Hypertensive Hemorrhage Research Articles

Clinical features and risk factors of portal vein thrombosis in 28 patients with antiphospholipid syndrome

Objective: Portal vein thrombosis (PVT) is a rare and severe clinical manifestation of antiphospholipid syndrome (APS), as well as a predictor of poor prognosis. This study was conducted to explore the clinical features and risk factors of PVT in APS patients. Methods: A total of 123 APS patients diagnosed from 2012 to 2019 were retrospectively enrolled. The diagnosis of PVT was made according to the 2009 American College of Liver Diseases (AASLD) criteria. Clinical and laboratory data were collected. A multivariate (MV) logistic regression model was constructed using a stepwise forward selection procedure among those candidate univariables with P values<0.10. Results: A total of 28 cases with PVT, and 95 control cases without PVT were finally enrolled.The 28 APS-PVT patients included 5 males and 23 females with age range from 17 to 63 years. Clinical manifestations included acute thrombosis in 8 patients, chronic thrombosis in 16, and 4 with portal vein spongiform. As to the involved vessels, single portal vein thrombosis was seen in 20 patients, portal combined with superior mesenteric vein (SMV) and splenic vein in one patient, portal plus SMV in 4 and only SMV in 3 patients. Other manifestations were portal hypertension (16/28), esophageal varices (13/28), spleen infarction (7/28) and gastrointestinal bleeding (4/28). Two antiphospholipid antibodies were positive in 13 cases. Triple positive antibodies were seen in 7 cases. Multivariate logistic regression analysis showed that disease duration less than 0.5 years (OR=72.74, 95%CI 7.50-705.45, P<0.001), hypoalbuminemia (OR=356.45, 95%CI 19.19-6 620.14, P<0.001), and elevated erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP) (OR=14.41, 95%CI 1.49-139.20, P<0.001) were independent risk factors for PVT in APS. Conclusion: PVT is usually misdiagnosed due to insidious onset. Short disease duration, hypoalbuminemia and elevated ESR/CRP are risk factors for PVT in APS. Better understanding, early diagnosis and treatment will improve the clinical outcome.

ATRİAL FİBRİLASYON NEDENİYLE KAROTİS ENDARTEREKTOMİSİ GEÇİREN HASTALARDA POSTOPERATİF ANTİKOAGÜLAN VE ANTİAGREGAN STRATEJİSİ - TEK MERKEZ TECRÜBESİ

<div><!--block-->Objective: Literature does not contain a standard procedure about anticoagulant therapy aimed at patients with atrial fibrillation and carotid artery stenosis following carotid endarterectomy. In this paper, we present our therapy modality at these patients in our clinic.&nbsp;<br><br>Material and Method: The study includes 424 patients and 498 carotid endarterectomy operations performed by two surgeons with the same technique between June 2010 and December 2017. Fourty-five patients had chronic or paroxysmal atrial fibrillation. Therefore, the patients were receiving Coumadin and aspirin. The median age was 63.4±7.9. There were 27 female and 18 male patients. Thirty seven patients were hypertensive and 17 patients were diabetic. Nine patients underwent bilateral carotid endarterectomy operations. Thirty three patients were symptomatic. Eleven patients had coronary artery disease and 5 patients had cardiac valvular pathologies.&nbsp;<br><br>Results: The whole carotid endarterectomy operations were performed under locoregional anesthesia. Early mortality occured in one patient because of hypertensive intracranial bleeding. The median follow up period was 68.4±19.2 months. One patient was lost due to aging and co-morbid factors and one patient was lost due to malignancy in late follow up period. Three patients required revisions for hematoma at incision region but an active bleeding focus could not be detected. There was no re-stenosis in any patient during follow-up.&nbsp;<br><br>Conclusion: The large and multi-centered studies are needed for the anticoagulant therapy protocol for the patients with atrial fibrillation following carotid endarterectomy. We prefer combination of warfarin, providing INR value between 2-3, and 100 mg aspirin per day at our patients as therapy modality.</div>

An Observational Pilot Study Evaluating the Utility of Minimally Invasive Tissue Sampling to Determine the Cause of Stillbirths in South African Women.

BackgroundDespite approximately 2.6 million stillbirths occurring annually, there is a paucity of systematic biological investigation and consequently knowledge on the causes of these deaths in low- and middle-income countries (LMICs). We investigated the utility of minimally invasive tissue sampling (MITS), placental examination, and clinical history, in attributing the causes of stillbirth in a South African LMIC setting.MethodsThis prospective, observational pilot study undertook sampling of brain, lung, and liver tissue using core biopsy needles, blood and cerebrospinal fluid collection, and placental examination. Testing included microbial culture and/or molecular testing and tissue histological examination. The cause of death was determined for each case by an international panel of medical specialists and categorized using the World Health Organization’s International Classification of Diseases, Tenth Revision application to perinatal deaths.ResultsA cause of stillbirth was identifiable for 117 of 129 (90.7%) stillbirths, including an underlying maternal cause in 63.4% (n = 83) and an immediate fetal cause in 79.1% (n = 102) of cases. The leading underlying causes of stillbirth were maternal hypertensive disorders (16.3%), placental separation and hemorrhage (14.0%), and chorioamnionitis (10.9%). The leading immediate causes of fetal death were antepartum hypoxia (35.7%) and fetal infection (37.2%), including due to Escherichia coli (16.3%), Enterococcus species (3.9%), and group B Streptococcus (3.1%).ConclusionsIn this pilot, proof-of-concept study, focused investigation of stillbirth provided granular detail on the causes thereof in an LMIC setting, including provisionally highlighting the largely underrecognized role of fetal sepsis as a dominant cause.

1357 Pseudocirrhosis in Subacute/Chronic Budd-Chiari Syndrome With JAK 2 Mutation

INTRODUCTION: Budd Chiari Syndrome (BCS) is a rare disorder often characterized by hepatic venous outflow obstruction. Myeloproliferative disorders especially V617F-JAK2 mutations account for almost 40% of these patients. BCS may present differently depending on location, extent, severity of obstruction and existence of collaterals. The course of disease may be fulminant, acute, subacute or chronic, ranging from incidental findings to fatal acute hepatic failure. CASE DESCRIPTION/METHODS: A 74-year-old female with remote history of alcoholism, presented to our facility with bleeding per rectum for 2 days. Labs on admission revealed WBC 18.4, HGB 16.8, PLT 588, AST 570, ALT 804 and TB 4.6. Ultrasound Abdomen with Doppler revealed ascites and portal vein thrombosis. Follow-up MRI Abdomen confirmed thrombus in main portal vein and non-opacification of major intrahepatic veins suggesting Budd Chiari Syndrome. Hypercoagulability workup showed positive JAK2 mutation. She was started on IV Heparin immediately. Diagnostic paracentesis revealed transudative fluid and liver elastography confirmed cirrhosis. Grade 2 esophageal varices were seen on EGD with a negative colonoscopy. Other possible etiology of congestive hepatopathy/cirrhosis were excluded. Patient was discharged on daily oral Rivaroxaban with intermittent therapeutic paracentesis. Over next 3 months, she had recurrent admissions for decompensated liver disease. During her last visit however, we noted preserved synthetic liver function and inconsistencies in her presentation thus a liver biopsy was obtained which revealed centrilobular hepatocellular necrosis, sinusoidal dilatation and mild portal fibrosis consistent with hepatic venous outflow obstruction. However, there was no evidence of cirrhosis. She was transferred to an advanced facility for portal vein reconstruction to relieve the obstruction from splanchnic venous thrombosis and possibly reverse the “pseudocirrhosis”. DISCUSSION: Pseudocirrhosis is often associated with metastatic cancers in response to chemotherapy induced ischemic injury. Although it radiologically and clinically mimics liver cirrhosis, it can be prevented with early detection. To our knowledge, this is the first reported case of pseudocirrhosis in BCS. Subacute/chronic BCS may present with cirrhotic complications like portal hypertension, ascites and variceal bleeding. Apart from anticoagulation, these patients may require other interventions to bypass the obstruction like Direct Intrahepatic Portosystemic Shunt (DIPS) placement.

618 The Use of Antibiotics Prophylaxis in Cirrhotic Patients Presenting With Gastrointestinal Portal Hypertensive Bleeding in a Community Teaching Hospital

INTRODUCTION: Background: Bacterial infections are common in cirrhotic patients with acute gastrointestinal portal hypertensive bleeding, occurring in 20% within 48 hours. Outcomes including early re-bleeding and failure to control bleeding are strongly associated with bacterial infection. The use of short-term prophylactic antibiotics in patients with cirrhosis and GI hemorrhage with or without ascites has been shown not only to decrease the rate of bacterial infections but also to increase survival. This improved survival is partly related to a decrease in the incidence of early re-bleeding in patients with GI hemorrhage who receive prophylactic antibiotics. Therefore, short-term antibiotic prophylaxis should be considered standard practice in all patients with cirrhosis and acute variceal hemorrhage. The antibiotic of choice in most centers is intravenous Ceftriaxone at a dose of 1 g daily. Duration of antibiotic prophylaxis is short term, for 5-7 days (to be discontinued when hemorrhage resolve and vasoactive drugs discontinued). METHODS: 300 charts were reviewed in retrospective data analysis for patients presented during 2017 and 2018 with cirrhosis related diagnoses and gastrointestinal bleeding related diagnoses. 43% (171 patients) of the presented patients had active cirrhosis. RESULTS: Anatomy and EGJ opening determine outcome in achalasia. Of those 171 patients: 17% (30 of 171) patients that have cirrhosis presented in 2017 and 2018 with gastrointestinal bleeding, 36% (11 out of the 30) patients received empiric antibiotics, whether as prophylaxis or for other indications such as sepsis,64% (19 out of the 30) patients, antibiotics were not started on admission; therapy started on the second or third day by gastroenterology service, or other service/team. CONCLUSION: Our results showed that the majority of patients (64%) with cirrhosis presenting with GI bleed were not started on a proper prophylaxis antibiotic. The ideas and the actions that were proposed and implemented post this study: Increase awareness through nursing and pharmacy staff teaching sessions, as well as residents didactic lectures. Also, through periodic awareness/teaching emails to medical staff. Hospital protocols were reviewed. A questionnaire step, “Warning window,” were integrated into the EMR, that to pop up when a medical provider add “liver cirrhosis” or “variceal hemorrhage” to patient admitting/visit diagnosis list. This intervention was implemented recently. In the next phase, we plan to gather data obtained post intervention, and to be studied and compared.

Clinical Study on Minimally Invasive Liquefaction and Drainage of Hypertensive Putaminal Hemorrhage through Frontal Approach

Background Hypertensive intracerebral hemorrhage is one of the most common cerebrovascular diseases with high mortality and high disability rate. The aim of this study was to observe the curative effect of minimally invasive liquefaction and drainage of hypertensive putaminal hemorrhage (HPH) through frontal approach. Methods This study retrospectively reviewed the clinical data of 66 HPH patients who underwent surgery from January 2012 to January 2017 including 35 males and 31 females, aged 51 to 82 years, with an average age of 61.6 ± 7.32 years. All patients were treated in the first people's hospital of Kunshan. They were divided into two groups: puncture thrombolysis and drainage therapy (PTDT) group and conventional craniotomy (CC) group. Result The pulmonary infection rate in PTDT group was 13.8%, significantly lower than that of 27.7% in CC group ( p < 0.05). One year after onset, the modified Rankin scale (mRS) score of surviving patients was evaluated. The mRS score of the PTDT group with 30 to 60 mL of preoperative bleeding was 1.91 ± 0.82, which was significantly better than that of the CC group (2.21 ± 0.83) ( p < 0.05). There was no significant difference in mRS score between PTDT group (2.59 ± 0.62) and CC group (2.88 ± 0.87) with preoperative bleeding > 60 mL ( p > 0.05). In patients with Glasgow coma scale (GCS) 5 to 8 scores, the mRS of PTDT and CC groups were 2.73 ± 0.72 and 2.94 ± 0.96, respectively ( p > 0.05). In patients with GCS 9 to 13 scores, the mRS score of PTDT group was 1.83 ± 0.69, which was significantly better than that of CC group (2.06 ± 0.74) ( p < 0.05). Conclusion HPH can be treated effectively through PTDT. PTDT group has lower lung infection rate than CC group. And it can significantly improve the prognosis of patients with preoperative bleeding volume of 30 to 60 mL and preoperative GCS score of 9 to 13.

Role of rehabilitation in prevention of early thromboembolic complications in hemorrhagic stroke

Hemorrhagic strokes (ICH) affects mainly young active people, with increasing incidence in developing countries. Mortality is high in acute phase, and patients are prone to complications related to stroke itself and to coexisting medical conditions. Patients with ICH are at high risk in developing deep venous thrombosis (DVT) with secondary pulmonary embolism (PE). Prevention of venous thrombotic events in hemorrhagic stroke patients requires intermittent pneumatic compression and preventive doses of low molecular weight heparins (LMWH) in high-risk patients. If DVT and /or PE occurs, the therapeutic management should balance the risk of recurrent cerebral bleeding and the life-threatening risk of PE, making the decision to start anticoagulation challenging. We present a case of a young patient with a large hypertensive capsulo-lenticular hemorrhage, who was diagnosed with pulmonary embolism 21 days after stroke onset. The decision was for anticoagulant treatment initial with LWMH, and switch to direct oral anticoagulants (DOAC) after 10 days; strict control of vascular risk factors of the patients (hypertension, diabetes and obesity) was achieved. Rehabilitation treatment, delayed until day 21, was recommended with progressive intensity. Evolution of the patient was favorable, with complete hematoma resorbtion under DOAC treatment at 10 weeks follow-up and important motor recovery. Rehabilitation program was intensive during this interval, and strongly contributive to neurologic improvement.

Incidence and Risk Factors for Developing Post-Traumatic Hydrocephalus, Analysis of a Prospective Cohort of 402 Patients

Abstract INTRODUCTION Post-traumatic hydrocephalus (PTH) is a common complication after traumatic brain injury (TBI). PTH incidence and risk factors have principally been derived from retrospective studies or those in the context of hydrocephalus following decompressive craniectomy. The goal of this study was to identify, in a large prospective cohort, the incidence and risk factors for PTH. METHODS This is a single-center retrospective review of a prospectively collected database of patients with severe TBI. PTH was defined as the need for permanent CSF diversion by shunt insertion. Patient demographics, GCS, bleeding patterns, intracranial pressure (ICP) monitoring, and the need for a decompressive craniectomy were considered as explanatory variables. An inverse probability weighted logistic regression model, which considers potential censoring induced by in-hospital mortality, was used as our primary analysis. RESULTS Of the 402 patients included, 40 required permanent CSF for a PTH cumulative incidence of 10% (95% CI: 7.3-13.6). PTH was associated with the need for a decompressive craniectomy [odds ratio (OR): 3.62 (1.62-8.07), P &lt; .01]. Neither age nor gender nor GCS nor bleeding pattern (including intraventricular hemorrhage) was associated with the occurrence of PTH. There were no differences on the initial ICP measurement (10.1 (8.8) vs 9.9 (7.9) mm Hg) or the trend of the ICP between patients who ultimately developed PTH and those who did not. CONCLUSION PTH develops in approximately 10% of patients with severe TBI. Patients who require a decompressive craniectomy are at a higher risk. Neither intracranial hypertension nor intraventricular hemorrhage was a relevant risk factor.

Effectiveness of Combined External Ventricular Drainage with Intraventricular Fibrinolysis for the Treatment of Intraventricular Haemorrhage with Acute Obstructive Hydrocephalus

Background: Intraventricular haemorrhage (IVH) patients with acute obstructive hydrocephalus (AOH) who require external ventricular drainage (EVD) are at high risk for poor outcomes. Intraventricular fibrinolysis (IVF) with low-dose recombinant tissue plasminogen activator (rtPA) can be used to improve patient outcomes. Here, we evaluated the impact of IVF on the risk of death and the functional outcomes in IVH patients with AOH. Methods: This prospective cohort study included IVH patients with hypertensive intracranial haemorrhage complicated by AOH who required EVD. We evaluated the risk of death and the functional outcomes at 1 and 3 months, with a specific focus on the impact of combined EVD with IVF by low-dose rtPA. Results: Between November 30, 2011 and December 30, 2014, 80 patients were included. Forty-five patients were treated with EVD alone (EVD group) and 35 received IVF (EVD+IVF group). The 30- and 90-day mortality rates were lower in the EVD+IVF group than in the EVD group (42.2 vs. 11.4%, p = 0.003, and 62.2 vs. 20%, p < 0.001, respectively). The Graeb scores were significantly lower in the EVD+IVF group than in the EVD group (p ≤ 0.001) during the first 3 days and on day 7 after assignment. The 30-day good functional outcome (modified Rankin Scale [mRS] score 0–3) was also higher in the EVD+IVF group than in the EVD group (6.7 vs. 28.6%, p = 0.008). However, the 90-day good functional outcome (mRS score 0–3) did not significantly increase in the EVD+IVF group (30.8% in the EVD group vs. 51.6% in the EVD+IVF group, p = 0.112). Conclusions: In our prospective observational study, EVD+IVF was associated with a lower risk of death in IVH patients. EVD+IVF improved the chance of having a good functional outcome at 1 month; however, this result was no longer observed at 3 months.

Laparoscopic splenectomy and azygoportal disconnection combining with pre- and postoperative endoscopic intervention - A sandwich-style sequential therapy for portal hypertensive bleeding: A retrospective cohort study

In patients who survive the first esophageal variceal bleeding (EVB) resulting from portal hypertension, the probability of fatal esophageal variceal re-bleeding (EVR) is high. We have developed a sandwich-style sequential therapy combining laparoscopic splenectomy and azygoportal disconnection (LSD) with preoperative and postoperative endoscopic intervention (LSDE). The aim of the present study was to investigate whether LSDE is safe and effective and to evaluate whether the postoperative EVR rate for LSDE was lower than that for LSD without periodical postoperative endoscopic intervention (NLSDE). We retrospectively investigated the outcomes of 226 patients with cirrhosis with EVB and secondary hypersplenism who all received preoperative endoscopic variceal ligation (EVL) to manage emergency EVB then underwent NLSDE (n=106) or LSDE (n=120) between February 2012 and April 2016. The perioperative and follow-up variables of the two groups were evaluated. Between the two groups, there were no differences in number of blood transfusions, intraoperative blood loss, postoperative complications, and hospital stay. LSDE showed shorter operation time (p=0.001) and lower EVR rates during the periods ranging from 1 to 12 months, 4 to 6 months, 4 to 12 months, and 7 to 12 months (all p<0.05) than NLSDE. Dynamic changes in the diameter of the esophageal varices and the rates of EVL in the LSDE group both decreased gradually and significantly over the 12-month follow-up period (all p<0.0001). Laparoscopic splenectomy and azygoportal disconnection with periodical postoperative endoscopy is safe and effective for reducing the EVR rate in cirrhotic portal hypertension.

Intracranial Hypertension and Cerebral Perfusion Pressure Insults in Adult Hypertensive Intraventricular Hemorrhage: Occurrence and Associations With Outcome.

Elevated intracranial pressure and inadequate cerebral perfusion pressure may contribute to poor outcomes in hypertensive intraventricular hemorrhage. We characterized the occurrence of elevated intracranial pressure and low cerebral perfusion pressure in obstructive intraventricular hemorrhage requiring extraventricular drainage. Prospective observational cohort. ICUs of 73 academic hospitals. Four hundred ninety-nine patients enrolled in the CLEAR III trial, a multicenter, randomized study to determine if extraventricular drainage plus intraventricular alteplase improved outcome versus extraventricular drainage plus saline. Intracranial pressure and cerebral perfusion pressure were recorded every 4 hours, analyzed over a range of thresholds, as single readings or spans (≥ 2) of readings after adjustment for intracerebral hemorrhage severity. Impact on 30- and 180-days modified Rankin Scale scores was assessed, and receiver operating curves were analyzed to identify optimal thresholds. Of 21,954 intracranial pressure readings, median interquartile range 12 mm Hg (8-16), 9.7% were greater than 20 mm Hg and 1.8% were greater than 30 mm Hg. Proportion of intracranial pressure readings from greater than 18 to greater than 30 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 70 mm Hg were associated with day-30 mortality and partially mitigated by intraventricular alteplase. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and intracranial pressure greater than 20 mm Hg in spans were associated with both 30-day mortality and 180-day mortality. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 60 mm Hg were associated with poor day-30 modified Rankin Scale, whereas cerebral perfusion pressure less than 65 and less than 75 mm Hg were associated with poor day-180 modified Rankin Scale. Elevated intracranial pressure and inadequate cerebral perfusion pressure are not infrequent during extraventricular drainage for severe intraventricular hemorrhage, and level and duration predict higher short-term mortality and long-term mortality. Burden of low cerebral perfusion pressure was also associated with poor short- and long-term outcomes and may be more significant than intracranial pressure. Adverse consequences of intracranial pressure-time burden and cerebral perfusion pressure-time burden should be tested prospectively as potential thresholds for therapeutic intervention.

Increasing Economic Burden in Hospitalized Patients With Cirrhosis: Analysis of a National Database.

INTRODUCTION:The prevalence of cirrhosis is increasing despite advances in therapeutics, and it remains an expensive medical condition. Studies examining the healthcare burden of inpatient cirrhosis-related care regardless of etiology, stage, or severity are lacking. This study aims to describe the current drivers of cost, length of stay (LOS), and mortality in hospitalized patients with cirrhosis.METHODS:Using the National Inpatient Sample (NIS) data from 2008 to 2014, we categorized admissions into decompensated cirrhosis (DC), compensated cirrhosis (CC), and NIS without cirrhosis. Descriptive statistics and regression analysis were used to analyze the association between patient characteristics, comorbidities, complications, and procedures with costs, LOS, and mortality in each group.RESULTS:The hospitalization costs for patients with cirrhosis increased 30.2% from 2008 to 2014 to $7.37 billion. Cirrhosis admissions increased by 36% and 24% in the DC and CC groups, respectively, compared with 7.7% decrease in the NIS without cirrhosis group. DC admissions contributed to 58.6% of total cirrhotic admissions by 2014. Procedures increased costs in both DC and CC groups by 15%–152%, with mechanical ventilation being associated with high cost increase and mortality increase. Complications are also key drivers of costs and LOS, with renal and infectious complications being associated with the highest increases in the DC group and infections and nonportal hypertensive gastrointestinal bleeding for the CC group.DISCUSSION:Economic burden of hospitalized patients with cirrhosis is increasing with more admissions and longer LOS in DC and CC groups. Important drivers include procedures and portal hypertensive and nonportal hypertensive complications.

Safety of reduced antigen content diphtheria-tetanus-acellular pertussis vaccine when administered during pregnancy as part of the maternal immunization program in Brazil: a single center, observational, retrospective, cohort study

ABSTRACT Reduced antigen diphtheria-tetanus-acellular pertussis (Tdap) vaccination is included in the maternal immunization program in Brazil since September 2014. We investigated associations between maternal Tdap vaccination and pregnancy-related adverse events (AEs) (gestational diabetes, pregnancy-related hypertension, and pregnancy hemorrhage) and neonatal AEs of interest (preterm birth and small for gestational age). This descriptive, observational, retrospective, single-center study in Brazil (NCT02757950) compared data from medical charts of 1203 pregnant women who received Tdap as part of the maternal immunization program and delivered between May 2015 and February 2017 (exposed cohort) and 1259 unvaccinated women who delivered between September 2012 and August 2014 (unexposed cohort). Index dates were defined as the time of vaccination (27–39 gestational weeks; exposed cohort) or 27 gestational weeks (unexposed cohort). Cumulative incidences were calculated as the number of women with each event between index and delivery dates divided by the total number of women with vaccination date available in the exposed cohort (N = 1199) or the total number of women in the unexposed cohort (N = 1259). Cumulative incidences per 1000 persons were 8.34 versus 17.47 for gestational diabetes, 9.17 versus 24.62 for pregnancy-related hypertension, 3.34 versus 15.09 for pregnancy hemorrhage, 53.38 versus 96.11 for preterm birth, and 57.55 versus 49.25 for small for gestational age in the exposed versus unexposed cohorts. No increased risk of pregnancy-related AEs or neonatal AEs of interest was found following maternal vaccination with Tdap. These results should be interpreted cautiously due to limitations inherent to retrospective observational studies.

ENDOSCOPIC INTRAVENTRICULAR HEMORRHAGE REMOVAL: CLINICAL OBSERVATION AND TECHNICAL FEATURES

The study objective is to describe a successful endoscopic therapy for a patient with hypertensive ventricular hemorrhage complicated by occlusive third ventricular hydrocephalus. Materials and methods. A 71-year-old patient with hypertensive hemorrhage into the III and IV ventricles, complicated by non-communicating hydrocephalus, was brought to hospital on the 1st day of the disease onset. Non-communicating hydrocephalus was accompanied by clinical signs of decompensation, depressed level of consciousness up to moderate coma (Glasgow Coma Scale score of 7). Specialists performed emergency endoscopic aspiration of blood clots from the III and IV ventricles and third ventriculostomy. Results. Endoscopically it was possible to remove the clots from the third ventricle and through the cerebral aqueduct from the fourth ventricle. Resuscitation and intensive care measures resulted in a favorable outcome: the patient was released with a moderate neurological deficit – left oculomotor nerve dysfunction. After 4 months, the patient required a ventriculoperitoneal shunt due to disresponsive form of hydrocephalus. Conclusion. Endoscopic aspiration allows removing hematomas from the third and fourth ventricles via the lateral ventricle effectively and safely.

Recurrent ruptured abdominal aneurysms in polyarteritis nodosa successfully treated with infliximab.

Systemic polyarteritis nodosa (PAN) is a rare form of necrotizing vasculitis in children. Recurrent episodes of abdominal aneurysm ruptures are uncommon and life-threatening condition in children. Failures of response to immunosuppressive medications and radiological intervention also lead to high mortality. Some reports suggested that tumor necrosis factor (TNF) might have role in the inflammation of this disease. After an English-language literature review, this is the first case report in children of recurrent abdominal-ruptured aneurysms with a failure of conventional therapy but successfully treated with anti-TNF-α monoclonal antibody. We herein describe a 9-year-old girl who presented with chronic abdominal pain, hypertension, and massive lower gastrointestinal bleeding. The disease was refractory to conventional treatment, including administration of a corticosteroid, cyclophosphamide, and intravenous immunoglobulin, and recurrent-ruptured aneurysms developed in the gastrointestinal tract. Arterial embolization during angiography resulted in temporary improvement of the gastrointestinal bleeding. Infliximab, a chimeric anti-tumor necrosis factor-α monoclonal antibody, was initiated and resulted in disease remission with resolution of the gastrointestinal bleeding and abdominal pain. Anti-TNF therapy might be another treatment option for refractory disease to prevent ongoing inflammation that could lead to aneurysmal dilatation or even rupture. However, early recognition of refractory disease and aggressive treatment in the early course of the disease are crucial to reduce morbidity and mortality.

An Optimized Data Management Model for Maternal Mortality in Bayelsa State

Maternal Mortality Rate (MMR) is the quantity of maternal deaths in a given duration per 100,000 of reproductive aged (15-49) women. This amounts to both the obstetric risk and the rate of recurrence at which women are unprotected to this risk. In Bayelsa State, the maternal mortality has high rates. The driving reasons for death are related with hypertensive disorder, severe bleeding, infection and other complications of delivery that could be avoided. This research aims to develop a maternal mortality system using Data mining techniques; estimation of maternal mortality rate in Otuasega Cottage Hospital in Ogbia Local Government Area in Bayelsa State was carried out by analyzing the causes of death during pregnancy; Naive Bayes was used in Bayes Server to classify Hypertensive diseases into preeclampsia and gestational, identifying the symptoms and risk factors. Among other causes of maternal death evaluated, Hypertensive disease was the highest cause of maternal death in Bayelsa State between 2012 to 2018. We developed a Bayesian maternal mortality estimation model, that catches increasing speeds and deceleration in the rate of progress in the maternal death rate. Result shows that the trend was as low as 2 maternal deaths in every 202 live births in 2012 but increased to 12 per 210 live births in 2016. The maternal mortality rate continued its upward trend and increased to 14 deaths per 172 live births in the year 2018. Maternal mortality rate which was very low have increased significantly, and most death were caused by Hypertensive, followed by bleeding, complications and little of infections. Keywords : Naïve Bayes, Bayesian Estimation Model, Maternal Mortality DOI : 10.7176/CEIS/10-5-02 Publication date :June 30 th 2019

Mo1223 SEASONAL VARIATION IN VARICEAL BLEDING IN THE UNITED STATES: A DATABASE STUDY

Gastroesophageal variceal bleeding (EVB) carries a significant morbidity and mortality in cirrhotic patients. Th effect of changing season on portal hypertension and variceal bleeding has been demonstrated in few countries like France and China in the past. However, a similar trend has not been studied in the United States. The aim of this study was to evaluate the seasonal variation in variceal bleeding in the US using national inpatient sample (NIS) data.

Effects of hemoglobin levels during pregnancy on adverse maternal and infant outcomes: a systematic review and meta-analysis.

Maternal anemia affects approximately 56 million women worldwide and increases the risk of adverse pregnancy outcomes. Our study aimed to summarize the evidence for the association between maternal hemoglobin (Hb) concentrations and maternal or infant outcomes, evaluating it in a continuous manner. In this systematic review and meta-analysis, we conducted an electronic search on PubMed, Embase, CINAHL, and Web of Science from inception to April 19, 2017, and further updated to November 21, 2018, applying subject heading terms related to pregnant women with anemia. We included 117 studies with 4,127,430 pregnancies. Maternal anemia increased the risk of low birth weight (odds ratio (OR), 1.65; 95% confidence interval (CI): 1.45-1.87), preterm birth (PTB) (OR, 2.11; 95% CI: 1.76-2.53), perinatal mortality (PNM) (OR, 3.01; 95% CI: 1.92-4.73), stillbirth (OR, 1.95; 95% CI: 1.15-3.31), and maternal mortality (OR, 3.20; 95% CI: 1.16-8.85). A nonlinear relationship was found between maternal Hb and adverse maternal and infant outcomes. The OR of outcomes such as PTB, small-for-gestational age, PNM, preeclampsia, gestational hypertension, and postpartum hemorrhage was increased by two to three times. Assessing Hb as a continuous variable is important to determine the associated risk of adverse outcomes with decreasing or increasing levels.

Using Near Miss Model to Evaluate the Quality of Maternal Care at a Tertiary Health-Care Center: A Prospective Observational Study.

Near miss (NM) concept has led to a more comprehensive and better assessment of effect of care on maternal health. It indicates the degree of organ function failure in the wide spectrum of severity. This was a prospective observational study conducted from July 2015 to Feb 2016. Among women with potentially life-threatening conditions (PLTCs), those fulfilling one or more WHO NM criteria were included and followed up till the final outcome (NM or death). Various critical interventions done in them were associated with the final outcome. Standardized mortality ratio (SMR) was calculated for assessment of overall quality of health care provided. One thousand seven hundred and thirty-nine patients had PLTCs of which 174 (10%) patients were identified as NM. Of 174 patients, 116 patients (66.66%) were discharged in stable condition (group A) and 58 patients (33.34%) died (group B). Hemorrhage (31.8%) was the most frequent complication in group A followed by hypertensive disorders (18.1%) and severe anemia (11.2%). The two most common causes of maternal mortality were hypertensive disorders (27.6%) and hemorrhage (24.1%). Only two critical interventions (assisted ventilation and massive blood transfusion) had significant association with the final outcome. SMR of our center was 1.187 indicating adequate quality of provision of care to the patients. Hemorrhage and hypertensive disorders were the two most common causes of NM and deaths highlighting the importance of their prompt diagnosis and vigorous management. Periodic SMR calculation can be used as an audit to guide us in improving the overall status of maternal health.

Apatinib in treating patients with platinum-resistant or platinum-refractory recurrent or metastatic nasopharyngeal carcinoma.

e17502 Background: To evaluate the efficacy and safety of apatinib in treating patients with platinum-resistant or platinum-refractory recurrent or metastatic nasopharyngeal carcinoma. Methods: In this phase 2, single-arm, prospective study, we recruited patients aged 18–65 years with platinum-resistant or platinum-refractory recurrent /metastatic nasopharyngeal carcinoma. Patients were treated with apatinib at an initial dose of 500 mg once daily and continued until disease progression, patient withdrawal, or unacceptable toxic effects. The primary endpoint was clinical benefit rate (CBR) and toxicity. Secondary endpoints included progression-free survival (PFS) at 3 months and overall survival (OS). We used Simon’s two-stage design, and analysed efficacy and toxicity in the intention-to-treat and per-protocol populations. This study is registered with ClinicalTrials.gov, number NCT03213587. Results: Between Aug 5,2017 and Oct 13,2018, we enrolled 16 patients. Until the final follow-up (Jan 14, 2019), the CBR (complete response + partial response+ stable disease) was 69.2% (9/13) in the per-protocol population. Median PFS and 3-month PFS rate were 3.70 (95% CI, 0-8.771) months and 67.1%, respectively. Median OS and 1-year OS rate were 12.9 (95% CI 5.56-20.23) months and 47.9%, respectively. The most common grade 3-4 adverse events were neutropenia (1[6.25%]), hand-foot syndrome (2[12.5%]), albuminuria (2[12.5%]), hypertension (1[6.25%]), hyponatremia (1[6.25%]), artery dissection (1[6.25%]) and nasopharyngeal hemorrhage (2[12.5%]) in the intention-to-treat population. Serious adverse event was reported in one patient who died of nasopharyngeal hemorrhage. Conclusions: Apatinib achieved excellent disease control in platinum-resistant or platinum-refractory recurrent or metastatic nasopharyngeal carcinoma. More attention needs to be paid to toxicity management. Clinical trial information: NCT03213587.