Hemostatic Research Articles

The effectiveness of antifibrinolytic drugs as anti-Haemorrhage treatment for patients with anticoagulant during tooth extraction procedure: A review

Significant increases in major bleeding have been reported in patients receiving antithrombotic therapy who are undergoing dental extractions. To manage this risk, local hemostatic agents are commonly used, either to enhance the blood's natural clotting process or to mechanically limit external bleeding. These agents work by reducing the proteolytic activity of plasminogen activators, which prevents the formation of plasmin and inhibits clot dissolution. Among the various local hemostatic agents available, such as gelatin sponge, collagen sponge, oxidized cellulose, fibrin sealant, and tannic acid, tranexamic acid (TA) is the most frequently utilized. TA is widely employed both topically and as a mouthwash due to its proven efficacy in controlling bleeding. It can be administered in various forms, including as a dressing with gauze, local irrigation (250 mg/5mL solution), or as an oral suspension using crushed tablets (250 mg) mixed with saline or local anesthetic. Furthermore, it can be applied directly to the wound site for localized effect. The most common and effective approach involves using TA as a mouthwash before the extraction and continuing its application for 3-7 days post-extraction to minimize bleeding risk and promote hemostasis. The findings suggest that the localized application of antifibrinolytic agents can play a crucial role in ensuring safe dental extractions for anticoagulated patients.

Use of Ultra-Hydrophilic Absorbable Polysaccharide for Bleeding Control in Cardiothoracic Surgical Procedures

Background and Objectives: Operative blood loss is strongly correlated with morbidity and mortality in surgery. Various hemostatic agents are used to reduce bleeding in cardiothoracic procedures. We report our experience with a plant-based microporous polysaccharide hemostatic powder (Starsil® Hemostat, Hemostat Medical GmbH, Velen, Germany). Materials and Methods: Data were collected retrospectively from 65 patients who underwent cardiac surgery at our institution from January 2012 to January 2015 with (n = 42) or without (n = 23; control group) the use of the hemostat powder. Primary endpoints were safety (e.g., laboratory parameters, adverse events, and infection parameters) and time to hemostasis when the hemostat powder was used. Other endpoints included operation time, hospitalization, quantity of the hemostat powder applied, and length of stay in the intensive care unit. Results: The 65 patients (49 male:16 female) analyzed in the study underwent 65 cardiothoracic procedures, including off-pump coronary artery bypass grafts (n = 25), on-pump coronary artery bypass grafts (n = 6), valve procedures (n = 6), valve procedures in combination with bypass grafts (n = 7), and others (n = 21). The application of the hemostat powder did not increase adverse events. The laboratory parameters did not exceed the expected range after heart surgery in both groups. The hemostat powder had no significant impact on the laboratory parameters compared to the control group. Blood control was sufficient and was rated by surgeons from good to very good on a visual analog scale (VAS) from 1 (very bad) to 10 (very good) [VAS = 8.3 ± 1.2]. Intraoperative hemostasis was possible in nearly all patients. The hemostat powder led to satisfactory bleeding control within 2 min in 88% of cases. Five patients needed a second 5 g unit of the hemostat powder. Conclusions: The observed parameters between groups did not differ significantly. Therefore, the use of Starsil® Hemostat in cardiothoracic surgery is safe and effective bleeding control was achieved.

The impact of absorbable hemostatic agents on wound healing in an experimental penile fracture rat model

ObjectiveThis study aimed to evaluate the effects of two absorbable hemostatic agents, oxidized regenerated cellulose (ORC) and gelatin sponge, on wound healing in a rat model of penile fracture.Materials and methodsA total of 32 Wistar albino rats were divided into four groups: Control (C), Primary Suturing (PS), ORC, and Gelatin Sponge (GS). A penile fracture model was created in all rats, and wound healing was assessed histopathologically after two weeks. Key parameters assessed included primary healing, fibrosis, inflammation, and cavernous tissue healing.ResultsThe ORC group showed significantly higher primary healing rates (100%) compared to the other groups (p < 0.01). Fibrosis was more common in the GS group (87.5%), whereas no fibrosis was observed in the ORC group (p < 0.01). In terms of cavernous tissue healing, the group treated with the ORC absorbable hemostatic agent demonstrated significantly higher healing rates compared to the control group (p = 0.000). No significant differences were observed between groups regarding inflammation.ConclusionORC absorbable hemostatic agents significantly promote primary wound healing and reduce fibrosis in an experimental penile fracture model, whereas the gelatin sponge was associated with increased fibrosis and did not improve healing. These findings suggest that ORC may have potential clinical applications in penile fracture repair. Further clinical studies are necessary to validate these results.

Brain-derived textiloma post glioblastoma resection and application of oxidized regenerated cellulose: A pilot, bedside-to-bench, translational study.

Oxidized regenerated cellulose (ORC; marketed as Surgicel® and Tabotamp®) is routinely used as an intraoperative hemostatic agent. Rarely, residual ORC has been associated with a foreign body reaction generating cystic or granulomatous lesions (i.e., textilomas) at the surgical site. Here, we report a bedside-to-bench, translational report of an intracranial mass after neurosurgical resection of glioblastoma with ORC application. As part of patient care, we performed magnetic resonance imaging and histopathological analysis of the mass. We then performed in vitro studies to evaluate the effect of ORC on cytokine production and viability of BV-2 murine microglial cells by using quantitative PCR along with live cell microscopy and crystal violet staining, respectively. Magnetic resonance imaging demonstrated a recurrent mass pressing on the adjacent right ventricle, which was removed in a second surgery for diagnostic and therapeutic purposes. Unexpectedly, histopathological examination of the resected mass revealed abundant ORC arising from the site with inflammation, microglial activation, and collagenization. Mechanistically, we show an ORC-induced modest increase in inflammatory cytokines with a subsequent decrease in microglial cell viability. These findings suggest that ORC may mediate microglial immune response and viability, and serve to raise awareness and guide interpretation of post-treatment surveillance imaging findings in the instance of foreign body reaction.

Retrograde thrombosis of the superficial sylvian vein following liquid adhesive hemostat use during craniotomy: illustrative case.

Intravascular injection of liquid adhesive hemostats is a rare but serious complication that can result in cerebral thromboembolism. A 64-year-old female underwent orbitozygomatic craniotomy for posterior communicating artery aneurysm clipping with the routine use of a flowable hemostatic agent during extradural dissection. After placement of the aneurysm clip, flow was confirmed through the parent vessel and nearby branches. On postoperative day 1, the patient was found to have superficial middle cerebral vein thrombosis with retrograde embolization and subsequent hemorrhagic infarction of the temporal lobe. Eight prior cases of intracranial infarction or hemorrhage secondary to thrombosis with intravascular liquid adhesive were identified. With a craniotomy approach, the transverse and sigmoid sinuses were the most common sites of thrombosis, and the vertebral and basilar arteries had the highest incidence of thrombosis after cervical fusion. Intravascular injection of liquid adhesive agents can result in cerebral venous thrombosis, typically of a dural venous sinus. This may present following retrograde embolization, which has not previously been reported. The choice of hemostat, surgical approach, nearby vasculature, and anatomical variations should be carefully considered in the operative management of neurosurgical patients. https://thejns.org/doi/10.3171/CASE24607.

Drug delivery strategy of hemostatic drugs for intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is associated with high rates of mortality and disability, underscoring an urgent need for effective therapeutic interventions. The clinical prognosis of ICH remains limited, primarily due to the absence of targeted, precise therapeutic options. Advances in novel drug delivery platforms, including nanotechnology, gel-based systems, and exosome-mediated therapies, have shown potential in enhancing ICH management. This review delves into the pathophysiological mechanisms of ICH and provides a thorough analysis of existing treatment strategies, with an emphasis on innovative drug delivery approaches designed to address critical pathological pathways. We assess the benefits and limitations of these therapies, offering insights into future directions in ICH research and highlighting the transformative potential of next-generation drug delivery systems in improving patient outcomes.

Development of a 50% (w/v) aluminium chloride hexahydrate solution as haemostatic agent

ObjectivesAcceleration of the haemostasis process after dermatological surgery predominantly relies on mechanical methods, such as the use of sutures or staples. To our knowledge, there is currently no commercialised haemostatic...

Red cell microparticles produced using high-pressure extrusion enhance both primary and secondary hemostasis.

Current therapies to treat excessive bleeding are associated with significant complications, which may outweigh their benefits. Red blood cell-derived microparticles (RMPs) are a promising hemostatic agent. Previous studies demonstrated that they reduce bleeding in animal models, correct coagulation defects in patient blood, and have an excellent safety profile. However, their exact mechanism of action is not known. We investigated the potential role of RMPs on primary and secondary hemostasis. To evaluate the effects of RMPs, prepared using high-pressure extrusion, on primary hemostasis, we employed platelet aggregometry with platelet inhibitors, eptifibatide, and ticagrelor, with and without RMPs. To evaluate their effects on secondary hemostasis, we employed thromboelastography with plasma deficient in factors VII, VIII, IX, XI, and XII with and without RMPs. We found that RMPs significantly increased collagen-induced platelet aggregation. However, there were no significant differences with and without RMP in the presence of the platelet inhibitors, indicating that RMPs may work through these receptors, either directly or indirectly. For secondary hemostasis, RMPs significantly decreased clotting times for plasma deficient in factors VII, VIII, IX, and XI but not in XII. Our results indicate that RMPs enhance primary hemostasis and both pathways of secondary hemostasis.

Hemostatic effect of oxidized regenerated cellulose vs. topical tranexamic acid in total knee arthroplasty-a prospective randomized controlled trial.

This study compared the hemostatic effects and complications of oxidized regenerated cellulose (ORC) and topical TXA in total knee arthroplasty (TKA), thus providing a reference for the use of ORC as an alternative hemostatic agent to TXA in TKA. A total of 105 patients were included in this study and randomized into blank control, ORC, and TXA groups. The primary outcomes were total blood loss, hemoglobin drop (Hb drop), transfusion rates, and incidence of thrombosis. The secondary outcomes included operation time, tourniquet duration, coagulation parameters, inflammation markers, and complication rates. Total blood loss was 1,002.47 ± 308.58 ml and 964.68 ± 273.00 ml in the ORC and TXA groups, respectively, both significantly lower than that in the blank control group (1,168.94 ± 405.04 ml) (P 1 = 0.043 and P 2 = 0.014, respectively). Hb Drop was statistically insignificantly different between the ORC (36.03 ± 12.17 g/L) and TXA (34.32 ± 10.19 g/L) groups (P = 0.555). There was no statistically significant difference in transfusion rate, operation time, tourniquet duration, coagulation parameters, inflammation markers, and complication rates among the three groups. In conclusion, our prospective randomized controlled trial (RCT) highlights that, oxidized regenerated cellulose (ORC) can reduce postoperative invisible blood loss in total knee arthroplasty and achieve a hemostatic effect similar to topical tranexamic acid (TXA). This provides a safe and effective hemostatic option for patients with severe underlying diseases or contraindications to tranexamic acid. https://www.chictr.org.cn/bin/project/edit?pid=186370, identifier (ChiCTR2200066633).

Zinc oxide nanoparticle-embedded tannic acid/chitosan-based sponge: A highly absorbent hemostatic agent with enhanced antimicrobial activity.

This study reports the development of a highly absorbent Chitosan (CS)/Tannic Acid (TA) sponge, synthesized via chemical cross-linking with Epichlorohydrin (ECH) and integrated with zinc oxide nanoparticles (ZnO NPs) as a novel hemostatic anti-infection agent. The chemical properties of the sponges were characterized using Fourier-transform infrared spectroscopy (FT-IR), X-ray diffraction (XRD), thermogravimetric analysis (TGA), and zeta potential measurements. Morphological and elemental analyses conducted through scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDAX) revealed a uniform distribution of ZnO NPs, with particle sizes below 20 nm. Compression tests indicated that the incorporation of ECH enhanced the compressive strength of the TA/CS sample, increasing from 0.614 MPa to 1.03 MPa for TA/CS-ECH and 1.16 MPa for ZnO@TA/CS-ECH, while preserving its flexibility. ZnO@TA/CS-ECH sponges exhibited high swelling ratios, consistent with their mesoporous structure revealed by porosity analysis. MTT assays confirmed that the addition of ECH did not adversely affect the biocompatibility of the final ZnO@TA/CS-ECH sample. Hemostatic performance was assessed through prothrombin time (PT), activated partial thromboplastin time (aPTT), blood clotting index (BCI), blood clotting time (BCT) assays, and platelet adhesion imaging. ZnO@TA/CS-ECH significantly reduced the BCT of untreated blood from 349 to 49 s, outperforming Celox™ (182 s). This performance was further confirmed using a rat liver hemostatic model. Moreover, ZnO@TA/CS-ECH demonstrated substantial antimicrobial activity against E. coli, S. aureus, and C. albicans, comparable to standard antibiotics and antifungals. These findings suggest that the three-dimensional ZnO@TA/CS-ECH sponge holds promise in managing infected bleeding and inspiring the next-generation of hemostatic agents.

Implementation of a Cost and Variation Reduction Program for Hemostasis Products at a Large Academic Medical Center: A Multi-Stakeholder Perspective.

Cost-saving initiatives targeting surgical supplies management have become increasingly common to address rising healthcare costs. However, few studies provide details on hospital stakeholder experiences or learnings from implementing such initiatives. Thus, we sought to evaluate hospital stakeholder satisfaction with conversion to a sole supplier for hemostasis products, in addition to economic and clinical impacts, to help develop best practices for implementation. This cross-sectional study assessed satisfaction with converting to a sole supplier for hemostasis products at a large US academic medical center using qualitative interviews and quantitative surveys with clinical and non-clinical stakeholders, on the decision-making process, conversion, and vendor-supported hemostasis optimization program (HOP) post-implementation (February 2022-May 2022). Perioperative hemorrhage events, adjunctive hemostat utilization, and total annual hospital expenditure on hemostatic products were also evaluated pre- and post-conversion (2020-2022) to identify impacts on clinical and economic outcomes. Ten hospital stakeholders completed qualitative interviews (n = 7 surgeons, n = 2 surgical technicians, n = 1 administrator) and 22 completed quantitative surveys (n = 6 surgeons, n = 5 surgical technicians, n = 11 nurses). Survey respondents noted overall satisfaction with conversion, including the level of input they provided in the decision-making process (75% were somewhat to extremely satisfied), availability of hemostatic agents during the conversion process (87%), and the vendor-supported HOP (100%). The outcomes analyses revealed a nearly 25% decrease in supply expenditure without changes to the number of postoperative hemorrhage events following implementation. Converting to a sole vendor for hemostasis products was achieved with high satisfaction among hospital stakeholders and cost savings to the institution without impacting the quality of patient care. This study provides a roadmap of best practices for other institutions interested in implementing similar initiatives and presents an example of a successful transition to a sole vendor for hemostasis products driven by effective supplier, institution, and hospital stakeholder coordination.

5 The impact of haemostatic agent used during robot assisted radical prostatectomy on post-op infection and anastomotic leak

5 The impact of haemostatic agent used during robot assisted radical prostatectomy on post-op infection and anastomotic leak

Co-assembled biomimetic fibrils from collagen and chitosan for performance-enhancing hemostatic dressing.

The development of safe and efficient hemostatic materials is medically important to prevent death due to trauma bleeding. Exploiting the synergistic effect between the D-periodic functional domain of collagen fibrils on platelet activation and cationic chitosan on erythrocyte aggregation is expected to develop performance-enhanced hemostatic materials. In this study, we prepared collagen fibrils and chitosan composite hemostatic materials by modulating the self-assembled bionic fibrillation of collagen with different degrees of deacetylation (DD, 50%, 70% and 85%) of chitosan. The findings indicated that chitosan promoted collagen self-assembly, with all the collagen fibrils demonstrating a typical D-periodical structure similar to that of the native collagen. Furthermore, the composite demonstrated enhanced structural integrity and procoagulant capacity along with good biocompatibility. Notably, the fibrillar composites with 70% DD of chitosan exhibited optimal mechanical properties, procoagulant activity, and adhesion of erythrocytes and platelets. Compared to pure collagen fibrils and the commercial hemostatic agent Celox™, the collagen/chitosan fibrillar composite treatment significantly accelerated hemostasis in the rat tail amputation model and liver injury model. This research offers new insights into the development of hemostatic materials and indicates that collagen-chitosan composites hold promising potential for clinical applications.

How I Approach It: Topical Hemostatic Agents.

How I Approach It: Topical Hemostatic Agents.

Absorbable Powder Haemostat Use in Minimally Invasive Thoracic Surgery.

Background: Significant intraoperative and postoperative blood loss are rare but possibly life-threatening complications after lung resection surgery either during open or minimally invasive procedures. Microporous Polysaccharide Haemospheres (ARISTA™AH) have demonstrated time-efficient haemostasis, lower postoperative blood volumes and a lower blood transfusion requirement, without any identified adverse events across other specialities. The primary aim of our study was to evaluate the impact of ARISTA™AH on short-term postoperative outcomes in thoracic surgery. Our secondary aim was to compare ARISTA™AH with other commonly used haemostatic agents. Methods: We retrospectively reviewed a prospectively collected database of consecutive early-stage lung cancer patients surgically treated in two European centres (October 2020-December 2022). Exclusion criteria included open surgery, patients with coagulopathy/anticoagulant medication, major intraoperative bleeding, non-anatomical lung resection and age <18 years. The cohort was divided into five groups according to the haemostatic agent that was used. Propensity score matching was used to estimate the effect of ARISTA™AH on various intra- and postoperative parameters (continuous and binary outcome modelling). Results: A total of 482 patients (M/F:223/259; VATS 97/RATS 385) with a mean age of 68.9 (±10.6) years were analysed. In 253 cases, ARISTA™AH was intraoperatively used to control bleeding. This cohort of patients had a significant reduction in total drain volume by 135 mls (standard error 53.9; p = 0.012). The use of ARISTA™AH did reduce the average length of a hospital stay (-1.47 days) and the duration of chest drainage (-0.596 days), albeit not significantly. In the ARISTA™AH group, we observed no postoperative bleeding, no blood transfusion requirement, no 30-day mortality and no requirement for redo surgery. The use of ARISTA™AH significantly reduced the odds of postoperative complications, as well as the need for transfusion and redo surgery. Conclusions: Our data showed that Microporous Polysaccharide Haemospheres are a safe and effective haemostatic device. Their use has a positive effect on the short-term postoperative outcomes of patients surgically treated for early-stage lung cancer.

Assessment of Oral Anticoagulant Reversal Strategies in Emergency Surgery: Insights from a Prospective Study

Introduction: The management of thrombotic risk in clinical medicine has been a longstanding challenge. Oral anticoagulants, specifically vitamin K antagonists (VKAs) like warfarin, have been used for over fifty years. However, VKAs present significant challenges such as frequent monitoring and dietary interactions. Direct oral anticoagulants (DOACs) were developed to address these limitations, offering simplified dosing and fewer interactions. Both VKAs and DOACs, however, pose challenges in managing major bleeding and urgent surgical interventions. Methods: This prospective study, conducted at Mohammed V Military Hospital in Rabat from January 2022 to January 2023, examined the clinical practice, efficacy, and safety of different treatment strategies in patients on oral anticoagulants (VKAs and DOACs) requiring emergency surgery within 24 hours of hospital admission. Inclusion criteria included being over 18 years of age, on anticoagulant therapy, and requiring emergency surgery. Patients were evaluated for bleeding before and after surgery, use of hemostatic agents, blood loss, transfusions, and adverse events. Results: A total of 69 patients were included, with 48 treated with VKAs and 21 with DOACs. The mean age was 63.8 years (range 36-78), with a mean age of 62.5 years (±10.2) for the VKA group and 66.7 years (±9.1) for the DOAC group (p = 0.44). There was no significant difference in delays to surgery between the VKA (68%) and DOAC (66.6%) groups for surgeries performed within 24 hours. Hemostatic treatment varied significantly, with more VKA patients receiving resh frozen plasma (77% vs. 52%) and more DOAC patients receiving prothrombin complex concentrates (48% vs. 23%). Bleeding complications were observed in 12.5% of VKA patients and 9.5% of DOAC patients. Thromboembolic events were observed in one patient within 30 days, specifically, a pulmonary embolism occurring on day 3 in a patient who underwent surgery for a hip fracture. The mortality rate ...

Comparative analysis of the hemostatic effect of systemic recombinant Factor VIIa and exogenous fibrin monomer in an experimental model of heparinization and posttraumatic blood loss

This article presents the results of a study of the systemic hemostatic action of recombinant Factor VIIa in a rabbit model of heparin-induced coagulopathy and posttraumatic bleeding, compared to the administration of exogenous fibrin monomer. The coagulopathy was induced by a single intravenous injection of unfractionated heparin at a dose of 150 IU/kg 15 minutes before injury. Recombinant Factor VIIa (270 μg/kg) or fibrin monomer (0.25 mg/kg) was used as systemic hemostatic agents. One hour after administrating the agents, a standardized liver injury was inflicted, followed by an assessment of blood loss characteristics. Using rotational thromboelastometry and coagulation tests, animal venous blood was analyzed for coagulation time, alpha angle, clot formation time, maximum clot firmness, clot density at 10 minutes, activated partial thromboplastin time, prothrombin time, thrombin time, and fibrinogen concentration. Pharmacologically induced coagulopathy resulted in shifts to a hypocoagulable profile, associated with severe blood loss (1.9 times, p = 0.028) and high animal mortality (26.1%, p = 0.022) compared to the control group. Preventive administration of fibrin monomer or recombinant Factor VIIa reduced posttraumatic blood loss (by 5.4 times, p 0.001, and by 2.1 times, p = 0.009, respectively), resulting in a decrease in mortality rates. However, the administration of these agents did not correct the hypocoagulable profile as observed in thromboelastometry and coagulation tests. These data demonstrate the hemostatic effect of both agents, with a more pronounced effect after fibrin monomer administration, and suggest potential use of low doses of fibrin monomer in trauma-related hemorrhage. The mechanism of action of fibrin monomer requires further investigation. Therefore, fibrin monomer, a fibrinogen derivative obtained from blood plasma, could be a valuable candidate for managing wound bleeding in addition to recommended systemic hemostatics.

Hemorrhage risk after coblation tonsillectomy in Chinese pediatric: a multicenter, prospective, observational cohort study.

The study aimed to assess the incidence of post-coblation tonsillectomy hemorrhage (PCTH) and identify associated risk factors in a pediatric Chinese population. This prospective, multicenter cohort study, conducted over 17 months, included 8854 pediatric patients who underwent coblation tonsillectomy across 15 research centers in China. Patient data were collected through an Electronic Data Capture (EDC) system. The primary outcome was the incidence of PCTH within 21 days post-surgery. Secondary outcomes involved analyzing risk factors for PCTH using multivariable logistic regression. The incidence of PCTH was 1.99%, with 176 patients experiencing hemorrhage. Significant risk factors included abnormal coagulation indicators (OR 10.56), longer surgery duration (OR 1.02), simultaneous adenoidectomy (OR 0.35), semi-liquid diet (OR 0.13), postoperative cough (OR 1.76), and the use of hemostatic agents (OR 1.58), intravenous antibiotics (OR 2.34), and painkillers (OR 2.33). Regional variations showed lower hemorrhage rates in East, Southwest, Central, and South China compared to North China. The study found that the hemorrhage rate after coblation tonsillectomy is comparable to traditional tonsillectomy. Risk factors include coagulation status, surgical duration, and postoperative care. Regional differences in hemorrhage rates suggest the need for tailored approaches based on location. Coblation tonsillectomy is a safe and effective procedure for pediatric patients. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: This study was registered on Clinical trials.gov (NCT05206799), and approved by the Ethics Committee of Shanghai Children's Hospital, Shanghai Jiaotong University (2021R096-E01).

Real-World Data on Patients With Acquired Haemophilia A in Japan Undergoing Rehabilitation or With Low Activities of Daily Living Scores: The ORIHIME II Study.

Acquired haemophilia A (AHA) is characterized by the development of autoantibodies against factor VIII, reducing its activity and potentially resulting in bleeding. To assess the characteristics of people with AHA undergoing rehabilitation and/or with low activities of daily living (ADL) scores, thereby characterizing unmet needs in the management of AHA and informing treatment optimization. ORIHIME II, the largest epidemiological and treatment survey of AHA in Japan, is a descriptive, retrospective, observational study conducted using health claims data from April 2008 to October 2021. The primary outcome measures were rehabilitation practice and ADL scores on hospital admission and discharge; use of haemostatic agents and immunosuppressive therapy were also assessed. Overall, 427 patients in Japan were eligible for the study. Median (Q1-Q3) age was 78.0 (70.0-84.0) years; 264 patients (61.8%) were male. Median (Q1-Q3) time to start rehabilitation was 9 (4-21) and 14 (6-31) days for those with an admission ADL score of<85 and ≥85, respectively. Of the 427 patients, 249 underwent rehabilitation. The most common rehabilitation type was for disuse syndrome; haemostatic agents were more commonly used in patients undergoing earlier rehabilitation. The physical condition of the patient at hospitalization was associated with rehabilitation practice and the ability of the patient to perform day-to-day activities independently. Treatment strategies should be optimized to allow initiation of rehabilitation as early as possible in the course of AHA.

Successful Perinatal Management and Resection of Large Sacrococcygeal Teratoma in an Extremely Premature Neonate

Objectives Sacrococcygeal teratomas are the most frequently diagnosed fetal neoplasms, with premature birth remaining one of the greatest risk factors for poor prognosis. We report an exceptional case of survival to discharge of an extremely premature infant with a large sacrococcygeal teratoma (SCT). Case Presentation An extremely premature infant with a large SCT was delivered via Cesarean section at 27 weeks gestational age (GA) due to preterm labor. At birth, the SCT measured 14.2 × 11.6 × 8.4 cm, and was ruptured with mild hemorrhage that was controlled with topical hemostatic agent and compression. The infant required positive pressure ventilation and intubation at birth due to apnea. She was transferred from the birth hospital to a level IV neonatal intensive care unit for surgical management. She underwent urgent surgery early on second day of life because of worsening heart failure and ongoing hemorrhage from the capsular rupture. The infant survived to discharge on room air without any major complications. Conclusions Despite multiple negative prognostic factors, we report the success and feasibility of SCT management and repair at 27 weeks GA.