Frequency Of Bleeding In Patients Research Articles

Platelet count threshold for hemorrhage in patients with immune thrombocytopenia treated with antiplatelet agents

A significant proportion of older patients with immune thrombocytopenia (ITP) also have clinical indications for treatment of cardiovascular disease with antiplatelet agents. Ollier and colleagues sought to determine the frequency of bleeding in patients with ITP on aspirin therapy, finding that the pattern of bleeding, segregated by platelet count, is similar to that observed in other adults with ITP not on aspirin. They show that a platelet count of <20 × 109/L is associated with most bleeding in ITP patients on antiplatelet agents.

Management of children with hemophilia A on emicizumab who need surgery.

The introduction of emicizumab into the treatment regime of persons with hemophilia A has dramatically reduced frequency of bleeding in patients with and without inhibitors. However, in children with Hemophilia A (CwHA) who require surgical or other invasive procedures, additional treatment with factor replacement or other hemostatic agents may still be needed to prevent intraoperative or postoperative bleeding. This review will look at the reported outcomes in CwHA on emicizumab who have had surgery and propose recommendations for the best perioperative management of major and minor procedures.

Clinical profile and demographic characteristics of moderate and severe hemophilia patients in a tertiary care hospital of Bangladesh

BackgroundHemophilia is one of the commonest inherited bleeding disorders which may lead to chronic bleeding tendencies and life-long disabilities if not properly managed. Knowing the pattern of the disease aids in the prevention of disability and improvement of quality of life in hemophilia. However, there is a dearth of literature on the issue in Bangladesh. So, this study was designed to explore the frequency and site of spontaneous bleeding in moderate and severe hemophilia patients visiting in a tertiary level hospital.MethodsThis descriptive cross-sectional study was conducted at the department of Hematology and Bone Marrow Transplantation (BMT) Center in Dhaka Medical College Hospital, Dhaka between February 2020 and August 2020. A total of 44 diagnosed cases of moderate to severe hemophilia were included in the study according to inclusion criteria. A detailed inquiry of history, thorough physical examination and relevant investigations were done and were recorded in case-record form. Informed written consent was taken from patients or their guardians where appropriate. All procedures were done according to Declaration of Helsinki. After entry and checking, data was analysed using SPSS version 26.ResultsOut of 44 participants, 25 (56.8%) and 19 (43.2%) had moderate and severe hemophilia. Mean age of the study population was 21.31 (± 9.78) years with the majority aged between 11 and 20 years (45.5%). All sociodemographic features were similar across severity. Hemophilia A and B was found in 90.9% and 9.1%, respectively. However, all type B patients severe hemophilia making it statistically significantly different from type A (p = 0.029). The median age of first bleeding was 3.5 years and median age of first diagnosis was 5 years. Nevertheless, approximately 67.4% patients were diagnosed as a case of hemophilia at the time of their first diagnosis. The median spontaneous bleedings episodes among all patients was 32 (range: 0–97) which did not different significantly between severe and moderate patients. The most common affected (target) joint was knee joint (88.6%) followed by elbow joint (64%) among all patients. The knee joint was more commonly involved in severe than moderate disease.ConclusionThis study observed the variations in pattern and frequency of spontaneous bleeding in patients with hemophilia. Severe disease was more frequent in hemophilia B than A and knee joint was the most frequent site of bleeding. However, further extensive studies are recommended.

Impact of Pharmacokinetics to Reduce Bleeding in a Cohort of Patients with Severe Hemophilia A in a Personalized Comprehensive Management Program

In recent decades, hemophilia A treatment has been focused on body weight, without taking pharmacokinetic parameters into account. Previous research has shown that the individual pharmacokinetic response is more effective in predicting the required dose of clotting factor. We want to evaluate the impact on reducing the frequency of bleeding in patients treated with recombinant factor VIII, based on a personalized comprehensive management program. Our aim was to compare the results of a standard comprehensive treatment program (stage I) vs. a personalized pharmacokinetic - based treatment program (stage II) in a cohort of 60 patients with severe hemophilia without inhibitors. The median age was 15.5 years (3-68). The annual bleeding rate (ABR) was 1.03 (62 episodes) in the first stage and 0.58 (35 episodes) in the second one, (p=0.004). By type of bleeding, the impact of the intervention differs significantly in spontaneous bleeding (p=0.007) and a 73% reduction in the first stage. There were no significant differences in traumatic bleeding. The use of pharmacokinetics (PK) for personalized dosing of patients with severe hemophilia A, significantly reduces ABR and spontaneous bleeding, improving the patient’s quality of life and costs for the health system.

Hikoboshi Study: Remaining Burden and Current Medical Care Status of Patients with Congenital Hemophilia a: A Study Using Two Japanese Medical Information Databases

Introduction:FVIII prophylaxis for hemophilia A (HA) has reduced the bleeding frequency in patients and enabled the prevention of hemophilic arthropathy and severe bleeding. However, the treatment/disease burden remains a concern, as evidenced by requiring intravenous injections two/three times a week; regular hospital visits to receive a prescription for medication, as drug delivery is not a provision in Japan; and frequent hospital visits because of complications, like bleeding. Moreover, there is no national patient registry for hemophilia in Japan, and few studies have examined the state of medical care and patient burden due to symptoms and medical practices. Herein, data from medical information databases (DBs) were assessed to investigate the state of medical care and patient burden for HA patients in Japan.Methods:The DBs of health insurance subscribers provided by JMDC Inc. (JMDC-DB) and of electronic medical care records provided by Real World Data Co., Ltd. (RWD-DB) were reviewed. Two DBs were used because the differences between them, such as data source for HA patients, may lead to intergroup differences in the characteristics and traceability of each patient.The targets of analysis were HA patients (ICD-10 code: D66) prescribed FVIII concentrates, emicizumab, or bypassing agents. The definition of targets in this analysis was deemed appropriate in a separate validation study.The occurrence rates of intracranial hemorrhage, ischemic heart disease, hospitalizations, emergency visits, and outpatient visits were calculated to evaluate patient burden. Further, data on the number of hospitals visited and prescribed amounts of FVIII concentrates per month were tabulated and descriptive statistics, applied. Table 1 shows the outcome measures.Results:The number of patients included, based on the target period and inclusion criteria, was 459 from JMDC-DB (January 2005 to March 2020) and 229 from RWD-DB (January 1985 to March 2020). Both DBs had a large proportion of patients aged 0-9 years (23.09% in JMDC-DB and 47.16% in RWD-DB) and a small proportion of patients aged ≥60 years (2.61% in JMDC-DB and 5.68% in RWD-DB).The mean (standard deviation [SD]) and median values for the monthly prescribed amount of FVIII concentrate were 10526.36 IU (11260.42) and 8594.91 IU in JMDC-DB and 12569.11 IU (54846.02) and 1514.35 IU in RWD-DB, respectively. The yearly trends of monthly prescribed amounts of FVIII concentrate for patients in JMDC-DB were analyzed. The median values for every 3 years since 2007 were as follows: 1916.67 IU (2007), 3375.00 IU (2010), 7229.17 IU (2013), 8614.58 IU (2016), and 10000.00 IU (2019), indicating an increasing trend in recent years.The occurrence rates (95% confidence intervals [CIs]) of intracranial hemorrhage, ischemic heart disease, and hospitalizations were 2.61% (1.36-4.52), 0.00%, and 32.68% (28.40-37.18) in JMDC-DB and 4.42% (2.14-7.99), 0.44% (0.01-2.44), and 57.08% (50.35-63.62) in RWD-DB, respectively. The age-stratified occurrence rates (95% CIs) of intracranial hemorrhage in JMDC-DB and RWD-DB were 9.43% (4.62-16.67) for 0-9 years, 1.67% (0.04-8.94) for 40-49 years, and 4.00% (0.10-20.35) for 50-59 years and 3.70% (1.02-9.21) for 0-9 years, 13.04% (2.78-33.59) for 10-19 years, 9.09% (1.12-29.16) for 30-39 years, and 6.67% (0.17-31.95) for 40-49 years, respectively. The overall occurrence rates of intracranial hemorrhage were similar in the two DBs: 2.61% (JMDC-DB) vs. 4.42% (RWD-DB).Additional results of our analysis will be presented at the conference.Conclusions:The prescription of FVIII concentrates for Japanese patients with HA is increasing, probably because FVIII prophylaxis in the clinical setting has become more common. The widespread use of FVIII has many benefits for HA patients. However, there are still treatment burdens that should be considered, such as the need for several drug prescriptions and severe bleeding, such as intracranial hemorrhage. [Display omitted] DisclosuresNagao: CHUGAI PHARMACEUTICAL CO., LTD.: Consultancy, Honoraria, Speakers Bureau; Takeda Pharmaceutical Company Limited.: Honoraria, Research Funding; Bayer Yakuhin, Ltd.: Honoraria, Research Funding; Sanofi K.K.: Honoraria; Fujimoto Pharmaceutical Corporation: Honoraria; KM Biologics Co., Ltd.: Honoraria; Pfizer Japan Inc.: Honoraria; Japan Blood Products Organization: Honoraria; Novo Nordisk Pharma Ltd.: Honoraria; CSL Behring K.K.: Honoraria. Ioka: Chugai Pharmaceutical, Co., Ltd.: Current Employment. Nakamura: Chugai Pharmaceutical Co., Ltd.: Current Employment. Murakami: Chugai Pharmaceutical Co., Ltd.: Current Employment. Makishima: Chugai Pharmaceutical, Co., Ltd.: Current Employment. Okada: Chugai Pharmaceutical Co., Ltd.: Current Employment. Sakai: Bayer Yakuhin, Ltd.: Consultancy, Speakers Bureau; Novo Nordisk Pharma Ltd.: Consultancy, Speakers Bureau; CSL Behring K.K.: Speakers Bureau; Takeda Pharmaceutical Company Limited.: Speakers Bureau; CHUGAI PHARMACEUTICAL CO., LTD.: Speakers Bureau; Sanofi K.K.: Speakers Bureau.

In silico Modeling of the Impact of Antithrombin Lowering on Thrombin Generation in Rare Bleeding Disorders

Introduction: Rare bleeding disorders (RBDs) arise from deficiencies in various clotting factors, such as factors V, VII, and X, which like hemophilia A or B, are often characterized by an inability to generate sufficient thrombin to prevent bleeds. However, compared to hemophilia, RBDs are less prevalent, more heterogeneous in phenotype, and less understood clinically. Furthermore, RBD patients, subsets of whom can suffer from frequent and severe bleeding episodes, often have limited treatment options. Fitusiran is an investigational RNAi therapeutic targeting antithrombin (AT), a major endogenous inhibitor of thrombin production, and is currently in Phase 3 trials for the treatment of hemophilia A or B, with or without inhibitors. Initial clinical studies with fitusiran have demonstrated that lowering AT resulted in improved thrombin generation and was correlated with reduced bleeding frequency in patients with hemophilia (Pasi et al. New Engl J Med . 2017.). Based on this mechanism of action, pharmacological lowering of AT may potentially have clinical applicability in RBDs. In this light, in silico kinetic models that predict the dynamic behavior of coagulation, including thrombin generation in plasma under a diverse set of experimental conditions, can provide a useful theoretical platform to test whether AT lowering may be effective in RBDs. In this abstract, we demonstrate the use of a computational model to predict the impact of AT lowering on thrombin generation in plasma with various degrees of deficiencies in Factors V, VII, and X.Methods: We implemented the model developed by Nayak et al. (Nayak et al. CPT Pharmacometrics Syst. Pharmacol. 2015.), which describes the coagulation cascade and simulates thrombin generation under various experimental conditions, using Matlab and the Simbiology Toolbox®. For each Factor deficiency (V, VII, X), we tested thrombin generation at factor levels of 0.1, 0.5, 1.0, 2.0, 5.0, and 10.0% of their mean plasma concentrations in normal healthy individuals as well as AT lowering of 0, 40, 60, 80, 90, and 99% of baseline levels. Peak thrombin values from each thrombin curve were computed and compared across experimental conditions. Patient heterogeneity was simulated by monte-carlo sampling of plasma factor concentrations based on known mean and variances reported in literature.Results: Consistent with published results in hemophilia A and B, the model predicted an increase in thrombin generation as AT was lowered in the setting of factor V, VII, and X deficiencies. AT lowering to 20% resulted in increased thrombin generation by 14, 4, and 3-fold for conditions of 1% factor V, VII, and X, respectively.Conclusions: Our results suggest that pharmacological AT lowering may serve as an effective strategy for certain RBDs. DisclosuresSridharan:Alnylam: Employment, Equity Ownership. Liu:Alnylam: Employment, Equity Ownership. Qian:Alnylam: Employment, Equity Ownership. Goel:Alnylam: Employment, Equity Ownership. Huang:Alnylam: Employment, Equity Ownership. Akinc:Alnylam: Employment, Equity Ownership.

ASSOCIATION OF VARICEAL BLEED WITH SEVERITY OF LIVER CIRRHOSIS AT A TERTIARY CARE HOSPITAL

Background; A major cause of cirrhosis-related morbidity and mortality is the development of variceal bleeding, a direct consequence of portal hypertension. Each episode of active variceal bleeding is associated with 30 percent mortality. This study was planned to determine frequency of variceal bleeding in patients with liver cirrhosis and frequency of in-hospital mortality of these patients in our population. Objective; To determine the frequency of variceal bleed in hospitalized patients with cirrhosis of liver and its outcome in terms of in-hospital mortality. Material and Methods; Consecutive 139 Patient diagnosed with cirrhosis of liver were included in this cross-sectional study from department of Medicine, Bahawal Victoria hospital Bahawalpur. Complete history and physical examination was assessed to document duration of duration of liver disease, ascites, Hepatic encephalopathy, Previous GI bleed and systemic coagulopathy. All the patients had undergone diagnostic upper GI endoscopic examination to document varices. Results; Of these 139 study cases, 77 (55.4 %) were male and 62 (44.6 %) were female. Mean age of our study cases was 45.50 ± 10.81 years. Mean duration of disease (liver cirrhosis) was 3.25 ± 2.32 years. Majority of our study cases i.e. 94 (67.6%) were having liver cirrhosis for the duration of less than 5 years. Child-Pugh class C was more prevalent i.e. 77 (55.4%) of our study cases. Variceal bleeding was observed in 100 (71.9 %) of our study cases. Frequency of mortality was 35 (25.2%) in our study cases with liver cirrhosis, while frequency of mortality in patients with variceal bleeding was seen in 31 (31%). Variceal bleeding was significantly associated with disease severity (p<0.001). Conclusion; Very high frequency of variceal bleeding was observed in patients with liver cirrhosis. In-hospital mortality was significantly more prevalent in patients with variceal bleeding than without bleed. Variceal bleeding was significantly more seen in patients with increasing age, duration of disease and with more severe level of disease (Child Pugh class C). There was no statistically significant difference of bleeding with regards to gender. Keywords; Liver Cirrhosis, Variceal bleeding, Mortality. DOI : 10.7176/JMPB/62-13 Publication date: December 31 st 2019

DIABETES AS A PREDICTOR OF MORTALITY IN CIRRHOTIC PATIENTS PRESENTING WITH VARICEAL BLEED

Background; A major cause of cirrhosis-related morbidity and mortality is the development of variceal bleeding, a direct consequence of portal hypertension. Each episode of active variceal bleeding is associated with 30 percent mortality. This study was planned to determine frequency of variceal bleeding in patients with liver cirrhosis and frequency of in-hospital mortality of these patients in our population. Objective; To determine association of diabetes with mortality in patients with liver cirrhosis presenting with of variceal bleed. Material and Methods; Consecutive 139 Patient diagnosed with cirrhosis of liver were included in this cross-sectional study from department of Medicine, Nishtar hospital Multan. Complete history and physical examination was assessed to document duration of duration of liver disease, ascites, Hepatic encephalopathy, Previous GI bleed and systemic coagulopathy. All the patients had undergone diagnostic upper GI endoscopic examination to document varices. Results; Of these 139 study cases, 77 (55.4 %) were male and 62 (44.6 %) were female. Mean age of our study cases was 45.50 ± 10.81 years. Mean duration of disease (liver cirrhosis) was 3.25 ± 2.32 years. Majority of our study cases i.e. 94 (67.6%) were having liver cirrhosis for the duration of less than 5 years. Child-Pugh class C was more prevalent i.e. 77 (55.4%) of our study cases. Variceal bleeding was observed in 100 (71.9 %) of our study cases. Frequency of diabetes in cirrhotic patients with variceal bleed was 47 (33.81%) and mortality in these diabetics was 26 (55.31%) (p = 0.001). Conclusion; Diabetes was found to be significantly associated with mortality in cirrhotic patients presenting with variceal bleeding. Healthcare professionals should anticipate adverse outcomes in diabetic patients of liver cirrhosis presenting with variceal bleeding and should educate them regarding glycemic control at early stages of diagnosis. Keywords; Liver Cirrhosis, Variceal bleeding, Mortality. DOI : 10.7176/JMPB/58-01 Publication date : August 31 st 2019

Bleeding risk of surgery and its prevention in patients with inherited platelet disorders.

Excessive bleeding at surgery is a feared complication in patients with inherited platelet disorders. However, very few studies have evaluated the frequency of surgical bleeding in these hemorrhagic disorders. We performed a worldwide, multicentric, retrospective study to assess the bleeding complications of surgery, the preventive and therapeutic approaches adopted, and their efficacy in patients with inherited platelet disorders: the Surgery in Platelet disorders And Therapeutic Approach (SPATA) study. We rated the outcome of 829 surgical procedures carried out in 423 patients with well-defined forms of inherited platelet disorders: 238 inherited platelet function disorders and 185 inherited platelet number disorders. Frequency of surgical bleeding was high in patients with inherited platelet disorders (19.7%), with a significantly higher bleeding incidence in inherited platelet function disorders (24.8%) than in inherited platelet number disorders (13.4%). The frequency of bleeding varied according to the type of inherited platelet disorder, with biallelic Bernard Soulier syndrome having the highest occurrence (44.4%). Frequency of bleeding was predicted by a pre-operative World Health Organization bleeding score of 2 or higher. Some types of surgery were associated with a higher bleeding incidence, like cardiovascular and urological surgery. The use of pre-operative pro-hemostatic treatments was associated with a lower bleeding frequency in patients with inherited platelet function disorders but not in inherited platelet number disorders. Desmopressin, alone or with antifibrinolytic agents, was the preventive treatment associated with the lowest bleedings. Platelet transfusions were used more frequently in patients at higher bleeding risk. Surgical bleeding risk in inherited platelet disorders is substantial, especially in inherited platelet function disorders, and bleeding history, type of disorder, type of surgery and female sex are associated with higher bleeding frequency. Prophylactic pre-operative pro-hemostatic treatments appear to be required and are associated with a lower bleeding incidence.

Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Patients on Antiplatelet Agents

Purpose: PEG tube placement is a common endoscopic procedure. A number of patients requiring PEG tubes are on antiplatelet agents. Little data exist that address the risk of post operative bleeding when PEG is performed with the patient still on antiplatelet agents. Aim: To determine the frequency of bleeding in patients taking Aspirin, Clopidogrel or both while having PEG tube placement and if this was affected by the number of days these agents were held prior to the procedure. Methods: We performed a retrospective review of 537 patients who had PEG tubes placed from1999–2007. Exclusion criteria included use of anticoagulants, an INR > 1.7, intubated patients, platelet count <50,000/μL, and incomplete documentation. Bleeding criteria was defined as hemoglobin drop >2 gm/dl, melena or hematochezia within 48 hrs of the procedure, the need for infusion of blood products or repeat endoscopy and readmission within one week of discharge for any GI bleeding. Patients divided in two groups. Group A (Aspirin, Clopidogrel or both within 5 days of the procedure): Group B (controls not on antiplatelet agents). History of PPI/H2 blocker, NSAIDS, SSRI's or Steroid use and previous ulcer disease were recorded. Results: 214 (64.8%) patients were included in Group A (Ages 27–98, median 79), and 116 (35.1%) were in Group B (Ages 22–100, median 78); 207 patients were excluded due to improper documentation. Bleeding was seen in 11 (5.1%) patients in Group A: 2 out of 85 patients on Aspirin alone and 2 out of 46 patients on Clopidogrel alone. (P= 0.215 and 0.140 respectively compared to controls); 7 out of 72 (10%) on Aspiring/Clopidogrel bled (P= 0.01 vs. controls). In Group B, 3 (2.6%) patients bled. Among bleeding patients, 2 were on Aspirin alone also on a NSAID and steroid; In the Clopidogrel alone group 2 patients were on NSAID and SSRI at the time of procedure. Bleeding patients were managed by stopping the respective drug/s, blood transfusion (required in 1 patient, 1 units of PRBC). No patient needed repeat endoscopy and there were no mortalities. Most patients in Group A stopped taking the antiplatelet agents 2–3 days prior to the procedure. All episodes of bleeding occurred if PEG placed between days 0–3 of stopping meds. No patients taking a PPI in this study bled. Conclusion: The combination of ASA and Clopidogrel increases the risk of post PEG bleeding especially when patients are on concomitant use of SSRI's, NSAIDS and steroids 2) Aspirin or Clopidogrel does not appear to significantly increase the risk of bleeding in patients undergoing PEG procedure. 3) Though bleeding appears to be minor, elective PEG should not be performed in patients on more than one antiplatelet agent.

A Relatively Low Frequency of Bleeding in Patients with Severe Factor XI Deficiency Who Undergo Surgery Involving Tissues with Low Fibrinolytic Activity Supports on Demand Rather Than Prophylactic Use of Plasma.

Severe factor XI (FXI) deficiency is an injury related bleeding tendency. Fresh frozen plasma (FFP) or FXI concentrate are usually used for achieving hemostasis in such patients undergoing surgery but this can lead to inhibitor formation in 33% of patients with FXI level <1 U/dL (Blood 101:4783, 2002). Based on observations in a limited number of patients with severe FXI deficiency, we previously suggested that surgery at tissues with known fibrinolytic activity is accompanied by bleeding more frequently than in other sites (NEJM 325:153, 1991). In this study we retrospectively assessed the frequency of post surgical bleeding in 165 unrelated patients with severe FXI deficiency who were not treated by hemostatic means. Criteria for bleeding included local hematoma, need for surgical arrest of bleeding, or use of blood components. Bleeding occurred in 7/57 (12.3%) patients operated at tisues with low fibrinolytic activity, and in 29/48 (60.4%) patients operated at fibrinolytic sites (Table). Bleeding following circumcision (a non-fibrinolytic site) was accompanied by bleeding only in 1/64 (1.6%) and following oral surgery in 55/110 patients (50%). The relatively low frequency of bleeding following surgery at non-fibrinolytic sites advocates on demand rather than prophylactic replacement therapy when such surgery is performed.SITE OF SURGERYNBLEEDERS% BLEEDERSNon-fibrinolyticAppendicectomy2211.6Gastric300Cholecystectomy5120Herniotomy13323Hysterectomy5240Orthopedic900FibrinolyticTonsillectomy332060.6Nose12758.3Prostatectomy3266.6Circumcision6411.6OralTooth extractions1004949Gum10660

Severe Hemophilia and Physiologic Inhibitors of Coagulation

Patients with hemophilia demonstrate quite variable clinical phenotype even in cases with the same level of deficient factor or the same molecular abnormality. Different interacting factors including congenital and acquired alterations of coagulation inhibitors can modulate both clinical expression and severity of hemophilia. In this study, plasma levels of factor VIII (FVIII), factor IX (FIX) as well as protein C (PC), protein S (PS), and antithrombin (AT) plasma levels were measured in 80 patients with severe hemophilia A and B. Patients were divided into two groups according to the risk of bleeding: the first group (n = 32) with mild bleeding (< 2 bleeds/year), and the second group (n = 48) with severe bleeding (> or = 2 bleeds/year). Both hemophilia groups showed significantly decreased PC plasma levels compared to levels in healthy control subjects (the first group: p < 0.0001 and second group: p < 0.01). The difference in PC plasma levels between the first and second hemophilia group was significant (p < 0.05). Moreover, there was positive correlation between age and the functional PC in both hemophilia groups. Our results suggest that decreased PC plasma levels can testify to a slightly protective effect of the PC pathway on the severity and frequency of bleeding in patients with severe hemophilia A and B.

Comfort and bleeding after percutaneous transluminal coronary angioplasty: comparison of a flexible sheath and a standard sheath

Patients often have discomfort, especially back pain, after percutaneous transluminal coronary angioplasty because they must stay relatively flat while the sheath remains in the femoral vessel after the procedure. Flexible sheaths are now available, allowing the head of the bed to be raised to 60 degrees during this period of bed rest. We assessed comfort and the frequency of bleeding in patients who had undergone percutaneous transluminal coronary angioplasty and compared the findings between patients with a flexible sheath and patients with a standard sheath. Patients were randomly assigned either a flexible sheath or a standard sheath during percutaneous transluminal coronary angioplasty. Patients' comfort was assessed by administering a comfort questionnaire at two intervals after the procedure, and the frequency of bleeding was determined by reviewing the patients' charts. One hundred seven patients completed the questionnaire. The patients with a flexible sheath showed a significantly higher level of comfort than the patients with a standard sheath 5 hours after the procedure. Patients with a flexible sheath also received less pain medication than did patients with a standard sheath. The frequency of bleeding was comparable in both groups. Results of this study support the use of a flexible sheath to increase patients' comfort after percutaneous transluminal coronary angioplasty without increasing the frequency of bleeding.

Heparin Treatment of Deep Venous Thrombosis in 280 Patients: Symptoms Related to Dosage

280 patients with phlebographically proven deep venous thrombosis received intravenous heparin infusion, mean duration 6.8 days, mean dose 370 U/kg/day. In 58 patients (21%) there was no apparent predisposing factor. Leg pain diminished more rapidly than edema. At discharge, 46% had edema. Symptoms suggesting pulmonary embolism (PE) occurred in 13 patients (4.6%) whose mean daily heparin dose was similar to that of the others. The only fatal PE occurred three days after cessation of heparin administration. Eight patients (3%) experienced major bleeding, the only fatal occurring after thoracocentesis. The frequency of major bleeding in patients above 70 years was 8% in females and 4% in males, in those below 70 years it was 0.5%; 22 patients (8%) had minor bleeding. Control phlebography after one week revealed completely cleared thrombus in 3%, partial clearance in 36%, unchanged in 39% and increased thrombosis in 22%. Dosage was significantly correlated to thrombus resolution.

Frequency of Heavy Menstrual Bleeding in Patients with Uterine Fibroids

Background: Uterine fibroids are the most common form of benign uterine tumors and cause severe menstrual bleeding pelvic pain, infertility, and pressure. Almost one-third of women with uterine fibroids seek treatment. Objective: To determine the frequency of heavy menstrual bleeding in patients presenting with uterine fibroids. Material and Methods: This cross sectional descriptive study was conducted in DHQ Hospital Timergara for six months, a total of 147 females presenting with uterine fibroids fulfilling the inclusion criteria were selected through a consecutive sampling technique. All the patients were subjected to ultrasound examination.Results: The mean age recorded was 30.45±7.9. 37 (25.2%) patients were in the age group of 18 to 24 years, 51 (34.7%) patients were in the age group of 25 to 34 years and 59 (40.1%) patients were in the age group of 35 to 45 years. Frequency of HMB was 31.3%.Conclusion: There was a high prevalence of heavy menstrual bleeding in patients presenting with uterine fibroids.Keywords: Heavy Menstrual Bleeding; Uterine Fibroids