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Haemorrhagic Complications (haemorrhagic + complications)
Selected AbstractsIdentification and management of women with inherited bleeding disorders: a survey of obstetricians and gynaecologists in the United KingdomHAEMOPHILIA, Issue 4 2006C. CHI Summary., A mail survey of members and fellows of Royal College of Obstetricians and Gynaecologists was carried out to determine current practices of obstetricians and gynaecologists in the United Kingdom in the management of women with inherited bleeding disorders. In total, 3929 questionnaires were sent, 707 returned and analysis was limited to 545 valid questionnaires. In the past 5 years, 91% have managed women with inherited bleeding disorders. The majority (83%) considered inherited bleeding disorders to be under diagnosed in obstetrics and gynaecology. More than 80% considered the prevalence of von Willebrand's disease (VWD) to be <0.2% in the general population and <1% in women with menorrhagia and no gynaecological pathology, although the reported prevalence is 1% and 5,25% respectively. Twelve percent of the respondents would arrange testing for VWD when reviewing an 18-year-old with menorrhagia and no pelvic pathology, while only 2% would do the same for a 35-year-old with the same presentation. Twenty-one percent thought elective caesarean section is indicated in all fetuses known to be at risk of being affected by haemophilia. Eighty-four percent considered vacuum extraction unsafe in these cases, but 76% would consider the use of low forceps. In conclusion, obstetricians and gynaecologists underestimate inherited bleeding disorders as an underlying cause for menorrhagia. Increased awareness and management guidelines are essential in minimizing haemorrhagic complications and improving quality of care of these women. [source] Dental procedures in adult patients with hereditary bleeding disorders: 10 years experience in three Italian Hemophilia CentersHAEMOPHILIA, Issue 5 2005M. Franchini Summary., Excessive bleeding after dental procedures are one of the most frequent complications occurring in patients with hereditary bleeding disorders. In this retrospective study we collected data from 10 years of experience in the oral care of patients with congenital haemorrhagic disorders in three Italian Hemophilia Centers. Between 1993 and 2003, 247 patients with inherited bleeding disorders underwent 534 dental procedures including 133 periodontal treatments, 41 conservative dentistry procedures, 72 endodontic treatments and 288 oral surgery procedures. We recorded 10 bleeding complications (1.9%), most of which occurred in patients with severe/moderate haemophilia A undergoing multiple dental extractions. Thus, our protocol of management of patients with hereditary bleeding tendency undergoing oral treatment or surgery has been shown to be effective in preventing haemorrhagic complications. [source] Proposal of a standard approach to dental extraction in haemophilia patients.HAEMOPHILIA, Issue 5 2000A case-control study with good results We found no case,control studies on dental extraction in haemophilia patients in the literature even though the use of antifibrinolytic agents following a single infusion of factor VIII or IX has been accompanied by a lower number of bleeding complications in dental extractions. In this study we verified the incidence of bleeding complications after dental extraction in a group of 77 haemophilia patients. One hundred and eighty-four male patients requiring dental extraction represented the control group. All haemophilia patients received 20 mg kg,1 of tranexamic acid and a single infusion of factor VIII or IX to achieve a peak level about 30% of factor VIII or IX in vivo prior to dental extraction. Forty-five of 98 (45.9%) dental extractions in haemophilia patients and 110 of 239 (46%) dental extractions in the control group were surgical ones. We registered two bleeding complications in the group of haemophilia patients (one late bleeding and one haematoma in the site of the anaesthetic injection) and one (a late bleeding) in the control group. The difference of bleeding complications in the two groups of patients were not statistically significant (P=0.2; OR 0.2; CI 0.01,2.22). The protocol proposed in this study, characterized by the feasibility and the number of haemorrhagic complications not different from normal population, make dental extractions in haemophilia patients possible on an out-patient basis with a cost reduction for the community and minor discomfort for the patients. [source] Analysis of risk factors predicting thrombotic and/or haemorrhagic complications in 306 patients with Essential ThrombocythemiaHEMATOLOGICAL ONCOLOGY, Issue 3 2007Franca Radaelli Abstract Thrombotic and haemorrhagic complications are the main causes of morbidity in Essential Thrombocythemia (ET). We investigated the clinical and laboratory characteristics associated with the occurrence of these events with the aim of identifying subgroups of patients who might benefit from anti-aggregant and/or cytoreductive therapy. The study involved 306 consecutive ET patients (median age 58 years and median follow-up 96 months); the investigated variables were age, gender, platelet count, previous history of thrombotic or haemorrhagic events, disease duration and cardiovascular risk factors. Forty-six patients (15%) experienced thrombotic complications during the follow-up: 26/64 patients with a previous history of thrombosis (40.6%) and 20/242 patients without (8.3%; p,<,0.0001). Thirty-one patients (10%) experienced major haemorrhagic complications, mainly gastrointestinal tract bleeding: 3 with and 28 without a history of haemorrhagic events (p,=,0.052). When the patients with a negative history of thrombosis were stratified on the basis of the number of cardiovascular risk factors (none vs. one vs. more than one), there was a significant correlation with the occurrence of thrombotic events (p,<,0.05). ET patients with a positive history of thrombosis are at high risk of thrombotic complications, and should receive cytoreductive and anti-aggregant treatment. Asymptomatic patients with a negative thrombotic history and no cardiovascular risk factors are at low risk, and should not be treated. Patients with a negative thrombotic history and one or more cardiovascular risk factors are at intermediate risk, and should be treated with anti-aggregant and/or cytoreductive therapy. The need for treatment should be periodically re-evaluated. Age and platelet count, generally accepted as very important risk factors for thrombosis, did not seem in our series associated with an increased risk for thrombosis. Copyright © 2007 John Wiley & Sons, Ltd. [source] Post pancreaticoduodenectomy haemorrhage: outcome prediction based on new ISGPS Clinical severity gradingHPB, Issue 5 2008G. Rajarathinam Abstract Objective & background data. Mortality following pancreatoduodenectomy (PD) has fallen below 5%, yet morbidity remains between 30 and 50%. Major haemorrhage following PD makes a significant contribution to this ongoing morbidity and mortality. The aim of the present study was to validate the new International Study Group of Pancreatic Surgery (ISGPS) Clinical grading system in predicting the outcome of post pancreaticoduodenectomy haemorrhage (PPH). Material and methods. Between January 1998 and December 2007 a total of 458 patients who underwent Whipple's pancreaticoduodenectomy in our department were analysed with regard to haemorrhagic complications. The onset, location and severity of haemorrhage were classified according to the new criteria developed by an ISGPS. Risk factors for haemorrhage, management and outcome were analysed. Results. Severe PPH occurred in 14 patients (3.1%). Early haemorrhage (<24 hours) was recorded in five (36%) patients, and late haemorrhage (>24 hours) in nine (64%) patients. As per Clinical grading of ISGPS 7 (50%) belongs to Grade C and 7 (50%) belongs to Grade B. Haemostasis was attempted by surgery in 10 (71%) patients; angioembolisation was successful in two (14%) and endotherapy in one (7%) patient. The overall mortality is 29%(n=4). Age >60 years (p=0.02), sentinel bleeding (p=0.04), pancreatic leak (p=0.04) and ISGPS Clinical grade C (p=0.02) were associated with increased mortality. Conclusion. Early haemorrhage was mostly managed surgically with better outcome when endoscopy is not feasible. Late haemorrhage is associated with high mortality due to pancreatic leak and sepsis. ISGPS Clinical grading of PPH is useful in predicting the outcome. [source] A critical review of aspirin in the secondary prevention of noncardioembolic ischaemic strokeINTERNATIONAL JOURNAL OF STROKE, Issue 4 2010Domenico Inzitari Both secondary prevention (such as lifestyle modifications, pharmacotherapy or surgery) and an understanding of the influence of risk factors (including the different aetiologic mechanisms of cerebral ischaemia) play a pivotal role in reducing the burden of recurrent stroke. Regarding the types of preventative treatments available, variations exist across all clinical studies, including differences in target populations (including the type of cerebral ischaemia), risk factors, length of follow-up, drop-out rates and outcomes, which makes translating the results of clinical trials to individual patients difficult. However, with such limitations in mind, this critical albeit nonsystematic review, which compared aspirin with other antiplatelets and in combination with other drugs, showed that the benefit from aspirin treatment is consistently shown in ischaemic stroke, while harms are limited. Furthermore, no definite superiority is apparent across different antiplatelet therapies. Dual antiplatelet regimens may expose to a slight but measurable higher risk of haemorrhagic complications, perhaps in selective groups of patients (i.e. those with severe small-vessel disease or in selective racial groups). Based on our analysis, the indication of aspirin as the first-line choice, also recommended by several acknowledged international or national guidelines, may be confirmed. However, the complex nature of patients at risk of recurrent ischaemic stroke necessitates a comprehensive approach, which should be driven by the primary care physician, whose role is central to successful actions for secondary stroke prevention. [source] Promoting acute thrombolysis for ischaemic stroke (PRACTISE)INTERNATIONAL JOURNAL OF STROKE, Issue 2 2007Protocol for a cluster randomised controlled trial to assess the effect of implementation strategies on the rate, effects of thrombolysis for acute ischaemic stroke (ISRCTN 20405426) Rationale Thrombolysis with intravenous rtPA is an effective treatment for patients with ischaemic stroke if given within 3 h from onset. Generally, more than 20% of stroke patients arrive in time to be treated with thrombolysis. Nevertheless, in most hospitals, only 1,8% of all stroke patients are actually treated. Interorganisational, intraorganisational, medical and psychological barriers are hampering broad implementation of thrombolysis for acute ischaemic stroke. Aims To evaluate the effect of a high-intensity implementation strategy for intravenous thrombolysis in acute ischaemic stroke, compared with regular implementation; to identify success factors and obstacles for implementation and to assess its cost-effectiveness, taking into account the costs of implementation. Design The PRACTISE study is a national cluster-randomised-controlled trial. Twelve hospitals have been assigned to the regular or high-intensity intervention by random allocation after pair-wise matching. The high-intensity implementation consists of training sessions in conformity with the Breakthrough model, and a tool kit. All patients who are admitted with acute stroke and onset of symptoms not longer than 24 h are registered. Study outcomes The primary outcome measure is treatment with thrombolysis. Secondary outcomes are admission within 4 h after onset of symptoms, death or disability at 3 months, the rate of haemorrhagic complications in patients treated with thrombolysis, and costs of implementation and stroke care in the acute setting. Tertiary outcomes are derived from detailed criteria for the organisational characteristics, such as door-to-needle time and protocol violations. These can be used to monitor the implementation process and study the effectiveness of specific interventions. Discussion This study will provide important information on the effectiveness and cost-effectiveness of actively implementing an established treatment for acute ischaemic stroke. The multifaceted aspect of the intervention will make it difficult to attribute a difference in the primary outcome measure to a specific aspect of the intervention. However, careful monitoring of intermediate parameters as well as monitoring of accomplished SMART tasks can be expected to provide useful insights into the nature and role of factors associated with implementation of thrombolysis for acute ischaemic stroke, and of effective acute interventions in general. [source] Managing oral anticoagulation therapy: improving clinical outcomes.JOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 6 2008A review Summary Many physicians are reluctant to prescribe oral anticoagulation therapy (OAT) because of the fear of haemorrhagic complications. Changes in patient health, lifestyle or diet and other drugs can alter the effectiveness of oral anticoagulants. These potential interferences, added to the fact that each individual has a different reaction to these drugs, requires that therapy is monitored regularly. This article aims to review those strategies which help to achieve optimal anticoagulation control and improve the outcomes of OAT. Relevant articles were identified through a search of MEDLINE and included publications reporting on intensity of anticoagulation, the initiation of therapy and the role of pharmacogenetics, the transition from primary to secondary care, management by specialized clinics using decision support software and home-testing. Implementation of these strategies would increase the use of oral anticoagulants by physicians and offers the potential to improve patient safety and reduce adverse events. [source] Imaging of the haemorrhagic complications of the haemophiliasJOURNAL OF MEDICAL IMAGING AND RADIATION ONCOLOGY, Issue 1 2009S Constantine Summary Haemorrhage is the main manifestation of the haemophilias. Although acute haemorrhages can be life threatening, especially if involving the central nervous system, repeated haemorrhages involving the musculoskeletal system lead to two conditions unique to patients with haemophilias. This pictorial essay reviews the typical imaging appearances of haemorrhages and consequences in those with haemophilias, with particular emphasis on haemophilic arthropathy and pseudotumours. [source] Systemic and splanchnic haemodynamic effects of sildenafil in an in vivo animal model of cirrhosis support for a risk in cirrhotic patientsLIVER INTERNATIONAL, Issue 1 2004Isabelle Colle Abstract: Objectives: Sildenafil is a selective inhibitor of the cGMP-specific phosphodiesterase type V (PDE-V) in the corpus cavernosum. PDE-V is also present in the mesenteric artery. Cirrhosis is complicated by a splanchnic vasodilation attributed to a local overproduction of nitric oxide (NO). As sildenafil potentiates the effects of NO, it may further decrease mesenteric vascular tone and increase portal venous blood flow. The aim is to evaluate the effects of sildenafil on the systemic and splanchnic haemodynamics in an experimental model of cirrhosis. Methods: Secondary biliary cirrhosis was induced in male Wistar rats by common bile duct ligation (CBDL, n=8); control rats were sham-operated (sham, n=7). The mean arterial pressure (MAP), portal venous pressure (PVP) and arterial mesenteric blood flow (MBF) were measured after intramesenteric (0.01,10 mg/kg) and after intravenous (i.v.) (0.01,10 mg/kg) administration of sildenafil. Results: Baseline PVP was significantly higher in CBDL than in sham rats, whereas baseline MAP tended to be lower and MBF tended to be higher in CBDL compared with sham rats. Both intramesenteric and i.v. injection of sildenafil significantly decreased MAP and increased MBF and PVP in a dose-dependent way. The decrease in MAP was significantly less important in CBDL than in sham rats. The increase in MBF was importantly lower in CBDL than in sham rats. PVP tended to increase more significantly in sham rats than in CBDL. Conclusion: Sildenafil increases MBF and PVP and induces systemic hypotension. The effects are less pronounced in cirrhosis, suggesting vascular hyporesponsiveness to sildenafil. Although the rise in PVP in cirrhotic animals is smaller than in controls, it may present a risk for haemorrhagic complications. Further studies are necessary before prescribing sildenafil to patients with cirrhosis. [source] Maternal complications and pregnancy outcome in women with mechanical prosthetic heart valves treated with enoxaparinBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 12 2009C McLintock Objective, To determine maternal and fetal outcomes in women with mechanical heart valves managed with therapeutic dose enoxaparin during pregnancy. Design, Retrospective audit. Setting, Hospital-based high-risk antenatal clinics. Population, Pregnant women with mechanical heart valves attending high-risk antenatal clinics, treated with enoxaparin (1 mg/kg twice daily) during pregnancy. Methods, Women with mechanical heart valves treated with enoxaparin at any stage during pregnancy (1997,2008) identified using a database of women with mechanical heart valves attending the high-risk clinics and a prospective database of women prescribed enoxaparin for any indication during pregnancy. Main outcome measures, Maternal outcomes included thromboembolic and haemorrhagic complications. Pregnancy and fetal outcomes included miscarriage, stillbirth, baby death and live birth, small-for-gestational-age infants, warfarin embryopathy and warfarin-related fetal loss. Results, Thirty-one women underwent 47 pregnancies. In 34 pregnancies (72.3%), anticoagulation was with predominantly enoxaparin and 13 (27.7%) pregnancies women received mainly warfarin, with enoxaparin given in the first trimester and/or peri-delivery. Seven (14.9%) thrombotic complications occurred, of which five (10.6%) were associated with enoxaparin treatment. Non-compliance or sub-therapeutic anti-Xa levels contributed in each case. Antenatal and postpartum haemorrhagic complications occurred in eight (17%) and 15 (32%) pregnancies respectively. Of 35 pregnancies continuing after 20 weeks' gestation, 96% (22/23) of women taking predominantly enoxaparin had a surviving infant compared with 75% (9/12) in women taking primarily warfarin. Four perinatal deaths occurred, three attributable to warfarin. Conclusions, Compliance with therapeutic dose enoxaparin and aspirin during pregnancy in women with mechanical heart valves is associated with a low risk of valve thrombosis and good fetal outcomes, but close monitoring is essential. [source] Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomised controlled trialBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 3 2005M.A. Hefni Objective To assess the safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles during vaginal hysterectomy in comparison with the conventional method of securing the pedicles by suture ligation. Design Randomised controlled trial. Setting Gynaecology Department, Benenden Hospital, Kent. Population One hundred and sixteen women undergoing vaginal hysterectomy were prospectively randomised to either LigaSure (Group I) or suture ligation (Group II) for securing the pedicles. Methods Data of patients were collected prospectively. Statistical analysis was performed using the Mann,Whitney U test, ,2 and Fisher's exact test as appropriate. Main outcome measures Operating time, operative blood loss and peri-operative complications. Results The operating time was significantly shorter in the LigaSure group compared with the control group (P < 0.04). There was no statistical significant difference between the two groups in operative blood loss (P= 0.433), but peri-operative haemorrhagic complications were less frequent in the LigaSure group (0%vs 6.8%, P= 0.057). Four patients in the control group required either conversion to laparotomy because of bleeding, return to theatre for immediate post-operative haemorrhage or readmission for vault haematoma, whereas none in the LigaSure group had bleeding from unsecured pedicles. Conclusion The LigaSure vessel sealing system is a safe alternative for securing pedicles in vaginal hysterectomy when compared with conventional suture ligation. Larger studies are required to determine its place in gynaecological surgery. [source] Letter 1: Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin (Br J Surg 2008; 95: 834,836)BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 11 2008W. Kittisupamongkol The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and,if approved,appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] | |||||||||||||||||||||||||