Risk Of Bleeding Research Articles

Could a Two-Staged Repair Be the Solution to the Dilemma of Repair Timing for Severe Congenital Diaphragmatic Hernia Requiring Extracorporeal Membrane Oxygenation?

Congenital diaphragmatic hernia (CDH) remains a significant challenge, particularly in severe cases with persistent pulmonary hypertension (PPHN) and hypoplastic lungs and heart. For patients unresponsive to conventional therapies, ECMO is required. While the surgical repair is relatively simple, determining the optimal timing for surgery in patients requiring ECMO is particularly challenging. This review explores the dilemma of surgical timing and proposes a two-staged approach: a reduction in herniated organs and the creation of a silo to relieve abdominal pressure before initiating ECMO, with defect closure following ECMO decannulation. Studies support pre-, on-, and post-ECMO repair, each with its own risks and benefits. Pre-ECMO repair may enhance ECMO efficacy by relieving organ compression but poses risks due to instability. Post-ECMO repair is safer but may result in losing the chance to repair. On-ECMO repair has significant hemorrhage risks, but early repair with careful anticoagulation management is currently recommended. Recently, the author reported a successful case using a two-staged approach-reducing herniated organs and creating a silo before ECMO, followed by defect closure after ECMO decannulation-which suggests a potential alternative strategy for managing severe CDH. A two-staged approach may offer a solution for severe CDH patients requiring ECMO.

Ability of activated clotting time measurements to monitor unfractionated heparin activity during non-cardiac arterial procedures

ObjectivesActivated clotting time (ACT) measurements are frequently used to monitor unfractionated heparin activity during non-cardiac arterial procedures (NCAP). Accuracy of ACT-guided heparinization is mandatory to prevent heparin under- and overdosing, thereby minimizing thrombo-embolic complications (TEC) and bleeding risk. The main objective of this study was to investigate accuracy of ACT to monitor heparin activity during NCAP using the Hemostasis Management System Plus with high-range cartridges. ACT values were compared with anti-Xa measurements, regarded as the standard test to measure active heparin. MethodsThis was a single centre, prospective, observational cohort study. Perioperative blood samples of patients undergoing NCAP between December 2022 and September 2023 were used to perform bedside ACT measurements and anti-Xa assays in the clinical laboratory. Primary outcome was correlation between ACT and anti-Xa measurements. TEC, mortality and bleeding complications within 30 days postoperatively or during primary admission were also scored. Results196 pairs of ACT and anti-Xa measurements were performed in 34 patients. Strong correlation was observed between anti-Xa and ACT measurements (Pearson correlation coefficient = 0.84, 95% CI = 0.79 – 0.87, p < 0.001). Apart from anti-Xa, no additional variables were associated with ACT in multivariate linear regression analyses (regression coefficient β = 36.7, 95% CI = 33.3 – 40.1, p < 0.001). Bleeding complications occurred in 29% of the patients, while both TEC and mortality were observed in one patient.Conclusions: strong correlation and an independent association were observed between heparin activity measured by anti-Xa and ACT using the Hemostasis Management System Plus.

Long-Term Outcome of Patients with Atrial Fibrillation and High Risk of Stroke Treated with Oral Anticoagulation or Left Atrial Appendage Occlusion: A Cardinality Matched Analysis.

Atrial fibrillation (AF) poses a significant risk of stroke. Left atrial appendage occlusion (LAAO) is an alternative for patients with contraindications to oral anticoagulation (OAC) or with high risk of bleeding. This study aims to compare the outcomes of LAAO versus conventional stroke prevention in high-risk AF-patients. This secondary analysis incorporates data from the prospective Swiss-AF and Beat-AF cohorts, and the Zurich LAAO Registry. Cardinality matching was performed to create two comparable cohorts: conventional treatment (92% OAC) and LAAO. The primary endpoint was a composite of stroke, cardiovascular (CV) death, and clinically relevant bleeding. Kaplan-Meier method with competing risk analysis was used. Each group included 468 patients (age 76.4 [70.5, 82.0] years, 33% female). The LAAO group exhibited higher baseline bleeding risk (HAS BLED 2.0 [1.0-3.0] versus 3.0 [3.0-4.0]; p < 0.001). Median follow-up time: 6.0 (4.7-7.0) years in conventional treatment group and 4.0 (1.5-6.1) in LAAO group. No significant difference in the primary composite endpoint (HR 0.87, 95% CI: 0.72-1.06, p = 0.18), stroke risk (HR 1.14, 95% CI: 0.66-1.97, p = 0.64), or CV mortality (HR 1.08, 95% CI: 0.82-1.42, p = 0.60) was observed between groups. LAAO correlated with a significantly lower risk of clinically relevant bleeding (HR 0.61, 95% CI: 0.47-0.80, p < 0.001). In this cardinality matched analysis with long-term follow-up, LAAO showed similar stroke and CV death rates but lower clinically relevant bleeding risk compared to conventional therapy in high-risk AF-patients.

Alteplase vs. Tenecteplase: An In-depth Analysis of Their Relative Effectiveness in Treating Acute Ischemic Stroke

Dear Editor, Stroke stands as the second-leading cause of death worldwide [1, 2]. Each year, over 12 million individuals are impacted by stroke, resulting in approximately 6.5 million fatalities [1]. Stroke globally ranks as the third-leading factor causing a combination of death and disability [2]. Every year, around seven hundred thousand individuals in the United States undergo an Acute Ischemic Stroke (AIS), making up 85% of all stroke cases [2]. New treatments like intravenous thrombolysis and mechanical thrombectomy have cut mortality by 10% compared to older methods, enhancing long-term disability prevention rates following Acute Ischemic Stroke [2]. Alteplase is the sole FDA-approved thrombolytic drug in AIS within the first 4.5 hours. Despite its potential for disability-free recovery, its usage is constrained by a brief time window and adverse effects, notably a 6% risk of symptomatic bleeding. In addition, its fibrinolytic efficacy is limited, achieving vascular reopening in less than half of the patients, and can cause cytotoxicity to the already hypoxic brain with resultant cerebral edema [2]. Tenecteplase (TNK), a modified variant of alteplase, has improved features including greater fibrin selectivity and longer half-life and is given as a single bolus instead of an infusion, thanks to genetic recombinant technology [3]. Numerous studies have supported TNK's efficacy over alteplase in treating AIS. In 2016, Bruce C.V. Campbell and colleagues demonstrated that, according to the analysis of modified Rankin scale scores, tenecteplase exhibited a more favorable overall functional outcome compared to alteplase [4]. A dosage of 0.25 mg/kg of tenecteplase emerges as a promising alternative to replace alteplase as the preferred treatment for patients with AIS occurring within 4.5 hours due to TNK's superior early neurological recovery rates and comparable safety outcomes [3]. Despite gathering evidence from experimental trials indicating TNK's advantages over alteplase for AIS, the use of TNK at a dosage of 0.4 mg/kg appears to pose safety concerns when compared to alteplase [3]. Bruce C.V. Campbell and his fellow researchers revealed in their study that in spite of the beneficial effects of TNK relative to alteplase, there was no significant variation in the speed of recovery to independent function. Notably, they found no discernible distinction in the occurrence of intracranial hemorrhage [4]. ---Continue

Clinical analysis of bleeding and thrombotic events in haematological-oncology patients with severe thrombocytopenia and a high risk of thrombosis

Background: Haematological patients with severe thrombocytopenia and high thrombotic risk face challenges related to balancing bleeding and thrombosis risks. This study investigated factors associated with bleeding and thrombosis in high-risk haematological oncology patients with severe thrombocytopenia not receiving anticoagulant therapy and characterized their clinical features when both events occurred. Methods: A total of 446 haematological oncology patients with Caprini scores ≥ 5 were included from July 2022 to June 2023 at Mianyang City Central Hospital. Those not receiving prophylactic anticoagulants due to an admission platelet count < 50 × 109/L were studied. Patients were categorized into bleeding/nonbleeding and thrombotic/nonthrombotic groups on the basis of hospital course. Relevant clinical data were collected, and univariate/multivariate logistic regression was used to analyse the influencing factors. The platelet count at admission was assessed via ROC curves for thrombosis prediction. Results: In the bleeding group, higher proportions of patients with leukaemia, myeloid tumours, lung infections, and a central venous catheter (CVC) with two lumens were observed, along with shorter catheter durations, lower initial and minimum platelet counts during hospitalization, and prolonged plasminogen times (all P < 0.05). The thrombotic group had a greater thrombosis history, initial platelet count, use of two venous catheter lumens, parenteral nutrition, sedation, and autologous haematopoietic stem cell transplantation (Auto-HSCT), with a lower leukaemia proportion (P < 0.05). Logistic regression identified lymphoma type and minimum platelet count as bleeding protective factors and the Charlson Comorbidity Index (CCI) score as an independent risk factor. Thrombosis history, two venous catheter lumens, and sedation were risk factors for thrombosis. The median platelet count was lower at bleeding and thrombosis than at admission (P = 0.007). The platelet count at admission had predictive value for thrombosis, especially severe thrombocytopenia, with an AUC of 0.735 (95% CI 0.613–0.858, P = 0.003) and a cut-off value of 42.5 × 109/L. Conclusions: For haematological neoplasm patients with a high risk of venous thromboembolism (VTE), severe thrombocytopenia and high CCI scores, risk prevention and control of bleeding take precedence over thrombosis prophylaxis. Prophylactic anticoagulation is still recommended for patients with lymphoma assessed at high risk for VTE and with platelet counts of at least 42.5 × 109/L.

PEGylation of New Thrombin Inhibitor Peptide Ultravariegin for Prolonged In Vivo Circulation and Enhanced Antithrombotic Effects.

Anticoagulant therapy is commonly used to prevent and treat arterial and venous blood clots in patients with cardiovascular disease, cerebrovascular disease, and cancer. Venous blood clots are the third leading cause of cardiovascular death following acute coronary artery disease and stroke. There is a significant need for effective anticoagulant therapy with minimal risk of bleeding. Variegin and its variants are a new type of antithrombin peptide that has shown promising results in preclinical studies. Variegin and its best variant, ultravariegin (UV), can more effectively inhibit blood clot formation while causing less bleeding than traditional medications such as heparin and bivalirudin. However, the short lifespan of UV remains a limitation for its use in clinical settings. PEGylation, a method of conjugating poly(ethylene glycol) (PEG) chains to peptides or drugs, may help improve the effectiveness of UV by extending its circulation time in the body. In this study, UV was PEGylated using maleimide-PEG5k and 10k. The impact of PEGylation on the antithrombin activity of UV was assessed in vitro and ex vivo in rat and rabbit plasma, showing minimal effects on the efficacy. In vivo studies in rats and rabbits revealed that PEGylated UV had a longer half-life and greater anticoagulant effects than unmodified UV did, especially when it was administered subcutaneously. PEGylation significantly extended the half-life of UV in rabbits, resulting in sustained anticoagulant effects for up to 4 days. This demonstrated that increasing the size of UV and shielding it with PEG could reduce clearance by the kidneys and prolong its circulation time. The improved half-life and antithrombin activity of PEGylated UV make it a more favorable choice for anticoagulant therapy.

Phase angle variability on bleeding risks in hemodialysis patients.

This study investigated the association between Phase Angle (PhA), measured by bioelectrical impedance analysis, and bleeding risk in hemodialysis patients to evaluate PhA as a predictive marker for bleeding events. This retrospective cohort study included 102 hemodialysis patients who underwent PhA measurements between July 2019 and April 2024. Demographic data, medical histories, dialysis parameters, and bleeding events were collected. Patients were stratified by PhA values and followed for a median of 832days (IQR: 516-1304days). Multivariate Cox proportional hazards regression and Kaplan-Meier analysis were performed. The cohort had an average age of 74.0years and a median dialysis vintage of 6.7years. During follow-up, 19 patients (18.6%) experienced major bleeding events. Lower PhA was an independent risk factor for bleeding (HR: 0.24, 95% CI 0.11-0.52, p < 0.001). Kaplan-Meier analysis showed that patients with PhA ≥ 4.00 had a higher probability of remaining free from major bleeding at 2years (94.3%) compared to those with PhA < 4.00 (75.0%) (p < 0.001). In 82 patients with repeat PhA measurements, bleeding event-free rates at 2years were 97.5%, 75%, 100%, and 78.3% for the High to High, High to Low, Low to High, and Low to Low groups, respectively (p < 0.001). PhA is a predictive marker for bleeding risk in hemodialysis patients. Routine PhA monitoring could help stratify bleeding risk and optimize clinical management.

A Systematic Review of Safety and Efficacy of Factor XI/XIa Inhibitors in Patients With ESKD on Hemodialysis

IntroductionFactor XI/XIa (FXI/XIa) has emerged as a potential target for antithrombotic therapy, driven by preclinical evidence showing a role of FXI/XIa inhibition for preventing thrombosis without impeding hemostasis. This is particularly promising for patients at high risk of both thromboembolic events and bleeding, such as patients with end-stage kidney disease (ESKD) on hemodialysis (HD). MethodsWe systematically searched Embase, MEDLINE, and ClinicalTrials.gov for randomized controlled trials evaluating FXI/XIa inhibitors in patients with ESKD on HD, without restricting inclusion to specific comparators or indications. Interventional treatment arms were pooled, and study results were synthesized by fitting random-effects models, calculating odds ratios (OR) and 95% confidence intervals (CI). ResultsFive phase II studies encompassing 1,270 participants were identified, investigating gruticibart, IONIS-FXIRx, osocimab, or fesomersen in the general HD population and using placebo as a comparator. Four studies were fully published and included in the meta-analysis. Use of FXI/XIa inhibitors was associated with an OR of 0.80 (95% CI, 0.47-1.35) for clinically relevant bleeding, 0.51 (95% CI, 0.21-1.28) for major bleeding, and 0.90 (95% CI, 0.49-1.68) for clinically relevant non-major bleeding. The ORs for thromboembolic events and all-cause mortality were 0.66 (95% CI, 0.28-1.56) and 0.46 (95% CI, 0.15-1.40), respectively. ConclusionCurrently available evidence does not indicate a significantly increased bleeding risk of FXI/XIa inhibitors in patients with ESKD on HD compared to placebo. Their efficacy and their association with all-cause mortality need to be investigated in sufficiently powered, randomized controlled phase III trials.

Emergency management and perioperative strategies for intra-tumoral hemorrhage in neurofibromatosis type 1-related giant plexiform neurofibroma

To review the emergency management and perioperative strategies for ruptured neurofibromatosis type 1 (NF1)-related giant plexiform neurofibroma (PNF), providing a systematic treatment protocol to improve the therapeutic outcomes and quality of life for patients with giant PNF. The literature on the management of giant PNF rupture and hemorrhage was reviewed, and the diagnosis, treatment, and perioperative management were summarized based on clinical experiences. By implementing an integrated diagnostic and treatment strategy that includes early diagnosis, imaging evaluation, emergency ultra-selective arterial embolization combined with surgical excision, acute hemorrhage can be effectively controlled while also reducing the risk of major intraoperative bleeding and minimizing postoperative complications. As a result, this approach significantly improves treatment success rates and patient quality of life. For ruptured NF1-related giant PNF, employing emergency ultra-selective arterial embolization combined with surgical excision, under the collaboration of a multidisciplinary team, can effectively improve treatment success rates, rapidly control bleeding, reduce tumor size, and lower mortality. Future research should focus on assessing the long-term quality of life of patients treated for ruptured and hemorrhaging giant PNF and on further optimizing treatment protocols.

Hypothesizing the interplay of thrombus formation, wall enhancement, and perifocal edema as predictive factors for rupture in brain AVMs

The presence of shear stress within intracranial AVMs (arteriovenous malformations) due to high flow, perinidal angiogenesis, intranidal aneurysms, and biological factors are presumed risk factors for rupture. However, emerging imaging and histological evidence suggests that risk factors for AVM rupture may extend beyond the classical understanding. The presence of perifocal edema at the time of rupture, luminal thrombosis, and vessel wall enhancement on vessel wall MRI elucidate the possibility of an underlying inflammatory process within AVMs, which may predispose them to instability and eventual rupture. We hypothesize that for some AVM ruptures, the occurrence of thrombosis within vascular outpouchings of the AVM initiates a cascade of events, including local hypoxia, inflammation, breakdown of the blood–brain barrier and wall matrix degradation, which is evident from the presence of perifocal edema and vessel wall enhancement observed on imaging. These changes might ultimately raise the risk of AVM rupture and subsequent hemorrhage. Understanding this inflammatory component offers promising insights into AVM pathogenesis and may facilitate the development of preventive strategies to mitigate rupture risk.

Analyzing the safety and efficacy of pipeline embolization device in pediatric aneurysms: insight from a mul-ticenter cohort and pooled analysis.

Pediatric patients with intracranial aneurysms face high risks of spontaneous subarachnoid hemorrhages. Despite its approval for adults aged 22 and above, the Pipeline Embolization Device (PED, Covidien/Medtronic, Irvine, California, USA) is being considered for younger patients due to its efficacy. This study aims to assess the safety and effectiveness of using PEDs in pediatric aneurysm treatment. A retrospective study across 14 institutions identified 25 patients (age ≤ 18) treated with PED from November 2014 to October 2019. A literature review included all published pediatric aneurysm cases treated with PED from 2007 to 2023. Analyzed data included patient demographics, aneurysm characteristics, treatment, clinical outcomes, and complications. We analyzed 81 pediatric patients, including 25 from the multi-center registry and 56 from 38 relevant literature. In the entire cohort of 81 patients, mean age of the patients was 11.9 ± 4.0 years (ranged from 9 months to 18 years), with 58.0% males. Ruptured aneurysms were observed in 7 patients (8.6%), whereas 43 patients (53.1%) harbored large/giant aneurysms. The aneurysm occlusion rate was 87.7% during the median 7 months follow-up. Complications occurred in 12.3% of patients, resulting in morbidity in 5 cases (6.1%) and mortality in 4 cases (4.9%). Patient age was not associated with the occurrence of aneurysm residual, complications, and mortality following PED treatment. PED can be effective for pediatric aneurysms, but morbidity and mortality can be substantial compared to the adults. Surgical timing should depend on clinical judgment and patient factors, without age-related delays.

Drug-drug-interactions in patients with atrial fibrillation admitted to the emergency department.

Polypharmacy is a growing concern in healthcare systems. While available data on potential drug-drug interactions (pDDI) from emergency department (ED) patients is derived from heterogenous populations, this study specifically focused on patients with atrial fibrillation (AF). We hypothesized that patients with AF have similar comorbidities, receive similar drugs, and have similar pDDIs. The overarching aim was to highlight frequent pDDIs, providing practical guidance for treating healthcare professionals and consequently reduce the risk of adverse drug reactions. Two hundred patients ≥18years with AF, who received rate- or rhythm-controlling medication at the ED of the University Hospital Vienna, and who were on long-term medication before admission, were eligible. Long-term medication alone, as well as in combination with medication administered at the ED were analyzed for pDDIs using the Lexicomp® Drug interactions database. Within the long-term medication of patients', we identified 664 pDDIs. Drugs administered at the ED increased pDDIs more than 3-fold to 2085. Approximately, every fifth patient received a contraindicated drug combination (on average 0.24 per patient), while 70% received drug combinations for which therapy modifications are recommended (on average 1.59 per patient). The most frequently involved drugs included amiodarone, propofol, bisoprolol, enoxaparin, and acetylsalicylic acid. Increased risk of bleeding, QTc prolongation, and myopathy were among the most relevant potential consequences of these interactions. In conclusion, an optimization of medication would be advisable in almost every AF patient. Treating healthcare professionals should be cautious of drugs that increase bleeding risk, prolong QTc, or bear a risk for myopathy.

Impact of Ticagrelor vs. Clopidogrel in Patients With Acute Coronary Syndrome Undergoing Left Main Percutaneous Coronary Intervention

Abstract Objective: There is limited evidence regarding the choice of P2Y12 receptor inhibitors as a component of dual antiplatelet therapy (DAPT) in patients with left main (LM) disease undergoing percutaneous coronary intervention (PCI). This study aimed to evaluate long-term clinical outcomes of ticagrelor- vs. clopidogrel-based DAPT strategy in acute coronary syndrome (ACS) patients undergoing LM PCI. Methods: This is a post-hoc analysis from a prospective, single-center, real-world PCI registry. A total of 1,163 patients discharged post-ACS who underwent LM PCI and received ticagrelor or clopidogrel between March 2016 and March 2019 were included in the study. The primary endpoint was ischemic events at 12 months, including cardiac death, myocardial infarction, or stroke. Secondary outcomes included all-cause death and Bleeding Academic Research Consortium types 2, 3, and 5, and types 3 and 5 bleeding. Propensity score matching was used to adjust for bias due to confounders between the 2 groups. Results: The ticagrelor and clopidogrel groups comprised 529 (45.49%) and 634 (54.51%) patients, respectively. During the follow-up period, ticagrelor significantly reduced the rate of ischemic events compared to clopidogrel before (1.32% (7/529) vs. 3.63% (23/634), P = 0.0136) and after propensity score matching (1.41% (6/425) vs. 4.00% (17/425), P = 0.0201). The rates of all-cause death, Bleeding Academic Research Consortium-defined type 2, 3, and 5 bleeding, and type 3 and 5 bleeding were similar between the ticagrelor group and clopidogrel group before or after propensity score matching adjustment (all P &gt; 0.05). Conclusion: Among patients with ACS undergoing LM PCI, ticagrelor use was associated with ischemic events benefit without excessive risk of bleeding at 12 months compared with clopidogrel.

Clinical experiences in precision treatment of giant plexiform neurofibromas of head, face, and neck

To summarize the treatment strategies and clinical experiences of 5 cases of giant plexiform neurofibromas (PNF) involving the head, face, and neck. Between April 2021 and May 2023, 5 patients with giant PNFs involving the head, face, and neck were treated, including 1 male and 4 females, aged 6-54 years (mean, 22.4 years). All tumors showed progressive enlargement, involving multiple regions such as the maxillofacial area, ear, and neck, significantly impacting facial appearance. Among them, 3 cases involved tumor infiltration into deep tissues, affecting development, while 4 cases were accompanied by hearing loss. Imaging studies revealed that all 5 tumors predominantly exhibited an invasive growth pattern, in which 2 and 1 also presenting superficial and displacing pattern, respectively. The surgical procedure followed a step-by-step precision treatment strategy based on aesthetic units, rather than simply aiming for maximal tumor resection in a single operation. Routine preoperative embolization of the tumor-feeding vessels was performed to reduce bleeding risk, followed by tumor resection combined with reconstructive surgery. All 5 patients underwent 1-3 preoperative embolization procedures, with no intraoperative hemorrhagic complications reported. Four patients required intraoperative blood transfusion. A total of 10 surgical procedures were performed across the 5 patients. One patient experienced early postoperative flap margin necrosis due to ligation for hemostasis; however, the incisions in the remaining patients healed without complications. All patients were followed up for a period ranging from 6 to 36 months, with a mean follow-up duration of 21.6 months. No significant tumor recurrence was observed during the follow-up period. For patients with giant PNF involving the head, face, and neck, precision treatment strategy can effectively control surgical risks and improve the standard of aesthetic reconstruction. This approach enhances overall treatment outcomes by minimizing complications and optimizing functional and cosmetic results.

Serologic investigation and management of an antibody screen negative para-Bombay phenotype during pregnancy

Abstract Introduction/Objective Individuals with the Bombay and para-Bombay red blood cell (RBC) phenotypes express anti- H antibodies associated with acute hemolytic transfusion reactions. The rarity of compatible donor units creates unique logistical challenges. However, para-Bombay individuals have been shown to tolerate transfusion of non- Bombay RBCs without acute hemolysis. Therefore, accurate serologic identification and judicious management of blood products are crucial when planning to transfuse patients with anti-H. This is especially true during pregnancy, as early onset of labor and fetal distress can occur without warning. Methods/Case Report A 24-year-old gravida 2 para 1 (G2P1) at approximately 38 weeks gestation with the fetus in breech position was transferred to our hospital after anti-H antibodies were detected. Although our in-house antibody screen was negative on automated solid-phase red cell adherence (SPRCA) testing, manual tube testing revealed the presence of anti-H antibodies, and forward typing with Ulex europaeus lectin confirmed the absence of H-antigen. Further, Lewis B phenotyping and saliva neutralization demonstrated the presence of H-antigen in secretions, consistent with the O-para-Bombay phenotype. Finally, differential adsorption ruled out other clinically significant allo- antibodies. An external cephalic version (ECV) was initially planned since vaginal delivery carries lower bleeding risk than cesarean section (CS). Three frozen Bombay RBC units were obtained, with one possibly compromised before arrival. Four pre-warmed, cross-match compatible units of O-positive RBCs (non-Bombay) were also prepared. Acknowledging the unpredictability of ECV, the challenge of timing thawed frozen units, and the possibilities of massive hemorrhage versus wasting rare donor blood, our transfusion service ultimately recommended an elective CS with only one Bombay unit deglycerolized. The patient underwent an uneventful procedure without transfusion. Results (if a Case Study enter NA) NA Conclusion Overall, this case highlights key diagnostic and management considerations for patients with Bombay and para-Bombay phenotypes. First, automated SPRCA testing may provide false negative results for anti-H antibodies. Second, backup transfusion strategies for para-Bombay patients may include non-Bombay RBCs. Finally, the procurement, preparation, and use of rare donor blood products requires multidisciplinary clinical decision-making to optimize patient outcomes, especially for high-risk labor when unexpected acute bleeding events can occur.

Impact of statins on incidence of gastrointestinal bleeding events among patients with continuous-flow left ventricular assist devices.

Patients with continuous flow left ventricular assist devices (CF-LVADs) are at increased risk of gastrointestinal bleeding (GIB). Statins are commonly prescribed in LVAD patients for cardiovascular disease prevention. However, their impact on GIB events is controversial. Importantly, literature regarding statins impact on GIB in CF-LVAD patients is lacking. A single-center, retrospective review of adult patients who underwent CF-LVAD implantation between May 2016 and January 2020 was performed. Patients were categorized based on statin use throughout the study period. The primary outcome was the composite of arteriovenous malformation confirmed GIB and major GIB events for up to 1-year post-LVAD implantation. Of 123 patients included in the final analysis, 66 (54%) received statin therapy during the study period. No difference was observed in the primary outcome between the statin and control groups (RR: 1.73; 95% CI: 0.75-3.98; p=0.20). Multivariable Cox regression revealed that older age and higher baseline creatinine were associated with an increased risk of GIB within 1-year of CF-LVAD implantation. Among patients with CF-LVADs, there was no significant difference in the incidence of major GIB events associated with the use of statin therapy. Further studies are needed to assess whether a true association exists.

The prevalence of subdural blood products in extremely premature infants with no history of abusive head trauma, studied by magnetic resonance imaging around term-equivalent age.

Prematurity and enlarged subarachnoid spaces are both hypothesised to represent an increased risk of subdural haemorrhages (SDHs) in infancy, both with and without a history of abuse. To examine the prevalence of a previous haemorrhage, particularly SDHs, in infants born extremely prematurely around term-equivalent age; to examine intra- and inter-observer agreement for identification of haemorrhages; and to examine the width of the subarachnoid spaces. A total of 121 extremely premature infants had cerebral magnetic resonance imaging (MRI) performed around term-equivalent age (mean chronological age 14.7weeks, range 10.3-24.0weeks). There were no infants investigated for abuse in our cohort. Intracranial haemorrhages were classified as isolated germinal matrix-haemorrhages, parenchymal haemorrhages (cerebellar- and cerebral haemorrhages), or extra-axial haemorrhages (subarachnoid haemorrhages, SDHs, or epidural haemorrhages). Sinocortical width and interhemispheric distance were measured. No appreciable SDH was detected with the performed sequences. Haemorrhage/blood products related to prematurity were seen in 60 (49.5%) of the neonates. Agreement was good to very good for identification of haemorrhage. The mean sinocortical width was 3.5mm with a standard deviation (SD) of 1.4mm on the right side and 3.3mm (SD 1.2mm) on the left side. The mean interhemispheric distance was 3.1mm (SD 1.1mm). 61.1% of the infants had a sinocortical width > 3mm on one or both sides. Our study does not support the hypothesis that premature infants are more prone to SDH unrelated to abusive head trauma during the first 3-4months of life. A large percentage of the ex-premature infants had prominent subarachnoid spaces.

Helicobacter pylori infection increases risk of bleeding during endoscopic submucosal dissection for early gastric cancer.

Endoscopic submucosal dissection (ESD) is commonly used to treat early gastric cancer (EGC). The effects of Helicobacter pylori (HP) infection on ESD and the potential benefits of preoperative eradication of HP remain unclear. The study aims to evaluate the impact of HP infection on bleeding and lesion detection during ESD in patients with EGC. We retrospectively analyzed 634 consecutive patients who underwent ESD for EGC at our center between January 2018 and January 2023. Logistic regression was used to assess the impact of HP infection status on intraoperative bleeding and lesion detection rates. We developed a predictive model based on selected indicators and evaluated its performance using the ROC curve. HP-positive patients experienced a higher rate of intraoperative bleeding (28.8%) compared with HP-negative patients (8.9%) (P < 0.001). HP-positive patients also had longer procedure time (median: 58.5 vs. 50.0min, P < 0.001) and postoperative hospital stays (median: 4.35 vs. 4.07days, P = 0.036). Multivariate analysis identified HP-positive (OR = 4.84), multiple lesions (OR = 1.81), specimen size > 40mm (OR = 3.67), and submucosal invasion (OR = 2.27) as independent risk factors for intraoperative bleeding. The predictive model achieved an AUC of 0.807 (95%CI 0.761-0.852), with a sensitivity of 72.1% and specificity of 75.9%. Preoperative HP eradication was associated with an increased rate of lesion detection (OR = 2.82). Eradicating HP before ESD in patients with EGC reduces intraoperative bleeding and improves lesion detection. Preoperative HP eradication is therefore recommended in patients with EGC.

Anticoagulation therapy for complex patient populations

Managing anticoagulant therapy in patients with comorbidities such as kidney disease, liver disease, obesity, thrombophilia and increased bleeding risk with thrombocytopenia presents unique challenges. Renal impairment affects drug clearance. Liver disease alters coagulation and drug metabolism. Obesity affects drug distribution and dosing. Increased bleeding risk with thrombocytopenia often requires different dosing. This review finds that tailored therapeutic strategies are essential to balance the risks and benefits in these complex patient populations.

Optimizing Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation: Insights from the ORCA Trial-A Retrospective Study on 10 Years of Practice.

(1) Background: Citrate is preferred in continuous renal replacement therapy (CRRT) for critically ill patients because it prolongs filter life and reduces bleeding risks compared to unfractionated heparin (UFH). However, regional citrate anticoagulation (RCA) can lead to acid-base disturbances, citrate accumulation, and overload. This study compares the safety and efficacy of citrate-based CRRT with UFH and no anticoagulation (NA) in acute kidney injury (AKI) patients. (2) Methods: A retrospective analysis was conducted on adult patients (≥18 years) who underwent CRRT from July 2010 to June 2021 in an intensive care unit. (3) Results: Among 829 AKI patients on CRRT: 552 received RCA, 232 UFH, and 45 NA. The RCA group had a longer filter lifespan compared to UFH and NA (56 h [IQR, 24-110] vs. 36.0 h [IQR, 17-63.5] vs. 22 h [IQR, 12-48]; all Padj < 0.001). Bleeding complications were fewer in the RCA group than in the UFH group (median 3 units [IQR, 2-7 units] vs. median 5 units [IQR, 2-12 units]; Padj < 0.001) and fewer in the NA group than in the UFH group (median 3 units [IQR, 1-5 units] vs. 5 units [IQR, 2-12 units]; Padj = 0.03). Metabolic alkalosis was more common in the RCA group (32.5%) compared to the UFH (16.2%) and NA (13.5%) groups, while metabolic acidosis persisted more in the UFH group and NA group (29.1% and 34.6%) by the end of therapy vs. the citrate group (16.8%). ICU mortality was lower in the RCA group (52.7%) compared to the UFH group (63.4%; Padj = 0.02) and NA group (77.8%; Padj = 0.003). (4) Conclusions: Citrate anticoagulation outperforms heparin-based and no anticoagulation in filter patency, potentially leading to better outcomes through improved therapy effectiveness and reduced transfusion needs. However, careful monitoring is crucial to limit potential complications attributable to its use.