Prothrombin Time-international Normalized Ratio Research Articles

Pre-operative Serum Albumin Predicts Native Liver Survival in Biliary Atresia.

To predict native liver survival (NLS) after Kasai portoenterostomy (KP) for biliary atresia (BA) using pre-operative clinical data. Pre-operative data were collected from 29 patients with BA who underwent KP at our department between 1989 and 2017 and were analysed including serum albumin, bilirubin, prothrombin time-international normalised ratio, body height, body weight, age at KP, paediatric end-stage liver disease score calculated using the pre-operative data and the period of NLS. The 10-year NLS rate of all patients was 51%. A multivariate analysis revealed that among all factors, the pre-KP serum albumin level was the only independent predictor of NLS (P = 0.04, hazard ratio = 0.269, 95% confidence interval = 0.077-0.934). The area under the receiver operating characteristic curve for NLS, determined using pre-KP serum albumin was 0.760 and 3.75 mg/dl was selected as the cut-off value. There was a significant difference in NLS between patients with high (≥3.8 mg/dl) and low (≤3.7 mg/dl) pre-KP serum albumin (90.0% vs. 31.5%, P < 0.01). Decreased pre-KP serum albumin may reflect not only functional impairment of the liver, but also the inflammatory process, which is hypothesized to occur during its advancement. The pre-KP serum albumin level may be a good prognostic factor for NLS in post-KP BA patients.

International Normalized Ratio Predicts Recurrence and Bleeding in Patients With Acute Venous Thromboembolism Who Undergo Direct Oral Anticoagulants.

Prothrombin time/international normalized ratio (PT/INR) is related to both antithrombotic effect and risk of bleeding. Its role in the prediction of venous thromboembolism (VTE) recurrence and bleeding for patients with acute VTE who undergo direct oral anticoagulants (DOACs) treatment is unclear, despite previous studies revealed some association between them. The predictive efficiency of INR for VTE recurrence and bleeding were analyzed in a retrospective cohort with VTE patients who underwent DOACs treatment. Then its predictive efficiency for VTE recurrence and bleeding were validated in a prospective cohort with the acquired cutoffs range, and compared with anti-Xa level, DASH and VTE-BLEED scores. In the retrospective cohort (n = 1083), the sensitivity and specificity of INR for the prediction of VTE recurrence were 79.4% and 92.8%, respectively. The area under the curve (AUC) was 0.881 (0.803-0.960)(P = .025). The cutoff value of INR was 0.9. The sensitivity and specificity of INR for the prediction of bleeding were 85.7% and 77.9%, respectively. The AUC was 0.876 (0.786-0.967)(P < .001). The cutoff value of INR was 2.1. In the prospective cohort (n = 202), the calibration showed that there were 4 (50%) patients with VTE recurrence, 156 (97.5%) patients with non-recurrence and bleeding (non-R&B), and 20 (58.8%) patients with bleeding in the low (INR < 0.9)(n = 8), intermediate (0.9 ≤ INR ≤ 2.1)(n = 160), and high (INR > 2.1)(n = 34) groups, respectively. The baseline PT/INR value at the initiation of DOACs treatment is an independent predictor for VTE recurrence and bleeding in patients with acute VTE who undergo DOACs treatment.

Extremely elevated international normalized ratio in a patient using dabigatran etexilate: a case report

Background: We present the case of a patient who was administered dabigatran and showed an extremely elevated prothrombin time-international normalized ratio (PT-INR).Case report: A 79-year-old man was referred due to PT-INR 12.6. The patient was taking 110 mg of dabigatran twice daily in capsule form. On admission, blood urea nitrogen level was 23 mg/dL, creatinine was 1.51 mg/dL, and the estimated glomerular filtration rate was 44.8 mL/min/1.73 m2. Coagulation tests revealed PT 96.8 seconds, PT-INR 12.46, and activated partial thromboplastin time 125.5 seconds. Dabigatran was discontinued, PT-INR on the day after admission was 8.96. PT-INR recovered to 1.61 on the fourth day without any treatment.Conclusion: The PT-INR was not directly correlated with dabigatran activity. Regular monitoring of coagulation was not necessary in all patients taking dabigatran. However, it may be useful to regularly perform coagulation tests in patients with renal impairment or in those at a high risk of bleeding.

Kinetic-pharmacodynamic model of warfarin for prothrombin time-international normalized ratio in Japanese patients.

Genotype-guided dosing algorithms can explain about half of the interindividual variability in prothrombin time-international normalized ratio (PT-INR) under warfarin treatment. This study aimed to refine a published kinetic-pharmacodynamic model and guide warfarin dosage for an optimal PT-INR based on renal function. Using a retrospective cohort of adult patients (>20 years) who were administered warfarin and underwent PT-INR measurements, we refined the kinetic-pharmacodynamic model with age and the genotypes of cytochrome P450 2C9 and vitamin K epoxide reductase complex subunit 1 using the PRIOR subroutine in the nonlinear-mixed-effect modelling programme. We searched the significant covariates for parameters, such as the dose rate for 50% inhibition of coagulation (EDR50 ), using a stepwise forward and backward method. Monte Carlo simulation determined a required daily dose of warfarin with a target range of PT-INR (2.0-3.0 or 1.6-2.6) based on the significant covariates. A total of 350 patients with 2762 PT-INR measurements were enrolled (estimated glomerular filtration rate [eGFR]: 47.5 [range: 2.6-199.0] mL/min/1.73 m2 ). The final kinetic-pharmacodynamic model showed that the EDR50 changed power functionally with body surface area, serum albumin level and eGFR. Monte Carlo simulation revealed that a lower daily dose of warfarin was required to attain the target PT-INR range as eGFR decreased. Model-informed precision dosing of warfarin is a valuable approach for estimating its dosage in patients with renal impairment.

The mortality of hospitalized patients with COVID-19 and non-cirrhotic chronic liver disease: a retrospective multi-center study

Background Patients with chronic liver disease (CLD) have a higher risk of mortality when infected with severe acute respiratory syndrome coronavirus 2. Although the fibrosis-4 (FIB-4) index, aspartate aminotransferase-to-platelet ratio index (APRI), and albumin-bilirubin grade (ALBI) score can predict mortality in CLD, their correlation with the clinical outcomes of CLD patients with coronavirus disease 2019 (COVID-19) is unclear. This study aimed to investigate the association between the liver severity and the mortality in hospitalized patients with non-cirrhotic CLD and COVID-19. Methods This retrospective study analyzed 231 patients with non-cirrhotic CLD and COVID-19. Clinical characteristics, laboratory data, including liver status indices, and clinical outcomes were assessed to determine the correlation between liver status indices and the mortality among patients with non-cirrhotic CLD and COVID-19. Results Non-survivors had higher levels of prothrombin time-international normalized ratio (PT-INR), alanine aminotransferase, aspartate aminotransferase, and high-sensitivity C-reactive protein (hs-CRP) and lower albumin levels. Multivariable analysis showed that ALBI grade 3 (odds ratio (OR): 22.80, 95% confidence interval (CI) [1.70–305.38], p = 0.018), FIB-4 index ≥ 3.25 (OR: 10.62, 95% CI [1.12–100.31], p = 0.039), PT-INR (OR: 19.81, 95% CI [1.31–299.49], p = 0.031), hs-CRP (OR: 1.02, 95% CI [1.01–1.02], p = 0.001), albumin level (OR: 0.08, 95% CI [0.02–0.39], p = 0.002), and use of vasopressors (OR: 4.98, 95% CI [1.27–19.46], p = 0.021) were associated with the mortality. Conclusion The ALBI grade 3 and FIB-4 index ≥ 3.25, higher PT-INR, hsCRP levels and lower albumin levels could be associated with mortality in non-cirrhotic CLD patients with COVID-19. Clinicians could assess the ALBI grade, FIB-4 index, PT-INR, hs-CRP, and albumin levels of patients with non-cirrhotic CLD upon admission.

Role of electrode configuration and morphology in printed prothrombin time sensors

Patients on long-term anticoagulation therapy require frequent testing of prothrombin time/international normalized ratio (PT/INR) to ensure therapeutic efficacy. Point-of-care (POC) PT tests for at-home monitoring eliminate the burden of visiting the clinic, but realizing a cost-effective and robust at-home POC test for PT has remained elusive. Recent demonstrations of printed PT sensors show promise for addressing the cost concerns; however, the printed sensors have lacked quality control to ensure reliability between tests. In this work, on-chip redundancy is introduced with fully printed impedimetric PT sensors by incorporating simultaneous testing with a single fingerstick volume of blood (8 µL). The influence of electrode dimensions and composition were studied, revealing an optimal electrode spacing of 200 µm and an unexpected dependence on the morphology of the electrodes. Three distinct silver morphologies were studied: aerosol jet printed silver nanoparticles (AgNPs), aerosol jet printed silver nanowires (AgNWs), and evaporated silver (Ag). In general, AgNPs exhibited the best PT sensor performance, due to relatively low conductance and high porosity. Overall, the printed impedimetric PT sensor functionalization was improved by incorporating simultaneous testing and, when combined with a handheld control device, shows promise for leading to a system that overcomes the challenges of commercial PT/INR coagulometers.

Effect of fibrinogen concentrate on the initial fibrinogen level in trauma and postpartum hemorrhage.

Massive hemorrhage is a serious event that threatens the lives of patients. Fibrinogen concentrate (FC) can control bleeding without causing viral complications and without volume loading, which can happen in transfusion-associated circulatory overload and transfusion-associated acute lung injury. FC application is easy and does not require dissolution or extra devices. It is a cost-effective agent when considering the blood and products used in large quantities. A total of 67 postpartum hemorrhage (PPH) and trauma patients' medical records, who had ASA I-III classification (The American Society of Anesthesiologists classification of physical status), were obtained. Patients were divided into two groups (fibrinogen level ≤ 100 mg/dl and ≥ 101 mg/dl). The following information was obtained from patient files: demographic parameters, history of operations, and laboratory findings (i.e., complete blood counts, coagulation tests, and fibrinogen levels). Also, the duration of intensive care unit stays and mechanical ventilation application days, the administration of fresh frozen plasma (FFP), erythrocytes, platelets, and FC numbers, and tranexamic acid infusion were recorded. There was no mortality in PPH patients in either group (fibrinogen level ≤ 100 mg/dl and ≥ 101 mg/dl). The mortality rate in trauma patients was significantly higher in the group with fibrinogen levels ≤ 100. A total of 170 g of FC were given to PPH patients and 92 g to trauma patients. There were statistically significant differences between the preoperative PT (prothrombin time), postoperative APTT (activated partial thromboplastin time), postoperative PT, and postoperative INR (international normalized ratio) levels of the patients in the group with fibrinogen levels ≤ 100. Mortality rates were also significantly higher, and hospital stays significantly longer in trauma patients in the group with fibrinogen levels ≤ 100. Therapy may be considered during massive bleeding and transfusion, as it can help to increase fibrinogen levels quickly and efficiently. Compared with FFP, fibrinogen concentrate may have some advantages in reducing the risk of fluid overload. FFP contains a range of clotting factors, including fibrinogen. It also contains other proteins and fluids that can lead to fluid overload, especially when given in large volumes during massive transfusions.

The prothrombin time/international normalized ratio predicts prognosis in cardiogenic shock.

The study investigates the prognostic impact of the prothrombin time/international normalized ratio (PT/INR) in patients with cardiogenic shock. Despite ongoing improvements regarding the treatment of cardiogenic shock patients, intensive care unit (ICU)-related mortality in cardiogenic shock patients remains unacceptably high. Limited data regarding the prognostic value of the PT/INR during the course of cardiogenic shock treatment is available. All consecutive patients with cardiogenic shock from 2019 to 2021 were included at one institution. Laboratory values were collected from the day of disease onset (day 1) and days 2, 3, 4 and 8. The prognostic impact of the PT/INR was tested for 30-day all-cause mortality, as well as the prognostic role of PT/INR changes during course of ICU hospitalization. Statistical analyses included univariable t -test, Spearman's correlation, Kaplan-Meier analyses, C-Statistics and Cox proportional regression analyses. Two hundred twenty-four cardiogenic shock patients were included with a rate of all-cause mortality at 30 days of 52%. The median PT/INR on day 1 was 1.17. The PT/INR on day 1 was able to discriminate 30-day all-cause mortality in cardiogenic shock patients [area under the curve 0.618; 95% confidence interval (CI), 0.544-0.692; P = 0.002). Patients with PT/INR > 1.17 were associated with an increased risk of 30-day mortality [62% vs. 44%; hazard ratio (HR) = 1.692; 95% CI, 1.174-2.438; P = 0.005], which was still evident after multivariable adjustment (HR = 1.551; 95% CI, 1.043-2.305; P = 0.030). Furthermore, especially patients with an increment of the PT/INR by ≥10% from day 1 to day 2 were associated with an increased risk of 30-day all-cause mortality (64% vs. 42%; log-rank P = 0.014; HR = 1.833; 95% CI, 1.106-3.038; P = 0.019). Baseline PT/INR and an increase of the PT/INR during the course of ICU treatment were associated with the risk of 30-day all-cause mortality in cardiogenic shock patients.

Effect of fat emulsion administration on blood coagulation in terminal lung cancer patients.

Patients with cancer, especially those with lung cancer, are at high risk of developing thrombosis. Intralipos® infusion 20% is contraindicated for thrombosis, and there is no consensus on whether it can be safely used in cases of advanced cancer. We conducted a retrospective observational study to elucidate the impact of fat emulsion administration on blood coagulation in patients with terminal lung cancer. The subjects were patients with terminal lung cancer in the Department of Surgery and Palliative Medicine, Fujita Health University Nanakuri Memorial Hospital between January 2016 and December 2019. We compared changes in their blood coagulation profile before hospitalization and one month later. There were a total of 213 patients with lung cancer-139 who were administered fat emulsion and 74 who were not-with no significant differences in baseline characteristics. In the fat emulsion administration group (n=27), the prothrombin time-international normalized ratio (PT-INR) and activated partial thromboplastin time (APTT), respectively, were 1.17±0.26 (mean±standard deviation) and 30.5±5.0s at hospitalization and 1.16±0.12 and 31.2±4.2s one month later with no significant differences. In the non-administration group (n=6), the PT-INR and APTT, respectively, were 1.44±0.43 and 30.6±5.2s before hospitalization and 1.28±0.18 and 33.0±7.5s one month later with no significant differences. We did not identify any changes in PT-INR and APTT after fat emulsion administration in patients with terminal lung cancer. There were also no new cases of thrombosis, suggesting that fat emulsions were administered safely in patients with terminal lung cancer.

Effects of changing the timing of warfarin administration in combination with fluconazole on prolongation of the PT-INR: a case report

BackgroundFluconazole (FLCZ) inhibits cytochrome P450 (CYP) 2C9, 2C19, and 3A4 and has a drug-drug interaction that potentiates the effects of warfarin and prolong the prothrombin time-international normalized ratio (PT-INR). Although a drug-drug interaction have been reported between FLCZ and warfarin, the effects of the timing of their administration on this interaction have not yet been investigated.Case presentationA female patient in her 30s with Marfan syndrome had undergone the Bentall procedure with a mechanical valve and total arch replacement for acute aortic dissection Stanford A type and rupture of the ascending aorta. Warfarin was administered to prevent thromboembolism. She was hospitalized 1 year ago for graft infection caused by Candida albicans, and treatment with FLCZ was initiated. She received FLCZ 200 mg once a day in the morning and warfarin 1.75 mg once a day in the evening, and the PT-INR remained stable at approximately 2.0 and within the therapeutic range. However, 42 days after changing the timing of administration of warfarin from evening to morning, the PT-INR was prolonged by approximately 3-fold to 6.25. The PT-INR then decreased to the previous level by changing the timing of administration of warfarin from morning to evening.ConclusionsThe timing of administration of FLCZ and warfarin may affect the magnitude of drug-drug interaction.

Time-to-event modeling for achieving a stable warfarin dose using genetic and non-genetic covariates.

Time-to-event modeling is gaining importance in drug dosage determination, particularly using pharmacometrics approaches. To evaluate the various time-to-event models for estimating the time to achieve a stable warfarin dose in the Bahraini population. A cross-sectional study evaluating the non-genetic and genetic covariates (single nucleotide polymorphisms (SNPs) in CYP2C9, VKORC1 and CYP4F2 genotypes) was conducted in patients receiving warfarin for at least 6 months. Time to achieving a stable dose of warfarin was defined as the duration (in days) from the day of initiating warfarin until 2 consecutive prothrombin time-international normalized ratio (PT-INR) values were observed in the therapeutic range with a gap of at least 7 days. Exponential, Gompertz, log-logistics, and Weibull models were tested, and the model with the lowest objective function value (OFV) was chosen. The covariate selection was carried out using the Wald test and OFV. A hazard ratio (HR) with a 95% confidence interval (95% CI) was estimated. A total of 218 participants were included in the study. The Weibull model was observed to have the lowest OFV (1989.82). The expected time to reach a stable dose in the population was 21.35 days. The CYP2C9 genotypes were identified as the only significant covariate. The HR (95% CI) for achieving a stable warfarin dose within 6 months of initiation for individuals with CYP2C9 *1/*2 was 0.2 (0.09, 0.3), 0.2 (0.1, 0.5) for CYP2C9 *1/*3, 0.14 (0.04, 0.6) for CYP2C9 *2/*2, 0.2 (0.03, 0.9) for CYP2C9 *2/*3, and 0.8 (0.45, 0.9) for those with the C/T genotype for CYP4F2. We estimated the population time-to-event parameters for achieving a stable warfarin dose in our population and observed CYP2C9 genotypes to be the main predictor covariate followed by CYP4F2. The influence of these SNPs needs to be validated in a prospective study and an algorithm to predict a stable warfarin dose and the time to achieve it needs to be developed.

Potential utility of a multi-component coagulation factor panel to calculate MELD scores and assess the risk of portal vein thrombosis in chronic liver disease

BackgroundCurrent quantitative approaches to assess chronic liver disease (CLD) severity have limitations. Further, portal vein thrombosis (PVT) pre-liver transplant (LT) is a major contributor to morbidity in CLD; the means of detecting and/or predicting PVT are limited. We sought to explore whether plasma coagulation factor activity levels can serve as a substitute for prothrombin time/international normalized ratio (PT/INR) in the Model for End-stage Liver Disease (MELD), and/or help assess the risk of PVT.MethodsPlasma activity levels of Factor V (FV), Factor VIII (FVIII), Protein C (PC), and Protein S (PS) and the concentrations of D-dimer, sP-selectin, and asTF were assessed in two cohorts of CLD patients (ambulatory, n = 42; LT, n = 43).ResultsFV and PC activity levels strongly correlated with MELD scores, which enabled the development of a novel scoring system based on multiple linear regressions of the correlations of FV and PC activity with MELD-Na that substitutes PT/INR. Six-month and 1-year follow-up revealed that our novel approach was non-inferior to MELD-Na at predicting mortality. A significant inverse correlation between FVIII activity levels and PVT was found in the LT cohort (p = 0.010); FV and PS activity levels were in-trend (p = 0.069, p = 0.064). We developed a logistic regression-based compensation score to identify patients at risk of PVT.ConclusionsWe demonstrate that FV and PC activity levels may be used to replace PT/INR in MELD scoring. We also show the potential of using the combination of FV, FVIII, and PS activity levels to assess the risk of PVT in CLD.

Isolated Insular Stroke: An Interesting Report of Two Cases.

Isolated Insular Stroke: An Interesting Report of Two Cases.

Sepsis-related coagulopathy treatment based on the disseminated intravascular coagulation diagnostic criteria: a post-hoc analysis of a prospective multicenter observational study

BackgroundThe development of disseminated intravascular coagulation (DIC) in patients with sepsis has been repeatedly confirmed as a factor associated with poor prognosis. Anticoagulant therapy has been expected to improve sepsis patient outcomes, whereas no randomized controlled trials have demonstrated the survival benefit of anticoagulant therapies in non-specific overall sepsis. Patient selection based on the component of “high disease severity” in addition to “sepsis with DIC” has recently proved important in identifying appropriate targets for anticoagulant therapy. The aims of this study were to characterize “severe” sepsis DIC patients and to identify the patient population benefiting from anticoagulant therapy.MethodsThis retrospective sub-analysis of a prospective multicenter study included 1,178 adult patients with severe sepsis from 59 intensive care units in Japan from January 2016 to March 2017. We examined the association of patient outcomes, including organ dysfunction and in-hospital mortality, with the DIC score and prothrombin time-international normalized ratio (PT-INR), one of the components of the DIC score, using multivariable regression models including the cross-product term between these indicators. Multivariate Cox proportional hazard regression analysis with non-linear restricted cubic spline including a three-way interaction term (anticoagulant therapy × the DIC score × PT-INR) was also performed. Anticoagulant therapy was defined as the administration of antithrombin, recombinant human thrombomodulin, or their combination.ResultsIn total, we analyzed 1013 patients. The regression model showed that organ dysfunction and in-hospital mortality deteriorated with higher PT-INR values in the range of < 1.5 and that this trend was more pronounced with higher DIC scores. Three-way interaction analysis demonstrated that anticoagulant therapy was associated with better survival outcome in patients with a high DIC score and high PT-INR. Furthermore, we identified a DIC score ≥ 5 and PT-INR ≥ 1.5 as the clinical threshold for identification of optimal targets for anticoagulant therapy.ConclusionsThe combined use of the DIC score and PT-INR helps in selecting the optimal patient population for anticoagulant therapy in sepsis-induced DIC. The results obtained from this study will provide valuable information regarding the study design of randomized controlled trials examining the effects of anticoagulant therapy for sepsis.Trial registration: UMIN-CTR, UMIN000019742. Registered on November 16, 2015.

Cefoperazone-induced Coagulopathy in Critically Ill Patients Admitted to Intensive Care Unit.

N-methylthiotetrazole side chain (NMTT) of cefoperazone was attributed to inhibit the vitamin K epoxide enzyme. This mechanism is similar to warfarin; thus, vitamin K was suggested to antagonize the hematological effects of cefoperazone. The literature on critically ill patients receiving cefoperazone and its clinical significance on bleeding diathesis is sparse. To assess the incidence of cefoperazone-induced coagulopathy (CIC), its clinical impact on bleeding episodes, and transfusion requirements. Predisposing factors and the role of prophylactic and therapeutic vitamin K were evaluated. Prospective observational study of adult intensive care unit (ICU) patients (>18 years) receiving cefoperazone between December 2017 and December 2018. We excluded those on warfarin, those with preexisting elevated prothrombin time/international normalized ratio (PT/INR), and with bleeding manifestations. Relevant laboratory investigations and specific outcomes were noted for 6 days following therapy. Panel data regression was used to determine predictors of coagulopathy. Among 65 patients, 17 (26%) had probable CIC. Hypoalbuminemia and vancomycin co-administration were risk factors for CIC. Hemoglobin drops and blood transfusions were not different between INR non-elevated and elevated groups (11 vs 8 gm/dL; p = 0.06 and 11 vs 8 units; p = 0.23, respectively). Prophylactic vitamin K did not offer any benefit toward preventing INR elevation. Therapeutic vitamin K significantly reduced INR when elevated [absolute risk reduction (ARR):57.5% and number needed to treat (NNT):1.7]. Results of this study revealed that CIC is not uncommon in ICUs. Based on the findings of the study, we suggest INR monitoring in patients receiving nephrotoxic agents and patients with hypoalbuminemia. We also recommend vitamin K administration in patients with elevated INR. Gudivada KK, Krishna B, Sampath S. Cefoperazone-induced Coagulopathy in Critically Ill Patients Admitted to Intensive Care Unit. Indian J Crit Care Med 2023;27(3):183-189.

Relationship between elevated bilirubin levels and enhanced warfarin effects during biliary obstruction.

A marked prolongation of the prothrombin time-international normalized ratio (PT-INR) is frequently observed during biliary obstruction in patients using warfarin. The objective of this study was to identify factors associated with PT-INR prolongation during biliary obstruction in patients using warfarin. Among 44 patients using warfarin who had biliary obstruction, we retrospectively investigated warfarin doses and laboratory data before and during biliary obstruction. The primary outcome was the association between changes in PT-INR (ΔPT-INR) and changes in laboratory data before and during biliary obstruction. Median PT-INR was 1.59 (IQR 1.38-1.95) before biliary obstruction and 2.27 (IQR 1.60-3.49) during biliary obstruction, indicating significant prolongation during the obstruction (P < 0.001). ΔPT-INR showed strong positive correlations with change in total bilirubin (ΔT-Bil; ρ = 0.692, P < 0.001) and change in conjugated bilirubin (ΔC-Bil; ρ = 0.731, P < 0.001). ΔPT-INR showed a weak negative correlation with the change in albumin (ΔAlb; ρ = -0.371, P < 0.05). When ΔPT-INR was used as the dependent variable in multiple linear regression analysis, ΔT-Bil, ΔC-Bil, and ΔAlb were significantly associated with ΔPT-INR. PT-INR was prolonged during biliary obstruction in patients using warfarin, and changes in bilirubin levels were associated with ΔPT-INR. If biliary obstruction with markedly elevated bilirubin levels occurs, measuring PT-INR could lead to safer warfarin therapy.

Development and validation of a prediction model for the prolonged length of stay in Chinese patients with lower extremity atherosclerotic disease: a retrospective study

ObjectivesThis study aims to develop and internally validate a prediction model, which takes account of multivariable and comprehensive factors to predict the prolonged length of stay (LOS) in patients with...

Prediction of Esophageal Varices by Non-Invasive Markers in Patients of Hepatic Cirrhosis due To Chronic Hepatitis C

Background: Esophageal varices develop as a consequence of portal hypertension in patients with chronic liver disease. Predicting the varices by non-invasive methods at the time of registration is likely to predict the need for prophylactic β blockers or endoscopic variceal ligation in patients with cirrhosis and portal hypertension. Objective: To evaluate the accuracy of combined non-invasive parameters in predicting the presence of esophageal varices in patients with hepatic cirrhosis due to chronic hepatitis C, using the positive predictive value (PPV) as a measure of performance. Methods: In this cross-sectional study conducted in the Department of Medicine, Unit-I, Sir Ganga Ram Hospital, Lahore, 125 patients fulfilling the inclusion criteria were included. Platelet count, Prothrombin Time/International Normalized Ratio (PT/INR) and portal vein diameter was assessed. Upper gastrointestinal endoscopy was done in all patients to check the presence or absence of esophageal varices. Results: Mean age of the patients was 52.52±8.39 years with 64% males. Mean PT was 10.09±3.13, mean INR was 1.75±0.22, mean platelet count was 83.56±13.47 while mean portal vein diameter was 13.79±0.84. In 61 patients (48.8%) esophageal varices were present on endoscopy and in 85 patients (68%) esophageal varices were predicted by combined non-invasive parameters. Positive predictive value of combined non-invasive parameters was 71.7%. Practical implications: Noninvasive predictors can be used as a screening tool to decide need for preventive drug therapy in esophageal varices and thus help reduce the workload and financial burden of routine endoscopies in all cirrhosis patients. Conclusion: The results suggest that combined non-invasive parameters may be a useful tool in the prediction of esophageal varices in patients with hepatic cirrhosis Keywords: Esophageal varices, Non-invasive predictors, Portal hypertension

Reliability of International Normalized Ratio Results in the CoaguChek Pro II System in a Clinical Setting.

The National Institute of Cardiology has previously used the CoaguChek® XS Plus system (Roche Diagnostics International Ltd), comparing capillary blood prothrombin time/international normalized ratio (PT/INR) results with those obtained using BCS-XP/Thromborel (Siemens). We assessed the reliability of PT/INR results using the third-generation CoaguChek Pro II system, the CoaguChek XS Plus system, and cobas® t 411 for citrated plasma analysis. Venous and capillary PT/INR were measured (N = 204). Spearman's correlation, Bland-Altman, and concordance analysis between methods were conducted. Spearman's correlation coefficients between venous/capillary INR were high for CoaguChek Pro II versus CoaguChek XS Plus (r = 0.994), CoaguChek Pro II versus cobas t 411 (r = 0.967), and CoaguChek XS Plus versus cobas t 411 (r = 0.968). Good concordance was observed among capillary methods (concordance coefficient [κ] = 0.888) and remaining relationships (P < .001 for all): cobas t 411 versus CoaguChek XS Plus (κ = 0.696) and cobas t 411 versus CoaguChek Pro II (κ = 0.684). In conclusion, good agreement was observed between CoaguChek Pro II, CoaguChek XS Plus, and cobas t 411.

Beware of accidental ingestion of Colchicum autumnale mistaken for Allium victorialis.

Beware of accidental ingestion of Colchicum autumnale mistaken for Allium victorialis.