ISTH DIC subcommittee communication on anticoagulation in COVID‐19

Hypercoagulability is an increasingly recognized complication of SARS‐CoV‐2 infection. As such, anticoagulation has become part and parcel of comprehensive COVID‐19 management. However, several uncertainties exist in this area, including the appropriate type and dose of heparin. In addition, special patient populations, including those with high body mass index and renal impairment, require special consideration. Although the current evidence is still insufficient, we provide a pragmatic approach to anticoagulation in COVID‐19, but stress the need for further trials in this area.     

Phenotypic implications of a co-existent haemorrhagic and thrombotic genotype

Inherited bleeding disorders such as Von Willebrands disease (VWD) present with varying bleeding tendencies in different individuals. There have been several attempts to identify the determinants for this varying severity of the haemorrhagic manifestations, especially in those with milder forms or type 1 VWD. Genetic mutations have been noted in persons with haemophilia to be contributing to a milder bleeding phenotype. This report describes the clinical implications of a similar mixed haemorrhagic-thrombotic genotype.     

Emergency and out of hours care of patients with inherited bleeding disorders

Recently, the United Kingdom Haemophilia Centre Doctors Organisation published recommendations for the standard of care for assessment and treatment of patients with bleeding disorders in the emergency department (A&E). An audit was undertaken to compare the level of care to the acceptable standards in a tertiary hospital A&E, attached to a haemophilia comprehensive care centre. A&E attendances were found by cross referencing all patients with known bleeding disorders against the EDMS attendance system. Visits from the past 3 years were identified to produce sufficient data and electronic notes from these visits were then accessed, and marked against the proforma. Data were available from 45 of a total of 54 patients, who had a total of 75 emergency visits documented. In all aspects of care, the standards were not adequately met including the average length of time between booking and clinical assessment, early initiation of specific haemostatic treatment, seeking haematology advice and arrangement of follow-up. Also no specialist clotting investigations were done with only 9/11 patients admitted having their haematological diagnosis recorded. In addition, only very few patients had the severity of bleeding disorder noted and less than half their first line treatment documented. There were significant differences in the standard of care for haemophilia patients provided by the A&E department when compared with acceptable standards. Measures have been put in place and policies have been drafted to improve this situation and provide the best possible care to persons with haemophilia.     

Extreme thrombocytosis--an unusual presentation of inflammatory bowel disease

Thrombocytosis or a high platelet count (a count greater than 400 x 10(9)/L) is a common observation especially with the increased ordering of routine complete blood counts. When found, it may create a diagnostic challenge as transient elevations in platelet counts can occur for a number of reasons such as inflammation or infection, and these usually resolve spontaneously; but an elevated platelet count may be the only indication of an underlying serious disease to which no other clinical findings pertain. The report details a case of extreme thrombocytosis which masked an underlying diagnosis of inflammatory bowel disease.     

The evidence base of complementary and alternative therapies in depression

BACKGROUND: Depression is one of the leading indications for using Complementary and Alternative Medicine (CAM). This paper reviews the evidence of efficacy of different types of CAM in depression with the aim of identifying the highest level of evidence. METHODS: We conducted literature searches restricted to the English language for studies on CAM as monotherapy in depression. All papers were reviewed by two researchers and the evidence was ranked according to a widely referenced hierarchy of evidence. RESULTS: 19 papers formed the final review. We found Grade 1 evidence on the use of St. John's wort, Tryptophan/5-Hydroxytryptophan, S-adenosyl methionine, Folate, Inositol, Acupuncture and Exercise in Depressive disorders, none of which was conclusively positive. We found RCTs at the Grade 2 level on the use of Saffron (Herbal medicine), Complex Homoeopathy and Relaxation training in Depressive disorders, all of which showed inconclusive results. Other RCTs yielded unequivocally negative results. Studies below this level yielded inconclusive or negative results. LIMITATIONS: Searches were restricted to the English language. Our list of CAM approaches may not have been comprehensive. We excluded studies on the use of CAM as an adjunctive treatment and this review aimed to identify only the highest level of evidence. CONCLUSIONS: None of the CAM studies show evidence of efficacy in depression according to the hierarchy of evidence. The RCT model and the principles underlying many types of CAM are dissonant, making its application in the evaluation of those types of CAM difficult. The hierarchy of evidence we used has limited utility in grading trials of CAM.     

Brain death: a challenging diagnosis in trauma patients

Brain death is a catastrophic consequence of trauma, and diagnosing it can be a challenging for physicians because it presents in numerous ways. Since existing recommendations are not applicable to all hospitals because of the requirement of special equipment and highly-trained personnel, a committee of health care professionals at Charleston Area Medical Center in Charleston decided to review the available literature and create a new set of protocols regarding brain death. This article summarizes the findings of the committee and provides recommendations for physicians working with trauma patients.