Fall In Hemoglobin Research Articles

Comparison of Intraoperative and Postoperative morbidity between in situ and extra-abdominal Uterine repair at Cesarean delivery

In-situ and extra abdominal repair of uterine wound during cesarean section are two valid approaches. This study was carried out to compare intra operative and post operative morbidity in women undergoing caesarean delivery using these two techniques. This is a prospective interventional randomized controlled study. The study subjects include 170 women undergoing Lower segment caesarean section (LSCS) at Southern Railway HQ hospital, Chennai. Intra operative and post operative parameters were analysed in all the study subjects. In in-situ group, 12.6 % women experienced intra operative pain and 30.1% women in extra abdominal group. Intra operative nausea and vomiting was seen in 16.1% women in in-situ group and 28.9% women in extra abdominal group. 1.1% women in in-situ had post-operative febrile morbidity and 8.4 % had in extra abdominal group. The median fall in haemoglobin was 1.30 g/dL and 1.40 g/dL in in-situ and extra abdominal group respectively. In-situ repair of the uterine wound at cesarean delivery is associated with lesser incidence of intra operative pain , intra operative nausea or vomiting and post operative febrile morbidity compared to extra abdominal repair technique.

Pre-operative and intra-operative chemical thromboprophylaxis increases bleeding risk following elective cholecystectomy: a multicentre (PROTECTinG) study.

Cholecystectomy is commonly performed in general surgery. Despite guidelines recommending chemical thromboprophylaxis in the perioperative period, the most appropriate time for its initiation is unknown. Here, we investigated whether timing of chemoprophylaxis affected venous thromboembolism (VTE) and bleeding rates post-cholecystectomy. Retrospective review of all elective cholecystectomies performed between 1 January 2018 and 30 June 2019, across seven Victorian hospitals. Clinical VTE was defined as imaging-proven symptomatic disease within 30 days of surgery. Major bleeding was defined as the need for blood transfusion, surgical intervention or >20 g/L fall in haemoglobin from baseline. A total of 1744 cases were reviewed. Chemoprophylaxis was given early (pre- or intra-operatively), post-operatively or not given in 847 (48.6%), 573 (32.9%) and 324 (18.6%) patients, respectively. This varied significantly between surgeons, fellows, trainees and institutions. Clinical VTE occurred in 5 (0.3%) patients and was not associated with chemoprophylaxis timing. Bleeding occurred in 42 (2.4%) patients. Of this, half were major events, requiring surgical control in 5 (11.9%) patients and blood transfusion in 9 (21.4%) patients. Bleeding also extended length of stay (mean (SD), 3.1 (4.0) versus 1.4 (2.2) days, P < 0.001). One bleeding-related mortality was recorded. Importantly, when compared with post-operative (risk ratio 1.46, 95% confidence interval 1.21-1.62) and no (RR 1.23, 95% CI 1.03-1.35) chemoprophylaxis, early usage significantly increased bleeding risk and independently predicted its occurrence. Perioperative chemoprophylaxis is variable among patients undergoing elective cholecystectomy. The rate of clinical VTE post-cholecystectomy is low. Early chemoprophylaxis increases bleeding risk without an appreciable additional protection from VTE.

Use of Desmopressin Prior to Kidney Biopsy in Patients With High Bleeding Risk

IntroductionTo prevent bleeding after native kidney biopsy (NKB), nephrologists often prescribe desmopressin, especially for patients with reduced estimated glomerular filtration rate (eGFR) at risk of uremia-related platelet dysfunction. However, only 1 randomized study has suggested a beneficial effect for desmopressin in patients with eGFR ≥60 ml/min per 1.73 m2. This retrospective cohort study aimed to evaluate desmopressin effect on postbiopsy bleeding in all patients, regardless of eGFR and other comorbidities.MethodsIn this retrospective cohort study, all adult patients who underwent an NKB from April 1, 2013, to April 30, 2018, in a tertiary hospital were identified. The association between desmopressin use and bleeding complications, including hemoglobin fall, transfusion, hematoma, symptomatic hematoma, urgent radiologic study, and hypotension, was analyzed using multivariable logistic regression models.ResultsA total of 413 native kidney biopsies were studied, 79% of which were performed after receiving desmopressin. Patients receiving desmopressin had worse chronic kidney disease (eGFR 28 vs. 45 ml/min per 1.73 m2; P < 0.001) and were more often hospitalized (48% vs. 32%; P = 0.009). Despite higher bleeding risk, patients using desmopressin had a similar likelihood of symptomatic hematomas (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.13–1.14) and a lower need for urgent radiologic studies (OR, 0.33; 95% CI, 0.11–0.98).ConclusionPatients at higher risk of bleeding using desmopressin before kidney biopsy had bleeding complications similar to those not using desmopressin. These results highlight potential important clinical and financial benefits of desmopressin use before kidney biopsy.

Maternal complications following caesarean myomectomy and caesarean alone-an observational comparative study

Uterine leiomyoma is the commonest tumour of female genital tract. Earlier myomectomy at caesarean sections was generally avoided due to fear of intractable haemorrhage and atonicity leading to subsequent hysterectomy and future fertility issues. The aim of this study is to compare the intra-operative and post-operative complications following caesarean myomectomy and caesarean section alone in antenatal patients with myomas. A hospital based observational comparative study was peformed on 38 antenatal woman with myomas, include 19 antenatal patients with myomas who were posted for caesarean myomectomy compared with age matched 19 antenatal women who were posted for caesarean alone , were selected for the study in the department of obstetrics and gynecology. In the present study patients mean age was of 30.8+5 yearsand 30.8+5 years respectively for caesarean myomectomy and caesarean group. Out of the 38 patients 15 patients were primipara and 13 patients were multipara. The duration of surgery for caesarean myomectomy was 65 ± 12.9minutes compared to 47.4 +4.2 minutes in caesarean only group. Out of the 38 patients mean and standard deviation of hemoglobin fall during surgery in caesarean myomectomy was 1.1+0.7gm/dl when compared to 0.7+0.2gm/dl in caesarean group. And 2 patients needed blood transfusions post-operatively in caesarean myomectomy compared one patient in caesarean group. The hospital stay in hours in caesarean myomectomy was 126.3±10.9 hours and 121.3±5.5 hours in caesarean group. None of them ended on obstetric hysterectomy. In this study, No significant difference was observed in haemoglobin change, incidence of intra-operative complications and length of hospital stay, in the caesarean myomectomy group as compared to other post caesarean group. The possibility of performing myomectomy during caesarean section has become a safe procedure with experienced surgeons and anaesthetic facilities

A COMPARATIVE STUDY OF ASSESSMENT OF ROLE OF TRANEXAMIC ACID IN CONTROLLING BLOOD LOSS IN ORTHOPAEDIC SURGERIES: A RANDOMISED CONTROL TRIAL.

Aim: to study the role of Tranexamic Acid in Controlling Blood Loss In orthopaedic surgeries.&#x0D; Material &amp; Methods: 50 patients were included in the study during the study period. Patients were randomly allotted to 2 groups of equal participants. The first group (Group A) received Tranexamic Acid. The second group (Group B) was given Normal saline as placebo. The Total Blood Loss ( intra operative + post operative ) and Fall in Haemoglobin levels were measured post-operatively at 24 and 72 hrs of post-operative period.&#x0D; Result: The group A had showed significantly reduced total blood loss and fall in Haemoglobin, thus, requiring fewer blood transfusions. No complications were observed.&#x0D; Conclusions: the present investigation concluded that Tranexamic acid can be effective in reducing blood loss and subsequent fall in haemoglobin.&#x0D; Keywords: Tranexamic acid, Bleeding, Major Orthopaedic surgeries.

Safety and efficacy of bipolar versus monopolar transurethral resection of bladder tumor: a systematic review and meta-analysis.

Transurethral resection of bladder tumor is the standard of care for the management of patients with bladder mass. Primary objective of this study was to compare safety and efficacy of the two energy modalities used for TURBT (monopolar and bipolar). Systematic literature search of various electronic databases was conducted to include all the randomized studies comparing two groups. Standard PRISMA (Preferred reporting Items for Systematic reviews and Meta-analysis) guidelines were pursued for this review and study protocol was registered with PROSPERO (CRD42019139987). In the present review, eight RCTs including 1147 patients were included. Resection time, hospital stay and catheter duration were significantly shorter with bipolar group. There was no significant difference in incidence of obturator reflex (OR 0.65, CI [0.35, 1.2], p = 0.17), whereas incidence of bladder perforation was significantly higher in the monopolar group (6.4% versus 3.3%, p = 0.01. However, sensitivity analysis including 3 high quality studies revealed equal incidence of bladder perforations. Need for blood transfusion was similar in the two groups but fall in hemoglobin was significantly lower in bipolar group (MD - 0.45 CI [- 0.72, - 0.18], p = 0.0009). Bipolar group was found to have significantly lower incidence of tissue artifacts due to thermal energy on pathological examination (OR 0.27 CI [0.15, 0.47], p < 0.00001). Bipolar and monopolar devices are equally safe in terms of obturator jerk and bladder perforation. Bipolar group was significantly better as compared to monopolar for hospital stay, catheter duration and fall in hemoglobin; however, the clinical relevance of most of these parameters is little.

Delayed haemolysis after treatment with intravenous artesunate in patients with severe malaria in India

BackgroundParenteral artesunate is the treatment of choice for severe malaria. It is safe, efficacious and well tolerated anti-malarial. However, delayed haemolysis has been reported in travellers, non-immune individuals and in African children.MethodsA prospective, observational study was carried out in admitted severe malaria patients receiving parenteral artesunate. The patients were followed up until day 28 for monitoring clinical as well as laboratory parameters for haemolytic anaemia.ResultsTwenty-four patients with severe malaria receiving injection artesunate were enrolled in the study. Post-artesunate delayed haemolysis following parenteral artesunate therapy was observed in three of 24 patients (12.5%, 95% confidence interval 4.5–31.2%). Haemolysis was observed in two more patients possibly due to other reasons. The haemoglobin fall ranged from 13.6 to 38.3% from day 7 to day 28 in these patients.ConclusionThe possibility of delayed haemolysis should be considered while treating the severe malaria patients with parenteral artesunate. The study highlights the need for further studies in different epidemiological settings.

Comparison of blood loss between intra-articular and intra-venous administration of tranexamic acid in primary total knee arthroplasty.

Objective: To compare the blood loss between intra-articular and intra-venous administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty. Design of study: It was a randomized controlled trial. Study duration and settings: This study was carried out at the Orthopedic Departments of Combined Military Hospital Lahore and Rawalpindi from Jan 2016 to March 2018. Methodology: Patients of both the genders were involved this study who had age in the rage of 40–80 years undergoing primary unilateral total knee arthroplasty for degenerative conditions like osteoarthritis and rheumatoid arthritis. These patients were randomly divided into two treatment groups. Patients in IA group received intra-articular tranexamic acid while those in IV group received intravenous tranexamic acid. From all the patients, a written signed consent was taken. Findings: Females were predominant with male-to-female ratio of 1:3.7. The mean age of the patients was 67.3 ± 8.2 years while the mean BMI was 30.9 ± 2.9 Kg/m2. Majority (n = 191, 95.5%) of the patients had osteoarthritis while remaining 9 (4.5%) patients had rheumatoid arthritis. There was no statistically significant difference between intra-articular and intra-venous administration of tranexamic acid in terms of mean post-operative hemoglobin (9.93 ± 1.14 vs. 9.87 ± 1.26 g/dL; p-value = 0.724), mean post-operative hematocrit (34.8 ± 1.66 vs. 34.73 ± 1.27%; p-value = 0.594), and mean fall in hemoglobin (2.27 ± 0.34 vs. 2.25 ± 0.30 g/dL; p-value = 0.587) and hematocrit (2.34 ± 0.94 vs. 2.46 ± 0.28%; p-value = 0.216). Conclusion: Intra-articular administration of tranexamic acid was found to be as effective and safe as intra-venous administration in reducing blood loss in primary total knee arthroplasty. Due to convenience, the use of intra-articular administration of tranexamic acid after primary TKA may be considered in future practice.

Does pre-operative stenting affect post-operative outcome in peri-ampullary carcinoma?

Background: Pre-operative biliary stenting in patients undergoing surgery for peri-ampullary malignancy has been considered to cause technical difficulty during surgery due to local inflammatory response, post-operative infective complications leading to morbidity and mortality. The aim of this study was to compare the early outcomes of patients undergoing pre-operative stenting versus non-stented patients. Materials & Methods: This was a retrospective observational study of patients undergoing surgery for peri-ampullary malignancy in a tertiary medical college & hospital from January 2015 to October 2018. The patients were divided into two groups: those stented pre-operatively (cases) and those not stented pre-operatively (controls). They were compared (matched) for age, type of surgery – curative (pancreaticoduodenectomy) or palliative (double or triple bypass), pre-operative haemoglobin, bilirubin and albumin. The outcome measures were duration of surgery, number of transfusions, post-operative fall of haemoglobin, post-operative complications (anastomotic leak), duration of ICU and hospital stay and in-hospital mortality. Results: Records of 41 patients could be retrieved. There were 26 non-stented and 15 stented patients. Both the groups were comparable for age, type of surgery, pre-op bilirubin, haemoglobin and albumin levels. The stented group had zero in-hospital mortality versus non-stented group with 30.76 percent mortality (p value 0.018). The anastomotic leak and post-operative infective complications were lower in the stented group (not statistically significant). The duration of surgery, number of blood transfusions, post-operative fall of haemoglobin, duration of ICU stay and hospital stay were not higher in the stented group. Conclusion: Unlike the published western literature which reports higher anastomotic leak rates and infective complications among stented patients, among Indian patients pre-operative stenting seems to have a survival advantage. This may be due to beneficial effect of stenting in correcting physiological disturbances caused by obstructive jaundice.

Tranexamic acid in primary total knee arthroplasty: ideal route of administration

Background &amp; Study Aims: Consensus is lacking regarding the optimal route and dose of administration of Tranexamic acid (TXA) so this study was conducted to compare the efficacy and safety of topical, oral and intravenous routes (iv) of TXA with routine hemostasis alone in patients undergoing primary total knee arthroplasty (TKA). Materials and methods: A prospective randomized trial was conducted in patients undergoing primary TKA. Patients were divided into four groups of 50 each; group 1 received intraarticular TXA, group 2 received oral TXA three hours before surgery, group 3 received IV TXA just before tourniquet release and group 4 did not receive TXA. Post-operative drain volume (PODV), fall in haemoglobin (Hb) level and the required amount of blood transfusion were evaluated. Results: PODV and drop in Hb level respectively were (158±90 ml and 1±0.5 g/dl) in group 1, (328±149 ml and 1.7±0.7 g/dl) in group 2, (311±151 ml and 2.1±1 g/dl) in group 3 and (589±115 ml and 3.2±1.2 g/dl) in group 4. The difference in drain volume between all groups was statistically significant except between groups 2 and 3. Transfusion requirements were significantly greater in group 4 (p&lt; 0.001). Conclusions: Intra-articular, oral and IV TXA were observed to be safe strategies and more effective than tamponade effect alone to reduce drain volume and transfusion requirements after TKA. Additionally, intra-articular TXA was better than oral or IV TXA with respect to drain volume and post-op drop in Hb

MVP (Micro Vascular Plug\xae) embolization of severe renal hemorrhages after nephrostomic tube placement

BackgroundWe report our experience in managing iatrogenic renal bleedings after nephrostomic procedures by transarterial embolization using Micro Vascular Plug (MVP) (Medtronic, USA) as single or complementary embolization device with parenchimal sparing.Materials and methodsFive patients have been treated in a single center with transarterial embolization because of renal hemorrhages occurring after positioning of nephrostomic drainages.All patients presented with back pain, severe hematuria and/or bright red blood into the nephrostomic bag, with fall in hemoglobin value.After contrast enhanced CT scan confirming arterial active bleeding, rescue embolization was performed using MVP.The renal parenchimal loss was estimated on final postembolization DSA. Creatinine values were monitored before and after the procedure.ResultsTechnical and clinical successes were obtained in all patients.Two patients presented with extraluminal blush, one with multiple pseudoaneurysms, one with pseudoaneurysm with arterovenous fistula, one with extraluminal blush with arterovenous fistula.MVP models were choosen oversized because of vasospasm that would underestimate the effective caliber of target vessel; MVP 3Q and MVP 7Q were adopted in one patient each, while MVP 5Q was released in three cases.MVP was the sole embolizing agent in four patients; in one patient, MVP was employed after microcoils failed to obtain complete embolization.The percentage of renal parenchimal lost was lower than 20%; no increase in Creatinine values was detected at dismission.ConclusionsAccording to proposed data, MVP seems to be a safe, effective and fast embolizing device that interventionalists could consider when facing renal bleedings, even as sole agent.

Mifepristone Followed by Misoprostol or Ethacridine Lactate and Oxytocin for Second Trimester Abortion: A Randomized Trial.

To compare two medical methods for second-trimester abortion, mifepristone followed by misoprostol versus mifepristone followed by ethacridine lactate and oxytocin for success rate, induction to abortion time and acceptability. This is a randomized trial conducted from July 2014 to May 2016 and enrolled 120 women undergoing second trimester abortion (13-20 weeks). All patients received 200mg mifepristone orally and were randomized to receive further treatment after 36 hrs. Patients in Group M (n=60) received 400 microgram of misoprostol vaginally every 3 hours (maximum - 5 doses) and Group E (n=60) had extra-amniotic ethacridine lactate instillation followed by oxytocin infusion (max-100miu). Baseline demographic characteristics were comparable in both the groups. Success rate was 100% in group M and 98.3% in group E (p=0.31). Mean induction to abortion time was significantly shorter in group M than group E (8.2+2.3hours & 10.9+2.6 hours respectively; p=0.001). Majority of women reported side effects, 96.7% women in group M and 75% women in group E (p=0.001). Fall in hemoglobin after procedure was significantly higher in group M (0.70+0.33gram %) than group E (0.52+0.23 gram %) (p=0.001). Perception of intensity of pain was significantly more in group M but patient satisfaction in both groups was similar. Both methods are comparable for success rate, induction interval was more for ethacridine lactate compared to misoprostol.

Thrombocytopenia and Anticoagulation: Impact of the ISTH SCC Anticoagulation Guidelines in Patients with Thrombocytopenia

Background Thrombosis is the second leading cause of death for cancer patients undergoing chemotherapy. Despite this, cancer patients also have a higher risk of clinically relevant bleeding related to thrombocytopenia secondary to chemotherapy or underlying disease. Optimal management of venous thromboembolism (VTE) in the setting of these competing risks is difficult. Generally, two strategies are used: (1) full dose anticoagulation with supportive platelet transfusions to maintain platelet count above 40,000-50,000/μL or (2) reduced-dose anticoagulation while platelets are &lt;50,000/μL. The International Society on Thrombosis and Haemostasis Scientific and Standardization Committee (ISTH SCC) recently released updated guidance on management of anticoagulation in patients with cancer-associated thrombosis (CAT) and thrombocytopenia. We retrospectively reviewed cancer patients diagnosed with VTE and thrombocytopenia before and after implementation of the ISTH SCC guidance to determine the impact of the statement on platelet transfusion, bleeding, and recurrent thrombosis. Methods We evaluated cancer patients with thrombocytopenia who required anticoagulation for VTE for 11 months before and after implementation of the ISTH SCC guidance statement. Patients with malignancy, thrombocytopenia (platelets &lt;50,000), and administration of an anticoagulant were identified through an electronic medical search. Charts were retrospectively reviewed to identify the type of VTE event, number of platelet transfusions, incidence of bleeding, and VTE recurrence during thrombocytopenia within the pre- and post-intervention time periods. Cases were excluded if they were treated with anticoagulation for indications other than VTE. Summary statistics were calculated. Chi-square and Fisher's exact tests were used to compare categorical variables. Continuous variables were compared using the Mann-Whitney test. Results A total of 42 cases were identified in the pre-intervention time period and 82 cases in the post-intervention time period (Table 1). The median age was 62 years and the majority of patients (55% and 64%) were male. A total of 34 (80%) patients had experienced a PE or proximal DVT in the pre-intervention and 59 (72%) in the post-intervention time period (p=0.27). Significantly less patients experienced a VTE less than 30 days prior to thrombocytopenia in the pre-intervention compared to the post intervention time periods (33% vs. 55%, p=0.03). Likely secondary to this difference in acuity of the thrombosis, there was a trend to an increased per patient platelet transfusion in the post-intervention time period (median 2.5 vs. 4, p=0.05). Hemorrhage was noted in 2 (4%) of cases pre-intervention; and 14 (17%) in the post-intervention, only 4 (4%) of which were considered major hemorrhages by ISTH criteria (fatal bleeding and/or symptomatic bleeding into a critical area or organ, and/or bleeding causing a fall in hemoglobin of 2g/dL or more or that requires transfusion of two or more units of whole blood or red cells). A trend towards less recurrent thrombosis was noted in the post-intervention group (9% vs. 21%, p=0.07). Recurrent VTE events included 2 PE and 15 DVT. Adherence to the guidance statement was excellent (95% for medication management and 98% for platelet transfusions). Conclusion The ISTH guidance on management of cancer-associated thrombosis in patients with thrombocytopenia can be successfully implemented in an academic medical center. Trends towards higher incidence of bleeding and reduced incidence of thrombosis occurred. Disclosures Baumann Kreuziger: CSL Behring: Consultancy; Vaccine Injury Compensation Program: Consultancy.

The change in haemoglobin concentration between the first and third trimesters of pregnancy: a population study

BackgroundThe physiological fall in haemoglobin concentration from the 1st to the 3rd trimester of pregnancy is often quoted as 5 g/L. However, other studies have suggested varying levels of fall between 8 and 13 g/L. We evaluated the change in haemoglobin concentration between the 1st and 3rd trimesters of pregnancy in a multi-ethnic population of pregnant women.MethodsA retrospective cohort analysis of 7054 women with singleton pregnancies, giving birth during 2013–15 in a single urban maternity unit in England.We calculated the changes in haemoglobin concentration from 1st to 3rd trimester using the first trimester haemoglobin as the reference point. The population was stratified into sub-groups to explore any differences that existed within the population.ResultsIn general the fall in haemoglobin concentration was in the order of 14 g/L or 11% of the first trimester value. This fall was consistent for the majority of sub-groups of the population. The fall was lower (7.7%) in the most deprived section of the population, IMD1, but it increased to 11.7% when we restricted that sub-group to pregnant women without health problems during the index pregnancy. Conversely, there was an increase in haemoglobin of 10.2% in women whose first trimester haemoglobin concentration was in the lowest 5% of the total study population. The population fall in haemoglobin was 10.2 g/L (7.8%), after excluding cases above the 95th and below the 5th centiles, and women with a medical and/or obstetric disorder during the pregnancy.ConclusionThe fall in haemoglobin during pregnancy is in the order of 14 g/L or 11% of the first trimester level. This is 2 to 3 times higher than suggested by some guidelines and higher than previously published work. The results challenge the current accepted thresholds for practice, and have broader implications for diagnosis and managment of antenatal anaemia.Tweetable abstractFall in haemoglobin across pregnancy is around 14 g/L (11%) and significantly higher than previously stated in the pregnant population. This poses questions over currently accepted thresholds for anaemia in pregnancy.

Vitamin D rise enhances blood perfusion in patients with multiple sclerosis.

The chemical structure of vitamin D resembles steroids and anabolics. Following activation by enzymatic hydroxylation, vitamin D enhances numerous body functions. We determined 25-hydroxy-vitamin D, number of erythrocytes, haematocrit, mean corpuscular haemoglobin and mean corpuscular volume in 97 patients with multiple sclerosis initially and 6 months later. Patients with deficient levels of 25-hydroxyvitamin D (< 30ng/mL) were advised to perform vitamin D supplementation and received a prescription of a vitamin D formulation. Six months later we observed a rise of 25-OH-vitamin D, as to be expected, and a modified constellation of blood parameters such as elevation of mean corpuscular haemoglobin concentration and fall of mean corpuscular volume. Mean corpuscular haemoglobin and number of erythrocytes remained stable. The haematocrit went down. We suggest that vitamin D elevation may be beneficial in disorders characterised by chronic neuroinflammation and neurodegeneration, since changes of blood perfusion parameters may enhance cellular tissue oxygenation.

2036 A Rare Cause of Obscure Gastrointestinal Bleeding

INTRODUCTION: Serrated adenomas are most commonly detected in the colon and characterized by the saw-tooth-shaped infoldings of the mucosa and crypt epithelium. It is a precursor precancerous lesion accounting for 10–30% of all colorectal carcinomas. Serrated adenoma in the small intestine have been reported much less frequently and are localized predominantly in the duodenum, with jejunal adenomas being rarer (&lt; 10 cases). We hereby describe a case of recurrent melena in the setting of a jejunal serrated adenoma. CASE DESCRIPTION/METHODS: A 63-year-old male with a past medical history of CAD, ischemic cardiomyopathy with ejection fraction 10-15%, paroxysmal A Fib, PE on warfarin presented to the hospital in acute decompensated heart failure. After further workup and evaluation, the patient underwent LVAD placement. The hospital course was complicated by respiratory failure requiring intubation and cardiogenic shock requiring inotropes. He then had an episode of melena with a fall in hemoglobin from 9.4 to 7.0 gm/dl on anticoagulation. He underwent push enteroscopy that revealed a pedunculated jejunal polyp with active bleeding noted in the proximal jejunum. This was resected, clipped and the site was tattoed leading to stabilization of his hemoglobin.10 days later the patient had a repeat episode of melena after resumption of anticoagulation. Repeat push enteroscopy showed visible bleeding vessel adjacent to jejunal tattoo treated with epinephrine injection and bicap cautery. The pathology report was consistent with serrated adenomatous polyp of the jejunum. The patient recovered well after the repeat procedure and is doing well after resumption of anticoagulation. DISCUSSION: The small bowel accounts for 75% of the length of the alimentary tract yet small intestinal serrated adenomas are extremely rare. They are challenging to diagnose because of their nonspecific presenting symptoms. Barium GI series or CT scans are not sensitive in detecting lesions smaller than 4 cm. Enteroscopy is an ideal tool in evaluating these cases with obscure GI bleeds. Although the morphology of small bowel serrated adenoma resembles that of traditional adenomas of the colon, the biomolecular alterations and biological behaviors indicate a distinct subtype with more aggressiveness and higher malignant potential. Hence they need therapeutic resection either endoscopically or surgically based on an assessment of their size and location. Given the paucity of data, currently, there is no consensus on surveillance interval.

Hematological Parameters Throughout the First Month of Direct-Acting Antivirus (DAA) Plus Ribavirin for HCV

Abstract Introduction Hematological complications such as neutropenia, thrombocytopenia, and anemia of DAAs/ribavirin in HCV can result in suboptimal outcomes. This study was aimed to investigate the frequency of hematological variations and their impact on the response to DAA therapy. Patients were defined as having hematological abnormalities if they had the presence of either/or a combination of the following hematological parameters at least once during the first month of treatment: drop in (Hb) level, TLC, and PLT count. Pretreatment, Hb, WBC count, and PLT count were not statistically related to the treatment response. However, lower count of all parameters was associated with moderate or advanced hepatic fibrosis stages according to the METAVIR scoring (P &lt; .001). Static analysis showed that drop in Hb, TLC, and PLT count was significantly associated with response to treatment; P &lt; .001, .21, and .41, respectively. Methods Fifty-eight patients for treatment of chronic hepatitis were studied. Their hematological parameters including TLC, Hb, and platelet counts were recorded before starting antiviral therapy and then at 3 monthly intervals. All the patients were given DAAS/ribavirin as antiviral therapy. Data were collected over a period of 3 months. Results Fifty-eight patients with mean (SD) age of 54.38 (12.67) years were studied. There was a mean hemoglobin (Hb) fall of 1.5 g/dL at the first 4 weeks of antiviral therapy. Mean TLC fell to 1.03 × 10⁹/L in the first month. A similar downward trend was noted in platelet values with a mean fall of 12.3 × 10⁹/mm in the first month of the antiviral therapy. Of the cases, 41.4% developed clinically significant anemia as evidenced by hemoglobin 11 g/dL after 4 weeks of antiviral therapy; this fall was noted only in first 4 weeks of treatment. Conclusion Significant hematological abnormalities occurred within the first 4 weeks of antiretroviral therapy. There was significant decrease in hemoglobin level.

Evaluation of tranexamic acid in reducing blood loss and transfusions in total knee replacement

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Total knee replacement (TKR) is associated with substantial blood loss and thus the need for blood transfusions. Risks and costs of allogenic blood transfusions requires strategies to reduce blood loss in surgery. The objective of this study was to assess the efficacy of tranexamic acid treatment in reducing blood loss and blood transfusion requirements during TKR.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A randomized controlled trial was conducted on 60 patients who were operated for unilateral TKR from January 2016 to January 2019 in Shadan Institute of Medical Sciences. 30 patients were in each control and study groups. In study group 12 mg/kg bolus of tranexamic acid was given as a slow IV dose, 40 minutes before deflation of tourniquet followed by 1.2 mg/kg/hr infusion for 12 hours with standard treatment of hospital and compared to the control group. Later blood loss was compared both intra and post operatively. Fall in haemoglobin after surgery was also compared.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Total blood loss in tranexamic acid group was 543.3±184.85&lt;strong&gt; &lt;/strong&gt;ml (control group 685.83±176.74 ml) which is statistically significant (p&amp;lt;0.05). Blood loss was markedly decreased in tranexamic acid group (379.16±174 ml in tranexamic acid vs. 513.33±143.89 ml in control group) statistically significant (p&amp;lt;0.05).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Tranexamic acid is an effective strategy to reduce blood loss in patients undergoing total knee replacement and thus minimizing the need for blood transfusions.&lt;/p&gt;

How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin?

ObjectiveWe aimed to better understand how well postpartum blood loss and common postpartum hemorrhage (PPH) definitions (i.e. blood loss ≥500ml = PPH, ≥1000ml = “severe” PPH) correlate with postpartum anemia and fall in hemoglobin.MethodsSecondary analysis of data from three randomized trials that objectively measured postpartum blood loss and pre- and post-delivery hemoglobin among vaginal deliveries: one trial included 1056 home-births in Pakistan and two multi-country hospital-based trials included 1279 women diagnosed with PPH. We calculated Spearman’s correlation coefficients (rs) for blood loss with hemoglobin drop and postpartum hemoglobin, and we compared PPH blood loss markers (≥500ml, ≥1000ml) with large hemoglobin drops (≥2 g/dL) and the threshold for moderate postpartum anemia (<10g/dL).ResultsIn the Pakistan study and the multi-country trials, blood loss was weakly correlated with hemoglobin drop (Pakistan: rs = -0.220, multi-country trials: rs = -0.271) and postpartum hemoglobin (Pakistan: rs = -0.220, multi-country trials: rs = -0.316). In both the Pakistan and multi-country trials, hemoglobin drop ≥2 g/dL occurred in less than half of women with 500–999 ml blood loss (55/175 [31%] and 302/725 [42%], respectively) and was more common among women who bled ≥1000ml (19/28 [68%] and 347/554 [63%], respectively). Similarly, in the Pakistan and multi-country trials, postpartum anemia <10 g/dL was less frequent among women who bled 500–999 ml (55/175 [31%] and 390/725 [54%], respectively) and more frequent among women with ≥1000ml blood loss (20/28 [71%] and 416/554 [75%], respectively).ConclusionsPostpartum morbidity as measured by hemoglobin markers was common for women with blood loss ≥1000ml and relatively infrequent among women with blood loss 500-999ml. These findings reinforce the importance of severe PPH as the preferred outcome to be used in research. The weak correlation between blood loss and hemoglobin markers also suggests that this relationship is not straightforward and should be carefully interpreted.

The haematological consequences of Plasmodium vivax malaria after chloroquine treatment with and without primaquine: a WorldWide Antimalarial Resistance Network systematic review and individual patient data meta-analysis

BackgroundMalaria causes a reduction in haemoglobin that is compounded by primaquine, particularly in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. The aim of this study was to determine the relative contributions to red cell loss of malaria and primaquine in patients with uncomplicated Plasmodium vivax.MethodsA systematic review identified P. vivax efficacy studies of chloroquine with or without primaquine published between January 2000 and March 2017. Individual patient data were pooled using standardised methodology, and the haematological response versus time was quantified using a multivariable linear mixed effects model with non-linear terms for time. Mean differences in haemoglobin between treatment groups at day of nadir and day 42 were estimated from this model.ResultsIn total, 3421 patients from 29 studies were included: 1692 (49.5%) with normal G6PD status, 1701 (49.7%) with unknown status and 28 (0.8%) deficient or borderline individuals. Of 1975 patients treated with chloroquine alone, the mean haemoglobin fell from 12.22 g/dL [95% CI 11.93, 12.50] on day 0 to a nadir of 11.64 g/dL [11.36, 11.93] on day 2, before rising to 12.88 g/dL [12.60, 13.17] on day 42. In comparison to chloroquine alone, the mean haemoglobin in 1446 patients treated with chloroquine plus primaquine was − 0.13 g/dL [− 0.27, 0.01] lower at day of nadir (p = 0.072), but 0.49 g/dL [0.28, 0.69] higher by day 42 (p < 0.001). On day 42, patients with recurrent parasitaemia had a mean haemoglobin concentration − 0.72 g/dL [− 0.90, − 0.54] lower than patients without recurrence (p < 0.001). Seven days after starting primaquine, G6PD normal patients had a 0.3% (1/389) risk of clinically significant haemolysis (fall in haemoglobin > 25% to < 7 g/dL) and a 1% (4/389) risk of a fall in haemoglobin > 5 g/dL.ConclusionsPrimaquine has the potential to reduce malaria-related anaemia at day 42 and beyond by preventing recurrent parasitaemia. Its widespread implementation will require accurate diagnosis of G6PD deficiency to reduce the risk of drug-induced haemolysis in vulnerable individuals.Trial registrationThis trial was registered with PROSPERO: CRD42016053312. The date of the first registration was 23 December 2016.