Preventing and managing catastrophic bleeding during extracorporeal circulation

The use of extracorporeal circulation for cardiac surgery and extracorporeal life support poses tremendous challenges to the hemostatic equilibrium given its diametric tendency to trigger hyper- and hypocoagulopathy. The necessity of anticoagulant therapy to counteract the hemostatic activation by the extracorporeal circuitry compounded by unfavorable patient and surgical factors significantly increase the risk of catastrophic bleeding in patients who require extracorporeal circulation. Preoperative measures, such as stratification of high-risk bleeding patients, and optimization of the modifiable variables, including anemia and thrombocytopenia, provide a crude estimation of the likelihood and may modify the risk of catastrophic bleeding. The anticipation for catastrophic bleeding subsequently prompts the appropriate preparation for potential resuscitation and massive transfusion. Equally important is intraoperative prevention with the prophylactic application of tranexamic acid, an antifibrinolytic agent that has promising benefits in reduction of blood loss and transfusion. In the event of uncontrolled catastrophic bleeding despite preemptive strategies, all effort must be centered on regaining hemostasis through surgical control and damage control resuscitation to protect against worsening coagulopathy and end organ failure. When control of bleeding is reinstated, management should shift focus from systemic therapy to targeted hemostatic therapy aimed at the potential culprits of coagulopathy as identified by point of care hemostatic testing. This review article outlines the strategies to appropriately intervene using prediction, prevention, preparation, protection, and promotion of hemostasis in managing catastrophic bleeding in extracorporeal circulation.

The rheumatology/hematology interface: CAPS and MAS diagnosis and management

Catastrophic antiphospholipid antibody syndrome (CAPS) and macrophage activation syndrome (MAS) are both life-threatening hematologic disorders that infrequently afflict patients with rheumatologic disease. CAPS is characterized by fulminant multiorgan damage related to small vessel thrombosis in the setting of persistent antiphospholipid antibodies. It can occur in patients with rheumatologic diseases such as systemic lupus erythematosus but can also affect patients who do not have rheumatologic disease. By contrast, the term MAS is applied when patients with rheumatologic disease develop hemophagocytic lymphohistiocytosis (HLH); therefore, patients with MAS have an underlying rheumatologic disease by definition. Similar to CAPS, HLH/MAS can have a fulminant presentation, but the pathogenesis and manifestations are different. In both CAPS and MAS, management generally includes but is not limited to immunosuppression with steroids. Fatalities are relatively common and morbidity is often significant. Early recognition of these disorders and initiation of timely treatment are important. More effective therapies for both syndromes are urgently needed.

Has the Financial Protection Been Materialized in Iranian Health System? Analyzing Household Income and Expenditure Survey 2003-2014

BACKGROUND

The financial protection against catastrophic and impoverishing health expenditures is one of the main aspects of the universal health coverage. This study aimed to present a clear picture of the financial protection situation in Iran from 2003-2014.

STUDY DESIGN

This is an analytical study on secondary data of Statistical Center of Iran (SCI). The study has some policy implications for policy makers; therefore, it is an applied one.

METHODS

Data related to the Iranian rural and urban household payments on health expenditures was obtained from annual surveys of the SCI. WHO researchers' approach was used to calculate the Fairness of Financial Contribution Indicator (FFCI), the headcount and overshoot ratios of catastrophic and impoverishing health expenditures. A logistic regression was conducted to identify the determinants of probability of occurrence of catastrophic health expenditure among Iranian households in 2014.

RESULTS

The mean of FFCI for rural and urban households was 0.854 (0.41) and 0.867 (0.32), respectively. The average headcount ratios of catastrophic and impoverishing health expenditures were 1.32% (0.24) and 0.33% (P=0.006) for rural households and 1.4% (0.6) and 0.28% (P=0.001) for urban households. Concerning rural households, the overshoot of catastrophic and impoverishing health expenditures was 14.94% (P=0.001) and 7.22% (0.53); it was 15.59% (1.54) and 7.76% (0.52) for urban households.

CONCLUSIONS

No significant and considerable change was found in the headcount ratios of catastrophic and impoverishing health expenditure and in their overshoot or gap amounts. This suggested a lack of well-designed and effective schemes for materializing the financial protection in Iran.

Catastrophic Antiphospholipid Syndrome

Catastrophic antiphospholipid syndrome is a rapidly progressive life-threatening disease that causes multiple organ thromboses and dysfunction in the presence of antiphospholipid antibodies. A high index of clinical suspicion and careful investigation are required to make an early diagnosis so that treatment with anticoagulation and corticosteroids can be initiated; plasma exchange and/or intravenous immunoglobulins can be added if the life-threatening condition persists. Despite aggressive treatment and intensive care unit management, patients with catastrophic antiphospholipid syndrome have a 48% mortality rate, primarily attributable to cardiopulmonary failure. This article reviews the current information on the etiopathogenesis, clinical manifestations, diagnosis, management, and prognosis of catastrophic antiphospholipid syndrome.

The Risk of Epithelial Ovarian Cancer of Women With Endometriosis May be Varied Greatly if Diagnostic Criteria Are Different: A Nationwide Population-Based Cohort Study

This article aims to test the hypothesis that the risk of epithelial ovarian cancer (EOC) in women with endometriosis might be changed by enrolling different population. A nationwide 14-year historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan and the Registry for Catastrophic Illness Patients was conducted. A total of 239,385 women aged between 20 and 51 years, with at least 1 gynecologic visit after 2000, were analyzed. Cases included women with a diagnosed endometriosis, which was established along a spectrum from at least 1 medical record of endometriosis (recalled endometriosis) to tissue-proved ovarian endometriosis (n = X). Controls included women without any diagnosis of endometriosis (n = 239,385 - X). We used Cox regression, and computed hazard ratios (HRs) with 95% confidence intervals (95% CI) to determine the risk of EOC in patients. The EOC incidence rates (IRs, per 10,000 person-years) of women with endometriosis ranged from 1.90 in women with recalled endometriosis to 18.70 in women with tissue-proved ovarian endometrioma, compared with those women without any diagnosis of endometriosis (0.77-0.89), contributing to crude HRs ranging from 2.59 (95% CI, 2.09-3.21; P < 0.001) to 24.04 (95% CI, 17.48-33.05; P < 0.001). After adjustment for pelvic inflammatory disease, infertility, Charlson co-morbidity index, and age, adjusted HRs were ranged from the lowest of 1.90 (95% CI, 1.51-2.37; P < 0.001) in recalled endometriosis to the highest of 18.57 (95% CI, 13.37-25.79; P < 0.001) in tissue-proved ovarian endometrioma, which was inversely related to the prevalence rate of endometriosis (from the highest of 30.80% in recalled endometriosis to the lowest of 1.54% in tissue-proved ovarian endometrioma). The risk of EOC in women with endometriosis varied greatly by different criteria used. Women with endometriosis might have a more apparently higher risk than those reported by systematic review and meta-analysis.

Atypical Subacute Recurrence of Catastrophic Antiphospholipid Syndrome in a Japanese Female Patient

Catastrophic antiphospholipid syndrome (CAPS) survivors rarely relapse. We herein report a case of a second CAPS episode with an unusual subacute course and no microangiopathic hemolytic anemia (MAHA), a common CAPS symptom. During the first episode, the 69-year-old woman responded well to high-dose glucocorticoids and plasma exchange. On relapse, these treatments plus rituximab were ineffective and she died of multi-organ failure and bacterial cholangitis. The absence of MAHA and a subacute course do not exclude a CAPS recurrence.

CALIFORNIA STATE UNIVERSITY CATASTROPHIC (CAT) LEAVE DONATION PROGRAM: DEMOGRAPHICS, ECONOMIC SECURITY, AND SOCIAL EQUITY

The California State University (CSU) Chancellor's Office reached an agreement with all CSU collective bargaining units and Employee Relations on a uniform Catastrophic (CAT) Leave Donation Program in 1992. The CAT Leave Donation Program allows employees to donate sick and/or vacation leave credits to employees who are incapacitated due to a catastrophic illness or injury and have exhausted all of their own leave credits. This also extends to employees with whom family illnesses are deemed catastrophic, thus requiring the employee to care for an immediate family member. Stakeholders include union represented employees who accrue leave credits as well as any employee who receives or donates hours of leave credits in the program. Other stakeholders include the family members and program administrators.

Efficacy of eculizumab in a patient with immunoadsorption-dependent catastrophic antiphospholipid syndrome: a case report

Catastrophic antiphospholipid syndrome (CAPS) is a rare but devastating complication in patients with antiphospholipid syndrome (APS) with a high morbidity and mortality.We describe a case of a 30-year old female patient with immunoglobulin A (IgA) deficiency who underwent splenectomy because of idiopathic thrombocytopenic thrombocytopenia. Subsequently, an APS and finally systemic lupus erythematosus was diagnosed. After an uncomplicated pregnancy that was terminated by cesarean section, the patient developed severe CAPS with cerebral, myocardial, renal, and pulmonary involvement.Because of IgA deficiency, standard therapy consisting of plasmapheresis and intravenous immunoglobulins in addition to steroids was not tolerated. After 8 sessions of immunoadsorption (IAS), massive pulmonary hemorrhage was controlled but relapsed twice whenever IAS was terminated. As other immunosuppressive agents were considered dangerous because of the risk of infections in the face of severe hypogammaglobulinemia, we administered eculizumab, an inhibitor of the terminal complement pathway, which led to a persistent control of her disease. Interestingly, eculizumab therapy was associated with a further decline of complement C3 and C4 serum levels. The patient developed a subsequent flare of her systemic lupus erythematosus, potentially indicating that complement inhibition by eculizumab is not effective in preventing lupus flares.Taken together, we describe a unique case of life-threatening and difficult-to-treat CAPS with a good clinical response after terminal complement complex inhibition with eculizumab. Further controlled trials are necessary to investigate the value of eculizumab in patients with CAPS.

Catastrophic hemophagocytic lymphohistiocytosis in a young man with nephrotic syndrome

BACKGROUND

In its early stage, necrotizing fasciitis mimics a milder cutaneous infection, such as cellulitis, and is an uncommon but potentially fatal complication of nephrotic syndrome. It may trigger an uncontrolled and catastrophic immune response, such as hemophagocytic lymphohistiocytosis (HLH).

CASE REPORT

A 19-y-old man presented with steroid-resistant nephrotic syndrome and rapidly progressing Escherichia coli monomicrobial necrotizing fasciitis with bacteremia. The conditions developed one day after steroid therapy, leading to multiple organ dysfunction syndrome. A provisional diagnosis of HLH was promptly made, based upon the patient's fever, unremitting shock, marked pancytopenia, hyperferritinemia, hypofibrinogenemia, and the typical histiocytic hemophagocytosis in pleural effusion. Despite aggressive medical treatment and organ support, the patient died 8 days after transfer to our intensive care unit. Final bone marrow examination confirmed the diagnosis of HLH.

CONCLUSIONS

Although nephrotic syndrome associated with E. coli infection is common, this is the first reported case of E. coli monomicrobial necrotizing fasciitis with bacteremia resulting in HLH in a patient with nephrotic syndrome.

The impact of out-of-pocket payments on health care inequity: the case of national health insurance in South Korea

The global financial crisis of 2008 has led to the reinforcement of patient cost sharing in health care policy. This study aimed to explore the impact of direct out-of pocket payments (OOPs) on health care utilization and the resulting financial burden across income groups under the South Korean National Health Insurance (NHI) program with universal population coverage. We used the fourth Korean National Health and Nutrition Examination Survey (KNHNES-IV) and the Korean Household Income and Expenditure Survey (KHIES) of 2007, 2008 and 2009. The Horizontal Inequity Index (HIwv) and the average unit OOPs were used to measure income-related inequity in the quantitative and qualitative aspects of health care utilization, respectively. For financial burden, the incidence rates of catastrophic health expenditure (CHE) were compared across income groups. For outpatient and hospital visits, there was neither pro-poor or pro-rich inequality. The average unit OOPs of the poorest quintile was approximately 75% and 60% of each counterpart in the richest quintile in the outpatient and inpatient services. For the CHE threshold of 40%, the incidence rates were 5.7%, 1.67%, 0.72%, 0.33% and 0.27% in quintiles I (the poorest quintile), II, III, IV and V, respectively. Substantial OOPs under the NHI are disadvantageous, particularly for the lowest income group in terms of health care quality and financial burden.

[Alterations of the complement system in patients with catastrophic antiphospholipid syndrome]

AIM

To investigate alterations of the complement system in patients with catastrophic antiphospholipid syndrome (CAPS).

SUBJECTS AND METHODS

Four patients (2 men aged 23 and 40 years and 2 women aged 39 and 58 years) diagnosed as having CAPS, including 3 patients with systemic lupus erythematosus and secondary antiphospholipid syndrome (APS) and 1 patient with primary APS, were examined. The activity of the complement components C1-C5 and total hemolytic activity were determined in all the patients at the moment of an acute episode and in 1 patient after treatment.

RESULTS

The activity of the studied complement components and total hemolytic complement activity proved to be significantly decreased in all the patients. That of complement components recovered after treatment using fresh frozen plasma. The possibility and mechanisms of complement system activation in the patients with CAPS are discussed.

CONCLUSION

The preliminary results obtained by the examination of few cases may lead to the conclusion that the complement system may be involved in the development of CAPS.

Catastrophic antiphospholipid syndrome (CAPS)

Catastrophic antiphospholipid syndrome (CAPS) is a very severe variant of the classic APS, characterised by clinical evidence of multiple organ involvement developing over a very short period of time, histopathological evidence of multiple small vessel occlusions and laboratory confirmation of the presence of antiphospholipid antibodies (aPL), usually in high titre. Although patients with catastrophic APS represent less than 1% of all patients with APS, this is usually a life-threatening condition. In this article, we aimed to review the state-of-the art about current knowledge in pathogenesis, clinical manifestations, diagnosis and treatment strategies in CAPS.

A case of seronegative catastrophic antiphospholipid antibody syndrome

Catastrophic antiphospholipid antibody syndrome (CAPS) is a rare syndrome associated with multiorgan failure that carries a high mortality rate. It has been defined previously by the presence of autoantibodies in a patient with acute multiorgan failure as a result of small vessel occlusion by multiple thrombi. We report a patient who meets all criteria of CAPS except for persistent seronegativity.

[Anticoagulation and antiphospholipid syndrome: be careful to the catastrophe]

Antiphospholipid syndrome associate thromboembolic events (arterial or venous), and presence of antiphospholipid antibodies, and require anticoagulation. A catastrophic variant may develop, resulting in multiorgan failure, with high mortality rate. This article presented a patient with antiphospholipid syndrome presenting a catastrophic antiphospholipide syndrome after anticoagulation suspending for gastrointestinal bleeding. Multidisciplinary management in intensive care unit and aggressive therapies (corticosteroids, anticoagulation, plasma exchange) were essential to rescue the patient.

Tracheotomy-related catastrophic events: results of a national survey

OBJECTIVES/HYPOTHESIS

To gather qualitative and semiquantitative information about catastrophic complications during and following tracheotomy.

STUDY DESIGN

National survey distributed to American Academy of Otolaryngology-Head and Neck Surgery members via the Academy weekly email newsletter during April and May 2011.

METHODS

A total of 478 respondents provided estimates of the number of four specific tracheotomy-related complications (innominate artery fistula, esophageal fistula, acute tracheotomy occlusion, and obstructing granuloma), all catastrophic events, and events resulting in death or permanent disability encountered during their careers. There were 253 respondents who provided 405 free-text descriptions of specific events.

RESULTS

The respondents experienced approximately one catastrophic event every 10 years and one event resulting in death or permanent disability every 20 years. More than 90% occurred more than 1 week after surgery. Categories of physicians who experienced more events per year included academic physicians and laryngologists. Pediatric otolaryngologists had twice as many innominate artery fistulas per year of practice as others. Qualitative (free-text) descriptions of the most serious events demonstrated that more of these events involved loss of airway and volume bleeds, usually from innominate or carotid artery erosion. Many of the events due to airway loss involved potentially correctable deficits in family education, nursing care, home care, and other structural factors.

CONCLUSIONS

Even when we allow for selection bias, these data suggest that a substantial number of tracheotomy complications leading to death or permanent disability occur at a national level. The vast majority of events occur more than 1 week after the procedure. Many of the described events were caused by factors that should be amenable to prospective system improvement strategies.

Catastrophic antiphospholipid syndrome presenting as fever of unknown origin

Antiphospholipid syndrome is characterized by the presence of antiphospholipid antibodies with characteristic clinical manifestation, which include venous, arterial thrombosis, thrombotic microangiopathy, and recurrent fetal loss. The syndrome can be secondary to many causes including systemic lupus erythematosus (SLE) or "primary" antiphospholipid syndrome (APLS). We report a case of a man with catastrophic antiphospholipid syndrome (CAPS), which occurs when three or more organ systems are affected by thrombosis in less than a week. Catastrophic antiphospholipid syndrome is uncommon but often fatal. The patient received a successful treatment that controlled this disease and included intravenous heparin, antiplatelet, intravenous corticosteroid, and plasmapheresis.

Catastrophic massive intracardiac thrombus in a 40-year-old patient with dilated cardiomyopathy

Dilated cardiomyopathy has been associated with left ventricular (LV) thrombosis which leads to substantial morbidity and mortality as a site for systemic emboli. We report an interesting case of a stroke and acute limb ischemia secondary to a large mobile pedunculated LV thrombus in 40-year-old patient with dilated cardiomyopathy.