5 research outputs found
Netraumatski obostrani subduralni hematom uzrokovan antiagregacijskom terapijom: Prikaz sluÄaja i pregled literature
A 64-year-old female receiving clopidogrel and aspirin antiaggregation therapy after percutaneous coronary intervention for non-STEMI myocardial infarction developed nontraumatic bilateral subdural hematoma with dizziness, vertigo and headache. Craniotomy had to be postponed because of reduced ADP platelet aggregability. Four days after clopidogrel withdrawal and transfusion of 12 platelet concentrate units, ADP aggregation transiently normalized and bilateral trepanation with hematoma evacuation was performed. The procedure was followed by excellent neurologic and clinical recovery; however, decreased platelet aggregability was recorded by postoperative day 12 despite strict clopidogrel and other platelet inhibitor withdrawal. Suspicion of Glanzmann thrombastenia was excluded by flow cytometry. Two weeks after neurosurgery, the right femoral vein thrombosis was detected by color doppler ultrasonography and therapy with fractionated heparin was initiated, followed by warfarin. The risk and incidence of hemorrhagic complications of antiaggregation and anticoagulation therapy are discussed. Caution is warranted on prescribing this potentially harmful therapy to older patients, generally burdened with other chronic comorbidities.U 64-godiÅ”nje bolesnice koja je zbog ne-STEMI srÄanog infarkta dobivala aspirin i klopidogrel razvio se netraumatski obostrani subduralni hematom praÄen smuÅ”enoÅ”Äu, vrtoglavicom i glavoboljom. Kod prijma je utvrÄena smanjena agregacija trombocita u ADP testu pa je kraniotomija i dekompresija odgoÄena za 4 dana. Äetiri dana nakon prestanka uzimanja klopidogrela i aspirina te uz transfuziju od 12 doza trombocita prolazno se normalizirala agregabilnost trombocita pa je uÄinjena obostrana trepanacija i uklonjeni su hematomi. Slijedio je odliÄan neuroloÅ”ki oporavak. Smanjena agregabilnost trombocita bila je prisutna do 12. poslijeoperacijskog dana. Sumnja na Glanzmannovu trombasteniju iskljuÄena je protoÄnom citometrijom. Äetrnaestoga poslijeoperacijskog dana nastala je tromboza desne femoralne vene koja je lijeÄena smanjenim dozama heparina i varfarina. Uz prikaz bolesnice analizira se rizik od krvarenja i tromboze u bolesnika koji uzimaju antitrombocitne lijekove. PreporuÄa se oprez u starijih bolesnika kod kojih su prisutne i druge teÅ”ke bolesti, Å”to poveÄava rizik od krvarenja
Recidivi venske tromboze unatoÄ āoptimalne antikoagulantne terapijeā antifosfolipidnog sindroma. Mogu li novi peroralni antikoagulansi rijeÅ”iti problem ?
The aim was to determine the validity of the international normalized ratio (IN R) and prothrombin time (PT ) as a monitor for warfarin therapy in patients with lupus anticoagulants and recurrent thrombosis, and to investigate alternative approaches to monitoring warfarin therapy and new treatment options in these patients. A case is described of a 63-year-old female with antiphospholipid syndrome and recurrent venous thrombosis despite optimal adjusted warfarin therapy. In patients with lupus anticoagulants, the IN Rs obtained while receiving warfarin vary and often overestimate the extent of anticoagulation, while PT without receiving warfarin is often prolonged. In conclusion, lupus anticoagulants can influence PT and lead to IN R that does not accurately reflect the true level of anticoagulation. Optimizing of (warfarin) oral anticoagulation therapy could be achieved by individual monitoring of anticoagulation effect with a test that is insensitive to lupus anticoagulants (chromogenic factor X assay). Emerging oral anticoagulants, direct thrombin inhibitors and direct factor Xa inhibitors, such as dabigatran and rivaroxaban, with a predictable anticoagulant response and little potential for food or drug interactions, have been designed to be administered in fixed doses without coagulation monitoring and could be the treatment choice for these patients.Cilj je bio analizirati uzroke neuspjeha āoptimalno doziranogā varfarina kod prevencije recidiva duboke venske tromboze u bolesnika s antifosfolipidnim sindromom. Opisuje se sluÄaj 63-godiÅ”nje bolesnice s antifosfolipidnim sindromom i recidivima venske tromboze tijekom uzimanja varfarina. Vrijednosti IN R bile su u terapijskim granicama. Analizirali su se patofizioloÅ”ki mehanizmi nastanka tromboze i literaturni podaci. Rezultati su pokazali kako u bolesnika s pozitivnim lupus antikoagulans (LA) testom vrijednost PV -IN R ne daje pravu sliku protuzgruÅ”avajuÄeg uÄinka varfarina. Aktivnost PV je zbog interferencije Äesto lažno smanjena, iako u Äasu mjerenja bolesnik ne uzima varfarin ili drugi antagonist vitamina K. ZakljuÄak je kako prisutnost LA može interferencijom lažno smanjiti aktivnost u PV testu i rezultirati nalazom IN R koji ne odražava pravo stanje protuzgruÅ”avajuÄe aktivnosti izazvane varfarinom. U tom bi sluÄaju umjesto PV testa trebalo mjeriti aktivnost faktora Xa kromogenom metodom koja je neosjetljiva na LA. Drugo moguÄe rjeÅ”enje bi u bolesnika s antifosfolipidnim sindromom bila zamjena varfarina novim lijekovima, oralnim inhibitorima trombina i faktora X. Ovi lijekovi u fiksnoj dozi s predvidivim te o hrani i lijekovima uglavnom neovisnim protuzgruÅ”avajuÄim uÄinkom imaju djelotvornost i nuspojave uglavnom sliÄne varfarinu, ali ne trebaju kontrole IN R
Pedesetpet godina (1955.-2010.) Odsjeka za koagulaciju pri hematoloÅ”kom laboratoriju KliniÄke bolnice Sestara milosrdnica i njegova osnivaÄa, hematologa Ljubomira PopoviÄa
The Coagulation Section at Laboratory of Hematology, Sestre milosrdnice University Hospital, Zagreb, was founded in 1955 by Ljubomir PopoviÄ, hematologist and assistant at School of Medicine, University of Zagreb, in cooperation with hard-working laboratory technicians. Apart from papers on hematologic neoplasms, plasmacytoma and lymphoma, Ljubomir PopoviÄ published a number of papers in the field of anticoagulant therapy with heparin and oral anticoagulants, some of which are also in use today. After Ljubomir PopoviÄ left the Hospital in 1964, the Laboratory was run by Professor Nedjeljko MiliÄ, head of the newly founded Division of Hematology. In 1968, the management of the Laboratory of Hematology was taken over by Biserka RaiÄ, MS , medical biochemist, until her retirement in 2007. Great development in morphological and cytometric studies of blood and blood cells has been paralleled by continuous progress and almost dominating activities in the diagnosis of hemostasis disorders. In the 1970s, Marko KoprÄina, hematologist, and Biserka RaiÄ introduced the then latest tests in practice at all Hospital departments. In that golden age of the Coagulation Section, M. KoprÄina, B. RaiÄ and their associates transferred their knowledge to all colleagues in the Hospital. Through that collaboration, high standards in the diagnosis of hemostasis disorders were achieved, from which the currently high level of clinical knowledge about coagulation disorders and their treatment has derived, making Sestre milosrdnice University Hospital one of the leading hospitals in this field in the country. By describing development of the Coagulation Section and the life of its founder Ljubomir PopoviÄ, the authors tried to provide an answer to the following question: can todayās clinicians still have a deciding role in laboratory development, considering that assessments of different phenomena are always initiated by an interested clinician who is trying to interpret and understand the nature of the disorder? This means that the clinicianās place may still be in the laboratory, or else, it will become clear that the laboratory, as well as knowledge in general, has undergone such an expansion that the clinician is no longer able to run it by himself. It is our belief that the answer will assert itself through the survey of the history of the Coagulation Section at Laboratory of Hematology, Division of Hematology, and the lives of its founders and beneficiaries.Koagulacijski odsjek HematoloÅ”kog laboratorija u KliniÄkoj bolnici āSestre milosrdniceā osnovao je davne 1955. godine hematolog Ljubomir PopoviÄ, uza svesrdno zalaganje suradnika laboratorijskih tehniÄara. Doktor PopoviÄ je tada bio asistent na Medicinskom fakultetu i voditelj Odsjeka hematologije na internom odjelu. U novoosnovanom laboratoriju doktor PopoviÄ traži rjeÅ”enja i odgovore na pitanja koja se javljaju u kliniÄkoj praksi uz bolesniÄki krevet. StruÄni napredak praÄen je objavljivanjem niza Älanaka o hemoblastozama i protuzgruÅ”avajuÄoj terapiji, koje postavke vrijede i danas. Ujesen 1964. godine PopoviÄ u naponu snage napuÅ”ta Bolnicu, a Koagulacijski laboratorij dalje vodi profesor Nedjeljko MiliÄ, proÄelnik novostvorenoga Zavoda za hematologiju. Godine 1968. dolazi inženjerka medicinske biokemije magistra Biserka RaiÄ i vodi HematoloÅ”ki laboratorij do svog umirovljenja 2007. godine. Golem napredak bilježi dijagnostika poremeÄaja hemostaze, ali i citometrijske i morfoloÅ”ke analize krvnih stanica. Sedamdesetih i osamdesetih godina proÅ”loga stoljeÄa, u zlatno doba razvoja i rada Koagulacijskog laboratorija, hematolog Marko KoprÄina sa suradnicima te inženjeri biokemije Biserka RaiÄ i Biserka GetaldiÄ uvode niz novih koagulacijskih i viskozimetrijskih testova u kliniÄku praksu Bolnice. Ovaj hematoloÅ”ko-koagulacijski kliniÄki rad Äini Zavod za hematologiju naÅ”e bolnice, s lijeÄnicima i inženjerima, jedinstvenim i prepoznatljivim. Uz opis razvoja Koagulacijskog laboratorija te života njegova osnivaÄa Ljubomira PopoviÄa autori pokuÅ”avaju odgovoriti na pitanje može li i mora li danas, kao prije pedeset godina, kliniÄar imati odluÄujuÄu ulogu u razvoju i radu laboratorija. Autori smatraju da je kliniÄaru internistu i dalje mjesto u laboratoriju, ali uz gotovo neispunjiv uvjet sinteze baziÄnih znanja iz biologije, tehnologije s kliniÄkom praksom. Razvoj Koagulacijskog laboratorija te životni put njegova osnivaÄa doktora Ljubomira PopoviÄa pokazuju kako bi njemu ova sinteza, isto kao i prije 55 godina, možda uspjela i danas
Kombinirana megaloblastiÄna i imunohemolitiÄka anemija - Prikaz sluÄaja
A 55-year-old female with a history of psychosis and rheumatoid arthritis was admitted to the hospital for fatigue and dizziness. At admission, macrocytic anemia, high serum lactic acid dehydrogenase (LDH) and gastrin concentrations, decreased serum vitamin B concentration, with macroovalocytes and poikilocytes in peripheral blood smear suggested the diagnosis of pernicious anemia. Indirect antiglobulin test (IAT) was negative. Surprisingly, treatment by vitamin B and folic acid administered for two weeks was ineffective and followed by transitory worsening of hemoglobin concentration on day 8. Repeat direct antiglobulin test (DAT) and IAT were positive. This immunotransfusion conversion, suggesting the presence of autoimmune hemolytic anemia, could be explained by change in the macroblastic erythrocyte population, i.e. emerging red cells with completely exposed membrane antigens due to vitamin B treatment and/or higher degree of dysregulation of the lymphocyte clone secreting erythrocyte autoantibodies. We proposed the coexistence of pernicious and autoimmune hemolytic anemia; therefore, methylprednisolone was added to vitamin B treatment. This therapy successfully improved hemoglobin and erythrocyte concentration. Although megaloblastic-pernicious anemia is a common disease, association of pernicious and autoimmune hemolytic anemia with two mechanisms of hemolysis (ineffective erythropoiesis and immune mechanism) is a rare condition, with only several dozens of cases described so far.Opisuje se 55-godiÅ”nja bolesnica koja je primljena u bolnicu zbog slabosti i vrtoglavica. Ranije je bila lijeÄena od reumatoidnog artritisa i psihoze. Pri dolasku su nalazi makrocitne anemije s makroovalocitima i hipersegmentiranim neutrofilima u perifernom razmazu, u serumu visoka koncentracija laktat dehidrogenaze (LDH) i gastrina, te snižena koncentracija vitamina B upuÄivali na dijagnozu perniciozne anemije. Indirektni antiglobulinski test (IAT) bio je negativan. Dvotjedno lijeÄenje vitaminom B i folnom kiselinom ne samo da nije imalo uÄinka, nego se osmog dana lijeÄenja pogorÅ”ao stupanj anemije. Razmatralo se lijeÄenje transfuzijom eritrocita, ali su kontrolni IAT i direktni antiglobulinski test (DAT) sada bili pozitivni, Å”to je ukazivalo na autoimunu hemolitiÄku anemiju (AIHA). Ova imunotransfuzioloÅ”ka konverzija, uz ostale razloge možda vezana i uz dvotjedno lijeÄenje vitaminom B , mogla je biti uzrokovana pojaÄanom reaktivnoÅ”Äu i "gubitkom nadzora" klona limfocita koji luÄe anteritrocitna antitijela i/ili promjenama u sazrijevanju i konformaciji eritrocitne membrane makroblasta s jaÄim izražajem antigena na koje su reagirali "nekontrolirani" limfociti. Anemija je tada shvaÄena kao združena pojava perniciozne anemije i AIHA. Dodatkom metilprednisolona vitaminu B postignut je porast hemoglobina i eritrocita, a stanje bolesnice se popravilo. Iako je perniciozna anemija Äesta bolest, udružena perniciozna i autoimuna hemolitiÄka anemija su opisane samo u nekoliko desetaka sluÄajeva, uglavnom u sastavu drugih autoimunih bolesti
Combined megaloblastic and immunohemolytic anemia associated - case report
A 55-year-old female with a history of psychosis and rheumatoid arthritis was admitted to the hospital for fatigue and dizziness. At admission, macrocytic anemia, high serum lactic acid dehydrogenase (LDH) and gastrin concentrations, decreased serum vitamin B concentration, with macroovalocytes and poikilocytes in peripheral blood smear suggested the diagnosis of pernicious anemia. Indirect antiglobulin test (IAT) was negative. Surprisingly, treatment by vitamin B and folic acid administered for two weeks was ineffective and followed by transitory worsening of hemoglobin concentration on day 8. Repeat direct antiglobulin test (DAT) and IAT were positive. This immunotransfusion conversion, suggesting the presence of autoimmune hemolytic anemia, could be explained by change in the macroblastic erythrocyte population, i.e. emerging red cells with completely exposed membrane antigens due to vitamin B treatment and/or higher degree of dysregulation of the lymphocyte clone secreting erythrocyte autoantibodies. We proposed the coexistence of pernicious and autoimmune hemolytic anemia; therefore, methylprednisolone was added to vitamin B treatment. This therapy successfully improved hemoglobin and erythrocyte concentration. Although megaloblastic-pernicious anemia is a common disease, association of pernicious and autoimmune hemolytic anemia with two mechanisms of hemolysis (ineffective erythropoiesis and immune mechanism) is a rare condition, with only several dozens of cases described so far