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Activated partial thromboplastin time (APTT) is widely practiced in preoperative screening. The value of using this test to predict the risk of perioperative bleeding is not well documented in Sweden. In this article, a literature review is performed to determine whether unselected APTT testing can predict abnormal perioperative bleeding. The current literature does not support coagulation screening with APTT in routine perioperative bleeding assessment, as preoperative screening with APTT has a low sensitivity for detection of clinically significant bleeding disorder. While a comprehensive bleeding history is crucial, the APTT test should only be performed on patients with a history of increased bleeding tendency. The conclusion of this literature review is that patients with a negative bleeding history do not require routine screening with APTT prior to surgery, which, if implemented, would lead to a more cost-effective perioperative routine.

Edoxaban is an oral direct factor Xa inhibitor for prophylaxis and treatment of thromboembolic disorders. The effects on common coagulation assays are clinically valuable information and in certain clinical situations a quick assessment of the anticoagulant is wanted. Our aim was to investigate the effect of edoxaban on routine coagulation methods and evaluate anti-Xa assays, commonly used for other direct factor Xa inhibitors, for estimation of the drug concentration. Edoxaban was spiked to plasma samples from healthy subjects in the concentration range 0–742 µg/L and analyzed using different reagents for activated partial thromboplastin time (APTT) and prothrombin time (PT). Assays for antithrombin, activated protein C resistance, lupus anticoagulant (LA) and chromogenic anti-Xa assays were also included. Edoxaban displayed similar effects in vitro to other oral direct Xa inhibitors. The concentration needed to double the coagulation time varied between assays and reagents; 539–758 µg/L for the APTT and between 329 and 2505 µg/L for the PT. Edoxaban gave false high antithrombin activities in assays based on Xa-inhibition. Two integrated assays for LA, both based on activation with dilute Russell’s viper venom, displayed different results. Chromogenic anti-Xa assays displayed linear dose-response curves with edoxaban up to approximately 500 µg/L. In conclusion, therapeutic concentrations of edoxaban variably affect different coagulation assays, and even different reagents within an assay group. In comparison with other oral Xa-inhibitors, the in vitro effects of edoxaban were more similar to rivaroxaban than apixaban. For measurement of edoxaban concentration in plasma, it is possible to use the chromogenic anti-Xa assays. (Less)

Standard surgical treatment for patients operated for rectal cancer is abdominoperineal excision of the tumor result- ing in a permanent colostomy or an anterior resection, often with construction of a temporary loop ileostomy. Both options impact bowel function. Living with a permanent colostomy has been studied in depth, but knowledge is limited about patients' experiences living with a resected rectum after stoma reversal and how it affects daily life. A qualitative study was conducted to describe the rst 4 to 6 weeks after reversal of a temporary loop ileostomy due to rectal cancer. Patients from 1 university hospital and 1 county hospital in Sweden were recruited by telephone and were eligible to participate in the study if they: 1) had been operated for rectal cancer with an anterior resection and a temporary loop ileostomy that had been reversed; 2) were18 years of age, fully oriented, and understood the Swedish language; and 3) had a postoperative course without complications. Interviews were conducted be- tween December 2013 and June 2015 either at the hospital or at the participants' homes. Participants were asked to narrate their experiences since stoma reversal. Probing open-ended questions were used to stimulate narration and clarify and enhance understanding. The interviews were recorded, transcribed verbatim, and analyzed us- ing thematic content analysis. The 16 participants included 9 women and 7 men (median age 67 years). Three (3) main themes emerged: Life being controlled by the altered bowel function, with the subthemes loss of control over bowel function, uncertainty regarding bowel function, and being limited in social life; Striving to regain control over the bowel, with the subthemes using ability and knowledge, social support, and being grateful and hopeful; and A desire to be normal, with subthemes getting rid of the stoma and restoration of body image. Patients experienced severe bowel function problems, including increased bowel movement frequency and inability to anticipate or trust bowel function after stoma reversal. Outwardly, patients experienced a signi cant improvement in body image but continued to struggle with suboptimal bowel function. Patients needed reassurance that their bowel symptoms were normal. Participants strove to regain control over bowel function using various strategies, including what they had learned about diet and medication before stoma reversal and by trying to defy the restrictions of their new normal. They felt they were ghting to regain bowel control without help from health care professionals. In order to cope with altered bowel function, they needed the support of family and friends. The results suggest that, following stoma reversal, patients need information about available treatments to address their symptoms and require regular follow- up visits to evaluate and address functional results.

To illuminate what it means to live with a resected rectum due to rectal cancer, after reversal of a temporary loop ileostomy.Today, treatment for rectal cancer is performed with increasing emphasis on sphincter-saving surgery, meaning that an anterior resection often includes construction of a temporary loop ileostomy that is later reversed. The majority of patients will subsequently have disordered bowel function, with symptoms ranging from urgency to faecal incontinence. The symptoms are thought to decrease over time, reaching a plateau 1 year after surgery. There is a lack of knowledge about patients' lived experience after 1 year.An explorative qualitative study.In-depth interviews were conducted with ten participants, 12-20 months after surgical closure of a temporary loop ileostomy following rectal cancer surgery. The transcribed interviews were analysed using a phenomenological hermeneutical method.The thematic structural analysis resulted in three themes: living with uncertainty, struggling to live with altered bowel function and a preoccupation with bowel function. In the comprehensive understanding, a deeper overall understanding emerged, illuminating that the meaning of living with a resected rectum could be interpreted as being resilient.The participants' lived experiences were understood as being resilient in that they struggled with the uncertainty and adversity of living with an unpredictable bowel, which was a constantly preoccupation and affected every aspect of life. The participants had not yet adapted to their situation but were struggling in solitude to get there, with little or no help from healthcare professionals.The insight from this study highlights the importance of patients being systematically examined and followed up in regard to functional results and impact of symptoms on everyday life. Treatment, information, advice and counselling should be given to promote adaption to the new situation.

INTRODUCTION: Apixaban is an oral direct factor Xa inhibitor developed for the prophylaxis and treatment of thromboembolic disorders. Laboratory monitoring is not necessary, but the effects on common coagulation reagents and assays constitute clinically valuable information. OBJECTIVES: To investigate the effects of apixaban on commonly used coagulation methods, and to evaluate anti-FXa assays for specific determination of the drug concentration. MATERIALS AND METHODS: Apixaban was added to plasma from healthy subjects in the concentration range 0-1000 μg L(-1) , and analyses were performed with different reagents for activated partial thromboplastin time (APTT), prothrombin time (PT), antithrombin, protein C, and protein S. A lupus anticoagulant assay and an APTT assay with varying phospholipid concentrations were used to study the phospholipid dependence. RESULTS: In general, apixaban showed fewer effects in vitro than have been shown for rivaroxaban, another direct FXa inhibitor. The concentration needed to double the APTT varied between 2200 and 4700 μg L(-1) , and the concentration needed to double the PT varied between 700 and 3900 μg L(-1) . The effects on antithrombin, protein C and protein S assays were dependent on the type of reagent. Apixaban did not cause false-positive lupus anticoagulant results. Chromogenic anti-FXa assays showed linear dose-response curves with apixaban. CONCLUSIONS: Therapeutic concentrations of apixaban variably affect different assay groups, and even different reagents within an assay group. The effects were much smaller than with rivaroxaban. The use of APTT and/or PT assays to screen the anticoagulant activity of apixaban cannot be recommended. A chromogenic anti-FXa assay can be used for reliable measurements of apixaban concentration. Funding Agencies|Bristol Meyers Squibb

Dabigatran is an oral, reversible thrombin inhibitor that has shown promising results in large clinical trials. Laboratory monitoring is not needed but the effects on common coagulation assays are incompletely known. Dabigatran was added to plasma from healthy subjects in the concentration range 0-1,000 mu g/l and analysed using several reagents for activated thromboplastin time (APTT), prothrombin time (PT), fibrinogen, antithrombin, and activated protein C resistance. Typical trough concentrations are about 50 mu g/l, peak concentrations 100-300 mu g/l. At 100 mu g/l all APTT-results were prolonged. The concentration required to double APTT ranged between 227 and 286 mu g/l, the responses for all five reagents were similar. PT-reagents were much less affected with almost no samples above INR 1.2 at 100 mu g/l. The effect was sample dilution dependent with PT Quick type more sensitive than PT Owren type methods. If a patient on dabigatran has prolonged APTT, andgt; 90 seconds, and Quick PT INR andgt; 2 or Owren PT INR andgt; 1.5 over-dosing or accumulation of dabigatran should be considered. Two of four fibrinogen reagents underestimated the fibrinogen concentration considerably at expected peak concentration. Methods based on inhibition of thrombin over-estimated the antithrombin concentration, but not Xa-based. The APC-resistance methods over-estimated the APC-ratio, which may lead to miss-classification of factory Leiden patients as being normal. Different coagulation assays, and even different reagents within an assay group, display variable effects at therapeutic concentrations of dabigatran. Some of these assay variations are of clinical importance, thus knowledge is needed for a correct interpretation of results. This article is not an exact copy of the original published article in THROMBOSIS AND HAEMOSTASIS. The definitive publisher-authenticated version is available:: Tomas Lindahl, Fariba Baghaei, Inger Fagerberg Blixter, Kerstin Gustafsson, Lennart Stigendal, Margareta Sten-Linder, Karin Strandberg and Andreas Hillarp, Effects of the oral, direct thrombin inhibitor dabigatran on five common coagulation assays, 2011, THROMBOSIS AND HAEMOSTASIS, (105), 2, 371-378. http://dx.doi.org/10.1160/TH10-06-0342

Introduction: Rivaroxaban is an oral direct factor Xa inhibitor developed for prophylaxis and treatment of thromboembolic disorders. Laboratory monitoring is not necessary but the dose-dependent effects on common reagents and assay procedures are largely unknown. Objectives: To investigate the effect of rivaroxaban on commonly used coagulation assays. Materials and Methods: Rivaroxaban was added to plasma from healthy subjects in the concentration range 0-1000 mu g L-1 and analyzed using different reagents for activated partial thromboplastin time (APTT), prothrombin time (PT), antithrombin, fibrinogen and activated protein C (APC) resistance assays. Results: At an expected peak concentration of rivaroxaban in clinical use, the APTTs were almost invariably prolonged but at lower concentrations the effect was weak. The concentration needed to double the APTT varied between 389 +/- 106 and 617 +/- 149 mu g L-1 for different reagents. The PT assays showed a marked degree of difference. In general, the Quick PT type assays were more sensitive compared with the Owren type PT assays. The results from antithrombin assays were dependent on the type of reagent, with the Xa-based assay being sensitive for rivaroxaban with an estimated increase of 0.09 IU mL-1 per 100 mu g L-1 rivaroxaban. There were only minor effects on fibrinogen assays based on thrombin reagents. The APTT-based assay for APC resistance is affected in a dose-dependent manner whereas an assay based on the activation of coagulation at the prothrombinase level was unaffected. Conclusions: Different assays, and even different reagents within an assay group, display variable effects by therapeutic concentrations of rivaroxaban. This is the authors’ version of the following article:A Hillarp, F Baghaei, I Fagerberg Blixter, K M Gustafsson, L Stigendal, M Sten-Linder, K Strandberg and Tomas Lindahl, Effects of the oral, direct factor Xa inhibitor rivaroxaban on commonly used coagulation assays, 2011, JOURNAL OF THROMBOSIS AND HAEMOSTASIS, (9), 1, 133-139.which has been published in final form at: http://dx.doi.org/10.1111/j.1538-7836.2010.04098.xCopyright: Blackwell Publishinghttp://eu.wiley.com/WileyCDA/Brand/id-35.html