International Normalized Ratio Levels Research Articles

Related factors and safety of reaching the therapeutic target of warfarin after heart valve surgery in hospitalized patients: A retrospective cohort study.

Warfarin is a commonly employed anticoagulant drug aimed at rapidly reaching the optimal international normalized ratio (INR), potentially reducing the hospitalization time in clinical settings. However, limited research has been conducted on the influencing factors and the safety implications of promptly reaching the target INR range in patients with valvular heart disease who have undergone valve replacement or repair. The present study aimed to assess the factors related to the safety considerations of rapidly reaching the target INR range in patients treated with warfarin. A retrospective cohort investigation was performed on hospitalized patients treated with warfarin between July 2022 and June 2023. Patient data were gathered from patient documentation. A total of 175 patients were included in the current study. The mean time to reach an effective INR threshold was 9.8 days (median, 3-28 days). Age >65 years, body mass index <24 kg/m2, no smoking history and warfarin starting dose ≥3 mg/day were separate factors linked to rapidly reaching the effective INR threshold for warfarin management. The occurrence of INR levels ≥4 was significantly elevated among patients who reached the effective INR threshold more rapidly, while bleeding incidents were not significantly different. Inpatients aged >65 years, those with a body mass index <24 kg/m², no smoking history or prescribed a starting warfarin dosage ≥3 mg/day had a higher likelihood of rapidly reaching the effective INR threshold with warfarin. To enhance safety for these patients, enhanced INR tracking and suitable warfarin dosage adjustments are suggested following the initiation of oral warfarin therapy.

Increasing incidence of mycotoxicosis in South-Eastern Germany: a comprehensive analysis of mushroom poisonings at a University Medical Center

Abstract Background Mushrooms, an integral component of human diets, range from esteemed delicacies to potentially lethal toxins. The risk of severe poisoning from misidentified species, poses a significant challenge. For clinicians, recognizing mushroom poisoning amidst nonspecific symptoms and determining the specific mushroom ingested are critical yet complex tasks. Additionally, climate change affects the distribution and proliferation of mushroom species, potentially heightening the risk of exposure to toxic varieties. The identification of mushroom intoxication is critical for appropriate treatment. Poisoning with highly toxic species, such as Amanita phalloides (death cap), can result in acute liver and kidney failure. Considering the limited therapeutic options currently available for acute liver failure, we investigated the application of plasmapheresis, a procedure involving the replacement of the patient's plasma with donor plasma, as a potential intervention to improve clinical outcomes in severe cases of mushroom poisoning. Methods This study aimed to assess the trends and treatment outcomes of mushroom poisoning cases from 2005 to 2022, with a particular focus on the number of incidents and the potential impacts of climate change. We undertook a retrospective monocentric cohort study, evaluating 43 patients with mushroom poisoning. The study focused on identifying the variety of mushrooms involved, including psychotropic, spoiled, inedible, or toxic species, and closely examined patients with elevated transaminases indicative for liver damage. To assess clinical outcomes, we evaluated several aspects, including hepatic encephalopathy and other symptoms. Additionally, we monitored blood analysis results through serial measurements, including transaminases, bilirubin, INR, and creatinine levels. Furthermore, we explored the impact of climate changes on the incidence of mushroom poisoning. Results While the incidence of mushroom poisonings remained relatively stable during the first eight years of the study period, it nearly doubled over the past nine years. Nine distinct mushroom types were documented. The study showed no change in season patterns of mushroom poisonings. In cases of severe liver damage accompanied by coagulopathy, plasmapheresis was utilized to replace deficient clotting factors and mitigate the inflammatory response. This intervention proved effective in stabilizing coagulation parameters, such as the international normalized ratio (INR) Plasmapheresis was performed until the INR reached stable levels, preventing the occurrence of severe bleeding complications. In instances where liver failure was deemed irreversible, plasmapheresis functioned as a bridging therapy to manage bleeding risks and to stabilize the patient while awaiting liver transplantation. Conclusion The findings underscore the need for heightened awareness among healthcare professionals regarding mushroom poisoning and emphasize the importance of considering climate change as a factor that may alter mushroom distribution and toxicity. Additionally, this study highlights the potential of plasmapheresis in managing severe cases.

Predicting the risk of mortality in children with dengue-induced hepatitis admitted to the paediatric intensive care unit.

Dengue-associated acute liver failure (PALF) accounts for a high mortality rate in children admitted to the pediatric intensive care unit (PICU). To date, there is a lack of data on clinical algorithms for estimating the risk of mortality in pediatric patients with dengue-induced severe hepatitis (DISH). To determine the prevalence of PALF and identify the predictors of mortality among patients with DISH. This single-institution retrospective study was performed at a tertiary pediatric hospital in Vietnam between 2013 and 2022. The primary outcome was in-hospital mortality in pediatric patients with DISH, which was defined as either aspartate aminotransferase > 350 IU/L or alanine aminotransferase > 400 IU/L. Prognostic models for estimating the risk of death among patients with DISH were developed using a predefined set of clinical covariables and hepatic biomarkers on PICU admission and during the first 72 hours of admission. Area under the curve, multivariable logistic regression, and multiple imputation using the chained equation for missing values were performed. Backward stepwise model selection based on the Akaike information criterion was employed. Bootstrapping, calibration slope, and Brier score were used to assess the final models. A total of 459 children with DISH were included in the analysis. The median patient age was 7.7 years (interquartile range: 4.3-10.1 years). The prevalence of dengue-associated PALF in children with DISH was 18.3%. Thirty-nine DISH patients developing PALF (8.5%) died. Hepatic biomarkers, including the international normalized ratio (INR) ≥ 2.11 and total serum bilirubin (≥ 1.7 mg/dL), showed high predictive values for mortality (all P values < 0.001). Multivariable models showed the significant clinical predictors of death from dengue-induced PALF in patients with DISH, including reduced level of consciousness (pain and unresponsive levels on the Alert, Verbal, Pain, Unresponsive scale), high vasoactive-inotropic score (> 30), and elevated levels of blood lactate, INR, and serum bilirubin. The final prognostic model demonstrated high discrimination, Brier score, and an acceptable calibration slope. The prevalence of PALF in children with DISH is 18.3%. We developed robust prognostic models to estimate the risk of death in hospitalized children with severe dengue-induced hepatitis.

The association between mortality due to COVID-19 and coagulative parameters: a systematic review and meta-analysis study

Aims and objectivesThis systematic review and meta-analysis study evaluated the association between mortality due to COVID-19 and coagulative factors.MethodsA systematic search was conducted on electronic databases including PubMed, Scopus, and the Web of Science from the beginning of the pandemic until October 2024 to identify relevant studies on COVID-19 patients and their laboratory findings related to coagulation markers and mortality outcome. Eligibility criteria were defined based on the PICO framework, and data extraction was performed by two authors independently using a standardized sheet. Statistical analysis was accomplished using the random effects model, and heterogeneity among studies was assessed using the I2 test. R and RStudio were used for statistical analysis and visualization.ResultsOur systematic literature search yielded 6969 studies, with 48 studies meeting the inclusion criteria for our meta-analysis. The mean platelet count was significantly lower in deceased COVID-19 patients compared to survivors (20.58), while activated partial thromboplastin time (aPTT) and fibrinogen levels did not show significant differences. The pooled mean difference of D-Dimer, International Normalized Ratio (INR), and prothrombin time (PT) were significantly lower in survived patients (-2.45, -0.10, and -0.84, respectively). These findings suggest that platelet count, D-Dimer, INR, and PT may serve as potential indicators of mortality in COVID-19 patients.ConclusionThe results of our systematic review and meta-analysis revealed a significant reduction in the pooled platelet count among deceased individuals when compared to survivors. However, no significant distinctions were observed in the pooled mean activated aPTT and fibrinogen levels between the deceased and survivor groups. On the other hand, there were noticeable variations in the pooled estimated mean of INR, PT, and D-Dimer levels, with significantly higher values in the deceased group compared to those who survived.

Factors affecting target INR levels in homebound and ambulatory patients who use warfarin.

To investigate the rates of reaching target international normalised ratio levels and the factors affecting these rates in patients undergoing warfarin therapy. The prospective cross-sectional study was conducted between 16.08.2023 and 16.11.2023 at Izmir Bozyaka Training and Research Hospital and comprised patients of either gender who had been reciving warfarin therapy for at least 6 months. Those who were under the care of Home Health Services were in group A, while those being followed up at the cardiology outpatient clinic were in group B. All the patients had been receiving regular monitoring for international normalised ratio. Data was collected using a self-designed 41-item questionnaire. Data was analysed using SPSS 27. Of the 200 patients, 100(50%) were in each of the 2 groups. The overall mean age of the sample was 69.54±12.70 years. There were 131(65.5%) females, 108(54%) had international normalised ratio level within the target range, 101(50.5%) stated they had received education about warfarin, 120(60%) were aware of the side effects, and 81(40.5%) indicated they experienced complications while using warfarin. Group A patients received more education/information about warfarin, and warfarin-related complications were few in such patients (p<0.05). International normalised ratio monitoring among patients under the care of Home Healthcare Service was more reliably and effective compared to cardiology inpatients.

International normalized ratio measurement during perioperative anticoagulation bridging with low-molecular-weight heparin in patients undergoing heart valve replacement surgery

BackgroundSurgical procedures in anticoagulated patients require specific attention due to increased bleeding risk. Preoperative anticoagulation interruption in high-risk patients is often necessary. Bridging anticoagulation with low-molecular-weight heparin (LMWH) minimizes thromboembolic risk, but its effect on international normalized ratio (INR) measurement is not well established, necessitating careful monitoring and individual assessment. ObjectivesTo investigate the effect of heparin bridging on INR measurements in anticoagulated patients on vitamin K antagonist (VKA) and in in vitro spiking experiments. MethodsThirty-eight anticoagulated patients on VKA undergoing valve replacement surgery were studied using 2 plasma-based INR assays and 1 whole blood point-of-care INR method at multiple time points after postoperatively resuming VKA. In addition, INR levels in pooled plasma of both normal and VKA-treated individuals were compared, with 7 spiked concentrations of LMWH or unfractionated heparin (UFH) in 4 INR assays. ResultsIn LMWH-bridged anticoagulated patients, the INR results obtained with HemosIL RecombiPlasTin and point-of-care Coaguchek were significantly higher than those obtained with STA Hepato Prest within 3 days after restart of VKA. After spiking LMWH or UFH in various concentrations into pooled plasma, only the STA Hepato Prest assay showed no interference in INR measurement within the therapeutic range (1.0-2.0 international units/mL) in both VKA and normal plasma. All other assays showed substantial interference, with the Thromborel S assay being the most heparin-sensitive assay. ConclusionDifferences between INR methods are seen within 72 hours after restarting VKA in postoperative patients who receive LMWH bridging. In vitro experiments using LMWH and UFH show the interference of heparin in multiple INR methods, even with concentrations below the suppliers’ stated heparin interference limits.

Serum microRNA-181a Expression Level in Patients with Acute Liver Failure and Its Correlation with Prognosis.

This paper examined miR-181a expression in the serum of patients with acute liver failure (ALF) and investigated the impact of its expression in the prognosis of ALF patients. A total of 112 ALF patients (ALF group) and 100healthy controls during the same period (control group) were recruited as study subjects, and ALF patients were separated into the survival group and the death group. Serum ALT, AST, SCr, TBil, PTA, and International Normalized Ratio (INR) indices as well as serum miR-181a expression were assessed by using a fully automated biochemistry analyzer and RT-qPCR. Patients in the ALF group were evaluated using the Model for End-Stage Liver Disease (MELD) score. Correlation between serum miR-181a expression and MELD scores of ALF patients was processed by Pearson correlation analysis, and the diagnostic value of miR-181a level for the occurrence of ALF was estimated by ROC curve analysis. Multivariate logistic regression analysis was executed to assess the factors influencing the occurrence of death in ALF patients. ALF patients had higher levels of ALT, AST, TBiL, SCr, INR and miR-181a and lower PTA levels in comparison to healthy controls. Serum miR-181a expression level in ALF patients revealed a significant positive correlation with MELD score. Multivariate logistic regression analysis unveiled that TBil, INR, SCr, and miR-181a were the independent risk factors for the occurrence of death in ALF patients, and that PTA was an independent protective factor for the prognosis of ALF patients. miR-181a exhibited a favorable diagnostic value in ALF and its prognosis. miR-181a expression is upregulated in the serum of ALF patients, and it can be utilized as an indicator for ALF diagnostic and prognostic assessment.

Investigation of ADAMTS-13 levels in patients with COVID-19 infection.

Coronavirus disease 2019 (COVID-19) patients are predisposed to thrombotic events. COVID-19 coagulopathy can be associated with ADAMTS-13 (a disintegrin-like and metalloprotease with thrombospondin type I repeats 13) levels. ADAMTS-13, the cleaving protease of highly thrombogenic ultra-large von Willebrand Factor (vWF) multimers, was rarely investigated in COVID-19 patients and inconsistent results were obtained. We measured ADAMTS-13 levels of patients admitted to emergency department. A prospective study was carried out with 180 individuals at the Emergency Department of Uşak Training and Research Hospital. The patients were divided into three groups: mild COVID-19 (group 2), severe COVID-19 with oxygen saturation below 94% (group 3), and control group (group 1). ADAMTS-13 levels were analyzed with an enzyme linked immunosorbent assay (ELISA) kit (SunRed, Shanghai, China). Demographic data, clinical findings, and routine laboratory test results (alanine aminotransferase (ALT), aspartate aminotransferase (AST), white blood cell, lymphocyte, platelet, C-reactive protein (CRP), lactate dehydrogenase (LDH), prothrombin time, international normalized ratio (INR), partial thromboplastin time, D-dimer, creatinine, urea) were evaluated. ADAMTS-13 serum levels were slightly lower in groups 2 and 3 compared to the control group, with no significant difference between the ADAMTS-13 median values (p > 0.05). Groups 1 and 2 exhibited comparable outcomes. Group 3 demonstrated notably elevated levels of CRP, LDH, D-dimer, AST, ALT, creatinine; and decreased platelet counts and INR levels (p < 0.05). COVID-19-associated coagulopathy is still unclear. Based on our data, ADAMTS-13 levels cannot be used as a biomarker to help stratify patients' risks at the time of admission.

Association between coagulation indicators and menorrhagia among women in Kenya.

Despite the significant burden of menorrhagia (bleeding > 80 mL every menstrual cycle) among women in Western Kenya, it remains unknown whether coagulation disorders are an important underlying cause of this condition in the region. This study assessed differences in coagulation profiles, associations between menorrhagia and coagulation profiles and compared morphological features of platelets among women attending Bungoma County Referral Hospital in Kenya. A comparative cross-sectional study of women with and without menorrhagia, aged 18-45 years, was performed between December 2022 and September 2023. Sociodemographic factors, prothrombin time (PT), activated partial thromboplastin time, thrombin time, fibrinogen, international normalised ratio (INR), and platelet count were compared between groups, and associations with menorrhagia were assessed. Prothrombin time and INR levels above normal references were deemed increased. A total of 428 (214 per group) women were included. Family history of bleeding disorders (p < 0.0001) was more frequent in menorrhagic than in non-menorrhagic women. Additionally, menorrhagic women had high PT (p < 0.0001) and high INR (p < 0.0001) levels. Menorrhagia was significantly associated with an increased PT (odds ratio = 2.129, 95% confidence interval = 1.658-2.734; p < 0.0001) and increased INR (odds ratio = 7.479, 95% confidence interval = 3.094-18.080; p < 0.0001). In this population in Western Kenya, menorrhagia was associated with a family history of bleeding disorders, increased PT, and increased INR. Routine assessment of the coagulation profile and family history of bleeding disorders is crucial for diagnosing and managing menorrhagia. Our findings suggest that menorrhagic and non-menorrhagic women differ in terms of PT and INR, which may be predictive of menorrhagia.

The effect of high-normal preoperative international normalized ratios on postoperative outcomes and complications following posterior cervical spine surgery

IntroductionCurrent guidelines recommend that the International Normalized Ratio (INR) be less than 1.5 prior to spine intervention. Recent studies have shown that an INR > 1.25 is associated worse outcomes following anterior cervical surgery. We sought to determine the risk of complications associated with an INR > 1.25 following elective posterior cervical surgery.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried. Patients undergoing elective posterior cervical surgery from 2012 to 2016 with an INR level within 24 h of surgery were included. Primary outcomes were hematoma requiring surgery, 30-day mortality, and transfusions within 72-hours. There were 815 patients in the INR ≤ 1 cohort (Cohort A), 410 patients in the 1 < INR ≤ 1.25 cohort (Cohort B), and 33 patients in the 1.25 < INR ≤ 1.5 cohort (Cohort C).ResultsCohort C had a higher rate of transfusion (4% Cohort A; 6% Cohort B; 12% Cohort C; p = 0.028) and the rate of mortality within 30 days postoperatively trended toward significance (0.4% Cohort A; 0.5% Cohort B; 3% Cohort C; p = 0.094). There was no significant difference in the rate of postoperative hematoma formation requiring surgery (0.2% Cohort A; 0% Cohort B; 0% Cohort C; p = 0.58). On multivariate analysis, increasing INR was not associated with an increased risk of developing a major complication.ConclusionAn INR > 1.25 but ≤ 1.5 may be safe for posterior cervical surgery. An INR > 1.25 but ≤ 1.5 was associated with a significantly higher rate of transfusions. However, increasing INR was not significantly associated with increased risk of any of the major complications.

C-reactive protein, fibrinogen, prothrombin time and international normalized ratio levels as indicators of chronic inflammation in patients with metabolic syndrome

Aims: Although it has been stated in studies conducted in patients with metabolic syndrome (MetS) that elevated serum fibrinogen and C-Reactive Protein (CRP) may be due to chronic inflammation, sufficient studies have not been conducted on International normalized ratio (INR) and prothrombin time (PT). The aim of this study is to examine the fibrinogen, INR and PT levels of patients with MetS and to investigate the relationship between these parameters and MetS components. Methods: A total of 56 patients, 19 males and 37 females were included in our study who applied to the Internal Medicine outpatient clinic of Ondokuz Mayıs University Faculty of Medicine and met the MetS diagnostic criteria. The control group consists of a total of 64 people, 35 men and 29 women, who have at least one of the MetS criteria and do not have a chronic disease. Fasting blood glucose, total cholesterol (Total-C), triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), creatinine, thyroid stimulating hormone (TSH), PT, INR and fibrinogen levels were examined from the available samples. Data were compared between healthy and patient groups. Results: As a result of our study, it was determined that the CRP level was significantly higher in the patient group (p&lt;0.01). The average fibrinogen level was calculated as 3.56 g/l in the patient group and 2.95 g/l in the control group, and a significant difference was detected when the two groups were compared (p&lt;0.001). The average PT value was 13.1 in the patient group and 12.04 in the control group and a significant difference was detected between both groups (p&lt;0.001). The average INR level was 1.14 in the patient group and 1.04 in the control group and a significant difference was detected between both groups (p&lt;0.001). Conclusion: MetS is associated with high CRP. In patients with MetS, PT, INR and fibrinogen levels are also high. In the follow-up and treatment of patients with MetS, the presence of chronic inflammation and factors affecting the coagulation system should be taken into consideration.

Warfarin-related nephropathy: unveiling the hidden dangers of anticoagulation

Warfarin-related nephropathy (WRN) is defined as acute kidney injury subsequent to excessive anticoagulation with warfarin. Patients with mechanical prosthetic valves require long-term anticoagulant therapy. Nonetheless, warfarin remains the sole available option for anticoagulant therapy. Consequently, patients with mechanical prosthetic valves constitute a special group among the entire anticoagulant population. The present study recorded two cases of patients who had undergone mechanical prosthetic valve surgery and were receiving warfarin therapy. They presented to the hospital with gross hematuria and progressive creatinine levels. Notably, their international normalized ratio (INR) did not exceed three. Subsequent renal biopsies confirmed WRN with IgA nephropathy. The two patients continued to receive warfarin as anticoagulation therapy and were prescribed oral corticosteroids and cyclophosphamide, which resulted in improved renal function during the follow-up. Based on a review of all relevant literature and the present study, we proposed a new challenge: must elevated INR levels be one of the criteria for clinical diagnosis of WRN? Perhaps some inspiration can be drawn from the present article.

Evaluation of the use and efficacy of prothrombin complex concentrates in patients presenting to the emergency department with warfarin

Aims: Warfarin administration has been a standard treatment for preventing thromboembolism in patients with atrial fibrillation prosthetic heart valves for many years. It is one of the leading drugs implicated in emergency room visits for adverse drug reactions. Because of a narrow therapeutic window, as many as 3% to 7% of patients taking warfarin are at risk of significant, life-threatening bleeding, and it is generally considered that this requires rapid and complete warfarin reversal. Although there are treatments such as vitamin K and fresh frozen plasma to reverse the effects of warfarin, the most effective method involves using prothrombin complex concentrates (PCC). This study aims to evaluate the use and efficacy of PCC in patients with warfarin-induced bleeding in the emergency department. Methods: The patients receiving PCC for warfarin reversal in the emergency department between January 1, 2019 – April 1, 2021, were identified from the hospital's electronic database. Demographic data, reasons for warfarin use, PCC indications, INR values before and after PCC, and mortality of the patients were evaluated. The four-factor PCC dose was determined according to the patient's body weight, admission INR level, and target INR level. The study was conducted with 73 patients. Results: The mean age of the patients was 69.3 ± 15.5 years. The female/male ratio was 1/1.5. The most common PCC indications were gastrointestinal bleeding (32.9%), urogenital bleeding (23.3%), epistaxis (12.3%), and urgent surgical need (12.3%), respectively. The median international normalized ratio (INR) before and after treatment with PCC was 9.2 (min-max 2.1-11.8) and 1.8 (min-max 1.0-4.6). The mean dose of PCC was 1500 IU (min-max 750-3250 IU). In addition to PCC, all patients received vitamin K; 17.8% received erythrocyte suspension, and 10.9% received fresh frozen plasma. There were no PCC-related complications in the emergency department. While 38.4% of the patients consulted the inpatient services after the emergency department, 5.5% were referred to an external center, and 56.2% were discharged from the emergency department after successful treatment. 26% of the patients were followed in the intensive care unit. No patient died in the emergency department. However, in-hospital mortality was 5.5%. Conclusion: Four-factor PCC is an effective and safe treatment for reversing warfarin-associated bleeding.

Correction of Warfarin Coagulopathy for Non-bleeding Patients in the Outpatient Setting at an Ambulatory Care Organization: Application of Vitamin K Guidance

Background: Warfarin is an effective anticoagulant but requires close International Normalized Ratio (INR) monitoring and may occasionally require correction of excessive anticoagulation. Current guidelines provide limited practical guidance on the administration of vitamin K for the management of supratherapeutic INR levels ≥ 5.0 in non-bleeding outpatients. Objective: Based on expert consensus and guidelines, the Atrius Health Anticoagulation Management Services (AMS) has developed internal guidance for oral vitamin K use in highly selected populations. This study will describe the internal guidance for oral vitamin K use and present associated results and clinical outcomes Methods: Episodes with INR &gt; 5.0 were included, with vitamin K considered for episodes with INR ≥ 6. Moreover, compelling indications and exclusions to select ideal patients for vitamin K intervention were also defined Results: Overall, episodes were managed conservatively; of the 246 collected episodes of excessive anticoagulation, in 18 episodes (7%), patients received vitamin K, and in 228 (93%) episodes, patients did not receive vitamin K. The mean index INR was 6.0 (range 5.0 – 10.5, SD 1.07), with nearly 57% of episodes achieving INR correction and 15% of episodes developing INR overcorrection. High thrombotic risk patients, regardless of hemorrhagic risk, were less likely to receive vitamin K. Three episodes (1.2%) resulted in bleeding complications. No thrombotic complications occurred during the 30-day follow-up of the index INR value ≥ 5.0. Conclusion: Our internal guidance is a novel, standardized approach that serves as a decision support tool for the management of warfarin-associated coagulopathy and vitamin K intervention using patient-specific characteristics and index INR values. This guidance may assist other anticoagulation management services with practical applications and require validation in a prospective clinical trial.

Therapeutic plasma exchange provides native liver survival benefit in children with acute liver failure: A propensity score-matched analysis.

This study aimed to evaluate the safety and efficacy of therapeutic plasma exchange (TPE) in pediatric acute liver failure (PALF). All children aged 2-18 years with PALF were included. The intervention cohort included a subset of PALF patients undergoing complete three sessions of TPE, whereas the matching controls were derived by propensity score matching from the patient cohort who did not receive any TPE. Propensity matching was performed based on the international normalized ratio (INR), grade of hepatic encephalopathy (HE), age, bilirubin, and ammonia levels. The primary outcome measure was native liver survival (NLS) in the two arms on day 28. Of the total cohort of 403 patients with PALF, 65 patients who received TPE and 65 propensity-matched controls were included in analysis. The 2 groups were well balanced with comparable baseline parameters. On day 4, patients in the TPE group had significantly lower INR (P = 0.001), lower bilirubin (P = 0.008), and higher mean arterial pressure (MAP) (P = 0.033) than controls. The NLS was 46.15% in the TPE arm and 26.15% in the control arm. The overall survival (OS) was 50.8% in the TPE arm and 35.4% in the control arm. Kaplan-Meier survival analysis showed a significantly higher NLS in patients receiving TPE than controls (P = 0.001). On subgroup analysis, NLS benefit was predominantly seen in hepatitis A-related and indeterminate PALF. TPE improved NLS and OS in a propensity-matched cohort of patients with PALF. Patients receiving TPE had lower INR and bilirubin levels and higher MAP on day 4.

Outcomes of patients with acute severe autoimmune hepatitis: Predictors of non-response to corticosteroids and need for liver transplantation.

Acute severe autoimmune hepatitis (AS-AIH) is an evolving concept and the outcomes and optimal treatment have been less studied. In this study, we aimed to investigate the outcomes of patients with AS-AIH and predictors of non-response to corticosteroid therapy and need for liver transplantation. In a retrospective cohort, we included patients with AS-AIH admitted to our liver center. We defined AS-AIH based on the international autoimmune hepatitis group score as acute presentation of AIH with an international normalized ratio (INR)≥1.5 and without liver cirrhosis and hepatic encephalopathy. All patients received high dose corticosteroid therapy. Treatment response was defined as liver transplant free survival at 4months after presentation. Factors associated with response to corticosteroids and survival of patients were studied. In total, 61 patients with AS-AIH were included. Forty-seven patients responded to corticosteroid therapy. In the multivariate regression model, baseline INR (odds ratio [OR]: 0.184; 95% confidence interval [CI]: 0.048-0.699; p=0.013) and delayed versus early initiation of corticosteroid (after vs. before 5days of presentation) (OR: 0.189; 95% CI: 0.039-0.919; p=0.039) were independent predictors of clinical non-response to corticosteroid therapy. In the multivariable Cox regression model, baseline INR level (hazard ratio [HR]: 2.542; 95% CI: 1.188-5.440; p=0.016) and delayed initiation of corticosteroids (HR: 3.578; 95% CI: 1.084-11.812; p=0.036) were independent predictors of liver transplant free survival at 6months after diagnosis. Delayed initiation of corticosteroid therapy might be predictive of clinical non-response to medical therapy and need for liver transplantation in patients with AS-AIH.

A retrospective cohort analysis of factors associated with the development of refeeding syndrome in children 0–59 months diagnosed with severe acute malnutrition in a South African setting

BackgroundRefeeding syndrome (RFS) is a life-threatening, underdiagnosed, and under-researched complication in treating children with severe acute malnutrition (SAM). This study aimed to determine the incidence and onset of RFS and identify biochemical abnormalities, clinical signs, and complications associated with RFS development in children, 0–59 months, treated with SAM in a South African public hospital setting. MethodsA retrospective cohort study was performed on hospital medical records of children aged 0–59 months, diagnosed with SAM at Rahima Moosa Mother and Child Hospital, Johannesburg, from 1/10/2014 to 31/12/2018. The onset of RFS among children included in the study was diagnosed based on published criteria for RFS. On admission, children who developed RFS and those who did not were compared concerning biochemistry and clinical signs and symptoms. ResultsA total of 148 medical records were retrieved from the hospital archives. The diagnosis of SAM based on the World Health Organization (WHO) definition was confirmed in 126 children who were then included in the study. The median age of the 126 children (63 % male) with confirmed SAM was 11.2 months (P25:7.0 months; P75:17.0 months). The in-hospital mortality rate was 18.2 %, of which 8.7 % were retrospectively diagnosed as having developed RFS during their recorded hospital stay, despite implementing the WHO treatment guidelines for SAM. A significantly higher percentage of the children who developed RFS presented on admission with hypophosphatemia (p = 0.015), hypokalemia (p = 0.001), hyponatremia (p = 0.001), an international normalized ratio (INR) of above 1.7 (p = 0.025), diarrhea (p = 0.042), dehydration (p = 0.029) and urinary tract infection (UTI) (p = 0.041), than those who did not. Children who developed RFS stayed in hospital significantly longer than those who did not (18 vs. 12 days with a p-value of 0.003). ConclusionIn this population of children with SAM treated in a South African public hospital setting, the presence on hospital admission of low levels of electrolytes, elevated INR, dehydration, diarrhea, and UTI was significantly associated with developing RFS. Recognizing these as possible red flags for developing RFS in children admitted with SAM might contribute to improved outcomes and needs further investigation.

Comparison of the therapeutic effect of different anticoagulation regimens after total hip arthroplasty based on enhanced recovery after surgery: A retrospective study

This retrospective study investigated the efficacy and economic outcomes of low molecular weight heparin (LMWH), fondaparinux sodium (FPX), and rivaroxaban after total hip arthroplasty (THA) under Enhanced Recovery After Surgery (ERAS). The clinical data of patients who underwent primary THA due to hip joint disease in our Hospital from October 2020 to June 2022 were retrospectively collected and analyzed. According to different anticoagulant methods, patients were divided into LMWH group (42 cases), FPX group (24 cases), and Rivaroxaban group (39 cases). Perioperative blood coagulation-related factors, D-dimer, platelet (PLT) changes, blood routine, blood loss, lower limb vein thrombosis (DVT), pulmonary embolism, and allogeneic blood transfusion were compared among the three groups. There was no statistical significance difference for coagulation indexes and Visual Analog Scale score before the operation among the three groups, but there were statistical significance differences for prothrombin time and international normalized ratio levels at 3 days after the operation. The postoperative drainage volume and blood loss of the three groups were different, but there were no significant differences in intraoperative blood loss, hidden blood loss, total blood loss, blood transfusion rate, DVT incidence rate and Visual Analog Scale score score 3 days after surgery among the three groups. Besides, the treatment cost in the LMWH group was significantly lower than that of the FPX group and the rivaroxaban group. Hence, Based on the ERAS concept, the use of LMWH, FPX, and Rivaroxaban after THA can effectively and safely prevent the occurrence of VTE and has no significant difference in postoperative pain, perioperative blood loss, and coagulation function. However, Rivaroxaban can be taken orally and has more advantages in some pharmacological effects, while LMWH is cheaper.

The Relationship Between Preoperative International Normalized Ratio and Postoperative Major Bleeding in Total Shoulder Arthroplasty.

This study aimed to assess the relationship between preoperative international normalized ratio (INR) levels and major postoperative bleeding events after total shoulder arthroplasty (TSA). The American College of Surgeons National Surgical Quality Improvement Program database was queried for TSA from 2011 to 2020. A final cohort of 2405 patients with INR within 2 days of surgery were included. Patients were stratified into four groups: INR ≤ 1.0, 1.0 < INR ≤ 1.25, 1.25< INR ≤ 1.5, and INR > 1.5. The primary outcome was bleeding requiring transfusion within 72 hours, and secondary outcome variables included complication, revision surgery, readmission, and hospital stay duration. Multivariable logistic and linear regression analyses adjusted for relevant comorbidities were done. Of the 2,405 patients, 48% had INR ≤ 1.0, 44% had INR > 1.0 to 1.25, 7% had INR > 1.25 to 1.5, and 1% had INR > 1.5. In the adjusted model, 1.0 < INR ≤ 1.25 (OR 1.7, 95% CI 1.176 to 2.459), 1.25 < INR ≤ 1.5 (OR 2.508, 95% CI 1.454 to 4.325), and INR > 1.5 (OR 3.200, 95% CI 1.233 to 8.302) were associated with higher risks of bleeding compared with INR ≤ 1.0. The risks of thromboembolism and bleeding lie along a continuum, with higher preoperative INR levels conferring higher postoperative bleeding risks after TSA. Clinicians should use a patient-centered, multidisciplinary approach to balance competing risks.

Factors influencing voriconazole plasma level in intensive care patients.

In clinical routine, voriconazole plasma trough levels (Cmin) out of target range are often observed with little knowledge about predisposing influences. To determine the distribution and influencing factors on voriconazole blood levels of patients treated on intensive- or intermediate care units (ICU/IMC). Data were collected retrospectively from patients with at least one voriconazole trough plasma level on ICU/IMC (n = 153) to determine the proportion of sub-, supra- or therapeutic plasma levels. Ordinal logistic regression analysis was used to assess factors hindering patients to reach voriconazole target range. Of 153 patients, only 71 (46%) reached the target range at the first therapeutic drug monitoring, whereas 66 (43%) patients experienced too-low and 16 (10%) too-high plasma levels. Ordinal logistic regression analysis identified the use of extra corporeal membrane oxygenation (ECMO), low international normalized ratio (INR) and aspartate-aminotransferase (AST) serum levels as predictors for too-low plasma levels. Our data highlight an association of ECMO, INR and AST levels with voriconazole plasma levels, which should be considered in the care of critically ill patients to optimize antifungal therapy with voriconazole.