SummaryUnselected coagulation testing is widely practiced in the process of assessing bleeding risk prior to surgery. This may delay surgery inappropriately and cause unnecessary concern in patients who are found to have 'abnormal' tests. In addition it is associated with a significant cost. This systematic review was performed to determine whether patient bleeding history and unselected coagulation testing predict abnormal perioperative bleeding. A literature search of Medline between 1966 and 2005 was performed to identify appropriate studies. Studies that contained enough data to allow the calculation of the predictive value and likelihood ratios of tests for perioperative bleeding were included. Nine observational studies (three prospective) were identified. The positive predictive value (0AE03-0AE22) and likelihood ratio (0AE94-5AE1) for coagulation tests indicate that they are poor predictors of bleeding. Patients undergoing surgery should have a bleeding history taken. This should include detail of previous surgery and trauma, a family history, and detail of anti-thrombotic medication. Patients with a negative bleeding history do not require routine coagulation screening prior to surgery.Keywords: surgery, coagulation screen, bleeding, clinical history. ObjectiveThe aim of this guideline is to provide a rational approach to the use of bleeding history and coagulation tests prior to surgery or invasive procedures to predict bleeding risk. The aim is to evaluate the use of indiscriminate testing. Appropriate testing of patients with relevant clinical features on history or examination is not the topic of this guideline. The target population includes clinicians responsible for assessment of patients prior to surgery and other invasive procedures. MethodsThe writing group was made up of UK haematologists with a special interest in bleeding disorders and an anaesthetist. First, the commonly employed coagulation screening tests were identified and their general and specific limitations considered. Second, Medline was systematically searched for English language publications from 1966 to September 2005. Relevant references generated from initial papers and published guidelines/reviews were also examined. Meeting abstracts were not included. Key terms: routine, screening, preoperative, surgery, coagulation testing, APTT, PT, bleeding, invasive procedures. Inclusion criteria: studies had to contain enough data to enable the calculation of (i) the predictive value (PV) and likelihood ratio (LR) of the coagulation test for postoperative bleeding and/or (ii) the PV and LR of the bleeding history for postoperative bleeding. The rationale and methods for the calculations are described in Appendix 1. Nine observational case series with usable data (Table I) and one systematic review were identified (Table II).Data elements extracted from these articles were study type, surgical setting, number and age of patients and coagulation tests performed. Outcome data extracted included abnormal tests, positive bleeding history,...
Summary. Conditions which result in hypercoagulable blood or venous stasis may predispose to the development of deep vein thrombosis (DVT). Most of the recently described risk factors for DVT induce a hypercoagulable state. Over a 3-year period we have observed anomaly of the inferior vena cava (IVC) in four young patients presenting with spontaneous unprovoked DVT. This is a greater than expected rate (5% observed versus 0´5% expected). Further, bilateral DVT, which constitutes less than 10% of cases in most series, was present in three of the four cases. Anomaly of the IVC is a rare example of a prevalent congenital condition that predisposes to DVT, presumably by favouring venous stasis. This diagnosis should be considered in young patients with spontaneous and bilateral DVT.
Coagulation testing is employed widely prior to open surgery and invasive procedures. This is based on the assumption that such testing is of clinical value in the prediction of bleeding. In order to improve the clinical understanding of the potential limitations of first-line coagulation tests used in this way, we have systematically reviewed the literature that addresses the value of routine coagulation testing in helping to predict bleeding risk. We conclude unreservedly that indiscriminate coagulation testing is not useful in a surgical or a medical setting. This is due to the limited sensitivity and specificity of the tests, coupled with the low prevalence of bleeding disorders resulting in a high number of false positives, poor positive predictive value for bleeding and numerous false negatives resulting in false reassurance. Since most abnormal results can be predicted and most cases of significant bleeding disorder identified from a complete clinical assessment, the employment of selective laboratory testing is more cost-effective and represents evidence-based clinical practice.
Summary. Acute myeloid leukaemia (AML) of FAB subtype M3 is associated with t(15;17)(q22;q21) and a relatively good prognosis when treated with all-trans retinoic acid (ATRA) and combination chemotherapy. Rarely, alternative balanced translocations have been described in this subtype of AML. The translocation t(11;17)(q23;q21) leading to a PLZF/RARa rearrangement has been described in a very small number of cases and has been associated with a poor response to ATRA and an adverse prognosis. We describe a case of AML FAB type M3 with this translocation who entered morphological and cytogenetic complete remission after concurrent prolonged ATRA and one course of induction chemotherapy and remains in morphological and molecular remission at 10 months after presentation. This diagnosis therefore may not always be associated with a poor initial response to treatment.
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