Occurrence Of Bleeding Research Articles

Clinical and economic benefits of patients undergoing lobectomy with the use of powered vascular staplers—based on China’s real-world data

Background Endoscopic surgery is widely performed with an increasing use of powered vascular staplers (PVS). However, few studies have examined PVS use in China, most of which have focused on clinical effects; fewer studies have examined the economic benefits of PVS. This study evaluated the clinical and economic benefits of the PVS compared to standard-of-care (SOC) staplers in lobectomy using results from a single-arm, multicenter clinical trial conducted in China and actual clinical use in a hospital collected in a real healthcare setting. Methods Patients with lung cancer undergoing thoracoscopic lobectomy were included in the study. The clinical and economic benefits of powered vascular stapler have been evaluated from a hospital’s perspective based on parameters such as bleeding occurrence, hospitalization time, secondary thoracotomy, and hospitalization costs. To compare the bleeding associated with use of PVS and SOC stapler in clinical use, PVS single-arm multi-center clinical trial data is used for the intervention group, and sampling data from hospitals is used for the control group. To ensure the outcome indicators between the two groups are comparable, we set the same inclusion criteria for the two groups of data and then used propensity score matching (PSM) to match two groups of patients according to the baseline characteristics. Results The results show that bleeding incidence in patients with SOC stapler group is 17.33% from hospital sampling data. In contrast, in the PVS group, it is 4.00%, and these rates are statistically different (P = 0.0167). Considering converted to open thoracic surgery, the rate of the SOC stapler group is 5.78% and that of the PVS group is 4.00%. These rates are not statistically different (P = 0.6166). Regarding hospitalization days, the length of the SOC stapler group is 18.97 days, while that in the PVS group is 12.38 days, and these data are statistically different (P = 0.0002). As patients in the PVS group have reduced bleeding, they will require less resource use from blood transfusion, drug services and surgical services. If PVS is used for transection of vessel, it can reduce the bleeding incidence by 13.33% and save 75.47 CNY in blood transfusion costs, 571.36 CNY in drug costs, and 183.38 CNY in surgical service costs per patient. From these three aspects, the hospital saves per patient 830.21 CNY. Conclusions Compared with the SOC stapler group, the PVS group has a lower bleeding incidence and shorter hospital days for lobectomy. In terms of blood transfusion costs, drug costs and surgical service costs, the hospital saves per patient 830.21 CNY.

Asiatic acid alleviates subarachnoid hemorrhage-induced brain injury in rats by inhibiting ferroptosis of neurons via targeting acyl-coenzyme a oxidase 1

The occurrence of subarachnoid hemorrhage (SAH) can lead to brain injury, which is a fatal condition with limited effective clinical intervention strategies. The naturally occurring component Asiatic acid (AA), found in the tropical plant Centella asiatica, has been reported to possess neuroprotective properties. The objective of this study was to evaluate the neuroprotective effect of AA following SAH and investigate its potential mechanisms. The SAH model was established in male Sprague-Dawley (SD) rats through intravascular perforation, following a standardized protocol. The administration of AA was performed via gavage following SAH. A lentiviral vector was constructed and utilized for the knockdown of Acyl Coenzyme A Oxidase 1 (ACOX1) Firstly, AA treatment effectively improves brain neurological deficit, neuronal damage, and iron deposition induced by SAH. Furthermore, it has been demonstrated that AA directly interacts with ACOX1, which exhibits decreased expression in neurons following SAH. Additionally, our study reveals AA can reverse SAH-induced reduction in ACOX1 expression, concurrently ameliorating neuronal ferroptosis. This improvement is evidenced by reduced lipid peroxidation, including mitigated GSH depletion, decreased MDA production, and increased GPX4 content and activity. Also, AA enhances mitochondrial constriction while alleviating cristae disruption induced by SAH, providing crucial insights into its neuroprotective effects against neuronal ferroptosis in SAH. Moreover, when ACOX1 is knocked down, the neuroprotective effects of AA are weakened. Collectively, this study elucidated the neuroprotective effect of AA by inhibiting neuronal cell ferroptosis through targeting ACOX1. These findings suggest that AA holds promise as a potential therapeutic candidate for ameliorating SAH-induced brain injury.

Modified Double-Tract Reconstruction in Gastrointestinal Reconstruction after Proximal Gastrectomy.

To determine the clinical efficacy and safety of modified double-channel anastomosis for digestive tract reconstruction in proximal gastrectomy for early gastric cancer (EGC). Case series. Place and Duration of the Study: Department of Gastrointestinal Surgery, Heji Hospital, Changzhi Medical College, Shanxi, China, from January to November 2022. Based on inclusion and exclusion criteria, this study included a total of 21 patients with oesophagogastric junction cancer or proximal gastric cancer who underwent laparoscopic proximal gastrectomy with modified double-channel anastomosis. After resection of the proximal stomach, the remaining stomach was shaped into a tube. The distal end of the oesophagus was anastomosed to the jejunum. The jejunum was anastomosed 10-15 cm from the oesophagojejunostomy site laterally to the anterior wall of the stomach 3 cm from the gastric remnant. General data including operative time, anastomosis time, intraoperative blood loss, time to oral intake, length of hospital stay, and postoperative complications were evaluated. Postoperative gastroscopy and gastrointestinal imaging were performed to assess the residual stomach motility and anti-reflux effect. All twenty-one patients underwent modified double-channel anastomosis. The mean operation time was 254 (211 - 297) minutes. Mean reconstruction time was 65 (60 - 70) minutes. A mean of 19 (15 - 29) lymph nodes were cleared. Mean intraoperative blood loss was 86 (78.5-105ml). Mean time to oral intake was 6 (5 - 6.5) days. Postoperatively, there were two cases of pulmonary infection. There was no occurrence of anastomotic stenosis, anastomotic bleeding, or leakage. Gastrointestinal contrast study at 6 months postoperatively revealed reduced gastrointestinal motility in three cases and good residual gastric motility observed in the remaining patients. Gastroscopic examination at 6 months postoperatively revealed only one case of reflux oesophagitis. Modified double-channel anastomosis for proximal gastrectomy is safe and feasible. It provides a good anti-reflux effect and gastric emptying function without increasing the risk of postoperative complications. Adenocarcinoma of the oesophagogastric junction, Upper gastric carcinoma, Proximal gastrectomy, Double-tract reconstruction.

Modified Double-Tract Reconstruction in Gastrointestinal Reconstruction after Proximal Gastrectomy.

To determine the clinical efficacy and safety of modified double-channel anastomosis for digestive tract reconstruction in proximal gastrectomy for early gastric cancer (EGC). Case series. Place and Duration of the Study: Department of Gastrointestinal Surgery, Heji Hospital, Changzhi Medical College, Shanxi, China, from January to November 2022. Based on inclusion and exclusion criteria, this study included a total of 21 patients with oesophagogastric junction cancer or proximal gastric cancer who underwent laparoscopic proximal gastrectomy with modified double-channel anastomosis. After resection of the proximal stomach, the remaining stomach was shaped into a tube. The distal end of the oesophagus was anastomosed to the jejunum. The jejunum was anastomosed 10-15 cm from the oesophagojejunostomy site laterally to the anterior wall of the stomach 3 cm from the gastric remnant. General data including operative time, anastomosis time, intraoperative blood loss, time to oral intake, length of hospital stay, and postoperative complications were evaluated. Postoperative gastroscopy and gastrointestinal imaging were performed to assess the residual stomach motility and anti-reflux effect. All twenty-one patients underwent modified double-channel anastomosis. The mean operation time was 254 (211 - 297) minutes. Mean reconstruction time was 65 (60 - 70) minutes. A mean of 19 (15 - 29) lymph nodes were cleared. Mean intraoperative blood loss was 86 (78.5-105ml). Mean time to oral intake was 6 (5 - 6.5) days. Postoperatively, there were two cases of pulmonary infection. There was no occurrence of anastomotic stenosis, anastomotic bleeding, or leakage. Gastrointestinal contrast study at 6 months postoperatively revealed reduced gastrointestinal motility in three cases and good residual gastric motility observed in the remaining patients. Gastroscopic examination at 6 months postoperatively revealed only one case of reflux oesophagitis. Modified double-channel anastomosis for proximal gastrectomy is safe and feasible. It provides a good anti-reflux effect and gastric emptying function without increasing the risk of postoperative complications. Adenocarcinoma of the oesophagogastric junction, Upper gastric carcinoma, Proximal gastrectomy, Double-tract reconstruction.

Prevalence of adenomyosis in adolescents: diagnostic process and symptoms. Systematic review.

Adenomyosis is a uterine disorder commonly associated with painful menstrual cycles, abnormal uterine bleeding, and dyspareunia, which can significantly impact fertility, pregnancy outcomes and overall quality of life. Recent literature reports suggest that adenomyosis is increasingly being identified in adolescents, particularly in those presenting with severe dysmenorrhea and heavy menstrual bleeding. In this review we evaluate the frequency of adenomyosis diagnosis on imaging studies in relation to the occurrence of dysmenorrhea, pelvic pain and heavy menstrual bleeding (HMB). A thorough literature search was performed using PubMed, EMBASE and SCOPUS databases. It was confined to articles published from 1 January 2019, to 1 August 2024 and included only those available in English. Due to the very limited number of publications on this topic, an age range of 12-25 years was selected as the inclusion criteria. For articles that met the inclusion criteria, information regarding diagnosis on imaging and relation to the occurrence of symptoms was extracted. Five full-text articles were reviewed. Studies including adolescents and young women from 12-25 years of age who presented with HMB, pelvic pain, dysmenorrhea and an imaging-based diagnosis of adenomyosis. The prevalence of adenomyosis in this population ranged from 25 to 45%. It is crucial to consider adenomyosis in the differential diagnosis of adolescent girls presenting with dysmenorrhea, heavy menstrual bleeding, and pelvic pain. Dysmenorrhea was the most frequently reported symptom (from 81 to 100%) associated with imaging features of adenomyosis.

Trends in home treatment and early discharge of patients with low-risk pulmonary embolism

Abstract Background A strategy of ambulatory treatment or early discharge (≤ 48 hours) of patients with acute low-risk pulmonary embolism (PE) has been adopted by the most recent guideline recommendations. However, the adoption of such a change of paradigm in PE care in the ‘real-world’ clinical setting, outside the concept of prospective cohort (management) studies, remains unknown. Aims To determine the proportion of patients with PE who fulfill eligibility criteria for home treatment or early discharge, to investigate in how many of them such a management strategy is actually followed, and to discover differences in early complications between early or later discharge among low-risk patients. Methods We used two nationwide databases, the US Nationwide Emergency Department Sample (NEDS) and Nationwide Readmission Database (NRD), to identify patients with low-risk PE (absence of the following at presentation: haemodynamic instability, cor pulmonale, tachycardia, dyspnea, hypothermia, altered mental status, and fulfilment of the Hestia critieria). We investigated the proportion of patients that were discharged entirely at home, or discharged early (hospital stay £ 2 days) and their association with predictor variables. We also studied the 90-day occurrence of venous thromboembolism recurrence and major bleeding. Results From 2016 to 2020, there were 2,099,390 emergency department visits for PE (NEDS Database), with 641,621 (30.6%) classified as low-risk. Home treatment was documented in 20.3% of all cases, with 31.5% of low-risk PE cases being treated at home and an increasing trend over time (Figure 1A). Factors associated with home treatment for low-risk PE included younger age, female sex, and absence of comorbidities; home treatment was more frequent at university hospitals, non-metropolitan hospitals, and those with higher emergency department volumes (Figure 2A). In the NRD Database, there were 1,950,708 PE hospitalizations during the same period with 481,321 classified as low-risk (24.7%). An early discharge strategy was followed in 22.6% of all cases, increasing to 45.9% for low-risk PE admissions, with a rising trend observed from 2016 (Figure 1B). Factors associated with early discharge for low-risk PE included younger age, male sex, and absence of comorbidities; here, university hospitals and metropolitan hospitals were less likely to implement early discharge (Figure 2B). The 90-day incidence of VTE recurrence among low-risk patients was lower with early discharge (1.3% vs. 1.8%, p<0.001), as was major bleeding (1.5% vs. 2.8%, p<0.001). Conclusion Our results reveal an increasing implementation of early discharge and home treatment for low-risk PE across recent years. Factors influencing these strategies are related to demographics and hospital type. Early discharge was associated with favourable outcomes in the real-world setting, thus supporting the results of previously performed prospective cohort studies and randomized trials.Figure 1Figure 2

Long-term administration of atorvastatin had no effect on the occurrence and progression of spontaneous hypertensive intracerebral hemorrhage in mice

Abstract Background Intracerebral hemorrhage (ICH) is a catastrophic disease with limited treatment options. Statins and low low-density lipoprotein cholesterol (LDL-C) levels have been reported to be associated with increased risk of ICH. Safety concerns of statins were raised as statins become the cornerstone of anti-atherosclerosis therapy. To date, the effect of statins on the incidence of ICH still remains a controversial topic. Purpose The aim of this study was to investigate the effect of atorvastatin on the occurrence and progression of hypertensive ICH in mice. Methods Male wild-type C57BL/6J mice, 13 months old, were randomly divided into atorvastatin (Ato, n=20) group and vehicle (Veh, n=20) group. The atorvastatin group and vehicle group were given atorvastatin (20 mg/kg) and same volume of 0.5% sodium carboxymethylcellulose by oral gavage for 8 weeks, separately. Angiotensin II (Ang II) and L-NAME were then used to induce hypertensive ICH. The time of stroke symptom onset was documented. Hemorrhage volumes were measured by spectrophotometric hemoglobin assay. Results After 8 weeks of atorvastatin or vehicle administration, serum LDL-C levels were significantly lower in the mice treated with atorvastatin than vehicle controls (0.705 vs. 1.008 mmol/L, P<0.001). The administration of atorvastatin did not show significant effects on the systolic blood pressure (SBP) levels when compared with the vehicle group (164 vs. 166 mmHg, P=0.497) after the induction of Ang II and L-NAME. Hemorrhage was observed in brain morphology, and was further verified by hematoxylin and eosin staining or MRI scans in mice that showed signs of stroke. During the 28-day experimental period, 75% (15/20) of mice in the atorvastatin group developed signs of ICH, and 70% (14/20) of mice in the vehicle group developed in the similar time window. The incidence of hypertensive ICH had no significant difference between atorvastatin and vehicle groups (Log-rank P=0.761). Hemorrhage volumes were also comparable between the two groups (1.462 vs. 1.392 uL, P=0.788). Conclusion Reducing serum LDL-C levels by long-term administration of atorvastatin had no effect on the occurrence and progression of spontaneous hypertensive ICH in middle-aged mice.

Analysis of the role of perfusion parameters in predicting rupture of brain arteriovenous malformations: a multi-center study

This study aimed to investigate the potential correlation between the perfusion parameters of brain arteriovenous malformations (bAVMs) as determined by multiphase CT angiography and bAVM rupture. Based on the occurrence of bAVM-related hemorrhage, 480 diagnosed bAVM patients were divided into hemorrhage (n = 220) and non-hemorrhage (n = 260) groups in this retrospective multi-center study spanning 2010 to 2020. On initial rupture CT images, the bAVM nidus and major draining vein were segmented, and time-density curves were extracted to compute perfusion parameters including mean transit time (MTT), time to peak (TTP), blood volume (BV), and blood flow (BF). To examine the potential correlation between these parameters and bAVM rupture, logistic regression was utilized to analyze multifactorial data and compare differences between the two groups. The ruptured group demonstrated a bAVM nidus characterized by an increased BF, a shorter TTP and MTT, and a higher peak density. The veins that were draining exhibited a reduced TTP, MTT, and peak density. A nidus TTP of less than 4s was identified by the multifactorial analysis as a critical risk factor for bAVM rupture. The statistical results highlight the noteworthy correlation between nidus TTP and bAVM rupture, presenting an original framework for assessing the risk of rupture.

Time to Treatment and Outcomes of Hemorrhagic Stroke, Comparing Patients Entering Surgery before and after 120 Minutes Upon Arrival at the Emergency Department Pattani Hospital

Background: The duration between a patient’s hospital arrival and the point at which they enter surgery for hemorrhagic stroke affects survival, length of stay, health care costs, and outcome (Glasgow Outcome Scale). Therefore, a study to explore the effects of time on these outcomes is warranted. Objective: To compare treatment outcomes of patients with hemorrhagic stroke having entered surgery before and after 120 minutes upon arrival at the emergency department. Materials and Methods: A therapeutic and interventional study with a retrospective observational cohort design at Pattani Hospital in patients with hemorrhagic stroke who received treatment between October 2018 and April 2023. A retrospective review of medical records, which collected clinical characteristics and the time to treatment. Glasgow Outcome Scale was evaluated at 72 hours, two weeks, one month, and date of hospital discharge. Length of stay, health care costs, and survival status at date of hospital discharge were analyzed. Comparative analysis was performed by Fisher’s exact probability test and t-test, and prognostic analysis was performed by risk ratio. Results: Of all the patients in the present study, 49 and 182 received treatment before and after 120 minutes, respectively, upon arrival at the emergency department. Clinical characteristics of gender, age, underlying conditions, regular medications, and level of consciousness were not significantly different between the two groups. Patients who entered surgery within 120 minutes of arrival had more occurrences of basal ganglia hemorrhage compared with those who received surgery thereafter. Furthermore, patients who received surgery within 120 minutes had a 11.4% increased chance of survival. The number needed to treat (NNT) hemorrhagic stroke patients with a time to treatment of under 120 minutes is 9. However, there was an associated increase in complications, health care cost, and length of stay. The Glasgow Outcome Scale improvement was greater only in the two-week follow-up period. These results were similar when subarachnoid hemorrhage and anticoagulating medication used were excluded. Conclusion: Patients with hemorrhagic stroke who receive early surgical treatment have lower mortality rates. Adequate provision of personnel and facilities for delivering prompt care should be made available. Measures should be taken to reduce the complications of patients who receive surgical treatment after 120 minutes upon arrival at the emergency department.

Patients treated with vitamin K oral anticoagulants in family practice: a new approach to bleeding risk assessment. An ancillary study by the CACAO prospective general practice cohort.

The ability of bleeding risk scores to predict major bleeding (MB) or clinically relevant nonmajor bleeding (CRNMB) remains a topic of contention, particularly in nonselected patients in family practice. In addition, the capacity to predict bleeding risk using simple variables has yet to be established. The main objective was to confirm that severe anemia was the most predictive factor for the estimation of bleeding risk in patients treated with vitamin K antagonists (VKAs). Secondary objectives were to test the capacity of different bleeding scores to detect high-risk patients. Subsequently, the impact of functional decline on bleeding incidence was explored. The CACAO study was a multicenter prospective cohort study of patients who, due to nonvalvular atrial fibrillation (NVAF) and/or venous thromboembolism (VTE), had been prescribed an oral anticoagulant by their general practitioner (GP) as a prophylactic measure. Patient characteristics were collected at the time of inclusion by GPs, who then monitored them in accordance with standard practice for one year. MB and CRNMB were the main outcomes for one year. By applying this approach, a total of 13 scores were analyzed. Aaemia was found to be strongly associated with MB (HR: 2.77, 95% CI: 1.2-6.36), with a particularly pronounced association observed in cases of severe anemia (HR: 12.9, 95% CI: 2.76-60.35). Twelve out of 27 MB cases were not identified by at least half of the scores. By contrast, functional decline was identified as a novel factor associated with MB (HR: 2.45, 95% CI: 1.13-5.31). Preexisting anemia is a major prognostic factor associated with the occurrence of bleeding. It seems relevant to suggest that functional decline should be considered by GPs when assessing bleeding risk.

Saliva of persons with hemophilia A triggers coagulation via extrinsic tenase complexes

AbstractHuman saliva contains extracellular vesicles (EVs). These EVs expose extrinsic tenase complexes of tissue factor (TF) and activated factor VII (FVIIa), and trigger blood coagulation. Here, we show that EVs exposing extrinsic tenase complexes are also present in saliva of persons with severe hemophilia A, that is, persons with FVIII deficiency. Addition of these salivary EVs to autologous FVIII-deficient blood results in FXa generation, thereby compensating for the lack of FXa generation via intrinsic tenase (FVIIIa/FIXa) complexes. Consistently, in our retrospective analysis of persons with severe hemophilia A who do not receive prophylactic FVIII substitution, oropharyngeal mucosal bleedings are infrequent and self-limited. Conversely, in saliva of persons with severe FVII deficiency, in whom oropharyngeal bleedings are prevalent, functional extrinsic tenase complexes are absent, because EVs lack FVII. Saliva of persons with severe FVII deficiency is unable to restore blood coagulation, which is because of the absence of FVII in both their saliva and blood. Picomolar levels of recombinant FVIIa can restore the coagulant potential of saliva of persons with FVII deficiency. Taken together, our findings may explain the paucity of oropharyngeal bleedings in persons with hemophilia A as well as the occurrence of such bleedings in persons with severe FVII deficiency.

Association of liver dysfunction with outcomes after percutaneous coronary intervention – a systematic review and meta-analysis

BackgroundLiver dysfunction is a known risk factor in the cardiovascular field. It specifically increases perioperative risk in patients undergoing coronary bypass surgery. Since percutaneous coronary intervention (PCI) is the much less invasive procedure for the treatment of coronary artery disease, we aimed to assess the relationship of liver dysfunction with outcomes in patients undergoing PCI.MethodsThree libraries were searched (MEDLINE, Web of Science and The Cochrane Library). We performed a meta-analysis of all studies in patients who underwent PCI that provided information on the presence or absence of liver dysfunction. Primary outcome was short-term mortality. Secondary outcomes were major adverse cardio- and cerebrovascular events (MACCE), bleeding and acute kidney injury. Random-effects model was applied.ResultsFive studies were selected and the data from 10,710,317 patients were included in the final analysis. In comparison with the absence of liver dysfunction, patients with liver dysfunction were associated with higher short-term mortality (OR 2.97, 95%CI 1.23–7.18, p = 0.02), higher MACCE (OR 1.42, 95%CI 1.08–1.87, p = 0.01), and higher bleeding (OR 2.23, 95%CI 1.65-3.00, p < 0.01). There was no significant difference regarding acute kidney injury (OR 1.20, 95%CI 0.50–2.87, p = 0.69).ConclusionsThe analysis suggests that liver dysfunction in patients undergoing PCI is independently associated with higher risk of short-term mortality and increased occurrence of MACCE and bleeding. However, there appears to be no association to acute kidney injury.

Demographic characteristics, clinical manifestations, and treatment outcomes of May-Thurner Syndrome: a five-year retrospective analysis using computed tomography venography in a Chinese population

Objective This study aimed to analyze the demographic characteristics, symptoms, and treatment outcomes of patients diagnosed with May-Thurner syndrome (MTS) using computed tomography venography (CTV). Methods Medical records of patients diagnosed with MTS through CTV at Hebei General Hospital of China between April 1, 2017, and May 31, 2022, were reviewed. The data collected included: (1) gender, age, body mass index (BMI), and smoking and drinking habits; (2) time of onset and symptoms of MTS, as well as other accompanying symptoms; (3) additional diagnoses, length of hospital stay (days), treatment methods, treatment success, and the occurrence of post-treatment bleeding or recurrence. Descriptive statistics were used, with mean ± standard deviation and median values reported. The t-test/u-test and Chi-square test (including the exact probability method) were used to compare means and rates, respectively, with a significance level set at α = 0.05. Results Out of 402 patients (233 males, 169 females), 118 (29.4%) were diagnosed with MTS, with 47 (21.1%) males and 71 (39.7%) females. The incidence of MTS was significantly higher in females than males (χ2 proportion = 16.545, χ2 composition = 9.763, P < 0.05). The average ages of male and female MTS patients were 56.4 and 59.9 years, respectively, with mean BMIs of 27.05 and 27.09 kg/m2. Among male patients, 27.7% (13) were smokers, and 17.0% (8) consumed alcohol. Inferior vena cava (IVC) thrombosis was notable in 59.3% of MTS patients, with a significantly higher proportion in females (70.4%) than in males (42.6%) (χ2 = 9.102, P < 0.05). Lower limb swelling without pain was reported by 70.3% of patients, with 53.4% (44.7% male, 59.2% female) experiencing swelling on the left side only, which was significantly more common than swelling on the right side only or both sides (χ2 = 44.554, P < 0.05). Additionally, 12.7% of patients reported both swelling and pain, with left-side symptoms being more prevalent than right-side or both sides. The average ages at symptom onset were 51.3 ± 17.1 years in males and 57.1 ± 13.2 years in females. All treatments for MTS were successful without bleeding or recurrence. The most common treatment method was balloon dilation combined with stent placement (57.6%). Conclusion CTV is highly effective in detecting and facilitating the successful treatment of MTS. It should be fully utilized to promote early diagnosis and treatment of MTS. Female MTS patients need more medical resources for diagnosis and treatment.

Comparison of continuous flow centrifugal left ventricular assist devices as a bridge to transplant strategy in a low organ donation environment: single center experience

ObjectiveIn patients with advanced heart failure, heart transplantation is currently the most effective treatment. However, in a low-organ environment, it is usually necessary to proceed in long-term mechanical circulatory support through left ventricular assist device (LVAD) implantation as bridge-to-transplantation. MethodsThe study included all patients with advanced heart failure who underwent continuous flow LVAD implantation as a bridge to transplant strategy in our center (n = 68). Following LVAD implantation and for the period that patients were on LVAD support, pump thrombosis, strokes, gastrointestinal bleeding, and right heart failure occurrence rates were recorded. Outcomes were compared between patients implanted with HeartMate 3 (HM3) and HeartWare LVADs, as well as between patients who did reach heart transplantation (HTx group) and those who did not (noHTx group). ResultsA total of 35 out of 68 patients underwent heart transplantation at a mean time of 691 ± 457 days; 41 received a HeartWare and 27 a HM3 device. HM3 patients had significantly better survival (p = 0.010) and lower complication rates (p = 0.025). In addition, the noHTx group had significantly higher complication rates compared with the HTx group (p = 0.00041). The 5-year estimated Kaplan–Meier survival rate following heart transplantation was 77%. ConclusionPatients with advanced heart failure gain substantial benefit from LVADs awaiting heart transplantation. In a low organ donation environment, the need for reliable LVADs can further improve the outcomes through the reduction of complications provided by current devices.

Alteplase vs. Tenecteplase: An In-depth Analysis of Their Relative Effectiveness in Treating Acute Ischemic Stroke

Dear Editor, Stroke stands as the second-leading cause of death worldwide [1, 2]. Each year, over 12 million individuals are impacted by stroke, resulting in approximately 6.5 million fatalities [1]. Stroke globally ranks as the third-leading factor causing a combination of death and disability [2]. Every year, around seven hundred thousand individuals in the United States undergo an Acute Ischemic Stroke (AIS), making up 85% of all stroke cases [2]. New treatments like intravenous thrombolysis and mechanical thrombectomy have cut mortality by 10% compared to older methods, enhancing long-term disability prevention rates following Acute Ischemic Stroke [2]. Alteplase is the sole FDA-approved thrombolytic drug in AIS within the first 4.5 hours. Despite its potential for disability-free recovery, its usage is constrained by a brief time window and adverse effects, notably a 6% risk of symptomatic bleeding. In addition, its fibrinolytic efficacy is limited, achieving vascular reopening in less than half of the patients, and can cause cytotoxicity to the already hypoxic brain with resultant cerebral edema [2]. Tenecteplase (TNK), a modified variant of alteplase, has improved features including greater fibrin selectivity and longer half-life and is given as a single bolus instead of an infusion, thanks to genetic recombinant technology [3]. Numerous studies have supported TNK's efficacy over alteplase in treating AIS. In 2016, Bruce C.V. Campbell and colleagues demonstrated that, according to the analysis of modified Rankin scale scores, tenecteplase exhibited a more favorable overall functional outcome compared to alteplase [4]. A dosage of 0.25 mg/kg of tenecteplase emerges as a promising alternative to replace alteplase as the preferred treatment for patients with AIS occurring within 4.5 hours due to TNK's superior early neurological recovery rates and comparable safety outcomes [3]. Despite gathering evidence from experimental trials indicating TNK's advantages over alteplase for AIS, the use of TNK at a dosage of 0.4 mg/kg appears to pose safety concerns when compared to alteplase [3]. Bruce C.V. Campbell and his fellow researchers revealed in their study that in spite of the beneficial effects of TNK relative to alteplase, there was no significant variation in the speed of recovery to independent function. Notably, they found no discernible distinction in the occurrence of intracranial hemorrhage [4]. ---Continue

Is the use of direct oral anticoagulants after non-cardiac thoracic surgery safe for patients?

The outcomes of direct oral anticoagulant use after noncardiac thoracic surgery have not been elucidated. We compared the safety and efficacy of the postoperative use of direct oral anticoagulants versus warfarin. This retrospective cohort study included patients taking anticoagulants after noncardiac thoracic surgery between 2008 and 2021. Patients were divided into 2 groups based on drug type: Group D (direct oral anticoagulants) and Group W (warfarin). The occurrence of bleeding and thromboembolic events was also assessed. Anticoagulants were administered to 434 postoperative patients. One (0.4%) of the 247 patients in Group D and 3 (1.6%) of the 187 patients in Group W experienced thromboembolic events. Four patients (1.6%) in Group D and 4 (2.1%) patients in Group W experienced bleeding events. All bleeding events in Group D occurred within 1week of oral administration, whereas only 1 case of bleeding occurred after resumption in Group W. The outcomes of patients treated with direct oral anticoagulants did not differ from those of patients treated with warfarin. However, major bleeding can occur after the postoperative resumption of direct oral anticoagulant use. Attention should be paid to resuming oral anticoagulants within a few days of non-cardiac thoracic surgery.

Cognition in (pre)symptomatic Dutch-type hereditary and sporadic cerebral amyloid angiopathy.

Cerebral amyloid angiopathy (CAA) is a main cause of cognitive dysfunction in the elderly. We investigated specific cognitive profiles, cognitive function in the stage before intracerebral hemorrhage (ICH), and the association between magnetic resonance imaging (MRI) based cerebral small vessel disease (cSVD) burden in CAA because data on these topics are limited. We included Dutch-type hereditary CAA (D-CAA) mutation carriers with and without ICH, patients with sporadic CAA (sCAA), and age-matched controls. Cognition was measured with a standardized test battery. Linear regression was performed to assess the association between MRI-cSVD burden and cognition. D-CAA ICH- mutation carriers exhibited poorer global cognition and executive function compared to age-matched controls. Patients with sCAA performed worse across all cognitive domains compared to D-CAA ICH+ mutation carriers and age-matched controls. MRI-cSVD burden is associated with decreased processing speed. CAA is associated with dysfunction in multiple cognitive domains, even before ICH, with increased MRI-cSVD burden being associated with slower processing speed. Cognitive dysfunction is present in early disease stages of cerebral amyloid angiopathy (CAA) before the occurrence of symptomatic intracerebral hemorrhage (sICH). Presymptomatic Dutch-type CAA (D-CAA) mutation carriers show worse cognition than age-matched controls. More early awareness of cognitive dysfunction in CAA before first sICH is needed. Increased cerebral small vessel disease CAA-burden on magnetic resonance imaging is linked to a decrease in processing speed.

Efficacy and uterine bleeding patterns in initiating goserelin therapy during different menstrual phases in patients with adenomyosis: a prospective cohortstudy.

We carried out this study to explore the possibility of initiating goserelin therapy during the non-menstrual period in patients diagnosed with adenomyosis. 115 premenopausal adenomyosis patients were enrolled and divided into three groups based on their menstrual cycle phase during the initial outpatient visit: menstrual, follicular, and luteal. Each received a 3.6 mg subcutaneous dose of goserelin monthly for three months. The endpoints encompassed alterations in uterine volume, dysmenorrhea Numerical Rating Scale (NRS) score, CA125 level, hemoglobin (HGB) after a 12-week treatment course, and the occurrence and duration of uterine hemorrhage during the first treatment cycle. Analysis revealed that the timing of goserelin therapy initiation in the menstrual cycle did not significantly impact its effectiveness in reducing uterine size, alleviating pain, lowering CA125 levels, or improving hemoglobin concentrations. However, patients starting treatment during the luteal phase experienced increased uterine bleeding (reference: menstrual period, OR = 4.33, 95% CI 1.23-15.25, p = .023). The results suggested non-inferiority of goserelin therapy initiated during the non-menstrual period, but the uterine bleeding rate was higher in the luteal phase group. Therefore, goserelin treatment for outpatient adenomyosis patients should not be limited to starting during the menstrual period; it can also be initiated outside the menstrual period, providing more convenience for patients as most consultations occur outside the menstrual period. However, the use of goserelin during the luteal phase should be avoided to reduce the risk of exacerbated bleeding, especially in anemic patients with heavy menstrual bleeding. This study highlights the importance of individualizing treatment initiation based on the patient's health profile to optimize therapeutic outcomes and minimize adverse effects. ChiCTR2200059548.

Using heart rate variability to predict neurological outcomes in preterm infants: a scoping review.

Infants born preterm are at higher risk of neurological complications, including intraventricular haemorrhage and white matter injury. After discharge, these infants may experience adverse neurodevelopmental outcomes and exhibit lower educational attainment. Early detection of brain injury and accurate prediction of neurodevelopmental impairment would allow early intervention and support. Heart rate variability (HRV) describes the variation of time intervals between each subsequent heartbeat. HRV is controlled by the autonomic nervous system, which may be affected by hypoxia and compromised blood flow. While HRV has primarily been investigated in neonatal sepsis, the association between HRV, brain injury and neurodevelopmental outcomes in preterm infants is less established. The present scoping review examines the utility of HRV monitoring for predicting short-term and long-term neurological outcomes in preterm infants. Following systematic search of Medline, Embase, Web of Science and the Cochrane Library, 15 studies were included. Nine studies examined the relationship between HRV and brain injury, with all but two showed an association. Eight studies examined the relationship between HRV and long-term outcomes and all eight found an association. This scoping review suggests that decreased HRV in the neonatal period is associated with short- and long-term neurodevelopmental outcomes in preterm infants. IMPACT: Changes in heart rate variability correlate with the occurrence of intraventricular haemorrhage in preterm infants. A decrease in heart rate variability may precede the development of intraventricular haemorrhage. Alterations in heart rate variability correlate with long-term neurodevelopmental outcomes. Significant variability exists in metrics used in assessing heart rate variability.

A rare occurrence of Vancomycin-induced gastrointestinal hemorrhage without thrombocytopenia: a case report and literature review

BackgroundVancomycin-induced bleeding has been reported, attributed to the mechanism of immune thrombocytopenia. A rare case of vancomycin-induced gastrointestinal hemorrhage in a young patient with no underlying disease, receiving intravenous vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) infection, is presented. This occurrence occurred without thrombocytopenia. Relevant cases reported in the literature were also reviewed.Case presentationA 34-year-old male patient presented with maxillofacial multiple spaces infection accompanying left temporal abscess, bilateral lung abscesses. Culture results from both blood and secretion indicated that the infection was caused by MRSA. The patient received standard-dose vancomycin (1 g q12h intravenously guttae) for treatment. On the 5th day of therapy, he presented with bright red blood in his stool; however, vancomycin treatment was continued. By the 9th day, a decrease in hemoglobin level to 76 g/L and a platelet (PLT) count of 424 × 109/L raised concerns about gastrointestinal hemorrhage. The hemoglobin level decreased to 62 g/L on day 12. Due to the high tissue concentration of linezolid, administration of linezolid at a dose of 600 mg q12h intravenously guttae commenced on the 13th day as an alternative to vancomycin(D13-D17). Subsequently, on the 17th day, there was an improvement in hemoglobin level to 78 g/L. However, despite treatment with linezolid, the patient’s fever showed no significant improvement, prompting a switch back to vancomycin at a dosage of 1 g q12h intravenously guttae(D18-D22). On the 21st day, there was a recurrence of gastrointestinal hemorrhage, accompanied by a hemoglobin level of 42 g/L and a PLT count of 224 × 109/L. Gastroscopy revealed the presence of a gastroduodenal ulcer. The patient had no prior history of hemorrhoids, gastrointestinal ulcers, liver cirrhosis, or purpura. Prior to admission, he had not been administered non-steroidal anti-inflammatory drugs (NSAIDs) or steroids. During hospitalization, the only medications given were vancomycin, ambroxol and lidocaine. Additional tests ruled out immunological disorders as the cause of gastrointestinal ulcers, and a positive vancomycin rechallenge test indicated an association between vancomycin and bleeding. After discontinuation of vancomycin, no further bleeding occurred. This case highlights a rare occurrence of vancomycin-induced bleeding without thrombocytopenia, classified as “Certain” according to the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) scale for standardized case causality assessment.ConclusionThis case represents the first documented instance of vancomycin-induced bleeding without thrombocytopenia, as confirmed by a positive rechallenge test. This discovery will aid in the early detection of this rare adverse reaction in future cases.