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Sathianathan S, Meili Z, Romero CM, Juarez JJ, Bashir R. Racial and gender disparities in the management of acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101817. [PMID: 38296110 DOI: 10.1016/j.jvsv.2024.101817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 02/19/2024]
Abstract
OBJECTIVE The aim of this study was to assess race and sex disparities in use and outcomes of various interventions in patient with acute pulmonary embolism (PE). METHODS We included 129,445 patients with acute PE from the NIS from January 2016 to December 2019. Rates of inferior vena cava (IVC) filter placement, catheter-directed thrombolysis (CDT), CDT with ultrasound, systemic thrombolysis, surgical embolectomy, percutaneous thrombectomy, extracorporeal membrane oxygenation, and mechanical ventilation were compared between race and sex subgroups, along with length of hospital stay, major bleeding events, mortality, and other adverse events. Multivariate linear regression analysis was used to adjust for variables that were significantly different between race and sex, including demographic factors, comorbidities, socioeconomic factors, and hospital characteristics. RESULTS Compared with White male patients, all subgroups had significantly higher odds of in-hospital mortality highest in Hispanic male patients (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.090-1.640; P < .01). All subgroups also had a higher odds of major bleeding events and increased length of stay. All subgroups also had lower odds of receiving CDT, lowest in Black female patients (OR, 0.740; 95% CI, 0.660-0.820; P < .001) and Hispanic female patients (0.780; 95% CI, 0.650-0.940; P < .001) compared with White male patients. There was no significant difference in the use of systemic thrombolysis among subgroups. CONCLUSIONS Black and Hispanic patients and female patients are less likely to undergo CDT compared with White male patients, in addition to having higher odds of mortality, major bleeding, and increased length of stay after management of PE. Further efforts are needed to mitigate disparate outcomes of PE management at not only an institutional, but at a national, level to promote health care equality.
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Affiliation(s)
- Shyama Sathianathan
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA
| | - Zachary Meili
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA
| | - Carlos M Romero
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA
| | - Jordan J Juarez
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA.
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Hansen S, Otten ND, Nissen SD, Carstensen H, Hopster-Iversen C, Fjeldborg J, Staun SH, Fenner M, Hesselkilde EM, Buhl R. Atrial fibrillation as a risk factor for exercise-induced pulmonary haemorrhage following a standardised exercise test. Equine Vet J 2024; 56:552-561. [PMID: 37654233 DOI: 10.1111/evj.13995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) has been proposed as a risk factor for exercise-induced pulmonary haemorrhage (EIPH) due to increased pressure in the left atrium. OBJECTIVE To evaluate if AF was associated with EIPH following a standardised exercise test (SET) to fatigue. STUDY DESIGN Two-arm controlled experiment. METHODS Ten untrained Standardbred mares mean (standard deviation [SD]) age 6 (2) years performed a SET on the treadmill in sinus rhythm (SR) (SET1) and 25-44 days after induction of self-sustained AF (SET2). AF was induced by tachypacing using a pacing device. Endoscopy, including tracheal wash and bronchoalveolar lavage (BAL), was performed 48-72 h before and 24 h after the two SETs. In addition, endoscopic grading of tracheal blood was performed 2 h after each SET. RESULTS After SET1, none of the horses showed blood in the trachea, and two horses showed erythrophagocytosis. Following SET2, two horses had grade 1 blood in the trachea and free erythrocytes and erythrophagocytosis in the BAL, while another two horses had erythrophagocytosis in the BAL. In SET2, the overall performance on the treadmill was decreased with a lower maximum velocity (SET1 10.3 ± 0.8 m/s vs. SET2 8.9 ± 0.9 m/s, p = 0.004), a higher heart rate (284 ± 21 vs. 221 ± 18 bpm, p = 0.003) and more abnormal QRS complexes (p < 0.001) compared with SET1. CONCLUSIONS Two horses showed signs of EIPH, resulting in visible blood in the trachea, when exercising in AF compared with SR. However, a possible link between EIPH, pulmonary pressure and AF needs to be further elucidated.
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Affiliation(s)
- Sanni Hansen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Nina D Otten
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg C, Denmark
| | - Sarah D Nissen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Helena Carstensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Charlotte Hopster-Iversen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Julie Fjeldborg
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Sophie H Staun
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Merle Fenner
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Eva M Hesselkilde
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
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Collie BL, Lyons NB, O'Neil CF, Ramsey WA, Lineen EB, Schulman CI, Proctor KG, Meizoso JP, Namias N, Ginzburg E. When is it safe to start thromboprophylaxis after splenic angioembolization? Surgery 2024; 175:1418-1423. [PMID: 38418296 DOI: 10.1016/j.surg.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events. METHODS All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05. RESULTS In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]). CONCLUSION This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.
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Affiliation(s)
- Brianna L Collie
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL.
| | - Nicole B Lyons
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Christopher F O'Neil
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Walter A Ramsey
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Edward B Lineen
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Carl I Schulman
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Kenneth G Proctor
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Jonathan P Meizoso
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Nicholas Namias
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Enrique Ginzburg
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
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Li FF, Guan YX, Li TX, Jiang D, He ZX, Xia P, Zhao XS. Analysis of hemorrhage upon ultrasound-guided percutaneous renal biopsy in China: a retrospective study. Int Urol Nephrol 2024; 56:1713-1720. [PMID: 37991602 PMCID: PMC11001650 DOI: 10.1007/s11255-023-03860-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/17/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE Ultrasound-guided percutaneous renal biopsy (PRB) has been considered as a golden standard for CKD diagnosis and is employed to identify potential therapeutic targets since 1950s. Post-biopsy hemorrhage is the most common complication, while severe bleeding complication might cause nephrectomy or death. Therefore, how to reduce the occurrence of complications while ensuring the success of PRB is always a clinical research topic. METHODS This study retrospectively collected and established a renal biopsy database of each patient who underwent ultrasound-guided PRB at a tertiary teaching hospital from September 2017 to December 2020 through the Health Information System. All the data were statistically processed by SPSS software. RESULTS A total of 1146 patients underwent PRB for various reasons. The overall rate of post-biopsy hemorrhage was 37.70% (432/1146). Of those bleedings, minor bleeding after PRB was found in 337 (29.41%), middle bleeding 84 (7.33%), major bleeding 11 (0.96%). Besides that, there were 96 patients (8.38%) reported their discomfort symptoms. There was no death. Females were at significantly increased risk of hemorrhagic complication than males (OR = 2.017, CI = 1.531-2.658). While the risk for hemorrhagic complication significantly decreased as BMI and platelet before renal biopsy increased (OR = 0.956, CI = 0.924-0.989; OR = 0.998, CI = 0.996-1.000). As the APTT time prolonged, the risk for hemorrhagic complication significantly increased (OR = 1.072, CI = 1.023-1.123). Those patients whose albumin were higher, also had higher risk for hemorrhagic complication than other patients (OR = 1.020, CI = 1.000-1.041). Specifically, postoperative urination within 4 h increased the risk for hemorrhagic complication (OR = 1.741, CI = 1.176-2.576). CONCLUSION Our analysis finds that the incidence of post-biopsy bleeding complication is 37.70%, and its risk is associated with female, lower BMI, lower platelet before renal biopsy, prolonged APTT, higher albumin, and postoperative urination within 4 h. The findings highlighted the importance of perioperative management for renal biopsy, including adequate risk assessment, tailored careful observation after PRB. And medical staff should pay more attention to fluid management after ultrasound-guided PRB.
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Affiliation(s)
- Fang-Fang Li
- Department of Endocrinology, Peking Union Medical College Hospital, Peking, China
| | - Yu-Xia Guan
- Department of Nephrology, Peking Union Medical College Hospital, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| | - Tong-Xin Li
- Department of Nephrology, Peking Union Medical College Hospital, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Di Jiang
- Intensive Care Unit, Peking Union Medical College Hospital, Peking, China
| | - Zi-Xia He
- Department of Nephrology, Peking Union Medical College Hospital, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Peng Xia
- Department of Nephrology, Peking Union Medical College Hospital, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Xue-Song Zhao
- Department of Nephrology, Peking Union Medical College Hospital, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
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Aoki M, Katsura M, Matsushima K. Association Between Whole Blood Transfusion and Mortality Among Injured Pediatric Patients. Ann Surg 2024; 279:880-884. [PMID: 37938850 DOI: 10.1097/sla.0000000000006150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
OBJECTIVE The aim of this study was to assess the association between whole blood (WB) and mortality among injured children who received immediate blood transfusion. BACKGROUND The use of WB for transfusion therapy in trauma has been revisited, and recent studies have reported an association between WB and improved survival among adults. However, evidence of a similar association lacks in children. METHODS We performed a retrospective cohort study from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2020 and 2021. Patients were aged less than or equal to 16 years and had immediate blood transfusion within 4 hours of hospital arrival. Survival at 24 hours and 30 days were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, injury type, vital signs on admission, trauma severity scores, hemorrhage control procedures, hospital characteristics, and the need for massive transfusion. RESULTS A total of 2729 patients were eligible for analysis. The median age was 14 years (interquartile range: 8-16 years); 1862 (68.2%) patients were male; and 1207 (44.2%) patients were White. A total of 319 (11.7%) patients received WB. After a 1:1 ratio propensity score matching, 318 matched pairs were compared. WB transfusion was associated with improved survival at 24 hours, demonstrating a 42% lower risk of mortality (hazard ratio, 0.58; 95% CI, 0.34-0.98; P =0.042) Similarly, the survival benefit associated with WB transfusion remained consistent at 30 days (hazard ratio, 0.65; 95% CI, 0.46-0.90; P =0.011). CONCLUSION The use of WB was associated with improved survival among injured pediatric patients requiring immediate transfusion.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Morihiro Katsura
- Department of Surgery, Okinawa Chubu Hospital, Okinawa, Japan
- Department of Surgery, Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Kazuhide Matsushima
- Department of Surgery, Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
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Katzenschlager S, Schneider NRE, Weilbacher F, Weigand MA, Popp E. Evaluating time until ligation in a novel tourniquet - A crossover randomized-controlled trial. Am J Emerg Med 2024; 79:97-104. [PMID: 38412670 DOI: 10.1016/j.ajem.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/16/2024] [Accepted: 02/17/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION AND AIM Severe external hemorrhage is a significant reason for morbidity and mortality in adults; thus, the swift and correct application of a tourniquet by laypersons can be lifesaving. We conducted this randomized-controlled cross-over study to investigate the use of a novel tourniquet. METHODS Participants were recruited at the Heidelberg University Hospital. Eligible participants were ≥ 18 years old with a medical background but without prior experience in applying a tourniquet. Participants were 1:1 randomized to the intervention group (PAX tourniquet) or the control group (SAM or CAT tourniquet). In the control group, participants underwent another randomization to either the SAM or CAT tourniquet without a predefined allocation ratio. Hyperspectral measurements were undertaken (i) before ligation, (ii) 30 s after ligation, and (iii) 30 s after the reopening of the tourniquet. The primary outcome was time until ligation before crossover between the respective groups. The analysis of secondary endpoints included all attempts to assess a possible learning effect, intraoperator variability, and hyperspectral measurements. Participants were crossed to the other study group after a brief wash-out phase. RESULTS In total, 50 participants were recruited, resulting in 100 attempts. A success rate of 98% was observed across the study population. Time until ligation was 49 s and 56 s (p = 0.572) in the intervention and control group, respectively. However, there was a significant difference between the PAX and SAM (54 vs 75 s; p = 0.037) and the SAM and CAT tourniquet (75 vs. 47 s; p = 0.015). Further, we observed a significant learning effect in participants allocated to the control group first, with a median reduction of 9 s in the time until ligation. Hyperspectral measurements showed a significant decrease in perfusion and tissue oxygenation after ligation. Further, a significant increase in perfusion and tissue oxygenation was found after reopening the tourniquet compared to the baseline measurement. CONCLUSION The novel PAX tourniquet can be applied quickly and effectively by medical personnel without prior experience in applying a tourniquet.
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Affiliation(s)
| | - Niko R E Schneider
- University of Southampton, Medical Faculty Campus Kassel, Department of Anaesthesiology and Critical Care Medicine.
| | - Frank Weilbacher
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology.
| | - Markus A Weigand
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology.
| | - Erik Popp
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology.
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陈 克, 邓 绍, 刘 茁, 张 洪, 马 潞, 张 树. [Discussion on the surgical timing of rupture and hemorrhage of renal angiomyolipoma]. Beijing Da Xue Xue Bao Yi Xue Ban 2024; 56:326-331. [PMID: 38595253 PMCID: PMC11004956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To investigate the effect of different surgical timing on the surgical treatment of renal angiomyolipoma (RAML) with rupture and hemorrhage. METHODS The demographic data and perioperative data of 31 patients with rupture and hemorrhage of RAML admitted to our medical center from June 2013 to February 2023 were collected. The surgery within 7 days after hemorrhage was defined as a short-term surgery group, the surgery between 7 days and 6 months after hemorrhage was defined as a medium-term surgery group, and the surgery beyond 6 months after hemorrhage was defined as a long-term surgery group. The perioperative related indicators among the three groups were compared. RESULTS This study collected 31 patients who underwent surgical treatment for RAML rupture and hemorrhage, of whom 13 were males and 18 were females, with an average age of (46.2±11.3) years. The short-term surgery group included 7 patients, the medium-term surgery group included 12 patients and the long-term surgery group included 12 patients. In terms of tumor diameter, the patients in the long-term surgery group were significantly lower than those in the recent surgery group [(6.6±2.4) cm vs. (10.0±3.0) cm, P=0.039]. In terms of operation time, the long-term surgery group was significantly shorter than the mid-term surgery group [(157.5±56.8) min vs. (254.8±80.1) min, P=0.006], and there was no significant difference between other groups. In terms of estimated blood loss during surgery, the long-term surgery group was significantly lower than the mid-term surgery group [35 (10, 100) mL vs. 650 (300, 1 200) mL, P < 0.001], and there was no significant difference between other groups. In terms of intraoperative blood transfusion, the long-term surgery group was significantly lower than the mid-term surgery group [0 (0, 0) mL vs. 200 (0, 700) mL, P=0.014], and there was no significant difference between other groups. In terms of postoperative hospitalization days, the long-term surgery group was significantly lower than the mid-term surgery group [5 (4, 7) d vs. 7 (6, 10) d, P=0.011], and there was no significant difference between other groups. CONCLUSION We believe that for patients with RAML rupture and hemorrhage, reoperation for more than 6 months is a relatively safe time range, with minimal intraoperative bleeding. Therefore, it is more recommended to undergo surgical treatment after the hematoma is systematized through conservative treatment.
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Affiliation(s)
- 克伟 陈
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 绍晖 邓
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 茁 刘
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 洪宪 张
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 潞林 马
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 树栋 张
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
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Mitsuishi A, Miura Y, Nomura Y, Hirota T, Arima N, Kitaoka H, Tateiwa H, Katsumata Y. Bleeding sites and treatment strategies for cardiac tamponade by catheter ablation requiring thoracotomy: risks of catheter ablation in patients with left atrial diverticulum. J Cardiothorac Surg 2024; 19:238. [PMID: 38632637 DOI: 10.1186/s13019-024-02710-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND There is insufficient information regarding the bleeding sites and surgical strategies of cardiac tamponade during catheter ablation for atrial fibrillation (AF). CASE PRESENTATION Of the five patients with cardiac tamponade, three required surgical intervention and two required pericardiocentesis. In the first case of three cardiac tamponades requiring surgical intervention, considering that the peripheral route was used, the catecholamines did not reach the heart, and due to unstable vital signs, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was inserted. No bleeding point was identified, but a thrombus had spread around the left atrium (LA) with diverticulum. Hemostasis was achieved with adhesives placed around the LA under on-pump beating. In the second case, pericardiocentesis was performed, but the patient showed heavy bleeding and unstable vital signs. Thus, VA-ECMO was inserted. Heavy bleeding was expected, and safety was enhanced by attaching a reservoir to the VA-ECMO. The bleeding point was found between the left upper pulmonary artery and LA under cardiac arrest to obtain a good surgical view for suturing repair. In the third case, the LA diverticulum was damaged. Pericardiocentesis resulted in stable vitals, but sustained bleeding was present. A bleeding point was found at the LA diverticulum, and suture repair under on-pump beating was performed. CONCLUSIONS When cardiac tamponade occured in any patient with LA diverticulum, treatment could not be completed with pericardiocentesis alone, and thoracotomy was likely to be necessary. If the bleeding point could be confirmed, suturing technique is a more reliable surgical strategy than adhesive alone that leads to pseudoaneurysm. If the bleeding point is unclear, it is important to confirm the occurrence of LA diverticulum using a preoperative CT, and if confirmed, cover it with adhesive due to a high possibility of diverticulum bleeding. The necessity of CPB should be determined based on whether these operations can be completed while maintaining vital stability.
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Affiliation(s)
- Atsuyuki Mitsuishi
- Department of Cardiovascular Surgery, Kochi Medical School Hospital, 185-1, Kohasu, Okohmachi, Nankoku-shi, Kochi Prefecture, 783-8505, Japan.
| | - Yujiro Miura
- Department of Cardiovascular Surgery, Kochi Medical School Hospital, 185-1, Kohasu, Okohmachi, Nankoku-shi, Kochi Prefecture, 783-8505, Japan
| | - Yoshinori Nomura
- Department of Clinical Engineering, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-shi, Kochi Prefecture, 783-8505, Japan
| | - Takayoshi Hirota
- Department of Cardiology and Geriatrics, Kochi Medical School Hospital, 185-1, Kohasu, Okohmachi, Nankoku-shi, Kochi Prefecture, 783-8505, Japan
| | - Naoki Arima
- Department of Cardiology and Geriatrics, Kochi Medical School Hospital, 185-1, Kohasu, Okohmachi, Nankoku-shi, Kochi Prefecture, 783-8505, Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School Hospital, 185-1, Kohasu, Okohmachi, Nankoku-shi, Kochi Prefecture, 783-8505, Japan
| | - Hiroki Tateiwa
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, 185-1, Kohasu, Okohmachi, Nankoku-shi, Kochi Prefecture, 783-8505, Japan
| | - Yoshifumi Katsumata
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, 185-1, Kohasu, Okohmachi, Nankoku-shi, Kochi Prefecture, 783-8505, Japan
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Zhang J, Zhen T, Jian H, Yang J, Zhang N. Arterial embolization in the treatment of multiple renal and hepatic hamartomas with spontaneous hemorrhage and 2-year follow-up: a case report. J Med Case Rep 2024; 18:208. [PMID: 38622693 PMCID: PMC11020817 DOI: 10.1186/s13256-024-04368-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 01/06/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Hamartoma is a common benign tumor that usually occurs in the kidney, liver, lung, and pancreas. Large renal hamartomas may spontaneously rupture and hemorrhage, which is potentially life-threatening. CASE PRESENTATION This report describes a 46-year-old Han Chinese female patient with multiple renal and hepatic hamartomas with rupture and hemorrhage of giant hamartoma in the left kidney. She underwent arterial embolization three times successively, and her condition was stable during the 2-year follow-up. This report includes a review of the relevant literature CONCLUSIONS: the findings in this report and previous literature suggest that arterial embolization can not only rapidly treat hamartoma hemorrhage in the acute phase but can also effectively control multiple lesions in the long term after repeated multisite arterial embolization.
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Affiliation(s)
- Jianhua Zhang
- Department of Interventional Radiology, Fengjie County People's Hospital, Chongqing, China
| | - Tao Zhen
- Department of Oncology, Fengjie County People's Hospital, Chongqing, China
| | - Hongmei Jian
- Department of Oncology, Fengjie County People's Hospital, Chongqing, China
| | - Jinlan Yang
- Department of Oncology, Fengjie County People's Hospital, Chongqing, China
| | - Ni Zhang
- Department of Oncology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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10
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Barg AA, Livnat T, Kenet G. Factor XI deficiency: phenotypic age-related considerations and clinical approach towards bleeding risk assessment. Blood 2024; 143:1455-1464. [PMID: 38194679 DOI: 10.1182/blood.2023020721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/11/2024] Open
Abstract
ABSTRACT Factor XI (FXI) deficiency is a rare bleeding disorder that presents complex challenges in patient assessment and bleeding risk management. Despite generally causing mild to moderate bleeding symptoms, clinical manifestations can vary, and bleeding tendency does not always correlate with FXI plasma levels or genotype. Our manuscript delves into the age-related nuances of FXI deficiency across an individual's lifespan. We emphasize issues faced by specific groups, including neonates and females of reproductive age experiencing abnormal uterine bleeding and postpartum hemorrhage. Older patients present unique challenges and concerns related to the management of bleeding as well as thrombotic complications. The current assortment of diagnostic laboratory assays shows limited success in predicting bleeding risk in the perisurgical setting of patients with FXI deficiency. This review explores the intricate interplay between individual bleeding profiles, surgical sites, and FXI activity levels. We also evaluate the accuracy of existing laboratory assays in predicting bleeding and discuss the potential role of investigational global assays in perioperative assessment. Furthermore, we outline our suggested diagnostic approach to refine treatment strategies and decision making. Available treatment options are presented, including antifibrinolytics, replacement products, and recombinant activated FVII. Finally, we discuss promising nonreplacement therapies for the treatment of rare bleeding disorders that can potentially address the challenges faced when managing FXI deficiency-related bleeding complications.
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Affiliation(s)
- Assaf Arie Barg
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Ziaja D, Sznapka M, Stasiów B, Ziaja K, Chudek J. X-ray-guided self-expandable metal stent (SEMS) implantation in oesophageal malignancy as an alternative treatment. Pol Przegl Chir 2024; 96:21-25. [PMID: 38629277 DOI: 10.5604/01.3001.0054.0954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
<b><br>Indroduction:</b> Significant dysphagia, aspiration pneumonia, and impossible oral nutrition in patients with unresectable or recurrent gastroesophageal malignancy or bronchial cancer invading the oesophagus with a tracheoesophageal fistula lead to cachexia. Dehiscence of the esophago-jejunal or gastroesophageal anastomosis may cause severe oesophageal haemorrhage. We believe that X-ray-guided oesophageal stent implantation (SEMS) is an alternative palliative method for microjejunostomy or full parenteral nutrition.</br> <b><br>Aim:</b> The aim of this paper was to assess the safety and efficacy of a novel X-ray-guided oesophageal stent implantation technique.</br> <b><br>Materials and methods:</b> This retrospective analysis included 54 patients (35 men and 19 women) treated for malignant dysphagia, gastroesophageal/gastrointestinal anastomotic fistula or bronchoesophageal fistula in two Surgical Units between 2010 and 2019, using a modified intravascular approach to oesophageal stent implantation.</br> <b><br>Results:</b> The presented modified intravascular method of oesophageal stent implantation was successfully performed in all described patients requiring oral nutrition restoration immediately following oesophageal stent implantation. Two patients with oesophageal anastomotic dehiscence died on postoperative days 7 and 9 due to circulatory and respiratory failure. One patient was reimplanted due to a recurrent fistula. Two patients with ruptured thoracic aneurysm and thoracic stent graft implantation due to oesophageal haemorrhage, who were implanted with an oesophageal stent, died on postoperative days 4 and 14.</br> <b><br>Conclusions:</b> The modified intravascular X-ray-guided SEMS technique may be a palliative treatment for patients with unresectable oesophageal malignancies.</br>.
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Affiliation(s)
- Damian Ziaja
- Department of Physiotherapy, Faculty of Health Sciences, Silesian Medical University in Katowice, Poland; Department of Vascular Surgery District Hospital in Sosnowiec, Poland
| | - Mariola Sznapka
- Department of Vascular Surgery District Hospital in Sosnowiec, Poland; Katowice Business University Faculty of Medicine, Poland
| | - Bartłomiej Stasiów
- Department of Radiology, Upper-Silesian Medical Centre in Katowice of Silesian Medical University in Katowice, Poland
| | - Krzysztof Ziaja
- Faculty of Medicine, Katowice Business University, Poland; Department of Vascular Surgery District Hospital in Sosnowiec, Poland
| | - Jerzy Chudek
- Department of Internal Medicine and Oncological Chemotherapy, Faculty of Medicine in Katowice, Silesian Medical University in Katowice, Poland
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12
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Lier H, Hossfeld B. Massive transfusion in trauma. Curr Opin Anaesthesiol 2024; 37:117-124. [PMID: 38390985 DOI: 10.1097/aco.0000000000001347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of currently recommended treatment approaches for traumatic hemorrhage shock, with a special focus on massive transfusion. RECENT FINDINGS Severe trauma patients require massive transfusion, but consensual international definitions for traumatic hemorrhage shock and massive transfusion are missing. Current literature defines a massive transfusion as transfusion of a minimum of 3-4 packed red blood cells within 1 h. Using standard laboratory and/or viscoelastic tests, earliest diagnosis and treatment should focus on trauma-induced coagulopathy and substitution of substantiated deficiencies. SUMMARY To initiate therapy immediately massive transfusion protocols are helpful focusing on early hemorrhage control using hemostatic dressing and tourniquets, correction of metabolic derangements to decrease coagulopathy and substitution according to viscoelastic assays and blood gases analysis with tranexamic acid, fibrinogen concentrate, red blood cells, plasma and platelets are recommended. Alternatively, the use of whole blood is possible. If needed, further support using prothrombin complex, factor XIII or desmopressin is suggested.
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Affiliation(s)
- Heiko Lier
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine, and University Hospital Cologne
| | - Björn Hossfeld
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Center of Emergency Medicine, HEMS 'Christoph 22', Armed Forces Hospital, Ulm, Germany
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13
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Arsenault V, Lieberman L, Akbari P, Murto K. Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review. Can J Anaesth 2024; 71:453-464. [PMID: 38057534 DOI: 10.1007/s12630-023-02641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada. METHODS After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content. RESULTS The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool. DISCUSSION/CONCLUSION Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.
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Affiliation(s)
- Valérie Arsenault
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of Montreal, Montreal, QC, Canada
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Mother and Child Hospital of Montreal, Montreal, QC, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Pegah Akbari
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Canada.
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14
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Appell LE, Mack JM, Farrar JE, Roper SN, Savage MR, Pandey S, Crary SE. Acquired Hemophilia: A Rare Complication of Pediatric Idiopathic Multicentric Castleman Disease. Pediatrics 2024; 153:e2023063168. [PMID: 38511235 DOI: 10.1542/peds.2023-063168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 03/22/2024] Open
Abstract
Acquired hemophilia is caused by acquired autoantibodies to 1 of the factors of the coagulation cascade, usually factor VIII or IX, and is an exceedingly rare phenomenon in children. The finding of an acquired factor VIII inhibitor in a pediatric patient with idiopathic multicentric Castleman disease has never been reported. Patients with acquired hemophilia can have life-threatening bleeds that are refractory to blood product support, requiring bypassing agents to manage bleeding symptoms. We present the novel finding of acquired hemophilia resulting from an autoantibody to factor VIII in a pediatric patient with idiopathic multicentric Castleman disease and discuss the optimal management of bleeding in a patient with acquired hemophilia.
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Affiliation(s)
- Lauren E Appell
- Department of Pediatrics, Division of Pediatric Hematology/Oncology
- Arkansas Children's Hospital, Little Rock Arkansas
| | - Joana M Mack
- Department of Pediatrics, Division of Pediatric Hematology/Oncology
- Arkansas Children's Hospital, Little Rock Arkansas
| | - Jason E Farrar
- Department of Pediatrics, Division of Pediatric Hematology/Oncology
- Arkansas Children's Hospital, Little Rock Arkansas
| | - Sydney N Roper
- College of Medicine
- Department of Medicine & Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew R Savage
- College of Medicine
- Department of Family Medicine, Baptist Health-University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Soumya Pandey
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Shelley E Crary
- Department of Pediatrics, Division of Pediatric Hematology/Oncology
- Arkansas Children's Hospital, Little Rock Arkansas
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15
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Ørskov M, Skjøth F, Behrendt CA, Nicolajsen CW, Eldrup N, Søgaard M. External Validation of the OAC 3-PAD Bleeding Score in a Nationwide Population of Patients Undergoing Invasive Treatment for Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2024; 67:621-629. [PMID: 38056523 DOI: 10.1016/j.ejvs.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/30/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE The OAC3-PAD score was developed to predict bleeding risk in patients with lower extremity peripheral arterial disease (PAD), but its performance in concomitant international cohorts is largely unknown. This study aimed to validate the OAC3-PAD score in an unselected nationwide population of patients undergoing invasive treatment for symptomatic PAD. METHODS This was a nationwide cohort study including all patients who underwent a first revascularisation procedure or major amputation for symptomatic PAD in Denmark from 2000 - 2021. The study population was stratified based on OAC3-PAD score, and the one year risk of major bleeding was assessed, accounting for the competing risk of death. The score performance was evaluated using calibration plots, C statistic, Brier score, and the index of prediction accuracy (IPA). RESULTS A total of 52 016 patients were included (mean age 71 years, 43.8% female). The one year risk of major bleeding increased with higher OAC3-PAD score, ranging from 1.6% (95% confidence interval [CI] 1.4 - 1.8%) to 2.3% (95% CI 2.0 - 2.5%), 3.5% (95% CI 3.2 - 3.8%), and 5.2% (95% CI 4.8 - 5.6%) for patients with low, low moderate, moderate high, and high score, respectively. Using patients with low risk as reference, the OAC3-PAD score effectively categorised patients, demonstrating statistically significant differences in bleeding risk across strata. However, the score showed modest discriminative performance, with a C statistic of 65% (95% CI 63 - 66%) and a Brier score of 2.6% (95% CI 2.5 - 2.7%). Nevertheless, it performed significantly better than the null model, as indicated by an IPA of 3.1%. CONCLUSION Among patients who underwent invasive treatment for symptomatic PAD in routine care, the OAC3-PAD score was associated with greater risk of major bleeding with increasing score level. However, its discriminatory ability was modest, and the clinical utility remains to be determined.
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Affiliation(s)
- Marie Ørskov
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark.
| | - Flemming Skjøth
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Research Data and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Chalotte W Nicolajsen
- Department of Surgery, Unit of Vascular Surgery, Regional Hospital Viborg, Viborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Mette Søgaard
- Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
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Cappato R, Mark DB, Silverstein AP, Noseworthy PA, Bonitta G, Poole JE, Piccini JP, Bahnson TD, Daniels MR, Al-Khalidi HR, Lee KL, Packer DL. Regional differences in outcomes with ablation versus drug therapy for atrial fibrillation: Results from the CABANA trial. Am Heart J 2024; 270:103-116. [PMID: 38307365 DOI: 10.1016/j.ahj.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/18/2024] [Accepted: 01/27/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND The finding of unexpected variations in treatment benefits by geographic region in international clinical trials raises complex questions about the interpretation and generalizability of trial findings. We observed such geographical variations in outcome and in the effectiveness of atrial fibrillation (AF) ablation versus drug therapy in the Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial. This paper describes these differences and investigates potential causes. METHODS The examination of treatment effects by geographic region was a prespecified analysis. CABANA enrolled patients from 10 countries, with 1,285 patients at 85 North American (NA) sites and 919 at 41 non-NA sites. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Death and first atrial fibrillation recurrence were secondary endpoints. RESULTS At least 1 primary endpoint event occurred in 157 patients (12.2%) from NA and 33 (3.6%) from non-NA sites over a median 54.9 and 40.5 months of follow-up, respectively (NA/non-NA adjusted hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.48-3.21, P < .001). In NA patients, 78 events occurred in the ablation and 79 in the drug arm, (HR 0.91, 95% CI 0.66, 1.24) while 11 and 22 events occurred in non-NA patients (HR 0.51, 95% CI 0.25,1.05, interaction P = .154). Death occurred in 53 ablation and 51 drug therapy patients in the NA group (HR 0.96, 95% CI 0.65,1.42) and in 5 ablation and 16 drug therapy patients in the non-NA group (HR 0.32, 95% CI 0.12,0.86, interaction P = .044). Adjusting for baseline regional differences or prognostic risk variables did not account for the regional differences in treatment effects. Atrial fibrillation recurrence was reduced by ablation in both regions (NA: HR 0.54, 95% CI 0.46, 0.63; non-NA: HR 0.44, 95% CI 0.30, 0.64, interaction P = .322). CONCLUSIONS In CABANA, primary outcome events occurred significantly more often in the NA group but assignment to ablation significantly reduced all-cause mortality in the non-NA group only. These differences were not explained by regional variations in procedure effectiveness, safety, or patient characteristics. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0091150; https://clinicaltrials.gov/study/NCT00911508.
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Affiliation(s)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC.
| | | | | | - Gianluca Bonitta
- L'altra Statistica Consultancy and Training, Biostatistics Office, Roma, Italy
| | | | | | | | | | | | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC
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Nardelli S, Riggio O, Marra F, Gioia S, Saltini D, Bellafante D, Adotti V, Guasconi T, Ridola L, Rosi M, Caporali C, Fanelli F, Roccarina D, Bianchini M, Indulti F, Spagnoli A, Merli M, Vizzutti F, Schepis F. Episodic overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt does not increase mortality in patients with cirrhosis. J Hepatol 2024; 80:596-602. [PMID: 38097113 DOI: 10.1016/j.jhep.2023.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/30/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND & AIMS Overt hepatic encephalopathy (OHE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS) placement, given its high incidence and possibility of refractoriness to medical treatment. Nevertheless, the impact of post-TIPS OHE on mortality has not been investigated in a large population. METHODS We designed a multicenter, non-inferiority, observational study to evaluate the mortality rate at 30 months in patients with and without OHE after TIPS. We analyzed a database of 614 patients who underwent TIPS in three Italian centers and estimated the cumulative incidence of OHE and mortality with competitive risk analyses, setting the non-inferiority limit at 0.12. RESULTS During a median follow-up of 30 months (IQR 12-30), 293 patients developed at least one episode of OHE. Twenty-seven (9.2%) of them experienced recurrent/persistent OHE. Patients with OHE were older (64 [57-71] vs. 59 [50-67] years, p <0.001), had lower albumin (3.1 [2.8-3.5] vs. 3.25 [2.9-3.6] g/dl, p = 0.023), and had a higher prevalence of pre-TIPS OHE (15.4% vs. 9.0%, p = 0.023). Child-Pugh and MELD scores were similar. The 30-month difference in mortality between patients with and without post-TIPS OHE was 0.03 (95% CI -0.042 to 0.102). Multivariable analysis showed that age (subdistribution hazard ratio 1.04, 95% CI 1.02-1.05, p <0.001) and MELD score (subdistribution hazard ratio 1.09, 95% CI 1.05-1.13, p <0.001), but not post-TIPS OHE, were associated with a higher mortality rate. Similar results were obtained when patients undergoing TIPS for variceal re-bleeding prophylaxis (n = 356) or refractory ascites (n = 258) were analyzed separately. The proportion of patients with persistent OHE after TIPS was significantly higher in the group of patients who died. The robustness of these results was increased following propensity score matching. CONCLUSION Episodic OHE after TIPS is not associated with mortality in patients undergoing TIPS, regardless of the indication. IMPACT AND IMPLICATIONS Overt hepatic encephalopathy (OHE) is a common complication in patients with advanced liver disease and it is particularly frequent following transjugular intrahepatic portosystemic shunt (TIPS) placement. In patients with cirrhosis outside the setting of TIPS, the development of OHE negatively impacts survival, regardless of the severity of cirrhosis or the presence of acute-on-chronic liver failure. In this multicenter, non-inferiority, observational study we demonstrated that post-TIPS OHE does not increase the risk of mortality in patients undergoing TIPS, irrespective of the indication. This finding alleviates concerns regarding the weight of this complication after TIPS. Intensive research to improve patient selection and risk stratification remains crucial to enhance the quality of life of patients and caregivers and to avoid undermining the positive effects of TIPS on survival.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy.
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Dario Saltini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniele Bellafante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Valentina Adotti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Tomas Guasconi
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Martina Rosi
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Cristian Caporali
- Department of Radiology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Fanelli
- Interventional Radiology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Davide Roccarina
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Marcello Bianchini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Federica Indulti
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Spagnoli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Filippo Schepis
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
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Levy-Mendelovich S, Greenberg-Kushnir N, Budnik I, Barg AA, Cohen O, Avishai E, Barazani-Brutman T, Livnat T, Kenet G. Emicizumab prophylaxis in infants: Single-centre experience. Br J Haematol 2024; 204:1375-1382. [PMID: 38266507 DOI: 10.1111/bjh.19312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 01/26/2024]
Abstract
The hallmark of haemophilia A (HA) therapy is prophylaxis, aimed at spontaneous bleeding prevention. Emicizumab provides a viable alternative to intravenous factor replacement therapy. However, data on its use in infants are limited. This single-centre open arm prospective study reports on emicizumab prophylaxis in infants. We included severe HA patients under 1 year who started emicizumab prophylaxis since 2018, with longitudinal follow-up. The study collected data on demographics, clinical and laboratory variables, the occurrence of bleeding events, surgeries and treatment outcomes. Of the 27 enrolled infants, whose median age at prophylaxis initiation was 7 months, 24 primarily choose to start emicizumab therapy (3/27 switched from FVIII prophylaxis due to development of FVIII inhibitors). The median age for prophylaxis initiation decreased to 3 months in 2023. Following emicizumab initiation, the median calculated ABR decreased, and no intracranial haemorrhages were observed. Thrombin generation showed a significant improvement in peak height and endogenous thrombin potential at steady state after a loading period. Our study highlights a shift towards early prophylaxis in the era of non-replacement therapies. It underscores the need for continuous evaluation and refinement of treatment approaches, emphasizing personalized care and diligent monitoring in the evolving field of paediatric haemophilia care.
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Affiliation(s)
- Sarina Levy-Mendelovich
- National Haemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
- Talpiot Medical Leadership Program, Sheba Medical center, Ramat Gan, Israel
| | - Noa Greenberg-Kushnir
- Department of Paediatric Hematology-Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Ivan Budnik
- Department of Internal Medicine, Division of Hematology/Oncology, University of Iowa, Iowa City, Iowa, USA
| | - Assaf Arie Barg
- National Haemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
| | - Omri Cohen
- National Haemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Einat Avishai
- National Haemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
| | - Tami Barazani-Brutman
- National Haemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- National Haemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Haemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
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19
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Anderson C, Towers S, Cribb B, Vermeulen W. Seminoma-a rare cause of a bleeding intra-abdominal mass. ANZ J Surg 2024; 94:767-768. [PMID: 38366702 DOI: 10.1111/ans.18908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
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Dorken-Gallastegi A, Naar L, Argandykov D, Lagazzi E, Dowling M, Montero P, Wallace B, Pallotta JB, Beagle J, Breen K, Velmahos GC, Duggan MJ, King DR. Safety of the injectable expanding biopolymer foam for non-compressible truncal bleeding in swine. Surgery 2024; 175:1189-1197. [PMID: 38092635 DOI: 10.1016/j.surg.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/15/2023] [Accepted: 11/07/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND A novel hydrophobically modified chitosan (hm-chitosan) polymer has been previously shown to improve survival in a non-compressible intra-abdominal bleeding model in swine. We performed a 28-day survival study to evaluate the safety of the hm-chitosan polymer in swine. METHODS Female Yorkshire swine (40-50 kg) were used. A mild, non-compressible, closed-cavity bleeding model was created with splenic transection. The hm-chitosan polymer was applied intra-abdominally through an umbilical nozzle in the same composition and dose previously shown to improve survival. Animals were monitored intraoperatively and followed 28 days postoperatively for survival, signs of pain, and end-organ function. Gross pathological and microscopic evaluations were performed at the conclusion of the experiment. RESULTS A total of 10 animals were included (hm-chitosan = 8; control = 2). The 2 control animals survived through 28 days, and 7 of the 8 animals from the hm-chitosan group survived without any adverse events. One animal from the hm-chitosan group required early termination of the study for signs of pain, and superficial colonic ulcers were found on autopsy. Laboratory tests showed no signs of end-organ dysfunction after exposure to hm-chitosan after 28 days. On gross pathological examination, small (<0.5 cm) peritoneal nodules were noticed in the hm-chitosan group, which were consistent with giant-cell foreign body reaction in microscopy, presumably related to polymer remnants. Microscopically, no signs of systemic polymer embolization or thrombosis were noticed. CONCLUSION Prolonged intraperitoneal exposure to the hm-chitosan polymer was tolerated without any adverse event in the majority of animals. In the single animal that required early termination, the material did not appear to be associated with end-organ dysfunction in swine. Superficial colonic ulcers that would require surgical repair were identified in 1 out of 8 animals exposed to hm-chitosan.
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Affiliation(s)
- Ander Dorken-Gallastegi
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA. https://twitter.com/AnderDorken
| | - Leon Naar
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA. https://twitter.com/lnaar
| | - Dias Argandykov
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA. https://twitter.com/argandykov
| | - Emanuele Lagazzi
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Surgery, Humanitas Research Hospital, Rozzano, Italy. https://twitter.com/EmanueleLagazzi
| | | | | | | | - Jessica B Pallotta
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - John Beagle
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kerry Breen
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - George C Velmahos
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael J Duggan
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David R King
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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21
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Nakamura M, Sakon M, Sasako M, Okusaka T, Mukai H, Fujiwara K, Kunitoh H, Oba MS, Wada H, Hosokawa J, Takita A, Ikeda M. Association of D-dimer level with thrombotic events, bleeding, and mortality in Japanese patients with solid tumors: a Cancer-VTE Registry subanalysis. Int J Clin Oncol 2024; 29:407-416. [PMID: 38430303 DOI: 10.1007/s10147-024-02475-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/10/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND The D-dimer test is a simple test frequently used in routine clinical screening for venous thromboembolism (VTE). The Cancer-VTE Registry was a large-scale, multicenter, prospective, observational study in Japanese patients with cancer. This study aimed to clarify the relationship between D-dimer level at cancer diagnosis (baseline) and the incidence of events during cancer treatment (1-year follow-up period). METHODS This was a post hoc sub-analysis of patients from the Cancer-VTE Registry whose D-dimer levels were measured at baseline. The incidence of events during the 1-year follow-up period was evaluated stratified by baseline D-dimer level. Adjusted hazard ratios for D-dimer level and events during the follow-up period were evaluated. RESULTS Among the total enrolled patients, baseline D-dimer level was measured in 9020 patients. The mean ± standard deviation baseline D-dimer level was 1.57 ± 3.94 µg/mL. During the follow-up period, the incidence of VTE, cerebral infarction/transient ischemic attack (TIA)/systemic embolic events (SEE), bleeding, and all-cause death increased with increasing baseline D-dimer level. The incidence of all-cause death increased with increasing D-dimer level regardless of cancer stage. The adjusted hazard ratio of all-cause death was 1.03 (95% confidence interval: 1.02-1.03) per 1.0-µg/mL increase in baseline D-dimer level. CONCLUSIONS Increases in D-dimer levels were associated with a higher risk of thrombotic events, such as VTE and cerebral infarction/TIA/SEE, during cancer treatment. Furthermore, higher D-dimer levels at cancer diagnosis were associated with a higher mortality rate, regardless of cancer stage.
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Affiliation(s)
- Mashio Nakamura
- Nakamura Medical Clinic, 7-1510, Hidamarinooka, Kuwana, Mie, 511-0867, Japan.
| | - Masato Sakon
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Chuo-Ku, Osaka, Japan
| | - Mitsuru Sasako
- Department of Surgery, Yodogawa Christian Hospital, Higashi Yodogawa-Ku, Osaka, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-Ku, Tokyo, Japan
| | - Hirofumi Mukai
- Division of Medical Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Keiichi Fujiwara
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Hideo Kunitoh
- Department of Medical Oncology, Japanese Red Cross Medical Center, Shibuya-Ku, Tokyo, Japan
| | - Mari S Oba
- Department of Medical Statistics, Toho University, Ota-Ku, Tokyo, Japan
- Department of Clinical Data Science, Clinical Research & Education Promotion Division, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Mie, Japan
| | - Jun Hosokawa
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd, Chuo-Ku, Tokyo, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd, Shinagawa-Ku, Tokyo, Japan
| | - Masataka Ikeda
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
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22
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Abdelaziz A, Elsayed H, Atta K, Mechi A, Kadhim H, Aboutaleb AM, Elaraby A, Ellabban MH, Eid M, AboElfarh HE, Ibrahim RA, Zawaneh EA, Ezzat M, Abdelaziz M, Hafez A, Mahmoud A, Ghaith HS, Suppah M. A comprehensive guide on the optimal timing of PCI in the setting of acute coronary syndrome: An updated meta-analysis. Int J Cardiol 2024; 400:131774. [PMID: 38211674 DOI: 10.1016/j.ijcard.2024.131774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/19/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Invasive revascularization is recommended for cohorts of patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE-ACS). However, the optimal timing of invasive revascularization is still controversial and no defined consensus is established. We aim to give a comprehensive appraisal on the optimal timing of invasive strategy in the heterogenous population of ACS. METHODS Relevant studies were assessed through PubMed, Scopus, Web of science, and Cochrane Library from inception until April 2023. Major adverse cardiovascular events (MACE) and all-cause mortality were our primary outcomes of interest, other secondary outcomes were cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. The data was pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random effect model using STATA 17 MP. RESULTS A total of 26 studies comprising 21,443 patients were included in the analysis. Early intervention was favor to decrease all-cause mortality (OR = 0.79, 95% CI: 0.64 to 0.98, p = 0.03), when compared to delayed intervention. Subgroup analysis showed that early intervention was significantly associated with all-cause mortality reduction in only NSTE-ACS (OR = 0.83, 95% CI [0.7 to 0.99], p = 0.04). However, there was no significant difference between early and delayed intervention in terms of MACE, cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. CONCLUSION An early intervention was associated with lower mortality rates compared to delayed intervention in NSTE-ACS with no significant difference in other clinical outcomes. PROSPERO registration: CRD42023415574.
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Affiliation(s)
- Ahmed Abdelaziz
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
| | - Hanaa Elsayed
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Karim Atta
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Institute of Medicine, National Research Mordovia State University, Saransk, Russia
| | - Ahmed Mechi
- University of Kufa, Medicine College, Internal Medicine Department, Najaf, Iraq
| | | | - Aya Moustafa Aboutaleb
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Elaraby
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Hatem Ellabban
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mahmoud Eid
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Hadeer Elsaeed AboElfarh
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Mansoura Manchester Programme for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Rahma AbdElfattah Ibrahim
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Kafr Elsheikh University, Kafr Elsheikh, Egypt
| | - Emad Addin Zawaneh
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of medicine, Jordan university of science and technology, Irbid, Jordan
| | - Mahmoud Ezzat
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Mohamed Abdelaziz
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Abdelrahman Hafez
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Mahmoud
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Hazem S Ghaith
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mustafa Suppah
- Department of Cardiovascular Medicine, Mayo Clinic, 13400 E Shea Boulevard, Scottsdale, AZ 85259, USA
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23
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Sakai M, Sohda M, Uchida S, Yamaguchi A, Watanabe T, Saito H, Nakazawa N, Kuriyama K, Sano A, Ogawa H, Yokobori T, Nagai K, Shirabe K, Saeki H. Efficacy of thoracic endovascular aortic repair for aorto-esophageal fistula due to esophageal cancer: a systematic review and meta-analysis. Esophagus 2024; 21:95-101. [PMID: 38302854 DOI: 10.1007/s10388-024-01042-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/31/2023] [Indexed: 02/03/2024]
Abstract
Aorto-esophageal fistula (AEF) due to esophageal cancer (EC) is a life-threatening condition characterized by sudden hemorrhage, which often causes sudden death. To evaluate the efficacy and safety of thoracic endovascular aortic repair (TEVAR) for AEF due to EC, we performed a systematic review and meta-analysis. We searched the MEDLINE (PubMed) databases, the Cochrane Library databases, Ichushi-Web (the databases of the Japan Medical Abstract Society), and CiNii (Academic information search service of the National Institute of Information from Japan) from January 2000 to November 2023 for articles about TEVAR for an emergent aortic hemorrhage (salvage TEVAR [S-TEVAR]), and the prophylactic procedure (P-TEVAR). Six studies (140 cases) were eligible for meta-analysis. The 90-day mortality of S-TEVAR and P-TEVAR was 40% (95% CI 23-60, I2 = 36%) and 8% (95% CI 3-17, I2 = 0%), respectively. Post-S-TEVAR hemorrhagic and infectious complications were 17% (95% CI 3-57, I2 = 71%) and 20% (95% CI 5-57, I2 = 66%), respectively. Post-P-TEVAR hemorrhagic and infectious complications were 2% (95% CI 0-10, I2 = 0%) and 3% (95% CI 1-12, I2 = 0%), respectively. TEVAR for AEF due to EC may be a useful therapeutic option to manage or prevent hemorrhagic oncological emergencies.
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Affiliation(s)
- Makoto Sakai
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Makoto Sohda
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Shintaro Uchida
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Arisa Yamaguchi
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Takayoshi Watanabe
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Hideyuki Saito
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Nobuhiro Nakazawa
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Kengo Kuriyama
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Akihiko Sano
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Hiroomi Ogawa
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | | | - Kazue Nagai
- Gunma University Center for Food Science and Wellness, Maebashi, Japan
| | - Ken Shirabe
- Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Hiroshi Saeki
- Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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24
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Araujo AV, Wax MK, Clayburgh DR, Andersen PE, Chandra RA, Li RJ. Acute and definitive management of oropharyngeal hemorrhage in patients with squamous cell carcinoma of the oropharynx. Head Neck 2024; 46:896-904. [PMID: 38216834 DOI: 10.1002/hed.27632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 12/19/2023] [Accepted: 12/31/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Massive oropharyngeal bleeding post-chemoradiotherapy is a life-threatening condition that requires emergent management. METHODS This retrospective case series included 11 patients with oropharyngeal squamous cell carcinoma who suffered from massive bleeding during or following treatment with definitive chemoradiotherapy. Details of acute and definitive management of oropharyngeal bleeding are reported. RESULTS Nine of 11 hemorrhagic events occurred a mean (SD) of 88.6 days (53.6) after radiotherapy. Airway intubation and embolization were performed in 10 of 11 patients, followed by surgery in 7 of 11 patients. The most commonly embolized vessels were the external carotid and lingual arteries. At the time of discharge, 3 of 11 patients had a tracheostomy, and 7 of 11 continued to use a gastrostomy tube. Four patients died. CONCLUSIONS Hemorrhagic complications in oropharyngeal cancer treatment require emergent responses. Developing a workflow for coordination between multidisciplinary teams can maximize probability of survival and decrease morbidity.
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Affiliation(s)
- Ana V Araujo
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark K Wax
- Department of Otolaryngology - Head and Neck Surgery, School of Medicine Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel R Clayburgh
- Department of Otolaryngology - Head and Neck Surgery, School of Medicine Oregon Health & Science University, Portland, Oregon, USA
| | - Peter E Andersen
- Department of Otolaryngology - Head and Neck Surgery, School of Medicine Oregon Health & Science University, Portland, Oregon, USA
| | - Ravi A Chandra
- Department of Radiation Oncology, Mid-Atlantic Permanente Medical Group, Kensington, Maryland, USA
| | - Ryan J Li
- Department of Otolaryngology - Head and Neck Surgery, School of Medicine Oregon Health & Science University, Portland, Oregon, USA
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25
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Hur JY, Choi N, Choi JH, Kim J, Won YW. Risk of thrombosis, hemorrhage and leukemic transformation in patients with myeloproliferative neoplasms: A nationwide longitudinal cohort study. Thromb Res 2024; 236:209-219. [PMID: 38461615 DOI: 10.1016/j.thromres.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION There are few large-scale, population-based studies detailing the risks of thrombosis, hemorrhage, leukemic transformation in patients with myeloproliferative neoplasms (MPNs), including essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (PMF). METHODS We performed a nationwide longitudinal cohort study using the Korean National Health Insurance System (NHIS) database. MPN patients (n = 11,991) and their 1:4 age- and sex-matched controls (n = 47,964) were enrolled. The risk of thrombosis, hemorrhage, leukemic transformation was estimated using a Cox proportional hazards regression, and stratified analyses were performed for related factors. RESULTS During a median of 7.8 years of follow-up, 30.1 % of MPN patients (3614/11,991) and 19.0 % of the matched controls (9141/47,964) developed arterial thrombosis, 11.6 % of MPN patients (1397/11,991) and 6.4 % of the matched controls (3099/47,964) developed venous thrombosis and 18.7 % of MPN patients (2251/11,991) and 12.1 % of the matched controls (5836/47,964) developed hemorrhage. 4.9 % of MPN patients (597/11,991) and 0.1 % of matched controls (50/47,964) developed leukemia. The overall risk of developing thrombosis, hemorrhage, leukemic transformation was higher in MPN patients (adjusted hazard ratio [aHR] 1.695, 95 % confidence interval [CI]: 1.629-1.765 for arterial thrombosis, aHR 1.963, 95 % CI: 1.838-2.096 for venous thrombosis, and aHR 1.714, 95 % CI: 1.630-1.802 for hemorrhage) than in the controls. Patients with MPNs had a 10-year cumulative incidence of leukemic transformation of 6.2 %. CONCLUSION The patients with MPNs have a higher risk of thrombosis, hemorrhage, and leukemic transformation than matched controls. Strategies are warranted to reduce the risk of thrombosis, hemorrhage, and leukemic transformation in MPN patients.
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Affiliation(s)
- Joon Young Hur
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Republic of Korea
| | - Nayeon Choi
- Biostatistics Lab, Medical Research Collaborating Center, Industry-University Cooperation Foundation, Hanyang University, Seoul, Republic of Korea
| | - Jung Hye Choi
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Republic of Korea
| | - Jiyeong Kim
- Biostatistics Lab, Medical Research Collaborating Center, Industry-University Cooperation Foundation, Hanyang University, Seoul, Republic of Korea; Department of Pre-Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Young-Woong Won
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Republic of Korea.
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26
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Dahlbacka S, Nykänen AI, Juvonen T, Jormalainen M. Access site complications in thoracic endovascular aortic repair. J Vasc Surg 2024; 79:740-747.e2. [PMID: 38056701 DOI: 10.1016/j.jvs.2023.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Percutaneous access and use of vascular closure devices facilitate thoracic endovascular aortic repair (TEVAR) procedures during local anesthesia and allow immediate detection of signs of spinal ischemia. However, the very large bore access (usually ≥22F sheath) associated with TEVAR increases the risk of vascular complications. In this study, we sought to define the safety and feasibility of two percutaneous femoral artery closure devices during TEVAR, in terms of access site vascular complications and major, life-threatening, or fatal bleeding (≥major) within 48 hours. Access site vascular complications were defined as technical failure of vascular closure or later formation of pseudoaneurysm. METHODS From March 2010 to December 2022, 199 transfemoral TEVAR were performed at Helsinki University Central Hospital, Finland. We retrospectively categorized these into three groups, based on surgeon preference for the access technique and femoral artery closure method: (1) surgical cut-down and vessel closure, n = 85 (42.7%), (2) percutaneous access and vascular closure with suture-based ProGlide, n = 56 (28.1%), or (3) percutaneous access and vascular closure with ultrasound-guided plug-based MANTA, n = 58 (29.1%). The primary outcome measure was technical success of vascular closure and access site vascular complications during index hospitalization. Secondary outcome measures were ≥major bleeding, early mortality, and hospital stay. RESULTS The technical success rate was 97.6% vs 91.1% vs 93.1% for surgical cut-down, ProGlide, and MANTA, respectively (P = .213). The rate of access site vascular complication was 3.5% vs 8.9% vs 10.3%, respectively (P = .290), with two pseudoaneurysms detected postoperatively and conservatively managed in the MANTA group. The vascular closure method was not associated with increased risk of ≥major bleeding, early mortality, or hospital stay on univariate analysis. Predictors for ≥major bleeding after TEVAR in multivariable analysis were urgent procedure (odds ratio: 2.8, 95% confidence interval: 1.4-5.5; P = .003) and simultaneous aortic branch revascularization (odds ratio: 2.7, 95% confidence interval: 1.3-5.4; P = .008). CONCLUSIONS In this study, the technical success rates of the percutaneous techniques demonstrated their feasibility during TEVAR. However, the number of access site complications for percutaneous techniques was higher compared with open approach, although the difference was not statistically significant. In the lack of evidence, the safety of the new MANTA plug-based vascular closure for TEVAR warrants further investigation.
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Affiliation(s)
- Sebastian Dahlbacka
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Antti I Nykänen
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tatu Juvonen
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Jormalainen
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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27
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Noye J, Beggs J, Mason J. Discrepant low von Willebrand factor activity results on the ACL TOP analyzer are frequent in unselected patients with myeloproliferative neoplasms and show no correlation with high-molecular-weight multimer loss or bleeding phenotype. J Thromb Haemost 2024; 22:965-974. [PMID: 38160725 DOI: 10.1016/j.jtha.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Bleeding complications are common in patients with myeloproliferative neoplasms (MPNs), with a subset developing acquired von Willebrand disease. Despite this association, a wide spectrum of von Willebrand factor (VWF) abnormalities are described, and the performance of modern assays remains unclear. OBJECTIVES To comprehensively describe the pattern of VWF laboratory abnormalities in the MPN population. METHODS We collected samples from 74 unselected clinic patients with MPNs to evaluate VWF quantitatively and qualitatively via multiple methods, correlating findings with a retrospective analysis of clinical bleeding data. VWF assays were performed on both ACL TOP (Instrumentation Laboratory) and Acustar (Instrumentation Laboratory) analyzers using HemosIL reagents (Instrumentation Laboratory), along with multimer analysis by gel electrophoresis. RESULTS Functional VWF measurements were not concordant between assays, with a median ACL TOP VWF glycoprotein IbR to antigen ratio (VWF:GPIbR/VWF:Ag) of 0.57 (IQR, 0.43-0.71) compared to a median Acustar VWF:GPIbR/VWF:Ag of 0.91 (IQR: 0.82-1.03;P < .001). The ACL TOP showed disproportionately lower results, with 73% of patients having a ratio <0.7. Despite this, no patient experienced loss of high-molecular-weight multimers by gel electrophoresis. An inverse relationship was observed between platelet count and functional ratios on both ACL TOP (R2 = 0.20; P < .001) and Acustar (R2 = 0.18; P = .0011) analyzers. While clinically significant bleeding events were relatively common (11% patients), there was no association with VWF assay abnormalities, and generally, an alternate cause(s) was identified. CONCLUSION Discrepancies in functional VWF assays are common in patients with MPN, particularly by ACL TOP VWF:GPIbR. Based on our limited series, a VWF functional to an antigenic ratio of <0.7 ("type 2 pattern") alone is poorly predictive of bleeding risk.
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Affiliation(s)
- Joseph Noye
- Department of Haematology, Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
| | - Joanne Beggs
- Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jane Mason
- Department of Haematology, Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Kartika T, Mathews R, Migneco G, Bundy T, Kaempf AJ, Pfeffer M, DeLoughery TG, Moore K, Beardshear R, Oetken HJ, Case J, Hinds MT, McCarty OJT, Shatzel JJ, Zonies D, Zakhary B. Comparison of bleeding and thrombotic outcomes in veno-venous extracorporeal membrane oxygenation: Heparin versus bivalirudin. Eur J Haematol 2024; 112:566-576. [PMID: 38088062 DOI: 10.1111/ejh.14146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
OBJECTIVES We aimed to evaluate thrombotic and hemorrhagic complications with heparin versus bivalirudin use in veno-venous extracorporeal membrane oxygenation (V-V ECMO). METHODS We performed a retrospective cohort study of adult patients placed on V-V ECMO with intravenous anticoagulation with either heparin or bivalirudin. Time to thrombotic event and major bleed were analyzed in addition to related outcomes. RESULTS We identified 95 patients placed on V-V ECMO: 61 receiving heparin, 34 bivalirudin. The bivalirudin group had a higher rate of severe COVID-19, higher BMI, and longer ECMO duration. Despite this, bivalirudin was associated with reduced risk of thrombotic event (HR 0.14, 95% CI 0.06-0.32, p < .001) and increased average lifespan of the circuit membrane lung (16 vs. 10 days, p = 0.004). While there was no difference in major bleeding, the bivalirudin group required fewer transfusions of packed red blood cells and platelets per 100 ECMO days (means of 13 vs. 39, p = 0.004; 5 vs. 19, p = .014, respectively). Lastly, the bivalirudin group had improved survival to ECMO decannulation in univariate analysis (median OS 53 vs. 26 days, p = .015). CONCLUSIONS In this real-world analysis of bivalirudin versus heparin, bivalirudin is a viable option for V-V ECMO and associated with lower risk of thrombotic complications and fewer transfusion requirements.
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Affiliation(s)
- Thomas Kartika
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Rick Mathews
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Gina Migneco
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Taylor Bundy
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Andy J Kaempf
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Michael Pfeffer
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Kerry Moore
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Rachel Beardshear
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Heath J Oetken
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Jonathan Case
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Monica T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - David Zonies
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Ahmad S, Yousaf A, Ghumman GM, Dvalishvili M, Ahsan MJ, Dilibe A, Reis HL, Qavi AH, Szerlip M, Goldsweig AM. Outcomes of transcatheter aortic valve replacement in patients with mitral annular calcification and concomitant mitral valve dysfunction: A systematic review and meta-analysis. Cardiovasc Revasc Med 2024; 61:99-109. [PMID: 37867120 DOI: 10.1016/j.carrev.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Calcific aortic stenosis is the principal indication for transcatheter aortic valve replacement (TAVR). Comorbid mitral annular calcification (MAC) is often present in patients undergoing TAVR. Limited data exist on the impact of MAC on TAVR outcomes. We conducted a systematic review and meta-analysis to explore the effects of MAC and concomitant mitral valve dysfunction (MVD) on TAVR outcomes. METHODS A comprehensive literature review was conducted using PubMed, Embase, Google Scholar, ClinicalTrials.gov, Scopus, and OVID for studies until March 20, 2023. Using the random-effects Mantel-Haenszel method, we calculated pooled risk ratios (RRs) and their corresponding 95 % confidence intervals (CIs) for all dichotomous variables. RESULTS Six studies comprising 5822 patients (2541 with MAC [severe MAC (>4 mm thickness) 583; non-severe MAC 1958; 400 with MVD; and 1071 without MVD], 3281 without MAC) met inclusion criteria. At 30 days and 1 year, no significant differences were observed between the overall MAC and no MAC groups in terms of mortality, stroke, and permanent pacemaker implantation. However, MAC with MVD was associated with a higher risk of all-cause mortality compared to MAC without MVD at 30 days (RR = 3.43, 95 % CI 2.04-5.76, P < 0.00001) and at 1 year (RR = 2.44, 95 % CI 1.85-3.20, P < 0.00001). Moreover, the risk of cardiovascular mortality was higher in patients with MAC and MVD compared to those with MAC alone (RR = 2.77, 95 % CI 1.89-4.06, P < 0.00001). Additionally, patients with severe MAC had a higher risk of major bleeding at 30 days compared to the non-severe MAC group (RR = 1.33, 95 % CI 1.04-1.69, P = 0.02). CONCLUSION TAVR appears to be safe in patients with non-severe MAC, but severe MAC is associated with a higher risk of major bleeding and concomitant MVD increases the mortality risk in patients undergoing TAVR.
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Affiliation(s)
- Soban Ahmad
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Department of Medicine, East Carolina University, Greenville, NC, USA.
| | - Amman Yousaf
- Department of Medicine, McLaren Flint-Michigan State University, Flint, MI, USA
| | | | | | | | - Arthur Dilibe
- Department of Medicine, East Carolina University, Greenville, NC, USA
| | - Heidi Lynn Reis
- William E Laupus Health Sciences Library, East Carolina University, Greenville, NC, USA
| | - Ahmed Hassaan Qavi
- Division of Cardiovascular Medicine, East Carolina Heart Institute, Greenville, NC, USA
| | - Molly Szerlip
- Department of Cardiology, Baylor Scott and White, The Heart Hospital Plano, Plano, TX, USA
| | - Andrew Michael Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Department of Cardiology, Baystate Medical Center/UMass Chan Medical School, Springfield, MA, USA
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Schiller O, Pula G, Shostak E, Manor-Shulman O, Frenkel G, Amir G, Yacobovich J, Nellis ME, Dagan O. Patient-tailored platelet transfusion practices for children supported by extracorporeal membrane oxygenation. Vox Sang 2024; 119:326-334. [PMID: 38175143 DOI: 10.1111/vox.13583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Extracorporeal membrane oxygenation (ECMO) serves as cardiopulmonary therapy in critically ill patients with respiratory/heart failure and often necessitates multiple blood product transfusions. The administration of platelet transfusions during ECMO is triggered by the presence or risk of significant bleeding. Most paediatric ECMO programmes follow guidelines that recommend a platelet transfusion threshold of 80-100 × 109/L. To reduce exposure to platelets, we developed a practice to dynamically lower the threshold to ~20 × 109/L. We describe our experience with patient-tailored platelet thresholds and related bleeding outcomes. MATERIALS AND METHODS We retrospectively evaluated our platelet transfusion policy, bleeding complications and patient outcome in 229 ECMO-supported paediatric patients in our unit. RESULTS We found that more than 97.4% of patients had a platelet count <100 × 109/L at some point during their ECMO course. Platelets were transfused only on 28.5% of ECMO days; and 19.2% of patients never required a platelet transfusion. The median lowest platelet count in children who had bleeding events was 25 × 109/L as compared to 33 × 109/L in children who did not bleed (p < 0.001). Our patients received fewer platelet transfusions and did not require more red blood cell transfusions, nor did they experience more haemorrhagic complications. CONCLUSION We have shown that a restrictive, 'patient-tailored' rather than 'goal-directed' platelet transfusion policy is feasible and safe, which can greatly reduce the use of platelet products. Although there was a difference in the lowest platelet counts in children who bled versus those who did not, the median counts were much lower than current recommendations.
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Affiliation(s)
- Ofer Schiller
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Giulia Pula
- Children's Heart Centre, Division of Cardiology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Eran Shostak
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orit Manor-Shulman
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Georgy Frenkel
- Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Gabriel Amir
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Joanne Yacobovich
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology-Oncology Center, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, New York, USA
| | - Ovadia Dagan
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Wienhold J, Rayatdoost F, Schöchl H, Grottke O. Antidote vs. unspecific hemostatic agents for the management of direct oral anticoagulant-related bleeding in trauma. Curr Opin Anaesthesiol 2024; 37:101-109. [PMID: 38390922 DOI: 10.1097/aco.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The advent of direct oral anticoagulants (DOACs) marks a significant milestone in anticoagulant treatment. However, DOACs can exacerbate bleeding, which is challenging for the treating clinician, especially when combined with traumatic injury. RECENT FINDINGS In major bleeding associated with DOACs, rapid reversal of the anticoagulant effects is crucial. Recent observational and nonrandomized interventional trials have demonstrated the effectiveness of the specific antidotes andexanet alfa and idarucizumab as well as the unspecific prothrombin complex concentrates (PCCs) to counteract the anticoagulant effects of DOACs. The European Society of Anaesthesiology and Intensive Care guideline for severe perioperative bleeding and the European trauma guideline propose divergent recommendations for the use of andexanet alfa and PCC to obtain hemostasis in Factor Xa inhibitor-related bleeding. The conflicting recommendations are due to limited evidence from clinical studies and the potential increased risk of thromboembolic complications after the administration of andexanet. Regarding dabigatran-associated major bleeding, both guidelines recommend the specific reversal agent idarucizumab as first-line therapy. SUMMARY Current guidelines recommend specific antidots and PCCs in DOAC-related major bleeding. Prospective randomized trials comparing specific vs. nonspecific hemostatic agents in the perioperative setting are needed to evaluate the effectiveness and safety of the hemostatic agents.
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Affiliation(s)
- Jan Wienhold
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Farahnaz Rayatdoost
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, Vienna, Austria
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
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Lambert C, Maitland H, Ghanima W. Risk-based and individualised management of bleeding and thrombotic events in adults with primary immune thrombocytopenia (ITP). Eur J Haematol 2024; 112:504-515. [PMID: 38088207 DOI: 10.1111/ejh.14154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 03/19/2024]
Abstract
Although bleeding is one of the main symptoms of primary immune thrombocytopenia (ITP), risk factors for bleeding have yet to be fully established. Low platelet count (PC; <20-30 × 109 /L) is generally indicative of increased risk of bleeding. However, PC and bleeding events cannot be fully correlated; many other patient- and disease-related factors are thought to contribute to increased bleeding risk. Furthermore, even though ITP patients have thrombocytopenia and are at increased risk of bleeding, ITP also carries higher risk of thrombotic events. Factors like older age and certain ITP treatments are associated with increased thrombotic risk. Women's health in ITP requires particular attention concerning haemorrhagic and thrombotic complications. Management of bleeding/thrombotic risk, and eventually antithrombotic therapies in ITP patients, should be based on individual risk profiles, using a tailored, patient-centric approach. Currently, evidence-based recommendations and validated tools are lacking to support decision-making and help clinicians weigh risk of bleeding against thrombosis. Moreover, evidence is lacking about optimal PC for achieving haemostasis in invasive procedures settings. Further research is needed to fully define risk factors for each event, enabling development of comprehensive risk stratification approaches. This review discusses risk-based and individualised management of bleeding and thrombosis risk in adults with primary ITP.
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Affiliation(s)
- Catherine Lambert
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Hillary Maitland
- Division of Hematology and Oncology, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Waleed Ghanima
- Department of Hemato-oncology, Østfold Hospital, Oslo University, Oslo, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
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Parvin-Nejad FP, Vegunta G, Mele G, Sifri ZC. Stop the Bleed in the Era of Virtual Learning: A Novel Strategy for Remote Teaching and Evaluation. J Surg Res 2024; 296:759-765. [PMID: 38377702 DOI: 10.1016/j.jss.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/16/2023] [Accepted: 01/06/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Traumatic hemorrhage is a leading cause of preventable mortality worldwide. The Stop the Bleed (STB) course was developed to equip layperson bystanders with basic bleeding control knowledge and skills. However, large in-person courses have been disrupted due to COVID-19. The aim of this study was to determine the feasibility of teaching and evaluating STB skills through remote video-based instruction. METHODS After undergoing COVID-19 screening, groups of up to eight STB-naive adults were seated in a socially distanced manner and given individual practice kits. A remote STB-certified instructor provided the standard STB lecture and led a 10-min skills practice session via videoconferencing. Participants' skills were evaluated on a 10-point rubric by one in-person evaluator and three remote evaluators. Participants completed a postcourse survey assessing their perceptions of the course. RESULTS Thirty-five participants completed the course, all scoring ≥8/10 after examination by the in-person evaluator. Remote instructors' average scores (9.8 ± 0.45) did not significantly differ from scores of the in-person evaluator (9.9 ± 0.37) (P = 0.252). Thirty-three participants (94%) completed the postcourse survey. All respondents reported being willing and prepared to intervene in scenarios of life-threatening hemorrhage, and 97% reported confidence in using all STB skills. CONCLUSIONS STB skills can be effectively taught and evaluated through a live video-based course. All participants scored highly when evaluated both in-person and remotely, and nearly all reported confidence in skills and knowledge following the course. Remote instruction is a valuable strategy to disseminate STB training to students without access to in-person courses, especially during pandemic restrictions.
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Affiliation(s)
| | | | - Giovanna Mele
- Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Baker JE, Werner NL, Burlew CC. Management of Pelvic Trauma. Surg Clin North Am 2024; 104:367-384. [PMID: 38453308 DOI: 10.1016/j.suc.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.
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Affiliation(s)
- Jennifer E Baker
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO 80045, USA
| | - Nicole L Werner
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue H4/367, Madison, WI 53792, USA
| | - Clay Cothren Burlew
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 E 17th Avenue, Box C313, Aurora, CO 80045, USA.
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Van Gent JM, Kaminski CW, Praestholm C, Pivalizza EG, Clements TW, Kao LS, Stanworth S, Brohi K, Cotton BA. Empiric Cryoprecipitate Transfusion in Patients with Severe Hemorrhage: Results from the US Experience in the International CRYOSTAT-2 Trial. J Am Coll Surg 2024; 238:636-643. [PMID: 38146823 DOI: 10.1097/xcs.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
BACKGROUND Hypofibrinogenemia has been shown to predict massive transfusion and is associated with higher mortality in severely injured patients. However, the role of empiric fibrinogen replacement in bleeding trauma patients remains controversial. We sought to determine the effect of empiric cryoprecipitate as an adjunct to a balanced transfusion strategy (1:1:1). STUDY DESIGN This study is a subanalysis of patients treated at the single US trauma center in a multicenter randomized controlled trial. Trauma patients (more than 15 years) were eligible if they had evidence of active hemorrhage requiring emergent surgery or interventional radiology, massive transfusion protocol (MTP) activation, and received at least 1 unit of blood. Transfer patients, those with injuries incompatible with life, or those injured more than 3 hours earlier were excluded. Patients were randomized to standard MTP (STANDARD) or MTP plus 3 pools of cryoprecipitate (CRYO). Primary outcomes included all-cause mortality at 28 days. Secondary outcomes were transfusion requirements, intraoperative and postoperative coagulation laboratory values, and quality-of-life measures (Glasgow outcome score-extended). RESULTS Forty-nine patients (23 in the CRYO group and 26 in the STANDARD group) were enrolled between May 2021 and October 2021. Time to randomization was similar between groups (14 vs 24 minutes, p = 0.676). Median time to cryoprecipitate was 41 minutes (interquartile range 37 to 48). There were no differences in demographics, arrival physiology, laboratory values, or injury severity. Intraoperative and ICU thrombelastography values, including functional fibrinogen, were similar between groups. There was no benefit to CRYO with respect to post-emergency department transfusions (intraoperative and ICU through 24 hours), complications, Glasgow outcome score, or mortality. CONCLUSIONS In this study of severely injured, bleeding trauma patients, empiric cryoprecipitate did not improve survival or reduce transfusion requirements. Cryoprecipitate should continue as an "on-demand" addition to a balanced transfusion strategy, guided by laboratory values and should not be given empirically.
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Affiliation(s)
- Jan-Michael Van Gent
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Carter W Kaminski
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Caroline Praestholm
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Evan G Pivalizza
- Anesthesiology (Pivalizza), McGovern Medical School, Houston, TX
| | - Thomas W Clements
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Lillian S Kao
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
- The Center for Translational Injury Research, Houston, TX (Kao, Cotton)
| | | | - Karim Brohi
- Department of Haematology, University of Oxford, UK (Brohi)
| | - Bryan A Cotton
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
- The Center for Translational Injury Research, Houston, TX (Kao, Cotton)
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Mangiavillano B, Lakhtakia S, Samanta J, Auriemma F, Vargas-Madrigal J, Arcidiacono PG, Barbera C, Ashhab H, Song TJ, Pham KDK, Teoh AYB, Moon JH, Crinò SF, Kongkam P, Aragona G, De Lusong MA, Dhar J, Ofosu A, Ventra A, Paduano D, Franchellucci G, Repici A, Larghi A, Facciorusso A. Lumen-apposing metal stents for the treatment of pancreatic and peripancreatic fluid collections and bleeding risk: a propensity matched study. Endoscopy 2024; 56:249-257. [PMID: 38237633 DOI: 10.1055/a-2219-3179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Endoscopic ultrasound (EUS)-guided drainage of symptomatic pancreatic fluid collections (PFCs) using the Hot-Axios device has recently been associated with a significant risk of bleeding. This adverse event (AE) seems to occur less frequently with the use of a different device, the Spaxus stent. The aim of the current study was to compare the rates of bleeding between the two stents. METHODS Patients admitted for treatment of PFCs by EUS plus lumen-apposing metal stent in 18 endoscopy referral centers between 10 July 2019 and 28 February 2022 were identified and their outcomes compared using a propensity-matching analysis. RESULTS 363 patients were evaluated. After a 1-to-1 propensity score match, 264 patients were selected (132 per group). The technical and clinical success rates were comparable between the two groups. Significantly more bleeding requiring transfusion and/or intervention occurred in the Hot-Axios group than in the Spaxus group (6.8% vs. 1.5%; P = 0.03); stent type was a significant predictor of bleeding in both univariate and multivariate regression analyses (P = 0.03 and 0.04, respectively). Bleeding necessitating arterial embolization did not however differ significantly between the two groups (3.0% vs. 0%; P = 0.12). In addition, the Hot-Axios was associated with a significantly higher rate of overall AEs compared with the Spaxus stent (9.8% vs. 3.0%; P = 0.04). CONCLUSION Our study showed that, in patients with PFCs, bleeding requiring transfusion and/or intervention occurred significantly more frequently with use of the Hot-Axios stent than with the Spaxus stent, although this was not the case for bleeding requiring embolization.
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Affiliation(s)
- Benedetto Mangiavillano
- Gastrointestinal Endoscopy, Humanitas Mater Domini, Castellanza, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Jorge Vargas-Madrigal
- Gastroenterology Department, Enrique Baltodano Briceno Hospital, Liberia, Costa Rica
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Istituto Scientifico Universitario San Raffaele, Milano, Italy
| | - Carmelo Barbera
- Gastroenterology Unit, Civil Hospital Giuseppe Mazzini, Teramo, Italy
| | - Hazem Ashhab
- Gastroenterology, Ahli Hospital, Hebron, Palestine, State of
| | - Tae Jun Song
- Gastroenterology, Asan Medical Center, Songpa-gu, Korea (the Republic of)
| | - Khanh Do-Kong Pham
- Bergen Research group for Gastrointestinal Endoscopy (BRAGE), Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Anthony Y B Teoh
- Division of Upper Gastrointestinal and Metabolic Surgery, Prince of Wales Hospital, Hong Kong, Hong Kong
| | - Jong Ho Moon
- Internal Medicine, Soon Chung Hyang University School of Medicine, Bucheon, Korea (the Republic of)
| | | | - Pradermchai Kongkam
- Division of Hospital and Ambulatory Medicine, and Pancreas Research Unit, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Giovanni Aragona
- Internal Medicine, Gastroenterology and Hepatology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Mark A De Lusong
- Interventional Endoscopy, University of the Philippines Manila, Manila, Philippines
| | - Jahnvi Dhar
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Andrew Ofosu
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, United States
| | - Agostino Ventra
- Gastroenterology, Azienda Ospedaliera Grande Ospedale Metropolitano Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Danilo Paduano
- Gastrointestinal Endoscopy, Humanitas Mater Domini, Castellanza, Italy
| | | | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Antonio Facciorusso
- Gastroenterology, University of Foggia Department of Medical and Surgical Sciences, Foggia, Italy
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De Maria GL, Greenwood JP, Zaman AG, Carrié D, Coste P, Valgimigli M, Behan M, Berry C, Erglis A, Panoulas VF, Van Belle E, Juhl Terkelsen C, Hunziker Munsch L, Jain AK, Lassen JF, Palmer N, Stone GW, Banning AP. Pressure-Controlled Intermittent Coronary Sinus Occlusion (PiCSO) in Acute Myocardial Infarction: The PiCSO-AMI-I Trial. Circ Cardiovasc Interv 2024; 17:e013675. [PMID: 38626079 DOI: 10.1161/circinterventions.123.013675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/09/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Primary percutaneous coronary intervention (pPCI) has improved clinical outcomes in patients with ST-segment-elevation myocardial infarction. However, as many as 50% of patients still have suboptimal myocardial reperfusion and experience extensive myocardial necrosis. The PiCSO-AMI-I trial (Pressure-Controlled Intermittent Coronary Sinus Occlusion-Acute Myocardial Infarction-I) evaluated whether PiCSO therapy can further reduce myocardial infarct size (IS) in patients undergoing pPCI. METHODS Patients with anterior ST-segment-elevation myocardial infarction and Thrombolysis in Myocardial Infarction flow 0-1 were randomized at 16 European centers to PiCSO-assisted pPCI or conventional pPCI. The PiCSO Impulse Catheter (8Fr balloon-tipped catheter) was inserted via femoral venous access after antegrade flow restoration of the culprit vessel and before proceeding with stenting. The primary end point was the difference in IS (expressed as a percentage of left ventricular mass) at 5 days by cardiac magnetic resonance. Secondary end points were the extent of microvascular obstruction and intramyocardial hemorrhage at 5 days and IS at 6 months. RESULTS Among 145 randomized patients, 72 received PiCSO-assisted pPCI and 73 conventional pPCI. No differences were observed in IS at 5 days (27.2%±12.4% versus 28.3%±11.45%; P=0.59) and 6 months (19.2%±10.1% versus 18.8%±7.7%; P=0.83), nor were differences between PiCSO-treated and control patients noted in terms of the occurrence of microvascular obstruction (67.2% versus 64.6%; P=0.85) or intramyocardial hemorrhage (55.7% versus 60%; P=0.72). The study was prematurely discontinued by the sponsor with no further clinical follow-up beyond 6 months. However, up to 6 months of PiCSO use appeared safe with no device-related adverse events. CONCLUSIONS In this prematurely discontinued randomized trial, PiCSO therapy as an adjunct to pPCI did not reduce IS when compared with conventional pPCI in patients with anterior ST-segment-elevation myocardial infarction. PiCSO use was associated with increased procedural time and contrast but no increase in adverse events up to 6 months. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03625869.
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Affiliation(s)
- Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (G.L.D.M., A.P.B.)
- National Institute for Health Research Oxford Biomedical Research Centre, United Kingdom (G.L.D.M., A.P.B.)
| | - John P Greenwood
- Leeds University and Leeds Teaching Hospitals NHS Trust, United Kingdom (J.P.G.)
| | - Azfar G Zaman
- Cardiothoracic Centre, Freeman Hospital and Newcastle University, Newcastle upon Tyne, United Kingdom (A.G.Z.)
| | | | - Pierre Coste
- Hôpital Cardiologique du Haut Lévéque, University of Bordeaux, France (P.C.)
| | - Marco Valgimigli
- Istituto Cardiocentro Ticino-Ente Ospedaliero Cantonale, Lugano, Switzerland (M.V.)
| | - Miles Behan
- Edinburgh Heart Centre, United Kingdom (M.B.)
| | - Colin Berry
- Golden Jubilee National Hospital, Glasgow, United Kingdom (C.B.)
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, University of Latvia, Riga, Latvia (A.E.)
| | - Vasileios F Panoulas
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (V.F.P.)
| | - Eric Van Belle
- Institut Coeur-Poumon, Centre Hospitalier Regional, INSERM U1011, Lille Cedex, France (E.V.B.)
| | | | | | - Ajay K Jain
- Barts Heart Centre, London, United Kingdom (A.K.J.)
| | | | - Nick Palmer
- Liverpool Heart and Chest Hospital, United Kingdom (N.P.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.)
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (G.L.D.M., A.P.B.)
- National Institute for Health Research Oxford Biomedical Research Centre, United Kingdom (G.L.D.M., A.P.B.)
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Shahul S A, Chauhan NK, Dutt N, Chakraborti A, Elhence P, Jalandra R. Bronchoscopic Electrocautery Versus Adrenaline and Cold Saline Instillation for Prophylactic Haemostasis Prior to Biopsy of Endobronchial Lesions (BEVACS): A Randomized Controlled Trial. J Bronchology Interv Pulmonol 2024; 31:199-204. [PMID: 38158758 DOI: 10.1097/lbr.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Flexible bronchoscopy-guided endobronchial biopsy (EBB) is routinely performed as an outpatient daycare procedure. Bleeding after EBB is a common complication, that at times disrupts the procedure and can rarely lead to a catastrophe. We aimed to compare the efficacy of prebiopsy prophylactic bronchoscopic electrocautery with adrenaline and cold saline instillation in achieving hemostasis in patients with endobronchial lesions with a higher risk of bleeding during EBB. METHODS In this open-label, randomized controlled trial, 60 patients with endobronchial lesions were randomized to either the prophylactic electrocautery arm or the adrenaline and cold saline arm. Postbiopsy endobronchial bleed was quantified in millimeters using the Visual Analog Scale (VAS) and graded as per the British Thoracic Society grading system. Electrocautery-induced tissue damage was graded by the pathologist as "no damage," "mild," "moderate," and "severe." RESULTS The median VAS score of bleeding was 6.14 mm (interquartile range: 8 mm) in the electrocautery arm and 10.17 mm (interquartile range: 7 mm) in the adrenaline and cold saline arm. Though the difference in the VAS score of bleeding between the two groups was statistically significant, there was no significant difference in the proportion of grade 2 or higher bleeding. CONCLUSION No difference in postbiopsy bleed was observed between the application of electrocautery or instillation of cold saline plus adrenaline before biopsy of those endobronchial lesions which were likely to bleed more after biopsy. Although controlled prophylactic electrocautery using 15 watts did not impair the quality of EBB specimens, a higher wattage may change this observation, as well as the bleeding quantity.
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Affiliation(s)
- Aneesa Shahul S
- Department of Pulmonary Medicine, Ananthapuri Hospital and Research Institute, Thiruvananthapuram, KL
| | | | | | | | - Poonam Elhence
- Department of Pathology, All India Institute of Medical Sciences, Jodhpur, RJ
| | - Ramniwas Jalandra
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Bathinda, PB, India
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Yelnik CM, Erton ZB, Drumez E, Cheildze D, de Andrade D, Clarke A, Tektonidou MG, Sciascia S, Pardos-Gea J, Pengo V, Ruiz-Irastorza G, Belmont HM, Pedrera CL, Fortin PR, Wahl D, Gerosa M, Kello N, Signorelli F, Atsumi T, Ji L, Efthymiou M, Branch DW, Nalli C, Rodriguez-Almaraz E, Petri M, Cervera R, Shi H, Zuo Y, Artim-Esen B, Pons-Estel G, Willis R, Barber MRW, Skeith L, Bertolaccini ML, Cohen H, Roubey R, Erkan D. Thrombosis recurrence and major bleeding in non-anticoagulated thrombotic antiphospholipid syndrome patients: Prospective study from antiphospholipid syndrome alliance for clinical trials and international networking (APS ACTION) clinical database and repository ("Registry"). Semin Arthritis Rheum 2024; 65:152347. [PMID: 38185079 DOI: 10.1016/j.semarthrit.2023.152347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/13/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Long-term anticoagulant therapy is generally recommended for thrombotic antiphospholipid syndrome (TAPS) patients, however it may be withdrawn or not introduced in routine practice. OBJECTIVES To prospectively evaluate the risk of thrombosis recurrence and major bleeding in non-anticoagulated TAPS patients, compared to anticoagulated TAPS, and secondly, to identify different features between those two groups. PATIENTS/METHODS Using an international registry, we identified non-anticoagulated TAPS patients at baseline, and matched them with anticoagulated TAPS patients based on gender, age, type of previous thrombosis, and associated autoimmune disease. Thrombosis recurrence and major bleeding were prospectively analyzed using Kaplan-Meier method and compared using a marginal Cox's regression model. RESULTS As of June 2022, 94 (14 %) of the 662 TAPS patients were not anticoagulated; and 93 of them were matched with 181 anticoagulated TAPS patients (median follow-up 5 years [interquartile range 3 to 8]). The 5-year thrombosis recurrence and major bleeding rates were 12 % versus 10 %, and 6 % versus 7 %, respectively (hazard ratio [HR] 1.38, 95 % confidence interval [CI] 0.53 to 3.56, p = 0.50 and HR 0.53; 95 % CI 0.15 to 1.86; p = 0.32, respectively). Non-anticoagulated patients were more likely to receive antiplatelet therapy (p < 0.001), and less likely to have more than one previous thrombosis (p < 0.001) and lupus anticoagulant positivity (p = 0.01). CONCLUSION Fourteen percent of the TAPS patients were not anticoagulated at recruitment. Their recurrent thrombosis risk did not differ compared to matched anticoagulated TAPS patients, supporting the pressing need for risk-stratified secondary thrombosis prevention trials in APS investigating strategies other than anticoagulation.
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Affiliation(s)
- Cecile M Yelnik
- Univ. Lille, CHU Lille, Département de Médecine Interne et d'Immunologie Clinique, INSERM, UMR 1167, F-59000 Lille, France.
| | | | - Elodie Drumez
- Univ. Lille, CHU Lille, Département de Médecine Interne et d'Immunologie Clinique, INSERM, UMR 1167, F-59000 Lille, France
| | - Dachi Cheildze
- Hospital for Special Surgery, New York, NY, USA; Yale New Haven Hospital, New Haven, CT, USA
| | | | - Ann Clarke
- University of Calgary, Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | - Paul R Fortin
- Centre ARThrite - CHU de Québec- Université Laval, Quebec, QC, Canada
| | - Denis Wahl
- Université de Lorraine, Inserm DCAC, and CHRU-Nancy, Nancy, France
| | | | - Nina Kello
- Northwell Health, New Hyde Park, NY, USA
| | | | | | - Lanlan Ji
- Peking University First Hospital, Beijing, China
| | | | - D Ware Branch
- University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | | | | | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zuo
- University of Michigan, Ann Arbor, MI, USA
| | | | - Guillermo Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas del Grupo Oroño (GO-CREAR), Rosario, Argentina
| | - Rohan Willis
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | | | - Hannah Cohen
- University College London, London, United Kingdom
| | | | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
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Salvá-Arteaga M, García-Muro C, Toledo-Gotor C, Fernández-Vallejo MB. [Translated article] Massive Bleeding from a Congenital Hemangioma: A Dermatologic Emergency. Actas Dermo-Sifiliográficas 2024; 115:T422-T424. [PMID: 38331173 DOI: 10.1016/j.ad.2023.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 02/09/2023] [Indexed: 02/10/2024] Open
Affiliation(s)
| | - C García-Muro
- Servicio de Pediatría, Hospital San Pedro, Logroño, Spain
| | - C Toledo-Gotor
- Centro de Salud Puerta de Arnedo, Arnedo, La Rioja, Spain
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Ross DS, Nogic J, Cong H, Nuzzi V, Thanikachalam P, Veenuraju S, Gruner-Hegge N, Anwar M, O'Sullivan M, Costopoulos C, Davies WR, Costanzo P. Ultrasound-guided deployment of ProGlide™ device in transfemoral transcatheter aortic valve implantation and risk reduction of vascular complications: A propensity-matched cohort study. Catheter Cardiovasc Interv 2024; 103:771-781. [PMID: 38451155 DOI: 10.1002/ccd.30999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/15/2023] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND ProGlide is a percutaneous suture-mediated closure device used in arterial and venous closure following percutaneous intervention. Risk of vascular complications from use, particularly related to failure in hemostasis, or acute vessel closure, remains significant and often related to improper suture deployment. We describe a technique of ultrasound-guided ProGlide deployment in transfemoral transcatheter aortic valve implantation (TF-TAVI). AIMS The aim of this study is to assess vascular outcomes for ultrasound-guided deployment of ProGlide vascular closure devices in patients undergoing TF-TAVI. METHODS We collected relevant clinical data of patients undergoing TAVI in a large volume centre. PRIMARY OUTCOME main access Valve Academic Research Consortium 3 (VARC-3) major vascular complication. SECONDARY OUTCOME any major/minor VARC-3 vascular complication, its type (bleed or ischemia), and treatment required (medical, percutaneous, or surgical). We performed inverse weighting propensity score analysis to compare the population undergoing ultrasound-guided versus conventional ProGlide deployment for main TAVI access. Ultrasound technique for ProGlide insertion was performed as described below. RESULTS Five hundred and seventeen patients undergoing TF-TAVI were included. PRIMARY OUTCOME In 126 (ultrasound-guided) and 391 (conventional ProGlide insertion), 0% versus 1.8% (p < 0.001) had a major VARC-3 vascular complication, respectively. SECONDARY OUTCOME 0.8% (one minor VARC-3 bleed) vs 4.1% (13 bleeds and three occlusions) had any VARC-3 vascular complication (major and minor) (p < 0.001). Surgical treatment of vascular complication was required in 0.8% versus 1.3% (p = NS). CONCLUSIONS Ultrasound-guided deployment of ProGlide for vascular closure reduced the risk of major vascular complications in a large population undergoing TAVI.
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Affiliation(s)
- Daniel S Ross
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Jason Nogic
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Hey Cong
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Vincenzo Nuzzi
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Clinical Cardiology and Heart Failure Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Prakash Thanikachalam
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Shree Veenuraju
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nicolai Gruner-Hegge
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Majid Anwar
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Michael O'Sullivan
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Charis Costopoulos
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Willaim R Davies
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Pierluigi Costanzo
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Christoffel J, Maegele M. Guidelines in trauma-related bleeding and coagulopathy: an update. Curr Opin Anaesthesiol 2024; 37:110-116. [PMID: 38390904 DOI: 10.1097/aco.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The diagnosis and treatment of patients with severe traumatic bleeding and subsequent trauma-induced coagulopathy (TIC) is still inconsistent, although the implementation of standardized algorithms/treatment pathways was repeatedly linked to improved outcome. Various evidence-based guidelines for these patients now exist, three of which have recently been updated. RECENT FINDINGS A synopsis of the three recently updated guidelines for diagnosis and treatment of seriously bleeding trauma patients with TIC is presented: (i) AWMF S3 guideline 'Polytrauma/Seriously Injured Patient Treatment' under the auspices of the German Society for Trauma Surgery; (ii) guideline of the European Society of Anesthesiology and Intensive Care (ESAIC) on the management of perioperative bleeding; and (iii) European guideline on the management of major bleeding and coagulopathy after trauma in its 6th edition (EU-Trauma). SUMMARY Treatment of trauma-related bleeding begins at the scene with local compression, use of tourniquets and pelvic binders and rapid transport to a certified trauma centre. After arrival at the hospital, measures to record, monitor and support coagulation function should be initiated immediately. Surgical bleeding control is carried out according to 'damage control' principles. Modern coagulation management includes individualized treatment based on target values derived from point-of-care viscoelastic test procedures.
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Affiliation(s)
- Jannis Christoffel
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
| | - Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Germany
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Alomar-Dominguez C, Bösch J, Fries D. Prehospital transfusion of allogeneic blood products. Curr Opin Anaesthesiol 2024; 37:144-147. [PMID: 38390984 DOI: 10.1097/aco.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The purpose of this article is to provide a structural and practical analysis of the currently available data concerning prehospital transfusion of allogeneic blood products in cases of trauma and severe bleeding. RECENT FINDINGS Prehospital transfusion of allogeneic blood products is a very early intervention, which may offer the potential to improve outcome, but that also comes with challenges including resource allocation, blood product storage, logistics, patient selection, legal and ethical considerations, adverse effects, and costs. Potential benefits including improved stability and reduction in coagulopathy and blood loss have not yet been clearly demonstrated. SUMMARY The questionable efficacy and challenges in clinical practice may outweigh the potential benefits of prehospital allogeneic transfusion.
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Affiliation(s)
- Cristina Alomar-Dominguez
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Li Y, Liu X, Sun A, Deng X, Chen Z, Fan Y. Multi-Method Investigation of Blood Damage Induced By Blood Pumps in Different Clinical Support Modes. ASAIO J 2024; 70:280-292. [PMID: 38215762 DOI: 10.1097/mat.0000000000002116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024] Open
Abstract
To investigate the effects of blood pumps operated in different modes on nonphysiologic flow patterns, cell and protein function, and the risk of bleeding, thrombosis, and hemolysis, an extracorporeal blood pump (CentriMag) was operated in three clinical modalities including heart failure (HF), venous-venous (V-V) extracorporeal membrane oxygenation (ECMO), and venous-arterial (V-A) ECMO. Computational fluid dynamics (CFD) methods and coupled hemolysis models as well as recently developed bleeding and thrombosis models associated with changes in platelet and von Willebrand factor (vWF) function were used to predict hydraulic performance and hemocompatibility. The V-A ECMO mode had the highest flow losses and shear stress levels, the V-V ECMO mode was intermediate, and the HF mode was the lowest. Different nonphysiologic flow patterns altered cell/protein morphology and function. The V-A ECMO mode resulted in the highest levels of platelet activation, receptor shedding, vWF unfolding, and high molecular weight multimers vWF (HMWM-vWF) degradation, leading to the lowest platelet adhesion and the highest vWF binding capacity, intermediate in the V-V ECMO mode, and opposite in the HF mode. The V-A ECMO mode resulted in the highest risk of bleeding, thrombosis, and hemolysis, with the V-V ECMO mode intermediate and the HF mode lowest. These findings are supported by published experimental or clinical statistics. Further studies found that secondary blood flow passages resulted in the highest risk of blood damage. Nonphysiologic blood flow patterns were strongly associated with cell and protein function changing, blood damage, and complications.
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Affiliation(s)
- Yuan Li
- From the Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
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Van Gent JM, Clements TW, Cotton BA. Resuscitation and Care in the Trauma Bay. Surg Clin North Am 2024; 104:279-292. [PMID: 38453302 DOI: 10.1016/j.suc.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Start balanced resuscitation early (pre-hospital if possible), either in the form of whole blood or 1:1:1 ratio. Minimize resuscitation with crystalloid to minimize patient morbidity and mortality. Trauma-induced coagulopathy can be largely avoided with the use of balanced resuscitation, permissive hypotension, and minimized time to hemostasis. Using protocolized "triggers" for massive and ultramassive transfusion will assist in minimizing delays in transfusion of products, achieving balanced ratios, and avoiding trauma induced coagulopathy. Once "audible" bleeding has been addressed, further blood product resuscitation and adjunct replacement should be guided by viscoelastic testing. Early transfusion of whole blood can reduce patient morbidity, mortality, decreases donor exposure, and reduces nursing logistics during transfusions. Adjuncts to resuscitation should be guided by laboratory testing and carefully developed, institution-specific guidelines. These include empiric calcium replacement, tranexamic acid (or other anti-fibrinolytics), and fibrinogen supplementation.
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Affiliation(s)
- Jan-Michael Van Gent
- The Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, USA; McGovern Medical School, University of Texas Health Science Center-Houston, Houston, TX, USA
| | - Thomas W Clements
- The Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, USA; McGovern Medical School, University of Texas Health Science Center-Houston, Houston, TX, USA
| | - Bryan A Cotton
- The Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, USA; McGovern Medical School, University of Texas Health Science Center-Houston, Houston, TX, USA; Center for Translational Injury Research, Houston, TX, USA.
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Bottiger B, Klapper J, Fessler J, Shaz BH, Levy JH. Examining Bleeding Risk, Transfusion-related Complications, and Strategies to Reduce Transfusions in Lung Transplantation. Anesthesiology 2024; 140:808-816. [PMID: 38345894 DOI: 10.1097/aln.0000000000004829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
Blood product transfusions for bleeding management in lung transplantation affect recipient outcomes. Interventions are needed to reduce perioperative bleeding risk and optimize outcomes.
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Affiliation(s)
- Brandi Bottiger
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, North Carolina
| | - Jacob Klapper
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Julien Fessler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France
| | - Beth H Shaz
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Jerrold H Levy
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, North Carolina
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Ritondale J, Piehl M, Caputo S, Broome J, McLafferty B, Anderson A, Belding C, Tatum D, Duchesne J. Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage. J Am Coll Surg 2024; 238:367-373. [PMID: 38197435 DOI: 10.1097/xcs.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. STUDY DESIGN This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. RESULTS A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). CONCLUSIONS This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.
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Affiliation(s)
- Joseph Ritondale
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Mark Piehl
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC (Piehl)
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC (Piehl)
| | - Sydney Caputo
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Jacob Broome
- Department of Surgery, MedStar Georgetown Washington Hospital Center, Washington DC (Broome)
| | - Bryant McLafferty
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Augustus Anderson
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Cameron Belding
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Danielle Tatum
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Juan Duchesne
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
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Bui IT, Silfvast-Kaiser AS, Hudson A, Saad SS, Albahra SM. Hemorrhagic bullous IgA vasculitis in pediatric skin of color: an mpox mimicker. Int J Dermatol 2024; 63:541-542. [PMID: 38308487 DOI: 10.1111/ijd.17051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 02/04/2024]
Affiliation(s)
- Ian T Bui
- Texas A&M Health Science Center School of Medicine, Dallas, TX, USA
| | | | - Andrew Hudson
- Department of Dermatology, Baylor Scott & White Healthcare, Temple, TX, USA
| | - Saadeddine S Saad
- Department of Dermatology, Baylor Scott & White Healthcare, Temple, TX, USA
| | - Said M Albahra
- Department of Pathology, Baylor Scott & White Healthcare, Temple, TX, USA
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Zhu E, Yuriditsky E, Raco V, Katz A, Papadopoulos J, Horowitz J, Maldonado T, Ahuja T. Anti-factor Xa as the preferred assay to monitor heparin for the treatment of pulmonary embolism. Int J Lab Hematol 2024; 46:354-361. [PMID: 37989523 DOI: 10.1111/ijlh.14207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION The mainstay of acute pulmonary embolism (PE) treatment is anticoagulation. Timely anticoagulation correlates with decreased PE-associated mortality, but the ability to achieve a therapeutic activated partial thromboplastin time (aPTT) with unfractionated heparin (UFH) remains limited. Although some institutions have switched to a more accurate and reproducible test to assess for heparin's effectiveness, the anti-factor Xa (antiXa) assay, data correlating a timely therapeutic antiXa to PE-associated clinical outcomes remains scarce. We evaluated time to a therapeutic antiXa using intravenous heparin after PE response team (PERT) activation and assessed clinical outcomes including bleeding and recurrent thromboembolic events. METHODS This was a retrospective cohort study at NYU Langone Health. All adult patients ≥18 years with a confirmed PE started on IV UFH with >2 antiXa levels were included. Patients were excluded if they received thrombolysis or alternative anticoagulation. The primary endpoint was the time to a therapeutic antiXa level of 0.3-0.7 units/mL. Secondary outcomes included recurrent thromboembolism, bleeding and PE-associated mortality within 3 months. RESULTS A total of 330 patients with a PERT consult were identified with 192 patients included. The majority of PEs were classified as sub massive (64.6%) with 87% of patients receiving a bolus of 80 units/kg of UFH prior to starting an infusion at 18 units/kg/hour. The median time to the first therapeutic antiXa was 9.13 hours with 93% of the cohort sustaining therapeutic anticoagulation at 48 hours. Recurrent thromboembolism, bleeding and mortality occurred in 1%, 5% and 6.2%, respectively. Upon univariate analysis, a first antiXa <0.3 units/ml was associated with an increased risk of mortality [27.78% (5/18) vs 8.05% (14/174), p = 0.021]. CONCLUSION We observed a low incidence of recurrent thromboembolism or PE-associated mortality utilizing an antiXa titrated UFH protocol. The use of an antiXa based heparin assay to guide heparin dosing and monitoring allows for timely and sustained therapeutic anticoagulation for treatment of PE.
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Affiliation(s)
- Eric Zhu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eugene Yuriditsky
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Veronica Raco
- Department of Pharmacy, NYU Langone Brooklyn, Brooklyn, New York, USA
| | - Alyson Katz
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
| | | | - James Horowitz
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Thomas Maldonado
- Department of Surgery, Vascular, NYU Grossman School of Medicine, New York, New York, USA
| | - Tania Ahuja
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
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50
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Eghbalzadeh K, Kuhn EW, Gerfer S, Djordjevic I, Rahmanian P, Mader N, Wahlers TCW. Ten-Year Long-Term Analysis of Mechanical and Biological Aortic Valve Replacement. Thorac Cardiovasc Surg 2024; 72:167-172. [PMID: 35667381 DOI: 10.1055/s-0042-1744477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND For patients undergoing aortic valve replacement (AVR), structural valve deterioration (SVD) of a bioprosthesis (BP) is substantially accelerated in younger patients and valve-in-valve implantation is not always a considerable option. The risk-benefit assessment between SVD versus the risk of bleeding and thromboembolic events in patients with a mechanical prosthesis (MP) resulted in an age limit shift irrespective of inconsistent results reported in literature. METHOD This retrospective single-center study compared 10-year long-term outcomes in patients undergoing isolated AVR with MP or BP. The risk-adjusted comparison of patients undergoing isolated AVR (n = 121) was performed after 1:1 propensity score matching (PSM) for age, sex, endocarditis, and chronic renal impairment (caliper of 0.2) leading to 29 pairs. Short- and long-term outcomes with respect to reoperation, major bleeding, stroke, all-cause and cardiovascular mortality, and overall survival at 10 years were analyzed. RESULTS After PSM, groups were comparable with respect to preoperative characteristics, including patients with a mean age of 65 ± 3 years (MP) and 66 ± 4 years (BP) and an incidence rate of 6.9% for infective endocarditis in both cohorts. Short-term outcomes (transient neurologic disorder = 0.0 vs. 6.9%; stroke = 0.0%; in-hospital mortality = 3.4%) and in-hospital stays were comparable between MP and BP. CONCLUSION After isolated AVR with MP and BP, 10-year long-term outcomes were comparable in the reported single-center cohort. MP can still be implanted safely without a disadvantage as regards long-term survival.
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Affiliation(s)
- Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | - Elmar W Kuhn
- Department of Cardiothoracic Surgery, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | - Thorsten C W Wahlers
- Department of Cardiothoracic Surgery, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
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