Effect of Tranexamic Acid on Intra- and Postoperative Bleeding in Eyelid Surgery: A Prospective, Randomized, Multicenter, Double-Masked, Control Trial.

PURPOSE: Pilot studies suggest that waiting 15 minutes after a subcutaneous tranexamic acid injection is associated with decreased intraoperative bleeding and postoperative ecchymosis in eyelid surgery. The outcomes of commencing eyelid surgery immediately after injection without a waiting period remain unexplored. METHODS: This prospective, randomized, multicenter, double-masked, controlled study examined bilateral symmetric upper and/or lower lid blepharoplasty or ptosis repair. Patients received tranexamic acid in 1 eyelid and control in the contralateral eyelid. The surgeon recorded the side with more intraoperative bleeding. Two masked graders evaluated periocular ecchymosis at postoperative day 0 and postoperative week 1 (POW 1) with a 5-point scale. At POW 1, patients reported subjective grading of bruising as increased on 1 side or similar on both sides. Results were analyzed with Wilcoxon signed-rank and sign tests. RESULTS: Of 130 patients, there was less eyelid ecchymosis on the tranexamic side at postoperative day 0 ( p = 0.001) and POW 1 ( p < 0.001). By surgery type, the 69 levator advancement surgeries had significantly less ecchymosis at postoperative day 0 ( p < 0.001) and POW 1 ( p = 0.001), while upper eyelid blepharoplasty, combined upper and lower lid blepharoplasty, and conjunctivomullerectomy trended toward significance. Of 68 patients reporting a POW 1 grading, 69% reported less bruising on the tranexamic side ( p < 0.001). Intraoperative bleeding was not significantly different between sides ( p = 0.930). CONCLUSIONS: Without a postinjection waiting period, subcutaneous tranexamic acid for eyelid surgery significantly decreased postoperative ecchymosis on postoperative day 0 and POW 1 but did not affect intraoperative bleeding. Subcutaneous tranexamic acid was not associated with any complications.

Raccoon Eyes Presentation in a Child Diagnosed With Acute Lymphoblastic Leukemia: A Case Report.

Raccoon's eyes (periorbital ecchymosis) may present as the first sign in patients with skull base/base/facial fractures and tumors. In childhood, orbital metastases of neuroblastoma should be considered in the absence of trauma history. Herein, we report a 3-year-old girl diagnosed with acute lymphoblastic leukemia who presented with periorbital ecchymosis. To the best of our knowledge, this is the first pediatric patient with acute lymphoblastic leukemia in the literature who presented with raccoon eyes.

A Multi-stage Segmentation Method for Tongue Ecchymosis.

Tongue diagnosis is an important component of traditional Chinese medicine (TCM), in which tongue ecchymosis is the main diagnostic basis for the blood stasis syndrome of TCM. Most of the existing methods are unsupervised and cannot accurately segment tongue ecchymosis. In this paper, we propose a multi-stage segmentation method for tongue ecchymosis. We first employ an object detection model for rough localization of tongue ecchymosis, and then use the unsupervised clustering and the watershed transform for rough segmentation and fine segmentation of tongue ecchymosis respectively. To the best of our knowledge, we are the first to combine machine learning and deep learning to segment tongue ecchymosis. Experimental results show that the tongue ecchymoses obtained by our method are more similar to the real tongue ecchymoses compared with the existing methods, and the Intersection-over-Union (IoU) is improved by 0.12 compared with the latest method.Clinical Relevance-Tongue ecchymosis obtained by this paper is the main diagnostic basis for the blood stasis syndrome of TCM.

Spontaneous ecchymoses.

The patient's lifestyle was undoubtedly to blame for the appearance of her skin. The loss of her beloved pet may have been a tipping point.

Improving forensics: Characterizing injuries among community-dwelling physically abused older adults.

BACKGROUND: Physical elder abuse affects a substantial number of older adults, leaving victims at increased risk for negative health outcomes. Improved detection of abuse-related injuries may increase victim access to professional support, but providers report difficulties distinguishing between accidental and abuse-related injuries, due in part to victims' pre-existing health conditions and medication use. OBJECTIVES: To describe the spectrum and characteristics of injuries among physically abused older adults and identify injury characteristics associated with abuse. DESIGN: Case-control study. SETTING: Physically abused adult protective services clients were interviewed in their home; non-abused comparison group participants were interviewed in an outpatient geriatrics clinic. PARTICIPANTS: Sample included 156 community-dwelling adults aged 65 and older, including 57 physically abused and 99 non-abused individuals. Self-reported abuse history was confirmed through independent case assessment by a LEAD (Longitudinal, Expert All-Data) panel of clinicians with family violence expertise. MEASUREMENTS: Full-body assessments were conducted, documenting injury incidence, diagnosis, and location. We also collected sociodemographic characteristics, level of social support, functional ability, medical history, and medication use. RESULTS: Physically abused older adults were more likely to be injured upon assessment (79.0% vs 63.6%; p < 0.05) and have a greater number of injuries ( x¯=2.9 vs x¯=2.0 , p < 0.05). Injuries seen more often among abused individuals included: upper extremity ecchymoses (42.1% vs 26.3%; p < 0.05), abrasions (31.6% vs 11.1%; p < 0.01), and areas of tenderness (8.8% vs 0.0%; p < 0.01); and head/neck/maxillofacial ecchymoses (15.8% vs 2.0%; p < 0.01) and tenderness (15.8% vs 0.0%; p < 0.001). Lower extremity abrasions (12.3%) were common but unrelated to abuse status. CONCLUSION: While physical abuse does not always result in physical injury, victims more commonly display head/neck/maxillofacial ecchymoses or tenderness and upper extremity abrasions, ecchymoses, or tenderness. Detection of these injuries among older adults warrants further interview and examination.

A refugee child with multiple patterned ecchymoses: a diagnostic dilemma between nonaccidental injury and primary hemostatic defect.

A 4-year-old girl from Syria presented to the hospital with multiple bruises on her body. Bruises were observed in protected areas in a shape of fingerprints and objects, while no other bruises occurred during hospitalization. The parents also reported a history of bleeding diathesis from infancy. Both the initial laboratory evaluation and the secondary tests done for possible thrombocytopenia and coagulation factors deficiencies were normal. Thus, the nonaccidental injury protocol of the Hospital was activated, and the possibility of abuse was not quite evident. Investigation for platelet disorders followed. Platelet aggregation test and flow cytometry were indicative of Glanzmann's thrombasthenia. It is of great importance in these cases, that the doctor eliminates any possibility of physical abuse and examines the patient for common and rare primary hemostatic defects, although both can co-exist.

Anesthesia using microcannula and sharp needle in upper blepharoplasty: A randomized, double-blind clinical trial evaluating pain, bruising, and ecchymoses.

INTRODUCTION: With the emergence of blunt-tipped microcannulas, there is a hypothesis that these could cause less damage and reduce pain as compared to conventional sharp needles in eyelid surgery. The purpose is to determine whether an 18G blunt-tipped cannula can be better than a 26G needle. METHODS: This prospective, observer-blinded, randomized clinical trial was conducted from June 2017 to December 2018. Sixty-eight patients were randomized to receive local anesthesia injections for upper blepharoplasty. Infiltration was performed by using a 26-gauge sharp needle on one side and on the other side, infiltration was performed by using an 18-gauge stainless-steel blunt-tipped microcannula. A numeric rating scale (NRS) from 0 to 10 was used to blindly assess pain in patients receiving anesthesia injections with both needle types. Photographs of the eyelids of each patient were taken in five different periods and used by three blinded observers to identify bruise or ecchymoses. RESULTS: A total of 136 eyelid operations were performed. There was no statistically significant difference when both groups were compared; however, the average score of pain was higher in patients taking the infiltration through the needle (2.85 versus 2.50). Regarding the evaluation of bruising and ecchymoses, the results showed that, in the five periods evaluated, there was no statistical difference in bruising and ecchymosis in the eyelids when taking the infiltration through a sharp needle when compared with that of the eyelids taking infiltration through a (blunt-tipped) microcannula. CONCLUSION: The evaluation of the blunt-tipped microcannula showed a lower pain score mean than that obtained for the sharp needle (2.5 versus 2.85) (p > 0.05). There was no statistically significant difference in the bruising and ecchymosis courses.

Scurvy presenting as lower limb ecchymoses in the setting of metastatic colorectal cancer.

A 58-year-old woman presented with a 1-week history of lower limb bruising. She had a medical history of recurrent metastatic colon cancer with a sigmoid colectomy and complete pelvic exenteration leading to colostomy and urostomy formation. She had malignant sacral mass encroaching on the spinal cord. This caused a left-sided foot drop for which she used an ankle-foot orthosis. She was on cetuximab and had received radiotherapy to the sacral mass 1 month ago. On examination, there were macular ecchymoses with petechiae on the lower limbs. There was sparing of areas that had been compressed by the ankle-foot orthosis. Bloods showed mild thrombocytopaenia and anaemia with markedly raised inflammatory markers. Coagulation studies consistent with inflammation rather than disseminated intravascular coagulation. She was found to have Klebsiella bacteraemia secondary to urinary source. Skin biopsy showed dermal haemorrhage without vessel inflammation. Vitamin C levels were low confirming the diagnosis of scurvy.

Acquired hemophilia A in a woman with systemic lupus erythematosus: A case report and review of literature.

RATIONALE: Acquired hemophilia A (AHA) is a rare autoimmune disease caused by autoantibodies directed against the activity of factor VIII (FVIII) and presents with prolonged bleeding. 5.7% of systemic lupus erythematosus (SLE) patients are affected by AHA. PATIENT CONCERNS: A 51-year-old female patient with SLE presenting with the fatigue and spontaneous clinical bleeding symptoms such as hematuria and ecchymoses for 1 week. DIAGNOSIS: Laboratory examinations revealed prolongation of the activated partial thromboplastin time (APTT) (65.7 s), decreased FVIII activity (1.4%), and a titer of FVIII inhibitors of 8.5 Bethesda units/mL. INTERVENTIONS: Transfusion of recombinant human FVIII (ADVATE) in combination with intravenous methylprednisolone, cyclophosphamide, plasmapheresis, and fresh frozen plasma successfully stopped the bleeding and reduced the level of FVIII inhibitor. OUTCOMES: The size of the hematoma slowly decreased. The skin ecchymosis was gradually absorbed, the hemoglobin count increased, and the coagulation index gradually improved. There was no new bleeding or bleeding site. The patient was discharged and transferred to a local hospital for hospice care. LESSONS: AHA in a patient with SLE is rare. Once it occurs, it can be life-threatening. Clinicians should remain aware that because some cases of AHA may have features of SLE, appropriate distinction and diagnosis of these different but associated diseases is necessary.