Differences In Bleeding Rates Research Articles

Bleeding Risk During Colorectal Endoscopic Mucosal Resection With Continued Anticoagulant Therapy: A Multicenter Study.

Background and aims Endoscopic mucosal resection (EMR) is a standard preventive method for colorectal cancer. Managing patients on anticoagulants during EMR is challenging because of balancing bleeding and thrombotic risks. Updated guidelines recommend continuing anticoagulants over heparin bridging; however, data on bleeding risks with continuing anticoagulants remain limited. This multicenter prospective study evaluated bleeding rates in patients who continued oral anticoagulants during EMR. Methods Patients on warfarin or direct oral anticoagulants (DOACs) undergoing EMR were enrolled from 12 tertiary hospitals. Warfarin was maintained on the day of EMR, while DOACs were paused on the day of EMR and resumed afterward. Post-EMR mucosal defects were closed with clips per protocol. Adverse events were monitored for 30 days. The primary endpoint was the major bleeding rate, defined as immediate bleeding requiring difficult hemostasis or delayed bleeding necessitating endoscopic intervention. The secondary endpoints were minor bleeding, other adverse events, and differences in bleeding rates between warfarin and DOACs. Results Among 107 patients (341 polyps; mean size = 6.7 mm), major bleeding occurred in five (4.7%) patients (95% confidence interval: 2.0%-10.5%), and all cases were managed endoscopically. Minor bleeding and thromboembolism events occurred in eight (7.5%)patients and one (0.9%) patient, respectively. No significant differences in bleeding rates were observed between warfarin and DOACs. Major bleeding rates were lower than those reported for heparin bridging. Conclusions Continuing anticoagulanttherapy during EMR was associated with a low major bleeding rate (4.7%) and minimal thrombotic events, supporting its safety as an alternative to heparin bridging.

Comparative efficacy of endoscopic variceal ligation versus non-selective beta-blockers in primary prevention of gastroesophageal varix type 2: an IPTW-adjusted study.

Practice guidelines recommend non-selective beta-blockers (NSBB) and endoscopic variceal ligation (EVL) for primary prevention in cirrhosis patients with esophageal varices. However, there is no clear recommendation for primary prevention strategies for gastric varices, particularly GOV-2. Our objective is to investigate the incidence of initial bleeding and liver-related complications when NSBB and EVL are used for primary prevention in GOV-2. A retrospective analysis was conducted on data from patients with GOV-2 gastric varices. Patients were divided into the NSBB group or the EVL group. Differences in the incidence of initial bleeding within 1year, as well as the occurrence of complications such as hepatic encephalopathy and ascites, were compared between the two groups before and after adjustment for Inverse Probability of Treatment Weighting (IPTW). A Cox proportional hazards model was used to identify independent risk factors for the first bleeding event. There were 60 patients in the NSBB group and 66 patients in the EVL group. Before IPTW adjustment, there were differences between the two groups in sex, portal hypertensive gastropathy, esophageal variceal diameter, red signs, FIB-4, and MELD scores. After IPTW adjustment, these differences were balanced, with standardized mean differences (SMDs) within acceptable ranges. Kaplan-Meier survival analysis showed no difference in bleeding rates between the two groups before or after IPTW adjustment. After IPTW adjustment, Cox regression analysis identified esophageal variceal diameter (HR:5.59 (2.03-15.39), p < 0.001) and MELD score (HR:1.17 (1.01-1.23), p = 0.042) were independent risk factors for bleeding. NSBB treatment did not reduce the incidence of liver-related complications within one year compared to EVL. For primary prevention of bleeding in cirrhotic patients with GOV-2, EVL does not significantly reduce initial bleeding episodes or liver-related complications compared to NSBB.

Early postoperative water exposure does not increase complications in cutaneous surgeries: A randomized, investigator-blinded, controlled trial

Patients are often advised to keep the initial postoperative dressings dry and undisturbed for 24 to 72 hours. However, these requirements may result in significant disruption of patients' activities of daily living, such as bathing, leisure, and exercise. Compare standard management of keeping wounds dry and covered (48 hours) with early (6 hours) postoperative water exposure. Investigator-blinded, randomized (1:1), controlled trial evaluating rate of infection and additional outcomes of interest. Overall, 437 patients were randomized to either the early (6-hour) water exposure (n=218) intervention group or the standard cohort (n=219). The incidence of culture-proven infection in the intervention group (1.8%) was similar to the standard group (1.4%) (P>.99). There was also no difference in rates of bleeding or bruising. Scar assessment using the Patient and Observer Scar Assessment Scale revealed similar scar outcomes. Single site, academic center. Surgical wounds can be allowed to get wet in the immediate postoperative period with no increased incidence of infection or other complications and with similar cosmesis.

Parenteral Anticoagulation at First Medical Contact Improves Infarct Related Artery Patency in STEMI.

(1) Background: Acute ST-segment elevation myocardial infarction (STEMI) remains one of the main morbidity and mortality contributors worldwide. Its main treatment, primary percutaneous coronary intervention (pPCI), can only be performed with a high anticoagulation regimen, usually with heparin. There is still not enough evidence regarding the timing of heparin administration. (2) Methods: We conducted a multicenter observational study of 614 consecutive STEMI patients treated between 2017 and 2019. We split the population in two groups: one that received heparin at the first medical contact, as early as possible, and the second group that received heparin at the PCI capable center or in the cath lab. (3) Results: There was a significantly higher rate of infarct-related artery (IRA) patency at the time of the coronary angiogram in the pre-transfer heparin group than in the on-site heparin group, 44.7% vs. 37.3%, p = 0.042. Also, the early heparin group received shorter and wider stents. There was no difference in bleeding rates or in the in-hospital and two-year mortality rates. (4) Conclusions: Early administration of heparin leads to a higher rate of reperfusion in the IRA, before pPCI, with significant related benefits, such as better stent implantation parameters, without increased bleeding rates.

Establishing a safe pediatric surgery day unit: Process, procedures, and performance

Abstract Background: Ambulatory surgery for babies and infants is commonly practiced worldwide. There are no reports on this special service from the UAE. A Pediatric Surgery Day Unit (PSDU) has been in operation at Danat Al Emarat Hospital Women and Children since the hospital opened in 2016. Objective: To describe the day-to-day structure and functioning of the PSDU, the technical aspects of the four main procedures delivered (Circumcision, Release of Tongue Tie, Excision of Umbilical Granuloma, and Excision of Accessory Digits) and the outcomes for the babies. Materials and Methods: The hospital’s Health Information System was interrogated for the relevant diagnostic and procedural codes for all babies operated between January 1st, 2016, and December 31st, 2019. Data were analyzed for basic demographics, biostatistics, procedures performed, and follow-up encounters. Results: The PSDU has a core team, including a coordinator/scheduler, one practical nurse, two staff nurses, and two surgeons. Up to 10 sessions are offered per week, and out-of-hours cover is provided for emergencies or advice on a 24/7 basis. A total of 5262 medical records were examined and data on 3891 procedures for 3801 babies were analyzed. Babies of 68 nationalities were operated and 65% were local Emirati. Circumcision was performed at a median age of 16 days and a weight of 3.5 kg. Bleeding occurred in 1.4% and retention of the ring occurred in 1%. Significant factors associated with bleeding are age, weight, and ring size. There is no difference in bleeding rates between surgeons. There is a learning curve for the technique. Retention of the ring on the glans is associated with the size of ring chosen and retention rates vary significantly between surgeons. The remaining procedures were performed without complication, giving an overall adverse event rate of 2.75%. Conclusion: A well-structured and consistently staffed PSDU results in a safe and effective service.

Risk of Bleeding Among Cangrelor-Treated Patients Administered Upstream P2Y12 Inhibitor Therapy: The CAMEO Registry

Little is known about the bleeding risk associated with cangrelor use in patients with myocardial infarction (MI) who are exposed to an oral P2Y12 inhibitor before coronary angiography. Cangrelor in Acute MI: Effectiveness and Outcomes (CAMEO) is an observational registry studying platelet inhibition for patients with MI. Upstream oral P2Y12 inhibition was defined as receipt of an oral P2Y12 inhibitor within 24 hours before hospitalization or in-hospital before angiography. Among cangrelor-treated patients, we compared bleeding after cangrelor use through 7 days postdischarge between patients with and without upstream oral P2Y12 inhibitor exposure. Among 1802 cangrelor-treated patients with MI, 385 (21.4%) received upstream oral P2Y12 inhibitor treatment. Of these, 101 patients (33.8%) started cangrelor within 1 hour, 103 (34.4%) between 1 and 3 hours, and 95 (31.8%), >3 hours after in-hospital oral P2Y12 inhibitor administration; the remaining received an oral P2Y12 inhibitor before hospitalization. There was no statistically significant difference in rates of bleeding among cangrelor-treated patients with and without upstream oral P2Y12 inhibitor exposure (6.5% vs 8.8%; adjusted odds ratio [OR], 0.62; 95% CI, 0.38-1.01). Bleeding was observed in 5.0%, 10.7%, and 3.2% of patients treated with cangrelor <1, 1 to 3, and >3 hours after the last oral PY12 inhibitor dose, respectively; bleeding rates were not statistically different between groups (1-3 hours vs <1 hour: adjusted OR, 2.70; 95% CI, 0.87-8.32; >3 hours vs <1 hour: adjusted OR, 0.65; 95% CI, 0.15-2.85). Bleeding risk was not observed to be significantly higher after cangrelor treatment in patients with and without upstream oral P2Y12 inhibitor exposure.

Validation of the PRECISE-DAPT score in a population-based sample of patients undergoing percutaneous coronary intervention with stent implantation

Abstract Background Dual antiplatelet therapy (DAPT) after coronary stenting reduces the risk of recurrent ischemia but increases bleeding risk. The PRECISE-DAPT score was developed using data from clinical trials to identify individuals at high bleeding risk who may benefit from shorter DAPT duration. Although use of the PRECISE-DAPT score is recommended in clinical guidelines, its applicability to patients seen in routine clinical practice is uncertain. Purpose To assess the performance of the PRECISE-DAPT score in a population-based cohort of patients undergoing coronary stenting. Methods We calculated the PRECISE-DAPT score in patients enrolled in the Swedish register of cardiac care (SWEDEHEART) who underwent coronary stenting and received DAPT in an urban region in Sweden between January 1, 2013, and December 31, 2018. Patients were followed from day 30 after discharge after coronary stenting until a bleeding event (TIMI major/minor bleeding using ICD-codes for bleeding and data on changes in hemoglobin levels from healthcare registers), an ischemic event (myocardial infarction/ischemic stroke), discontinuation of DAPT, death, 12 months after stenting, or end of study period. We assessed the score’s discrimination and estimated rates of bleeding and ischemic events in groups of patients categorized using the score’s decision rule for "high bleeding risk" (score ≥25). We then compared bleeding rates in groups of patients categorized based on their score with those observed in the clinical trials used to derive the PRECISE-DAPT score. Results Of the 8,348 patients (mean (SD) age 67 (11) years; 27% women) included in the study, 2,001 (24%) were categorized as "high bleeding risk" (Figure 1). The PRECISE-DAPT score had a moderate discrimination (c-statistic 0.64, 95% CI, 0.56– 0.71) for bleeding. Patients with "high bleeding risk", compared to those not at "high bleeding risk", had a higher rate of bleeding (2.0 vs 0.9 events per 100 patient years; hazard ratio 2.17, 95% CI 1.29–3.65) and a higher rate of ischemic events (12.8 vs 9.0 events per 100 patient years; hazard ratio, 1.33, 95% CI 1.10–1.61). Patients with "high bleeding risk" in our study population had lower rates of bleeding as compared with those at "high bleeding risk" in the clinical trials used to derive the score. Rates of bleeding in other risk categories were largely similar to those in the clinical trials. (Figure 2). Conclusion In a population-based cohort from routine clinical practice in Sweden, the PRECISE-DAPT score identified patients with increased bleeding risk, although those patients also had an increased ischemic risk. Differences in bleeding rates among those categorized as "high bleeding risk" across patient populations may mean that the absolute risk differences in bleeding risk for short vs long DAPT duration demonstrated in the clinical trials used to derive the PRECISE-DAPT score may not be directly applicable to patients seen in routine clinical practice.

High Frequency of Genetic Variants Influencing Diagnosis and Bleeding Pattern in Patients with Presumed Primary Immune Mediated Thrombocytopenia (ITP)

Introduction Immune mediated thrombocytopenia (ITP) is a platelet disorder in which the immune system attacks and destroys the body's own platelets. Mechanisms leading to low platelet count in ITP are multifactorial, involving both increased peripheral platelet destruction and decreased platelet production. This is caused by autoantibodies targeting megakaryocytes and platelet-specific glycoproteins, as well as cytotoxic T cells directly acting on platelets. Although antibodies in some cases can be found in patients with ITP, there is no well-established diagnostic test and the diagnosis is thus, one of exclusion. While most cases of ITP resolve within 3 months with or without treatment, some patients do not respond to conventional treatment and develop a refractory ITP. It is likely that in the group of patients diagnosed with refractory ITP, some does not have an immune mediated thrombocytopenia, but other causes of low counts (PLC)s. With the development of high throughput sequencing and the increasing knowledge of inherited bleeding disorders, the possibility to identify the underlying cause of disease in these patients is steadily growing. In ITP, there is a high degree of interindividual differences in bleeding rates, where some patients have no bleeding symptoms despite of unmeasurable PLC, whereas other patients show severe bleeding symptoms at PLC &amp;gt; 30 x10 9 /L. The underlying etiology of these discrepancies is currently unknown and complicates the clinical care of these patients. We hypothesize that genetic defects influence the bleeding pattern in true ITP patients as well as being one of the underlying causes of thrombocytopenia in patients misdiagnosed with “refractory ITP”. The aim of this pilot study was to investigate whether upfront genetic screening of patients suspected of ITP could be a valuable diagnostic tool to determine presence of inherited thrombocytopenia, secondary thrombocytopenia and genetic variants that might affect bleeding pattern. Method Patients were included after informed consent following the declaration of Helsinki. We performed whole genome sequencing (WGS) in patients diagnosed with presumed ITP at the Skåne University Hospital, Sweden. Whole genome sequencing was performed at the Center for Genomic Medicine at Rigshospitalet, Copenhagen. An in-silico gene panel consisting of 113 genes known to be associated with bleeding disorders as well as 86 genes associated with ITP (Using the VarSeq gene prioritisation algorithm phorank) was analysed and pathogenicity was classified according to the ACMG/AMP guidelines. Patients' medical records were examined, laboratory work up was performed and clinical data regarding demographics and information regarding bleeding was collected. A final evaluation of susceptible variants took place at multiple disciplinary team conferences. Results Twenty-one patients were enrolled (9 women, 12 men, 17 were adults and 4 children). Mean age of adult patients was 50,5 years and mean age of paediatric patients was 11,5 years. Out of 21 patients, 7 were shown to have genetic variants with relevance to their disease. All variants were found in adult patients. Two patients had variants related to inherited thrombocytopenia (X-linked thrombocytopenia(WAS) and monoallelic Bernard-Soulier Syndrome(GP1BB)), 4 had variants in genes related to secondary ITP (3 with variants associated with common variable immunodeficiency (NFKB1, TNFRSF13B) and 1 with systemic lupus erythematosus (TREX1)) and 1 had a variant associated with platelet dysfunction (platelet delta storage pool deficiency (UNC13D)). Only the variant associated with X-linked thrombocytopenia was previously described (class 5) whereas the remaining 6 variants were initially classified as variants of unknown significance (VUS). Functional work-up and co-segregation studies indicated them as probably pathogenic (class 4) but confirming studies are still pending. Conclusion In this pilot study, 33% of patients with presumed primary ITP had variants with relevance to their clinical phenotype, and we were able to diagnose 1 patient with an inherited bleeding disorder (X-linked thrombocytopenia). Whole genome sequencing seems to be a useful diagnostic tool in the work up of patients with thrombocytopenia where ITP is suspected to ensure the diagnosis and could also add important information when assessing bleeding risk in individual patients.

Hetrombopag plus recombinant human thrombopoietin for chemotherapy-induced thrombocytopenia in patients with solid tumors

Hetrombopag plus recombinant human thrombopoietin for chemotherapy-induced thrombocytopenia in patients with solid tumors

Epoprostenol (Prostacyclin Analog) as a Sole Anticoagulant in Continuous Renal Replacement Therapy for Critically Ill Children With Liver Disease: Single-Center Retrospective Study, 2010-2019.

Despite deranged coagulation, children with liver disease undergoing continuous renal replacement therapy (CRRT) are prone to circuit clotting. Commonly used anticoagulants (i.e., heparin and citrate) can have side effects. The aim of this study was to describe our experience of using epoprostenol (a synthetic prostacyclin analog) as a sole anticoagulant during CRRT in children with liver disease. Single-center, retrospective study, 2010-2019. Sixteen-bedded PICU within a United Kingdom supra-regional center for pediatric hepatology. Children with liver disease admitted to PICU who underwent CRRT anticoagulation with epoprostenol. None. Regarding CRRT, we assessed filter life duration, effective 60-hour filter survival, and effective solute clearance. We also assessed the frequency of major or minor bleeding episodes per 1,000 hours of CRRT, the use of platelet and RBC transfusions, and the frequency of hypotensive episodes per 1,000 hours of CRRT. In the 10 years 2010-2019, we used epoprostenol anticoagulation during 353 filter episodes of CRRT, lasting 18,508 hours, in 96 patients (over 108 admissions). Median (interquartile range [IQR]) filter life was 48 (IQR 32-72) hours, and 22.9% of filters clotted. Effective 60-hour filter survival was 60.5%.We identified that 5.9% of filters were complicated by major bleeding (1.13 episodes per 1,000 hr of CRRT), 5.1% (0.97 per 1,000 hr) by minor bleeding, and 11.6% (2.22 per 1,000 hr) by hypotension. There were no differences in filter life or clotting between patients with acute liver failure and other liver diseases; there were no differences in rates of bleeding, hypotension, or transfusion when comparing patients with initial platelets of ≤ 50 × 109 per liter to those with a higher initial count. Epoprostenol, or prostacyclin, as the sole anticoagulant for children with liver disease receiving CRRT in PICU, results in a good circuit life, and complications such as bleeding and hypotension are similar to reports using other anticoagulants, despite concerns about coagulopathy in this cohort.

Thirty day low-dose versus regular-dose aspirin for venous thromboembolism prophylaxis in primary total joint arthroplasty.

The optimal dosing of aspirin (ASA) monotherapy for prophylaxis after total joint arthroplasty is debatable. The objective of this study was to compare two ASA regimens with regards to symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding, and infection 90days after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We retrospectively identified 625 primary THA and TKA surgeries in 483 patients who received ASA for 4weeks post-op. 301 patients received 325mg once daily (QD) and 324 patients received 81mg twice daily (BID). Patients were excluded if they were minors, had a prior venous thromboembolism (VTE), had ASA allergy, or received other VTE prophylaxis drugs. There was a significant difference in rate of bleeding and suture reactions between the two groups. Bleeding was 7.6% for 325mg QD and 2.5% for 81mg BID (p = .0029 Χ2, p = .004 on multivariate logistic regression analysis). Suture reactions were 3.3% for 325mg QD and 1.2% for 81mg BID (p = .010 Χ2, p = .027 on multivariate logistic regression analysis). Rates of VTE, symptomatic DVT, and PE were not significantly different. The incidence of VTE was 2.7% for 325mg QD and 1.5% for 81mg BID (p = .4056). Symptomatic DVT rates were 1.6% for 325mg QD and 0.9% for 81mg BID (p = .4139). Deep infection was 1.0% for 325mg QD and 0.31% for 81mg BID (p = .3564). Low-dose ASA in patients with limited comorbidities undergoing primary THA and TKA is associated with significant lower rates of bleeding and suture reactions than high dose ASA. Low-dose ASA was not inferior to higher dose ASA for the prevention of VTE, wound complications, and infection 90days postoperatively.

Effect of renal insufficiency on the short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer: Propensity score-matched analysis.

It is unclear whether renal insufficiency (RI) itself is a risk factor for adverse outcomes after gastric endoscopic submucosal dissection (ESD). We aimed to evaluate the safety and efficacy of gastric ESD in patients with and without RI using propensity score-matching analysis. In all, 4775 patients with 4775 early gastric cancer lesions undergoing ESD were analyzed. 1:1 propensity score-matching was performed between patients with and without RI using 12 variables. After matching, logistic regression and survival analyses were performed for short- and long-term outcomes of ESD, respectively. The matching yielded 188 pairs of patients with and without RI. In both univariable and multivariable analyses, the presence of RI was not significantly associated with postprocedural bleeding (unadjusted odds ratio 1.81, 95% confidence interval 0.74-4.42; adjusted odds ratio 1.86, 95% confidence interval 0.74-4.65, respectively). When RI patients were subclassified into patients with estimated glomerular filtration rate (eGFR) 30-59 mL/min/1.73 m2 and eGFR <30 mL/min/1.73 m2 , no significant differences in bleeding rates were found compared to their matched controls in both groups. Perforation, en bloc resection, en bloc and R0 resection, and curative resection rates of RI patients were 2.1%, 98.4%, 91.0%, and 78.2%, respectively, which were comparable to those of non-RI patients. During a median follow-up of 119 months, there was no difference in gastric cancer-specific survival between patients with and without RI (P = 0.143). The outcomes of ESD were comparable in patients with and without RI. Decreased renal function itself may not be a reason to keep patients with RI from receiving gastric ESD.

Endoscopic N-butyl-2-cyanoacrylate and ethanolamine oleate injection is equivalent to balloon-occluded retrograde transvenous obliteration for preventing gastric variceal bleeding.

Endoscopic injection sclerotherapy (EIS) is effective for temporary hemostasis, but EIS and balloon-occluded retrograde transvenous obliteration (BRTO) have been reported as effective for secondary prophylaxis of gastric varices (GV) bleeding. This study retrospectively compared EIS and BRTO in patients with GV in terms of the efficacy for secondary prevention of GV bleeding and effects on liver function. From our database of patients with GV who underwent EIS or BRTO between February 2011 and April 2020, a total of 42 patients with GV were retrospectively enrolled. The primary endpoint was the bleeding rate from GV, which was compared between EIS and BRTO groups. Secondary endpoints were liver function after treatment and rebleeding rate from EV, compared between EIS and BRTO groups. Rebleeding rates from GV and EV and liver function after treatment were also compared between EIS-ethanolamine oleate (EO)/histoacryl (HA) and EIS-HA groups. Technical success was achieved for all EIS cases, but two cases were unsuccessful in the BRTO group and underwent additional EIS. No significant differences in bleeding rates or endoscopic findings for GV improvement were seen between EIS and BRTO groups. Liver function also showed no significant difference in the amount of change after treatment between groups. EIS therapy appears effective for GV in terms of preventing GV rebleeding and effects on liver function after treatment. EIS appears to represent an effective treatment for GV.

The impact of thrombocytopenia on variceal bleeding in cirrhotic patients with transjugular intrahepatic portosystemic shunt

Thrombocytopenia is the most frequent haematologic disorder in patients with cirrhosis, and it is perceived as a contributory factor for bleeding events. Cirrhosis patients with portal hypertension (PHT) is often accompanied with mild to moderate thrombocytopenia when they treated with transjugular intrahepatic portosystemic shunt (TIPS). To address whether the risk of variceal hemorrhage after TIPS varies with different platelet count in patients with normal platelet count and thrombocytopenia, we conducted the retrospective controlled study to evaluate the association of platelet count with the risk of variceal bleeding after TIPS. 304 patients were selected to the study. Propensity score matching was performed to adjust for potential selection bias. 63 patients from each group could be paired. Cox proportional hazards models were used to evaluate the association between platelet and variceal bleeding after TIPS. Platelet counts of two groups are 185.0 ± 98.7 × 109/L (normal platelet count) and 70.6 ± 39.3 × 109/L (thrombocytopenia) respectively. The bleeding rates of two groups in overall cohort are 10.9% (normal platelet count) and 12.9% (thrombocytopenia). After matched, the bleeding rates of two groups are 11.1% (normal platelet count) and 14.3% (thrombocytopenia) There was no statistically significant difference in bleeding rates between the two groups, either in the whole cohort (P = 0.671) or in the matched cohort (P = 0.593). Platelet count was not associated with bleeding events after TIPS (hazard ratio (HR) 95% confidence interval: 0.986–1.005, P = 0.397 in normal platelet count and 95% confidence interval: 0.968–1.020, P = 0.648 in thrombocytopenia). Thrombocytopenia in patients with cirrhosis was not associated with the risk of variceal bleeding episodes post-TIPS. Thrombocytopenia should not be viewed as an absolute contraindication for TIPS.

Does infection play a role in post-tonsillectomy haemorrhage? A narrative review.

Post-tonsillectomy haemorrhage is an increasingly common cause of morbidity following tonsillectomy. Secondary post-tonsillectomy haemorrhage occurring more than 24 hours after an operation has long been attributed to post-operative infection; however, there is little evidence to support this hypothesis and the associated use of antibiotics in the current literature. This study looked at the aetiology and evidence-based management of post-tonsillectomy haemorrhage, and investigated the impact of bacterial infection and antimicrobials on the pathogenesis and clinical course of this complication. A number of peri-operative risk factors for post-tonsillectomy haemorrhage exist, and infective pathologies, including recurrent or chronic tonsillitis and group A streptococcus on blood cultures, may predispose to bleeding. Very few studies have shown a link between post-tonsillectomy haemorrhage and objective markers of infection such as pyrexia, raised inflammatory markers or positive microbiology cultures. The role of antibiotics in secondary post-tonsillectomy haemorrhage remains controversial, and numerous randomised, controlled trials of peri-operative antibiotics have shown no significant difference in bleeding rates between antibiotics and controls. Further trials investigating the role of antibiotics and more robust studies investigating the presence of bacterial infection at the time of bleeding may be required to determine the true role of infection in post-tonsillectomy haemorrhage.

Population based study of morbidity and mortality rates associated to radical prostatectomy cases in Spain

There is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention. Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation. We designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos» (CMBD). We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables. Between 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9±3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with <500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year. In national terms, morbidity and mortality rates after RP are comparable to those described in the literature. This study reveals a clear dispersion in the hospitals that carry out this intervention, showing clear differences in terms of morbidity and hospital stay between the different regions.

Prevention of Cardioembolic Complications in Patients with Atrial Fibrillation: Efficacy and Safety of Left Atrial Appendage Isolation and Oral Anticoagulants

Aim. To study the outcomes frequency and structure in patients with atrial fibrillation (AF) depending on the cardioembolic events preventing method: left atrial appendage (LAA) isolation, direct oral anticoagulants (DOACs) or warfarin.Material and methods. A prospective observational study included patients with AF and high risk of cardioembolic complications and without contraindications to anticoagulants. Patients who refused long-term oral anticoagulants taking underwent LAA isolation, the rest of the patients received DOACs or warfarin. The observation period was 3 years. Mortality, cardioembolic complications and major bleeding (according to GARFIELD criteria) cumulative incidence was assessed.Results. We included 245 patients: 46 patients were treated with LAA isolation, 100 with warfarin, and 99 with DOACs. Multivariate regression analysis demonstrated a statistically significant advantage of LAA occluder in terms of combined endpoint achieving frequency compared to warfarin (hazard ratio [HR] 3.10; 95% confidence interval [CI] 1.01-9.54; p=0.049), and to DOACs (HR 3.44, 95% CI 1.15-10.29; p=0.027). A similar result was obtained for all-cause mortality (HR 5.24; 95% CI 1.12-24.55; p=0.036 and HR 5.58; 95% CI 1.22-25.49; p=0.027, respectively). There were no significant differences in bleeding rates between the groups.Conclusion. This observational study demonstrates the superiority of LAA isolation as a first-line therapy over DOACs and warfarin in patients with AF and high risk of cardioembolic complications. Randomized trials are required to confirm these observations.

Estudio poblacional de casuística y morbimortalidad de la prostatectomía radical en España

No existe ningún estudio poblacional que contabilice en número de prostatectomías radicales (PR) realizadas España, ni la morbimortalidad de dicha intervención. Nuestro objetivo es estudiar la morbimortalidad de la PR en España desde el 2011 al 2015 y evaluar la variabilidad geográfica. Diseñamos un estudio observacional retrospectivo de todos los pacientes intervenidos de PR en España durante cinco años consecutivos (2011-2015) a partir de los datos registrados en el Conjunto Mínimo Básico de Datos (CMBD). Hemos estudiado la distribución del número de casos y la variabilidad intercomunitaria en términos de morbilidad y de estancia hospitalaria, así como el impacto del volumen quirúrgico medio anual por cada centro en dichas variables. Entre los años 2011-2015 se han realizado un total de 37.725 PR en 221 hospitales españoles públicos del sistema nacional de salud. La edad media de la serie fue 63,9 ± 3,23 años. El 50% de las PR se han realizado por vía abierta, y un 43,4% se han intervenido en hospitales de < 500 camas. Encontramos una gran variabilidad en la distribución de los casos intervenidos en las distintas Comunidades Autónomas (CCAA Las comunidades que realizan un mayor número de prostatectomías son Andalucía, Cataluña, Galicia y Madrid. La tasa de complicaciones a nivel nacional es de 8,6%, siendo las más frecuentes la hemorragia y necesidad de transfusión (5,3 y 4%, respectivamente). Encontramos importantes diferencias en las tasas de hemorragia y en la estancia hospitalaria entre las distintas CCAA, que se mantienen tras ajustar por las características del paciente y del tipo de hospital. Al estudiar el volumen quirúrgico anual de cada hospital vemos que el impacto en la tasa de hemorragia o transfusión es lineal sin embargo en la estancia a partir de 60 PR/año la estancia se mantiene estable en torno a cinco días. En términos nacionales la morbimortalidad de la PR presenta cifras superponibles a las descritas en la literatura. Este trabajo pone de manifiesto una clara dispersión en los centros que realizan esta intervención, objetivándose diferencias claras en la morbilidad y la estancia hospitalaria entre las distintas comunidades autónomas. There is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention. Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation. We designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos» (CMBD). We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables. Between 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9 ± 3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with < 500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year. In national terms, morbidity and mortality rates after RP are comparable to those described in the literature. This study reveals a clear dispersion in the hospitals that carry out this intervention, showing clear differences in terms of morbidity and hospital stay between the different regions.

A Retrospective Analysis of q12hr and q8hr Heparin for DVT/PE Prophylaxis in an Inpatient Rehabilitation Setting.

Purpose: There is little clinical evidence comparing the safety and efficacy of prophylactic subcutaneous heparin given every 8 hours and every 12 hours. We performed a retrospective analysis incorporating these dosing intervals in an inpatient rehabilitation setting. Methods: Heparin usage data was collected and patient charts were analyzed for both therapeutic failure and bleeding events. A 2-tailed Fisher's exact test was performed for both outcomes, with a P-value of less than 0.05 being considered significant. Odds ratios were also calculated with P-values less than 0.05 being considered significant. Study Population: A Cerner report was run to identify patients ordered prophylactic heparin in an inpatient rehabilitation setting from April 7, 2020, to October 27, 2021. One hundred patients receiving heparin every 8 hours and every 12 hours were randomly selected for chart review. These study groups were further stratified by Padua risk scores. Results: In both groups, 4 (4.0%) patients were identified as having a documented bleeding event and 2 (2.0%) patients from each group were identified as having a therapy failure. Conclusion: For both endpoints, no significant differences in bleeding rates or therapy failure rates were detected in any of the population stratifications.

Effects of Aspirin Therapy on Bypass Efficacy and Survival of Patients Receiving Direct Cerebral Revascularization.

Background: Both patency maintenance and neoangiogenesis contribute to cerebrovascular bypass efficacy. However, the combined impact of the aforementioned two indicators on postoperative revascularization following superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass has been less well elucidated. Meanwhile, there is a paucity of evidence with conflicting results about postoperative aspirin therapy. Objective: The objective of the study was to investigate the correlation between aspirin use and STA-MCA bypass efficacy, including patency, postoperative neoangiogenesis, and follow-up outcomes. Methods: A total of 181 MMD patients (201 procedures) undergoing STA-MCA bypass at our institution (2017–2019) were retrospectively reviewed. The bypass efficacy level and postoperative complications were compared between aspirin and non-aspirin groups. Results: Among 95 PS-matched pairs, the aspirin group presented a significantly more favorable bypass efficacy than the non-aspirin group [odds ratio (OR) 2.23, 95% confidence interval (CI) 1.11–4.61; p = 0.026]. Multivariate logistic regression analysis confirmed the profound impact of aspirin as an independent predictor of bypass efficacy [adjusted OR 2.91, 95% CI 1.34–6.68; p = 0.009]. A remarkable negative correlation was found between bypass efficacy and the rate of ischemic complications (Phi = −0.521). Postoperative aspirin therapy was associated with a non-significant trend toward a lower incidence of ischemic events [OR 0.73, 95% CI 0.23–2.19; p = 0.580]. No significant difference in bleeding rates was observed between aspirin and control groups [OR 1.00, 95% CI 0.12–8.48; p = 1.000]. Conclusion: Among patients undergoing STA-MCA bypass procedures, bypass efficacy is a good predictor of follow-up outcomes. Postoperative aspirin therapy can improve patency, neoangiogenesis, and overall bypass efficacy, thereby protecting against postoperative ischemic complications. Clinical Trial Registration: http://www.chictr.org.cn/, identifier CTR2100046178.