Chronic Bleeding Research Articles

Spinal subarachnoid hematoma involving a thoracic ventral dural defect: illustrative case.

Spinal subarachnoid hematoma of unknown origin is rare. Superficial siderosis has been associated with chronic bleeding from spinal dural defects; however, the relationship between these defects and spinal subarachnoid hematoma remains unclear. A 32-year-old woman presenting with severe back pain and leg weakness exhibited an extensive thoracic spinal hematoma with spinal cord compression on magnetic resonance imaging. Emergency surgery was performed, which revealed a ventral subarachnoid hematoma that was evacuated. A ventral dural defect at the hematoma site and venous bleeding from the surrounding area were observed. Hemostasis was achieved and the defect closed. After surgery, her neurological symptoms quickly resolved. Postoperative spinal angiography showed no vascular lesions. Like superficial siderosis, ventral spinal subarachnoid hematoma can be caused by a spinal dural defect. https://thejns.org/doi/10.3171/CASE24435.

Red blood cell alloimmunization in transfused patients with hereditary hemorrhagic telangiectasia: A single centre retrospective study

BackgroundHereditary hemorrhagic telangiectasia (HHT) is a genetic blood vessel disorder which may lead to chronic bleeding and red blood cell (RBC) transfusions. Data on transfusion requirements and complications in HHT patients are sparse. Study Design and MethodsRetrospective chart review was conducted at St. Michael’s Hospital (SMH) in Toronto, Canada. All adults with a definite clinical diagnosis of HHT AND inpatient hospital visits between January 1, 2011 and December 31, 2020 AND had undergone transfusion compatibility testing at SMH, were identified. Data were abstracted from electronic medical records. Simple descriptive statistics were used to analyze data. Institutional Research Ethics Board approval was obtained. Results63 HHT patients underwent compatibility testing and were subsequently transfused at SMH. Median patient age at data abstraction was 70 years (Interquartile Range [IQR]: 18) and 35 (56 %) were female. RBC alloantibodies were found in 23 transfused patients (36.5 %) and were predominantly directed against Rh and Kell antigens: Anti-E (65 %), Anti-K (39 %) and Anti-c (22 %) were most common. Excluding an outlier who received 611 RBC units during the study period, the mean number of RBC units transfused per HHT patient at SMH was 22.1 units (Standard Deviation: 40.9, IQR: 17). Six (9.5 %) transfused patients experienced at least one transfusion reaction. ConclusionRBC alloimmunization rate was 36.5 % in our cohort of transfused HHT patients; this is much higher than described in the general population and another transfused HHT cohort. The most commonly observed alloantibodies were Rh and Kell, supporting our policy of prophylactic phenotypic matching for these antigens for all transfused patients with HHT.

Where did my O units go? Assessing a Month of O RBC Utilization in a Level 1 Trauma Center

Abstract Introduction/Objective The availability of red blood cells (RBCs) can be unpredictable and influenced by various factors affecting inventory levels. Anticipating future requirements can prove difficult, particularly in medical facilities catering to both trauma and chronically ill patients. By analyzing the fluctuation in blood indications, we can improve our planning and promote the responsible use of O RBCs. Methods/Case Report O units transfused in December 2023 in a level 1 trauma center were reviewed for transfusion indication, which was categorized into symptomatic anemia (SA), bleeding, sickle cell-related transfusion (SCRT), and surgery-related transfusion (SRT). Results (if a Case Study enter NA) During this month, our institution transfused 320 O units, of which 79% (254/320) were D positive. Most RBCs were given to patients with bleeding (43%,136/320) and SA (36%, 115/320). About half of the units used for acutely bleeding patients had massive transfusion protocol (MTP) activated (48%, 51/105), with 2/3 of those units used for trauma patients. Because most of our patients are African Americans, SCRT was also evaluated. Only 17/320(5%) of the units were given to our sickle cell disease patients. Lastly, we evaluated SRT because of our busy surgical service. We noted that 46 (14%) are SRT units, with 20% used prophylactically on the same admission and 50% used post-operatively. Conclusion It’s important to note that while patients with acute bleeding can cause a sudden depletion in the blood supply, patients with chronic anemia and bleeding can still make up a significant portion of those who require RBCs in a level 1 trauma hospital. In such a setting, where cases requiring MTP can be unpredictable, managing inventory levels can be challenging, and it requires careful monitoring to ensure that the appropriate blood units are used.

Incidental diagnosis of gastric antral vascular ectasia in a case of chronic kidney disease from Nepal: a case report

IntroductionGastric antral vascular ectasia is an uncommon clinical disease that affects elder people and is characterized by severe chronic upper gastrointestinal bleeding mainly affecting the gastric antrum. It is generally unusual among patients undergoing maintenance hemodialysis for chronic kidney disease.Case presentationHere, we aim to present an uncommon case of incidental diagnosis of the gastric antral vascular ectasia and erosive gastritis in a 71-year-old Hindu male patient belonging to the Gurung ethnicity of Nepal undergoing maintenance hemodialysis due to chronic kidney disease. The patient presented with a history of melena and fatigue. On investigation, a low hemoglobin level of 7.3 gm% was used for blood transfusion. The patient was on regular hemodialysis after admission at our institution. Upper gastrointestinal bleeding was suspected after analyzing patient’s history and investigations. Therefore, an upper gastrointestinal endoscopy was performed that showed linear ectatic punctuate lesions radiating from the body of the stomach to the antrum, and hence, an incidental diagnosis of the gastric antral vascular ectasia was made. Initial fluid resuscitation, iron therapy, and a triple regimen were administered. Proper management with argon plasma coagulation therapy was scheduled at another institution due to lack of respective facilities in our institution.DiscussionGastric antral vascular ectasia is an unusual cause of upper gastrointestinal bleeding, primarily affecting the gastric antrum and pylorus with rare cases affecting the duodenum, jejunum, and gastric fundus. It is generally associated with other chronic disease conditions. Several hypotheses have been proposed for the pathogenesis of gastric antral vascular ectasia, especially its association with chronic kidney disease, as in our case, which is considered to be rare. Management varies from medical to endoscopic interventions to even surgery.ConclusionPrompt proper diagnosis and treatment for the gastric antral vascular ectasia should be sought, as it is frequently misdiagnosed or missed during upper gastrointestinal endoscopy. Our case report presents a case of gastric antral vascular ectasia in chronic kidney disease undergoing maintenance hemodialysis, which is quite uncommon, as literature has suggested the same point.

Connecting the Dots on Female Digital Health Education: A Systematic Review.

Identified barriers to care for common, chronic conditions that impact millions of females suggest that patient education is critical to improving the care experience, expediting a diagnosis, and elevating outcomes. This article aims to understand the efficacy of digital patient education interventions on patient outcomes, specifically those addressing common causes of chronic abnormal uterine bleeding, premenstrual dysphoric disorder, and endometriosis. We queried MEDLINE, PubMed, Cochrane Library, and Google Scholar for articles published in English between January 1, 2014, and May 1, 2024, on digital patient education and urogenital diseases. The search identified 260 articles, 247 of which were retrieved for title and abstract review, 27 of which were retrieved for full-text review, and 25 of which were excluded. Two studies were included in this review. Both studies were individual-/community-level interventions involving digitally delivered patient education. Participants had received a diagnosis and were engaged in accessing care when enrolled, and each study was conducted at a single site. Both interventions produced positive results. Despite the potential of digital health education to improve patient outcomes, limited research in this field underscores the need for further studies to validate interventions and address gaps in knowledge.

S1026 Efficacy and Safety of Somatostatin Analogue in Chronic Bleeding From Gastrointestinal Angiodysplasia: A Systematic Review and Meta-Analysis

S1026 Efficacy and Safety of Somatostatin Analogue in Chronic Bleeding From Gastrointestinal Angiodysplasia: A Systematic Review and Meta-Analysis

Risk Factors Associated With Seizure After Treatment of Chronic Subdural Hemorrhage: A Systematic Review and Meta-Analysis.

Chronic subdural hemorrhage (cSDH) is a prevalent neurosurgical pathology, marked by blood collection between the dura mater and the arachnoid membrane. The aim of this systematic review was to provide a comprehensive overview of the risk factors associated with seizures after cSDH treatment. We systematically searched the following databases for studies conducted until September 28, 2023: PubMed, Embase, SCOPUS, Cochrane Central, WOS, and EBSCO. We selected all studies aiming to assess risk factors associated with seizures after treatment of cSDH. Observation studies written in English, Spanish, and Portuguese were included. The quality of studies was assessed using the Newcastle-Ottawa scale for observational studies. A total of 1830 studies were screened after the elimination of duplicates. A total of 18 studies were included, representing 4966 patients. The pooled proportion of seizures after treatment of cSDH is 10% [95% CI 7%, 13%; I2 = 93%]. The risk of seizures was lower in patients undergoing burr hole surgery compared to craniotomy, with an odds ratio of 0.23 (95% CI [0.10, 0.55]; I2 = 0%). Additionally, the risk of seizures in patients receiving prophylactic antiepileptic treatment compared to those without was higher, with an odds ratio of 2.62 (95% CI [0.53, 13.06]; I2 = 66%). Burr-hole treatment after cSDH presents a lower risk of seizures compared with craniotomy, and the use of prophylactic antiepileptic treatment did not conclusively affect seizure outcomes. Standardization in the reporting of outcomes and more comparative studies are needed to enable better recognition of risk factors of seizures after cSDH treatment.

Argon plasma photocoagulation for prevention of chronic ulcers and bleeding in solitary rectal ulcer syndrome: Scoping review and narrative summary

Argon plasma photocoagulation for prevention of chronic ulcers and bleeding in solitary rectal ulcer syndrome: Scoping review and narrative summary

Morphology of endometrial inflammatory changes in foci of endometriosis and adenomyosis

The high prevalence of endometriosis, its impact on menstrual and reproductive functions, obstetric complications, and the quality of life of women in the reproductive age determines the urgency of the problem.The objective: to assess the prevalence of inflammatory changes in foci of heterotopic endometrium in patients with endometriosis and adenomyosis.Materials and methods. 92 women of reproductive age – from 21 to 46 years old – who applied for surgical treatment for symptomatic adenomyosis (47 women – 1st group) and ovarian endometriosis (45 patients – 2nd group), and 30 practically healthy women of the same age (control group) were examined.Histological examination of adenomyosis and ovarian endometriosis biopsies was performed using a light microscope at magnifications of 40 and 100. For immunohistochemical examination, primary and secondary antibodies were used to determine CD34, CD68, and CD138 markers.Results. In patients with adenomyosis and ovarian endometriosis the following concomitant gynecological pathologies as uterine fibroids, endometrial hyperplasia, chronic endometritis, chronic abnormal uterine bleeding, the frequency of which is significantly higher in adenomyosis, were diagnosed. This may indicate the pathogenetic role of chronic inflammation in the development of these pathological conditions.In patients with adenomyosis the positive expression of CD68 in the epithelial component of heterotopias was determined in 8 (17.0±5.6%) women, and in 4 (8.9±4.2%) women with ovarian endometriosis, which indicated a low phagocytic activity. During the assessment of CD34 expression in vessel walls and the stromal component of endometrioid heterotopias, a positive reaction was determined in 16 (34.0±6.9%) patients with adenomyosis and in 10 (22.2±6.2%) patients with ovarian endometriosis, which reflects the processes of neoangiogenesis and the activity of the pathological process.Positive expression of CD138 in endometrioid heterotopias prevailed in the group of patients with adenomyosis – 12 (25.5±6.4%) cases versus 4 (8.9±4.2%) cases in the group of patients with ovarian endometriosis (p<0.05). This confirmed the histological results and clinical data regarding the presence of chronic endometritis and isthmocele.Conclusions. The identified inflammatory changes, weak phagocytic activity and signs of neoangiogenesis in foci of heterotopic endometrium are more significant in patients with adenomyosis, which is confirmed by clinical and morphological data.

An Analysis of Emergency Surgical Outcomes for Pediatric Traumatic Brain Injury: A Ten-Year Single-Institute Retrospective Study in Taiwan.

Background and Objectives: Pediatric traumatic brain injury (pTBI) remains a major pediatric public health problem, despite well-developed injury prevention programs. The purpose of this study is to analyze the emergency surgical outcomes of pTBI in a single institute ten-year retrospective study to offer a real-world clinical result. Materials and Methods: Our institute presented a clinical retrospective, single-institute research study of 150 pediatric TBI cases that were diagnosed and underwent emergency surgical treatment from 2010 to 2019. Results: The incidence of radiological findings is detailed as follows: brain edema (30%, 45/150), followed by acute subdural hematoma (27.3%, 41/150), epidural hematoma (21.3%, 32/150), chronic subdural hemorrhage (10%, 15/150), skull fracture (6.7%, 10/150), and traumatic subarachnoid hemorrhage (4.7%, 7/150). Surgical intervention data revealed that decompressive craniectomy was still the main effective surgical method. The results showed longer hospital stays and higher morbidity rates in the brain edema, acute subdural hematoma, and chronic subdural hemorrhage groups, which were viewed as poor surgical outcome groups. Epidural hematoma, skull fracture and traumatic subarachnoid hemorrhage were categorized into good surgical outcome groups. Notably, the data revealed gross improvement in Glasgow Coma Scale/Score (GCS) evolution after surgical interventions, and the time to cranioplasty was a significant factor in the development of post-traumatic hydrocephalus (PTH). Conclusions: Our study provided real-world data for the distribution of etiology in pTBI and also categorized it into six groups, indicating disease-orientated treatment. In addition, our data supported that decompressive craniectomy (DC) remains a mainstay surgical treatment in pTBI and early cranioplasty could decrease the incidence of PTH.

Model of Distraction and Therapy of Pain Due to Abscess Swelling

Swollen gums and/or ulcers (abscess) are lumps or ulcers on the gums, accompanied by the presence or absence of pus exit, occurring due to chronic inflammation and bleeding in the root area of the tooth (periapical abscess). The origin of this disease is the occurrence of caries (cavities) in the teeth, usually in the molars, but it can occur in all teeth. One of the impacts of this abscess is the onset of pain. One of the efforts to overcome pain problems in children is easier and can be done by nurses. Techniques that can be done are by using distraction and therapy techniques. This study aims to produce a distraction and therapy model to reduce pain in swelling due to abscesses. The research method used is Research and Development (R&D) with the Friedman Test effectiveness test. The distraction and therapy model is feasible as an effort to reduce the pain of abscess swelling in abscess patients. This is evidenced by the results of the feasibility test based on expert validation which shows that the p-value is 0.000. The distraction model and therapy are effective as an effort to reduce the pain of abscess swelling in abscess patients. This is evidenced by the results of the effectiveness test of paired variable data showing that the p-value of the compression and infrared intervention group is 0.000 (p <0.05), meaning that there is a difference before and after the distraction and therapy model is given to abscess patients.

Successful treatment of juvenile polyposis of infancy with sirolimus: a case report

BackgroundInfantile Juvenile polyposis of infantile (JPI) is a rare and aggressive form of juvenile polyposis syndrome (JPS) typically diagnosed in the first year of life. It often carries a poor prognosis due to chronic gastrointestinal bleeding, protein-losing enteropathy, malnutrition and immune deficiency.Case presentationWe report a case of a girl initially presented with pallor at 7 months of age, which progressed to gastrointestinal bleeding and protein-losing enteropathy. Endoscopic examination, which included both upper gastrointestinal endoscopy and enteroscopy, showed diffuse polyposis. Histopathology results indicated the presence of juvenile polyps with no dysplasia in all removed polyps. Genetic testing identified a 2.1 Mb deletion on chromosome 10q23.2q23.31 involving the phosphatase and tensin homolog (PTEN) and bone morphogenetic protein receptor type IA (BMPR1A) genes. Treatment with sirolimus initiated at 10 months of age led to a reduction in the need for blood and albumin infusions, improved patient growth, and quality of life. While the frequency of endoscopic evaluations decreased with sirolimus, regular endoscopic polypectomy every 5 months remained necessary. However, discontinuation of sirolimus resulted in polyp recurrence after 2 months due to pneumonia.ConclusionThis case highlights sirolimus treatment can alleviate many complications of JPI, it does not eliminate the need for aggressive polypectomy.

The Impact of Adenomyosis on Pregnancy.

Adenomyosis is characterized by ectopic proliferation of endometrial tissue within the myometrium. Histologically, this condition is marked by the presence of islands of benign endometrial glands surrounded by stromal cells. The myometrium appears thinner, and cross-sectional analysis often reveals signs of recent or chronic hemorrhage. The ectopic endometrial tissue may respond to ovarian hormonal stimulation, exhibiting proliferative or secretory changes during the menstrual cycle, potentially leading to bleeding, uterine swelling, and pain. Adenomyosis can appear as either a diffuse or focal condition. It is crucial to understand that adenomyosis involves the infiltration of the endometrium into the myometrium, rather than its displacement. The surgical management of adenomyosis is contingent upon its anatomical extent. The high incidence of the disease and the myths that develop around it increase the need to study its characteristics and its association with pregnancy and potential obstetric complications. These complications often require quick decisions, appropriate diagnosis, and proper counseling. Therefore, knowing the possible risks associated with adenomyosis is key to decision making. Pregnancy has a positive effect on adenomyosis and its painful symptoms. This improvement is not only due to the inhibition of ovulation, which inhibits the bleeding of adenomyotic tissue, but also to the metabolic, hormonal, immunological, and angiogenic changes associated with pregnancy. Adenomyosis affects pregnancy through disturbances of the endocrine system and the body's immune response at both local and systemic levels. It leads to bleeding from the adenomyotic tissue, molecular and functional abnormalities of the ectopic endometrium, abnormal placentation, and destruction of the adenomyotic tissue due to changes in the hormonal environment that characterizes pregnancy. Some of the obstetric complications that occur in women with adenomyosis in pregnancy include miscarriage, preterm delivery, placenta previa, low birth weight for gestational age, obstetric hemorrhage, and the need for cesarean section. These complications are an understudied field and remain unknown to the majority of obstetricians. These pathological conditions pose challenges to both the typical progression of pregnancy and the smooth conduct of labor in affected women. Further multicenter studies are imperative to validate the most suitable method for concluding labor following surgical intervention for adenomyosis.

Pediatric portal hypertensive enteropathy after Kasai surgery

BackgroundPortal hypertensive enteropathy (PHE) can cause chronic or acute gastrointestinal (GI) bleeding. Although there is a consensus on the diagnosis and treatment guidelines for PHE in adults, there are few reports on children. We aimed to report the clinical progress and outcomes of children with PHE treated with Kasai surgery and compare them with those of adults with PHE. MethodsIn total, 309 patients who underwent postoperative endoscopy were enrolled among 336 patients who underwent Kasai surgery for biliary atresia at Severance Children's Hospital between May 2005 and March 2022. ResultsThe PHE diagnosis rate was 15.2 % (n = 47). PHE was not diagnosed until 2012; however, the diagnosis rates significantly increased over time (13.3 % and 36.1 % between 2013 and 2017 and 2018–2022, respectively). Of the 47 patients diagnosed with PHE, 14 (29.8 %) had GI bleeding caused solely by PHE. None of the PHE patients required ICU care at the time of bleeding, compared to 32 (24.1 %) in the gastroesophageal varix (GEV) group. After initial management, the rates of re-bleeding, refractory bleeding, and mortality were 78.6 %, 28.6 %, and 0.0 %, respectively, in the PHE group. ConclusionsPediatric PHE diagnosis rates after Kasai surgery have increased since clinicians have become aware of the existence of the disease. Pediatric PHE has a high re-bleeding rate (78.6 %), although fatal GI bleeding is rare compared to GEV. Diagnosis and treatment of pediatric PHE can be performed according to adult guidelines. Level of evidenceIII.

Abstract We098: Target-Specific Novel Therapeutic Approach for Prevention of Arteriovenous Malformations in Hereditary Hemorrhagic Telangiectasia

Background: Hereditary hemorrhagic telangiectasia (HHT) is a rare genetic vascular disease with no cure. HHT is characterized by abnormalities in blood vessels that occur in mucocutaneous tissues (telangiectasias) and deep tissues (arteriovenous malformations, AVMs). The tangled, enlarged, fragile, and aberrant vasculature in HHT patients is prone to chronic bleeding or hemorrhage and may cause serious complications, especially in the brain. Problem Statement: While diagnosed AVMs can be surgically treated, there are no FDA-approved drugs to prevent or manage them. Developing targeted therapeutics to manage AVMs has been incredibly challenging as the mechanism of AVM formation is not clearly understood. Rationale: Dysregulation of pro-angiogenic signaling pathways is considered to play a major role in AVM development. For instance, VEGFA-VEGFR2, ANG2–TIE2 and MAP Kinase 1/2 signaling have been implicated individually in HHT pathogenesis. While MAPK 1/2 signaling is difficult to target because of its universal presence, its upstream activators VEGFA and ANG2 are lucrative targets for their relative specificity primarily affecting vasculature (Figure 1). Innovation: We use a novel approach to target VEGFA and ANG2 simultaneously using IgG CrossMab bispecific inhibitor, allowing superior efficacy by inhibiting dual specific targets to prevent genetic vasculature abnormalities. Approach: We use vascular latex casting and molecular quantification techniques to assess the benefits of inhibiting abnormal pro-angiogenic signaling in HHT mice models. Our preliminary data shows improved vasculature development with small doses of MAPK 1/2 inhibitor, but early mortality due to its damaging side effects. Preliminarily, the combined effect of the bispecific inhibitor in smaller doses improves the vasculature defects in the mutant brain more robustly than the individual inhibitors alone, while not negatively affecting the wild-type model (Figure 2). We further expect this dual inhibition to normalize the transcriptomic signature of mutants to mimic the wild-type setting. Societal Impact: The expected beneficial effects of the bispecific inhibitor will provide a pre-clinical assessment of the cerebrovascular AVM management strategies for 1.4 million HHT patients. It will further the mechanistic understanding of AVM development and prevention in HHT, the 2 nd most common bleeding disorder.

Greater readmission rates after total hip arthroplasty with discharge to a facility vs. home: A propensity score matched analysis

PurposeProvided that total hip arthroplasties (THA) are some of the most common surgical procedures performed, there is a necessity to understand all factors that contribute to risks of adverse outcomes postoperatively and to find solutions to avoid these events with preventive measures. This retrospective cohort study sought to assess differences in (1) postoperative complication rates, (2) readmission rates and reasons, and (3) demographic variables that contribute to readmissions based on discharge destination within the first 30 days after a THA. MethodsPatients undergoing THA (27130) between 2015 and 2020 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database based on procedural codes. Propensity score matching was then employed to reduce selection bias, and Chi-square tests and one-way analysis of variance (ANOVA) were performed. Multivariable analysis was then used to look for other factors associated with readmission risk. Results219,960 patients were identified with 189,841 discharged to home, 19,355 to a skilled nursing facility (SNF), and 10,764 to a rehabilitation facility. The rehabilitation and SNF cohorts both had greater rates of readmission (4.56 % home vs. 6.88 % SNF vs. 6.90 % rehabilitation, P<0.001) and any adverse event (AAE, 9.02 % vs. 18 % vs. 21.3 %, P<0.001) after matching. Older age, longer operative time, American Society of Anesthesiologists (ASA) classification four, chronic obstructive pulmonary disease (COPD), bleeding disorders, steroid use, and smoking were associated with an increased risk of readmission after THA. ConclusionOverall, THAs were shown to have low postoperative complications and readmissions in all patient populations despite differences in discharge destination which continues to demonstrate the safety and validity of this often elective procedure. However, the statistically significant risk of complications and readmissions in addition to the higher costs associated should be accounted for when considering patient discharges to a non-home facility.

Gastrointestinal disorders in systemic sclerosis: cluster analysis and prognosis from a French prospective cohort.

The gastrointestinal tract (GIT) is frequently involved in systemic sclerosis (SSc) and is responsible for alteration of quality of life. Many complications can occur, including chronic intestinal pseudo-obstruction, digestive haemorrhage and small-intestinal bacterial overgrowth. Since early development of organ failure is associated with poor prognosis, we need to identify risk factors associated with severe GIT involvement to prevent severe forms of the disease. We conducted an observational prospective study, which included 90 SSc patients from December 2019 to September 2021. We collected questionnaires about digestive manifestations and quality of life, blood and stool samples, and performed imaging. At inclusion and throughout the study we assessed the occurrence of malnutrition and severe GIT disorders. We performed statistical analysis to highlight eventual risk factors associated with digestive manifestations, including hierarchical cluster analysis. A majority of our patients had gastro-oesophageal manifestations (93.3%), followed by intestinal manifestations (67.8%) and anorectal manifestations (18.9%). We found a correlation between anorectal disorders and cardiac disease, and between gastro-oesophageal involvement and impaired pulmonary function tests. Smoking was significantly associated with occurrence of severe GIT disorders. Malnutrition was frequent and associated with more cardiac and pulmonary disease. Cluster analysis identified three groups of patients, including one cluster with cardiac and digestive involvement. GIT manifestations are frequent and severe in SSc. Smoking appears to be associated with severe disease. Anorectal manifestations may be associated with cardiac disease, but we need more studies to validate these results.

Catastrophic CPR-Related Injuries in Vascular Ehlers-Danlos Syndrome: A Case Report and Review.

This article presents a case of severe CPR-related injuries leading to diagnosis of vascular Ehlers-Danlos syndrome. The subject is a 36-year-old female with a past medical history of a 10-mm aneurysm of the right internal carotid artery discovered on imaging 3 years prior to death. Major autopsy findings included subarachnoid hemorrhage in the base of the brain, bilateral hemothoraces, hemopericardium, laceration of the interatrial septum, laceration of the left pulmonary artery, and changes secondary to chronic alveolar hemorrhage in the lungs. The autopsy findings and subsequent unremarkable toxicology studies led to the suspicion of an underlying and clinically undiagnosed connective tissue disorder. Broad genetic exome testing revealed a mutation consistent with vascular Ehlers-Danlos syndrome. An overview of this disease, its diagnosis, and differential are further described herein, along with recommendations for forensic pathologists.

Cerebrovascular Disease Detected on Preprocedural Computed Tomography in Patients With Severe Aortic Stenosis Undergoing Aortic Valve Replacement.

There is a scarcity of data on the prevalence and clinical impact of cerebrovascular disease detected on preprocedural computed tomography (CT) before aortic valve replacement (AVR) in patients with severe aortic stenosis. Among patients with severe aortic stenosis undergoing AVR, the authors compared clinical outcomes between patients with and without cerebrovascular disease detected on preprocedural CT, which was defined as chronic brain infarction or hemorrhage. The primary outcome measure in this study was a composite of all-cause death or stroke. Among 567 study patients, 200 patients (35.3%) had cerebrovascular disease on preprocedural CT. Among 200 patients with cerebrovascular disease on preprocedural CT, only 28.5% of patients had a clinical history of symptomatic stroke. The cumulative 3-year incidence of death or stroke was higher in patients with cerebrovascular disease on preprocedural CT than in those without cerebrovascular disease on preprocedural CT (40.7% versus 24.1%, log-rank P<0.001). After adjusting for confounders, the higher risk of patients with cerebrovascular disease on preprocedural CT relative to those without remained significant for death or stroke (hazard ratio [HR], 1.42 [95% CI, 1.02-1.98]; P=0.04). Among 200 patients with cerebrovascular disease on preprocedural CT, patients with prior symptomatic stroke compared with those without were not associated with higher adjusted risk for death or stroke (HR, 1.18 [95% CI, 0.72-1.94]; P=0.52). Among patients with severe aortic stenosis undergoing AVR, a substantial proportion had cerebrovascular disease on preprocedural CT, with a clinical history of symptomatic stroke in one-fourth of patients. Regardless of history of symptomatic stroke, patients with cerebrovascular disease on preprocedural CT had worse clinical outcomes compared with those without cerebrovascular disease on preprocedural CT.

Diagnostic Dilemma: A Case Report on Non-Resolving Chronic Vitreous Haemorrhage Secondary to Idiopathic Vasculitis or Trauma with Macular Hole

Diagnostic Dilemma: A Case Report on Non-Resolving Chronic Vitreous Haemorrhage Secondary to Idiopathic Vasculitis or Trauma with Macular Hole