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Introduction: Tactical Combat Casualty Care guidelines recommend packing junctional wounds with gauze, applying direct pressure for 3 minutes, and then securing with an external pressure dressing. This method is time-consuming, which can be problematic in a combat environment. Alternatively, the iTClamp has documented efficacy and rapid application. However, no studies have evaluated device application by military prehospital medical providers, such as Navy corpsmen, or their user experience with the device., Materials and Methods: Research data derived from a protocol were approved by the Naval Medical Center Portsmouth's Institutional Review Board in compliance with all applicable federal regulations governing the protection of human subjects. Navy corpsmen with the current Tactical Combat Casualty Care certification applied the iTClamp or standard pressure dressing on a manikin model of femoral hemorrhage in a crossover study design. Each participant used both devices in a randomized fashion. Time to application was recorded, and participants completed Likert scale surveys to evaluate both devices for preference, ease of use, and physical assessment. A repeat assessment was performed 1 month later to assess skill atrophy. Repeated-measures ANOVA was used to compare application time. Likert scale survey data were analyzed using Mann-Whitney and Wilcoxon tests to compare survey data within and between time points, respectively., Results: The application of the iTClamp was more than twice as fast as the application of pressure dressings at both the initial and follow-up evaluations. There was no statistically significant difference in application times between the first evaluation and the 30-day assessment of either device, indicating no atrophy in skill. While 65% and 52% of the participants expressed preference in for the iTClamp in their surveys during the initial and follow-up respective visits, the difference in preference was not statistically significant for either the initial or the follow-up survey. Open-ended survey responses yielded both perceived advantages and disadvantages for each treatment option., Conclusions: In austere or hostile environments, speed of treatment and extrication can have significant implications for the safety of both the patient and the medical providers. Hemorrhage control interventions must be both effective and easy to use for a prehospital provider to ensure its efficacy in a live battlefield situation. The iTClamp is small, simple, and fast to use, but its wide adoption in the field may be based on limitations perceived by participants, including narrow indications for use. However, based on our findings, it is reasonable to field the iTClamp depending on provider preference., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Haemorrhagic cystitis (HC) is a severe complication of haematopoietic stem cell transplantation (HSCT), which significantly affects patients' quality of life. However, no qualitative studies have described to date the experience of patients who have developed this complication. Therefore, the aim of this interpretative phenomenological study performed on 2019 was to explore the experience of patients who developed HC after HSCT., Method: A purposeful sample of nine patients who had experienced at least one episode of HC after the HSCT were approached. The audio-recorded interviews were transcribed verbatim and then analysed according to Giorgi's method. Member checking of the findings was also performed., Results: The experience of the participants with HC after HSCT has been summarised around three main themes: "Being alerted", "It has arrived" and "It has been overcome." Patients reported to have been informed regarding the HC; after the first devastating symptoms, they reported fear and in searching for causes and strategies to alleviate the problem, which seemed to be never resolved. Patients' experience with HC is complex and experienced dramatically due to the pain and the discomforting consequences of the treatments received; they develop a sense of exhaustion that can further increase both their physical and emotional burden. The process of recovery from the huge impact, required time over the end of the HC symptoms., Conclusions: Patients' experience of HC is complex, and varies according to the various phases of the complication. HC creates an increased physical and psychological stresses that demand additional coping strategies: therefore, the emotional support of patients is crucial. Moreover, strategies used autonomously by patients to alleviate symptoms are at merit of consideration in future studies., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Acute bleeding is an omnipresent challenge for all physicians. Uncontrolled hemorrhage is the most common preventable cause of death after trauma worldwide. In different surgical disciplines, hemorrhage represents an independent risk factor for increased postoperative morbimortality, directly affecting patients' outcomes. This study asked anesthesiologists about their personal perceived challenges when treating bleeding patients., Methods: This investigator-initiated, prospective, international, dual-center, mixed qualitative and quantitative study interrogated anesthesiologists about what they found easy and what difficult in treating acutely bleeding patients. Following the template approach for qualitative research, we identified major and minor topics through free inductive coding and word count. In a second step, we derived ten statements from the participants' answers. Using a field survey, we then asked the participants to rate their level of agreement with the derived statements. We analyzed the answers using one sample Wilcoxon test and the Mann-Whitney test., Results: We included a total of 84 physicians in the qualitative interrogations and a different group of 42 anesthesiologists in the quantitative part. We identified 11 major topics and 19 associated subtopics. The main topics and the degree of agreement (here as agree or strongly agree) were as follows: "Complexity of the topic" (52.4% agreed to find the topic complex), "Cognitive aids" (92.9% agreed to find them helpful), "Time management" (64.3% agreed to feeling time pressure), "Human factors" (95.2% agreed that human factors are essential), "Resources" (95.2% agreed that resources are essential), "Experience" and "Low frequency of cases" (57.1% agreed to lack practice), "Diagnostic methods" (31.0% agreed that the interpretation of test results is difficult), "Anticoagulation" (85.7% agreed to it being difficult), "Treatment" (81.0% agreed to knowing the first therapeutic steps), and "Nothing"., Conclusions: Anesthesiologists in two large tertiary care facilities in different parts of the world found coagulation management, especially in anticoagulated patients, complex. We identified the delayed diagnostic test results and their interpretation as challenges. Resources, treatment protocols and human factors such as team communication were perceived to facilitate management. Future studies should explore the challenges in smaller hospitals and other parts of the world and test new technologies addressing the identified difficulties.

The treatment process of patients using warfarin is expected to be hindered during the COVID-19 pandemic. Therefore we investigated whether the time in therapeutic range (TTR) and bleeding complications were affected during the COVID-19 pandemic. 355 patients using warfarin were included between March 2019 to March 2021. Demographic parameters, INR (international normalized ratio), and bleeding rates were recorded retrospectively. The TTR value was calculated using Rosendaal's method. The mean age of the patients was 61 ± 12 years and 55% of them were female. The mean TTR value during the COVID-19 pandemic was lower than the pre-COVID-19 period (56 ± 21 vs 68 ± 21, P < 0.001). Among the patients, 41% had a lack of outpatient INR control. During the COVID-19 pandemic, 71 (20%) patients using VKA suffered bleeding. Among patients with bleeding, approximately 60% did not seek medical help and 6% of patients performed self-reduction of the VKA dose. During the COVID-19 pandemic, TTR values have decreased with the lack of monitoring. Furthermore, the majority of patients did not seek medical help even in case of bleeding.

A severe hemorrhage can result in death within minutes, before professional first responders have time to arrive. Thus, intervention by bystanders, who may lack medical training, may be necessary to save a victim's life in situations with bleeding injuries. Proper intervention requires that bystanders accurately assess the severity of the injury and respond appropriately. As many bystanders lack tools and training, they are limited in terms of the information they can use in their evaluative process. In hemorrhage situations, visible blood loss may serve as a dominant cue to action. Therefore, understanding how medically untrained bystanders (i.e., laypeople) perceive hemorrhage is important. The purpose of the current study was to investigate the ability of laypeople to visually assess blood loss and to examine factors that may impact accuracy and the classification of injury severity. A total of 125 laypeople watched 78 short videos each of individuals experiencing a hemorrhage. Victim gender, volume of blood lost, and camera perspective were systematically manipulated in the videos. The results revealed that laypeople overestimated small volumes of blood loss (from 50 to 200 ml), and underestimated larger volumes (from 400 to 1900 ml). Larger volumes of blood loss were associated with larger estimation errors. Further, blood loss was underestimated more for female victims than male victims and their hemorrhages were less likely to be classified as life-threatening. These results have implications for training and intervention design., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: CJ is a member of the Red Cross; EP and CJ have filed a patent application for a Tourniquet Training Device (application number 20200170649). This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background and Objective: After cerebral hemorrhage, cognitive functions and activities of daily living (ADL) are affected by various factors, including hematoma volume and patient age. In the present study, we investigated the effect of age and hematoma volume on cognitive functions and on ADL., Methods: The sample comprised 274 patients (183 men and 91 women; mean age 58.2 ± 12.5 years) with putaminal hemorrhage who were hospitalized in a convalescent rehabilitation ward. Hematoma volume was estimated from computed tomography imaging at stroke onset. Cognitive functions were evaluated using Raven's Colored Progressive Matrices test (RCPM) and the Mini-Mental State Examination (MMSE) at hospital admission, while ADL score was assessed at discharge using the Functional Independence Measure motor subscale (FIM-M). In the present study, we classified the patients into six groups according to whether they were non-elderly or elderly (cutoff age, 60 years) and whether their hematoma was small, medium, or large (cutoff volumes, 20 and 40 mL, respectively). Subsequently, the scores on the RCPM, MMSE, and FIM-M were compared among the groups., Results: In both age groups, patients with a larger hematoma volume had lower RCPM and MMSE scores. Patients <60 years old exhibited different trends in their RCPM and MMSE scores, such that the RCPM score showed a step-wise decrease according to hematoma volume, while a difference in the MMSE score was only observed at the 20 mL boundary. Most of the younger patients (<60 years of age) attained high FIM-M scores at discharge, as long as their hematoma volume was either medium or small (<40 mL). This age group had higher RCPM scores on admission, which may have contributed to their higher FIM-M scores on discharge., Conclusions: In the present study, we demonstrated that advancing age increases the effect of hematoma volume on RCPM and MMSE scores and identified differences in the effects observed on these two scores. Thus, it may be important to use the RCPM alongside the MMSE for patient assessment., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The research was conducted at a UK teaching hospital and Haemophilia Comprehensive Care Centre (CCC) as part of a research programme investigating physiotherapy for acute bleed management., Aim: The aim of the study was to understand the perspectives of people with haemophilia (PWH) on validated outcome measures (OM) and whether these measures capture changes relevant to them whilst recovering from an acute bleed episode., Methods: Any person with haemophilia registered to the CCC who reported an acute bleed within the past 2 years was invited to participate. Semi-structured interviews or workshops (activity-focused discussions with small groups) were conducted with PWH who had received physiotherapy treatment in the previous two years. These were used to explore opinions of PWH of commonly used outcome measures., Results: Eight male PWH participated, mean age 61 years, ranging between 39 and 71. Seven participants had severe haemophilia A and 1 had von Willebrands. Participants described numerical rating scales of pain as abstract and expressed a preference for verbal or visual descriptors. In relation to function, the men generally found haemophilia-specific OM to be more relevant. The EuroQol 5-Dimension 5-Level (EQ5D-5L) and Haemophilia and Exercise Project Test Questionnaire (HEP-Test-Q) were considered as good measures due to brevity and ability to capture relevant changes promptly., Conclusion: Participants in this study reported a preference for short OMs that allow them to reference their ability during the acute bleed episode in comparison with their normal function., (© 2019 John Wiley & Sons Ltd.)

Little is known about the health-related quality of life (HRQOL) following adverse bleeding events associated with antithrombotic drug therapy. This systematic review assesses the HRQOL of patients who suffered a bleeding event related to antithrombotic drug use. A literature search was performed using PubMed, EMBASE, and the Cochrane Library from inception through June 16, 2017. Studies measuring HRQOL after a bleeding event related to antithrombotic drug therapy for primary or secondary prevention of a thromboembolic event were included. Four studies with a total of 13,209 patients met the inclusion criteria, and of them, 3,649 patients developed a bleeding event. Patients who were included received antithrombotic drugs because of acute myocardial infarction or atrial fibrillation. EQ-5D, SF-36, and GHP MOS-13 were used to measure HRQOL. The follow-up time ranged from 6 to 29 months. Patients who suffered a bleeding event reported worse HRQOL compared to those who did not (EQ-5D - average increase on all domains of 0.09, p-values ranging from <0.001 to 0.003; SF-36 - average decrease on all domains of 21.4, p < 0.001; and GHP MOS-13 score - decrease of 11.9 points, p < 0.05) and an increased health concern (13.4-point increase; p < 0.05). In conclusion, adverse bleeding events occurring because of the use of antithrombotic agents are associated with a clinically relevant lower HRQOL and hence deserve more attention as part of the shared decision-making process between patients and providers. These data should be valuable for facilitating more substantive care and risk discussions regarding potential changes in outcome and rehabilitation., (Published by Elsevier B.V.)

Introduction: Venous thromboembolism (VTE) including deep vein thrombosis (DVT) or pulmonary embolism (PE) is associated with reduced survival, poorer quality of life, and substantial health-care-costs. Limited research, primarily qualitative, suggests that those with VTE may have elevated fear of recurrence, and associated emotional dysfunction and distress., Methods: A national online survey was administered to 907 patients who had experienced a VTE event in the past two years. The survey assessed for the prevalence of self-reported bleeding harms associated with VTE, the levels of anxiety, depression, cognitive dysfunction and distress experienced by patients, and a range of potential psychosocial correlates that may be associated with these bleeding or emotional harms., Results: The majority (63.0%) of respondents had experienced at least one bleeding related harm following their VTE diagnosis, and 40.6% indicated they experienced fear of another clot often or almost all the time. One-in-four (24.7%) and one-in-ten (11.6%) had abnormal levels of anxiety and depression, respectively. Structural equation modeling was used to define two composite latent bleeding harm and emotional harm factors. Emotional and bleeding harms were associated with younger age, a belief that one's health is due to luck, having multiple comorbidities, having a history of prior VTE events, having multiple barriers to VTE care, and experiencing medical mistakes in diagnosis or treatment. Emotional harms were uniquely predicted by having poorer health literacy, having low self-reported medication adherence, belief others are responsible for one's health, and more recent VTE events. Bleeding harms were uniquely predicted by having a lower frequency of primary care provider contact and having a history of switching between warfarin and direct oral anticoagulants for VTE treatment., Conclusions: The findings show high levels of self-reported bleeding and emotional harms in a general population of VTE sufferers that are clearly associated with readily identifiable demographic, health status, and psychosocial characteristics. These represent targets for intervention and changes in clinical practice., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Venous thromboembolism (VTE) is common in cancer patients and its treatment is associated with a high risk of recurrent VTE (rVTE) and bleeding., Objectives: To analyze data from the Comparison of Acute Treatments in Cancer Hemostasis (CATCH) trial to describe the impact of rVTE and bleeding events on health-related quality of life., Methods: The three-level EuroQol five-dimensional questionnaire (EQ-5D) data were collected monthly for up to 7 months in patients starting anticoagulation for newly diagnosed VTE. Analyses were designed to describe the impact of rVTE and bleeding on EQ-5D scores while controlling for effects of covariates such as background and clinical variables and longitudinal changes. A repeated-measures model with specification of the variance-covariance matrix to characterize the intrapatient correlation was used to estimate the utility values. The impact of an rVTE or a bleeding event was assumed to be reflected in the utility value when it occurred within 2 weeks from a planned data collection point., Results: Data were available from 883 patients. A total of 76 rVTE and 159 bleeding events occurred during follow-up. rVTE had a significant impact on EQ-5D scores, with a decrement of -0.075 on the basis of our reference case (male, no metastasis, Eastern Cooperative Oncology Group score = 1, Western European), but different patients might have different decrements. Bleeding events had a smaller (nonstatistically significant) impact on EQ-5D scores., Conclusions: This data set study has quantified the decline in EQ-5D scores associated with experiencing rVTE or bleeding events in cancer patients. These results indicate the net gain in quality of life and impact on cost-effectiveness of secondary VTE prevention., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

The aim of this study is to evaluate quality of life (QOL) in patients with rare bleeding disorders (RBDs). In this cross-sectional study, 52 consecutive children aged between 4 and 18 years old with RBDs registered at the Haemophila Center of Fars province in Southern Iran were investigated from January to April 2015. Quality of life was evaluated using Haemo-QOL questionnaire. Final score is defined between 0 and 100, and higher score of QOL shows worse condition. P value less than .05 was considered statistically significant. Mean age of the patients was 13.96 ± 4.50 and ranged from 4 to 18 years old including 28 males and 24 females. Family and friends were the 2 most impaired domains of Haemo-QOL in these patients. In univariate analysis, bleeding severity based on bleeding score, health status, and being bothered by the disease showed statistically significant correlations with QOL of the patients ( P < .05). In multiple linear regression models, only degree of being bothered by the disease was determined as an independent influencing factor on QOL. Taking together, Haemo-QOL of children with RBDs was better than what was reported in patients with hemophilia in our region, but it was worse than that reported in patients with hemophilia in other developing and developed countries. Due to chronic feature of bleeding disorders, more attention to different aspects of the disease, especially in 2 dimensions of family and friends through considering educational and psychological program for the patients and their family, are recommended to improve QOL of the patients with RBDs.

Background: To better understand self-reported health-related quality-of-life (HrQoL) in children and adults with chronic hemostatic conditions compared with healthy controls., Methods/patients/results: Group 1 consisted of 74 children/adolescents aged 8-18years with hereditary bleeding disorders (H-BD), 12 siblings and 34 peers. Group 2 consisted of 82 adult patients with hereditary/acquired bleeding disorders (H/A-BD), and group 3 of 198 patients with deep venous thrombosis (DVT) on anticoagulant therapy. Adult patients were compared to 1011 healthy blood donors. HrQoL was assessed with a 'revised KINDer Lebensqualitaetsfragebogen' (KINDL-R)-questionnaire adapted to adolescents and adults. No differences were found in multivariate analyses of self-reported HrQoL in children with H-BD. In contrast, apart from family and school-/work-related wellbeing in female patients with DVT the adult patients showed significantly lower HrQoL sub-dimensions compared to heathy control subjects. Furthermore, adults with H/A-BD disorders reported better friend-related HrQoL compared to patients with DVT, mainly due to a decreased HrQoL subscale in women on anticoagulation., Conclusion: In children with H-BD, HrQoL was comparable to siblings and peers. In adults with H/A-BD HrQoL was comparable to patients with DVT while healthy blood donors showed better HrQoL. The friend-related HrQoL subscale was significantly reduced in female compared to male patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress., Design: Longitudinal survey., Setting: Two hospital-based colposcopy clinics., Population: Women with abnormal cytology who underwent colposcopy (±related procedures)., Methods: Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables., Main Outcome Measures: Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress., Results: Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up., Conclusions: The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress., Tweetable Abstract: Experiencing multiple physical after-effects of colposcopy is associated with psychological distress., (© 2017 Royal College of Obstetricians and Gynaecologists.)

The Bridging Hemophilia B Experiences, Results and Opportunities Into Solutions (B-HERO-S) initiative was launched in an effort to address specific gaps in the understanding of the psychosocial impact of mild-moderate-severe hemophilia B. The original Hemophilia Experiences, Results and Opportunities (HERO) qualitative study evaluated the needs of people with hemophilia A or B in multiple countries; however, a majority of participants had the more common moderate-severe hemophilia A. The B-HERO-S study was designed in collaboration with the hemophilia community to evaluate the needs of adults with hemophilia B and caregivers of children with hemophilia B, including affected women and caregivers of girls with hemophilia. The report presented here describes participant demographics and comorbidities, as well as treatment regimens and access to treatment. Bleeding symptoms were reported by 27% of mothers of children with hemophilia B who participated. Women were more likely than men to self-report arthritis and depression/anxiety as comorbidities associated with hemophilia B. More adults and children with hemophilia B were on routine treatment than on on-demand treatment, and a high percentage of adults with moderate hemophilia B received routine treatment (86%). Many adults with hemophilia B (78%) and caregivers (69%) expressed concern about access to factor in the next 5 years, and of adults with hemophilia B, women more commonly experienced issues with access to factor in the past than did men (72% vs 44%). The findings of the B-HERO-S study reveal potential unmet needs of some patients with mild-moderate hemophilia B, and the results may be leveraged to inform patient outreach by hemophilia treatment centers and education initiatives., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Distress may affect a patient's ability to cope with and manage disease., Aim: To report distress prevalence in adult patients with bleeding disorders and determine whether specific clinical and health characteristics, including disease severity and employment status, are associated with distress., Methods: Patients who visited a Haemophilia Treatment Centre (HTC) between January 1st, 2012 through February 28th, 2014 and who completed a distress screen, pain screen and questionnaire were evaluated cross sectionally. Distress was measured by the National Comprehensive Cancer Network Distress Management Tool, which allowed patients to rate recent distress on a 0-10 point scale. A rating of five or more was categorized as high distress. Pain was measured by the Brief Pain Inventory Short Form, which asked patients to rate pain types on 0-10 point scales. Patients reported employment and other demographic and behavioural information on the questionnaire. Primary diagnosis, age, HIV and HCV status were abstracted from medical records. Adjusted logistic regression was used to identify distress associations., Results: High distress prevalence among 152 patients with bleeding disorders was 31.6%. Unemployment, disability, greater depressive symptoms and higher pain were associated with high distress in multivariable models. Bleeding disorder diagnosis, race/ethnicity, HIV/HCV status and on-demand treatment regimen were not associated with high distress., Conclusion: Distress among patients with congenital bleeding disorders followed at a comprehensive HTC was high and similar to that reported among patients with cancer. Future research should determine whether distress impacts clinical outcomes in patients with bleeding disorders as demonstrated in other chronic disorders., (© 2015 John Wiley & Sons Ltd.)

Background: Delays in escalation of care for patients may contribute to poor outcome. The factors that influence surgical patients' willingness to call for help on wards are currently unknown. This study explored the factors that affect patients' willingness to call for help on surgical wards; how patients call for help and to whom; how to encourage patients to call for help, and the barriers to patients calling for help., Methods: A cross-sectional study was conducted in three London hospitals using a questionnaire designed through expert opinion and the published literature. A total of 155 surgical patients (83% response rate) participated., Results: Patients were more willing to call for help using the bedside buzzer or by calling a nurse compared to a doctor (p < 0.001). The prompts to calling for help patients were most likely to act on were bleeding and pain. Patients were more willing to call for help if encouraged by a healthcare professional than a relative or fellow patient (p < 0.01). Patients were more likely to worry about taking up too much time when calling for help than being perceived as difficult (p < 0.001). For some prompts, male patients were more willing to call for help (p < 0.05)., Conclusions: This is the first study to identify factors affecting patients' willingness to call for help on surgical wards. Interventions that take these factors into account can be developed to encourage patients to call for help and may avoid delays in treatment.

Background: A pharmacist managed anticoagulation service was initiated in a multi-physician family medicine clinic in December 2006. In order to determine the patient and physician satisfaction with the service, a study was designed to describe the patients' satisfaction with the warfarin education and management they received from the pharmacist, and to describe the physicians' satisfaction with the level of care provided by the pharmacist for patients taking warfarin. A self-administered survey was completed by both eligible patients receiving warfarin and physicians prescribing warfarin between December 2006 and May 2008. The patient survey collected information on patient demographics, satisfaction with warfarin education and daily warfarin management. The physician survey collected data about the satisfaction with patient education and daily anticoagulation management by the pharmacist., Results: Seventy-six of 94 (81%) patients completed the survey. Fifty-nine percent were male with a mean age of 65 years (range 24-90). Ninety-six percent agreed/strongly agreed the pharmacist did a good job teaching the importance of warfarin adherence, the necessity of INR testing and the risks of bleeding. Eighty-five percent agreed/strongly agreed the risk of blood clots was well explained, 79% felt the pharmacist did a good job teaching about dietary considerations and 77% agreed/strongly agreed the pharmacist explained when to see a doctor. All patients felt the pharmacist gave clear instructions on warfarin dosing and INR testing. Four of nine physicians (44%) completed the survey. All agreed/strongly agreed the pharmacist was competent in the care provided, were confident in the care their patients received, would like the pharmacist to continue the service, and would recommend this program to other clinics., Conclusions: Patients and family physicians were satisfied with the pharmacist managed anticoagulation program and recommended continuation of the program. These results support the role of the pharmacist in the management of anticoagulation in a multi-physician family medicine clinic.

A10-year boy presented with spontaneous episodes of oral bleeding for the last 6 months. Detailed ENT examination showed no pathology, bleeding profile was normal, endoscopy and dental examination also did not reveal any abnormality. Child abuse or malingering was also ruled out. Initially the child was managed with platelet transfusion and fresh frozen plasma and then put on follow-up treatment with antifibrinolytics, Vitamin C but the episodes became recurrent. Psychiatric evaluation revealed that child was suffering from depression. Antidepressants were prescribed by the psychiatrist that not only cured the depression with time but also the bleeding episodes which were actually related to child's depression (Gardner-Diamond syndrome or psychogenic purpura). This is a diagnosis by exclusion where the patients bleed due to dysregulated steroid secretion secondary to stress; resulting in development of sensitization to RBC membrane, and dysregulated fibrinolytic system activity.

Background: Patients with haemophilia experience bleeds because of absent or reduced clotting factor. The study objective was to understand the bleeding experience from the patients' perspective., Materials and Methods: Individuals with moderate/severe haemophilia participated in interviews and were asked to describe their most recent bleeding experience, including symptoms, signs of onset, impacts, when bleeding stopped and treatment effectiveness. Interview transcripts were analysed using a thematic analysis involving the coding of transcripts to identify key concepts and themes., Results: Twenty males [10 adults, mean age = 41 (19-52); 10 adolescents, mean age = 13 (12-17)] with moderate (n = 5) or severe (n = 15) haemophilia participated. Symptoms signalling bleed onset included pain, swelling, stiffness, tingling/numbness and/or warmth. Participants reported feeling anger and frustration due to the unpredictable nature, pain and inconvenience of the episode. Adults sometimes reported delaying treatment due to inconvenience or cost; adolescents generally treated right away. Reported bleed severity was influenced by pain level, speed of symptom progression, location, continued use of the affected area, recurrence in same location of recent bleed and treatment delay. Participants reported that it was 'easy' to know when the bleed had stopped. Participants reported that symptoms might linger for days before they returned back to 'normal'., Conclusions: This qualitative study details the substantial impact of an acute bleed from the patient perspective. Given that treatment was reported to be delayed in part due to inconvenience, more convenient treatment options could help reduce delays in treating bleeds and thereby minimise bleed-related impacts. Clinical studies in haemophilia should include validated patient-reported measurements of acute symptoms and bleed severity to comprehensively assess the bleeding event., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Psychological adaption after pacemaker implantation can be challenging in patients with psychiatric disease. Suicide by self-removal of a permanent pacemaker system is a rare phenomenon described in a few cases in patients with psychiatric disorders., Methods and Results: We describe a case of attempted suicide by complete self-removal of a 12-year-old permanent pacemaker system in a 70-year-old male patient with a bipolar disorder and a history of previous suicide attempts., Conclusions: Suicide attempt by self-removal of a permanent pacemaker system is very rare. In patients with a history of psychiatric disease and previous suicide attempts, careful information about the function of a pacemaker should be given., (© 2014 Wiley Periodicals, Inc.)

Purpose: In this qualitative study, school-age children between 7 and 11 years, living with a bleeding disorder or other chronic illness, defined how they understand their partnership role in family-centred care (FCC), and recommended FCC strategies., Methods: This systematic ethnography had three phases: unstructured interviews explored how children understood FCC partnership roles (phase I); document review provided FCC institutional context (phase II); and validation interviews generated FCC partnership recommendations (phase III). This study took place within the area served by a Western Canadian children's hospital. Interviews were held at the hospital or children's home. In phase I, purposive sampling was used to recruit children receiving outpatient care for a bleeding disorder (n = 4) or another chronic illness (n = 4). In phase II, policies and legislation were compared with how children understand their FCC partnership role. In phase III, validation interviews were conducted with children (n = 3) to confirm domains and generate FCC supporting strategies. Data collection and analysis were based on domain analysis and qualitative ethnographic content analysis., Results: Phase I outcomes included seven domains regarding how children understood their role as partners in FCC: my best interests, virtues, talking and listening, being involved, knowing, making decisions and being connected. Phase II outcomes revealed how these domains were represented in institutional contexts. Phase III outcomes confirmed domains and generated key strategies to support children's role as FCC partners through graphic representation of FCC as a treasure map, interactive workshop and online game., Conclusions: School-age children, living with a bleeding disorder or other chronic illness, similarly want to learn how to be FCC partners by developing competence as healthcare team members, identifying their own best interests, learning how to communicate with 'grown-ups', clarifying roles and goals, and guided opportunities for decision making. Facilitating school-age children's FCC partnership roles is worthy to explore in youth transition programmes., (© 2011 Blackwell Publishing Ltd.)

Introduction: Quality-of-life (QOL) assessments in frequently bleeding patients with congenital hemophilia with inhibitors and their families are confounded by preexisting arthropathy and family circumstances. Periodic QOL assessments typically made on nonbleed days may not provide complete reflections of the burden on patients/families., Aim: To evaluate the impact of bleeding episodes on patients/caregivers/families and the association between monthly QOL scores and patients' average diary experiences., Methods: Frequently bleeding inhibitor patients (≥four bleeds in 3 months), or their caregivers, provided daily assessment of EuroQol five-dimensional questionnaire and EuroQol five-dimensional questionnaire visual analogue scale, pain (11-point Likert scale), and family anxiety/stress/activity change over 3 to 6 months. QOL scores were stratified by bleed/nonbleed days., Results: Patient QOL assessments were recorded by 37 of the 39 enrolled patients/caregivers (3771 of 3777 eligible dairy days, 472 bleed/3299 nonbleed days). Median (range) diary duration was 91 (66-180) days, with 8.2% (0%-72.2%) bleed days. Mean health scores were significantly worse on bleed days than on nonbleed days (P < 0.0001 for all): EuroQol five-dimensional questionnaire index, 0.66 versus 0.82; visual analogue scale health, 69.7 versus 77.4; and pain score, 4.1 versus 1.8. Bleed days also had higher (P < 0.001) proportions of days with abnormalities in family anxiety/stress (42% vs. 30%) and family activity changes (34% vs. 21%)., Conclusions: Assessing the impact of hemophilia with inhibitors on patient/family QOL typically includes periodic (likely nonbleed day) evaluations reflecting baseline abnormalities. Daily assessment, however, indicated that frequent acute bleeds impair QOL beyond patient's nonbleed day baseline. New approaches are required to assess the cumulative impact of frequent acute bleeds on patients and their families., (Copyright © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Bleeding malignant wounds in palliative care patients can be anxiety-provoking for patients, their caregivers, and healthcare providers, and can be difficult to manage. We present the case of a 60-year-old man with a bleeding neck wound due to squamous cell carcinoma of the hypopharynx admitted to our inpatient palliative care unit. Management of bleeding included local wound care measures and psychosocial support for the patient and his wife. We review therapeutic approaches to managing bleeding malignant wounds with the aim of providing clinically useful information.

Unlabelled: INTRODUCTION/RESULTS: This study examined whether a belief of significant blood loss may be associated with vasovagal symptoms, irrespective of actual blood loss. Individual differences in vasovagal symptoms among blood donors who had an equivalent amount of blood withdrawn were significantly associated with their rating of perceived blood loss., Conclusion: The anticipation or belief of blood loss, and perhaps more remotely associated ideas, may trigger processes similar to those induced by actual hemorrhage though further research is required to address other possibilities such as the inflation of ratings by vasovagal symptoms.

Background and Purpose: Warfarin is an effective drug for the prevention of thromboembolism in the elderly. The major risk for patients taking warfarin is bleeding. We aimed to assess the impact of psychosocial factors, including mood, cognition, social isolation, and health literacy on warfarin instability among community-based elderly patients., Methods: A case-control study was conducted between March 2008 and June 2009 in a community-based setting. Cases were patients previously stabilized on warfarin who recorded an international normalized ratio≥6.0. Control subjects were patients whose international normalized ratio measurement was maintained within the therapeutic range. Patient interviews investigated potential predisposing factors to elevated International Normalized Ratio levels., Results: A total of 486 patients were interviewed: 157 cases and 329 control subjects, with an approximate mean age of 75 years. Atrial fibrillation was the most common primary indication. Adjusted multivariate logistic regression revealed impaired cognition (OR, 1.9; 95% CI, 1.0 to 3.6), depressed mood (OR, 2.2; 95% CI, 1.2 to 3.9), and inadequate health literacy (OR, 4.0;95% CI, 2.1 to 7.4) were associated with increased risk of an elevated International Normalized Ratio., Conclusions: This study identified impaired cognition, depressed mood, and inadequate health literacy as risk factors for warfarin instability. These had a similar impact to well-recognized demographic, clinical, and medication-related factors and are prevalent among the elderly. These findings suggest that elderly patients prescribed warfarin should be reviewed regularly for psychosocial deficits.

Background: Physical disability and psychologic morbidity are frequent and important complications of severe trauma injury with serious consequences for long-term health-related quality of life (HRQOL). Little prospective data exist, however, in a global trauma population on the risk factors for poor HRQOL., Methods: The CONTROL trial was a prospective, randomized, double-blinded, multicenter, placebo-controlled trial conducted from August 2005 to September 2008. HRQOL was assessed 3 months after injury using the Polytrauma Outcome Chart (Glasgow Outcomes Scale, Short Form 36, European Quality of Life-5 Dimensions (EQ-5D), and Trauma Outcome Profile). Multivariate stepwise regression analysis identified predictors of poor HRQOL., Results: Three hundred forty-seven (72%) patients completed at least one HRQOL instrument. Three percent had an EQ-5D score <0 (worse than death); 92% had a score <0.87 (average score in the general population). All HRQOL instruments identified physical functioning and activities of daily living as the dimensions of health most significantly affected by trauma injury. Mental functioning was also significantly affected according to the Trauma Outcome Profile. Independent predictors of poor HRQOL were higher age, female gender, extremity injury, blunt injury, intensive care unit stay >3 days, repeated nonadherence to transfusion guidelines, and inability to work postinjury., Conclusions: Three months after severe trauma injury, survivors report very poor HRQOL. Physical wellbeing is generally more negatively affected than mental wellbeing. A trauma-specific HRQOL instrument reveals more diverse mental health problems than generic instruments. In a global trauma population, postinjury HRQOL is predicted by demographic and socioeconomic characteristics, type of injury, and treatment received.

Objective: It is common in health care settings for adolescent patients to report physical symptoms that are unexplained by physical disease or pathophysiologic processes. The diagnosis of conversion disorder is difficult to make as many of these patients present to primary care with complex, difficult-to-understand medical symptoms. Patients can present with a medical dilemma and a symptom model consistent with a conversion disorder, but there is a danger of misdiagnosis without a thorough medical work up., Method: This case report describes a patient where the misdiagnosis of conversion disorder could have had devastating long-lasting neurologic sequelae. It appeared as if an unconscious conflict was being expressed through physical symptoms as she had ongoing family stressors prior to the onset of mysterious symptoms., Conclusions: The patient was found to have a spinal cord arteriovenous malformation. This condition is relatively uncommon in the pediatric age group, and early diagnosis is rarely made.

Lasthénie de Ferjol syndrome is a very rare psychiatric illness that occurs mainly in women. It is characterized by severe recurrent iron-deficiency anemia caused be repeated episodes self-induced blood-letting. We report the case of a young homosexual male repeatedly admitted to various hospitals for severe hypochromic anemia. We discovered that the anemia was indeed due to psychotic self-provoked hemorrhages. Based on this experience and a review of the few cases reported in the literature, we discuss issues of early diagnosis, management and treatment of Lasthénie de Ferjol patients.

Introduction: Self-mutilation is direct and deliberate harm to one's body without conscious intent to die. It is observed in both men and women with various psychiatric disorders, but most of those who self-mutilate are women diagnosed with borderline personality disorder. Cocaine addiction is a significant worldwide public health problem, associated with somatic, psychological, psychiatric, socioeconomic and legal complications. Amphetamine use, but not cocaine use, has previously been associated with severe self-injurious behavior., Case: We report here a case of a female patient with recurring self-injurious behavior ("the pleasure of bleeding") induced by cocaine abuse., Discussion: The clinical characteristics of self-mutilation are manifold and there is a lack of agreement about its etiology. The complex behavior associated with cocaine abuse may be one cause of self-mutilation. Dysfunction of the inhibitory brain circuitry caused by drug addiction could explain why this cocaine-addicted patient loses control and self-mutilates during cocaine use.

Background: Lethal injuries can be repaired under asanguineous hypothermic arrest (suspended animation) with excellent survival. This experiment was designed to test the impact of this strategy on neuronal and astroglial damage in a swine model of lethal hemorrhage. Furthermore, our goal was to correlate the histological changes in the brain with neurological outcome, and the levels of circulating brain specific markers., Materials and Methods: Uncontrolled hemorrhage was induced in 32 female swine (80-120 lbs) by creating an iliac artery and vein injury, followed 30 min later by laceration of the thoracic aorta. Through a thoracotomy approach, organ preservation fluid was infused into the aorta using a roller pump. Experimental groups included normothermic controls (no cooling, NC), and groups where hypothermia was induced at three different rates: 0.5 degrees C/min (slow, SC), 1 degrees C/min (medium, MC), or 2 degrees C/min (fast, FC). Profound hypothermia (core temperature of 10 degrees C) was maintained for 60 min for repair of vascular injuries, after which the animals were re-warmed (0.5 degrees C/min) and resuscitated on cardiopulmonary bypass (CPB). Circulating levels of neuron specific enolase (NSE) and S-100beta were serially measured as markers of damage to neurons and astrocytes, respectively. Light microscopy and quantitative immunohistochemical techniques were used to evaluate hippocampal CA1 area and caudate putamen for neuronal injury and astrogliosis (astrocyte hyperplasia/hypertrophy). Surviving animals were observed for 6 weeks and neurological status was documented on an objective scale, and cognitive functions were evaluated using a technique based upon the concept of operant conditioning., Results: Normothermic arrest resulted in clinical brain death in all of the animals. None of the surviving hypothermic animals displayed any neurological deficits or cognitive impairment. On histological examination, normothermic animals were found to have ischemic changes in the neurons and astrocytes (hypertrophy). In contrast, all of the hypothermic animals had histologically normal brains. The circulating levels of brain specific proteins did not correlate with the degree of brain damage. The changes in NSE levels were not statistically significant, whereas S-100beta increased in the circulation after CPB, largely independent of the temperature modulation., Conclusions: Profound hypothermia can preserve viability of neurons and astrocytes during prolonged periods of cerebral hypoxia. This approach is associated with excellent cognitive and neurological outcome following severe shock. Circulating markers of central nervous system injury did not correlate with the actual degree of brain damage in this model.

Objective: To examine the relationship of stress and incidence of bleeding in boys with hemophilia., Study Design: We conducted a 6-month longitudinal study of 97 subjects (ages 4 to 16 years) from six hemophilia centers. Diaries recorded bleeding episodes (including site and history of previous trauma) and both child and parent daily stress. Parent and child stressful life event measures were obtained monthly. Socioeconomic data and clotting factor level were determined at enrollment. Logistic regression models examined the influence of recent stress on likelihood of bleeding on each day, controlling for factor level and socioeconomic data. We also determined associations of aggregated previous month's events with bleeding likelihood in the succeeding month., Results: Fifty-eight percent of study participants had severe hemophilia. The sample population averaged nine bleeding episodes per 6 months; of these; two thirds of bleeding incidents occurred into joints and 44% after injury. Factor level strongly predicted bleeding incidence (p < 0.0001). Increased parent stress was associated with increased bleeding in general (odds ratio = 1.37, p < 0.003) and with injury (odds ratio = 1.65, p < 0.001), but not bleeding into joints. Similar findings followed parent reports of positive life events. Increased parent negative life events in 1 month were associated with increased bleeding in the succeeding month (p < 0.05)., Conclusion: Short- and long-term parental stress may lead to increased bleeding incidence in hemophilia, although factor level much more strongly predicts bleeding.

Psychogenic "purpura" consists in the spontaneous appearance of recurrent bruising, it is a reality which is still unexplained. Most often woman with an underlying emotional disorder are affected. In addition to cutaneous ecchymoses and hematomas they may have menometrorrhagia, hematuria, epistaxis and gastrointestinal bleeding in addition to many other complaints encompassing multiple organ systems. Cutaneous bruising is heralded by a burning or stinging sensation followed after a few hours by local warmth, puffiness and erythema, most often with some itching. The pain subsides when the ecchymoses appear a day later or earlier. Blood coagulation and hemostatic tests remain normal in all patients. A rare but poorly studied variety of psychogenic bleeding are religious or other stigmata with periodic bleeding at hands and feet, under the left breast and at the forehead, occasionally with bloody tears. It would be risky to substitute one poorly understood diagnosis (stigmata) with another (hysterical conversion). It is very difficult to distinguish spontaneous psychogenic from selfinflicted iatrogenic bleeding (purpura factitia) because patients may have the same obsessive-compulsive behavior or hysterical trait. Moreover, patients with self-induced bleeding act in a most clever manner and their continuous observation is difficult. The differential diagnosis with the "battered child" syndrome is rather easy. Other bleeding disorders with normal coagulation tests are an inherited failure of the collagen biosynthesis (f.i. Ehlers-Danlos syndrome) or congenital or acquired vascular disorders (purpura senilis of Bateman, vitamin C deficiency, morbus Schamberg, purpura annularis of Majocchi, orthostatic purpura). There is virtually no scientific information on the interaction between the nervous system and hemostasis or blood coagulation. The only therapeutic approach in patients with psychogenic bleeding is psychiatric with particular attention to the sociocultural background of the patient and his family.

A most unusual case of Munchausen's syndrome in an 18-year-old Yemeni female is described. The patient presented with bleeding from various sites; repeated subcutaneous emphysema of the face, orbit and upper chest; ulcers on the tongue, and dermatitis autogenica. The illness was confirmed to be factitious and self-induced when she was caught red-handed trying to inject air. We believe this to be the first report of a case where all these features occurred concurrently and only the second report where a patient developed self-induced orbital emphysema.

Using a mock injury involving arterial bleeding, we explored the impact of variables on two different decisions in the decision-making process leading to help. Expertise (Red Cross Training), ambiguity, and number of bystanders were manipulated in a 2 X 2 X 2 design. We observed the following responses: (a) nonhelp, (b) ineffective direct help, (c) indirect help, and (d) direct help. The decision to help or not was affected by ambiguity, sex, and the presence or absence of other bystanders. Greater ambiguity led to less help; women helped less than men; and fewer people helped when other bystanders were present. Expertise affected the decision leading to the type of help used but not the decision to help. Although training did not raise the intervention rate, it did dramatically change the effectiveness of the help used and could yield as many as 28 more saved lives out of 80 such incidents. The number of bystanders affected both the decision to help and the type of help used. Ineffective direct help occurred most frequently when the bystander was alone. The presence of other bystanders also affected the type of indirect help that was used.

Motivated by previous reports of relaxation successes with hemophiliacs, we sought to isolate the value of relaxation strategies. The effects of progressive and self-control relaxation on spontaneous bleeding and collateral symptoms were tested with seven hemophiliacs in a combined multiple-baseline partial-crossover design. Following 6 or 12 weeks of training in either or both relaxation methods, there was no strong evidence that the treatment affected bleeding or perceived pain in these subjects. These disappointing results were obtained despite within-session physiological evidence of relaxation induction and self- and spouse reports of faithful relaxation practice. The present results failed to replicate previous findings, cast doubt on the stress theory of spontaneous bleeding, and recommend further research to clarify the role of psychological interventions for hemophiliacs.

The Gardner-Diamond Syndrome is an infrequently diagnosed impressive psychosomatosis. The patients (exclusively female) suffering from this disorder are described as "angry young women". They are considered hysterical, masochistic, depressive, hostile and timid. Physically the syndrome is characterized by atypical, painful, apparently spontaneous skin bleeding in young women and these patients look like they have been beaten, injured or are seriously ill. Besides hematoma, renal hemorrhage, uterine hemorrhage, headaches or unconsciousness as well as numerous symptoms of conversion in the narrower sense of the word have been observed, e.g. loss speech, gait deviation, or feelings of discomfort. To this day the pathophysiological peculiarity that enables the patients to transform subconscious psychic events into the specific temporary alteration in the permeability of the capillary walls being a constitutional variant characteristic of females suffering from Gardner-Diamond Syndrome and activated by psychic stimuli. In the case history presented, the problem is the psychic working out of narcissistic injuries in the context of a borderline structure. These injuries turn into physical symptoms analogous to the process of conversion. Since, in this case, there is no question of a defense against oedipal fantasies one would prefer to speak of a "narcissistic conversion". Quite peculiar is the universally described resemblance of the patients to one another. The syndrome, together with the character and psychodynamic features, is repeated in almost a stereotypical manner. An explanation for this phenomenon cannot be expected even from the discovery of a pathophysiological detail in the blood vessels. Rather, we are confronted with one of those extremely rare syndromes where, in a limited field, physical and psychic events are completely blended. The physical events such as affects and defense mechanisms for which they can be substituted at random and without mutual interference. It is as though these disorders had retained a phylogenetically lost unity and primeval capability of interchanging psychic and somatic structures and, so to speak, preserved them in the manner of a museum. These syndromes make us surmise that in processes of somatization a recourse to ancient, long-faded psychosomatic relationships may play a certain role.