Results of Surgery in General Surgical Patients Receiving Warfarin: Retrospective Analysis of 61 Patients

The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries—being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.Key words: Emergency, Postoperative complications, Morbidity, Mortality, WarfarinThromboembolism is a major global health concern contributing to more than 0.5 million deaths in Europe and up to 300,000 deaths in the United States each year.¹ Versatile arrays of anticoagulant and/or anti-aggregant agents are available. They are used to treat and prevent thrombosis occurring as a result of venous stasis, valvular heart disease, prosthetic valves, atrial fibrillation, or myocardial infarction. After using these medications, patients who require elective or emergency surgery represent a specific population; moreover, they are prone to developing either excessive bleeding or thrombosis.The annual incidence of major bleeding as a result of oral anticoagulant (OAC) use is reported between 2 and 5%.² Patients on OAC may require elective or sometimes emergency surgical or invasive procedures. There is no consensus on standard protocol to follow for those who require perioperative management.³In the current literature, there are limited numbers of studies regarding the discussions about the operations in general surgery patient population receiving warfarin treatments. In this retrospective study, our aim was to document the complications and outcomes of general surgical procedures implemented on patients receiving warfarin. Along with the comparison of the emergency and elective surgeries performed, we also aimed to determine the factors affecting mortality.     

Poststreptococcal reactive arthritis in children: is it really a different entity from rheumatic fever?

Poststreptococcal reactive arthritis (PSRA) is an acute, nonsuppurative arthritis following documented streptococcal infections. Although most authors accepted it as a different entity, the differences from acute rheumatic fever (ARF) are not clear. To document and compare the clinical and laboratory characteristics of PSRA and ARF, 24 patients with PSRA and 20 with ARF were enrolled in the study. The latency period from upper respiratory tract infection was shorter in patients with PSRA ( P<0.01). However, 25% of the patients with ARF had also short (<10 days) latency periods. Although symmetric and nonmigratory arthritis were more frequent in patients with PSRA, there was no significant difference for the distribution of mono-, oligo-, and polyarticular disease between PSRA and ARF patients. The frequency of small joint and hip involvement was also similar between the patient groups. Unresponsiveness of articular symptoms to salicylate therapy within 72 h was more frequent in patients with PSRA (P<0.001). However, in a substantial part of the patients with ARF (nine patients, 45%), joint symptoms also had no response during the first 72 h. Since there is a considerable overlap of symptoms, signs, and laboratory features of PSRA and ARF, a line between these two entities could not be easily drawn. We conclude that these two conditions are actually different presentations of the same disease.     

D-dimer level predicts in-hospital mortality in patients with infective endocarditis: A prospective single-centre study

Background

Increased circulating D-dimer levels have been correlated with adverse outcomes in various clinical conditions. To our knowledge, the association of on-admission D-dimer and in-hospital mortality in infective endocarditis (IE) has not been investigated. We hypothesized that increased on-admission D-dimer levels would correlate with adverse outcomes when prospectively studied in patients with IE.

Methods

In this prospective study, a total of 157 consecutive patients with the definite IE diagnosis met the inclusion criteria and underwent testing for on-admission D-dimer and CRP assays. The outcome measure was in-hospital death from any cause.

Results

In-hospital mortality occurred in 40 (26%) patients. Increased levels of plasma D-dimer (5.1 ± 1.7 vs 1.9 ± 0.8, p < 0.001), CRP [45(13-98) vs 12(5–28), p < 0.001] were found in dead patients compared with those survived. In addition to S. aureus infection, increased leukocyte count, end-stage renal disease, LVEF < 50%, vegetation size of > 10 mm, perivalvular abscess, on-admission D-dimer (HR: 1.32; 95% CI: 1.24-1.40; p < 0.001) and CRP (HR: 1.18; 95% CI: 1.09-1.36; p = 0.001) levels were significantly associated with in-hospital mortality. Furthermore, the sensitivity and specificity of D-dimer ≥ 4.2 mg/L in predicting in-hospital death in IE were 86% and 85%, respectively. Moreover, the sensitivity and specificity of CRP levels ≥ 13.6 mg/L were 72% and 69%, respectively.

Conclusion

Our findings suggest that on-admission D-dimer level may be a simple, available and valuable biomarker that allows us to identify high-risk IE patients for in-hospital mortality. D-dimer ≥ 4.2 mg/L, CRP ≥ 13.6 mg/L were independently associated with IE related in-hospital death.     

Multivessel Coronary Thrombosis in a Patient with Idiopathic Thrombocytopenic Purpura

A 49-year-old woman who had idiopathic thrombocytopenic purpura was admitted to our hospital with severe chest pain. Electrocardiography revealed inferolateral myocardial infarction. The patient underwent immediate coronary angiography, which revealed thrombi in the left coronary system. Percutaneous intervention was not indicated, because the thrombi had occluded the distal segments of multiple coronary arteries. Administration of tirofiban satisfactorily dissolved the thrombi.Key words: Coronary thrombosis, multivessel; myocardial infarction; platelet aggregation inhibitors/therapeutic use; purpura, thrombocytopenic, idiopathic/therapy; tirofibanIdiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder in which autoantibodies bind platelets, leading to their sequestration by the reticuloendothelial system.¹ Patients with ITP typically have mucocutaneous bleeding. Although such reports are rare, thrombotic complications such as acute myocardial infarction (MI) and stroke also occur in patients with ITP.^2–4 We present the case of a middle-aged woman with ITP who sustained an acute MI caused by multivessel coronary thrombosis.     

Conservative rehabilitation of missing teeth before placement of implant dentures: clinical reports

Although implant-supported restorations often are preferred for the replacement of missing teeth, their high cost means that they can be given only to patients who can afford them. The clinical reports in this article describe interim conservative restorations made after orthodontic treatment to achieve esthetics, phonation, and function until implant-supported dentures were made. In all cases, the patients who received fiber-reinforced resin composite fixed partial dentures returned for follow-up visits at three-month intervals and reported no complaints during a year of follow-up visits. The desired esthetics can be achieved with temporary conservative treatment until the implant dentures are applied; if this treatment meets the patient's esthetic expectations, the final restoration can be fabricated according to these contours.     

Surgery for Hepatolithiasis: Single Center Experience of 12 Patients

Hellenic Journal of Surgery - Hepatolithiasis is the presence of stones within the intrahepatic bile ducts, regardless of common bile duct and gallbladder stones. It is rarely seen in our country...