Risk Of Serious Bleeding Research Articles

Enhanced thromboprophylaxis in critically ill patients with COVID-19 infection

BackgroundPatients with severe SARS-CoV-2 infection have been shown to have abnormal coagulation parameters and are at increased risk of thromboembolism. The optimal thromboprophylaxis regimen that minimizes thrombosis without increased risk of serious bleeding is uncertain. ObjectivesTo describe the efficacy and safety of increased intensity (enhanced) thromboprophylaxis in patients with COVID-19 admitted to the medical intensive care unit (MICU). MethodsThis is a retrospective cohort analysis of patients with a diagnosis of COVID-19 admitted to the MICU of an urban safety net hospital. With the exception of patients being supported with extracorporeal membrane oxygenation or on chronic anticoagulation who received therapeutic dosing of anticoagulation, thromboprophylaxis was given as either enoxaparin or unfractionated heparin in doses higher than those recommended for standard prophylaxis, but lower than those used for therapeutic anticoagulation. Main resultsOf the 120 patients managed with an enhanced thromboprophylaxis protocol, 6 (5%) experienced thromboembolism as a result of their COVID-19 disease (1 pulmonary embolus, 4 deep vein thromboses, and 1 arterial embolism). Four patients experienced major bleeding while receiving therapeutic anticoagulation. ConclusionsIn critically ill patients with COVID-19, increased intensity (enhanced) thromboprophylaxis appears to be effective at preventing clinically significant thromboembolic events without an increased risk of serious bleeding.

Safety of antithrombotic therapy in East Asian patients.

Antithrombotic agents are widely used on the globe for prevention of thrombotic events such as atherothrombotic events and thromboembolic stroke in atrial fibrillation or for prevention and treatment of venous thromboembolism. However, the net clinical benefit of antithrombotic intervention may differ substantially in various sub-population of patients. Here, the authors attempt to address the risk of serious bleeding in East Asian as compared to the other regions of the world. The community-based epidemiological data suggest numerically higher risk of hemorrhage stroke in East Asian as compared to the globe. Importantly, the life-time risk of ischemic stroke in East Asia is higher than that of the globe. Regarding the serious bleeding risk in East Asians with the use of antithrombotic agents, various clinical trials and international registries provided conflicting information. It is hard to draw generalized conclusion, but there are some specific sub-population in East Asian with higher risk of specific serious bleeding events with the use of specific antithrombotic agents such as the risk of intra-cranial bleeding (ICH) with Vitamin K antagonists. Specific characteristics in East Asian such as higher prevalence of lacunar stroke may contribute higher risk of ICH in East Asian, but the detailed mechanism is still to be elucidated. In conclusion, further investigations are necessary to clarify the specific conditions where the risk of serious bleeding events in East Asian patients differ substantially compared to the global. In addition, further understanding of the mechanisms causing the different bleeding response in specific conditions in East Asian is awaited.

Immune thrombocytopenia: the patient’s perspective

: Immune thrombocytopenia (ITP) is a rare heterogeneous autoimmune bleeding disorder that causes a lower than normal circulating platelet count resulting from impaired platelet production and accelerated platelet destruction. Patients with ITP face a complex set of challenges. The multifaceted burden of living with ITP impacts the overall health-related quality of life (HRQoL) of patients and their families. Here, we review the patients’ perspective on unmet needs, and the physical and emotional burden of disease in an attempt to highlight areas where healthcare providers treating ITP can enhance their current approach to managing a patient with this rare disease. Patients want their voices heard and their experiences with ITP acknowledged beyond simply treating the platelet count. Unmet needs identified include knowledge and communication deficiencies, the need for diagnostic improvements, access issues to the most appropriate treatments, and awareness of the extent to which ITP impacts HRQoL both on physical and mental health. ITP leads to fatigue, challenges with daily activities, reduced physical functioning, anxiety, and depression. Aside from the constant risk for serious bleeding, patients experience both physical and emotional consequences living with their disease on a daily basis. Further studies are needed to clarify the nature and source of pain, anxiety, depression, and fatigue reported in both adults and pediatric patients living with ITP.

Outcomes of catheter-directed interventions in high-risk pulmonary embolism-a retrospective analysis.

BackgroundFirst‐line treatment of high‐risk pulmonary embolism with persistent hypotension and/or signs of shock is intravenous thrombolysis. However, if thrombolysis is contraindicated due to risk of serious bleeding, or if it yields insufficient effect, surgical thrombectomy or catheter‐directed intervention (CDI) plus anticoagulation is recommended. The aim of this study was to assess the outcomes of the CDI modality introduced in a tertiary referral centre in 2013.MethodsRetrospective comparison between patients treated with CDI plus anticoagulation (n = 22) and patients treated with anticoagulation only (n = 23) as used before the CDI technique was available. The main outcomes of interest were 90‐day survival and reduction of right to left ventricle diameter (RV/LV) ratio, using the Fischer's exact test and a mixed model, respectively, for statistical analysis.ResultsNinety‐day survival was 59% after CDI and 61% after anticoagulation only; P = .903. The rate of RV/LV ratio reduction was 0.4 units higher per 24 hours in the CDI group (median 2.1 pre‐treatment), than in the anticoagulation only group (median 1.3 pre‐treatment); P = .007.ConclusionIn patients with high‐risk pulmonary embolism, 90‐day survival was similar after treatment with CDI plus anticoagulation compared to anticoagulation only. The mean reduction in RV/LV ratio was larger in the CDI group. Our results support the use of CDI in selected patients, respecting the limitations and potential side effects of each technical device used.

Rare Clinical Onset of Nontraumatic Intracavernous Aneurysm of the Internal Carotid Artery: A Diagnostic and Therapeutic Challenge

AbstractWhile the so-called pseudoaneurysms can result from arterial injury during trans-sphenoidal surgery or after a trauma, spontaneous aneurysms of cavernous–internal carotid artery (CICA) are rare. Symptoms vary and the differential diagnosis with other, more frequent, sellar lesions is difficult. We describe three cases of misdiagnosed CICA spontaneous aneurysm. In two cases the onset was with neuro-ophthalmological manifestations, classifiable as “cavernous sinus syndrome.” The emergency computed tomography scan did not show CICA aneurysm and the diagnosis was made by surgical exploration. The third patient came to our attention with a sudden severe unilateral epistaxis; endonasal surgery revealed also in this case a CICA aneurysm, eroding the wall and protruding into the sphenoidal sinus. When the onset was with a cavernous sinus syndrome, misdiagnosis exposed two patients to potential serious risk of bleeding, while the patient with epistaxis was treated with embolization, using coils and two balloons. Intracavernous nontraumatic aneurysms are both a diagnostic and therapeutic challenge, because of their heterogeneous onset and risk of rupture, potentially lethal. Intracavernous aneurysms can be managed with radiological follow-up, if asymptomatic or clinically stable, or can be surgically treated with endovascular or microsurgical techniques.

Apixaban in non-valvular atrial fibrillation and treatment of venous thromboembolism: universal safety advantage in different categories of patients

This review presents data on the frequency of bleeding in direct comparison of apixaban and vitamin K antagonists in the context of prospective randomized controlled trials. According to ARISTOTLE, AUGUSTUS and AMPLIFY studies, Apixaban has an advantage over vitamin K antagonists in terms of safety regardless of the indications (prevention of cardioembolic complications in nonvalvular atrial fibrillation, treatment of venous thromboembolic complications), which applies to all categories of patients studied, including those with increased risk of bleeding (elderly and old age, chronic renal failure, low body weight, arterial hypertension, the need for simultaneous use of one or two antiagregants, 3 or more points on the HAS-BLED scale). Moreover, the course of the accumulation curves of clinically significant bleedings indicates a constant increase in the number of patients who can prevent bleeding with prolonged use of apixaban instead of vitamin K antagonists. Prospective randomized clinical trials AMPLIFY and CARAVAGGIO show that in early treatment of proximal deep vein thrombosis of the lower limbs and/or thromboembolism of pulmonary arteries in patients without malignant tumors apixaban is safer than low-molecular-weight heparin enoxaparin, In long-term treatment of venous thromboembolic complications in patients with malignant tumors is not worse in safety than low-molecular-weight heparin dalteparin. Additional evidence for the safety of apixaban was obtained by comparing it with placebo in the prolonged treatment of venous thromboembolic complications in patients with low risk of serious bleeding in a prospective randomized controlled trial AMPLIFY-EXT.

Low-molecular-weight fucosylated glycosaminoglycan and its oligosaccharides from sea cucumber as novel anticoagulants: A review

Antithrombotic drugs have some side effects, such as risk of serious bleeding. Development of antithrombotic drugs that inhibit components of the intrinsic coagulation pathway and have a low risk of causing bleeding has recently been a focus of research. Fucosylated glycosaminoglycan (FG), also named as fucosylated chondroitin sulfate (FCS), has potent anticoagulant activity and inhibits intrinsic factor tenase (FXase) complex. Low-molecular-weight FG (LFG) and its oligosaccharides show characteristics of anticoagulant and antithrombotic activities with negligible side effects, such as activation of human FXII, induction of platelet aggregation, and especially, the risk of serious bleeding. They are potential new anticoagulant drugs and have been extensively studied in recent years. This review presents recent findings regarding the preparation, structural analysis, pharmacological activity, and structure–activity relationships of LFG and its derived oligosaccharides, so as to provide a reference for the development of new anticoagulants with low side effects.

Optimal Antithrombotic Treatment of Patients with Atrial Fibrillation Early after an Acute Coronary Syndrome-Triple Therapy, Dual Antithrombotic Therapy with an Anticoagulant… Or, Rather, Temporary Dual Antiplatelet Therapy?

The combination of atrial fibrillation (AF) and acute coronary syndrome (ACS) is a complex situation in which a three-dimensional risk—cardioembolic, coronary, and hemorrhagic—has to be carefully managed. Triple antithrombotic therapy (TAT) is burdened with a high risk of serious bleeding, while dual antithrombotic therapy with an anticoagulant (DAT) likely provides only suboptimal coronary protection early after stent implantation. Moreover, TAT precludes the advantages provided by the use of the latest and more potent P2Y12 inhibitors in ACS patients. Here, we aimed to simulate and compare the expected coronary, cardioembolic, and hemorrhagic outcomes offered by DAT, TAT, or modern dual antiplatelet therapy (DAPT) with aspirin plus one of the latest P2Y12 inhibitors in AF patients early after an ACS. The comparison of numbers needed to treat to prevent major adverse events with the various antithrombotic regimens suggests that AF–ACS patients at high ischemic and hemorrhagic risk and at moderately low embolic risk (CHA2DS2VASc score 2–4) might safely withhold anticoagulation after revascularization for one month taking advantage of a modern DAPT, with a favorable risk-to-benefit ratio. In conclusion, this strategy, not sufficiently addressed in recent European and North American guidelines or consensus documents, adds to the spectrum of treatment options in these difficult patients; it might be the best choice in a substantial number of patients; and should be prospectively tested in a randomized controlled trial.

Major GI bleeding in older persons using aspirin: incidence and risk factors in the ASPREE randomised controlled trial

ObjectiveThere is a lack of robust data on significant gastrointestinal bleeding in older people using aspirin. We calculated the incidence, risk factors and absolute risk using data from a large...

EkoSonic® endovascular system and other catheter-directed treatment reperfusion strategies for acute pulmonary embolism: overview of efficacy and safety outcomes

ABSTRACT Introduction Studies performed in the past decade suggested that evolving reperfusion strategies may improve early outcomes of patients with acute pulmonary embolism (PE) and hemodynamic decompensation. In this regard, catheter-directed treatment (CDT) options are receiving increasing attention. Areas covered A broad spectrum of CDT options exists for the treatment of patients with acute PE. Procedures include catheter-directed local thrombolysis with or without ultrasound assistance, catheter-directed mechanical or suction embolectomy, and combined pharmaco-mechanical approaches. We present here an overview of the available CDT techniques, focusing on the EkoSonic® endovascular system. Expert commentary CDT, particularly local ultrasound accelerated thrombolysis, continues to evolve. Its increasing popularity is the result of accumulating promising results, which suggest a relief of right ventricular (RV) pressure overload and improvement of RV function. These favorable effects on surrogate endpoints were accompanied by a low rate of procedure-related adverse events, notably intracranial hemorrhage. Although the overall risk of serious bleeding appears to be low in CDT, the lack of direct comparisons with other reperfusion options does not allow definitive conclusions. Prospective controlled trials with robust clinical outcomes are urgently needed to establish the postulated benefits of CDT in selected patients with acute PE.

3-h drain clamping is not effective to reduce total blood loss after primary total knowledge

PurposeTotal knee arthroplasty (TKA) is a clinically efficacious surgical option for end-stage knee osteoarthritis. However, TKA increases the risk of serious bleeding and blood transfusion. The objective of this study was to evaluate the difference in postoperative blood loss in groups subjected to 3 h of clamping and non-clamping and determine the variations in rate and amount of transfusion after TKA between the two groups.Materials and methodsPropensity score matching of the group subjected to 3-h drain clamping (43 patients; September 2015 to April 2016) and the control group (43 patients; before initiating the clamping method) was performed in patients undergoing unilateral primary posterior stabilized TKA. The two groups were compared. We measured the total drained blood volume until the drain was removed 48 h after surgery, and we compared the preoperative levels of hemoglobin and hematocrit with levels observed on days 1 and 2 after surgery. We also determined the blood transfusion rate and volume as well as the occurrence of clamping-associated complications.ResultsIn the group subjected to 3-h drain clamping, the mean volume of total drained blood was significantly lower than in the control group (333.8 ± 190.2 mL vs. 839.9 ± 339.8 mL, P <0.001). There was no significant difference in total blood loss between the two groups (1226.9 ± 488.1 mL vs. 1127.1 ± 424.5 mL, P = 0.315), but the hidden blood loss was significantly higher in the 3-h drain clamping group than in the control group (893.1 ± 487.7 mL vs. 294.7 ± 531.8 mL, P <0.001). Both the transfusion rate and amount in the 3-h drain clamped group were higher than in the control group but were not statistically significant (30.2% vs. 37.2%, P = 0.494 and 269.8 ± 483.8 mL vs. 316.3 ± 158.2 mL, P = 0.648, respectively). No significant differences in complications, including deep vein thrombosis, pulmonary thromboembolism, and oozing, were noted between the two groups (all, P = 1.000).ConclusionsThe 3-h drain clamping method after primary TKA using posterior stabilized implant reduced the loss of postoperative drained blood. However, hidden blood loss was significantly higher in the 3-h drain clamping group; as a result, there were no differences in total blood loss and transfusion rate. The clamping method did not significantly alter the complication rate.

Continuation of Dual Antiplatelet Therapy in a Patient with a Coronary Artery Stent with Dengue Hemorrhagic Fever: A Clinical Conundrum.

Severe thrombocytopenia with impairment of the activity of platelets and impairment of blood clotting occurs in dengue hemorrhagic fever (DHF). Continuation of dual antiplatelet therapy in such patients can result in life-threatening hemorrhages. On the other hand, withholding of antiplatelets in a patient undergone coronary stenting lately can lead to stent thrombosis, resulting in myocardial infarctions and sudden cardiac death. There are no guidelines on management of DHF in patients with coronary stents. Here, we discuss about several divergent factors that need to be considered and balanced when managing such patients. We describe a case as an example to illustrate how we balanced the risk of serious bleeding versus the risk of stent thrombosis successfully according to evolution of the disease process, by temporary withholding of antiplatelets in such a patient.

The safety of oral anticoagulants registry (SOAR): A national, ED-based study of the evaluation and management of bleeding and bleeding concerns due to the use of oral anticoagulants

ObjectiveThe Safety of Oral Anticoagulants Registry (SOAR) was designed to describe the evaluation and management of patients with oral anticoagulant (OAC)-related major bleeding or bleeding concerns who present to the emergency department (ED) with acute illness or injury. Patients in the ED are increasingly taking anticoagulants, which can cause bleeding-related complications as well as impact the acute management of related or unrelated clinical issues that prompt presentation. Modifications of emergency evaluation and management due to anticoagulation have not previously been studied. MethodsThis was a multicenter observational in-hospital study of patients who were judged to be experiencing an active OAC effect and had (a) an obvious bleeding event or (b) were deemed at risk for serious bleeding spontaneously, after injury, or during an indicated invasive procedure. Diagnostic testing, therapies employed, and clinical outcomes were collected. ResultsThirty-one US hospitals contributed data to SOAR. Of 1513 subjects, acute hemorrhage (AH) qualified 78%, while 22% had a bleeding concern (BC). Warfarin was the index OAC in 37.3%, dabigatran in 13.3%, and an anti-Factor Xa in 49.4%. The most common sites of AH were gastrointestinal (51.0%) and intracranial (26.8%). In warfarin-treated patients, the mean (IQR) presenting INR was 3.1 (2.2, 4.8) in AH patients and 3.9 (2.4, 7.2) in BC patients. Three-fifths of SOAR patients were treated with factor repletion or specific reversal agents, and those patients had a longer length of stay. In addition, seven (0.76%) of the treated patients experienced an in-hospital thrombotic complication; two of these seven died on the index admission, both of fatal pulmonary embolism. Vitamin K was used and dosed inconsistently in both warfarin and NOAC cohorts. ConclusionCare of anticoagulated patients in the acute care setting is inconsistent, reflecting the diversity of presentation. As the prevalence of OAC use increases with the aging of the US population, further study and targeted educational efforts are needed to drive more evidence-based care of these patients.

Molecular Methodology for the Detection of the Leishmania Genus in Different Biological Samples Extracted from Dogs

Background: The leishmaniases are a group of parasitic diseases caused by trypanosomatids belonging to the genus Leishmania, members of the class Kinetoplastida, order Trypanosomatidae, family Trypanosomatidae. Despite innumerous wild species that are infected, the domestic dog is a potential reservoir of Leishmania infantum in urban areas, which expands the transmission pathway to humans. When infected, the dog becomes Visceral Canine Leishmaniasis (CVL), which is characterized by a diverse clinical picture that ranges from asymptomatic to non-specific signs, such as skin lesions, lymphadenomegaly, weight loss, splenomegaly, and/or ocular lesions, thus impairing accurate and rapid diagnosis.In Brazil, it is considered a public health problem since it is endemic in certain regions. Therefore, parasitological, serological, and molecular methods can be used for the detection of the disease. However, the possibility of serological cross-reaction and the occurrence of co-infection with other trypanosomatids decreases the specificity rate to below 100%, which suggests the use of more accurate diagnostic tools. Several molecular targets and starting samples for leishmaniasis diagnosis are already standardized, but there is lack of data allowing the evaluation of the target, as well as which biological material is more efficient for the molecular diagnosis of CVL. The sensitivity of PCR may vary with DNA quality, primer type, parasitemia level, and number of target copies per cell. The spleen, blood, liver, aspirate of bone marrow and lymph nodes are the most frequently used for molecular diagnosis of CVL. The present study aimed to evaluate and compare three protocols of the polymerase chain reaction (PCR) for the molecular diagnosis of CVL in different biological samples removed from animals with different clinical and anatomopathological signs.Materials, Methods &amp; Results: Fifty seropositive dogs for CVL were used, their clinical and anatomopathological signs were evaluated, and were classified as asymptomatic, oligosymptomatic, and polysymptomatic. The PCR was conducted with specific primers for each region of the smaller subunit of rRNA, ITS-1, and KDNA genes. The four types of biological samples (spleen, blood, lymph nodes, and liver) were analyzed. Among the 50 dogs studied, 19 (38%) were in the asymptomatic group; all the animals showed healthy appearance, 15/50 (30%) of the dogs presented up to two symptoms, being classified as oligosymptomatic. The polysymptomatic dogs [16/50 (32%)] presented with a compromised clinical status. The study showed that all dogs had a positive result in at least one analyzed PCR methodology. Comparing the results of the three types of tests in the four types of studied samples, the nested-PCR was the one which presented a greater frequency of amplifications. Of a total of 200 samples, 124 showed amplification, showing a 62% sensitivity.Discussion: The results revealed that, when 50 dogs were analyzed, the spleen tissue samples had a better performance in all the tests, but the sensitivity of blood samples was also satisfactory in Nested SSU rRNA-PCR and MC-PCR. The blood samples can be easily accessed with minimal invasion. One of the limitations around the use of biopsy of the spleen or its aspirate is the risk of serious bleeding or even death of the animal. Taking into consideration the practicality and because it has a lower grade of invasiveness, the combination of peripheral blood with Nested SSU rRNA-PCR becomes the methodology of first choice.

Protamine Reduces the Risk of Serious Bleeding at the Time of CEA without Increased Risk of Stroke, MI or Death

Protamine Reduces the Risk of Serious Bleeding at the Time of CEA without Increased Risk of Stroke, MI or Death

Impact of Nutritional and Inflammation Status on Long-Term Bleeding in Patients Undergoing Percutaneous Coronary Intervention with an Oral Anticoagulant.

Aim: Patients undergoing percutaneous coronary intervention (PCI) who require both oral anticoagulant (OAC) and antiplatelet therapy (APT) are exposed to a serious risk of bleeding. The aim of this study was to clarify the relationship among nutritional and inflammation status and long-term bleeding in patients requiring both OACs and APT after PCI.Methods: We performed PCI in 3,718 consecutive patients between April 2011 and March 2017, 302 of whom were treated with both OACs and APT. Patients were followed for up to 3 years for bleeding events, defined as the Bleeding Academic Research Consortium (BARC) class ≥3 bleeding. We retrospectively evaluated the ability of the Geriatric Nutritiosk Index (GNRI) and high-sensitivity C-reactive protein (hs-CRP) to detect bleeding events.Results: During a median follow-up of 1,080 days, bleeding events were observed in 53 (17.5%) patients. Bleeding events were associated with a low GNRI (≤98) (hazard ratio [HR], 3.16; 95% confidence interval [CI], 1.84–5.45; p<0.0001) and hs-CRP level ≥2.5 mg/L (HR, 2.75; 95% CI, 1.61–4.78; p=0.0003). A low GNRI+high hs-CRP showed a 5.12-fold increase in the incidence of BARC class ≥3 bleeding (95% CI, 2.68–9.91; p<0.0001) compared with a normal GNRI+low hs-CRP. The addition of the GNRI and hs-CRP to the PRECISEDAPT score improved C-statistics from 0.67 to 0.71 and enhanced the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI, 0.36, p<0.0001; IDI, 0.066, p<0.0001).Conclusions: The GNRI and hs-CRP were novel predictors of the long-term bleeding risk in patients requiring both OACs and APT after PCI.

Atherothrombotic stroke in non-valvular atrial fibrillation

The review analyzes data on the detection rate of and the abilities to predict and prevent non-cardioembolic strokes in non-valvular atrial fibrillation. According to accumulated facts, vitamin K antagonists in non-valvular atrial fibrillation are noted to be inferior to antiplatelet drugs in efficiency in preventing non-cardioembolic (atherothrombotic in particular) strokes, and the widespread use of oral anticoagulants in combination with antiplatelet drugs does not generally reduce the incidence of poor outcomes, markedly increasing the risk of serious bleeding. Nevertheless, it is conceivable that this combination antithrombotic therapy may be useful for certain categories of patients at the highest risk for atherothrombotic stroke and at relatively low risk for hemorrhagic complications. Cohorts of patients, to whom such an approach should be reasonable considered to be applied, have not yet been identified.

Risk of Serious Bleeding with Antiplatelet Therapy for Secondary Prevention Post Ischemic Stroke in Middle East Population

IntroductionStroke is a devastating disease, causing significant mortality and long-term disability worldwide. Since the bulk of ischemic strokes is attributed to atherothrombosis, secondary prevention with antiplatelet agents is essential to decrease the recurrence of stroke. Aspirin, as well as clopidogrel monotherapy, has been shown to reduce the relative risk of recurrent stroke. However, concerns regarding the efficacy and safety of dual antiplatelet approach still exist. Stroke patients are particularly susceptible to bleeding complications, which might be due to advanced age and comorbidities. Our study assessed the risk of serious bleeding among adult patients on antiplatelet therapy for secondary prevention after stroke who were admitted to Mount Lebanon Hospital (MLH) between 2010 and 2015. It also studied the effect of the antiplatelet therapy, including dose and combination in increasing the risk of bleed.MethodsA retrospective monocentric study included 454 patients who were admitted for ischemic cerebrovascular accident (CVA) between 2010 and 2015, and discharged on antiplatelet therapy for secondary prevention. Those patients’ records were followed to assess the percentage of patients who developed a major bleed after initiation of antiplatelet therapy.ResultsThe risk of serious bleed was highest with aspirin 100 mg monotherapy and dual antiplatelet therapy (DAPT) (Aspirin 100 mg + Clopidogrel 75 mg). Bleeding risk was high during the first three months of therapy. However, the highest risk of bleed exists during the duration extending between three months and one year for both aspirin 100 mg monotherapy and DAPT. Moreover, there was an established relation between patients’ related factors and bleeding risk. Advanced age and smoking were found to contribute to increasing this risk.ConclusionAspirin 100 mg monotherapy and DAPT are associated with the highest risk of bleeding. Although this exists regardless of the duration of antiplatelet therapy, it is highest during the duration extending between three months and one year post initiation of antiplatelet therapy.

Bernard-Soulier Syndrome in Pregnancy: A Case Report

Background: Bernard-Soulier Syndrome (BSS) is a rare autosomal recessively inherited bleeding disorder of platelet function. Pregnancy in BSS is associated with a high risk of serious bleeding for both mother and neonate, and current data show no consensual approach. Aim: To report the case of a pregnant woman with BSS, in order to provide more information about management of these cases. Case Presentation: This case report describes a successful pregnancy outcome in a woman with BSS who was closely monitored throughout pregnancy and postpartum period, and had a judiciously planned birth. Conclusion: Management of BSS during pregnancy is still unclear. However, it is important to strictly control platelet counts and plan the birth in advance.

Serious hemorrhages after ischemic stroke or TIA - Incidence, mortality, and predictors.

BackgroundData are lacking on the risk and impact of a serious hemorrhage on the prognosis after ischemic stroke (IS) or transient ischemic attack (TIA). We aimed to estimate the incidence of serious hemorrhage, analyze the impact on mortality, and identify predictors of hemorrhage after discharge from IS or TIA.Methods and findingsAll patients admitted to Östersund Hospital for an IS or TIA in 2010–2013 were included (n = 1528, mean age: 75.1 years). Serious hemorrhages were identified until 31st December 2015. Incidence rates were calculated. The impact on mortality (stratified by functional level) was determined with Kaplan-Meier analysis. Non-parametric estimation under the assumption of competing risk was performed to assess the cumulative incidence and predictors of serious hemorrhages.The incidence rates of serious (n = 113) and intracranial hemorrhages (n = 45) after discharge from IS and TIA were 2.48% and 0.96% per year at risk, respectively. Patients with modified Rankin Scale (mRS) scores of 3–5 exhibited 58.9% mortality during follow-up and those with mRS scores of 0–2 exhibited 18.4% mortality. A serious hemorrhage did not affect mortality in patients with impaired functional status, but it increased the risk of death in patients with mRS scores of 0–2. Hypertension was associated with increased risk of serious hemorrhage.ConclusionsWe found that, after discharge from an IS or TIA, serious hemorrhages were fairly common. Impairments in function were associated with high mortality, but serious hemorrhages only increased the risk of mortality in patients with no or slight disability. Improved hypertension treatment may decrease the risk of serious hemorrhage, but in patients with low functional status, poor survival makes secondary prevention challenging.