Bleeding and clotting in hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia(HHT) is arelatively common inherited vascular disorder that was first described in 1864, and is notable for epistaxis, telangiectasia, and arterial venous malformations. While genetic tests are available, the diagnosis remains clinical, and is based on the Curacao criteria. Patients with HHT are at increased risk for both bleeding and clotting events. Because of these competing complications, hematologists are often faced with difficult clinical decisions. While the majority of management decisions revolve around bleeding complications, it is not infrequent for these patients to require anticoagulation for thrombosis. Any anticoagulation recommendations must take into account the bleeding risks associated with HHT. Recent reviews have found that HHT patients can be safely anticoagulated, with the most frequent complication being worsened epistaxis. Large clinical trials have shown that factor Ⅱa and Ⅹa inhibitors have less intracranial bleeding than warfarin, and basic coagulation research has provided a possible mechanism. This article describes the anticoagulation dilemma posed when a 62-year-old female patient with a history of bleeding events associated with HHT was diagnosed with a pulmonary embolism. The subsequent discussion focuses on the approach to anticoagulation in the HHT patient, and addresses the role of the new oral anticoagulants.     

Edoxaban Versus Warfarin for the Treatment of Symptomatic Venous Tnromboembolism

By the end of last year, a group of investigators led by Professor Btiller HR accomplished the global HOKUSAI-VTE trial which was funded by Daiichi-Sankyo. They conducted this trial to investigate whether the oral factor Xa inhibitor edoxaban can be an alterna- tive to warfarin in patients with venous thromboembolism. Edoxaban is a newly developed oral factor Xa direct inhibitor with stable pharmacodynamics and pharmacoefficacy in spite of race, age, gender, body weight and very few interaction with food and drug. The study was designed as a randomized, double-blind, noniuferiority one which randomly assigned patients with acute venous thromboem- bolism including DVT and/or PE, who had initially received heparin （mostly enoxaparin） , to receive edoxaban at a dose of 60 mg once daily, or 30 mg once daily （ e. g. , in the case of patients with creatinine clearance of 30 to 50 ml per minute or a body weight below 60 kg） or to receive standard warfarin therapy. Patients received the study drug for 3 to 12 months. The primary efficacy outcome was re- current symptomatic venous thromboembolism. The principal safety outcome was major or clinically relevant nonmajor bleeding.     

Effects of preoperative other diseases on the compications of senile cervical vertebral operation in perioperative period

AIM：To investigate the effects of preoperative other diseases on the complications of senile cerical vertebral operation in perioperative period.METHODS:800 senile cervical vertebral cases were divided into two group:group A included the cases without other comorbidities,and group B included the cases with hypertension,diabetes mellitus,coronary heart disease (GHD) or chronic obstructive pulmonary disease(COPD).We retrospectively analyzed the changes of BP,oxygen saturation (SaO2) and the incidence of cardiac arrhythmia during operation of group A and B.RESULTS:In perioperative period,the incidence of B reduction or rising and cardiac arrhythmia in group B was more than that of group A.Incidence of SaO2 decreasing increases apparently in each stage and incidence of cerebrovascular,pulmonary complications and asphyxia led by incision bleeding increases apparently.CONCLUSION:The hypertension,CHD,diabetes mellitus and COPD were the main reasons of complications of the heart,the cerebral vessels and the lung,kidney and the incision bleeding in perioperative period of senile patients.     

机械瓣膜置换术后远期抗凝状态观察及临床意义

Objective To investigate the long-term anticoagulation starus and relation of INR and complica-tion,best anticoagulation range and clinical significance in patients after mechanical heart valve replacement. Meth-ods The data of blood clotting test series(containing PT,PT% ,PTR,INR,Fbg,APTT) for patients after 6 months of mechanical heart valve replacement were collected, then the cases were divided into 4 groups according to their INR levels( group Ⅰ : INR < 1.5; group Ⅱ : INR 1.5 ～ 2.0 ; group Ⅲ : INR 2.1 ～ 2.5 ; group Ⅳ : INR > 2.5 ). Results Group Ⅰ contained 28 person-times, with their dosage of warfarin for (3.61 ± 1.44 ) mg, INR 1.38 ± 0. 12, core-bral embolism occurred for 4 person-times,with a inception rate of 14%. Group Ⅱ contained 92 person-times,with their dosage of warfarin for (3.5±1.37)mg,INR 1.65±0. 14,hemorrhinia occurred for 2 person-times,with a in-ception rate of 2%. Group Ⅲ contained 80 person-times, with their dosage of warfarin for (3.18±1.63 )mg, INR 2.23±0.19 ,bematuria occurred for 2 person-times, bemorrhinia occurred for 2 person-times, with a total inception rate of 5% ; Group Ⅳ contained 16 person-times, with their dosage of warfarin for ( 2.32 ± 1. 23 ) mg, INR 2.80± 0.19, hemorrhinia occurred for 2 person-times and hemoptysis occurred for 1 person-times, with a total inception rate of 18.7%. The person-times in group Ⅱ and Ⅲ accounted for 79.6% and the complication rate was the lowest when INR was between 1.5-2.5. Conclusions INR levels between 1.5-2.5 is the most secure, which is the best antico-agu]ation range in our region. Since the anticoagulation strength dynamically changes, the long-term anticoagulation status in patients after mechanical heart valve replacement should be deeply concerned.     

高危出血患者血液透析不同的抗凝护理方法和安全性比较

目的 探讨4种不同抗凝方法用于高危出血患者血液透析中的安全性、可行性和护理特点.方法 将有高危出血倾向的血液透析患者128例随机分成4组,A组采用30%枸橼酸钠局部体外抗凝(RCA)透析,B组采用鱼精蛋白中和肝素的局部肝素抗凝法,C组采用低分子肝素抗凝,D组采用无肝素透析.分别观察4组患者出血、体外循环的凝血情况、不良反应以及护理特点.结果 (1)A组透析68例次,均顺利完成透析;B组透析60例次中发生6例次出血或原有出血加剧;C组透析64例次中发生8例次出血或原有出血加剧;D组透析66例次中8例次因透析中出现体外循环Ⅲ级凝血而终止透析.(2)透析过程中A组有3例次、B组有2例次出现不良反应,经处理后症状缓解,可继续进行透析.C、D组均无不良反应出现.结论 RCA用于高危出血患者血液透析是安全可行的,护理方法也简便易于掌握.

Abstract：

Objective To observe the efficacy, safety and feasibility of the four kinds of anticoagulation method in hemodialysis patients with high risk of hemorrhage. Methods 128 patients with high risk of hemorrhage who had undergone hemodialysis were randomly divided into four groups. In group A, 68patients were resorted with 30% regional sodium citrate anticoagulation(RCA). In group B, 60 patients were treated with local heparin anticoagulation. In group C, 64 patients were treated with low molecular weight heparin (LMWH). In group D, 66 patients received no heparinization hemodialysis. The changes of bleeding, clotting function, adverse effect and nursing strategies were studied. Results All patients of group A completed regular hemodialysis with satisfactory indices, 6 cases with bleeding and primary bleeding aggravated in group B, 8 cases with bleeding and primary bleeding aggravated in group C, 8 cases occurred grade three coagulation and finished dialysis in group D. 3 cases in group A and 2 cases in group B occurred adverse reaction, but no adverse reaction was seen in group C and D. Conclusions RCA is safe,effective and can be easily handled in regular hemodialysis. It is an ideal dialysate for hemodialysis in patients with high risk of hemorrhage.     

护理干预对宫颈癌患者放疗后并发症的影响

Objective To investigate the nursing intervention on the complication after radiotherapy of cervical cancer patients.Methods A total of 130 cervical cancer patients undergoing radiotherapy were randomly divided into two groups:control group was given conventional methods only treatment and care,while the observation group was given additional routine treatment and care according to the situation in which two radiation therapy in patients with stages of psychological nursing,health education,guidance,individualized care and symptomatic treatment intervention,and then the number of cases of complications for the patients as well as the degree of satisfaction were compared.Results After the first phase of the second phase,the incidence of complications was significantiy lower in observation group than that of the control group,the degree of satisfaction was significantly higher (P＜0.05) .Conclusions The implementation of nursing intervention for cervical cancer patients undergoing radiotherapy can be effective in reducing the incidence of complications and improve patients' satisfaction.     

LAPAROSCOPIC TREATMENT OF ACUTE CHOLECYSTITIS

Objctive: To assess the current treatment of AC in a single institution in the series, which the best treatment modality for acute cholecystitis (AC) is still under debate, whereas early cholecystectomy is accepted as the optimal timing for surgery. Methods: From December 1996 to December 2001, 138 (102 women and 36 men) patients underwent laparoscopic cholecystectomy for acute cholecystitis confirmed by histopathological examination. The patients ranged in age from 21 to 85 years of age ( mean age: 45.3 years). Patients were divided into 2 groups (similar in age and ASA classification): group 1 (98 patients) underwent LC within 3 days after the onset of symptoms of acute cholecystitis and group 2 (40 patients) underwent LC after 3 days. Results: Approximately one half of the cases were uncomplicated, 26 %were empyema, 13 % had gangrenous changes and 7% had hydrops of the gallbladder. Conversion to open cholecystectomy was required in 21 (15.2%) cases. The principal reason for conversion was anatomic uncertainty (14 cases), uncontrolled bleeding (7 cases). The conversion rates in patients who underwent surgery before and after the onset of symptoms were respectively 6 : 15. There was no significant difference in operative time (122.0 min in 1 group versus 124.0 min in 2 group) and postoperative stay ( 5.1 days in group 1 vs 6.8 days in group 2). The hepatorenal space was drained in 78 (56.5 % ), and the drain is removed in 3rd postoperative days. Twenty six patients (18.8%) had undergone previous abdominal surgery. Thirty seven patients (26.8%) had spillage of bile and/or stones during the procedure. There were no deaths and major complications. Conclusions: LC for acute cholecystitis should be done immediately after the diagnosis is established because delaying surgery allows inflammation to become more intense, thus increasing the technical difficulty of LC. Intraoperative spillage of bile and stones does not lead to an increase in early complications. LC is safe and effective for acute cholecystitis even when complicated previous surgery, inflammatory adhesions and gangrene. LC has significantly fewer operative complications and provides shorter hospital stay which are medical and economic benefits. LC is safe and effective for acute cholecystitis.     

Pilon骨折的治疗与临床康复

AIM: To analyze the effect of three kinds of method on different types of Pilon fracture and advance the best treatment plan. METHODS: From March 1989 to August 2000,107 patients were regarded as having Pilon fracture by two hospitals, among which 76 cases were followed up. They were divided into three groups according to treatment method. A group included 24 cases with the treatment of manual reduction, traction of calcaneus and plaster ex-opexy. B group included 30 cases with the treatment of AO key-shaped anatomical steal plate. C group included 22 cases with the treatment of limited internal fixation combined with exopexy stand. RESULTS: After 6 months to 8 years follow-up, it was found that three kinds of treatment methods had obvious differences on the complications and effects of different types of fracture. In A group, the excellent and good rate of treatment on I type fracture was 70%, II type was 25%, Ⅲ type was 0%. In B group, the excellent and good rate of treatment on I type fracture was 7     

重组组织型纤溶酶原激活剂治疗妇科盆腔术后下肢深静脉血栓形成的临床研究

目的 探讨妇科盆腔术后并发下肢深静脉血栓形成(DVT)早期应用溶栓的疗效及安全性.方法 25例妇科盆腔术后并发早期下肢DVT患者随机分为抗凝治疗组(抗凝组13例)和溶栓治疗组[重组组织纤溶酶原激活剂(rt-PA)组12例].抗凝组予低分子肝素0.4 ml/d皮下注射,rt-PA组在此基础上一次性予rt-PA 100 mg经患肢静脉注射,7 d观察静脉再通率、凝血酶原时间(PT)及出血等不良并发症.结果 超声检查静脉rt-PA组复通率为91.7%(11/12),抗凝组为53.8%(7/13),2组差异有统计学意义(x2=15.68,P<0.01);2组各有1例发生阴道残端出血,未发现其他器官部位出血,2组出血率差异无明显统计学意义(x2=1.48,P>0.05),2例阴道残端出血患者均经局部止血后未再出血.结论 rt-PA用于妇科盆腔术后并发早期下肢.DVT的治疗,能有效提高下肢DVT静脉复通率,且不良反应较低.

Abstract：

Objective To explore the clinical effect and safety of using recombinant tissue type plasminogen activator (rt-PA) in early lower extremity deep venous thrombosis (DVT) after gynecological surgeries. Methods Twenty-five cases with early DVT after gynecological operation were enrolled and randomly divided into two groups,contorl group (n = 13) and the rt-PA therapy group (n = 12). The patients from contorl group were treated with Low-Molecular-Weight Heparins Calcium 0. 4 ml/d alone, and the rt-PA group accepted rt-PA 100 mg i. v in addition to the Low-Molecular-Weight Heparins Calcium. The recanalization rates of lamb veins,prothrombin time (PT) ,bleeding event and other adverse complications were observed and evaluated at day seven. Results The recanalization rates of lamb veins were 91. 7% (11/12) and 53. 8 % (7/13) in rtPA and the control group respectively,which showed significant difference between each other (x2 = 15. 68, P <0. 01). One case had vaginal stump bleeding in each group but no other hemorrhage in both group,the difference of bleeding rates between two groups didn't reach statistically significance (x2 = 1. 48 ,P> 0. 05). Two patients with vaginal stump bleeding were healed by local hemostasis. Conclusion The usage of rt-PA could improve the recanalization rate of DVT after gynecological surgery. The rates of adverse complications, including vaginal stump bleeding,were extremly low.     

Effects of preoperative other diseases on the complications of senile cervical Tertebral operation in perioperative period

AIM: To investigate the effects of preoperative other diseases on the complications of senile cervical vertebral operation in perioperative period METHODS: 800 senile cervical vertebral cases were divided into two group: group A included the cases without other comorbidilies, and group B included the cases with hypertension, diabetes mellitus, coronary heart disease (CHD) or chronic obstructive pulmonary disease(COPD) . We retrospectively analyzed the changes of BP, oxygen saturation (Sad) and the incidence of cardiac arrhythmia during operation of group A and B. RESULTS: In perioperative period, the incidence of BP reduction or rising and cardiac arrhythmia in group B was more than that of group A. Incidence of SaO2 decreasing increases apparently in each stage and incidence of cerebrovascular, pulmonary complications and asphyxia led by incision bleeding increases apparently. CONCLUSION: The hypertension, CHD, diabetes mellitus and COPD were the main reasons of complications of the heart, the cerebral     

Outcomes of anticoagulated trauma patients

Patients on warfarin are at high risk for potentially life-threatening hemorrhage even after relatively minor trauma. Outcomes of these patients and the potential complications of reversing the effects of anticoagulation have received little attention. This study was performed to determine the overall outcome of orally anticoagulated patients who sustained injury as well as to determine any untoward effects of reversing their anticoagulated states. A retrospective study of injured patients on warfarin was conducted on patients admitted to an urban, university, tertiary-referral, level I trauma center between 1/1/93 and 12/31/96. Surviving patients were followed for a period of at least 1 month. Injuries were grouped by anatomic site. Charts were reviewed for degree of anticoagulation on admission (ie, initial international normalized ratio [INR]), survival, adverse effects of reversal of anticoagulation, and reinstitution of warfarin therapy. Discharged patients were contacted at home for follow-up. Thirty-five consecutive patients, 18 men and 17 women, on warfarin therapy at the time of their injuries were reviewed. The mean age was 75 years, with a range of 39 to 96. The mean follow-up period was 12.7 months. Reasons for anticoagulation included atrial fibrillation, prosthetic heart valves, revascularized limb, hypercoagulable state, deep venous thrombosis, pulmonary embolism, phlebitis, and aortic stenosis. Mean admission INR was 3.2, with a range of 1.6 to 10.0. There were 8 in-hospital deaths. Intracranial hemorrhages accounted for the majority of injuries. Ten patients were not given reversal therapy. Four complications were attributable to reversal therapy (upper extremity hemiplegia, transient ischemic attack, deep venous thrombosis, arterial thrombosis). Twenty-one patients had their warfarin reinstituted. Follow-up of surviving patients ranged from 1.5 to 42 months. Patients on warfarin are at high risk for intracranial hemorrhage following trauma. Patients on warfarin may be reversed during the acute period following injury, but transient complications may arise. Further prospective studies need to be conducted to determine which anticoagulated trauma patients may not require reversal therapy.     

Tinzaparin in outpatients with pulmonary embolism or deep vein thrombosis

BACKGROUND: The low-molecular-weight heparins (LMWHs) have been shown to be effective in the outpatient treatment of deep vein thrombosis (DVT). Data regarding outpatient use of any LMWH in pulmonary embolism (PE) or tinzaparin in DVT while transitioning therapy to a vitamin K antagonist are limited. OBJECTIVE: To determine the safety and efficacy of tinzaparin in patients with either DVT or PE being transitioned to warfarin during LMWH therapy in the outpatient setting. METHODS: All patients who were treated with at least one outpatient dose of tinzaparin for venous thromboembolism (VTE) were identified. Charts of all patients followed within the University of California Davis healthcare system were reviewed. The incidence of bleeding and recurrent thromboembolism over a minimum of the first 4 weeks to a maximum of 12 weeks after initiating anticoagulation was assessed. RESULTS: A total of 178 patients with acute VTE were treated with tinzaparin, and outcomes could be determined in 140 cases. Forty-seven percent of these patients had objectively documented PE. Only one (0.7%) case of recurrent VTE was observed. Major bleeding was documented in 5 (3.6%) and minor bleeding in 8 (5.8%) patients. Two bleeding events, both major, occurred during tinzaparin therapy. CONCLUSIONS: Outpatient use of tinzaparin during transition to warfarin therapy in the treatment of VTE, including PE, appears to be feasible in patients who are judged candidates for home therapy.     

Treatment of venous thromboembolic disease. A pragmatic approach to anticoagulation and thrombolysis

Heparin (Lipo-Hepin, Liquaemin Sodium) and warfarin sodium (Coumadin, Panwarfin) are the classic anticoagulants in use for venous thromboembolic disease. They work by modifying the coagulation mechanism, heparin having an immediate effect and warfarin having a more delayed effect. The most common adverse effects of anticoagulation therapy are hemorrhagic complications. Thrombolytic therapy should be considered in all patients with massive pulmonary embolism with hypotension and in patients with deep venous thrombosis in the popliteal area or higher. Such therapy has been shown to help preserve the pulmonary microcirculation after pulmonary embolism and to decrease the incidence of the postthrombotic syndrome following deep venous thrombosis. If certain clinical guidelines are followed rigidly, the incidence of significant bleeding complications is low. Although the use of tissue plasminogen activator in venoocclusive disease has been limited to isolated cases, results have been very promising.     

心脏机械瓣膜置换术后华法林抗凝的调整策略

目的：研究心脏机械瓣膜置换术后华法林抗凝的调整策略及年龄、性别、体重与华法林抗凝剂量、疗效的关系。方法：回顾192例心脏机械瓣膜置换术后服用华法林抗凝患者的临床资料,总结华法林抗凝调整国际标准化比值（INR）的方法,分析年龄、性别、体重和华法林剂量、INR值的关系,观察其抗凝效果及主要不良反应。结果：1例患者因过量服用华法林出现颅内出血死亡,1例过量出现严重皮下出血及鼻出血,1例出现腔隙性脑梗死,2例单用华法林效果不佳,合用拜阿司匹林后INR可调整到目标范围,其余患者效果较好,无严重出血及血栓形成。结论：心脏机械瓣膜置换术后华法林抗凝维持剂量个体差异较大,与年龄、性别、体重无关;抗凝治疗维持INR在1.8-2.5间较为适宜,不增加出血及血栓风险。     

Bilateral Phlegmasia Cerulea Dolens After Warfarin Reversal for Acute Rectal Bleeding: A Case Report

Background

Deep vein thrombosis (DVT) is a common disease that is diagnosed in approximately 1 in 1000 adults annually. Extensive DVT can lead to life- or limb-threatening diagnoses such as phlegmasia cerulea dolens (PCD), phlegmasia alba dolens, and venous gangrene. PCD, also known as massive iliofemoral venous thrombosis, is rare, and a severe complication of DVT.

Prolonged hospitalization because of inappropriate delay of warfarin therapy in deep venous thrombosis

Current anticoagulation practices of physicians in an academic medical center were examined by retrospective review of records of 26 patients admitted for uncomplicated deep venous thrombosis (DVT) between 1978 and 1982. Patients received intravenous heparin for an average of 11.5 +/- 2.8 days. Warfarin therapy was started on day 8.3 +/- 3.1 and therapeutic oral anticoagulation was achieved by day 14.5 +/- 4.5. Total hospital stay averaged 16.8 +/- 5.1 days. No patient received concurrent initiation of heparin and warfarin therapy and only two patients received warfarin before day 5. These findings are in contrast to anticoagulation practices in Great Britain and Scandinavia where concurrent initiation of heparin and warfarin has been common practice for many years. Such a regimen is safe and usually requires fewer days of hospitalization for DVT. We conclude that failure to start warfarin therapy on the first hospital day resulted in a costly and unnecessarily prolonged hospital stay.     

下腔静脉滤器置人应用于下肢深静脉血栓形成的临床分析

目的探讨下腔静脉滤器（VCF）置入联合抗凝溶栓治疗下肢深静脉血栓形成（DVT）的效果及防治肺动脉栓塞的意义。方法回顾性分析2009年1月至2011年9月我院收治的DVT患者．115例,选择27例适合行VCF置入的患者,在数字减影血管造影术下行VCF置入,术后给予溶栓、抗凝等治疗。结果27例患者下腔静脉内均成功置入VCF,经溶栓、抗凝后患肢肿胀明显消退,术后无肺栓塞及滤器置入相关并发症发生。结论VCF置入联合抗凝溶栓治疗DVT疗效好且安全,VCF置入可有效预防下肢深静脉血栓患者肺栓塞的发生。     

凝血酶生成试验在监测华法林抗凝治疗中的应用

目的 探讨不同抗凝强度口服华法林治疗患者的凝血酶生成情况及其与出血的关系以及凝血酶生成试验在监测华法林抗凝治疗中的应用.方法 采集78例因心脏瓣膜置换术后房颤而口服华法林3个月以上的患者血样,检测凝血酶原时间-国际正常化比值(FT-INR)及凝血酶生成状况.结果 华法林治疗组按PT-INR不同分成三组:I组23例,PT-INR为1.51～2.00;Ⅱ组39例,PT-INR为2.01～3.00;Ⅲ组16例,PT-INR为3.01～4.26.三组凝血酶生成的延迟时间(lagtime)、峰值(peak)、达峰时间(ttpeak)都存在显著性差异(P《0.01),而反映凝血酶总体生成量的指标凝血酶生成潜力(endogenous thrombin potential,ETP),Ⅰ组和Ⅱ组比较差异存在统计学意义(P=0.0001),Ⅱ组和Ⅲ组比较差异无统计学意义(P=0.06).有出血并发症的患者5例,其ETP值小于正常对照组的15%.结论 口服华法林抗凝治疗患者,当PT-INR》3.0后,提高剂量会增加出血风险,但并不降低凝血酶生成量.服用华法林抗凝治疗期间同时检测PT-INR和ETP能更好地反映机体的凝血状态,从而有效地防止出血发生.     

A randomized clinical trial of high-intensity warfarin vs. conventional antithrombotic therapy for the prevention of recurrent thrombosis in patients with the antiphospholipid syndrome (WAPS).

BACKGROUND: The optimal intensity of oral anticoagulation for the prevention of recurrent thrombosis in patients with antiphospholipid antibody syndrome is uncertain. Retrospective studies show that only high-intensity oral anticoagulation [target international normalized ratio (INR) >3.0] is effective but a recent randomized clinical trial comparing high (INR range 3.0-4.0) vs. moderate (INR 2.0-3.0) intensities of anticoagulation failed to confirm this assumption. METHODS: We conducted a randomized trial in which 109 patients with antiphospholipid syndrome (APS) and previous thrombosis were given either high-intensity warfarin (INR range 3.0-4.5, 54 patients) or standard antithrombotic therapy (warfarin, INR range 2.0-3.0 in 52 patients or aspirin alone, 100 mg day(-1) in three patients) to determine whether intensive anticoagulation is superior to standard treatment in preventing symptomatic thromboembolism without increasing the bleeding risk. RESULTS: The 109 patients enrolled in the trial were followed up for a median time of 3.6 years. Mean INR during follow-up was 3.2 (SD 0.6) in the high-intensity warfarin group and 2.5 (SD 0.3) (P < 0.0001) in the conventional treatment patients given warfarin. Recurrent thrombosis was observed in six of 54 patients (11.1%) assigned to receive high-intensity warfarin and in three of 55 patients (5.5%) assigned to receive conventional treatment [hazard ratio for the high intensity group, 1.97; 95% confidence interval (CI) 0.49-7.89]. Major and minor bleeding occurred in 15 patients (two major) (27.8%) assigned to receive high-intensity warfarin and eight (three major) (14.6%) assigned to receive conventional treatment (hazard ratio 2.18; 95% CI 0.92-5.15). CONCLUSIONS: High-intensity warfarin was not superior to standard treatment in preventing recurrent thrombosis in patients with APS and was associated with an increased rate of minor hemorrhagic complications.     

Low-molecular-weight heparin in outpatient treatment of DVT

Patients with a diagnosis of acute deep venous thrombosis have traditionally been hospitalized and treated with unfractionated heparin followed by oral anticoagulation therapy. Several clinical trials have shown that low-molecular-weight heparin is at least as safe and effective as unfractionated heparin in the treatment of uncomplicated deep venous thrombosis. The use of low-molecular-weight heparin in an outpatient program for the management of deep venous thrombosis provides a treatment alternative to hospitalization in selected patients. Use of low-molecular-weight heparin on an outpatient basis requires coordination of care, laboratory monitoring, and patient education and participation in treatment. Overlapping the initiation of warfarin permits long-term anticoagulation. Advantages include a decreased incidence of heparin-induced thrombocytopenia and fewer episodes of bleeding complications. Future clinical trials evaluating the safety and efficacy of low-molecular-weight heparin in the treatment of complicated deep venous thrombosis will further define appropriate indications for use and strategies for outpatient management.