Likelihood Of Bleeding Research Articles

An initiative for better patient handling and process evolution using BD Vacutainer® UltraTouch™ Push Button Blood Collection Set with Pre-Attached Holder

Objectives: Venepuncture and intravenous cannula insertions frequently cause pain and anxiety in paediatric patients. Various studies have observed that higher gauge and shorter needles are less painful, and the likelihood of bleeding was decreased compared to the lesser gauge needles. Hence a study was designed with objective of evaluation of BD UT PBBCS – PAH (latest blood collection device) for pain perception of paediatric patients. Material and Methods: The current study was conducted at the outpatient department of Bai Jerbai Wadia Hospital for Children. In this study, 33 paediatric individuals were included. Venepuncture was performed with UTPBBCS-PAH (25G) and after the procedure feedback was collected. Pain perception feedback was gathered using a categorical scale ranging from 0 to 5, also known as the “verbal pain intensity scale”. Results: The current study found that pain intensity was significantly lower with UTPBBCS-PAH, and the overall experience was less traumatic. Conclusion: The UTPBBCS is deemed to be the appropriate blood collection device for the paediatric population due to design elements contributing to less painful experience.

Left atrial appendage occlusion for atrial fibrillation and bleeding diathesis.

Patients with atrial fibrillation(AF) and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. Short-term anti-thrombotic drugs are used postprocedure to offset the risk of device-related thrombus, evidence for this practice is limited. To investigate optimal postimplant antithrombotic strategy in high bleeding-risk patients. Patients with AF and high-risk for both stroke and bleeding undergoing LAAO were advised their perioperative drug therapy by a multidisciplinary physician panel. Those deemed to be at higher risk of bleeding from anti-thrombotic drugs were assigned to minimal treatment with no antithrombotics or Aspirin-alone. The remaining patients received standard care (STG) with a 12 week course of dual-antiplatelets or anticoagulation postimplant. We compared mortality, device-related thrombus, ischemic stroke, and bleeding events during the 90 days postimplant and long-term. Event-free survival was assessed using Kaplan-Meier survival analysis, with logrank testing for statistical significance. Seventy-five patientsunderwent LAAO of whom 63 patients(84%) had a prior serious bleeding event. The 42 patientson minimal treatment were older (74.3 ± 7.7 vs. 71.2 ± 7.2) with higher HASBLED score (3.6 ± 0.9 vs. 3.3 ± 1.2) than the 33 patientshaving standard care. There were no device-related thrombi or strokes in either group at 90 days postprocedure; STG had more bleeding events (5/33 vs. 0/42,p = 0.01) with associated deaths (3/33 vs. 0/42,p = 0.05). During long-term follow-up (median 2.2 years), all patients transitioned onto no antithrombotic drugs (43 patients [61%]) or a single-antiplatelet (29 patients[39%]). There was no evidence of early minimal treatment adversely affecting long-term outcomes. Short-term anti-thrombotic drugs may not be needed after LAAO implant in patients with high bleeding risk and could be harmful. Larger, prospective studies would be warranted to test these findings.

Impact of perioperative direct oral anticoagulant assays: a multicenter cohort study

ABSTRACT Background There is little evidence to guide the perioperative management of patients on a direct oral anticoagulant (DOAC) in the absence of a last known dose. Quantitative serum titers may be ordered, but there is little evidence supporting this. Aims This multi-center retrospective cohort study of consecutive surgical in-patients with a DOAC assay, performed over a five-year period, aimed to characterize preoperative DOAC assay orders and their impact on perioperative outcomes. Materials and methods Patients prescribed regular DOAC (both prophylactic and therapeutic dosing) with a preoperative DOAC assay were included. The DOAC assay titer was evaluated against endpoints. Further, patients with an assay were compared against anticoagulated patients who did not receive a preoperative DOAC assay. The primary endpoint was major bleeding. Secondary endpoints included perioperative hemoglobin change, blood transfusions, idarucizumab or prothrombin complex concentrate administration, postoperative thrombosis, in-hospital mortality and reoperation. Adjusted and unadjusted linear regression models were used for continuous data. Binary logistic models were performed for dichotomous outcomes Results 1065 patients were included, 232 had preoperative assays. Assays were ordered most commonly by Spinal (11.9%), Orthopedics (15.4%), and Neurosurgery (19.4%). For every 10 ng/ml increase in titer, the hemoglobin decreases by 0.5066 g/L and the odds of a preoperative reversal increases by 13%. Compared to those without an assay, patients with preoperative DOAC assays had odds 1.44× higher for major bleeding, 2.98× higher for in-hospital mortality and 16.3× higher for receiving anticoagulant reversal. Conclusion A preoperative DOAC assay order was associated with worse outcomes despite increased reversal administration. However, the DOAC assay titer can reflect the patient’s likelihood of bleeding.

Thrombocytopenia Induced by Direct Oral Anticoagulants: a Clinical Case and Literature Review

The last decade has dramatically changed the strategy of anticoagulant therapy in patients with atrial fibrillation. Direct oral anticoagulants have replaced vitamin K antagonists: either direct thrombin blockers (dabigatran) or factor IIa blockers (apixaban, rivaroxaban, edoxaban). According to the regulatory domestic and foreign documents, the use of direct oral anticoagulants in patients with atrial fibrillation has priority in comparison with vitamin K antagonists, since they have a predictable anticoagulant effect, the possibility of taking fixed doses without the need for routine anticoagulant monitoring, rapid onset and termination of action, relatively low potential for food and drug interactions. Direct oral anticoagulants are used for the prevention of thromboembolic complications in patients with atrial fibrillation, for the prevention of deep vein thrombosis in patients who have undergone surgery on the knee or hip joints, for emergency treatment and secondary prevention of deep vein thrombosis and pulmonary embolism. Alertness to side effects tends to focus on the likelihood of bleeding, with the possibility of other side effects of direct oral anticoagulants receiving less attention or going unnoticed. These mainly include liver damage, kidney damage and a number of other rare adverse reactions. The finding of isolated thrombocytopenia in patients taking direct oral anticoagulants may be associated with a high risk of life-threatening bleeding. The article analyzes published data on the occurrence of thrombocytopenia associated with the intake of direct oral anticoagulants, and presents a clinical case of thrombocytopenia while taking apixaban.

A Systematic Review and Meta-Analysis of Systemic Antibiotic Therapy in the Treatment of Peri-Implantitis.

Research has been conducted into the advantages of the systemic administration of antibiotics. The aim of this systematic review and meta-analysis was to assess the efficacy of systemic antibiotic administration in the treatment of peri-implantitis in terms of bleeding on probing (BoP) and probing pocket depth (PPD). Literature searches were performed across PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials and observational clinical studies. After peri-implantitis treatment, PPD was reduced by 0.1 mm (p = 0.58; IC 95% [−0.24, 0.47]), indicating a non-significant effect of antibiotic administration on PPD. The BoP odds ratio value was 1.15 (p = 0.5; IC 95% [0.75, 1.75]), indicating that the likelihood of bleeding is almost similar between the test and control groups. Secondary outcomes were found, such as reduced clinical attachment level, lower suppuration and recession, less bone loss, and a reduction in total bacterial counts. In the treatment of peri-implantitis, the systemic antibiotic application reduces neither PPD nor BoP. Therefore, the systemic administration of antibiotics, in the case of peri-implantitis, should be rethought in light of the present results, contributing to address the problem of increasing antibiotic resistance.

Oral Anticoagulation in Patients in the Emergency Department: High Rates of Off-Label Doses, No Difference in Bleeding Rates

BackgroundEmpirically, a significant proportion of patients using direct oral anticoagulation (DOAC) take off-label reduced doses. We aimed to investigate the prevalence, indications, dosages, and bleeding complications of oral anticoagulants on admission to the emergency department. MethodsIn this retrospective analysis, patients presenting to our emergency department between January 1 and December 31, 2018, with therapeutic oral anticoagulation were included (ie, vitamin-K antagonists, rivaroxaban, apixaban, edoxaban, and dabigatran). A detailed chart review was performed for each case concerning characteristics, indication, and bleeding complications. ResultsA total of 19,662 consecutive cases in the emergency department were reported: 1721 (9%) had therapeutic oral anticoagulation. Vitamin-K antagonists (41%), rivaroxaban (36%), and apixaban (19%) were the most common. Stroke prophylaxis in patients with atrial fibrillation (63.2%) and venous thromboembolism (24.1%) were the most common indications. In 27 cases (1.6%), no indication could be identified; further, 32% of patients were classified to have either off-label doses of DOACs or an international normalized ratio (INR) out of range (in vitamin-K antagonists), whereas 20% were classified as off-label underdosed and 12% as overdosed. No difference in the likelihood of bleeding on admission could be found between the respective drugs. Only concomitant use of aspirin was significantly associated with presence and higher severity of bleeding. ConclusionsVitamin-K antagonists are still the most widely used drug followed by rivaroxaban. A significant proportion of patients are being prescribed off label-doses. While no difference was found for the respective anticoagulants with respect to bleeding, concomitant aspirin use was a significant predictor for bleeding in our collective.

Aspirin Use for Primary Prevention of Cardiovascular Disease in Older Patients: A Review of Clinical Guidelines and Updated Evidence.

OBJECTIVE: To provide an up-to-date review of current guidelines, previous trials, and new trials regarding aspirin use in primary prevention of cardiovascular (CV) disease in the elderly population. DATA SOURCES: A PubMed search of articles published through April 2019 was performed using a combination of the following words: aspirin, bleeding, cardiovascular, elderly, hemorrhage, myocardial infarction, primary prevention, stroke. STUDY SELECTION/DATA EXTRACTION: Relevant randomized controlled trials, meta-analyses, and guidelines were assessed for the use of aspirin in primary prevention of CV disease in older patients. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS: The role of aspirin for primary prevention of CV disease in older adults is not well defined. As a result, the guideline recommendations for the use of aspirin in this setting are inconsistent. In 2018, the ARRIVE, ASCEND, and ASPREE studies were published. These studies tried to address some of the inconsistencies regarding the use of aspirin in primary prevention of CV disease. This article reviews the current recommendations along with previous and recent studies for aspirin use for primary prevention in older adults. CONCLUSION: The role of aspirin for primary prevention of CV disease in older adults should be individualized based on patient's risk factors, including risk of CV disease and likelihood of bleeding. Updated evidence provides more guidance regarding which patient populations will benefit from therapy.

Aspirin Use for Primary Prevention of Cardiovascular Disease in Older Patients: A Review of Clinical Guidelines and Updated Evidence

OBJECTIVE: To provide an up-to-date review of current guidelines, previous trials, and new trials regarding aspirin use in primary prevention of cardiovascular (CV) disease in the elderly population. DATA SOURCES: A PubMed search of articles published through April 2019 was performed using a combination of the following words: aspirin, bleeding, cardiovascular, elderly, hemorrhage, myocardial infarction, primary prevention, stroke. STUDY SELECTION/DATA EXTRACTION: Relevant randomized controlled trials, meta-analyses, and guidelines were assessed for the use of aspirin in primary prevention of CV disease in older patients. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS: The role of aspirin for primary prevention of CV disease in older adults is not well defined. As a result, the guideline recommendations for the use of aspirin in this setting are inconsistent. In 2018, the ARRIVE, ASCEND, and ASPREE studies were published. These studies tried to address some of the inconsistencies regarding the use of aspirin in primary prevention of CV disease. This article reviews the current recommendations along with previous and recent studies for aspirin use for primary prevention in older adults. CONCLUSION: The role of aspirin for primary prevention of CV disease in older adults should be individualized based on patient's risk factors, including risk of CV disease and likelihood of bleeding. Updated evidence provides more guidance regarding which patient populations will benefit from therapy.

SAT-238 Predictors Of Vaginal/Uterine Bleeding With Oral TX-001HR (Estradiol and Progesterone) Capsules Taken For Menopausal Vasomotor Symptoms

Vaginal bleeding associated with hormone therapy (HT) is the most common reason for treatment discontinuation. Cumulative amenorrhea rates (no bleeding or spotting for 13 cycles) ranging from 23% to 49% with current HT options1-3 are relatively lower than the 56% to 73% observed in the REPLENISH trial.4 The REPLENISH trial (NCT01942668) was a 12-month, phase 3, randomized, double-blind, placebo-controlled, multicenter trial that evaluated TX-001HR (bioidentical 17β-estradiol and progesterone [E2/P4] combined in a single, oral softgel capsule; 1 mg E2/100 mg P4 FDA approved as BIJUVATM; TherapeuticsMD, Boca Raton, FL) vs placebo in 1835 menopausal women (40−65 y; intact uterus) for the treatment of menopausal, moderate to severe vasomotor symptoms (VMS). Overall, the proportion of women with no bleeding was high (74%-90%) with up to 1 year of TX-001HR. The objective of this analysis was to determine predictors of vaginal bleeding. Univariate analyses were used to assess the impact of age, race, BMI, smoking, time since last menstrual period (LMP), age at LMP, tubal ligation, parity, baseline E2 concentration, and baseline frequency and severity of VMS (mild=1 to severe=3) on the incidence of vaginal bleeding at any time during the study (cumulative incidence at cycle 13) and for bleeding that occurred in the first 3 months of the study (cumulative incidence at cycle 3). Predictors of vaginal bleeding with HT (at cycle 13) were age, time since LMP, E2 concentration, and severity of VMS. The likelihood of bleeding was reduced by 42% for every 5-year increase in age (P<0.0001) and by 39% for every 5-year increase in the time since LMP (P<0.0001). Incidence of bleeding significantly decreased by 54% with baseline E2 levels <10 pg/mL (P=0.0001), 59% with E2 levels <5 pg/mL (P<0.0001), and 47% for E2 levels 5 to <10 pg/mL (P=0.0040), when compared with E2 levels ≥10 pg/mL. There was 33% less bleeding reported for women with less severe VMS (<2.5 points). No statistically significant differences in reports of bleeding were noted for race, BMI, smoking, age at LMP, tubal ligation, parity, or baseline frequency of moderate to severe VMS. Similar predictors were noted for bleeding at cycle 3, except for baseline VMS severity, which was no longer a significant predictor. Cumulative amenorrhea was relatively high in TX-001HR users. Vaginal bleeding in women treated with TX-001HR increased in women who were younger, experienced their LMP more recently, and had higher baseline E2 concentrations. Even though the rate/amount of bleeding was relatively low overall,4 these data may help clinicians inform women who may be more likely to experience vaginal bleeding while taking combined E2/P4 for menopausal symptoms. 1. Prempro tablets PI. Wyeth Pharmaceuticals. 2. Activella tablets PI. Novo Nordisk FemCare AG. 3. Angeliq Tablets PI. Berlex. 4. Lobo RA, et al. Obstet Gynecol. 2018;132:161-170.

Assessment of Sleeve Gastrectomy Surgical Technique: First Look at 30-Day Outcomes Based on the MBSAQIP Database

Obesity rates in the US have reached epidemic proportions, and sleeve gastrectomy (SG) is the procedure performed most commonly. Controversies exist about the most appropriate surgical technique. Using the 2016 MBSAQIP database, we selected all primary SG procedures and compared 4 surgical techniques (staple line reinforcement [SLR] alone; SLR and oversewing [OS]; no SLR or OS; and OS alone). Primary outcomes were bleeding and organ space infection (OSI), including leakage. Secondary outcomes were 30-day severe adverse events (SAEs) and readmissions. We conducted separate chi-square tests of association, followed by 4 separate exploratory multivariable logistic regression models. There were significant differences in bleeding (p= 0.002) and SAE rates (p= 0.003) among the 4 SG techniques; both SLR and OS yielded lower bleeding and SAE rates compared with the other techniques (0.3% and 1.9%, respectively). The associations between SG technique and OSI (p= 0.93) and readmission (p= 0.24) were not significant. The following SG techniques independently predicted less likelihood of bleeding: SLR alone (adjusted odds ratio [AOR] 0.70; 95% CI 0.54 to 0.90; p= 0.006) and both SLR and OS (AOR 0.50; 95% CI 0.33 to 0.77; p= 0.002). In addition, SLR and OS independently predicted less likelihood of SAEs (AOR 0.76; 95% CI 0.64 to 0.91; p= 0.003). Our study demonstrated that SLR resulted in lower postoperative bleeding rates, but not lower leak rates. When combined with OS, SLR yielded lower 30-day SAE rates. Future studies must clarify and confirm these results.

Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery.

Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery.

Platelet Reactivity Unit in Predicting Risk of Bleeding in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Bleeding is a common complication of cardiac surgery, accounting for a significant proportion of the total transfusions performed in the United States and Europe. The relationship between platelet reactivity, bleeding, and other adverse events after coronary artery bypass graft surgery (CABGS) has been incompletely characterized. This study investigated the relationship between platelet reactivity and bleeding as a clinical outcome after successful CABGS. A total of 238 patients who underwent CABGS were retrospectively followed for postoperative bleeding. Platelet reactivity unit (PRU) values for all patients were obtained preoperatively to assess the platelet reactivity. The data showed that a range of 180-200 PRU suggests the likelihood of bleeding after CABGS (P = 0.004), with a statistically significant association only for dual antiplatelet therapy with aspirin and clopidogrel. In conclusion, by using PRU values as a method to assess platelet reactivity and antiplatelet responsiveness, our findings suggest that it may be possible to stratify patients undergoing CABGS for the risk of postoperative bleeding particularly patients on dual antiplatelet therapy.

A Randomized Clinical Trial of the Effect of Intensive Versus Non-intensive Counseling on Discontinuation Rates Due to Bleeding Disturbances of Three Long-Acting Reversible Contraceptives

Long-acting reversible contraceptives (LARCs) include the etonogestrel (ENG)–releasing subdermal implant, the levonorgestrel-releasing intrauterine system (LNG-IUS), and the TCu380A intrauterine device (IUD). Despite the high contraceptive efficacy of LARCs, adverse effects may lead to their premature removal, reduce continuation rates, and potentially increase unintended pregnancies. The primary reason for premature discontinuation is unpredictable menstrual bleeding, especially for users of the ENG-implant and the LNG-IUS. Counseling is a well-accepted strategy to improve acceptance, continuation, and satisfaction among contraceptive users and new users. The aim of this randomized clinical trial was to determine whether intensive counseling before insertion and during the first year of use would reduce discontinuation rates due to unpredictable menstrual bleeding in new users of these 3 LARCs. The study was conducted between 2011 and 2013 at an obstetrics-gynecology clinic in Brazil. Contraceptive efficacy and satisfaction rates were investigated for 98 users of the ENG-releasing implant, 99 users of the LNG-IUS, and 100 users of the TCu380A IUD. Each participant had been allowed to choose any one of these methods. Subjects were randomized to 1 of 2 counseling strategies: Women in group I received routine counseling at the clinic, which included information on safety, efficacy, and adverse effects, especially the likelihood of bleeding. Women in group II received the same information, but in addition were given “intensive counseling,” which included leaflets on their chosen method and counseling throughout 1 year of follow-up by the same 3 professionals, who were the most experienced at the clinic. All subjects were instructed to return to the clinic after 45 (+7) days and at 6 and 12 (+1) months after insertion and to record all bleeding episodes in a menstrual diary specifically provided for this purpose. Satisfaction of the women with each contraceptive method was evaluated 12 months after initial use by a questionnaire. No significant differences between the groups or between the 3 contraceptives were found for discontinuation rates due to unpredictable menstrual bleeding. Cumulative discontinuation rates at 1 year due to menstrual bleeding irregularities for the ENG implant, the LNG-IUS, and the TCu380A IUD users were 2.1%, 2.7%, and 4.0%, respectively; continuation rates were 82.6%, 81.0%, and 73.2%. The primary reason for discontinuation was weight gain in users of the ENG implant and expulsion in users of the TCu380A. These data indicate that routine counseling is as effective as intensive counseling in reducing premature discontinuation rates, improving continuation rates, and achieving high satisfaction among new users of LARC methods. However, these findings should be interpreted with caution. The results may not apply to other settings, and premature discontinuation due to menstrual bleeding was already low. Moreover, some women could be discouraged by counseling from using the LARC methods and could decide to use other contraceptives.

The effectiveness of computerized drug-lab alerts: A systematic review and meta-analysis

BackgroundInadequate lab monitoring of drugs is a potential cause of ADEs (adverse drug events) which is remediable. ObjectivesTo determine the effectiveness of computerized drug-lab alerts to improve medication-related outcomes. Data sourcesCitations from the Computerized Clinical Decision Support System Systematic Review (CCDSSR) and MMIT (Medications Management through Health Information Technology) databases, which had searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts from 1974 to March 27, 2013. Study selectionRandomized controlled trials (RCTs) of clinician-targeted computerized drug lab alerts conducted in any healthcare setting. Two reviewers performed full text review to determine study eligibility. Data abstractionA single reviewer abstracted data and evaluated validity of included studies using Cochrane handbook domains. Data synthesisThirty-six studies met the inclusion criteria (25 single drug studies with 22,504 participants, 14 targeting anticoagulation; 11 multi-drug studies with 56,769 participants). ADEs were reported as an outcome in only four trials, all targeting anticoagulants. Computerized drug-lab alerts did not reduce ADEs (OR 0.89, 95% CI 0.79–1.00, p=0.05), length of hospital stay (SMD 0.00, 95%CI −0.93 to 0.93, p=0.055, 1 study), likelihood of hypoglycemia (OR 1.29, 95% CI 0.31–5.37) or likelihood of bleeding, but were associated with increased likelihood of prescribing changes (OR 1.73, 95% CI 1.21–2.47) or lab monitoring (OR 1.47, 95% confidence interval 1.12–1.94) in accordance with the alert. ConclusionsThere is no evidence that computerized drug-lab alerts are associated with important clinical benefits, but there is evidence of improvement in selected clinical surrogate outcomes (time in therapeutic range for vitamin K antagonists), and changes in process outcomes (lab monitoring and prescribing decisions).

Rare Bleeding Disorders in Children: Identification and Primary Care Management

Bleeding symptoms are common in healthy children but occasionally may indicate an underlying congenital or acquired bleeding diathesis. The rare bleeding disorders (RBDs) comprise inherited deficiencies of coagulation factors I (congenital fibrinogen deficiencies), II, V, VII, X, XI, and XIII and combined factor deficiencies, most notably of factors V and VIII and of vitamin K-dependent factors. These disorders often manifest during childhood and may present with recurrent or even serious or life-threatening bleeding episodes, particularly during the neonatal period. Accordingly, primary care and other nonhematologist pediatric providers should be familiar with the clinical presentation and initial evaluation of these rare disorders. Bleeding manifestations generally vary within the same RBD and may be indistinguishable from 1 RBD to another or from other more common bleeding disorders. Serious bleeding events such as intracranial hemorrhage may be heralded by less serious bleeding symptoms. The results of initial coagulation studies, especially prothrombin time and activated partial thromboplastin time, are often helpful in narrowing down the potential factor deficiency, with factor XIII deficiency being an exception. Consultation with a hematologist is advised to facilitate accurate diagnosis and to ensure proper management and follow-up. The approach to bleeding episodes and invasive procedures is individualized and depends on the severity, frequency, and, in the case of procedures, likelihood of bleeding. Prophylaxis may be appropriate in children with recurrent serious bleeding and specifically after life-threatening bleeding episodes. When available, specific purified plasma-derived or recombinant factor concentrates, rather than fresh frozen plasma or cryoprecipitate, are the treatment of choice.

Interacción warfarina y acetaminofén: Evaluación para establecer su relevancia clínica

Objetivo: realizar una revisión estructurada de la interacción warfarina y acetaminofén, buscando establecer su relevancia clínica y profundizar en el mecanismo de dicha interacción. &#x0D; Método: revisión estructurada en PubMed/Medline, de artículos en inglés y español, buscando los términos warfarin AND (acetaminophen OR paracetamol) en el título o resumen. La búsqueda se complementó con las referencias de artículos valorados como importantes. Los trabajos se agruparon en: relacionados con el aumento de sangrado por la interacción warfarina-acetaminofén, o relacionados con el mecanismo de la interacción. &#x0D; Resultados: se identificaron 45 artículos, de los cuales se incluyeron 15 en la revisión: 11 relacionados con el aumento del riesgo de sangrado por la interacción y cuatro con el mecanismo de la interacción. La gravedad del efecto (aumento de la probabilidad de sangrado) se consideró moderada; mientras que la probabilidad de aparición fue valorada como definida. Además, se identificó una relación entre la dosis de acetaminofén y el riesgo de sangrado. Por su parte, el N-acetil-para-benzoquinona-imina (metabolito del acetaminofén) inhibe enzimas del ciclo de la vitamina K y tiene un efecto sinérgico con el efecto anticoagulante de la warfarina. &#x0D; Conclusiones: la relevancia clínica de la interacción warfarina - acetaminofén es de riesgo alto, debido a que la gravedad del efecto (aumento del riesgo de sangrado) es moderada y su probabilidad de presentación es definida. Por tanto, estos dos medicamentos pueden ser utilizados conjuntamente, pero se debe realizar una estricta monitorización. El metabolito N-acetil-para-benzoquinona-imina es el responsable del aumento del efecto anticoagulante de la warfarina. (Acta Med Colomb 2013; 38: 22-27)

Net Clinical Benefit of Warfarin

The decision to use antithrombotics for stroke prevention in atrial fibrillation (AF) requires the assessment of an individual patient's risk of stroke balanced with their likelihood of bleeding on treatment. US practice guidelines have recommended the use of the CHADS2 score (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke [2 points]; graded from 0–6 according to presence of major risk factors; see the Table) for the assessment of stroke risk in patients with AF.1 However, this score cannot precisely categorize all patients at different risks of thromboembolism.2 The CHADS2 model does not account for certain previously underappreciated risk factors, including the increase in stroke risk with age in patients <75 years old and in those with vascular disease, and thus allocates many patients to the low- and intermediate-risk categories who might actually be relatively stroke prone.3 The 2010 European Society of Cardiology guidelines for the management of AF4 recommend use of the more inclusive CHA2DS2-VASc score (Congestive heart failure, Hypertension, Age ≥75 years [2 points], Diabetes mellitus, Stroke/TIA/Thromboembolism [2 points], Vascular disease, Age 65–74 years, Sex category; graded 0–9; see the Table), which incorporates additional risk factors, including age of 65 to 74 years and vascular disease. Validation studies have shown that the CHA2DS2-VASc score performs better than CHADS2 in distinguishing patients at low or intermediate thromboembolic risk.5 In a large Danish registry, thromboembolism rates at 1 year for patients at low risk (score=0) were 0.78%/y with CHA2DS2-VASc and 1.67%/y with CHADS2.6 View this table: Table. CHADS2, CHA2DS2-VASc, and HAS-BLED Risk Factors and Scoring Schema Article see p 2298 Risk models have also been developed to stratify bleeding risk in anticoagulated patients. The …

Predictors of Bleeding From Stable Pelvic Fractures

Stable pelvic fractures (SPFs) that do not need operative fixation are only infrequently associated with significant bleeding (SigBleed). Our hypothesis is that simple indicators, easily detectable at the bedside, can alert the clinician about the likelihood of bleeding and the need for closer monitoring or early intervention in patients with SPFs. Retrospective review of medical records. Academic level 1 trauma center. The medical records of patients with SPFs admitted to our academic level 1 trauma center from January 1, 2002, to June 30, 2007, were reviewed. Stable pelvic fractures were defined as fractures not requiring external or internal fixation. SigBleed was defined as the need for blood transfusion and/or intervention for bleeding control within the first 24 hours after admission. The patients were divided into group A, which included patients without SigBleed; group B, which included patients with SigBleed of a nonpelvic cause; and group C, which included patients with SigBleed caused by the SPF. The 3 groups were compared by univariate and multivariate analysis. Significant bleeding from SPFs. Of 391 patients with SPFs, 280 (72%) were in group A, 90 (23%) were in group B, and 21 (5%) were in group C. Compared with group A patients, those in group C were older and had a lower hematocrit and systolic blood pressure on admission. They also had longer hospital stays and a higher mortality. The following independent predictors of SigBleed from SPF were identified: hematocrit of 30% or lower (odds ratio [OR], 43.93; 95% confidence interval [CI], 9.78-197.32; P < .001); presence of pelvic hematoma on computed tomographic scan (OR, 39.37; 95% CI, 4.58-338.41; P < .001); and systolic blood pressure of 90 mm Hg or lower (OR, 18.352; 95% CI, 1.98-169.87; P = .01). When all independent predictors were present, 100% of the patients had SigBleed; when all were absent, no one had SigBleed. The incidence of SigBleed due to SPFs is low (5% in this study) and independently predicted by an admission hematocrit of 30% or lower, the presence of a pelvic hematoma on computed tomographic scan, and systolic blood pressure of 90 mm Hg or lower.

Overview of Platelet Transfusion

Most platelet transfusions are given to prevent bleeding in thrombocytopenic patients undergoing chemotherapy for malignancy or hematopoietic stem cell transplant. In stable, uncomplicated patients the risk of bleeding is similar until the platelet count falls to <5,000/microL. However, many patients have clinical complications that necessitate transfusion at higher counts. Therefore, the recommended indication for prophylactic transfusion is a platelet count of 10,000/microL. The usual dose of platelets is 1 apheresis unit or a pool of four to six concentrates from individual units of whole blood. The likelihood of bleeding is the same if half or double the usual dose is given, but half-dose transfusions must be given more often and double-dose transfusions less often than the standard dose. For patients with inherited defects of platelet function or acquired defects such as due to drugs or uremia, the platelet count is usually normal and prophylactic transfusion is not recommended. Transfusion may be helpful to treat serious bleeding. Patients undergoing cardiopulmonary bypass may be slightly thrombocytopenic but usually have platelet dysfunction. Transfusion is helpful to treat nonsurgical serious bleeding. In idiopathic thrombocytopenic purpura, platelet survival is short and transfusion is useful only for severe bleeding.

Upper gastrointestinal bleeding in haemophiliacs: incidence and relation to use of non‐steroidal anti‐inflammatory drugs

This multicentre study sought to estimate the incidence of upper gastrointestinal (UGI) bleeding in haemophiliacs and its relationship to use of non-steroidal anti-inflammatory drugs (NSAIDs). Cox models were used to estimate relative hazards (RH) with 95% confidence intervals (CI) for postulated risk factors. Conditional logistic regression and stored sera were used to assess UGI bleeding risk with Heliobacter pylori seropositivity in cases compared with closely matched controls. During a mean of 17.4 months (range 2-34), 2285 participants, ages 13-89 (mean 36.5) were followed for 3309 person-years (py). Forty-two experienced a UGI bleeding event (incidence 1.3 per 100 py), most from ulcer (11), gastritis (four), varices (five) and Mallory Weiss tears (eight). RH was significantly increased with traditional NSAID use for <1 month (OR: 3.66; 95% CI: 1.1-11.9), but not with coxibs use. RH was significantly and independently increased with age >46 years (3.5; 95% CI: 1.1-10.6) and hepatic decompensation (4.4; 95% CI: 1.7-11.6). Likelihood of bleeding was substantially but not significantly increased (OR: 4.6; 95% CI: 0.3-83.9) with H. pylori seropositivity. These findings suggest that coxibs are a safer alternative than traditional NSAIDs in the treatment of haemophilic arthropathy.