Myeloproliferative neoplasms (MPNs) are clonal hematopoietic stem cell disorders with shared gene mutations, excess blood production and wide range of clinicopathological changes. JAK2, CALR and MPL gene mutation study has become one of the major criteria in the diagnosis of MPNs. This study focused on the common laboratory findings in patients with genetically proven MPNs at age 50 and younger with clinical correlation and follow up. There were 54 patients in this study, including 36 essential thrombocythemia (66.7%), 13 polycythemia vera (24.1%), 2 primary myelofibrosis (3.7%) and 3 MPN-unclassifiable (5.5%). The male/female ratio was 1/2 in patients with essential thrombocythemia, and about 1/1 in patients with other types of MPNs. Thrombocytosis and abnormal megakaryocytic proliferation were the most common findings in peripheral blood and bone marrow biopsy specimens, 88.9% and 96.8% respectively. Thrombotic event was recorded more often in patients with polycythemia vera than essential thrombocythemia, 30.1% and 19.4% respectively. Myelofibrosis, evolving acute myeloid leukemia and disease related mortality were seen only in patients with polycythemia vera, but not in patients with essential thrombocythemia. The findings in this study suggested that genetically induced abnormal megakaryocytic proliferation might play a critical role in the early pathogenesis of MPNs. With an increased risk for thrombotic event and disease progression, patients with polycythemia vera may need more follow up evaluation and therapeutic intervention than those with essential thrombocythemia. Anti-megakaryocytic therapy may be a future direction in the management of young MPN patients.
Introduction/Objective Direct oral anticoagulants (DOACs) have gained wide use in prevention and treatment of thromboembolic diseases. Although relatively rare with DOAC therapy, intracranial hemorrhage may become a medical emergency and needs to be managed with caution to avoid adverse consequences. Methods During the review of 94 patients with DOAC therapy related bleeding complications at William Beaumont hospital – Troy, Michigan, 3 patients were identified with intracranial hemorrhage. Information on DOAC therapy, the cause related to intracranial hemorrhage, and clinical assessment and management of these patients were collected from electronic medical charts with concurrent laboratory studies. Results There were 1 male and 2 female patients, ages 63, 67 and 86. Two patients were taking rivaroxaban 20 mg daily and 1 patient apixaban 5 mg bid for atrial fibrillation and DVT. Patients were clinically stable with no prior significant bleeding events, except for minor skin rashes. All patients experienced a minor trauma to the head and showed signs of brain injury. They were brought to the emergency department immediately. DOAC therapy was discontinued during the emergency evaluation. CT studies revealed 1 patient with subdural hematoma and 2 patients with focal intraparenchymal hemorrhage without mass effects. Both clinical and laboratory assessment revealed stable medical conditions. Patients received conservative care without surgical intervention and repeat CT studies demonstrated resolution of hemorrhage. One patient discontinued DOAC therapy permanently and the others resumed DOAC therapy with antidotes available. Clinical follow up showed no additional bleeding events. Conclusion Intracranial hemorrhage can occur in patients received DOAC therapy, even in clinically stable patients, and most likely happens after head injury. In this small group of patients, both clinical and laboratory evaluations showed stable medical conditions, with no need for surgery intervention. However, the decision of continuing DOAC therapy should be made with caution and it is reasonable to have antidote available for these patients.
Direct oral anticoagulants (DOACs)-apixaban, rivaroxaban and dabigatran have become the first line medications for patients with thromboembolism. However, DOAC therapy-associated bleeding complications remain the major clinical concern for these patients. This study compared laboratory test results from 82 patients with and 361 patients without DOAC-associated bleeding with the goal of determining the value of laboratory tests in assessing bleeding risk in these patients. There was no age or gender difference between patients with and without DOAC therapy-associated bleeding complications. Both prothrombin time (PT) and partial thromboplastin time (PTT) prolonged at the same time showed good correlation with bleeding complications for patients receiving dabigatran (91.7%) and rivaroxaban (41.2%). When comparing patients with bleeding and those without bleeding complications, impaired renal function showed high correlation (p < 0.01), impaired liver function showed moderate correlation (p = 0.03), and thrombocytopenia showed no correlation (p > 0.05) among patients with bleeding complications. A small population of patients had never experienced bleeding complications, despite the laboratory test results being similar to patients who suffered from bleeding complications. Laboratory tests may be useful in the assessment and prediction of bleeding complications in patients receiving DOAC therapy. However, it is important to incorporate both laboratory findings with the clinical information, such as concomitant antithrombotic agents and other underlying diseases in the decision making of DOAC therapy in order to reduce therapy-related bleeding risk.
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