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Factor VII deficiency is a rare autosomal recessive disorder. Its incidence is thought to be 1 in 500,000. Symptoms vary from mild to severe. Factor VII deficient patients usually do not experience bleeding if their level of factor VII is less than 10%. Manifestations are seen with levels less than 5%, and severe bleeding can occur with levels less than 1%. Surgical hemostasis is obtained with levels greater than 25%. Factor VII deficiency is notable for causing a prolonged PT with a normal aPTT, making the diagnosis easy to determine. This is a descriptive study based on a population of patients from our community based teaching hospital with severe Factor VII deficiency. We reviewed lab data and found any patients with less than a 5% factor deficiency from March 2004- June 2006. In our experience we have noted varying manifestations in moderate factor deficiency patients. We describe four patients with varying symptoms, all with factor levels less than 3%. Their charts were reviewed, and three of the patients were available for a telephone interview. Patient A is a 75 yo African American female found to have factor deficiency after an increased Prothrombin time (PT) of 31.2 seconds, INR 5.9, and Partial thromboplastin time (PTT) of 34.9 seconds on routine blood work. This patieny’s factor level was found to be 1.86%. Patient A denied any history of bleeding complications, including an uncomplicated tooth extraction. Patient B is a 46 yo African American female with a long history of bleeding complications. Laboratory data revealed a PT of 26 seconds, INR 4.2, PTT 22 seconds and a Factor level of 1%. She experienced years of heavy menstrual periods and nose bleeds. A hysterectomy was performed secondary to bleeding fibroids. She required multiple doses of novoseven as well as FFP. Patient C was diagnosed at the age of 11. Laboratory results revealed a factor level of 1.87 %, and a PT of 25.1 seconds and an INR of 4.1. She has had minor bleeding events, such as gum bleeding. She did receive FFP prior to a foot surgery, and tooth extraction. Patient D is a 46 year old Hispanic man found to have and INR of 4.3 and, factor VII 1.45. Pt had an uncomplicated cholocystectomy. This is a descriptive study of four different patients with factor VII levels of less than 2%. These four cases demonstrate the wide range of clinical manifestations that factor VII patients may experience. One patient did require novoseven prior to a hysterectomy. Though, as our cases illustrate, some patients do not experience any bleeding manifestations, and therefore, prophylactic plasma may not be required. Furthermore, treatment of factor VII deficient patients needs to be individualized, and guided by personal history. Coagulation Studies of our Patients Patient Prothrombin Time INR Factor VII A 31.2 5.9 1.86% B 26 4.2 1% C 25.1 4.1 1.87% D 46 4.3 1.45%

Proton Pump Inhibitors (PPIs) are widely used in the treatment of peptic ulcer disease, Helicobacter pylori (H pylori) gastritis and gastro-esophageal reflux disease. PPIs are known to be relatively safe medications, with the most common adverse reactions reported as diarrhea, nausea, vomiting, abdominal pain and headache. Thrombocytopenia has not been found to be a significant side effect of PPI use. Furthermore, successful treatment of H pylori associated immune thrombocytopenic purpura (ITP) with PPI therapy has been reported in the literature. In clinical practice, however, PPI use has been thought to be associated with medication-induced thrombocytopenia, although the precise prevalence of this consequence has not been quantified. The purpose of this study is to determine the prevalence of thrombocytopenia in hospitalized patients treated with pantoprazole, a commonly prescribed PPI, compared to non-medicated controls. In this retrospective, case-controlled analysis, we analyzed the platelet counts of 626 patients between 18 and 80 years of age who were admitted to an urban, community-based hospital and were medicated with pantoprazole for at least three days during their hospital stay. Thrombocytopenia was defined as a drop in the platelet count to below 150,000/ml, or a drop of at least 50% from baseline. Patients who had a platelet count below 150,000/ml on admission or were hospitalized for less than 3 days were excluded from the study. A control group of 560 patients with the same inclusion criteria who had not been prescribed pantoprazole was analyzed for comparison. 626 patients were included in the study group and 560 patients in the control group. The median age was 67 years in study group, and 61 years in the control group. The mean platelet count on admission was 260,00/ml in the study group, and 257,000/ml in the control group. Of the subject group, 39 patients (6.2%) met our definition of thrombocytopenia, which was not statistically different from the 35 patients (6.2%) with thrombocytopenia in the control group (p=0.90). Our study compared patients who received PPI therapy with pantoprazole for at least three hospital days to patients without treatment. We found no difference in the rate of thrombocytopenia between hospitalized patients treated with pantoprazole and the non-medicated controls. The rate of thrombocytopenia that we observed is probably an estimate of the overall thrombocytopenia rate in hospitalized patients irrespective of specific medications. While our report did not control for variables such as concurrent medication use, comorbid illnesses, and patient demographics, we are confident that the sample size selected for this study is large enough to provide sufficient evidence that thrombocytopenia is not a significant side effect of pantoprazole therapy.