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Journal of thrombosis and thrombolysis [journal]
- EPC mobilization after erythropoietin treatment in acute ST-elevation myocardial infarction: the REVEAL EPC substudy. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 23.
Erythropoietin (EPO) was hypothesized to mitigate reperfusion injury, in part via mobilization of endothelial progenitor cells (EPCs). The REVEAL trial found no reduction in infarct size with a single dose of EPO (60,000 U) in patients with ST-segment elevation myocardial infarction. In a substudy, we aimed to determine the feasibility of cryopreserving and centrally analyzing EPC levels to assess the relationship between EPC numbers, EPO administration, and infarct size. As a prespecified substudy, mononuclear cells were locally cryopreserved before as well as 24 and 48-72 h after primary percutaneous coronary intervention. EPC samples were collected in 163 of 222 enrolled patients. At least one sample was obtained from 125 patients, and all three time points were available in 83 patients. There were no significant differences in the absolute EPC numbers over time or between EPO- and placebo-treated patients; however, there was a trend toward a greater increase in EPC levels from 24 to 48-72 h postintervention in patients receiving ≥30,000 U of EPO (P = 0.099 for CD133(+) cells, 0.049 for CD34(+) cells, 0.099 for ALDH(br) cells). EPC numbers at baseline were inversely related to infarct size (P = 0.03 for CD133(+) cells, 0.006 for CD34(+) cells). Local whole cell cryopreservation and central EPC analysis in the context of a multicenter randomized trial is feasible but challenging. High-dose (≥30,000 U) EPO may mobilize EPCs at 48-72 h, and baseline EPC levels may be inversely associated with infarct size.
- Pulmonary embolism in pregnancy. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 21.
Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during pregnancy or early after delivery, remaining a diagnostic and therapeutic challenge in both states. The absolute incidence of pregnancy-associated VTE has been reported as 1 in 1,000 to 1 in 2,000 deliveries. With 5-6 million new births computed in Europe in 2010, the potential clinical relevance of diagnosing and treating gravidic VTE is immediately evident. Fivefold higher in a pregnant as compared with a non-pregnant woman, VTE risk is also higher in postpartum than antepartum period. Ranked absolute and relative thrombotic risk may be described in the several thrombophilic conditions experienced by women at risk, according to which specific prophylactic and therapeutic recommendations have been formulated by recent guidelines. The main purpose of the present review article was to emphasize the most recent findings and recommendations in diagnostic strategies, discussing thrombophilic risk evaluation, as well as risks and benefits of various diagnostic techniques for both mother and fetus.
- Giant right atrial thrombus in premature newborn. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 21.
Pediatric guidelines for treatment options of right atrial thrombosis in newborn are quite limited. Herein we present a case with giant atrial thrombosis resulting from umbilical venous catheter and intend to discuss the therapy in the area of current literature on right atrial thrombus in newborn and children.
- Prednisone versus high-dose dexamethasone for untreated primary immune thrombocytopenia. A retrospective study of the Japan Hematology & Oncology Clinical Study Group. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 18.
High-dose dexamethasone (HDD) has been shown to be an effective initial treatment for immune thrombocytopenia (ITP), but it is not clear whether HDD offers any advantages over conventional-dose prednisone (PSL). We retrospectively compared the efficacy and toxicity of HDD and PSL for newly diagnosed ITP. The response was evaluated according to the International Working Group (IWG) criteria. We analyzed data from 31 and 69 patients in the HDD and PSL groups, respectively. There were no significant differences in patient characteristics between the two groups except for the incidence of the eradication of Helicobacter pylori. The response rate was better in the HDD group (42.7 vs. 28.4 %), and this difference was statistically significant when adjusted for other factors including the eradication of H. pylori. In the HDD group, a response was achieved earlier (28 vs. 152 days in median) and steroids were more frequently discontinued at 6 months (64.5 vs. 37.7 %). Among patients who achieved a response, there was no significant difference in the incidence of loss of response. There were no significant differences in the rate of adverse events, transition to chronic ITP, and splenectomy. In conclusion, HDD might enable the early cessation of steroids without a loss of response.
- Lemierre's syndrome: the forgotten disease. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 18.
Lemierre's syndrome is an often un-diagnosed disease seen in previously healthy young subjects, presenting with symptoms of pharyngitis, fever and elevated markers of inflammation. The syndrome is characterised by infectious thrombosis of the jugular vein due to infection with Fusobacteria, causing a variety of infectious complications. Rapid diagnosis and treatment is necessary to avoid severe complications or death. Close collaboration with local microbiologist is pivotal. Treatment consists of longterm treatment with penicillin and metronidazole. This is a case report of Lemierre's syndrome.
- Discrepant ratios of arterial versus venous thrombosis in hemophilia A as compared with hemophilia B. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 17.
The occurrence of thrombosis in patients with congenital bleeding disorders represents an exceptional event. Hemophilia A and hemophilia B patients have been showed to present both arterial and venous thrombosis (85 cases of arterial thrombosis and 34 cases of venous thrombosis). The great majority of arterial thrombosis are myocardial infarction or other acute coronary syndromes, whereas the majority of venous thrombosis are deep vein thrombosis and/or pulmonary embolisms. However there are discrepancies in the proportion of arterial and venous thrombosis seen in hemophilia A versus hemophilia B. The ratio of arterial versus venous thrombosis in hemophilia A is 3.72 whereas that for hemophilia B is 1.12. This indicates that arterial thrombosis is more frequent in hemophilia A as compared to hemophilia B and the opposite is true for venous thrombosis. The potential significance of this discrepancy is discussed.
- Clinical features in patients with pulmonary embolism at a community hospital: analysis of 4 years of data. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 17.
The aim of this study is to assess the various clinical features, risk factors, and electrocardiographic (EKG) findings associated with acute pulmonary embolism (PE). Knowledge gained from the study may enable health care providers in diagnosis of PE, thus allowing them to carry out appropriate diagnostic testing and treatment after recognition of this potentially lethal disease. PE is common but frequently under-diagnosed clinical problem, associated with potentially fatal outcomes. Clinical presentation is highly variable, non-specific and most patients have an underlying identifiable risk factor. The presentation of PE can easily be confused with other cardio-pulmonary or systemic disorders. Prompt diagnosis of this potentially deadly disease is of utmost importance. Knowledge of salient features associated with PE may enable health care providers in diagnosis of PE, thus allowing them to carry out appropriate diagnostic testing and treatment after its recognition. We performed a single-center, cross-sectional descriptive study including all inpatient and emergency department encounters ≥18 years of age diagnosed with PE at our institution, a 300-bed inner city community hospital, during the dates January 2007 to December 2010. All patients were diagnosed with multi-detector 64-slice spiral computed tomography angiography. Using a standardized form, we performed simultaneous retrospective chart review to collect the necessary data required for the study. PE was confirmed in 334 patients during the 4 years study period. Mean age of subjects was 65.8 years (±16.4, range 22-98). Females represented 54 % of study subjects. Dyspnea, chest pain, and cough were present in 72, 38, and 19 % of the patients, respectively. Dyspnea was the only presenting symptom in 29 %. Tachypnea, hypoxia, tachycardia, and signs of DVT were present in 39, 35, 33, and 29 %, respectively. Cancer was most common risk factor present in 27 %, followed by prior history of venous thromboembolism (DVT or PE), immobilization, and surgery in 19, 15, and 15, respectively. EKG interpretation revealed normal sinus rhythm in 53 %, sinus tachycardia in 31 %, S1Q3T3 pattern in 6 %, and atrial fibrillation (AF) in 6 %.We also noted that 8 % of elderly patients had new onset AF at the time of diagnosis of PE. Diagnosis of PE remains a challenging task due to its variable presentation. Many of the classical features associated with this potentially fatal disease are often missing. This data re-emphasizes a wide spectrum of clinical presentation and non-specificity of symptoms of PE. Clinical suspicion of PE is a critical step and of paramount importance for further objective investigations, which would assist in the diagnosis and appropriate timely management of PE.
- The effect of CYP2C9, VKORC1 and CYP4F2 polymorphism and of clinical factors on warfarin dosage during initiation and long-term treatment after heart valve surgery. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 16.
The dosage of warfarin is restricted due to its narrow therapeutic index, so, the required dose must be adapted individually to each patient. Variations in warfarin dosage are influenced by genetic factors, the changes in patient diet, anthropometric and clinical parameters. To determine whether VKORC1 G3730A and CYP4F2 G1347A genotypes contribute to warfarin dosage in patients during initiation and long-term anticoagulation treatment after heart valve surgery. From totally 307 patients, who underwent heart valve surgery, 189 patients (62 %) who had been treated with warfarin more than 3 months, were included into the study. A hierarchical stepwise multivariate linear regression model showed, that during initiation clinical factors can explain 17 % of the warfarin dose variation. The addition of CYP2C9 and VKORC1 G-1639A genotype raises the accuracy about twice-to 32 %. The CYP4F2 G1347A genotype can add again about 2-34 %. During long-term treatment clinical factors explain about 26 % of warfarin dose variation. If the CYP2C9 *2, *3, VKORC1*2 alleles are detected, model can explain about 49 % in dose variation. The *3 allele of VKORC1 raises the accuracy by 1-50 %. The carriers of CYP4F2 A1347A genotype required higher daily warfarin doses during initiation of warfarin therapy after heart valve surgery than comparing to G/G and G/A carriers, but during the longer periods of warfarin use, the dosage of warfarin depended significantly on VKORC1 *3 allele (G3730A polymorphism) and on the thyroid stimulating hormone level in the blood plasma.
- Dabigatran-associated subdural hemorrhage: using thromboelastography (TEG(®)) to guide decision-making. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 11.
Novel oral anticoagulants present challenges and uncertainties in the management of hemorrhagic emergencies. An 84-year-old man taking dabigatran presented with a subdural hematoma requiring neurosurgical intervention. Routine coagulation assays were prolonged at admission and following administration of Factor VIII Inhibitor Bypassing Activity (FEIBA). Thromboelastography (TEG(®)) was utilized to assess clot dynamics prior to placement of a subdural drain, which was safely inserted despite a prolonged thrombin time (TT). Exclusive reliance on the TT may delay necessary interventions. TEG(®) may be a valuable tool to investigate hemostasis in patients on dabigatran requiring emergent procedures.
- Reversal of target-specific oral anticoagulants. [JOURNAL ARTICLE]
- J Thromb Thrombolysis 2013 May 9.
The target-specific oral anticoagulants represent the first new oral anti-thrombotic therapy in over 50 years and have the potential to make therapy easier and hence more accessible to many patients. Like any new therapy, the potential benefits must be weighed against the potential challenges and one of the most concerning aspects of the new target-specific oral anticoagulants is the lack of a proven method to reverse their effect. Unlike the vitamin K antagonist, i.e. warfarin, there is no specific antidote for these medications. This paper will review the limited data on the use of non-specific therapies to reverse anticoagulation for the new agents. We hope to prepare clinicians who are faced with a patient who has serious bleeding or needs emergent surgery while taking dabigatran, rivaroxaban or apixaban.