Prophylaxis Of Bleeding Research Articles

Nonselective beta-blockers in primary prophylaxis of esophageal variceal bleeding in patients with ascites waitlisted for liver transplantation

Objective: to determine the efficacy of non-selective beta-blockers (NSBBs) in the primary prevention of bleeding esophageal varices and to assess their impact on the survival of patients with ascites enrolled in the liver transplant waiting list (LTWL).Materials and methods. We carried out a retrospective comparative study of cirrhotic patients with severe ascites and esophageal varices without bleeding before enrollment in the LTWL. Primary prophylaxis of variceal bleeding included the use of NSBBs (n = 97, group 1). These drugs were not used in the other patients (n = 91, group 2).Results. There were no significant differences between the groups in terms of clinical, laboratory and demographic parameters, MELD scores and Child-Turcotte-Pugh (CTP) classes for cirrhosis. Patient groups included in the study had no significant differences with respect to incidence of medium- and large-sized varices and incidence of severe ascites. Bleeding incidence was significantly lower in the NSBBs group than in the non-NSBBs group (52.6% and 95.6%, respectively, p = 0.0001).Conclusion. NSBBs constitute an efficacious therapy in primary prophylaxis of esophageal variceal bleeding, thereby saving life and preventing delisting of patients with ascites from the LTWL.

Minimal invasive prophylaxis of bleeding from esophageal varices in children with extrahepatic portal hypertension

The objective of the work was to study the efficacy of minimally invasive endoscopic treatment of esophageal varices (EV) in children with extrahepatic portal hypertension (EHPH).Methods and Materials. Eighty children aged 3 to 17 years of age with EHPH included in this study. The patients were divided into three analysis groups. The group I (n=14) included children with EHPH who had not previously undergone any surgical interventions and endoscopic ligation of EV was performed against the background of acute bleeding or after medical hemostatic treatment. The group II (n=37) included patients who had undergone the endoscopic treatment of EV after an unsatisfactory outcome of previously performed surgical interventions. The group III included 29 children who underwent only azygos-portal disconnection procedures. We performed the comparative analysis of the severity of EV before and after sessions of the endoscopic treatment of EV, as well as the analysis of the frequency of recurrent bleedings in comparison groups.Results. According to the research results, recurrent gastroesophageal hemorrhages were noted in 44.4 % of cases in the group I. In the group II, 37 patients underwent a total of 68 sessions of the stage endoscopic treatment of EV. According to the control endoscopic examinations, there was a significant reduction in the risk of bleeding from EV between ligation sessions (p=0.001) of the endoscopic treatment of EV. During the follow-up period, in the group II, recurrent bleedings from EV were noted in 6 (16.2 %) patients. Whereas in 10 (34.5 %) children of the group III, recurrent gastroesophageal hemorrhages were noted in the postoperative period. The analysis showed a significant correlation of the presence of «red flags» with recurrent episodes of bleedings in children of the group II after the endoscopic treatment of EV (r=0.32 p=0.05). Analysis of the causes of recurrent gastroesophageal bleedings in children of the group III did not reveal significant differences in such parameters as the degree of EV and «red flags».Conclusion. Thus, the endoscopic treatment of EV is a safe and effective method of secondary prevention of bleedings from EV. The question concerning the primary prevention of gastroesophageal hemorrhages require further study.

Placenta percreta management in a patient with a severe congenital hypofibrinogenemia

The obstetrical follow-up of patients with a severe hypofibrinogenemia requires a multidisciplinary collaboration because of potential maternal-fetal complications (recurrent miscarriages, intrauterine fetal demise, post-partum hemorrhage, thrombosis). We report the obstetrical management of a multiparous patient with a severe congenital hypofibrinogenemia associated with a platelet disorder (abnormal phospholipid externalization). A therapeutic strategy based on a biweekly administration of fibrinogen concentrates associated with enoxaparin and aspirin allowed the maintenance of pregnancy. But this last one got complicated by a placenta percreta requiring a salvage hysterectomy with an appropriate hemorrhage prophylaxis.

The Role of the Transjugular Intrahepatic Porto-Systemic Shunt in an Emergency Setting.

Transjugular intrahepatic porto-systemic shunt (TIPSS) is an interventional radiology procedure whose aim is to create artificial communication between the portal and the hepatic blood flow in order to reduce the pressure gradient in portal hypertension. The indications to perform a TIPSS procedure can be framed in an elective or emergency setting: refractory ascites to diuretic therapy and secondary prophylaxis of variceal hemorrhage are the most frequent reasons for executing a TIPSS in an election context, while acute uncontrolled variceal bleeding is the principal indication that a TIPSS needs to be performed in an emergency setting. In recent years, the role of the TIPSS has been redefined for several conditions, such as ectopic varices, portal vein thrombosis, Budd-Chiari syndrome, hepatic veno-occlusive disease, and many others. This review aims to perform a deep analysis of when and why a TIPSS procedure should be carried out in an emergency, pointing out the related most common technical difficulties and complications.

Incidence of Symptomatic Venous Thromboembolism (VTE) in 8,885 Elective Total Hip Arthroplasty Patients Receiving Post-operative Aspirin VTE Prophylaxis.

Venous thromboembolism (VTE) is a potentially reducible cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Health and Care Excellence (NICE) published updated guidelines in 2018 which recommend the use of both mechanical and pharmacological methods in patients undergoing elective total hip arthroplasty (THA). The aim of this study was to present the symptomatic VTE incidence in 8,885 patients who underwent THA between January 1998 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Intermittent calf compression stockings are routinely used from the time of surgery until mobilization (usually the following day) with prophylactic doses of low molecular weight heparin (LMWH) during inpatient stay (from 2005 onwards) and then Aspirin 150mg once daily for six weeks on hospital discharge (or Aspirin only prior to 2005), with use of other therapies occasionally as required. Analysis of prospective data collection from consecutive patients at a single institution undergoing THA was performed with the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within six months of the index operation as the primary outcome measure. Ninety-day all-cause mortality of this cohort of patients was also analysed. 8,885 patients were reviewed. This included 7230 primary, 224 complex primary and 1431 revision cases. The overall incidence of symptomatic VTE after elective THA was 1.11% (99/8885) - with the incidence of symptomatic DVT of 0.59% (52/8885) and the incidence of symptomatic PE of 0.53% (47/8885). There was no significant difference (χ2 test, p=0.239) in the symptomatic VTE incidence between primary (1.20% - 89/7230), complex primary (0.89% - 2/224) and revision cases (0.70% - 10/1431). The 90-day all-cause mortality was 0.88% (78/8885). Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to PE. There was no significant difference (p=0.327) in length of stay (and hence amount of pharmacologic prophylaxis with LMWH received by patients before commencement of Aspirin) with the average length of stay for those patients who did not suffer a VTE of 6.8 days compared with 7.6 days for those who did suffer a VTE. Our results support the use of aspirin as an effective form of prophylaxis against symptomatic VTE following THA in contradiction to NICE and American Academy of Orthopaedic Surgery (AAOS) recommendations. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other advantages of using aspirin for VTE prophylaxis.

WCN23-0320 DDAVP for bleeding prophylaxis in patients undergoing kidney biopsy procedures: A randomized controlled trial.

WCN23-0320 DDAVP for bleeding prophylaxis in patients undergoing kidney biopsy procedures: A randomized controlled trial.

Real pandemic world results of pharmacokinetic-tailored personalized prophylaxis of bleeds in Polish children and adolescents with severe hemophilia A.

In 2020, the new nationwide protocol of prophylaxis in Polish plasma-derived FVIII (pdFVIII) previously treated patients (PTPs) with severe hemophilia A (sHA) was introduced, resulting in the necessity of switching from pdFVIII to recombinant FVIII (octocog-alpha; rFVIII). The study aimed to: (1) assess the safety of switching from pdFVIII to rFVIII, (2) assess the safety and efficacy of pharmacokinetically based (PK-based) personalized prophylaxis in severe hemophilia A. 151 children and adolescents receiving prophylaxis with a standard dose (40 U/kg 3 x weekly) of pdFVIII were included in this study. Annualized bleeding rate (ABR) and annualized joint bleeding rate (AJBR) were analyzed for all patients before enrollment. Using myPKFiT application, pharmacokinetic (PK) analysis followed by the selection of the optimal model of prophylaxis was performed in all patients. Two possible models of prophylaxis (standard-dose rFVIII versus PK-based rFVIII) were discussed, with parents leaving the choice to their decision. Parents reported all episodes of bleeds. Screening for inhibitor was performed every 3 months. ABR and AJBR were prospectively analyzed again after a minimum follow-up time of 26 weeks. 141/151 (93.4%) patients completed the study. 34 patients decided to continue standard prophylaxis with rFVIII (Group I), whereas 107 were switched to PK-based prophylaxis (Group II). The risk of inhibitor development could be assessed in 137/151 (90.7%) patients. Only 2/137 (1.47%) patients (both on PK-based prophylaxis) developed low-titer inhibitor with its spontaneous elimination. The retrospective analysis of bleeds during the last 12 months of standard pdFVIII prophylaxis revealed that patients who decided to continue standard prophylaxis had historically lower ABR and AJBR than those who started PK-based personalized prophylaxis. After a minimum of 26 weeks, ABR and AJBR improved significantly in both groups. There was no significant difference in ABR and AJBR between Group I and Group II during the follow-up period. However, the rate of reduction of ABR and AJBR was higher in patients on PK-based personalized prophylaxis. (1) Switching from pdFVIII to rFVIII (octocog-alpha) in PTPs with sHA is safe, (2) PK-based personalized prophylaxis may decrease ABR and AJBR in children and adolescents with sHA.

Pain: a neglected symptom in hemophilia.

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

Optimality of 2-week Versus 4-week Intervals in Secondary Prophylaxis of Bleeding by Endoscopic Esophageal Variceal Ligation

Optimality of 2-week Versus 4-week Intervals in Secondary Prophylaxis of Bleeding by Endoscopic Esophageal Variceal Ligation

Acquired Hemophilia A: An Update on the Etiopathogenesis, Diagnosis, and Treatment.

Acquired haemophilia A (AHA) is a rare bleeding disorder caused by inhibitory autoantibodies against coagulation factor VIII (FVIII). AHA is a disease that most commonly affects the elderly but has also been observed in children and in the postpartum period. AHA is idiopathic in 50% of cases and is associated with autoimmune diseases, malignancies, and infections in the remaining 50%. Recently, cases of association between AHA, COVID-19 vaccination, and infection have been reported in the literature. For diagnoses, determining FVIII levels is crucial to distinguish the different causes of aPTT prolongation. Treatment of AHA is based on bypassing agents (recombinant factor VIIa, activated prothrombin complex concentrate) and porcine FVIII to control the bleeding and immunosuppressive therapy (corticosteroids, rituximab, cyclophosphamide) to suppress autoantibody production. It is important to start a prophylactic regimen to prevent further bleeding episodes until the inhibitor is negative. Recently, the series of cases reported in the literature suggest that emicizumab may provide effective and safe haemorrhage prophylaxis in the outpatient setting.

Metástasis de origen pulmonar de localización inusual

Esophageal varices are present in majority of the patients with hepatic cirrhosis at the time of diagnosis, especially in those with advanced liver disease. Variceal size, red wale marks on varices, and advanced liver disease are risk factors for variceal hemorrhage. Esophageal variceal ligation (EVL) is a standard endoscopic procedure in the management of acute variceal bleeding and is beneficial in the primary and secondary prophylaxis of esophageal variceal bleeding. Multiband devices are commonly used for EVL. Various endoscopic techniques, common clinical scenarios, and procedure-related complications in EVL are described in the video manuscript provided. This article is part of an expert video encyclopedia.

REX SHUNT IN CHILDREN: COULD DYSFUNCTION BE PROGNOSED? A RETROSPECTIVE ANALYSIS.

The aim: To analyze retrospectively our experience of Rex shunt in children with symptomatic portal hypertension, its effect on hypersplenism regression and varices eradication, assess shunt survival and investigate risk factors, that could lead to shunt dysfunction and thrombosis. Materials and methods: 24 children (16 males, 8 females) ,with portal hypertension included into the study. All surgeries were performed within single center in a period from January 2010 to March 2022. Follow up period was 6.75±1.19 years. Results: Age at diagnosis was 5.39±0.64 years. 5 (20.8%) had umbilical catheter in anamnesis. 16 (66.7%) manifested bleeding episodes as the first sign of portal hypertension. 9 (37.5%) of children manifested severe hypersplenism. Age at Rex shunting was 7.5±0.7 years. In 7 (31.8%) cases Rex shunt thrombosis occurred. 1 successful thrombectomy and 6 splenorenal shunting were performed. Kaplan-Meyer analysis showed Rex shunt survival 0.670 (95%CI 0.420-0.831). Logistic regression model indicated thrombocytes count (p=0.0423) and cytopenia (p=0.0272) as factors that could influence shunt thrombosis. Follow-up group included 18 patients. Spleen volume regression became significant by 1 p/o year p<0,05, thrombocytes significant increasement reached in 1 p/o months (p<0.01), varices involution was achieved by 1 p/o year (p<0,001). Conclusions: Rex shunt effectiveness in study group was 70.9%., shunt survival assessed 0.670 (95%CI 0.420-0.831). Rex shunt was effective in bleeding prophylaxis in all patients of follow up group. Preoperative thrombocytes count (p=0.0423) and cytopenia (p=0.0272) were detected as factors that could influence shunt thrombosis, that is to be considered in RS preoperative period and require following studies.

Impact and outcome of primary prophylaxis of variceal bleeding among Egyptian hepatocellular carcinoma patients with portal vein thrombosis treated with Sorafenib

Impact and outcome of primary prophylaxis of variceal bleeding among Egyptian hepatocellular carcinoma patients with portal vein thrombosis treated with Sorafenib

Porto-sinusoidal vascular disease: a new definition of an old clinical entity.

Porto-sinusoidal vascular disease (PSVD) is defined as a vascular liver disease characterized by the absence of cirrhosis and the presence of characteristic histological features, with or without the presence of portal hypertension (PH). Half of the patients with PSVD also have associated disease that may contribute to the development of PSVD. Patients usually remain asymptomatic until complications of PH arise. Variceal bleeding and portal vein thrombosis are major complications associated with PSVD. The treatment is focused on managing complications of PH, mainly through primary prophylaxis of variceal bleeding and treatment of portal vein thrombosis. Currently, there is insufficient evidence to support the use of anticoagulants for thrombosis prevention in these patients. Despite the increase of recognition of PSVD, further research is needed to enable early disease diagnosis, establish optimal screening methods, and develop strategies to slow down disease progression.

Considerations for shared decision management in previously untreated patients with hemophilia A or B.

Points to be taken into account to help families make decisions to best care for children born with hemophilia Medical advances are providing a range of treatment options for adults and children with hemophilia. There is, however, relatively limited information about managing newborns with the condition. Doctors and nurses can help parents to understand the choices for infants born with hemophilia. We describe the various points doctors and nurses should ideally discuss with families to enable informed decision-making. We focus on infants who require early treatment to prevent spontaneous or traumatic bleeding (prophylaxis), which is recommended to start before 2 years of age. Families with a history of hemophilia may benefit from discussions before pregnancy, including how an affected child would be treated to protect against bleeds. When mothers are pregnant, doctors can explain investigations that can provide information about their unborn child, plan for the birth, and monitor mother and baby to minimize bleed risks at delivery. Testing will confirm whether the baby is affected by hemophilia. Not all infants with hemophilia will be born to families with a history of the condition. Identification of hemophilia for the first time in a family (which is 'sporadic hemophilia') occurs in previously undiagnosed infants who have bleeds requiring medical advice and possibly hospital treatment. Before any mothers and babies with hemophilia are discharged from hospital, doctors and nurses will explain to parents how to recognize bleeding and available treatment options can be discussed. Over time, ongoing discussions will help parents to make informed treatment decisions:• When and how to start, then continue, prophylaxis.• How to deal with bleeds (reinforcing previous discussions about bleed recognition and treatment) and other ongoing aspects of treatment. ○ For instance, children may develop neutralizing antibodies (inhibitors) to treatment they are receiving, requiring a change to the planned approach.• Ensuring treatment remains effective as their child grows, considering the varied needs and activities of their child.

Long-term impact of primary prophylaxis on joint status in patients with severe hemophilia A

BackgroundPrimary prophylaxis with factor VIII concentrates is the therapeutic gold standard for severe hemophilia A. Although this approach will change substantially with the use of nonsubstitutive therapies, the long-term effects of primary prophylaxis remain unclear. We present information on joint health with tailored primary prophylaxis in a consecutive series at a single center. MethodsWe retrospectively analyzed 60 patients who did not develop early inhibitors. The annual bleeding rate and annual joint bleeding rate, prophylaxis characteristics, physical activity, adherence, and development of inhibitors were compared between those with and without joint involvement at the end of follow-up. Joint involvement was defined as a Hemophilia Joint Health Score or Hemophilia Early Arthropathy Detection with an ultrasound score ≥1. ResultsAmong 60 patients with median follow-up of 113 ± 6 months after starting prophylaxis, 76.7% had no joint involvement at the end of the follow-up. Those without joint involvement started prophylaxis at a younger median age (1 [IQR 1-1] year vs 3 [IQR 2-4.3] years). They also had lower annual joint bleeding rate (0.0 [IQR 0-0.2] vs 0.2 [IQR 0.1-0.5]), were more often physically active (70% vs 50%), and had lower trough factor VIII levels. Adherence to treatment was not significantly different between groups. ConclusionInitiation of primary prophylaxis at a younger age was the main factor associated with long-term preservation of joint status in patients with severe hemophilia A.

Comprehensive treatment of patients with gastric variceal bleeding

Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Bleeding from gastric varices is usually severe and is associated with higher mortality and a higher risk of rebleeding than from esophageal varices. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiological interventions. In terms of treatment, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires prompt intervention to stop it and achieve long-term hemostasis. This review describes the features of pharmacological, endoscopic and interventional radiological prophylactic and treatment options in gastric variceal bleeding. We searched the literature in the MedLine database on the PubMed platform.

Carvedilol versus Band Ligation for Primary Prophylaxis of Variceal Bleeding in ‎Cirrhosis with Systemic Hypertension: A Randomized Controlled Trial

Carvedilol versus Band Ligation for Primary Prophylaxis of Variceal Bleeding in ‎Cirrhosis with Systemic Hypertension: A Randomized Controlled Trial

Budget Impact Analysis of the use of emicizumab for bleeding prophylaxis in patients with Hemophilia A with inhibitors in the Brazilian Health System

Hemophilia A is a hereditary hemorrhagic disorder characterized by deficiency or dysfunction of the coagulation protein factor VIII. The standard therapy consists of factor VIII replacement, which can lead to the development of neutralizing antibodies (inhibitors), a major complication that implies a burden on patient health and the healthcare system because of the decreased quality of life and further costs with treatment. The current work was to assess the budget impact of a bispecific monoclonal antibody, for patients with inhibitors, considering the Brazilian Public System perspective. Results demonstrated high efficacy on preventing bleeds and savings of R$ 1.5 billion in five years.

Can warfarin be replaced by non-vitamin K anticoagulants in prosthetic valves?

ABSTRACT Introduction Despite the improved safety and efficacy profile of non-Vitamin K Antagonist Oral Anticoagulants (NOACAs), the current guidelines still limit their use to stroke prevention in non-valvular atrial fibrillation (AF) patients and venous thromboembolism prophylaxis and treatment. Areas covered In this report, the authors discussed the published data related to NOACs use in prosthetic valves highlighting the proposed mechanisms of NOACs failure and other controversial data regarding their efficacy and safety in prosthetic valves. Expert opinion Although NOACs have proven to be even safer and more effective alternatives to vitamin K antagonists (VKAs) in several indications for anticoagulation, the data regarding their safety and efficacy in prosthetic heart valves is still debatable. The controversial data regarding NOACs use in prosthetic valves renders it difficult to define specific guideline-recommendation for safe and efficient use in this population. The available evidence suggesting that NOACs are as safe and as efficient as VKA regarding thromboembolic prophylaxis and risk of bleeding was primarily based on patients who had undergone bioprosthetic valve and concomitant atrial fibrillation. Further research is warranted to establish if NOACs can be a safer and more efficient alternative to VKAs in patients with prosthetic valves either metallic or bioprosthetic.