Recurrent Bleeding Research Articles

Hepatosplenic schistosomiasis, treatment outcomes and associated factors among adult patients treated at public hospitals in the Harari Region of Ethiopia: retrospective cross-sectional study.

Schistosomiasis is one of the neglected tropical diseases that pose a significant burden in developing countries, particularly in sub-Saharan Africa. Hepatosplenic schistosomiasis (HSS) is a substantial cause of morbidity and mortality. This study aimed to determine clinical patterns, outcomes and factors associated with HSS in the Harari Region of Ethiopia. An institutional-based retrospective cross-sectional study was conducted among 93 adult patients diagnosed with HSS at public hospitals in the Harari Region from December 2018 to November 2022. Data were extracted from medical records using a standardized data extraction tool. EpiData version 4.2 and SPSS version 26.0 were used for data entry and analysis. Fisher's exact test was used to identify the association between dependent and independent variables, and statistical significance was declared at p<0.05. In the current study, HSS-related mortality was recorded in 7.5% of patients. Recurrent episodes of upper gastrointestinal (GI) bleeding (p=0.04), hypotension (p=0.02), altered mental status at admission (p=0.009) and antibiotic use for the treatment of spontaneous bacterial peritonitis (p=0.04) were significant factors associated with HSS-related mortality. The study found that treatment outcomes of HSS patients were strongly associated with recurrent upper GI bleeding, hypotension, altered mental status and antibiotic use for spontaneous bacterial peritonitis treatment. The use of antibiotics for spontaneous bacterial peritonitis treatment was strongly associated with the treatment outcome of patients with HSS and was unique to our study. Adequate recording of patient data, improving chart keeping, integration of preventive and curative programs, improvement of the diagnostic tools, comprehensive treatment guidelines, early diagnosis and treatment are strongly recommended. Rigorous prospective studies that can fully reflect cause-and-effect relationships are crucial to fill fundamental evidence gaps.

Knee Arthroplasty for Ankylosis in a Patient with Severe Hemophilia A

Abstract Hemophilic arthropathy is a common complication of hemophilia A and can lead to chronic synovitis, joint damage, and eventually ankylosis. We present a case report of a 39-year-old male patient with a history of recurrent hemorrhages into the joints. He had a history of traumatic injury to both upper limbs and lower limbs. The patient was on bed rest for 6 months. Subsequently, he developed ankylosis of both elbows in 30° of flexion and ankylosis of the right (Right) knee in 40° of flexion with tricompartmental arthritis of the left knee joint. Radiologically, the left knee joint showed reduced joint space with tricompartmental arthritis. The patient was managed by the tumor prosthesis for the Rt knee. He was advised for management of the elbow joints for which he was not willing. Postoperatively, he was allowed knee range of motion exercises and walking with a walker for 4 weeks followed by a stick for 1 month. At 6-month follow-up, he was able to walk effortlessly without support. The Knee Society Score improved from 47 preoperatively to 75 at 6-month follow-up.

Portal Hypertensive Gastropathy and MELD-Na Score Predict Recurrent Gastrointestinal Bleeding After TIPSS: An ALTA Group Study.

Transjugular intrahepatic portosystemic shunt (TIPSS) is highly effective for treatment of variceal bleeding; however, factors contributing to rebleeding complications remain unclear. In this study, we aim to determine risk factors for recurrent portal hypertensive gastrointestinal bleeding following TIPSS. Utilising the Advancing Liver Therapeutic Approaches multicentre database, we retrospectively identified adult patients who underwent TIPSS for secondary prophylaxis of variceal bleeding and had a gastrointestinal rebleeding event within 1 year. We developed multivariable logistic regression models to identify clinical/procedural characteristics associated with rebleeding. We identified 476 patients, predominately middle-aged (mean age 57), male (62%) and White (65%), with mean MELD-Na 16. 16% (n = 77) had a rebleeding event; these patients were more likely to be male (p = 0.016), with higher serum creatinine (p = 0.005), MELD-Na (p = 0.0002), portal hypertensive gastropathy on pre-TIPSS upper endoscopy (p = 0.000) and with higher incidence of TIPSS revision (p = 0.000). There were no significant differences in type of TIPSS endoprosthesis, concurrent embolotherapy, and post-TIPSS pressure gradients between those who experienced rebleeding and those who did not. After adjusting for TIPSS revision, multivariable analysis revealed MELD-Na and presence of portal hypertensive gastropathy on pre-TIPSS endoscopy were independently associated with rebleeding. In this retrospective analysis of a multicentre, nationally representative database, we found that apart from TIPSS-related factors, high MELD-Na and portal hypertensive gastropathy on pre-TIPSS endoscopy were independent predictors of rebleeding within 1 year following TIPSS. These variables may be used to identify high-risk patients who may require additional monitoring following TIPSS.

Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding

Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding

Before, during, and after: An Argument for Safety and Improved Outcome of Thrombolysis in Acute Ischemic Stroke with Direct Oral Anticoagulant Treatment.

Direct oral anticoagulants are the primary stroke prevention option in patients with atrial fibrillation. Anticoagulant use before stroke, however, might inhibit clinician comfort with thrombolysis if a stroke does occur. Resuming anticoagulants after ischemic stroke is also problematic for fear of hemorrhage. We describe extensive literature showing that thrombolysis is safe after stroke with direct anticoagulant use. Early reinstitution of direct anticoagulant treatment is associated with lower risk of embolic recurrence and lower hemorrhage risk. The use of direct anticoagulants before, during, and after thrombolysis appears to be safe and is likely to promote improved outcomes after ischemic stroke. ANN NEUROL 2024;96:871-886.

Evidence for preventing EVRB in cirrhotic patients: A systematic review.

Systematic strategies for preventing and treating esophagogastric variceal rebleeding (EVRB) are currently inadequate. This systematic review aimed to update this critical gap by searching contemporary studies from major guideline websites, databases, and professional associations focused on EVRB prevention in cirrhosis patients. Key findings highlight evaluation methods, risk management, preventive measures, health education, and follow-up strategies. Notably, a hepatic venous pressure gradient exceeding 18 mmHg is identified as a reliable predictor of gastroesophageal varices (GOV) rebleeding. Effective management of primary diseases is crucial, with methods including antiviral and anti-fibrotic therapies, alcohol avoidance, vaccination, and careful medication management. The combination of nonselective β-blockers (NSBBs) and endoscopic variceal ligation (EVL) is established as the gold standard for secondary EVRB prevention. For patients experiencing recurrent bleeding despite NSBBs and EVL, transjugular intrahepatic portosystemic shunt (TIPS) therapy is recommended. Surgical options, such as surgical shunt and devascularization, are advised for those unsuitable for endoscopic therapy or TIPS, particularly in Child-Pugh A and B patients unresponsive to treatment. Additionally, traditional Chinese medicine options, such as Fufang Biejia Ruangan Tablets, Fuzheng Huayu Capsules, and Anluo Huaxian Pills, have shown promise in improving hepatic fibrosis and GOV in cirrhotic patients. This review offers a comprehensive overview of current prevention and treatment strategies for EVRB, providing valuable insights for clinicians and healthcare professionals.

The comparative study between treatment with Cryoprecipitate and recombinant Factor VIII in Hemophilia in children

Introduction: Hemophilia A is a genetic disorder caused by a deficiency or absence of coagulation Factor VIII, leading to impaired blood clotting and prolonged bleeding, especially into joints and muscles. Without appropriate treatment, recurrent bleeding can result in chronic joint damage and disability. Traditionally, Cryoprecipitate, a blood product containing concentrated clotting factors, has been used to manage bleeding episodes in patients with Hemophilia A. However, with advancements in biotechnology, recombinant Factor VIII, a synthetic product, has become an alternative. Recombinant Factor VIII eliminates the risks associated with blood-derived products, such as viral transmission, and offers more consistent dosing and availability. Despite these advantages, recombinant therapies are significantly more expensive. This study seeks to compare the clinical efficacy, safety of Cryoprecipitate versus recombinant Factor VIII in pediatric patients with Hemophilia A, providing critical insights for optimal management strategies. Purpose: The purpose of this study is to compare the clinical outcomes, safety of Cryoprecipitate versus recombinant Factor VIII in the management of children diagnosed with Hemophilia A. Materials and methods: This retrospective study included 32 pediatric patients diagnosed with Hemophilia A, treated either with Cryoprecipitate or recombinant Factor VIII. Clinical data were collected on bleeding frequency, Factor VIII recovery. Statistical analyses were conducted to determine significant differences between the two groups. Results: The study demonstrated that treatment with recombinant Factor VIII resulted in significantly improved clinical outcomes compared to Cryoprecipitate. In the group treated with recombinant Factor VIII, patients required scheduled hospitalizations for routine follow-up and management, with no reports of acute bleeding episodes during these admissions. This contrasts sharply with the Cryoprecipitate group, where all hospitalizations were precipitated by acute bleeding events, necessitating urgent intervention. Conclusions: Recombinant Factor VIII demonstrates superior efficacy in managing Hemophilia A in children compared to Cryoprecipitate. Recombinant therapy provides better clinical outcomes, justifying its use in modern treatment protocols.

The association between steroid use and recurrent venous thromboembolism: from the COMMAND VTE Registry-2

Abstract Background It is well known that use of oral steroids is a risk factor for development of venous thromboembolism (VTE). However, the impact of use of oral steroids on VTE recurrence has not been fully evaluated in the era of direct oral anticoagulants (DOAC), which has been a clinically relevant issue in the decision-making of anticoagulation strategies for patients who need oral steroids after VTE diagnosis. Purpose We aimed to investigate long-term clinical outcomes in VTE patients treated with oral steroids after VTE diagnosis in the DOAC era. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. The current study population were divided into 2 groups according to the use of oral steroids after VTE diagnosis; the steroid group and the non-steroid group. We compared clinical characteristics, management strategies, and outcomes including recurrent VTE, major bleeding and all-cause death, between the 2 groups. Results Patients with steroids and those without accounted for 693 (13%) and 4,504 (87%), respectively. Patients with steroids more often had chronic kidney disease (29% vs. 18%, P&amp;lt;0.001), autoimmune disease (50% vs. 5.4%, P&amp;lt;0.001), thrombocytopenia (7.7% vs 4.9%, P=0.002), and anemia (64.4% vs 54.1%, P&amp;lt;0.001), whereas there was no significant difference in the mean age (68.5 vs. 67.6 years old, P=0.16), the prevalence of women (62% vs 58%, P=0.06), active cancer (30% vs. 29%, P=0.42), and history of VTE (8.4% vs 6.8%, P=0.12) between the 2 groups. The cumulative 5-year incidence of discontinuation of anticoagulation therapy were not significantly different between the 2 groups (61.5% vs. 58.5%, log-rank P=0.16). The cumulative 5-year incidences of recurrent VTE nor major bleeding were not significantly different between the 2 groups (10.4% vs. 9.4%, log-rank P=0.55; 16.9% vs. 13.3%, log-rank P=0.16, respectively). Even after adjusting confounders, the risks of recurrent VTE nor major bleeding were not significantly different (adjusted hazard ratio = 0.97, 95% confidence interval = 0.65-1.45, P = 0.89; adjusted hazard ratio = 1.12, 95% confidence interval = 0.84-1.50, P = 0.44). The cumulative 5-year incidences of all-cause death was significantly different between the 2 groups (44.2% vs. 30.2%, log-rank P&amp;lt;0.001). Even after adjusting confounders, the risk of all-cause death remained significantly different (adjusted hazard ratio = 1.82, 95% confidence interval = 1.56-2.12, P&amp;lt;0.001). Conclusions Use of oral steroids after VTE diagnosis was not significantly associated with an increased risk of VTE recurrence in the DOAC Era, which might suggest that there could be no major concerns on an increased risk of recurrent VTE with oral steroids after VTE diagnosis under appropriate anticoagulation therapy.

The influence of concomitant antiplatelet therapy in venous thromboembolism patients treated with anticoagulants in the DOAC era: insight from the COMMAND VTE Registry-2

Abstract Background/Introduction The mainstay of treatment and second prevention of venous thromboembolism (VTE) is anticoagulation therapy, and recently direct oral anticoagulant (DOAC) for VTE have prevailed all over the world as oral anticoagulation therapy. Although concomitant antiplatelet therapy in addition to oral anticoagulation therapy could have an influence on both recurrent VTE and bleeding events, there have been still limited real-world data on the issue in the DOAC era. Purpose We aimed to investigate long-term clinical outcomes in VTE patients treated with concomitant antiplatelet therapy in the DOAC era. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. After excluding 407 patients without oral anticoagulation therapy, the current study population was consisted of 4790 VTE patients with oral anticoagulation therapy, who were divided into 374 patients (7.8%) treated with concomitant antiplatelet therapy and 4416 patients (92.2%) treated with only oral anticoagulation therapy. Results Patients with concomitant antiplatelet therapy were older (Concomitant antiplatelet therapy: 74.1 vs. Only oral anticoagulation therapy: 67.3 years, P&amp;lt;0.001), were less often women (52% vs 59%, P=0.005) and more frequently had history of major bleeding (9.8% vs 6.0%, P=0.003), myocardial infarction (16% vs 0.9%, P&amp;lt;0.001) and stroke (33% vs 6.8%, P&amp;lt;0.001). The cumulative incidences of recurrent VTE were not significantly different between the 2 groups (5.9% vs 9.6% at 5-year, Log rank P=0.06). Similarly, the cumulative incidences of major bleeding (14.6% vs 13.3% at 5-year, Log rank P=0.11) and stroke (8.3% vs 6.0% at 5-year, Log rank P=0.12) were not significantly different between 2 groups. However, the cumulative incidences of clinically relevant all bleeding (29.0% and 23.0% at 5-year, Log rank P=0.007) were significantly higher in concomitant antiplatelet therapy group, which was statistically significant even after adjusting confounders. Conclusion In the current large VTE registry in the DOAC era, concomitant antiplatelet therapy in addition to oral anticoagulation therapy for patients with VTE was not significantly associated with the risks recurrent VTE, major bleeding or stroke, but was associated with an increased risk of clinically relevant all bleeding.Study Flow ChartMain results

The impact of targeted bleeding source treatment on the risk of recurrent bleeding after percutaneous coronary intervention among patients with a history of prior bleeding

Abstract Background Prior bleeding is one of the strongest predictors for bleeding after percutaneous coronary intervention (PCI). Whether targeted treatment of the prior bleeding site affects the risk of bleeding after PCI is unknown to date. Methods From an all-comers population undergoing PCI between 2009-2019, patients with BARC 2-4 bleeding prior to index PCI were identified. Among those, the recurrence of BARC 2-5 bleeding at the same bleeding site, any BARC 2-5 bleeding, and mortality were compared throughout 1 year after PCI between patients with vs. without targeted treatment at the prior bleeding site. Targeted treatment was defined as medical, interventional, or surgical therapy targeted to cure the cause of bleeding. Adjusted hazard ratios (HRadj) were extracted from Cox regressions. Inverse probability weights were computed from a logistic regression with targeted treatment as dependent variable, and the following covariates: ARC-HBR variables associated with ≥4% 1-year bleeding risk in this registry (including oral anticoagulation), aspirin, potent P2Y12 inhibitor treatment, and prior bleeding site. Results Out of 18’510 patients enrolled from 2009-2019, 845 (4.6%) had a history of prior BARC 2-4 bleeding before PCI. Mean age was 71.6 years, 25% were female, and 52% presented with acute coronary syndrome. Patients with targeted treatment were significantly younger (70.3 vs. 72.5 years, p=0.005) and had more frequently malignancies (25% vs. 18%, p=0.012). 26/344 (7.6%) of patients with targeted treatment vs. 31/501 (6.2%) of patients without targeted treatment experienced recurrent BARC 2-5 bleeding at the same bleeding site (HRadj 1.35, 95% CI 0.79-2.30, p=0.268). 45/344 (13.1%) of patients with targeted treatment vs. 59/501 (11.8%) of patients without targeted treatment experienced any recurrent BARC 2-5 bleeding (HRadj 1.16, 95% CI 0.78-1.72, p=0.473). The rate of mortality was also similar between the groups (targeted treatment 13.7% vs. no targeted treatment 12.4%, HRadj 1.13, 95% CI 0.76-1.67, p=0.549). Conclusions Among patients with a bleeding history before PCI, half of the recurrent bleeding events throughout 1-year after PCI occurred at the same bleeding site, regardless of whether the bleeding source underwent targeted treatment. These findings imply that targeted treatment is not protective for recurrent bleeding events after PCI and that prior bleeding represents rather a systemic than local bleeding risk.Frequency of bleeding sitesKaplan Meier curves

Trends in home treatment and early discharge of patients with low-risk pulmonary embolism

Abstract Background A strategy of ambulatory treatment or early discharge (≤ 48 hours) of patients with acute low-risk pulmonary embolism (PE) has been adopted by the most recent guideline recommendations. However, the adoption of such a change of paradigm in PE care in the ‘real-world’ clinical setting, outside the concept of prospective cohort (management) studies, remains unknown. Aims To determine the proportion of patients with PE who fulfill eligibility criteria for home treatment or early discharge, to investigate in how many of them such a management strategy is actually followed, and to discover differences in early complications between early or later discharge among low-risk patients. Methods We used two nationwide databases, the US Nationwide Emergency Department Sample (NEDS) and Nationwide Readmission Database (NRD), to identify patients with low-risk PE (absence of the following at presentation: haemodynamic instability, cor pulmonale, tachycardia, dyspnea, hypothermia, altered mental status, and fulfilment of the Hestia critieria). We investigated the proportion of patients that were discharged entirely at home, or discharged early (hospital stay £ 2 days) and their association with predictor variables. We also studied the 90-day occurrence of venous thromboembolism recurrence and major bleeding. Results From 2016 to 2020, there were 2,099,390 emergency department visits for PE (NEDS Database), with 641,621 (30.6%) classified as low-risk. Home treatment was documented in 20.3% of all cases, with 31.5% of low-risk PE cases being treated at home and an increasing trend over time (Figure 1A). Factors associated with home treatment for low-risk PE included younger age, female sex, and absence of comorbidities; home treatment was more frequent at university hospitals, non-metropolitan hospitals, and those with higher emergency department volumes (Figure 2A). In the NRD Database, there were 1,950,708 PE hospitalizations during the same period with 481,321 classified as low-risk (24.7%). An early discharge strategy was followed in 22.6% of all cases, increasing to 45.9% for low-risk PE admissions, with a rising trend observed from 2016 (Figure 1B). Factors associated with early discharge for low-risk PE included younger age, male sex, and absence of comorbidities; here, university hospitals and metropolitan hospitals were less likely to implement early discharge (Figure 2B). The 90-day incidence of VTE recurrence among low-risk patients was lower with early discharge (1.3% vs. 1.8%, p&amp;lt;0.001), as was major bleeding (1.5% vs. 2.8%, p&amp;lt;0.001). Conclusion Our results reveal an increasing implementation of early discharge and home treatment for low-risk PE across recent years. Factors influencing these strategies are related to demographics and hospital type. Early discharge was associated with favourable outcomes in the real-world setting, thus supporting the results of previously performed prospective cohort studies and randomized trials.Figure 1Figure 2

Prior fecal immunochemical test positivity is associated with adverse prognosis in patients with acute ST-segment elevation myocardial infarction

Abstract Backgrounds While fecal immunochemical testing (FIT) is commonly used for disease screening, its significance in other conditions, particularly in patients with ST-segment elevation myocardial infarction (STEMI), is not extensively researched. Purpose This study aimed to investigate the impact of prior positive FIT results on the clinical prognosis of patients with STEMI. Methods The data for this study were derived from the Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients discharged from 72 hospitals from 2010 to 2023. A total of 76,157 patients with acute STEMI patients were enrolled. Positive FIT was defined as "+-" or higher on the fecal occult blood test. Propensity score matching (PSM) was employed to balance differences between the two groups. Kaplan-Meier analysis with log-rank tests compared endpoint risks between groups, and a multivariable Cox regression model adjusted for potential confounders. The primary endpoint was Net Adverse Clinical Event (NACE), including cardiac death, recurrent myocardial infarction, revascularization, stroke, cerebral hemorrhage, and gastrointestinal bleeding. Results After 1:3 PSM,2,148acute STEMI patients were included, with 537 having prior positive FIT and 1,611 without. Patients with prior positive FIT were more likely to have comorbidities such as hyperlipidemia, prior malignancy, post-coronary artery bypass grafting, renal insufficiency, and prior cerebral hemorrhage. The prior positive FIT group had a higher proportion of prior clopidogrel and indobufen usage, while aspirin use during follow-up was lower. Kaplan-Meier analysis demonstrated a significantly higher risk of NACE in acute STEMI patients with prior positive FIT (before PSM: log-rank P = 0.001, after PSM: log-rank P = 0.005, Figure 1）, as well as increased rates of Major Adverse Cardiac and Cerebral Events (MACCE), all-cause death, and gastrointestinal bleeding (log-rank P &amp;lt; 0.05 for all). Multivariate Cox-proportional hazard analysis adjusted for age, sex, percutaneous coronary intervention during hospitalization, diabetes, hypertension, ischemic stroke, atrial fibrillation, medication during hospitalization, and follow-up showed similar results (Figure 2). Conclusions This study reveals a significant association between prior positive FIT and higher rates of NACE, MACCE, all-cause death, and gastrointestinal bleeding in STEMI patients within 1 year. A history of positive FIT results could serve as a prognostic indicator in this specific patient population.

The prognosis evaluation of guideline-directed medical therapy for type 2 acute myocardial infarction patients with acute respiratory failure

Abstract Backgrounds Type 2 myocardial infarction (T2MI) arises from an imbalance between myocardial oxygen supply and demand during acute illness such as tachyarrhythmia, hypoxia, or hypotension without acute atherothrombosis. The efficacy of guideline-directed medical therapy (GDMT) in T2MI complicated by acute respiratory failure remains uncertain. Purposes This study was aimed to assess the impact of GDMT (including dual antiplatelet therapy, statins and β-blockers) on the prognosis of patients with T2MI and acute respiratory failure. Methods The data for this study were derived from a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals between 2010 and 2023. Inclusion criteria included patients with a discharge diagnosis of T2MI and acute respiratory failure. GDMT was defined according to the ACC/AHA Class I recommendations. Patients were divided into GDMT and N-GDMT groups, with differences in clinical characteristics adjusted using propensity score matching (PSM). Primary outcome indicators were major adverse cardiac and cerebrovascular events (MACCE), while secondary outcome indicators included in-hospital mortality, cardiac mortality, non-lethal myocardial infarction, recurrent ischemic stroke, bleeding events and revascularization. Results This study comprised 898 patients in the GDMT group and 3,777 in the N-GDMT group, resulting in 888 matched pairs after PSM. Baseline data showed that patients in the GDMT group had a higher burden of pre-existing comorbidities. In terms of treatment, the GDMT group had a higher proportion of patients undergoing Percutaneous Coronary Intervention (PCI) (4.84% vs. 1.80%, p= 0.001). In-hospital mortality was significantly lower in the GDMT group (12.4% vs. 26.4%, p&amp;lt; 0.001).Over amedian follow-up of 1,304 days, the incidence of MACCE within 1 month was significantly lower in the GDMT group (23.1% vs. 41.3%, p&amp;lt; 0.001). Furthermore, the GDMT group exhibited lower all-cause mortality (52.4% vs. 60.1%, p＜0.01) and cardiac mortality (41.3% vs. 50.3%, p&amp;lt; 0.001) compared to the N-GDMT group, with higher rates of revascularization (3.15% vs. 1.24%, p＜0.01). There were no statistically significant differences in the incidence of bleeding BARC3 (0.45% vs. 0.45%, p=1), recurrent non-lethal myocardial infarction (0.23% vs. 0%, p =0.5) and recurrent stroke (1.46% vs. 0.79%, p =0.261). GDMT at discharge was associated with a lower risk of MACCE in unadjusted analysis (HR=0.51, 95%CI= 0.44-0.59, p＜0.01) and after adjusting for age, gender, Killip classification and comorbidities in multivariate Coxregression analysis (aHR = 0.49, 95%CI= 0.41-0.58). Conclusions Adherence to GDMT was associated with a lower incidence of MACCE during 1-month follow-up, suggesting the importance of GDMT in this patient population.Clinical characteristics of patients

Correlation analysis of self-rated health and net adverse clinical events in patients with acute myocardial infarction

Abstract Backgrounds Self-rated health (SRH） is a recognized standard risk factor for myocardial infarction, but its impact on prognosis remains uncertain. Purpose This study aims to investigate the impact of self-rated health on the long-term clinical outcomes of myocardial infarction patients. Methods The data for this study were derived from a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023, Patients were divided into satisfied and unsatisfied groups based on their responses to an SRH questionnaire. Propensity score matching (PSM) was utilized to balance covariates between the two groups and analyze the relationship between SRH and clinical outcomes. The primary endpoint was net adverse clinical events (NACE), comprising cardiac death, recurrent myocardial infarction, revascularization, ischemic stroke, and bleeding events (BARC ≥3). The secondary endpoint comprised the individual components of the primary endpoint. Results The study included a total of 55,054 AMI patients, with 54,049 rating their health as satisfactory and 1,005 patients as unsatisfactory. In the satisfactory group, patients tended to be younger, had fewer females, better Killip classification, a higher proportion of STEMI cases, a higher rate of undergoing PCI, and a lower prevalence of concomitant disease such as diabetes, hypertension, chronic kidney disease, cerebrovascular disease, peripheral vascular disease, thyroid disease, and chronic lung disease. Additionally, patients in the satisfactory group had a higher proportion of antiplatelet therapy use (aspirin, ticagrelor). 1,005 pairs were well matched after PSM. After a median follow-up of 1626 days, the proportion of all-cause death, cardiac death, and recurrent myocardial infarction in the satisfied group was significantly lower than that in the unsatisfied group. Multivariable Cox regression analysis revealed that satisfactory SRH was associated with a reduced risk of NACE (aHR 0.809, 95%CI 0.704-0.930, P=0.002), cardiac death (aHR 0.790, 95%CI 0.665-0.939, P=0.007), and recurrent myocardial infarction (aHR 0.734, 95%CI 0.563-0.955, P=0.021). Conclusions Good SRH can decrease the risk of NACE in myocardial infarction patients, underscoring the importance of considering SRH in clinical assessment.

Oral anticoagulants or antiplatelets for cryptogenic stroke: a systematic review and meta-analysis

Abstract Background Cryptogenic strokes comprise 20 to 30% of ischemic strokes and include a substantial proportion classified as embolic stroke of undetermined source (ESUS). However, the optimal antithrombotic strategy for cryptogenic stroke remains contentious. Purpose We conducted a systematic review and meta-analysis to compare the efficacy and safety of oral anticoagulants (OAC) versus antiplatelets in patients with cryptogenic stroke. Methods Six electronic databases of PubMed, Embase, Web of Science, the Cochrane Library, Google Scholar and ClinicalTrials.gov were searched from inception to Feb 15, 2024 to identify relevant randomized controlled trials (RCTs) comparing stroke recurrence and major bleeding rates between OAC and antiplatelets in cryptogenic stroke patients. We included trials adhering to a stringent diagnostic work-up for cryptogenic stroke, defined as cerebral infarction not attributed to definite sources of cardioembolism, large artery atherosclerosis, or small artery disease despite undergoing comprehensive investigations. The primary outcome was recurrent ischemic stroke, and the secondary outcome was major bleeding based on International Society of Thrombosis and Hemostasis criteria. Subgroup analysis was conducted for ESUS patients with an increased risk of cardiac emboli, such as patent foramen ovale (PFO) and atrial cardiopathy, defined as lead V1 terminal P-wave &amp;gt; 5000 μV × ms in electrocardiogram, serum N-terminal pro-B-type natriuretic peptide level &amp;gt; 250 pg/mL, and left atrial diameter (LAE) &amp;gt; 4 cm, or LAE index ≥ 3 cm/m2 on echocardiogram. Hazard ratio (HR) with 95% confidence (CI) was used as a measure of the effect estimates for aforementioned outcomes. Random-effects meta-analysis was performed using a restricted maximum likelihood model given between-study variance is inevitable. Results Our meta-analysis included 9 RCTs with a total of 15,139 patients (OAC = 7,343; antiplatelets = 7,796). ARCADIA, RE-SPECT ESUS, and NAVIGATE ESUS Trial investigated apixaban, dabigatran, and rivaroxaban, respectively, while warfarin was primarily used as OAC in the remaining six trials. Aspirin was predominantly utilized for antiplatelet therapy. There was no significant difference in recurrent ischemic stroke between OAC and antiplatelets (HR, 0.90; 95% CI, 0.78 to 1.04; I2 = 0%). However, OAC use was associated with a significantly higher risk of major bleeding (HR, 1.66; 95% CI, 1.07 to 2.56; I2 = 36%). Subgroup analysis in ESUS patients revealed comparable rates of recurrent ischemic stroke in those with atrial cardiopathy (HR, 0.91; 95% CI, 0.65 to 1.29; I2 = 0%) and PFO (HR, 0.72; 95% CI, 0.49 to 1.07; I2 = 0%). Conclusions Our meta-analysis suggests that OAC use does not decrease the risk of recurrent ischemic stroke compared with antiplatelet use but is associated with a significantly higher risk of major bleeding in patients with cryptogenic stroke.Primary (A) and secondary (B) outcomesSubgroup analysis for recurrent stroke

Clinical outcomes of edoxaban treatment without parenteral anticoagulation therapy for acute venous thromboembolism: Insight from the COMMAND VTE Registry-2

Abstract Background Direct oral anticoagulants (DOACs) including edoxaban are currently widely used all over the world. Each DOAC has a specific usage for the treatment and second prevention of venous thromboembolism (VTE) in the acute phase as well as in the chronic phase. Edoxaban is recommended to be administered after an appropriate initial treatment including parenteral anticoagulation therapy such as heparin. However, because of the rapid anticoagulant effect of edoxaban after oral intake, some physicians could administer edoxaban initially without parenteral anticoagulation therapy in the daily clinical practice, which has not been investigated so far. Purpose The purpose of this study is to explore the effectiveness and safety of edoxaban treatment for VTE without initial parenteral anticoagulation therapy. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. Of those, 1842 patients received edoxaban including 848 patients with pulmonary embolism (PE) and 994 patients with deep vein thrombosis (DVT) alone, who were divided into 2 groups based on the presence or absence of initial parenteral anticoagulation therapy with heparin. Propensity score matching (PSM) was performed to adjust for potential baseline differences in the 2 groups. Results PE and DVT patients with initial parenteral anticoagulation therapy with heparin accounted for 623 (73.5%) and 244 (24.5%), respectively. After the PSM, 195 pairs of PE patients and 226 pairs of DVT patients were matched. In PE patients, those matched by the PSM were relatively mild cases compared to the unmatched cases (simplified PESI score=0: 25.9% vs. 12.4%, P&amp;lt;0.001). Whereas, in DVT patients, those matched were relatively severe cases compared to unmatched cases (isolated distal DVT: 24.1% vs. 71.0%, P&amp;lt;0.001). In the matched cohort, there was no significant difference in baseline characteristics between the 2 groups, including simplified PESI score in PE patients and thrombus location profile in DVT patients. In both PE patients and DVT patients, the 30-day cumulative incidences of all-cause death were not significantly different between the 2 groups (PE patients: 3.7% vs. 2.6%, P=0.56; DVT patients: 2.7% vs. 4.5%, P=0.31). Similarly, the 30-day cumulative incidences of recurrent VTE and major bleeding were not significantly different between the 2 groups (recurrent VTE: PE patients: 0% vs. 0.5%, P=0.32; DVT patients: 0.6% vs. 0.9%, P=0.99; major bleeding: PE patients: 1.5% vs. 3.2%, P=0.32; DVT patients: 2.2% vs. 3.2%, P=0.54) Conclusion In this current real-world VTE registry, a certain number of patients received edoxaban without parenteral anticoagulation therapy, who did not show a signal of worse clinical outcomes.

Outcome of Transanal suture haemorrhoidopexy and Stapled haemorrhoidopexy -A prospective observational study

Background: Transanal suture haemorrhoidopexy is the preferred treatment due to its low cost, less post operative complication and decreased chance of recurrence in grade II and grade III Hemorrhoids. Objective: To compare the post-operative outcome of transanal suture haemorrhoidopexy and stapled haemorrhoidopexy in patients with grade II and III haemorrhoids. Methods: This study was conducted in the Department of Colorectal Surgery, Shaheed Suhrawardy Medical College hospital over a period of one-year. Sixty-two patients with haemorrhoids were enrolled in this study according to selection criteria. Data were collected, compiled and tabulated according to key variables. Qualitative data were expressed as frequency with percentage and quantitative data as mean with standard deviation. Quantitative data were analyzed by student’s t-test and qualitative data by Chi-square test. Data were processed and analyzed by using software SPSS 22.0. For all analyses p-value &lt;0.05 was considered statistically significant. Result: Mean age of the patients was 49.38 ± 7.17 years and 52.45 ± 6.17 years in Stapled hemorrhoidopexy and Trans anal suture hemorrhoidopexy group respectively (p&gt;0.05). Males were predominant in both the two groups. In stapled hemorrhoidopexy group, grade of hemorrhoids was II (51.6%) and III (48.4%) whereas in Transanal suture hemorrhoidopexy group, grade of hemorrhoids was II (38.7%) and III (61.3%) (p&gt;0.05). Operative time was lower in Stapled hemorrhoidopexy (26.93 ± 1.59 min) than Transanal suture hemorrhoidopexy (27.74 ± 1.63 min). Per operative bleeding was found more in stapled group. Most of the patients stayed in the hospital only one day in both the two groups. Only four patients in Stapled hemorrhoidopexy group and one patient in Transanal suture hemorrhoidopexy group stayed more than one day. Post-operative pain according to VAS was lower in Stapled hemorrhoidopexy group (1.90 ± 0.54) than Transanal suture hemorrhoidopexy group (2.09 ± 0.30) after 24 hours of the surgery. But there was no significant difference in pain after 7 days of surgery between the two groups. Post-operative complications were more in stapled hemorrhoidopexy than Trans anal suture hemorrhoidopexy, but not statistically significant. Recurrence (bleeding &amp; prolapse) found more in stapled group than suture hemorrhoidopexy group. Treatment cost was significantly lower in trans anal suture hemorrhoidopexy. Conclusion: Based on this study, transanal suture hemorrhoidopexy showed less intra and post-operative hemorrhage, shorter duration of hospital stay, lower post-operative complications, and lower recurrence rate when compared to stapled hemorrhoidopexy. However, these differences were not statistically significant. The only statistically significant difference was in the operative cost, which was in favor of transanal suture hemorrhoidopexy. J Shaheed Suhrawardy Med Coll 2023; 15(1): 45-49

Features of diagnosis and treatment of chronic endometritis of bacterial-viral etiology

The study revealed the combined effect of conditionally pathogenic flora and viral agents on the endometrium. Combined inflammatory and proliferative processes lead to severe changes in the endometrium and increase the risk of recurrent bleeding, pregnancy loss and infertility.

Endoscopic resection of a juvenile jejunum polyp which caused recurrent intestinal bleeding in a 12-month-old child

Introduction To verify a source of obscure gastrointestinal bleeding (GIB) leading to iron deficiency anemia is a challenging diagnostic problem. Intestinal polyps can be one of such sources. Sporadic juvenile intestinal polyps are extremely rare at the first year of life. The authors present a clinical case which demonstrates endoscopic diagnostics and resection of a jejunum polyp in a 12-month-old child weighing 6,3 kg. We did not find similar publications in literature. Clinical observation A 12-month-old boy was admitted to our clinic with long-lasting complaints of dark stool and iron deficiency anemia. For the first time, GIB symptoms appeared at the age of one month. The child was repeatedly examined (ultrasound, computed tomography, esophagogastroduodenoscopy (EGD), colonoscopy), but GIB source was not found. The child was prescribed symptomatic therapy for iron deficiency anemia including red blood cell transfusion. At current hospitalization in our clinic an intestinal polyp and transient small intestinal intussusception were suspected at ultrasound examination. The child underwent EGD, video capsule endoscopy, colonoscopy, laparoscopy. But the source of the bleeding was not found. During the repeated enteroscopy a sporadic juvenile jejunum polyp 17x15 mm was found at 40 cm distally to the pylorus. Endoscopic mucosal resection with the polyp was performed. The postoperative period was uneventful. One month later there were no complaints, no signs of anemia, stool was normal. Conclusion A sporadic juvenile jejunal polyp may be a cause of obscure recurrent intestinal bleeding in children. Modern intraluminal endoscopy allows not only to put diagnosis, but also to perform a minimally invasive surgical intervention.

Impact of thrombocytopenia on bleeding and thrombotic outcomes in adults with cancer-associated splanchnic vein thrombosis

AbstractMalignancy is a risk factor for splanchnic vein thrombosis (SpVT). Data on the natural history of cancer-associated SpVT are limited. This was a single-center, retrospective cohort study of 581 adult patients with cancer and SpVT. We aimed to characterize the impact of thrombocytopenia on major bleeding and progression or recurrence of SpVT within 1 year of an initial cancer-associated SpVT diagnosis. Baseline thrombocytopenia (platelet <100 000 per μL within 15 days of SpVT diagnosis) was present in 39.5% of patients. A total of 39.2% of patients received therapeutic anticoagulation within 2 weeks of an SpVT diagnosis. The cumulative 1-year incidence of major bleeding was 10.7% (95% confidence interval [CI], 8.2-13.2) and 16.2% (95% CI, 13.2-19.2) for SpVT recurrence/progression. In the multivariable regression analysis, therapeutic anticoagulation was associated with increased major bleeding (adjusted risk ratio [aRR], 1.74; 95% CI, 1.08-2.81) and decreased progression/recurrence of SpVT (aRR, 0.55; 95% CI, 0.35-0.86). Baseline thrombocytopenia was not independently associated with either major bleeding (aRR, 0.76; 95% CI, 0.43-1.34) or progression/recurrence of SpVT (aRR, 1.14; 95% CI, 0.73-1.78). A secondary analysis using inverse probability of treatment weighting with propensity scores for baseline thrombocytopenia corroborated that patients with thrombocytopenia did not have an increased bleeding risk (adjusted hazard ratio [aHR], 0.81; 95% CI, 0.48-1.39). The multivariable analysis in which platelets were treated as a time varying covariate also did not reveal an association with major bleeding (aHR, 0.89; 95% CI, 0.55-1.45). Bleeding and thrombosis progression were frequent in patients with cancer-associated SpVT. Anticoagulation was associated with increased major bleeding and decreased thrombotic progression; thrombocytopenia did not impact the outcomes.