Subsequent Bleeding Research Articles

Tricobezoar gástrico con resolución laparoscópica en mujer adolescente: Reporte de Caso


 
 
 Un bezoar es una masa indigestible atrapada en el tracto gastrointestinal. Está formado por una variedad de materiales que fueron ingeridos intencional o accidentalmente. En el Ecuador no existen datos epidemiológicos de esta patología. El tricobezoar se produce principalmente en asociación con un trastorno psiquiátrico (tricotilomanía y tricofagia). Las modalidades de tratamiento para los tricobezoares incluyen: terapia endoscópica con fragmentación, disolución con líquidos carbonatados, tratamiento médico que implica disolución enzimática y cirugía, incluido el procedimiento laparoscópico. Este tipo de resolución se ha practicado con resultados favorables comparados con la cirugía abierta; sin embargo, aún no se tiene suficiente experiencia en este procedimiento por la baja incidencia de esta complicación. Se presenta el caso clínico de una joven de 17 años con antecedentes de tricofagia, que acudió por dolor abdominal y masa palpable en epigastrio. Mediante historia clínica y exámenes de imagen se diagnosticó de tricobezoar y fue sometida a gastrotomía laparoscópica, con extracción por incisión de Pfannenstiel, con evolución favorable, estadía hospitalaria corta (5 días luego de la intervención quirúrgica), tolerando dieta blanda y siendo dada de alta en buenas condiciones. 
 
 

Utility of Complementary Magnetic Resonance Plaque Imaging andContrast-Enhanced Ultrasound to Detect Carotid VulnerablePlaques.

BackgroundWe aimed to improve the assessment quality of plaque vulnerability with combined use of magnetic resonance imaging and contrast‐enhanced ultrasound (CEUS).Methods and ResultsWe prospectively enrolled 71 patients with internal carotid artery stenosis who underwent carotid endarterectomy and performed preoperative CEUS and magnetic resonance plaque imaging. We distinguished high–signal‐intensity plaques (HIPs) and non‐HIPs based on magnetization‐prepared rapid acquisition with gradient echo images. We graded them according to the CEUS contrast effect and compared the CEUS images with the carotid endarterectomy specimens. Among the 70 plaques, except 1 carotid endarterectomy tissue sample failure, 59 were classified as HIPs (43 symptomatic) and 11 were classified as non‐HIPs (5 symptomatic). Although the magnetization‐prepared rapid acquisition with gradient echo findings alone had no significant correlation with symptoms (P=0.07), concomitant use of magnetization‐prepared rapid acquisition with gradient echo and CEUS findings did show a significant correlation (P<0.0001). CEUS showed that all 5 symptomatic non‐HIPs had a high‐contrast effect. These 5 plaques were histopathologically confirmed as vulnerable, with extensive neovascularization but only a small amount of intraplaque hemorrhage.ConclusionsComplementary use of magnetic resonance imaging and CEUS to detect intraplaque hemorrhage and neovascularization in plaques can be useful for evaluating plaque vulnerability, consistent with the destabilization process associated with neovessel formation and subsequent intraplaque hemorrhage.

P53 - Melanoma Metastatic to Brain and Subsequent Bleeds: The Roles of BRAF Status and Whole Brain Radiotherapy

P53 - Melanoma Metastatic to Brain and Subsequent Bleeds: The Roles of BRAF Status and Whole Brain Radiotherapy

Predictive value of a bleeding score for postpartum hemorrhage

BackgroundA reliable screening tool that could contribute to the identification of women with an increased risk of postpartum hemorrhage would be of great clinical significance. ObjectivesThe aim of this study was to examine the added predictive value of a bleeding assessment tool for postpartum hemorrhage exceeding 1000 mL. Patients/MethodsProspective two‐center cohort study among 1147 pregnant women visiting the outpatient clinic or the maternity ward who completed a bleeding assessment tool prior to birth. The condensed MCMDM‐1VWD bleeding assessment tool was adjusted to a questionnaire that could be used as a self‐assessment bleeding tool. A score of ≥4 was considered to be abnormal. ResultsIn the 1147 pregnant women in our cohort, bleeding scores ranged from −3 to 13, with a median of 1 (IQR −1 to 3); 197 (17%) women developed postpartum hemorrhage. Among women with a history of postpartum hemorrhage 29% developed postpartum hemorrhage. Among 147 women with an abnormal bleeding score (≥4), 27 (18%) developed postpartum hemorrhage, whereas the remaining 170 cases of postpartum hemorrhage had a normal bleeding score. Despite the high incidence of postpartum hemorrhage, the ability of the bleeding score to predict postpartum hemorrhage was poor: area under receiver operating curve 0.53 (95% CI 0.49‐0.58) for postpartum hemorrhage (PPH) ≥1000 mL. ConclusionsA history of significant postpartum hemorrhage was associated with an increased risk of subsequent postpartum hemorrhage. However, screening with a bleeding assessment tool did not help to discriminate women who will develop postpartum hemorrhage from women who will not.

Lymphostasis and Hemostasis in Body-Contouring Surgery Using a Polysaccharide Based Hemostat (4DryField PH).

Background:Following liposuction, abdominoplasty is the most frequent body-contouring intervention in the world. The transection of small blood vessels in large areas and subsequent bleeding is a viable risk during this procedure. The resulting microvascular bleedings should be stopped thoroughly to reduce the probability of related complications. In this prospective, monocentric, randomized study, the efficacy of the polysaccharide-based hemostat 4DryField PH (4DF) (PlanTec Medical, Lueneburg, Germany) is examined in classic abdominoplasty and lower body lift after Lockwood.Methods:For this prospective, monocentric, randomized study, 40 patients underwent surgery for both interventions. Twenty patients received an abdominoplasty, and 20 patients underwent a body lift. In each group, 10 patients have been treated with 4DF, whereas 10 have been served as the untreated control group.Results:4DF had neither a beneficial nor a negative effect on necessity of drainages, drainage volume and duration, length of hospital stay or frequency of postoperative seromas, wound healing disturbances, and infections, independent of surgical intervention. Patients in the 4DF group, however, had more individual risk factors, and required extended surgical interventions that might mask primary outcome results.Conclusions:This is the first prospective, monocentric, randomized study on 4DF in body-contouring surgery. The use of 4DF did not lead to a better postoperative outcome regarding hemostasis and lymphostasis. Potential benefits need further evaluation in high-volume studies.

Management of calcified hilar lymph nodes during thoracoscopic lobectomies: avoidance of conversions.

Our objective in this paper is to introduce a new method for handling calcified hilar lymph nodes during lobectomies by video-assisted thoracoscopy that effectively avoids arterial injury and possible conversions. The 12 cases in this study were initially evaluated as eligible and were subsequently scheduled for thoracoscopic lobectomies. However, calcification of the hilar lymph nodes was discovered during the operations, and its presence hampered the conventional process of pulmonary artery dissection. To avoid vessel injuries and subsequent massive bleeding, we developed two techniques specific to the position and exposure of the target vessels and nodes. The space between the bronchus and lymph nodes is exposed by sharp dissection ("scissor first") either before or after suturing the artery. These techniques are illustrated in detail. Seven male and five female patients participated in this study, with an average age of 72.5 years. We performed five right-upper lobectomies, three right-middle lobectomies, three right-lower lobectomies, and a left-lower lobectomy. Using this new technique, no conversions to thoracotomy occurred. The average operation time was 125 minutes, the mean blood loss was 275 mL, and no intra-operative massive bleeding occurred. Two patients experienced minor complications, one pulmonary infection and another postoperative subcutaneous emphysema. The proposed "scissor first" technique provides an effective solution for the thoracoscopic management of calcified hilar lymph nodes, and is a safe and effective method for avoiding arterial injury and conversion.

Reconsidering an important subclass of high-risk dural arteriovenous fistulas for stereotactic radiosurgery.

Aggressive dural arteriovenous fistulas (dAVFs) with cortical venous drainage (CVD) are known for their relatively high risk of recurrent neurological events or hemorrhage. However, recent natural history literature has indicated that nonaggressive dAVFs with CVD have a significantly lower prospective risk of hemorrhage. These nonaggressive dAVFs are typically diagnosed because of symptomatic headache, pulsatile tinnitus, or ocular symptoms, as in low-risk dAVFs. Therefore, the viability of stereotactic radiosurgery (SRS) as a treatment for this lesion subclass should be investigated. The authors evaluated their institutional experience with SRS for dAVFs with CVD for the period from 1991 to 2016, assessing angiographic outcomes and posttreatment hemorrhage rates. They subsequently pooled their results with those published in the literature and stratified the results based on the mode of clinical presentation. In an institutional cohort of 42 dAVFs with CVD treated using SRS, there were no complications or hemorrhages after treatment in 19 patients with nonaggressive dAVFs, but there was 1 radiation-induced complication and 1 hemorrhage among the 23 patients with aggressive dAVFs. In pooling these cases with 155 additional cases from the literature, the authors found that the hemorrhage rate after SRS was significantly lower among the patients with nonaggressive dAVFs (0% vs 6.8%, p = 0.003). Similarly, the number of radiation-related complications was 0/124 in nonaggressive dAVF cases versus 6/73 in aggressive dAVF cases (p = 0.001). The annual rate of hemorrhage after SRS for aggressive fistulas was 3.0% over 164.5 patient-years, whereas none of the nonaggressive fistulas bled after radiosurgery over 279.4 patient-years of follow-up despite the presence of CVD. Cortical venous drainage is thought to be a significant risk factor in all dAVFs. In the institutional experience described here, SRS proved to be a low-risk strategy associated with a very low risk of subsequent hemorrhage or radiation-related complications in nonaggressive dAVFs with CVD.

The risk of abnormal placentation and hemorrhage in subsequent pregnancy following primary elective cesarean delivery

Objective: We aimed to evaluate the relationship between mode of first delivery with subsequent placenta previa, placenta accreta/increta, and significant postpartum hemorrhage (PPH).Method: This retrospective cohort study included women with two consecutive singleton deliveries between 2007 and 2017 at our institution if the women were nulliparous and delivered at term at the time of first delivery. The first pregnancy delivery mode was classified as (1) vaginal delivery, (2) antepartum cesarean delivery (CD) without labor, or (3) intrapartum CD after the onset of labor. Within these three groups, rates of placenta previa, placenta accreta/increta, and significant PPH at the time of the second delivery were compared. Significant PPH was defined as hemorrhage requiring a blood transfusion.Results: A total of 8208 women were analyzed. Most first deliveries were vaginal (n = 5210, 63.5%), followed by antepartum CD (n = 2432, 29.6%) and intrapartum CD (n = 566, 6.9%). The incidence of placenta previa in subsequent deliveries differed by previous delivery mode: vaginal, 0.9%; antepartum CD, 2.0%; intrapartum CD, 1.6% (p < .001). Similar differences were also observed with respect to placenta accreta/increta (0.5 versus 1.5 versus 0.9%, p < .001) and PPH (0.6 versus 1.2 versus 0.4%, p = .017). Compared to the previous vaginal delivery group, the antepartum CD group had increased risks of placenta previa (aORs 2.02, 95% CI 1.35–3.05), placenta accreta/increta (aOR 2.52; 95% CI 1.53–4.14) and PPH (aOR 1.78, 95% CI 1.14–2.98) in subsequent pregnancies. However, the previous intrapartum CD was not significantly associated with increased risks of these complications.Conclusion: Previous antepartum CD was associated with two-fold increased risks of placenta previa, placenta accreta/increta, and significant PPH in the second delivery compared to women with a prior vaginal delivery. The increased risks of subsequent abnormal placentation following primary antepartum CD may be important for counseling concerning nonmedically indicated elective cesarean.Condensation: Previous antepartum cesarean delivery (CD) was associated with two-fold increased risks of placenta previa, placenta accreta/increta, and significant PPH in the second delivery.

Association of Thrombelastographic Parameters with Complications in Patients with Intracranial Aneurysm After Stent Placement

A prospective trial was conducted to investigate the platelet function and association between thrombelastographic (TEG) parameters and embolic or hemorrhagic complications in patients with intracranial aneurysm undergoing stent treatment. Between September 2013 and June 2016, we prospectively recruited patients with intracranial aneurysm who were treated with stent-assisted coiling. TEG parameters were used to assess the platelet function before stenting procedures. The primary study end point was the onset of ischemic stroke, transient ischemic attack, or silent ischemic events in the territory of the stented artery within 6 months after the procedure. The secondary end point was assessed by bleeding events. Four hundred and thirty-one patients with 453 intracranial aneurysms were enrolled. A total of 519 neurovascular stents were implanted. During the follow-up, a total of 70 primary end points (16.2%) and 59 secondary end points (13.7%) were detected. Thromboembolic complications such as symptomatic and slient ischemic complications were more frequently observed in patients with large aneurysms (>10 mm, P= 0.01), lower adenosine diphosphate (ADP) inhibition rate (P < 0.0001), and higher ADP-induced platelet-fibrin clot strength (maximum amplitude of adenosine diphosphate [MA-ADP]) (P < 0.0001). Besides, based on multivariate analysis, a higher ADP inhibition ratio was identified as a significant independent predictor of subsequent bleeding events (P < 0.0001). According to the receiver operating characteristic curve analysis, the safe range of the ADP inhibition ratio and MA-ADP of the TEG analysis were identified as 29.45%-55.4% and <46.15, respectively. The ADP inhibition ratio and MA-ADP of TEG analysis were associated with subsequent cerebral ischemic events and intracranial or extracranial bleeding events in patients with intracranial aneurysm after stent treatment.

Multimodality Imaging for Radiosurgical Management of Arteriovenous Malformations

Background: Cerebral arteriovenous malformations (AVMs) are rarely seen congenital vascular anomalies. AVMs may lead to intracranial hemorrages due to disorganized tangle of vessels. Lifetime risk of bleeding from AVMs may be significant given the diagnosis at typically earlier ages of the lifespan, and complications associated with hemorrhage may lead to substantial morbidity or mortality. Management of AVMs aims at eliminating or reducing the risk of subsequent bleeding. In this context, microvascular surgical resection, endovascular embolization and radiosurgical treatment may be used for management of AVMs.Objective: In this study, we assessed the incorporation of Magnetic Resonance Imaging (MRI) in treatment planning for AVM radiosurgery. Methods: We identified 25 patients receiving radiosurgery for AVMs at our institution. Radiosurgery target volumes generated by using CT-only based imaging and CT-MR fusion based imaging for each patient were evaluated.Results: Twenty five patients undergoing SRS for AVMs were evaluated for target volume determination in this study. Mean target volume was 4.9 cc (range: 1.3-15.9 cc) on CT-only imaging, 5.7 cc (range: 1.4-16.7 cc) on CT-MR fusion based imaging, and 5.9 cc (range: 1.4-16.9 cc) on consensus decision of all treating physicians with colleague peer review. Target definition based on CT-MR fusion based imaging was identical to the consensus decision of all treating physicians in majority of patients.Conclusions: Treatment planning for AVM radiosurgery may be improved by incorporating CT-MR fusion based imaging, which clearly should be supplemented with additional data from angiography. There is need for additional studies to establish a consensus on optimal target definition by multimodality imaging for SRS of AVMs.

\u2018Birds of the same feathers fly together\u2019: midwives\u2019 experiences with pregnant women and FGM/C complications - a grounded theory study in Liberia

BackgroundIn Liberia, approximately 70% of the women of the North-Central and North-Western regions could have undergone female genital mutilation/cutting (FGM/C) in their childhood during a traditional ceremony marking their entrance into Sande, a secret female society. Little is known about FGM/C from Liberian women’s perspective. This study aimed to understand the health implications of FGM/C as perceived by qualified female midwives.MethodsThis qualitative study was conducted in 2017 in Monrovia, Liberia’s capital. Twenty midwives were approached. Of these, seventeen consented to participate in in-depth interviews. A thematic guide was used to gain insights about their knowledge on FGM/C and their experiences attending women victims of FGM/C. A feminist interpretation of constructivist grounded theory guided data generation and analysis.ResultsThe midwives participants described how clitoridectomy was the most common FGM/C type done to the girls during the Sande initiation ceremonies. Sexual impairment and intrapartum vulvo-perineal laceration with subsequent hemorrhage were described as frequent FGM/C-attributable complications that some midwives could be unable to address due to lack of knowledge and skills. The majority of midwives would advocate for the abandonment of FGM/C, and for the preservation of the traditional instructions that the girls in FGM/C-practicing regions receive when joining Sande. The midwives described how migration to urban areas, and improved access to information and communication technologies might be fuelling abandonment of FGM/C.ConclusionLiberian midwives need tailored training to provide psychosexual counseling, and to attend the obstetric needs of pregnant women that have undergone FGM/C. In spite of FGM/C being seemingly in the decline, surveillance at clinic-level is warranted to prevent its medicalization. Any clinic- or community-based training, research, prevention and awareness intervention targeting FGM/C-practicing populations should be designed in collaboration with Sande members, and acknowledging that the Liberian population may place a high value in Sande’s traditional values.

Development of a risk score for predicting the benefit versus harm of extending dual antiplatelet therapy beyond 6 months following percutaneous coronary intervention for stable coronary artery disease.

BackgroundDecisions on dual antiplatelet therapy (DAPT) duration should balance the opposing risks of ischaemia and bleeding. Our aim was to develop a risk score to identify stable coronary artery disease (SCAD) patients undergoing PCI who would benefit or suffer from extending DAPT beyond 6 months.MethodsRetrospective analysis of a cohort of patients who completed 6 months of DAPT following PCI. Predictors of ischaemic and bleeding events for the 6–12 month period post-PCI were identified and a risk score was developed to estimate the likelihood of benefiting from extending DAPT beyond 6 months. Incidence of mortality, ischaemic and bleeding events for patients treated with DAPT for 6 vs. 6–12 months, was compared, stratified by strata of the risk score.ResultsThe study included 2,699 patients. Over 6 months’ follow up, there were 78 (2.9%) ischaemic and 43 (1.6%) bleeding events. Four variables (heart failure, left ventricular ejection fraction ≤30%, left main or three vessel CAD, status post (s/p) PCI and s/p stroke) predicted ischemic events, two variables (age>75, haemoglobin <10 g/dL) predicted bleeding. In the lower stratum of the risk score, 6–12 months of treatment with DAPT resulted in increased bleeding (p = 0.045) with no decrease in ischaemic events. In the upper stratum, 6–12 months DAPT was associated with reduced ischaemic events (p = 0.029), with no increase in bleeding.ConclusionIn a population of SCAD patients who completed 6 months of DAPT, a risk score for subsequent ischaemic and bleeding events identified patients likely to benefit from continuing or stopping DAPT.

Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations

ObjectiveThere is a paucity of literature investigating the clinical course of patients with spinal intramedullary cavernous malformations (ISCMs). We present a large case series of ISCMs to describe clinical presentation,...

Abstract TP315: A Novel Mechanism for Hemorrhagic Transformation of Ischemic Strokes

Introduction: Ischemic strokes are frequently accompanied by subsequent hemorrhage, particularly in patient subpopulations treated with anticoagulants or platelet inhibitors. In an AHA-funded study, we are investigating how symptomatic hemorrhagic transformation (HT) occurs subsequent to experimental ischemic stroke in mice. Hypothesis: In various settings where HT contributes to stroke pathology, increased vascular 12/15-lipoxygenase (12/15-LOX) is central to a vascular injury program that causes HT. Methods: Mice were pretreated with warfarin for 24h, or with aspirin plus clopidogrel (ASA/CPG) for 72h, in both cases added to the drinking water. Control mice in both cases received regular drinking water. The filament model was used to induce MCAO in C57Bl6J mice for the times indicated. tPA was infused i.v. at the time of reperfusion, and the 12/15-LOX inhibitor ML351 or vehicle were injected i.p. Shortwave infrared (SWIR) imaging of i.v. injected fluorescent quantum dot nanoparticles was used in some mice to detect early HT in vivo, and used to determine the appropriate time point for sacrifice. Immunohistochemistry of brain sections was used to further analyze the hemorrhage and surrounding areas. Results: Pretreatment with either warfarin or with aspirin plus clopidogrel led to increased 12/15-LOX predominantly in the vasculature of mice subjected to experimental stroke. SWIR imaging of brain sections taken at the early stages of hemorrhage showed 12/15-LOX specifically increased near sites of hemorrhage. ASA/CPG pretreatment combined with tPA at the time of reperfusion led to increased HT, which was significantly reduced when the 12/15-LOX inhibitor ML351 was administered. Conclusions: 12/15-LOX is increased in the vasculature under conditions that favor HT, suggesting it may have a causal role. Inhibition of 12/15-LOX may be considered as a strategy to limit HT of ischemic strokes.

Risk-to-Benefit Ratio of Venous Thromboembolism Prophylaxis for Neurosurgical Procedures at a Quaternary Referral Center.

Pharmacological prophylaxis for venous thromboembolism (VTE) in the neurosurgical population is still a matter of debate, as the risk-to-benefit ratio is not well defined. To further evaluate the risk-to-benefit ratio of VTE prophylaxis (VTEP) for all neurosurgical procedures. A prospective evaluation was performed after the initiation of a VTEP protocol for 11 436 patients undergoing neurosurgical procedures over 24 mo. Unless a bleeding complication was present, 5000 international units of subcutaneous heparin every 8 h was ordered on postoperative day (POD) 1 for spine, POD2 for cranial, and by POD4 for subdural, intracerebral, and epidural hematoma cases. Incidence of VTE and any subsequent bleeding complications were noted. A total of 70 VTEs (0.6% overall) were documented (28 deep vein thrombosis, 42 pulmonary embnolism). The highest rates of VTE were associated with deformity (6.7%); open cerebrovascular (6.5%); subdural, intracerebral, and epidural hematoma (3.2%); spinal trauma (2.4%); and craniotomy for tumor (1.6%) cases. Seven cases of deep vein thrombosis progressed to pulmonary embolisms, and 66 of 70 VTEs occurred while on pharmacological VTEP. Fifty-four bleeding complications occurred on or after POD2 following initiation of VTEP. These bleeding complications consisted of any new clinically or radiographically observed hemorrhages. Twenty-eight of the 54 delayed bleeding complications required operative intervention with 1 mortality. Forty-five patients were on anticoagulation when the initial bleeding event occurred. Overall, an estimated 0.5% incidence of delayed bleeding complications was noted with 99.4% of patients within the study cohort remaining VTE free. This VTEP protocol was determined to afford a good risk-to-benefit ratio for a wide variety of neurosurgical procedures.

Contributions of 12/15-Lipoxygenase to Bleeding in the Brain Following Ischemic Stroke.

Ischemic strokes are caused by one or more blood clots that typically obstruct one of the major arteries in the brain, but frequently also result in leakage of the blood-brain barrier and subsequent hemorrhage. While it has long been known that the enzyme 12/15-lipoxygenase (12/15-LOX) is up-regulated following ischemic strokes and contributes to neuronal cell death, recent research has shown an additional major role for 12/15-LOX in causing this hemorrhagic transformation. These findings have important implications for the use of 12/15-LOX inhibitors in the treatment of stroke.

The occurrence of acute demyelinating encephalomyelitis after respiratory viral infection (clinical observation)

This article examines the development of acute demyelinating encephalomyelitis against a background of a viral infection in a clinical case. Based on the literature review, it is known that acute disseminated encephalomyelitis is an immuno-mediated single-phase inflammatory demyelinating disorder of white matter of the brain and spinal cord. It is noted that one of the proposed mechanisms of pathogenesis is that myelin autoantigens, such as myelin main protein, proteolipid protein and myelin oligodendrocyte protein, have antigenic determinants with the infecting agent. Antiviral antibodies or cell-mediated cross-reacting pathogens respond to myelin autoantigens, resulting in acute demyelinating encephalomyelitis. Acute demyelinating encephalomyelitis has been found to be associated with increased vascular permeability and accumulation of circulating immune complexes or other humoral factors that develop after exposure to a foreign antigen introduced by infection or vaccination. This process then leads to infiltration of the walls of the vessels by mononuclear cells with subsequent swelling and periodic hemorrhage. Microglia, lymphocytes, and phagocytes appear throughout the day, ultimately leading to demyelination and possible gliosis and necrosis. The degree of demyelination and subsequent glial and neural changes explain the difference between clinical features and disease prognosis. In clinical case, we have demonstrated the appearance of this disease, which developed in close temporal connection with infectious disease. Positive meningeal signs, tenderness and limited movements of the eyeballs, diplopia when viewed sideways, decreased convergence, horizontal nystagmus when viewed sideways, symptoms of oral automatism, decreased muscle strength diffuse, tendons and tendons = D, average liveliness; from the feet S&gt; = D, average liveliness, tremor of the hands. The MRI findings, in addition to the clinical picture, helped to establish the diagnosis. As a result of this, a cure for the disappearance of a neurological deficit was achieved. Thus, this clinical case proves that disseminated encephalomyelitis proceeds by type of acute disease with rapid increase of symptoms and their subsequent regression.

Interstitial Pregnancy a Rare form of Ectopic Pregnancy: Case Report

Interstitial pregnancy is a rare variety of ectopic pregnancy, it can have disturbed 8-16 weeks of amenorrhea (later than the distal tubal ectopic pregnancy), due to the dispensability of the myometrium covering the interstitial segment of the fallopian tube, with subsequent massive internal hemorrhage.A 29-years-old female, Gravida 3, Para 2, presented with severe abdominal pain, vomiting, and syncope 3 days after her missing period, and positive pregnancy test. Trans-vaginal ultrasound showed empty uterine cavity, free pelvic fluid with severe cervical motion tenderness. She was diagnosed with ruptured ectopic pregnancy. Ruptured ectopic pregnancy in the proximal segment of right fallopian tube was confirmed with laparotomy.The ruptured pregnancy was managed by right salpingectomy, and hemostatic stitches at the right uterine corn. Her hemoglobin was 8 gr on admission, and she received 3 units of packed RBCs (one intra-operative, and two post-operative). Her post-operative hemoglobin was 10.5 gr, and she was discharged from the hospital on the 3rd post-operative day in good general condition for follow up in the outpatients` department. This case report represents a rare variety of ectopic pregnancy, which is the interstitial pregnancy, because it can rupture few days or weeks after the missed period with subsequent massive internal hemorrhage. Interstitial pregnancy is a rare form of ectopic pregnancy, the obstetricians should be aware of rare forms of ectopic pregnancies, it can have disturbed few days or weeks after the missed period leading to subsequent significant morbidity.

Prediction of bleeding by thromboelastography in ICU patients with haematological malignancy and severe sepsis

: ICU patients with haematological malignancy have an increased risk of bleeding. Recently, global haemostatic methods such as thromboelastography (TEG) have gained impact in evaluating coagulation. The aim of this study was to observe whether TEG could predict bleeding in haematological ICU patients with severe sepsis. Post-hoc single-centre analysis of patients with haematological malignancy included in the Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial. Clinical characteristics, TEG measurements and details regarding bleeding complications were retrieved from the 6S database. The association between TEG and bleeding were analysed by Cox regression and receiver operating characteristic curves. A total of 202 patients with severe sepsis were admitted to the ICU of Rigshospitalet, Copenhagen and included in the 6S trial. Forty-one had haematological malignancy and were analysed in the current study. During ICU stay, 20 patients (49%) had bleeding complications and 13 (32%) patients bled within the first 5 ICU days. We observed no associations between TEG and subsequent bleeding in Cox regression models. TEG variables at baseline had low predictive value for bleeding. Baseline TEG variables did not add value in identifying patients with high risk of bleeding in ICU patients with haematological malignancy and severe sepsis.

Association of Anemia With Outcomes Among ST-Segment-Elevation Myocardial Infarction Patients Receiving Primary Percutaneous Coronary Intervention.

Anemia may confer a poor prognosis among patients with the acute coronary syndrome. However, few data exist on the association of anemia with in-hospital outcomes, including bleeding, among ST-segment-elevation myocardial infarction patients receiving primary percutaneous coronary intervention. We identified 1919 ST-segment-elevation myocardial infarction patients who had undergone primary percutaneous coronary intervention within the Vancouver Coastal Health Authority (2007-2016) of whom 322 (16.8%) had anemia on admission. Between-group differences in (unadjusted) in-hospital outcomes, including heart failure, cardiogenic shock, major bleeding, and death were examined. Spearman correlation ( rs) and multivariate logistic regression were used to evaluate the relationship of anemia on admission with clinical outcomes. Compared with nonanemic patients, anemic patients were more likely to have preexisting hypertension, diabetes mellitus, and prior myocardial infarction. Anemic patients had higher unadjusted rates of in-hospital death (8.1% versus 3.7%; P<0.001), bleeding (18.2% versus 9.4%; P<0.001), and were more likely to develop heart failure (odds ratio [OR], 1.62; 95% CI, 1.19-2.22), shock (OR, 2.35; 95% CI, 1.62-3.40), or cardiac arrest (OR, 1.94; 95% CI, 1.10-3.40) during their hospital stay. Baseline anemia was independently associated with major bleeding (OR, 1.78; 95% CI, 1.25-2.56) but not all-cause mortality (OR, 0.99; 95% CI, 0.57-1.73). There was no significant correlation between anemia and overall reperfusion times (OR, 0.95; 95% CI, 0.74-1.22). In a contemporary ST-segment-elevation myocardial infarction cohort receiving primary percutaneous coronary intervention, nearly 1 in 5 patients were anemic. Anemia was associated with increased comorbidities and higher-risk features on presentation and was independently associated with subsequent major in-hospital bleeding but not all-cause mortality. These results suggest that anemic ST-segment-elevation myocardial infarction patients may safely receive timely primary percutaneous coronary intervention but with particular consideration for bleeding avoidance strategies.