Seminars in thrombosis and hemostasis
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Semin. Thromb. Hemost. · Mar 2013
ReviewEvaluation of patients with microangiopathic hemolytic anemia and thrombocytopenia.
When a patient presents with unexpected microangiopathic hemolytic anemia and thrombocytopenia, the diagnosis of thrombotic thrombocytopenic purpura (TTP) is often considered. However, many different disorders, including many different systemic infections and malignancies, can cause thrombotic microangiopathy (TMA), with the clinical features of microangiopathic hemolytic anemia and thrombocytopenia. ⋯ This article focuses on distinguishing TTP from other etiologies of microangiopathic hemolytic anemia and thrombocytopenia, because consideration of the diagnosis of TTP requires an urgent decision for the initiation of plasma exchange treatment. Awareness of the many etiologies of TMA is essential for the appropriate evaluation of patients presenting with microangiopathic hemolytic anemia and thrombocytopenia and the appropriate diagnosis of TTP.
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Semin. Thromb. Hemost. · Feb 2013
ReviewMassive posttraumatic bleeding: epidemiology, causes, clinical features, and therapeutic management.
Bleeding typically results as a consequence of derangements of primary hemostasis, secondary hemostasis, or both, and can be dramatically amplified by the presence of other predisposing conditions, especially inherited bleeding disorders. Life-threatening hemorrhages are, however, almost exclusively caused by penetrating wounds, blunt traumas of chest and abdomen, suicide attempts, amputations, bone fractures with concomitant injury to internal organs and blood vessels, and shearing forces from sudden rotation, violent flexion, extension, or deceleration injuries. ⋯ The mortality rate of severe posttraumatic bleeding can be as high as 50%, especially when an appropriate treatment is not established in a timely manner. The damage control sequence basically entails a four-step approach including damage control surgery, damage control resuscitation with fluid restoration, and hemocomponents administration, as well as correction of the coagulopathy with platelets, antifibrinolytic (e.g., tranexamic acid), and/or procoagulant agents such as fresh frozen plasma, prothrombin complex concentrate, or recombinant-activated Factor VII.
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Thrombotic microangiopathy is a pathological process that results in thrombocytopenia, schistocytes, and organ ischemia. A wide variety of causes of thrombotic microangiopathy have been described, each associated with a different pathological stimulus and predisposition toward certain vascular territories. This review will summarize our understanding of key drugs that have been classically and newly associated with thrombotic microangiopathy as well as mention of treatment options focusing on the role of plasma exchange.
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Although vitamin K antagonists (VKAs) such as warfarin have been used clinically for decades, evidence supporting how best to manage their use in clinical practice is lacking, but continues to emerge. This article summarizes available information regarding the clinical management of VKAs with focus on dosing strategies. For patients with previously stable international normalized ratio (INR) control, the single mildly out-of-range INR does not warrant a change in VKA dose. ⋯ Patient self-management of VKA therapy offers advantages for motivated patients who can demonstrate competency in self-management including fingerstick INR testing. Most patients with excessive anticoagulation who are not bleeding can be managed without administering vitamin K. There is an ongoing need for research evaluating VKA dosing practices that can consistently improve the outcomes of VKA therapy.
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Semin. Thromb. Hemost. · Oct 2012
ReviewApproach to the diagnosis and management of common bleeding disorders.
Mild mucocutaneous bleeding symptoms are common in the general population. Differentiating normal from pathological bleeding complaints begins with a detailed bleeding history that assesses: the pattern (primary versus secondary hemostasis), the severity, and the onset (congenital versus acquired) of bleeding. ⋯ Clinical management focuses on the particular symptoms experienced by the patient. Medical interventions include replacement of the factor that is deficient or defective, or indirect treatments, such as antifibrinolytics (tranexamic acid), desmopression, and hormone-based therapy (e.g., oral contraceptive pill for menorrhagia).