Number Of Hemorrhagic Complications Research Articles

Clopidogrel versus newer P2Y12 inhibitors in the dual antiplatelet therapy for stent-assisted coil embolization of intracranial aneurysms: A meta-analysis.

Stent-assisted coil embolization (SACE) for cerebral aneurysms requires dual antiplatelet therapy (DAPT), commonly clopidogrel plus aspirin is preferable to ticagrelor or prasugrel plus aspirin. However, there are few studies assessing the safety of the association of ticagrelor or prasugrel plus aspirin. Compare the safety of newer P2Y12 inhibitors with clopidogrel in patients that underwent a SACE for cerebral aneurysms. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we searched PubMed and Embase for studies comparing newer P2Y12 inhibitors with clopidogrel in patients undergoing DAPT for SACE. Outcomes were total number of complications, number of hemorrhagic complications, and number of thromboembolic complications both intraoperative and follow-up. A random effects model was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs). We included 1026 patients from six studies. Newer P2Y12 inhibitors were used in 562 (54,77%) patients. There were no significant differences between groups in total number of complications (OR 0.80; 95% CI 0.32, 1.99; p < 0.01; I2 = 78%), in intraoperative hemorrhagic complications (OR 0.66; 95% CI 0.09, 4.71; p = 0.68; I2 = 0%), follow-up hemorrhagic complications (OR 1.23; 95% CI 0.70, 2.15; p = 0.49; I2 = 0%), intraoperative thromboembolic complications (OR 0.43; 95% CI 0.14, 1.35; p = 0.25; I2 = 24%), and in follow-up thromboembolic complications (OR 0.89; 95% CI 0.33, 2.39; p = 0.03; I2 = 59%). In patients who underwent a SACE, newer P2Y12 inhibitors showed no differences in intraoperative and follow-up complications compared with clopidogrel.

MO184ANTICOAGULANT THERAPY IN PATIENTS WITH CHRONIC KIDNEY DISEASE AND ATRIAL FIBRILLATION

Abstract Background and Aims Chronic kidney disease (CKD) significantly alters the pharmacokinetics of drugs, which in practice complicates the selection of adequate anticoagulant therapy (ACT) in patients with atrial fibrillation (AF) and CKD. At the same time, in the vast majority of patients with AF and CKD, ACT is required to prevent life-threatening thromboembolic complications. In such an environment, maintaining a balance between the effectiveness and safety of ACTs is extremely important. Aim is evaluation of the efficacy and safety of the use of direct oral anticoagulants (OAC) in CKD stages 1-3 in combination with AF. Method The study included 93 patients (38 men and 55 women) aged 41 to 86 years with CKD stages 1-3 and AF receiving therapy with OAC (rivaroxaban) and vitamin K antagonists (warfarin). The observation period was 12 months. Results An analysis of 75 patients with CKD of various stages and AF receiving rivaroxaban was performed, the control group consisted of 18 patients taking warfarin. The average CHA2 DS2-VASc score in the OAC group was 4.1±1.8 points, in the warfarin group - 4.2±1.3 points. There were also no significant differences between the groups in terms of the average score on the HAS-BLED scale (risk of developing hemorrhagic complications): 2.3±0.94 points in the OAC group, 2.5±0.6 points in the warfarin group. Among the comorbidities in the OAC group, 93.2% of patients had arterial hypertension (AH), 24.5% had type 2 diabetes mellitus (DM); in the warfarin group, 94.3% of patients had hypertension and 16.8% had type 2 diabetes. In 23.9% of patients in the OAC group, minor bleeding was recorded. The largest number of hemorrhagic complications occurred in patients with stage 3 CKD: 18.9% of bleeding, which significantly (p&amp;lt;0.05) exceeds the number of bleeding in patients with a more pronounced decrease in renal function. In 33.3% of patients with diabetes, hemorrhagic complications were recorded, which is significantly (p&amp;lt;0.05) more than in the group of patients without diabetes - 21.4%. The greater number of hemorrhagic complications is most likely due to a more pronounced progression of the decline in renal function compared with patients without diabetes: 71.4% of patients with diabetes showed a decrease in GFR by an average of 16.6 ml/min/1.73 m2 for 12 months, which is significantly more (p&amp;lt;0.05) than in patients without diabetes (an average of 5.7 ml/min/1.73 m2). Conclusion In patients with CKD stages 1-3 with non-valvular AF, the use of OAC is most effective and safe in preventing thromboembolic complications. At the same time, the progression of CKD against the background of diabetes when taking anticoagulants occurs faster than in its absence, regardless of the specific anticoagulant. Patients with AF, DM and CKD are more likely to have hemorrhagic complications, which requires more frequent monitoring and monitoring of the functional state of the kidneys.

Перкутанная нефролитотрипсия у детей младшей возрастной группы

Introduction. Urolithiasis remains one of the most common diseases in the pediatric urology practice. A special category is made up of children weighing up to 15 kg with large and coral-like kidney stones, which require a smaller instrument to remove. Aim. The aim of the study was to evaluate the effectiveness of percutaneous nephrolithotripsy, used for urolithiasis treatment in children aged 1 to 3 years. Materials and methods. Between 2008 and 2019 in the pediatric uroandrology department of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation 93 children aged 1 to 3 years (69 (74.2%) boys and 24 (25.8%) girls) had nephrolithotripsy. The average patients age was 1 year and 9 months. Fifty-one (54.8%) patients had coral-like kidney stones, while the remaining 42 (45.2%) had kidney pelvic stones. The average stone size was 25.8mm. (15 – 56 mm). Nephrolithotripsy was performed according to the standard technique, all patients underwent cystoscopy and ureteral catheterization. In the prone position, under ultrasound and X-ray guidance, a puncture of the renal collecting system was performed. In 59 cases (63.5.1%) the puncture was performed through the lower calyx, in 31 cases (33.3%) – through the middle one, and in nine children two approaches were performed. In 93 children the intervention was performed using a mini-nephroscope with tubes of 12, 15 and 16.5 Ch. To disintegrate the stone, a pneumatic lithotripter and a holmium laser "Auriga" with a fiber of 365 and 600 μm in diameter were used. Only in 31 cases, when the kidney size allowed, a standard 24 Ch nephroscope and combined lithotripsy (ultrasound and pneumatic) were used. The duration of the procedure varied from 32 to 145 minutes, with an average of 43.5 minutes. In the postoperative period, all patients underwent infusion and antibiotic therapy based on the results of urine bacteriological examination. After the patients’ activation on days 1 – 3, a survey urography and antegrade pyeloureterography were performed. In the absence of residual stones and urinary passage disorders, nephrostomy drainage was removed. Results. The effectiveness of nephrolithotripsy in our cohort of patients was 87.1% (81 patients). Four children (4.3%) required second percutaneous intervention. The remaining 8 (8.6%) patients with residual stones underwent distance lithotripsy in the short postoperative period. Significant bleeding occurred in 2 patients who then required transfusion of blood products. Fever was noted in 5 (5.4%) patients. We have not observed a single case of septic and bacteriotoxic shock. Discussion. As a first-line surgical treatment in pediatric practice, it is recommended to use extracorporeal shock wave lithotripsy (ESWL). This treatment is ideal for stones ≤ 15 mm in size, with SFR of 68-95%. However, the need for repeated ESWL sessions occurs in 14-54% cases. Complications rate, frequency of retreatment, as well as a decrease in SFR, increase when a stone size is greater than 1.5 cm. Since all types of surgical treatment in children require anesthesia, and the treatment approach may not provide a complete problem solution, it is preferable to choose a procedure with the greatest possible success in one session. Primary SFR was significantly lower in children with stones ≥ 30 mm in size and multiple kidney stones. Mini– percutaneous nephrolithotripsy is an effective (87.1%) method for nephrolithiasis treatment in children aged 1 to 3 years. Conclusion. Mini-percutaneous nephrolithotripsy in children aged 1 to 3 years is an effective treatment for nephrolithiasis. However, in a small percentage of cases, it becomes necessary to combine the procedure with extracorporeal lithotripsy. Paying attention to the small size of the organ, to reduce the number of hemorrhagic complications, it is preferable to perform this intervention with one approach. The occurrence of even a small amount of bleeding during the operation is a formidable complication, given the small volume of circulating blood in children.

Оценка безопасности прямых пероральных антикоагулянтов у пациентов старческого возраста с перенесенным тромбозом в системе нижней полой вены

to evaluate the frequency of hemorrhagic complications in elderly patients with deep vein thrombosis taking direct oral anticoagulants (DOACs). Patients and methods: depending on the type of prescribed DOACs, all patients were randomized by sequential numbers into 3 groups: group 1 (n=124, 79.7±4.3 years) — patients took apixaban at a dose of 5 mg 2 times a day; group 2 (n=125, 78.9±4.6 years) — patients received rivaroxaban at a dose of 20 mg once a day; group 3 (n=121, 77.8±2.3 years) — patients received dabigatran 150 mg twice a day. The groups were comparable by gender, age, and concomitant pathology. The follow-up period for patients was 3 or 6 months from the start of DOACs therapy, depending on the form of thrombosis (distal, proximal) and the terms of anticoagulant administration. Hemorrhagic complications were classified as "major" in the case of retroperitoneal or intracranial bleeding, if there was a need for transfusable components, as well as when surgical intervention was required. In all other cases, the bleeding was classified as "minor". Results and Discussion: in group 1, the total number of hemorrhagic complications was 10.3% less than in group 2 (p=0.029), and 8.4% less than in group 3 (p=0.049). No statistically significant differences were found, when comparing the frequency of hemorrhagic complications in patients from the rivaroxaban and dabigatran groups. Conclusion: in the study course, apixaban demonstrated a more favorable safety profile concerning the overall frequency of hemorrhagic complications in the treatment of inferior vena cava thrombosis versus the other DOACs. KEYWORDS: deep vein thrombosis, hemorrhagic complications, venous thromboembolism, senile asthenia, direct oral anticoagulants. FOR CITATION: Khruslov M.V., Ponomareva I.V., Safronova L.V., Sorokina A.S. Safety evaluation of direct oral anticoagulants in elderly patients with inferior vena cava thrombosis. Russian Medical Inquiry. 2021;5(5):268–272 (in Russ.). DOI: 10.32364/2587-6821-2021- 5-5-268-272.

In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

PurposeMechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO.Materials and MethodsWe collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis.ResultsFifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients.ConclusionsMT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

Using Extracorporeal Shock Wave Lithotripsy of Kidney Stones and the Upper Third of the Ureters

The objective: of the study was evaluate efficiency and safety of ethamsylate and tranexamic acid administration for prevention of the hemorrhagic complications of ESWL.Materials and methods. Patient with urinary stone diseases (stone localized in kidney or upper part of urether) without coagulation disorders and who did not take medicines that affect the blood coagulation system was included. All patient was undergo ESWL. The group І included 1400 patients who did not receive preventive antihemorrhagic therapy. Group II – 375 patients who received 250 mg ethamsilate intravenously before the ESWL session. Group III – 300 patients – 500 mg tranexamic acid intravenously. During the postoperative period, the occurrence of kidney hematomas, prolonged macrohematuria and the occurrence of diseases associated with hypercoagulation were assessed.Results. Group I: hemorrhagic complications were found in 52 (3.71 %) patients; 19 (1.36 %) people had renal hematomas, and 33 (2.36 %) had prolonged macrohematuria. In group II –3 (0.8 %) patients had hematomas and 3 (0.8%) – prolonged macrohematuria. In the group ІІІ, there was no hematomas and only 2 (0.67 %) patients had macrohematuria. The number of hemorrhagic complications in the tranexamic acid group was lower than in the control one (p=0.006). More severe complications predominated in the control group, compared with patients receiving hemostatic. None of the experimental groups didn’t show an increase in the frequency of pathology associated with hypercoagulation.Conclusions. ethamsylate and tranexamic acid can reduces the likelihood of renal hematoma and prolonged macrohematuria after ESWL. We did not find any complications specific to these medicines. The use of tranexamic acid is much more effective than ethamsylate.

Efficacy and safety of new oral anticoagulants as part of triple antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome. Data from an observational study

Aim To study efficacy and safety of a triple antithrombotic therapy with direct oral anticoagulants (DOAC) versus warfarin in patients with atrial fibrillation after acute coronary syndrome, for 12 months following discharge from the hospital.Materials and methods This single-site cohort, prospective, observational study performed at the Regional Vascular Center 2 of the N.A. Semashko Nizhniy Novgorod Regional Clinical Hospital included 402 patients. It was possible to maintain contacts with 206 patients for 12 months. These patients were divided into two groups, the DOAC treatment (n=105) and the warfarin treatment (n=101) as a part of triple antithrombotic therapy upon discharge. Clinical observation was performed at 1, 3, 6, and 12 months after the discharge by structured telephone interview. Predetermined efficacy endpoints included cardiovascular death, myocardial infarction, stent thrombosis, and ischemic stroke. Safety endpoints included bleeding defined as small, medium (clinically significant), and major in accordance with the TIMI classification.Results At 12 months of follow-up, 80 patients (76.19%) continued taking DOAC and 39 patients (38.61%, p&lt;0.001) continued taking warfarin; in this process, only 25 patients (24.75%) monitored their INR on a regular basis. With a regular INR monitoring and TTR &gt;70%, death rate did not differ in the warfarin and the DOAC treatment groups. However, there was a difference in reaching the composite efficacy endpoint (p=0.048): ischemic events occurred statistically significantly more frequently in the warfarin treatment group than in the DOAC treatment group.Conclusions In 12 months after discharge from the hospital, compliance with the DOAC treatment as a part of the antithrombotic therapy was significantly higher than compliance with the warfarin treatment. The triple antithrombotic therapy with DOAC was safer than the warfarin treatment by the number of hemorrhagic complications and more effective in prevention of ischemic events, primarily due to no need for monitoring of lab test values.

Algorithm for the Choice of Anticoagulant for Patients with Atrial Fibrillation

Aim. To evaluate the effectiveness of the anticoagulant choice algorithm in the prevention of complications of atrial fibrillation (AF). Material and methods. Patients with AF (n=98) were included into observational prospective study. The level of adherence to treatment, risk of food interactions and presence of CYP2C9 and VKORC1 genes mutations were determined at the initial examination. These indicators were necessary to specify an eligible anticoagulant according to the evaluated algorithm. Therapy was prescribed by the attending physician. Hemorrhagic and thromboembolic complications were assessed at the next examination after 24 weeks. Results. Hemorrhagic complications were observed in 31.6% of patients during the follow-up. Their number was comparable in individuals taking antiplatelet agents and direct oral anticoagulants (DOACs) (χ2=1.44; p&lt;0.49, Pearson) and significantly more in individuals taking warfarin (as compared to DOACs: χ2=25.08; p&lt;0.000, Pearson; and antiplatelet agents: χ2=34.32; p&lt;0.000, Pearson). Thromboembolic complications were reported in 8.16% of patients. Their number was more in patients taking DOACs than warfarin (χ2=7.03; p&lt;0.03, Pearson). Patients who had to take DOACs according to the algorithm, but in the study took warfarin, demonstrated significantly greater number of thromboembolic complications, with a comparable number of hemorrhagic complications. Patients who could take warfarin according to the algorithm, but in the study took DOACs, had significantly greater number of thromboembolic complications, with a comparable number of hemorrhagic complications. Conclusion. The results of the study demonstrated the potential for reduction in complications, especially thromboembolic, in the choice of anticoagulant using the algorithm; and reduction in complications of therapy, primarily with warfarin, due to the initial prescription of DOACs. The proposed approach, which consists in using the quantitative assessment of adherence to treatment, and only if necessary supplemented by the assessment of food preferences and/or pharmacogenetic studies, contributes to the treatment optimization.

Thrombotic and hemorrhagic complications in atrial fibrillation patients, undergoing elective percutaneous coronary intervention

To evaluate efficacy and safety of reduced dose of direct oral anticoagulants (DOACs) as part of triple antithrombotic therapy in AF patients, undergoing elective percutaneous coronary intervention (PCI), and to identify factors, associated with this strategy. The study is a cohort analysis of AF patients with AF, who successfully underwent elective PCI and assigned DOACs as part of triple antithrombotic therapy (TAT).Influence of a reduced DOACs dose as a part of TAT on the frequency of thecomposite efficacy endpoint (acute coronary syndrome, ischemic stroke, venous thromboembolic events, cardiovascular death and angina pectoris aggravation/need for unplanned PCI) and safety endpoint (hemorrhagic complications BARC types 2-5) were assessed using the Log-Rank criterion. The study included 124 pts (69.4% women, mean aged 69±8.2 years). Themedian total score CHA2DS2-VASc was 5, the median of the Charlson index composed 7. Half (52%) of AF patients with high risk of thrombotic events after elective PCI received reduced-DOACs dose. Median follow up period was 11.0 month. 17 adverse thrombotic events were recorded during this period, BARC 2-5 bleedings occurred in 27 patients. Reduced DOACs doses in AF patients undergoing PCI were associated with significant increase of thrombotic events during follow up period compared to patients received full DOACs doses (0.79 vs 0.93, Log-Rank p=0.0292). Patients, who received full and reduced DOAC doses, were comparable in the frequency of BARC 2-5 bleedings (0.78 vs 0.75, Log-Rank p=0.06742). The administration of a reduced DOACs dose as a part of TAT in patients with AF, who underwent PCI, was associated with significant increase in the incidence of all thrombotic events, compared to patients, who received full dose of anticoagulants. The number of hemorrhagic complications was comparable.

Experience of Laparoscopic and Robot-assisted Distal Pancreatectomy

Aim. To analyze the outcomes of robot-assisted and laparoscopic distal pancreatectomies. Material and Methods. 42 patients were enrolled: 27 patients underwent laparoscopic distal pancreatectomy, 15 – robot-assisted distal pancreatectomy. Results . Both groups were statistically homogeneous and comparable. Time of laparoscopic and robot-assisted distal pancreatectomy was 184 ± 21.4 and 236 ± 31.6 min (p = 0.0384), respectively; intraoperative blood loss – 310 ± 54 ml and 240 ± 86 ml (p = 0.0564), respectively. There were 6 (66.7%) spleen-sparing laparoscopic distal pancreatectomies and 6 (85.7%) robotic procedures in the same fashion. The length of hospital-stay after laparoscopy was 5.4 ± 1.8 days, after robot-assisted operation – 6.1 ± 1.6 days (p = 0.073). The number of hemorrhagic complications and pancreatic fistulas ISGPS 2016 was similar in both groups. There were 16 Clavien–Dindo complications after laparoscopic pancreatectomy and 8 after robot-assisted surgery. Conclusion . It was established that laparoscopic pancreatectomy is associated with reduced time of surgery and lower percentage of spleen-sparing interventions. Intraoperative blood loss, hospital-stay and postoperative morbidity do not depend on the type of surgery.

What Is the Safety and Efficacy of Chemical Venous Thromboembolism Prophylaxis Following Vestibular Schwannoma Surgery?

The benefit of routine chemical prophylaxis use for venous thromboembolism (VTE) prevention in skull base surgery is controversial. Chemical prophylaxis can prevent undue morbidity and mortality, however there are risks for hemorrhagic complications. Retrospective case-control. A retrospective chart review of patients who underwent surgery for vestibular schwannoma from 2011 to 2016 was performed. Patients were divided by receipt of chemical VTE prophylaxis. Number of VTEs and hemorrhagic complications (intracranial hemorrhage, abdominal hematoma, and postauricular hematoma) were recorded. One hundred twenty-six patients were identified, 55 received chemical prophylaxis, and 71 did not. All the patients received mechanical prophylaxis. Two patients developed a deep vein thrombosis (DVT) and one patient developed a pulmonary embolism (PE). All patients who developed a DVT or PE received chemical prophylaxis. There was no difference in DVT (p = 0.1886) or PE (p = 0.4365) between those who received chemical prophylaxis and those who did not. Five patients developed a hemorrhagic complication, two intracranial hemorrhage, three abdominal hematoma, and zero postauricular hematoma. All five patients with a complication received chemical prophylaxis (p = 0.00142). The relative risk of a hemorrhagic complication was 14.14 (95% CI = 0.7987-250.4307; p = 0.0778). There was a significant difference between the number of hemorrhagic complications but not between numbers of DVT or PE. Mechanical and chemical prophylaxis may lower the risk of VTE but in our series, hemorrhagic complications were observed. These measures should be used selectively in conjunction with early ambulation.

Extended Antithrombotic Therapy in Elderly Patients with Deep Venous Thrombosis

Objective. The objective of the present study was to evaluate the quality of the extended anticoagulation in elderly patients with a history of deep vein thrombosis. Material and methods. We examined and treated 50 women with deep venous thrombosis in the inferior vena cava system. The mean age was 72.8±6.08 age. The study group included 24 people taking rivaroxaban as secondary prevention of recurrent venous thrombosis (mean age 72.7±5.7). The control group included 26 patients taking vitamin K antagonist warfarin (mean age 72.9±6.5). Evaluation criteria were the frequency of recurrence of deep venous thrombosis and bleeding complications. Results. There was 3 episodes of recurrent deep venous thrombosis in the control group (11.5%) and no episodes in the basic group taking rivaroxaban (p=0.235). The number of haemorrhagic complications in the control group was 46.2% (n=12) and found to be higher than in the group taking rivaroxaban (20.8%, n=5), but not statistically significant (p=0.077). The number of patients at the age of 75—89 years who had haemorrhagic complications was higher in the control group comparing to group taking rivaroxaban (p=0.04). Doctors of clinics in a residence of patients have not managed to provide the adequate INR therapeutic range. Conclusion. Administration of rivaroxaban in elderly patients is efficient in prevention of recurrent deep venous thrombosis. Use of vitamin K antagonists is associated with certain difficulties, in particular carrying out adequate control of the anticoagulation therapy and further adjustments that in turn can lead to development of haemorrhagic complications or recurrent deep venous thrombosis.

Клиническое значение лактоферрина слюны в индивидуальном прогнозировании осложнений при санации полости рта больных с местно-распространенным раком слизистой полости рта

Purpose of the investigation is to develop and introduce the methods of prognosis complications of oral sanitation at the treatment of the patients with locally common cancer of oral mucosa. Sanitation of oral cavity in patients with locally common cancer of oral mucus membrane is connected with development of various complications among which infections and hemorrhages play a leading part. It determines problem of development of methods of forecasting of these complications as relevant. Material and methods: Based on a comparative analysis of 340 patients with above pathology the authors have traced dependence between the development of complications in oral cavity after chemical and radial therapy and levels of lactoferrin (LF) in saliva. This simple and non-invasive method can be as a marker of pathological states in oral cavity. Among the complex of the parameters the authors have studied risk factors of complications after the use of the cytostatics and radial therapy with resulting index of prognosis (IP) for development of complications. Based on the index of prognosis individual tactics of treatment was determined. Results: Depending on the saliva levels of lactoferrin in patients receiving chemo- and radial therapy a complex of prophylactic and curable measures was developed, which allowed to decreasing the number of inflammatory processes in a zone of dental procedures from 14,1 to 2,8% and the number of bleedings from 8,0 to 5,0%. Conclusions. Level of LF in saliva can be considered as valid prognostic marker of the development of destructive complications while oral sanitation in patients received chemo- and radial therapy. Assessment of the probability of these complications with correction of preventive and therapeutic measures should be implemented depending on the prognostic value of the index. Prevention activities for development of complications in sanitation of oral cavity in cancer patients after combined and complex treatment can reduce the number of hemorrhagic complications to 5.0%, and the local inflammatory processes to 2.8%.

High prevalence and risk factors of thromboembolism in stage IV melanoma

Patients with cancer are at a high risk of thromboembolism (TE), which contributes to morbidity and mortality. Several case reports of thromboembolic events have been reported in patients with melanoma in the literature. The aim of this study was to evaluate the prevalence of venous thromboembolism (VTE) in stage IV melanoma and determine risk factors, outcomes associated with the development of VTE and the number of haemorrhagic complications in patients under anti-coagulant treatment. In this retrospective study, we included all consecutive patients with stage IV melanoma among 290 patients followed-up in the department of Dermatology each year between January 2005 and 31 December 2007. The diagnosis of VTE was confirmed by venous ultrasound, pulmonary perfusion-ventilation technetium scan and angiography. The primary outcome was to evaluate the number of TE diagnosed in stage IV melanoma patients. The secondary outcomes were to study the influence of TE on survival, its prevalence according to metastatic sites and to evaluate the number of haemorrhagic complications. Twenty-four VTE events were found [25.2% (CI: 16.5-34)]. Eighteen VTE were deep venous thrombosis in lower limbs associated with pulmonary embolism (PE) in 50% of cases. Twenty-five percent were asymptomatic and were revealed in the pulmonary scan performed for follow-up. Eight percent of VTE events revealed stage IV melanoma. Seventeen patients developed thrombosis at home after stopping heparin prophylaxis. Seven thrombotic events occurred during oral anti-coagulant therapy. We found as high a prevalence of VTE in stage IV melanoma as in lung and gastrointestinal cancers. All patients suffered thrombotic events when they were treated with chemotherapy and at home when they stopped heparin prophylaxis. Therefore, heparin prophylaxis should be maintained at home.

Proposal of a standard approach to dental extraction in haemophilia patients. A case-control study with good results.

We found no case-control studies on dental extraction in haemophilia patients in the literature even though the use of antifibrinolytic agents following a single infusion of factor VIII or IX has been accompanied by a lower number of bleeding complications in dental extractions. In this study we verified the incidence of bleeding complications after dental extraction in a group of 77 haemophilia patients. One hundred and eighty-four male patients requiring dental extraction represented the control group. All haemophilia patients received 20 mg kg-1 of tranexamic acid and a single infusion of factor VIII or IX to achieve a peak level about 30% of factor VIII or IX in vivo prior to dental extraction. Forty-five of 98 (45.9%) dental extractions in haemophilia patients and 110 of 239 (46%) dental extractions in the control group were surgical ones. We registered two bleeding complications in the group of haemophilia patients (one late bleeding and one haematoma in the site of the anaesthetic injection) and one (a late bleeding) in the control group. The difference of bleeding complications in the two groups of patients were not statistically significant (P=0.2; OR 0.2; CI 0.01-2.22). The protocol proposed in this study, characterized by the feasibility and the number of haemorrhagic complications not different from normal population, make dental extractions in haemophilia patients possible on an out-patient basis with a cost reduction for the community and minor discomfort for the patients.

ACUTE ABDOMINAL CONDITION DUE TO BISHYDROXYCOUMARIN (DICUMAROL) POISONING

THE NUMBER and variety of the complications as a result of bishydroxycoumarin (Dicumarol) intoxication, or poisoning, are of staggering proportions. A review of the literature leads one to conclude that in this drug one is dealing with a truly fine pharmaceutical tool but one that without proper surveillance may easily become a lethal weapon. In the report of a fatal case of bishydroxycoumarin poisoning Duff and Shull 1 state succinctly: The most important of all contraindications to the use of dicumarol ® is lack of reliable laboratory facilities for prothrombin determinations. Employment of this beneficial drug without laboratory control is hazardous and may result in fatal widespread hemorrhage. Aggeler 2 has collected and tabulated from the American literature the number of hemorrhagic complications following bishydroxycoumarin therapy up to 1946. He reports that of a total of 1,471 patients treated with the drug hemorrhagic complications developed in 123 (8.3%). There were