis has been described, but it is uncertain whether NexoBrid application has a clinically relevant impact in this regard. We present the clinical case of a patient with burns who showed a coagulation abnormality shortly after NexoBrid use.
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Affiliation(s)
- Nuria Martín
- Anesthesia and Critical Care Department and Burn Center, Barcelona, Spain
| | - Patricia Guilabert
- Anesthesia and Critical Care Department and Burn Center, Barcelona, Spain
| | - Luis Abarca
- Anesthesia and Critical Care Department and Burn Center, Barcelona, Spain
| | - Gemma Mª Usua
- Anesthesia and Critical Care Department and Burn Center, Barcelona, Spain
| | - Jordi Serracanta
- Plastic Surgery Department and Burn Centre, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Maria J Colomina
- Anesthesia and Critical Care Department, Bellvitge University Hospital, Universitat de Barcelona, Spain
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Abstract
Cancer can be associated with several distinct coagulation defects which can lead to bleeding complications. The primary hyperfibrinolytic syndrome associated with acute promyelocytic leukemia has been well recognized and is one of the most severe bleeding disorders. Acquired hemophilia, while rare and not only seen in the oncology setting, can be triggered by a malignancy and must be promptly recognized in order to prevent catastrophic hemorrhage. Other, less serious coagulopathic states have been linked to cancer, including acquired von Willebrand disease. Finally, several anti-neoplastic drugs can alter hemostasis and increase the risk of bleeding. A good understanding of this field can help mitigate the risk of complications in the cancer patient.
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Affiliation(s)
- Simon Mantha
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Bahouth MN, Kraus P, Dane K, Plazas Montana M, Tsao W, Tabaac B, Jasem J, Schmidlin H, Einstein E, Streiff MB, Shanbhag S. Synthetic cannabinoid-associated coagulopathy secondary to long-acting anticoagulant rodenticides: Observational case series and management recommendations. Medicine (Baltimore) 2019; 98:e17015. [PMID: 31490385 PMCID: PMC6739027 DOI: 10.1097/md.0000000000017015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Synthetic cannabinoids have become increasingly popular drugs of abuse due to low cost and inability to detect these substances on routine drug screenings. In the United States, incidence of synthetic cannabinoid contamination with long-acting anticoagulant rodenticides (LAARs) resulting in coagulopathy and bleeding complications has been described.We sought to describe the natural history, management approach, and outcomes of bleeding secondary to synthetic cannabinoid-associated LAAR toxicity in an observational case series of patients evaluated at an urban academic medical system.We conducted an observational study of patients with suspected exposure to LAAR-contaminated synthetic cannabinoids and associated bleeding treated within the Johns Hopkins Health System.In this 16 subject cohort, hematuria was the most common bleeding symptom at presentation. The majority of the cohort (75%) had international normalized ratio (INR) > 9.6 at presentation. Of the 13 patients with brodifacoum testing, 12/13 (92%) were positive. Twelve patients (75%) had at least 1 INR value below 2 within 24 hours of the first INR measurement. Of this cohort, 1/16 (6%) died in hospital. The median length of hospital stay was 4 days, (interquartile range = 3-6). The average cost of pharmacological treatment for coagulopathy during inpatient hospitalization was $5300 (range, $2241-$8086).In patients presenting with unexplained coagulopathy it is important for emergency department providers to consider LAAR intoxication and consider formal testing for brodifacoum to assist with treatment planning. Use of a standardized management algorithm including intravenous/oral vitamin K, judicious use of blood products and close laboratory monitoring is essential to optimizing outcomes.
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Affiliation(s)
| | | | | | | | - William Tsao
- Department of Neurology, Johns Hopkins School of Medicine
| | | | - Jagar Jasem
- Department of Hematology, Johns Hopkins Hospital
| | | | - Evan Einstein
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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Berger M, de Moraes JA, Beys-da-Silva WO, Santi L, Terraciano PB, Driemeier D, Cirne-Lima EO, Passos EP, Vieira MAR, Barja-Fidalgo TC, Guimarães JA. Renal and vascular effects of kallikrein inhibition in a model of Lonomia obliqua venom-induced acute kidney injury. PLoS Negl Trop Dis 2019; 13:e0007197. [PMID: 30763408 PMCID: PMC6392336 DOI: 10.1371/journal.pntd.0007197] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 02/27/2019] [Accepted: 10/30/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Lonomia obliqua venom is nephrotoxic and acute kidney injury (AKI) is the main cause of death among envenomed victims. Mechanism underlying L. obliqua-induced AKI involves renal hypoperfusion, inflammation, tubular necrosis and loss of glomerular filtration and tubular reabsorption capacities. In the present study, we aimed to investigate the contribution of kallikrein to the hemodynamic instability, inflammation and consequent renal and vascular impairment. METHODOLOGY/PRINCIPAL FINDINGS Addition of L. obliqua venom to purified prekallikrein and human plasma in vitro or to vascular smooth muscle cells (VSMC) in culture, was able to generate kallikrein in a dose-dependent manner. Injected in rats, the venom induced AKI and increased kallikrein levels in plasma and kidney. Kallikrein inhibition by aprotinin prevented glomerular injury and the decrease in glomerular filtration rate, restoring fluid and electrolyte homeostasis. The mechanism underlying these effects was associated to lowering renal inflammation, with decrease in pro-inflammatory cytokines and matrix metalloproteinase expression, reduced tubular degeneration, and protection against oxidative stress. Supporting the key role of kallikrein, we demonstrated that aprotinin inhibited effects directly associated with vascular injury, such as the generation of intracellular reactive oxygen species (ROS) and migration of VSMC induced by L. obliqua venom or by diluted plasma obtained from envenomed rats. In addition, kallikrein inhibition also ameliorated venom-induced blood incoagulability and decreased kidney tissue factor expression. CONCLUSIONS/SIGNIFICANCE These data indicated that kallikrein and consequently kinin release have a key role in kidney injury and vascular remodeling. Thus, blocking kallikrein may be a therapeutic alternative to control the progression of venom-induced AKI and vascular disturbances.
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Affiliation(s)
- Markus Berger
- Laboratório de Bioquímica Farmacológica, Centro de Pesquisa Experimental (CPE), Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Porto Alegre, RS, Brazil
- Programa de Pós-Graduação em Ciências de Saúde: Ginecologia e Obstetrícia (PPGGO), Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
- * E-mail:
| | - João Alfredo de Moraes
- Laboratório de Biologia REDOX, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
- Laboratory of Cellular and Molecular Pharmacology, IBRAG, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - Walter Orlando Beys-da-Silva
- Laboratório de Bioquímica Farmacológica, Centro de Pesquisa Experimental (CPE), Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Porto Alegre, RS, Brazil
- Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Lucélia Santi
- Laboratório de Bioquímica Farmacológica, Centro de Pesquisa Experimental (CPE), Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Porto Alegre, RS, Brazil
- Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Paula Barros Terraciano
- Programa de Pós-Graduação em Ciências de Saúde: Ginecologia e Obstetrícia (PPGGO), Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
- Laboratório de Embriologia e Diferenciação Celular, Centro de Pesquisa Experimental (CPE), Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Porto Alegre, RS, Brazil
| | - David Driemeier
- Departamento de Patologia Clínica Veterinária, Faculdade de Medicina Veterinária, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Elizabeth Obino Cirne-Lima
- Programa de Pós-Graduação em Ciências de Saúde: Ginecologia e Obstetrícia (PPGGO), Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
- Laboratório de Embriologia e Diferenciação Celular, Centro de Pesquisa Experimental (CPE), Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Porto Alegre, RS, Brazil
| | - Eduardo Pandolfi Passos
- Programa de Pós-Graduação em Ciências de Saúde: Ginecologia e Obstetrícia (PPGGO), Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
- Laboratório de Embriologia e Diferenciação Celular, Centro de Pesquisa Experimental (CPE), Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Porto Alegre, RS, Brazil
| | - Maria Aparecida Ribeiro Vieira
- Laboratório de Fisiologia Renal, Departamento de Fisiologia e Biofísica, Instituto de Ciências Biológicas (ICB), Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Thereza Christina Barja-Fidalgo
- Laboratory of Cellular and Molecular Pharmacology, IBRAG, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - Jorge Almeida Guimarães
- Laboratório de Bioquímica Farmacológica, Centro de Pesquisa Experimental (CPE), Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Porto Alegre, RS, Brazil
- Programa de Pós-Graduação em Biologia Celular de Molecular (PPGBCM), Centro de Biotecnologia (Cbiot-UFRGS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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Shanbhag S, Dane KE, Streiff MB. "The 700-Dollar Vitamin": The Epidemic of Synthetic Cannabinoid-Associated Coagulopathy. A Case Study of Excessive Generic Drug Prices in the American Health Care System. Mayo Clin Proc 2019; 94:199-201. [PMID: 30711118 DOI: 10.1016/j.mayocp.2018.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 10/04/2018] [Accepted: 10/09/2018] [Indexed: 11/19/2022]
Affiliation(s)
| | - Kathryn E Dane
- The Johns Hopkins Hospital Department of Pharmacy, Baltimore, MD
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Abstract
BACKGROUND In March and April 2018, more than 150 patients presented to hospitals in Illinois with coagulopathy and bleeding diathesis. Area physicians and public health organizations identified an association between coagulopathy and synthetic cannabinoid use. Preliminary tests of patient serum samples and drug samples revealed that brodifacoum, an anticoagulant, was the likely adulterant. METHODS We reviewed physician-reported data from patients admitted to Saint Francis Medical Center in Peoria, Illinois, between March 28 and April 21, 2018, and included in a case series adult patients who met the criteria used to diagnose synthetic cannabinoid-associated coagulopathy. A confirmatory anticoagulant poisoning panel was ordered at the discretion of the treating physician. RESULTS A total of 34 patients were identified as having synthetic cannabinoid-associated coagulopathy during 45 hospitalizations. Confirmatory anticoagulant testing was performed in 15 of the 34 patients, and superwarfarin poisoning was confirmed in the 15 patients tested. Anticoagulant tests were positive for brodifacoum in 15 patients (100%), difenacoum in 5 (33%), bromadiolone in 2 (13%), and warfarin in 1 (7%). Common symptoms at presentation included gross hematuria in 19 patients (56%) and abdominal pain in 16 (47%). Computed tomography was performed to evaluate abdominal pain and revealed renal abnormalities in 12 patients. Vitamin K1 (phytonadione) was administered orally in all 34 patients and was also administered intravenously in 23 (68%). Red-cell transfusion was performed in 5 patients (15%), and fresh-frozen plasma infusion in 19 (56%). Four-factor prothrombin complex concentrate was used in 1 patient. One patient died from complications of spontaneous intracranial hemorrhage. CONCLUSIONS Our data indicate that superwarfarin adulterants of synthetic cannabinoids can lead to clinically significant coagulopathy. In our series, in most of the cases in which the patient presented with bleeding diathesis, symptoms were controlled with the use of vitamin K1 replacement therapy. The specific synthetic cannabinoid compounds are not known.
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Affiliation(s)
- Amar H Kelkar
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Nichole A Smith
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Annia Martial
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Harsha Moole
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Michael D Tarantino
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Jonathan C Roberts
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
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Sano-Martins IS, González C, Anjos IV, Díaz J, Gonçalves LRC. Effectiveness of Lonomia antivenom in recovery from the coagulopathy induced by Lonomia orientoandensis and Lonomia casanarensis caterpillars in rats. PLoS Negl Trop Dis 2018; 12:e0006721. [PMID: 30114211 PMCID: PMC6112677 DOI: 10.1371/journal.pntd.0006721] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/28/2018] [Accepted: 07/26/2018] [Indexed: 11/18/2022] Open
Abstract
In South America, accidental contact with Lepidoptera larvae can produce a diversity of reactions that vary from dermatological problems to severe hemorrhagic syndromes, such as those caused by contact with caterpillars of the genus Lonomia (Saturniidae). Lonomia venom can alter the hemostatic system and lead to renal failure, internal and brain bleeding, and in severe cases, death. The only specific treatment available for these envenomations is the Lonomia Antivenom (LAV) produced by the Butantan Institute, in Brazil, using an extract of Lonomia obliqua scoli as the antigen. LAV has been used to treat exposure to other Lonomia species across South America. However, no experimental studies have been performed to test the efficacy of LAV in neutralizing the venom of species other than L. obliqua found in Southern Brazil. In this study, we tested the effectiveness of LAV in reversing the hemostatic disturbances induced by injecting Lonomia casanarensis (Lca) and Lonomia orientoandensis (Lor) scolus extracts into rats and compared the effects to the case of L. obliqua (Lob) scolus extract-induced envenomation. Lca and Lor caterpillars were collected in Colombia, and some of them were reared to adults for identification. The Minimum Defibrinating Doses (MDD) of Lca and Lor were estimated. Rats were injected (i.d.) with a dose of 3 MDD per rat of each scolus extract and treated (i.v.) with 1.5 mL of LAV or 1.5 mL of saline. Twenty-four hours after the treatment, the fibrinogen levels and platelet counts had recovered to the hemostatic levels in the groups treated with LAV. The groups treated with the saline solution had fibrinogen levels and platelet counts at non-hemostatic levels. Thromboelastometric analyses confirmed these results. In conclusion, the results showed that LAV is effective at neutralizing the envenomation induced by Lca and Lor spine extracts in rats and restoring hemostasis.
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Affiliation(s)
- Ida S. Sano-Martins
- Laboratório de Fisiopatologia, Instituto Butantan, São Paulo–SP, Brazil
- * E-mail: ,
| | - Camila González
- Centro de Investigaciones en Microbiología y Parasitología Tropical (CIMPAT), Facultad de Ciencias, Universidad de los Andes, Bogotá, Colombia
| | | | - Juana Díaz
- Centro de Investigaciones en Microbiología y Parasitología Tropical (CIMPAT), Facultad de Ciencias, Universidad de los Andes, Bogotá, Colombia
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25
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Hussain N, Hussain F, Haque D, Saeed S, Jesudas R. An Outbreak of Brodifacoum Coagulopathy Due to Synthetic Marijuana in Central Illinois. Mayo Clin Proc 2018; 93:957-958. [PMID: 29976379 DOI: 10.1016/j.mayocp.2018.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/08/2018] [Indexed: 11/25/2022]
Affiliation(s)
| | | | - Danish Haque
- Windsor University School of Medicine, St Kitts and Nevis, West Indies, Cayan
| | - Sarah Saeed
- University of Illinois College of Medicine, Peoria, IL
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26
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Zeng Z, Huo X, Zhang Y, Xiao Z, Zhang Y, Xu X. Lead exposure is associated with risk of impaired coagulation in preschool children from an e-waste recycling area. Environ Sci Pollut Res Int 2018; 25:20670-20679. [PMID: 29752673 DOI: 10.1007/s11356-018-2206-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 05/01/2018] [Indexed: 02/05/2023]
Abstract
Environmental lead exposure leads to various deleterious effects on multiple organs and systems, including the hematopoietic system. To explore the effects of lead exposure on platelet indices in preschool children from an informal, lead-contaminated electronic waste (e-waste) recycling area, we collected venous blood samples from 466 preschool children (331 from an e-waste area (Guiyu) and 135 from a non-e-waste area (Haojiang)). Child blood lead levels (BLLs) were determined by graphite furnace atomic absorption spectrophotometry, while platelet indices were quantified using a Sysmex XT-1800i hematology analyzer. Higher blood lead levels are observed in e-waste lead-exposed preschool children. Significant relationships between high blood lead levels (exceeding current health limits) and elevated platelet count (PLT), plateletcrit (PCT), mean platelet volume (MPV), and platelet large cell ratio (P-LCR) were also uncovered. Furthermore, the median PLT and PCT levels of children from the exposed group both exceeded the respective recommended maximum reference range value, whereas the reference group did not. Location of child residence in Guiyu and BLLs were both risk factors related to platelet indices. These results suggest that high blood lead exposure from e-waste recycling may increase the risk of an amplified coagulation process through the activation of platelets in preschool children.
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Affiliation(s)
- Zhijun Zeng
- Laboratory of Environmental Medicine and Developmental Toxicology, Provincial Key Laboratory of Infectious Diseases and Molecular Immunopathology, Shantou University Medical College, Shantou, 515041, China
| | - Xia Huo
- School of Environment, Guangzhou Key Laboratory of Environmental Exposure and Health, Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou, 510632, China
| | - Yu Zhang
- Laboratory of Environmental Medicine and Developmental Toxicology, Provincial Key Laboratory of Infectious Diseases and Molecular Immunopathology, Shantou University Medical College, Shantou, 515041, China
| | - Zhehong Xiao
- Laboratory of Environmental Medicine and Developmental Toxicology, Provincial Key Laboratory of Infectious Diseases and Molecular Immunopathology, Shantou University Medical College, Shantou, 515041, China
| | - Yuling Zhang
- Laboratory of Environmental Medicine and Developmental Toxicology, Provincial Key Laboratory of Infectious Diseases and Molecular Immunopathology, Shantou University Medical College, Shantou, 515041, China
| | - Xijin Xu
- Laboratory of Environmental Medicine and Developmental Toxicology, Provincial Key Laboratory of Infectious Diseases and Molecular Immunopathology, Shantou University Medical College, Shantou, 515041, China.
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, 515041, China.
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Abstract
RATIONALE Tigecycline is the first member of the glycylcycline family. There are rarely reports of tigecycline causing coagulopathy and hypofibrinogenemia until now. We report a case on tigecycline-associated coagulopathy and hypofibrinogenemia and discuss the characteristics of the adverse reaction. PATIENT CONCERNS A 47-year-old male patient with severe acute cholangitis who developed sepsis was treated with a high dosage (100 mg twice daily) of tigecycline. He experienced coagulopathy and hypofibrinogenemia as substantiated by increased levels of prolonged prothrombin time (PT), the international normalized ratio (INR) and activated partial thromboplastin time (APTT), and in particular, the fibrinogen (FIB) levels obviously decreased. DIAGNOSES Coagulopathy and hypofibrinogenemia. INTERVENTIONS We discontinued tigecycline and gave the patient several blood products to prevent spontaneous bleeding. OUTCOMES The adverse reaction disappeared after the withdrawal of tigecycline. After 30 days of hospitalization, the patient discharged with symptom free. LESSONS We suggest that coagulation parameters should be closely monitored in patients treated with tigecycline, specifically in patients who may be renal insufficiency, female or use the high-dose.
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Affiliation(s)
- Xiaoqin Wu
- Department of Pharmacy, Ruijin Hospital Suzhou Branch Affiliated to Shanghai Jiaotong University School of Medicine
| | - Ping Zhao
- Department of Pharmacy, Jiangsu Shengze Hospital, Suzhou
| | | | - Xiuhong Zhang
- Department of Pharmacy, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, PR China
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28
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Abstract
Advanced cancer and life-limiting chronic nonmalignant diseases are associated with a number of hematological problems. Anemia and coagulation disorders, principally venous thrombosis and thrombocytopenia, are most commonly observed. Patients undergoing chemotherapy and bone marrow transplant have unique problems that include neutropenias and chemotherapy-induced drug toxicities, which will not be covered in this article.
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Affiliation(s)
- Mellar P Davis
- The Harrny R. Horvitz Center for Palliative Medicine, Cleveland Taussig Cancer Center, Cleveland, Ohio, USA
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29
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Ponce RA, Visich JE, Heffernan JK, Lewis KB, Pederson S, Lebel E, Andrews-Jones L, Elliott G, Palmer TE, Rogge MC. Preclinical Safety and Pharmacokinetics of Recombinant Human Factor XIII. Toxicol Pathol 2016; 33:495-506. [PMID: 16036868 DOI: 10.1080/01926230490966247] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Factor XIII (FXIII) is a thrombin-activated protransglutaminase responsible for fibrin clot stabilization and longevity. Deficiency in FXIII is associated with diffuse bleeding and wound-healing disorders in humans. This report summarizes results from several studies conducted in adult cynomolgus monkeys ( M. fascicularis) to evaluate the safety and pharmacokinetics of recombinant human factor XIII A2 dimer (rFXIII). Intravenous slow bolus injection of rFXIII resulted in the expected formation of the heterotetramer rA2cnB2, prolonged circulating half-life (5–7 days), and increased plasma transglutaminase activity. Recombinant FXIII was well tolerated as a single dose up to 20 mg/kg rFXIII (2840 U/kg), as repeated daily doses up to 6 mg/kg (852 U/kg) for 14 days, and as 3 repeated doses of 8 mg/kg (1136 U/kg) separated by 14 days. Overt toxicity occurred after a single intravenous injection of ≥ 22.5 mg/kg rFXIII (3150 U/kg), or with 2 doses of =12.5 mg/kg (1775 U/kg) administered within 72 hours. The rFXIII-mediated toxicity was expressed as an acute systemic occlusive coagulopathy. Evaluation of plasma samples from dosed animals demonstrated formation of cross-linked fibrin/fibrinogen oligomers and higher-order protein aggregates, which are hypothesized to be responsible for the observed vessel occlusion and associated embolic sequelae. These results demonstrate that rFXIII-mediated toxicity results from exaggerated pharmacological activity of the molecule at supraphysiological concentrations. The absence of observed toxicological effect with repeated intravenous doses up to 8 mg/kg (1136 U/kg) was used to support an initial clinical dose range of 0.014 to 0.35 mg/kg (2–50 U/kg).
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Affiliation(s)
- Rafael A Ponce
- ZymoGenetics Inc., 1201 Eastlake Avenue E., Seattle, WA 98102, USA.
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30
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Zhang C, Liu Y, Liu G. [Hypofibrinogenemia caused by hemocoagulase after endoscopic sinus surgery: a case report]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2016; 30:70-71. [PMID: 27197462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A 61 year-old male patient, plasma fibrinogen level was 2.98 g/L, endoscopic sinus surgery was performed under general anesthesia for polypoid of uncinate process with mycotic maxillary sinusitis. Hemocoagulase were given in pre- and post-operative for treatment. The patient was found postoperative drain blood continuously since 3 days after surgery, when the dose of hemocoagulase reach 26 KU, and fibrinogen determined in Plasma was 0.48 g/L. Coagulation returned to normal and nasal bleeding stopped after discontinuation of the hemocoagulase and supplement with fibrinogen.
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31
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Płusa T, Smędzik K. [The threat of snake and scorpion venoms]. Pol Merkur Lekarski 2015; 39:167-172. [PMID: 26449581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Venoms of snakes and scorpions pose a significant threat to the health and life of humans. The speed and range of their actions causes damage of the organ responsible for the maintenance of vital signs. Venomous snake venoms cause blood clotting disorders, tissue necrosis and hemolysis, and the release of a number of proinflammatory cytokines and impair antibody synthesis. Availability of antitoxins is limited and in the most cases supportive treatment is recommended. In turn, the venom of scorpions beside intestinal symptoms cause significant impairment of neuromuscular conduction, causing severe respiratory disorders. Action venom poses a particular threat to sensitive patients. The degree of threat to life caused by the venom of snakes and scorpions authorizes the treatment of these substances as a potential biological weapon.
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Affiliation(s)
- Tadeusz Płusa
- Military Medical Institute in Warsaw, Poland, Department of Internal Medicine, Pulmonology and Allergology, Central Clinical Hospital of the Ministry of National Defense
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32
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Isidori AM, Minnetti M, Sbardella E, Graziadio C, Grossman AB. Mechanisms in endocrinology: The spectrum of haemostatic abnormalities in glucocorticoid excess and defect. Eur J Endocrinol 2015; 173:R101-13. [PMID: 25987566 DOI: 10.1530/eje-15-0308] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 05/14/2015] [Indexed: 12/28/2022]
Abstract
Glucocorticoids (GCs) target several components of the integrated system that preserves vascular integrity and free blood flow. Cohort studies on Cushing's syndrome (CS) have revealed increased thromboembolism, but the pathogenesis remains unclear. Lessons from epidemiological data and post-treatment normalisation time suggest a bimodal action with a rapid and reversible effect on coagulation factors and an indirect sustained effect on the vessel wall. The redundancy of the steps that are potentially involved requires a systematic comparison of data from patients with endogenous or exogenous hypercortisolism in the context of either inflammatory or non-inflammatory disorders. A predominant alteration in the intrinsic pathway that includes a remarkable rise in factor VIII and von Willebrand factor (vWF) levels and a reduction in activated partial thromboplastin time appears in the majority of studies on endogenous CS. There may also be a rise in platelets, thromboxane B2, thrombin-antithrombin complexes and fibrinogen (FBG) levels and, above all, impaired fibrinolytic capacity. The increased activation of coagulation inhibitors seems to be compensatory in order to counteract disseminated coagulation, but there remains a net change towards an increased risk of venous thromboembolism (VTE). Conversely, GC administered in the presence of inflammation lowers vWF and FBG, but fibrinolytic activity is also reduced. As a result, the overall risk of VTE is increased in long-term users. Finally, no studies have assessed haemostatic abnormalities in patients with Addison's disease, although these may present as a consequence of bilateral adrenal haemorrhage, especially in the presence of antiphospholipid antibodies or anticoagulant treatments. The present review aimed to provide a comprehensive overview of the complex alterations produced by GCs in order to develop better screening and prevention strategies against bleeding and thrombosis.
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Affiliation(s)
- Andrea M Isidori
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Marianna Minnetti
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Emilia Sbardella
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Chiara Graziadio
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Ashley B Grossman
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
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33
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Biasucci DG, Zamparelli R, Martinelli L, Corrado M, Antoniucci E, Cavaliere F. Life-threatening hemorrhage after cardiopulmonary bypass with bilivarudin. Minerva Anestesiol 2015; 81:700-701. [PMID: 25644992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- D G Biasucci
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart in Rome, Rome, Italy -
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34
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Abstract
Long-term low dose oestrogen therapy has a protective effect on bone mineral content in the post-menopausal or castrated female. As yet the only obvious clinical side effect of such therapy has been transient leg muscle cramps. Several biochemical side effects could be observed. Low dose mestranol caused a persistent elevation of factor VII and a dose-dependent increase in both factors VII and X was observed using oestriol hemisuccinate. Such effects are more likely to be dose-related than related to the type of oestrogen prescribed. Effects of oestrogens on lipids, and cholesterol in particular, may be dose-related also. Changes in blood pressure in post-menopausal women are more likely to be related to obesity than to oestrogen treatment which would seem to have a protective effect against weight increase. No marked changes in the mean risk score for ischaemic heart disease could be detected during oestrogen treatment.
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35
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Bababunmi EA, Thabrew I, Bassir O. Aflatoxin-induced coagulopathy in different nutritionally classified animal species. World Rev Nutr Diet 2015; 34:161-81. [PMID: 6766600 DOI: 10.1159/000403311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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36
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Miyazaki Y. [ATRAC therapy]. Nihon Rinsho 2015; 73 Suppl 2:628-631. [PMID: 25831836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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37
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Fehre K, Plössnig M, Schuler J, Hofer-Dückelmann C, Rappelsberger A, Adlassnig KP. Detecting, Monitoring, and Reporting Possible Adverse Drug Events Using an Arden-Syntax-based Rule Engine. Stud Health Technol Inform 2015; 216:950. [PMID: 26262252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The detection of adverse drug events (ADEs) is an important aspect of improving patient safety. The iMedication system employs predefined triggers associated with significant events in a patient's clinical data to automatically detect possible ADEs. We defined four clinically relevant conditions: hyperkalemia, hyponatremia, renal failure, and over-anticoagulation. These are some of the most relevant ADEs in internal medical and geriatric wards. For each patient, ADE risk scores for all four situations are calculated, compared against a threshold, and judged to be monitored, or reported. A ward-based cockpit view summarizes the results.
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Affiliation(s)
| | | | - Jochen Schuler
- Paracelsus Medical University Salzburg - Private Foundation, Salzburg, Austria
| | | | - Andrea Rappelsberger
- Section for Medical Expert and Knowledge-Based Systems, CeMSIIS, Medical University of Vienna, Vienna, Austria
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38
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Chen J, Zhang R, Wang W, Li W. [A case report on severe coagulations dysfunction induced by interaction of Warfarin and gestgestrinone]. Zhonghua Xin Xue Guan Bing Za Zhi 2014; 42:1055. [PMID: 25623355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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39
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Affiliation(s)
- Christiane S Hartog
- Department of Anaesthesiology and Intensive Care Medicine, Centre for Sepsis Care and Control, Jena University Hospital, D-07747 Jena, Germany
| | - Charles Natanson
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD 20892, USA
| | - Junfeng Sun
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD 20892, USA
| | - Harvey G Klein
- Department of Transfusion Medicine, National Institutes of Health, Bethesda
| | - Konrad Reinhart
- Department of Anaesthesiology and Intensive Care Medicine, Centre for Sepsis Care and Control, Jena University Hospital, D-07747 Jena, Germany
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40
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Hale SF, Lesar TS. Interaction of vitamin K antagonists and trimethoprim-sulfamethoxazole: ignore at your patient's risk. ACTA ACUST UNITED AC 2014; 29:53-60. [PMID: 24231121 DOI: 10.1515/dmdi-2013-0049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 10/17/2013] [Indexed: 11/15/2022]
Abstract
The aim of the study was to summarize available literature regarding the interaction between vitamin K antagonists (VKAs) and trimethoprim-sulfamethoxazole (co-trimoxazole, TMP-SMX), and to provide recommendations for managing patient risk from this interaction. Data sources were English-language publications in the medical literature and Internet databases. Relevant publications that directly or indirectly addressed the VKA-TMP-SMX interaction were selected and reviewed. The mechanism of the VKA-TMP-SMX interaction, frequency of concurrent use, effect on international normalized ratio (INR), increased risk of bleeding, and strategies for risk reduction are summarized. The concurrent use of VKA and TMP/SMX rapidly and consistently raises INR and is associated with a two- to five-fold increase in bleeding. Concurrent use of VKA and TMP-SMX should be avoided when possible. When VKA and TMP-SMX are co-prescribed, VKA dose reduction is usually required. Patient education as well as early and frequent INR monitoring is recommended to reduce risk from this interaction.
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41
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Yamashita KM, Alves AF, Barbaro KC, Santoro ML. Bothrops jararaca venom metalloproteinases are essential for coagulopathy and increase plasma tissue factor levels during envenomation. PLoS Negl Trop Dis 2014; 8:e2814. [PMID: 24831016 PMCID: PMC4022520 DOI: 10.1371/journal.pntd.0002814] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 03/10/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND/AIMS Bleeding tendency, coagulopathy and platelet disorders are recurrent manifestations in snakebites occurring worldwide. We reasoned that by damaging tissues and/or activating cells at the site of the bite and systemically, snake venom toxins might release or decrypt tissue factor (TF), resulting in activation of blood coagulation and aggravation of the bleeding tendency. Thus, we addressed (a) whether TF and protein disulfide isomerase (PDI), an oxireductase involved in TF encryption/decryption, were altered in experimental snake envenomation; (b) the involvement and significance of snake venom metalloproteinases (SVMP) and serine proteinases (SVSP) to hemostatic disturbances. METHODS/PRINCIPAL FINDINGS Crude Bothrops jararaca venom (BjV) was preincubated with Na2-EDTA or AEBSF, which are inhibitors of SVMP and SVSP, respectively, and injected subcutaneously or intravenously into rats to analyze the contribution of local lesion to the development of hemostatic disturbances. Samples of blood, lung and skin were collected and analyzed at 3 and 6 h. Platelet counts were markedly diminished in rats, and neither Na2-EDTA nor AEBSF could effectively abrogate this fall. However, Na2-EDTA markedly reduced plasma fibrinogen consumption and hemorrhage at the site of BjV inoculation. Na2-EDTA also abolished the marked elevation in TF levels in plasma at 3 and 6 h, by both administration routes. Moreover, increased TF activity was also noticed in lung and skin tissue samples at 6 h. However, factor VII levels did not decrease over time. PDI expression in skin was normal at 3 h, and downregulated at 6 h in all groups treated with BjV. CONCLUSIONS SVMP induce coagulopathy, hemorrhage and increased TF levels in plasma, but neither SVMP nor SVSP are directly involved in thrombocytopenia. High levels of TF in plasma and TF decryption occur during snake envenomation, like true disseminated intravascular coagulation syndrome, and might be implicated in engendering bleeding manifestations in severely-envenomed patients.
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Affiliation(s)
- Karine M. Yamashita
- Laboratory of Pathophysiology, Institute Butantan, São Paulo, São Paulo, Brazil
- Department of Clinical Medicine, School of Medicine, University of São Paulo, São Paulo, São Paulo, Brazil
| | - André F. Alves
- Laboratory of Pathophysiology, Institute Butantan, São Paulo, São Paulo, Brazil
| | - Katia C. Barbaro
- Immunopathology, Institute Butantan, São Paulo, São Paulo, Brazil
| | - Marcelo L. Santoro
- Laboratory of Pathophysiology, Institute Butantan, São Paulo, São Paulo, Brazil
- Department of Clinical Medicine, School of Medicine, University of São Paulo, São Paulo, São Paulo, Brazil
- * E-mail: ,
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Edavettal M, Rogers A, Rogers F, Horst M, Leng W. Prothrombin complex concentrate accelerates international normalized ratio reversal and diminishes the extension of intracranial hemorrhage in geriatric trauma patients. Am Surg 2014; 80:372-376. [PMID: 24887668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Warfarin therapy increases the incidence intracranial hemorrhage (ICH), especially in the geriatric population. Timely reversal of international normalized ratio (INR) is integral in the management of these patients for whom fresh frozen plasma (FFP) with vitamin K is the standard of treatment. We hypothesized that implementing a protocol that used prothrombin complex concentrate (PCC) would reverse INR values more swiftly and decrease the amount of FFP administered. In November 2011, a protocol was implemented for administering PCC to the geriatric population on warfarin admitted for life-threatening bleeds. These patients received 25 IU/kg ideal body weight of a three-factor PCC (Profilnine SD) if their INR was over 1.5 or greater. FFP was given if follow-up INR revealed an INR of 1.5 or greater. Retrospectively the data from 29 patients who received PCC were compared with a historical control group of 34 patients. Protocol use resulted in a significantly faster INR reversal (PCC: 151.6 ± 84.3 minutes vs control: 485.0 ± 321 minutes; P < 0.001), time to achieve an INR less than 1.5 (PCC: 484 ± 242 minutes vs control: 971 ± 1208 minutes; P = 0.036), and less FFP administered (PCC: 1.3 ± 1.0 vs control:3.3 ± 1.5; P < 0.001). PCC patients had a decreased incidence of progression of their ICH (PCC: 17.2% vs control: 44.2%; P = 0.031). Rapid reversal of coagulopathy in geriatric patients on warfarin is vital to limit the extent of ICH. PCC allows a much more rapid reversal than standard treatment with only FFP and vitamin K. Adopting such a protocol is associated not only with a more rapid reversal and less FFP use, but also less patients went on to extend their head bleeds.
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Liu L, Xie XT. [Advances on the role of pegaspargase in the treatment of childhood leukemia]. Zhongguo Dang Dai Er Ke Za Zhi 2014; 16:155-160. [PMID: 24568909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The chemotherapy agent L-asparaginase (L-asp) has been an important part of acute lymphoblastic leukemia therapy for over 30 years. It is evident that L-asp has a long-term curative effect. However, L-asp is associated with high incidence of adverse reactions. This has prompted the development of pegylated asparaginase (PEG-asp), which has undergone extensive testing. Apparently, PEG-asp has a prolonged half-life with a better tolerance profile while retaining the antileukemic effect. In this review, we attempt to outline the history of clinical application of L-asp, the pharmacological and clinical potential of various preparations of L-asp, the development of PEG-asp, and the clinical application and adverse events of PEG-asp. The literatures reviewed in this article is collected through online search of the major databases both in English and Chinese.
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Affiliation(s)
- Li Liu
- Department of Pediatrics, Tongji Hospital, Tongji University, Shanghai 200065, China.
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Sychev DA, Ivashchenko DV, Rusin IV. [Impact of pharmacogenetic testing on the risk of bleedings and excessive hypocoagulation episodes in the use of warfarin: the first meta-analysis of Russian prospective studies]. TERAPEVT ARKH 2014; 86:64-71. [PMID: 24864470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
AIM To perform a meta-analysis of Russian prospective studies comparing the pharmacogenetic versus conventional warfarin dosing procedures. MATERIALS AND METHODS Publications were sought in the PubMed and eLibrary through September 30, 2013. Seven prospective studies comparing the pharmacogenetic method of warfarin dosing with consideration for CYP2C9, VKORC1, and CYP4F2 gene polymorphisms with the conventional one were selected. The number of minor and major bleedings and hypocoagulation episodes was taken into account. The meta-analysis was performed using MIX Pro 2.0. RESULTS Six studies compared the number of bleedings in experimental and control groups. Analysis of statistical heterogeneity showed that extraneous factors did not influence the results of meta-analysis. The pharmacogenetic approach decreases the risk of bleeding. The pooled odds ratio (OR) was significant for minor (OR = 0.49; 95% confidence interval (CI), 0.31 to 0.78; p = 0.002), major (OR = 0.07; 95% CI, 0.008 to 0.54; p = 0.01) and both minor and major bleedings (OR = 0.49; 95% CI, 0.31 to 0.78; p = 0.002). Six studies estimated the number of hypocoagulation cases. There was no evidence for statistical heterogeneity (Q-test p = 0.13; I2 = 40%). Four studies showed a group difference in the number of hypocoagulation cases (p < 0.05). The pooled OR was 0.21 (95% CI, 0.15 to 0.3; p < 0.01). The pharmacogenetic dosing groups had fewer hypocoagulation episodes than the control ones. CONCLUSION The pharmacogenetic approach decreases the risk of bleeding and the episodes of hypocoagulation. The performed meta-analysis covered only two randomized trials. Improving the metalogic quality and statistical power of Russian studies will be able to get more reliable data on the impact of pharmacogenetic testing on clinical outcomes during warfarin therapy.
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Kcentra: a 4-factor prothrombin complex concentrate for reversal of warfarin anticoagulation. Med Lett Drugs Ther 2013; 55:53-4. [PMID: 23836371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Abstract
BACKGROUND The success of digital replantation is highly dependent on the patency of the repaired vessels after microvascular anastomosis. Antithrombotic agents are frequently used for preventing vascular occlusion. Low molecular weight heparin (LMWH) has been reported to be as effective as unfractionated heparin (UFH) in peripheral vascular surgery, but with fewer adverse effects. Its benefit in microvascular surgery such as digital replantation is unclear. OBJECTIVES To assess whether subcutaneous LMWH treatment improves the salvage rate of the digits in patients with digital replantation after traumatic amputation. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (October 2012), CENTRAL (2012, Issue 10) and trials databases. In addition, the authors searched PubMed, CNKI (China National Knowledge Infrastructure) and CEPS (Chinese Electronic Periodical Services), and sought additional trials from reference lists of relevant publications. SELECTION CRITERIA We selected randomised or quasi-randomised controlled trials of LMWH in patients who received digital replantation. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of the included trials. Disagreements were resolved by discussion. MAIN RESULTS Two randomised trials involving 114 patients with at least 122 replanted digits met the inclusion criteria and were included. Both trials compared the efficacy and safety of LMWH with UFH. We found no trials comparing LMWH with placebo or other anticoagulants. The data from the two included studies were insufficient for meta-analysis. The overall success rate of replantation did not differ between the LMWH and UFH groups, 92.3% versus 89.2% in one trial (risk ratio (RR) 1.03; 95% confidence interval (CI) 0.87 to 1.22) and 94.3% versus 94.15% in the other trial (RR 1.00; 95% CI 0.89 to 1.13). The incidence of both postoperative arterial and venous insufficiency were reported in one trial and did not significantly differ between the LMWH and UFH groups (RR 1.08; 95% CI 0.16 to 7.10 and RR 0.81; 95% CI 0.20 to 3.27, respectively). Direct and indirect causes of microvascular insufficiency were not reported in the trials. Different methods were used to monitor the adverse effects related to anticoagulation in the two trials. Bleeding tendency was monitored for the LMWH and UFH groups in one trial and was reported by the incidence of wound haemorrhage (11.5% versus 17.9%; RR 0.65; 95% CI 0.17 to 2.44), ecchymoses (3.8% versus 10.7%; RR 0.36; 95% CI 0.04 to 3.24), haematuria (3.8% versus 7.1%; RR 0.54; 95% CI 0.05 to 5.59), nasal bleeding (0% versus 7.1%; RR 0.21; 95% CI 0.01 to 4.28), gingival bleeding (0% versus 10.7%; RR 0.15, 95% CI 0.01 to 2.83) and faecal occult blood (0% versus 3.6%; RR 0.36; 95% CI 0.02 to 8.42). The bleeding tendency was increased in the UFH group but this was not statistically significant. This trial also monitored coagulability changes using parameters such as antithrombin activity, factor Xa activity, bleeding time, clotting time and activated partial thromboplastin time (aPTT). No comparison was made between the LMWH and UFH groups but all data consistently showed that coagulability was reduced more in the UFH group than in the LMWH group. The other trial reported a postoperative decrease in platelet count in the UFH group (preoperative 278.4 ± 18.7 x 10(9)/L, postoperative 194.3 ± 26.5 x 10(9)/L; P < 0.05) but not in the LMWH group (preoperative 260.8 ± 32.5 x 10(9)/L, postoperative 252.4 ± 29.1 x 10(9)/L; P > 0.05). AUTHORS' CONCLUSIONS Current limited evidence based on two small-scaled low-to-medium quality randomised trials found no differences in the success rate of replantation between LMWH and UFH, but a lower risk of postoperative bleeding and hypocoagulability after the use of LMWH. Further well-designed and adequately powered clinical trials are warranted.
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Affiliation(s)
- Yi-Chieh Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Lukins TR, Pett SI, Brett J. Is it worth the weight? Anaesth Intensive Care 2013; 41:553-554. [PMID: 23808521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Abstract
OBJECTIVE To provide a practical formula for fresh frozen plasma (FFP) dosing for warfarin reversal. PATIENTS AND METHODS We reviewed data on all adult patients who received a total of 7778 units of FFP for warfarin reversal at Sentara Norfolk General Hospital (Norfolk, VA) between April 1, 2009, and March 31, 2010. Patients with advanced liver disease, consumptive or dilutional coagulopathy, and administration of activated factor VII or prothrombin complex concentrate were excluded. First, we used regression analysis on the FFP1 subset (patients whose international normalized ratio [INR] was checked before and after 1 FFP administration) and derived a simple formula: DeltaINR (PreINR - PostINR) after 1 FFP =a × PreINR +b, where PreINR and PostINR are the INR values before and after FFP administration, respectively, and a and b are constants. In the validation step, the formula obtained for the FFP1 subset was repeatedly applied to the FFP2 (patients who received 2 units of FFP back-to-back without an intervening INR check), FFP3, and FFP4 subsets. RESULTS A total of 956 patients were included. The formula DeltaINR after 1 FFP = 0.57 × PreINR - 0.72 explained 82.6% of the total variance in INR change in the FFP1 subset (n=308; P<.01). Including age, sex, weight, FFP-to-PostINR interval, or administration of vitamin K marginally improved the model. Repeated application of the FFP1 formula to the FFP2 to 4 subsets combined confirmed the accuracy of the FFP1 formula across the entire data set (n=643; R(2)=95% between predicted and actual DeltaINR; P<.01). CONCLUSION This formula provides a practical and accurate method for FFP dosing for warfarin reversal.
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Affiliation(s)
- Armin Rashidi
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Ogawa C, Manabe A, Ohara A, Ishiguro A. [Current national and international status of supportive therapy for the coagulopathy associated with L-asparaginase containing regimen for acute lymphoblastic leukemia]. Rinsho Ketsueki 2013; 54:316-318. [PMID: 23676650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
We investigated supportive therapy against coagulopathy associated with L-asparaginase treatment in patients with acute lymphoblastic leukemia who were enrolled in the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG), Japan Adult Leukemia Study Group (JALSG), and foreign institutes. Fresh frozen plasma (FFP) was administered as a supplement in 46% patients in the JPLSG and 86% in the JALSG. The threshold level of FFP infusion was less than 100 mg/dl plasma fibrinogen in 70% of the JALSG and 20% of the JPLSG, while in another 20% of the JPLSG, FFP was administered when the fibrinogen level was less than 50 mg/dl. The preventive use of antithrombin products (AT) was prescribed in 93% of the JPLSG and 63% of the JALSG: The threshold level of AT supplementation was less than 70% of plasma antithrombin activity, which was similar in both groups. Most foreign institutes do not routinely use FFP or AT.
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Affiliation(s)
- Chitose Ogawa
- Division of Translational Research for Drug Development, Fukushima Medical University School of Medicine, Japan
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Huang GS, Chance EA. When dabigatran and trauma collide. Am Surg 2013; 79:113-114. [PMID: 23317625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Gregory S Huang
- General Surgery/Trauma/Surgical Critical Care, St. Elizabeth Health Center, Youngstown, Ohio 44501, USA.
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