Absence Of Anticoagulant Therapy Research Articles

P464 ELEVATED SPONTANEOUS INR: THE COMPLEXITY OF REAL LIFE BETWEEN CARDIOLOGY AND HEMATOLOGY

Abstract Direct acting oral anticoagulants (DOACs) have guaranteed safety and convenience of use in anticoagulated patients. DOACs only require monitoring of hepato–renal function. But how to handle a patient with persistently elevated INR (International Normalized Ratio) in the absence of anticoagulant therapy? We present the case of a 77 years old woman with hypertension and hypothyroidism. The patient was admitted to our division for high frequency atrial fibrillation with initial heart failure. The patient gradually improved with rate control therapy (metoprolol and digoxin) and a few diuretic therapy. The echocardiogram didn’t showed anything significant. Laboratory tests showed a persistently elevated INR, even after she achieved clinical stability. Liver funcion tests and abdomen echography were normal. Patient’s CHA2DS2–VASc risk score was 3 with indication to anticoagulant therapy. We opted for rate control therapy because, in the absence of a diagnosis, there was uncertainty as to start or not anticoagulation therapy, with the doubt whether the persistently high INR corresponded to real anticoagulation. We didn‘t want to expose the patient to bleeding risks by initiating a DOAC. Blood tests showed mild to moderate factor X deficiency with prolonged dRVVT (diluited Russel Viper Venom time) but normal aPTT (activated partial thromboplastin time). Factor X (FX) deficiency is a rare hereditary bleeding disorder characterized by decreased antigen and/or activity of FX leading to mild to severe bleeding symptoms. Severe congenital form manifests itself early while heterozygous patients are often asymptomatic. Indeed, no previous literature data are reported about use of DOACs in this kind of patient. In mild to moderate FX deficiency there are no known contraindications for the use of anticoagulant therapy. According to the hematologist we started low–dose dabigatran, the only DOAC that acts by directly inhibiting thrombin. Regular 6 months follow–up. In conclusion this case was particularly challenging because of the lack of indications about how to manage these patients. The complexity of patients in real–life goes beyond the guidelines, which must therefore be adapted to the individual case

New prospects for assessing the hemostasis system in atrial fibrillation and left atrial appendage thrombosis

Thromboembolic syndrome, the frequency of which is 8–15%, is the main danger for a patient with atrial fibrillation (AF). The left atrial appendage is the most common source of thromboembolia in atrial fibrillation. The frequency of detection of left atrial appendage thrombus in AF is 15.2% in the absence of anticoagulant therapy and 1–8% in patients using this group of drugs. The reason for the formation of thrombi in this localization during anticoagulant therapy today it is not reliably known. This article describes a clinical case of a 67-year-old patient with persistent AF and left atrial appendage thrombosis, who was hospitalized to determine further management strategies. A left atrial appendage thrombus lasted for a year despite continuous anticoagulant therapy with various oral anticoagulants at doses consistent with clinical guidelines due to the patient's absolute refusal to take warfarin, vitamin K antagonist. In addition, this article discusses the use of Thrombodynamics, a new global coagulation test, in patients with AF, which revealed a plasma hypercoagulable state with underlying persistent thrombosis in this patient on continuous oral anticoagulant treatment. The Thrombodynamics test is a promising procedure for assessing the coagulation system state and may be promising as a method for measuring the effectiveness of any oral anticoagulant. However, it is impossible to draw any definite conclusions on the basis of single observations; large clinical studies with the potential of long-term case follow-up of patients are needed.

ФАКТОРИ РИЗИКУ ТРОМБОЗУ У ОСІБ, ЯКІ ПЕРЕНЕСЛИ НЕГОСПІТАЛЬНУ ПНЕВМОНІЮ НА ТЛІ КОРОНАВІРУСНОЇ ХВОРОБИ (COVID-19)

The aim of the study was to identify the risk factors for thrombotic events in individuals who have experienced community acquired pneumonia associated with COVID-19 and did not have thrombotic events during the acute period of COVID-19. Materials and methods. 45 individuals were examined in postCOVID-19 period (age - 61.0 (54.0; 68.0) years, males - 22 (48,9 %), females - 23 (51,1 %)). All patients were examined twice: at visit 1 — 45,0 (40,0; 60,0) days from the onset of COVID-19, and at visit 2 — 150,0 (117,5; 160,0) days from the onset of COVID-19. Depending on whether the patients received anticoagulant therapy during post-COVID-19 period, the main group was divided into two subgroups: subgroup 1 included 25 (55,6 %) individuals who received anticoagulants during post-COVID-19 period (the course of acute COVID-19 was moderate in 7 (28,0 %) individuals, and severe or critical in 18 (72.0 %) individuals); subgroup 2 included 20 (44,4 %) individuals who did not receive anticoagulants during post-COVID-19 period (the course of acute COVID-19 was moderate in 12 (60,0 %) individuals and severe in 8 (40,0 %) individuals). Clinical methods, pulse oximetry, laboratory and instrumental methods as well as assessment of the probability of thrombosis according to the Wells and Padua scales were used. Results. There was not any thrombotic event occurred in subgroup 1 during post-COVID-19 period. The duration of anticoagulant use in patients from subgroup 1 was 63,0 (60,0; 90,0) days from the onset of COVID-19 symptoms. In subgroup 2, thrombosis was detected in 5 (25,0%) patients during post-COVID-19 period (4 patients had pulmonary embolism and 1 patient had a combination of pulmonary embolism and acute ischemic stroke). Thrombotic events had occurred before visit 1, at 40,0 (33,0; 45,0) days from the onset of COVID-19, which corresponded to 16,0 (15,0; 18,0) days after the end of anticoagulant therapy. Age, gender, body mass index, and comorbidities (hypertension, obesity, diabetes) were not associated with the occurrence of thrombotic events. Risk factors included severe COVID-19 (p=0,04) and the presence of hereditary thrombophilia. Conclusion. The risk of thrombosis in post-acute COVID-19 period is higher in patients after severe course of the acute period of COVID-19, in the absence of anticoagulant therapy during the post-COVID-19 period. On the other hand, the administration of anticoagulants during at least two months from the onset of COVID-19 symptoms, decreased the risk of thrombosis in the post-COVID-19 period not only in patients with severe course but in patients with critical course of the acute period of COVID-19 as well. Key words: COVID-19, post-COVID-19 period, thrombosis, pulmonary embolism, anticoagulants.

A Review of the Role of Transthoracic and Transesophageal Echocardiography, Computed Tomography, and Magnetic Resonance Imaging in Cardioembolic Stroke.

Stroke is a major source of morbidity and mortality worldwide, accounting for the second largest cause of mortality and the third greatest cause of disability. Stroke is frequently preceded by a transient ischemic attack (TIA). The etiologies of 20–30% of ischemic strokes are unknown, and thus are termed “cryptogenic strokes”. About 25% of ischemic strokes are cardioembolic. Strokes occur at a rate of around 2% per year in individuals with heart failure with reduced ejection fraction (HFrEF), with a strong correlation between stroke risk and the degree of ventricular impairment. Furthermore, stroke risk is augmented in the absence of anticoagulation therapy. Cardioembolic strokes, when treated inadequately, have a greater predilection for recurrences than atherothrombotic strokes, both early and late in life. The role of a patent foramen ovale in strokes, specifically in “cryptogenic strokes”, is a matter of concern that deserves due attention. The use of tissue-engineered heart valves and aspirin for minimizing the risk of stroke is recommended.Transthoracic echocardiography (TTE) is advantageous for assessing heart function in the acute phase of ischemic stroke. Transesophageal echocardiography (TEE) is considered the criterion standard procedure for detecting LAA thrombi. Computed tomography (CT) scans are good imaging modalities for identifying and excluding bleeding. Magnetic resonance imaging (MRI) images are by far the most effective imaging technique available for assessing the brain parenchymal state.We conducted a thorough review of the literature on the use of imaging modalities, highlighting the important contribution of TTE, TEE, CT, and MRI in the evaluation of cardioembolic stroke.

COVID-19 ассоциированная пневмония – предиктор ретинальных окклюзий (клиническое наблюдение)

Aim. To present a clinical case of bilateral retinal occlusions in a 40-year-old woman who suffered COVID-19 associated pneumonia. Materials and methods. The analysis of the dynamics of the development of clinical manifestations of the disease of a patient R., born in 1981 with a burdened obstetric and gynecological history before the disease with a new coronavirus infection was carried out. Results. The absence of anticoagulant therapy during rehabilitation in the patient after 4 months led to an increase in blood pressure, after 6 months of vascular occlusion of the left eye, after 1 year and 4 months of vascular occlusion of the right eye. The data of a small coagulogram reflect the state of individual units of the coagulation system and are not informative for patients of this category. Conclusion. After undergoing a new coronavirus infection, it is recommended that patients undergo thromboelastography and a thrombodynamics test.

Хроническая головная боль как проявление венозного тромбоза дурального синуса

Пациентам с мозговым венозным тромбозом (МВТ) присущ широкий спектр клинических проявлений — от головной боли до комы. Хроническая окклюзия венозных синусов твердой мозговой оболочки приводит к формированию ряда компенсаторных явлений, таких как сосудистая коллатерализация, реканализация организованного тромба, эффективность которых и определяет тяжесть состояния и течение заболевания. Целью нашего исследования стало освещение клинической проблемы диагностирования хронического субкомпенсированного МВТ. С учетом того, что такое течение процесса наблюдается в 20 % случаев, около четверти пациентов, у которых заболевание проявляется головной болью неясной этиологии, остаются незамеченными и с низким качеством жизни. Для анализа течения и прогноза заболевания нашей задачей стало тщательное изучение механизмов адаптации организма при хроническом тромбозе дурального синуса в виде формирования системы венозных коллатералей и реканализации. Однако весомым подводным камнем хронической окклюзии венозных синусов твердой мозговой оболочки при отсутствии соответствующего лечения является то, что гемодинамические компенсаторные явления также определяют и высокий риск развития цереброваскулярных катастроф, которые приводят к летальному исходу или инвалидизации. В представленном нами клиническом случае имел место хронический венозный тромбоз поперечного и сигмовидного синусов, который манифестировал мигренеподобным цефалгическим синдромом с вегетативным компонентом и постепенным нарастанием синдрома внутричерепной гипертензии. Без антикоагулянтной терапии венозный дренаж через коллатеральные пути, отсроченная реканализация тромбированных синусов осуществлялись у пациента неэффективно, что привело к формированию диффузного отека, вторичному повреждению мозговой ткани. После проведения тщательного обследования, установления диагноза, назначения индивидуализированного лечения и длительного наблюдения с коррекцией терапии у пациента имел место регресс симптомов МВТ. Церебральная МР-венография — это важный инструмент в диагностике и прогнозе данного заболевания. Таким образом, пациентам с длительным анамнезом головной боли, которая не поддается лечению и имеет признаки внутричерепной гипертензии, нужно проводить МР-венографию. Тем не менее в случаях геморрагических инсультов неясного генеза, которые не соответствуют артериальным территориям, часто возникает необходимость исследовать состояние вен головного мозга и твердомозговых синусов. С целью индивидуального анализа течения и прогноза заболевания необходимо изучать формирование венозных коллатералей и процессов реканализации тромбов дурального синуса пациента.

Effectiveness of a comprehensive ambulatory monitoring system for patients with atrial fibrillation after cardioembolic stroke

Aim. To improve the long-term outcomes of patients with atrial fibrillation (AF) after cardioembolic stroke by creating and testing a comprehensive ambulatory monitoring system.Material and methods. The present study included 139 AF patients after cardioembolic stroke for the period 2016-2019, of which 80 (57,55%) were women and 59 (42,45%) were men. The mean age of the patients was 72,25±6,33years. Before the hospital discharge, all patients signed an informed consent and were randomized into two groups. Patients of the group I (n=72) were followed up during the year in accordance with a specially developed comprehensive ambulatory monitoring system. This system included a rehabilitation program created individually for each patient, monthly visits to a physician-researcher, during which a complex of diagnostic tests was carried out. Also, the changes of complaints, symptoms, and medical adherence were assessed. The latter was corrected. A physician talked with the patient's relatives about the need to comply with the recommended medication regimen, supporting the motivation for treatment. Patients of group II (n=67) were followed up at the primary care level in accordance with the current program, and a control visit to was performed for them once — after 12 months.Results. After one-year follow-up, a significant decrease in all-cause mortality was obtained in the first group in comparison with the second one: 3 (4,17%) and 18 (26,87%) deaths, respectively (p=0,021).In addition, in group II, a relationship was found between the death and absence of anticoagulant therapy (odds ratio, 7,68; 95% confidence interval, 1,59-37,03; p=0,01). The ROC analysis confirmed the relationship between the absence of anticoagulant therapy and death, while the regression quality was good (area under the curve, 0,77, sensitivity — 94,74%, specificity — 59,17%).Conclusion. Comprehensive ambulatory monitoring program for AF patients after cardioembolic stroke has proven high effectiveness, and its widespread practice is an urgent task of modern healthcare.

157 Prevalence and Patterns of Drug-Disease Interactions in Long-Term Residents in Nursing Home Facilities in the Czech Republic

Abstract Introduction Prescription of potentially inappropriate medications, non-geriatric doses and drug-disease interactions contribute to high prevalence of adverse drug events, geriatric syndromes and symptoms, and increased frailty in older adults. Despite serious health and socio-economic consequences, a very few studies have been published on phenomenon of prescribing of drug-disease interactions (DDI) in older patients in Central and Eastern Europe. Methods This study aimed to investigate the prevalence of DDI and differences across nursing home (NH) facilities applying relevant parts of Beers 2012 criteria, Czech national consensus 2012 (CNC), and STOPP/START criteria vers.1. This is a retrospective cross-sectional study that analysed semi-implicitly InterRAI-LTC assessment protocols of 490 NH residents from 10 Czech NH facilities (N = 490, 65+) participating in the EU SHELTER project. Retrospective analyses were conducted in 2019 year. Results Prevalence of potentially inappropriate DDI ranged from 44.5% to 62.3% identified by STOPP criteria and CNC, respectively. The most common DDIs were long-term use of benzodiazepines in depressive residents (7.8%) and use of opioids in residents with chronic constipation without osmotic laxative treatment (7.4%). The prevalence of undertreatment identified by START criteria was 52.9%, mainly due to absence of statins in NH residents with diabetes mellitus and cardiovascular risk factors (9.8%) and the absence of anticoagulation therapy in patients with atrial fibrillation (7.1%). Conclusions Potentially inappropriate DDI were highly prevalent in Czech long-term NH residents with significant differences across NH facilities. Using method of semi-implicit medication reviews, we cannot judge the real quality of drug treatment, but there is a necessity to reduce the high prevalence of DDI in NHs in order to prevent potential adverse drug events. Grant support: InoMed project (reg. No: CZ.02.1.01/0.0/0.0/18_069/0010046, 2019–2022), H2020-MCSF-ITN-764632, PROGRESS Q42 FoP, Charles University, FP7-HEALTH-F4–2008-201,917, SVV 260417.

Доступная и современная антитромботическая терапия при фибрилляции предсердий

Atrial fibrillation (AF) is the most common arrhythmia that can be complicated by stroke at the 1 to 30% credible level per year in the absence of anticoagulant therapy, depending on the risk factor profile. Numerous clinical studies have strongly confirmed the efficacy of antithrombotic therapy, mainly with anticoagulants, in patients with AF [1].

Clinical Outcomes of Mortality, Readmissions, and Ischemic Stroke Among Medicare Patients Undergoing Left Atrial Appendage Closure via Implanted Device

Left atrial appendage closure (LAAC) has emerged as a nonpharmacological alternative for stroke prevention in patients with nonvalvular atrial fibrillation. Contemporary data regarding the characteristics and outcomes of patients undergoing this procedure are limited. To determine the characteristics, postprocedural mortality rate, and rates of readmission and ischemic stroke among Medicare beneficiaries who underwent LAAC via implanted device. This population-based cohort study used Medicare inpatient claims from January 2015 to December 2017 for 13 627 patients aged older than 65 years with a diagnosis of atrial fibrillation who underwent LAAC with an implanted device from January 2015 to November 2017. Data analyses were conducted from January through August 2019. Left atrial appendage closure. Mortality rates during the index admission and for 1 year after LAAC were assessed. The 30-day readmission rate and the primary reasons for readmission were also examined. In addition, the likelihood of hospitalization for ischemic stroke within 180 days among 9231 patients for whom 6 months of follow-up data were available was evaluated. Among the 13 627 patients undergoing LAAC, the mean (SD) age was 78.0 (6.3) years, 9406 (69.0%) were older than 75 years, 11 980 (87.9%) were white, and 5630 (41.3%) were women. The mean (SD) CHA2DS2-VASc score was 4.3 (1.4). Twenty-eight patients (0.2%) died during the index admission. Mortality rates were 0.6% (80 patients) at 30 days, 1.9% (262 patients) at 90 days, 4.0% (547 patients) at 180 days, and 7.5% (1027 patients) at 365 days. The 30-day readmission rate among 13 599 patients discharged alive was 9.4% (1284 patients). Among 9231 patients with 6 months of follow-up data, 111 (1.2%) experienced readmission for ischemic stroke or transient ischemic attack within 180 days of discharge. In this cohort study of patients older than 65 years with atrial fibrillation who underwent LAAC with an implanted device, readmission rates for ischemic strokes over the course of 6 months were lower than expected given the patients' CHA2DS2-VASc scores in the absence of anticoagulation therapy. Mortality at 1 year was higher than that reported in previous randomized clinical trials, likely because the patients in the present study were older, had a higher number of comorbidities, and were ineligible to receive warfarin.

Incidence of Stent Thrombosis after Endovascular Treatment of Iliofemoral or Caval Veins in Patients with the Postthrombotic Syndrome.

Patients with postthrombotic syndrome (PTS) treated with stents are at risk of stent thrombosis (ST). The incidence of ST in the presence and absence of anticoagulation therapy (AT) is unknown. Risk factors are not well understood. From the prospective Swiss Venous Stent registry, we conducted a subgroup analysis of 136 consecutive patients with PTS. Incidence of ST was estimated from duplex ultrasound or venography, and reported for the time on and off AT. Baseline, procedural, and follow-up data were evaluated to identify factors associated with ST. Median follow-up was 20 (interquartile range [IQR] 9-40) months. AT was stopped in 43 (32%) patients after 12 (IQR 6-14) months. Cumulative incidence of ST was 13.7% (95% confidence interval [CI] 7.8-19.6%) and 21.2% (95% CI 13.2-29.2%) during the first 6 and 36 months, respectively. The time-adjusted incidence rate was 11.2 (95% CI 7.7-16.2) events per 100 patient-years, 11.3 (95% CI 7.3-17.3) for the period on, and 11.2 (95% CI 5.3-23.6) for the period off AT. May-Thurner syndrome (MTS) was associated with decreased incidence of ST (hazard ratio [HR] 0.37, 95% CI 0.15-0.91), whereas age < 40 years (HR 2.26, 95% CI 1.03-4.94), stents below the common femoral vein (HR 3.03, 95% CI 1.28-7.19), and postthrombotic inflow veins (HR 2.92, 95% CI 1.36-6.25) were associated with increased incidence. The 6-month incidence of ST was considerably high. Beyond 6 months, consecutive annual incidence rates persisted at 4.1 and 3.4% per year thereafter. Patients with higher incidence of ST were younger, had stents below the common femoral vein, postthrombotic leg inflow veins, and less often MTS. Incidence rates for the period on and off AT must be interpreted with caution. The study is registered on the National Institutes of Health Web site (ClinicalTrials.gov; identifier NCT02433054).

Calcification and Thrombosis as Mediators of Bioprosthetic Valve Deterioration

Calcific aortic valve disease is the most common indication for surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) of diseased valves worldwide. 1 For years,...

Spontaneous expanding internal oblique hematoma induced by vigorous cough in an elderly patient under antiplatelet therapy: Case report and review of literature

Oblique muscle hematomas are an uncommon cause of acute abdominal pain and are more common in elderly individuals, particularly in those under anticoagulant therapy. They are often misdiagnosed from other causes of abdominal pain. We report a case of a cough-induced internal oblique hematoma in an elderly 62-year-old male patient under antiplatelet therapy. He had no history of trauma and presented with acute worsening pain in the left flank. Ultrasonography revealed a hypoechoic mass in the right lateral abdominal wall. Nonenhanced computed tomography of the abdomen showed a 6 cm × 4 cm × 7 cm hematoma in the left internal oblique muscle. The patient was managed conservatively without blood transfusion. Differential diagnosis of an acute-onset flank mass should include oblique muscle hematoma even in the absence of anticoagulant therapy or trauma.

Complex Cusp Repair in Patients Undergoing the David Procedure: Is It Worth It?

Valve-sparing aortic root replacement has already proven its excellent long-term results, with low valve-related complications comparable with conventional aortic valve replacement. The aim of this study was to investigate whether additional expanded cusp repair is an alternative with comparable results. Data of 192 elective patients undergoing valve-sparing aortic root replacement were prospectively recorded: 58 patients (30.2%) received an isolated aortic root replacement (group I, isolated David), and 134 patients (69.8%) received additional cusp repair (group II, complex David), such as plication of the free margin (n=77), decalcification (n= 45), or pericardial patch (n= 39). Cumulative follow-up was 480 patient-years, with a mean of 2.5 ± 1.5 years. Mean age was 60 years, and 76.6% were men. In hospital mortality was 3.4% in group I and 0.0% in group II. Freedom from cardiac death at 5 years (by Kaplan-Meier estimation) was 83% vs 98% (p= 0.058). Freedom from moderate or severe aortic insufficiency at 5years was 100% in group I vs 93% (95% confidence interval, 86% to 97%) in group II (p= 0.110). Seven patients required reoperation for aortic insufficiency or stenosis: repeat repair (n= 3), Ross procedure (n= 2), and biologicical aortic valve replacement (n= 2). Freedom from reoperation at 5 years was 96% (95% confidence interval, 76% to 99%) in group I vs 89% (95% confidence interval, 71% to 96%) in group II (p= 0.305). Overall survival and freedom from reoperation after valve-sparing aortic root replacement, even with additional complex cusp repair, provides excellent midterm results. Low risk of valve-related complications and absence of anticoagulation therapy are distinctive advantages of this complex procedure.

Incidence, Timing, and Predictors of Valve Hemodynamic Deterioration After Transcatheter Aortic Valve Replacement: Multicenter Registry

BackgroundScarce data exist on the incidence of and factors associated with valve hemodynamic deterioration (VHD) after transcatheter aortic valve replacement (TAVR). ObjectivesThis study sought to determine the incidence, timing, and predictors of VHD in a large cohort of patients undergoing TAVR. MethodsThis multicenter registry included 1,521 patients (48% male; 80 ± 7 years of age) who underwent TAVR. Mean echocardiographic follow-up was 20 ± 13 months (minimum: 6 months). Echocardiographic examinations were performed at discharge, at 6 to 12 months, and yearly thereafter. Annualized changes in mean gradient (mm Hg/year) were calculated by dividing the difference between the mean gradient at last follow-up and the gradient at discharge by the time between examinations. VHD was defined as a ≥10 mm Hg increase in transprosthetic mean gradient during follow-up compared with discharge assessment. ResultsThe overall mean annualized rate of transprosthetic gradient progression during follow-up was 0.30 ± 4.99 mm Hg/year. A total of 68 patients met criteria of VHD (incidence: 4.5% during follow-up). The absence of anticoagulation therapy at hospital discharge (p = 0.002), a valve-in-valve (TAVR in a surgical valve) procedure (p = 0.032), the use of a 23-mm valve (p = 0.016), and a greater body mass index (p = 0.001) were independent predictors of VHD. ConclusionsThere was a mild but significant increase in transvalvular gradients over time after TAVR. The lack of anticoagulation therapy, a valve-in-valve procedure, a greater body mass index, and the use of a 23-mm transcatheter valve were associated with higher rates of VHD post-TAVR. Further prospective studies are required to determine whether a specific antithrombotic therapy post-TAVR may reduce the risk of VHD.

A PK-PD model-based assessment of sugammadex effects on coagulation parameters

Exposure–response analyses of sugammadex on activated partial thromboplastin time (APTT) and prothrombin time international normalized ratio (PT(INR)) were performed using data from two clinical trials in which subjects were co-treated with anti-coagulants, providing a framework to predict these responses in surgical patients on thromboprophylactic doses of low molecular weight or unfractionated heparin. Sugammadex-mediated increases in APTT and PT(INR) were described with a direct effect model, and this relationship was similar in the presence or absence of anti-coagulant therapy in either healthy volunteers or surgical patients. In surgical patients on thromboprophylactic therapy, model-based predictions showed 13.1% and 22.3% increases in respectively APTT and PT(INR) within 30min after administration of 16mg/kg sugammadex. These increases remain below thresholds seen following treatment with standard anti-coagulant therapy and were predicted to be short-lived paralleling the rapid decline in sugammadex plasma concentrations.

Prevalence and significance of clinically unsuspected pulmonary embolism: detection using coronary computed tomography angiography.

Clinically unsuspected pulmonary embolism can be detected using coronary computed tomography (CT), but the clinical significance of unsuspected pulmonary embolism remains unclear. Pulmonary embolism was assessed using consecutive coronary CT from March 2003 to June 2007 to assess 1077 patients. Coronary CT was performed using a 16-row multidetector CT (MDCT) scanner with ECG-gating. A radiologist and a cardiologist retrospectively assessed the images of pulmonary arteries to arrive at a consensus diagnosis. Unsuspected pulmonary embolism was detected in 32/1,077 (3.0%) patients. No significant difference was observed with regard to death and acute pulmonary embolism between patients with and without unsuspected pulmonary embolism at five years (6.7% vs. 4.1%, p = 0.61). Prior cardiac surgery within three months of diagnosis of pulmonary embolism was an independent risk factor for unsuspected pulmonary embolism, which was detected in 10/89 (11%) of such patients. The absence of anticoagulant therapy was a risk factor (p = 0.015) for unsuspected pulmonary embolism post-cardiac surgery. Although only one out of 10 patients received anticoagulant therapy, none of the 10 experienced critical events. Five of the 10 patients underwent repeated coronary CT, and the embolus disappeared regardless of its size and location in four of the five patients who did not receive anticoagulant therapy. The prevalence of unsuspected pulmonary embolism detected using coronary CT was 3.0%. Prior cardiac surgery within three months of diagnosing pulmonary embolism was an independent risk factor for unsuspected pulmonary embolism. The long-term clinical outcomes of patients with unsuspected pulmonary embolism were favorable.

An oblique muscle hematoma as a rare cause of severe abdominal pain: a case report

BackgroundAbdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They are more common in elderly individuals, particularly in those under anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and hematomas within the oblique muscle are very rare and are poorly described in the literature. Here we report the case of an oblique muscle hematoma in a middle-aged patient who was not under anticoagulant therapy.Case presentationA 42-year-old Japanese man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. Abdominal computed tomography and ultrasonography showed a large soft tissue mass located in the patient’s left internal oblique muscle. A diagnosis of a lateral oblique muscle hematoma was made and the patient was treated conservatively.ConclusionPhysicians should consider an oblique muscle hematoma during the initial differential diagnosis of pain in the lateral abdominal wall even in the absence of anticoagulant therapy or trauma.

Risk of recurrence of unusual site venous thromboembolism

The term unusual site venous thrombosis defines uncommon clinical manifestations of venous thromboembolism occurring in sites different from the lower limbs or the lungs, with peculiar pathophysiological features and clinical history. Information on long-term outcomes of unusual site thrombosis is generally scant, because most studies are small and usually retrospective. Recurrence rate of cerebral vein thrombosis is about 2/100 patient-years; the only identified predisposing factors have been male gender and personal history of thrombosis. Retinal vein occlusion showed a recurrence in the same eye of 2.5% and in the fellow eye of 11.9% within four years. Hypercholesterolemia, hypertriglyceridaemia and hyperhomocysteinaemia were significantly associated with recurrent events. Recurrence rates of splanchnic vein thrombosis are difficult to estimate given the heterogeneity of patient populations; higher recurrence rates are reported in the cirrhotic population (from 27% to 38.5%). Hormone therapy, myeloproliferative neoplasm or other prothrombotic states, and absence of anticoagulant therapy emerged as independent prognostic factors. Future studies should aim at better assessing the risk of recurrence in different patients subgroups and at identifying more accurate prognostic markers.

A 24-Year-Old Man with Previously Diagnosed Hemophilia

A 24-year-old Middle Eastern man diagnosed with hemophilia at the age of 4 or 5 years presented to the hematology clinic for follow-up after a recent hospitalization for excessive bleeding from an accidental knife cut. The patient reported a history of prolonged bleeding after teeth extractions, an upper gastrointestinal bleed 3 years previously, and excessive bruising since childhood. He denied hemarthroses but reported chronic pain in his ankles and joints. The patient reported having been treated for episodes of excessive bleeding with fresh frozen plasma (FFP)3 and factor VIII during past hospitalizations. Because of poor continuity of care, his disease had not been monitored or treated on an ongoing outpatient basis. The patient's family history is noteworthy for consanguineous parents (first cousins) and a sister who also experienced excessive bleeding, although her diagnosis was uncertain. Initial laboratory test results included a normal complete blood count, including platelets, a prolonged activated partial thromboplastin time (aPTT), and a prolonged prothrombin time (PT) (Table 1). Fibrinogen activity was normal. A 1:1 mixture of the patient's plasma with pooled normal plasma demonstrated full correction of the PT and aPTT, a result consistent with factor deficiency. View this table: Table 1. Patient's laboratory results (citrated plasma). ### ADDITIONAL PATIENT DATA AND DIFFERENTIAL DIAGNOSIS Patients with isolated hemophilia A, B, or C (due to deficiencies in factors VIII, IX, and XI, respectively) or factor VIII deficiency due to von Willebrand disease typically have a prolonged aPTT but a normal PT. In the absence of anticoagulation therapy or suspected vitamin K deficiency, a prolonged PT in this patient's initial workup should raise clinical suspicion for a bleeding disorder of a different etiology. Given the patient's clinically notable bleeding symptoms since childhood, a genetic disorder should be considered. The differential diagnosis includes dysfibrinogenemia, prothrombin deficiency, factor V deficiency, combined deficiency of factors V and VIII (F5F8D), factor X deficiency, and hereditary combined deficiency of …