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Background: Low‐titer group O whole blood (LTOWB) use is increasing due to data suggesting improved outcomes and safety. One barrier to use is low availability of RhD‐negative LTOWB. This survey examined US hospital policies regarding the selection of RhD type of blood products in bleeding emergencies. Study Design and Methods: A web‐based survey of blood bank directors was conducted to determine their hospital's RhD‐type selection policies for blood issued for massive bleeding. Results: There was a 61% response rate (101/157) and of those responses, 95 were complete. Respondents indicated that 40% (38/95) use only red blood cells (RBCs) and 60% (57/95) use LTOWB. For hospitals that issue LTOWB (N = 57), 67% are supplied only with RhD‐positive, 2% only with RhD‐negative, and 32% with both RhD‐positive and RhD‐negative LTOWB. At sites using LTOWB, RhD‐negative LTOWB is used exclusively or preferentially more commonly in adult females of childbearing potential (FCP) (46%) and pediatric FCP (55%) than in men (4%) and boys (24%). RhD‐positive LTOWB is used exclusively or preferentially more commonly in men (94%) and boys (54%) than in adult FCP (40%) or pediatric FCP (21%). At sites using LTOWB, it is not permitted for adult FCPs at 12%, pediatric FCP at 21.4%, and boys at 17.1%. Conclusion: Hospitals prefer issuing RhD‐negative LTOWB for females although they are often ineligible to receive RhD‐negative LTOWB due to supply constraints. The risk and benefits of LTOWB compared to the rare occurrence of hemolytic disease of the fetus/newborn (HDFN) need further examination in the context of withholding a therapy for females that has the potential for improved outcomes. [ABSTRACT FROM AUTHOR]

The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions.

Objective. Temporal trends in admissions for atrial fibrillation (AF) and severe bleeding associated with AF vary worldwide. We aimed to explore their temporal trends in England and their relation to the introduction of DOACs in 2014 in the UK. Design. This longitudinal ecological study utilised aggregated data that was extracted from the Hospital Episode Statistics database, which captured annual admissions for AF and severe bleeding associated with AF between 2001 and 2018. Trends in admissions over the study period and across age groups, gender and regions in England were assessed. Results. In total, there were 11,292,177 admissions for AF and 324,851 admissions for severe bleeding associated with AF. There was a steady rise in admissions for AF from 2001 to 2017 (204,808 to 1,109,295; p for trend<.001). A similar trend was observed for severe bleeding (4940 to 30,169; p for trend <.001), but the increase dropped slightly between 2013 and 2014 and continued thereafter. Conclusions. There was a rise in admissions for AF and severe bleeding in England between 2001 and 2018. There is little evidence that the slight drop in admissions for severe bleeding between 2013 and 2014 may have been caused by the introduction of DOACs in 2014. Contributors to these trends need urgent exploration. [ABSTRACT FROM AUTHOR]

[Display omitted] Rare but critical bleeding events in primary immune thrombocytopenia (ITP) present life-threatening complications in patients with ITP, which severely affect their prognosis, quality of life, and treatment decisions. Although several studies have investigated the risk factors related to critical bleeding in ITP, large sample size data, consistent definitions, large-scale multicenter findings, and prediction models for critical bleeding events in patients with ITP are unavailable. For the first time, in this study, we applied the newly proposed critical ITP bleeding criteria by the International Society on Thrombosis and Hemostasis for large sample size data and developed the first machine learning (ML)-based online application for predict critical ITP bleeding. In this research, we developed and externally tested an ML-based model for determining the risk of critical bleeding events in patients with ITP using large multicenter data across China. Retrospective data from 8 medical centers across the country were obtained for model development and prospectively tested in 39 medical centers across the country over a year. This system exhibited good predictive capabilities for training, validation, and test datasets. This convenient web-based tool based on a novel algorithm can rapidly identify the bleeding risk profile of patients with ITP and facilitate clinical decision-making and reduce the occurrence of adversities. [ABSTRACT FROM AUTHOR]

Severe bleeding is the leading cause of early death in patients with newly diagnosed acute promyelocytic leukemia (APL). However, there are no means for hemorrhagic risk stratification in APL. This study aimed to identify optimized predictors of severe bleeding events related to APL. A total of 109 consecutive patients with newly diagnosed APL from January 2015 to April 2022 were retrospectively investigated. A systematic review of computer-based patient medical records was conducted to obtain clinical date, including baseline characteristics, routine blood examination findings, coagulation and fibrinolysis indexes, and bleeding events. Among the 109 patients, 89 were classified into the no-severe bleeding group, while 20 had severe bleeding. Compared with the patients with no severe bleeding, the patients with severe bleeding had significantly higher circulating leukemic cell percentages, disseminated intravascular coagulation (DIC) scores, D-dimer (D-D) levels, and fibrin degradation product (FDP) levels. They also had lower fibrinogen (FIB) levels and a longer prothrombin time. Multivariate analysis revealed that the circulating leukemic cell percentage (OR = 1.040, CI = 1.008–1.072, P = 0.012), FIB level (OR = 0.101, CI = 0.011–0.896, P = 0.040), and FDP level (OR = 1.012, CI = 1.000–1.024, P = 0.047) were independent risk factors for severe bleeding. FDP/FIB, D-D/FIB, and seven meaningful indicators in the single-factor analysis were included in the receiver operating characteristic (ROC) curve analysis. The results showed that FDP/FIB was the best indicator for predicting severe bleeding related to newly diagnosed APL. The area under the ROC curve of FDP/FIB was 0.915, and the best cutoff value was 61.77, with 100% sensitivity and 74.2% specificity. Statistical analysis showed a higher incidence of severe bleeding and higher DIC scores when FDP/FIB was >61.77 in APL patients. FDP/FIB has obvious advantages in predicting the degree of bleeding associated with primary promyelocytic leukemia; the greater the FDP/FIB value, the more severe the bleeding. The risk of severe bleeding was the highest when FDP/FIB > 61.77. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to determine the safety of direct oral anticoagulants (DOACs) for stroke prevention and treatment in patients with atrial fibrillation (AF). Methods: A systematic search of four databases (PubMed, EMBASE, Web of Science, and Cochrane Library) was performed to identify randomized controlled trials (RCTs) reporting severe bleeding events in patients taking DOACs or vitamin K antagonists (VKAs). In this frequency-based network meta-analysis, odds ratios and 95% confidence intervals were used for reporting. Based on the surface under the cumulative ranking curves (SUCRA), the relative ranking probability of each group was generated. Results: Twenty-three RCTs met the inclusion criteria, and a total of 87,616 patients were enrolled. The bleeding safety of DOACs for stroke prevention and treatment in patients with AF was ranked from highest to lowest as follows: fatal bleeding: edoxaban (SUCRA,80.2), rivaroxaban (SUCRA,68.3), apixaban (SUCRA,48.5), dabigatran (SUCRA,40.0), VKAs (SUCRA,12.9); major bleeding: dabigatran (SUCRA,74.0), apixaban (SUCRA,71.5), edoxaban (SUCRA,66.5), rivaroxaban (SUCRA,22.7), VKAs (SUCRA,15.4); gastrointestinal bleeding: apixaban (SUCRA,55.9), VKAs (SUCRA,53.7), edoxaban (SUCRA,50.5), rivaroxaban (SUCRA,50.4), dabigatran (SUCRA,39.5); intracranial hemorrhage: dabigatran (SUCRA,84.6), edoxaban (SUCRA,74.1), apixaban (SUCRA,65.8), rivaroxaban (SUCRA,24.4), VKAs (SUCRA,1.1). Conclusion: Based on current evidence, for stroke prevention and treatment in patients with AF, the most safe DOAC is edoxaban in terms of fatal bleeding; dabigatran in terms of major bleeding and intracranial hemorrhage and apixaban in terms of gastrointestinal bleeding. However, given the nature of indirect comparisons, more high-quality evidence from head-to-head comparisons is still needed to confirm them. [ABSTRACT FROM AUTHOR]

Despite evolving evidence, the use of direct oral anticoagulants (DOACs) in patients with extremes of body weight remains controversial. This study aimed to measure the impact of DOACs compared to warfarin on safety and efficacy outcomes in extreme body weight patients. This multi-center, health system, retrospective study examined the outcomes of patients with all body weights and extreme body weights prescribed a DOAC (rivaroxaban, apixaban, dabigatran, edoxaban) or warfarin for atrial fibrillation or venous thromboembolism over a 9-year period. The primary outcome was a composite of thromboembolism, symptomatic recurrent VTE, or severe bleeding; analyzed by pre-determined BMI cutoffs. A total of 19,697 patients were included in the study: 11,604 in the DOAC group and in the 8093 in the warfarin group. 295 patients were underweight and 9108 patients were pre-obese to obese class 3. After adjusting for potential confounders, warfarin patients had higher odds of experiencing the composite outcome compared to DOAC patients (OR 1.337, 95% CI 1.212–1.475). Additionally, obese patients were 24.6% more likely to experience the outcome compared to normal BMI patients. Adjusted modeling showed that warfarin patients experienced higher bleed rates compared to DOAC patients (OR 1.432, 95% CI 1.266–1.620). Obese patients were less likely to be diagnosed with a bleed (OR 0.749, 95% CI 0.658–0.854), and underweight patients were more likely to be diagnosed with a bleed (OR 1.522, 95% CI 1.095–2.115) compared to normal BMI patients. In conclusion, DOACs for atrial fibrillation or VTE in patients with extreme body weights appear safe and effective when compared to warfarin. [ABSTRACT FROM AUTHOR]

The incidence of ulcerative colitis is rising among Asian population. Massive bleeding per rectum is an uncommon, but serious, complication of UC accounting for 0.1–1.4 % of admissions. A 22-year-old male, reported persistent abdominal pain, bloody diarrhea, and intermittent vomiting for one week. Physical examination revealed signs of dehydration and pallor. Laboratory tests showed elevated inflammatory markers. CT and colonoscopy confirmed ulcerative colitis, refractory to corticosteroids, leading to a subtotal colectomy followed by Ileal Pouch-Anal Anastomosis. The patient was symptom free at a 24-month follow-up. Bleeding that occurs during the initial stages of the disease or in cases where the diagnosis of ulcerative colitis hasn't been confirmed makes it challenging for patients to accept the need for extensive surgery and the creation of a stoma. Conservative procedures are advised in such settings. Acute severe bleeding in ulcerative colitis is rare but demands a multidisciplinary approach for timely diagnosis and treatment. In resource and expertise limited situation, where patients are noncompliant to regular follow-ups surgical treatment can still be intervention of choice for these cases. • The incidence and prevalence of ulcerative colitis (UC) is increasing in Asia. • Bleeding that occurs in newly diagnosed UC makes it challenging to accept extensive surgery and stoma creation. • In resource limited setting, surgical treatment can be an option for newly diagnosed UC with refractory bleeding. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine the severe bleeding safety of direct oral anticoagulants (DOACs) for the prevention and treatment of venous thromboembolism (VTE). PubMed, EMBASE, Web of Science, and the Cochrane Library databases were searched up to 6 January 2021. The incidence of severe bleeding (major, gastrointestinal [GI], intracranial, and fatal) was investigated. Using frequentist network meta-analysis, interventions that were not compared directly could be compared indirectly by the 95% confidence interval (CI), making the search results more intuitive. Based on surface under the cumulative ranking curves (SUCRA), the relative ranking probability of each group was generated. Thirty-one randomised controlled trials (76 641 patients) were included. For the treatment of VTE, the risk of major bleeding with apixaban was significantly lower than dabigatran (odds ratio [OR] 2.10, 95% CI 1.07 – 4.12) and edoxaban (OR 2.64, 95% CI 1.36 – 5.15). The safety of the drugs was ranked from highest to lowest as follows: major bleeding: apixaban (SUCRA 98.0), rivaroxaban (SUCRA 69.6), dabigatran (SUCRA 50.7), edoxaban (SUCRA 26.5), and vitamin K antagonists (VKAs; SUCRA 5.1); GI bleeding: apixaban (SUCRA 80.7), rivaroxaban (SUCRA 66.8), edoxaban (SUCRA 62.3), VKAs (SUCRA 34.4), and dabigatran (SUCRA 5.8); intracranial bleeding: rivaroxaban (SUCRA 74.4), edoxaban (SUCRA 70.4), dabigatran (SUCRA 58.2), apixaban (SUCRA 44.4), and VKAs (SUCRA 5.6); fatal bleeding: edoxaban (SUCRA 82.7), rivaroxaban (SUCRA 59.2), dabigatran (SUCRA 48.6), apixaban (SUCRA 43.0), and VKAs (SUCRA 16.3). For the prevention of VTE, the risk of major bleeding with apixaban was significantly lower than rivaroxaban (OR 2.14, 95% CI 1.02 – 4.52). Among the four types of bleeding, apixaban had the lowest bleeding risk among DOACs (major bleeding: SUCRA 81.6; GI bleeding: SUCRA 75.4; intracranial bleeding: SUCRA 64.1; fatal bleeding: SUCRA 73.6). For the treatment of VTE, in terms of major bleeding and GI bleeding, apixaban had the lowest bleeding risk; in terms of intracranial bleeding, rivaroxaban had the lowest bleeding risk; in terms of fatal bleeding, edoxaban had the lowest bleeding risk. For the prevention of VTE, apixaban had the lowest bleeding risk. [ABSTRACT FROM AUTHOR]

Acute promyelocytic leukemia (APL) is often accompanied by potentially fatal coagulopathy, especially in high-risk APL. Bleeding, particularly severe bleeding is the leading cause of early death (ED). Meanwhile, thrombosis, the other major coagulopathic complication, is being increasingly recognized. However, predictors of thrombohemorrhagic disorders are still not well investigated. In this study, we retrospectively studied 83 patients with high-risk APL and categorized them into severe bleeding, thrombosis and no evident events groups. Severe bleeding was observed in 15 patients, nearly half of whom died of hemorrhage, while thrombosis was observed in 12 patients. Risk factor analysis showed that high WBC (>58.76 × 109/L) (p = 0.001) and prolonged PT (>17.7 s) (p = 0.015) could be independent predictors for severe bleeding, while high WBC/D-dimer>5.12 (p = 0.002) and low D-dimer/FIB<5.14 (p = 0.03) could be independent predictors for thrombosis in high-risk APL patients. Moreover, there are significant differences in WBC/D-dimer and D-dimer/FIB between DIC and Non-DIC groups (p < 0.001). Notably, we found that the WBC/D-dimer was dramatically higher in the thrombotic group than in the other two groups at the time of admission or during the first week of induction therapy. High WBC and prolonged PT could predict severe bleeding in high-risk APL patients, while high WBC/D-dimer and low D-dimer/FIB could be independent predictors for thrombosis. For high-risk APL, WBC/D-dimer and D-dimer/FIB are also beneficial in the diagnosis of DIC. WBC/D-dimer might help early identification of thrombosis at the time of admission or during the first week of induction therapy. • High WBC and prolonged PT could predict severe bleeding in high-risk APL patients. • WBC/D-dimer and D-dimer/FIB can be beneficial for early identification of thrombosis and the diagnosis of DIC. • PT, D-dimer, FDP/FIB, D-dimer/FIB and WBC/D-dimer could differentiate severe hemorrhage from thrombosis. • WBC/D-dimer might help early identification of thrombosis at admission or during the first week of induction therapy. [ABSTRACT FROM AUTHOR]

Abstract Background Renal arteriovenous fistula was rarely reported in retrograde endoscopic procedure. Up to now, there is still an absence of report on the formation of renal arteriovenous fistula after semi-rigid ureteroscopic lithotripsy for lower ureteral stones. Case presentation An 83-year-old man was admitted to our hospital complaining about intermittent left flank pain that had persisted for 1 week. He suffered medium hypertension and nephrolithiasis treated with left open ureterolithotomy and two ureteroscopic lithotripsies. Non-contrast abdominal CT scan revealed two left lower ureteral stones diametered 8 mm and 7 mm respectively with mild hydronephrosis. A retrograde semi-rigid ureteroscopic lithotripsy was performed to remove the stones, after which two Double-J stents were placed for the ureteral stricture. Due to the continuous gross hematuria and hemoglobin droppings 2 days after operation, a variety of conservative therapies, including blood transfusion and bed rest, were adopted. Then, the patient was discharged with a stable hemoglobin. However, he presented himself to our emergency department with aggravating left flank pain and severe gross hematuria as little as 2 days later. Emergent digital subtraction angiography was conducted to reveal an arteriovenous fistula in the left kidney, which was embolized with two platinum coils to stop the bleeding. His hematuria was resolved in 3 days, and two Double-J stents were removed in 4 weeks. The patient was followed up for 1 year, during which no hematuria or flank pain recurred. Conclusion This is the first case report on the formation of renal arteriovenous fistula after semi-rigid ureteroscopic lithotripsy. In this case, elevated intrapelvic pressure, historical surgery and hydronephrosis might be associated with the primary risk of the complication.

Purpose of review: Recurrent stroke after ischemic stroke (IS) or high-risk transient ischemic attack (TIA) increases morbidity and mortality. Secondary stroke prevention strategies include modification of behavioral and vascular risk factors and antithrombotic use, including single or dual antiplatelet therapy (DAPT). In this review, we focus on DAPT indications, combinations, and treatment duration. Recent findings: Studies showed that for patients with mild to moderate non-cardioembolic strokes or those with symptomatic intracranial or mild extracranial stenosis (≤ 30% diameter reduction), short-term DAPT (21–90 days) with aspirin plus clopidogrel, compared with mono-antiplatelet therapy (MAPT), decreases recurrent stroke risk without significantly increasing major bleeding risk. The combination of aspirin plus extended release dipyridamole or cilostazol may confer decrease of risk for recurrent stroke with long-term use, at the expense of increasing major bleeding risk. Treatment with aspirin plus ticagrelor for a short time period is superior to aspirin monotherapy for decreasing risk for recurrent stroke, but significantly increases the risk for major bleeding. Summary: Short-term DAPT with aspirin plus clopidogrel, compared with MAPT, decreases risk for recurrent stroke without increasing major bleeding risk. Short-term DAPT with aspirin plus ticagrelor also reduces risk for recurrent stroke, but with a significant increase in the risk of major bleeding, compared with MAPT. Direct comparisons among different DAPT regimens are currently underway. [ABSTRACT FROM AUTHOR]

Severe bleeding is a major cause of death in acute leukemia (AL) patients with graft-versus-host disease (GVHD) after allogene hematopoietic stem-cell transplantation (allo-HSCT). However, the prognostic value and prediction of HSCT-associated severe bleeding in GVHD patients have not been reported in cohort studies. We did a retrospective analysis of 200 AL patients with GVHD after allo-HSCT from Feb 1, 2014, to Dec 1, 2015. Multivariate analysis showed that the severe bleeding class was associated with the risk of death (HR 2.26, 95% CI 1.31–3.92, p<0.001***). In order to predict severe bleeding and figure out the solution to bleeding events, we established a multiple logistic regression model. HLA-DQB1 unmatching, megakaryocyte reconsititution failure, and III or IV GVHD were the independent risk factors for severe bleeding. Among all the variations above, OR of HLA-DQB1 was the highest (OR: 16.02, 95% CI: 11.54–48.68). Adding HLA-DQB1 to other factors improved the reclassification for predicting severe bleeding (NRI=0.195, z=2.634, p=0.008**; IDI=0.289, z=3.249, p<0.001***). Lasso regression was used to select variants. A nomogram of the logistic model was generated and displayed. Calibration curve demonstrated excellent accuracy in estimating severe bleeding (C index of 0.935). HLA-DQB1 showed excellent efficacy of predicting severe bleeding in HSCT patients. [ABSTRACT FROM AUTHOR]

To determine the relationship between the value of fibrinogen assessed by the FIBTEM clot amplitude at 10 minutes (A10 FIBTEM) measured on admission to the intensive care unit (ICU) and the amount of drainage output at 24 hours, to investigate whether the A10 FIBTEM predicts severe bleeding (SB), and to define A10 FIBTEM thresholds to prevent (trigger) and treat (target) severe bleeding by fibrinogen supplementation. In a single centre, retrospective observational study, 166 patients underwent elective open thoraco-abdominal aortic aneurysm (TAAA) repair between March 2016 and January 2019. Exclusion criteria were emergency, congenital, or acquired coagulopathy, or administration of P 2 Y 12 inhibitor antiplatelet agents in the five days before surgery. All patients were managed intra-operatively and post-operatively according to a rotational thromboelastometry driven transfusion protocol. The principal endpoint was a composite outcome, which included bleeding, large volume transfusion, and re-operation. FIBTEM clot amplitude after 10 minutes measured on ICU admission and post-operative bleeding at 24 hours showed an inverse linear relationship (R2 =.03; p =.026). Performance of A10 FIBTEM in predicting SB evaluated by Receiving Operating Curve analysis showed an area under the curve of 0.63 (95% CI 0.56 – 0.70; p =.026) with a best cutoff of 9 mm. An A10 FIBTEM of 3 mm was the cutoff associated with a positive predictive value of 50%, while an A10 FIBTEM of 9 mm showed a negative predictive value of 92%. On multivariable analysis, an A10 FIBTEM ≤ 3 mm remained independently associated with SB. The present investigation shows for the first time in a population undergoing open TAAA repair that an A10 FIBTEM ≤ 3mm on ICU admission is associated with post-operative severe bleeding. Trigger and target values for fibrinogen supplementation, based on A10 FIBTEM, have been provided. The transferability and reliability of these cutoff values require further study. [ABSTRACT FROM AUTHOR]

Background/Aims: The prevalence of acute lower gastrointestinal bleeding (ALGIB) has progressively increased worldwide but there are few studies in Asian populations. This study aimed to develop and validate a scoring system to predict severe ALGIB in Vietnamese. Methods: Risk factors for severe ALGIB were identified by multiple logistic regression analysis using data from a retrospective cohort of 357 patients admitted to a tertiary hospital. These factors were weighted to develop the severe acute lower gastrointestinal bleeding (SALGIB) score to predict severe ALGIB. The performance of SALGIB was validated in a prospective cohort of 324 patients admitted to 6 other hospitals using area under the receiver operating characteristics curve (AUC) analysis. Results: There were four factors at admission independently associated with severe ALGIB in the derivation cohort: heart rate ≥ 100/min, systolic blood pressure < 100 mmHg, hematocrit < 35%, and platelets ≤ 150 × 103/µL. The SALGIB score determined severe ALGIB with AUC values of 0.91 and 0.86 in the derivation and validation cohorts, respectively. A SALGIB score < 2 associated with low risk of severe ALGIB in both cohorts (3.7% and 1.2%; respectively). Conclusions: The SALGIB score has good performance in discriminating risk of severe ALGIB in Vietnamese. [ABSTRACT FROM AUTHOR]

Background: Bronchiectasis is a chronic inflammation of the bronchi with recurrent infections and hemoptysis. The MAGELLAN study compared oral rivaroxaban, 10 mg once daily (QD), for 35 ± 4 days with subcutaneous enoxaparin 40 mg QD for 10 ± 4 days followed by placebo for 25 ± 4 days to prevent venous thromboembolism in patients hospitalized with an acute medical illness. MAGELLAN included a subset of patients with bronchiectasis. In a post hoc analysis, we evaluated the incidence and severity of pulmonary bleeding in patients with bronchiectasis who were hospitalized for an acute medical illness. This analysis included MAGELLAN patients diagnosed with bronchiectasis at baseline. Patients were evaluated by treatment group for International Society on Thrombosis and Haemostasis major bleeding, non-major clinically relevant (NMCR) bleeding, and the composite of the 2 (ie, clinically relevant bleeding). Results: Medically ill patients with bronchiectasis were randomized to rivaroxaban (n = 60) or enoxaparin/placebo (n = 61). There were 2 fatal pulmonary bleeds and 1 fatal gastrointestinal bleed in the rivaroxaban arm and no fatal or major bleeding in the enoxaparin/placebo arm. The incidence of major bleeding was 5% in the rivaroxaban arm. One NMCR bleed occurred in the rivaroxaban arm and 2 NMCR bleeds occurred in the enoxaparin/placebo arm. The incidence of clinically relevant bleeding was 6.7% versus 3.3% in the rivaroxaban and enoxaparin/placebo groups, respectively (relative risk = 2.06 [95% confidence interval: 0.351-12.046]). Conclusion: In-patients hospitalized with bronchiectasis and an acute medical illness, clinically relevant bleeding, including fatal pulmonary hemorrhage, occurs more frequently with extended rivaroxaban thromboprophylaxis than with enoxaparin followed by placebo. [ABSTRACT FROM AUTHOR]

The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions., Competing Interests: Conflicts of interest None., (Copyright © 2024. Published by Elsevier España, S.L.U.)

Background: Heterotopic pregnancy is the condition in which intrauterine and ectopic pregnancy coexist. The conservative management of the ectopic pregnancy, with the intrauterine pregnancy preserved, has been reported. Case(s): Here, we report a very rare case: intrauterine and cervical pregnancy coexist: intrasacular Potassium chloride (KCL) injection successfully terminated cervical pregnancy with intrauterine pregnancy preserved, but later massive bleeding occurred from the cervix. A 39-year-old woman at 7+1 weeks was diagnosed with a heterotopic cervical gestation, with intrauterine and cervical sac, both with live embryos. The ectopic pregnancy was successfully terminated with intrasacular injection of KCl, preserving the intrauterine pregnancy. At 32+4 weeks of gestation the patient started with a profuse bleeding from the cervical sac, causing maternal hypotension (80/45 mmHg) and tachycardia (160 bpm) and a decelerative pattern in the cardiotocographic fetal monitoring, prompting us to perform caesarean section. The cessation of bleeding was achieved using a double balloon intracervical catheter, which was withdrawn 24 hours after its insertion without observing a new bleeding episode. The patient was discharged after 8 days and the newborn after 35 days of life, both in good health. Conclusions: Conservative treatment of a heterotopic gestation is possible, managing to preserve the viability of the intrauterine pregnancy.

Objectives: The aim of this study was to evaluate the characteristics of the renal arterial segment bleeding and assess the outcome of selective renal artery embolization (SRAE). Methods: Data on 35 patients in whom SRAE was performed after percutaneous nephrolithotomy (PCNL) from January 2005 to December 2015 in our institute were retrospectively analyzed. All patients had severe bleeding but failed to respond to conservative therapy. Results: Forty-four SRAEs were performed in 35 patients (36 kidney units) after PCNL. The findings of 44 renal arteriographies before embolization revealed bleeding in 44 renal artery branch segments. Upper artery segment bleeding in 0, upper and anterior segment bleeding in 3, lower and anterior artery segment bleeding in 6, lower artery segment bleeding in 9, posterior artery segment bleeding in 24, and negative finding in 2 patients. Renal arteriography revealed pseudoaneurysms in 20 (45.5%) patients, arteriovenous fistulas in 6 (13.6%) patients, renal artery branch laceration in 16 (36.4%) patients, and negative angiography finding in 2 (4.5%) patients. Acute bleeding in 7 patients (20.0%) and delayed bleeding in 28 patients (80.0%) were observed. The target vascular lesions were successfully treated by embolization in the first time in 28 cases. Six patients underwent 2 sessions and 1 had 3 sessions. New vascular lesions were the most common cause of failure of initial SEAE in our hospital. Abnormal renal function was observed in 5 patients, and they recovered to preoperative or normal level within 3 weeks. Conclusions: The posterior artery segment of the kidney is the most common bleeding site due to the choice of puncture site. Delayed bleeding (>24 h) was the most common type of bleeding. SRAE is an effective and safe method to treat the severe bleeding after PCNL. [ABSTRACT FROM AUTHOR]

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Purpose: To investigate risk factors for severe bleeding during warfarin treatment, including the influence of sex, age, comorbidity and co-medication on bleeding risk. Methods: Patients initiating warfarin treatment between 2007 and 2011 were identified in the nationwide Swedish Prescribed Drug Register, and diagnoses of severe bleeding were retrieved from the National Patient Register. Hazard ratios (HR) with 95% confidence intervals (CI) for severe bleeding were estimated using multiple Cox regression adjusting for indications and including covariates age, sex, comorbidities and co-medications. Interactions between sex and other covariates were investigated. Results: The study cohort included 232,624 patients ≥ 18 years (101,011 women and 131,613 men). The incidence rate of severe bleeding was 37 per 1000 person-years, lower among women than men with an adjusted HR (95% CI) of 0.84 (0.80–0.88). Incidence of bleeding increased with age, HR 2.88 (2.37–3.50) comparing age ≥ 80 to < 40 years, and comorbidities associated with the highest risk of severe bleeding were prior bleeding, HR 1.85 (1.74–1.97); renal failure, HR 1.82 (1.66–2.00); and alcohol dependency diagnosis, HR 1.79 (1.57–2.05). Other comorbidities significantly associated with bleeding events were hypertension, diabetes, peripheral vascular disease, congestive heart failure, liver failure, stroke/TIA, COPD and cancer. Conclusion: Most of the well-established risk factors were found to be significantly associated with bleeding events in our study. We additionally found that women had a lower incidence of bleeding. Potential biases are selection effects, residual confounding and unmeasured frailty. [ABSTRACT FROM AUTHOR]

Introduction: Bleeding in the context of critical illness must be distinguished from critical (or major) bleeding, although the two circumstances are often conflated. Recent comprehensive guidelines exist for both circumstances. We will concentrate exclusively on major bleeding. Research programs ranging from preclinical studies to multicenter randomized trials with patient-centered outcomes are underway to address identified knowledge gaps. However, some questions that are highly relevant to clinicians—e.g. identifying when the benefit of transfusion (of red blood cells [RBCs], clotting factors, or platelets) outweighs the risk, or when to change from a pro- to an anti-thrombotic strategy, are unlikely to be answered using currently available technology. Such questions are likely to require cost-effective, rapid, and repeatable diagnostic tests for individual patients, validated in studies that pair testing with interventions. Further, many current trial designs seem unlikely to succeed, which aim to observe the effect of an intervention applied in the first few hours of a patient’s treatment through the subsequent ‘noise’ of the next 90 days or 6 months when allcause mortality is assessed. The two major challenges in this field are personalizing interventions and seeking meaningful outcomes plausibly amenable to improvement. The purpose of this study is to investigate the value of administering platelets, whole blood versus separated blood components, fibrinogen versus cryoprecipitate, starting empiric therapy with fibrinogen, prothrombin complex, and other coagulation factors (usually in combination with crystalloids) in Versus Fresh-Frozen Plasma (FFP), lyophilized plasma versus FFP, as well as the value of viscoelastic testing in critically ill patients with severe bleeding. In this study, the available evidence will be presented and the reasons for the uncertainty will be determined. Trials currently underway will be reviewed, followed by a discussion of what innovations in study design might lead to better guidance for clinicians. [ABSTRACT FROM AUTHOR]

Aim: The purpose of this study was to evaluate the complications and reproductive outcome after uterine artery embolization (UAE) for retained products of conception (RPOC). Methods: This was a retrospective medical‐records review study of 57 women treated for RPOC. Participants were divided into two groups: women who underwent treatment with UAE (UAE group: n = 32, 56.1%) and those without UAE (control group: n = 25, 43.9%). The complications and reproductive outcomes were compared between the two groups. Information on subsequent pregnancies and their outcomes was available for 30 women who attempted to conceive. Results: There were no significant differences in the interval from the last delivery or abortion (40.1 ± 3.4 vs 51.0 ± 5.1 months, respectively; P = 0.16), the rate of severe bleeding under hysteroscopy (18.5 vs 9.1%, respectively; P = 0.65), the conception rate (58.8 vs 61.5%, respectively; P = 1.0) and mean time to conception (9.9 ± 1.6 vs 11.0 ± 2.9 months, respectively; P = 0.17) in women in the UAE group compared with those in the control group. Rates of post‐partum hemorrhage (PPH) and manual removal of placenta (25.0% in the UAE group and 16.7% in the control group, respectively) were higher than the general population. Conclusion: Selective UAE for RPOC may be a preferable procedure in women who are suspected as having a risk of severe bleeding under treatment. Women who were treated for RPOC, regardless of UAE, were at risk of PPH and difficulty in removing the placenta in future pregnancies. [ABSTRACT FROM AUTHOR]

Introduction Severe bleeding with platelet transfusion refractoriness (PTR) is a common complication associated with reduced survival in patients with hematologic malignancies. The present study aimed to evaluate the efficacy of recombinant factor VIIa (rFVIIa) for severe bleeding complicated by PTR. Materials and methods Sixty-four patients suffering from severe bleeding with PTR hospitalized in our center between September 2012 and December 2016 were enrolled in this study. Thirty-two patients received rFVIIa (rFVIIa group) and other conventional hemostatic treatments, while the other 32 patients received conventional hemostatic treatments other than rFVIIa (control group). Results The baseline parameters of patients before treatment were similar in both groups. The total response rates to hemostatic treatment at 24 h and 48 h were significantly higher in the rFVIIa group compared with the control group (p = 0.014, p = 0.020, respectively). Significantly more patients in the rFVIIa group achieved complete responses (CR) at 24 h (p = 0.031), 48 h (p = 0.039), and 72 h (p = 0.021) compared with the control group. The bleeding score (p = 0.029), time to control bleeding (p = 0.034), and activated partial thromboplastin time (p = 0.021) after hemostatic treatment were significantly lower in the rFVIIa group compared with the control group. Patients who achieved a CR to rFVIIa had a significant survival advantage compared with those with a partial response/no response (p = 0.020). No complications with venous or arterial thromboembolism were observed during treatment. Conclusions rFVIIa may provide effective and safe hemostasis in patients suffering from severe bleeding and PTR. [ABSTRACT FROM AUTHOR]

To determine the indicators of severe bleeding in children with severe dengue viral infection (DVI), the medical records of patients aged <15 years admitted to Songklanagarind Hospital in southern Thailand during 1989-2011 were reviewed. Severe-bleeding DVI was defined as needing blood products transfusion owing to DVI-caused bleeding. Of the 238 children with severe DVI according to the World Health Organization 2009 criteria, 44 (18.5%) had severe bleeding, of whom 28 (63.6%) died. The international normalized ratio (INR) had high correlations with both transaminase enzymes (Spearman correlation, rs = 0.67-0.69, p <0.01). Multivariate analysis found that patients who had dengue haemorrhagic fever (DHF) grade IV, platelets <20 000/mm3 and INR ≥ 1.5 had increased risk of severe bleeding with odds ratios (95% confidence intervals) of 3.4 (1.4, 8.6), 2.6 (1.1, 6.2) and 10.6 (4.0, 28.4), respectively. Blood products should be at hand in severe DHF children with high risk of severe bleeding. [ABSTRACT FROM AUTHOR]

Background The prognosis for patients with severe acute lower intestinal bleeding (ALIB) may be assessed by complex artificial neural networks (ANNs) or user-friendly regression-based models. Comparisons between these modalities are limited, and predicting the need for surgical intervention remains elusive. We hypothesized that ANNs would outperform the Strate rule to predict severe bleeding and would also predict the need for surgical intervention. Methods We performed a 4-y retrospective analysis of 147 adult patients who underwent endoscopy, angiography, or surgery for ALIB. Baseline characteristics, Strate risk factors, management parameters, and outcomes were analyzed. The primary outcomes were severe bleeding and surgical intervention. ANNs were created in SPSS. Models were compared by area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals. Results The number of Strate risk factors for each patient correlated significantly with the outcome of severe bleeding ( r = 0.29, P < 0.001). However, the Strate model was less accurate than an ANN (AUROC 0.66 [0.57-0.75] versus 0.98 [0.95-1.00], respectively) which incorporated six variables present on admission: hemoglobin, systolic blood pressure, outpatient prescription for Aspirin 325 mg daily, Charlson comorbidity index, base deficit ≥5 mEq/L, and international normalized ratio ≥1.5. A similar ANN including hemoglobin nadir and the occurrence of a 20% decrease in hematocrit was effective in predicting the need for surgery (AUROC 0.95 [0.90-1.00]). Conclusions The Strate prediction rule effectively stratified risk for severe ALIB, but was less accurate than an ANN. A separate ANN accurately predicted the need for surgery by combining risk factors for severe bleeding with parameters quantifying blood loss. Optimal prognostication may be achieved by integrating pragmatic regression-based calculators for quick decisions at the bedside and highly accurate ANNs when time and resources permit. [ABSTRACT FROM AUTHOR]

Background: Fibrinogen and prothrombin have been suggested to become rate limiting in trauma associated coagulopathy. Administration of fibrinogen is now recommended, however, the importance of prothrombin to patient outcome is unknown. Methods: We have utilized two trauma patient databases (database 1 n = 358 and database 2 n = 331) to investigate the relationship of plasma prothrombin concentration on clinical outcome and coagulation status. Database 1 has been used to assess the relationship of plasma prothrombin to administered packed red blood cells (PRBC), clinical outcome and coagulation biomarkers (Prothrombin Time (PT), ROTEM EXTEM Coagulation Time (CT) and Maximum Clot Firmness (MCF)). ROC analyses have been performed to investigate the ability of admission coagulation biomarkers to predict low prothrombin concentration (database 1), massive transfusion and 24 h mortality (database 1 and 2). The importance of prothrombin was further investigated in vitro by PT and ROTEM assays in the presence of a prothrombin neutralizing monoclonal antibody and following step-wise dilution. Results: Patients who survived the first 24 h had higher admission prothrombin levels compared to those who died (94 vs.67 IU/dL). Patients with lower transfusion requirements within the first 24 h (⩽10 units of PRBCs) also had higher admission prothrombin levels compared to patients with massive transfusion demands (>10 units of PRBCs) (95 vs.62 IU/dL). Admission PT, in comparison to admission ROTEM EXTEM CT and MCF, was found to be a better predictor of prothrombin concentration <60 IU/dL (AUC 0.94 in database 1), of massive transfusion (AUC 0.92 and 0.81 in database 1 and 2 respectively) and 24 h mortality (AUC 0.90 and 0.78 in database 1 and 2, respectively). In vitro experiments supported a critical role for prothrombin in coagulation and demonstrated that PT and ROTEM EXTEM CT are sensitive methods to measure low prothrombin concentration. Discussion: Our analyses suggest that prothrombin concentration at admission is predictive of mortality and transfusion and indicates that prothrombin and fibrinogen are rate limiting in coagulopathy. Conclusions: Admission PT is predictive of low prothrombin concentration and clinical outcome. PT could therefore be used as a surrogate for prothrombin concentration and further evaluation of point-of-care devices for faster PT analysis is warranted. [ABSTRACT FROM AUTHOR]