Monitoring of rivaroxaban levels in patients with class III obesity

Abstract Purpose There is little evidence to guide the use of direct oral anticoagulants (DOACs) in patients with class III obesity. Clinicians face the dilemma that using DOACs in patients with class III obesity may not provide adequate anticoagulation, while avoiding DOACs may deprive them of a useful therapeutic option. We present 2 cases describing our experience navigating rivaroxaban use in patients with class III obesity and review available case reports of measurement of rivaroxaban levels using a calibrated anti–factor Xa assay. Summary In patient case 1, the rivaroxaban trough level was within the reference range, and therapy was continued. In patient case 2, the rivaroxaban trough level was below the reference range, and the patient’s anticoagulation therapy was switched to warfarin. No thromboembolic events were noted in the 2 patients more than 1 year (15 and 22 months, respectively) after initiation of anticoagulation therapy. Because of the many advantages associated with use of DOACs instead of vitamin K antagonists, further research is critical to enabling clinicians to use DOACs more confidently in a broader population. Conclusion When monitoring rivaroxaban therapy in patients with class III obesity, there is uncertainty regarding clinical interpretation of drug levels that fall outside of established reference ranges, and monitoring is not standardized or widely available. In addition to case reports found in the literature, the presented cases highlight these challenges and differing clinical decisions made when evaluating rivaroxaban levels in patients with class III obesity.

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Adrenal Mass Hemorrhage Clinically Mimicking a Pheochromocytoma

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.225 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A112-A112

Author(s):

Panadeekarn Panjawatanan ◽

Muhammad Daniyal ◽

Juan Jose Delgado Hurtado

Keyword(s):

Adrenal Mass ◽

Reference Range ◽

Case Reports ◽

Adrenal Adenoma ◽

Vital Signs ◽

Healthy Woman ◽

Reference Ranges ◽

Mri Findings ◽

Plasma Metanephrines ◽

Urine Metanephrines

Abstract Background: A pheochromocytoma is diagnosed clinically using correlation of clinical, imaging, and laboratory studies. We report the case of an adrenal mass hemorrhage that presented with significantly elevated urine metanephrines mimicking a pheochromocytoma. Clinical Case: A 59-year-old healthy woman presented to the ED with chest pain, left flank and upper quadrant pain associated with diaphoresis and palpitations. Vital signs were significant for a pulse of 92 bpm, and a BP of 213/88 mm Hg. Physical exam revealed tenderness to palpation on the left upper quadrant and left costovertebral angle. Laboratory tests were significant for an elevated D-dimer (2,449 ng/mL, reference range 215–499 ng/mL). CT abdomen with IV contrast showed a 3.5 x 2.9 cm round mass abutting the lateral limb of the left adrenal gland with surrounding fat stranding with suspicion of inflammation or hemorrhage. 24-hour urine metanephrines showed elevated metanephrine (7,227 mcg/24hr; reference range <400 mcg/24 hr) and normetanephrine (1,209 mcg/24hr; reference range 900 mcg/24 hr). In the setting of up trending cardiac enzymes and inferior-lateral ST segment depression, a cardiac catheterization was performed which was unrevealing. She was discharged from the hospital and referred to endocrinology. On that visit, ~ 1 month after the patient was admitted to the hospital, plasma metanephrines were ordered which showed mildly elevated plasma metanephrine (0.83 nmol/L; reference range <0.5 nmol/L) and normetanephrine (1.2 nmol/L; reference ranges <0.9 nmol/L). An MRI abdomen with and without contrast revealed a 2.7 x 2.2 x 1.8 cm nodule arising from the lateral limb, with loss of signal on in-phase images suggestive of blood products. Plasma metanephrines and MRI findings ruled out the diagnosis of a pheochromocytoma. Conclusion: To our knowledge, few cases of an adrenal mass hemorrhage clinically mimicking a pheochromocytoma have been reported. Although the inpatient clinical presentation of our patient was consistent with this, the outpatient plasma metanephrines and MRI were not. An adrenal adenoma hemorrhage should be considered as a potential differential diagnosis for elevated metanephrines, which can clinically mimick a pheochromocytoma. References: (1)Sekos K, Short T, Ing SW. Adrenal hemorrhage due to hypercoagulable state mimicking pheochromocytoma. Journal of Clinical and Translational Endocrinology: Case Report. 8. 9–12. 2018.(2)Wordsworth S, Thomas B, Agarwal N, Hoddell K, Davies S. Elevated urinary cathecholamines and adrenal haemorrhage mimicking phaechromocytoma. BMJ Case Reports. 2010.

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790 Pacemaker lead and atrial thrombosis, a rare event but of high clinical importance

European Heart Journal Supplements ◽

10.1093/eurheartj/suab141.003 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Lorenzo Pistelli ◽

Giuseppe Dattilo ◽

Francesca Parisi ◽

Pasquale Crea ◽

Lorenzo Gurioli ◽

...

Keyword(s):

Pulmonary Embolism ◽

Right Ventricle ◽

Therapeutic Option ◽

Vitamin K Antagonists ◽

Anticoagulation Therapy ◽

Rare Event ◽

Clinical Importance ◽

Heart Team ◽

Reduced Ejection Fraction ◽

Vein Thrombosis

Abstract Aims Trans-venous lead-related thrombosis is an undervalued issue. Since the lack of guidelines or evidences regarding the best therapeutic option, treatment of endocavitary clots on pacemaker wire is left to individual decision between surgical catheter extraction, thrombolysis, or anticoagulation therapy. In some patients, the labile equilibrium between hemorrhagic and thrombotic events may further complicate management. Methods and results We report the case of a 86-years-old man with heart failure (HF) severely reduced ejection fraction due to chronic ischaemic cardiomyopathy and several co-morbidities. He had a reacution of HF requiring hospitalization secondary to new-onset atrial flutter. During hospital stay, in light of episodes of severe bradycardia, he underwent single-lead PM implantation. Few days after discharge he developed deep vein thrombosis in situ of PM electro catheter insertion (poor compliance to anticoagulation therapy was reported) which improved after few days of regular therapy assumption. After few months anticoagulation therapy was dismitted due to etiology unknown-anemization requiring transfusion, but 20 days later he was once again admitted, this time because of pulmonary embolism. Trans thoracic echocardiography (TTE) enlightened a severely dysfunctioning right ventricle and a mass in right atrium hanging the wire. Trans oesophageal echocardiography was then performed showing hyper-reflective and highly mobile material with numerous ‘arborizations’. Intravenous heparin was started as pulmonary embolism therapy. Once infective etiology was excluded, total body computer tomography was performed to investigate a possible paraneoplastic origin. Presence of a meningioma was enlightened. Heart-team evaluation excluded catheter extraction in light of patient’s frailty, while thrombolysis was controindicated. Vitamin K antagonists was then started. At 1 month follow up no further embolic neither haemorrhagic events were reported. TTE showed a reduction in mass dimension and an improvement in right ventricle function. Conclusions In a guidelines-lacking field, VKA can be an effective option in cases of lead-related thrombosis when surgery or thrombolysis is not suitable. Further studies are needed to establish their real effectiveness in management of E-C-related endocavitary thrombi.

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Effects of Age and Health on the Euthyroid Reference Ranges for Serum Free Thyroxine and Free Triiodothyronine

Nuklearmedizin ◽

10.1055/s-0038-1624280 ◽

1985 ◽

Vol 24 (02) ◽

pp. 57-65 ◽

Cited By ~ 6

Author(s):

J. E. M. Midgley ◽

K. R. Gruner

Keyword(s):

Lower Limit ◽

Healthy Subjects ◽

Thyroid Dysfunction ◽

Reference Range ◽

Free Thyroxine ◽

Reference Ranges ◽

Free Triiodothyronine ◽

Serum Free ◽

Young Subjects ◽

Age Range

SummaryAge-related trends in serum free thyroxine (FT4) and free triiodothyronine (FT3) concentrations were measured in 7248 euthyroid subjects (age-range 3 months to 106 years). 5700 were patients referred to hospitals for investigation of suspected thyroid dysfunction, but who were diagnosed euthyroid. 1548 were healthy blood donors (age-range 18-63 years) with no indication of thyroid dysfunction. FT4 concentrations were little affected by the age, the sex or the state of health of the subjects in either group. Serum FT3 concentrations were significantly affected by both age and health factors. The upper limit of the euthyroid reference range for young subjects up to 15 years was about 20% higher (10.4 pmol/1) than for adult subjects older than 25 years (8.8 pmol/1). The change in the upper limits typical of young subjects to that typical of adults occurred steadily over the decade 15–25 years. After this age, little further change occurred, especially in healthy subjects. Additionally, the lower limit of the euthyroid range for FT3 was extended by the inclusion in the reference group of patients referred to hospitals. Compared with the lower limit of the FT3 range for healthy subjects (5 pmol/1), the corresponding limit for referred subjects (young or adult) was 3.5–3.8 pmol/1. Broadening of the FT3 reference range was probably brought about by a significant number of patients in the hospital-referred group with the “1OW-T3 syndrome” of mild non-thyroidal illness. Accordingly, FT3 was inferior to FT4 in the discrimination of hypothyroidism, as FT4 was unaffected by this phenomenon. Effects of age and non-thyroidal illness on serum FT3 concentrations require great care when selecting subjects for a laboratory euthyroid reference range typical of the routine workload. Constraints on the choice of subjects for FT4 reference ranges are less stringent.

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Bimaxillary Surgical Orthodontic Treatment Combined with Bimaxillary Anterior Segmental Osteotomy of Skeletal Class III Malocclusion Patient: Case Report

Clinical Journal of Korean Association of Orthodontists ◽

10.33777/cjkao.2020.10.1.55 ◽

2020 ◽

Vol 10 (1) ◽

pp. 55-67

Author(s):

Keunoh Lim ◽

Ji-Hoon Park ◽

Jung-Sub An

Keyword(s):

Case Report ◽

Orthodontic Treatment ◽

Class Iii ◽

Class Iii Malocclusion ◽

Patient Case ◽

Skeletal Class

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Faculty Opinions recommendation of Percutaneous gastrostomy device for the treatment of class II and class III obesity: results of a randomized controlled trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.727083236.793526748 ◽

2016 ◽

Author(s):

Vivek Kumbhari

Keyword(s):

Randomized Controlled Trial ◽

Controlled Trial ◽

Class Ii ◽

Class Iii ◽

Percutaneous Gastrostomy ◽

Randomized Controlled ◽

Class Iii Obesity

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Computerized method for validating laboratory reference ranges for triiodothyronine and thyroxin immunoassays

Clinical Chemistry ◽

10.1093/clinchem/37.3.438 ◽

1991 ◽

Vol 37 (3) ◽

pp. 438-442 ◽

Cited By ~ 1

Author(s):

Brian Luttrell ◽

Sall Watters

Keyword(s):

Reference Range ◽

Normal Values ◽

Reference Group ◽

Normal Population ◽

Normal Subjects ◽

Reference Ranges ◽

Large Samples ◽

Laboratory Reference ◽

Euthyroid Status ◽

Computer Based

Abstract We used a computer-based method to help validate the reference ranges of assays for triiodothyronine (T3) and thyroxin (T4). A retrospective search of a database of laboratory results for the previous six months identified all patients with apparent euthyroid status, as defined by methods independent of the immunoassay under review. A computer-generated reference group (CGR Group) of 2001 records had a gaussian distribution of T4 values and a reference range (mean +/- 2 SD) of 56-161 nmol/L, compared with the supplier's suggested range for euthyroid subjects (58-148 nmol/L) and an in-house range of 60-144 nmol/L for a group of 97 normal subjects. A similar CGR Group of 1902 records gave a reference range for T3 of 0.7-2.1 nmol/L (manufacturer's range 0.8-2.8; normal subjects 0.8-2.2). An attempt to devise a reference range for thyrotropin failed when we found that its concentration in the population of patients with normal values for thyroid hormones was distributed differently from that in the normal population. The method is intended to be used in addition to conventionally derived ranges based on results for healthy subjects. It allows the laboratory to conveniently verify the reference ranges for T3 and T4 assays at regular intervals by using very large samples with appropriate age, sex, and weight distribution, drawn from the population of patients' samples submitted for analysis.

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Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account

Journal of Clinical Medicine ◽

10.3390/jcm10153212 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3212

Author(s):

Fabiana Lucà ◽

Simona Giubilato ◽

Stefania Angela Di Fusco ◽

Laura Piccioni ◽

Carmelo Massimiliano Rao ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Thrombus Formation ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Significant Advance ◽

Thromboembolic Events ◽

Thromboembolic Risk ◽

Pharmacological Cardioversion

The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.

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Research Trends in Anticoagulation Therapy over the Last 25 Years

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0040-1718892 ◽

2020 ◽

Vol 46 (08) ◽

pp. 919-931

Author(s):

Mustafa K. Mian ◽

Subhashaan Sreedharan ◽

Neeraj S. Limaye ◽

Chris Hogan ◽

Jai N. Darvall

Keyword(s):

Conflicts Of Interest ◽

Relative Rate ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Citation Count ◽

Anticoagulation Therapy ◽

Journal Title ◽

Common Source ◽

Level I ◽

High Level

AbstractA large volume of literature has become available to practitioners prescribing anticoagulants. The aim of this study was to analyze the bibliometric characteristics of the top 100 most cited articles related to anticoagulation over the past 25 years, with special consideration to impact of direct or “nonvitamin K antagonist” oral anticoagulants (NOACs) compared with vitamin K antagonists. A bibliometric analysis of the 100 most cited journal articles related to anticoagulants published between 1994 and 2019 was performed in April 2019. The top 100 articles by citation count were analyzed to extract bibliometric data related to journal title, impact factor, year of publication, place of publication, anticoagulant studied, indication for anticoagulation, study design, and conflicts of interest. The median (interquartile range) number of citations per article was 806 (621–1,085). The anticoagulant most frequently researched was warfarin (37%). NOAC publications (21%) grew at a relative rate of 3.4 times faster compared with all publications. The indication most commonly researched was venous thromboembolism (26%). Eighty articles constituted level I or II evidence, with randomized controlled trials the most common type of study (74). A financial conflict of interest was declared in 87% of articles with private, for-profit organizations the most common source of funding (26%). In summary, top research related to anticoagulation is highly impactful but may be at risk of sponsorship bias. High-level evidence for NOACs continues to expand across a range of indications with citation metrics likely to soon approach or surpass that of older drugs.

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