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Skin
Published in Keith Hopcroft, Vincent Forte, Symptom Sorter, 2020
SMALL PRINT: Autoimmune testing, further hospital investigations (see below). FBC, ESR/CRP: FBC may reveal thrombocytopenia or evidence of blood dyscrasia. ESR/CRP and WCC may be raised in blood dyscrasia, connective tissue disorder and infection.LFT, U&E: For underlying liver or renal disease.INR: If on warfarin.Autoimmune testing: If possible connective tissue disease causing vasculitis.Coagulation screen: To test haemostatic function (e.g. bleeding time, prothrombin time, activated partial thromboplastin time).Plasma electrophoresis: For hypergammaglobulinaemia, paraproteinaemia and cryoglobulinaemia.Further investigations (usually secondary care): To investigate underlying cause, e.g. skin biopsy to confirm vasculitis, bone marrow biopsy if possible marrow infiltrate.
Investigation and management of recurrent cholestasis of pregnancy
Published in Minakshi Rohilla, Recurrent Pregnancy Loss and Adverse Natal Outcomes, 2020
ICP has been associated with a higher prevalence of gestational diabetes and even preeclampsia [24]. Thus, women with ICP must also be evaluated for gestational diabetes. A coagulation screen should also be done as steatorrhea may cause a deficiency of vitamin K absorption that is required for the formation of coagulation factors.
Perioperative Care
Published in Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams, Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
Newer non-VKA oral anticoagulants (NOAC) are increasingly being used. These include direct thrombin inhibitors (dabigatran) or direct Xa inhibitors (rivaroxaban, apixaban, edoxaban). They do not affect the routine coagulation screen and therefore cannot be monitored with the normal INR, PT or APTT levels. NOACs have a shorter half-life (6–11 to 1214 hours). They are stopped in general 2 days prior to surgery (2–3 times their half-lives) or longer for surgery with higher risk of bleeding. Bridging therapy is often not required except in patients at increased risk of thrombosis.85 Discussion with a haematologist is helpful in cases of uncertainty.
Pediatric bronchoscopy: recent advances and clinical challenges
Published in Expert Review of Respiratory Medicine, 2021
P Goussard, P Pohunek, E Eber, F Midulla, G Di Mattia, M Merven, JT Janson
Safety concerns were apparently the main reason why routine use of bronchial biopsy was only slowly accepted as a possible supplemental method in pediatric flexible bronchoscopy. However, accumulated experience with this method in children proved that correctly indicated and properly performed endobronchial biopsy did not add any significant risk to that inherent in the bronchoscopy itself [81,82]. The possibility of adverse effect of such procedure should, however, be always on one´s mind. Especially in situations with expected increased fragility and increased vascularization, the risk of bleeding or bronchial perforation might be theoretically higher. On the other hand, performing a routine coagulation screen in patients without clinically apparent bleeding disorders was proven unnecessary when endobronchial biopsy was planned. Taking bronchial biopsy has been shown to prolong flexible bronchoscopy by about 5 minutes; this might be relevant in children with impaired ventilation [83].
Do we still need cryoprecipitate? Cryoprecipitate and fibrinogen concentrate as treatments for major hemorrhage — how do they compare?
Published in Expert Review of Hematology, 2018
Alex Novak, Simon J. Stanworth, Nicola Curry
As previously described, major hemorrhage in the context of trauma is often associated with an early depletion of fibrinogen levels, as part of ATC which may impair hemostasis [16]. Measurement of patients’ clotting status by means of a standard coagulation screen including PT or INR and APTT is routinely performed in major trauma cases, but these typically do not include fibrinogen concentrations. While PT and APPT may be prolonged in very low fibrinogen concentrations, generally coagulation screens will appear near normal [22]. Fibrinogen concentrations may be specifically measured as a derived level, based on PT, or directly as a Clauss measurement. While the former is generally the cheaper and faster of the two methods, it is not a recommended test as the derived fibrinogen level tends to be significantly less accurate than that obtained by the Clauss assay which is generally seen as the ‘gold standard’ [23]. In a 2014 review Levy et al. characterize the trigger threshold of 1.0g/L fibrinogen as being based on inherited fibrinogen deficiency, with little evidence for its application in acquired deficiency due to hemorrhage [24]. More recent 2016 European trauma guidelines suggest a plasma fibrinogen of 1.5–2.0 g/L as the trigger threshold, though again this is based on scanty evidence [6].
Acquired hemophilia A with SARS-CoV-2 mRNA vaccine: first case from Pakistan
Published in Scandinavian Journal of Clinical and Laboratory Investigation, 2022
Anila Rashid, Zurrya Khan, Junaid Alam
A 75-year-old diabetic male presented to emergency with complaints of spontaneous large bruises on both thighs extending to his back. There was no past personal or family history of bleeding disorder. He was not on any regular medication, except for insulin. He received COVID-19 vaccine booster dose of Pfizer-BioNTech, six days prior to his symptoms. He had his first and second dose of SinoPharm BBIBP COVID-19 vaccine six months back which were uneventful. He never contracted COVID-19 infection during pandemic. On examination, he was pale with extensive bruising approximately 12 × 5 cm on right arm, 15 × 10 × 11 cm on right leg extending up to his back and 10 × 9 × 5 cm on left leg. There was no palpable visceromegaly or active bleeding from any site. Laboratory investigations showed Hb: 84 g/L, WBC: 8.7 × 109/L and platelet: 346 × 109/L. Peripheral blood smear showed normocytic normochromic anemia. His renal and liver function was normal. Coagulation screen showed normal PT and prolonged aPTT. The prolonged aPTT did not show correction on 1:1 mixing studies with normal plasma both on immediate and incubated mix which indicated presence of immediate acting inhibitor. Subsequently, clotting factor assay was performed with multiple dilutions that revealed non-parallelism with both factor VIII (FVIII) and IX (FIX). However, the activity of FIX normalized while FVIII remained undetectable despite performing extended dilutions (Table 1). The inhibitor titer was not performed due to non-availability of Bethesda assay at our facility. The auto-immune profile including ANA, ANAG-EET, ASMA, ANA and anti-DNA were negative. On admission, SARs-CoV-2 rapid antigen test was performed as hospital COVID protocol which was negative.