Bleeding Classification Research Articles

The Effect of Preoperative Anemia on the Outcome After Coronary Surgery.

Preoperative anemia is associated with increased morbidity and mortality after cardiac surgery. Since anemia is ultimately treated with red blood cell transfusions, we investigated the independent impact of anemia and transfusion on the outcome after coronary artery bypass grafting (CABG). This study included 2761 consecutive patients who underwent isolated CABG. Anemia was defined as hemoglobin <12.0g/dL in women and <13.0g/dL in men. The main outcomes were 30-day and late mortality. Patients with preoperative anemia had an increased prevalence of significant comorbidities and were associated with higher unadjusted risk of early and late adverse events. Propensity score matching resulted in 560 pairs with similar baseline and operative characteristics. In these matched pairs, anemic patients had an increased risk of late all-cause death (P=0.047) and acute kidney injury (P<0.0001). However, when adjusted for the severity of perioperative bleeding, preoperative anemia was not associated with an increased mortality risk (HR 1.10, 95% CI 0.86-1.39). Instead, this regression model showed that the European CABG registry (E-CABG) bleeding classification was an independent predictor of late mortality (compared to grade 0: grade 1, HR 1.93, 95% CI 1.37-2.73, grade 2, HR 2.19, 95% CI 1.50-3.18, grade 3, HR 5.59, 95% CI 3.34-9.39, P<0.0001). When adjusted for important baseline characteristics and operative factors as well as for the severity of perioperative bleeding and the amount of transfused blood products, anemia was not associated with an increased risk of adverse events. Increased exposure to blood transfusion among anemic patients may be the determinant of their poorer late survival.

Validation of Bleeding Classifications in Coronary Artery Bypass Grafting

Perioperative bleeding is a determinant of poor outcome in patients undergoing coronary artery bypass grafting (CABG), but there is a lack of adequate stratification of its severity. The ability of the European registry of Coronary Artery Bypass Grafting (E-CABG), Universal Definition of Perioperative Bleeding (UDPB), Study of Platelet Inhibition and Patient Outcomes (PLATO), Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events-Seventh Organization to Assess Strategies in Ischemic Syndromes (CURRENT-OASIS 7), Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events (ESSENCE), and SafeTy and Efficacy of Enoxaparin in Percutaneous coronary intervention patients, an internationaL randomized Evaluation (STEEPLE) bleeding classifications to predict early mortality, stroke, acute kidney injury (AKI) stage 3, and deep sternal wound infection/mediastinitis was investigated in 3,730 patients from the prospective, multicentre E-CABG registry. Increasing grades of the E-CABG, UDPB, PLATO, and CURRENT-OASIS 7 classifications were associated with increasing risks of early mortality, had similar receiver-operating characteristic area under the curves (>0.7), and were predictive also when adjusted for EuroSCORE II. The E-CABG and UDPB classifications had satisfactory area under the curves (>0.6) in predicting stroke, AKI stage 3, and deep sternal wound infection/mediastinitis even when adjusted for EuroSCORE II. The PLATO and CURRENT-OASIS 7 classifications had similar predictive ability for stroke and AKI stage 3 as confirmed by multivariate analysis adjusted for EuroSCORE II but showed inferior ability in predicting severe wound infection compared to the E-CABG and UDPB classifications. The STEEPLE and ESSENCE classifications had a poor ability of predicting all these adverse events. Decision curve analysis showed a benefit of the E-CABG bleeding classification over the other classifications in predicting alladverse events. In conclusion, the E-CABG, UDPB, PLATO, and CURRENT-OASIS 7bleeding classifications have a satisfactory ability in predicting adverse events afterCABG. Decision curve analysis showed that the E-CABG bleeding classification had the best predictive performance.

Effect of Pregnancy in Women with a History of Primary Immune Thrombocytopenia Considered As Cured

Immune thrombocytopenia (ITP) is an autoimmune disease that occurs in young women. Pregnancy is a well-known risk factor for developing newly diagnosed ITP as well as for inducing disease flares in patients with current ITP. However, the impact of pregnancy in women with an old history of ITP, considered as cured, has not been assessed. The aim of this study was to describe the course of ITP in pregnant women with an ITP in complete remission (platelets count >100x109/L and absence of bleeding symptoms) for at least 5 years without any ITP treatment.We retrospectively selected all pregnant women with delivery at Toulouse University Hospital, South of France, between 2010 and 2015 with a hospital discharge code of ITP (international classification of diseases; version 10 code D69.3). This code has a sensitivity of 81.2% and a positive predictive value of 89.8% in this database. All medical charts were reviewed to confirm the diagnosis of ITP. We included adult women (≥18 years) with a diagnosis of primary ITP according to French guidelines (platelet count <150 x 109 /L and exclusion of other causes of thrombocytopenia, especially other causes of thrombocytopenia during pregnancy) in complete remission for at least 5 years.We identified 50 pregnancies in 39 ITP patients during the study period. Eleven pregnancies occurred in 10 patients in long-term complete remission of ITP at the time of pregnancy onset. Baseline characteristics were: median age at ITP diagnosis: 21 years (range: 4-29); median age at pregnancy onset:32 years (range: 26-34; history of ITP during a previous pregnancy: 1; history of bleeding: 4 (36.4%); previous treatment for ITP: 8 (72.7%), corticosteroids-CS (5), CS and intravenously immunoglobulin-IVIg (3), splenectomy (4), dapsone (1); last median platelet count before pregnancy: 170x109/L (range: 118-363).Platelets count decreased below 100x109/L in 3 pregnancies (27.2%) from the first trimester for one patient, from the second trimester for one other and from the third trimester for the last one, with a nadir of 3, 39 and 87 (x109/L) respectively. One of them experienced a severe bleeding (grade 3 according to the International Working Group bleeding classification). All thrombocytopenic patients required treatment during pregnancy: CS+IVIg for 2 (one for bleeding and one to allow epidural analgesia) and IVIg for the other (to allow epidural analgesia). For these 3 women, the median platelet count at delivery was 128 (range: 38-159) and consequently only 2 of them could have epidural analgesia. No bleeding during delivery was observed. Transient thrombocytopenia occurred in 2 newborns.Primary ITP considered as cured may relapse during pregnancy and may induce severe bleeding requiring specific treatment. A tight monitoring should be proposed to all pregnant women with a history of primary ITP, even after several years of complete remission. DisclosuresRécher:Celgene, Sunesis, Amgen, Novartis, Chugai: Membership on an entity’s Board of Directors or advisory committees, Research Funding.

Endovascular stroke therapy may be safe in patients with elevated international normalized ratio

IntroductionEndovascular therapy in acute ischemic stroke is safe and efficient. However, patients receiving oral anticoagulation were excluded in the larger trials.ObjectiveTo analyze the safety of endovascular therapy in patients with...

Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting

The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial. To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone. This prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015. Before surgery, patients received ticagrelor with or without aspirin or aspirin alone. Severe bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates. Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]). Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion (22.7% [5 of 22] vs 6.4% [12 of 187]) and E-CABG bleeding grades 2 and 3 (18.2% [4 of 22] vs 5.9% [11 of 187]) and tended to have an increased risk of UDPB grades 3 and 4 (22.7% [5 of 22] vs 9.6% [18 of 187]). Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12.4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group. In propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.

FIGO's PALM-COEIN Classification of Abnormal Uterine Bleeding: A Clinico-histopathological Correlation in Indian Setting.

Abnormal uterine bleeding (AUB) is the commonest menstrual problem during perimenopause. The International Federation of Gynaecology and Obstetrics working group on menstrual disorders has developed a classification system (PALM-COEIN) for causes of the AUB in non-gravid women. The present study was conducted with the aim to study the two components of this system in clinical practice in general and to establish a clinico-pathological correlation of AUB with context of PALM component in particular. Two hundred and thirty-six perimenopausal women (aged 40years and above till 1year beyond menopause) admitted with complaints of abnormal uterine bleeding were studied. After thorough history and examination, a clinical diagnosis was made as per PALM-COEIN classification. Relative contribution of various causes of PALM (structural) and COEIN (functional) components was analysed. After all indicated investigations, endometrial sampling and hysterectomy specimen were assessed by histology. A clinicopathological correlation was analysed statistically. PALM and COEIN components contributed almost equally for AUB when assessed clinically. On the other hand, the histological examination revealed significantly more cases of PALM (structural or anatomical) component of AUB, i.e. 50.23 versus 63.98% (p≤0.05) The difference was mainly attributed to the detection of more cases of AUB-M (malignancy and hyperplasia) in highly significant proportions (p≤.01) and coexistent cases of AUB-A;L. AUB-L was the commonest (41.1%) aetiology overall. The PALM-COEIN classification system should take into account both the clinical and histopathological diagnoses in women having AUB around perimenopause as the two diagnostic modalities are complementary to each other and clinical impression should be placed into proper perspective of this classification in order to optimise outcome.

Abnormal Uterine Bleeding: American College of Nurse-Midwives.

Variations in uterine bleeding, termed abnormal uterine bleeding, occur commonly among women and often are physiologic in nature with no significant consequences. However, abnormal uterine bleeding can cause significant distress to women or may signify an underlying pathologic condition. Most women experience variations in menstrual and perimenstrual bleeding in their lifetimes; therefore, the ability of the midwife to differentiate between normal and abnormal bleeding is a key diagnostic skill. A comprehensive history and use of the PALM-COEIN classification system will provide clear guidelines for clinical management, evidence-based treatment, and an individualized plan of care. The purpose of this Clinical Bulletin is to define and describe classifications of abnormal uterine bleeding, review updated terminology, and identify methods of assessment and treatment using a woman-centered approach.

Utility of the PALM-COEIN classification of abnormal uterine bleeding for Indian gynecologists.

To study the clinical utility of the PALM-COEIN classification for abnormal uterine bleeding in day-to-day practice in India. Between April and November 2014, a cross-sectional survey was undertaken of gynecologists practicing in Chittoor and Nellore. Doctors possessing a postgraduate degree in gynecology and obstetrics, and postgraduate students in the gynecology department of medical colleges were invited to participate. A validated questionnaire containing 15 questions was distributed, the opinions were collated, and the results analyzed. Among 150 invited gynecologists, 120 agreed to participate, and 119 completed the survey fully. Overall, 95 (79.8%) respondents were aware of the classification, and 56 (47.1%) responded that the PALM-COEIN system is very good, 46 (38.7%) that it is average, and 17 (14.3%) that it is poor. By subgroup, 16 of 20 (80.0%) faculty members, 46 of 56 (82.1%) postgraduate students, and 33 of 43 (76.7%) practitioners responded that the system is useful. Indian doctors generally believe that the PALM-COEIN system is clinically useful and a step forward in the management of abnormal uterine bleeding.

Discriminant nonnegative matrix factorization for classification of rectal bleeding in prostate cancer radiotherapy

External beam radiotherapy is one of the standard treatments for prostate cancer. Despite advanced radiotherapy techniques allowing precise dose delivery on cancer targets, efficiency of the treatment is limited by the risk of side-effects due to the irradiation to the surrounding organs. Characterizing the local dose–toxicity relationship is crucial to provide new recommendations for treatment planning. Standing on a voxel wise analysis, in this paper we proposed a new method, named Discriminant Nonnegative Matrix Factorization (DNMF), for classifying patients at risk of presenting rectal bleeding. Comparative studies with a classical Nonnegative Matrix Factorization (NMF) algorithm and principal component analysis (PCA) based method are also given. The features extracted by the proposed method for different rank values are used to classify the planned dose distribution images into rectal-bleeding and non-rectal-bleeding. The sensitivity and specificity obtained on 118 patients (Se=0.77 and Sp=0.82) show the DNMF as a promising method for predicting the toxicity-related side-effect in the rectum following prostate radiotherapy.

Clinical impact and course of major bleeding with rivaroxaban and vitamin K antagonists

Rivaroxaban is a new oral anticoagulant (NOAC) that can be prescribed in a fixed dose, making regular monitoring and dose adjustments unnecessary. It has been proven to be safe and effective in comparison with enoxaparin/vitamin K antagonists (LMWH/VKA) for the (extended) treatment of venous thromboembolism in the EINSTEIN studies. Nevertheless, there is a need for information regarding the clinical impact of (major) bleeding events with NOACs such as rivaroxaban. A post-hoc analysis was performed to compare the severity of clinical presentation and subsequent clinical course of major bleeding with rivaroxaban vs. LMWH/VKA. Two investigators performed a blinded classification of major bleeding using a priori defined criteria. During the EINSTEIN studies, data concerning the clinical course and measures applied were prospectively collected for each major bleed. Treatment with LMWH/VKA caused more major bleeding events (1.7%) than rivaroxaban (1.0%; hazard ratio, 0.54; 95% confidence interval [CI], 0.37-0.79). Major bleeding events during rivaroxaban therapy had a milder presentation (23% were adjudicated to the worst categories vs. 38% for LMWH/VKA; hazard ratio or HR, 0.35; 95% CI, 0.17-0.74; P=0.0062). The clinical course was severe in 25% of all major bleeding events associated with rivaroxaban, compared with 33% of LMWH/VKA-associated bleeds (HR, 0.46; 95% CI, 0.22-0.96; P=0.040). Rivaroxaban-associated major bleeding events occurred less frequently, had a milder presentation and appeared to take a less severe clinical course compared with major bleeding with LMWH/VKA.

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding.

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

National consensus of management patients with abnormal uterine bleeding by association of gynecologist and endocrinologist of Ukraine

Current classification of abnormal uterine bleeding, review of diagnostic methods and treatment strategies of the condition are presented in the article. Moreover, evidence based algorithms of the diagnosis and treatment of this condition considering the features of the health care system in Ukraine are given

Bleeding Frame and Region Detection in the Wireless Capsule Endoscopy Video.

Wireless capsule endoscopy (WCE) enables noninvasive and painless direct visual inspection of a patient's whole digestive tract, but at the price of long time reviewing large amount of images by clinicians. Thus, an automatic computer-aided technique to reduce the burden of physicians is highly demanded. In this paper, we propose a novel color feature extraction method to discriminate the bleeding frames from the normal ones, with further localization of the bleeding regions. Our proposal is based on a twofold system. First, we make full use of the color information of WCE images and utilize K-means clustering method on the pixel represented images to obtain the cluster centers, with which we characterize WCE images as words-based color histograms. Then, we judge the status of a WCE frame by applying the support vector machine (SVM) and K-nearest neighbor methods. Comprehensive experimental results reveal that the best classification performance is obtained with YCbCr color space, cluster number 80 and the SVM. The achieved classification performance reaches 95.75% in accuracy, 0.9771 for AUC, validating that the proposed scheme provides an exciting performance for bleeding classification. Second, we propose a two-stage saliency map extraction method to highlight bleeding regions, where the first-stage saliency map is created by means of different color channels mixer and the second-stage saliency map is obtained from the visual contrast. Followed by an appropriate fusion strategy and threshold, we localize the bleeding areas. Quantitative as well as qualitative results show that our methods could differentiate the bleeding areas from neighborhoods correctly.

Clinical significance and determinants of the universal definition of perioperative bleeding classification in patients undergoing coronary artery bypass surgery

We evaluated the clinical significance and identified the predictors of the universal definition of perioperative bleeding (UDPB) classes in patients undergoing isolated coronary artery bypass grafting (CABG). Data on antithrombotic medication, perioperative bleeding, blood transfusion, and adverse events were available for 2764 patients who had undergone isolated CABG. The Papworth risk score correlated significantly with the UDPB classes (rate of UDPB class 3-4 and Papworth risk score of 0, 12.1%; 1, 23.9%; 2, 37.5%; and 3, 45.0%; P<.0001). Ordinal regression showed that increased age, female sex, low body mass index, low estimated glomerular filtration rate, low hemoglobin, dialysis, urgent or emergency operation, critical status, on-pump surgery, potent antiplatelet drug pause of <5 days, and warfarin pause of <2 days were independent predictors of high UDPB classes. These risk factors also predicted UDPB classes 3-4 in logistic regression analysis. Increasing UDPB classes were associated with an increased risk of in-hospital mortality (P=.002), stroke (P=.023), low cardiac output (P<.0001), prolonged use of inotropes (P<.0001), renal replacement therapy (P<.0001), length of stay in the intensive care unit (P<.0001), and late mortality (P<.0001) as assessed by multilevel propensity score-adjusted analysis. Similar findings were observed in the propensity score-adjusted analysis for the most severe grades of perioperative bleeding (ie, UDPB class 3-4). High UDPB classes were associated with significantly poorer immediate and late outcomes. The UDPB classification seems to be a valuable research tool to estimate the severity of bleeding and its prognostic impact affect after coronary surgery.

Bleeding complications in patients undergoing percutaneous coronary interventions

Bleeding complications are among the most common complications of percutaneous coronary intervention (PCI) procedures. A multitude of studies carried out over the last decade have confirmed that bleeding complications after PCI have a negative impact on patients' outcome (dissatisfaction, morbidity, and mortality) and hospital indices (length of stay and costs). Apart from better recognition and classification of bleeding, recent research has helped to device several risk stratification tools that have markedly improved prediction of peri-PCI bleeding. Moreover, parallel with the recognition of the deleterious effects of peri-PCI bleeding, several strategies (pre-PCI risk stratification for bleeding, the use of bivalirudin as an antithrombotic/anticoagulant strategy, the radial artery route for vascular access and vascular closure devices) that aim to reduce peri-PCI bleeding were developed and used. Their application has markedly reduced the incidence of bleeding and improved the clinical outcome. In this review, we focus primarily on the bleeding complications occurring during PCI procedures. Specifically, we summarize recent research on the need for a consensus in bleeding definition, incidence of bleeding events, and their impact on outcome, factors associated with increased risk and risk stratification for bleeding, putative mechanisms through which bleeding impact on outcome, and bleeding-avoidance strategies to be used in the setting of PCI procedures.

The Prognostic Value of Bleeding Academic Research Consortium (BARC)-Defined Bleeding Complications in ST-Segment Elevation Myocardial Infarction: A Comparison With the TIMI (Thrombolysis In Myocardial Infarction), GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries), and ISTH (International Society on Thrombosis and Haemostasis) Bleeding Classifications

The aim of the present analysis was to compare 1-year mortality prediction of Bleeding Academic Research Consortium (BARC)-defined bleeding complications with existing bleeding definitions in patients with ST-segment elevation myocardial infarction (STEMI) and to investigate the prognostic value of the individual data elements ofthebleeding classifications for 1-year mortality. BARC recently proposed a novel standardized bleeding definition. The in-hospital occurrence of bleeding defined according to the BARC, TIMI (Thrombolysis In Myocardial Infarction), GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries), andISTH (International Society on Thrombosis and Haemostasis) bleeding classifications was assessed in 2,002 STEMI patients undergoing primary percutaneous coronary intervention between January 1, 2003, and July 31,2008. BARC types 2, 3, 4, and 5 bleeding occurred in 4.4%, 14.2%, 1.4%, and 0.3% of patients, respectively. By multivariable analysis, GUSTO- and ISTH-defined bleeding was not significantly associated with 1-year mortality, whereas TIMI major and BARC type 3b or 3c bleeding conferred a 2-fold higher risk of 1-year mortality (hazard ratios[HRs]: 2.00 [95% confidence interval (CI): 1.32 to 3.01] and 1.84 [95% CI: 1.23 to 2.77], respectively). Data elements most strongly associated with mortality were a hemoglobin decrease≥5 g/dl (HR: 1.94 [95% CI: 1.26 to 2.98]), the use of vasoactive agents for bleeding (HR: 2.01 [95% CI: 0.91 to 4.44]), cardiac tamponade (HR: 2.38 [95% CI: 0.56 to 10.1]), and intracranial hemorrhage (HRs for 1-year mortality were not computable because there was only 1 patient with intracranial bleeding). Both the BARC and TIMI bleeding classification identified STEMI patients at risk of 1-year mortality.

Современное СоСтояние проблемы кровотечений из варикозно-раСширенных вен пищевода и желудка

Modern views on the etiology, pathogenesis, classification, diagnosis and treatment of bleeding from esophageal and gastric varices changed viens for different versions of portal hypertension are presented. Summarized own clinical experience in treating patients with portal hypertension of various origins, complicated by bleeding from esophageal and gastric varices. We made the comparative analysis of modern methods of treatment of patients with portal hypertension of various etiologies. Summarized own clinical experience in treating 115 patients with portal hypertension of various origins, complicated by bleeding from esophageal and gastric varices. In 77 patients (control group) treatment program included a waiting conservative tactics. In this group variceal needling as a «desperate operation» was performed only in 13 (16,9%) patients. In 38 patients (study group) active surgical tactics using M.D. Patsiora operation was applied as much as possible before the onset of early hepatic decompensation. Inclusion the active surgical tactics in the treatment program for compensated (Class A) and subcompensated (Class B) patients with hepatic cirrhosis, complicated by bleeding from esophagealand gastric varices made possible to reduce the total number of complications from 97,4 to 23,0%, including the number of recurrent bleedings — from 31,2 to 6,8%, the incidence of liver failure — from 89,6 to 33,7%, reduced hospital mortality from 76,6 to 32,2%.

CIRRHOTIC PATIENTS;

Objective: To determine the frequency of upper GI bleeding and its predicting factors and esophageal varices in the patientswith liver cirrhosis disease admitted at medicine ward of Isra university hospital. Design: Prospective and observational study. Setting:Isra university hospital. Period: March 2012 to August 2012 (six months). Methods: Containing 100 patients, mean age was 45.8, and allthe patients with cirrhosis disease were included in this study with liver cirrhosis disease. All patients were under went endoscopy andFrequency of upper GI bleeding and varices presentation and classification according to grade were noted. Results: All the 100 patientswere selected on the basis of presenting liver cirrhosis disease. Male were more found than the female with the mean age 45.8. Mostlycirrhotic patients were found with HCV positive and upper GI bleeding were noted in (40%) of the cases. With the endoscopic findingmostly patients were noted in ll - lll grad of esophageal varices and according to child pug classification majority of patients was noted inclass “C” In addition, thrombocytopenia and red wale markings along with the presence of large sized varices were associated with thepresence of esophageal varices. Conclusions: In the conclusion of this study we found majority of the cirrhotic patients with HCV,Esophageal varices and thrombocytopenia are the important factors of upper GI bleeding. Knowledge and etiology of this manuscript mayhelpful in the prevention of oesophageal varices and upper GI bleeding.

Risk stratification for two-year mortality after primary percutaneous coronary intervention according to BARC bleeding classification

Risk stratification for two-year mortality after primary percutaneous coronary intervention according to BARC bleeding classification

Clinical validation of BARC definitions of bleeding after an ACS in the TRACER trial

Purpose: We aimed to study the relationship between Bleeding Academic Research Consortium (BARC)-graded events and mortality in the TRACER trial, which randomized 12,944 patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS) to vorapaxar or placebo. Methods: In this analysis from the TRACER trial data, all non-coronary artery bypass graft (CABG)-related bleeding events were reclassified using the BARC bleeding scale, using data from clinical events committee adjudication. The association between BARC hierarchical grading and death from all causes was assessed. Results: During the median follow-up of 502 days post randomization (interquartile range, 349–667), BARC-grade ≥2 and BARC-grade ≥3 bleeding events occurred in 1803 (14.0%) and 572 (4.4%) of 12,887 patients, respectively. The rate of death from all causes in the first year 1) following the first BARC-class ≥2 bleeding event was 9.8%, and 2) following the first BARC-class ≥3 bleeding event was 21.0%. There was a gradual increase in post randomization mortality with an increase in the severity of bleeding. The adjusted estimated hazard of fatality for intracranial hemorrhage (3c) was at least 6 times higher than BARC classes 3a and 3b. View this table: Table 1. Association between BARC bleeding classification and mortality post randomization Conclusions: Following an NSTE ACS episode, there was a graded association between bleeding severity according to the BARC scale and subsequent mortality.