Prolonged Prolonged Prothrombin Time Research Articles

The magnitude and associated factors of coagulation abnormalities among liver disease patients at the University of Gondar Comprehensive Specialized Hospital Northwest, Ethiopia, 2022

BackgroundLiver disease is any condition that affects the liver cells and their function. It is directly linked to coagulation disorders since most coagulation factors are produced by the liver. Therefore, this study aimed to assess the magnitude and associated factors of coagulation abnormalities among liver disease patients.MethodsA cross-sectional study was conducted from August to October 2022 among 307 consecutively selected study participants at the University of Gondar Comprehensive Specialized Hospital. Sociodemographic and clinical data were collected using a structured questionnaire and data extraction sheet, respectively. About 2.7 mL of venous blood were collected and analyzed by the Genrui CA51 coagulation analyzer. Data were entered into Epi-data and exported to STATA version 14 software for analysis. The finding was described in terms of frequencies and proportions. Factors associated with coagulation abnormalities were analyzed by bivariable and multivariable logistic regression.ResultIn this study, a total of 307 study participants were included. Of them the magnitude of prolonged Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT) were 68.08% and 63.51%, respectively. The presence of anaemia (AOR = 2.97, 95% CI: 1.26, 7.03), a lack of a vegetable feeding habit (AOR = 2.98, 95% CI: 1.42, 6.24), no history of blood transfusion (AOR = 3.72, 95% CI: 1.78, 7.78), and lack of physical exercise (AOR = 3.23, 95% CI: 1.60, 6.52) were significantly associated with prolonged PT. While the presence of anaemia (AOR = 3.02; 95% CI: 1.34, 6.76), lack of vegetable feeding habit (AOR = 2.64; 95% CI: 1.34, 5.20), no history of blood transfusion (AOR = 2.28; 95% CI: 1.09, 4.79), and a lack of physical exercise (AOR = 2.35; 95% CI: 1.16, 4.78) were significantly associated with abnormal APTT.ConclusionPatients with liver disease had substantial coagulation problems. Being anemic, having a transfusion history, lack of physical activity, and lack of vegetables showed significant association with coagulopathy. Therefore, early detection and management of coagulation abnormalities in liver disease patients are critical.

Prolonged prothrombin time does not correlate with clinical bleeding symptoms in newly diagnosed paediatric leukaemia patients.

Prolonged prothrombin time (PT) and/or activated partial thromboplastin time (aPTT) are frequently seen in newly diagnosed paediatric leukaemia patients (NDPLP), which can lead to delayed diagnostic and therapeutic procedures due to concern for bleeding. A single-centre retrospective chart review of NDPLP between 2015 and 2018 aged 1-21 years. We analysed 93 NDPLP of whom 33.3% had bleeding symptoms within 30 days of presentation, predominantly mucosal bleeding (80.6%) and petechiae (64.5%). Median laboratory values: white blood cell count 15.7, haemoglobin 8.1, platelets 64, PT 13.2 and a PTT 31. Red blood cells were administered in 41.2%, platelets in 52.9%, fresh frozen plasma in 7.8% and vitamin K in 21.6% of patients. Prolonged PT was found in 54.8% of patients, while aPTT was prolonged in 5.4%. Anaemia and thrombocytopenia did not correlate with prolonged PT (P = 0.73 and P = 0.18, respectively), or prolonged aPTT (P = 0.52 and 0.42). Leukocytosis showed significant correlation with elevated PT (P < 0.001), but not aPTT (P = 0.3). Bleeding symptoms upon presentation did not correlate with prolonged PT (P = 0.83), prolonged aPTT (P = 1) or anaemia (P = 0.06) but had a significant correlation with thrombocytopenia (P ≤ 0.0001). Therefore, a prolonged PT in NDPLP may not necessitate the reflexive use of blood product replacement, in the absence of significant bleeding, which is likely related to leukocytosis than to a true coagulopathy.

MO376CLINICAL OUTCOMES OF ACUTE KIDNEY INJURY FOLLOWING SNAKE BITE INJURIES

Abstract Background and Aims Snakebite is a common animal bite injury in tropical countries. Acute kidney injury (AKI) is an important complication in snakebite patients. This study aimed to comprehensively investigate the clinical profiles and outcomes of patients following hematotoxin-related snakebite associated with kidney impairment. Method We conducted a hospital-based, cross-sectional study of 238 patients with hematotoxin-related snakebite injuries. Data were retrieved from the King Narai Hospital Registry from October 2014 to August 2020. The prevalence of complications associated with snakebite injuries, including acute kidney injury (AKI) and its severity, was determined. Univariate and Multivariate predictors of AKI diagnosis were evaluated using binary logistic regression analysis Results A total of 238 patients, with 63.4% men, median (IQR) age 49.8 (39-61) years and median duration from injury to a hospital arrival of 1 hour (0.5-2) hours, were injured by Green pit viper (85.7%), Russell’s viper (12.6%) and Malayan pit viper (1.7%). AKI mostly occurred in Russell’s viper group 66.7%. An AKI was reported in thirty (12.6%, 95% CI: 8.7 % - 17.5%) patients, with the severity of 66.7% stage one, 6.7% stage two, 26.6% stage three by KDIGO classifications, and 13.3% requiring hemodialysis. Complete renal recovery was seen in twenty-two patients (73.3%), while partial renal recovery was 23.3%. Other complications included 84.4 % limb cellulitis, 4.6% significantly bleeding, 2.5% hypotension, 25.6% prolonged venous clotting time (VCT), 46.7% prolonged prothrombin time (PT), and 14.3% prolonged partial thromboplastin time (PTT). Of total patients, 60.1% were treated with anti-venom. Mortality was relatively low (0.4%). In multivariable logistic regression analyses, AKI was significantly associated with time to hospital arrival more than 3 hours (p = 0.04), Russell’s viper bitten (p = 0.01), clinical bleeding (p = 0.01), and prolonged PT (p &amp;lt; 0.01). Conclusion The prevalence of AKI in patients bitten by hematotoxin snakes was 12.6%, mostly from Russell’s viper. Factors associated with AKI outcomes were time to hospital arrival more than 3 hours, Russell’s viper bitten, clinical bleeding, and prolonged PT. Besides, one-fourth of AKI patients turned to chronic kidney disease.

Consumptive coagulopathy is associated with a disturbed host response in patients with sepsis

BackgroundA prolonged prothrombin time (PT) is a common feature in sepsis indicating consumptive coagulopathy. ObjectivesTo determine the association between a prolonged PT and aberrations in other host response mechanisms in sepsis. MethodsPatients admitted to the intensive care unit with sepsis were divided in quartiles according to the highest PT value measured within 24 h after admission. The host response was evaluated by measuring 19 plasma biomarkers reflecting pathways implicated in sepsis pathogenesis and by blood leukocyte gene expression profiling. Measurements and Main ResultsOf 1524 admissions for sepsis, 386 (25.3%) involved patients with a normal PT (≤12.7 s); the remaining quartiles entailed 379 (24.9%) patients with a slightly prolonged PT (12.8 ≤ PT ≤ 15.0 s), 383 (25.1%) with an intermediately prolonged PT (15.1 ≤ PT ≤ 17.2 s), and 376 (24.7%) with an extremely prolonged PT (≥17.3 s). While patients with an extremely prolonged PT showed an increased crude mortality up to 1 year after admission, none of the prolonged PT groups was independently associated with 30‐day adjusted mortality. Comparison of the host response between patients with a normal PT or an extremely prolonged PT matched for baseline characteristics including severity of disease showed that an extremely prolonged PT was associated with impaired anticoagulant mechanisms, a more disturbed endothelial barrier integrity and increased systemic inflammation, and blood leukocyte transcriptomes indicating more prominent metabolic reprogramming and protein catabolism. ConclusionA prolonged PT is associated with stronger anomalies in pathways implicated in the pathogenesis of sepsis, suggesting that activation of coagulation impacts other host response mechanisms.

Incidence of delirium in the critical care unit and risk factors in the Central Region, Saudi Arabia.

Objectives:To determine the incidence and risk factors of delirium in the cardiac care unit (CCU) and intensive care unit (ICU).Methods:This multicenter prospective observational study was conducted between July 2019 and November 2019 in the central region of Saudi Arabia. All patients admitted to the critical care units were enrolled, and their demographic data and risk factors of delirium were reported.Results:A total of 165 patients were included: 76 (46.1%) admitted to the CCU and 89 (53.9%) admitted to the ICU. The mean age was 55.1±18 years, and 45 (27.3%) were women. We found that 24/165 (14.5%) patients developed delirium during admission. Importantly, variables significantly associated with delirium group were female gender: (24.5% versus 10.8%, p=0.028), malnutrition (29.2% versus 5%, p<0.001), the presence of urinary catheter (75% versus 30.5%, p=0.001), septicemia (50% versus 14.9%, p<0.001), intubation (41.7% versus 10.6%, p=0.001), low hemoglobin (10.79±2.91 versus 12.05±2.77, p=048), and prolonged prothrombin time (PT) (15.87±5.17 versus 13.60±3.28, p=0.011).Conclusion:The incidence of delirium was 14.5% among patients admitted to critical care units in the central region of Saudi Arabia. Septicemia, prolonged PT, malnutrition, and urinary catheter are significant predictors of delirium.

Coagulation Abnormalities in Light Chain Amyloidosis

ObjectiveTo assess the prevalence of coagulation abnormalities in patients with systemic light chain (AL) amyloidosis and their association with disease-related characteristics, disease progression, and survival. Patients and MethodsThis is a retrospective study of patients with AL amyloidosis seen at Mayo Clinic, Rochester, Minnesota, from January 1, 2006, to December 31, 2015. We studied the association between abnormal coagulation parameters and baseline characteristics and their association with survival outcomes. ResultsThe study included 411 patients. Abnormalities at diagnosis included prolonged clotting times and coagulation factor deficiencies; prolonged prothrombin time (PT) and factor X (FX) deficiency were found in 19% (73 of 390) and 43% (177 of 411) of patients, respectively. The FX deficiency was associated with higher Mayo stage, involvement of more than 1 organ, liver and cardiac involvement, and greater than 10% bone marrow plasma cells. On univariate analysis, the risk for disease progression or death was higher in patients with abnormal values for PT and factor V, factor VII (FVII), FX, and factor XII compared with those with normal values. Prolonged PT and FVII and FX deficiencies were independent predictors of death after adjusting for Mayo stage and more than 1 organ involvement. Only 106 patients had repeat testing after treatment; no clear relationship was found between treatment response and changes in coagulation parameters. ConclusionCoagulation abnormalities occur in a significant proportion of patients with AL amyloidosis and are associated with advanced disease and inferior outcomes. Larger studies are needed to establish whether a relationship exists between treatment response and improvement in individual parameters.

Нарушения гемостаза, тромбозы, антифосфолипидные антитела у пациентов с covid-19

The article provides an overview of main blood clotting disorders in coronavirus infection 2019 (COVID-19), which is associated with several hematological changes. Patients with COVID-19 develop typically two hemostasis disorders – an increased D-dimer levels and moderate thrombocytopenia, which occur in more than 40% of cases. Other hemostasis abnormalities, which are frequently reported in COVID-19, included prolonged prothrombin time (PT), also expressed as international normalized ratio, prolonged thrombin time, and activated partial thromboplastin time (APTT), which were typical acute phase reactions. Prolonged APTT or PT, and thrombocytopenia are common, especially in patients with severe clinical course. It has been hypothesized that increased D-dimer concentration and prolongation of PT, APTT are associated with higher mortality in patients with COVID-19. Disseminated intravascular coagulation occurs most often in severe cases of COVID-19 (about 2% of all hospitalized patients) and indicates a poor prognosis, i.e. about 90% mortality. It remains unclear whether SARS-CoV-2 can induce antiphospholipid antibodies. An increased incidence of positive lupus anticoagulants was observed in patients with COVID-19, it can be assumed that all patients with COVID-19 in whom antiphospholipid antibodies are revealed should be monitored and receive thromboprophylaxis even with no history of thromboembolism. Keywords: coronavirus infection (COVID-19), hemostasis disorder, antiphospholipid antibodies, antiphospholipid syndrome, thrombosis, anticoagulants For citation: Reshetnyak TM, Chel'dieva FA, Lila AM, Nasonov EL. Hemostasis disorders, thrombosis, antiphospholipid antibodies in patients with COVID-19. Consilium Medicum. 2021; 23 (1): 35–42. DOI: 10.26442/20751753.2021.1.200607

Diagnostic and prognostic value of hematological and immunological markers in COVID-19 infection: A meta-analysis of 6320 patients.

Evidence-based characterization of the diagnostic and prognostic value of the hematological and immunological markers related to the epidemic of Coronavirus Disease 2019 (COVID-19) is critical to understand the clinical course of the infection and to assess in development and validation of biomarkers. Based on systematic search in Web of Science, PubMed, Scopus, and Science Direct up to April 22, 2020, a total of 52 eligible articles with 6,320 laboratory-confirmed COVID-19 cohorts were included. Pairwise comparison between severe versus mild disease, Intensive Care Unit (ICU) versus general ward admission and expired versus survivors were performed for 36 laboratory parameters. The pooled standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated using the DerSimonian Laird method/random effects model and converted to the Odds ratio (OR). The decision tree algorithm was employed to identify the key risk factor(s) attributed to severe COVID-19 disease. Cohorts with elevated levels of white blood cells (WBCs) (OR = 1.75), neutrophil count (OR = 2.62), D-dimer (OR = 3.97), prolonged prothrombin time (PT) (OR = 1.82), fibrinogen (OR = 3.14), erythrocyte sedimentation rate (OR = 1.60), procalcitonin (OR = 4.76), IL-6 (OR = 2.10), and IL-10 (OR = 4.93) had higher odds of progression to severe phenotype. Decision tree model (sensitivity = 100%, specificity = 81%) showed the high performance of neutrophil count at a cut-off value of more than 3.74x109/L for identifying patients at high risk of severe COVID-19. Likewise, ICU admission was associated with higher levels of WBCs (OR = 5.21), neutrophils (OR = 6.25), D-dimer (OR = 4.19), and prolonged PT (OR = 2.18). Patients with high IL-6 (OR = 13.87), CRP (OR = 7.09), D-dimer (OR = 6.36), and neutrophils (OR = 6.25) had the highest likelihood of mortality. Several hematological and immunological markers, in particular neutrophilic count, could be helpful to be included within the routine panel for COVID-19 infection evaluation to ensure risk stratification and effective management.

Prevalence and Impact of Coagulation Dysfunction in COVID-19 in China: A Meta-Analysis.

Background The aim of this meta-analysis is to assess the prevalence of coagulation dysfunction in Chinese COVID-19 patients and to determine the association of coagulopathy with the severity and prognosis of COVID-19. Methods A meta-analysis of the prevalence of different abnormal coagulation indicators in COVID-19 patients in China was performed. The difference of coagulation indicators and the incidence of DIC were compared between severe cases and nonsevere cases as well as nonsurvivors and survivors, respectively. Results A total of 22 Chinese studies involving 4,889 confirmed COVID-19 inpatients were included. The average D-dimer value of COVID-19 patients is 0.67 µg/mL (95% confidence interval [CI]: 0.56–0.78), and 29.3% (95% CI: 20.1–38.5%) of patients showed elevated D-dimer values. Severe patients had significantly higher D-dimer levels and prolonged prothrombin time (PT) compared with nonsevere patients. Nonsurvivors had significantly higher D-dimer levels, prolonged PT, and decreased platelet count compared with survivors. In total, 6.2% (95% CI: 2.6–9.9%) COVID-19 patients were complicated by disseminated intravascular coagulation (DIC), in which the log risk ratio in nonsurvivors was 3.267 (95% CI: 2.191–4.342, Z = 5.95, p < 0.05) compared with that in survivors. Conclusion The prevalence of coagulopathy in Chinese COVID-19 inpatients is high, and both the abnormal coagulation indicators and DIC are closely associated with the severity and poor prognosis of these COVID-19 patients. Therefore, attention should be paid to coagulation dysfunction in COVID-19 patients. Closely monitoring of coagulation indicators and application of appropriate anticoagulation may improve the prognosis of COVID-19 inpatients in China.

Outcomes following venoarterial extracorporeal membrane oxygenation in children with refractory cardiogenic disease

Retrospective analysis was performed at an affiliated university children's hospital with consecutive patients receiving a venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock from July 2007 to May 2018. Fifty-six patients underwent VA-ECMO for refractory cardiogenic shock with the median age of 39.0 (1.5, 103.5)months were included. Median ECMO duration was 87h, and the median length of hospital stay was 22days. Successful ECMO weaning rate was 68%. Thirty-day mortality in this cohort was 39% (22/56), among which the mortality of fulminant myocarditis and postcardiotomy cardiogenic shock (PCS) were 23% (6/26) and 52% (12/23), respectively. Multivariate Cox proportional hazard regression analysis identified prolonged prothrombin time (PT) > 6s and elevated lactate level 24h after ECMO initiation were associated with 30-day mortality.Conclusions: Pediatric VA-ECMO for refractory cardiogenic shock appears to be a satisfactory salvage therapy to various fatal diseases in this retrospective study. Prolonged PT > 6s and elevated lactate level 24h were significant predictors of 30-day mortality. What is Known: • VA-ECMO is a salvage therapy for refractory cardiogenic shock in pediatrics. What is New: • Prothrombin time > 6s was a significant predictor of 30-day mortality. • Elevated lactate level 24h was a significant predictor of 30-day mortality.

A Single-Institution Retrospective Study of Causes of Prolonged Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) in the Outpatient Setting

Background:Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are screening tests of hemostasis commonly ordered for anticoagulant therapy monitoring, evaluation of bleeding, screening for acquired or inherited deficiencies of coagulation factors, and preoperative screening. Evaluation of a prolonged PT/aPTT is best accomplished in an algorithmic fashion consisting of mixing studies and factors assays or inhibitor testing as indicated. However, there is little data available on frequency of conditions that may result in abnormalities of PT/aPTT. The Special Coagulation Laboratory (SCL) at our institution offers an algorithmic approach termed Prolonged PT/aPTT Profile (PT/aPTT profile).Aim:To review our institutional experience with PT/aPTT profile testing (indications and outcomes), and to provide clinical correlation of abnormal PT/aPTT tests on patients seen at our institution in an effort to explain common causes of altered hemostatic testing in outpatient clinical practice.Methods:In this retrospective study, following IRB approval, we reviewed the medical records of patients who underwent outpatient PT/aPTT profile testing in the SCL at Mayo Clinic in Rochester, Minnesota between 2010 and 2017. Data abstracted included patient demographics and clinical presentation, indications for testing, use of anticoagulants, medical diagnoses which could potentially influence coagulation, and results of hemostatic testing (Table 1). Statistical analyses were completed using SAS 9.4 (SAS Institute Inc., Cary, North Carolina). Continuous variables are presented as median (range) while discrete variables are summarized as frequency (percentage). Comparisons of clinical characteristics between groups are made using the rank-sum test for continuous variables. Statistical significance is defined as a 2-tailed P value of less than 0.05.Results:A total of 107 patients met our study criteria, 58 (54 %) male, median age 55 years (range 1-89). Indications for testing included prior prolongation of PT (48%), PTT (29%), PT and aPTT (8%) on outside coagulation testing performed in a non-SCL setting, clinical bleeding episodes (10%) and preoperative screening (5%). Patients with established medical diagnoses known to influence coagulation testing including solid tumors, hematologic malignancies, liver disease, renal disease, autoimmune and rheumatologic conditions and pregnancy were documented along with other baseline patient characteristics (Table 1).SCL PT/aPTT profile testing revealed normal results in 29 of 107 (27%) patients on repeat testing while 78 patients warranted further evaluation of which 27 (35%) had an isolated prolonged PT, 28 (36%) had a prolonged APTT and 23 (29%) had prolongations of both PT and aPTT.After further workup and clinical correlation, causes of abnormal outpatient PT/aPTT profile testing were found to be related to an underlying congenital condition in 16 (21%) patients - most commonly factor VII deficiency (9%) and factor VIII deficiency (4%) - acquired conditions in 53 (68%) patients - most commonly anticoagulant therapy effects (31%) and liver disease (21%) - and of unclear etiology in 7 (9%) cases (Table 2).Specifically, the most common cause of an isolated prolonged PT in our study was found to be vitamin K deficiency (37%) whereas elevations in aPTT and both PT/aPTT were most frequently attributed to the effects of anticoagulant therapy (29% and 52% respectively). Other causes of prolongation on PT/aPTT profile testing following clinical correlation were also identified (Table 2).Discussion:While PT and aPTT are commonly ordered tests, there is little evidence regarding epidemiology of testing indications, distribution of test results, and the clinical correlation of test results. Our study demonstrates that abnormalities in hemostatic testing can be attributed to a wide range of causes including artefactual prolongation influenced by pretest variables or marked abnormalities in secondary hemostasis due to inherited and acquired conditions. Strengths of this study include the SCL algorithmic approach to testing to further elucidate coagulation cascade abnormalities to properly characterize conditions that pose severe hemostatic risk while limitations of this study reflect the experience of a single institution and possible referral bias. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Risk of complications of ultrasound-guided renal biopsy for adult and pediatric patients with systemic lupus erythematosus.

Objective The objective of this paper is to identify the risk of complications of real-time ultrasound-guided renal biopsy in adult and pediatric patients with systemic lupus erythematosus (SLE). Materials and methods This retrospective study examined outcomes of 296 renal biopsy procedures in 275 SLE patients. Imaging-confirmed symptomatic hematoma was regarded as a major complication when intervention (blood transfusion, angiographic embolization, or surgery) was required or as a minor complication otherwise. Clinical and laboratory data were compared between groups with or without complications after initial or subsequent renal biopsy. Binary logistic regressions were used to evaluate complication risk of initial renal biopsy. Results Overall complication rate of initial renal biopsy was 8.7% (major: 2.9%, minor: 5.8%). Three patients expired from pulmonary hemorrhage, thrombotic microangiopathy, and pneumonia. Pediatric SLE patients tended to have a higher rate of major complications (12.5%) than adult patients (2.3%). According to multivariable analysis results, elevated serum creatinine (SCr) level (OR 1.45; 95% CI 1.17-1.81 per mg/dl), prolonged prothrombin time (PT) (OR 2.2; 95% CI 1.05-4.62 per second), and thrombocytopenia (OR 4.3; 95% CI 1.56-11.9) increased overall complication risk of initial renal biopsy. Age < 18 years (OR 8.43; 95% CI 1.21-58.8), thrombocytopenia (OR 16.4; 95% CI 2.44-110.5), and elevated SCr level (OR 1.97; 95% CI 1.36-2.86 per md/dl) increased risk of major complications. Thrombocytopenia, prolonged PT, and elevated SCr level were associated with complications after subsequent renal biopsy (all p = 0.01). Conclusions SLE patients, particularly patients under 18 years old or with elevated SCr level, prolonged PT, or thrombocytopenia, have an increased risk of complications after initial or subsequent renal biopsy.

Determinants of mortality and prolonged hospital stay among dengue patients attending tertiary care hospital: a cross-sectional retrospective analysis

ObjectivesDengue imposes substantial economic, societal and personal burden in terms of hospital stay, morbidity and mortality. Early identification of dengue cases with high propensity of increased hospital stay and death...

Clinical characteristics and prognosis of sepsis-associated liver injure in pediatric intensive care unit

Objective To discuss the incidence, clinical characteristics of sepsis-associated liver injure in pediatric patients and risk factors that may affect the prognosis. Methods A retrospective analysis was made on the data of patients with sepsis-associated liver injure that had been hospitalized in Shanghai Children′s Hospital from January 2011 to December 2015.The cases were divided into the survival group and the death group.Logistic regression analysis was made to screen out risk factors of patients with sepsis-associated liver injure that influence the prognosis. Results The incidence of sepsis associated liver dysfunction was 9.7%(120/1 242), the mortality rate was 35.8%(43/120). The most common focus of infection was respiratory tract infection(50.0%), followed by abdominal cavity infection(33.3%) and central nervous system infection(6.7%). The pathogenic microorganisms were mainly gram-negative bacilli(51.3%), followed by virus(26.5%) and gram-positive bacterium(17.7%). The main manifestations of the liver injure were elevated glutamic-pyruvic transaminase(117 cases, 97.5%), prolonged prothrombin time(PT)(93 cases, 77.5%), hypoproteinemia(83 cases, 69.2%) and hyperbilirubinemia(70 cases, 58.3%). The total bilirubin(TBIL), PT, activated partial thromboplastin time and total bile acid of the death group were higher than thoes of the survival group.Logistic regression analysis indicated that elevated TBIL(OR=2.937, 95%CI 1.179-7.315, P=0.021) was the independent risk factor for death.The area under receiver operating characteristic curve for TBIL(cut off was 64.5 μmol/L)was 0.736 with sensitivity 57.7% and specificity 84.8%. Conclusion The incidence rate of sepsis-associated liver injure among pediatric patient is high.Gram-negative bacilli are the main pathogenic microorganisms.This disease is manifested as the elevated glutamic-pyruvic transaminase, hypoproteinemia, prolonged PT and hyperbilirubinemia.Hyperbilirubinemia is the independent risk factor that influences the prognosis. Key words: Sepsis; Total Bilirubin; Sepsis-associated liver injure; Pediatric intensive care unit; Children,

Evaluation of coagulation tests before newborn circumcision: is it necessary?

Evaluation of coagulation parameters prior to newborn circumcision is routinely performed in many countries. However, the value of this screening in predicting the bleeding risk is unknown. The aim of this study was to evaluate the correlation between the preoperative prolonged prothrombin time (PT), activated partial thromboplastin time (aPTT) and excessive bleeding after the circumcision in term, healthy newborns without family history of coagulopathy. The medical records of healthy, full term newborns born at VKV American Hospital, in Istanbul, Turkey, between 2009 and 2012 who were circumcised within the first week of life, were reviewed retrospectively. The data for family history of coagulopathy, clinical sign(s) of bleeding during and/or after delivery, preoperative PT, aPTT levels and the amount of bleeding after circumcision were gathered. The most recent medical records of the patients' were also reviewed for any possible, lately diagnosed bleeding disorder. A total of 450 newborns met the above criteria. None had a family history of bleeding disorder or clinical bleeding. A total of 158 (35%) newborns had an aPTT result greater than 54.5 s, 269 (59%) had PT result greater than 15.9 s and 72 (16%) had international normalized ratio result greater than 1.62. Neither of the patients with prolonged PT and/or aPTT had prolonged or excessive bleeding. The evaluation of PT and aPTT before elective newborn circumcision is not necessary in the absence of clinical bleeding or a family history of bleeding disorder. It is rather a habit in general practice and possibly a result of defensive medicine.

Hypersplenism is correlated with increased risk of hepatocellular carcinoma in patients with post-hepatitis cirrhosis.

Several risk factors exist for hepatocellular carcinoma in patients with post-hepatitis cirrhosis (PHC), including hypersplenism. Splenectomy is a common but controversial procedure in the management of hypersplenism, but its impact on hepatocellular carcinoma (HCC) remains uncertain. We conducted a hospital-based study of PHC patients to identify potential risk factors, including a history of splenectomy, which has been associated with progression from PHC to HCC. From 2002 to 2012, 2678 patients developed hypersplenism secondary to PHC. Of these patients, 828 developed HCC and 1850 did not. Potential risk factors of HCC were determined by univariate and multivariate analyses to exclude confounding variables. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were determined for each factor. Many factors, such as liver function, platelet (PLT) counts, Child-Pugh class, and history of hepatitis, were associated with progression to HCC. PHC patients with hypersplenism who displayed elevated levels of alanine transaminase (ALT), aspartate transaminase (AST), γ-glutamyltransferase (GGT), ALK, phosphatase, and prolonged prothrombin time (PT) had a significantly increased risk of HCC. However, the patients who had splenectomy showed better liver function test results and less progression to HCC. In patients with PHC and hypersplenism, abnormal levels of ALT, AST, ALP, and GGT and prolonged PT are risk factors of HCC. Splenectomy, as the intervention method of hypersplenism, is performed less frequently in patients who developed HCC than in patients who did not develop HCC. Therefore, splenectomy may act as an independent factor that is significantly associated with HCC development.

Effect of serum monoclonal protein concentration on haemostasis in patients with multiple myeloma.

Abnormalities in haemostasis are often detected in patients with multiple myeloma and the fundamental factors that lead to these abnormities are worthy of exploration. The objective of this study was to investigate bleeding diathesis and coagulopathy in different multiple myeloma types or stages and assess how paraprotein concentration contributes to differences in these conditions. Haemostasis screening tests and serum monoclonal protein (M protein) concentration were retrospectively analysed in 101 patients newly diagnosed with multiple myeloma from January 2012 to April 2014. No significant differences were found between bleeding diathesis and types or International Staging System (ISS) stages of multiple myeloma; however, prolonged thrombin time (TT) was found in most of patients (77.7%) and was positively related to light-chain concentration (P ≤ 0.01). Prolonged prothrombin time (PT) was more obvious in IgA and IgG-type multiple myeloma than in the light-chain type (P ≤ 0.01). With increased clinical staging, PT remarkably increased (P ≤ 0.01). M protein concentration was significantly higher in patients with prolonged PT than in those with normal PT (P ≤ 0.01). The D-dimer mean was significantly higher than normal (>0.5 μg/ml) (P ≤ 0.01). Fibrinogen was negatively related to M protein levels (P ≤ 0.01); however, there was no correlation between activated partial thromboplastin time (APTT) and multiple myeloma stages or types, M protein levels and serum light-chain concentration (P ≥ 0.05). Patients with light-chain type multiple myeloma were more likely to have prolonged TT than patients with other types. M protein levels had an obvious effect on PT. Prolonged PT was more common in IgA and IgG-type multiple myeloma. Abnormal haemostasis test results are not always accompanied by clinically apparent haemostatic complications.

Strong lupus anticoagulant (LA) as a cause for prolonged prothrombin time (PT), activated partial thromboplastin time (APTT) and abnormally low intrinsic factor (IF) levels

We report the case of a previously healthy 53-year-old male who presented with an incidental finding of both prolonged PT (57 seconds) and APTT (41 seconds) whilst being investigated for acute abdominal pain. There was no personal or family history of bleeding or thrombosis. Partial correction of both PT and APTT was demonstrated on mixing studies, with presence of heparin excluded. Intrinsic factor assays showed universal reduction, with Bethesda assay failed to identify an inhibitor. Extrinsic factors and von Willebrand assays were normal. LA testing showed a moderate strength LA, confirmed by a strongly positive IgM anticardiolipin (ACL) and moderately positive IgG ACL antibody. PT is normally relatively insensitive to LA. Nevertheless, falsely increased PT has been reported, likely from interference of LA with the phospholipid component of the PT reagent, particularly where recombinant tissue factor and purified phospholipids are used. This can result in difficulties with INR monitoring in warfarinised patients. This case also illustrates how the presence of a potent LA can also interferes with factor assays interpretations. Therefore all diagnostic laboratories should develop a robust policy to detect and monitor this unique group of patients.

Early-onset thrombocytopenia in near-term and term infants with perinatal asphyxia.

Neonates after perinatal asphyxia are at increased risk of thrombocytopenia. The correlation between perinatal asphyxia and the risk and severity of early-onset thrombocytopenia is not well known. To estimate the incidence, severity and risk factors for early-onset thrombocytopenia in neonates after perinatal asphyxia. We included all newborns (gestational age ≥ 36 weeks) admitted to our neonatal nursery due to perinatal asphyxia in this retrospective study. We collected platelet counts that were obtained within the first 48 h of life to estimate the incidence and severity of early-onset thrombocytopenia. A total number of 171 neonates with perinatal asphyxia were included in the study. The incidence of early-onset thrombocytopenia (platelet count < 150 × 109/l) was 51% (87/171). Several factors were associated with increased risk of early-onset thrombocytopenia, including prolonged prothrombin time (PT) [odds ratio (OR) 1·18, 95% confidence interval (CI) 1·08–1·30, P < 0·01], prolonged activated partial thromboplastin time (APTT) (OR 1·07, 95% CI 1·03–1·11, P < 0·01), low Apgar score at 10 min (OR 1·25, 95% CI 1·08–1·45, P < 0·01) and high serum lactate (OR 1·12, 95% CI 1·06–1·19, P < 0·01). After multiple logistic regression analysis, we found an independent association between early-onset thrombocytopenia and prolonged PT (OR 1·15, 95% CI 1·00–1·33, P = 0·045) and higher lactate level (OR 1·15, 95% CI 1·03–1·28, P = 0·01). Early-onset thrombocytopenia occurs frequently in neonates after perinatal asphyxia and is independently associated with PT and lactate level.

How to differentiate spontaneous intramural intestinal hemorrhage from acute mesenteric ischemia

ObjectsThe purpose of our study was to assess the diagnostic values of laboratory tests to differentiate spontaneous intramural intestinal hemorrhage (SIIH) from acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department (ED). MethodWe retrospectively included 76 patients diagnosed SIIH or AMI after abdominal CT. ResultsThe mean ages of 28 SIIH patients and 48 AMI patients were 75.9 ± 13.7 years and 75.8 ± 11.6 years, respectively. Patients with SIIH had significantly higher rate of Coumadin use (P < .001) and localized tenderness (P < .05). In laboratory findings, SIIH patients had prolonged prothrombin time (PT) (83.6 ± 30.0 vs. 13.4 ± 3.2, P < .001), lower blood urea nitrogen (P < .05), lower creatinine (P < .05), and lower creatine kinase (P < .05). Prolonged PT showed good discriminative value to differentiate acute abdomen patients with SIIH from AMI after abdominal CT, with an area under the receiver operating characteristic curve of 0.980 (95% confidence interval, 0.918-0.998; P < .0001). Prolonged PT cut-off value of ≧22.5 seconds had a sensitivity of 92.9% and a specificity of 100%. Logistic regression analysis identified prolonged PT as an independent predictor of SIIH (odds ratio, OR, 22.2; P = .007). ConclusionAbdominal pain patients with either SIIH or AMI are rare in the ED, but abdominal CT sometimes cannot help to differentiate them due to similar CT findings. Prolonged PT might help emergency physicians and surgeons differentiate SIIH from AMI in such cases.