Bleeding Manifestations Research Articles

Adrenal Hematoma in Newborns: What to do?

Purpose: The adrenal gland is vulnerable to hemorrhage in the neonatal period because of its large size and its increased vascularity. The clinical manifestations are variable and non-specific. The aim of our work is to describe the clinical aspects, evolution and management of adrenal hemorrhage in the neonatal period.Methodology: This report is based on a presentation of a newborn with an adrenal hematoma who was hospitalized in our neonatology unit.Findings: The patient is a three-day old newborn female admitted in a state of shock. The anamnesis does not find any particular antecedent in antenatal or perinatal except an early rupture of membrane for more than 6 hours. The newborn was urgently transfused with phenotyped red blood cells and an antibiotic therapy was prescribed. The abdominal ultrasound showed a right adrenal hematoma measuring 42mm x 33mm.Unique Contribution to Theory, Policy and Practice: The clinical manifestations of adrenal hemorrhage depend on the severity of the hemorrhage and the extent of which the adrenal cortex is involved. In extreme cases, the newborn can present a hypovolemic shock, as shown in our observation, requiring an emergency blood transfusion. Acute adrenal insufficiency is rarely reported in adrenal hemorrhage because the bleeding is mainly subcapsular and hormonal insufficiency does not occur below 90% of adrenal tissue damage.

Management of Gastrointestinal Bleeding and Resumption of Oral Anticoagulant Therapy in Patients with Atrial Fibrillation: A Multidisciplinary Discussion.

Direct oral anticoagulants (DOACs) are recommended for the prevention of thromboembolism in patients with atrial fibrillation (AF), and are now preferred over vitamin K antagonists due to their beneficial efficacy and safety profile. However, all oral anticoagulants carry a risk of gastrointestinal (GI) bleeding. Although the risk is well documented and acute bleeding well codified, there is limited high-quality evidence and no guidelines to guide physicians on the optimal management of anticoagulation after a GI bleeding event. The aim of this review is to provide a multidisciplinary critical discussion of the optimal management of GI bleeding in patients with AF receiving oral anticoagulants to help physicians provide individualized treatment for each patient and optimize outcomes. It is important to perform endoscopy when a patient presents with bleeding manifestations or hemodynamic instability to determine the bleed location and severity of bleeding and then perform initial resuscitation. Administration of all anticoagulants and antiplatelets should be stopped and bleeding allowed to resolve with time; however, anticoagulant reversal should be considered for patients who have life-threatening bleeding or when the bleeding is not controlled by the initial resuscitation. Anticoagulation needs to be timely resumed considering that bleeding risk outweighs thrombotic risk when anticoagulation is resumed early after the bleeding event. To prevent further bleeding, physicians should prescribe anticoagulant therapy with the lowest risk of GI bleeding, avoid medications with GI toxicity, and consider the effect of concomitant medications on potentiating the bleeding risk.

Recent outbreaks of Marburg virus in Africa: an urgent call for public concern

Recent outbreaks of Marburg virus in Africa: an urgent call for public concern

Le prove coagulative nel bambino che sanguina (prima parte)

This brief report presents a practical approach to the diagnosis of the main coagulopathies in children with haemorrhagic manifestations. It discusses the clinical-anamnestic elements that should suggest further laboratory investigations. Then, after a brief review of coagulation physiology and main coagulation tests, three clinical scenarios based on PT and aPTT results are described. In particular, the paper focuses on the two most common congenital coagulopathies: haemophilia and von Willebrand disease. Recently, a new drug, emicizumab, has been introduced in the prophylaxis of severe haemophilia A, with great benefits on patients’ quality of life.

Bleeding disorders and postpartum hemorrhage by mode of delivery: a retrospective cohort study

BackgroundPregnant persons with bleeding disorders and their potentially affected newborns are at a higher risk of peripartum bleeding complications. The safest mode of delivery for persons with bleeding disorders remains debated, leading to uncertainties in decision-making between the patient and her multidisciplinary team. ObjectivesThis study aimed to describe maternal outcomes for pregnant persons with bleeding disorders by mode of delivery and to examine whether postpartum hemorrhage (PPH) and neonatal hemorrhagic manifestations are associated with the mode of delivery. MethodsWe collected retrospective data on pregnant persons with bleeding disorders who delivered at a single center from 2010 to 2021. Descriptive statistics, Fisher exact test, and odds ratios were used for analysis. ResultsA total of 82 pregnancies in 56 subjects were included. Hemophilia A and von Willebrand disease represented the largest cohort, at 30% (17/56) each. Overall rates of primary and secondary PPH were 7.3% (6/82) and 17.4% (12/69), respectively. We did not find a statistically significant difference between mode of delivery and PPH. Upon comparing vaginal and cesarian deliveries, we found an odds ratio of 0.7 (95% CI, 0.1-3.4) for primary PPH and 2.6 (95% CI, 0.4-16.4) for secondary PPH. One male newborn with severe hemophilia A was treated for a suspected intracranial hemorrhage. ConclusionIn our cohort, high rates of PPH remained an important complication for pregnant persons with bleeding disorders. There was no significant difference in PPH based on modes of delivery. The small sample size likely limited the power of our study, and consequently, future larger studies are needed.

Intramural Hematoma of Gastrointestinal Tract in People with Hemophilia A and B.

People with hemophilia (PWH), especially severe hemophilia, often experience bleeding episodes, which occur mostly at major joints. Intramural hematoma of the gastrointestinal (GI) tract is a rare, potentially life-threatening clinical bleeding manifestation in PWH. Prompt identification and timely administration of clotting factor concentrates are of utmost importance for effective management and optimal patient outcomes. In this report, we present the case of a 48-year-old male with severe hemophilia A. The patient developed a spontaneous intramural hematoma of the jejunum, leading to signs of acute abdomen, bloody stool, and paralytic ileus. Conservative management with factor VIII (FVIII) infusion was successfully administered. However, within a span of three months, the patient suffered from a recurrent episode of intramural hematoma, which was again effectively treated with conservative therapy. Subsequently, prophylactic FVIII therapy was administered to the patient, resulting in the absence of recurrence for over three years. Inspired by this case, we conducted a comprehensive review of the relevant literature and gathered data from 79 reported cases of intramural hematoma that were documented between the years 1956 and 2022. We classified these cases based on the site affected within the gastrointestinal (GI) tract (spread across five different locations) and proceeded to conduct a simple pooling analysis on the data collected, which subsequently revealed that the overall mortality rate of intramural hematoma in people with hemophilia (PWH) was found to be 12.2%, while children have a higher mortality rate (23.3%) than adults (4.9%). We hope this case report and literature review increase awareness of this rare bleeding manifestation in PWH, the effectiveness of conservative treatment, and the possibility of prophylaxis against recurrence.

Assessing the Clinical Treatment Dynamics of Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention in the US

A platelet ADP P2Y12 receptor (P2Y12) inhibitor plus aspirin is standard therapy for patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Compared with clopidogrel, prasugrel and ticagrelor are associated with superior antiatherothrombotic effects but increased bleeding risk; with recent guideline updates, it is important to describe current treatment patterns and the role of bleeding risk in treatment choice. To describe secular trends and determinants of initial P2Y12 inhibitor choice and switching, including deescalation (switch from prasugrel or ticagrelor to clopidogrel). This retrospective cohort study used MarketScan Commercial Claims Data from 2010 to 2019 for patients aged 18 years or older who underwent PCI for ACS, had no P2Y12 inhibitor use in the past year, and filled a P2Y12 inhibitor prescription within 30 days after PCI hospitalization discharge. Data were analyzed from February to May 2022. Clopidogrel, prasugrel, and ticagrelor, with determinants including bleeding risk measured using Academic Research Consortium for High Bleeding Risk criteria, sociodemographic characteristics, P2Y12 inhibitor copays, and bleeding events during follow-up. The prevalence of each P2Y12 inhibitor among patients who initiated the drugs and the prevalence of switching within 12 months after PCI were evaluated. The association between baseline bleeding risk and bleeding manifestations during follow-up and initial treatment and deescalation were calculated using multivariable logistic and Cox proportional hazards regression models. Between 2010 and 2019, 62 423 patients were identified who initiated P2Y12 inhibitors (females, 22.4%; males, 77.6%; mean [SD] age, 54.32 [7.13] years). The prevalence of clopidogrel as initial therapy decreased from 77.5% in 2010 to 29.6% in 2019, while initial use of prasugrel or ticagrelor increased from 22.5% to 60.4%. Within 1 year after PCI, 11.0% of patients switched therapy, mostly for deescalation. Deescalation prevalence increased from 1.8% in 2010 to 12.6% in 2018. Between 2016 and 2018, 8588 of 22 886 (37.5%) patients had major baseline bleeding risk, which decreased the selection of prasugrel or ticagrelor as initial therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.84). Among 11 285 patients who initiated prasugrel or ticagrelor, major bleeding risk at baseline (adjusted hazard ratio, 1.11; 95% CI, 1.00-1.23) and the occurrence of bleeding during follow-up (adjusted hazard ratio, 4.42; 95% CI, 3.62-5.93) were associated with deescalation. A strong shift in preference for prasugrel and ticagrelor as initial therapy following PCI for ACS was observed. Deescalation increased over the study period. Major bleeding risk at baseline was moderately associated with initial treatment choice but had a limited association with deescalation. The increasing use of more potent P2Y12 inhibitors emphasizes opportunities to enhance preemptive patient-centered treatment strategies to maintain optimal antiplatelet activity while reducing bleeding risk during the subacute period following PCI for ACS.

A thrombophilic allele of clotting Factor VII/VIIa promoting recurrent pulmonary emboli, clinical details, and a structural model of the altered protein: a case report

BackgroundThe clotting or hemostasis system is a meticulously regulated set of enzymatic reactions that occur in the blood and culminate in formation of a fibrin clot. The precisely calibrated signaling system that prevents or initiates clotting originates with the activated Factor Seven (FVIIa) complexed with tissue factor (TF) formed in the endothelium. Here we describe a rare inherited mutation in the FVII gene which is associated with pathological clotting.Case presentationThe 52-year-old patient, with European, Cherokee and African American origins, FS was identified as having low FVII (10%) prior to elective surgery for an umbilical hernia. He was given low doses of NovoSeven (therapeutic Factor VIIa) and had no unusual bleeding or clotting during the surgery. In fact, during his entire clinical course he had no unprovoked bleeding. Bleeding instances occurred with hemostatic stresses such as gastritis, kidney calculus, orthopedic surgery, or tooth extraction, and these were handled without factor replacement. On the other hand, FS sustained two unprovoked and life-threatening instances of pulmonary emboli, although he was not treated with NovoSeven at any time close to the events. Since 2020, he has been placed on a DOAC (Direct Oral Anticoagulant, producing Factor Xa inhibition) and has sustained no further clots.Possible mechanism of (unauthorized) FVII activationFS has a congenitally mutated FVII/FVIIa gene, which carries a R315W missense mutation in one allele and a mutated start codon (ATG to ACG) in the other allele, thus rendering the patient effectively homozygous for the missense FVII. Structure based comparisons with known crystal structures of TF-VIIa indicate that the patient's missense mutation is predicted to induce a conformational shift of the C170's loop due to crowding of the bulky tryptophan to a distorted "out" position (Fig. 1). This mobile loop likely forms new interactions with activation loop 3, stabilizing a more active conformation of the FVII and FVIIa protein. The mutant form of FVIIa may be better able to interact with TF, displaying a modified serine protease active site with enhanced activity for downstream substrates such as Factor X.ConclusionsFactor VII can be considered the gatekeeper of the coagulation system. Here we describe an inherited mutation in which the gatekeeper function is altered. Instead of the expected bleeding manifestations resulting from a clotting factor deficiency, the patient FS suffered clotting episodes. The efficacy of the DOAC in treating and preventing clots in this unusual situation is due to its target site of inhibition (anti-Xa), which lies downstream of the site of action of FVIIa/TF.

Various Factors in Pediatric to Severe Dengue Infection-A Retrospective Study

Introduction: Dengue epidemics are known to have occurred over the last three centuries in tropical, subtropical and temperate areas of the world. The World Health Organization (WHO) estimated that approximately 2.5 billion people living in dengue-endemic countries. Objective: To assess the various factors in pediatric to severe dengue infection-A Retrospective study. Methods: A hospital-based Retrospective study was conducted at Emergency, Observation and Referral Unit, Bangladesh Shishu Hospital and Institute, Dhaka, Bangladesh from January to June 2021. Number of patients included in the study was 52. In children with high degree clinical suspicion of Dengue infection NS 1 antigen (who came within first 48 hours of fever) and/or Dengue Antibody IgM, IgG (who came after five days of fever) were performed. Results: The study was enrolled 102 patients of suspected dengue fever of whom 52 (50.98%) were serologically confirmed to have dengue infection. 29 (55.8%) patients were males and 23 (44.2%) were females. 38 (37.25%) patients had classic dengue fever while 12 (11.76%) fulfilled the criteria of dengue hemorrhagic fever. Of those patients with dengue hemorrhagic fever, 6 patients had developed dengue shock syndrome. Most of dengue cases occurred during the month of June to September depicts the role of rainy season on clustering of cases. Maximum number of cases 52 cases (68.49%) was in the children age groups. All cases and is the most common symptom followed by headache, myalgia, vomiting etc. Hemorrhagic manifestations were seen that included petechiae, ecchymosis, gum bleeding, hematuria, malena, hematemesis and epistaxis. Most common complications were hepatic dysfunction, renal failure, multi organ failure, encephalopathy and ARDS. Conclusion: Dengue is one amongst the key causes of dedifferentiated fever. It presents as an extremely broad wellness and is hardly recognized as a clinical entity by primary health care physicians. This study support additional studies on applying intervention measures to boost the diagnostic accuracy and exactness at the first tending level in dandy fever endemic regions.

Ramifications of Pancytopenia in Children in a Tertiary Care Center in North Indian

BACKGROUND: Pancytopenia generally suggests the likelihood of bone marrow failure syndromes or leukemias. However, other easily treatable entities can also cause pancytopenia. To know the underlying cause of pancytopenia is essential for definite management and prognosis. AIM: The aim of this study is to study the prevalence, clinico-hematological profile, and etiology of pancytopenia in hospitalized children of 1 month to 18 years of age. METHODS: Descriptive study conducted in a tertiary care center included children of age 1 month to 18 years hospitalized with pancytopenia. Sociodemographic data, presenting complaints, and detailed history were noted. Detailed clinical examination and relevant investigations were done. RESULTS: The prevalence of pancytopenia was 2%. Majority of the patients were >10 years of age. Female: Male ratio was 1.15:1. The most common presentation was progressive pallor, followed by fever, icterus, and bleeding manifestations. The most common clinical examination finding was pallor, followed by splenomegaly, hepatomegaly, icterus, and lymphadenopathy. Macrocytic blood picture was most common, followed by microcytic, atypical cells, and normocytic picture. Mean serum ferritin (ng/ml) was 374.77 ± 1662.64. Mean serum B12 (pg/ml) was 117.72 ± 64.71. In bone marrow aspirate examination, megaloblastic erythropoiesis was most common, followed by normoblastic erythropoiesis, dual deficiency, malignant cells of lymphoid series, hypocellular marrow, and malignant cells of myeloid series. Megaloblastic anemia was the most common etiology, followed by dimorphic anemia amid acute leukemia. CONCLUSION: The study showed that megaloblastic anemia and infections (tuberculosis, dengue fever, and enteric fever) both of which are eminently treatable, cause nearly 65% of pancytopenia cases in pediatric patients.

Clinicopathological Features of Rare Bleeding Disorders in High Consanguinity Population; A Retrospective Analysis from Two Tertiary Hospitals in Saudi Arabia

BACKGROUND: Rare bleeding disorder (RBDs) encompasses a deficiency of one or more of FXIII, FXI, FX, FVII, FV, FII, and FI clotting factors, leading to bleeding disorders with variable presentations and outcomes ranging from none or minimal to life-threatening events. RBDs are still underdiagnosed and underreported, especially in Saudi population with a high prevalence of consanguinity. OBJECTIVES: The study aimed to determine the frequency of RBDs, grading of their bleeding severity, and assessment of clinical manifestations and management of RBDs in tertiary Saudi Arabian hospitals. DESIGN AND SETTINGS: This retrospective study of RBDs describes the clinicopathological features of refereed cases to both Prince Sultan Military Medical City and King Khaled University Hospital in Riyadh, Saudi Arabia, from September 2018 to September 2021. Any patient who had already been diagnosed or suspected to have RBDs was enrolled in the study. PATIENTS AND METHODS: Patient's medical records were reviewed for demographic data, clinical presentations, bleeding and family history, consanguinity, treatment outcomes, and molecular testing. Samples were run in specialized coagulation laboratories. Patients with liver dysfunction or acquired factor deficiency were excluded. Patients were categorized into four groups according to the severity of bleeding episodes: asymptomatic, Grade I, Grade II, and Grade III. RESULTS: A total of 26 cases with RBDs were identified during the study period. Most of the included patients are males and pediatrics (<14 years) representing 15 (57.7%) and 14 (53.8%), respectively. FVII was the most common factor deficiency encountered in 9 (35%) patients, followed by FXIII in 5 (19%), FXI in 4 (15%), FX in 3 (11.5%), FV in 3 (11.5%), and combined factor deficiency in 2 (8%) patients. 17 (65.4%) RBD patients presented with bleeding manifestation either with Grade I (9%), Grade II (39%), or Grade III (15%), whereas 47% were asymptomatic. CONCLUSION: The study emphasizes on importance of establishing a national registry of RBDs in Saudi Arabia and the need for further genetic studies to clarify the genotype/phenotype relationships.

School Examination Stress Precipitating Hematohidrosis in a Girl

Background: Hematohidrosis is a rare clinical disorder characterized by transient, self-limited bleeding from the eccrine sweat glands through intact skin in the absence of an underlying bleeding disorder. Clinical Description: We report a 10-year-old girl who presented with a history of bleeding from the dorsum of her right hand. The child has had recurrent episodes in the past. Many of the episodes were temporally related to her school examination. She did not have any other bleeding manifestations or susceptibility to bruising. Her general condition and systemic examination were unremarkable, and the skin underlying the bleeding site was normal and healthy. All investigations related to bleeding and coagulation parameters were within normal limits. Skin biopsy showed normal histology. Having ruled out all organic causes of bleeding, the typical history of transient episodes of bloody secretions from the skin, triggered by examination stress and normal skin histology, was consistent with a diagnosis of hematohidrosis. Management: The child responded dramatically to oral propranolol with a subsequent reduction in the frequency of the bloody sweating episodes, even during stressful times. Psychological counseling was also provided. Conclusion: In a child presenting with oozing of blood from the skin, a possibility of hematohidrosis may be considered, when all causes of bleeding diathesis have been ruled out by a thorough workup. Pediatricians need to counsel both parents and the child regarding the benign nature of the condition.

A second local dengue fever outbreak: A field experience from Muscat Governorate in Oman, 2022

Dengue fever is an infectious disease of global health concern. This study aimed to describe the epidemiology and field experience of a locally transmitted outbreak of dengue fever in Muscat Governorate, Oman from mid-March to mid-April 2022, and the multi-sectoral approach to control the outbreak. Data were collected from an electronic e-notification system, active surveillance and contact investigations. Of 250 suspected and probable cases, 169 were confirmed as dengue fever with DENV-2 serotype. Of these, 108 (63.9%) were male and 94 (55.6%) were Omani. The mean age was 39 years (standard deviation 13 years). Fever was the most common symptom and occurred in 100% of cases. Haemorrhagic manifestations occurred in 10% (n=17) of cases. Hospitalization was required for 93 cases (55.1%). The field investigation included 3444 houses and other suspected sites. Breeding sites for Aedes aegypti were identified in 565 (18.5%) sites visited. Interventions to control the outbreak included environmental and entomological assessment of the affected houses and surrounding areas (400 m radius of each house). Outbreaks are expected to continue, with the possibility of severe cases due to antibody-dependent enhancement. More data are required to understand the genetics, geographical spread and behaviour of A. aegypti in Oman.

Consensus on hemophilia in Mexico

Hemophilia is a hemorrhagic disorder with a sex-linked inherited pattern, characterized by an inability to amplify coagulation due to a deficiency in coagulation factor VIII (hemophilia A or classic) or factor IX (hemophilia B). Sequencing of the genes involved in hemophilia has provided a description and record of the main mutations, as well as a correlation with the various degrees of severity. Hemorrhagic manifestations are related to levels of circulating factor, mainly affecting the musculoskeletal system and specifically the large joints (knees, ankles, and elbows). This document is a review and consensus of the main genetic aspects of hemophilia, from the inheritance pattern to the concept of women carriers, physiopathology and classification of the disorder, the basic and confirmation studies when hemophilia is suspected, the various treatment regimens based on infusion of the deficient coagulation factor as well as innovative factor-free therapies and recommendations for the management of complications associated with treatment (development of inhibitors and/or transfusion-transmitted infections), or secondary to articular hemorrhagic events (hemophilic arthropathy). Finally, relevant reviews of clinical and treatment aspects of hemorrhagic pathology characterized by acquired deficiency of FVIII secondary to neutralized antibodies named acquired hemophilia.

Разработка метода первичного скрининга болезни Виллебранда на основе балльной оценки выраженности геморрагических проявлений по результатам опроса пациентов

Разработка метода первичного скрининга болезни Виллебранда на основе балльной оценки выраженности геморрагических проявлений по результатам опроса пациентов

CLINICOHEMATOLOGICAL STUDY OF PATIENTS PRESENTING WITH THROMBOCYTOPENIA

AIMS/OBJECTIVES: To study cases of thrombocytopenia on the basis of bone marrow findings and correlating it with clinical findings and hematological parameters. To study role of morphological examination of bone marrow aspirate in diagnosis of various disorders leading to thrombocytopenia and classify them. It was a retrospective METHODS: study on 100 patients who presented with persistent thrombocytopenia either isolated or combined with other cytopenias in tertiary care hospital in 2022. Complete clinical details were recorded. Routine hematological investigations like CBC were performed using automated cell counter. Detailed peripheral blood examination was done. The bone marrow examination was done in every case and findings were recorded. Final diagnosis was listed under 2 categories: neoplastic and non-neoplastic. A total of 100 cases were included in our study and categorized into RESULT: neoplastic and non- neoplastic. The most common neoplastic condition was acute leukemiaand most common non-neoplastic condition was megaloblastic anemia followed by ITP. Overall most common condition was megaloblastic anemia. Age distribution of patient varied over a wide range from 9 months to 83 years of age. The most common clinical feature was generalized weakness followed by progressive pallor, fever, bleeding tendencies etc. CONCLUSION We concluded that thrombocytopenia is not a disease but it is an entity which can be seen in a number of clinical problems including neoplastic and non neoplastic diseases. We also found that bleeding is not very common manifestation in thrombocytopenia and moreover few patients with very low platelet count had no bleeding manifestation

Risk factors for future bleeding in patients with mild bleeding disorders: longitudinal data from the Vienna Bleeding Biobank

BackgroundThe future bleeding risk, especially after hemostatic challenges, and thus the requirement for hemostatic treatment in patients with mild-to-moderate bleeding disorders (MBDs) is largely unknown. ObjectivesThis study aimed to prospectively examine the recurrence of bleeding symptoms and clinical risk factors for future bleeding in patients with MBD, including patients with bleeding disorder of unknown cause (BDUC). MethodsBleeding symptoms of patients with MBD included in the Vienna Bleeding Biobank were re-evaluated at in-person follow-up visits or by mail. ResultsIn total, 392 patients, including 62.8% with BDUC, were investigated for the recurrence of bleeding events. During the follow-up time of median (IQR) 4.3 years (2.6–6.7), 72% of patients had at least 1 bleeding event.Most persistent bleeding manifestations were hematomas (n = 146/245, 59.6%) and bleeding from small wounds (n = 69/141, 48.9%), followed by epistaxis (n = 42/132, 31.8%), oral mucosal bleeding (n = 26/87, 29.9%), and joint bleeding (n = 7/14, 50.0%). Patients with previous postinterventional bleeding had a significantly increased risk for bleeding events after surgery (n = 33/114, 29.0 %) or tooth extraction (n = 16/39, 41.0%).A high bleeding score (OR [95% CI], 1.14 [1.05 to 2.94], per 1 unit) and follow-up time (OR [95% CI], 1.23 [1.12 to 1.36], per 1 year) were independently associated with any bleeding event. For bleeding after hemostatic challenges, blood group O (OR, 3.17 [1.57 to 6.40]), previous postsurgical bleeding (OR, 2.40 [1.06 to 5.46]), and an established diagnosis (OR, 2.07 [1.04 to 4.10]) were independent risk factors. ConclusionPatients with MBD have a high risk for recurrent bleeding. This encourages prophylactic hemostatic treatment in patients with MBD, particularly when they face hemostatic challenges.

Thrombocytopenia in Children: A Large Prospective Study on Clinical Manifestations, Seasonal Variation, Etiology, and Outcome.

To study the clinico-etiological profile of children with thrombocytopeniaMethods: This prospective hospital-based study included all children (<18 years) with thrombocytopenia at the time of hospitalization and/or thrombocytopenia during the course of their hospital stay. A detailed history was recorded and appropriate laboratory investigations were carried out Results: The study group comprised 246 children (mean age, 9.29 years; median age, 10 years) with male to female ratio of 1.5:1. Nearly 45% of children were above 10 years of age. Trends of admissions showed that the majority of children with thrombocytopenia (n = 115) got hospitalized during the rainy season, followed by summer (n = 84). Fever (72.8%), pallor (52.8%), bleeding manifestations (22%), lymphadenopathy (20.3%), and splenomegaly (20.3%) were common clinical features. Petechiae was the most common bleeding manifestation (63%). Septicemia (24%) was the most common etiology, followed by megaloblastic anemia (14.6%), undiagnosed fever (10.2%), local infection (9.3%), hepatitis (6.5%), and scrub typhus (6.1%). About nine children died. All those who died had septicemia and multi-organ dysfunction (MOD). On logistic regression analysis, age >10 years, presence of bleeding, arthralgia, rash, pallor, gastrointestinal (GI) symptoms, hematological disorders, and malignancy were associated with severe thrombocytopeniaConclusion: Thrombocytopenia is a common hematological observation. This study revealed seasonal variation in the occurrence of thrombocytopenia in children, with the maximum number of cases in the rainy season. Septicemia is the commonest etiology. The majority of children with thrombocytopenia have no bleeding manifestations. Age >10 years, presence of bleeding, arthralgia, rash, pallor, GI symptoms, hematological disorders, and malignancy are associated with severe thrombocytopenia.

SEVERITY AND CLINICO-HAEMATOLOGICAL FEATURES OF APLASTIC ANEMIA IN ADULTS PRESENTING TO PUBLIC SECTOR TERTIARY CARE HOSPITAL OF LAHORE: A DESCRIPTIVE CROSS SECTIONAL STUDY

Background & Objective: Aplastic anemia is a rare and heterogeneous disorder. Literature shows inconsis- tencies in frequency and its clinico-hematological findings. Objective of this study was to assess frequency of different severity grades and clinico-hematological features in newly diagnosed cases of aplastic anemia in adults.
 Methods: In this descriptive, cross-sectional study, conducted in Allama Iqbal Medical College Lahore from October 2021 through April 2022, a total of 100 diagnosed cases of acquired aplastic anemia were included. Modified Camitta's criteria were applied to assess the severity of aplastic anemia. Clinical features such as pallor, fever and bleeding manifestations were determined by history and physical examination. About 3ml whole blood was collected in EDTA vial and run for complete blood count on automated hematology analyzer for hematological Parameters (Hb, Platelets, total leukocyte count and absolute Neutrophil count). Data were entered and analyzed using SPSS version 20. Quantitative variables like age, Hb, TLC and platelet count were expressed as mean ±Standard deviation. Qualitative variables such as gender, severity of aplastic anemia and clinical features were expressed as percentages.
 Results: In this study, 55% participants were male and 45% were female. All patients had pallor, 61% had fever and 66% had bleeding on presentation. Regarding severity of aplastic anemia, 56% were categorized as severe, 24% as very severe and 20% were as non severe aplastic anemia.
 Conclusion: Severe aplastic anemia is frequent among male population and at younger age. This information has prognostic implications. Therefore, all patients with aplastic anemia should be assessed for severity for further clinical management.

Cefoperazone-induced Coagulopathy in Critically Ill Patients Admitted to Intensive Care Unit.

N-methylthiotetrazole side chain (NMTT) of cefoperazone was attributed to inhibit the vitamin K epoxide enzyme. This mechanism is similar to warfarin; thus, vitamin K was suggested to antagonize the hematological effects of cefoperazone. The literature on critically ill patients receiving cefoperazone and its clinical significance on bleeding diathesis is sparse. To assess the incidence of cefoperazone-induced coagulopathy (CIC), its clinical impact on bleeding episodes, and transfusion requirements. Predisposing factors and the role of prophylactic and therapeutic vitamin K were evaluated. Prospective observational study of adult intensive care unit (ICU) patients (>18 years) receiving cefoperazone between December 2017 and December 2018. We excluded those on warfarin, those with preexisting elevated prothrombin time/international normalized ratio (PT/INR), and with bleeding manifestations. Relevant laboratory investigations and specific outcomes were noted for 6 days following therapy. Panel data regression was used to determine predictors of coagulopathy. Among 65 patients, 17 (26%) had probable CIC. Hypoalbuminemia and vancomycin co-administration were risk factors for CIC. Hemoglobin drops and blood transfusions were not different between INR non-elevated and elevated groups (11 vs 8 gm/dL; p = 0.06 and 11 vs 8 units; p = 0.23, respectively). Prophylactic vitamin K did not offer any benefit toward preventing INR elevation. Therapeutic vitamin K significantly reduced INR when elevated [absolute risk reduction (ARR):57.5% and number needed to treat (NNT):1.7]. Results of this study revealed that CIC is not uncommon in ICUs. Based on the findings of the study, we suggest INR monitoring in patients receiving nephrotoxic agents and patients with hypoalbuminemia. We also recommend vitamin K administration in patients with elevated INR. Gudivada KK, Krishna B, Sampath S. Cefoperazone-induced Coagulopathy in Critically Ill Patients Admitted to Intensive Care Unit. Indian J Crit Care Med 2023;27(3):183-189.