Oral Bleeding Research Articles

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.

Mandibular AV Malformation: Life-Threatening Bleeding from the Mouth managed by Endovascular Intervention Complicated by Acute Ischemic Stroke on table. Case Report

Arteriovenous malformations (AVM) of mandibula are rare abnormal congenital vascular condition that can result in serious complications. Although, various treatment options have been advocated in the literature, there seems to be no complete consensus on a suitable treatment option in these cases. Here, we describe a case of mandibular AVM, who has presented with massive oral bleeding, treated successfully by embolization of the bilateral external carotid arteries and the left superior thyroid artery. During the procedure, the patient developed symptoms of acute ischemic stroke that was diagnosed and managed during the same session by endovascular techniques.

Thirty-day mortality with andexanet alfa compared with prothrombin complex concentrate therapy for life-threatening direct oral anticoagulant-related bleeding.

ObjectiveCompare 30‐day mortality among patients receiving the specific reversal agent andexanet alfa versus replacement prothrombin complex concentrate (PCC) in the management of direct‐acting oral anticoagulant (DOAC)–related bleeds.MethodsTwo patient‐level datasets were used: ANNEXA‐4, a prospective, single‐arm trial of patients taking apixaban or rivaroxaban who received andexanet alfa and ORANGE, a prospective, observational study of anticoagulated patients in UK hospitals, some of whom received PCC. Patients were propensity score matched based on demographic and clinical characteristics. Subgroup analyses were performed by bleed type (intracranial hemorrhage [ICH], gastrointestinal [GI], other). Relative risk (RR) of all‐cause 30‐day mortality was calculated.Results322 ANNEXA‐4 patients treated with andexanet alfa (mean age = 77.7 years; 64.9% ICH) were matched with 88 ORANGE patients treated with PCC (mean age = 74.9 years, 67.1% ICH). Adjusted 30‐day mortality for patients treated with andexanet alfa (14.6%) was lower than patients treated with PCC (34.1%; RR, 0.43; 95% CI, 0.29–0.63). In the ICH subgroup, patients treated with andexanet alfa had lower mortality (15.3%) than patients treated with PCC (48.9%; RR, 0.31; 95% CI, 0.20–0.48). Mortality risk was lowest for patients in the GI subgroup but did not differ significantly by treatment (12.2% for andexanet alfa vs 25.0% for PCC; RR, 0.49; 95% CI, 0.21–1.16).ConclusionsIn this propensity score–matched comparison across 2 independent datasets, adjusted 30‐day mortality rates were lower for patients treated with andexanet alfa than in matched patients receiving PCC. This indirect comparison was limited in that it could not account for several highly predictive variables including GCS score, hematoma volume, and expected survival. Further research is warranted to confirm the mortality differences between reversal/replacement agents for DOAC‐related bleeding.

Oral lesions and saliva alterations of COVID-19 patients in an intensive care unit: A retrospective study.

AimTo detect the type and frequency of oral lesions and clinical conditions suggestive of saliva alterations in COVID‐19 patients in an intensive care unit (ICU), as well as to describe the patient´s management in each caseMethodsInformation about oral conditions and mechanical ventilation was collected from oral medicine records of COVID‐19 patients in an ICU (n = 519)ResultsFrom the total collected, 472 patients (90.9%) were examined by the oral medicine staff. In 242/472 patients (51.3%), alterations in the oral cavity were noted. The most frequent changes were mechanical trauma (18.1%, derived mainly from intubation), vascular/coagulation disturbances (24.1%, petechiae, bruises, varicoses, and oral bleeding), and saliva alterations (24.4%, dry mouth, and sialorrhea). Infectious lesions were mentioned in the oral medicine records (16.9%), most associated with a viral infection (15.7%), mainly herpesvirus. Improved oral change protocols included oral hygiene, use of specific medications, and laser therapyConclusionCOVID‐19 patients in the ICU often showed dryness in the oral and mucosa oral lesions related to vascular/coagulation disturbances, and mechanical trauma derived from orotracheal tube. An oral medicine staff must be aligned with the ICU multidisciplinary team to manage COVID‐19 patients, as well as to establish diagnoses and oral cavity treatments.

Oral anticoagulants but not antiplatelet agents increase the risk of delayed bleeding after endoscopic papillectomy: a large study in a tertiary referral center.

Endoscopic papillectomy (EP) is an effective curative treatment in patients with ampullary adenomas. However, EP is burdened by a not-negligible risk of bleeding. The aim of this study was to determine risk factors for delayed bleeding after EP. A retrospective analysis of a prospectively-collected database was performed, retrieving all EP performed over a 20-year period. Anti-thrombotic treatments were managed according to guidelines. Delayed bleeding was defined as overt gastrointestinal bleeding or drop in haemoglobin level. Multivariate logistic regression was used to identify variables related to delayed bleeding. Three-hundred-seven patients (48.5% male, median age 68-year-old) entered the study; of them, 51 (16.6%) received anti-thrombotic treatments. Delayed bleeding occurred in 44 (14.3%) patients. No difference was observed in patients receiving antiplatelet agents. Multivariate analysis identified oral anticoagulant agents (odd Ratio 4.37 [2.86-5.95]) and procedural bleeding (OR 2.22 [1.10-4.40]) as independently related to delayed bleeding; in patients with no procedural bleeding, oral anticoagulant agents (OR 5.63 [2.25-9.83]) and ampullary tumor size (OR 1.07 [1.01-1.13]) were independently related to delayed bleeding. Patients on anticoagulant agents presented significantly higher need for blood transfusion (16.7 vs. 1.5%); no difference in intensive care unit admission, surgery or mortality was observed. This study demonstrates that patients on oral antiplatelet agents do not present increased risk for post-EP delayed bleeding. EP represents a valid alternative to surgery even in patients on anticoagulant agents, despite significantly increased risk of delayed bleeding. A tailored approach to those cases should be planned.

Pseudo-Aneurysm of Lingual Artery a Rare Complication of Squamous Cell Carcinoma of Tongue and a Cause of Oral Bleed

Pseudo-aneurysm of lingual artery a branch of external carotid artery is rarely seen. Most of cases of pseudo-aneurysm occur after trauma, surgery, inflammation, post chemotherapy, radiotherapy and infection. Pseudo-aneurysm of lingual artery secondary to lingual carcinoma with oral bleeding is a rare presentation, hence we discuss the CT imaging findings of lingual artery pseudo-aneurysm in a patient with known case of carcinoma of tongue on chemotherapy and radiotherapy presented with oral bleeding.

Evaluation of definitions for oral anticoagulant-associated major bleeding: A population-based cohort study

IntroductionMajor bleeding is the most serious complication of oral anticoagulants (OACs). While consensus criteria to define major bleeding have been established by the International Society for Thrombosis and Haemostasis (ISTH), Bleeding Academic Research Consortium (BARC) and Thrombolysis in Myocardial Infarction (TIMI), significant variability exists across these definitions. We sought to evaluate the agreement of cases identified by the three definitions and to assess their effect on mortality and OAC resumption. MethodsWe used a dataset of individuals ≥66 years in Ontario, Canada presenting with OAC-related bleeding from 2010 to 2015. For case agreement, we calculated Cohen's κ between the three major bleeding definitions. We used multivariate regression to determine differences in mortality and OAC resumption among ISTH, BARC and TIMI-defined major bleeds. ResultsAmong 2002 cases of OAC-related bleeding, agreement in case identification between ISTH and BARC was substantial (Cohen's κ = 0.69); however, agreement between TIMI and other definitions were poor. Using 30-day mortality of clinically relevant non-major bleeds as comparator, ISTH-, BARC- and TIMI-defined major bleeds conferred 3.3-, 3.2- and 5.9-fold increased risk. Among survivors, 50% with ISTH- and BARC-defined major bleeds resumed OACs at 180 days, compared to 31% of TIMI-associated cases. ConclusionMajor bleeds identified by ISTH and BARC criteria showed good agreement and similar prognostic utility, whereas TIMI criteria identified patients at greater clinical risk. Our results highlight the need to revise major bleeding definitions based on criteria that are independently predictive of clinically relevant morbidity and mortality to more effectively reflect the risk associated with major bleeding and appropriately influence anticoagulant therapy decisions.

Decrease in incidence of oral anticoagulant-related intracerebral hemorrhage over the past decade in the Netherlands.

BackgroundData on oral anticoagulant-related (OAC) intracerebral hemorrhage (ICH) incidence are scarce. Most studies on incidence time trends were performed before the introduction of Direct Oral Anticoagulants (DOACs). Between 2008 and 2018, the number of OAC-users in the Netherlands increased by 63%, with the number of DOAC-users almost equaling that of Vitamin K Antagonists (VKA)-users. We aimed to determine the recent total and OAC-related ICH incidence and assess changes over the last decade, including the effect of DOAC introduction.MethodsAll adult non-traumatic ICH patients presenting in any of three hospitals in the enclosed region of South-Limburg, the Netherlands, were retrospectively included, during two 3-year time periods: 2007–2009 and 2017–2019. OAC-related ICH was defined as ICH in patients using VKAs or DOACs. We calculated the incidence rate ratio (IRR) between the two study periods.ResultsIn the 2007–2009 period, we registered 652 ICHs of whom 168 (25.8%) were OAC-related (all VKA). In the 2017–2019 period, we registered 522 ICHs, 121 (23.2%) were OAC-related (70 VKA and 51 DOAC). In 2007–2009, the annual incidence of total ICH and OAC-related ICH was 40.9 and 10.5 per 100,000 person-years, respectively, which decreased to 32.4 and 7.5 per 100,000 person-years in 2017–2019. The IRR for total ICH and OAC-related ICH was 0.67 (95%-CI: 0.60–0.75) and 0.58 (0.46–0.73), respectively.ConclusionBoth total ICH and OAC-related ICH incidence decreased over the past decade in South-Limburg, the Netherlands, despite the aging population and increasing number of OAC-users. The introduction of DOACs, and possibly an improved cardiovascular risk management and change in OAC prescription pattern, could explain these findings.

Hemostatic Dysfunction in Dogs Naturally Infected with Angiostrongylus vasorum-A Narrative Review.

This narrative review aims to describe Angiostrongylus vasorum-induced hemostatic dysfunction of dogs with emphasis on clinical and laboratory findings as well as potential therapeutic strategies for the bleeding patient. Canine angiostrongylosis (CA) is a disease with potentially high morbidity and mortality in endemic areas and with fatal outcome often associated with either severe respiratory compromise, pulmonary hypertension and right-sided heart failure, or hemostatic dysfunction with severe bleeding. The most common signs of hemorrhage are hematomas, petecchiation, ecchymoses, oral mucosal membrane bleeding and scleral bleeding, while intracranial and pulmonary hemorrhage are among the most severe. The pathophysiological mechanisms underlying hemostatic dysfunction in these patients are presently researched. While the larval effect on platelets remains unknown, the parasite appears to induce dysregulation of hemostatic proteins, with studies suggesting a mixture of pro-coagulant protein consumption and hyperfibrinolysis. Importantly, not all dogs display the same hemostatic abnormalities. Consequently, characterizing the hemostatic state of the individual patient is necessary, but has proven difficult with traditional coagulation tests. Global viscoelastic testing shows promise, but has limited availability in general practice. Treatment of A. vasorum-infected dogs with hemostatic dysfunction relies on anthelmintic treatment as well as therapy directed at the individual dog’s specific hemostatic alterations.

A pilot study to evaluate the impact of digital imaging on the delivery of oral hygiene instruction

AimsTo determine whether personalised Oral Hygiene Advice (OHA) using an intra-oral-camera (IOC) combined with standard OHA as provided in general dental practice reduces plaque levels after 4 weeks more than the provision of standard OHA. Materials and Methods22 healthy adult participants diagnosed with gingivitis took part in this pilot parallel-designed, randomised, examiner-blind, 2x-treatment, study regarding their home-care oral hygiene habits and attitudes to oral health. An IOC-image was taken and plaque, gingival and bleeding scores were recorded. Test group participants received standard OHA with IOC-images to indicate areas for improvement, control group participants received standard OHA. Questionnaires and plaque, gingival and bleeding scores were repeated after 4 weeks. Plaque was scored from the IOC-images and scores compared to clinical plaque scores. ResultsLifestyle habits, attitudes to oral health, plaque (0.63vs0.61, control vs test) and bleeding scores (1.17vs0.96, control vs test) were similar at baseline. After 4-weeks, plaque scores improved more in test as compared to control group (39.4vs20.6%, p<0.05, while gingival and bleeding scores approached significance. There was no difference in lifestyle habits between groups, but the test group reported significantly greater confidence in adhering to their bespoke oral health plan. Agreement between the clinical and IOC plaque scores was good. ConclusionsUse of IOC further personalises the prevailing standard of oral hygiene advice and generates great patient engagement with pictorial reports to facilitate a more in-depth patient explanation of their gingival health, resulting in significant plaque reduction and improved gingival health compared to the standard OHA alone.

Qingwei San treats oral ulcer subjected to stomach heat syndrome in db/db mice by targeting TLR4/MyD88/NF-\u03baB pathway

BackgroundQingwei San (QWS), one of classic Chinese Medicine prescripts, has been widely used to treat stomach heat syndrome which manifests oral ulcer (OU), periodontitis and upper gastrointestinal bleeding for seven hundred years. However, the therapeutic effects of QWS on diabetic OU subjected to stomach heat syndrome are still ambiguous. In the study, we investigated the pharmacological mechanisms.MethodsThe main components of QWS aqueous extract were analyzed by LC–MS, and potential pathways of QWS targeting OU were predicted by network pharmacology. The db/db mice were administered with the decoction of dried Zingiber officinale Rosc. rhizome combined with NaOH cauterization to establish the model of diabetic OU subjected to stomach heat syndrome. Subsequently, the model mice were treated with QWS, and OU wound healing status were recorded. The pathological changes of gastric tissue and oral mucosa were evaluated using hematoxylin–eosin staining, and the morphology of collagen fibers in oral mucosa was assessed by Masson staining. The levels of thromboxane B2 (TXB2), 6-Keto-prostaglandin F1α (6-keto-PGF1α), interleukin-1 β (IL-1β), IL-2, IL-6, tumor necrosis factor-α (TNF-α), β-endorphin (β-EP) and 5-Hydroxytryptamine (5-HT) were determined by ELISA assay. The protein expressions of Toll-like receptor 4 (TLR4), TNF receptor associated factor 6 (TRAF6), myeloid differentiation factor 88 (MyD88), inhibitor of NF-κB alpha (IκΒα), p-IκΒα and nuclear factor kappa-B (NF-κB) p65 were measured by Western Blotting.ResultsA total of 183 compounds in QWS were identified by LC–MS, and identified 79 bioactive compounds corresponded to 269 targets and 59 pathways. QWS high-dose treatment significantly reduced the level of TXB2 and the ratio of TXB2/6-keto-PGF1α. Meanwhile, it improved mucosal pathological morphology, and reduced the area of OU and local edema. Simultaneously, the levels of TNF-α, IL-1β, IL-6, IL-2 and 5-HT, and the expressions of TLR4, TRAF6, MyD88, p-IκΒα and NF-κB p65 were decreased.ConclusionQWS treatment facilitates the healing of OU, ameliorates pathological morphologies of gastric and oral mucosa and decreases the levels of pro-inflammatory cytokines in db/db mice subjected to stomach heat syndrome, whose mechanism may be associated with the inhibition of TLR4/MyD88/NF-κB signaling pathway to exert anti-inflammatory effects.

Systemic lupus erythematosus: a rare clinical image.

Systemic lupus erythematosus (SLE), is the most common type of lupus. Systemic lupus erythematous is an autoimmune disease in which the immune system attacks its tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels. A 12-year-girl visited the outpatient department with the complaint of skin lesions (red color) over sun-exposed areas on the hand, feet, and face. Oral mucosal bleeding, joint pain including knee, shoulder, elbow, and wrist. On physical examination, photosensitive rash and oral bleeding were observed. Laboratories investigation revealed the patient had systemic lupus erythematosus. The patient was referred to the dermatology department for further medical management.

Utility of the ISTH bleeding assessment tool (BAT) in diagnosis of Glanzmann Thrombasthenia patients.

Objectives:To assess the utility of ISTH-BAT (International Society on Thrombosis and Hemostasis- Bleeding Assessment Tool) in the diagnosis of Glanzmann Thrombasthenia (GT) in comparison to controls.Methods:It was a case-control study carried out at The Children’s Hospital, Lahore from January 2012 to May 2021. All patients from neonates to 18 years with a final diagnosis of GT were studied retrospectively. The clinical details were collected from hospital records and telephonically on ISTH-BAT questionnaire after taking informed consent. The same proforma was obtained from 75 healthy controls. Data was analyzed on SPSS version 26.Results:Out of 427 patients with suspected platelet function disorders, 133 were diagnosed as GT. The mean age was 7.29±5 years. Male to female ratio was 1.1:1. Among cases, 76.6% were products of consanguineous marriage. Epistaxis was the commonest symptom with highest score (p value<0.001). Cutaneous and oral cavity bleeds were more severe and frequent in patients than controls (p value < 0.004). The median ISTH-BAT score among patients was nine while in control group was one. Sensitivity was 86.4%, specificity was 77.3%, positive predictive value was 0.87 and negative predictive value was 0.76. Area under the receiver operator curve was 0.78 (95% confidence interval 0.82–0.90, p< 0.001*).Conclusion:ISTH-BAT scores were significantly higher in GT patients than controls. So, we recommend the inclusion of ISTH-BAT in diagnostic evaluation of patients with suspected Glanzmann Thrombasthenia.

Assessment of self-perceived oral malodor, oral hygiene practices, and smoking habits among dental and engineering students: A cross-sectional study

Aim and Objectives: This study aimed to assess the prevalence and knowledge of self-perceived oral malodor, oral hygiene practices, and smoking habits among dental and engineering students of Dhule district. Materials and Methodology: A structured self-administered, close-ended questionnaire was prepared and was given to 435 dental and engineering e students. This was to assess the self-reported perception of oral breath, awareness of bad breath, timing of bad breath, treatment received for bad breath, oral hygiene practices, caries and bleeding gums, dryness of the mouth, smoking and tea-drinking habits, and tongue coating. The students who responded to the questionnaire were included in the study. Informed consent was obtained from the subjects willing to participate in the study. Results: Toothbrushing was prevalent among 100% of dental students and 87% of engineering students. Self-perception of oral malodor was prevalent among 7% of dental students and 66% of engineering students. Smoking habit was prevalent in 26% of engineering students and 8% of dental students, for which self-treatment was sought for bad breath by 6% of dental students and 8% of engineering students. Conclusion: Dental students had increased awareness regarding self-perceived oral malodor, oral hygiene practices, and smoking habits compared to engineering students.

Effect of Virgin Coconut Oil in Plaque Related Gingivitis

Introduction: In all individuals oral health is important. Irrespective of nationality, oral hygiene habits are taught in childhood itself. Tooth cleaning by the mechanical method is the most accepted method in the maintenance of oral hygiene worldwide. Presently to reduce plaque formation chemotherapeutic agents are used. Oil pulling is used for many years for strengthening gums, teeth and to prevent oral malodor and bleeding gums. Coconut oil is consumed as a staple diet. Coconut oil contains 50% of Lauric acid and 92% of saturated acid. The lauric acid contains anti-inflammatory properties.&#x0D; Aim: This study aimed to find out the efficacy of virgin coconut oil in plaque-related gingivitis.&#x0D; Materials and Methods: The sample size used for the study is 108, A self-structured questionnaire has been prepared and uploaded in Google forms. This standard questionnaire in Google forms is being circulated among the sample study population and at the end of the survey, all the data were collected and the data is been analyzed by using Chi-square analysis. The Chi-square analysis was done using the software IBM SPSS Software Version 23.&#x0D; Results: The Chi-square analysis was done and the association between gender and improvement in gingival health after oil pulling in the South Indian population was found to be statistically significant. Chi-square value:11.77 and p-value:0.038, (p&lt;0.05) hence a statistically significant decrease in gingival and plaque was noticed during the study period.&#x0D; Conclusion: In summary, using Virgin coconut oil pulling could be an effective procedure in decreasing plaque-related gingivitis. This preliminary study shows that coconut oil is easily usable, cost-effective, and safe with minimal side effects which are used as an adjuvant in oral hygiene maintenance. Further studies on the antimicrobial potency of coconut oil are required for the use of coconut oil as an effective oral antimicrobial agent.

Management of Coagulopathy in Bleeding Patients.

Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.

A rare case of Acute Motor and Sensory Axonal Neuropathy (AMSAN) and Immune Thrombocytopenic Purpura (ITP) related to Hemophilus influenzae

We describe a rare case presenting with both signs of acute motor and sensory axonal neuropathy (AMSAN) and immune thrombocytopenic purpura (ITP) possibly triggered by Hemophilus influenzae. Guillain-Barre is an autoimmune disorder purported to be due to molecular mimicry, often with a preceding infection, leading to myelin sheath or even axonal damage, AMSAN, in the peripheral nervous system (PNS). Rarely, there have been case reports of concurrent acute autoimmune disorders leading to a more complex presentation and additional comorbidities.&#x0D; A 42-year-old man presented with 2 days of progressive lower and upper extremity paresthesia’s, ataxia preceded by an upper respiratory infection. Examination showed areflexia and purpura, recent oral mucosal hemorrhage. Lab results showed severe thrombocytopenia suspicious for ITP. Over the ensuing weeks while inpatient, his condition quickly deteriorated to requiring an intubation for respiratory failure and not immediately responsive to IVIG. Recovery, both for AMSAN confirmed by EMG and ITP, was eventually achieved with time and five treatments of plasmapheresis and eventually was discharged to a rehabilitation facility. A thorough infectious workup revealed a possible trigger being Haemophilus influenzae.&#x0D; There have been rare occasions of concurrent GBS and ITP, but even more rare is the presence of both AMSAN and ITP which requires quick recognition and evaluation. This case highlights the need for a thorough initial history taking and a general physical exam, in addition to unique management decisions and strategies in patients with suspected GBS as there may be signs of other associated disorders that require immediate attention.

A case involving eltrombopag administration for oral bleeding due to idiopathic thrombocytopenic purpura

A case involving eltrombopag administration for oral bleeding due to idiopathic thrombocytopenic purpura

A Cross-Sectional Study of the American Thrombosis and Hemostasis Network Dataset for Outcomes of Dental Extractions in People with Hemophilia

BACKGROUND: Dental extraction (DE) is one of the most common procedures in people with hemophilia A or hemophilia B (PWH-A, PWH-B), yet little is known about impact of the type of hemophilia, hemostatic therapies, and bleeding outcomes. To date, there is no standard protocol for how to treat PWH undergoing DE. Similar overall bleeding rates occur with pre- and postoperative factor replacement (FRP) therapy and single dose preoperative FRP (11.9% and 11.4%, respectively) (DE. Bajkin et al. Haemophilia 2020).METHODS: We analyzed the American Thrombosis and Hemostasis Network dataset (ATHNdataset) to assess trends in prophylactic factor use and its impact on bleeding outcomes following dental extraction in PWH-A and PWH-B ≥2 years of age. A DE bleeding episode was defined as any oral or mouth bleeding occurring during or within one week following a DE procedure. Treated bleeds were defined as any oral or mouth bleeds treated with hemostatic medications during or within one week post-DE. Hospitalization and emergency department (ED) visit events were defined as any that occurred during or one day after a DE. Data on sociodemographic, clinical characteristics, and outcomes were collected prospectively between 2013 and 2019 at annual clinical visits to 134 ATHN-affiliated sites. Categorical variables were summarized using frequency and percentage. Logistic regression was used to evaluate associations between DE and sociodemographic and clinical variables. Simple logistic regression models were applied to identify factors potentially associated with dental bleeding episodes among PWH.RESULTS: Sociodemographic and clinical characteristics revealed that of the 19,048 PWH in the ATHNdataset, 1,157 subjects underwent 1,301 episodes of DE; a majority (74.9%) were diagnosed hemophilia A and 94.4% were male. The odds of a DE were approximately 148% higher among male PWH compared to female PWH (OR: 2.48; 95%CI: 1.93-3.20). PWH with severe disease were less likely to undertake DE than those with mild hemophilia (OR: 0.83; 95%CI: 0.72-0.95). Compared to PWH-B, PWH-A tended to have DEs at a younger age (<30 years). The chance of a DE did not differ by race, hemophilia type, and currently having or having a history of inhibitor. No significant associations were found between dental extraction, education or employment among PWH ages >18 years.Dental extraction clinical outcomes and related treatments indicated approximately 34% of PWH used prophylaxis versus on-demand therapy (18%) 292for dental/mouth bleeding. Approximately 5% of PWH who underwent DE reported oral/mouth bleeds within one week of the procedure. Of those bleeding episodes, 28.0% of hemophilia A patients and 12.5% of hemophilia B patients reported two or more oral/mouth bleeds during, and one-week post-DE. Rates of hospitalizations and ED visits were 7.4% and 1.3% respectively for PWH-A and 8.8% and 0.9% respectively for PWH-B. Among oral/mouth bleeds related to dental extraction, 34.0% and 50.0% patients with hemophilia A and B respectively received hemostatic therapies such as DDAVP, factor concentrates, or antifibrinolytics.Factors associated with DE bleeding were as follows: Dental extractions performed with prophylactic regimen were found to experience insignificantly fewer dental bleeding episodes (P>0.05). Similarly, no statistically significant difference in bleeding rate after DE was found in those using extended half-life factor (EHL) compared to standard half-life products (SHL). Prophylaxis was more prevalent among PWH-A compared to PWH-B (37.3% vs. 25.2% respectively). SHL products were more commonly used than EHL products for on-demand therapy (8.3% vs. 0.5% respectively) as well as prophylaxis (19.8% vs. 8.1%). PWH who have ever developed an inhibitor significantly increased the odds of dental bleeding (OR:2.09, 95%CI: 1.21-3.63). However, no significant relationship was found between inhibitor and DE bleedings among PWH who have been exposed to emicizumab (P=0.168).DISCUSSION: This is the largest study of DE outcomes in PWH. DE tends to be performed more in those with mild hemophilia and at an earlier age. The use of hemostatic therapies and factor prophylaxis is associated with insignificantly less bleeding. The ATHNdataset allowed studies of outcomes in a large cohort of PWH. This project was part of the ATHN CARE Award. DisclosuresHe: ATHN: Ended employment in the past 24 months. Recht: Foundation for Women and Girls with Blood Disorders, Partners in Bleeding Disorders: Speakers Bureau; uniQure: Consultancy; Takeda: Consultancy; Sanofi: Consultancy; Pfizer: Consultancy; Octapharma: Consultancy; Novo Nordisk: Consultancy; Kedrion: Consultancy; Hema Biologics: Consultancy; Genentech: Consultancy; CSL Behring: Consultancy; Catalyst Biosciences: Consultancy; American Thrombosis and Hemostasis Network: Current Employment; Oregon Health & Science University: Current Employment. Kulkarni: Bayer: Consultancy, Research Funding; CSL Behring: Consultancy; Genentech/Roche: Consultancy, Research Funding; NovoNordisk: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Sanofi: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Catalyst Bioscience: Research Funding; Foundation for Women and Girls with Blood Disorders: Membership on an entity's Board of Directors or advisory committees.