COVID-19 and venous thromboembolism: Known and unknown for imaging decisions

As we continue to fight against the current coronavirus disease-2019 (COVID-19) pandemic, healthcare professionals across the globe are trying to answer questions surrounding how to best help patients with the up-to-date available science while awaiting the development of new therapies and mass vaccination. Since early in the pandemic, studies indicated a heightened risk of venous thromboembolism (VTE) in COVID-19 infected patients. There have been differing expert opinions about how to assess pretest probability of VTE in this patient population. This has been partly due to the high prevalence of respiratory failure in this patient population and the use of D-dimer as a prognostic test which is also frequently elevated in patients with COVID-19 in absence of VTE. Some experts have argued for an approach similar to usual care with testing if clinical suspicion is high enough. Some have argued for more routine screening at different points of care. Others have even suggested empiric therapeutic anti-coagulation in moderate to severely ill COVID-19 patients. In the following article, we review and summarize the most current literature in hopes of assisting clinicians in decision making and guidance for when to be concerned for VTE in COVID-19 patients. We also discuss research gaps and share pathways currently being used within our institution.     

Low-molecular-weight heparin followed by rivaroxaban for acute occlusive portomesenteric vein thrombosis in a cirrhotic patient treated with multiple endoscopic variceal procedures

Acute portomesenteric vein thrombosis is potentially lethal. In the present paper, a cirrhotic patient with a previous history of esophageal variceal bleeding presented with acute occlusive portomesenteric vein thrombosis, but achieved complete recanalization by low-molecular-weight heparin followed by rivaroxaban. Notably, no bleeding episode occurred during anticoagulation therapy. This case supported early initiation of anticoagulation in such patients.     

长期接受抗凝抗聚药物治疗病人并发脑出血的治疗分析

目的 探讨长期接受抗凝抗聚药物治疗病人发生脑出血的治疗方法及疗效。方法 回顾性分析2014年8月至2018年8月收治的33例长期接受抗凝抗聚药物治疗的脑出血的临床资料。保守治疗10例，急诊开颅血肿清除+去骨瓣减压术7例，钻孔引流术16例。结果 术后死亡1例（3%）。32例平均随访6个月，依据日常生活能力量表:Ⅰ级2例，Ⅱ级11例，Ⅲ级12例，Ⅳ级5例，Ⅴ级2例。结论 对长期接受抗凝抗聚药物治疗的脑出血，应密切监测凝血功能及相关指标参数，根据病人的具体情况选择针对性的治疗措施。     

临床药师在导管接触性溶栓联合抗凝治疗急性下肢深静脉血栓的用药分析与药学监护中的作用

目的 探讨临床药师在急性下肢深静脉血栓患者个体化治疗中的作用。 方法 对南京鼓楼医院血管外科2018年8月收治的8例急性下肢深静脉血栓患者的治疗过程进行分析，结合临床药学知识制定导管接触性溶栓及抗凝用药方案，对患者实施全程药学监护。 结果 溶栓治疗期间，患者血浆纤维蛋白原水平呈明显下降趋势，血浆D-二聚体水平呈先升高后降低的趋势，血小板未见明显下降趋势；8例患者在溶栓治疗过程中，2例出现轻微牙龈出血后自行止血，1例出现血尿，停止溶栓治疗后改为口服抗凝药，血尿现象消失。患者预后改善明显，血栓完全溶解，静脉恢复畅通，用药安全得到有效保障。 结论 临床药师在导管接触性溶栓联合抗凝治疗急性下肢深静脉血栓患者的个体化用药监护方面发挥了积极作用。     

Non-vitamin K oral anticoagulants in nonvalvular atrial fibrillation: a network meta-analysis

Objectives. We conducted a systematic review and network meta-analysis of randomized controlled trials (RCTs) including the comparison of non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin for patients with atrial fibrillation (AF). Design. Network meta-analysis. Two authors independently extracted data. All authors evaluated overall confidence in the evidence. Results. Eighteen RCTs included in our review, a total of 78,796 patients with AF, with sample sizes from 90 to 21,105 patients. Apixaban 5?mg (OR: 0.79, 95% CI: 0.66 to 0.95), dabigatran 110?mg (0.91, 0.74–1.12), dabigatran 150?mg (0.66, 0.53–0.82), edoxaban 60?mg (0.87, 0.74–1.02), and rivaroxaban 20?mg (0.88, 0.74–1.03) reduced the risk of stroke or systemic embolism compared with warfarin. Dabigatran 150?mg had the highest P-score for reducing stroke or systemic embolic events. The risk of haemorhagic stroke and all-cause mortality was lower with all NOACs than with warfarin. Apixaban 5?mg (0.69, 0.60–0.80), dabigatran 110?mg (0.80, 0.69–0.93), dabigatran 150?mg (0.93, 0.80–1.08), edoxaban 30?mg (0.46, 0.40–0.54), and edoxaban 60?mg (0.78, 0.69–0.90) reduced the risk of major bleeding compared with warfarin. Edoxaban 30?mg had the highest P-score for reducing major bleeding. The plots of P-scores rank showed that apixaban offered the most favorable balance of efficacy and safety. Conclusions. This study adds an attempt for treatment ranking of both efficacy and safety outcomes. Future trials comparing directly NOACs are needed in order to provide conclusive proofs for these results and not only circumstantial evidence offered by a network meta-analysis.     

Anticoagulantes orales directos en cirugía dermatológica

Direct-acting oral anticoagulants (DOACs) have emerged as safer, easier-to-manage alternatives to traditional vitamin K antagonists and are used increasingly because they require no monitoring, have a wider therapeutic window, and react less with other drugs. However, there is little consensus on optimal perioperative management when these drugs are used in dermatologic surgery. This article describes the characteristics of DOACs and reviews current evidence on their use in this setting.