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PubMedDate not supplied

Antithrombotic strategy after total hip replacement. A cost-effectiveness analysis comparing prolonged oral anticoagulants with screening for deep vein thrombosis.

BACKGROUND: Deep vein thrombosis (DVT) in the lower limbs is a major postoperative complication in patients undergoing total hip replacement. However, even with the most effective perioperative antithrombotic prophylactic methods, its incidence at the time of hospital discharge remains as high as 15 to 25. METHODS: We used a decision analysis model to determine the clinical and economic effects of the following interventions: (1) stopping prophylactic antithrombotic therapy after the in-hospital perioperative period (7-14 days), (2) extending prophylactic antithrombotic therapy with oral anticoagulants up to 6 weeks or 3 months, and (3) screening for DVT at the time of hospital discharge by compression ultrasonography or venography. We measured for a hypothetical cohort of 10 000 patients the risk of developing recurrent DVT and symptomatic pulmonary embolism, the risk of major bleeding complications, and the costs associated with each strategy. Data were drawn from the published literature (MEDLINE search) and from our hospital cost manager. RESULTS: Compared with stopping prophylaxis at the time of hospital discharge, a 6-week course of prophylactic oral anticoagulant therapy would reduce the number of cases of recurrent DVT from 1172 to 493 and the number of symptomatic pulmonary embolisms from 234 to 99, and would be less costly. This gain would be achieved at the cost of 29 major bleeding complications if the bleeding risk is low (0.2 per month) and 71 if the bleeding risk is moderate (0.5 per month). Compared with stopping prophylaxis at discharge, ultrasound screening would reduce symptomatic pulmonary embolisms from 234 to 142, induce only 13 major bleeding episodes, and be cost-effective, with marginal costs per additional pulmonary embolism averted ranging from $3000 to $7000, depending on ultrasound sensitivity. Venography screening would be the most effective strategy; however, compared with ultrasound, its marginal costs per additional pulmonary embolism averted would exceed $80 000. CONCLUSIONS: After hip replacement with conventional perioperative antithrombotic prophylaxis, oral anticoagulation administered for 6 weeks is effective in preventing recurrent DVT and symptomatic pulmonary embolism, unless the bleeding risk is very high. Moreover, this strategy is less costly compared with stopping antithrombotic prophylaxis at the time of hospital discharge. Alternatively, ultrasound screening is also effective, minimizes the risks of bleeding, and has a low marginal cost-effectiveness ratio.

Administration, Oral↗

PubMed2026

Clinical and genetic features of Ph-negative myeloproliferative neoplasms with dual-driver gene positivity.

OBJECTIVES: To investigate the clinical laboratory characteristics and gene mutation features of dual-driver gene positivity in patients with Philadelphia chromosome-negative myeloproliferative neoplasm (Ph-negative MPN). METHODS: We conducted a retrospective analysis of clinical data and genetic test results from 203 newly diagnosed patients with Ph-negative MPN. Of these, 194 had single-driver gene positivity and 9 had dual-driver gene positivity. High-throughput sequencing was used to detect mutations in JAK2, CALR, and MPL. Clinical characteristics and gene mutation profiles were compared between the two patient groups. RESULTS: The incidence of dual-driver gene positivity was 4.4% (9/203), with the most common combinations being JAK2 with CALR (4 patients) and JAK2 with MPL (4 patients). Compared with the single-driver group, the dual-driver group had a significantly higher risk of bleeding [4.1% (8/194) vs. 33.3% (3/9), P = 0.008] and a higher proportion of uncommon mutations [3.6% (7/194) vs. 33.3% (3/9), P = 0.006]. No statistically significant differences were observed between the two groups regarding age, thrombosis incidence, splenomegaly, or routine blood test indicators. During follow-up, 1 patient in the dual-driver group died from cerebrovascular disease. No leukaemia transformation or disease-related deaths occurred among the remaining patients. DISCUSSION: The increased bleeding risk in dual-driver patients may be related to a higher proportion of CALR mutations, elevated platelet counts, and higher variant allele frequencies, though these findings require validation in larger cohorts due to the small sample size. The higher prevalence of uncommon mutations suggests a more complex mutational landscape in this subgroup. CONCLUSION: Patients with Ph-negative MPN and dual-driver gene positivity may have a higher risk of bleeding and a more complex gene mutation profile.

Humans↗

PubMed2000

Heparin-induced thrombocytopenia with thromboembolic complications: meta-analysis of 2 prospective trials to assess the value of parenteral treatment with lepirudin and its therapeutic aPTT range.

This meta-analysis focuses on 2 prospective studies in patients with heparin-induced thrombocytopenia (HIT) and thromboembolic complication (TEC) who were treated with lepirudin (n = 113). Data were compared with those of a historical control group (n = 91). The primary endpoint (combined incidence of death, new TEC, and limb amputation) occurred in 25 lepirudin-treated patients (22.1%; 95% CI, 14.5%-29.8%): 11 died (9.7%; 95% CI, 4.9%-16.8%), 7 underwent limb amputation (6.2%; 95% CI, 2.5%-12.3%), and 12 experienced new TEC (10.6%; 95% CI, 5.8%-18.3%). The risk was highest in the period between diagnosis of HIT and the start of lepirudin therapy (combined event rate per patient day 6.1%). It markedly decreased to 1.3% during lepirudin treatment and to 0.7% in the posttreatment period. From the start of lepirudin therapy to the end of follow-up, lepirudin-treated patients had consistently lower incidences of the combined endpoint than the historical control group (P =.004, log-rank test), primarily because of a reduced risk for new TEC (P =. 005). Thrombin-antithrombin levels in the pretreatment period (median, 43.9 microg/L) decreased after the initiation of lepirudin (at 24 hours +/- 6 hours; median, 9.18 microg/L.) During treatment with lepirudin, aPTT ratios of 1.5 to 2.5 produced optimal clinical efficacy with a moderate risk for bleeding, aPTT ratios lower than 1. 5 were subtherapeutic, and aPTT levels greater than 2.5 were associated with high bleeding risk. Bleeding events requiring transfusion were significantly more frequent in patients taking lepirudin than in historical control patients (P =.02). In conclusion, this meta-analysis provides further evidence that lepirudin is an effective and acceptably safe treatment for patients with HIT.

Aged↗

PubMed2006

Safety of citrate based hemofiltration in critically ill patients at high risk for bleeding: a comparison with nadroparin.

PURPOSE: To study the incidence and severity of bleeding in high risk critically ill patients during high volume, citrate based continuous veno-venous hemofiltration (CVVH). DESIGN: A prospective 1-year observational cohort study comparing citrate based CVVH with nadroparin based CVVH. PROCEDURES: Critically ill patients with multiple organ dysfunction and in need of CVVH were observed for bleeding complications during their CVVH sessions. Pre-defined criteria determined that patients were treated with citrate based CVVH in case of active bleeding or increased risk for bleeding. Otherwise nadroparin was used as anticoagulant. Statistical and outcome methods: The incidence of bleeding complications, the number of transfused blood cell concentrates and the filter-run-time were recorded. Analyses were made by non-parametric tests. MAIN FINDINGS: Fifty-five patients received 272 CVVH sessions. In the citrate group 14.8% experienced a bleeding complication compared to 25% in the nadroparin group (p=0.04). The number of transfused red blood cell concentrates was not different between groups. The nadroparin group had a longer filter run time (median 31.5 hours versus 22.5 hours, p=0.0001). CONCLUSIONS: In high risk critically ill patients citrate based anticoagulation for CVVH is safe in terms of bleeding complications and transfusion requirements.

Anticoagulants↗

PubMed1986

Does large spontaneous portal systemic shunt in cirrhosis protect from the risk of gastroesophageal bleeding?

The risk of gastroesophageal bleeding in cirrhotic patients with massive spontaneous portosystemic shunt (SPSS) has been evaluated variously in the literature. We undertook a retrospective study in a large group of cirrhotic patients admitted to our surgical department to evaluate the incidence of large SPSS and the correlation with current or previous episodes of gastroesophageal hemorrhage. Of 456 patients submitted to splenoportography or celiac-mesenteric angiography, 20 showed evidence on the roentgenograms of large self-established SPSS. They were classified into three groups: (a) splenorenal shunts (three patients); (b) mesenteric-caval shunts (two patients), and (c) large patent umbilical vein (15 patients). Twelve of these 20 patients had one or more episodes of gastrointestinal bleeding, and seven of them were submitted to surgical treatment to prevent recurrent bleeding. No correlation was found between the risk of esophageal hemorrhage and the type of SPSS. We concluded that, despite the presence of massive SPSS, cirrhotic patients have an unpredictable risk of bleeding and they often require surgical treatment to prevent recurrent episodes.

Collateral Circulation↗

PubMed1988

Epoprostenol (PGI2, prostacyclin) during high-risk hemodialysis: preventing further bleeding complications.

The frequency of hemodialysis-associated hemorrhage was studied prospectively in two successive, parallel, heparin-controlled studies using epoprostenol (PGI2; average dose, 4.1 ng/kg.min) as the sole antithrombotic agent. Sixty-three patients with active or recently active bleeding underwent 163 hemodialysis treatments in each of which prospective bleeding risk was assessed. PGI2 was associated with up to 50% overall reduction in the frequency of bleeding, particularly in the highest risk circumstances. PGI2 also allowed successful completion of the full, prospectively prescribed hemodialysis time in the most treatments (82% versus 93% with heparin). Furthermore, the efficiency of hemodialysis using PGI2, as indicated by the reduction in concentration of blood urea nitrogen and serum creatinine, was equal to that using heparin, even though there was a tendency toward modest reduction in residual volume of the hollow fiber dialyzer and slightly more frequent early termination of treatment from dialyzer clotting with PGI2. No severe vasodilatory side effects of PGI2 were observed during these studies. Hypotension was equally frequent during hemodialysis with heparin as with PGI2. The current results suggest that PGI2 should be considered as a substitute for heparin during high-risk hemodialysis because PGI2 may reduce the incidence of dialysis-associated bleeding without severe adverse side effects.

Adolescent↗

PubMed2006

The risk of bleeding in thrombocytopenic patients with acute myeloid leukemia.

BACKGROUND AND OBJECTIVES: Patients with acute myeloid leukemia are at risk of bleeding. The risk factors for different severities of bleeding are poorly studied. DESIGN AND METHODS: Data from Rebulla et al. were analyzed in an exploratory analysis using multivariate Cox regression analyses for time-to-first bleed with time-depend- ent covariates reflecting measures of clinical and laboratory variables on the previous day. The relationships of the variables with three bleeding categories were studied: mild bleeding (WHO grades 1 and 2) clinically significant (bleeding grades 2, 3 and 4) and severe (bleeding grades 3 and 4). RESULTS: Bleeding of any severity occurred in 149 (58.4%) of 255 patients. There were 743 days of bleeding over 7335 patient-days of observation. Risk factors for mild bleeding included increased body temperature and decreased platelet count; the risk was decreased with administration of antifungal medication or platelet transfusion on the previous day. Risk factors for clinically significant bleeding included grade 1 bleeding on the previous day, decreased platelet count and elevated body temperature. Decreased platelet count and mild bleeding on the previous day were risk factors for severe bleeding. Higher hemoglobin values were associated with a delay in the time-to-first clinically significant bleed. INTERPRETATION AND CONCLUSIONS: These results support clinical guidelines for increasing the platelet transfusion threshold in the presence of fever and support the use of milder bleeding symptoms as an outcome in clinical trials. The suggestion that hemo- globin concentration maybe predictive of bleeding risk supports the hypothesis that this maybe a valuable intervention in anemic thrombocytopenic patients at high risk of bleeding.

Adolescent↗

PubMed2005

Management options for thrombophilias.

Thrombophilias may be inherited or acquired, continuing or transient, and may contribute strongly or weakly to thrombosis. They may predispose to venous thromboembolism alone or also to artery occlusion. Advice on management must recognize these variations. The presence of an inherited thrombophilia should not alter the intensity of anticoagulant therapy, given that antithrombin, protein C, or protein S deficiency, factor V Leiden, and the prothrombin G20210A mutation are not unusually anticoagulant resistant. However, they can increase the optimal treatment duration after a first thromboembolic event. Optimal duration depends on the balance between thrombosis risk off treatment and bleeding risk during extended anticoagulant therapy, and needs to be separately estimated for each individual with thrombosis and thrombophilia. The higher the thrombosis risk and the lower the bleeding risk, the longer the optimal treatment duration. This balance favors continued (but perhaps not indefinite) therapy in antithrombin, protein C, and protein S deficiency, and perhaps also in patients with the factor V Leiden or prothrombin mutations if their bleeding risk is low. Thrombosis that complicates active malignancy, the antiphospholipid syndrome, or heparin-induced thrombocytopenia needs special consideration: recent clinical trials suggest that low molecular weight heparins are more effective than warfarin in thrombosis with cancer, and that a more intense warfarin effect is not needed for patients with antiphospholipid syndrome and thrombosis. Debate continues about the place of screening for presymptomatic but affected relatives of patients with thrombosis and an inherited predisposition. It is essential that any family testing be done only with the informed consent of all concerned. Given consent, there is general support for family testing in antithrombin, protein C, or protein S deficiency and where the factor V Leiden or prothrombin mutation is strongly penetrant and expressed. There is, however, a strong argument that any testing in families in which clotting factor polymorphisms are weakly expressed should be restricted to young women when they consider hormonal contraception or pregnancy, given that these acquired factors multiply the risk.

Anticoagulants↗

PubMed2006

Which patients taking SSRIs are at greatest risk of bleeding?

For patients at high risk of abnormal bleeding, consider prescribing an antidepressant with low serotonin reuptake inhibition, which may lower risk. For patients taking high-serotonin reuptake inhibition antidepressants, recommend avoidance or minimal use of nonsteroidal anti-inflammatory drugs and aspirin.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1993

Nafamostat mesilate: a regional anticoagulant for hemodialysis in patients at high risk for bleeding.

107 hemodialysis patients at high risk for intradialytic bleeding due to previous surgery or active bleeding from other sites were treated with nafamostat mesilate (FUT-175; FUT) as hemodialysis anticoagulant for 2 weeks. In contrast to heparin. FUT prolonged clotting times only in the extracorporeal circuit. Clotting times were not prolonged even at the conclusion of the treatment, and bleeding from the puncture site after removal of the needle was shorter than with heparin. The exacerbation of bleeding by hemodialysis was noted in only 21 out of 573 hemodialysis procedures (3.7%), and 134 of 145 hemodialysis procedures (92.4%) with active bleeding were successfully completed without increasing the bleeding. Adverse effects of FUT were noted in only 6 cases (5.6%) or 1.2% of HD procedures. These results indicate that FUT is a very useful anticoagulant for HD, especially in patients with high risk of bleeding.

Aged↗

PubMedDate not supplied

Atrial fibrillation in the elderly: anticoagulation strategies and indications in the very elderly.

With increasing life expectancy and the older mean age of the general population, the prevalence of atrial fibrillation is likely to increase, making this arrhythmia an even more important public health problem, especially in the elderly. While atrial fibrillation is increasingly common in the elderly, paradoxically, the data on intervention trials in atrial fibrillation among the elderly are limited. When considering anticoagulation in the elderly patient with atrial fibrillation, the following five questions should be addressed. 1) Is there a definite indication (for example, atrial fibrillation plus risk factor[s])? 2) Is there a high risk of bleeding or strong contraindication against anticoagulation? 3) Will concurrent medication or disease states significantly increase bleeding risk or interfere with anticoagulation control? 4) Is drug compliance and attendance at anticoagulant clinic for monitoring likely to be a problem? 5) Will there be regular review of the patient, especially with regard to risks and benefits of anticoagulation? Careful and continuing evaluation of the elderly patient with atrial fibrillation is necessary to ensure that the risks of bleeding do not outweigh the benefits from anticoagulation.

Age Factors↗

PubMed2004

The risk of bleeding complications in patients with cytochrome P450 CYP2C92 or CYP2C93 alleles on acenocoumarol or phenprocoumon.

The principal enzyme involved in coumarin metabolism is CYP2C9. Allelic variants of CYP2C9, CYP2C9*2 and CYP2C9*3, code for enzymes with reduced activity. Despite increasing evidence that patients with these genetic variants require lower maintenance doses of anticoagulant therapy, there is lack of agreement among studies on the risk of bleeding and CYP2C9 polymorphisms. It was, therefore, our objective to study the effect of the CYP2C9 polymorphisms on bleeding complications during initiation and maintenance phases of coumarin anticoagulant therapy. The design of the study was a population-based cohort in a sample of the Rotterdam Study, a study in 7,983 subjects. All patients who started treatment with acenocoumarol or phenprocoumon in the study period from January 1, 1991 through December 31, 1998 and for whom INR data were available were included. Patients were followed until a bleeding complication, the end of their treatment, death or end of the study period. Proportional hazards regression analysis was used to estimate the risk of a bleeding complication in relation to CYP2C9 genotype after adjustment for several potentially confounding factors such as age, gender, target INR level, INR, time between INR measurements, and aspirin use. The effect of variant genotype on bleeding risk was separately examined during the initiation phase of 90 days after starting therapy with coumarins. The 996 patients with analysable data had a mean follow-up time of 481 days (1.3 years); 311 (31.2%) had at least 1 variant CYP2C9 allele and 685 (68.8%) had the wild type genotype. For patients with the wild type genotype, the rate of minor bleeding, major bleeding and fatal bleeding was 15.9, 3.4 and 0.2 per 100 treatment-years, respectively. For patients with a variant genotype, the rate of minor, major and fatal bleeding was 14.6, 5.4 and 0.5 per 100 treatment-years. Patients with a variant genotype on acenocoumarol had a significantly increased risk for a major bleeding event (HR 1.83, 95% CI: 1.01-3.32). During the initiation phase of therapy we found no effect of variant genotype on bleeding risk. In this study among outpatients of an anticoagulation clinic using acenocoumarol or phenprocoumon, having a variant allele of CYP2C9 was associated with an increased risk of major bleeding events in patients on acenocoumarol, but not in patients on phenprocoumon. Although one might consider the assessment of the CYP2C9 genotype of a patient for dose adjustment before starting treatment with acenocoumarol, a prospective randomised trial should demonstrate whether this reduces the increased risk of major bleeding events.

Acenocoumarol↗

PubMed1996

Molecular biology of plasminogen activators: what are the clinical implications of drug design?

The initial work on thrombolytic therapy for acute myocardial infarction (AMI) focused on intracoronary administration of streptokinase. Continuing research has given rise to the development of both second- and third-generation agents and consequent refinements in thrombolytic regimens. Intravenous recombinant tissue plasminogen activator (t-PA, or alteplase) proved superior to both intracoronary and intravenous streptokinase with regard to reperfusion efficacy and impact on survival. An accelerated dosage regimen was later devised to allow the administration of t-PA over a shorter period of time. Unfortunately, t-PA failed to lessen the risk of bleeding complications that had plagued the use of streptokinase. The wild-type t-PA molecule has since been modified in an attempt to achieve improved lytic characteristics with less bleeding risk. Among these third-generation agents is reteplase (r-PA); compared with alteplase, reteplase has a prolonged half-life and seems to offer more rapid thrombolysis. Promising results have been obtained in large, randomized trials of reteplase. Another new agent is the TNK mutant of t-PA, which also has a prolonged half-life and seems to produce more rapid and complete thrombolysis, as well as less risk of intracranial bleeding than with alteplase in animal models. Although large, randomized trials have not yet been conducted, encouraging results have emerged from preliminary dose-ranging trials with TNK. A third new agent, n-PA, has an even longer half-life and has shown improved lytic activity in animal models. A dose-ranging trial of n-PA is currently under way. Despite the fact that each of the third-generation drugs has shown considerable potential with regard to improving the efficacy of thrombolytic therapy, the risk of intracranial bleeding remains problematic and will need to be assessed in large, randomized trials.

Animals↗

PubMed2003

Screening for the risk for bleeding or thrombosis.

BACKGROUND: Numerous tests are available to assess patient risk for bleeding or thrombosis. Appropriate use of these tests must involve consideration of the clinical setting, disease prevalence, performance characteristics of the tests, cost, and consequences of false-positive and false-negative results. PURPOSE: To summarize information about coagulation testing in three common clinical settings: nonsurgical hospitalized patients, surgical patients, and patients having a first venous thromboembolic event. DATA SOURCES: All English-language studies identified in searches of MEDLINE (1966 to April 2002) and reference lists of key articles. STUDY SELECTION: All published studies of blood coagulation testing as routine diagnostic tests or in the preoperative care of patients reporting postoperative bleeding complications, and all published studies of patients with the factor V Leiden mutation reporting venous thromboembolic outcomes. DATA EXTRACTION: 5 observational studies of routine coagulation testing in nonsurgical hospitalized patients and 12 observational studies of preoperative coagulation testing, from which both sensitivity and specificity could be calculated. DATA SYNTHESIS: Test performance characteristics for the partial thromboplastin time in predicting postoperative hemorrhage were pooled by type of surgery. Likelihood ratios for positive and negative results were calculated for each group; 95% confidence intervals were calculated. Patients with prolonged partial thromboplastin times did not have a statistically significantly increased risk for postoperative complications. CONCLUSION: For nonsurgical and surgical patients without synthetic liver dysfunction or a history of oral anticoagulant use, routine testing has no benefit in assessment of bleeding risk. Routine testing after a first episode of venous thromboembolism is not recommended for most patients.

Blood Coagulation Tests↗

PubMed2004

Hemodialysis using heparin-bound Hemophan in patients at risk of bleeding.

BACKGROUND/AIMS: Since heparin can bind to Hemophan, hemodialysis using heparin-bound Hemophan (HBH-HD) could be a useful modality in patients at risk of bleeding. We designed a simplified heparin binding technique and assessed the safety and efficiency of HBH-HD. METHODS: To bind heparin to Hemophan, heparin solution (1 liter, 20 IU/ml saline) was recirculated through Hemophan (GFS plus 11, Gambro) for 1 h while the saline solution (700 ml/h) was removed. In 28 maintenance dialysis patients at risk of bleeding, we evaluated the heparin concentration (HC) and activated partial thromboplastin time (aPTT) during HBH-HD to assess the increased risk of bleeding. We compared the safety and efficiency of HBH-HD with that of routine hemodialysis with low-dose heparinization (R-HD) in a prospective cross-over study, and then analyzed the outcomes of 1,057 HBH-HD in 159 patients. RESULTS: During HBH-HD, there was a slight increase in both HC (0.15 +/- 0.03 IU/ml, p < 0.01) and aPTT (43.7 +/- 5.7 s, p < 0.01) at 15 min after the initiation of dialysis compared to predialysis levels (0.11 +/- 0.03 IU/ml and 37.5 +/- 6.3 s). However, there was no increase in HC and aPTT at 60 min, 120 min and at the end of dialysis. In a cross-over study, aPTT during dialysis was markedly lower in HBH-HD than in R-HD (p < 0.01). The Kt/V (1.22 +/- 0.31, p > 0.05) and urea clearance (136 +/- 17 ml/min, p > 0.05) of HBH-HD did not significantly differ from those of R-HD (1.29 +/- 0.57 and 136 +/- 13 ml/min). However, the loss of total blood compartment volume of the dialyzer was greater in HBH-HD (17.5 +/- 9.2%, p < 0.01) than in R-HD (2.9 +/- 1.2%). Out of 1,057 HBH-HD, 982 HBH-HD (93%) were successfully completed while 75 HBH-HD (7%) resulted in severe clotting. CONCLUSION: We conclude that the HBH-HD could minimize the bleeding risk and be an efficient HD technique in patients at high risk of bleeding. Careful observation for extracorporeal clotting is, however, required during HBH-HD.

Adsorption↗

PubMed2006

A systematic review of postcoital bleeding and risk of cervical cancer.

BACKGROUND: Postcoital bleeding may be a symptom of cervical cancer. Guidance to aid a GP in determining whom to investigate or refer exists but recommendations vary. Women need to be involved in decisions about their care and this involves communicating risk and an exploration of the implications of the risk. Risk estimates of postcoital bleeding for cervical cancer are not available. AIM: To provide an estimate of the positive predictive values of postcoital bleeding for cervical cancer to aid decision making in primary care about whom to investigate for cervical cancer. DESIGN OF STUDY: A systematic review. SETTING: Community, primary and secondary care. METHOD: Six electronic databases were searched from the beginning of each of their time frames. Inclusion criteria were that the study was published in English and reported or contained enough data to calculate the prevalence or incidence of postcoital bleeding within the study population. No studies were excluded on issues of methodological quality. RESULTS: The search strategy identified 910 unique articles. The point prevalence of postcoital bleeding in the community ranged from 0.7 to 9% among women. One study reported an annual cumulative incidence of 6% of menstruating women. The prevalence of postcoital bleeding in women with cervical cancer ranged from 0.7 to 39%. Calculation of risk that a woman in the community developing postcoital bleeding has cervical cancer ranges from 1 in 44,000 at age 20-24 years to 1 in 2 400 aged 45-54 years. There was no information allowing the direct calculation of risk in women presenting to primary care. CONCLUSION: The evidence base for management strategies of postcoital bleeding and calculations of risk for cervical cancer in women with postcoital bleeding are poor. Recommendations for clinical practice are made on the current evidence.

Adult↗

PubMed2003

Anticoagulation during haemodialysis in patients at high-risk of bleeding.

Routine haemodialysis is performed with systemic anticoagulation, usually with heparin, to prevent thrombosis in the extracorporeal blood circuit. However, systemic anticoagulation can produce haemorrhagic complications in patients at high risk of bleeding. To minimize the risk of bleeding, a number of alternative regimens have been proposed: regional heparinization with protamine reversal; minimal heparinization; no heparin with saline flushes; regional anticoagulation with citrate; or prostacyclin anticoagulation. Although the incidence of bleeding complications has been reduced, each of these methods has its own limitations and complications. Among the types of membrane used in dialysers, cellulose membranes have been made more biocompatible by attaching N,N-diethyl-aminoehtyl (DEAE) groups to cellulose backbone. Positively charged DEAE groups on Hemophan enable negative charged heparin to be bound with the membrane. Haemodialysis using heparin-bound Hemophan has been reported to be a possible modality for patients at risk of bleeding. We designed more simplified heparin binding technique and have performed haemodialysis using heparin-bound Hemophan in patients at risk of bleeding during the past 7 years. In this review, current strategies to minimize bleeding complications and our experience of haemodialysis using heparin-bound Hemophan will be discussed.

Anticoagulants↗

PubMed2000

Oesophageal varices: assessment of the risk of bleeding and mortality.

Patients with oesophageal varices run a high risk of bleeding and even death, however rates of bleeding and mortality vary greatly. Indeed, a number of patients with varices never bleed. Prophylactic therapy is effective, but can be associated with side-effects. It remains to be determined which patients are at high risk of bleeding and require treatment. In addition, since non-response to medical therapy has been reported to occur in 20-40% of patients, the effect of a given prophylactic drug, or combinations of drugs, needs to be tested. A review is given of available methods of assessment. The Hepatic Venous Pressure Gradient, and measurements of the variceal pressure, are two proven methods, and the latter has the advantages of being non-invasive and having value in presinusoidal portal hypertension.

Esophageal and Gastric Varices↗