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Kidney dysfunction is a major determinant of prognosis in patients with decompensated cirrhosis awaiting transplantation. We hypothesized that for identical model for end-stage liver disease (MELD) scores at listing, outcomes before and after liver transplantation may vary if the predominant driver of the MELD score is serum creatinine (Cr) vs. serum bilirubin (Br) or international normalized ratio (INR). We evaluated all adult patients registered for liver transplantation (LT) between 2016–2020 and excluded patients receiving MELD exceptions or undergoing dual organ transplantation. Using K-Means clustering analysis, we classified each patient as MELD-Br, MELD-INR or MELD-Cr depending on the dominant variable for their MELD score. The primary outcome was intent-to-treat (ITT) survival, defined as survival within 1 year from listing with or without LT. MELD scores of LT waitlist registrants were clustered into three subtypes: MELD-Br (n = 13,658), MELD-INR (n = 13,809), and MELD-Cr (n = 12,412). One-year ITT survival rates were 78% (MELD-Br), 75% (MELD-INR), and 65% (MELD-Cr), p < 0.01. ITT survival was lower for each MELD subtype for females compared to males (e.g. MELD-Cr: 63% females vs. 67% males, p < 0.0001). The MELD-Cr subtype had the highest MELD at listing (MELD-Cr 23.4 vs. MELD-Br 19.2 vs. MELD-INR 21.0) and the largest decline in MELD over 3 months (23% vs. 12% vs. 21%). In adjusted analyses including MELD-Na, MELD-Cr was associated with higher waitlist mortality (hazard ratio 1.339, 95% CI 1.279-1.402) and lower LT rates (hazard ratio 0.688, 95% CI 0.664-0.713) compaed to the other subtypes. For equivalent listing practices, registrants with the MELD-Cr subtype have lower ITT survival. MELD subtype may serve as a more sophisticated variable for dynamic assessment of mortality risk and to guide organ allocation. The model for end-stage liver disease (MELD) score is an excellent predictor of waitlist mortality; however, our work highlights that the driver of a patient's MELD score matters and particularly those driven by elevated creatinine are associated with lower 1-year intent-to-treat survival. The 1-year intent-to-treat survival is also lower for women compared to men within the Cr-dominant subtype. These results are important for physicians and patients undergoing LT evaluation as creatinine may serve as a marker of prognosis and even if creatinine levels improve the prognosis remains poor, necessitating discussion about alternative pathways for transplant. Our work also highlights that the type of kidney injury matters, in that those with acute kidney injury were more likely to die or remain on the waitlist than those with chronic kidney disease within the creatinine-dominant subtype. [Display omitted] • Patients with MELD scores dominated by Cr have lower 1 year ITT survival compared to scores dominated by bilirubin or INR. • For each of the subtypes, females have lower 1 year ITT survival compared to males. • Within the MELD-Cr subtype, those with AKI were less likely to get transplanted and more likely to die than those with CKD. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMethodsResultsDiscussionConclusionPatients poisoned with paracetamol are treated with acetylcysteine. In patients without hepatocellular injury, an increased prothrombin time or international normalized ratio has been observed during acetylcysteine administration. The international normalized ratio is preferred as it is a standardized calculation of prothrombin time independent of reagents and machinery. Since the prothrombin time and international normalized ratio are used as markers of liver injury in patients with paracetamol poisoning, it is important to assess the magnitude of the effect of acetylcysteine treatment on the prothrombin time and international normalized ratio. The aim of this narrative review is to describe the effect of acetylcysteine on the prothrombin time and international normalized ratio.Embase, PubMed and Web of Science were searched to identify the effect of acetylcysteine on coagulation factors II, VII, IX or X, the prothrombin time and the international normalized ratio in in vitro and in vivo studies in healthy subjects and clinical studies involving both those poisoned with paracetamol and surgical patients. The search terms employed were acetylcysteine combined with prothrombin time, international normalized ratio, coagulation or haemostasis.The search identified a total of 2,471 articles, of which 19 studies were included. Six in vitro and/or in vivo studies, five clinical studies in paracetamol-poisoned patients and eight clinical studies in surgical patients were included. Acetylcysteine caused a 15–30% increase in prothrombin time and international normalized ratio. This increase was dose-dependent and was caused by a decrease in the activity of coagulation factors II, VII, IX and X. The effect of acetylcysteine on the increased prothrombin time and international normalized ratio was more prominent after the high loading dose but remained present during the lower maintenance dose of acetylcysteine. The effect was observed in both in vitro and in vivo studies and confirmed in clinical studies in paracetamol-poisoned patients without hepatic injury. Studies in surgical patients treated with acetylcysteine showed conflicting results. Twelve of the 13 clinical studies suffered from risk of bias, limiting the value of these studies.The moderate 15–30% increase in the international normalized ratio induced by acetylcysteine is especially important in hospitals using the international normalized ratio as a marker for hepatotoxicity due to paracetamol poisoning and underlines the need for the international normalized ratio to be assessed at admission.Acetylcysteine treatment leads to an estimated 15–30% increase in prothrombin time and international normalized ratio in both experimental studies and paracetamol-poisoned patients. Isolated increases in prothrombin time and international normalized ratio during acetylcysteine infusion are common and do not necessarily reflect liver dysfunction or liver injury. [ABSTRACT FROM AUTHOR]

Knee osteoarthritis (KOA) represents a progressive degenerative disorder characterized by the gradual erosion of articular cartilage. This study aimed to develop and validate biomarker-based predictive models for KOA diagnosis using machine learning techniques. Clinical data from 2594 samples were obtained and stratified into training and validation datasets in a 7:3 ratio. Key clinical features were identified through differential analysis between KOA and control groups, combined with least absolute shrinkage and selection operator (LASSO) regression. The SHapley Additive Planning (SHAP) method was employed to rank feature importance quantitatively. Based on these rankings, predictive models were constructed using Logistic Regression (LR), Random Forest (RF), eXtreme Gradient Boosting (xGBoost), Naive Bayes (NB), Support Vector Machine (SVM), and Decision Tree (DT) algorithms. Models were developed for subsets of variables, including the top 5, top 10, top 15, and all identified features. Receiver operating characteristic (ROC) curves were applied to compare diagnostic performance across models. Additionally, a risk stratification framework for KOA prediction was designed using recursive partitioning analysis (RPA). Using difference analysis and LASSO, 44 critical clinical features were identified. Among these, age, plasma prothrombin time, gender, body mass index (BMI), and prothrombin time and international normalized ratio (PTINR) emerged as the top five features, with SHAP values of 0.1990, 0.0981, 0.0471, 0.0433, and 0.0422, respectively. Machine learning analysis demonstrated that these variables provided robust diagnostic performance for KOA. In the training set, area under the curve (AUC) values for LR, RF, xGBoost, NB, SVM, and DT models were 0.947, 0.961, 0.892, 0.952, 0.885, and 0.779, respectively. Similarly, in the validation dataset, these models achieved AUC values of 0.961, 0.943, 0.789, 0.957, 0.824, and 0.76. Among them, RF consistently exhibited superior diagnostic accuracy for KOA. Additionally, RPA analysis indicated a higher prevalence of KOA among individuals aged 54 years and older. The integration of the top five clinical variables significantly enhanced the diagnostic accuracy for KOA, particularly when employing the RF model. Moreover, the RPA model offered valuable insights to assist clinicians in refining prognostic assessments and optimizing clinical decision-making processes. [ABSTRACT FROM AUTHOR]

Objective: To explore the safety and efficacy of low-intensity anticoagulation in patients after On-X mechanical aortic valve replacement. Methods: A total of 104 patients undergoing aortic valve replacement in Cardiac Surgery Department of Sichuan Provincial People's Hospital from December 2018 to December 2021 were randomly divided into low-intensity anticoagulant (INR:1.5-2.0) and high-intensity anticoagulant (INR:2.0-2.5) to compare the incidence of adverse events related to postoperative anticoagulation between the two groups. Results: Fifty-three patients were included in the low-intensity anticoagulation group (INR 1.5-2.0), and 51 patients were included in the high-intensity group (2.0-2.5). There was no significant difference in baseline data and surgical index between the two groups (P > 0.05); there were statistically significant differences in PT, INR and bleeding events (P < 0.05), but no significant difference in embolic events (P > 0.05). Conclusion: For patients requiring On-X mechanical aortic valve replacement who have no risk factors for thromboembolism, it is appropriate to control the INR in the target range 1.5-2.0, which can reduce the incidence of bleeding adverse events and significantly improve the quality of life, without increasing the risk of thromboembolic adverse events. [ABSTRACT FROM AUTHOR]

Thrombosis is one of the most frequent complications of cancer, with a potential impact on morbidity and mortality, particularly those with acute myeloid leukemia (AML). Therefore, effective thrombosis prevention is a crucial aspect of cancer management. However, preventive measures against thrombosis may carry inherent risks and complications. Consequently, the application of thrombosis prevention should be limited to patients with a reasonable risk of developing thrombosis. This thesis explores the potential of data science (DS) methods for predicting venous thrombosis in patients with acute myeloid leukemia. In order to ascertain which patients are at risk, statistical and machine-learning (ML) algorithms were employed to predict which patients with leukemia will develop thrombosis. Multilayer Perceptron (MLP) was found to be the best fit among the models evaluated, achieving the C statistic of 0.749. We examined which attributes are significant and what role they play in prediction and found six significant parameters: sex of the patient, prior history of thrombotic event, type of therapy, international normalized ratio (INR), Eastern Cooperative Oncology Group (ECOG) performance status, and Hematopoietic Cell Transplantation-specific Comorbidity. These findings suggest that subtle DS techniques can improve the prediction of Thrombosis in AML patients, thereby aiding in individual treatment planning. [ABSTRACT FROM AUTHOR]

Aim: Recent evidence suggests that acute liver failure (ALF) in some patients may reflect a dysregulated immune response, and that corticosteroids improve survival of the native liver in ALF patients with high serum alanine aminotransferase levels, which are an indication of liver inflammation. However, it is unclear whether steroids are effective for pediatric acute liver failure (PALF). The aim of this retrospective case–control study is to examine whether steroid therapy for PALF accompanied by immune activation improves the survival of native liver and to identify factors that predict responses to steroid treatment. Methods: Of 38 patients with PALF treated at Kyoto University Hospital from February 2006 to August 2022, 19 receiving steroids who met the specific criteria for identifying the pathophysiology of immune activity in the liver (the "Steroid group"), and seven steroid‐free patients who also met the criteria ("Nonsteroid group") were enrolled. Patients in the "Steroid group" were categorized as "responders" or "nonresponders" according to treatment outcome. Clinical and histological data were analyzed. Results: Survival of the native liver in the Steroid group was significantly higher than that in the Nonsteroid group (68% vs. 0%, respectively; p = 0.0052). Nonresponders were significantly younger, with higher Model for End‐stage Liver Disease and pediatric end‐stage liver disease scores, higher prothrombin time – international normalized ratio, and higher serum ferritin levels than responders. Massive hepatic necrosis was more common in nonresponders. Conclusion: Steroid therapy is effective for PALF patients with liver inflammation; however, liver transplantation should be prioritized for young children with ALF accompanied by severe coagulopathy or massive hepatic necrosis. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Hospitalized patients with acute decompensation (AD) of cirrhosis are at risk of progressing to acute-onchronic liver failure (ACLF), significantly increasing their mortality. The aim of this study was to identify key predictors and patient trajectories predisposing to ACLF. METHODS: In this multicenter, prospective study spanning 2 years, clinical, biochemical, and 90-day survival data were collected from 625 patients with AD (European Association for the Study of the Liver criteria) across North, South, and East India. We divided the cohort into a Derivation cohort (DC: 318 patients) and a Validation cohort (VC: 307 patients). Predictive models for pre-ACLF were derived, validated, and compared with established scores such as model for end-stage liver disease (MELD) 3.0 and chronic liver failure Consortium acute decompensation. RESULTS: Of 625 patients (mean age 49 years, 83% male, 77.5% with alcohol-related liver disease), 32.2% progressed to ACLF. Patients progressing to ACLF showed significantly higher bilirubin (10.9 vs 8.1 mg/ dL), leukocyte counts (9,400 vs 8,000 per mm³), international normalized ratio (1.9 vs 1.8), and MELD 3.0 (28 vs 25) but lower sodium (131 vs 134 mEq/L) and survival (62% vs 86%) compared with those without progression (P < 0.05) in the DC. Consistent results were noted with alcohol-associated hepatitis, infection and hepatic encephalopathy as additional risk factors in VC. Liver failure at presentation (odds ratio: 2.4 [in DC], 6.9 [in VC]) and the 7-day trajectories of bilirubin, international normalized ratio, and MELD 3.0 significantly predicted ACLF progression (P < 0.001). A new pre-ACLF model showed superior predictive capability (area under the curve of 0.71 in DC and 0.82 in VC) compared with MELD 3.0 and chronic liver failure Consortium acute decompensation scores (P < 0.05). DISCUSSION: Approximately one-third of AD patients in this Indian cohort rapidly progressed to ACLF, resulting in high mortality. Early identification of patients at risk can guide targeted interventions to prevent ACLF. [ABSTRACT FROM AUTHOR]

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Background: The aim of this study was to explore the value of heparin-binding protein (HBP) in the early recognition of sepsis coagulopathy (SIC) and the prognosis of sepsis patients. Methods: A retrospective analysis was performed for 139 patients with sepsis admitted to the Intensive Care Unit (ICU) of Hefei Third People's Hospital from April 2022 through April 2024. The clinical baseline data, disease scores [sequential organ failure (SOFA) score, acute physiology and chronic health status (APACHE II) score, and SIC score], inflammatory markers [HBP, procalcitonin (PCT), and interleukin 6 (IL-6)], coagulation-related indexes [platelet count (PLT), prothrombin time (PT), prothrombin time international normalized ratio (PT-INR), activated partial thromboplastin time (APTT), fibrinogen (Fib), and D dimer (D-D)], and the survival time and 28-day prognosis of all patients were observed. The correlation between HBP and disease scores, inflammatory indexes, and coagulation-related indexes was analyzed. The receiver operating characteristic (ROC) curve was used to analyze the predictive value of HBP for SIC and the value of HBP and SIC score for the prognosis of sepsis, the risk stratification was carried out according to the optimal cutoff value of HBP, the differences in the occurrence of major clinical events under different HBP stratifications were compared, and the Kaplan-Meier survival curve was used to analyze the 28-day cumulative survival rate under different HBP stratifications. Results: Among the 139 patients, 98 developed SIC, 41 did not, 73 died at 28 days, and 66 survived. The disease score, inflammation index, and coagulation-related indexes of the non-SIC group were better than those of the SIC group, and the disease scores, inflammation indexes, and coagulation-related indexes of the survival group were better than those of the death group. Correlation analysis showed that HBP was positively correlated with disease score and inflammation index. Coagulation-related index was positively correlated with PT, APTT, PTINR, Fib, and D-D, and negatively correlated with PLT, among which HBP had the best correlation with disease score (HBP was best correlated with SIC, SOFA, and APACHE II scores; r = 0.818, 0.847, and 0.829, p < 0.001). ROC analysis showed that HBP had a high efficacy in identifying SIC (AUC = 0.934, sensitivity 96.9%, specificity 87.8%, p < 0.001), and the AUC of HBP and SIC score and their combination for 28-day death prediction were 0.802, 0.773, and 0.844 (p < 0.001), respectively. Compared with the HBP ≤ 118.25 ng/mL group (n = 52), the 28-day mortality rate, SIC incidence, APACHE II, and SOFA scores were higher in the HBP > 118.25 ng/mL group (n = 52) (p < 0.001). Kaplan-Meier survival curve analysis showed that the cumulative survival rate of the HBP > 118.25 ng/mL group was significantly lower than that of the HBP ≥ 118.25 ng/mL group (p < 0.001). Conclusions: HBP has a high predictive value in the early identification of SIC and the prognosis evaluation of sepsis, and patients with sepsis with an early HBP > 118.25 ng/mL in the ICU have a higher risk of SIC and death. [ABSTRACT FROM AUTHOR]

Jaundice is an indication of hyperbilirubinemia and is caused by derangements in bilirubin metabolism. It is typically apparent when serum bilirubin levels exceed 3 mg/dL and can indicate serious underlying disease of the liver or biliary tract. A comprehensive medical history, review of systems, and physical examination are essential for differentiating potential causes such as alcoholic liver disease, biliary strictures, choledocholithiasis, drug-induced liver injury, hemolysis, or hepatitis. Initial laboratory evaluation should include assays for bilirubin (total and fractionated), a complete blood cell count, aspartate transaminase, alanine transaminase, gamma-glutamyltransferase, alkaline phosphatase, albumin, prothrombin time, and international normalized ratio. Measuring fractionated bilirubin allows for determination of whether the hyperbilirubinemia is conjugated or unconjugated. Ultrasonography of the abdomen, computed tomography with intravenous contrast media, and magnetic resonance cholangiopancreatography are first-line options for patients presenting with jaundice, depending on the suspected underlying etiology. If the etiology of jaundice is unclear despite laboratory testing and imaging, liver biopsy may be required to establish the diagnosis, prognosis, and management of the disease. [ABSTRACT FROM AUTHOR]

Background: Percutaneous Endoscopic Gastrostomy (PEG) tube insertion, a routine procedure for long-term enteral nutrition, serves as a crucial intervention for patients who are incapable of tolerating oral intake or meeting adequate nutritional requirements. PEG tube placement carries complications like bleeding and infection. Impact of PEG tubes on the 30-day and long-term mortality in HIV patients is unknown. Despite the ongoing utilization of PEG tubes in HIV patients, a comprehensive exploration of its outcomes is yet to be explored. We intended to study the impact of HIV positive status on post-PEG mortality and review other PEG tube related complications. Methods: Our study comprised a total of 639 PEG tubes placed on 461 unique patients, from which 85 patients (n = 18%) were HIV positive. We reviewed all these PEG tube patients at our institution and compared their complications and mortality outcome between the two groups of HIV positive as against HIV negative. Results: Our findings reveal a statistically significant increase (p-value 0.001) in post-PEG insertion site bleeding in the HIV group (15.3%) compared to the non-HIV group (4.5%). This difference occurred despite no notable variations in laboratory parameters such as platelet count and (international normalized ratio), as well as similar usage of anticoagulant or antiplatelet medications between the two groups. Notably, the 1-year mortality rate in the HIV group stands at 37.6% (p < 0.001), contrasting sharply with the non-HIV group's rate of 17.8%. Conclusion: This study underscores the need for heightened vigilance and tailored management strategies when considering PEG tube procedures in the context of HIV, given the observed elevated bleeding risks and increased 1-year mortality rates in this patient population. Further research is warranted to elucidate the underlying factors contributing to these outcomes, facilitating the development of targeted interventions to optimize the care of HIV patients undergoing PEG placement. [ABSTRACT FROM AUTHOR]

Background: Mushrooms, an integral component of human diets, range from esteemed delicacies to potentially lethal toxins. The risk of severe poisoning from misidentified species, poses a significant challenge. For clinicians, recognizing mushroom poisoning amidst nonspecific symptoms and determining the specific mushroom ingested are critical yet complex tasks. Additionally, climate change affects the distribution and proliferation of mushroom species, potentially heightening the risk of exposure to toxic varieties. The identification of mushroom intoxication is critical for appropriate treatment. Poisoning with highly toxic species, such as Amanita phalloides (death cap), can result in acute liver and kidney failure. Considering the limited therapeutic options currently available for acute liver failure, we investigated the application of plasmapheresis, a procedure involving the replacement of the patient's plasma with donor plasma, as a potential intervention to improve clinical outcomes in severe cases of mushroom poisoning. Methods: This study aimed to assess the trends and treatment outcomes of mushroom poisoning cases from 2005 to 2022, with a particular focus on the number of incidents and the potential impacts of climate change. We undertook a retrospective monocentric cohort study, evaluating 43 patients with mushroom poisoning. The study focused on identifying the variety of mushrooms involved, including psychotropic, spoiled, inedible, or toxic species, and closely examined patients with elevated transaminases indicative for liver damage. To assess clinical outcomes, we evaluated several aspects, including hepatic encephalopathy and other symptoms. Additionally, we monitored blood analysis results through serial measurements, including transaminases, bilirubin, INR, and creatinine levels. Furthermore, we explored the impact of climate changes on the incidence of mushroom poisoning. Results: While the incidence of mushroom poisonings remained relatively stable during the first eight years of the study period, it nearly doubled over the past nine years. Nine distinct mushroom types were documented. The study showed no change in season patterns of mushroom poisonings. In cases of severe liver damage accompanied by coagulopathy, plasmapheresis was utilized to replace deficient clotting factors and mitigate the inflammatory response. This intervention proved effective in stabilizing coagulation parameters, such as the international normalized ratio (INR) Plasmapheresis was performed until the INR reached stable levels, preventing the occurrence of severe bleeding complications. In instances where liver failure was deemed irreversible, plasmapheresis functioned as a bridging therapy to manage bleeding risks and to stabilize the patient while awaiting liver transplantation. Conclusion: The findings underscore the need for heightened awareness among healthcare professionals regarding mushroom poisoning and emphasize the importance of considering climate change as a factor that may alter mushroom distribution and toxicity. Additionally, this study highlights the potential of plasmapheresis in managing severe cases. [ABSTRACT FROM AUTHOR]

The article discusses the treatment of polycythaemia vera (PV) with ropeginterferon alfa-2b, focusing on the molecular remission and complete haematological response achieved in patients. The study enrolled 49 patients in China, all carrying the JAK2V617F mutation, and demonstrated a significant reduction in JAK2V617F allele burden over 24 months of treatment. Ropeg treatment at a higher initiating dose regimen showed strong anti-neoplastic effects, leading to durable complete molecular remission and favourable safety outcomes in patients with PV. The study was conducted ethically and with patient consent, with data availability upon request. [Extracted from the article]

Background: Prothrombin time (PT) and international normalized ratio (INR) prolongation have traditionally been utilized as indications of the degree of coagulopathy in cirrhosis. Which is thought to be a hypocoagulable state. It most likely overestimates the risk of bleeding in people with liver disease. Despite the common misconception that liver cirrhosis increases the risk of bleeding, elevated INR levels may be able to predict presence of portal vein thrombosis (PVT) in cirrhotic patients, helping them to avoid the complications that come with it. Aim: To assess the value of elevated INR as a predictor of occurrence of PVT in patients with cirrhosis. Methods: This case control study was conducted at Tropical Medicine Department, Zagazig University Hospitals. This study included one hundred thirty four (134) individuals, divided into two groups: 67 cirrhotic patients with PVT (case group) and 67 cirrhotic patients without PVT (control group). Results: The case group had significantly elevated INR compared to the controls. INR was a strong predictor of PVT (AUC=0.737, p<0.001), with a cut off (>1.2) showing sensitivity of 80.6%, specificity of 53.7%, PPV of 63.5%, and NPV of 73.5%. Conclusions: An elevated international normalized ratio may be able to predict portal vein thrombosis in cirrhotic patients. Also, INR can be used as a measure of disease severity in liver cirrhosis So, don't treat the INR, treat the patient. [ABSTRACT FROM AUTHOR]

Introduction: The combination of antibiotics and warfarin is used frequently in clinical practice. However, the impact of this combination on the anticoagulant efficacy of warfarin remains uncertain, posing challenges to clinical decision-making. This study aimed to evaluate the influence of various antibiotics on the international normalized ratio (INR) values in hospitalized patients who were concurrently administered warfarin. Methodology: This retrospective cohort study enrolled patients who received concomitant warfarin and antibiotic therapy at the Nanjing Drum Tower Hospital, between January 2013 and December 2022. The patients were categorized into 8 groups based on the type of antibiotics they were received. The demographic characteristics were recorded, and the clinical outcomes were focused on changes in INR values after combining antibiotics in warfarin users. Results: A total of 623 patients were enrolled in this study. Based on analysis of covariance (ANCOVA), the maximum INR values of the combinations were as follows: 2.72 for oxazolidinones, 2.86 for β-lactams, 2.86 for carbapenems, 2.91 for glycopeptides, 2.91 for macrolides, 3.77 for quinolones, 4.13 for sulfonamides, and 4.37 for antifungal agents. Pairwise comparisons revealed that quinolones, sulfonamides, and antifungal agents manifested the most substantial elevation in INR values when co-administered with warfarin. β-lactams, glycopeptides, oxazolidinones, macrolides, and carbapenems demonstrated a comparatively weaker impact on INR values. Conclusions: Co-administration of warfarin with antibiotics led to an elevation in INR values in patients. Quinolones, sulfonamides, and antifungal agents had the most pronounced impact. [ABSTRACT FROM AUTHOR]

Background: Although the risk of serious bleeding following peritoneal dialysis catheter insertion is low, pericannular bleeding can increase the risk of catheter-related infections and reduce catheter survival. We aimed to analyze the risk factors for bleeding complications during peritoneal dialysis catheter insertion and assess whether temporary preemptive hemodialysis before catheterization can reduce bleeding and improve catheter survival. Methods: We retrospectively analyzed bleeding complications and catheter survival in patients who underwent temporary hemodialysis prior to peritoneal dialysis catheter insertion. Cox regression analysis was performed to determine the risk factors for bleeding complications and catheter survival. Results: Among 336 patients, 216 and 120 comprised the non-hemodialysis and hemodialysis groups, respectively. No significant association was found between temporary hemodialysis and bleeding (hazard ratio: 1.6, 95% confidence interval: 0.87–2.95, p < 0.134). Multivariate analysis revealed an inverse association of platelet count (hazard ratio: 0.99, 95% confidence interval: 0.99–0.99, p < 0.048) and hemoglobin level (hazard ratio: 0.78, 95% confidence interval: 0.61–0.99, p < 0.04) with bleeding. A positive association was observed between international normalized ratio (hazard ratio: 2.24, 95% confidence interval: 1.19–4.19, p < 0.012) and bleeding. Conversely, temporary hemodialysis was not associated with catheter survival (hazard ratio: 1.64, 95% confidence interval: 0.63–4.25, p < 0.308). Conclusions: Temporary hemodialysis before peritoneal dialysis catheter insertion did not significantly affect bleeding risk in patients with a high risk of uremic bleeding. [ABSTRACT FROM AUTHOR]

Introduction: Specific assays of plasma rivaroxaban level are not always readily available with short turnaround time, which hamper the management of urgent clinical situations. In this study, we aimed to build a predictive formula of plasma rivaroxaban levels from international normalized ratio (INR) value and validated in real world clinical situations. Methods: Ninety‐four patients who were taking rivaroxaban participated in the study. Patients were randomized into testing cohort and validation cohorts. The prediction formula was built from the testing cohort and then validated in validation cohort. The predictive performance was further validated on real‐world clinical requests. Results: The root mean square error (RMSE) of the predictive formula for the testing and validation cohorts were 61.81 and 69.32 ng/mL, respectively. The sensitivity and specificity for the formula to predict the threshold plasma rivaroxaban level of 75 ng/mL were 95% (95% CI: 85.4%–100%) and 87.5% (95% CI: 71.3%–100%), respectively, in real‐world clinical situations. Conclusion: Plasma rivaroxaban level of threshold level of 75 ng/mL can be calculated from prediction formula by INR value with satisfactory accuracy and it can be used to guide the decision for reversal. [ABSTRACT FROM AUTHOR]

Background: A high portal pressure gradient (PPG) is associated with an increased risk of failure to control esophagogastric variceal hemorrhage and refractory ascites in patients with decompensated cirrhosis. However, direct measurement of PPG is invasive, limiting its routine use in clinical practice. Consequently, there is an urgent need for non-invasive techniques to assess PPG. Aim: To develop and validate a deep learning model that predicts PPG values for patients with decompensated cirrhosis and identifies those with high-risk portal hypertension (HRPH), who may benefit from early transjugular intrahepatic portosystemic shunt (TIPS) intervention. Methods: Data of 520 decompensated cirrhosis patients who underwent TIPS between June 2014 and December 2022 were retrospectively analyzed. Laboratory and imaging parameters were used to develop an artificial neural network model for predicting PPG, with feature selection via recursive feature elimination for comparison experiments. The best performing model was tested by external validation. Results: After excluding 92 patients, 428 were included in the final analysis. A series of comparison experiments demonstrated that a three-parameter (3P) model, which includes the international normalized ratio, portal vein diameter, and white blood cell count, achieved the highest accuracy of 87.5%. In two distinct external datasets, the model attained accuracy rates of 85.40% and 90.80%, respectively. It also showed notable ability to distinguish HRPH with an AUROC of 0.842 in external validation. Conclusion: The developed 3P model could predict PPG values for decompensated cirrhosis patients and could effectively distinguish HRPH. [ABSTRACT FROM AUTHOR]

Background : Several studies have examined INR fluctuations using pharmacokinetic (PK) models or post-hoc INR values after completing nirmatrelvir/ritonavir, but further study of the effects of the drug interaction with warfarin during treatment is necessary. Case Summary : Nirmatrelvir/ritonavir is largely utilized in the outpatient setting so data regarding INR trends in hospitalized patients on warfarin is limited. However, many who receive nirmatrelvir/ritonavir outpatient experience difficulty with presenting to clinic for INR checks due to feeling acutely ill along with isolation precautions. We present the case of a patient receiving warfarin and utilizing home INR testing for monitoring. After diagnosis of coronavirus disease of 2019 (COVID-19), she was started on nirmatrelvir/ritonavir on day five after testing positive. Most recent INR prior to the start of therapy was 2.7 and had been stable on the same dose for months prior to infection. On day two of nirmatrelvir/ritonavir, her INR rose to 4.0 on home point of care INR testing. Despite reducing her dose of warfarin by 15%, her INR remained supratherapeutic the day after completing nirmatrelvir/ritonavir (4.0) and for several checks after. One month after completion of therapy, her INR returned to therapeutic levels. Practice Implications : While PK models and case series have hypothesized both potential increases or decreases in INR with the nirmatrelvir/ritonavir and warfarin interaction, COVID-19 infection itself can cause several pharmacodynamic changes which can increase INR, including decreased appetite and, in severe cases, organ dysfunction. This case provides real-world insight into the drug interaction between nirmatrelvir/ritonavir and the drug-disease state interaction between warfarin and COVID-19. [ABSTRACT FROM AUTHOR]

Background: Survival estimation for patients with symptomatic skeletal metastases ideally should be made before a type of local treatment has already been determined. Currently available survival prediction tools, however, were generated using data from patients treated either operatively or with local radiation alone, raising concerns about whether they would generalize well to all patients presenting for assessment. The Skeletal Oncology Research Group machine-learning algorithm (SORG-MLA), trained with institution-based data of surgically treated patients, and the Metastases location, Elderly, Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy model (METSSS), trained with registry-based data of patients treated with radiotherapy alone, are two of the most recently developed survival prediction models, but they have not been tested on patients whose local treatment strategy is not yet decided. Questions/purposes: (1) Which of these two survival prediction models performed better in a mixed cohort made up both of patients who received local treatment with surgery followed by radiotherapy and who had radiation alone for symptomatic bone metastases? (2) Which model performed better among patients whose local treatment consisted of only palliative radiotherapy? (3) Are laboratory values used by SORG-MLA, which are not included in METSSS, independently associated with survival after controlling for predictions made by METSSS? Methods: Between 2010 and 2018, we provided local treatment for 2113 adult patients with skeletal metastases in the extremities at an urban tertiary referral academic medical center using one of two strategies: (1) surgery followed by postoperative radiotherapy or (2) palliative radiotherapy alone. Every patient's survivorship status was ascertained either by their medical records or the national death registry from the Taiwanese National Health Insurance Administration. After applying a priori designated exclusion criteria, 91% (1920) were analyzed here. Among them, 48% (920) of the patients were female, and the median (IQR) age was 62 years (53 to 70 years). Lung was the most common primary tumor site (41% [782]), and 59% (1128) of patients had other skeletal metastases in addition to the treated lesion(s). In general, the indications for surgery were the presence of a complete pathologic fracture or an impending pathologic fracture, defined as having a Mirels score of ≥ 9, in patients with an American Society of Anesthesiologists (ASA) classification of less than or equal to IV and who were considered fit for surgery. The indications for radiotherapy were relief of pain, local tumor control, prevention of skeletal-related events, and any combination of the above. In all, 84% (1610) of the patients received palliative radiotherapy alone as local treatment for the target lesion(s), and 16% (310) underwent surgery followed by postoperative radiotherapy. Neither METSSS nor SORG-MLA was used at the point of care to aid clinical decision-making during the treatment period. Survival was retrospectively estimated by these two models to test their potential for providing survival probabilities. We first compared SORG to METSSS in the entire population. Then, we repeated the comparison in patients who received local treatment with palliative radiation alone. We assessed model performance by area under the receiver operating characteristic curve (AUROC), calibration analysis, Brier score, and decision curve analysis (DCA). The AUROC measures discrimination, which is the ability to distinguish patients with the event of interest (such as death at a particular time point) from those without. AUROC typically ranges from 0.5 to 1.0, with 0.5 indicating random guessing and 1.0 a perfect prediction, and in general, an AUROC of ≥ 0.7 indicates adequate discrimination for clinical use. Calibration refers to the agreement between the predicted outcomes (in this case, survival probabilities) and the actual outcomes, with a perfect calibration curve having an intercept of 0 and a slope of 1. A positive intercept indicates that the actual survival is generally underestimated by the prediction model, and a negative intercept suggests the opposite (overestimation). When comparing models, an intercept closer to 0 typically indicates better calibration. Calibration can also be summarized as log(O:E), the logarithm scale of the ratio of observed (O) to expected (E) survivors. A log(O:E) > 0 signals an underestimation (the observed survival is greater than the predicted survival); and a log(O:E) < 0 indicates the opposite (the observed survival is lower than the predicted survival). A model with a log(O:E) closer to 0 is generally considered better calibrated. The Brier score is the mean squared difference between the model predictions and the observed outcomes, and it ranges from 0 (best prediction) to 1 (worst prediction). The Brier score captures both discrimination and calibration, and it is considered a measure of overall model performance. In Brier score analysis, the "null model" assigns a predicted probability equal to the prevalence of the outcome and represents a model that adds no new information. A prediction model should achieve a Brier score at least lower than the null-model Brier score to be considered as useful. The DCA was developed as a method to determine whether using a model to inform treatment decisions would do more good than harm. It plots the net benefit of making decisions based on the model's predictions across all possible risk thresholds (or cost-to-benefit ratios) in relation to the two default strategies of treating all or no patients. The care provider can decide on an acceptable risk threshold for the proposed treatment in an individual and assess the corresponding net benefit to determine whether consulting with the model is superior to adopting the default strategies. Finally, we examined whether laboratory data, which were not included in the METSSS model, would have been independently associated with survival after controlling for the METSSS model's predictions by using the multivariable logistic and Cox proportional hazards regression analyses. Results: Between the two models, only SORG-MLA achieved adequate discrimination (an AUROC of > 0.7) in the entire cohort (of patients treated operatively or with radiation alone) and in the subgroup of patients treated with palliative radiotherapy alone. SORG-MLA outperformed METSSS by a wide margin on discrimination, calibration, and Brier score analyses in not only the entire cohort but also the subgroup of patients whose local treatment consisted of radiotherapy alone. In both the entire cohort and the subgroup, DCA demonstrated that SORG-MLA provided more net benefit compared with the two default strategies (of treating all or no patients) and compared with METSSS when risk thresholds ranged from 0.2 to 0.9 at both 90 days and 1 year, indicating that using SORG-MLA as a decision-making aid was beneficial when a patient's individualized risk threshold for opting for treatment was 0.2 to 0.9. Higher albumin, lower alkaline phosphatase, lower calcium, higher hemoglobin, lower international normalized ratio, higher lymphocytes, lower neutrophils, lower neutrophil-to-lymphocyte ratio, lower platelet-to-lymphocyte ratio, higher sodium, and lower white blood cells were independently associated with better 1-year and overall survival after adjusting for the predictions made by METSSS. Conclusion: Based on these discoveries, clinicians might choose to consult SORG-MLA instead of METSSS for survival estimation in patients with long-bone metastases presenting for evaluation of local treatment. Basing a treatment decision on the predictions of SORG-MLA could be beneficial when a patient's individualized risk threshold for opting to undergo a particular treatment strategy ranged from 0.2 to 0.9. Future studies might investigate relevant laboratory items when constructing or refining a survival estimation model because these data demonstrated prognostic value independent of the predictions of the METSSS model, and future studies might also seek to keep these models up to date using data from diverse, contemporary patients undergoing both modern operative and nonoperative treatments. Level of Evidence: Level III, diagnostic study. [ABSTRACT FROM AUTHOR]

The contribution of endothelial injury to the pathogenesis of burn shock is not well characterized. This work investigates potential mechanisms underlying dysregulation of endothelial barrier function by burn patient plasmas. Plasma was collected from burn-injured patients (n = 8) within 4 h of admission. Demographic and injury characteristics were collected and markers of injury severity including international normalized ratio, activated partial thromboplastin time, and levels of syndecan-1 and interleukin (IL)-6, IL-1B, IL-10, Il-12p70, and tumor necrosis factor-α measured. Human umbilical vein endothelial cell monolayers (HUVEC-m) exposed to either burn patient plasma or multidonor plasma (HHP) were assessed for permeability (40 kDa fluorescein isothiocyanate (FITC)-Dextran diffusion), intercellular gap area (F-actin staining) and incidence of apoptosis (TUNEL assay). Post plasma exposure, RNA was isolated and used in polymerase chain reaction (PCR) arrays targeting genes relevant to cytoskeletal structure or apoptosis. Differences between HHP and burn plasma-treated HUVEC-m were analyzed. Five plasmas promoted significant increases in HUVEC-m permeability. When plasmas were grouped based on their capacity to increase permeability, no differences in age, %total body surface area, gender, hospital mortality, international normalized ratio, activated partial thromboplastin time, or cytokine concentration were observed; however, significantly higher syndecan-1 levels were seen in the plasmas inducing increased permeability. Increases in intercellular gap area and apoptosis and relevant gene expression were observed after exposure to patient plasmas but none of these metrics correlated completely with the pattern or magnitude of the changes in permeability. Burn patient plasmas variably disrupt HUVEC-m homeostasis, differentially inducing changes in permeability, intercellular gap area, and apoptosis. Neither increases in intercellular gap size nor apoptosis appear sufficient to explain the pattern of changes in permeability. [ABSTRACT FROM AUTHOR]

Purpose: To determine the safety and efficacy of phytonadione in patients with an elevated international normalized ratio (INR) secondary to chronic liver disease without active bleeding. Methods: This retrospective chart review compared hospitalized patients from 2015 to 2022 with a diagnosis of chronic liver disease, a baseline INR of 1.2 to 1.9, and without active bleeding who did or did not receive phytonadione. The primary outcome was the incidence of new bleeding. The incidence of thrombosis and change in INR were also evaluated. Results: A total of 133 patients were included, of which 46 received phytonadione (mean 2.46 doses and mean dose 7.95 mg, 72.74% intravenously). Child-Pugh scores were higher in phytonadione patients (8.7 vs 9.93, P =.0003). There was no difference in the incidences of new bleeding (9.20 vs 13.04%, P =.492) or thrombosis (3.45 vs 0%, P =.203) between the control and phytonadione groups. After phytonadione administration, there was no change in INR, while INR increased by 0.24 in the control group (P =.025). Conclusion: In chronic liver disease patients who were not bleeding, phytonadione did not reduce INR or the incidence of new bleeding. [ABSTRACT FROM AUTHOR]

Introduction: Real‐world studies comparing safety and efficacy of combined percutaneous left atrial appendage occlusion (LAAO) and catheter ablation (CA) to LAAO alone are limited. Methods: Patients from a large US hospital system undergoing combined LAAO and left‐atrial CA from 8/2020 to 2/2024 were retrospectively analyzed and compared to a control group undergoing LAAO alone. Controls were identified using a 1:2 propensity score match based on LAAO device type (Watchman FLX vs. Amulet), CHA2D2‐VASc and Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio [INR], Elderly, Drugs/alcohol (HAS‐BLED) scores and compared for safety, sealing performance and clinical outcomes at 6 months. Results: Patients were younger in the combined (n = 72) than in the control group (n = 144, 70.2 ± 7.3 vs. 76.7 ± 6.9 years, p < 0.001) but otherwise comparable with a mean CHA2D2‐VASc score of 4.2 ± 1.1 and 4.4 ± 1.2 (p = 0.26) and HAS‐BLED score of 2.2 ± 0.8 and 2.3 ± 0.7 (p = 0.34). Successful LAAO implantation rates were the same (95.8% vs. 95.8%, p = 0.99) with longer procedure times seen in the combined group (156.5 ± 53 vs. 56 ± 26 min, p < 0.001). Both major (1.4% vs. 2.1%, p = 0.72) and minor (27.8% vs. 19.4%, p = 0.17) in‐hospital complications were similar between the combined and control group, respectively. At 45 days, presence of peri‐device leak (18.3% vs. 30.4%, p = 0.07) and device related thrombosis (4.5% vs. 4.5%, p = 0.96) on transesophageal echocardiogram did not differ. Finally, all‐cause mortality (0% vs. 1.4%, p = 0.99), thromboembolic (0% vs. 0%, p = 0.99) and bleeding (6.1% vs. 4.4%, p = 0.73) events during follow‐up were comparable. Conclusion: This large, real‐world analysis indicates comparable safety and efficiency of combined LAAO and CA when compared with LAAO alone. [ABSTRACT FROM AUTHOR]

Background: The International Normalized Ratio (INR) monitors anticoagulant treatment but relies on laboratory-based services. This could limit access to rapid monitoring and increase the diagnostic delay, both of which may be addressed by point-of-care testing (POCT). This study investigated the LumiraDx POC platform for INR monitoring. Methods: INR was measured on recalcified residual venous (n = 94) specimens from Chris Hani Baragwanath Hospital and capillary blood specimens (n = 254) from consenting enrolled participants at Charlotte Maxeke Johannesburg Academic Hospital Anticoagulation clinic, Johannesburg, South Africa. Standard-of-care (SOC) INR was measured on sodium-citrated venous blood using the Sysmex-CS2500 platform (Siemens Healthcare) and Neoplastin-R (Roche Diagnostics and Diagnostica Stago, Paris, France) within 2 h post-venipuncture. Within run, precision was measured using 2 LumiraDx control levels. The statistical agreement of paired INR measurements was also stratified by dosing decision. Results: The precision was within the manufacturer's claim for controls (level 1%CV: 3.63, level 2%CV: 2.24). Accuracy analysis showed a moderate overall agreement compared to the SOC INR results with a correlation coefficient of 0.94 (95% Cl, (0.9267 to 0.9497)). The overall precision (ρ > 0.9) and accuracy (Cb = 0.9842) were good with an absolute bias of 0.07. The 95% confidence intervals for the slope and intercept did not include 1.00 and 0.00, respectively; however, the total calculated error was within the minimal acceptable limits. Conclusion: The LumiraDx INR Test showed a good performance compared to laboratory-based testing and provided opportunity for rapid and patient-centric care. Owing to an increasing positive bias for INR > 3.5, confirmation with laboratory INR measurements may be required. [ABSTRACT FROM AUTHOR]

The document discusses stress ulcer bleeding as a complication of critical illness and the use of stress ulcer prophylaxis to prevent such ulcers. Proton pump inhibitors are the main agents prescribed for stress ulcer prophylaxis, with histamine-2-receptor blockers being less commonly used. The document also highlights the challenges of predicting the severity of bleeding episodes and the uncertainty surrounding the effect of stress ulcer prophylaxis on mortality. Additionally, it explores the potential impact of enteral nutrition on bleeding risk and the importance of discontinuing stress ulcer prophylaxis when no longer needed. [Extracted from the article]

Gastrointestinal bleeding is a common clinical problem. In 5% of these cases, no source of bleeding can be found by gastroscopy or colonoscopy. The aim of this study was to investigate which of these patients benefit from capsule endoscopy (CE) and how it affects subsequent management. 305 patients who underwent CE for suspected obscure gastrointestinal bleeding at two German gastroenterological centers were analysed retrospectively. All patients had previously undergone gastroscopy and colonoscopy without evidence of a sufficient source of bleeding. The PillCam SB (Medtronic) was used for CE. A source of bleeding was identified in 63.9% (195/305) of cases with CE. A source of bleeding tented to be detected more frequently by CE in patients with melena only (72.4%, p=0.002) compared to patients with hematochezia with or without melena (55.6% and 45.9%). Furthermore, early CE (day 1: 73.3%, day 2: 61.5%, day 3: 53.8%; p=0.378) and complete CE (71.1% vs. 38.8%, p=2.56*10-6) were associated with a higher detection rate. Blood was detected in 31.5% (96/305) of all CEs. However, this tended to be observed more often in patients with a high need for red blood concentrates (0 RBC: 21.4%, 1-2 RBC: 34.9%, 3-4 RBC: 38.3%, ≥5 RBC: 45.7%; p=0.026), a derailed INR (<1.15: 32.6%, 1.16-2.0: 19.5%, 2.0-3.0: 32.0%, >3: 60.0%; p=0.023) and early CE (day 1: 46.7% (7/15), day 2: 41.0% (16/39), day 3: 25.0% (13/52); p=0.244). In 12.5% of the patients a double-ballon enteroscopy (DBE) was conducted. The detection of blood during CE increased the probability for a DBE (25.0% vs. 6.7%; OR: 4.61; p=2.061*10-5). Detection of a source of hemorrhage with CE increased the likelihood of detecting a source of hemorrhage with DBE (48.1% vs. 9.1%; OR: 8.83; p=0.030). Performing a DBE did not affect the length of hospitalisation (without DBE 10d, with DBE 9.1d, p=0.81) or the number of RBCs transfused after CE (without DBE 1.9 RBC, with DBE 2.4 RBC, p=0.67). In particular, patients with melena and an increased need for RBCs could benefit from an early and complete capsule endoscopy. If a source of bleeding was detected by CE, the probability of a finding in DBE could be increased. [ABSTRACT FROM AUTHOR]

Background and objective: Plasma is a critical element in hemostatic resuscitation post-injury, and its prompt administration within the prehospital setting may reduce the complications resulting from hemorrhage and shock. Our objective is to assess the efficacy and safety of prehospital plasma infusion in patients susceptible to hemorrhagic shock. Methods: We conducted our study by aggregating randomized controlled trials (RCTs) sourced from PubMed, EMBASE, Scopus, Web of Science, and Cochrane CENTRAL up to January 29, 2023. Quality assessment was implemented using the Cochrane RoB 2 tool. Our study protocol is registered in PROSPERO under ID: CRD42023397325. Results: Three RCTs with 760 individuals were included. There was no difference between plasma infusion and standard care groups in 24-h mortality (P = 0.11), 30-day mortality (P = 0.12), and multiple organ failure incidences (P = 0.20). Plasma infusion was significantly better in the total 24-h volume of PRBC units (P = 0.03) and INR on arrival (P = 0.009). For all other secondary outcomes evaluated (total 24-h volume of packed FFP units, total 24-h volume of platelets units, massive transfusion, vasopressor need during the first 24 h, any adverse event, acute lung injury, transfusion reaction, and sepsis), no significant differences were observed between the two groups. Conclusion: Plasma infusion in trauma patients at risk of hemorrhagic shock does not significantly affect mortality or the incidence of multiple organ failure. However, it may lead to reduced packed red blood cell transfusions and increased INR at hospital arrival. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To investigate and screen the risk factors for hypoproteinemia after total hip arthroplasty, and to establish a nomogram prediction model so as to provide guidance for judging whether hypoproteinemia occurs after total hip arthroplasty. METHODS: A total of 355 patients who underwent total hip arthroplasty were included, and according to whether hypoproteinemia occurred on the first day after surgery, they were divided into 238 cases in the hypoproteinemia group and 117 cases in the normal group, with a hypoproteinemia rate of 67%. Data were collected, including age, gender, diabetes mellitus, hypertension, hyperuricemia, hyperlipidemia, anesthesia method, preoperative leukocytes, preoperative erythrocytes, preoperative hemoglobin, preoperative platelets, preoperative plasma prothrombin time, preoperative activated partial prothrombin time, preoperative international normalized ratio, preoperative thrombin time, preoperative fibrinogen, preoperative erythrocyte sedimentation rate, preoperative C-reactive protein, preoperative D-dimer, preoperative mean corpuscular hemoglobin content, preoperative mean corpuscular volume, operation time, body mass index, preoperative procalcitonin, and preoperative hematocrit. SPSS 27.0 software was used for univariate analysis, followed by R language (4.3.1) to perform least absolute shrinkage and selection operator regression and 10-fold cross-validation of the observation indicators to obtain the intersection of the two risk factors. SPSS 27.0 software was used to perform multivariate binary logistic regression to obtain the final risk factors. The prediction model of hypoproteinemia after total hip arthroplasty was constructed by R language. The receiver operating characteristic curve, calibration curve, and clinical decision curve were constructed to assess the predictive model predictive ability. RESULTS AND CONCLUSION: (1) Univariate analysis, least absolute shrinkage and selection operator regression, and multivariate logistic regression were used to screen out significant differences in age (OR=1.024, P=0.023), preoperative platelets (OR=0.995, P=0.028), and preoperative erythrocyte sedimentation rate (OR=1.031, P=0.045) in judging whether hypoproteinemia would occur after surgery (P < 0.05). (2) The nomogram prediction model was constructed based on the final risk factors screened by multivariate Logistic regression, and the prediction ability of the model was evaluated by constructing the receiver operating characteristic curve, and the area under the calculated receiver operating characteristic curve reached 0.835 (95%CI=0.779-0.891), C-index=0.835. A threshold of 0-0.83 could bring better clinical efficacy calculated by the decision curve analysis. The model has good sensitivity and accuracy, which can better identify the risk of postoperative hypoproteinemia for medical staff and patients before total hip arthroplasty. [ABSTRACT FROM AUTHOR]

Abstract This study aimed to ascertain how the current two ART regimens used in Ghana affected HIV patients’ coagulation profiles. A case-control study was conducted on 102 HIV positive patients at the Mampong Municipal Hospital. Coagulation parameters measured showed APTT was normal in majority of ART-experienced participants but prolonged in majority of ART-naïve participants. The mean platelet count was significantly higher in ART-experienced participants. No significant differences were found between the coagulation profiles of ART-experienced patients on two different drug regimens. In conclusion, current ART can enhance the coagulation profiles in HIV-infected patients, by improving platelet count and APTT.

Objective Methods Results Conclusions This study aimed to compare the coagulation and platelet parameters in women with spontaneous premature ovarian insufficiency (POI) with those in age‐matched controls.This case–control study recruited 202 women with POI and 202 age‐matched women with benign gynecological diseases as controls. Coagulation parameters, including prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (APTT), and thrombin time (TT), fibrinogen, and platelet parameters, including platelet count (PLT), mean platelet volume (MPV), plateletcrit (PCT), and platelet distribution width (PDW), were compared between women with POI and controls. Factors associated with coagulation and platelet parameters were also analyzed in women with POI.In women with POI, higher fibrinogen levels and PDW, lower PLT, MPV, and PCT levels, and shorter TT were observed (p < 0.001). Linear regression analysis further revealed that women with POI were more likely to exhibit increased serum fibrinogen levels (β = 0.465, 95% confidence interval [CI] 0.366–0.564) and PDW (β = 0.340, 95% CI 0.300–0.379), decreased TT (β = −1.101, 95% CI –1.233–−0.969), PLT (β = −50.985, 95% CI –65.087–−36.882), MPV (β = −1.498, 95% CI –1.875 to −1.120), PCT levels (β = −0.084, 95% CI –0.095–−0.973). Additionally, follicle‐stimulating hormone levels were positively associated with fibrinogen levels in women with POI. There were no statistically significant differences in PT, INR, and APTT between women with POI and controls.Women with POI exhibited decreased platelet numbers, abnormal platelet morphology, and elevated fibrinogen concentrations, potentially implicating POI's etiopathogenesis or contributing to an increased risk of cardiovascular disease in women with POI. No coagulation abnormalities were observed in women with POI. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course Background: Coagulopathy caused by trauma itself is defined as trauma-induced coagulopathy (TIC). The pathophysiology of TIC is considered to consist of coagulation activation, hyperfibrinolysis, and consumption coagulopathy, similar to disseminated intravascular coagulation (DIC). This report describes a 48-year-old man with a history of epilepsy presenting with TIC associated with multiple traumatic fractures and hemothorax. Case Report: A 48-year-old man with a history of epilepsy fell while working on a second-floor roof and had right rib fractures (6th to 12th rib), right hemothorax, right clavicle fracture, right elbow fracture, and pelvic fractures. The right hemothorax became exacerbated and he went into shock. We performed the emergency surgery 5 hours after the trauma. Although circulation dynamics became stable and the discharge of chest drainage became thinned at postoperative day (POD) 1 while administering blood transfusions and tranexamic acid, hemoglobin remained below 8 g/dl, platelet count was below 60 000/µl, and prothrombin time - international normalized ratio (1.22) remained prolonged. Furthermore, the right hemothorax became exacerbated and re-operation was performed on the evening of POD2. Oozing hemorrhages from multiple rib fractures were observed. Although hemostatic management was performed with electrocautery and ultrasound energy devices, the hemorrhage could not be completely managed, so hemostasis was secured using hemostatic materials. Conclusions: The pathophysiologic mechanism of TIC has been emphasized as being different from that of DIC, and management of severe traumatic patients with TIC should be based on an understanding of the pathophysiology of TIC. [ABSTRACT FROM AUTHOR]

Background: Peptic ulcers are a common gastrointestinal disease that could cause death when combined with bleeding. The aim of this study was to identify risk factors for peptic ulcer bleeding (PUB) recurrence after the initial episode. Methods: This retrospective study analyzed medical records of PUB patients who were admitted through the emergency department between January 1, 2020, and December 31, 2022. A multivariate logistic regression model was used to identify independent risk factors predicting readmission due to recurrent PUB within one year. Results: A total of 775 PUB inpatient samples were collected, among which 172 and 603 were placed respectively in the readmission group and non-readmission group. Multivariate analysis indicated that PUB inpatients who were aged 70 or above (OR = 1.62, 95% CI: 1.06–2.47), had more severe ulcers (Forrest 1a, 1b, 2a, or 2b) (OR = 2.41, 95% CI:1.57–3.71), had a CCI score of 3 or higher (OR = 2.25, 95% CI:1.45–3.50), had a medical history of peptic ulcers (OR = 3.87, 95% CI:2.56–5.85), had a medical history of cardiovascular disease (CVD) (OR = 2.31, 95% CI:1.53–3.50), or had an international normalized ratio (INR) > 1.2 on admission (OR = 2.14, 95% CI:1.28–3.57) were respectively more likely to be readmitted within a year due to PUB than those who were under the age of 70, had less severe ulcers (Forrest 2c or 3), had a CCI score of less than 3, had no medical history of peptic ulcers, had no medical history of CVD, or had admission INR ≤ 1.2. Conclusion: This study confirmed that age (≥70 years), Forest classification (Forrest 1a, 1b, 2a, or 2b), multiple comorbidities, a medical history of peptic ulcers, a medical history of CVD, and admission INR > 1.2 were independent risk factors for patient readmission within a year due to recurrent PUB. [ABSTRACT FROM AUTHOR]

Brain swelling after Traumatic Brain Injury (TBI) can elevate intracranial pressure, necessitating Decompressive Craniectomy (DC) as the preferred surgical intervention. This study aimed to analyze a large institutional database to identify clinical characteristics of patients requiring primary DC and their outcomes. We reviewed TBI patients admitted to our center from 2015 to 2021, utilizing a prospectively maintained registry. Data collected included demographics, injury mechanisms, admission findings, neuroimaging results, DC necessity, procedures during hospitalization, and functional outcomes at discharge and six-month follow-up. A total of 4,011 patients were analyzed, with 506 undergoing primary DC. Factors such as International Normalized Ratio, activated Partial Thromboplastin Time, subdural hematoma, midline shift, epidural hematoma, intracerebral hemorrhage, and the presence of compressed or absent basal cisterns were independently linked to the need for DC. Additionally, the requirement for DC correlated with an increased likelihood of tracheostomy. For patients requiring DC, older age, lower hemoglobin levels, higher Rotterdam scores, and the presence of compressed or absent basal cisterns were associated with unfavorable outcomes in mild to moderate TBI cases. In severe TBI patients, lower Glasgow Coma Scale scores and fixed pupils were linked to poor outcomes. This study represents one of the most comprehensive analyses of primary DC requirements and outcomes, revealing that the need for DC is associated with worse outcomes in TBI patients and identifying several independent predictors of outcomes across varying severity levels. [ABSTRACT FROM AUTHOR]

Hyponatremia can worsen the outcomes of patients with liver cirrhosis. However, it remains unclear about how to predict the risk of death in cirrhotic patients with hyponatremia. Patients with liver cirrhosis and hyponatremia were screened. Eligible patients were randomly divided into the training (n = 472) and validation (n = 471) cohorts. In the training cohort, the independent predictors for in-hospital death were identified by logistic regression analyses. Odds ratios (ORs) were calculated. An artificial neural network (ANN) model was established in the training cohort. Areas under curve (AUCs) of ANN model, Child-Pugh, model for end-stage liver disease (MELD), and MELD-Na scores were calculated by receiver operating characteristic curve analyses. In multivariate logistic regression analyses, ascites (OR = 2.705, P = 0.042), total bilirubin (OR = 1.004, P = 0.003), serum creatinine (OR = 1.004, P = 0.017), and international normalized ratio (OR = 1.457, P = 0.005) were independently associated with in-hospital death. Based on the four variables, an ANN model was established. Its AUC was 0.865 and 0.810 in the training and validation cohorts, respectively, which was significantly larger than those of Child-Pugh (AUC = 0.757), MELD (AUC = 0.765), and MELD-Na (AUC = 0.769) scores. An ANN model has been developed and validated for the prediction of in-hospital death in patients with liver cirrhosis and hyponatremia. [ABSTRACT FROM AUTHOR]

(1) Background: Cirrhosis is associated with frequent alterations in standard coagulation tests that do not adequately reflect hemostasis. Thromboelastography provides a global assessment of coagulation and evaluates the functional status of clotting factors, fibrinogen, platelets, and fibrinolysis. The study aimed to assess whether liver disease severity leads to progressive alterations in the thromboelastography-based assessment of coagulation. (2) Methods: Consecutive patients with cirrhosis and abnormal standard coagulation tests (at least one of International Normalized Ratio > 2, platelet count < 50 × 103/µL, fibrinogen < 200 mg/dL) were analyzed using native thromboelastography. (3) Results: A total of 106 patients were included, of whom 69 (65.1%) had a normal thromboelastography. While the standard coagulation tests were significantly worse in patients in the Child C group (n = 62, 58.5%) than in patients staged in Child A and B, no significant differences existed between any of the thromboelastography variables. Of the 50 patients (47.1%) with an International Normalized Ratio > 2, only two patients (4%) had features of hypocoagulation, while 26% had features of hypercoagulability on thromboelastography. Patients with a platelet count < 50 × 103/µL had significantly lower platelet function as assessed by thromboelastography, yet only eight patients (20%) met the criteria for platelet transfusion. A thromboelastography-based transfusion protocol might lead to a 94.6% reduction in blood product transfusion indications in a simulation where the included patients would require interventional procedures. (4) Conclusion: Standard coagulation tests showed a poor correlation with thromboelastography. Based on thromboelastography, patients with severe, decompensated liver disease have a preserved hemostasis balance despite abnormal standard coagulation tests. Therefore, standard coagulation tests should not be used to guide the administration of blood products in patients with cirrhosis. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate if implementation of the 2019 Society of Interventional Radiology (SIR) guidelines for periprocedural management of bleeding risk in patients undergoing percutaneous ultrasound guided liver biopsy is associated with increased haemorrhagic adverse events, change in pre-procedural blood product utilization, and evaluation of guideline compliance rate at a single academic institution. Methods: Ultrasound guided percutaneous liver biopsies from (January 2019-January 2023) were retrospectively reviewed (n = 504), comparing biopsies performed using the 2012 SIR pre-procedural coagulation guidelines (n = 266) to those after implementation of the 2019 SIR pre-procedural guidelines (n = 238). Demographic, preprocedural transfusion, laboratory, and clinical data were reviewed. Chart review was conducted to evaluate the incidence of major bleeding adverse events defined as those resulting in transfusion, embolization, surgery, or death. Results: Implementation of the 2019 SIR periprocedural guidelines resulted in reduced guideline non-compliance related to the administration of blood products, from 5.3% to 1.7% (P =.01). The rate of pre-procedural transfusion remained the same pre and post guidelines at 0.8%. There was no statistically significant change in the incidence of bleeding adverse events, 0.8% pre guidelines versus 0.4% post (P = 1.0). Conclusion: Implementation of the 2019 SIR guidelines for periprocedural management of bleeding risk in patients undergoing percutaneous ultrasound guided liver biopsy did not result in an increase in bleeding adverse events or pre-procedural transfusion rates. The guidelines can be safely implemented in clinical practice with no increase in major adverse events. [ABSTRACT FROM AUTHOR]

Background: Despite prophylactic platelet transfusions, hypoproliferative thrombocytopenia is associated with bleeding; historical risk factors include hematocrit (HCT) ≤25%, activated partial thromboplastin time ≥30 s, international normalized ratio ≥1.2, and platelets≤5000/μL. Methods: We performed a post hoc analysis of bleeding outcomes and risk factors in participants with hematologic malignancy and hypoproliferative thrombocytopenia enrolled in the American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (A‐TREAT) and randomized to receive either tranexamic acid (TXA) or placebo. Results: World Health Organization (WHO) grade 2+ bleeding occurred in 46% of 330 participants, with no difference between the TXA (44%) and placebo (47%) groups (p = 0.66). Overall, the most common sites of bleeding were oronasal (18%), skin (17%), gastrointestinal (11%), and genitourinary (11%). Among participants of childbearing potential, 28% experienced vaginal bleeding. Platelets ≤5000/μL and HCT < 21% (after adjusting for severe thrombocytopenia) were independently associated with increased bleeding risk (HR 3.78, 95% CI 2.16–6.61; HR 2.67, 95% CI 1.35–5.27, respectively). Allogeneic stem cell transplant was associated with nonsignificant increased risk of bleeding versus chemotherapy alone (HR 1.34, 95% CI 0.94–1.91). Discussion: The overall rate of WHO grade 2+ bleeding was similar to previous reports, albeit with lower rates of gastrointestinal bleeding. Vaginal bleeding was common in participants of childbearing potential. Platelets ≤5000/μL remained a risk factor for bleeding. Regardless of platelet count, bleeding risk increased with HCT < 21%, suggesting a red blood cell transfusion threshold above 21% should be considered to mitigate bleeding. More investigation is needed on strategies to reduce bleeding in this population. [ABSTRACT FROM AUTHOR]

Performing cardiac surgery on patients with bleeding diatheses poses significant challenges since these patients are at an increased risk for complications secondary to excessive bleeding. Despite its rarity, patients with factor VII (FVII) deficiency may require invasive procedures such as cardiac surgery. However, we lack guidelines on their pre-, peri-, and post-operative management. As FVII deficiency is rare, it seems unlikely to design and learn from large clinical studies. Instead, we need to base our clinical decision-making on single reported cases and registry data. Herein, we present the rare case of a patient with FVII deficiency who underwent double valve surgery. Pre-operatively, activated recombinant FVII (rFVIIa) was administered to reduce the risk of bleeding. Nevertheless, the patient experienced major bleeding. This case highlights the significance of FVII deficiency in patients undergoing cardiac surgery and emphasizes the importance of adequate and appropriate transfusion of blood products for these patients. [ABSTRACT FROM AUTHOR]

Background: Effect of inhalational agents, namely, isoflurane and sevoflurane on patients having renal parameters has been explored quite often but the effect on liver function test has been rarely reviewed till date. Aims and Objectives: The aim of the study was to study the pre-operative liver function of patients who underwent general anesthesia by measuring their liver function test, post-operative effects of isoflurane, sevoflurane, and comparison. Materials and Methods: A total of 90 patients aged between 18 and 60 years who were further divided into two groups, that is, Group 1: (Isoflurane, n=45) and Group 2: (Sevoflurane, n=45) were included in the study. Results: The study comprised 51.1% of males and 48.9% of females, with similar distribution in either group (P>0.05). Comparison of various pre-operative parameters at 24, 48, and 72 h in isoflurane cases showed that bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), protein, albumin, globulin were found to be statistically significant but urea, creatinine, prothrombin time, and international normalized ratio were insignificant (P>0.05, NS). Comparison of pre-operative hemoglobin with that at 24, 48, and 72 h in isoflurane cases showed that mean isoflurane was 12.69±1.77 which was found to be nil within 24 h, 48 h, and 72 h. Comparison of various parameters at 24, 48, and 72 h in sevoflurane cases showed that pre-operative mean sevoflurane was 0.49±0.18 which was found to increase within 72 h, that is, 0.60±0.18. Similarly, SGOT was found increased from pre-operative 27.58±8.09 to 29.32±7.32, SGPT 23.29±7.02 to 26.22±6.81. Conclusion: Inhalation agent isoflurane and sevoflurane cause significant changes in patient's liver function test, postoperatively under general anesthesia as indicated by various liver function parameters. [ABSTRACT FROM AUTHOR]

Objectives Demand for rapid coagulation testing for massive transfusion events led to development of an emergency hemorrhage panel (EHP; hemoglobin, platelet count, prothrombin time/international normalized ratio, and fibrinogen), with laboratory turnaround time (TAT) of less than 20 minutes. Ten years on, we asked if current laboratory practices were meeting that TAT goal and differences were evident in TAT between the 2 major institutions in our system. Methods We identified EHPs ordered at our 2 largest hospitals, February 2, 2021, to July 17, 2022, comparing order to specimen draw time, specimen draw to specimen received time, laboratory analytic time, and total TAT results from emergency department and operating room. Site 1 houses a level I trauma center; site 2 includes tertiary care, transplant, and obstetrics services. Results In total, 1137 EHPs were recorded in our study period. Laboratory TAT was significantly faster at site 1 (~14 vs ~27 minutes, P <.01). Average laboratory TAT was under 20 minutes at site 1 but only for 50% of specimens at site 2. Outlier specimens were collection delays at site 1 and specimen processing delays at site 2. Conclusions The EHP can be performed as rapidly as described. However, compromises in laboratory location, available personnel, and processing differences can degrade performance. [ABSTRACT FROM AUTHOR]

In this study, we investigated the feasibility of the Alberta Stroke Program Early CT Score (ASPECTS) and multiphase computed tomography angiography (mCTA) lateral branch circulation grading combined with clinical and laboratory indicators to predict the clinical prognosis of patients with acute ischemic stroke after 90 days. The clinical data of 80 patients with acute anterior circulation ischemic stroke were retrospectively analyzed and divided into the good prognosis (37 cases) and poor prognosis groups (43 cases) according to their clinical function score at 90 days after discharge. Various factors, including basic imaging parameters (ASPECTS), occluded vessel location, affected side location and clinical indicators (time from onset to computed tomography examination, height, weight, body mass index, previous hypertension, and degree of hypertension and diabetes mellitus), laboratory blood rutine, and biochemical tests (white blood count, neutrophil count, lymphocyte count, neutrophil-to-lymphocyte ratio, hematocrit test, platelet count, international normalized ratio, blood glucose, triglycerides, uric acid, and D-dimer) were considered in the analysis. Logistic regression analysis showed that the mCTA score, hypertension, and neutrophil count were significant independent predictors. A nomogram of the mCTA score, hypertension, and neutrophil count may predict functional recovery after 90 days in patients with acute ischemic stroke. • The worse the computed tomography angiography (CTA) collateral circulation, the poorer the prognosis for acute ischemic stroke (AIS) patients. • AIS patients with higher hypertension classification have poorer clinical prognosis. • Increase in neutrophil ratio will lead to a poor clinical prognosis for AIS patients. [ABSTRACT FROM AUTHOR]

In this study we tried to determine the existence of a link between the INR at admission of patients with acute subdural hematomas and their subsequent evolution, the risk of requiring decompressive surgery and the mortality rate. We thus formulate the following questions to be researched, in correlation with the objectives of the study: 1. Does anticoagulant treatment with VKA increase the risk of needing surgery in patients with acute SDH? 2. Are acute subdural hematomas larger in patients anticoagulated with VKA? 3. Is mortality in patients with acute subdural hematomas higher in the case of association with anticoagulant treatment with VKA? MATERIAL AND METHODS: Retrospective study. Inclusion criteria: Patients discharged from the "Neurosurgery" Department of the "Sf. Pantelimon" from Bucharest with the main diagnosis at discharge "Traumatic subdural hemorrhage", identified in the ICD-10 system with code S06.5. Exclusion criteria: - Patients with other post-traumatic intracerebral injuries (lacerations, cerebral contusions, epidural hematomas) that required surgical treatment. - Patients with severe polytrauma. - Patients with severe thrombocytopenia (< 50000 platelets / mmc). - Patients with increased INR due to other causes (hepatopathies, alcoholism, etc.). - Patients with chronic subdural hematomas with rebleeding. Thus, in the interval 01.01.2020 - 31.12.2023 (4 years), after applying the inclusion and exclusion criteria, we obtained a group of 294 patients who had an acute subdural hematoma as their main or secondary diagnosis. Of these, 130, representing 44.2%, underwent a surgical intervention to evacuate the hematoma through craniotomy. Mortality for the entire group was 36.7% (108 deaths). In the case of operated patients, the postoperative mortality was 47.7% (62 deaths out of 130 patients), and in that of conservatively treated patients the mortality from various causes was 28.1% (46 cases out of 164). Having this general information, we began the analysis of the situation of patients who, at the time of the trauma, were under anticoagulant treatment with vitamin K antagonists (Thrombostop or Sintrom). We found 42 such patients, most of them on anticoagulant therapy for atrial fibrillation, but there were also a few cases of valve prostheses. Of these patients, 20 (47.6%) underwent decompression surgery by evacuation of acute HSD. By comparison, 110 patients without anticoagulant treatment out of 252 underwent surgery (43.6%). Only a small difference is observed, at the limit of statistical significance, between the 2 groups, which made us analyze this aspect in more detail. First, we observed the INR in all 42 patients under VKA treatment and found a surprising fact: only 20 patients (47.6%) had an altered INR. Of these, 11 (55%) were operated and 9 (45%) treated conservatively. If we compare these numbers with those of all patients with a normal INR (274 of which 119 were operated on, i.e. 43.4%) we will find a significant difference between the 2 groups, a fact that confirms the assumption that patients with a modified INR and HSD acute have a higher risk of requiring surgery to evacuate the hematoma. Going even further with this analysis, we tracked the indication for surgery in patients on anticoagulant treatment by hematoma size and Glasgow score. Thus, we found that 25 of the 42 (59.5%) anticoagulated patients had an indication for surgical treatment. If we look only at patients with altered INR (20), we find that 16 of them (80%) had a surgical indication. Where does this difference between the surgical indication and the actual number of operations come from? The explanation is simple: 5 patients in the anticoagulant group, all with modified INR (average INR in this group 3.33) and aged over 70 years, were in such a serious condition that they died before they could be operated on, either in the EU or in the ICU, during attempts to stabilize the coagulant balance. At this point in the presentation, we can answer the first question of this study: "Does anticoagulant treatment with VKA increase the risk of requiring surgery in patients with acute SDH?" The answer is yes, provided the treatment is properly administered and changes the INR. If we nuance things a little, we will notice that there are 13 patients with an INR below 3 and 7 with an INR above 3. In the first group, the surgical indication was present in 10 out of 13 patients (76.9%) and in the second in 6 from 7 patients (85.7%), so we can conclude that the higher the INR, the more the subdural hematoma risks to become a surgical lesion. We also analyzed the average thickness of the hematoma in the patients in the group receiving anticoagulant treatment and found a significant difference between the group of patients with normal INR (0.9 cm) and that of patients with modified INR (1.55 cm). And within this group we have a difference between patients with an INR below 3 (1.36 cm) and those with an INR above 3 (2.04 cm). Therefore, the answer to the question: "Are acute subdural hematomas larger in patients anticoagulated with VKA?", is clearly affirmative. Next, we tried to highlight the causal relationship between the INR value at the time of trauma and the mortality rate. Thus, in patients with normal INR, the overall mortality was 33.9% (93 deaths out of 274 cases) and the postoperative mortality was 45.4% (54 deaths out of 119 cases). In those with modified INR, it was 70% (14 deaths out of 20 cases), respectively 63.6% (7 deaths out of 11 cases). Paradoxically, in patients with altered INR operated the mortality is lower than in non-operated ones (7 deaths out of 9 cases i.e. 77.7%), which would suggest that a more aggressive surgical approach could be beneficial in patients with acute subdural hematomas and anticoagulant treatment. Of the 7 patients with INR above 3, the only one who survived was an operated patient. Therefore, the answer to question 3: Is mortality in patients with acute subdural hematomas higher in the case of association with VKA treatment with modified INR? is also affirmative CONCLUSIONS: 1. Properly administered vitamin K anticoagulant treatment resulting in elevated INR increases the risk of patients with acute subdural hematomas, who will be more likely to require decompressive surgery, have larger hematomas, and have a higher mortality rate, regardless of therapeutic conduct. 2. In these patients, early surgical intervention, even if the INR has not been completely brought under control, is a therapeutic approach associated with a lower mortality than conservative treatment until the normalization of the INR. [ABSTRACT FROM AUTHOR]

Background and Objectives: Early initiation and maintenance of anticoagulation appears to be the mainstay of treatment of cerebral venous thrombosis (CVT), but the evidence supporting the intensity and duration of anticoagulation is limited. Methods: We retrospectively collected data of patients admitted with CVT over a 5-year period, who had a minimum of 6 months of clinical follow-up and three or more prothrombin time international normalized ratio (INR) values spread over 6 months. Data collected included demographic, clinical, and radiologic parameters, anticoagulation status during the follow-up, complications, and clinical status at the last follow-up. Results: We identified 204 patients, and the mean age was 34.4 ± 11.1 years. The majority had a provoked etiology (194, 95.1%) for CVT. After initial anticoagulation with unfractionated heparin, all patients transitioned to acenocoumarol or warfarin and this was maintained for a mean duration of 16.02 ± 11.2 months. Time in therapeutic range of INR 2–3 was only 5.1 ± 11.8 percent days and time spent in an INR of 1–1.5 was 68.7 ± 31.8 percent days. The average INR over 6 months was 1.37 ± 0.33. Duration of follow-up was 18.9 ± 13.25 months, and a good outcome was noted in 183 (89.7%) patients. Complications were seen in 29 (14.2%) patients. Multivariate analysis showed only the CVT grading scale score to be an independent predictor of good outcome. Conclusions: Maintenance of an intensive level of anticoagulation may not be required in patients with CVT and may be particularly true when a transient and treatable risk factor is the provoking etiology. [ABSTRACT FROM AUTHOR]

Objective To assess the outcome of patients with cancer-related sepsis requiring continuous renal replacement therapy (CRRT) in a single-center pediatric intensive care unit (PICU). Method Children with sepsis who necessitate CRRT from January 2017 to December 2021 were enrolled. The patients with leukemia/lymphoma or solid tumors were defined as underlying cancer. Multivariate logistic regression analysis was performed to identify the death risk factors in patients with cancer-related sepsis. Results A total of 146 patients were qualified for inclusion. Forty-six (31.5%) patients with cancer-related sepsis and 100 (68.5%) non-cancer-related sepsis. The overall PICU mortality was 28.1% (41/146), and mortality was significantly higher in cancer-related sepsis patients compared with non-cancer patients (41.3% vs. 22.0%, p = 0.016). Need mechanical ventilation, p-SOFA, acute liver failure, higher fluid overload at CRRT initiation, hypoalbuminemia, and high inotropic support were associated with PICU mortality in cancer-related sepsis patients. Moreover, levels of IL-6, total bilirubin, creatinine, blood urea nitrogen, and international normalized ratio were significantly higher in non-survivors than survivors. In multivariate logistic regression analysis, pediatric sequential organ failure assessment (p-SOFA) score (OR:1.805 [95%CI: 1.047–3.113]) and serum albumin level (OR: 0.758 [95%CI: 0.581 -0.988]) were death risk factors in cancer-related sepsis receiving CRRT, and the AUC of combined index of p-SOFA and albumin was 0.852 (95% CI: 0.730–0.974). Conclusion The overall PICU mortality is high in cancer-related sepsis necessitating CRRT. Higher p-SOFA and lower albumin were independent risk factors for PICU mortality. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation is a growing epidemic in Africa. Anticoagulation, considered the backbone for non-valvular atrial fibrillation (NVAF) management, is limited to warfarin as the mainstay of available anticoagulation therapy in most low- and middle-income countries (LMIC). The optimal time in the therapeutic range (TTR) while on warfarin is essential to avoid bleeding and thromboembolic complications. This study assessed anticoagulation control in patients with NVAF on warfarin in Johannesburg, South Africa. Methods: We conducted a cross-sectional retrospective study on patients with NVAF managed in the Division of Cardiology, at a tertiary-level academic centre in Johannesburg, South Africa, between 1 January 2015 and 31 December 2019. Anticoagulation control for patients with NVAF was assessed by calculating the TTR using the Rosendaal method. Results: The study population comprised 177 patients diagnosed with NVAF. The mean age was 65.0 ± 13.1 years. The median TTR among patients with NVAF was 46% [interquartile range (IQR): 8.7–86.0], and 63 (35.6%) patients with NVAF had a TTR ≥ 70% (optimal anticoagulation control). Patients with poor anticoagulation control (TTR < 70%) were on warfarin for a shorter duration compared with those with optimal anticoagulation control [56 days (IQR: 43–84) vs. 70 days (IQR: 56–140), p = 0.0013]. The mean CHA2DS2-VASc score was 4 ± 1.5, and it did not differ between patients with poor or optimal anticoagulation control. Among the 175 patients with available HAS-BLED scores, 21 (12.0%), 112 (64.0%) and 42 (24.0%) were at a low, moderate, and high risk for bleeding, respectively. Of the 21 patients in the HAS BLED low-risk category, only 4 (19.0%) had a TTR < 70% (p < 0.001). Warfarin toxicity was documented in 13 (7.3%) patients. Conclusion: In our study, a TTR ≥ 70%, suggesting optimal anticoagulation control, was found in only 35.6% of patients with NVAF on warfarin. [ABSTRACT FROM AUTHOR]

Massive transfusion of blood products poses challenges in determining the need for transfusion and the appropriate volume of blood products. This review explores the use of machine learning (ML) models to predict transfusion risk during surgical procedure, focusing on the methodology, variables, and software employed to predict transfusion. This scoping review investigates the development and current state of machine learning models for predicting transfusion risk during surgical procedure, aiming to inform physicians about the field's progress and potential directions. The review was conducted using the databases Cochrane, Embase, and PubMed. The search included keywords related to blood transfusion, statistical models, and surgical procedures. Peer-reviewed articles were included, while literature reviews, case reports, and non-human studies were excluded. A total of 40 studies met the inclusion criteria. The most frequently studied biological variables included haemoglobin, platelet count, international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen, creatinine, white blood cells, and albumin. Clinical variables of importance included age, sex, surgery type, blood pressure, weight, surgery duration, american society of anesthesiology (ASA) status, blood loss, and body mass index (BMI). The software employed varied, with Python, R, SPSS, and SAS being the most commonly used. Logistic regression was the predominant methodology used in 20 studies. Our scoping review highlights the need for improved reporting and transparency in methodology, variables, and software used. Future research should focus on providing detailed descriptions and open access to codes of respective models, promoting reproducibility, and enhancing the clinical relevance of transfusion risk prediction models. [ABSTRACT FROM AUTHOR]

This study aimed to ascertain how the current two ART regimens used in Ghana affected HIV patients' coagulation profiles. A case-control study was conducted on 102 HIV positive patients at the Mampong Municipal Hospital. Coagulation parameters measured showed APTT was normal in majority of ART-experienced participants but prolonged in majority of ART-naïve participants. The mean platelet count was significantly higher in ART-experienced participants. No significant differences were found between the coagulation profiles of ART-experienced patients on two different drug regimens. In conclusion, current ART can enhance the coagulation profiles in HIV-infected patients, by improving platelet count and APTT. [ABSTRACT FROM AUTHOR]

This study aimed to identify predictive factors for the prognosis of acute-on-chronic liver disease (AoCLD) due to both hepatitis B virus (HBV) and alcohol and to develop prognostic models to improve treatment management. AoCLD patients with HBV and alcohol as etiological factors were selected from two multicenter prospective cohorts (NCT02457637,NCT03641872) and included in separate training and validation cohorts (n = 180 and n = 148). In the training cohort, the CATCH-LIFE A nomogram (based on age, bilirubin, international normalized ratio, serum sodium, and hepatic encephalopathy score) and CATCH-LIFE B nomogram (based on age, bilirubin, international normalized ratio, serum albumin, white blood cell, platelet count, and hepatic encephalopathy score) had discriminatory ability for predicting 28-day (c-indexes of 0.910 and 0.899) and 90-day mortality (c-indexes of 0.878 and 0.887, respectively). The area under the curve values for 28-day and 90-day mortality prediction by the CATCH-LIFE A nomogram were 0.922 (95% CI : 0.874, 0.971) and 0.905 (0.856, 0.956), respectively, while those for the CATCH-LIFE B nomogram were 0.916(0.861,0.972) and 0.915 (0.866,0.964), respectively. Similar performance results were observed in the validation cohort. Optimal cut-off scores for each nomogram could be used for patient stratification in high- and low-risk groups, and the high-risk groups showed shorter survival times than the low-risk groups in both the training and validation cohorts. Two nomograms constructed from the first short-term follow-up data from patients with AoCLD due to combined HBV infection and alcohol exposure showed good predictive performance for 28-day and 90-day mortality and might be used to guide clinical management. [ABSTRACT FROM AUTHOR]