Clinical impact of chemotherapy-induced thrombocytopenia in patients with gynecologic cancer.

PURPOSE AND METHODS This retrospective analysis of 501 patients with gynecologic cancer treated with chemotherapy evaluates the relationship between platelet count and clinical bleeding, as well as the clinical effects of platelet transfusion therapy. Thrombocytopenic patients were divided into six groups according to platelet counts, and major or minor bleeding manifestations were documented. Thrombocytopenia was defined as a platelet count less than 100,000/microL. RESULTS Thrombocytopenia occurred in 182 (36.3%) patients over 808 of 1,546 chemotherapy cycles (52%). No intracranial or life-threatening bleeding occurred in any patient. The majority of patients (139 [76.4%]) had no clinical bleeding. Minor bleeding, such as purpura, occurred in 34 patients (18.7%) and 44 cycles (5.4%). Major bleeding occurred in nine patients (4.9%) and 10 cycles (1.3%). Five major bleeding events occurred in 49 patients with platelet counts between 0 and 10,000/microL. Forty-three of these patients received platelet transfusions. Thirty-eight of 43 transfused patients (88.3%) had no bleeding. Of the remaining five patients, two were transfused prophylactically with no effect. Three major bleeding events occurred in patients with platelet counts that ranged from 11,000 to 20,000/microL, but these were due to chronic instrumentation or trauma. In patients with platelet counts more than 20,000/microL, major bleeding occurred only from necrotic metastatic lesions. Random-donor platelet transfusions provided inconsistent increments in platelet counts. Overall, 27.5% of patients achieved the expected increase in platelet number based on units of platelet concentrate transfused. The use of single-donor or human leukocyte antigen (HLA)-matched platelets did not provide greater increments in those patients who were refractory to random-donor platelets. CONCLUSION Platelet counts > or = 10,000/microL are not associated with spontaneous major bleeding. Prophylactic platelet transfusions in patients with gynecologic malignancies and chemotherapy-induced thrombocytopenia should be limited to those with platelet counts < or = 10,000/microL, provided they are not bleeding and have no major anatomic or pathophysiologic precursors of bleeding.

Download Full-text

Romiplostim in Management of the Thrombocytopenic Surgical Patient

Blood ◽

10.1182/blood.v124.21.1459.1459 ◽

2014 ◽

Vol 124 (21) ◽

pp. 1459-1459

Author(s):

Ariela L. Marshall ◽

Katayoon Goodarzi ◽

David J. Kuter

Keyword(s):

Platelet Count ◽

Liver Disease ◽

Hematologic Malignancy ◽

Lung Resection ◽

Foley Catheter ◽

Surgical Patient ◽

Bleeding Events ◽

Time Of Surgery ◽

Platelet Counts ◽

Platelet Transfusions

Abstract Background: The thrombopoietin (TPO) mimetics are FDA-approved for the treatment of chronic immune thrombocytopenia (ITP) and have the potential for use in several additional clinical settings. At our institution, the TPO-mimetic romiplostim has been used to boost platelet counts in the perioperative setting. Objective: Use of romiplostim for perioperative thrombocytopenia was examined with regards to patient characteristics, dosing and duration of use, success in achieving platelet counts high enough for surgery, and clinical outcomes. Methods: A retrospective review of patients with thrombocytopenia who received romiplostim prior to an operative intervention in 2010-2014 was performed. Inclusion criteria included age 18 or older, thrombocytopenia (baseline platelet count <150,000/uL), administration of at least one dose of romiplostim, and documentation of platelet counts before and after administration of romiplostim. Results: 18 patients undergoing 22 procedures were included. Median age at surgery was 61 years (range 47-74). Etiologies of baseline thrombocytopenia (some patients had more than one) included mild ITP (not on romiplostim at baseline) in 8 patients, liver disease in 12 patients (5 with hepatitis C, 2 with hepatitis B, 2 with alcoholic cirrhosis, 1 with fatty liver, and 2 with hepatocellular carcinoma), hematologic malignancy in 4 patients (2 with lymphoma, 1 with MDS, and 1 with myeloma) and drug-related thrombocytopenia in 3 patients (2 chemotherapy induced and 1 antibiotic-related). 3 patients were Jehovah's witnesses. Median platelet count at time of romiplostim initiation was 46,500/uL (range, 11,000-120,000) and median starting dose of romiplostim was 2.5 mcg/kg (range 1-7.5). Patients remained on romiplostim for a median of 5 weeks prior to surgery (receiving doses on average once weekly) and while on therapy the dose of romiplostim was changed on average one time. Procedures performed included 5 orthopedic surgeries (3 total hip replacements, 1 total knee replacement, and 1 open reduction/internal fixation), 3 open cardiac surgeries, 2 cholecystectomies, 2 EGD/colonoscopies, 2 biopsies of masses, and 1 each of: angioplasty and stenting, dental extraction, eyelid resection, liver biopsy, lung resection, prostate surgery, spinal surgery, and a TACE procedure. Median platelet count at the time of surgery was 144,000/uL (range 28,000-370,000). All patients had a rise in platelet count between time of initiation of romiplostim and time of surgery (see Figure); median rise was 97,500/uL (range 17,000-252,000). There were no surgical delays or cancellations for thrombocytopenia. Four bleeding events occurred: one thigh hematoma (at a platelet count of 185,000/uL), one episode of hematemesis (at a platelet count of 98,000/uL), one episode of melena (at a platelet count of 88,000/uL), and one persistent oozing from a tooth extraction (platelets 82,000/uL). Four patients received perioperative platelet transfusions and 3 received perioperative red cell transfusions. One patient developed a Foley-catheter associated clot after prostate surgery. No other thromboembolic events were recorded during the time of romiplostim administration and for up to 30 days following the last dose. Conclusions: 18 patients with thrombocytopenia due to several conditions (primarily ITP and liver disease) received romiplostim prior to 22 surgical procedures. Romiplostim prompted a rise in platelet count in all patients, allowing all planned procedures to be performed without delays or cancellations for thrombocytopenia. Few patients received perioperative platelet transfusions. Four bleeding episodes occurred (none in the context of significant thrombocytopenia), and one patient developed a clot (likely procedure-related). Romiplostim may be of clinical utility in the preoperative management of thrombocytopenic patients, and further trials are indicated. Figure 1 Figure 1. Disclosures Off Label Use: Romiplostim (Nplate) used for periprocedural management of thrombocytopenia. Kuter:Amgen: Research Funding.

Download Full-text

Calculation of HAS-BLED Score Is Useful for Early Identification of Venous Thromboembolism Patients at High Risk for Major Bleeding Events: A Prospective Outpatients Cohort Study

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0037-1607433 ◽

2017 ◽

Vol 44 (04) ◽

pp. 348-352 ◽

Cited By ~ 4

Author(s):

Reinhard Raggam ◽

Franz Hafner ◽

Alexander Avian ◽

Gerald Hackl ◽

Gerhard Cvirn ◽

...

Keyword(s):

Venous Thromboembolism ◽

Major Bleeding ◽

Odds Ratio ◽

Bleeding Complications ◽

Minor Bleeding ◽

Prospective Evaluation ◽

Bleeding Events ◽

Increased Risk ◽

Major Bleeding Events

AbstractThe aim of this study was prospective evaluation of the performance of the HAS-BLED score in predicting major bleeding complications in a real-world outpatient cohort, during long-term anticoagulation for venous thromboembolism (VTE), treated with a broad spectrum of anticoagulants. We analyzed 111 outpatients objectively diagnosed with VTE and treated long-term with various anticoagulants. Patients were grouped in three cohorts based on the anticoagulant regimen. Calculation of the HAS-BLED score and documentation of bleeding events were performed every 6 months for 1 year. Patients with a HAS-BLED score ≥ 3 had an increased risk for major bleeding events (odds ratio [OR]: 13.05, 95% confidence interval [CI]: 0.96–692.58, p = 0.028) and a trend to higher risk for minor bleeding events as well (OR: 2.25, 95% CI: 0.87–5.85, p = 0.091) when compared with patients with a HAS-BLED score < 3.This indicates that a HAS-BLED score ≥ 3 allows for identification of patients with VTE on long-term anticoagulation at an increased risk for major bleeding events, irrespective of the anticoagulant agent used.

Download Full-text

Bleeding management in computed tomography-guided liver biopsies by biopsy tract plugging with gelatin sponge slurry

Scientific Reports ◽

10.1038/s41598-021-04155-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Nikolaus A. Handke ◽

Dennis C. Koch ◽

Eugen Muschler ◽

Daniel Thomas ◽

Julian A. Luetkens ◽

...

Keyword(s):

Computed Tomography ◽

Liver Biopsy ◽

Adverse Events ◽

Major Bleeding ◽

Odds Ratio ◽

Gelatin Sponge ◽

Minor Bleeding ◽

Safe Procedure ◽

Bleeding Events ◽

Major Bleeding Events

AbstractTo evaluate the safety and impact of biopsy tract plugging with gelatin sponge slurry in percutaneous liver biopsy. 300 consecutive patients (158 females, 142 males; median age, 63 years) who underwent computed tomography-guided core biopsy of the liver in coaxial technique (16/18 Gauge) with and without biopsy tract plugging were retrospectively reviewed (January 2013 to May 2018). Complications were rated according to the common criteria for adverse events (NCI-CTCAE). The study cohort was dichotomized into a plugged (71%; n = 214) and an unplugged (29%; n = 86) biopsy tract group. Biopsy tract plugging with gelatin sponge slurry was technically successful in all cases. Major bleeding events were only observed in the unplugged group (0.7%; n = 2), whereas minor bleedings (4.3%) were observed in both groups (plugged, 3.6%, n = 11; unplugged, 0.7%, n = 2). Analysis of biopsies and adverse events showed a significant association between number of needle-passes and overall (P = 0.038; odds ratio: 1.395) as well as minor bleeding events (P = 0.020; odds ratio: 1.501). No complications associated with gelatin sponge slurry were observed. Biopsy tract plugging with gelatin sponge slurry is a technically easy and safe procedure that can prevent major bleeding events following liver biopsy.

Download Full-text

Efficacy and Safety of Direct Oral Anticoagulants in Obese Patients with Venous Thromboembolism

Blood ◽

10.1182/blood-2019-121765 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3675-3675

Author(s):

Renata Almeida Sa ◽

Fatimah Al-Ani ◽

Alejandro Lazo-Langner ◽

Martha L Louzada

Keyword(s):

Body Weight ◽

Venous Thromboembolism ◽

Major Bleeding ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Minor Bleeding ◽

Obese Patients ◽

Efficacy And Safety ◽

Bleeding Events ◽

Major Bleeding Events

Background: Obesity is a well-known risk factor for venous thromboembolism (VTE), however, obese patients are under-represented in clinical trials (1;2). Four direct oral anticoagulants (DOACs) have been approved for the treatment of acute VTE (3-6), including the direct Factor Xa inhibitors rivaroxaban, apixaban and edoxaban and the direct thrombin inhibitor, dabigatran. Given the lack of data in this population, it is unclear if DOACs can be used safely. Objectives: To evaluate the efficacy and safety of DOACs for the treatment of VTE in obese patients. Methods: We conducted a retrospective, single-centre cohort study in London (Canada) to compare the efficacy and safety of DOACs for the treatment of acute VTE in obese patients. We screened electronic and hard copy charts of adult patients referred to our thrombosis clinic for treatment of an objectively confirmed acute VTE between January 2012 and December 2017. Patients treated with DOACs or Warfarin were selected and followed from diagnosis of the index event until cessation of anticoagulation or up to 1 year. Our study population was analyzed by BMI (BMI ≥ 30 kg/m2versus < 30 kg/m2) and body weight (≥120 kg vs. <120 kg). Patients were excluded if they were on anticoagulation therapy for conditions other than VTE (e.g; atrial fibrillation), cancer-associated thrombosis, or missing data. The primary outcome measure was VTE recurrence during the anticoagulation treatment period and was defined according to the ISTH criteria (7). Our secondary outcome was the occurrence of bleeding events A bleeding event is defined as: a) Major Bleeding: bleed resulting in a hemoglobin drop of > 20 g/L, clinically overt and requiring more than 2 units of packed red blood cells, a hemorrhage requiring permanent cessation of anticoagulation and any retroperitoneal or intracranial hemorrhage; b) Minor Bleeding: bleed with no or little clinical significance, associated with no cost and does not require medical evaluation; and c) clinically significant non-major bleeding: does not fulfill criteria for major or minor bleeding but requires patients to be seek medical attention and/or minor procedures (8). Groups were compared using Chi-square or Fisher's exact test for categorical variables, as appropriate. The significance level was set at 0.05. Risk ratios (RR) and 95% confidence intervals (95% CI) for VTE recurrence and bleeding among DOAC groups and patients treated with Warfarin were analyzed by logistic regression. All statistical analyses were conducted using IBM SPSS Statistics version 25 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Results: Of 1143 potentially eligible patients, 777 fulfilled our inclusion criteria: 278 (35.8%) obese patients treated with DOACs, 266 (34.2%) non-obese patients on DOACS and 233 (30%) obese patients on Warfarin. Of the patients on DOACs, 80% (n= 436) were on rivaroxaban, while the remaining 20% were either on apixaban or edoxaban (n= 108). Among patients on DOACs VTE recurrence was observed in 2.1% (N=6) of patients with BMI ≥ 30 kg/m2 and 2.8% (N=2) of patients with 120 kg or more, with no differences in the risk of VTE recurrence (Table 1). The proportion of major bleeding events for patients on DOACs was 1.1% (N=3) for patients with BMI ≥ 30 kg/m2 and 1.4% (N=1) for patients with 120kg or more. There were no significant differences with respect to major and total bleeding risk (Table1). When comparing obese patients on DOACs vs Warfarin we did not find differences in the risk of VTE recurrence among patients with a BMI ≥ 30 kg/m2 [RR 2.59 95% IC (0.51-12.96), p= 0. 247] or body weight ≥120 kg [RR 4.33 95% IC (0.21-89.43), p= 0. 337] (Table 2). Among obese patients those treated with DOACs had a similar proportion and risk of total bleeding and major bleeding events compared to those on warfarin (Table 2). Conclusions: Our retrospective study suggests that DOACs at standard doses appear to have similar efficacy and safety in obese patients as defined herein. However, since most of our patients were treated with rivaroxaban, information on other agents is inconclusive. Information on patients with extreme body weight was limited. Disclosures Louzada: Bayer: Honoraria; Janssen: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria.

Download Full-text

Efficacy and Safety of Bivalirudin Versus Heparin Anticoagulation Therapy for Extracorporeal Membrane Oxygenation: Meta-Analysis

10.21203/rs.3.rs-993942/v1 ◽

2021 ◽

Author(s):

Jie Gu ◽

Hongjie Yu ◽

Dang Lin

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Major Bleeding ◽

Meta Analysis ◽

Minor Bleeding ◽

Efficacy And Safety ◽

Bleeding Events ◽

Heparin Induced Thrombocytopenia ◽

Membrane Oxygenation ◽

Major Bleeding Events

Abstract Background We aimed to compare the efficacy and safety of bivalirudin versus heparin as the anticoagulant in patients undergoing Extracorporeal Membrane Oxygenation (ECMO). Methods We conducted a search in PubMed, Embase and the Cochrane Library for all the studies in which bivalirudin was compared to heparin as the anticoagulant for ECMO. Efficacy outcomes were defined as the time to reach therapeutic levels, time within therapeutic range (TTR), thrombotic events, circuit thrombosis, circuit exchanges. Safety outcomes were reported as Heparin-Induced Thrombocytopenia (HIT), major bleeding events, minor bleeding events. Other outcomes included hospital length of stay (LOS), ICU LOS, mortality, 30-day mortality and in-hospital mortality. Results Ten studies were included, involving 1091 patients (Bivalirudin was administered in 405 patients while 686 patients were treated with heparin). A significant reduction in thrombotic events [OR 0.51, 95%CI 0.36,0.73, p=0.0002, I2=0%], major bleeding events [OR 0.31, 95%CI 0.10,0.92, p=0.04, I2=75%] and in-hospital mortality [OR 0.63, 95%CI 0.44,0.89, p=0.009, I2=0%] treated with bivalirudin were found compared with heparin. There were no significant differences between groups regarding the time to reach therapeutic levels[MD 3.53, 95%CI -4.02,11.09, p=0.36, I2=49%], TTR[MD 8.64, 95%CI -1.72,18.65, p=0.10, I2=77%], circuit exchanges[OR 0.92, 95%CI 0.27,3.12, p=0.90, I2=38%], Heparin-Induced Thrombocytopenia (HIT)[OR 0.25, 95%CI 0.02,2.52, p=0.24, I2=0%], minor bleeding events[OR 0.93, 95%CI 0.38,2.29, p=0.87, I2=0%], hospital LOS[MD -2.93, 95%CI -9.01,3.15, p=0.34, I2=45%], ICU LOS[MD -4.22, 95%CI -10.07,1.62, p=0.16, I2=0%], mortality[OR 1.84, 95%CI 0.58,5.85, p=0.30, I2=60%] and 30-day mortality[OR 0.75, 95%CI 0.38,1.48, p=0.41, I2=0%]. The benefit of bivalirudin over heparin was not significant for patients undergoing ECMO for major bleeding events while ruling out the Rivosecchi’s study (OR 0.44, 95%CI 0.71-1.14). Subgroup analysis by patient’s type revealed that studies in children generated lower rate of thrombotic events and major bleeding events compared with adults. Conclusion Our meta-analysis suggests that bivalirudin use as the anticoagulant for ECMO are associated with lower thrombotic events, major bleeding events and in-hospital mortality. Meanwhile, the differences are more pronounced in children than adults. However, the results should be interpreted with caution and further larger, randomized trials are needed to confirm the results.

Download Full-text

Treatment of Idiopathic (autoimmune) Thrombocytopenic Purpura (ITP): A Single Mexican Institution Experience

Blood ◽

10.1182/blood.v112.11.4559.4559 ◽

2008 ◽

Vol 112 (11) ◽

pp. 4559-4559

Author(s):

Gregorio Campos-Cabrera ◽

Virgina Campos-Cabrera ◽

Augusto Gomez-Leal ◽

Fernando Gomez-Garcia ◽

Jose-Luis Campos-Villagomez

Keyword(s):

Platelet Count ◽

Chronic Disease ◽

Major Bleeding ◽

Initial Treatment ◽

Complete Response ◽

Minor Bleeding ◽

Special Cases ◽

Chronic Course ◽

Immunological Alterations ◽

Platelet Transfusions

Abstract Background: ITP is an autoimmune disorder in wich an IgG autoantibody is formed that binds to platelets. The platelet autoantibody may bind complement, but platelets are not destroyed by direct lysis, rather, destruction takes place in the spleen, where splenic macrophages with Fc receptors bind to antibody coated platelets. It has an incidence from 50 to 100 cases per million persons per year and half of these occur in children. The infantile form affects both sexes the same, with greater incidence between the 2 and 4 years, major bleeding is common, the response to the treatment is good and mortality is low. In the adult form, women are effected more the men in relation 3 to 1, specially between 15 and 40 years, with minor bleeding, it may requires long treatment and it has greater mortality. The diagnosis is based in medical history and physical examination, valuing the type of bleeding and data of systemic diseases that can cause thrombocytopenia; by laboratory the CBC is necessary, coagulation tests, immunological panel and study of bone marrow, antiplatelet autoantibodies are not necessary; in special cases the imaging studies will be indicated. The treatment is established by guides from the American Society of Hematology. Material and methods: consecutive patients with newly diagnosed ITP were enrolled between October 2004 and April 2008 to study the treatment, response, evolution, fatality and current status. Ambulatory patients received prednisone (PDN), and hospitalized patients received methylprednisolone (MPD). In these second groups platelets transfusions were given as necessary. Results: 88 patients were eligible: 24 were 15 years or younger and 64 were older. Among infantile patients relation female/male was of 1 to the 1 (12/12), major bleeding in 29% (7/24), platelet count less than 20,000 per cubic millimeter in 83% (20/24), chronic course 12% (3/24), no death by any cause, the lab studies without immunological alterations. In the adult patients relation female/male was of 3 to 1 (48/16), major bleeding 23% (15/64), platelet count less than 20,000 per cubic millimeter in 43% (28/64), chronic course 23% (15/64), death by hemorrhage 3% (2/64), nonrelated deaths 8% (5/64), only one patient had positive autoimmune panel without systemic autoimmune disease. Initial treatment with MPD in 45 patients, 8 evolved to chronic disease (18%) and was 7 deaths; 43 patients received PDN as initial treatment, 6 evolved to chronic disease (14%) and had not fatalities in this group. Refractory to steroids patients from both groups received other treatments: 12 (2 children) splenectomy with 8 in complete response, 2 (one child) with chronic disease in complete remission with azathioprine; and 2 deaths without any response; 2 patients did not accept splenectomy and are receiving azathioprine with complete response. Thirteen patients received platelet transfusions, 6 evolved to chronic disease and 7 deaths: 2 by hemorrhage and 5 by non related causes, mainly sepsis. Conclusions: similar epidemiology that is reported in the world; minor frequency of immunological alterations; the majority of patients had remissions with initial treatment and in the evolution to chronic disease it does not concern the initial treatment, but platelet transfusions do; greater mortality of the MPD arm due to a more aggressive disease.

Download Full-text

Assessment of Predicted Rate and Associated Factors of Dabigatran-induced Bleeding Events in Malaysian Patients with Non-Valvular Atrial Fibrillation

Journal of Pharmacy & Pharmaceutical Sciences ◽

10.18433/j3tp9q ◽

2017 ◽

Vol 20 (1) ◽

pp. 365 ◽

Cited By ~ 1

Author(s):

Semira Abdi Beshir ◽

Lok Bin Yap ◽

Szyuin Sim ◽

Kok Han Chee ◽

Yoke Lin Lo

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Congestive Heart Failure ◽

Major Bleeding ◽

Bleeding Event ◽

Minor Bleeding ◽

Bleeding Events ◽

Laboratory Test Results ◽

Major Bleeding Events

Purpose: To assess the predicted rate and the factors associated with bleeding events among patients with non-valvular atrial fibrillation (NVAF) receiving dabigatran therapy. Methods: This retrospective cohort study includes adult patients of two tertiary hospitals in Malaysia. Potential study subjects were identified using pharmacy supply database or novel oral anticoagulant (NOAC) registry. Demographics, clinical data and laboratory test results were extracted from the medical records of the patients or electronic databases. The main outcome measure is the occurrence of a bleeding event. Bleeding events were classified into major bleeding, clinically relevant non-major bleeding, or minor bleeding, according to the International Society on Thrombosis and Haemostasis criteria. We consider clinically relevant non-major bleeding events or major bleeding events as clinically relevant bleeding events. An occurrence of any bleeding event was recorded from the initiation of NOAC therapy until the death of a patient, or the date of permanent discontinuation of NOAC use, or the last day of data collection. The predicted rate of dabigatran-induced bleeding events per 100 patient-years was estimated. Results: During a median follow-up period of 18 months, 73 patients experienced 90 bleeding events. Among these patients, 25 including 4 fatal cases, experienced major bleeding events. The predicted rate per 100 patient-years of follow-up of any bleeding events was 9.0 [95% CI 6.9 to 11.1]; clinically relevant bleeding events 6.0 [95% CI 4.8 to 8.3], and major bleeding events 3.0 [95% CI 1.9 to 4.2]. The independent risk factor for clinically relevant bleeding events is prior bleeding. While prior bleeding or congestive heart failure is linked with major bleeding events. Conclusions: The predicted rate for dabigatran-induced major bleeding episodes is low but these adverse events carry a high fatality risk. Preventive measures should target older patients who have prior bleeding or congestive heart failure. This article is open to POST-PUBLICATION REVIEW. Registered readers (see “For Readers”) may comment by clicking on ABSTRACT on the issue’s contents page.

Download Full-text

Effectiveness of the Alfalfa App in Warfarin Therapy Management for Patients Undergoing Venous Thrombosis Prevention and Treatment: A Cohort Study (Preprint)

10.2196/preprints.23332 ◽

2020 ◽

Author(s):

Hua Cao ◽

Shaojun Jiang ◽

Meina Lv ◽

Tingting Wu ◽

Wenjun Chen ◽

...

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Major Bleeding ◽

Hospital Admissions ◽

Point Of Care ◽

Emergency Department Visits ◽

Minor Bleeding ◽

Bleeding Events ◽

Anticoagulation Management ◽

Major Bleeding Events

BACKGROUND In the past years, the internet has enabled considerable progress in the management of chronic diseases, especially hypertension and diabetes. And it also provides novel opportunities in online anticoagulation management. Nevertheless, there is insufficient evidence regarding the effectiveness of online anticoagulation management. OBJECTIVE This study explored the effectiveness and safety of warfarin management via the Alfalfa app, so as to provide evidence in support of anticoagulant management through online services. METHODS In this retrospective, observational cohort study, 824 patients were included. In the offline group, patients went to the hospital clinic for warfarin management. In the Alfalfa app group, patients reported the dose of warfarin, current INR value and other related information through the Alfalfa app. Physicians or pharmacists used the app to adjust the dose of warfarin and determined the time for the next blood INR testing. Patients completed INR testing by point-of-care at home or hospital. The primary outcome of the study was the percentage of time in therapeutic range (TTR). Secondary outcomes included minor and major bleeding events, thrombotic events, warfarin-related emergency department visits, hospital admissions, and high INR values. RESULTS TTR and percentage of INR values in the range were significantly higher in the Alfalfa app than in the offline (79.35% vs. 52.38%, P < .001; 77.39% vs. 47.72%, P < .001, respectively). Patients managed via the Alfalfa app had lower rate of subtherapeutic (4.02% vs. 9.23%, P < .001), supratherapeutic (11.37% vs. 20.99%, P < .001), and extreme subtherapeutic INR values (6.77% vs. 21.66%, P < .001). Additionally, the Alfalfa app had lower incidences of major bleeding (0.47% vs. 3.01%, P = .005), warfarin-related emergency department visits (3.06% vs. 9.07%, P < .001), and hospital admissions (0.24% vs. 3.01%, P = .001) compared with the offline. However, the Alfalfa app had higher incidences of minor bleeding than the offline (10.59% vs. 5.01%, P = .003). There were similar incidences in extreme supratherapeutic INR values (0.44 %vs. 0.40%, P = .782) and thromboembolic events (0.24% vs. 0.25%, P = .964) between the two groups. CONCLUSIONS Warfarin management is superior via Alfalfa app than via offline services in terms of major bleeding events, warfarin-related emergency department visits, and hospital admissions. CLINICALTRIAL

Download Full-text

PATHOPHYSIOLOGY OF THROMBOCYTOPENIA AND RESULTANT CLINICAL INDICATIONS FOR PLATELET TRANSFUSION

10.1055/s-0038-1643996 ◽

1987 ◽

Author(s):

Sherrill J Slichter

Keyword(s):

Platelet Count ◽

Survival Data ◽

Platelet Transfusion ◽

Disease Process ◽

Bleeding Risk ◽

Underlying Disease ◽

Transfusion Therapy ◽

Platelet Counts ◽

Platelet Survival ◽

Platelet Transfusions

Careful evaluation of platelet survival data in normal individuals and patients with thrombocytopeniasecondary to marrow aplasia has demonstrated that platelets are lost from circulation by two mechanisms a fixed fraction of platelets, amounting to approxi mately 7,100 platelets/ul/day, are lost randomly while the remaining platelets are removed by senescent mechanisms. At platelet counts of <100,000/ul, platelet survival becomes progressively shorter as the fixed platelet loss becomes a proportionately greater fraction of the circulating platelets. Thus, there is a direct relationship between platelet count and platelet survival in thrombocytopenic patients. Therefore, when judging the effectiveness of platelet therapy in thrombocytopenic patients, the influence of platelet count on platelet survival must be considered. As yet, there have been no studies to determine if there are ways to interrupt this fixed platelet loss? whether such therapy might improve platelet support in thrombocyotpenic patients by prolonging platelet survival? or, alternatively, whether such therapy might enhance the bleeding risk if random platelet removal is related to physiologic platelet-endothelial cell interactions.Besides taking into account the effect of thrombocytopenia on the expected response to platelet transfusions, the risk of alloimmunization with platelet transfusion therapy requires a careful assessment of the indications for platelet transfusions for each patient.Based on 51Cr-labeled stool blood loss measurements, we have determined that the bleeding risk is minimal at platelet counts above 10,000 platelets/ul.Only when the platelet count falls to a lower level of 5,000/ul is GI bleeding significantly increased. However, there are certain medications that may enhance the bleeding risk and require platelet transfusions to be given at higher platelet counts.In those patients who are thrombocytopenic, not because of failure of marrow platelet production, but rather because of accelerated platelet removal, indications for platelet transfusions must be adjusted to meet the particular problem. For example, for patients with autoimmune thrombocytopenic purpura, platelet transfusions are rarely indicated (one exception being intracerebral bleeding) because of the rapid rate of platelet removal and because the patients are usually releasing young hyperfunctional platelets from the bone marrow reducing the hemorrhagic risk at any given platelet count. In some patients with consumptive coagulopathies, even though platelet removal is rapid, platelets may have to be provided until specific therapy resolves the underlying disease process causing the platelet consumption. For these patients, increased levels of fibrinogen/fibrin degregation products, as well as various medications they maybe receiving, may produce platelet dysfunction necessitating platelet transfusions at higher platelet levels. Finally, massive transfusion patients may develop a dilution thrombocytopenia requiring platelet transfusions.

Download Full-text

478 Clinical outcomes of patients at very high stroke risk undergoing watchman implantation

European Heart Journal Supplements ◽

10.1093/eurheartj/suab134.052 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Michele Magnocavallo ◽

Domenico Giovanni Della Rocca ◽

Carlo Lavalle ◽

Gianni Carola ◽

Sa Mohanty ◽

...

Keyword(s):

Major Bleeding ◽

Stroke Risk ◽

Bleeding Event ◽

Minor Bleeding ◽

Bleeding Events ◽

Related Complication ◽

Watchman Device ◽

Major Bleeding Events ◽

Very High

Abstract Aims Left atrial appendage occlusion (LAAO) with the Watchman device is an effective alternative to oral anticoagulation in patients with non-valvular atrial fibrillation at high thromboembolic risk. We sought to evaluate the safety and effectiveness of LAAO for stroke and bleeding prevention in patients at very high stroke risk. Methods and results Data were extracted from a prospective database of 488 AF patients who underwent LAA closure with a Watchman device. Periprocedural complications, thromboembolic (TE), and bleeding event rates among patients with a CHA2DS2-VASc ≥ 5 were reported. Predicted annual rates of TE or major bleeding events were compared to the annualized observed risk of the population. Overall, 209 patients with a CHA2DS2-VASc ≥5 (CHA2DS2-VASc: 6.0 ± 1.0; HAS-BLED: 3.7 ± 1.1) were included in the study. The mean age was 78 ± 6 years and 52.2% (n = 109) were males. Watchman implantation was successful in all patients. Overall procedure-related complication rate was 3.3% (n = 7). Two major complications were observed (1.0%): one pericardial tamponade requiring surgery and one major bleeding event at 3 days post-procedure. The incidence of minor complications was 2.3% (n = 5). Specifically, two patients experienced a pericardial effusion that required drainage and three had a groin hematoma. During a mean follow-up duration of 12 ± 5 months (193 pt/years), six TE events (2.9%/annualized rate: 3.1%) were documented after a median of 6.3 months (IQR: 2.2–9.6). Based on the estimated annual TE risk according to the CHA2DS2-VASc score (8.5%), the % risk reduction after LAAO was 63.5%. Four major bleeding events [1.9% (median time to event: 2.1 months; IQR: 1.0–3.4)] and five minor bleeding events occurred (2.5%) during follow-up. Compared to the expected rate of bleeding events as assessed by the HAS-BLED of the population (8.03%), LAAO led to a 42% reduction of bleeding risk. Conclusions In a population at very high TE risk, LAAO with the Watchman device was a safe and effective approach, and led to a 63.5% of stroke risk.

Download Full-text