Monitoring of oral anticoagulant therapy in lupus anticoagulant positive patients with the anti-phospholipid syndrome

Introduction of the International Normalized Ratio (INR) has improved the standardization of laboratory control of oral anticoagulant therapy (OAT). However, it has been reported that misleading INR results can be obtained from OAT patients with lupus anticoagulant (LA). To investigate this claim, we studied 35 OAT patients, 14 of whom had anti-phospholipid syndrome (APS) with a documented LA. Attainment of anticoagulation was confirmed by chromogenic assay of factor VII and factor X. Prothrombin times were performed using eight thromboplastins (five derived from rabbit brain, two recombinant human tissue factor and one made from human placenta) with an International Sensitivity Index (ISI) of <1.40. When using the thromboplastin manufacturers' ISI there was a significant difference (ANOVA, P<0.0001) between INR results obtained with the eight reagents for both APS (average CV = 12.4%) and non-APS (average CV = 12.5%) patient groups. Variation using the eight thromboplastins was assessed by calculating the CV for each sample; these values were then pooled for each patient group to give the average CV for all samples with all reagents for the two patient groups. Results for both patient groups exhibited markedly reduced variation (APS group average CV = 6.5%, non-APS group average CV = 5.8%) when locally assigned ISI values were employed in the calculation of INRs. Our data does not support the suggestion that the INR may not reflect the true level of anticoagulation in the long-term warfarin-treated patient, in whom lupus anticoagulant was detected. However, there was strong evidence that thromboplastin use should be restricted to those clot detection systems for which the reagent's manufacturer has assigned an ISI, or local ISI assignment must be undertaken. The inappropriate use of a generic (i.e. optical or mechanical clot detection system without regard to specific analyser type) ISI value can lead to ambiguous results.     

Spinal para-medullary conduction anesthesia in therapy with anticoagulant drugs]

Epidural and spinal blocks can lead to iatrogenic bleeding in the spinal canal. Incidence of this severe complication is considered low, but the risk of irreversible neurological defects for the patient requires increased attention by the anaesthetist. The perioperative risk is higher in patients under anticoagulant therapy. The different pharmacodynamics and pharmacokinetics of practically relevant anticoagulants are discussed and recommendations for the performance of centroneuraxis blocks in patients under anticoagulant therapy are given.     

Femoral neuropathy complicating anticoagulant therapy

Recoveries of Streptococcus mutans from human dental plaque were lower when plated on mitis-salivarius agar obtained from Baltimore Biological Laboratories as compared with mitis-salivarius agar obtained from Difco Laboratories. However, no difference in recoveries of established laboratory strains of S. mutans was observed between these two agar preparations.     

Thrombophilia, anticoagulant therapy and pregnancy

Thromboembolic complications during pregnancy are the most common causes of maternal death. Here we report on thromboembolic prophylaxis of 60 pregnancies of 32 pregnant women with familial thrombophilia. Long-term Fraxiparine (Sanofi-Chinoin) as thromboprophylaxis was applied in 26 cases throughout pregnancy. UFH (Heparin-Ca inj.) was used in 11 cases, and there were 23 pregnancies without thromboembolic prophylaxis in our patient's case histories. Artificial abortions were not included in this paper. The ratio of successful pregnancies were: with Fraxiparine: 24/26 (92.3%), with UFH (Heparin-Ca): 8/11 (72.7%), without prophylaxis: 4/23 (17.4%). In the patient group treated with Fraxiparine there were no foetopathy, thrombocytopenia or bleeding complication. LMWH is recommended for pregnant women with familial thrombophilia. According to literature data and our own experiences the doses of LMWH in patients with familial thrombophilia, and -antiphospholipid syndrome, and -artificial heart value are suggested.     

Self management of peroral anticoagulant therapy in patients with artificial heart valves

Twenty-one heart valve operated patients (age 19-70 years) were trained in self-managed oral anticoagulant therapy using a home coagulometer (CoaguChek). Twenty patients accomplished between eight and 29 (median 24) months of self management and were fully capable of self management after 30 weeks of training. No patients experienced major bleeds or thrombo-embolic events. A control group of 20 patients from our department was matched, retrospectively, to the study group. The self-managing patients were within the therapeutic INR range 78% of the study period compared to 54% for the control patients. All self-managing patients had their median INR-value within the therapeutic range, versus only 14 in the control group. Self-management of oral anticoagulant therapy seems feasible for selected patients.     

Complications in connection with venous port systems: prevention and therapy

OBJECTIVE: To assess the effects of graded intramedullary reaming and nailing on the healing pattern of segmental diaphyseal fractures using male Wistar rats. STUDY DESIGN: In male Wistar rats we produced two standardized, partial osteotomies with an eight-millimeter intermediary fragment in the femoral diaphysis. The osteotomies were subsequently manually broken. In Group A, intramedullary reaming was performed to 1.6 millimeters, and the fracture was stabilized with a 1.6-millimeter steel pin. In Group B, the femoral canal was reamed to 2.0 millimeters, and a hollow steel tube of 2.0 millimeters was installed. The rats were allowed free movement. After four, eight, and twelve weeks, eight rats in each group were sacrificed and callus formation, biomechanical properties, and bone blood flow were evaluated. RESULTS: The callus area was relatively constant with time in Group B, whereas a reduction was observed in Group A at twelve weeks. The biomechanical properties increased throughout the experimental period in both groups, and no significant differences between the groups were detected in bending moment, bending rigidity, or fracture energy. Total bone blood flow was substantially increased at four weeks in both groups and decreased throughout the experimental period. In addition, blood flow of the segmental fractured area was substantially increased after four weeks and decreased gradually thereafter. The increases in blood flow tended to be largest in the moderately reamed group. CONCLUSION: This study indicates that the degree of reaming does not significantly affect the healing pattern measured as restoration of mechanical characteristics.     

Complications of growth hormone therapy in children

The introduction of human growth hormone (GH) prepared by recombinant DNA technology has resulted in increased numbers of children and adults receiving treatment. This trend has led to questions concerning the safety of GH, particularly when used for indications other than GH deficiency. This review discusses the effects of GH on fluid, lipid, and carbohydrate metabolism; the risk of intracranial hypertension or pseudotumor cerebri; the effects on the skeletal system; the risk of malignancy; and the effects on the immune system. At present, GH treatment appears to be safe, although long-term follow-up of GH-treated patients is necessary.     

Complications and adverse effects of laser therapy in patients with suppurative-septic diseases

The complications and side-effects of laser therapy in 229 patients with septic-purulent diseases were analyzed. Metal taste in oral cavity, sleepiness, vertigo, weakness, sense of heat were the most frequently occurring side-effects of laser therapy observed.     

Treatment of the patient receiving Coumadin anticoagulant therapy

Minimizing the risk of bleeding as well as the risk of thromboembolism in dental patients being treated with anticoagulants is a common challenge for practitioners. This article features tips on evaluating and managing these patients.     

Complications of "slow-K" therapy

(1) The failure of ;Slow-K' tablets to disintegrate prevents rapid release but allows them to be trapped by their bulk in the intestine.(2) Two cases are reported. In the first the tablet was trapped in a caecal diverticulum and the patient developed an abcess. In the second, abdominal pain developed which subsided when ;Slow-K' was stopped. Later ;Slow-K' was again started and the patient developed dysphagia.(3) The possibility of abdominal complications with this treatment should be remembered.(4) Effervescent KC1 preparations may replace ;Slow-K' but KC1 supplementation may be necessary only in cardiac disease.     

The possibilities and dangers of longterm infusion therapy in severely ill newborn and premature infants

The development of pediatric intensive medicine in the past 10 years has today made it possible to carry out specific longterm infusion therapy even in severely ill newborn and premature infants. The present study discusses the various technical possibilities and indications for the introduction of a caval catheter in newborn and premature infants. Although we only used a caval catheter for longterm parenteral nutrition in 9 newborn infants from 1965 to 1969, improved techniques have enabled us over the past 2 years to choose this method in 43 newborn and premature infants presenting with a wide variety of clinical conditions. We conclude that the use of caval catheters still requires a very strong indication.