An investigation of bleed configurations and their effect on shock wave/boundary layer interactions

NASA Technical Reports Server (NTRS)

Hamed, Awatef

1995-01-01

The design of high efficiency supersonic inlets is a complex task involving the optimization of a number of performance parameters such as pressure recovery, spillage, drag, and exit distortion profile, over the flight Mach number range. Computational techniques must be capable of accurately simulating the physics of shock/boundary layer interactions, secondary corner flows, flow separation, and bleed if they are to be useful in the design. In particular, bleed and flow separation, play an important role in inlet unstart, and the associated pressure oscillations. Numerical simulations were conducted to investigate some of the basic physical phenomena associated with bleed in oblique shock wave boundary layer interactions that affect the inlet performance.

Process improvement in cardiac surgery: development and implementation of a reoperation for bleeding checklist.

PubMed

Loor, Gabriel; Vivacqua, Alessandro; Sabik, Joseph F; Li, Liang; Hixson, Eric D; Blackstone, Eugene H; Koch, Colleen G

2013-11-01

High-performing health care organizations differentiate themselves by focusing on continuous process improvement initiatives aimed at enhancing patient outcomes. Reoperation for bleeding is an event associated with considerable morbidity risk. Hence, our primary objective was to develop and implement a formal operative checklist to reduce technical reasons for postoperative bleeding. From January 1, 2011, through June 30, 2012, 5812 cardiac surgical procedures were performed at Cleveland Clinic (Cleveland, OH). A multidisciplinary team developed a simple, easy-to-perform hemostasis checklist based on the most common sites of bleeding. An extensive educational in-service was performed before limited, then universal, checklist implementation. Geometric charts were used to track the number of cases between consecutive reoperations for bleeding. We compared these before (phase 0) and after the first limited implementation phase (phase 1) and the universal implementation phase (phase 2) of the checklist. The average number of cases between consecutive reoperations for bleeding increased from 32 in phase 0 to 53 in both phase 1 (P = .002) and phase 2 (P = .01). A substantial reduction in reoperation for bleeding cases followed implementation of a formalized hemostasis checklist. Our findings underscore the important influence of memory aids that focus attention on surgical techniques to improve patient outcomes in a complex, operative work environment. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Long-term bleeding risk prediction in 'real world' patients with atrial fibrillation: Comparison of the HAS-BLED and ABC-Bleeding risk scores. The Murcia Atrial Fibrillation Project.

PubMed

Esteve-Pastor, María Asunción; Rivera-Caravaca, José Miguel; Roldan, Vanessa; Vicente, Vicente; Valdés, Mariano; Marín, Francisco; Lip, Gregory Y H

2017-10-05

Risk scores in patients with atrial fibrillation (AF) based on clinical factors alone generally have only modest predictive value for predicting high risk patients that sustain events. Biomarkers might be an attractive prognostic tool to improve bleeding risk prediction. The new ABC-Bleeding score performed better than HAS-BLED score in a clinical trial cohort but has not been externally validated. The aim of this study was to analyze the predictive performance of the ABC-Bleeding score compared to HAS-BLED score in an independent "real-world" anticoagulated AF patients with long-term follow-up. We enrolled 1,120 patients stable on vitamin K antagonist treatment. The HAS-BLED and ABC-Bleeding scores were quantified. Predictive values were compared by c-indexes, IDI, NRI, as well as decision curve analysis (DCA). Median HAS-BLED score was 2 (IQR 2-3) and median ABC-Bleeding was 16.5 (IQR 14.3-18.6). After 6.5 years of follow-up, 207 (2.84 %/year) patients had major bleeding events, of which 65 (0.89 %/year) had intracranial haemorrhage (ICH) and 85 (1.17 %/year) had gastrointestinal bleeding events (GIB). The c-index of HAS-BLED was significantly higher than ABC-Bleeding for major bleeding (0.583 vs 0.518; p=0.025), GIB (0.596 vs 0.519; p=0.017) and for the composite of ICH-GIB (0.593 vs 0.527; p=0.030). NRI showed a significant negative reclassification for major bleeding and for the composite of ICH-GIB with the ABC-Bleeding score compared to HAS-BLED. Using DCAs, the use of HAS-BLED score gave an approximate net benefit of 4 % over the ABC-Bleeding score. In conclusion, in the first "real-world" validation of the ABC-Bleeding score, HAS-BLED performed significantly better than the ABC-Bleeding score in predicting major bleeding, GIB and the composite of GIB and ICH.

High Dose Proton Pump Inhibitor Infusion Versus Bolus Injection for the Prevention of Bleeding After Endoscopic Submucosal Dissection: Prospective Randomized Controlled Study.

PubMed

Choi, Cheol Woong; Kang, Dae Hwan; Kim, Hyung Wook; Hong, Joung Boom; Park, Su Bum; Kim, Su Jin; Cho, Mong

2015-07-01

A high dose of continuous intravenous infusion of proton pump inhibitor (PPI) is the standard treatment for peptic ulcer bleeding. The optimal dose for the prevention of bleeding after endoscopic submucosal dissection (ESD) is unclear. The purpose of this study was to determine whether stronger acid suppression more effectively prevents bleeding and high risk ulcer stigma (HRS) after gastric ESD. A total of 273 patients who underwent ESD were randomly assigned to one of two treatment groups: the continuous infusion group and the bolus injection group. Second-look endoscopy was performed on the following day after ESD. The incidences and risk factors of HRS identified by second-look endoscopy and delayed bleeding were analyzed. There were no differences in the incidences of HRS and delayed bleeding between two treatment groups. The incidence of HRS was 15.8 % (43/273) and the gross morphology (flat or depressed) was identified as a significant factor associated with HRS. The incidence of delayed bleeding was 8.4 % (23/273) and the gross morphology (flat) and the presence of submucosal invasive cancer were identified as the associated risk factors for delayed bleeding. The incidences of delayed bleeding and HRS identified by second-look endoscopy were not affected by PPI infusion methods. Flat or depressed morphologic lesions and submucosal invasive cancer should be closely monitored.

TANKS 18 AND 19-F STRUCTURAL FLOWABLE GROUT FILL MATERIAL EVALUATION AND RECOMMENDATIONS

DOE Office of Scientific and Technical Information (OSTI.GOV)

Stefanko, D.; Langton, C.

2011-11-01

Cementitious grout will be used to close Tanks 18-F and 19-F. The functions of the grout are to: (1) physically stabilize the final landfill by filling the empty volume in the tanks with a non compressible material; (2) provide a barrier for inadvertent intrusion into the tank; (3) reduce contaminant mobility by (a) limiting the hydraulic conductivity of the closed tank and (b) reducing contact between the residual waste and infiltrating water; and (4) providing an alkaline, chemically reducing environment in the closed tank to control speciation and solubility of selected radionuclides. The objective of this work was to identifymore » a single (all-in-one) grout to stabilize and isolate the residual radionuclides in the tank, provide structural stability of the closed tank and serve as an inadvertent intruder barrier. This work was requested by V. A. Chander, High Level Waste (HLW) Tank Engineering, in HLW-TTR-2011-008. The complete task scope is provided in the Task Technical and QA Plan, SRNL-RP-2011-00587 Revision 0. The specific objectives of this task were to: (1) Identify new admixtures and dosages for formulating a zero bleed flowable tank fill material selected by HLW Tank Closure Project personnel based on earlier tank fill studies performed in 2007. The chemical admixtures used for adjusting the flow properties needed to be updated because the original admixture products are no longer available. Also, the sources of cement and fly ash have changed, and Portland cements currently available contain up to 5 wt. % limestone (calcium carbonate). (2) Prepare and evaluate the placement, compressive strength, and thermal properties of the selected formulation with new admixture dosages. (3) Identify opportunities for improving the mix selected by HLW Closure Project personnel and prepare and evaluate two potentially improved zero bleed flowable fill design concepts; one based on the reactor fill grout and the other based on a shrinkage compensating flowable fill mix design. (4) Prepare samples for hydraulic property measurements for comparison to the values in the F and H- Tank Farm Performance Assessments (PAs). (5) Identify a grout mix for the Tanks 18-F and 19-F Grout Procurement Specification [Forty, 2011 a, b, c]. Results for two flowable zero bleed structural fill concepts containing 3/8 inch gravel (70070 Series and LP-8 Series) and a sand only mix (SO Series) are provided in this report. Tank Farm Engineering and SRNL Project Management selected the 70070 mix as the base case for inclusion in Revision 0 of the Tanks 18-F and 19-F grout procurement specification [Forty 2011 a] and requested admixture recommendations and property confirmation for this formulation [Forty, 2011 b]. Lower cementitious paste mixes were formulated because the 70070 mix is over designed with respect to strength and generates more heat from hydration reactions than is desirable for mass pour application. Work was also initiated on a modification of the recommended mix which included shrinkage compensation to mitigate fast pathways caused by shrinkage cracking and poor physical bonding to the tank and ancillary equipment. Testing of this option was postponed to FY12.« less

Twice-Daily Enoxaparin among Plastic Surgery Inpatients: An Examination of Pharmacodynamics, 90-Day Venous Thromboembolism, and 90-Day Bleeding.

PubMed

Pannucci, Christopher J; Fleming, Kory I; Momeni, Arash; Prazak, Ann Marie; Agarwal, Jayant; Rockwell, W Bradford

2018-06-01

Low anti-factor Xa level, indicative of inadequate enoxaparin dosing, has a significant association with 90-day venous thromboembolism events. The authors examined the pharmacodynamics of enoxaparin 40 mg twice daily and its correlation with anti-factor Xa level, postoperative venous thromboembolism, and bleeding. Adult patients were admitted after plastic and reconstructive surgery and received enoxaparin 40 mg twice daily. Peak anti-factor Xa levels, which quantify enoxaparin's antithrombotic effect, were drawn, with a goal level of 0.2 to 0.4 IU/ml. Ninety-day symptomatic venous thromboembolism and clinically relevant bleeding were identified. The authors enrolled 118 patients who received enoxaparin 40 mg twice daily. Of these patients, 9.6 percent had low peak anti-factor Xa levels (<0.2 IU/ml), 62.6 percent had in-range peak anti-factor Xa levels (0.2 to 0.4 IU/ml), and 27.8 percent had high anti-factor Xa levels (>0.4 IU/ml). With enoxaparin 40 mg twice daily, 90.4 percent of patients received at least adequate prophylaxis. Patient weight predicted the rapidity of enoxaparin metabolism. Zero acute 90-day venous thromboembolism occurred. Eight patients (6.8 percent) had clinically relevant 90-day bleeding: clinical consequences ranged from cessation of enoxaparin prophylaxis to transfusion to operative hematoma evacuation. When enoxaparin 40 mg twice daily is provided, 90 percent of patients receive at least adequate venous thromboembolism prophylaxis (anti-factor Xa level >0.2 IU/ml). However, 27 percent of the overall population is overtreated (anti-factor Xa level >0.4 IU/ml). These pharmacodynamics data likely explain the low rate of 90-day acute venous thromboembolism (0 percent) and the high rate of clinically relevant bleeding (6.8 percent) observed. Future studies are needed to better optimize the risks and benefits of enoxaparin prophylaxis in plastic and reconstructive surgery patients. Therapeutic, IV.

Emergency pancreatoduodenectomy (whipple procedure) for massive upper gastrointestinal bleeding caused by a diffuse B-cell lymphoma of the duodenum: report of a case.

PubMed

Stratigos, Panagiotis; Kouskos, Efstratios; Kouroglou, Maria; Chrisafis, Ioannis; Fois, Lucia; Mavrogiorgis, Anastasios; Axiotis, Efthimios; Zamtrakis, Sotirios

2007-01-01

We herein report a rare case of a massive upper gastrointestinal (GI) bleeding, caused by high-grade diffuse B-cell lymphoma of the duodenum, secondary to immunoproliferative small intestinal disease (IPSID) and treated with an emergency partial pancreatoduodenectomy. A 42-year-old man was admitted to our hospital because of hematemesis. Upper GI endoscopy was unrevealing because of the copious bleeding. Initially, the patient underwent conservative treatment, thus resulting in the temporary cessation of the bleeding. Later, the hemorrhage massively relapsed. An urgent abdominal ultrasound raised the suspicion of a large, possibly bleeding, neoplasm of the duodenum, which was finally confirmed by abdominal computed tomography. The patient underwent an emergency laparotomy, during which a partial pancreatoduodenectomy was performed (Whipple procedure). Histologically, the tumor was a high-grade B-cell lymphoma of the duodenum. The nearby small intestinal mucosa was suggestive of IPSID. A massive upper GI hemorrhage from a high-grade B-cell non-Hodgkin lymphoma of the duodenum, which develops secondary to IPSID, is a very rare clinical demonstration of this disease. Our case is one of the few reports in the English literature, for which the Whipple procedure has been performed as a curative treatment.

Safety Outcomes of Apixaban Compared With Warfarin in Patients With End-Stage Renal Disease.

PubMed

Sarratt, Stefanie C; Nesbit, Ross; Moye, Robert

2017-06-01

Current guidelines make no specific recommendations on the selection of direct oral anticoagulants for the prevention and treatment of venous thromboembolism in patients with end-stage renal disease (ESRD) receiving hemodialysis. Based on these guidelines, warfarin remains the anticoagulant of choice in these patients. To compare bleeding rates in patients receiving apixaban or warfarin with ESRD undergoing chronic hemodialysis. This was a single-center, retrospective, institutional review board-approved cohort analysis. Patients with ESRD undergoing chronic hemodialysis and receiving anticoagulation therapy with either apixaban or warfarin were included in this study. All data were collected from paper charts and electronic medical records and included documentation of bleeding events and related interventions. The primary outcome of this study was clinically relevant major bleeding events. Secondary outcomes included clinically relevant nonmajor bleeding events and minor bleeding events. A total of 160 patients were included in this study (warfarin group, n = 120; apixaban group, n = 40). There were 7 major bleeding events in the warfarin group compared with zero in the apixaban group ( P = 0.34). There were similar rates of clinically relevant nonmajor bleeding events (12.5% vs 5.8%, P = 0.17) and minor bleeding (2.5% vs 2.5%, P = 0.74) events in patients receiving apixaban and warfarin. There were no observed differences in bleeding rates in patients receiving apixaban compared with those receiving warfarin. Apixaban may be a cautious consideration in hemodialysis patients until there is further insight into the effect of subsequent, multiple doses on drug accumulation and clinical outcomes.

Prediction models for intracranial hemorrhage or major bleeding in patients on antiplatelet therapy: a systematic review and external validation study.

PubMed

Hilkens, N A; Algra, A; Greving, J P

2016-01-01

ESSENTIALS: Prediction models may help to identify patients at high risk of bleeding on antiplatelet therapy. We identified existing prediction models for bleeding and validated them in patients with cerebral ischemia. Five prediction models were identified, all of which had some methodological shortcomings. Performance in patients with cerebral ischemia was poor. Background Antiplatelet therapy is widely used in secondary prevention after a transient ischemic attack (TIA) or ischemic stroke. Bleeding is the main adverse effect of antiplatelet therapy and is potentially life threatening. Identification of patients at increased risk of bleeding may help target antiplatelet therapy. This study sought to identify existing prediction models for intracranial hemorrhage or major bleeding in patients on antiplatelet therapy and evaluate their performance in patients with cerebral ischemia. We systematically searched PubMed and Embase for existing prediction models up to December 2014. The methodological quality of the included studies was assessed with the CHARMS checklist. Prediction models were externally validated in the European Stroke Prevention Study 2, comprising 6602 patients with a TIA or ischemic stroke. We assessed discrimination and calibration of included prediction models. Five prediction models were identified, of which two were developed in patients with previous cerebral ischemia. Three studies assessed major bleeding, one studied intracerebral hemorrhage and one gastrointestinal bleeding. None of the studies met all criteria of good quality. External validation showed poor discriminative performance, with c-statistics ranging from 0.53 to 0.64 and poor calibration. A limited number of prediction models is available that predict intracranial hemorrhage or major bleeding in patients on antiplatelet therapy. The methodological quality of the models varied, but was generally low. Predictive performance in patients with cerebral ischemia was poor. In order to reliably predict the risk of bleeding in patients with cerebral ischemia, development of a prediction model according to current methodological standards is needed. © 2015 International Society on Thrombosis and Haemostasis.

Liquefied Bleed for Stability and Efficiency of High Speed Inlets

NASA Technical Reports Server (NTRS)

Saunders, J. David; Davis, David; Barsi, Stephen J.; Deans, Matthew C.; Weir, Lois J.; Sanders, Bobby W.

2014-01-01

A mission analysis code was developed to perform a trade study on the effectiveness of liquefying bleed for the inlet of the first stage of a TSTO vehicle. By liquefying bleed, the vehicle weight (TOGW) could be reduced by 7 to 23%. Numerous simplifying assumptions were made and lessons were learned. Increased accuracy in future analyses can be achieved by: Including a higher fidelity model to capture the effect of rescaling (variable vehicle TOGW). Refining specific thrust and impulse models ( T m a and Isp) to preserve fuel-to-air ratio. Implementing LH2 for T m a and Isp. Correlating baseline design to other mission analyses and correcting vehicle design elements. Implementing angle-of-attack effects on inlet characteristics. Refining aerodynamic performance (to improve L/D ratio at higher Mach numbers). Examining the benefit with partial cooling or densification of the bleed air stream. Incorporating higher fidelity weight estimates for the liquefied bleed system (heat exchange and liquid storage versus bleed duct weights) could be added when more fully developed. Adding trim drag or 6-degree-of-freedom trajectory analysis for higher fidelity. Investigating vehicle optimization for each of the bleed configurations.

Gastrointestinal bleeding in patients with renal failure under hemodialysis treatment: a single-center experience.

PubMed

Can, Özgür; Koç, Gözde; Ocak, Sema Berk; Akbay, Nursel; Ahishali, Emel; Canbakan, Mustafa; Şahin, Gülizar Manga; Apaydin, Süheyla

2017-05-01

Gastrointestinal bleeding remains the leading cause of morbidity and mortality for patients who need hemodialysis treatment. Our aim was to evaluate patients who needed hemodialysis and presented with bleeding during their hospital stay (uremic bleeding patients). Factors that increased the risk of bleeding and death were evaluated. Additionally, uremic bleeding patients were compared to non-uremic bleeding patients regarding gastrointestinal findings. Fifty-one uremic bleeding patients were compared to two control groups which included uremic (hemodialysis dependent and non-bleeding) and non-uremic (no renal insufficiency and bleeding) patients. NSAIDs and anti-ulcer drug usage were more common in uremic bleeding and in uremic non-bleeding groups, respectively. Dialysis vintage was longer in uremic bleeding group. Comparison of uremic bleeding and non-bleeding uremic patients regarding the usage of ACEI or ARB drugs yielded non-significant results. Acute kidney injury, lower plasma albumin level and high CRP level were significantly increased the risk of mortality in uremic bleeding patients. Hospital stay more than 1 week was the only strong factor for mortality when multivariate analysis was performed. Gastroduodenal and duodenal ulcers were significantly detected in uremic bleeding and non-uremic bleeding patients; respectively. Hemodialysis patients presenting with gastrointestinal bleeding should be evaluated regarding use of prescriptions and efforts should be done in order to shorten their hospital stay and decrease their mortality. Effect of ACEI or ARB drugs should also be evaluated in future studies.

An experimental investigation of shock wave-turbulent boundary layer interactions with and without boundary layer suction: A data summary report

NASA Technical Reports Server (NTRS)

Sun, C. C.; Childs, M. E.

1977-01-01

Tabulated data from a series of experimental studies of the interaction of a shock wave with a turbulent boundary layer in axisymmetric flow configurations is presented. The studies were conducted at the walls of circular wind tunnels and on the cylindrical centerbody of an annular flow channel. Detailed pitot pressure profiles and wall static pressure profiles upstream of, within and downstream of the interaction region are given. Results are presented for flows at nominal freestream Mach Numbers of 2, 3 and 4. For studies at the tunnel sidewalls, the shock waves were produced by conical shock generators mounted on the centerline of the wind tunnel at zero angle of attack. The annular ring generator was used to produce the shock wave at the centerbody of the annular flow channel. The effects of boundary layer bleed were examined in the investigation. Both bleed rate and bleed location were studied. Most of the bleed studies were conducted with bleed holes drilled normal to the wall surface but the effects of slot suction were also examined. A summary of the principal results and conclusions is given.

Cost-effectiveness analysis of high-dose omeprazole infusion as adjuvant therapy to endoscopic treatment of bleeding peptic ulcer.

PubMed

Lee, Kenneth K C; You, Joyce H S; Wong, Ian C K; Kwong, Sunny K S; Lau, James Y W; Chan, Thomas Y K; Lau, Joseph T F; Leung, Wilson Y S; Sung, Joseph J Y; Chung, Sydney S C

2003-02-01

Intravenous administration of proton pump inhibitors after endoscopic treatment of bleeding peptic ulcers has been shown to decrease the rate of recurrent bleeding and the need for subsequent surgery. Yet there is a relative lack of formal assessment of this practice. The aim of this study was to examine the cost-effectiveness of this therapy by using standard pharmacoeconomic methods. The present study was performed in conjunction with a randomized controlled clinical trial that included 232 patients who received either omeprazole (80 mg intravenous bolus followed by infusion at 8 mg/hour for 72 hours) or placebo after hemostasis was achieved endoscopically. A cost-effectiveness analysis was performed to evaluate the different outcomes of the trial. All related direct medical costs were identified from patient records. Cost-effectiveness ratios were calculated. Analysis by the Kolmogorov-Smirnov test showed that the direct medical cost in the omeprazole group was lower than that for the placebo group. Cost-effectiveness ratios for omeprazole and placebo groups were, respectively, HK$ 28,764 (US$ 3688) and HK$ 36,992 (US$ 4743) in averting one episode of recurrent bleeding in one patient after initial hemostasis was achieved endoscopically. Intravenous administration of high-dose omeprazole appears to be a cost-effective therapy in reducing the recurrence of bleeding and need for surgery in patients with active bleeding ulcer after initial hemostasis is obtained endoscopically.

Design of a very-low-bleed Mach 2.5 mixed-compression inlet with 45 percent internal contraction

NASA Technical Reports Server (NTRS)

Wasserbauer, J. F.; Shaw, R. J.; Neumann, H. E.

1975-01-01

A full-scale, mixed-compression inlet was designed for operation with the TF30-P-3 turbofan engine and tested at Mach numbers of 2.5 and 2.0. The two-cone axisymmetric inlet had minimum internal contraction consistent with high total pressure recovery and low cowl drag. At Mach 2.5, inlet recovery was 0.906 with only 0.021 centerbody bleed mass-flow ratio and no cowl bleed. Increased centerbody bleed gave a maximum inlet unstart angle of attack of 6.85 deg. At Mach 2.0, inlet recovery was 0.94 with only 0.014 centerbody bleed mass-flow ratio and no cowl bleed. Inlet performance and angle-of-attack tolerance is presented for operation at Mach numbers of 2.5 and 2.0.

Successful Endoscopic Hemostasis Is a Protective Factor for Rebleeding and Mortality in Patients with Nonvariceal Upper Gastrointestinal Bleeding.

PubMed

Han, Yong Jae; Cha, Jae Myung; Park, Jae Hyun; Jeon, Jung Won; Shin, Hyun Phil; Joo, Kwang Ro; Lee, Joung Il

2016-07-01

Rebleeding and mortality rates remain high in patients with nonvariceal upper gastrointestinal bleeding. To identify clinical and endoscopic risk factors for rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding. This study was performed in patients with nonvariceal upper gastrointestinal bleeding who underwent upper endoscopic procedures between July 2006 and February 2013. Clinical and endoscopic characteristics were compared among patients with and without rebleeding and mortality. Logistic regression analysis was performed to determine independent risk factors for rebleeding and mortality. After excluding 64 patients, data for 689 patients with nonvariceal upper gastrointestinal bleeding were analyzed. Peptic ulcer (62.6 %) was by far the most common source of bleeding. Endoscopic intervention was performed within 24 h in 99.0 % of patients, and successful endoscopic hemostasis was possible in 80.7 % of patients. The 30-day rebleeding rate was 13.1 % (n = 93). Unsuccessful endoscopic hemostasis was found to be the only independent risk factor for rebleeding (odds ratio 79.6; 95 % confidence interval 37.8-167.6; p = 0.000). The overall 30-day mortality rate was 3.2 % (n = 23). Unsuccessful endoscopic hemostasis (odds ratio 4.9; 95 % confidence interval 1.7-13.9; p = 0.003) was also associated with increased 30-day mortality in patients with nonvariceal upper gastrointestinal bleeding. Successful endoscopic hemostasis is an independent protective factor for both rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding.

Introduction to Cost Control Strategies for Zero Energy Buildings: High-Performance Design and Construction on a Budget (Fact Sheet)

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

2014-09-01

Momentum behind zero energy building design and construction is increasing, presenting a tremendous opportunity for advancing energy performance in the commercial building industry. At the same time, there is a lingering perception that zero energy buildings must be cost prohibitive or limited to showcase projects. Fortunately, an increasing number of projects are demonstrating that high performance can be achieved within typical budgets. This factsheet highlights replicable, recommended strategies for achieving high performance on a budget, based on experiences from past projects.

A clinically viable capsule endoscopy video analysis platform for automatic bleeding detection

NASA Astrophysics Data System (ADS)

Yi, Steven; Jiao, Heng; Xie, Jean; Mui, Peter; Leighton, Jonathan A.; Pasha, Shabana; Rentz, Lauri; Abedi, Mahmood

2013-02-01

In this paper, we present a novel and clinically valuable software platform for automatic bleeding detection on gastrointestinal (GI) tract from Capsule Endoscopy (CE) videos. Typical CE videos for GI tract run about 8 hours and are manually reviewed by physicians to locate diseases such as bleedings and polyps. As a result, the process is time consuming and is prone to disease miss-finding. While researchers have made efforts to automate this process, however, no clinically acceptable software is available on the marketplace today. Working with our collaborators, we have developed a clinically viable software platform called GISentinel for fully automated GI tract bleeding detection and classification. Major functional modules of the SW include: the innovative graph based NCut segmentation algorithm, the unique feature selection and validation method (e.g. illumination invariant features, color independent features, and symmetrical texture features), and the cascade SVM classification for handling various GI tract scenes (e.g. normal tissue, food particles, bubbles, fluid, and specular reflection). Initial evaluation results on the SW have shown zero bleeding instance miss-finding rate and 4.03% false alarm rate. This work is part of our innovative 2D/3D based GI tract disease detection software platform. While the overall SW framework is designed for intelligent finding and classification of major GI tract diseases such as bleeding, ulcer, and polyp from the CE videos, this paper will focus on the automatic bleeding detection functional module.

Residents' response to bleeding during a simulated robotic surgery task.

PubMed

Walker, Jessica L; Nathwani, Jay N; Mohamadipanah, Hossein; Laufer, Shlomi; Jocewicz, Frank F; Gwillim, Eran; Pugh, Carla M

2017-12-01

The aim of this study was to assess performance measurement validity of our newly developed robotic surgery task trainer. We hypothesized that residents would exhibit wide variations in their intercohort performance as well as a measurable difference compared to surgeons in fellowship training. Our laboratory synthesized a model of a pelvic tumor that simulates unexpected bleeding. Surgical residents and fellows of varying specialties completed a demographic survey and were allowed 20 minutes to resect the tumor using the da Vinci robot and achieve hemostasis. At a standardized event in the simulation, venous bleeding began, and participants attempted hemostasis using suture ligation. A motion tracking system, using electromagnetic sensors, recorded participants' hand movements. A postparticipation Likert scale survey evaluated participants' assessment of the model's realism and usefulness. Three of the seven residents (postgraduate year 2-5), and the fellow successfully resected the tumor in the allotted time. Residents showed high variability in performance and blood loss (125-700 mL) both within their cohort and compared to the fellow (150 mL blood). All participants rated the model as having high realism and utility for trainees. The results support that our bleeding pelvic tumor simulator has the ability to discriminate resident performance in robotic surgery. The combination of motion, decision-making, and blood loss metrics offers a multilevel performance assessment, analyzing both technical and decision-making abilities. Copyright © 2017 Elsevier Inc. All rights reserved.

Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

PubMed Central

Loffroy, Romaric; Guiu, Boris

2009-01-01

Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients, endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduodenal ulcers after failed endoscopic hemostasis. Here, we present an overview of indications, techniques, and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment, can be performed with high technical and clinical success rates, and should be considered the salvage treatment of choice in patients at high surgical risk. PMID:20014452

Effects of turbine cooling assumptions on performance and sizing of high-speed civil transport

NASA Technical Reports Server (NTRS)

Senick, Paul F.

1992-01-01

The analytical study presented examines the effects of varying turbine cooling assumptions on the performance of a high speed civil transport propulsion system as well as the sizing sensitivity of this aircraft to these performance variations. The propulsion concept employed in this study was a two spool, variable cycle engine with a sea level thrust of 55,000 lbf. The aircraft used for this study was a 250 passenger vehicle with a cruise Mach number of 2.4 and 5000 nautical mile range. The differences in turbine cooling assumptions were represented by varying the amount of high pressure compressor bleed air used to cool the turbines. It was found that as this cooling amount increased, engine size and weight increased, but specific fuel consumption (SFC) decreased at takeoff and climb only. Because most time is spent at cruise, the SFC advantage of the higher bleed engines seen during subsonic flight was minimized and the lower bleed, lighter engines led to the lowest takeoff gross weight vehicles. Finally, the change in aircraft takeoff gross weight versus turbine cooling level is presented.

Endoscopic Management of Tumor Bleeding from Inoperable Gastric Cancer

PubMed Central

Kim, Young-Il

2015-01-01

Tumor bleeding is not a rare complication in patients with inoperable gastric cancer. Endoscopy has important roles in the diagnosis and primary treatment of tumor bleeding, similar to its roles in other non-variceal upper gastrointestinal bleeding cases. Although limited studies have been performed, endoscopic therapy has been highly successful in achieving initial hemostasis. One or a combination of endoscopic therapy modalities, such as injection therapy, mechanical therapy, or ablative therapy, can be used for hemostasis in patients with endoscopic stigmata of recent hemorrhage. However, rebleeding after successful hemostasis with endoscopic therapy frequently occurs. Endoscopic therapy may be a treatment option for successfully controlling this rebleeding. Transarterial embolization or palliative surgery should be considered when endoscopic therapy fails. For primary and secondary prevention of tumor bleeding, proton pump inhibitors can be prescribed, although their effectiveness to prevent bleeding remains to be investigated. PMID:25844339

Occult gastrointestinal bleeding. An evaluation of available diagnostic methods.

PubMed

Richardson, J D; McInnis, W D; Ramos, R; Aust, J B

1975-05-01

Occult gastrointestinal bleeding was defined as continued bleeding in spite of a normal series of roentgenorgrams of the upper part of the gastrointestinal tract, barium enema, and sigmoidoscopy. Twenty-six such patients were treated. A thorough systematic evaluation, including gastroscopy, colonoscopy, visceral angiography, and isotopic scanning, was done preoperatively. Using colonoscopy and arteriography, nearly 60% of the bleeding sites were identified. Seventy-six percent of the lesions identified were in the terminal part of the ileum or the ascending colon. Exploratory laparotomy should be performed for life-threatening hemorrhage or as a diagnostic test only after a thorough preoperative evaluation. If results of a complete preoperative evaluation including arteriography were normal, then the likelihood of finding a discrete cause of bleeding at laparotomy was high (80%). A systematic evaluation and diligence of both physcian and patient in localizing the site of bleeding are essential.

Performance of an asymmetric short annular diffuser with a nondiverging inner wall using suction. [control of radial profiles of diffuser exit velocity

NASA Technical Reports Server (NTRS)

Juhasz, A.

1974-01-01

The performance of a short highly asymmetric annular diffuser equipped with wall bleed (suction) capability was evaluated at nominal inlet Mach numbers of 0.188, 0.264, and 0.324 with the inlet pressure and temperature at near ambient values. The diffuser had an area ratio of 2.75 and a length- to inlet-height ratio of 1.6. Results show that the radial profiles of diffuser exit velocity could be controlled from a severely hub peaked to a slightly tip biased form by selective use of bleed. At the same time, other performance parameters were also improved. These results indicate the possible application of the diffuser bleed technique to control flow profiles to gas turbine combustors.

Tanks 18 And 19-F Structural Flowable Grout Fill Material Evaluation And Recommendations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Langton, C. A.; Stefanko, D. B.

2013-04-23

Cementitious grout will be used to close Tanks 18-F and 19-F. The functions of the grout are to: 1) physically stabilize the final landfill by filling the empty volume in the tanks with a non-compressible material; 2) provide a barrier for inadvertent intrusion into the tank; 3) reduce contaminant mobility by a) limiting the hydraulic conductivity of the closed tank and b) reducing contact between the residual waste and infiltrating water; and 4) providing an alkaline, chemically reducing environment in the closed tank to control speciation and solubility of selected radionuclides. The objective of this work was to identify amore » single (all-in-one) grout to stabilize and isolate the residual radionuclides in the tank, provide structural stability of the closed tank and serve as an inadvertent intruder barrier. This work was requested by V. A. Chander, High Level Waste (HLW) Tank Engineering, in HLW-TTR-2011-008. The complete task scope is provided in the Task Technical and QA Plan, SRNL-RP-2011-00587 Revision 0. The specific objectives of this task were to: 1) Identify new admixtures and dosages for formulating a zero bleed flowable tank fill material selected by HLW Tank Closure Project personnel based on earlier tank fill studies performed in 2007. The chemical admixtures used for adjusting the flow properties needed to be updated because the original admixture products are no longer available. Also, the sources of cement and fly ash have changed, and Portland cements currently available contain up to 5 wt. % limestone (calcium carbonate). 2) Prepare and evaluate the placement, compressive strength, and thermal properties of the selected formulation with new admixture dosages. 3) Identify opportunities for improving the mix selected by HLW Closure Project personnel and prepare and evaluate two potentially improved zero bleed flowable fill design concepts; one based on the reactor fill grout and the other based on a shrinkage compensating flowable fill mix design. 4) Prepare samples for hydraulic property measurements for comparison to the values in the F and H- Tank Farm Performance Assessments (PAs). 5) Identify a grout mix for the Tanks 18-F and 19-F Grout Procurement Specification [Forty, 2011 a, b, c]. Results for two flowable zero bleed structural fill concepts containing 3/8 inch gravel (70070 Series and LP#8 Series) and a sand only mix (SO Series) are provided in this report. Tank Farm Engineering and SRNL Project Management selected the 70070 mix as the base case for inclusion in Revision 0 of the Tanks 18-F and 19-F grout procurement specification [Forty 2011 a] and requested admixture recommendations and property confirmation for this formulation [Forty, 2011 b]. Lower cementitious paste mixes were formulated because the 70070 mix is over designed with respect to strength and generates more heat from hydration reactions than is desirable for mass pour application. Work was also initiated on a modification of the recommended mix which included shrinkage compensation to mitigate fast pathways caused by shrinkage cracking and poor physical bonding to the tank and ancillary equipment. Testing of this option was postponed to FY12. Mix, LP#8-16 is recommended for inclusion in the specification for furnishing and delivering tank closure grout for Tanks 18-F and 19-F [Forty, 2011 c]. A shrinkage compensating variation of this mix, LP#16C, has not been fully developed and characterized at this time.« less

Using a Harmonic Scalpel "Drilling and Clamping" Method to Implement Zero Ischemic Robotic-assisted Partial Nephrectomy: An Observation Case Report Study.

PubMed

Hou, Chen-Pang; Lin, Yu-Hsiang; Hsu, Yu-Chao; Chen, Chien-Lun; Chang, Phei-Lang; Tsui, Ke-Hung

2016-01-01

Robot-assisted partial nephrectomy (RAPN) has gradually become a popular minimally invasive nephron-sparing surgical option for small renal tumors. Ischemic injury should be minimized because it impacts renal function outcomes following partial nephrectomy. Herein, the authors detail the technique and present initial perioperative outcomes of our novel harmonic scalpel "drilling and clamping" method to implement zero-ischemic RAPN. The authors prospectively collected baseline and perioperative data of patients who underwent zero ischemic RAPN performed by our harmonic scalpel "drilling and clamping" method. From April 2012 to December 2014, a total of 19 consecutive zero ischemic RAPN procedures were performed by a single surgeon. For 18 of the 19 patients, RAPN using our harmonic scalpel "Drilling and Clamping" method was successfully completed without the need for hilar clamping. The median tumor size was 3.4 cm (range: 1.8-6.2); operative time was 3.2 hours (range: 1.9-4.5); blood loss was 100 mL (range: 30-950); and postoperative hospital stay was 4 days (3-26). One patient required intraoperative blood transfusion. Two patients had intra or postoperative complications: 1 was converted to traditional laparotomy because of massive bleeding, whereas another had postoperative stress ulcer. Pathology confirmed renal cell carcinoma in 13 patients (63.2%), angiomyolipoma in 6 patients: (31.5%), and oncocytoma in 1 patient (5.3%). Mean pre- and postoperative serum creatinine (0.82 mg/dL and 0.85 mg/dL, respectively), estimated glomerular filtration rate (84.12 and 82.18, respectively), and hemoglobin (13.27 g/dL and 12.71 g/dL, respectively) were comparable. The authors present a novel zero-ischemic technique for RAPN. They believe that this technique is feasible and reproducible.

IBUPROFEN DOES NOT INCREASE BLEEDING RISK IN PLASTIC SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS

PubMed Central

Kelley, Brian P.; Bennett, Katelyn G.; Chung, Kevin C.; Kozlow, Jeffrey H.

2016-01-01

Background Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are common medications with multiple useful effects including pain relief and reduction of inflammation. However, surgeons commonly hold all NSAIDs peri-operatively because of bleeding concerns. However, not all NSAIDs irreversibly block platelet function. We hypothesized that the use of ibuprofen would have no effect on postoperative bleeding in plastic surgery patients. Methods A literature review was performed using Medline (PubMed), EMBASE, and the Cochrane Collaboration Library for primary research articles on ibuprofen and bleeding. Inclusion criteria were primary journal articles examining treatment of acute postoperative based on any modality. Data related to pain assessment, postoperative recovery, and complications were extracted. Bias assessment and meta-analysis were performed. Results A total of 881 publications were reviewed. Four primary randomized controlled trials were selected for full analysis. Articles were of high quality by bias assessment. No significant difference was noted regarding bleeding events (p = 0.32) and pain control was noted to be equivalent. Conclusion Ibuprofen is a useful medication in the setting of surgery with multiple beneficial effects. This meta-analysis represents a small set of high quality studies that suggests ibuprofen provides equivalent pain control to narcotics. Importantly, ibuprofen was not associated with an increased risk of bleeding. Further large studies will be necessary to elucidate this issue further, but ibuprofen is a safe postoperative analgesic in patients undergoing common plastic surgery soft tissue procedures. PMID:27018685

Risk factors for re-bleeding of aneurysmal subarachnoid hemorrhage: meta-analysis of observational studies.

PubMed

Alfotih, Gobran Taha Ahmed; Li, FangCheng; Xu, XinKe; Zhang, ShangYi

2014-01-01

The mortality of re-bleeding following aneurysmal subarachnoid hemorrhage is high, and surviving patients often have poor clinical condition and worse outcome than patients with a single bleed. In this study, we performed an updated systematic review and meta-analysis to determine the most common risk factors for re-bleeding in this patient population, with the goal of providing neurologists, neurosurgeons, neuro-interventionalists with a simple and fast method to evaluate the re-bleeding risk for aneurysmal subarachnoid hemorrhage. We conducted a thorough meta-analysis of the risk factors associated with re-bleeding or re-rupture of intracranial aneurysms in cases published between 2000 and 2013. Pooled mean difference was calculated for the continuous variables (age), and pooled odds ratio (OR) was calculated for categorical factors. If heterogeneity was significant (p<0.05), a random effect model was applied; otherwise, a fixed model was used. Testing for pooled effects and statistical significance for each potential risk factor were analyzed using Review Manager software. Our literature search identified 174 articles. Of these, only seven retrospective studies met the inclusion criteria. These seven studies consisted of 2470 patients, 283 of which had aneurysmal re-bleeding, resulting in a weighted average rate of re-bleeding of 11.3% with 95% confidence interval [CI]: 10.1-12.6. In this population, sex (OR 1.46; 95% CI: 1.11-1.92), high systolic blood pressure [SBP] (OR 2.52; 95% CI: 1.40-4.53), aneurysm size (OR 3.00; 95% CI: 2.06-4.37), clinical condition (Hunt & Hess) (OR 4.94; 95% CI: 2.29,10.68), and Fisher grade (OR 2.29; 95% CI: 1.45, 3.61) were statistically significant risk factors for re-bleeding. Sex, high SBP, high Fisher grade, aneurysm size larger than 10mm, and poor clinical condition were independent risk factors for aneurysmal re-bleeding. The importance of early aneurysm intervention and careful consideration of patient risk factors should be emphasized to eliminate the risk of re-bleeding and poor outcome. Copyright © 2014 Polish Neurological Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

Establishment of a prenatal diagnosis schedule as part of a prophylaxis program of factor XIII deficiency in the southeast of Iran.

PubMed

Naderi, Majid; Reykande, Samira Esmaeili; Dorgalaleh, Akbar; Alizadeh, Shaban; Tabibian, Shadi; Einollahi, Nahid; Moghaddam, Ebrahim Miri

2016-01-01

Factor XIII deficiency (FXIIID) is an extremely rare bleeding disorder with a prevalence of 1 in 3 million in the general population. Compared to its global incidence, it has the greatest prevalence in Sistan and Baluchistan Province in the southeast of Iran. The high incidence of FXIIID in this region causes a high rate of morbidity and mortality among the affected individuals because of life-threatening episodes such as central nervous system (CNS) bleeding, umbilical cord bleeding, as well as miscarriage. CNS bleeding leads to a considerable number of neurological and behavioral complications. Therefore, we have designed an established prenatal diagnosis (PND) program to prevent the increasing incidence of life-threatening bleeding episodes and related complications among neonates with congenital FXIIID. This study was conducted from September 2013 to August 2014. A consent form was signed by the parents. Fetal sampling was done via abdominal chorionic villus sampling passage under local anesthesia and ultrasonic guidance within the first trimester of pregnancy. Fetal DNA was extracted, and PCR-restriction fragment length polymorphism was performed for the only reported mutation of FXIII (Trp187Arg) in the southeast of Iran. During the period of study, PND was performed on eight fetuses. Six fetuses were offspring of parental consanguineous marriages, and all of them had a positive family history of FXIIID. Seven out of the eight fetuses had a family member with CNS bleeding due to FXIIID. Four fetuses had a FXIIID-related death. One of the fetuses bore homozygous Trp187Arg mutation, whereas six were heterozygous, and one of the mothers gave birth to an unaffected fetus. To the best of our knowledge, PND is a possible solution to control high incidence of life-threatening episodes of FXIIID in southeast Iran.

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding.

PubMed

Gerson, Lauren B; Fidler, Jeff L; Cave, David R; Leighton, Jonathan A

2015-09-01

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding.

PubMed

Singh-Bhinder, Nimarta; Kim, David H; Holly, Brian P; Johnson, Pamela T; Hanley, Michael; Carucci, Laura R; Cash, Brooks D; Chandra, Ankur; Gage, Kenneth L; Lambert, Drew L; Levy, Angela D; Oliva, Isabel B; Peterson, Christine M; Strax, Richard; Rybicki, Frank J; Dill, Karin E

2017-05-01

Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, "postsurgical and traumatic causes of UGIB; endoscopy contraindicated" is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.

[Comparative results of surgical treatment for perforating and bleeding pyloroduodenal ulcers].

PubMed

Gorbunov, V N; Sytnik, A P; Korenev, N N; Gordeev, S A; Stoliarchuk, E V; Urzhumtseva, G A

1998-01-01

Results of treatment of 1309 patients with perforated and bleeding pyloroduodenal ulcers for 20-years period have been analysed. Resection of the stomach performed in 85 cases resulted in high postoperative lethality which made up in bleeding ulcers 14.8%. Drainage operations of the stomach with excision or suturing of ulcer combined with bilateral truncal vagotomy was performed in 60 patients, postoperative lethality rate being 8.4%. 128 patients underwent selective proximal vagotomy together with pyloro- and duodenoplasty, lethality rate being 1.6%. Combined vagotomy (posterior truncal and anterior sero-muscular) with excision of ulcer, transversal pyloroplasty and duodenoplasty was carried out in 1036 patients (postoperative lethality--2.4%). Excellent and good functional results were achieved in 79.6% of the patients.

The medical management of abnormal uterine bleeding in reproductive-aged women.

PubMed

Bradley, Linda D; Gueye, Ndeye-Aicha

2016-01-01

In the treatment of women with abnormal uterine bleeding, once a thorough history, physical examination, and indicated imaging studies are performed and all significant structural causes are excluded, medical management is the first-line approach. Determining the acuity of the bleeding, the patient's medical history, assessing risk factors, and establishing a diagnosis will individualize their medical regimen. In acute abnormal uterine bleeding with a normal uterus, parenteral estrogen, a multidose combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic acid are all viable options, given the appropriate clinical scenario. Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid with high efficacy. Nonsteroidal antiinflammatory drugs may be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding. Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions. In women with inherited bleeding disorders all hormonal methods as well as tranexamic acid can be used to treat abnormal uterine bleeding. Women on anticoagulation therapy should consider using progestin-only methods as well as a gonadotropin-releasing hormone agonist to treat their heavy menstrual bleeding. Given these myriad options for medical treatment of abnormal uterine bleeding, many patients may avoid surgical intervention. Copyright © 2016 Elsevier Inc. All rights reserved.

Serious Bleeding Events due to Warfarin and Antibiotic Co-prescription In a Cohort of Veterans

PubMed Central

Lane, Michael A.; Zeringue, Angelique; McDonald, Jay R.

2014-01-01

Background Antibiotics may interact with warfarin, increasing the risk for significant bleeding events. Methods Retrospective cohort study of veterans prescribed warfarin for ≥ 30 days without interruption through the VA between October 1, 2002 and September 1, 2008. Antibiotics considered to be high-risk for interaction with warfarin include: trimethoprim/sulfamethoxazole (TMP/SMX), ciprofloxacin, levofloxacin, metronidazole, fluiconazole, azithromycin, and clarithromycin. Low-risk antibiotics include: clindamycin and cephalexin. Risk of bleeding event within 30 days of antibiotic exposure was measured using Cox proportional hazards regression, adjusted for demographic characteristics, comorbid conditions and receipt of other medications interacting with warfarin. Results A total of 22,272 patients met inclusion criteria with 14,078 and 8,194 receiving high- and low-risk antibiotics, respectively. There were 93 and 36 bleeding events in the high- and low-risk groups, respectively. Receipt of a high-risk antibiotic (HR 1.48, 95% CI 1.00-2.19) and azithromycin (HR 1.93, 95% CI 1.13-3.30) were associated with increased risk of bleeding as a primary diagnosis. TMP/SMX (HR 2.09, 95% CI 1.45-3.02), ciprofloxacin (HR 1.87, 95% CI 1.42-2.50), levofloxacin (HR 1.77, 95% CI 1.22-2.50), azithromycin (HR 1.64, 95% CI 1.16-2.33), and clarithromycin (HR 2.40, 95% CI 1.16-4.94) were associated with serious bleeding as a primary or secondary diagnosis. INR alterations were common; 9.7% of patients prescribed fluconazole had INR value >6. Patients who had INR performed 3-14 days of co-prescription were at a decrease risk of serious bleeding (HR 0.61, 95% CI 0.42-0.88). Conclusions Warfarin users who are prescribed high-risk antibiotics are at higher risk for serious bleeding events. Early INR evaluation may mitigate this risk. PMID:24657899

Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications.

PubMed

Lin, David; Soetikno, Roy M; McQuaid, Kenneth; Pham, Chi; Doan, Gilbert; Mou, Shanshan; Shergill, Amandeep K; Somsouk, Ma; Rouse, Robert V; Kaltenbach, Tonya

2018-04-01

Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy. We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding. There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < .001) and more polyps ≥2 cm (41% vs 10%; P < .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P < .001), having polyps ≥2 cm (OR 5.94; P < .001), performing right-sided cautery (OR 2.61; P = .004), and having multiple large polyps (OR 2.92; P = .001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = .0001). We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk. Copyright © 2018. Published by Elsevier Inc.

The predictive ability of the CHADS2 and CHA2DS2-VASc scores for bleeding risk in atrial fibrillation: the MAQI(2) experience.

PubMed

Barnes, Geoffrey D; Gu, Xiaokui; Haymart, Brian; Kline-Rogers, Eva; Almany, Steve; Kozlowski, Jay; Besley, Dennis; Krol, Gregory D; Froehlich, James B; Kaatz, Scott

2014-08-01

Guidelines recommend the assessment of stroke and bleeding risk before initiating warfarin anticoagulation in patients with atrial fibrillation. Many of the elements used to predict stroke also overlap with bleeding risk in atrial fibrillation patients and it is tempting to use stroke risk scores to efficiently estimate bleeding risk. Comparison of stroke risk scores to bleeding risk scores to predict bleeding has not been thoroughly assessed. 2600 patients followed at seven anticoagulation clinics were followed from October 2009-May 2013. Five risk models (CHADS2, CHA2DS2-VASc, HEMORR2HAGES, HAS-BLED and ATRIA) were retrospectively applied to each patient. The primary outcome was the first major bleeding event. Area under the ROC curves were compared with C statistic and net reclassification improvement (NRI) analysis was performed. 110 patients experienced a major bleeding event in 2581.6 patient-years (4.5%/year). Mean follow up was 1.0±0.8years. All of the formal bleeding risk scores had a modest predictive value for first major bleeding events (C statistic 0.66-0.69), performing better than CHADS2 and CHA2DS2-VASc scores (C statistic difference 0.10 - 0.16). NRI analysis demonstrated a 52-69% and 47-64% improvement of the formal bleeding risk scores over the CHADS2 score and CHA2DS2-VASc score, respectively. The CHADS2 and CHA2DS2-VASc scores did not perform as well as formal bleeding risk scores for prediction of major bleeding in non-valvular atrial fibrillation patients treated with warfarin. All three bleeding risk scores (HAS-BLED, ATRIA and HEMORR2HAGES) performed moderately well. Copyright © 2014 Elsevier Ltd. All rights reserved.

Clinical outcome of acute nonvariceal upper gastrointestinal bleeding after hours: the role of urgent endoscopy.

PubMed

Ahn, Dong-Won; Park, Young Soo; Lee, Sang Hyub; Shin, Cheol Min; Hwang, Jin-Hyeok; Kim, Jin-Wook; Jeong, Sook-Hyang; Kim, Nayoung; Lee, Dong Ho

2016-05-01

This study was performed to investigate the clinical role of urgent esophagogastroduodenoscopy (EGD) for acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) performed by experienced endoscopists after hours. A retrospective analysis was performed for consecutively collected data of patients with ANVUGIB between January 2009 and December 2010. A total of 158 patients visited the emergency unit for ANVUGIB after hours. Among them, 60 underwent urgent EGD (within 8 hours) and 98 underwent early EGD (8 to 24 hours) by experienced endoscopists. The frequencies of hemodynamic instability, fresh blood aspirate on the nasogastric tube, and high-risk endoscopic findings were significantly higher in the urgent EGD group. Primary hemostasis was achieved in all except two patients. There were nine cases of recurrent bleeding, and 30-day mortality occurred in three patients. There were no significant differences between the two groups in primary hemostasis, recurrent bleeding, and 30-day mortality. In a multiple linear regression analysis, urgent EGD significantly reduced the hospital stay compared with early EGD. In patients with a high clinical Rockall score (more than 3), urgent EGD tended to decrease the hospital stay, although this was not statistically significant (7.7 days vs. 12.0 days, p > 0.05). Urgent EGD after hours by experienced endoscopists had an excellent endoscopic success rate. However, clinical outcomes were not significantly different between the urgent and early EGD groups.

Antiplatelet agents and/or anticoagulants are not associated with worse outcome following nonvariceal upper gastrointestinal bleeding.

PubMed

Teles-Sampaio, Elvira; Maia, Luís; Salgueiro, Paulo; Marcos-Pinto, Ricardo; Dinis-Ribeiro, Mário; Pedroto, Isabel

2016-11-01

Nonvariceal upper gastrointestinal bleeding emerges as a major complication of using antiplatelet agents and/or anticoagulants and represents a clinical challenge in patients undergoing these therapies. To characterize patients with nonvariceal upper gastrointestinal bleeding related to antithrombotics and their management, and to determine clinical predictors of adverse outcomes. Retrospective cohort of adults who underwent upper gastrointestinal endoscopy after nonvariceal upper gastrointestinal bleeding from 2010 to 2012. The outcomes were compared between patients exposed and not exposed to antithrombotics. Five hundred and forty-eight patients with nonvariceal upper gastrointestinal bleeding (67% men; mean age 66.5 ± 16.4 years) were included, of which 43% received antithrombotics. Most patients had comorbidities. Peptic ulcer was the main diagnosis and endoscopic therapy was performed in 46% of cases. The 30-day mortality rate was 7.7% (n = 42), and 36% were bleeding-related. The recurrence rate was 9% and 14% of patients with initial endoscopic treatment needed endoscopic retreatment. There were no significant differences between the exposed and non-exposed groups in most outcomes. Co-morbidities, hemodynamic instability, high Rockall score, low hemoglobin (7.76 ± 2.72 g/dL) and higher international normalized ratio (1.63 ± 1.13) were associated significantly with mortality in a univariate analysis. Adverse outcomes were not associated with antithrombotic use. The management of nonvariceal upper gastrointestinal bleeding constitutes a challenge to clinical performance optimization and clinical cooperation.

The effects of intraoperative lung protective ventilation with positive end-expiratory pressure on blood loss during hepatic resection surgery: A secondary analysis of data from a published randomised control trial (IMPROVE).

PubMed

Neuschwander, Arthur; Futier, Emmanuel; Jaber, Samir; Pereira, Bruno; Eurin, Mathilde; Marret, Emmanuel; Szymkewicz, Olga; Beaussier, Marc; Paugam-Burtz, Catherine

2016-04-01

During high-risk abdominal surgery the use of a multi-faceted lung protective ventilation strategy composed of low tidal volumes, positive end-expiratory pressure (PEEP) and recruitment manoeuvres, has been shown to improve clinical outcomes. It has been speculated, however, that mechanical ventilation using PEEP might increase intraoperative bleeding during liver resection. To study the impact of mechanical ventilation with PEEP on bleeding during hepatectomy. Post-hoc analysis of a randomised controlled trial. Seven French university teaching hospitals from January 2011 to August 2012. Patients scheduled for liver resection surgery. In the Intraoperative Protective Ventilation trial, patients scheduled for major abdominal surgery were randomly assigned to mechanical ventilation using low tidal volume, PEEP between 6 and 8  cmH2O and recruitment manoeuvres (lung protective ventilation strategy) or higher tidal volume, zero PEEP and no recruitment manoeuvres (non-protective ventilation strategy). The primary endpoint was intraoperative blood loss volume. A total of 79 (19.8%) patients underwent liver resections (41 in the lung protective and 38 in the non-protective group). The median (interquartile range) amount of intraoperative blood loss was 500 (200 to 800)  ml and 275 (125 to 800)  ml in the non-protective and lung protective ventilation groups, respectively (P = 0.47). Fourteen (35.0%) and eight (21.5%) patients were transfused in the non-protective and lung protective groups, respectively (P = 0.17), without a statistically significant difference in the median (interquartile range) number of red blood cells units transfused [2.5 (2 to 4) units and 3 (2 to 6) units in the two groups, respectively; P = 0.54]. During hepatic surgery, mechanical ventilation using PEEP within a multi-faceted lung protective strategy was not associated with increased bleeding compared with non-protective ventilation using zero PEEP. The current study was not registered. The original Intraoperative Protective Ventilation study was registered on clinicaltrials.gov; number NCT01282996.

Objectives and Design of BLEEDS: A Cohort Study to Identify New Risk Factors and Predictors for Major Bleeding during Treatment with Vitamin K Antagonists.

PubMed

van Rein, Nienke; Lijfering, Willem M; Bos, Mettine H A; Herruer, Martien H; Vermaas, Helga W; van der Meer, Felix J M; Reitsma, Pieter H

2016-01-01

Risk scores for patients who are at high risk for major bleeding complications during treatment with vitamin K antagonists (VKAs) do not perform that well. BLEEDS was initiated to search for new biomarkers that predict bleeding in these patients. To describe the outline and objectives of BLEEDS and to examine whether the study population is generalizable to other VKA treated populations. A cohort was created consisting of all patients starting VKA treatment at three Dutch anticoagulation clinics between January-2012 and July-2014. We stored leftover plasma and DNA following analysis of the INR. Of 16,706 eligible patients, 16,570 (99%) were included in BLEEDS and plasma was stored from 13,779 patients (83%). Patients had a mean age of 70 years (SD 14), 8713 were male (53%). The most common VKA indications were atrial fibrillation (10,876 patients, 66%) and venous thrombosis (3920 patients, 24%). 326 Major bleeds occurred during 17,613 years of follow-up (incidence rate 1.85/100 person years, 95%CI 1.66-2.06). The risk for major bleeding was highest in the initial three months of VKA treatment and increased when the international normalized ratio increased. These results and characteristics are in concordance with results from other VKA treated populations. BLEEDS is generalizable to other VKA treated populations and will permit innovative and unbiased research of biomarkers that may predict major bleeding during VKA treatment.

Non-steroidal anti-inflammatory drug related upper gastrointestinal bleeding: types of drug use and patient profiles in real clinical practice.

PubMed

Sostres, Carlos; Carrera-Lasfuentes, Patrica; Lanas, Angel

2017-10-01

The best available evidence regarding non-steroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) bleeding comes from randomized controlled trials including patients who use NSAIDs to manage chronic rheumatic diseases; however, patients with varying background profiles commonly take NSAIDs for many other reasons, often without prescription, and such usage has not been well studied. To define the characteristics of patients hospitalized for upper GI bleeding in clinical practice, we conducted a case-control study among patients with endoscopy-proven major upper GI bleeding due to gastroduodenal peptic lesions and control subjects. We used adjusted logistic regression models to estimate bleeding risks. Data analysis was performed using SPSS 22.0. Our analysis included 3785 cases and 6540 controls, including 1270 cases (33.55%) and 834 controls (12.75%) reporting recent use (<30 days) of NSAIDs including high-dose acetylsalicylic acid (ASA). NSAID use was associated with increased risk of upper GI bleeding, with an adjusted relative risk of 4.86 (95% CI, 4.32-5.46). Acute musculoskeletal pain (36.1%), chronic osteoarthritis (13.5%), and headache (13.6%) were the most common reasons for NSAID use. Among cases, only 17.31% took NSAIDs and 6.38% took high dose ASA due to chronic osteoarthritis. Demographic characteristics significantly differed between subjects with chronic vs. acute musculoskeletal pain. Proton pump inhibitor use was significantly higher in patients who used NSAIDs due to chronic osteoarthritis compared to patients with acute musculoskeletal pain. NSAID (65.15%) or high-dose ASA use (65.83%) preceding upper GI bleeding was most often short-term. In over half of cases (63.62%), the upper GI bleeding event was not preceded by dyspeptic warning symptoms. The majority of patients hospitalized due to NSAID-related upper GI bleeding reported short-term NSAID use for reasons other than chronic rheumatic disease. These findings suggest that current prevention strategies may not reach a wide population of short-term NSAID users.

Predicting Major Bleeding in Ischemic Stroke Patients With Atrial Fibrillation.

PubMed

Hilkens, Nina A; Algra, Ale; Greving, Jacoba P

2017-11-01

Performance of risk scores for major bleeding in patients with atrial fibrillation and a previous transient ischemic attack or ischemic stroke is not well established. We aimed to validate risk scores for major bleeding in patients with atrial fibrillation treated with oral anticoagulants after cerebral ischemia and explore the net benefit of oral anticoagulants among bleeding risk categories. We analyzed 3623 patients with a history of transient ischemic attack or stroke included in the RE-LY trial (Randomized Evaluation of Long-Term Anticoagulation Therapy). We assessed performance of HEMORR 2 HAGES (hepatic or renal disease, ethanol abuse, malignancy, older age, reduced platelet count or function, hypertension [uncontrolled], anemia, genetic factors, excessive fall risk, and stroke), Shireman, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and ORBIT scores (older age, reduced haemoglobin/haematocrit/history of anaemia, bleeding history, insufficient kidney function, and treatment with antiplatelet) with C statistics and calibration plots. Net benefit of oral anticoagulants was explored by comparing risk reduction in ischemic stroke with risk increase in major bleedings on warfarin. During 6922 person-years of follow-up, 266 patients experienced a major bleed (3.8 per 100 person-years). C statistics ranged from 0.62 (Shireman) to 0.67 (ATRIA). Calibration was poor for ATRIA and moderate for other models. The reduction in recurrent ischemic strokes on warfarin was larger than the increase in major bleeding risk, irrespective of bleeding risk category. Performance of prediction models for major bleeding in patients with cerebral ischemia and atrial fibrillation is modest but comparable with performance in patients with only atrial fibrillation. Bleeding risk scores cannot guide treatment decisions for oral anticoagulants but may still be useful to identify modifiable risk factors for bleeding. Clinical usefulness may be best for ORBIT, which is based on a limited number of easily obtainable variables and showed reasonable performance. © 2017 American Heart Association, Inc.

Medical and endoscopic treatment in peptic ulcer bleeding: a national German survey.

PubMed

Maiss, J; Schwab, D; Ludwig, A; Naegel, A; Ende, A; Hahn, G; Zopf, Y

2010-02-01

Peptic ulcers are the leading cause of upper gastrointestinal (GI) bleeding. The aim of this study was the evaluation of the recent clinical practice in drug therapy and endoscopic treatment of ulcer bleedings in Germany and to compare the results with the medical standard. A structured questionnaire (cross-sectional study) was sent to 1371 German hospitals that provide an emergency service for upper GI bleeding. The project was designed similar to a nationwide inquiry in France in 2001. Forty-four questions concerning the following topics were asked: hospital organisation, organisation of emergency endoscopy service, endoscopic and drug therapy of ulcer bleeding, endoscopic treatment of variceal bleeding. Return of the questionnaires was closed in August 2004. Response rate was 675 / 1371 (49 %). Mean hospitals size was < 200 beds, 49 % (n = 325) had basic care level. 92 % provided a 24-hour endoscopy service, specialized nurses were available in 75 %. Fiberscopes were used only in 15 %. A mean of 10 +/- 12 (range: 0 - 160) bleeding cases/month were treated, 6 +/- 6 cases per month (60 %) were ulcer bleedings. Endoscopy was performed in 72 % immediately after stabilization but in all cases within 24 hours. The Forrest classification was used in 99 % whereas prognostic scores were applied only in 3 %. Forrest Ia,/Ib/IIa/IIb/IIc/III ulcers were indications for endoscopic therapy in 99 %/ 99 %/ 90 %/ 58 %/ 4 %/ 2 % respectively. Favoured initial treatment was injection (diluted epinephrine, mean volume 17 +/- 13 mL/lesion) followed by clipping. In re-bleedings, 93 % tried endoscopic treatment again. Scheduled re-endoscopy was performed in 63 %. PPI were used in 99.6 %, 85 % administered standard dose twice daily. PPI administration was changed from intravenous to oral with the end of fasting in nearly all hospitals. PPI administration schemes can be improved. Indications for Helicobacter pylori eradication followed rational principles. Medical and endoscopic treatment of bleeding ulcers reached a high standard, although some therapeutic strategies leave room for improvement. Bigger hospitals tend to be closer to the medical standard.

Endoscopic hemostasis using endoclip in early gastrointestinal hemorrhage after gastric bypass surgery.

PubMed

Tang, Shou-Jiang; Rivas, Homero; Tang, Linda; Lara, Luis F; Sreenarasimhaiah, Jayaprakash; Rockey, Don C

2007-09-01

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed bariatric operation in the USA. In the early postoperative stage, gastrointestinal (GI) bleeding is an infrequent but potentially serious complication that usually results from bleeding at the gastrojejunostomy staple-line. Observant management with transfusion for stable patients and surgical exploration for unstable patients is typically recommended for early GI bleeding. We hypothesized that use of endoclips, which do not cause thermal injury to the surrounding tissues (or anastomosis), may be preferable to thermal approaches which could cause tissue injury. We report 2 cases of early GI bleeding after RYGBP that were successfully managed with endoclip application to bleeding lesions. Emergent endoscopy was performed, and major stigmata such as active spurting vessel and adherent clot were noted at the gastrojejunostomy staple-lines. Endoscopic hemostasis using endoclips was readily applied to bleeding lesions at staple-lines. Primary hemostasis was achieved, and there was no recurrent bleeding or complication. We conclude that therapeutic endoscopy can be performed safely for early bleeding after RYGBP. In patients with early bleeding after RYGBP, use of endoclips is mechanistically preferable to other options.

Flow Coefficient Behavior for Boundary Layer Bleed Holes and Slots

NASA Technical Reports Server (NTRS)

Willis, B. P.; Davis, D. O.; Hingst, W. R.

1995-01-01

An experimental investigation into the flow coefficient behavior for nine boundary layer bleed orifice configurations is reported. This test was conducted for the purposes of exploring boundary layer control through mass flow removal and does not address issues of stability bleed. Parametric data consist of bleed region flow coefficient as a function of Mach number, bleed plenum pressure, and bleed orifice geometry. Seven multiple hole configurations and two single slot configurations were tested over a supersonic Mach number range of 1.3 to 2.5 (nominal). Advantages gained by using multiple holes in a bleed region instead of a single spanwise slot are discussed and the issue of modeling an entire array of bleed orifices based on the performance of a single orifice is addressed. Preconditioning the flow approaching a 90 degree inclined (normal) hole configuration resulted in a significant improvement in the performance of the configuration. The same preconditioning caused only subtle changes in performance for a 20 degree inclined (slanted) configuration.

A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions.

PubMed

Albéniz, Eduardo; Fraile, María; Ibáñez, Berta; Alonso-Aguirre, Pedro; Martínez-Ares, David; Soto, Santiago; Gargallo, Carla Jerusalén; Ramos Zabala, Felipe; Álvarez, Marco Antonio; Rodríguez-Sánchez, Joaquín; Múgica, Fernando; Nogales, Óscar; Herreros de Tejada, Alberto; Redondo, Eduardo; Guarner-Argente, Carlos; Pin, Noel; León-Brito, Helena; Pardeiro, Remedios; López-Roses, Leopoldo; Rodríguez-Téllez, Manuel; Jiménez, Alejandra; Martínez-Alcalá, Felipe; García, Orlando; de la Peña, Joaquín; Ono, Akiko; Alberca de Las Parras, Fernando; Pellisé, María; Rivero, Liseth; Saperas, Esteban; Pérez-Roldán, Francisco; Pueyo Royo, Antonio; Eguaras Ros, Javier; Zúñiga Ripa, Alba; Concepción-Martín, Mar; Huelin-Álvarez, Patricia; Colán-Hernández, Juan; Cubiella, Joaquín; Remedios, David; Bessa I Caserras, Xavier; López-Viedma, Bartolomé; Cobian, Julyssa; González-Haba, Mariano; Santiago, José; Martínez-Cara, Juan Gabriel; Valdivielso, Eduardo

2016-08-01

After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk. We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding. Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%-4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0-3), average-risk (score, 4-7), or high-risk (score, 8-10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70-0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively. The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8-10) had a 40% probability of delayed bleeding. Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.

Efficacy of Prophylactic Uterine Artery Embolization before Obstetrical Procedures with High Risk for Massive Bleeding

PubMed Central

Ko, Heung Kyu; Ko, Gi Young; Gwon, Dong Il; Kim, Jin Hyung; Han, Kichang; Lee, Shin-Wha

2017-01-01

Objective To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE) before obstetrical procedures with high risk for massive bleeding. Materials and Methods A retrospective review of 29 female patients who underwent prophylactic UAE from June 2009 to February 2014 was performed. Indications for prophylactic UAE were as follows: dilatation and curettage (D&C) associated with ectopic pregnancy (cesarean scar pregnancy, n = 9; cervical pregnancy, n = 6), termination of pregnancy with abnormal placentation (placenta previa, n = 8), D&C for retained placenta with vascularity (n = 5), and D&C for suspected gestational trophoblastic disease (n = 1). Their medical records were reviewed to evaluate the safety and efficacy of UAE. Results All women received successful bilateral prophylactic UAE followed by D&C with preservation of the uterus. In all patients, UAE followed by obstetrical procedure prevented significant vaginal bleeding on gynecologic examination. There was no major complication related to UAE. Vaginal spotting continued for 3 months in three cases. Although oligomenorrhea continued for six months in one patient, normal menstruation resumed in all patients afterwards. During follow-up, four had subsequent successful natural pregnancies. Spontaneous abortion occurred in one of them during the first trimester. Conclusion Prophylactic UAE before an obstetrical procedure in patients with high risk of bleeding or symptomatic bleeding may be a safe and effective way to manage or prevent serious bleeding, especially for women who wish to preserve their fertility. PMID:28246515

CHOBS: Color Histogram of Block Statistics for Automatic Bleeding Detection in Wireless Capsule Endoscopy Video.

PubMed

Ghosh, Tonmoy; Fattah, Shaikh Anowarul; Wahid, Khan A

2018-01-01

Wireless capsule endoscopy (WCE) is the most advanced technology to visualize whole gastrointestinal (GI) tract in a non-invasive way. But the major disadvantage here, it takes long reviewing time, which is very laborious as continuous manual intervention is necessary. In order to reduce the burden of the clinician, in this paper, an automatic bleeding detection method for WCE video is proposed based on the color histogram of block statistics, namely CHOBS. A single pixel in WCE image may be distorted due to the capsule motion in the GI tract. Instead of considering individual pixel values, a block surrounding to that individual pixel is chosen for extracting local statistical features. By combining local block features of three different color planes of RGB color space, an index value is defined. A color histogram, which is extracted from those index values, provides distinguishable color texture feature. A feature reduction technique utilizing color histogram pattern and principal component analysis is proposed, which can drastically reduce the feature dimension. For bleeding zone detection, blocks are classified using extracted local features that do not incorporate any computational burden for feature extraction. From extensive experimentation on several WCE videos and 2300 images, which are collected from a publicly available database, a very satisfactory bleeding frame and zone detection performance is achieved in comparison to that obtained by some of the existing methods. In the case of bleeding frame detection, the accuracy, sensitivity, and specificity obtained from proposed method are 97.85%, 99.47%, and 99.15%, respectively, and in the case of bleeding zone detection, 95.75% of precision is achieved. The proposed method offers not only low feature dimension but also highly satisfactory bleeding detection performance, which even can effectively detect bleeding frame and zone in a continuous WCE video data.

Congenital portosystemic shunts with and without gastrointestinal bleeding - case series.

PubMed

Gong, Ying; Zhu, Hui; Chen, Jun; Chen, Qi; Ji, Min; Pa, Mier; Zheng, Shan; Qiao, Zhongwei

2015-12-01

The clinical presentation of congenital portosystemic shunt is variable and gastrointestinal bleeding is an uncommon presentation. To describe the imaging features of congenital portosystemic shunt as it presented in 11 children with (n = 6) and without gastrointestinal bleeding (n = 5). We performed a retrospective study on a clinical and imaging dataset of 11 children diagnosed with congenital portosystemic shunt. A total of 11 children with congenital portosystemic shunt were included in this study, 7 with extrahepatic portosystemic shunts and 4 with intrahepatic portosystemic shunts. Six patients with gastrointestinal bleeding had an extrahepatic portosystemic shunt, and the imaging results showed that the shunts originated from the splenomesenteric junction (n = 5) or splenic vein (n = 1) and connected to the internal iliac vein. Among the five cases of congenital portosystemic shunt without gastrointestinal bleeding, one case was an extrahepatic portosystemic shunt and the other four were intrahepatic portosystemic shunts. Most congenital portosystemic shunt patients with gastrointestinal bleeding had a shunt that drained portal blood into the iliac vein via an inferior mesenteric vein. This type of shunt was uncommon, but the concomitant rate of gastrointestinal bleeding with this type of shunt was high.

Severe bleeding complications other than intracranial hemorrhage in neonatal alloimmune thrombocytopenia: a case series and review of the literature.

PubMed

Winkelhorst, Dian; Kamphuis, Marije M; de Kloet, Liselotte C; Zwaginga, Jaap Jan; Oepkes, Dick; Lopriore, Enrico

2016-05-01

The most feared bleeding complication in fetal and neonatal alloimmune thrombocytopenia (FNAIT) is an intracranial hemorrhage (ICH). However, FNAIT may also lead to other severe bleeding problems. The aim was to analyze this spectrum and evaluate the occurrence of severe hemorrhages other than ICH in fetuses or neonates with FNAIT. A retrospective chart analysis of cases of FNAIT presenting with severe bleeding complications other than ICH at our institution from 1990 to 2015 was conducted. Additionally, a review of the literature was performed to identify case reports and case series on FNAIT presenting with extracranial hemorrhage. Of 25 fetuses or neonates with severe bleeding due to FNAIT, three had isolated severe internal organ hemorrhage other than ICH, two pulmonary hemorrhages and one gastrointestinal hemorrhage. Two of these three neonates died due to this bleeding. Eighteen cases of extracranial bleeding complications as a first presentation of FNAIT were found in the literature, including ocular, gastrointestinal, spinal cord, pulmonary, renal, subgaleal, and genitourinary hemorrhages. Bleeding complications other than ICH may be more extensive, and the presentation of FNAIT may have a greater spectrum than previously described. A high index of suspicion on the possible diagnosis of FNAIT with any bleeding complication in a fetus or neonate may enable adequate diagnostics, adequate treatment, and appropriate follow-up in future pregnancies, as is especially relevant for FNAIT. © 2016 AABB.

Simultaneous monitoring of static and dynamic intracranial pressure parameters from two separate sensors in patients with cerebral bleeds: comparison of findings.

PubMed

Eide, Per Kristian; Holm, Sverre; Sorteberg, Wilhelm

2012-09-07

We recently reported that in an experimental setting the zero pressure level of solid intracranial pressure (ICP) sensors can be altered by electrostatics discharges. Changes in the zero pressure level would alter the ICP level (mean ICP); whether spontaneous changes in mean ICP happen in clinical settings is not known. This can be addressed by comparing the ICP parameters level and waveform of simultaneous ICP signals. To this end, we retrieved our recordings in patients with cerebral bleeds wherein the ICP had been recorded simultaneously from two different sensors. During a time period of 10 years, 17 patients with cerebral bleeds were monitored with two ICP sensors simultaneously; sensor 1 was always a solid sensor while Sensor 2 was a solid -, a fluid - or an air-pouch sensor. The simultaneous signals were analyzed with automatic identification of the cardiac induced ICP waves. The output was determined in consecutive 6-s time windows, both with regard to the static parameter mean ICP and the dynamic parameters (mean wave amplitude, MWA, and mean wave rise time, MWRT). Differences in mean ICP, MWA and MWRT between the two sensors were determined. Transfer functions between the sensors were determined to evaluate how sensors reproduce the ICP waveform. Comparing findings in two solid sensors disclosed major differences in mean ICP in 2 of 5 patients (40%), despite marginal differences in MWA, MWRT, and linear phase magnitude and phase. Qualitative assessment of trend plots of mean ICP and MWA revealed shifts and drifts of mean ICP in the clinical setting. The transfer function analysis comparing the solid sensor with either the fluid or air-pouch sensors revealed more variable transfer function magnitude and greater differences in the ICP waveform derived indices. Simultaneous monitoring of ICP using two solid sensors may show marked differences in static ICP but close to identity in dynamic ICP waveforms. This indicates that shifts in ICP baseline pressure (sensor zero level) occur clinically; trend plots of the ICP parameters also confirm this. Solid sensors are superior to fluid - and air pouch sensors when evaluating the dynamic ICP parameters.

Objectives and Design of BLEEDS: A Cohort Study to Identify New Risk Factors and Predictors for Major Bleeding during Treatment with Vitamin K Antagonists

PubMed Central

van Rein, Nienke; Lijfering, Willem M.; Bos, Mettine H. A.; Herruer, Martien H.; Vermaas, Helga W.; van der Meer, Felix J. M.; Reitsma, Pieter H.

2016-01-01

Background Risk scores for patients who are at high risk for major bleeding complications during treatment with vitamin K antagonists (VKAs) do not perform that well. BLEEDS was initiated to search for new biomarkers that predict bleeding in these patients. Objectives To describe the outline and objectives of BLEEDS and to examine whether the study population is generalizable to other VKA treated populations. Methods A cohort was created consisting of all patients starting VKA treatment at three Dutch anticoagulation clinics between January-2012 and July-2014. We stored leftover plasma and DNA following analysis of the INR. Results Of 16,706 eligible patients, 16,570 (99%) were included in BLEEDS and plasma was stored from 13,779 patients (83%). Patients had a mean age of 70 years (SD 14), 8713 were male (53%). The most common VKA indications were atrial fibrillation (10,876 patients, 66%) and venous thrombosis (3920 patients, 24%). 326 Major bleeds occurred during 17,613 years of follow-up (incidence rate 1.85/100 person years, 95%CI 1.66–2.06). The risk for major bleeding was highest in the initial three months of VKA treatment and increased when the international normalized ratio increased. These results and characteristics are in concordance with results from other VKA treated populations. Conclusion BLEEDS is generalizable to other VKA treated populations and will permit innovative and unbiased research of biomarkers that may predict major bleeding during VKA treatment. PMID:27935941

DOE Zero Energy Ready Home Case Study: Alliance Green Builders, Casa Aguila

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pacific Northwest National Laboratory

Alliance Green Builders built this 3,129-ft2 home in the hills above Ramona, California, to the high-performance criteria of the DOE Zero Energy Ready Home (ZERH) program. The home should perform far better than net zero thanks to a super-efficient building shell, a wind turbine, three suntracking solar photovoltaic arrays, and solar thermal water heating.

Severe bleeding events in adults and children with primary immune thrombocytopenia: a systematic review.

PubMed

Neunert, C; Noroozi, N; Norman, G; Buchanan, G R; Goy, J; Nazi, I; Kelton, J G; Arnold, D M

2015-03-01

The burden of severe bleeding in adults and children with immune thrombocytopenia (ITP) has not been established. To describe the frequency and severity of bleeding events in patients with ITP, and the methods used to measure bleeding in ITP studies. We performed a systematic review of all prospective ITP studies that enrolled 20 or more patients. Two reviewers searched Medline, Embase, CINAHL and the Cochrane registry up to May 2014. Overall weighted proportions were estimated using a random effects model. Measurement properties of bleeding assessment tools were evaluated. We identified 118 studies that reported bleeding (n = 10 908 patients). Weighted proportions for intracerebral hemorrhage (ICH) were 1.4% for adults (95% confidence interval [CI], 0.9-2.1%) and 0.4% for children (95% CI, 0.2-0.7%; P < 0.01), most of whom had chronic ITP. The weighted proportion for severe (non-ICH) bleeding was 9.6% for adults (95% CI, 4.1-17.1%) and 20.2% for children (95% CI, 10.0-32.9%; P < 0.01) with newly-diagnosed or chronic ITP. Methods of reporting and definitions of severe bleeding were highly variable in primary studies. Two bleeding assessment tools (Buchanan 2002 for children; Page 2007 for adults) demonstrated adequate inter-rater reliability and validity in independent assessments. ICH was more common in adults and tended to occur during chronic ITP; other severe bleeds were more common in children and occurred at all stages of disease. Reporting of non-ICH bleeding was variable across studies. Further attention to ITP-specific bleeding measurement in clinical trials is needed to improve standardization of this important outcome for patients. © 2014 International Society on Thrombosis and Haemostasis.

Severe bleeding events in adults and children with primary immune thrombocytopenia: a systematic review

PubMed Central

NEUNERT, C.; NOROOZI, N.; NORMAN, G.; BUCHANAN, G. R.; GOY, J.; NAZI, I.; KELTON, J. G.; ARNOLD, D. M.

2016-01-01

Summary Background The burden of severe bleeding in adults and children with immune thrombocytopenia (ITP) has not been established. Objectives To describe the frequency and severity of bleeding events in patients with ITP, and the methods used to measure bleeding in ITP studies. Patients/Methods We performed a systematic review of all prospective ITP studies that enrolled 20 or more patients. Two reviewers searched Medline, Embase, CINAHL and the Cochrane registry up to May 2014. Overall weighted proportions were estimated using a random effects model. Measurement properties of bleeding assessment tools were evaluated. Results We identified 118 studies that reported bleeding (n = 10 908 patients). Weighted proportions for intracerebral hemorrhage (ICH) were 1.4% for adults (95% confidence interval [CI], 0.9–2.1%) and 0.4% for children (95% CI, 0.2–0.7%; P < 0.01), most of whom had chronic ITP. The weighted proportion for severe (non-ICH) bleeding was 9.6% for adults (95% CI, 4.1–17.1%) and 20.2% for children (95% CI, 10.0–32.9%; P < 0.01) with newly-diagnosed or chronic ITP. Methods of reporting and definitions of severe bleeding were highly variable in primary studies. Two bleeding assessment tools (Buchanan 2002 for children; Page 2007 for adults) demonstrated adequate interrater reliability and validity in independent assessments. Conclusions ICH was more common in adults and tended to occur during chronic ITP; other severe bleeds were more common in children and occurred at all stages of disease. Reporting of non-ICH bleeding was variable across studies. Further attention to ITP-specific bleeding measurement in clinical trials is needed to improve standardization of this important outcome for patients. PMID:25495497

Similar Efficacy of Proton-Pump Inhibitors vs H2-Receptor Antagonists in Reducing Risk of Upper Gastrointestinal Bleeding or Ulcers in High-Risk Users of Low-Dose Aspirin.

PubMed

Chan, Francis K L; Kyaw, Moe; Tanigawa, Tetsuya; Higuchi, Kazuhide; Fujimoto, Kazuma; Cheong, Pui Kuan; Lee, Vivian; Kinoshita, Yoshikazu; Naito, Yuji; Watanabe, Toshio; Ching, Jessica Y L; Lam, Kelvin; Lo, Angeline; Chan, Heyson; Lui, Rashid; Tang, Raymond S Y; Sakata, Yasuhisa; Tse, Yee Kit; Takeuchi, Toshihisa; Handa, Osamu; Nebiki, Hiroko; Wu, Justin C Y; Abe, Takashi; Mishiro, Tsuyoshi; Ng, Siew C; Arakawa, Tetsuo

2017-01-01

It is not clear whether H 2 -receptor antagonists (H2RAs) reduce the risk of gastrointestinal (GI) bleeding in aspirin users at high risk. We performed a double-blind randomized trial to compare the effects of a proton pump inhibitor (PPI) vs a H2RA antagonist in preventing recurrent upper GI bleeding and ulcers in high-risk aspirin users. We studied 270 users of low-dose aspirin (≤325 mg/day) with a history of endoscopically confirmed ulcer bleeding at 8 sites in Hong Kong and Japan. After healing of ulcers, subjects with negative results from tests for Helicobacter pylori resumed aspirin (80 mg) daily and were assigned randomly to groups given a once-daily PPI (rabeprazole, 20 mg; n = 138) or H2RA (famotidine, 40 mg; n = 132) for up to 12 months. Subjects were evaluated every 2 months; endoscopy was repeated if they developed symptoms of upper GI bleeding or had a reduction in hemoglobin level greater than 2 g/dL and after 12 months of follow-up evaluation. The adequacy of upper GI protection was assessed by end points of recurrent upper GI bleeding and a composite of recurrent upper GI bleeding or recurrent endoscopic ulcers at month 12. During the 12-month study period, upper GI bleeding recurred in 1 patient receiving rabeprazole (0.7%; 95% confidence interval [CI], 0.1%-5.1%) and in 4 patients receiving famotidine (3.1%; 95% CI, 1.2%-8.1%) (P = .16). The composite end point of recurrent bleeding or endoscopic ulcers at month 12 was reached by 9 patients receiving rabeprazole (7.9%; 95% CI, 4.2%-14.7%) and 13 patients receiving famotidine (12.4%; 95% CI, 7.4%-20.4%) (P = .26). In a randomized controlled trial of users of low-dose aspirin at risk for recurrent GI bleeding, a slightly lower proportion of patients receiving a PPI along with aspirin developed recurrent bleeding or ulcer than of patients receiving an H2RA with the aspirin, although this difference was not statistically significant. ClincialTrials.gov no: NCT01408186. Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.

The impact of bleeding complications in patients receiving target-specific oral anticoagulants: a systematic review and meta-analysis.

PubMed

Chai-Adisaksopha, Chatree; Crowther, Mark; Isayama, Tetsuya; Lim, Wendy

2014-10-09

Vitamin K antagonists (VKAs) have been the standard of care for treatment of thromboembolic diseases. Target-specific oral anticoagulants (TSOACs) have been developed and found to be at least noninferior to VKAs with regard to efficacy, but the risk of bleeding with TSOACs remains controversial. We performed a systematic review and meta-analysis of phase-3 randomized controlled trials (RCTs) to assess the bleeding side effects of TSOACs compared with VKAs in patients with venous thromboembolism or atrial fibrillation. We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials; conference abstracts; and www.clinicaltrials.gov with no language restriction. Two reviewers independently performed study selection, data extraction, and study quality assessment. Twelve RCTs involving 102 607 patients were retrieved. TSOACs significantly reduced the risk of overall major bleeding (relative risk [RR] 0.72, P < .01), fatal bleeding (RR 0.53, P < .01), intracranial bleeding (RR 0.43, P < .01), clinically relevant nonmajor bleeding (RR 0.78, P < .01), and total bleeding (RR 0.76, P < .01). There was no significant difference in major gastrointestinal bleeding between TSOACs and VKAs (RR 0.94, P = .62). When compared with VKAs, TSOACs are associated with less major bleeding, fatal bleeding, intracranial bleeding, clinically relevant nonmajor bleeding, and total bleeding. Additionally, TSOACs do not increase the risk of gastrointestinal bleeding. © 2014 by The American Society of Hematology.

High-power diode laser in the circumvestibular incision for Le Fort I osteotomy in orthognathic surgery: a prospective case series study.

PubMed

Jaeger, Filipe; Chiavaioli, Gustavo Marques; de Toledo, Guilherme Lacerda; Freire-Maia, Belini; Amaral, Marcio Bruno Figueiredo; Mesquita, Ricardo Alves

2018-01-01

The incisions during orthognathic surgery are classically performed with conventional scalpel or electrocautery. Considering that the high-power diode laser surgery may provide advantages when compared to conventional incision techniques, the current study aimed to present a prospective case series of patients submitted to circumvestibular incision for Le Fort I osteotomy. Ten patients with dentofacial deformities who underwent to rapid assisted maxillary expansion or bimaxillary orthognathic surgery were enrolled in the study. All incisions were performed by a single surgeon using an 808-nm diode laser, with an optical fiber of 600 μm, at a power of 2.5 W, in a continuous-wave mode. The performance of the incision was evaluated by incision velocity, bleeding, edema, secondary infection, clinical healing, and pain. The velocity of the incision ranged from 0.10 to 0.20 mm/s (mean 0.13 ± 0.03 mm/s). Considering bleeding during the soft tissue incision, all surgeries were classified as absent bleeding. All patients presented a clinical healing of the surgical wound in a period that range from 3 to 5 weeks and experienced swelling during the follow-up period. On average, approximately 50% of the swelling had resolved after the third postoperative week, and 28.8% of swelling remained after 2 months after the surgery. The pain decreased after 2 and 3 days, and 90.0% of the patients reported no pain after 7 postoperative days. High-power diode laser is effective and safety during circumvestibular incisions for Le Fort I osteotomy in orthognathic surgery decreasing bleeding, surgery time, pain, and edema after orthognathic surgery.

Hepatitis A and B immunization for individuals with inherited bleeding disorders.

PubMed

Steele, M; Cochrane, A; Wakefield, C; Stain, A-M; Ling, S; Blanchette, V; Gold, R; Ford-Jones, L

2009-03-01

Hepatitis A and B vaccines are highly effective tools that can greatly reduce infection risk in the bleeding disorder population. Although hepatitis A and B immunization for individuals with bleeding disorders is universally recommended, various advisory bodies often differ with respect to many practical aspects of vaccination. To review the published literature and guidelines and form a practical, comprehensive and consistent approach to hepatitis A and B immunization for individuals with bleeding disorders. We reviewed published immunization guidelines from North American immunization advisory bodies and published statements from North American and international haemophilia advisory bodies. A search of the MEDLINE database was performed to find original published literature pertaining to hepatitis A or B immunization of patients with haemophilia or bleeding disorder patients that provided supporting or refuting evidence for advisory body guidelines. Various advisory bodies' immunization guidelines regarding individuals with bleeding disorders have contradictory statements and often did not clarify issues (e.g. post vaccination surveillance). Published literature addressing immunization in bleeding disorder patients is sparse and mostly examines route of vaccine administration, complications and corresponding antibody response. Although the risk of hepatitis A and B infection is low, the use of simple measures such as vaccination is reasonable and advocated by haemophilia advisory bodies. Following our review of the available literature and North American guidelines, we have developed comprehensive and practical recommendations addressing hepatitis A and B immunization for the bleeding disorder population that may be applicable in Bleeding Disorder clinics.

Outcomes of Propofol Sedation During Emergency Endoscopy Performed for Upper Gastrointestinal Bleeding.

PubMed

Park, Chan Hyuk; Han, Dong Soo; Jeong, Jae Yoon; Eun, Chang Soo; Yoo, Kyo-Sang; Jeon, Yong Cheol; Sohn, Joo Hyun

2016-03-01

Although propofol-based sedation can be used during emergency endoscopy for upper gastrointestinal bleeding (UGIB), there is a potential risk of sedation-related adverse events, especially in patients with variceal bleeding. We compared adverse events related to propofol-based sedation during emergency endoscopy between patients with non-variceal and variceal bleeding. Clinical records of patients who underwent emergency endoscopy for UGIB under sedation were reviewed. Adverse events, including shock, hypoxia, and paradoxical reaction, were compared between the non-variceal and variceal bleeding groups. Of 703 endoscopies, 539 and 164 were performed for non-variceal and variceal bleeding, respectively. Shock was more common in patients with variceal bleeding compared to those with non-variceal bleeding (12.2 vs. 3.5%, P < 0.001). All patients except one recovered from shock after normal saline hydration, and emergency endoscopy could be finished without interruption in most cases. The incidence of hypoxia and paradoxical reaction did not differ based on the source of bleeding (non-variceal bleeding vs. variceal bleeding: hypoxia, 3.5 vs. 1.8%, P = 0.275; paradoxical reaction interfering with the procedure, 4.1 vs. 5.5%, P = 0.442). Although shock was more common in patients with variceal bleeding compared to those with non-variceal bleeding, most cases could be controlled without procedure interruption. Paradoxical reaction, rather than shock or hypoxia, was the most common cause of procedure interruption in patients with variceal bleeding, but the rate did not differ between patients with non-variceal and variceal bleeding.

Catheter-directed, ultrasound-assisted thrombolysis is a safe and effective treatment for pulmonary embolism, even in high-risk patients.

PubMed

Lee, Kristen A; Cha, Andrew; Kumar, Mark H; Rezayat, Combiz; Sales, Clifford M

2017-03-01

We sought to assess the early success and safety of catheter-directed, ultrasound-assisted (CDUA) thrombolysis for acute pulmonary embolism (PE) in patients deemed to be "high risk" for thrombolytic therapy. A retrospective evaluation of patients who underwent CDUA pulmonary thrombolysis in our practice during 39 months is reported. There were 91 patients considered, all of whom presented with acute PE as diagnosed by computed tomography angiography. The ratio of the right ventricle to left ventricle diameter (RV axial :LV axial ) was noted, as were preprocedure pulmonary artery pressures (PAPs). Demographic data, significant medical history, and procedure details were recorded. Standard thrombolysis protocol was followed (1 mg of tissue plasminogen activator per hour per catheter after an initial 2-mg bolus per catheter). Minitab 17 (Minitab Inc, State College, PA) was used for data analysis. There were 91 patients who had a computed tomography diagnosis of acute PE and pulmonary hypertension (PAP >25 mm Hg). Seventeen patients (19%) were deemed to be at high risk for bleeding, predicted by recent hemorrhage, major surgery within 3 weeks, acute myocardial infarction, and cardiac arrest with cardiopulmonary resuscitation within 1 week. The high-risk patients in our study were noted to have higher RV:LV ratios and lower oxygen saturations on admission (P < .05). On computed tomography angiography, the mean pretherapy RV axial :LV axial ratio was 1.5 ± 0.4. The mean pretherapy PAP was 56.2 ± 15.2 mm Hg. After 18.5 ± 3.5 hours of thrombolysis, the mean post-therapy PAP was 34.3 ± 10.4 mm Hg, with a pressure drop of 21.9 ± 4.8 mm Hg (39% decrease; P < .001). In total, seven patients (8%) suffered bleeding complications that required intervention-four gastrointestinal bleeds, a rectus sheath hematoma, and one gross hematuria. Three of the seven complications occurred in the high-risk group (3/17) and the other four in the general population of patients (4/74; P = .118). Minor bleeding complications (n = 14 [15%]) did not require intervention and included puncture site hematomas, ecchymosis, and mild traumatic hematuria. Considering all bleeding complications, increasing RV axial :LV axial ratio was a predictor of any bleeding complication, independent of all risk factors (P = .005). CDUA thrombolysis for acute PE effectively reduced mean PAPs. Given the low incidence of major bleeding complications, even in those deemed to be clinically at high risk for bleeding, we additionally conclude that this procedure can be performed safely. Although larger studies with longer follow-up are necessary, CDUA pulmonary thrombolysis for the management of acute submassive PE appears to be effective in decreasing right-sided heart strain and can be performed with an acceptable risk profile. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Delayed bleeding and hemorrhage of mucosal defects after gastric endoscopic submucosal dissection on second-look endoscopy.

PubMed

Ono, Shoko; Ono, Masayoshi; Nakagawa, Manabu; Shimizu, Yuichi; Kato, Mototsugu; Sakamoto, Naoya

2016-04-01

Although second-look endoscopy is performed within several days after gastric endoscopic submucosal dissection (ESD), there has been no evidence supporting the usefulness of the intervention. We investigated the relationship between delayed bleeding and hemorrhage of mucosal defects after ESD on second-look endoscopy and analyzed risk factors of active bleeding on second-look endoscopy. A total of 441 consecutive ESD cases with gastric cancer or adenoma were retrospectively analyzed. Second-look endoscopy was performed in the morning after the day of ESD. Bleeding of mucosal defects on second-look endoscopy was classified according to the Forrest classification, and active bleeding was defined as Forrest Ia or Ib. Delayed bleeding was defined as hematemesis or melena after second-look endoscopy. A total of 406 second-look endoscopies were performed, and delayed bleeding occurred in 11 patients. The incidence rate of delayed bleeding after second-look endoscopy in patients with Forrest Ia or Ib was significantly higher than that in patients with Forrest IIa, IIb or III (7.69 vs. 2.02 %, p < 0.05). Complication of a histological ulcer, large size of the resected specimen and long ESD procedure time were shown to be risk factors for hemorrhage of mucosal defects after ESD on second-look endoscopy by univariate analysis. Multivariate analysis indicated that only large size of the resected specimen was a risk factor. In a specimen size of >35 mm, the odds ratio of active bleeding on second-look endoscopy was 1.9. Active bleeding of mucosal defects on second-look endoscopy is a risk factor for delayed bleeding.

CHOBS: Color Histogram of Block Statistics for Automatic Bleeding Detection in Wireless Capsule Endoscopy Video

PubMed Central

Ghosh, Tonmoy; Wahid, Khan A.

2018-01-01

Wireless capsule endoscopy (WCE) is the most advanced technology to visualize whole gastrointestinal (GI) tract in a non-invasive way. But the major disadvantage here, it takes long reviewing time, which is very laborious as continuous manual intervention is necessary. In order to reduce the burden of the clinician, in this paper, an automatic bleeding detection method for WCE video is proposed based on the color histogram of block statistics, namely CHOBS. A single pixel in WCE image may be distorted due to the capsule motion in the GI tract. Instead of considering individual pixel values, a block surrounding to that individual pixel is chosen for extracting local statistical features. By combining local block features of three different color planes of RGB color space, an index value is defined. A color histogram, which is extracted from those index values, provides distinguishable color texture feature. A feature reduction technique utilizing color histogram pattern and principal component analysis is proposed, which can drastically reduce the feature dimension. For bleeding zone detection, blocks are classified using extracted local features that do not incorporate any computational burden for feature extraction. From extensive experimentation on several WCE videos and 2300 images, which are collected from a publicly available database, a very satisfactory bleeding frame and zone detection performance is achieved in comparison to that obtained by some of the existing methods. In the case of bleeding frame detection, the accuracy, sensitivity, and specificity obtained from proposed method are 97.85%, 99.47%, and 99.15%, respectively, and in the case of bleeding zone detection, 95.75% of precision is achieved. The proposed method offers not only low feature dimension but also highly satisfactory bleeding detection performance, which even can effectively detect bleeding frame and zone in a continuous WCE video data. PMID:29468094

A simplified clinical risk score predicts the need for early endoscopy in non-variceal upper gastrointestinal bleeding.

PubMed

Tammaro, Leonardo; Buda, Andrea; Di Paolo, Maria Carla; Zullo, Angelo; Hassan, Cesare; Riccio, Elisabetta; Vassallo, Roberto; Caserta, Luigi; Anderloni, Andrea; Natali, Alessandro

2014-09-01

Pre-endoscopic triage of patients who require an early upper endoscopy can improve management of patients with non-variceal upper gastrointestinal bleeding. To validate a new simplified clinical score (T-score) to assess the need of an early upper endoscopy in non variceal bleeding patients. Secondary outcomes were re-bleeding rate, 30-day bleeding-related mortality. In this prospective, multicentre study patients with bleeding who underwent upper endoscopy were enrolled. The accuracy for high risk endoscopic stigmata of the T-score was compared with that of the Glasgow Blatchford risk score. Overall, 602 patients underwent early upper endoscopy, and 472 presented with non-variceal bleeding. High risk endoscopic stigmata were detected in 145 (30.7%) cases. T-score sensitivity and specificity for high risk endoscopic stigmata and bleeding-related mortality was 96% and 30%, and 80% and 71%, respectively. No statistically difference in predicting high risk endoscopic stigmata between T-score and Glasgow Blatchford risk score was observed (ROC curve: 0.72 vs. 0.69, p=0.11). The two scores were also similar in predicting re-bleeding (ROC curve: 0.64 vs. 0.63, p=0.4) and 30-day bleeding-related mortality (ROC curve: 0.78 vs. 0.76, p=0.3). The T-score appeared to predict high risk endoscopic stigmata, re-bleeding and mortality with similar accuracy to Glasgow Blatchford risk score. Such a score may be helpful for the prediction of high-risk patients who need a very early therapeutic endoscopy. Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

A second generation 50 Mbps VLSI level zero processing system prototype

NASA Technical Reports Server (NTRS)

Harris, Jonathan C.; Shi, Jeff; Speciale, Nick; Bennett, Toby

1994-01-01

Level Zero Processing (LZP) generally refers to telemetry data processing functions performed at ground facilities to remove all communication artifacts from instrument data. These functions typically include frame synchronization, error detection and correction, packet reassembly and sorting, playback reversal, merging, time-ordering, overlap deletion, and production of annotated data sets. The Data Systems Technologies Division (DSTD) at Goddard Space Flight Center (GSFC) has been developing high-performance Very Large Scale Integration Level Zero Processing Systems (VLSI LZPS) since 1989. The first VLSI LZPS prototype demonstrated 20 Megabits per second (Mbp's) capability in 1992. With a new generation of high-density Application-specific Integrated Circuits (ASIC) and a Mass Storage System (MSS) based on the High-performance Parallel Peripheral Interface (HiPPI), a second prototype has been built that achieves full 50 Mbp's performance. This paper describes the second generation LZPS prototype based upon VLSI technologies.

[Massive hemorrhage of upper gastrointestinal tract caused by gastrointestinal stromal tumor of the stomach--case report].

PubMed

Lalović, Nenad; Dukić Vladicić, Nikolina; Marić, Radmil; Cuk, Mirjana; Simatović, Milan; Jokanović, Dragana

2012-01-01

Acute bleeding from the upper gastrointestinal system is a medical emergency which is followed by high mortality rate, ranging from 6 to 15% in spite of modern diagnostic methods and treatment. Bleeding from the upper gastrointestinal system may be caused by gastrointestinal stromal tumors of the stomach, which are mainly characterized by occult bleeding, while profuse bleeding rarely occurs accompanied by hemorrhagic shock. Gastrointestinal stromal tumors of stomach are the most common mesenchimal tumors of the gastrointestinal tract. In our study we showed a 60-year-old female patient with profuse bleeding from the stomach and the clinical picture of severe hemorrhagic shock, caused by gastrointestinal stromal tumor. An ovoid junction, raised towards the lumen, covered with ulcerated mucosa in several places and followed by massive arterial bleeding was found intraoperatively, after the performed gastrotomy. Histopathological examination with immunohistochemical analysis confirmed that this was a gastrointestinal stromal tumor of the stomach. Acute bleeding from the digestive system is a sudden and serious condition of the body. Urgent esophagogastroduodenoscopy is a sensitive and specific diagnostic and therapeutic method of choice. Massive bleeding from the upper gastrointestinal tract is very rarely caused by gastrointestinal stromal tumors, whose clinical picture is very heterogeneous and depends on tumor size and location. Abundant bleeding from the tumor is an indication for urgent surgical intervention. According to the literature massive hemorrhage of the upper digestive system can rarely be caused by gastrointestinal stromal tumor of the stomach. It is shown that abundant hemorrhage of the upper digestive tract can be caused with gastric gastrointestinal stromal tumor. Surgical resection is the main form of treatment of gastrointestinal stromal tumors of the digestive system and bleeding from these tumors caused by failure of endoscopic hemostasis.

Intraoperative bleeding control by uniportal video-assisted thoracoscopic surgery†.

PubMed

Gonzalez-Rivas, Diego; Stupnik, Tomaz; Fernandez, Ricardo; de la Torre, Mercedes; Velasco, Carlos; Yang, Yang; Lee, Wentao; Jiang, Gening

2016-01-01

Owing to advances in video-assisted thoracic surgery (VATS), the majority of pulmonary resections can currently be performed by VATS in a safe manner with a low level of morbidity and mortality. The majority of the complications that occur during VATS can be minimized with correct preoperative planning of the case as well as careful pulmonary dissection. Coordination of the whole surgical team is essential when confronting an emergency such as major bleeding. This is particularly important during the VATS learning curve, where the occurrence of intraoperative complications, particularly significant bleeding, usually ends in a conversion to open surgery. However, conversion should not be considered as a failure of the VATS approach, but as a resource to maintain the patient's safety. The correct assessment of any bleeding is of paramount importance during major thoracoscopic procedures. Inadequate management of the source of bleeding may result in major vessel injury and massive bleeding. If bleeding occurs, a sponge stick should be readily available to apply pressure immediately to control the haemorrhage. It is always important to remain calm and not to panic. With the bleeding temporarily controlled, a decision must be made promptly as to whether a thoracotomy is needed or if the bleeding can be solved through the VATS approach. This will depend primarily on the surgeon's experience. The operative vision provided with high-definition cameras, specially designed or adapted instruments and the new sealants are factors that facilitate the surgeon's control. After experience has been acquired with conventional or uniportal VATS, the rate of complications diminishes and the majority of bleeding events are controlled without the need for conversion to thoracotomy. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Comparison of the Risk of Gastrointestinal Bleeding among Different Statin Exposures with Concomitant Administration of Warfarin: Electronic Health Record-Based Retrospective Cohort Study.

PubMed

Shin, Dahye; Yoon, Dukyong; Lim, Sun Gyo; Hong, Ji Man; Park, Rae Woong; Lee, Jin Soo

2016-01-01

Patients who should be treated with both warfarin and a statin are frequently seen in vascular clinics. The risk for bleeding and potential drug interactions should be considered when prescribing both medications together. This study aimed to compare the risk for gastrointestinal bleeding among different statin exposures with concomitant administration of warfarin. This is a single-hospital retrospective cohort study. We included patients who were concomitantly exposed to one of four statins (pravastatin, simvastatin, atorvastatin, and rosuvastatin) and warfarin for up to 2 years (730 days). The observation period ended when a gastrointestinal bleeding event occurred or the observation was censored. Within-class comparisons were used, and 1:1 matching using a propensity score was performed for comparisons between each statin and all of the other statins. Kaplan-Meier analyses with log-rank tests and Cox proportional hazard regression analyses were conducted to determine associations with the risk of gastrointestinal bleeding. Data were analyzed for 1,686 patients who were concomitantly administered a statin and warfarin. Log-rank tests for the gastrointestinal bleeding-free survival rate showed that the risk for gastrointestinal bleeding was significantly lower in the pravastatin group (p = 0.0499) and higher in the rosuvastatin group (p = 0.009). In the Cox proportional hazard regression analysis, the hazard ratio of 5.394 for gastrointestinal bleeding based on statin exposure in the rosuvastatin group was significant (95% confidence interval, 1.168-24.916). There was a relatively high risk of gastrointestinal bleeding with rosuvastatin when administered concomitantly with warfarin.

Emergency right hepatectomy after laparoscopic tru-cut liver biopsy

PubMed Central

Quezada, Nicolás; León, Felipe; Martínez, Jorge; Jarufe, Nicolás; Guerra, Juan Francisco

2015-01-01

Background Liver biopsy is a common procedure usually required for final pathologic diagnosis of different liver diseases. Morbidity following tru-cut biopsy is uncommon, with bleeding complications generally self-limited. Few cases of major hemorrhage after liver biopsies have been reported, but to our knowledge, no cases of emergency hepatectomy following a tru-cut liver biopsy have been reported previously. Presentation of case We report the case of a 38 years-old woman who presented with an intrahepatic arterial bleeding after a tru-cut liver biopsy under direct laparoscopic visualization, initially controlled by ligation of the right hepatic artery and temporary liver packing. On tenth postoperative day, she developed a pseudo-aneurysm of the anterior branch of the right hepatic artery, evolving with massive bleeding that was not amenable to control by endovascular therapy. Therefore, an emergency right hepatectomy had to be performed in order to stop the bleeding. The patient achieved hemodynamic stabilization, but developed a biliary fistula from the liver surface, refractory to non-operative treatment. In consequence, a Roux-Y hepatico-jejunostomy was performed at third month, with no further complications. Discussion Bleeding following tru-cut biopsy is a rare event. To our knowledge, this is the first report of an emergency hepatectomy due to hemorrhage following liver biopsy. Risks and complications of liver biopsy are revised. Conclusion Care must be taken when performing this kind of procedures and a high level of suspicion regarding this complication should be taken in count when clinical/hemodynamic deterioration occurs after these procedures. PMID:25618399

Portal hypertension in children: High-risk varices, primary prophylaxis and consequences of bleeding.

PubMed

Duché, Mathieu; Ducot, Béatrice; Ackermann, Oanez; Guérin, Florent; Jacquemin, Emmanuel; Bernard, Olivier

2017-02-01

Primary prophylaxis of bleeding is debated for children with portal hypertension because of the limited number of studies on its safety and efficacy, the lack of a known endoscopic pattern carrying a high-risk of bleeding for all causes, and the assumption that the mortality of a first bleed is low. We report our experience with these issues. From 1989 to 2014, we managed 1300 children with portal hypertension. Endoscopic features were recorded; high-risk varices were defined as: grade 3 esophageal varices, grade 2 varices with red wale markings, or gastric varices. Two hundred forty-six children bled spontaneously and 182 underwent primary prophylaxis. The results of primary prophylaxis were reviewed as well as bleed-free survival, overall survival and life-threatening complications of bleeding. High-risk varices were found in 96% of children who bled spontaneously and in 11% of children who did not bleed without primary prophylaxis (p<0.001), regardless of the cause of portal hypertension. Life-threatening complications of bleeding were recorded in 19% of children with cirrhosis and high-risk varices who bled spontaneously. Ten-year probabilities of bleed-free survival after primary prophylaxis in children with high-risk varices were 96% and 72% for non-cirrhotic causes and cirrhosis respectively. Ten-year probabilities of overall survival after primary prophylaxis were 100% and 93% in children with non-cirrhotic causes and cirrhosis respectively. In children with portal hypertension, bleeding is linked to the high-risk endoscopic pattern reported here. Primary prophylaxis of bleeding based on this pattern is fairly effective and safe. In children with liver disease, the risk of bleeding from varices in the esophagus is linked to their large size, the presence of congestion on their surface and their expansion into the stomach but not to the child's age nor to the cause of portal hypertension. Prevention of the first bleed in children with high-risk varices can be achieved by surgery or endoscopic treatment, and decreases mortality and morbidity. Copyright © 2016 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Efficacy of Over-the-Scope Clips in Management of High-Risk Gastrointestinal Bleeding.

PubMed

Brandler, Justin; Baruah, Anushka; Zeb, Muhammad; Mehfooz, Ayesha; Pophali, Prachi; Wong Kee Song, Louis; AbuDayyeh, Barham; Gostout, Christopher; Mara, Kristin; Dierkhising, Ross; Buttar, Navtej

2018-05-01

Standard endoscopic therapies do not control bleeding or produce complications in as many as 20% of patients with nonvariceal gastrointestinal bleeding. Most bleeding comes from ulcers with characteristics such as high-risk vascular territories and/or large vessels. We evaluated the efficacy of using over-the-scope clips (OTSCs) as primary or rescue therapy for patients with bleeding from lesions that have a high risk for adverse outcomes. We performed a retrospective analysis of data from 67 patients with gastrointestinal bleeding from high-risk lesions who were treated with OTSCs as primary (n = 49) or rescue therapy (n = 18) at a quaternary center, from December 2011 through February 2015. The definition of high-risk lesions was lesions that were situated in the area of a major artery and larger than 2 mm in diameter and/or a deep penetrating, excavated, fibrotic ulcer with high-risk stigmata, in which a perforation could not be ruled out or thermal therapy would cause perforation, or lesions that could not be treated by standard endoscopy. Clinical severity was determined based on the Rockall score and a modified Blatchford score. Our primary outcome was the incidence of rebleeding within 30 days after OTSC placement. We assessed risk factors for rebleeding using univariate hazard models followed by multivariable analysis. Of the 67 patients, 47 (70.1%) remained free of rebleeding at 30 days after OTSC placement. We found no difference in the proportion of patients with rebleeding who received primary or rescue therapy (hazard ratio, 0.639; 95% confidence interval, 0.084-4.860; P = .6653). Only 9 rebleeding events were linked clearly to OTSCs and required intervention, indicating an OTSC success rate of 81.3%. We found no significant associations between rebleeding and clinical scores. However, on multivariable analysis, patients with coronary artery disease had a higher risk of rebleeding after OTSC independent of international normalized ratio and antiplatelet use (hazard ratio, 7.30; P = .0002). In a retrospective analysis of 67 patients with bleeding from high-risk gastrointestinal lesions, we found OTSCs to prevent rebleeding in more than 80% of cases. In the past, these lesions were treated with surgical or radiologic interventions. Patients with coronary artery disease have an increased risk of rebleeding after OTSCs, suggesting the need for escalated therapies. Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.

The effects of compressor seventh-stage bleed air extraction on performance of the F100-PW-220 afterburning turbofan engine

NASA Technical Reports Server (NTRS)

Evans, Alison B.

1991-01-01

A study was conducted to determine the effects of seventh-stage compressor bleed on the performance of the F100 afterburning turbofan engine. The effects of bleed on thrust, specific fuel consumption, fan turbine inlet temperature, bleed total pressure, and bleed total temperature were obtained from the engine manufacturer's status deck computer simulation. These effects were determined for power settings of intermediate, partial afterburning, and maximum afterburning for Mach numbers between 0.6 and 2.2 and for altitudes of 30,000, 40,000, and 50,000 ft. It was found that thrust loss and specific fuel consumption increase were approximately linear functions of bleed flow and, based on a percent-thrust change basis, were approximately independent of power setting.

Parametrics on 2D Navier-Stokes analysis of a Mach 2.68 bifurcated rectangular mixed-compression inlet

NASA Technical Reports Server (NTRS)

Mizukami, M.; Saunders, J. D.

1995-01-01

The supersonic diffuser of a Mach 2.68 bifurcated, rectangular, mixed-compression inlet was analyzed using a two-dimensional (2D) Navier-Stokes flow solver. Parametric studies were performed on turbulence models, computational grids and bleed models. The computer flowfield was substantially different from the original inviscid design, due to interactions of shocks, boundary layers, and bleed. Good agreement with experimental data was obtained in many aspects. Many of the discrepancies were thought to originate primarily from 3D effects. Therefore, a balance should be struck between expending resources on a high fidelity 2D simulation, and the inherent limitations of 2D analysis. The solutions were fairly insensitive to turbulence models, grids and bleed models. Overall, the k-e turbulence model, and the bleed models based on unchoked bleed hole discharge coefficients or uniform velocity are recommended. The 2D Navier-Stokes methods appear to be a useful tool for the design and analysis of supersonic inlets, by providing a higher fidelity simulation of the inlet flowfield than inviscid methods, in a reasonable turnaround time.

The risk of venous thromboembolism, myocardial infarction, stroke, major bleeding and death in patients undergoing total hip and knee replacement: a 15-year retrospective cohort study of routine clinical practice.

PubMed

Pedersen, A B; Mehnert, F; Sorensen, H T; Emmeluth, C; Overgaard, S; Johnsen, S P

2014-04-01

We examined the risk of thrombotic and major bleeding events in patients undergoing total hip and knee replacement (THR and TKR) treated with thromboprophylaxis, using nationwide population-based databases. We identified 83 756 primary procedures performed between 1997 and 2011. The outcomes were symptomatic venous thromboembolism (VTE), myocardial infarction (MI), stroke, death and major bleeding requiring hospitalisation within 90 days of surgery. A total of 1114 (1.3%) and 483 (0.6%) patients experienced VTE and bleeding, respectively. The annual risk of VTE varied between 0.9% and 1.6%, and of bleeding between 0.4% and 0.8%. The risk of VTE and bleeding was unchanged over a 15-year period. A total of 0.7% of patients died within 90 days, with a decrease from 1% in 1997 to 0.6% in 2011 (p < 0.001). A high level of comorbidity and general anaesthesia were strong risk factors for both VTE and bleeding, with no difference between THR and TKR patients. The risk of both MI and stroke was 0.5%, which remained unchanged during the study period. In this cohort study of patients undergoing THR and TKR patients in routine clinical practice, approximately 3% experienced VTE, MI, stroke or bleeding. These risks did not decline during the 15-year study period, but the risk of dying fell substantially.

Association of Short-term Bleeding and Cramping Patterns with Long-Acting Reversible Contraceptive Method Satisfaction

PubMed Central

Diedrich, Justin T.; Desai, Sanyukta; Zhao, Qiuhong; Secura, Gina; Madden, Tessa; Peipert, Jeffrey F.

2014-01-01

Objectives To examine the short-term (3 and 6-month), self-reported bleeding and cramping patterns with intrauterine devices (IUDs) and the contraceptive implant, and the association of these symptoms with method satisfaction. Study Design We analyzed 3 and 6-month survey data from IUD and implant users in the Contraceptive CHOICE Project, a prospective cohort study. Participants who received a long-acting reversible contraceptive (LARC) method (levonorgestrel intrauterine system (LNG-IUS), copper IUD, or the etonogestrel implant) and completed their 3- and 6-month surveys were included. Univariable and multivariable analyses were performed to examine the association of bleeding and cramping patterns with short-term satisfaction. Results Our analytic sample included 5,011 CHOICE participants: 3001 LNG-IUS users, 826 copper IUD users, and 1184 implant users. At 3 months, over 65% of LNG-IUS and implant users reported no change or decreased cramping, while 63% of copper IUD users reported increased menstrual cramping. Lighter bleeding was reported by 67% of LNG-IUS users, 58% of implant users, and 8% of copper IUD users. Satisfaction of all LARC methods was high (≥90%) and significantly higher than non-LARC methods (p<0.001). LARC users with increased menstrual cramping (HR 0.96, 95% CI 0.92 – 0.99), heavier bleeding (HR 0.91, 95% CI 0.87 – 0.96), and increased bleeding frequency (HR 0.92, 95% CI 0.89 – 0.96) were less likely to report being very satisfied at 6 months. Conclusion Regardless of the LARC method, satisfaction at 3 and 6 months is very high. Changes in self-reported bleeding and cramping are associated with short-term LARC satisfaction. PMID:25046805

Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction.

PubMed

Diedrich, Justin T; Desai, Sanyukta; Zhao, Qiuhong; Secura, Gina; Madden, Tessa; Peipert, Jeffrey F

2015-01-01

We sought to examine the short-term (3- and 6-month), self-reported bleeding and cramping patterns with intrauterine devices (IUDs) and the contraceptive implant, and the association of these symptoms with method satisfaction. We analyzed 3- and 6-month survey data from IUD and implant users in the Contraceptive CHOICE Project, a prospective cohort study. Participants who received a long-acting reversible contraceptive (LARC) method (levonorgestrel-releasing intrauterine system [LNG-IUS], copper IUD, or the etonogestrel implant) and completed their 3- and 6-month surveys were included. Univariable and multivariable analyses were performed to examine the association of bleeding and cramping patterns with short-term satisfaction. Our analytic sample included 5011 Contraceptive CHOICE Project participants: 3001 LNG-IUS users, 826 copper IUD users, and 1184 implant users. At 3 months, >65% of LNG-IUS and implant users reported no change or decreased cramping, while 63% of copper IUD users reported increased menstrual cramping. Lighter bleeding was reported by 67% of LNG-IUS users, 58% of implant users, and 8% of copper IUD users. Satisfaction of all LARC methods was high (≥90%). LARC users with increased menstrual cramping (relative risk adjusted [RRadj], 0.78; 95% confidence interval [CI], 0.72-0.85), heavier bleeding (RRadj, 0.83; 95% CI, 0.76-0.92), and increased bleeding frequency (RRadj, 0.73; 95% CI, 0.67-0.80) were less likely to report being very satisfied at 6 months. Regardless of the LARC method, satisfaction at 3 and 6 months is very high. Changes in self-reported bleeding and cramping are associated with short-term LARC satisfaction. Copyright © 2015 Elsevier Inc. All rights reserved.

Intracranial Hemorrhage: A Devastating Outcome of Congenital Bleeding Disorders-Prevalence, Diagnosis, and Management, with a Special Focus on Congenital Factor XIII Deficiency.

PubMed

Alavi, Seyed Ezatolla Rafiee; Jalalvand, Masumeh; Assadollahi, Vahideh; Tabibian, Shadi; Dorgalaleh, Akbar

2018-04-01

Intracranial hemorrhage (ICH) is a medical emergency. In congenital bleeding disorders, ICH is a devastating presentation accompanied with a high rate of morbidity and mortality. The prevalence of ICH is highly variable among congenital bleeding disorders, with the highest incidence observed in factor (F) XIII deficiency (FXIIID) (∼30%). This life-threatening presentation is less common in afibrinogenemia, FVIII, FIX, FVII, and FX deficiencies, and is rare in severe FV and FII deficiencies, type 3 von Willebrand disease and inherited platelet function disorders (IPFDs). In FXIIID, this diathesis most often occurs after trauma in children, whereas spontaneous ICH is more frequent in adults. About 15% of patients with FXIIID and ICH die; the bleeding causes 80% of deaths in this coagulopathy. Although in FXIIID, the bleed most commonly is intraparenchymal (> 90%), epidural, subdural, and subarachnoid hemorrhages also have been reported, albeit rarely. As this life-threatening bleeding causes neurological complications, early diagnosis can prevent further expansion of the hematoma and secondary damage. Neuroimaging plays a crucial role in the diagnosis of ICH, but signs and symptoms in patients with severe FXIIID should trigger replacement therapy even before establishment of the diagnosis. Although a high dose of FXIII concentrate can reduce the rate of morbidity and mortality of ICH in FXIIID, it may occasionally trigger inhibitor development, thus complicating ICH management and future prophylaxis. Nevertheless, replacement therapy is the mainstay of treatment for ICH in FXIIID. Neurosurgery is performed in patients with FXIIID and epidural hematoma and a hemorrhage diameter exceeding 2 cm or a volume of ICH is more than 30 cm 3 . Contact sports are not recommended in people with FXIIID as they can elicit ICH. However, a considerable number of safe sports and activities have been suggested to have more benefits than dangers for patients with congenital bleeding disorders, and are hence suitable for these patients. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Sub-micrometer epsilon-near-zero electroabsorption modulators enabled by high-mobility cadmium oxide

DOE Office of Scientific and Technical Information (OSTI.GOV)

Campione, Salvatore; Wood, Michael; Serkland, Darwin K.

Here, epsilon-near-zero materials provide a new path for tailoring light-matter interactions at the nanoscale. In this paper, we analyze a compact electroabsorption modulator based on epsilon-near-zero confinement in transparent conducting oxide films. The non-resonant modulator operates through field-effect carrier density tuning. We compare the performance of modulators composed of two different conducting oxides, namely indium oxide (In2O3) and cadmium oxide (CdO), and show that better modulation performance is achieved when using high-mobility (i.e. low-loss) epsilon-near-zero materials such as CdO. In particular, we show that non-resonant electroabsorption modulators with sub-micron lengths and greater than 5 dB extinction ratios may be achievedmore » through the proper selection of high-mobility transparent conducting oxides, opening a path for device miniaturization and increased modulation depth.« less

Sub-micrometer epsilon-near-zero electroabsorption modulators enabled by high-mobility cadmium oxide

DOE PAGES

Campione, Salvatore; Wood, Michael; Serkland, Darwin K.; ...

2017-07-06

Here, epsilon-near-zero materials provide a new path for tailoring light-matter interactions at the nanoscale. In this paper, we analyze a compact electroabsorption modulator based on epsilon-near-zero confinement in transparent conducting oxide films. The non-resonant modulator operates through field-effect carrier density tuning. We compare the performance of modulators composed of two different conducting oxides, namely indium oxide (In2O3) and cadmium oxide (CdO), and show that better modulation performance is achieved when using high-mobility (i.e. low-loss) epsilon-near-zero materials such as CdO. In particular, we show that non-resonant electroabsorption modulators with sub-micron lengths and greater than 5 dB extinction ratios may be achievedmore » through the proper selection of high-mobility transparent conducting oxides, opening a path for device miniaturization and increased modulation depth.« less

Late vitamin K deficiency bleeding leading to a diagnosis of cystic fibrosis: a case report.

PubMed

Ngo, B; Van Pelt, K; Labarque, V; Van De Casseye, W; Penders, J

2011-01-01

Vitamin K deficiency bleeding (VKDB) in infants still occurs despite worldwide use of prophylaxis. Clinical manifestations can be dramatic with over 50% of patients presenting with intracranial haemorrhage and a mortality rate of 20% in late vitamin K deficiency bleeding. Special attention should be given to infants with a high risk profile (preterm, breast feeding, cholestasis, malabsorption). A tentative diagnosis can be made observing quick normalisation of some easy-to-perform haemostatic parameters (PT, aPTT) after administration of vitamin K. Nowadays, VKDB can still be the first clinical sign of diseases causing malabsorption of fat-soluble vitamins. In this case report, VKDB led to the diagnosis of cystic fibrosis, the most common fatal autosomal recessive disease among Caucasian people.

Evaluation of the predictive performance of bleeding risk scores in patients with non-valvular atrial fibrillation on oral anticoagulants.

PubMed

Beshir, S A; Aziz, Z; Yap, L B; Chee, K H; Lo, Y L

2018-04-01

Bleeding risk scores (BRSs) aid in the assessment of oral anticoagulant-related bleeding risk in patients with atrial fibrillation. Ideally, the applicability of a BRS needs to be assessed, prior to its routine use in a population other than the original derivation cohort. Therefore, we evaluated the performance of 6 established BRSs to predict major or clinically relevant bleeding (CRB) events associated with the use of oral anticoagulant (OAC) among Malaysian patients. The pharmacy supply database and the medical records of patients with non-valvular atrial fibrillation (NVAF) receiving warfarin, dabigatran or rivaroxaban at two tertiary hospitals were reviewed. Patients who experienced an OAC-associated major or CRB event within 12 months of follow-up, or who have received OAC therapy for at least 1 year, were identified. The BRSs were fitted separately into patient data. The discrimination and the calibration of these BRSs as well as the factors associated with bleeding events were then assessed. A total of 1017 patients with at least 1-year follow-up period, or those who developed a bleeding event within 1 year of OAC use, were recruited. Of which, 23 patients experienced a first major bleeding event, whereas 76 patients, a first CRB event. Multivariate logistic regression results show that age of 75 or older, prior bleeding and male gender are associated with major bleeding events. On the other hand, prior gastrointestinal bleeding, a haematocrit value of less than 30% and renal impairment are independent predictors of CRB events. All the BRSs show a satisfactory calibration for major and CRB events. Among these BRSs, only HEMORR 2 HAGES (C-statistic = 0.71, 95% CI 0.60-0.82, P < .001) and ATRIA score (C-statistic = 0.70, 95% CI 0.58-0.82, P < .001) show acceptable discrimination performance for major bleeding events. All the 6 BRSs, however, lack acceptable predictive performance for CRB events. To the best of our knowledge, this is the first evaluation study of the predictive performance of these 6 BRSs on clinically relevant bleeding events applied to the same cohort consisting of mainly Asian novel oral anticoagulant users. These BRSs show poor to acceptable predictive performance on OAC-induced major or CRB events. An improvement in the existing BRSs for OAC users is warranted. © 2017 John Wiley & Sons Ltd.

Physical activity and risk of bleeding in elderly patients taking anticoagulants.

PubMed

Frey, P M; Méan, M; Limacher, A; Jaeger, K; Beer, H-J; Frauchiger, B; Aschwanden, M; Rodondi, N; Righini, M; Egloff, M; Osterwalder, J; Kucher, N; Angelillo-Scherrer, A; Husmann, M; Banyai, M; Matter, C M; Aujesky, D

2015-02-01

Although the possibility of bleeding during anticoagulant treatment may limit patients from taking part in physical activity, the association between physical activity and anticoagulation-related bleeding is uncertain. To determine whether physical activity is associated with bleeding in elderly patients taking anticoagulants. In a prospective multicenter cohort study of 988 patients aged ≥ 65 years receiving anticoagulants for venous thromboembolism, we assessed patients' self-reported physical activity level. The primary outcome was the time to a first major bleeding, defined as fatal bleeding, symptomatic bleeding in a critical site, or bleeding causing a fall in hemoglobin or leading to transfusions. The secondary outcome was the time to a first clinically relevant non-major bleeding. We examined the association between physical activity level and time to a first bleeding by using competing risk regression, accounting for death as a competing event. We adjusted for known bleeding risk factors and anticoagulation as a time-varying covariate. During a mean follow-up of 22 months, patients with a low, moderate, and high physical activity level had an incidence of major bleeding of 11.6, 6.3, and 3.1 events per 100 patient-years and an incidence of clinically relevant non-major bleeding of 14.0, 10.3, and 7.7 events per 100 patient-years, respectively. A high physical activity level was significantly associated with a lower risk of major bleeding (adjusted sub-hazard ratio 0.40, 95% confidence interval 0.22-0.72). There was no association between physical activity and non-major bleeding. A high level of physical activity is associated with a decreased risk of major bleeding in elderly patients receiving anticoagulant therapy. © 2014 International Society on Thrombosis and Haemostasis.

Simultaneous monitoring of static and dynamic intracranial pressure parameters from two separate sensors in patients with cerebral bleeds: comparison of findings

PubMed Central

2012-01-01

Background We recently reported that in an experimental setting the zero pressure level of solid intracranial pressure (ICP) sensors can be altered by electrostatics discharges. Changes in the zero pressure level would alter the ICP level (mean ICP); whether spontaneous changes in mean ICP happen in clinical settings is not known. This can be addressed by comparing the ICP parameters level and waveform of simultaneous ICP signals. To this end, we retrieved our recordings in patients with cerebral bleeds wherein the ICP had been recorded simultaneously from two different sensors. Materials and Methods: During a time period of 10 years, 17 patients with cerebral bleeds were monitored with two ICP sensors simultaneously; sensor 1 was always a solid sensor while Sensor 2 was a solid -, a fluid - or an air-pouch sensor. The simultaneous signals were analyzed with automatic identification of the cardiac induced ICP waves. The output was determined in consecutive 6-s time windows, both with regard to the static parameter mean ICP and the dynamic parameters (mean wave amplitude, MWA, and mean wave rise time, MWRT). Differences in mean ICP, MWA and MWRT between the two sensors were determined. Transfer functions between the sensors were determined to evaluate how sensors reproduce the ICP waveform. Results Comparing findings in two solid sensors disclosed major differences in mean ICP in 2 of 5 patients (40%), despite marginal differences in MWA, MWRT, and linear phase magnitude and phase. Qualitative assessment of trend plots of mean ICP and MWA revealed shifts and drifts of mean ICP in the clinical setting. The transfer function analysis comparing the solid sensor with either the fluid or air-pouch sensors revealed more variable transfer function magnitude and greater differences in the ICP waveform derived indices. Conclusions Simultaneous monitoring of ICP using two solid sensors may show marked differences in static ICP but close to identity in dynamic ICP waveforms. This indicates that shifts in ICP baseline pressure (sensor zero level) occur clinically; trend plots of the ICP parameters also confirm this. Solid sensors are superior to fluid – and air pouch sensors when evaluating the dynamic ICP parameters. PMID:22958653

Control of shock-wave boundary-layer interactions by bleed in supersonic mixed compression inlets

NASA Technical Reports Server (NTRS)

Fukuda, M. K.; Reshotko, E.; Hingst, W. R.

1975-01-01

An experimental investigation has been conducted to determine the effect of bleed region geometry and bleed rate on shock wave-boundary layer interactions in an axisymmetric, mixed-compression inlet at a Mach number of 2.5. The full realizable reduction in transformed form factor is obtained by bleeding off about half the incident boundary layer mass flow. Bleeding upstream or downstream of the shock-induced pressure rise is preferable to bleeding across the shock-induced pressure rise. Slanted holes are more effective than normal holes. Two different bleed hole sizes were tested without detectable difference in performance.

Zero-Time Renal Transplant Biopsies: A Comprehensive Review.

PubMed

Naesens, Maarten

2016-07-01

Zero-time kidney biopsies, obtained at time of transplantation, are performed in many transplant centers worldwide. Decisions on kidney discard, kidney allocation, and choice of peritransplant and posttransplant treatment are sometimes based on the histological information obtained from these biopsies. This comprehensive review evaluates the practical considerations of performing zero-time biopsies, the predictive performance of zero-time histology and composite histological scores, and the clinical utility of these biopsies. The predictive performance of individual histological lesions and of composite scores for posttransplant outcome is at best moderate. No single histological lesion or composite score is sufficiently robust to be included in algorithms for kidney discard. Dual kidney transplantation has been based on histological assessment of zero-time biopsies and improves outcome in individual patients, but the waitlist effects of this strategy remain obscure. Zero-time biopsies are valuable for clinical and translational research purposes, providing insight in risk factors for posttransplant events, and as baseline for comparison with posttransplant histology. The molecular phenotype of zero-time biopsies yields novel therapeutic targets for improvement of donor selection, peritransplant management and kidney preservation. It remains however highly unclear whether the molecular expression variation in zero-time biopsies could become a better predictor for posttransplant outcome than donor/recipient baseline demographic factors.

DOE Zero Energy Ready Home Case Study: Greenhill Contracting, Inc., Hickory Ridge

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pacific Northwest National Laboratory

Greenhill Contracting built this 3,912-ft2 house in Gardiner, New York, to the high-performance criteria of the DOE Zero Energy Ready Home (ZERH) program. A highly efficient air-source heat pump heats and cools the home’s interior, while the roof-mounted photovoltaic system offsets electricity usage to cut energy bills to nearly zero. Many months the home owners see a credit on their utility bill.

Numerical simulations of heat transfer distribution of a two-pass square channel with V-rib turbulator and bleed holes

NASA Astrophysics Data System (ADS)

Kumar, Sourabh; Amano, R. S.; Lucci, Jose Martinez

2013-08-01

The blade tip region in gas turbine encounters high thermal loads due to temperature difference and hence efforts for high durability and safe operations are essential. Improved and robust methods of cooling are required to downgrade heat transfer rate to turbine blades. The blade tip regions, which are exposed to high gas flow, suffers high local thermal load which are due to external tip leakage. Jet impingement, pin cooling etc. are techniques used for cooling blades. A more usual way is to use serpentine passage with 180-degree turn. In this study, numerical simulation of heat transfer distribution of a two-pass square channel with rib turbulators and bleed holes were done. Periodical rib turbulators and bleed holes were used in the channel. The ribs arrangement were 60 degree V rib, 60 degree inverted V ribs, combination of 60 degree V rib at inlet and 60 inverted V rib at outlet section and combination of Inverted V at inlet and V rib at the outlet. The results were numerically computed using Fluent with Reynolds number of 12,500 and 28,500. Turbulence models used for computations were k-ω-SST and RSM. Temperature based and shear stress based techniques were used for heat transfer distribution prediction. The results for 60 degree V rib, 60 degree inverted V ribs were compared with the experimental results for validation of the results obtained. Detailed distribution shows distinctive peaks in heat transfer around bleed holes and rib turbulator. Comparisons of the overall performance of the models with different orientation of rib turbulator are presented. It is found that due to the combination of 60 degree inverted V rib in inlet and 60 V rib in outlet with bleed holes provides better heat treatment. It is suggested that the use of rib turbulator with bleed holes provides suitable for augmenting blade cooling to achieve an optimal balance between thermal and mechanical design requirements.

Self-Recirculating Casing Treatment Concept for Enhanced Compressor Performance

NASA Technical Reports Server (NTRS)

Hathaway, Michael D.

2002-01-01

A state-of-the-art CFD code (APNASA) was employed in a computationally based investigation of the impact of casing bleed and injection on the stability and performance of a moderate speed fan rotor wherein the stalling mass flow is controlled by tip flow field breakdown. The investigation was guided by observed trends in endwall flow characteristics (e.g., increasing endwall aerodynamic blockage) as stall is approached and based on the hypothesis that application of bleed or injection can mitigate these trends. The "best" bleed and injection configurations were then combined to yield a self-recirculating casing treatment concept. The results of this investigation yielded: 1) identification of the fluid mechanisms which precipitate stall of tip critical blade rows, and 2) an approach to recirculated casing treatment which results in increased compressor stall range with minimal or no loss in efficiency. Subsequent application of this approach to a high speed transonic rotor successfully yielded significant improvements in stall range with no loss in compressor efficiency.

Aminocaproic acid for the management of bleeding in patients on extracorporeal membrane oxygenation: Four adult case reports and a review of the literature.

PubMed

Buckley, Leo F; Reardon, David P; Camp, Phillip C; Weinhouse, Gerald L; Silver, David A; Couper, Gregory S; Connors, Jean M

2016-01-01

Extracorporeal membrane oxygenation (ECMO) is associated with a significant risk of bleeding and thrombosis. Despite high rates of bleeding and bleeding-related mortality in patients on ECMO, there is little evidence available to guide clinicians in the management of ECMO-associated bleeding. We report the use of aminocaproic acid in four patients with bleeding on ECMO and a review of the literature. High D-dimer levels and low fibrinogen levels suggested that an antifibrinolytic agent may be effective as an adjunct to control bleeding. After aminocaproic acid administration, bleeding was controlled in each patient as evidenced by clinical and laboratory parameters. One patient suffered a cardiac arrest and care was withdrawn. In patients on ECMO with evidence of fibrinolysis, aminocaproic acid may be an effective option to control bleeding and to stabilize clot formation. Copyright © 2016 Elsevier Inc. All rights reserved.

Efficacy and Clinical Outcomes of Transcatheter Arterial Embolization for Gastrointestinal Bleeding from Gastrointestinal Stromal Tumor.

PubMed

Koo, Hyun Jung; Shin, Ji Hoon; Shin, Sooyoung; Yoon, Hyun-Ki; Ko, Gi-Young; Gwon, Dong Il

2015-09-01

To evaluate the efficacy and clinical outcomes of transcatheter arterial embolization (TAE) for gastrointestinal (GI) bleeding from gastrointestinal stromal tumor (GIST). TAE was performed in 20 referred patients (male:female = 13:7; median age, 56.3 y) for GI bleeding from GISTs. The locations of GISTs were assessed using contrast-enhanced computed tomography (CT) and catheter angiography. The technical and clinical success of TAE and clinical outcomes including procedure-related complications, recurrent bleeding, 30-day and overall mortality, and cumulative survival were evaluated. The sites of GIST-related bleeding or tumor staining were the jejunum (n = 9), stomach (n = 5), ileum (n = 3), duodenum (n = 2), and jejunum and colon (n = 1). Angiography showed bleeding from GIST in 5 patients, and tumor staining was noted in only 15 patients. TAE was performed for patients with and without contrast medium extravasation on angiography. Technical and clinical success rates of TAE were 95% (19 of 20 patients) and 90% (18 of 20 patients), respectively. Recurrent bleeding was noted in 1 patient. There were no procedure-related complications. In 15 patients, surgical resection of the tumors was performed after TAE. The 30-day and overall mortality rates were 10% (2 of 20 patients) and 30% (6 of 20 patients), respectively. TAE is a safe and effective method for controlling GI bleeding from the GIST. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.

Use of a collagen matrix for recession coverage in patients who received orthodontic therapy: a case series.

PubMed

Tan, Wah C; Tan, Wah L; Ong, Marianne M A; Lang, Niklaus P

2017-02-01

The aim of the present study was to determine the percentage of recession coverage achieved following surgery with a collagen matrix, and patient-reported outcome measures. Five healthy adults who had completed orthodontic therapy with a gingival recession defect were recruited. Gingival recession coverage was performed using a two-layer, xenogeneic collagen matrix (Mucograft). During the first 2 weeks, the patients charted their perceptions on bleeding, swelling, pain, and bruising using a visual analog scale (VAS). Post-surgical complications were assessed clinically at 1 week, 2 weeks, and 1 month post-surgery. Recession dimensions were examined at 1, 3, 6, and 12 months. At 1 year, an average of 67% root coverage was achieved. The amount of recession coverage achieved was stable from 3 months. The results were maintained at 1 year. There were no post-surgical complications. All VAS parameters decreased to almost zero by day 14. From day 1, bleeding and pain decreased over time. However, there were peaks on days 2 and 3 for swelling and bruising, respectively, followed by a subsequent decrease. The use of Mucograft for recession coverage is effective and safe, with low morbidity and no post-surgical complications. Recession coverage achieved at 3 months remained stable in the 1-year follow-up period. © 2015 Wiley Publishing Asia Pty Ltd.

Major bleeding and intracranial hemorrhage risk prediction in patients with atrial fibrillation: Attention to modifiable bleeding risk factors or use of a bleeding risk stratification score? A nationwide cohort study.

PubMed

Chao, Tze-Fan; Lip, Gregory Y H; Lin, Yenn-Jiang; Chang, Shih-Lin; Lo, Li-Wei; Hu, Yu-Feng; Tuan, Ta-Chuan; Liao, Jo-Nan; Chung, Fa-Po; Chen, Tzeng-Ji; Chen, Shih-Ann

2018-03-01

While modifiable bleeding risks should be addressed in all patients with atrial fibrillation (AF), use of a bleeding risk score enables clinicians to 'flag up' those at risk of bleeding for more regular patient contact reviews. We compared a risk assessment strategy for major bleeding and intracranial hemorrhage (ICH) based on modifiable bleeding risk factors (referred to as a 'MBR factors' score) against established bleeding risk stratification scores (HEMORR 2 HAGES, HAS-BLED, ATRIA, ORBIT). A nationwide cohort study of 40,450 AF patients who received warfarin for stroke prevention was performed. The clinical endpoints included ICH and major bleeding. Bleeding scores were compared using receiver operating characteristic (ROC) curves (areas under the ROC curves [AUCs], or c-index) and the net reclassification index (NRI). During a follow up of 4.60±3.62years, 1581 (3.91%) patients sustained ICH and 6889 (17.03%) patients sustained major bleeding events. All tested bleeding risk scores at baseline were higher in those sustaining major bleeds. When compared to no ICH, patients sustaining ICH had higher baseline HEMORR 2 HAGES (p=0.003), HAS-BLED (p<0.001) and MBR factors score (p=0.013) but not ATRIA and ORBIT scores. When HAS-BLED was compared to other bleeding scores, c-indexes were significantly higher compared to MBR factors (p<0.001) and ORBIT (p=0.05) scores for major bleeding. C-indexes for the MBR factors score was significantly lower compared to all other scores (De long test, all p<0.001). When NRI was performed, HAS-BLED outperformed all other bleeding risk scores for major bleeding (all p<0.001). C-indexes for ATRIA and ORBIT scores suggested no significant prediction for ICH. All contemporary bleeding risk scores had modest predictive value for predicting major bleeding but the best predictive value and NRI was found for the HAS-BLED score. Simply depending on modifiable bleeding risk factors had suboptimal predictive value for the prediction of major bleeding in AF patients, when compared to the HAS-BLED score. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.

Technique of antroduodenectomy without ulcer excision as a safe alternative treatment for bleeding chronic duodenal ulcers.

PubMed

Guinier, David; Destrumelle, Nicolas; Denue, Pierre Olivier; Mathieu, Pierre; Heyd, Bruno; Mantion, Georges Andre

2009-05-01

The treatment of a bleeding chronic posterior duodenal ulcer, with bleeding recurrence or persistence despite endoscopic therapy, requires surgical treatment and constitutes a challenge for the surgeon; furthermore such chronic ulcers are often wide and sclerotic, so the surgeon needs to avoid the risk of recurrent bleeding if conservative surgery is applied. If radical surgery must be performed, the greater risk involves duodenal leakage, hepatic hilar injury, or pancreatic injury. This study aimed to evaluate the efficacy and complications arising from a surgical procedure, described by Dubois in 1971 (Gastrectomy and gastroduodenal anastomosis for post-bulbar ulcers and peptic ulcers of the second part of the duodenum. J Chir 101:177-186). This operation involves antroduonectomy with gastroduodenal anastomosis. It is similar to a Billroth I gastrectomy but without dissection of the ulcer. We retrospectively studied the medical data of patients who underwent this procedure for the treatment of bleeding chronic posterior duodenal ulcers during the past 20 years. There were 28 such patients admitted to our institution for emergency surgery, who went on to be treated by the Dubois procedure. Ulcerous disease was efficiently treated without rebleeding or duodenal leakage. The mortality rate was 17%; most deaths resulted from medical failure in older patients suffering from massive bleeding. The rate of medical complications reached 21%. Surgical complications developed in 14% of patients. The Dubois antroduodenectomy is a safe and effective surgical procedure for the treatment of bleeding chronic duodenal ulcers. The number of fatal outcomes among patients with this condition remains high, particularly in older and vulnerable patients experiencing massive bleeding.

Different doses of prophylactic platelet transfusion for preventing bleeding in people with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation

PubMed Central

Estcourt, Lise J; Stanworth, Simon; Doree, Carolyn; Trivella, Marialena; Hopewell, Sally; Blanco, Patricia; Murphy, Michael F

2015-01-01

Background Platelet transfusions are used in modern clinical practice to prevent and treat bleeding in people who are thrombocytopenic due to bone marrow failure. Although considerable advances have been made in platelet transfusion therapy in the last 40 years, some areas continue to provoke debate, especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding. This is an update of a Cochrane review first published in 2004, and updated in 2012 that addressed four separate questions: prophylactic versus therapeutic-only platelet transfusion policy; prophylactic platelet transfusion threshold; prophylactic platelet transfusion dose; and platelet transfusions compared to alternative treatments. This review has now been split into four smaller reviews; this review compares different platelet transfusion doses. Objectives To determine whether different doses of prophylactic platelet transfusions (platelet transfusions given to prevent bleeding) affect their efficacy and safety in preventing bleeding in people with haematological disorders undergoing myelosuppressive chemotherapy with or without haematopoietic stem cell transplantation (HSCT). Search methods We searched for randomised controlled trials in the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2015, Issue 6), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 23 July 2015. Selection criteria Randomised controlled trials involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people with malignant haematological disorders or undergoing HSCT that compared different platelet component doses (low dose 1.1 × 1011/m2 ± 25%, standard dose 2.2 × 1011/m2 ± 25%, high dose 4.4 × 1011/m2 ± 25%). Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We included seven trials (1814 participants) in this review; six were conducted during one course of treatment (chemotherapy or HSCT). Overall the methodological quality of studies was low to moderate across different outcomes according to GRADE methodology. None of the included studies were at low risk of bias in every domain, and all the included studies had some threats to validity. Five studies reported the number of participants with at least one clinically significant bleeding episode within 30 days from the start of the study. There was no difference in the number of participants with a clinically significant bleeding episode between the low-dose and standard-dose groups (four studies; 1170 participants; risk ratio (RR) 1.04, 95% confidence interval (CI) 0.95 to 1.13; moderate-quality evidence); low-dose and high-dose groups (one study; 849 participants; RR 1.02, 95% CI 0.93 to 1.11; moderate-quality evidence); or high-dose and standard-dose groups (two studies; 951 participants; RR 1.02, 95% CI 0.93 to 1.11; moderate-quality evidence). Three studies reported the number of days with a clinically significant bleeding event per participant. There was no difference in the number of days of bleeding per participant between the low-dose and standard-dose groups (two studies; 230 participants; mean difference −0.17, 95% CI −0.51 to 0.17; low quality evidence). One study (855 participants) showed no difference in the number of days of bleeding per participant between high-dose and standard-dose groups, or between low-dose and high-dose groups (849 participants). Three studies reported the number of participants with severe or life-threatening bleeding. There was no difference in the number of participants with severe or life-threatening bleeding between a low-dose and a standard-dose platelet transfusion policy (three studies; 1059 participants; RR 1.33, 95% CI 0.91 to 1.92; low-quality evidence); low-dose and high-dose groups (one study; 849 participants; RR 1.20, 95% CI 0.82 to 1.77; low-quality evidence); or high-dose and standard-dose groups (one study; 855 participants; RR 1.11, 95% CI 0.73 to 1.68; low-quality evidence). Two studies reported the time to first bleeding episodes; we were unable to perform a meta-analysis. Both studies (959 participants) individually found that the time to first bleeding episode was either the same, or longer, in the low-dose group compared to the standard-dose group. One study (855 participants) found that the time to the first bleeding episode was the same in the high-dose group compared to the standard-dose group. Three studies reported all-cause mortality within 30 days from the start of the study. There was no difference in all-cause mortality between treatment arms (low-dose versus standard-dose: three studies; 1070 participants; RR 2.04, 95% CI 0.70 to 5.93; low-quality evidence; low-dose versus high-dose: one study; 849 participants; RR 1.33, 95% CI 0.50 to 3.54; low-quality evidence; and high-dose versus standard-dose: one study; 855 participants; RR 1.71, 95% CI 0.51 to 5.81; low-quality evidence). Six studies reported the number of platelet transfusions; we were unable to perform a meta-analysis. Two studies (959 participants) out of three (1070 participants) found that a low-dose transfusion strategy led to more transfusion episodes than a standard-dose. One study (849 participants) found that a low-dose transfusion strategy led to more transfusion episodes than a high-dose strategy. One study (855 participants) out of three (1007 participants) found no difference in the number of platelet transfusions between the high-dose and standard-dose groups. One study reported on transfusion reactions. This study’s authors suggested that a high-dose platelet transfusion strategy may lead to a higher rate of transfusion-related adverse events. None of the studies reported quality-of-life. Authors’ conclusions In haematology patients who are thrombocytopenic due to myelosuppressive chemotherapy or HSCT, we found no evidence to suggest that a low-dose platelet transfusion policy is associated with an increased bleeding risk compared to a standard-dose or high-dose policy, or that a high-dose platelet transfusion policy is associated with a decreased risk of bleeding when compared to a standard-dose policy. A low-dose platelet transfusion strategy leads to an increased number of transfusion episodes compared to a standard-dose strategy. A high-dose platelet transfusion strategy does not decrease the number of transfusion episodes per participant compared to a standard-dose regimen, and it may increase the number of transfusion-related adverse events. Findings from this review would suggest a change from current practice, with low-dose platelet transfusions used for people receiving in-patient treatment for their haematological disorder and high-dose platelet transfusion strategies not being used routinely. PMID:26505729

Outcomes of peptic ulcer bleeding following treatment with proton pump inhibitors in routine clinical practice: 935 patients with high- or low-risk stigmata.

PubMed

Lanas, Angel; Carrera-Lasfuentes, Patricia; García-Rodríguez, Luis A; García, Santiago; Arroyo-Villarino, María Teresa; Ponce, Julio; Bujanda, Luis; Calleja, José L; Polo-Tomas, Mónica; Calvet, Xavier; Feu, Faust; Perez-Aisa, Angeles

2014-10-01

To assess rates of further bleeding, surgery and mortality in patients hospitalized owing to peptic ulcer bleeding. Consecutive patients hospitalized for peptic ulcer bleeding and treated with a proton pump inhibitor (PPI) (esomeprazole or pantoprazole) were identified retrospectively in 12 centers in Spain. Patients were included if they had high-risk stigmata (Forrest class Ia-IIb, underwent therapeutic endoscopy and received intravenous PPI ≥120 mg/day for ≥24 h) or low-risk stigmata (Forrest class IIc-III, underwent no therapeutic endoscopy and received intravenous or oral PPI [any dose]). Of 935 identified patients, 58.3% had high-risk stigmata and 41.7% had low-risk stigmata. After endoscopy, 88.3% of high-risk patients and 22.1% of low-risk patients received intravenous PPI therapy at doses of at least 160 mg/day. Further bleeding within 72 h occurred in 9.4% and 2.1% of high- and low-risk patients, respectively (p < 0.001). Surgery to stop bleeding was required within 30 days in 3.5% and 0.8% of high- and low-risk patients, respectively (p = 0.007). Mortality at 30 days was similar in both groups (3.3% in high-risk and 2.3% in low-risk patients). Among patients hospitalized owing to peptic ulcer bleeding and treated with PPIs, patients with high-risk stigmata have a higher risk of further bleeding and surgery, but not of death, than those with low-risk stigmata.

Clinical comparison of Zero-profile interbody fusion device and anterior cervical plate interbody fusion in treating cervical spondylosis.

PubMed

Yan, Bin; Nie, Lin

2015-01-01

the aim of the study was to compare the clinical effect of Zero-profile interbody fusion device (Zero-P) with anterior cervical plate interbody fusion system (PCB) in treating cervical spondylosis. a total of 98 patients with cervical spondylosis (110 segments) in February 2011 to January 2013 were included in our hospital. All participants were randomly divided into observation group and control group with 49 cases in each group. The observation group was treated with Zero-P, while the control group received PCB treatment. Comparison of the two groups in neurological function score (JOA), pain visual analogue scale (VAS), the neck disability index (NDI), quality of life score (SF-36) and cervical curvature (Cobb angle) change were recorded and analyzed before and after treatment. The observation group was found with 90% excellent and good rate, which was higher than that of the control group (80%). Dysphagia rate in observational group was 16.33% (8/49), which was significantly less than that in control group (46.94%). Operation time and bleeding volume in the observation group was less than those in control group. Postoperative improvements of JOA score, VAS score, and NDI in observational group were also significantly better than that in control group (P<0.05). The clinical effect of Zero-P and PCB for the treatment of cervical spondylosis was quite fair, but Zero-P showed a better therapeutic effect with improvement of life quality.

A novel concept for subsonic inlet boundary-layer control

NASA Technical Reports Server (NTRS)

Miller, B. A.

1977-01-01

A self-bleeding method for boundary layer control is described and tested for a subsonic inlet designed to operate in the flowfield generated by high angles of attack. Naturally occurring surface static pressure gradients are used to remove the boundary layer from a separation-prone region of the inlet and to reinject it at a less critical location with a net performance gain. The results suggest that this self-bleeding method for boundary-layer control might be successfully applied to other inlets operating at extreme aerodynamic conditions.

Laboratory test variables useful for distinguishing upper from lower gastrointestinal bleeding.

PubMed

Tomizawa, Minoru; Shinozaki, Fuminobu; Hasegawa, Rumiko; Shirai, Yoshinori; Motoyoshi, Yasufumi; Sugiyama, Takao; Yamamoto, Shigenori; Ishige, Naoki

2015-05-28

To distinguish upper from lower gastrointestinal (GI) bleeding. Patient records between April 2011 and March 2014 were analyzed retrospectively (3296 upper endoscopy, and 1520 colonoscopy). Seventy-six patients had upper GI bleeding (Upper group) and 65 had lower GI bleeding (Lower group). Variables were compared between the groups using one-way analysis of variance. Logistic regression was performed to identify variables significantly associated with the diagnosis of upper vs lower GI bleeding. Receiver-operator characteristic (ROC) analysis was performed to determine the threshold value that could distinguish upper from lower GI bleeding. Hemoglobin (P = 0.023), total protein (P = 0.0002), and lactate dehydrogenase (P = 0.009) were significantly lower in the Upper group than in the Lower group. Blood urea nitrogen (BUN) was higher in the Upper group than in the Lower group (P = 0.0065). Logistic regression analysis revealed that BUN was most strongly associated with the diagnosis of upper vs lower GI bleeding. ROC analysis revealed a threshold BUN value of 21.0 mg/dL, with a specificity of 93.0%. The threshold BUN value for distinguishing upper from lower GI bleeding was 21.0 mg/dL.

Laboratory test variables useful for distinguishing upper from lower gastrointestinal bleeding

PubMed Central

Tomizawa, Minoru; Shinozaki, Fuminobu; Hasegawa, Rumiko; Shirai, Yoshinori; Motoyoshi, Yasufumi; Sugiyama, Takao; Yamamoto, Shigenori; Ishige, Naoki

2015-01-01

AIM: To distinguish upper from lower gastrointestinal (GI) bleeding. METHODS: Patient records between April 2011 and March 2014 were analyzed retrospectively (3296 upper endoscopy, and 1520 colonoscopy). Seventy-six patients had upper GI bleeding (Upper group) and 65 had lower GI bleeding (Lower group). Variables were compared between the groups using one-way analysis of variance. Logistic regression was performed to identify variables significantly associated with the diagnosis of upper vs lower GI bleeding. Receiver-operator characteristic (ROC) analysis was performed to determine the threshold value that could distinguish upper from lower GI bleeding. RESULTS: Hemoglobin (P = 0.023), total protein (P = 0.0002), and lactate dehydrogenase (P = 0.009) were significantly lower in the Upper group than in the Lower group. Blood urea nitrogen (BUN) was higher in the Upper group than in the Lower group (P = 0.0065). Logistic regression analysis revealed that BUN was most strongly associated with the diagnosis of upper vs lower GI bleeding. ROC analysis revealed a threshold BUN value of 21.0 mg/dL, with a specificity of 93.0%. CONCLUSION: The threshold BUN value for distinguishing upper from lower GI bleeding was 21.0 mg/dL. PMID:26034359

Two genera of Aulacoscelinae beetles reflexively bleed azoxyglycosides found in their host cycads.

PubMed

Prado, Alberto; Ledezma, Julieta; Cubilla-Rios, Luis; Bede, Jacqueline C; Windsor, Donald M

2011-07-01

Aulacoscelinae beetles have an ancient relationship with cycads (Cycadophyta: Zamiaceae), which contain highly toxic azoxyglycoside (AZG) compounds. How these "primitive" leaf beetles deal with such host-derived compounds remains largely unknown. Collections were made of adult Aulacoscelis appendiculata from Zamia cf. elegantissima in Panama, A. vogti from Dioon edule in Mexico, and Janbechynea paradoxa from Zamia boliviana in Bolivia. Total AZG levels were quantified in both cycad leaves and adult beetles by high performance liquid chromatography (HPLC). On average, cycad leaves contained between 0.5-0.8% AZG (frozen weight, FW), while adult beetles feeding on the same leaves contained even higher levels of the compounds (average 0.9-1.5% FW). High AZG levels were isolated from reflex bleeding secreted at the leg joints when beetles were disturbed. Nuclear magnetic resonance and mass spectroscopy identified two AZGs, cycasin and macrozamin, in the reflex bleeding; this is the first account of potentially plant-derived compounds in secretions of the Aulacoscelinae. These data as well as the basal phylogenetic position of the Aulacoscelinae suggest that sequestration of plant secondary metabolites appeared early in leaf beetle evolution.

Multinational Prospective Study of Patient-Reported Outcomes After Prostate Radiation Therapy: Detailed Assessment of Rectal Bleeding

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lee, Jae Y.; Daignault-Newton, Stephanie; Heath, Gerard

Purpose: The new short Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) patient-reported health-related quality of life (HRQOL) tool has removed the rectal bleeding question from the previous much longer version, EPIC-26. Herein, we assess the impact of losing the dedicated rectal bleeding question in 2 independent prospective multicenter cohorts. Methods and Materials: In a prospective multicenter test cohort (n=865), EPIC-26 patient-reported HRQOL data were collected for 2 years after treatment from patients treated with prostate radiation therapy from 2003 to 2011. A second prospective multicenter cohort (n=442) was used for independent validation. A repeated-effects model was used to predictmore » the change from baseline in bowel summary scores from longer EPIC instruments using the change in EPIC-CP bowel summary scores with and without rectal bleeding scores. Results: Two years after radiation therapy, 91% of patients were free of bleeding, and only 2.6% reported bothersome bleeding problems. Correlations between EPIC-26 and EPIC-CP bowel scores were very high (r{sup 2}=0.90-0.96) and were statistically improved with the addition of rectal bleeding information (r{sup 2}=0.94-0.98). Considering all patients, only 0.2% of patients in the test cohort and 0.7% in the validation cohort reported bothersome bleeding and had clinically relevant HRQOL changes missed with EPIC-CP. However, of the 2.6% (n=17) of men with bothersome rectal bleeding in the test cohort, EPIC-CP failed to capture 1 patient (6%) as experiencing meaningful declines in bowel HRQOL. Conclusions: Modern prostate radiation therapy results in exceptionally low rates of bothersome rectal bleeding, and <1% of patients experience bothersome bleeding and are not captured by EPIC-CP as having meaningful HRQOL declines after radiation therapy. However, in the small subset of patients with bothersome rectal bleeding, the longer EPIC-26 should strongly be considered, given its superior performance in this patient subset.« less

Single-photon emission computed tomography enhanced Tc-99m-pertechnetate disodium-labelled red blood cell scintigraphy in the localization of small intestine bleeding: a single-centre twelve-year study.

PubMed

Dolezal, Jiri; Vizda, Jaroslav; Kopacova, Marcela

2011-01-01

To present our experience with the detection of bleeding in the small intestine by means of scintigraphy with in vivo-labelled red blood cells (RBCs) in the period of 1998-2009. A 12-year prospective study was accomplished with 40 patients (23 men, 17 women, aged 12-91, mean 56 years) who had lower gastrointestinal bleeding (obscure-overt bleeding) and underwent scintigraphy with in vivo-labelled RBCs by means of technetium 99m. The scintigraphy was usually performed after other diagnostic tests had failed to locate the bleeding. A total of 26 patients had a positive scintigraphy with in vivo-labelled RBCs and 14 patients had negative scintigraphy. The final diagnosis was confirmed in 20 of 26 patients with a positive scintigraphy by push enteroscopy (6/20), intraoperative enteroscopy (7/20), surgery (4/20), duodenoscopy (1/20), double-balloon enteroscopy (1/20) and X-ray angiography (1/20). The correct location of the bleeding site was identified by RBC scintigraphy in 15 of 20 (75%) patients with the confirmed source. The locations of the bleeding site identified by scintigraphy and enteroscopy (push, intraoperative) and surgical investigations were highly correlated in patients with a positive scintigraphy within the first 3 h. Eleven of the 20 correctly localized studies and none of the incorrectly localized studies were positive in the dynamic phase of imaging. In 5 patients (all erroneously localized), scintigraphy was positive only at a period longer than 18 h. RBC scintigraphy is an effective imaging modality in localizing lower gastrointestinal bleeding in patients for whom other diagnostic tests have failed to locate the bleeding. RBC scintigraphy can be successful in the detection of bleeding sites in the small intestine. Copyright © 2011 S. Karger AG, Basel.

SPARTAN: An Instructional High Resolution Land Combat Model

DTIC Science & Technology

1992-03-01

being: Next Event Time Advance - this method initializes the time clock at zero and updates the clock to the time of the next most imminent event and...whenever the soldier’s movement attribute switch is on and his speed is greater than zero . When startmove is called, it begins by performing several...status attribute goes to zero , his movement goes to zero , and his posture goes to prone. Lastly, the "killsoldier" subprogram is called which removes

40 CFR 60.2210 - What information must I include in my annual report?

Code of Federal Regulations, 2014 CFR

2014-07-01

... Performance for Commercial and Industrial Solid Waste Incineration Units Recordkeeping and Reporting § 60.2210... was inoperative, except for zero (low-level) and high-level checks. (3) The date, time, and duration.... (1) The zero (low-level), mid-level (if applicable), or high-level calibration drift exceeds two...

Placenta previa with early opening of the uterine isthmus is associated with high risk of bleeding during pregnancy, and massive haemorrhage during caesarean delivery.

PubMed

Goto, M; Hasegawa, J; Arakaki, T; Takita, H; Oba, T; Nakamura, M; Sekizawa, A

2016-06-01

To demonstrate the relationship between the timing of opening of the uterine isthmus and bleeding during pregnancy and caesarean section in patients with placenta previa. A prospective observational study was conducted at a single perinatal centre. All patients with placenta previa, diagnosed between 20 and 22 weeks of gestation, who were followed up at the study hospital and underwent caesarean section were enrolled. The condition of the uterine isthmus was examined every 2 weeks. The timing (in gestational weeks) of complete opening of the uterine isthmus was determined. Patients were divided into two groups: patients in whom the uterine isthmus opened before 25 weeks of gestation (EO-previa), and patients in whom the uterine isthmus opened after 25 weeks of gestation (LO-previa). The frequency of bleeding during pregnancy and the amount of intra-operative bleeding were compared between the two groups. Forty-four cases of EO-previa and 55 cases of LO-previa were analysed. Complete placenta previa at delivery was observed more frequently in the EO-previa group than in the LO-previa group (88.6% vs 47.3%, p<0.001). An emergency caesarean section due to active bleeding was performed more frequently in the EO-previa group (48%) than in the LO-previa group (25%) (p=0.021). The frequency of massive haemorrage (>2500ml) during caesarean section was higher in the EO-previa group than in the LO-previa group (25% vs 9%, p=0.033). Placenta previa was associated with a high risk of bleeding leading to emergency caesarean section during pregnancy, and massive haemorrhage during caesarean section in patients in whom the uterine isthmus opened before 25 weeks of gestation. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

78 FR 70198 - Airworthiness Directives; Rolls-Royce Deutschland Ltd & Co KG Turbofan Engines

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-25

.... This AD requires a one-time inspection of the high-pressure (HP) air bleed valve operating mechanism... discovered that the High Pressure (HP) air bleed valve operating mechanism is exposed to excessive... excessive deterioration of the high- pressure (HP) air bleed valve operating mechanism which is influencing...

High-intensity focused ultrasound combined with hysteroscopic resection to treat retained placenta accreta.

PubMed

Lee, Jae-Seong; Hong, Gi-Youn; Park, Byung-Joon; Hwang, Hyejin; Kim, Rayon; Kim, Tae-Eung

2016-09-01

We present a case of retained placenta accreta treated by high-intensity focused ultrasound (HIFU) ablation followed by hysteroscopic resection. The patient was diagnosed as submucosal myoma based on ultrasonography in local clinic. Pathologic examination of several pieces of tumor mass from the hysteroscopic procedure revealed necrotic chorionic villi with calcification. HIFU was performed using an ultrasound-guided HIFU tumor therapeutic system. The ultrasound machine had been used for real-time monitoring of the HIFU procedure. After HIFU treatment, no additional vaginal bleeding or complications were observed. A hysteroscopic resection was performed to remove ablated placental tissue 7 days later. No abnormal vaginal bleeding or discharge was seen after the procedure. The patient was stable postoperatively. We proposed HIFU and applied additional hysteroscopic resection for a safe and effective method for treating retained placenta accreta to prevent complications from the remaining placental tissue and to improve fertility options.

Continuing use of antithrombotic medications for patients with bleeding gastroduodenal ulcer requiring endoscopic hemostasis: a case-control study.

PubMed

Kawasaki, Keisuke; Nakamura, Shotaro; Kurahara, Koichi; Nagasue, Tomohiro; Yanai, Shunichi; Harada, Akira; Yaita, Hiroki; Fuchigami, Tadahiko; Matsumoto, Takayuki

2017-09-01

The aim of this study was to compare clinical characteristics and outcomes of bleeding gastroduodenal ulcer between patients taking antithrombotic medications and those not taking antithrombotic medications. We performed a case-control study of 346 patients with endoscopically verified bleeding gastroduodenal ulcer, which included 173 cases taking antithrombotic medications throughout peri-bleeding period and 173 age- and sex-matched controls not taking antithrombotic medications. The cases showed less frequent Helicobacter pylori (H. pylori) infections (45.1% versus 60.7%, p = .005), more frequent duodenal location (31.8% versus 19.1%, p = .009), and more frequent rebleeding (13.9% versus 5.8%, p = .02) than the controls. Multivariate analysis revealed that duodenal location (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.37-6.65) and use of antithrombotic medications (OR 2.47, 95% CI 1.13-5.77) were independent factors for rebleeding. However, there were no differences in clinical outcomes, including final successful endoscopic hemostasis, need for surgical intervention, and mortality between cases and controls. Thromboembolic events did not occur in any cases and controls during the periendoscopic period. Low prevalence of H. pylori infection, frequent duodenal location, and high rebleeding rate are characteristics of patients with bleeding gastroduodenal ulcer under antithrombotic medications. Continuation of antithrombotic medications can be accepted for bleeding gastroduodenal ulcer.

Bleeding and Blood Disorders in Clients of Voluntary Medical Male Circumcision for HIV Prevention - Eastern and Southern Africa, 2015-2016.

PubMed

Hinkle, Lawrence E; Toledo, Carlos; Grund, Jonathan M; Byams, Vanessa R; Bock, Naomi; Ridzon, Renee; Cooney, Caroline; Njeuhmeli, Emmanuel; Thomas, Anne G; Odhiambo, Jacob; Odoyo-June, Elijah; Talam, Norah; Matchere, Faustin; Msungama, Wezi; Nyirenda, Rose; Odek, James; Come, Jotamo; Canda, Marcos; Wei, Stanley; Bere, Alfred; Bonnecwe, Collen; Choge, Isaac Ang'Ang'A; Martin, Enilda; Loykissoonlal, Dayanund; Lija, Gissenge J I; Mlanga, Erick; Simbeye, Daimon; Alamo, Stella; Kabuye, Geoffrey; Lubwama, Joseph; Wamai, Nafuna; Chituwo, Omega; Sinyangwe, George; Zulu, James Exnobert; Ajayi, Charles A; Balachandra, Shirish; Mandisarisa, John; Xaba, Sinokuthemba; Davis, Stephanie M

2018-03-23

Male circumcision reduces the risk for female-to-male human immunodeficiency virus (HIV) transmission by approximately 60% (1) and has become a key component of global HIV prevention programs in countries in Eastern and Southern Africa where HIV prevalence is high and circumcision coverage is low. Through September 2017, the President's Emergency Plan for AIDS Relief (PEPFAR) had supported 15.2 million voluntary medical male circumcisions (VMMCs) in 14 priority countries in Eastern and Southern Africa (2). Like any surgical intervention, VMMC carries a risk for complications or adverse events. Adverse events during circumcision of males aged ≥10 years occur in 0.5% to 8% of procedures, though the majority of adverse events are mild (3,4). To monitor safety and service quality, PEPFAR tracks and reports qualifying notifiable adverse events. Data reported from eight country VMMC programs during 2015-2016 revealed that bleeding resulting in hospitalization for ≥3 days was the most commonly reported qualifying adverse event. In several cases, the bleeding adverse event revealed a previously undiagnosed or undisclosed bleeding disorder. Bleeding adverse events in men with potential bleeding disorders are serious and can be fatal. Strategies to improve precircumcision screening and performance of circumcisions on clients at risk in settings where blood products are available are recommended to reduce the occurrence of these adverse events or mitigate their effects (5).

Review article: hyperammonaemic and catabolic consequences of upper gastrointestinal bleeding in cirrhosis.

PubMed

Olde Damink, S W M; Dejong, C H C; Jalan, R

2009-04-15

Upper gastrointestinal (UGI) bleeding in patients with cirrhosis of the liver induces hyperammonaemia and leads to a catabolic cascade that precipitates life-threatening complications. The haemoglobin molecule is unique because it lacks the essential amino acid isoleucine and contains high amounts of leucine and valine. UGI bleed therefore presents the gut with protein of very low biologic value, which may be the stimulus to induce net catabolism. To describe the hyperammonaemic and catabolic consequences of UGI bleeding in cirrhosis. A semi-structured literature search was performed using PubMed and article references. It has recently been proven that ('simulation of ') a UGI bleed in patients with cirrhosis leads to impaired protein synthesis that can be restored by intravenous infusion of isoleucine. This may have therapeutic implications for the function of rapidly dividing cells and short half-life proteins such as clotting factors. Renal and small bowel ammoniagenesis were shown to be the most prominent causes for the hyperammonaemia that resulted from a UGI bleed. This provides an explanation for the therapeutic failure of the current clinical therapies that are aimed at large bowel-derived ammonia production. Isoleucine infusion did not diminish renal ammoniagenesis. New pharmacological therapies to diminish postbleeding hyperammonaemia should target the altered inter-organ ammonia metabolism and promote ammonia excretion and/or increase the excretion of precursors of ammoniagenesis, e.g. l-ornithine-phenylacetate.

The bleeding time may be longer in children than in adults.

PubMed

Sanders, J M; Holtkamp, C A; Buchanan, G R

1990-01-01

The bleeding time, the most frequently performed test reflecting in vivo platelet function, is the duration of blood flow from a standardized incision on the volar surface of the forearm. Normal values have been determined in adult subjects, but with the exception of neonates, data on the range of bleeding time values in pediatric patients are unavailable. Standard hematology textbooks imply that bleeding time values in children are similar to those of adults. We have reviewed our 9 years of experience with 137 children (mean age 6.5 years) who were referred for diagnostic evaluation of a bleeding disorder but whose history and physical examination were felt by us to be inconsistent with an abnormality of hemostasis. Bleeding time values in these individuals (mean 6.0 min, 95th percentile 9.0 min) were compared with those of 85 normal adult volunteers (mean 4.4 min, 95th percentile 6.5 min). The Simplate-I disposable device and vertical (perpendicular to elbow crease) incision direction were used in both groups. This difference between the pediatric and adult bleeding time values is statistically significant (p less than 0.0001). Neither age nor sex had a significant effect on the pediatric bleeding time measurements. We conclude that the bleeding time, when performed as described, is longer in children than in adults and that pediatric standards for bleeding time should be used in order to avoid a spurious diagnosis of a primary hemostatic disorder in some normal children.

A case of gastrointestinal bleeding due to right hepatic artery pseudoaneurysm following total remnant pancreatectomy: A case report.

PubMed

Fujio, Atsushi; Usuda, Masahiro; Ozawa, Yohei; Kamiya, Kurodo; Nakamura, Takanobu; Teshima, Jin; Murakami, Kazushige; Suzuki, On; Miyata, Go; Mochizuki, Izumi

2017-01-01

Pseudoaneurysm is a serious complication after pancreatic surgery, which mainly depends on the presence of a preceding pancreatic fistula. Postpancreatectomy hemorrhage following total pancreatectomy is a rare complication due to the absence of a pancreatic fistula. Here we report an unusual case of massive gastrointestinal bleeding due to right hepatic artery (RHA) pseudoaneurysm following total remnant pancreatectomy. A 75-year-old man was diagnosed with intraductal papillary mucinous carcinoma recurrence following distal pancreatectomy and underwent total remnant pancreatectomy. After discharge, he was readmitted to our hospital with melena because of the diagnosis of gastrointestinal bleeding. Gastrointestinal endoscopy was performed to detect the origin of bleeding, but an obvious bleeding point could not be detected. Abdominal computed tomography demonstrated an expansive growth, which indicated RHA pseudoaneurysm. Emergency angiography revealed gastrointestinal bleeding into the jejunum from the ruptured RHA pseudoaneurysm. Transcatheter arterial embolization was performed; subsequently, bleeding was successfully stopped for a short duration. Because of improvements in his general condition, the patient was discharged. To date, very few cases have described postpancreatectomy hemorrhage following total remnant pancreatectomy. We suspect that the aneurysm ruptured into the jejunum, possibly because of the scarring and inflammation associated with his two complex surgeries. Pseudoaneurysm should be considered when the fragility of blood vessels is suspected, despite no history of anastomotic leak and intra-abdominal abscess. Our case also highlighted that detecting gastrointestinal bleeding is necessary to recognize sentinel bleeding if the origin of bleeding is undetectable.

Effects of bleed-hole geometry and plenum pressure on three-dimensional shock-wave/boundary-layer/bleed interactions

NASA Technical Reports Server (NTRS)

Chyu, Wei J.; Rimlinger, Mark J.; Shih, Tom I.-P.

1993-01-01

A numerical study was performed to investigate 3D shock-wave/boundary-layer interactions on a flat plate with bleed through one or more circular holes that vent into a plenum. This study was focused on how bleed-hole geometry and pressure ratio across bleed holes affect the bleed rate and the physics of the flow in the vicinity of the holes. The aspects of the bleed-hole geometry investigated include angle of bleed hole and the number of bleed holes. The plenum/freestream pressure ratios investigated range from 0.3 to 1.7. This study is based on the ensemble-averaged, 'full compressible' Navier-Stokes (N-S) equations closed by the Baldwin-Lomax algebraic turbulence model. Solutions to the ensemble-averaged N-S equations were obtained by an implicit finite-volume method using the partially-split, two-factored algorithm of Steger on an overlapping Chimera grid.

[Does the antisecretory agent used affect the evolution of upper digestive hemorrhage?].

PubMed

Ortí, E; Canelles, P; Quiles, F; Zapater, R; Cuquerella, J; Ariete, V; Tomé, A; Medina, E

1995-06-01

To investigate whether omeprazole has improved morbidity-mortality among patients with upper gastrointestinal bleeding of non-variceal origin in comparison with ranitidine. Prospective, randomized and open study. We study 519 consecutive patients admitted to our Service between June 1991 and January 1993 for upper gastrointestinal bleeding of peptic origin, dividing the patients into two randomized groups that were homogeneous in terms of age, sex, previous history of gastric disease and upper gastrointestinal bleeding, intake of non-steroidal antiinflammatory drugs, and the severity of bleeding on admittance. Thus, Group A consisted of 252 patients treated immediately upon arrival at the emergency ward with 50 mg intravenous ranitidine, followed by a further 50 mg every 6 hours. Group B in turn consisted of 267 patients initially given a bolus dose of 80 mg omeprazole intravenously, followed by an additional 40 mg every 8 hours for 48 hours. Forty mg were subsequently administered every 12 hours until hospital discharge. Endoscopy was performed in all cases within the first 24 hours following admittance, those patients with active upper gastrointestinal bleeding resulted from Forrest-type ulcer of subjected to endoscopic sclerotherapy were excluded. Duodenal ulcer was the most common cause of bleeding, followed by gastric ulcer and acute lesions of the mucosa. Emphasis should be placed on the high incidence of previous non-steroidal antiinflammatory drug intake in our series (54.5%). We encountered no statistically significant differences between the two groups on comparing bleeding stigmata, transfusion requirements, recurrences, emergency surgery, the duration of hospital stay, and mortality. Both drugs were found to possess a similar efficacy in treating upper gastrointestinal bleeding of peptic origin.

Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding?

PubMed

Monsanto, Pedro; Almeida, Nuno; Lérias, Clotilde; Figueiredo, Pedro; Gouveia, Hermano; Sofia, Carlos

2012-04-01

in 21st century, endoscopic study of the small intestine has undergone a revolution with capsule endoscopy and balloon-assisted enteroscopy. The difficulties and morbidity associated with intraoperative enteroscopy, the gold-standard in the 20th century, made this technique to be relegated to a second level. evaluate the actual role and assess the diagnostic and therapeutic value of intraoperative enteroscopy in patients with obscure gastrointestinal bleeding. we conducted a retrospective study of 19 patients (11 males; mean age: 66.5 ± 15.3 years) submitted to 21 IOE procedures for obscure GI bleeding. Capsule endoscopy and double balloon enteroscopy had been performed in 10 and 5 patients, respectively. with intraoperative enteroscopy a small bowel bleeding lesion was identified in 79% of patients and a gastrointestinal bleeding lesion in 94%. Small bowel findings included: angiodysplasia (n = 6), ulcers (n = 4), small bowel Dieulafoy´s lesion (n = 2), bleeding from anastomotic vessels (n = 1), multiple cavernous hemangiomas (n = 1) and bleeding ectopic jejunal varices (n = 1). Agreement between capsule endoscopy and intraoperative enteroscopy was 70%. Endoscopic and/or surgical treatment was used in 77.8% of the patients with a positive finding on intraoperative enteroscopy, with a rebleeding rate of 21.4% in a mean 21-month follow-up period. Procedure-related mortality and postoperative complications have been 5 and 21%, respectively. intraoperative enteroscopy remains a valuable tool in selected patients with obscure GI bleeding, achieving a high diagnostic yield and allowing an endoscopic and/or surgical treatment in most of them. However, as an invasive procedure with relevant mortality and morbidity, a precise indication for its use is indispensable.

Calculated effects of turbine rotor-blade cooling-air flow, altitude, and compressor bleed point on performance of a turbojet engine

NASA Technical Reports Server (NTRS)

Arne, Vernon L; Nachtigall, Alfred J

1951-01-01

Effects of air-cooling turbine rotor blades on performance of a turbojet engine were calculated for a range of altitudes from sea level to 40,000 feet and a range of coolant flows up to 3 percent of compressor air flow, for two conditions of coolant bleed from the compressor. Bleeding at required coolant pressure resulted in a sea-level thrust reduction approximately twice the percentage coolant flow and in an increase in specific fuel consumption approximately equal to percentage coolant flow. For any fixed value of coolant flow ratio the percentage thrust reduction and percentage increase in specific fuel consumption decreased with altitude. Bleeding coolant at the compressor discharge resulted in an additional 1 percent loss in performance at sea level and in smaller increase in loss of performance at higher altitudes.

A rare cause of bleeding after laparoscopic sleeve gastrectomy : pseudo-aneurysm of the gastro-omental artery.

PubMed

Mege, D; Louis, G; Berthet, B

2013-01-01

A serious complication of laparoscopic sleeve gastrectomy (LSG) is bleeding that is primarily located along the staples lines. Bleeding may be due to several causes, including hematomas, trocar sites, or visceral pseudo-aneurysms. We reported here a case of bleeding related to a pseudo-aneurysm of the gastro-omental artery. An LSG was performed on a 43-year-old woman (BMI = 46 kg/m2) without apparent surgical complications. Fifteen days later, she was admitted to the emergency department for hematemesis and symptoms of hemorrhagic shock. Abdominal computed tomography angiography revealed blood in the stomach, without a digestive leak, and active bleeding from a pseudo-aneurysm of the gastro-omental artery. An arterial embolisation was performed with the sandwich technique and angiographic guide wires and the placement of several detachable coils. The patient was discharged two days later. We demonstrated for the first time that post-LSG bleeding may involve a pseudo-aneurysm of the gastro-omental artery.

On the influence of zero-padding on the nonlinear operations in Quantitative Susceptibility Mapping

PubMed Central

Eskreis-Winkler, Sarah; Zhou, Dong; Liu, Tian; Gupta, Ajay; Gauthier, Susan A.; Wang, Yi; Spincemaille, Pascal

2016-01-01

Purpose Zero padding is a well-studied interpolation technique that improves image visualization without increasing image resolution. This interpolation is often performed as a last step before images are displayed on clinical workstations. Here, we seek to demonstrate the importance of zero padding before rather than after performing non-linear post-processing algorithms, such as Quantitative Susceptibility Mapping (QSM). To do so, we evaluate apparent spatial resolution, relative error and depiction of multiple sclerosis (MS) lesions on images that were zero padded prior to, in the middle of, and after the application of the QSM algorithm. Materials and Methods High resolution gradient echo (GRE) data were acquired on twenty MS patients, from which low resolution data were derived using k-space cropping. Pre-, mid-, and post-zero padded QSM images were reconstructed from these low resolution data by zero padding prior to field mapping, after field mapping, and after susceptibility mapping, respectively. Using high resolution QSM as the gold standard, apparent spatial resolution, relative error, and image quality of the pre-, mid-, and post-zero padded QSM images were measured and compared. Results Both the accuracy and apparent spatial resolution of the pre-zero padded QSM was higher than that of mid-zero padded QSM (p < 0.001; p < 0.001), which was higher than that of post-zero padded QSM (p < 0.001; p < 0.001). The image quality of pre-zero padded reconstructions was higher than that of mid- and post-zero padded reconstructions (p = 0.004; p < 0.001). Conclusion Zero padding of the complex GRE data prior to nonlinear susceptibility mapping improves image accuracy and apparent resolution compared to zero padding afterwards. It also provides better delineation of MS lesion geometry, which may improve lesion subclassification and disease monitoring in MS patients. PMID:27587225

On the influence of zero-padding on the nonlinear operations in Quantitative Susceptibility Mapping.

PubMed

Eskreis-Winkler, Sarah; Zhou, Dong; Liu, Tian; Gupta, Ajay; Gauthier, Susan A; Wang, Yi; Spincemaille, Pascal

2017-01-01

Zero padding is a well-studied interpolation technique that improves image visualization without increasing image resolution. This interpolation is often performed as a last step before images are displayed on clinical workstations. Here, we seek to demonstrate the importance of zero padding before rather than after performing non-linear post-processing algorithms, such as Quantitative Susceptibility Mapping (QSM). To do so, we evaluate apparent spatial resolution, relative error and depiction of multiple sclerosis (MS) lesions on images that were zero padded prior to, in the middle of, and after the application of the QSM algorithm. High resolution gradient echo (GRE) data were acquired on twenty MS patients, from which low resolution data were derived using k-space cropping. Pre-, mid-, and post-zero padded QSM images were reconstructed from these low resolution data by zero padding prior to field mapping, after field mapping, and after susceptibility mapping, respectively. Using high resolution QSM as the gold standard, apparent spatial resolution, relative error, and image quality of the pre-, mid-, and post-zero padded QSM images were measured and compared. Both the accuracy and apparent spatial resolution of the pre-zero padded QSM was higher than that of mid-zero padded QSM (p<0.001; p<0.001), which was higher than that of post-zero padded QSM (p<0.001; p<0.001). The image quality of pre-zero padded reconstructions was higher than that of mid- and post-zero padded reconstructions (p=0.004; p<0.001). Zero padding of the complex GRE data prior to nonlinear susceptibility mapping improves image accuracy and apparent resolution compared to zero padding afterwards. It also provides better delineation of MS lesion geometry, which may improve lesion subclassification and disease monitoring in MS patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Achieving highly efficient and broad-angle polarization beam filtering using epsilon-near-zero metamaterials mimicked by metal-dielectric multilayers

NASA Astrophysics Data System (ADS)

Wu, Feng

2018-03-01

We report a highly efficient and broad-angle polarization beam filter at visible wavelengths using an anisotropic epsilon-near-zero metamaterial mimicked by a multilayer composed of alternative subwavelength magnesium fluoride and silver layers. The underlying physics can be explained by the dramatic difference between two orthogonal polarizations' iso-frequency curves of anisotropic epsilon-near-zero metamaterials. Transmittance for two orthogonal polarization waves and the polarization extinction ratio are calculated via the transfer matrix method to assess the comprehensive performance of the proposed polarization beam filter. From the simulation results, the proposed polarization beam filter is highly efficient (the polarization extinction ratio is far larger than two orders of magnitude) and has a broad operating angle range (ranging from 30° to 75°). Finally, we show that the proper tailoring of the periodic number enables us to obtain high comprehensive performance of the proposed polarization beam filter.

[Predicting very early rebleeding after acute variceal bleeding based in classification and regression tree analysis (CRTA).].

PubMed

Altamirano, J; Augustin, S; Muntaner, L; Zapata, L; González-Angulo, A; Martínez, B; Flores-Arroyo, A; Camargo, L; Genescá, J

2010-01-01

Variceal bleeding (VB) is the main cause of death among cirrhotic patients. About 30-50% of early rebleeding is encountered few days after the acute episode of VB. It is necessary to stratify patients with high risk of very early rebleeding (VER) for more aggressive therapies. However, there are few and incompletely understood prognostic models for this purpose. To determine the risk factors associated with VER after an acute VB. Assessment and comparison of a novel prognostic model generated by Classification and Regression Tree Analysis (CART) with classic-used models (MELD and Child-Pugh [CP]). Sixty consecutive cirrhotic patients with acute variceal bleeding. CART analysis, MELD and Child-Pugh scores were performed at admission. Receiver operating characteristic (ROC) curves were constructed to evaluate the predictive performance of the models. Very early rebleeding rate was 13%. Variables associated with VER were: serum albumin (p = 0.027), creatinine (p = 0.021) and transfused blood units in the first 24 hrs (p = 0.05). The area under the ROC for MELD, CHILD-Pugh and CART were 0.46, 0.50 and 0.82, respectively. The value of cut analyzed by CART for the significant variables were: 1) Albumin 2.85 mg/dL, 2) Packed red cells 2 units and 3) Creatinine 1.65 mg/dL the ABC-ROC. Serum albumin, creatinine and number of transfused blood units were associated with VER. A simple CART algorithm combining these variables allows an accurate predictive assessment of VER after acute variceal bleeding. Key words: cirrhosis, variceal bleeding, esophageal varices, prognosis, portal hypertension.

Climbing therapy under PK-tailored prophylaxis.

PubMed

Stemberger, M; Schmit, E; Czepa, D; Kurnik, K; Spannagl, M

2014-01-01

Climbing has a low risk of injury and strengthens the entire musculature. Due to its benefits in physical and mental health as well as its high fun factor climbing is an established way of therapy. So far, the usefulness of climbing therapy has not been shown for people with haemophilia (PWH). A crucial requirement for physical activity in PWH is regular prophylaxis. As the patient's individual pharmacokinetic (PK) response varies significantly, PK-tailored prophylaxis may decrease bleeding frequency. We describe a man (age 25 years) with severe haemophilia A who took part in an 8.5-month weekly climbing program under PK-tailored prophylaxis. Bleeding frequency, factor consumption, joint health (Haemophilia Joint Health Score, HJHS), quality of life (Haemo-QoL-A) and climbing performance (UIAA scale) were assessed before and after the training. Prior to the study, the patient was on demand treatment. The patient was started on standard prophylaxis for a 2 months period and then observed for 6.5 months under PK-tailored prophylaxis. PK-tailored prophylaxis was targeted to a trough level of 1-3%. For high-impact activities a factor activity >15%, for low-impact activities a factor activity >5% was suggested. Climbing therapy was safe. The bleeding rate decreased from 14 (2012) to 1 (during the study period of 8.5 months). The one bleeding event was due to a missed infusion and was not triggered by physical activity. The elimination half-life using Bayesian statistics was determined to be 16h. Using this half-life for PK-tailored prophylaxis reduced the factor VIII consumption in comparison to standard prophylaxis. Joint health was particularly improved in the categories range of motion and swelling. Quality of life scores stayed at a high level. Climbing performance improved by 1 grade. The combination of PK-tailored prophylaxis with therapeutic climbing improved clinical outcome in this young adult with severe haemophilia. The tailored concept for high- and low-impact activities appeared to be safe.

DOE Zero Energy Ready Home Case Study: Amaris Homes, Afton Model

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pacific Northwest National Laboratory

Amaris Homes built this 3,734-ft2 home in Afton, Minnesota, to the performance criteria of the DOE Zero Energy Ready Home (ZERH) program. A high-efficiency gas boiler provides hot water for the zoned radiant floor system as well as for faucets and showers. A high-efficiency heat pump provides zoned cooling.

High performance MIIM diode based on cobalt oxide/titanium oxide

NASA Astrophysics Data System (ADS)

Herner, S. B.; Weerakkody, A. D.; Belkadi, A.; Moddel, G.

2017-05-01

Optical rectennas for infrared energy harvesting commonly incorporate metal/double-insulator/metal diodes. Required diode characteristics include high responsivity and low resistance near zero bias with a sub-micron area, which have not been obtainable simultaneously. Diodes based on a new material set, Co/Co3O4/TiO2/Ti and an area of 0.071 μm2, provide a median maximum responsivity of 4.1 A/W, a median zero-bias responsivity of 1.2 A/W, and a median resistance of 14 kΩ. The highest performing diode has a maximum responsivity of 4.4 A/W, a zero-bias responsivity of 2.2 A/W, and a resistance of 18 kΩ.

Manipulating the transmission through valve structure composed of zero-index metamaterial

NASA Astrophysics Data System (ADS)

Wang, Yongxing; Sun, Zhouzhou; Xu, Ping

2017-11-01

We propose a valve structure composed of zero-index metamaterial to manipulate the electromagnetic wave conveniently and effectively through regulating the phase of reflected waves. Both the structure and characteristics of zero-index metamaterial need not to be changed when manipulating the transmission, which maintains the stability of zero-index metamaterial. Moreover, the good performance of tuning the electromagnetic wave is not limited by the shape and size of our proposed structure. By using our proposed valve structure, we demonstrate the realization of the tunable curved anisotropic ɛ-near-zero material waveguide with irregular shape, arbitrarily sized isotropic ɛ-near-zero material waveguide with high transmittance and the curved isotropic impedance matched ɛ-near-zero material waveguide without polarization limitations.

A Fibreoptic endoscopic study of upper gastrointestinal bleeding at Bugando Medical Centre in northwestern Tanzania: A retrospective review of 240 cases

PubMed Central

2012-01-01

Background Upper gastrointestinal (GI) bleeding is recognized as a common and potentially life-threatening abdominal emergency that needs a prompt assessment and aggressive emergency treatment. A retrospective study was undertaken at Bugando Medical Centre in northwestern Tanzania between March 2010 and September 2011 to describe our own experiences with fibreoptic upper GI endoscopy in the management of patients with upper gastrointestinal bleeding in our setting and compare our results with those from other centers in the world. Findings A total of 240 patients representing 18.7% of all patients (i.e. 1292) who had fibreoptic upper GI endoscopy during the study period were studied. Males outnumbered female by a ratio of 2.1:1. Their median age was 37 years and most of patients (60.0%) were aged 40 years and below. The vast majority of the patients (80.4%) presented with haematemesis alone followed by malaena alone in 9.2% of cases. The use of non-steroidal anti-inflammatory drugs, alcohol and smoking prior to the onset of bleeding was recorded in 7.9%, 51.7% and 38.3% of cases respectively. Previous history of peptic ulcer disease was reported in 22(9.2%) patients. Nine (3.8%) patients were HIV positive. The source of bleeding was accurately identified in 97.7% of patients. Diagnostic accuracy was greater within the first 24 h of the bleeding onset, and in the presence of haematemesis. Oesophageal varices were the most frequent cause of upper GI bleeding (51.3%) followed by peptic ulcers in 25.0% of cases. The majority of patients (60.8%) were treated conservatively. Endoscopic and surgical treatments were performed in 30.8% and 5.8% of cases respectively. 140 (58.3%) patients received blood transfusion. The median length of hospitalization was 8 days and it was significantly longer in patients who underwent surgical treatment and those with higher Rockall scores (P < 0.001). Rebleeding was reported in 3.3% of the patients. The overall mortality rate of 11.7% was significantly higher in patients with variceal bleeding, shock, hepatic decompensation, HIV infection, comorbidities, malignancy, age > 60 years and in patients with higher Rockall scores and those who underwent surgery (P < 0.001). Conclusion Oesophageal varices are the commonest cause of upper gastrointestinal bleeding in our environment and it is associated with high morbidity and mortality. The diagnostic accuracy of fibreoptic endoscopy was related to the time interval between the onset of bleeding and endoscopy. Therefore, it is recommended that early endoscopy should be performed within 24 h of the onset of bleeding. PMID:22537571

A fibreoptic endoscopic study of upper gastrointestinal bleeding at Bugando Medical Centre in northwestern Tanzania: a retrospective review of 240 cases.

PubMed

Jaka, Hyasinta; Koy, Mheta; Liwa, Anthony; Kabangila, Rodrick; Mirambo, Mariam; Scheppach, Wolfgang; Mkongo, Eliasa; McHembe, Mabula D; Chalya, Phillipo L

2012-07-03

Upper gastrointestinal (GI) bleeding is recognized as a common and potentially life-threatening abdominal emergency that needs a prompt assessment and aggressive emergency treatment. A retrospective study was undertaken at Bugando Medical Centre in northwestern Tanzania between March 2010 and September 2011 to describe our own experiences with fibreoptic upper GI endoscopy in the management of patients with upper gastrointestinal bleeding in our setting and compare our results with those from other centers in the world. A total of 240 patients representing 18.7% of all patients (i.e. 1292) who had fibreoptic upper GI endoscopy during the study period were studied. Males outnumbered female by a ratio of 2.1:1. Their median age was 37 years and most of patients (60.0%) were aged 40 years and below. The vast majority of the patients (80.4%) presented with haematemesis alone followed by malaena alone in 9.2% of cases. The use of non-steroidal anti-inflammatory drugs, alcohol and smoking prior to the onset of bleeding was recorded in 7.9%, 51.7% and 38.3% of cases respectively. Previous history of peptic ulcer disease was reported in 22(9.2%) patients. Nine (3.8%) patients were HIV positive. The source of bleeding was accurately identified in 97.7% of patients. Diagnostic accuracy was greater within the first 24 h of the bleeding onset, and in the presence of haematemesis. Oesophageal varices were the most frequent cause of upper GI bleeding (51.3%) followed by peptic ulcers in 25.0% of cases. The majority of patients (60.8%) were treated conservatively. Endoscopic and surgical treatments were performed in 30.8% and 5.8% of cases respectively. 140 (58.3%) patients received blood transfusion. The median length of hospitalization was 8 days and it was significantly longer in patients who underwent surgical treatment and those with higher Rockall scores (P < 0.001). Rebleeding was reported in 3.3% of the patients. The overall mortality rate of 11.7% was significantly higher in patients with variceal bleeding, shock, hepatic decompensation, HIV infection, comorbidities, malignancy, age > 60 years and in patients with higher Rockall scores and those who underwent surgery (P < 0.001). Oesophageal varices are the commonest cause of upper gastrointestinal bleeding in our environment and it is associated with high morbidity and mortality. The diagnostic accuracy of fibreoptic endoscopy was related to the time interval between the onset of bleeding and endoscopy. Therefore, it is recommended that early endoscopy should be performed within 24 h of the onset of bleeding.

Post-ritual Circumcision Bleeding-Characteristics and Treatment Outcome.

PubMed

Mano, Roy; Nevo, Amihay; Sivan, Bezalel; Morag, Roy; Ben-Meir, David

2017-07-01

To report the characteristics, treatment, and short-term outcome of neonatal post-circumcision bleeding, and to identify predictors of surgical treatment. The medical records of 90 consecutive neonates who presented to the emergency room with post-circumcision bleeding between 2009 and 2014 were reviewed. Circumcisions were performed using the traditional Mogen shield device. The study end point was surgical intervention for hemostasis. Predictors of surgical treatment were evaluated. An estimated total of 28,383 circumcisions were performed during the study period; thus, the post-circumcision bleeding rate was 0.32%. Initial treatment included compressive dressing in 15 infants (17%) and hemostatic dressing in 47 infants (52%); 28 infants (31%) did not require treatment upon arrival to the emergency room. Two infants (2%) received blood transfusion. Surgical treatment was required in 11 infants (12%); 10 of 43 infants (23%) with active bleeding on arrival to the emergency room required surgery compared to 1 of 47 infants (2%) without active bleeding (P = .003). Similarly, 3 of 7 infants (43%) referred from other hospitals required surgery compared to 8 of 83 infants (10%) referred from the community (P = .037). Abnormal blood tests at presentation were not associated with surgical treatment. At 1 month of follow-up, 2 infants were admitted for recurrent bleeding. Coagulation abnormalities were found in 4 infants. Surgical treatment was required in 12% of infants presenting to the emergency room with post-circumcision bleeding. The rate of surgical intervention was significantly higher in infants with active bleeding at presentation and in those referred from other hospitals. Physicians should consider admitting infants presenting with active post-circumcision bleeding, whereas infants without active bleeding may be observed and discharged. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical impact and course of major bleeding with rivaroxaban and vitamin K antagonists.

PubMed

Eerenberg, E S; Middeldorp, S; Levi, M; Lensing, A W; Büller, H R

2015-09-01

Rivaroxaban is a new oral anticoagulant (NOAC) that can be prescribed in a fixed dose, making regular monitoring and dose adjustments unnecessary. It has been proven to be safe and effective in comparison with enoxaparin/vitamin K antagonists (LMWH/VKA) for the (extended) treatment of venous thromboembolism in the EINSTEIN studies. Nevertheless, there is a need for information regarding the clinical impact of (major) bleeding events with NOACs such as rivaroxaban. A post-hoc analysis was performed to compare the severity of clinical presentation and subsequent clinical course of major bleeding with rivaroxaban vs. LMWH/VKA. Two investigators performed a blinded classification of major bleeding using a priori defined criteria. During the EINSTEIN studies, data concerning the clinical course and measures applied were prospectively collected for each major bleed. Treatment with LMWH/VKA caused more major bleeding events (1.7%) than rivaroxaban (1.0%; hazard ratio, 0.54; 95% confidence interval [CI], 0.37-0.79). Major bleeding events during rivaroxaban therapy had a milder presentation (23% were adjudicated to the worst categories vs. 38% for LMWH/VKA; hazard ratio or HR, 0.35; 95% CI, 0.17-0.74; P = 0.0062). The clinical course was severe in 25% of all major bleeding events associated with rivaroxaban, compared with 33% of LMWH/VKA-associated bleeds (HR, 0.46; 95% CI, 0.22-0.96; P = 0.040). Rivaroxaban-associated major bleeding events occurred less frequently, had a milder presentation and appeared to take a less severe clinical course compared with major bleeding with LMWH/VKA. © 2015 The Authors. Journal of Thrombosis and Haemostasis published by Wiley Periodicals, Inc. on behalf of International Society on Thrombosis and Haemostasis.

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Mechanical Selling High Performance Homes Water Efficiency Zero Energy Homes Upcoming Sessions HERS Associate Search High Performance Home Summit October 16-18, 2018 - San Diego, CA High Performance Home Summit Join collaboration with high performance building professionals from across the United States and Canada. More

Timely Antecedent CT or MRI Can Help Predict Hemorrhage Site of Posttreatment Head and Neck Cancer, With Digital Subtraction Angiography Used as the Reference Standard.

PubMed

Ku, Yi-Kang; Wong, Yon-Cheong; Fu, Chen-Ju; Tseng, Hsiao-Jung; Wang, Li-Jen; Wang, Chao-Jan; Chin, Shy-Chyi

2016-04-01

We investigated the timing of CT and MRI performed before digital subtraction angiography (DSA) in the prediction of hemorrhage sites in patients with head and neck cancers who present with acute oral or neck bleeding after receiving treatment. A total of 123 DSA examinations that evaluated 123 oral or neck bleeding events in 85 patients were analyzed. The last CT or MRI examinations performed within a time frame of 0-337 days before transarterial embolization were reviewed retrospectively, with three findings (pseudoaneurysm, air-containing necrotic tissue, and residual tumor) used to predict hemorrhage sites. DSA findings of pseudoaneurysm or active contrast extravasation were used as a reference standard. The sensitivity of CT and MRI for correctly predicting hemorrhage sites was used to determine the optimal timing of CT or MRI examinations performed before DSA. A total of 8.9% of the DSA examinations (11/123) had equivocal findings but were followed by another bleeding event for which DSA findings were positive. CT or MRI was statistically significantly better at predicting hemorrhage sites in patients with bleeding events associated with nonhypopharyngeal cancers (p = 0.019) than in those with bleeding events associated with hypopharyngeal cancers. The sensitivity of CT or MRI in the prediction of hemorrhage sites was statistically significantly higher for the common carotid artery and the internal carotid artery when CT or MRI was performed less than 30 days before bleeding events occurred. Prediction of hemorrhagic sites was better with the use of CT angiography than with the use of enhanced CT or MRI, although it was not statistically significant. DSA findings can temporarily be equivocal. CT or MRI examinations performed within 30 days of bleeding events can predict the site of hemorrhage. If no CT or MRI findings from the past 30 days are available, we suggest performing emergent CT angiography for the sake of obtaining better arterial detail.

Treatment of Recurrent Hemarthrosis after Total Knee Arthroplasty

PubMed Central

Yoo, Ju-Hyung; Oh, Hyun-Cheol; Park, Sang-Hoon; Lee, Sanghyeon; Lee, Yunjae

2018-01-01

Purpose The purpose of this study is to evaluate the incidence and treatment of recurrent hemarthrosis after total knee replacement (TKR). Materials and Methods Among a total of 5,510 patients who underwent TKR from March 2000 to October 2016, patients who had two or more bleeding 2 weeks after surgery were studied. Conservative treatments were performed for all cases with symptoms. In patients who did not respond to conservative treatment several times, embolization was performed. We retrospectively evaluated the postoperative bleeding time, bleeding frequency, treatment method, and outcome. Results Seventeen (0.3%) of the 5,510 patients developed recurrent hemarthrosis. Bleeding occurred at an average of 2 years 3 months after the operation. Joint aspiration was performed 3.5 times (range, 2 to 10 times) on average, and 14 cases (82.3%) were treated with conservative treatment. In 3 patients with severe bleeding and hemorrhage, embolization was performed. Conclusions Recurrent hemarthrosis after TKR is a rare disease with a low incidence of 0.3% and usually could be treated by conservative treatment. If recurrences occur repeatedly, embolization through angiography or surgical treatment may be considered, but the results are not satisfactory and careful selection of treatment modalities is warranted. PMID:29715715

Rationale and design of the HepZero study: a prospective, multicenter, international, open, randomized, controlled clinical study with parallel groups comparing heparin-free dialysis with heparin-coated dialysis membrane (Evodial) versus standard care: study protocol for a randomized controlled trial.

PubMed

Rossignol, Patrick; Dorval, Marc; Fay, Renaud; Ros, Joan Fort; Loughraieb, Nathalie; Moureau, Frédérique; Laville, Maurice

2013-06-01

Anticoagulation for chronic dialysis patients with contraindications to heparin administration is challenging. Current guidelines state that in patients with increased bleeding risks, strategies that can induce systemic anticoagulation should be avoided. Heparin-free dialysis using intermittent saline flushes is widely adopted as the method of choice for patients at risk of bleeding, although on-line blood predilution may also be used. A new dialyzer, Evodial (Gambro, Lund, Sweden), is grafted with unfractionated heparin during the manufacturing process and may allow safe and efficient heparin-free hemodialysis sessions. In the present trial, Evodial was compared to standard care with either saline flushes or blood predilution. The HepZero study is the first international (seven countries), multicenter (10 centers), randomized, controlled, open-label, non-inferiority (and if applicable subsequently, superiority) trial with two parallel groups, comprising 252 end-stage renal disease patients treated by maintenance hemodialysis for at least 3 months and requiring heparin-free dialysis treatments. Patients will be treated during a maximum of three heparin-free dialysis treatments with either saline flushes or blood predilution (control group), or Evodial. The first heparin-free dialysis treatment will be considered successful when there is: no complete occlusion of air traps or dialyzer rendering dialysis impossible; no additional saline flushes to prevent clotting; no change of dialyzer or blood lines because of clotting; and no premature termination (early rinse-back) because of clotting.The primary objectives of the study are to determine the effectiveness of the Evodial dialyzer, compared with standard care in terms of successful treatments during the first heparin-free dialysis. If the non-inferiority of Evodial is demonstrated then the superiority of Evodial over standard care will be tested. The HepZero study results may have major clinical implications for patient care. ClinicalTrials.gov NCT01318486.

The novel biomarker-based ABC (age, biomarkers, clinical history)-bleeding risk score for patients with atrial fibrillation: a derivation and validation study.

PubMed

Hijazi, Ziad; Oldgren, Jonas; Lindbäck, Johan; Alexander, John H; Connolly, Stuart J; Eikelboom, John W; Ezekowitz, Michael D; Held, Claes; Hylek, Elaine M; Lopes, Renato D; Siegbahn, Agneta; Yusuf, Salim; Granger, Christopher B; Wallentin, Lars

2016-06-04

The benefit of oral anticoagulation in atrial fibrillation is based on a balance between reduction in ischaemic stroke and increase in major bleeding. We aimed to develop and validate a new biomarker-based risk score to improve the prognostication of major bleeding in patients with atrial fibrillation. We developed and internally validated a new biomarker-based risk score for major bleeding in 14,537 patients with atrial fibrillation randomised to apixaban versus warfarin in the ARISTOTLE trial and externally validated it in 8468 patients with atrial fibrillation randomised to dabigatran versus warfarin in the RE-LY trial. Plasma samples for determination of candidate biomarker concentrations were obtained at randomisation. Major bleeding events were centrally adjudicated. The predictive values of biomarkers and clinical variables were assessed with Cox regression models. The most important variables were included in the score with weights proportional to the model coefficients. The ARISTOTLE and RE-LY trials are registered with ClinicalTrials.gov, numbers NCT00412984 and NCT00262600, respectively. The most important predictors for major bleeding were the concentrations of the biomarkers growth differentiation factor-15 (GDF-15), high-sensitivity cardiac troponin T (cTnT-hs) and haemoglobin, age, and previous bleeding. The ABC-bleeding score (age, biomarkers [GDF-15, cTnT-hs, and haemoglobin], and clinical history [previous bleeding]) score yielded a higher c-index than the conventional HAS-BLED and the newer ORBIT scores for major bleeding in both the derivation cohort (0·68 [95% CI 0·66-0·70] vs 0·61 [0·59-0·63] vs 0·65 [0·62-0·67], respectively; ABC-bleeding vs HAS-BLED p<0·0001 and ABC-bleeding vs ORBIT p=0·0008). ABC-bleeding score also yielded a higher c-index score in the the external validation cohort (0·71 [95% CI 0·68-0·73] vs 0·62 [0·59-0·64] for HAS-BLED vs 0·68 [0·65-0·70] for ORBIT; ABC-bleeding vs HAS-BLED p<0·0001 and ABC-bleeding vs ORBIT p=0·0016). A modified ABC-bleeding score using alternative biomarkers (haematocrit, cTnI-hs, cystatin C, or creatinine clearance) also outperformed the HAS-BLED and ORBIT scores. The ABC-bleeding score, using age, history of bleeding, and three biomarkers (haemoglobin, cTn-hs, and GDF-15 or cystatin C/CKD-EPI) was internally and externally validated and calibrated in large cohorts of patients with atrial fibrillation receiving anticoagulation therapy. The ABC-bleeding score performed better than HAS-BLED and ORBIT scores and should be useful as decision support on anticoagulation treatment in patients with atrial fibrillation. BMS, Pfizer, Boehringer Ingelheim, Roche Diagnostics. Copyright © 2016 Elsevier Ltd. All rights reserved.

Highlighted Steps of the Management Algorithm in Acute Lower Gastrointestinal Bleeding - Case Reports and Literature Review.

PubMed

Andrei, Gabriel Nicolae; Popa, Bogdan; Gulie, Laurentiu; Diaconescu, Bogdan Ionut; Martian, Bogdan Valeriu; Bejenaru, Mircea; Beuran, Mircea

2016-01-01

Acute lower gastrointestinal bleeding is a major problem worldwide, being a rare and life threatening condition, with a mortality rate situated between 2 and 4%. Acute lower gastrointestinal bleeding is solvent for 1 - 2% of the entire hospital emergencies, 15% presenting as massive bleeding and up to 5% requiring surgery. Lower gastrointestinal bleeding can be classified depending on their location in the small or large intestine. The small bowel is the rarest site of lower gastrointestinal bleeding, at the same time being the commonest cause of obscure bleeding. 5% of total lower GI bleeding appears in the small bowel. When endoscopic therapy associated with medical treatment are insufficient, endovascular intervention can be lifesaving. Unfortunately in some rare cases of acute lower gastrointestinal bleeding with hemo-dynamic instability and the angiography performed being unable to locate the source of bleeding, the last therapeutic resource remains surgery. In the following we exemplify two cases of acute lower gastrointestinal bleeding which were resolved in different ways, followed by a thorough description of the different types of available treatment and finally, in the conclusions, we systematize the most important stages of the management algorithm in acute lower gastrointestinal bleeding. Celsius.

High Cost of Hospitalization for Colonic Diverticular Bleeding Depended on Repeated Bleeding and Blood Transfusion: Analysis with Diagnosis Procedure Combination Data in Japan.

PubMed

Ito, Yoichiro; Sakata, Yasuhisa; Yoshida, Hisako; Nonaka, Sayuri; Fujii, Susumu; Tanaka, Yuichiro; Shirai, Shimpei; Takeshita, Eri; Akutagawa, Takashi; Kawakubo, Hiroharu; Yamamoto, Koji; Tsuruoka, Nanae; Shimoda, Ryo; Iwakiri, Ryuichi; Fujimoto, Kazuma

2017-01-01

Bleeding from a colonic diverticulum is serious in aged patients. The aim of this study was to determine the risk factors for high-cost hospitalization of colonic diverticular bleeding using the diagnosis procedure combination (DPC) data. From January 2009 to December 2015, 78 patients with colonic diverticular bleeding were identified by DPC data in Saga Medical School Hospital. All patients underwent colonic endoscopy within 3 days. The patients were divided into 2 groups: the low-cost group (DPC cost of <500,000 yen) and the high-cost group (DPC cost of >500,000 yen). Univariate analysis revealed that aging, hypertension, rebleeding, a low hemoglobin concentration at admission, and blood transfusion were risk factors for high hospitalization cost. Multivariate analysis revealed that rebleeding (OR 5.3; 95% CI 1.3-21.3; p = 0.017) and blood transfusion (OR 3.8; 95% CI 1.01-14.2; p = 0.048) were definite risk factors for high hospitalization cost. Rebleeding and blood transfusion were related to high hospitalization cost for colonic diverticular bleeding. © 2017 S. Karger AG, Basel.

Late pubertal growth spurt in a girl with growth hormone deficiency: Is Kaufmann therapy effective in a girl with short stature who responds poorly to growth hormone therapy and estrogen-replacement therapy?

PubMed

Yasuda, Katsuhiko

2017-05-01

A Japanese senior high school girl aged 18 years and 5 months with growth hormone deficiency was referred for primary amenorrhea. Her height was 1.36 m, and her bodyweight was 23.5 kg. She had received daily growth hormone therapy from the age of 5 years. Growth hormone therapy was discontinued at the age of 16 years and 11 months, and estrogen-replacement therapy (ERT) was started to stimulate secondary sexual characteristics. Although ERT was performed until the age of 18 years and 11 months, genital bleeding did not occur. ERT was changed to Kaufmann therapy, and the first genital bleeding occurred 1 year and 4 months later. Finally, regular medically induced menses occurred at the age of 21 years and 10 months. Her height increased by 9 cm in 1 year after the initiation of menstrual bleeding. Kaufmann therapy was associated not only with menstrual bleeding but also with growth spurt. © 2017 Japan Society of Obstetrics and Gynecology.

Control of traumatic wound bleeding by compression with a compact elastic adhesive dressing.

PubMed

Naimer, Sody Abby; Tanami, Menachem; Malichi, Avishai; Moryosef, David

2006-07-01

Compression dressing has been assumed effective, but never formally examined in the field. A prospective interventional trial examined efficacy and feasibility of an elastic adhesive dressing compression device in the arena of the traumatic incident. The primary variable examined was the bleeding rate from wounds compared before and after dressing. Sixty-two consecutive bleeding wounds resulting from penetrating trauma were treated. Bleeding intensity was profuse in 58%, moderate 23%, and mild in 19%. Full control of bleeding was achieved in 87%, a significantly diminished rate in 11%, and, in 1 case, the technique had no influence on the bleeding rate. The Wilcoxon test for variables comparing bleeding rates before and after the procedure obtained significant difference (Z = -6.9, p < 0.01). No significant complications were observed. Caregivers were highly satisfied in 90% of cases. Elastic adhesive dressing was observed as an effective and reliable technique, demonstrating a high rate of success without complications.

Secondary flow and heat transfer control in gas turbine inlet nozzle guide vanes

NASA Astrophysics Data System (ADS)

Burd, Steven Wayne

1998-12-01

Endwall heat transfer is a very serious problem in the inlet nozzle guide vane region of gas turbine engines. To resolve heat transfer concerns and provide the desired thermal protection, modern cooling flows for the vane endwalls tend to be excessive leading to lossy and inefficient designs. Coolant introduction is further complicated by the flow patterns along vane endwall surfaces. They are three-dimensional and dominated by strong, complex secondary flows. To achieve performance goals for next-generation engines, more aerodynamically efficient and advanced cooling concepts, including combustor bleed cooling, must be investigated. To this end, the overall performance characteristics of several combustor bleed flow designs are assessed in this experimental study. In particular, their contributions toward secondary flow control and component cooling are documented. Testing is performed in a large-scale, guide vane simulator comprised of three airfoils encased between one contoured and one flat endwall. Core flow is supplied to this simulator at an inlet chord Reynolds number of 350,000 and turbulence intensity of 9.5%. Combustor bleed cooling flow is injected through the contoured endwall via inclined slots. The slots vary in cross-sectional area, have equivalent slot widths, and are positioned with their leeward edges 10% of the axial chord ahead of the airfoil leading edges. Measurements with hot-wire anemometry characterize the inlet and exit flow fields of the cascade. Total and static pressure measurements document aerodynamic performance. Thermocouple measurements detail thermal fields and permit evaluation of surface adiabatic effectiveness. To elucidate the effects of bleed injection, data are compared to an experiment taken without bleed. The influence of bleed mass flow rate and slot geometry on the aerodynamic losses and thermal protection arc given. This study suggests that such combustor bleed flow cooling offers significant thermal protection without imposing aerodynamic penalties. Such performance is contrary to the performance of present vane cooling schemes. The results of this investigation support designs which incorporate combustor coolant injection upstream of the airfoil leading edges. To complement, a short exploratory study regarding the effects of surface roughness was also performed. Results indicate modified cooling performance and significantly higher aerodynamic losses with rough surfaces.

Pelvic radiation disease: Updates on treatment options

PubMed Central

Frazzoni, Leonardo; La Marca, Marina; Guido, Alessandra; Morganti, Alessio Giuseppe; Bazzoli, Franco; Fuccio, Lorenzo

2015-01-01

Pelvic cancers are among the most frequently diagnosed neoplasms and radiotherapy represents one of the main treatment options. The irradiation field usually encompasses healthy intestinal tissue, especially of distal large bowel, thus inducing gastrointestinal (GI) radiation-induced toxicity. Indeed, up to half of radiation-treated patients say that their quality of life is affected by GI symptoms (e.g., rectal bleeding, diarrhoea). The constellation of GI symptoms - from transient to long-term, from mild to very severe - experienced by patients who underwent radiation treatment for a pelvic tumor have been comprised in the definition of pelvic radiation disease (PRD). A correct and evidence-based therapeutic approach of patients experiencing GI radiation-induced toxicity is mandatory. Therapeutic non-surgical strategies for PRD can be summarized in two broad categories, i.e., medical and endoscopic. Of note, most of the studies have investigated the management of radiation-induced rectal bleeding. Patients with clinically significant bleeding (i.e., causing chronic anemia) should firstly be considered for medical management (i.e., sucralfate enemas, metronidazole and hyperbaric oxygen); in case of failure, endoscopic treatment should be implemented. This latter should be considered the first choice in case of acute, transfusion requiring, bleeding. More well-performed, high quality studies should be performed, especially the role of medical treatments should be better investigated as well as the comparative studies between endoscopic and hyperbaric oxygen treatments. PMID:26677440

Gastrointestinal Bleeding.

PubMed

Nable, Jose V; Graham, Autumn C

2016-05-01

Acute gastrointestinal bleeding is a commonly encountered chief complaint with a high morbidity and mortality. The emergency physician is challenged with prompt diagnosis, accurate risk assessment, and appropriate resuscitation of patients with gastrointestinal bleeding. Goals of care aim to prevent end-organ injury, manage comorbid illnesses, identify the source of bleeding, stop continued bleeding, support oxygen carrying capacity, and prevent rebleeding. This article reviews current strategies for risk stratification, diagnostic modalities, localization of bleeding, transfusion strategies, adjunct therapies, and reversal of anticoagulation. Copyright © 2016 Elsevier Inc. All rights reserved.

Ileal Varices Treated with Balloon-Occluded Retrograde Transvenous Obliteration

PubMed Central

Sato, Takahiro; Yamazaki, Katsu; Toyota, Jouji; Karino, Yoshiyasu; Ohmura, Takumi; Akaike, Jun

2009-01-01

A 55-year-old man with hepatitis B virus antigen-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed blood retention in the entire colon, but no bleeding lesion was found. Computed tomography images showed that vessels in the ileum were connected to the right testicular vein, and we suspected ileal varices to be the most probable cause of bleeding. We immediately performed double balloon enteroscopy, but failed to find any site of bleeding owing to the difficulty of fiberscope insertion with sever adhesion. Using a balloon catheter during retrograde transvenous venography, we found ileal varices communicating with the right testicular vein (efferent vein) with the superior mesenteric vein branch as the afferent vein of these varices. We performed balloon occluded retrograde transvenous obliteration by way of the efferent vein of the varices and have detected no further bleeding in this patient one year after treatment. PMID:27956966

Ileal Varices Treated with Balloon-Occluded Retrograde Transvenous Obliteration.

PubMed

Sato, Takahiro; Yamazaki, Katsu; Toyota, Jouji; Karino, Yoshiyasu; Ohmura, Takumi; Akaike, Jun

2009-04-01

A 55-year-old man with hepatitis B virus antigen-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed blood retention in the entire colon, but no bleeding lesion was found. Computed tomography images showed that vessels in the ileum were connected to the right testicular vein, and we suspected ileal varices to be the most probable cause of bleeding. We immediately performed double balloon enteroscopy, but failed to find any site of bleeding owing to the difficulty of fiberscope insertion with sever adhesion. Using a balloon catheter during retrograde transvenous venography, we found ileal varices communicating with the right testicular vein (efferent vein) with the superior mesenteric vein branch as the afferent vein of these varices. We performed balloon occluded retrograde transvenous obliteration by way of the efferent vein of the varices and have detected no further bleeding in this patient one year after treatment.

A Source-Term Based Boundary Layer Bleed/Effusion Model for Passive Shock Control

NASA Technical Reports Server (NTRS)

Baurle, Robert A.; Norris, Andrew T.

2011-01-01

A modeling framework for boundary layer effusion has been developed based on the use of source (or sink) terms instead of the usual practice of specifying bleed directly as a boundary condition. This framework allows the surface boundary condition (i.e. isothermal wall, adiabatic wall, slip wall, etc.) to remain unaltered in the presence of bleed. This approach also lends itself to easily permit the addition of empirical models for second order effects that are not easily accounted for by simply defining effective transpiration values. Two effusion models formulated for supersonic flows have been implemented into this framework; the Doerffer/Bohning law and the Slater formulation. These models were applied to unit problems that contain key aspects of the flow physics applicable to bleed systems designed for hypersonic air-breathing propulsion systems. The ability of each model to predict bulk bleed properties was assessed, as well as the response of the boundary layer as it passes through and downstream of a porous bleed system. The model assessment was performed with and without the presence of shock waves. Three-dimensional CFD simulations that included the geometric details of the porous plate bleed systems were also carried out to supplement the experimental data, and provide additional insights into the bleed flow physics. Overall, both bleed formulations fared well for the tests performed in this study. However, the sample of test problems considered in this effort was not large enough to permit a comprehensive validation of the models.

Zero adjusted models with applications to analysing helminths count data.

PubMed

Chipeta, Michael G; Ngwira, Bagrey M; Simoonga, Christopher; Kazembe, Lawrence N

2014-11-27

It is common in public health and epidemiology that the outcome of interest is counts of events occurrence. Analysing these data using classical linear models is mostly inappropriate, even after transformation of outcome variables due to overdispersion. Zero-adjusted mixture count models such as zero-inflated and hurdle count models are applied to count data when over-dispersion and excess zeros exist. Main objective of the current paper is to apply such models to analyse risk factors associated with human helminths (S. haematobium) particularly in a case where there's a high proportion of zero counts. The data were collected during a community-based randomised control trial assessing the impact of mass drug administration (MDA) with praziquantel in Malawi, and a school-based cross sectional epidemiology survey in Zambia. Count data models including traditional (Poisson and negative binomial) models, zero modified models (zero inflated Poisson and zero inflated negative binomial) and hurdle models (Poisson logit hurdle and negative binomial logit hurdle) were fitted and compared. Using Akaike information criteria (AIC), the negative binomial logit hurdle (NBLH) and zero inflated negative binomial (ZINB) showed best performance in both datasets. With regards to zero count capturing, these models performed better than other models. This paper showed that zero modified NBLH and ZINB models are more appropriate methods for the analysis of data with excess zeros. The choice between the hurdle and zero-inflated models should be based on the aim and endpoints of the study.

Hypertonic saline-epinephrine local injection therapy for post-endoscopic sphincterotomy bleeding: removal of blood clots using pure ethanol local injection.

PubMed

Sakai, Yuji; Tsuyuguchi, Toshio; Sugiyama, Harutoshi; Nishikawa, Takao; Kurosawa, Jo; Saito, Masayoshi; Tawada, Katsunobu; Mikata, Rintaro; Tada, Motohisa; Ishihara, Takeshi; Yokosuka, Osamu

2013-08-01

Bleeding following endoscopic sphincterotomy (EST) is a rare but unavoidable complication of the procedure. We routinely perform local injection of hypertonic saline-epinephrine (HSE) for the treatment of post-EST bleeding. Any blood clot is removed only by irrigation with water after local injection of pure ethanol into the blood clot to cause crusting. We evaluated the usefulness of this treatment method. Subjects were 8 patients (1.2%) with post-EST bleeding requiring hemostatic intervention among 682 patients undergoing EST. After determination of the bleeding point, local injection of HSE was performed. When an adherent blood clot was present, pure ethanol was injected into the blood clot and then irrigation with water was performed to remove the blood clot. Endoscopic hemostasis was successfully achieved in all the 8 patients (100%). In 4 patients (50%), the adherent blood clots were successfully removed only with pure ethanol local injection into the blood clot followed by irrigation with water. No complications of the hemostatic procedure occurred in any patients. This study indicated that hemostasis with HSE local injection can be safe and useful for the treatment of post-EST bleeding, and also that blood clot removal with pure ethanol local injection can be useful.

Prevalence of upper gastrointestinal bleeding risk factors among the general population and osteoarthritis patients.

PubMed

Kim, Sang Hyuck; Yun, Jae Moon; Chang, Chong Bum; Piao, Heng; Yu, Su Jong; Shin, Dong Wook

2016-12-28

To assess the prevalence of possible risk factors of upper gastrointestinal bleeding (UGIB) and their age-group specific trend among the general population and osteoarthritis patients. We utilized data from the National Health Insurance Service that included claims data and results of the national health check-up program. Comorbid conditions (peptic ulcer, diabetes, liver disease, chronic renal failure, and gastroesophageal reflux disease), concomitant drugs (aspirin, clopidogrel, cilostazol, non-steroidal anti-inflammatory drugs, steroid, anticoagulants, and SSRI), personal habits (smoking, and alcohol consumption) were considered as possible UGIB risk factors. We randomly imputed the prevalence of infection in the data considering the age-specific prevalence of Helicobacter pylori ( H. pylori ) infection in Korea. The prevalence of various UGIB risk factors and the age-group specific trend of the prevalence were identified. Prevalence was compared between osteoarthritis patients and others. A total of 801926 subjects (93855 osteoarthritis patients) aged 20 and above were included. The prevalence of individual and concurrent multiple risk factors became higher as the age increased. The prevalence of each comorbid condition and concomitant drug were higher in osteoarthritis patients. Thirty-five point zero two percent of the overall population and 68.50% of osteoarthritis patients had at least one or more risk factors of UGIB. The prevalence of individual and concurrent multiple risk factors in younger age groups were also substantial. Furthermore, when personal habits (smoking, and alcohol consumption) and H. pylori infection were included, the prevalence of concurrent multiple risk factors increased greatly even in younger age groups. Prevalence of UGIB risk factors was high in elderly population, but was also considerable in younger population. Patient with osteoarthritis was at higher UGIB risk than those without osteoarthritis. Physicians should consider individualized risk assessment regardless of age when prescribing drugs or performing procedures that may increase the risk of UGIB, and take necessary measures to reduce modifiable risk factors such as H. pylori eradication or lifestyle counseling.

[Comparison of clinical effects between anterior cervical Zero-incision fusion system and traditional nail plate system in the treatment of cervical spondylotic myelopathy].

PubMed

Chang, Bu-Qing; Feng, Hu; Yu, Chao-Jiang; Huang, Kai; Gao, Xiao; Tang, Hao; Jiang, Yun-Chang

2017-05-25

To compare the short-term efficacy of anterior cervical discectomy and fusion(ACDF) with traditional nail plate system and Zero-profile device in the treatment of cervical spondylotic myelopathy(CSM). The clinical data of 45 patients with CSM treated from July 2014 to August 2015 was retrospectively analyzed. There were 23 males and 22 females with an average age of 53.7 years old(range, 32 to 71 years old). The course of disease was 5 months to 2 years. All the patients were treated with ACDF with 24 cases by traditional nail plate system fixation(group A) and 21 cases by Zero-P system fixation(group B). Operation time and intraoperative bleeding were compared between two groups. Neurological function and cervical pain were evaluated by Japanese Orthopaedic Association scores (JOA) and visual analogue scale (VAS), respectively. Cervical curvature(Cobb angle) change and intervertebral fusion were evaluated by X-rays and CT. And associated complications were analyzed in two groups. All the patients were followed up for 12 to 16 months with an average of 14 months. Operation time of group A and B was(87.6±23.2) min and (62.7±17.3) min respectively, and the difference was significant between two groups; and intraoperative bleeding was (80.2±36.8) ml and (78.4±29.6) ml respectively, and the difference was not significant. At final follow-up, JOA and VAS of all patients were obvious improved, but there was no significant difference between two groups. Preoperative Cobb angle in group A and B was (8.7±4.3) ° and (8.6±4.2) ° respectively, and the difference was significant. The Cobb angle at final follow-up was (14.5±6.4) ° and (17.4±8.6) ° respectively, and the difference between two groups was significant. The incidence of dysphagia in group A and B were 29.17% and 9.52% respectively, and there was significant difference between two groups. All intervertebral spaces got fusion at final follow-up. No tracheo-asophageal injury and recurrent laryngeal nerve damage or other complications were found. No fusional migration, subsidence, loosening, breakage, etc. were found. The clinical comparison of Zero-P interbody fixation system and cervical plate internal fixation for the treatment of cervical spondylosis was quite fair, but Zero-P showed a better therapeutic effect with improvement of life quality.

Optimal timing for performing hysterectomy according to different phase of menstrual cycle: Which is best?

PubMed

Kim, Jeong Jin; Kang, Jun Hyeok; Lee, Kyo Won; Kim, Kye Hyun; Song, Taejong

2017-05-01

The aim of this study was to determine whether the different phases of the menstrual cycle could affect operative bleeding in women undergoing laparoscopic hysterectomy. This was a retrospective comparative study. Based on the adjusted day of menstrual cycle, 212 women who underwent laparoscopic hysterectomy were classified into three groups: the follicular phase (n = 51), luteal phase group (n = 125), and menstruation group (n = 36). The primary outcome measure was the operative bleeding. There was no difference in the baseline characteristics of the patients belonging to the three groups. For the groups, there were no significant differences in operative bleeding (p = .469) and change in haemoglobin (p = .330), including operative time, length of hospital stay and complications. The menstrual cycle did not affect the operative bleeding and other parameters. Therefore, no phase of the menstrual cycle could be considered as an optimal timing for performing laparoscopic hysterectomy with minimal operative bleeding. Impact statement What is already known on this subject: the menstrual cycle results in periodic changes in haemostasis and blood flow in the reproductive organs. What the results of this study add: the menstrual cycle did not affect the operative bleeding and other operative parameters during laparoscopic hysterectomy. What the implications are of these findings for clinical practice and/or further research: no phase of the menstrual cycle could be considered as an optimal timing for performing laparoscopic hysterectomy with minimal operative bleeding.

Bleeding Risk Profile in Patients With Symptomatic Peripheral Artery Disease.

PubMed

Baumann, Frederic; Husmann, Marc; Benenati, James F; Katzen, Barry T; Del Conde, Ian

2016-06-01

To assess the bleeding risk profile using the HAS-BLED score in patients with symptomatic peripheral artery disease (PAD). A post hoc analysis was performed using data from a series of 115 consecutive patients (mean age 72.4±11.4 years; 68 men) with symptomatic PAD undergoing endovascular revascularization. The endpoint of the study was to assess bleeding risk using the 9-point HAS-BLED score, which was previously validated in cohorts of patients with and without atrial fibrillation. For the purpose of this study, the low (0-1), intermediate (2), and high-risk (≥3) scores were stratified as low/intermediate risk (HAS-BLED <3) vs high risk (HAS-BLED ≥3). The mean HAS-BLED score was 2.76±1.16; 64 (56%) patients had a HAS-BLED score ≥3.0. Patients with PAD Rutherford category 5/6 ischemia had an even higher mean HAS-BLED score (3.20±1.12). Logistic regression analysis revealed aortoiliac or femoropopliteal segment involvement, chronic kidney disease, as well as Rutherford category 5/6, to be independent risk factors associated with a HAS-BLED score ≥3. Patients with PAD, especially those presenting with Rutherford category 5/6 ischemic symptoms, have high HAS-BLED scores, suggesting increased risk for major bleeding. Prospective clinical validation of the HAS-BLED score in patients with PAD may help with the risk-benefit assessment when prescribing antithrombotic therapy. © The Author(s) 2016.

Intermittent pneumatic compression to prevent venous thromboembolism in patients with high risk of bleeding hospitalized in intensive care units: the CIREA1 randomized trial.

PubMed

Vignon, Philippe; Dequin, Pierre-François; Renault, Anne; Mathonnet, Armelle; Paleiron, Nicolas; Imbert, Audrey; Chatellier, Delphine; Gissot, Valérie; Lhéritier, Gwenaelle; Aboyans, Victor; Prat, Gwenael; Garot, Denis; Boulain, Thierry; Diehl, Jean-Luc; Bressollette, Luc; Delluc, Aurélien; Lacut, Karine

2013-05-01

Venous thromboembolism (VTE) is a frequent and serious problem in intensive care units (ICU). Anticoagulant treatments have demonstrated their efficacy in preventing VTE. However, when the bleeding risk is high, they are contraindicated, and mechanical devices are recommended. To date, mechanical prophylaxis has not been rigorously evaluated in any trials in ICU patients. In this multicenter, open-label, randomized trial with blinded evaluation of endpoints, we randomly assigned 407 patients with a high risk of bleeding to receive intermittent pneumatic compression (IPC) associated with graduated compression stockings (GCS) or GCS alone for 6 days during their ICU stay. The primary endpoint was the occurrence of a VTE between days 1 and 6, including nonfatal symptomatic documented VTE, or death due to a pulmonary embolism, or asymptomatic deep vein thrombosis detected by ultrasonography systematically performed on day 6. The primary outcome was assessed in 363 patients (89.2%). By day 6, the incidence of the primary outcome was 5.6% (10 of 179 patients) in the IPC + GCS group and 9.2% (17 of 184 patients) in the GCS group (relative risk 0.60; 95% confidence interval 0.28-1.28; p = 0.19). Tolerance of IPC was poor in only 12 patients (6.0%). No intergroup difference in mortality rate was observed. With the limitation of a low statistical power, our results do not support the superiority of the combination of IPC + GCS compared to GCS alone to prevent VTE in ICU patients at high risk of bleeding.

Zero-block mode decision algorithm for H.264/AVC.

PubMed

Lee, Yu-Ming; Lin, Yinyi

2009-03-01

In the previous paper , we proposed a zero-block intermode decision algorithm for H.264 video coding based upon the number of zero-blocks of 4 x 4 DCT coefficients between the current macroblock and the co-located macroblock. The proposed algorithm can achieve significant improvement in computation, but the computation performance is limited for high bit-rate coding. To improve computation efficiency, in this paper, we suggest an enhanced zero-block decision algorithm, which uses an early zero-block detection method to compute the number of zero-blocks instead of direct DCT and quantization (DCT/Q) calculation and incorporates two adequate decision methods into semi-stationary and nonstationary regions of a video sequence. In addition, the zero-block decision algorithm is also applied to the intramode prediction in the P frame. The enhanced zero-block decision algorithm brings out a reduction of average 27% of total encoding time compared to the zero-block decision algorithm.

Incidence of Gastrointestinal Bleeding After Percutaneous Coronary Intervention: A Single Center Experience.

PubMed

Aziz, Fahad

2014-02-01

Gastrointestinal (GI) bleeding is a hemorrhagic complication after percutaneous coronary intervention in patients with acute myocardial infarction. The purpose of the study is to determine predictors of GI bleeding and impact of GI bleeding on the patients undergoing percutaneous coronary intervention. GI bleeding occurred in 6 (7.1%) of 84 patients with STEMI/NSETMI (ST-segment elevated myocardial infarction/Non ST-segment elevated myocardial infarction) undergoing primary percutaneous coronary intervention. Univariate analysis demonstrates that patients with GI bleeding had a significantly higher previous GI bleeding (16.66% vs. 8.6%, P < 0.001). Higher Killip classification at presentation was associated with higher incidence of GI bleeding (61% vs. 18%, P < 0.01). The use of proton pump inhibitors did not reduce the risk of GI bleeding. The GI bleeding in these patients was associated with higher mortality and morbidity in the post percutaneous coronary intervention period. Although, GI bleeding in patients with MI significantly increases mortality and morbidity, previous GI bleeding and higher Killip class are associated with higher incidence of GI bleeding. High-risk patients for GI bleeding can be identified at presentation.

Frequency and prognostic significance of access site and non-access site bleeding and impact of choice of antithrombin therapy in patients undergoing primary percutaneous coronary intervention. The EUROMAX trial.

PubMed

Kilic, Sinem; Van't Hof, Arnoud W J; Ten Berg, Jurrien; Lopez, Ana Ayesta; Zeymer, Uwe; Hamon, Martial; Soulat, Louis; Bernstein, Debra; Deliargyris, Efthymios N; Steg, Phillippe Gabriel

2016-05-15

The overall impact of post percutaneous coronary intervention (PCI) bleeding on long term prognosis after acute coronary syndromes (ACS) has been established, but it may differ between access and non-access related bleeding events. The impact of antithrombin choice on bleeding may also differ according to the origin of the bleed. We sought to determine the origin of bleeding relative to the access site, its prognostic significance and the respective impact of antithrombin therapy in the EUROMAX trial. We performed a blinded review of the case records of all TIMI major or minor bleeds in the EUROMAX trial and assigned them in one of 2 categories: access site bleeds (ASB), or rest of bleeds (ROB). Incidence of bleeding for each category was assessed according to randomization to antithrombotic treatment. A total of 231 out of 2198 patients suffered a TIMI major/minor bleed (10.5%) and ASB accounted for 48.5%, while ROB for 51.5% of the bleeds. Thirty day mortality was 2.5% (50/1967) for patients without a bleed, 2.7% (3/112, p=0.76 vs. no bleed) for patients with ASB, and 10.9% (13/119, p<0.0001 vs. no bleed) for ROB patients. The use of bivalirudin reduced both ASB and ROB with relative risk reductions of 34% and 46% respectively. In contemporary primary PCI, bleeding originates with equal frequency either at or away from the access site. Access site bleeds were not associated with an excess in 30day mortality, but the rest of the bleeds were. Bivalirudin is associated with a lower risk of bleeding irrespective of origin. ClinicalTrials.gov identifier NCT01087723. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Transcatheter arterial embolisation in upper gastrointestinal bleeding in a sample of 29 patients in a gastrointestinal referral center in Germany.

PubMed

Heining-Kruz, S; Finkenzeller, T; Schreyer, A; Dietl, K H; Kullmann, F; Paetzel, C; Schedel, J

2015-09-01

This is a retrospective analysis of interventional embolisation performed with catheter angiography in 29 patients with upper gastrointestinal bleeding in the setting of a secondary care hospital. From April 2007 to February 2013, 29 patients with upper gastrointestinal bleeding underwent endovascular diagnostics and treatment. The diagnosis was established by endoscopy, computed tomography or clinically based on a significant decrease in hemoglobin. Transcatheter arterial embolisation was performed with coils, liquid embolic agents, and particles. The technical and clinical outcomes were assessed by postinterventional endoscopy, hemoglobin concentrations, number of necessary transfusions, or surgical interventions, as well as by post-interventional mortality within 28 days after the procedure. Selective angiographic embolisation in upper gastrointestinal bleeding was primarily successful technically and clinically in 22 of 29 patients. In 4/29 cases an angiographic reintervention was performed, which was successful in 3 cases. In 3 cases of primarily technically unsuccessful procedures reintervention was not attempted. No catheterisation-related complications were recorded. Peri-interventional mortality was 31%, but only 2 of these patients died due to uncontrolled massive bleeding, whereas the lethal outcome in the other 7 patients was due to their underlying diseases. Transcatheter arterial embolisation is an effective and rapid method in the management of upper gastrointestinal bleeding. Radiological endovascular interventions may considerably contribute to reduced mortality in GI bleeding by avoiding a potential surgical procedure following unsuccessful endoscopic treatment. The study underlines the importance of the combination of interventional endoscopy with interventional radiology in secondary care hospitals for patient outcome in complex and complicated upper gastrointestinal bleeding situations. © Georg Thieme Verlag KG Stuttgart · New York.

Effect of nabumetone and aspirin on colonic mucosal bleeding time.

PubMed

Basson, M D; Panzini, L; Palmer, R H

2001-04-01

The management of patients taking aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) who require colonoscopy remains controversial because of concerns over bleeding after biopsy or polypectomy. To determine whether patients using the NSAID nabumetone, a non-acidic prodrug with mixed activity against cyclooxygenase-1 (COX-1) and COX-2, exhibited prolonged mucosal bleeding times and how this might compare with mucosal bleeding times in patients using aspirin. We assessed triplicate mucosal bleeding times in patients undergoing screening flexible sigmoidoscopy. We compared 90 patients who had taken no aspirin or NSAIDs within the previous 2 weeks, to 60 patients who had received nabumetone 1 g b.d. by mouth for the previous 2 weeks, and 30 patients who had taken 325 mg aspirin daily for the previous 2 weeks. In each case, the investigator performing the study was blinded to the patient's medication. Mucosal bleeding times did not differ significantly among control or nabumetone-using patients. However, the patients receiving aspirin exhibited significant prolongation. Mucosal bleeding time correlated statistically significantly, but weakly, with skin bleeding time. Nabumetone does not appear to prolong mucosal bleeding time after mucosal pinch biopsy, and skin bleeding time does not reliably screen for prolonged mucosal bleeding time.

Risk of bleeding with dabigatran in atrial fibrillation.

PubMed

Hernandez, Inmaculada; Baik, Seo Hyon; Piñera, Antonio; Zhang, Yuting

2015-01-01

It remains unclear whether dabigatran etexilate mesylate is associated with higher risk of bleeding than warfarin sodium in real-world clinical practice. To compare the risk of bleeding associated with dabigatran and warfarin using Medicare data. In this retrospective cohort study, we used pharmacy and medical claims in 2010 to 2011 from a 5% random sample of Medicare beneficiaries. We identified participants as those newly diagnosed as having atrial fibrillation from October 1, 2010, through October 31, 2011, and who initiated dabigatran or warfarin treatment within 60 days of initial diagnosis. We followed up patients until discontinued use or switch of anticoagulants, death, or December 31, 2011. Dabigatran users (n = 1302) and warfarin users (n = 8102). We identified any bleeding events and categorized them as major and minor bleeding by anatomical site. Major bleeding events included intracranial hemorrhage, hemoperitoneum, and inpatient or emergency department stays for hematuria, gastrointestinal, or other hemorrhage. We used a propensity score weighting mechanism to balance patient characteristics between 2 groups and Cox proportional hazards regression models to evaluate the risk of bleeding. We further examined the risk of bleeding for 4 subgroups of high-risk patients: those 75 years or older, African Americans, those with chronic kidney disease, and those with more than 7 concomitant comorbidities. Dabigatran was associated with a higher risk of bleeding relative to warfarin, with hazard ratios of 1.30 (95% CI, 1.20-1.41) for any bleeding event, 1.58 (95% CI, 1.36-1.83) for major bleeding, and 1.85 (95% CI, 1.64-2.07) for gastrointestinal bleeding. The risk of intracranial hemorrhage was higher among warfarin users, with a hazard ratio of 0.32 (95% CI, 0.20-0.50) for dabigatran compared with warfarin. Dabigatran was consistently associated with an increased risk of major bleeding and gastrointestinal hemorrhage for all subgroups analyzed. The risk of major bleeding among dabigatran users was especially high for African Americans and patients with chronic kidney disease. Dabigatran was associated with a higher incidence of major bleeding (regardless of the anatomical site), a higher risk of gastrointestinal bleeding, but a lower risk of intracranial hemorrhage. Thus, dabigatran should be prescribed with caution, especially among high-risk patients.

Automated Analysis of Vital Signs Identified Patients with Substantial Bleeding Prior to Hospital Arrival

DTIC Science & Technology

2015-10-01

Flight (MHLF; Houston, TX) by Cooke et al. [4] and Holcomb et al. [5]. In both datasets, we analyzed all subjects with at least one recorded non-zero...4] W. H. Cooke , J. Salinas, V. A. Convertino, D. A. Ludwig, D. Hinds, J. H. Duke, F. A. Moore, and J. B. Holcomb, "Heart rate variability and its...McManus, C. C. Miller, W. H. Cooke , and V. A. Convertino, "Manual vital signs reliably predict need for life-saving interventions in trauma patients

Pantoprazole for the treatment of peptic ulcer bleeding and prevention of rebleeding.

PubMed

van Rensburg, Christo J; Cheer, Susan

2012-01-01

Adding proton pump inhibitors (PPIs) to endoscopic therapy has become the mainstay of treatment for peptic ulcer bleeding, with current consensus guidelines recommending high-dose intravenous (IV) PPI therapy (IV bolus followed by continuous therapy). However, whether or not high-dose PPI therapy is more effective than low-dose PPI therapy is still debated. Furthermore, maintaining pH ≥ 4 appears to prevent mucosal bleeding in patients with acute stress ulcers; thus, stress ulcer prophylaxis with acid-suppressing therapy has been increasingly recommended in intensive care units (ICUs). This review evaluates the evidence for the efficacy of IV pantoprazole, a PPI, in preventing ulcer rebleeding after endoscopic hemostasis, and in controlling gastric pH and protecting against upper gastrointestinal (GI) bleeding in high-risk ICU patients. The review concludes that IV pantoprazole provides an effective option in the treatment of upper GI bleeding, the prevention of rebleeding, and for the prophylaxis of acute bleeding stress ulcers.

Pantoprazole for the Treatment of Peptic Ulcer Bleeding and Prevention of Rebleeding

PubMed Central

van Rensburg, Christo J.; Cheer, Susan

2012-01-01

Adding proton pump inhibitors (PPIs) to endoscopic therapy has become the mainstay of treatment for peptic ulcer bleeding, with current consensus guidelines recommending high-dose intravenous (IV) PPI therapy (IV bolus followed by continuous therapy). However, whether or not high-dose PPI therapy is more effective than low-dose PPI therapy is still debated. Furthermore, maintaining pH ≥ 4 appears to prevent mucosal bleeding in patients with acute stress ulcers; thus, stress ulcer prophylaxis with acid-suppressing therapy has been increasingly recommended in intensive care units (ICUs). This review evaluates the evidence for the efficacy of IV pantoprazole, a PPI, in preventing ulcer rebleeding after endoscopic hemostasis, and in controlling gastric pH and protecting against upper gastrointestinal (GI) bleeding in high-risk ICU patients. The review concludes that IV pantoprazole provides an effective option in the treatment of upper GI bleeding, the prevention of rebleeding, and for the prophylaxis of acute bleeding stress ulcers. PMID:24833934

Standardizing a simpler, more sensitive and accurate tail bleeding assay in mice

PubMed Central

Liu, Yang; Jennings, Nicole L; Dart, Anthony M; Du, Xiao-Jun

2012-01-01

AIM: To optimize the experimental protocols for a simple, sensitive and accurate bleeding assay. METHODS: Bleeding assay was performed in mice by tail tip amputation, immersing the tail in saline at 37 °C, continuously monitoring bleeding patterns and measuring bleeding volume from changes in the body weight. Sensitivity and extent of variation of bleeding time and bleeding volume were compared in mice treated with the P2Y receptor inhibitor prasugrel at various doses or in mice deficient of FcRγ, a signaling protein of the glycoprotein VI receptor. RESULTS: We described details of the bleeding assay with the aim of standardizing this commonly used assay. The bleeding assay detailed here was simple to operate and permitted continuous monitoring of bleeding pattern and detection of re-bleeding. We also reported a simple and accurate way of quantifying bleeding volume from changes in the body weight, which correlated well with chemical assay of hemoglobin levels (r2 = 0.990, P < 0.0001). We determined by tail bleeding assay the dose-effect relation of the anti-platelet drug prasugrel from 0.015 to 5 mg/kg. Our results showed that the correlation of bleeding time and volume was unsatisfactory and that compared with the bleeding time, bleeding volume was more sensitive in detecting a partial inhibition of platelet’s haemostatic activity (P < 0.01). Similarly, in mice with genetic disruption of FcRγ as a signaling molecule of P-selectin glycoprotein ligand-1 leading to platelet dysfunction, both increased bleeding volume and repeated bleeding pattern defined the phenotype of the knockout mice better than that of a prolonged bleeding time. CONCLUSION: Determination of bleeding pattern and bleeding volume, in addition to bleeding time, improved the sensitivity and accuracy of this assay, particularly when platelet function is partially inhibited. PMID:24520531

Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients.

PubMed

Richardson, Marlin Dustin; Palmeri, Nicholas O; Williams, Sarah A; Torok, Michelle R; O'Neill, Brent R; Handler, Michael H; Hankinson, Todd C

2016-01-01

OBJECT NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures. METHODS A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury. Variables associated with both the exposure and outcomes (p < 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated. RESULTS Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15-3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43-1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01-9.57), surgical procedure (OR 2.35; 95% CI 1.11-4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19-4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage. CONCLUSIONS Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.

The use of selective serotonin receptor inhibitors (SSRIs) is not associated with increased risk of endoscopy-refractory bleeding, rebleeding or mortality in peptic ulcer bleeding.

PubMed

Laursen, S B; Leontiadis, G I; Stanley, A J; Hallas, J; Schaffalitzky de Muckadell, O B

2017-08-01

Observational studies have consistently shown an increased risk of upper gastrointestinal bleeding in users of selective serotonin receptor inhibitors (SSRIs), probably explained by their inhibition of platelet aggregation. Therefore, treatment with SSRIs is often temporarily withheld in patients with peptic ulcer bleeding. However, abrupt discontinuation of SSRIs is associated with development of withdrawal symptoms in one-third of patients. Further data are needed to clarify whether treatment with SSRIs is associated with poor outcomes, which would support temporary discontinuation of treatment. To identify if treatment with SSRIs is associated with increased risk of: (1) endoscopy-refractory bleeding, (2) rebleeding or (3) 30-day mortality due to peptic ulcer bleeding. A nationwide cohort study. Analyses were performed on prospectively collected data on consecutive patients admitted to hospital with peptic ulcer bleeding in Denmark in the period 2006-2014. Logistic regression analyses were used to investigate the association between treatment with SSRIs and outcome following adjustment for pre-defined confounders. Sensitivity and subgroup analyses were performed to evaluate the validity of the findings. A total of 14 343 patients were included. Following adjustment, treatment with SSRIs was not associated with increased risk of endoscopy-refractory bleeding (odds ratio [OR] [95% Confidence Interval (CI)]: 1.03 [0.79-1.33]), rebleeding (OR [95% CI]: 0.96 [0.83-1.11]) or 30-day mortality (OR [95% CI]: 1.01 [0.85-1.19]. These findings were supported by sensitivity and subgroup analyses. According to our data, treatment with SSRIs does not influence the risk of endoscopy-refractory bleeding, rebleeding or 30-day mortality in peptic ulcer bleeding. © 2017 John Wiley & Sons Ltd.

Risks and benefits of clopidogrel-aspirin in minor stroke or TIA: Time course analysis of CHANCE.

PubMed

Pan, Yuesong; Jing, Jing; Chen, Weiqi; Meng, Xia; Li, Hao; Zhao, Xingquan; Liu, Liping; Wang, David; Johnston, S Claiborne; Wang, Yilong; Wang, Yongjun

2017-05-16

To investigate the short-term time course risks and benefits of clopidogrel with aspirin in minor ischemic stroke or TIA. Data were derived from the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial. The primary outcome was a new ischemic stroke. Safety outcomes included any bleeding and moderate to severe bleeding. Time course analyses were performed for the outcomes of both stroke and bleeding. A total of 145 (71.1%), 13 (6.4%), and 12 (5.9%) of 204 new ischemic strokes in the clopidogrel-aspirin group vs 223 (75.6%), 19 (6.4%), and 8 (2.7%) of 295 in the aspirin alone group occurred at the first, second, and third week, respectively. A total of 23 (38.3%), 15 (25.0%), and 9 (15.0%) of 60 bleeding cases in the clopidogrel-aspirin group vs 15 (36.6%), 8 (19.5%), and 3 (7.3%) of 41 in the aspirin alone group occurred at the first, second, and third week, respectively. Clopidogrel-aspirin treatment numerically reduced the risk of ischemic stroke within the first 2 weeks. From the 10th day, the number of any bleeding cases caused by dual antiplatelets outweighed that of new stroke reduced by dual antiplatelets. Clopidogrel-aspirin treatment may have a benefit of reducing stroke risk outweighing the potential risk of increased bleeding especially within the first 2 weeks compared with aspirin alone in patients with minor stroke or TIA. NCT00979589. This study provides Class II evidence that for patients with minor stroke or TIA, the reduction of stroke risk from clopidogrel plus aspirin within the first 2 weeks outweighs the risk of bleeding compared with aspirin alone. © 2017 American Academy of Neurology.

Bleeding 'downhill' esophageal varices associated with benign superior vena cava obstruction: case report and literature review.

PubMed

Loudin, Michael; Anderson, Sharon; Schlansky, Barry

2016-10-24

Proximal or 'downhill' esophageal varices are a rare cause of upper gastrointestinal hemorrhage. Unlike the much more common distal esophageal varices, which are most commonly a result of portal hypertension, downhill esophageal varices result from vascular obstruction of the superior vena cava (SVC). While SVC obstruction is most commonly secondary to malignant causes, our review of the literature suggests that benign causes of SVC obstruction are the most common cause actual bleeding from downhill varices. Given the alternative pathophysiology of downhill varices, they require a unique approach to management. Variceal band ligation may be used to temporize acute variceal bleeding, and should be applied on the proximal end of the varix. Relief of the underlying SVC obstruction is the cornerstone of definitive treatment of downhill varices. A young woman with a benign superior vena cava stenosis due to a tunneled internal jugular vein dialysis catheter presented with hematemesis and melena. Urgent upper endoscopy revealed multiple 'downhill' esophageal varices with stigmata of recent hemorrhage. As there was no active bleeding, no endoscopic intervention was performed. CT angiography demonstrated stenosis of the SVC surrounding the distal tip of her indwelling hemodialysis catheter. The patient underwent balloon angioplasty of the stenotic SVC segment with resolution of her bleeding and clinical stabilization. Downhill esophageal varices are a distinct entity from the more common distal esophageal varices. Endoscopic therapies have a role in temporizing active variceal bleeding, but relief of the underlying SVC obstruction is the cornerstone of treatment and should be pursued as rapidly as possible. It is unknown why benign, as opposed to malignant, causes of SVC obstruction result in bleeding from downhill varices at such a high rate, despite being a less common etiology of SVC obstruction.

Influence of high-risk esophageal varices on outcomes in hepatocellular carcinoma patients: benefits of prophylactic endoscopic therapies.

PubMed

Tamaoki, Masashi; Toshikuni, Nobuyuki; Matsueda, Kazuhiro; Yamamoto, Hiroshi

2012-01-01

To clarify whether high-risk esophageal varices (EVs) influence outcomes in hepatocellular carcinoma (HCC) patients and to determine whether prophylactic endoscopic therapies(PETs) provide benefits for such patients. Ninety-six consecutive patients with naive HCC complicated by EVs were analyzed. Patients with low-risk EVs (group A, n=53), those with high-risk EVs not treated with PETs (group B, n=31), and those with high-risk EVs treated with PETs (group C, n=12) were compared with respect to first bleeding and mortality. Furthermore, factors associated with outcomes were examined. The first bleeding rates were higher in group B than in group A; the survival rates were lower in group B than in group A. High-risk EVs and advanced stage HCC were risk factors for both outcomes in groups A and B. By contrast, the first bleeding rates tended to be lower in group C than in group B, while the survival rates did not significantly differ. In groups B and C, advanced stage HCC was a risk factor for both outcomes, whereas PETs significantly decreased first bleeding. High-risk EVs negatively influence both first bleeding and mortality in HCC patients and PETs may have a preventive effect on bleeding.

Emicizumab Prophylaxis in Hemophilia A with Inhibitors.

PubMed

Oldenburg, Johannes; Mahlangu, Johnny N; Kim, Benjamin; Schmitt, Christophe; Callaghan, Michael U; Young, Guy; Santagostino, Elena; Kruse-Jarres, Rebecca; Negrier, Claude; Kessler, Craig; Valente, Nancy; Asikanius, Elina; Levy, Gallia G; Windyga, Jerzy; Shima, Midori

2017-08-31

Emicizumab (ACE910) bridges activated factor IX and factor X to restore the function of activated factor VIII, which is deficient in persons with hemophilia A. This phase 3, multicenter trial assessed once-weekly subcutaneous emicizumab prophylaxis in persons with hemophilia A with factor VIII inhibitors. We enrolled participants who were 12 years of age or older. Those who had previously received episodic treatment with bypassing agents were randomly assigned in a 2:1 ratio to emicizumab prophylaxis (group A) or no prophylaxis (group B). The primary end point was the difference in bleeding rates between group A and group B. Participants who had previously received prophylactic treatment with bypassing agents received emicizumab prophylaxis in group C. A total of 109 male participants with hemophilia A with inhibitors were enrolled. The annualized bleeding rate was 2.9 events (95% confidence interval [CI], 1.7 to 5.0) among participants who were randomly assigned to emicizumab prophylaxis (group A, 35 participants) versus 23.3 events (95% CI, 12.3 to 43.9) among those assigned to no prophylaxis (group B, 18 participants), representing a significant difference of 87% in favor of emicizumab prophylaxis (P<0.001). A total of 22 participants in group A (63%) had zero bleeding events, as compared with 1 participant (6%) in group B. Among 24 participants in group C who had participated in a noninterventional study, emicizumab prophylaxis resulted in a bleeding rate that was significantly lower by 79% than the rate with previous bypassing-agent prophylaxis (P<0.001). Overall, 198 adverse events were reported in 103 participants receiving emicizumab prophylaxis; the most frequent events were injection-site reactions (in 15% of participants). Thrombotic microangiopathy and thrombosis were reported in 2 participants each (in the primary analysis) who had received multiple infusions of activated prothrombin complex concentrate for breakthrough bleeding. No antidrug antibodies were detected. Emicizumab prophylaxis was associated with a significantly lower rate of bleeding events than no prophylaxis among participants with hemophilia A with inhibitors. (Funded by F. Hoffmann-La Roche and Chugai Pharmaceutical; HAVEN 1 ClinicalTrials.gov number, NCT02622321 .).

An unexpected cause of vaginal bleeding: the role of pelvic radiography.

PubMed

Kyrgios, Ioannis; Emmanouilidou, Eleftheria; Theodoridis, Theodoros; Galli-Tsinopoulou, Assimina

2014-02-14

Vaginal bleeding and/or discharge in young girls may result from infection, urological problems, endocrine causes, bleeding disorders, dermatological conditions, trauma, sexual abuse, masses or foreign bodies. We report a case of excessive vaginal bleeding caused by a foreign body in a prepubertal girl with emphasis on the diagnostic challenges and pitfalls regarding imaging techniques. In our patient, although invasive and expensive investigations had been initially made, the foreign body was last detected only when a plain pelvic radiography was performed.

High-speed inlet research program and supporting analyses

NASA Technical Reports Server (NTRS)

Coltrin, Robert E.

1987-01-01

A Mach 5 cruise aircraft was studied in a joint program effort. The propulsion system chosen for this aircraft was an over-under turbojet/ramjet system. The ramjet portion of the inlet is to be tested in NASA Lewis' 10 x 10 SWT. Goals of the test program are to obtain performance data and bleed requirements, and also to obtain analysis code validation data. Supporting analysis of the inlet using a three-dimensional Navier-Stokes code (PEPSIS) indicates that sidewall shock/boundary layer interactions cause large separated regions in the corners underneath the cowl. Such separations generally lead to inlet unstart, and are thus a major concern. As a result of the analysis, additional bleed regions were added to the inlet model sidewalls and cowl to control separations in the corners. A two-dimensional analysis incorporating bleed on the ramp is also presented. Supporting experiments for the Mach 5 programs were conducted in the Lewis' 1 x 1 SWT. A small-scale model representing the inlet geometry up to the ramp shoulder and cowl lip was tested to verify the accelerator plate test technique and to obtain data on flow migration in the ramp and sidewall boundary layers. Another study explored several ramp bleed configurations to control boundary layer separations in that region. Design of a two-dimensional Mach 5 cruise inlet represents several major challenges including multimode operation and dual flow, high temperatures, and three-dimensional airflow effects.

Bleeding complications and mortality in warfarin-treated VTE patients, dependence of INR variability and iTTR.

PubMed

Sandén, Per; Renlund, Henrik; Svensson, Peter J; Själander, Anders

2017-01-05

High quality of warfarin treatment is important to prevent recurrence of venous thromboembolism (VTE) without bleeding complications. The aim of this study was to examine the effect of individual time in therapeutic range (iTTR) and International Normalised Ratio (INR) variability on bleeding risk and mortality in a large cohort of well-managed patients with warfarin due to VTE. A cohort of 16612 patients corresponding to 19502 treatment periods with warfarin due to VTE between January 1, 2006 and December 31, 2011 was retrieved from the Swedish national quality register AuriculA and matched with the Swedish National Patient Register for bleeding complications and background characteristics and the Cause of death register for occurrence and date of death. The rate of bleeding was 1.79 (confidence interval (CI) 95 % 1.66-1.93) per 100 treatment years among all patients. Those with poor warfarin treatment quality had a higher rate of clinically relevant bleeding, both when measured as iTTR below 70 %, 2.91 (CI 95 % 2.61-3.21) or as INR variability over the mean value 0.85, 2.61 (CI 95 % 2.36-2.86). Among those with both high INR variability and low iTTR the risk of clinically relevant bleeding was clearly increased hazard ratio (HR) 3.47 (CI 95 % 2.89-4.17). A similar result was found for all-cause mortality with a HR of 3.67 (CI 95 % 3.02-4.47). Both a low iTTR and a high INR variability increase the risk of bleeding complications or mortality. When combining the two treatment quality indicators patients at particular high risk of bleeding or death can be identified.

Prediction of SFL Interruption Performance from the Results of Arc Simulation during High-Current Phase

NASA Astrophysics Data System (ADS)

Lee, Jong-Chul; Lee, Won-Ho; Kim, Woun-Jea

2015-09-01

The design and development procedures of SF6 gas circuit breakers are still largely based on trial and error through testing although the development costs go higher every year. The computation cannot cover the testing satisfactorily because all the real processes arc not taken into account. But the knowledge of the arc behavior and the prediction of the thermal-flow inside the interrupters by numerical simulations are more useful than those by experiments due to the difficulties to obtain physical quantities experimentally and the reduction of computational costs in recent years. In this paper, in order to get further information into the interruption process of a SF6 self-blast interrupter, which is based on a combination of thermal expansion and the arc rotation principle, gas flow simulations with a CFD-arc modeling are performed during the whole switching process such as high-current period, pre-current zero period, and current-zero period. Through the complete work, the pressure-rise and the ramp of the pressure inside the chamber before current zero as well as the post-arc current after current zero should be a good criterion to predict the short-line fault interruption performance of interrupters.

Major bleeding events and risk stratification of antithrombotic agents in hemodialysis: Results from the DOPPS

PubMed Central

Sood, Manish M.; Larkina, Maria; Thumma, Jyothi R.; Tentori, Francesca; Gillespie, Brenda W.; Fukuhara, Shunichi; Mendelssohn, David C.; Chan, Kevin; de Sequera, Patricia; Komenda, Paul; Rigatto, Claudio; Robinson, Bruce M.

2013-01-01

Benefits and risks of antithrombotic agents remain unclear in the hemodialysis population. We aimed to determine variation in antithrombotic agent use, rates of major bleeding events, and to determine factors predictive of stroke and bleeding to allow for risk stratification, enabling more rational decisions about using antithrombotic agents. The sample included 48,144 patients in 12 countries in the Dialysis Outcomes and Practice Patterns Study Phase I–IV. Antithrombotic agents included oral anticoagulants (OAC), ASA and anti-platelet agents (APA). OAC prescription, comorbidities and vascular access were assessed at study entry; data on clinical events including hospitalization due to bleeding were collected every four months during follow-up. There was wide variation in OAC (0.3–18%), APA (3–25%) and ASA use (8–36%), and major bleeding rates (0.05–0.22 events/year) among countries. Rates of all-cause mortality, cardiovascular mortality, and bleeding events requiring hospitalization were elevated in patients prescribed OAC across adjusted models. The CHADS2 score predicted the risk of stroke in atrial fibrillation patients. Gastrointestinal bleeding in the past 12 months was highly predictive of major bleeding events; for patients with previous gastrointestinal bleeding, the rate of bleeding exceeded the rate of stroke by at least 2-fold across categories of CHADS2 score. Prescription of antithrombotic agents varied greatly. The CHADS2 score and a history of gastrointestinal bleeding were predictive of stroke and bleeding events, respectively, with bleeding rates substantially exceeding stroke rates in all groups including patients at high stroke risk. Appropriate risk stratification and a cautious approach should be considered before OAC use in the dialysis population. PMID:23677245

Ectopic Varices in the Gastrointestinal Tract: Short- and Long-Term Outcomes of Percutaneous Therapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Macedo, Thanila A., E-mail: macedo.thanila@mayo.edu; Andrews, James C.; Kamath, Patrick S.

2005-04-15

To evaluate the results of percutaneous management of ectopic varices, a retrospective review was carried out of 14 patients (9 men, 5 women; mean age 58 years) who between 1992 and 2001 underwent interventional radiological techniques for management of bleeding ectopic varices. A history of prior abdominal surgery was present in 12 of 14 patients. The interval between the surgery and percutaneous intervention ranged from 2 to 38 years. Transhepatic portal venography confirmed ectopic varices to be the source of portal hypertension-related gastrointestinal bleeding. Embolization of the ectopic varices was performed by a transhepatic approach with coil embolization of themore » veins draining into the ectopic varices. Transjugular intrahepatic portosystemic shunt (TIPS) was performed in the standard fashion. Eighteen procedures (12 primary coil embolizations, 1 primary TIPS, 2 re-embolizations, 3 secondary TIPS) were performed in 13 patients. One patient was not a candidate for percutaneous treatment. All interventions but one (re-embolization) were technically successful. In 2 of 18 interventions, re-bleeding occurred within 72 hr (both embolization patients). Recurrent bleeding (23 days to 27 months after initial intervention) was identified in 9 procedures (8 coil embolizations, 1 TIPS due to biliary fistula). One patient had TIPS revision because of ultrasound surveillance findings. New encephalopathy developed in 2 of 4 TIPS patients. Percutaneous coil embolization is a simple and safe treatment for bleeding ectopic varices; however, recurrent bleeding is frequent and reintervention often required. TIPS can offer good control of bleeding at the expense of a more complex procedure and associated risk of encephalopathy.« less

Eltrombopag Use in Thrombocytopenia for Endoscopic Submucosal Dissection of a Gastric Carcinoid

PubMed Central

Kaltenbach, Tonya; Martin, Beth; Rouse, Robert V.; Soetikno, Roy

2014-01-01

Severe thrombocytopenia is a contraindication for therapeutic endoscopy due to the risk of bleeding. Platelet transfusions can temporarily increase platelet count, but are difficult to administer in the 2 weeks following endoscopic resection, during which the patient is at high risk for delayed bleeding. We present the use of a novel thrombopoietin receptor agonist, eltrombopag, to sustain platelet levels for the safe and complete endoscopic submucosal dissection of a gastric carcinoid in a patient with severe thrombocytopenia due to cirrhosis and idiopathic thrombocytopenic purpura. We performed complete and safe endoscopic removal of a gastric carcinoid after correcting the thrombocytopenia. PMID:26157896

TIPS treatment in a patient with severe lower gastrointestinal bleeding with a misdiagnosis of cirrhotic portal hypertension.

PubMed

Laborda, Alicia; Guirola, José Andrés; Medrano, Joaquín; Simón, Miguel Ángel; Ioakeim, Ignatios; de-Gregorio, Miguel Ángel

2015-12-01

Abernethy malformation is a rare abnormal embryological development of splanchnic venous system characterised by the presence of a congenital extrahepatic portosystemic shunt. We present a rare case of an adult male patient that was admitted with severe lower gastrointestinal bleeding, requiring multiple blood transfusions. The patient's medical history and the laboratory tests performed led to the misdiagnosis of a congenital Abernethy malformation. We present a rare case, discussing the reasons for the misdiagnosis and we conclude that management of clinical data and imaging are highly important to discard these types of congenital malformations that can mimic a portal hypertension condition.

Ileal polypoid lymphangiectasia bleeding diagnosed and treated by double balloon enteroscopy

PubMed Central

Park, Min Seon; Lee, Beom Jae; Gu, Dae Hoe; Pyo, Jeung-Hui; Kim, Kyeong Jin; Lee, Yun Ho; Joo, Moon Kyung; Park, Jong-Jae; Kim, Jae Seon; Bak, Young-Tae

2013-01-01

Intestinal lymphangiectasia is a rare disease characterized by focal or diffuse dilated enteric lymphatics with impaired lymph drainage. It causes protein-losing enteropathy and may lead to gastrointestinal bleeding. Commonly, lymphangiectasia presents as whitish spots or specks. To our knowledge, small bowel bleeding resulting from polypoid intestinal lymphangiectasia has not been reported. Here, we report a rare case of active bleeding from the small bowel caused by polypoid lymphangiectasia with a review of the relevant literature. An 80-year-old woman was hospitalized for melena. Esophagogastroduodenoscopy could not identify the source of bleeding. Subsequent colonoscopy showed fresh bloody material gushing from the small bowel. An abdominal-pelvic contrast-enhanced computed tomography scan did not reveal any abnormal findings. Video capsule endoscopy showed evidence of active and recent bleeding in the ileum. To localize the bleeding site, we performed double balloon enteroscopy by the anal approach. A small, bleeding, polypoid lesion was found in the distal ileum and was successfully removed using endoscopic snare electrocautery. PMID:24363538

Joint use of cardio-embolic and bleeding risk scores in elderly patients with atrial fibrillation.

PubMed

Marcucci, Maura; Nobili, Alessandro; Tettamanti, Mauro; Iorio, Alfonso; Pasina, Luca; Djade, Codjo D; Franchi, Carlotta; Marengoni, Alessandra; Salerno, Francesco; Corrao, Salvatore; Violi, Francesco; Mannucci, Pier Mannuccio

2013-12-01

Scores for cardio-embolic and bleeding risk in patients with atrial fibrillation are described in the literature. However, it is not clear how they co-classify elderly patients with multimorbidity, nor whether and how they affect the physician's decision on thromboprophylaxis. Four scores for cardio-embolic and bleeding risks were retrospectively calculated for ≥ 65 year old patients with atrial fibrillation enrolled in the REPOSI registry. The co-classification of patients according to risk categories based on different score combinations was described and the relationship between risk categories tested. The association between the antithrombotic therapy received and the scores was investigated by logistic regressions and CART analyses. At admission, among 543 patients the median scores (range) were: CHADS2 2 (0-6), CHA2DS2-VASc 4 (1-9), HEMORR2HAGES 3 (0-7), HAS-BLED 2 (1-6). Most of the patients were at high cardio-embolic/high-intermediate bleeding risk (70.5% combining CHADS2 and HEMORR2HAGES, 98.3% combining CHA2DS2-VASc and HAS-BLED). 50-60% of patients were classified in a cardio-embolic risk category higher than the bleeding risk category. In univariate and multivariable analyses, a higher bleeding score was negatively associated with warfarin prescription, and positively associated with aspirin prescription. The cardio-embolic scores were associated with the therapeutic choice only after adjusting for bleeding score or age. REPOSI patients represented a population at high cardio-embolic and bleeding risks, but most of them were classified by the scores as having a higher cardio-embolic than bleeding risk. Yet, prescription and type of antithrombotic therapy appeared to be primarily dictated by the bleeding risk. © 2013.

HIA 2016 DOE Zero Energy Ready Home Case Study: Imery & Co, High-performance Bungalow, Roswell, GA

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pacific Northwest National Laboratory

Case study of a DOE 2016 Housing Innovation Award winning custom for buyer home in the mixed-humid climate that met the DOE Zero Energy Ready Home criteria and achieved a HERS 41 without PV or HERS 6 with PV.

Bleeding from duodenal ulcer in a patient with bilio-pancreatic diversion.

PubMed

Garancini, Mattia; Luperto, Margherita; Delitala, Alberto; Maternini, Matteo; Uggeri, Franco

2011-12-01

Scopinaro's bilio-pancreatic diversion is considered as an acceptable malabsorptive surgical approach for the treatment of morbid obesity. We describe a case of acute recurrent gastro-intestinal bleeding in a patient with a previous Scopinaro's bilio-pancreatic diversion. At the first admission in our department, gastroscopy, colonoscopy, contrast-enhanced computerized tomography and angiography resulted negative for active bleeding. Hypovolemic shock indicated laparotomy and an intraoperative enteroscopy performed through a small enterotomy showed an ulcerative perforation sourced in an ischemic portion of a distended duodenal stump, with a bleeding branch of gastro-duodenal artery at the bottom. Hemorrhage was stopped with stitches. Two years later a new episode of duodenal bleeding associated with severe malnutrition occurred. A covered chronic ischemic perforation sustained by duodenal distension due to biliopancreatic limb sub-obstruction appeared to be the most probable etiology of the recurrent duodenal bleeding. The patient underwent again to laparotomy and adhesiolysis; hemorrhage was stopped by means of ligation of gastroduodenal artery and bilio-pancreatic diversion was converted into a standard Roux-en-Y gastroenterostomy with an entero-entero anastomosis 40 cm from the Treitz ligament in order to restore an anatomo-functional condition guaranteeing normal absorption and intestinal transit. After Scopinaro's bilio-pancreatic diversion duodenal bleeding can represent a rare serious presentation of biliopancreatic limb obstruction; because of the complex anatomical reconstruction performed during this intervention, the duodenum results unavailable during upper gastro-intestinal endoscopy, and if a duodenal bleeding is suspected laparotomy followed by enteroscopy represents an effective diagnostic approach.

Outcome Following a Negative CT Angiogram for Gastrointestinal Hemorrhage

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chan, Victoria, E-mail: drvictoriac@gmail.com; Tse, Donald, E-mail: donald.tse@gmail.com; Dixon, Shaheen, E-mail: shaheen7noorani@gmail.com

2015-04-15

ObjectiveThis study was designed to evaluate the role of a negative computed tomography angiogram (CTA) in patients who present with gastrointestinal (GI) hemorrhage.MethodsA review of all patients who had CTAs for GI hemorrhage over an 8-year period from January 2005 to December 2012 was performed. Data for patient demographics, location of hemorrhage, hemodynamic stability, and details of angiograms and/or the embolization procedure were obtained from the CRIS/PACS database, interventional radiology database, secure electronic medical records, and patient’s clinical notes.ResultsA total of 180 patients had 202 CTAs during the 8-year period: 87 CTAs were performed for upper GI hemorrhage (18 positivemore » for active bleeding, 69 negative) and 115 for lower GI hemorrhage (37 positive for active bleeding, 78 negative); 58.7 % (37/63) of patients with upper GI bleed and 77.4 % (48/62) of patients with lower GI bleed who had an initial negative CTA did not rebleed without the need for radiological or surgical intervention. This difference was statistically significant (p = 0.04). The relative risk of rebleeding, following a negative CTA, in lower GI bleeding versus upper GI bleeding patients is 0.55 (95 % confidence interval 0.32–0.95).ConclusionsPatients with upper GI bleed who had negative CTAs usually require further intervention to stop the bleeding. In contrast, most patients presenting with lower GI hemorrhage who had a negative first CTA were less likely to rebleed.« less

Efficacy of ankaferd blood stopper application on non-variceal upper gastrointestinal bleeding

PubMed Central

Gungor, Gokhan; Goktepe, M Hakan; Biyik, Murat; Polat, Ilker; Tuna, Tuncer; Ataseven, Huseyin; Demir, Ali

2012-01-01

AIM: To prospectively assess the hemostatic efficacy of the endoscopic topical use of ankaferd blood stopper (ABS) in active non-variceal upper gastrointestinal system (GIS) bleeding. METHODS: Endoscopy was performed on 220 patients under suspiciency of GIS bleeding. Patients with active non-variceal upper gastrointestinal bleeding (NVUGIB) with a spurting or oozing type were included. Firstly, 8-10 cc of isotonic saline was sprayed to bleeding lesions. Then, 8 cc of ABS was applied on lesions in which bleeding continued after isotonic saline application. The other endoscopic therapeutic methods were applied on the lesions in which the bleeding did not stop after ABS. RESULTS: Twenty-seven patients had an active NVUGIB with a spurting or oozing type and 193 patients were excluded from the study since they did not have non-variceal active bleeding. 8 cc of ABS was sprayed on to the lesions of 26 patients whose bleeding continued after isotonic saline and in 19 of them, bleeding stopped after ABS. Other endoscopic treatment methods were applied to the remaining patients and the bleeding was stopped with these interventions in 6 of 7 patients. CONCLUSION: ABS is an effective method on NVUGIB, particularly on young patients with no coagulopathy. ABS may be considered as part of a combination treatment with other endoscopic methods. PMID:23293725

A Rare Case of Pancreas Divisum Accompanied by Acute Pancreatitis Following Endoscopic Hemostasis for Duodenal Ulcer Bleeding.

PubMed

Choi, Yong Hyeok; Yoon, Soon Man; Kim, Eun Bee; Oh, Youngmin; Kim, Keunmo; Lee, Jisun; Park, Seon Mee; Youn, Sei Jin

2017-04-25

Peptic ulcer bleeding is treated using endoscopic hemostasis using clips or bands. Pancreas divisum (PD), a congenital anomaly of the pancreas, usually has no clinical symptoms; however, pancreatitis may occur if there are disturbances in the drainage of pancreatic secretions. We report an unusual case of PD accompanied by acute pancreatitis, following endoscopic band ligation for duodenal ulcer bleeding. A 48-year-old woman was admitted to our hospital due to melena. An upper endoscopy revealed a small ulcer with oozing adjacent minor papilla. An endoscopic band ligation was performed on this lesion. Acute pancreatitis developed suddenly 6 hours after the band ligation and improved dramatically after removal of the band. Magnetic resonance cholangiopancreatography was performed, revealing complete PD. Endoscopic band ligation is known as the effective method for peptic ulcer bleeding; however, it should be used carefully in duodenal ulcer bleeding near the minor duodenal papilla due to the possibility of PD.

Diagnosis, Treatment, and Outcome in Patients with Bleeding Peptic Ulcers and Helicobacter pylori Infections

PubMed Central

2014-01-01

Upper gastrointestinal (UGI) bleeding is the most frequently encountered complication of peptic ulcer disease. Helicobacter pylori (Hp) infection and nonsteroidal anti-inflammatory drug (NSAID) administration are two independent risk factors for UGI bleeding. Therefore, testing for and diagnosing Hp infection are essential for every patient with UGI hemorrhage. The presence of the infection is usually underestimated in cases of bleeding peptic ulcers. A rapid urease test (RUT), with or without histology, is usually the first test performed during endoscopy. If the initial diagnostic test is negative, a delayed 13C-urea breath test (UBT) or serology should be performed. Once an infection is diagnosed, antibiotic treatment is advocated. Sufficient evidence supports the concept that Hp infection eradication can heal the ulcer and reduce the likelihood of rebleeding. With increased awareness of the effects of Hp infection, the etiologies of bleeding peptic ulcers have shifted to NSAID use, old age, and disease comorbidity. PMID:25101293

Jejunal variceal bleeding after esophageal transection in a patient with idiopathic portal hypertension.

PubMed

Migou, S; Hashizume, M; Tsugawa, K; Kishihara, F; Kawanaka, H; Ohta, M; Tanoue, K; Kuroiwa, T; Kawamoto, K; Sugimachi, K

1998-01-01

This report describes a 38-year-old man with massive gastrointestinal bleeding from jejunal varices. He had been previously diagnosed to have idiopathic portal hypertension and esophageal varices, and had undergone an esophageal transection 8 years earlier. The pre-operative diagnosis was a suspected hemorrhage from the small intestine as visualized by 99mTc-HSAD scintigraphy (technetium 99m-labeled human serum albumin D-type) and was not considered to be repeated massive lower GI tract bleeding. An exploratory laparotomy was performed, and intra-operative endoscopy revealed active bleeding from the jejunal varices. A partial resection of the small intestine resulted in a complete resolution of the bleeding. A review of the literature thereafter disclosed twelve previously reported cases of jejunal variceal bleeding.

Management protocol for acute gastrointestinal bleeding.

PubMed

Singhal, Dinesh; Kakodkar, Rahul; Nundy, Samiran

2006-05-01

Gastro-intestinal haemorrhage is not uncommon and is manifested as haematemesis, melaena or haematochezia. The first step is to resuscitate the patient if necessary and then proceed to make a diagnosis as well as divide patients into high and low-risk groups after taking a good history and performing a physical examination especially to detect the presence of an enlarged spleen. Then one should proceed with an endoscopy and other investigations chosen carefully for their usefulness. Control of bleeding is then tailored to the diagnosis and is usually with drugs, endoscopy, angio-embolisation and surgery in that order. The mortality rate for upper GI bleeding varies from 10 to 30% depending on the proportion of patients with variceal haemorrhage included. For lower GI bleeding mortality is in the region of 20% and for obscure GI bleeding outpatient mortality is 12%. The main points to remember are that the management of these patients in India should be different from those described in Western textbooks and suited to their specific needs and the facilities available locally. However, in spite of the widespread lack of complex diagnostic techniques and a shortage of blood for transfusion we believe that by adopting an aggressive step-by-step approach tailored to our own environment we will be able to save most of our patients who are usually young and have few comorbid conditions.

Obesity Does Not Impact Perioperative or Postoperative Outcomes in Patients with Inflammatory Bowel Disease.

PubMed

Guardado, Jesse; Carchman, Evie; Danicic, Ashley E; Salgado, Javier; Watson, Andrew R; Celebrezze, James P; Medich, David S; Holder-Murray, Jennifer

2016-04-01

While the prevalence of obesity in IBD patients is rapidly increasing, it is unclear if obesity impacts surgical outcomes in this population. We aim to investigate the effects of BMI on perioperative and postoperative outcomes in IBD patients by stratifying patients into BMI groups and comparing outcomes between these groups. This is a retrospective cohort study where IBD patients who underwent intestinal surgeries between the years of 2000 to 2014 were identified. The patients were divided into groups based on BMI: underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obese (BMI ≥30). Preoperative patient demographics, operative variables, and postoperative complications were collected and compared between BMI groups. A total of 391 surgeries were reviewed (34 underweight, 187 normal weight, 105 overweight, and 65 obese) from 325 patients. No differences were observed in preoperative patient demographics, type of IBD, preoperative steroid or biologic mediator use, or mean laboratory values. No differences were observed in percent operative procedures with anastomosis, surgeries converted to open, estimated blood loss, intraoperative complications, and median operative time. Thirty-day postoperative complication rates including total complications, wound infection, or anastomotic leak were similar between groups. There was a statistically significant increased postoperative bleeding risk (p = 0.029) in underweight patients. The relative percent for increased postoperative bleeding risk between BMI groups was as follows: 2.9% in underweight, zero in normal weight, 2.9% in overweight, and zero in obese. Obesity does not appear to impact intraoperative variables nor does obesity appear to worsen postoperative complication rates in IBD patients.

Prospective analysis of delayed colorectal post-polypectomy bleeding.

PubMed

Park, Soo-Kyung; Seo, Jeong Yeon; Lee, Min-Gu; Yang, Hyo-Joon; Jung, Yoon Suk; Choi, Kyu Yong; Kim, Hungdai; Kim, Hyung Ook; Jung, Kyung Uk; Chun, Ho-Kyung; Park, Dong Il

2018-01-17

Although post-polypectomy bleeding is the most frequent complication after colonoscopic polypectomy, only few studies have investigated the incidence of bleeding prospectively. The aim of this study was to investigate the incidence of delayed post-polypectomy bleeding and its associated risk factors prospectively. Patients who underwent colonoscopic polypectomy at Kangbuk Samsung Hospital from January 2013 to December 2014 were prospectively enrolled in this study. Trained nurses contacted patients via telephone 7 and 30 days after polypectomy and completed a standardized questionnaire regarding the development of bleeding. Delayed post-polypectomy bleeding was categorized as minor or major and early or late bleeding. Major delayed bleeding was defined as a > 2-g/dL drop in the hemoglobin level, requiring hospitalization for control of bleeding or blood transfusion; late delayed bleeding was defined as bleeding occurring later than 24 h after polypectomy. A total of 8175 colonoscopic polypectomies were performed in 3887 patients. Overall, 133 (3.4%) patients developed delayed post-polypectomy bleeding. Among them, 90 (2.3%) and 43 (1.1%) patients developed minor and major delayed bleeding, respectively, and 39 (1.0%) patients developed late delayed bleeding. In the polyp-based multivariate analysis, young age (< 50 years; odds ratio [OR] 2.10; 95% confidence interval [CI] 1.18-3.68), aspirin use (OR 2.78; 95% CI 1.23-6.31), and polyp size of > 10 mm (OR 2.45; 95% CI 1.38-4.36) were significant risk factors for major delayed bleeding, while young age (< 50 years; OR 2.6; 95% CI 1.35-5.12) and immediate bleeding (OR 3.3; 95% CI 1.49-7.30) were significant risk factors for late delayed bleeding. Young age, aspirin use, polyp size, and immediate bleeding were found to be independent risk factors for delayed post-polypectomy bleeding.

Sustainable and Net Zero Buildings on the NREL Campus | NREL

Science.gov Websites

NREL Campus Many of the high-performance buildings on NREL's South Table Mountain campus have achieved high-performance, sustainable buildings on the South Table Mountain (STM) campus as of FY17. The campus campus also reported 100% compliance with the Guiding Principles for High Performance Sustainable

Nonsurgical treatment of actively bleeding internal hemorrhoids with a novel endoscopic device (with video).

PubMed

Kantsevoy, Sergey V; Bitner, Marianne

2013-10-01

Internal hemorrhoids often present with bleeding, prolapse, and other symptoms. Currently used nonsurgical treatment modalities have limited effectiveness and usually require several treatment sessions. To evaluate effectiveness and safety of a novel endoscopic device for nonsurgical treatment of internal hemorrhoids. Retrospective study. Single center. This study involved 23 patients with actively bleeding internal hemorrhoids. The HET Bipolar System is a modified anoscope, with a treatment window, light source, and tissue temperature monitor. The device is inserted into the rectum under direct observation. The tissue carrying superior hemorrhoidal branches and the apex of the internal hemorrhoid is positioned inside the treatment window, clamped with incorporated tissue forceps, and treated with bipolar energy to ligate hemorrhoidal feeding vessels. Rate of hemorrhoidal bleeding after the treatment. The mean age of the patients was 64.3 ± 9.9 years (range 44-79 years). Eleven patients (47.8%) had grade I hemorrhoids and 12 patients (52.2%) had grade II hemorrhoids. In 18 patients (78.3%), treatment with the HET System was performed with the patient under conscious sedation. Five patients (21.7%) were treated without sedation. All patients tolerated treatment without complaints. The average follow-up period was 11.2 ± 4.7 months. No bleeding or prolapse occurred after the procedure in any of the treated patients. Retrospective study. The newly developed HET System is easy to use, safe, and highly effective in eliminating bleeding in grade I and II internal hemorrhoids and prolapse in grade II internal hemorrhoids. Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.

Management of congenital quantitative fibrinogen disorders: a Delphi consensus.

PubMed

Casini, A; de Moerloose, P

2016-11-01

No evidence-based guidelines for the management of patients suffering from afibrinogenaemia and hypofibrinogenaemia are available. The aim of this study was to harmonize patient's care among invited haemophilia experts from Belgium, France and Switzerland. A Delphi-like methodology was used to reach a consensus on: prophylaxis, bleeding, surgery, pregnancy and thrombosis management. The main final statements are as follows: (i) a secondary fibrinogen prophylaxis should be started after a first life-threatening bleeding in patients with afibrinogenaemia; (ii) during prophylaxis the target trough fibrinogen level should be 0.5 g L -1 ; (iii) if an adaptation of dosage is required, the frequency of infusions rather than the fibrinogen amount should be modified; (iv) afibrinogenaemic patients undergoing a surgery at high bleeding risk should receive fibrinogen concentrates regardless of the personal or family history of bleeding; (v) moderate hypofibrinogenaemic patients (i.e. ≥0.5 g L -1 ) without previous bleeding (despite haemostatic challenges) undergoing a surgery at low bleeding risk may not receive fibrinogen concentrates as prophylaxis; (vi) monitoring the trough fibrinogen levels should be performed at least once a month throughout the pregnancy and a foetal growth and placenta development close monitoring by ultrasound is recommended; (vii) fibrinogen replacement should be started concomitantly to the introduction of anticoagulation in afibrinogenaemic patients suffering from a venous thromboembolic event; and (viii) low-molecular-weight heparin is the anticoagulant of choice in case of venous thromboembolism. The results of this initiative should help clinicians in the difficult management of patients with congenital fibrinogen disorders. © 2016 John Wiley & Sons Ltd.

Systematic review: benefits and harms of transarterial embolisation for treating hepatocellular adenoma.

PubMed

Zhao, C; Pei, S-L; Cucchetti, A; Tong, T-J; Ma, Y-L; Zhong, J-H; Li, L-Q

2017-03-20

Transarterial embolisation (TAE) is a standard treatment for bleeding hepatocellular adenoma (HCA) and, occasionally, symptomatic HCA involving large tumours. Whether TAE is similarly safe and effective as an elective treatment for bleeding and nonbleeding HCA remains unclear. To investigate the benefits and harms of TAE for bleeding and nonbleeding HCA. PubMed, Scopus, Embase and Cochrane Library databases were systematically searched for studies that examined post-TAE tumour reduction in patients with bleeding or nonbleeding HCA and that were published between January 2000 and January 2017. Systematic review of 21 case series involving 1468 patients with HCA in the systematic review identified 140 (9.5%) patients with 189 lesions who received TAE. Of these 140 patients, 66.4% had bleeding HCA and 33.6% had nonbleeding HCA. Intended elective TAE was performed in 27.1% of patients (38.6% of HCA lesions). Adenomatosis was observed in 6.1% of patients, and the rate of β-catenin expression was 4.5%. No malignant transformation was observed among the 189 tumours during a median follow-up time of 40 months. The complete response rate among 70 patients was 10.6%, and the partial response rate was 71.7%. No mortality or severe adverse side effects were reported during the hospitalisation period. The available evidence suggests that TAE can be considered safe for elective managment of HCA as well as for management of bleeding HCA. Elective TAE can be regarded as a reasonable alternative to surgery. High-quality prospective studies with long-term follow-up are needed to corroborate and strengthen available evidence. © 2017 John Wiley & Sons Ltd.

Perioperative management of vitamin K antagonists in patients with low thromboembolic risk undergoing elective surgery: A prospective experience.

PubMed

Becerra, Ana Florencia; Cornavaca, María Teresita; Revigliono, José Ignacio; Contreras, Alejandro; Albertini, Ricardo; Tabares, Aldo Hugo

2017-10-11

To quantify thromboembolic and bleeding events in patients with low thromboembolic risk, who were chronically receiving vitamin K antagonists and undergoing elective surgery. A descriptive, prospective, single-center study was conducted between December 2010 and July 2014. Patients aged over 18 years old, chronically anticoagulated with vitamin K antagonists and admitted for elective surgery were included in the study. We excluded patients with a creatinine clearance<30ml/min, a body weight>120kg, heparin-induced thrombocytopenia, pregnant women, carriers of an epidural catheter for analgesia, patients who underwent unscheduled surgery and high thromboembolic risk-patients. Vitamin K antagonists were discontinued 5 days prior to the procedure without administering anticoagulant enoxaparin. The NIR was measured 24h before the procedure. A single dose of 3mg of vitamin K was administered in cases of a NIR>1.5. Vitamin K antagonists was resumed according to the surgical bleeding risk. Events were registered between 5 days prior to the procedure until 30 days after it. A total of 75 procedures were included in the study. Fifty-six patients (74.7%) received vitamin K antagonists for atrial fibrillation, 15 suffered from venous thromboembolism (20%) and 4 had mechanical heart valves (5.3%). Twenty-six patients (34.5%) underwent high-bleeding risk surgeries and 49 (65.5%) underwent low risk procedures. No thromboembolic event was recorded. Four bleeding events (5.3%) were reported, 3 of which were considered major bleeding events (2 fatal). Suspending vitamin K antagonists with no bridging therapy performed in patients with a low thromboembolic risk does not expose such patients to a significant risk of embolic events. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Prevention of VTE in Nonorthopedic Surgical Patients

PubMed Central

Garcia, David A.; Wren, Sherry M.; Karanicolas, Paul J.; Arcelus, Juan I.; Heit, John A.; Samama, Charles M.

2012-01-01

Background: VTE is a common cause of preventable death in surgical patients. Methods: We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients by using systematic methods as described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results: We describe several alternatives for stratifying the risk of VTE in general and abdominal-pelvic surgical patients. When the risk for VTE is very low (< 0.5%), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE (∼1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE (∼3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE (∼6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava filter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations. Conclusions: Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients. PMID:22315263

Bleeding complications with dual antiplatelet therapy among patients with stable vascular disease or risk factors for vascular disease: results from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial.

PubMed

Berger, Peter B; Bhatt, Deepak L; Fuster, Valentin; Steg, P Gabriel; Fox, Keith A A; Shao, Mingyuan; Brennan, Danielle M; Hacke, Werner; Montalescot, Gilles; Steinhubl, Steven R; Topol, Eric J

2010-06-15

Uncertainty exists about the frequency, correlates, and clinical significance of bleeding with dual antiplatelet therapy (DAPT), particularly over an extended period in a stable population. We sought to determine the frequency and time course of bleeding with DAPT in patients with established vascular disease or risk factors only; identify correlates of bleeding; and determine whether bleeding is associated with mortality. We analyzed 15 603 patients enrolled in the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial, a double-blind, placebo-controlled, randomized trial comparing long-term clopidogrel 75 mg/d versus placebo; all patients received aspirin (75 to 162 mg) daily. Patients had either established stable vascular disease or multiple risk factors for vascular disease without established disease. Median follow-up was 28 months. Bleeding was assessed with the use of the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) criteria. Severe bleeding occurred in 1.7% of the clopidogrel group versus 1.3% on placebo (P=0.087); moderate bleeding occurred in 2.1% versus 1.3%, respectively (P<0.001). The risk of bleeding was greatest the first year. Patients without moderate or severe bleeding during the first year were no more likely than placebo-treated patients to have bleeding thereafter. The frequency of bleeding was similar in patients with established disease and risk factors only. In multivariable analysis, the relationship between moderate bleeding and all-cause mortality was strong (hazard ratio, 2.55; 95% confidence interval, 1.71 to 3.80; P<0.0001), along with myocardial infarction (hazard ratio, 2.92; 95% confidence interval, 2.04 to 4.18; P<0.0001) and stroke (hazard ratio, 4.20; 95% confidence interval, 3.05 to 5.77; P<0.0001). In CHARISMA, there was an increased risk of bleeding with long-term clopidogrel. The incremental risk of bleeding was greatest in the first year and similar thereafter. Moderate bleeding was strongly associated with mortality. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00050817.

Embolization of a Hemorrhoid Following 18 Hours of Life-Threatening Bleeding

DOE Office of Scientific and Technical Information (OSTI.GOV)

Berczi, Viktor, E-mail: berczi@hotmail.com; Gopalan, Deepa; Cleveland, Trevor J

2008-01-15

Hemorrhoids usually do not pose diagnostic difficulties and they rarely cause massive bleeding. We report a case of massive rectal bleeding over 18 h needing 22 U blood transfusion treated by superselective transcatheter coil embolization 12 h following operative treatment performed in a different hospital. Diagnostic angiography with a view to superselective embolization, following failure of sigmoidoscopy to localize and treat the cause of hemorrhage, might act as a life-saving treatment in massive rectal bleeding, obviating the need for repeated endoscopy or emergency surgery.

Transcatheter Arterial Embolization for Gastrointestinal Bleeding Associated with Gastric Carcinoma: Prognostic Factors Predicting Successful Hemostasis and Survival.

PubMed

Park, Sangik; Shin, Ji Hoon; Gwon, Dong-Il; Kim, Hyoung Jung; Sung, Kyu-Bo; Yoon, Hyun-Ki; Ko, Gi-Young; Ko, Heung Kyu

2017-07-01

To evaluate outcomes of transcatheter arterial embolization (TAE) for gastric cancer-related gastrointestinal (GI) bleeding and factors associated with successful TAE and improved survival after TAE. This retrospective study included 43 patients (34 men; age 60.6 y ± 13.6) with gastric cancer-related GI bleeding undergoing angiography between January 2000 and December 2015. Clinical course, laboratory findings, and TAE characteristics were reviewed. Technical success of TAE was defined as target area devascularization, and clinical success was defined as bleeding cessation with hemodynamic stability during 72 hours after TAE. Student t test was used for comparison of continuous variables, and Fisher exact test was used for categorical variables. Univariate and multivariate analysis were performed to identify predictors of successful TAE and 30-day survival after TAE. TAE was performed in 40 patients. Technical and clinical success rates of TAE were 85.0% and 65.0%, respectively. Splenic infarction occurred in 2 patients as a minor complication. Rebleeding after TAE occurred in 7 patients. Death related to bleeding occurred in 5 patients. Active bleeding (P = .044) and higher transfusion requirement (3.3 U ± 2.6 vs 1.8 U ± 1.7; P = .039) were associated with TAE failure. Successful TAE predicted improved 30-day survival after TAE on univariate and multivariate analysis (P = .018 and P = .022; odds ratio, 0.132). TAE for gastric cancer-associated GI bleeding may be a lifesaving procedure. Severe bleeding with a higher transfusion requirement and active bleeding on angiography predicted TAE failure. Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.

Enhancing Near Zero Volt Storage Tolerance of Lithium-ion Batteries

NASA Astrophysics Data System (ADS)

Crompton, Kyle R.

There are inherent safety risks associated with inactive lithium ion batteries leading to greater restrictions and regulations on shipping and storage. Maintaining all cells of a lithium ion battery at near zero voltage with an applied fixed resistive load is one promising approach which can lessen (and potentially eliminate) the risk of a lithium ion battery entering thermal runaway when in an inactive state. However, in a conventional lithium ion cell, a near zero cell voltage can be damaging if the anode electrochemical potential increases to greater than the potential where dissolution of the standard copper current collector occurs (i.e. 3.1 V vs. Li/Li+ at room temperature). Past approaches to yield lithium ion cells that are resilient to a near zero volt state of charge involve use of secondary active materials or alternative current collectors which have anticipated tradeoffs in terms of cell performance and cost. In the the present dissertation work the approach of managing the amount of reversible lithium in a cell during construction to prevent the anode potential from increasing to greater than 3.1 V vs. Li/Li+ during near zero volt storage is introduced. Anode pre-lithiation was used in LiCoO 2/MCMB pouch cells to appropriately manage the amount of reversible lithium so that there is excess reversible lithium compared to the cathodes intercalation capacity (reversible lithium excess cell or RLE cell). RLE LiCoO 2/MCMB cells maintained 99% of their original capacity after three, 3-day and three, 7-day storage periods at near zero volts under fixed load. A LiCoO2/MCMB pouch cell fabricated with a pre-lithiated anode also maintained its original discharge performance after three, 3-day storage periods under fixed load at 45°C. The strong recharge performance after near zero volt storage is attributed to the anode potential remaining below the copper dissolution potential during near zero volt storage as informed by reference electrode measurements. Pulse discharge measurements were performed and show that double layer capacitance likely plays a major role in determining the behavior of electrode potentials during near zero volt storage. To further the viability of the anode pre-lithiation method in LiCoO2/MCMB cells, stabilization coatings on the cathode materials are being investigated to increase the tolerance of the cathode to the low potentials it may experience during near zero volt storage of an RLE lithium ion cell. Results show that an AlPO4 coating prevents cation exhange in the cathode crystal structure and substantially increases the cathode's resilience to low electrochemical potentials. Investigations into applying anode pre-lithiation to cells utilizing LiNiCoAlO2 (NCA) cathodes have also been initiated and found to maintain the anode potential below the copper dissolution potential during near zero volt storage. RLE NCA/MCMB cells showed strong recharge performance and improved rate capability retention over a conventional NCA/MCMB cell after ten, 3-day near zero volt storage periods. Scale up of reversible lithium management to NCA/MCMB x3450 pouch cells was achieved using bath lithium addition and rendered a cell that retained 100% of its discharge performance after a 14 day period at near zero volts under fixed load. The near zero volt storage tolerance of lithium ion cells utilizing an advanced, high energy density lithium rich cathode material (0.49Li2MnO3˙0.51LiNi 0.37Co0.24Mn0.39O2 or HE5050) has also been studied and found to be high at room temperature without the need for anode pre-lithiation. HE5050/MCMB cells maintained 100% of their discharge capacity after five, 3-day and five, 7-day near zero volt storage periods at room temperature. HE5050/MCMB also maintained 99% of their discharge capacity after two, 3-day near zero volt storage periods at 40°C. The high first cycle loss and lower intercalation potential of the HE5050 cathode lead to the anode potential remaining <2.8 V vs. Li/Li+ during near zero volt storage and as such, no copper dissolution is expected to be occurring. Finally, Carbon Nanotube (CNT) papers have been shown to be stable up to high potentials vs. Li/Li+ and thus, using them as an anode current collector in place of standard copper can generate lithium ion cells that can tolerate near zero volt storage. However, CNT papers suffer from significant irreversible loss due to their high surface area. An Al2O3 coating deposited by atomic layer deposition is investigated for its effect in reducing the irreversible losses of a CNT paper. The Al2O3 coating was found to reduce irreversible loss by 55% over 50 cycles and still serve as an effective current collector for a graphitic anode composite.

Cycle O(CY1991) NLS trade studies and analyses report. Book 2, part 2: Propulsion

NASA Technical Reports Server (NTRS)

Cronin, R.; Werner, M.; Bonson, S.; Spring, R.; Houston, R.

1992-01-01

This report documents the propulsion system tasks performed in support of the National Launch System (NLS) Cycle O preliminary design activities. The report includes trades and analyses covering the following subjects: (1) Maximum Tank Stretch Study; (2) No LOX Bleed Performance Analysis; (3) LOX Bleed Trade Study; (4) LO2 Tank Pressure Limits; (5) LOX Tank Pressurization System Using Helium; (6) Space Transportation Main Engine (STME) Heat Exchanger Performance; (7) LH2 Passive Recirculation Performance Analysis; (8) LH2 Bleed/Recirculation Study; (9) LH2 Tank Pressure Limits; and (10) LH2 Pressurization System. For each trade study an executive summary and a detailed trade study are provided. For the convenience of the reader, a separate section containing a compilation of only the executive summaries is also provided.

[Endoscopic treatment of gastroduodenal digestive hemorrhage].

PubMed

Llanos, J; Valdés, E; Cofré, C; Tapia, A; Denegri, E

1992-12-01

Endoscopy is extremely useful for the diagnosis of upper gastrointestinal bleeding. At the present time, therapeutic measures are been used during the endoscopy to stop bleeding. This paper reports the experience of hospital de Talca in the endoscopic treatment of upper gastrointestinal bleeding. Thirty four patients (22 male) with bleeding not originating from esophageal or gastric varices were treated with direct absolute alcohol injection into the bleeding lesions. The procedure was successful in 31 patients. Three of the 34 patients required surgery, but only one of those successfully sclerosed (97% success). There were no complications attributable to the procedure. It is concluded that this therapeutic modality must be implemented in places were gastrointestinal endoscopy is performed.

Experimental investigation of a two-dimensional shock-turbulent boundary layer interaction with bleed

NASA Technical Reports Server (NTRS)

Hingst, W. R.; Tanji, F. T.

1983-01-01

The two-dimensional interaction of an oblique shock wave with a turbulent boundary layer that included the effect of bleed was examined experimentally using a shock generator mounted across a supersonic wind tunnel The studies were performed at Mach numbers 2.5 and 2.0 and unit Reynolds number of approximately 2.0 x 10 to the 7th/meter. The study includes surface oil flow visualization, wall static pressure distributions and boundary layer pitot pressure profiles. In addition, the variation of the local bleed rates were measured. The results show the effect of the bleed on the boundary layer as well as the effect of the flow conditions on the local bleed rate.

Does antiplatelet therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than 1,000 laparoscopic operations in a single tertiary referral hospital.

PubMed

Fujikawa, Takahisa; Tanaka, Akira; Abe, Toshihiro; Yoshimoto, Yasunori; Tada, Seiichiro; Maekawa, Hisatsugu; Shimoike, Norihiro

2013-12-01

The effect of antiplatelet therapy (APT) on surgical blood loss and perioperative complications in patients receiving abdominal laparoscopic surgery still remains unclear. A total of 1,075 consecutive patients undergoing abdominal laparoscopic surgery between 2005 and 2011 were reviewed. Our perioperative management protocol consisted of interruption of APT 1 week before surgery and early postoperative reinstitution in low thromboembolic risk patients (n = 160, iAPT group). Preoperative APT was maintained in patients with high thromboembolic risk or emergent situation (n = 52, cAPT group). Perioperative and outcomes variables of cAPT and iAPT groups, including bleeding and thromboembolic complications, were compared with those of patients without APT (non-APT group, n = 863). In this cohort, 715 basic and 360 advanced laparoscopic operations were included. No patient suffering excessive intraoperative bleeding due to continuation of APT was observed. There were 10 postoperative bleeding complications (0.9%) and 3 thromboembolic events (0.3%), but the surgery was free of both complications in the cAPT group. No significant differences were found between the groups in operative blood loss, blood transfusion rate, and the occurrence of bleeding and thromboembolic complications. Multivariable analyses showed that multiple antiplatelet agents (p = 0.015) and intraoperative blood transfusion (p = 0.046) were significant prognostic factors for postoperative bleeding complications. Increased thromboembolic complications were independently associated with high New York Heart Association class (p = 0.019) and history of cerebral infarction (p = 0.048), but not associated with APT use. Abdominal laparoscopic operations were successfully performed without any increase in severe complications in patients with APT compared with the non-APT group under our rigorous perioperative assessment and management. Maintenance of single APT should be considered in patients with high thromboembolic risk, even when an abdominal laparoscopic approach is considered. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

National consensus on management of peptic ulcer bleeding in Denmark 2014.

PubMed

Laursen, Stig Borbjerg; Jørgensen, Henrik Stig; Schaffalitzky de Muckadell, Ove B

2014-11-01

The Danish Society of Gastroenterology and Hepatology have compiled a national guideline for the management of peptic ulcer bleeding. Sources of data included published studies up to June 2014. Quality of evidence and strength of recommendations have been graded. The guideline was approved by the Danish Society of Gastroenterology and Hepatology September 4, 2011. The current version is revised June 2014. RECOMMENDATIONS emphasize the importance of early and efficient resuscitation. Use of a restrictive blood transfusion policy is recommended in haemodynamically stable patients without serious ischaemic disease. Endoscopy should generally be performed within 24 hours, reducing operation rate, rebleeding rate and duration of in-patient stay. When serious ulcer bleeding is suspected and blood found in gastric aspirate, endoscopy within 12 hours will result in faster discharge and reduced need for transfusions. Endoscopic hemostasis remains indicated for high-risk lesions. Hemoclips, thermocoagulation, and epinephrine injection are effective in achieving endoscopic hemostasis. Use of endoscopic monotherapy with epinephrine injection is not recommended. Intravenous high-dose proton pump inhibitor (PPI) therapy for 72 hours after successful endoscopic hemostasis is recommended even though the evidence is questionable. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least three days after endoscopic hemostasis. Patients with peptic ulcer bleeding who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) within 24 hours from primary endoscopy. Patients in need of continued treatment with ASA or a nonsteroidal anti-inflammatory drug should be put on prophylactic treatment with PPI at standard dosage. The combination of 75 mg ASA and PPI should be preferred to monotherapy with clopidogrel in patients needing anti-platelet therapy on the basis of indications other than coronary stents. Low-risk patients without clinical suspicion of peptic ulcer bleeding who have a Glasgow Blatchford score ≤ 1 can be offered out-patient care, unless hospital admission is required for other reasons.

Prognostic impact of gastrointestinal bleeding and expression of PTEN and Ki-67 on primary gastrointestinal stromal tumors

PubMed Central

2014-01-01

Background Prognostic indicators for gastrointestinal stromal tumors (GISTs) are under investigation. The latest risk classification criteria may still have room for improvement. This study aims to investigate prognostic factors for primary GISTs from three aspects, including clinicopathological parameters, immunohistochemical (IHC) expression of PTEN, and Ki-67 labeling index (LI), and attempts to find valuable predictors for the malignancy potential of primary GISTs. Methods Tumor samples and clinicopathological data from 84 patients with primary GISTs after R0 resection were obtained. Immunohistochemical analysis was performed based on tissue microarray (TMA) to estimate expression of PTEN and Ki-67 in tumor cells. Results The cut-off point of Ki-67 LI was determined as 1%, using a receiver operator characteristic test with a sensitivity of 71.7% and a specificity of 64.5%. Univariate analysis demonstrated the following factors as poor prognostic indicators for relapse-free survival (RFS) against a median follow-up of 40.25 months: gastrointestinal (GI) bleeding (P = 0.009), non-gastric tumor location (P = 0.001), large tumor size (P = 0.022), high mitotic index (P < 0.001), high cellularity (P = 0.012), tumor rupture (P = 0.013), absent or low expression of PTEN (P = 0.036), and Ki-67 LI >1% (P = 0.043). Gastrointestinal bleeding (hazard ratio, 3.85; 95% confidence interval, 1.63 to 9.10; P = 0.002) was a negative independent risk predictor in multivariate analysis, in addition to tumor size (P = 0.023), and mitotic index (P = 0.002). In addition, GI bleeding showed a good ability to predict recurrence potential, when included in our re-modified risk stratification criteria. Conclusions This study suggests that GI bleeding is an independent predictor of poor prognosis for RFS in primary GISTs. Expression of PTEN and Ki-67 are correlated with high risk potential and may predict early recurrence in univariate analysis. PMID:24712384

Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices: Concept, Basic Techniques, and Outcomes

PubMed Central

Saad, Wael E. A.

2012-01-01

Patients with gastric variceal bleeding require a multidisciplinary team approach including hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnostic and management tool for bleeding gastric varices, as it is in all upper gastrointestinal bleeding scenarios. In the United States when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) traditionally is performed along the classic teachings of decompressing the portal circulation. However, TIPS has not shown the same effectiveness in controlling gastric variceal bleeding that it has with esophageal variceal bleeding. For the past 2 decades, the balloon-occluded retrograde transvenous obliteration (BRTO) procedure has become common practice in Asia for the management of gastric varices. BRTO is gaining popularity in the United States. It has been shown to be effective in controlling gastric variceal bleeding with low rebleed rates. BRTO has many advantages over TIPS in that it is less invasive and can be performed on patients with poor hepatic reserve and those with encephalopathy (and may even improve both). However, its by-product is occlusion of a spontaneous hepatofugal (TIPS equivalent) shunt, and thus it is contradictory to the traditional American doctrine of portal decompression. Indeed, BRTO causes an increase in portal hypertension, with potential aggravation of esophageal varices and ascites. This article discusses the concept, technique, and outcomes of BRTO within the broader management of gastric varices. PMID:23729982

Does magnetic resonance imaging produce further benefit for detecting a bleeding source in subarachnoid hemorrhage of unknown origin?

PubMed

Maslehaty, Homajoun; Petridis, Athanassios K; Barth, Harald; Doukas, Alexandros; Mehdorn, Hubertus Maximilian

2011-01-01

Spontaneous subarachnoid hemorrhage (SAH) without evidence of a bleeding source on the first digital subtraction angiogram (DSA) - also called SAH of unknown origin - is observed in up to 27% of all cases. Depending on the bleeding pattern on CT scanning, SAH can be differentiated into perimesencephalic (PM-SAH) and non-perimesencephalic SAH (NON-PM-SAH). The aim of our study was to investigate the effectiveness of magnetic resonance imaging (MRI) for detecting a bleeding source in SAH of unknown origin. We retrospectively reviewed 1,226 patients with spontaneous SAH between January 1991 and December 2008 in our department. DSA was performed in 1,068 patients, with negative results in 179 patients. Forty-seven patients were categorized as having PM-SAH and 132 patients as having NON-PM-SAH. MRI of the brain and the craniocervical region was performed within 72 h after diagnosis of SAH and demonstrated no bleeding sources in any of the PM-SAH and NON-PM-SAH patients (100% negative). In our experience MRI did not produce any additional benefit for detecting a bleeding source after SAH with a negative angiogram. The costs of this examination exceeded the clinical value. Despite our results MRI should be discussed on a case-by-case basis because rare bleeding sources are periodically diagnosed in cases of NON-PM-SAH.

Experimental Study of Load Carrying Capacity of Point Contacts at Zero Entrainment Velocity

NASA Technical Reports Server (NTRS)

Shogin, B. A.; Jones, W. R., Jr.; Kingsbury, E. P.; Jansen, M. J.; Prahl, J. M.

1998-01-01

A capacitance technique was used to monitor the film thickness separating two steel balls while subjecting the ball-ball contact to highly stressed, zero entrainment velocity conditions. Tests were performed in a nitrogen atmosphere and utilized 52100 steel balls and a polyalphaolefin lubricant. Capacitance to film thickness accuracy was verified under pure rolling conditions using established EHL theory. Zero entrainment velocity tests were performed at sliding speeds from 6.0 to 10.0 m/s and for sustained amounts of time to 28.8 min. The protective lubricant film separating the specimens at zero entrainment velocity had a film thickness between 0.10 to 0.14 microns (4 to 6 micro in.), which corresponded to a k value of 4. The formation of an immobile surface film formed by lubricant entrapment is discussed as an explanation of the load carrying capacity at zero entrainment velocity conditions, relevant to the ball-ball contacts occurring in retainerless ball bearings.

[Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndromes].

PubMed

Baeza Román, Anna; Latour Pérez, Jaime; de Miguel Balsa, Eva; Pino Izquierdo, Karel; Coves Orts, Francisco Javier; García Ochando, Luis; de la Torre Fernández, Maria José

2014-05-20

In the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS), several studies have shown a reduction in mortality with the use of an invasive strategy in high-risk patients, including diabetic patients. Paradoxically, other studies have shown an under-utilization of this invasive strategy in these patients. The aim of this study is to determine the characteristics of patients managed conservatively and identify determinants of the use of invasive or conservative strategy. Retrospective cohort study conducted in diabetic patients with NSTE-ACS included in the ARIAM-SEMICYUC registry (n=531) in 2010 and 2011. We performed crude and adjusted unconditional logistic regression. We analyzed 531 diabetic patients, 264 (49.7%) of which received invasive strategy. Patients managed conservatively were a subgroup characterized by older age and cardiovascular comorbidity, increased risk of bleeding and the absence of high-risk electrocardiogram (ECG). In diabetic patients with NSTE-ACS, independent predictors associated with conservative strategy were low-risk ECG, initial Killip class>1, high risk of bleeding and pretreatment with clopidogrel. The fear of bleeding complications or advanced coronary lesions could be the cause of the underutilization of an invasive strategy in diabetic patients with NSTE-ACS. Copyright © 2012 Elsevier España, S.L. All rights reserved.

Bleeding Risk and Antithrombotic Strategy in Patients with Sinus Rhythm Heart Failure with Reduced Ejection Fraction Treated with Warfarin or Aspirin

PubMed Central

Ye, Siqin; Cheng, Bin; Lip, Gregory Y. H.; Buchsbaum, Richard; Sacco, Ralph L.; Levin, Bruce; Di Tullio, Marco R.; Qian, Min; Mann, Douglas L.; Pullicino, Patrick M.; Freudenberger, Ronald S.; Teerlink, John R.; Mohr, J.P.; Graham, Susan; Labovitz, Arthur J.; Estol, Conrado J.; Lok, Dirk J.; Ponikowski, Piotr; Anker, Stefan D.; Thompson, John L.P.; Homma, Shunichi

2015-01-01

We sought to assess the performance of existing bleeding risk scores, such as HAS-BLED or OBRI, in patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm (SR) treated with warfarin or aspirin. We calculated HAS-BLED and OBRI risk scores for 2,305 patients with HFrEF in SR enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial. Proportional hazards models were used to test whether each score predicted major bleeding, and comparison of different risk scores was performed using Harell’s c-statistic and net-reclassification improvement (NRI) index. For the warfarin arm, both scores predicted bleeding risk, with OBRI having significantly higher c-statistic (0.72 vs 0.61; p=0.03) compared to HAS-BLED, though the NRI for comparing OBRI to HAS-BLED was not significant (0.32, 95% CI - 0.18-0.37). Performance of the OBRI and HAS-BLED risk scores were similar for the aspirin arm. For participants with OBRI score of 0 to 1, warfarin compared with aspirin reduced ischemic stroke (HR 0.51, 95% CI 0.26-0.98, p=0.042) without significantly increasing major bleeding (HR 1.24, 95% CI 0.66-2.30, p=0.51). For those with OBRI score of ≥2, there was a trend for reduced ischemic stroke with warfarin compared to aspirin (HR 0.56, 95% CI 0.27-1.15, p=0.12), but major bleeding was increased (HR 4.04, 95% CI 1.99-8.22, p<0.001). In conclusion, existing bleeding risk scores can identify bleeding risk in HFrEF patients in SR, and could be tested for potentially identifying patients with a favorable risk / benefit profile for antithrombotic therapy with warfarin. PMID:26189039

Electrocauterization and no packing may be comparable with nasal packing for postoperative hemorrhage after endoscopic sinus surgery.

PubMed

Kim, Dong-Kyu; Rhee, Chae Seo; Kim, Jeong-Whun

2016-05-01

Nasal packing is commonly performed after functional endoscopic sinus surgery (FESS). However, nasal packing is associated with higher cost (owing to the cost of packing materials), patient discomfort, delayed wound healing, and concern about toxic shock syndrome. Some surgeons have been performing FESS without packing, but there are few studies that show its safety. The purpose of this study was to evaluate the safety of electrocauterization and no packing. A total of 490 patients who underwent bilateral FESS for chronic rhinosinusitis were included in this retrospective study, 242 in the nasal packing group and 248 in the electrocauterization and no-packing group. Electrocauterization was performed by using a suction coagulator. Rates of immediate (first 24 hours after surgery) and delayed postoperative bleeding were compared. Patient characteristics, including concomitant disease and medication history, and Lund-Mackay computed tomography score were also assessed Results: There were no significant differences in age; sex; Lund-Mackay score; use of anticoagulant drugs; or prevalence of hypertension, diabetes, or asthma between the two groups. In the electrocauterization and no-packing group, there were fewer patients with allergic rhinitis and more smokers. Primary bleeding did not occur in the nasal packing group, but 11 patients (4.4%) had delayed bleeding. Primary bleeding occurred in four patients (1.7%) in the electrocauterization and no-packing group, and five patients (2.1%) had delayed bleeding. There were no significant differences in primary (p = 0.058) and secondary bleeding (p = 0.142) between the two groups. All bleeding was minor and easily controlled. Multivariate logistic regression analysis ruled out significant correlation between no packing and postoperative bleeding. This study provided evidence that, in terms of postoperative hemorrhage, the safety of the electrocauterization and no-packing technique after FESS was comparable with that of nasal packing.

DOE Office of Scientific and Technical Information (OSTI.GOV)

none,

This builder took home the Grand Winner prize in the Custom Builder category in the 2014 Housing Innovation Awards for its high performance building science approach. The builder used insulated concrete form blocks to create the insulated crawlspace foundation for its first DOE Zero Energy Ready Home, the first net zero energy new home certified in the state of California.

Generation and detection of 80-Gbit/s return-to-zero differential phase-shift keying signals

NASA Astrophysics Data System (ADS)

Möller, Lothar; Su, Yikai; Xie, Chongjin; Liu, Xiang; Leuthold, Juerg; Gill, Douglas; Wei, Xing

2003-12-01

Nonlinear polarization rotation between a pump and a probe signal in a highly nonlinear fiber is used as a modulation process to generate 80-Gbit/s return-to-zero differential phase-shift keying signals. Its performance is analyzed and compared with a conventional on-off keying modulated signal.

Mortality in high-risk patients with bleeding Mallory-Weiss syndrome is similar to that of peptic ulcer bleeding. Results of a prospective database study.

PubMed

Ljubičić, Neven; Budimir, Ivan; Pavić, Tajana; Bišćanin, Alen; Puljiz, Zeljko; Bratanić, Andre; Troskot, Branko; Zekanović, Dražen

2014-04-01

The aim of this study was to identify the predictive factors influencing mortality in patients with bleeding Mallory-Weiss syndrome in comparison with peptic ulcer bleeding. Between January 2005 and December 2009, 281 patients with endoscopically confirmed Mallory-Weiss syndrome and 1530 patients with peptic ulcer bleeding were consecutively evaluated. The 30-day mortality and clinical outcome were related to the patients' demographic data, endoscopic, and clinical characteristics. The one-year cumulative incidence for bleeding Mallory-Weiss syndrome was 7.3 cases/100,000 people and for peptic ulcer bleeding 40.4 cases/100,000 people. The age-standardized incidence for both bleeding Mallory-Weiss syndrome and peptic ulcer bleeding remained unchanged during the observational five-year period. The majority of patients with bleeding Mallory-Weiss syndrome were male patients with significant overall comorbidities (ASA class 3-4). Overall 30-day mortality rate was 5.3% for patients with bleeding Mallory-Weiss syndrome and 4.6% for patients with peptic ulcer bleeding (p = 0.578). In both patients with bleeding Mallory-Weiss syndrome and peptic ulcer bleeding, mortality was significantly higher in patients over 65 years of age and those with significant overall comorbidities (ASA class 3-4). The incidence of bleeding Mallory-Weiss syndrome and peptic ulcer bleeding has not changed over a five-year observational period. The overall 30-day mortality was almost equal for both bleeding Mallory-Weiss syndrome and peptic ulcer bleeding and was positively correlated to older age and underlying comorbid illnesses.

Oral surgery in patients under antithrombotic therapy: perioperative bleeding as a significant risk factor for postoperative hemorrhage.

PubMed

Rocha, Amanda L; Souza, Alessandra F; Martins, Maria A P; Fraga, Marina G; Travassos, Denise V; Oliveira, Ana C B; Ribeiro, Daniel D; Silva, Tarcília A

2018-01-01

: To investigate perioperative and postoperative bleeding, complications in patients under therapy with anticoagulant or antiplatelet drugs submitted to oral surgery. To evaluate the risk of bleeding and safety for dental surgery, a retrospective chart review was performed. Medical and dental records of patients taking oral antithrombotic drugs undergoing dental surgery between 2010 and 2015 were reviewed. Results were statistically analyzed using Fisher's exact test, t test or the χ test. One hundred and seventy-nine patients underwent 293 surgical procedures. A total of eight cases of perioperative and 12 episodes of postoperative bleeding were documented. The complications were generally managed with local measures and did not require hospitalization. We found significant association of postoperative hemorrhage with increased perioperative bleeding (P = 0.043) and combination of anticoagulant and antiplatelet therapy (P < 0.001). The chance of postoperative hemorrhage for procedures with increased perioperative bleeding is 8.8 times bigger than procedures without perioperative bleeding. Dental surgery in patients under antithrombotic therapy might be carried out without altering the regimen because of low risk of perioperative and postoperative bleeding. However, patients with increased perioperative bleeding should be closely followed up because of postoperative complications risk.

Transarterial embolization for the treatment of massive bleeding in gynecologic and obstetric emergencies: a single center experience.

PubMed

Hongsakul, Keerati; Songjamrat, Apiradee; Rookkapan, Sorracha

2014-08-01

Delayed treatment of the massive bleeding in gynecologic and obstetric conditions can cause high morbidity and mortality. The aim of this study is to assess the angiographic findings and outcomes of transarterial embolization in cases of massive hemorrhage from underlying gynecological and obstetrical conditions. This is a retrospective study of 18 consecutive patients who underwent transarterial embolization of uterine and/or hypogastric arteries due to massive bleeding from gynecological and obstetrical causes from January 2006 to December 2011. The underlying causes of bleeding, angiographic findings, technical success rates, clinical success rates, and complications were evaluated. Massive gynecological and obstetrical bleeding occurred in 12 cases and 6 cases, respectively. Gestational trophoblastic disease was the most common cause of gynecological bleeding. The most common cause of obstetrical hemorrhage was primary post-partum hemorrhage. Tumor stain was the most frequent angiographic finding (11 cases) in the gynecological bleeding group. The most common angiographic findings in obstetrical patients were extravasation (2 cases) and pseudoaneurysm (2 cases). Technical and final clinical success rates were found in all 18 cases and 16 cases. Collateral arterial supply, severe metritis, and unidentified cervical laceration were causes of uncontrolled bleeding. Only minor complications occurred, which included pelvic pain and groin hematoma. Percutaneous transarterial embolization is a highly effective and safe treatment to control massive bleeding in gynecologic and obstetric emergencies.

Research and Development of High-Performance Axial-Flow Turbomachinery

DTIC Science & Technology

1968-05-01

following conditions: 1. At any orientation of the turbocompressor in a zero to 0.18-g accelera- tion field; 2. At any angle between zero and 180...degrees shaft angle (where zero would correspond to a vertically oriented shaft with the compressor-end up and 180 degrees would be vertical with the...rpm. Hence, the absolute values of bearing forces in the vicinity of the rigid body criticals are approximate. Over the range of 40,000 to 60,000 rpm

Ileal polypoid lymphangiectasia bleeding diagnosed and treated by double balloon enteroscopy.

PubMed

Park, Min Seon; Lee, Beom Jae; Gu, Dae Hoe; Pyo, Jeung-Hui; Kim, Kyeong Jin; Lee, Yun Ho; Joo, Moon Kyung; Park, Jong-Jae; Kim, Jae Seon; Bak, Young-Tae

2013-12-07

Intestinal lymphangiectasia is a rare disease characterized by focal or diffuse dilated enteric lymphatics with impaired lymph drainage. It causes protein-losing enteropathy and may lead to gastrointestinal bleeding. Commonly, lymphangiectasia presents as whitish spots or specks. To our knowledge, small bowel bleeding resulting from polypoid intestinal lymphangiectasia has not been reported. Here, we report a rare case of active bleeding from the small bowel caused by polypoid lymphangiectasia with a review of the relevant literature. An 80-year-old woman was hospitalized for melena. Esophagogastroduodenoscopy could not identify the source of bleeding. Subsequent colonoscopy showed fresh bloody material gushing from the small bowel. An abdominal-pelvic contrast-enhanced computed tomography scan did not reveal any abnormal findings. Video capsule endoscopy showed evidence of active and recent bleeding in the ileum. To localize the bleeding site, we performed double balloon enteroscopy by the anal approach. A small, bleeding, polypoid lesion was found in the distal ileum and was successfully removed using endoscopic snare electrocautery. © 2013 Baishideng Publishing Group Co., Limited. All rights reserved.

A blind area of origins of epistaxis: technical or cognitive?

PubMed

Wei, Wei; Lai, Yuting; Zang, Chaoping; Luo, Jiqin; Zhu, Bijun; Liu, Quan; Liu, Ying

2018-04-24

To investigate common origins and features of anterior epistaxis. Patients (168) with anterior nose bleed were studied from May to October 2013. Endoscopic examination with angled endoscope and then subsequent management (radiofrequency, selective packing,) was performed. Under thorough nasal endoscopy, anterior nasal bleeding origin was ranked in turn as follows: the anterior nasal septum (NS 83.3%), the small area of anterior lateral wall of nasal cavity corresponding to the nasal back (NB 7.1%), the anterior end of the inferior turbinate (IT 5.4%), and the nasal part of the nasal cavity roof (NR 4.2%). Arterial lesion and hypertension led to large instant quantity of bleeding; hypertension and negligible bleeding origin prolonged bleeding duration. Bleeding was successfully controlled with nasal endoscopy and radiofrequency or selective packing. The arterial bleeding small area of anterior lateral wall of nasal cavity corresponding to the nasal back and the nasal part of the nasal cavity roof accounted for more than 10% of anterior epistaxis and a thorough endoscopic examination should include these area with angled endoscope. Then radiofrequency and selective packing will sharply reduce the bleeding duration.

Congenital Shunts of the Portal Venous System: Case-series of Uncommon Shunts.

PubMed

Santos, Liliana; Nobre, Susana; Laezza, Nadia; Cunha, Catarina; Gonçalves, Isabel; Lopes, Maria F

Congenital shunts of the portal venous system are rare entities that can present in children with clinical heterogeneity. To evaluate the clinical course of children with uncommon shunts presenting to our institution and examine the available literature on this topic. Medical records of children with rare forms of congenital shunts were retrospectively reviewed for demographics, symptoms, management, and outcome between 2003 and 2016. Three female patients with congenital shunts, including a congenital mesenterico-portal Rex shunt (n = 1) and congenital portosystemic shunts (CPSS) (n = 2), were referred for surgical evaluation between ages 4 and 9. Median follow-up was 8 years (range, 6-13 years). One asymptomatic patient did not require treatment and remained disease-free during long-term follow-up. The other 2 patients with CPSS and unusual symptoms, including liver focal nodular hyperplasia (FNH) in infancy (n = 1) and bleeding from esophageal varices (n = 1), showed subsequent progression to liver nodules that were managed by endovascular shunt occlusion. One patient showed symptom resolution and the other showed stable lesions at last follow-up. Literature yielded descriptions of two cases of congenital mesenterico-portal Rex shunt, one case of coincident CPSS and FNH in infancy, but zero reports of bleeding from esophageal varices. This case series examines each distinct patient's presentation, discusses the diagnosis, management and outcome and compares findings while discussing literature on this topic. A high index of suspicion and familiarity with unusual forms and treatment options is required to allow timely diagnosis and appropriate treatment.

The efficacy and safety of epinephrine for postoperative bleeding in total joint arthroplasty

PubMed Central

Teng, Yanbin; Ma, Jianxiong; Ma, Xinlong; Wang, Ying; Lu, Bin; Guo, Chaowei

2017-01-01

Abstract Background: Total joint arthroplasty (TJA) usually results in postoperative bleeding. Some randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) have been performed to evaluate the effects of epinephrine on postoperative bleeding after TJA. However, this remained controversial about the efficacy and safety of epinephrine for postoperative bleeding in TJA. The objective of our meta-analysis was to compare the overall effect and safety of epinephrine and placebo for postoperative bleeding in TJA. Methods: PubMed, Embase, and the Cochrane Library were searched to identify potentially relevant articles. RCTs or non-RCTs involving epinephrine and placebo for blood loss in total knee arthroplasty or total hip arthroplasty were included. Our study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RevMan v5.3 was used to analyze the relevant data. Results: Four RCTs and 1 non-RCT involving 646 participants met the inclusion criteria. The overall pooled results from meta-analysis demonstrated that compared with control groups, epinephrine groups could significantly reduce the postoperative bleeding volume (mean difference [MD] = −168.42, 95% confidence interval [CI]: −272.37 to −64.47, P = 0.001). There was no significant difference in intraoperative bleeding volume between epinephrine and control groups (MD = −12.89, 95% CI: −53.45 to 27.69, P = 0.53). No significant difference was found between 2 groups in terms of postoperative hemoglobin loss (MD = −0.28, 95% CI: −0.66 to 0.10, P = 0.15). Compared with the control groups, no statistically significant difference was found in terms of postoperative transfusion rate in epinephrine groups (relative risk [RR] 0.86, 95% CI: 0.64–1.15, P = 0.31). In addition, the results of the meta-analysis also indicated no significant difference in terms of the incidence rate of deep venous thrombosis (DVT) between 2 groups (RR 0.28, 95% CI: 0.05–1.64, P = 0.16). Conclusion: The meta-analysis showed that epinephrine could significantly reduce postoperative bleeding volume in TJA without increasing the incidence of DVT. However, there was no significant reduction in intraoperative bleeding volume, postoperative hemoglobin loss, and transfusion rate after the administration of epinephrine. Limitations: In this study, a higher heterogeneity and a risk of selection bias may be present in postoperative hemoglobin loss. In addition, the sample size of the included studies was too small, so our findings need to be further validated with more high-quality and larger scale RCTs in the future. Systematic review registration number: None. PMID:28445306

Inlet Performance Characteristics from Wind-Tunnel Tests of a 0.10-Scale Air-Induction System Model of the YF-108A Airplane at Mach Numbers of 2.50, 2.76, and 3.00

NASA Technical Reports Server (NTRS)

Blackaby, James R.; Lyman, E. Gene; Altermann, John A., III

1959-01-01

Inlet-performance and external-drag-coefficient characteristics are presented without analysis. Effects are shown of variations of fuselage boundary-layer diverter profile, bleed-surface porosity, bleed-exit area, and inlet ramp, and lip angle.

Predictors of perioperative major bleeding in patients who interrupt warfarin for an elective surgery or procedure: Analysis of the BRIDGE trial.

PubMed

Clark, Nathan P; Douketis, James D; Hasselblad, Vic; Schulman, Sam; Kindzelski, Andrei L; Ortel, Thomas L

2018-01-01

The use of low-molecular weight heparin bridge therapy during warfarin interruption for elective surgery/procedures increases bleeding. Other predictors of bleeding in this setting are not well described. BRIDGE was a randomized, double-blind, placebo-controlled trial of bridge therapy with dalteparin 100 IU/kg twice daily in patients with atrial fibrillation requiring warfarin interruption. Bleeding outcomes were documented from the time of warfarin interruption until up to 37 days postprocedure. Multiple logistic regression and time-dependent hazard models were used to identify major bleeding predictors. We analyzed 1,813 patients of whom 895 received bridging and 918 received placebo. Median patient age was 72.6 years, and 73.3% were male. Forty-one major bleeding events occurred at a median time of 7.0 days (interquartile range, 4.0-18.0 days) postprocedure. Bridge therapy was a baseline predictor of major bleeding (odds ratio [OR]=2.4, 95% CI: 1.2-4.8), as were a history of renal disease (OR=2.9, 95% CI: 1.4-6.0), and high-bleeding risk procedures (vs low-bleeding risk procedures) (OR=2.9, 95% CI: 1.4-5.9). Perioperative aspirin use (OR=3.6, 95% CI: 1.1-11.9) and postprocedure international normalized ratio >3.0 (OR=2.1, 95% CI: 1.5-3.1) were time-dependent predictors of major bleeding. Major bleeding was most common in the first 10 days compared with 11-37 days postprocedure (OR=3.5, 95% CI: 1.8-6.9). In addition to bridge therapy, perioperative aspirin use, postprocedure international normalized ratio >3.0, a history of renal failure, and having a high-bleeding risk procedure increase the risk of major bleeding around the time of an elective surgery/procedure requiring warfarin interruption. Copyright © 2017 Elsevier Inc. All rights reserved.

The need for investigations to elucidate causes and effects of abnormal uterine bleeding.

PubMed

Munro, Malcolm G; Heikinheimo, Oskari; Haththotuwa, Rohana; Tank, Jaydeep D; Fraser, Ian S

2011-09-01

This article describes a modern perspective on the basic investigations for abnormal uterine bleeding (AUB) in low-resource settings compared with a much more detailed approach for high-resource settings, bearing in mind issues of effectiveness and cost effectiveness. AUB includes any one or more of several symptoms, and it should be evaluated for the characteristics of the woman's specific bleeding pattern, her "complaint" and the presence of other symptoms (especially pain), the impact on several aspects of body functioning and lifestyle, and the underlying cause(s), especially cancer. Ideally, the evaluation is comprehensive, considering each of the potential etiological domains defined by the International Federation of Gynecology and Obstetrics PALM-COEIN system for the classification of causes. However, the detail of the questions and the extent of investigations will be significantly influenced by the technologies available and the time allotted for a consultation. In general, investigations should be performed only if they will make a material difference to the management approaches that can be offered. This should be an important consideration when a range of costly high-technology tests is accessible or when certain tests only have limited availability. © Thieme Medical Publishers.

Rivaroxaban in patients with atrial fibrillation: from ROCKET AF to everyday practice.

PubMed

Barón-Esquivias, Gonzalo; Marín, Francisco; Sanmartín Fernandez, Marcelo

2017-05-01

Registries and non-interventional studies offer relevant and complementary information to clinical trials, since they have a high external validity. Areas covered: The information regarding the efficacy and safety of rivaroxaban compared with warfarin, or rivaroxaban alone in clinical practice was reviewed in this manuscript. For this purpose, a search on MEDLINE and EMBASE databases was performed. The MEDLINE and EMBASE search included both medical subject headings (MeSH) and keywords including: atrial fibrillation (AF) OR warfarin OR clinical practice OR ROCKET AF AND rivaroxaban. Case reports were not considered. Expert commentary: In ROCKET AF, rivaroxaban was at least as effective as warfarin for the prevention of stroke in patients with nonvalvular AF at high risk of stroke, but, importantly, with a lesser risk of intracranial, critical and fatal bleedings. A number of observational comparative and non-comparative studies, with more than 60,000 patients included treated with rivaroxaban, have analyzed the efficacy and safety of rivaroxaban in real-life patients with AF in different clinical settings. These studies have shown that in clinical practice, rates of stroke and major bleeding were consistently lower than those reported in ROCKET AF, likely due to the lower thromboembolic and bleeding risk observed in these patients.

Rare cause of upper gastrointestinal bleeding owing to hepatic cancer invasion: a case report.

PubMed

Wu, Wei-Ding; Wu, Jia; Yang, Hong-Guo; Chen, Yuan; Zhang, Cheng-Wu; Zhao, Da-Jian; Hu, Zhi-Ming

2014-09-21

Upper gastrointestinal bleeding refers to bleeding that arises from the gastrointestinal tract proximal to the ligament of Treitz. The primary reason for gastrointestinal bleeding associated with hepatocellular carcinoma is rupture of a varicose vein owing to pericardial hypotension. We report a rare case of gastrointestinal bleeding with hepatocellular carcinoma in a patient who presented with recurrent gastrointestinal bleeding. The initial diagnosis was gastric cancer with metastasis to the multiple lymph nodes of the lesser curvature. The patient underwent exploratory laparotomy, which identified two lesions in the gastric wall. Total gastrectomy and hepatic local excision was then performed. Pathological results indicated that the hepatocellular carcinoma had invaded the stomach directly, which was confirmed immunohistochemically. The patient is alive with a disease-free survival of 1 year since the surgery. Hepatocellular carcinoma with gastric invasion should be considered as a rare cause of upper gastrointestinal bleeding in hepatocellular carcinoma patients, especially with lesions located in the left lateral hepatic lobe. Surgery is the best solution.

New advances in lower gastrointestinal bleeding management with embolotherapy

PubMed Central

Ierardi, Anna Maria; Urbano, Josè; De Marchi, Giuseppe; Micieli, Camilla; Duka, Ejona; Iacobellis, Francesca; Fontana, Federico

2016-01-01

Lower gastrointestinal bleeding (LGIB) is associated with high morbidity and mortality. Embolization is currently proposed as the first step in the treatment of acute, life-threatening LGIB, when endoscopic approach is not possible or is unsuccessful. Like most procedures performed in emergency setting, time represents a significant factor influencing outcome. Modern tools permit identifying and reaching the bleeding site faster than two-dimensional angiography. Non-selective cone-beam CT arteriography can identify a damaged vessel. Moreover, sophisticated software able to detect the vessel may facilitate direct placement of a microcatheter into the culprit vessel without the need for sequential angiography. A further important aspect is the use of an appropriate technique of embolization and a safe and effective embolic agent. Current evidence shows the use of detachable coils (with or without a triaxial system) and liquid embolics has proven advantages compared with other embolic agents. The present article analyses these modern tools, making embolization of acute LGIB safer and more effective. PMID:26764281

Celiac Injury Due to Arcuate Ligament: An Endovascular Approach

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zini, Chiara, E-mail: zini.chiara@gmail.com; Corona, Mario, E-mail: mario.corona@uniroma.it; Boatta, Emanuele, E-mail: emanuele.boatta@yahoo.it

2013-06-15

Celiac trunk injures are rare events, with high mortality rates and difficult management. Endovascular treatment may be considered to avoid bleeding. We report a case of severe bleeding in a 37-year-old man resulting from celiac trunk stretching after a motorcycle crash. Because direct celiac trunk catheterization was not possible, a retrograde catheterization of the common hepatic artery was performed via the superior mesenteric artery. Two vascular plugs (type IV) were released, and the exclusion of the celiac trunk origin was completed with the deployment of an aortic cuff. The patient's clinical condition immediately improved, and after 6 months' follow-up, imagingmore » confirmed the complete exclusion of the celiac trunk.« less

Pulmonary artery perforation by plug anchoring system after percutaneous closure of left appendage.

PubMed

Bianchi, Giacomo; Solinas, Marco; Gasbarri, Tommaso; Bevilacqua, Stefano; Tiwari, Kaushal Kishore; Berti, Sergio; Glauber, Mattia

2013-07-01

Patients receiving oral anticoagulant therapy for atrial fibrillation who are at high risk of bleeding are increasingly referred for percutaneous left atrial appendage exclusion. Although effective, this procedure is not free from risk. We report a case of pericardial tamponade due to pulmonary artery tear caused by a trespassing anchoring hook of an AGA plug. Intraoperatively, no actual bleeding was found from the left appendage, a proof of its complete occlusion by the device. The patient underwent successful surgical repair and radio-frequency ablation of atrial fibrillation was performed by pulmonary veins encircling. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

An endovascular option is the final treatment for a giant arteriovenous malformation.

PubMed

Benedetto, Filippo; Pipitò, Narayana; Barillà, David; Spinelli, Domenico; Stilo, Francesco; Spinelli, Francesco

2014-11-01

We report the case of a 58-year-old man presented with bleeding ulcer of the left arm caused by a high-flow type-C arteriovenous malformation (AVM), feed by branches from both the subclavian arteries. He had been previously treated with AVM sclerotherapy, embolization, humeral artery endografting, and open surgery. We urgently performed coil embolization of the left vertebral artery, and we covered the huge subclavian artery by a thoracic endograft. Then, we embolized the right tyrocervical trunk. The result was an immediate interruption of bleeding. At 12 months, the patient had no neurologic complications, and the upper limb continued to decompress. Copyright © 2014 Elsevier Inc. All rights reserved.

Examining the bleeding incidences associated with targeted therapies used in metastatic renal cell carcinoma.

PubMed

Crist, MacKenzie; Hansen, Elizabeth; Chablani, Lipika; Guancial, Elizabeth

2017-12-01

A systematic review was conducted to illustrate the bleeding risks associated with targeted therapies used in the treatment of metastatic renal cell carcinoma (mRCC). Eligible studies included phase II, III, or IV clinical trials using pazopanib, sunitinib, cabozantinib, lenvatinib, everolimus, temsirolimus, bevacizumab, axitinib, and/or sorafenib in the setting of mRCC. Types of bleeding event(s), bleeding event frequency, and incidence of thrombocytopenia were collected from the relevant articles. ClinicalTrials.gov was also searched for incidence of "Serious bleeding adverse effects" reported in these trials. The incidences of bleeding events ranged from 1 to 36%, and incidences of thrombocytopenia ranged from 2 to 78%. Available serious bleeding adverse events ranged from 1 to 7%. The highest percentage of bleeding incidences were seen with bevacizumab, while the lowest percentage of bleeding incidences were seen with axitinib. All of the included trials were of high quality per Jadad scoring. Copyright © 2017 Elsevier B.V. All rights reserved.

Early Recurrence and Cerebral Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation: Effect of Anticoagulation and Its Timing: The RAF Study.

PubMed

Paciaroni, Maurizio; Agnelli, Giancarlo; Falocci, Nicola; Caso, Valeria; Becattini, Cecilia; Marcheselli, Simona; Rueckert, Christina; Pezzini, Alessandro; Poli, Loris; Padovani, Alessandro; Csiba, Laszló; Szabó, Lilla; Sohn, Sung-Il; Tassinari, Tiziana; Abdul-Rahim, Azmil H; Michel, Patrik; Cordier, Maria; Vanacker, Peter; Remillard, Suzette; Alberti, Andrea; Venti, Michele; Scoditti, Umberto; Denti, Licia; Orlandi, Giovanni; Chiti, Alberto; Gialdini, Gino; Bovi, Paolo; Carletti, Monica; Rigatelli, Alberto; Putaala, Jukka; Tatlisumak, Turgut; Masotti, Luca; Lorenzini, Gianni; Tassi, Rossana; Guideri, Francesca; Martini, Giuseppe; Tsivgoulis, Georgios; Vadikolias, Kostantinos; Liantinioti, Chrissoula; Corea, Francesco; Del Sette, Massimo; Ageno, Walter; De Lodovici, Maria Luisa; Bono, Giorgio; Baldi, Antonio; D'Anna, Sebastiano; Sacco, Simona; Carolei, Antonio; Tiseo, Cindy; Acciarresi, Monica; D'Amore, Cataldo; Imberti, Davide; Zabzuni, Dorjan; Doronin, Boris; Volodina, Vera; Consoli, Domenico; Galati, Franco; Pieroni, Alessio; Toni, Danilo; Monaco, Serena; Baronello, Mario Maimone; Barlinn, Kristian; Pallesen, Lars-Peder; Kepplinger, Jessica; Bodechtel, Ulf; Gerber, Johannes; Deleu, Dirk; Melikyan, Gayane; Ibrahim, Faisal; Akhtar, Naveed; Mosconi, Maria Giulia; Bubba, Valentina; Silvestri, Ilenia; Lees, Kennedy R

2015-08-01

The best time for administering anticoagulation therapy in acute cardioembolic stroke remains unclear. This prospective cohort study of patients with acute stroke and atrial fibrillation, evaluated (1) the risk of recurrent ischemic event and severe bleeding; (2) the risk factors for recurrence and bleeding; and (3) the risks of recurrence and bleeding associated with anticoagulant therapy and its starting time after the acute stroke. The primary outcome of this multicenter study was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding within 90 days from acute stroke. Of the 1029 patients enrolled, 123 had 128 events (12.6%): 77 (7.6%) ischemic stroke or transient ischemic attack or systemic embolism, 37 (3.6%) symptomatic cerebral bleeding, and 14 (1.4%) major extracranial bleeding. At 90 days, 50% of the patients were either deceased or disabled (modified Rankin score ≥3), and 10.9% were deceased. High CHA2DS2-VASc score, high National Institutes of Health Stroke Scale, large ischemic lesion and type of anticoagulant were predictive factors for primary study outcome. At adjusted Cox regression analysis, initiating anticoagulants 4 to 14 days from stroke onset was associated with a significant reduction in primary study outcome, compared with initiating treatment before 4 or after 14 days: hazard ratio 0.53 (95% confidence interval 0.30-0.93). About 7% of the patients treated with oral anticoagulants alone had an outcome event compared with 16.8% and 12.3% of the patients treated with low molecular weight heparins alone or followed by oral anticoagulants, respectively (P=0.003). Acute stroke in atrial fibrillation patients is associated with high rates of ischemic recurrence and major bleeding at 90 days. This study has observed that high CHA2DS2-VASc score, high National Institutes of Health Stroke Scale, large ischemic lesions, and type of anticoagulant administered each independently led to a greater risk of recurrence and bleedings. Also, data showed that the best time for initiating anticoagulation treatment for secondary stroke prevention is 4 to 14 days from stroke onset. Moreover, patients treated with oral anticoagulants alone had better outcomes compared with patients treated with low molecular weight heparins alone or before oral anticoagulants. © 2015 American Heart Association, Inc.

Scoring model to predict massive post-partum bleeding in pregnancies with placenta previa: A retrospective cohort study.

PubMed

Lee, Ji Yeon; Ahn, Eun Hee; Kang, Sukho; Moon, Myung Jin; Jung, Sang Hee; Chang, Sung Woon; Cho, Hee Young

2018-01-01

We aimed to identify factors associated with massive post-partum bleeding in pregnancies with placenta previa and to establish a scoring model to predict post-partum severe bleeding. A retrospective cohort study was performed in 506 healthy singleton pregnancies with placenta previa from 2006 to 2016. Cases with intraoperative blood loss (≥2000 mL), packed red blood cells transfusion (≥4), uterine artery embolization, or hysterectomy were defined as massive bleeding. After performing multivariable analysis, using the adjusted odds ratios (aOR), we formulated a scoring model. Seventy-three women experienced massive post-partum bleeding (14.4%). After multivariable analysis, seven variables were associated with massive bleeding: maternal old age (≥35 years; aOR 1.79, 95% confidence interval [CI] 1.00-3.20, P = 0.049), antepartum bleeding (aOR 4.76, 95%CI 2.01-11.02, P < 0.001), non-cephalic presentation (aOR 3.41, 95%CI 1.40-8.30, P = 0.007), complete placenta previa (aOR 1.93, 95%CI 1.05-3.54, P = 0.034), anterior placenta (aOR 2.74, 95%CI 1.54-4.89, P = 0.001), multiple lacunae (≥4; aOR 2.77, 95%CI 1.54-4.99, P = 0.001), and uteroplacental hypervascularity (aOR 4.51, 95%CI 2.30-8.83, P < 0.001). We formulated a scoring model including maternal old age (<35: 0, ≥35: 1), antepartum bleeding (no: 0, yes: 2), fetal non-cephalic presentation (no: 0, yes: 2), placenta previa type (incomplete: 0, complete: 1), placenta location (posterior: 0, anterior: 1), uteroplacental hypervascularity (no: 0, yes: 2), and multiple lacunae (no: 0, yes: 1) to predict post-partum massive bleeding. According to our scoring model, a score of 5/10 had a sensitivity of 81% and a specificity of 77% for predicting massive post-partum bleeding. The area under the receiver-operator curve was 0.856 (P < 0.001). The negative predictive value was 95.9%. Our scoring model might provide useful information for prediction of massive post-partum bleeding in pregnancies with placenta previa. © 2017 Japan Society of Obstetrics and Gynecology.

A case of nodal malignant lymphoma presenting with arterial bleeding related to its duodenal penetration.

PubMed

Miyake, Takakazu; Iida, Tomoya; Masaki, Yoshiharu; Onodera, Kei; Kubo, Toshiyuki; Yamashita, Kentaro; Yamano, Hiroo; Nakase, Hiroshi

2018-06-01

A 62-year-old man with a chief complaint of dysphagia visited our hospital. Enhanced computed tomography showed the tumor near the duodenal wall and lymphadenopathy in the left supraclavicular fossa and para-aortic lymph node. Upper gastrointestinal endoscopy showed an ulcer accompanied with a fistula in the anterior wall of duodenal bulb, suggesting that the tumor penetrated into duodenal wall. Biopsy from the lymph node in the left supraclavicular fossa indicated diffuse large B-cell lymphoma. Although chemotherapy was planned, massive arterial bleeding occurred from the part of duodenal penetration. Endoscopic hemostasis was unsuccessfully performed. Therefore, we performed transcathether arterial embolization for hemostasis. After the procedure, the patient received six cycles of chemotherapy, and he achieved complete response. He has been alive 5 years without recurrence. There were many cases of gastrointestinal bleeding from primary gastrointestinal lymphomas, while there were few cases with nodal involvement by malignant lymphoma resulting in bleeding from gastrointestinal tract. We herein report a case of duodenal bleeding by nodal involvement of diffuse large B-cell lymphoma with review of literature.

Rectal bleeding after high-dose-rate brachytherapy combined with hypofractionated external-beam radiotherapy for localized prostate cancer: Impact of rectal dose in high-dose-rate brachytherapy on occurrence of grade 2 or worse rectal bleeding

DOE Office of Scientific and Technical Information (OSTI.GOV)

Akimoto, Tetsuo; Katoh, Hiroyuki; Kitamoto, Yoshizumi

2006-06-01

Purpose: To evaluate the incidence of Grade 2 or worse rectal bleeding after high-dose-rate (HDR) brachytherapy combined with hypofractionated external-beam radiotherapy (EBRT), with special emphasis on the relationship between the incidence of rectal bleeding and the rectal dose from HDR brachytherapy. Methods and Materials: The records of 100 patients who were treated by HDR brachytherapy combined with EBRT for {>=}12 months were analyzed. The fractionation schema for HDR brachytherapy was prospectively changed, and the total radiation dose for EBRT was fixed at 51 Gy. The distribution of the fractionation schema used in the patients was as follows: 5 Gy xmore » 5 in 13 patients; 7 Gy x 3 in 19 patients; and 9 Gy x 2 in 68 patients. Results: Ten patients (10%) developed Grade 2 or worse rectal bleeding. Regarding the correlation with dosimetric factors, no significant differences were found in the average percentage of the entire rectal volume receiving 30%, 50%, 80%, and 90% of the prescribed radiation dose from EBRT between those with bleeding and those without. The average percentage of the entire rectal volume receiving 10%, 30%, 50%, 80%, and 90% of the prescribed radiation dose from HDR brachytherapy in those who developed rectal bleeding was 77.9%, 28.6%, 9.0%, 1.5%, and 0.3%, respectively, and was 69.2%, 22.2%, 6.6%, 0.9%, and 0.4%, respectively, in those without bleeding. The differences in the percentages of the entire rectal volume receiving 10%, 30%, and 50% between those with and without bleeding were statistically significant. Conclusions: The rectal dose from HDR brachytherapy for patients with prostate cancer may have a significant impact on the incidence of Grade 2 or worse rectal bleeding.« less

Bleeding frequency and characteristics among hematologic malignancy inpatient rehabilitation patients with severe thrombocytopenia.

PubMed

Fu, Jack B; Tennison, Jegy M; Rutzen-Lopez, Isabel M; Silver, Julie K; Morishita, Shinichiro; Dibaj, Seyedeh S; Bruera, Eduardo

2018-03-28

To identify the frequency and characteristics of bleeding complications during acute inpatient rehabilitation of hematologic malignancy patients with severe thrombocytopenia. Retrospective descriptive analysis. Comprehensive cancer center acute inpatient rehabilitation unit. Consecutive hematologic malignancy patients with a platelet count of less than or equal to 20,000/microliter (μL) on the day of acute inpatient rehabilitation admission from 1/1/2005 through 8/31/2016. Medical records were retrospectively analyzed for demographic, laboratory, and medical data. Patients were rehabilitated using the institutional exercise guidelines for thrombocytopenic patients. Bleeding events noted in the medical record. Out of 135 acute inpatient rehabilitation admissions, 133 unique patients were analyzed with a total of 851 inpatient rehabilitation days. The mean platelet count was 14,000/μL on the day of admission and 22,000/μL over the course of the rehabilitation admission. There were 252 days of inpatient rehabilitation where patients had less than 10,000/μL platelets. A total of 97 bleeding events were documented in 77/135 (57%) admissions. Of the 97 bleeding events, 72 (74%), 14 (14%), and 11 (11%) were considered to be of low, medium, and high severity, respectively. There were 4/97 (4%) bleeding events that were highly likely attributable to physical activity but only 1/4 was considered high severity. Bleeding rates were .09, .08, .17, and .37 for > 20,000, 15-20,000, 10-15,000, and < 10,000/μL mean platelet counts respectively (p = .003). Forty-four percent of patients were transferred back to the primary acute care service with infection being the most common reason for transfer. This study is the first to examine exercise-related bleeding complications during acute inpatient rehabilitation in severely thrombocytopenic hematologic cancer patients. Bleeding rates increased with lower platelet counts. However, using the exercise guidelines for severely thrombocytopenic patients, the risk of severe exercise-related bleeding events was low.

Transcatheter treatment of life-threatening lower gastrointestinal bleeding due to advanced pelvic malignancy.

PubMed

Spinosa, D J; Angle, J F; McGraw, J K; Maurer, E J; Hagspiel, K D; Matsumoto, A H

1998-01-01

We present two patients with life-threatening, massive, lower gastrointestinal (GI) bleeding and locally advanced cervical carcinoma. Selective pelvic arteriography demonstrated that the site of bleeding originated from a pseudoaneurysm of the right internal iliac artery with fistulous communication to the sigmoid colon in one patient and from the left internal iliac artery into the rectum in the second patient. Transcatheter embolotherapy was then performed using balloon occlusion in one patient and coil embolization in the second patient. The iliac arteries should also be evaluated in patients with pelvic cancer who present with lower GI bleeding.

The Efficacy of a Pre-Workout Vegan Supplement on High-Intensity Cycling Performance in Healthy College-Aged Males.

PubMed

Gallien, Gabrielle; Bellar, David; Davis, Greggory R

2017-11-02

There is a limited supply of sport nutrition supplements currently available for vegan or vegetarian athletes. In addition, the efficacy of a vegan or vegetarian pre-workout supplement that does not contain any processed ingredients or stimulants is currently unknown. The purpose of the current study was to examine the effects of an unprocessed vegan pre-workout supplement on high-intensity cycling performance. Participants completed three separate cycling trials following the consumption of a vegan pre-workout supplement, an isocaloric processed supplement, or a zero-calorie placebo supplement. Each supplement was consumed 30 minutes prior to each trial, and each cycling trial was separated by a minimum of 72 hours. Supplements were administered using a randomized, double-blind cross-over design. Each cycling trial was performed at a workload equal to 80% VO 2peak until exhaustion. The average time in seconds (s) until exhaustion values for the vegan, isocaloric, and zero-calorie supplements were 482 ± 163, 480 ± 157, and 496 ± 238, respectively. Consumption of the vegan supplement did not significantly improve performance compared to an isocaloric and zero-calorie supplement (F = 0.12, p =.89). The results of this study indicate that individuals who choose a vegan pre-workout supplement (over an isocaloric or zero-calorie product) will not experience any acute decrements or ergogenic benefits in cycling performance. Although the present study does not support performance benefits of the tested vegan pre-workout supplement before cycling, additional research examining various exercise intensities and modalities is warranted.

Diagnosis and management of upper gastrointestinal bleeding in children.

PubMed

Owensby, Susan; Taylor, Kellee; Wilkins, Thad

2015-01-01

Upper gastrointestinal bleeding is an uncommon but potentially serious, life-threatening condition in children. Rapid assessment, stabilization, and resuscitation should precede all diagnostic modalities in unstable children. The diagnostic approach includes history, examination, laboratory evaluation, endoscopic procedures, and imaging studies. The clinician needs to determine carefully whether any blood or possible blood reported by a child or adult represents true upper gastrointestinal bleeding because most children with true upper gastrointestinal bleeding require admission to a pediatric intensive care unit. After the diagnosis is established, the physician should start a proton pump inhibitor or histamine 2 receptor antagonist in children with upper gastrointestinal bleeding. Consideration should also be given to the initiation of vasoactive drugs in all children in whom variceal bleeding is suspected. An endoscopy should be performed once the child is hemodynamically stable. © Copyright 2015 by the American Board of Family Medicine.

Alternative Treatment for Bleeding Peristomal Varices: Percutaneous Parastomal Embolization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pabon-Ramos, Waleska M., E-mail: waly.pr@duke.edu; Niemeyer, Matthew M.; Dasika, Narasimham L., E-mail: narasimh@med.umich.edu

2013-10-15

Purpose: To describe how peristomal varices can be successfully embolized via a percutaneous parastomal approach. Methods: The medical records of patients who underwent this procedure between December 1, 2000, and May 31, 2008, were retrospectively reviewed. Procedural details were recorded. Median fluoroscopy time and bleeding-free interval were calculated. Results: Seven patients underwent eight parastomal embolizations. The technical success rate was 88 % (one failure). All embolizations were performed with coils combined with a sclerosant, another embolizing agent, or both. Of the seven successful parastomal embolizations, there were three cases of recurrent bleeding; the median time to rebleeding was 45 daysmore » (range 26-313 days). The remaining four patients did not develop recurrent bleeding during the follow-up period; their median bleeding-free interval was 131 days (range 40-659 days). Conclusion: This case review demonstrated that percutaneous parastomal embolization is a feasible technique to treat bleeding peristomal varices.« less

Posterior epistaxis: Common bleeding sites and prophylactic electrocoagulation.

PubMed

Liu, Juan; Sun, Xicai; Guo, Limin; Wang, Dehui

2016-01-01

Posterior epistaxis is a frequent emergency, and the key to efficient management is identification of the bleeding point. We performed a retrospective study of 318 patients with posterior epistaxis treated with endoscopic bipolar electrocautery during a 4-year period. Distribution of the bleeding sites was recorded. Patients with no definite bleeding sites in the first operation were assigned to Group A (n = 39) and Group B (n = 34). Patients in Group A were only observed in the ward. Patients in Group B were given prophylactic electrocoagulation at the common bleeding points. Of the 318 patients, bleeding sites were successfully identified and coagulated in 263 patients. All of them were located posteriorly, with 166 on the lateral nasal wall, 86 on the septum, and 11 on the anterior face of the sphenoid sinus. The rebleeding rate of Group B (8.8%) was lower than that of Group A (38.5%) (p < 0.01).

Factor VII Deficiency: Clinical Phenotype, Genotype and Therapy.

PubMed

Napolitano, Mariasanta; Siragusa, Sergio; Mariani, Guglielmo

2017-03-28

Factor VII deficiency is the most common among rare inherited autosomal recessive bleeding disorders, and is a chameleon disease due to the lack of a direct correlation between plasma levels of coagulation Factor VII and bleeding manifestations. Clinical phenotypes range from asymptomatic condition-even in homozygous subjects-to severe life-threatening bleedings (central nervous system, gastrointestinal bleeding). Prediction of bleeding risk is thus based on multiple parameters that challenge disease management. Spontaneous or surgical bleedings require accurate treatment schedules, and patients at high risk of severe hemorrhages may need prophylaxis from childhood onwards. The aim of the current review is to depict an updated summary of clinical phenotype, laboratory diagnosis, and treatment of inherited Factor VII deficiency.

Factor VII Deficiency: Clinical Phenotype, Genotype and Therapy

PubMed Central

Napolitano, Mariasanta; Siragusa, Sergio; Mariani, Guglielmo

2017-01-01

Factor VII deficiency is the most common among rare inherited autosomal recessive bleeding disorders, and is a chameleon disease due to the lack of a direct correlation between plasma levels of coagulation Factor VII and bleeding manifestations. Clinical phenotypes range from asymptomatic condition—even in homozygous subjects—to severe life-threatening bleedings (central nervous system, gastrointestinal bleeding). Prediction of bleeding risk is thus based on multiple parameters that challenge disease management. Spontaneous or surgical bleedings require accurate treatment schedules, and patients at high risk of severe hemorrhages may need prophylaxis from childhood onwards. The aim of the current review is to depict an updated summary of clinical phenotype, laboratory diagnosis, and treatment of inherited Factor VII deficiency. PMID:28350321

40 CFR 60.2210 - What information must I include in my annual report?

Code of Federal Regulations, 2012 CFR

2012-07-01

... Performance for Commercial and Industrial Solid Waste Incineration Units for Which Construction Is Commenced..., time, and duration that each CMS was inoperative, except for zero (low-level) and high-level checks. (3... procedure in 40 CFR part 60, appendix F of this part, as if any of the following occur. (1) The zero (low...

40 CFR 60.2210 - What information must I include in my annual report?

Code of Federal Regulations, 2011 CFR

2011-07-01

... Performance for Commercial and Industrial Solid Waste Incineration Units for Which Construction Is Commenced..., time, and duration that each CMS was inoperative, except for zero (low-level) and high-level checks. (3... procedure in 40 CFR part 60, appendix F of this part, as if any of the following occur. (1) The zero (low...

Zero-CO2 emission and low-crossover 'rechargeable' PEM fuel cells using cyclohexane as an organic hydrogen reservoir.

PubMed

Kariya, Nobuko; Fukuoka, Atsushi; Ichikawa, Masaru

2003-03-21

High performance (open circuit voltage = 920 mV, maximum power density = 14-15 mW cm(-2)) of the PEM fuel cell was achieved by using cyclohexane as a fuel with zero-CO2 emission and lower-crossover through PEM than with a methanol-based fuel cell.

Unidirectional transmission using array of zero-refractive-index metamaterials

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fu, Yangyang; Xu, Lin; Hong Hang, Zhi

2014-05-12

In this Letter, we find that high efficient unidirectional transmission occurs for an array of prisms made of zero-refractive-index metamaterials. As a specific demonstration, we further design the device using Dirac-cone-like photonic crystals. The device can function for a broadband of spectrum. Numerical simulations are performed to verify the one-way wave functionality.

Transcatheter arterial embolization for upper gastrointestinal tract bleeding

PubMed Central

Širvinskas, Audrius; Smolskas, Edgaras; Brimienė, Vilma; Brimas, Gintautas

2017-01-01

Introduction Transcatheter arterial embolization is a possible treatment for patients with recurrent bleeding from the upper gastrointestinal tract after failed endoscopic management and is also an alternative to surgical treatment. Aim To analyze the outcomes of transcatheter arterial embolization and identify the clinical and technical factors that influenced the rates of morbidity and mortality. Material and methods A retrospective analysis was carried out, based on the data of 36 patients who underwent transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding in 2013 to 2015 in our center. An analysis was performed between early rebleeding rates, mortality and the following factors: patient sex, age, number of units of packed red blood cells and packed plasma administered to the patients, length of hospital stay, therapeutic or prophylactic embolization. Results The technical success rate of the embolization procedure was 100%. There were 15 (41.70%) therapeutic embolizations and 21 (58.3%) prophylactic embolizations. There was a 77.8% clinical success rate. Following embolization, 10 (27.80%) patients had repeated bleeding and 9 (25.0%) patients died. Significant associations were found between rebleeding and prophylactic embolization (OR = 10.53; p = 0.04) and between mortality and prophylactic embolization (OR = 10.53; p = 0.04) and units of packed red blood cells (OR = 1.25; p < 0.01). Conclusions In our experience, transcatheter arterial embolization is a safe treatment method for acute nonvariceal upper gastrointestinal bleeding and a possible alternative to surgery for high-risk patients. PMID:29362654

Transcatheter Arterial Embolization for Gastrointestinal Bleeding Secondary to Gastrointestinal Lymphoma.

PubMed

Zheng, Lin; Shin, Ji Hoon; Han, Kichang; Tsauo, Jiaywei; Yoon, Hyun-Ki; Ko, Gi-Young; Shin, Jong-Soo; Sung, Kyu-Bo

2016-11-01

To evaluate the effectiveness of transcatheter arterial embolization (TAE) for gastrointestinal (GI) bleeding caused by GI lymphoma. The medical records of 11 patients who underwent TAE for GI bleeding caused by GI lymphoma between 2001 and 2015 were reviewed retrospectively. A total of 20 TAE procedures were performed. On angiography, contrast extravasation, and both contrast extravasation and tumor staining were seen in 95 % (19/20) and 5 % (1/20) of the procedures, respectively. The most frequently embolized arteries were jejunal (n = 13) and ileal (n = 5) branches. Technical and clinical success rates were 100 % (20/20) and 27 % (3/11), respectively. The causes of clinical failure in eight patients were rebleeding at new sites. In four patients who underwent repeat angiography, the bleeding focus was new each time. Three patients underwent small bowel resection due to rebleeding after one (n = 2) or four (n = 1) times of TAEs. Another two patients underwent small bowel resection due to small bowel ischemia/perforation after three or four times of TAEs. The 30-day mortality rate was 18 % due to hypovolemic shock (n = 1) and multiorgan failure (n = 1). Angiogram with TAE shows limited therapeutic efficacy to manage GI lymphoma-related bleeding due to high rebleeding at new sites. Although TAE can be an initial hemostatic measure, surgery should be considered for rebleeding due to possible bowel ischemic complication after repeated TAE procedures.

DOE Zero Energy Ready Home Case Study: United Way of Long Island, United Veterans Beacon House

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pacific Northwest National Laboratory

United Way of Long Island’s Housing Development Corporation built this 3,719-ft2 two–story, 5-bedroom home in Huntington Station, New York, to the rigorous performance requirements of the U.S. Department of Energy’s Zero Energy Ready Home Program. The home is packed with high-performance features like LED lighting and ENERGY STAR appliances. The asymmetrical, optimally angled roof provides plenty of space for roof-mounted solar panels for electric generation and hot water.

Laparoscopic splenectomy and azygoportal disconnection for bleeding varices with hypersplenism.

PubMed

Wang, Yue D; Ye, Huan; Ye, Zai Y; Zhu, Yang W; Xie, Zhi J; Zhu, Jin H; Liu, Jin M; Zhao, Ting

2008-02-01

Bleeding from esophageal varices is an important cause of morbidity and mortality in patients with portal hypertension. The ideal surgical procedure should control bleeding with as little impairment of liver function as possible and with low rates of encephalopathy. Recently, significant progress in laparoscopic technology has enabled laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach in a less invasive way. In this paper, we present preliminary results for 25 patients in whom laparoscopic splenectomy and azygoportal disconnection were performed. Laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach were performed in 25 patients with cirrhosis, bleeding portal hypertension, and secondary hypersplenism between January 2000 and October 2006. Among them, 5 patients underwent a laparoscopic modified Sugiura procedure, the lower esophagus was transected, and then reanastomosed with a circular stapler. Laparoscopic splenectomy and azygoportal disconnection were completed in all patients, except in 1 conversion, without significant morbidity. The operation time ranged from 4.0 to 5.5 hours and the blood loss was 100-400 mL. The postoperative hospital stay was 6-15 days. During a postoperative follow-up period of 3 months to 5 years in 22 patients, neither esophagus variceal bleeding nor encephalopathy has recurred. Laparoscopic splenectomy and azygoportal disconnection are feasible, effective, and safe surgical procedures, and have all the benefits of minimally invasive surgery for patients with bleeding portal hypertension and hypersplenism. Laparoscopic splenectomy and azygoportal disconnection offer a new operative method for treatment of bleeding portal hypertension with hypersplenism.

[Re-operations in patients with heart wounds].

PubMed

Radchenko, Yu A; Abakumov, M M; Vladimirova, E S; Pogodina, A N; Nikitina, O V

To define the risk factors of complications which are followed by re-operations in patients with cardiac and pericardial wounds and to prevent these complications. Retrospective and prospective analysis of 1072 victims with cardiac and pericardial injuries for 35 years was performed. Overall mortality was 17.2%. 98 patients died during surgery. Postoperative bleeding was observed in 38 (3.9%) cases. In 28 cases re-operations were performed for bleeding-related complications. Indications for re-thoracotomy were one-time drainage from pleural cavity over 500 ml or bleeding rate over 100 ml per hour for 4 hours. Prevention of postoperative bleeding in case of cardiac and pericardial wounds was developed on basis of analysis of these observations. Risk factors of complications requiring re-operation are cardiomyopathy of different etiology, technical and tactical errors during primary intervention and hypocoagulation with massive blood loss. Prevention of these complications includes careful heart wound closure, comprehensive intraoperative control, correction of hemostatic system.

Efficacy and safety of percutaneous left atrial appendage closure to prevent thromboembolic events in atrial fibrillation patients with high stroke and bleeding risk.

PubMed

Seeger, Julia; Bothner, Carlo; Dahme, Tillman; Gonska, Birgid; Scharnbeck, Dominik; Markovic, Sinisa; Rottbauer, Wolfgang; Wöhrle, Jochen

2016-03-01

The randomized PROTECT AF trial demonstrated non-inferiority of left atrial appendage (LAA) closure to oral anticoagulation with warfarin. Current guidelines give a class IIb recommendation for LAA closure. We evaluated the efficacy and safety of LAA closure in a consecutive series of non-valvular atrial fibrillation patients with contraindications to long-term oral anticoagulation or at high bleeding risk. 101 consecutive non-valvular atrial fibrillation patients (age 74.7 ± 7.5 years) at high risk for stroke (CHA2DS2-VASc Score 4.4 ± 1.6) and high bleeding risk (HAS-BLED Score 4.2 ± 1.3) received LAA closure with either the Watchman closure device (n = 38) or the Amplatzer cardiac plug (n = 63). Dual antiplatelet therapy with aspirin and clopidogrel was recommended for 3-6 months after device implantation, followed by long-term antiplatelet therapy with aspirin. No anticoagulation was given after device implantation. Mean follow-up was 400 days. One patient (1 %) experienced a transient ischemic attack, and two patients (2 %) suffered from ischemic stroke. While on recommended antiplatelet therapy, bleeding occurred in 12/101 patients (12 %). Bleeding was significantly reduced with 3 compared with 6 months dual antiplatelet therapy (3.0 vs. 16.2 %, p < 0.05) while ischemic or thrombotic events were similar. Left atrial appendage closure in patients with non-valvular atrial fibrillation and high risk for stroke and bleeding events effectively prevented stroke and reduced cerebral ischemic events compared to expected stroke rate according to CHA2DS2-VASc Score. Dual antiplatelet therapy for 3 months reduced the rate of bleeding events compared to 6 months therapy with no increase of thrombotic events.

40 CFR 86.523-78 - Oxides of nitrogen analyzer calibration.

Code of Federal Regulations, 2014 CFR

2014-07-01

... analyzer to optimize performance. (2) Zero the oxides of nitrogen analyzer with zero grade air or zero... samples. Proceed as follows: (1) Adjust analyzer to optimize performance. (2) Zero the oxides of nitrogen analyzer with zero grade air or zero grade nitrogen. (3) Calibrate on each normally used operating range...

Midterm and one-year outcome of amphilimus polymer free drug eluting stent in patients needing short dual antiplatelet therapy. Insight from the ASTUTE registry (AmphilimuS iTalian mUlticenTer rEgistry).

PubMed

Godino, Cosmo; Chiarito, Mauro; Donahue, Michael; Testa, Luca; Colantonio, Riccardo; Cappelletti, Alberto; Monello, Alberto; Magni, Valeria; Milazzo, Diego; Parisi, Rosario; Nicolino, Annamaria; Moshiri, Shahram; Fattori, Rossella; Aprigliano, Gianfranco; Palloshi, Altin; Caramanno, Giuseppe; Montorfano, Matteo; Bedogni, Francesco; Briguori, Carlo; Margonato, Alberto; Colombo, Antonio

2017-03-15

To assess clinical outcomes of patients needing short dual antiplatelet therapy (S-DAPT) after PCI with Cre8 polymer-free amphilimus eluting-stent (AES). The Cre8-AES with pure i-Carbofilm coating was supposed to induce faster stent endothelialization and reduce device thrombogenicity. We performed a sub-analysis of unrestricted consecutive patients treated with Cre8-AES between August 2011 and January 2015. Two groups were formed: 1) patients discharged with S-DAPT (≤3-month), because of high bleeding risk or attending urgent non-cardiac surgery; and 2) patients discharged with Recommended DAPT duration (R-DAPT; ≥6-month). The primary ischemic- and bleeding-safety endpoints were Target Vessel Failure (TVF, composite endpoint of cardiac-death, target vessel-myocardial infarction and target vessel-revascularization), and major-bleeding (BARC ≥type-3a) at 6-month and 1-year. 106 patients (8.7%) were discharged with ≤3-month DAPT (83±19days; S-DAPT group) and 1102 patients (90.6%) with ≥6-month DAPT (342±62days; R-DAPT group). Between S-DAPT and R-DAPT groups no significant differences were observed in TVF at 1-year (5.7% vs 5.1%); 1-year BARC major bleeding rate was higher in S-DAPT group (3.4% vs 0.2%, p=0.007) with all bleeding events occurred within 3months. The landmark analysis (started at 90days, ended at 1year) showed no differences in BARC major bleedings between groups (0% vs. 0.3%). The results of this multicenter registry show that the use of Cre8 AES in patients needing short DAPT (≤3-month) was safe regarding ischemic events and could favor a reduction of bleeding events related to the recommended DAPT. A large randomized trial is necessary to support these preliminary findings. Copyright © 2017 Elsevier B.V. All rights reserved.

First bleeding episode from oesophageal varices in cirrhotic patients: a prospective study of endoscopic predictive factors.

PubMed

Colombo, E; Casiraghi, M A; Minoli, G; Prada, A; Terruzzi, V; Bortoli, A; Carnovali, M; Gullotta, R; Imperiali, G; Comin, U

1995-09-01

Two hundred patients affected by liver cirrhosis and oesophageal varices were studied in 9 Gastrointestinal Units in Lombardy (Northern Italy) in order to assess factors possibly related to variceal bleeding. Only patients without any previous episode of gastrointestinal bleeding were included in the prospective evaluation. For each patient demographic data, aetiology of cirrhosis, various clinical and biochemical parameters able to group patients into the three Child-Pugh Classes, endoscopic items for calculation of Beppu's and of NIEC prognostic scores were recorded on computerized cards. Patients were regularly interviewed every three months for one year and underwent an upper gastrointestinal endoscopy at enrollment, after six months and in case of bleeding. Within the twelve-month follow-up period, 29 out of the 200 patients (14%) bled and 52 out of 200 died (26%). In 16 of the 52 patients who died (59% of bleeding patients) death was directly related to gastrointestinal bleeding. Bleeding from oesophageal varices was endoscopically proven in 19/29 patients, in another 9 bleeding was classified as from unknown source and in one patient a bleeding gastric ulcer was diagnosed. Univariate analysis of all the recorded clinical, biochemical and endoscopic parameters, performed by Chi-square method and Fisher exact test showed that the presence of RWM (p < 0.001) was the only factor significantly associated to variceal bleeding within one year. Relationship between size of varices and bleeding was very close to the statistical significance but did not achieve it (p = 0.058).

Evaluating the Life Cycle Environmental Benefits and Trade-Offs of Water Reuse Systems for Net-Zero Buildings.

PubMed

Hasik, Vaclav; Anderson, Naomi E; Collinge, William O; Thiel, Cassandra L; Khanna, Vikas; Wirick, Jason; Piacentini, Richard; Landis, Amy E; Bilec, Melissa M

2017-02-07

Aging water infrastructure and increased water scarcity have resulted in higher interest in water reuse and decentralization. Rating systems for high-performance buildings implicitly promote the use of building-scale, decentralized water supply and treatment technologies. It is important to recognize the potential benefits and trade-offs of decentralized and centralized water systems in the context of high-performance buildings. For this reason and to fill a gap in the current literature, we completed a life cycle assessment (LCA) of the decentralized water system of a high-performance, net-zero energy, net-zero water building (NZB) that received multiple green building certifications and compared the results with two modeled buildings (conventional and water efficient) using centralized water systems. We investigated the NZB's impacts over varying lifetimes, conducted a break-even analysis, and included Monte Carlo uncertainty analysis. The results show that, although the NZB performs better in most categories than the conventional building, the water efficient building generally outperforms the NZB. The lifetime of the NZB, septic tank aeration, and use of solar energy have been found to be important factors in the NZB's impacts. While these findings are specific to the case study building, location, and treatment technologies, the framework for comparison of water and wastewater impacts of various buildings can be applied during building design to aid decision making. As we design and operate high-performance buildings, the potential trade-offs of advanced decentralized water treatment systems should be considered.

Ten-year study of postoperative complications following dental extractions in patients with inherited bleeding disorders.

PubMed

Hsieh, J-T; Klein, K; Batstone, M

2017-09-01

Dental extractions challenge the body's haemostatic mechanism. Postoperative bleeding from dental extraction can be prolonged, or even life threatening in patients with inherited bleeding disorders. Pre- and postoperative clotting factor replacements or systemic desmopressin (ddAVP) have been advocated at our institution to prevent bleeding complications in these patients. This study aimed to assess the postoperative bleeding rate in patients with inherited bleeding disorders that underwent dental extractions at our institution between 2003 and 2012. Patients with inherited bleeding disorders such as haemophilia A, haemophilia B, and von Willebrand's disease were included. Retrospective chart review was conducted. The result showed 53 extraction events occurred in 45 patients over the 10-year period. Ten out of 53 extraction events (18.9%) had postoperative bleeding requiring further factor replacement or ddAVP. Postoperative bleeding in one patient with mild haemophilia A was complicated by the development of inhibitors. Type and severity of bleeding disorder, bone removal, and use of a local haemostatic agent did not have any significant effect on postoperative bleeding. Despite the use of perioperative factors and desmopressin, the postoperative bleeding rates remain high for patients with inherited bleeding disorders. More studies are required to assess the safety and effectiveness of using local haemostatic control to achieve haemostasis following extractions. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Comparison of a novel bedside portable endoscopy device with nasogastric aspiration for identifying upper gastrointestinal bleeding.

PubMed

Choi, Jong Hwan; Choi, Jae Hyuk; Lee, Yoo Jin; Lee, Hyung Ki; Choi, Wang Yong; Kim, Eun Soo; Park, Kyung Sik; Cho, Kwang Bum; Jang, Byoung Kuk; Chung, Woo Jin; Hwang, Jae Seok

2014-07-07

To compare outcomes using the novel portable endoscopy with that of nasogastric (NG) aspiration in patients with gastrointestinal bleeding. Patients who underwent NG aspiration for the evaluation of upper gastrointestinal (UGI) bleeding were eligible for the study. After NG aspiration, we performed the portable endoscopy to identify bleeding evidence in the UGI tract. Then, all patients underwent conventional esophagogastroduodenoscopy as the gold-standard test. The sensitivity, specificity, and accuracy of the portable endoscopy for confirming UGI bleeding were compared with those of NG aspiration. In total, 129 patients who had GI bleeding signs or symptoms were included in the study (age 64.46 ± 13.79, 91 males). The UGI tract (esophagus, stomach, and duodenum) was the most common site of bleeding (81, 62.8%) and the cause of bleeding was not identified in 12 patients (9.3%). Specificity for identifying UGI bleeding was higher with the portable endoscopy than NG aspiration (85.4% vs 68.8%, P = 0.008) while accuracy was comparable. The accuracy of the portable endoscopy was significantly higher than that of NG in the subgroup analysis of patients with esophageal bleeding (88.2% vs 75%, P = 0.004). Food material could be detected more readily by the portable endoscopy than NG tube aspiration (20.9% vs 9.3%, P = 0.014). No serious adverse effect was observed during the portable endoscopy. The portable endoscopy was not superior to NG aspiration for confirming UGI bleeding site. However, this novel portable endoscopy device might provide a benefit over NG aspiration in patients with esophageal bleeding.

Massive oral bleeding after full-mouth extraction in a patient with B-cell lymphocytic leukemia/small lymphocytic lymphoma reversed with recombinant activated factor VII.

PubMed

Sprenker, Collin; Omar, Hesham R; Powless, R Andrew; Mangar, Devanand; Camporesi, Enrico

2016-02-01

Full-mouth extraction can be associated with intraoral bleeding, which usually is controlled with local hemostatic measures. Recombinant activated factor VII (rFVIIa) occasionally is used to stop bleeding in a variety of off-label indications, with the main argument curtailing its use being thrombotic events. The authors describe the use of rFVIIa for bleeding after full-mouth extraction in a patient with undiagnosed B-cell lymphocytic leukemia/small lymphocytic lymphoma. A 72-year-old man underwent full-mouth extraction (18 teeth). The next day, the patient experienced massive oral bleeding. The authors administered tranexamic acid, aminocaproic acid, and a total of 12 units of packed red blood cells in addition to local hemostatic measures without control of bleeding. On postoperative day 10, the authors administered 5,000 micrograms of rFVIIa, and within 2 hours oral the bleeding ceased. The authors performed flow cytometry and diagnosed B-cell lymphocytic leukemia/small lymphocytic lymphoma. Unexplained massive oral bleeding despite adequate local hemostatic measures should prompt further investigations for underlying bleeding or coagulation disorders. The authors describe the successful use of rFVIIa in massive oral bleeding. Further studies are mandatory to study the effectiveness of this drug for this off-label indication. Copyright © 2016 American Dental Association. Published by Elsevier Inc. All rights reserved.

Gingival bleeding, a possible "serious" adverse drug reaction: An observational study in the French PharmacoVigilance Database.

PubMed

Bondon-Guitton, Emmanuelle; Mourgues, Thibaut; Rousseau, Vanessa; Cousty, Sarah; Cottin, Judith; Drablier, Guillaume; Micallef, Joëlle; Montastruc, Jean-Louis

2017-09-01

Antithrombotic drugs are known to increase the risk of gingival bleeding because they affect coagulation. However, other drugs could also be involved in gingival bleeding. We performed a pharmacoepidemiological study to identify the drugs most frequently "suspected" in the occurrence of gingival bleeding. We selected reports of "gingival bleeding" from 1 January 1985 to 30 September 2014 in the French PharmacoVigilance Database. Among 523,808 reports of adverse drug reactions, we identified 454 reports of gingival bleeding (0.09%). Most of them were "serious" (58.4%) and occurred in females (54.6%). The frequency of gingival bleeding increased with age. The most frequently "suspected" drugs were antithrombotics (67.8%), particularly fluindione. Other drugs frequently involved were furosemide followed by paracetamol, amiodarone, amoxicillin, paroxetine, ketoprofen, zolpidem, enalapril and ramipril. Thirty-nine reports involved a drug-drug interaction with antithrombotics, mainly with anti-infectives. Gingival bleeding can be an adverse drug reaction, often "serious" and rarely fatal. Patients older than 50 years and women are particularly at risk. Among drugs known to increase the risk of gingival bleeding, the most frequently involved were fluindione, furosemide, paracetamol, amiodarone, amoxicillin, paroxetine or ketoprofen. We also identified signal for drugs not usually known to be involved in bleeding, like zolpidem, enalapril or ramipril. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Abnormal vaginal bleeding in women with venous thromboembolism treated with apixaban or warfarin.

PubMed

Brekelmans, Marjolein P A; Scheres, Luuk J J; Bleker, Suzanne M; Hutten, Barbara A; Timmermans, Anne; Büller, Harry R; Middeldorp, Saskia

2017-04-03

Abnormal vaginal bleeding can complicate direct oral anticoagulant (DOAC) treatment. We aimed to investigate the characteristics of abnormal vaginal bleeding in patients with venous thromboembolism (VTE) receiving apixaban or enoxaparin/warfarin. Data were derived from the AMPLIFY trial. We compared the incidence of abnormal vaginal bleeding between patients in both treatment arms and collected information on clinical presentation, diagnostic procedures, management and outcomes. In the AMPLIFY trial, 1122 women were treated with apixaban and 1106 received enoxaparin/warfarin. A clinically relevant non-major (CRNM) vaginal bleeding occurred in 28 (2.5 %) apixaban and 24 (2.1 %) enoxaparin/warfarin recipients (odds ratio [OR] 1.2, 95 % confidence interval [CI] 0.7-2.0). Of all CRNM bleeds, 28 of 62 (45 %) and 24 of 120 (20 %) were of vaginal origin in the apixaban and enoxaparin/warfarin group, respectively (OR 3.4; 95 % CI 1.8-6.7). Premenopausal vaginal bleeds on apixaban were characterised by more prolonged bleeding (OR 2.3; 95 %CI 0.5-11). In both pre- and postmenopausal vaginal bleeds, diagnostic tests were performed in six (21 %) and in seven (29 %) apixaban and enoxaparin/warfarin treated patients, respectively. Medical treatment was deemed not necessary in 16 (57 %) apixaban and 16 (67 %) enoxaparin/warfarin recipients. The severity of clinical presentation and course of the bleeds was mild in 75 % of the cases in both groups. In conclusion, although the absolute number of vaginal bleeding events is comparable between apixaban and enoxaparin/warfarin recipients, the relative occurrence of vaginal bleeds is higher in apixaban-treated women. The characteristics and severity of bleeding episodes were comparable in both treatment arms.

Early lactate clearance for predicting active bleeding in critically ill patients with acute upper gastrointestinal bleeding: a retrospective study.

PubMed

Wada, Tomoki; Hagiwara, Akiyoshi; Uemura, Tatsuki; Yahagi, Naoki; Kimura, Akio

2016-08-01

Not all patients with upper gastrointestinal bleeding (UGIB) require emergency endoscopy. Lactate clearance has been suggested as a parameter for predicting patient outcomes in various critical care settings. This study investigates whether lactate clearance can predict active bleeding in critically ill patients with UGIB. This single-center, retrospective, observational study included critically ill patients with UGIB who met all of the following criteria: admission to the emergency department (ED) from April 2011 to August 2014; had blood samples for lactate evaluation at least twice during the ED stay; and had emergency endoscopy within 6 h of ED presentation. The main outcome was active bleeding detected with emergency endoscopy. Classification and regression tree (CART) analyses were performed using variables associated with active bleeding to derive a prediction rule for active bleeding in critically ill UGIB patients. A total of 154 patients with UGIB were analyzed, and 31.2 % (48/154) had active bleeding. In the univariate analysis, lactate clearance was significantly lower in patients with active bleeding than in those without active bleeding (13 vs. 29 %, P < 0.001). Using the CART analysis, a prediction rule for active bleeding is derived, and includes three variables: lactate clearance; platelet count; and systolic blood pressure at ED presentation. The rule has 97.9 % (95 % CI 90.2-99.6 %) sensitivity with 32.1 % (28.6-32.9 %) specificity. Lactate clearance may be associated with active bleeding in critically ill patients with UGIB, and may be clinically useful as a component of a prediction rule for active bleeding.

Clinical significance of residual platelet reactivity in patients treated with platelet P2Y12 inhibitors.

PubMed

Thomas, Mark R; Storey, Robert F

2016-09-01

Platelet P2Y12 inhibitors have become an essential component of the treatment strategy for patients with acute coronary syndromes and patients undergoing percutaneous coronary intervention. It is now well-established that approximately 30% of patients treated with the P2Y12 inhibitor clopidogrel display high residual platelet reactivity despite treatment. Patients with high on-treatment platelet reactivity have approximately 2-3-fold greater risk of adverse cardiovascular events and stent thrombosis than those without high platelet reactivity. Conversely, clopidogrel-treated patients with low platelet reactivity display approximately 1.7-fold increased risk of major bleeding. High platelet reactivity is uncommon during treatment with prasugrel and ticagrelor, which achieve a greater reduction in adverse cardiovascular events compared to clopidogrel in ACS patients treated with PCI. This is at the expense of an increase in spontaneous bleeding, however. Minor bleeding events, such as skin haematomas, are more common in prasugrel- and ticagrelor-treated patients that have particularly low platelet reactivity values. These minor bleeding events may occasionally prompt discontinuation of therapy, but their overall prognostic impact is uncertain. However, risk factors for bleeding tend to overlap with risk factors for adverse cardiovascular events. Therefore, patients with these minor bleeding events may also be at higher risk of adverse cardiovascular events, conferring a benefit from low platelet reactivity. Further work is needed to determine the optimal level of platelet reactivity in individuals by taking into account their risk of subsequent adverse cardiovascular events and bleeding. Copyright © 2016 Elsevier Inc. All rights reserved.

A novel semi-quantitative method for measuring tissue bleeding.

PubMed

Vukcevic, G; Volarevic, V; Raicevic, S; Tanaskovic, I; Milicic, B; Vulovic, T; Arsenijevic, S

2014-03-01

In this study, we describe a new semi-quantitative method for measuring the extent of bleeding in pathohistological tissue samples. To test our novel method, we recruited 120 female patients in their first trimester of pregnancy and divided them into three groups of 40. Group I was the control group, in which no dilation was applied. Group II was an experimental group, in which dilation was performed using classical mechanical dilators. Group III was also an experimental group, in which dilation was performed using a hydraulic dilator. Tissue samples were taken from the patients' cervical canals using a Novak's probe via energetic single-step curettage prior to any dilation in Group I and after dilation in Groups II and III. After the tissue samples were prepared, light microscopy was used to obtain microphotographs at 100x magnification. The surfaces affected by bleeding were measured in the microphotographs using the Autodesk AutoCAD 2009 program and its "polylines" function. The lines were used to mark the area around the entire sample (marked A) and to create "polyline" areas around each bleeding area on the sample (marked B). The percentage of the total area affected by bleeding was calculated using the formula: N = Bt x 100 / At where N is the percentage (%) of the tissue sample surface affected by bleeding, At (A total) is the sum of the surfaces of all of the tissue samples and Bt (B total) is the sum of all the surfaces affected by bleeding in all of the tissue samples. This novel semi-quantitative method utilizes the Autodesk AutoCAD 2009 program, which is simple to use and widely available, thereby offering a new, objective and precise approach to estimate the extent of bleeding in tissue samples.

Consequences of bleeding after thyroid surgery – analysis of 7805 operations performed in a single center

PubMed Central

Aporowicz, Michał; Kaliszewski, Krzysztof; Bolanowski, Marek

2016-01-01

Introduction Surgical treatment of thyroid gland diseases is associated with the possibility of severe complications. The most dangerous of them is bleeding. Current studies focus on its risk factors, rather than reoperation-related consequences. Material and methods We analyzed 7805 thyroid operations performed from 1996 to 2014 in the Clinic of General, Gastroenterological and Endocrine Surgery of Wroclaw Medical University. Typical risk factors, symptoms and consequences of bleeding were analyzed. Results Among operated patients 88.2% were female and 11.8% male. Bleeding occurred in 84 (1.08%) patients. Sex (p = 0.006), preoperative thyroid pathology (p = 0.03), and type of operation (p < 0.001) are significant risk factors for bleeding, while retrosternal goiter and surgeon’s experience are not. Risk of bleeding is highest in the case of male sex, toxic goiter and total resection of the thyroid gland. Most reoperations took place within 6 h. In 88.8% of cases of this kind of complication the surgeon indicated the exact source of bleeding; most commonly it was the neck muscles, skin and subcutaneous tissue, or the thyroid stump. Three patients required a second reoperation, 24 suffered further complications, and 8 required transfer to the Intensive Care Unit (ICU). Cardiac arrest occurred in 3 patients and 2 suffered bilateral vocal cord palsy. Conclusions Bleeding after thyroid operations is a direct life threat that requires immediate intervention. As a result death may occur, half of patients suffer other complications and some require intensive care. The risk is highest in the case of male sex, toxic goiter and total resection of the thyroid gland. Each patient after thyroid surgery needs to be closely observed. An operating theatre and ICU should be available at all times. PMID:29593806

Women with congenital factor VII deficiency: clinical phenotype and treatment options from two international studies.

PubMed

Napolitano, M; Di Minno, M N D; Batorova, A; Dolce, A; Giansily-Blaizot, M; Ingerslev, J; Schved, J-F; Auerswald, G; Kenet, G; Karimi, M; Shamsi, T; Ruiz de Sáez, A; Dolatkhah, R; Chuansumrit, A; Bertrand, M A; Mariani, G

2016-09-01

A paucity of data exists on the incidence, diagnosis and treatment of bleeding in women with inherited factor VII (FVII) deficiency. Here we report results of a comprehensive analysis from two international registries of patients with inherited FVII deficiency, depicting the clinical picture of this disorder in women and describing any gender-related differences. A comprehensive analysis of two fully compatible, international registries of patients with inherited FVII deficiency (International Registry of Factor VII deficiency, IRF7; Seven Treatment Evaluation Registry, STER) was performed. In our cohort (N = 449; 215 male, 234 female), the higher prevalence of mucocutaneous bleeds in females strongly predicted ensuing gynaecological bleeding (hazard ratio = 12.8, 95% CI 1.68-97.6, P = 0.014). Menorrhagia was the most prevalent type of bleeding (46.4% of patients), and was the presentation symptom in 12% of cases. Replacement therapies administered were also analysed. For surgical procedures (n = 50), a receiver operator characteristic analysis showed that the minimal first dose of rFVIIa to avoid postsurgical bleeding during the first 24 hours was 22 μg kg(-1) , and no less than two administrations. Prophylaxis was reported in 25 women with excellent or effective outcomes when performed with a total weekly rFVIIa dose of 90 μg kg(-1) (divided as three doses). Women with FVII deficiency have a bleeding disorder mainly characterized by mucocutaneous bleeds, which predicts an increased risk of ensuing gynaecological bleeding. Systematic replacement therapy or long-term prophylaxis with rFVIIa may reduce the impact of menorrhagia on the reproductive system, iron loss and may avoid unnecessary hysterectomies. © 2016 John Wiley & Sons Ltd.

Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding

PubMed Central

Mylonaki, M; Fritscher-Ravens, A; Swain, P

2003-01-01

Background: The development of wireless capsule endoscopy allows painless imaging of the small intestine. Its clinical use is not yet defined. The aim of this study was to compare the clinical efficacy and technical performance of capsule endoscopy and push enteroscopy in a series of 50 patients with colonoscopy and gastroscopy negative gastrointestinal bleeding. Methods: A wireless capsule endoscope was used containing a CMOS colour video imager, transmitter, and batteries. Approximately 50 000 transmitted images are received by eight abdominal aerials and stored on a portable solid state recorder, which is carried on a belt. Push enteroscopy was performed using a 240 cm Olympus video enteroscope. Results: Studies in 14 healthy volunteers gave information on normal anatomical appearances and preparation. In 50 patients with gastrointestinal bleeding and negative colonoscopy and gastroscopy, push enteroscopy was compared with capsule endoscopy. A bleeding source was discovered in the small intestine in 34 of 50 patients (68%). These included angiodysplasia (16), focal fresh bleeding (eight), apthous ulceration suggestive of Crohn’s disease (three), tumour (two), Meckel’s diverticulum (two), ileal ulcer (one), jejunitis (one), and ulcer due to intussusception (one). One additional intestinal diagnosis was made by enteroscopy. The yield of push enteroscopy in evaluating obscure bleeding was 32% (16/50). The capsule identified significantly more small intestinal bleeding sources than push enteroscopy (p<0.05). Patients preferred capsule endoscopy to push enteroscopy (p<0.001). Conclusions: In this study capsule endoscopy was superior to push enteroscopy in the diagnosis of recurrent bleeding in patients who had a negative gastroscopy and colonoscopy. It was safe and well tolerated. PMID:12865269

Mortality and need of surgical treatment in acute upper gastrointestinal bleeding: a one year study in a tertiary center with a 24 hours / day-7 days / week endoscopy call. Has anything changed?

PubMed

Botianu, Am; Matei, D; Tantau, M; Acalovschi, M

2013-01-01

Acute upper gastrointestinal bleeding, previously often a surgical problem, is now the most common gastroenterological emergency. To evaluate the current situation in terms of mortality and need of surgery. Retrospective non-randomised clinical study performed between 1st January-31st December 2011, at "Professor Dr. Octavian Fodor" Regional Institute of Gastroenterology and Hepatology in Cluj Napoca. 757 patients with upper gastrointestinal bleeding were endoscopically examined within 24 hours from presentation in the emergency unit. Data were collected from admission charts and Hospital Manager programme. Statistical analysis was performed with GraphPad 2004, using the following tests: chi square, Spearman, Kruskall-Wallis, Mann-Whitney, area under receiver operating curve. Non-variceal etiology was predominant, the main cause was bleeding being peptic ulcer. In hospital global mortality was of 10.43%, global rebleeding rate was 12.02%, surgery was performed in 7.66% of patients. Urgent haemostatic surgery was needed in 3.68% of patients with nonvariceal bleeding. The need for surgery correlated with the postendoscopic Rockall score (p=0.0425). In peptic ulcer, the need for surgery was not influenced by time to endoscopy or type of treatment (p=0.1452). Weekend (p=0.996) or night (p=0.5414) admission were not correlated with a higher need for surgery. Over the last decade, the need for urgent surgery in upper gastrointestinal bleeding has decreased by half, but mortality has remained unchanged. Celsius.

Zero-inflated Poisson model based likelihood ratio test for drug safety signal detection.

PubMed

Huang, Lan; Zheng, Dan; Zalkikar, Jyoti; Tiwari, Ram

2017-02-01

In recent decades, numerous methods have been developed for data mining of large drug safety databases, such as Food and Drug Administration's (FDA's) Adverse Event Reporting System, where data matrices are formed by drugs such as columns and adverse events as rows. Often, a large number of cells in these data matrices have zero cell counts and some of them are "true zeros" indicating that the drug-adverse event pairs cannot occur, and these zero counts are distinguished from the other zero counts that are modeled zero counts and simply indicate that the drug-adverse event pairs have not occurred yet or have not been reported yet. In this paper, a zero-inflated Poisson model based likelihood ratio test method is proposed to identify drug-adverse event pairs that have disproportionately high reporting rates, which are also called signals. The maximum likelihood estimates of the model parameters of zero-inflated Poisson model based likelihood ratio test are obtained using the expectation and maximization algorithm. The zero-inflated Poisson model based likelihood ratio test is also modified to handle the stratified analyses for binary and categorical covariates (e.g. gender and age) in the data. The proposed zero-inflated Poisson model based likelihood ratio test method is shown to asymptotically control the type I error and false discovery rate, and its finite sample performance for signal detection is evaluated through a simulation study. The simulation results show that the zero-inflated Poisson model based likelihood ratio test method performs similar to Poisson model based likelihood ratio test method when the estimated percentage of true zeros in the database is small. Both the zero-inflated Poisson model based likelihood ratio test and likelihood ratio test methods are applied to six selected drugs, from the 2006 to 2011 Adverse Event Reporting System database, with varying percentages of observed zero-count cells.

Incidence and outcome of surgical procedures after coronary artery bypass grafting compared with those after percutaneous coronary intervention: a report from the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2.

PubMed

Tokushige, Akihiro; Shiomi, Hiroki; Morimoto, Takeshi; Ono, Koh; Furukawa, Yutaka; Nakagawa, Yoshihisa; Kadota, Kazushige; Ando, Kenji; Shizuta, Satoshi; Tada, Tomohisa; Tazaki, Junichi; Kato, Yoshihiro; Hayano, Mamoru; Abe, Mitsuru; Hamasaki, Shuichi; Ohishi, Mitsuru; Nakashima, Hitoshi; Mitsudo, Kazuaki; Nobuyoshi, Masakiyo; Kita, Toru; Imoto, Yutaka; Sakata, Ryuzo; Okabayashi, Hitoshi; Hanyu, Michiya; Shimamoto, Mitsuomi; Nishiwaki, Noboru; Komiya, Tatsuhiko; Kimura, Takeshi

2014-08-01

Noncardiac surgery after percutaneous coronary intervention (PCI) has been reported to be carrying high risk for both ischemic and bleeding complications. However, there has been no report comparing the incidence and outcomes of surgical procedures after coronary artery bypass grafting (CABG) with those after PCI. Among 14 383 patients undergoing first coronary revascularization (PCI, n=12 207; CABG, n=2176) enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) PCI/CABG Registry Cohort-2, surgical procedures were performed more frequently after CABG (n=560) than after PCI (n=2398; cumulative 3-year incidence: 27% versus 22%; unadjusted P<0.0001), particularly <6 months of coronary revascularization. The risk for the primary ischemic outcome measure (death/myocardial infarction) at 30-day postsurgical procedures was not significantly different between the CABG and PCI groups (cumulative incidence: 3.1% versus 3.2%; unadjusted P=0.9; adjusted hazard ratio, 0.97; 95% confidence interval, 0.47-1.89; P=0.9). The risk for the primary bleeding outcome measure (moderate or severe bleeding by Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries classification) was lower in the CABG groups than in the PCI group (cumulative incidence: 1.3% versus 2.6%; unadjusted P=0.07; adjusted hazard ratio, 0.36; 95% confidence interval, 0.12-0.87; P=0.02). There were no interactions between the timing of surgery and the types of coronary revascularization (CABG/PCI) for both ischemic and bleeding outcomes. Surgical procedures were performed significantly more frequently after CABG than after PCI, particularly <6 months after coronary revascularization. Surgical procedures after CABG as compared with those after PCI were associated with similar risk for ischemic events and lower risk for bleeding events, regardless of the timing after coronary revascularization. © 2014 American Heart Association, Inc.

Overview of platelet physiology and laboratory evaluation of platelet function.

PubMed

Rodgers, G M

1999-06-01

Appropriate laboratory testing for the platelet-type bleeding disorders hinges on an adequate assessment in the history and physical examination. Patients with histories and screening laboratory results consistent with coagulation disorders (hemophilia, disseminated intravascular coagulation) are not appropriate candidates for platelet function testing. In contrast, patients with a lifelong history of platelet-type bleeding symptoms and perhaps a positive family history of bleeding would be appropriate for testing. Figure 6 depicts one strategy to evaluate these patients. Platelet morphology can easily be evaluated to screen for two uncommon qualitative platelet disorders: Bernard-Soulier syndrome (associated with giant platelets) and gray platelet syndrome, a subtype of storage pool disorder in which platelet granulation is morphologically abnormal by light microscopy. If the bleeding disorder occurred later in life (no bleeding with surgery or trauma early in life), the focus should be on acquired disorders of platelet function. For those patients thought to have an inherited disorder, testing for vWD should be done initially because approximately 1% of the population has vWD. The complete vWD panel (factor VIII coagulant activity, vWf antigen, ristocetin cofactor activity) should be performed because many patients will have abnormalities of only one particular panel component. Patients diagnosed with vWD should be classified using multimeric analysis to identify the type 1 vWD patients likely to respond to DDAVP. If vWD studies are normal, platelet aggregation testing should be performed, ensuring that no antiplatelet medications have been ingested at least 1 week before testing. If platelet aggregation tests are normal and if suspicion for an inherited disorder remains high, vWD testing should be repeated. The evaluation of thrombocytopenia may require bone marrow examination to exclude primary hematologic disorders. If future studies with thrombopoietin assays confirm preliminary results, however, the bone marrow examination of certain patients may be replaced by a thrombopoietin level.

Corrosion performance of prestressing strands in contact with dissimilar grouts.

DOT National Transportation Integrated Search

2013-01-01

To improve the corrosion protection provided to prestressing strands, anti-bleed grouts are used to fill voids in post-tensioning : ducts that result from bleeding and shrinkage of older Portland Cement grouts. Environmental differences caused by exp...

[Severe Bleeding from the Middle Ear Cavity after Myringotomy: Review Based on a Case Report].

PubMed

Hofmann, Veit M; Niehues, Stefan M; Albers, Andreas E; Pudszuhn, Annett

2017-03-01

Report of a rare case of severe bleeding from the middle ear cavity after myringotomy. On the basis of the case report, the procedure for such bleeding is discussed in the context of the literature. A 6-year-old boy received a revision myringotomy in an ambulant setting. During the procedure a severe bleeding occurred. The external auditory canal was adequately packed. The patient was extubated and transferred to the clinic as an emergency. Computer tomography of the temporal bone showed the anatomical variant of a dehiscent high jugular bulb, which had been injured. Because no rebleeding occurred, the packing of the ear canal was removed and an explorative tympanoscopy was performed on the third postoperative day. When the tympanomeatal flap was lifted, the defect in the jugular bulb was found. The lesion was covered with Tutopatch ® pads and fibrin glue and the auditory canal was packed again. After removal of the packing three weeks postoperatively a properly healed situs was found. No further measures were taken. The injury of a dehiscent jugular bulb in the course of ear surgeries leads to a massive hemorrhage. The case describes the diagnostic and therapeutic procedure for this relatively rare but severe complication. © Georg Thieme Verlag KG Stuttgart · New York.

Successful early romiplostim use in a case of severe immune thrombocytopenia with critical carotid arterial injury.

PubMed

Watanabe, Reiko; Tabayashi, Takayuki; Tomikawa, Tatsuki; Sagawa, Morihiko; Anan-Nemoto, Tomoe; Kimura, Yuta; Takahashi, Yasuyuki; Tokuhira, Michihide; Otaki, Satoshi; Oi, Hidenori; Sawano, Makoto; Sugiyama, Satoshi; Kizaki, Masahiro

2017-01-01

Thrombopoietin receptor (TPO-R) agonists have been shown to be effective in refractory chronic immune thrombocytopenia (ITP); however, their efficacy in patients under critical care is not known. We report the case of a female patient with a newly diagnosed ITP who experienced severe bleeding from an external wound. The patient was administered the standard treatments for ITP, which are high-dose intravenous immunoglobulin (IVIg) and corticosteroids. However, following failure of these treatments, we administered romiplostim on day 6 after the onset of ITP. On day 6 after the initiation of romiplostim, there was improvement in platelet count and bleeding tendency. We were subsequently able to perform a splenectomy successfully. The efficacy of TPO-R agonists in ITP has been reported in several situations, including before surgery in an ITP patient; however, the use of TPO-R for arterial bleeding with shock has not been reported. To our knowledge, the present article is a rare case report of the use of a TPO-R agonist in a patient with critical artery injury. Our data suggest that the early use of romiplostim is effective in emergency cases of newly diagnosed ITP with life-threatening bleeding, which is refractory to standard treatment.

A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.

PubMed

Ryan, Barbara M; Stockbrugger, Reinhold W; Ryan, J Mark

2004-04-01

Gastric varices (GV) occur in 20% of patients with portal hypertension either in isolation or in combination with esophageal varices (EV). There is no consensus for optimum treatment of GV and because they comprise an inhomogeneous entity, accurate classification is vital to determine the appropriate management. Gastroesophageal varices (GOV) are classified as GOV1 (EV extending down to cardia or lesser curve) or GOV2 (esophageal and fundal varices). Isolated gastric varices (IGV) may be located in the fundus (IGV1) or elsewhere in the stomach (IGV2). GV possibly bleed less frequently than EV, but GV bleeding is typically difficult to control, associated with a high risk for rebleeding, and high mortality. Fundal varices, large GV (>5 mm), presence of a red spot, and Child's C liver status are associated with a high risk for bleeding. GOV1 have a much lower risk for bleeding. A portosystemic pressure gradient of > or =12 mm Hg is not necessary for GV bleeding, probably related to the high frequency of spontaneous gastrorenal shunts in these patients. GOV1 should be treated as for EV. First-line treatment of bleeding fundal varices is endoscopic variceal obturation. TIPS is currently second-line acute treatment and is used for prevention of rebleeding. The role of some newer interventional radiologic techniques requires further appraisal. This review describes the pathophysiology, diagnosis, natural history, endoscopic, and interventional radiologic treatment options for GV.

[Gastrointestinal bleeding].

PubMed

Lanas, Ángel

2015-09-01

In the Digestive Disease Week in 2015 there have been some new contributions in the field of gastrointestinal bleeding that deserve to be highlighted. Treatment of celecoxib with a proton pump inhibitor is safer than treatment with nonselective NSAID and a proton pump inhibitor in high risk gastrointestinal and cardiovascular patients who mostly also take acetylsalicylic acid. Several studies confirm the need to restart the antiplatelet or anticoagulant therapy at an early stage after a gastrointestinal hemorrhage. The need for urgent endoscopy before 6-12 h after the onset of upper gastrointestinal bleeding episode may be beneficial in patients with hemodynamic instability and high risk for comorbidity. It is confirmed that in Western but not in Japanese populations, gastrointestinal bleeding episodes admitted to hospital during weekend days are associated with a worse prognosis associated with delays in the clinical management of the events. The strategy of a restrictive policy on blood transfusions during an upper GI bleeding event has been challenged. Several studies have shown the benefit of identifying the bleeding vessel in non varicose underlying gastric lesions by Doppler ultrasound which allows direct endoscopic therapy in the patient with upper GI bleeding. Finally, it has been reported that lower gastrointestinal bleeding diverticula band ligation or hemoclipping are both safe and have the same long-term outcomes. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

Efficacy and toxicity of Samen-ista emulsion on treatment of cutaneous and mucosal bleeding.

PubMed

Hosseini, Mousalreza; Pourakbar, Ali; Forouzanfar, Fatemeh; Arian, Amirali; Ghaffarzadegan, Kamran; Salehi, Maryam; Esfandiari, Samaneh; Rakhshandeh, Hassan

2016-10-01

Despite new treatment methods, upper gastrointestinal bleeding remains challenging. Samen-ista emulsion is a new agent based on traditional medicine with coagulant properties. The efficacy and safety of Samen-ista were assessed in cutaneous and mucosal bleeding animal models. Coagulant properties of Samen-ista were evaluated using mice tail bleeding assay, marginal ear vein and upper gastrointestinal mucosal bleeding times in rabbits. After 7 days, clinical signs, mortality and end-organ (kidney, liver, lung, brain and gastric mucosa) histopathological changes were also examined. Samen-ista dose-dependently decreased mean cutaneous tail (128 vs. 14 s) and marginal ear vein (396 vs. 84 s) bleeding times. Rabbit's upper gastrointestinal bleeding time was also significantly decreased (214 vs. 15.8 s) upon Samen-ista local endoscopic application. Treatment with Samen-ista for 7 days did not cause any mortality, abnormal signs of bleeding, changes in appetite or significant histopathologicl changes. Samen-ista emulsion is well tolerated and highly effective in achieving hemostasis in cutaneous and mucosal bleeding animal models.

[Gastrointestinal bleeding from capillary hemangioma of the ileum detected by 99mTc-HSAD scintigraphy].

PubMed

Asano, Y; Ishii, K; Sagiuchi, T; Aoki, Y; Yanaihara, H; Hayakawa, K

2001-05-01

It has been well-known that technetium-99m-human serum albumin-diethylenetriaminepenta-acetic acid (99mTc-HSAD) scintigraphy is useful for diagnosis of the localization of the gastrointestinal arterial or venous bleeding. In this report, we describe a case of venous bleeding from capillary hemangioma of the ileum end detected by 99mTc-HSAD scintigraphy. This patient was a 9-year-old girl with severe anemia. Gastrointestinal bleeding was suspected from her clinical course and laboratory tests. Immediately after melena occurred, 99mTc-HSAD scintigraphy showed the extravasation of RI suggesting gastrointestinal bleeding in the ileum end. Abdominal angiography immediately after 99mTc-HSAD scintigraphy, however, could not show the extravasation of contrast agent. Because the condition of the patient became worse, laparotomy was performed on the basis of 99mTc-HSAD scintigraphy findings. At surgery, venous bleeding from capillary hemangioma in the ileum end was observed. It was suggested that 99mTc-HSAD scintigraphy was very useful for identifying the gastrointestinal venous bleeding.

Naproxen or Estradiol for Bleeding and Spotting with the Levonorgestrel Intrauterine System: A Randomized Controlled Trial

PubMed Central

MADDEN, Tessa; PROEHL, Sarah; ALLSWORTH, Jenifer E.; SECURA, Gina M.; PEIPERT, Jeffrey F.

2011-01-01

Objective To evaluate whether oral naproxen or transdermal estradiol decreases bleeding and spotting in women initiating the levonorgestrel-releasing intrauterine system (LNG-IUS). Study Design We conducted a randomized controlled trial of naproxen, estradiol, or placebo administered over the first 12 weeks of LNG-IUS use. Participants completed a written bleeding diary. We imputed missing values and performed an intention-to-treat analysis. Results There were 129 women randomized to naproxen (n=42), estradiol (n=44), or placebo (n=43). The naproxen group was more likely to be in the lowest quartile of bleeding and spotting days compared to placebo, 42.9% versus 16.3% (p=0.03). In the multivariable analysis, the naproxen group had a 10% reduction in bleeding and spotting days (RRadj 0.90, 95%CI 0.84–0.97) compared to placebo. More frequent bleeding and spotting was observed in the estradiol group (RRadj 1.25, 95%CI 1.17–1.34). Conclusions Administration of naproxen resulted in a reduction in bleeding and spotting days compared to placebo. (150 words) PMID:22055339

40 CFR 60.2210 - What information must I include in my annual report?

Code of Federal Regulations, 2013 CFR

2013-07-01

... Performance for Commercial and Industrial Solid Waste Incineration Units Recordkeeping and Reporting § 60.2210..., time, and duration that each CMS was inoperative, except for zero (low-level) and high-level checks. (3... procedure in 40 CFR part 60, appendix F of this part, as if any of the following occur. (1) The zero (low...

Mobile/android application for QRS detection using zero cross method

NASA Astrophysics Data System (ADS)

Rizqyawan, M. I.; Simbolon, A. I.; Suhendra, M. A.; Amri, M. F.; Kusumandari, D. E.

2018-03-01

In automatic ECG signal processing, one of the main topics of research is QRS complex detection. Detecting correct QRS complex or R peak is important since it is used to measure several other ECG metrics. One of the robust methods for QRS detection is Zero Cross method. This method uses an addition of high-frequency signal and zero crossing count to detect QRS complex which has a low-frequency oscillation. This paper presents an application of QRS detection using Zero Cross algorithm in the Android-based system. The performance of the algorithm in the mobile environment is measured. The result shows that this method is suitable for real-time QRS detection in a mobile application.

Factors associated with the effect of open splenectomy for immune thrombocytopenic purpura.

PubMed

Li, Ying; Zhang, Dawei; Hua, Fanli; Gao, Song; Wu, Yangjiong; Xu, Jianmin

2017-01-01

To assess the effect and complications of open splenectomy (OS) for immune thrombocytopenic purpura (ITP) and determine preoperative factors associated with surgical effect. This was a retrospective analysis of ITP patients who failed medical therapy and were treated with OS between 1997 and 2014 at the Jinshan Hospital, China. Follow-up was 60 months. Surgical effect was determined from platelet counts and bleeding episodes. Complications were assessed including bleeding episodes. Preoperative factors were identified by logistic regression analysis. Fifty-six patients (48.2 ± 16.2 yr old; 39 females) were included. Disease course was 31.2 ± 48.2 months; 91.1% patients had preoperative platelet count <20 × 10 9 /L. OS effect at 1 wk, 1 month, 1 yr, and 5 yrs was in 91.1%, 92.9%, 91.1%, and 89.3% patients, respectively. Pneumonia or lower extremity thrombosis occurred in 7.1% patients. Postoperative mild, moderate, and severe bleeding occurred in 33.9%, 50.0%, and 16.1% patients, respectively. No patients required blood transfusion. Mortality was zero. Larger spleen size associated with surgical effect at 1 wk, 1 month, and 1 yr, and lower preoperative minimum platelet count associated with effect at 5 yrs (P < 0.05). Open splenectomy is an effective treatment with less complications for the management of ITP. Lower preoperative minimum platelet count associated with successful OS at 5 yrs. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Is the AIMS65 score useful in predicting outcomes in peptic ulcer bleeding?

PubMed

Jung, Sung Hoon; Oh, Jung Hwan; Lee, Hye Yeon; Jeong, Joon Won; Go, Se Eun; You, Chan Ran; Jeon, Eun Jung; Choi, Sang Wook

2014-02-21

To evaluate the applicability of AIMS65 scores in predicting outcomes of peptic ulcer bleeding. This was a retrospective study in a single center between January 2006 and December 2011. We enrolled 522 patients with upper gastrointestinal haemorrhage who visited the emergency room. High-risk patients were regarded as those who had re-bleeding within 30 d from the first endoscopy as well as those who died within 30 d of visiting the Emergency room. A total of 149 patients with peptic ulcer bleeding were analysed, and the AIMS65 score was used to retrospectively predict the high-risk patients. A total of 149 patients with peptic ulcer bleeding were analysed. The poor outcome group comprised 28 patients [male: 23 (82.1%) vs female: 5 (10.7%)] while the good outcome group included 121 patients [male: 93 (76.9%) vs female: 28 (23.1%)]. The mean age in each group was not significantly different. The mean serum albumin levels in the poor outcome group were slightly lower than those in the good outcome group (P = 0.072). For the prediction of poor outcome, the AIMS65 score had a sensitivity of 35.5% (95%CI: 27.0-44.8) and a specificity of 82.1% (95%CI: 63.1-93.9) at a score of 0. The AIMS65 score was insufficient for predicting outcomes in peptic ulcer bleeding (area under curve = 0.571; 95%CI: 0.49-0.65). The AIMS65 score may therefore not be suitable for predicting clinical outcomes in peptic ulcer bleeding. Low albumin levels may be a risk factor associated with high mortality in peptic ulcer bleeding.

Can the Platelet Function Analyzer (PFA)-100 test substitute for the template bleeding time in routine clinical practice?

PubMed

Francis, J; Francis, D; Larson, L; Helms, E; Garcia, M

1999-01-01

The bleeding time (BT) is widely used in clinical medicine as a screening test of platelet function, although its deficiencies in such a role are well recognized. The Platelet Function Analyzer (PFA)-100 measures the ability of platelets activated in a high-shear environment to occlude an aperture in a membrane treated with collagen and epinephrine (CEPI) or collagen and ADP (CADP). The time taken for flow across the membrane to stop (closure time) is recorded. This study compared the PFA-100 with the BT as a screening test of platelet dysfunction in 113 hospital inpatients. The PFA-100 test was performed initially using the CEPI cartridge; CADP tests were performed on those with abnormal (> 163 s) CEPI closure times. Whole blood platelet aggregation studies and chart review were performed on patients in whom the BT and PFA-100 results did not agree.Abnormal bleeding times and PFA-100 results were obtained in 20.4% and 35.4% of patients, respectively. The results of BT and PFA-100 agreed in 74.3% of patients. Of the 29 patients in whom the BT and PFA-100 results were discordant, whole blood platelet aggregation studies supported the PFA-100 result in 25 (86.2%). The PFA-100 was more sensitive to aspirin-induced platelet dysfunction and was more rapidly and cheaply performed than the BT. Since the PFA-100 test reflects platelet function better than the BT, we conclude that this test could replace the BT as a first-line screening test for platelet dysfunction in clinical practice.

Endoscopic Obliteration for Bleeding Peptic Ulcer

PubMed Central

Zawadzki, J.J. J.; Gajda, A.G. G.; Kamiński, P. Ł.; Lembas, L.; Bielecki, K.

1997-01-01

A group of 133 patients treated for bleeding peptic ulcer in our Department, is reviewed. Within several hours of admission, all patients underwent upper gastrointestinal tract gastroscopy and obliteration of the bleeding ulcer. Bleeding gastric ulcers were found in 41 patients, and duodenal ulcers in 92 patients. Patients were classified according to the Forrest scale: IA – 11 patients, IB – 49 patients, IIA – 35 patients, lIB – 40 patients. In 126 (94.7%) patients the bleeding was stopped, and 7 required urgent surgery: 3 patients with gastric ulcer underwent gastrectomy, and 4 with duodenal ulcer – truncal vagotomy with pyloroplasty and had the bleeding site underpinned. Fifty-five patients underwent elective surgery: gastrectomy and vagotomy (18 patients with gastric ulcer), highly selective vagotomy (25 patients with duodenal ulcer) and truncal vagotomy and pyloroplasty (12 patients with duodenal ulcer). None of the patients was observed to have recurrent bleeding. PMID:18493453

Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery.

PubMed

Coppola, Antonio; Windyga, Jerzy; Tufano, Antonella; Yeung, Cindy; Di Minno, Matteo Nicola Dario

2015-02-09

In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of the last search: 20 November 2014. Randomised and quasi-randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta-analyses were performed on available and relevant data. Of the 16 identified trials, four (112 participants) were eligible for inclusion.Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon-aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post-operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re-intervention was not reported by either trial.Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re-intervention). In one trial a high-dose rFVIIa regimen (90 μg/kg) was compared with a low-dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well-designed randomised controlled trials would be needed, in particular to address the cost-effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies.

Proton-pump inhibitors can decrease gastrointestinal bleeding after percutaneous coronary intervention.

PubMed

Jiang, Zongdan; Wu, Hailu; Duan, Zhaotao; Wang, Zhibing; Hu, Kewei; Ye, Fei; Zhang, Zhenyu

2013-12-01

Current medical therapies for patients who have an acute coronary syndrome (ACS) focus on the coagulation cascade and platelet inhibition. These, coupled with early use of cardiac catheterization and revascularization, have decreased morbidity and mortality rates in patients who have acute ischemic heart disease with risk of bleeding. The study aimed to determine the incidence of gastrointestinal bleeding after percutaneous coronary intervention (PCI). The effect of proton-pump inhibitor (PPI) treatment was also analyzed. This case-control study evaluated gastrointestinal bleeding within a year of PCI for stable angina and acute coronary syndromes at Nanjing First Hospital between 2008 and 2011. Cases were identified and outcomes assessed using linkage analysis of data from cardiology and gastroenterology department databases. Analysis of the case and control groups for both risk and protective factors was performed using independent two-sample Student's t-test with Fisher's exact P value and logistic regression. The incidence of gastrointestinal bleeding following PCI was 1.3% (35/2680 patients). The risk factors for gastrointestinal bleeding were advanced age, female gender, smoking, drinking, previous peptic ulcer and previous gastrointestinal bleeding. PPI use after PCI (P=0.000) was accompanied by a lower risk of gastrointestinal bleeding, with only a few cases of gastrointestinal bleeding events reported. The incidence of gastrointestinal bleeding associated with the combination of aspirin and clopidogrel therapy was estimated to be 1.3%. Advanced age, being female, smokers, drinkers, previous peptic ulcer and previous gastrointestinal bleeding were significant independent risk factors. PPI for the prevention and treatment of gastrointestinal bleeding induced by the combination of aspirin and clopidogrel in patients after PCI was safe and effective. Published by Elsevier Masson SAS.

Comparison of a novel bedside portable endoscopy device with nasogastric aspiration for identifying upper gastrointestinal bleeding

PubMed Central

Choi, Jong Hwan; Choi, Jae Hyuk; Lee, Yoo Jin; Lee, Hyung Ki; Choi, Wang Yong; Kim, Eun Soo; Park, Kyung Sik; Cho, Kwang Bum; Jang, Byoung Kuk; Chung, Woo Jin; Hwang, Jae Seok

2014-01-01

AIM: To compare outcomes using the novel portable endoscopy with that of nasogastric (NG) aspiration in patients with gastrointestinal bleeding. METHODS: Patients who underwent NG aspiration for the evaluation of upper gastrointestinal (UGI) bleeding were eligible for the study. After NG aspiration, we performed the portable endoscopy to identify bleeding evidence in the UGI tract. Then, all patients underwent conventional esophagogastroduodenoscopy as the gold-standard test. The sensitivity, specificity, and accuracy of the portable endoscopy for confirming UGI bleeding were compared with those of NG aspiration. RESULTS: In total, 129 patients who had GI bleeding signs or symptoms were included in the study (age 64.46 ± 13.79, 91 males). The UGI tract (esophagus, stomach, and duodenum) was the most common site of bleeding (81, 62.8%) and the cause of bleeding was not identified in 12 patients (9.3%). Specificity for identifying UGI bleeding was higher with the portable endoscopy than NG aspiration (85.4% vs 68.8%, P = 0.008) while accuracy was comparable. The accuracy of the portable endoscopy was significantly higher than that of NG in the subgroup analysis of patients with esophageal bleeding (88.2% vs 75%, P = 0.004). Food material could be detected more readily by the portable endoscopy than NG tube aspiration (20.9% vs 9.3%, P = 0.014). No serious adverse effect was observed during the portable endoscopy. CONCLUSION: The portable endoscopy was not superior to NG aspiration for confirming UGI bleeding site. However, this novel portable endoscopy device might provide a benefit over NG aspiration in patients with esophageal bleeding. PMID:25009396

Continuous Aspirin Use Does Not Increase Bleeding Risk of Split-Thickness Skin Transplantation Repair to Chronic Wounds.

PubMed

Sun, Yanwei; Wang, Yibing; Li, Liang; Zhang, Zheng; Wang, Ning; Wu, Dan

Discontinuation of aspirin therapy before cutaneous surgery may cause serious complications. The aim of this prospective study was to evaluate the bleeding risk of split-thickness skin transplantation repair to chronic wounds in patients on aspirin therapy. A total of 97 patients who underwent split-thickness skin transplantation surgery of chronic wounds during a 2-year period were enrolled. They were categorized on the basis of aspirin therapies. The primary outcome was postoperative bleeding and bleeding complications. Univariate analysis was performed to examine the association between aspirin and bleeding complications. Among the 26 patients taking aspirin continuously in group A, there were 5 bleeding complications (19.23%). Among the 55 nonusers in group B, there were 10 bleeding complications (18.18%). Among the 16 discontinuous patients in group C, there were 3 bleeding complications (18.75%). No statistical differences were found among the groups ( P = .956). Univariate analysis showed that continuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.933; 95% confidence interval, 0.283-3.074; P = .910 in the aspirin and control groups) and that discontinuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.963; 95% confidence interval, 0.230-4.025; P = .959 in the aspirin and control groups; odds ratio, 0.969; 95% confidence interval, 0.198-4.752; P = .969 in the aspirin and discontinuous groups). Continuous aspirin use does not produce an additional bleeding risk in patients who undergo split-thickness skin transplantation repair of chronic wounds.

A novel approach to assess the spontaneous gastrointestinal bleeding risk of antithrombotic agents using Apc(min/+) mice.

PubMed

Wei, Huijun; Shang, Jin; Keohane, CarolAnn; Wang, Min; Li, Qiu; Ni, Weihua; O'Neill, Kim; Chintala, Madhu

2014-06-01

Assessment of the bleeding risk of antithrombotic agents is usually performed in healthy animals with some form of vascular injury to peripheral organs to induce bleeding. However, bleeding observed in patients with currently marketed antithrombotic drugs is typically spontaneous in nature such as intracranial haemorrhage (ICH) and gastrointestinal (GI) bleeding, which happens most frequently on top of preexisting pathologies such as GI ulcerations and polyps. Apc(min/+) mice are reported to develop multiple adenomas through the entire intestinal tract and display progressive anaemia.In this study, we evaluated the potential utility of Apc(min/+) mice as a model for assessing spontaneous GI bleeding with antithrombotic agents. Apc(min/+) mice exhibited progressive blood loss starting at the age of nine weeks. Despite the increase in bleeding, Apc(min/+) mice were in a hypercoagulable state and displayed an age-dependent increase in thrombin generation and circulating fibrinogen as well as a significant decrease in clotting times. We evaluated the effect of warfarin, dabigatran etexilate, apixaban and clopidogrel in this model by administering them in diet or in the drinking water to mice for 1-4 weeks. All of these marketed drugs significantly increased GI bleeding in Apc(min/+) mice, but not in wild-type mice. Although different exposure profiles of these antithrombotic agents make it challenging to compare the bleeding risk of compounds, our results indicate that the Apc(min/+) mouse may be a sensitive preclinical model for assessing the spontaneous GI bleeding risk of novel antithrombotic agents.

Desmopressin acetate (DDAVP) for preventing and treating acute bleeds during pregnancy in women with congenital bleeding disorders.

PubMed

Karanth, Laxminarayan; Barua, Ankur; Kanagasabai, Sachchithanantham; Nair, Sreekumar

2015-09-09

Congenital bleeding disorders can cause obstetric haemorrhage during pregnancy, labour and following delivery. Desmopressin acetate is found to be an effective drug which can reduce the risk of haemorrhage and can also stop bleeding in certain congenital bleeding disorders. Its use in pregnancy has been controversial. Hence beneficial and adverse effects of desmopressin acetate in these groups of pregnant women should be evaluated.This is an update of a Cochrane review first published in 2013. To determine the efficacy of desmopressin acetate in preventing and treating acute bleeds during pregnancy in women with congenital bleeding disorders. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coaguopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant and abstract books of conferences proceedings. We also searched for any randomised controlled trials in a registry of ongoing trials and the reference lists of relevant articles and reviews.Date of most recent search: 18 June 2015. Randomised and quasi-randomised controlled trials investigating the efficacy of desmopressin acetate versus tranexamic acid or factor VIII or rFactor VII or fresh frozen plasma in preventing and treating congenital bleeding disorders during pregnancy were eligible. No trials matching the selection criteria were eligible for inclusion. No trials matching the selection criteria were eligible for inclusion. The review did not identify any randomised controlled trials investigating the relative effectiveness of desmopressin acetate for bleeding during pregnancy in women with congenital bleeding disorders. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials) to decide whether or not to treat women with congenital bleeding disorders with desmopressin acetate.Given the ethical considerations, future randomised controlled trials are unlikely. However, other high quality controlled studies (such as risk allocation designs, sequential design, parallel cohort design) to investigate the risks and benefits of using desmopressin acetate in this population are needed.

Desmopressin acetate (DDAVP) for preventing and treating acute bleeds during pregnancy in women with congenital bleeding disorders.

PubMed

Karanth, Laxminarayan; Barua, Ankur; Kanagasabai, Sachchithanantham; Nair, N S

2013-04-30

Congenital bleeding disorders can cause obstetric haemorrhage during pregnancy, labour and following delivery. Desmopressin acetate is found to be an effective drug which can reduce the risk of haemorrhage and can also stop bleeding in certain congenital bleeding disorders. Its use in pregnancy has been controversial. Hence beneficial and adverse effects of desmopressin acetate in these groups of pregnant women should be evaluated. To determine the efficacy of desmopressin acetate in preventing and treating acute bleeds during pregnancy in women with congenital bleeding disorders. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coaguopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant and abstract books of conferences proceedings. We also searched for any randomised controlled trials in a registry of ongoing trials and the reference lists of relevant articles and reviews.Date of most recent search: 28 February 2013. Randomised and quasi-randomised controlled trials investigating the efficacy of desmopressin acetate versus tranexamic acid or factor VIII or rFactor VII or fresh frozen plasma in preventing and treating congenital bleeding disorders during pregnancy were eligible. No trials matching the selection criteria were eligible for inclusion. No trials matching the selection criteria were eligible for inclusion. The review did not identify any randomised controlled trials investigating the relative effectiveness of desmopressin acetate for bleeding during pregnancy in women with congenital bleeding disorders. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials) to decide whether or not to treat women with congenital bleeding disorders with desmopressin acetate.Given the ethical considerations, future randomised controlled trials are unlikely. However, other high quality controlled studies (such as risk allocation designs, sequential design, parallel cohort design) to investigate the risks and benefits of using desmopressin acetate in this population are needed.

Monitoring and treatment of acute gastrointestinal bleeding.

PubMed

Lenjani, Basri; Zeka, Sadik; Krasniqi, Salih; Bunjaku, Ilaz; Jakupi, Arianit; Elshani, Besni; Xhafa, Agim

2012-01-01

Acute gastrointestinal bleeding-massive acute bleeding from gastrointestinal section is one of the most frequent forms of acute abdomen. The mortality degree in emergency surgery is about 10%. It's very difficult to identify the place of bleeding and etiology. The important purpose of this research is to present the cases of acute gastrointestinal bleeding from the patients which were monitored and treated at The University Clinical Center of Kosova-Emergency Center in Pristina. These inquests included 137 patients with acute gastrointestinal bleeding who were treated in emergency center of The University Clinical Center in Pristina for the period from January 2005 until December 2006. From 137 patients with acute gastrointestinal bleeding 41% or 29% was female and 96% or 70.1% male. Following the sex we gained a high significant difference of statistics (p < 0.01). The gastrointestinal bleeding was two times more frequent in male than in female. Also in the age-group we had a high significant difference of statistics (p < 0.01) 63.5% of patients were over 55 years old. The mean age of patients with an acute gastrointestinal bleeding was 58.4 years SD 15.8 age. The mean age for female patients was 56.4 age SD 18.5 age. The patients with arterial systolic pressure under 100 mmHg have been classified as patients with hypovolemic shock. They participate with 17.5% in all prevalence of acute gastrointestinal bleeding. From the number of prevalence 2 {1.5%} patients have been diagnosed with peptic ulcer, 1 {0.7%} as gastric perforation and 1 {0.7%} with intestine ischemia. Abdominal Surgery and Intensive Care 2 or 1.5% died, 1 at intensive care unit and 1 at nephrology. As we know the severe condition of the patients with gastrointestinal bleeding and etiology it is very difficult to establish, we need to improve for the better conditions in our emergency center for treatment and initiation base of clinic criteria.

Intravenous pantoprazole versus ranitidine for prevention of rebleeding after endoscopic hemostasis of bleeding peptic ulcers

PubMed Central

Hsu, Ping-I; Lo, Gin-Ho; Lo, Ching-Chu; Lin, Chiun-Ku; Chan, Hoi-Hung; Wu, Chung-Jen; Shie, Chang-Bih; Tsai, Pei-Min; Wu, Deng-Chyang; Wang, Wen-Ming; Lai, Kwok-Hung

2004-01-01

AIM: The role of intravenous pantoprazole in treatment of patients with high-risk bleeding peptic ulcers following endoscopic hemostasis remains uncertain. We therefore conducted the pilot prospective randomized study to assess whether intravenous pantoprazole could improve the efficacy of H2-antagonist as an adjunct treatment following endoscopic injection therapy for bleeding ulcers. METHODS: Patients with active bleeding ulcers or ulcers with major signs of recent bleeding were treated with distilled water injection. After hemostasis was achieved, they were randomly assigned to receive intravenous pantoprazole or ranitidine. RESULTS: One hundred and two patients were enrolled in this prospective trial. Bleeding recurred in 2 patients (4%) in the pantoprazole group (n = 52), as compared with 8 (16%) in the ranitidine group (n = 50). The rebleeding rate was significantly lower in the pantoprazole group (P = 0.04). There were no statistically significant differences between the groups with regard to the need for emergency surgery (0% vs 2%), transfusion requirements (4.9 ± 5.9 vs 5.7 ± 6.8 units), hospital days (5.9 ± 3.2 vs 7.5 ± 5.0 d) or mortality (2% vs 2%). CONCLUSION: Pantoprozole is superior to ranitidine as an adjunct treatment to endoscopic injection therapy in high-risk bleeding ulcers. PMID:15534928

2-Year Outcomes of High Bleeding Risk Patients After Polymer-Free Drug-Coated Stents.

PubMed

Garot, Philippe; Morice, Marie-Claude; Tresukosol, Damras; Pocock, Stuart J; Meredith, Ian T; Abizaid, Alexandre; Carrié, Didier; Naber, Christoph; Iñiguez, Andres; Talwar, Suneel; Menown, Ian B A; Christiansen, Evald H; Gregson, John; Copt, Samuel; Hovasse, Thomas; Lurz, Philipp; Maillard, Luc; Krackhardt, Florian; Ong, Paul; Byrne, Jonathan; Redwood, Simon; Windhövel, Ute; Greene, Samantha; Stoll, Hans-Peter; Urban, Philip

2017-01-17

A 1-year follow-up, polymer-free metallic stent coated with biolimus-A9 followed by 1-month dual antiplatelet therapy is safer and more effective than a bare-metal stent (BMS) for patients with high risk of bleeding. This study analyzed 2-year outcomes to determine whether these benefits are maintained. In a prospective, multicenter, double-blind trial, we randomized 2,466 high bleeding risk patients to receive a drug-coated stent (DCS) or a BMS followed by 1-month dual antiplatelet therapy. The primary safety endpoint was a composite of cardiac death, myocardial infarction, or stent thrombosis. The primary efficacy endpoint was clinically driven target lesion revascularization. At 2 years, the primary safety endpoint had occurred in 147 DCS and 180 BMS patients (15.3%) (hazard ratio: 0.80; 95% confidence interval: 0.64 to 0.99; p = 0.039). Clinically driven target lesion revascularization occurred for 77 DCS and 136 BMS patients (12.0%) (hazard ratio: 0.54; 95% confidence interval: 0.41 to 0.72; p < 0.0001). Major bleeding occurred in 8.9% of DCS and 9.2% of BMS patients (p = 0.95), and a coronary thrombotic event (myocardial infarction and/or stent thrombosis) occurred in 8.2% of DCS and 10.6% of BMS patients (p = 0.045). One-year mortality was 27.1% for a major bleed and 26.3% for a thrombotic event. At 2 years, multivariate correlates of major bleeding were age >75 years, anemia, raised plasma creatinine, and planned long-term anticoagulation. Correlates of the primary safety endpoint were age, anemia, congestive heart failure, multivessel disease, number of stents implanted, and use of a BMS rather than a DCS. Safety and efficacy benefits of DCS over BMS were maintained for 2 years in high bleeding risk patients. Rates of major bleeding and coronary thrombotic events were no different and were associated with a substantial and comparable mortality risk. (A Prospective Randomized Comparison of the BioFreedom Biolimus A9 Drug Coated Stent Versus the Gazelle Bare Metal Stent in Patients With High Risk of Bleeding [LEADERS FREE]; NCT01623180). Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Advanced high performance vertical hybrid synthetic jet actuator

NASA Technical Reports Server (NTRS)

Xu, Tian-Bing (Inventor); Jiang, Xiaoning (Inventor); Su, Ji (Inventor)

2011-01-01

The present invention comprises a high performance, vertical, zero-net mass-flux, synthetic jet actuator for active control of viscous, separated flow on subsonic and supersonic vehicles. The present invention is a vertical piezoelectric hybrid zero-net mass-flux actuator, in which all the walls of the chamber are electrically controlled synergistically to reduce or enlarge the volume of the synthetic jet actuator chamber in three dimensions simultaneously and to reduce or enlarge the diameter of orifice of the synthetic jet actuator simultaneously with the reduction or enlargement of the volume of the chamber. The jet velocity and mass flow rate for the present invention will be several times higher than conventional piezoelectric synthetic jet actuators.

Tubeless percutaneous nephrolithotomy with non-absorbable hemostatic sealant (Quikclot®) versus nephrostomy tube placement: a propensity score-matched analysis.

PubMed

Koo, Kyo Chul; Park, Sang Un; Jang, Ho Sung; Hong, Chang-Hee

2015-11-01

The purpose of this study was to determine the efficacy and safety of tubeless percutaneous nephrolithotomy (PNL) using a non-absorbable hemostatic sealant (Quikclot(®)) as an adjunct compared to nephrostomy tube placement in patients exhibiting significant parenchymal bleeding following PNL. We identified 113 PNL cases performed between May 2011 and October 2014. For patients with insignificant parenchymal bleeding following stone removal, defined as a clear visualization of the surgical field at full irrigation of the nephroscope, tubeless PNL was performed. For patients with significant parenchymal bleeding, we introduced the tubeless Quikclot(®) technique as of September 2013 and have performed it ever since. Formerly, nephrostomy placement PNL was performed. In this study, 40 Quikclot(®) applied PNL cases were matched with an equal number of nephrostomy placement cases by propensity scoring based on body mass index, stone size, and Guy's stone score. The mean postoperative drop in hematocrit was comparative between the Quikclot(®) group and the nephrostomy group on both postoperative days 1 (p = 0.459) and 2 (p = 0.325). Quikclot(®) application was associated with lower VAS scores throughout the postoperative period, lower cumulative analgesic requirement (p = 0.025), and with shorter hospitalization (p = 0.002). Complication rates were comparable with no need for blood transfusions in any patients. Tubeless Quikclot(®) PNL was safe and provided effective hemostasis of significant parenchymal bleeding. By avoiding nephrostomy placement, we were able to reduce postoperative pain, analgesic requirements, and hospitalization. Application of Quikclot(®) may be considered prior to nephrostomy placement in patients with significant parenchymal bleeding.

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital

PubMed Central

Kurumi, Hiroki; Takeda, Yohei; Yashima, Kazuo; Isomoto, Hajime

2017-01-01

Background Peptic ulcer bleeding (PUB) is the main cause of non-variceal upper gastrointestinal bleeding (UGIB). Endoscopic treatment and acid suppression with proton-pump inhibitors (PPIs) are most important in the management of PUB and these treatments have reduced mortality. However, elderly patients sometimes have a poor prognostic outcome due to severe comorbidities. Methods A retrospective study was performed on 504 cases with acute non-variceal UGIB who were examined in our hospital, in order to reveal the risk factor of a poor outcome in elderly patients. Results Two hundred and thirty-four cases needed hemostasis; 11 cases had unsuccessful endoscopic treatments; 31 cases had re-bleeding after endoscopic hemostasis. Forty-three cases died within 30 days after the initial urgent endoscopy, but only seven cases died from bleeding. Elderly patients aged over 65 years had more severe comorbidities, and were prescribed non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents and/or anticoagulation agents, more frequently, compared with non-elderly patients. The significant risk factor of needing hemostatic therapy was the taking of two or more NSAIDs, antiplatelet agents and/or anticoagulation agents. The most important risk of a poor outcome in elderly patients was various kinds of severe comorbidities. And so, it is important to predict such an outcome in these cases. AIMS65 is a simple and relatively useful scoring system that predicts the risk of a poor outcome in UGIB. High-score patients via AIMS65 were associated with a high mortality rate because of death from comorbidities. Conclusions The elderly patients in whom were prescribed two or more NSAIDs, antiplatelet agents and/or anticoagulation agents, should have UGIB prevented using a PPI. The most significant risk of a poor outcome in elderly patients was severe comorbidities. We recommend that elderly patients with UGIB should be estimated as having a poor outcome as soon as possible via the risk scoring system AIMS65. PMID:28616396

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital.

PubMed

Kawaguchi, Koichiro; Kurumi, Hiroki; Takeda, Yohei; Yashima, Kazuo; Isomoto, Hajime

2017-04-01

Peptic ulcer bleeding (PUB) is the main cause of non-variceal upper gastrointestinal bleeding (UGIB). Endoscopic treatment and acid suppression with proton-pump inhibitors (PPIs) are most important in the management of PUB and these treatments have reduced mortality. However, elderly patients sometimes have a poor prognostic outcome due to severe comorbidities. A retrospective study was performed on 504 cases with acute non-variceal UGIB who were examined in our hospital, in order to reveal the risk factor of a poor outcome in elderly patients. Two hundred and thirty-four cases needed hemostasis; 11 cases had unsuccessful endoscopic treatments; 31 cases had re-bleeding after endoscopic hemostasis. Forty-three cases died within 30 days after the initial urgent endoscopy, but only seven cases died from bleeding. Elderly patients aged over 65 years had more severe comorbidities, and were prescribed non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents and/or anticoagulation agents, more frequently, compared with non-elderly patients. The significant risk factor of needing hemostatic therapy was the taking of two or more NSAIDs, antiplatelet agents and/or anticoagulation agents. The most important risk of a poor outcome in elderly patients was various kinds of severe comorbidities. And so, it is important to predict such an outcome in these cases. AIMS65 is a simple and relatively useful scoring system that predicts the risk of a poor outcome in UGIB. High-score patients via AIMS65 were associated with a high mortality rate because of death from comorbidities. The elderly patients in whom were prescribed two or more NSAIDs, antiplatelet agents and/or anticoagulation agents, should have UGIB prevented using a PPI. The most significant risk of a poor outcome in elderly patients was severe comorbidities. We recommend that elderly patients with UGIB should be estimated as having a poor outcome as soon as possible via the risk scoring system AIMS65.

Liver stiffness and platelet count for identifying patients with compensated liver disease at low risk of variceal bleeding.

PubMed

Marot, Astrid; Trépo, Eric; Doerig, Christopher; Schoepfer, Alain; Moreno, Christophe; Deltenre, Pierre

2017-05-01

The 2015 Baveno VI guidelines recommend against performing upper gastrointestinal endoscopy in patients with compensated cirrhosis who have a liver stiffness <20 kPa and a platelet count >150 000/mm³ because of a low prevalence of varices at risk of bleeding in this population. The aim was to synthesize the available evidence on the usefulness of the combined use of liver stiffness and platelet count to identify patients without oesophageal varices. Meta-analysis of trials evaluating the usefulness of a given cut-off for liver stiffness and platelet count to rule out the presence of oesophageal varices. Fifteen studies were included. All studies excepting five used the Baveno VI criteria. Compared to patients with either high liver stiffness or low platelet count, those with low liver stiffness and normal platelet count had a lower risk of varices at risk of bleeding (OR=0.22, 95% CI=0.13-0.39, P<.001) with low heterogeneity between studies (I 2 =21%). They also had a lower risk of varices (OR=0.23, 95% CI=0.17-0.32, P<.001) with moderate heterogeneity between studies (I 2 =28%). In patients with low liver stiffness and normal platelet count, the pooled estimate rates for varices at risk of bleeding was 0.040 (95% CI=0.027-0.059) with low heterogeneity between studies (I 2 =3%). Patients with low liver stiffness and normal platelet count have a lower risk of varices than those with either high liver stiffness or low platelet count. Varices at risk of bleeding are found in no more than 4% of patients when liver stiffness is <20 kPa and platelet count is normal. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Dual Antithrombotic Therapy with Clopidogrel and Novel Oral Anticoagulants in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Real-world Study.

PubMed

Kebernik, Julia; Borlich, Martin; Tölg, Ralph; El-Mawardy, Mohamed; Abdel-Wahab, Mohamed; Richardt, Gert

2018-06-01

For patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), proper antithrombotic therapy is equivocal. Current guidelines recommend triple therapy, which carries a high risk of bleeding. Recent large trials suggest that dual therapy (DT) with novel oral anticoagulant (NOAC) plus P2Y 12 inhibitor can be an appropriate alternative, but real-world data for this alternative are scarce and the optimal duration of DT has not yet been established. This analysis was performed in a single-center prospective cohort. We investigated 216 PCI patients with indication for anticoagulation due to AF. After PCI patients received DT with reduced doses NOAC plus P2Y 12 inhibitor for 6 months, which was followed by standard dose NOAC monotherapy. Efficacy endpoints were defined as cardiac death, myocardial infarction (MI), stent thrombosis (ST), and stroke. Safety endpoints were bleeding events as defined by Bleeding Academic Consortium (BARC). Baseline characteristics of our study population were described by a CHA 2 DS 2 -VASc score of greater than 4 and a HAS-BLED score of greater than 3. After a mean follow-up of 18.7 months, efficacy events occurred in 12 patients (5.6%). We observed three (1.4%) cardiac deaths, two (0.9%) MIs, six (2.8%) strokes, and one (0.5%) definite ST. After switching from DT to NOAC monotherapy after 6.3 ± 1.7 months, there was no rebound of ischemic events. Bleeding events occurred in 34 patients (15.7%) mainly under DT, while bleeding was less during NOAC monotherapy. In this long-term study of high-risk and real-world AF-patients with PCI, DT with NOAC and P2Y 12 inhibitor (6 months) followed by NOAC monotherapy was safe and effective.

Motivation for DOC III: 64-bit digital optical computer

NASA Astrophysics Data System (ADS)

Guilfoyle, Peter S.

1991-09-01

OptiComp has focused on a digital optical logic family in order to capitalize on the inherent benefits of optical computing, which include (1) high FAN-IN and FAN-OUT, (2) low power consumption, (3) high noise margin, (4) high algorithmic efficiency using 'smart' interconnects, and (5) free-space leverage of gate interconnect bandwidth product. Other well-known secondary advantages of optical logic include zero capacitive loading of signals at a detector, zero cross-talk between signals, zero signal dispersion, and minimal clock skew (a few picoseconds or less in an imaging system). The primary focus of this paper is to demonstrate how each of the five advantages can be used to leverage other logic family performance such as GaAs; the secondary attributes are discussed only in the context of introducing the DOC III architecture.

Zero-voltage DC/DC converter with asymmetric pulse-width modulation for DC micro-grid system

NASA Astrophysics Data System (ADS)

Lin, Bor-Ren

2018-04-01

This paper presents a zero-voltage switching DC/DC converter for DC micro-grid system applications. The proposed circuit includes three half-bridge circuit cells connected in primary-series and secondary-parallel in order to lessen the voltage rating of power switches and current rating of rectifier diodes. Thus, low voltage stress of power MOSFETs can be adopted for high-voltage input applications with high switching frequency operation. In order to achieve low switching losses and high circuit efficiency, asymmetric pulse-width modulation is used to turn on power switches at zero voltage. Flying capacitors are used between each circuit cell to automatically balance input split voltages. Therefore, the voltage stress of each power switch is limited at Vin/3. Finally, a prototype is constructed and experiments are provided to demonstrate the circuit performance.

New Target-Specific Oral Anticoagulants and Intracranial Bleeding: Management and Outcome in a Single-Center Case Series.

PubMed

Senger, Sebastian; Keiner, Dörthe; Hendrix, Philipp; Oertel, Joachim

2016-04-01

New target-specific anticoagulants such as the direct thrombin inhibitor dabigatran and the factor Xa inhibitor rivaroxaban are used in an increasing number of patients. Several studies comparing these new oral anticoagulants with vitamin K antagonists revealed a lower risk of severe bleeding complications and reduced thromboembolic events. However, the lack of antidotes is a challenging issue in the treatment of traumatic or spontaneous intracranial hemorrhage. A retrospective analysis of patients with intracranial bleeding under new oral anticoagulants was performed; these patients were admitted to our department between January 2011 and November 2014. Treatment, reversal management of blood coagulopathy, and outcome of the patients were analyzed. Seventeen patients were included. The median age was 80.4 years. Seven patients were treated with dabigatran and 10 with rivaroxaban. Eight patients had traumatic intracranial bleeding and 9 patients had spontaneous intracranial hemorrhage. Complex perioperative hematologic treatment followed. In 9 cases, the clinical outcome was devastating with severe neurologic deficits (n = 2), comatose status (n = 4), or death (n = 3). Patients with the indication for acute surgical treatment had a high risk for a critical clinical outcome. Only a few case reports have analyzed the clinical course and the outcome after intracranial bleeding under new target-specific oral anticoagulants. Here, one of the first larger series is presented. Because of the lack of reversibility of the anticoagulative effects and the overall risks with geriatric patients, surgical treatment should be delayed as long as possible and comorbidities have to be considered. Copyright © 2016 Elsevier Inc. All rights reserved.

Transcatheter Arterial Embolization for Gastrointestinal Bleeding Secondary to Gastrointestinal Lymphoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zheng, Lin; Shin, Ji Hoon, E-mail: jhshin@amc.seoul.kr; Han, Kichang

PurposeTo evaluate the effectiveness of transcatheter arterial embolization (TAE) for gastrointestinal (GI) bleeding caused by GI lymphoma.Materials and MethodsThe medical records of 11 patients who underwent TAE for GI bleeding caused by GI lymphoma between 2001 and 2015 were reviewed retrospectively.ResultsA total of 20 TAE procedures were performed. On angiography, contrast extravasation, and both contrast extravasation and tumor staining were seen in 95 % (19/20) and 5 % (1/20) of the procedures, respectively. The most frequently embolized arteries were jejunal (n = 13) and ileal (n = 5) branches. Technical and clinical success rates were 100 % (20/20) and 27 % (3/11), respectively. The causes of clinical failuremore » in eight patients were rebleeding at new sites. In four patients who underwent repeat angiography, the bleeding focus was new each time. Three patients underwent small bowel resection due to rebleeding after one (n = 2) or four (n = 1) times of TAEs. Another two patients underwent small bowel resection due to small bowel ischemia/perforation after three or four times of TAEs. The 30-day mortality rate was 18 % due to hypovolemic shock (n = 1) and multiorgan failure (n = 1).ConclusionAngiogram with TAE shows limited therapeutic efficacy to manage GI lymphoma-related bleeding due to high rebleeding at new sites. Although TAE can be an initial hemostatic measure, surgery should be considered for rebleeding due to possible bowel ischemic complication after repeated TAE procedures.« less

Recurrent Bleeding After Perimesencephalic Hemorrhage.

PubMed

Kauw, Frans; Velthuis, Birgitta K; Kizilates, Ufuk; van der Schaaf, Irene C; Rinkel, Gabriel J E; Vergouwen, Mervyn D I

2017-12-01

Perimesencephalic hemorrhage (PMH) is a type of subarachnoid hemorrhage with excellent long-term outcomes. Only 1 well-documented case of in-hospital rebleeding after PMH is described in the literature, which occurred after initiating antithrombotic treatment because of myocardial ischemia. We describe a patient with PMH without antithrombotic treatment who had 2 episodes of recurrent bleeding on the day of ictus. To validate the radiologic findings, we conducted a case-control study. Six neuroradiologists and 2 neuroradiology fellows performed a blinded assessment of serial unenhanced head computed tomography (CT) scans of 8 patients with a perimesencephalic bleeding pattern (1 index patient, 6 patients with PMH, 1 patient with perimesencephalic bleeding pattern and basilar artery aneurysm) to investigate a potential increase in amount of subarachnoid blood. A 56-year-old woman with a perimesencephalic bleeding pattern and negative CT angiography had 2 episodes after the onset headache with a sudden increase of the headache. Blinded assessment of serial head CT scans of 8 patients with a perimesencephalic bleeding pattern identified the patient who was clinically suspected to have 2 episodes of recurrent bleeding to have an increased amount of subarachnoid blood on 2 subsequent CT scans. Recurrent bleeding after PMH may also occur in patients not treated with antithrombotics. Even after early rebleeding, the prognosis of PMH is excellent. Copyright © 2017 Elsevier Inc. All rights reserved.

Reversal of Direct Oral Anticoagulants: Current Status and Future Directions.

PubMed

Weitz, Jeffrey I

2017-02-01

Direct oral anticoagulants (DOACs) are increasingly used for prevention and treatment of venous thromboembolism and for prevention of stroke in patients with nonvalvular atrial fibrillation. In phase III clinical trials that included more than 100,000 patients, the DOACs were at least as effective as vitamin K antagonists (VKAs) and were associated with less serious bleeding, particularly less intracranial bleeding. Real-world evidence supports these outcomes. Despite this, some physicians and patients are concerned about serious bleeding or emergencies unless specific reversal agents for the DOACs are available. However, in clinical trials performed without reversal agents, the outcome of major bleeds was similar or better in patients receiving DOACs than in those taking VKAs. Because of their short half-lives, supportive measures are sufficient to manage most bleeds in patients receiving DOACs. Anticoagulant reversal should only be considered with life-threatening bleeds, with bleeds that fail to respond to usual measures and in patients requiring urgent surgery. Idarucizumab is licensed for dabigatran reversal and andexanet alfa is likely to be soon licensed for reversal of rivaroxaban, apixaban, and edoxaban. To ensure responsible use of these agents, every hospital needs a bleeding management algorithm that identifies patients eligible for reversal and outlines appropriate dosing regimens. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Gastrointestinal Bleeding Following LVAD Placement from Top to Bottom.

PubMed

Cushing, Kelly; Kushnir, Vladimir

2016-06-01

Left ventricular assist devices (LVADs) are an increasingly prevalent form of mechanical support for patients with end-stage heart failure. These devices can be implanted both as a bridge to transplant and as definitive/destination therapy. Gastrointestinal (GI) bleeding is one of the most common and recalcitrant long-term complications following LVAD implantation, with an incidence approaching 30 %. This review will discuss what is known about the pathophysiology of GI bleeding in LVADs and the currently available options for medical and/or endoscopic management. The pathophysiology of bleeding is multifactorial, with hemodynamic alterations, acquired von Willebrand factor deficiency, and coagulopathy being most often implicated. The majority of bleeding events in this population result from angioectasias and gastroduodenal erosive disease. While these bleeding events are significant and often require transfusion therapy, they are rarely life threatening. Endoscopy remains the standard of care with upper endoscopy offering the highest diagnostic yield in these patients. However, the effectiveness of endoscopic hemostasis in this population is not well established. A small number of studies have evaluated medical therapy and alterations in LVAD settings as a means of preventing or treating bleeding with variable results. In summary, GI bleeding with LVADs is a common occurrence and will continue to be as more LVADs are being performed for destination therapy.

Telemetric real-time sensor for the detection of acute upper gastrointestinal bleeding.

PubMed

Schostek, Sebastian; Zimmermann, Melanie; Keller, Jan; Fode, Mario; Melbert, Michael; Schurr, Marc O; Gottwald, Thomas; Prosst, Ruediger L

2016-04-15

Acute upper gastrointestinal bleedings from ulcers or esophago-gastric varices are life threatening medical conditions which require immediate endoscopic therapy. Despite successful endoscopic hemostasis, there is a significant risk of rebleeding often requiring close surveillance of these patients in the intensive care unit (ICU). Any time delay to recognize bleeding may lead to a high blood loss and increases the risk of death. A novel telemetric real-time bleeding sensor can help indicate blood in the stomach: the sensor is swallowed to detect active bleeding or is anchored endoscopically on the gastrointestinal wall close to the potential bleeding source. By telemetric communication with an extra-corporeal receiver, information about the bleeding status is displayed. In this study the novel sensor, which measures characteristic optical properties of blood, has been evaluated in an ex-vivo setting to assess its clinical applicability and usability. Human venous blood of different concentrations, various fluids, and liquid food were tested. The LED-based sensor was able to reliably distinguish between concentrated blood and other liquids, especially red-colored fluids. In addition, the spectrometric quality of the small sensor (size: 6.5mm in diameter, 25.5mm in length) was comparable to a much larger and technically more complex laboratory spectrophotometer. The experimental data confirm the capability of a miniaturized sensor to identify concentrated blood, which could help in the very near future the detection of upper gastrointestinal bleeding and to survey high-risk patients for rebleeding. Copyright © 2015 Elsevier B.V. All rights reserved.

Primary aortoduodenal fistula associated with abdominal aortic aneurysm with presentation of gastrointestinal bleeding: a case report.

PubMed

Lin, Tzu-Chieh; Tsai, Chung-Lin; Chang, Yao-Tien; Hu, Sung-Yuan

2018-06-07

Primary aortoduodenal fistula (ADF) is a rare cause of gastrointestinal (GI) bleeding and is difficult to diagnose as the clinical presentation is subtle. Clinicians should keep a high level of suspicion for an unknown etiology of GI bleeding, especially in older patients with or without abdominal aortic aneurysm (AAA). Computed tomographic angiography (CTA) can be used to detect primary ADF. Open surgery or endovascular aortic repair (EVAR) for ADF with bleeding will improve the survival rate. We report a rare case of AAA complicating ADF with massive GI bleeding in a 73-year-old Taiwanese man. He presented with abdominal pain and tarry stool for 5 days and an initial upper GI endoscopy at a rural hospital showed gastric ulcer only, but hypotension with tachycardia and a drop in hemoglobin of 9 g/dl from 12 g/dl occurred the next day. He was referred to our hospital for EVAR and primary closure of fistula defect due to massive GI bleeding with shock from ADF caused by AAA. Diagnosis was made by CTA of aorta. A timely and accurate diagnosis of primary ADF may be challenging due to insidious episodes of GI bleeding, which are frequently under-diagnosed until the occurrence of massive hemorrhage. Clinical physicians should keep a high index of awareness for primary ADF, especially in elderly patients with unknown etiology of upper GI bleeding with or without a known AAA.

SvO2 Trigger in Transfusion Strategy After Cardiac Surgery

ClinicalTrials.gov

2018-03-27

Undergoing Nonemergent Cardiac Surgery; Central Venous Catheter on the Superior Vena Cava (to Perform ScVO2 Measure); Anemia (<9g/dL) Requiring Blood Transfusion; Hemodynamic and Respiratory Stability; Bleeding Graded as Insignificant, Mild, Moderate of Universal Definition of Perioperative Bleeding

Use of intra-arterial nitroglycerin during uterine artery embolization for severe postpartum hemorrhage with uterine artery vasospasm.

PubMed

Wang, Liangcheng; Horiuchi, Isao; Mikami, Yukiko; Takagi, Kenjiro; Okochi, Tomohisa; Hamamoto, Kohei; Chiba, Emiko; Matsuura, Katsuhiko

2015-04-01

Uterine artery embolization (UAE) is a standard method for treating postpartum hemorrhage (PPH), although uterine artery vasospasm during UAE may lead to failure of hemostasis. Here, we report our experience with a case of PPH in which the bleeding was successfully controlled by intra-arterial administration of nitroglycerin during the second UAE. A 30-year-old woman experienced PPH following a successful cesarean section, and a UAE was performed. However, 6 hours later, vaginal bleeding restarted; the reason for unsuccessful embolization during the first UAE was vasoconstriction due to hypovolemic shock. We performed a second UAE, but uterine bleeding continued. After intra-arterial administration of nitroglycerin, hemostasis was confirmed, and there was no reperfusion of the uterine artery. After these two UAE procedures, no recurrence of bleeding was observed. Thus, use of intra-arterial nitroglycerin was effective for controlling uterine artery vasospasm during UAE. However, larger studies are required to confirm these findings. Copyright © 2015. Published by Elsevier B.V.

Gastrointestinal Bleeding Due to Gastrointestinal Tract Malignancy: Natural History, Management, and Outcomes.

PubMed

Schatz, Richard A; Rockey, Don C

2017-02-01

Gastrointestinal (GI) tumor bleeding can vary from occult bleeding to massive hemorrhage and can be the presenting sign of malignancy. Our primary aims were to: (1) characterize the natural history, treatment, and outcomes in patients with GI tumor bleeding and (2) compare and contrast bleeding in upper GI (UGI)/small bowel (SB) and lower GI malignancies. Patients with endoscopically confirmed tumor bleeding were identified through search of consecutive electronic medical records: Bleeding was determined by the presence of melena, hematochezia, hematemesis, or fecal occult blood. Comprehensive clinical and management data were abstracted. A total of 354 patients with GI tumors were identified: 71 had tumor bleeding (42 UGI/SB and 29 colonic). GI bleeding was the initial presenting symptom of malignancy in 55/71 (77%) of patients; 26/71 patients had widely metastatic disease at presentation. Further, 15 of 26 patients with metastatic disease presented with GI bleeding. Visible bleeding was present in 14/42 (33%) and 4/29 (14%) of UGI/SB and colonic tumors, respectively. Endoscopic hemostasis was attempted in 10 patients, and although initial control was successful in all, bleeding recurred in all of these patients. The most common endoscopic lesion was clean-based tumor ulceration. Overall mortality at 1 year was 57% for esophageal/gastric, 14% for SB, and 33% for colonic tumors. When patients with GI malignancy present with GI bleeding, it is often the index symptom. Initial endoscopic hemostasis is often successful, but rebleeding is typical. Esophageal and gastric tumors carry the poorest prognosis, with a high 1-year mortality rate.

Development of a prognostic nomogram for cirrhotic patients with upper gastrointestinal bleeding.

PubMed

Zhou, Yu-Jie; Zheng, Ji-Na; Zhou, Yi-Fan; Han, Yi-Jing; Zou, Tian-Tian; Liu, Wen-Yue; Braddock, Martin; Shi, Ke-Qing; Wang, Xiao-Dong; Zheng, Ming-Hua

2017-10-01

Upper gastrointestinal bleeding (UGIB) is a complication with a high mortality rate in critically ill patients presenting with cirrhosis. Today, there exist few accurate scoring models specifically designed for mortality risk assessment in critically ill cirrhotic patients with upper gastrointestinal bleeding (CICGIB). Our aim was to develop and evaluate a novel nomogram-based model specific for CICGIB. Overall, 540 consecutive CICGIB patients were enrolled. On the basis of Cox regression analyses, the nomogram was constructed to estimate the probability of 30-day, 90-day, 270-day, and 1-year survival. An upper gastrointestinal bleeding-chronic liver failure-sequential organ failure assessment (UGIB-CLIF-SOFA) score was derived from the nomogram. Performance assessment and internal validation of the model were performed using Harrell's concordance index (C-index), calibration plot, and bootstrap sample procedures. UGIB-CLIF-SOFA was also compared with other prognostic models, such as CLIF-SOFA and model for end-stage liver disease, using C-indices. Eight independent factors derived from Cox analysis (including bilirubin, creatinine, international normalized ratio, sodium, albumin, mean artery pressure, vasopressin used, and hematocrit decrease>10%) were assembled into the nomogram and the UGIB-CLIF-SOFA score. The calibration plots showed optimal agreement between nomogram prediction and actual observation. The C-index of the nomogram using bootstrap (0.729; 95% confidence interval: 0.689-0.766) was higher than that of the other models for predicting survival of CICGIB. We have developed and internally validated a novel nomogram and an easy-to-use scoring system that accurately predicts the mortality probability of CICGIB on the basis of eight easy-to-obtain parameters. External validation is now warranted in future clinical studies.

Comparative risk of major bleeding with new oral anticoagulants (NOACs) and phenprocoumon in patients with atrial fibrillation: a post-marketing surveillance study.

PubMed

Hohnloser, Stefan H; Basic, Edin; Nabauer, Michael

2017-08-01

Non-vitamin K antagonist oral anticoagulants (NOACs) are at least as effective and safe as vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF). All pivotal trials have compared NOACs to warfarin. However, other VKAs are commonly used, for instance phenprocoumon. A retrospective cohort study using a German claims database assessed the comparative risks of bleeding leading to hospitalization during therapy with NOACs and phenprocoumon in AF patients. Endpoints consisted of major bleeding, gastrointestinal bleeding, and any bleeding. Data were collected from January 1, 2013 to March 31, 2015. Patients newly initiated on dabigatran, apixaban, rivaroxaban, or phenprocoumon were included. Hazard Ratios for bleeding events were derived from Cox proportional hazard models, adjusting for differences in baseline characteristics. Propensity score matching was performed as a sensitivity analysis. A total of 35,013 patients were identified, including 3138 on dabigatran, 3633 on apixaban, 12,063 on rivaroxaban, and 16,179 on phenprocoumon. Patients prescribed apixaban or phenprocoumon were older compared to those on dabigatran or rivaroxaban and had a higher CHA 2 DS 2 -VASc score. After adjusting for baseline confounders, apixaban was associated with lower risks of major bleeding (HR 0.68, 95% CI 0.51-0.90, p = 0.008), gastrointestinal bleeding (HR 0.53, 95% CI 0.39-0.72, p < 0.001), and any bleeding (HR 0.80, 95% CI 0.70-0.92, p = 0.002) compared to phenprocoumon. There were no significant differences in bleeding risk between dabigatran and phenprocoumon. Rivaroxaban was associated with more gastrointestinal bleeding (HR 1.39, 95% CI 1.21-1.60, p < 0.001) and any bleeding (HR 1.19, 95% CI 1.10-1.28, p < 0.001). Sensitivity analysis using propensity score matching confirmed these observations. Apixaban therapy is associated with a significantly reduced risk of bleeding compared to phenprocoumon. Bleeding risk with dabigatran was similar to that of phenprocoumon but bleeding risk with rivaroxaban was higher.

Agonist-induced platelet reactivity correlates with bleeding in haemato-oncological patients.

PubMed

Batman, B; van Bladel, E R; van Hamersveld, M; Pasker-de Jong, P C M; Korporaal, S J A; Urbanus, R T; Roest, M; Boven, L A; Fijnheer, R

2017-11-01

Prophylactic platelet transfusions are administered to prevent bleeding in haemato-oncological patients. However, bleeding still occurs, despite these transfusions. This practice is costly and not without risk. Better predictors of bleeding are needed, and flow cytometric evaluation of platelet function might aid the clinician in identifying patients at risk of bleeding. This evaluation can be performed within the hour and is not hampered by low platelet count. Our objective was to assess a possible correlation between bleeding and platelet function in thrombocytopenic haemato-oncological patients. Inclusion was possible for admitted haemato-oncology patients aged 18 years and above. Furthermore, an expected need for platelet transfusions was necessary. Bleeding was graded according to the WHO bleeding scale. Platelet reactivity to stimulation by either adenosine diphosphate (ADP), cross-linked collagen-related peptide (CRP-xL), PAR1- or PAR4-activating peptide (AP) was measured using flow cytometry. A total of 114 evaluations were available from 21 consecutive patients. Platelet reactivity in response to stimulation by all four studied agonists was inversely correlated with significant bleeding. Odds ratios (OR) for bleeding were 0·28 for every unit increase in median fluorescence intensity (MFI) [95% confidence interval (CI) 0·11-0·73] for ADP; 0·59 [0·40-0·87] for CRP-xL; 0·59 [0·37-0·94] for PAR1-AP; and 0·43 [0·23-0·79] for PAR4-AP. The platelet count was not correlated with bleeding (OR 0·99 [0·96-1·02]). Agonist-induced platelet reactivity was significantly correlated to bleeding. Platelet function testing could provide a basis for a personalized transfusion regimen, in which platelet transfusions are limited to those at risk of bleeding. © 2017 International Society of Blood Transfusion.

Post-tonsillectomy hemorrhagic outcomes in children with bleeding disorders at a single institution.

PubMed

Patel, Priyesh N; Arambula, Alexandra M; Wheeler, Allison P; Penn, Edward B

2017-09-01

To report on the post-tonsillectomy bleeding outcomes and factors associated with hemorrhage among children with pre- or post-operatively diagnosed bleeding disorders treated with an institutional protocol. Retrospective cohort study of patients with hematologic disorders who underwent tonsillectomy between 2003 and 2016 and were treated with perioperative desmopressin or factor replacement and/or aminocaproic acid. Postoperative outcomes were compared to controls matched for age, sex, and indication for surgery. Analysis of factors associated with hemorrhage was performed in patients with bleeding disorders using Mann-Whitney U or chi-squared tests. 45 patients with hematologic disorders met inclusion criteria. Platelet dysfunction, including von Willebrand Disease (vWD), was the most common diagnosis (77.8%). Most patients had a preoperative diagnosis of a bleeding disorder and received perioperative hematologic medications (86.7%). Compared to matched controls, patients with hematologic disorders experienced more postoperative bleeding (15.5%; 12 bleeds, 7 patients vs. 1.7%; 1 bleed, 1 patient, p = 0.05) and had longer postoperative stays (1.3 days vs. 0.4 days, p < 0.001). Among the patients with hematologic disorders, patients who experienced a postoperative bleed were significantly more likely to have a factor deficiency (e.g. Hemophilia over vWD) and have a postoperative diagnosis (compared to preoperative diagnosis) for which they did not receive perioperative hematologic medication. Of patients with a postoperative bleed, all those diagnosed postoperatively required at least one surgical intervention to control bleeding compared to 33% of patients with a preoperative diagnosis. A history of post-surgical bleeding, male sex, age at surgery, and pharyngitis as surgical indication were not associated with higher hemorrhage rates in this group. This study suggests a clinically important magnitude of increased bleeding risk in patients with hematologic disease. This risk appears to decrease with the use of an institutional protocol consisting of desmopressin or factor replacement and an antifibrinolytic agent extending through postoperative day 10. Copyright © 2017 Elsevier B.V. All rights reserved.

Lower gastrointestinal bleeding: Role of 64-row computed tomographic angiography in diagnosis and therapeutic planning

PubMed Central

Ren, Jian-Zhuang; Zhang, Meng-Fan; Rong, Ai-Mei; Fang, Xiang-Jie; Zhang, Kai; Huang, Guo-Hao; Chen, Peng-Fei; Wang, Zhao-Yang; Duan, Xu-Hua; Han, Xin-Wei; Liu, Yan-Jie

2015-01-01

AIM: To determine the value of computed tomographic angiography (CTA) for diagnosis and therapeutic planning in lower gastrointestinal (GI) bleeding. METHODS: Sixty-three consecutive patients with acute lower GI bleeding underwent CTA before endovascular or surgical treatment. CTA was used to determine whether the lower GI bleeding was suitable for endovascular treatment, surgical resection, or conservative treatment in each patient. Treatment planning with CTA was compared with actual treatment decisions or endovascular or surgical treatment that had been carried out in each patient based on CTA findings. RESULTS: 64-row CTA detected active extravasation of contrast material in 57 patients and six patients had no demonstrable active bleeding, resulting in an accuracy of 90.5% in the detection of acute GI bleeding (57 of 63). In three of the six patients with no demonstrable active bleeding, active lower GI bleeding recurred within one week after CTA, and angiography revealed acute bleeding. The overall location-based accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the detection of GI bleeding by 64-row CTA were 98.8% (249 of 252), 95.0% (57 of 60), 100% (192 of 192), 100% (57 of 57), and 98.5% (192 of 195), respectively. Treatment planning was correctly established on the basis of 64-row CTA with an accuracy, sensitivity, specificity, PPV and NPV of 98.4% (248 of 252), 93.3% (56 of 60), 100% (192 of 192), 100% (56 of 56), and 97.5% (192 of 196), respectively, in a location-based evaluation. CONCLUSION: 64-row CTA is safe and effective in making decisions regarding treatment, without performing digital subtraction angiography or surgery, in the majority of patients with lower GI bleeding. PMID:25852291

The risk of gastrointestinal bleeding in patients receiving dabigatran etexilate: a systematic review and meta-analysis of the literature.

PubMed

Di Minno, Matteo Nicola Dario; Ambrosino, Pasquale; Di Minno, Alessandro; Tremoli, Elena; Di Minno, Giovanni

2017-06-01

Evidence on the risk of gastrointestinal (GI) bleeding associated with dabigatran etexilate (DE) is contrasting. We performed a meta-analysis of literature to address this issue. Studies on GI bleeding risk in patients receiving DE or vitamin-K antagonists (VKA) were systematically searched. Twenty-three studies (26 datasets) showed no difference in the GI bleeding risk between the 250,871 patients treated with DE and the 460,386 receiving VKA (OR: 1.052, 95% CI: 0.815, 1.359). Similar results were obtained when pooling together adjusted ORs/HRs, obtained by means of multivariate analysis (OR: 1.06, 95% CI: 0.914, 1.222). Compared with VKA, DE use was associated with a significantly lower risk of upper GI (OR: 0.742, 95% CI: 0.569, 0.968), but not of lower GI bleedings (OR: 1.208, 95% CI: 0.902, 1.619). Furthermore, no significant difference in the GI bleeding risk was found when data on DE 110 mg and DE 150 mg twice-daily were separately compared with VKA. No difference in GI bleeding risk was found between DE and VKA. These results were confirmed for both dosages of DE and when specifically analyzing lower GI bleeding. In contrast, the risk of upper GI bleeding was lower with DE than with VKA. KEY MESSAGES No difference in the risk of gastrointestinal (GI) bleeding can be found between dabigatran etexilate (DE) and vitamin K-antagonists (VKA). These results are confirmed for both dosages of DE. The risk of upper GI bleeding is lower with DE than with VKA.

Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom.

PubMed

Gilliam, A D; Speake, W J; Lobo, D N; Beckingham, I J

2003-01-01

The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer. A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001. Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01). Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications. Copyright 2002 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd

Prevention and management of gastroesophageal varices

PubMed Central

2018-01-01

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices. PMID:29249128

Reduced thrombin formation and excessive fibrinolysis are associated with bleeding complications in patients with dengue fever: a case–control study comparing dengue fever patients with and without bleeding manifestations

PubMed Central

2013-01-01

Background Dengue cases have been classified according to disease severity into dengue fever (DF) and dengue hemorrhagic fever (DHF). Although DF is considered a non-severe manifestation of dengue, it has been recently demonstrated that DF represents a heterogeneous group of patients with varied clinical complications and grades of severity. Particularly, bleeding complications, commonly associated to DHF, can be detected in half of the patients with DF. Although a frequent complication, the causes of bleedings in DF have not been fully addressed. Thus, the aim of this study was to perform a comprehensive evaluation of possible pathophysiological mechanisms that could contribute to the bleeding tendency observed in patients with DF. Methods This is a case–control study that enrolled adults with DF without bleeding and adults with DF and bleeding complications during the defervescence period. Healthy controls were also included. Peripheral blood counts, inflammatory, fibrinolysis and endothelial cell activation markers, and thrombin generation were evaluated in patients and controls. Results We included 33 adults with DF without complications, 26 adults with DF and bleeding and 67 healthy controls. Bleeding episodes were mild in 15 (57.6%) and moderate in 11 (42.4%) patients, 8 (30.7%) patients had bleedings in multiple sites. Patients with DF and bleedings had lower platelet counts than DF without bleeding (median = 19,500 vs. 203,500/mm3, P < 0,0001). Levels of TNF-α, thrombomodulin and VWF were significantly increased in the two dengue groups than in healthy controls, but similar between patients with and without bleedings. Plasma levels of tPA and D-dimer were significantly increased in patients with bleedings (median tPA levels were 4.5, 5.2, 11.7 ng/ml, P < 0.0001 and median D-dimer levels were 515.5, 1028 and 1927 ng/ml, P < 0.0001). The thrombin generation test showed that patients with bleeding complications had reduced thrombin formation (total thrombin generated were 3753.4 in controls, 3367.5 in non-bleeding and 2274.5nM in bleeding patients, P < 0.002). Conclusions DF can manifest with spontaneous bleedings, which are associated with specific coagulation and fibrinolysis profiles that are not significantly present in DF without this complication. Particularly, thrombocytopenia, excessive fibrinolysis and reduced thrombin formation may contribute to the bleeding manifestations in DF. PMID:23890510

Reduced thrombin formation and excessive fibrinolysis are associated with bleeding complications in patients with dengue fever: a case-control study comparing dengue fever patients with and without bleeding manifestations.

PubMed

Orsi, Fernanda A; Angerami, Rodrigo N; Mazetto, Bruna M; Quaino, Susan K P; Santiago-Bassora, Fernanda; Castro, Vagner; de Paula, Erich V; Annichino-Bizzacchi, Joyce M

2013-07-28

Dengue cases have been classified according to disease severity into dengue fever (DF) and dengue hemorrhagic fever (DHF). Although DF is considered a non-severe manifestation of dengue, it has been recently demonstrated that DF represents a heterogeneous group of patients with varied clinical complications and grades of severity. Particularly, bleeding complications, commonly associated to DHF, can be detected in half of the patients with DF. Although a frequent complication, the causes of bleedings in DF have not been fully addressed. Thus, the aim of this study was to perform a comprehensive evaluation of possible pathophysiological mechanisms that could contribute to the bleeding tendency observed in patients with DF. This is a case-control study that enrolled adults with DF without bleeding and adults with DF and bleeding complications during the defervescence period. Healthy controls were also included. Peripheral blood counts, inflammatory, fibrinolysis and endothelial cell activation markers, and thrombin generation were evaluated in patients and controls. We included 33 adults with DF without complications, 26 adults with DF and bleeding and 67 healthy controls. Bleeding episodes were mild in 15 (57.6%) and moderate in 11 (42.4%) patients, 8 (30.7%) patients had bleedings in multiple sites. Patients with DF and bleedings had lower platelet counts than DF without bleeding (median = 19,500 vs. 203,500/mm3, P < 0,0001). Levels of TNF-α, thrombomodulin and VWF were significantly increased in the two dengue groups than in healthy controls, but similar between patients with and without bleedings. Plasma levels of tPA and D-dimer were significantly increased in patients with bleedings (median tPA levels were 4.5, 5.2, 11.7 ng/ml, P < 0.0001 and median D-dimer levels were 515.5, 1028 and 1927 ng/ml, P < 0.0001). The thrombin generation test showed that patients with bleeding complications had reduced thrombin formation (total thrombin generated were 3753.4 in controls, 3367.5 in non-bleeding and 2274.5nM in bleeding patients, P < 0.002). DF can manifest with spontaneous bleedings, which are associated with specific coagulation and fibrinolysis profiles that are not significantly present in DF without this complication. Particularly, thrombocytopenia, excessive fibrinolysis and reduced thrombin formation may contribute to the bleeding manifestations in DF.

Empiric transcatheter arterial embolization for massive bleeding from duodenal ulcers: efficacy and complications.

PubMed

Ichiro, Ikushima; Shushi, Higashi; Akihiko, Ishii; Yasuhiko, Iryo; Yasuyuki, Yamashita

2011-07-01

To evaluate the efficacy and safety of empiric transcatheter arterial embolization (TAE) for patients with massive bleeding from duodenal ulcers. During January 2000 and December 2009, 59 patients with duodenal ulcer bleeding in whom TAE was attempted after endoscopic therapy failed were retrospectively analyzed. The patients were divided into empiric TAE (n = 36) and identifiable TAE (n = 23) groups according to angiographic findings with or without identification of the bleeding sites. The technical and clinical success rate, recurrent bleeding rate, procedure-related complications, and clinical outcomes were evaluated. The technical and clinical success rates of TAE were 100% and 83%. The recurrent bleeding rate, clinical success, duodenal stenosis, and 30-day mortality after TAE were not significantly different between the empiric and identifiable TAE groups. A high rate of technical and clinical success was obtained with empiric TAE comparable to identifiable TAE in patients with massive bleeding from duodenal ulcers. There were no severe complications. Empiric TAE is an effective and safe method when a bleeding site cannot determined by angiography. Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.

Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

PubMed Central

Nojkov, Borko; Cappell, Mitchell S

2016-01-01

AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis. METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’. RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population. CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS. PMID:26755890

SU-D-204-06: Integration of Machine Learning and Bioinformatics Methods to Analyze Genome-Wide Association Study Data for Rectal Bleeding and Erectile Dysfunction Following Radiotherapy in Prostate Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Oh, J; Deasy, J; Kerns, S

Purpose: We investigated whether integration of machine learning and bioinformatics techniques on genome-wide association study (GWAS) data can improve the performance of predictive models in predicting the risk of developing radiation-induced late rectal bleeding and erectile dysfunction in prostate cancer patients. Methods: We analyzed a GWAS dataset generated from 385 prostate cancer patients treated with radiotherapy. Using genotype information from these patients, we designed a machine learning-based predictive model of late radiation-induced toxicities: rectal bleeding and erectile dysfunction. The model building process was performed using 2/3 of samples (training) and the predictive model was tested with 1/3 of samples (validation).more » To identify important single nucleotide polymorphisms (SNPs), we computed the SNP importance score, resulting from our random forest regression model. We performed gene ontology (GO) enrichment analysis for nearby genes of the important SNPs. Results: After univariate analysis on the training dataset, we filtered out many SNPs with p>0.001, resulting in 749 and 367 SNPs that were used in the model building process for rectal bleeding and erectile dysfunction, respectively. On the validation dataset, our random forest regression model achieved the area under the curve (AUC)=0.70 and 0.62 for rectal bleeding and erectile dysfunction, respectively. We performed GO enrichment analysis for the top 25%, 50%, 75%, and 100% SNPs out of the select SNPs in the univariate analysis. When we used the top 50% SNPs, more plausible biological processes were obtained for both toxicities. An additional test with the top 50% SNPs improved predictive power with AUC=0.71 and 0.65 for rectal bleeding and erectile dysfunction. A better performance was achieved with AUC=0.67 when age and androgen deprivation therapy were added to the model for erectile dysfunction. Conclusion: Our approach that combines machine learning and bioinformatics techniques enabled designing better models and identifying more plausible biological processes associated with the outcomes.« less

Arterial Embolization in the Management of Mesenteric Bleeding Secondary to Blunt Abdominal Trauma.

PubMed

Ghelfi, Julien; Frandon, Julien; Barbois, Sandrine; Vendrell, Anne; Rodiere, Mathieu; Sengel, Christian; Bricault, Ivan; Arvieux, Catherine; Ferretti, Gilbert; Thony, Frédéric

2016-05-01

Mesenteric bleeding is a rare but potentially life-threatening complication of blunt abdominal trauma. It can induce active hemorrhage and a compressive hematoma leading to bowel ischemia. Emergency laparotomy remains the gold standard treatment. We aimed to study the effectiveness and complications of embolization in patients with post-traumatic mesenteric bleeding. The medical records of 7 consecutive patients with active mesenteric bleeding treated by embolization in a level-one trauma center from 2007 to 2014 were retrospectively reviewed. All patients presented with active mesenteric bleeding on CT scans without major signs of intestinal ischemia. We focused on technical success, clinical success, and the complications of embolization. Six endovascular procedures were successful in controlling hemorrhage but 1 patient had surgery to stop associated arterial and venous bleeding. One patient suffered from bowel ischemia, a major complication of embolization, which was confirmed by surgery. No acute renal failure was noted after angiography. For 1 patient we performed combined management as the endovascular approach allowed an easier surgical exploration. In mesenteric trauma with active bleeding, embolization is a valuable alternative to surgery and should be considered, taking into account the risk of bowel ischemia.

Naproxen or estradiol for bleeding and spotting with the levonorgestrel intrauterine system: a randomized controlled trial.

PubMed

Madden, Tessa; Proehl, Sarah; Allsworth, Jenifer E; Secura, Gina M; Peipert, Jeffrey F

2012-02-01

The purpose of this study was to evaluate whether oral naproxen or transdermal estradiol decreases bleeding and spotting in women who are initiating the levonorgestrel-releasing intrauterine system. We conducted a randomized controlled trial of naproxen, estradiol, or placebo that was administered over the first 12 weeks of levonorgestrel-releasing intrauterine system use. Participants completed a written bleeding diary. We imputed missing values and performed an intention-to-treat analysis. There were 129 women who were assigned randomly to naproxen (n = 42 women), estradiol (n = 44 women), or placebo (n = 43 women). The naproxen group was more likely to be in the lowest quartile of bleeding and spotting days compared with placebo (42.9% vs 16.3%; P = .03). In the multivariable analysis, the naproxen group had a 10% reduction in bleeding and spotting days (adjusted relative risk, 0.90; 95% confidence interval, 0.84-0.97) compared with placebo. More frequent bleeding and spotting was observed in the estradiol group (adjusted relative risk, 1.25; 95% confidence interval, 1.17-1.34). The administration of naproxen resulted in a reduction in bleeding and spotting days compared with placebo. Copyright © 2012 Mosby, Inc. All rights reserved.

Arterial Embolization in the Management of Mesenteric Bleeding Secondary to Blunt Abdominal Trauma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ghelfi, Julien, E-mail: JGhelfi@chu-grenoble.fr; Frandon, Julien, E-mail: JFrandon2@chu-grenoble.fr; Barbois, Sandrine, E-mail: SBarbois@chu-grenoble.fr

IntroductionMesenteric bleeding is a rare but potentially life-threatening complication of blunt abdominal trauma. It can induce active hemorrhage and a compressive hematoma leading to bowel ischemia. Emergency laparotomy remains the gold standard treatment. We aimed to study the effectiveness and complications of embolization in patients with post-traumatic mesenteric bleeding.Materials and MethodsThe medical records of 7 consecutive patients with active mesenteric bleeding treated by embolization in a level-one trauma center from 2007 to 2014 were retrospectively reviewed. All patients presented with active mesenteric bleeding on CT scans without major signs of intestinal ischemia. We focused on technical success, clinical success, andmore » the complications of embolization.ResultsSix endovascular procedures were successful in controlling hemorrhage but 1 patient had surgery to stop associated arterial and venous bleeding. One patient suffered from bowel ischemia, a major complication of embolization, which was confirmed by surgery. No acute renal failure was noted after angiography. For 1 patient we performed combined management as the endovascular approach allowed an easier surgical exploration.ConclusionIn mesenteric trauma with active bleeding, embolization is a valuable alternative to surgery and should be considered, taking into account the risk of bowel ischemia.« less

Peripheral arterial disease in a female using high-dose combined oral contraceptive pills.

PubMed

Pallavee, P; Samal, Sunita; Samal, Rupal

2013-01-01

The association between oral contraceptive (OC) pills and vascular diseases is well-known, although, the present generation of pills is considered to be relatively safer in this regard. Hormonal treatment for severe abnormal uterine bleeding is usually considered after ruling out malignancy, when such bleeding is resistant to all other forms of treatment. We report a case of severe peripheral arterial disease in a female, who had been on high-dose OC pills for an extended period of time for severe uterine bleeding.

Decidualized Human Endometrial Stromal Cells Mediate Hemostasis, Angiogenesis, and Abnormal Uterine Bleeding

PubMed Central

Lockwood, Charles J.; Krikun, Graciela; Hickey, Martha; Huang, S. Joseph; Schatz, Frederick

2011-01-01

Factor VII binds trans-membrane tissue factor to initiate hemostasis by forming thrombin. Tissue factor expression is enhanced in decidualized human endometrial stromal cells during the luteal phase. Long-term progestin only contraceptives elicit: 1) abnormal uterine bleeding from fragile vessels at focal bleeding sites, 2) paradoxically high tissue factor expression at bleeding sites; 3) reduced endometrial blood flow promoting local hypoxia and enhancing reactive oxygen species levels; and 4) aberrant angiogenesis reflecting increased stromal cell-expressed vascular endothelial growth factor, decreased Angiopoietin-1 and increased endothelial cell-expressed Angiopoietin-2. Aberrantly high local vascular permeability enhances circulating factor VII to decidualized stromal cell-expressed tissue factor to generate excess thrombin. Hypoxia-thrombin interactions augment expression of vascular endothelial growth factor and interleukin-8 by stromal cells. Thrombin, vascular endothelial growth factor and interlerukin-8 synergis-tically augment angiogenesis in a milieu of reactive oxygen species-induced endothelial cell activation. The resulting enhanced vessel fragility promotes abnormal uterine bleeding. PMID:19208784

Upper gastrointestinal bleeding - state of the art.

PubMed

Szura, Mirosław; Pasternak, Artur

2014-01-01

Upper gastrointestinal (GI) bleeding is a condition requiring immediate medical intervention, with high associated mortality exceeding 10%. The most common cause of upper GI bleeding is peptic ulcer disease, which largely corresponds to the intake of NSAIDs and Helicobacter pylori infection. Endoscopy is the essential tool for the diagnosis and treatment of active upper GI hemorrhage. Endoscopic therapy together with proton pump inhibitors and eradication of Helicobacter pylori significantly reduces rebleeding rates, mortality and number of emergency surgical interventions. This paper presents contemporary data on the diagnosis and treatment of upper gastrointestinal bleeding.

Digital Rectal Examination Reduces Hospital Admissions, Endoscopies, and Medical Therapy in Patients with Acute Gastrointestinal Bleeding.

PubMed

Shrestha, Manish P; Borgstrom, Mark; Trowers, Eugene

2017-07-01

Although digital rectal examination is an established part of physical examinations in patients with acute gastrointestinal bleeding, clinicians are reluctant to perform a rectal examination. We intended to assess whether rectal examination affects the clinical management decision in these patients. We performed a single-center, retrospective, cross-sectional study using data from electronic health records of patients aged ≥18 years presenting to the emergency department with acute gastrointestinal bleeding. Hospital admissions, intensive care unit admissions, gastroenterology consultation, initiation of medical therapy (proton pump inhibitor or octreotide), and inpatient endoscopy (upper endoscopy or colonoscopy) were assessed as outcomes. Univariate and multivariate logistic regression analyses were performed. Of 1237 patients with acute gastrointestinal bleeding, 549 (44.4%) did not have a rectal examination. Patients who had a rectal examination were less likely to be admitted than patients who did not have a rectal examination (adjusted odds ratio [AOR], 0.49; 95% confidence interval [CI], 0.30-0.79; P = .004). Patients who had a rectal examination were less likely to be started on medical therapy (AOR, 0.64; 95% CI, 0.41-0.98; P = .04) and to have endoscopy (AOR, 0.64; 95% CI, 0.44-0.94; P = .02) than patients who did not have a rectal examination. Rectal examination in patients with acute gastrointestinal bleeding can assist clinicians with clinical management decision and reduce admissions, endoscopies, and medical therapy in these patients. Copyright © 2017 Elsevier Inc. All rights reserved.

From Zero Energy Buildings to Zero Energy Districts

DOE Office of Scientific and Technical Information (OSTI.GOV)

Polly, Ben; Kutscher, Chuck; Macumber, Dan

Some U.S. cities are planning advanced districts that have goals for zero energy, water, waste, and/or greenhouse gas emissions. From an energy perspective, zero energy districts present unique opportunities to cost-effectively achieve high levels of energy efficiency and renewable energy penetration across a collection of buildings that may be infeasible at the individual building scale. These high levels of performance are accomplished through district energy systems that harness renewable and wasted energy at large scales and flexible building loads that coordinate with variable renewable energy supply. Unfortunately, stakeholders face a lack of documented processes, tools, and best practices to assistmore » them in achieving zero energy districts. The National Renewable Energy Laboratory (NREL) is partnering on two new district projects in Denver: the National Western Center and the Sun Valley Neighborhood. We are working closely with project stakeholders in their zero energy master planning efforts to develop the resources needed to resolve barriers and create replicable processes to support future zero energy district efforts across the United States. Initial results of these efforts include the identification and description of key zero energy district design principles (maximizing building efficiency, solar potential, renewable thermal energy, and load control), economic drivers, and master planning principles. The work has also resulted in NREL making initial enhancements to the U.S. Department of Energy's open source building energy modeling platform (OpenStudio and EnergyPlus) with the long-term goal of supporting the design and optimization of energy districts.« less

Low-Molecular-Weight Heparin and the Relative Risk of Surgical Site Bleeding Complications: Results of a Systematic Review and Meta-Analysis of Randomized Controlled Trials of Venous Thromboprophylaxis in Patients After Total Joint Arthroplasty.

PubMed

Suen, Kary; Westh, Roger N; Churilov, Leonid; Hardidge, Andrew J

2017-09-01

Venous thromboembolism causes significant morbidity and mortality in patients after total joint arthroplasty. Although network meta-analyses have demonstrated a benefit of various thromboprophylactic agents, there remains a concern in the surgical community regarding the resulting wound complications. There is currently no systematic review of the surgical site bleeding complications of thromboprophylactic agents. The aim of this study was to systematically review the surgical site bleeding outcomes of venous thromboembolism prophylaxis in this population. A systematic review and meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials comparing more than one of low-molecular-weight heparin (LMWH), warfarin, rivaroxaban, apixaban, dabigatran, aspirin, or no pharmacologic treatment in patients after total hip or knee arthroplasty were selected for inclusion. Five meta-analyses were performed to compare LMWH with control, warfarin, apixaban, rivaroxaban, and dabigatran. Forty-five randomized controlled trials of 56,730 patients were included. LMWH had a significantly increased relative risk of surgical site bleeding in comparison with control (relative risk, 2.32; 95% confidence interval, 1.40-3.85) and warfarin (1.54; 1.23-1.94). The relative risk of LMWH trended higher than apixaban (1.27; 1.00-1.63) and was similar to rivaroxaban (0.95; 0.74-1.23). Only 1 study reported the risk of surgical site bleeding in LMWH vs dabigatran (5.97; 2.08-17.11). LMWH increased the risk of surgical site bleeding compared with control, warfarin. and dabigatran and trended toward an increased risk compared with apixaban. The risk of surgical site bleeding was similar with LMWH and rivaroxaban. Copyright © 2017 Elsevier Inc. All rights reserved.

[Rupture of splenic artery pseudoaneurysm: an unusual cause of upper gastrointetinal bleeding].

PubMed

Herrera-Fernández, Francisco Antonio; Palomeque-Jiménez, Antonio; Serrano-Puche, Félix; Calzado-Baeza, Salvador Francisco; Reyes-Moreno, Montserrat

2014-01-01

Bleeding from a pancreatic pseudocyst is a severe complication after pancreatitis that can lead to a massive gastrointestinal blood loss. Pseudocyst rupture into the stomach is an unusual complication. We report the case of a 34-year-old woman with a history of alcoholism and a pancreatic pseudocyst. One year after follow-up of her pseudocyst, she arrived at the emergency room with an episode of upper gastrointestinal bleeding. An upper digestive endoscopy showed active bleeding in the subcardial fundus, which could not be endoscopically controlled. Abdominal angio-CT confirmed the diagnosis of a splenic artery pseudoaneurysm in close contact with the back wall of the stomach, as well as a likely fistulization of it. The patient was urgently operated and a distal splenopancreatectomy and fistulorrhaphy was performed. The rupture of a splenic artery pseudoaneurysm may rarely present as upper gastrointestinal bleeding. This may be lethal if not urgently treated.

Performance of a Supersonic Over-Wing Inlet with Application to a Low-Sonic-Boom Aircraft

NASA Technical Reports Server (NTRS)

Trefny, Charles J.; Hirt, Stefanie M.; Anderson, Bernhard H.; Fink, Lawrence E.; Magee, Todd E.

2014-01-01

Development of commercial supersonic aircraft has been hindered by many related factors including fuel-efficiency, economics, and sonic-boom signatures that have prevented over-land flight. Materials, propulsion, and flight control technologies have developed to the point where, if over-land flight were made possible, a commercial supersonic transport could be economically viable. Computational fluid dynamics, and modern optimization techniques enable designers to reduce the boom signature of candidate aircraft configurations to acceptable levels. However, propulsion systems must be carefully integrated with these low-boom configurations in order that the signatures remain acceptable. One technique to minimize the downward propagation of waves is to mount the propulsion systems above the wing, such that the wing provides shielding from shock waves generated by the inlet and nacelle. This topmounted approach introduces a number of issues with inlet design and performance especially with the highly-swept wing configurations common to low-boom designs. A 1.79%-scale aircraft model was built and tested at the NASA Glenn Research Center's 8-by 6-Foot Supersonic Wind Tunnel (8x6 SWT) to validate the configuration's sonic boom signature. In order to evaluate performance of the top-mounted inlets, the starboard flow-through nacelle on the aerodynamic model was replaced by a 2.3%-scale operational inlet model. This integrated configuration was tested at the 8x6 SWT from Mach 0.25 to 1.8 over a wide range of angles-of-attack and yaw. The inlet was also tested in an isolated configuration over a smaller range of angles-of-attack and yaw. A number of boundary-layer bleed configurations were investigated and found to provide a substantial positive impact on pressure recovery and distortion. Installed inlet performance in terms of mass capture, pressure recovery, and distortion over the Mach number range at the design angle-of-attack of 4-degrees is presented herein and compared to that at 0- degrees, as well as the isolated inlet configuration to highlight installation effects. Performance of the installed inlet fell below that of the isolated inlet at Mach numbers of 1.4 and greater. The installed inlet demonstrated adequate operability over the expected range of angles-of-attack and yaw, but did exhibit definite angle-ofattack and yaw limits at supersonic conditions. At each supersonic flight Mach number, performance parameters near zero yaw angle were relatively insensitive to yaw, but in general the yaw angle yielding best performance was non-zero and varied with angle-of-attack. Performance of the installed inlet is also presented as functions of angle-of-attack and yaw to highlight these effects. Distortion at the aerodynamic interface plane ranged between 10 and 25% at the inlet critical points over the range of flight Mach numbers tested and did not decrease significantly for the isolated inlet. Although these distortion levels would be considered high for operation with a turbine engine, the over-wing installation is likely not as significant a contributor as the low test Reynolds number. This is demonstrated by comparing CFD analysis of the isolated inlet at test scale with that at intermediate and full scales.

A global quantitative survey of hemostatic assessment in postpartum hemorrhage and experience with associated bleeding disorders.

PubMed

James, Andra H; Cooper, David L; Paidas, Michael J

2017-01-01

Coagulopathy may be a serious complicating or contributing factor to postpartum hemorrhage (PPH), and should be promptly recognized to ensure proper bleeding management. This study aims to evaluate the approaches of obstetrician-gynecologists worldwide towards assessing massive PPH caused by underlying bleeding disorders. A quantitative survey was completed by 302 obstetrician-gynecologists from 6 countries (the UK, France, Germany, Italy, Spain, and Japan). The survey included questions on the use of hematologic laboratory studies, interpretation of results, laboratory's role in coagulation assessments, and experience with bleeding disorders. Overall, the most common definitions of "massive" PPH were >2,000 mL (39%) and >1,500 mL (34%) blood loss. The most common criteria for rechecking a "stat" complete blood count and for performing coagulation studies were a drop in blood pressure (73%) and ongoing visible bleeding (78%), respectively. Laboratory coagulation (prothrombin time/activated partial thromboplastin time [PT/aPTT]) and factor VIII/IX assays were performed on-site more often than were mixing studies (laboratory coagulation studies, 93%; factor VIII/IX assays, 63%; mixing studies, 22%). Most commonly consulted sources of additional information were colleagues within one's own specialty (68%) and other specialists (67%). Most respondents had consulted with a hematologist (78%; least, Germany [56%]; greatest, UK [98%]). The most common reason for not consulting was hematologist unavailability (44%). The most commonly reported thresholds for concern with PT and aPTT were 13 to 20 seconds (36%) and 30 to 45 seconds (50%), respectively. Most respondents reported having discovered an underlying bleeding disorder (58%; least, Japan [35%]; greatest, Spain [74%]). Global survey results highlight similarities and differences between countries in how PPH is assessed and varying levels of obstetrician-gynecologist experience with identification of underlying bleeding disorders and engagement of hematology consultants. Opportunities to improve patient management of PPH associated with bleeding disorders include greater familiarity with interpreting PT/aPTT test results and identification of and consistent consultation with hematologists with relevant expertise.

Laboratory outreach: student assessment of flow cytometer fluidics in zero gravity.

PubMed

Crucian, B; Norman, J; Brentz, J; Pietrzyk, R; Sams, C

2000-10-01

Due to the the clinical utility of the flow cytometer, the National Aeronautics and Space Administration (NASA) is interested in the design of a space flight-compatible cytometer for use on long-duration space missions. Because fluid behavior is altered dramatically during space flight, it was deemed necessary to validate the principles of hydrodynamic focusing and laminar flow (cytometer fluidics) in a true microgravity environment. An experiment to validate these properties was conducted by 12 students from Sweetwater High School (Sweetwater, TX) participating in the NASA Reduced Gravity Student Flight Opportunity, Class of 2000. This program allows high school students to gain scientific experience by conducting an experiment on the NASA KC-135 zero gravity laboratory aircraft. The KC-135 creates actual zero-gravity conditions in 30-second intervals by flying a highly inclined parabolic flight path. The experiment was designed by their mentor in the program, the Johnson Space Center's flow cytometrist Brian Crucian, PhD, MT(ASCP). The students performed the experiment, with the mentor, onboard the NASA zero-gravity research aircraft in April 2000.

The AIMS65 Score Is a Useful Predictor of Mortality in Patients with Nonvariceal Upper Gastrointestinal Bleeding: Urgent Endoscopy in Patients with High AIMS65 Scores

PubMed Central

Park, Sun Wook; Song, Young Wook; Tak, Dae Hyun; Ahn, Byung Moo; Kang, Sun Hyung; Moon, Hee Seok; Sung, Jae Kyu; Jeong, Hyun Yong

2015-01-01

Background/Aims: To validate the AIMS65 score for predicting mortality of patients with nonvariceal upper gastrointestinal bleeding and to evaluate the effectiveness of urgent (<8 hours) endoscopic procedures in patients with high AIMS65 scores. Methods: This was a 5-year single-center, retrospective study. Nonvariceal, upper gastrointestinal bleeding was assessed by using the AIM65 and Rockall scores. Scores for mortality were assessed by calculating the area under the receiver-operating characteristic curve (AUROC). Patients with high AIMS65 scores (≥2) were allocated to either the urgent or non-urgent endoscopic procedure group. In-hospital mortality, success of endoscopic procedure, recurrence of bleeding, admission period, and dose of transfusion were compared between groups. Results: A total of 634 patients were analyzed. The AIMS65 score successfully predicted mortality (AUROC=0.943; 95% confidence interval [CI], 0.876 to 0.99) and was superior to the Rockall score (AUROC=0.856; 95% CI, 0.743 to 0.969) in predicting mortality. The group with high AIMS65 score included 200 patients. The urgent endoscopic procedure group had reduced hospitalization periods (p<0.05) Conclusions: AIMS65 score may be useful in predicting mortality in patients with nonvariceal upper gastrointestinal bleeding. Urgent endoscopic procedures in patients with high scores may be related to reduced hospitalization periods. PMID:26668799

Severe gastric variceal bleeding successfully treated by emergency splenic artery embolization.

PubMed

Sankararaman, Senthilkumar; Velayuthan, Sujithra; Vea, Romulo; Herbst, John

2013-06-01

Bleeding from gastric varices due to splenic vein obstruction is extremely rare in children, but it can be catastrophic. Reported herein is the case of a teenager with splenic vein thrombosis and chronic decompensated liver disease from autoimmune hepatitis who presented with massive gastric variceal bleeding. Standard medical management did not control the bleeding. Due to decompensated liver disease and continuous active bleeding, emergency partial splenic artery embolization was preferred over splenectomy or a shunt procedure. Bleeding was successfully controlled by partial splenic artery embolization by decreasing the inflow of blood into the portal system. It is concluded that emergency partial splenic artery embolization is a safer alternative life-saving procedure to manage severe gastric variceal bleeding due to splenic vein obstruction in a patient with high surgical risk. To our knowledge, only one other patient with similar management has been reported in the pediatric age group. © 2013 The Authors. Pediatrics International © 2013 Japan Pediatric Society.

Rescue endoscopic bleeding control for nonvariceal upper gastrointestinal hemorrhage using clipping and detachable snaring.

PubMed

Lee, J H; Kim, B K; Seol, D C; Byun, S J; Park, K H; Sung, I K; Park, H S; Shim, C S

2013-06-01

Nonvariceal upper gastrointestinal (UGI) bleeding recurs after appropriate endoscopic therapy in 10 % - 15 % of cases. The mortality rate can be as high as 25 % when bleeding recurs, but there is no consensus about the best modality for endoscopic re-treatment. The aim of this study was to evaluate clipping and detachable snaring (CDS) for rescue endoscopic control of nonvariceal UGI hemorrhage. We report a case series of seven patients from a Korean tertiary center who underwent endoscopic hemostasis using the combined method of detachable snares with hemoclips. The success rate of endoscopic hemostasis with CDS was 86 %: six of the seven patients who had experienced primary endoscopic treatment failure or recurrent bleeding after endoscopic hemostasis were treated successfully. In conclusion, rescue endoscopic bleeding control by means of CDS is an option for controlling nonvariceal UGI bleeding when no other method of endoscopic treatment for recurrent bleeding and primary hemostatic failure is possible. © Georg Thieme Verlag KG Stuttgart · New York.

Consensus recommendations for preventing and managing bleeding complications associated with novel oral anticoagulants in singapore.

PubMed

Ng, Heng Joo; Chee, Yen Lin; Ponnudurai, Kuperan; Lim, Lay Cheng; Tan, Daryl; Tay, Jam Chin; Handa, Pankaj Kumar; Akbar Ali, Mufeedha; Lee, Lai Heng

2013-11-01

Novel oral anticoagulants (NOACs) have at least equivalent efficacy compared to standard anticoagulants with similar bleeding risk. Optimal management strategies for bleeding complications associated with NOACs are currently unestablished. A working group comprising haematologists and vascular medicine specialists representing the major institutions in Singapore was convened to produce this consensus recommendation. A Medline and EMBASE search was conducted for articles related to the 3 available NOACs (dabigatran, rivaroxaban, apixaban), bleeding and its management. Additional information was obtained from the product monographs and bibliographic search of articles identified. The NOACs still has substantial interactions with a number of drugs for which concomitant administration should best be avoided. As they are renally excreted, albeit to different degrees, NOACs should not be prescribed to patients with creatinine clearance of <30 mLs/min. Meticulous consideration of risk versus benefits should be exercised before starting a patient on a NOAC. In patients presenting with bleeding, risk stratification of the severity of bleeding as well as identification of the source of bleeding should be performed. In life-threatening bleeds, recombinant activated factor VIIa and prothrombin complex may be considered although their effectiveness is currently unsupported by firm clinical evidence. The NOACs have varying effect on the prothrombin time and activated partial thromboplastin time which has to be interpreted with caution. Routine monitoring of drug level is not usually required. NOACs are an important advancement in antithrombotic management and careful patient selection and monitoring will permit optimisation of their potential and limit bleeding events.

Prognostic Value of the Amount of Bleeding After Aneurysmal Subarachnoid Hemorrhage: A Quantitative Volumetric Study.

PubMed

Lagares, Alfonso; Jiménez-Roldán, Luis; Gomez, Pedro A; Munarriz, Pablo M; Castaño-León, Ana M; Cepeda, Santiago; Alén, José F

2015-12-01

Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a new tool of assessing prognosis. To determine the prognostic value of the quantitative estimation of the amount of bleeding after aneurysmal subarachnoid hemorrhage, as well the relative importance of this factor related to other prognostic indicators, and to establish a possible cut-off value of volume of bleeding related to poor outcome. A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume. Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding. Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk. : aSAH, aneurysmal subarachnoid hemorrhage.

Risk of Hemorrhage Attributed to Underlying Chronic Diseases and Uninterrupted Aspirin Therapy of Patients Undergoing Minor Oral Surgical Procedures: A Retrospective Cohort Study.

PubMed

Rojanaworarit, Chanapong; Limsawan, Soontaree

2017-01-01

This study aimed to estimate the risk of bleeding following minor oral surgical procedures and uninterrupted aspirin therapy in high-risk patients or patients with existing chronic diseases compared to patients who did not use aspirin during minor oral surgery at a public hospital. This retrospective cohort study analyzed the data of 2912 patients, aged 20 years or older, who underwent 5251 minor oral surgical procedures at a district hospital in Thailand. The aspirin group was comprised of patients continuing aspirin therapy during oral surgery. The non-aspirin group (reference) included all those who did not use aspirin during surgery. Immediate and late-onset bleeding was evaluated in each procedure. The risk ratio of bleeding was estimated using a multilevel Poisson regression. The overall cumulative incidence of immediate bleeding was 1.3% of total procedures. No late-onset bleeding was found. A significantly greater incidence of bleeding was found in the aspirin group (5.8% of procedures, p<0.001). After adjusting for covariates, a multilevel Poisson regression model estimated that the bleeding risk in the aspirin group was 4.5 times higher than that of the non-aspirin group (95% confidence interval, 2.0 to 10.0; p<0.001). However, all bleeding events were controlled by simple hemostatic measures. High-risk patients or patients with existing chronic diseases who continued aspirin therapy following minor oral surgery were at a higher risk of hemorrhage than general patients who had not used aspirin. Nonetheless, bleeding complications were not life-threatening and could be promptly managed by simple hemostatic measures. The procedures could therefore be provided with an awareness of increased bleeding risk, prepared hemostatic measures, and postoperative monitoring, without the need for discontinuing aspirin, which could lead to more serious complications.

Protamine reduces bleeding complications associated with carotid endarterectomy without increasing the risk of stroke.

PubMed

Stone, David H; Nolan, Brian W; Schanzer, Andres; Goodney, Philip P; Cambria, Robert A; Likosky, Donald S; Walsh, Daniel B; Cronenwett, Jack L

2010-03-01

Controversy persists regarding the use of protamine during carotid endarterectomy (CEA) based on prior conflicting reports documenting both reduced bleeding as well as increased stroke risk. The purpose of this study was to determine the effect of protamine reversal of heparin anticoagulation on the outcome of CEA in a contemporary multistate registry. We reviewed a prospective regional registry of 4587 CEAs in 4311 patients performed by 66 surgeons from 11 centers in Northern New England from 2003-2008. Protamine use varied by surgeon (38% routine use, 44% rare use, 18% selective use). Endpoints were postoperative bleeding requiring reoperation as well as potential thrombotic complications, including stroke, death, and myocardial infarction (MI). Predictors of endpoints were determined by multivariate logistic regression after associated variables were identified by univariate analysis. Of the 4587 CEAs performed, 46% utilized protamine, while 54% did not. Fourteen patients (0.64%) in the protamine-treated group required reoperation for bleeding compared with 42 patients (1.66%) in the untreated cohort (P = .001). Protamine use did not affect the rate of MI (1.1% vs 0.91%, P = .51), stroke (0.78% vs 1.15%, P = .2), or death (0.23% vs 0.32%, P = .57) between treated and untreated patients, respectively. By multivariate analysis, protamine (odds ratio [OR] 0.32, 95% confidence interval [CI], 0.17-0.63; P = .001) and patch angioplasty (OR 0.46, 95% CI, 0.26-0.81; P = .007) were independently associated with diminished reoperation for bleeding. A single center was associated with a significantly higher rate of reoperation for bleeding (OR 6.47, 95% CI, 3.02-13.9; P < .001). Independent of protamine use, consequences of reoperation for bleeding were significant, with a four-fold increase in MI, a seven-fold increase in stroke, and a 30-fold increase in death. Protamine reduced serious bleeding requiring reoperation during CEA without increasing the risk of MI, stroke, or death, in this large, contemporary registry. In light of significant complications referable to bleeding, liberal use of protamine during CEA appears warranted.

Extending the Applicability of the Generalized Likelihood Function for Zero-Inflated Data Series

NASA Astrophysics Data System (ADS)

Oliveira, Debora Y.; Chaffe, Pedro L. B.; Sá, João. H. M.

2018-03-01

Proper uncertainty estimation for data series with a high proportion of zero and near zero observations has been a challenge in hydrologic studies. This technical note proposes a modification to the Generalized Likelihood function that accounts for zero inflation of the error distribution (ZI-GL). We compare the performance of the proposed ZI-GL with the original Generalized Likelihood function using the entire data series (GL) and by simply suppressing zero observations (GLy>0). These approaches were applied to two interception modeling examples characterized by data series with a significant number of zeros. The ZI-GL produced better uncertainty ranges than the GL as measured by the precision, reliability and volumetric bias metrics. The comparison between ZI-GL and GLy>0 highlights the need for further improvement in the treatment of residuals from near zero simulations when a linear heteroscedastic error model is considered. Aside from the interception modeling examples illustrated herein, the proposed ZI-GL may be useful for other hydrologic studies, such as for the modeling of the runoff generation in hillslopes and ephemeral catchments.

[Endovascular Treatment for Carotid Blowout Syndrome after Radiation for Esophageal Cancer:A Case Report].

PubMed

Takahashi, Shigefumi; Kawaguchi, Tomohiro; Niizuma, Kuniyasu; Nakagawa, Atsuhiro; Fujimura, Miki; Ogawa, Takenori; Katori, Yukio; Tominaga, Teiji

2017-09-01

Here, we discuss a case of carotid blowout syndrome successfully treated with endovascular parent artery occlusion. A 71-year-old woman underwent treatment for esophageal cancer resection, followed by 50-Gy radiotherapy, 19 years prior. Due to local recurrence, she underwent 66- and 72-Gy radiation treatments at 2 and 4 years after the initial treatment, respectively. Afterward, tracheostomy and enterostomy were performed. This time, she was transported to our emergency department because of acute eruptive bleeding from the tracheal tube. As her vitals indicated shock, emergency endovascular treatment was performed. Digital subtraction angiography revealed that the common carotid artery in the left-sided of the neck had a pseudoaneurysm extruding to the pharyngeal cavity, which was considered to be the lesion responsible for the acute rupture. She was diagnosed as having carotid blowout syndrome. Balloon test occlusion showed that the cross flow via the anterior and posterior communicating arteries was sufficient, so parent artery occlusion was chosen for bleeding control. Carotid bifurcation was preserved to keep the collateral circulation via the external carotid artery. The patient was discharged 22 days after treatment, without any neurological deficits. Although injured vessel removal with high-flow bypass was an ideal treatment to achieve bleeding control without ischemic complication, endovascular treatment can be an efficient second-best treatment. To minimize the risk of late ischemic complications, flow preservation via carotid bifurcation might be important.

Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair.

PubMed

Forster, Rachel; Stewart, Marlene

2016-03-30

The optimal duration of thromboprophylaxis after total hip or knee replacement, or hip fracture repair remains controversial. It is common practice to administer prophylaxis using low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) until discharge from hospital, usually seven to 14 days after surgery. International guidelines recommend extending thromboprophylaxis for up to 35 days following major orthopaedic surgery but the recommendation is weak due to moderate quality evidence. In addition, recent oral anticoagulants that exert effect by direct inhibition of thrombin or activated factor X lack the need for monitoring and have few known drug interactions. Interest in this topic remains high. To assess the effects of extended-duration anticoagulant thromboprophylaxis for the prevention of venous thromboembolism (VTE) in people undergoing elective hip or knee replacement surgery, or hip fracture repair. The Cochrane Vascular Information Specialist searched the Specialised Register (last searched May 2015) and CENTRAL (2015, Issue 4). Clinical trials databases were searched for ongoing or unpublished studies. Randomised controlled trials assessing extended-duration thromboprophylaxis (five to seven weeks) using accepted prophylactic doses of LMWH, UFH, vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC) compared with short-duration thromboprophylaxis (seven to 14 days) followed by placebo, no treatment or similar extended-duration thromboprophylaxis with LMWH, UFH, VKA or DOACs in participants undergoing hip or knee replacement or hip fracture repair. We independently selected trials and extracted data. Disagreements were resolved by discussion. We performed fixed-effect model meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs). We used a random-effects model when there was heterogeneity. We included 16 studies (24,930 participants); six compared heparin with placebo, one compared VKA with placebo, two compared DOAC with placebo, one compared VKA with heparin, five compared DOAC with heparin and one compared anticoagulants chosen at investigators' discretion with placebo. Three trials included participants undergoing knee replacement. No studies assessed hip fracture repair.Trials were generally of good methodological quality. The main reason for unclear risk of bias was insufficient reporting. The quality of evidence according to GRADE was generally moderate, as some comparisons included a single study, low number of events or heterogeneity between studies leading to wide CIs.We showed no difference between extended-duration heparin and placebo in symptomatic VTE (OR 0.59, 95% CI 0.35 to 1.01; 2329 participants; 5 studies; high quality evidence), symptomatic deep vein thrombosis (DVT) (OR 0.73, 95% CI 0.39 to 1.38; 2019 participants; 4 studies; moderate quality evidence), symptomatic pulmonary embolism (PE) (OR 0.61, 95% CI 0.16 to 2.33; 1595 participants; 3 studies; low quality evidence) and major bleeding (OR 0.59, 95% CI 0.14 to 2.46; 2500 participants; 5 studies; moderate quality evidence). Minor bleeding was increased in the heparin group (OR 2.01, 95% CI 1.43 to 2.81; 2500 participants; 5 studies; high quality evidence). Clinically relevant non-major bleeding was not reported.We showed no difference between extended-duration VKA and placebo (one study, 360 participants) for symptomatic VTE (OR 0.10, 95% CI 0.01 to 1.94; moderate quality evidence), symptomatic DVT (OR 0.13, 95% CI 0.01 to 2.62; moderate quality evidence), symptomatic PE (OR 0.32, 95% CI 0.01 to 7.84; moderate quality evidence) and major bleeding (OR 2.89, 95% CI 0.12 to 71.31; low quality evidence). Clinically relevant non-major bleeding and minor bleeding were not reported.Extended-duration DOAC showed reduced symptomatic VTE (OR 0.20, 95% CI 0.06 to 0.68; 2419 participants; 1 study; moderate quality evidence) and symptomatic DVT (OR 0.18, 95% CI 0.04 to 0.81; 2459 participants; 2 studies; high quality evidence) compared to placebo. No differences were found for symptomatic PE (OR 0.25, 95% CI 0.03 to 2.25; 1733 participants; 1 study; low quality evidence), major bleeding (OR 1.00, 95% CI 0.06 to 16.02; 2457 participants; 1 study; low quality evidence), clinically relevant non-major bleeding (OR 1.22, 95% CI 0.76 to 1.95; 2457 participants; 1 study; moderate quality evidence) and minor bleeding (OR 1.18, 95% CI 0.74 to 1.88; 2457 participants; 1 study; moderate quality evidence).We showed no difference between extended-duration anticoagulants chosen at investigators' discretion and placebo (one study, 557 participants, low quality evidence) for symptomatic VTE (OR 0.50, 95% CI 0.09 to 2.74), symptomatic DVT (OR 0.33, 95% CI 0.03 to 3.21), symptomatic PE (OR 1.00, 95% CI 0.06 to 16.13), and major bleeding (OR 5.05, 95% CI 0.24 to 105.76). Clinically relevant non-major bleeding and minor bleeding were not reported.We showed no difference between extended-duration VKA and heparin (one study, low quality evidence) for symptomatic VTE (OR 1.64, 95% CI 0.85 to 3.16; 1279 participants), symptomatic DVT (OR 1.36, 95% CI 0.69 to 2.68; 1279 participants), symptomatic PE (OR 9.16, 95% CI 0.49 to 170.42; 1279 participants), major bleeding (OR 3.87, 95% CI 1.91 to 7.85; 1272 participants) and minor bleeding (OR 1.33, 95% CI 0.64 to 2.76; 1279 participants). Clinically relevant non-major bleeding was not reported.We showed no difference between extended-duration DOAC and heparin for symptomatic VTE (OR 0.70, 95% CI 0.28 to 1.70; 15,977 participants; 5 studies; low quality evidence), symptomatic DVT (OR 0.60, 95% CI 0.11 to 3.27; 15,977 participants; 5 studies; low quality evidence), symptomatic PE (OR 0.91, 95% CI 0.43 to 1.94; 14,731 participants; 5 studies; moderate quality evidence), major bleeding (OR 1.11, 95% CI 0.79 to 1.54; 16,199 participants; 5 studies; high quality evidence), clinically relevant non-major bleeding (OR 1.08, 95% CI 0.90 to 1.28; 15,241 participants; 4 studies; high quality evidence) and minor bleeding (OR 0.95, 95% CI 0.82 to 1.10; 11,766 participants; 4 studies; high quality evidence). Moderate quality evidence suggests extended-duration anticoagulants to prevent VTE should be considered for people undergoing hip replacement surgery, although the benefit should be weighed against the increased risk of minor bleeding. Further studies are needed to better understand the association between VTE and extended-duration oral anticoagulants in relation to knee replacement and hip fracture repair, as well as outcomes such as distal and proximal DVT, reoperation, wound infection and healing.

Gastrointestinal Bleeding in Patients With Atrial Fibrillation Treated With Rivaroxaban or Warfarin: ROCKET AF Trial.

PubMed

Sherwood, Matthew W; Nessel, Christopher C; Hellkamp, Anne S; Mahaffey, Kenneth W; Piccini, Jonathan P; Suh, Eun-Young; Becker, Richard C; Singer, Daniel E; Halperin, Jonathan L; Hankey, Graeme J; Berkowitz, Scott D; Fox, Keith A A; Patel, Manesh R

2015-12-01

Gastrointestinal (GI) bleeding is a common complication of oral anticoagulation. This study evaluated GI bleeding in patients who received at least 1 dose of the study drug in the on-treatment arm of the ROCKET AF (Rivaroxaban Once-daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) trial. The primary outcome was adjudicated GI bleeding reported from first to last drug dose + 2 days. Multivariable modeling was performed with pre-specified candidate predictors. Of 14,236 patients, 684 experienced GI bleeding during follow-up. These patients were older (median age 75 years vs. 73 years) and less often female. GI bleeding events occurred in the upper GI tract (48%), lower GI tract (23%), and rectum (29%) without differences between treatment arms. There was a significantly higher rate of major or nonmajor clinical GI bleeding in rivaroxaban- versus warfarin-treated patients (3.61 events/100 patient-years vs. 2.60 events/100 patient-years; hazard ratio: 1.42; 95% confidence interval: 1.22 to 1.66). Severe GI bleeding rates were similar between treatment arms (0.47 events/100 patient-years vs. 0.41 events/100 patient-years; p = 0.39; 0.01 events/100 patient-years vs. 0.04 events/100 patient-years; p = 0.15, respectively), and fatal GI bleeding events were rare (0.01 events/100 patient-years vs. 0.04 events/100 patient-years; 1 fatal events vs. 5 fatal events total). Independent clinical factors most strongly associated with GI bleeding were baseline anemia, history of GI bleeding, and long-term aspirin use. In the ROCKET AF trial, rivaroxaban increased GI bleeding compared with warfarin. The absolute fatality rate from GI bleeding was low and similar in both treatment arms. Our results further illustrate the need for minimizing modifiable risk factors for GI bleeding in patients on oral anticoagulation. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

The Application of Censored Regression Models in Low Streamflow Analyses

NASA Astrophysics Data System (ADS)

Kroll, C.; Luz, J.

2003-12-01

Estimation of low streamflow statistics at gauged and ungauged river sites is often a daunting task. This process is further confounded by the presence of intermittent streamflows, where streamflow is sometimes reported as zero, within a region. Streamflows recorded as zero may be zero, or may be less than the measurement detection limit. Such data is often referred to as censored data. Numerous methods have been developed to characterize intermittent streamflow series. Logit regression has been proposed to develop regional models of the probability annual lowflows series (such as 7-day lowflows) are zero. In addition, Tobit regression, a method of regression that allows for censored dependent variables, has been proposed for lowflow regional regression models in regions where the lowflow statistic of interest estimated as zero at some sites in the region. While these methods have been proposed, their use in practice has been limited. Here a delete-one jackknife simulation is presented to examine the performance of Logit and Tobit models of 7-day annual minimum flows in 6 USGS water resource regions in the United States. For the Logit model, an assessment is made of whether sites are correctly classified as having at least 10% of 7-day annual lowflows equal to zero. In such a situation, the 7-day, 10-year lowflow (Q710), a commonly employed low streamflow statistic, would be reported as zero. For the Tobit model, a comparison is made between results from the Tobit model, and from performing either ordinary least squares (OLS) or principal component regression (PCR) after the zero sites are dropped from the analysis. Initial results for the Logit model indicate this method to have a high probability of correctly classifying sites into groups with Q710s as zero and non-zero. Initial results also indicate the Tobit model produces better results than PCR and OLS when more than 5% of the sites in the region have Q710 values calculated as zero.

Gynaecological and obstetric management of women with inherited bleeding disorders.

PubMed

Demers, Christine; Derzko, Christine; David, Michèle; Douglas, Joanne

2006-10-01

The prevalence of bleeding disorders, notably von Willebrand disease (vWD), among adult women with objectively documented menorrhagia is consistently reported to be 10% to 20% and is even higher in adolescents presenting with menorrhagia. This consensus document has been developed by a multidisciplinary committee consisting of an anesthesiologist, 2 hematologists, and an obstetrician/gynaecologist and has been endorsed by their relevant specialty bodies. It has been prepared with the express purpose of providing guidelines for both women with inherited bleeding disorders and for their caregivers regarding the gynaecological and obstetric management of these women, including appropriate anesthesia support where indicated. Diagnostic tools and specific medical and, where appropriate, surgical alternatives to management are reviewed and evidence-based recommendations presented. A MEDLINE search of the English literature between January 1975 and November 2003 was performed using the following key words: menorrhagia, uterine bleeding, pregnancy, von Willebrand, congenital bleeding disorder, desmopressin/DDAVP, tranexamic acid, oral contraceptives, medroxyprogesterone, therapy, hysterectomy, anesthesia, epidural, spinal. Recommendations from other society guidelines were reviewed. 1. Inherited bleeding disorders should be considered in the differential diagnosis of all patients presenting with menorrhagia (II-2B). The graphical scoring system presented is a validated tool which offers a simple yet practical method that can be used by patients to quantify their blood loss (II-2B). 2. Because underlying bleeding disorders are frequent in women with menorrhagia, physicians should consider performing a hemoglobin/hematocrit, platelet count, ferritin, PT (INR) and APTT in women with menorrhagia. In women who have a personal history of other bleeding or a family history of bleeding, further investigation should be considered, including a vWD workup (factor VIII, vWF antigen, and vWF functional assay) (II-2B). 3. Treatment of menorrhagia in women with inherited bleeding disorders should be individualized (III-B). 4. An inherited bleeding disorder is not a contraindication to hormonal therapy (oral contraceptives [II-1B], depot medroxyprogesterone acetate (DMPA) [II-3B], danazol [II-2B], GnRH analogs [II-3B]) or local treatments (levonorgestrel-releasing IUS [II-1B]) and non-hormonal therapy (antifibrinolytic drug tranexamic acid [II-1B]) as well as desmopressin (II-1B). These therapies represent first line treatment. Blood products should not be used for women with mild bleeding disorders (III-A). 5. In women who no longer want to preserve their fertility, conservative surgical therapy (ablation) and hysterectomy may be options (III-B). Clinicians may consult the "SOGC Clinical Practice Guideline: Guidelines for the Management of Abnormal Uterine Bleeding" for an in-depth discussion of the available therapeutic modalities, both medical and surgical. To minimize the risk of intraoperative and post-operative hemorrhage, coagulation factors should be corrected preoperatively with post-operative monitoring (II-1B). 6. Girls growing up in families with a history of vWD or other inherited bleeding disorders should be tested pre-menarchally to determine whether or not they have inherited the disease to allow both the patient and her family to prepare for her first and subsequent menstrual periods (III-C). 7. In adolescents presenting with menorrhagia, an inherited bleeding disorder should be excluded (III-B). When possible, investigation should be undertaken before oral contraceptive therapy is instituted, as the hormonally induced increase in factor VIII and vWF may mask the diagnosis (II-B). 8. Pregnancy in women with inherited bleeding disorders may require a multidisciplinary approach. A copy of their recommendations should be given to the patient and she should be instructed to present it to the health care provider admitting her to the birthing centre. Women with severe bleeding disorders or with a fetus at risk for a severe bleeding disorder should deliver in a hospital (level three) or where there is access to consultants in obstetrics, anesthesiology, hematology, and pediatrics (III-C). 9. Vacuum extraction, forceps, fetal scalp electrodes, and fetal scalp blood sampling should be avoided if the fetus is known or thought to be at risk for a congenital bleeding disorder. A Caesarean section should be performed for obstetrical indications only (II-2C). 10. Epidural and spinal anesthesia are contraindicated if there is a coagulation defect. There is no contraindication to regional anesthesia if coagulation is normalized. The decision to use regional anesthesia should be made on an individual basis (III-C). 11. The risk of early and late postpartum hemorrhage is increased in women with bleeding disorders. Women with inherited bleeding disorders should be advised about the possibility of excessive postpartum bleeding and instructed to report this immediately (III-B). 12. Intramuscular injections, surgery, and circumcision should be avoided in neonates at risk for a severe hereditary bleeding disorder until adequate workup/preparation are possible (III-B). The quality of evidence reported in this document has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam (Table 1).

Gynaecological and obstetric management of women with inherited bleeding disorders.

PubMed

Demers, Christine; Derzko, Christine; David, Michèle; Douglas, Joanne

2005-07-01

The prevalence of bleeding disorders, notably von Willebrand disease (vWD), among adult women with objectively documented menorrhagia is consistently reported to be 10% to 20% and is even higher in adolescents presenting with menorrhagia. This consensus document has been developed by a multidisciplinary committee consisting of an anesthesiologist, 2 hematologists, and an obstetrician/gynaecologist and has been endorsed by their relevant specialty bodies. It has been prepared with the express purpose of providing guidelines for both women with inherited bleeding disorders and for their caregivers regarding the gynaecological and obstetric management of these women, including appropriate anesthesia support where indicated. Diagnostic tools and specific medical and, where appropriate, surgical alternatives to management are reviewed and evidence-based recommendations presented. A MEDLINE search of the English literature between January 1975 and November 2003 was performed using the following key words: menorrhagia, uterine bleeding, pregnancy, von Willebrand, congenital bleeding disorder, desmopressin/DDAVP, tranexamic acid, oral contraceptives, medroxyprogesterone, therapy, hysterectomy, anesthesia, epidural, spinal. Recommendations from other society guidelines were reviewed. 1. Inherited bleeding disorders should be considered in the differential diagnosis of all patients presenting with menorrhagia (II-2B). The graphical scoring system presented is a validated tool which offers a simple yet practical method that can be used by patients to quantify their blood loss (II-2B). 2. Because underlying bleeding disorders are frequent in women with menorrhagia, physicians should consider performing a hemoglobin/hematocrit, platelet count, ferritin, PT (INR) and APTT in women with menorrhagia. In women who have a personal history of other bleeding or a family history of bleeding, further investigation should be considered, including a vWD workup (factor VIII, vWF antigen, and vWF functional assay) (II-2B). 3. Treatment of menorrhagia in women with inherited bleeding disorders should be individualized (III-B). 4. An inherited bleeding disorder is not a contraindication to hormonal therapy (oral contraceptives [II-1B], depot medroxyprogesterone acetate (DMPA) [II-3B], danazol [II-2B], GnRH analogs [II-3B]) or local treatments (levonorgestrel-releasing IUS [II-1B]) and non-hormonal therapy (antifibrinolytic drug tranexamic acid [II-1B]) as well as desmopressin (II-1B). These therapies represent first line treatment. Blood products should not be used for women with mild bleeding disorders (III-A). 5. In women who no longer want to preserve their fertility, conservative surgical therapy (ablation) and hysterectomy may be options (III-B). Clinicians may consult the "SOGC Clinical Practice Guideline: Guidelines for the Management of Abnormal Uterine Bleeding" for an in-depth discussion of the available therapeutic modalities, both medical and surgical. To minimize the risk of intraoperative and post-operative hemorrhage, coagulation factors should be corrected preoperatively with post-operative monitoring (II-1B). 6. Girls growing up in families with a history of vWD or other inherited bleeding disorders should be tested pre-menarchally to determine whether or not they have inherited the disease to allow both the patient and her family to prepare for her first and subsequent menstrual periods (III-C). 7. In adolescents presenting with menorrhagia, an inherited bleeding disorder should be excluded (III-B). When possible, investigation should be undertaken before oral contraceptive therapy is instituted, as the hormonally induced increase in factor VIII and vWF may mask the diagnosis (II-B). 8. Pregnancy in women with inherited bleeding disorders may require a multidisciplinary approach. A copy of their recommendations should be given to the patient and she should be instructed to present it to the health care provider admitting her to the birthing centre. Women with severe bleeding disorders or with a fetus at risk for a severe bleeding disorder should deliver in a hospital (level three) or where there is access to consultants in obstetrics, anesthesiology, hematology, and pediatrics (III-C). 9. Vacuum extraction, forceps, fetal scalp electrodes, and fetal scalp blood sampling should be avoided if the fetus is known or thought to be at risk for a congenital bleeding disorder. A Caesarean section should be performed for obstetrical indications only (II-2C). 10. Epidural and spinal anesthesia are contraindicated if there is a coagulation defect. There is no contraindication to regional anesthesia if coagulation is normalized. The decision to use regional anesthesia should be made on an individual basis (III-C). 11. The risk of early and late postpartum hemorrhage is increased in women with bleeding disorders. Women with inherited bleeding disorders should be advised about the possibility of excessive postpartum bleeding and instructed to report this immediately (III-B). 12. Intramuscular injections, surgery, and circumcision should be avoided in neonates at risk for a severe hereditary bleeding disorder until adequate workup/preparation are possible (III-B). The quality of evidence reported in this document has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam (Table 1).

Correlation of inhibition of platelet aggregation after clopidogrel with post discharge bleeding events: assessment by different bleeding classifications.

PubMed

Serebruany, Victor; Rao, Sunil V; Silva, Matthew A; Donovan, Jennifer L; Kannan, Abir O; Makarov, Leonid; Goto, Shinya; Atar, Dan

2010-01-01

To correlate inhibition of platelet aggregation (IPA) with bleeding events assessed by TIMI, GUSTO, and BleedScore scales in a large cohort of patients with coronary artery disease (CAD) and ischaemic stroke (IS) treated with chronic low-dose aspirin plus clopidogrel. Data from recent trials and registries suggest a link between increased risk of bleeding and cardiovascular mortality. However, the potential association of bleeding risk and IPA is not established. It may play a critical role for the safety of more aggressive platelet inhibition or/and individual tailoring of antiplatelet strategies. Secondary post hoc analyses of 5 microM ADP-induced IPA and bleeding complications assessed by TIMI, GUSTO, and BleedScore scales in a combined data set consisting of patients with documented CAD (n = 246) and previous IS (n = 117). Demographic characteristics differ substantially depending on the underlying vascular disease; however, IPA and bleeding risks were similar between CAD and IS. All three bleeding scales adequately captured serious haemorrhagic events, where the TIMI scale was the most exclusive, whereas BleedScore was the most inclusive. Over half of all patients experienced superficial event(s), most commonly occurring during two to three distinct bleeding episodes. There was no correlation between IPA and duration of antiplatelet therapy. Inhibition of platelet aggregation >50% strongly correlates with minor (r(2) = 0.58, P < 0.001; c-statistic = 0.92), but not severe (r(2) = 0.11, P = 0.038; c-statistic = 0.57), bleeding events. Chronic oral combination antiplatelet regimens are associated with a very high (56.5-60.7%) prevalence of superficial bleeding episodes, which are grossly underestimated in trials and registries. The role of such frequent mild complications for the overall benefit of antiplatelet therapy is entirely unknown, as is their effect on compliance. Although IPA is well suited for defining the risk of minor complications, prediction of more severe bleeding events may be challenging.

A randomized controlled study comparing omeprazole and cimetidine for the prophylaxis of stress-related upper gastrointestinal bleeding in patients with intracerebral hemorrhage.

PubMed

Liu, Bo-lin; Li, Bing; Zhang, Xiang; Fei, Zhou; Hu, Shi-jie; Lin, Wei; Gao, Da-kuan; Zhang, Li

2013-01-01

Patients with intracerebral hemorrhage (ICH) are at high risk for severe stress-related upper gastrointestinal (UGI) bleeding, which is predictive of higher mortality. The aim of this study was to evaluate the effectiveness of omeprazole and cimetidine compared with a placebo in the prevention and management of stress-related UGI bleeding in patients with ICH. In a single-center, randomized, placebo-controlled study, 184 surgically treated patients with CT-proven ICH within 72 hours of ictus and negative results for gastric occult blood testing were included. Of these patients, 165 who were qualified upon further evaluation were randomized into 3 groups: 58 patients received 40 mg intravenous omeprazole every 12 hours, 54 patients received 300 mg intravenous cimetidine every 6 hours, and 53 patients received a placebo. Patients whose gastric occult blood tests were positive at admission (n = 70) and during/after the prophylaxis procedure (n = 48) were treated with high-dose omeprazole at 80 mg bolus plus 8 mg/hr infusion for 3 days, followed by 40 mg intravenous omeprazole every 12 hours for 7 days. Of the 165 assessable patients, stress-related UGI bleeding occurred in 9 (15.5%) in the omeprazole group compared with 15 patients (27.8%) in the cimetidine group and 24 patients (45.3%) in the placebo group (p = 0.003). The occurrence of UGI bleeding was significantly related to death (p = 0.022). Nosocomial pneumonia occurred in 14 patients (24.1%) receiving omeprazole, 12 (22.2%) receiving cimetidine, and 8 (15.1%) receiving placebo (p > 0.05). In patients with UGI bleeding in which high-dose omeprazole was initiated, UGI bleeding arrested within the first 3 days in 103 patients (87.3%). Omeprazole significantly reduced the morbidity of stress-related UGI bleeding in patients with ICH due to its effective prophylactic effect without increasing the risk of nosocomial pneumonia, but it did not reduce the 1-month mortality or ICU stay. Further evaluation of high-dose omeprazole as the drug of choice for patients presenting with UGI bleeding is warranted. Clinical trial registration no.: ChiCTR-TRC-12001871, registered at the Chinese clinical trial registry (http://www.chictr.org/en/proj/show.aspx?proj=2384).

A bleeding assessment tool correlates with intraoperative blood loss in children and adolescents undergoing major spinal surgery.

PubMed

Anadio, Jennifer M; Sturm, Peter F; Forslund, Johan M; Agarwal, Sunil; Lane, Adam; Tarango, Cristina; Palumbo, Joseph S

2017-04-01

Screening laboratory studies for bleeding disorders are of little predictive value for operative bleeding risk in adults. Predicting perioperative bleeding in pediatric patients is particularly difficult as younger patients often have not had significant hemostatic challenges. This issue is distinctly important for high bleeding risk surgeries, such as major spinal procedures. The aim of this study was to determine if the score of a detailed bleeding questionnaire (BQ) correlated with surgical bleeding in pediatric patients undergoing major spinal surgery. A total of 220 consecutive pediatric patients (mean age 14.2years) undergoing major spinal surgery were administered the BQ preoperatively, as well as having routine screening laboratory studies (i.e., PT, aPTT, PFA) drawn. A retrospective analysis was conducted to determine if there was a correlation between either the results of the BQ and/or laboratory studies with operative outcomes. A BQ score>2 showed a strong positive correlation with intraoperative bleeding based on both univariate and multivariate analyses. In contrast, abnormalities in screening laboratory studies showed no significant correlation with operative bleeding outcomes. Relying on screening laboratory studies alone is inadequate. The BQ used here correlated with increased intraoperative hemorrhage, suggesting this tool may be useful for assessing pediatric surgical bleeding risk, and may also be useful in identifying a subset of patients with a very low bleeding risk that may not require laboratory screening. Copyright © 2017 Elsevier Ltd. All rights reserved.

Vibration isolation using six degree-of-freedom quasi-zero stiffness magnetic levitation

NASA Astrophysics Data System (ADS)

Zhu, Tao; Cazzolato, Benjamin; Robertson, William S. P.; Zander, Anthony

2015-12-01

In laboratories and high-tech manufacturing applications, passive vibration isolators are often used to isolate vibration sensitive equipment from ground-borne vibrations. However, in traditional passive isolation devices, where the payload weight is supported by elastic structures with finite stiffness, a design trade-off between the load capacity and the vibration isolation performance is unavoidable. Low stiffness springs are often required to achieve vibration isolation, whilst high stiffness is desired for supporting payload weight. In this paper, a novel design of a six degree of freedom (six-dof) vibration isolator is presented, as well as the control algorithms necessary for stabilising the passively unstable maglev system. The system applies magnetic levitation as the payload support mechanism, which realises inherent quasi-zero stiffness levitation in the vertical direction, and zero stiffness in the other five dofs. While providing near zero stiffness in multiple dofs, the design is also able to generate static magnetic forces to support the payload weight. This negates the trade-off between load capacity and vibration isolation that often exists in traditional isolator designs. The paper firstly presents the novel design concept of the isolator and associated theories, followed by the mechanical and control system designs. Experimental results are then presented to demonstrate the vibration isolation performance of the proposed system in all six directions.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bros, Sebastien, E-mail: sebbros@wanadoo.fr; Chabrot, Pascal, E-mail: pchabrot@chu-clermontferrand.fr; Kastler, Adrian, E-mail: a_kastler@chu-clermontferrand.fr

Purpose: To retrospectively identify predictive factors of recurrent bleeding within 24 h after uterine artery embolization (UAE) for postpartum hemorrhage (PPH). Materials and Methods: A total of 194 patients underwent UAE for PPH between August 1999 and April 2009 at our institution. Twelve patients experienced recurrent bleeding within the next 24 h; a second attempt at UAE was thus necessary, which was successful in 10 cases. In two cases, hemostatic hysterectomy was performed. Epidemiological, gynecological-obstetrical, anatomic, and biological data were analyzed. Results: Complete data were available for 148 of the 194 (76%) included patients. Sixty-four (43%) were primiparous, 18 (12.2%)more » had a placenta accreta, 21 (14%) had a coagulopathy, and 28 (18.9%) had an anatomic variant of the uterine arterial vasculature. Mean age and pregnancy term were similar in both recurring and nonrecurrent bleeding groups. After multivariate analysis, three criteria emerged as risk factors of recurrent bleeding: primiparity (10 patients, 83%; odds ratio [OR] = 18.84; P = 0.014), coagulation disorders (6 patients, 50%; OR = 12.08; P = 0.006), and anatomic variant of the uterine arterial vasculature (28 patients; OR = 9.83; P = 0.003). Conclusions: earch for uterine collaterals must be performed before UAE for PPH. Primiparity and coagulation disorders increase the risk of recurrent bleeding after UAE for PPH.« less

Efficacy of primed infusions with high dose ranitidine and omeprazole to maintain high intragastric pH in patients with peptic ulcer bleeding: a prospective randomised controlled study.

PubMed Central

Labenz, J; Peitz, U; Leusing, C; Tillenburg, B; Blum, A L; Börsch, G

1997-01-01

BACKGROUND: In healthy subjects, continuous infusions of high dose ranitidine and omeprazole produce high intragastric pH values. AIM: To test the hypothesis that both drugs also maintain high intragastric pH values in patients with bleeding ulcers. PATIENTS AND METHODS: In two parallel studies, 20 patients with bleeding duodenal ulcers and 20 patients with bleeding gastric ulcers were randomly assigned to receive either ranitidine (0.25 mg/kg/hour after a bolus of 50 mg) or omeprazole (8 mg/hour after a bolus of 80 mg) for 24 hours. Intragastric pH was continuously recorded with a glass electrode placed 5 cm below the cardia. RESULTS: Both drugs rapidly raised the intragastric pH above 6. During the second 12 hour period, however, the percentage of time spent below a pH of 6 was 0.15% with omeprazole and 20.1% with ranitidine (p = 0.0015) in patients with duodenal ulcer; in patients with gastric ulcer it was 0.1% with omeprazole and 46.1% with ranitidine (p = 0.002). CONCLUSIONS: Primed infusions of omeprazole after a bolus produced consistently high intragastric pH values in patients with bleeding peptic ulcers, whereas primed infusions with ranitidine were less effective during the second half of a 24 hour treatment course. This loss of effectiveness may be due to tolerance. PMID:9155573

Motivation for DOC III: 64-bit digital optical computer

NASA Astrophysics Data System (ADS)

Guilfoyle, Peter S.

1991-09-01

This paper suggests a new class of digital logic. OptiComp has focused on a digital optical logic family in order to capitalize on the inherent benefits of optical computing, which include (1) high FAN-IN and FAN-OUT, (2) low power consumption, (3) high noise margin, (4) high algorithmic efficiency using 'smart' interconnects, (5) free space leverage of GIBP (gate interconnect bandwidth product). Other well-known secondary advantages of optical logic include (but are not limited to) zero capacitive loading of signals at a detector, zero cross-talk between signals, zero signal dispersion, minimal clock skew (a few picoseconds or less in an imaging system). The primary focus of this paper is to demonstrate how each of the five advantages can be used to leverage other logic family performance such as GaAs; the secondary attributes will be discussed only in the context of introducing the DOC III architecture.

Motivation for DOC III: 64-bit digital optical computer

NASA Astrophysics Data System (ADS)

Guilfoyle, Peter S.

1991-09-01

The objective of this paper is to motivate a new class of digital logic. OptiComp has focused on a digital optical logic family in order to capitalize on the inherent benefits of optical computing, which include: (1) high FAN-IN and FAN-OUT, (2) low power consumption, (3) high noise margin, (4) high algorithmic efficiency using 'smart' interconnects, (5) free space leverage of GIBP (gate interconnect bandwidth product). Other well-known secondary advantages of optical logic include (but are not limited to): zero capacitive loading of signals at a detector, zero cross-talk between signals, zero signal dispersion, and minimal clock skew (a few picoseconds or less in an imaging system). The primary focus of this paper is on demonstrating how each of the five advantages can be used to leverage other logic family performance such as GaAs; the secondary attributes will be discussed only in the context of introducing the DOC III architecture.

Short and long-term mortality of patients presenting with bleeding events to the Emergency Department.

PubMed

Conti, Alberto; Renzi, Noemi; Molesti, Daniele; Bianchi, Simone; Bogazzi, Irene; Bongini, Giada; Pepe, Giuseppe; Frosini, Fabiana; Bertini, Alessio; Santini, Massimo

2017-12-01

Death of patients presenting with bleeding events to the Emergency Department still represent a major problem. We sought to analyze clinical characteristics associated with worse outcomes including short- and long-term death, beyond antithombotic treatment strategy. Patients presenting with any bleeding events during 2016-2017years were enrolled. Clinical parameters, site of bleeding, major bleeding, ongoing anti-thrombotic treatment strategy and death were collected. Hard 5:1 propensity score matching was performed to adjust dead patients in baseline characteristics. Endpoints were one-month and one-year death. Out of 166,000 visits to the Emergency Department, 3.050 patients (1.8%) were enrolled and eventually 429 were analyzed after propensity. Overall, anticoagulants or antiplatelets were given to 234(54%). Major bleeding account for 111(26%) patients, without differences between those taking anticoagulants or antiplatelets versus others. Death at one-month and one-year was 26(6%) and 72(17%), respectively. Independent predictors of one-month death were major bleeding (Odds Ratio, OR 26, p<0.001), female gender (OR 7, p<0.001) and white blood cells (OR 1.2, p=0.01); of one-year were major bleeding (OR 7, p<0.001), age (OR 1.1, p<0.001) and female gender (OR 2.3, p=0.043). Of note, death rate of gastrointestinal and intracranial bleeding where higher than others (p<0.001). Overall mortality was approximately 40% on one-month; 60% in older patients and 80% in female gender with CHA 2 D 2 VASC-score≥2. Receiver operator characteristics analysis showed larger areas for major bleeding and age (0.75 and 0.72, respectively) over others; p<0.05 on C-statistic. In patients with bleeding events, death rate was driven by major bleeding on short-term and older age on long-term. Among dead patients mortality was approximately 40% on one-month; 60% in older patients, and 80% in female gender. Copyright © 2017 Elsevier Inc. All rights reserved.

[Surgical treatment of lower digestive tract hemorrhage. Experience at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán].

PubMed

García-Osogobio, Sandra; Remes-Troche, José María; Takahashi, Takeshi; Barreto Camilo, Juan; Uscanga, Luis

2002-01-01

Lower gastrointestinal bleeding is usually self-limiting in about 80% of cases; however, surgical treatment may be required in selected cases. Preoperative precise identification of the bleeding source is crucial for a successful outcome. To determine the most frequent diagnoses, as well as short and long-term results in a series of patients who underwent a surgical procedure for lower gastrointestinal bleeding. Retrospective analysis of 39 patients operated upon for lower gastrointestinal bleeding from 1979 through 1997 in a referral center. Demographic data, history, physical examination, laboratory tests, resuscitative measures, preoperative work-up for identification of bleeding source, definitive cause of bleeding, surgical procedure, operative morbidity and mortality, as well as long-term status and recurrence of bleeding were recorded. There were 54% women and 46% men. Mean age was 56 years (range, 15-92). Most patients presented hematochezia (69%). Colonoscopy was the most used diagnostic procedure (69%). The bleeding source was located in 90% of patients. Diverticular disease was the most frequent cause of bleeding. A segmental bowel resection was the treatment in 97% of cases. Morbidity was 23% with 18% of mortality. Recurrence occurred in 9% of survivors. Morbidity and mortality were high. Patients who require a surgical operation should be carefully selected and evaluated with a complete work-up to determine the site and cause of bleeding.

Risk Factors for and Management of MPN-Associated Bleeding and Thrombosis.

PubMed

Martin, Karlyn

2017-10-01

The Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) are characterized by both thrombotic and bleeding complications. The purpose of this review is to describe the risk factors associated with bleeding and thrombosis in MPN, as well as to review prevention strategies and management of these complications. Well-described risk factors for thrombotic complications include older age and history of prior thrombosis, along with traditional cardiovascular and venous thromboembolic risk factors. More recently, JAK2 V617F mutation has been found to carry an increased risk of thrombotic complications, whereas CALR has a lower risk than JAK2 mutation. Factors associated with an increased risk of bleeding in MPN include a prior history of bleeding, acquired von Willebrand syndrome, and primary myelofibrosis. Recent findings suggest that thrombocytosis carries a higher risk of bleeding than thrombosis in MPN, and aspirin may exacerbate this risk of bleeding, particularly in CALR-mutated ET. Much of the management of MPN focuses on predicting risk of bleeding and thrombosis and initiating prophylaxis to prevent complications in those at high risk of thrombosis. Emerging evidence suggests that sub-populations may have bleeding risk that outweighs thrombotic risk, particularly in setting of antiplatelet therapy. Future work is needed to better characterize this balance. At present, a thorough assessment of the risks of bleeding and thrombosis should be undertaken for each patient, and herein, we review risk factors for and management of these complications.

A novel hemostatic powder for upper gastrointestinal bleeding: a multicenter study (the "GRAPHE" registry).

PubMed

Haddara, Sami; Jacques, Jeremie; Lecleire, Stéphane; Branche, Julien; Leblanc, Sarah; Le Baleur, Yann; Privat, Jocelyn; Heyries, Laurent; Bichard, Philippe; Granval, Philippe; Chaput, Ulriikka; Koch, Stephane; Levy, Jonathan; Godart, Bruno; Charachon, Antoine; Bourgaux, Jean-François; Metivier-Cesbron, Elodie; Chabrun, Edouard; Quentin, Vincent; Perrot, Bastien; Vanbiervliet, Geoffroy; Coron, Emmanuel

2016-12-01

Background and study aims: The hemostatic powder TC-325 (Hemospray; Cook Medical, Winston-Salem, North Carolina, USA) has shown promising results in the treatment of upper gastrointestinal bleeding (UGIB) in expert centers in pilot studies. The aim of this study was to evaluate the feasibility and efficacy of TC-325 in a large prospective registry of use in routine practice. Patients and methods: The data of all patients treated with TC-325 were prospectively collected through a national registry. Outcomes were the immediate feasibility and efficacy of TC-325 application, as well as the rates of rebleeding at Day 8 and Day 30. Multivariate analysis was performed to determine predictive factors of rebleeding. Results: A total of 202 patients were enrolled and 64 endoscopists participated from 20 centers. TC-325 was used as salvage therapy in 108 patients (53.5 %). The etiology of bleeding was an ulcer in 75 patients (37.1 %), tumor in 61 (30.2 %), postendoscopic therapy in 35 (17.3 %), or other in 31 (15.3 %). Application of the hemostatic powder was found to be very easy or easy in 31.7 % and 55.4 %, respectively. The immediate efficacy rate was 96.5 %. Recurrence of UGIB was noted at Day 8 and Day 30 in 26.7 % and 33.5 %, respectively. Predictive factors of recurrence at Day 8 were melena at initial presentation and use of TC-325 as salvage therapy. Conclusion: These multicenter data confirmed the high rate of immediate hemostasis, excellent feasibility, and good safety profile of TC-325, which could become the treatment of choice in bleeding tumors or postendoscopic bleeding but not in bleeding ulcers where randomized studies are needed. ClinicalTrials.gov (NCT02595853). © Georg Thieme Verlag KG Stuttgart · New York.

Safety and efficacy of rivaroxaban compared with warfarin in patients undergoing peripheral arterial procedures.

PubMed

Talukdar, Anjan; Wang, S Keisin; Czosnowski, Lauren; Mokraoui, Nassim; Gupta, Alok; Fajardo, Andres; Dalsing, Michael; Motaganahalli, Raghu

2017-10-01

Rivaroxaban is a United States Food and Drug Administration-approved oral anticoagulant for venous thromboembolic disease; however, there is no information regarding the safety and its efficacy to support its use in patients after open or endovascular arterial interventions. We report the safety and efficacy of rivaroxaban vs warfarin in patients undergoing peripheral arterial interventions. This single-institution retrospective study analyzed all sequential patients from December 2012 to August 2014 (21 months) who were prescribed rivaroxaban or warfarin after a peripheral arterial procedure. Our study population was then compared using American College of Chest Physicians guidelines with patients then stratified as low, medium, or high risk for bleeding complications. Statistical analyses were performed using the Student t-test and χ 2 test to compare demographics, readmissions because of bleeding, and the need for secondary interventions. Logistic regression models were used for analysis of variables associated with bleeding complications and secondary interventions. The Fisher exact test was used for power analysis. There were 44 patients in the rivaroxaban group and 50 patients in the warfarin group. Differences between demographics and risk factors for bleeding between groups or reintervention rate were not statistically significant (P = .297). However, subgroup evaluation of the safety profile suggests that patients who were aged ≤65 years and on warfarin had an overall higher incidence of major bleeding (P = .020). Patients who were aged >65 years, undergoing open operation, had a significant risk for reintervention (P = .047) when they received rivaroxaban. Real-world experience using rivaroxaban and warfarin in patients after peripheral arterial procedures suggests a comparable safety and efficacy profile. Subgroup analysis of those requiring an open operation demonstrated a decreased bleeding risk when rivaroxaban was used (in those aged <65 years) but an increased risk for secondary interventions. Further studies with a larger cohort are required to validate our results. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Life-threatening subdural hematoma after aortic valve replacement in a patient with Heyde syndrome: a case report.

PubMed

Uchida, Tetsuro; Hamasaki, Azumi; Ohba, Eiichi; Yamashita, Atsushi; Hayashi, Jun; Sadahiro, Mitsuaki

2017-08-08

Heyde syndrome is known as a triad of calcific aortic stenosis, anemia due to gastrointestinal bleeding from angiodysplasia, and acquired type 2A von Willebrand disease. This acquired hemorrhagic disorder is characterized by the loss of the large von Willebrand factor multimers due to the shear stress across the diseased aortic valve. The most frequently observed type of bleeding in these patients is mucosal or skin bleeding, such as epistaxis, followed by gastrointestinal bleeding. On the other hand, intracranial hemorrhage complicating Heyde syndrome is extremely rare. A 77-year-old woman presented to our hospital with severe aortic stenosis and severe anemia due to gastrointestinal bleeding and was diagnosed with Heyde syndrome. Although aortic valve replacement was performed without recurrent gastrointestinal bleeding, postoperative life-threatening acute subdural hematoma occurred with a marked midline shift. Despite prompt surgical evacuation of the hematoma, she did not recover consciousness and she died 1 month after the operation. Postoperative subdural hematoma is rare, but it should be kept in mind as a devastating hemorrhagic complication, especially in patients with Heyde syndrome.

Gastric ulcer bleeding from a variant left gastric artery accompanied by congenital absence of the splenic artery successfully treated with coil embolization: a case report and review of the literature.

PubMed

Namikawa, Masashi; Kakizaki, Satoru; Takakusaki, Satoshi; Saito, Shuichi; Yata, Yutaka; Mori, Masatomo

2011-12-01

Endoscopic hemostasis is a useful treatment modality for gastric ulcer bleeding. However, it is sometimes difficult to achieve hemostasis in cases with arterial bleeding, especially those complicated with vascular abnormalities. We describe a case with gastric ulcer bleeding from a variant left gastric artery accompanied by congenital absence of the splenic artery. A 50-year-old female was admitted to our hospital with dizziness and tarry stools. Upper gastrointestinal endoscopy revealed bleeding from a gastric ulcer, and endoscopic hemostasis by endoscopic clipping was carried out. Computed tomography and abdominal angiography revealed the variant left gastric artery running below the gastric ulcer. In spite of endoscopic hemostasis and medication, re-bleeding from the gastric ulcer occurred. A transcatheter coil embolization for the variant left gastric artery was performed and successfully achieved hemostasis. This case was accompanied by congenital absence of the splenic artery, which is an extremely rare condition. We herein describe this rare case and review previously reported cases.

Numerical Study on Wake Flow Field Characteristic of the Base-Bleed Unit under Fast Depressurization Process

NASA Astrophysics Data System (ADS)

Xue, Xiaochun; Yu, Yonggang

2017-04-01

Numerical analyses have been performed to study the influence of fast depressurization on the wake flow field of the base-bleed unit (BBU) with a secondary combustion when the base-bleed projectile is propelled out of the muzzle. Two-dimensional axisymmetric Navier-Stokes equations for a multi-component chemically reactive system is solved by Fortran program to calculate the couplings of the internal flow field and wake flow field with consideration of the combustion of the base-bleed propellant and secondary combustion effect. Based on the comparison with the experiments, the unsteady variation mechanism and secondary combustion characteristic of wake flow field under fast depressurization process is obtained numerically. The results show that in the fast depressurization process, the variation extent of the base pressure of the BBU is larger in first 0.9 ms and then decreases gradually and after 1.5 ms, it remains basically stable. The pressure and temperature of the base-bleed combustion chamber experience the decrease and pickup process. Moreover, after the pressure and temperature decrease to the lowest point, the phenomenon that the external gases are flowing back into the base-bleed combustion chamber appears. Also, with the decrease of the initial pressure, the unsteady process becomes shorter and the temperature gradient in the base-bleed combustion chamber declines under the fast depressurization process, which benefits the combustion of the base-bleed propellant.

Assessment of Bleeding and Thrombosis Based on Aspirin Responsiveness after Continuous-Flow Left Ventricular Assist Device Placement.

PubMed

Floroff, Catherine K; Rieger, Krista L; Veasey, Tara M; Strout, Sara E; DeNino, Walter F; Meadows, Holly B; Stroud, Martha R; Toole, John M; Heyward, Dawn P; Brisco-Bacik, Meredith A; Cook, Jennifer L; Lazarchick, John; Uber, Walter E

Pump thrombosis (PT) is a severe complication of left ventricular assist device (LVAD) support. This study evaluated PT and bleeding after LVAD placement in patients responsive to a standard aspirin dose of 81 mg using platelet inhibition monitoring compared with initial nonresponders who were then titrated upward to achieve therapeutic response. Patients ≥ 18 years of age with initial placement of HeartMate II LVAD at our institution and at least one VerifyNow Aspirin test performed during initial hospitalization were included. The primary endpoints were bleeding and PT compared between initial aspirin responders and nonresponders. Of 85 patients, 19 (22%) were nonresponsive to initial aspirin therapy. Responders and nonresponders showed similar survival (p = 0.082), freedom from suspected/confirmed PT (p = 0.941), confirmed PT (p = 0.273), bleeding (p = 0.401), and incidence rates in PT and bleeding. Among the initial responders (<500 vs. 500-549 aspirin reaction units), there were no significant differences in survival (p = 0.177), freedom from suspected/confirmed PT (p = 0.542), confirmed PT (p = 0.159), bleeding (p = 0.879), and incidence of PT and bleeding. Platelet function testing may detect resistance to standard aspirin regimens used in LVAD patients. Dose escalation in initially nonresponsive patients to achieve responsiveness may confer a similar PT risk to patients initially responsive to standard aspirin dosing without increased bleeding risk.

Comparison of marginal bleeding using a periodontal probe or an interdental brush as indicators of gingivitis.

PubMed

Hofer, D; Sahrmann, P; Attin, T; Schmidlin, P R

2011-08-01

To compare the use of interdental brushes to a periodontal probe in assessing marginal bleeding, in natural gingivitis. Sixty-four consecutive volunteers presenting with gingival inflammation were recruited at their semi-annual recall appointments for this study. All had ≥50% papillary height and no pocketing that exceeded 4 mm. Contra-lateral quadrants (1 & 3 or 2 & 4) were randomly tested for bleeding with one pass-through with an interdental brush or with a periodontal probe inserted 2 mm into the gingival sulcus. The presence or absence of both bleeding and plaque were then recorded. Correlation coefficients were calculated for the interdental brushes and the periodontal probe, and the plaque and bleeding scores. The periodontal probe and the interdental brushes showed mean average bleeding scores of 47.39% and 45.74% respectively. The correlation coefficient for the two methods was 0.73 (P < 0.0001). No correlation between plaque and bleeding was found. Interdental brushes can be considered a valid alternative to a periodontal probe in assessing marginal bleeding in gingivitis patients. An interdental brush, sized correctly for each interdental space, is easy to handle, atraumatic to the papillae and will allow gingivitis patients to monitor their own progress, while at the same time performing a beneficial oral hygiene procedure and removing any interdental plaque present. © 2010 John Wiley & Sons A/S.

Plasma copeptin levels in the patients with gastrointestinal bleeding.

PubMed

Salt, Ömer; Durukan, Polat; Ozkan, S; Saraymen, R; Sen, A; Yurci, M A

2017-10-01

Gastrointestinal bleeding is a significant cause of morbidity and mortality worldwide. In addition, it constitutes an important part of health expenditures. In this study, we aimed to determine whether there is a relationship between plasma copeptin levels and the etiology, location and severity of gastrointestinal bleeding. This study was performed prospectively in 104 consecutive patients who were admitted to an emergency department with complaints of bloody vomiting or bloody or black stool. To evaluate the level of biochemical parameters such as Full Blood Count (FBC), serum biochemistry, bleeding parameters and copeptin, blood samples were obtained at admission. For the copeptin levels, 2 more blood samples were obtained at the 12th and 24th hours after admission. The values obtained were compared using statistical methods. In terms of the etiology of bleeding, the copeptin levels in the patients with peptic ulcer were higher than the levels in patients with other gastrointestinal bleeding. However, the difference was not statistically significant. There were no significant differences among all groups' 0th, 12th and 24th hour levels of copeptin. We conclude that copeptin cannot be effectively used as a biochemical parameter in an emergency department to determine the etiology and location of gastrointestinal bleeding. It can, however, be used to make decisions on endoscopy and the hospitalization of patients with suspected gastrointestinal bleeding. Copyright © 2017 Elsevier Inc. All rights reserved.

Upper non-variceal gastrointestinal bleeding - review the effectiveness of endoscopic hemostasis methods

PubMed Central

Szura, Mirosław; Pasternak, Artur

2015-01-01

Upper non-variceal gastrointestinal bleeding is a condition that requires immediate medical intervention and has a high associated mortality rate (exceeding 10%). The vast majority of upper gastrointestinal bleeding cases are due to peptic ulcers. Helicobacter pylori infection, non-steroidal anti-inflammatory drugs and aspirin are the main risk factors for peptic ulcer disease. Endoscopic therapy has generally been recommended as the first-line treatment for upper gastrointestinal bleeding as it has been shown to reduce recurrent bleeding, the need for surgery and mortality. Early endoscopy (within 24 h of hospital admission) has a greater impact than delayed endoscopy on the length of hospital stay and requirement for blood transfusion. This paper aims to review and compare the efficacy of the types of endoscopic hemostasis most commonly used to control non-variceal gastrointestinal bleeding by pooling data from the literature. PMID:26421105

Characteristics and Outcomes of Pediatric Patients With Ebola Virus Disease Admitted to Treatment Units in Liberia and Sierra Leone: A Retrospective Cohort Study.

PubMed

Smit, Michael A; Michelow, Ian C; Glavis-Bloom, Justin; Wolfman, Vanessa; Levine, Adam C

2017-02-01

The clinical and virologic characteristics of Ebola virus disease (EVD) in children have not been thoroughly documented. Consecutive children aged <18 years with real-time polymerase chain reaction (RT-PCR)-confirmed EVD were enrolled retrospectively in 5 Ebola treatment units in Liberia and Sierra Leone in 2014/2015. Data collection and medical management were based on standardized International Medical Corps protocols. We performed descriptive statistics, multivariate logistic regression, and Kaplan-Meier survival analyses. Of 122 children enrolled, the median age was 7 years and one-third were aged <5 years. The female-to-male ratio was 1.3. The most common clinical features at triage and during hospitalization were fever, weakness, anorexia, and diarrhea, although 21% of patients were initially afebrile and 6 patients remained afebrile. Bleeding was rare at presentation (5%) and manifested subsequently in fewer than 50%. The overall case fatality rate was 57%. Factors associated with death in bivariate analyses were age <5 years, bleeding at any time during hospitalization, and high viral load. After adjustment with logistic regression modeling, the odds of death were 14.8-fold higher if patients were aged <5 years, 5-fold higher if the patient had any evidence of bleeding, and 5.2-fold higher if EVD RT-PCR cycle threshold value was ≤20. Plasmodium parasitemia had no impact on EVD outcomes. Age <5 years, bleeding, and high viral loads were poor prognostic indicators of children with EVD. Research to understand mechanisms of these risk factors and the impact of dehydration and electrolyte imbalance will improve health outcomes. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America.

Thrombotic safety of prothrombin complex concentrate (Beriplex P/N) for dabigatran reversal in a rabbit model.

PubMed

Herzog, Eva; Kaspereit, Franz J; Krege, Wilfried; Doerr, Baerbel; van Ryn, Joanne; Dickneite, Gerhard; Pragst, Ingo

2014-09-01

In vivo animal data have shown prothrombin complex concentrate (PCC) to be effective in preventing bleeding induced by excessive plasma levels of the direct thrombin inhibitor dabigatran. This animal model study was designed to determine the risk of thrombosis associated with administration of a PCC (Beriplex P/N) to reverse dabigatran-induced bleeding. Anesthetized rabbits were treated with initial 0, 75, 200 or 450 μg kg(-1) dabigatran boluses followed by continuous infusions to maintain elevated plasma dabigatran levels. At 15 min after the start of dabigatran administration, PCC doses of 0, 50 or 300 IU kg(-1) were administered. Thereafter, coagulation in an arteriovenous (AV) shunt was evaluated and histopathologic examination for thrombotic changes performed. Venous thrombosis was also assessed in a modified Wessler model. At the suprapharmacologic dose of 300 IU kg(-1), PCC increased thrombus weight during AV shunting, but this effect could be prevented by dabigatran at all tested doses. AV shunt occlusion after PCC administration was delayed by 75 μg kg(-1) dabigatran and abolished by progressively higher dabigatran doses. High-dose treatment with 300 IU kg(-1) PCC resulted in histologically evident low-grade pulmonary thrombi; however, that effect could be blocked by dabigatran in a dose-dependent manner (p=0.034). In rabbits treated with high-dose PCC, dabigatran inhibited thrombus formation during venous stasis. PCC effectively reversed dabigatran-induced bleeding. In this animal study, thrombosis after PCC administration could be prevented in the presence of dabigatran. PCC reversed dabigatran-induced excessive bleeding while retaining protective anticoagulatory activity of dabigatran. Copyright © 2014. Published by Elsevier Ltd.

The Effect Of Hypotensive Resuscitation And Fluid Type On Mortality, Bleeding,Coagulation And Dysfunctional Inflammation In A Swine Grade V Liver Injury Model

DTIC Science & Technology

2012-01-01

Once the swine were anesthetized, left cervical cut downs were performed and a central venous polyethylene catheter was inserted into the external...open and the liver injury will be examined for evidence of re-bleeding. The venous and arterial pressures at which re-bleeding occur will be...Fig. 1) Figure 1. Clamp used for the pig liver injury model The clamp is placed centrally in the liver and it produces laceration of 1

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy.

PubMed

Marmo, Riccardo; Del Piano, Mario; Rotondano, Gianluca; Koch, Maurizio; Bianco, Maria Antonia; Zambelli, Alessandro; Di Matteo, Giovanni; Grossi, Enzo; Cipolletta, Livio; Prometeo Investigators

2012-02-01

Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality. To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB). Secondary analysis of prospectively collected data from 3 national databases. Community and teaching hospitals. Consecutive patients admitted for acute nonvariceal UGIB. Early endoscopy, medical and endoscopic treatment as appropriate. Thirty-day mortality, recurrent bleeding, and need for surgery. A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001). No data on the American Society of Anesthesiologists class score in the Prometeo study. Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient. Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.

Effect of a Low-Dose Contraceptive Patch on Efficacy, Bleeding Pattern, and Safety

PubMed Central

Wiegratz, Inka; Bassol, Susana; Weisberg, Edith; Mellinger, Uwe

2014-01-01

This Phase III, uncontrolled, open-label, multicenter study was conducted to investigate the contraceptive efficacy, bleeding pattern, and cycle control of a novel once-a-week contraceptive patch, delivering low-dose ethinyl estradiol (EE) and gestodene (GSD) at the same systemic exposure seen after oral administration of a combined oral contraceptive containing 0.02 mg EE/0.06 mg GSD. Participants were women aged 18 to 35 years, all of whom received the EE/GSD patch for 13 cycles each of 21 treatment days (one patch per week for 3 weeks) followed by a 7-day, patch-free interval. The primary efficacy variable was the occurrence of unintended pregnancies during the study period as assessed by life table analysis and the Pearl Index. Secondary efficacy variables were days with bleeding during four 90-day reference periods and during 1 treatment year, bleeding pattern, and cycle control. The Kaplan-Meier probability of contraceptive protection after 364 treatment days was 98.8% and the adjusted Pearl Index was 0.81. The percentage of participants with intracyclic bleeding/spotting decreased over time, from 11.4% to 6.8% in cycles 1 and 12, respectively. Almost all participants (range: 90.8%-97.6%) experienced withdrawal bleeding across the study period. Compliance was very high (mean: 97.9%; median: 100%). The most frequent adverse events were headache (9.5%) and application site reaction (8.5%); no clinically significant safety concerns were observed. Results suggest the EE/GSD patch is highly effective in preventing pregnancy. Menstrual bleeding pattern was favorable and within the ranges expected of a healthy female population. The patch was well tolerated and treatment compliance was high. PMID:24784719

Design and development of an advanced two-stage centrifugal compressor

DOE Office of Scientific and Technical Information (OSTI.GOV)

Palmer, D.L.; Waterman, W.F.

1995-04-01

Small turboshaft engines require high-pressure-ratio, high-efficiency compressors to provide low engine fuel consumption. This paper describes the aeromechanical design and development of a 3.3 kg/s (7.3 lb/sec), 14:1 pressure ratio two-stage centrifugal compressor, which is used in the T800-LHT-800 helicopter engine. The design employs highly nonradial, splitter bladed impellers with swept leading edges and compact vaned diffusers to achieve high performance in a small and robust configuration. The development effort quantified the effects of impeller diffusion and passive inducer shroud bleed on surge margin as well as the effects of impeller loading on tip clearance sensitivity and the impact ofmore » sand erosion and shroud roughness on performance. The developed compressor exceeded its performance objectives with a minimum of 23% surge margin without variable geometry. The compressor provides a high-performance, rugged, low-cost configuration ideally suited for helicopter applications.« less

Zero Gravity Flights as the Most Effective Embryonic Operation for Planned Commercial Spaceport

NASA Astrophysics Data System (ADS)

Abu Samah, Shamsul Kamar; Ridzuan Zakaria, Norul; Nasrun, Nasri; Abu, Jalaluddin; Muszaphar Shukor, Dato'Sheikh

2013-09-01

From the experience gained by the management team of Spaceport Malaysia, a popular service that can be provided by a planned commercial spaceport in a country without existing space travel infrastructure are zero gravity flights. Zero gravity flights range from parabolic flights using aerobatic airplane to suborbital flights using rockets, and in the near future using suborbital rocketplanes. Therefore, zero gravity flights can be operated from a certified runway or planned for operation at a future commercial spaceport. With such range of operation, zero gravity flights provide a natural link between a low cost operation of small airplane to exclusive high profile operation of suborbital rocketplane, and this attracts the attention of individuals and organizations that are planning for the establishment of a commercial spaceport. This is the approach chosen by the planners and developers of Spaceport Malaysia. A significant factor in zero gravity flight is the zero gravity time, the period where the payload onboard the airplane or rocketplane will experience zero gravity. Based on the momentum of the airplane or rocketplane, the zero gravity time may vary from few seconds to few minutes and that determines the quality of the zero gravity flight. To achieve zero gravity, the airplane or rocketplane will fly with a steady velocity for a significant time as a gravity control flight, accelerate upwards with an angle producing hypergravity and perform parabolic flight with natural momentum producing zero gravity and followed by dive that will result in another hypergravity flight. 2 zero gravity platforms being considered for operation at and by Spaceport Malaysia are F-5E Tiger II and Airbus A300, since both platforms have been successfully used by a partner of Spaceport Malaysia in performing zero gravity flights. An F-5E fighter jet owned by Royal Malaysian Air Force is being planned to be converted into a zero gravity platform to be operated at and by Spaceport Malaysia. Based on recorded zero gravity flights of the fighter jet, an F-5E will be able to produce 45 seconds of zero gravity time, long enough for effective zero gravity experiments. An A300 in operation in Europe is also being considered to be operated bySpaceport Malaysia. Even though this airplane can only produce less than half the zero gravity time produced by F-5E, the A300 has the advantage off passengers to experience zero gravity. Both zero gravity platforms have been promoting Spaceport Malaysia project and suborbital flights to be operational at the spaceport as both zero gravity flights and suborbital flights attract the interest from similar and preferred operators and markets. Therefore based on Spaceport Malaysia as a case study, zero gravity flights are the most effective embryonic operation for a planned commercial spaceport.

Resuscitative endovascular balloon occlusion of the aorta may increase the bleeding of minor thoracic injury in severe multiple trauma patients: a case report.

PubMed

Maruhashi, Takaaki; Minehara, Hiroaki; Takeuchi, Ichiro; Kataoka, Yuichi; Asari, Yasushi

2017-12-14

The resuscitative endovascular balloon occlusion of the aorta, because of its efficacy and feasibility, has been widely used in treating patients with severe torso trauma. However, complications developing around the site proximal to the occlusion by resuscitative endovascular balloon occlusion of the aorta have almost never been studied. A 50-year-old Japanese woman fell from a height of approximately 10 m. At initial arrival, her respiratory rate was 24 breaths/minute, her blood oxygen saturation was 95% under 10 L/minute oxygenation, her pulse rate was 90 beats per minute, and her blood pressure was 180/120 mmHg. Mild lung contusion, hemopneumothorax, unstable pelvic fracture, and retroperitoneal bleeding with extravasation of contrast media were observed in initial computed tomography. As her vital signs had deteriorated during computed tomography, a 7-French aortic occlusion catheter (RESCUE BALLOON®, Tokai Medical Products, Aichi, Japan) was inserted and inflated for aortic occlusion at the first lumbar vertebra level and transcatheter arterial embolization was performed for the pelvic fracture. Her bilateral internal iliac arteries were embolized with a gelatin sponge; however, the embolized sites presented recanalization as coagulopathy appeared. Her bilateral internal iliac arteries were re-embolized by n-butyl-2-cyanoacrylate. The balloon was deflated 18 minutes later. After embolization, repeat computed tomography was performed and a massive hemothorax, which had not been captured on arrival, had appeared in her left pleural cavity. Thoracotomy hemostasis was performed and a hemothorax of approximately 2500 ml was aspirated to search for the source of bleeding. However, clear active bleeding was not captured; resuscitative endovascular balloon occlusion of the aorta may have been the cause of the increased bleeding of the thoracic injury at the proximal site of the aorta occlusion. It is necessary to note that the use of resuscitative endovascular balloon occlusion of the aorta may increase bleeding in sites proximal to occlusions, even in the case of minor injuries without active bleeding at the initial diagnosis.

Endoscopic variceal ligation-induced ulcer bleeding

PubMed Central

Cho, Eunae; Jun, Chung Hwan; Cho, Sung Bum; Park, Chang Hwan; Kim, Hyun Soo; Choi, Sung Kyu; Rew, Jong Sun

2017-01-01

Abstract This study was aimed to determine the risk factors of endoscopic variceal ligation-(EVL) induced ulcer bleeding. The prevalence of EVL-induced ulcer bleeding is reported to be 3.6%. However, there are only limited reports of this serious complication, and the risk factors and the treatment methods are not well established. A total of 430 patients who had undergone EVL in Chonnam National University Hospital from January 2014 to October 2016 were studied. EVL was performed for prophylaxis or acute hemorrhage. The patients were classified into 2 groups: a bleeding group (n = 33) and a non-bleeding group (n = 397). The patients who had endoscopically confirmed EVL-induced ulcer bleeding were included in the bleeding group. EVL-induced ulcer bleeding occurred in 7.7% (n = 33) of the patients. In a multivariate analysis, model for end-stage liver disease (MELD) score >10 (odds ratio [OR]: 3.42, 95% confidence interval [CI]: 1.10–10.64), concomitant GV F3 (OR: 14.1, 95% CI: 2.84–71.43), and detachment of o-ring bands on follow-up endoscopy (OR: 8.06, 95% CI: 2.55–25.64) were independent predictive factors of EVL-induced ulcer bleeding. Various endoscopic modalities were attempted for hemostasis (EVL in 8 cases [24.2%], endoscopic variceal obturation [EVO] with cyanoacrylate in 6 cases [18.2%], argon plasma coagulation [APC] in 1 case (3%), Sengstaken–Blakemore (SB) tube in 3 cases [9.1%]), and proton pump inhibitor therapy only in 15 cases (45.5%). MELD score >10, concomitant GV F3, and detachment of o-ring bands on follow-up endoscopy are risk factors for EVL-induced ulcer bleeding. PMID:28614248

The HAT Score-A Simple Risk Stratification Score for Coagulopathic Bleeding During Adult Extracorporeal Membrane Oxygenation.

PubMed

Lonergan, Terence; Herr, Daniel; Kon, Zachary; Menaker, Jay; Rector, Raymond; Tanaka, Kenichi; Mazzeffi, Michael

2017-06-01

The study objective was to create an adult extracorporeal membrane oxygenation (ECMO) coagulopathic bleeding risk score. Secondary analysis was performed on an existing retrospective cohort. Pre-ECMO variables were tested for association with coagulopathic bleeding, and those with the strongest association were included in a multivariable model. Using this model, a risk stratification score was created. The score's utility was validated by comparing bleeding and transfusion rates between score levels. Bleeding also was examined after stratifying by nadir platelet count and overanticoagulation. Predictive power of the score was compared against the risk score for major bleeding during anti-coagulation for atrial fibrillation (HAS-BLED). Tertiary care academic medical center. The study comprised patients who received venoarterial or venovenous ECMO over a 3-year period, excluding those with an identified source of surgical bleeding during exploration. None. Fifty-three (47.3%) of 112 patients experienced coagulopathic bleeding. A 3-variable score-hypertension, age greater than 65, and ECMO type (HAT)-had fair predictive value (area under the receiver operating characteristic curve [AUC] = 0.66) and was superior to HAS-BLED (AUC = 0.64). As the HAT score increased from 0 to 3, bleeding rates also increased as follows: 30.8%, 48.7%, 63.0%, and 71.4%, respectively. Platelet and fresh frozen plasma transfusion tended to increase with the HAT score, but red blood cell transfusion did not. Nadir platelet count less than 50×10 3 /µL and overanticoagulation during ECMO increased the AUC for the model to 0.73, suggesting additive risk. The HAT score may allow for bleeding risk stratification in adult ECMO patients. Future studies in larger cohorts are necessary to confirm these findings. Copyright © 2017 Elsevier Inc. All rights reserved.

The natural history of occult or angiodysplastic gastrointestinal bleeding in von Willebrand disease.

PubMed

Makris, M; Federici, A B; Mannucci, P M; Bolton-Maggs, P H B; Yee, T T; Abshire, T; Berntorp, E

2015-05-01

Recurrent gastrointestinal bleeding is one of the most challenging complications encountered in the management of patients with von Willebrand disease (VWD). The commonest cause is angiodysplasia, but often no cause is identified due to the difficulty in making the diagnosis. The optimal treatment to prevent recurrences remains unknown. We performed a retrospective study of VWD patients with occult or angiodysplastic bleeding within the setting of the von Willebrand Disease Prophylaxis Network (VWD PN) to describe diagnostic and treatment strategies. Centres participating in the VWD PN recruited subjects under their care with a history of congenital VWD and gastrointestinal (GI) bleeding due to angiodysplasia, or cases in which the cause was not identified despite investigation. Patients with acquired von Willebrand syndrome or those for whom the GI bleeding was due to another cause were excluded. Forty-eight patients from 18 centres in 10 countries were recruited. Seven individuals had a family history of GI bleeding and all VWD types except 2N were represented. Angiodysplasia was confirmed in 38%, with video capsule endoscopy and GI tract endoscopies being the most common methods of making the diagnosis. Recurrent GI bleeding in VWD is associated with significant morbidity and required hospital admission on up to 30 occasions. Patients were treated with multiple pharmacological agents with prophylactic von Willebrand factor concentrate being the most efficient in preventing recurrence of the GI bleeding. The diagnosis and treatment of recurrent GI bleeding in congenital VWD remains challenging and is associated with significant morbidity. Prophylactic treatment with von Willebrand factor concentrate was the most effective method of preventing recurrent bleeding but its efficacy remains to be confirmed in a prospective study. © 2014 John Wiley & Sons Ltd.

Acute lower gastrointestinal bleeding.

PubMed

Jocić, Tatiana; Latinović Bošnjak, Olgica; Hadnađev, Ljiljana; Damjanov, Dragomir; Savić, Željka; Orlić, Tihomir

2014-01-01

Acute lower gastrointestinal bleeding accounts for approximately 20% of all acute gastrointestinal hemorrhages, and they are the most common urgent cases in gastroenterology. The aim of this study was to determine the most common etiology, efficacy in diagnostics and therapy, and the outcome in patients with acute lower gastrointestinal bleeding. Data were collected from the medical records of 86 patients who had been hospitalized for acute lower gastrointestinal bleeding in 2009 at the Ward of Gastroenterology and Hepatology, Clinical Centre of Vojvodina. The average age of the patients was 70.4 years (ranging from 37 to 88), and the largest number of patients 41/86 (47.7%) were between the ages 71 and 80. Colon diverticulosis was the most common cause of bleeding, and it occurred in 21 patients from the study sample (24.4%), and the other causes were malignant tumors (12/86, i.e. 13.9%), polyps (10/86, i.e. 11.6%), anorectal diseases (7/86, i.e. 8.3%/0) and colitis (8/86, i.e. 9.3%). No diagnostic procedures were performed in 15 patients (17.4%) due to their poor medical condition and comorbidities. The total mortality rate was 6/86 (6.9%), and the largest number of deaths occurred (5/86 i.e. 5.8%) due to a multisystem organ failure and underlying diseases which were not associated with acute lower gastrointestinal bleeding. Uncontrolled bleeding was the cause of death in only 1 patient (1.2%). Acute lower gastrointestinal bleeding is most commonly found in the older population, whose age, comorbidities, and ongoing therapy have impact on bleeding lesions, diagnostic and therapeutic modalities and the outcomes of bleeding. Endoscopic procedures are still the gold standard in diagnostics.

Can Sequential Coagulation Monitoring Predict Major Haemorrhage in Extremely Low Birth Weight Infants?

PubMed

Thanhaeuser, Margarita; Binder, Christoph; Derhaschnig, Ulla; Jilma, Bernd; Kornsteiner-Krenn, Margit; Huber-Dangl, Mercedes; Repa, Andreas; Kreissl, Alexandra; Berger, Angelika; Haiden, Nadja

2018-06-04

 Bleeds such as intra-ventricular (IVH) and pulmonary haemorrhage (PH) are life-threatening events in extremely low birth weight (ELBW) infants. Serial coagulation monitoring by measuring the international normalized ratio (INR) with small volume samples might facilitate early diagnosis and possibly prevent major bleeds.  This was a prospective longitudinal study performed in ELBW infants, who received serial INR monitoring by point of care testing during their first 30 days of life. The primary objective was to explore whether INR monitoring could predict major bleeding events (IVH, PH). Secondary objectives were mortality and feasibility in this patient population.  A total of 127 ELBW infants were stratified into a bleeding and a non-bleeding group. Bleeding events occurred in 31% (39/127) of the infants, whereupon 24% developed IVH and 9% PH. Infants in the bleeding group were 4 days younger at birth ( p  = 0.05) and had a substantially higher mortality rate of 26% versus 5% in controls ( p  = 0.005). Median INR during the first 3 days before a bleeding event was 1.55 (95% confidence interval [CI]: 1.39-1.74) compared with the control group with 1.45 (95% CI: 1.44-1.58; p  = 0.81). Platelet counts were significantly lower in the bleeding group on the 3rd day and during the 2nd to 4th week of life.  Serial coagulation monitoring by an INR point of care testing is feasible in ELBW infants but could not predict bleeding events. Further studies with daily monitoring of INR and platelet counts during the first days of life might be able to more precisely detect a risk of major haemorrhage in ELBW infants. Schattauer GmbH Stuttgart.

An Unusual Cause of GI Bleeding in a Quadriplegic: Report of a Case and Review of the Literature

PubMed Central

Joseph, Raymond E.; Epsten, Robert; Kowlessar, O. Dhodanand

1982-01-01

The authors report a case of upper gastrointestinal hemorrhage in a quadriplegic. The cause was a Mallory-Weiss tear, a previously unrecognized problem in these patients. The incidence of bleeding in patients with spinal cord injury is as high as 25 percent in the few reported series. We feel that with the increased risk of gastrointestinal bleeding in the spinal cord patient and the accompanying significant mortality, early endoscopy is essential for accurate diagnosis since clues to the presence, etiology, and severity of the bleeding are often lacking. PMID:6981707

Genotype and phenotype relationships in 10 Pakistani unrelated patients with inherited factor VII deficiency.

PubMed

Borhany, M; Boijout, H; Pellequer, J-L; Shamsi, T; Moulis, G; Aguilar-Martinez, P; Schved, J-F; Giansily-Blaizot, M

2013-11-01

Inherited factor VII (FVII) deficiency is one of the commonest rare bleeding disorders. It is characterized by a wide molecular and clinical heterogeneity and an autosomal recessive pattern of inheritance. Factor VII-deficient patients are still scarcely explored in Pakistan although rare bleeding disorders became quite common as a result of traditional consanguineous marriages. The aim of the study was to give a first insight of F7 gene mutations in Pakistani population. Ten unrelated FVII-deficient patients living in Pakistan were investigated (median FVII:C = 2%; range = 2-37%). A clinical questionnaire was filled out for each patient and direct sequencing was performed on the coding regions, intron/exon boundaries and 5' and 3' untranslated regions of the F7 gene. Nine different mutations (eight missense mutations and one located within the F7 promoter) were identified on the F7 gene. Five of them were novel (p.Cys82Tyr, p.Cys322Ser, p.Leu357Phe, p.Thr410Ala, c-57C>T, the last being predicted to alter the binding site of transcription factor HNF-4). Half of the patients had single mutations in Cys residues involved in disulfide bridges. The p.Cys82Arg mutation was the most frequent in our series. Six of seven patients with FVII:C levels below 10% were homozygous in connection with the high percentage of consanguinity in our series. In addition, we graded the 10 patients according to three previously published classifications for rare bleeding disorders. The use of the bleeding score proposed by Tosetto and co-workers in 2006 appears to well qualify the bleeding tendency in our series. © 2013 John Wiley & Sons Ltd.

Clinical and laboratory variability in a cohort of patients diagnosed with type 1 VWD in the United States

PubMed Central

Christopherson, Pamela A.; Gill, Joan Cox; Friedman, Kenneth D.; Haberichter, Sandra L.; Bellissimo, Daniel B.; Udani, Rupa A.; Dasgupta, Mahua; Hoffmann, Raymond G.; Ragni, Margaret V.; Shapiro, Amy D.; Lusher, Jeanne M.; Lentz, Steven R.; Abshire, Thomas C.; Leissinger, Cindy; Hoots, W. Keith; Manco-Johnson, Marilyn J.; Gruppo, Ralph A.; Boggio, Lisa N.; Montgomery, Kate T.; Goodeve, Anne C.; James, Paula D.; Lillicrap, David; Peake, Ian R.; Montgomery, Robert R.

2016-01-01

von Willebrand disease (VWD) is the most common inherited bleeding disorder, and type 1 VWD is the most common VWD variant. Despite its frequency, diagnosis of type 1 VWD remains the subject of debate. In order to study the spectrum of type 1 VWD in the United States, the Zimmerman Program enrolled 482 subjects with a previous diagnosis of type 1 VWD without stringent laboratory diagnostic criteria. von Willebrand factor (VWF) laboratory testing and full-length VWF gene sequencing was performed for all index cases and healthy control subjects in a central laboratory. Bleeding phenotype was characterized using the International Society on Thrombosis and Haemostasis bleeding assessment tool. At study entry, 64% of subjects had VWF antigen (VWF:Ag) or VWF ristocetin cofactor activity below the lower limit of normal, whereas 36% had normal VWF levels. VWF sequence variations were most frequent in subjects with VWF:Ag <30 IU/dL (82%), whereas subjects with type 1 VWD and VWF:Ag ≥30 IU/dL had an intermediate frequency of variants (44%). Subjects whose VWF testing was normal at study entry had a similar rate of sequence variations as the healthy controls (14%). All subjects with severe type 1 VWD and VWF:Ag ≤5 IU/dL had an abnormal bleeding score (BS), but otherwise BS did not correlate with VWF:Ag. Subjects with a historical diagnosis of type 1 VWD had similar rates of abnormal BS compared with subjects with low VWF levels at study entry. Type 1 VWD in the United States is highly variable, and bleeding symptoms are frequent in this population. PMID:26862110

Clinical and laboratory variability in a cohort of patients diagnosed with type 1 VWD in the United States.

PubMed

Flood, Veronica H; Christopherson, Pamela A; Gill, Joan Cox; Friedman, Kenneth D; Haberichter, Sandra L; Bellissimo, Daniel B; Udani, Rupa A; Dasgupta, Mahua; Hoffmann, Raymond G; Ragni, Margaret V; Shapiro, Amy D; Lusher, Jeanne M; Lentz, Steven R; Abshire, Thomas C; Leissinger, Cindy; Hoots, W Keith; Manco-Johnson, Marilyn J; Gruppo, Ralph A; Boggio, Lisa N; Montgomery, Kate T; Goodeve, Anne C; James, Paula D; Lillicrap, David; Peake, Ian R; Montgomery, Robert R

2016-05-19

von Willebrand disease (VWD) is the most common inherited bleeding disorder, and type 1 VWD is the most common VWD variant. Despite its frequency, diagnosis of type 1 VWD remains the subject of debate. In order to study the spectrum of type 1 VWD in the United States, the Zimmerman Program enrolled 482 subjects with a previous diagnosis of type 1 VWD without stringent laboratory diagnostic criteria. von Willebrand factor (VWF) laboratory testing and full-length VWF gene sequencing was performed for all index cases and healthy control subjects in a central laboratory. Bleeding phenotype was characterized using the International Society on Thrombosis and Haemostasis bleeding assessment tool. At study entry, 64% of subjects had VWF antigen (VWF:Ag) or VWF ristocetin cofactor activity below the lower limit of normal, whereas 36% had normal VWF levels. VWF sequence variations were most frequent in subjects with VWF:Ag <30 IU/dL (82%), whereas subjects with type 1 VWD and VWF:Ag ≥30 IU/dL had an intermediate frequency of variants (44%). Subjects whose VWF testing was normal at study entry had a similar rate of sequence variations as the healthy controls (14%). All subjects with severe type 1 VWD and VWF:Ag ≤5 IU/dL had an abnormal bleeding score (BS), but otherwise BS did not correlate with VWF:Ag. Subjects with a historical diagnosis of type 1 VWD had similar rates of abnormal BS compared with subjects with low VWF levels at study entry. Type 1 VWD in the United States is highly variable, and bleeding symptoms are frequent in this population. © 2016 by The American Society of Hematology.

Risk Factors for Inhibitor Formation in Hemophilia: A Prevalent Case-Control Study

PubMed Central

Ragni, Margaret V.; Ojeifo, Oluseyi; Feng, Jinong; Yan, Jin; Hill, Kathleen A.; Sommer, Steve S.; Trucco, Massimo N.; Brambilla, Donald J.

2009-01-01

Background Inhibitor formation is a major complication of hemophilia treatment. Aim In a prevalent case-control study, we evaluated blood product exposure, genotype, and HLA type on hemophilia A inhibitor formation. Methods Product exposure was extracted from medical records. Genotype was determined on stored DNA samples by detection of virtually all mutations-SSCP (DOVAM-S) and subcycling PCR. HLA typing was performed by PCR amplification and exonuclease-released fluorescence. Results Cases experienced higher intensity factor, 455 vs. 200 U per exposure, p<0.005, more frequent central nervous system (CNS) bleeding, 7 of 20 (35.0%) vs. 1 of 57 (1.7%), p=0.001, and more commonly from inhibitor families, 7 of 20 (35.0%) vs. 0 of 57 (0%), p<0.001, and African-American, 12 of 63 (19.0%) vs. 6 of 117 (5.1%), p=0.015. Among the latter, CNS bleeding was more commonly the initial bleed, 60% vs. 0%, p<0.001, and survival was shorter, 14 vs. 38 yr, p=0.025. Inhibitor formation was uncommon in those with missense mutations, 2 of 65 (3.1%) vs. 31 of 119 (26.0%), p=0.008, and unrelated to factor VIII immunogenic epitope, p=0.388, or HLA type, p>0.100. Genotype was not associated with race. Time to immune tolerance was shorter for titers < 120 vs. ≥ 120 BU/ml, 6 vs. 16 months, p<0.01, but unaffected by tolerizing dose regimen, p>0.50. Conclusions Inhibitor formation is associated with high intensity product exposure, CNS bleeding, African-American race, and low frequency of missense mutations. The ideal time to initiate prophylaxis to reduce CNS bleeding and inhibitor formation will require prospective studies. PMID:19563499

Emergency Cardiac Surgery in Patients with Acute Coronary Syndromes: A Review of the Evidence and Perioperative Implications of Medical and Mechanical Therapeutics

PubMed Central

Brown, Charles; Joshi, Brijen; Faraday, Nauder; Shah, Ashish; Yuh, David; Rade, Jeffrey J.; Hogue, Charles W.

2011-01-01

Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly due to subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarcation. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly rFVIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk-stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes needs more stringent analysis. PMID:21385977

[Risk for the development of upper gastrointestinal bleeding in children in an intensive care unit].

PubMed

Gutiérrez-Gutiérrez, Glenda Karina; Villasís-Keever, Miguel Angel; González-Ortiz, Beatriz; Troconis-Trens, Germán; Tapia-Monge, Dora María; Flores-Calderón, Judith

2014-01-01

Although gastrointestinal tract bleeding can occur at any age, most studies trying to establish causes or risk factors for its development have been conducted in adults. The aim of this study was to determine risk factors in children admitted in a pediatric intensive care unit. A retrospective case-control study was conducted. Children who developed upper gastrointestinal bleeding children during their stay at the intensive care unit were considered the cases. Variables were obtained from medical records including age, sex, nutritional status, mechanical ventilation, use of nasogastric tube, development of complications, presence of coagulopathy, use of prophylaxis for upper gastrointestinal tract bleeding, fasting and use of steroids. Using a multivariate analysis, risk factors were identified, with odds ratios (OR) and 95 % confidence intervals (95 % CI) calculations. Out of 165 patients, 58 had upper gastrointestinal bleeding (35 %). Risk factors identified were prolonged clotting times (OR = 3.35), thrombocytopenia (OR = 2.39), development of sepsis (OR = 6.74) or pneumonia (OR = 4.37). Prophylaxis for upper gastrointestinal bleeding was not a protective factor. Upper gastrointestinal bleeding frequency in children hospitalized in an intensive care unit was high. Identifying risk factors should help to reduce upper gastrointestinal bleeding frequency.

Applications of massively parallel computers in telemetry processing

NASA Technical Reports Server (NTRS)

El-Ghazawi, Tarek A.; Pritchard, Jim; Knoble, Gordon

1994-01-01

Telemetry processing refers to the reconstruction of full resolution raw instrumentation data with artifacts, of space and ground recording and transmission, removed. Being the first processing phase of satellite data, this process is also referred to as level-zero processing. This study is aimed at investigating the use of massively parallel computing technology in providing level-zero processing to spaceflights that adhere to the recommendations of the Consultative Committee on Space Data Systems (CCSDS). The workload characteristics, of level-zero processing, are used to identify processing requirements in high-performance computing systems. An example of level-zero functions on a SIMD MPP, such as the MasPar, is discussed. The requirements in this paper are based in part on the Earth Observing System (EOS) Data and Operation System (EDOS).

A fast and zero-biased photodetector based on GaTe-InSe vertical 2D p-n heterojunction

NASA Astrophysics Data System (ADS)

Feng, W.; Jin, Z.; Yuan, J.; Zhang, J.; Jia, S.; Dong, L.; Yoon, J.; Zhou, L.; Vajtai, R.; Tour, J. M.; Ajayan, P. M.; Hu, P.; Lou, J.

2018-04-01

p-n junctions serve as the building blocks for fundamental semiconductor devices, such as solar cells, light-emitting diodes (LEDs) and photodetectors. With recent studies unveiling the excellent optoelectronic properties of two-dimensional (2D) semiconductors, they are considered to be superb candidates for high performance p-n junctions. Here, we fabricate a vertical GaTe-InSe van der Waals (vdWs) p-n heterojunction by a PDMS-assisted transfer technique without etching. The fabricated p-n heterojunction shows gate-tunable current-rectifying behavior with a rectification factor reaching 1000. In addition, it features fast photodetection under zero bias as well as a high power conversion efficiency (PCE). Under 405 nm laser excitation, the zero-biased photodetector shows a high responsivity of 13.8 mA W-1 as well as a high external quantum efficiency (EQE) of 4.2%. Long-term stability is also observed and a response time of 20 µs is achieved due to stable and fast carrier transit through the built-in electric field in the depletion region. Fast and efficient charge separation in the vertical 2D p-n junction paves the way for developing 2D photodetectors with zero dark current, high speed and low power consumption.

Bayesian network modelling of upper gastrointestinal bleeding

NASA Astrophysics Data System (ADS)

Aisha, Nazziwa; Shohaimi, Shamarina; Adam, Mohd Bakri

2013-09-01

Bayesian networks are graphical probabilistic models that represent causal and other relationships between domain variables. In the context of medical decision making, these models have been explored to help in medical diagnosis and prognosis. In this paper, we discuss the Bayesian network formalism in building medical support systems and we learn a tree augmented naive Bayes Network (TAN) from gastrointestinal bleeding data. The accuracy of the TAN in classifying the source of gastrointestinal bleeding into upper or lower source is obtained. The TAN achieves a high classification accuracy of 86% and an area under curve of 92%. A sensitivity analysis of the model shows relatively high levels of entropy reduction for color of the stool, history of gastrointestinal bleeding, consistency and the ratio of blood urea nitrogen to creatinine. The TAN facilitates the identification of the source of GIB and requires further validation.

Treatment tailoring for factor V deficient patients and perioperative management using global hemostatic coagulation assays.

PubMed

Levy-Mendelovich, Sarina; Barg, Assaf Arie; Rosenberg, Nurit; Avishai, Einat; Luboshitz, Jacob; Misgav, Mudi; Kenet, Gili; Livnat, Tami

2018-07-01

Congenital factor V deficiency (FVD) is a rare bleeding disorder with an estimated incidence of 1 in 1000,000 in the general population. Since the common coagulation tests do not correlate with the bleeding tendency there is an unmet need to predict FVD patients' bleeding hazard prior to surgical interventions. To optimize treatment prior to surgical interventions, using global coagulation assays, thrombin generation (TG) and rotating thromboelastogram (ROTEM). Our cohort included 5 patients with FVD, 4 severe and one mild. Two of them underwent TG and ROTEM prior to surgical interventions, including ex vivo spiking assays using bypass agents and platelets spiking. All five patients exhibited prolonged PT and PTT, non-dependent on their bleeding tendency. Patient 1, who demonstrated severe bleeding phenotype, underwent surgery treated by combination of APCC (FEIBA) and platelet transfusion. Therapy was guided by global tests (TG as well as ROTEM) results. During the pre and post-operative period neither excessive bleeding nor any thrombosis was noted. In contrast, TG and ROTEM analysis of patient 4 has lead us to perform the surgery without any blood products' support. Indeed, the patient did not encounter any bleeding. Global coagulation assays may be useful ancillary tools guiding treatment decisions in FVD patients undergoing surgical procedures. Copyright © 2018 Elsevier Inc. All rights reserved.

Prevention of bleeding after islet transplantation: lessons learned from a multivariate analysis of 132 cases at a single institution.

PubMed

Villiger, P; Ryan, E A; Owen, R; O'Kelly, K; Oberholzer, J; Al Saif, F; Kin, T; Wang, H; Larsen, I; Blitz, S L; Menon, V; Senior, P; Bigam, D L; Paty, B; Kneteman, N M; Lakey, J R T; Shapiro, A M James

2005-12-01

Islet transplantation is being offered increasingly for selected patients with unstable type 1 diabetes. Percutaneous transhepatic portal access avoids a need for surgery, but is associated with potential risk of bleeding. Between 1999 and 2005, we performed 132 percutaneous transhepatic islet transplants in 67 patients. We encountered bleeding in 18/132 cases (13.6%). In univariate analysis, the risk of bleeding in the absence of effective track ablation was associated with an increasing number of procedures (2nd and 3rd procedures with an odds ratio (OR) of 9.5 and 20.9, respectively), platelets count <150,000 (OR 4.4), elevated portal pressure (OR 1.1 per mm Hg rise), heparin dose > or =45 U/kg (OR 9.8) and pre-transplant aspirin (81 mg per day) (OR 2.6, p = 0.05). A multivariate analysis further confirmed the cumulative transplant procedure number (p < 0.001) and heparin dose > or =45 U/kg (p = 0.02) as independent risk factors for bleeding. Effective mechanical sealing of the intrahepatic portal catheter tract with thrombostatic coils and tissue fibrin glue completely prevented bleeding in all subsequent procedures (n = 26, p = 0.02). We conclude that bleeding after percutaneous islet implantation is an avoidable complication provided the intraparenchymal liver tract is sealed effectively.

Bleeding risk of patients with acute venous thromboembolism taking nonsteroidal anti-inflammatory drugs or aspirin.

PubMed

Davidson, Bruce L; Verheijen, Sara; Lensing, Anthonie W A; Gebel, Martin; Brighton, Timothy A; Lyons, Roger M; Rehm, Jeffrey; Prins, Martin H

2014-06-01

Combined anticoagulant and aspirin therapy is associated with increased bleeding risk in patients with atrial fibrillation, but the bleeding risk of combined use of anticoagulant and nonsteroidal anti-inflammatory drugs (NSAIDs) is poorly documented. To estimate the bleeding risk of combined anticoagulant (rivaroxaban or enoxaparin-vitamin K antagonist [VKA]) and NSAID or aspirin therapy in patients with venous thromboembolism. Prospective analysis of observational data from the EINSTEIN deep vein thrombosis and pulmonary embolism clinical trials comparing rivaroxaban with enoxaparin-VKA treatment, trials performed in hospitals and clinics in 8246 patients enrolled from 2007 to 2009. Bleeding event rates during exposure to NSAID and aspirin therapy were compared to time without exposure. Days of NSAID or aspirin use and nonuse, clinically relevant bleeding event and major bleeding event rates by patient-years, and hazard ratios. During NSAID-anticoagulant concomitant treatment, clinically relevant bleeding occurred with an event rate of 37.5 per 100 patient-years vs 16.6 per 100 patient-years during anticoagulant use only (hazard ratio [HR], 1.77 [95% CI, 1.46-2.14]). Major bleeding during NSAID-anticoagulant treatment occurred with an event rate of 6.5 per 100 patient-years, compared to 2.0 per 100 patient-years during nonuse (HR, 2.37 [95% CI, 1.51-3.75]). For aspirin-anticoagulant concomitant treatment, clinically relevant bleeding occurred with an event rate of 36.6 per 100 patient-years, compared to 16.9 per 100 patient-years during aspirin nonuse (HR, 1.70 [95% CI, 1.38-2.11]). Major bleeding in aspirin-anticoagulant-treated patients occurred with an event rate of 4.8 per 100 patient-years, compared to 2.2 per 100 patient-years during aspirin nonuse (HR, 1.50 [95% CI, 0.86-2.62]). Increases in risk for clinically relevant and major bleeding were similar for rivaroxaban and enoxaparin-VKA anticoagulation regimens. Among patients with venous thromboembolism receiving anticoagulant therapy, concomitant use of an NSAID or aspirin is associated with an increased risk of clinically relevant and major bleeding.

Prediction of esophageal variceal bleeding in B-viral liver cirrhosis using the P2/MS noninvasive index based on complete blood counts.

PubMed

Kim, Beom Kyung; Ahn, Sang Hoon; Han, Kwang-Hyub; Park, Jun Yong; Han, Min Seok; Jo, Jung Hyun; Kim, Ja Kyung; Lee, Kwan Sik; Chon, Chae Yoon; Kim, Do Young

2012-01-01

Periodic endoscopy for esophageal varices (EVs) and prophylactic treatment of high-risk EVs, i.e., medium/large EVs, small EVs with the red-color sign or decompensation, are recommended in cirrhotic patients. We assessed the cumulative risks for future EV bleeding using the following simple P2/MS index: (platelet count)2/[monocyte fraction (%) × segmented neutrophil fraction (%)]. We enrolled 475 consecutive B-viral cirrhosis patients for 4 years, none of whom experienced EV bleeding. All underwent laboratory work-ups, endoscopy and ultrasonography. Those with EV bleeding took a nonselective β-blocker as prophylaxis. The major endpoint was the first occurrence of EV bleeding, analyzed using the Kaplan-Meier and Cox regression methods. Among patients with EV bleeding (n = 131), 25 experienced their first EV bleeding during follow-up. To differentiate the risk for EV bleeding, we divided them into two subgroups according to their P2/MS value (subgroup 1: P2/MS ≥9 and subgroup 2: P2/MS <9). The risk was significantly higher in subgroup 2 (p = 0.029). From multivariate analysis, a lower P2/MS (p = 0.040) remained a significant predictor for EV bleeding along with large varix size (p = 0.015), red-color sign (p = 0.041) and Child-Pugh classification B/C (p = 0.001). In subgroup 1, the risk for EV bleeding was similar to that of patients with low-risk EVs (p = 0.164). The P2/MS is a reliable predictor for the risk of EV bleeding among patients with EV bleeding. According to risk stratification, different prophylactic treatments should be considered for the subgroup with a P2/MS <9. Copyright © 2012 S. Karger AG, Basel.

Short-term use of serotonin reuptake inhibitors and risk of upper gastrointestinal bleeding.

PubMed

Wang, Yen-Po; Chen, Yung-Tai; Tsai, Chia-Fen; Li, Szu-Yuan; Luo, Jiing-Chyuan; Wang, Shuu-Jiun; Tang, Chao-Hsiun; Liu, Chia-Jen; Lin, Han-Chieh; Lee, Fa-Yauh; Chang, Full-Young; Lu, Ching-Liang

2014-01-01

The association between selective serotonin receptor inhibitors (SSRIs) and risk of upper gastrointestinal bleeding remains controversial. Previous studies have generally evaluated the issue for approximately 3 months, even though the SSRI-mediated inhibition of platelet serotonin concentrations occurs within 7-14 days. The authors explored the risk of upper gastrointestinal bleeding after short-term SSRI exposure by a case-crossover design. The records of psychiatric inpatients with upper gastrointestinal bleeding were retrieved from the Taiwan National Health Insurance Database (1998-2009). Rates of antidepressant use were compared for case and control periods with time windows of 7, 14, and 28 days. The adjusted self-matched odds ratios from a conditional logistic regression model were used to determine the association between SSRI use and upper gastrointestinal bleeding. A total of 5,377 patients with upper gastrointestinal bleeding were enrolled. The adjusted odds ratio for the risk of upper gastrointestinal bleeding after SSRI exposure was 1.67 (95% CI=1.23-2.26) for the 7-day window, 1.84 (95% CI=1.42-2.40) for the 14-day window, and 1.67 (95% CI=1.34-2.08) for the 28-day window. SSRIs with high and intermediate, but not low, affinity for serotonin transporter were associated with upper gastrointestinal bleeding. An elevated risk of upper gastrointestinal bleeding after SSRI exposure was seen in male but not female patients. Short-term SSRI use (7-28 days) is significantly associated with upper gastrointestinal bleeding. Gender differences may exist in the relationship between SSRI use and upper gastrointestinal bleeding. Physicians should carefully monitor signs of upper gastrointestinal bleeding even after short-term exposure to SSRIs, as is done with nonsteroidal anti-inflammatory drugs and aspirin.

Flight prototype regenerative particulate filter system development

NASA Technical Reports Server (NTRS)

Green, D. C.; Garber, P. J.

1974-01-01

The effort to design, fabricate, and test a flight prototype Filter Regeneration Unit used to regenerate (clean) fluid particulate filter elements is reported. The design of the filter regeneration unit and the results of tests performed in both one-gravity and zero-gravity are discussed. The filter regeneration unit uses a backflush/jet impingement method of regenerating fluid filter elements that is highly efficient. A vortex particle separator and particle trap were designed for zero-gravity use, and the zero-gravity test results are discussed. The filter regeneration unit was designed for both inflight maintenance and ground refurbishment use on space shuttle and future space missions.

Relevance of surgery after embolization of gastrointestinal and abdominal hemorrhage.

PubMed

Köhler, Gernot; Koch, Oliver Owen; Antoniou, Stavros A; Mayer, Franz; Lechner, Michael; Pallwein-Prettner, Leo; Emmanuel, Klaus

2014-09-01

Gastrointestinal and abdominal bleeding can lead to life-threatening situations. Embolization is considered a feasible and safe treatment option. The relevance of surgery has thus diminished in the past. The aim of the present study was to evaluate the role of surgery in the management of patients after embolization. We performed a retrospective single-center analysis of outcomes after transarterial embolization of acute abdominal and gastrointestinal hemorrhage between January 2009 and December 2012 at the Sisters of Charity Hospital, Linz. Patients were divided into three groups, as follows: upper gastrointestinal bleeding (UGIB), lower gastrointestinal bleeding (LGIB), and abdominal hemorrhage. Fifty-four patients with 55 bleeding events were included. The bleeding source could be localized angiographically in 80 %, and the primary clinical success rate of embolization was 81.8 % (45/55 cases). Early recurrent bleeding (<30 days) occurred in 18.2 % (10/55) of the patients, and delayed recurrent hemorrhage (>30 days) developed in 3.6 % (2/55). The mean follow-up was 8.4 months, and data were available for 85.2 % (46/54) of the patients. Surgery after embolization was required in 20.4 % of these patients (11/54). Failure to localize the bleeding site was identified as predictive of recurrent bleeding (p = 0.009). More than one embolization effort increased the risk of complications (p = 0.02) and rebleeding (p = 0.07). Surgery still has an important role after embolization in patients with gastrointestinal and abdominal hemorrhage. One of five patients required surgery in cases of early and delayed rebleeding or because of ischemic complications (2/55 both had ischemic damage of the gallbladder) and bleeding consequences.

Lonoctocog Alfa: A Review in Haemophilia A.

PubMed

Al-Salama, Zaina T; Scott, Lesley J

2017-10-01

Lonoctocog alfa (rVIII-SingleChain; Afstyla ® ) is a novel single-chain recombinant factor VIII (FVIII) molecule, with a truncated B-domain and the heavy and light chains covalently linked to form a stable and homogenous drug that binds with high affinity to von Willebrand factor (VWF). Intravenous lonoctocog alfa is approved for the prophylaxis and treatment of bleeding in patients with haemophilia A in several countries worldwide. In two pivotal, multicentre trials, lonoctocog alfa was effective in the treatment of bleeding episodes and as prophylaxis, including for perioperative management in adults, adolescents and children. In terms of haemostatic efficacy in controlling bleeding episodes, overall treatment and investigator-assessed success rates were high across all age groups, with the majority of these bleeds controlled with a single injection of lonoctocog alfa. Low median spontaneous, overall and traumatic annualized bleeding rates were evident with prophylactic lonoctocog alfa regimens in both trials. Lonoctocog alfa was generally well-tolerated, with very low rates of injection-site reactions. No previously treated patient experienced an anaphylactic reaction or developed an inhibitor. In conclusion, lonoctocog alfa is an effective and generally well-tolerated alternative to conventional FVIII products for the treatment and prophylaxis of bleeding, including in the surgical setting, in adults, adolescents and children with haemophilia A.

Vascular Plug Assisted Retrograde Transvenous Obliteration (PARTO) for Gastric Varix Bleeding Patients in the Emergent Clinical Setting

PubMed Central

Yang, Heechul; Lee, Chun Kyon; Kim, Gun Bea

2016-01-01

Purpose To evaluate the technical feasibility and safety of vascular plug assisted retrograde transvenous obliteration (PARTO) for bleeding gastric varix performed in the emergent clinical setting and describe the mid-term clinical results. Materials and Methods From April 2012 to January 2015, emergent PARTO was tried in total 9 patients presented with active gastric varix bleeding. After initial insufficient or failure of endoscopic approach, they underwent PARTO in the emergent clinical setting. Gelatin sponge embolization of both gastrorenal (GR) shunt and gastric varix was performed after retrograde transvenous placement of a vascular plug in GR shunt. Coil assisted RTO (CARTO) was performed in one patient who had challenging GR shunt anatomy for vascular plug placement. Additional embolic materials, such as microcoils and NBCA glue-lipiodol mixture, were required in three patients to enhance complete occlusion of GR shunt or obliteration of competitive collateral vessels. Clinical success was defined as no variceal rebleeding and disappearance of gastric varix. Results All technical and clinical success–i.e., complete GR shunt occlusion and offending gastric varix embolization with immediate bleeding control–was achieved in all 9 patients. There was no procedure-related complication. All cases showed successful clinical outcome during mean follow up of 17 months (12–32 months), evidenced by imaging studies, endoscopy and clinical data. In 4 patients, mild worsening of esophageal varices or transient ascites was noted as portal hypertensive related change. Conclusion Emergent PARTO is technically feasible and safe, with acceptable mid-term clinical results, in treating active gastric varix bleeding. PMID:27189294

FAST for blunt abdominal trauma: Correlation between positive findings and admission acid-base measurement.

PubMed

Heidari, Kamran; Taghizadeh, Mehrdad; Mahmoudi, Sadrollah; Panahi, Hamidreza; Ghaffari Shad, Ensieh; Asadollahi, Shadi

2017-06-01

This study aimed to determine any association between positive findings in ultrasonography examination and initial BD value with regard to diagnosis of intra-abdominal bleeding following blunt abdominal trauma. A prospective, multi-center study of consecutive adult patients was performed from April to September 2015. Demographics, initial vital signs and arterial BD were evaluated with respect to presence of any association with intra-abdominal bleeding and in-hospital mortality. FAST study was performed to find intra-abdominal bleeding. Receiver operating characteristic (ROC) curves tested the ability of BD to identify patients with intra-abdominal hemorrhage and probable mortality. A total of 879 patients were included in final analysis. The mean (SD) age was 36.68 (15.7) years and 714 patients (81.2%) were male. According to multivariable analysis, statistically significant association was observed between negative admission BD and both intra-abdominal bleeding (OR 3.48, 95% CI 2.06-5.88, p<0.001) and in-hospital mortality (OR 1.55, 95% CI 1.49-1.63, p<0.001). ROC curve analysis demonstrated sensitivity of 92.7% and specificity of 22.1% for the best cut-off value of BD (-8mEq/L) to diagnose internal hemorrhage. Further, a cut-off value of -7mEq/L demonstrated significant predictive performance, 94.8% sensitivity and 53.6% specificity for in-hospital mortality. This study revealed that arterial BD is an early accessible important marker to identify intra-abdominal bleeding, as well as to predict overall in-hospital mortality in patients with blunt abdominal trauma. Copyright © 2017. Published by Elsevier Inc.

Superstition and post-tonsillectomy hemorrhage.

PubMed

Kumar, Veena V; Kumar, Naveen V; Isaacson, Glenn

2004-11-01

The objective was to determine whether post-tonsillectomy hemorrhages occur more frequently in redheaded children, in patterns of threes, on Friday-the-13th days, or with the full moon. Case-control analysis. The authors performed multiple statistical analyses of all children undergoing tonsillectomy at Temple University Children's Medical Center (Philadelphia, PA) during a 29-month period. Children readmitted to the hospital with or without surgical control of bleeding were compared with children who did not bleed. Relation of post-tonsillectomy hemorrhages to the phase of the moon was evaluated using a standard normal deviate. The frequency of surgery performed on Friday-the-13th days was compared with a differently dated Friday chosen at random. Clusters of three hemorrhages in a 7-day period were recorded. Families of children were contacted and asked whether their child had red hair. A chi analysis compared redheaded and non-redheaded tonsillectomy patients. Twenty-eight of 589 tonsillectomy cases performed required readmission for bleeding events. Twenty tonsillectomies occurred on a full-moon day, resulting in one bleeding event. One cluster of three post-tonsillectomy hemorrhages occurred in a 7-day period. Four of the children who bled had red hair. Two tonsillectomies occurred on Friday the 13th, with no associated hemorrhage. Statistical analysis revealed a random pattern to post-tonsillectomy hemorrhage. Post-tonsillectomy hemorrhages do not occur in clusters of three and are not more frequent with the full moon or on Friday the 13th. The bleeding rate among children with red hair is similar to that of non-redheaded children.

Effect of kaolin addition on the performance of controlled low-strength material using industrial waste incineration bottom ash.

PubMed

Naganathan, Sivakumar; Razak, Hashim Abdul; Hamid, Siti Nadzriah Abdul

2010-09-01

Incineration of industrial waste produces large quantities of bottom ash which are normally sent to secured landfill, but is not a sustainable solution. Use of bottom ash in engineering applications will contribute to sustainability and generate revenue. One way of using the industrial waste incineration bottom ash is in controlled low-strength material (CLSM). Use of bottom ash in CLSM has problems related to bleeding and excessive strength development and so an additive has to be used to control bleeding and strength development. The main objective of this research is to study the effect of kaolin addition on the performance of CLSM made using industrial waste incineration bottom ash. CLSM mixes were made with bottom ash, cement, and refined kaolin. Various tests were performed on the CLSM in fresh and hardened states including compressive strength, water absorption, California bearing ratio (CBR) and the tests for concentration of leachable substances on the bleed and leachate. The compressive strength of CLSM tested ranged from 0.11 to 9.86 MPa. CBR values ranged from 6 to 46, and water absorption values from 12 to 36%. It was shown that the addition of kaolin delayed the initial setting time of CLSM mixtures, reduced bleeding, lowered the compressive strength, and increased the values of water absorption, sorption, and initial surface absorption. The CLSM tested did not have corrosivity. It was shown that the hardened CLSM was non hazardous, and the addition of kaolin increased the concentration of heavy metals and salts in the bleed and leachate.

Solar Assisted Ground Source Heat Pump Performance in Nearly Zero Energy Building in Baltic Countries

NASA Astrophysics Data System (ADS)

Januševičius, Karolis; Streckienė, Giedrė

2013-12-01

In near zero energy buildings (NZEB) built in Baltic countries, heat production systems meet the challenge of large share domestic hot water demand and high required heating capacity. Due to passive solar design, cooling demand in residential buildings also needs an assessment and solution. Heat pump systems are a widespread solution to reduce energy use. A combination of heat pump and solar thermal collectors helps to meet standard requirements and increases the share of renewable energy use in total energy balance of country. The presented paper describes a simulation study of solar assisted heat pump systems carried out in TRNSYS. The purpose of this simulation was to investigate how the performance of a solar assisted heat pump combination varies in near zero energy building. Results of three systems were compared to autonomous (independent) systems simulated performance. Different solar assisted heat pump design solutions with serial and parallel solar thermal collector connections to the heat pump loop were modelled and a passive cooling possibility was assessed. Simulations were performed for three Baltic countries: Lithuania, Latvia and Estonia.

A new scoring system (DAIGA) for predicting bleeding complications in atrial fibrillation patients after drug-eluting stent implantation with triple antithrombotic therapy.

PubMed

Kobayashi, Norihiro; Yamawaki, Masahiro; Nakano, Masatsugu; Hirano, Keisuke; Araki, Motoharu; Takimura, Hideyuki; Sakamoto, Yasunari; Mori, Shinsuke; Tsutsumi, Masakazu; Ito, Yoshiaki

2016-11-15

No scoring system for evaluating the bleeding risk of atrial fibrillation (AF) patients after drug-eluting stent (DES) implantation with triple antithrombotic therapy (TAT) is available. We aimed to develop a new scoring system for predicting bleeding complications in AF patients after DES implantation with TAT. Between April 2007 and April 2014, 227 AF patients undergoing DES implantation with TAT were enrolled. Bleeding incidence defined as Bleeding Academic Research Consortium criteria≥2 was investigated and predictors of bleeding complications were evaluated using multivariate analysis. Bleeding complications occurred in 58 patients (25.6%) during follow-up. Multivariate analysis revealed dual antiplatelet therapy (DAPT) continuation (OR 3.33, P=0.01), age>75 (OR 2.14, P=0.037), international normalized ratio>2.2 (OR 5.82, P<0.001), gastrointestinal ulcer history (OR 3.06, P=0.037), and anemia (OR 2.15, P=0.042) as predictors of major bleeding complications. A score was created using the weighted points proportional to the beta regression coefficient of each variable. The DAIGA score showed better predictive ability for bleeding complications than the HAS-BLED score (AUC: 0.79 vs. 0.62, P=0.0003). Bleeding incidence was well stratified: 17.8% in low-risk (scores 0-1), 55.5% in moderate-risk (2-3), and 83.0% in high-risk (4-7) patients (P<0.001). This scoring system is useful for predicting bleeding complications and risk stratification of AF patients after DES implantation with TAT. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

High-performance zero-bias ultraviolet photodetector based on p-GaN/n-ZnO heterojunction

DOE Office of Scientific and Technical Information (OSTI.GOV)

Su, Longxing; Zhang, Quanlin; Chen, Mingming

2014-08-18

Lattice-match p-GaN and n-ZnO bilayers were heteroepitaxially grown on the c-sapphire substrate by metal organic chemical vapor deposition and molecular beam epitaxy technique, respectively. X-ray diffraction and photoluminescence investigations revealed the high crystal quality of the bilayer films. Subsequently, a p-GaN/n-ZnO heterojunction photodetector was fabricated. The p-n junction exhibited a clear rectifying I-V characteristic with a turn-on voltage of 3.7 V. At zero-bias voltage, the peak responsivity was 0.68 mA/W at 358 nm, which is one of the best performances reported for p-GaN/n-ZnO heterojunction detectors due to the excellent crystal quality of the bilayer films. These show that the high-performance p-GaN/n-ZnO heterojunction diodemore » is potential for applications of portable UV detectors without driving power.« less

Single-Stage, 3.4:1-Pressure-Ratio Aspirated Fan Developed and Demonstrated

NASA Technical Reports Server (NTRS)

Braunscheidel, Edward P.

2004-01-01

Researchers are constantly pursuing technologies that will increase the performance of gas turbine engines. The aspirated compressor concept discussed here would allow the compression system to perform its task with about one-half of the compressor blades. To accomplish this, the researchers applied boundary layer control to the blades, casing, and hub. This method of boundary layer control consisted of removing small amounts of air from the main flow path at critical areas of the compressor. This bleed air could be used by other systems such as engine cooling or could be re-injected into lower pressure areas that require air for enhanced performance. This effort was initiated by the Massachusetts Institute of Technology (MIT) in response to a solicitation from the Defense Advanced Research Projects Agency (DARPA) who sought to advance research in flow control technology. The NASA Glenn Research Center partnered with MIT (principal investigator), Honeywell Aircraft Engines (cycle analysis, structural analysis, and mechanical design), and Pratt & Whitney (cycle analysis and aero-analysis) to conceptualize, design, analyze, build, and test the aspirated fan stage. The aero-design and aero-analysis of this fan stage were jointly executed by MIT and Glenn to minimize the amount of bleed flow needed and to maintain the highest efficiency possible (ref. 1). Mechanical design issues were complicated by the need to have a shrouded rotor with hollow blades, with rotor stress levels beyond the capabilities of titanium. The high stress issues were addressed by designing a shroud that was filament wound with a carbon fiber/epoxy matrix, resulting in an assembly that was strong enough to handle the high stresses. Both the rotor (preceding photographs) and stator (following photograph) were fabricated in two halves and then bolted together at the hub and tip, permitting the bleed passages to be machined into each half before assembly.

Dual control of low concentration CO poisoning by anode air bleeding of low temperature polymer electrolyte membrane fuel cells

NASA Astrophysics Data System (ADS)

Klages, Merle; Tjønnås, Johannes; Zenith, Federico; Halvorsen, Ivar J.; Scholta, Joachim

2016-12-01

Fuel impurities, fed to a polymer electrolyte membrane fuel cell, can affect stack performance by poisoning of catalyst layers. This paper describes the dynamic behaviour of a stack, including state-of-the-art membrane electrode assemblies (MEA) of three different manufacturers, at different operating conditions. The voltage transients of the step responses to CO poisoning as well as air bleed recovery are compared, revealing differences in performance loss: slow poisoning versus fast recovery, incomplete recovery and voltage oscillation. The recorded behaviour is used to develop a model, based on Tafel equation and first order dynamic response, which can be calibrated to each MEA type. Using this model to predict voltage response, a controller is built with the aim of reducing the total amount of air bleed and monitoring upstream stack processes without the need of sensors measuring the poisoning level. Two controllers are implemented in order to show the concept from a heuristic, easy to implement, and a more technical side allowing more detailed analysis of the synthesis. The heuristic algorithm, based on periodic perturbations of the manipulated variable (air-bleed), is validated on a real stack, revealing a stabilized performance without the need of detailed stack properties knowledge.

Hemophilic Chronic Synovitis: Therapy of Hemarthrosis using Endovascular Embolization of Knee and Elbow Arteries

DOE Office of Scientific and Technical Information (OSTI.GOV)

Galli, E., E-mail: emgalli1@yahoo.com.ar; Baques, A.; Moretti, N.

2013-08-01

PurposeCongenital hemophilia is a hereditary bleeding disorder that affects 1 in 5,000 males and is characterized by repetitive musculoskeletal bleeding episodes. Selective embolization of the knee and elbow arteries can prevent bleeding episodes. To evaluate the long-term efficacy of these procedures, we assessed the outcomes of 30 procedures performed in our center.MethodsWe performed 30 procedures in 27 hemophilic patients, including 23 knee, and 7 elbow procedures. To evaluate the efficacy of selective embolization of knee and elbow arteries in people with hemophilia, we analyzed the number of bleeding episodes during 12 months before the procedure compared with the amount ofmore » episodes that occurred 3, 6, and 12 months after embolization.ResultsTwenty-nine of 30 procedures were classified as successful. The median of 1.25 episodes per month (range 0-3) observed before the procedure was reduced to 0 (range 0-1.67; p < 0.001) at 3 months, 0.17 (range 0-1.67; p < 0.001) at 6 months, and 0.33 (range 0-1.67; p = 0.024) at 12 months. Three patients remained free of bleeding events for more than 6 months. Additionally, after the procedure there was a significant reduction in factor FVIII usage that sustained up to 12 months after the procedures. No serious adverse events were observed.ConclusionsSelective angiographic embolization of knee and elbow arteries is a feasible procedure that can prevent repetitive bleedings, which would translate in better joint outcomes for these patients.« less

Defining the rectal dose constraint for permanent radioactive seed implantation of the prostate.

PubMed

Albert, Michele; Song, Jun S; Schultz, Delray; Cormack, Robert A; Tempany, Clare M; Haker, Steve; Devlin, Phillip M; Beard, Clair; Hurwitz, Mark D; Suh, Wonsuk W; Jolesz, Ferenc; D'Amico, Anthony V

2008-01-01

This study was performed to define the rectal dose constraint that would predict late rectal bleeding requiring argon plasma coagulation (APC) following prostate brachy mono-therapy. Between February 1999 and April 2002, 91 patients with low risk prostate cancer underwent permanent I(125) radioactive seed implantation without the use of supplemental external beam radiation or androgen suppression therapy. Patients received both CT and MRI scans 6 weeks postimplant for evaluation of dosimetry. The CT and MRI scans were fused. Rectal volumes were contoured on the T2 weighted MR images. For those patients requiring APC, the date on which a patient reported rectal bleeding was recorded. A Cox regression analysis was performed to assess whether there was a significant association between the rectal volume (continuous) exceeding 100 Gy time rectal bleeding. Comparisons of estimates of rectal bleeding requiring APC were made using a 2-sided log rank test. There was a significant association (hazard ratio = 5.6 [95% confidence interval: 1.3, 23.8]; P = 0.002) between the rectal volume exceeding 100 Gy and rectal bleeding requiring APC. After a median follow-up of 4.25 (1-6) years, no patient with less than a median value of 8 cc of rectum exceeding 100 Gy required APC, whereas 20% (P = 0.004) were estimated to require APC within 3 years following treatment. Keeping the rectal volume receiving more than 100 Gy below 8 cc will minimize the risk of rectal bleeding requiring APC following I(125) permanent prostate brachy mono-therapy.

Predictors of in-hospital mortality in a cohort of elderly Egyptian patients with acute upper gastrointestinal bleeding.

PubMed

Elsebaey, Mohamed A; Elashry, Heba; Elbedewy, Tamer A; Elhadidy, Ahmed A; Esheba, Noha E; Ezat, Sherif; Negm, Manal Saad; Abo-Amer, Yousry Esam-Eldin; Abgeegy, Mohamed El; Elsergany, Heba Fadl; Mansour, Loai; Abd-Elsalam, Sherief

2018-04-01

Acute upper gastrointestinal bleeding (UGIB) affects large number of elderly with high rates of morbidity and mortality. Early identification and management of the factors predicting in-hospital mortality might decrease mortality. This study was conducted to identify the causes of acute UGIB and the predictors of in-hospital mortality in elderly Egyptian patients.286 elderly patients with acute UGIB were divided into: bleeding variceal group (161 patients) and bleeding nonvariceal group (125 patients). Patients' monitoring was done during hospitalization to identify the risk factors that might predict in-hospital mortality in elderly.Variceal bleeding was the most common cause of acute UGIB in elderly Egyptian patients. In-hospital mortality rate was 8.74%. Increasing age, hemodynamic instability at presentation, co-morbidities (especially liver cirrhosis associated with other co-morbidity) and failure to control bleeding were the predictors of in-hospital mortality.Increasing age, hemodynamic instability at presentation, co-morbidities (especially liver cirrhosis associated with other co-morbidity) and failure to control bleeding should be considered when triaging those patients for immediate resuscitation, close observation, and early treatment.

Endoscopic variceal ligation for primary prophylaxis of esophageal variceal hemorrhage in pre-liver transplant patients.

PubMed

Lim, Eu Jin; Gow, Paul J; Angus, Peter W

2009-11-01

Endoscopic variceal ligation (EVL) is widely used to prevent esophageal variceal bleeding in patients with advanced cirrhosis. However, the safety and efficacy of EVL in this setting have not been clearly established. This study included 300 adult patients with cirrhosis on our liver transplant waitlist who underwent upper gastrointestinal endoscopy. Esophageal varices deemed to be at high risk of bleeding were banded until eradication or transplantation. A retrospective review of patient notes and endoscopy databases was undertaken, and the number of banding episodes, complications, and patient outcomes were recorded. Forty-two of 300 patients presented with or had previous variceal bleeding prior to referral and were excluded from the analysis. Of the remaining 258 patients, 101 underwent a total of 259 banding episodes (2.6 per patient) with a median follow-up post-banding of 18.4 months per patient (a total of 150 patient years). Failed prophylaxis occurred in 2 patients (2%), and there were 3 episodes (1.2%) of acute hematemesis from band-induced ulceration. One patient (1%) had mild esophageal stricturing post-banding without dysphagia. Four of 36 patients (11%) previously found to have moderately sized or larger varices that were not banded presented with hematemesis due to variceal bleeding and were subsequently banded. None of the patients that received banding died because of bleeding or failed to receive a transplant as a result of banding complications. This study shows that in liver transplant candidates, EVL is highly effective in preventing first variceal bleed. Although banding carries a small risk of band-induced bleeding, this rate is low in comparison with the predicted rate of variceal bleeding in this population.

Dual nozzle aerodynamic and cooling analysis study

NASA Technical Reports Server (NTRS)

Meagher, G. M.

1981-01-01

Analytical models to predict performance and operating characteristics of dual nozzle concepts were developed and improved. Aerodynamic models are available to define flow characteristics and bleed requirements for both the dual throat and dual expander concepts. Advanced analytical techniques were utilized to provide quantitative estimates of the bleed flow, boundary layer, and shock effects within dual nozzle engines. Thermal analyses were performed to define cooling requirements for baseline configurations, and special studies of unique dual nozzle cooling problems defined feasible means of achieving adequate cooling.

Immunosuppressive agents are associated with peptic ulcer bleeding.

PubMed

Tomizawa, Minoru; Shinozaki, Fuminobu; Hasegawa, Rumiko; Shirai, Yoshinori; Motoyoshi, Yasufumi; Sugiyama, Takao; Yamamoto, Shigenori; Ishige, Naoki

2017-05-01

Peptic ulcer bleeding can be fatal. Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids and immunosuppressive agents are administered for long-term usage. The present study assessed the association between peptic ulcer bleeding and administration of NSAIDs, corticosteroids and immunosuppressive agents. Furthermore, the efficacy of lowering the risk of peptic ulcer bleeding with proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) was evaluated. Medical records were retrospectively analyzed for patients subjected to an upper gastrointestinal (GI) endoscopy performed at the National Hospital Organization Shimoshizu Hospital (Yotsukaido, Japan) from October 2014 to September 2015. During this period, a total of 1,023 patients underwent an upper GI endoscopy. A total of 1,023 patients, including 431 males (age, 68.1±12.9 years) and 592 females (age, 66.4±12.3 years), who had been administered NSAIDs, corticosteroids, immunosuppressive agents, PPIs and H2RAs, were respectively enrolled. Endoscopic findings of the patients were reviewed and their data were statistically analyzed. Logistic regression analysis was used to determine the odds ratio of peptic ulcer bleeding for each medication; immunosuppressive agents had an odds ratio of 5.83, which was larger than that for NSAIDs (4.77). The Wald test was applied to confirm the correlation between immunosuppressive agents and peptic ulcer bleeding. Furthermore, χ 2 tests were applied to the correlation between peptic ulcer bleeding and administration of PPIs or H2RAs. Immunosuppressive agents had the largest χ 2 , and the P-value was 0.03. Administration of PPIs was significantly correlated with non-peptic ulcer bleeding (P=0.02); furthermore, a tendency toward non-peptic ulcer bleeding with administration of H2RA was indicated, but it was not statistically significant (P=0.12). In conclusion, immunosuppressive agents were correlated with peptic ulcer bleeding and PPIs were effective at lowering the risk of peptic ulcer bleeding.

Immunosuppressive agents are associated with peptic ulcer bleeding

PubMed Central

Tomizawa, Minoru; Shinozaki, Fuminobu; Hasegawa, Rumiko; Shirai, Yoshinori; Motoyoshi, Yasufumi; Sugiyama, Takao; Yamamoto, Shigenori; Ishige, Naoki

2017-01-01

Peptic ulcer bleeding can be fatal. Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids and immunosuppressive agents are administered for long-term usage. The present study assessed the association between peptic ulcer bleeding and administration of NSAIDs, corticosteroids and immunosuppressive agents. Furthermore, the efficacy of lowering the risk of peptic ulcer bleeding with proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) was evaluated. Medical records were retrospectively analyzed for patients subjected to an upper gastrointestinal (GI) endoscopy performed at the National Hospital Organization Shimoshizu Hospital (Yotsukaido, Japan) from October 2014 to September 2015. During this period, a total of 1,023 patients underwent an upper GI endoscopy. A total of 1,023 patients, including 431 males (age, 68.1±12.9 years) and 592 females (age, 66.4±12.3 years), who had been administered NSAIDs, corticosteroids, immunosuppressive agents, PPIs and H2RAs, were respectively enrolled. Endoscopic findings of the patients were reviewed and their data were statistically analyzed. Logistic regression analysis was used to determine the odds ratio of peptic ulcer bleeding for each medication; immunosuppressive agents had an odds ratio of 5.83, which was larger than that for NSAIDs (4.77). The Wald test was applied to confirm the correlation between immunosuppressive agents and peptic ulcer bleeding. Furthermore, χ2 tests were applied to the correlation between peptic ulcer bleeding and administration of PPIs or H2RAs. Immunosuppressive agents had the largest χ2, and the P-value was 0.03. Administration of PPIs was significantly correlated with non-peptic ulcer bleeding (P=0.02); furthermore, a tendency toward non-peptic ulcer bleeding with administration of H2RA was indicated, but it was not statistically significant (P=0.12). In conclusion, immunosuppressive agents were correlated with peptic ulcer bleeding and PPIs were effective at lowering the risk of peptic ulcer bleeding. PMID:28565788

Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants.

PubMed

Lanas, Ángel; Carrera-Lasfuentes, Patricia; Arguedas, Yolanda; García, Santiago; Bujanda, Luis; Calvet, Xavier; Ponce, Julio; Perez-Aísa, Ángeles; Castro, Manuel; Muñoz, Maria; Sostres, Carlos; García-Rodríguez, Luis A

2015-05-01

Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose aspirin is associated with increased risk of upper gastrointestinal bleeding. There is little evidence on the risk of lower gastrointestinal bleeding with NSAIDs, antiplatelet agents (APAs), or anticoagulants. We aimed to quantify the relative risk (RR) of upper and lower gastrointestinal bleeding associated with use of NSAIDs, APAs, or anticoagulants. We performed a case-control study that used data collected from consecutive patients hospitalized for gastrointestinal bleeding (563 upper, mean age, 63.6 ± 16.7 years and 415 lower, mean age, 70.8 ± 13.8 years), confirmed by endoscopy or other diagnostic procedures. Unhospitalized patients were used as controls (n = 1008) and matched for age, hospital, and month of admission. Drug use was considered current when taken within 7 days or less before hospitalization. RRs and 95% confidence intervals (CIs) were estimated by unconditional logistic regression analysis. Use of anticoagulants, low-dose aspirin, and other drugs (non-aspirin-APA, 82.3% thienopiridines) was associated with upper and lower gastrointestinal bleeding; the risk was 2-fold higher for anticoagulants (RR, 4.2; 95% CI, 2.9-6.2) than for low-dose aspirin (RR, 2.1; 95% CI, 1.4-3.3) or other non-aspirin-APA drugs (RR, 2.0; 95% CI, 1.6-2.6). NSAID use was also associated with increased risk of gastrointestinal bleeding and greater for upper (RR, 2.6; 95% CI, 2.0-3.5) than lower gastrointestinal bleeding (RR, 1.4; 95% CI, 1.0-1.9). Use of proton pump inhibitors was associated with reduced risk of upper, but not lower, gastrointestinal bleeding. Anticoagulants, low-dose aspirin, NSAIDs, and other non-aspirin-APA drugs are associated with increased risk of upper and lower gastrointestinal bleeding. Use of anticoagulants appears to be the strongest risk factor for gastrointestinal bleeding. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.

Effectiveness of therapeutic barium enema for diverticular hemorrhage

PubMed Central

Matsuura, Mizue; Inamori, Masahiko; Nakajima, Atsushi; Komiya, Yasuhiko; Inoh, Yumi; Kawasima, Keigo; Naitoh, Mai; Fujita, Yuji; Eduka, Akiko; Kanazawa, Noriyoshi; Uchiyama, Shiori; Tani, Rie; Kawana, Kennichi; Ohtani, Setsuya; Nagase, Hajime

2015-01-01

AIM: To evaluate the effectiveness of barium impaction therapy for patients with colonic diverticular bleeding. METHODS: We reviewed the clinical charts of patients in whom therapeutic barium enema was performed for the control of diverticular bleeding between August 2010 and March 2012 at Yokohama Rosai Hospital. Twenty patients were included in the review, consisting of 14 men and 6 women. The median age of the patients was 73.5 years. The duration of the follow-up period ranged from 1 to 19 mo (median: 9.8 mo). Among the 20 patients were 11 patients who required the procedure for re-bleeding during hospitalization, 6 patients who required it for re-bleeding that developed after the patient left the hospital, and 3 patients who required the procedure for the prevention of re-bleeding. Barium (concentration: 150 w%/v%) was administered per the rectum, and the leading edge of the contrast medium was followed up to the cecum by fluoroscopy. After confirmation that the ascending colon and cecum were filled with barium, the enema tube was withdrawn, and the patient’s position was changed every 20 min for 3 h. RESULTS: Twelve patients remained free of re-bleeding during the follow-up period (range: 1-19 mo) after the therapeutic barium enema, including 9 men and 3 women with a median age of 72.0 years. Re-bleeding occurred in 8 patients including 5 men and 3 women with a median age of 68.5 years: 4 developed early re-bleeding, defined as re-bleeding that occurs within one week after the procedure, and the remaining 4 developed late re-bleeding. The DFI (disease-free interval) decreased 0.4 for 12 mo. Only one patient developed a complication from therapeutic barium enema (colonic perforation). CONCLUSION: Therapeutic barium enema is effective for the control of diverticular hemorrhage in cases where the active bleeding site cannot be identified by colonoscopy. PMID:25987779

Protons pump inhibitor treatment and lower gastrointestinal bleeding: Balancing risks and benefits.

PubMed

Lué, Alberto; Lanas, Angel

2016-12-28

Proton pump inhibitors (PPIs) represent a milestone in the treatment of acid-related diseases, and are the mainstay in preventing upper gastrointestinal bleeding in high-risk patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose aspirin. However, this beneficial effect does not extend to the lower gastrointestinal tract. PPIs do not prevent NSAID or aspirin-associated lower gastrointestinal bleeding (LGB). PPIs may increase both small bowel injury related to NSAIDs and low-dose aspirin treatment and the risk of LGB. Recent studies suggested that altering intestinal microbiota by PPIs may be involved in the pathogenesis of NSAID-enteropathy. An increase in LGB hospitalization rates may occur more frequently in older patients with more comorbidities and are associated with high hospital resource utilization, longer hospitalization, and increased mortality. Preventive strategies for NSAID and aspirin-associated gastrointestinal bleeding should be directed toward preventing both upper and lower gastrointestinal damage. Future research should be directed toward identifying patients at low-risk for gastrointestinal events associated with the use of NSAIDs or aspirin to avoid inappropriate PPI prescribing. Alternatively, the efficacy of new pharmacologic strategies should be evaluated in high-risk groups, with the aim of reducing the risk of both upper and lower gastrointestinal bleeding in these patients.

Optimization of solar cells for air mass zero operation and a study of solar cells at high temperatures, phase 2

NASA Technical Reports Server (NTRS)

Hovel, H.; Woodall, J. M.

1976-01-01

Crystal growth procedures, fabrication techniques, and theoretical analysis were developed in order to make GaAlAs-GaAs solar cell structures which exhibit high performance at air mass 0 illumination and high temperature conditions.

Inlet-engine matching for SCAR including application of a bicone variable geometry inlet

NASA Technical Reports Server (NTRS)

Wasserbauer, J. F.; Gerstenmaier, W. H.

1978-01-01

Airflow characteristics of variable cycle engines (VCE) designed for Mach 2.32 can have transonic airflow requirements as high as 1.6 times the cruise airflow. This is a formidable requirement for conventional, high performance, axisymmetric, translating centerbody mixed compression inlets. An alternate inlet is defined, where the second cone of a two cone center body collapses to the initial cone angle to provide a large off-design airflow capability, and incorporates modest centerbody translation to minimize spillage drag. Estimates of transonic spillage drag are competitive with those of conventional translating centerbody inlets. The inlet's cruise performance exhibits very low bleed requirements with good recovery and high angle of attack capability.

Recombinant activated factor VII in the treatment of bleeds and for the prevention of surgery-related bleeding in congenital haemophilia with inhibitors.

PubMed

Santagostino, Elena; Escobar, Miguel; Ozelo, Margareth; Solimeno, Luigi; Arkhammar, Per; Lee, Hye Youn; Rosu, Gabriela; Giangrande, Paul

2015-06-01

The availability of recombinant activated factor VII (rFVIIa, eptacog alfa activated) has greatly advanced the care of patients with haemophilia A or B who have developed inhibitors against the infused replacement factor. Recombinant FVIIa is licensed for the on-demand treatment of bleeding episodes and the prevention of bleeding in surgery or invasive procedures in patients with congenital haemophilia with inhibitors. This article attempts to review in detail the extensive evidence of rFVIIa in congenital haemophilia patients with inhibitors. Patients with acute bleeding episodes are best treated on demand at home, to achieve the short- and long-term benefits of rapid bleed control. Key prospective studies have shown that rFVIIa achieves consistently high efficacy rates in the management of acute (including joint) bleeds in inhibitor patients in the home treatment setting. Substantial post-approval data from key registries also support the on-demand efficacy profile of rFVIIa established by the prospective clinical trials. The availability of rFVIIa has allowed major surgery to become a reality for inhibitor patients. Studies in key surgery, including orthopaedic procedures, have found that rFVIIa provides consistently high efficacy rates. Importantly, the wealth of data does not raise any unexpected safety concerns surrounding rFVIIa use; this is likely because rFVIIa is a recombinant product with a localised mechanism of action at the site of vascular injury. In summary, rFVIIa is established as an effective and well-tolerated first-line treatment for on-demand bleeding control and bleed prevention during minor and major (including elective orthopaedic) surgery in inhibitor patients. Use of rFVIIa has been a major step towards narrowing the gap in outcomes between inhibitor patients and non-inhibitor patients. Copyright © 2015 Elsevier Ltd. All rights reserved.

Evaluation of nasogastric tubes to enable differentiation between upper and lower gastrointestinal bleeding in unselected patients with melena.

PubMed

Kessel, Boris; Olsha, Oded; Younis, Aurwa; Daskal, Yaakov; Granovsky, Emil; Alfici, Ricardo

2016-02-01

Gastrointestinal (GI) bleeding is a common surgical problem. The aim of this study was to evaluate how insertion of the nasogastric tube may enable differentiation between upper and lower GI bleeding in patients with melena. A retrospective study involving patients admitted to our surgery division with a melena was carried out between the years 2010 and 2012. A total of 386 patients were included in the study. Of these, 279 (72.2%) patients had negative nasogastric aspirate. The sensitivity of examination of nasogastric aspirate to establish the upper GI as the source of bleeding was only 28% and the negative predictive value of a negative nasogastric aspirate was less than 1%. Most patients who initially presented with melena and were found to have upper GI bleeding had a negative nasogastric aspirate. Insertion of a nasogastric tube does not affect the clinical decision to perform upper endoscopy and should not be routinely carried out.

Upper Gastrointestinal Bleeding in Chinese Children: A Multicenter 10-Year Retrospective Study.

PubMed

Yu, Yi; Wang, Baoxiang; Yuan, Lan; Yang, Hui; Wang, Xinqiong; Xiao, Yuan; Mei, Hong; Xu, Chundi

2016-08-01

Objective This study aims to analyze the clinical and endoscopic presentations of upper gastrointestinal bleeding (UGIB) in the Chinese children. Methods A 10-year retrospective study was made on children with UGIB and undertaken esophagogastroduodenoscopy (EGD) from 4 tertiary referral centers in China. Results Of the 1218 children studied, the bleeding source was found in 76.4%. Erosive gastritis was the most common endoscopic finding (33.5%), followed by duodenal ulcer (23.2%). The proportion of erosive gastritis decreased with age (correlation coefficient = -0.787), and duodenal ulcer increased with age (correlation coefficient = 0.958). The bleeding source was more likely to be determined in children having EGDs within 48 hours (80.6% vs 67.9%). Conclusions In Chinese children with UGIB, erosive gastritis and duodenal ulcer were the leading causes, and their proportions varied with age. EGDs performed within 48 hours may improve the possibility of finding the source of bleeding. © The Author(s) 2015.

Emergency arterial embolization of upper gastrointestinal and jejunal tumors: An analysis of 12 patients with severe bleeding.

PubMed

Zandrino, F; Tettoni, S M; Gallesio, I; Summa, M

2017-01-01

The goal of this study was to retrospectively assess the efficacy of emergency percutaneous transcatheter arterial embolization in patients with severe bleeding due to upper gastrointestinal or jejunal tumor. Twelve patients (7 men, 5 women; mean age, 74 years±14 (SD); range: 54-86 years) with severe bleeding from the upper gastrointestinal tract, with failed endoscopic treatment not eligible for emergency surgery were treated by emergency percutaneous transcatheter arterial embolization. The bleeding cause was gastric tumor in 7 patients, duodenal tumor in 4 patients and jejunal tumor in one patient. Procedure details and follow-up were reviewed. Twelve embolization procedures were performed using various embolic agents. Embolization was achieved and bleeding was stopped in all patients. Five patients underwent surgery within the 30 days following embolization. In the remaining 7 patients, no bleeding occurred at 1 month follow-up in 6 patients and bleeding recurred in one patient at 1 month. In this later patient, endoscopic treatment was successful. The results of our study suggest that transcatheter arterial embolization is safe and effective in patients with severe arterial bleeding due to upper gastrointestinal or jejunal tumor. In some patients, transcatheter arterial embolization can be used as a bridge to surgery. Copyright © 2016 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Haemostasis in Oral Surgery with Blue-Violet Light.

PubMed

Veleska-Stevkoska, Daniela; Koneski, Filip

2018-04-15

The invasive dental procedures usually result in wounds accompanied by physiological bleeding. Even though the bleeding is easily manageable, it is still one of the major concerns of the patients and a reason for their subjective discomfort. Recently, a novel approach with light-emitting diode (LED) was introduced to control the bleeding. This study aims to examine the effectiveness of the irradiation with blue-violet light LEDs on the haemostasis. The study included 40 patients with an indication for tooth extraction, divided into two groups: examination group (n = 30) and a control group (n = 10). The site of the extraction socket in the examination group was irradiated with LED (410 nm) until the bleeding stopped. The patients from the control group were treated by conventional gauze pressure to stop the bleeding (control group). The duration of irradiation and gauze pressure was measured and compared. The statistical analysis was performed with Student T-test. The examination group showed the shorter duration of bleeding compared to the control group for 13.67 seconds and 156 seconds, respectively. The most of the cases in the examination group were irradiated in 10 seconds (70%), followed by irradiation of 20 seconds (23.3%) and 30 seconds (6.6%). In the control group, the average time to stop the bleeding by the conventional method was 156 second. The blue-violet LED light shortens the bleeding time from the extraction socket after tooth extraction and may be a promising method for achieving haemostasis.

Pooled analysis of two randomized, open-label studies comparing the effects of nomegestrol acetate/17β-estradiol and drospirenone/ethinyl estradiol on bleeding patterns in healthy women.

PubMed

Mansour, Diana; Westhoff, Carolyn; Kher, Uma; Korver, Tjeerd

2017-04-01

To obtain more precise and detailed information regarding the bleeding patterns of nomegestrol acetate (NOMAC)/17β-estradiol (E2) and drospirenone/ethinyl estradiol (DRSP/EE) and to identify whether baseline demographic characteristics were associated with unscheduled bleeding, absent scheduled bleeding, or amenorrhea. This analysis pooled results from two pivotal open-label, randomized trials that compared bleeding patterns of NOMAC/E2 and DRSP/EE. In the two studies 4317 women aged 18-50 years from 24 countries across the Americas, Europe, and Asia underwent treatment. 2835 women taking NOMAC/E2 (2.5 mg/1.5 mg) in a 24/4-day regimen and 938 women taking DRSP/EE (3 mg/30 μg) in a 21/7-day regimen had at least 1 evaluable cycle for vaginal bleeding analyses. The frequency of absent scheduled bleeding was higher (p<.0001) for women using NOMAC/E2 than DRSP/EE across all 11 cycles (cycles 2-12), ranging between 17.6% and 31.6% and between 3.4% and 5.8%, respectively. For women who had absent scheduled bleeding in cycles 2, 3, or 4 the incidence of absent scheduled bleeding in subsequent cycles was high and ranged between approximately 50%-60% for NOMAC/E2 and approximately 40%-50% for DRSP/EE. Amenorrhea increased over time with both regimens, being higher with NOMAC/E2. Both absent scheduled bleeding and amenorrhea with NOMAC/E2 were more common in older women, overweight women, switchers, and smokers; unscheduled bleeding was more common in starters, but had no association with age, body mass index, and smoking. NOMAC/E2 is associated with a higher prevalence of absent scheduled bleeding compared with DRSP/EE. Absent scheduled bleeding and amenorrhea were associated with age, body weight, switching and smoking. Unscheduled bleeding was more common in starters. Information about the factors associated with bleeding patterns may help clinicians provide guidance to women considering use of the NOMAC/E2 oral contraceptive. Copyright © 2016 Elsevier Inc. All rights reserved.

Three axis electronic flight motion simulator real time control system design and implementation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gao, Zhiyuan; Miao, Zhonghua, E-mail: zhonghua-miao@163.com; Wang, Xiaohua

2014-12-15

A three axis electronic flight motion simulator is reported in this paper including the modelling, the controller design as well as the hardware implementation. This flight motion simulator could be used for inertial navigation test and high precision inertial navigation system with good dynamic and static performances. A real time control system is designed, several control system implementation problems were solved including time unification with parallel port interrupt, high speed finding-zero method of rotary inductosyn, zero-crossing management with continuous rotary, etc. Tests were carried out to show the effectiveness of the proposed real time control system.

Zero Gyro Kalman Filtering in the presence of a Reaction Wheel Failure

NASA Technical Reports Server (NTRS)

Hur-Diaz, Sun; Wirzburger, John; Smith, Dan; Myslinski, Mike

2007-01-01

Typical implementation of Kalman filters for spacecraft attitude estimation involves the use of gyros for three-axis rate measurements. When there are less than three axes of information available, the accuracy of the Kalman filter depends highly on the accuracy of the dynamics model. This is particularly significant during the transient period when a reaction wheel with a high momentum fails, is taken off-line, and spins down. This paper looks at how a reaction wheel failure can affect the zero-gyro Kalman filter performance for the Hubble Space Telescope and what steps are taken to minimize its impact.

Zero Gyro Kalman Filtering in the Presence of a Reaction Wheel Failure

NASA Technical Reports Server (NTRS)

Hur-Diaz, Sun; Wirzburger, John; Smith, Dan; Myslinski, Mike

2007-01-01

Typical implementation of Kalman filters for spacecraft attitude estimation involves the use of gyros for three-axis rate measurements. When there are less than three axes of information available, the accuracy of the Kalman filter depends highly on the accuracy of the dynamics model. This is particularly significant during the transient period when a reaction wheel with a high momentum fails, is taken off-line, and spins down. This paper looks at how a reaction wheel failure can affect the zero-gyro Kalman filter performance for the Hubble Space Telescope and what steps are taken to minimize its impact.

The 77 K operation of a multi-resonant power converter

NASA Technical Reports Server (NTRS)

Ray, Biswajit; Gerber, Scott S.; Patterson, Richard L.; Myers, Ira T.

1995-01-01

The liquid-nitrogen temperature (77 K) operation of a 55 W, 200 kHz, 48/28 V zero-voltage switching multi-resonant dc/dc converter designed with commercially available components is reported. Upon dipping the complete converter (power and control circuits) into liquid-nitrogen, the converter performance improved as compared to the room-temperature operation. The switching frequency, resonant frequency, and the characteristic impedance did not change significantly. Accordingly, the zero-voltage switching was maintained from no-load to full-load for the specified line variations. Cryoelectronics can provide high density power converters, especially for high power applications.

Stable long-time semiclassical description of zero-point energy in high-dimensional molecular systems.

PubMed

Garashchuk, Sophya; Rassolov, Vitaly A

2008-07-14

Semiclassical implementation of the quantum trajectory formalism [J. Chem. Phys. 120, 1181 (2004)] is further developed to give a stable long-time description of zero-point energy in anharmonic systems of high dimensionality. The method is based on a numerically cheap linearized quantum force approach; stabilizing terms compensating for the linearization errors are added into the time-evolution equations for the classical and nonclassical components of the momentum operator. The wave function normalization and energy are rigorously conserved. Numerical tests are performed for model systems of up to 40 degrees of freedom.

Three axis electronic flight motion simulator real time control system design and implementation.

PubMed

Gao, Zhiyuan; Miao, Zhonghua; Wang, Xuyong; Wang, Xiaohua

2014-12-01

A three axis electronic flight motion simulator is reported in this paper including the modelling, the controller design as well as the hardware implementation. This flight motion simulator could be used for inertial navigation test and high precision inertial navigation system with good dynamic and static performances. A real time control system is designed, several control system implementation problems were solved including time unification with parallel port interrupt, high speed finding-zero method of rotary inductosyn, zero-crossing management with continuous rotary, etc. Tests were carried out to show the effectiveness of the proposed real time control system.

Robotic right colectomy for hemorrhagic right colon cancer: a case report and review of the literature of minimally invasive urgent colectomy.

PubMed

Felli, Emanuele; Brunetti, Francesco; Disabato, Mara; Salloum, Chady; Azoulay, Daniel; De'angelis, Nicola

2014-01-01

Right colon cancer rarely presents as an emergency, in which bowel occlusion and massive bleeding are the most common clinical presentations. Although there are no definite guidelines, the first line treatment for massive right colon cancer bleeding should ideally stop the bleeding using endoscopy or interventional radiology, subsequently allowing proper tumor staging and planning of a definite treatment strategy. Minimally invasive approaches for right and left colectomy have progressively increased and are widely performed in elective settings, with laparoscopy chosen in the majority of cases. Conversely, in emergent and urgent surgeries, minimally invasive techniques are rarely performed. We report a case of an 86-year-old woman who was successfully treated for massive rectal bleeding in an urgent setting by robotic surgery (da Vinci Intuitive Surgical System®). At admission, the patient had severe anemia (Hb 6 g/dL) and hemodynamic stability. A computer tomography scanner with contrast enhancement showed a right colon cancer with active bleeding; no distant metastases were found. A colonoscopy did not show any other bowel lesion, while a constant bleeding from the right pre-stenotic colon mass was temporarily arrested by endoscopic argon coagulation. A robotic right colectomy in urgent setting (within 24 hours from admission) was indicated. A three-armed robot was used with docking in the right side of the patient and a fourth trocar for the assistant surgeon. Because of the patient's poor nutritional status, a double-barreled ileocolostomy was performed. The post-operative period was uneventful. As the neoplasia was a pT3N0 adenocarcinoma, surveillance was decided after a multidisciplinary meeting, and restoration of the intestinal continuity was performed 3 months later, once good nutritional status was achieved. In addition, we reviewed the current literature on minimally invasive colectomy performed for colon carcinoma in emergent or urgent setting. No study on robotic approach was found. Seven studies evaluating the role of laparoscopic colectomy concluded that this technique is a safe and feasible option associated with lower blood loss and shorter hospital stay. It may require longer operative time, but morbidity and mortality rates appeared comparable to open colectomy. However, the surgeon's experience and the right selection of candidate patients cannot be understated.

Relative threshold of detection of active arterial bleeding: in vitro comparison of MDCT and digital subtraction angiography.

PubMed

Roy-Choudhury, Shuvro H; Gallacher, David J; Pilmer, John; Rankin, Sheila; Fowler, Geoff; Steers, Jeff; Dourado, Renato; Woodburn, Paul; Adam, Andreas

2007-11-01

The objective of our study was to determine the relative sensitivity and the lowest threshold of bleeding detectable with digital subtraction angiography (DSA) and with MDCT using an in vitro physiologic system. A closed pulsatile cardiopulmonary bypass circuit was connected to tubes traversing a water bath to simulate the abdominal aorta and inferior vena cava. Three smaller interconnecting acrylic plastic tubes were connected as branches to the aortic tubing to simulate branch vessels. One of the three tubes, the control, had no holes in it, one had a 100-microm hole, and one had a 280-microm hole. The leakage rates were predetermined with a cardiac output of 2 and 4 L/min and with a mean arterial pressure (MAP) ranging from 30 to 100 mm Hg for each hole size. The following studies were performed for each of the predetermined leakage rates. For study 1, 16-MDCT was performed using bolus tracking after 35 mL of contrast medium had been injected into a simulated peripheral vein. For study 2, DSA was performed using a 4-French straight catheter placed 10 cm proximal to the holes (selective first aortic branch cannulation). For study 3, DSA was performed with a catheter placed in the small branch at the site of the hole (highly superselective). For study 4, 16-MDCT was performed with a catheter placed as in study 2, 10 cm proximal to the holes, for the detection of lower leakage rates. Cine loops of MDCT and DSA images were examined by two blinded observers to detect extravasation from the holes in the tubes (i.e., the branch arteries). Interobserver agreement was studied using Cohen's kappa statistic. The threshold to detect bleeding was as follows for each study: For IV contrast-enhanced MDCT (study 1), it was 0.35 mL/min; DSA with a catheter 10 cm proximal to the holes (study 2), 0.96 mL/min; DSA with a catheter at the holes (study 3), 0.05 mL/min [corrected] or lower; and intraarterial selective MDCT (study 4), 0.05 mL/min [corrected] or lower. The ease of detection improved with increasing MAPs and larger volumes of leakage. Interobserver correlation was excellent. In vitro, i.v. contrast-enhanced MDCT is more sensitive than first-order aortic branch-selective DSA in detecting active hemorrhage unless the catheter position is highly superselective and is close to the bleeding artery. These results suggest that MDCT can be used as the initial imaging technique in the diagnosis of active hemorrhage if the clinical condition of the patient allows.

Minimizing the Risk of Infection and Bleeding at Trans-Vaginal Ultrasound-Guided Ovum Pick-up: Results of a Prospective Web-Based World-Wide Survey.

PubMed

Bhandari, Harish; Agrawal, Rina; Weissman, Ariel; Shoham, Gon; Leong, Milton; Shoham, Zeev

2015-12-01

The objective of this study was to identify clinical practices worldwide, which would help in recognizing women at risk of excessive bleeding or of developing pelvic infection following trans-vaginal ovum pick-up (TV-OPU), measures taken to minimize risks and their management. A prospective, web-based questionnaire with distinct questions related to the practice of TV-OPU. A total of 155 units from 55 countries performing 97,200 IVF cycles annually responded to this web-based survey. A majority (65 %) responded that they would routinely carry out full blood count, while 35 % performed coagulation profile. Less than a third agreed screening women for vaginal infections. About a third used both sterile water and antiseptic to minimize ascending infection, and 52 % used antibiotics for prophylaxis. Doppler ultrasound was routinely used by 20 % of clinicians. 73 % of the clinicians preferred conservative management as their first line management for patients diagnosed with intra-abdominal bleeding. The study has identified a wide variation in the practices of minimizing infection and bleeding complications. The dearth of good quality evidence may be responsible for the lack of published guidelines, and therefore a lack of consensus on the optimum practice for minimizing the risk of infection and bleeding during TV-OPU.

[Pleural procedures in patients treated by platelet aggregation inhibitors: An opinion survey].

PubMed

Dangers, L; Similowski, T; Chenivesse, C

2016-01-01

When pleural procedures (thoracocentesis, blind pleural biopsies and chest tube insertion) are required in patients taking long-term platelet aggregation inhibitors, the risk of bleeding must be balanced against the risk of arterial thrombosis. Currently, the bleeding risk of pleural procedures is poorly understood. The objective of the survey was to gather the opinion of respiratory physicians regarding the bleeding risk of pleural procedures in patients taking platelet aggregation inhibitors. We emailed a standardized questionnaire designed by the French National Authority for Health to 2697 French respiratory physicians. One hundred and eighty-eight of the 2697 questionnaires were returned (response rate: 7 %). The respiratory physicians declared that they performed an average of 8 pleural procedures per month. One hundred and seventy-five responders (95 %) practised pleural procedures in patients receiving platelet aggregation inhibitors; 68 of them (39 %) reported experiencing haemorrhagic complications. The bleeding risk associated with thoracentesis and chest tube insertion was considered minor by 97.8 and 65 % of responders respectively, whereas it was considered major for blind pleural biopsies by 73.4 %. Respiratory physicians were more reticent about performing pleural procedures in patients treated with clopidogrel than in those taking aspirin. This study provides an overview of how respiratory physicians perceive the bleeding risk associated with pleural procedures in patients taking platelet aggregation inhibitors. Copyright © 2016 SPLF. Published by Elsevier Masson SAS. All rights reserved.

76 FR 2922 - Notice of Lodging of Consent Decree Under the Clean Air Act

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-18

... in emissions through a requirement to retrofit or replace certain high bleed pneumatic controllers with ``low bleed'' components. The Department of Justice will receive for a period of thirty (30) days...

ENDOSCOPIC DIAGNOSIS AND THERAPY IN GASTRO-ESOPAGEAL VARICEAL BLEEDING

PubMed Central

Sanyal, Arun J.

2016-01-01

Gastroesophageal variceal hemorrhage is a medical emergency with high morbidity and mortality. Endoscopic therapy is the mainstay of management of bleeding varices. It requires attention to technique and the appropriate choice of therapy for a given patient at a given point in time. Subjects must be monitored continuously after initiation of therapy for control of bleeding and second line definitive therapies introduced quickly if endoscopic and pharmacologic treatment fails. PMID:26142034

Laryngeal kaposiform hemangioendothelioma: case report and literature review.

PubMed

Kim, Dong Wook; Chung, Jin Haeng; Ahn, Soon Hyun; Kwon, Tack-Kyun

2010-04-01

The kaposiform hemangioendothelioma (KHE) is an uncommon vascular neoplasm of borderline or intermediate malignant potential in which involvement of the head and neck region is rare. A 5-year-old girl was admitted to the emergency room with abrupt massive hemoptysis. Transoral laryngoscopy revealed a round, reddish mass with active bleeding on the anterior portion of the left vocal fold region. Since re-hemoptysis and large amount of aspiration caused breathing difficulties for the patient, suspension exam was performed under general anesthesia. Mass excision and thorough bleeding control was performed with laser assisted laryngo-micro system. Postoperatively, there was no further bleeding. The pathologic diagnosis of the tumor was KHE. To the best of our knowledge, this is the first report of a KHE in the larynx presenting as recurrent hemoptysis in childhood. Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.

Mesocaval Shunt Creation for Jejunal Variceal Bleeding with Chronic Portal Vein Thrombosis.

PubMed

Yoon, Ja Kyung; Kim, Man Deuk; Lee, Do Yun; Han, Seok Joo

2018-01-01

The creation of transjugular intrahepatic portosystemic shunt (TIPS) is a widely performed technique to relieve portal hypertension, and to manage recurrent variceal bleeding and refractory ascites in patients where medical and/or endoscopic treatments have failed. However, portosystemic shunt creation can be challenging in the presence of chronic portal vein occlusion. In this case report, we describe a minimally invasive endovascular mesocaval shunt creation with transsplenic approach for the management of recurrent variceal bleeding in a portal hypertension patient with intra- and extrahepatic portal vein occlusion. © Copyright: Yonsei University College of Medicine 2018.

Transcatheter arterial embolization of acute gastrointestinal tumor hemorrhage with Onyx.

PubMed

Sun, C J; Wang, C E; Wang, Y H; Xie, L L; Liu, T H; Ren, W C

2015-02-01

Endovascular embolization has been used to control gastrointestinal tumor bleeding. Lots of embolic agents have been applied in embolization, but liquid embolic materials such as Onyx have been rarely used because of concerns about severe ischemic complications. To evaluate the clinical efficacy and safety of transcatheter arterial embolization (TAE) with Onyx for acute gastrointestinal tumor hemorrhage. Between September 2011 and July 2013, nine patients were diagnosed as acute gastrointestinal tumor hemorrhage by clinical feature and imaging examination. The angiographic findings were extravasation of contrast media in the five patients. The site of hemorrhage included upper gastrointestinal bleeding in seven cases and lower gastrointestinal bleeding in two cases. TAE was performed using Onyx in all the patients, and the blood pressure and heart rate were monitored, the angiographic and clinical success rate, recurrent bleeding rate, procedure related complications and clinical outcomes were evaluated after therapy. The clinical parameters and embolization data were studied retrospectively. All the patients (100%) who underwent TAE with Onyx achieved complete hemostasis without rebleeding and the patients were discharged after clinical improvement without a second surgery. No one of the patients expired during the hospital course. All the patients were discharged after clinical improvement without a second surgery. Postembolization bowel ischemia or necrosis was not observed in any of the patients who received TAE with Onyx. TAE with Onyx is a highly effective and safe treatment modality for acute gastrointestinal tumor hemorrhage, even with pre-existing coagulopathy.

Efficacy of the heater probe in peptic ulcer with a non-bleeding visible vessel. A controlled, randomised study.

PubMed Central

Jaramillo, J L; Carmona, C; Gálvez, C; de la Mata, M; Miño, G

1993-01-01

A controlled, randomised study was performed to evaluate the efficacy of treatment with heater probe in the prevention of rebleeding from peptic ulcer with a non-bleeding visible vessel. One hundred and one patients were randomised into two groups: patients to be treated by heater probe (n = 51) and controls without active treatment (n = 50). In the heater probe group rebleeding occurred in five patients (10%) v 13 (26%) in the control group (p = 0.03), with a comparative risk of 0.38 in favour of the heater probe group. The difference in proportions of successful treatment for each group was 16.2% in favour of the heater probe (95% CI = 2 to 31%). Haemorrhage directly related to heater probe treatment occurred in four patients. In three of them bleeding was easily controlled by further heater probe pulses. There were no other complications and no death in the heater probe group. One patient in the control group died of pulmonary embolism. No significant differences in the length of stay in hospital, blood transfusions, surgical rates, or death were found; the design of the study, however, precluded an adequate assessment of these variables, because the heater probe was an optional rescue treatment when high surgical risk patients rebled. These results suggest that the heater probe is an effective and safe procedure in the prevention of recurrent haemorrhage in peptic ulcer with a non-bleeding visible vessel. PMID:8244132

Arterial hemorrhage from cesarean scar: a rare cause of recurring massive uterine bleeding and successful surgical management.

PubMed

Wang, Chun-Feng; Hu, Min

2015-02-01

Abnormal uterine bleeding and other gynecologic complications associated with a previous cesarean section scar are only recently being identified and described. Herein we report a rare case of a woman with recurring massive uterine bleeding after 2 cesarean sections. Curettage and hormone therapy were unsuccessfully used in an attempt to control the bleeding. After she was transferred to our hospital, she had another episode of vaginal bleeding that was successfully managed with oxytocin and hemostatic. Diagnostic hysteroscopy performed under anesthesia revealed an abnormal transected artery in the cesarean section scar with a thrombus visible. In the treatment at the beginning of laparoscopic management, we adopted temporary bilateral uterine artery occlusion with titanium clips to prevent massive hemorrhage. Secondly, with the aid of hysteroscopy, the bleeding site was opened, and then the cesarean scar was wedge resected and stitched interruptedly with 1-0 absorbable sutures. The postoperative recovery was uneventful. It would seem that the worldwide use of cesarean section delivery may contribute to the risk of gynecologic disturbances including some unrecognized and complex conditions as seen in this case. Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.

Monopolar soft-mode coagulation using hemostatic forceps for peptic ulcer bleeding.

PubMed

Yamasaki, Yasushi; Takenaka, Ryuta; Nunoue, Tomokazu; Kono, Yoshiyasu; Takemoto, Koji; Taira, Akihiko; Tsugeno, Hirofumi; Fujiki, Shigeatsu

2014-01-01

Upper gastrointestinal hemorrhage from bleeding peptic ulcer is sometimes difficult to treat by conventional endoscopic methods. Recently, monopolar electrocoagulation using a soft-coagulation system and hemostatic forceps (soft coagulation) has been used to prevent bleeding during endoscopic submucosal dissection. The aim of this study was to assess the safety and efficacy of soft coagulation in the treatment of bleeding peptic ulcer. A total of 39 patients with peptic ulcers were treated using soft coagulation at our hospital between January 2005 and March 2010. Emergency treatment employed an ERBE soft-mode coagulation system using hemostatic forceps. Second-look endoscopy was performed to evaluate the efficacy of prior therapy. Initial hemostasis was defined as accomplished by soft coagulation, with or without other endoscopic therapy prior to soft coagulation. The rate of initial hemostasis, rebleeding, and ultimate hemostasis were retrospectively analyzed. The study subjects were 31 men and 8 women with a mean age of 68.3±13.7 years, with 29 gastric ulcers and 10 duodenal ulcers. Initial hemostasis was achieved in 37 patients (95%). During follow-up, bleeding recurred in two patients, who were retreated with soft coagulation. The monopolar soft coagulation is feasible and safe for treating bleeding peptic ulcers.

Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women

PubMed Central

2012-01-01

Background In 2009 the Uterine Bleeding and Pain Women's Research Study (UBP-WRS) was conducted interviewing 21,479 women across 8 countries in order to gain patient-based prevalence data on uterine pain and bleeding indications and investigate uterine symptoms and women's treatment experiences. This article shows relevant results of the study for the indication uterine fibroids providing data on self-reported prevalence, symptomatology and management of uterine fibroids. Methods 2,500 women (USA: 4,500 women) in each country (Brazil, Canada, France, Germany, Italy, South Korea, the UK, the USA) completed an online survey. Women included were in their reproductive age (age group 15-49 years; USA: 18-49 years) and had ever experienced menstrual bleedings. Quotas were applied for age, region, level of education and household income of respondents. Variables have been analyzed descriptively and exploratory statistical tests have been performed. Results The self-reported prevalence of uterine fibroids ranged from 4.5% (UK) to 9.8% (Italy), reaching 9.4% (UK) to 17.8% (Italy) in the age group of 40-49 years. Women with a diagnosis of uterine fibroids reported significantly more often about bleeding symptoms than women without a diagnosis: heavy bleedings (59.8% vs. 37.4%), prolonged bleedings (37.3% vs. 15.6%), bleeding between periods (33.3% vs. 13.5%), frequent periods (28.4% vs. 15.2%), irregular and predictable periods (36.3% vs. 23.9%). Furthermore women with diagnosed uterine fibroids reported significantly more often about the following pain symptoms: pressure on the bladder (32.6% vs. 15.0%), chronic pelvic pain (14.5% vs. 2.9%), painful sexual intercourse (23.5% vs. 9.1%) and pain occurring mid-cycle, after and during menstrual bleeding (31.3%, 16.7%, 59.7%, vs. 17.1%, 6.4%, 52.0%). 53.7% of women reported that their symptoms had a negative impact on their life in the last 12 month, influencing their sexual life (42.9%), performance at work (27.7%) and relationship & family (27.2%). Conclusions Uterine fibroid is a common concern in women at fertile age causing multiple bleeding and pain symptoms which can have a negative impact on different aspects in women's life. PMID:22448610

Predicting the risk of bleeding during dual antiplatelet therapy after acute coronary syndromes.

PubMed

Alfredsson, Joakim; Neely, Benjamin; Neely, Megan L; Bhatt, Deepak L; Goodman, Shaun G; Tricoci, Pierluigi; Mahaffey, Kenneth W; Cornel, Jan H; White, Harvey D; Fox, Keith Aa; Prabhakaran, Dorairaj; Winters, Kenneth J; Armstrong, Paul W; Ohman, E Magnus; Roe, Matthew T

2017-08-01

Dual antiplatelet therapy (DAPT) with aspirin + a P2Y12 inhibitor is recommended for at least 12 months for patients with acute coronary syndrome (ACS), with shorter durations considered for patients with increased bleeding risk. However, there are no decision support tools available to predict an individual patient's bleeding risk during DAPT treatment in the post-ACS setting. To develop a longitudinal bleeding risk prediction model, we analy sed 9240 patients with unstable angina/non-ST segment elevation myocardial infarction (NSTEMI) from the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial, who were managed without revasculari sation and treated with DAPT for a median of 14.8 months. We identified 10 significant baseline predictors of non-coronary artery bypass grafting (CABG)-related Global Use of Strategies to Open Occluded Arteries (GUSTO) severe/life-threatening/moderate bleeding: age, sex, weight, NSTEMI (vs unstable angina), angiography performed before randomi sation, prior peptic ulcer disease, creatinine, systolic blood pressure, haemoglobin and treatment with beta-blocker. The five significant baseline predictors of Thrombolysis In Myocardial Infarction (TIMI) major or minor bleeding included age, sex, angiography performed before randomi sation, creatinine and haemoglobin. The models showed good predictive accuracy with Therneau's C- indices: 0.78 (SE = 0.024) for the GUSTO model and 0.67 (SE = 0.023) for the TIMI model. Internal validation with bootstrapping gave similar C -indices of 0.77 and 0.65, respectively. External validation demonstrated an attenuated C -index for the GUSTO model (0.69) but not the TIMI model (0.68). Longitudinal bleeding risks during treatment with DAPT in patients with ACS can be reliably predicted using selected baseline characteristics. The TRILOGY ACS bleeding models can inform risk -benefit considerations regarding the duration of DAPT following ACS. ClinicalTrials.gov identifier: https://clinicaltrials.gov/ct2/show/NCT00699998. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Use of Ulipristal Acetate for the Management of Fibroid-Related Acute Abnormal Uterine Bleeding.

PubMed

Arendas, Kristina; Leyland, Nicholas A

2016-01-01

Episodes of acute abnormal uterine bleeding related to uterine fibroids can cause significant morbidity. Traditional management with high-dose hormonal regimens may not be as effective when used in women with fibroids. A 32-year-old woman with a 12 cm uterine fibroid presented with an episode of acute abnormal uterine bleeding requiring blood transfusion. In lieu of using a hormonal maintenance regimen after the bleeding had stabilized, the patient was treated with ulipristal acetate 5 mg daily for three months. Amenorrhea was induced rapidly and the patient had no further episodes of acute excessive uterine bleeding. She subsequently underwent a laparoscopic myomectomy with a satisfactory outcome. Ulipristal acetate has been shown to induce amenorrhea rapidly in women with uterine fibroids, and it can be a useful treatment in the emergency management of fibroid-related acute abnormal uterine bleeding. Copyright © 2016 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.

Effect of Sugammadex on Postoperative Bleeding and Coagulation Parameters After Septoplasty: A Randomized Prospective Study

PubMed Central

Taş, Nilay; Korkmaz, Hakan; Yağan, Özgür; Korkmaz, Mukadder

2015-01-01

Backround Sugammadex is a reversal agent with well known advantages but it’s effects on haemostasis and bleeding have been a topic of interest. Septoplasty is a common surgical procedure with postoperative respiratory complications and bleeding. The aim of this study is to investigate the effects of sugammadex on postoperative coagulation parameters and bleeding after septoplasty procedure. Material/Methods In this randomized controlled study, fifty patients were grouped into two groups; neostigmine (Group N) vs. sugammadex (Group S). For the evaluation of PT, aPTT and INR, blood samples were taken for at the postoperative 120th minutes and alteration of these values with respect to preoperative values were documented. Postoperative bleeding was measured by evaluating the amount of blood absorbed on the nasal tip dressing during 3 hours postoperatively. Results Postoperative bleeding amount was significantly higher in the Group S compared to Group N (p=0.013). No significant difference was observed between two groups according to coagulation parameters (PT; p=0.953, aPTT; p=0.734, INR; p=0.612). Conclusions Sugammadex was associated with higher amount of postoperative bleeding than neostigmine in septoplasty patients. In surgical procedures having high risk of bleeding the safety of sugammadex need to be verified. PMID:26271275

A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study.

PubMed

Ammerman, Stacy R; Nelson, Anita L

2013-06-01

The objective of this investigation was to study short-term efficacy and feasibility of a new progestogen-only treatment for outpatient management of acute abnormal uterine bleeding. This was a prospective, single-arm, pilot clinical trial of a progestogen-only bridging treatment for acute abnormal uterine bleeding in nonpregnant, premenopausal women in the Gynecologic Urgent Care Clinic at Harbor-UCLA Medical Center. Subjects were administered a depo-medroxyprogesterone acetate 150 mg intramuscular injection and given medroxyprogesterone acetate 20 mg to be taken orally every 8 hours for 3 days. The primary outcome measures included a percentage of women who stopped bleeding in 5 days, time to bleeding cessation, reduction in numbers of pads used, side effects, and patient satisfaction. All 48 women stopped bleeding within 5 days; 4 women had spotting only at the time of their last contact during the 5 day follow-up. Mean time to bleeding cessation was 2.6 days. Side effects were infrequent and patient satisfaction was high. Injection of depo-medroxyprogesterone acetate 150 mg intramuscularly combined with 3 days of oral medroxyprogesterone acetate 20 mg every 8 hours for 9 doses is an effective outpatient therapy for acute abnormal uterine bleeding. Copyright © 2013 Mosby, Inc. All rights reserved.

Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study.

PubMed

Müller, Martin; Seufferlein, Thomas; Perkhofer, Lukas; Wagner, Martin; Kleger, Alexander

2015-01-01

Despite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool. We evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis "gastrointestinal bleeding" according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed. The initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients. Self-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).

Health-related quality of life, developmental milestones, and self-esteem in young adults with bleeding disorders.

PubMed

Limperg, P F; Haverman, L; Maurice-Stam, H; Coppens, M; Valk, C; Kruip, M J H A; Eikenboom, J; Peters, M; Grootenhuis, M A

2018-01-01

The treatment of bleeding disorders improved in the last decades. However, the effect of growing up with bleeding disorders on developmental, emotional, and social aspects is understudied. Therefore, this study assesses HRQOL, developmental milestones, and self-esteem in Dutch young adults (YA) with bleeding disorders compared to peers. Ninety-five YA (18-30 years) with bleeding disorders (78 men; mean 24.7 years, SD 3.5) and 17 women (mean 25.1 years, SD 3.8) participated and completed the Pediatric Quality of Life Inventory Young Adult version, the Course of Life Questionnaire, and the Rosenberg Self-Esteem Scale. Differences between patients with bleeding disorders and their peers, and between hemophilia severity groups, were tested using Mann-Whitney U tests. YA men with bleeding disorders report a slightly lower HRQOL on the total scale, physical functioning, and school/work functioning in comparison to healthy peers (small effect sizes). YA men with severe hemophilia report more problems on the physical functioning scale than non-severe hemophilia. YA men with bleeding disorders achieved more psychosexual developmental milestones than peers, but show a delay in 'paid jobs, during middle and/or high school.' A somewhat lower self-esteem was found in YA men with bleeding disorders in comparison to peers (small effect size). For YA women with bleeding disorders, no differences were found on any of the outcomes in comparison to peers. This study demonstrates some impairments in HRQOL and self-esteem in YA men with bleeding disorders. By monitoring HRQOL, problems can be identified early, especially with regard to their physical and professional/school functioning.

Outpatient management of low-risk patients with upper gastrointestinal bleeding: can we safely extend the Glasgow Blatchford Score in clinical practice?

PubMed

Mustafa, Zia; Cameron, Allan; Clark, Elaine; Stanley, Adrian J

2015-05-01

The Glasgow Blatchford Score (GBS) is a validated prognostic score for patients presenting with upper gastrointestinal (GI) bleeding (UGIB). The score predicts the need for therapeutic intervention or death, and studies have suggested that outpatient management is safe for patients with a GBS of zero. Our aim was to assess whether we could safely extend the threshold for outpatient management to patients with GBS≤1. Following assessment of our historical data, our UGIB protocol was changed to recommend outpatient management for patients with a GBS≤1, unless required for other reasons. Data on all patients presenting with UGIB over the following 12 months were prospectively recorded, including GBS and clinical Rockall scores. Adverse outcomes were defined by a 30-day combined endpoint of death, endotherapy, interventional radiology, surgery or transfusion. Negative predictive value (NPV) of GBS≤1 for adverse outcomes in UGIB was calculated. A total of 514 patients presented with UGIB in the 12 month study period. Of the patients, 183 (35.6%) had GBS≤1 (111, GBS=0; 72, GBS=1). Of these, 88 (48.1%) were managed as outpatients, and none had an adverse outcome. Of the 95 (51.9%) patients with GBS≤1 managed as inpatients, 80 (84.2%) had comorbidities requiring inpatient care. Within this admitted group with GBS≤1, one patient required transfusion and one died from a nongastrointestinal malignancy. GBS≤1 had an NPV of 99.45% (95% confidence interval 95.53-99.97%) in predicting adverse outcomes within 30 days. GBS≤1 has a high NPV for adverse outcomes in UGIB. This suggests outpatient management of patients with UGIB and that GBS≤1 is safe in our population.

Blockade of protease-activated receptor-4 (PAR4) provides robust antithrombotic activity with low bleeding.

PubMed

Wong, Pancras C; Seiffert, Dietmar; Bird, J Eileen; Watson, Carol A; Bostwick, Jeffrey S; Giancarli, Mary; Allegretto, Nick; Hua, Ji; Harden, David; Guay, Jocelyne; Callejo, Mario; Miller, Michael M; Lawrence, R Michael; Banville, Jacques; Guy, Julia; Maxwell, Brad D; Priestley, E Scott; Marinier, Anne; Wexler, Ruth R; Bouvier, Michel; Gordon, David A; Schumacher, William A; Yang, Jing

2017-01-04

Antiplatelet agents are proven efficacious treatments for cardiovascular and cerebrovascular diseases. However, the existing drugs are compromised by unwanted and sometimes life-threatening bleeding that limits drug usage or dosage. There is a substantial unmet medical need for an antiplatelet drug with strong efficacy and low bleeding risk. Thrombin is a potent platelet agonist that directly induces platelet activation via the G protein (heterotrimeric guanine nucleotide-binding protein)-coupled protease-activated receptors PAR1 and PAR4. A PAR1 antagonist is approved for clinical use, but its use is limited by a substantial bleeding risk. Conversely, the potential of PAR4 as an antiplatelet target has not been well characterized. Using anti-PAR4 antibodies, we demonstrated a low bleeding risk and an effective antithrombotic profile with PAR4 inhibition in guinea pigs. Subsequently, high-throughput screening and an extensive medicinal chemistry effort resulted in the discovery of BMS-986120, an orally active, selective, and reversible PAR4 antagonist. In a cynomolgus monkey arterial thrombosis model, BMS-986120 demonstrated potent and highly efficacious antithrombotic activity. BMS-986120 also exhibited a low bleeding liability and a markedly wider therapeutic window compared to the standard antiplatelet agent clopidogrel tested in the same nonhuman primate model. These preclinical findings define the biological role of PAR4 in mediating platelet aggregation. In addition, they indicate that targeting PAR4 is an attractive antiplatelet strategy with the potential to treat patients at a high risk of atherothrombosis with superior safety compared with the current standard of care. Copyright © 2017, American Association for the Advancement of Science.

Prophylactic Transcatheter Arterial Embolization After Successful Endoscopic Hemostasis in the Management of Bleeding Duodenal Ulcer.

PubMed

Mille, Markus; Huber, Juliane; Wlasak, Rüdiger; Engelhardt, Thomas; Hillner, Yvette; Kriechling, Henri; Aschenbach, Rene; Ende, Katrin; Scharf, Jens-Gerd; Puls, Ralf; Stier, Albrecht

2015-10-01

The aim of this study was to demonstrate the new strategy of prophylactic transcatheter arterial embolization (TAE) of the gastroduodenal artery after endoscopic hemostasis of bleeding duodenal ulcers. TAE is a well-established method for the treatment of recurrent or refractory ulcer bleeding resistant to endoscopic intervention, which increasingly replaces surgical procedures. A new approach for improving outcome and reducing rebleeding episodes is the supplemental and prophylactic TAE after successful endoscopic hemostasis. This retrospective study included all patients (n=117) treated from 2008 to 2012 for duodenal ulcer bleeding. After initial endoscopic hemostasis, patients were assessed regarding their individual rebleeding risk. Patients with a low rebleeding risk (n=47) were conservatively treated, patients with a high risk for rebleeding (n=55) had prophylactic TAE of the gastroduodenal artery, and patients with endoscopically refractory ulcer bleeding received immediate TAE. The technical success of prophylactic TAE was 98% and the clinical success was 87% of cases. Rebleeding occurred in 11% of patients with prophylactic TAE and was successfully treated with repeated TAE or endoscopy. The major complication rate was 4%. Surgery was necessary in only 1 prophylactic TAE patient (0.9%) during the whole study period. Mortality associated with ulcer bleeding was 4% in patients with prophylactic TAE. Prophylactic TAE in patients with duodenal ulcers at high risk for rebleeding was feasible, effective at preventing the need for surgery, and had low major complication rates. Given these promising outcomes, prophylactic TAE should be further evaluated as a preventative therapy in high-risk patients.

QCD equation of state with almost physical quark masses

NASA Astrophysics Data System (ADS)

Cheng, M.; Christ, N. H.; Datta, S.; van der Heide, J.; Jung, C.; Karsch, F.; Kaczmarek, O.; Laermann, E.; Mawhinney, R. D.; Miao, C.; Petreczky, P.; Petrov, K.; Schmidt, C.; Soeldner, W.; Umeda, T.

2008-01-01

We present results on the equation of state in QCD with two light quark flavors and a heavier strange quark. Calculations with improved staggered fermions have been performed on lattices with temporal extent Nτ=4 and 6 on a line of constant physics with almost physical quark mass values; the pion mass is about 220 MeV, and the strange quark mass is adjusted to its physical value. High statistics results on large lattices are obtained for bulk thermodynamic observables, i.e. pressure, energy and entropy density, at vanishing quark chemical potential for a wide range of temperatures, 140MeV≤T≤800MeV. We present a detailed discussion of finite cutoff effects which become particularly significant for temperatures larger than about twice the transition temperature. At these high temperatures we also performed calculations of the trace anomaly on lattices with temporal extent Nτ=8. Furthermore, we have performed an extensive analysis of zero temperature observables including the light and strange quark condensates and the static quark potential at zero temperature. These are used to set the temperature scale for thermodynamic observables and to calculate renormalized observables that are sensitive to deconfinement and chiral symmetry restoration and become order parameters in the infinite and zero quark mass limits, respectively.

Ultrahigh-sensitive multimode interference-based fiber optic liquid-level sensor realized using illuminating zero-order Bessel-Gauss beam

NASA Astrophysics Data System (ADS)

Saha, Ardhendu; Datta, Arijit; Kaman, Surjit

2018-03-01

A proposal toward the enhancement in the sensitivity of a multimode interference-based fiber optic liquid-level sensor is explored analytically using a zero-order Bessel-Gauss (BG) beam as the input source. The sensor head consists of a suitable length of no-core fiber (NCF) sandwiched between two specialty high-order mode fibers. The coupling efficiency of various order modes inside the sensor structure is assessed using guided-mode propagation analysis and the performance of the proposed sensor has been benchmarked against the conventional sensor using a Gaussian beam. Furthermore, the study has been corroborated using a finite-difference beam propagation method in Lumerical's Mode Solutions software to investigate the propagation of the zero-order BG beam inside the sensor structure. Based on the simulation outcomes, the proposed scheme yields a maximum absolute sensitivity of up to 3.551 dB / mm and a sensing resolution of 2.816 × 10 - 3 mm through the choice of an appropriate length of NCF at an operating wavelength of 1.55 μm. Owing to this superior sensing performance, the reported sensing technology expedites an avenue to devise a high-performance fiber optic-level sensor that finds profound implication in different physical, biological, and chemical sensing purposes.

Impact of preoperative dual antiplatelet therapy on bleeding complications in patients with acute coronary syndromes who undergo urgent coronary artery bypass grafting.

PubMed

Nagashima, Zenko; Tsukahara, Kengo; Uchida, Keiji; Hibi, Kiyoshi; Karube, Norihisa; Ebina, Toshiaki; Imoto, Kiyotaka; Kimura, Kazuo; Umemura, Satoshi

2017-01-01

A 5- to 7-day washout period before coronary artery bypass grafting (CABG) is recommended for patients who have recently received a thienopyridine derivative; however, data supporting this guideline recommendation are lacking in Japanese patients. Urgent isolated CABG was performed in 130 consecutive patients with acute coronary syndromes (ACS) (101 men; mean age, 69 years). Urgent CABG was defined as operation performed within 5 days after coronary angiography. All patients continued to receive aspirin 100mg/day. The subjects were retrospectively divided into 2 groups: 30 patients with preoperative thienopyridine (clopidogrel in 15 patients, ticlopidine in 15) exposure within 5 days [dual antiplatelet therapy (DAPT) group] and 100 patients without exposure [single antiplatelet therapy (SAPT) group]. Although the DAPT group had a higher proportion of patients who received perioperative platelet transfusions than the SAPT group (50% vs. 18%, p<0.001), intraoperative bleeding (median, 1100ml; interquartile range, 620-1440 vs. 920ml; 500-1100) and total drain output within 48h after surgery (577±262 vs. 543±277ml) were similar. CABG-related major bleeding, which was defined as type 4 or 5 bleeding according to the Bleeding Academic Research Consortium definitions, occurred in a significantly higher proportion of patients in the DAPT group than in the SAPT group (20% vs. 3%, p=0.005). This difference in major bleeding was driven mainly by the higher rate of transfusion of ≥5U red blood cells within a 48-h period in the DAPT group (13% vs. 1%, p=0.01). There was no significant difference in the 30-day composite endpoint including death, myocardial (re)infarction, ischemic stroke, and refractory angina between the DAPT group and SAPT group (17% vs. 19%). Preoperative DAPT increases the risk of CABG-related major bleeding in Japanese patients with ACS undergoing urgent CABG. Copyright © 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Comparison of intravenous pantoprazole with intravenous ranitidine in peptic ulcer bleeding.

PubMed

Demetrashvili, Z M; Lashkhi, I M; Ekaladze, E N; Kamkamidze, G K

2013-10-01

Following successful endoscopic therapy in patients with peptic ulcer bleeding, rebleeding occurs in 4% to 30% of cases. Rebleeding remains the most important determinant of poor prognosis. The aim of our study is to compare the efficacy of intravenous pantoprazole and ranitidine for prevention of rebleeding of peptic ulcers following initial endoscopic hemostasis. In our study patients who had gastric or duodenal ulcers with bleeding received combined endoscopy therapy with injection of epinephrine and thermocoagulation. Patients with initial hemostasis were randomly assigned to two groups. One group (45 patients) was treated with intravenous pantoprazole, with an initial dose of 40 mg and subsequently with 40 mg every twelve hours during the first three days, followed by 40 mg a day orally. The other group (44 patients) was treated with intravenous ranitidine, with an initial dose of 50 mg and subsequently every eight hours during the first three days, followed by 150 mg ranitidine every 12 h. In all case of rebleeding repeated endoscopy was performed. One patient (2,2%) had rebleeding in pantoprazole group. Bleeding could not be blocked by repeated endoscopic intervention, thus the patient underwent emergency surgery. 6 patients (13,6%) from ranitidine group had recurrence of bleeding. Repeated endoscopy was performed in all these patients: bleeding was stopped in 3 cases endoscopically, other 3 patients were surgically treated urgently as endoscopic hemostasis was not successful. None of the patients died of uncontrolled rebleeding. The frequency of rebleeding was significantly low in the group of pantoprazole compared to ranitidine group (2,2% vs 13,6% P=0,046). There were no statistically significant differences between the groups with regard to need for emergency surgery (2,2% vs 6,8%), the length of hospital stay (6,7±3,3 vs 7,4±4,3 d) and mortality (0%vs 0%). After endoscopic treatment of bleeding peptic ulcers, intravenous pantoprazole is more effective than ranitidine for the prevention of rebleeding.

Medically significant late bleeding after treated crotaline envenomation: a systematic review.

PubMed

Lavonas, Eric J; Khatri, Vaishali; Daugherty, Claire; Bucher-Bartelson, Becki; King, Thomas; Dart, Richard C

2014-01-01

We estimate the proportion of patients with crotaline snake envenomation who are treated with Crotalidae polyvalent immune Fab (ovine) antivenom and who develop medically significant late bleeding. We performed a systematic review of all published cohort studies of North American crotaline snake envenomation patients treated with Fab antivenom. We searched PubMed, Ovid MEDLINE, and EMBASE from January 1, 1997, to April 30, 2012. Data were extracted by 2 trained researchers. Late bleeding was defined as bleeding that began or recurred after initial control of the envenomation syndrome. Medically significant late bleeding was defined a priori as late bleeding treated with RBC transfusion, vasoactive drug infusion, surgery, or rehospitalization or associated with a hemoglobin decrease of greater than or equal to 3 g/dL, hematocrit decrease of greater than or equal to 8%, disability, or death. Summary incidence and 95% confidence intervals (CIs) were calculated with a random-effects Poisson regression model. Nineteen unique cohort studies were identified. Four studies collected data prospectively, and in 9 studies, patients were followed actively after hospital discharge. A total of 1,017 subjects were enrolled in these cohort studies. Late bleeding was reported in 9 subjects (0.9%; 95% CI 0.4% to 2.2%), of whom 5 subjects (0.5%; 95% CI 0.1% to 1.7%) had medically significant late bleeding. Three patients received RBC transfusion; no deaths or permanent sequelae were reported. Estimates of risk may be affected by underreporting. Medically significant late bleeding appears to be uncommon in snakebite victims treated with Fab antivenom. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Single nucleotide polymorphism markers for low-dose aspirin-associated peptic ulcer and ulcer bleeding.

PubMed

Shiotani, Akiko; Murao, Takahisa; Fujita, Yoshihiko; Fujimura, Yoshinori; Sakakibara, Takashi; Nishio, Kazuto; Haruma, Ken

2014-12-01

In our previous study, the SLCO1B1 521TT genotype and the SLCO1B1*1b haplotype were significantly associated with the risk of peptic ulcer in patients taking low-dose aspirin (LDA). The aim of the present study was to investigate pharmacogenomic profile of LDA-induced peptic ulcer and ulcer bleeding. Patients taking 100 mg of enteric-coated aspirin for cardiovascular diseases and with a peptic ulcer or ulcer bleeding and patients who also participated in endoscopic surveillance were studied. Genome-wide analysis of single nucleotide polymorphisms (SNPs) was performed using the Affymetrix DME Plus Premier Pack. SLCO1B1*1b haplotype and candidate genotypes of genes associated with ulcer bleeding or small bowel bleeding identified by genome-wide analysis were determined using TaqMan SNP Genotyping Assay kits, polymerase chain reaction-restriction fragment length polymorphism, and direct sequencing. Of 593 patients enrolled, 111 patients had a peptic ulcer and 45 had ulcer bleeding. The frequencies of the SLCO1B1*1b haplotype and CHST2 2082 T allele were significantly greater in patients with peptic ulcer and ulcer bleeding compared to the controls. After adjustment for significant factors, the SLCO1B1*1b haplotype was associated with peptic ulcer (OR 2.20, 95% CI 1.24-3.89) and CHST2 2082 T allele with ulcer bleeding (2.57, 1.07-6.17). The CHST2 2082 T allele as well as SLCO1B1*1b haplotype may identify patients at increased risk for aspirin-induced peptic ulcer or ulcer bleeding. © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

Transcatheter Arterial Embolization of Angiographically Visible and Occult Renal Capsular Artery Hemorrhage in 28 Patients.

PubMed

Park, Hyo Jung; Shin, Ji Hoon; Han, Ki-Chang; Yoon, Hyun-Ki; Ko, Gi-Young; Sung, Kyu-Bo

2016-07-01

To evaluate the effectiveness and safety of transcatheter arterial embolization to control bleeding from the renal capsular artery (RCA). Embolization was performed in 28 patients (14 men; mean age, 49.7 y). Presence and type of previous invasive procedures, initial presentation, and coagulation profile were reviewed. Any preceding abdominal computed tomography (CT) findings were analyzed. Angiographic findings were categorized as active bleeding, suspicious for bleeding, or no bleeding. Technical and clinical success and clinical outcomes were evaluated. Changes in hemoglobin level and transfusion volume of packed red blood cells (pBRCs) before and after embolization were evaluated with the paired t test and Wilcoxon signed-rank test, respectively. Technical and clinical success rates of therapeutic embolization for active bleeding (n = 11) were 90.9% and 80%, respectively. One case of technical failure (5.9%) and 3 cases of postembolization bleeding (18.7%) were noted in the prophylactic embolization group in patients with suspicion of bleeding (n = 13) or no bleeding (n = 4). Transient renal insufficiency occurred in 4 patients (14.3%). The average hemoglobin level and volume of transfused pBRCs changed from 8.1 g/dL to 9.9 g/dL and from 871 mL to 543 mL, respectively (P < .05). Extravasation of contrast media or acute hematoma in the right subhepatic or perirenal space on CT was noted in 21 patients (78%). Embolization can provide an effective and safe method to control RCA bleeding. Perirenal invasive procedures and signs of active or recent right subhepatic or perirenal hemorrhage should raise the suspicion of an RCA source. Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.

Cesarean section scar diverticulum evaluation by saline contrast-enhanced magnetic resonance imaging: The relationship between variable parameters and longer menstrual bleeding.

PubMed

Yao, Min; Wang, Wenjing; Zhou, Jieru; Sun, Minghua; Zhu, Jialiang; Chen, Pin; Wang, Xipeng

2017-04-01

This study was conducted to determine a more accurate imaging method for the diagnosis of cesarean scar diverticulum (CSD) and to identify the parameters of CSD strongly associated with prolonged menstrual bleeding. We enrolled 282 women with a history of cesarean section (CS) who presented with prolonged menstrual bleeding between January 2012 and May 2015. Transvaginal ultrasound, general magnetic resonance imaging (MRI) and contrast-enhanced MRI were used to diagnose CSD. Five parameters were compared among the imaging modalities: length, width, depth and thickness of the remaining muscular layer (TRM) of CSD and the depth/TRM ratio. Correlation between the five parameters and days of menstrual bleeding was performed. Finally, multivariate analysis was used to determine the parameters associated with menstrual bleeding longer than 14 days. Contrast-enhanced MRI yielded greater length or width or thinner TRM of CSD compared with MRI and transvaginal ultrasound. CSD size did not significantly differ between women who had undergone one and two CSs. Correlation analysis revealed that CSD (P = 0.038) and TRM (P = 0.003) lengths were significantly associated with days of menstrual bleeding. Longer than 14 days of bleeding was defined by cut-off values of 2.15 mm for TRM and 13.85 mm for length. TRM and number of CSs were strongly associated with menstrual bleeding longer than 14 days. CE-MRI is a relatively accurate and efficient imaging method for the diagnosis of CSD. A cut-off value of TRM of 2.15 mm is the most important parameter associated with menstrual bleeding longer than 14 days. © 2017 Japan Society of Obstetrics and Gynecology.

The Prevalence and Impact of Heavy Menstrual Bleeding (Menorrhagia) in Elite and Non-Elite Athletes

PubMed Central

Bruinvels, Georgie; Burden, Richard; Brown, Nicola; Richards, Toby; Pedlar, Charles

2016-01-01

To identify the prevalence and impact of heavy menstrual bleeding (HMB) in exercising females where anemia may have a significant effect on training and performance a ‘Female Health Questionnaire’ was designed incorporating a validated diagnostic HMB series, demographics, exercise ability data, training status, anemia, iron supplementation and whether the menstrual cycle had affected training and performance. The survey was conducted in two stages; initially online, advertised via social media, and then repeated via face-to-face interviews with runners registered for the 2015 London Marathon. 789 participants responded to the online survey, and 1073 completed the survey at the marathon. HMB was reported by half of those online (54%), and by more than a third of the marathon runners (36%). Surprisingly, HMB was also prevalent amongst elite athletes (37%). Overall, 32% of exercising females reported a history of anemia, and 50% had previously supplemented with iron. Only a minority (22%) had sought medical advice. HMB is highly prevalent in exercising females, associated with self-reported anemia, increased use of iron supplementation and a perceived negative impact on performance. Further research is needed to investigate the impact of HMB, iron deficiency and anemia in exercising females. PMID:26901873

The Prevalence and Impact of Heavy Menstrual Bleeding (Menorrhagia) in Elite and Non-Elite Athletes.

PubMed

Bruinvels, Georgie; Burden, Richard; Brown, Nicola; Richards, Toby; Pedlar, Charles

2016-01-01

To identify the prevalence and impact of heavy menstrual bleeding (HMB) in exercising females where anemia may have a significant effect on training and performance a 'Female Health Questionnaire' was designed incorporating a validated diagnostic HMB series, demographics, exercise ability data, training status, anemia, iron supplementation and whether the menstrual cycle had affected training and performance. The survey was conducted in two stages; initially online, advertised via social media, and then repeated via face-to-face interviews with runners registered for the 2015 London Marathon. 789 participants responded to the online survey, and 1073 completed the survey at the marathon. HMB was reported by half of those online (54%), and by more than a third of the marathon runners (36%). Surprisingly, HMB was also prevalent amongst elite athletes (37%). Overall, 32% of exercising females reported a history of anemia, and 50% had previously supplemented with iron. Only a minority (22%) had sought medical advice. HMB is highly prevalent in exercising females, associated with self-reported anemia, increased use of iron supplementation and a perceived negative impact on performance. Further research is needed to investigate the impact of HMB, iron deficiency and anemia in exercising females.

High sensitivity zero-biased magnetic field sensor based on multiphase laminate heterostructures with FeCuNbSiB nanocrystalline soft magnetic alloy

NASA Astrophysics Data System (ADS)

Qiu, Jing; Wen, Yumei; Li, Ping; Chen, Hengjia

2016-05-01

In this paper, a high sensitivity zero-biased magnetic field sensor based on multiphase laminate heterostructures consisting of FeCuNbSiB/Terfenol-D (Tb1-xDyxFe2)/PZT (Pb(Zr1-x,Tix)O3)/Terfenol-D/PZT/Ternol-D/FeCuNbSiB (FMPMPMF) is presented, whose ME coupling characteristics and sensing performances have been investigated. Compared to traditional Terfenol-D/PZT/Terfenol-D (MPM) and Terfenol-D/PZT/Terfenol-D/PZT/Terfenol-D (MPMPM) sensors, the zero-biased ME coupling characteristics of FMPMPMF sensor were significantly improved, owing to a build-in magnetic field in FeCuNbSiB/Terfenol-D layers. The optimum zero-biased resonant ME voltage coefficient of 3.02 V/Oe is achieved, which is 1.65 times as great as that of MPMPM and 2.51 times of MPM sensors. The mean value of low-frequency ME field coefficient of FMPMPMF reaches 122.53 mV/cm Oe, which is 2.39 times as great as that of MPMPM and 1.79 times of MPM sensors. Meanwhile, the induced zero-biased ME voltage of FMPMPMF sensor shows an excellent linear relationship to ac magnetic field both at the low frequency (1 kHz) and the resonant frequency (106.6 kHz). Remarkably, it indicates that the proposed zero-biased magnetic field sensor give the prospect of being able to applied to the field of highly sensitive ac magnetic field sensing.

Standard and double-dose intravenous proton pump inhibitor injections for prevention of bleeding after endoscopic resection.

PubMed

Jung, Sung Woo; Kim, Seung Young; Choe, Jung Wan; Hyun, Jong Jin; Jung, Young Kul; Koo, Ja Seol; Yim, Hyung Joon; Lee, Sang Woo

2017-04-01

Endoscopic resection is commonly used to remove gastric neoplasms. However, effective dosing or scheduling of proton pump inhibitors for the prevention of delayed bleeding after endoscopic resection remains unclear. One hundred sixty-six patients with gastric adenoma or early gastric cancer were enrolled. After an endoscopic procedure, each subject was randomly assigned to 40 mg every 24 h (standard dose group) or 40 mg every 12 h (double-dose group) of intravenous pantoprazole for 48 h. Second-look endoscopy was performed on day 2 after endoscopic resection to compare signs of rebleeding and ulcer status between the two groups. Eighty-one patients of the standard dose group and 81 of the double-dose group were analyzed. There were no significant differences in the incidence of delayed bleeding events (1.3% vs 6.2%, P = 0.21) and bleeding ulcer at the second-look endoscopy (6.2% vs 3.9%, P = 0.69) between standard and double-dose groups. There were no other significant variables associated with delayed bleeding or bleeding ulcer on second-look endoscopy. Intravenous pantoprazole 40 mg every 24 h or 12 h for 2 days after endoscopic resection was equally effective for the prevention of delayed bleeding. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

A survey on rectal bleeding in children, a report from Iran

PubMed

Dehghani, Seyed Mohsen; Shahramian, Iraj; Ataollahi, Maryam; Bazı, Ali; Seirfar, Nosaibe; Delaramnasab, Mojtaba; Sargazi, Alireza; Shariatrazavi, Mahsa

2018-04-30

Background/aim: Studies on the epidemiology of rectal bleeding in children are limited in Iran. Our aim was to assess etiologies of rectal bleeding in children in Iran. Materials and methods: We enrolled 730 children with rectal bleeding. All the patients underwent colonoscopy, and 457 were further evaluated with histopathology. Results: According to colonoscopy and histopathology, respectively, inflammatory bowel disease (IBD) (29.4%, 15.8%), nodular hyperplasia (NH) (24.9%, 10%), and juvenile polyposis (JP) (12.6%, 9.9%) were the most common causes of rectal bleeding. Other conditions were solitary rectal ulcer (5.3%), chronic colitis (4.6%), allergic colitis (3.3%), focal colitis (1.3%), and infectious colitis (1.1%). In colonoscopy, there were no significant differences in the distribution of pathologies regarding sex, while the youngest and oldest mean ages were found for patients with NH (4.6 ± 3.9 years, P < 0.0001) and those with normal appearance (8.1 ± 4.4 years, P < 0.0001) respectively. Based on histopathologic reports, the youngest patients were diagnosed with infectious colitis (4.6 ± 2.8 years), while patients with chronic colitis were the oldest (9.2 ± 4.6 years, P = 0.003). Conclusion: JP, NH, and IBD constituted the most common etiologies of rectal bleeding in our patients. It is recommended to perform a complete diagnostic approach to accurately assess rectal bleeding in children.

Prediction and Reduction of Noise in Pneumatic Bleed Valves

NASA Astrophysics Data System (ADS)

Taghavi Nezhad, Shervin

This study investigates numerically the fluid mechanics and acoustics of pneumatic bleed valves used in turbofan engines. The goal is to characterized the fundamental processes of noise generation and devise strategies for noise reduction. Three different methods are employed for both analysis and redesign of the bleed valve to reduce noise. The bleed valve noise problem is carefully divided into multiple smaller problems. For large separations and tonal noises, the unsteady Reynolds-Averaged Navier-Stokes (URANS) method is utilized. This method is also applied in the re-designing of the bleed valve geometry. For the bleed valve muffler, which is comprised of perforated plates and a honeycomb, a Reynolds-Averaged Navier-Stokes (RANS) method combined with a simplified acoustic analogy is used. The original muffler design is modified to improve noise attenuation. Finally, for sound scattering through perforated plates, a fully implicit linearized Euler solver is developed. The problem of sound interaction with perforated plates is studied from two perspectives. In the first study the effect of high--speed mean flow is considered and it is shown that at Strouhal numbers of around 0.2-0.25 there is an increase in transmitted incident sound. In the second part, the interaction of holes in two--dimensional perforated plates is investigated using three different configurations. The study demonstrates that the hole interaction has a significant impact on sound attenuation, especially at high frequencies.

Long-term safety and efficacy of a pasteurized nanofiltrated prothrombin complex concentrate (Beriplex P/N): a pharmacovigilance study.

PubMed

Hanke, A A; Joch, C; Görlinger, K

2013-05-01

The rapid reversal of the effects of vitamin K antagonists is often required in cases of emergency surgery and life-threatening bleeding, or during bleeding associated with high morbidity and mortality such as intracranial haemorrhage. Increasingly, four-factor prothrombin complex concentrates (PCCs) containing high and well-balanced concentrations of vitamin K-dependent coagulation factors are recommended for emergency oral anticoagulation reversal. Both the safety and efficacy of such products are currently in focus, and their administration is now expanding into the critical care setting for the treatment of life-threatening bleeding and coagulopathy resulting either perioperatively or in cases of acute trauma. After 15 yr of clinical use, findings of a pharmacovigilance report (February 1996-March 2012) relating to the four-factor PCC Beriplex P/N (CSL Behring, Marburg, Germany) were analysed and are presented here. Furthermore, a review of the literature with regard to the efficacy and safety of four-factor PCCs was performed. Since receiving marketing authorization (February 21, 1996), ~647 250 standard applications of Beriplex P/N have taken place. During this time, 21 thromboembolic events judged to be possibly related to Beriplex P/N administration have been reported, while no incidences of viral transmission or heparin-induced thrombocytopenia were documented. The low risk of thromboembolic events reported during the observation period (one in ~31 000) is in line with the incidence observed with other four-factor PCCs. In general, four-factor PCCs have proven to be well tolerated and highly effective in the rapid reversal of vitamin K antagonists.

Evaluation of the utility of the ISTH-BAT in haemophilia carriers: a multinational study.

PubMed

James, P D; Mahlangu, J; Bidlingmaier, C; Mingot-Castellano, M E; Chitlur, M; Fogarty, P F; Cuker, A; Mancuso, M E; Holme, P A; Grabell, J; Satkunam, N; Hopman, W M; Mathew, P

2016-11-01

There has been increasing recognition in recent years that female carriers of haemophilia manifest abnormal bleeding; however, data on the use of bleeding assessment tools in this population are lacking. Our objective was to validate the ISTH-BAT in haemophilia carriers to describe bleeding symptoms and allow for comparisons with factor levels and other patient groups. This was a prospective, observational, cross-sectional study performed by members of Global Emerging HEmostasis Panel (GEHEP). Unselected consecutive haemophilia carriers were recruited and a CRF and the ISTH-BAT were completed by study personnel. A total of 168 haemophilia carriers were enrolled: 155 haemophilia A and 13 haemophilia B. The mean age was 40 years (range: 20-82). Carriers had higher mean bleeding scores (BS) compared with age-matched controls (n = 46; 5.7 vs. 1.43; P < 0.0001) and Type 3 VWD OC (n = 32; 3.0; P = 0.009), but lower BS compared with women with Type 1 VWD (n = 83; 8.7; P < 0.0001). Fifteen carriers reported haemarthrosis, and of those six had normal FVIII/FIX levels. There was a significant but weak negative correlation between BS and factor level (Spearman's r 2  = -0.36, P < 0.001). Our results show that haemophilia carriers experience abnormal bleeding, including haemarthrosis. Overall, BS in women with Type 1 VWD > haemophilia carriers > Type 3 VWD OC > controls. Understanding the performance of the ISTH-BAT in this population is a critical step in future research aimed at investigating the underlying pathophysiology of abnormal bleeding, with the ultimate goal of optimizing treatment. © 2016 John Wiley & Sons Ltd.

Upper gastrointestinal bleeding in children from a hospital center of Northeast Romania.

PubMed

Gimiga, Nicoleta; Olaru, Claudia; Diaconescu, Smaranda; Miron, Ingrith; Burlea, Marin

2016-06-01

The aim of this study was to investigate the common etiologies, clinical and biological patterns of upper gastrointestinal bleeding (UGIB) in children from a hospital center in Northeast Romania. This seven-year retrospective study was performed from 2007 to 2013 in St. Mary Children's Emergency Hospital, Jassy, Romania and included all children who referred to our center with UGIB exteriorized by hematemesis or melena. Endoscopy was performed under conscious sedation/general anesthesia after the informed consent was obtained. One hundred and three patients aged 1-18 years were included in this study. There were 57 males and 46 females with male to female ratio 1.2:1; 43.69% presented with hematemesis, 31.07% had melena and 25.24% had both. The most common causes of UGIB were erosive gastritis (33.98%), followed by esophagitis (14.56%), duodenitis (11.65%), duodenal ulcer (10.68%), gastric ulcer (5.83%), esophageal varices (4.85%), Mallory-Weiss syndrome (1.94%); multiple etiologies counted for 16.50% cases. A certain bleeding source was found in 34.95% cases, a possible one in 39.81% of the patients; the source could not be ascertained in 25.24% of cases. Nonsteroidal anti-inflammatory drug (NSAID) consumption was documented in in 17.51% of patients. The incidence of H. pylori infection was 36.89%. The most common cause of of upper GI bleeding in our series was gastritis, followed by oesophagitis and duodenitis. Most of the patients presented with hematemesis; previous consumption of NSAIDs and H. pylori infection were associated with gastroduodenal ulceration and bleeding. Early endoscopy was associated with a higher detection rate of the bleeding source.

Safety and Outcomes of Transradial Access in Patients with International Normalized Ratio 1.5 or above.

PubMed

Titano, Joseph J; Biederman, Derek M; Zech, John; Korff, Ricki; Ranade, Mona; Patel, Rahul; Kim, Edward; Nowakowski, Francis; Lookstein, Robert; Fischman, Aaron M

2018-03-01

To examine the safety and outcomes for patients undergoing transradial noncoronary interventions with international normalized ratio (INR) ≥1.5. A retrospective review of 2,271 transradial access (TRA) cases performed from July 2012 to July 2016 was conducted. Criteria for inclusion were moderate bleeding risk cases with preprocedure INR ≥1.5. Within the study period, there were 176 moderate bleeding risk procedures (transarterial chemoembolization: 70/176 [39.8%]; Barbeau B: 121/176 [68.8%]; 5-F sheath: 157/176 [89.2%]) performed on 122 patients (age 61.6 ± 12.1 years, 68.9% male, body mass index 28.0 kg/m 2 ) with INR ≥1.5. Technical success was achieved in 98.9% of cases. Grade 1/2 hematomas developed in 10 cases (5.7%). Age ≥65 years (P = .042) and female sex (P = .046) were predictive of access site bleeding complications. Fresh frozen plasma (FFP) transfusion was administered in 11.4% of cases (n = 20). Baseline INR and creatinine were significantly different between transfused and nontransfused cases (P values .006 and .028, respectively). Minor access site bleeding occurred in 3/20 cases (15%) receiving prior FFP transfusion and 7/156 nontransfused cases (4.5%), with no significant difference between these 2 groups (P = .072). TRA in patients with elevated INR appears to be safe in our experience. Age ≥65 years and female sex were associated with increased incidence of access site bleeding. Although INR correction was not standardized in this cohort, preprocedure FFP transfusion did not decrease bleeding complications. Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.

A zero-knowledge protocol for nuclear warhead verification

NASA Astrophysics Data System (ADS)

Glaser, Alexander; Barak, Boaz; Goldston, Robert J.

2014-06-01

The verification of nuclear warheads for arms control involves a paradox: international inspectors will have to gain high confidence in the authenticity of submitted items while learning nothing about them. Proposed inspection systems featuring `information barriers', designed to hide measurements stored in electronic systems, are at risk of tampering and snooping. Here we show the viability of a fundamentally new approach to nuclear warhead verification that incorporates a zero-knowledge protocol, which is designed in such a way that sensitive information is never measured and so does not need to be hidden. We interrogate submitted items with energetic neutrons, making, in effect, differential measurements of both neutron transmission and emission. Calculations for scenarios in which material is diverted from a test object show that a high degree of discrimination can be achieved while revealing zero information. Our ideas for a physical zero-knowledge system could have applications beyond the context of nuclear disarmament. The proposed technique suggests a way to perform comparisons or computations on personal or confidential data without measuring the data in the first place.

Results of the HepZero study comparing heparin-grafted membrane and standard care show that heparin-grafted dialyzer is safe and easy to use for heparin-free dialysis.

PubMed

Laville, Maurice; Dorval, Marc; Fort Ros, Joan; Fay, Renaud; Cridlig, Joëlle; Nortier, Joëlle L; Juillard, Laurent; Dębska-Ślizień, Alicja; Fernández Lorente, Loreto; Thibaudin, Damien; Franssen, Casper; Schulz, Michael; Moureau, Frédérique; Loughraieb, Nathalie; Rossignol, Patrick

2014-12-01

Heparin is used to prevent clotting during hemodialysis, but heparin-free hemodialysis is sometimes needed to decrease the risk of bleeding. The HepZero study is a randomized, multicenter international controlled open-label trial comparing no-heparin hemodialysis strategies designed to assess non-inferiority of a heparin grafted dialyzer (NCT01318486). A total of 251 maintenance hemodialysis patients at increased risk of hemorrhage were randomly allocated for up to three heparin-free hemodialysis sessions using a heparin-grafted dialyzer or the center standard-of-care consisting of regular saline flushes or pre-dilution. The first heparin-free hemodialysis session was considered successful when there was neither complete occlusion of air traps or dialyzer, nor additional saline flushes, changes of dialyzer or bloodlines, or premature termination. The current standard-of-care resulted in high failure rates (50%). The success rate in the heparin-grafted membrane arm was significantly higher than in the control group (68.5% versus 50.4%), which was consistent for both standard-of-care modalities. The absolute difference between the heparin-grafted membrane and the controls was 18.2%, with a lower bound of the 90% confidence interval equal to plus 7.9%. The hypothesis of the non-inferiority at the minus 15% level was accepted, although superiority at the plus 15% level was not reached. Thus, use of a heparin-grafted membrane is a safe, helpful, and easy-to-use method for heparin-free hemodialysis in patients at increased risk of hemorrhage.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy.

PubMed

Gjeorgjievski, Mihajlo; Cappell, Mitchell S

2016-02-08

To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review. Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG. PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension. PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

[Mechanical suture in colorectal surgery].

PubMed

Alecu, L; Pascu, A; Costan, I; Deacu, A; Marin, A; Corodeanu, G; Gulinescu, L

2001-01-01

Of this work was the study of using, as well as the utility of the mechanical sutures in colorectal surgery; because of the special caution needed to be taken for any colonic or rectal suture, more than any other digestive segment. The frequency of the postoperative fistulas after the suture and anastomosis is higher at this level and so it increases the period and costs of the hospitalization. We studied the possibilities of performing and evolution of 64 mechanical sutures for 19 patients, with colorectal pathology, hospitalized in our department from july 1999 to december 2000. We performed 64 mechanical sutures, as followed: 47 in open surgery and 17 in laparoscopic. From all these, 56 was bowel sutures, 8 of them were vascular (in laparoscopic, for cutting the most important vascular pedicles). We did 18 anastomosis: 15 in open and 3 in laparoscopic surgery. It was 2 postoperative fistulas from all 56 intestinal sutures (3.57%). We haven't any intra or postoperative bleeding from the vascular anastomosis. It was 3 intraoperative bleeding from the intestinal anastomosis, and only 1 case of postoperative bleeding (5.26% of the cases: 1.56% of all mechanical sutures). In only one case, the mechanical suture couldn't be initially done, but it succeeded after the removing of the segment of the bowel involved. Mechanical sutures offers a high level of safety to the colorectal anastomosis. It provides a very good vascularization to the anastomosis and decreases the time needed for performing the suture or anastomosis, versus manual sature. Also, for the patients with rectal ampular neoplasm, it creates the possibility of anal sphincter preservation by making a low colorectal anastomoses--which is difficult by manual suture.

Frequency and management of breakthrough bleeding with continuous use of the transvaginal contraceptive ring: a randomized controlled trial.

PubMed

Sulak, Patricia J; Smith, Virginia; Coffee, Andrea; Witt, Iris; Kuehl, Alicia L; Kuehl, Thomas J

2008-09-01

To assess bleeding patterns with continuous use of the transvaginal contraceptive ring. We did a prospective analysis of daily menstrual flow during a 21/7 cycle followed by 6 months of continuous use and institution of a randomized protocol to manage breakthrough bleeding/spotting. Seventy-four women completed the baseline 21/7 phase and were randomized equally into two groups during the continuous phase. Group 1 was instructed to replace the ring monthly on the same calendar day with no ring-free days. Group 2 was instructed to use the same process, but if breakthrough bleeding/spotting occurred for 5 days or more, they were to remove the ring for 4 days, store it, and then reinsert that ring. Sixty-five women completed the continuous phase with reduced average flow scores in the continuous phase compared with the 21/7 phase (P<.02). Most patients had no to minimal bleeding during continuous use, with group 2 experiencing a statistically greater percentage of days without breakthrough bleeding or spotting (95%) compared with group 1 (89%) (P=.016). Instituting a 4-day hormone-free interval was more (P<.001) effective in resolving breakthrough bleeding/spotting than continuing ring use. A reduction in bleeding occurred during continuous use with replacement of the transvaginal ring compared with baseline 21/7 use. Continuous vaginal ring use resulted in an acceptable bleeding profile in most patients, reduction in flow, reduction in pelvic pain, and a high continuation rate.