Common Bleeding Research Articles

Activation of the HMGB1-TLR4 pathway impacts the functionality of bone marrow mesenchymal stem cells and disrupts macrophage polarization in immune thrombocytopenia.

Recent evidence suggests that immune thrombocytopenia (ITP), a common bleeding disorder, is linked to an imbalance in macrophage polarization and impaired bone marrow mesenchymal stem cells (BMSCs). However, the relationship between macrophage polarization imbalance and functional defects in BMSCs, as well as the involvement of associated molecules in BMSCs' defects, is not well understood. This study aimed to investigate the regulatory effects of high mobility group protein 1 (HMGB1) on the physiological functions of BMSCs, specifically in relation to macrophage polarization imbalance. Patients with ITP showed dysregulation in monocyte/macrophage polarization and impaired BMSCs function. HMGB1 was found to have a negative impact on the ability of BMSCs to regulate the imbalance in macrophage polarization, especially when inflammatory factors are present. The MyD88-dependent pathway downstream of BMSCs was found to be significantly enhanced with HMGB1 treatment. Furthermore, treatment with toll-like receptor 4 (TLR4) inhibitors successfully restored the regulatory capacity of BMSCs in ameliorating macrophage polarization imbalance and effectively inhibited the activation of the MyD88-dependent pathway. Meanwhile, infusion of si-TLR4-BMSCs reversed HMGB1-induced platelet dysfunction and reduced over-polarization to M1-like macrophages in the ITP mouse model. Consequently, targeting the HMGB1-TLR4 pathway could be a potential approach to restore the immunoregulatory function of BMSCs.

Menorrhagia in inherited bleeding disorders in Iraqi women

Abstract: BACKGROUND: Menorrhagia, or excessive menstrual bleeding, is a common symptom in women with inherited bleeding disorders; they are conditions where the blood ability to clot is impaired. Some of the common bleeding disorders include von Willebrand disease (VWD), clotting factor deficiencies, and platelet function disorders. OBJECTIVE: To assess different types of inherited bleeding disorders in women with menorrhagia referred to the National Center of Hematology/Mustansiriyah University in Baghdad/Iraq. PATIENTS AND METHODS: A prospective study was carried out on 193 women who had experienced menorrhagia for a duration of 3 years, from 2020 to 2023. These women sought consultation at the National Centre of Hematology/Mustansiriyah University. All participants were diagnosed through various laboratory tests, including complete blood count, blood film, blood group and Rh, bleeding time, prothrombin time, activated partial thromboplastin time, fibrinogen level, factor assay, von Willebrand factor antigen using ELISA technique, ristocetin cofactor, and platelet function test. RESULTS: Out of the 193 women with menorrhagia who participated in this study, the majority of whom had an unidentified cause (36.3%), followed by VWD (30.1%) and platelet function disorders (21.2%). Other bleeding disorders (thrombocytopenia and factors deficiencies) were 5.7% and 6.7%, respectively. Furthermore, the results showed that there was a significant difference in family history and consanguinity between patients with a hereditary bleeding disorder and nonhereditary bleeding disorder (P < 0.001). CONCLUSIONS: Fifty eight percent of females with Menorrhagia in this study have inherited bleeding disorders(IBDs), VWD, and thrombasthenia account for 51.3% are the most common causes of inherit bleeding disorder (IBD). Consanguineous marriage should be discouraged in Iraqi society to reduce such inherited diseases.

Platelet-Type von Willebrand Disease: Complex Pathophysiology and Insights on Novel Therapeutic and Diagnostic Strategies.

von Willebrand disease (VWD) is the most common well-studied genetic bleeding disorder worldwide. Much less is known about platelet-type VWD (PT-VWD), a rare platelet function defect, and a "nonidentical" twin bleeding phenotype to type 2B VWD (2B-VWD). Rather than a defect in the von Willebrand factor (VWF) gene, PT-VWD is caused by a platelet GP1BA mutation leading to a hyperaffinity of the glycoprotein Ibα (GPIbα) platelet surface receptor for VWF, and thus increased platelet clearing and high-molecular-weight VWF multimer elimination. Nine GP1BA gene mutations are known. It is historically believed that this enhanced binding was enabled by the β-switch region of GPIbα adopting an extended β-hairpin form. Recent evidence suggests the pathological conformation that destabilizes the compact triangular form of the R-loop-the GPIbα protein's region for VWF binding. PT-VWD is often misdiagnosed as 2B-VWD, even the though distinction between the two is crucial for proper treatment, as the former requires platelet transfusions, while the latter requires VWF/FVIII concentrate administration. Nevertheless, these PT-VWD treatments remain unsatisfactory, owing to their high cost, low availability, risk of alloimmunity, and the need to carefully balance platelet administration. Antibodies such as 6B4 remain undependable as an alternative therapy due to their questionable efficacy and high costs for this purpose. On the other hand, synthetic peptide therapeutics developed with In-Silico Protein Synthesizer to disrupt the association between GPIbα and VWF show preliminary promise as a therapy based on in vitro experiments. Such peptides could serve as an effective diagnostic technology for discriminating between 2B-VWD and PT-VWD, or potentially all forms of VWD, based on their high specificity. This field is rapidly growing and the current review sheds light on the complex pathology and some novel potential therapeutic and diagnostic strategies.

When Type 1 von Willebrand Disease Lives Together with Hashimoto Thyroiditis, Hypothyroidism, Hypoparathyroidism, Morbid Obesity, and Bariatric Surgery: A Case Report

Von Willebrand disease (vWD) is the most common bleeding disorder with type 1 being the more prevalent, although underdiagnosis is an actual concern. This case is the first clinical report of a type 1 vWD with several comorbidities submitted to bariatric surgery. The authors demonstrate the importance of a diagnosis and the consideration of other diseases or disturbances in vWD patients’ perioperative management. A multidisciplinary approach is crucial for minimizing and preventing bleeding risk.

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.

Von Willebrand disease.

von Willebrand disease (VWD) is the most common inherited bleeding disorder. The disorder is characterized by excessive mucocutaneous bleeding. The most common bleeding manifestations of this condition include nosebleeds, bruising, bleeding from minor wounds, menorrhagia or postpartum bleeding in women as well as bleeding after surgery. Other less frequent symptoms include gastrointestinal bleeding, haematomas or haemarthroses. VWD pathophysiology is complex and results from defects in von Willebrand factor (VWF) glycoprotein. Quantitative deficiencies are responsible for type 1 VWD with a partial decrease of VWF and type 3 with the complete absence of VWF. Qualitative abnormalities cause type 2 VWD, being further divided into types 2A, 2B, 2M and 2N. Although common, VWD is at risk of misdiagnosis, overdiagnosis and underdiagnosis owing to several factors, including complex diagnosis, variability of bleeding symptoms, presence of external variables (blood groups and other physiological modifiers such as exercise, thyroid hormones, oestrogens, and ageing), and lack of disease awareness among non-specialist health-care providers. Establishing the correct VWD diagnosis requires an array of specialized phenotypic assays and/or molecular genetic testing of the VWF gene. The management of bleeding includes increasing endogenous VWF levels with desmopressin or infusion of exogenous VWF concentrates (plasma-derived or recombinant). Fibrinolytic inhibitors, topical haemostatic agents and hormonal therapies are used as effective adjunctive measures.

Epidemiology, Treatment Patterns, and Cost Analysis of Immune Thrombocytopenia in Spain between 2014 and 2020: A Population-based Study.

Background Immune thrombocytopenia (ITP) is characterised by low platelet counts and often leads to bleeding, fatigue, and reduced health-related quality of life. Methods This observational, retrospective, population-based study using BIG-PAC® database included Spanish paediatric and adult patients with primary ITP diagnosed in primary care and hospitals between 2014 and 2020 (median follow-up: 4 years). Epidemiology, baseline/clinical characteristics, treatment trends, healthcare resources and costs were analysed. Results The BIG-PAC® database contains records of 1,818,588 patients; 170 adults and 27 children with ITP were included in our analysis. ITP prevalence and annual incidence per 100,000 were estimated in 10.8 (2.8 in chronic ITP [cITP] patients) and 1.5 (0.3 in cITP patients), respectively. Epistaxis was the most common bleeding event, followed by genitourinary and gastrointestinal bleeding; >50%/> 75% of ITP/cITP patients reported fatigue. Chronic patients had lower platelet counts at baseline and required more transfusions. Corticosteroids, immunosuppressants, and thrombopoietin receptor agonists were the most used agents in first-, second- and third-line treatment, respectively. Thirty-five patients, all of them in chronic phase, underwent splenectomy. Patients had on average 13.9, 6.6, and 1.2 visits/year to primary care, haematology/internal medicine, and emergency departments, respectively. More than one-fourth of adult patients took on average 16.3 days of sick leave annually. Mean annual total health care costs were €10,741 (ITP patients) and €19,809 (cITP patients). Conclusion This is the first study to provide an overall perspective on the situation of the Spanish ITP population in terms of epidemiology, treatment trends, health care resources and costs, highlighting unmet patient needs, and direct and indirect costs/resource use between 2014 and 2020.

Real-world experience of thrombopoietin receptor agonists in pediatric immune thrombocytopenia: a report from a Chinese tertiary children's hospital.

Primary immune thrombocytopenia (ITP) is the most common bleeding disorder in children. There are approximately 20% pediatric ITP patients respond poor to corticosteroids as first-line treatment. Recently thrombopoietin receptor agonists (TPO-RAs) have been used to treat refractory ITP and have achieved certain therapeutic effects. To investigate the efficacy and safety of TPO-RAs in the treatment of pediatric ITP, we conducted this real-world study. Fifty-three pediatric patients with ITP who did not respond well to corticosteroids were treated with TPO-RAs. Clinical data, including therapeutic response rate, changes in platelet (PLT) count, and adverse events (AEs) were collected. Of the 51 evaluable patients, 37 (72.5%) responded to TPO-RAs. Patients aged >4 years had a higher response rate than those aged ≤4 years (81.1% vs. 50.0%, P=0.04). There was no effect of sex, duration of disease, prior therapy, Mycoplasma pneumoniae (MP) immunoglobulin M (IgM) positivity, antinuclear antibody (ANA) positivity, CD4/CD8 ratio or baseline PLT count on the response rate (P>0.05). Other than 10 patients with PLT counts that exceeded the upper limit of normal, AEs were sporadic, including increased aminotransferase levels, cough, headache, and vomiting. TPO-RAs exhibited good clinical efficacy in pediatric ITP patients who failed to respond to first-line treatment, especially patients aged >4 years, and the side effects were minor.

Sutureless Repair for Iliac Vein Bleeding Using an Elastomeric Sealant.

Addressing venous bleeding is a frequent complication of vascular and abdominopelvic surgeries. We present a novel sutureless repair technique using HydrofitⓇ(Terumo, Tokyo, Japan), an elastomeric sealant. In a patient experiencing common iliac vein bleeding during abdominal aortic aneurysm surgery, this technique successfully achieved complete hemostasis. By applying the elastomeric sealant with an autologous arterial patch to the bleeding site, we demonstrate the simplicity and effectiveness of sutureless hemostasis for venous bleeding.

Identification of the Efficient Enhancer Elements in FVIII-Padua for Gene Therapy Study of Hemophilia A.

Hemophilia A (HA) is a common X-linked recessive hereditary bleeding disorder. Coagulation factor VIII (FVIII) is insufficient in patients with HA due to the mutations in the F8 gene. The restoration of plasma levels of FVIII via both recombinant B-domain-deleted FVIII (BDD-FVIII) and B-domain-deleted F8 (BDDF8) transgenes was proven to be helpful. FVIII-Padua is a 23.4 kb tandem repeat mutation in the F8 associated with a high F8 gene expression and thrombogenesis. Here we screened a core enhancer element in FVIII-Padua for improving the F8 expression. In detail, we identified a 400 bp efficient enhancer element, C400, in FVIII-Padua for the first time. The core enhancer C400 extensively improved the transcription of BDDF8 driven by human elongation factor-1 alpha in HepG2, HeLa, HEK-293T and induced pluripotent stem cells (iPSCs) with different genetic backgrounds, as well as iPSCs-derived endothelial progenitor cells (iEPCs) and iPSCs-derived mesenchymal stem cells (iMSCs). The expression of FVIII protein was increased by C400, especially in iEPCs. Our research provides a novel molecular target to enhance expression of FVIII protein, which has scientific value and application prospects in both viral and nonviral HA gene therapy strategies.

STUDY OF ENDOMETRIAL PATHOLOGY IN ABNORMAL UTERINE BLEEDING

Objective: Endometrial pathology is becoming the most common issue that affects women of reproductive age group worldwide. AUB encompasses a wide variety of presentations, for example, frequent menstrual cycles, frequent and heavy cyclical bleeding, irregular bleeding, and postcoital bleeding. This study was done to evaluate the endometrial causes of AUB and to determine the specific pathology in different age groups.
 Methods: This study was a prospective cross-sectional study conducted on 200 patients from January 2023 to October 2023 in the department of pathology in a reputed teaching hospital and research centre. All the endometrial biopsies/curretages and hysterectomy specimens sent for Histopathological examination with history of AUB were included in the study.
 Results: Age of the patients with AUB ranged from 17 to 71 y in our study. Out of 200 cases, 90 cases (45%) were seen in Perimenopausal group followed by 68 cases (34 %) in Reproductive age group and 42 cases (21%) in Postmenopausal age group. Menorrhagia was the most common bleeding pattern seen in 54% pf patient with AUB. In 28% in reproductive age group, hormonal imbalance was observed in 13% of reproductive age group and 6% in perimenopausal age group. Atrophic endometrium was observed in 7.5% of women in post-menopausal age group. Chronic endometritis was seen 3% of reproductive age group.
 Conclusion: Abnormal uterine bleeding in women belonging to different age group show variable endometrial pattern on histopathological examination. They are valuable in early detection of pre-cancerous endometrial lesions as well as malignancy.

Relationship between bleeding sites and clinical data: experience of 646 epistaxis cases in 8years.

This study aims to investigate the bleeding sites and their relationship with clinical characteristics in hospitalized epistaxis patients. We retrospectively reviewed the data of 646 hospitalized epistaxis patients. The bleeding sites were identified in 395 (61.1%) patients and unidentified in 251 (38.9%). We found that age > 50years (P = 0.030) and the history of cardiovascular diseases (P = 0.027) were more frequent in patients with unidentified bleeding sites. Among patients with identified sites, inferior meatus (n = 130, 32.9%) was the most common site, followed by the septal surface of the olfactory region (n = 102, 25.8%), nasal septum (n = 80, 20.3%), middle meatus (n = 60, 15.2%), and others (n = 23, 5.8%). After dividing patients into five groups by the area of the bleeding sites, we found significant differences in age (P = 0.026), history of hypertension (P = 0.001), cardiovascular diseases (P = 0.032), and nasal packing (P = 0.011). The logistic regression also revealed that these four factors were predictors for different bleeding sites. The bleeding sites can be identified in most epistaxis patients. Age > 50years and the history of cardiovascular diseases are more frequent in patients with unidentified bleeding sites. In our patients, the most common bleeding site is inferior meatus, followed by the septal surface of the olfactory region, nasal septum, and middle meatus. Age, histories of hypertension, cardiovascular diseases, and nasal packing are factors associated with the bleeding risks of different bleeding sites. According to the different clinical characteristics of patients, the order of the nasal endoscopic examination should be adjusted to develop their treatment plans.

Outcomes Following Total Hip Arthroplasty in Patients Who Have Von Willebrand Disease Depend on Postoperative Anticoagulation

BackgroundVon Willebrand disease (VWD) is the most common congenital bleeding disorder. This autosomal dominant condition arises from quantitative or qualitative defects of Von Willebrand factor. To our knowledge, this study leveraged a national database to characterize the largest VWD cohort of total hip arthroplasty (THA) patients to date, assessing 90-day postoperative adverse events and 5-year revision-free survival. MethodsAdult patients who underwent primary THA for osteoarthritis were identified from January 2010 to October 2021 in a nationwide database. Patients who had and did not have VWD were matched (4:1) on age, sex, and Elixhauser Comorbidity Index and compared with multivariable logistic regression. Patients were then categorized based upon venous thromboembolism (VTE) chemoprophylaxis prescription patterns to compare bleeding and thrombotic adverse events. ResultsOf 544,851 THA patients, VWD was identified in 309 patients (0.06%). The matched cohorts contained 1,221 patients who did not have VWD and 306 patients who have VWD. On multivariable analysis, VWD patients had increased odds of 90-day VTE (odds ratio [OR] = 1.86) and hematoma (OR = 3.40) (P < .05 for all). No difference in 5-year revision-free survival was found. The VWD patients receiving aspirin or no prescriptions had greater odds of VTE (OR = 2.39, P = .048). Those on other chemoprophylaxis agents had greater odds of hematoma (OR = 4.84, P = .006). ConclusionsPatients with VWD undergoing THA had increased odds of 90-day VTE if using aspirin or no prescriptions, or hematoma if using other chemoprophylaxis. There is a delicate balancing act of clotting versus bleeding that must be considered in managing such patients, but it was reassuring that no difference in overall 5-year revision-free survival was found.

Post-ERCP Pancreatitis Risk Factors: Is Post-Sphincterotomy Bleeding Another Risk Factor?

Despite advancements in technology and expertise, ERCP carries risks of significant complications, such as pancreatitis, bleeding, and perforation. Post-ERCP pancreatitis is the most common and important complication following ERCP. In our study, we aimed to examine the relationship between patient and procedure-related parameters and the development of pancreatitis. Four hundred patients who underwent ERCP between January 1, 2019 and December 31, 2020, at the General Surgery Clinic of the Bakirköy Dr. Sadi Konuk Health Application and Research Center of the University of Health Sciences Faculty of Medicine were retrospectively evaluated. Patient and procedure-related factors were analyzed statistically through univariate and multivariate analyses. Age, urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, pancreatic cannulation, pancreatic stent, and bleeding were statistically significant risk factors for post-ERCP pancreatitis (+). In multivariate analysis, the effects of urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, and pancreatic cannulation on post-ERCP pancreatitis were statistically significant risk factors ( P <0.05). This study demonstrates that emergency indication, ERCP history, cholangitis, precut sphincterotomy, and pancreatic cannulation are significant risk factors for the development of post- ERCP pancreatitis. One notable contribution of our study to the existing literature is the unique analysis of post-sphincterotomy bleeding as an independent factor.

Inter-Sphincteric Resection of Rectum for Ulcerated S-100 Negative Large Granular Cell Tumour

Non-neural granular cell tumor was first described in 1991 as an unusual primitive, polypoid variant of the conventional GCT (granular cell tumor). To date, this neoplasm remains as a rare entity and the cell of origin is uncertain. While the histological features are similar to the conventional (traditional) GCTs, it represents a distinct entity, as it is negative for S-100 and lacks true nerve sheath differentiation. We report here a case of a 49-year-old male patient with S-100 negative, vimentin positive large benign, ulcerated, bleeding non-neural GCT in the lower rectum. We confirmed the diagnosis histopathologically and immunohistochemically. We treated it by ISRR (Inter-Sphincteric Resection of Rectum) and primary colo-anal anastomosis. We find no other report of non-neural GCT located in the rectum in surgical literature. This is probably the first case of non-neural GCT identified in the rectum. This case report is presented here to document a non-neural GCT located in the rectum for the first time ever reported, and also to highlight the optimum best surgical approach, as we deemed here for this large ulcerated bleeding tumor in the rectum. This rectal non-neural GCT posed here as an unusual differential diagnosis from such more common neoplastic bleeding lesions in the rectum as carcinoma rectum, hemorrhoid, rectal polyp, etc. Here we like to discuss our experience, reviewing in brief the available literature implicating the biological behavior, histopathological and immunohistochemical features, differential diagnosis and therapeutic considerations of neural and non-neural GCTs. KYAMC Journal Volume: 14, No: 03, October 2023: 181-187.

MANAGEMENT OF ASRIGDRA W.S.R. TO DUB- CASE STUDY

In Ayurveda, the most common bleeding disorders in women are referred to as Asrigdara and are characterised by Pradirana (excess excretion) of Raja (menstrual blood). In modern medicine, it is called "Dysfunctional Uter-ine Bleeding." Despite their high costs, hormonal therapy, anti-prostaglandins, and anti-fibrinolytic agents have not proven their definitive efficacy in modern medicine; their side effects have resulted in hormonal imbalances. In Ayurvedic classics, all gynaecological disorders are classified as Yonivyapad. Charaka Acharya Raktapra-dara is described as Pradara Roga by Charaka Aacharya. Excessive vaginal white discharge is referred to as Shweta Pradara and excessive or heavy menstrual bleeding is referred to as Raktapradara. It is known as Pra-dara due to pradirana (excessive excretion) of raja (menstrual blood) and Asrigdara due to dirana (excessive excretion) of Asrk (menstrual blood). Menorrhagia is treated with Haemostatic, analgesic, and hormonal thera-pies in modern medicine, which has limitations. As a result, an integrated and comprehensive therapeutic inter-vention in Ayurveda is required to prevent recurrence. Sodhana and Shamana therapies are recommended, but if Rugnabala is low, only Shamana is recommended. Many herbals and herbo-mineral preparations are mentioned in Ayurveda to treat Asrgdara and related symptoms, and these can be used according to Anubandha Dosha and Lakshana. Because Asrgdara is primarily caused by Vata Pitta Dosha, Kashaya Rasa and Pittashamaka Chikitsa may be used. Ayurvedic formulations aid in the breakdown of Asrgdara pathogeneses and their recur-rence.

A case of unusual hemorrhage as a complication of dengue fever in a tertiary hospital in Dhaka

Common bleeding complications of dengue hemorrhagic fever are epistaxis, gum bleeding, gastrointestinal bleeding, menorrhagia, hematuria.1 Major hemorrhage like intracranial hemorrhage have been documented but rare. We present here a case of a 24 year old man with complaints of high grade intermittent fever for 5 days, upper abdominal discomfort for 3 days and swelling of right upper limb for same duration. Laboratory investigations revealed a positive dengue serology, thrombocytopenia and elevated transaminases. USG of the hand revealed a hematoma involving the right upper arm. The patient was managed conservatively with elevation and immobilization of the upper limb and recovered gradually. J MEDICINE 2024; 25: 100-101

Trombocitopenia primária imune com púrpura palpável: um relato de caso

Immune thrombocytopenia is a relatively common bleeding disorder characterized by isolated destruction of platelets by autoantibodies, with a typically acute onset, benign course and self-limiting in most cases. The aim of this report is to present a rare case of Primary Immune Thrombocytopenia (ITP) with palpable purpura, an uncommon manifestation in this disease and little described in the literature. This is a 12-year-old female adolescent who presented with palpable purpura, ecchymosis and oral cavity bleeding associated with thrombocytopenia and anemia. Initial investigation excluded autoimmune diseases, vasculitis, lymphoproliferative diseases and coagulation disorders, in addition to the myelogram showing typical findings of ITP: hypercellular bone marrow with megakaryocytic hyperplasia and decreased thrombocytogenesis. Due to the diversity of clinical presentation and the possibility of atypical manifestations, the diagnosis is often challenging, as in the case of this patient in which the main finding on physical examination was the presence of palpable purpura.

Anaesthesiologist’s Role in Patient with Von Willebrand Disease for Elective Adenoidectomy: A Case Report

The most common bleeding disorder is von Willebrand disease (vWD). It is however a complex disease to diagnose. Management of this disease is not well understood by many anaesthesiologists who may experience these patients in elective or even emergency settings. This is a case presentation of a six-year-old patient of Arabic ethnicity who was diagnosed with vWD during preoperative testing and was managed perioperatively with a multidisciplinary team for a good outcome. Keyword: Von Willebrand disease, Von Willebrand factor, Adenoidectomy, Preoperative testing

Histopathological patterns of abnormal uterine bleeding in endometrial biopsies: a retrospective study in Najran Region, Saudi Arabia

Objective: This retrospective study aimed to elucidate the histopathological patterns of endometrial biopsies in women presented with abnormal uterine bleeding (AUB) across various age groups in Najran, Saudi Arabia. Methods: A total of 365 subjects, spanning perimenarchal to perimenopausal stages, were included in the study, conducted at the Maternity and Children Hospital in Najran, Saudi Arabia. The study period extended from October, 2020 to September, 2022. Histopathological patterns were analyzed in relation to age, parity, bleeding patterns, cause, and management of AUB. Results: The predominant age group was 40-50 years (40.5%), with proliferative endometrium being the most prevalent histopathological pattern. Menorrhagia was the most common bleeding pattern (34.0%), and functional causes accounted for 46.0% AUB cases. Surgical treatment was the primary management approach (50.7%). Multinomial logistic regression highlighted the unique contributions of age, parity, bleeding patterns, cause, and management of AUB to endometrial histopathology (p &amp;lt; 0.001). Conclusion: The current study findings provided a comprehensive understanding of the complex interplay between demographic and clinical factors in shaping endometrial histopathology in women with AUB in Najran, Saudi Arabia. Tailoring diagnostic and management strategies based on these factors can enhance personalized care for this diverse patient population.