Dear Editor,Bleeding represents the most feared complication of oral anticoagulant therapy (OAT) with vitamin K antagonists (VKA), one of the major classes of drugs used in cardiovascular medicine. Of the general population in developed countries, 1-1.5% is subject to OAT, 1 with widespread use over the last two decades. 2,3 Elderly patients represent the main group of patients treated with OAT, with a high prevalence in this group of diseases needing OAT, such as atrial fibrillation. 4 But advanced age also represents one of the main risk factors for VKA-related bleeding, together with severe liver and kidney diseases, severe thrombocytopenia, history of previous bleeding, anemia, dementia and risk of falls. 5 The incidence rate of major hemorrhage rises gradually with age from 1.5 per 100 patient-years for patients younger than 60 years to 4.2 per 100 patientyears for patients older than 80 years, yielding a hazard ratio of 2.7 (95% confidence interval, 1.7-4.4). 6 Bleeding is classified as major if it leads directly to death, it occurs in critical organs (brain, retroperitoneum, peritoneum, chest, spinal cord, joints, gastrointestinal tract), if it results in hemorrhagic shock, a decrease of 2 g/dL in hemoglobin (Hb) levels, or if it requires surgical or invasive maneuvers. The remaining bleedings are classified as minor bleedings. 7 Spontaneous and/or traumatic retroperitoneal bleedings represents a well-recognized OAT-related major complication, often related to a rupture of the iliopsoas muscle, whereas spontaneous renal hematoma (SRH) is a very uncommon example of OAT-related bleeding, diagnosis of it being often difficult and late, especially when signs such as macrohematuria are absent. Prothrombin complex concentrate (PCC) is now considered the first choice for urgent OAT reversal together with intravenous vitamin K1 (VK1) in VKA-related major bleedings. 8 The cornerstone of OAT reversal is bringing the International Normalized Ratio (INR) to a value less than 1.5, to restore normal coagulation, in association with maneuvers to stop bleedings and/or resolve hemorrhagic shock. 9,10 Recently, an 86-year-old man taking warfarin for chronic atrial fibrillation came to our attention for the abrupt onset of dyspnea and fatigue; he suffered from left sciatica for 3 days and left lumbar pain for a few hours. He denied fever, and macrohematuria was absent. Recent trauma was excluded.His past history revealed previous coronary artery bypass and prostatic cancer. Physical examination showed pallor and sweating. Systemic blood pressure (SBP) measured 75/50 mmHg, demonstrating a status of shock. Blood arterial gas analysis was substantially normal. A 12-lead electrocardiogram (ECG) revealed tachycardic atrial fibrillation (120 beats per minute) and complete right bundle branch block. Chest and abdominal radiographs and abdominal ultrasonography performed in the emergency department were unremarkable. Results of laboratory assays showed Hb levels of 10.6 g/dL, creatinine 1.41 mg/dL, normal values of brain natriuretic...

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BACKGROUND: Intracranial haemorrhage represents the most feared stroke subtype. AIM: To evaluate the burden of intracranial haemorrhage in Tuscany hospitals with special reference to Livorno district. MATERIALS AND METHODS: Data of patients discharged in 2009 from Tuscan and Livorno hospitals with codes ICD-9-CM related to any type of spontaneous intracranial haemorrhage were selected and analyzed. RESULTS: 3,472 patients were discharged from Tuscan hospitals with these diagnoses. Overall mortality was 24.3%. 50% of patients were admitted in Internal Medicine wards. Incidence of intracranial haemorrhage and intracerebral haemorrhage (ICH) in population of Livorno district was 64 and 45/100,000 inhabitants/year with related mortality of 36.5% and 39.4%respectively. Intra-hospital mortality of patients admitted in Livorno hospitals for intracranial haemorrhage were 36.7%. 40% of deaths occurred in the first 48 hours. 69.6% of intracranial haemorrhage were ICHs, 16.8% subaracnoideal. Intra-hospital mortality, admissions for intracranial haemorrhage in respect of total admissions and mortality for intracranial haemorrhage in respect to total mortality increased in the last decade. 23% of patients with intracranial haemorrhage and 16% of patients with ICH underwent to surgical procedures. ICHs related to antithrombotic treatment significantly increased in the last years. Mortality in patients on antithrombotic drugs was three times over compared to that in patients not undergone these drugs (43.7% vs 12.8%, p < 0.01). CONCLUSION: There is an increasing trend in frequency, mortality and hospital burden of intracranial haemorrhage and ICH. Efforts aimed at reducing the burden and consequences of this devasting disease are warranted.

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Acquired hemophilia is a severe, potentially life-threatening condition usually involving elderly patients, caused by an auto-antibody against factor VIII of coagulation. We describe the case of a 92-years-old woman who came to our attention for severe acute anemia associated with many spontaneous diffuse skin bleedings secondary to a prolonged aPTT 110 sec, factor VIII < 1% with a titer of factor VIII inhibitor of 5.5 Bethesda Units. A diagnosis of chronic lymphocytic leukemia was determined. We treated the patient with a blood transfusion and intravenous corticosteroids with prompt reduction of aPTT and inhibitor factor VIII titer. The present case report involving a very old patient could represent an example of acquired hemophilia as a first manifestation of a lymphoproliferative syndrome.