Potential Bleeding Research Articles

Outcomes and management of Haemoptysis in the Fontan population

Abstract Background Patients with a Fontan circulation for palliation of a univentricular congenital heart defect commonly possess pulmonary vascular abnormalities including arteriovenous malformations (AVM), aortopulmonary and venous-venous collaterals (1). These vessels are prone to haemorrhage which may result in life-threatening haemoptysis (2). This risk is increased with oral anticoagulant medication, given to reduce the risk of thromboembolism in Fontan patients (3). Management of these patients is difficult, and strategies vary across institutions. Purpose We aim to describe our experience with managing adult Fontan patients presenting with haemoptysis in a tertiary centre with a large Fontan cohort. Methods We retrospectively reviewed the records of 410 adult Fontan patients. Individuals admitted to our institution with an episode of haemoptysis were included. Details relating to anticoagulation regimens, interventions and mortality of patients were captured. Results From a cohort of 410 Fontan patients, 35 haemorrhagic events were observed in 11 patients (2.68%). The median age at initial haemoptysis was 24.5 years (range 19 to 43 years). 6 of the 11 patients were female (54.5%). Haemoptysis recurred in 8 of the 11 patients (72.7%). 2 out of 11 had a prior history of haemoptysis in childhood. All patients were administered with oral vitamin K antagonists at presentation. 24 of the 35 events were managed conservatively with IV fluids, anticoagulation reversal and tranexamic acid (66.7%). 11 events required catheter-based interventions, with coil and/or plug embolization of bleeding vessels. Prior to intervention, CT successfully identified potential bleeding sites in 10 of the 11 events (90.9%) but could not visualise all vessels that were subsequently embolized. The most common culprits for haemoptysis were aortopulmonary collaterals, followed by AVMs and venous-venous collaterals. In severe cases, more extensive management was required including transfusions, bronchoscopy, intubation, surgical exploration (1 patient) and pneumonectomy (1 patient). 3 patients died following recurrent severe haemoptysis (27.3%), and 2 patients died of subsequent Fontan failure and sudden cardiac death respectively. Total mortality of the cohort is 5 out of 11 (45.5%) with a median follow up of 10.75 years (range 3 days to 27 years). Conclusions Haemoptysis is a rare but potentially fatal complication in patients who have undergone a Fontan procedure. The variability in presentation of this condition mandates an individualised approach to management with involvement of a multidisciplinary team. There is a high rate of recurrence following haemoptysis and a comprehensive assessment of all potential bleeding sites is necessary. CT is a useful tool to help facilitate this and guide further management. Our policy is to close all potential sources of bleeding as CT and invasive angiography rarely identifies an active point of bleeding.

Sudden Hearing Loss as the Initial Manifestation of Chronic Myeloid Leukemia

Sudden hearing loss rarely presents as an initial manifestation of a hematologic disorder, although it can result from various factors. A 48-year-old male had sudden hearing loss in both ears. The pure tone audiometry and audiometry brainstem response revealed profound hearing loss in both ears. Further examination indicated an elevated leukocyte count, and a temporal bone magnetic resonance image suggested potential bleeding in the cochlear and labyrinth of both ears. Upon consultation with hematologic oncology, chronic myeloid leukemia was diagnosed. Hearing loss in leukemia patients is attributed to leukemic infiltration, hemorrhage, infection, and hyperviscosity. Following treatment using tyrosine kinase inhibitor for chronic myeloid leukemia, the leukocyte count was normalized. However, on the 90th day of treatment, both profound hearing loss persisted. We suspect that the cause of sudden hearing loss may be related to hemorrhage in both cochlear and labyrinth. Accurate diagnosis and treatment are essential for preventing complications.

A clinical assessment of preperitoneal packing adequacy for pelvic fracture bleeding control

BackgroundThis study aimed to objectively assess the laparotomy pads to potential hemorrhage sites proximity in pelvic fracture patients who underwent post-pre peritoneal packing (PPP) CT scans with packs in situ. MethodsThe CT scans of 19 patients were assessed to measure the distance between laparotomy pads and predetermined pelvic anatomical landmarks. ResultsA total of 38 measurements showed that the median pack-to-point distance for the sacroiliac joint was 2.7 cm (IQR, 2.1–4.0), for the common iliac artery 4.1 cm (IQR, 3.2–5.0), for the external iliac artery 0 cm (IQR, 0.0–0.2), for the internal iliac artery 0.1 cm (IQR, 0–0.7), and for the iliac bifurcation 2.0 cm (IQR, 1.7–3.9). There were 60 % direct contact measurements for the iliac arteries. ConclusionThis study shows that with adequately executed PPP a reasonable proximity of laparotomy packs to the potential bleeding sites to provide tamponade for arresting hemorrhage may be achieved.

Hepatocellular adenoma update: diagnosis, molecular classification, and clinical course.

Hepatocellular adenomas (HCA) are acquired focal liver lesions, that occur mainly in young-to-middle-aged women who are on long-term estrogen-containing contraceptives or young men after prolonged use of anabolic steroids. Furthermore, distinct underlying diseases, such as obesity, metabolic dysfunction-associated steatotic liver disease, glycogen storage disease, etc. are considered risk factors. The 2017 Bordeaux classification, in particular Nault et al, divided HCAs into eight subtypes according to their pheno- and genotypic characteristics. This includes HCAs with hepatocyte-nuclear-factor (HNF1-alpha mutation), HCAs with β-catenin mutation, and HCAs without either of these genetic mutations, which are further subdivided into HCAs with and without inflammatory cells. HCAs should no longer be classified as purely benign without histologic workup since three of the eight subtypes are considered high-risk lesions, requiring adequate management: malignant transformation of the pure (ßex3-HCA) and mixed inflammatory/β-catenin exon 3 (ßex3-IHCA) adenomas, as well as potential bleeding of the sonic hedgehog HCA and pure (ßex7/8-HCA) and mixed inflammatory/β-catenin exon 7/8 (ßex7/8-IHCA). Elective surgery is recommended for any HCA in a male, or for any HCA exceeding 5 cm. Although MRI can classify up to 80% of adenomas, if findings are equivocal, biopsy remains the reference standard for adenoma subtype.

Magnetically Powered Microrobotic Swarm for Integrated Mechanical/Photothermal/Photodynamic Thrombolysis.

Current thrombolytic drugs exhibit suboptimal therapeutic outcomes and potential bleeding risks due to their limited circulation time, inadequate thrombus penetration, and off-target biodistribution. Herein, a photosensitizer-loaded, red cell membrane-encapsuled multiple magnetic nanoparticles aggregate is successfully developed for integrated mechanical/photothermal/photodynamic thrombolysis. Red cell membrane coating endows magnetic particles with prolonged blood circulation and superior biocompatibility. Under a preset rotating magnetic field (RMF), the aggregate with asymmetric magnetic distribution initiates rolling motion toward the blood clot interface, and because of magnetic dipole-dipole interactions, the aggregate tends to self-assemble into longer, flexible chain-like microrobotic swarm with powerful mechanical stir forces, thereby facilitating thrombus penetration and mechanical thrombolysis. Moreover, precise magnetic control enables targeted photosensitizer accumulation, allowing effective conversion of near-infrared (NIR) light into heat and reactive oxygen species (ROS) for thrombus phototherapy. In thrombolysis assays, the weight of thrombi is massively reduced by ≈90%. The work presents a safer and more promising combination of magnetic microrobotic technology and phototherapy for multi-modality thrombolysis.

Localization and etiological stratification of non-neoplastic small bowel bleeding via CT imaging: a 10-year study

ObjectivesThe purpose of this study is to assess the diagnostic efficacy of contrast-enhanced CT scans for small bowel bleeding.MethodsThis retrospective study evaluated patients diagnosed with non-neoplastic small intestinal bleeding (including duodenum) who underwent abdominal CT at our institution from December 2013 to March 2023. Patients were categorized into diverticulum and non-diverticulum groups based on the cause of bleeding. Active bleeding was defined on the CT images as extravasation of contrast material in the intestinal lumen during the arterial phase and/or progressive accumulation of contrast material during the venous phase. We have documented the original report (extracted from the medical record system and additional consultation opinions from senior radiologists), including the presence of active bleeding and its potential bleeding location. Furthermore, two radiologists reassessed the CT images, seeking consensus on the diagnosis between them.ResultsThe study included 165 patients, predominantly male, with a median age of 30 years. Active bleeding was identified in 48.3% of patients. Notably, all identified bleeding diverticula in the diverticulum group exhibited cul-de-sac termination. Among the identified causes of bleeding, Crohn’s disease was most prevalent (46.7%, N of causes = 64). Significant differences were observed in the diagnostic methods between the diverticulum and non-diverticulum groups, with surgery predominantly applied in the diverticulum group, and endoscopy in the non-diverticulum group (n = 49 vs n = 15, p = 0.001). Contrast agent extravasation was significantly higher in the diverticulum group (n = 54 vs n = 16, p = 0.001), and Meckel’s diverticulum cases appearing tubular were significantly higher than in other diverticulum cases (n = 25 vs n = 3, p < 0.001).ConclusionCT allows for a higher detection rate of diverticular bleeding, even if asymptomatic, guiding classification into multiple potentially clinically relevant categories.Critical relevance statementContrast-enhanced CT imaging is effective in determining the location and cause of non-neoplastic small bowel bleeding, especially diverticular bleeding. Therefore, the use of enhanced CT should be prioritized in the diagnosis and management of small bowel bleeding.Key PointsCT has potential value in the diagnosis of small bowel bleeding.CT imaging suggests possible surgical intervention for active bleeding detection.CT diagnoses and localizes small bowel bleeding, aiding in treatment and prioritizing in guidelines.Graphical

Co-Administration of Amiodarone Increases Bleeding by Affecting Rivaroxaban Pharmacokinetics in Patients with Atrial Fibrillation.

This study aimed to investigate the impact of the drug-drug interaction between rivaroxaban and amiodarone on the clinical outcomes in patients with non-valvular atrial fibrillation (NVAF), focusing on pharmacokinetic and pharmacodynamic (PK/PD) aspects. A prospective study enrolling 174 patients with NVAF who were treated with rivaroxaban was conducted. The patients were divided into two groups based on postoperative antiarrhythmic and anticoagulation strategies: the rivaroxaban group (Control group) and the rivaroxaban plus amiodarone group (Riv/Amio group). The trough plasma concentrations (Ctrough) of rivaroxaban, activated partial thromboplastin time (APTT), prothrombin time (PT), and the clinical outcomes between the two groups were compared. Patients receiving 20 mg of rivaroxaban in the Riv/Amio group had a higher concentration of rivaroxaban Ctrough than those in the Control group (p = 0.009). Furthermore, in patients with moderate to severe renal impairment, rivaroxaban Ctrough was significantly increased in the Riv/Amio group. There was no significant difference in PT and APTT between the two groups. Regarding the clinical outcomes, the combination of rivaroxaban and amiodarone medication was associated with a higher incidence of bleeding events (p = 0.041; HR = 2.83, 95% CI 1.05-7.66) and clinically relevant non-major bleeding (p = 0.021; HR = 3.65, 95% CI 1.21-10.94). Finally, independent risk factors for bleeding in NAVF patients treated with rivaroxaban were identified as its combination with amiodarone (p = 0.044; OR = 2.871, 95% CI 1.028-8.023). The combination of rivaroxaban and amiodarone led to changes in rivaroxaban pharmacokinetics and an elevated risk of bleeding events. Therefore, physicians prescribing rivaroxaban medications should assess the potential bleeding risk associated with the concurrent use of amiodarone, particularly in patients with renal impairment.

Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology

IntroductionPreoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The “Patient Blood Management” (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM. ObjectiveTo make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice. Material and MethodsA coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety.Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants).In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14).The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations.Statistical treatment: tabulation of mean, median and interquartiles 25–75 of the value of each survey question (Tables 1, 2 and 3). ResultsExcept for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into:1.- “It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients”.2.- “The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition”.3.- “There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8−10g/dL who are candidates for potentially bleeding surgery that cannot be delayed.”4.- “It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients.”5.- “Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term”. ConclusionsThere was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.

Method development for estimation of bleed momentum coefficient using surface pressure measurements and in situ hot wire calibration

Recently, as a passive flow control method, bleeding technique allowing flow of upstream towards suction side by interior passages, has been utilized on non-slender delta wing planforms, where effective geometries can enhance the flow field characteristics. In order to quantify the effect of the flow control, estimation of the momentum induced by the technique is of significant importance in addition to quantified aerodynamic favor. In the current work, passive bleeding momentum coefficient estimation method is developed and presented based on surface pressure measurements by utilizing Bernoulli equation and loss coefficient for a 45° swept non-slender delta wing. For the characterization of the presented technique in-situ hot wire measurements were performed allowing to extract across bleed slot pressure loss coefficient. Results represent that proposed approach can be used to compute the bleeding momentum where further advancements might lead to an important control parameter for potential active bleeding systems in different flow regimes.

Aesthetic Mandibular Angloplasty to Improve Patient Quality of Life in Chronic Recurrent Multifocal Osteomyelitis

Summary: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoimmune disease that typically develops during adolescence and primarily affects women. CRMO primarily targets the bone in arms and legs, with sporadic occurrences in the mandible. CRMO is typically managed with medical treatment, and the efficacy of surgery remains controversial. Complications of surgery include massive bleeding and potential flare-up of CRMO symptoms. Herein, we report a patient with CRMO who had lesions in the bilateral rami of the mandible treated with aesthetic mandibular angloplasty. This is the first case of aesthetic mandibular angloplasty in a patient with CRMO who had bilateral rami involvement of the mandible. The patient began experiencing jaw pain accompanied by swelling and throbbing discomfort beneath the jawline at the age of 10. A pediatrician diagnosed CRMO, and the symptoms were controlled with nonsteroidal antiinflammatory drugs and immunosuppressants (infliximab, adalimumab). Aesthetic mandibular angloplasty was performed at our center because of mandibular hypertrophy. This procedure necessitated considerable removal of the spongy bone, raising concerns about potential massive intraoperative bleeding. Approximately 1.5 cm of the mandibular body was excised to reveal the cortical bone. Bleeding during surgery was not severe, rendering blood transfusions unnecessary. The patient was satisfied with the surgical results. This case indicates the feasibility of angloplasty for such cases.

A low bleeding risk thrombolytic agent: citPA5.

Alteplase is a cornerstone thrombolytic agent in clinical practice but presents a potential bleeding risk. Stroke patients need pre-screening to exclude haemorrhagic stroke before using alteplase. In this study, we develop a new thrombolytic agent citPA5, characterized by an enhanced safety profile and minimal bleeding tendency. A clot lysis agent, named citPA5, is developed based on rtPA with point mutations to completely suppress its proteolytic activity in the absence of fibrin. In the presence of fibrin, citPA5 exhibited significantly higher fibrinolytic activity (a 15.8-fold increase of kcat/Km). Furthermore, citPA5 showed resistance to endogenous fibrinolysis inhibitor, PAI-1, resulting in enhanced potency. In a series of safety evaluation experiments, including thrombelastography assay, mice tail bleeding assay, and a murine intracerebral haemorrhage (ICH) model, citPA5 did not cause systemic bleeding or worsen ICH compared with alteplase. This highlights the low risk of bleeding associated with citPA5. Finally, we found that citPA5 effectively improved cerebral blood flow and reduced infarct volume in a carotid embolism-induced stroke model. This clot lysis agent, citPA5, not only exhibits a low risk of bleeding but also demonstrates highly effective thrombolysis capabilities. As a result, citPA5 shows great potential for administration prior to the classification of stroke types, making it possible for use in ambulances at the onset of stroke when symptoms are identified. The findings presented in this study also suggest that this strategy could be applied to develop a new generation of fibrinolytic drugs that offer greater safety and specificity in targeting fibrin.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Assessment and management of coagulation in the preoperative period

Managing coagulation disorders and potential bleeding risks, especially in the context of anticoagulant medications, is of immense value both clinically and prior to surgery. Coagulation disorders can lead to bleeding complications, affecting patient safety and surgical outcomes. The use of Patient Blood Management protocols offers a comprehensive, evidence-based approach that effectively addresses these challenges. The problem is to find a delicate balance between preventing thromboembolic events (blood clots) and reducing the risk of bleeding. Anticoagulant medications, although crucial to preventing clot formation, can increase the potential for bleeding during surgical procedures. Patient blood management protocols aim to optimize patient outcomes by minimizing blood loss and unnecessary transfusions.

Pathophysiology, Diagnosis, and Management of Portal Hypertension in the Pediatric Population

AbstractPortal hypertension is caused by resistance to the portal blood flow, which most commonly occurs in the setting of cirrhosis. Complications of portal hypertension can cause significant morbidity and mortality in the pediatric population. Portal hypertension is diagnosed when the hepatic venous pressure gradient (HVPG) is more than 5 mm Hg, and potential bleeding complications from esophageal and gastric varices are more likely when the HVPG is more than 10 mm Hg. Diagnosis can be made clinically; however, liver biopsy with measurement of the HVPG is ultimately required. The management of portal hypertension in pediatric patients is typically aimed at treatment of the complications. Despite the multiple pharmacologic, endoscopic, surgical, and interventional radiologic management techniques that are available, some pediatric patients will ultimately require liver transplant. Prompt referral is needed in such cases.

Displacement of a Ureteral Single J Stent into the Heart: A Case Report and Literature Review

The placement of urethral stents is a commonly performed procedure in urology, typically without complications. However, as illustrated in the present case, major complications can arise. It is crucial to be vigilant about the risk of intravascular or intracardiac malpositioning of the ureteral device, especially when there is an unfavorable evolution or the presence of hematuria. We present the case of a 68-year-old patient undergoing treatment for locally advanced cervical cancer with concomitant radiotherapy and chemotherapy. In the course of her follow-up, the patient developed obstructive renal failure due to extrinsic compression of the ureters. Despite attempts with JJ stent placement, emergency renal drainage became necessary, leading to bilateral nephrostomy. In order to alleviate the patient from nephrostomy tubes and enhance her quality of life, bilateral direct cutaneous ureterostomy was performed, with Single-J probes placed in both ureters. However, during the 4th tube change, conducted without scopic control, the patient experienced thoracic and low back pain at 8 days post-operatively. The CT scan revealed that the left Single-J probe bypassed the renal pelvis without penetrating it. Instead, it ascended the IVC, entering the right atrium, and subsequently reached the right ventricle, accompanied by left pyelocaliectasis. The resolution of the issue was achieved through the implementation of a multidisciplinary approach, engaging the expertise of both urologists and vascular surgeons. The removal procedure involved extracting the distal end of the catheter using a ureteroscope, with simultaneous collaboration from the vascular surgery team. The vascular surgeons performed femoral access and phlebography both during and after catheter removal to mitigate the risk of potential bleeding from the inferior vena cava (IVC). Abdominal access for laparotomy was prepared in anticipation of potential bleeding." The patient underwent placement of a left Single-

Shear Stress‐Triggered Theranostic Nanoparticles for Piezoelectric‐Fenton‐Photodynamic Thrombolysis and Endogenous Thrombus Imaging

AbstractThrombus therapy is challenged by potential bleeding risk of thrombolytic agents, and external irradiation is usually needed in thrombus imaging. Herein, highly efficient theranostic platforms are designed for piezoelectric‐Fenton‐photodynamic thrombolysis and endogenous thrombus imaging in response to the elevated shear stress at the thrombus site. Piezoelectric tetragonal barium titanate (tBT) nanoparticles (NPs) are coated with Fe3+‐coordinated metal‐organic frameworks (MOFs), followed by inoculation of chlorin e6‐luminol conjugates and heparin absorption to obtain theranostic tBT@MOFCL/Hep NPs. Shear stress‐induced piezopotential on NPs accelerates Fe3+/Fe2+ transformation to deplete MOF layers, activates Fenton reaction and produces reactive oxidative species (ROS) for non‐pharmacological thrombolysis. In the meantime, the site‐specific ROS generation oxidizes luminol and the chemiluminescent resonance energy transfer with chlorin e6 generates red fluorescence for thrombus imaging without using external light irradiation. After intravenous injection into a carotid artery thrombosis model, the heparin‐mediated thrombus targeting yields 6.5‐fold higher luminescent intensity at the thrombus site. Thrombi in the carotid arteries are almost completely dissolved with integration of piezoelectric dynamic therapy, piezopotential‐enhanced Fenton reaction, and chemiluminescence‐excited photodynamic therapy, while causing no haematologic and histopathologic abnormality. This study demonstrates a concise strategy to generate shear stress‐responsive built‐in piezoelectric potentials, site‐specific non‐pharmacological thrombolysis, self‐illuminating, and stenosis degree‐adaptable thrombus imaging.

Development of Bleeding Artificial Intelligence Detector (BLAIR) System for Robotic Radical Prostatectomy

Background: Addressing intraoperative bleeding remains a significant challenge in the field of robotic surgery. This research endeavors to pioneer a groundbreaking solution utilizing convolutional neural networks (CNNs). The objective is to establish a system capable of forecasting instances of intraoperative bleeding during robot-assisted radical prostatectomy (RARP) and promptly notify the surgeon about bleeding risks. Methods: To achieve this, a multi-task learning (MTL) CNN was introduced, leveraging a modified version of the U-Net architecture. The aim was to categorize video input as either “absence of blood accumulation” (0) or “presence of blood accumulation” (1). To facilitate seamless interaction with the neural networks, the Bleeding Artificial Intelligence-based Detector (BLAIR) software was created using the Python Keras API and built upon the PyQT framework. A subsequent clinical assessment of BLAIR’s efficacy was performed, comparing its bleeding identification performance against that of a urologist. Various perioperative variables were also gathered. For optimal MTL-CNN training parameterization, a multi-task loss function was adopted to enhance the accuracy of event detection by taking advantage of surgical tools’ semantic segmentation. Additionally, the Multiple Correspondence Analysis (MCA) approach was employed to assess software performance. Results: The MTL-CNN demonstrated a remarkable event recognition accuracy of 90.63%. When evaluating BLAIR’s predictive ability and its capacity to pre-warn surgeons of potential bleeding incidents, the density plot highlighted a striking similarity between BLAIR and human assessments. In fact, BLAIR exhibited a faster response. Notably, the MCA analysis revealed no discernible distinction between the software and human performance in accurately identifying instances of bleeding. Conclusion: The BLAIR software proved its competence by achieving over 90% accuracy in predicting bleeding events during RARP. This accomplishment underscores the potential of AI to assist surgeons during interventions. This study exemplifies the positive impact AI applications can have on surgical procedures.

Fibrinolysis Assessment with Tpa-ROTEM in Patients with Bleeding Disorders of Unknown Cause (BDUC)

Background: In 40-70% of patients referred to the hematologist for evaluation of bleeding symptoms, no cause for their increased bleeding tendency can be found using currently available hemostasis laboratory tests. This group is classified as patients with bleeding disorder of unknown cause (BDUC). The lack of clear guidelines concerning diagnosis, management and genetic counseling in BDUC-patients poses a challenge for patients, family members and treating physicians. Several hemostasis assays have been investigated in BDUC-patients, but little is known about the role of the fibrinolytic pathway in this patient group. This can be explained by the lack of standardized fibrinolysis tests and the limited availability of these tests in laboratories. To further unravel potential bleeding mechanisms in BDUC, in the present study we assessed fibrinolysis in BDUC patients by using a global whole blood tPA ROTEM assay and determining of individual fibrinolysis proteins. Aim: To investigate the capacity of the tPA-ROTEM assay to detect fibrinolytic abnormalities in BDUC-patients and to correlate these findings with fibrinolytic protein activity levels in plasma. Methods: Data from patients referred to the hematologist for bleeding evaluation and included in the Prediction of Evaluation in Adult Hematologic Patients with Bleeding Tendencies (ProBe-AHP) study (METC:14-4-036) were used. BDUC-patients were identified based on (1) a clinically relevant increased bleeding tendency and (2) no abnormalities in extended hemostasis laboratory testing. tPA-ROTEM assay was done according to the in 2016 validated and published method on the ROTEM device. Fibrinolysis protein plasma levels, including plasminogen, plasminogen activator inhibitor 1 (PAI-1) antigen and activity, tissue plasminogen activator (tPA) antigen, alpha2-antiplasmin and thrombin activatable fibrinolysis inhibitor (TAFI), were measured using ELISA assays. Pre-specified definitions of hyper- and hypofibrinolysis as measured by tPA-ROTEM were applied to identify hyper- and hypofibrinolytic profiles. Results: tPA-ROTEM identified a hyperfibrinolytic profile in 15/73 (20%) of BDUC-patients, a hypofibrinolytic profile in 16/73 (22%) of BDUC-patients and a normal profile in 42 BDUC-patients (58%). Plasminogen activity inhibitor 1 (PAI-1) activity and antigen levels and α2-antiplasmin levels were lower in BDUC-patients with a hyperfibrinolytic profile compared to BDUC-patients with a hypofibrinolytic profile. No statistically significant correlations between tPA-ROTEM parameters and fibrinolysis protein plasma levels were identified using multivariate regression analysis. Conclusion: tPA-ROTEM identified a hyperfibrinolytic profile in 20% of BDUC-patients. In this group, the lower PAI-1 activity and antigen levels and lower α2-antiplasmin levels are in concordance with the expected changes in case of hyperfibrinolysis. These findings indicate that these fibrinolysis protein plasma levels are within the lower functional range of their distribution, shifting the balance towards increased clot lysis leading to an increased bleeding tendency. These findings might deliver evidence to the use of antifibrinolytic therapies in BDUC-patients in case of bleeding or interventions. Informed consent and approval from the medical-ethical committee from Maastricht (METC azM/UM) were obtained.

A minority of women of childbearing potential are tested for pregnancy before chemoimmunotherapy: an Australian cancer centre experience.

Chemotherapy is potentially harmful to a developing foetus, and there are limited data on the foetal impact of chemoimmunotherapy (CIT). Therefore, determining pregnancy status prior to initiation of CIT should be standard of care. To determine how many women of childbearing age are tested for pregnancy prior to immunochemotherapy administration. A retrospective chart review at a large Australian metropolitan cancer referral centre, including 304 women aged 18-51 years with a diagnosis of cancer receiving outpatient-based CIT between 1 May 2015 and 12 June 2020. We assessed the uptake of pregnancy screening and contraception counselling prior to and during first-line CIT. Only 17.3% of CIT cycles (n = 416) screened patients for pregnancy no more than 90 days prior to administration, and the median time between pregnancy screening and treatment was approximately 3 weeks. One patient with early breast cancer had a spontaneous miscarriage estimated at 3-4 weeks' gestation, and neither the patient nor the treating oncologist was aware of this event. This was also the only patient who had a pregnancy test beyond the first cycle of CIT during their treatment. Our results highlight a concerningly low rate of pregnancy screening in women of childbearing age receiving CIT. The implication of missing a positive pregnancy test in this group of women could result in foetal complications, accidental miscarriage, potential bleeding risks and avoidable psychosocial stress. This highlights the urgent need for guidelines to mandate pregnancy testing in women of childbearing age receiving CIT and evidence-based implementation tools.

EGS P22 Prophylactic PPIs in NOF Fractures to prevent UGI bleed- Can It Be a Lifesaving Intervention?

Abstract Background Assess the incidence of UGI bleed in patients with NOF fractures. Develop trust-based guidelines to include PPIs in the management of such patients. Methods A total of 119 patients who were admitted with NOF fractures between January and March 2022 were included. All the patients admitted to RAEI with NOF fractures were included in the study. All the patients with a previous diagnosis of GORD, peptic ulcers, or perforated peptic ulcers and those who were already taking PPIs before admission were excluded from the study. Information was collected about the hospital number, age, gender and if there was any gastrointestinal bleeding was noticed in such patients during the hospital admission. Results Our results showed that most of the patients who were admitted with NOF fractures were elderly. A total of 5/119 patients had major gastrointestinal bleeding during there hospital admission thus warranting further procedures such as endoscopy, transfusions, and prolonged hospital stay. Conclusions Elderly patients with NOF fractures are at an increased risk of stress-related mucosal damage and subsequent UGIB. Due to the devastating and potentially threatening complications of mucosal damage, preventative measures are mandatory. Therefore, PPIs should a routine part of drug prescription in patients admitted with NOF fractures. This can not only help prevent this potential bleeding but can also be cost-effective in terms of preventing prolonged stays and readmissions. A reaudit is planned to be done in 1 month's time after the implementation of the changes.

Risk of bleeding in patients with and without cancer on antiplatelet therapy following myocardial infarction: a study in primary care

Abstract Background Antithrombotic medication and antiplatelet therapy (ATPL) are used in the treatment and prevention of thrombotic disorders, especially in patients following a myocardial infarction (MI). However, the risk reduction of future ischaemic events must be balanced against the potential bleeding risk. Co-morbidities may predispose individuals to bleeding events. Cancer influences risk of bleeding either directly through bleeding of fragile cancer-associated blood vessels or by indirectly increasing the risk of bleeding remote from the cancer site. In patients with cancer, bleeding risk may be increased due to ATPL given for concomitant cardiovascular disease. Purpose To investigate the association between pre-existing cancer and risk of bleeding in patients on ATPL after myocardial infarction in a primary care population. Methods We performed a matched cohort analysis using data from the Clinical Practice Research Datalink (CPRD) and linked Hospital Episodes Statistics (HES) in England. People with an MI between 2006–2017 were matched to patients without an MI at a 1:5 ratio. Four groups: patients with both MI and cancer (breast, digestive tract, lung, prostate at baseline [within 1-year prior to MI]), patients with only cancer or MI; and patients without either condition. Using flexible parametric methods, hazard ratios were calculated to determine the association between patient group and risk of bleeding, as well as between APTL-regimen after MI and bleeding risk during 1-year of follow-up after MI. All data were processed using STATA/SE16, using a significance level of ≤0.05. Results We included 58,951 patients with an average (mean) age of 74±10 years (66% male). Of all patients, 12,526 (21%) patients had cancer, and 9,942 (17%) had an MI; numbers per subgroup are presented in Figure 1. A bleeding event was observed in 1,193 (2%) patients. The vast majority (N=56,148 [95%]) of patients did not take ATPL. Of those who did receive ATPL, aspirin was the most common (N=2,359 [4%]). In a multivariable model (adjusted for age, gender, ethnicity, prior bleeding, diabetes, renal disease, smoking status, drug, hypertension, hypercholesteraemia and cancer), people with MI had a risk (hazard) of bleeding of 2.52 (95% CI 2.23-2.86), p&amp;lt;0.001. For people with cancer only, the risk of bleeding was 1.26 (95% CI 1.10-1.44), p&amp;lt;0.001. Conclusion(s) Bleeding risks are higher in people with cancer after an MI than those with MI or cancer alone. More research is needed on individual anti-platelet therapies for people with cancer who have a MI to minimize the risk of bleeding and future cardiovascular events.Figure 1