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Background: Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites. Methods: 140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,n = 70) or propranolol alone (Gr.B,n = 70). Primary outcome was incidence of bleed at 1 year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects. Results: Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1 year was lower in Gr.A than B (8.5%vs.27.1%,p-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6 mg vs. 76.52 ± 24.4 mg; p-0.01) and more patients achieved THR (84.2%vs.55.7%,p-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,p-0.014), diuretic tolerance (80%vs.60%,p-0.047) at higher doses(p-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;p-0.01), plasma renin activity (54.4% from baseline) (p = 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81 mmHg(23.5%) vs. 2.61 ± 2.87 mmHg(14.5%),p-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,p = 0.013 and 10%vs.15.7%, p = 0.03, respectively). Conclusion: Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites. [ABSTRACT FROM AUTHOR]

From reenactments to pilgrimages, extraordinary experiences engage consumers with frames and roles that govern their actions for the duration of the experience. Exploring such extraordinary frames and roles, however, can make the act of returning to everyday life more difficult, a process prior research leaves implicit. The present ethnography of live action role-playing explains how consumers return from extraordinary experiences and how this process differs depending on consumers' subjectivity. The emic term "bleed" captures the trace that extraordinary frames and roles leave in everyday life. The subjective tension between the extraordinary and the ordinary intensifies bleed. Consumers returning from the same experience can thus suffer different bleed intensities, charting four trajectories of return that differ in their potential for transformation: absent, compensatory, cathartic, and delayed. These findings lead to a transformative recursive process model of bleed that offers new insights into whether, how, and why consumers return transformed from extraordinary experiences with broader implications for experiential consumption and marketing. [ABSTRACT FROM AUTHOR]

Time-accurate numerical calculations are performed to investigate the effect of air recirculation on NASA Rotor 37. An annular casing-mounted recirculation passageway is designed and located over the blades. Because the investigated rotor does not have any stator, the bleed air has a high circumferential velocity component (in the same direction of the rotor). Therefore, the injected air would have a high swirl component, reducing the injection's effectiveness. As a result, anti-swirl blades have been installed within the recirculation duct, to reduce flow swirl and improve injector effectiveness. Different anti-swirl vanes have been simulated in order to determine the best vanes in terms of minimum pressure loss and zero injection yaw angle (axial injection). Results show that these vanes can effectively turn the circulated fluid to the axial direction and provide a high velocity axial injection upstream of the rotor blades. As a result of the effective injection, the leakage flow moves downstream, improving stability by shifting the stalling point to lower mass flow rates. Because the injection port is close to the blade, the interaction of the passage shock and the injection port causes unsteadiness in the injection mass flow, which is discussed in the paper. [ABSTRACT FROM AUTHOR]

The presence of bleed in an aero engine's compressor can significantly impact its flow characteristics and contribute to rotating instability. This study focuses on the impact of a typical cavity bleed structure on the internal flow characteristics of a compressor, specifically its circumferential non-uniformity and aerodynamic stability. A numerical simulation involving multiple flow passages was conducted on the transonic high-pressure rotor of the E3 compressor, considering its typical bleed structure. The study delves deep into the non-uniform flow characteristics and the mechanisms behind their generation in the compressor flow field. Furthermore, the influence of bleed on the rotating instability of the compressor is explored by comparing changes in compressor instability and adiabatic efficiency under uniform and non-uniform flow field conditions. The findings indicate that the axial position of the cavity bleed structure plays a crucial role in influencing key parameters such as rotor stall margin, peak efficiency, and total pressure ratio under near-stall conditions. The circumferential non-uniformity, resulting from the presence of the cavity bleed, intensifies with higher bleed air flow rates. For the upstream bleed configuration applied to the rotor, with a total bleed rate of 5%, the maximum variation in absolute flow angle at the inlet of different rotor channels can reach up to 1°. Additionally, the maximum difference in inlet flow coefficient can reach 0.0392. These findings demonstrate that the non-uniformity caused by the typical bleed structure leads to a loss in stall margin for the rotor when compared to a uniform flow field scheme. [ABSTRACT FROM AUTHOR]

Time-accurate numerical calculations are performed to investigate the effect of air recirculation on NASA Rotor 37. An annular casing-mounted recirculation passageway is designed and located over the blades. Because the investigated rotor does not have any stator, the bleed air has a high circumferential velocity component (in the same direction of the rotor). Therefore, the injected air would have a high swirl component, reducing the injection's effectiveness. As a result, anti-swirl blades have been installed within the recirculation duct, to reduce flow swirl and improve injector effectiveness. Different anti-swirl vanes have been simulated in order to determine the best vanes in terms of minimum pressure loss and zero injection yaw angle (axial injection). Results show that these vanes can effectively turn the circulated fluid to the axial direction and provide a high velocity axial injection upstream of the rotor blades. As a result of the effective injection, the leakage flow moves downstream, improving stability by shifting the stalling point to lower mass flow rates. Because the injection port is close to the blade, the interaction of the passage shock and the injection port causes unsteadiness in the injection mass flow, which is discussed in the paper.

As an essential component, the bleed system plays a critical role in supplying turbine cooling air, guaranteeing stage matching, pressurizing the cabin, and de-icing at the wing and engine inlet. However, the extraction of the bleeding air from the compressor causes the engine efficiency degradation and thrust deficit. Therefore, flow control based on bleed is conducted to compensate the bleed induced disadvantages. The influence of the circumferential bleeding slot location on the tip leakage vortex and passage vortex controlling in a compressor cascade with the tip clearance is numerically studied using large eddy simulation. Three bleed configurations and the smooth casing configuration are investigated. 17.11% loss reduction is obtained through bleeding at 10% cx upstream of the blade leading edge with a bleeding rate of 2.76%. The vortex structures and flow patterns are compared and analyzed to reveal the controlling mechanism. Subsequently, the axial vorticity and loss evolution is discussed, and the interaction between the primary flow and bleeding air is revealed. It's found that bleeding slot placed within the blade passage is exposed into a highly static pressure gradient, and this causes the bleeding air flows into and spills out the bleeding slot and leads to unnecessary loss. Moreover, the influence of large bleeding rate and inlet boundary layer is assessed. [ABSTRACT FROM AUTHOR]

Abstract Background and Aim Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding. Methods We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan–Meir survival curve showed GI bleed‐free survival following initial bleed and was compared using the log rank test. Results A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity‐score‐matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P

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Background and Aim: Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding. Methods: We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan–Meir survival curve showed GI bleed‐free survival following initial bleed and was compared using the log rank test. Results: A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity‐score‐matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed‐free survival compared to those in the nonemergent group (P = 0.009). Conclusion: Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE. [ABSTRACT FROM AUTHOR]

Background: Capsule endoscopy (CE) is an emerging tool in the diagnosis and management of occult bleeding and overt obscure gastrointestinal bleeding (OOGIB). Maximizing the efficiency of CE can lead to rapid bleeding localization and shorter time to therapy. We investigated whether a trained registered nurse (RN) can accurately interpret bleeding by observing the CE findings in real time by measuring inter-observer agreement between RN and physician interpretation. Methods: We conducted a prospective study of patients admitted for OOGIB who underwent live-view capsule endoscopy (LVCE) between December 2016 and November 2017. A matched control group who underwent standard CE was obtained through retrospective review. An RN received a 2-day training program for CE interpretation. RN bedside interpretation for bleeding was followed by interpretation by 2 gastrointestinal physicians blinded to LVCE findings. Outcomes were compared between groups using t-tests and χ2 tests. Cohen's kappa measured the agreement between the physicians and the RN. Results: Ten subjects were in the LVCE group, and 12 subjects were in the standard-of-care group. The agreement between the physicians and the RN was 9/10 (90%), with a kappa of 0.73 (95% CI: 0.26–1.00; p = 0.016). Patients in the LVCE group had shorter duration to physician interpretation (0.6 vs. 0.7 days [p = 0.50]), shorter duration to endoscopy (1.8 days vs. 3 days [p = 0.240]), and shorter length of stay (8.1 vs. 11.4 days [p = 0.26]) compared to the standard-of-care group. Conclusion: This study utilizing an RN for LVCE interpretation found inter-observer agreement between RN and physician findings. Larger studies are needed to assess whether this RN-physician team approach can translate to improved outcomes. [ABSTRACT FROM AUTHOR]

Background Geographical mapping of variations in the treatment and outcomes of a disease is a valuable tool for identifying inequity. We examined international and intranational variations in initiating oral anticoagulation (OAC) therapy and clinical outcomes among patients with atrial fibrillation (AF) in Nordic countries. We also tracked real-world trends in initiating OAC and the clinical outcomes. Methods We conducted a registry-based multinational cohort study of OAC-naive patients with an incident hospital diagnosis of AF in Denmark (N = 61,345), Sweden (N = 124,120), and Finland (N = 59,855) and a CHA2DS2-VASc score of ≥1 in men and ≥2 in women between 2012 and 2017. Initiation of OAC therapy was defined as dispensing at least one prescription between 90 days before and 90 days after the AF diagnosis. Clinical outcomes included ischemic stroke, intracerebral hemorrhage, intracranial bleeding, other major bleeding, and all-cause mortality. Results The proportion of patients initiating OAC therapy ranged from 67.7% (95% CI: 67.5–68.0) in Sweden to 69.6% (95% CI: 69.2–70.0) in Finland, with intranational variation. The 1-year risk of stroke varied from 1.9% (95% CI: 1.8–2.0) in Sweden and Finland to 2.3% (95% CI: 2.2–2.4) in Denmark, with intranational variation. The initiation of OAC therapy increased with a preference for direct oral anticoagulants over warfarin. The risk of ischemic stroke decreased with no increase in intracranial and intracerebral bleeding. Conclusion We documented inter- and intranational variation in initiating OAC therapy and clinical outcomes across Nordic countries. Adherence to structured care of patients with AF could reduce future variation.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has shown unprecedented impact world-wide since the eruption in late 2019. Importantly, emerging reports suggest an increased risk of thromboembolism development in patients with COVID-19. Meanwhile, it is found that aspirin reduced mortality in critically ill patients with non-COVID-19 acute respiratory distress syndrome. Therefore, a meta-analysis was performed to investigate the effects of aspirin on COVID-19 mortality. Methods: A systematic literature search was conducted in 10 electronic databases and 4 registries. Random effects models were used to calculate pooled relative risks (RRs) with 95% confidence intervals (Cis) to estimate the effect of aspirin on COVID-19 mortality. Relevant subgroup analyses and sensitivity analyses were also performed. Results: The results showed that aspirin use was associated with a reduction in COVID-19 mortality (adjusted RR 0.69; 95% CI 0.50–0.95; P < 0.001). Subgroup analysis found that the low-dose group was associated with a reduced COVID-19 mortality (adjusted RR 0.64; 95% CI 0.48–0.85; P < 0.01). Aspirin use was associated with reduced COVID-19 mortality in Europe and America (crude RR 0.71; 95% CI 0.52–0.98; P = 0.04), and results from cohort studies suggested that aspirin use was a protective factor for COVID-19 mortality (adjusted RR 0.73; 95% CI 0.52–0.99; P = 0.04). Meanwhile, aspirin use was not associated with bleeding risk (crude RR 1.22; 95% CI 0.80–1.87; P = 0.96). Conclusions: This meta-analysis found that aspirin use was associated with a reduction in mortality in patients with COVID-19 and not with an increased risk of bleeding. [ABSTRACT FROM AUTHOR]

Bariatric metabolic surgery is a common elective general surgical procedure. Sleeve gastrectomy and Roux-en-Y gastric bypass are the two most common surgeries performed. They are considered safe with low morbidity and mortality. Leaks and bleeding are early complications after surgery. Endoscopy plays an important role in the diagnostic and therapeutic management of these complications. Advances in endoscopic interventions have increased the available options. It is important that healthcare professionals in non-specialized bariatric units who encounter these complications liaise with specialized units for advice and management. [ABSTRACT FROM AUTHOR]

Perfusion bioreactors are commonly used for the continuous production of monoclonal antibodies (mAb). One potential benefit of continuous bioprocessing is the ability to operate under steady-state conditions for an extended process time. However, the process performance is often limited by the feedback control of feed, harvest, and bleed flow rates. If the future behavior of a bioprocess can be adequately described, predictive control can reduce set point deviations and thereby maximize process stability. In this study, we investigated the predictive control of biomass in a perfusion bioreactor integrated to a non-chromatographic capture step, in a series of Monte-Carlo simulations. A simple algorithm was developed to estimate the current and predict the future viable cell concentrations (VCC) of the bioprocess. This feature enabled the single prediction controller (SPC) to compensate for process variations that would normally be transported to adjacent units in integrated continuous bioprocesses (ICB). Use of this SPC strategy significantly reduced biomass, product concentration, and harvest flow variability and stabilized the operation over long periods of time compared to simulations using feedback control strategies. Additionally, we demonstrated the possibility of maximizing product yields simply by adjusting perfusion control strategies. This method could be used to prevent savings in total product losses of 4.5–10% over 30 days of protein production. [ABSTRACT FROM AUTHOR]

Parth Vashi,1,&ast; Katharine Batt,2,&ast; Robert Klamroth,3 Maria Elisa Mancuso,4 Renata Majewska,5,6 Andreas Tiede,7 Lorenzo Giovanni Mantovani8,9 1US Data Generation and Observational Studies, Bayer Corporation, Whippany, NJ, USA; 2Department of Internal Medicine, Section on Hematology/Medical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA; 3Department for Internal Medicine - Vascular Medicine and Coagulation Disorders, Vivantes Klinikum im Friedrichshain, Berlin, Germany; 4Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; 5HEOR, Creativ-Ceutical, Krakow, Poland; 6Department of Epidemiology, Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, Poland; 7Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany; 8Center for Public Health Research, University of Milan - Bicocca, Monza, Italy; 9Value-Based Healthcare Unit, IRCCS Multimedica, Sesto San Giovanni, Italy&ast;These authors contributed equally to this workCorrespondence: Renata MajewskaCreativ-Ceutical, ul. Przemys&lstrok;owa 12, Kraków, 30-701, PolandTel +33176704790Email renata.majewska@creativ-ceutical.comPurpose: To assess the efficacy and FVIII consumption of BAY 94-9027 versus N8-GP in prophylaxis in adolescent and adult patients with severe hemophilia A (HA).Patients and Methods: A systematic literature review was conducted to identify studies on the efficacy of BAY-94-9027 and N8-GP for prophylaxis in patients with HA aged ≥ 12 years without a history of inhibitors. Eight studies met systematic literature review inclusion criteria, but only data from PROTECT VIII on BAY 94-9027 and PATHFINDER 2 on N8-GP could be used for an indirect comparison. Matching-adjusted indirect comparison (MAIC) and simulated treatment comparison were performed.Results: No significant differences (unadjusted and adjusted) were observed in the mean annualized bleeding rate (ABR) for any bleed and proportion of patients with zero bleeds when comparing BAY 94-9027 to N8-GP. The adjusted treatment difference [incidence rate ratio (IRR)] in terms of ABR was 1.11 (95% CI, 0.85– 1.44). The odds ratio (OR) of any bleed, measuring the relative effect of BAY 94-9027 versus N8-GP on the proportion of patients with zero bleeds, was 1.03 (95% CI, 0.60– 1.77). FVIII consumption was significantly lower in BAY 94-9027 [mean adjusted difference=− 1292.57 IU/kg/year (95% CI, ‒2152.44 to ‒432.70)]; a 26.7% reduction in consumption of BAY-94-9027. The results of the sensitivity analyses were similar to the main analysis for mean ABRs, percentages of patients with zero bleeds, and significant reduction in rFVIII consumption. For patients on BAY 94-9027 every-5-days and every-7-days, no differences versus every-4-days N8-GP were observed for the mean ABR for any bleed [IRR=0.90 (95% CI, 0.68‒1.20)] and proportion of patients with zero bleeds [OR=1.06 (95% CI, 0.56‒2.02)].Conclusion: BAY 94-9027 prophylaxis demonstrated 26.7% lower annual consumption when compared to N8-GP with similar efficacy in terms of ABR and percentage of patients with zero bleeds.Keywords: BAY 94-9027, N8-GP, prophylaxis, bleed, coagulation factor VIII, adults, factor VIII consumption

Dosing of 4-factor prothrombin complex concentrate (4FPCC) in warfarin treated patients generally utilizes international normalized ratio (INR) and patient weight. The recommended maximum dosing for all INR categories is capped at 100 kg weight. Whether this affects INR reversal is unknown. Furthermore, characteristics associated with adequate INR reversal need to be further elucidated. This was a multi-center, retrospective cohort study of 186 patients who received 4FPCC for INR reversal in the setting of warfarin-associated hemorrhage or need for emergent INR reversal. Utilizing multiple regression analysis, we evaluated INR reversal, achievement of hemostasis, and 28-day all-cause mortality. A target INR < 1.4 was achieved in 132 of 186 patients (71%). Factors significantly affecting the odds of achieving target INR were age in years (OR 1.03; 95% CI 1.01–1.06; P = 0.01), weight-based 4FPCC dose (units/kg) (OR 1.04; 95% CI 1.00–1.08; P = 0.03), and 4FPCC dosing normalized to INR (units/kg/INR) (OR 1.18; 95% CI 1.03–1.35; P = 0.02). Hemostasis was achieved in 109 of 148 bleeding patients (73.6%). Blood transfusions were associated with not achieving hemostasis (OR 0.44; 95% CI 0.21–0.93; P = 0.03). All-cause 28-day mortality was 21.5% and was associated with intracranial hemorrhage (OR 2.83; 95% CI 1.38–5.8; P = 0.01). Adequate INR reversal was associated with age, weight-based 4FPCC dose, and dosing normalized to INR (units/kg/INR). Future studies should evaluate the appropriateness of current INR targets for warfarin reversal and alternative 4FPCC dosing strategies such as utilizing a 4FPCC dosing ratio of units/kg/INR. [ABSTRACT FROM AUTHOR]

Background: The direct comparison of twice daily (BID) and thrice daily (TID) dosing of subcutaneous low dose unfractionated heparin (LDUH) for venous thromboembolism (VTE) prophylaxis in a mixed inpatient population is not well-studied. Objective: This study evaluated the effectiveness and safety of BID compared to TID dosing of LDUH for prevention of VTE. Methods: Retrospective, single-center analysis of patients who received LDUH for VTE prophylaxis between July and September 2015. Outcomes were identified by ICD-9 codes. A matched cohort was created using propensity scores and multivariate analysis was conducted to identify independent risk factors for VTE. The primary outcome was incidence of symptomatic VTE. Results: In the full cohort, VTE occurred in 0.71% of patients who received LDUH BID compared to 0.77% of patients who received LDUH TID (p = 0.85). There was no difference in major (p = 0.85) and minor (p = 0.52) bleeding between the BID and TID groups. For the matched cohort, VTE occurred in 1.4% of BID patients and 2.1% of TID patients (p = 0.32). Major bleed occurred in 0.36% of BID patients and 0.52% of TID patients (p = 0.7), while a minor bleed was seen in 3.4% of BID patients and 2.1% of TID patients (p = 0.13). Personal history of VTE (p = 0.002) and weight (p = 0.035) were independently associated with increased risk of VTE. Conclusion: This study did not demonstrate a difference in effectiveness or safety between BID and TID dosing of LDUH for VTE prevention. [ABSTRACT FROM AUTHOR]

Varices are a common cause of gastrointestinal (GI) bleed. When ectopic, there is often a delay in diagnosis as it is difficult to localize these varices. Ectopic small bowel varices usually arise from portal hypertension, which commonly develops in the setting of cirrhosis. This case presents a much rarer cause of bleeding ectopic varices with portal hypertension secondary to chronic superior mesenteric vein (SMV) thrombosis that developed after an episode of hemorrhagic pancreatitis. An 81‐year‐old man with a past medical history of a recent GI bleeds secondary to an arteriovenous malformation presented to the hospital with continued melena after a recent admission at another hospital for the same symptom. Upper endoscopy and colonoscopy showed no evidence of active bleeding. Subsequently computed tomography angiography (CTA) showed bleeding from collaterals in the third part of the duodenum, consistent with ectopic varices. The CTA also showed SMV thrombosis. The patient underwent an ultrasound‐guided transhepatic venogram with coiling and sclerosant embolization of SMV varices and distal SMV balloon angioplasty. Capsule endoscopy after showed no evidence of further bleeding. The patient was discharged 72 h after the intervention with stabilized hemoglobin and resolved melena. Ectopic varices should be on the differential diagnosis for patients presenting with a GI bleed that remains nonlocalized after endoscopy and colonoscopy. EGD or colonoscopy is the first‐line intervention for the treatment of bleeding ectopic varices. If unreachable by these means, percutaneous coil embolization is an alternative way to stabilize the patient. As no general management guidelines exist, treatment of bleeding ectopic varices should continue to be case‐dependent and involve a multidisciplinary team. [ABSTRACT FROM AUTHOR]

BACKGROUND: Immune tolerance induction (ITI) is the gold standard approach for eradicating inhibitors and increasing patient tolerance to factor VIII. The success rate of ITI may vary depending on patient variables and factors relating to the pattern of treatment for the induction of immune tolerance. Children with recently diagnosed inhibitors are the best candidates for ITI, and those with favourable expected results should be offered ITI as soon as inhibitors are identified. Recombinant factor VIII Fc fusion protein has proved a therapeutic advantage in patients with high factor VIII inhibitor titers AIMS AND OBJECTIVES: To evaluate the clinical characteristics and outcomes of ten hemophilic pediatric patients who underwent ITI therapies to eliminate FVIII inhibitors at Tawam Hospital, UAE MATERIALS AND METHODS: The data of ten hemophilia A children aged 2–7 years with high inhibitor titers who underwent ITI therapy at Tawam Hospital, UAE, were retrospectively collected for this case series. A comparison of bleeds before and after the ITI therapy was also made. Patients with either failed or partially successful primary ITI therapy underwent rescue ITI therapy. Data analysis was performed using SPSS version 26. RESULTS: Full success was achieved in 60% (6/10) of the patients, 10% (1/10) achieved partial success, whereas 30% (3/10) failed the primary ITI therapy. The rescue ITI therapy was successful in 50% (2/4) of the patients and the remaining 50% (2/4) achieved partial success [Table 2]. The rescue ITI was successful in 66% (2/3) of those patients who received Elocta and partially successful in 33% (1/3) CONCLUSION: ITI therapy is the gold standard for the eradication of antibodies against FVIII. The patients with good expected outcomes should be offered ITI as soon as the inhibitors are confirmed. The use of extended half life rFVIIIFc demonstrated therapeutic benefit, particularly in challenging ITI patients with high inhibitor titers [ABSTRACT FROM AUTHOR]

Abstract Varices are a common cause of gastrointestinal (GI) bleed. When ectopic, there is often a delay in diagnosis as it is difficult to localize these varices. Ectopic small bowel varices usually arise from portal hypertension, which commonly develops in the setting of cirrhosis. This case presents a much rarer cause of bleeding ectopic varices with portal hypertension secondary to chronic superior mesenteric vein (SMV) thrombosis that developed after an episode of hemorrhagic pancreatitis. An 81‐year‐old man with a past medical history of a recent GI bleeds secondary to an arteriovenous malformation presented to the hospital with continued melena after a recent admission at another hospital for the same symptom. Upper endoscopy and colonoscopy showed no evidence of active bleeding. Subsequently computed tomography angiography (CTA) showed bleeding from collaterals in the third part of the duodenum, consistent with ectopic varices. The CTA also showed SMV thrombosis. The patient underwent an ultrasound‐guided transhepatic venogram with coiling and sclerosant embolization of SMV varices and distal SMV balloon angioplasty. Capsule endoscopy after showed no evidence of further bleeding. The patient was discharged 72 h after the intervention with stabilized hemoglobin and resolved melena. Ectopic varices should be on the differential diagnosis for patients presenting with a GI bleed that remains nonlocalized after endoscopy and colonoscopy. EGD or colonoscopy is the first‐line intervention for the treatment of bleeding ectopic varices. If unreachable by these means, percutaneous coil embolization is an alternative way to stabilize the patient. As no general management guidelines exist, treatment of bleeding ectopic varices should continue to be case‐dependent and involve a multidisciplinary team.

Background: Tracheostomy-related arterial haemorrhage can be devastating especially if arising from an obscure anomalous vessel which can potentially complicate treatment decision. Methods: We report a case of non-Hodgkin's lymphoma with upper airway obstruction, who had profuse bleeding, post-tracheostomy, from the stomal site. CT angiography showed presence of a pseudoaneurysm adjacent to the tracheostomy site which was confirmed on catheter angiography to be arising from anomalous thymic branch of right common carotid artery (CCA). Superselective cannulation of the anomalous thymic artery was done using a microcatheter with subsequent coil embolization. Results: Post-coiling, the bleeding stopped immediately and the patient recovered. He was under oncology care till 3 months following embolization and was doing well. Conclusions: The emergency physicians should be aware of this rare variation of thymic artery while performing tracheostomy. Ultrasound as point-of-care device may help mitigate these complications. Endovascular embolization is a minimally invasive and effective management option for an injured arterial branch from a tracheostomy. [ABSTRACT FROM AUTHOR]

Hepatic adenomas are benign liver tumors typically found in females of reproductive age. Though benign, hepatic adenomas are highly vascularized tumors, thus rupture and consequent hemorrhage present a feared complication. We report a case of a 31-year-old woman with hepatic adenoma who underwent preoperative portal vein embolization and subsequently suffered a rupture of her tumor. We postulate that the change in blood flow after portal vein embolization, a phenomenon known as the hepatic artery buffer response, may have contributed to the tumor rupture, though the possibility that the rupture was purely incidental remains. There is currently no prior report of such rupture occurring following portal vein embolization, and this case brings to light a potentially fatal complication of a generally safely regarded procedure in patients with hepatic adenoma.

Purpose: Patients with atrial fibrillation or flutter (AF) on anticoagulation (AC) for stroke prevention are at an increased risk of bleeding. A common clinical dilemma is deciding when to safely restart AC following a bleed. Although studies have shown better outcomes with re-initiation of AC after hemostasis, there are clinical barriers to restarting AC. Left atrial appendage occlusion (LAAO) is a safe and efficacious alternative for patients who are unable to tolerate AC following major bleeding. We aimed to evaluate the rate of stroke prevention strategies instituted at time of discharge in patients with AF on AC who had been hospitalized for a bleeding event.Methods: We retrospectively identified patients with AF on AC admitted for bleeding between January 2016 and August 2019. The type of AC, form of bleeding, and CHA2DS2VASc were collected. Stroke prevention strategies upon discharge and at 3 months were noted.Results: One hundred seventy-four patients with AF on AC were hospitalized with a bleeding event, of which 10.9% died. Among patients who survived, AC was restarted in 45.2% of patients, 9.7% were referred for LAAO, and 45.1% were discharged without stroke prevention strategy. At 3 months, 32.6% of patients still had no documented stroke prophylaxis. Those referred for LAAO had, on average, higher CHA2DS2VASc (5 ± 1 vs 4 ± 1, p = 0.007).Conclusions: A significant number of patients with AF hospitalized for bleeding were discharged with no plan for stroke prophylaxis. Despite its safety and efficacy, LAAO appears to be an underutilized alternative in AF patients with high bleeding risk. [ABSTRACT FROM AUTHOR]

Purpose: Guidelines have differing recommendations for aspirin use in patients with an indication for anticoagulation. The purpose of this study was to evaluate the incidence of major bleeding and thromboembolic events (TEs) in patients with atrial fibrillation (AF) receiving warfarin alone (monotherapy group) versus warfarin plus aspirin (combination therapy group). Methods: This was a retrospective, cohort study including patients from a pharmacist-run anticoagulation clinic. Inclusion criteria were patients with AF receiving anticoagulation between January 2013 and January 2014 observed over 5 years. Results: One hundred forty-two patients were included in the combination group versus 89 in monotherapy group. In the combination group, 60 (42.3%) patients were on aspirin for no apparent indication, 19 (13.4%) had stable coronary artery disease and diabetes, and 26 (18.3%) had diabetes alone. Major bleeding occurred in 21 (14.9%) patients in the combination group versus 7 (7.9%) patients in the monotherapy group (odds ratio [OR] = 2.02, 95% confidence interval [CI]: 0.78-5.91; P =.17). TE occurred in 10 (7%) patients in the combination group versus 4 (4.5%) in the monotherapy group (OR = 1.61, 95% CI: 0.44-7.24; P =.57). There was no significant difference in bleeding (P =.85) or TE (P =.37) rates between aspirin indications in the combination group. Conclusion: Combination therapy versus monotherapy may increase bleeding risk with little benefit in decreasing AF-related stroke or cardiovascular events. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) is the third most common diagnosed cancer and the third leading cause of all cancer deaths in the USA. Some evidences are shown that aspirin can reduce the morbidity and mortality of different cancers, including CRC. Aspirin has become a new focus of cancer prevention and treatment research so far; clinical studies, however, found conflicting conclusions of its anti-cancer characteristics. This study is to summarize the latest evidence of correlation between aspirin use and CRC and/or colorectal adenomas. Methods: Databases were searched to identify randomized controlled trials (RCTs) in the salvage setting. The pooled relative risk (RR) with 95% confidence interval (CI) was used to estimate the effect of aspirin on colorectal cancer and/or colorectal adenomas. Subgroup analysis and sensitivity analysis were also conducted. Results: The result showed that aspirin use was not associated with incidence of CRC (RR 0.97; 95% CI 0.84–1.12; P = 0.66; I2 = 34%), aspirin use was found to be associated with reduced recurrence of colorectal adenomas (RR 0.83; 95% CI 0.72–0.95; P = 0.006; I2 = 63%) and reduced mortality of CRC (RR 0.79; 95% CI 0.64–0.97; P = 0.02; I2 = 14%). Subgroup analysis found a statistically significant association in low dose with a pooled RR of 0.85 (95% CI 0.74–0.99; P = 0.03; I2 = 31%). Conclusions: This meta-analysis of randomized controlled trial data indicates that aspirin reduces the overall risk of recurrence and mortality of CRC and/or colorectal adenomas. Incidence of CRC was also reduced with low-dose aspirin. The emerging evidence on aspirin's cancer protection role highlights an exciting time for cancer prevention through low-cost interventions. Trial registration: Clinicaltrials.gov no: CRD42020208852; August 18, 2020; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020208852). [ABSTRACT FROM AUTHOR]

Study Objective: Previous studies have shown that aspirin is noninferior to other anticoagulation therapies in preventing postoperative venous thromboembolism following lower extremity arthroplasty or revision; however, its optimal dosing for this indication is less clear. This study aims to compare the odds of bleeding between different aspirin dosages following lower extremity joint arthroplasty or revision. Design: This is a 3‐year retrospective multi‐center cohort study across the United States and its territories. Setting: This study included patients admitted for total hip or knee arthroplasty or revision and were treated with prophylactic aspirin. Patients, Intervention, Measurements: Patients were assigned to groups based on a total daily aspirin dose of 81, 162, 325, or 650 mg. Data were analyzed for postsurgical bleeding and thromboembolism events occurring during the initial admission and up to 40 days following surgery. Other exploratory variables included type of surgery, hip or knee arthroplasty, length of stay, and patient demographic data. Main Results: Among 53,848 patients receiving aspirin, 3922 received a total daily dose of 81 mg, 19,341 received a total daily dose of 162 mg, 5256 received a total daily dose of 325 mg, and 25,329 received a total daily dose of 650 mg. Bleeding occurred in 466 (0.87%) patients and venous thromboembolism (VTE) in 209 patients (0.39%). The odds of bleeding were compared using logistic regression, with the 650‐mg dose as the reference group. None were statistically significant for bleeding between all studied aspirin doses: 81 mg (OR 1.12, 95% CI 0.83–1.51, p = 0.451), 162 mg (OR 0.83, 95% CI 0.67–1.03, p = 0.097), and 325 mg (OR 0.83, 95% CI 0.59–1.13, p = 0.245). The odds of VTE were also not statistically significant: 81 mg (OR 0.71, 95% CI 0.40–1.17, p = 0.181), 162 mg (OR 0.75 95% CI 0.54–1.03, p = 0.072), and 325 mg (OR 1.00, 95% CI 0.64–1.53, p = 0.989). Conclusions: There were no significant differences in the odds of bleeding or venous thromboembolism among all studied aspirin dosages in patients receiving aspirin for thromboprophylaxis following lower extremity joint arthroplasty or revision. [ABSTRACT FROM AUTHOR]

Study Objective: Rivaroxaban, enoxaparin, and aspirin are commonly used medications for thromboprophylaxis following lower extremity joint arthroplasty or revision. Previous research has demonstrated efficacy in preventing venous thromboembolism with each medication, however, the comparative risk of bleeding between them remains poorly understood. The aim of this study was to compare the odds of bleeding between rivaroxaban, enoxaparin, and aspirin following lower extremity joint arthroplasty or revision. Design: This is a 3‐year retrospective cohort study. Setting: Data were obtained from 148 facilities across 55 states and territories of the United States. Patients: This study included 85,938 patients who underwent hip or knee arthroplasty or revision. Intervention: Patients received enoxaparin, rivaroxaban, or aspirin as monotherapy for thromboprophylaxis. Measurements: The primary outcome was all bleeding, classified as major or minor bleeding, occurring in the 40 days following surgery. The secondary outcome was venous thromboembolism. Main Results: Among 85,938 patients, 10,465 received rivaroxaban, 14,047 received enoxaparin, and 61,426 received aspirin. Bleeding occurred in 126 (1.20%) patients with rivaroxaban, 253 (1.80%) with enoxaparin, and 611 (0.99%) with aspirin. There was a significant increase in odds of bleeding in the enoxaparin compared to aspirin group odds ratio (OR) 1.18, 95% confidence interval (CI) 1.01–1.38, p = 0.042), and a trend toward increased odds of bleeding in rivaroxaban compared to aspirin group (OR 1.21, 95% CI 0.99–1.47, p = 0.058) and rivaroxaban compared to enoxaparin (OR 1.03, 95% CI 0.82–1.28, p = 0.827). Odds of venous thromboembolism were not statistically significant between all three study medications. Conclusions: Among rivaroxaban, enoxaparin, and aspirin used for thromboprophylaxis in knee and hip arthroplasty or revision, aspirin had significantly decreased odds of bleeding complications compared to enoxaparin. Although not statistically significant, aspirin also had a trend toward decreased odds of bleeding complications compared to rivaroxaban. Our study results suggest that aspirin is a safer alternative for use in postoperative thromboprophylaxis following lower extremity joint arthroplasty or revision. [ABSTRACT FROM AUTHOR]

Platelet, Activation, Continuous-flow left ventricular assist device, Thrombosis, Bleed, Flow cytometry. [Extracted from the article]

Introduction: Management strategies and hemostatic treatments to achieve control of bleeding are relevant across many disease areas. Identification of primary outcomes for studies assessing hemostatic intervention was the objective of a National Heart, Lung and Blood Institute (NHLBI) sponsored multidisciplinary initiative. The aim of this report is to summarize the evidence reviewed, and the outcomes identified by the subgroup tasked to assess outcomes for inherited bleeding disorders. Methods: The subgroup decided to focus on haemophilia, the prototypal congenital bleeding disorder and the one with the largest available body of evidence. MEDLINE, EMBASE and PsycINFO, The Cochrane Review, CINAHL, and Web of Science were searched for systematic and narrative reviews on outcomes used in haemophilia clinical trials. Three different clinical goals were identified as typical objectives of future research. Results: Out of 1322 unique citations, 24 reviews published in the period 2002–2019 were included. We identified 113 outcome measures, categorized in 6 domains: health‐related quality of life (HRQoL), comorbidities and mortality, overall physical functioning and participation, bleeding and hemostasis, joint health, and costs and resource use. Three different clinical goals were identified as typical objectives of future research: Episodic 'on demand' replacement therapy, prevention of bleeding (Prophylaxis), and long‐term and overall impact of bleeding. For each of these scenarios, specific outcomes were recommended. Conclusions: Primary outcomes for clinical trials assessing the efficacy of hemostatic treatment in achieving control, prevention and limiting long‐term consequences of bleeding in inherited bleeding disorders are suggested, and their strength and limitations discussed. [ABSTRACT FROM AUTHOR]

Swine models are commonly utilized in endovascular research for development of intravascular interventions and medical device development. As part of a pilot study for a venous vascular stent device, a 5-year-old female Yucatan mini-pig underwent bilateral external iliac vein stent placement under general anesthesia. To reduce thrombotic complications by reduction of thrombus formation on wires, sheaths, and catheters, the pig was heparinized with a total of 300 IU/kg of heparin, establishing an activated clotting time (ACT) of 436 s. The ACT had returned to below 200 s by the end of the procedure. To prevent postoperative thrombosis, the pig received an anticoagulation therapy protocol consisting of enoxaparin, clopidogrel, and aspirin. There were no complications during the immediate postoperative period. However, the pig died 4 days after surgery. Necropsy established the cause of death as abdominal exsanguination due to severe, acute, intra-ovarian hemorrhage, most likely related to ovulation. Life-threatening ovarian hemorrhage is occasionally seen in women with congenital or acquired bleeding disorders; to our knowledge this is the first report of fatal ovarian hemorrhage in an animal enrolled in a pre-clinical research trial.

Safe administration of warfarin presents challenges due to a narrow therapeutic INR range and significant variability in inter-individual dose response. Bleeding secondary to warfarin use is a leading cause of hospitalization. Five warfarin dosing algorithms were assessed for accuracy of predicted compared to the INR target dose for patients with a HAS-BLED score ≥3 participating in the ENGAGE-AF TIMI 48 trial. Three warfarin metabolism subgroups (normal, sensitive, and highly sensitive responders) were established based on genotype. Mean differences between calculated and prescribed dose were determined for each algorithm across groups. A total of 7036 patients were analyzed and 1846 participants with HAS-BLED ≥3 were genotyped. The mean absolute error of predicted versus INR target dose for warfarin ranged from 8.1 mg/week on the pharmacogenetic-guided International Warfarin Pharmacogenetics Consortium (IWPC) and Gage algorithms to 11.3 mg/week on fixed dose. Overestimation of INR target dose occurred in 98% of highly sensitive responders by 21 mg/week for subjects on fixed dose. Pharmacogenetic-guided IWPC saw 89% overestimation with mean difference of 8.3 mg/week for highly sensitive responders. Major or clinically relevant non-major bleeding in the first 90 days of beginning warfarin was 3.27 times more likely for highly sensitive than normal responders. Initial doses were higher than INR target doses in high-risk bleeding subpopulations as defined by the modified HAS-BLED and genotype sensitivity analysis when compared to established algorithms. Clinical and pharmacogenetic-guided algorithms improved dosing in highly sensitive responders with HAS-BLED ≥3 compared to fixed dosing. • Narrow therapeutic INR range and dose variability challenges safe warfarin use. • Sensitive responders with modified HAS-BLED ≥3 had 2 mg/day higher on fixed dose. • Pharmacogenetic Gage and IWPC algorithms had best prediction performance. • Clinical and pharmacogenetic algorithms improved dosing accuracy by 8–9 mg/week. • Bleeding events were most likely to occur in the first 90 days of treatment onset. [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolism is a cause of morbidity and mortality in hospitalized patients, and morbid obesity increases this risk. Various prophylaxis dosing strategies have been investigated. However, it is unclear if high-fixed dose enoxaparin or high-fixed dose unfractionated heparin thromboprophylaxis is optimal for minimizing the incidence of major bleeding and reducing hospital-acquired venous thromboembolism.Methods: A single-center retrospective observational study was conducted in hospitalized patients who were morbidly obese (body mass index ≥40 kg/m2) and who received either high-fixed dose enoxaparin (40 mg every 12 hours) or unfractionated heparin (7500 units every 8 hours) for venous thromboembolism prophylaxis. Co-primary outcomes included incidence of major bleeding and venous thromboembolism diagnosed during hospitalization. Predictors of major bleeding were evaluated by multivariable regression.Results: In the 305 patients included (n = 190 unfractionated heparin, n = 115 enoxaparin), the incidence of major bleeding was significantly higher in the unfractionated heparin group (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.07-3.13; P = 0.025), with no significant difference in the incidence of venous thromboembolism diagnosed during hospitalization. The only independent predictors of major bleeding were intensive care acuity (OR 3.32, 95% CI 1.91-5.78; P <0.001) and selection of unfractionated heparin rather than enoxaparin for venous thromboembolism prophylaxis (OR 2.16, 95% CI 1.22-3.82; P = 0.008).Conclusion: High-fixed dose unfractionated heparin for venous thromboembolism prophylaxis may lead to a higher risk of major bleeding events compared with high-fixed dose enoxaparin in patients who are morbidly obese. [ABSTRACT FROM AUTHOR]

Background: Four-factor prothrombin complex concentrate (4F-PCC) is the standard of care for reversal of vitamin K antagonists (VKAs). Research has demonstrated noninferior efficacy with the use of lower, fixed-dose strategies for 4F-PCC dosing.Objectives: We compared a fixed-dose 4F-PCC protocol to weight-based dosing at our institution.Methods: This was a multicenter, noninferiority, interventional, quasiexperimental cohort study including subjects who were administered 4F-PCC for VKA reversal. The retrospective cohort consisted of subjects given a weight-based dose of 4F-PCC dependent on international normalized ratio (INR). The prospective cohort was managed with a fixed-dose protocol. The fixed dose was 1500 units of factor IX unless subjects weighed >100 kg or had a baseline INR >7.5, in which case the dose was 2000 units of factor IX. The primary endpoint was achievement of a postinfusion INR of <2. Secondary endpoints included achievement postinfusion INR <1.5, mean 24-h INR, 7-day mortality, and 7-day venous thromboembolic events.Results: Twenty-four subjects were enrolled in the prospective cohort and 30 in the retrospective cohort. A postinfusion INR <2 was achieved in 96% of subjects in the retrospective cohort and 95% in the prospective cohort (p = 0.0035 for noninferiority). A postinfusion INR <1.5 occurred in 90% of subjects in the retrospective cohort and 75% in the prospective cohort (p > 0.4 for noninferiority). There were no significant differences in 24-h postinfusion INRs, mortality, or venous thromboembolic events.Conclusion: The use of a fixed-dose 4F-PCC protocol is safe and effective for the rapid reversal of VKA-associated anticoagulation. [ABSTRACT FROM AUTHOR]

Background: Nonacog beta pegol (N9-GP) is an extended half-life PEGylated factor (F)IX product with established efficacy and short-term safety in persons with hemophilia B (HB). Long-term safety has been evaluated for polyethylene glycol exposure but not N9-GP., Objectives: To assess safety, neurodevelopmental, and efficacy outcomes of children with HB receiving N9-GP prophylaxis across 2 open-label, single-arm, phase 3 studies: paradigm5 (previously treated patients [PTPs]) and paradigm6 (previously untreated patients [PUPs]) in this interim analysis., Methods: PTPs (aged ≤12 years) and PUPs (aged <6 years) with severe/moderate (≤2% FIX level) HB were recruited to N9-GP prophylaxis (40 IU/kg once weekly) in paradigm5 and paradigm6, respectively. Safety assessments included FIX inhibitor incidence, adverse events, neurocognitive and neurologic outcomes, polyethylene glycol concentration in plasma, and medical events of special interest. Efficacy endpoints included bleeds, N9-GP hemostatic effect, and FIX consumption., Results: Overall, 25 patients in paradigm5 and 50 patients in paradigm6 received N9-GP and were followed for up to 8 and 6 years, respectively. No inhibitory antibodies were reported in PTPs; 4 of the 50 PUPs developed inhibitors. Extensive evaluation revealed no neurocognitive or neurologic concerns with N9-GP use in children during the study period. Across both studies, few adverse events were reported as possibly related to N9-GP. High hemostatic response rate, high treatment adherence, low annualized bleeding rates, and no new target joints were reported., Conclusion: These data provide the longest follow-up for an extended half-life FIX and confirm the long-term efficacy of N9-GP prophylaxis in children with HB with no observed neurocognitive or neurologic safety concerns., (© 2024 The Authors.)

Intraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB). This is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using χ2 test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes. We included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission. Use of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact. [ABSTRACT FROM AUTHOR]

Bleeding after laparoscopic sleeve gastrectomy (LSG) is an important complication associated with significant morbidity and a drastic increase in healthcare resources. Multiple strategies have been developed to minimize bleeding, including varying bougie size, line reinforcement, and intra-operative tranexamic acid. These techniques, however, have been implemented without a clear understanding of the pre-, intra-, and postoperative predictors of bleeding in patients undergoing SG. The purpose of this study was to examine predictors and outcomes associated with postoperative bleeding in patients undergoing LSG. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry. We identified Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent LSG in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of bleeding in LSG patients. Our secondary outcomes of interest include characterizing overall complication rates in LSG patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ2 tests for categorical data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of postoperative bleed. A total of 175,353 patients underwent LSG from 2015 to 2016. The majority of patients were female (79.0%), with a mean age of 44.4 ± 12.0 years and a mean body mass index of 45.2 kg/m2 ± standard deviation of 7.9 kg/m2. A total of 1116 (.6%) patients had a postoperative bleed. Bleeding was associated with a mortality of 1.0% versus.1% among patients without bleeding. The mean operative time was 74.0 ± 36.6 minutes with a mean bougie size of 36.9 ± 2.9 Fr, and a mean pylorus distance of 4.80 ± 1.1 cm. Staple-line reinforcement was used in 67.8% of patients while 22.4% were oversewn. Bleeds were associated with a statistically significant increase in all complications, readmission, reoperation, and mortality rates at 30 days. The following statistically significant independent predictors of bleed after LSG were identified using multivariable logistic regression analysis: bougie size, age, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation, diabetes, obstructive sleep apnea, and operative length. Staple-line reinforcement, staple-line oversewing, and higher body mass index were found to be protective for bleed after adjusting for confounders and interactions. An increase in pylorus distance did show a signal toward a protective effect; however, this was not statistically significant. Bleeding after LSG is associated with increased complications, readmission and reoperation rates, and mortality at 30 days. Staple-line reinforcement techniques independently predict a lower risk of postoperative bleeding after LSG. Adoption of these techniques may therefore have an important role in reducing morbidity and mortality for patients who undergo LSG. • LSG is a safe procedure with a low morbidity and mortality • LSG leak rate was 0.6% in 175353 patients from 2015 to 2016 • Bleed increases all complications, readmission, reoperation and mortality at 30 days • Staple line reinforcement and oversewing are the greatest protective factors for bleeding following LSG • Therapeutic anticoagulation is the greatest predictor of bleeding after LSG [ABSTRACT FROM AUTHOR]

Because the prognosis of high-grade aneurysmal subarachnoid hemorrhage (aSAH), classified as World Federation of Neurosurgical Societies (WFNS) grade IV–V, is generally poor, the functional outcomes of survivors have not been thoroughly explored. The aim of this retrospective cohort study is to determine predictors of functional independence in patients who survive a high-grade aSAH. We retrospectively evaluated consecutive patients with aSAH admitted to a single institution from January 2000 to April 2015. Adult (age ≥18 years) patients with WFNS grade IV–V aSAH were included for analysis. Patients without sufficient baseline data, those who died before discharge, and those without follow-up data were excluded. Univariable and multivariable logistic regression analyses were used to identify factors associated with functional independence, defined as a modified Rankin Scale score of 0–2, at last follow-up. Of the 260 patients with a WFNS grade IV–V aSAH during the study period, 139 met the inclusion criteria. After a mean follow-up of 6.3 months, functional independence was achieved in 73% of high-grade aSAH survivors (101/139 patients) and in 39% of all high-grade aSAH cases (101/260 patients). Only a lack of cerebrospinal fluid shunt placement was found to be an independent predictor of functional independence in the multivariable analysis (odds ratio 0.28 [0.109–0.722]; P = 0.008). Because functional independence can be achieved in the majority of high-grade aSAH survivors, aggressive initial management of high-grade aSAH is warranted. Strategies that reduce the need for permanent cerebrospinal fluid diversion may improve functional outcomes in survivors of high-grade aSAH. [ABSTRACT FROM AUTHOR]

Background: We compared healthcare utilization outcomes and persistence among non-valvular atrial fibrillation (NVAF) patients newly treated with dabigatran or warfarin.Methods: Using a nationwide, US administrative claims database, a retrospective matched-cohort of newly diagnosed NVAF patients (age≥18 years) treated with dabigatran or warfarin (propensity score matched 1:1) in 01/01/2011-12/31/2013 was evaluated. All-cause, stroke-, and bleed-specific per patient per month (PPPM) healthcare resource utilization (HCRU), incidence rate of hospitalization for stroke or bleed, 30-day readmission, and persistence were reported.Results: In total, 18,890 dabigatran patients were matched to corresponding warfarin patients. Compared to warfarin users, dabigatran users PPPM had significantly fewer all-cause hospitalizations (0.04 vs 0.05), total outpatient visits (3.98 vs 5.87), and lower 30-day readmissions (14.5% vs 17.4%, all p < 0.001). Dabigatran users had lower incidence rate for stroke (0.65 vs 1.06) and bleed (1.69 vs 2.20), stroke (0.0006 vs 0.0011, p < 0.001) and bleed-specific hospitalizations (0.002 vs 0.003, p = 0.008), and stroke (0.03 vs 0.04, p < 0.001) and bleed-specific outpatient visits (0.07 vs 0.08, p = 0.018), and significantly lower non-persistence (62.1% vs 66.3%, p < 0.001).Conclusion: Among newly diagnosed newly treated NVAF patients, dabigatran users had significantly lower all-cause, stroke- and bleed-specific HCRU, lower risk of hospitalization for stroke or bleed events, lower 30-day readmissions, and higher persistence than warfarin users. [ABSTRACT FROM AUTHOR]

The article discusses the installation model of "Stop the Bleed" in the U.S. military and the implementation of the rapid hemorrhage control program. Topics mention including the life-threatening hemorrhage from traumatic injury, importance of early hemorrhage control and the Tactical Combat Casualty Care (TCCC).

Objectives: To systemically review and compare the efficacy of intravenous, local, and oral steroids in decreasing post-tonsillectomy pain, nausea, and vomiting, and its risk of causing hemorrhage.Methods: We searched electronic databases (PubMed, Scopus, Cochrane Library) and additional sources. The date of the most recent search was June 20th, 2018. We selected RCTs of steroids in all routes of administration, in all age groups who underwent tonsillectomy or adenotonsillectomy and studied the results of nausea/vomiting, pain, and hemorrhage. Data analysis was done using Review Manager 5.3.5 software.Results: We included 64 studies (6,327 participants) with variety quality assessed by the Cochrane Handbook for Systematic Reviews of Interventions. IV steroids statistically and clinically significant decrease post-tonsillectomy nausea/vomiting in children and adult, with superior effect to local steroids (Children: OR 0.21; 95% CI 0.15-0.30; P < 0.001, I2 = 67%, Adult: OR 0.32; 95% CI 0.16-0.67; P = 0.002, I2 = 40%). In the analysis of local steroids studies, there was only evidence in children that local steroids decrease post-tonsillectomy nausea/vomiting (OR 0.54; 95% CI 0.33-0.88; P = 0.01, I2 = 32%). IV and local steroids statistically significant decrease immediate post-operative pain severity. Local steroids had extended effect in reducing pain scores on the first day after tonsillectomy. However, the clinical significance of pain relief had to be concerned due to decreasing VAS only about 1 out of 10. Adding oral steroids to IV steroids gave no difference in effect from IV steroids alone. There are very few local steroids studies in adults and oral steroids studies to show the significant effects. Steroids have no statistically significant effect in reducing pain severity after a 1-day period. Steroids in all routes had no statistically significant effects on post-operative hemorrhage (primary hemorrhage: OR 0.96; 95% CI 0.55-1.67; P = 0.88, I2 = 0%; secondary hemorrhage: OR 1.05; 95% CI 0.74-1.51; P = 0.79, I2 = 0%).Conclusion: Intravenous steroids statistically significantly decrease post-tonsillectomy nausea/vomiting, and immediate pain scores (< 24 h) in children and adults. There is evidence in only children that local steroids statistically significantly decreases post-tonsillectomy nausea/vomiting, and pain scores during the 0-h to 1-day period. [ABSTRACT FROM AUTHOR]

Andexanet alfa is approved for the reversal of factor Xa inhibitors in patients with major bleeding events. We aimed to review the incidence of effective hemostasis with andexanet alfa in a real-world environment. This retrospective cohort included patients hospitalized for a major bleed that resulted in andexanet alfa administration. The primary outcome was effective hemostasis at 12 hours after andexanet alfa treatment. Thromboembolic events and mortality within 30 days were also assessed. Over a 14-month period, 13 patients received andexanet alfa with a mean age of 69 ±10 years, 54% male, 69% exposed to apixaban (31% rivaroxaban), and had intracranial (46%) and nonintracranial (54%) bleeding sites. Effective hemostasis was observed in 10 (77%) patients. Four (31%) patients experienced 5 thromboembolic events with a median time to event of 6.5 days (range: 0.5-29). Four thrombotic events occurred during the period in which anticoagulation (prophylaxis or therapeutic) was not restarted. Mortality rate was 15%. Andexanet alfa was effective in obtaining hemostasis in a majority of patients. However, the incidence of thromboembolic events was high and may be attributed to a delay in restarting anticoagulation. [ABSTRACT FROM AUTHOR]