Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study

INTRODUCTION

To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use.

METHODS

Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models.

RESULTS

Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were.

CONCLUSIONS

Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study

BACKGROUND

While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs).

METHODS

This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis.

RESULTS

Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality.

CONCLUSION

Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic

OBJECTIVE

The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic.

METHODS

This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th-April 24th 2020) at a large medical center in NYC (n = 657).

RESULTS

Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest.

CONCLUSIONS

NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.

The impact of facial lipoatrophy treatment with polymethyl methacrylate in AIDS patients as measured by four quality-of-life questionnaires

Life-expectancy increased in patients infected with HIV/AIDS with the advent of highly active antiretroviral therapy (ART). Facial lipoatrophy is a common complication in these patients, eventually leading to stigma, segregation and a negative impact in quality of life (QOL). We measured the impact of the treatment of facial lipoatrophy with polymethyl methacrylate (PMMA) in the QOL of patients with HIV/AIDS by using four questionnaires that address QOL. Forty consecutive patients on ART referred for facial lipoatrophy treatment were enrolled in this study. The first 20 were allocated to the intervention group and were treated with tissue augmentation with PMMA. The other 20 were allocated to the control group, which received treatment only after six months. At baseline, four questionnaires were applied to all patients in both groups and again after six months. The variation in scores within the control group for all domains of all four instruments was significantly better when compared with that within the control group. We detected improvement in the QOL of patients with HIV/AIDS and facial lipoatrophy when they were treated with PMMA.

Richard B. Cattell: master surgeon, teacher, and innovator

Richard B. Cattell (1900-1964) was a general surgeon widely revered for his masterful technical skills and innovative approaches to complicated surgical cases. In addition to his surgical prowess, he fostered a deep commitment to medical education,but above all emphasized the importance of humanity inpatient care. He has left a remarkable legacy for present and future surgeons to strive to emulate. “To know him was to admire him, to respect him, and to love him. He was a magnificent physician who walked among the greatest, but never lost the common touch.

Carnitine palmitoyltransferase deficiency: an underdiagnosed condition?

Two apparently healthy adults were admitted because of acute muscle cramps, severe weakness, and red urine excretion. Patient No. 1 developed the symptoms following intense exercise and patient No. 2 during a febrile infection. Both of them experienced such episodes in the past, but these were medically misinterpreted. Their present manifestations were accompanied by renal failure which subsided gradually and was found to be a result of rhabdomyolsis and myoglobinuria. Further investigations yielded a deficiency of carnitine palmitoyltransferase as a background to the acute muscular destruction. Examination of a sister of patient No. 2 who had a similar past history revealed the same metabolic disorder. Carnitine palmitoyltransferase deficiency, as a cause of nontraumatic rhabdomyolysis, is a distinct entity in the pathogenesis of acute renal failure. Our experience (3 patients within 2 years) makes us presume that this condition is not as rare as hitherto reported and should rather be considered in cases of 'nonhematuric' red urine and acute renal failure.

The clinicopathologic features of cryoglobulinemic nephropathy

Renal biopsy specimens from eight patients with cryoglobulinemic nephropathy were examined by light, electron, and immunofluorescence microscopy. The light microscopic features were not diagnostic. Characteristic ultrastructural findings were observed in all except one specimen and consisted of glomerular electron-dense deposits, which had a coarse, granular appearance at low-power magnifications and revealed tubular, annular and in a few cases, also fibrillar structures at high-power magnifications. Subendothelial deposits were a constant finding. The presence of intravascular thrombi (deposits), osmiophilic bodies, and crystals within the cytoplasm of the glomerular cells are also helpful for the diagnosis of this entity. Because of these specific findings, cryoglobulinemic nephropathy should be recognized as a clinicopathologic entity.

Is secondary hyperparathyroidism an important etiologic factor in the anemia of chronic renal failure?

Twenty patients with chronic renal failure being treated with hemodialysis were investigated in an attempt to ascertain whether hyperparathyroidism is an important etiologic factor in these patients' anemia. The patients were divided into two groups, one with hemoglobin of greater than 8 g/dl and the other with hemoglobin of less than 8 g/dl. These groups differed in blood transfusion requirements and in serum iron saturation. There was no difference between their levels of serum calcium, serum phosphate, serum alkaline phosphatase or serum parathyroid hormone. On bone biopsy endosteal fibrosis with bone marrow involvement was found in 2 of the 11 patients with high hemoglobin and in 5 of the 9 patients with low hemoglobin. Endosteal fibrosis with bone marrow involvement may thus be an important factor in the pathogenesis of anemia, and its presence or absence in association with hyperparathyroidism may explain the controversial observations reported by other investigators.