Moderate Bleeding Research Articles

Езофагодуоденостомія за методом Накаяма як реконструктивний етап після гастректомії з приводу раку шлунка, ускладненого гострою кровотечею та метастазами Крукенберга. Клінічний випадок

Purpose - on a clinical case to justify the technical aspects of applying the Nakayama esophago-duodenostomy as a reconstructive stage after gastrectomy for gastric cancer complicated by acute bleeding and Krukenberg metastases. Clinical case. Patient O., born in 1975, was being treated for stomach cancer complicated by moderate acute bleeding and Krukenberg metastases in the surgery department No. 3 of the Kyiv City Emergency Clinical Hospital. The patient general clinical, special laboratory and instrumental research methods were carried out (electrocardiography, esophagogastroduodenoscopy, ultrasound examination of the organs of the abdominal cavity and small pelvis, computer tomography of the organs of the abdominal cavity and small pelvis with intravenous contrast). The patient had cancer of the cardiac part of the stomach, complicated by moderate gastrointestinal bleeding with the presence of Krukenberg metastases, in connection with which the patient underwent surgery in the early delayed period according to a unique method - gastrectomy with lymphodissection in the volume of D2+ and overlapping esophageal-duodenal anastomosis according to the Nakayama type in the modification of the clinic. The patient was discharged in a satisfactory condition on the 10th day after surgery under the supervision of an oncologist and a surgeon at her place of residence. During the dynamic observation for 12 months, she felt satisfactory. Conclusions. Using the example of a clinical case, the technical aspects of applying the Nakayama esophagoduodenostomy as a reconstructive stage after gastrectomy for gastric cancer complicated by acute bleeding and Krukenberg metastases are substantiated. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Clinical outcomes of transbronchial cryobiopsy using a 1.1-mm diameter cryoprobe for peripheral lung lesions - A prospective pilot study

ObjectivesTransbronchial cryobiopsy (TBCB) is a novel technique for the diagnosis of peripheral lung lesions (PLLs). We aim to evaluate the clinical outcomes of TBCB using a new 1.1-mm diameter cryoprobe for the diagnosis of PLLs. Materials and methodsWe performed a prospective observational pilot study on the diagnosis of PLLs (diameter ≤30 mm) by TBCB, using a 1.1-mm diameter cryoprobe with radial endobronchial ultrasound (RP-EBUS), virtual bronchoscopic navigation and fluoroscopy from December 2021 to July 2022. Primary outcome was the pathological diagnostic yield of TBCB, and secondary outcome was adverse event. ResultsA total of 50 patients were enrolled (mean lesion size, 21 mm). TBCB was performed in 49 patients up to three times except for the one with “invisible” finding on RP-EBUS. The overall diagnostic yield of TBCB was 90% (45/50). There was no difference in the diagnostic yield between size (20 mm vs. 20–30 mm; 88% [22/25] vs. 92% [23/25]; P = 1.000), RP-EBUS findings (concentric vs. others; 97% [28/29] vs. 81% [17/21]; P = 0.148), and acute angle location (apical segment of both upper lobes vs. others; 92% [12/13] vs. 89% [33/37]; P = 1.000). The cumulative diagnostic yields of the first, second, and third TBCB were 82% (41/50), 88% (44/50), and 90% (45/50), respectively. Mild bleeding was developed in 56% (28/50), and moderate bleeding was found in 26% (13/50). ConclusionTBCB using a 1.1-mm diameter cryoprobe is an effective, reasonable method for the diagnosis of PLLs regardless of its size, RP-EBUS finding, and anatomical location without serious complication. Trial registrationClinical Trials.Gov (NCT05046093).

Применение «безнефростомной» перкутанной нефролитотрипсии у детей.

Introduction. Currently, percutaneous renal surgery is a common surgical procedure in urologic practice for the treatment of large and staghorn renal stones. Placement of a nephrostomy tube has been well recognized as a standard procedure to provide hemostasis, adequate drainage, and access for additional endoscopic procedures. At the same time, the use of a nephrostomy tube has negative consequences such as discomfort/pain symptom, longer hospital stay and possible urine extravasation. In view of the above, draining of the access tract raises questions in some cases. The aim of the study was effectiveness of tubeless percutaneous nephrolithotripsy in the treatment of urolithiasis in children. Materials and methods. Between 2013 and 2019, 66 patients (aged 1-17 y/o) underwent tubeless percutaneous nephrolithotomy (PNL) at the Department of Pediatric Urology of N. Lopatkin Scientific Research Institute of Urology and Interventional Radiology. Patients were divided into three groups depending on the size of the instruments and the way the operation was completed. The first group (n=28) underwent surgery using the mini-PNL technique with the closure of the access tract. The second group (n=21) underwent surgery using the mini-PNL technique in the end of the surgery, moderate bleeding along the tract was detected in order to stop bleeding, a hemostatic matrix with thrombin was introduced. The third group (n=17) underwent surgery using the standard PNL technique and moderate bleeding was also determined in this group with the aim of tubeless completion, a hemostatic matrix with thrombin was introduced. Drainage of the upper urinary tract in the postoperative period was carried out by "JJ"-internal and "J"-external ureteral stents, which were held for up to 14 days. Results. The complete removal of the calculus in one surgical session was similar in all three groups. In the first group there were 26 (92.8%) children, in the second group 19 (90.4%) and in the third group 16 patients (94.1%). In the first group it was 26 (92.8%) children, in the second group 19 (90.4%) and in the third group 16 patients (94.1%). The need for additional interventions after surgical treatment was 21.4% in the first group, 23.7% in the second and 17.5% in the third group. Febrile fever (persistent temperature 380 C) most often occurred in the first group – in 10.7% of cases, while in the second and third groups this complication was detected in 4.7% and 5.8% of cases, respectively. Gross hematuria in the postoperative period was noted in the group without the use of a hemostatic matrix, averaging 35 (2-115) hours. Conclusion. The proposed tubeless PNL with the use of a hemostatic matrix is indicated for children without bacteriuria, with complete removal of the calculus, in the absence of trauma of the pelvicalyceal system and intensive bleeding. The duration of gross hematuria decreased with the introduction of the matrix in standard tubeless PNL by 51.4% and in mini-PNL by 25.8% compared with the 1-st group

Association of CYP2C19 Loss-of-Function Metabolizer Status With Stroke Risk Among Chinese Patients Treated With Ticagrelor-Aspirin vs Clopidogrel-Aspirin

The Clopidogrel With Aspirin in High-Risk Patients With Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial showed that ticagrelor-aspirin combination therapy reduced the risk of stroke compared with a clopidogrel-aspirin combination among carriers of CYP2C19 loss-of-function (LOF) alleles after a transient ischemic attack (TIA) or minor ischemic stroke. However, the association between the degree of CYP2C19 LOF and ideal treatment allocation remains unknown. To investigate whether the efficacy and safety of ticagrelor-aspirin vs clopidogrel-aspirin are consistent with the expected degree of CYP2C19 LOF after TIA or minor stroke. CHANCE-2 was a multicenter, double-blind, double-dummy, placebo-controlled randomized clinical trial. Patients were enrolled at 202 centers in China from September 23, 2019, through March 22, 2021. Patients with at least two *2 or *3 alleles (*2/*2, *2/*3, or *3/*3) according to point-of-care genotyping were classified as "poor metabolizers," and those with one *2 or *3 allele (*1/*2 or *1/*3) were classified as "intermediate metabolizers." Patients were randomly assigned in a 1:1 ratio to receive ticagrelor (180-mg loading dose on day 1 followed by 90 mg twice daily for days 2-90) or clopidogrel (300-mg loading dose on day 1 followed by 75 mg/d for days 2-90). All patients received aspirin (75- to 300-mg loading dose followed by 75 mg/d for 21 days). The primary efficacy outcome was a new ischemic or hemorrhagic stroke. The secondary efficacy outcome was a composite of new clinical vascular events and individual ischemic stroke events within 3 months. The primary safety outcome was severe or moderate bleeding. Analyses were performed according to the intention-to-treat principle. Of the 6412 patients enrolled, the median age was 64.8 years (IQR, 57.0-71.4 years), and 4242 patients (66.2%) were men. Of the 6412 patients, 5001 (78.0%) were intermediate metabolizers, and 1411 (22.0%) were poor metabolizers. The primary outcome occurred less often with ticagrelor-aspirin vs clopidogrel-aspirin, irrespective of metabolizer status (6.0% [150 of 2486] vs 7.6% [191 of 2515]; hazard ratio [HR], 0.78 [95% CI, 0.63-0.97] among intermediate metabolizers and 5.7% [41 of 719] vs 7.5% [52 of 692]; HR, 0.77 [95% CI, 0.50-1.18] among poor metabolizers; P = .88 for interaction). Patients taking ticagrelor-aspirin had a higher risk of any bleeding event compared with those taking clopidogrel-aspirin, irrespective of metabolizer status: 5.4% (134 of 2486) vs 2.6% (66 of 2512) (HR, 2.14 [95% CI, 1.59-2.89]) among intermediate metabolizers and 5.0% (36 of 719) vs 2.0% (14 of 692) (HR, 2.99 [95% CI, 1.51-5.93]) among poor metabolizers (P = .66 for interaction). This prespecified analysis of a randomized clinical trial found no difference in treatment effect between poor and intermediate CYP2C19 metabolizers. The relative clinical efficacy and safety of ticagrelor-aspirin vs clopidogrel-aspirin were consistent across CYP2C19 genotypes. ClinicalTrials.gov Identifier: NCT04078737.

Proton pump inhibitor has no effect in the prevention of post-endoscopic sphincterotomy delayed bleeding: a prospective randomized controlled trial.

Bleeding is one of the common adverse events of endoscopic retrograde cholangiopancreatography (ERCP), which is mainly caused by endoscopic sphincterotomy (EST). At present, it remains unclear whether proton pump inhibitor (PPI) should be used to prevent post-EST bleeding. Therefore, we performed a randomized controlled trial to investigate whether PPI is effective in the prevention of post-EST delayed bleeding. Consecutive eligible patients were randomly assigned (1:1) to experimental group (PPI group) or control group (normal saline, NS group). The patients in PPI group received intravenous esomeprazole 40 mg and normal saline 100 mL every 12 h for 2 days after ERCP immediately, and followed by oral esomeprazole (Nexium) 20 mg once a day for 7 days. Correspondingly, patients in the control group received intravenous normal saline 100 mL and did not take PPIs or any acid-suppressing drugs during hospitalization and after discharge. All patients were followed up for 30 days after ERCP. The primary endpoint was the incidence and severity of post-EST delayed bleeding. Between July 2020 and July 2022, 290 patients were randomly assigned to PPI group (n = 146) or NS group (n = 144). 5 patients from each group were excluded from the final analysis. There were 6 patients with post-EST delayed bleeding, with an incidence rate of 2.14%. The median time of delayed bleeding was 2.5 days after ERCP. 3 cases (2.12%, 3/141) occurred in the PPI group, with 1 case of mild and 2 cases of moderate bleeding. 3 cases (2.16%, 3/139) occurred in the NS group, with 2 cases of mild and 1 case of moderate bleeding. There was no significant difference in the incidence and the severity of post-EST delayed bleeding between the two groups (p = 1.000). Prophylactic use of PPI after EST does not reduce the incidence and severity of post-EST delayed bleeding in patients. https://www.chictr.org.cn/searchproj.aspx, identifier ChiCTR2000034697.

Overcoming Obstacles During Caesarean Section with a Fibroid in the Uterus, from Diagnosis to Decision: A Case Series.

We regularly face pregnancy with fibroid since pregnancy at advanced ages has been more prevalent and the prevalence of lower segment caesarean section (LSCS) has also increased over the previous three decades. Myomectomy with cesarean section has historically been avoided because of the danger of haemorrhage, but obstetricians now place more emphasis on it. Since fibroids can range widely in terms of location, size, and patient features, the intervention should be individualized. Under this article, we, therefore,provide a case series of seven pregnant women with uterine myomas who had delivery via LSCS. Seven pregnant patients who had uterine fibroid and undergone cesarean section were enrolled in this observational study done over the period of one year with consent and after taking ethical approval. Results: The mean age was 27.7 years. Three of the cases were primigravida, while the remainder were multigravida.One patient had red degeneration and was hospitalized with abdominal discomfort at 29 weeks gestation. Four patients had a solitary fibroid, while the three had numerous. The biggest myoma sizewas 8×7 cm, while the smallest was 5×5 cm. Due to the presence of the fibroid in the lower segment of the uterus, three patients had a caesarean myomectomy, while in rest four cases it was not done. During cesarean myomectomy, two of them had uterine artery ligation to limit themoderate intraoperative haemorrhage. If the patient is wisely chosen and the surgeon has the experience, a caesarean myomectomy can be performed safely and successfully during LSCS, especially if located in the lower uterine segment (LUS).

Tirofiban combined with Aspirin in the Treatment of Acute Penetrating Artery Territory Infarction (STRATEGY): protocol for a multicentre, randomised controlled trial

BackgroundPerforating artery territorial infarction (PAI) caused by branch atheromatous disease (BAD) is prone to recurrence and early progression without an effective and well-documented antiplatelet treatment regimen. Tirofiban, an adjunctive antiplatelet...

Bleeding disorder of unknown cause: Results from Iranian study

BackgroundDefinite diagnosis of patients with mild to moderate bleeding is challenging. Some studies reported that even more than 50% of their patients remained undiagnosed which is classified as a Bleeding disorder of unknown cause (BDUC). This study aims to document the clinical characteristics and proportion of patients with BDUC in the Iranian Comprehensive Hemophilia Care Center (ICHCC) one of the referral centers for diagnosis of congenital bleeding disorder in Iran. MethodsThis study was conducted on 397 patients who were referred with a bleeding manifestation to ICHCC from 2019 to 2022. Demographic and laboratory data were documented for all patients. Bleeding questionnaires including ISTH-Bleeding Assessment tool (ISTH-BAT) and the Molecular and Clinical Markers for the Diagnosis and Management of Type 1 (MCMDM-1 (ISTH-BAT, MCMDM-1, and the Pictorial Bleeding Assessment Chart (PBLAC) were filled out for all patients. The data were analyzed by the statistical package for social science (SPSS version 22, SPSS, Chicago, Illinois, USA). ResultsBDUC was diagnosed in 200 patients and 197 patients reached the final diagnosis. Hemophilia, von Willebrand disease (VWD), factor (F) VII deficiency, and platelet functional disorders (PFDs) were confirmed in 54, 49, 34, and 15 of the patients, respectively. No significant difference was found in bleeding scores between patients with BDUC and those with confirmed disease. In contrast, after setting cut-off (ISTH-BAT for males ≥ 4 and females ≥ 6 and MCMDM-1 for males ≥ 3 and females ≥ 5) clinically significant difference was found. There was no association between having a positive consanguineous marriage and setting a diagnosis; however, significant associations were seen for having a positive family history of bleeding. Age (OR =0.977, 95% CI.965–0.989), gender (BDUC female, 151/200; final diagnosis female, 95/197) (OR=3.3, 95% CI 2.16–5.06), family history (OR = 3.19, 95% CI 1.99–5.11), and consanguineous marriage (OR=1.59, 95% CI 1.03–2.45) were considered as a risk factor for categorizing the patients with BDUC or final diagnosis. ConclusionThe findings are mainly in line with previous studies about BDUC patients. The large number of patients with BDUC underlines the incompleteness of available routine laboratory tests and shows the necessity of progress in the development of reliable diagnostic tools to identify underlying bleeding disorders.

Safety and efficacy of a kaolin-impregnated hemostatic gauze in cardiac surgery: A randomized trial

ObjectiveA kaolin-based nonresorbable hemostatic gauze, QuikClot Control+, has demonstrated effective hemostasis and safety when used for severe/life-threatening (grade 3/4) internal organ space bleeding. We evaluated the efficacy and safety of this gauze for mild to moderate (grade 1-2) bleeding in cardiac surgery compared with control gauze. MethodsThis was a randomized, controlled, single-blinded study of patients who underwent cardiac surgery between June 2020 and September 2021 across 7 sites with 231 subjects randomized 2:1 to QuikClot Control+ or control. The primary efficacy end point was hemostasis rate (ie, subjects achieving grade 0 bleed) through up to 10 minutes of bleeding site application, assessed using a semiquantitative validated bleeding severity scale tool. The secondary efficacy end point was the proportion of subjects achieving hemostasis at 5 and 10 minutes. Adverse events, assessed up to 30 days postsurgery, were compared between arms. ResultsThe predominant procedure was coronary artery bypass grafting, and 69.7% and 29.4% were sternal edge and surgical site (suture line)/other bleeds, respectively. Of the QuikClot Control+ subjects, 121 of 153 (79.1%) achieved hemostasis within 5 minutes, compared with 45 of 78 (58.4%) controls (P < .001). At 10 minutes, 137 of 153 patients (89.8%) achieved hemostasis compared with 52 of 78 controls (68.4%) (P < .001). At 5 and 10 minutes, hemostasis was achieved in 20.7% and 21.4% more QuikClot Control+ subjects, respectively, compared with controls (P < .001). There were no significant differences in safety or adverse events between treatment arms. ConclusionsQuikClot Control+ demonstrated superior performance in achieving hemostasis for mild to moderate cardiac surgery bleeding compared with control gauze. The proportion of subjects achieving hemostasis was more than 20% higher in QuikClot Control+ subjects at both timepoints compared with controls, with no significant difference in safety outcomes.

Effects of a novel acetaminophen (APAP) analog on survival time after extremity trauma and moderate or severe conscious hemorrhage in rats

Background: Multiple analgesics are used for acute pain relief following trauma in both the military and civilian settings. However, in addition to their ability to relieve pain, medical providers must also be concerned about secondary effects of the analgesics, especially effects on the cardiovascular and respiratory systems when the pain of trauma is associated with hemorrhage. Kalyra Pharmaceuticals has developed novel analogs of APAP to circumvent liver toxicity and improve analgesic efficacy. These analogs have the potential to replace opioids for severe pain while minimizing adverse effects. The objective of this study is to test a pain-reducing dose of D-112, an APAP analog, for its effects on survival to hemorrhage after extremity trauma (ET). We hypothesize that D-112 will not affect survival after either moderate or severe hemorrhage. Methods: Male Rats (~360 grams) were randomly assigned to receive either 0.9% saline (V) or 50 mg/kg D-112 (D) after either ~37% or ~50% of blood volume hemorrhage. All rats were surgically implanted with a carotid catheter under anesthesia. Carotid catheters were used for blood withdrawal and for injection of V or D. 24 hrs later, rats were briefly (~10 min) anesthetized again and ET consisting of soft tissue injury (crushing of the right gastrocnemius and semimembranosus muscles for 30 sec with forceps) and fibula fracture was performed. After completion of ET, rats were allowed to recover. 90 min after ET, rats underwent a conscious hemorrhage via the indwelling catheter. At the end of hemorrhage, rats received either V or D via the carotid catheter. Rats were observed for a maximum of 4 hrs after the start of the 25 min hemorrhage. Results: Survival after hemorrhage was recorded in the 4 groups: V-37% (n=13), D-37% (n=11), V-50% (n=10), D-50% (n=11). The survival proportions at 240 min were 92.3% for V-37%, 81.8% for D-37%, 60.0% for V-50%, and 18.1% for D-50%. While there was no significant difference in the survival curves of V-37% and D-37%, the survival curves of V-50% and D-50% were significantly different ( p = 0.036). Conclusions: The analgesic dose of D-112 tested decreased survival after ET and severe hemorrhage (~50% of blood volume), but not after ET and moderate hemorrhage (~37%). These results suggest that D-112 may not be an appropriate analgesic following traumatic hemorrhage. Applied Pain Research Program, US Army Clinical and Rehabilitative Medicine/Joint Program Committee 8, and US Army Combat Casualty Care Research Program, US Army Medical Research and Development Command. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Indobufen versus aspirin in patients with acute ischaemic stroke in China (INSURE): a randomised, double-blind, double-dummy, active control, non-inferiority trial

Aspirin is recommended for secondary stroke prevention in patients with moderate-to-severe ischaemic stroke but can lead to gastrointestinal intolerance and bleeding. Indobufen is used as an alternative antiplatelet agent in some countries, despite an absence of large-scale clinical trials for this indication. We tested the hypothesis that indobufen is non-inferior to aspirin in reducing the risk of new stroke at 90 days in patients with moderate-to-severe ischaemic stroke. We conducted a randomised, double-blind, double-dummy, active control, non-inferiority trial at 163 tertiary and district general hospitals in China. Eligible participants were aged 18-80 years with acute moderate-to-severe ischaemic stroke (National Institutes of Health Stroke Scale score 4-18). We randomly assigned (1:1) participants within 72 h of the onset of symptoms to receive either indobufen (100 mg tablet twice per day) or aspirin (100 mg tablet once per day) for 90 days. The randomisation sequence was computer generated centrally and stratified by local participating centres. Masked local investigators assigned the random code to patients in ascending order and provided a treatment kit corresponding to the random code. The primary efficacy outcome was new stroke and the primary safety outcome was severe or moderate bleeding, both within 90 days. This primary efficacy outcome was assessed in all randomly assigned and consenting patients and in a per-protocol group (ie, all patients finishing the treatment without major violation of the trial protocol). Safety analyses were done in the safety-analysis population (ie, all patients who received at least one dose of the study drug and had a safety assessment available). We assessed the non-inferiority of indobufen versus aspirin using the one-sided upper limit of the 95% CI of the hazard ratio (HR) with a prespecified non-inferiority margin of 1·25. This trial is registered with ClinicalTrials.gov (NCT03871517). This trial took place between June 2, 2019, and Nov 28, 2021. Of 84 093 patients screened, 5438 patients were randomly assigned to receive either indobufen (n=2715) or aspirin (n=2723), all of whom were included in the primary analyses. Median age was 64·2 years (IQR 56·1-70·6); 1921 (35·3%) were women and 3517 (64·7%) were men. Stroke occurred within 90 days in 213 (7·9%) patients in the indobufen group versus 175 (6·4%) in the aspirin group (HR 1·23, 95% CI 1·01-1·50; pnon-inferiority=0·44). Moderate or severe bleeding occurred in 18 (0·7%) patients in the indobufen group and in 28 (1·0%) in the aspirin group (0·63, 95% CI 0·35 to 1·15; p=0·13). Adverse events within 90 days occurred in 666 (24·5%) patients in the indobufen group and 679 (24·9%) patients in the aspirin group (p=0·73). In patients with acute moderate-to-severe ischaemic stroke, indobufen was not non-inferior to aspirin because the upper limit of the 95% CI was greater than 1·25. Furthermore, indobufen seemed to be inferior to aspirin in reducing the risk of recurrent stroke at 90 days because the lower limit of the 95% CI was greater than 1·00. Although moderate or severe bleeding did not differ between groups, these findings do not support the use of indobufen for secondary stroke prevention in patients with moderate-to-severe ischaemic stroke. Hangzhou Zhongmei Huadong Pharmaceutical and Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences. For the Chinese translation of the abstract see Supplementary Materials section.

Striving for humane deaths for laboratory mice: hypobaric hypoxia provides a potential alternative to carbon dioxide exposure.

Killing is often an unavoidable and necessary procedure for laboratory mice involved in scientific research, and providing a humane death is vital for public acceptance. Exposure to carbon dioxide (CO2) gas is the most widely used methodology despite well proven welfare concerns. Consequently, the continued use of CO2 and its globally permitted status in legislation and guidelines presents an ethical dilemma for users. We investigated whether killing with hypobaric hypoxia via gradual decompression was associated with better welfare outcomes for killing laboratory mice. We compared the spontaneous behaviour of mice exposed to CO2, decompression or sham conditions, and used analgesic or anxiolytic interventions to determine their relative welfare impact. Gradual decompression resulted in longer times to unconsciousness and death and the pharmacological interventions support the notion of a minimally negative animal experience, while providing further evidence for pain and anxiety associated with exposure to CO2. Decompression resulted in moderate ear haemorrhage, but our welfare assessment suggests this may happen when mice are unconscious. Hence, gradual decompression could be the basis of significant refinement for killing laboratory mice. Future work should corroborate behaviour with neurobiological markers of loss of consciousness to verify the conscious phase of concern for animal welfare.

Adverse events related to central venous catheters (CVC) and the influence of CVC characteristics on peripheral blood hematopoietic progenitor cell collection in children.

The use of peripheral blood progenitor cells (PBPCs) as a source for hematopoietic stem cell transplantation (HSCT) in pediatric healthy donors is still under debate. The risk of a central venous catheter (CVC) placement and catheter-related complications continue to be the main arguments to discourage its use. we present a retrospective analysis of 140 PBPC collections in pediatric patients and donors, describing adverse events (AE) related to CVCs as well as the influence of catheterrelated variables on the efficiency of the leukapheresis. 14 CVC-related AEs were recorded (10%). The most common was fever in 5 patients, 4 of which had a catheter-related bacteriemia. Thrombotic events were only observed in 3 patients with active malignancy. A healthy donor presented a moderate bleeding after catheter withdrawal that resolved with local measures, and none of the rest presented any AE. Regarding variables related to the development of AEs, the subject group (patient or donor) was the only one significantly associated (p < 0.0001). Of interest, efficiency was also related to catheter location, being worse in those located in the femoral vein than in into the jugular or the subclavian veins (p < 0.05). In a multivariate analysis, the only variable significantly associated was catheter size (beta 0.238, p < 0.01). Placing a CVC for PBPC collection in pediatric subjects is overall safe; CVC-related complications in pediatric healthy donors are very rare. Furthermore, we should try to place catheters of the largest caliber possible, since the efficiency of the collection is related to this variable.

Pre-emptive epinephrine nebulization prior to nasotracheal intubation for mandibular fracture fixation surgeries: Does it really differ? A randomised controlled clinical trial

ABSTRACT Introduction Isolated mandibular fractures as any other fracture are associated with pain and inflammation which possess difficulty for both laryngoscopy and intubation. Nasotracheal intubation is relatively more efficient in individuals with isolated mandibular injuries. Epistaxis is the most common complication of nasal intubation. This study aimed to highlight the role of preoperative usage of epinephrine 1:1000 combined with lidocaine as a nebulization session before induction of anaesthesia as a method to spread vasoconstriction and analgesia. Methods The patients were randomly assigned to one of two equal groups; nasal Lidocaine drops followed by Oxymetazoline nasal drops (OL as control group) or Epinephrine mixed with Lidocaine as nebulization session (EL as the study group). Our primary measures were to estimate the degree of epistaxis and its effect on intubation time. Results Lidocaine with epinephrine as a nebulization session prior to NTI has statistically significant less intubation time (37.8 ± 6.32) versus (42.16 ± 5.1) in the control group with p- value (0.000028). This correlates with higher incidence of moderate nasal bleeding in OL group (7/60 = 11.66%) versus (4/60 = 6.66%) in EL group and P- value = 0.01. EL mixture has a higher priority of decreasing surgical blood loss. Mean± SD measures were (406.86 ± 89.6) and (468.6 ± 139), p-value = 0.00026*in EL and OL groups respectively. Conclusion Despite being time consuming measure. Yet, lidocaine epinephrine nebulization session can be considered as an efficient method for prophylaxis against nasotracheal intubation induced epistaxis, to control intraoperative field bleeding, acts as an adjuvant to control intraoperative pain and protects against postextubation nasal complications.

Role of Transbronchial Lung Cryobiopsy in the Diagnosis of Interstitial Lung Disease: A Meta-analysis of 68 Studies and 6300 Patients.

Diagnosis of interstitial lung disease (ILD) is based on multidisciplinary team discussion (MDD) with the incorporation of clinical, radiographical, and histopathologic information if available. We aim to evaluate the diagnostic yield and safety outcomes of transbronchial lung cryobiopsy (TBLC) in the diagnosis of ILD. We conducted a meta-analysis by comprehensive literature search to include all studies that evaluated the diagnostic yields and/or adverse events with TBLC in patients with ILD. We calculated the pooled event rates and their 95% confidence intervals (CIs) for the diagnostic yield by MDD, histopathologic diagnostic yield, and various clinical adverse events. We included 68 articles (44 full texts and 24 abstracts) totaling 6386 patients with a mean age of 60.7±14.1 years and 56% men. The overall diagnostic yield of TBLC to achieve a definite or high-confidence diagnosis based on MDD was 82.3% (95% CI: 78.9%-85.2%) and histopathologic diagnosis of 72.5% (95% CI: 67.7%-76.9%). The overall rate of pneumothorax was 9.6% (95% CI: 7.9%-11%), while the rate of pneumothorax requiring drainage by a thoracostomy tube was 5.3% (95% CI: 4.1%-6.9%). The rate of moderate bleeding was 11.7% (95% CI: 9.1%-14.9%), while the rate of severe bleeding was 1.9% (95% CI: 1.4%-2.6%). The risk of mortality attributed to the procedure was 0.9% (95% CI: 0.7%-1.3%). Among patients with undiagnosed or unclassified ILD requiring tissue biopsy for diagnosis, transbronchial cryobiopsy represents a reliable alternative to surgical lung biopsy with decreased incidence of various clinical adverse events.

Efficacy of a novel polyoxazoline-based hemostatic patch in liver and spleen surgery

BackgroundA new hemostatic sealant based on a N-hydroxy-succinimide polyoxazoline (NHS-POx) polymer was evaluated to determine hemostatic efficacy and long-term wound healing and adverse effects in a large animal model of parenchymal organ surgical bleeds.MethodsExperiment 1 included 20 pigs that were treated with two NHS-POx patch prototypes [a gelatin fibrous carrier (GFC) with NHS-POx and an oxidized regenerated cellulose (ORC) with poly(lactic-co-glycolic acid)-NHS-POx:NU-POx (nucleophilically activated polyoxazoline)], a blank gelatin patch (GFC Blank), TachoSil® and Veriset™ to stop moderate liver and spleen punch bleedings. After various survival periods (1–6 weeks), pigs were re-operated to evaluate patch degradation and parenchymal healing. During the re-operation, experiment 2 was performed: partial liver and spleen resections with severe bleeding, and hemostatic efficacy was evaluated under normal and heparinized conditions of the two previous prototypes and one additional NHS-POx patch. In the third experiment an improved NHS-POx patch (GATT-Patch; GFC-NHS-POx and added 20% as nucleophilically activated polyoxazoline; NU-POx) was compared with TachoSil®, Veriset™ and GFC Blank on punch bleedings and partial liver and spleen resections for rapid (10s) hemostatic efficacy.ResultsNHS-POx-based patches showed better (GFC-NHS-POx 83.1%, ORC-PLGA-NHS-POx: NU-POx 98.3%) hemostatic efficacy compared to TachoSil® (25.0%) and GFC Blank (43.3%), and comparable efficacy with Veriset™ (96.7%) on moderate standardized punch bleedings on liver and spleen. All patches demonstrated gradual degradation over 6 weeks with a reduced local inflammation rate and an improved wound healing. For severe bleedings under non-heparinized conditions, hemostasis was achieved in 100% for Veriset™, 40% for TachoSil and 80–100% for the three NHS-POx prototypes; similar differences between patches remained for heparinized conditions. In experiment 3, GATT-Patch, Veriset™, TachoSil and GFC Blank reached hemostasis after 10s in 100%, 42.8%, 7.1% and 14.3%, respectively, and at 3 min in 100%, 100%, 14.3% and 35.7%, respectively, on all liver and spleen punctures and resections.ConclusionsNHS-POx-based patches, and particularly the GATT-Patch, are fast in achieving effective hemostatic sealing on standardized moderate and severe bleedings without apparent long-term adverse events.

Redefining the Role of Bronchoscopy in the Workup of Severe Uncontrolled Asthma in the Era of Biologics: A Prospective Study

Severe uncontrolled asthma (SUA) is frequently treated with biologic therapy if a T2 phenotype is found. Bronchoscopy is not routinely recommended in these patients unless a specific indication to rule out comorbidities is present. Is routine bronchoscopy safe and useful in phenotyping and endotyping SUA patients prior to the indication of a biologic therapy?. Prospective study of consecutive SUA patients who were referred to a specialized asthma clinic to assess the indication of a biologic therapy. Patients were clinically phenotyped as T2-allergic, T2-eosinophilic and non-T2. All patients underwent bronchoscopy and systematic data collection of endoscopic findings, microbiology of bronchial aspirate (BAS) and presence of eosinophils in bronchial biopsy were recorded and compared between asthma phenotypes. Cluster analysis was performed accordingly. One-hundred patients were recruited and classified as T2-allergic (28%), T2-eosinophilic (64%) and non-T2 (8%). On bronchoscopy, signs of gastroesophageal reflux disease were detected in 21%, vocal cord dysfunction in 5% and tracheal abnormalities in 3%. BAS culture isolated bacteria in 27% of patients, and fungi in 14%. Three clusters were identified: non-specific, upper airway, and infection being the latter less frequently associated to submucosal eosinophilia. Eosinophils were detected in 91% of bronchial biopsies. Despite a correlation to blood eosinophils, five patients with T2-phenotypes showed no eosinophils in bronchial biopsy, and 3 patients with non-T2 showed eosinophils in bronchial biopsy. Only one patient had a moderate bleeding. Routine bronchoscopy in SUA eligible for biologic therapy is a safe procedure that can help to better phenotype and personalize asthma management.

Effect of P2Y12 platelet reactivity level on peri- and postoperative outcomes of cardiac surgery patients.

Evidence surrounding P2Y12 platelet reactivity units (PRU) impact on bleeding outcomes in patients undergoing coronary artery bypass is varied. This study sought to assess whether on-pump CABG procedures result in increased bleeding in patients with high compared to low PRUs. This retrospective cohort study compared those with a PRU level ≤237 (low PRU group) to >237 (high PRU group). The primary outcome assessed massive or severe bleeding in accordance with universal definition of perioperative bleeding criteria. Secondary outcomes assessed mortality, length of stay and relevant bleeding related outcomes (e.g., rates of moderate or lower classifications of bleeding, chest tube output, blood product receipt). A total of 69 patients were included, 47 in the low and 22 in the high PRU groups. Patients were a median (IQR) 66 (62-74) years and 84.1% (N.=58) were male. Most patients received clopidogrel prior to procedure (39 [83%] in low and 18 [81.8%] in high PRU group; P=1.0000). The rate of the primary outcome was 14.9% (N.=7) in patients with a low PRU and 18.2% (N.=4) in patients with a high PRU; P=0.7345. The rate of moderate bleeding was 59.6% (N.=28) in the low and 27.3% (N.=6) in the high PRU group (P=0.0124). Packed red blood cells (PRBCs) were administered to more patients in the low (23 [48.9%]) than the high PRU group (2 [22.7%]; P=0.0388). There were no differences in other blood product requirement, chest tube output, factor products administered, mortality, or length of stay. This study determined that low preoperative P2Y12 PRU levels may influence moderate bleeding in patients undergoing cardiac surgery, but not massive or severe bleeding.

Experimental Pathogenicity of H9N2 Avian Influenza Viruses Harboring a Tri-Basic Hemagglutinin Cleavage Site in Sonali and Broiler Chickens.

Low-pathogenic avian influenza (LPAI) H9N2 virus is endemic in Bangladesh, causing huge economic losses in the poultry industry. Although a considerable number of Bangladeshi LPAI H9N2 viruses have been molecularly characterized, there is inadequate information on the pathogenicity of H9N2 viruses in commercial poultry. In this study, circulating LPAI H9N2 viruses from recent field outbreaks were characterized, and their pathogenicity in commercial Sonali (crossbred) and broiler chickens was assessed. Phylogenetic analysis of currently circulating field viruses based on the hemagglutinin (HA) and neuraminidase (NA) gene sequences revealed continuous circulation of G1 lineages containing the tri-basic hemagglutinin cleavage site (HACS) motif (PAKSKR*GLF) at the HA protein. Both the LPAI susceptible Sonali and broiler chickens were infected with selected H9N2 isolates A/chicken/Bangladesh/2458-LT2/2020 or A/chicken/Bangladesh/2465-LT56/2021 using intranasal (100 µL) and intraocular (100 µL) routes with a dose of 106 EID50/mL. Infected groups (LT_2-So1 and LT_56-So2; LT_2-Br1 and LT_56-Br2) revealed no mortality or clinical signs. However, at gross and histopathological investigation, the trachea, lungs, and intestine of the LT_2-So1 and LT_56-So2 groups displayed mild to moderate hemorrhages, congestion, and inflammation at different dpi. The LT 2-Br1 and LT 56-Br2 broiler groups showed nearly identical changes in the trachea, lungs, and intestine at various dpi, indicating no influence on pathogenicity in the two commercial bird species under study. Overall, the prominent lesions were observed up to 7 dpi and started to disappear at 10 dpi. The H9N2 viruses predominantly replicated in the respiratory tract, and higher titers of virus were shed through the oropharyngeal route than the cloacal route. Finally, this study demonstrated the continuous evolution of tri-basic HACS containing H9N2 viruses in Bangladesh with a low-pathogenic phenotype causing mild to moderate tracheitis, pneumonia, and enteritis in Sonali and commercial broiler chickens.

Observational findings of transbronchial lung biopsy in patients with interstitial lung disease: a retrospective study in Aleppo University Hospital.

This retrospective cohort research was done between 1 January 2020 and 18 April 2022 at the pulmonary department of Aleppo University Hospital, Syria, using patient records. In our study, 174 patients were examined. We included patients over the age of 18 who were referred or admitted to our department at Aleppo University Hospital after being diagnosed with diffuse parenchymal lung disease based on high-resolution computed tomography and clinical symptoms, while excluding other respiratory diseases such as tuberculosis and coronavirus disease 2019. Patients in the research were 53±7.1 years old on average. Cough and dyspnea were the most common clinical complaints among the patients, which accounted for 79.12 and 78.16%, respectively. A significant fraction of ground-glass opacity was detected on the high-resolution computed tomography, amounting to 102 (58.62%) and 74 (42.53%) for the reticular lesions, respectively. As a complication there were 40 patients with bleeding, of whom 24 had moderate bleeding, and 11 had major bleeding. We also had three patients with pneumothorax. The diagnostic yield of the TBLB in our ILD patients was 66.66%. An adequate diagnostic accuracy (66.66%) was detected in the TBLB in confirming the diagnosis of ILD; in addition, the bleeding was the most prevalent complication of this procedure. More interventional studies are needed to compare the diagnostic accuracy of this procedure with other invasive and noninvasive diagnostic methodologies of ILD.