exudates and Pulmonary-Embolism

Patients with low antithrombin III (AT III) has increased risk for arteriovenous thromboembolic (TE) disease. We report a 28-year-old Malay lady who presented with spontaneous right calf pain and swelling of one week duration. She was on oral contraceptive pills and had a history of travelling for a long distance prior to the presentation. Her brother who was diagnosed with AT III deficiency had arterial thrombosis at a young age. She was diagnosed as having right popliteal vein thrombosis by ultrasound and treated with subcutaneous fondaparinux. While on treatment, she developed massive bilateral pulmonary embolism (PE). Thrombophilia study showed reduced AT III activity (38μl/dl) and normal results for protein C, protein S, activated protein C resistance and lupus anticoagulant assays. This patient has heterozygous AT III deficiency added with significant acquired factors responsible for the TE events. Those with AT III deficiency may have resistance to heparin therapy and require higher doses of heparin.

Topics: Adult; Antithrombin III Deficiency; Female; Humans; Malaysia; Male; Middle Aged; Pulmonary Embolism; Siblings; Venous Thrombosis

Anticoagulant responses to warfarin vary among patients, based on genetic factors, diet, concomitant medications, and disease state. We evaluated the effectiveness and safety of a 10mg warfarin initiation nomogram in an Asian population. Retrospective cross-sectional audit studies were conducted from March 2009 to March 2010. The use of a 10mg-loading dose to initiate warfarin treatment resulted in 33(84.6%) patients attaining a therapeutic INR within four days (mean time, 2.6 days). There was no significant correlation between age, gender, race, and serum albumin for the time to reach a therapeutic INR. A significant correlation was noted for patient's baseline INR and time to reach a therapeutic INR (P<0.05). No significant differences were observed in time to reach a therapeutic INR in patients treated with specific class of concomitant drugs or patients with specific disease states. The overall incidence of over-anticoagulation was 35.9%; however, no bleeding episodes were encountered. In conclusion, the use of a 10mg warfarin nomogram was effective in rapidly achieving a therapeutic INR. However, the nomogram's safety is debatable owing to the high over-anticoagulation rate warfarin-administered patients. Caution is recommended in the initiation of warfarin treatment using the 10mg nomogram.

Topics: Adult; Aged; Anticoagulants; Asian People; Atrial Fibrillation; Coronary Thrombosis; Cross-Sectional Studies; Humans; Malaysia; Male; Middle Aged; Nomograms; Pulmonary Embolism; Retrospective Studies; Stroke; Venous Thrombosis; Warfarin

Within the Asian populations, Indian patients had been reported to require higher warfarin dose compared with the Chinese and Malay patients, and this could not entirely be explained by cytochrome P450 (CYP)2C9 gene variants. Genetic variants of vitamin K epoxide oxidase reductase complex subunit 1 (VKORC1) has been well established as one of key determinants in the different responses of warfarin amongst patients. Adult patients who attended an anticoagulation clinic with stable INR were recruited. VKORC1 and CYP2C9 genotype were sequenced, and clinical characteristics were assessed. A total of 91 Malays, 96 Chinese, and 46 Indian patients were recruited. The mean age was 55 years and 51.5% were males. The mean dose of warfarin for all patients was 3.7 mg, and the mean daily dose of warfarin was significantly higher in Indians compared with the Chinese and Malay patients, 4.9 versus 3.5 and 3.3 mg, respectively (p < 0.001). VKORC1 GG genotype was more commonly seen in Indian patients. The mean warfarin dose in patients with GG genotype required a significant higher warfarin dose compared with those with AG and AA genotype (4.9 vs. 3.7 vs. 3.1 mg, respectively; p < 0.001). CYP2C9*2 and *3 is associated with a lower maintenance dose, 2.9 versus 3.7 mg in CYP2C9*1; p < 0.01. In multivariate analysis, age, ethnic groups, and genotypes had a significant influence on the required warfarin dose. In conclusion, VKORC1 and CYP2C9 polymorphism contribute to the difference dose requirement amongst the patients but other additional possible factors may play a role in the Indian race.

Topics: Adult; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Asian People; Cytochrome P-450 CYP2C9; Dose-Response Relationship, Drug; Ethnicity; Female; Genetics, Population; Genotype; Heart Diseases; Heart Valve Prosthesis Implantation; Humans; India; Malaysia; Male; Middle Aged; Mixed Function Oxygenases; Pharmacogenetics; Polymorphism, Single Nucleotide; Pulmonary Embolism; Vitamin K Epoxide Reductases; Warfarin

Venous thromboembolism (VTE) has historically been perceived to be a rare disorder in Asia. However, new evidence has emerged recently that contradicts this perception. The question of routine VTE prophylaxis has been hotly debated in Asia due to disagreement on its incidence. We reviewed and analysed studies on postoperative VTE in Asian patients to determine if the condition was indeed rare and if the routine prophylactic measures as recommended by internationally accepted guidelines should be adopted in Asia.. A review of published reports, from 1966 to December 2002, on deep vein thrombosis (DVT) and pulmonary embolism (PE) in the Asian population was made. A literature search of studies published in English was conducted via a detailed MEDLINE search. Studies had to attain a minimum inclusion and quality criteria to be accepted for the review, including the diagnostic modality used for the diagnosis of VTE. The appraisal was carried out independently and accepted by at least two of the three authors. The study population was classified into orthopaedic and general surgical/colorectal groups.. Twelve orthopaedic publications reviewed revealed an incidence of postoperative DVT of 10% to 63%. Six general and colorectal surgical publications reported an incidence of DVT ranging from 3% to 28%. The incidence was slightly lower than the reported incidence of 40% to 80% following orthopaedic surgery and 28% to 44% following general surgical operations in studies reporting on Caucasian populations.. While there is a wide variation in the incidence of DVT and VTE as reported in the Asian population, these diseases are by no means rare. The wide variation could be due to the study designs, heterogeneity of the procedures performed and the application of different diagnostic criteria. Results based on prospective studies with objective diagnostic criteria confirm the incidence of VTE as common. Routine chemoprophylaxis must be seriously considered in high-risk patients.

Topics: Female; Humans; Incidence; Malaysia; Male; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Risk Factors; Survival Analysis; Venous Thrombosis

Acute pulmonary thromboembolism (PE) has been considered rare among Asians. We aim to describe the frequency and clinical features of this condition in a hospital in Singapore. Among patients admitted by the Emergency Department (ED), comparisons were made between those primarily diagnosed in the ED and those who were not.. Retrospective review of all cases of radiologically proven acute PE over a 20-month period.. Sixty-two patients were identified. The mean age was 61.5 +/- 18.0 years with a female to male ratio of 1.8:1. There were more Malays compared to other races. There were also more Caucasians, given the proximity of the hospital to the airport and the inclusion of tourists. The commonest symptoms were dyspnoea and chest pain, while the commonest signs were tachycardia and tachypnoea. Prolonged immobilisation was the commonest risk factor. Electrocardiographic S1Q3T3 pattern was seen in more patients compared to Western studies. Cardiomegaly was the commonest chest X-ray finding. Thirty-two patients were identified to have a source of embolisation. Overall mortality rate was 21%. The ED diagnosed 36% of the cases. Alternative admitting diagnoses were predominantly ischaemic heart disease and pneumonia. The group diagnosed in the ED were notably female (P = 0.044), Caucasian (P = 0.002) and had prolonged immobilisation (P = 0.025) prior to the onset of PE.. Acute PE is not as rare here as previously thought. Clinical features reveal more similarities than differences compared to other studies in the literature. We advocate a high index of suspicion for earlier diagnosis in the ED.

Topics: Acute Disease; Adult; Age Distribution; Aged; Aged, 80 and over; Cardiomegaly; Chest Pain; Diagnostic Errors; Dyspnea; Electrocardiography; Female; Hospitals, General; Humans; Immobilization; Malaysia; Male; Middle Aged; Pulmonary Embolism; Retrospective Studies; Risk Factors; Sex Distribution; Singapore; Tachycardia; Tomography, X-Ray Computed; Travel; White People

A confidential system of enquiry into maternal mortality was introduced in Malaysia in 1991. The methods used and the findings obtained up to 1994 are reported below and an outline is given of the resulting recommendations and actions.. This is a report on the methods, findings, resulting recommendations and actions of a study on maternal mortality in Malaysia during the period 1991-94. Maternal death was defined as the death of a woman while pregnant or within 42 days following termination of pregnancy from any cause related to the pregnancy or its management but not from accidental causes. Between 1991 and 1994 there were 1066 reported maternal deaths, and the maternal mortality ratios for the successive years were respectively 44, 48, 46 and 39 per 100,000 live births. The primary causes of maternal death were postpartum hemorrhage (24%), hypertensive disorders of pregnancy (16%), obstetric pulmonary embolism (13%), and associated medical conditions (7%). Analysis of the 375 deaths from 1992 - 1993 showed that the maternal mortality ratio was 53/100,000 live births for deliveries performed at home, 36/100,000 in government hospitals, and 21/100,000 in private institutions. Shortcomings among health personnel were detected in several cases; these involved failure to diagnose, failure to appreciate the severity of a patient's condition, inadequate therapy, and inappropriate, delayed or failed adherence to protocols. The high proportion of maternal mortality associated with substandard care demonstrates that it is important to make the standard of care more widely available. Reports have been circulated to institutions and organizations providing maternal care and to medical schools. Articles and case histories have been published, and many new protocols and procedures have been developed. Furthermore, seminars have been organized and training modules have been distributed to all involved in the provision of maternity care.

Topics: Adolescent; Adult; Cause of Death; Female; House Calls; Humans; Malaysia; Maternal Mortality; Postpartum Hemorrhage; Pre-Eclampsia; Pregnancy; Pregnancy Complications, Cardiovascular; Prenatal Care; Puerperal Infection; Pulmonary Embolism

Obstetric pulmonary embolism forms the most serious vascular problem during pregnancy. The following report is a retrospective study into maternal deaths in Malaysian mothers probably due to obstetrical pulmonary embolism. Obstetric pulmonary embolism can be divided into amniotic fluid embolism and obstetric blood clot embolism. There were 37 maternal deaths attributable to this cause -9.9 per cent of all maternal deaths to blood clot embolism and 6.7 per cent to amniotic fluid embolism. Most cases were diagnosed clinically because a postmortem examination was not done. Eleven cases of embolism were associated with Caesarean delivery. The typical profile of a Malaysian mother dying from obstetrical pulmonary embolism is that of a Malay mother in the "non-risk" parities of one to four and usually aged between 31-35 years. In the management of these patients, there should be an urgency in diagnosis and improvement in diagnostic procedures. Health staff at all levels should be trained to pick up patients who present with features of deep vein thrombosis.

Topics: Adult; Cause of Death; Cesarean Section; Death, Sudden; Embolism, Amniotic Fluid; Female; Humans; Malaysia; Maternal Mortality; Population Surveillance; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Embolism; Retrospective Studies; Risk Factors

The defendant, an obstetrician and gynaecologist, was accused of voluntarily causing a woman to miscarry, such miscarriage having been performed without good faith and an intention to save the woman's life. The Court upheld the conviction of the defendant, rejecting his argument, supported by an expert witness, that he had performed the abortion in order to avoid the possibility of pulmonary embolism, which might result because the woman had enlarged varicose veins. It held that the argument was not reasonable under the current law and that procuring an abortion was a serious matter to be done only as a last resort to save the life of a woman or to save her from becoming a mental "wreck."

Topics: Abortion, Induced; Abortion, Therapeutic; Asia; Asia, Southeastern; Crime; Delivery of Health Care; Developing Countries; Disease; Embolism; Family Planning Services; Health; Health Personnel; Jurisprudence; Legislation as Topic; Malaysia; Physicians; Pulmonary Embolism; Social Problems; Vascular Diseases