Minimal Bleeding Research Articles

Sinonasal Organised Haematoma- A Case Report and Review of Literature.

Sinonasal organised haematoma (SOH) is an uncommon, benign condition that can be locally aggressive. SOH can be mistaken for a malignant tumour but the characteristic imaging findings and histopathology facilitate the diagnosis of an organised haematoma. We report a 26 year old male patient presenting with unilateral nasal obstruction and painless epistaxis, which are the most common presenting symptoms of sinonasal tumour lesions. Based on the clinical features, age, radiological investigation, intraoperative finding, location of the lesion and histopathological examination; a diagnosis of SOH was arrived at. Surgical excision utilized the COBLATION technology and endoscopic complete removal of the nasal mass was done. Intraoperatively minimal bleeding was encountered. On histopathology, haematoma at the center and fibrosis at the periphery was noted. To our knowledge, this is the first reported case of SOH excision using Coblator. No recurrence was seen in subsequent follow ups. Although SOH can be mistaken for a malignant tumour, the characteristic imaging and histopathology findings facilitate the diagnosis of an organised haematoma.

Management of cesarean scar pregnancy: Importance of gestational age at diagnosis and disease type-A single center's 5 years of experience involving 223 cases.

This study aims to evaluate the importance of the gestational age at diagnosis and the types of cesarean scar pregnancy (CSP) for treatment outcomes and to identify the optimal treatment based on both the gestational age at diagnosis and the CSP type. A retrospective cohort study included 223 pregnant women diagnosed with CSP at Peking University First Hospital, Beijing, China, between 2014 and 2018. All CSP cases underwent ultrasound-guided vacuum aspiration followed by supplementary curettage. Adjuvant treatment modalities included intramuscular injection of systemic methotrexate, uterine artery embolization, and hysteroscopy before ultrasound-guided vacuum aspiration. Linear regression was used to determine the relationship between intraoperative blood loss and gestational age at diagnosis, CSP type, highest β-human chorionic gonadotropin level, and management procedures. None of the patients required blood transfusions or hysterectomies. Patients presenting at <8, 8-10, and >10 weeks had median estimated blood loss of 5, 10, and 35 ml, respectively. Patients with type I CSP, type II CSP, and type III CSP had median blood loss of 5, 5 and 10 ml, respectively. Multivariate linear regression analysis demonstrated that the gestational age at diagnosis (p < 0.001) and type of CSP (p = 0.023) were independent predictors of intraoperative estimated blood loss. For type I CSP patients, ultrasound-guided vacuum aspiration followed by supplementary curettage alone was performed in 15 of 34 (44.1%) patients, including 12/27 (44.4%) diagnosed at <8 weeks, 2/6 (33.3%) at 8-10 weeks, and 1/1 for >10 weeks. In type II CSP patients, fewer cases were managed by ultrasound-guided vacuum aspiration followed by supplementary curettage alone as the gestational age at diagnosis increased [18/96 (18.8%) for <8 weeks, 7/41 (17.1%) for 8-10 weeks, none for >10 weeks]. Most type III CSP patients (41/45, 91.1%) needed treatments in addition to the ultrasound-guided vacuum aspiration regardless of the gestational age at diagnosis. All CSP patients were treated successfully and did not require readmission or further medical interventions. Gestational age at diagnosis of CSP and its type show a strong correlation with estimated blood loss during ultrasound-guided vacuum aspiration. With careful management, CSPs may be treated at any gestational week, regardless of their type, with minimal intraoperative bleeding.

Management of Bleeding due to Vitamin K Deficiency in Neonates: A Case Report

Vitamin K deficiency bleeding (VKDB) is an uncommon and life-threatening bleeding condition in infancy. This study aimed to present a case of bleeding due to vitamin K deficiency in neonates. A 7-day-old male infant presented to an emergency department (ED) following bleeding from an umbilical stump for 3 hours upon arrival at the hospital. On examination of the general condition, the patient is in good health, responsive, conscious and active tonus. Physical examination revealed there were no petechiae, purpura, or ecchymoses. On the abdomen region, there was minimal bleeding in an umbilical area with periumbilical hemorrhagic crusting. Intense palpation revealed mild tenderness near the periumbilical area. When the umbilical area was palpated deeply, a thin, watery blood fluid oozed out. The results of routine blood laboratory examinations showed within normal limits (Hb 12 g/dL, leukocytes 6.9x103/μL, and platelets 150x10³/μL). This patient was diagnosed with bleeding due to vitamin K deficiency. The management given is in the form of a subcutaneous injection of vitamin K 10 mg for 3 days. After administration of the third injection, the patient's condition improves, and the umbilical hemorrhage subsides.

Woman with a lump under her tongue.

A 44-year-old woman presented to the emergency department with a complaint of a “stone under [her] tongue.” She reported that the “stone” had been present and painless for 2 years. The day prior she began experiencing pain at this site while brushing her teeth. She squeezed the area in an attempt to expel it, but this action only increased her pain. Physical exam revealed erythema and swelling localized to the inferior lingual frenulum at the Wharton's duct. A white calculus was partially visualized and palpable through the mucosal membrane (Figure 1). Otolaryngology was telephonically consulted and recommended infiltrating with local anesthetic and attempting manual expulsion or excising, if needed. Manual expulsion was unsuccessful; a single, 1-cm incision was made over the calculus, and a 0.5 cm × 0.75 cm sialolith was removed with minimal bleeding (Figure 2). The patient was discharged on a course of amoxicillin–clavulanic acid. Dehydration, trauma, anticholinergics, and diuretics predispose to the formation of sialoliths, with 80% to 90% arising from the submandibular glands.1 As with our patient, the most common presentation is a single calculus within Wharton's duct causing pain and swelling during periods of increased salivation (ie, brushing teeth, preparing to eat).2 The majority of sialoliths can be managed conservatively with hydrating, applying moist heat, massaging the gland, milking the duct, and advising the patient to suck on tart candies to promote salivation. Larger, more superficial sialoliths may require excision. Imaging and specialist referral should be considered in cases concerning for tumor, abscess, or treatment failure.3

DELAYED ONSET OF TREATMENT IN A PATIENT WITH ULCERATIVE COLITIS: A CASE OF HOW DISPARITIES AFFECT HEALTHCARE ACCESS

Abstract INTRODUCTION Most of the literature available on Inflammatory Bowel Disease (IBD) comes from studies performed in white population. Recent studies indicate a potential shift in the epidemiology of IBD in the United States, with significantly greater increases in incidence rates noted in non-White patients. (1) However, the burden of this disease on black and non-black Hispanic is unknown. This prompts a re-examination of the challenges these populations face including access to care issues and financial barriers. (2) Patients and health outcomes are impacted by multiple social and community factors often referred to as Social Determinants of Health (SDOH). SDOH are defined as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”(1) The concept of social determinants of health contributing to poor healthcare outcomes in certain populations comes from the recognition that race and economic factors are linked to awareness of disease and access to care. In this abstract, we describe a case that exhibits the mechanism in which social determinants of health lead to a poor health outcome. CASE DESCRIPTION An 18-year-old female college student from Hispanic background who presented with diarrhea associated with weight loss for 6 months, seen by a local gastroenterologist who performed a colonoscopy that depicted patchy inflammatory changes throughout the colon with microscopic evidence of ulcerative colitis for which she was prescribed Infliximab, however, she was unable to afford the medication due to the high out-of-pocket cost and she did not receive and alternative medication nor follow up from her physician. For the next few months, the patient was not receiving treatment which resulted in a course of protracted diarrhea and gastrointestinal bleed with hypovolemic shock and ICU admission. At that time, abdominopelvic CT scan demonstrated inflammatory changes of the transverse and left colon. During admission she was started on the aforementioned drug and on discharge she was again prescribed Infliximab, however this time our patient started working as part time and was able to obtain the medication through her private insurance. Since the onset of treatment she has improved, her bowel frequency went from about 20 bowel movements daily to 4-5. She is still having minimal rectal bleeding, but the volume of blood has decreased considerably. DISCUSSION This case illustrates one of the many examples of how health disparities impact disease course. Although recently literature that discusses health disparities in IBD patients is increasing, it is essential to focus on social determinants of health as the cause of inequities in patient care in order to improve disease outcome on these underrepresented populations.

Electrothermal Vessel Sealing Versus Conventional Suturing in Abdominal Hysterectomy: A Randomised Trial.

The present randomised controlled trial was conducted to compare haemostatic efficiency, operative time, and overall performance of the electrothermal bipolar vessel sealing (EBVS) system with conventional suturing in abdominal hysterectomy. The trial was designed with standard parallel arms, i.e., vessel sealing and suture ligature arms. Sixty patients were block randomised into either arms with 30 patients in each. A hand-held vessel sealing instrument was used to perform a hysterectomy in the vessel sealing arm and the quality of the uterine artery seal achieved at the first attempt was graded on an ordinal scale of 1-3 to quantify haemostatic efficiency. Operative time, intra-operative blood loss, and peri-operative complications were compared between the two arms. Significantly reduced mean operative time (26.97±8.92vs 33.67±8.62 minutes; p=0.005) and intra-operative blood loss (111±53.31 mL vs 320±193.90 mL; p=0.001) was observed in the Vessel Sealing Arm compared to Suture Ligature Arm. Of total 60 uterine seals (from bilateral uterine artery transaction in 30 hysterectomies in the Vessel Sealing Arm), 83.34% were Level 1 with Complete Seal and no residual bleeding, 8.33% were Level 2 or Partial Seals with minimal bleeding, requiring the use of vessel sealers for a second time, while 8.33% had Seal Failure (Level 3) with significant bleeding requiring additional re-security of stumps with sutures. Modal pain scores on the first three postoperative days and duration of hospital staywere significantly less in the Vessel Sealer Arm, reflecting reduced postoperative morbidity. Outcomes were comparable across operators. Vessel Sealing System gives superior surgical results with lesser operative time, minimal blood loss, and reduced morbidity.

Attaining competency and proficiency in minimally invasive mitral valve repair: a learning curve assessment using cumulative sum analysis

ObjectiveTo evaluate the learning curve of minimally invasive mitral valvuloplasty (MVP).BackgroundMinimally invasive MVP is characterized by minimal trauma, minimal bleeding, and short postoperative recovery time. The learning curve of any new procedure needs to be evaluated for learning and replication. However, minimally invasive mitral valve technique is a wide-ranging concept, no further analysis of the outcomes and learning curve of minimally invasive Mitral valvuloplasty has been performed.MethodsOne hundred and fifty consecutive patients who underwent minimally invasive MVP alone without concurrent surgery were evaluated. Using cardiopulmonary bypass (CPB) time and aortic clamping (AC) time as evaluation variables, we visualized the learning curve for minimally invasive MVP using cumulative sum analysis. We also analyzed important postoperative variables such as postoperative drainage, duration of mechanical ventilation, ICU stay and postoperative hospital stay.ResultsThe slope of the fitted curve was negative after 75 procedures, and the learning curve could be crossed after the completion of the 75th procedure when AC and CPB time were used as evaluation variables. And as the number of surgical cases increased, CPB, AC, postoperative drainage, duration of mechanical ventilation, ICU stay and postoperative hospital stay all showed different degrees of decrease. The incidence of postoperative adverse events is similar to conventional Mitral valvuloplasty.ConclusionCompared to conventional MVP, minimally invasive MVP provides the same satisfactory surgical results and stabilization can be achieved gradually after completion of the 75th procedure.

A novel obstetrical surgical intervention – New episiotomy: Case series study

ObjectivesTo establish anatomical structures responsible for creating a resistance force on a fetal head during vaginal delivery at term; to develop a new episiotomy to widen the vaginal outlet. DesignA prospective observational case series study. SettingInternational centers. PopulationEighteen consecutive women at term during vaginal delivery. MethodsV-shape excision made on the hymeneal membrane, hymeneal ring, and hymeneal plate without extending an incision to the posterior perineal structures. Outlectorrhaphy (repairing the vaginal outlet to repair the surgical defect. Excisional specimens are subjected to histological examinations. Main outcome measuresThe primary maternal outcome measures were postpartum posterior perineum pain associated with vaginal outlectomy. The secondary outcomes measured a) complication of vaginal outlectomy; b) occurrence of dyspareunia after vaginal outlectomy; c) applicability of vaginal outlectomy; d) neonatal outcome measured by an APGAR score to show how the neonate tolerated the vaginal delivery process with vaginal outlectomy implementation. ResultsThe V-shape excision widened the vaginal outlet sufficiently for a vaginal delivery without a perineal incision. Outlectorrhaphy requires two or three simple interrupted sutures to close surgical defects and eliminate the vaginal gapping appearance. Eleven out of eighteen women were primigravida (61.1 %), and four multiparas (38.9 %) delivered a live newborn vaginally with a newly developed vaginal outlectomy. A median newborn’s weight was 350 g ± 250 g, and APGAR scores at 5 min were median of 9 ± 1. One out of eighteen patients experienced extension of the skin, perineal fascia, and bulbospongiosus muscle. Bleeding from the extension tearing of vaginal outlectomy was heavier than from uncomplicated vaginal outlectomy but negligible. Immediately postpartum, patients reported no moderate or severe perineal pain. At a 3-month postpartum, none of the subjects reported superficial or deep dyspareunia. Histology from the vaginal outlectomy specimens described the direct connection of the longitudinal vaginal smooth muscles to the hymeneal plate and compact connective tissues (like cartilage) of the hymeneal ring. Additionally, the histological examination showed the absence of the perineal skeletal muscle within the vaginal outlectomy specimens. ConclusionsThe vaginal outlet is responsible for the most vital resistance force on a fetal head during delivery. Vaginal outlectomy widens the vaginal outlet sufficiently for a fetal vaginal birth with minimal bleeding and is easy to repair. No moderate-severe perineal pain or dyspareunia occurred in this study group. Tweetable abstractVaginal outlectomy eliminates postpartum moderate-to-severe perineal pain and superficial dyspareunia.The posterior perineum creates no resistance force on the fetal head during vaginal delivery to warrant incision.

Red Out: Bleeding During Robotic Retroperitoneal Lymph Node Dissection and Strategies To Manage It

Robotic retroperitoneal lymph node dissection is emerging as an attractive minimally invasive technique to remove residual and recurrent retroperitoneal masses in patients with germ cell malignancies. It has huge potential benefits for patients in terms of lower rates of blood loss, ileus, postoperative pain, and scarring, and faster return to full activity. Inadvertent injury to the great vessels, lumbar tributaries, and other vessels is not uncommon and requires a calm but strategic management response. A thorough knowledge of the standard anatomy, specific pathology, and anatomic variations will help robotic surgeons in managing intraoperative haemorrhage. We describe the anatomy of the retroperitoneal vessels, surgical case selection, and the technical and nontechnical skills essential for success in this complex and high-risk procedure. Patient summaryRobot-assisted surgical removal of lymph nodes from the area behind the abdominal cavity is a complex operation that has minimal bleeding if all goes well. However, as it involves operating on the major abdominal blood vessels, there is a risk of life-threatening bleeding that the operating team must be able to rapidly control. Effective teamwork and a range of advanced technical skills are required to respond to any serious bleeding.

Posterior Sagittal Approach for Nonanorectal Malformation: Widening Spectrum.

Posterior sagittal is a very well accepted approach in the treatment of anorectal malformations. This approach provides good access and exposure through the perineum to the deep pelvic structures. It reduces risk of injury to important structures as dissection remains in midline. To access feasibility of posterior sagittal approach for non-anorectal malformation indications and to widen the spectrum. We present a series of 10 cases of non-anorectal malformations operated by this approach for 4 years. Six patients included in the study were of Disorders of Sexual Differentiation with pseudovagina, three of Y duplication of the urethra, and one of cervical atresia. All patients had good results. Posterior sagittal approach is feasible, safe with minimal bleeding, and no postoperative incontinence. It can safely be used for non-anorectal indications.

Impact of Dexmedetomidine Infusion during Functional Endoscopic Sinus Surgery: A Randomised Controlled Trial

Introduction: Functional Endoscopic Sinus Surgery (FESS) requires a surgical field with minimal bleeding, and numerous pharmacological agents have been used to achieve this. Dexmedetomidine has been widely used as a sedative, analgesic, and as a supplement to general anaesthesia. It has been found to decrease norepinephrine release, thereby decreasing heart rate (HR) and blood pressure. These properties, along with its opioid-sparing analgesic effects, make it an attractive drug to use during FESS. Aim: The aim of this study was to determine if dexmedetomidine infusion during FESS improves the visibility of the surgical field, provides stable haemodynamics, and alters the consumption of sevoflurane and other anaesthetic agents. Materials and Methods: This randomised, double-blinded controlled trial was conducted at the Otorhinolaryngology Operation Theatre, BYL Nair Charitable Hospital, Mumbai, India, from July 2018 to December 2019. The study included 100 patients of either sex, with American Society of Anaesthesiologists (ASA) I and II classification, aged 18-55 years, who were randomly divided into two groups. Group D received a dexmedetomidine infusion (0.5 mcg/kg/hour), while group C (control group) received a saline infusion. Haemodynamic parameters, Minimum Alveolar Concentration (MAC) of sevoflurane, surgeon’s grading of the operative field, and the requirement of additional hypotensive agents were compared. Statistical analysis was performed using Student’s unpaired t-test to evaluate the significance of normally distributed variables, Mann-Whitney U test and Chi-square test for ordinal data and categorical variables. Results: The groups were comparable with respect to age, weight, gender, and ASA grade. The average mean MAC of sevoflurane at various time intervals was 1.135±0.664635 in group D and 1.9675±0.438 in group C, which was statistically significant. The surgeon’s grading of the surgical field using the Fromme and Boezaart scale was significantly better in group D (1.53±0.45625 versus 2.907±0.5835 in the control group). Although not statistically significant, more number of patients in group C needed additional drugs to lower HR and blood pressure. Conclusion: Dexmedetomidine infusion during FESS is effective in maintaining stable haemodynamics with a lesser need for additional agents to lower HR and Mean Arterial Pressure (MAP). It improves the visibility of the surgical field and decreases the MAC of sevoflurane required to maintain anaesthesia.

Pressure Therapy for Pyogenic Granuloma.

Pyogenic granuloma is a benign vascular tumor, with a tendency to bleed on manipulation. A young female presented to us with a disfiguring facial pyogenic granuloma. We adopted a novel approach using pressure therapy to treat the same. The use of an elastic adhesive bandage reduced the size and vascularity of the lesion, following which laser ablation was done with minimal bleeding and scarring. This is a simple, inexpensive method to approach large and disfiguring pyogenic granulomas.

Comparative evaluation of the antibacterial activity of red diode laser therapy and 0.2% chlorhexidine against Aggregatibacter actinomycetemcomitans on implant healing abutments: An ex vivo study.

The intraoral microbiota has a high potential to undergo dysbiosis, causing inflammatory changes with respect to the tissues surrounding either a natural tooth or an implant. Thus, the longevity of implant prosthesis depends on a thorough implant decontamination protocol. Among all the techniques available for doing so, laser is garnering increasing popularity, owing to minimal bleeding, high efficiency, and faster healing. However, limited literature exists regarding the superiority of lasers over chlorhexidine (CHX), the indisputable gold standard antibacterial chemical agent. The aim of this study was to compare the percentage of bacterial reduction of Aggregatibacter actinomycetemcomitans from implant healing abutments post red diode laser therapy versus 0.2% CHX treatment. The current study had an ex vivo, observational, case-control design. Patients reporting for the second stage of the implant surgery were taken as the source of data and the healing abutments, the clinical samples. Eleven patients were chosen with one intraoral implant serving as the test site for laser treatment and another, the control site for CHX treatment. Microbiological analysis was performed via quantitative real time polymerase chain reaction to compare the bacterial reduction percentage after each treatment. Repeated measures ANOVA and independent sample t test were used. The mean bacterial viability of the test group (laser) was 1.2%-1.6%, and 0.6%-1.4% for the control group (CHX). The former caused a mean bacterial reduction of 96.1% while the latter, 96.3%. Both the treatments caused a highly statistically significant reduction of viable bacterial counts (P = 0.001). However, when compared, there was no statistically significant difference in the bacterial reduction, when compared in between the two (P = 0.902). Laser treatment is at par with chemical implant surface decontamination. It can help bypass the complications of CHX and revolutionize the protocols for implant surface decontamination.

Stroke-Specific Predictors of Major Bleeding in Anticoagulated Patients With Stroke and Atrial Fibrillation: A Nationwide Multicenter Registry-Based Study.

The congestive heart failure, hypertension, age, diabetes, previous stroke/transient ischemic attack (CHA2DS2-VASc) and hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) scores have been validated in estimating the risks of ischemic stroke and major bleeding, respectively, in patients with atrial fibrillation (AF). This study investigated stroke-specific predictors of major bleeding in patients with stroke and AF who were taking oral anticoagulants (OACs). Subjects were selected from patients enrolled in the Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION) nationwide multicenter registry between 2013 and 2015. Patients were excluded if they were not taking OACs, had no brain imaging data, or had intracranial bleeding directly related to the index stroke. Major bleeding was defined according to International Society of Thrombosis and Haemostasis criteria. Cox regression analyses were performed to assess the associations between clinical variables and major bleeding and Kaplan-Meier estimates were performed to analyze event-free survival. Of a total of 3,213 patients, 1,414 subjects (mean age of 72.6 years, 52.5% males) were enrolled in this study. Major bleeding was reported in 34 patients during the median follow-up period of 1.73 years. Multivariable analysis demonstrated that initial National Institutes of Health Stroke Scale scores (hazard ratio [HR] 1.07, p=0.006), hypertension (HR 3.18, p=0.030), persistent AF type (HR 2.51, p=0.016), and initial hemoglobin level (HR 0.74, p=0.001) were independently associated with major bleeding risk. Except for hypertension, these associations remained significant after adjusting for the HAS-BLED score. Intracranial atherosclerosis presented a trend of association without statistical significance (HR 2.21, p=0.050). This study found that major bleeding risk was independently associated with stroke-specific factors in anticoagulated patients with stroke and AF. This has the clinical implication that baseline characteristics of patients with stroke and AF should be considered in secondary prevention, which would bring the net clinical benefit of balancing recurrent stroke prevention with minimal bleeding complications.

A Rare Case of Large Hydatidiform Mole Mimicking a Term Pregnancy

Molar pregnancy is a type of abnormal pregnancy that usually presents with amenorrhea, vaginal bleeding and elevated serum ß-hCG levels. We report a rare case of complete hydatidiform mole occurring in a 46-year-old P2L2 lady who presented with a term size uterus and elevated serum ß-hCG level (&gt; 15,00,000 per deciliter, anemia (hemoglobin: 8.1 g/dL), difficulty in breathing and minimal vaginal bleeding. During the course of her evaluation, she had profuse vaginal bleeding, she underwent suction and evacuation, but bleeding was not controlled despite measures to control it. She was given uterotonics and antifibrinolytic agents and uterine artery ligation. But was proceeded with emergency hysterectomy for uncontrolled hemorrhage. The content of suction and evacuation was vesicles with blood clots and histopathology was reported as complete hydatidiform mole. The patient received a total of 4 units of packed red blood cells. She was discharged from hospital on 5th postoperative day and was followed up serial serum ß-hCG level. Therefore, complete mole can present with enlarged uterus, vaginal bleeding and anemia. It is also important to note that intractable bleeding following suction and evacuation not being controlled with uterotonics and antifibrinolytic agents and uterine artery ligation may require hysterectomy to save the patient’s life.

CASE STUDY OF A PARAVAGINAL HAEMATOMA FOLLOWING VAGINAL DELIVERY

We present the case of a primigravida who had an induced delivery for mild IUGR at 38+6weeks. She had a normal vaginal delivery with right mediolateral episiotomy and minimal vaginal bleeding. She complained of increasing rectal pain in the postpartum period. Vaginal examination revealed a large left sided vaginal haematoma with intact episiotomy wound site.The haematoma was evacuated ,wound exploration done and sutured in layers. Vaginal packing was done. Postoperatively she again complained of rectal pain. Urgent CT scan conrmed nding of a large left pararrectal haematoma with possibility of small left broad ligament extension. She was managed conservatively with vaginal and rectal packing, analgesics,intravenous antibiotics and 3units of packed red cell transfusion. Follow up ultrasound showed reduction in the size of the haematoma and eventual resolution. This case supports the conservative management of even large paravaginal haematomas, when surgical evacuation is technically difcult as long as the patient is clinically stable.

Interventional treatment of haemorrhoids in anticoagulated patients

Anticoagulants are currently widely used for cardiological reasons, stroke prevention and in other vascular diseases. Colorectal surgeons face patients suffering from haemorrhoids who are put on anticoagulant therapy in their everyday practice. Anticoagulation strategy for patients undergoing interventional treatment of haemorrhoids has not been discussed in detail in the literature so far. Standard management of grade 1-3 haemorrhoids includes rubber band ligation (RBL), sclerotherapy (SCL) and infrared coagulation (IRC) after unsuccessful conservative treatment. The rates of postprocedural bleeding range from 0.9-2.8% after rubber band ligation, 0-2.7% after sclerotherapy and 5% after infrared coagulation. Surgical procedures including dearterialization, haemorrhoidectomy and stapled haemorrhoidopexy are indicated in more advanced degrees as the third line of treatment and are complicated by postoperative bleeding in 1.4-5.9% and 2-7.9% patients, respectively. Haemorrhoidectomy is the best option in grade 4 haemorrhoids and is associated with 6.2-8.4% risk of bleeding. However, closed haemorrhoidectomy, Ligasure technique and/or anal tamponade can reduce this risk. Surgical guidelines recommend continuing acetylsalicylic acid in low bleeding risk procedures, including haemorrhoidal surgery. However, postoperative bleeding after rubber band ligation was more common in the aspirin group. On the other hand, haemorrhage incidence after sclerotherapy did not differ significantly between the group on anticoagulation compared with the group without anticoagulation. Haemorrhoidectomy should be postponed for 6 months in patients receiving dual antiplatelet therapy. According to the guidelines, vitamin K antagonists should be discontinued 5 days before haemorrhoidal surgery. Minimal bleeding risk procedures do not require discontinuation of anticoagulation,but this option seems to be hazardous for patients undertaking rubber band ligation. Sclerotherapy, on the other hand, could not require warfarin discontinuation if the international normalized ratio (INR) is within therapeutic range. Novel oral anticoagulants (NOACs) should be discontinued 1 day before low bleeding risk operations, including haemorrhoidectomy and resumed 1 day after the procedure. In conclusion, all anticoagulants should be ceased prior to operation except for aspirin. There are not clear recommendations on the perioperative protocols for continuation or discontinuation of blood thinners in patients undergoing minimally invasive procedures.

The Effectiveness of Total Intravenous Anesthesia (TIVA) in Functional Endoscopic Sinus Surgery (FESS)

A 58-year-old female presented for Functional Endoscopic Sinus Surgery (FESS) to treat chronic rhinosinusitis. FESS is the mainstay treatment currently for chronic rhinosinusitis, with or without nasal polyps. Goals for FESS include optimal visualization of anatomical structures with minimal bleeding in the surgical field.1 The anesthetic technique chosen, either total intravenous anesthesia (TIVA) or inhalational anesthesia (IA), has shown to affect the visibility of the sinonasal mucosa, dictating the outcome of intraoperative blood loss. The difference between these agents are how they produce vasodilation in the body, particularly in the nasal mucosa.2,7,8 Current evidence supports TIVA as the superior anesthetic technique in FESS, as it has shown to successfully reduce intraoperative blood loss with superior surgical visibility.

Long-term dual antiplatelet therapy and nuisance bleeding: impact on quality of life.

Long term dual antiplatelet therapy (LTDAPT), with ticagrelor 60 mg and low-dose aspirin, is indicated after acute coronary syndrome (ACS) for the secondary prevention of atherothrombotic events in high-risk patients with a history of ACS of at least 1 year. LTDAPT had a good tolerability and safety profile, but the risk of TIMI major bleeding was increased. However, even non-significant bleeding may be important because it has an effect on the quality of life and therefore may lead to treatment discontinuation. We, therefore, evaluated patients' experiences with LTDAPT and the impact of nuisance bleeding on quality of life and treatment adherence. We retrospectively reviewed 225 patients in follow-up after ACS with at least one high-risk condition, treated with ticagrelor 60 mg twice daily (after 90 mg twice daily for 12 months). The outpatient follow-up program after hospitalization provides a visit on day 30 after discharge, then after 3 months, continuing with six-monthly checks. We assessed the presence and intensity of bleeding, as well as health-related quality of life (HRQoL), at each visit. The TIMI score was used to determine the severity of the bleeding. Any overt bleeding event that did not meet the major and minor criteria was labeled "minimal" and could be framed as "nuisance bleeding." The HRQoL was assessed by the EuroQol-5 and Dimension (EQ-5D) visual analog scale (VAS) score. Minimal bleedings were present in 49 patients (21%), but only in one case (by decision of the patient) there was a cause for discontinuation of therapy. However, 39 (79%) subjects had asked for opinions on stopping the therapy during the telephone consultation. Factors influencing LTDAPT knowledge included access to medication counselling, engaging with information communicated during medication counselling, and access to timely, relevant and expert information and advice after discharge from the hospital. All adverse events, judged to be "not serious" in trials, may have an effect on the quality of life and therefore may lead to treatment discontinuation. The authors underline the importance of careful outpatient follow-up and ongoing counselling, to check out compliance and possible adverse effect of LTDAPT.

Updated Results of the Alta Study, a Phase 1/2 Study of Giroctocogene Fitelparvovec (PF-07055480/SB-525) Gene Therapy in Adults with Severe Hemophilia Α

Introduction: Hemophilia A, a sex-linked (F8 gene) disorder of hemostasis, results in insufficient factor VIII (FVIII) activity. Adeno-associated virus (AAV)-mediated gene transfer enables the delivery of a modified functional F8 coding sequence to hepatocytes. This subsequently synthesizes FVIII at levels preventing unprovoked bleeding events in the absence of exogenous FVIII. We present updated results with nearly 3-year follow-up on all participants from Alta, an ongoing gene therapy study in patients with severe hemophilia A (FVIII activity <1%). Methods: The phase 1/2 Alta study (NCT03061201) is a dose-ranging study of giroctocogene fitelparvovec (PF-07055480, previously called SB-525), which is a recombinant AAV serotype 6 vector encoding a modified B-domain-deleted F8 coding sequence. Giroctocogene fitelparvovec was infused into adults aged ≥18 years with severe hemophilia A in 4 cohorts (n=2 each) across 4 ascending doses: 9e11, 2e12, 1e13, and 3e13 vg/kg. The 3e13-vg/kg dose cohort was expanded with 3 additional participants. Key endpoints included safety, circulating FVIII activity, use of FVIII replacement therapy, and frequency of bleeding events. We present data with nearly 3 years of follow-up (data cutoff date: May 20, 2022). Results: Eleven male patients participated in the study (mean [SD] age, 30.3 [7.8] years; White, 81.8%). As of the cutoff date, participants had been followed for 147 to 247 weeks and 2 had not completed 3 years (156 weeks) . The most common treatment-related adverse events (AEs) reported in the highest dose cohort (3e13-vg/kg) included elevated liver enzymes and infusion-related reactions (n/N [%]): increased alanine aminotransferase (ALT; 3/5 [60.0%]), increased aspartate aminotransferase (AST; 2/5 [40.0%]), pyrexia (3/5 [60.0%]), and tachycardia (2/5 [40.0%]). Treatment-related serious AEs were reported in 1 participant (in the 3e13-vg/kg cohort) who experienced hypotension and fever with onset ≈6 h after giroctocogene fitelparvovec infusion; the events fully resolved with treatment and did not delay post-infusion discharge the next day. AEs (all causality) of ALT increases requiring ≥7 days of corticosteroids were observed in 4 of the 5 participants in the 3e13-vg/kg cohort: elevations in ALT were managed with a tapering course of corticosteroids (median duration: 56 days; range: 7-135 days), with maintenance of efficacious levels of FVIII activity, as evidenced by a lack of bleeding events around the time of corticosteroid treatment and minimal bleeding events afterwards. No participant in the 3e13-vg/kg cohort developed a confirmed inhibitor to FVIII, and there have been no thrombotic events or hepatoma detected. The three of the 5 participants in the 3e13-vg/kg cohort with available data through Week 156 had mean FVIII activity maintained in the mild to normal range (Table). Of the data available for the remaining 2 participants, 1 maintained FVIII activity levels in the mild range through Week 130 and 1 participant had FVIII activity levels below lower level of quantification (<3%) as measured with a chromogenic assay and 5.4% measured with a 1-stage assay at Week 130. In this cohort, the mean annualized total bleeding rate [(number of all bleeding episodes starting 3 weeks after study drug infusion) / (observation period in years)] was 0 for the first year postinfusion and 0.9 throughout the total duration of follow-up. In the 3e13-vg/kg cohort, 2 participants experienced an overall total of 12 bleeding events necessitating treatment with exogenous FVIII (participant 1 (n=1 event): circumstances of bleed unknown, event occurred in a target joint; participant 2 (n=11): 6 traumatic; 4 spontaneous; 1 unknown, no events occurred in a target joint). No participants in the 3e13-vg/kg cohort have resumed prophylaxis. Conclusions: A single infusion of giroctocogene fitelparvovec gene therapy in participants with severe hemophilia A remains generally well tolerated over a period of nearly 3 years postinfusion, with associated increases in FVIII levels in the moderate to normal range, without sustained AEs and with minimal overall bleeding in the highest-dose cohort (3e13 vg/kg). The ongoing phase 3 study (NCT04370054) in a larger cohort will provide more long-term data to further characterize the safety and durability of giroctocogene fitelparvovec in patients with moderately severe to severe hemophilia A. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal