History Of Bleeding Research Articles

Cervical ulcer caused by group B streptococcus with bacterial vaginosis: a case report

The female genital ulcer is a manifestation of many diseases, which may vary depending on the etiology, disease duration, age, and host immunity. A middle-aged (40–50 years) woman had a 4-month history of vaginal bleeding. The results of syphilis, herpes, the cervical cancer, tuberculosis, and fungi or acute cervical inflammation caused by Chlamydia trachomatis and Mycoplasma hominis were negative through the blood test and the biopsy. Cervical discharge culture revealed positive for group B Streptococcus and bacterial vaginosis. The patient was treated with oral antibiotics for 7 days. One month later, repeat colposcopy revealed a smooth cervix and complete ulcer disappearance, while cervical discharge culture retested no group B Streptococcus and bacterial vaginosis. The patient was diagnosed with cervical ulcer. Complete medical history taking and bacterial culture of cervical discharge are important for identifying the etiology of the cervical ulcer and deciding the appropriate treatment for the disease.

Acute water intoxication in hysteroscopic myomectomy: a rare case report.

Water intoxication is rarely seen in forensic practice and is typically associated with excessive water consumption, amphetamine intake, and child abuse. Iatrogenic water intoxication is rare but usually related to medical disputes. Here, we report a 44-year-old female was admitted to the hospital due to a 3-month history of excessive menstrual bleeding. B-ultrasound revealed multiple substantial intrauterine masses, leading to a diagnosis of multiple uterine fibroids. After admission, she underwent submucous myomectomy, endometrial resection, and transcervical resection of endometrial polyps. During the procedure, the patient suffered dizziness and chest tightness, her blood pressure decreased to 89/52mmHg, and moist rales were heard in her both lungs; she died despite medical efforts. A forensic autopsy was performed and revealed severe pulmonary edema. Considering the patient's clinical history, acute water intoxication was considered to be the cause of death. This highlights the need for forensic pathologists to be vigilant of postoperative water intoxication, a rare complication in obstetrics, to ensure accurate assessments.

Predictors of All-Cause Mortality After Successful Transcatheter Aortic Valve Implantation in Patients With Atrial Fibrillation

Prevalent and incident atrial fibrillation are common in patients who undergo transcatheter aortic valve implantation and are associated with impaired postprocedural outcomes, including mortality. We determined predictors of long-term mortality in patients with atrial fibrillation after successful transcatheter aortic valve implantation. The EdoxabaN Versus standard of care and theIr effectS on clinical outcomes in pAtients havinG undergonE Transcatheter Aortic Valve Implantation-Atrial Fibrillation (ENVISAGE-TAVI AF) trial (NCT02943785) was a multicenter, prospective, randomized controlled trial in patients with prevalent or incident atrial fibrillation after successful transcatheter aortic valve implantation who received edoxaban or vitamin K antagonists. A Cox proportional hazard model was performed to identify predictors of all-cause mortality using a stepwise approach for multiple regression analysis. In addition, we assessed the performance of different risk scores and prediction models using ENVISAGE-TAVI AF data. Of 1,426 patients in ENVISAGE-TAVI AF, 178 (12.5%) died during the follow-up period (median 548days). Our stepwise approach identified greater risk of mortality with older age, impaired renal function, nonparoxysmal atrial fibrillation, excessive alcohol use, New York Heart Association heart failure class III/IV, peripheral artery disease, and history of major bleeding or predisposition to bleeding. The present model (concordance statistic [c-statistic] 0.67) was a better discriminator than were other frequently used risk scores, such as the Society of Thoracic Surgeons score (c-statistic 0.56); Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke, Vascular disease, Age 65 to 74years, and Sex category (CHA2DS2-VASc) score (c-statistic 0.54); or Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, and Drugs/alcohol concomitantly (HAS-BLED) score (c-statistic 0.58). In ENVISAGE-TAVI AF, several modifiable and nonmodifiable clinical characteristics were significantly associated with greater long-term all-cause mortality. Improved risk stratification to estimate the probability of mortality after successful transcatheter aortic valve implantation in patients with atrial fibrillation may improve long-term patient prognosis.

A Novel Risk Prediction Score for Clinically Significant Bleeding in Patients Anticoagulated for Venous Thromboembolism with Active Cancer.

Cancer-associated venous thromboembolism (Ca-VTE) treatment with anticoagulation is associated with bleeding complications and there are limited data on risk factors. Current models do not provide accurate bleeding risk prediction. UK Clinical Practice Research Datalink data (2008-2020) were used to generate a cohort of patients with anticoagulant initiation for first Ca-VTE. Patients were observed up to 180 days for significant bleeding including major bleeding and clinically relevant nonmajor bleeding requiring hospitalization (CRNMB-H). A scoring scheme was developed from sub-distribution hazard ratios, and its discrimination (expressed by the C-statistic) estimated from cross-validation. A total of 15,749 patients with Ca-VTE and anticoagulant treatment were included. In total, 537 significant bleeding events, 161 major bleeds, and 376 CRNMB-H were identified after adjudicated review in 4,914 person-years of observation. Incidence rates of 3.3 and 7.7 per 100 person-years were noted for major bleeding and CRNMB-H. Independent predictors of significant bleeding included cancer of the bladder, central nervous system, cervix, kidney, melanoma, prostate and upper gastrointestinal tract, metastases, minor surgery, minor trauma, and history of major bleeding or CRNMB (before or after the Ca-VTE diagnosis). Patients recognized as low, medium, and high risk (30.4, 56.8, and 1.7% of the population, respectively) had a 6-month significant bleeding incidence rate of 5.1, 19.0, and 56.5 per 100 person-years, respectively. Overall C-statistic for significant bleeding was 0.70 (95% confidence interval: 0.65-0.75), and 0.76 (0.68-0.84) and 0.67 (0.61-0.73) for major bleeding and for CRNMB-H, respectively. This risk score may identify patients at risk of significant bleeding, while also helping to determine treatment duration.

Re-bleeding and all-cause mortality risk in non-variceal upper gastrointestinal bleeding: focusing on patients receiving oral anticoagulant therapy

Objective Non-variceal upper gastrointestinal bleeding (NVUGIB) in patients receiving oral anticoagulants (OACs) may be fatal; however, little is known about re-bleeding and all-cause mortality after successful hemostasis. We investigated the clinical characteristics and risk factors for re-bleeding and death after successful hemostasis. Methods Patients receiving OACs and diagnosed with NVUGIB between 2007 and 2021 were enrolled. All NVUGIB incidents were confirmed if definite bleeding in the upper gastrointestinal tract was detected via esophagogastroduodenoscopy. Results A total of 132 patients receiving OACs were diagnosed with NVUGIB. Males were the majority (72, 54.5%), and bleeding was detected mostly in the stomach (99, 75%) and was most often due to peptic ulcers (PU) (88, 66.7%). After successful hemostasis of index NVUGIB, 40 patients (30.3%) experienced re-bleeding. Among them, 15 (37.5%) died, and among those, 3 (2.3%) were related to re-bleeding. Multivariate analysis revealed that duodenal bleeding (odds ratio [OR]: 3.305; 95% confidence interval [CI]: 1.152-9.479, p = 0.026) and Charlson comorbidity index score (CCI) (OR: 1.22; 95% CI: 1.052–1.419, p = 0.009) were significant risk factors for re-bleeding. Index albumin levels (OR: 0.134; 95% CI: 0.035–0.506, p = 0.003), previous PU or upper gastrointestinal bleeding (UGIB) history (OR: 4.626; 95% CI: 1.375–15.567, p = 0.013), and CCI (OR: 1.293; 95% CI: 1.058–1.581, p = 0.012) were related all-cause mortality. Conclusion CCI and duodenal bleeding are risk factors for re-bleeding in patients with NVUGIB who were receiving OACs, while low index albumin levels and previous PU and UGIB history are associated with all-cause mortality.

Surgery in rare bleeding disorders: the prospective MARACHI study

BackgroundDespite the wide use of bleeding scores and the reliability of clotting factor level measurement, bleeding risk stratification before surgery remains challenging in patients with rare inherited bleeding disorders. ObjectivesThis multicenter observational prospective study assessed in patients with rare coagulation factor deficiency, the perioperative hemostatic management choices by hemostasis experts and the bleeding outcomes after surgery. MethodsOne hundred seventy-eight patients with low coagulation activity level (factor [F] II, FV, combined FV-FVIII, FVII, FX, or FXI <50%) underwent 207 surgical procedures. The bleeding outcome, Tosetto’s bleeding score, and perioperative hemostatic protocols were collected. ResultsAmong the 81 procedures performed in patients with severe factor deficiency (level ≤10%), 27 were done without factor replacement (including 6 in patients at high bleeding risk), without any bleeding event. Factor replacement therapy was used mainly for orthopedic procedures. In patients with mild deficiency, 100/126 surgical procedures were carried out without perioperative hemostatic treatment. In patients with FVII or FXI deficiency, factor replacement therapy was in function of the procedure, bleeding risk, and to a lesser extent previous bleeding history. Tranexamic acid was used in almost half of the procedures, particularly in case of surgery in tissues with high fibrinolytic activity (76.8%). ConclusionsThe current perioperative hemostatic management of patients with rare bleeding disorders appears to be adapted. Among the 207 procedures, only 6 were associated with excessive bleeding. Our findings suggest that rather than the bleeding score, factor level and surgery type are the most relevant criteria for perioperative factor replacement therapy.

The effect of prenatal yoga and acupressure on lowering blood pressure in pregnant women

&lt;p&gt;&lt;strong&gt;&lt;em&gt;Background: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;Hypertension in pregnancy is one of the contributors to the maternal mortality rate (MMR) in Indonesia. The combination of yoga and acupressure was expected to help pregnant women in lowering blood pressure.&lt;/em&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Objectives: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;This study aimed to test the combination of prenatal yoga and acupressure against blood pressure in pregnant women who had hypertension.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Methods: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;This study was a quasi-experiment using a pre-post-test design with control group. The population in this study was all pregnant women in the Depok Regional Health Center. The inclusion criteria for this study included: pregnant women aged &amp;gt; 20 weeks of pregnancy, suffering from hypertension, namely systolic TD ≥140 mmHg and diastolic ≥90 mmHg. As for pregnant women who had a history of preeclampsia, had a history of bleeding in this pregnancy, pregnant women with placenta previa totalis were excluded from this study. The sample was taken by purposive sampling with the number of respondents as many as 30 pregnant women in the intervention group and 30 pregnant women in the control group. Data analysis used SPSS version 20 with descriptive and Chi-square tests for respondent characteristics. Bivariate analysis was analyzed with the Wilcoxon test, while to find out the difference in blood pressure between the two groups, the Mann-Witney U test was used.&lt;/em&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Results: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;Statistical results obtained that there was a significant difference in the blood pressure of pregnant women before and after yoga and acupressure. In addition, there were significant differences in blood pressure reduction between the intervention group and the control group.&lt;/em&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Conclusions: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;Yoga and acupressure combination was proven to reduce blood pressure. It is hoped that midwives or other health workers could implement it by teaching pregnant women, especially who suffer hypertension&lt;/em&gt;&lt;/p&gt;

Reply to the Letter Titled, "A History of Upper Gastrointestinal Bleeding in Hemodialysis Patients".

Reply to the Letter Titled, "A History of Upper Gastrointestinal Bleeding in Hemodialysis Patients".

Ultrasonic presentation variation of patients with pathological evidence of endometrial atrophy.

Post-menopausal bleeding is one of the most common reasons for attending the gynecology outpatient clinic. The major proportion of the symptoms is endometrial atrophy (about 60%) despite of the endometrial thickness is over 4mm. Therefore, the aim of this study is to evaluate the endometrial thickness under sonogram in the women with atrophic endometrium, with or without post-menopausal vaginal bleeding. This is a retrospective study and we enrolled 237 post-menopausal women with pathological evidence of atrophic endometrium from Jan. 2014 to Dec. 2018 in Mackay Memorial hospital. Patient's characteristics taken into account were age, vaginal bleeding status, the methods of obtaining endometrial tissue, hormonal replacement therapy and breast cancer history under tamoxifen treatment. Endometrial thickness was classified as ≤ 4mm, >4mm-10 mm and >10mm. We calculated the proportion of the characteristic mentioned before. In total, 237 patients were enrolled and 35 patients were excluded; therefore, the remaining 202 patients were analyzed. There were 42 (20.8%), 109 (54%) and 51 (25.2%) patients with endometrial thickness ≤4mm, >4mm-10 mm and >10mm respectively. There was significant difference in the numbers of patients with post-menopausal bleeding (p=0.002) and breast cancer history under tamoxifen therapy (p<0.05) among the three groups. In the patients with endometrial atrophy, the endometrial thickness may be variable. There were only 20.8% of patients with endometrial thickness less than 4mm in our study. Before endometrial sampling, comprehensive evaluation of the morphology of endometrium under image study, the patient's symptoms and medical history is important.

Superficial siderosis presenting as hemiparesis in a paediatric patient with congenital Factor V deficiency – A case report.

Superficial siderosis is a rare abnormality caused by deposition of hemosiderin in the subpial or subarachnoid spaces of the brain, cranial nerves, and spinal cord. It results from chronic repetitive bleeding in the subpial/subarachnoid space. Magnetic resonance imaging of the brain is the diagnostic modality of choice. We describe a rare case of an 18-month-old male, a known case of congenital Factor V deficiency, who presented with recurrent vomiting, irritability and right-sided hemiparesis. On Magnetic resonance imaging, there was hypointense coating of the surface of the brainstem and cerebellum with ventricular dilatation. This case emphasizes the fact that superficial siderosis should be specifically looked for when evaluating a patient with a history of previous intracranial bleed followed by a thorough search for the source of the hemorrhage.

Immune Thrombocytopenic Purpura in Pregnancy: A Case Report in a Health Institution in Benin City, Nigeria

In comparison with reports among Caucasians, immune thrombocytopaenic purpura (ITP) is thought to be uncommon in native black Africans and persons of African ancestry worldwide. The uncommon presentation of these instances provides the information required for the collection of data for prospective research and as a foundation for improving illness management techniques aimed at promoting feto-maternal health. This paper offers a retrospective review of a 32-year-old woman who was diagnosed with ITP in her first trimester of pregnancy following a two-day history of nasal bleeding. Four years prior to her presentation, the patient had similar bleeding event, but was undiagnosed; however, it was managed by unorthodox means, with resolution of symptoms. Thereafter, she had recurrent episodes at this index presentation and a year earlier. For the treatment of this condition, corticosteroids such as oral prednisolone, intravenous methylprednisolone and dexamethasone were used in curtailing the bleeding episodes, despite the recurrence. The effectiveness of these medications was striking. She gave birth to a live female neonate through spontaneous vaginal delivery, and overall, the outcome was excellent in both the mother and neonate.

Successful Management of Follicular Cyst-induced Dermatoses in a Labrador Retriever Dog

Background: Sex hormone dermatoses are uncommon in dog and causes overproduction of one or more of the sex hormones or exogenous administration. Ovarian cyst-induced hyperestrogenemia increased cortisol, hypertestosteronemia, and skin lesions mostly underwent undiagnosed and untreated. This case was documented as clinical pathological changes, diagnosis, and treatment of sex hormone imbalance-induced dermatosis due to an ovarian follicular cyst in a Labrador Retriever bitch. Methods: This clinical investigation was carried out in the month of April’2022 at Veterinary Clinical Complex, Veterinary College and Research Institute, Tirunelveli with a history of prolonged proestrus bleeding, perineal pruritus with reddening, swelling, and enlargement of the vulva. Vaginal exfoliative cytology, hormonal assay, ultrasonography, histopathology of skin, and haemato-biochemistry were performed. Result: Physical examination revealed hyperpigmentation and hyperkeratinization of the skin. Vaginal exfoliative cytology and progesterone assay revealed cytological estrus. Ultrasonography revealed greater than 10 mm-sized anechoic structures in both ovaries along with uterine endometrial hyperplasia. Hormonal analysis revealed hyperestrogenemia and increased cortisol and testosterone. A biopsy of the perineal skin revealed hyperplasia and hyperkeratosis. The case was confirmed as sex hormone imbalance-induced dermatosis due to an ovarian follicular cyst. The animal was treated with two shots of Inj. hCG 500IU in 48 hrs interval followed by OHE after three months.

Development and Validation of the DOAC Score: A Novel Bleeding Risk Prediction Tool for Patients With Atrial Fibrillation on Direct-Acting Oral Anticoagulants.

Current clinical decision tools for assessing bleeding risk in individuals with atrial fibrillation (AF) have limited performance and were developed for individuals treated with warfarin. This study develops and validates a clinical risk score to personalize estimates of bleeding risk for individuals with atrial fibrillation taking direct-acting oral anticoagulants (DOACs). Among individuals taking dabigatran 150 mg twice per day from 44 countries and 951 centers in this secondary analysis of the RE-LY trial (Randomized Evaluation of Long-Term Anticoagulation Therapy), a risk score was developed to determine the comparative risk for bleeding on the basis of covariates derived in a Cox proportional hazards model. The risk prediction model was internally validated with bootstrapping. The model was then further developed in the GARFIELD-AF registry (Global Anticoagulant Registry in the Field-Atrial Fibrillation), with individuals taking dabigatran, edoxaban, rivaroxaban, and apixaban. To determine generalizability in external cohorts and among individuals on different DOACs, the risk prediction model was validated in the COMBINE-AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) pooled clinical trial cohort and the Quebec Régie de l'Assurance Maladie du Québec and Med-Echo Administrative Databases (RAMQ) administrative database. The primary outcome was major bleeding. The risk score, termed the DOAC Score, was compared with the HAS-BLED score. Of the 5684 patients in RE-LY, 386 (6.8%) experienced a major bleeding event, within a median follow-up of 1.74 years. The prediction model had an optimism-corrected C statistic of 0.73 after internal validation with bootstrapping and was well-calibrated based on visual inspection of calibration plots (goodness-of-fit P=0.57). The DOAC Score assigned points for age, creatinine clearance/glomerular filtration rate, underweight status, stroke/transient ischemic attack/embolism history, diabetes, hypertension, antiplatelet use, nonsteroidal anti-inflammatory use, liver disease, and bleeding history, with each additional point scored associated with a 48.7% (95% CI, 38.9%-59.3%; P<0.001) increase in major bleeding in RE-LY. The score had superior performance to the HAS-BLED score in RE-LY (C statistic, 0.73 versus 0.60; P for difference <0.001) and among 12 296 individuals in GARFIELD-AF (C statistic, 0.71 versus 0.66; P for difference = 0.025). The DOAC Score had stronger predictive performance than the HAS-BLED score in both validation cohorts, including 25 586 individuals in COMBINE-AF (C statistic, 0.67 versus 0.63; P for difference <0.001) and 11 945 individuals in RAMQ (C statistic, 0.65 versus 0.58; P for difference <0.001). In individuals with atrial fibrillation potentially eligible for DOAC therapy, the DOAC Score can help stratify patients on the basis of expected bleeding risk.

Low-coverage whole-genome sequencing for the effective diagnosis of early endometrial cancer: A pilot study

BackgroundEndometrial carcinoma (EC) is a disease that predominantly affects peri- and post-menopausal women and its incidence has continued to rise over recent years. Since the gold standard for EC diagnosis—hysteroscopic biopsy—is invasive, expensive, and unsuitable for wide use, there is an urgent need for a non-invasive method that exhibits both high sensitivity and high specificity. We therefore investigated the efficacy of UterCAD (the uterine exfoliated cell chromosomal aneuploidy detector) using tampon-collected specimens for the early detection of EC. MethodsWe prospectively recruited 51 patients with a history of abnormal bleeding and who planned to undergo hysteroscopic examination or hysterectomy between March 2020 and January 2021. Before executing an invasive procedure, a tampon was inserted into the patient's vagina for 6 h to collect exfoliated cells from the uterine cavity. Total DNA was extracted and low-coverage whole-genome sequencing was performed on an Illumina HiSeq X10, and we analyzed the differences in chromosomal status between women with EC and those bearing benign lesions using UterCAD. ResultsThirty EC patients—including 26 with endometrioid carcinoma (EEC) and four with uterine serous carcinoma (USC), as well as 14 benign cases—were enrolled in our final analysis. Copy-number variations (CNVs) were detected in tampon specimens collected from 26 EC patients (83.3%), including 21 with EEC (80.7%) and four with USC (100%). In the benign group, only one woman with focal atypical hyperplasia presented with a 10q chromosomal gain (P < 0.001). In the EC group, the most common CNVs were copy gains of 8q (N = 14), 2q (N = 4), and 10q (N = 3); and copy losses of 2q (N = 3) and 17p (N = 2). When we stratified by FIGO stage, the CNV rates in stages IA, IB, and II/III were 83.3% (15/18), 85.7% (6/7), and 80.0% (4/5), respectively. At the optimal cutoff (|Z| ≥ 2.3), UterCAD discriminated 83.3% of EC cases from benign cases, with a specificity of 92.9%. ConclusionsWe initially reported that UterCAD could serve as a non-invasive method for the early detection of EC, especially in the rare and aggressive USC subtype. The use of UterCAD might thus avoid unnecessary invasive procedures and thereby reduce the treatment burden on patients.

Factor VIII Level in the Potential Female Carrier Mothers of Patients with Hemophilia A and Its Impact on Joint Health

Background Hemophilia A is an X-linked bleeding disorder. The characteristic bleeding phenotype in patients with severe hemophilia is recurrent spontaneous hemarthrosis with development of hemophilic arthropathy. Heterozygous female carriers with factor VIII (FVIII) activity level lower than 40% may be at risk for bleeding that is usually comparable to that seen in males with mild hemophilia. Aim of the Work To assess factor VIII level in mothers of known patients of hemophilia A correlating it with the frequency of clinically and radiologically documented arthropathy. Patients and Methods A cross sectional study included 40 mothers of patient with hemophilia A during the period from September 2020 to September 2021. Studied participants were subjected to detailed analysis of bleeding history, six major joints range of motion (ROM) examination, functional independence score in hemophilia (FISH), FVIII level one stage assessment and magnetic resonant imaging (MRI) of the reported affected joints. Results Mean age of mothers is 42.25 ± 7.74 years. Eleven mothers (27.5%) had no bleeding symptoms, 16 (40%) had one bleeding symptoms and 13 (32.5%) had two or more bleeding symptoms. As regard joint pain, 13 (32.5%) had severe pain, 3 (7.5%) had ankle pain and 2 (5%) had elbow pain with a mean pain score of 2.55±3.32, and 7 (17.5%) had bilateral pain. Mean FVIII activity was 43.33 IU (± 22.79), ranging from FVIII (0 &amp;lt; 30 IU) in 13 (32.5%), FVIII (30 &amp;lt;60) in 18 (45.0%) and FVIII ≥ 60 IU in 9 (22.5%) among the studied participants. Knees were the most affected joints with decreased mean ROM (±SD) in right and left knees of (123.25 (±12.06) and 120.00 (±15.81)) respectively. The median MRI scores were studied was 5 (2.6%) with median osteochondral changes of 4 (2.5%) and median soft tissue changes of 1 (0-1), their median FISH score of 8 (8-9). By comparing groups at the level of factor VIII, there was no significant difference according to anthropometric bleeding parameters, pain, and MRI score. None of participants needed hospital admission, factor VIII replacement or packed red cells replacement. Conclusion Potential female hemophilia A carriers are at risk of spontaneous bleeding which may entail bleeding in the joints, causing early joint damage. They showed reduced overall joint ROM and structural osteochondral changes in MRI joint examination which mandates further studies about early detection of potential female hemophilia carriers for the possible need of early medical intervention.

Assessment of adherence to the national stress ulcer prophylaxis guidelines: A cross-sectional analysis

BackgroundClinical guidelines support the use of stress ulcer prophylaxis (SUP) in patients at risk of gastrointestinal (GI) bleeding such as those with coagulopathy, renal replacement therapy, and mechanical ventilation. Despite the observed benefits of SUP, its overuse has been highly associated with serious adverse effects. ObjectiveTo assess the adherence to the national SUP guidelines in a tertiary hospital in Saudi Arabia. MethodsA cross-sectional study was conducted using electronic health records at King Fahad Specialist Hospital (KFSH), Buraydah, Saudi Arabia. We collected the data from January 1st to December 31st, 2020. Adult patients aged 18 and older who received SUP prescriptions were included. Descriptive analysis was performed to assess the adherence to the guidelines and to explore the factors associated with SUP use in a hospital-based setting. ResultsA total of 424 patients were enrolled in this study. The median age of patients was 55.2 years old. Only 54% of patients were candidates for SUP. Internal medicine and surgery wards ranked the highest in prescribing SUP at 34.2% and 30.4%, respectively. The most common major criterion to start SUP was the concomitant use of two or more of these medications (anticoagulants, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and antidepressants) followed by using NSAIDs or corticosteroids by older adult patients aged (≥65 years) or have GI bleeding history at 43.2% and 21.5%, respectively. ConclusionThe observed overuse of anti-ulcer drugs (AUD) indicates a need for greater adherence to SUP guidelines. Areas of improvement can be implemented to ensure appropriate adherence to SUP guidelines to control the costs and avoid unnecessary anti-ulcer-related adverse effects.

Immune Checkpoints in Recurrent Pregnancy Loss: New Insights into a Detrimental and Elusive Disorder.

Recurrent pregnancy loss (RPL) refers to two or more miscarriages before 20 weeks gestation. Its prevalence is 1-2%; its pathogenesis remains unexplained in more than 50% of cases, in which the cause is thought to be abnormal immune activity during placentation leading to a lack of pregnancy-induced immune tolerance. It is unknown whether immune activity is deranged in the endometrium of women with RPL. We studied the gene expression and the quantitative tissue protein levels of three immune checkpoints (CD276, which enhances cytotoxic T-cell activity, cytotoxic T-lymphocyte-associated antigen-4 [CTL-4], which reduces Th1 cytokine production, and lymphocyte activation gene-3 [LAG-3], which shows suppressive activity on Tregs and CD4+ T-cells) in endometrial samples from 27 women with unexplained RPL and in 29 women with dysfunctional uterine bleeding and previous uneventful pregnancies as controls. RNA isolation, real-time PCR, protein isolation, and ELISA were performed. CD276 gene expression and protein tissue levels were significantly lower in the endometrium of the RPL group than in the controls, whereas both CTL-4 and LAG-3 were significantly higher. This difference suggests defective endometrial immune regulation and overactivation of immune response in women with a history of RPL, at least in relation to controls with dysfunctional uterine bleeding and previous normal reproductive history.

Characteristics of pregnancy with placenta previa in Prof. Dr. I. G. N. G. Ngoerah General Hospital, Bali, in 2017

Introduction: Cesarean sections (CS) are rising annually worldwide. Globally, based on data from 121 countries, from 1990-2014, the number of CS increased by 12.4%, with an average increase of 4.4% per year. The high rate of CS increases the risk of complications in subsequent pregnancies, including placenta previa. In a study conducted in England with nearly 400,000 women with a second pregnancy, the incidence rate of placenta previa was 8.7 in 1000 births in women with previous CS history and about 4.4 in 1000 births in women with previous vaginal delivery. This study aimed to determine pregnancy characteristics with placenta previa at Prof. Dr. I. G. N. G. Ngoerah General Hospital in 2017. Methods: This study is a cross-sectional study with a retrospective descriptive approach using medical records of patients admitted from 1st January-31st December 207. This research was conducted at Prof. I. G. N. G. Ngoerah General Hospital, Bali, from February 1 to April 1, 2018. All data from medical records were collected and processed to describe pregnancy characteristics with placenta previa. Results: There were 49 (4.89%) cases of placenta previa from 1001 deliveries in 2017. This number was higher than the placenta previa case in other countries, around 0.3-0.5%. There were 2 cases excluded, and 47 cases were processed for data presentation. Pregnancy characteristics that dominated placenta previa cases in this research were aged 30-34 years old, second to third pregnancy, age of gestation ≥ 37 weeks, no history of vaginal bleeding, no history of curettage, and no history of CS Conclusion: The characteristics of pregnancy in this study which dominated placenta previa cases were aged 30-34 years old, second to third pregnancy, age of gestation ≥ 37 weeks, no history of vaginal bleeding, no history of curettage, and no history of CS Further investigation is required.

Physicians' perspectives on percutaneous left atrial appendage occlusion for patients with atrial fibrillation

There has been an increasing uptake of transcatheter left atrial appendage occlusion (LAAO) for stroke reduction in atrial fibrillation. To investigate the perceptions and approaches among a nationally representative sample of physicians. Using the American Medical Association Physician Masterfile, we selected a random sample of 500 physicians from each of the specialties: general cardiologists, interventional cardiologists, electrophysiologists, and vascular neurologists. The participants received the survey by mail up to three times from November 9, 2021 to January 14, 2022. In addition to the questions about experiences, perceptions, and approaches, physicians were randomly assigned to 1 of the 4 versions of a patient vignette: white man, white woman, black man, and black woman, to investigate potential bias in decision-making. The top three reasons for considering LAAO were: a history of intracranial bleeding (94.3%), a history of major extracranial bleeding (91.8%), and gastrointestinal lesions (59.0%), whereas the top three reasons for withholding LAAO were: other indications for long-term oral anticoagulation (87.7%), a low bleeding risk (77.0%), and a low stroke risk (65.6%). For the reasons limiting recommendations for LAAO, 59.8% mentioned procedural risks, 42.6% mentioned "limiting efficacy data comparing LAAO to NOAC" and 32.8% mentioned "limited safety data comparing LAAO to NOAC." There was no difference in physicians' decision-making by patients' race, gender, or the concordance between patients' and physicians' race or gender. In the first U.S. national physician survey of LAAO, individual physicians' perspectives varied greatly, which provided information that will help customize future educational activities for different audiences. Although diverse practice patterns of LAAO have been documented, little is known about the reasoning or perceptions that drive these variations. Unlike prior surveys that were directed to Centers that performed LAAO, the current survey obtained insights from individual physicians, not only those who perform the procedures (interventional cardiologists and electrophysiologists) but also those who are closely involved in the decision-making and referral process (general cardiologists and vascular neurologists). The findings identify key evidence gaps and help prioritize future studies to establish a consistent and evidence-based best practice for AF stroke prevention.

Incidence, Risk Factors and Mortality Associated with Major Bleeding Events in Hospitalized COVID-19 Patients.

Thromboprophylaxis is a mainstay of treatment of hospitalized COVID-19 patients, due to the high occurrence of thrombotic events. This increases the risk of bleeding. However, data on bleeding events and associated risk factors are scarce. Thus, we aimed to investigate the incidence, predictors and clinical outcomes associated with major bleeding in hospitalized COVID-19 patients. We retrospectively evaluated a cohort of 4014 consecutively hospitalized COVID-19 patients treated in a tertiary-level institution in the period 3/2020-3/2021. Bleeding of any kind was documented in 322 (8%) and major bleeding in 129 (3.2%) patients. A total of 129 (40.1%) bleeding events were present at the time of hospital admission, and 193 (59.9%) occurred during hospitalization. In the multivariate logistic regression analysis, intensive-care-unit treatment (adjusted odds ratio (aOR) 6.55; p < 0.001), atrial fibrillation (aOR 2.55; p = 0.029), higher white-blood-cell count (WBC) (aOR 1.03; p = 0.021), lower hemoglobin (aOR 0.97; p = 0.002) and history of bleeding (aOR 17.39; p < 0.001) were recognized as mutually independent predictors of major bleeding. Major bleeding was significantly associated with increased in-hospital mortality compared to non-major-bleeding patients (59.7% vs. 34.8%, p < 0.001), especially if occurring during hospitalization. Median time from major bleeding to death was 5 days. Bleeding events are frequent in hospitalized COVID-19 patients, with a significant proportion of patients presenting at the time of hospital admission, and others almost universally exposed to anticoagulant and corticosteroid therapies. Major bleeding is associated with high mortality, especially if occurring during hospitalization. The recognition of patients at risk and implementation of timely interventions are of high clinical importance.