Oral Bleeding Research Articles

Adjuvant therapy with imatinib for an incompletely resected multilobular tumour of bone in a dog

A 5-year-old neutered male Shiba Inu dog presented with a history of oral bleeding, dysphagia, and depression for 3 weeks. The physical examination revealed a firm mass in the right caudal palatal region along the level of PM4–M2. On the computed tomography, the mass was round-to-oval in shape and 22 mm × 30 mm × 15 mm in size. The mass contained multiple bone attenuated materials with a palatal bone lysis of 4 mm × 6 mm. A complete resection of the mass was proposed; however, the owner declined due to the risk of complications associated with the radical surgery. Therefore, a palliative resection and biopsy of the mass were performed. On the histological examination, the mass was diagnosed as grade 2 multilobular tumour of bone (MTB). Since the mass was incompletely resected, adjuvant therapy was pursued along with targeted therapy using a tyrosine kinase inhibitor. The tumour cells showed overexpression of the receptor of tyrosine kinase for c-KIT, PDGFR-α, PDGFR-β, and FGFR1 compared to normal tissue cells. Additionally, the cytotoxic effect of imatinib on the MTB cells was confirmed in vitro. Four weeks postoperatively, the administration of imatinib and carprofen was initiated and continued for 259 days. The patient maintained a good functional outcome for 306 days after the initial presentation.

Dexmedetomidine Sedation Combined With Remifentanil in MitraClip Procedures is Feasible and Improves Hemodynamics

The objective of the study was to compare the overall feasibility, respiratory and hemodynamic stability, as well as process times of a dexmedetomidine-based sedative regimen compared with general anesthesia among patients undergoing MitraClip procedures. A retrospective cohort study. A single tertiary care university center. The study included 79 patients. Dexmedetomidine sedation versus general anesthesia. Seventy-nine MitraClip procedures in dexmedetomidine/remifentanil conscious sedation (DCS, n=26) or general anesthesia (GA, n=53), performed between 2018 and 2020 at Charité - Universitätsmedizin Berlin, were analyzed retrospectively. Patients' median age was 81 years in both groups without differences in preinterventional EuroScore I (DCS 6 [5; 8], GA 7 [6; 8]) or systolic function (left ventricular ejection fraction: DCS 50% [32; 60] v. GA 50% [36; 60]; tricuspid annular plane systolic excursion: DCS 19 mm [16; 22] v GA 19 mm [15; 22]). During MitraClip procedures, respiratory parameters revealed no differences between groups, whereas patients under DCS showed higher mean arterial pressures (DCS 64 mmHg [59; 74] v GA 58 mmHg [53; 66]) and needed less norepinephrine (DCS 0.0µg/kg/min [0.0; 0.2] v GA 0.08 µg/kg/min [0.05; 0.15]). Emergence from both anesthesia regimens to readiness for intensive care unit transfer was faster in DCS (8 min [4; 18] v GA 16 min [11; 23]); however, total process time was comparable between groups (DCS 128 min [104; 155] v GA 142 min [117; 190]). Two patients required a switch from DCS to GA due to oral bleeding or prolonged procedure time. Both were excluded from the analysis. There was no switch to open surgery and no differences in postoperative complications between DCS and GA. Dexmedetomidine/remifentanil sedation appears to be feasible and a safe option for MitraClip procedures, and provides better hemodynamic stability with faster emergence times compared with general anesthesia.

A RARE CASE OF ACUTE LIVER FAILURE, HEPATITIS ASSOCIATED APLASTIC ANEMIA, AND HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

A RARE CASE OF ACUTE LIVER FAILURE, HEPATITIS ASSOCIATED APLASTIC ANEMIA, AND HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

Randomised controlled trial comparing the clinical effectiveness of mouthwashes based on essential oils, chlorhexidine, hydrogen peroxide and prebiotic in gingivitis treatment.

The present clinical study aimed to investigate the clinical efficacy of 5 types of mouthwash based on different active substances. The study included 180 patients divided into 6 groups of 30 patients, each group rinsing with one of the following types of mouthwash based on: essential oils, combination of essential oils and 0.12% chlorhexidine, hydrogen peroxide (0.8%), prebiotic, 0.2% chlorhexidine, and placebo. All participants underwent professional mechanical plaque removal after which they were instructed to rinse with 15 ml mouthwash 2 times a day for 21 days. During the study period, patients were monitored at days 0, 14, and 21, examining oral hygiene index, gingival index, bleeding index, and presence of side effects. Gingival index, bleeding index, and oral hygiene index were reduced statistically significantly in all treatment groups. Adjunctive use of mouthwashes demonstrated better clinical effectiveness compared to mechanical plaque control (and placebo mouthwash). The gingival index and the plaque index were reduced most significantly in the group using mouthwash with hydrogen peroxide. The bleeding index decrease was most significant in the group using 0.2% chlorhexidine. All tested mouthwashes demonstrated significant clinical effectiveness in different degrees in gingivitis treatment. New formulas with prebiotic and combination of essential oils and chlorhexidine indicate promising effectiveness.

Utilization of Fresh Frozen Plasma and Cryoprecipitate in Factor VIII and Factor IX Deficient Hemophilia Patient

Haemophilia is one of the most common causes of inherited bleeding disorder resulting from deficiency of coagulation factor VIII or factor IX. Ideally, replacement should be done with factor concentrate. Due to economic constraints associated with its procurement, bleeding episodes are regularly dealt with Fresh Frozen Plasma (FFP) or cryoprecipitate in low-resource countries. This study was carried out to compare the utilization profile and clinical characteristics of haemophilia patients receiving FFP and cryoprecipitate for replacing clotting factor deficiency. This cross-sectional comparative study was conducted in the day care unit of the Department of Transfusion Medicine of Bangabandhu Sheikh Mujib Medical University between 2 groups of haemophilia patients receiving either cryoprecipitate or FFP for treatment. Out of the total 100 haemophilia patients, 50 were treated with cryoprecipitate and 50 with FFP. In FFP group, the majority of patients (48% in cryoprecipitate group and 36% in FFP group) were in the age group of more than 5 to 10 years followed by 11 to 15 years age (24% versus 30%) with a mean SD of age in cryoprecipitate group and FFP group being 11.78±5.61 and 13.42±6.12 years, respectively. About 33 (66.0%) had a history of bleeding following trauma and 32 (64.0%) had a history of spontaneous bleeding among the patients in cryoprecipitate group as a cause of swelling/bleeding and in FFP group, 23 (46.0%) had history of spontaneous bleeding followed by 23 (34.0%) with history of bleeding following trauma. Regarding the type of bleeding, oral bleeding was most common, followed by soft tissue bleeding in both group (40.0% versus 38.0%). Presence of ecchymosis in both groups was statistically significant. The difference in type of haemophilia between the two groups was statistically significant (p<0.001) with a prevalence of haemophilia A of about 88%. The life expectancy of haemophilia patients is increasing dramatically day by day with successful and effective treatment with the appropriate plasma component. Cryoprecipitate is better than FFP as there is less chance of volume overload minimizing leucocyte induced non-haemolytic febrile transfusion reaction and rapid correction of coagulation factor.

Patient factors associated with receiving reversal therapy in oral anticoagulant-related intracerebral hemorrhage.

We aimed to describe baseline characteristics of patients with oral anticoagulant-related intracerebral hemorrhage (OAC-ICH) in Sweden and to identify predictive variables associated with receiving hemostatic treatment in the event of OAC-ICH. We performed an observational study based on data from Riksstroke and the Swedish Causes of Death Register to define baseline characteristics of patients with OAC-ICH who received reversal treatment compared with patients who did not receive reversal treatment during 2017-2019. Predictive analysis was performed using multivariable logistic regression to identify odds ratios for factors associated with receiving OAC reversal treatment. We included 1902 patients ((n=1146; OAC reversal treatment) (n=756; no OAC reversal treatment)). The proportion of non-Vitamin K oral anticoagulant associated ICH (NOAC-ICH) patients who received reversal treatment was 48.4% and the proportion of Vitamin K antagonist-associated ICH (VKA-ICH) patients was 72.9%. Factors associated with a lower odds of receiving reversal treatment were increased age (OR=0.98; 95% CI: 0.96-0.99), previous stroke (OR=0.78; 95% CI: 0.62-0.98), comatose LOC (OR=0.36;95%CI: 0.27-0.48; ref.=alert), pre-stroke dependency (OR=0.72; 95% CI: 0.58-0.91), and NOAC treatment (OR=0.34; 95% CI: 0.28-0.42). Care at a university hospital was not associated with higher odds of receiving reversal treatment compared to treatment at a county hospital. Treatment with a reversal agent following OAC-ICH was related to several patient factors including type of OAC drug. We identified that only 48% of patients with NOAC-ICH received hemostatic treatment despite an increase in these cases. Further studies are required to guide the use of reversal therapies more precisely, particularly in NOAC-ICH.

Enhanced healing of oral chemical burn by inhibiting inflammatory factors with an oral administration of shengFu oil.

ShengFu oil is a compounded Chinese medicinal prescription, and provides antibacterial, anti-inflammatory, and analgesic effects, favoring burn wound repair. In this study, we aimed at investigating the effects of topical applications of ShengFu oil and its active ingredients in oral chemical burns and elucidating its regulatory effects on β-catenin, COX-2, and MMP-9 expression caused by exposure to acid or alkaline agents. ShengFu oil contains 16 components, such as Frankincense, Radix Scutellariae and Radix Rehmanniae, and the main active ingredients from Frankincense are α-pinene, linalool, and n-octanol. Mouse models of oral chemical burns were induced by using glacial acetic acid or sodium hydroxide. Hematoxylin and eosin staining and immunohistochemical staining were used to detect the protein expressions of β-catenin, COX-2, and MMP-9 in wound tissues. They were further quantified by multispectral imaging analysis to clarify the effective mechanism of ShengFu oil for intervening inflammatory factors and active components. Our results indicated that the application of ShengFu oil on oral chemical burns effectively stopped the oral burn bleeding and reduced the inflammatory reaction in the damaged tissues, demonstrating that ShengFu oil can promote wound tissue repair in burns caused by heat, acids, and alkalis. The immunohistochemical staining results illustrated that ShengFu oil and its active ingredients significantly reversed the abnormal changes in inflammation-related proteins in mouse tongue tissues that were caused by chemical burns. Regarding long-term toxic effects of ShengFu oil on the gastrointestinal tract, liver, and kidney system, the results of hematoxylin and eosin staining experiments depicted that ShengFu oil was safe and effective for liver, kidney, intestine, esophagus, and tongue. All of these demonstrated that ShengFu oil and its active ingredients are effective and safe in preventing and treating oral chemical burns by interfering with the inflammatory microenvironment.

Transcatheter arterial chemoembolization is safe and effective for patients with late-stage or recurrent oral carcinoma.

ObjectiveWe reported the long-term outcomes of transcatheter chemoembolization (TACE) for patients with late-stage or recurrent oral carcinoma.MethodsThis retrospective study enrolled 18 patients with late-stage or recurrent oral carcinoma between December 2015 and April 2021. The tumor-feeding artery was catheterized, and cisplatin/oxaliplatin and 5-FU/raltitrexed were infused with embolization using polyvinyl alcohol or gelatin sponge. Computed tomography was performed at about 1, 3, and 6 months after the procedure, and every 6 months after that. During the procedure and follow-up, procedure outcomes, complications, treatment efficacy, and overall survival were analyzed.ResultsA total of 31 sessions of TACE were performed, with a technical success rate of 100%. Of 12 patients combined with oral hemorrhage, two patients showed rebleeding 35 and 37 days later, with a clinical efficiency of hemostasis of 88.9%. Mild complications were observed in 11 patients (61.1%). Severe complications or procedure-related deaths were not observed during or after the procedure. The objective response rate and disease control rate were 20.0% and 86.7%, 38.5% and 61.5%, and 25.0% and 50.0% at 1, 3, and 6 months later, respectively. Seventeen patients (94.4%) were followed up, with a median duration of 37.8 months (IQR 22.3–56.8). Nine patients died of tumor progression, one died of massive rebleeding, and one died of severe lung infection. The median overall survival was 23.8 months.ConclusionTACE is a safe and effective procedure with minimal invasiveness for treating late-stage or recurrent oral carcinoma. TACE can be recommended as a palliative treatment, particularly for patients with oral hemorrhage.

Concomitant Use of Diltiazem With Direct Oral Anticoagulants and Bleeding Risk in Atrial Fibrillation.

Background Diltiazem, a moderate cytochrome P450 3A4 isozyme/P-glycoprotein inhibitor, may potentiate the bleeding risk of direct oral anticoagulants (DOACs) through pharmacokinetic interactions. We evaluated the association between concomitant use of diltiazem with DOACs and bleeding among patients with atrial fibrillation, across varying degrees of kidney function. Methods and Results We identified 4544 patients with atrial fibrillation who were initiated on rivaroxaban (n=1583), apixaban (n=2373), or dabigatran (n=588), between 2010 and 2019 in Geisinger Health, with a mean age of 72 years and an estimated glomerular filtration rate of 70 mL/min per 1.73 m2. At the time of DOAC initiation, 15% patients were taking diltiazem and an additional 5% were initiated on diltiazem during follow-up. Among DOAC users, using diltiazem concurrently (versus DOAC alone) was associated with an increased risk of any bleeding-related hospitalization (unadjusted risk difference, 2.4; 95% CI, 0.6-4.2 events per 100 person-years; adjusted hazard ratio, 1.56, 95% CI, 1.15-2.12), as well as major bleeding (unadjusted risk difference, 1.4 [95% CI, 0.1-2.6 events per 100 person-years]; adjusted hazard ratio, 1.84 [95% CI, 1.18-2.85]). Increased risk of any/major bleeding with diltiazem was observed in both patients with and without CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m2) (P for interaction=0.524 and 0.629, respectively). Among 13 179 warfarin users (the negative control), concomitant diltiazem use was not associated with bleeding. Conclusions Concomitant use of diltiazem with DOACs was associated with a higher bleeding risk in patients with atrial fibrillation, consistently in both subgroups of chronic kidney disease and non-chronic kidney disease. For DOAC users, concomitant diltiazem should be prescribed only when the benefit outweighs the risk, with close monitoring for signs of bleeding.

Outcomes of a postoperative day one call to families after adenotonsillectomy in children.

ObjectiveTo examine the outcomes of a postoperative day one (POD 1) phone call to families of ambulatory surgical patients, as a means of guiding clinical interventions and quality initiatives, with a focus on children undergoing adenotonsillectomy (T&A).MethodsRetrospective analysis of outcomes of a POD 1 questionnaire completed in children <18 years of age undergoing T&A at a tertiary care children's hospital over a 3‐year period (August 14, 2018–August 31, 2021).ResultsResponses to the questionnaire were obtained for a total of 1428/3464 (41.2%) children undergoing T&A during the study period. There was no difference in gender, age at surgery, race, ethnicity, insurance product, or preoperative diagnosis for those whose caregiver responded to the questionnaire versus those who did not. Parent responses included 84 (5.9%) who reported problems or concerns postdischarge. These included 18 (1.3%) patients unable to take their pain medication, 9 (0.6%) refusing oral intake, 28 (2.0%) with postoperative emesis, 27 (1.9%) with fevers, and 6 (0.4%) with a change in breathing. A total of 75/122 (61.5%) who reported pain were taking their pain medication as directed. Nineteen (1.3%) patients were noted to have bleeding after surgery, including 4 (21.5%) with nosebleeds, and 12 (63.2%) with oral cavity bleeding requiring no interventions.ConclusionsThe POD 1 questionnaire identified patients with common concerns and complications after T&A. Although most of these concerns were infrequent, it afforded the clinical team the opportunity to provide additional education and instructions on care and management to caregivers after their child's surgical procedure.

First description of Vibrio harveyi as the causative agent of morbidity and mortality in farmed flathead grey mullet Mugil cephalus

Flathead grey mullet Mugil cephalus is an important species in the aquaculture industry in the Mediterranean basin and throughout the world. During the last 10 yr, M. cephalus breeding stocks, larvae, and juveniles cultured in Eilat (Israel) have shown neurological signs such as uncoordinated circular swimming, while also presenting oral hemorrhages. Death follows days after the onset of the clinical signs, and mortality rates may reach 80% in some cases, causing high economical losses. Bacteriology isolations from different organs, including the brain, and a Koch’s postulate experiment, confirmed Vibrio harveyi as the causative agent. Histological analyses showed the presence of the bacterium in different organs. However, in the brain, the bacterium was observed only within blood vessels and meninges. In some samples, mild to severe brain tissue damage was seen. In order to understand the virulence and lethality of V. harveyi, a median lethal dose was calculated, and the result was 106 colony-forming units fish-1. To the best of our knowledge, this is the first report that describes V. harveyi isolated from the brain of M. cephalus and validates it as an etiological agent causing neurological signs in this fish species.

Acute promyelocytic leukemia: A single institution's experience.

e19001 Background: Acute Promyelocytic Leukemia (APL) is highly curable but carries high risk of early morbidity and mortality, including hemostatic abnormalities, differentiation syndrome and infection. Induction regimens include all-trans-retinoic acid (ATRA) to promote promyelocyte differentiation and arsenic trioxide (ATO), with chemotherapy added for high-risk patients. Our objective was to characterize clinical characteristics and complications during APL induction. Methods: Electronic medical records were screened for ATRA, ATO, or idarubicin from 2011-2021. APL induction hospitalization records were reviewed for: demographics, white blood cell (WBC) and platelet count at presentation, fibrinogen at presentation, time to ATRA administration, time to complete remission (CR), infection, thrombohemorrhagic complications, ATO related QT interval prolongation, incidence of and time to differentiation syndrome. Results: 56 patients (pts) (median age 50) were analyzed. Mean time from initial presentation at our institution to ATRA administration was 1.5 days (range 0-6 days). Findings upon arrival: median WBC 1.7 K/UL (range 0.3-134.9), median platelets 32 K/UL (range 7-373), hypofibrinogenemia in 39.2% (N = 22) (median 161 MG/DL, range 35-473). 80.3% had documented thrombohemorrhagic complications during induction hospitalization: DIC (N = 24), venous thromboembolism (N = 12), gastrointestinal bleed (N = 6), oral mucosal bleeding (N = 5), vaginal bleeding (N = 3), gross hematuria (N = 3), intracranial hemorrhage (N = 3), epistaxis (N = 2), intraocular hemorrhage (N = 1), cerebral vascular accident (CVA) (N = 1). 21% (N = 12) developed differentiation syndrome with mean time of onset of 8.8 days (range 1-23 days). 55% (N = 31) had clinically significant infections most commonly neutropenic fever (N = 13), bacterial pneumonia (N = 10), skin (N = 5) and bacteremia (N = 5). 48 pts were given ATO during induction and 31% (N = 15) developed QT interval prolongation with no arrhythmias in the cohort. Among 8 pts who did not receive ATO, one died prior to therapy initiation and 7 were treated prior to ATO as standard of care. Among evaluable patients (N = 51): 98% (N = 50) achieved complete remission (CR) or complete remission with incomplete count recovery (CRi). Median time to CR was 35 days (range 27-50). 6 pts did not achieve CR or had unknown status: 1 patient died during induction (CVA) and 5 had post-induction bone marrow evaluations at outside facilities. Conclusions: Thrombohemorrhagic complications, infection and differentiation syndrome are critical to be mindful of during the early phase of treatment in APL. Our data adds to the landscape of knowledge regarding the incidence and timeline of complications. Although we observed prolonged QTc in pts on ATO, there were no arrhythmias detected and all pts were able to quickly resume therapy.

Effectiveness of long-term prophylaxis using pdFVIII/VWF concentrate in patients with inherited von Willebrand disease.

BackgroundPatients with symptomatic von Willebrand disease (VWD) should be offered long‐term prophylaxis (LTP) to prevent recurrent bleedings. Our objective was to evaluate the effectiveness and safety of Voncento®, a plasma‐derived FVIII/VWF concentrate (ratio 1:2.4), administrated in LTP.MethodsWe included patients from the OPALE study (May 2016 to April 2021), a French multicenter observational study following patients with inherited VWD, who received a Voncento® LTP during the study period.ResultsAmong the 130 OPALE‐study patients, 23 patients (12 women) received a LTP and were therefore included. The median (range) age was 16 (1–85) years; 16 patients were type 3, 1 was type 2A, 6 were type 2B. Before inclusion, 19 (83%) were under LTP and 4 (17%) received on‐demand (OD) treatment. The indications for initiating prophylaxis in the overall population were joint bleeding (43%), ear, nose, and throat (ENT) bleeding including epistaxis or oral bleeding (39%), and recurrent muscle hematoma (22%). The medians (ranges) dose of Voncento® per infusion, frequency, and weekly dose were 45 (33–109) IU/kg, 2 infusions per week, and 96 (44–222) IU/kg/week, respectively. The median (range) annualized bleeding rate (ABR) was 0.8, 0.7 (0–3.5), and 0 (0–2.3) for type 2A, 2B, 3 patients, respectively. There was no difference regarding to the dose, frequency of infusion, or in terms of ABR in 9/19 patients who replaced previous concentrates with Voncento®. During the study period, no adverse event was reported.ConclusionThese results suggest that Voncento® is effective to prevent recurrent bleedings in patients symptomatic VWD.

Comparison of the Jcerity Endoscoper Airway with the LMA supreme for airway management in patients undergoing cerebral aneurysm embolization: a randomized controlled non-inferiority trial

BackgroundJcerity Endoscoper Airway is a new back-open endoscopic laryngeal mask airway device with a unique design. Our study sought to compare the implantation, ventilation quality and complications of JEA (Jcerity Endoscoper airway) versus LMA (Laryngeal Mask Airway) Supreme in the procedure of cerebral aneurysm embolization.MethodsIn this prospective, randomised clinical trial, 182 adult patients with American Society of Anesthesiologists class Ι-II scheduled for interventional embolization of cerebral aneurysms were randomly allocated into the Jcerity Endoscoper airway group and the LMA Supreme group. We compared success rate of LMA implantation, ventilation quality, airway sealing pressure, peak airway pressure, degree of blood staining, postoperative oral hemorrhage, sore throat and other complications between the groups.ResultsThere were no significant differences between the groups in terms of one-time success rate of LMA implantation, ventilation quality, airway sealing pressure or airway peak pressure. However, LMA Supreme group showed a higher degree of blood staining than the JEA group when the laryngeal mask airway was removed (P = 0.04), and there were also more oral hemorrhages and pharyngeal pain than JEA group (P = 0.03, P = 0.02). No differences were observed between groups in terms of other airway complications related to the LMA.ConclusionsThe JEA could not only achieve comparable one-time success rate of implantation and quality of ventilation as the LMA Supreme, but also have lower blood staining degree of mask and less sore throat in patients undergoing perioperative anticoagulation for cerebral aneurysm interventional embolization.Trial registrationChinese Clinical Trial Registry, ChiCTR2100044133; Registered 11/03/2021.Statement: This study adheres to CONSORT guidelines.

Case-Control Study to Evaluate the Oral Hygiene Habits in 31 Children with Hemophilia in Bulgaria Using the Oral Health Impact Profile-14 (OHIP-14) Questionnaire

BackgroundFor patients with hereditary coagulopathies such as hemophilia, the most common dental problem is spontaneous oral bleeding caused by daily oral hygiene habits like tooth brushing. Because of fear of bleeding, children with hemophilia often skip routine oral hygiene procedures, which can lead to dental caries and periodontal diseases. This case control study aimed to evaluate the oral hygiene awareness and hygiene practices of children with hemophilia from 6 to 18 years of age in Bulgaria.Material/MethodsThis study was conducted over 4 years and included 31 patients (children). A sociological approach was used, with direct individual questionnaires for self-assessment of dental habits. Statistical analyses were performed using SPSS.ResultsThere was no significant difference between groups in methods of oral hygiene. The duration of oral hygiene procedures was 1 min (n=5, 16.13±6.61%) or 2 min (n=13, 41.94±8.86%), which was considered insufficient for proper oral hygiene. Children who had received oral hygiene advice by a dentist brushed their teeth significantly longer (n=9, 69.23±12.80%) than those who had not. There was a considerable difference between the reasons for the last dental visit between the groups of children (χ2=5.18, P<0.05).ConclusionsChildren with hemophilia have high awareness of oral hygiene methods; however, more attention should be focused on additional individual educational methods at the dental office. Frequent professional and self-assessment of the oral hygiene routine of children with hemophilia could identify the factors compromising dental status in this vulnerable population.

Sulfamethoxazole-trimethoprim Induced Thrombocytopenia: A report of two cases and a literature review

Sulfamethoxazole- trimethoprim (ST) is a sulfonamide derivative antibiotic that interferes with bacterial folic acid synthesis and growth by blocking dihydrofolic acid formation from para-aminobenzoic acid. One of the more common and concerning side effects of sulfamethoxazole-trimethoprim is thrombocytopenia. Thrombocytopenia is a blood disorder characterized by a decreased number of circulating platelets. A normal platelet count is generally considered between 200,000-400,000 cells/mm³. Spontaneous oral bleeding, purpura and petechiae of the oral mucosa may be seen when the platelet count drops below 100,000 cells/mm³. Here we present two cases of ST induced thrombocytopenia where the oral manifestations were the first indication of the low platelet count subsequently leading to life saving interventions. It is our aim to educate dentists about both the oral manifestations of thrombocytopenia and its association with ST as their examination may be instrumental in directing treatment. Case 1 is a 69 year old male who was given ST 10 days post gynecomastia surgery and presented to an oral surgeon with the chief complaint of "blisters". Case 2 is a 75 year old female who presented to an oral surgeon with a chief complaint of "blood blisters" after having a difficult time swallowing her antibiotic pill the night before. Clinically both patients had intraoral purpura and petechiae. Both patients were admitted to the hospital with platelet counts less than 5,000 cells/mm³. Due to the very low platelet counts, both were given IV immunoglobulins and steroids after discontinuing ST. After several days they recovered and demonstrated a normal platelet count. The best treatment for ST induced thrombocytopenia is discontinuation of the causative agent. Blood transfusions are not usually indicated due to continued platelet destruction in the presence of the drug. However, transfusions can be helpful in patients with a platelet count of <20,000 cells/mm³ after discontinuation of the drug.

Molecular and Clinical Characterization of 7 Iranian Patients with Severe Congenital Factor V Deficiency: Identification of 4 Novel Mutations

Background and Aims: Congenital factor V (FV) deficiency is a rare bleeding disorder with 1 in 1000000 persons in the general population. Individuals with FV activity &lt;1% and very low FV antigen levels are characterized as severe FV deficient patients. Little data is available about the molecular basis of this bleeding disorder in Iran.&#x0D; Materials and Methods: We analyzed 7 unrelated Iranian FV deficient patients regarding clinical manifestation and genotype. The molecular dynamic simulation was carried out to analyze the effect of novel mutations on the FV structure. &#x0D; Results: All cases had recurrence epistaxis, oral cavity bleeding, and hematoma were frequent in our patients. The molecular analysis led to the identification of three already reported mutations (IVS 19+3 A&gt;T, 4014-4017 del TCAG and p.P419R) and four novel mutations (IVS9-1 G&gt;C, Y478D, L1844P, I1556T) in the FV gene of our patients. According to the molecular modeling results, it seems that in the two mutations Y478D and I1556T, an increased number of H-bonds in mutant proteins compared to natural ones reduces the flexibility and increases the stability of the mutant proteins. The results also show that in L1844P and I1556T mutations, the total solvent accessible surface area (both hydrophilic and hydrophobic) significantly decreases compared to the natural variants. &#x0D; Conclusion: Identifying the causative mutation in patients with FV deficiency helps to determine the molecular basis of this bleeding disorder and gain more insight into explaining the variable clinical manifestations of patients with FV deficiency.

Use of Prothrombin Complex Concentrate in Oral Anticoagulant-Associated Major Bleeding.

Severe bleeding remains the most significant adverse effect associated with both warfarin and the direct oral anticoagulant agents. Due to the life-threatening nature of these bleeds, knowledge and understanding of agents that are able to rapidly overcome the anticoagulation effects of these medications is paramount to their use. Worldwide, the most commonly used agent for this indication is prothrombin complex concentrate (PCC). This review summarizes the evidence on the use of PCC in this population and provides practical information regarding patient-specific administration considerations.

Salivary Test Assessment in an Oncohematological Pediatric Sample: A Case Control Study

Background: In recent years, the incidence of neoplastic diseases in children has increased significantly. Immunodepression triggers undesirable effects in the oral cavity such as mucositis, opportunistic infections, oral bleeding, xerostomia, dysgeusia, decay, dental malformations and pain. Objective: We aim to assess, through salivary tests, the quality of saliva in pediatric patients affected by oncohematological diseases and treated with chemo/radiotherapy compared to non-treated subjects. Methods: A total of 20 subjects aged between 5 and 18 years, with oncological pathologies undergoing radio and/or chemotherapy, were evaluated. The control group consisted of 20 healthy children of the same age. The two groups of subjects were asked to undergo salivary tests. Descriptive statistics were computed for each item. Fisher’s exact test was conducted to compare case and control groups. Results: Subjects treated with chemo/radiotherapy had a lower pH and therefore a higher salivary acidity that predisposes to caries and the oral hygiene of children with oncohematological diseases was more deficient than that of the control group. Conclusions: The early detection of these indicators, and the prevention carried out to limit their severity, is an important aspect of the comprehensive care of oncohematological subjects. Pediatric dentists can play a crucial a role enabling good quality of life during cancer therapy.

Cost-effectiveness of andexanet alfa versus four-factor prothrombin complex concentrate for the treatment of oral factor Xa inhibitor-related intracranial hemorrhage in the US

Aim To conduct a cost-effectiveness analysis (CEA) on the use of andexanet alfa for the treatment of factor Xa inhibitor-related intracranial hemorrhage (ICH) from the US third-party payer and societal perspectives. Methods CEA compared andexanet alfa to prothrombin complex concentrate for the treatment of patients receiving factor Xa inhibitors admitted to hospital inpatient care with an ICH. The model comprised two linked phases. Phase 1 utilized a decision tree to model the acute treatment phase (admission of a patient with ICH into intensive care for the first 30 days). Phase 2 modeled long-term costs and outcomes using three linked Markov models comprising the six health states defined by the modified Rankin score. Results The analysis showed that the strategy of using andexanet alfa for the treatment of factor Xa inhibitor-related ICH is cost-effective, with incremental cost-effectiveness per quality-adjusted life-year gained of $35,872 from a third-party payer perspective and $40,997 from a societal perspective over 20 years. Limitations (1) Absence of head-to-head trials comparing therapies included in the economic model, (2) lack of comparative long-term data on treatment efficacy, and (3) bias resulting from the study designs of published literature. Conclusion Given these results, the use of andexanet alfa for the reversal of anticoagulation in patients with factor Xa inhibitor-related ICH may improve quality of life and is likely to be cost-effective in a US context.