Blood-thinning Medication Research Articles

Management of blood thinning medications in elderly populations presenting with rectal bleeding: Are we doing right?

Introduction Rectal bleeding commonly occurs in elderly patients using blood thinners, posing management challenges due to limited guidance on reversal agents and medication restart criteria. This study aims to review the demographics and management of elderly patients with rectal bleeding while on blood thinners. Methods A retrospective analysis of patients aged 60 or older presenting with rectal bleeding at West Suffolk Hospital’s emergency department was conducted from January 2018 to December 2020. Data were extracted from electronic records, focusing on patients using blood thinners and adhering to British Society of Gastroenterology guidelines. All patients ceased blood-thinning medications upon admission. The hospital’s ethics committee approved the study, which focused on demographics, diagnosis, and management, particularly regarding re-initiation of blood-thinning medicines. Results During the study period, 170 patients were admitted to the emergency department of West Suffolk Hospital. 93 (54.71%) patients were included in the study. The average age of the participants was 82 years, and 62.3% were male. All patients were followed up for three months. Atrial fibrillation accounted for 52% of patients, while previous strokes accounted for 20%. The most typical pathology was diverticulosis. Regarding restarting of anticoagulants, Among patients on DOAC (Direct oral anticoagulant), 39% were restarted on discharge, 23% were switched to warfarin, and another 23% were not restarted; 15% planned to restart after seven days. For those on Warfarin, 62% were restarted on discharge, 22% stopped the medication, and the rest were switched to Dual Oral Anticoagulant. Among aspirin patients, 60% were restarted at discharge, while the remaining discontinued. All patients receiving clopidogrel and dual antiplatelet therapy were started at discharge. None of the patients were readmitted during the follow-up period of 3 months. Conclusion Restarting of blood-thinning drugs in patients with rectal bleeding is subject to individual patient variation. Necessitates more extensive trials to achieve greater standardization.

Predictors and surgical outcome of hemorrhagic metastatic brain malignancies

PurposeIntracerebral metastases present a substantial risk of tumor-associated intracerebral hemorrhage (ICH). This study aimed to investigate the risk of hemorrhagic events in brain metastases (BM) from various primary tumor sites and evaluate the safety and outcomes of surgical tumor removal.MethodsA retrospective, single-center review of medical records was conducted for patients who underwent BM removal between January 2016 and December 2017. Patients with hemorrhagic BM were compared to those with non-hemorrhagic BM. Data on preoperative predictors, perioperative management, and postoperative outcomes were collected and analyzed.ResultsA total of 229 patients met the inclusion criteria. Melanoma metastases were significantly associated with preoperative hemorrhage, even after adjusting for confounding factors (p = 0.001). Poor clinical status (p = 0.001), larger tumor volume (p = 0.020), and unfavorable prognosis (p = 0.001) independently predicted spontaneous hemorrhage. Importantly, preoperative use of anticoagulant medications was not linked to increased hemorrhagic risk (p = 0.592). Surgical removal of hemorrhagic BM, following cessation of blood-thinning medication, did not significantly affect intraoperative blood loss, surgical duration, or postoperative rebleeding risk (p > 0.096). However, intra-tumoral hemorrhage was associated with reduced overall survival (p = 0.001).ConclusionThis study emphasizes the safety of anticoagulation in patients with BM and highlights the safety of neurosurgical treatment in patients with hemorrhagic BM when blood-thinning medication is temporarily paused. The presence of intra-tumoral hemorrhage negatively impacts survival, highlighting its prognostic significance in BM patients. Further research with larger cohorts is warranted to validate these findings and elucidate underlying mechanisms.

Survey on blood thinning therapy in patients with age-related macular degeneration

Patients with age-related macular degeneration (AMD) often receive concomitant systemic blood thinning medications. These are known to increase the risk of severe hemorrhage also in connection with AMD, which can lead to extensive subretinal hemorrhaging. The purpose of this study was to investigate the proportion of patients with AMD and concomitant blood thinning treatment, including the type and reason for blood thinning treatment. This survey was prospectively conducted at the University Eye Hospital, Bonn, Germany. Volunteers were recruited during retinal consultations and the consultations for intravitreal injections (IVOM). The questionnaire was completed by 178 patients. The mean age was 81.7 years (58-100) and 101 patients (57.7%) were undergoing blood thinning treatment. The majority of patients were taking antiplatelet agents (n = 59; 58.4%), especially ASA (n = 55; 54.5%). Direct oral anticoagulants (DOAC) were taken by 33patients (32.7%), including most frequently apixaban (17.8%). VitaminK antagonists (VKA) was taken by 4patients (4%). The most common reason for blood thinning treatment was atrial fibrillation (n = 32, 31.7%), followed by stent implantation (n = 20, 19.8%) and stroke (n = 12, 11.9%) but 13 patients (12.9%) did not know why they were undergoing blood thinning treatment. No clear indications for the use of blood thinners were found in 31patients (30.7%). Alarge proportion of patients with AMD undergo blood thinning treatment; however, not every patient has aclear indication. Due to the increased risk of bleeding, the use of blood thinners should be critically evaluated in close cooperation with primary care physicians and cardiologists.

Hemoglobin F and Incidence of Thrombotic Event in Sickle Cell Disease

Introduction Characterized by abnormally sickle-shaped erythrocytes disrupting blood flow in small vessels, Sickle Cell Disease (SCD) continues to be the most common hemoglobinopathy in the United States, affecting approximately 100,000 people (Onimoe & Rotz, 2020). A 2017 cohort study of SCD patients found that there is an increased risk and earlier incidence of venous thromboembolisms compared to their matched controls (Brunson et al., 2017). Fetal hemoglobin (HbF) is the best characterized modifier of disease severity in SCD, and historically, patients with low HbF percentages are at a higher risk of developing vaso-occlusive complications, organ damage, and early death (Agrawal et al., 2014). We hypothesize that having a higher hemoglobin F (unaffected by sickle cell mutation), would confer some protection from hemolysis and would be inversely related to the incidence of thrombosis in sickle cell disease patients. Methods This study uses a descriptive and cross-sectional design to analyze existing, secondary medical record data of 496 SCD patients that received care from the Center for Blood Disorders in Augusta, Georgia. Data abstraction included history of thrombotic event (TE) and HbF values closest to the TE, along with, presence of SCD clinical complications, use of blood thinning medications, specific lab values, hemoglobin electrophoresis, and history of COVID-19. For those without a history of TE, the most recent data in these categories was collected. To test the association of HbF with a categorical variable such as medical history of thrombosis, we used a two-sample t-test. To test the association of HbF with a continuous variable such as D-dimer, we computed Pearson's correlation coefficient and used Fisher's z-test. Patients with SCD who developed thrombosis were further divided into quantiles based on HbF levels [Table 1]. We collected mean age at thrombosis and mean D-dimer for these quantiles and ANOVA was used for statistical analysis. All analyses were performed using R version 4.2.3. Results Of the 496 charts reviewed, 131 patients had a history of TE and 27 of those patients have more than one recorded TE (total=189). Twenty patients did not have HbF data close to TE and were not included in this analysis. The mean HbF for patients without history of TE was 8.89 (SD 10.0), whereas the mean HbF for patients with history of TE was 10.1 (SD 10.3). A two-sample t-test comparing these two groups produced a p-value of 0.2126. Mean age of thrombosis in each quantile were 31.6 (SD 14.6), 28.7 (SD 10.5), 34.8 (SD 11.7), and 37.1 (SD 11.9), respectively, with ANOVA producing a p-value of 0.008059. Mean D-dimer in each quantile were 1017 (SD 1408), 1417 (SD 1415), 1404 (SD 1493), and 2921 (SD 8898), respectively, with ANOVA producing a p-value of .6645. Conclusions While there is no significant relationship between mean HbF levels and development of thrombosis in this cohort of 496 SCD patients, the mean age of development of thrombosis was significantly higher in higher quantiles of HbF, compared to lower quantiles, suggesting that patients with higher HbF are protected longer from thrombosis. There was no relationship between mean D-dimer level and development of thrombosis in the patients we analyzed. In SCD patients with thrombosis, D-dimer was not significantly associated with thrombosis even between different quantiles of HbF. To our knowledge, this is the first study evaluating association between HbF level, D-dimer, and development of thrombosis in SCD patients. Current therapies for SCD focus on symptom management and disease modification. While the mechanism is still not completely understood, Hydroxyurea increases the number of red blood cells (RBCs) with detectable HbF, protecting RBCs from sickle hemoglobin polymerization, thus interrupting the natural disease pathophysiology (Steinberg, 2020). Some gene therapy for sickle cell disease aims at increasing HbF in SCD patients (Abraham & Tisdale, 2021). Would such therapy be protective against increased risk of thrombosis associated with SCD, remains to be determined. One limitation of this project is the restricted sample size of SCD patients with thromboembolism, and larger data size of sickle cell patients may better elucidate a relationship between Hemoglobin F and thrombosis in SCD patients.

Abstract 176: Management of Unruptured Intracranial Aneurysms in SubArachnoid Hemorrhage

Introduction Subarachnoid hemorrhage (SAH) has an estimated prevalence of 7.9 per 100,000 person yearsi. It is primarily caused by the rupture of intracranial aneurysms, leading to severe consequences and a 60% 6‐month mortality rateii. The management of UIAs in SAH cases poses a unique dilemma due to the potential increased risk of rupture, especially when the exact source of SAH remains ambiguous in the presence of multiple UIAs. Although tools like the PHASES scoreiii and the Unruptured Intracranial Aneurysms Treatment Score (UIATS)iv help guide aneurysm management, they are not tailored specifically to the scenario of UIAs in SAH. Thus, there is a need to study and comprehend the management strategies and outcomes of these cases. We reviewed the management and outcomes of UIAs in SAH at our institution in the past 10 years. Methods A retrospective review of all patients presenting between July 2013 and July 2023 with SAH and one concomitant UIA at our institution were analyzed. Results A total of 79 patients with confirmed UIA on angiography met inclusion criteria. Of these, 20 patients (25.3%) with UIAs were intervened on, as opposed to 59 (74.7%) that were not. UIAs >7 mm in diameter were found in 6 patients, and of these, 5 patients received intervention. 45.6% of the patients had a Hunt Hess Score of ≥3, and of these, 27.8% were intervened on. 72.2% of the patients had a Modified Fisher score >2, and of these, only 22.8% of the UIAs were intervened on. 58.2% of patients had a PHASES score >3, and of these, 34.7% were intervened on. Of the patients that were intervened on, 80% had a PHASES score >3. There was no significant difference in the UIATS score between the two groups. 34.9% of patients were noted to have the UIA in the same vascular territory as the SAH and of these 36.3% were intervened on. Current use of blood thinning medication, personal history of SAH or UIA, hypertension history, age, nor gender significantly affected the rate of UIA intervention Conclusion The majority of the UIAs in SAH were not intervened on, and the PHASES score and the UIATS score did not correlate with the decision on intervention. Of the ones that were intervened on, most of them were in the same vascular territory as the SAH. The decision to intervene appears to be on a case‐by‐case basis.

Hemorrhagic Safety of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Tremor without Interruption of Antiplatelet or Anticoagulant Therapy

Introduction: Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is an incision-less ablative technique used to treat medically refractory tremor. Although intracerebral hemorrhage has not been reported with MRgFUS thalamotomy for the treatment of movement disorders, clinicians commonly interrupt active blood thinning medications prior to the procedure or offer gamma knife radiosurgery instead. However, MRgFUS uses focal thermoablation, and bleeding risk is likely minimal. This study aimed to evaluate the safety of MRgFUS thalamotomy in patients with essential tremor (ET) and tremor-dominant Parkinson’s disease (PD) without interrupting anticoagulant or antiplatelet therapies. Methods: This was a single-center retrospective case series of all patients with ET or PD undergoing MRgFUS from February 2019 through December 2022 (n = 96). Demographic variables and medications taken at the time of surgery were obtained. Our primary outcome was the type and frequency of hemorrhagic complications noted on the operative report or postoperative imaging. Results: The mean age of patients was 74.2 years, and 26% were female. Forty patients were taking ≥1 antiplatelet or anticoagulant medications. No patient actively taking anticoagulant or antiplatelet therapies had a hemorrhagic complication during or <48 h after the procedure. Conclusion: The frequency of intra- or postoperative complications from MRgFUS was not higher in patients actively taking anticoagulant or antiplatelet therapies relative to those who were not. Our findings suggest that MRgFUS thalamotomy does not necessitate interrupting anticoagulant or antiplatelet therapies. However, given the limited number of patients actively taking these therapies in our cohort (n = 40), additional testing in large, prospective studies should be conducted to further establish safety.

(220) Penile Enhancement Supplements: The Only Thing Getting Bigger is Demand &amp; False Hope

Abstract Introduction Penile dysmorphophobia is common, with up to 20% of men reporting dissatisfaction with their genital size. The global market for Sexual Enhancement Supplements is estimated at $300 Million in the year 2020 and is projected to reach $608 Million by 2027 in the US alone. Evidence for efficacy is minimal, and purported claims are hyperbolic. Objective We sought to assess penile elongation internet offerings, quantify cost, ingredients, and risk and investigate scientific literature of product ingredients when available. Methods Three online marketplaces (Amazon, Google market, and Walmart) were queried for dietary supplements available without a prescription to improve penile size. Product labels were reviewed to compile penile size-related claims and active ingredients. The one-course (60-day) cost of treatment and consumer star rating were assessed. MEDLINE, Web of Science, and Google Scholar were queried with labeled ingredients to assess the scientific evidence from published and lay sources. Results A total of 84 dietary supplements claimed either increased penile length, girth, enhanced sexual performance, or a combination thereof. Of these 84 products, 90 ingredients were listed. The Mean 60-day cost was $52 (range of $12–$222). The median score by consumers in the markets with a possibility of star rating was 3.5 (range 2.4-4.2) with obvious repetitive and self-promotional tactics. Unsurprisingly, no scientific evidence supporting change in penile size was found for any products in our search. Actual described physiologic activity from active ingredients included were described as antidepressant, lipid and glucose lowering/metabolizing, blood pressure effecting, anti-inflammatory, renally protective, cognitive function effecting, antioxidant, and several ingredients weakly enhancing erectile activity. Renal failure, warnings against long-term use, heart problems, neuropathy, blood pressure effects, fertility toxicity, bleeding, liver disease, and numerous interactions with diabetes, blood thinning, immunosuppressant, and PDE5 medications were found for the ingredients. Conclusions Dietary supplements claiming to enhance penile size contained ingredients with conflicting or no scientific evidence to support their claims. Several ingredients were dangerous. Clinician awareness of these sham “solutions” and their continued mass consumption highlight the magnitude of misinformation, unrealistic expectations, shame, and enhancement desperation regarding penile size in the male public psyche. Disclosure No

Improving Prescribing through User-Centered Design: Design Guide and Interface Examples for Anticoagulant Medication Alerts

Direct Oral Anticoagulants (DOACs) are beneficial blood-thinning medications that are frequently misprescribed. Clinical decision support systems can be effective in reducing these prescription errors through well-designed medication alerts. The effectiveness of alerts can be improved through a User Centered Design (UCD) process. We describe the multi-stage UCD process used to (1) produce initial draft alerts, (2) refine the designs, and (3) validate the designs and findings. The resulting prototype DOAC prescribing alert design is presented with annotations of design principles that were derived and applied. The principles of design for these DOAC medication alerts may be relevant more broadly to the design of other medication alerts.

Antiplatelet and anticoagulant therapy in patients with submacular hemorrhage caused by neovascular age-related macular degeneration

PurposePatients with extensive submacular hemorrhage (SMH) caused by age-related macular degeneration (AMD) have a poor visual prognosis despite surgical intervention. Systemic blood-thinning drugs, which are commonly prescribed in the same age group, are known to increase the risk of severe hemorrhage in many parts of the body. This study aimed to investigate whether systemic blood-thinning drugs have an impact on the severity of SMH and if there are differences between the different types of blood-thinning medication.MethodsWe reviewed the medical records of patients who suffered from surgically treated SMH between 2020 and 2022. All patients received a full ophthalmologic examination upon presentation including best-corrected visual acuity (BCVA) and optical coherence tomography. Other characteristics that were recorded included size of hemorrhage, blood-thinning therapy, and reason for intake.ResultsA total of 115 patients with a mean age of 82 years were included in this retrospective analysis. Eighty-three patients (72.2%) were on blood-thinning therapy. The mean size of SMH was 32.01 mm2. Mean BCVA at initial presentation was 1.63 logMAR and 1.59 logMAR 1 year after surgery. The size of SMH was significantly larger in patients on blood-thinning medication (35.92 mm2 vs. 21.91 mm2) (p = 0.001) and their BCVA postoperatively was worse with 1.68 logMAR compared to 1.30 logMAR after 1 year (p = 0.503). Patients with vitamin K antagonists had larger SMH size and worse outcomes regarding BCVA compared to direct oral anticoagulants.ConclusionBlood thinners in patients with AMD affect the severity of SMH. Consequently, the indication for their intake should be critically evaluated.

172 Quality improvement project on the peri-procedural management of lumbar punctures

IntroductionCancellation rate of elective lumbar punctures (LPs) due to inappropriate management of antithrombotic medications and lack of adequate training of junior doctors in the peri-procedural man- agement of LPs encouraged us to conduct a quality improvement project aiming to address these issues.MethodsRetrospective review of day case elective LPs (01/10/2018 - 01/01/2019) Junior doctor surveys aiming to assess LP related knowledge and confidenceResults37.5% (75/200) of the scheduled LPs were cancelled due to mistakes in the pre-procedural man- agement of patients’ blood-thinning medication. Junior doctors’ knowledge of consent and antithrom- botic management was suboptimal. As was self-reported confidence and competency in independent performance of LPs at CMT/SHO level.Change implementedImplementation of Trust-approved Guidelines on peri-procedural management of LPs based on systematic review of literatureLP training clinicRe-audit.LP cancellation rate fell to 8% after implementation of these measures (15/04/2019 - 15/07/2019) with meaningful improvement in LP knowledge/confidence of junior doctors. christinamousele92@gmail.com

Does Pre-existing Anticoagulation or Antiplatelet Therapy Increase the Risk of Traumatic Subarachnoid Hemorrhage Progression?

Isolated traumatic subarachnoid hemorrhage (tSAH) is a common finding in mild traumatic brain injury that often results in transfer to a tertiary center. Patients prescribed blood-thinning medications (BTs) are believed to be at higher risk of clinical or radiographic worsening. To compare the rates of radiographic progression and need for neurosurgical intervention in patients with tSAH who are on anticoagulation (AC) and antiplatelet (AP) therapies with those who are not. Analysis using a retrospective cohort design identified patients older than 18 years with isolated tSAH and a Glasgow Coma Scale of 15 on admission. Clinical information including use of BTs, administration of reversal agents, radiographic progression, and need for neurosurgical intervention was collected. Patients on BTs were divided into AP, AC, and AP/AC groups based on drug type. Three hundred eighty-four patients were included with 203 in the non-BT group and 181 in the BT group. Overall, 2.1% had worsening scans, and none required operative intervention. There was no difference in radiographic worsening between the non-BT and BT groups (2.4% vs 1.6%; P = 1.00). Crosswise comparison revealed no difference between the non-BT group and each BT subtype (AP, AP/AC, or AC). The non-BT group was more likely to have radiographic improvement than the BT group (45.8% vs 30.9%; P = .002). Neurologically intact patients on BTs with isolated tSAH are not at increased risk of radiographic progression or neurosurgical intervention. The presence of BTs should not influence management decisions for increased surveillance.

The role of anticoagulation for superior sagittal sinus thrombosis following craniotomy for resection of parasagittal/parafalcine meningiomas

The safety and efficacy of anticoagulation in managing superior sagittal sinus (SSS) thrombosis remains unclear. The present study investigated the relationship between anticoagulation and cerebrovascular complications in parasagittal/parafalcine meningioma patients presenting with post-surgical SSS thrombosis. We analyzed 266 patients treated at a single institution between 2005 and 2020. Bivariate analysis was conducted using the Mann-Whitney U test and Fisher's exact test. Multivariate analysis was conducted using a logistic regression model. Blood thinning medications investigated included aspirin, warfarin, heparin, apixaban, rivaroxaban, and other novel oral anticoagulants (NOACs). A symptomatic SSS thrombosis was defined as a radiographically apparent thrombosis with new headaches, seizures, altered sensorium, or neurological deficits. Our patient cohort was majority female (67.3%) with a mean age ([Formula: see text] SD) of 58.82 [Formula: see text] 13.04years. A total of 15 (5.6%) patients developed postoperative SSS thrombosis and 5 (1.9%) were symptomatic; 2 (0.8%) symptomatic patients received anticoagulation. None of these 15 patients developed cerebrovascular complications following observation or anticoagulative treatment of asymptomatic SSS thrombosis. While incidence of any other postoperative complications was significantly associated with SSS thrombosis in bivariate analysis (p = 0.015), this association was no longer observed in multivariate analysis (OR = 2.15, p = 0.16) when controlling for patient age, sex, and anatomical location of the tumor along the SSS. Our single-institution study examining the incidence of SSS thrombosis and associated risk factors highlights the need for further research efforts better prognosticate this adverse outcome. Conservative management may represent a viable treatment strategy for patients with SSS thrombosis.

Trigeminal Neuralgia: Current Approaches and Emerging Interventions.

Trigeminal neuralgia (TN) has been described in the literature as one of the most debilitating presentations of orofacial pain. This review summarizes over 150 years of collective clinical experience in the medical and surgical treatment of TN. Fundamentally, TN remains a clinical diagnosis that must be distinguished from other types of trigeminal neuropathic pain and/or facial pain associated with other neuralgias or headache syndromes. What is increasingly clear is that there is no catch-all medical or surgical intervention that is effective for all patients with trigeminal neuralgia, likely reflective of the fact that TN is likely a heterogenous group of disorders that jointly manifests in facial pain. The first-line treatment for TN remains anticonvulsant medical therapy. Patients who fail this have a range of surgical options available to them. In general, microvascular decompression is a safe and effective procedure with immediate and durable outcomes. Patients who are unable to tolerate general anesthesia or whose medical comorbidities preclude a suboccipital craniectomy may benefit from percutaneous methodologies including glycerol or radiofrequency ablation, or both. For patients with bleeding diathesis due to blood thinning medications who are ineligible for invasive procedures, or for those who are unwilling to undergo open surgical procedures, radiosurgery may be an excellent option—provided the patient understands that maximum pain relief will take on the order of months to achieve. Finally, peripheral neurectomies continue to provide an inexpensive and resource-sparing alternative to pain relief for patients in locations with limited economic and medical resources. Ultimately, elucidation of the molecular mechanisms underlying trigeminal neuralgia will pave the way for novel, more effective and less invasive therapies.

Turmeric: A holistic Solution for Biochemical malfunction

Turmeric: A holistic Solution for Biochemical malfunction

EP.TU.440Managements of blood thinning medications in elderly populations presenting with rectal bleeding: Are we doing it right?

Abstract Purpose Rectal bleeding is a common adverse effect of blood thinners in elderly patients resulting in admission. Our aim is to review the management of bold thinning medications in populations. Methods A retrospective analysis of patients admitted with per-rectal bleed from 2018 to December 2020 was performed. All patients above the age of 60 years on blood-thinning medications were analyzed in terms of management and discharge. Results A total of 93 (54.71%) patients out of 170 were included in the study. The median age was 83 years. The majority of them were on Direct Oral-Anticoagulants (DOAC) (35.4%), Clopidogrel (26.8%) and Aspirin (32.5%) with remaining on warfarin (14%) and dual anti-platelets (3.2%). On admission DOAC and warfarin was stopped in all the patients and antiplatelets was stopped in 76% of them. Identical percentage of patients in all the groups required blood transfusion. At discharge, DOAC was restarted in 33% of the patients with similar percentage discontinued. 6% were switched to alternative and the rest were due to outpatient review. Warfarin and antiplatelets was restarted in 61% and 62% of the patients respectively. Alternative medications were initiated on 7.6% of patients on warfarin and 5.4% on antiplatelets. Readmissions were mainly seen in patients on antiplatelets (10%). No patients in the study developed thrombotic complications. Conclusion Individual patient circumstances lead to variations in the management of blood thinning medications with per-rectal bleed. Larger trials are needed to ensure uniformity. Readmissions were mostly seen in patients on antiplatelets.

Recommencement of anticoagulation/antiplatelet therapy following non-operative management of a Chronic Subdural Hematoma - Is there an optimal time frame?

Background: There is no consensus among clinicians regarding recommencement of antithrombotic agents following conservative management of a Chronic Subdural Hematoma (cSDH). Thus, the primary objective of this study was to determine the most commonly recommended interval and whether the data reveal a general consensus that should be adopted.Methods: A retrospective analysis of Salford Royal Foundation Trust’s Neurosurgical referral database for patients referred with a cSDH between March 2017 and March 2020 was carried out. Patients were sorted by whether they were on blood-thinning medications.Results: Over the 3-year period, there were a total of 1220 referral and 1099 patients. 502 (41.14%) of these referrals and 479 (43.59%) patients were on one more blood thinning agent. Of these patients 221 (46.13%) conservative management, there was a clear male predominance (M: F ≈ 2.5:1) in this cohort. 2 weeks was the most commonly advised time-frame (n = 76, 36.36%) to withhold. Of the 234 referrals, there were 13 (5.88%) re-referrals in total. Crucially, there was no significant difference in reaccumulation rates between patients asked to withhold their blood thinners for 2 weeks versus those asked to stop for longer than 2 weeks (P = 0.57).Conclusion: For the majority of bleeds, there is no clear benefit from asking patients to withhold their anticoagulant/antiplatelet for longer than 2 weeks. In cases, where it is deemed appropriate to stop for longer than 2 weeks, clear instructions should be provided and documented along with reasons behind the decision.

The Risk of Bleeding Complications in Intra-Articular Injections and Arthrocentesis in Patients on Novel Oral Anticoagulants: A Systematic Review.

Novel oral anticoagulants (NOACs) are increasingly prescribed blood-thinning medication. Surpassing Warfarin, NOACs are more favored and extensively used in paroxysmal atrial fibrillation, acute coronary syndrome, and in elderly patients. Well-known benefits of novel oral anticoagulants include predictable pharmacokinetics, pharmacodynamics, and shorter half-life. However, as with any anticoagulant, there are bleeding risks with NOACs. There is a lack of evidence and consensus on the management of novel anticoagulants for intraarticular injections and arthrocentesis. This systematic review aims to analyze the risk of bleeding complications in patients on novel oral anticoagulants who underwent joint injections and arthrocentesis to help physicians in the decision-making and consenting process. A literature search of three online databases was completed using the Cochrane methodology for systematic reviews. Eligibility criteria included any study that reported bleeding complication rates in adult patients on novel oral anticoagulants that had a joint injection or aspiration whilst continuing their regular oral anticoagulation. All studies with any number of patients and published in any language were included. Review articles and systematic reviews were excluded. The search of databases resulted in a total of 310 articles. After screening, a total of four articles were deemed suitable to be included in the analysis. These described a total of 668 patients undergoing injections/aspiration procedures with patients on three different novel oral anticoagulants namely Rivaroxaban, Apixaban, and Dabigatran. Only one patient joint had a bleeding complication and the patient was on Dabigatran. The results of this systematic review show that it is relatively safe to perform joint injections and arthrocentesis whilst continuing on Novel oral anticoagulation.

Prevalence of Drug-Drug Interaction in Hospitalized Patient in Basrah City; Southern of Iraq

Objectives: Although multiple drugs administrationmostly increase therapeutic effect, some combinations lead to adverse drug-drug interactions and increased morbidity. This study was designed to identify the types,frequency, severity, and significance of drug–drug interactions (DDIs)Methods: This retrospective cross-sectional study was conducted from September 2018 to February 2019 in Al-Fayha’a teaching hospital in Basrah, Iraq.The data of 186 patients were collected from hospital patients case sheets. The type and significance of DDIs were analyzed using “Medscape drug Interaction Checker.Results: At least one to two DDI are noticed in about three quarters of the patients, about 30% cases have three to nine DDIs and 15% of them have ten or more DDIs. According to their severity, there are 85 (11.5%) of serious or potent DDIs. The largest percentage of reported interactions 544 (73.5%) were moderate were close monitoring required. Out of 740documented DDIs,65.1% were pharmacodynamics and 19.5% were Pharmacokinetic interactions, in addition, there were 15.4%of DDIs due to Unknown mechanisms. Most of the major potential DDIs occur with the antibiotic ceftriaxone and blood thinning medications (heparin and warfarin).Conclusion: The findings of this study revealed a high prevalence of drug-drug interactions in hospitalized patients particularly in patients withcardiovascular disease. Potential DDIs in this study sufficiently high to alert health care providers to pay more attentions in order to prevent or decrease their adverse effects on patients.

The Use of Antiplatelet Agents and Heparin in the 24-Hour Postintravenous Alteplase Window for Neurointervention.

Intravenous (IV) alteplase with mechanical thrombectomy has been found to be superior to alteplase alone in select patients with intracranial large vessel occlusion. Current guidelines discourage the use of antiplatelet agents or heparin for 24 h following alteplase. However, their use is often necessary in certain circumstances during thrombectomy procedures. To study the safety and outcomes in patients who received blood thinning medications for thrombectomy after IV Tissue-Type plasminogen activator (tPA). This is a multicenter retrospective review of the use of antiplatelet agents and/or heparin in patients within 24 h following tPA administration. Patient demographics, comorbidities, bleeding complications, and discharge outcomes were collected. A series of 88 patients at 9 centers received antiplatelet medications and/or heparin anticoagulation following IV alteplase for revascularization procedures requiring stenting. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 14.6. Reasons for use of a stent included internal carotid artery occlusion in 74% of patients. Thrombolysis in cerebral infarction (TICI) 2b-3 revascularization was accomplished in 90% of patients. The rate of symptomatic intracranial hemorrhage (sICH) was 8%; this was not significantly different than the sICH rate for a matched group of patients not receiving antiplatelets or heparin during the same time frame. Functional independence at 90 d (modified Rankin Scale 0-2) was seen in 57.8% of patients. All-cause mortality was 12%. The use of antiplatelet agents and heparin for stroke interventions following IV alteplase appears to be safe without significant increased risk of hemorrhagic complications in this group of patients when compared to control data and randomized controlled trials.

COVID-19: Nanomedicine Uncovers Blood-Clot Mystery.

Further complications associated with infection by severe acute respiratory syndrome coronavirus 2 (a.k.a. SARS-CoV-2) continue to be reported. Very recent findings reveal that 20–30% of patients at high risk of mortality from COVID-19 infection experience blood clotting that leads to stroke and sudden death. Timely assessment of the severity of blood clotting will be of enormous help to clinicians in determining the right blood-thinning medications to prevent stroke or other life-threatening consequences. Therefore, rapid identification of blood-clotting-related proteins in the plasma of COVID-19 patients would save many lives. Several nanotechnology-based approaches are being developed to diagnose patients at high risk of death due to complications from COVID-19 infections, including blood clots. This Perspective outlines (i) the significant potential of nanomedicine in assessing the risk of blood clotting and its severity in SARS-CoV-2 infected patients and (ii) its synergistic roles with advanced mass-spectrometry-based proteomics approaches in identifying the important protein patterns that are involved in the occurrence and progression of this disease. The combination of such powerful tools might help us understand the clotting phenomenon and pave the way for development of new diagnostics and therapeutics in the fight against COVID-19.