Antiaggregant Therapy Research Articles

Robotic-assisted laparoscopic partial nephrectomy. Retrospective descriptive study over a 10-year period. Anesthetic experience

Introduction: Robot-assisted laparoscopic surgery is currently the surgical treatment of choice for small renal masses.
 Objective: Reviewing the anesthetic management and perioperative morbidity of patients undergoing robotic-assisted laparoscopic partial nephrectomy (RALPN) from 2009 to 2019 at Hospital Universitario Donostia.
 Material and methods: Retrospective, descriptive, observational study involving 343 patients.
 Results: 95 % of the patients were ASA II-III. Transient renal artery clamping was performed in 91 %, with a mean ischemia time of 17.79 minutes. The mean duration of the procedure under balanced general anesthesia was 184 min. Standard monitoring was performed along with invasive arterial pressure monitoring (IAP), central venous catheter (CVC) and EV1000 platform (Edwards®) for complex patients. Complications were recorded in 40 patients (11.67 %). Patients under anti-aggregation therapy experienced more bleeding than non-anti-aggregation patients (p 0.04) but did not require more transfusions. Patients with a higher anesthetic risk did not experience more complications. No statistically significant association was found between worsening renal function and the occurrence of intraoperative complications. 21 patients (6 %) were readmitted due to complications; the most frequent complication was renal artery pseudoaneurysm that required endovascular embolization.
 Conclusions: It should be highlighted that after ten years of experience with this technique, the patients with a higher anesthetic risk have not experienced serious perioperative complications. RALPN is a safe technique that demands a careful anesthetic support. A robot-assisted approach alone is not a guarantee for success without strong teamwork.

Morbidity following image-guided brachytherapy for cervical cancer: Patient and treatment related factors

PurposeThis retrospective study aims to assess factors associated with the occurrence of toxicity after brachytherapy (BT), as boost after external beam radiotherapy (EBRT) for treatment of invasive cervix carcinoma. METHODS AND MATERIALSAll consecutive patients diagnosed with cervical carcinoma, and treated with concurrent radiochemotherapy from August 2017 to January 2020 were retrospectively included. An isodose conformation index (ICI) was developed to assess the percentage of the prescription isodose contained within the intermediate risk clinical target volume (IR-CTV). ResultsEighty-one patients with invasive cervix carcinoma from stage IB to stage IVa were included. Thirty-two (40%) and 49 (60%) patients were treated with Pulsed Dose Rate (PDR) and High Dose Rate (HDR) BT, respectively. Median follow-up was 19.6 months (5.6–41.2). The main factors associated with development of gastrointestinal toxicity were: the median volume of the prescription isodose (67.9cm[3] [37.6–92.9] vs. 49.1cm[3] [34.5–53.5], p = 0.05), the value of ICI (59% [51%-83%] vs. 86% [65%-96%], p = 0.01), the median equivalent dose delivered to the sigmoid (D2cc= 58.4 GyEQD2 [53.9–61.1] vs. 55.2 GyEQD2 [52.8–57.5], p = 0.06) and the median equivalent dose delivered to the IR-CTV (D90= 63.9 GyEQD2 [60.6–66.4] vs. 61.2 GyEQD2 [59.4–64.5], p = 0.03). The proportion of patients who received EBRT lymph node boost was higher in patients who developed urinary toxicity than in patients who did not (57.1% vs. 28.6%, p = 0.08). Anticoagulant (p = 0.02) and antiaggregant therapy (p = 0.01) were associated with occurrence of both urinary and gastrointestinal toxicity. ConclusionSOur study confirms the predictive value of irradiated volume in the occurrence of gastrointestinal toxicity, as well as the need for a better conformation to the target volume. Precautions should be considered in patients with vascular comorbidities.

The viscosity and thrombocytic-aggregation disorders in patients, suffering myocardial infarction with the ST segment elevation

Objective. Analysis of changes in viscosity and disorders of the thrombocytes-aggregation process under impact of various tactical, diagnostic and intervention approaches in patients, suffering myocardial infarction with persistent elevation of ST segment in presence of multivascular affection of coronary arteries.
 Materials and methods. In the investigation four tactical and treatment-diagnostic approaches were used through year of observation.
 Results. In patients, suffering myocardial infarction and persistent elevation of ST segment the hyperviscosity and hypercoagulation syndromes were revealed, which have manifested in first weeks by compensatory growth of thrombocytes quantity, the blood viscosity, level of fibrinogen and aggregation properties of thrombocytes. Conduction of additional more profound examination of coronary blood circulation and further application of postponed stenting of the infarction-dependent arteries have promoted lesser amplitude of fluctuations of all laboratory indices, than in other tactical and treatment approaches.
 Conclusion. Standard tactical and treatment-diagnostic principles in management of such category of patients do not permit to improve the state of the viscosity and coagulation-aggregation parameters principally, even while application of double antiaggregation therapy.

High residual platelet aggregation in patients with coronary artery disease: a new methodological approach to detection

Aim. To develop a new methodological approach to assessment of collagen-induced platelet aggregation in patients with coronary artery disease (CAD) and to determine the quality of various methods for detecting high residual platelet reactivity (HRPR) to predict the risk of myocardial perfusion disturbance. Materials and methods. 36 patients (10 men and 26 women) aged 41–83 years and having stable CAD were examined. All patients had been undergoing continuous antiaggregation therapy for 6 months. We evaluated platelet aggregation using a laser analyzer with collagen as an aggregation inducer by the standard method 1 and our own patented method 2. The degree of platelet aggregation (%) and the size of aggregates in relative units (r.u.) in platelet-rich plasma were estimated. Myocardial perfusion scintigraphy with 99mTc-methoxy-isobutylisonitrile was performed according to a two-day stress-rest protocol. The summed stress score (SSS) values were used for analysis. SSS < 4 was regarded as normal myocardial perfusion. Results . The degree of platelet aggregation according to method 1 was 12 (5; 64)%, the aggregate size was 3 (2; 7) r.u. The degree of platelet aggregation according to method 2 was 44 (13; 78)%, and the aggregate size was 5 (4; 8) r.u. Method 2 allowed to diagnose the presence of myocardial ischemia with an aggregation degree ≥ 44.9% with sensitivity of 84% and specificity of 92% (area under the curve (AUC) = 0.89; p < 0.0001; odds ratio (OR) 2.18; 95% confidence interval (CI) 0.57–0.98) and an increase in aggregate size ≥ 4.80 r.u. with sensitivity of 84% and specificity of 84% (AUC = 0.95; p < 0.00001; OR 5.83; 95% CI 0.72–0.99). Conclusion. In patients with CAD, detection of high rates of collagen- induced platelet aggregation using the patented technique is associated with the risk of impaired myocardial perfusion. The developed new methodological approach to detection of HRPR allowed to determine high risk of atherothrombotic complications in additional 22% of the examined patients.

Risk for Major Bleeding in Patients with Severe Factor XI Deficiency Treated with Aspirin and Clopidogrel

IntroductionIsrael contains within it a unique variety of groups predisposed to autosomal recessive diseases secondary to the history of segregated religious communities. Indicated groups include Ashkenazi Jews and Israeli Arabs. Factor XI deficiency is one of the conditions that can be included in this group of diseases. It is reported to have a prevalence of 8-13.4% within the Ashkenazi Jewish community. Due to the risk for bleeding and delayed coagulation as a result of a deficient Factor XI, it has been suggested to avoid use of Aspirin and Clopidogrel in patients with severe deficiency. However, cardiovascular interventions mandate use of anti-aggregation therapy. We investigated the risk for major bleeding events in patients with severe factor XI deficiency treated with Aspirin and Clopidogrel.MethodsThis is an observational, historical cohort study performed using the electronic data base of Clalit Health organization, largest HMO in Israel. The objective of this study is to determine the incidence of major bleeding in patients with severe Factor XI deficiency (activity ≤ 15%). The study was approved by a centralized IRB committee. In the population of subjects with severe factor XI deficiency we identified subjects treated with Aspirin alone (n=126), Clopidogrel alone (n=38), and subjects treated with both simultaneously (n=21). Individuals were followed retrospectively, during the time on anti-aggregation treatment, for the occurrence of bleeding episodes classified according to bleeding severity; life threatening bleeding, severe bleeding (needed blood transfusion), and minor bleedingResultsOne hundred and eighty five subjects with severe factor XI deficiency were treated with anti-aggregation therapy. Most of the patients treated with Aspirin (68%) followed by Plavix (21%) and both (11%). Among patients treated with aspirin 4.7% (6/126) had life threatening bleeding and 2.3% (3/126) had minor bleeding. Among patients treated with Clopidogrel 2.6% (1/38) had life threatening bleeding, 2.6% (1/38) had severe bleeding, and 2.6% (1/38) had minor bleeding. Among patients treated with Aspirin and Plavix 4.7% (1/21) had life threatening bleeding following a trauma but no other bleeding was observed.DiscussionUse of Aspirin and/or clopidogrel in patients with severe factor XI deficiency is associated with overall low risk for major bleeding. The use of Clopidogrel doesn't seem to add significantly to the risk of bleeding in this unique population. DisclosuresNo relevant conflicts of interest to declare.

Thiotriazolin effectiveness in complex treatment of patients with post-COVID syndrome

The aim of this work is to evaluate the complex therapeutic effect of Thiotriazolin (anticoagulant, antiplatelet, metabolitotropic, endothelioprotective activity) in patients with post-COVID syndrome in comparison with basic therapy. Materials and methods. The studies involved 30 patients aged between 30 to 60 years with post-COVID syndrome. Of these, 15 persons received basic therapy (antibiotics, anticoagulants, acetylsalicylic acid), and other 15 patients received Thiotriazolin in the form of 200 mg tablets twice a day for 30 days against the background of basic therapy. Inclusion criteria were a positive PCR test for COVID-19; if the PCR test was negative, then the patients were enrolled based on the presence of IgM COVID-19 or IgG COVID-19 (with X-ray confirmed pneumonia). The rate of lung damage is up to 45 %. The patients had the following comorbidities: diabetes mellitus in the stage of compensation, arterial hypertension, ischemic heart disease without heart failure. The results of the study were calculated using the standard statistical package Statistica for Windows 13 (StatSoft Inc., № JPZ804I382130ARCN10-J), аs well as SPSS 16.0, Microsoft Office Excel 2003. Results. The inclusion of Thiotriazolin in the complex basic therapy of post-COVID syndrome led to a significant increase in the effectiveness of basic endothelioprotective, anticoagulant and antiaggregatory therapy and contributed to the prevention of thrombus formation. The administration of Thiotriazolin led to a significant improvement in general clinical parameters in patients with post-COVID syndrome – complaints of tachycardia disappeared, blood pressure was stabilized (without additional correction with antihypertensive drugs), weakness and increased fatigue disappeared. Saturation in 14 (93.4 %) patients increased to 97–98 %. In the control group only 7 (46.7 %) of 15 patients had oxygen saturation at 97–98 % level. Conclusions. The introduction of the drug Thiotriazolin in the form of 200 mg tablets twice a day for 30 days into the complex basic therapy of post-COVID syndrome leads to a significant increase in the basic endothelioprotective, antiaggregatory and anticoagulant therapy and contributes to the prevention of thrombus formation against the background of improving the state of the myocardium and vascular endothelium.

The Relationship Between Transthoracic Echocardiography Findings, Localization of Stroke, and Risk Factors in Patients With Ischemic Stroke

Objective: Ischemic stroke is one of the common neurological pathology. Identifying the risk factors and treating cardiac pathologies play an important role in preventing ischemic stroke stroke. In this study, we aimed to examine the relationship between transthoracic echocardiography findings, localization of ischemia and the etiology of stroke.
 Methods: We included 149 patients with ischemic stroke who were followed up at Neurology Department of İzmir Katip Çelebi University Atatürk Training and Research Hospital between January 2018-January 2019. Demographic characteristics of the patients, etiology and localization of stroke, presence of cardiac arrhythmias, and transthoracic electrocardiography findings were recorded and the relationship between these parameters were examined.
 Results: We enrolled 81 female (54.4%) and 68 male (45.6%) patients in this study. The mean age was 68.0312.35. 84.6% of the patients have atherosclerotic and15.4% have cardioembolic stroke. The most common risk factor was hyperlipidemia. Atrial fibrillation was detected in 21.1% of the patients. While atrial fibrillation was more common in patients with cardioembolic stroke, smoking was more common in patients with atherosclerotic stroke. Although most patients had multiple risk factors prior to stroke, almost half of the patients did not use any antiaggregant or anticoagulant therapy. Cardioembolic strokes were positively correlated with greater left atrium width. There was no correlation between transthoracic electrocardiography findings and stroke location.
 Conclusion: Determination of risk factors in patients with ischemic stroke, investigation of cardiac pathologies, and applying appropriate treatments are important in terms of preventing both new and recurrent stroke development.

Hyperbaric oxygenation therapy treatment option in perioperative visual loss in spine surgery

<p class="abstract">Perioperative vision loss (POVL) is a catastrophic complication of spine surgery and several risk factors are identified. As spine fusion surgery is rising in number, POVL incidence is increasing. Preventive strategies can decrease the risk of this complication. Prognosis depends on the level of occlusion and how quickly oxygen supply can be restored to retina. We present a 65-year-old female patient with multiple cardiovascular risk factors that who underwent lumbar fusion. Upon waking up from anesthesia, the patient reported total loss of vision in her left eye. An occlusion of the central retinal artery due to a probable embolic cause was diagnosed and the patient promptly started treatment with anti-aggregation therapy and hyperbaric oxygen therapy (HBOT) with good results. The combination of HBOT with anti-aggregation therapy may have had a synergistic effect contributing to the good outcome presented in this case and may be a good option for the treatment of this patients. </p>

Atherosclerotic Cardiovascular Diseases and Type 2 Diabetes Mellitus - new Developments in the Treatment

Despite obvious success in the management of patients with type 2 diabetes mellitus, incidence of myocardial infarction, stroke, critical ischemia, and lower extremity amputation remains high. Results of clinical studies of new hypoglycemic drugs have demonstrated their high efficacy in decreasing mortality, incidence of cardiovascular complications, and progression of chronic heart failure. At the same time, prevention of atherothrombotic complications is essential for this patient category. Traditionally, the antiaggregant therapy with acetylsalicylic acid (ASA) is administered to patients with stable atherosclerotic diseases to reduce the risk. Attempts of reducing additionally the risk with ASA combinations with other antiplatelet drugs did not produce an expected result. Theoretical prerequisites suggested that anticoagulant supplements would increase the treatment efficacy in prevention of atherothrombotic complications in patients with cardiovascular diseases. Recently emerged oral anticoagulants can be administered at a considerably lower dose. In the COMPASS study, a combination of rivaroxaban 2.5 mg twice a day and ASA 100 mg/day compared to ASA 100 mg/day significantly reduced the total risk of stroke and cardiovascular death by 24 % and incidence of stroke and cardiovascular death by 42% and 22 %, respectively. Patients with peripheral artery disease showed for the first time improvement of prognosis, decreased number of amputations, major complications of lower extremity disease. Results of the COMPASS study confirmed the validity of influencing simultaneously the platelet and the coagulation components of hemostasis in patients with stable atherosclerotic cardiovascular diseases.

Infarto agudo do miocárdio em raro caso de dextrocardia e situs solitus – reconhecendo a síndrome isquêmica aguda em meio à pandemia por COVID-19

The reduction of care for acute coronary syndrome during the COVID-19 pandemic is recognized. We describe a case of a patient with dextrocardia and situs solitus, a rare condition that occurs in adults in up to 1:900 thousand cases, admitted due to acute coronary syndrome in the context of paroxysmal atrial fibrillation. Some of the particularities of the congenital condition are described, such as epidemiology, associated structural abnormalities, and the strategy to perform the examination, as well as the discussion of anti-aggregation and anticoagulation therapies, given the concomitance with arrhythmia.

Analysing the effectiveness of topical bleeding care following tooth extraction in patients receiving dual antiplatelet therapy-retrospective observational study

BackgroundPatients using antiplatelet drugs following infarctions, acute coronary syndrome or stroke pose a significant clinical problem if it is necessary to perform surgery, including dental surgery, since they are at risk of prolonged or secondary post-extraction bleeding. Discontinuation of this therapy is associated with a high risk of serious thromboembolic complications. The purpose of this study was to assess the effectiveness of TachoSil fibrin-collagen patches in stopping and preventing of secondary post-extraction bleeding in patients undergoing chronic antiplatelet therapy.MethodsThe study was conducted through retrospective examination of the medical records of 153 patients using chronic antiplatelet therapy and those qualified for tooth extraction. The largest group comprised 74 patients using aspirin and clopidogrel as dual platelet antiaggregation therapy; in this group 75 tooth extractions were carried out. In all of the patients TachoSil fibrin-collagen patches and stiches were applied to the wounds resulting from tooth removal.ResultsFollowing tooth extraction, primary bleeding was stopped in all the patients and their wounds closed via coagulation within 20–30 min. In eight cases, accounting for 4.9% of the patients, secondary bleeding occurred and was successfully stopped only by applying a pressure dressing soaked in tranexamic acid. Secondary bleeding occurred in three patients on the second day and in five patients on the third day following tooth removal.ConclusionTopical application of TachoSil patches following tooth removal in patients using single or dual antiplatelet therapy effectively stopped bleeding and prevented secondary bleeding after tooth extraction.

The effect of warfarin administration on platelet aggregation.

The aim of this study was to assess the effect of anticoagulation treatment on platelet aggregation. The study group consisted of 24 patients on long-term warfarin therapy without any antiaggregation therapy. Platelet aggregation was measured using VerifyNow with arachidonic acid (AA) as an inducer in 23 patients and with light transmission aggregometry (LTA) in 19 patients using four different agonists. All patients had their international normalized ratio (INR) checked regularly. The mean INR value was 2.07 (SD 0.6). The average aggregation measured by VerifyNow was found to be 637.5 (SD 36.6) aspirin reaction units. The values of average aggregability in LTA were 73.3 % (SD 4.5 %), 73.2 % (SD6 %) and 72.1 % (SD 4.8 %) in case of aggregation induced by AA, ADP, and collagen, respectively. Epinephrine‑induced aggregability was 65.3 % (SD 14.7 %). Regression analysis between INR and values of collagen- or epinephrine‑induced aggregability (r = 0.654 and 0.575) was found statistically significant (p = 0.004 and 0.016); every increase in INR by 0,1 brings about an increase in collagen- and epinephrine‑induced aggregation values by 1.5 and 4, respectively. Administration of warfarin does not produce a significant reduction in platelet aggregation. On the contrary, prolonged INR evokes a mild increase in aggregation induced by collagen or epinephrine (Tab. 2, Fig. 3, Ref. 32). Text in PDF www.elis.sk Keywords: platelet aggregation, anticoagulation, warfarin, platelet function tests, chronic ischemic heart disease.

Statins: cause of fibrosis or the opposite? Effect of cardiovascular drugs in idiopathic pulmonary fibrosis

Background and objectiveIdiopathic pulmonary fibrosis (IPF) is a progressive and irreversible interstitial lung disease with poor prognosis despite the recent availability of two antifibrotic drugs. Patients are more susceptible to cardiovascular comorbidities. In this study, we aimed to determine the impact of concomitant cardiovascular drugs on disease progression and survival in a modern IPF cohort. MethodsThe database of a tertiary referral centre for interstitial lung diseases in Belgium was reviewed for statin, antiaggregant, anticoagulant and metformin therapy. For a study period of four years, we noted both FVC% and DLCO% trajectories along with survival as outcome measurements. Results323 patients were included of which 45% had at least one cardiovascular comorbidity. 274 (86%) patients received antifibrotic therapy. Statin users (n = 171) displayed significantly slower annual FVC% (difference 2.9%, CI 1.6–4.4, p < 0.001) and DLCO% decline (difference 1.3%, CI 0.24–2.3, p = 0.013). Results for antiaggregant therapy (n = 152) were inconclusive: we found a trend for slower FVC decline (p = 0.098) and a numerically decrease in survival rates (HR 1.63, p = 0.074) in a multivariate Cox analysis. Anticoagulant use (n = 49) showed a trend towards worse DLCO decline (difference −1.3%, CI -2.6 - 0.02, p = 0.055).r Metformin (n = 28) therapy did not affect IPF progression in terms of pulmonary function test evolution or survival. ConclusionThis retrospective study demonstrated a benefit of statin therapy on IPF progression. Our observations emphasize the need for large clinical trials analysing the effect of statins, as well as other cardiovascular drugs, in the management of IPF patients.

Possible Approaches to Primary Prevention of Cardiovascular Diseases

In recent years there is a positive trend in the development of preventive medicine, in particular, primary prevention of diseases. However, in most cases, patients seek help from a doctor after the manifestation of the disease, and therefore, early identification of risk factors (RF) remains relevant. Conduction of a large number of studies that are aimed at studying modifiable RF associated with the development of cardiovascular diseases (CVD), allowed the experts of the American Heart Association to develop recommendations “Life's Simple 7”, which makes it possible to structure methods of primary prevention of CVD and minimize the risk of their development. In 2019, experts from the American College of Cardiology presented a simplified version of these recommendations, to improve approaches to primary prevention and their effectiveness not only for doctors but also for patients. Thus, by involving the patient in the decision-making process about follow-up treatment, doctors can achieve a high level of compliance, which is essential for improving the prognosis. The “ABCDE” recommendations, in name of which are reflected the first letters of the leading CVD RF, include such paragraphs as RF assessment, the use of antiaggregating therapy, correction of blood pressure, cholesterol levels, smoking elimination, correction of high glucose levels and diabetes treatment, weight loss, assessment of social and economic factors affecting the morbidity in a particular patient. Despite the undoubted benefit of the “ABCDE” recommendations, some problems of primary prevention currently cannot be solved: the inability to accurately assess social and economic RF; the imperfection of the used CVD risk scales. The updated version of the recommendations allows not only to assess the existing RF of the patient, but also to effectively correct them. In addition, the patient himself can read the recommendations, which improves understanding of the primary prevention importance.

Lumbar puncture in patients on anticoagulants

Lumbar puncture is an important invasive procedure often used in the diagnosis of neurological disorders. Generally, lumbar puncture is a safe procedure, with a very low incidence of serious complications, the risk of which, however, may increase in the group of patients on anticoagulant therapy (anticoagulants and platelet anti-aggregation agents). This applies to both the risk of haemorrhagic complications and the risk of thrombotic events during temporary discontinuation of anticoagulants. This paper presents the current knowledge on the management in patients receiving anticoagulants (vitamin K antagonists, new anticoagulants, heparins, fondaparinux) and platelet anti-aggregation agents (P2Y12 platelet receptor antagonists, glycoprotein IIb/IIIa inhibitors, acetylsalicylic acid) who require lumbar puncture. Furthermore, we present the issue of bridging therapy in patients at a high risk of thrombotic complications. In the case of neurological indications for a lumbar puncture in a patient on anticoagulants or anti-aggregation therapy, the urgency of the procedure and the risk of adverse effects should be assessed and other diagnostic methods should be considered in the first place. If there is a need for an urgent lumbar puncture, treatment modification or the use of drugs to reverse the anticoagulant or anti-aggregation effect may be necessary. Each case must be treated individually, considering medical and family history, comorbidities and other medications taken by the patient. Most of the available recommendations related to the presented problem have been developed by anaesthetic associations. There is a need to popularise the principles of management in patients on anticoagulants who require lumbar puncture due to neurological disorders.

Cryptogenic Stroke and Valvular Strands.

BackgroundIschaemic stroke can be classified according to its aetiology. In cryptogenic stroke, Lambl’s excrescences should be considered since they can only be detected through transesophageal echocardiography (TEE), which is not routinely performed.Case descriptionThe authors report the case of a 63-year-old Caucasian man with two ischaemic cerebral events associated with the presence of Lambl’s excrescences in the aortic valve detected with TEE. Switching antiaggregant therapy to anticoagulant therapy allowed the patient to remain asymptomatic throughout a 3-year follow-up.ConclusionThe lack of protocols for the management of cryptogenic stroke results in a delay in the identification of less frequent causes of stroke, leading to recurrent vascular events, morbidity and loss of functionality. The authors describe a patient who experienced multiple cerebral ischaemic events until the correct diagnosis was made.LEARNING POINTSLambl’s excrescences are a considered a rare cause of embolic stroke, probably because they are underdiagnosed.The pathophysiology is not fully understood, making therapeutic decisions difficult.Early recognition and management of this structural valve disease can prevent life-threatening complications.

Subretinal alteplase injections in massive subretinal hemorrhage due to age-related macular degeneration: A case report series.

This report describes a series of cases with massive subretinal hemorrhage (SRH) due to age-related macular degeneration (AMD) treated by subretinal alteplase injections. In all cases, the surgical technique consisted in 25-gauge pars plana vitrectomy (PPV) and alteplase injection under the retina using a 38-gauge cannula. After the fluid-gas exchange, bevacizumab injection was performed in all patients. Three cases of SRH in which this technique was used, as well as their evolution at one week and one month postoperatively are described. Visual acuity was hand motion in all three cases at presentation. After surgery, a significant anatomical and functional improvement was noted in all cases. One month postoperatively, none of the patients had blood under the macula, and visual acuities significantly improved to 0.8, 0.2 and 0.16 (decimal fraction). A consistent reduction of central retinal thickness was observed on optical coherence tomography (OCT) from the first week postoperatively. No intra and postoperative complications were noted. Subretinal alteplase injection proved as a viable solution in these severe SRH with early presentation. There was no need to change the systemic anticoagulant and antiaggregant therapy. Bevacizumab intravitreal injection at the end of surgery has an important role in preventing further bleeding.

Intra-operative local plus systemic tranexamic acid significantly decreases post-operative bleeding and the need for allogeneic blood transfusion in total knee arthroplasty.

Aim To evaluate the efficacy of systemic plus local tranexamic acid (TXA) in reducing post-operative bleeding, haemoglobin loss and the need for allogeneic blood transfusion (ABT) in total knee arthroplasty (TKA). Methods All patients undergoing TKA between January 2017 and September 2019 were retrospectively evaluated. Exclusion criteria were cardiovascular comorbidities, diabetes and the assumption of any anticoagulant/antiaggregant therapy in the pre-operative period. All patients received the same prosthesis with the same surgical technique and were operated on by the same surgeon. Twenty patients were found (group A) that received intra-operative TXA (20 mg/kg intravenous 10 minutes before deflating tourniquet and 1g intra-articular after capsular suture). A control group of 26 patients not receiving TXA was matched for demographics (group B). Results Two (10%) patients in group A and 16 (61.5%) in group B needed ABT in the post-operative period (p=0.0004). Each patient in group A received 2 red blood cells (RBCs) units, while in group B 2 patients received one RBCs unit and one patient 4 RBCs units, for a total of 4 and 32 RBCs units in group A and B, respectively (p=0.0006). The minimum haemoglobin level was observed at 48 hours post-operatively in both groups: mean decrease was 3.54 and 4.64 g/dL in group A and B, respectively (p=0.0126). Conclusion The association of systemic and local TXA administration seems to significantly reduce post-operative bleeding and the need for RBCs transfusions after TKA in patients not assuming any anticoagulant / antiaggregant therapy and without cardiovascular and diabetic morbidities.

Evaluasi Penggunaan Aspirin Jangka Panjang terhadap Fungsi Ginjal Pasien Penyakit Jantung Koroner

Low-dose aspirin (75-100 mg/day) is a long-term platelet antiaggregation therapy for certain coronary heart disease (CHD) patients. This study aims to evaluate the long-term use of aspirin on kidney function by examining the changes in the levels of serum creatinine, blood urea nitrogen (BUN), and creatinine clearance of CHD patients. The research method used was a prospective observational cohort analysis. The number of study subjects was 37 CHD patients who took 80 mg/day of aspirin and never experienced kidney disease. Serum creatinine and BUN levels were examined in the 1st and 3rd month of the study. Patient creatinine clearance values were calculated using the Cockcroft-Gault equation. The results of the study showed that the mean levels of serum creatinine, BUN, and creatinine clearance on the 1st and 3rd month were 1.03 ± 0.27 mg/dL and 1.03 ± 0.29 mg/dL; 13.05 ± 4.10 mg/dL and 14.65 ± 4.44 mg/dL; 73.16 ± 18.14 mL/min and 72.92 ± 19.76 mL/min, respectively. The paired t-test results showed that the differences in the mean of creatinine serum, BUN, and creatinine clearance on the 1st and 3rd month were not statistically significant (p &gt; 0.05). The One Way ANOVA test results on the effect of the duration of aspirin use on kidney function were also not statistically significant (p &gt; 0.05) however there is a tendency to decrease creatinine clearance and increase in serum creatinine and BUN. Long-term use of low-dose aspirin has the potential to cause a decrease in kidney function that is seen from a decrease in creatinine clearance as well as an increase in serum creatinine and BUN.

COVID-19 retinal microangiopathy as an in vivo biomarker of systemic vascular disease?

COVID-19 is caused by SARS-CoV-2, a betacoronavirus that uses the angiotensin-converting enzyme-related carboxypeptidase (ACE2) receptor to gain entry into cells. ACE2 receptor is widely expressed in multiple organs, including the retina, an extension of the central nervous system. The ACE2 receptor is involved in the diabetic and hypertensive retinopathy. Additionally, coronaviruses cause ocular infections in animals, including retinitis, and optic neuritis. To assess whether there is any retinal disease associated with COVID-19. We have evaluated 27 asymptomatic subjects, with retinal fundoscopic, optical coherence tomography (OCT) and OCT angiography fourteen days after hospital discharge due to COVID-19 bilateral pneumonia. Cotton wool exudates were evident in six out of 27 patients evaluated, a 22%. Cotton wool exudates are a marker vascular disease severity in other medical context, that is diabetes and hypertension, and are associated with increased risk for acute vascular events. Whether antiaggregation therapy may play a role on fundoscopic-selected patients with COVID-19 requires prospective trials.