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The efficacy and safety of new oral anticoagulants for cancer-associated venous thromboembolism: a meta-analysis

ObjectivesTo systematically review the efficacy and safety of new oral anticoagulants (NOACs) for cancer-associated venous thromboembolism.MethodsStudies about the efficacy and safety of NOACs versus low molecular weight heparins (LMWHs) or vitamin K antagonists (VKAs) for cancer-associated venous thromboembolism were collected by searching PubMed, EMbase, The Cochrane Library, CNKI, WanFang Data and CBM databases from inception to August, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Meta-analysis was then performed by RevMan 5.3 software.ResultsA total of 8 studies involving 2 448 patients were included. The results of meta-analysis showed that: there was no significant difference in the recurrent VTE rate (OR=0.74, 95%CI 0.49 to 1.11, P=0.15) or bleeding rate (OR=0.80, 95%CI 0.57 to 1.13, P=0.21) between NOACs group and VKAs group. The major bleeding rate was significantly higher in the VKAs group than in the NOACs group (OR=0.47, 95%CI 0.27 to 0.84, P=0.01). The incidences of recurrent VTE (OR=0.84, 95%CI 0.16 to 4.14, P=0.83), bleeding (OR=0.46, 95%CI 0.18 to 1.20, P=0.11), major bleeding (OR=0.45, 95%CI 0.12 to 1.60, P=0.21) were similar between NOACs group and LMWHs group.ConclusionsThe current evidence indicates that for cancer patients with VTE, NOACs are superior to warfarin and comparable to LMWHs. Due to limited quantity and quality of the included studies, more high quality studies are required to verify the above conclusion.

Neodoxy of Superficial Thrombophlebitis

育齡女性心瓣膜置換術后的抗凝治療

目的 探討心瓣膜置換術后抗凝治療對妊娠分娩、月經量過多、避孕失敗后人工流產手術等的影響，調整抗凝方案。方法 回顧我院1989年2月至1998年2月292例15～40歲育齡女性心瓣膜置換術后的抗凝治療，術后隨訪時間0.5～9年，比較不同抗凝方案對育齡女性術后的生理影響。結果 調整育齡女性心瓣膜置換術后抗凝方案，減少華法林用量，調控凝血酶原時間比值(PTR)為1.3～1.5，國際正常比值(INR)為2～3(國際敏感指數ISI=2.4校正)，既能有效預防血栓栓塞，又能提高術后妊娠分娩的安全性。結論 調整抗凝方案，減少華法林用量，能有效改善心瓣膜置換術后育齡女性的生活質量。

Efficacy and safety of DOAC on preventing venous thromboembolism after major orthopedic surgery: a systematic review

ObjectivesTo systematically review the efficacy and safety of direct oral anticoagulants (DOAC) on preventing venous thromboembolism (VTE) after major orthopedic surgery (MOS).MethodsThe Cochrane Library, PubMed, EMbase, CNKI, WanFang Data and CBM databases were electronically searched for randomized controlled trials (RCTs) on the efficacy and safety of DOAC on preventing VTE after MOS from inception to March 2019. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using RevMan 5.3 software.ResultsA total of 22 RCTs involving 41 244 patients were included. The results of meta-analysis showed that: the rate of symptomatic deep vein thrombosis (DVT) after MOS in rivaroxaban (Peto OR=0.54, 95%CI 0.35 to 0.82, P=0.004) and apixaban (Peto OR=0.49, 95%CI 0.26 to 0.92, P=0.03) were lower than enoxaparin. Additionally, the rate of symptomatic pulmonary embolism (PE) after MOS in rivaroxaban was lower than enoxaparin (Peto OR=0.53, 95%CI 0.29 to 0.96, P=0.04), however, in major bleeding after MOS rivaroxaban was significant higher than enoxaparin (Peto OR=1.98, 95%CI 1.30 to 3.01, P=0.001).ConclusionsCurrent evidence shows that rivaroxaban and apixaban is superior to enoxaparin on preventing symptomatic DVT after MOS. Rivaroxaban is superior to enoxaparin on preventing symptomatic PE, however, the risk of major bleeding is higher than enoxaparin. Due to limited quality and quantity of the included studies, more high quality studies are required to verify the above conclusions.

Application of regional citrate anticoagulation in continuous renal replacement therapy for patients with sepsis and hyperlactacidemia

Objective To explore the application of regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT) for patients with sepsis and hyperlactacidemia, and to provide a basis for the clinical application of RCA in such patients. Methods Sepsis patients who underwent RCA-CRRT at West China Hospital of Sichuan University between May 2021 and May 2023 were retrospectively included. Patients were divided into a normal lactate group (≤2.0 mmol/L) and a hyperlactacidemia group (>2.0 mmol/L) based on their initial lactate levels before CRRT, and subgroup analysis was performed on patients with moderate hyperlactacidemia (2 mmol/L<lactate level<4 mmol/L) and severe hyperlactacidemia (≥4.0 mmol/L). Propensity score matching (PSM) was used, and baseline characteristics and outcome measures of different groups of patients were compared. Results A total of 441 patients were included, with 228 in the normal lactate group and 213 in the hyperlactacidemia group. Before PSM, there were statistically significant differences in the proportion of liver failure, proportion of chronic kidney disease, mean arterial pressure, bicarbonate, total bilirubin, creatinine, activated partial thromboplastin time, international standardized ratio, procalcitonin, and interleukin-6 between the normal lactate group and the hyperlactacidemia group (P<0.05). After PSM, there were 162 patients in both the normal lactate group and the hyperlactacidemia group. There was no statistically significant difference in baseline characteristics between the two groups of patients (P>0.05). The incidence of citric acid accumulation in the normal lactate group and the hyperlactacidemia group was 13.0% and 25.9%, respectively (P<0.05). There was no statistically significant difference in the incidence of metabolic acidosis, metabolic alkalosis, hypernatremia, filter coagulation events, or in-hospital mortality between the two groups (P>0.05). Kaplan-Meier survival analysis showed that there was no statistically significant difference in the first extracorporeal circulation lifespan between the normal lactate group and the hyperlactacidemia group (P>0.05). Among 213 patients with hyperlactacidemia, 186 had moderate hyperlactacidemia and 27 had severe hyperlactacidemia. Before PSM, there were statistically significant differences in the proportion of male, proportion of diabetes, albumin level, international standardized ratio, and interleukin-6 between moderate and severe hyperlactacidemia groups (P<0.05). After PSM, there were 22 patients in both the moderate and severe hyperlactacidemia groups. There was no statistically significant difference in baseline characteristics between the two groups of patients (P>0.05). The incidence of citric acid accumulation was 18.2% and 50.0% in the moderate and severe hyperlactacidemia groups, respectively (P<0.05). There was no statistically significant difference in the incidence of metabolic acidosis, metabolic alkalosis, hypernatremia, filter coagulation events, or in-hospital mortality between the two groups (P>0.05). Kaplan-Meier survival analysis showed that there was no statistically significant difference in the first extracorporeal circulation lifespan between the moderate and severe hyperlactacidemia groups (P>0.05). Conclusion When RCA is used for CRRT anticoagulation in patients with sepsis and hyperlactacidemia, the incidence of citric acid accumulation is high (especially in patients with severe hyperlactacidemia), and should be closely monitored.

心臟機械瓣膜置換術后抗凝治療的安全性

目的 探討心臟機械瓣膜置換術后服用華法令的安全劑量及抗凝期間的注意事項。 方法 回顧性分析1999 年12 月至2010 年10 月皖南醫學院附屬弋磯山醫院132 例行心臟瓣膜置換術后進行華法令抗凝治療患者的臨床資料，其中男73 例，女59 例；年齡27 ～ 78 歲；術后口服華法令抗凝，隨訪3 個月～ 10 年，分析華法令應用情況及其并發癥發生情況。 結果 手術時間（240±96） min，體外循環時間（112±52） min，主動脈阻斷時間（81±23） min。全組術后出現皮膚紫癜2 例，死亡2 例。隨訪117 例，隨訪率90%（117/130），隨訪期間月經期月經量過多導致貧血4 例，血尿3 例，反復鼻衄或牙齦出血共4 例，消化道出血1 例，腦出血1 例，下肢栓塞1 例，腦梗死1 例，均治愈或好轉。 結論 心臟機械瓣膜置換術后正確服用華法令抗凝治療，及時監測，注意各種干擾因素可以明顯降低并發癥的發生率。

Surgery Therapy of Thrombosis Accompanied with Nephrotic Syndrome：Report of 4 Cases and Literature Review

目的　探討腎病綜合征并發血栓形成的外科治療特點。方法　從筆者所在單位收治的腎病綜合征并發血栓形成的患者中選取4例血栓形成部位罕見、治療難度大的病例，對其臨床資料進行分析。結果　1例在下肢深靜脈血栓形成基礎上發生下腔靜脈血栓形成；1例腹主動脈急性血栓形成伴下肢動脈栓塞導致下肢壞疽行高位截肢；1例股動脈支架內反復血栓形成導致下肢壞疽行高位截肢；1例人工血管及下肢動脈支架內短時間內血栓形成，經干細胞移植后下肢缺血得到緩解。結論　在血栓形成的診治過程中提高對腎病綜合征的認識，針對腎病綜合征患者高凝狀態在圍手術期進行預防性抗凝治療，以及充分認識腎病綜合征并發血栓形成抗凝治療的特殊性，可能會降低腎病綜合征患者血栓形成的發生率，提高腎病綜合征并發血栓形成的外科治療水平。

系統性紅斑狼瘡并抗磷脂綜合征致視網膜中央動靜脈阻塞1例

Development of a checklist for assessing credibility of cohort studies on effects of oral anticoagulants treatments for atrial fibrillation

ObjectivesTo develop a tool to assess the credibility of cohort studies regarding anticoagulants treatment for patients with atrial fibrillation.MethodsMEDLINE, EMbase and CBM databases were retrieved for eligible studies on the methodological quality and credibility of the cohort study. The retrieval period was from inception to December 19th, 2017, and the languages were limited to Chinese and English. Based on the search results, the items on the methodology quality of the research or the credibility of the results were collected. Through brainstorming of the core group, the collected items were expanded and sorted out to a preliminary scale. Furthermore, we conducted 4 rounds of internal expert seminars to discuss and evaluate the preliminary scale content and discuss the scale framework. Finally, we organized domestic authoritative experts to conduct 4 external evaluations on the scale and formed the final scale.ResultsA total of 7 734 literatures were obtained from primary search, in which 17 of which were included. Fifty-five tools with 780 items for the quality assessment of observational studies were collected from the included studies. After removing duplicated keywords with similar meanings, we obtained the " keyword pool” with 46 keywords, which were preliminarily formed 46 items. After discussion of the core group, which aimed to supplement the potential items, eliminate the items irrelevant to methodology, and integrate the items with partial overlapping meanings, a preliminary scale of 43 items was formed. According to the four rounds of internal expert consultative meetings, these items were integrated to form a preliminary scale of 40 items. After further evaluation by four rounds of external expert consultative meetings, a consensus was reached and a scale of 21 items from seven domains (i.e., definition of question, measurement, follow-up, confounder, missing data, statistical analysis, and results assessment) was finally formed.ConclusionsThis study developed an assessment tool for the credibility of the results from the cohort studies regarding anticoagulants treatment in patients with atrial fibrillation, which has practical clinical value. Clinicians can refer to the results of credibility assessment by using this tool to better assist clinical decision-making in clinical practice. In addition, in the preparation of relevant guidelines, this tool can be used to assess the credibility of results from cohort studies.

The effects of antiepileptic drugs on warfarin anticoagulation

Objective To investigate the effects of antiepileptic drugs (AEDs) with warfarin functions and blood coagulation system, to provide the reference for clinicians of the selection of AEDs under the combination therapy with warfarin. Methods Analyse the clinical data of the patient with symptomatic epilepsy from the Second Clinical Medical College of Guiyang University of Chinese Medicine on April 1, 2017, whom taking AEDs and warfarin at the same time, clear the drug adverse reactions, and analysed related literature. Results After the treatment with valproate, abnormal blood coagulation, a danger and emergency data appeared, so we stopped using warfarin immediately, and reduce the dosage of valproate gradually, insteadly, we used levetiracetam as antiepileptic therapy. Monitoring blood coagulation function, when it returned to normal, restart warfarin anticoagulant therapy. Conclusions When start antiepileptic treatment in relevant basic diseases of symptomatic epilepsy, for a variety of combination reactions, AEDs can affect the anticoagulant effect of warfarin, so we need to consider the interaction between drugs and avoid adverse reactions.