More than 1 million hip and knee total joint arthroplasties (THAs and TKAs) are performed annually in the United States. While major perioperative complications are relatively uncommon, they may substantially increase healthcare expenditures. The economic impact of individual complications, however, remains poorly defined. This study aimed to assess the effect of major complications on hospital costs and length of stay (LOS). This study analyzed data from 2,361,402 THA/TKA patients in the Premier Healthcare claims database (2006 to 2022). The exposure was the occurrence of major postoperative complications ( e.g. , cardiac, pulmonary, renal, gastrointestinal, infectious, central nervous system, and thromboembolic complications), evaluated individually and in clusters (two coinciding or three or more coinciding). The primary outcome was total cost of hospital stay. Generalized estimating equation models compared costs across groups, reported as percent change with 95% CI. Median costs without complications were $16,802 (interquartile range [IQR], $13,731 to $20,838) for TKA and $17,250 (IQR, $14,072 to $21,355) for THA. In TKA, the highest costs occurred with three or more complications ($35,477; IQR, $26,078 to $52,071), sepsis ($30,633; IQR, $21,748 to $44,530), and myocardial infarction ($28,908; IQR, $21,805 to $38,744). Multivariable models confirmed the greatest adjusted increases with 3 or more complications (+136%), sepsis (+88%), and myocardial infarction (+73%) at the patient level. Frequent complications such as renal failure (+26%), pulmonary complications (+23%), and intensive care unit admission (+61%) emerged as leading drivers of overall costs. LOS accounted for a substantial share of additional costs. In this large national cohort, perioperative complications substantially increased hospital costs, largely via prolonged LOS. Although sepsis, stroke, and myocardial infarction were most expensive per case, the overall healthcare burden was driven by frequent complications and resource use, including intensive care unit admission, acute renal failure, pulmonary complications, mechanical ventilation, and concurrent complications. These findings suggest that targeting frequent complications and resource intensive care processes may yield the greatest impact on reducing hospital expenditures in arthroplasty surgery.

Hemophilia A and hemophilia B are rare genetic disorders characterized by low plasma levels of coagulation factor VIII or factor IX, resulting in a bleeding tendency with a clinical severity proportional to the degree of the clotting factor deficiency. Although rare, hemophilia patients can paradoxically experience thrombotic events that complicate the clinical picture and the management by physicians operating at hemophilia treatment centers. Such thromboembolic complications, which can involve either the arterial or the venous districts, recognize various causes, including aging (due to the progress of care during the last three decades) and inherited and acquired (treatment-related) risk factors. These determinants often interact with each other to increase patients' susceptibility to thrombosis. In this narrative review, we summarize the current knowledge on the mechanisms, clinical presentation, and management of thrombotic complications in hemophilia patients.

Extended venous thromboembolism prophylaxis after bariatric surgery does not increase postoperative bleeding complications.

Deep vein thrombosis (DVT) is associated with potentially serious complications such as pulmonary embolism (PE) and postthrombotic syndrome. Superficial vein thrombosis (SVT) is also clinically relevant, as concomitant DVT and/or PE may already be present at initial diagnosis or may develop during follow-up. Which diagnostic and therapeutic steps are most relevant for dermatologists in clinical practice? Overview of the German S2k guideline and selected literature, supplemented by two case vignettes. DVT diagnostics are guided by clinical pretest probability (Wells score). In patients with low probability, anegative D‑dimer test can rule out DVT. In patients with high probability or apositive D‑dimer test, duplex compression ultrasonography is indicated. In confirmed DVT, prompt therapeutic anticoagulation is required, preferably with direct oral anticoagulants, usually for ≥ 3months depending on provocation status and risk of recurrence. In SVT, thrombus length and proximity to the deep venous junction determine management. SVT ≥ 5 cm, marked symptoms, or relevant risk factors warrant 45days of anticoagulation (e.g., fondaparinux 2.5 mgs.c. once daily). SVT < 3 cm from the junction or with progression into the deep venous system requires therapeutic-dose anticoagulation analogous to DVT. Short-segment distal SVT can often be managed symptomatically. Structured risk stratification, focused diagnostic work-up, and guideline-concordant therapy are essential to prevent thromboembolic complications.

Several studies have questioned the efficacy of the standard perioperative low-molecular-weight heparin (LMWH) dose in preventing venous thromboembolic complications and have recommended dose escalation to a weight-based regimen. Other studies, however, have cautioned that higher anticoagulation regimens may be associated with an elevated risk of wound complications and periprosthetic joint infections. This dichotomy underscores the need for identifying the safety of the thromboprophylaxis approach in surgical settings. To analyze the effect of LMWH regimen modification to weight-based with dose administration the morning of surgery on the incidence of early (within 3 months) postoperative prosthetic joint infection (PJI) in patients with hip hemiarthroplasty (HA). At our multi-hospital health system, LMWH dose escalation to the weight-based regimen without holding the morning dose on the day of surgery started in mid-June 2019. We have reviewed all cases of HA performed at our institution from 2007 to 2024 and divided them into two groups: Before and after the dose modification protocol. The number of early PJI cases has been studied in each group. A total of 33 HA early PJI cases fit the study selection criteria and were included in this study. Of the 1517 cases performed before the new protocol, 19 cases (1.25%) had early infections, while within the modified protocol (weight-based with morning dose), 14 cases (1.49%) had infections out of a total of 937 cases. The difference between the two groups was found to be not statistically significant (z = -0.5, P = 0.6). Our results indicate that LMWH dose escalation to a weight-based regimen without withholding the LMWH morning dose on the day of surgery did not lead to a significant change in the rate of early PJI in this study. A larger, multicenter study would be ideal for providing stronger evidence.

Aims: To describe a severe case of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) associated with sequential cephalosporin and vancomycin exposure, and to highlight the diagnostic challenges and hematologic and thromboembolic complications encountered during the clinical course. Place and Duration of Study: Central Maine Medical Center, Lewiston, Maine, USA; September 2025 to November 2025. Methodology: Clinical data were obtained through detailed review of the patient’s medical records, including medication timeline, laboratory trends, imaging studies, histopathology reports, and clinical response to therapeutic interventions. Serial eosinophil percentages and absolute neutrophil counts were analyzed in relation to antibiotic exposure and treatment milestones. Diagnostic probability was assessed using the RegiSCAR scoring system, and drug causality was evaluated using the World Health Organization–Uppsala Monitoring Centre (WHO–UMC) causality assessment method. Results: A 45-year-old woman with transfusion-dependent chronic anemia, cognitive delay, and chronic kidney disease developed a progressive morbilliform rash, facial edema, marked eosinophilia, and profound neutropenia following prolonged exposure to intravenous ceftriaxone and oral cefdinir for a complicated urinary tract infection secondary to an obstructive renal stone. Brief exposure to vancomycin was followed by rapid clinical worsening, raising concern for immunologic amplification of an evolving hypersensitivity reaction. Her course was further complicated by acute deep vein thrombosis and pulmonary embolism. Skin biopsy demonstrated findings consistent with a drug-induced hypersensitivity reaction. Initiation of systemic corticosteroids resulted in rapid improvement in both cutaneous and hematologic abnormalities. Discussion: This case underscores the importance of early recognition of DRESS in patients receiving sequential antibiotic therapy. The clinical timeline supports cephalosporins as the likely primary sensitizing agents, with vancomycin acting as a potential immunologic accelerator. Concurrent exposure to two cell wall synthesis inhibitors may also have contributed to immune activation in this case. Both cephalosporins and vancomycin target bacterial cell wall formation but are independently associated with severe delayed hypersensitivity reactions. Sequential exposure may increase antigenic stimulation and immune dysregulation in susceptible individuals, potentially contributing to clinical severity. Prompt initiation of systemic corticosteroids may be critical in reversing severe hematologic and systemic complications.

Gynecologic cancer is a major global health burden, and improvements in screening, surgical techniques, and systemic therapies have significantly prolonged survival. As a result, cardiopulmonary disease has emerged as a leading non-cancer cause of morbidity and mortality among gynecologic cancer survivors. Obesity, which is highly prevalent in this population, substantially increases cardiopulmonary risk by contributing to metabolic syndrome, cardiovascular disease, chronic inflammation, and reduced cardiopulmonary reserve. This narrative review summarizes current evidence on the epidemiology, pathophysiological mechanisms, and clinical spectrum of cardiopulmonary complications in obese patients with gynecologic malignancy. We review the contribution of obesity-related metabolic and endothelial dysfunction, cancer-associated hypercoagulability, and treatment-related toxicities, with particular emphasis on complications arising from surgery, chemotherapy, and radiotherapy. Epidemiologic data demonstrate a markedly increased burden of cardiovascular and pulmonary disease in obese gynecologic cancer patients, including higher rates of myocardial injury, heart failure, venous thromboembolism, and postoperative respiratory complications. Surgical treatment, although central to oncologic management, imposes substantial cardiopulmonary stress, placing obese patients at heightened perioperative risk. Future studies should focus on preoperative risk stratification, optimization of obesity-related comorbidities, and multidisciplinary perioperative management, including enhanced recovery pathways, as well as appropriate use of high-dependency or intensive care monitoring to reduce morbidity and improve both oncologic and long-term non-oncologic outcomes in this population.

Introduction Trauma, the leading cause of mortality in young, results in significant socio-economic costs. The rate of avoidable deaths remains high mainly due to the underestimation of the initial severity of injuries. Currently, indices derived from hemogram such as RDW, NLR, and PLR show promising prognostic potential. This study aims to evaluate these indices in polytrauma patients. Materials and methods This is a retrospective and analytical observational study conducted in the anesthesia and intensive care unit of Sahloul Teaching Hospital (Sousse, Tunisia) over a four month period. Patients admitted between January 2022 and March 2024, with an ICU stay exceeding 5 days were included. Excluding criteria were conditions interfering with leukocytes or recent transfusion. Data were collected via a pre-established form covering sociodemographic parameters, trauma mechanisms, severity assessment, management, hematological indices, and patient outcomes. Results Among the 553 polytrauma patients admitted, 384 were included in the study. The mean age was 44.9 years with a male predominance (sex ratio of 3.4). Road traffic accidents were the most frequent mechanism (78.1%). Thoracic (86.7%) and cranial injuries (57.6%) were the most common. The mortality rate was 16.9%. Upon admission, the SAPS II and APACHE II scores had the best predictive capacities for mortality (AUC of 0.819 and 0.817). Among hematological indices, RDW was the most performant with AUCs &amp;gt; 0.7. The SAPS II and APACHE II had AUC ≥ 0.7 for predicting infectious complications, while for thromboembolic complications; no index reached an AUC ≥ 0.7. Conclusion Hematological indices such as the RDW have prognostic value in trauma. Their integration to preexisting scores may improve the assessment of polytrauma patients.

Dual antiplatelet therapy (DAPT) is critical for safe flow diversion (FD), yet unlike the extensive coronary literature, FD remains less common and lacks strong evidence to guide DAPT choice. Clopidogrel's variable responsiveness has pushed clinicians towards platelet function testing and more potent agents. In 2023, our institution adopted universal prasugrel-based DAPT, and this study compares outcomes across clopidogrel, ticagrelor, and prasugrel. We present a retrospective review of all intracranial aneurysms treated with the Pipeline Embolization Device (PED) between July 2021 and July 2024 using a prospectively maintained database. Primary outcomes were thromboembolic and hemorrhagic complications, occlusion rates, and functional outcomes (modified Rankin Scale (mRS)). Secondary analyses were conducted based on surface modification. A total of 243 FD procedures were performed in 229 patients (mean age 55.2 years; 84.3% women) treating 265 aneurysms. DAPT regimens included ticagrelor (38.7%), clopidogrel (31.7%), and prasugrel (29.6%). At median 12-month follow-up, 97.8% of patients achieved favorable functional outcomes (mRS ≤2), with no differences between regimens. No significant differences in aneurysm occlusion (complete/near-complete in 86.4%) were found between the DAPT regimens. Thromboembolic (4.1%) and hemorrhagic (4.9%) complications did not differ significantly; notably, all intracranial hemorrhages occurred in ticagrelor-treated patients. Retreatment rates were significantly higher in non-surface-modified versus surface-modified PEDs (8.3% vs 0.9%, P=0.01). Prasugrel showed comparable safety and occlusion outcomes relative to clopidogrel and ticagrelor. Our findings underscore a critical gap in the evidence base and highlight the urgent need for multicenter registries and prospective trials to establish standardized, data-driven DAPT protocols for intracranial FD.

Oral anticoagulation in patients with atrial fibrillation in Primary Care in Spain. Rationale, design and baseline data of the RACOVIR study.

Tranexamic acid (TXA) is widely used across surgical specialties to reduce perioperative blood loss, yet its specific role in hepatic resection remains unclear. This meta-analysis, performed according to PRISMA guidelines, evaluated the efficacy and safety of TXA in liver surgery. Outcomes of interest included mean intraoperative blood loss, the proportion of patients receiving transfusion, and mean units of red blood cells transfused intraoperatively and postoperatively. Secondary endpoints included postoperative mortality, thromboembolic events, and hospital length of stay. Of 36 articles assessed, nine studies met eligibility criteria for inclusion. TXA use was associated with a statistically significant reduction in intraoperative blood loss (SMD - 0.18; 95% CI, - 0.28 to - 0.09; p < 0.01), although transfusion requirements did not differ significantly between groups (RR 0.81; 95% CI, 0.47-1.38; p = 0.44). Interpretation of these findings is limited by substantial heterogeneity among included studies (I² = 82%). While TXA appears effective in reducing intraoperative bleeding, its use may confer a higher risk of postoperative thromboembolic complications, suggesting that TXA administration during hepatic resection should be selective and individualized rather than routine.

Venous thromboembolic (VTE) complications contribute substantially to perioperative morbidity and mortality. The decision for mechanical and/or chemo-prophylaxis is currently based on VTE risk assessment models since conventional laboratory assays of coagulation usually fail to detect changes indicating hypercoagulability. Rotational thromboelastometry is a novel assay of coagulation, that it could potentially be used in objectively selecting patients at risk for VTE, who should indisputably undergo prophylaxis. We evaluated the association of conventional and novel assays of coagulation and VTE risk. VTE risk was preoperatively assessed in 45 patients scheduled for endoscopic, open and laparoscopic urologic surgery, including transurethral resection of prostate, transurethral resection of bladder tumor, endoscopic vesical or ureteral stone lithotripsy, open prostatectomy, open cystectomy and urinary diversion, open or laparoscopic radical or partial nephrectomy, between March 2021 and October 2022, using three different risk assessment models (RAMs): the European Association of Urology (EAU) RAM, the American Urological Association (AUA) RAM, and the Caprini model. Patients under antiplatelet or anticoagulation agents were excluded. Patients' coagulation profile was determined by measuring PT, fibrinogen, aPTT, and rotational thromboelastometry analysis. For rotational thromboelastometry analysis, extrinsic rotational thromboelastometry and fibrinogen rotational thromboelastometry were examined in every patient. Statistical analysis was performed with ANOVA test and χ2 test. Mean values of all rotational thromboelastometry variables did not vary significantly among different EAU VTE categories. In extrinsic rotational thromboelastometry assessment, a significant difference was observed in the mean values of the Clotting time (CT) between the different risk groups based on AUA RAM. In the comparison between the risk groups defined based on the Caprini score, statistically significant differences were observed in the extrinsic rotational thromboelastometry clot formation time (CFT). In fibrinogen rotational thromboelastometry analysis, significant differences were identified in the clot amplitude after five minutes (A5) and maximum clot firmness (MCF) indices between the AUA risk groups, along with a significant difference in the mean clot formation rate (CFR) value between the risk groups defined based on the Caprini score. Rotational thromboelastometry can provide a detailed evaluation of the hemostatic status in patients undergoing urologic surgery that can be used as an adjunct to the VTE risk assessment models and thus, help to offer prophylaxis on a rather personalized basis. Future studies should assess the utility of thromboelastometry in identifying patients at high risk for VTE after major urological procedures.

We report a case of hypereosinophilia syndrome (HES) due to Wuchereria bancrofti infection presenting with a deep venous thrombosis in a previously healthy adult male. The patient presented with a 3-mo history of low-grade intermittent fever and an acute onset of swelling of the left lower limb. Laboratory investigations revealed marked eosinophilia with a peak absolute eosinophil count of 8194 cells/µl and ultrasound evidence of extensive left iliofemoro-popliteal thrombosis. Our workup for secondary causes confirmed W. bancrofti antigen positivity, following which antiparasitic therapy was promptly initiated and a reduction in eosinophil count was noted. Our case highlights the importance of recognition of filariasis as a cause of reactive HES in an endemic region and recognising the thromboembolic complications that may arise from it.

Recently, increasing studies have reported that Parkinson's disease (PD) may experience an increased incidence of venous thromboembolic events and complications for patients who undergo surgery. We aimed to explore the actual prevalence and risk factors of venous thromboembolism (VTE) for patients with PD as well as its influence on the operative outcomes. We searched PubMed, Embase, and Cochrane library up to 1 May 2025 for observational studies exploring the risk factors of venous thromboembolic events or comparing the frequency of venous thromboembolic events and complications in PD and non-PD patients. The primary outcomes were the risk factors for and incidence of venous thromboembolic events in patients with PD. The secondary outcome was comparing the complications or adverse events between PD and non-PD patients. Two reviewers screened the titles and abstracts of searched records for qualified reports according to the including and excluding criteria and extracted the data independently. Finally, we totally identified 17 observational studies involving 760380 patients for the present analysis. Our pooled results indicated that when compared to patients without PD, patients with PD had significantly higher incidence of venous thromboembolic events, including VTE (OR 1.35, 95% CI 1.11-1.65), deep vein thrombosis (DVT; OR 1.56, 95% CI 1.24-1.96) and pulmonary embolism (PE; OR 1.54, 95% CI 1.20-1.96), respectively. In addition, when comparing DVT (+) and DVT (-) in patients with PD, female patients with PD had a higher frequency of DVT (OR 2.45, 95% CI 1.47-4.06), patients with lower Barthel index [mean difference (MD) -11.5, 95% CI -20.85-2.15] and those with smaller abdominal circumference (MD -7.13 cm, 95% CI -9.99 to -4.26), respectively. When compared to PD patients without DVT, PD patients with DVT had significantly higher average real variability of systolic blood pressure (MD 3.2mmHg, 95% CI 0.75-5.65), lower heart rate at admission (MD -3.32bpm, 95% CI -6.58 to -0.06), higher D-dimer (MD 2.14µg/mL, 95% CI 1.20-3.08), and longer duration of illness (MD 22.68months, 95% CI 6.77-38.58), respectively. Our pooled analysis also indicated that PD increased complications and adverse events of patients receiving operation. Patients with PD were more prone to venous thromboembolic events and had an increased incidence of intra- and post-operative complications. Though several risk factors of DVT were identified for Parkinson's patients, they need further demonstration with specific researches in the future. Greater vigilance should be exercised to make an informed decision regarding patient care and preferred healthcare setup for patients with PD.

Background: Unfractionated heparin (UFH) is routinely administered during transcatheter aortic valve replacement (TAVR) to prevent thromboembolic complications. However, there are no clear evidence-based guidelines defining optimal heparin dosing or target activated clotting time (ACT) values. This study aimed to evaluate the association between intraprocedural UFH dosing, ACT values, and peri-procedural stroke risk in the overall population of patients undergoing TAVR, with a prespecified stratified analysis according to body mass index (BMI ≥ 30 vs. <30 kg/m2). Methods: This analysis enrolled consecutive individuals with severe aortic stenosis (AS) who were treated with TAVR using either balloon-expandable or self-expanding valves. The primary outcome was the occurrence of stroke during the periprocedural period in the overall population and according to BMI (<30 vs. ≥30 kg/m2). Secondary endpoints included periprocedural parameters, clinical outcomes (in-hospital and 1-year mortality), and safety outcomes. Subgroup analysis was performed to assess stroke risk according to ACT values. Patients with atrial fibrillation or receiving chronic oral anticoagulation were excluded. Results: A total of 1045 patients underwent TAVR between 2022 and 2024, including 827 with BMI < 30 and 218 with BMI ≥ 30. The study population had a mean age of 82 ± 6 years, and 56% of patients were male. In the overall study population, the mean heparin dose was 47 U/kg and the mean ACT value was 218 s. Patients with lower BMI received higher heparin doses (50 vs. 40 U/kg, p < 0.01) and had higher ACT values (221 vs. 208 s, p < 0.01). Protamine use was low and similar between groups. Periprocedural stroke rates were low overall (1.1%) and comparable between study groups (1.2% vs. 0.9%, p = 0.71). One-year mortality was also similar (3% vs. 4%, p = 0.53), with no significant differences in other safety outcomes. Subgroup analysis by ACT (≤250 vs. >250 s) showed no difference in stroke rates (1% vs. 1.5%, p = 0.60). Conclusions: In this single-center cohort, differences in heparin dosing and ACT values were not associated with differences in peri-procedural stroke or overall procedural outcomes. However, given the low number of stroke events, these findings should be interpreted cautiously. Prospective randomized studies are needed to define optimal anticoagulation strategies during TAVR.

INTRODUCTION . The correct use of anticoagulants in patients with severe traumatic brain injury is a difficult task for a practicing physician. On the one hand, their irrational use may play a negative role in the development of late intracranial hemorrhages in the acute period of traumatic brain injury. On the other hand, the risk of thrombotic complications in this group of patients is also high, so the need for correction of the hemostasis system is beyond doubt. AIM . To determine the timing of the start of taking anticoagulants in patients with a high risk of delayed parenchymal hemorrhagic brain damage in the acute period of traumatic brain injury. MATERIALS AND METHODS . The inpatient records of 81 patients with severe traumatic brain injury who were treated at the Clinical Emergency Hospital in Tver from 2016 to 2020 were studied. RESULTS . As a result of statistical processing of data from laboratory tests (coagulogram, platelet count in the general blood test), it was found that patients in the group with delayed parenchymal brain damage have a tendency to hypocoagulation and thrombocytopenia. The peak of hypocoagulation occurs on the 9–14th day. CONCLUSION . In patients with a high risk of delayed parenchymal hemorrhagic brain damage, it is advisable to prescribe anticoagulants on day 14, and if the patient has a high risk of thromboembolic complications, then anticoagulants are recommended to be prescribed as early as 4 days after the injury.

Despite advances in treatment for intracranial aneurysms, recurrence remains a clinical challenge. Studies have suggested associations between treatment modality, aneurysm morphology, and recanalization risk, but comprehensive evaluation of these factors and their relationships is limited. The goal of this study was to evaluate the role of aneurysm location and packing density (PD) as predictors for recurrence. This is a retrospective cohort study where records of patients who underwent coiling for intracranial aneurysms from 2013 to 2023 from a single institution were reviewed. Recurrence was defined as worsening of angiographic aneurysm occlusion status. Demographics, aneurysm characteristics, clinical outcomes, and follow-up data were recorded. Analysis was performed in RStudio. A total of 505 were included; 195 aneurysms were ruptured (38.6%). The most frequent locations were anterior communicating artery (163), internal carotid artery (85), basilar (76), posterior communicating artery (63), and middle cerebral artery (43). Mean PD was 23.3%, with 109 recurrences (21.6%) and 76 retreatments (15.1%); 31 patients (6.1%) experienced thromboembolic complications. In multivariable analysis, incomplete occlusion (Raymond-Roy [RR] Grades II-III), presence of an incorporated branch vessel, and higher size ratio independently predicted recurrence, whereas male sex and age older than 75 years were protective. Size ratio also predicted retreatment, while stent-assisted coiling reduced the likelihood of retreatment. Although higher PD was associated with better immediate RR Grade, PD (including extremes <15% vs >30%), aneurysm volume, and anatomical location were not independently associated with recurrence or retreatment after adjustment. In this modern series, the immediate RR Grade, not PD or anatomical site, drove long-term durability; PD improved the index occlusion but had no independent association with recurrence after adjustment. Incorporated perforators independently increased recurrence risk, and stent assistance reduced retreatment. These data reframe technical priorities toward achieving complete occlusion safely, especially in perforator-bearing lesions, rather than chasing PD thresholds alone in the contemporary era.

Logistic regression model for predicting higher hospital costs in ICU-COVID patients during the pandemic: Results from a tertiary hospital.

Impact of different preferred functional outcomes on the results of the pre-hospital antifibrinolytics for traumatic coagulopathy and hemorrhage (PATCH-trauma) trial.

Limb occlusion pressure versus standard tourniquet pressure in total: A prospective comparative study.