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McCahill, Laurence E., Sunil Konduri, Alan T. Davis, Mary May, Coralyn Martinez, Wendy K. Taylor, and Gerald P. Wright. "Quality of gastrointestinal cancer care at a community hospital under the paradigm of multidisciplinary care." Journal of Clinical Oncology 30, no. 4_suppl (February 1, 2012): 133. http://dx.doi.org/10.1200/jco.2012.30.4_suppl.133.
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133 Background: Benefits of MDC have been established for other cancers but not GI malignancies. Benefits of GI NDC cancer care for underserved populations is yet to be quantified. Our GI-MDC was established to provide efficient, evidenced-based, high quality cancer care to patients of all ethnic and socioeconomic backgrounds. Methods: We prospectively identified underserved patients in seven categories. A GI nurse navigator (NN) contacted patients, coordinated appointments /diagnostic studies and prepared for prospective case evaluation and weekly multidisciplinary GI clinic. Health care efficiency/quality data was abstracted by an R.N. quality analyst. Outcomes were compared between underserved and non-underserved populations. Percentages were compared using Chi square and medians by Mann-Whitney U test. Results: From Jan 2010-July 2011, 208 patients were evaluated, with 137 confirmed new cancers, clinically estimated as Stage I=31, II=30, III=26, and IV=47. Among underserved patients, categories included age >80(n=26), public aid (n=28), uninsured (n=12), mental disability/impairment (n=15), incarcerated/institutionalized (n=4), and language barrier (n=2), more then one category could be selected. Outcomes are listed in the Table. Conclusions: A model of GI cancer care including a GI NN, treatment planning conference, and MDC clinic is feasible in a community cancer center. Preliminary data demonstrates small differences between underserved and non underserved patient populations. This model of health care may help to reduce disparities in cancer care. [Table: see text]
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BAWANY, MUHAMMAD ADNAN, JAHANGIR LIAQUAT, MUHMMAD AKBER, Falak Naz, Shereen Rahat Khanzada, Adnan Ali Khahro, and Saeed Arain. "CIRRHOTIC PATIENTS;." Professional Medical Journal 20, no. 06 (December 15, 2013): 876–81. http://dx.doi.org/10.29309/tpmj/2013.20.06.1732.
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Objective: To determine the frequency of upper GI bleeding and its predicting factors and esophageal varices in the patientswith liver cirrhosis disease admitted at medicine ward of Isra university hospital. Design: Prospective and observational study. Setting:Isra university hospital. Period: March 2012 to August 2012 (six months). Methods: Containing 100 patients, mean age was 45.8, and allthe patients with cirrhosis disease were included in this study with liver cirrhosis disease. All patients were under went endoscopy andFrequency of upper GI bleeding and varices presentation and classification according to grade were noted. Results: All the 100 patientswere selected on the basis of presenting liver cirrhosis disease. Male were more found than the female with the mean age 45.8. Mostlycirrhotic patients were found with HCV positive and upper GI bleeding were noted in (40%) of the cases. With the endoscopic findingmostly patients were noted in ll - lll grad of esophageal varices and according to child pug classification majority of patients was noted inclass “C” In addition, thrombocytopenia and red wale markings along with the presence of large sized varices were associated with thepresence of esophageal varices. Conclusions: In the conclusion of this study we found majority of the cirrhotic patients with HCV,Esophageal varices and thrombocytopenia are the important factors of upper GI bleeding. Knowledge and etiology of this manuscript mayhelpful in the prevention of oesophageal varices and upper GI bleeding.
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Snelling, S., R. Ghaffar, and ST Ward. "CT angiograms for lower GI bleeding: the experience of a large UK teaching hospital." Annals of The Royal College of Surgeons of England 104, no. 2 (February 2022): 100–105. http://dx.doi.org/10.1308/rcsann.2021.0127.
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Introduction The clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or ‘blush’ and to determine any association between positive CT-A with various patient and clinical characteristics. Methods A retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans. Results In total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A. Conclusion In our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging.
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Khoury, Leen, David Hill, Miroslav Kopp, Melissa Panzo, Tushar Bajaj, Carson Schell, Andrew Corrigan, Ryan Rodriguez, and Stephen M. Cohn. "The Natural History of Gastrointestinal Bleeding in Patients without an Obvious Source." American Surgeon 84, no. 8 (August 2018): 1345–49. http://dx.doi.org/10.1177/000313481808400850.
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With the advent of proton pump inhibitors and H. Pylori treatment, the old dogma “the most common cause of lower GI bleeding is upper GI bleeding” may no longer be valid. We sought to determine the most common causes of GI bleeding in patients without an obvious source and their clinical outcomes. We queried our hospital database for GI hemorrhage during 2015, excluding patients with obvious sources such as hematemesis or anal pathology. We collected data from patients with GI bleeding defined as bright red blood per rectum, melena, or a positive fecal occult blood test. The primary endpoints were etiology of GI bleed, amount of transfusions required, and types of interventions performed. Ninety-three patients were admitted with GI bleeding as defined previously: mean age was 74 years and mean hemoglobin was 8.2. Seventy-four per cent received blood transfusions with an average of 2 units transfused per patient; 22 per cent received 3 or more units of blood. The etiology of bleeding was 17 per cent upper GI source, 15 per cent lower GI source, and in 68 per cent, the source remained unknown. Bleeding stopped spontaneously in 86 per cent of patients and 9 per cent died. Endoscopy was performed in 71 per cent, but only 6 per cent underwent therapeutic endoscopic intervention. No patient had surgical or interventional radiologic procedures related to their GI bleed. Gastrointestinal bleeding, without an obvious source on presentation, rarely requires operative intervention or interventional radiologic procedure. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6 per cent of patients.
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Badiger, Raju H., Santosh Hajare, Ravindra Kantamaneni, Ashray Kole, and Deebanshu. "Etiological profile of patients presenting with lower gastrointestinal bleeding at tertiary care hospital at Belagavi: a cross sectional study." International Journal of Advances in Medicine 4, no. 5 (September 22, 2017): 1429. http://dx.doi.org/10.18203/2349-3933.ijam20174297.
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Background: Lower gastrointestinal bleeding (LGIB) is bleeding arising below the ligament of Treitz. Hemorrhage from the lower gastrointestinal (GI) tract accounts for about 20% of all cases of acute GI bleeding. Lower GI bleeding is that which occurs from the colon, rectum, or anus, and presenting as either hematochezia (bright red blood or red wine color stools) or malena, blood streaking of the stool. The objective of this study was to evaluate the etiological profile of patients presenting with lower gastrointestinal bleeding.Methods: This one-year cross-sectional study was conducted in the Department of Medicine, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi from January 2015 to December 2015. The study design was a cross-sectional study. This study was carried out from January 2015 to December 2015. Patients with lower gastro-intestinal bleeding presenting at Department of Medicine and Department of Gastro-enterology, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi were studied.Results: In the present study majority of the patients were males with the mean age was 43.82±17.96 years and majority of the patients were married with moderate built and nourishment. As per the occupation majority were housewives followed by students. In the present study diabetes mellitus was the most common medical history reported. Internal haemorrhoids was significantly associated with male sex, student’s profession followed by housewife with mixed diet consumption, the clinical presentations significantly associated with internal haemorrhoids were haematochezia, loss of appetite, tenesmus, passage of mucus in stools, constipation, abdominal pain and vomiting.Conclusions: Internal hemorrhoids is the most common cause followed by ulcerative colitis. Though not common, carcinoma colon, solitary rectal ulcer syndrome, polyp, colonic diverticulosis, ischaemic colitis, non-specific proctitis, and radiation proctitis are the other causes of LGIB.
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Nadeem, Shoket, Kumar Dinesh, Zargar Tasneef, Sahni Bhavna, Sharma Rahul, and Bala Kiran. "Dietary risk factors in gastrointestinal cancers: A case–control study in North India." Journal of Cancer Research and Therapeutics 19, no. 5 (2023): 1385–91. http://dx.doi.org/10.4103/jcrt.jcrt_1830_21.
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ABSTRACT Background: One-third of all cancer deaths are preventable by alterations in diet. Methods: A case control study was conducted in a Regional Cancer Center in North India to evaluate the relationship of diet with selected gastrointestinal cancers. A total of 171 cases, 151 hospital controls, and 167 healthy controls were interviewed using food frequency questionnaire. Data was analyzed using odds ratio with 95% confidence interval and Chi-square test. Results: Two to three times increased risk of GI cancers was observed with hot and salted tea. Alcohol [OR 2.30 (1.32-4)] and smoking [OR (2.77 (1.77-4.33)] emerged as risk factors in healthy controls among whom freshly prepared food had significant protective effect [OR 0.57 (0.37-0.88)]. Sweet tea showed protective effect in hospital and healthy controls (OR 0.33 and 0.26, respectively). NSAIDS was associated with significantly higher risk of GI cancers. Consumption of dietary fibers decreased risk, which was significant for wheat and pulses but insignificant for rice. Vegetables and fruits showed significant protective effect ranging from 20 to 80% while intake of non-vegetarian foods showed significantly higher odds among controls (OR 2.37–13.4). Odds of GI cancer cases having consumed chutneys and pickles were significantly higher in comparison to healthy controls while consumption of dairy products showed protection. Low and medium intake of mixed spices inclusive of curcumin showed protection (OR 0.13 and 0.39, respectively) while intake of red chillies was associated with 2–30 times significantly higher odds. Conclusions: We have been able to generate baseline evidence of association between diet and selected GI cancers to encourage prevention and further research.
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Alam, Md F., AKM S. Kabir, and Md N. Islam. "Endoscopic Findings of Upper Gastrointestinal Diseases at a Tertiary Care Hospital in Dhaka." Journal of Medical Science & Research 24, Number 1 (January 1, 2015): 22–26. http://dx.doi.org/10.47648/jmsr.2015.v2401.04.
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Endoscopic findings help the clinical to give the treatment properly The purpose of the present study was to find out common findings of UGI endoscopy at a tertiary care hospital in Dhaka. This retrospective study was conducted in the Department of Gastroenterology at Holy Family Red Crescent Hospital, Dhaka from 14th October 2009 to 25th June 2013 among all the patients presented with GI symptoms. Endoscopies were documented on a computer-based datasheet. Under topical lidocaine, a Fujinon EG fiber optic Upper GI scope was passed through the mouth of a patient in left lateral position through the upper esophageal sphincter into the esophagus stomach and duodenum. Biopsies were collected and histopathology reports were recorded A total number of 2632 patients were recruited for this study and endoscopy was done of which 1406(53.4%) cases were reported as abnormal findings. Male (52.1%) was predominant than female (47.9%). Maximum patients were diagnosed as peptic ulcer disease (54.2%) followed by varices with or without gastropathy (20.04, gastric cancer (11.5%), esophageal cancer (9.6%) and gastritis with or without duodenitis which were 267cases, 154cases, 128cases and 63(4.7%) cases respectively. The most common cause of UGI bleeding was due to PUD (43.1%) followed by varices (34.7%), Gastric cancer (12.5%). The most common endoscopic findings are the PUD, varices with or without gastropathy, gastric cancer, esophageal cancer and gastritis with or without duodenitis.
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Khoury, Leen, Patrick Tobin-Schnittger, Nicholas Champion, Vasiliy Sim, Asaf Gave, Samuel Hawkins, Melissa Panzo, and Stephen Cohn. "Natural History of Patients Undergoing Therapeutic Endoscopies for Acute Gastrointestinal Bleeding." American Surgeon 85, no. 11 (November 2019): 1246–52. http://dx.doi.org/10.1177/000313481908501131.
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When endoscopy is performed for acute GI bleeding, therapeutic endoscopic procedures are infrequently required (only 6% of cases). We sought to determine the natural history of GI hemorrhage in patients who have undergone therapeutic endoscopy. We queried our hospital database for inpatients with acute GI bleeding who underwent therapeutic endoscopy between 2015 and 2017. The primary endpoints were recurrence of bleeding and the subsequent need for repeated endoscopic interventions, angioembolization, or surgery. Demographic information was collected. We reviewed 205 hospitalized patients: mean age was 70 years, 58 per cent were male, and mean hemoglobin was 9 g/dL. Patients had medical conditions predisposing them to bleeding in 59 per cent and history of previous GI bleeding in 37 per cent of cases. Sixty per cent were on antiplatelet/ anticoagulation medications, and 10 per cent were receiving nonsteroidal anti-inflammatory medications. Blood transfusions were given to 78 per cent of patients, with an average of 2.3 units of packed red blood cells transfused per patient before intervention. Recurrence of hemorrhage after therapeutic endoscopy was seen in 9 per cent of patients. Only 2 per cent underwent a second therapeutic endoscopic procedure, and 5 per cent had surgery or angioembolization (half of these patients then had a further recurrence of bleeding). In total, seven patients died (3%). Recurrence of GI bleeding after therapeutic endoscopies is uncommon (9%). Surgery and angioembolization are not commonly necessary, but when used are only successful in 50 per cent of cases.
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Hawken, James, Amy Knott, Wesam Alsakkaf, Amanda Clark, and Faisal Fayyaz. "Rituximab to the rescue: novel therapy for chronic gastrointestinal bleeding due to angiodysplasia and acquired von Willebrand syndrome." Frontline Gastroenterology 10, no. 4 (January 9, 2019): 434–37. http://dx.doi.org/10.1136/flgastro-2018-101116.
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Identification of acquired von Willebrand syndrome (AVWS) was key to treating a patient with chronic gastrointestinal (GI) bleeding due to angiodysplasia. After exhausting endoscopic and pharmacological options, the patient was successfully treated with rituximab. A 78-year-old man developed chronic GI bleeding from caecal and jejunal angiodysplasia. Red cell transfusion was required weekly despite argon plasma coagulation. A diagnosis of AVWS was made from analysis of clotting factors. Therapies including von Willebrand factor concentrate, thalidomide and tranexamic acid were unsuccessful. With failed endoscopic therapy and no viable surgical option, the patient was given intravenous immunoglobulins (IVIGs). Haemoglobin remained stable from this point. The impact on the patient and hospital of attending for IVIG every 3 weeks necessitated consideration to longer-term therapy. After a single course of rituximab, no further blood products, IVIG or rituximab were required. This case is the first to describe the use of rituximab in AVWS-associated angiodysplasia.
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Jajeh, Ahmad. "Management of Major Bleeding Caused By Rivaroxaban and the Use of Desmopressin." Blood 124, no. 21 (December 6, 2014): 5099. http://dx.doi.org/10.1182/blood.v124.21.5099.5099.
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Abstract Rivaroxaban is a new anticoagulant that is substituted for Coumadin on a large scale in the treatment and prevention of Deep Vein Thrombosis DVT and Pulmonary Embolism PE. It is an oral agent that inhibits Factor Xa. The most attractive attribute of this new anticogulant is the lack of monitoring PT/INR. However, out of many cases put on Rivaroxaban a few reports of major and threatening bleed that could be fatal. Particularly, the the GI bleeding. Unfortunately, no set standard antidote or management is available when such catastrophic bleeds happen. This abstract present our experience with three major bleeding cases that presented with massive GI bleeding. Two are associated with peptic ulcer upon Upper GI endoscopy. Two males and one female age 60, 71 (males) and 71 (female). The first two patients were treated with Prothrombin complex product. The female patient presented with sever anemia of 4 grams of Hb with hematemesis and bright red blood per rectum. The Prothrombin complex product was not readly available . She was given multipe doses of Fresh Frozen Plasma FFP and multiple units of packed red blood cells. She was also given a product Profilnine which contains Factor II, IX and VII. Patient's coagulation profile of PTT, PT and Thrombin time were corrected. However, she continue to have bright blood per NG suction. Upon receiving D-DAVP Desmopressin 0.3 micrograms per Kg she stopped bleeding and EGD was done later with sclerosing treatment of gastric ulcer and ligation. Patient was given later a small dose of Prothrombine complex when was available since the last dose of Rivaroxaban was given less than 13 hours from her presentation to the hospital. All of the mentioned patients had prolongation of PT/INR/PTT at presentation. Thrombin time was monitored in all of them. All patients had survived the magor GI bleeding. D-DAVP were given to all of them. In conclusion D-DAVP Desmopressin should be considered as an adjuvant drug in patient presentong with major GI bleeding secondary to Rivaroxaban. Disclosures No relevant conflicts of interest to declare.
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Deane, Adam M., Waleed Alhazzani, Gordon Guyatt, Simon Finfer, John C. Marshall, John Myburgh, Nicole Zytaruk, et al. "REVISE:Re-Evaluating theInhibition ofStressErosions in the ICU: a randomised trial protocol." BMJ Open 13, no. 11 (November 2023): e075588. http://dx.doi.org/10.1136/bmjopen-2023-075588.
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IntroductionTheRe-Evaluating theInhibition ofStressErosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE.Methods and analysisREVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia,Clostridioides difficileinfection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial.Ethics and disseminationAll participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to – Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide.Trial registration numberNCT03374800.
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Merrill, Chaya T., Jeffery L. Miller, and Claudia Steiner. "Analysis of Increased Blood Transfusions in U.S. Hospitals, 1997 – 2006." Blood 112, no. 11 (November 16, 2008): 1302. http://dx.doi.org/10.1182/blood.v112.11.1302.1302.
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Abstract Blood transfusion during hospitalization (Tx-hospitalization) in the U.S. is very common in medical practice. In-hospital blood transfusions are indicated for multiple medical, surgical and hemorrhagic conditions. However, descriptions of the patient populations receiving transfusions in U.S. hospitals are vague. The purpose of this study is to use nationally representative hospital discharge data to provide information regarding the patient populations and associated diagnoses that have caused the demand for blood transfusions in U.S. hospitals. Data were obtained through cross-sectional analysis of the 1997 through 2006 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). The NIS is the largest, multi-year, all-payer inpatient care database that is publicly available in the U.S. The NIS contains data from 5 to 8 million unweighted hospital stays from about 1,000 hospitals sampled to approximate a 20-percent stratified sample of U.S. community hospitals. The NIS is drawn from the States participating in HCUP, which represent 90% of all hospital discharges in 2006. The NIS includes weights that allow calculation of reliable, representative national estimates of care in U.S hospitals. Blood transfusion was identified using the Clinical Classifications Software (CCS) procedure grouping 222. In 2006, 2.4 hospital hospitalizations included at least one blood product transfusion compared with 1.1 million in 1997. This 117% increase in Tx-hospitalizations was steady, with an average of 140,000 additional Tx-hospitalizations during each year. During that same period, the total number of U.S. hospitalizations increased 14%. Blood transfusions were among the top 10 procedures performed in all age groups. The elderly (>65+ years of age) accounted for the greatest number of hospitalizations with a transfusion with 1.4 million in 2006 compared to 622,000 in 1997. The most common type of transfusion was packed red cells, which accounted for about 90 percent of all types of transfusions (2.1 million of the 2.4 million transfusions in 2006). Coding of diagnosis at discharge was utilized to determine the conditions contributing to the increased utilization of transfusions. Transfusion was coded as a primary procedure during hospitalizations in which more invasive procedures were not performed. From 1997 to 2006, the fraction of hospitalizations with transfusion listed as the principle procedure was stable, and represented one-fourth of all Tx-hospitalizations. Within that group, the most common principle diagnoses were coded as anemia (15.8%), gastrointestinal hemorrhage (7.3%), CHF (5.5%), pneumonia (5.2%), and septicemia (5.0%). Cancers accounted for <1%. Transfusions were coded as a secondary procedure another invasive procedure occurred during the same hospitalization and represented the remaining three-fourths of cases. In that group, the most common principle diagnoses were osteoarthritis (8.3%), GI hemorrhage (6.5%), fracture of hip (5.1%), septicemia (4.3%), and complication of a device, implant or graft (4.2%). The most common principle procedures were UGI endoscopy (9.1%), hip replacement (6.0%), knee arthroscopy (6.0%) hip fracture repair (4.4%) and CABG (3.7%). In separate analyses, it was demonstrated that 20 percent of all hospitalizations for knee arthoplasty and 30 percent for hip replacement included a transfusion in 2006. In summary, hospital discharge data from the NIS provides critical and detailed clinical information on uses and trends of blood transfusions in U.S. hospitals. There has been a steady and significant increase in Tx-hospitalizations during the last decade that far exceeds the overall increase in hospitalizations (117% vs. 14%). A relatively small group of diagnoses including gastrointestinal bleeding and lower extremity arthroplasty represent one-third of the Tx-hospitalizations. Understanding the clinical demand for blood components in U.S. hospitals should facilitate optimal management of these limited and life-saving resources.
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Rafa, Elżbieta, Małgorzata Kołpa, Marta Zofia Wałaszek, Adam Domański, Michał Jan Wałaszek, Anna Różańska, and Jadwiga Wójkowska-Mach. "Healthcare-Acquired Infection Surveillance in Neurosurgery Patients, Incidence and Microbiology, Five Years of Experience in Two Polish Units." International Journal of Environmental Research and Public Health 19, no. 12 (June 20, 2022): 7544. http://dx.doi.org/10.3390/ijerph19127544.
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Introduction: Patients in neurosurgical units are particularly susceptible to healthcare-associated infections (HAI) due to invasive interventions in the central nervous system. Materials and methods: The study was conducted between 2014 and 2019 in neurosurgery units in Poland. The aim of the study was to investigate the epidemiology and microbiology of HAIs and to assess the effectiveness of surveillance conducted in two hospital units. Both hospitals ran (since 2012) the unified prospective system, based on continuous surveillance of HAIs designed and recommended by the European Centre for Disease Prevention and Control (protocol version 4.3) in the Healthcare-Associated Infections Surveillance Network (HAI-Net). In study hospitals, HAIs were detected by the Infection Prevention Control Nurse (IPCN). The surveillance of healthcare infections in hospital A was based mainly on analysis of microbiological reports and telephone communication between the epidemiological nurse and the neurosurgery unit. HAI monitoring in hospital B was an outcome of daily personal communication between the infection prevention and control nurse and patients in the neurosurgery unit (HAI detection at the bedside) and assessment of their health status based on clinical symptoms presented by the patient, epidemiological definitions, microbiological and other diagnostic tests (e.g., imaging studies). In hospital A, HAI monitoring did not involve personal communication with the unit but was rather based on remote analysis of medical documentation found in the hospital database. Results: A total of 12,117 patients were hospitalized. There were 373 HAIs diagnosed, the general incidence rate was 3.1%. In hospital A, the incidence rate was 2.3%, and in hospital B: 4.8%. HAI types detected: pneumonia (PN) (n = 112, 0.9%), (urinary tract infection (UTI) (n = 108, 0.9%), surgical site infection (SSI) (n = 96, 0.8%), bloodstream infection (BSI) (n = 57, 0.5%), gastrointestinal system infection (GI) (n = 13, 0.1%), skin and soft tissue (SST) (n = 9, 0.1%). HAI with invasive devices: 44 ventilator-associated pneumonia (VAP) cases (45.9/1000 pds with ventilator); catheter-associated urinary tract infection (CA-UTI): 105 cases (2.7/1000 pds with catheter); central venous catheter (CVC-BSI): 18 cases (1.9/1000 pds with CVC). The greatest differences between studied units were in the incidence rate of PN (p < 0.001), UTI (p < 0.001), and SSI (p < 0.05). Conclusions: The way HAIs are diagnosed and qualified and the style of work of the infection control team may have a direct impact on the unit epidemiology with the application of epidemiological coefficients. Prospective surveillance run by the infection prevention and control nurse in hospital B could have been associated with better detection of infections expressed in morbidity, especially PN and UTI, and a lower risk of VAP. In hospital A, the lower incidence might have resulted from an inability to detect a UTI or BSI and less supervision of VAP. The present results require further profound research in this respect.
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Abowali, Hesham, Antoinette Pacifico, Burak Erdnic, Karim Elkholy, Umida Burkhanova, Tarilate Aroriode, Althea Watson, et al. "Assessment of Bleeding Risk in Hospitalized COVID-19 Patients: A Tertiary Hospital Experience during the Pandemic in a Predominant Minority Population—Bleeding Risk Factors in COVID-19 Patients." Journal of Clinical Medicine 11, no. 10 (May 13, 2022): 2754. http://dx.doi.org/10.3390/jcm11102754.
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Introduction: In the wake of the SARS-CoV-2 (COVID-19) pandemic, our world has faced multiple challenges. Infection with this virus has commonly been associated with thrombotic events. However, little is known about bleeding risk and anticoagulation therapy. This study aims to determine factors that are associated with increased risk of bleeding in COVID-19 patients. Methods: A retrospective cohort study was conducted using the records of COVID-19 patients admitted during the COVID-19 pandemic from March 2020 through May 2020. Using patient charts, investigators manually collected data regarding patient characteristics and bleeding. Patients were included in the analysis if they had a confirmed COVID-19 PCR test, were older than 18 years of age and were admitted to the hospital. Patients who were pregnant or had incomplete charts were excluded from the study. ANOVA and logistic regression were used to determine the statistical significance of the data using SPSS version 27. Results: A total of 651 patients were included in the analysis out of 685 patients located in the database of COVID-19 infected patients during that time frame. The general characteristics of the patients were as follows: 54.2% were males; females 45.8% ages ranged from 28 to 83 years old (median age = 66 years old). There were 31 patients (4.9%) who required more than 1 unit of packed red blood cell (PRBC). A total of 16 (2.85%) patients had a documented gastrointestinal bleed (GIB), of which 8 received a total of 29 units of PRBC transfusions. The HAS-BLED score (without alcohol/drug due to inadequate charting) is calculated for patients who had a documented GI bleed and who received more than one unit of PRBC. It was noted that the higher the HAS-BLED score the greater the likelihood of having a GI bleed (p < 0.001). The HAS-BLED score (not including alcohol/drug) was also predictive for patients who received more than one unit of PRBC during their hospital stay (p < 0.001). Discussion: Using the HAS-BLED score without alcohol/drugs, patients with COVID-19 can be stratified in regard to their risk of GI bleeding and their risk of transfusion while in the hospital. When administering anticoagulation therapy, cautious monitoring should be carried out. Decisions regarding anticoagulant therapy should be based on individual patient characteristics.
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Escobar, Miguel A., Kenneth Chong, and Keith W. Hoots. "Experience with the “Off Label” Use of Recombinant Factor VIIa in a University Hospital." Blood 104, no. 11 (November 16, 2004): 4017. http://dx.doi.org/10.1182/blood.v104.11.4017.4017.
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Abstract Recombinant factor VIIa (rFVIIa), NovoSeven@ (Denmark), is a bypass agent approved in the United States for patients with hemophilia and inhibitors. The off-label use of this medication (non approved use) is becoming common in large institutions. Its main use seems to be for excessive bleeding due to trauma and surgery. Here we report our 2 year experience with the off-label use of this product and describe a protocol that is followed at our teaching hospital. Administration of rFVIIa was based on the described protocol. The medication is controlled by the hospital pharmacy and authorization for its use has to be given by the hematologists in collaboration with the clinical pharmacist. To be eligible for the use of rFVIIa the patient has to have received at least 10 units of red pack cells and fresh frozen plasma. In addition, the patient should have fibrinogen level greater than 100 mg/dl, platelet count greater than 70,000/mm3 and fibrin split products less than 80 mcg/ml. A total of 25 patients where treated off-label for excessive bleeding and 4 patients where given rFVIIa preoperative for prevention of bleeding. The doses ranged from 35 to 120 micrograms/kg of body weight with an average of 2 doses given per patient. The use of Factor VIIa was more common in the neurosurgical (NS) setting (7), followed by cardiovascular (CV) (6), gastrointestinal (GI) surgery (6), trauma (6) and others (4). Overall 62% of the patients had adequate hemostasis after the administration of rFVIIa. Successful hemostasis with rFVIIa by diagnosis was 100% for preoperative prophylaxis and GI, for NS 57%, for trauma 50% and for CV 17%. All the patients in the CV group where admitted with acute dissecting aortic aneurysms. No evidence of thromboembolic events where described. The “off-label” use of rFVIIa continues to be widely used with variable results. Until further randomized or controlled, double blind, clinical trials are done, no definitive recommendations can be given. Although this report includes a small cohort of patients, we will consider revising our protocol for bleeding following cardiovascular surgery and trauma.
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Souka, Samia, Hanaa Kandil, Soheir Korraa, Aida A. Abdel Hameed, and Marwa Hassan. "Homocysteinemia in relation to anemia in hypothyroid patients." Scientific Journal of Al-Azhar Medical Faculty, Girls 2, no. 3 (2018): 171–80. http://dx.doi.org/10.4103/sjamf.sjamf_31_18.
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Background Anemia and hypothyroidism are both common diseases in the community. Homocysteine (HCY) levels are increased in patients with hypothyroidism and methylenetetrahydrofolate reductase (MTHFR) deficiency is the most common genetic cause of hyperhomocysteinemia. The aim of the present study was to evaluate the level of serum HCY in patients with hypothyroidism and to study the relation of associated anemia with the serum level of HCY and MTHFR gene in patients with hypothyroidism. Patients and methods The study was conducted on 60 adult women attending the Endocrinology Outpatient Clinic of Al-Zahraa Hospital between September 2014 and June 2015 for proper diagnosis and management. Individuals of the study were divided into two main groups: group I (GI) with 30 hypothyroid patients, where 13 of them were postsurgical cases, and group II (GII) with 30 euthyroid individuals as a control group. Diagnosis was based on thyroid-stimulating hormone level reference values. Patients in GI were further classified into two subgroups: mild hypothyroid (subgroup I) and overt hypothyroid (subgroup II). Patient and control groups also were classified into anemic and nonanemic subgroups according to hemoglobin levels. The selected hypothyroid patients were women under thyroid hormone replacement therapy. Blood sample was obtained for proper investigations. Complete blood count, routine blood chemistry, serum iron level, thyroid function tests, vitamin B12 level, serum homocysteine (HCY), and MTHFR were performed. We performed a pilot study on MTHFR gene polymorphism. The C677T MTHFR gene mutation was detected in three of 10 patients and in two of 10 controls. No evidence of TT MTHFR gene mutation was observed in both patient and control groups. IBM SPSS statistics (version 23.0, USA, 2015) was used for data analysis. Results revealed the presence of anemia according to hemoglobin level (<12 g/dl). In patients group (GI), 50% (15/30) as compared with 13.3% (4/30) in the control group (GII) had anemia. Serum iron level in patients group (GI) was deficient in 40% (11/30), whereas deficient in 16.7% (5/30) in control group (GII). Vitamin B12 deficiency was found to be 44% (11/25) in patients group (GI), whereas in the control group (GII) was 6.7% (2/30). Analysis by Wilcoxon's rank sum test, homocysteine (HCY) serum level showed a highly significant increase among patients (GI) as compared with control (GII). Ranked Spearman's correlation test for the patients (GI) and control (GII) showed a significant negative correlation between homocysteine (HCY) and MTHFR serum levels, whereas the correlation with red cell indices parameters was insignificant. Serum iron and B12 levels were significantly correlated in patient group (GI). Pearson χ 2 tests were done between both patients and control groups for the presence of anemia, iron deficiency, and elevated serum homocysteine (HCY) level and all revealed statistically significant results. Conclusion There is no significant correlation between homocysteinemia and anemia. However, the strong association between anemia and hypothyroidism is attributed mainly owing to combined iron and vitamin B12 deficiencies. This might explain the decreased response to treatment among the selected hypothyroid patients.
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Movahedi, Behnaz, Shokufeh Zamani, and Farshad Nouri. "Lead Poisoning in Opium Addicts in Shahid Rajaei Hospital of Karaj, Iran." International Journal of Enteric Pathogens 11, no. 3 (August 29, 2023): 97–101. http://dx.doi.org/10.34172/ijep.5590.
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Background: Lead (Pb) is a heavy metal that can harm major organs in humans, and its high serum levels can cause poisoning. In Iran, one of the major causes of Pb poisoning is opium consumption because drug dealers combine opium with henna, a plant extract color; Pb is added to this plant for the fixation of its color. Considering that henna makes opium heavier, it costs more, and none of the users can differentiate opium from henna as their color is the same. According to the statistics of the Iranian Ministry of Health and Medical Education, 2.3% of people between the ages of 15 and 60 are drug addicted, of whom 69% to 94% have opiate addiction. Regarding these issues, it seems necessary to study the serum level of Pb in Iranian addicts. Objectives: The status of the serum Pb level and Pb poisoning symptoms among opium addicts was investigated in this study. Materials and Methods: In this study, all addicted patients were selected based on their history of using opium who were referred to the emergency department of Shahid Rajaei Hospital in Karaj (Center of Alborz province in Iran) and were evaluated between March 2016 and September 2016. Blood samples were collected from patients to measure serum Pb levels with atomic absorption by a Perkin device (USA) and evaluate basophilic stippling of red blood cells (RBCs) in a peripheral blood smear under a light microscope. The clinical signs and symptoms of patients were evaluated in several fields. They included neurological problems (including headache, memory impairment, sensory impairment, muscle weakness, seizure, and decreased consciousness), gastrointestinal (GI) problems (including constipation, nausea and vomiting, abdominal colic pain, and anorexia), and general signs and symptoms (including myalgia, fatigue, and the presence of a Pb line on the gum). Results: During the study, 75 patients with opium addiction were enrolled, including 67 (89.3%) males and 8 (10.7%) females. The mean age of patients entering the study was 52 years. Of these patients, only one case (1.3%) used opium by inhalation, and the remaining 74 cases (98.7%) had oral addiction. The mean serum Pb level among these patients was 57.7 μg/dL (the lowest and highest levels were 0.2 and 193 μg/dL, respectively). Of these 75 patients, the serum level of 15 cases (20%) was less than 15 μg/dL, and that of 60 (80%) cases was greater than 15 μg/dL. Of all the patients, the one who had the highest serum levels of Pb (193 μg/dL) went through a seizure, lost consciousness, and died. In general, GI signs and symptoms were more common among patients than any other signs and symptoms. Conclusion: The findings of this study could reveal the most common complications of Pb poisoning in addicted patients, but no relationship was found between rare complications and Pb poisoning level.
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K., Dhinesh Babu, and M. Bhaskar. "A comparative study between benign and malignant conditions of upper gastrointestinal tract of helicobacter pylori using upper gastrointestinal scopy in a tertiary care hospital, Kanchipuram, Tamil Nadu, India." International Surgery Journal 4, no. 3 (February 25, 2017): 1082. http://dx.doi.org/10.18203/2349-2902.isj20170866.
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Background: Acid peptic disease comprises of a wide spectrum of diseases, which cause considerable morbidity. The objective of this study was to study the prevalence of Helicobacter pylori in patients with dyspepsia and symptomatic patients undergoing upper gastrointestinal endoscopy (UGIE) in Karpaga Vinayaga Medical College and Hospital, Kanchipuram, Tamilnadu, India and to study the association of Helicobacter pylori with acid peptic diseases and malignant conditions of upper Gastro intestinal tract.Methods: 389 cases of dyspepsia, studied clinically, were subjected to UGIE, during which 4 biopsies, two each from the antrum and the pathological areas were taken. One of the antral area and the other of the pathological finding were immediately subjected to Rapid urease test. Positive test for Helicobacter pylori was indicated by change in colour of the medium from yellow to pink or red. The other two biopsy specimens were sent for routine histopathology and special staining with Giemsa stain. The case was taken as Helicobacter pylori positive when the rapid urease test and/or histopathological examination was positive.Results: Out of 468 patients, with mean age of 41.8 years, 171 patients were diagnosed to have been infected with Helicobacter pylori (44.21%). Out of 49 patients with gastric and duodenal ulcers, 37 patients were infected with Helicobacter pylori (75.51%). In which 22 out of 25 patients (88%) with duodenal ulcers and 10 out of 14 patients (71.4%) with gastric ulcers were positive for H. pylori while only 8 out of 10 patients (80%) with gastric cancer were positive for H. pylori.Conclusions: In this study, we found that Helicobacter pylori were consistently associated with peptic ulcer disease and malignant conditions of upper GI tract, which is in broad agreement with the studies done earlier. Thus, we conclude that, Helicobacter pylori infection may have a major role in the etiopathogenesis of peptic ulcer disease and malignant conditions of upper GI tract appear to be no significant association between Helicobacter pylori infection and unexplained dyspepsia.
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Kreuziger, Lisa M. Baumann, Josh Salzman, Amar T. Subramanian, Colleen T. Morton, and David J. Dries. "Massive Transfusion in Non-Trauma Patients,." Blood 118, no. 21 (November 18, 2011): 3376. http://dx.doi.org/10.1182/blood.v118.21.3376.3376.
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Abstract Abstract 3376 Background: Hemorrhagic shock accounts for a significant number of deaths in patients with acute injury. Early administration of multicomponent blood product transfusion in high plasma to red cell ratios have been associated with decreased mortality. Significant bleeding may occur in many settings outside of injury, including abdominal aortic aneurysm (AAA) rupture and postpartum or gastrointestinal hemorrhage. At a Level I Adult and Pediatric Trauma Center, activation of a Massive Transfusion Protocol (MTP) provides immediate release of sets of blood products with high component ratios (i.e. 1 unit plasma for every 1 unit PRBC) for patients with severe injury. The protocol has also been utilized in patients with major bleeding from non-trauma etiologies. To our knowledge, there are no systematic studies of the effectiveness of blood transfusion with high component ratios in non-traumatic hemorrhage; therefore, we performed a retrospective case review of patients transfused via the MTP for non-traumatic indications and outcomes at our institution. Methods: Clinical data for 58 patients with non-traumatic activation of the MTP between October 2009 and May 2011 was reviewed. Medications, laboratory parameters prior to transfusion, medical conditions affecting bleeding, and amount of blood products administered were evaluated. Outcomes including 24 hour and in-hospital mortality and incidence of transfusion reactions including Transfusion Related Acute Lung Injury (TRALI) were assessed. Associations between medications or medical problems and transfused blood products, as well as component ratio on mortality were assessed using logistic regression. Fisher's exact test was used to examine the impact of transfusion reactions including TRALI on mortality. Results: Forty-nine of 58 patients studied (84%) received blood products after activation of the MTP. Patients ranged in age between 19 and 82 years-old (median 61 years) and 69% were male. Thirty eight percent of patients had the MTP activated for vascular catastrophies (AAA), 24% for GI bleeding, 16% for open heart surgery, and 10% for obstetrical complications. Patients on average received 9 units of red blood cells (range 0–39 units), 6.6 units of plasma (range 0–34 units), and 1.5 apheresis units of platelets (range 0–5). Twelve patients (24%) received cryoprecipitate. Administered adjunctive medications included activated factor VII for 11 patients (22%), aminocaproic acid in 14 patients (28%), vitamin K in 15 patients (30%), and desmopressin in 6 patients (12%). The odds of a patient receiving activated Factor VII increased significantly as the units of PRBCs increased (OR = 3.925; 95% CI = 1.15 – 13.38). Concurrent medications most likely to affect bleeding included heparin in 26 patients (53%), aspirin in 18 patients (37%), and warfarin in 4 patients (8%). Active liver failure was seen in 11 patients (22%), renal failure in 16 patients (32%), and one patient with either a hematologic or solid malignancy. Patient's medications or these medical diagnoses were not associated with the amount of blood product transfused. Twenty one patients (43%) died during the hospitalization, and six patients (12% of total) died within the first 24 hours. In hospital mortality for patients with GI hemorrhage was the highest at 66%. No patients died after receiving transfusion for obstetric complications. Influence of ratio of Plasma:PRBC transfusion on in-hospital morality was seen with mortality of 80% in the <1:4 group, 60% in 1:4–1:2 group, and 36% in both 1:2 to 1:1 and ≥1:1 groups. These differences were not statistically significant, however, potentially due to sample size. Three patients experienced signs and symptoms consistent with TRALI but no other transfusion reactions were found. These cases were not associated with mortality (24-hour or in hospital) and were not correlated with the component ratio. Conclusions: MTPs with infusion of blood products with high ratios of plasma to red cells compared to transfusion with low ratios have improved mortality in patients with hemorrhage due to trauma. Our data suggests the applicability of MTP as part of resuscitation in the management of acute hemorrhage in non-trauma settings. Transfusion reactions were infrequent. Therefore, physicians should strive for transfusion of high ratios of Plasma:PRBC in all instances of major hemorrhage. Disclosures: Off Label Use: Use of activated factor VII to assist with cessation of hemorrhage in patients without hemophilia.
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Dar, Imtiyaz Ahmad, Waseem Raja Dar, Mushtaq Ahmad Khan, Basharat Ahmad Kasana, Najeeb Ullah Sofi, Moomin Hussain, Faheem Arshad, Manzoor Ahmad Wani, Muzamil Latief, and Jaswinder Singh Sodhi. "Etiology, clinical presentation, diagnosis and management of lower gastrointestinal bleed in a Tertiary Care Hospital in India: A retro-prospective study." Journal of Digestive Endoscopy 6, no. 03 (July 2015): 101–9. http://dx.doi.org/10.4103/0976-5042.165697.
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Abstract Introduction: Lower gastrointestinal bleeding (LGIB) is one of the leading causes for hospital admissions in gastroenterology wards all over the world. Patients usually present with hematochezia or bloody diarrhea. Colonoscopy is usually the initial diagnostic intervention followed by other more sophisticated tests. Bleeding may stop spontaneously, but evaluation is important because patients may harbor a sinister lesion like cancer. Aim of the Study: To determine the various etiologies, clinical presentations, a diagnostic test used and treatments received by LGIB patients admitted in our department. Materials and Methods: A total of 300 cases were studied which included 180 retrospective cases and 120 prospective cases. For retrospective cases, all the information was obtained by analyzing their case records while as prospective patients were managed as per a predefined protocol and details of various investigations and treatments documented. Results: Most commonly affected was elderly population (>60 years), constituting 40% (120/300) of studied population. Males constituted 59% (177/300) and females 41% (123/300). The most common clinical presentation of LGIB in our patients was hematochezia (63.6%, 191/300). Growth/polyp was the most common finding on colonoscopic examination seen in 29.3% (n = 88) patients. Inflammatory lesions were seen in 77 out of 239 (25.7%) patients. Wireless capsule endoscopy was positive in 13 out of 24 patients (54%). Computed tomography (CT) enterography showed positive results in 6 out of 25 (24%) cases. Red blood cell scan was done in seven patients while as CT angiography in in four patients. Therapeutic endoscopy was successful in 115 out of 239 patients with positive colonoscopy, polypectomy was the commonest procedure performed. Medical management was carried out in 34.6% patients. Surgical treatment was offered to 21% patients. Conclusion: Colonoscopy is the initial and most common investigation used in the evaluation of GI bleed. A polyp is the most common diagnosis while as polypectomy the most common therapeutic procedure.
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Yang, Li-Ping, Peng Zhao, Ye-Jun Wu, Hai-Xia Fu, Yun He, Xiao-Dong Mo, Meng Lv, et al. "Treatment Outcome and Efficacy of Therapeutic Plasma Exchange for Transplant-Associated Thrombotic Microangiopathy in a Real-World Large Cohort Study." Blood 138, Supplement 1 (November 5, 2021): 1013. http://dx.doi.org/10.1182/blood-2021-149373.
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Abstract Introduction Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT), with mortality over 80%. Effective management of TA-TMA is hampered by obscure pathogenesis and delayed diagnosis. There are no well-acknowledged therapeutic strategies for TA-TMA. TA-TMA-directed therapy includes therapeutic plasma exchange (TPE), eculizumab, rituximab, and defibrotide. The efficacy and outcome of TPE for the treatment of TA-TMA remain controversial. To our knowledge, this is the largest cohort to date of patients treated with TPE for TA-TMA after allo-HSCT. We aimed to identify predictors of response and mortality in patients with TA-TMA who received TPE, and to recognize patients who will benefit from TPE management. Methods A total of 6241 subjects who underwent allo-HSCT were performed at Peking University People's Hospital from January 2010 to December 2019, of whom 538 patients were diagnosed with TA-TMA, with a cumulative incidence of 8.6%. Among them, 82 consecutive critically ill TA-TMA patients received TPE. TA-TMA was diagnosed using the criteria proposed by Cho et al. TPE was not performed in a protocol-defined manner. Patients were classified as achieving complete response (CR) if they showed disappearance of schistocytes, resolution of any changes in mental status, normalization of lactic dehydrogenase, and were not receiving red blood cells and platelet transfusions. Patients were considered to have achieved no response (NR) when they showed no improvement of laboratory features, remained dependent on red blood cell and/or platelet transfusions, or died with active TA-TMA. Subjects were considered to have a partial response (PR) when they did not meet the criteria for either CR or NR (BMT 2010; Blood 2020). Results TA-TMA was diagnosed at a median time of 64.5 [IQR 38.8-158] days post-HSCT. The 42 men (51.2%) and 40 women (48.8%) had an average age of 35.3 years. Renal involvement (59.8%), central nervous system dysfunction (70.7%), gastrointestinal (GI) bleeding (73.2%), and concomitant acute graft-versus-host disease (aGVHD, 78%) were common in our cohort of TA-TMA patients. All 82 patients in our analysis received TPE, and adjunctive TA-TMA-targeted therapy included the use of rituximab (11 patients), rituximab plus eculizumab (1 patient), and defibrotide (1 patient). However, the additional therapy showed no significant difference between the response and nonresponse groups. The median time from TA-TMA to TPE initiation was 8 days [IQR 2.0-16.5], and the cumulative volume of TPE was 6 L [IQR 3.6-8.5]. Our data revealed that the overall response was 52.4% (43/82), comprising 4 CRs and 39 PRs. Early TPE initiation trended towards a better response, but this difference was not statistically significant. The multivariate analysis showed that patients with GI bleeding (OR, 6.26; 95% CI, 1.30-30.12), grade III-IV aGVHD (OR, 5.00; 95% CI, 1.50-16.68), lower cumulative volume of TPE (OR, 8.51; 95% CI, 1.91-38.05), and severe anemia (OR, 7.48; 95% CI, 2.20-25.49) were less likely to respond to TPE. Regarding treatment outcome, 57% (47/82) of cases survived 100 days post HSCT, and 20% (16/82) survived 100 days after the diagnosis of TA-TMA. With a median follow-up of 467 days [IQR 248-1002], the OS at 1 year after TA-TMA was 15%. The leading causes of death were infection, active TA-TMA, and multiple organ dysfunction syndrome (MODS). The Kaplan-Meier analysis showed that GI bleeding, grade III-IV aGVHD, and no response to TPE were associated with poor survival at 1-year post TA-TMA (Figure 1). By multivariate analysis, TA-TMA patients treated with TPE had dismal survival with GI bleeding, lower loading volume of TPE, and elevated total bilirubin. Conclusions The results of this large cohort of real-world practice indicate that TPE may be effective for TA-TMA depending on given clinical circumstances. Our data underscore that GI bleeding is independently associated with poor response to TPE and mortality, while grade III-IV aGVHD is again confirmed as predicting a dismal response to TPE. We hypothesize that higher volume of TPE is warranted to achieve resolution and favorable outcome of TA-TMA. Multicenter prospective studies are required to further verify whether these patients could benefit from TPE and seek a paradigm for TPE in the management of TA-TMA. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.
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Tatlıparmak, Ali Cankut, Özlem Dikme, Özgür Dikme, and Hakan Topaçoğlu. "Cancer, platelet distribution width, and total protein levels as predictors of rebleeding in upper gastrointestinal bleeding." PeerJ 10 (September 15, 2022): e14061. http://dx.doi.org/10.7717/peerj.14061.
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Background Rebleeding is associated with poor outcomes in upper gastrointestinal bleeding (UGIB). Identifying predictors of rebleeding can assist in risk assessment. The aim of the study is to investigate the factors affecting rebleeding in patients with UGIB admitted to the emergency department. Methods This retrospective, observational, cross-sectional study was conducted on patients with UGIB presented to the emergency department. Patients who did not arrest in the first 24 h, who were not diagnosed with GI malignancy, and who were clinically diagnosed with UGIB were included in the study. Patient demographic characteristics, hemodynamic parameters, patient parameters, and bleeding that may affect rebleeding were evaluated. The primary endpoint was rebleeding within 7 days. Results The study included 371 patients. A total of 55 patients (14.8%) had rebleeding within 7 days, and 62 patients (16.7%) presented without bleeding manifestations. Rebleeding rates were higher in those who presented with bloody or coffee-ground vomitus, had a diagnosis of cancer, had blood in their nasogastric tube, and had peptic ulcers due to endoscopy. Mean cell hemoglobin concentration, lymphocyte, albumin, and total protein values of patients with rebleeding were low; red blood cell distribution width, neutrophil count, platelet distribution width (PDW), and neutrophil lymphocyte ratio were high. In-hospital mortality and 30-day mortality values of patients with rebleeding were significantly increased. In the multivariate analysis, cancer, PDW, and total protein levels were statistically significant. Conclusion The presence of cancer, low total protein level, and high PDW are effective parameters in predicting 7-day rebleeding in patients with UGIB admitted to the emergency department.
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Hasan, S., M. Dmitriew, and J. Leonard. "A72 VARICEAL BLEED & PORTAL HYPERTENSIVE GASTROPATHY IN A NON-CIRRHOTIC PATIENT WITH ISOLATED SPLENOMEGALY." Journal of the Canadian Association of Gastroenterology 3, Supplement_1 (February 2020): 85–86. http://dx.doi.org/10.1093/jcag/gwz047.071.
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Abstract Background Portal hypertension caused by cirrhosis is the most common etiology of esophageal varices. However, abnormalities of the spleno-portal axis in the absence of liver disease may also cause portal hypertension resulting in varices. We report a rare case of esophageal variceal bleed in a non-cirrhotic patient with isolated splenomegaly secondary to chronic G-CSF therapy. Aims This report outlines the case of a patient with Cohen Syndrome (CS) who presented with an upper gastrointestinal (GI) bleed in the setting of previously documented splenomegaly and portal hypertension. We expand on the clinical investigations, diagnosis, treatment plan and hospital course of this patient. Methods Case report, review of literature. Results A 26-year old male with previously diagnosed CS presented with large volume hematemesis and pancytopenia. CS is a rare autosomal recessive disorder. In our patient this manifested with congenital neutropenia, microcephaly, retinal dystrophy and global developmental delay. He required long term G-CSF therapy to manage chronic neutropenia and subsequently developed splenomegaly, a known side effect. The most recent MRI identified stable splenomegaly with a craniocaudal length of 23 cm, normal liver size and no radiographic evidence of cirrhosis. The imaging was also significant for gastroesophageal and splenorenal varices but no ascites or recanalization of the umbilical vein. A recent liver biopsy had shown mild pericellular fibrosis with no active liver disease or cirrhosis. In the past, the patient had declined EGD, therapeutic splenectomy or assessment of hepatic venous pressure gradient through invasive venography. His liver enzymes, bilirubin and albumin had always been within normal limits. The patient had no history of GI bleeding. Previous investigations for hematologic malignancies or myelodysplastic syndrome had been negative. Upon admission, an urgent EGD revealed active variceal bleeding in the esophagus and portal gastropathy. Given the extent of his congenital orofacial abnormalities a variceal band ligator could not be passed for appropriate intervention. The patient was transferred to the Intensive Care Unit and managed with intravenous proton pump inhibitor, octreotide, as well as transfusions of packed red blood cells, platelets and fresh frozen plasma. Within the next 48 hours, the patient underwent successful transjugular intrahepatic portosystemic shunt and CT-guided coil placements for the bleeding varices. Conclusions This is a rare case of variceal bleed in a non-cirrhotic patient with portal hypertension from iatrogenic splenomegaly. While there are previous reports of spontaneous splenic rupture secondary to G-CSF therapy we are the first to report variceal bleed as a complication. This is a life-threatening consequence that requires urgent intervention and intensive care. Funding Agencies None
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Tang, Yubo, Jennifer Carns, Timothy Quang, Enrique M. Reina, Susana Gonzalez, Daniel G. Rosen, Sharmila Anandasabapathy, and Rebecca R. Richards-Kortum. "A Multimodal Optical Imaging Platform for the Early Detection of Gastric Malignancies." Journal of Global Oncology 2, no. 3_suppl (June 2016): 6s. http://dx.doi.org/10.1200/jgo.2016.004820.
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Abstract 14 We developed a novel multimodal video endoscope and evaluated its usefulness for the early detection of gastric neoplastic lesions. The imaging platform is a modified upper GI endoscope capable of white light imaging (WLI), widefield vital-dye fluorescence imaging (VFI) and high-resolution microendoscopy (HRME) in a single endoscopic insertion. A custom filter module is attached to the distal tip of the endoscope to enable VFI; HRME is performed by introducing a fiber optic probe through the endoscope working channel. Proflavine, a vital dye that stains nuclei is used to provide image contrast in both VFI and HRME. VFI images of proflavine stained tissue reveal the glandular patterns of the gastric mucosa, while HRME images reveal nuclear morphology with subcellular resolution. The performance of the platform was evaluated in a pilot study to image 35 patients with known or suspected gastric cancer undergoing either endoscopy or surgical resection. Patients were recruited at Mount Sinai Hospital, NY, and Hospital Evangelico in Siguatepeque, Honduras. For each patient, images were acquired with WLI, VFI and HRME sequentially during endoscopy. Images of neoplasia show disruption and effacement of glandular patterns. These alterations are visualized with enhanced contrast in VFI when compared to WLI; HRME images presenting the nuclear architecture at a subcellular level confirm these findings. Results suggest that this multimodal imaging platform can potentially enable a two-step protocol for early gastric cancer detection, wherein suspicious areas are red flagged with improved contrast using VFI, and then further imaged with HRME to confirm whether neoplasia is present based on changes in nuclear morphology. Given the convenient adaptation of the system design to other commercial endoscopes and the low cost of HRME (< $2,500), the utility of this multimodal imaging platform should be further evaluated in in vivo studies and low-resource settings. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: Yubo Tang No relationship to disclose Jennifer Carns No relationship to disclose Timothy Quang No relationship to disclose Enrique M. Reina No relationship to disclose Susana Gonzalez No relationship to disclose Daniel G. Rosen Research Funding: Biotheragnostics Sharmila Anandasabapathy Honoraria: Medial Medical Rebecca R. Richards-Kortum Consulting or Advisory Role: Janssen Global Services Research Funding: Merck
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Minuk, Leonard, Anargyros Xenocostas, Anita Hibbert, Daphne Chan, and Ian Chin-Yee. "Red Blood Cell Transfusion and Chemotherapy Administration: A Study of Resource Utilization at the London Regional Cancer Program (LRCP)." Blood 108, no. 11 (November 16, 2006): 4143. http://dx.doi.org/10.1182/blood.v108.11.4143.4143.
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Abstract We conducted previously a prospective evaluation of the relative chair-time consumption between various clinical activities (chemotherapy administration, RBC transfusion, other treatment related events) at the LRCP. Transfusions were reported to occupy at least twice as much chair-time relative to an average chemotherapy session. We report here a retrospective analysis of the LRCP electronic database over a 6-month period to further evaluate clinic resource utilization. A total of 11016 clinic visits were documented and analyzed, of which 83% involved an active treatment session (chemotherapy/transfusion). The most prevalent tumours (>60%) were breast, gastrointestinal (GI), genitourinary (GU) and gynecological (GYN) cancers. Hematologic malignancies accounted for <20% of all tumour types, where myeloma and lymphoma constituted >50% of this cohort. One hundred seventy-one patients received a total of 337 transfusions (656 RBC units), of which the majority were solid (58.5%) and hematologic (40.9%) tumour patients. The transfusion trigger was observed at Hb <80g/L (mean 76.5 +/− 12.3g/L) and on average 1.9 +/− 0.3 units of blood were administered on each occasion. The incidence of transfusion (Mean 7.5 & 6.0 per transfused patient) and units of blood administered (Mean 15 & 12 units per transfused patient) were highest among chronic myeloproliferative disorder and non-malignant hematology patients. Based on our previous reported transfusion chair-time (i.e. Chair-time occupied by a patient while receiving 1 RBC unit, independent of time consumed by pre-/post-transfusion related nursing and laboratory activities) at 109 +/- 19 minutes, an estimated 71504 minutes were consumed by all RBC transfusions, constituting 5.4% of all LRCP out-patient clinic chair-time events. Only 11% of all transfused patients were treated with an erythropoietin receptor agonist (ERA), corroborating with published literature that ERAs are highly effective in reducing the transfusion burden of oncology patients. This study also identified a major discrepancy between the blood bank’s record of distributed blood and LRCP’s record of transfused blood. A total of 129 transfusions (37%) were not documented on the LRCP database but were administered to patients, of which 20% took place on stretcher beds. As hospital billings rely solely on this database, about 26923 min of clinic time and hospital resources that were utilized was not funded. A very conservative estimate of unbilled nursing time ($30/hr) alone translates into a minimum of $13461 over the study period. In conclusion, RBC transfusion consumes a significant proportion of chair-time at the LRCP, which could otherwise be more efficiently utilized by chemotherapy administration. Chemotherapy protocols commonly administered to GYN (platinum based) and lymphoma (combination regimens containing rituximab) patients are previously reported to be the most chair-time consuming (Median 3–4 hr, up to 7–8hrs). Since these tumour types accounted for a significant proportion of the patient population who receive care at the LRCP, an intense competition for chair-time and nursing resources that could lead to clinic cancellations and delayed treatment had likely occurred. A greater application of transfusion alternatives (e.g. ERAs) could reserve such facilities for their intended purposes, thus allowing the timely administration of chemotherapy and optimization of clinic resource utilization.
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Gundabolu, Krishna, Brian Trevarrow, and Scott A. Koepsell. "Efficacy and Safety of Four Factor Prothrombin Complex Concentrates As a Reversal Agent for Oral Xa Inhibitors." Blood 126, no. 23 (December 3, 2015): 4668. http://dx.doi.org/10.1182/blood.v126.23.4668.4668.
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Abstract INTRODUCTION: FDA had approved three oral Xa inhibitors (OXI) Rivaroxaban (R), Apixaban (A) and Edoxaban for the treatment of venous thromboembolism (VTE) and cardiac thromboembolism prophylaxis in patients with non-valvular atrial fibrillation (NV A fib). The incidence of major bleeding and intracranial hemorrhage (ICH) is lesser with OXI's compared to warfarin but due to lack of appropriate reversal agents, management of such situations are very difficult. In the healthy human volunteer studies Andexanet alfa, Activated or non-activated prothrombin complex concentrates (PCC) and recombinant factor VIIa have been studied but there is lack of good real time data due to which practices are diverse. KCentra (K) was FDA approved in 2013 for urgent reversal of warfarin in cases of acute major bleeding or emergent surgery and consists of inactive factors II, VII, IX, X, Protein C and Protein S. Our institution uses Kcentra to reverse OXIs starting in November 2014. METHODS: After IRB approval, all requests for KCentra from November 2014 to June 2015 were reviewed. For patients who were on an OXI and had acute life threatening bleeding or needed urgent surgery, the following variables were analyzed: demographics, clotting assays, dose and type of OXI, length of hospital stay, mortality, thrombotic events and medications. RESULTS: 12 requests for Kcentra were placed and at physicians discretion ten patients ultimately received it of which none died during that hospitalization. One of the two patients who didn't receive rapidly died (hepatic bleeding). Results include: Median age of 74 years (65-86 y), 6 were male (50%). Indications for OXI therapy- NV A fib (n=6), unprovoked VTE (n=2), provoked VTE (n=1), cancer associated VTE (n=1). The OXIs used were R (n=5) and A (n=5). Median time of administration of K from the last intake of the drug was 10 hours (8-15 h) and median length of hospital stay was 8 days (4-26). In 9 patients with available data, the pre-K median INR and PT was 1.4 (1.1-2.5)/20.6 s (11.8- 21.8s) and the median post-K INR and PT was 1.1 (1-1.8), 16.9 s (13.4-30.2 s), median activated partial thromboplastin time (aPTT) before K is 30.6 s (27.5-40.2 s). Anti Xa activity was tested in only 3 patients before K administration with a median of 0.66 IU/mL (0.54-1.48) and In 2 patients after K with a mean of 0.51 (0.32-0.71). Indications included emergent surgery in two (20%), ICH (20%)-1 spontaneous subdural hemorrhage (SDH) and 1 SDH after fall, 1 patient each on A and R, gastrointestinal bleeding (30%)- 1 gastric ulcer, 1 diverticular bleeding and 1 spontaneous with 2 of these 3 patients on R, Trauma (30%) causing spinal fractures (n=2) and hepatic bleeding (n=1). Median estimated glomerular filtration rate (eGFR), AST and ALT at the time of bleeding were 62 ml/min, 24 U/L and 17 U/L respectively. Median number of packed red blood cells (PRBC) transfused was 3 U with median hemoglobin at admission of 8.9 gm/dL (7-13.3) and median platelet count of 195 x10E3/cmm (163-356). The median K dose was 25 U/kg once (25-50) and one patient (10%) had acute VTE 14 days after administration (Lower extremity femoral DVT. 6 patients were on Aspirin (60%), 7 on p-glycoprotein (p-gp) inhibitors (70%), 3 (30%) on p-gp substrates & 2 (20%) on Selective Serotonin Reuptake Inhibitors. CONCLUSION: Kcentra use was observed to be safe as a reversal agent with acceptable risk of thrombosis. Advanced age, concurrent use of P-glycoprotein inhibitors, antiplatelet agents appear to be risk factors for bleeding and use of OXI's with such risk factors should be cautioned. Table. Age Sex Indication of A/C Drug Hospital days Indication for Kcentra # of PRBC ASA P-gp-X P-gp used 64 M NV Afib Rivaroxaban 20 mg QD 7 Spontaneous SDH 0 Yes Yes Atorvastatin 65 M UnprovokedVTE/PE Rivaroxaban 20 mg QD 9 Trauma-Liver cyst rupture 1 No No No 76 F ProvokedVTE Rivaroxaban 20 mg QD 4 Spontaneous GI bleeding Diverticular 7 No No No 70 M Cancer AssociatedVTE Rivaroxaban 20 mg QD 9 Bleeding penile cancer-surgery 4 Yes Yes EsomeprazolePravastatin 74 M UnprovokedVTE Rivaroxaban 20 mg QD 5 GI bleeding-gastric ulcer 3 No No No 84 F NV Afib Apixaban5 mg BID 4 Fall-SDH 0 Yes Yes Propafenone 73 F NV Afib Apixaban5 mg BID 26 Fall-Spinal trauma 2 No Yes Omeprazole 68 M NV Afib Apixaban5 mg BID 13 Surgery-Type A Aortic aneurysm 6 Yes Yes AmiodoroneSimvastatin 84 F NV Afib Apixaban5 mg BID 23 Trauma-Facial/spine fracture 3 Yes Yes Pravastatin 86 M NV Afib Apixaban5 mg BID 5 Spontaneous GI bleeding 6 Yes Yes Amiodorone Disclosures Off Label Use: Kcentra is not FDA approved as a reversal agent for oral direct Xa inhibitors.
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Faisal, Sobia, Misbah Azmath, and Vitaly Kantorovich. "PSAT001 A Case of Ectopic Cushing's Syndrome Complicated by COVID-19 Infection." Journal of the Endocrine Society 6, Supplement_1 (November 1, 2022): A573—A574. http://dx.doi.org/10.1210/jendso/bvac150.1190.
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Abstract Background Ectopic Cushing's syndrome is associated with high morbidity and mortality rates and patients can rapidly decline if not intervened on earlier. We report a case of Ectopic Cushing's syndrome and highlight the challenges that were encountered in managing this patient who subsequently developed Covid-19 infection during hospitalization. Clinical Case 61-year-old female with history of non-insulin dependent diabetes presented with increased confusion, elevated blood sugars and persistent hypokalemia. She was hypertensive, with exam findings of facial plethora, coarse chin hair growth, central adiposity with thin extremities. During evaluation Potassium was 2. 0 mmol/l (ref range 3.5-5), Cortisol 101.7 mcg/dl (AM ref range 6.2-19.4), ACTH 365 pg/ml (ref range 6-50), plasma renin activity of 1. 06 ng/ml/hr (ref range 0.25 - 5.82), and Aldosterone level of <1 ng/dl (supine ref range 3-16). CT abdomen/pelvis imaging revealed a 4.4×3.1 cm right pulmonary mass concerning for malignancy, two hepatic lesions suspicious for metastases and bilateral adrenal gland thickening with focal nodularity. Biopsy of the lung mass demonstrated a Grade I well differentiated neuroendocrine tumor. Unfortunately, ACTH staining was not performed on the biopsy specimen, but suspicion for ectopic hypercortisolemia remained high given her clinical presentation, resistant hypokalemia and neuroendocrine tumor. Gallium Dototate scan revealed increased uptake in the right lung infra-hilar mass and bilateral adrenal glands with decreased uptake in the liver lesions. Ketoconazole and Metyrapone were initiated along with Spironolactone and potassium supplements. She was thought to be a poor candidate for thoracic surgery and was seen by radiation oncology who recommended stereotactic body radiation therapy (SBRT) to the right lung lesion with IR guided bland embolization of the liver lesions. While awaiting further intervention, she decompensated developing hypoxic respiratory failure with high oxygen requirements and was found to have Covid-19 infection. She received convalescent plasma and Remdesevir. After much discussion, despite her endogenous hypercortisolemia, patient was given IV steroids per infectious disease and pulmonology recommendations. She continued to decline requiring intubation. Intravenous Etomidate infusion was started to decrease cortisol production. Despite many efforts, her hospital course was complicated by an upper GI bleed, acute L1-L3 fractures and significant hyperkalemia requiring hemodialysis. Family declined further intervention and withdrew treatment, shortly after which patient passed away. Discussion Ectopic cushing's disease may be associated with fatal progression of Covid-19 pneumonia and respiratory failure requiring emergent intervention. Due to endogenous hypercortisolemia, immune response may be blunted, and patients infected with Covid-19 infection may lack the typical clinical presentation and cytokine storm. Role of exogenous steroids in patients with Covid-19 infection with pre-existing endogenous hypercortisolemia is not clear with the concern being the resulting severe metabolic sequelae which may lead to adverse outcomes. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
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Zvinoera, Katherine, J. Mutsvangwa, E. Chikaka, T. D. Coutinho, V. Kampira, and S. Mharakurwa. "Geo-Spatial Distribution of Frequencies of MTB/RIF Detected Specimens based on Requesting Health Facilities in Manicaland Zimbabwe for 2017 and 2018." Medical Journal of Zambia 48, no. 2 (August 10, 2021): 78–84. http://dx.doi.org/10.55320/mjz.48.2.867.
Full textAbstract:
Objectives: The aim of this study was to produce Geo Spatial Distribution of Frequencies of MTB/RIF Detected Specimens based on RequestingHealth Facilities in Manicaland Zimbabwe for 2017 and 2018, so as to give insight to TB program managers. Focusing elimination interventions onhot pockets of Tuberculosis (TB) strengthens rationale use of resources in resource limited countries like Zimbabwe. Early detection and earlytreatment is backbone of breaking TB transmission. Drug resistant tuberculosis (DRTB) control interventions like Programmatic Management of Drug Resistant TB or mentoring on Short, all Oral Regimen for Rifampicin resistant Tuberculosis (ShORRT) will be driven by science.
Materials and Methods: The retrospective study was carried out in Manicaland, Zimbabwe. Manicaland one of the 10 provinces in Zimbabwe, has 7 districts with 308 health facilities. During this retrospective cross sectional study 2221 MTB detected results of 2017 and 2018, downloaded from 14 of the 15 Genexpert sites in Manicaland were employed to generate hotspot maps. Fifteenth Genexpert site lost its electronic records when Genexpert CPU crushed. Geographical Positioning System (GPS) of the health facilities were recorded.The study used MTB detected frequencies at a facility in relation to surrounding facilities inManicaland, then ran optimised hotspot analysis function in Arc Map 10.5 to implement the Gi* statistic.
Results: Overall provincial MTB detected positivity was 2221/36055 (6.2%).Overall provincial Rifampicin Resistant (RR) positivity was .111.2221(5.0%).Geo-spatial map of Manicaland showed 10 facilities that are RR hotspots with 7/10 (70%) of the facilities in Buhera district. Chipinge district had facilities that were MTB detected high hotspots.For the whole of Manicaland, Buhera district had100% MTB detected low hotspots facilities. Ninety percent hotspots were clusteredaround 2 of the 15 Genexpert Sites in Manicaland, namely Murambinda Mission Hospital and Chipinge District Hospital.
Conclusion: Study identified health facilities with high frequencies of RR areas. For the identified health facilities with high frequencies of RR specimens, NTP may focus DRTB control interventions like PMDT, or mentoring on ShORRT. For the health facilities with high frequencies of MTB detected NTP can focus trainings in TB Case Management. Instead of uniformly spreading the limited resources to all 325 facilities, efforts streamlined to manageable number of 20 facilities incommensurate with identified gap( e.g. objective selection of cadres for training, data driven supportive supervision & targeted awarenesscampaigns).
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Adelson, Kerin B., Amelia Anne Trant, Kim Framski, Mark Swidler, and Nitu Kashyap. "An EPIC electronic decision support tool to identify percentage of patients with stage IV thoracic or gastrointestinal malignancy who would benefit from concurrent palliative care but do not currently receive it." Journal of Clinical Oncology 35, no. 8_suppl (March 10, 2017): 133. http://dx.doi.org/10.1200/jco.2017.35.8_suppl.133.
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133 Background: In 2016 ASCO updated its guideline for early integration of palliative care (PC) into standard oncologic care for all “inpatients and outpatients with advanced cancer.” PC has been shown to improve quality of life, align care at the end of life with patient preferences, and reduce health-care utilization. In preparation for the expansion of our palliative care service into ambulatory disease-based practices at Smilow Cancer Hospital at Yale-New Haven, we sought to create a decision support tool (DST) in the EPIC Electronic Health Record (EHR) that would identify patients for PC referral. Methods: This DST identifies patients with a GI or thoracic malignancy who have had an ICD-10 diagnosis of metastatic or stage IV disease, have not had a palliative care visit in the last 6 months, and are not enrolled in hospice. If the patient meets criteria, the DST will remind providers that “this patient meets ASCO and IOM criteria for concurrent palliative care with oncologic care ” and offers a one-click option to place the referral. To understand the volume of patients this DST would refer, we ran it silently in the EHR background from 7/15/16 through 9/1/16. We tracked how many patients were seen in the clinics, how many were eligible, and how many were referred to PC. Results: See table. Conclusions: Our silent BPA indicated that only 5% of patients eligible for a palliative care consult received it at baseline; this matches national data, which suggests that most patients who would benefit from PC do not receive it. This DST has the potential to dramatically improve PC referral rates and increase adherence with ASCO and IOM guidelines. We plan to move the DST into the live clinical EHR in 2017 after the integrated PC clinics are open. We anticipate that once our BPA is activated, we will see a dramatic increase in the number of eligible patients referred to palliative care. [Table: see text]
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Pathak, Dr Gargi H., Dr Anuya V. Chauhan, and Dr Priyanka Goswami. "Kawasaki disease like presentation of Multisystem inflammatory syndrome in children - A Case report." BJKines National Journal of Basic & Applied Sciences 14, no. 1 (June 10, 2022): 111–14. http://dx.doi.org/10.56018/bjkines20220618.
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A new COVID-19 related clinical syndrome in children called Multisystem inflammatory syndrome in children (MISC) has been reported, with significant inflammation and similarities to Kawasaki disease (KD) with concurrent SARS-CoV-2 in Europe and in USA since 7 April 2020. On 25th April, concerns were initially raised in the United Kingdom regarding a cluster of children of various ages, presenting with a Multisystem inflammatory state who required intensive care, and who all displayed "overlapping features of toxic shock syndrome and atypical Kawasaki disease with blood parameters consistent with severe COVID 19 in children. Clinical presentations were variable, with significant gastrointestinal (GI) symptoms, cardiac disease, mild or absent respiratory symptoms, and variable incidence of rash, red eyes, oral mucous membrane changes. Later on this was diagnosed as part of a post covid Multisystem inflammatory disease (MISC). We report one patient admitted in Civil hospital, Ahmedabad with high grade fever for more than three days along with manifestations of multisystem disease involving cardiovascular system with myocarditis,and gastrointestinal system in form hepatitis, widespread blanchable rashes and respiratory distress due to pleural effusion.The clinical features had similarly to features of Kawasaki disease. Patients also had raised inflammatory markers in form of increased CRP, ESR, PT, APTT. Covid IgG antibody was found positive and patient was treated as per MISC protocol with steroid, IVIG and aspirin together with proper supportive management in form of oxygen through High flow nasal cannula and ionotropes for shock. Multiple theories on pathogenesis have been suggested in form of Antibody dependent enhancement precipitating kawasaki like illness due to cytokine storm provoked by type 1 and 3 interferon. Role of STING (Stimulator of interferon gamma) pathway has been found to be involved in MISC. With proper treatment as per protocol it is possible to successfully discharge patients with MISC admitted in decompensated states. Keywords: MISC, Kawasaki, steroids, PIMS-TS, blanchable rashes, COVID 19 antibody
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Das, L., K. L. Teh, X. Gao, and T. Arkachaisri. "AB1235 MULTISYSTEM INFLAMMATORY DISEASE IN CHILDREN (MIS-C) IN SINGAPORE CHILDREN: ARE WE DIFFERENT?" Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 1729.1–1729. http://dx.doi.org/10.1136/annrheumdis-2022-eular.1498.
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BackgroundMultisystem Inflammatory Syndrome in Children (MISC) is a hyper-inflammatory state with similarities to Kawasaki Disease, 4 to 6 weeks after Covid-19 infection1. Literature describes a 11:1 Relative Risk for Asian children versus Caucasians2. Since the start of the pandemic, 17,699 children under 12 years were infected with Covid-193.ObjectivesTo describe presentation and short term outcomes, for a cohort of children with MIS-C at the sole Children’s Hospital in Singapore.MethodsDemographic and clinical/lab data were collected from children diagnosed with MIS-C accrording to the WHO criteria4 at KK Woman’s and Children’s Hospital, Singapore. Nonparametric descriptive statistics were used to describe and analyse data.ResultsEleven patients were diagnosed with MIS-C between October 2021 and Jan 2022. Seven (64%) were male and 4 (36%) were Chinese, with median age at presentation was 8.08 years (IQR 4.54 - 9.79). All patients had positive COVID-19 serology at the time of diagnosis. Median duration of fever prior to diagnosis was 5 days (IQR 4 - 5); Nine (82%) had gastrointestinal symptoms and median number of Kawasaki Disease (KD) features were 2 (IQR 2 - 3.5); common manifestations were conjunctivitis (90%), red lips (55%) and rash (36%). Of note, 8 (70%) patients had KD type peeling on follow-up. No BCGitis was found during acute phase. Seven (64%) were admitted to higher dependency care.Table 1, all patient received IVIG and IV steroids; 6 (55%) as pulse (30mg/kg/day) therapy. Patient 8, additionally received Anakinra. Median duration of admission was 6 days (IQR 5-13). One patient developed complications post therapy and was re-admitted to hospital for hematochezia. Treatment involved stopping Enoxaparin and Prednisone. Aspirin was resumed as soon as bleeding ceased. Laboratory characteristics and outcomes are denoted in Table 1. All patients had a monophasic course during the median of 10 weeks (IQR 8 - 11.5) of follow-up.Table 1.NoAge (yr)GI symptomsKD featuresHemoglobin (g/DL)Absolute Lymphocyte (10x9/L)Platelet (10x9/L)CRP (mg/L)D-Dimer (mg/L FEU)Ferritin (ug/L)Enoxaparin startedPeelingAbnormal echo110YES212.20.2367173.2323179.1YESYESYES211NO214.8116694.92.51350NOYESYES34.25YES210.41.02241134.66.05277.2YESNOYES47.67YES5110.41102250.69.323607.6YESYESNO58.58YES411.40.5693105.61.31846.6NOYESNO64.58YES210.33.09198137.41.87291NONONO79.58YES312.21.311191842.51244.3NOYESNO84.5YES411.90.45102181.811.121798.4YESNOYES911YES110.11.235974.24.531445.8YESYESNO103.42NO29.11.09138153.98.66609.4YESYESNO118.08YES211.41.2510166.81.31521.8NOYESYESConclusion1.Asian prevalence of MIS-C is not as high as that reported from the West. Similarities in presentation as to age and gender were noted.2.Most of our MIS-c patients developed periungual peeling at follow up, similarly to Kawasaki Disease.3.Different from our typical KD population, no BCG site inflammation was found.References[1]Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA. 2021;325(11):1074-1087.[2]Middelburg JG, Crijnen TEM, D’Antiga L, et al. Association of Ethnicity with Multisystem Inflammatory Syndrome in Children Related to SARS-CoV-2 Infection Frontiers in Pediatrics Oct 2021 Vol 9.[3]Ang Qing, Number of children admitted for covid-19 at KKH doubles since December 2021. New Straits Times, 27 Jan 2022.[4]World Health Organization. Multisystem inflammatory syndrome in children and adolescents with COVID-19: Scientific Brief. 2020Disclosure of InterestsNone declared
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Cremone, Cristiano, Anouk Esch, Charlotte Gagniere, Alessandro Fugazza, Faria Mesli, Michael Levy, Aurelien Amiot, et al. "Patients’ comorbidities reduce the clinical value of emergency colonoscopy: results of a retrospective cohort study." Endoscopy International Open 05, no. 11 (November 2017): E1119—E1127. http://dx.doi.org/10.1055/s-0043-118001.
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Abstract Background and study aims Urgent endoscopy is often used to diagnose and sometimes treat acute upper gastrointestinal syndromes (hemorrhage, toxic ingestion, and occlusion). However, its suitability concerning the management of lower gastrointestinal conditions in emergency circumstances is controversial. Patients and methods We studied the role of emergency colonoscopy in diagnosis and treatment of all consecutive patients presenting with acute lower gastrointestinal symptoms referred to our hospital on an emergency basis. All patients were first managed by physicians from the emergency room and/or the intensive care unit (ICU); the treatments included fluid resuscitation, blood transfusion, and antibiotic or cardiotonic as needed. Bowel cleansing was performed to purge the colon of clots, stool, and blood when clinically possible; alternatively, a bowel enema was used. Patients only underwent a computed tomography (CT) scan prior to the colonoscopy in clinically relevant situations. Colonoscopy was performed within 6 – 36 hours after hospitalization or the beginning of the clinical symptoms (hemorrhage, sepsis, colon distension) or occlusion, as assessed by abdominal CT scan. Results From 2010 to 2015, 603 patients underwent urgent colonoscopy; among them, 214 (36 %) presented with lower GI bleeding, while 264 (44 %) had symptoms suggestive of intestinal ischemia; almost half (49 %, n = 295) of the patients were hospitalized in the ICU. Patients received therapies, such as clips (15 %), epinephrine injections (5 %), bipolar coagulation (7 %), or devolvulation (3 %) using colonoscopy or antibiotic therapy when needed. No perforation was observed after colonoscopy and only three cases of hemorrhage recurrence were documented as complications after the procedure. Overall, 192 patients died within 1 month after colonoscopy due to four independent risk situations, as follows: septic shock, heart transplantation, multiorgan failure, and ischemic colitis. Only 67 (35 %) underwent urgent intestinal surgery when ischemic colitis was identified, and this did not have a significant effect on the mortality rate. Conclusions Urgent bedside colonoscopy is feasible and safe for routine use. The highest advantage was observed in patients with red blood hemorrhage, diarrhea, and colon distension when symptoms were not associated with multiorgane failure, heart transplantation, or septic shock. As revealed by colonoscopy and pathological features, ischemic colitis is associated with a bad prognosis, and patients experience a higher rate of early mortality regardless of whether they undergo urgent colon surgery.
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Hegerova, Livia, Jeffrey P. Anderson, and Colleen T. Morton. "A Systems-Based Approach to Improve Fibrinogen Testing and Treatment of Low Fibrinogen in Patients Receiving Massive Transfusions: A Quality Improvement Initiative." Blood 128, no. 22 (December 2, 2016): 2335. http://dx.doi.org/10.1182/blood.v128.22.2335.2335.
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Abstract Background: Uncontrolled hemorrhage is the most common treatable cause of death and four of every ten trauma patients die as a results of exsanguination, or its late effects (Curry et al. Scand J Trauma 2014). There is an increasing understanding of the state of acute coagulopathy and the role that fibrinogen plays in major hemorrhage (Wikkelso A et al. Cochrane Syst Rev 2013). Fibrinogen is a critical protein for hemostasis and clot formation. Low fibrinogen is a risk factor for hemorrhage in patients with major hemorrhage including surgical, obstetrics and trauma patients. Observational studies have reported improved survival with higher fibrinogen:RBC transfusion ratios in trauma.At Regions Hospital, St. Paul, MN, the Transfusion Committee observed that many patients receiving massive transfusions did not have fibrinogen activity tested. Aim: To improve fibrinogen testing and treatment of low fibrinogen in patients receiving massive transfusions by using a hospital-wide, electronic medical record (EMR)-based Massive Transfusion Protocol (MTP) order set. Outcomes, including survival and transfusion requirements will also be evaluated. Methods: Retrospective analysis of data from existing databases identified 127 patients who had massive hemorrhage as defined by activation of the massive transfusion protocol (MTP) at Regions Hospital between 2014-2016. We performed chart reviews to assess fibrinogen replacement practice 6 months before (n=68) and 6 months (n=59) after implementation of an EMR-based MTP order set in a quality improvement model. The order set automatically orders fibrinogen activity, in addition to hemoglobin, platelet count, INR, and PTT. Once the order set is activated, it will alert the provider to a low fibrinogen activity result using a best practice alert. The alert then directs therapy by opening the order for administration of cryoprecipitate. To evaluate the impact of this order set on fibrinogen testing and clinical outcomes, we constructed multivariable logistic regression models. Results: During the study period, 127 patients had the MTP activated. The median age was 51 years and 67% were male. The majority of MTPs were activated for trauma (57%) located primarily in ED (64%). The common admitting diagnoses were motor vehicle accident (29%), heart surgery/procedure (18%), or GI bleed (16%). The admitting hemoglobin, platelet count, INR, and PTT were similar pre and post-intervention. Prior to the use of the MTP order set, only 32% of patients receiving the MTP had fibrinogen tested. Of the patients with a fibrinogen activity tested, over one-third had a low fibrinogen and of those 56% did not receive cryoprecipitate. Fibrinogen testing increased after the intervention (61% vs 32%, p=0.001), and among patients with low fibrinogen, transfusion of cryoprecipitate occurred more often (70% vs 44%, p=0.370). Blood transfusion requirements for red blood cells (7.0 vs 9.9, p=0.133), fresh-frozen plasma (4.9 vs 6.7, p=0.063), and platelets (1.2 vs 1.6, p=0.068) decreased post-intervention. In multivariate analysis, patients were approximately 3 times more likely to have fibrinogen activity tested after the intervention (OR 3.06, p=0.003). Deaths within 24 hours of MTP were more likely to occur among patients in the pre-intervention period (OR=1.45; 95% CI 0.42-5.00) and those with low fibrinogen (OR=1.34; 95% CI 0.26-7.08), however, due to the limited number of events, these estimates did not reach statistical significance. Conclusions: A systems-based approach with a hospital-wide EMR order set for the MTP improved the testing for and treatment of low fibrinogen in patients with massive hemorrhage. This resulted in a trend towards improved outcomes. We did not achieve 100% fibrinogen testing after the intervention because the MTP can still be activated without using the order set, and this will be corrected in a future update. The treatment of patients with traumatic hemorrhage remains challenging and varies widely between trauma centers. Standardized treatment, automation of lab ordering, and the use of alerts can help providers improve the quality of care and clinical outcomes for patients. Disclosures No relevant conflicts of interest to declare.
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Zvinoera, Katherine, J. Mutsvangwa, E. Chikaka, T. D. Coutinho, V. Kampira, and S. Mharakurwa. "Geo-Spatial Distribution of Frequencies of MTB/RIF Detected Specimens based on Requesting Health Facilities in Manicaland Zimbabwe for 2017 and 2018." Medical Journal of Zambia 48, no. 2 (August 13, 2021): 78–84. http://dx.doi.org/10.55320/mjz.48.2.29.
Full textAbstract:
Objectives: The aim of this study was to produce Geo Spatial Distribution of Frequencies of MTB/RIF Detected Specimens based on Requesting Health Facilities in Manicaland Zimbabwe for 2017 and 2018, so as to give insight to TB program managers. Focusing elimination interventions on hot pockets of Tuberculosis (TB) strengthens rationale use of resources in resource limited countries like Zimbabwe. Early detection and early treatment is backbone of breaking TB transmission. Drug resistant tuberculosis (DRTB) control interventions like Programmatic Management of Drug Resistant TB or mentoring on Short, all Oral Regimen for Rifampicin resistant Tuberculosis (ShORRT) will be driven by science.Materials and Methods: The retrospective study was carried out in Manicaland, Zimbabwe. Manicaland one of the 10 provinces in Zimbabwe, has 7 districts with 308 health facilities. During this retrospective cross sectional study 2221 MTB detected results of 2017 and 2018, downloaded from 14 of the 15 Genexpert sites in Manicaland were employed to generate hotspot maps. Fifteenth Genexpert site lost its electronic records when Genexpert CPU crushed. Geographical Positioning System (GPS) of the health facilities were recorded. The study used MTB detected frequencies at a facility in relation to surrounding facilities in Manicaland, then ran optimised hotspot analysis function in Arc Map 10.5 to implement the Gi*statistic.Results: Overall provincial MTB detected positivity was 2221/36055 (6.2%).Overall provincial Rifampicin Resistant (RR) positivity was .111.2221(5.0%).Geo-spatial map of Manicaland showed 10 facilities that are RR hotspots with 7/10 (70%) of the facilities in Buhera district. Chipinge district had facilities that were MTB detected high hotspots.For the whole of Manicaland, Buhera district had100% MTB detected low hotspots facilities. Ninety percent hotspots were clustered around 2 of the 15 Genexpert Sites in Manicaland, namely Murambinda Mission Hospital and Chipinge District Hospital.Conclusion: Study identified health facilities with high frequencies of RR areas. For the identified health facilities with high frequencies of RR specimens, NTP may focus DRTB control interventions like PMDT, or mentoring on ShORRT. For the health facilities with high frequencies of MTB detected NTP can focus trainings in TB Case Management. Instead of uniformly spreading the limited resources to all 325 facilities, efforts streamlined to manageable number of 20 facilities in commensurate with identified gap( e.g. objective selection of cadres for training, data driven supportive supervision & targeted awareness campaigns).
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Fleischmann, Arnold W., and Simon Mantha. "Effect of Selective Serotonin Reuptake Inhibitors On Intraoperative Blood Loss in Patients Undergoing Prostatectomy." Blood 114, no. 22 (November 20, 2009): 4454. http://dx.doi.org/10.1182/blood.v114.22.4454.4454.
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Abstract Abstract 4454 Background Selective serotonin reuptake inhibitors (SSRI's) are commonly used in the treatment of depression and anxiety disorders. They induce a mild inhibition of platelet aggregation; this is thought to be mediated by a depletion of platelet serotonin. Some studies have shown an association between SSRI intake and GI bleeding; aspirin and non-steroidal anti-inflammatory drugs (NSAID's) might increase the risk even more when used concomitantly. An increase in surgical bleeding during orthopedic procedures has also been noted in users of this class of medications. To our knowledge, there is no published data on the effect of SSRI's on hemostasis during prostatectomy. The objective of this study was to examine if patients taking a SSRI and undergoing prostatectomy had a higher rate of bleeding and required more red cell transfusions than patients not taking such a medication. Methods Institutional review board approval was obtained to perform this retrospective study; the initial phase was conducted on 1,308 adults undergoing either suprapubic, retropubic, perineal, laparoscopic or robotic-assisted laparoscopic prostatectomy for prostate cancer between 2002 and 2008 at the Lahey Clinic. The Department of Urology database was queried to identify relevant surgical cases, the amount of blood lost and the number of red cell transfusions given during each procedure. Patient records available through the Lahey electronic system were reviewed to identify pre-operative medications and comorbidities having a potential to affect surgical hemostasis. The use of antidepressants by type, aspirin, clopidogrel, NSAID's and anticoagulants was recorded, as were a history of liver disease, renal insufficiency, thrombocytopenia or any coagulopathy. Statistical analysis was conducted with the SAS software, version 9.2; means were compared using Student's T-test. Results 3.2% of the patients included in the analysis were on a SSRI until the day of the surgery. Aspirin, clopidogrel and warfarin were discontinued in view of the upcoming procedure, with rare exceptions. Analysis was stratified according to the type of prostatectomy, either open (suprapubic, retropubic or perineal) or laparoscopic (with or without robotic assistance). Mean age was 58.2 years for SSRI users and 59.2 years for non-users (p=0.31). There was no significant difference in the distribution of comorbidities between SSRI users and non-users. In the open prostatectomy group, use of aspirin in the immediate pre-operative period was more prevalent in the group of SSRI users compared to non-users (6.3% vs 0.8%, p=0.03), as was the uninterrupted use of NSAID's (6.3% vs 0.2%, p=0.0002); please see table 1 for details. In the open surgery group, mean volume of blood lost was 794 mL for SSRI users, compared to 878 mL for non-users (p=0.57). In the laparoscopic surgery group, mean blood loss was 178 mL in SSRI users vs 188 mL in non-users (p=0.69). In the laparoscopic procedure group, only 1 out of 807 patients was transfused. In the open surgery group, 31.3% of SSRI users required one unit of red cells, compared to 29.8% for non-users (p=NS). Only one patient died in the hospital; he belonged to the laparoscopic approach group (SSRI non-user). Conclusion In this study, the use of a SSRI did not confer an increased risk of surgical bleeding. This was noted even in patients undergoing open prostatectomy, in spite of more patients in the SSRI user group taking aspirin or a NSAID up to the day of the surgery. Disclosures: No relevant conflicts of interest to declare.
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Shaw, Joseph, Gregoire Le Gal, Melanie Tokessy, Nancy Cober, Elianna Saidenberg, Marc Carrier, and Lana Castellucci. "FEIBA™ for Reversal of Direct Oral Anticoagulant Associated Major Bleeding." Blood 124, no. 21 (December 6, 2014): 1540. http://dx.doi.org/10.1182/blood.v124.21.1540.1540.
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Abstract Introduction: Direct oral anticoagulants (DOACs) are indicated for the prevention of systemic embolism in patients with atrial fibrillation and for the prevention and treatment of venous thrombosis. Although DOACs offer advantages over the vitamin K antagonists, some hesitancy remains over their use given the lack of specific antidotes for management of life threatening bleeding events. In vivo studies, case reports and case series have shown that prothrombin complex concentrate (PCC) and activated PCC might potentially be used to control life threatening bleeding in patients with DOAC-associated bleeding episodes. Herein we describe management and outcomes of DOAC-associated life threatening bleeding events using an activated PCC (FEIBA™). Methods: A retrospective review of patients presenting with DOAC-associated (dabigatran, rivaroxaban or apixaban) life threatening bleeding to The Ottawa Hospital between January 2013 and June 2014 are included. Patients received 25 – 50 units/kg of FEIBA™. The primary outcome was adverse thrombotic and embolic events during follow-up. Secondary outcome was symptomatic control of bleeding. Results: Nine patients presented to hospital with life threatening bleeding episodes (post trauma: n=3; spontaneous bleeding: n=6). Spontaneous episodes included epistaxis or gastro-intestinal bleeding. Baseline characteristics are depicted in Table 1. A majority of patients had atrial fibrillation (n=8) and received rivaroxaban (n=5). The last dose of DOAC was taken within 24 hours of bleeding events for all patients. All patients received supportive management, interventions/procedures aimed at attaining source control of bleeding when possible, and transfusion of FEIBA™ for reversal of anticoagulant effect. Adverse events after receiving FEIBA™ were uncommon with one patient experiencing a TIA with expressive aphasia and visual field deficit on the evening of FEIBA™ transfusion; deficits resolved by the time of hospital discharge. Two patients with GI bleeding continued to have ongoing bleeding despite FEIBA™ administration and two patients died as a result of major bleeding. Conclusions: In this cohort of patients with major bleeding associated with DOACs, FEIBA™ administration, in addition to supportive care, was helpful in minimizing further complications of most bleeding events and associated with a low rate of adverse events. Prospective studies are needed to evaluate benefits and harms of FEIBA™ for management of DOAC associated major bleeding. Abstract 1540. Table 1: Patients with Life-threatening Bleeding Patient (Age and Gender) Indication for DOAC [AF(CHADS2); VTE] DOAC and Dosage Site of Bleeding Intervention/ Procedure Units of PRBCs Transfused Additional Treatment FEIBA™ Dose (IU)(1st/2nd) Adverse Events post-FEIBA™ Administration Survived Hospitalization 85 Male AF (2) Rivaroxaban 20 mg daily Epistaxis Nasal Packing 0 -- 3275 -- Yes 86 Male AF (2) Rivaroxaban 20 mg daily LGIB Angiogram, no embolization performed 10 Vitamin K 3159/ 2952 -- Yes 84 Male AF (2) Dabigatran 110 mg BID Orbital vitreous hemorrhage Surgical repair of ruptured globe 0 -- 1812 -- Yes 92 Male AF (6) Apixaban 5 mg BID Left hand Conservative management 1 Tranexamic acid 2718 TIA Yes 85 Male VTE Rivaroxaban 20 mg daily LGIB Conservative management 2 Vitamin K 1740 -- Yes 90 Female AF (5) Rivaroxaban 20 mg daily SDH Conservative management 0 -- 3275 -- No; died of major bleed 93 Female AF (6) Apixaban 2.5 mg BID LGIB Conservative management 4 -- 2241 -- No 93 Male AF (3) Rivaroxaban 15 mg daily UGIB Upper endoscopy, no intervention 4 Vitamin K 3000 -- No; died of major bleed and septic shock 81 Male AF (4) Dabigatran 110 mg BID LGIB Upper endoscopy and colonoscopy, no interventions 4 -- 3362 -- No AF = atrial fibrillation; BID = twice daily; CHADS = congestive heart failure, hypertension, age, diabetes, stroke; DOAC = direct oral anticoagulant; IU = international units; LGIB = lower gastrointestinal bleeding; PRBC = packed red blood cells; SDH = subdural hematoma; TIA = transient ischemic attack; UGIB = upper gastrointestinal bleeding; VTE = venous thromboembolism Disclosures Off Label Use: FEIBA is an activated prothrombin complex concentrate that was used during management of life threatening bleeding in patients with direct oral anticoagulant-associated bleeding episodes..
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Chai-Adisaksopha, Chatree, Matthew Cheah, Said Y. ALKindi, Alfonso Iorio, Mark A. Crowther, and Lori Ann Linkins. "Bleeding in Patients Receiving Low-Molecular-Weight Heparin for Cancer-Associated Thrombosis." Blood 126, no. 23 (December 3, 2015): 1120. http://dx.doi.org/10.1182/blood.v126.23.1120.1120.
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Abstract Background: Bleeding is a major concern in patients who are treated with anticoagulants. To date, there are no studies of predictors of bleeding in cancer-associated thrombosis patients who receive extended duration low-molecular-weight heparin (LMWH). This study aims to determine the incidence and predictors of bleedings in these patients in a real-world setting. Methods: A retrospective cohort (chart review) study was conducted from January 2011 to January 2014 at Juravinski Cancer Center, Hamilton, Canada. Consecutive objectively proven venous thromboembolism (VTE) patients were included if they had active cancer and were planned to receive extended duration LMWH (longer than 4 weeks). The primary outcome measure was the incidence of clinically relevant bleeding, which was defined as bleeding that required investigation, an invasive procedure, hospital admission or withholding LMWH for greater than or equal to 3 days. Secondary outcome measures included incidence of major bleeding (defined by bleeding that was associated with drop of hemoglobin at least 20 g/L or required at least 2 units of red blood cell transfusion, bleeding in critical site or fatal bleeding) and incidence of objectively proven recurrent VTE. Results: Data were available for 1,144 patients with a median follow-up of 8.5 months. The average age (standard deviation, [SD]) of the patients was 63.6 (12.2) years, and 53.6% were female. Concomitant antineoplastic treatment consisted of chemotherapy (45.1%), radiotherapy (5.7%), targeted therapy (1.9%) and combination therapy (17.5%). No antineoplastic treatment was given during the study period to 29.7% of the patients. The cumulative incidence of clinically relevant bleeding was 4.6% at 3 months, 7.3% at 6 months and 10.3% at 12 months, Figure 1. Sites of bleeding were gastrointestinal tract (49.6%), genitourinary tract (16.2%), intracranial (9.0%), muscle and retroperitoneal (8.2%), and others (17.1%). Of the gastrointestinal bleeds, 52.3% occurred in patients who were not documented to have the GI tract as the primary site of malignancy. The cumulative incidence of major bleeding was 5.5% (1.6% of the study cohort had a fatal bleed). At the time of the bleeding event, the mean (SD) hemoglobin was 87.2 (23.1) g/L, mean platelet count (SD) was 251.8 (158.4) x109/L and 61% of patients received a red blood cell transfusion (median 2 unit [range, 1-7]). The independent predictors of bleeding in a multivariable model were hypertension, metastatic disease, prostate cancer, soft tissue sarcoma and recurrent VTE (Table 1.). The presence of brain tumour (primary or secondary) was not statistically significantly associated with an increased risk of clinically relevant bleeding. The cumulative incidence of recurrent VTE was 12.0%. Seventy-six percent of recurrent VTE occurred while patients were receiving anticoagulant therapy. Conclusions: This study suggests that predictors for clinically relevant bleeding in patients who receive extended duration LMWH for treatment of cancer-associated thrombosis include hypertension, metastatic disease, and recurrent VTE, in addition to tumour-site specific characteristics. Investigation into measures to reduce the frequency of gastrointestinal bleeding, the most common form of anticoagulant-related bleeding in both gastrointestinal cancer and non-gastrointestinal cancer, would be beneficial. Table 1. Univariate and multivariate analysis of the predictors of bleeding Variables Univariate analysis Multivariate analysis Odd ratio 95% CI Odd ratio 95% CI P-value Age <45 y 45-75 y ≥75 y Reference 1.8 1.8 Reference 0.7-4.8 0.7-4.7 N/A N/A N/A CrCl≥60 ml/min 30-60 ml/min <30 ml/min Reference 1.4 2.9 Reference 0.9-2.0 0.8-10.9 N/A N/A N/A Hypertension 1.7 1.2-2.5 1.8 1.2-2.7 0.007 Metastasis 1.8 1.2-2.8 2.0 1.3-3.1 0.003 Prostate cancer 2.5 1.1-6.0 2.6 1.1-6.3 0.036 Soft tissue sarcoma 3.0 1.2-7.8 4.0 1.5-11.0 0.006 Recurrent VTE 2.1 1.3-3.4 2.1 1.3-3.4 0.004 Abbreviations: CrCl; creatinine clearance, CI; confidence interval, VTE; venous thromboembolism, N/A; not applicable Figure 1. Cumulative risk of clinically relevant bleeding in cancer-associated thrombosis patients who received low-molecular weight heparin Figure 1. Cumulative risk of clinically relevant bleeding in cancer-associated thrombosis patients who received low-molecular weight heparin Disclosures No relevant conflicts of interest to declare.
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Fleming, Patrick, Maggie Cheung, and David Sokol. "Complement-Mediated Thrombotic Microangiopathy: A Murky Presentation of a Rare Disease Entity." Blood 132, Supplement 1 (November 29, 2018): 5005. http://dx.doi.org/10.1182/blood-2018-99-119893.
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Abstract Complement-mediated thrombotic microangiopathy (TMA), also known as atypical hemolytic uremic syndrome (aHUS) is a rare, hereditary, progressive, life-threatening disorder caused by a disruption in regulation of the alternative pathway of the complement system. Eculizumab, a terminal complement inhibitor, has emerged as a first-line therapy, however data are limited to small case series (Brocklebank et al., 2017). Here, we present a diagnostically challenging case of complement-mediated TMA, who received eculizumab therapy with excellent hematologic response. A 68-year-old female with history of possible Sjogren's syndrome, migraine disorder, chronic fatigue syndrome, inflammatory colitis, hypertension, and poor medical follow up presented with 6-day history of severe fatigue, hematochezia, decreased urine output, dyspnea with exertion and anginal chest pain. 2 weeks prior, patient endorsed "flu-like" illness and had diffuse myalgias without fevers. Further history revealed ibuprofen usage of 800-1200 mg/day for several years. Shortly after admission, patient became severely agitated and confused with an attempt to elope from hospital. During diagnostic workup, labs were significant for hemoglobin 5.6 g/dL, platelets 57,000/uL, serum creatinine 6.6 mg/dL, BUN 101 mg/dL. Peripheral smear showed schistocytes and tear drop cells, low platelets without clumping, and hypochromic normocytic red cells. LDH of 2152 U/L, haptoglobin <34 mg/dL, and GI PCR was panel negative for E. coli O157 and Shiga-like toxin producing E. coli. She was presumed to have thrombotic thrombocytopenic purpura (TTP) as she presented with 4 of the 5 characteristic pentad, including microangiopathic hemolytic anemia, acute renal failure, thrombocytopenia, and severe neurologic findings. Patient received several PRBC transfusions, five plasma exchange treatments, hemodialysis and corticosteroids. She had initial improvement in platelet count and decrease in LDH with plasma exchange, however plateaued by day 5. Further testing revealed low complement C3 level of 51 mg/dL, low complement C4 level of 22.7 mg/dL, and pre-PLEX ADAMSTS13 level of 93%, suggesting complement-mediated TMA as the correct diagnosis. Patient was subsequently transferred to tertiary care center for initiation of eculizumab. Genetic testing was completed, notable for decreased Factor H and a heterozygous missense mutation in complement factor H of uncertain significance, only having been previously reported in a single patient with aHUS (Fremeaux-Bacci et al., 2013). She achieved excellent hematologic response with eculizumab evidenced by improved platelet count, haptoglobin, decreased LDH, however she unfortunately remained dialysis-dependent. Thrombotic microangiopathy (TMA) syndromes are overlapping entities which can be categorized by primary vs secondary etiology. Primary syndromes include TTP (hereditary or acquired), Shiga-toxin mediated HUS, drug-induced TMA and complement mediated TMA. Secondary causes include pregnancy-associated (pre-eclampsia/HEELP syndrome), malignancy, systemic infection, severe hypertension, autoimmune disorders like SLE, and complications from organ transplantation. When evaluating a patient with suspected TMA, it is important to correctly categorize their disease to guide appropriate treatment. Complement-mediated TMA results from a hereditary deficiency of regulatory proteins that restrict activation of alternative complement pathway. These proteins include complement factor H (CFG) and its related proteins (CFHRs), membrane cofactor protein (MCP), CFI. Instead, it may result from an autoantibody inhibiting CFH of CFI. The consequence of this up-regulation is uncontrolled damage to vascular endothelium and renal cells, which manifests as a characteristic pentad. In our case, a CFH gene mutation was identified and history revealed a flu-like illness preceding her hospitalization. It is plausible that this illness may have served as a "second-hit" via complement-amplification. (Asif et al., 2017). Alternatively, in this patient with history of inflammatory colitis and reported Sjogren's syndrome, subclinical autoimmune disorder may also have served as a trigger. This case presentation serves as a reminder to not overlook the "zebra" that is complement-mediated TMA, to allow for prompt initiation of eculizumab therapy. Figure. Figure. Disclosures No relevant conflicts of interest to declare.
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Songdej, Duantida, Nongnuch Sirachainan, Pakawan Wongwerawattanakoon, Praguywan Kadegasem, and Ampaiwan Chuansumrit. "Deferiprone Oral Solution, An Alternative for Early Chelation Therapy In Young Children with Transfusional Iron Overload: A Preliminary Data From A 6-Month Study Period." Blood 118, no. 21 (November 18, 2011): 2108. http://dx.doi.org/10.1182/blood.v118.21.2108.2108.
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Abstract Abstract 2108 Introduction: The choice of chelation therapy is limited in young children with transfusional iron overload. Desferrioxamine can disturb bone growth especially in those younger than 6 years of age. Moreover, incooperation of young patients to subcutaneous overnight infusion of the medication causes none adherence. Deferasirox is an unaffordable chelation for many patients in developing countries. Deferiprone has been evaluated in several studies for its safety and efficacy in young children. However, the widely used large tablet form of deferiprone may not be suitable for this group of patients. Objective: To study efficacy, safety and tolerability of deferiprone oral solution for early chelation therapy in young children with transfusional iron overload. Inclusion criteria: Patients age <10 years with transfusional iron overload (ferritin >1,000 ng/mL or received >10 transfusions) at Pediatrics Department, Faculty of Medicine, Ramathibodi Hospital, Mahidol University that fail to accomplish adequate chelation by desferrioxamine or deferiprone tablet due to poor compliance. Methods: Deferiprone oral solution (Ferriprox®) was given at a dose of 75 mg/kg/day in three divided dose for patients who previously received tablet form of deferiprone and 50 mg/kg/day for others who never experienced deferiprone. Ferritin level, complete blood counts, alanine transferase, serum creatinine and spot urine protein were measured every 4 weeks. Complete history taking and physical examination were performed and compliance was recorded during monthly visit. Results: A total of 10 patients were enrolled with equal male and female. The median age was 4.8 years (range 2–9.8 years) whereas seven patients was ≤5 years of age. Seven out of 10 patients were diagnosed β thalassemia HbE disease and the rest were diagnosed β thalassemia major, HbH disease and hereditary spherocytosis respectively. Only one patient was splenectomized and none of them was seropositive for hepatitis B or C virus. All patients have received regular packed red cell transfusion for the median of 3.9 years (range 1.1–6.4 years) to maintain pretransfusion hematocrit of 27%. The median transfusional iron load was 0.39 mg/kg/day (range 0.29–0.48 mg/kg/day) whereas the median ferritin level at the beginning of the study was 1,598.2 ng/mL (range 654.4–3, 163.8 ng/mL). Two patients were previously chelated with desferrioxamine, three patients with deferiprone tablet and 1 with combined desferrioxamine and deferiprone tablet. The remaining four patients were naïve for deferiprone oral solution. Efficacy The median ferritin level at the end of 6 months was significantly lower than that of pretreatment period (median 1,445.8 ng/mL, range 114.6–2806.2 ng/mL, p=0.037). Four out of 10 patients had final ferritin level at 6 months <1,000 ng/mL and half of them had ferritin level <500 ng/mL. This group of four patients were ≤5 years old and had ferritin level between 654.4–1, 507.8 ng/mL at the beginning of study. However, the transfusional iron load was ranging from 0.36–0.48 mg/kg/day. They all received 50 mg/kg/day of deferiprone solution. One out of these four was a patient with HbH disease who was occasionally transfused. The ferritin level of the boy decreased from 654.4 ng/mL to 114.6 ng/mL and deferiprone oral solution could be stopped at the end of the third month. Safety No episode of neutropenia or agranulocytosis occurred. One patient had an episode of mild thrombocytopenia of 137,000/μL during the second month of treatment. However, deferiprone oral solution was continued and spontaneous recovery of platelet counts was observed on the following month. No transaminitis and renal impairment were found. Neither arthralgia nor GI discomfort occurred. Tolerability All patients tolerated well with deferiprone oral solution and excellent compliance of the treatment was achieved. Conclusion: Deferiprone oral solution is a safe and effective alternative for chelation therapy in transfusion-related iron overload especially those with younger age. Serum ferritin level decreased well in a short period of time with only as low dose of deferiprone as 50 mg/kg/day when given at earlier age with starting ferritin level ≤1,000 ng/mL. Better absorption of deferiprone in the form of solution may be a reason for such efficacy. Moreover, liquid formulation of the medication could be a solution to improve adherence to chelation treatment in young children. Disclosures: No relevant conflicts of interest to declare.
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Bocian, Hillel, Caroline Piatek, Howard A. Liebman, Casey L. O'Connell, Ilene Ceil Weitz, and Cage Saul Johnson. "Combination Treatment of Rituximab, Cyclophosphamide, and Dexamethasone for Warm Autoimmune Hemolytic Anemia." Blood 128, no. 22 (December 2, 2016): 4802. http://dx.doi.org/10.1182/blood.v128.22.4802.4802.
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Abstract Introduction Warm autoimmune hemolytic anemia (WAIHA) is an uncommon blood disorder characterized by autoantibody destruction of red blood cells. Although the initial response rate to corticosteroid therapy is 70-85%, less than 20% of patients are cured by corticosteroid therapy alone (Murphy and LoBuglio, 1976). Treatment options for refractory disiease include splenectomy, rituximab, immunosuppression, and cytotoxic therapy. The combined regimen of rituximab, cyclophosphamide and dexamethasone (RCD) has been reported to have significant efficacy in the treatment of WAIHA in patients with chronic lymphocytic leukemia (Gupta et al 2002; Kaufman et al 2009). Due to our experience of a poor response to single agent rituxumab, we treated a cohort of patients with primary and secondary WAIHA with RCD. We now report the outcomes of 19 patients treated with this regimen. Methods Between January 1, 2009 to August 1, 2016, a cohort of patients with primary and secondary WAIHA was treated with RCD at LAC-USC Medical Center, USC Norris Cancer Center, and Keck Hospital of USC. RCD was administered as follows: rituximab 375 mg/m2 IV D1, cyclophosphamide 750 mg/m2 D1 or D2, and dexamethasone 12 mg PO/IV D1-7. Treatment cycles were repeated at 3-to-4-week intervals until the best achievable response. Complete response (CR) was defined as hemoglobin (Hb) > 12 g/dL and normalization of hemolytic markers (reticulocyte count, LDH, and indirect bilirubin). If Hb was > 12 g/dL and there was mild elevation in the hemolytic markers attributable to comorbid conditions, this was also considered a CR. Partial response (PR) was defined as Hb ≥ 10 g/dL or > 2 g/dL increase in Hb. Results 19 patients with WAIHA received RCD. The median number of cycles was 4 (range 2-7). Median age was 37 (range 21-77). 16 were female. 7 had secondary WAIHA (1 with Graves disease, 2 with systemic lupus erythematosus [SLE], 1 with rheumatoid arthritis [RA]-SLE overlap syndrome, 1 with RA-Sjogrens overlap syndrome, 1 with autoimmune hepatitis, and 1 with likely autoimmune lymphoproliferative syndrome (APLS). 12 had primary WAIHA. 2 patients had Evans syndrome. RCD was first line treatment in 6 patients. In pre-treated patients, the median number of prior treatments was 2 (range 1-7). All pre-treated patients had received steroids; 3 had received rituximab; 1 had splenectomy. Other prior treatments included mycophenolate, azathioprine, cyclosporine, intravenous immunoglobulin, alemtuzumab, and sirolimus. Overall response rate was 97% (18/19) (8 with CR, 10 with PR). Among those with CR, 4 had primary WAIHA and 6 had received prior treatment. Among those with PR, 7 had primary WAIHA and 5 had received prior treatment. 11 patients were placed on maintenance immunosuppression after completing RCD. Of the 7 patients who did not receive maintenance immunosuppression, the median duration of response was 8 months at the time of abstract submission. The longest duration of response was 22 months at the time of abstract submission. 1 patient who had a CR, relapsed 2 years later and received additional RCD without response. 1 patient with Evans syndrome, hypogammaglobinemia, and possible ALPS had received 7 prior lines of treatment, including rituximab and splenectomy. This patient had a CR of WAIHA and ITP with RCD. During and after RCD, she was continued on sirolimus and mycophenolate. Cyclophosphamide was held for ≥ 1 cycle in 4 patients (1 due to patient refusal due to alopecia, 1 due to mouth pain, 1 due to scheduling issues, 1 due to unclear reason). 1 patient had dose-reduction of cyclophosphamide due to young age. There was 1 missed dose of rituximab due to patient non-adherence. Treatment delays occurred in 1 patient due to patient non-adherence. Toxicities included GI symptoms (2), headache (1), oral pain with dysphagia (1), flu-like symptoms (1) syncopal episode (1), hypersensitivity reaction to rituximab (2), aplastic anemia from viral infection (1), alopecia (1), hospitalization for cellulitis (1), and thrombocytopenia (2). Conclusions RCD has a high overall response rate in the upfront and refractory treatment of patients with primary and secondary WAIHA with an acceptable toxicity profile. Disclosures No relevant conflicts of interest to declare.
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Landau, Heather J., Gunjan L. Shah, Morgan Reeds, Patrick Hilden, Marci Andrejko, Alison Applebaum, Jason Batalha, et al. "Homebound Autologous Hematopoietic Cell Transplantation for Plasma Cell Disorders in an Urban Setting Is Safe for Patients and Preferred By Patients and Caregivers." Blood 132, Supplement 1 (November 29, 2018): 2258. http://dx.doi.org/10.1182/blood-2018-99-120049.
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Abstract Background: Autologous hematopoietic stem cell transplantation (AHCT) is a mainstay of therapy for eligible patients with multiple myeloma (MM) and light chain (AL) amyloidosis and confers a progression free and overall survival benefit in most studies. Yet, AHCT requires specialized care at a transplant center and investment from patients and caregivers. To decrease the burden of therapy and increase access to AHCT, we studied the safety and feasibility of delivering transplant care in a homebound setting. Methods: Eligible MM and AL patients undergoing AHCT resided in designated zip codes, had 24hr caregiver support, adequate Wi-Fi connection, Sorror Co-morbidity index ≤ 3 and Karnofsky performance status ≥ 80. Following high-dose melphalan (day -2) and stem cell reinfusion (day 0) in the outpatient clinic, protocol-specific homecare commenced (day +1) until engraftment. Care included daily assessments by advanced practice providers and interventions were delivered by registered nurses in the afternoons. Attending physicians communicated through telemedicine daily. Due to regulation, blood products required infusion in the outpatient clinic. Patient and caregiver quality-of-life (QOL) and satisfaction were assessed using patient/caregiver reported outcome instruments (Functional Assessment of Cancer Therapy (FACT)-General and FACT-Bone Marrow Transplant (FACT-BMT) questionnaires, MD Anderson Symptom Inventory (MDASI), Caregiver QOL Index--Cancer (CQOL-C) and satisfaction surveys). Video diaries and one-on-one interviews provided detailed qualitative evaluations. The primary objective was feasibility defined by readmission within 21 days of AHCT. Descriptive statistics were used to describe the population, toxicities and QOL measures. Results: Between 2/2016 - 5/2018, 15 patients (60% MM; 40% AL) and caregivers met inclusion criteria. Patient median age was 62 years (range 40-71) with 80% male. AHCT was part of 1st line therapy in most patients (N=13); 2 with MM underwent 1st AHCT as part of salvage. Melphalan dose was 200mg/m2 (N=11) or less (N=4) in patients ≥70 or AL. All patients received pegfilgrastim 6mg on day +1; thereafter, intravenous fluids and electrolytes were the most common interventions administered at home. During homecare, a median of 2 (range 1-3) visits to clinic were required for platelet transfusions and only 1 patient required 1 red cell transfusion. Median time to neutrophil and platelet engraftment was 9 (range 8-10) and 18 (range 11-22) days, respectively. Overall 7/15 (47%) (95% CI; 0.21-0.73) of patients were admitted for a median of 4 (range 3-10) days. Admission occurred on day +7 (N=5), day +8 (N=1) and day +12(N=1). Reasons for admission included neutropenic fever (NF) (N=2), fever attributed to engraftment syndrome (N=2), diarrhea (N=2), and dehydration (N=1). Only 1 (7%) patient had a documented infection (C. difficile) and 1 admitted for NF required ICU care (2 days) for GI bleed. Overall, 47% of patients experienced grade ≥ 3 non-hematologic toxicities. There were no deaths on study. Results of thematic content analysis of transcripts for patient-caregiver dyads demonstrate that while feeling challenged, caregivers derived satisfaction from assisting with the patient's recovery through maintaining hygiene of the home environment, managing dietary needs and responding to symptoms. Caregivers reported that living with the patient during AHCT strengthened their relationship by being able to provide for one another in unanticipated ways. Patients reported positive support from the medical team, connection to the world and the ability to engage in relaxing activities and physical exercise as important during AHCT. Caregivers and patients unanimously described the homebound program as preferable to a hypothesized experience in the hospital and satisfaction surveys indicated favorable responses (Figure). Symptom burden and QOL data are being analyzed. Conclusion: Homebound AHCT is safe and feasible with less than half of patients requiring inpatient admission. Patients required an average of two outpatient visits while receiving homebound care for blood products. Qualitative evaluations of the program by patients and caregivers were overwhelmingly positive. Based on these results we intend to expand the homebound program and investigate other potential biologic (microbiota diversity preservation) and economic benefits. Disclosures No relevant conflicts of interest to declare.
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Montoro, Miguel, Mercedes Cucala, Ángel Lanas, Cándido Villanueva, Antonio José Hervás, Javier Alcedo, Javier P. Gisbert, et al. "Indications and hemoglobin thresholds for red blood cell transfusion and iron replacement in adults with gastrointestinal bleeding: An algorithm proposed by gastroenterologists and patient blood management experts." Frontiers in Medicine 9 (September 15, 2022). http://dx.doi.org/10.3389/fmed.2022.903739.
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Gastrointestinal (GI) bleeding is associated with considerable morbidity and mortality. Red blood cell (RBC) transfusion has long been the cornerstone of treatment for anemia due to GI bleeding. However, blood is not devoid of potential adverse effects, and it is also a precious resource, with limited supplies in blood banks. Nowadays, all patients should benefit from a patient blood management (PBM) program that aims to minimize blood loss, optimize hematopoiesis (mainly by using iron replacement therapy), maximize tolerance of anemia, and avoid unnecessary transfusions. Integration of PBM into healthcare management reduces patient mortality and morbidity and supports a restrictive RBC transfusion approach by reducing transfusion rates. The European Commission has outlined strategies to support hospitals with the implementation of PBM, but it is vital that these initiatives are translated into clinical practice. To help optimize management of anemia and iron deficiency in adults with acute or chronic GI bleeding, we developed a protocol under the auspices of the Spanish Association of Gastroenterology, in collaboration with healthcare professionals from 16 hospitals across Spain, including expert advice from different specialties involved in PBM strategies, such as internal medicine physicians, intensive care specialists, and hematologists. Recommendations include how to identify patients who have anemia (or iron deficiency) requiring oral/intravenous iron replacement therapy and/or RBC transfusion (using a restrictive approach to transfusion), and transfusing RBC units 1 unit at a time, with assessment of patients after each given unit (i.e., “don’t give two without review”). The advantages and limitations of oral versus intravenous iron and guidance on the safe and effective use of intravenous iron are also described. Implementation of a PBM strategy and clinical decision-making support, including early treatment of anemia with iron supplementation in patients with GI bleeding, may improve patient outcomes and lower hospital costs.
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Arpit, Bansal. "ETIOLOGICAL PROFILE OF LOWER GASTROINTESTINAL BLEED IN A TERTIARY CARE HOSPITAL IN NORTHERN INDIA." INDIAN JOURNAL OF APPLIED RESEARCH, November 1, 2019, 1–2. http://dx.doi.org/10.36106/ijar/6301547.
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NTRODUCTION - Lower Gastrointestinal(GI) bleeding refers to blood loss of recent onset originating from a site distal to the ligament of Treitz.1It usually presents as hematochezia i.e. passage of maroon or bright red blood or blood clots per rectum. Lower GI bleeding ( LGIB) accounts for almost 20% of all cases of acute GI bleeding.2 The etiology and the epidemiology of LGIB varies according to the environmental conditions depending upon the life style, dietary habits, the prevalence of smoking, history of drug intake, age and longevity of the population etc.2 Most of the studies pertaining to the etiologies of Lower GI bleeding are from the West. Data relating to the incidence and etiologies of Lower GI bleed in India is scarce hence this study was undertaken to identify the etiological profile of patients presenting with Lower GI bleeding in a tertiary care hospital in the northern part of India. MATERIALS AND METHODS - It is a Cross-sectional study done over a period of 1 year from January, 2018 to December, 2018. All the patients above 18 years of age with first presentation of Lower GI bleeding to the Department of Medicine, SRMS- IMS, Bareilly, Uttar Pradesh during the period of study are included in the study. RESULTS - A total of 232 patients meeting the inclusion criteria were included in the study. Majority of the patients were males (69.8%). Hematochezia (86%) was the most common presenting feature and was commonly associated with constipation (46%), abdominal pain (32%) and loss of weight (11%). 8% of the patients had a history of Diabetes. Alcohol consumption was seen in 17% of the patients while 26% of the patients had a history of smoking. The most common etiology of Lower GI bleed seen was Hemorrhoids (35.3%), followed by Inflammatory Bowel disease(16.3%), Malignancy(12%) and Radiation proctosigmoiditis (11.2%). CONCLUSION - LGIB is a common and alarming presenting condition in the practice of gastroenterology. It was found that Lower GI bleed is more common in males, usually in the 3rd to 4th decade of life and most commonly presents with hematochezia. Haemorrhoids, IBD and Malignancy were the major causes of Lower GI bleed.
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Paterson, Hugh M., Seonaidh Cotton, John Norrie, Susan Nimmo, Irwin Foo, Angie Balfour, Doug Speake, et al. "The ALLEGRO trial: a placebo controlled randomised trial of intravenous lidocaine in accelerating gastrointestinal recovery after colorectal surgery." Trials 23, no. 1 (January 28, 2022). http://dx.doi.org/10.1186/s13063-022-06021-5.
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Abstract Background Return of gastrointestinal (GI) function is fundamental to patient recovery after colorectal surgery and is required before patients can be discharged from hospital safely. Up to 40% of patients suffer delayed return of GI function after colorectal surgery, causing nausea, vomiting and abdominal discomfort, resulting in longer hospital stay. Small, randomised studies have suggested perioperative intravenous (IV) lidocaine, which has analgesic and anti-inflammatory effects, may accelerate return of GI function after colorectal surgery. The ALLEGRO trial is a pragmatic effectiveness study to assess the benefit of perioperative IV lidocaine in improving return of GI function after elective minimally invasive (laparoscopic or robotic) colorectal surgery. Methods United Kingdom (UK) multi-centre double blind placebo-controlled randomised controlled trial in 562 patients undergoing elective minimally invasive colorectal resection. IV lidocaine or placebo will be infused for 6–12 h commencing at the start of surgery as an adjunct to usual analgesic/anaesthetic technique. The primary outcome will be return of GI function. Discussion A 6–12-h perioperative intravenous infusion of 2% lidocaine is a cheap addition to usual anaesthetic/analgesic practice in elective colorectal surgery with a low incidence of adverse side-effects. If successful in achieving quicker return of gut function for more patients, it would reduce the rate of postoperative ileus and reduce the duration of inpatient recovery, resulting in reduced pain and discomfort with faster recovery and discharge from hospital. Since colorectal surgery is a common procedure undertaken in every acute hospital in the UK, a reduced length of stay and reduced rate of postoperative ileus would accrue significant cost savings for the National Health Service (NHS). Trial registration EudraCT Number 2017-003835-12; REC Number 17/WS/0210 the trial was prospectively registered (ISRCTN Number: ISRCTN52352431); date of registration 13 June 2018; date of enrolment of first participant 14 August 2018.
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Kim, Hyokee, Sun-Young Ko, and Jun Gyo Gwon. "Trends of Blood Transfusion According to Diseases in Korea: A 10-Year Nationwide Cohort Study." Transfusion Medicine and Hemotherapy, November 22, 2022, 1–9. http://dx.doi.org/10.1159/000526626.
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<b><i>Introduction:</i></b> Recent guidelines recommend restrictive red blood cell transfusion; therefore, hospitals have started introducing and implementing patient blood management programs. This is the first study to analyze changes in the trends of blood transfusions in the whole population over the past 10 years according to sex, age group, blood component, disease, and hospital type. <b><i>Methods:</i></b> This cohort study analyzed blood transfusion records for 10 years, from January 2009 to December 2018, using nationwide population-based data from the Korean National Health Insurance Service-Health Screening Cohort database. <b><i>Results:</i></b> The proportion of transfusion procedures conducted in the total population has increased constantly for 10 years. Although its proportion in the age group of 10–79 years decreased, the total number of transfusions increased significantly due to the increase in the population and proportion of transfusions in those aged 80 years or older. Furthermore, the proportion of multicomponent transfusion procedures increased in this age group, which was greater than that of transfusions. The most common disease among transfusion patients in 2009 was cancer, of which gastrointestinal (GI) cancer accounted for more than half, followed by trauma and hematologic diseases (GI cancers > trauma > other cancers > hematologic diseases). The proportion of patients with GI cancer decreased, whereas that of trauma and hematologic diseases increased over the 10 years, with trauma becoming the most common disease type in 2018 (trauma > GI cancers > hematologic diseases > other cancers). Although transfusion rates per hospitalization decreased, the total number of inpatients increased, thus increasing the number of blood transfusions in all types of hospitals. <b><i>Discussion/Conclusions:</i></b> The proportion of transfusion procedures in the total population increased owing to the increase in the total number of transfusions in patients aged 80 years or older. The proportion of patients with trauma and hematologic diseases has also increased. Moreover, the total number of inpatients has been increasing, which subsequently increases the number of blood transfusions performed. Specific management strategies targeting these groups may improve blood management.
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Fedidat, Raphael. "Gastrointestinal Bleeding on Anticoagulant Therapy: Comparison of Patients Receiving Vitamin K Antagonists and Non-Vitamin K Oral Antagonists." Journal of Surgery Research and Practice, February 1, 2023, 1–14. http://dx.doi.org/10.46889/jsrp.2023.4101.
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Objectives: Prior studies comparing Gastrointestinal (GI) bleeding in patients receiving Vitamin-K Antagonists (VKA) and Non-Vitamin K Antagonist Oral Anticoagulants (NOAC) focused on the crude rate of GI bleeding and less on severity of such events. The aim of our study was to assess characteristics of GI bleeding in patients on VKA therapy versus NOAC therapy. Methods: Retrospective data was collected from patients hospitalized with GI bleeding at Hadassah University Medical Center between January 2010 and July 2017. Retrieved data included demographics, laboratory results, clinical outcomes and details regarding the bleeding characteristics, evaluation, treatment and hospitalization. Patients were divided into two groups – those receiving VKA and those receiving NOAC. Results: 514 patients who presented with GI bleeding were included. 439 patients were on VKA treatment and 75 on NOAC treatment. Atrial fibrillation was the indication for anticoagulation in 64% of VKA patients and in 91% of NOAC patients. The mean HAS-BLED score was the same in VKA and NOAC patient groups. Major bleeding events were seen in 38.3% of VKA patients and 30.7% of NOAC patients and life-threatening bleeding was seen in 34.4% of VKA patients and 26.7% of NOAC (p<0.05). Packed red blood cell and fresh-frozen plasma transfusions were administered less in the NOAC patients as compared to the VKA patients. No statistically significant differences in length of hospitalization, re-bleeding, or mortality were seen between groups. Conclusions: GI bleeding events on NOAC therapy are less severe and use fewer hospital resources as compared to those treated with VKA.
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Gonzalez, Juan, Ahsan Wahab, and Kavitha Kesari. "Dysphagia unveiling systemic immunoglobulin light-chain amyloidosis with multiple myeloma." BMJ Case Reports, October 21, 2018, bcr—2018–226331. http://dx.doi.org/10.1136/bcr-2018-226331.
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Dysphagia is an uncommon presentation of systemic immunoglobulin light-chain (AL) amyloidosis with multiple myeloma (MM). Gastrointestinal (GI) involvement usually manifests with altered motility, malabsorption or bleeding. Furthermore, patients identified with GI amyloidosis, without previous diagnosis of a plasma cell disorder, are extremely rare. We report an elderly woman who presented with acute on chronic cardiac dysfunction, sick sinus syndrome and acute renal failure. While admitted, she developed intermittent dysphagia to both solids and liquids. Oesophagogastroduodenoscopy showed ulcerations of oesophagus and duodenum. Biopsies revealed focal amyloid deposition, stained with Congo red. Renal biopsy revealed amyloid deposition in renal arterioles. She underwent a bone marrow biopsy confirming MM, represented by more than 15% plasma cell population. She was started on treatment for heart failure, induction chemotherapy for MM and percutaneous gastrostomy tube for feeding. However, she continued to deteriorate, eventually opting for hospice, and ultimately died 2 days after discharge from hospital.
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Heels-Ansdell, Diane, Laurent Billot, Lehana Thabane, Waleed Alhazzani, Adam Deane, Gordon Guyatt, Simon Finfer, et al. "REVISE: re-evaluating the inhibition of stress erosions in the ICU—statistical analysis plan for a randomized trial." Trials 24, no. 1 (December 6, 2023). http://dx.doi.org/10.1186/s13063-023-07794-z.
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Abstract Background The REVISE (Re-Evaluating the Inhibition of Stress Erosions in the ICU) trial will evaluate the impact of the proton pump inhibitor pantoprazole compared to placebo in invasively ventilated critically ill patients. Objective To outline the statistical analysis plan for the REVISE trial. Methods REVISE is a randomized clinical trial ongoing in intensive care units (ICUs) internationally. Patients ≥ 18 years old, receiving invasive mechanical ventilation, and expected to remain ventilated beyond the calendar day after randomization are allocated to either 40 mg pantoprazole intravenously or placebo while mechanically ventilated. Results The primary efficacy outcome is clinically important upper GI bleeding; the primary safety outcome is 90-day mortality. Secondary outcomes are ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine concentration, and duration of mechanical ventilation, ICU, and hospital length of stay. Following an interim analysis of results from 2400 patients (50% of 4800 target sample size), the data monitoring committee recommended continuing enrolment. Conclusions This statistical analysis plan outlines the statistical analyses of all outcomes, sensitivity analyses, and subgroup analyses. REVISE will inform clinical practice and guidelines worldwide. Trial registration www.ClinicalTrials.gov NCT03374800. November 21, 2017.
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Sugita, Shinji, Masashi Ishikawa, Takahiro Sakuma, Masumi Iizuka, Sayako Hanai, and Atsuhiro Sakamoto. "Intraoperative serum lactate levels as a prognostic predictor of outcome for emergency abdominal surgery: a retrospective study." BMC Surgery 23, no. 1 (June 16, 2023). http://dx.doi.org/10.1186/s12893-023-02075-7.
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Abstract Background The relationship between intraoperative lactate levels and prognosis after emergency gastrointestinal surgery remains unclear. The purpose of this study was to investigate the prognostic value of intraoperative lactate levels for predicting in-hospital mortality, and to examine intraoperative hemodynamic managements. Methods We conducted a retrospective observational study of emergency GI surgeries performed at our institution between 2011 and 2020. The study group comprised patients admitted to intensive care units postoperatively, and whose intraoperative and postoperative lactate levels were available. Intraoperative peak lactate levels (intra-LACs) were selected for analysis, and in-hospital mortality was set as the primary outcome. The prognostic value of intra-LAC was assessed using logistic regression and receiver operating characteristic (ROC) curve analysis. Results Of the 551 patients included in the study, 120 died postoperatively. Intra-LAC in the group who survived and the group that died was 1.80 [interquartile range [IQR], 1.19–3.01] mmol/L and 4.22 [IQR, 2.15–7.13] mmol/L (P < 0.001), respectively. Patients who died had larger volumes of red blood cell (RBC) transfusions and fluid administration, and were administered higher doses of vasoactive drugs. Logistic regression analysis showed that intra-LAC was an independent predictor of postoperative mortality (odds ratio [OR] 1.210, 95% CI 1.070 –1.360, P = 0.002). The volume of RBCs, fluids transfused, and the amount of vasoactive agents administered were not independent predictors. The area under the curve (AUC) of the ROC curve for intra-LAC for in-hospital mortality was 0.762 (95% confidence interval [CI], 0.711–0.812), with a cutoff value of 3.68 mmol/L by Youden index. Conclusions Intraoperative lactate levels, but not hemodynamic management, were independently associated with increased in-hospital mortality after emergency GI surgery.
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Marti Sanchez, D., B. Biscotti Rodil, F. Delgado Calva, J. Duarte Torres, A. Marschall, C. Dejuan Bitria, A. Rueda Linares, D. Rodriguez Torres, H. Del Castillo Carnevali, and S. Alvarez Anton. "Clinical features, management and outcomes of gastrointestinal bleeding in patients treated with oral anticoagulants." European Heart Journal 42, Supplement_1 (October 1, 2021). http://dx.doi.org/10.1093/eurheartj/ehab724.0562.
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Abstract Background Gastrointestinal (GI) bleeding with the different antithrombotics may present peculiarities in terms of location, precipitating factors, clinical management and prognosis. Purpose Our objective was to compare the profile and clinical course of GI bleeding with direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA). Methods We carried out a retrospective study of all consecutive patients treated in a tertiary hospital during 2018 and 2019, and who met the following selection criteria: 1) diagnosis of confirmed or probable GI bleeding; 2) red blood cell transfusion; 3) treatment with an oral anticoagulant; 4) absence of concomitant antiplatelet therapy. We collected information on comorbidities, bleeding risk scores, baseline treatments, and clinical course of bleeding. We compared adjusted all-cause mortality at 12-months between DOACs and VKAs groups. Results We identified 115 patients with GI bleeding, mean age 83±9 years, 63% women, 50.4% on DOACs and 49.6% on VKAs. NOACs group showed more recent anticoagulation history, and more complex clinical profile, with older age (85 vs. 82 years, p=0.026), number of comorbidities (2.7 vs. 2.1, p=0.049), CHA2DS2VASc score (5.2 vs. 4.2, p=0.001) and ORBIT score (3.9 vs. 3.3, p=0.047). There were no differences in the location of bleeding (60.5% lower GI tract), number of units transfused (mean 2.6), or hemoglobin nadir (mean 7.6 g/dL). Notably, 42% of the patients on DOACs were receiving the high dose at the time of bleeding, 63% of them had some risk criterion for overdose (age>80 years, weight <60 kg, moderate P-glycoprotein inhibitors), and 37% had >1 of these criteria. 12-month cumulative mortality was high, but significantly lower in the DOACs group (15.5% vs. 35.7%, adjusted HR 0.31, p=0.002). Conclusions Patients who experience GI bleeding with anticoagulants represent a therapeutic challenge, with both high age and prevalence of comorbidities. One-year mortality is remarkably high, particularly in the VKA group. Our findings emphasize the need for close monitoring and optimization of preventive strategies in this complex clinical scenario. Funding Acknowledgement Type of funding sources: None.