Prevalence rate for inherited thrombophilia in patients with chronic and recurrent venous leg ulceration.

The aim of the study was to determine the prevalence rate for inherited thrombophilia (IT) in patients with chronic (CVU) and recurrent venous leg ulceration. We also investigated and evaluated the severity of the clinical pattern of CVU in patients with and without IT. We examined 110 patients with CVU (the study group) and 110 healthy subjects (the control group). We prepared a questionnaire to be completed by each study participant. Ultrasound Doppler color imaging or/and duplex ultrasonography was performed to evaluate the efficiency of the venous system. The ankle-brachial index was calculated to determine the efficiency of the arterial system. We examined both groups for the presence of IT. IT was diagnosed in 30% of study group and in 1.8% of control group. Our diagnoses of deep vein thrombosis (DVT) were based on medical interviews, physical examinations, and an ultrasonography of the venous system and concerned 64 study group patients (58.2%), 35 of whom (31.8%) experienced recurrent DVT. Proximal and/or distal DVT was determined in an interview and/or by an ultrasonography performed for all patients with CVU and IT. In 94% of these patients, DVT was recurrent, and in 88% of patients with CVU and IT, we observed recurrent DVT and CVU. It recurred more often and persisted longer when compared to patients with CVU and no IT, despite similar management. No differences were observed in ulcer size, localization, or pain level related to ulceration between patients with CVU and IT and those with CVU and no IT.

Perioperative bridging therapy with low molecular weight heparin for patients with inherited thrombophilia and antiphospholipid syndrome on long-term acenokumarol therapy.

The aim of the study is to present our own perioperative bridging therapy with low molecular weight heparin (LMWH) for surgical patients with thrombophilia on long-term acenokumarol therapy [oral anticoagulant (OAC)]. In some European countries, the drug used in secondary antithrombotic prophylaxis is acenokumarol. Forty-two patients with inherited thrombophilia and 21 with antiphospholipid syndrome underwent surgery. All patients were on long-term OAC. This OAC was interrupted 2 days before elective surgery and since that day half of the individual therapeutic dose of LMWH was administered. On day of surgery, the LMWH therapeutic dose was divided into two parts. Starting with day 2 after surgery, the patient was again given half of the individual dose of LMWH every 24 h. On day 4, OAC was additionally included. Both drugs were administered until stabilization of international normalized ratio (INR) values within the therapeutic target for 2 consecutive days. LMWH was then interrupted, whereas OAC continued. No symptoms or episodes of venous thromboembolism were observed. No intraoperative or postoperative hemorrhagic complications were reported. The results suggest that our perioperative bridging therapy is safe and effective for prevention of thromboembolic and hemorrhagic complications.

[Strategy for secure hemostasis in hemophilia patients undergoing surgery for malignant neoplasms]. / Strategia zapewnienia bezpiecznej hemostazy u chorych na hemofilie operowanych z powodu nowotworów zlosliwych.

UNLABELLED: Surgery for malignant neoplasms in hemophilia patients is no different from standard procedures in the general population on condition that the normal hemostatic activity of deficient factors: VIII in hemophilia A and IX in hemophilia B in perioperative period is ensured. The aim of the study was to determine the type and frequency of malignant neoplasms in hemophilia patients as well as to provide a strategy for establishing safe hemostatic activity in surgically treated hemophilia patients. MATERIAL AND METHODS: In the period 2003-2008, surgical procedures were performed on 19 hemophilia A and B patients with diagnosed malignant neoplasms of various location. The following cases were diagnosed: 9 colorectal neoplasms, 2 pancreatic carcinomas, 2 larynx carcinomas, 1 stomach carcinoma, 1 liver, 1 nasopharyngeal, 1 testicle, 1 prostate and 1 skin. Seventeen patients were hemophilia A (6 severe, 4 severe with inhibitor, including 2 high titre and 2 low titre, 1 moderate and 6 mild) and 2 were hemophilia B (1 severe, 1 moderate). Patients mean age was 55.8 years (22-82). In factor-replacement therapy for patients with no inhibitor the strategy was to maintain the activity of the deficient clotting factor VIII before the operation at 80-100% of normal value, within the 80-100% range on the 1-3 day following surgery, at 60-80% on days 4-6, at 30-60% on days 7-10 day and at 20-40% on all subsequent days until the surgical wound healed. In hemophilia B patients the levels were about 20% lower. Deficient factor was injected every 8 or 12 hours or administered in continuous intravenous infusion. In hemophilia A patients with high titre inhibitors to factor VIII (above 5 Bethesda units/ml) activated prothrombin complex concentrates (aPCC)-FEIBA (Baxter AG) were used at 50-100 U/kg b.m., every 8-12 hours. RESULTS: The nineteen patients with diagnosed malignant neoplasms (in the period 2003-2008) constituted 0.77% of the overall 2475 hemophilia patients entered into the National Registry Congenital of Hemorrhagic Diathesis. An overall number of 26 surgical procedures were performed in this group of 19 hemophilia patients including 20 procedures for malignant neoplasms and 6 for postoperative complications. All patients survived surgery. Two patients with pancreatic carcinoma died in the postoperative period due to multi-organ failure. Complications occured in 7 (37%) patients including 6 (32%) with bleeding complications: haemopneumothorax (n=1), intraperitoneal bleeding (n=2), abdominal parietal hematoma (n=1), hematuria (n=1), bleeding from esophago-pharyngo-cutaneous fistula following total laryngectomy (n=1). Other complications included: ileus (n=1), leakage of pancreato-jejunal anastomosis (n=1), dehiscence of abdominal wound (n=1) and bleeding from duodenal ulcer (n=1). These complications were successfully treated with surgery or endoscopy. CONCLUSIONS: Surgery of malignant neoplasms in hemophilia patients is burdened with a high risk of complications which include bleedings despite adequate replacement therapy and administration of factor eight by-passing concentrates in patients with high titre inhibitor. Therefore surgical procedures involving these patients should be performed in specialized centers with experienced team (surgeon, anaesthesiologist, haematologist) and supported by a laboratory for coagulation disorders.

[Small volume resuscitation for acute intraoperative haemorrhage: comparison of 7.5% saline and 6% hydroxyethyl starch]. / Porównanie wplywu przetoczen malych objetosci 7,5% roztworu NaCL lub 6% roztworu hydroksy-etylowanej skrobi na zaburzenia hemodynamiczne, morfologiczne i elektrolitowe u chorych ze sródoperacyjna, ostra utrata krwi krazacej.

BACKGROUND: The immediate effect of acute haemorrhage is a significant reduction in tissue blood flow, frequently resulting in haemorrhagic shock. The main aim of resuscitation after bleeding is the immediate restoration of intravascular volume. Intravenous administration of volume expanders should be commenced immediately, regardless of whether they are colloids or electrolytes. The purpose of the study was to analyze haemodynamic changes during intraoperative acute bleeding and to compare the effects of intravenous infusion with 7.5% saline solution to 6% starch solution on the volume resuscitation process. METHODS: Sixty adult patients, of both sexes, in whom massive loss of blood followed by rapid cardiovascular collapse occurred during elective surgery, were enrolled in the study. In addition to standard fluid transfusion, all patients received either 4 mL kg(-1) of 7.5% NaCl solution or an equal volume of 6% of hydroxyethyl starch. Heart rate (HR) and mean arterial pressure (MAP) were noted. Cardiac output (CO) and systemic vascular resistance (SVR) were measured using a descending aortic blood flow ultrasound monitor. RESULTS: Massive intraoperative haemorrhage resulted in a rapid decrease in CO and SV with a simultaneous increase in HR and SVR in all patients. Injection of hypertonic salt or 6% HAES over 5 min increased the CO and SV. HR and SVR returned quickly to pre-existing levels and remained so until the end of the procedures. CONCLUSION: Small volume resuscitation with 7.5% saline or starch can be regarded as an efficient and effective method for restoring intravascular volume.

[Isolated splenic vein thrombosis]. / Izolowana zakrzepica zyly sledzionowej.

We report the case of 61-year-old woman with isolated splenic vein thrombosis resulted from chronic pancreatitis. Left-sided portal hypertension secondary to splenic vein occlusion was responsible for development of the isolated gastric varices. The patient underwent prophylactic, successful splenectomy. Three months after splenectomy controlled endoscopy revealed disappearance of gastric varices.