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Severe Bleeding (severe + bleeding)
Selected AbstractsVariability in bleeding phenotype in Amish carriers of haemophilia B with the 31008 C,T mutationHAEMOPHILIA, Issue 1 2009A. SHARATHKUMAR Summary., The aim of this study was to characterize the variability of bleeding phenotype and its association with plasma factor IX coagulant activity (FIX:C) in haemophilia B carriers in a large Amish pedigree with a unifying genetic mutation, C-to-T transition at base 31008 of the factor IX gene (Xq27.1,27.2). A cross-sectional survey of haemophilia B carriers included a multiple choice questionnaire evaluating symptoms of mucocutaneous bleeding, joint bleeding and bleeding after haemostatic stress [menstruation, postpartum haemorrhage (PPH), dental extractions and invasive surgeries]. Severity of bleeding was graded as 0 to 4, 0 being no bleeding whereas 4 being severe bleeding. Association between total bleeding scores and the FIX:C was evaluated. Sixty-four haemophilia B carriers participated in this study. Median age: 18 years (range 1,70 years); median bleeding score: 1 (range 0,8). Besides PPH, isolated symptoms of bruising, epistaxis, menorrhagia and postsurgical bleeding including dental extraction were not associated with lower FIX:C. Bleeding score ,3 was associated with involvement of at least two bleeding sites and a lower mean FIX:C of 42 ± 10.3% (95% CI 36.4,47.7) while a score >3 had involvement of ,2 sites and higher mean FIX:C of 54.9 ± 21.5% (95% CI 49,61), P = 0.005. Subcutaneous haematoma formation and bleeding after haemostatic stress requiring treatment were associated with bleeding scores ,3. Phenotypic variability existed among the carriers of haemophilia B who belonged to a single pedigree carrying a single unifying mutation. The utility of bleeding scores to define bleeding phenotype precisely in haemophilia B carriers needs further evaluation. [source] Early and Late Results of Partial Left Ventriculectomy: Single Center Experience and Review of the LiteratureJOURNAL OF CARDIAC SURGERY, Issue 3 2003Raimondo Ascione M.D. Methods: From February 1996 to August 2001, 24 patients with dilated cardiomyopathy (DCM) (12 idiopathic, 12 ischemic) underwent PLV. Perioperative and follow-up data were prospectively entered into a database and analyzed. An observational analysis of the literature was carried out of all the published series of PLV reporting on ,15 patients. Results: In our series there were 22 males with amean age of 65 years (range 49 to73]). Of the 22, there were 3 (12.5%) in-hospital deaths. Mean duration of follow-up was 26 months (range 3 to 71) with 9 late deaths (38%), 6 in the idiopathic group. The five-year actuarial survival was 74% in the ischemic group and 33% in the idiopathic group. The observational analysis of literature included a total of 506 patients (425 males, age 50.2 ± 5.2 years)]. The etiology was idiopathic in 255 (50.4%), and ischemic in 89 (17.6%) patients. Baseline characteristics of the whole population include: ejection fraction 18.9 ± 3.9%, NYHA functional class 3.7 ± 0.2, and LVEDD of 7.7 ± 0.4 cm. Severe mitral regurgitation was present in 368 (72.7%) patients. There were 88 (17.4%) in-hospital deaths. Cause of death included 55 due to (62.5%) low cardiac output, 10 (11.3%) due to severe bleeding, 7 (7.95%) caused by malignant arrhythmias, 8 (9%) due to sepsis, and 5 (5.7%) as a result of stroke. Ten of the selected series (overall 386 patients) reported late outcome. There were 89 (22.9%) late deaths, 12 (13.5%) were not cardiac-related, 50 (56.2%) were due to recurrence of congestive heart failure (CHF), 20 (22.5%) caused by sudden arrhythmias, 5 (5.6%) due to infections, and 2 (2.2%) from strokes. Overall, there were 248 (64.2%) survivors, of whom 179 (72.17%) were reported to be in NYHA functional class I or II. All 10 papers reported one-year survival ranging from 50% to 85%. Seven reported a two-year survival of 45% to 72%, and 4 reported a three-year survival of 33% to 64%. Conclusions: Our results and the review of the literature seem to suggest a relatively high early mortality with satisfactory late results of PLV in patients with dilated cardiomyopathy.(J Card Surg 2003;18:190-196) [source] Clinical aspects of ulcerative colitis in mainland ChinaJOURNAL OF DIGESTIVE DISEASES, Issue 2 2006Jia Ju ZHENG Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is reported to be increasing in incidence and prevalence in provinces and cities in mainland China. This article specifically reviews clinical features, extra-intestinal manifestations, complications, diagnosis and differential diagnosis, and medical treatment of UC. Compared to patients in Western countries, more mild to moderate and left-sided colitis cases were observed in a nation-wide study in China. Complications included anal fistula, anal abscess, anal fissure, severe bleeding, intestinal perforation, intestinal obstruction and colonic carcinoma. The extra-intestinal manifestations were arthritis/arthralgia, eye and skin disorders and oral ulcers. The high specificity of antineutrophil cytoplasmic antibody may useful for distinguishing UC from infectious colitis; in addition, serum levels of antisaccharomyces cerevisia antibody may helpful for distinguishing between UC and CD. Oral sulfasalazine and 5-aminosalicylic acid (ASA) remain the mainstays for the management of mild to moderate UC in China. Corticosteroids and immunosuppressive agents are also widely used in severe or refractory UC. [source] Effects of recombinant human activated protein C on the coagulation system: a study with rotational thromboelastometryACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 9 2008C. U. NILSSON Background: Recombinant human activated protein C (rhAPC) is an anticoagulant that can be used for treatment of patients with severe sepsis. The use of rhAPC is accompanied by an increased risk of severe bleeding. Rotational thromboelastometry is a method for measuring the status of the coagulation. The aim of the study was to investigate whether rotational thromboelastometry could be used for monitoring the effects of rhAPC on the coagulation. Methods: Whole blood was mixed in vitro with concentrations of rhAPC ranging from 0 to 75 ng/ml and analysed with rotational thromboelastometry. Results: The parameter Coagulation Time was significantly prolonged by increasing the concentrations of rhAPC (P=0.002). Other parameters were not significantly affected. Conclusion: rhAPC dose dependently affects the early humoral parts of the coagulation, while platelet function and fibrinogen to fibrin conversion seem virtually unaffected. [source] Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleedingALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2010S. A. Hearnshaw Aliment Pharmacol Ther 2010; 32: 215,224 Summary Background, Acute upper gastrointestinal bleeding (AUGIB) accounts for 14% of RBC units transfused in the UK. In exsanguinating AUGIB the value of RBC transfusion is self evident, but in less severe bleeding its value is less obvious. Aim, To examine the relationship between early RBC transfusion, re-bleeding and mortality following AUGIB, which is one of the most common indications for red blood cell (RBC) transfusion. Method, Data were collected on 4441 AUGIB patients presenting to UK hospitals. The relationship between early RBC transfusion, re-bleeding and death was examined using logistic regression. Results, 44% were transfused RBCs within 12 hours of admission. In patients transfused with an initial haemoglobin of <8 g/dl, re-bleeding occurred in 23% and mortality was 13% compared with a re-bleeding rate of 15%, and mortality of 13% in those not transfused. In patients transfused with haemoglobin >8 g/dl, re-bleeding occurred in 24% and mortality was 11% compared with a re-bleeding rate of 6.7%, and mortality of 4.3% in those not transfused. After adjusting for Rockall score and initial haemoglobin, early transfusion was associated with a two-fold increased risk of re-bleeding (Odds ratio 2.26, 95% CI 1.76,2.90) and a 28% increase in mortality (Odds ratio 1.28, 95% CI 0.94,1.74). Conclusions, Early RBC transfusion in AUGIB was associated with a two-fold increased risk of re-bleeding and an increase in mortality, although the latter was not statistically significant. Although these findings could be due to residual confounding, they indicate that a randomized comparison of restrictive and liberal transfusion policies in AUGIB is urgently required. [source] Hereditary hemorrhagic telangiectasia: from molecular biology to patient careJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 7 2010S. DUPUIS-GIROD Summary., Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder characterized by severe and recurrent nosebleeds, mucocutaneous telangiectases, and, in some cases, life-threatening visceral arteriovenous malformations of various types, including pulmonary, hepatic, cerebral, and spinal. Gastrointestinal telangiectases are frequent and may cause severe bleeding. HHT type 1 results from mutations in ENG on chromosome 9 (coding for endoglin), and HHT type 2 results from mutations in ACVRL1 on chromosome 12 (coding for activin receptor-like kinase 1). Mutations of either of these two genes account for most clinical cases. In addition, mutations in MADH4 (encoding SMAD4), which cause a juvenile polyposis/HHT overlap syndrome, have been described, and recently, an HHT3 locus on chromosome 5 (5q31.3,5q32) has been reported. The mutated genes in HHT encode proteins that modulate transforming growth factor-, superfamily signaling in vascular endothelial cells. Management of patients has changed considerably in the last 20 years, in terms of both treatment and the prevention of complications. The goal of this review was to describe the underlying molecular and cellular physiopathology, explore clinical and genetic diagnostic strategies for HHT, and present clinical management recommendations in order to treat symptomatic disease and to screen for vascular malformations. [source] Treatment of acquired hemophilia AJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 5 2007P. W. COLLINS Summary., Acquired hemophilia A (AH) is an autoimmune disease that leads to potentially severe bleeding. Management relies on rapid and accurate diagnosis, control of bleeding episodes and eradication of the inhibitor by immunosuppression. There is extensive literature about the disease but only few controlled data are available. This paper reviews the current literature on treatment strategies for hemostatic therapy and inhibitor eradication. Potential future developments are discussed. [source] Review article: the management of lower gastrointestinal bleedingALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 11 2005J. J. Farrell Summary Several recent advances have been made in the evaluation and management of acute lower gastrointestinal bleeding. This review focuses on the management of lower gastrointestinal bleeding, especially acute severe bleeding. The aim of the study was to critically review the published literature on important management issues in lower gastrointestinal bleeding, including haemodynamic resuscitation, diagnostic evaluation, and endoscopic, radiologic, and surgical therapy, and to develop an algorithm for the management of lower gastrointestinal bleeding, based on this literature review. Publications pertaining to lower gastrointestinal bleeding were identified by searches of the MEDLINE database for the years 1966 to December 2004. Clinical trials and review articles were specifically identified, and their reference citation lists were searched for additional publications not identified in the database searches. Clinical trials and current clinical recommendations were assessed by using commonly applied criteria. Specific recommendations are made based on the evidence reviewed. Approximately, 200 original and review articles were reviewed and graded. There is a paucity of high-quality evidence to guide the management of lower gastrointestinal bleeding, and current endoscopic, radiologic, and surgical practices appear to reflect local expertise and availability of services. Endoscopic literature supports the role of urgent colonoscopy and therapy where possible. Radiology literature supports the role of angiography, especially after a positive bleeding scan has been obtained. Limited surgical data support the role of segmental resection in the management of persistent lower gastrointestinal bleeding after localization by either colonoscopy or angiography. There is limited high-quality research in the area of lower gastrointestinal bleeding. Recent advances have improved the endoscopic, radiologic and surgical management of this problem. However, treatment decisions are still often based on local expertise and preference. With increased access to urgent therapeutic endoscopy for the management of acute upper gastrointestinal bleeding, diagnostic and therapeutic colonoscopy can be expected to play an increasing role in the management of acute lower gastrointestinal bleeding. [source] Use of rotation thromboelastometry (ROTEM®) to achieve successful treatment of polytrauma with fibrinogen concentrate and prothrombin complex concentrateANAESTHESIA, Issue 2 2010H. Schöchl Summary Goal-directed coagulation therapy is essential in the management of trauma patients with severe bleeding. Due to the complex nature of coagulation disorders in trauma, a quick and reliable diagnostic tool is essential. We report a severely injured multiple trauma patient who received haemostatic therapy with coagulation factor concentrates, guided by rotational thromboelastometry (ROTEM®). Initial therapy consisted of fibrinogen concentrate (Haemocomplettan® P), as maximum clot firmness in the ROTEM analyses was low, whereas clotting time was normal. Later on, prothrombin complex concentrate was given to optimise thrombin generation. This approach enabled extended emergency hemihepatectomy to be performed without using fresh frozen plasma. As the EXTEM maximum clot firmness showed good clot quality, no platelets were transfused despite low platelet counts. This case shows the potential success of treatment using both fibrinogen concentrate and prothrombin complex concentrate, not only in restoring haemostasis but also in minimising requirement for transfusion of allogeneic blood products. [source] Efficacy and Safety of Anticoagulation With Heparin Versus Heparin Plus Epoprostenol in Patients Undergoing Extracorporeal Liver Support With PrometheusARTIFICIAL ORGANS, Issue 1 2010Peter Krisper Abstract Anticoagulation for extracorporeal liver support is delicate due to underlying coagulation disorders in patients with liver failure and to the associated elevated bleeding risk. To date, there has been no detailed report on anticoagulation issues in patients treated with Prometheus, a device based on the principle of fractionated plasma separation and adsorption. We studied 17 patients from two centers treated with Prometheus, comparing standard anticoagulation with heparin (15 treatments) and a combination of heparin and the synthetic prostacyclin epoprostenol (22 treatments). Standard coagulation tests, proteins C and S, and thrombin,antithrombin (TAT) complex were determined, and adverse events were recorded. All but two treatments could be completed as scheduled, although filter exchange due to filter clotting was required in 24% of the treatments. Three out of 17 patients developed severe bleeding complications within 24 h of treatment. There were no overt thrombotic events. Addition of epoprostenol neither reduced coagulation-related adverse events nor improved standard coagulation parameters. Protein C, but not protein S, showed a significant reduction (23 ± 18%) after Prometheus treatments, but levels rebounded to baseline within 18 h. TAT levels,a measure for activation of coagulation,were only altered by Prometheus in patients where TAT was already elevated before treatment. In conclusion, anticoagulation of Prometheus with heparin is feasible but still associated with a relatively high frequency of filter clotting and a considerable risk of severe bleeding in this high-risk patient population. As addition of epoprostenol did not prove beneficial, other strategies, such as regional anticoagulation with citrate, should be further evaluated. [source] A randomised controlled trial of 6 and 12 hourly administration of vaginal misoprostol for second trimester pregnancy terminationBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 9 2005Yongyoth Herabutya Objective To compare the effectiveness of vaginal misoprostol administered 6 or 12 hourly for second trimester pregnancy termination. Design A randomised controlled trial. Setting University teaching hospital. Sample Two hundred and seventy-nine pregnant women at gestations between 14 and 26 weeks undergoing pregnancy termination. Methods Women were randomised to receive 600-,g misoprostol tablets vaginally either every 6 hours or every 12 hours until abortion occurred. Main outcome measures Induction,abortion interval, success rate within 24 and 48 hours and adverse effects. Results There was no significant difference in the median induction to abortion interval 6 hours (16 hours) and 12 hours (16 hours; P= 0.80). The total dose of misoprostol was higher in the 6-hour group (1800 vs 1200 ,g). The cumulative abortion rates within 24 hours were 74% and 67% and within 48 hours 94% and 92%, in the 6- and 12-hour groups, respectively. Fever was more common in the 6-hour group (53%) versus the 12-hour group (31%; P < 0.001). The incidence of nausea, vomiting, diarrhoea, severe bleeding and abdominal pain were similar. Conclusions Misoprostol (600 ,g) administered at 12-hour intervals was associated with fewer adverse effects and was as effective as a 6-hour interval. [source] Simultaneous bilateral percutaneous nephrolithotomy in childrenBJU INTERNATIONAL, Issue 1 2005Morshed A. Salah In the paediatric section, two papers relating to the upper urinary tract are presented. The first, from Hungary, describes simultaneous bilateral percutaneous nephrolithotomy in 13 patients, where it was deemed feasible; this is the first such report. Authors from London report on unilateral nephrectomy in patients with nephrogenic hypertension, and found that it was successful in normalising blood pressure in patients with renal hypertension with a normal contralateral kidney. OBJECTIVE To evaluate the efficacy of removing bilateral kidney stones simultaneously from children, in one session. PATIENTS AND METHODS Thirteen patients (three girls and 10 boys, 26 kidneys; mean age 8 years, range 3,14) underwent simultaneous bilateral percutaneous nephrolithotomy (PCNL) in the same session, under general anaesthesia, starting with ureteric catheter insertion into both kidneys and using a 26 F adult nephroscope. The mean (range) stone diameter was 2 (1,3.5) cm. Three patients had staghorn stones in one of their kidneys. Ultrasonic disintegration was used; two patients had bilateral and two others unilateral endopylotomy, and one patient had percutaneous suprapubic cystolithotomy in the same session. The mean (range) operative duration was 65 (55,90) min. RESULTS All patients were rendered stone-free; there was no severe bleeding or any other complication. On one side in one of the patients, a second session was needed because of residual stone. The nephrostomy tubes were removed 3 and 4 days after PCNL and the hospital stay was 6 (1,11) days. CONCLUSION The advantages of simultaneous bilateral PCNL are reduced psychological stress, one cystoscopy and anaesthesia, less medication and a shorter hospital stay and convalescence, with considerable savings in cost. In experienced hands this method can be used not only in adults but also in children. To our knowledge this is the only report of this technique in children. [source] Protective mechanisms of activated protein C in severe inflammatory disordersBRITISH JOURNAL OF PHARMACOLOGY, Issue 4 2009Arne P Neyrinck The protein C system is an important natural anticoagulant mechanism mediated by activated protein C (APC) that regulates the activity of factors VIIIa and Va. Besides well-defined anticoagulant properties, APC also demonstrates anti-inflammatory, anti-apoptotic and endothelial barrier-stabilizing effects that are collectively referred to as the cytoprotective effects of APC. Many of these beneficial effects are mediated through its co-receptor endothelial protein C receptor, and the protease-activated receptor 1, although exact mechanisms remain unclear and are likely pleiotropic in nature. Increased insight into the structure,function relationships of APC facilitated design of APC variants that conserve cytoprotective effects and reduce anticoagulant features, thereby attenuating the risk of severe bleeding with APC therapy. Impairment of the protein C system plays an important role in acute lung injury/acute respiratory distress syndrome and severe sepsis. The pathophysiology of both diseases states involves uncontrolled inflammation, enhanced coagulation and compromised fibrinolysis. This leads to microvascular thrombosis and organ injury. Administration of recombinant human APC to correct the dysregulated protein C system reduced mortality in severe sepsis patients (PROWESS trial), which stimulated further research into its mechanisms of action. Several other clinical trials evaluating recombinant human APC have been completed, including studies in children and less severely ill adults with sepsis as well as a study in acute lung injury. On the whole, these studies have not supported the use of APC in these populations and challenge the field of APC research to search for additional answers. This article is part of a themed issue on Mediators and Receptors in the Resolution of Inflammation. To view this issue visit http://www3.interscience.wiley.com/journal/121548564/issueyear?year=2009 [source] UR-3216: A Manageable Oral GPIIb/IIIa AntagonistCARDIOVASCULAR THERAPEUTICS, Issue 1 2001Kosuke Baba ABSTRACT UR-3216, a prodrug, is a novel, selective, and orally active platelet surface glycoprotein GPIIb/IIIa) receptor antagonist. The most important property of UR-3216 is the very tight binding of its active metabolite to platelets (Ki for resting platelets is <1 nM). UR-2992, the active form of UR-3216, binds to platelets for a long period of time, while the unbound drug is rapidly cleared. Therefore, after an initial loading dose of 0.1 mg/kg, only once daily repeated low maintenance doses of UR-3216 (<0.05 mg/kg p.o.) are required. This regimen maintains a high level of inhibition of platelet aggregation and, due to a small peak-to-trough ratio, severe bleeding is avoided. The therapy with UR-3216 is easy to manage, because it has low peak-to-trough ratio and high efficacy (>80% inhibition of platelet aggregation). In addition, UR-3216 does not produce excessive bleeding or thrombocytopenia and does not interact with abciximab. UR-3216 is excreted mostly in bile, so that it will not accumulate in patients with chronic renal dysfunction. UR-2316 has the following abciximab-like features: (a) its half-lives for residence on platelets, inhibition of platelets aggregation and bleeding time prolongation are 60 to 80 h, 24, and 2 h, respectively; (b) its receptor binding occupancy is similar to that of abciximab (Mab1 is inhibited and Mab2 is unaltered). In conclusion, UR-3216 is a promising, orally active GPIIb/IIIa antagonist for the treatment of cardiovascular diseases. [source] Post-operative delayed bleeding from the superficial temporal arteryCLINICAL & EXPERIMENTAL DERMATOLOGY, Issue 5 2004A. J. Birnie Summary We present three patients who experienced late, severe bleeding from the superficial temporal artery (STA) following uncomplicated removal of basal cell carcinoma (BCC) from the temple. This is a common site for BCC and the risk of damage to the temporal branch of the facial nerve and the STA are well known. However, delayed bleeding as described in these individuals is potentially dangerous but poorly reported. [source] The relevance of the bleeding severity in the treatment of acquired haemophilia , an update of a single-centre experience with 67 patientsHAEMOPHILIA, Issue 102 2010H. ZEITLER Summary., Acquired haemophilia (AH), an autoimmune disorder with clinical features ranging from harmless haematomas to life-threatening bleedings, still has a mortality rate of up to 25%. Owing to its low frequency (1,4 × 106), standardized treatment protocols for its variable manifestations are not available. In case of prominent severe bleedings, the treatment should aim at rapid elimination of the antibody to protect patients from bleedings and on reinduction of long-term immune tolerance. Clinical data, short- and long-term treatment results of 67 patients diagnosed by our centre are presented. Patients were treated depending on their bleeding severity either by an immunosuppressive treatment alone, or in case of life-threatening bleedings, by a combined protocol (modified Bonn,Malmö protocol, MBMP) consisting of antibody depletion through immunoadsorption, intravenous immunoglobulin treatment, immunosuppression and high-dose factor VIII (FVIII) substitution. Mild bleedings occurred in two patients who were treated successfully alone by immunosuppression. Complete remission (CR) was achieved in 90% of the patients treated with MBMP (60). Of the six patients (10%) who achieved a partial remission (PR), four suffered from cancer. Mortality under MBMP was not seen. In contrast, five patients, in whom diagnosis of AH was delayed, experienced fatal outcome during surgical interventions before initiation of MBMP treatment. Prognosis in AH depends mainly on its prompt diagnosis. Treatment procedures should be adapted to bleeding severity and inhibitor titres. Under these conditions, AH is a potentially curable autoimmune disorder with an excellent prognosis. [source] | ||||||||||