Oral Warfarin Sodium Research Articles

Hem coagulase induced cerebral venous sinus thrombosis in patients with uterine fibroids surgery.

Cerebral venous sinus thrombosis (CVST) is a rare, high-risk, and easily misdiagnosed disease. Currently, there are case reports of hem coagulase-induced thrombotic events, but no reports of CVST being associated with hem coagulase. A 35-years-old woman presented to the outpatient clinic with a severe headache and sudden memory loss with intravenous hem coagulase for postoperative bleeding after uterine fibroids surgery. Abnormal neurological signs included slowed reactions, poor memory, and decreased numeracy. Magnetic resonance imaging and computed tomography scan showed multiple cerebral infarcts, and the infarct area was non-arterial. Brain magnetic resonance venography showed obstruction of the left sigmoid sinus. High-resolution magnetic resonance imaging of the left sigmoid sinus showed abnormally high signal. The patient was treated with a subcutaneous Low-Molecular-Weight Heparin Sodium injection 0.4 ml, twice a day (7 days), and oral Warfarin Sodium 3 mg, once a day, while monitoring the international normalized ratio, adjust the warfarin sodium dosage according to the international normalized ratio level. One month later, the patient had no neurological symptoms and her cognitive function returned to normal. hem coagulase may be a contributing factor to CVST in patients undergoing uterine fibroids surgery and should be administered intravenously with caution.

A case of thromboembolic events as first manifestation of membranous nephropathy

We present a case of idiopathic membranous glomerulonephritis that presented with venous thromboembolism and was successfully managed with corticosteroid, cyclosporin, appropriate anticoagulant therapy. A 59-year old male patient was referred to our nephrology department who had an outpatient history of swelling in the feet and flank pain was detected proteinuria and thrombosis in the inferior vena cava. Warfarin sodium treatment was started when thrombus was detected in the femoral vein, renal vein and inferior vena cava in the imaging. The patient had 12 g/day proteinuria, hypoalbuminemia, hyperlipidemia and antiphospholipase A2 receptor antibody positivity and treatment was started with the diagnosis of idiopathic membranous nephropathy. The patient who was discharged with oral steroid, cyclosporine and warfarin sodium, but warfarin sodium was changed to rivaroxaban in another clinic due to incompatibility problems, was presented again with dsypnea. Pulmonary embolism was detected. Rivaroxaban was discontinued and low molecular weight heparin treatment was started. There was a very high risk of morbidity and mortality and with appropriate treatment, clinical status and renal function were stabilized. In conclusion, although thromboembolism can be seen in nephrotic syndrome, it may rarely be encountered as the first presentation of nephrotic syndrome. This situation should not be overlooked, appropriate treatments should be provided without delay.

Successful Treatment for End—Stage Hepatic Alveolar Echinococcosis With ex vivo Liver Resection and Autologous Liver Transplantation: A Case Report

3045_A.tif Figure 1: Preoperative 3D imaging analysis system revealed the retro—hepatic IVC was involved (arrow)3045_B.tif Figure 2: The irregular outflow of right/short hepatic vein reconstruction (A: great saphenous veins; B—C: right/short hepatic vein reconstruction using the great saphenous veins wall)Objective To explore the surgical process of ex—vivo liver resection and autologous liver transplantation (ERAT) for end—stage hepatic alveolar echinococcosis (HAE) and evaluate the therapeutic effect and surgical benefit. Methods The clinical data of one end—stage HAE patient treated with ERAT combined complicated hepatic vein reconstructionwas analyzed retrospectively. Preoperative examination and intraoperative exploration revealed the second hepatic portal was involved. We successfully initiated an operation through ex—vivoliver resection, hepatic vein reconstruction with the autogenous saphenous vein, and subsequent piggyback autologous liver transplantation by wide—mouth hepatic vein—artificial inferior vena cava anastomosis (end to side). Results This patient discharged uneventfully 14 days after the operation. The injection of low—molecular—weight heparin sodium and consequent oral warfarin sodium tablets were administered for anticoagulant therapy. Regular autograft ultrasound examination revealed no tarombokinesis in autologous liver and inferior vena cava. Conclusion ERAT is an ideal surgical method for end—stage HAE. Wide—mouth hepatic vein reconstruction using an autogenous saphenous vein is the key procedure. Postoperative anticoagulant therapy is significant for the improvement of transplanted liver function.3045_C.tif Figure 3: Piggyback autologous liver transplantation (A—C)

Effect of Long Term Oral Warfarin Sodium Treatment on Bone Mineral Density Scores and Spinal Sagittal Alignment

Yaz›flma Adresi/Address for Correspondence: Dr. Kamil Eyvazov, Gazi Universitesi Tip Fakultesi, Ortopedi ve Travmatoloji Anabilim Dali, Ankara, Turkiye Tel.: +90 312 202 55 28 E-posta: kamileyvazov@gmail.com Gelis Tarihi/Received: 16.12.2015 Kabul Tarihi/Accepted: 15.02.2016 Uzun Donem Oral Varfarin Sodyum Tedavisinin Kemik Mineral Yogunlugu Degerleri ve Sagital Omurga Dizilimi Uzerindeki Etkisi DOI: 10.4274/tod.54366 Turk J Osteoporos 2016;22:29-34

ACUTE FEBRILE ILLNESS

Oral anticoagulation is needed in many patients like after prosthetic valvesinsertion, in atrial fibrillation, clots in LA, clots in LV and DVT etc. It is mainly achieved by warfarinsodium which has many interactions with multiple other drugs and its action varies in differentother chronic diseased states. Objectives: to see the response of acute febrile illness on thechronic stable state of INR on a fixed dose of oral warfarin sodium. Methods: All the patientswith acutely deranged INR who had a stable and controlled INR previously and a fixed doseof warfarin sodium were admitted in the cardiac surgical ward at FIC and their history wasexplored and recorded. A total of 966 patients were admitted in (CSW) during the period ofApril, 2012 to April, 2014 with deranged INR. INR was checked twice or sometimes thrice torule out the laboratory error. 504 patients were female & 462 patients were male, 56 patientshad repeated admission for their INR control, most of them were callous regarding taking doseof warfarin so they were excluded from the study. Result: A total of 631 patients had low INRdue to missed dose of warfarin sodium. Out of them 13 patients got stuck valve for whichemergency redo prosthetic valve replacement was done. 06 patients died in emergency dueto late presentation after the prosthetic valve got stuck. Only 279 patients had high INR onthe previous dose of warfarin sodium, out of them 216 patients had out of range INR. Theywere treated by FFP transfusion and holding the Warfarin sodium dose for certain period oftime.76% of the patients give H/o acute febrile states 101-103 with rigor & chills (Malaria, entericfever, pharangitis, cellulitis, boils and UTI etc. etc.) since last 3-4 days for which they had gottreatment from some local Gen. practitioners and gave the H/o bleeding gums, general bodymalaise, bruising, joint aches & pains. 24% of patients denied any acute febrile illness beforetheir INR got out of range 2 patients died in emergency due to intra cerebral bleed after INRgot uncontrolled. Conclusions: Any acute febrile illness even of short duration may causesudden derangement of previously controlled INR on certain fixed dose of warfarin sodiumwhich can create a life threatening situation like intra-cerebral bleed, haem-arthrosis, excessivemenstrual blood loss leading to severe anemia. Other less dangerous situation are gum bleed,bruising, joint aches & pains and general malaise. So, it is always advisable and logical to getINR check when ever any acute febrile illness even of short duration is encountered to avoidgrave situations.

Is it Justified to Exclude Patients with Minor Stroke from Intravenous Thrombolysis?

function. Aphemia is usually caused by an ischemic lesion seated in the opercular division of the precentral gyrus and can be a presenting symptom of acute stroke.As NIHSS scores in most cases of aphemia are likely to be low; the questionwhethertotreatornottotreatthese patients with IV rtPA may be a dilemma for physicians. We have recently treated two patients with aphemia because of an acute stroke successfully resolved with IV rtPA. The first patient was a 78-year-old man with history of hypertension and atrial fibrillation, and the second one was a 77-year-old man with history of dilated myocardiopathy.Both were attended in the emergency department after sudden development of speech difficulty. On examination, they made sounds but could not produce words. They kept intact written language expression and had also full comprehension. Oro-bucco-facial apraxia wasnotpresent.Theywereabletomove tongue on command. All other neurological examinations were normal.Both cases scored 3 in NIHSS. After brain computed tomography (CT) scan, both patients received intravenously 0·9 mg/kg rtPA 110 and 130 min after symptoms onset, respectively. Twohours later, both of them were fully recovered. CT brain at 24 h was normal in both cases. They were discharged after four-days with oral warfarin sodium prescription. As in ours patients, the NIHSS score in aphemia’s cases are likely to be lower than four but in this setting such a low score represents a devastating scenario for patient’s lifestyle because of severe inability to communicate. The question arises whether it is justified to exclude patients with low NIHSS from IV thrombolysis. Up to this date, there is no a controlled trial of reperfusion therapy to formally guide appropriate management of patients with minor stroke or RISS. Current guidelines

Unique Treatment Regimen for Effort Thrombosis in the Nondominant Extremity of an Overhead Athlete: A Case Report

To advise athletic trainers on the potential for effort thrombosis to occur in nonthrowing athletes and to underscore the importance of early recognition and treatment. An 18-year-old offensive lineman presented with a 1-day history of diffuse shoulder pain with no specific history of injury; swelling and erythema involved the entire left upper extremity. He was immediately referred to the team physician, who suspected deep vein thrombosis and sent the athlete to an imaging center. Duplex ultrasound was obtained on the day of presentation, and he was admitted to the hospital that evening. Deep vein thrombosis, thoracic outlet syndrome, shoulder tendinitis. Anticoagulation with heparin was administered at the hospital, and he was sent home the next day on subcutaneous enoxaparin sodium, followed by a 5-mg daily dose of oral warfarin sodium. Oral anticoagulants were continued for a total of 4 weeks. The athlete began upper body lifting and was released 5 weeks postinjury to gradually return to football without restrictions. Effort thrombosis is typically seen in the dominant arm of athletes, and the current treatment protocol calls for thrombolysis or surgical intervention. This athlete, whose position required repeated elevation of his arms in forward flexion, sustained the injury in his nondominant arm, was treated with anticoagulation only, and had a full return to football. At 18-month follow-up, he had no recurrence of symptoms. Early recognition and treatment of athletes with effort thrombosis is paramount to a successful clinical outcome and prompt return to play.

Warfarin Therapy for Livedoid Vasculopathy Associated With Cryofibrinogenemia and Hyperhomocysteinemia

Livedoid vasculopathy is an idiopathic, chronic disorder manifested by painful, purpuric macules on the lower extremities that superficially ulcerate, resulting in atrophic, stellate scars with peripheral telangiectasias and hyperpigmentation. A 50-year-old man presented with recurrent, painful ulcerations on the medial aspect of his malleoli and calves. The clinical presentation, histologic findings, and results of laboratory evaluation confirmed the diagnosis of livedoid vasculopathy in this case. Despite being refractory to treatment with multiple other medications, the lesions responded dramatically to oral warfarin sodium therapy. Treatment with warfarin may be a beneficial therapy for patients with livedoid vasculopathy.

Controversies in Timing of the First Dose of Anticoagulant Prophylaxis Against Venous Thromboembolism After Major Orthopedic Surgery

Adjusted doses of oral warfarin sodium or fixed doses of subcutaneous low-molecular-weight heparin (LMWH) are the standard approaches for preventing venous thromboembolism following major orthopedic surgery of the legs. In recent years, new anticoagulants have been compared with either LMWH or warfarin. The optimal timing for the first dose of LMWH prophylaxis and of the new anticoagulants is controversial. Recent clinical trials of LMWH and of newer anticoagulants have provided new information on the relationship between the timing of the first anticoagulant dose and the efficacy and safety of thromboprophylaxis after major orthopedic surgery. These data on the optimal timing of initiating prophylaxis come from limited direct randomized comparisons of different timing with the same anticoagulant, subgroup analysis of large studies with a single anticoagulant, indirect comparisons across studies in systematic reviews, and single randomized trials comparing different anticoagulants. In the direct comparison of the same anticoagulant, preoperative initiation of the same regimen of LMWH (dalteparin) increased major bleeding, without improved antithrombotic efficacy compared to the early postoperative regimen. Fondaparinux, 2.5 mg, begun 6 h postoperatively is more effective and as safe as the currently approved regimens of enoxaparin begun either 12 h preoperatively, or 12 to 24 h postoperatively, in patients undergoing major orthopedic surgery. In a subgroup analysis of several large randomized trials, fondaparinux, 2.5 mg, begun < 6 h postoperatively was associated with increased major bleeding, without improved efficacy. The results of indirect comparisons also favor the use of a 6-h postoperative starting time for the first dose, while the single randomized trials comparing different anticoagulants performed to date are not helpful in establishing an optimal time for the first dose. The aggregate clinical research evidence supports the following general conclusions about the relationship between the timing of the first anticoagulant dose and the efficacy and safety of prophylaxis: (1) preoperative initiation is not required for good efficacy and, when begun within 2 h of surgery, increases major bleeding; (2) initiation at 6 h postoperatively is effective and not associated with increased major bleeding; (3) initiation < 6 h postoperatively increases major bleeding, without improved efficacy; thus, 6 h appears to be the threshold for early postoperative administration; and (4) initiation 12 to 24 h postoperatively may be less effective than initiation at 6 h, but further randomized trials comparing the same anticoagulant initiated at different times postoperatively (eg, 6 h vs 12 h) are required to establish definitively the optimal timing of the first anticoagulant dose.

Estimation of Acute Blood Loss in the Anticoagulated Rabbit Model Using 3 Modalities of Radio Frequency Energy Ablation

An anticoagulated animal model was tested to evaluate estimated acute blood loss (EABL) following tissue ablation with 3 modalities of radio frequency (RF) thermal energy. Four groups of randomly divided rabbits were established. Group 1 (3 control and 3 anticoagulated rabbits) underwent sham treatment (noRF), group 2 (2 control and 7 anticoagulated) received single probe dry RF (dRF) (475 KHz and 5 W for 2 minutes), group 3 (2 control and 7 anticoagulated) received single probe wet RF (wRF) (475 KHz with 14.6% hypertonic saline at 50 W for 40 seconds) and group 4 (3 control and 7 anticoagulated) was treated with vapor RF (vRF) (0.9% normal saline for 10 seconds). Oral warfarin sodium was the anticoagulant. Following a midline incision ablation was performed on the left kidney and liver. Pre-weighed gauze pads were used to collect EABL for a 5-minute observation period after needle probe removal. Temperature data were recorded from the right kidney using fiberoptic thermocouples. Lesions were grossly inspected and measured. Anticoagulation resulted in super anticoagulated animals with an average prothrombin time of almost 140 seconds. EABL was the least from the ablated left kidney for vRF (50 mg), followed by wRF (260 mg), dRF (390 mg) and noRF (1,800 mg). EABL was the least from the liver for vRF (10 mg), followed by wRF (470 mg), dRF (1,260 mg) and noRF (2,680 mg). A greater percent of total ablative time at 10 mm was spent at greater than 50C during wRF and vRF. Measured ablative lesions size was largest following vRF ablation. The thermal coagulative effects of RF ablation resulted in less bleeding compared with controls in this orally anticoagulated animal model. The novel RF modality vRF is introduced.

Bilateral Lemierre's Syndrome: A Case Report and Literature Review

Lemierre's syndrome is characterized by thrombosis of the internal jugular vein that develops following an oropharyngeal infection. Sepsis and septic metastases frequently ensue and affect the lungs, the musculoskeletal system, and occasionally the liver. Most cases are caused by infection with Fusobacterium necrophorum. This infection responds to antibiotic therapy with beta-lactamase-resistant compounds that exert good anaerobic coverage. Anticoagulation and surgical intervention can be helpful in advanced cases. Fewer than 160 cases of classic Lemierre's syndrome have been described; approximately one-third of these reported cases have occurred since 1988. We describe a new case of Lemierre's syndrome that occurred in an otherwise healthy 27-year-old man. Thrombosis of both internal jugular veins extended through the subclavian system and into both upper extremities. The patient was treated with intravenous antibiotics and heparin during 14 days of hospitalization. He was discharged on oral clindamycin and warfarin sodium, and after 6 months he was able to return to full activity. To our knowledge, this is the first reported case of Lemierre's syndrome in which internal jugular vein thrombosis occurred bilaterally. By reporting this previously undescribed manifestation of Lemierre's syndrome, we hope to increase practitioner awareness of this disease entity.

PRELIMINARY RESULTS OF THROMBOSIS AND HEMOLYSIS IN BIOMEDLAB IMPLANTABLE VENTRICULAR ASSIST DEVICE

In Korea, an electromechanical implantable VAD (IVAD, Biomedlab Co., Seoul, South Korea) was developed and now it is being evaluated in vivo for the feasibility. We implanted the newly developed WAD to calf and examined the feasibility. We implanted IVAD in pre-peritoneal cavity in 4 Hallstein calves. The inflow tract was inserted through left ventricular apex and our flow tract was anatomized to descending thoracic aorta. We injected heparin intravenously for 2 days postoperatively then fed warfarin sodium daily. We examined SCOT, SCPT, BUN, Cr, LDH, serum haptoglobin, fibrinogen, serum hemoglobin, hematocrit, PT, PTT and plasma hemoglobin, preoperatively and postoperative day 1, 2, 3, 5, 7, 10, 21th. And we also recorded the assisting blood flow rate and hemodynamic data of animals. After WAD implantation, 4 calves lived for 6, 13, 3 and 21 days. Three of them were sacrificed due to mechanical problems, and the other died suddenly due to a leakage at the outflow tract. After WAD implantation, INR was maintained range of 3.5–4.0 with oral warfarin sodium. All serum haptoglobin levels were under 7 mg/dl and plasma hemoglobin levels were also under 7 mg/dl. And serum hemoglobin, hematocrit, fibrinogen levels were within normal ranges. After death or sacrifice of animal, pathological examination revealed no evidence of development of thromboembolism or hemorrhage in lungs, kidneys and liver.

Primary Subclavian Venous Thrombosis Which Developed After Sleeping with the Arm in an Outstretched Position: Report of a Case

Primary subclavian venous thrombosis is more rare than secondary thrombosis. This type of thrombosis is called "effort thrombosis" or Paget-Schroetter syndrome, and develops after a strenuous effort of the superior limb. A day after a 55-year-old man got drunk and slept in the left lateral position in combination with an abducted and elevated position of the left superior limb, he became aware of swelling and an oppressive feeling in his left superior limb and was admitted 9 days later. Thrombus of the left axillary-subclavian vein was confirmed by venography, and thrombolytic therapy with urokinase was performed immediately. The left arm symptoms improved for the most part. Venography after the therapy revealed thrombolysis at the site of the axillary vein, while the subclavian vein enhanced the collateral vessel pathway. The patient was discharged on the seventh hospital day, and anticoagulant therapy with oral warfarin sodium has since been continued. This is considered to be a rare case of subclavian venous thrombosis caused by sleeping in an abnormal position with the arm outstretched.

MESENTERIC VENOUS THROMBOSIS

MVT is an uncommon form of visceral ischemia. Symptoms and signs of MVT are usually nonspecific and should not be relied on for accurate diagnosis. A simple, logical diagnostic algorithm can be used to manage most of these patients (Fig. 6). CT or MRI appears to be the most sensitive diagnostic test and should be obtained early for any patient suspected of harboring MVT. Patients with peritonitis require prompt abdominal exploratory laparotomy to rule out ischemic bowel. Once the diagnosis of acute MVT is confirmed, the patient should be anticoagulated with heparin. During operation, all nonviable bowel should be resected with intent for a second-look laparotomy after 24 hours if there is any question of ongoing ischemia. We recommend using fluorescein-assisted evaluation of marginally viable bowel intraoperatively. After the operation, anticoagulation is continued with heparin and then oral warfarin sodium when the patient's bowel function returns. For those patients without peritonitis, we recommend prompt anticoagulation followed by at least a 48- to 72-hour period of close observation. All patients who have had an episode of acute MVT and do not have a contraindication to anticoagulation should be anticoagulated on a life-long basis with warfarin sodium. Despite our increased awareness of acute MVT, the 30-day mortality rate remains high. Acute MVT typically has a more insidious and unpredictable course than do other forms of visceral ischemic syndromes, with a mortality rate as high as that of its arterial counterpart. Although there has been a slight improvement in survival during the last 20 years, the recurrence rate remains high and the long-term prognosis is poor in this group of patients. Survival of patients with chronic MVT is better than that of those with acute MVT and appears to be determined by the underlying disease.

Tinzaparin. A review of its pharmacology and clinical potential in the prevention and treatment of thromboembolic disorders.

Tinzaparin, a low molecular weight (LMW) heparin with an average molecular weight of 4.5 +/- 1.5 kD, has greater bioavailability and a longer duration of action than unfractionated heparin, allowing it to be administered once daily by subcutaneous injection for both prophylaxis and treatment of deep venous thrombosis (DVT). Like other members of its class, tinzaparin has a greater ratio of antifactor Xa/anti-factor IIa activity than unfractionated heparin, providing the theoretical advantage of similar antithrombotic efficacy with a diminished risk of haemorrhagic complications. In a small number of clinical trials, tinzaparin was found to be more effective than intravenous dextran or oral warfarin sodium as prophylaxis against DVT in high-risk patients undergoing orthopaedic surgery, and more effective than subcutaneous heparin in both general surgical patients and medical patients with an immobilising illness. When used for the treatment of established DVT, tinzaparin was more effective in preventing DVT recurrence than intravenous heparin, both initially and during a 3-month follow-up period when patients received warfarin sodium. Tinzaparin was also used successfully in one small study to maintain the patency of haemodialysis circuits over a 6-month period, with favourable effects on the lipid profile of such patients. Tinzaparin is well tolerated, the most frequent complication being injection site haematoma. In comparative trials, tinzaparin was associated with fewer major haemorrhagic complications than intravenous heparin (when used for treatment of venous thrombosis), but more than warfarin sodium. Other adverse events which have been reported in tinzaparin-treated patients include elevated liver enzyme levels and thrombocytopenia. Thus, although clinical experience is limited at present, available data suggest that, in common with other LMW heparins, tinzaparin is likely to prove an effective alternative to unfractionated heparin for both the prevention and treatment of DVT, with the advantage of more convenient administration and decreased monitoring requirements.

Thrombosis in a congenitally bifurcated superior sagittal sinus.

A 26-year-old woman had a peripartum venous thrombotic stroke involving the right parietal lobe. The initial thrombus was present only in the right channel of a congenitally bifurcated superior sagittal sinus. This diagnosis and subsequent thrombus extension were readily shown by magnetic resonance imaging in contrast to equivocal angiography. A subsequent, prospective review of 100 patients undergoing cranial magnetic resonance imaging showed the presence of similarly bifurcated superior sagittal sinuses in two. The patient stabilized after therapy with intravenous heparin, but switching her medication to oral warfarin sodium was followed by clinical deterioration and propagation of the thrombus, necessitating resumption of intravenous heparin. No coagulopathy was identified.

A New Manifestation and Treatment Alternative for Heparin-Induced Thrombosis

We treated a coronary artery bypass patient whose postoperative course was complicated by heparin-induced thrombocytopenia and resultant pulmonary artery and saphenous vein graft thromboses. The pulmonary thromboemboli were found first, and pulmonary blood flow was restored with intravenously administered tissue plasminogen activator (tPA). A short time later, the vein grafts were found to be occluded, and we subsequently performed multivessel percutaneous transluminal coronary angioplasty (PTCA) using tPA as an adjuvant to oral warfarin sodium therapy with excellent results. We conclude that heparin-induced thromboses in the pulmonary arteries are amenable to thrombolytic therapy, including tPA, whereas this regimen appears to have little effect on saphenous vein grafts. We also found that a combination of warfarin and thrombolytic therapy is an alternative regimen for heparin-intolerant patients who require PTCA.

Thrombolytic Therapy of Axillary-Subclavian Venous Thrombosis-Reply

Patients with axillary-subclavian vein thrombosis often have a poor outcome when treated with intravenous heparin sodium and oral warfarin sodium. Four patients were therefore treated with thrombolytic therapy. Good initial and excellent long-term results were achieved. In follow-up that has ranged up to four years, these patients do not have the common complaints of edema, fatigue, cramping, or weakness seen after traditional anticoagulation. Patients have returned to their previous occupations and have normal arm function. Noninvasive Doppler vascular laboratory studies suggest continued patency of axillary veins. Thrombolytic therapy should be considered in the treatment of spontaneous axillary-subclavian vein thrombosis.

Hematological and Biochemical Studies in Calves Living over 100 Days with the Polymethylmethacrylate Total Artificial Heart TNS Brno II

A polymethylmethacrylate total artificial heart (kinetic components made of polyetherurethane) of TNS Brno II type was implanted into seven calves (2-5 months of age) surviving for the average of 152.4 +/- 19.1 days after the implantation. During the entire post-operative period the animals received oral warfarin-sodium, acetylsalicylic acid, dipyridamole and alpha-tocopherol. Blood was taken for biochemical and hematological examinations twice a week from the jugular vein. During the experiments there were decreases in the number of red blood cells, hematocrit and hemoglobin levels. Plasma free hemoglobin and serum enzymes (alkaline phosphatase, AST, ALT, LDH) increased. Coagulation tests were abnormal because anticoagulation therapy was used. There were minimal changes in the number of white blood cells and platelets, fibrinogen, blood pH, blood glucose, serum electrolytes, bilirubin (total and direct), creatinine, blood urea, and lactate. Possible reasons for observed changes include the gradual rise in the central venous pressure and damaged function of the liver parenchyma. Other factors playing a possible role in inducing changes in laboratory findings are also discussed.

Streptokinase Therapy of Pulmonary Emboli With Heparin-Associated Thrombocytopenia

A 59-year-old man developed pulmonary emboli with heparin-associated thrombocytopenia. He was treated simultaneously with intravenous streptokinase and oral warfarin sodium. He responded with complete resolution of perfusion defects on lung scan and did not have any hemorrhagic or thrombotic problems. Although optimal therapy for patients with heparin-associated thrombocytopenia and thrombosis is unknown, fibrinolytic therapy may be useful despite thrombocytopenia, provided appropriate resources are available for careful patient monitoring and transfusion therapy.