Research progress in perioperative management of portal vein thrombosis in liver transplantation / 器官移植

Portal vein thrombosis is one of the common complications of liver cirrhosis. The incidence of portal vein thrombosis is increased with the progression of diseases. The incidence and progression of portal vein thrombosis are associated with multiple factors. The indications of anticoagulant therapy remain to be investigated. At present, portal vein thrombosis is no longer considered as a contraindication for liver transplantation. Nevertheless, complicated portal vein thrombosis will increase perioperative risk of liver transplantation. How to restore the blood flow of portal vein system is a challenge for surgical decision-making in clinical practice. Rational preoperative typing, surgical planning and portal vein reconstruction are the keys to ensure favorable long-term prognosis of liver transplant recipients. In this article, epidemiological status, risk factors, typing and identification of portal vein thrombosis, preoperative and intraoperative management of portal vein thrombosis in liver transplantation, and the impact of portal vein thrombosis on the outcomes of liver transplantation were reviewed, aiming to provide reference for perioperative management of portal vein thrombosis throughout liver transplantation.

Management of anticoagulant therapy in a patient with complex venous thromboembolism complicated with acute renal insufficiency / 中国药房

OBJECTIVE To provide a reference for the safe use of drugs in patients with complex venous thromboembolism （VTE） and acute renal insufficiency. METHODS Clinical pharmacists participated in the management of anticoagulant therapy for a patient with complex VTE complicated with acute renal insufficiency， and evaluated the patient as high-risk thrombosis and bleeding based on their medical history， laboratory test results， etc.； combined with the complexity of thrombosis and renal insufficiency， clinical pharmacists suggested that enoxaparin sodium should be used in the acute stage of thrombosis （5 to 21 days after onset）， and then warfarin should be adopted for oral anticoagulation treatment. Because the patient’s anticoagulation was not up to the standard （the target range of the international normalized ratio was 2-3）， clinical pharmacists suggested increasing the warfarin dose， detecting the warfarin metabolism genotype， and adjusting the warfarin dose according to the genotype； at the same time， clinical pharmacists developed an anticoagulation monitoring plan to ensure the safety of anticoagulation treatment. RESULTS Doctors had adopted all the recommendations of clinical pharmacists. The patient did not experience adverse events such as bleeding or worsening of thromboembolism during anticoagulation in the hospital. When the anticoagulation met the standards， the patient was allowed to be discharged with medication. CONCLUSIONS By participating in the anticoagulation treatment management of patients with complex VTE and acute renal insufficiency， clinical pharmacists have assisted doctors in formulating personalized anticoagulation plans to promote the compliance with the anticoagulation treatment standard and ensure the safety and effectiveness of medication for patients.

Advances in anticoagulant therapy for cirrhosis combined with atrial fibrillation / 中华肝脏病杂志

Relevant research in recent years has demonstrated that the atrial fibrillation occurrence rate is significantly higher in patients with cirrhosis. The most common indication for long-term anticoagulant therapy is chronic atrial fibrillation. The use of anticoagulant therapy greatly reduces the incidence rate of ischemic stroke. Patients with cirrhosis combined with atrial fibrillation have an elevated risk of bleeding and embolism during anticoagulant therapy due to cirrhotic coagulopathy. At the same time, the liver of such patients will go through varying levels of metabolism and elimination while consuming currently approved anticoagulant drugs, thereby increasing the complexity of anticoagulant therapy. This article summarizes the clinical studies on the risks and benefits of anticoagulant therapy in order to provide a reference for patients with cirrhosis combined with atrial fibrillation.

Clinical characteristics of acute renal infarction: an analysis of 15 cases / 中华全科医师杂志

Clinical data of 15 patients diagnosed with acute renal infarction (ARI) in Affiliated Zhongshan Hospital of Dalian University from Jan 2011 to Dec 2021 were retrospectively analyzed. Of the included 15 patients, there were 14 cases of cardiac origin and 1 case of antiphospholipid syndrome. We found that there were 12 cases of atrial fibrillation, 2 cases of atrial premature beats, 12 cases of elevated level of D-dimer, 15 cases of elevated level of LDH, 11 cases of positive urine occult blood and positive urine protein. Among the 15 patients, catheter-directed thrombolysis was performed in 4 cases, of which 3 cases were revascularized successfully, intravenous thrombolysis in 2 cases and alone anticoagulation therapy in 9 cases. It is suggested that CECT or CTA can assist the early diagnosis of ARI especially in patients with acute onset and persistent abdominal pain with high risk factors of thromboembolism, high levels of LDH, microscopic hematuria and/or proteinuria. Despite prolonged embolic ischemia, try to reconstruct blood flow to save the kidney as much as possible. Late standardized anticoagulant therapy is of critical importance to prevent recurrent embolic episodes.

Compliance of oral anticoagulant medication and influencing factors among nonvalvular atrial fibrillation patients with new-onset acute ischemic stroke / 中华全科医师杂志

Objective:To investigate the compliance of oral anticoagulant(OAC) medication and influencing factors among nonvalvular atrial fibrillation(NVAF) patients with new-onset acute ischemic stroke (AIS).Methods:A total of 396 NVAF patients, who initiated OAC therapy after a new-onset AIS from August 2011 to December 2020 were enrolled from China Atrial Fibrillation Registry (China-AF). The demographic characteristics, medical history, comorbid diseases and medication of patients were collected before and after the index stroke, and the influencing factors of compliance of OAC medication were analyzed.Results:Patients were followed up for a mean of 26.9 months. Among 396 patients, 228 (57.6%) had continuous anticoagulant medication (persistent OAC group);while 168 (42.4%) discontinued OAC therapy within 2 years after the index stroke (non-persistent OAC group). Patients on persistence OAC had a higher proportion of atrial fibrillation episodes than patients on non-persistent OAC [83.3% (190/228) vs. 73.8% (126/168); χ 2=5.34, P=0.021], while lower proportion of radiofrequency ablation(RFA)[18.9% (43/228) vs. 32.1% (43/228); χ 2=9.22, P=0.002]. Multivariate Cox regression modelshowed that history of RFA ( HR=1.77, 95% CI: 1.25-2.50; P=0.001) was positively associated with non-persistence of OAC. Conclusion:The study indicates that quite large proportion of NVAD patients with a new-onset of AIS discontinued OAC therapy during 2 years of follow up, and a history of RFA procedure might be an independent factor associated with discontinuing of anticoagulant therapy.

Diagnosis and treatment of vascular complications after liver transplantation in adults / 器官移植

As an efficacious treatment for end-stage liver diseases and primary malignant liver tumors, liver transplantation has been widely applied worldwide, and gradually receives widespread recognition from patients. With the development of organ transplant technique, vascular complications have rarely occurred after adult liver transplantation. However, vascular complications, such as postoperative thrombosis and anastomotic stenosis, are still common in the recipients undergoing living donor liver transplantation and split liver transplantation. Inappropriate treatment may lead to the loss of grafts and death of recipients. The authors have been engaged in liver transplantation for many years, witnessing persistent development of diagnostic and therapeutic technologies for vascular complications after liver transplantation. In this article, current status and development trend of diagnosis and treatment of different vascular complications were illustrated from the etiology, clinical manifestations, diagnosis and treatment of hepatic artery complications, portal vein complications, inferior vena cava and hepatic vein complications, aiming to further improve the survival rate of grafts and recipients and provide reference for promoting the development of clinical liver transplantation.

Exploration and practice of information-based pharmaceutical care pathway of anticoagulant therapy in patients with atrial fibrillation / 中国药房

OBJECTIV E To develop the infor mation-based pharmaceutical care pathway of anticoagulant therapy in patients with atrial fibrillation and improve the efficacy and safety of treatment for them. METHODS The“anticoagulant pharmaceutical care”module was developed on the basis of medical intelligent and decision system. Patients with atrial fibrillation were taken pharmaceutical care in the whole anticoagulant treatment by evaluating the thromboembolism and bleeding risks ，pre-reviewing antithrombotic prescriptions ，monitoring efficacy and drug interactions ，and warning adverse reactions. RESULTS A total of 1 228 patients receiving anticoagulant therapy were enrolled. It was found after analysis of their doctor ’s orders that 9.27％ of the patients adjusted the improper antithrombotic therapies ，3.99％ modulated treatments according to the effects of potential drug interactions or the risk of adverse reactions ，and 70.29％ of the wrong prescriptions were intervened successfully. After the information-based pharmaceutical care ，the anticoagulation treatment rate increased from 88.73％ to 97.40％，the rate of patients ’achievements to warfarin’s international normalized ratio in hospital increased from 38.64％ to 66.67％，and the incidence of serious bleeding events decreased from 2.94％ to 0.37％ （P＜0.05）. CONCLUSIONS The information-based pharmaceutical care path of anticoagulant therapy achieved comprehensive ，efficient and accurate management of patients with atrial fibrillation ，and improved the rationality ，effectiveness and safety of anticoagulant therapy.

Potential drug-drug interactions among patients with spontaneous intracerebral hemorrhage treated at the Neurological Intensive Care Unit: a single-center experience

Abstract Our aim was to determine the prevalence of potential drug-drug interactions (pDDIs) and to identify relevant factors associated with the occurrence of the most dangerous or contraindicated pDDIs (pCDDIs) in hospitalized patients with spontaneous intracerebral hemorrhage (sICH). A retrospective cross-sectional study was performed enrolling all consecutive patients with sICH treated at the Neurological Intensive Care Unit, Clinical Center in Kragujevac, Serbia, during the three-year period (2012-2014). The inclusion criteria encompassed patients aged 18 years and over, those diagnosed with ICH, and those prescribed at least two drugs during hospitalization, while we did not include patients whose hospitalization lasted less than 7 days, those who were diagnosed with other neurological diseases and patients with incomplete medical files. For each day of hospitalization, the online checker Micromedex® software was used to identify pDDIs and classify them according to severity. A total of 110 participants were analysed. A high prevalence of pDDIs (98.2%) was observed. The median number of pDDIs regardless of severity, was 8.00 (IQR 4.75-13.00;1-30). The pairs of drugs involving cardiovascular medicines were the most commonly identified pDDIs. Twenty percent of the total number of participants was exposed to pCDDIs. The use of multiple drugs from different pharmacological-chemical subgroups and the prescribing of anticoagulant therapy significantly increase the chance of pCDDI (aOR with 95% CI 1.19 (1.05-1.35) and 7.40 (1.13-48.96), respectively). This study indicates a high prevalence of pDDIs and pCDDIs in patients with sICH. The use of anticoagulant therapy appears to be the only modifiable clinically relevant predictor of pCDDIs.

Preliminary clinical experiences of hepatic sinusoidal obstruction syndrome after orthotopic liver transplantation / 中华器官移植杂志

Objective:To explore the etiology, pathogenesis, clinical features, diagnosis and treatment of hepatic sinus obstruction syndrome(HSOS)after orthotopic liver transplantation(OLT).Methods:Clinical data were reviewed for 3 HSOS patients after OLT.Baseline profiles, primary disease, onset, clinical manifestations, abdominal imaging and pathological changes were recorded for summarizing the key points of diagnosis, treatment and outcomes of HSOS after OLT.Results:HSOS was an extremely rare complication after OLT with an incidence of 2%(2/117)and a median onset of 15(13-50)days.The major clinical manifestations were hepatic pain, abdominal distension, poor appetite, fatigue, jaundice, oliguria, peritoneal effusion and pleural effusion.Some of them were complicated with acute renal insufficiency.Abdominal ultrasonography revealed that blood stream of hepatic and portal veins was smooth but rather slow and hepatic parenchyma showed uneven echo changes.Abdominal enhanced computed tomography(CT)demonstrated " mosaic" and " map-like" uneven enhancement in portal vein and balance phases.The pathological manifestations of liver biopsy included obvious dilation and congestion of hepatic sinuses, swelling and necrosis of hepatic cells, thickening of hepatic venules and luminal stenosis or occlusion.All of them received immunosuppressants.Tacrolimus was switched to sirolimus, low molecular weight heparin or plus rivaroxaban anticoagulant thrombolytic therapy, methylprednisolone regulatory immunotherapy, albumin supplementation, diuresis, hepatic protection and fluid replacement.Afterward clinical symptoms of 2 patients improved, became cured and discharged.One case died from gastrointestinal hemorrhage and acute renal failure secondary to multiple organ failure.Conclusions:HSOS is an extremely rare but severe complication after OLT.Early diagnosis and fine-tuning of treatment protocols can avoid poor prognosis such as liver and kidney failure and significantly improve patient survival.

Anestesia regional en la paciente embarazada antiagregada o anticoagulada / Regional anesthesia in the antiplatelet or anticoagulated pregnant patient / Anestesia regional em paciente grávida antiplaquetária ou anticoagulada

Resumen: La anestesia regional es la técnica de elección debida a la menor morbimortalidad. Una de las complicaciones más temidas es el hematoma espinal, teniendo las pacientes que reciben antiagregantes y/o anticoagulantes mayor riesgo de desarrollarlo. El cuadro clínico es variable, y no siempre están todos los elementos presentes (dolor lumbar, déficit motor y/o sensitivo y/o vesical). El diagnóstico se realiza por resonancia nuclear magnética y el tratamiento es la descompresión por laminectomía. Estando el pronóstico neurológico vinculado al tiempo en que se realiza ésta. Se realiza una revisión sobre los distintos fármacos antiagregantes y anticoagulantes utilizados en el embarazo - puerperio y las recomendaciones necesarias para las pacientes que recibirán una anestesia regional.

Abstract: Regional anesthesia is the technique of choice due to lower morbidity and mortality. One of the most feared complications is spinal hematoma, with patients receiving antiplatelet and / or anticoagulants having a greater risk of developing it. The clinical picture is variable, and not all the elements are always present (lumbar pain, motor and / or sensory and / or bladder deficits). Diagnosis is made by magnetic resonance imaging and treatment is laminectomy decompression. Being the neurological prognosis linked to the time in which it is performed. A review is made of the different antiplatelet and anticoagulant drugs used in pregnancy - puerperium and the necessary recommendations for patients who will receive regional anesthesia.

Resumo: A anestesia regional é a técnica de escolha devido à menor morbimortalidade. Uma das complicações mais temidas é o hematoma espinhal, com pacientes em uso de antiagregantes plaquetários e / ou anticoagulantes com maior risco de desenvolvê-lo. O quadro clínico é variável e nem sempre os elementos estão presentes (dor lombar, déficits motores e / ou sensoriais e / ou vesicais). O diagnóstico é feito por ressonância magnética e o tratamento é a descompressão por laminectomia. Sendo o prognóstico neurológico ligado ao tempo em que é realizado. É feita uma revisão das diferentes drogas antiplaquetárias e anticoagulantes utilizadas na gravidez - puerpério e as recomendações necessárias para as pacientes que receberão anestesia regional.

Diagnosis and treatment of hepatic sinusoidal obstruction syndrome after liver transplantation: a single-center experience / 器官移植

Objective To summarize the incidence, diagnostic and therapeutic experience of hepatic sinusoidal obstruction syndrome (HSOS) after liver transplantation. Methods Clinical data of 4 patients with HSOS after liver transplantation were retrospectively analyzed. The incidence, clinical manifestations, imaging and pathological characteristics of HSOS after liver transplantation were collected, and the treatment methods and clinical outcomes of patients with HSOS were analyzed. Results The incidence of HSOS after liver transplantation was 0.8%(2/239), and the median time of onset was 4.5(1.7, 9.0) months after liver transplantation. The clinical manifestations of HSOS mainly included abdominal distension, ascites, hepatomegaly, increased bilirubin, and renal insufficiency in partial cases. Enhanced abdominal CT scan of 4 patients with HSOS showed uneven spot-like enhancement and the liver histopathological examination mainly showed the signs of hepatic sinusoidal dilatation complicated with congestion. Four patients were administered with an adjusted regime of immunosuppressant by replacing tacrolimus (Tac) with ciclosporin and adding anticoagulant therapy with warfarin. One patient received transjugular intrahepatic portosystemic shunt (TIPS). After treatment, the symptoms of 3 patients were completely relieved, and 1 patient died. One of the 3 surviving patients died from pulmonary infection and gastrointestinal bleeding. Conclusions HSOS is a rare and fatal complication after liver transplantation. Timely diagnosis and treatment can avoid the incidence of graft failure and improve clinical prognosis of the patients.

Study on warfarin dose adjustment strategy at different stages after mechanical valve replacement of mitral valve / 中国胸心血管外科临床杂志

@#Objective    To explore the anticoagulant strategy of adjusting the dose of warfarin at different stages after mechanical valve replacement of mitral valve. Methods    Clinical data of a total of 302 patients, including 76 males and 226 females, with an average age of 50.1±10.1 years, who underwent mechanical mitral valve replacement in the Chinese adult cardiac surgery database from 2013 to 2017 were retrospectively analyzed. According to the dose adjustment strategy of taking warfarin, the patients were divided into a D group (adjusting warfarin dose in days) and a W group (adjusting warfarin dose in weeks) to evaluate the anti-coagulation effect of warfarin. Results    The total follow-up time was 423 277 d (1 159.7 years). There was no significant difference in the overall anticoagulant strength, and the warfarin dose adjusted in days was better in the early postoperative period (P<0.05), especially in patients over 60 years. It was better to adjust warfarin dose in weeks in the middle and long periods (P<0.05), especially in patients ≤40 years. In terms of the stability of anticoagulation, it was better to adjust the dosage of warfarin in weeks (P<0.05). It was better to adjust the dosage of warfarin in weeks for early, middle- and long-term anticoagulant therapy after operation (P<0.05), especially in the females aged >40 and ≤50 years. Conclusion    Within the target range of international normalized ratio (1.5-2.5), the anticoagulant strategy of adjusting warfarin dose in days after mechanical valve replacement of mitral valve can   achieve a better anticoagulant strength, and adjusting the dosage of warfarin in weeks is better in the middle- and long-term after operation. In general, the anticoagulant effect is more stable in the short term when warfarin dose is adjusted on a weekly basis.

A Mobile Thrombus in the Aortic Arch / 日本心臓血管外科学会雑誌

A 51-year-old man was referred to our hospital with pain and coldness of the upper left extremity. Contrasted computed tomography revealed a silhouette protruding into the aortic arch. Peripheral embolism in upper left extremity by tumor or thrombosis was suspected. Magnetic resonance imaging revealed a mobile mass in the aortic arch. To prevent recurrent embolization, the mass and the aortic arch to which the mass was attached were excised and partial arch replacement was performed under cardiopulmonary bypass. Histologically, the mass was a fibrin thrombus with no malignancy. The aortic wall showed only mild atherosclerosis of the intima. No thrombotic predisposition such as protein S or C deficiency or antiphospholipid antibody syndrome was observed. Anticoagulant therapy was started and the patient was discharged on postoperative day 10 without recurrent thromboembolism. Three years have passed since the operation and there is no recurrence of thromboembolism.

Analysis of risk factors and clinical prognosis of massive blood transfusion during perioperative period of lung transplantation / 器官移植

Objective To investigate the risk factors and clinical prognosis of massive blood transfusion during the perioperative period of lung transplantation. Methods Clinical data of 159 lung transplant recipients were retrospectively analyzed. According to the quantity of perioperative blood transfusion, all recipients were divided into the massive blood transfusion group (n=20) and non-massive blood transfusion group (n=139). Clinical data of lung transplant recipients were statistically compared between two groups. The risk factors of perioperative massive blood transfusion were analyzed. Clinical prognosis of the recipients was observed in two groups. Results There were significant differences between the two groups in preoperative data including anticoagulant therapy, hemoglobin content, the number of recipents with idiopathic pulmonary fibrosis or idiopathic pulmonary hypertension, and intraoperative data including the number of recipents presenting with intraoperative intrathoracic adhesion, operation time and the amount of various component transfusion(all P < 0.05). Preoperative anticoagulant therapy, incidence of intraoperative intrathoracic adhesion, use of extracorporeal membrane oxygenation (ECMO) and long operation time were the risk factors of massive blood transfusion during perioperative period of lung transplantation(all P < 0.05). In the massive blood transfusion group, the incidence rate of grade Ⅲ primary graft dysfunction (PGD) and the fatality within postoperative 30 d were higher compared with those in the non-massive blood transfusion group(both P < 0.01). Low body mass index (BMI) and massive blood transfusion were the risk factors for death within postoperative 30 d(P=0.048、P < 0.001). The 1-year survival rate in the massive blood transfusion group was lower than that in the non-massive blood transfusion group(P < 0.001). Conclusions Preoperative anticoagulant therapy, incidence of intraoperative intrathoracic adhesion, use of ECMO and long operation time are the risk factors for massive blood transfusion during perioperative period of lung transplantation. Massive blood transfusion negatively affects the clinical prognosis of the recipients undergoing lung transplantation.

Significance and future of anticoagulant therapy for sepsis / 中华危重病急救医学

Sepsis is caused by the imbalance of the host body's response to infection, which causes life-threatening organ dysfunction. Disorders of blood coagulation play a very important role in the development of sepsis. In sepsis, the body's coagulation system is activated, leading to hypercoagulability, while the anticoagulation mechanism is significantly inhibited, causing a large number of microthrombi to form, and disseminated intravascular coagulation (DIC) may occur. Although there are obvious controversies about the anticoagulation treatment of sepsis at home and abroad, we cannot deny the significance of anticoagulation treatment in sepsis. Only appropriate anticoagulation can effectively reduce the mortality in septic DIC, septic shock and high-risk population, and ultimately effectively reduce the occurrence of multiple organ dysfunction syndrome. The sepsis-induced coagulation dysfunction (SIC) score is currently used internationally to guide anticoagulation. SIC score is optimized based on the International Society on Thrombosis and Haemostasis (ISTH) overt DIC score and Sepsis-3, including platelet, international normalized ratio (INR) and sequential organ failure assessment (SOFA). The SIC score can sensitively monitor sepsis-induced coagulation dysfunction. When the SIC score is≥4, it is the best timing to initiate anticoagulation therapy. At present, the internationally recommended anticoagulant drugs include antithrombin (AT), thrombomodulin (TM), tissue factor pathway inhibitor (TFPI), heparin, etc., while the domestically recommended anticoagulant drugs are only unfractionated heparin and low molecular weight heparin. Before using anticoagulant drugs, it is necessary to evaluate the possibility of bleeding and thrombosis in the patients. At the same time, it is necessary to pay attention to the patient's primary disease. Try to adopt the treatment strategy of transitioning from unfractionated heparin to low molecular weight heparin without obvious anticoagulation contraindications.

Cerebral venous sinus thrombosis: Endovascular treatment with different aproaches and anticoagulant therapy / 中国介入影像与治疗学

Objective: To compare the efficacy of multi-channel endovascular treatments and anticoagulant therapy in treatment of cerebral venous sinus thrombosis (CVST). Methods Data of 88 CVST patients were analyzed retrospectively, including 47 patients treated with multi-channel endovascular treatments (experimental group) and 41 patients treated with anticoagulation therapy (control group). Clinical follow-up was carried out for 6 months, and the efficacies were compared between the two groups. Results At the discharge, 3-month and 6-month follow-up points, modified Rankin scale (mRS) score and National Institute of Health stroke scale (NIHSS) score of the experimental group were 1 (1,2) and 1.43±0.50, 1 (0,2) and 1.04±0.33, 1 (0,1) and 0.87±0.28, lower than that of control group (2 [1,2] and 2.20±0.62, 2 [1,2] and 1.59±0.49, 1 [0,2] and 1.37±0.37, all P<0.05). Conclusion: Compared with traditional anticoagulant therapy, multi-channel endovascular treatments have better efficacies, which can reduce the disability rate and improve the quality of life of CVST patients.

Research progress of antithrombotic therapy after transcatheter aortic valve implantation / 中国胸心血管外科临床杂志

@#Traditional surgical aortic valve replacement is associated with a high risk of serious complications, especially in elderly patients with other preoperative diseases and unable to undergo thoracotomy. Therefore, transcatheter aortic valve implantation (TAVI) is now the accepted standard treatment for patients with symptomatic severe aortic stenosis at elevated risk for conventional surgical valve replacement. Currently, guidelines propose the use of dual antiplatelet therapy for the prevention of thromboembolic events after TAVI in the patients without an indication for oral anticoagulation. While, this strategy is empiric and largely based on expert consensus extrapolated from the arena of percutaneous coronary intervention. Antithrombotic therapy is associated with a significant occurrence of both thrombotic and bleeding complications, thus, the balance between thrombotic and bleeding risk is critical. This review summarizes current guidelines and the evidence underpinning them and explores the rational for using antiplatelet and/or anticoagulant strategies after TAVI.

Anticoagulación en enfermedad tromboembólica venosa / Anticoagulant therapy in venous thromboembolic disease

INTRODUCCIÓN: La enfermedad tromboembólica venosa está comprendida por la trombosis venosa profunda y el tromboembolismo pulmonar, las cuales son enfermedades comunes con alta morbilidad y mortalidad, incluso antes del diagnóstico. El tratamiento está basado principalmente en la terapia anticoagulante, con diferentes opciones dependiendo del ámbito clínico y la estabilidad del paciente (terapia oral vs parenteral). Objetivo: Revisar las diferentes opciones y escenarios clínicos para la indicación de terapia anticoagulante, basados en la evidencia médica actual. Metodología: Se realizó una búsqueda sistemática en las bases de datos PubMed, Scopus, Google Académico y Scielo sobre estudios que evaluaran la indicación de la terapia anticoagulante en pacientes con diagnóstico de enfermedad tromboembólica venosa, principalmente, estudios aleatorizados controlados y metaanálisis. Discusión y Resultados: Fueron encontrados estudios aleatorizados controlados donde se evidencian menores tasas de sangrado y recurrencia de la enfermedad tromboembólica venosa a favor de los anticoagulantes directos, excluyendo algunas situaciones especiales como cáncer y enfermedad renal crónica avanzada. Conclusión: La terapia anticoagulante es el pilar del tratamiento en la enfermedad tromboembólica, disminuyendo la morbilidad y mortalidad de esta entidad, aunque aumenta el riesgo de sangrado. Anteriormente, los anticoagulantes antagonistas de la vitamina K eran la única opción terapéutica, pero con altas tasas de sangrado, afortunadamente desde hace algunos años contamos con los anticoagulantes directos con mejores perfiles de seguridad y menor tasa de sangrado.

ABSTRACTS: Venous thromboembolic disease includes deep venous thrombosis and pulmonary embolism, which are common diseases with high morbidity and mortality. The treatment is based mainly on anticoagulant therapy, with different options depending on clinic context and patient stability (oral vs parenteral therapy). Objective: To review evidence based medical information regarding the use of anticoagulant therapy in venous thromboembolism. Methods: We performed a systematic review of PubMed, Scopus, Google scholar and Scielo databases, of randomized controlled studies and meta-analysis evaluating anticoagulant therapy in patients with thromboembolic venous disease. Results: Except for tromboembolic disease in patients with cancer or chronic kidney disease anticoagulation with direct (new) oral agents led to less bleeding episodes and lower relapse rate. Conclusion: anticoagulant therapy is the basis of treatment for thromboembolic disease, decreasing morbidity and mortality. New oral anticoagulants' are associated to better clinical results, notwithstanding a slight increase in bleeding episodes.

Quality evaluation and genetic study of anti-coagulation therapy of warfarin in stable period after mechanical valve replacement / 中国胸心血管外科临床杂志

@#Objective    To evaluate the quality of warfarin anticoagulant therapy in patients with stable stage after mechanical valve replacement surgery, to observe the effect of compound salvia miltiorrhiza tablet on the anticoagulant effect of warfarin in patients after mechanical valve replacement, and to understand the impact of genetic polymorphisms of VKORC1, CYP2C9 and CYP4F2 on warfarin resistance in patients with mechanical valve replacement in the stable period. Methods    From July 2011 to February 2014, 1 831 patients who had ≥ 6 months after mechanical valve  replacement surgery were enrolled at the outpatient follow-up. The basic clinical data were recorded. Anticoagulant therapy uses a target international normalized ratio（INR, 1.60–2.20) and a weekly warfarin dose adjustment strategy. Forty-six patients who needed compound salvia miltiorrhiza tablet were screened and the INR values. Before and after taking tablets were recorded and compared. The patients were divided into three groups according to the percentile of warfarin dosage including a warfarin sensitive patients group, a control patients group, and a warfarin resistance patients group. And 101 of them were selected. TIANGEN blood DNA Kit blood genomic DNA extraction kit was used to extract samples and polymerase chain restriction fragment length polymorphism (PCR-RELP) was used to determine the genotypes of patients. The detected gene loci included CYP4F2: rs2108622C>T locus; VKORC1:1639G>A locus; VKORC1:1173C>T locus; CYP2C9*2: rs1799853C>T locus; CYP2C9*3:1061A>C locus. Results    The time in therapeutic range (TTR) and fraction of time in therapeutic range (FTTR) in the target INR range of the patients included in the study period was 27.2% and 49.4%, respectively, and the TTR and FTTR in the acceptable INR range was 34.25% and 63.36%, respectively. Before and after the addition of compound salvia miltiorrhiza tablets, the INR value was 1.55±0.03 and 1.69±0.30, respectively, and the difference was statistically different (P<0.05). A total of 101 patients with genetic testing, in which the C/T composition of the VKORC1: 1173C>T locus increased in the warfarin sensitivity, contrast and warfarin resistance patients, while the ratio of allelic loci of C/T in CYP2C9*3: 1061A>C loci decreased in turn. There was no difference in the CYP4F2 gene, VKORC1639 gene, and CYP2C9*2 locus. The IWPC model predicts that warfarin dose is only consistent with the actual warfarin dose in warfarin sensitive patients. Conclusion    Relatively low TTR and FTTR are acceptable in patients with stable stage after mechanical valve replacement. It is beneficial to the patients with compound salvia miltiorrhiza tablets in terms of some appropriate patients. VKORC1: 1173C>T site and CYP2C9*3: 1061A>C site mutation is the main pharmacological gene factor of warfarin dose sensitivity and warfarin resistance in stable period after mechanical valve replacement. The IWPC dose prediction model is only consistent with the actual dose of warfarin sensitive patients.

Acute Compartment Syndrome after Anticoagulant Therapy to Misdiagnosed Deep Vein Thrombosis / 대한정형외과학회잡지

Acute compartment syndrome, which is an orthopedic emergency, induces irreversible tissue necrosis by increasing the compartment pressure. In serious cases, this event may result in functional impairment, loss of the lower limb, and death by renal failure. When the patient initially presents with pain and swelling that are similar to deep vein thrombosis, a differential diagnosis between the two diseases is very critical. The authors encountered a case of acute compartment syndrome after anticoagulant therapy in a patient presenting with painful swelling of the left leg following a massage that was initially misdiagnosed as deep vein thrombosis. A fasciotomy was performed on this case with satisfactory results. This paper reports this case with a review of the relevant literature.