Early Bleeding Research Articles

Characteristics and outcomes of 47, conventional flexible endoscopic interventions for Zenker's diverticulum Review of therapeutic options

Introduction: In the treatment of symptomatic Zenker's diverticulum, the flexible endoscopic myotomy of the cricopharyngeal muscle is considered to be a safe and effective technique. Objective and method: We retrospectively analyzed our experiences with conventional flexible endoscopic myotomy. Results and discussion: 38 patients with symptomatic Zenker's diverticulum were treated with flexible endoscopic myotomy and 47 myotomies were performed from September 2012 until February 2020. Most of our patients were male (23/38), with an average age of 71.5 (40-88) years. The mean size of diverticula was 3.94 (2-10) cm. In most cases, we used diverticuloscope, while free-hand technique was needed in 8 cases. We assessed our patients' symptoms by applying DRC (dysphagia, regurgitation, complication) score before the treatment and during follow-up. The overall rate of significant complications was 4.2% (2/47), and there was no procedure-related mortality. We observed pneumomediastinum in one patient that was treated conservatively. Intraprocedural bleeding occurred in several (8/47) cases, in all of them the bleeding was successfully stopped during intervention. In one of them, early recurrent massive bleeding required urgent surgery. All 38 patients were followed (mean 34.7 months). Clinical success at 1.5 months was 91.9% among endoscopically treated patients (34/37). 3 patients remained symptomatic, 2 of them were treated with re-myotomy, 1 of them needed surgery later on, another patient underwent percutan endo-scopic gastrostomy at 18 months. Over long-term period, complete success (DRC<2) was 78.4% (29/37), while clinical success (DRC: 0/1/2) reached in 89.2% (33/37). Conclusion: Our experiences confirmed that conventional method of flexible endoscopic myotomy is safe and effec-tive for the treatment of Zenker's diverticulum symptoms.

A Cohort Study of Rivaroxaban Combined with D-Dimer Dynamic Monitoring in the Prevention of Deep Venous Thrombosis after Knee Arthroplasty.

Objective To explore the cohort study of rivaroxaban combined with D-dimer dynamic monitoring in the prevention of deep venous thrombosis (DVT) after knee arthroplasty. Methods Eighty-four patients with knee osteoarthritis who went through total knee arthroplasty from June 2019 to June 2021 in our hospital were arbitrarily assigned into the study group and the control group. The patients in the control group were cured with rivaroxaban anticoagulation after operation, and the study group was cured with dynamic monitoring of D-dimer on the basis of the control group. The incidence of postoperative DVT, pulmonary embolism (PE), and bleeding complications (incision ecchymosis and bleeding events) were compared. The related indexes such as drainage volume and blood transfusion volume were compared. The levels of activated partial prothrombin time (APPT), prothrombin time (PT), and D-dimer were dynamically monitored before and after operation. Visual analogue scale (VAS) was adopted to assess the degree of postoperative incision pain, the level of limb swelling before and after operation was measured, the circumference difference of affected limb was calculated, the ecchymosis area was assessed in the form of nine-palace grid, and the scores were compared. Results According to the comparison of VAS score, there exhibited no remarkable difference before operation and on the first day after operation, but the VAS score decreased after operation, and the VAS score of the study group on the 3rd day, 7th day, and 14th day after operation was remarkably lower compared to the control group (P < 0.05). There exhibited no remarkable difference in drainage volume (P > 0.05), but the blood transfusion volume and total blood loss in the study group were remarkably lower (P < 0.05). There exhibited no remarkable difference in the level of PT on the 3rd day before operation and on the 3rd day after operation, but on the 7th day and 14th day after operation, the level of PT in the study group was remarkably higher (P < 0.05). The level of PT in the study group was remarkably higher (P < 0.05). There exhibited no remarkable difference in the level of APPT on the 3rd day before operation and on the 3rd day after operation, but on the 7th day and 14th day after operation, the level of APPT in the study group was remarkably higher (P < 0.05). The level of APPT in the study group was remarkably higher (P < 0.05). There exhibited no remarkable difference in the level of plasma D-dimer before operation (P > 0.05). The level of plasma D-dimer in the study group was lower (P < 0.05). In terms of the postoperative ecchymosis area score, the ecchymosis area score decreased remarkably after operation. Furthermore, the ecchymosis area score of the study group was remarkably lower (P < 0.05). In terms of the swelling degree of the affected limb, there exhibited no remarkable difference in thigh circumference and calf circumference before operation (P > 0.05), but after operation, the thigh circumference difference and calf circumference difference decreased, and the thigh circumference difference and calf circumference difference in the study group were lower (P < 0.05). The incidence of DVT in the study group was 16.67%, while that in the control group was 38.10%. No PE occurred in the two groups at the early stage after operation. There were 3 cases of incision ecchymosis, 1 case of bleeding event (incision oozing) in the study group, 11 cases of incisional ecchymosis, and 2 cases of bleeding event in the control group. In 3 patients with incisional bleeding, there were no obvious abnormalities in routine blood examination and blood coagulation indexes. The patients were given wound pressure bandaging and stopped using anticoagulants and changing wound dressings every day, all of which disappeared within 5 days. The incidence of early postoperative DVT and bleeding complications in the study group was lower (P < 0.05). Conclusion Rivaroxaban combined with D-dimer dynamic monitoring has high clinical value in preventing DVT after knee arthroplasty and can effectively reduce the amount of blood loss during operation and the incidence of postoperative DVT, PE, and bleeding complications, which is worth popularizing to reduce the area of ecchymosis and the degree of pain after operation and shorten the recovery process.

Prognostic Role of the Platelet-Lymphocyte Ratio in Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy: A Meta-Analysis.

BackgroundBoth inflammation and thrombotic/hemostatic mechanisms may play a role in acute ischemic stroke (AIS) pathogenesis, and a biomarker, such as the platelet-to-lymphocyte ratio (PLR), considering both mechanisms may be of clinical utility.ObjectivesThis meta-analysis sought to examine the effect of PLR on functional outcomes, early neurological changes, bleeding complications, mortality, and adverse outcomes in AIS patients treated with reperfusion therapy (RT).DesignSystematic Review and Meta-AnalysisData Sources and MethodsIndividual studies were retrieved from the PubMed/Medline, EMBASE and Cochrane databases. References thereof were also consulted. Data were extracted using a standardised data sheet, and systematic reviews and meta-analyses on the association of admission (pre-RT) or delayed (post-RT) PLR with defined clinical and safety outcomes were conducted. In the case of multiple delayed PLR timepoints, the timepoint closest to 24 hours was selected.ResultsEighteen studies (n=4878) were identified for the systematic review, of which 14 (n=4413) were included in the meta-analyses. PLR collected at admission was significantly negatively associated with 90-day good functional outcomes (SMD=−.32; 95% CI = −.58 to −.05; P=.020; z=−2.328), as was PLR collected at delayed timepoints (SMD=−.43; 95% CI = −.54 to −.32; P<.0001; z=−7.454). PLR at delayed timepoints was also significantly negatively associated with ENI (SMD=−.18; 95% CI = −.29 to −.08; P=.001. Conversely, the study suggested that a higher PLR at delayed timepoints may be associated with radiological bleeding and mortality. The results varied based on the type of RT administered.ConclusionsA higher PLR is associated with worse outcomes after stroke in terms of morbidity, mortality, and safety outcomes after stroke.

Robotically applied hemostatic clamping for care-under-fire: harnessing bomb robots for hemorrhage control.

Background:Early hemorrhage control after interpersonal violence is the most urgent requirement to preserve life and is now recognized as a responsibility of law enforcement. Although earlier entry of first responders is advocated, many shooting scenes remain unsafe for humans, necessitating first responses conducted by robots. Thus, robotic hemorrhage control warrants study as a care-under-fire treatment option.Methods:Two bomb disposal robots (Wolverine and Dragon Runner) were retrofitted with hemostatic wound clamps. The robots’ ability to apply a wound clamp to a simulated extremity exsanguination while controlled by 4 experienced operators was tested. The operators were randomly assigned to perform 10 trials using 1 robot each. A third surveillance robot (Stair Climber) provided further visualization for the operators. We assessed the success rate of the application of the wound clamp to the simulated wound, the time to application of the wound clamp and the amount of fluid loss. We also assessed the operators’ efforts to apply the wound clamp after an initial attempt was unsuccessful or after the wound clamp was dropped.Results:Remote robotic application of a wound clamp was demonstrated to be feasible, with complete cessation of simulated bleeding in 60% of applications. This finding was consistent across all operators and both robots. There was no difference in the success rates with the 2 robots (p = 1.00). However, there were differences in fluid loss (p = 0.004) and application time (p < 0.001), with the larger (Wolverine) robot being faster and losing less fluid.Conclusion:Law enforcement tactical robots were consistently able to provide partial to complete hemorrhage control in a simulated extremity exsanguination. Consideration should be given to using this approach in care-under-fire and care-behind-the-barricade scenarios as well as further developing the technology and doctrine for robotic hemorrhage control.

Prevalence, management, and outcomes of haemorrhagic events in left ventricular assist device recipients.

AimsLeft ventricular assist devices (LVADs) have reduced the mortality of patients with advanced heart failure both as bridge‐to‐transplant and as destination therapy. However, LVADs are associated with various complications, including bleedings, which affect the prognosis. The aim of the study was to explore the prevalence, management, and outcomes of haemorrhagic adverse events in LVAD recipients.Methods and resultsWe conducted a retrospective, single‐centre, cohort study including all patients who received an LVAD from January 2008 to December 2019 in our tertiary centre (Rangueil University Hospital, Toulouse, France). Bleeding events, death, and heart transplantation were collected from electronic medical files. Eighty‐eight patients were included, and 43 (49%) presented at least one bleeding event. Gastrointestinal (GI) bleeding was the most frequent (n = 21, 24%), followed by epistaxis (n = 12, 14%) and intracranial haemorrhage (n = 9, 10%). Bleeding events were associated with increased mortality [hazard ratio (HR) 3.8, 95% confidence interval (CI) 1.5–9.3, P < 0.01], particularly in case of intracranial haemorrhage (HR 14.6, 95% CI 4.2–51.1, P < 0.0001). GI bleedings were associated with a trend towards increased mortality (HR 3.0, 95% CI 0.9–9.3, P = 0.05). Each bleeding episode multiplied the risk of death by 1.8 (95% CI 1.2–2.7, P < 0.01). Finally, only early bleedings (<9 months post‐implantation) had an impact on mortality (HR 4.2, 95% CI 1.6–11.1, P < 0.01). Therapeutic management was mainly based on temporary interruption of anticoagulation and permanent interruption of antiplatelet therapy. Invasive management was rarely performed.ConclusionsHaemorrhagic events in LVAD recipients are frequent and associated with increased mortality. GI bleedings are the most frequent, and intracranial haemorrhages the most associated with mortality. Management remains empirical requiring more research.

Анализ геморрагических осложнений в хирургии пролиферативной диабетической ретинопатии

Purpose. Determination of factors associated with the incidence of hemophthalmos in the early and late postoperative period in patients with proliferative diabetic retinopathy (PDR). Material and мethods. Retrospective analysis of postoperative complications was performed in 124 patients (133 eyes) with PDR, who received treatment at the Research institute of Eye Diseases from 2018 to 2021. The study included patients with PDR with indications for surgical treatment (hemophthalmos, traction retinal detachment (TRD), traction diabetic macular edema). All patients underwent minimally invasive vitrectomy using additional chandelier-type illuminators with bimanual dissection and delamination of the proliferative tissue and careful removal of the vitreous base with sclerocompression. In all cases, the operation was completed without the use of any tamponade. Peripheral retinal photocoagulation (RP) was performed in 98 cases (73.7 %), phacoemulsification with intraocular lens implantation in 66 cases (49.6 %), angiogenesis inhibitors were used perioperatively in 47 cases (35.3 %). Results. Of 133 operated eyes, early postoperative intravitreal hemorrhage (EPH) was observed in 17 cases (12.8 %), of which 6 resorbed spontaneously and 11 required repeated surgical intervention. The development of EPH was significantly associated with the absence of intraoperative RP (p &lt; 0.01), and the frequency of revision of the vitreal cavity to eliminate EPH correlated with the unstable course of arterial hypertension (AH) (p= 0.048) and with the absence of panretinal photocoagulation (PRP) before surgery (p= 0.012). It was found that EPH developed more often in patients operated on for TRD (p= 0.007) and in cases accompanied by severe intraoperative bleeding (p= 0.001) and unintentional intraoperative damage to the retinal vessels of the 2nd-3rd order (p&lt; 0.01). Late postoperative intravitreal hemorrhage (LPH) was observed in 20 cases (19.8 %), of which 11 resorbed spontaneously and 9 required surgical treatment. The development of LPH is significantly associated with the absence of intraoperative RP (p&lt; 0.01 for self-resorbed LPH and p= 0.041 for LPH requiring revision of the vitreal cavity). The frequency of revision of the vitreal cavity for the treatment of LPH is significantly associated with the unstable course of hypertension (p= 0.007) and the presence of EPH requiring surgical intervention (p= 0.003). The use of anti-angiogenic drugs before and during surgery did not show a significant correlation with the occurrence of EPH and LPH. Conclusions. Analysis of complications showed that EPH and LPH occurred in 12.8 % and 19.8 % of cases, respectively. Factors associated with the development of EPH were identified: the absence of PRP before surgery, the absence of intraoperative RP, TRD, intraoperative damage to the retinal vessels of the 2nd-3rd order. Factors associated with the development of LPH were identified: failure to perform RP intraoperatively, unstable course of hypertension, and the presence of EPH that required surgical intervention. Keywords: diabetic retinopathy, vitrectomy, bianual vitrectomy, postoperative hemorrhage, panretinal photocoagulation, peripheral retinal photocoagulation, arterial hypertension.

Advanced medical monitoring for the battlefield: A review on clinical applicability of compensatory reserve measurements for early and accurate hemorrhage detection

Hemorrhagic shock remains the leading cause of mortality in civilian trauma and battlefield settings. The ability of combat medics and other military medical personnel to obtain early identification and assessment of a bleeding casualty is hampered by the use of standard vital signs that fail to provide early predictive indicators of the onset of shock because of compensatory mechanisms. Over the past decade, the emergence and application of new technologies that incorporate the use of artificial intelligence have revealed that continuous, real-time arterial waveform analysis (AWFA) reflects the recruitment of such compensatory mechanism. As such, AWFA can provide early hemorrhage detection and indication of the onset of overt shock compared with standard vital signs. In this review, we provide for the first time a summary of clinical data collected in patients with varying conditions of blood loss, sepsis, and resuscitation with direct comparison of AWFA and standard vital signs. Receiver operating characteristic area under the curve data clearly demonstrate that AWFA provides greater accuracy with early indicators for changes in blood volume compared with standard vital signs. A consistently greater sensitivity generated by AWFA compared with vital signs is associated with its ability to provide earlier hemorrhage detection, while higher specificity reflects its propensity to distinguish "poor" compensators (i.e., those with relatively low tolerance to blood loss) from "good" compensators. The data presented in this review demonstrate that integration of AWFA into medical monitoring capabilities has the potential to improve clinical outcomes of casualties by providing earlier and individualized assessment of blood loss and resuscitation.

Postoperative Bleeding in Patients Under Direct Oral Anticoagulation After Maxillary Sinus Floor Augmentation: A Case-Control Study.

The aim of this case-control study was to investigate the occurrence of bleeding events related to maxillary sinus elevation with a lateral window in patients under direct oral anticogulant therapy. Seventyseven consecutive patients were scheduled for unilateral maxillary sinus floor elevation using a lateral window approach. Participants were divided into two groups: group A, formed by 37 patients who were under novel oral anticoagulation therapy (rivaroxaban/apixaban), and a control group, composed of 40 healthy subjects. Within group A, assumption of direct oral anticoagulants was not suspended nor modified before surgical procedures. Time (early/delayed) and site (intraoral/extraoral) of bleeding episodes were recorded in both groups of patients, in addition to bleeding severity (mild, moderate, or severe). Maxillary sinus floor elevation was performed in all patients. One dropout happened due to intraoperative membrane perforation. Overall bleeding episodes were comparable in both groups, chi-square (1) = .68, P = .41. Early intraoral bleeding events were more common in absolute terms, but also occurred with approximately the same frequency in both group A and the control group (Fisher exact tests: P = 1.00 and P = .375, respectively). No severe bleeding was observed in any of the attended patients. Within the limitations of this case-control study, maxillary sinus floor augmentation with a lateral window approach can be safely administered to patients who are under direct oral anticoagulation therapy when specific recommendations are instituted.

Early Postoperative Bleeding After Laparoscopic Roux-En-Y Gastric Bypass: a Single Center Analysis.

Early postoperative bleeding is a common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB) and is associated with significant morbidity. We aimed to identify predictors of early postoperative bleeding after LRYGB and characterize hemorrhagic events and 30-day postoperative outcomes. We conducted a retrospective cohort study regarding all patients submitted to LRYGB in 2019 at a high-volume obesity center. Early postoperative bleeding was defined as any clinically significant evidence of hemorrhage in the early postoperative period. Demographic, preoperative, and intraoperative factors were evaluated for associations with postoperative bleeding. Postoperative outcomes were compared between patients with and without hemorrhage. Of 340 patients submitted to LRYGB, 14 (4.1%) had early postoperative bleeding. Patients with bleeding had an increased preoperative left hepatic lobe diameter (8.4 vs. 7.3cm, p = 0.048). Prior cholecystectomy (28.6 vs. 14.5%) and previous bariatric surgery (35.7 vs. 23.9%) tended to be more prevalent among these patients. Bleeding occurred at a median time of 31.2 [IQR 19.7-38.5] h. Thirteen patients presented with intraluminal bleeding and one with extraluminal bleeding. Melena was the most common symptom. All hemorrhages were clinically diagnosed, and 92.9% were managed conservatively. Postoperative bleeding was associated with longer hospital stay (3.5 vs. 2.0days), higher reintervention (7.1 vs. 0%), and readmission (14.3 vs. 0%), all p < 0.05. Bleeding was the most frequent early complication after LRYGB. Patients with hepatomegaly and prior surgeries may have technically challenging LRYGB and should be carefully assessed. Perioperative strategies should be encouraged in high-risk patients to prevent bleeding.

Conservative Surgical Management of Early Postpartum Hemorrhage: A 12-Year Experience in a Tertiary Care Center in the South of Thailand.

To evaluate the success rate and predictive factors of success in conservative surgical management of early postpartum hemorrhage (PPH). A retrospective study was conducted at a tertiary care hospital in the south of Thailand, from January 2006 to December 2017. PPH with conservative surgical management including Bakri balloon tamponade, B-Lynch uterine compression sutures, arterial embolization, vessel ligations, and combined surgical procedures was reviewed. The procedures were considered successful if bleeding could be controlled without subsequent hysterectomy. Multivariate logistic regression analysis was used to identify predictive factors for success of conservative surgical treatment. Among 39,327 deliveries, 1461 (3.7%) patients had early PPH, and 92 cases received conservative surgical management. Most patients (92.4%) underwent cesarean section. Median (IQR) blood loss before conservative surgery was 1800 (1100, 2575) mL, and median (IQR) time from early PPH to conservative surgical management was 41 (25.5, 60.0) minutes. The overall success rate of conservative surgical management was 80.4%, meanwhile the postoperative complication rate was 27.2%. The predictive factors significantly associated with success were maternal age < 35years (odds ratio [OR] 4.53, 95% confidence interval [CI] 1.27-16.23; p = 0.02), blood loss before conservative surgery < 1800mL (OR 5.82, 95% CI 1.45-23.33; p = 0.01), and time to start conservative surgery ≤ 40min (OR 4.76, 95% CI 1.13-20.12; p = 0.03). The overall success rate of conservative surgical procedures was high. Maternal age < 35years, blood loss before conservative management < 1800mL, and time to conservative surgery ≤ 40min were predictive factors of success.

Effectiveness of Clipping for Definitive Colonic Diverticular Bleeding in Preventing Early Recurrent Bleeding.

Objective Clipping is a common technique for managing colonic diverticular bleeding (CDB), despite the lack of published evidence regarding its effectiveness. We aimed to evaluate the effectiveness of clipping for CDB in preventing early recurrent bleeding. Methods This dual-center retrospective study included 93 patients who underwent emergency hospitalization for bloody stool, diagnosed with definitive CDB, and treated with clipping or conservative treatment. The primary outcome was early recurrent bleeding. A logistic regression analysis was performed to assess the association between the occurrence of early recurrent bleeding and clipping with adjustment for propensity scores. Secondary outcomes included death, transfusion, length of hospitalization, need for transcatheter arterial embolization or surgery, and adverse events. Results The patient characteristics were similar between the clipping (n=85) and conservative treatment (n=8) groups. The rate of early recurrent bleeding was significantly lower in the clipping group than in the conservative treatment group [23.5% (20 cases) vs. 75% (6 cases), p=0.005]. In the propensity score-adjusted logistic regression analysis, the odds ratio for early recurrent bleeding in the clipping group was 0.094 (95% confidence interval, 0.008-0.633, p=0.026). Secondary outcomes were not significantly different between the two groups. Stigmata of recent hemorrhage (SRH) at the time of recurrent bleeding was identified in 79.2% of patients (19/24). In the clipping group, recurrent bleeding was observed in 62.5% of cases (10/16) from the same diverticulum. However, early recurrent bleeding tended to be less likely with direct clipping (p=0.072). Conclusion Clipping for definite CDB was more effective in preventing early recurrent bleeding than conservative treatment.

Early post-partum hemorrhage after spontaneous vaginal delivery: prevention and management done by midwives at butare university teaching hospital

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal death in low-income countries and is the primary cause of approximately one-quarter of global maternal deaths. The purpose of this paper is to assess the prevention and management of early postpartum hemorrhage (PPH) after spontaneous vaginal delivery at Butare University Teaching Hospital. Methods: Quantitative prospective observational study, 31 women in labor from the end of the second stage of labor to the end of early postpartum after spontaneous vaginal delivery during data collection period (From March 20th to April 2, 2015). The participant involved in this Evidence Based Practice was observed after getting and signing consent form. Patient’s files, data correction form was used to correct data. All processes were done after getting approval from ethical committee and Butare University Teaching Hospital research committee permission to conduct the project. The data were entered in SPSS version 16 for being analyzed; Microsoft word for text elaboration and Microsoft excel was used for making tables. Results: Active management of the third stage of labor is considered the “gold standard” strategy for reducing the incidence of PPH. It combines nondrug interventions (controlled cord trac­tion and cord clamping) with the administration of an uterotonics drug, Unfortunately, Oxytocin is used in majority of cases(93.5%:n=29) followed by uterine massage (67,7%:n=21), but the controlled cord traction is the last one with (54,8%:n=17).For management vital signs are taken at 100% (n=6),estimated blood loss done at 66.7% (n=4) differently, establish intravenous access and prevention of shock are done at (83.3%: n=5). Transfusion done at 50% (n=3) and catheterized bladder not done at 83.3% (n=5). Conclusion: As the main cause of maternal mortality worldwide, PPH prevention interventions need to be prioritized. Increased access to prophylactic uterotonics, regardless of where deliveries occur, should be the primary means of reducing the complication of PPH.

Progesterone for the prevention of threatened miscarriage

Miscarriage, defined as the loss of a pregnancy before 24 weeks of gestation, is the most common complication of early pregnancy, affecting approximately 15% of clinically recognized pregnancies. The steroid hormone progesterone is essential for the maintenance of pregnancy, and progesterone deficiency is associated with miscarriage. Two important clinical risk factors for miscarriage are a history of previous miscarriages and vaginal bleeding in early pregnancy. Progesterone supplementation has therefore been attempted to prevent miscarriages in asymptomatic women with a history of miscarriages and in women who have started to bleed in early pregnancy. The latest evidence from high quality clinical trial research has shown that vaginal micronized progesterone treatment of women with the dual risk factors of early pregnancy bleeding and a history of one or more previous miscarriages increases the likelihood of a successful live birth (relative rate 1.08, 95% CI 1.02 to 1.15, high-certainty evidence). This treatment has also been shown to be cost-effective, leading to the National Institute for Health and Care Excellence committee for the guideline ‘Ectopic pregnancy and miscarriage: diagnosis and initial management (NG126)’ updating their guidance to recommend the use of vaginal micronized progesterone to treat women with the dual risk factors of a history of one or more previous miscarriages and early pregnancy bleeding. This change in practice has the potential to prevent up to 8,450 miscarriages a year in the UK.

Use of topical mineral powder as monotherapy for treatment of active peptic ulcer bleeding

The aim of this study was to evaluate the safety and effectiveness of Hemospray (Cook Medical, Winston-Salem, NC, USA), a hemostatic powder, as monotherapy for active peptic ulcer bleeding. In this prospective, multicenter, single-arm study, patients with Forrest Ia or Ib peptic ulcers underwent endoscopic application of Hemospray as treatment of first intent. Effectiveness endpoints were successful hemostasis at the end of the index endoscopy, recurrent bleeding within 72 hours and from 72 hours to 30 days, adverse events requiring reintervention or resulting in morbidity or mortality, and 30-day mortality. Hemospray was successfully administered in 98.5% of patients (66/67). Hemostasis was achieved at the index endoscopy in 90.9% of patients (60/66) with Hemospray alone and in an additional 4 patients treated with additional modalities, yielding an overall hemostasis rate of 97.0% (64/66). Rebleeding occurred in 13.3% of patients (8/60), 5 within 72 hours and 3 between 72 hours and 30 days. Two cases of perforation and 2 patient deaths occurred during the study, but none of these cases or any other adverse events were attributed to the use of Hemospray. The rate of early rebleeding was significantly higher in patients with Forrest Ia ulcers compared with patients with Forrest Ib ulcers. Higher rates of early bleeding in patients with Forrest Ia ulcers is consistent with results from studies where Hemospray was used as rescue after failure of conventional methods. Hemospray is an effective initial treatment for patients with active peptic ulcer bleeding, but care should be taken to monitor for recurrent bleeding. (Clinical trial registration number: NCT01306864.).

Management of acute lower gastrointestinal bleeding by pharmaco-induced vasospasm embolization therapy.

To report the clinical outcomes of vasospasm embolization technique in treating lower gastrointestinal bleeding (LGIB). Fifty LGIB patients (32 men and 18 women; mean age, 70.4 years) with positive contrast extravasation on multidetector computed tomography were treated with pharmaco-induced vasospasm embolization by semiselective catheterization technique. Distal rectal bleeding was excluded. The bleedings in three patients were considered to be tumor related. Eighteen underwent regular hemodialysis, and 22 showed unstable hemodynamic at intervention. Forty-two bleeders were found in superior mesenteric territory and eight in the inferior mesenteric territory. Successful, immediate hemostasis was achieved in 49 (98%) patients. Early recurrent bleeding (<30 days) was found in 13 (26.5%) patients with 6 local rebleeding (12.2%), 5 new-foci bleeding (10.2%), and 2 uncertain foci bleeding (4.1%). Repeated vasospasm embolization therapy was given to five patients, with successful hemostasis in four. All the three tumor-related bleeding patients undergoing vasospasm embolization had ceased bleeding and discharged. Patient-based primary and overall clinical successes were achieved in 73.5% and 83.7%, and lesion-based primary and overall clinical successes were 83.0% and 86.7%, respectively. The 30-day mortality rate was 21.3%, and the 1- and 2-year survival rates were 51.5% and 43.8%. No major procedure-related complications (eg, bowel ischemia) were encountered. This study confirmed our prior preliminary conclusion that pharmaco-induced vasospasm embolization is easy, safe, and effective for LGIB. This treatment may be considered the first-line alternative approach for LGIB, especially for patients of advanced age with complex medical problems and/or when vasa rectal embolization isn't feasible.

MODERN TECHNOLOGY TO DIAGNOSE EARLY POSTPARTUM HEMORRHAGE IN ISLAND AREAS : A SYSTEMATIC REVIEW

Mortality and morbidity due to bleeding occur due to delayed care. On the island, more advanced technology models based on the 4.0 digital development facilities and infrastructures are important to improve the health service quality. This literature review identifies modern technology-based bleeding detection as an effort to detect and diagnose early postpartum hemorrhage on the island. This systematic review study selected the data with the PRISMA protocol method. The researchers took 12 journal article outlets with years of publications from 2011 until 2020. The researchers found 587 articles. However, the most relevant articles with the applied keywords were 12 articles. Various modern technology-based detections for bleeding applied pantograph, gravimetric, bag collector, under-buttock, SAPHE mat, and scoring measurement to efficiently promote early bleeding. These investigated models were more effective than visual estimation with effectiveness percentages of 25-89%. Technology-based detections could early detect and facilitate postpartum hemorrhage and provide immediate care. High technological advancement in the health field facilitates the patients' care, especially in islands that need immediate action. The results of this research are useful to promote further research about modern-technology-based models to detect and diagnose postpartum hemorrhage in islands.

Impact of new-onset versus pre-existing atrial fibrillation on outcomes after transcatheter aortic valve replacement/implantation.

Patients with aortic stenosis who undergo transcatheter aortic valve replacement/transcatheter aortic valve implantation (TAVR/TAVI) experience a high incidence of pre-existing atrial fibrillation (pre-AF) and new-onset atrial fibrillation (NOAF) post-operatively. This systematic review and meta-analysis aimed to update current evidence concerning the incidence of 30-day mortality, stroke, acute kidney injury (AKI), length of stay (LOS), and early/late bleeding in patients with NOAF or pre-AF who undergo TAVR/TAVI. PubMed, Google Scholar, JSTOR, Cochrane Library, and Web of Science were searched for studies published between January 2012 and December 2020 reporting the association between NOAF/pre-AF and clinical complications after TAVR/TAVI. A total of 15 studies including 158,220 adult patients with TAVI/TAVR and NOAF or pre-AF were identified. Compared to patients in sinus rhythm, patients who developed NOAF had a higher risk of 30-day mortality, AKI, early bleeding events, extended LOS, and stroke after TAVR/TAVI (odds ratio [OR]: 3.18 [95% confidence interval [CI] 1.58, 6.40]) (OR: 3.83 [95% CI 1.18, 12.42]) (OR: 1.70 [95% CI 1.05, 2.74]) (OR: 13.96 [95% CI, 6.41, 30.40]) (OR: 2.51 [95% CI 1.59, 3.97], respectively). Compared to patients in sinus rhythm, patients with pre-AF had a higher risk of AKI and early bleeding episodes after TAVR/TAVI (OR: 2.43 [95% CI 1.10, 5.35]) (OR: 17.41 [95% CI 6.49, 46.68], respectively). Atrial fibrillation is associated with a higher risk of all primary and secondary outcomes. Specifically, NOAF but not pre-AF is associated with a higher risk of 30-day mortality, stroke, and extended LOS after TAVR/TAVI.

International Variation in the Management of Patent Ductus Arteriosus and Its Association with Infant Outcomes: A Survey and Linked Cohort Study

To assess whether treating patients with a presymptomatic patent ductus arteriosus (PDA), based on early routine echocardiography, performed regardless of clinical signs, improved outcomes. This multicenter, survey-linked retrospective cohort study used an institutional-level questionnaire and individual patient-level data and included infants of <29weeks of gestation born in 2014-2016 and admitted to tertiary neonatal intensive care units (NICUs) of 9 population-based national or regional neonatal networks. Infants in NICUs receiving treatment of presymptomatic PDA identified by routine echocardiography and those not were compared for the primary composite outcome (early death [≤7days after birth] or severe intraventricular hemorrhage) and secondary outcomes (any in-hospital mortality and major morbidities). The unit survey (response rates of 86%) revealed a wide variation among networks in the treatment of presymptomatic PDA (7%-86%). Among 246 NICUs with 17 936 infants (mean gestational age of 26weeks), 126 NICUs (51%) with 7785 infants treated presymptomatic PDA. The primaryoutcome of early death or severe intraventricular hemorrhage was not significantly different between the NICUs treating presymptomatic PDA and those who did not (17% vs 21%; aOR 1.00, 95% CI 0.85-1.18).The NICUs treating presymptomatic PDA had greater odds of retinopathy of prematurity treatment (13% vs 7%; aOR 1.47, 95% CI1.01-2.12); however, it was not significant in a sensitivity analysis excluding Japanese data. Treating presymptomatic PDA detected by routine echocardiography was commonplace but associated with no significant benefits. Well-designed trials are needed to assess the efficacy and safety of early targeted PDA treatment.

Predictors of early bleeding after endoscopic variceal ligation for esophageal varices: a systematic review and meta-analysis.

Endoscopic variceal ligation (EVL) is important for emergency as well as prophylactic management of esophageal varices. Early bleeding after EVL is associated with significant morbidity and mortality. Assessing the likelihood of early post-EVL bleeding and its determinants can help deciding therapeutic strategies for high-risk patients. The aim of the present meta-analysis was to identify predictors of early bleeding after EVL. A comprehensive search of the literature was conducted from 2000 to November 2021 for studies evaluating the incidence, predictors and outcome of post-EVL bleeding. Pooled odds ratios (OR), mean difference (MD) and their 95% confidence intervals (CI) were calculated for prognostic variables. A total of 16 studies with data on 13,378 patients were included in the meta-analysis. Among 34 parameters, 14 parameters were assessed for association with early bleeding after EVL. Lower hemoglobin at admission (MD = 1.11, 95% CI: -1.91 to -0.31), higher MELD score (MD = 2.00, 95% CI: 0.51-3.50), associated gastric varices (OR = 5.99, 95% CI: 1.06-33.90), higher number of bands (MD = 0.49, 95% CI: 0.02-0.97), and peptic esophagitis (OR = 11.38, 95% CI: 1.21-106.81) were significantly associated with increased risk of bleeding. However, there was significant heterogeneity among the studies with respect to all the analyzed parameters. Major predictors for early post-EVL bleeding in cirrhosis are admission hemoglobin level and MELD score, associated gastric varices, number of bands deployed during EVL, and peptic esophagitis on follow-up endoscopy. These risk factors may be useful for risk stratification after EVL in cirrhotics.

Diagnostic Value of Susceptibility-Weighted Imaging Combined with Diffusion-Weighted Imaging in Early Intracerebral Hemorrhage.

Objective The incidence of early intracerebral hemorrhage (ICH) is gradually increasing and has been shown to affect an increasing number of younger people. Conventional imaging modalities might have a low detection rate of early and small ICH lesions. This study aimed to investigate the diagnostic value of susceptibility-weighted imaging (SWI) combined with diffusion-weighted imaging (DWI) in early ICH. Materials and Methods The data of 61 patients with early ICH diagnosed by computed tomography (CT) scan between January 2019 and February 2020 were assessed. Using CT as the gold standard, we compared the diagnostic sensitivity, accuracy, and imaging characteristics of SWI + DWI versus SWI or DWI alone. Results A total of 78 lesions were detected by CT in 61 patients with early ICH. The diagnostic sensitivity and accuracy of SWI + DWI were significantly higher than those of SWI or DWI alone. In terms of imaging characteristics, DWI demonstrated very low signal intensity in the hematoma center at different stages of early ICH with high signal intensity in the surrounding tissue, and the signal range gradually increased over time. By contrast, SWI displayed very low signal intensity at different stages, and the signal intensity also gradually increased over time. Conclusion Compared with SWI or DWI alone, SWI combined with DWI could improve the detection rate of hematoma lesions in patients with early ICH.