Onset Of Bleeding Research Articles

Assessing the Relationship Between Infection Frequency and Risk of Post-Tonsillectomy Hemorrhage.

To determine the relationship between frequency of tonsillitis and the risk of post-tonsillectomy hemorrhage (PTH) in pediatric patients undergoing tonsillectomy for recurrent tonsillitis. After obtaining IRB approval from Nationwide Children's Hospital, charts for all patients who underwent a total tonsillectomy in 2017 for recurrent or chronic tonsillitis were retrospectively reviewed (n = 424). Patients were divided into 2 cohorts based on the frequency of tonsillitis prior to surgery: those meeting the 1-year criteria with 7 or more infections in the past year (n = 100), and those who did not meet criteria defined as those with fewer than 7 infections in the past year (n = 324). The primary outcome of interest was PTH. Comparison of cohorts and frequency of PTH were assessed using bivariate analyses. Kaplan-Meier curves were used to compare time to onset of hemorrhage between primary vs. secondary PTH. Generalized mixed and logistic regression models were used to evaluate risk of hemorrhage following tonsillectomy. Among a total cohort of 424 patients undergoing tonsillectomy, 23.58% (n = 100) met criteria while 76.42% (n = 324) did not. A total of 8.73% (n = 37) patients experienced PTH. Compared to those who did not meet criteria, those who met criteria had a higher odds of developing PTH; however, this was not significant (OR: 1.42 [95% CI: 0.67, 2.98], P = .3582). Estimated probability of developing PTH for those who met criteria was 11% [95% CI: 6.19, 18.81] compared to 8.03% [95% CI: 5.52, 11.54] for those who did not meet criteria. Among all PTH cases, 5.41% (n = 2) were primary hemorrhage while 94.59% (n = 35) were secondary hemorrhage with 50% of those with secondary PTH having experienced hemorrhage within 6 days [95% CI: 5, 7] of tonsillectomy. Patients with neuromuscular conditions had significantly higher odds of PTH (OR: 4.75 [95% CI: 1.19, 18.97], P = .0276). Patients who met the 1-year criteria for tonsillectomy did not have a significantly higher odds of PTH. Further research is needed to better evaluate the relationship between infection frequency and risk of PTH.

Hemostasis restoring in postpartum hemorrhage — algorithm 2023

Postpartum hemorrhage (PPH) is still the leading cause of perinatal death in women of reproductive age. It is characterized by high dynamics, and most women die within the first day of puerperium and as many as 88% of them within the first 4 hours from the onset of hemorrhage. Management of each massive obstetric hemorrhage requires interdisciplinary, team-based and multidirectional action. The need for simultaneous application of uterotonic agents, surgical and/or endovascular methods as well as procedures aimed at restoring volume and hemostasis should be emphasized. The protocol for the management of severe PPH should be individualized and take into account hemorrhage etiology. Each time the volume of circulating blood as well as the degree of blood loss have to be determined, and the adequate procedures, the starting points for implementing aggressive treatment and the satisfactory end points must be defined. The most common cause of severe, life-threatening PPH is uterine atony. Restoration of hemostasis in massive PPH consists in transfusion of blood components, administration of antifibrinolytic drugs and coagulation factor concentrates, rFVIIa included. Patient survival is often determined by the very risk assessment for hemorrhage, early diagnosis and rapid implementation of PPH management algorithms.

Impact of ABO blood group antigens on residual factor VIII levels and risk of inhibitor development in hemophilia A

The clinical phenotype of hemophilia A (HA) does not always correlate with severity. Similarly, the presence of inhibitors does not necessarily increase the risk of bleeding. This paradox between clinical and laboratory findings may be partially attributed to non-modifiable factors, such as blood group, which is known to influence FVIII levels in healthy individuals. Our aim was to assess the effect of ABO blood group antigens on FVIII levels across the severity spectrum of HA and risk of inhibitor development. Data of consecutive patients with HA who visited the coagulation unit of a northern Indian tertiary care hospital between 2010‒2021 were reviewed. Patients with missing blood group data, transfusion histories, or baseline FVIII levels were excluded. Mild, moderate, and severe HA was present in 41 (6.9%), 72 (12.2%), and 479 (80.9%) patients, respectively. There were no differences in the FVIII levels among the various blood groups across the HA severity spectrum. Inhibitors were administered to 35 patients (5.9%). In the multivariate analysis, blood group A was an independent risk factor for the development of inhibitors (adjusted odds ratio 2.70, P=0.04) after adjusting for age at onset of bleeding, FVIII transfusion, age at first FVIII transfusion, and severity of HA. Unlike what is observed in healthy individuals, blood group did not influence residual FVIII levels across the severity spectrum of HA. Patients in group A had a higher risk of developing inhibitors.

More than time: travel time to the delivery ward and maternal outcomes – onset of labour, postpartum haemorrhage and obstetric anal sphincter injury

BackgroundClosing delivery units increases travel time for some women. Whether increased travel time is associated with maternal outcomes is important for understanding the consequences of such closures. Previous studies are limited in measuring travel time and restricted to the outcome of caesarean section. MethodsOur population-based cohort includes data from the Swedish Pregnancy Register for women giving birth between 2014 and 2017 (N = 364,630). We estimated travel time from home to the delivery ward using coordinate pairs of actual addresses. The association between travel time and onset of labour was modelled using multinomial logistic regression, and logistic regression was used for the outcomes postpartum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS). FindingsOver three-quarters of women had ≤30 min travel time (median 13.9 min). Women who travelled ≥60 min arrived to care sooner and laboured there longer. Women with further to travel had increased adjusted odds ratio (aOR) of having an elective caesarean section (31–59 min aOR 1.11; 95% confidence interval [CI] 1.07–1.16; ≥60 min aOR 1.25; 95% CI 1.16–1.36) than spontaneous onset of labour. Women (at full term with spontaneous onset) living ≥60 min away had reduced odds of having a PPH (aOR 0.84; 95% CI 0.76–0.94) or OASIS (aOR 0.79; 95% CI 0.66–0.94). InterpretationLonger travel time increased the odds of elective caesarean section. Women with furthest to travel arrived sooner and spent more time in care; although they had a lower risk of PPH or OASIS, they also tended to be younger, have a higher body mass index and were Nordic born.

Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report

BackgroundSubarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital.Case presentationThe patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient’s symptoms improved, and she became lucid.In this case, we believe that in the presence of untreated hyperthyroidism, the onset of subarachnoid hemorrhage induced thyroid storm. Tachycardia of 130 bpm or higher, which is the diagnostic criterion for thyroid storm, rarely occurs with subarachnoid hemorrhage. Therefore, we believe it is an important factor for recognizing the presence of the thyroid storm. In this case, clipping surgery was prioritized which resulted in a favorable outcome. However, it is possible that invasive surgery may have exacerbated thyroid storm, suggesting that treatment should be tailored as per patient’s condition.ConclusionIf a pulse rate of 130 bpm or higher is observed alongside subarachnoid hemorrhage, we recommend considering the possibility of concomitant thyroid storm and testing for thyroid hormone. If concomitant thyroid storm is present, we believe that a treatment plan tailored to the patient’s condition is critical, and early diagnosis will lead to a favorable outcome for the patient.

Short-Term Complications and Outcomes in Pharmaco-Mechanical Thrombolysis First and Catheter-Directed Thrombolysis First in Patients with Acute Lower Limb Ischemia

Pharmaco-mechanical thrombolysis (PMT) has emerged as a treatment option in patients with acute lower limb ischemia (ALI), especially Rutherford IIb (motor deficit) for rapid revascularization, but supportive data is scarce. The aim of the present study was to compare the effects of thrombolysis, complications, and outcomes of PMT first versus catheter-directed thrombolysis (CDT) first in a large cohort of patients with ALI. All endovascular thrombolytic/thrombectomy events in patients with ALI performed between January 1st, 2009, and December 31st, 2018 (n=347) were included. Successful thrombolysis/thrombectomy was defined as complete or partial lysis. Reasons for using PMT were described. Complications such as major bleeding, distal embolization, and new onset of renal impairment, and major amputation and mortality at 30days were compared between PMT (AngioJet) first and CDT first groups in a multivariable logistic regression model with adjustment for age, gender, atrial fibrillation, and Rutherford IIb. The most common reason for initial use of PMT was the need for rapid revascularization, and the most common reason for use of PMT after CDT was the insufficient effect of CDT. Presentation of Rutherford IIb ALI was more common in the PMT first group (36.2% vs. 22.5%, respectively, P=0.027). Among the 58 patients receiving PMT first, 36 (62.1%) were terminated within a single session of therapy without need of CDT. The median duration of thrombolysis was shorter (P<0.001) for the PMT first group (n=58) compared to the CDT first group (n=289) (4.0hr vs. 23.0hr, respectively). There was no significant difference in amount of tissue plasminogen activator given, successful thrombolysis/thrombectomy (86.2% and 84.8%), major bleeding (15.5% and 18.7%), distal embolization (25.9% and 16.6%), major amputation or mortality at 30-days (13.8% and 7.7%) in the PMT first compared to the CDT first group, respectively. The proportion of new onset of renal impairment was higher in the PMT first compared to the CDT first group (10.3% vs. 3.8%, respectively), and the increased odds (odds ratio 3.57, 95% confidence interval 1.22-10.41) were maintained in the adjusted model. In Rutherford IIb ALI, no difference in rate of successful thrombolysis/thrombectomy (76.2% and 73.8%), complications or 30-day outcomes was found between PMT first (n=21) and CDT (n=65) first group. PMT first appears to be a good treatment alternative to CDT in patients with ALI, including Rutherford IIb. The found renal function deterioration in the PMT first group needs to be evaluated in a prospective, preferably randomized trial.

Pain: a neglected symptom in hemophilia.

Repetitive bleeding attacks may cause joint pain and arthropathy in patients with hemophilia (PWH). Despite being a common symptom, pain is not a well-studied topic in this disease. The aim of this cross-sectional, observational study was to assess the frequency and intensity of pain and analyze the success rates ofpain treatment methods. Adult hemophilia patients were included in the study. The Multidimensional Hemophilia Pain Questionnaire (MHPQ) was used to assess pain. In addition to the MHPQ, demographic data were collected. Fifty adult hemophilia patients were included in the study. Thirty-one (62%) of the patients reported pain due to hemophilia in the last year. Twenty-six of them (81.2%) reported pain during bleeding attacks. The most successful pain coping strategy was clotting factor replacement. None of the participants used opioids or adjuvant analgesics. None of them used a physical therapy modality or interventional pain therapy method. While 67.6% of the patients were very dissatisfied or dissatisfied with their global pain treatment, only 16.1% of the patients were satisfied or very satisfied. Patients with higher pain during bleeding episodes were more likely to continue their prophylaxis. There was no significant difference between plasma-derived or recombinant-derived factor prophylaxis in terms of pain complaints. Pain is a frequent and important symptom of hemophilia, but most of the patients are not treated sufficiently. A multidisciplinary approach is needed to improve the life quality of the patients. In addition to successful bleeding prophylaxis, administration of a proper and adequate analgesic regimen and combined physical therapy modalities may decrease pain intensity and prevent the development of arthropathy.

Close, but no cigar: an unfortunate case of primary angiitis of the central nervous system.

A 64-year-old male with a history of prostate cancer presented to the emergency department with expressive aphasia and severe headache. Previously, he was diagnosed with ischemic strokes at outside hospitals and was subsequently initiated on anticoagulation medication but was later readmitted with a new onset of nontraumatic subarachnoid hemorrhage and later was found to have ischemic changes in the right temporoparietal lobe. He was suspected to have hypercoagulability of malignancy, as he was unresponsive to a wide variety of anticoagulants and his symptoms continued to deteriorate. On presentation, the physical examination was significant for right homonymous hemianopia, with positive antinuclear antibodies and notable erythrocyte sedimentation rate. The results from the full serologic workup was negative. Subsequent imaging of the brain revealed multifocal stenoses in multiple arteries. On further examination, digital subtraction angiography was concerning for vasculopathy, and was initiated on corticosteroids and cyclophosphamide. This is one of the first cases of PACNS in which recurrent strokes were the presenting symptom for PACNS. Vasculitis should be a considered differential in patients with recurrent ischemic strokes and failed anticoagulant therapy. It is important to rule out malignancy and infectious causes due to the wide spectrum of conditions that cause central nervous system vasculitis.

Sex Differences in Onset and Progression of Cerebral Amyloid Angiopathy.

Cerebral Amyloid Angiopathy (CAA) disease course is highly variable even in hereditary forms. Sex may be a possible modifying factor. We investigated biological sex differences in clinical disease course and magnetic resonance imaging-markers in sporadic (sCAA) and Dutch-type hereditary CAA (D-CAA). Patients with D-CAA and sCAA were included from hospital and research databases of the Leiden University Medical Center (2012-2020) and Massachusetts General Hospital (1994-2012). Key outcomes were: sex differences in symptomatic intracerebral hemorrhage (sICH) onset, recurrence and survival (analyzed using Kaplan Meier survival and regression analyses), and sex differences in magnetic resonance imaging-markers in D-CAA (explored using scatterplots), and in sCAA (investigated using regression analysis). We included 136 patients with D-CAA (mean age 57 years, 56% women, 64% with previous sICH) and 370 patients with sCAA (mean age 76 years, 51% women, all with previous sICH). Men and women with D-CAA did not differ for sICH onset (median age 54 in men and 56 in women [P=0.13]). Men with D-CAA had a slightly higher number of sICH compared with women (median 2 versus 1; adjusted RR, 1.5 [95% CI, 1.1-1.9]) and a shorter interval between the first and second sICH (median 1.8 years for men and 3.1 years for women, P=0.02). Men with sCAA had their first sICH at an earlier age (median 75 versus 78 years, respectively, P=0.003) and more lobar microbleeds (median 1 versus 0, P=0.022) compared with women with sCAA. No substantial differences were found in the other magnetic resonance imaging markers. Survival after first sICH was comparable between sexes for D-CAA (P=0.12) and sCAA (P=0.23). Men with CAA seem to have an earlier onset (sCAA) and more hemorrhagic disease course (sCAA and D-CAA) compared with women. Future studies are necessary to confirm these findings and determine the underlying role of sex-related factors.

Tranexamic acid for gastrointestinal bleeding: can a reduction in the risk of death be discounted? A systematic review and meta-analysis of individual patient data from 64 724 bleeding patients

ObjectivesHALT-IT was an international, randomised trial which assessed the effects of tranexamic acid (TXA) in 12 009 patients with gastrointestinal (GI) bleeding. The results found no evidence that TXA reduces...

Epidemiology of Subarachnoid Hemorrhage in Isolated Islands in Japan: A Population-based Study in the Miyako Islands.

The Miyako Islands (with a population of approximately 50,000) are located in southwestern Japan, with a subtropical oceanic climate. This isolated location permitted a retrospective population-based epidemiological study of subarachnoid hemorrhage. We retrospectively enrolled 110 consecutive patients from 2010 to 2019 using the subarachnoid hemorrhage database at Okinawa Miyako Hospital, which is the only local facility with neurosurgeons. We calculated the incidence of subarachnoid hemorrhage standardized to the entire Japanese population. The seasonal distribution of subarachnoid hemorrhage onset and patients' epidemiological characteristics were also investigated. The standardized annual incidence of subarachnoid hemorrhage was 21.4 per 100,000 population, as reported previously in Japan. The patients' mean age was 62.1 ± 15.4 years, and women constituted 60.9%. Anterior communicating artery aneurysms were most common. The endovascular treatment for ruptured aneurysms was increasing as standard levels in Japan. The rates of symptomatic vasospasm and secondary hydrocephalus requiring additional neurosurgical treatment were 2.7% and 19.1%, respectively. The mortality rate was 23.6%. The percentage of patients with a modified Rankin scale score of 0-2 at discharge was 55.5%. There were no differences in the frequency of subarachnoid hemorrhage associated with seasonal distribution or climatic factors. The incidence, baseline characteristics, and clinical outcomes of subarachnoid hemorrhage in the Miyako Islands were similar to those in other regions of Japan. There are preferable epidemiological backgrounds for further practical clinical research.

Diagnosis and management of postpancreatectomy hemorrhage: A single-center experience of consecutive 1,096 pancreatoduodenectomies

Background/objectivesThis study aimed to assess the outcomes and characteristics of post-pancreatectomy hemorrhage (PPH) in over 1000 patients who underwent pancreatoduodenectomy (PD) at a high-volume hepatopancreaticobiliary center. MethodsThis retrospective study analyzed consecutive patients who underwent PD from 2010 through 2021. PPH was diagnosed and managed using our algorithm based on timing of onset and location of hemorrhage. ResultsOf 1096 patients who underwent PD, 33 patients (3.0%) had PPH; incidence of in-hospital and 90-day mortality relevant to PPH were one patient (3.0%) and zero patients, respectively. Early (≤24 h after surgery) and late (>24 h) PPH affected 9 patients and 24 patients, respectively; 16 patients experienced late-extraluminal PPH. The incidence of postoperative pancreatic fistula (p < 0.001), abdominal infection (p < 0.001), highest values of drain fluid amylase (DFA) within 3 days, and highest value of C-reactive protein (CRP) within 3 days after surgery (DFA: p < 0.001) (CRP: p = 0.010) were significantly higher in the late-extraluminal-PPH group. The highest values of DFA≥10000U/l (p = 0.022), CRP≥15 mg/dl (p < 0.001), and incidence of abdominal infection (p = 0.004) were identified as independent risk factors for PPH in the multivariate analysis. Although the hospital stay was significantly longer in the late-extraluminal-PPH group (p < 0.001), discharge to patient's home (p = 0.751) and readmission rate within 30-day (p = 0.765) and 90-day (p = 0.062) did not differ between groups. ConclusionsStandardized management of PPH according to the onset and source of hemorrhage minimizes the incidence of serious deterioration and mortality. High-risk patients with PPH can be predicted based on the DFA values, CRP levels, and incidence of abdominal infections.

PS-R06-1: A CASE OF PATIENT WITH END-STAGE KIDNEY DISEASE INTRODUCED HEMODIALYSIS AFTER CEREBRAL HEMORRHAGE.

A 46-year-old male had been treated for end-stage kidney disease due to diabetic nephropathy and adaptive FSGS, and underwent surgery of arteriovenous fistula 3 weeks before the admission. He was scheduled to be introduced hemodialysis, but was urgently hospitalized due to cerebral hemorrhage. The head CT scan showed a subcutaneous hematoma of about 45 ml in the left frontal lobe, and the patient had impaired consciousness and worsening respiratory status. There were no surgical indications for cerebral hemorrhage, we initiated blood pressure control with nicardipine. Hyperkalemia was also seen, but urgent dialysis was not necessary, and we planned to introduce dialysis the next day or later. The next day hemodialysis was introduced, but soon after hemodialysis completed, worsening of respiratory condition and dilated pupil were observed. The head CT scan showed worsening cerebral edema compared to pre-dialysis CT scan on the same day. Thereafter, respiratory and general condition did not improve, and he died 11 days after the admission. It is recommended that dialysis should be avoided within 24 hours of the onset of cerebral hemorrhage because of the high risk of hematoma expansion. In addition, in the acute phase of cerebral hemorrhage, it is considered to choose a dialysis method that causes less intracranial pressure increase, such as peritoneal dialysis or continuous hemodiafiltration dialysis, if possible. Administration of hypertonic glycerol may also be helpful. When a patient with end-stage kidney disease is introduced hemodialysis soon after cerebral hemorrhage, control of blood and intracranial pressure should be cared.

Наиболее значимые постнатальные факторы, влияющие на течение различных форм ретинопатии недоношенных

Purpose.To evaluate the most significant factors affecting the course of ROP. Material and methods. From 2009 to 2018, we examined 4120 children with ROP. The examination of children was carried out as part of a neonatal screening to detect ROP using standard diagnostic methods. Results. Against the background of prolonged oxygen therapy in children with broncho-pulmonary dysplasia (BPD), severe forms of ROP developed in 9.7% of cases, which is significantly lower than similar indicators in the pathology departments of premature and newborns. Among children with severe apnea, the onset of different-sized hemorrhages, mainly preretinal located in various parts of the fundus, mostly at the ends of the vascular arcades is observed in 70.4% of cases. In 25.9% of children with severe ROP, partial hemophthalmus appears. During blood transfusions in children with severe forms of ROP, the transition of the disease to a more severe stage was reduced in 64.0%, caliber and tortuosity of the retinal vessels increased in 79.8%, retinal edema and exudative manifestations intensified in 39,3%, hemorrhagic changes rose in 49,4%, extraretinal proliferation increased in 50.6%. Against the background of adenoviral epidemic keratoconjunctivitis (AEK) in children with severe forms of ROP, the exudation in the vitreous body sharply increased in 34.7%, retinal detachment developed in 4.1% of cases, even though the children had already undergone laser coagulation of the retina at the time of infection, fresh hemorrhages mainly at the ends of the vascular arcades appeared in 57.1%. Conclusions. Prolonged oxygen therapy under BPD reduces the severity of the ROP. The impact of blood transfusions is observed only in severe forms of ROP. Frequent episodes of apnea contribute to the development of intraocular hemorrhages during ROP. The course of adenoviral AEK exacerbates the course of severe forms of ROP. Key words: retinopathy of prematurity, blood transfusion, apnea, broncho-pulmonary dysplasia, adenoviral epidemic keratoconjunctivitis, risk factors of retinopathy of prematurity

Maternal and neonatal outcomes in delivery with diagnosis of antepartum hemorrhage due to placenta previa at a tertiary hospital in Surabaya, Indonesia

HIGHLIGHTS 1. To provide effective prevention and management of placenta previa, maternal and neonatal outcomes should be identified.2. Among mothers studied, no maternal mortality was found, but most newborns had prematurity and low birthweight. ABSTRACT Objective: To identify maternal and neonatal outcomes in delivery with diagnosis of antepartum hemorrhage (APH) due to placenta previa. Materials and Methods: This was a descriptive retrospective study with cross-sectional design. Samples were taken using medical records with convenience sampling technique. Deliveries with history of APH due to placenta previa at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, on January 1 until December 31, 2019, were included. Results: In our study, 36 mothers were included. Maternal characteristics included age of 20–35 years in 72.2%, overweight in 50%, referral visits in 69.4%, from out of town (66.7%), bleeding onset at 3rd trimester (97.2%), primigravida (8.3%), nulliparity (13.9%), 69.4% with history of C-section, and 83.3% no hospital readmissions. Maternal outcomes included 100% mothers diagnosed with complete placenta previa and performed C-section. The mothers were mostly (69.4%) diagnosed with placenta accreta spectrum (PAS). There were 36.1% hysterectomy, 33.3% postpartum hemorrhage, 50% blood transfusions, and zero maternal mortality. Neonatal outcomes included prematurity in 80%, low birth weight (LBW) in 51.5%, while 77.1% and 85.7% of newborns had no asphyxia at 1 and 5 minutes, consecutively. Conclusion: All mothers experienced complete placenta previa, and underwent C-section with most of the mothers were diagnosed with PAS. Less than half of them needed hysterectomy intervention because other patients with focal type PAS were planned for conservative surgery. Moreover, they mostly did not have postpartum hemorrhage with half of them needed blood transfusion. There was zero maternal mortality, with most newborns experienced prematurity, LBW but no significant asphyxia.

Impact of analgesic regimen on patient outcome following subarachnoid hemorrhage: positive adjuvant effects of metamizole

Introduction Various analgesics are used to control intense headaches in patients following subarachnoid hemorrhage. In addition to pain control, it has been shown that some analgesics can affect various pathophysiological cascades. Therefore, we devised a study to assess whether the use of metamizole has a significant impact on the development of ischemic complications, hydrocephalus, and the overall outcome in patients following aneurysmal subarachnoid hemorrhage in the context of the other non-opioids and opioids effects. Methods In our retrospective, single-center cohort study, we enrolled 192 patients diagnosed with subarachnoid hemorrhage. We recorded their initial clinical status, comorbidities, and the daily dosage of analgesics over 14 days of hospitalization after the onset of subarachnoid hemorrhage. Using univariate and subsequent multivariate logistic regression analysis, we assessed the influence of various factors, including analgesics, on the development of delayed cerebral ischemia and hydrocephalus, as well as on 2-week and 6-month outcomes. Results Although the administration of non-opioids, in general, had no effect on the development of delayed cerebral ischemia or hydrocephalus, the use of metamizole as the main analgesic was associated with a significantly lower chance of poor outcome at both 2-weeks and 6-months, as well as the development of delayed cerebral ischemia. As opioids were indicated primarily for analgosedation in mechanically ventilated patients with poor clinical status, their usage was associated with a significantly higher chance of poor outcome, delayed cerebral ischemia, and hydrocephalus. Conclusion Our results suggest that the prescription of metamizole may be associated with better outcomes and a lower chance of delayed cerebral ischemia development in patients after subarachnoid hemorrhage. Considering the retrospective nature of our study and the limited worldwide availability of metamizole due to its prohibition in some countries, our results do not demonstrate a clear benefit but rather justify the need for subsequent prospective studies.

Adverse Cardiovascular Events in Non-Traumatic Intracranial Hemorrhage and Ischemic Stroke Survivors.

We aimed to evaluate different measures of adverse cardiovascular events between non-traumatic intracranial hemorrhage (ICrH) and ischemic stroke (IS) survivors with and without atrial fibrillation (AF). Using a national hospitalization database we compared incidences and risks of all-cause in-hospital death, cardiovascular death, non-cardiovascular death, MACE-HF (in-hospital cardiovascular death, myocardial infarction, IS or new-onset heart failure [HF]) between ICrH and IS survivors with and without AF. Propensity-score matching was also performed. We identified 40,523 survivors of IS and 12,028 survivors of an ICrH without AF, and 20,449 IS survivors and 3574 ICrH survivors with AF. In unadjusted, adjusted and matched analyses, ICrH patients without AF had a higher risk of all-cause in-hospital death (Hazard Ratio (HR; for matched analyses) 1.80; 95% confidence interval (CI) 1.74-1.86), cardiovascular death (HR; 2.79; CI 2.64-2.94), MACE-HF (HR 1.97; CI 1.89-2.06) and new cerebrovascular events (HR 1.75; CI 1.57-1.96) but with lower risk of myocardial infarction (HR 0.81; CI 0.70-0.94), major bleeding (HR 0.92; CI 0.87-0.98) and new onset HF (HR 0.85; CI 0.79-0.91) compared to IS survivors without AF. Similar results were found for ICrH and IS survivors with AF except for myocardial infarction (HR 1.05; CI 0.79-1.34) and new onset HF (HR 0.94; CI 0.84-1.06) that were similar between the two groups. Adverse cardiovascular events are more frequent in ICrH survivors compared to IS survivors. New onset HF is a relatively frequent event after ICrH, especially in those patients with comorbid atrial fibrillation.

A Rare Cause of Abdominal Pain After Transjugular Intrahepatic Portosystemic Shunt

Question: A 77-year-old woman presented with progressive dyspnea for 4 months. The patient was diagnosed with primary biliary cirrhosis more than 1 years ago and was ever since on ursodeoxycholic acid medication. Recurrent ascites occurred at least 6 months before diagnosis and was responsive to diuretics. Beyond these, she did not experience any onset of gastrointestinal bleeding or hepatic encephalopathy. Laboratory examination indicated the decreased hemoglobin (10.7 g/dL, normal value [nv]: 11.5–15 g/dL), leukocyte (2.85 × 103/μL, nv: [3.5–9.5] × 103/μL), and platelet counts (53 × 103/μL, nv: [100–300] × 103 /μL), increased alkaline phosphatase (195 IU/L, nv: 50–135 IU/L) and glutamyl transpeptidase (149 IU/L, nv: <45 IU/L), and normal aminotransferase and total bilirubin levels. Chest computerized tomography showed a large amount of right-sided pleural effusion. Pleural fluid tests revealed an uncomplicated hepatic hydrothorax with serum-pleural fluid albumin gradient >1.1 g/dL and polymorphonuclear cell count <500 cells/μL. However, the patient did not show significant improvement of symptoms with dietary sodium restriction and adequate-dose diuretics. Considering the existence of hepatic hydrothorax refractory, transjugular intrahepatic portosystemic shunt (TIPS) was performed thereafter. The portal pressure gradient decreased from 18 mm Hg–7 mm Hg after stent implantation. The interventional procedure was uneventful and no complication occurred during the processes. Postoperatively, the patient experienced slight dull pain in the right upper abdomen, and the symptom intensified gradually despite giving analgesic medication in the following 36 hours. Abdominal examination showed tenderness in the right upper quadrant and percussion pain in the liver area. Liver function tests revealed obviously elevated alanine aminotransferase (1147 IU/L, nv: <50 IU/L) and aspartate aminotransferase (1582 IU/L, nv: <40 IU/L), mildly elevated total bilirubin (1.73 mg/dL, nv: 0.29–1.64 mg/dL). Blood routine showed the change of hemoglobin (11.4 g/dL) and leukocyte (6.67 × 103 /μL). Abdominal computerized tomography showed multiple strips of low-density shadows along the blood vessels and scattered low-density nodules in the liver parenchyma (Figure A, white arrowheads). What is the most likely diagnosis? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Abdominal contrast-enhanced computerized tomography (CECT) showed diffuse linear hypodensity around portal vein branches and multiple low-density nodules in the liver, but no obvious enhancement was observed (Figures B and C, white arrowheads). These imaging findings were absent from hepatic vein and intrahepatic inferior vena cava (Figure D). According to the history of hepatic invasive procedure, laboratory findings, and CECT presentation, intrahepatic lymphangiectasia was suspected. After a short course of nonsteroidal anti-inflammatory drug therapy, her symptoms completely resolved and transaminases gradually returned to normal levels. Follow-up CECT scans at 30 days showed complete resolution of the periportal low-density areas (Figures E and F). Intrahepatic lymphangiectasia (IHL), manifested as dilated hepatic lymphatics and related lymphedema, is caused by either increased lymph flow or lymphatic obstruction.1Pupulim L.F. Vilgrain V. Ronot M. et al.Hepatic lymphatics: anatomy and related diseases.Abdom Imaging. 2015; 40: 1997-2011Crossref PubMed Scopus (26) Google Scholar Liver transplantation, blunt abdominal trauma, hepatic malignant neoplasms, and congestive hepatomegaly due to cardiac decompensation are the most common underlying etiology of IHL.2Koslin D.B. Stanley R.J. Berland L.L. et al.Hepatic perivascular lymphedema: CT appearance.AJR Am J Roentgenol. 1988; 150: 111-113Crossref PubMed Google Scholar “Periportal halo,” characterized by hypodense appearance on computed tomography and hyperintense appearance on T2-weighted magnetic resonance images, has important clinical significance in the diagnosis of IHL.3Karcaaltincaba M. Haliloglu M. Akpinar E. et al.Multidetector CT and MRI findings in periportal space pathologies.Eur J Radiol. 2007; 61: 3-10Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Presence of hypodense appearance on both sides of the portal venous system can allow differentiation from biliary dilatation.3Karcaaltincaba M. Haliloglu M. Akpinar E. et al.Multidetector CT and MRI findings in periportal space pathologies.Eur J Radiol. 2007; 61: 3-10Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar In fact, IHL could be an overlooked complication of TIPS that has never been previously reported. Iatrogenic injury during a TIPS procedure may interrupt lymphatic vessels and initiate coagulation at the injury site, and thrombus/microthrombus provisionally compresses and blocks the hepatic lymphatic system. Once the thrombus/microthrombus dissolves, the occluded lymphatics are recanalized and IHL could be spontaneously resolved. In conclusion, IHL is a procedure-related complication of TIPS that should not be neglected. Periportal halo by CECT provides valuable evidence for both diagnosis and differential diagnosis. Further studies with a larger sample size are necessary to investigate the morbidity and natural course of IHL after TIPS.

Periapical lesion following Cnm-positive Streptococcus mutans pulp infection worsens cerebral hemorrhage onset in an SHRSP rat model.

Cerebral hemorrhage severely affects the daily life of affected individuals. Streptococcus mutans and its adhesion factor Cnm increase the adverse effects of cerebral hemorrhages. However, the mechanism by which Cnm-positive bacteria migrate from apical lesions to cerebral hemorrhage sites is unclear. Therefore, we established an S. mutans-infected apical lesion in a rat model of hypertension and investigated the neurological symptoms associated with cerebral hemorrhage. Eighteen 12-week-old stroke-prone spontaneously hypertensive rats were randomly divided into three groups, i.e. the no infection (control), dental infection with S. mutans KSM153 wild type (Cnm positive), and KSM153 Δcnm groups. Immunofluorescent staining was performed to visualize S. mutans protein. Serum interleukin-1β levels were measured. The adhesion of S. mutans to the extracellular matrix and human fibroblast cells was also analyzed. Serum antibody titers against S. mutans were comparable between Cnm positive and knockout mutants. However, 3-10 days post-infection, neurological symptom scores and cerebral hemorrhage scores were higher in Cnm-positive rats than in knockout mutants. The localization of S. mutans-derived protein was observed in the vicinity of disrupted blood vessels. Serum interleukin-1β levels significantly increased post-KSM153 WT infection. Cnm-positive S. mutans clinical isolates showed increased adhesion to the extracellular matrix, human dental pulp cells, and human umbilical vein endothelial cells compared with the Cnm-negative S. mutans isolates. In conclusion, Cnm-positive bacteria colonize the apical lesion site using the extracellular matrix as a foothold and affect cerebral hemorrhage via the bloodstream.

Effect of early stellate ganglion block in cerebral vasospasm after aneurysmal subarachnoid hemorrhage (BLOCK-CVS): study protocol for a randomized controlled trial

IntroductionStellate ganglion block has been reported to expand cerebral vessels and alleviate vasospasm after aneurysmal subarachnoid hemorrhage. However, the causal relationship between early stellate ganglion block and cerebral vasospasm prevention has not yet been established. The purpose of this study was to explore the effectiveness and safety of early stellate ganglion block as a preventive treatment for cerebral vasospasm and delayed cerebral ischemia.Methods/designThis is a single-center, prospective, randomized, controlled, blinded endpoint assessment superiority trial. A total of 228 patients will be randomized within 48 h of aneurysmal subarachnoid hemorrhage onset in a 1:1 ratio into two groups, one group receiving an additional e-SGB and the other group receiving only a camouflaging action before anesthesia induction in the operating room. The primary outcome is the incidence of symptomatic vasospasm within 14 days after aSAH. Further safety and efficacy parameters include the incidence of radiographic vasospasm, new cerebral infarction, postoperative delirium, and complications up to 90 days after surgery; postoperative cerebral hemodynamics; Mini-Mental State Examination score; modified Rankin scale score; and all-cause mortality up to 90 days after surgery.DiscussionThis is a randomized controlled trial to explore the effectiveness and safety of early stellate ganglion block as a preventive treatment to reduce cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. If the results are positive, it may provide a new direction for the prevention and treatment of cerebral vasospasm and delayed cerebral ischemia.Trial registrationThe study was registered on Clincaltrials.gov on December 13, 2020 (NCT04691271).