Subsequent Bleeding Research Articles

Expectant management of retained products of conception following abortion: A retrospective cohort study

ObjectiveTo clarify the natural history of retained products of conception (RPOC) following abortion at less than 22 weeks of gestation, and those who show major bleeding during course observation. Study designWe retrospectively reviewed 640 patients who had spontaneous or artificial abortion at less than 22 weeks of gestation between January 2011 and August 2019 in our institute. Of those, patients with RPOC were included. The maternal background, RPOC characteristics, and subsequent complications including additional interventions were reviewed. ResultsFifty-four patients with RPOC were included. The incidence of RPOC was 6.7 %. The median (interquartile range: IQR) RPOC length was 29 (20−38) mm. RPOC hypervascularity was observed in 26 (48 %) patients. The median (IQR) periods of RPOC flow disappearance and RPOC disappearance on ultrasound from abortive treatment were 50 (28−76) and 84 (50−111) days, respectively. Of the 54, 44 patients were selected for expectant management. Of the 44, 34 (77 %) patients were observed without intervention (recovery group); the other 10 (23 %) patients required additional interventions associated with subsequent bleeding (intervention group). Compared with the recovery group, heavy bleeding (> 500 mL) at abortion (6/10: 60 %) and RPOC hypervascularity (8/10: 80 %) were more frequently observed in the intervention group. ConclusionExpectant management was successful in almost 80 % of patients with RPOC following abortion. The additional interventions were required in patients with heavy bleeding at abortion and RPOC hypervascularity.

Thromboelastography During Rewarming for Management of Pediatric Cardiac Surgery Patients

BackgroundThromboelastography (TEG) predicts bleeding in pediatric patients undergoing cardiac surgical procedure. We hypothesize that TEG indicators at rewarming correlate with postprotamine values and that rewarming TEG is associated with surrogate end points for postoperative bleeding in pediatric patients undergoing complex cardiac surgical procedure. MethodsIn a retrospective study of 703 pediatric (≤18 years) patients undergoing complex cardiac surgical procedures, TEG results obtained during rewarming and after protamine administration were compared using linear regression. A composite end point of extended blood product transfusion or surgical reexploration for bleeding was used as a surrogate for postoperative bleeding. ResultsBy multivariable analysis, longer cardiopulmonary bypass time and lower TEG maximal amplitude (MA) during rewarming were independently associated with the risk of the composite end point in the operating room or in the intensive care unit (P < .05). Among patients with an MA of less than 45 mm during rewarming, those who received a platelet transfusion in the operating room compared with those who did not were less likely to reach the composite end point within the subsequent 24 hours (8% vs 32%, respectively; P < .01). Good correlation was observed between TEG variables at rewarming vs after protamine administration (Pearson r ≥ 0.7). The relationship between platelet transfusion volume (mL/kg) and the percentage change in the MA was determined using linear regression, and a platelet transfusion calculator was generated. ConclusionsA lower MA during rewarming is associated with an increased risk of perioperative bleeding. In patients with a rewarming MA of less than 45 mm, an intraoperative platelet transfusion may reduce the risk of subsequent bleeding. Individualized platelet transfusion therapy based on rewarming TEG may reduce the risk of bleeding while minimizing unnecessary platelet transfusion.

Association of tumor size and internal echo pattern with coagulopathy associated with hepatic hemangioma.

Little is known concerning causal factors associated with the size and echogenicity of hepatic hemangiomas. The aim of the present study was to investigate the associations between tumor size and echo pattern and coagulation factors, and to elucidate the growth pattern of hemangiomas. In 214 consecutive patients with hepatic hemangiomas, ultrasonography was performed to determine total tumor number, size, echogenicity and location, and serum laboratory tests for liver function and coagulation factors were carried out. The ultrasonographic appearance of hemangiomas was homogeneous in 75.7% of cases and mixed in 24.3% of cases. A mixed echo pattern was seen in 1 out of 145 masses (0.7%) with a diameter <20 mm, in 30 out of 48 (62.5%) with a diameter of 20-40 mm, and in all of the 21 (100%) with a diameter >40 mm. Platelet counts (P<0.0001) and fibrinogen levels (P<0.01) were lower in patients with larger and mixed tumors. Levels of thrombin-antithrombin III complex (TAT), D-dimer, and fibrin and fibrinogen degradation products (FDP) were significantly elevated along with an increase in tumor size (all P<0.0001), and the number of patients with the abnormal values of TAT, D-dimer, and FDP was significantly higher in the mixed group than in the homogeneous group (all P<0.0001). Fibrinogen (P<0.01), platelet count (P<0.001), portal vein diameter (P<0.0001), splenic index (P<0.01), and levels of TAT, D-dimer and FDP (all P<0.0001) were significantly associated with tumor size. Multivariate analysis revealed TAT, D-dimer and FDP as independent predictors of tumor size. The internal echo pattern became mixed as size increased. The size and echogenicity of hemangiomas were closely associated with coagulation factors. Therefore, it was speculated that differences in size and echogenicity were caused by intratumoral thrombosis and subsequent hemorrhage.

Embolization for acute gastrointestinal bleeding

Purpose: To retrospectively evaluate the clinical success and complication rates following interventional embolization for treatment of acute gastrointestinal bleeding (GIB) at a tertiary care centre. The secondary purpose was to evaluate results of practice change whereby multiphase CT angiography was requested prior to conventional angiograms.&#x0D; Methods: A retrospective chart review and analysis of 38 patients undergoing Interventional Radiology guided embolization for acute GIB was performed. Clinical success was defined as patient stability 30 days’ post embolization and complications included subsequent bleeding requiring endoscopy, surgery or additional embolization, or death.&#x0D; Results: Overall clinical success rate was 86.8% (33/38). Complications included 14 patients (36.8%) experiencing continued bleeding, 6 patients (15.8%) requiring repeat endoscopic evaluation, 8 patients (21.1%) requiring surgery, 3 patients (7.9%) requiring repeat embolization, and 4 deaths (10.5%). These results were not inferior to clinical success rates reported in the literature for GIB regardless of location. Positive predictive value for multiphase CT angiogram was 92.3% and the negative predictive value was 57.1%.&#x0D; Conclusions: Interventional angiography and embolization is an effective treatment for GIB with the most common complication being recurrent bleeding which may require additional endoscopic evaluation, surgical intervention or additional embolization. Clinical success and complication rates at this centre are similar to those reported in the literature. Continued evaluation of the utility of multiphase CT angiography prior to conducting embolization should be considered to determine its impact on rates of negative angiogram studies.

Long-Term Outcomes of Elderly Brain Arteriovenous Malformations After Different Management Modalities: A Multicenter Retrospective Study

Background: More and more elderly patients are being diagnosed with arteriovenous malformation (AVM) in this global aging society, while the treatment strategy remains controversial among these aging population. This study aimed to clarify the long-term outcomes of elderly AVMs after different management modalities.Methods: The authors retrospectively reviewed 71 elderly AVMs (>60 years) in two tertiary neurosurgery centers between 2011 and 2019. Patients were divided into four groups: conservation, microsurgery, embolization, and stereotactic radiosurgery (SRS). The perioperative complications, short-term and long-term neurological outcomes, obliteration rates, annualized rupture risk, and mortality rates were compared among different management modalities in the ruptured and unruptured subgroups. Kaplan-Meier survival analysis was employed to compare the death-free survival rates among different management modalities. Logistic regression analyses were conducted to calculate the odds ratios (ORs) and 95% confidence intervals (CI) for predictors of long-term unfavorable outcomes (mRS > 2).Results: A total of 71 elderly AVMs were followed up for an average of 4.2 ± 2.3 years. Fifty-four (76.1%) presented with hemorrhage, and the preoperative annualized rupture risk was 9.4%. Among these patients, 21 cases (29.6%) received conservative treatment, 30 (42.3%) underwent microsurgical resection, 13 (18.3%) received embolization, and 7 (9.9%) underwent SRS. In the prognostic comparison, the short-term and long-term neurological outcomes were similar between conservation and intervention both in the ruptured and unruptured subgroups (ruptured: p = 0.096, p = 0.904, respectively; unruptured: p = 0.568, p = 0.306, respectively). In the ruptured subgroup, the intervention cannot reduce long-term mortality (p = 0.654) despite the significant reduction of subsequent hemorrhage than conservation (p = 0.014), and the main cause of death in the intervention group was treatment-related complications (five of seven, 71.4%). In the logistic regression analysis, higher admission mRS score (OR 3.070, 95% CI 1.559–6.043, p = 0.001) was the independent predictor of long-term unfavorable outcomes (mRS>2) in the intervention group, while complete obliteration (OR 0.146, 95% CI 0.026–0.828, p = 0.030) was the protective factor.Conclusions: The long-term outcomes of elderly AVMs after different management modalities were similar. Intervention for unruptured elderly AVMs was not recommended. For those ruptured, we should carefully weigh the risk of subsequent hemorrhage and treatment-related complications. Besides, complete obliteration should be pursued once the intervention was initiated.Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT04136860

Acute visual deterioration and headaches in a patient with suprasellar lesion: Answer

•Cavernous malformation should be a differential diagnosis of suprasellar lesions.•Management of asymptomatic optic apparatus cavernous malformation is still debatable.•The relative risk of visual deterioration after repetitive hemorrhage may be higher than the risk of surgical removal. D. Optic tract cavernoma The patient underwent surgery through a left pterional craniotomy, and the intraoperative findings revealed a cavernoma in the left optic chiasm extending forward into the left optic nerve and posteriorly to the optic tract. (Fig. 3). Cavernous malformation (CM) is a common intracranial vascular lesion and accounts for 10 – 15% [1Tan T. Tee J.W. Trost N. McKelvie P. Wang Y.Y. Anterior visual pathway cavernous malformations.J Clin Neurosci. 2015; 22: 258-267Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 2Moriarity J.L. Clatterbuck R.E. Rigamonti D. The natural history of cavernous malformations.Neurosurg Clin N Am. 1999; 10: 411-417Abstract Full Text PDF PubMed Google Scholar] of the cases. The most common location is supratentorial (80%), brainstem (15%), and spinal cord (5%). Optic nerve CMs are very rare, with only 70 cases reported in the literature [3Voznyak O. Lytvynenko A. Maydannyk O. Kalenska O. Hryniv N. Cavernous Hemangioma of the Chiasm and Left Optic Nerve.Cureus. 2020; 12e8068PubMed Google Scholar, 4Hempelmann R.G. Mater E. Schröder F. Schön R. Complete resection of a cavernous haemangioma of the optic nerve, the chiasm, and the optic tract.Acta Neurochir (Wien). 2007; 149: 699-703Crossref PubMed Scopus (30) Google Scholar, 5Mano Y. Kumabe T. Saito R. Watanabe M. Tominaga T. Cavernous malformation of the optic pathway mimicking optic glioma: a case report.Childs Nerv Syst. 2014; 30: 1753-1758Crossref PubMed Scopus (7) Google Scholar, 6Hassler W. Zentner J. Wilhelm H. Cavernous angiomas of the anterior visual pathways.J Clin Neuroophthalmol. 1989; 9: 160-164PubMed Google Scholar]. The relative risk of hemorrhage from asymptomatic supratentorial cavernomas is 0.7 to 3.1% per year [[7]Liu J.K. Lu Y. Raslan A.M. Gultekin S.H. Delashaw J.B. Cavernous malformations of the optic pathway and hypothalamus: analysis of 65 cases in the literature.Neurosurg Focus. 2010; 29: E17https://doi.org/10.3171/2010.5.FOCUS10129Crossref PubMed Scopus (45) Google Scholar] Management of asymptomatic CM within the optic apparatus is problematic and requires consideration of the relative risk of hemorrhage with devastating visual loss consequences against those of surgery. In contrast, the risk increases in patients with previous hemorrhages up to 3.8% to 22.9% [[7]Liu J.K. Lu Y. Raslan A.M. Gultekin S.H. Delashaw J.B. Cavernous malformations of the optic pathway and hypothalamus: analysis of 65 cases in the literature.Neurosurg Focus. 2010; 29: E17https://doi.org/10.3171/2010.5.FOCUS10129Crossref PubMed Scopus (45) Google Scholar]. Since a small hemorrhage from a cavernoma located in the anterior optic apparatus could have catastrophic consequences, we recommend resection of the lesion in cases with radiological or clinical evidence of hemorrhage [[8]Crocker M. DeSouza R. King A. Connor S. Thomas N. Cavernous hemangioma of the optic chiasm: a surgical review.Skull Base. 2008; 18: 201-212Crossref PubMed Scopus (20) Google Scholar], as subsequent hemorrhage risk with visual loss is increased (Fig. 1, Fig. 2).Fig. 2A) Axial T1-weighted gadolinium-enhanced MRI, and B) axial T2-weighted MRI showing a left side non-enhancing hypointense suprasellar lesion, in a 62-year-old woman.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 3A) Intraoperative image of the left optic tract cavernoma removal (blue arrow) through a left pterional craniotomy, compressing the left optic nerve (red arrow) B) Intraoperative image after removal of the cavernoma, showing the left optic tract (blue star) and the optic chiasm (blue arrow head).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acute visual deterioration and headaches in a patient with suprasellar lesion: QuestionJournal of Clinical NeuroscienceVol. 86PreviewA 62-year-old woman presented with a history of headaches for two weeks and sudden loss of vision in her left eye. Neurological examination revealed right eye acuity 6/6, left eye 6/9.5, left eye relative afferent pupillary defect (RAPD), red desaturation reduced in the same eye, confrontation visual fields showed non-congruent right homonymous hemianopia. Fundoscopy did not show any sign of papilledema or chronic optic atrophy (Fig. 1). There was no other focal neurological deficit [1–8]. Full-Text PDF

Observational study of thrombosis and bleeding in COVID-19 VV ECMO patients.

COVID-19 has been associated with increased risk of thrombosis, heparin resistance and coagulopathy in critically ill patients admitted to intensive care. We report the incidence of thrombotic and bleeding events in a single center cohort of 30 consecutive patients with COVID-19 supported by veno-venous extracorporeal oxygenation (ECMO) and who had a whole body Computed Tomography Scanner (CT) on admission. All patients were initially admitted to other hospitals and later assessed and retrieved by our ECMO team. ECMO was initiated in the referral center and all patients admitted through our CT scan before settling in our intensive care unit. Clinical management was guided by our institutional ECMO guidelines, established since 2011 and applied to at least 40 patients every year. We diagnosed a thrombotic event in 13 patients on the initial CT scan. Two of these 13 patients subsequently developed further thrombotic complications. Five of those 13 patients had a subsequent clinically significant major bleeding. In addition, two patients presented with isolated intracranial bleeds. Of the 11 patients who did not have baseline thrombotic events, one had a subsequent oropharyngeal hemorrhage. When analyzed by ROC analysis, the area under the curve for % time in intended anticoagulation range did not predict thrombosis or bleeding during the ECMO run (0.36 (95% CI 0.10-0.62); and 0.51 (95% CI 0.25-0.78); respectively). We observed a high prevalence of VTE and a significant number of hemorrhages in these severely ill patients with COVID-19 requiring veno-venous ECMO support.

Varicella-Zoster Virus Vasculitis: A Case Report of Enteric Reactivation with Vasculopathy Leading to Arterial Dissection, Stroke, and Subarachnoid Hemorrhage

Varicella-Zoster virus (VZV) reactivation is known to cause vascular remodeling and creating a hypercoagulable state, which can result in vasculopathy and subsequent thrombotic complications. Frequently, these complications involve intracranial and extracranial arteries leading to ischemic stroke, cerebral aneurysm formation, subarachnoid hemorrhage, cerebral vasculitis, and giant cell arteritis. Symptoms involving veins, such as cerebral sinus thrombosis, deep venous thrombosis, and pulmonary embolism, are rare. VZV reactivation is classically identified in neuronal ganglia that are derived from neural crest cells, primarily the dorsal root ganglia with the typical zoster dermatomal rash. In addition to the dorsal root ganglia, the enteric nervous system and adrenal glands are also of neural crest origin. However, VZV reactivation in these regions is rarely recognized due to a lack of cutaneous innervation. Enteric VZV reactivation can present with vague gastrointestinal symptoms instead of the typical zoster skin rash, which may be overlooked and delay the diagnosis. We report a rare case of VZV reactivation in the enteric nervous system and adrenal gland leading to vasculitis and subsequent Subarachnoid Hemorrhage (SAH), multifocal ischemic stroke, right Internal Carotid Artery (ICA) dissection, Deep Venous Thrombosis (DVT), and Pulmonary Embolism (PE).

Incidental De Novo Cerebral Microhemorrhages are Predictive of Future Symptomatic Macrohemorrhages After Surgical Revascularization in Moyamoya Disease.

Patients with moyamoya disease who develop incidental cerebral microhemorrhages (CMHs) on magnetic resonance imaging (MRI) have higher risk of developing subsequent symptomatic repeat macro hemorrhages. To evaluate the effect of surgical revascularization on development of de novo CMHs and assess its correlation with repeat hemorrhage rates and functional outcome in hemorrhagic onset moyamoya disease (HOMMD). We retrospectively reviewed a prospectively managed departmental database of all patients presenting with HOMMD treated between 1987 and 2019. The search yielded 121 patients with adequate MRI follow-up for inclusion into the study. In total, 42 preoperative CMHs were identified in 18 patients (15%). Patients presenting with preoperative CMH were more likely to develop de novo CMH after surgical revascularization. 7 de novo CHMs were identified in 6 patients (5%) on routine postoperative MRI at distinct locations from previous sites of hemorrhage or CMH. Symptomatic repeat macro hemorrhage was confirmed radiographically in 15 patients (12%). A total 5 (83%) of 6 patients with de novo CMHs later suffered symptomatic repeat macro hemorrhage with 4 of 5 (80%) hemorrhages occurring at sites of previous CMH. On univariate and multivariate analysis, de novo CMHs was the only significant variable predictive for developing repeat symptomatic hemorrhage. Development of delayed repeat symptomatic hemorrhage was prognostic for higher modified Rankin Score and therefore poorer functional status, whereas preoperative functional status was predictive of final outcome. De novo CMHs after surgical revascularization might serve as a radiographic biomarker for refractory disease and suggest patients are at risk for future symptomatic macro hemorrhage.

Assessment of the results of left ventricular reconstruction in combination of coronary atherosclerosis and diabetes mellitus

To study the effect of type 2 diabetes mellitus on changes of intracardiac haemodynamics and myocardial morphology in patients with ischaemic heart disease and a postinfarction aneurysm of the left ventricle before and after corrective operations on the heart. The study included 79 patients with ischaemic heart disease and a chronic aneurysm of the left ventricle (Group I - patients with type 2 diabetes mellitus (n=27), mean age 57.5±3.9 years, average number of shunts 2.9±0.6; Group II - patients without diabetes mellitus (n=52), mean age 55,3 ±7.1 years, average number of shunts - 2.7±0.3). In the preoperative period all patients were examined taking into account the functional class of angina pectoris, with the assessment of the left ventricular ejection fraction, end-diastolic index, end-systolic index, sphericity index. All patients underwent coronary artery bypass grafting and surgical restoration of the normal geometry of the left ventricle according to the Menicanty technique with the target end-systolic index of 60 ml/m2, during which 39 patients from both groups were subjected to intraoperative biopsy of the left ventricular myocardium and right atrial auricle. The intergroup analysis revealed no statistically significant differences in age, angina pectoris class, level of arterial pressure between the groups. Neither were there statistically significant differences in the echocardiographic parameters at the preoperative stage. In the postoperative period, we detected a significant decrease in the end-systolic and end-diastolic volumes of the left ventricle in both groups, with a statistically significant increase of the left ventricular ejection fraction observed only in non-diabetic patients. One year after the operation, such patients still continued to demonstrate more favourable parameters of the systolic and diastolic functions of the left ventricle. A detailed analysis with determining the delta of the alterations in the parameters revealed more significant positive dynamics in the postoperative period in patients with ischaemic heart disease not associated with type 2 diabetes mellitus. The obtained findings are indicative of negative dynamics of the course of chronic ischaemic heart disease aggravated by type 2 diabetes mellitus after reconstruction of the left ventricle. Macro- and microangiopathy in type 2 diabetes mellitus significantly deteriorated the myocardial trophism. Subsequent bleedings draw phagocytic cells into the myocardial stroma, thus adversely affecting the further prognosis and course of the disease, since we demonstrated that the presence of inflammatory infiltrate in the myocardial stroma is a key factor of unfavourable outcomes of surgical treatment of patients with ischaemic cardiomyopathy.

Prevalence, predictors and prognosis of incidental intracranial aneurysms in patients with suspected TIA and minor stroke: a population-based study and systematic review

IntroductionUnruptured intracranial aneurysms (UIAs) are common incidental imaging findings, but there are few data in patients with transient ischaemic attack (TIA)/stroke. The frequency of UIA might be higher due to...

Helicobacter pylori screening in clinical routine during hospitalization for acute myocardial infarction

Potent antithrombotic therapy has significantly improved prognosis for patients with acute myocardial infarction (AMI), however, at a price of increased bleeding risk. Chronic gastric infection with Helicobacter pylori (Hp) commonly causes upper gastrointestinal bleeding and is proposed as a risk factor for subsequent bleeding post AMI. The prevalence of active Hp in a current AMI population and the feasibility of Hp screening as part of routine clinical care are unclear. To determine the prevalence of active Hp infection in a contemporary AMI cohort and to establish the feasibility of Hp diagnosis as part of routine clinical MI care. Multicenter, prospective cohort study. Two university hospitals in Stockholm, Sweden. Patients admitted for AMI between November 6, 2019 and April 4, 2020. After written informed consent, Hp diagnostics was performed with a bedside urea breath test (Diabact, Mayoly Spindler) incorporated into routine care during the hospitalization period. Positive test for Hp infection. The primary outcome was the prevalence of Hp infection. Secondary aims included predictive factors in patient characteristics and outcomes which were obtained from linkage with national registries. Predefined subgroup analyses included stratification for proton pump inhibitor use and infarct type. Three hundred and ten consecutive AMI patients (median age 67; 23% female; 41% ST-elevation MI [STEMI]) were enrolled. Overall, the Hp prevalence was 20% (95%CI, 15.5-24.7). Hp positive status was significantly more common in smokers compared with nonsmokers (36% vs 21%, respectively; P < .05) and in patients presenting with STEMI compared with Non-STEMI (26% vs 15%, respectively; P = .02). The latter observation remained significant after multivariable adjustment. After exclusion of 97 subjects with current proton pump inhibitor use, the Hp prevalence was 24% (95%CI, 18.9-31.0). Active Hp infection is common in a contemporary AMI population and may represent a modifiable risk factor for upper gastrointestinal bleeding, which has been hitherto disregarded. Hp screening as part of clinical routine during AMI hospitalization was feasible. A future randomized trial is needed to determine whether routine Hp screening and subsequent eradication therapy reduces bleeding complications and improves prognosis. Question: Is Helicobacter pylori (Hp) infection sufficiently common in patients with acute myocardial infarction (AMI) to consider systematic screening, and can Hp diagnostics be performed during AMI hospitalization? In this multicenter prospective cohort study of 310 consecutive AMI patients, Hp infection was established in at least 20% of patients. Infected patients were significantly more likely to be active smokers and to present with ST-elevation MI. Meaning: Hp screening as part of clinical routine during AMI hospitalization was feasible. Given the high Hp prevalence detected, Hp diagnostics and eradication to reduce bleeding complications and to improve prognosis after AMI should be further investigated.

Serial measurement of biomarkers and the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in ENGAGE AF-TIMI 48

Abstract Background Patients with atrial fibrillation (AF) have progressive cardiac structural changes that may be manifest by biomarkers of myocardial injury and hemodynamic stress. Baseline values of hsTnT (high-sensitivity troponin T), and NT-proBNP (N-terminal pro-brain natriuretic peptide) are associated with stroke risk and GDF-15 (growth differentiation factor-15) is associated with bleeding risk in patients with AF. However, the variability of these biomarkers over time and their associations with stroke or systemic embolism events (S/SEE) and bleeding in patients with AF remain unclear. Purpose We examined whether patients with AF demonstrate detectable changes in these biomarkers over 12 months and whether such changes from baseline to 12 months are associated with the subsequent risk of S/SEE (hsTnT, NT-proBNP) and bleeding (GDF-15). Methods ENGAGE AF-TIMI 48 was a multinational randomized trial of the oral factor Xa inhibitor edoxaban in patients with atrial fibrillation and a CHADS2 score ≥2. We performed a nested prospective biomarker study in 6062 patients, analyzing hsTnT, NT-proBNP, and GDF-15 at baseline and 12 months. Event rates were estimated and displayed with annualized event rates after 12 months. Results Of 6062 patients, hsTnT was dynamic in 46.9% (≥2 ng/L change), NT-proBNP in 51.9% (≥200 pg/L change), GDF-15 in 45.6% (≥300 pg/L change) between baseline and 12 months. In addition, 7.7% in hsTnT shifted from low-&amp;gt;high categories, 9.4% in NT-proBNP from low-&amp;gt;high, 10.6% in GDF-15 from low-&amp;gt;high over 12 months (Figure). Elevated hsTnT (≥14 ng/L) and NT-proBNP (≥900 pg/L) either at baseline or at 12 months were independently associated with higher rates of subsequent S/SEE, and elevated GDF-15 (≥1800 pg/L) either at baseline or at 12 months were independently associated with higher rates of subsequent bleeding (P&amp;lt;0.001 for each). In a Cox regression model, the absolute changes in log2-transformed hsTnT and NT-proBNP were associated with increased risk of S/SEE (adj-HR, 1.75; 95% CI, 1.38–2.23; p&amp;lt;0.001, and adj-HR, 1.31; 95% CI, 1.11–1.55; p=0.002, respectively) and log2-transformed GDF-15 with bleeding (adj-HR, 1.42; 95% CI, 1.04–1.92; p=0.025). Analyzed in a categorical manner (Figure), patients who increased hsTnT or NT-proBNP between baseline and 12 months or had high hsTnT or NT-proBNP at both timepoints were at higher risk for S/SEE (adj-HR 1.87 and 1.50 for hsTnT; adj-HR 1.80 and 2.59 for NT-proBNP, respectively). Patients with persistently elevated GDF-15 appeared to be at higher risk for bleeding (adj-HR,1.35) (Figure). Conclusions Serial assessment of hsTnT, NT-proBNP, and GDF-15 revealed a substantial proportion of patients with AF had dynamic values. Patients with either persistently elevated or dynamic values were at higher risk of adverse clinical outcomes. Those biomarkers may play a role in personalizing preventive strategies in patients with AF based on risk. Change in biomarkers and event rate Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Pharma Development

Serum Macrophage Migration Inhibitory Factor Levels in Patients with Ischemic Stroke in Iraqi Populations

Background: Stroke is one of the leading causes of permanent disability worldwide. The most commoncause of stroke is the occlusion of blood circulation by a thrombus (or embolism) although it can also beproduced by the rupture of a vessel and subsequent bleeding in a certain region of the brain. Strokes can,therefore, be classified as ischemic or hemorrhagic.Aim: The present study was conducted to investigate whether serum MIF levels are associated with severityin patients with ischemic stroke.Method: A total of 40 patients with ischemic stroke were included in the study who were admitted tohospital from the period between March to August 2019, and other groups consist of 40 apparently healthyindividuals. Two blood sample were taken from each patients one during attack (within 24 hours) and theother sample during follow up (within 1-3 months) for serum concentration of MIF by ELISA technique.Results: Mean serum concentration of MIF in Ischemic stroke during attack (within 24 hours) wassignificantly higher than that of Ischemic stroke during follow up (within 1-3 months) and healthy controlgroup; 17.094±2.25ng/ml versus 12.83± 4.16ng/ml and 6.407± 3.33ng/ml respectively.

Resumption of anticoagulant therapy after major bleeding and recurrence of hemorrhagic complications in patients with atrial fibrillation with a high risk of stroke and thromboembolism (based on the results of 20 years of observation)

To analyze the frequency of resumption of anticoagulant therapy (ACT) after major and clinically significant bleeding among AF patients who received oral anticoagulants and were observed in the Department of clinical problems of atherothrombosis from 1999 to 2019 within the retro-prospective register Regata-2, and to search for clinical factors associated with recurrence of hemorrhagic complications among patients who resumed anticoagulant therapy after a bleeding episode. In cohort study of patients with high-risk AF with absolute indications for ACT we enrolled 290 AF patients (130 women and 160 men) aged 32 to 85 years (the average age was 65.188.89 years). During the follow-up period, 92 patients developed hemorrhagic complications, and 73 of them resumed ACT. 35 of the 73 patients who resumed ACT developed a relapse of major/clinically significant bleeding. The frequency of resuming ACT after the first hemorrhagic complication increased over time from 75% in the period from 19992003 to 90% in the period 20152019. We were not able to establish an exact relationship between the presence of concomitant pathology and the decision to resume the ACT after bleeding. The only reliable reason for refusing to resume the ACT was the patients categorical reluctance. Among patients who had recurrent hemorrhagic complications, the total score on the Charleson comorbidity scale was significantly higher (4.232.01vs3.521.43;p=0.0425). Patients with recurrent bleeding were significantly more likely to suffer from CKD with a decrease in GFR less than 60 ml/min/1.73 sq. m, and also had a history of erosive and ulcerative lesions of the gastrointestinal tract. There was also a significant Association of recurrent bleeding with the use of proton pump inhibitors. Subgroups of patients who switched from warfarin to taking direct oral anticoagulants after the first bleeding and subsequent recurrent bleeding did not differ in basic clinical characteristics from patients without bleeding after changing the anticoagulant. According to multiple regression analysis, NSAIDs showed a tendency to develop a relapse of B/C bleeding on the background of direct oral anticoagulants in patients who underwent GO on the background of warfarin therapy (b=0.4524,p=0.0530). During the 20-year follow-up, the frequency of all major and clinically significant bleeding was 2.6/100 patients-years, the frequency of first bleeding was 5.86/100 patients-years, while the frequency of repeated hemorrhagic complications was 7.06/100 patients-years. Patients with a high thromboembolic risk should receive anticoagulants, provided that the modifiable risk factors for bleeding are carefully corrected.

Incidence of Upper Extremity Deep Vein Thrombosis in Acute Leukemia and Effect on Mortality.

The cumulative incidence, risk factors, rate of subsequent venous thromboembolism (VTE) and bleeding and impact on mortality of isolated upper extremity deep vein thrombosis (UE DVT) in acute leukemia are not well-described. The California Cancer Registry, used to identify treated patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) diagnosed between 2009 and 2014, was linked with the statewide hospitalization database to determine cumulative incidences of UE DVT and subsequent VTE and bleeding after UE DVT diagnosis. Cox proportional hazards regression models were used to assess the association of UE DVT on the risk of subsequent pulmonary embolism (PE) or lower extremity deep vein thrombosis (LE DVT) and subsequent bleeding, and the impact of UE DVT on mortality. There were 5,072 patients identified: 3,252 had AML and 1,820 had ALL. Three- and 12-month cumulative incidences of UE DVT were 4.8% (95% confidence interval [CI]: 4.1–5.6) and 6.6% (95% CI: 5.8–7.5) for AML and 4.1% (95% CI: 3.2–5.1) and 5.9% (95% CI: 4.9–7.1) for ALL, respectively. Twelve-month cumulative incidences of subsequent VTE after an incident UE DVT diagnosis were 5.3% for AML and 12.2% for ALL. Twelve-month cumulative incidences of subsequent bleeding after an incident UE DVT diagnosis were 15.4% for AML and 21.1% for ALL. UE DVT was associated with an increased risk of subsequent bleeding for both AML (hazard ratio [HR]: 2.07; 95% CI: 1.60–2.68) and ALL (HR: 1.62; 95% CI: 1.02–2.57) but was not an independent risk factor for subsequent PE or LE DVT for either leukemia subtype. Isolated incident UE DVT was associated with increased leukemia-specific mortality for AML (HR: 1.42; 95% CI: 1.16–1.73) and ALL (HR: 1.80; 95% CI: 1.31–2.47). UE DVT is a relatively common complication among patients with AML and ALL and has a significant impact on bleeding and mortality. Further research is needed to determine appropriate therapy for this high-risk population.

S1517 Evaluating Obscure GI Bleeding in Pancreatitis

INTRODUCTION: Pancreatic pseudoaneurysm is a rare complication of pancreatitis and occurs in as many as 10% of cases and has a mortality rate ranging from 11-50%. In pancreatitis, pancreatic enzymes cause a necrotizing arteritis of surrounding vessels. Weakened arterial vessel architecture can result in bleeding into a pseudocyst causing rupture and subsequent massive bleeding into the gut lumen or peritoneal cavity. Herein we describe a case involving pancreatitis with pseudocyst complicated by a splenic artery pseudoaneurysm presenting with abdominal pain, anemia, and GI bleeding. CASE DESCRIPTION/METHODS: A 50 year old woman was transferred to our hospital system with acutely worsening abdominal pain and anemia. Her medical history was significant for morbid obesity and recent pancreatitis complicated by necrotizing pancreatitis with large pseudocyst and a right sided pleural effusion. On admission, vitals revealed BP 148/74, HR 79 bpm, RR 20 resp/min, T 36.6 °C, SpO2 100% on room air. Labs revealed WBC 6.58g k/uL, hgb 6.9 g/dL, plts 47, t bili 1.4, alk phos 107, ALT 18, AST 13. CT redemonstrated a moderately sized acute necrotic collection of the pancreas head and neck with no clearly defined wall enclosing the area. A repeat CT scan in 2 weeks was ordered to ensure maturity of the walled off necrosis prior to EUS guided drainage. Shortly after admission the patient developed hematemesis and maroon colored stools. EGD was positive only for moderate edema, erythema, and friability of the entire duodenum, however, a fistula between the pancreatic collection and the stomach/duodenum was not excluded. Ongoing hematemesis prompted an emergent CTA which was notable for a 1.4 cm distal splenic artery pseudoaneurysm (Figure 1). IR performed a successful coil embolization of the splenic artery (Figure 2 A-B). The patient tolerated the procedure well with no complications. DISCUSSION: There is significant mortality associated with rupture of a splenic artery pseudoaneurysm. A high index of suspicion for ruptured splenic artery pseudoaneurysm resulting in GI bleeding through fistulation is required in patients with acute and/or chronic pancreatitis who experience worsening abdominal pain, anemia, and/or overt GI bleed. Early identification and intervention of these pseudoaneurysms is paramount and can be emergently managed with arterial embolization or surgery to prevent life threatening complications.Figure 1.: CT angiogram showing a splenic artery pseudoaneurysm near tail of pancreas.Figure 2.: IR embolization. A) Pseudoaneurysm of the distal splenic artery. B) Successful microcoil embolization of a splenic artery across a pseudoaneurysm with no evidence of active extravasation after embolization with stasis of flow in the splenic artery.

Long-term outcomes of brainstem arteriovenous malformations after different management modalities: a single-centre experience

ObjectiveThe aims of this study are to clarify the long-term outcomes of brainstem arteriovenous malformations (AVMs) after different management modalities.MethodsThe authors retrospectively reviewed 61 brainstem AVMs in their institution between...

Overview of Upper Airway Management During COVID-19 Outbreak: Head and Neck Surgeon's Perspective: Comment.

Overview of Upper Airway Management During COVID-19 Outbreak: Head and Neck Surgeon's Perspective: Comment.

Validation of MTL30 as a quality indicator for colorectal surgery.

BackgroundValid indicators are required to measure surgical quality. These ideally should be sensitive and selective while being easy to understand and adjust. We propose here the MTL30 quality indicator which takes into account 30-day mortality, transfer within 30 days, and a length of stay of 30 days as composite markers of an uneventful operative/postoperative course.MethodsPatients documented in the StuDoQ|Colon and StuDoQ|Rectal carcinoma register of the German Society for General and Visceral Surgery (DGAV) were analyzed with regard to the effects of patient and tumor-related risk factors as well as postoperative complications on the MTL30.ResultsIn univariate analysis, the MTL30 correlated significantly with patient and tumor-related risk factors such as ASA score (p<0.001), age (p<0.001), or UICC stage (p<0.001). There was a high sensitivity for the postoperative occurrence of complications such as re-operations (p<0.001) or subsequent bleeding (p<0.001), as well as a significant correlation with the CDC classification (p<0.001). In multivariate analysis, patient-related risk factors and postoperative complications significantly increased the odds ratio for a positive MTL30. A negative MTL30 showed a high specify for an uneventful operative and postoperative course.ConclusionThe MTL30 is a valid indicator of colorectal surgical quality.