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Introduction Critically ill patients with COVID-19 are at increased risk of developing a hypercoagulable state due to haemostatic changes directly related to the SARS-CoV-2 infection or to the consequence of the cytokine storm. Anticoagulation is now recommended to reduce the thrombotic risk. Ilio-psoas haematoma (IPH) is a potentially lethal condition that can arise during the hospitalization, especially in intensive care units (ICUs) and frequently reported as a complication of anticoagulation treatment. Materials and methods We report a case series of seven subjects with SARS-CoV-2 pneumonia complicated by Ilio-psoas haematomas (IPHs) at our COVID-Hospital in Rome, Italy. Results Over the observation period, 925 subjects with confirmed SARS-CoV-2 infection were admitted to our COVID-hospital. Among them, we found seven spontaneous IPHs with an incidence of 7.6 cases per 1000 hospitalization. All the reported cases had a severe manifestation of COVID-19 pneumonia, with at least one comorbidity and 5/7 were on treatment with low weight molecular heparin for micro or macro pulmonary thrombosis. Conclusions Given the indications to prescribe anticoagulant therapy in COVID-19 and the lack of solid evidences on the optimal dose and duration, it is important to be aware of the iliopsoas haematoma as a potentially serious complication in COVID-19 inpatients.KEY MESSAGECritically ill patients with COVID-19 are at increased risk of hypercoagulability state and anticoagulation therapy is recommended.Ilio-psoas haematoma (IPH) is found to be a complication of anticoagulation regimen especially in severe COVID-19 cases.An incidence of 7.6 cases per 1000 admission of IPHs was reported.Hypoesthesia of the lower limbs, pain triggered by femoral rotation, hypovolaemia and anaemia are the most common symptoms and signs of IPHs that should alert physician.

Background and Purpose— Bridging therapy with low-molecular-weight heparin reportedly leads to a worse outcome for acute cardioembolic stroke patients because of a higher incidence of intracerebral bleeding. However, this practice is common in clinical settings. This observational study aimed to compare (1) the clinical profiles of patients receiving and not receiving bridging therapy, (2) overall group outcomes, and (3) outcomes according to the type of anticoagulant prescribed. Methods— We analyzed data of patients from the prospective RAF and RAF-NOACs studies. The primary outcome was defined as the composite of ischemic stroke, transient ischemic attack, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding observed at 90 days after the acute stroke. Results— Of 1810 patients who initiated oral anticoagulant therapy, 371 (20%) underwent bridging therapy with full-dose low-molecular-weight heparin. Older age and the presence of leukoaraiosis were inversely correlated with the use of bridging therapy. Forty-two bridged patients (11.3%) reached the combined outcome versus 72 (5.0%) of the nonbridged patients ( P =0.0001). At multivariable analysis, bridging therapy was associated with the composite end point (odds ratio, 2.3; 95% CI, 1.4–3.7; P P =0.005) and hemorrhagic (odds ratio, 2.4; 95% CI, 1.2–4.9; P =0.01) end points separately. Conclusions— Our findings suggest that patients receiving low-molecular-weight heparin have a higher risk of early ischemic recurrence and hemorrhagic transformation compared with nonbridged patients.

Unter einer oralen Antikoagulation mit Vitamin-K-Antagonisten (VKA) mussen sich etwa 30 % der Patienten innerhalb von 2 Jahren einem chirurgischen Eingriff unterziehen. Dabei stellt sich die Frage nach der Notwendigkeit und Art einer periinterventionellen Uberbruckungstherapie mit Heparin. Wahrend fruher fast regelhaft von der Notwendigkeit dieses sogenannten Bridgings ausgegangen wurde, wird heute auf der Grundlage neuer Studienergebnisse eher diskutiert, wer uberhaupt noch ein Bridging benotigt. Die Sichtung und wissenschaftliche Einordnung der aktuell verfugbaren Empfehlungen und Studienergebnisse lassen die Schlussfolgerung zu, dass die Indikation zum Bridging mit Heparin heute eng gefasst werden muss, unter genauer Berucksichtigung und patientenindividueller Abwagung des Blutungs- und Thromboembolierisikos. Ein Bridging mit Heparin bleibt vor allem Patienten mit sehr hohem Risiko vorbehalten. Diese Ubersicht mochte daher Orientierung fur ein risikoadaptiertes periinterventionelles Vorgehen beim Management von Patienten bieten, die einer dauerhaften Antikoagulation mit VKA bedurfen.

Low-molecular-weight heparins (LMWH) are to date the standard for 3-to-6-month treatment of cancer-associated thrombosis (CAT) as they are consistently recommended by international clinical practice guidelines. Despite the high risk of VTE recurrence and death in patients with cancer and the favorable benefit-risk profile of LMWH demonstrated in randomized-control studies, the implementation of treatment guidelines remains insufficient in the clinical practice. A systematic review of observational studies, registries and surveys reveals that approximately only 50% of patients with CAT are treated according to practice guidelines while both physicians and patients may be accountable for this situation. Based on the few available published data, we have observed differences between guidelines and clinical practice and we have identified factors influencing patient's management with the perspective to improve adherence to clinical practice guidelines in patients with CAT. Improving the implementation of clinical practice guidelines requires a better knowledge of physician and patient-related factors that influence therapeutic decisions. A global approach of patients with CAT is warranted to optimize the therapeutic management of cancer-associated VTE.

Zusammenfassung. Die direkten oralen Antikoagulanzien (DOAK) gelten als Medikamente der Wahl in der Behandlung der tiefen Beinvenenthrombose und Lungenembolie. Aus der Patientenperspektive wäre es wünschenswert, diese oralen Substanzen auch in der Behandlung der krebsassoziierten Thrombose (Cancer-Associated Thrombosis, CAT) als Alternative zu der Standardtherapie mit niedermolekularen Heparinen (NMH) einzuführen. Da prospektive Daten zur Wirksamkeit und Sicherheit der DOAK im Vergleich zu NMH noch nicht zur Verfügung stehen, sollten DOAK vorerst für Patienten mit CAT reserviert werden, die eine subkutane Therapie mit NMH nicht tolerieren oder nach der initialen Behandlung mit NMH eine Langzeitantikoagulation erfordern. Die Interaktionen, möglich veränderte Bioverfügbarkeit und Organfunktionen müssen auch bei einer späteren breiteren Einführung der DOAK bei Krebspatienten berücksichtigt werden.

Chronic subdural hematoma is a commonly encountered disease in neurosurgic practice, whereas its increasing prevalence is compatible with the ageing population. Recommendations concerning postoperative thrombosis prophylaxis after burr-hole drainage of chronic subdural hematoma are lacking. The aim of this study was to analyze the correlation between recurrence of chronic subdural hematoma and postoperative application of thrombosis prophylaxis.Retrospective, consecutive sample of patients undergoing burr-hole drainage for chronic subdural hematoma over 3 years.Single, academic medical center.All patients undergoing surgical evacuation of a chronic subdural hematoma with burr-hole drainage. Exclusion: patients under the age of 18 years, who presented with an acute subdural hematoma and those who underwent a craniotomy.We compared patients receiving thrombosis prophylaxis treatment after burr-hole drainage of chronic subdural hematoma with those who were not treated. Primary outcome measure was reoperation of chronic subdural hematoma due to recurrence. Secondary outcome measures were thromboembolic and cardiovascular events, hematologic findings, morbidity, and mortality. In addition, a subanalysis comparing recurrence rate dependent on the application time of thrombosis prophylaxis (48 vs48 hr) was undertaken.Overall recurrence rate of chronic subdural hematoma was 12.7%. Out of the 234 analyzed patients, 135 (57.3%) received postoperative thrombosis prophylaxis (low-molecular-weight heparin) applied subcutaneously. Recurrence of chronic subdural hematoma occurred in the thrombosis prophylaxis group and control group in 12 patients (8.9%) and 17 patients (17.2%), respectively, showing no significant difference (odds ratio, 0.47 [95% CI, 0.21 - 1.04]). A subanalysis comparing recurrence rate of chronic subdural hematoma dependent on the application time of thrombosis prophylaxis (48 vs48 hr) showed no significant difference either (odds ratio, 2.80 [95% CI, 0.83-9.36]). Higher dosage of thrombosis prophylaxis correlated with recurrence rates of chronic subdural hematoma, both in univariate and multivariate analyses.Our data suggest that the application of postoperative thrombosis prophylaxis after burr-hole drainage for chronic subdural hematoma does not result in higher recurrence rates of chronic subdural hematoma. In addition, it seems that early administration of thrombosis prophylaxis (48 hr) has no influence on recurrence rates; however, high dosage seems to increase recurrence rates.

Anamnese und klinischer Befund Eine 84-jahrige Patientin mit persistierendem Vorhofflimmern und chronischer Niereninsuffizienz erhielt wahrend des stationaren Aufenthaltes eine subkutane Therapie mit niedermolekularem Heparin (NMH). Im Verlauf entwickelte sie ausgepragte abdominelle Schmerzen. Inspektorisch zeigten sich Einstichstellen mit subkutaner Einblutung, palpatorisch war eine schmerzhafte Raumforderung im rechten unteren Quadranten tastbar. Untersuchung Bei einem signifikanten Hamoglobinabfall erfolgte notfallmasig eine Angio-CT-Untersuchung des Abdomens. Diagnose Hierbei zeigte sich ein ausgepragtes intramuskulares Bauchwandhamatom. Therapie und Verlauf Mittels digitaler Subtraktionsangiografie visualisiert konnte die Blutung endovaskular durch Applikation von Mikrocoils in Kombination mit Histoacrylkleber gestillt werden. Im Verlauf konnte nach Implantation eines Vorhofohrverschlusses die orale Antikoagulation (oAK) beendet werden. Folgerung Bei unklaren Bauchschmerzen nach einer s. c.-Applikation von NMH sollte die Differenzialdiagnose eines spritzeninduzierten Bauchwandhamatoms in Erwagung gezogen werden.

A strategy for the comprehensive analysis of low molecular weight (LMW) heparins is described that relies on using an integrated top-down and bottom-up approach. Liquid chromatography-mass spectrometry, an essential component of this approach, is rapid, robust, and amenable to automated processing and interpretation. Nuclear magnetic resonance spectroscopy provides complementary top-down information on the chirality of the uronic acid residues comprising a low molecular weight heparin. Using our integrated approach four different low molecular weight heparins prepared from porcine heparin through chemical β-eliminative cleavage were comprehensively analyzed. Lovenox™ and Clexane™, the innovator versions of enoxaparin marketed in the US and Europe, respectively, and two generic enoxaparins, from Sandoz and Teva, were analyzed. The results which were supported by analysis of variation (ANOVA), while showing remarkable similarities between different versions of the product and good lot-to-lot consistency of each product, also detects subtle differences that may result from differences in their manufacturing processes or differences in the source (or parent) porcine heparin from which each product is prepared.

Resume Objectif Determiner la frequence du suivi plaquettaire et les risques hemorragiques associes a l’usage des anticoagulants injectables en vie reelle et estimer les couts associes. Methode Une analyse des donnees 2013 de l’echantillon generaliste des beneficiaires a ete realisee pour identifier les dosages plaquettaires effectues sur les periodes d’exposition aux anticoagulants injectables et les interruptions therapeutiques du fait d’une thrombopenie ou d’une transfusion. Ces evenements ont ete valorises et un differentiel de cout etabli. Resultats L’etude a porte sur 15 985 patients adultes representant 12 264 mois d’exposition aux anticoagulants injectables ; 2,8 % des sequences concernaient une heparine non fractionnee, 86,9 % une heparine de bas poids moleculaire et 13,1 % le fondaparinux. Les patients sous heparine non fractionnee etaient plus âges (77 vs 57 et 59 ans) avec des durees de traitement superieures (32,6 vs 25,1 et 21 jours). Le nombre mensuel moyen de dosages plaquettaires etait, apres ajustement, 1,36 fois inferieur chez les patients traites par fondaparinux par rapport aux heparines de bas poids moleculaire (p Conclusion Les patients sous fondaparinux effectuent significativement moins de dosages plaquettaires que les patients sous heparines de bas poids moleculaire sans risque hemorragique supplementaire. Cet aspect doit etre pris en compte dans l’evaluation des couts de ces traitements.

The risk of venous thromboembolism (VTE) is increased by more than 100-fold among hospitalised medical patients compared to subjects in the community. The Danish Council for the Use of Expensive Hospital Medicines has published national guidelines on thromboprophylaxis (TP) in which the risks of VTE and bleeding are balanced. We wanted to investigate the proportion of acutely admitted medical patients for whom thromboprophylaxis was indicated and to what extent the guidelines were followed. Data from patients hospitalised at two medical wards were screened. We registered the proportion of patients for whom mechanical or pharmacologic TP (MTP and PTP, respectively) was indicated and whether national guidelines were followed. All data extraction and analyses were performed retrospectively. After exclusion criteria were applied, 340 cases remained. PTP was indicated in 26 patients (7.6%) but only 4 patients were treated besides 12 patients who were already in anticoagulant treatment at submission. Conversely, 8/306 patients, in whom TP was not indicated, were started on PTP. MTP was indicated in 8/340 patients (2.4%) but therapy was not initiated in any of them. The majority (320/340, 94.1%) of cases was managed in accordance with existing guidelines. However, this high proportion was mainly explained by the large number of untreated patients, where TP was not indicated. A large proportion of hospitalised medical patients was managed in conflict with national guidelines. A systematic approach to TP in patients with acute medical illness should be implemented. Plain language summary available for this article.

Anticoagulation during pregnancy in women with mechanical prosthetic heart valves (MPHVs) is challenging. Maternal and foetal morbidity and mortality are high (MMBRACE-UK 2016). In the United Kingd...

Resume Introduction La maladie thromboembolique veineuse represente une complication frequente au cours du cancer et en est la deuxieme cause de deces apres les infections. L’heparine de bas poids moleculaire est le traitement de premier choix dans la maladie thromboembolique veineuse au cours du cancer. Ce travail avait pour but d’evaluer la prevalence des prescriptions d’heparines de bas poids moleculaire a dose curative ainsi que la conformite de nos pratiques au regard des recommandations. Methodes Une etude retrospective a ete menee, sur un trimestre, concernant les patients adultes presentant une thrombose et beneficiant d’un traitement par heparine de bas poids moleculaire a dose curative. Resultats Une prevalence de prescription d’heparine de bas poids moleculaire a dose curative de 4 % a ete retrouvee. Les resultats montraient une decouverte fortuite de la maladie thromboembolique veineuse dans 64 % des cas sur un bilan d’imagerie. L’indication la plus frequente etait le traitement d’une thrombose veineuse profonde (51 % des cas). La conformite globale des prescriptions est estimee a 55 %, compte tenu de la posologie. Discussion Le taux de decouverte fortuite retrouve (64 %) est coherent avec les donnees de la litterature qui confirment l’incidence importante des thromboses asymptomatiques. Le taux de non-conformite des prescriptions (45 %) resulterait d’un manque de reevaluation et d’adaptation des posologies. Ces resultats confirment la necessite de sensibiliser davantage les praticiens quant au diagnostic et a la prise en charge adaptee de la maladie thromboembolique veineuse.

Objective: To compare the efficacy and safety of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in the treatment of patients with cerebral venous sinus thrombosis (CVST), and to provide an appropriate treatment option in these patients. Method: This is a randomized double blind clinical trial conducted between December 2013 and December 2014. The subjects were selected among patients referred to Neurology Department, Imam Reza Hospital; affiliated to Kermanshah University of Medical Sciences, Kermanshah, Iran. Fifty-two cases of CVST were included in this study and randomly divided into 2 groups. Twenty-six cases received LMWH and the other 26 cases received UFH. The primary outcomes include hospital mortality rate and neurologic deficits as assessed by the National Institutes of Health Stroke Scale (NIHSS). The secondary end point was disability as measured by the Modified Rankin Scale (MRS). Results: We observed the rate of mortality and neurological deficits and disability based on NIHSS, and the MRS did not differ between the 2 groups. Conclusion: The efficacy of LMWH and UFH in reduction of neurologic deficit and functional disability in patients with CVST are similar.

The low incidence of partial segmental thrombosis of the corpus cavernosum (PSTCC) means its management is guided by isolated case reports. Erectile function is an important outcome that has not been described quantitatively in the literature. We present two cases of PSTCC managed conservatively. Although both patients reported resolution of local symptoms, formal analysis of sexual function at follow-up review has revealed that only one achieved complete recovery.

Resume Introduction La maladie de Mondor est une thrombophlebite superficielle rare, touchant historiquement le systeme veineux thoracique de la femme. Elle peut toutefois s’exprimer chez les deux sexes et interesser toute la surface cutanee. Observation Nous rapportons l’observation d’un homme de 40 ans, diabetique de type 1, souffrant d’une thrombose de la veine dorsale superficielle de la verge qu’il traitait comme une mycose. Un traitement anti-inflammatoire non steroidien complete par une heparine de bas poids moleculaire permettait une evolution favorable en 2 semaines. Conclusion L’etiopathogenie et le traitement de la maladie de Mondor sont encore incompletement domines. Certains facteurs predisposants ont ete toutefois soulignes dans la litterature, auxquels il nous paraitrait interessant d’integrer le terrain diabetique, susceptible par ses frequentes problematiques pelviennes, d’etre un irritant inflammatoire veineux local.

Acute pulmonary embolism (PE), a potentially life-threatening manifestation of venous thromboembolism (VTE), represents a major threat to the health and occasionally the life of a large number of patients worldwide. A systematic review of the published data, performed on the occasion of World

OBJECTIVE:To characterize the use of venous thromboembolism prophylaxis during antepartum and postpartum hospitalizations in the United States.METHODS:A retrospective cohort study using the Perspective database was performed to analyze temporal trends of mechanical and pharmacologic venous thromboem

Abstract 503 The optimal dosing strategy of low molecular weight heparins (LMWH) for the treatment of antenatal venous thromboembolism (VTE) is not known. The physiological changes associated with pregnancy alter the pharmacokinetic (PK) profile of LMWH, and this has led to controversy and subsequent variation in practice, when pregnant women are managed with LMWH for VTE [Voke et al., 2009]. The perceived impact of these PK changes has led to the Royal College of Obstetrics and Gynaecologists (RCOG) recommending a twice daily dose of LMWH, whilst the American College of Chest Physicians recommend that either a once or twice daily dose of LMWH can be used in this setting. We conducted a population PK modelling study of enoxaparin during pregnancy in order to address this issue. Women requiring antenatal enoxaparin, all indications and doses, referred to the specialist haematology clinic at King's College Hospital, a London teaching hospital, were eligible to enrol in the study. Recruited women were reviewed monthly in clinic during their pregnancy, and had up to three anti-Xa activities (trough, 1 hour post dose, and 3 hours post dose) drawn at each clinic attendance. This anti-Xa sampling strategy was based on d-optimal design, to ensure gestation related changes in enoxaparin clearance (CL) and volume of distribution (Vd) were captured in the PK model developed [van Hasselt et al., 2012]. Women under 18 years of age, those with impaired renal function and those non-adherent to enoxaparin were excluded. Compartmental PK modelling was conducted using non linear mixed effects modelling (NONMEM version 7.2.2). One hundred and twenty three patients contributed 795 anti-Xa activities (712 antenatal, 83 postnatal), for PK modelling purposes. A one compartment model with exponential between subject variability on CL and Vd, with a combined proportional and additive error model best fitted the data, with both enoxaparin CL and Vd found to have increased during pregnancy (table). Enoxaparin PK parameter CL (L/hr) Vd (L) Non-pregnancy (literature values) 0.5-0.7 3-7 Pregnancy (this study) 1.6 13.2 Time dependent changes during pregnancy were found to be significant covariates on both CL and Vd. A full covariate analysis identified weight to be a significant covariate for enoxaparin CL and gestation and baseline lean body weight to be significant covariates for Vd during pregnancy. The final pregnancy enoxaparin PK models for CL and Vd can be represented mathematically as: where Wt is the women's actual weight, GEST is their gestational stage, and LBW is their baseline lean body weight. Goodness of fit plots, a bootstrap analysis and a visual predictive check revealed that a robust enoxaparin model for use in pregnancy had been developed. Simulations of women injecting enoxaparin once versus twice daily demonstrate that both dosing regimens will reach RCOG target 3 hour plasma concentrations throughout the duration of the pregnancy (Figure 1). This should provide confidence to clinicians who prescribe a once daily dose of enoxaparin for the antenatal population. Perhaps the more important concentration to assess however is the trough anti-Xa activity, due to the historical thinking that during pregnancy CL increases, therefore so should the dose/dosing frequency. When the trough activity is simulated, the majority of women on a once daily dose, will have measurable anti-Xa activity; with both once and twice daily regimes demonstrating an increase in trough anti-Xa activity with the progression of pregnancy. This occurs due to the increase in Vd and demonstrates that enoxaparin never reaches a steady state during pregnancy. The measurable trough activity confirms the appropriateness of a once daily dose of enoxaparin in this setting. Our work provides compelling evidence that a once daily dose of enoxaparin for the treatment of antenatal VTE is appropriate. As a result, the current guidelines should be revised. Figure 1: Simulation of 3 hour (red) and trough (blue) anti-Xa activity of women receiving once daily and twice daily treatment doses of enoxaparin during their pregnancy. The solid line is the median concentration and the dashed lines represent the 5th and the 95th percentile concentrations. Grey horizontal lines represent RCOG 3 hour target anti-Xa concentration. Figure 1:. Simulation of 3 hour (red) and trough (blue) anti-Xa activity of women receiving once daily and twice daily treatment doses of enoxaparin during their pregnancy. The solid line is the median concentration and the dashed lines represent the 5th and the 95th percentile concentrations. Grey horizontal lines represent RCOG 3 hour target anti-Xa concentration. Disclosures: Off Label Use: Enoxaparin use during the antenatal period.

Low-molecular weight heparins (LMWHs) are widely used anticoagulant drugs. They inherit the heterogeneous backbone sequences of the parent heparin, while the chemical depolymerization process modifies the nonreducing end (NRE) and reducing end (RE) of their sugar chains. Some side reactions may also occur and increase the structural complexity of LMWHs. It is important to precisely characterize the structures of LMWHs, especially their chemical modifications, to ensure drug quality and safety. Compositional analysis provides a powerful approach to reveal the building blocks that make up the LMWHs, which are the mutual consequence of the heparin starting materials and the manufacturing process. Here, we introduce a comprehensive analytical method to recover the most basic building blocks of LMWHs. A strategy of combining both enzymatic digestion and oxidative degradation of LMWH was used to make the NRE, RE, and backbone structures differentiable from one another. Satisfactory separation, identification, and quantitation were achieved by coupling hydrophilic interaction chromatography with a triple quadrupole mass spectrometer operating under the multiple reaction monitoring mode. After enzymatic digestion, over 30 species were detected, with both natural and chemically modified heparin basic building blocks. Two novel structures, including a trisaccharide containing two glucosamine residues and a tetrasaccharide containing a 3-O-sulfated uronic acid residue, were discovered. Reduced and oxidatively degraded samples were analyzed to provide the complementary information on both termini of LMWHs. The reproducibility of this method was evaluated, and enoxaparin injections were analyzed to demonstrate the application of this method for evaluating the sameness of LMWH products.

Low-molecular-weight heparin (LMWH) has remained the most favorable form of heparin in clinics since the 1990s owing to its predictable pharmacokinetic properties. However, LMWH is mainly eliminated through the kidney, which limits its use in renal-impaired patients. In addition, the anticoagulant activity of LMWH is only partially neutralized by protamine. LMWH is obtained from a full-length, highly sulfated polysaccharide harvested from porcine mucosal tissue. The depolymerization involved in LMWH production generates a broad distribution of LMWH fragments (6-22 sugar residues). This, combined with the various methods used to produce commercial LMWHs, results in variable pharmacological and pharmacokinetic properties. An alternative chemoenzymatic approach offers a method for the synthesis of LMWH that has the potential to overcome the limitations of current LMWHs. This review summarizes the application of a chemoenzymatic approach to generate LMWH and the rationale for development of a synthetic LMWH.

Resumen Fundamento y objetivo El objetivo de este estudio es evaluar el grado de adecuacion de tromboprofilaxis en pacientes medicos hospitalizados aplicando 2 guias de practica clinica y analizar el grado de acuerdo entre ambas. Pacientes y metodo Estudio de corte transversal en servicios medicos de un hospital de tercer nivel. Calculamos el riesgo tromboembolico y la adecuacion de tromboprofilaxis aplicando las recomendaciones de la viii conferencia de la American College of Chest Physicians (ACCP) y la Guia de Profilaxis de Patologia Tromboembolica en Patologia Medica (PRETEMED), asi como su concordancia. Resultados Se analizaron 128 pacientes. Segun la guia PRETEMED, el 34,4% de los pacientes tenian riesgo bajo, un 6,3% moderado y un 59,4% alto; la tromboprofilaxis fue adecuada en el 72,7% (intervalo de confianza del 95% [IC 95%] 64,4-79,9), fueron infratratados el 18,8% (IC 95% 12,7-26,2) y sobretratados el 8,6% (IC 95% 4,6-14,4). Segun las recomendaciones de la ACCP, un 50% tenian bajo riesgo y un 50% alto; la tromboprofilaxis fue adecuada en el 74,2% (IC 95% 66,1-81,2), fueron infratratados el 10,9% (IC 95% 6,4-17,3) y sobretratados el 14,8% (IC 95% 9,4-21,8). Agrupando el riesgo PRETEMED en bajo o moderado-alto frente a riesgo ACCP bajo o alto, el indice de concordancia entre guias fue de 0,68 (IC 95% 0,56-0,81). Agrupando el riesgo PRETEMED en bajo-moderado o alto frente a riesgo ACCP bajo o alto el indice de concordancia fue de 0,81 (IC 95% 0,71-0,91). Conclusiones Alrededor de un cuarto de los pacientes medicos hospitalizados no recibieron tromboprofilaxis adecuada, demostrandose un importante margen de mejora. La guia PRETEMED y los criterios de la ACCP presentan diferencias en la valoracion del riesgo debido principalmente a que PRETEMED sobrestima el riesgo de enfermedad tromboembolica venosa al contemplar mas factores de riesgo.

Background: Endothelial dysfunction marker, von Willebrand factor (vWF), is physically connected with osteoprotegerin (OPG) in the Weibel-Palade bodies. We aimed to compare the effect of unfractionated (UFH) and low-molecular-weight (LMWH enoxaparin) heparin used as anticoagulants during hemodialysis (HD) on plasma levels and relationships of OPG, soluble receptor activator of nuclear factor κB Ligand (sRANKL), and vWF. Methods: Totally 21 clinically stable chronic HD patients were randomly assigned to either enoxaparin (n = 10) or UFH (n = 11) anticoagulation and followed prospectively for 12 weeks before crossing over to the alternate therapy for further 12 weeks. The OPG, RANKL, and vWF levels were measured at T0, T10, and T180 of HD session after each period of evaluation. Results: The baseline sRANKL level was higher under UFH treatment. Its over-HD level does not behave significantly different under enoxaparin and UFH treatment. Plasma OPG levels expressly changed during both enoxaparin (χ2 analysis of variance [ANOVA] = 31.13, P < .016) and UFH (χ2 ANOVA = 8.26, P = .016) anticoagulation, and its increment at T10 and T180 was significantly different between both the heparins. The main negative predictor of OPG concentration was the total cholesterol level (β = −.51, P = .025). von Willebrand factor concentration remained stable during UFH anticoagulation, whereas constant, no significant increments were noticed, under enoxaparin treatment. After 10 minutes of HD, especially under enoxaparin use, a positive correlation between OPG and vWF increase was noticed ( P = .03, R = .45). Conclusions: Impact of heparin on endothelial cells and simultaneously on OPG/RANK/RANKL axis reinforces the presumption of the pathophysiological linkage between bone mineralization and endothelial dysfunction in end-stage renal disease.

Pregnancy is associated with an increased risk of venous thromboembolism (VTE) and this condition remains an important cause of maternal morbidity and mortality. The use of anticoagulant therapy for treatment and prophylaxis of VTE during pregnancy is challenging because of the potential for fetal, as well as maternal, complications. Although evidence-based recommendations for the use of anticoagulants have been published, given the paucity of available data, guidelines are based largely upon observational studies and from data in nonpregnant patients. This article reviews the available literature and provides guidance for the management and prevention of VTE during pregnancy.

This article demonstrates how services provided in minor injury units (MIUs) and emergency departments (EDs) can be improved by the implementation of routine thromboprophylaxis by subcutaneous injections of low molecular weight heparin for patients whose lower limbs are immobilised by plaster casts. The author offers evidence of the need for such a change in practice from a literature review and a case study, and describes how it can be achieved in five steps. She also outlines a protocol for routine thromboprophylaxis in MIUs and EDs.

Both arterial and venous thromboembolism constitute a significant disease burden worldwide, leading to major use of healthcare resources. As anticoagulants play a pivotal role in the treatment of these disorders, it is vital for healthcare providers to have sufficient knowledge of their biochemical and clinical attributes.Enoxaparin is one of the most commonly used low-molecular-weight heparins in a wide variety of thromboembolic disorders and has several advantages over unfractionated heparin. An analysis of its biophysical profile, with special emphasis on pharmacokinetic and pharmacodynamic properties, is undertaken in this article. In addition, most recent major clinical studies elucidating its role in common thromboembolic conditions are discussed, while keeping the historical perspective at hand. Readers will be able to understand the pharmacologic properties of enoxaparin with their clinical relevance for day-to-day use and critically analyze the amount and weight of scientific evidence behind its use in various disorders.In summary, enoxaparin has been shown, by a vast amount of scientific data, to be a safe and effective agent in the treatment of a whole spectrum of acute coronary syndromes, with similar efficacy and safety in the prevention and treatment of venous thromboembolism.

Periprocedural bridging in high-thrombotic-risk mechanical heart valve (htr-MHV) bearers has not been definitively addressed [(1–3)][1]. In a previous study [(4)][2], we assessed the effectiveness and safety of a bridging protocol with an intermediate dose of low-molecular-weight heparins (LMWHs

A trombose venosa profunda (TVP) e uma doenca medica com uma incidencia anual, nos EUA, de 117 casos por cada 100.000 pessoas, sendo uma das principais causas de morte nos doentes hospitalizados. A sua etiologia e multifactorial, sendo necessaria a interaccao de varios factores para que exista a formacao de um trombo no interior de um vaso sanguineo. O estabelecimento do grau de risco, o seu diagnostico, e uma referenciacao adequada aos cuidados de saude secundarios, para confirmacao diagnostica e tratamento, permite diminuir a mortalidade e morbilidade desta doenca. Neste artigo faz-se uma revisao sucinta sobre a etiologia, criterios de diagnostico e tratamento da TVP.

Reisethrombosen sind wahrscheinlich weniger häufig als bisher vermutet. Problematisch sind Flugzeiten von acht und mehr Stunden. Üblicherweise reichen allgemeine Massnahmen wie Vermeiden von einengender Kleidung, ausreichende Flüssigkeitszufuhr, Fussgymnastik und Umhergehen in der Flugzeugkabine aus, um venöse Thromboembolien (VTE) zu verhindern. Kompressionsstrümpfe können empfohlen werden, wenn Risikofaktoren für VTE vorhanden sind. Die Gabe von niedermolekularen Heparinen in prophylaktischer Dosierung ist nach stattgehabten VTE sinnvoll.

Rationale:Superior mesenteric venous thrombosis (SMVT) is a rare condition that carries high mortality. Very few cases have been reported of SMVT, complicating acute appendicitis. Early recognition requires a high index of suspicion and is crucial in successful treatment of such a life-threa

Resume Introduction La dermatose bulleuse hemorragique sous heparine est un effet indesirable de description recente. Nous rapportons un nouveau cas de cette toxidermie, survenue a distance des sites d’injection d’heparine de bas poids moleculaire (HBPM). L’originalite de cette observation reside dans la survenue simultanee d’une reaction eczematiforme aux points d’injection de l’heparine. Observation Le traitement par anti-vitamine K d’un malade de 51 ans, hospitalise pour une pericardite constrictive chirurgicale, etait remplace par de l’enoxaparine sodique pendant dix jours, relayee ensuite par de la tinzaparine sodique. Quarante-huit heures apres l’introduction de la tinzaparine sodique apparaissaient des plaques d’eczema aux sites d’injection, et de petits bulles hemorragiques a distance. La biopsie d’une bulle montrait un decollement sous-corne contenant des hematies, sur peau, par ailleurs, saine. L’immunofluorescence directe etait negative. La recherche d’anomalies de la coagulation ou de l’immunite etait negative. L’arret des HBPM a ete suivi d’une guerison complete des lesions cutanees en dix jours. Les tests epicutanes et intradermiques a differentes heparines etaient negatifs. Discussion Notre observation presente des similitudes avec les rares cas publies de dermatose bulleuse hemorragique sous heparine : il s’agit de bulles multiples hemorragiques sur peau saine, infracentimetriques, apparaissant a distance des sites d’injection dans un delai de cinq a 21 jours apres le debut du traitement. La physiopathologie de cette toxidermie est encore inconnue. Notre malade a, par ailleurs, presente des lesions eczematiformes aux points d’injection des HBPM, compatibles avec une reaction d’hypersensibilite retardee. Nous ignorons si l’association des deux toxidermies est un evenement fortuit.

Venous thromboembolism represents a potentially threatening complication in surgical and medical patients. Thromboprophylaxis showed a significant reduction of venous thromboembolic events, and low-molecular-weight heparins have been considered the standardized prophylactic regimen for a long time. The purpose of this review is to provide updated evidence on the use of low-molecular-weight heparins for prevention of venous thromboembolism after the publication of the latest American College of Chest Physicians Evidence-Based Clinical Practice Guidelines on antithrombotic and thrombolytic therapy.Low-molecular-weight heparins, used as comparator or investigational drug, have been investigated in several studies not included in the analysis of the latest American College of Chest Physicians Guidelines on Antithrombotic and Thrombolytic Therapy. Data gathered from studies published from December 2007 up to May 2009 dealing with surgical and medical patients have been collected and discussed.Low-molecular-weight heparins are expanding their application, but progressively they will be replaced by other new antithrombotics for the prophylaxis of venous thromboembolism. Surgical patients undergo a more concerted approach to thromboprophylaxis than medical patients. Future research should aim at improving prophylaxis in the latter setting in order to significantly reduce the rate of venous thromboembolic events.