Protective effects of long term antiplatelet and anticoagulant therapy in hospitalized patients with inflammatory bowel disease

BACKGROUND Inflammatory bowel disease(IBD),with its rising prevalence rates is associated with an increased risk of cardiovascular and thromboembolic events.Antiplatelets and/or anticoagulants agents are often prescribed but the literature on the impact of long-term anticoagulation and/or antiplatelet use among patients hospitalized with IBD is scarce.The aim of this study is to assess the outcomes of patients hospitalized with IBD on antiplatelet and/or anticoagulant agents.AIM To investigate the effects of long-term use of antiplatelets/anticoagulants on clinical outcomes in patients hospitalized with IBD.METHODS We conducted a retrospective cohort study using the Nationwide Inpatient Sample database,including all adult IBD patients hospitalized in the United States from 2016 to 2019.Patient cohorts were stratified based on antiplatelet/anticoagulant therapy status.Multivariate regression analysis was done to assess outcomes,adjusting for potential confounders.The primary outcome was mortality,whereas length of stay(LOS),total parenteral nutrition,acute kidney injury,sepsis,shock,gastrointestinal bleeding,need for colonoscopy/sigmoidoscopy,abdominal surgery and total hospitalization charges were secondary outcomes.RESULTS Among 374744 hospitalized IBD patients,antiplatelet or anticoagulant therapy alone was associated with significantly lower in-hospital mortality and reduced healthcare utilization,including shorter LOS and decreased hospitalization costs.Combined therapy was associated with a protective effect on mortality,but did not reach statistical significance.Notably,therapy did not exacerbate disease severity or complications,although higher odds of gastrointestinal bleeding were observed.CONCLUSION Our study highlights the potential benefits of long-term anticoagulation/antiplatelet therapy in hospitalized IBD patients,with improved mortality outcomes and healthcare utilization.While concerns regarding gastrointestinal bleeding exist,the overall safety profile suggests a role for these agents in mitigating thromboembolic risks without exacerbating disease severity.Further research is needed to look at optimal treatment strategies and addressing limitations to guide clinical decision-making in this population.

Challenging anticoagulation therapy for multiple primary malignant tumors combined with thrombosis:A case report and review of literature

BACKGROUND Venous thromboembolism significantly contributes to patient deterioration and mortality.Management of its etiology and anticoagulation treatment is intricate,necessitating a comprehensive consideration of various factors,including the bleeding risk,dosage,specific anticoagulant medications,and duration of therapy.Herein,a case of lower extremity thrombosis with multiple primary malignant tumors and high risk of bleeding was reviewed to summarize the shortcomings of treatment and prudent anticoagulation experience.CASE SUMMARY An 83-year-old female patient was admitted to the hospital due to a 2-wk history of left lower extremity edema that had worsened over 2 d.Considering her medical history and relevant post-admission investigations,it was determined that the development of left lower extremity venous thrombosis and pulmonary embolism in this case could be attributed to a combination of factors,including multiple primary malignant tumors,iliac venous compression syndrome,previous novel coronavirus infection,and inadequate treatment for prior thrombotic events.However,the selection of appropriate anticoagulant medications,determination of optimal drug dosages,and establishment of an appropriate duration of anticoagulation therapy were important because of concurrent thrombocytopenia,decreased quantitative fibrinogen levels,and renal insufficiency.CONCLUSION Anticoagulant prophylaxis should be promptly initiated in cases of high-risk thrombosis.Individualized anticoagulation therapy is required for complex thrombosis.

Menstrual Abnormalities and Gynaecological Problems in Women on Anticoagulant and Antiplatelet Therapy: Management Options

Introduction: The aim of this study was: 1) To study the pattern of menstrual abnormality and severity in women on anticoagulant and antiplatelet drugs. 2) To analyze the correlation of prothrombin time (PT), International Normalised ratio (INR) and the bleeding severity. 3) To discuss the various management options in unexpected emergencies and menstrual complications in this subset of women on anticoagulants. Material & Methods: It is a prospective study, over a period of 18 months from July 2011 to december 2012. We had 44 women on antithrombotic therapy. 32 women were on anticoagulants and 12 were on antiplatelet agents. The severity of bleeding pattern was assessed with pictoral bleeding assessment chart (PBAC). 1) Out of 44 women studied, 32 women were on anticoagulants and 12 were on antiplatelet agents. 26 (81.25%) were on acenocoumarol, 5 (15.62%) on warfarin, 1 (3.12%) on heparin, among the 12 antiplatelet users, 8 (66.66%) were on aspirin and 4 (33.33%) on clopidogrel. 2) The indication for anticoagulants was mitral valve replacement (MVR) in 9, double valve replacement (DVR) in 6, aortic valve replacement (AVR) in 3, severe pulmonary artery hypertension (PAH) in 2, severe mitral stenosis (MS) with atrial thrombus in 2, deep vein thrombosis (DVT) in 5, severe mitral regurgitation (MR) in one, the other indications were subdural hematoma, thromboendarterectomy, chronic kidney disease (CKD) stage V, coarction of aorta, one each. The indication for antiplatelet therapy was percutaneous transluminal coronary angioplasty (PTCA) in 3, Wolf Parkinson White (WPW) syndrome + atrial fibrillation (AF), acute myocardial infarction (AMI), coronary artery bypass graft (CABG), mid basilar artery aneurysm, renal allograft recipient, dialated cardiomyopathy, aortic aneurysm repair, hypertension and unstable angina one each. Results: In women on anticoagulants (32), the main complaint was menorrhagia/heavy menstrual bleeding (HMB) in 20, polymenorrhoea with menorrhagia in 4, continuous per vaginal (PV) bleeding in 6. One lady had postmenopausal bleeding. Among the 12 antiplatelet users the main complaint was menorrhagia in 8, polymenorrhoea with menorrhagia in 2, postmenopausal bleeding in one. While on antithrombotic therapy apart from heavy menstrual bleeding, two women had intraperitoneal bleeding, two had post menopausal bleeding, two had secondary postpartum bleeding (PPH). CVA due to embolic stroke occurred in three, one during the study period. Subchoroidal haemorrhage causing choroidal detachment was noted in one. Conclusions: In patients with prolonged INR, excessive uterine bleeding can be an alerting initial manifestation. Antithrombotic therapy can cause HMB or exaggerate the symptom of HMB due to an underlying gynaec pathology. Mefanamic acid and norethisterone were used to arrest heavy menstrual bleeding. Antithrombotic therapy in women needs special consideration with alterations in menstrual pattern and contraception. Pregnancy and postpartum period present special challenges.

Evaluation of a Dose-Monitoring Method for Prophylactic Anticoagulant Therapy with Low-Molecular-Weight Heparin

Objective: In the present study, we report on the results of our investigation of optimum dose monitoring using coagulation and fibrinolytic system indicators during obstetric prophylactic anticoagulant therapy with enoxaparin. Study Design: Of 103 cases of cesarean section performed at our hospital, 37 cases were selected for this study after obtain ing their consent for blood collection. Variables of the coagulation and fibrinolytic systems [anti-factor Xa activity, endogenous thrombin potential (ETP), prothrombin time (PT) or international normalized ratio (INR), activated partial thromboplastin time (APTT) and D-dimer levels] were determined. Results: In the 5-day administration group, the anti-factor Xa activitywas 0.0 U/ml on the postoperative day 1, increased to 0.05 U/ml ± 0.04 U/ml on the postoperative day 3, and mildly increased to 0.06 U/ml ± 0.05 U/ml on the postoperative day 5. On the other hand, the anti-factor Xa activity in the 3-day administration group was 0.0 U/ml on the postoperative day 1 (before enoxaparin administration), increased to 0.06 U/ml ± 0.05 U/ml on the postoperative day 3, and significantly decreased to 0.02 U/ml ± 0.03 U/ml on the postoperative day 5 (p = 0.003);thus, the pattern of change was significantly different from that in the 5-day administration group (p = 0.004). Enoxaparin administration did not result in any significant fluctuation of the ETP, and no significant difference was observed between the 5-day and 3-day administration groups. Conclusion: Enoxaparin administration was associated with increase of the anti-factor Xa activity, and prolonged administration led to more sustained increase of the activity.

Transcatheter Arterial Embolization as a Treatment for Life-Threatening Retroperitoneal Hemorrhage in COVID-19 Patients on Anticoagulant Therapy

Retroperitoneal hemorrhage is a possible complication that has been noticed in COVID-19 patients on anticoagulant therapy. The data related to treatment and outcomes in this condition are scarce. We present a case series of four COVID-19 patients with lumbar artery bleeding, who were treated with transcatheter arterial embolization using embolization particles. The procedure was executed without any complications, and hemostasis was achieved in all four patients. Despite the patients survived the procedure, one patient died due to respiratory failure three weeks after the procedure, and one died due to hypovolemic shock two days later. Considering the ongoing state of COVID-19 pandemic, it is essential to be aware of transcatheter arterial embolization as a safe and effective procedure for treating retroperitoneal hemorrhage in COVID-19 patients.

Historical Evolution of the Anticoagulant-Antiplatelet Therapy in Patients with Mitral Valve Disease Associated to Atrial Fibrillation or Mechanical Valve Prosthesis. Role of Omeprazole

In this review article we analyze the historical evolution of anticoagulant and antiplatelet therapies in the treatment of atrial fibrillation plus complicated heart diseases. Its combined use, compared with anticoagulation alone, has been widely used to significantly reduce thromboembolic risk. Major bleeding risk has been usually registered during combined antithrombotic therapy, which is mainly due to gastric bleeding, but enteric coating antiplatelet tablets can effectively protect against gastric mucosal damage, and the addition of proton-pump inhibitors (omeprazole) can avoid it.

Acute compartment syndrome of the thigh following hip replacement by anterior approach in a patient using oral anticoagulants

Acute compartment syndrome(ACS) of the thigh following primary total hip arthroplasty(THA) is a highly uncommon complication and has not yet been reported before with regards to the anterior approach through the anterior supine interval. We present a case of a 69-year-old male patient with a history of stroke, who developed ACS of the thigh after elective THA while using therapeutic low molecular weight heparin as bridging for regular oral anticoagulation. ACS pathogenesis, diagnostic tools, treatment and relevant literature are discussed. The patient's ACS was recognized in time and treated by operative decompression with fasciotomy of the anterior compartment. Follow-up did not show any neurological deficit or soft-tissue damage.

Anticoagulation therapy prevents portal-splenic vein thrombosis after splenectomy with gastroesophageal devascularization

AIM:To compare the incidence of early portal or splenic vein thrombosis(PSVT) in patients treated with irregular and regular anticoagulantion after splenectomy with gastroesophageal devascularization.METHODS:We retrospectively analyzed 301 patients who underwent splenectomy with gastroesophageal devascularization for portal hypertension due to cirrhosis between April 2004 and July 2010.Patients were categorized into group A with irregular anticoagulation and group B with regular anticoagulation,respectively.Group A(153 patients) received anticoagulant monotherapy for an undesignated time period or with aspirin or warfarin without low-molecular-weight heparin(LMWH) irregularly.Group B(148 patients) received subcutaneous injection of LMWH routinely within the first 5 d after surgery,followed by oral warfarin and aspirin for one month regularly.The target prothrombin time/international normalized ratio(PT/INR) was 1.25-1.50.Platelet and PT/INR were monitored.Color Doppler imaging was performed to monitor PSVT as well as the effectiveness of thrombolytic therapy.RESULTS:The patients' data were collected and analyzed retrospectively.Among the patients,94 developed early postoperative mural PSVT,including 63 patients in group A(63/153,41.17%) and 31 patients in group B(31/148,20.94%).There were 50(32.67%) patients in group A and 27(18.24%) in group B with mural PSVT in the main trunk of portal vein.After the administration of thrombolytic,anticoagulant and antiaggregation therapy,complete or partial thrombus dissolution achieved in 50(79.37%) in group A and 26(83.87%) in group B.CONCLUSION:Regular anticoagulation therapy can reduce the incidence of PSVT in patients who undergo splenectomy with gastroesophageal devascularization,and regular anticoagulant therapy is safer and more effective than irregular anticoagulant therapy.Early and timely thrombolytic therapy is imperative and feasible for the prevention of PSVT.

Current practice of anticoagulant in the treatment of splanchnic vein thrombosis secondary to acute pancreatitis

Background:Severe acute pancreatitis is a common diagnosis in emergency general surgery and can be a cause of significant morbidity and mortality.A consequence of severe acute pancreatitis is thrombus in the splanchnic veins.These thrombi can potentially lead to bowel ischemia or hepatic failure.However,another complication of severe acute pancreatitis is retroperitoneal bleeding.At this time,it is unclear if treating patients for splanchnic vein thrombosis in the context of severe acute pancreatitis is associated with any outcome benefit.A systematic review might clarify this question.Data sources:A two-fold search strategy(one broad and one precise)looked at all published literature.The review was registered on PROSPERO(ID:CRD42018102705).MEDLINE,EMBASE,PubMed,Cochrane and Web of Science databases were searched and potentially relevant papers were reviewed indepen-dently by two researchers.Any disagreement was reviewed by a third independent researcher.Primary outcome was reestablishment of flow in the thrombosed vein versus bleeding complications.Results:Of 1462 papers assessed,a total of 16 papers were eligible for inclusion.There were no ran-domized controlled trials,2 were case series,5 retrospective single-center studies and 9 case reports.There were a total of 198 patients in these studies of whom 92(46.5%)received anticoagulation therapy.The rates of recanalization of veins in the treated and non-treated groups was 14%and 11%and bleeding complications were 16%and 5%,respectively.However,the included studies were too heterogeneous to undertake a meta-analysis.Conclusions:The systematic review highlights the lack evidence addressing this clinical question.There-fore a randomized controlled trial would be appropriate to undertake.

Management of regional citrate anticoagulation for continuous renal replacement therapy:guideline recommendations from Chinese emergency medical doctor consensus

Continuous renal replacement therapy(CRRT)is widely used for treating critically-ill patients in the emergency department in China.Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT.Regional citrate anticoagulation(RCA)has been shown to potentially be safer and more effective,and is now recommended as the preferred anticoagulant method for CRRT.However,there is still a lack of unified standards for RCA management in the world,and there are many problems in using this method in clinical practice.The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association(CMDA)organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues,including the advantages and disadvantages of RCA in CRRT anticoagulation,the principle of RCA,parameter settings for RCA,monitoring of RCA(mainly metabolic acid-base disorders),and special issues during RCA.Based on the latest available research evidence as well as the paneled experts'clinical experience,considering the generalizability,suitability,and potential resource utilization,while also balancing clinical advantages and disadvantages,a total of 16 guideline recommendations were formed from the experts'consensus.

Acute upper gastrointestinal bleeding in patients on long-term oral anticoagulation therapy: Endoscopic findings, clinical management and outcome

AIM: Acute gastrointestinal bleeding is a severe complication in patients receiving long-term oral anticoagulant therapy. The purpose of this study was to describe the causes and clinical outcome of these patients. METHODS: From January 1999 to October 2003, 111 patients with acute upper gastrointestinal bleeding (AUGIB) were hospitalized while on oral anticoagulants. The causes and clinical outcome of these patients were compared with those of 604 patients hospitalized during 2000-2001 with AUGIB who were not taking warfarin. RESULTS: The most common cause of bleeding was peptic ulcer in 51 patients (45%) receiving anticoagulants compared to 359/604 (59.4%) patients not receiving warfarin (P<0.05). No identifiable source of bleeding could be found in 33 patients (29.7%) compared to 31/604 (5.1%) patients not receiving anticoagulants (P=0.0001). The majority of patients with concurrent use of non-steroidal anti-inflammatory drugs (NSAIDs) (26/35, 74.3%) had a peptic ulcer as a cause of bleeding while 32/76 (40.8%) patients not taking a great dose of NSAIDs had a negative upper and lower gastrointestinal endoscopy. Endoscopic hemostasis was applied and no complication was reported. Six patients (5.4%) were operated due to continuing or recurrent hemorrhage, compared to 23/604 (3.8%) patients not receiving anticoagulants. Four patients died, the overall mortality was 3.6% in patients with AUGIB due to anticoagulants, which was not different from that in patients not receiving anticoagulant therapy. CONCLUSION: Patients with AUGIB while on long-term anticoagulant therapy had a clinical outcome, which is not different from that of patients not taking anticoagulants. Early endoscopy is important for the management of these patients and endoscopic hemostasis can be safely applied.

A Retrospective Study of Continuous Renal Therapy and Anticoagulation in Patients with Hemorrhagic Fever with Renal Syndrome

Objective To observe the application of continuous renal replacement therapy(CRRT) and heparin anticoagulation in patients with HFRS, and to explore a more suitable anticoagulant strategy. Methods Eighty-five severe-type patients(severe group) and 71 critical-type patients(critical group) were enrolled in this study. The frequency of CRRT was compared between the two groups; the frequency of CRRT treated with and without heparin anticoagulation and the frequency of hemorrhage and channel blood clotting induced by the two anticoagulant strategies were observed. Results The frequency of CRRT in the critical group was higher than that in the severe group(P < 0.001). The frequency of CRRT initiated during the overlapping phases in the critical group was significantly higher than that of the severe group(P = 0.032). The total times of CRRT was 103, and 70 of them were treated with heparin anticoagulation. The frequencies of hemorrhage induced by heparin anticoagulation and no heparinization were 16 and 0, respectively, and the frequencies of channel blood clotting were 2 and 4, respectively. Conclusions CRRT has been used extensively in the critical-type patients with HFRS. The heparin anticoagulation and no anticoagulant strategies should be used more rationally in patients treated with CRRT, according to the clinical characteristics of the disease.

Venous Thromboembolism Anticoagulation Therapy

VTE of the main treatment for anticoagulant therapy, anticoagulant therapy drug of choice for low molecular weight heparin (LMWH) for the overwhelming majority of clinicians agree that long-term oral anticoagulant therapy is still Vit.K antagonist (mainly warfarin).

Dual versus single antiplatelet therapy for patients with long-term oral anticoagulation undergoing coronary intervention： a systematic review and meta-analysis

Objective The main aim of this meta-analysis is to compare the efficacy and safety of dual versus single antiplatelet therapy for pa- tients taking oral anticoagulation （OAC） after coronary intervention. Background The optimal regimen remains controversial for patients taking OAC after coronary intervention. Methods PubMed, Embase and Cochrane Central Register of Controlled Trials were searched for eligible studies including data of triple therapy （TT） versus OAC plus single antiplatelet therapy for patients requiring OAC after coronary intervention. The primary outcome was major adverse cardiac and cerebrovascular event （MACCE）. The safety outcome was major bleeding. Results Fourteen studies with 32,825 patients were included. Among prospective studies, patients with TT had a trend toward a higher risk of major bleeding [odds ratios （OR）： 1.56, 95% confidence interval （CI）： 0.98-2.49, P = 0.06] and a markedly higher risk of all-cause death （OR; 2.11, 95% CI： 1.10-4.06 P = 0.02） compared with OAC plus clopidogrel. Meanwhile, TT was associated with decreased risks of MACCE （OR： 0.63, 95% CI： 051-0.77 P 〈 0.0001）, all-cause death （OR： 0.45, 95% CI： 0.20-0.97, P = 0.04）, and stroke/transient ischemic attack （TIA）/peripheral embolism （PE） （OR= 0.29, 95% CI： 0.09~3.96, P = 0.04） compared with OAC plus aspirin. Conclusions For pa- tients requiring OAC after coronary intervention, OAC plus clopidogrel may bring more clinical net benefit than TT, whereas OAC plus aspirin should be the last choice. More large-size randomized control trials are needed to confirm these findings.

Deciding the Gold Standard for Oral Anticoagulation Therapy

Healthcare practitioners have many anticoagulant options for treating various disease states pertaining to blood clots and blood clot formation. Each anticoagulant has pros and cons and the decision of which pharmacological agent to use can be confusing and difficult. In years past, Vitamin K antagonists have been the standard of care when treating specific disease states such as atrial fibrillation and venous thromboembolism based on habit and cost of care. The emergence of newer anticoagulants should be considered the new standard of care based on the evidence presented over the last several years.

Establishment of a nomogram model for predicting therapy complications in patients with polycythemia and deep venous thrombosis

BACKGROUND Patients with deep venous thrombosis(DVT)residing at high altitudes can only rely on anticoagulation therapy,missing the optimal window for surgery or thrombolysis.Concurrently,under these conditions,patient outcomes can be easily complicated by high-altitude polycythemia(HAPC),which increases the difficulty of treatment and the risk of recurrent thrombosis.To prevent reaching this point,effective screening and targeted interventions are crucial.Thus,this study analyzes and provides a reference for the clinical prediction of thrombosis recurrence in patients with lower-extremity DVT combined with HAPC.AIM To apply the nomogram model in the evaluation of complications in patients with HAPC and DVT who underwent anticoagulation therapy.METHODS A total of 123 patients with HAPC complicated by lower-extremity DVT were followed up for 6-12 months and divided into recurrence and non-recurrence groups according to whether they experienced recurrence of lower-extremity DVT.Clinical data and laboratory indices were compared between the groups to determine the influencing factors of thrombosis recurrence in patients with lowerextremity DVT and HAPC.This study aimed to establish and verify the value of a nomogram model for predicting the risk of thrombus recurrence.RESULTS Logistic regression analysis showed that age,immobilization during follow-up,medication compliance,compliance with wearing elastic stockings,and peripheral blood D-dimer and fibrin degradation product levels were indepen-dent risk factors for thrombosis recurrence in patients with HAPC complicated by DVT.A Hosmer-Lemeshow goodness-of-fit test demonstrated that the nomogram model established based on the results of multivariate logistic regression analysis was effective in predicting the risk of thrombosis recurrence in patients with lowerextremity DVT complicated by HAPC(χ^(2)=0.873;P>0.05).The consistency index of the model was 0.802(95%CI:0.799-0.997),indicating its good accuracy and discrimination.CONCLUSION The column chart model for the personalized prediction of thrombotic recurrence risk has good application value in predicting thrombotic recurrence in patients with lower-limb DVT combined with HAPC after discharge.

Low-intensity anticoagulation therapy in the pregnant women with mechanical heart valves:a report with 56 cases

Objective To evaluate the method of low-intensity anticoagulation therapy in the pregnant women who had received mechanical heart valve replacemant,and the effects of warfarin on the pregnant women and their fetus. Methods This retrospective study involved 56 pregnant women (61 pregnancies) who had received mechanical heart valve replacement. Their pregnant status,delivery, and anticoagulation therapy were observed

Is dual therapy the correct strategy in frail elderly patients with atrial fibrillation and acute coronary syndrome?

Atrial fibrillation(AF)is a very common arrhythmia in clinical practice.Its incidence and prevalence are age-related and are growing in the last years.Age is a risk factor also for coronary artery disease(CAD),and with the evolution of preventive care,the first event(acute coronary syndrome(ACS)or percutaneous coronary intervention(PCI))takes place at a later age.If elderly patients with AF and CAD undergo ACS or PCI,they have indication to assume triple therapy.Triple therapy(oral anticoagulation(OAC)plus dual antiplatelet therapy(DAPT))exposes patients to high bleeding risk.In the last 10 years,several clinical trials have tested dual therapy(OAC plus single antiplatelet therapy)in AF patients who undergo ACS or elective PCI.WOEST trial has tested warfarin+clopidogrel against triple therapy.PIONEER AF-PCI trial has tested low-dose rivaroxaban+P2Y12 inhibitor or very low-dose rivaroxaban+DAPT against standard triple therapy with warfarin.RE-DUAL PCI trial has tested two doses of dabigatran+P2Y12 inhibitor against standard triple therapy with Warfarin.AUGUSTUS trial has tested apixaban against warfarin both in dual therapy with P2Y12 inhibitor and in triple therapy with a P2Y12 inhibitor and aspirin.ENTRUST-AF PCI,last published study,has tested edoxaban+P2Y12 inhibitor against triple therapy.All these trials show dual therapy reduces significantly bleeding risk than triple therapy.In this paper,we analyze these clinical trials to understand if dual therapy results can be applied to elderly patients and what is probably the better approach in elderly AF patients undergo to ACS or PCI.

Who benefits from percutaneous closure of patent foramen ovale vs medical therapy for stroke prevention? In-depth and updated metaanalysis of randomized trials

BACKGROUND A few randomized clinical trials(RCT) and their meta-analyses have found patent foramen ovale closure(PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear.AIM To evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs.METHODS Electronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke(IS), transient ischemic attack(TIA), a composite of IS, TIA and systemic embolism(SE), mortality, major bleeding,atrial fibrillation(AF) and procedural complications were the major outcomes.Random-effects model was used to perform analyses.RESULTS Meta-analysis of 6 RCTs including 3560 patients showed that the PFOC,compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95%confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55(0.32-0.93); P = 0.02] and increased the AF risk [4.79(2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86(0.54-1.38); P = 0.54],mortality [0.74(0.28-1.93); P = 0.53] and major bleeding [0.81(0.42-1.56); P = 0.53]between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm.CONCLUSION In certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.

Combination of thrombolytic therapy and angioplastic stent insertion in a patient with Budd-Chiari syndrome

A 31-year-old female who had well-established polycythemia vera one year before, presented with the sudden onset. She had severe ascites and hepatic encephalopathy 12 d prior to admission. Real-time ultrasonography revealed a supra hepatic thrombosis extending toward the inferior vena cava （IVC）. Thrombolytic therapy with systemic streptokinase （250000 IU loading ＋ 100000 IU/h infusion） was started. At the end of 72 h infusion, the patient＇s general condition improved. A color Doppler ultrasonography then showed complete and partial resolution of the thrombosis in the supra hepatic vein and IVC, respectively. Despite this good response, 12 d later, the symptoms recurred. Venography detected complete obstruction of the IVC. Percutanous balloon angioplasty with stent insertion was performed successfully and the patient was discharged without any evidence of liver disease. A combination of systemic streptokinase and radiological intervention was effective in our patient.