Tract Bleeding Research Articles

Ventricular Catheter Tract Hemorrhage as a Risk Factor for Ventriculostomy-Related Infection.

Ventriculostomy-related infection (VRI) is a feared complication of external ventricular drain (EVD) placement. Although many contributing factors to VRI have been examined, little is known whether there is an association between ventriculostomy-related catheter tract hemorrhage (VCTH) and VRI. To evaluate risk factors for VRI and assess possible correlations with VCTH. We performed a retrospective analysis of patients with EVD placement in a neurocritical care unit between 2011 and 2015. VRI was defined as clinical signs of infection with a positive cerebrospinal fluid gram stain and isolation of cerebrospinal fluid culture. VCTH was diagnosed by computed tomography immediately after EVD insertion. A total of 247 patients with EVD were identified during the 5-yr study period. An association between VCTH and gram-negative VRI was identified (P=.02). Ten percent (25 of 247 patients) developed a VRI, and 7% (18 of 247 patients) had a VCTH. Of the 25 patients with VRI, 20% (n=5) had a VCTH, compared to 6% (n=13) of 222 patients who had an EVD placed but did not develop VRI. There were no significant differences in demographic and clinical factors except for multiple EVD insertions (P<.00001), EVD duration (P<.001), and hospital length of stay (P<.001). VCTH is a potentially significant risk factor for VRI. Further analysis will be needed to confirm the strength of this association, and to delineate the possible mechanisms by which tract hemorrhage may serve as a nidus for bacterial penetration into the central nervous system.

Ectopic Ascending Colonic Variceal Bleeding Treated with Balloon-Occluded Retrograde Transvenous Obliteration in a Decompensated Liver Cirrhosis Patient—A Hepatology Perspective

Ectopic colonic varices development from liver cirrhosis and portal hypertension is uncommon. They are part of the spectrum of portal hypertensive colopathy. Colonic variceal bleeding remains a rare cause of lower gastrointestinal tract (GI) bleeding. Due to the paucity of cases, there are no well-established conventional treatments for bleeding colonic varices. Different treatments have been reported. Here, we report a case of a 55-year-old gentleman, with a history of alcoholic liver cirrhosis, presenting with severe lower GI bleeding and symptomatic anaemia. An esophagogastroduodenoscopy revealed large esophageal varices with high-risk bleeding stigmata requiring endoscopic variceal ligation. A cross-sectional computed tomography scan showed colonic portosystemic shunts. In light of this and that the severe lower GI bleeding seemed out of proportion to the esophageal varices seen on upper endoscopy, an urgent unprepped colonoscopy was performed which revealed possible bleeding diverticula disease which required endoscopic mechanical hemoclip therapy. However, despite this, patient had recurrence of lower GI bleeding prompting a second colonoscopy. This relook colonoscopy showed ectopic ascending colon varices with high-risk bleeding stigmata. High-dose intravenous vasoactive agent somatostatin (500 mcg/hour) and subsequently terlipressin (2 mg every 4 hours) were used. The patient subsequently underwent successful balloon-occluded retrograde transvenous obliteration (B-RTO) and sclerotherapy. The non-selective beta-blocker (NSBB) carvedilol was started and bridged together with the vasoactive agent until stabilisation of portal hypertension. This difficult case illustrates the dynamic nature of portal hypertensive bleeding. It also highlights the presence of confounding non-variceal pathology complicating diagnosis of portal hypertensive colonic variceal bleeding, and that ectopic ascending colonic variceal bleeding can be treated successfully with B-RTO and sclerotherapy, with meticulous titration of high-dose vasoactive agents and NSBB, in a decompensated alcoholic liver cirrhosis patient.

Goodpasture syndrome as a rare cause of massive respiratory tract hemorrhage

AbstractIn this study, the cases of a patient with Goodpasture syndrome (also referred to as anti-glomerular basement membrane disease) and a patient with the morphological features of Goodpasture syndrome or Goodpasture-like syndrome found in a histopathological examination are described. In both cases the course of the disease was atypical, with a massive respiratory tract hemorrhage being the most significant symptom. Accordingly, the presented patients were treated surgically. Furthermore, the paper described diagnostic difficulties in identifying the cause of the hemorrhage. Finally, the importance of histopathological examination in the diagnosis of Goodpasture syndrome and the Goodpasture-like syndrome with atypical course is emphasized.

Safety and effectiveness of inguinal hernia repair in patients with liver cirrhosis: a retrospective study and literature review.

Inguinal hernia is a common feature of decompensated liver cirrhosis and a frequent cause of life-threatening complications. The traditional treatment of inguinal hernia in patients with liver cirrhosis includes non-operative management; however, emerging data suggest elective surgical repair as a preferable approach. Therefore, we aimed to assess the outcomes of inguinal hernia repair in patients with liver cirrhosis and describe their clinical characteristics. In this retrospective study, we included a total of 28 consecutive patients with liver cirrhosis who underwent inguinal hernia repair between March 2000 and May 2019 at the First People's Hospital of Xiaoshan, Hangzhou, China. We also reviewed the literature on inguinal hernia repair in patients with liver cirrhosis. Emergency surgery for complicated hernia was performed in 17.9% of the study patients. Two patients developed major complications including wound hematoma in 1, who required reoperation, and gastrointestinal tract hemorrhage in the other patient, who required blood transfusion. Further, minor complications developed in 6 patients, including wound seroma in 1 and scrotal swelling in 5. Emergency hernia repair was found to be associated with a higher complication rate than elective surgery in patients with liver cirrhosis. Elective surgery for inguinal hernia repair in patients with liver cirrhosis appears to be successful and might be associated with a lower complication rate than emergency surgery. Inguinal hernia repair is recommended for patients with liver cirrhosis to prevent the development of life-threatening complications.

Trans-arterial embolization of malignant tumor-related gastrointestinal bleeding: technical and clinical efficacy

BackgroundGastrointestinal (GI) tract bleeding is a major cause of mortality among patients with GI malignancies. We aimed to assess the technical and clinical efficacy of trans-arterial embolization (TAE) as a symptomatic treatment of tumor-related GI bleeding. This study was conducted for patients with GI bleeding secondary to histopathologically proven different GI malignancies. Fourteen patients underwent trans-arterial embolization. Patients were followed up clinically for any complications or episodes of recurrent bleeding.ResultsFourteen patients were included (9 males and 5 females) with mean age 55.5 years (range 42–69 years). All procedures were technically successful with post-procedural hemorrhage control and no immediate complication. The 30-day post-procedural clinical success rate was 78.4%. Three repeated clinically successful TAE sessions were done for recurrent bleeding. The median post-procedural follow-up duration was 241 days. The 30-day mortality rate was 7.1%, while the overall mortality rate was 35.7%.ConclusionTrans-arterial embolization of tumor-related GI bleeding controlled hemorrhage with acceptable clinical success rate and without complication in this small group of patients.

Novel IVS7+1G>T mutation of life-threatening congenital factor VII deficiency in neonates: A retrospective study in China.

In neonates, congenital factor VII deficiency (FVIID) is characterized by central nervous system bleeding and gastrointestinal hemorrhage, often resulting in poor prognosis and high mortality.To improve understanding of FVIID in neonates in Asia, we retrospectively analyzed the clinical manifestations, diagnosis, treatment, clinical course, and genetic diagnosis of 2 cases of neonatal FVIID in the Department of Neonatology, Guangzhou Women and Children's Medical Center, Guangzhou, China, from January 2007 to December 2017 and performed a review of the relevant literature.Both neonates were female and presented with severe gastrointestinal tract and intracranial hemorrhage. The laboratory findings were characterized by repeated and non–vitamin K1-dependent prolonged of the prothrombin time (PT), Factor VII (FVII) activity was 1.5% and 3%, respectively. Both neonates died of severe intracranial hemorrhage, at 31 days and 6 months after birth, respectively. Gene sequencing results revealed a homozygous mutation in the FVII gene splice site (IVS7+1G>T) in both cases. Upon review of relevant literature published since 1996, we identified 19 cases of neonatal FVIID. The patients were full-term neonates with onset of symptoms mostly within 7 days after birth (73.7%), which included gastrointestinal bleeding (blood stool, vomiting blood; 31.6%), nervous system signs (drowsiness, convulsions, poor response; 26.3%), severe intracranial hemorrhage (84.2%), significantly prolonged PT with significantly decreased FVII activity (89.5%), high mortality, and disability (68.4%). Gene sequencing was performed in 9 of the 19 children evaluated and revealed a mutation in the FVII gene in all cases.FVIID can be clinically diagnosed based on the presence of prolonged PT that is difficult to correct and significantly decreased FVII activity (≤5%). As mutations in some sites are associated with severe bleeding, genetic diagnosis represents a useful tool for prenatal diagnosis of FVIID. In brief, we should pay great attention to the FVIID onset of the neonatal period, although it is rare but result in life-threatening bleeding with poor prognosis.

Recurrent pre-retinal haemorrhages associated with coagulation factor VII deficiency

Abstract The case concerns a 20 year-old woman with a sudden visual loss in her left eye. In the fundus examination, a focal pre-retinal haemorrhage was observed in the superior temporal vascular branch with accompanying vitreous haemorrhage. There was a favorable spontaneous outcome. Eighteen months later, she presented with a new visual loss in the same eye, showing a sub-hyaloid pre-macular haemorrhage that was satisfactorily drained by hyaloidotomy using a Nd-YAG laser. The patient had also presented with an upper digestive tract haemorrhage and menorrhagia. A haemostasis study was performed that showed a coagulation factor VII deficiency. This is a very uncommon disorder that has not been previously described in association with the appearance of pre-retinal haemorrhages.

Modeling determinants of time-to-circumcision of girls: a comparison of various parametric shared frailty models

Female genital mutilation (FGM), also known as female genital cutting or female circumcision, is one of the deeply rooted traditional practices, in which the external female genital organ is either partially or totally removed for non-medical reasons. In Ethiopia, FGM is widespread across the majority of regions and ethnic groups, having the highest national prevalence that leads them to various complications such as immediate urinary and genital tract infection, pain and hemorrhage, complications in childbirth and social, psychological and sexual complications. This study aimed to model and investigate the potential risk factors of time-to-circumcision of girls in Ethiopia using parametric shared frailty models where regional states of the girls were used as a clustering effect in the models. The data source for the analysis was the 2016 EDHS data collected from January 18, 2016 up to June 27, 2016 from which the survival information of 2930 girls on age at circumcision obtained. The gamma and inverse Gaussian shared frailty distributions with Exponential, Weibull and log-logistic baseline models was employed to analyze risk factors associated with age at circumcision using socio-economic and demographic factors. All the fitted models were compared by using AIC and BIC values from simulation study and actual dataset. The result revealed that about 22.4% of girls were circumcised and 77.6% were not circumcised. The median age at circumcision was 3 years. Based on AIC and BIC values from simulation experiment and graphical evidences, log-logistic model with inverse Gaussian shared frailty distribution preferred when compared with other models for age at circumcision dataset. The clustering effect was significant for modeling the determinants of time-to-circumcision of girls dataset. Based on the result of log-logistic inverse Gaussian shared frailty model, mothers and fathers educational level, place of residence and religion of parents were found to be the most significant determinants of age at circumcision of girls. The estimated acceleration factor for the group of mothers who had secondary and higher educational level were highly prolonged age at circumcision of girls by the factor of ϕ = 3.119 and ϕ = 3.933 respectively. The log-logistic model with inverse Gaussian shared frailty distribution described age at circumcision of girls better than other models and there was heterogeneity between the regions on age at circumcision. Improving parents access to education would be an important way approach for preventing girls’ circumcision.

Hemorragias prerretinianas de repetición asociadas a déficit del factor VII de la coagulación

The case concerns a 20 year-old woman with a sudden visual loss in her left eye. In the fundus examination, a focal pre-retinal haemorrhage was observed in the superior temporal vascular branch with accompanying vitreous haemorrhage. There was a favourable spontaneous outcome. Eighteen months later, she presented with a new visual loss in the same eye, showing a sub-hyaloid pre-macular haemorrhage that was satisfactorily drained by hyaloidotomy using a Nd-YAG laser. The patient had also presented with an upper digestive tract haemorrhage and menorrhagia. A haemostasis study was performed that showed a coagulation factor VII deficiency. This is a very uncommon disorder that has not been previously described in association with the appearance of pre-retinal haemorrhages.

Comparison of Efficiency of TACE plus HIFU and TACE alone on Patients with Primary Liver Cancer.

To compare efficiency of trans-arterial chemo-embolization (TACE) plus high intensity focused ultrasound (HIFU), and TACE alone on patients with primary liver cancer. A descriptive, analytical study. Department of Ultrasound, Daqing Oilfield General Hospital, China, from March 2015 to March 2017. A total of 90 primary liver cancer patients were randomly divided into control group and observation group, 45 cases in each group. Control group was treated with TACE alone, while observation group was treated with HIFU plus TACE. Alpha-fetoprotein (AFP), alanine amino-transferase (ALT), aspartate amino-transferase (AST), total bilirubin (TBIL), and frequency of complications, were compared in the two groups. The total remission rate of observation group was higher than that of control group (p=0.017). At 6 months after treatment, AFP level in observation group was lower than that in control group (p <0.001). There was no statistical difference in liver function indicators of ALT, AST, and TBIL between two groups (p=0.968, 0.944 and 0.973, respectively). The incidence of digestive tract hemorrhage was lower than that in control group (p=0.049). After one year of follow-up, the tumor recurrence rate and tumor metastasis rate in observation group were lower than that of control group (p=0.036 and 0.044, respectively). Treatment of primary liver cancer by TACE plus HIFU has a higher overall remission rate, causes little damage to normal liver tissue, can fully kill tumor cells and reduce postoperative local recurrence and metastasis rate with less adverse reactions.

Vaginal Colpectomy in Transgender Men: A Retrospective Cohort Study on Surgical Procedure and Outcomes

BackgroundColpectomy, removal of the vaginal epithelium, may be performed in transgender men because of a disturbed male self-image, to reduce vaginal discharge, or to reduce the risk of fistula formation at the urethral–neourethral junction in future phalloplasty or metaidoioplasty. AimTo demonstrate that vaginal colpectomy in transgender men, either alone or in combination with, for example, laparoscopic hysterectomy, metaidoioplasty, scrotoplasty, or urethroplasty, is a feasible procedure. MethodsThis single-center retrospective cohort study included 143 transgender men who underwent vaginal colpectomy between January 2006 and April 2018. Surgical details and clinical outcomes were collected from all patients. OutcomesThe primary outcome was the number of perioperative and postoperative complications, including intraoperative blood loss. Secondary outcomes were operating time, change in hemoglobin level, and duration of hospital stay. ResultsIn 109 patients (76%), the procedure consisted of colpectomy only, whereas in 34 patients (23%), colpectomy was combined with other procedures. In the whole group (combined procedures included), the median blood loss was 300 mL (interquartile range [IQR] = 250 mL), the mean operating time was 132 ± 62 minutes, and the mean duration of hospital admission was 3.6 ± 1.9 days. In the colpectomy-only group, the median blood loss was 300 mL (IQR = 250 mL), mean operating time was 112 ± 40 minutes, and mean duration of hospital admission was 3.2 ± 1.5 days. For the total group, 15 patients (10%) experienced a major perioperative complication (ie, bowel injury, ureter injury, urethra injury, bladder injury, hemorrhage requiring transfusion and/or intervention and conversion to laparoscopy), and 1 patient (0.7%) had a minor perioperative complication (hemorrhage). Major postoperative complications (hemorrhage, hematoma, fistula, wound infection and prolonged pain complaints) were reported in 17 patients (12%), and minor postoperative complications (urinary tract infection, urinary retention, hemorrhage, and hematoma) occurred in 50 patients (35%). Clinical ImplicationsThis study provides a detailed description of our technique and comprehensive reporting on perioperative and postoperative complications and reintervention rate. Strengths & LimitationsStudy strengths include the large number of patients included and the detailed reporting on the complications of vaginal colpectomy. The main limitation is the retrospective design, which can cause data to go missing during extraction and is prone to bias. ConclusionVaginal colpectomy is a procedure with a high complication rate, but its advantages seem to outweigh its disadvantages. In all but 1 case, no long-term sequelae were reported. However, the high complication rate and reintervention rate should be discussed with patients who are considering undergoing this procedure.Nikkels C, van Trotsenburg M, Huirne J, et al. Vaginal Colpectomy in Transgender Men: A Retrospective Cohort Study on Surgical Procedure and Outcomes. J Sex Med 2019;16:924–933

Successful mast-cell-targeted treatment of chronic dyspareunia, vaginitis, and dysfunctional uterine bleeding

Dyspareunia, vaginitis and dysfunctional uterine bleeding (DUB) are common problems which, despite their polygenicity, commonly appear idiopathic and treatment-refractory. Mast cell (MC) activation syndrome (MCAS) is a newly-recognised, prevalent, chronic multisystem polymorbidity of general themes of inflammation ± allergic-type phenomena ± aberrant growth/development in assorted tissues. MCs produce significant quantities of heparin, too. As such, MCAS may underlie some cases of chronic dyspareunia, vaginitis or DUB. We report five such patients; all who responded well to MC-targeted treatment. We review aspects of MC biology and pathobiology of potential relevance to otherwise idiopathic persistent inflammatory or coagulopathic genital tract problems. Diagnostic testing for MCAS may be warranted in some patients with chronic dyspareunia, vaginitis or DUB (especially patients whose histories well fit the general profile of MCAS), and prospective therapeutic trials of MC-directed topical and/or systemic therapies may be warranted in such populations. Impact statement What is already known on this subject? Chronic, idiopathic, treatment-refractory female genital tract inflammation or bleeding are common problems for which mast cell (MC) disease, previously generally thought to consist of just rare cases of mastocytosis, and is seldom considered in the differential diagnosis. What do the results of this study add? The substantial prevalence of the newly recognised ‘mast cell activation syndrome’ (MCAS), featuring chronic inappropriate MC activation with little-to-no MC neoplasia, and its clinical presentation with chronic multisystem inflammation ± allergic-type phenomena ± aberrant growth/development in assorted tissues, raises the possibility that MCAS might underlie the aforementioned genital tract problems, especially in patients whose larger clinical presentations fit the MCAS profile. We report five example patients (among many more we have similarly treated) who enjoyed excellent responses to safe, inexpensive MC-targeted treatments, often given just intravaginally. What are the implications of these findings for clinical practice and/or further research? Our report identifies a potentially significant new MC-focused direction, of relevance to millions of affected women worldwide, for clinical treatment as well as for basic and clinical research, which historically has yielded major advancements disappointingly disproportionate to the scope of the affected population.

Ventriculoperitoneal Shunt Outcomes of Normal Pressure Hydrocephalus: A Case Series of 116 Patients.

BackgroundPermanent cerebrospinal fluid (CSF) diversion with a ventriculoperitoneal shunt (VPS) is a treatment option for patients with normal pressure hydrocephalus (NPH).ObjectivesHerein, we examine the outcomes, complication rates, and associations between predictors and outcomes after VPS in patients with NPH.MethodsThis was a retrospective review of 116 patients (68 males, 48 females) with NPH who underwent VPS placement from March 2008 to September 2017 after demonstrating objective and/or subjective improvement after a lumbar drain trial. The Chi-square test of independence was used to examine associations between predictors and clinical improvement after shunting. Complications associated with the VPS procedure were recorded.ResultsThe mean age was 77 years (range 52-93). The mean duration of disturbance in gait, cognition, and continence were 29, 32, and 28 months, respectively. Of the 116 patients, 111 followed up at two weeks; of these, improvement in gait, incontinence, and cognition were reported in 72, 20, and 23 patients, respectively. Gait improved more than incontinence or cognition. A shorter duration of gait disturbance predicted an improvement in gait after shunting (p<0.01). Being on a cognition-enhancing medication predicted an improvement in cognition and/or incontinence after shunting (p<0.05). Complications included misplaced proximal catheters (n=6), asymptomatic catheter tract hemorrhages (n=3), bilateral hygromas (n=7), subdural hematomas (SDH) (n=5), and CSF leak (n=1).ConclusionVPS placement in patients with NPH is well-tolerated and associated with improved outcomes at least in the short-term follow-up (<6 months). A shorter duration of gait disturbance and being on a cognition-enhancing medication are associated with greater improvement after VPS.

Prediction and feature selection for fatal gastrointestinal bleeding recurrence in hospital via machine learning

To propose a method of prediction for fatal gastrointestinal bleeding recurrence in hospital and a method of feature selection via machine learning models. 728 digestive tract hemorrhage samples were extracted from the first aid database of PLA General Hospital, and 343 patients among them were diagnosed as fatal gastrointestinal bleeding recurrence in hospital. A total of 64 physiological or laboratory indicators were extracted and screened. Based on the ten-fold cross-validation, Logistic regression, AdaBoost and XGBoost were used for classification prediction and comparison. XGBoost was used to search sequence features, and the key indicators for predicting fatal gastrointestinal bleeding recurrence in hospital were screened out according to the importance of the indicators during training. Logistic regression, AdaBoost and XGBoost all get better F1.5 score under each feature input dimension, among which XGBoost had the best effect and the highest score, which was able to identify as many patients as possible who might have fatal gastrointestinal bleeding recurrence in hospital. Through XGBoost iteration results, the Top 30 indicators with high importance for predicting fatal gastrointestinal bleeding recurrence in hospital were ranked. The F1.5 scores of the first 12 key indicators peaked at iteration (0.893), including hemoglobin (Hb), calcium (CA), red blood cell count (RBC), mean platelet volume (MPV), mean erythrocyte hemoglobin concentration (MCH), systolic blood pressure (SBP), platelet count (PLT), magnesium (MG), lymphocyte (LYM), glucose (GLU, blood gas analysis), glucose (GLU, blood biochemistry) and diastolic blood pressure (DBP). Logistic regression, AdaBoost and XGBoost could achieve the purpose of early warning for predicting fatal gastrointestinal bleeding recurrence in hospital, and XGBoost is the most suitable. The 12 most important indicators were screened out by sequential forward selection.

Venous Thromboembolism After Intraventricular Hemorrhage: Results From the CLEAR III Trial.

Venous thromboembolism (VTE) after intracerebral hemorrhage is well studied, but data on patients with spontaneous intraventricular hemorrhage (IVH) are limited. To study the factors associated with VTE, association between VTE and clinical outcomes in IVH, and safety of VTE chemoprophylaxis in IVH treated with intraventricular catheters and thrombolysis. Retrospective cohort study of patients enrolled in the CLEAR III trial, a multicenter, randomized trial comparing external ventricular drainage, with administration of intraventricular alteplase vs placebo, for obstructive IVH. Predictor variable was incident VTE in the first 30 d. Outcome measures were factors associated with VTE, and death/severe disability (modified Rankin Score 4-6) at 6 mo. Of the 500 patients with IVH, VTE occurred in 59 patients (11.8%) within the first 30 d. VTE chemoprophylaxis was initiated in 412 (82.4%) patients, but before VTE diagnosis in only 401 (80.2%) at median of 4 d (interquartile range, 1-8) from IVH onset, and was not associated with intracranial bleeding or catheter tract hemorrhage. In the multivariate logistic regression analysis, infection within 30 d (odds ratio, 1.80; confidence interval, 1.03-3.17) was significantly associated with higher odds of VTE occurrence. Starting VTE chemoprophylaxis after 72 h was additionally associated with VTE occurrence after the first week. Infection and delay in timely initiation of VTE chemoprophylaxis were associated with VTE occurrence. VTE chemoprophylaxis in IVH appears safe and should not be delayed beyond standard care policies for ICH including when intraventricular catheter placement and thrombolytic therapy are performed.

Long-term results of chest wall arteriovenous graft for establishing hemodialysis access

To explore the role of chest wall arteriovenous graft (CWAVG) for establishing hemodialysis access in patients with end-stage renal disease. A retrospective analysis was made on the clinical data of 12 patients with end-stage renal disease who underwent CWAVG for establishing hemodialysis access between January 2014 and June 2015. There were 3 males and 9 females with an average age of 63.6 years (range, 54-82 years). The renal disease causes were chronic glomerulonephritis in 2 cases, hypertensive renal damage in 4 cases, diabetic nephropathy in 1 case, both kidney resection because of urinary tract tumors in 3 cases, and causes unknown in 2 cases. Hemodialysis time ranged from 1 to 144 months, with an average of 38.4 months. The 12 patients all underwent 1-14 times (mean, 4.2 times) anterior pathway failure in CWAVG, all of which were caused by repeated occlusion of dialysis pathway or poor vascular condition of upper extremity, resulting in the exhaustion of vascular pathway in upper extremity. All patients were followed up 30-48 months (mean, 35.4 months). Two patients died, including 1 case of digestive tract hemorrhage, 1 case of heart failure. The other 10 CWAVGs were functionally useful for hemodialysis access about 6 weeks after operations. The primary patency rates at 6, 12, 18, 24, and 30 months were 83.3%, 75.0%, 33.3%, 33.3%, and 16.7%, respectively, and the cumulative patency rates at 6, 12, 18, 24, and 30 months were 83.3%, 75.0%, 50.0%, 33.3%, and 16.7%, respectively. Among 8 cases of CWAVG dysfunction, 6 cases had thrombosis, 1 case had seroma, and 1 case had vertebral artery stealing. Among them, 4 patients underwent hemodialysis using tunneled-cuffed catheter, 3 patients using fistula or graft on other limbs, and 1 patient was not treated with hemodialysis. Although the long-term patency rate of CWAVG is yet to be further increased by improvement of treatment strategies, but it is still a supplementary option for end-stage renal disease patients with inadequate upper extremity venous access sites.

Abstract WMP100: Prior Antiplatelet Use and Outcomes After Lobar, Deep, and Intraventricular Hemorrhage

Introduction: We examined the association between prior antiplatelet therapy and outcomes in patients with lobar versus deep intracerebral hemorrhage (ICH) versus intraventricular hemorrhage (IVH). Methods: We performed a retrospective cohort study using data from patients with lobar and deep ICH registered in the Virtual International Stroke Trials Archive (VISTA-ICH), and patients with IVH enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. We excluded patients in the intervention arms of the trials, and those on prior anticoagulation therapy. The exposure was antiplatelet therapy prior to ICH/IVH. Primary outcomes were hematoma expansion and death/major disability in the VISTA-ICH cohort, and ventriculostomy tract hemorrhage, hematoma expansion, and death/major disability in the CLEAR III cohort. We used separate sets of logistic regression models in each group—lobar ICH, deep ICH, and IVH—to examine the association between antiplatelet therapy and our outcomes. Results: Among 548 ICH patients in the VISTA-ICH cohort, there were 416 (75.9%) lobar and 121 (22.1%) deep hematomas. Median baseline ICH volumes were 19 ml (IQR, 11-26) in lobar and 8 ml (IQR, 4-13) in deep bleeds. Prior antiplatelet therapy was reported in 92 patients with lobar (22.1%) and 26 patients (20.8%) patients with deep ICH. After adjustment for demographics, comorbidities, and hematoma characteristics, antiplatelet therapy was not associated with hematoma expansion or poor functional outcomes after lobar (OR, 0.8; 95% CI, 0.5-1.8) or deep (OR, 1.3; 95% CI, 0.4-3.8) ICH. In the CLEAR cohort, the 62 of 222 IVH patients (27.9%) with prior antiplatelet therapy had similar odds of hematoma expansion (OR, 0.6; 95% CI, 0.2-1.7) or poor functional outcomes (OR, 0.9; 95% CI, 0.4-2.1), but higher odds of ventriculostomy tract hemorrhage (OR, 3.2; 95% CI, 1.3-7.7). Conclusions: Prior antiplatelet therapy was not associated with hematoma expansion or functional outcomes after lobar or deep ICH or IVH, but was associated with ventriculostomy tract hemorrhage.

Clinical observation on application of different enteral nutrition preparations in patients with severe traumatic brain injury

To observe the effects of enteral nutrition (EN) emulsion with different components on nutritional index, blood glucose, inflammatory reaction, gastrointestinal tolerance and prognosis in patients with severe traumatic brain injury (sTBI). Patients with sTBI [Glasgow coma scale (GCS) < 8] admitted to intensive care unit (ICU) of Affiliated Hospital of Guizhou Medical University from January 2016 to May 2018 were retrospectively analyzed. These patients had received EN, 30 cases of them were fed with Baipuli, 35 cases were fed with Ruineng, and 30 cases were fed with Ruisu. The EN support began within 48 hours after the patients were transferred to ICU, and the energy intake of 83.68-104.60 kJ×kg-1×d-1 was the nutritional support target. The hemoglobin (Hb), lymphocyte count (LYM), serum albumin (Alb), pre-albumin (PA), procalcitonin (PCT), average blood glucose (GLUave) and blood glucose variation coefficient (GLUcv) were observed 7 days after EN support, EN compliance time, gastrointestinal tolerance situations were recorded, and the duration of mechanical ventilation (MV), the length of ICU stay and incidence of nosocomial infection were compared among the three groups. There were no obvious changes in Hb, LYM, Alb, PCT among three groups after treatment on the 7th day, and there was no significant difference among the three groups. The PA of Baipuli group was significantly higher than that in Ruineng and Ruisu groups at 7 days after treatment (mg/L: 275.55±46.18 vs. 238.25±49.59, 240.70±55.59, both P < 0.05), but the GLUave and GLUcv were much higher than those in Ruineng and Ruisu groups [GLUave (mmol/L): 10.02±2.39 vs. 8.53±1.53, 8.98±1.75; GLUcv: (23.59±3.93)% vs. (14.79±3.65)%, (17.88±2.90)%, all P < 0.05]. The indexes of gastrointestinal tolerance in Baipuli group were better than those of Ruineng and Ruisu groups: the target feeding time was reached ahead (days: 4.40±1.20 vs. 5.50±1.07, 5.45±1.02, both P < 0.05), the incidence of gastric retention and digestive tract hemorrhage were both decreased [6.67% (2/30) vs. 31.43% (11/35), 33.33% (10/30); 3.33% (1/30) vs. 14.29% (5/35), 16.67% (5/30), all P < 0.05]. The duration of MV and the length of ICU stay in Ruisu and Baipuli groups were longer than those of Ruineng group [duration of MV (days): 6.94±1.64, 6.79±1.14 vs. 5.93±1.12; the length of ICU stay (days): 9.40±2.18, 10.40±2.35 vs. 7.45±1.83, all P < 0.05]. There was no significant difference in the incidences of nosocomial infection among Ruineng, Ruisu, and Baipuli groups [the incidence of ventilator-associated pneumonia (VAP): 11.43%, 10.00%, 10.00%; catheter related bloodstream infection: 0, 0, 3.33%; urinary tract infection: 5.71%, 6.67%, 6.67%; intracranial infection: 2.86%, 6.67%, 3.33%, all P > 0.05]. For patients with sTBI, short peptide EN preparations (Baipuli) is much better in gastrointestinal tolerance but it can cause fluctuations of blood glucose; the whole protein EN containing ω-3 fatty acid (Ruineng, Ruisu) has relatively less fluctuation on blood glucose, the duration of MV and the length of ICU stay can be shortened by Ruineng, therefore it is more suitable to be applied for such patients.

First case of acute respiratory distress syndrome and alimentary tract hemorrhage following mass ingestion of methylisothiazolinone

The frequency of methylisothiazolinone (MIT)-related health concerns regarding allergic contact dermatitis with a spongiotic reaction pattern and restrictive lung function indicating peripheral airway dysfunction caused by the use of humidifier disinfectant is increasingly rising. There is a limited number of evidences supporting the environmentally acute and mass exposure to MIT resulting in acute respiratory distress syndrome (ARDS). Here, we report the first case of ARDS and alimentary tract hemorrhage following mass ingestion of methylisothiazolinone.

Safe and Effective Use of Rivaroxaban for Treatment of Cancer Associated Venous Thromboembolic Disease

Introduction: Venous thromboembolism (VTE) is a common complication of cancer, associated with significant morbidity and mortality. Low-molecular weight heparin (LMWH), the most widely used anticoagulant in this setting, is expensive and burdensome. Rivaroxaban (Riva) was approved for treatment of VTE in 2012, but there is limited experience in cancer-associated thrombosis (CAT). In 2014, we established a Clinical Pathway (CP) to guide use of rivaroxaban (Riva) for CAT at Memorial Sloan Kettering Cancer Center. We were concerned that a direct oral anticoagulant (DOAC) would be more likely than LMWH to cause upper gastrointestinal (GI) bleeding in the presence of abnormal mucosa. DOACs have partial renal clearance and are active in the urine, in contrast to LMWH, and we also anticipated increased genitourinary (GU) tract bleeding in the presence of GU lesions. Therefore, the key to our CP has been to recommend against use of Riva or other DOAC in the setting of active (GI) or (GU) tract lesions. As the elderly are known to be at higher risk of bleeding from anticoagulation, the CP recommended reduced dose Riva in patients≥75 year old (yo), (10 mg bid X 3 wks., followed by 15 mg daily). Otherwise, we adhere to the standard FDA approved guidelines. We published a 200-patient cohort in 2016 demonstrating rates of recurrent VTE and bleeding that were at least as low as historical controls with LMWH.This past year, two randomized clinical trials were published comparing a DOAC with dalteparin (“Hokusai VTE Cancer” of edoxaban, Raskob G.E. et al, NEJM, 2017, and “Select-D” of Riva, Young A.M. et al, JCO 2018). Both studies showed a trend towards better efficacy with the DOAC, but with increased GI/GU bleeding. However, those studies did not exclude patients with known GI/GU lesions. We now report our expanded experience with Riva treatment of CAT, confirming the safety and efficacy of Riva treatment of CAT when guided by our CP.Methods: From 1/1/2014 through 10/31/2016, 2000 patients at MSKCC received Riva. 1072 had CAT, defined as a lower extremity DVT and/or PE in a patient with active cancer or receiving cancer therapy. (The other 928 patients did not have active cancer, or received Riva for other indication). All patients treated with Riva for CAT are included in this analysis, even in the presence of active GI/GU lesions. Recurrent VTE, major bleeding (MB), clinically relevant non-major bleeding (CRNMB) leading to discontinuation of Riva, and death were competing risk endpoints for the purpose of the analysis. We also evaluated the outcomes of the subgroup of patients ≥75 yo.Results: At 6 months, the cumulative incidence for the various endpoints estimated within a competing risks framework were; recurrent VTE (4.2%), MB (2.2%), CRNMB (5.5%). Overall, the 6-month incidence of death was 22.2%. In the elderly patients, the risks of recurrent VTE and bleeding were similar to the <75 yo patients. It should be noted that only approximately half (48%) the elderly patients received reduced-dose Riva, at the discretion of the treating physician, and the numbers were too small to allow for comparison of full-dose and reduced dose.Conclusions: In our expanded experience of Riva therapy for CAT, applying our CP, we continue to maintain low rates of recurrent VTE and bleeding. Allowing for differences in methodology between a cohort study and randomized clinical trials, the rate of recurrent VTE was as low as the DOAC arm in Hokusai VTE Cancer and Select-D studies. Further, by applying the exclusion criteria in our CP, and not treating patients with known GI/GU lesions, we achieved a low rate of bleeding compared with the DOAC treatment arms in the two recent randomized clinical trials. Those two trials demonstrated bleeding rates greater than LMWH, particularly GI/GU bleeds. We saw no increased rates of recurrent VTE or bleeding in the elderly, which is reassuring, but we cannot conclude if reduced dose is of benefit. These new expanded observations further support the validity of our CP.The key to anticoagulation choice for CAT is not which anticoagulant is “better,” but rather which anticoagulant to choose for a specific patient. In the absence of GI/GU contraindications, Riva provides effective and safe anticoagulation, at substantially lower cost and burden to the patient than LMWH. In contrast, we propose that LMWH is preferable in patients with GI/GU lesions. (We are now obtaining specific data for that subgroup). [Display omitted] DisclosuresSoff:Amgen: Research Funding; Janssen: Research Funding. Mantha:Heidell, Pittoni, Murphy & Bach, LLP: Consultancy; GLG: Consultancy; Janssen: Research Funding.