Significant Bleeding Research Articles

Role of preoperative CT imaging in penetrating thoraco-abdominal injuries: A multicenter study of urban trauma centers

IntroductionManagement of penetrating thoracoabdominal (PTA) injuries with signs of hemorrhage have warranted operative intervention but improved imaging capabilities have redefined interventions required. We examined outcomes of hemodynamically stable patients undergoing preoperative CT imaging with the hypothesis that CT imaging would decrease OR time without delaying OR arrival. MethodsA retrospective multicenter study was performed amongst four urban trauma centers examining hemodynamically stable patients with PTA injuries requiring operative intervention from January 2017–December 2021. The primary outcome was OR time. Secondary outcomes included length of stay (LOS), ICU LOS, and mortality. A multivariable logistic regression with random intercept for trauma center was fit to assess whether preoperative CT affected time in the OR. ResultsOf 534 hemodynamically stable patients with penetrating injuries, 322 (60.3 ​%) received preoperative CT. The median time in OR were 130 (IQR: 84,180) and 140 (IQR: 100, 180) minutes for patients with and without preoperative CT, respectively. Median time to OR was 68 (IQR: 47, 110) and 26 (IQR 17,38) minutes in patients with and without preop CT, respectively. Median ICU LOS were 0 vs 1 day, the median hospital LOS were 7 vs 8 days for patients with and without pre-op imaging respectively. The multivariable model showed that obtaining a pre-op CT scanning was not independently associated with time spent in OR. (Adjusted OR:0.94; 95 ​% CI: 0.85, 1.04). ConclusionIn patients with PTA injuries and hemodynamic stability, preoperative CT scanning was not associated with decreased OR time, postoperative complications, or mortality.

S956 Functional Disability After Clinically Significant Extracranial Bleeding: A Post Hoc ASPREE Analysis

S956 Functional Disability After Clinically Significant Extracranial Bleeding: A Post Hoc ASPREE Analysis

S4115 Unusual Occurrence of Significant Bleeding After Fine-Needle Biopsy of a Subepithelioid Gastrointestinal Stromal Tumor Successfully Managed with an Over-the-Scope-Clip (OTSC)

S4115 Unusual Occurrence of Significant Bleeding After Fine-Needle Biopsy of a Subepithelioid Gastrointestinal Stromal Tumor Successfully Managed with an Over-the-Scope-Clip (OTSC)

Comparison of oral pre-medication with clonidine and metoprolol on intraoperative hemodynamics and surgical conditions during functional endoscopic sinus surgery

Background: Functional endoscopic sinus surgery (FESS) is one of the most performed surgical procedures and requires minimal bleeding during the procedure. The success of surgeries is largely dependent on the surgical field, where the presence of significant bleeding is an important factor. Aims and Objectives: The objectives of this study were to evaluate the clinical efficacy of oral clonidine and metoprolol following their pre-medication for induced hypotension during FESS and to assess hemodynamic stability, surgical field quality, and sedation score. Materials and Methods: This is an observational hospital-based study conducted on 60 patients, aged 18–60 years old for FESS assigned by randomization method in two groups including clonidine or metoprolol. Heart rate (HR) and arterial blood pressure are measured after induction, during and end of the surgery. Assessment of bleeding was done by a surgeon who was blinded. Surgical field quality, satisfaction level of the surgeon, Aldrete score, and any side effects were observed. Results: There was no significant difference seen in HR in patients of Group C and Group M in the pre-operative period, after loading the dose of the drug, at extubation (P>0.05). A significant difference was seen in HR with lower mean values in Group C compared to Group M after induction (77.23±12.23), 10 min after induction (69.47±11.99), 20 min after induction (65.63±8.66), 30 min after induction (64±8.32), 40 min after induction (63.77±7.61), and 60 min after induction (63.63±7.89). A significant difference was seen in blood pressure, after loading the dose of the drug, after induction, during surgery monitored every 10 min, at extubation, after extubation monitored every hour for 6 h. Quality of surgical field and surgeon’s satisfaction was better in patients who received clonidine than in those who received metoprolol. Conclusion: Both clonidine and metoprolol can be effectively used for induced hypotension in FESS. Clonidine is better than metoprolol with respect to intraoperative hemodynamics, quality of the surgical field, and surgeon’s satisfaction with the added advantage of sedation, reduced analgesia requirement, and other anesthetic drugs.

A UTERINE RUPTURE NOT TO OVERLOOK IN THE CONTEXT OF RETROPLACENTAL HEMATOMA

Objective: To report a rare case of uterine rupture in the context of a Couvelaire uterus in a patient with no history of uterine surgery or manipulation and to discuss the clinical challenges and management strategies for such cases. Case Summary: A 34-year-old multiparous woman presented at 34 weeks gestation with intrauterine fetal death (IUFD) and preeclampsia. Despite an unremarkable history with no prior cesarean deliveries or intrauterine interventions, she developed sudden hemodynamic instability and was diagnosed with uterine rupture during an emergency laparotomy. Intraoperatively, a large posterior uterine rupture was identified and repaired. Postoperatively, the patient experienced uterine atony and significant hemorrhage, necessitating additional surgical interventions including Tsirulnikov ligation and the B-Lynch uterine compression technique. The patient recovered well following intensive care management. Discussion: Uterine rupture in an unscarred uterus is an exceedingly rare event, particularly in the absence of classic risk factors. This case occurred in the context of a Couvelaire uterus, where extensive intramyometrial hemorrhage due to placental abruption may have weakened the uterine wall. The nonspecific clinical presentation, including the absence of abdominal pain or vaginal bleeding, poses diagnostic challenges. Immediate surgical intervention is crucial, especially in low-resource settings where advanced treatment options may be limited. This case underscores the importance of maintaining a high index of suspicion for uterine rupture, even in patients without typical risk factors, and highlights the need for adaptable management strategies. Conclusion: Uterine rupture should be considered in the differential diagnosis of acute abdomen in pregnancy, regardless of the patients obstetric history. Early recognition, prompt surgical management, and flexible treatment strategies are essential for optimizing outcomes in such rare but potentially life-threatening situations. Further studies are needed to improve understanding and management of this rare complication.

CLINICAL PATTERNS AND OUTCOMES IN CIRRHOTIC YEMENI PATIENTS WITH ACUTE-ON-CHRONIC LIVER FAILURE

Acute-on-chronic liver failure (ACLF) is a clinical condition of abrupt hepatic decompensation in chronic liver disease patients that is associated with extra-hepatic organ failures and a higher mortality rate. This study aimed to identify the clinical patterns and outcomes in cirrhotic Yemeni patients with ACLF. This prospective cohort study was carried out on 160 cirrhotic patients admitted between May 2023 and May 2024 to the Internal Medicine Department in Al-Sadaqah General Teaching Hospital in Aden governorate, Yemen. Based on the European Association for Study of Liver's Chronic Liver Failure Consortium EASL-CLIF criteria, patients were divided into Group A: 54 patients with ACLF. Group B: 106 patients without ACLF. The prevalence of ACLF is 33.8%. The mean age was 41.54± 8.11 years in ACLF and 39.22± 8.14 years in non-ACLF patients. The proportion of males in ACLF was 51.9% vs. 57.5% in non-ACLF patients. The most common causes of cirrhosis were cryptogenic (58.8%) and autoimmune hepatitis (25.6%). A significant correlation was found between prior hospitalization, decompensation, and the increased risk of developing ACLF. The most common complications were jaundice, hepatic encephalopathy, renal failure, signs of bacterial infection, ascites, and gastrointestinal bleeding, respectively. The main precipitating events for ACLF were bacterial infection, especially SBP (48.1%), GIT bleeding (24.1%), and no identified precipitating events (24.1%). The most common organ failures were renal (70.4%), liver (42.6%), and cerebral (31.5%). ACLF patients showed higher levels of WBCs, bilirubin, and serum creatinine. Mortality rates were significantly higher in ACLF patients compared to non-ACLF at both 28 days (33.3% vs. 5.7%) and 90 days (685% vs. 23.6%). This study demonstrated that ACLF patients have worse prognoses, higher mortality rates, increased ICU admission, lower survival, and higher rates of organ failure than non-ACLF patients.

Safety and efficacy of conventional compared to segmented esophageal fully covered self-expanding metal stents: a retrospective multicenter case-control study.

Segmented self-expanding metal stents (SEMS) are an alternative to conventional unsegmented SEMS in the treatment of esophageal strictures. Due to their segmented design, they may adapt better to the surrounding structures making them less likely to migrate or cause trauma. We examined if there are clinically relevant differences between segmented and conventional esophageal SEMS in benign and malignant stenosis in terms of their functionality and safety. We performed a multicenter, retrospective case-control study of segmented and conventional SEMS implantations in esophageal stenosis. Outcome parameters were adverse events such as migration, occlusion, and severe complications (i.e., bleeding and perforation). 79 segmented SEMS were identified and compared to 79 conventional SEMS implantations. Groups were similar in terms of age, gender, and etiology. We observed 13.9% severe complications (SEMS-associated clinically significant bleeding or perforation) in the conventional SEMS group compared to 3.8% in the segmented SEMS group. This difference was statistically significant (p = 0.025). Rates of migration and occlusion were similar between both groups. Likewise, there was no significant difference in terms of short-term (30days) clinical success. In this first controlled analysis, segmented SEMS were associated with fewer severe clinical complications compared to conventional SEMS.

Molecular Characterization of a Clade 2.3.4.4b H5N1 High Pathogenicity Avian Influenza Virus from a 2022 Outbreak in Layer Chickens in the Philippines.

H5 subtype high-pathogenicity avian influenza (HPAI) viruses continue to devastate the poultry industry and threaten food security and public health. The first outbreak of H5 HPAI in the Philippines was reported in 2017. Since then, H5 HPAI outbreaks have been reported in 2020, 2022, and 2023. Here, we report the first publicly available complete whole-genome sequence of an H5N1 high-pathogenicity avian influenza virus from a case in Central Luzon. Samples were collected from a flock of layer chickens exhibiting signs of lethargy, droopy wings, and ecchymotic hemorrhages in trachea with excessive mucus exudates. A high mortality rate of 96-100% was observed within the week. Days prior to the high mortality event, migratory birds were observed around the chicken farm. Lungs, spleen, cloacal swabs, and oropharyngeal-tracheal swabs were taken from two chickens from this flock. These samples were positive in quantitative RT-PCR assays for influenza matrix and H5 hemagglutinin (HA) genes. To further characterize the virus, the same samples were subjected to whole-virus-genome amplification and sequencing using the Oxford Nanopore method with mean coverages of 19,190 and 2984, respectively. A phylogenetic analysis of the HA genes revealed that the H5N1 HPAI virus from Central Luzon belongs to the Goose/Guangdong lineage clade 2.3.4.4b viruses. Other segments also have high sequence identity and the same genetic lineages as other clade 2.3.4.4b viruses from Asia. Collectively, these data indicate that wild migratory birds are the likely source of H5N1 viruses from the 2022 outbreaks in the Philippines. Thus, biosecurity practices and surveillance for HPAI viruses in both domestic and wild birds should be increased to prevent and mitigate HPAI outbreaks.

Methylated tirilazad may mitigate oligofructose-induced laminitis in horses.

Laminitis is a serious health condition that can cause severe pain and lameness in horses. Due to lack of understanding of laminitis, treatments often fail to achieve the desired results. In recent years, we have begun to recognize that laminitis may involve a complex interaction between local and systemic inflammation. Dysbiosis of the gut microbiota has been linked in the development of systemic inflammation, and our previous findings suggest that the development of laminitis is closely linked to the production of harmful metabolites of the gut microbiota. In addition, it was found that localized lesions in the hoof, especially lamellar injuries, are the most direct cause of laminitis. Matrix metalloproteinases have been found to be strongly associated with the development of laminitis. Recent discovery has found that methylated tirilazad has a role in repairing laminar tissue in vitro. However, its efficacy in horses never has been studied. Therefore, we aimed to investigate the efficacy of methylated tirilazad (product name: PTP-102) in the prevention/treatment of oligofructose-induced laminitis. The results showed that oligofructose successfully induced laminitis in horses, resulting in detreated clinical signs. Blood indices (including inflammation-related indices and other related indices) were significantly increased. Observations of dissection and staining showed significant bleeding, swelling, and damage to hoof tissue. Analysis of the gut microbiota showed a significant decrease in abundance and diversity, and a significant increase in the relative abundance of specific bacteria. Following methylated tirilazad intervention, there were a significant improvement in clinical signs, blood markers and lamellar tissue damage. Additionally, methylated tirilazad positively influenced the gut microbiota structure by reducing the relative abundance of genera closely associated with the development of equine laminitis. This suggests that some of the therapeutic mechanism of methylated tirilazad may be linked to its effects on the gut microbiota. Notably, methylated tirilazad had better effect in the treatment group than the prophylactic group, indicating the post-diagnosis utility of methylated tirilazad for laminitis management.

Mass mortality associated with carpione rhabdovirus in golden pompano (Trachinotus ovatus) in China: First report

From August to November 2023, a severe epizootic outbreak occurred in an offshore cultured golden pompano (Trachinotus ovatus) population in Zhanjiang City, Guangdong Province, China, resulting in a cumulative mortality rate of 65–82 %. The diseased fish showed clinical signs of lethargy, anorexia, whirling movements, and hemorrhage at the base of the fins and in the upper and lower jaws before mass mortality. A rhabdovirus strain, designated as CARPV2023, was successfully isolated using fathead minnow (FHM) cells. The cytopathic effects of the tissue filtrate from the diseased golden pompano on FHM and epithelioma papulosum cyprini (EPC) cell monolayers were characterized by rounded cells, grape-like cluster formation, detachment, and lysis. Histopathology revealed congestion, hemorrhage, and necrosis in the spleen, liver, trunk kidney, and intestinal tissues of naturally and experimentally infected golden pompanos. Electron microscopy showed that bullet-shaped viral particles, measuring 183.5–217.6 nm in length and 57.3–82.7 nm in width, budded from the cell membrane or aggregated around the infected FHM cells. The virus remained stable for 7 d at 4–33 °C and replicated optimally at 28 °C. Whole-genome sequencing and subsequent phylogenetic analysis further indicated that the carpione rhabdovirus (CARPV)2023 strain is a new carpione rhabdovirus, and is related to novirhabdoviruses, however, is thus far unclassified. A specific nested reverse transcription-polymerase chain reaction assay confirmed the presence of CARPV in the affected golden pompano. Significantly higher mortality was observed in challenged golden pompanos than that in the controls through intraperitoneal injection and immersion infection. Fluorescence in situ hybridization showed showed positive reactions for RNA in multiple tissues (liver, spleen, trunk kidney, brain, heart, gill, and muscle) from infected fish. The highest expression level was confirmed in the spleen through qPCR. This is the first study to report natural CARPV infections in marine fish.

Rectus Abdominis Sheath Hematoma Following Cesarean Section: A Case Series

This case series describes two patients who underwent Cesarean section complicated by a rectus abdominis sheath hematoma that did not immediately resolve following exploratory laparotomy. One of the patients required an additional procedure by interventional radiology. Both patients had similar presentations. Both were noted to have symptomatic anemia on postoperative day 1 with an acute drop in hemoglobin. This was accompanied by severe abdominal pain and distension on physical exam. Computerized tomography (CT) abdomen/pelvis demonstrated evidence of active bleeding within the anterior abdominal wall musculature. Due to increasing concern for intrabdominal hemorrhage in the setting of an acute abdominal exam, the decision was made to proceed with an exploratory laparotomy. A substantial amount of blood was evacuated from the abdomen with greater than 1500 cc of estimated blood loss in both cases. A Jackson-Pratt drain was placed and had increased output immediately postoperatively. Both patients received blood products. One developed a consumptive coagulopathy. Interventional Radiology was consulted following exploratory laparotomy to consider intravascular embolization of the inferior epigastric arteries, which was eventually performed in one of the cases. The patients were discharged on hospital day 5 in good condition. Rectus abdominis sheath hematomas are a rare complication that can lead to significant postpartum hemorrhage. Prompt recognition and management is vital to avoid significant morbidity and mortality. Algorithms exist to guide treatment and standardize patient care. Despite using sound clinical judgment in line with existing algorithms, both patients had delayed resolution of their bleeding following initial management, requiring additional intervention.

Cornual Ectopic Pregnancy Rupture Early Diagnosis and Treatment: A Case Report

Cornual pregnancy is a severe form of ectopic pregnancy, comprising 2-4% of such cases and presenting a mortality rate 6-7 times higher than typical ectopic pregnancies. It is often confused with interstitial pregnancy which arises from the implantation of the gestational sac in the myometrium’s proximal part. Diagnosis and treatment are challenging and considered medical emergencies due to potential for significant maternal haemorrhage. This is a case report of a 26-year-old woman in hypovolemic shock due to a ruptured ectopic pregnancy, confirmed via ultrasound and treated with emergency laparotomy, revealing a left corneal ectopic pregnancy, which was successfully repaired.

Tunisian Dentist’s Knowledge and Attitudes toward Patients Undergoing Antithrombotic Therapy : A Cross Sectional Study

Introduction Invasive dental procedures, such as extractions, pose a significant bleeding risk for patients undergoing antithrombotic agents. Practitioners must navigate the delicate balance between managing hemorrhagic risks and preventing thromboembolic events in accordance with established treatment guidelines.  Objectives The aim of the study was to evaluate the knowledge and attitudes of Tunisian dentists towards patients undergoing anticoagulant and antiplatelet therapy.  Materials and Methods A cross-sectional study was conducted using an online survey consisting of 25 questions, which was completed by 363 participants.  Results A total of 363 dentists were included in the study, with an average age of 31.1 ± 8 years. Participants demonstrated a knowledge accuracy rate of approximately 67%. The study highlighted a lack of knowledge regarding the management of patients on direct oral anticoagulants, though recent graduates demonstrated a higher rate of appropriate clinical attitude.  Discussion The study showed some gaps in the training of Tunisian dentists regarding the management of these patients, highlighting the need to promote the latest recommendations, especially among older dentists.

Gastric Undifferentiated Pleomorphic Sarcoma Presenting as a Rapidly Growing Subepithelial Tumor

A 48-year-old man presented to our hospital for evaluation of melena. Abdominal computed tomography (CT) revealed an endophytic contrast-enhanced mass (approximately 9 cm) in the gastric fundus and upper body. CT showed no evidence of metastasis to other organs. Endoscopic examination revealed a large mass accompanied by an exudate and signs of surface hemorrhage. The shape of the mass resembled that of a subepithelial tumor, and >50% of the mucosa was peeled off. Endoscopic ultrasonography revealed hyperechoic spreading and dotor rod-shaped anechoic lesions arranged within an overall hypoechoic mass. The patient underwent total gastrectomy with lymph node dissection and was diagnosed with undifferentiated pleomorphic sarcoma without lymph node metastasis. Undifferentiated pleomorphic sarcoma, a high-grade aggressive soft tissue sarcoma, predominantly involves the extremities and rarely the stomach. It is usually asymptomatic but tends to grow rapidly. Endoscopic imaging performed a year prior to presentation was unremarkable. We report a case of a gastric undifferentiated pleomorphic sarcoma that presented as a rapidly growing subepithelial tumor. Malignancies other than a gastrointestinal stromal tumor should be considered in the differential diagnosis in patients presenting with a rapidly growing gastric subepithelial tumor.

Clinical characteristics, treatment, and outcomes of nivolumab induced immune thrombocytopenia.

Immune thrombocytopenia (ITP) represents an uncommon hematological side effect associated with nivolumab, and its distinct clinical attributes remain poorly defined. This research aimed to explore the clinical manifestations and outcomes of ITP induced by nivolumab. Reports on nivolumab induced ITP up to April 30, 2024, were collected for retrospective analysis. The study involved 34 patients with a median age of 67 years (range 32, 82). The onset of ITP varied from 10 to 100 days post initial dosage, with a median onset at 70 days. The majority of patients exhibited no symptoms, with only 23.5% experiencing clinically significant bleeding and 11.8% facing non-clinically significant bleeding. The median platelet count was 12 × 109/L (range 0, 115), with 67.6% of patients having platelet levels below 25 × 109/L. Bone marrow biopsy revealed mainly elevated megakaryocytes. Platelet-associated IgG levels were elevated with a median of 210 ng/107 cells (range 73, 1130). Subsequent interventions, which included cessation of nivolumab, administration of systemic corticosteroids, intravenous immunoglobulin therapy, a thrombopoietin receptor agonist, platelet transfusion, and rituximab treatment, resulted in 82.4% of subjects achieving normalized platelet counts, whereas 5.9% passed away due to ITP. ITP is a rare life-threatening immune-related adverse event and necessitates close monitoring. Systemic steroids are the primary treatment for ITP, while intravenous immunoglobulin, thrombopoietin receptor agonist and rituximab are other options.

Thrombopoietin Receptor Agonists as Second-Line Treatment in Children With Ongoing Immune Thrombocytopenia

What Is the Issue? Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by low platelets and an increase in bleeding risk; in the pediatric population, the reported incidence rate varies between 2 and 5 per 100,000 children per year. Spontaneous remission may be observed in up to 70% of patients, while 20% of patients may experience severe bleeding symptoms. In children whose ITP does not respond to first-line corticosteroids, IV immunoglobulin (IVIG), or anti-D immunoglobulin, guidelines recommend the use of thrombopoietin receptor agonists (TPO-RAs), i.e., eltrombopag or romiplostim (avatrombopag did not have a marketing authorization and Notice of Compliance at the time that the review was initiated). Rituximab is considered a subsequent-line of therapy. Splenectomy is not usually considered an appropriate treatment option in children. The goal of therapy in pediatric patients with ITP is to reduce bleeding and improve quality of life. Platelet response is considered a valid and appropriate surrogate end point in studies and routine assessment in clinical practice. Children whose ITP does not respond to available first-line drugs may require subsequent treatment with off-label drugs because they do not have access to TPO-RAs. What Did We Do? We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence. A systematic review of the literature identified 5 studies (4 randomized controlled trials [RCTs] and 1 observational study), which were synthesized narratively. The review addressed the following policy questions: In children with ongoing, active ITP, what is the overall body of evidence supporting the use of TPO-RAs and rituximab after failure of first-line therapies? Based on the level and quality of clinical evidence, should TPO-RAs be reimbursed for use earlier in the treatment sequencing for children with ongoing, active ITP, instead of being reimbursed only after a course of rituximab? What Did We Find? Evidence from 2 RCTs (n = 159) suggests that eltrombopag likely increases and maintains platelet response over time, in addition to decreasing the use of rescue medication and clinically significant bleeding compared to placebo, which were considered clinically meaningful outcomes for pediatric patients with ITP. There was a low risk of bias in the studies, but uncertainty was introduced due to the small sample sizes. Evidence from 1 RCT (n = 62) suggests that romiplostim may also increase and maintain platelet response, as well as reduce clinically significant bleeding compared to placebo. However, there was some concern due to a high risk of bias in the studies and uncertainty due to the small sample size, which suggests a need for caution in the interpretation of the findings. The effectiveness of rituximab was inconclusive due to the lack of evidence, as no comparative RCTs could be identified, while the observational study included presented only descriptive comparisons. No evidence was identified in support of trying rituximab before accessing TPO-RAs. What Does This Mean? Given that ITP is rare in children, there is a gap in available relevant evidence, and robust evidence from large RCTs in this patient population are unlikely to be conducted. Jurisdictions may consider requesting an implementation advice panel for use of eltrombopag and romiplostim after failure of first-line therapies in children with ongoing, active ITP.

Hematological Complications From Transcatheter Aortic Valve Replacement (TAVR): Recognition and Treatment.

Transcatheter aortic valve replacement (TAVR) has emerged as a pivotal intervention for patients with severe aortic stenosis who are at high or prohibitive surgical risk. Although TAVR is a minimally invasive procedure, it is linked to serious hematological problems, most notably thrombosis and bleeding. Numerous factors, such as procedural features, patient comorbidities, and anticoagulation management techniques, contribute to these complications. Bleeding complications can be major, minor, or life-threatening. They can be caused by problems with the vascular access site, anticoagulation medication, or coexisting conditions like renal dysfunction and frailty. Hemoglobin drop, overt bleeding, and hematoma signs must all be closely watched to identify bleeding. Careful selection and modification of anticoagulation medication, the use of vascular closure devices, and timely attention to bleeding sites are examples of management techniques. Thrombotic consequences, which include cerebrovascular accidents and valve thrombosis, are caused by endothelial injury, stent implantation, and patient hypercoagulability. Imaging modalities such as computed tomography and transesophageal echocardiography are used in the crucial process of detection. The goal of preventive care is to maximize anticoagulation regimens that are customized to each patient's risk profile, frequently striking a balance between the risk of thrombosis and bleeding. A multidisciplinary strategy that integrates surgical, hematological, and cardiology expertise is necessary for the effective management of these hematological complications. To improve patient outcomes, ongoing research attempts to improve risk stratification and create safer anticoagulation protocols. This review emphasizes how critical it is to identify bleeding and thrombotic events as soon as possible and treat them promptly to reduce the risk of negative outcomes for TAVR patients.

AN UPDATE ON DIAGNOSIS AND MANAGEMENT OF THROMBOEMBOLISM IN PREGNANCY

Thromboembolism during pregnancy poses a significant challenge in maternal healthcare, substantially contributing to maternal morbidity and mortality worldwide. Understanding its diagnosis and management is crucial for improving maternal and fetal outcomes. Objective: To evaluate the diagnosis and management of thromboembolism in pregnant women. Methods: A retrospective cohort study was conducted at Lady Reading Hospital, Peshawar, from July 2022 to July 2024. The study included 175 pregnant females diagnosed with venous thromboembolism (VTE) during their pregnancy. Data were collected on patient demographics, trimester of diagnosis, type of thromboembolism (deep vein thrombosis [DVT] or pulmonary embolism [PE]), treatment modalities, and outcomes. Patients were treated with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH). Descriptive statistics were used to analyze the data, with results presented as percentages and means with standard deviations. Results: The mean age of the participants was 32.01 ± 2.35 years. Thromboembolism was most commonly diagnosed in the third trimester (65%), followed by the second trimester (25%) and the first trimester (10%). DVT was observed in 74% of patients, while PE occurred in 26%. Among the 160 patients treated with LMWH, 3% (5 patients) experienced a recurrence of VTE. Of the 15 patients who received UFH, 5% (8 patients) had significant bleeding complications. Overall maternal outcomes included a 3% recurrence rate of VTE and a 5% rate of significant bleeding complications. No maternal mortality was reported. Conclusion: Early diagnosis and timely management of thromboembolism in pregnancy, mainly through the use of low molecular weight heparin and a multidisciplinary care approach, significantly improve maternal and fetal outcomes. LMWH was associated with fewer complications compared to UFH, highlighting its effectiveness and safety in treating pregnant women with VTE.

Phenotypic and genotypic evaluation of bleeding diagnostic dilemmas: Two case studies

Inherited platelet disorders (IPDs) are a heterogeneous group of conditions that present significant challenges in diagnosis and management. Here, we report two cases of patients presenting with clinically significant bleeding but with unclear etiologies by conventional clinical laboratory testing. Further evaluation, utilizing a combination of high-dimensional multiplexed mass cytometry and genetic sequencing, revealed the underlying causes of bleeding in both cases, leading to definitive diagnoses. These cases underscore the potential utility of combined multimodal approaches in evaluating patients with bleeding disorders. Moreover, these high-parameter methods can offer substantial mechanistic insights and can enhance our understanding of the molecular pathogenesis of IPDs. Future studies involving larger patient cohorts are needed to further validate this strategy, directly comparing its diagnostic yield and accuracy with current clinical laboratory testing approaches, which can ultimately improve patient care.

Rotational Thromboelastometry Reduces the Need for Preemptive Transfusion in Cirrhosis: A Randomized Controlled Trial (NCT:05698134)

Backgrounds and AimViscoelastic tests (VET) like Rotational Thromboelastometry (ROTEM) assess global hemostasis in cirrhosis. We aimed to assess whether ROTEM-guided blood product transfusion results in lower blood product requirement in patients with cirrhosis undergoing elective invasive procedures as compared to standard of care (SOC) based on conventional coagulation test (CCT). MethodsIn this open label randomized controlled trial, patients with cirrhosis and abnormal CCT who were undergoing an invasive procedure were randomized to receive blood products either by ROTEM-guidance or SOC. The primary outcome was the difference in blood products (fresh frozen plasma (FFP) or platelets) transfused between the group. The secondary outcome was procedure-related bleeding or complications within 7 days of the procedure. The trial protocol is registered at clinicaltrails.gov; NCT05698134. ResultsFrom August 2021 to January 2023, a total of 40 patients were recruited (ROTEM: (n=20) and SOC (n=20)). The trial was terminated earlier during interim analyses due to compelling benefit in the ROTEM group after a scheduled interim analysis. The ROTEM group required substantially less blood transfusion than the SOC group (40% [8/20] vs 100% [20/20], p<0.001). The benefit was consistent across all types of blood product including fresh frozen plasma (< 0.001) and pooled platelet (p=0.046). No patients experienced clinically significant bleeding events. Transfusion associated adverse events occurred in one patient (5%) in the SOC group (allergic reaction) and none in ROTEM group (p=NS). The mortality in both groups at 30 and 90 days were similar. ConclusionsViscoelastic tests like ROTEM provides global assessment of hemostasis in patients with cirrhosis. Institution of ROTEM based transfusion strategy significantly reduces the need for blood product transfusion in patients with cirrhosis undergoing elective procedure without any increased risk of bleeding events. Clinical Trial NumberNCT05698134