To determine the risk of mechanical vessel wall damage resulting in hemorrhage during and after hepatic and renal histotripsy in an anticoagulated in vivo porcine model.
Non-tumor-bearing pigs (n = ...8; mean weight, 52.5 kg) were anticoagulated with warfarin (initial dose, 0.08 mg/kg) to a target prothrombin time (PT) of 30%-50% above baseline. A total of 15 histotripsy procedures were performed (kidney: n = 8, 2.0-cm sphere; liver: n = 7, 2.5-cm sphere). Treatments were immediately followed by computed tomography (CT) imaging. Animals were observed for 7 days while continuing anticoagulation, followed by repeat CT and necropsy.
All animals survived to complete the entire protocol with no signs of disability or distress. Three animals had hematuria (pink urine without clots). Baseline PT values (mean, 16.0 seconds) were elevated to 22.0 seconds (37.5% above baseline, P = .003) on the day of treatment and to 28.8 seconds (77.8% above baseline, P < .001) on the day of necropsy. At the time of treatment, 5 of 8 (63%) animals were at a therapeutic anticoagulation level, and all 8 animals (100%) reached therapeutic levels by the time of necropsy. There were no cases of intraparenchymal, peritoneal, or retroperitoneal hemorrhage associated with any treatments despite 5 of 7 (71%) liver and all 8 (100%) kidney treatments extending to the organ surface.
Liver and kidney histotripsy seems safe with no elevated bleeding risk in this anticoagulated animal model, supporting the possibility of histotripsy treatments in patients on anticoagulation.
We report a patient with hereditary erythrocytosis who underwent a therapeutic phlebotomy and had a post-phlebotomy hematocrit that was higher than the pre-phlebotomy hematocrit. We could not discern ...a reason for this hematocrit increase after phlebotomy. Instead of performing another phlebotomy, we performed an automated red cell depletion via an apheresis instrument. This procedure is essentially a red cell exchange, but 5% albumin is used as the replacement fluid instead of red blood cells. The patient’s hematocrit decreased from 80% to 39% after three consecutive daily red cell depletion procedures. We share our experience to report the unusual finding of a patient’s hematocrit that increased with phlebotomy and to raise awareness of the red cell depletion procedure.
Coagulation concepts update O'Connor, Stacy D; Taylor, Andrew J; Williams, Eliot C ...
American journal of roentgenology (1976),
12/2009, Letnik:
193, Številka:
6
Journal Article
Recenzirano
Since the previous comprehensive radiology review on coagulation concepts that was done in 1990, many studies have been published in the medical and surgical literature that can guide the approach of ...a radiology practice. The purpose of this article is to provide an analysis of these works, updating the radiologist on proper use and interpretation of coagulation assessment tools, medications that modify the hemostatic system, and the use of transfusions prior to interventions.
The basic tools for coagulation assessment have not changed; however, results from subspecialty research have suggested ways in which the use of these tools can be modified and streamlined to safely reduce time and expense for the patient and the health care system.
Background
Acquired hemophilia A (AHA) is an uncommon coagulation disorder caused by the development of autoantibodies against coagulation factor VIII (FVIII). While intracranial hemorrhage is a ...known complication of AHA, intracranial hemorrhage as the presenting manifestation of AHA has only been described in three previous case reports.
Method
We report a case of an 86-year-old woman with no previously reported history of coagulopathy presenting with an acute intraparenchymal cerebellar hemorrhage and laboratory studies demonstrating an isolated prolonged activated partial thromboplastin time (aPTT). We discuss an approach to the prolonged aPTT, and review the literature concerning the diagnosis and treatment of AHA.
Results
Occipital decompressive craniectomy with evacuation of the hemorrhage was performed. Eight hours following the procedure, the patient’s status acutely declined with demonstration of a reoccurrence of the cerebellar hemorrhage and new right frontal lobe hemorrhage. After discussion with the patient’s family, life-sustaining support measures were withdrawn. Postmortem analysis revealed a low FVIII activity level and the presence of FVIII inhibitor.
Conclusion
The presentation of intracranial hemorrhage with an isolated prolonged aPTT is concerning for an acquired hemophilia with FVIII deficiency. Other causes of isolated prolonged aPTT such as a lupus anticoagulant must also be considered. Preoperative identification and work-up of the coagulation abnormality is essential to guide initial treatment.
The augmented Berlin-Frankfurt-Münster (aBFM) regimen has demonstrated improved outcomes in children with acute lymphomblastic leukemia (ALL), but efficacy in adults is unknown. In this retrospective ...study, we evaluated clinical outcomes in 29 adult ALL patients (aged 19-70) treated with standard BFM (sBFM) or dose-intensive aBFM. Patients were stratified into risk groups based on age, cytogenetic abnormalities, peripheral leukocytosis and response to induction chemotherapy. Inter-mediate risk patients less than 50 years old and all high-risk patients were assigned to aBFM. Complete remission after induction therapy was achieved in 93% of patients. Fifteen patients completed a full course of BFM chemotherapy, with seven discontinuing because of relapse, three because of toxicity, two because of transplantation and two toxic deaths. Five-year event-free survival (EFS) was 45% (95% CI 30-67%), with 39% and 50% rates of EFS observed in the aBFM and sBFM subgroups at 5 years, respectively. Overall survival at 5 years was 62% (95% CI 46-82%), with 61% and 62% in the aBFM and sBFM subgroups alive at 5 years, respectively. Two toxic deaths were observed, and infections and neuropathy were the most common toxicities. sBFM and aBFM have efficacy and toxicity comparable with other adult ALL regimens.
Abstract
Introduction
Rivaroxaban, a factor Xa inhibitor, is a novel oral anticoagulant that was approved in 2011 as an alternative to warfarin for stroke prevention in atrial fibrillation. Although ...thrombocytopenia induced by novel oral anticoagulant therapy in general is reported relatively infrequently, in a recent trial comparing warfarin to rivaroxaban, thrombocytopenia was reported in 3 of 1,280 patients (0.2%) on rivaroxaban. We report an exceptionally rare case of fatal intracranial hemorrhage caused by acute thrombocytopenia while anticoagulated on rivaroxaban.
Case Study
A 72-year-old man, who was on rivaroxaban (20 mg/d) for nonvalvular atrial fibrillation, was admitted to our hospital for sudden-onset left-sided hemiparesis. Cranial imaging revealed intraparenchymal hemorrhage and initial laboratory coagulation parameters showed a platelet count of 5 K/µL with an INR of 1.8; 6 months previously, his platelet levels had been normal. He was treated with platelets, vitamin K, and factor 7. His brain bleeding progressed on imaging despite aggressive blood product replacement. Thromboelastogram was consistent with thrombocytopenia but negative for other coagulation abnormalities. Other possible etiologies for thrombocytopenia were investigated without success. At autopsy, the patient had diffuse cutaneous and mucosal petechial hemorrhage. Neuropathologic examination showed two hemorrhagic foci with one occupying approximately 90% of the right frontoparietal white matter, extending into subarachnoid and subdural spaces, and the other seen in right temporoparietal white matter (2.3 cm). Transtentorial herniation was evident.
Discussion
Life-threatening bleeding is very rare in patients on rivaroxaban. Thrombocytopenia during the administration of rivaroxaban, however, can increase the risk of intracranial hemorrhage. Reversal of rivaroxaban in cases of hemorrhage can be challenging; prothrombin complex concentrates may not result in effective hemostasis. Clinicians are advised to carefully monitor platelet levels after initiating rivaroxaban or other novel oral anticoagulant therapy. Autopsy can be an important means of excluding other competing causes of thrombocytopenia/hemorrhage and establishing risk factors.
High-dose granulocyte transfusion therapy has been available for 20 years, yet its clinical efficacy has never been conclusively demonstrated. We report here the results of RING (Resolving Infection ...in Neutropenia with Granulocytes), a multicenter randomized controlled trial designed to address this question. Eligible subjects were those with neutropenia (absolute neutrophil count <500/μL) and proven/probable/presumed infection. Subjects were randomized to receive either (1) standard antimicrobial therapy or (2) standard antimicrobial therapy plus daily granulocyte transfusions from donors stimulated with granulocyte colony-stimulating factor (G-CSF) and dexamethasone. The primary end point was a composite of survival plus microbial response, at 42 days after randomization. Microbial response was determined by a blinded adjudication panel. Fifty-six subjects were randomized to the granulocyte arm and 58 to the control arm. Transfused subjects received a median of 5 transfusions. Mean transfusion dose was 54.9 × 109 granulocytes. Overall success rates were 42% and 43% for the granulocyte and control groups, respectively (P > .99), and 49% and 41%, respectively, for subjects who received their assigned treatments (P = .64). Success rates for granulocyte and control arms did not differ within any infection type. In a post hoc analysis, subjects who received an average dose per transfusion of ≥0.6 × 109 granulocytes per kilogram tended to have better outcomes than those receiving a lower dose. In conclusion, there was no overall effect of granulocyte transfusion on the primary outcome, but because enrollment was half that planned, power to detect a true beneficial effect was low. RING was registered at www.clinicaltrials.gov as #NCT00627393.
•Overall, no benefit of granulocyte transfusion therapy was observed, but the power of the study was reduced due to low accrual.•Post hoc secondary analysis suggested that patients receiving higher doses tended to have better outcomes than those receiving lower ones.
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