Venous thromboembolism in 13 Indonesian patients undergoing major orthopedic surgery.

Aim To estimate the incidence of VTE in Indonesian patients undergoing major orthopedic surgery and not receiving thromboprophylaxis. Methods This was an open clinical study of consecutive Indonesian patients undergoing major orthopedic surgery, conducted in 3 centers in Jakarta. Bilateral venography was performed between days 5 and 8 after surgery to detect the asymptomatic and to confi rm the symptomatic VTE. These patients were followed up to one month after surgery. Results A total of 17 eligible patients were studied, which a median age of 69 years and 76.5% were females. Sixteen out of the 17 patients (94.1%) underwent hip fracture surgery (HFS). The median time from injury to surgery was 23 days (range 2 to 197 days), the median duration of surgery was 90 minutes (range 60 to 255 minutes), and the median duration of immobilization was 3 days (range 1 to 44 days). Thirteen out of the 17 patients were willing to undergo contrast venography. A symptomatic VTE was found in 9 patients (69.2%) at hospital discharge. Symptomatic VTE was found in 3 patients (23.1%), all corresponding to clinical signs of DVT and none with clinical sign of PE. These patients were treated initially with a low molecular weight heparin, followed by warfarin. Sudden death did not occur up to hospital discharge. From hospital discharge until 1-month follow-up, there were no additional cases of symptomatic VTE. No sudden death, bleeding complication, nor re-hospitalization was found in the present study. Conclusion The incidence of asymptomatic (69.2%) and symptomatic (23.1%) VTE after major orthopedic surgery without thromboprophylaxis in Indonesian patients (SMART and AIDA), and still higher than the results of the Western studies. A larger study is required to establish the true incidence, and more importantly, that the use of thromboprophylaxis in these patients is warranted.

Cut-off levels based on deviation from standard negative control is better than moderate level based on fixed cut-off for ACA assessed using ELISA for the diagnosis of antiphospholipid syndrome.

AIM: To assess the consistency of the standard negative control of IgG and IgM ACA levels within runs and batches of tests, and levels of ACA agreement between those established according to deviation from standard negative control and those established based on a fixed level cut off. METHODS: Serum samples of 148 patients who presented an INR < 0.9 or prothrombin activity of > 130% or aPTT below 0.8 times control or thrombosis with aPTT below 1.2 times control were tested in a 22-time running test to determine IgG and IgM ACA levels using Quanta Lite ACA IgG (HRP) and Quanta Lite ACA IgM (HRP) commercial reagents. RESULTS: Coefficients of variant within runs and batches of standard negative control IgG and IgM ACA levels were 19.30% and 29.17% respectively. Using kappa statistics to determine degree of agreement between cut-off levels by deviation from standard negative control and fixed cut-off level of ACA identified using ELISA, the disagreement in IgM and IgG were k 0.30, and 95% CI of k 0.27 to 0.34 (z = 1.033, p = 0.3015), and k 0.63, and 95% CI of k 0.53 to 0.73 (z = 1.411, p = 0.1584) for cut-off levels based on deviations from standard negative control and fixed cut-off levels respectively. Cut-off levels based on deviation from standard negative control was more sensitive, with a 92% predictive true positive value, compared to a 69% predictive true positive value by fixed cut-off levels of IgM ACA detected using ELISA, and nearly equivalent to IgG ACA, with 84.4% and 87.1% predictive true positive values respectively. CONCLUSION: Cut-off points based on fixed levels of ACA detected using ELISA cannot be applied, because both IgG and IgM ACA levels of standard negative control were inconsistent among runs and batches. Cut-off points based on the deviation of 3 standard negative control levels for IgG ACA and based on deviations of 2.5 times from standard negative control levels for IgM ACA were better than cut off by fixed levels of ACA in producing true positive results.

The correlation between coagulation test and albumin with antithrombin III in Dengue hemorrhagic fever.

AIM: To analyse the correlation between coagulation tests (PT APTT fibrinogen, D-dimer) and albumin with AT-II in DHF as well to find the formula to calculate AT-III with the parameter of coagulation tests and albumin. METHODS: A descriptive-correlative cross sectional study was conducted to 49 patients with DHF consisted of DHF I(17), DHF (19), DHF III (6) and DHF IV (7). The diagnosis of DHF is based on WHO criteria 1997. The laboratory examinations were coagulation tests (PT, APT, fibrinogen and D-dimer), antithrombin III and albumin, performed when the fever subside and the platelets reached the lowest count(4(th) - 6(th) day). RESULTS: A significant correlation was found between PT and AT-III (r= -0.631; p=0.000), between D-dimer and AT-III (r= -0.337; p=0.021) and between albumin and AT-III (r= 0.291; p-0.045). In multiple linier regression analysis(backward), AT-III can be calculated with the formula, accuracy 68.3%. CONCLUSIONS: PT and D-dimer were correlated negatively with AT-III, however albumin was correlated positively with AT-III. PT, D-dimer and AT-III were correlated with the grading severity of the DHF. In this study, AT-III can be calculated with the formula, accuracy 68.3%.

Diagnosis of disseminated intravascular coagulation in sepsis scoring system of a thrombosis-hemostasis center.

BACKGROUND: Disseminated intravascular coagulation (DIC) is a septic complication that is not easily diagnosed. The purpose of the study is to obtain a scoring system to diagnose DIC in sepsis. SUBJECT AND METHODS: An observational study with a cross-sectional design was performed at the Department of Internal Medicine, University of Indonesia, Dr. Cipto Mangunkusumo General Hospital from February to August 2002. Subjects were septic patients in the emergency unit or inpatient ward of the Department of Internal Medicine, and were taken consecutively. The criteria of sepsis, severe sepsis and septic shock were based on ACCP/SCCM Consensus 1991. The evaluation conformed to the Thrombosis Hemostasis Center (THC) scoring system, compared with modified Bick scoring system as a gold standard. RESULTS: There were 34 subjects ranging from 19 to 78 years old, 32.4% were septic patients, 41.2% with severe sepsis and 26.5% with septic shock. The most common source of infection was pneumonia, where bacterial pathogens were found in 35.2% of blood aerobic culture and 17.7% in pus or urine culture. Gram negative bacteria was the most common pathogen found. According to a modified Bick and THC scoring system, DIC was found in all subjects, consisting of mild and moderate DIC. No severe DIC was found. There was no difference between both scoring systems, with a p value of 0.125 based on the Mc Nemar test. There was no difference found in mild and moderate DIC in sepsis, severe sepsis and septic shock of modified Bick scoring systems (p value of 0.987) and THC scoring system (p value of 1.000). CONCLUSION: No difference was found between THC and modified Bick scoring system in diagnosing DIC in septic patients. In sepsis, severe sepsis and septic shock, mild and moderate DIC complications can be diagnosed with THC scoring system, which are of the same potency with the modified Bick, with the assumption that the modified Bick scoring system was the same as the Bick scoring system.

Anti-thrombin III, Protein C, and Protein S deficiency in acute coronary syndrome.

The final most common pathway for the majority of coronary artery disease is occlusion of a coronary vessel. Under normal conditions, antithrombin III (AT III), protein C, and protein S as an active protein C cofactor, are natural anticoagulants (hemostatic control) that balances procoagulant activity (thrombin antithrombin complex balance) to prevent thrombosis. If the condition becomes unbalanced, natural anticoagulants and the procoagulants can lead to thrombosis. Thirty subjects with acute coronary syndrome (ACS) were studied for the incidence of antithrombin III (AT III), protein C, and protein S deficiencies, and the result were compare to the control group. Among patients with ACS, the frequency of distribution of AT-III with activity < 75% were 23,3% (7 of 30), and only 6,7% ( 2 of 30 ) in control subject. No one of the 30 control subject have protein C activity deficient, in ACS with activity < 70% were 13,3% (4 of 30). Fifteen out of the 30 (50%) control subjects had protein S activity deficiency, while protein S deficiency activity < 70% was found 73.3.% (22 out of 30). On linear regression, the deterministic coefficient of AT-III activity deficiency to the development ACS was 13,25 %, and the deterministic coefficient of protein C activity deficient to the development of ACS was 9,06 %. The cut-off point for AT-III without protein S deficiency expected to contribute to the development of vessel disease was 45%. On discriminant analysis, protein C activity deficiency posed a risk for ACS of 4,5 greater than non deficient subjects, and AT-III activity deficiency posed a risk for ACS of 3,5 times greater than non deficient subjects. On binary logistic regression, protein S activity acted only as a reinforcing factor of AT-III activity deficiency in the development of ACS. Protein C and AT III deficiency can trigger ACS, with determinant coefficients of 9,06% and 13,25% respectively. Low levels of protein C posed a greater risk of ACS than low levels of AT III. Protein S deficiency was a reinforcing factor on AT-III deficient to development of ACS. The cut-off point of AT-III without protein S deficiency expected to give single vessel disease was 45%, and 9,5% for the development of triple vessel disease.