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Seminars in Thrombosis and Hemostasis

Alison S Witkin, Savanah Harshbarger, Christopher Kabrhel
Pulmonary embolism is a common and often life-threatening event. Treatment options include anticoagulation alone, catheter-directed therapies, and surgical thromboembolectomy. While guidelines exist, there is often controversy over which treatment is most appropriate, particularly for intermediate-risk patients. The traditional care model, in which the primary team is responsible for consulting the appropriate specialists, may be inadequate and inefficient for emergent situations, as ensuring coordination and communication between various consulting services can be a time consuming and confusing process...
October 21, 2016: Seminars in Thrombosis and Hemostasis
Bengt Zöller, Xinjun Li, Henrik Ohlsson, Jianguang Ji, Ashfaque A Memon, Peter J Svensson, Karolina Palmér, Björn Dahlbäck, Jan Sundquist, Kristina Sundquist
Familial aggregation (clustering) of venous thromboembolism (VTE) is the clustering of VTE within a family. Though several genes, such as antithrombin, protein C, protein S, factor V, and prothrombin are associated with the familial clustering of VTE, these loci only partially explain the familial aggregation of VTE. The epidemiology of the familial aggregation of VTE exhibits typical characteristics of complex traits. The family history of VTE in first-degree relatives is associated with a two to three times increased familial relative risk (FRR)...
October 20, 2016: Seminars in Thrombosis and Hemostasis
Benjamin White, Rachel Rosovsky, Blair Alden Parry, Christopher Kabrhel
Pulmonary embolism (PE) and venous thromboembolism (VTE) are common diagnoses in the emergency department (ED), with significant potential morbidity and mortality. As a result, historically nearly all patients with PE have been admitted to the hospital for observation and treatment. In recent years, the ability to rapidly and accurately risk stratify patients with VTE according to their risk of short-term clinical deterioration has supported outpatient treatment, and non-vitamin K antagonist oral anticoagulants (NOACs) have further facilitated this approach...
October 20, 2016: Seminars in Thrombosis and Hemostasis
Sam Schulman
During the past 7 years, results from phase III trials comparing nonvitamin antagonist K oral anticoagulants (NOACs) with vitamin K antagonists (VKAs) or with placebo, including 34,900 patients, have been published. Recent guidelines have been updated and now suggest treatment with NOACs rather than with VKA. Other updates in the guidelines concern the initial thrombolytic treatment for selected patients with deep vein thrombosis or pulmonary embolism as well as the possibility of withholding anticoagulation for minimal venous thromboembolism...
October 20, 2016: Seminars in Thrombosis and Hemostasis
Paolo Prandoni, Enrico Bernardi, Fabio Dalla Valle, Adriana Visonà, Pietro F Tropeano, Carlo Bova, Eugenio Bucherini, Md Shahidul Islam, Andrea Piccioli
Patients with unprovoked venous thromboembolism (VTE) may harbor occult cancer. Whether an extensive diagnostic work-up for cancer has additional value over a more limited screening for detection of underlying malignancy in these patients is controversial. We performed a randomized multicenter trial to assess if in patients with unprovoked VTE, a computed tomography (CT)-based diagnostic strategy including thoracic, abdominal, and pelvic CT in combination with fecal occult blood test yields a higher cancer detection rate than a nonstandardized testing approach based on physicians' clinical judgment and patients' preferences...
October 20, 2016: Seminars in Thrombosis and Hemostasis
Søren Hess, Evan C Frary, Oke Gerke, Poul Henning Madsen
Pulmonary embolism (PE) is a common, ubiquitous, and potentially lethal disease. As symptoms and clinical findings are notoriously nonspecific, diagnostic imaging is essential to avoid undertreatment as well as overtreatment. Controversies remain regarding first-line imaging in suspected PE. The two main contemporary contenders are ventilation/perfusion scintigraphy with single-photon emission computed tomography (V/Q SPECT) with or without additional low-dose CT (SPECT/CT) and CT angiography (CTA). We present our results from a systematic review and meta-analysis of the diagnostic performances of these modalities: V/Q SPECT, V/Q SPECT/CT, and CTA are all viable options, but we consider V/Q SPECT/CT to be superior in most clinical settings with better overall diagnostic performance, that is, pooled sensitivities (97...
October 20, 2016: Seminars in Thrombosis and Hemostasis
Marta Crous-Bou, Laura B Harrington, Christopher Kabrhel
Venous thromboembolism (VTE) includes deep vein thrombosis and pulmonary embolism, and a combination of environmental and genetic risk factors contributes to VTE risk. Within environmental risk factors, some are provoking (e.g., cancer, surgery, trauma or fracture, immobilization, pregnancy and the postpartum period, long-distance travel, hospitalization, catheterization, and acute infection) and others are nonprovoking (e.g., age, sex, race/ethnicity, body mass index and obesity, oral contraceptive or hormone therapy use, corticosteroid use, statin use, diet, physical activity, sedentary time, and air pollution)...
October 20, 2016: Seminars in Thrombosis and Hemostasis
David J Cote, Heloise M Dubois, Aditya V Karhade, Timothy R Smith
Background Patients who undergo craniotomy for brain tumor have an increased risk of developing venous thromboembolism (VTE). Using the National Surgical Quality Improvement Program (NSQIP) registry, patients undergoing craniotomy for brain tumor from 2006 and 2014 were analyzed to identify risk factors for postoperative VTE. Methods The study population, identified by Current Procedural Terminology codes, included all NSQIP-reported patients who underwent a craniotomy for brain tumor resection. Results There were 629 instances of VTE among 19,409 craniotomies for brain tumor (3...
October 20, 2016: Seminars in Thrombosis and Hemostasis
Massimo Miniati
Pulmonary infarction occurs in nearly one-third of the patients with acute pulmonary embolism. Infarcts are still often mistaken for pneumonia or lung cancer because of the deeply rooted belief that they ought to be triangular in shape. In reality, the apical portion of an embolized region is spared from infarction thanks to sufficient collateral blood flow. Infarcts are always arranged peripherally along the surface of the visceral pleura (costal, diaphragmatic, mediastinal, or interlobar). Their free margin is sharp and convex toward the hilum, casting a semicircular or cushion-like density on chest radiography or computed tomography (CT)...
October 15, 2016: Seminars in Thrombosis and Hemostasis
Santosh S Hanmod, Rohith Jesudas, Roshni Kulkarni, Meera Chitlur
Neonates form a unique cohort with distinct features associated with the hemostatic system compared with older children and adults. The development of the human hemostatic system begins around 10 weeks in utero and continues to evolve during childhood. This dynamic period termed developmental hemostasis should be taken into consideration when diagnosing a neonate with disorders of bleeding or thrombosis.
October 5, 2016: Seminars in Thrombosis and Hemostasis
Rohan D'Souza, Candice K Silversides, Claire McLintock
The prothrombotic state of pregnancy increases the risk of thromboembolic complications and death in women with mechanical heart valves (MHVs). Although it is accepted that these women must be on therapeutic anticoagulation throughout pregnancy, competing maternal and fetal risks, as well as the lack of high-quality data from prospective studies, make the choice of the optimal method of anticoagulation challenging. Vitamin K antagonists (VKAs) are associated with fewer maternal complications, but conversely also the lowest live birth rates as well as warfarin-related embryopathy and fetopathy...
October 5, 2016: Seminars in Thrombosis and Hemostasis
Hannah Cohen, Deepa R J Arachchillage, Jan Beyer-Westendorf, Saskia Middeldorp, Rezan A Kadir
Direct oral anticoagulants (DOACs) provide an effective, safe, and convenient therapeutic alternative to warfarin and other vitamin K antagonists (VKAs), and are now established for a wide range of indications. The use of DOACs in women merits special consideration due to two main situations: first, in relation to fertility, pregnancy, and lactation in women of reproductive age; second, because of their bleeding risk, leading to abnormal uterine and/or other genital tract bleeding. This review focuses on these two clinical situations, including approaches to management in the context of available information...
October 5, 2016: Seminars in Thrombosis and Hemostasis
Andra H James, Chad Grotegut, Homa Ahmadzia, Cathleen Peterson-Layne, Evelyn Lockhart
The purpose of this article is to review the use of blood products and hemostatic agents in the management of coagulopathy at the time of postpartum hemorrhage. Blood product administration strategies are broadly reviewed, including the role of the blood bank, the role of massive transfusion protocols, the role of laboratory monitoring, and the role of anesthesia management. Aspects of patient blood management are discussed. The concept refers to an evidence-based, comprehensive, multidisciplinary approach to optimizing the care of patients who might need transfusion and includes measures to avoid or minimize transfusion such as preoperative anemia management, cell salvage, and the use of hemostatic medication to reduce bleeding...
October 3, 2016: Seminars in Thrombosis and Hemostasis
Joanna Davies, Rezan Kadir
Management of factor XI (FXI) deficiency in pregnancy is complicated by lack of correlation between FXI level and bleeding risk. Clinicians should be vigilant about the potential for prolonged or excessive bleeding following miscarriage or termination of pregnancy, or postpartum hemorrhage (PPH). A multidisciplinary approach along with an individual care plan is recommended to prevent bleeding complications. Assessment of bleeding history, FXI level, and global tests of hemostasis can aid management decisions regarding hemostatic prophylaxis...
October 3, 2016: Seminars in Thrombosis and Hemostasis
Linda Fredriksson, Daniel A Lawrence, Robert L Medcalf
The plasminogen activation (PA) system is best known for its role in fibrinolysis. However, it has also been shown to regulate many nonfibrinolytic functions in the central nervous system (CNS). In particular, tissue-type plasminogen activator (tPA) is reported to have pleiotropic activities in the CNS, regulating events such as neuronal plasticity, excitotoxicity, and cerebrovascular barrier integrity, whereas urokinase-type plasminogen activator is mainly associated with tissue remodeling and cell migration...
September 27, 2016: Seminars in Thrombosis and Hemostasis
Dominik F Draxler, Maithili Sashindranath, Robert L Medcalf
Plasmin is the effector protease of the fibrinolytic system, well known for its involvement in fibrin degradation and clot removal. However, plasmin is also recognized as a potent modulator of immunological processes by directly interacting with various cell types including leukocytes (monocytes, macrophages, and dendritic cells) and cells of the vasculature (endothelial cells, smooth muscle cells) as well as soluble factors of the immune system and components of the extracellular matrix. In fact, the removal of misfolded proteins and maintenance of tissue homeostasis seem to be major physiological functions of plasmin...
September 27, 2016: Seminars in Thrombosis and Hemostasis
Karen A Moffat, Clinton W Lewis
Vitamin K antagonists (VKA) have been used for many years as effective anticoagulant therapy. The laboratory plays a crucial role in measuring the prothrombin time (PT) and calculating the international normalized ratio (INR). Each component of the calculation has the potential to increase error in the final result. This article discusses the laboratory aspects of monitoring VKA including sample requirements, PT, determination of the INR, point of care (POC) testing, external quality assurance/proficiency testing, and reversal strategies for VKA therapy...
September 27, 2016: Seminars in Thrombosis and Hemostasis
Ashwini Bennett, Sanjeev Chunilal
Pregnancy-associated venous thromboembolism (PAVTE) consists of deep vein thrombosis and pulmonary embolism (PE) occurring during pregnancy or in the postpartum period. This condition is common and is a major source of morbidity in a population which is young and otherwise relatively healthy. Timely diagnosis and treatment are crucial in ensuring satisfactory patient outcomes. Diagnostic strategies for pregnancy-associated PE in particular require careful consideration of maternal and fetal risks. Low-molecular-weight heparins currently form the mainstay of treatment; however, there are uncertainties around optimal dosing of these agents in certain settings (e...
September 22, 2016: Seminars in Thrombosis and Hemostasis
Karen Schreiber, Beverley J Hunt
Antiphospholipid syndrome (APS) is classified as the association of thrombotic events and/or obstetric morbidity in patients persistently positive for antiphospholipid antibodies (aPL). APS is also the most frequently acquired risk factor for a treatable cause of recurrent pregnancy loss and increases the risk of conditions associated with ischemic placental dysfunction, such as stillbirth, intrauterine death, preeclampsia, premature birth, and fetal growth restriction. The use of low-dose aspirin and heparin has improved the pregnancy outcome in obstetric APS and approximately 70% of pregnant women with APS will deliver a viable live infant...
September 21, 2016: Seminars in Thrombosis and Hemostasis
Fazoil I Ataullakhanov, Ekaterina M Koltsova, Anna N Balandina, Ilya I Serebriyskiy, Tatiana A Vuimo, Mikhail A Panteleev
Pregnancy is associated with a significant procoagulant shift in the hemostatic system balance as well as other metabolic changes. Pregnancy can thereby provoke manifestation of otherwise dormant disorders of hemostasis (e.g., thrombophilia), or even cause new, pregnancy-specific disorders (e.g., HELLP syndrome). Application and interpretation of laboratory assays of hemostasis in pregnancy is particularly challenging, because normal physiological ranges are no longer applicable, and because the most dangerous and complex changes are not detected by classic routine coagulation/platelet assays...
September 21, 2016: Seminars in Thrombosis and Hemostasis
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