A dimensional analysis of experienced intensive care unit nurses' clinical decision-making for bleeding after cardiac surgery.

BACKGROUND: Bleeding following cardiac surgery is common and serious, yet a gap persists in understanding how experienced intensive care nurses identify and respond to such complications. AIM: To describe the clinical decision-making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery. STUDY DESIGN: This qualitative study adopted the Recognition-Primed Decision Model as its theoretical framework. Thirty-nine experienced nurses from four adult intensive care units participated in semi-structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory. RESULTS: Participants maintained consistent vigilance towards post-cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision-making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability. CONCLUSIONS: Nurses' decision-making was shaped by their personal attributes, the patient's condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision-making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation. RELEVANCE TO CLINICAL PRACTICE: This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability-focused educational programmes, and understanding decision-making intricacies are crucial for informing nursing education and decision-support systems.

Postpartum haemorrhage and risk of cardiovascular disease in later life: A population-based record linkage cohort study.

OBJECTIVE: To investigate the association between postpartum haemorrhage (PPH) and subsequent cardiovascular disease. DESIGN: Population-based retrospective cohort study, using record linkage between Aberdeen Maternity and Neonatal Databank (AMND) and Scottish healthcare data sets. SETTING: Grampian region, Scotland. POPULATION: A cohort of 70 904 women who gave birth after 24 weeks of gestation in the period 1986-2016. METHODS: We used extended Cox regression models to investigate the association between having had one or more occurrences of PPH in any (first or subsequent) births (exposure) and subsequent cardiovascular disease, adjusted for sociodemographic, medical, and pregnancy and birth-related factors. MAIN OUTCOME MEASURES: Cardiovascular disease identified from the prescription of selected cardiovascular medications, hospital discharge records or death from cardiovascular disease. RESULTS: In our cohort of 70 904 women (with 124 795 birth records), 25 177 women (36%) had at least one PPH. Compared with not having a PPH, having at least one PPH was associated with an increased risk of developing cardiovascular disease, as defined above, in the first year after birth (adjusted hazard ratio, aHR 1.96; 95% confidence interval, 95% CI 1.51-2.53; p < 0.001). The association was attenuated over time, but strong evidence of increased risk remained at 2-5 years (aHR 1.19, 95% CI 1.11-1.30, P < 0.001) and at 6-15 years after giving birth (aHR 1.17, 95% CI 1.05-1.30, p = 0.005). CONCLUSIONS: Compared with women who have never had a PPH, women who have had at least one episode of PPH are twice as likely to develop cardiovascular disease in the first year after birth, and some increased risk persists for up to 15 years.

A Rare and Unusual Case of Hypernatremic Dehydration in a Newborn Presenting With Adrenal Haemorrhage and Leading to Acute Kidney Injury.

Adrenal haemorrhage, although a rare entity in the neonatal period, is a known complication of birth asphyxia. Adrenal haemorrhage progresses differently depending on the type and extent of the glands involved. Adrenal haemorrhage can cause persistent jaundice, fever, dehydration, scrotal swelling, abdominal wall discolouration, septicemia, and a shock-like state. Here, we report the case of a four-day-old male infant who presented with jaundice, poor feeding, and hypernatremic dehydration. The patient developed acute kidney injury and, eventually, renal failure due to adrenal haemorrhage. He had an abdominal lump with deranged renal parameters along with hyperbilirubinemia. Abdominal ultrasonography and contrast computed tomography scan showed left suprarenal enlargement with evidence of adrenal haemorrhage. The patient was managed well with ventilatory support and peritoneal dialysis and discharged successfully. A subsequent follow-up showed complete resolution of the adrenal haemorrhage. Single ultrasonography is a good modality for diagnosis but not sufficient, so serial ultrasonography at subsequent follow-up is a must.

Capecitabine-associated gastrointestinal ulceration, haemorrhage, and obstruction: a pharmacovigilance analysis based on the FAERS.

Background: Capecitabine has been reported to be associated with severe gastrointestinal (GI) adverse drug reactions (gastrointestinal ulceration, haemorrhage, and obstruction). However, statistical correlations have not been demonstrated, and specific GI adverse drug reactions, such as GI obstruction, are not listed on its label. Aim: We aimed to determine the associations between capecitabine and GI ulceration, haemorrhage, or obstruction among patients with breast cancer by examining data from the United States Food and Drug Administration Adverse Event Reporting System (FAERS). Methods: We performed disproportionality analysis of GI ulceration, haemorrhage, and obstruction by evaluating the reporting odds ratio (ROR) and the information component (IC) with their 95% confidence intervals (CIs). Results: We identified 279 patients with capecitabine-associated GI ulceration, haemorrhage, or obstruction reported between 1 January 2004 and 31 December 2020. One-fourth of the cases of GI ulceration, haemorrhage, or obstruction resulted in death. Capecitabine as a drug class had disproportionately high reporting rates for GI ulceration [ROR 1.94 (1.71-2.21); IC 0.80 (0.60-0.99)], haemorrhage [ROR 2.27 (1.86-2.76); IC 0.99 (0.69-1.28)], and obstruction [ROR 2.19 (1.63-2.95); IC 0.96 (0.51-1.40)]. Conclusion: Pharmacovigilance research on the FAERS has revealed a slight increase in reports of GI ulceration, haemorrhage, and obstruction in capecitabine users, which may cause serious or deadly consequences. In addition to the adverse reactions described in the package insert, close attention should be paid to GI obstruction to avoid discontinuation or life-threatening outcomes.

Haemostatic management of von Willebrand disease during childbirth with a plasma-derived VWF/FVIII concentrate.

BACKGROUND: Females with VWD do not show the same increases in VWF and FVIII levels during pregnancy as females without VWD and are at higher risk of excessive bleeding associated with childbirth. Data on haemostatic management for childbirth in VWD patients are limited. OBJECTIVES: To evaluate the dosing, efficacy and safety of plasma-derived VWF/FVIII (wilate) for prevention of excessive bleeding associated with childbirth in females with any type of VWD. METHODS: Data for females with VWD who received wilate for haemostatic coverage for childbirth during two prospective clinical studies were analysed. RESULTS: Ten females with VWD and a mean age at enrolment of 29.6 years were treated with wilate to prevent excessive bleeding associated with childbirth. Two patients had Type 1, four had Type 2 (two 2A, one 2B and one 2M) and four had Type 3 VWD. Of the ten deliveries, five were by caesarean section. Patients received a mean of 9.5 infusions of wilate over 6.8 exposure days, with a mean total dose of 234 IU/kg per delivery and 25 IU/kg per infusion. Haemostatic management for all deliveries was rated excellent or good, with no excessive bleeding during delivery and no postpartum bleeds during the period of wilate treatment in any patient. Two patients experienced eight possible or probable treatment-related adverse events; all were mild or moderate and resolved. No thromboembolic events were observed. CONCLUSION: The results of this case series indicate that wilate provided effective haemostatic cover for childbirth in females with VWD during delivery and postpartum.

Experience of Multiple Super-Selective Renal Angiographic Embolization (SRAE) After Minimally-Percutaneous Nephrolithotomy Haemorrhage: A Case Report.

Minimally invasive percutaneous nephrolithotomy (mini-PCNL) maintains a stone clearance rate similar to standard PCNL while reducing blood loss. Bleeding is a complex and serious complication that can arise after PCNL surgery. Pseudoaneurysm (PA) is an uncommon type of delayed bleeding problem, which affects less than 1% of patients after PCNL. The most effective treatment for severe post-PCNL hemorrhage is super-selective renal angiographic embolization (SRAE), but it can fail in some patients and require additional surgical intervention. This report details the case of a male patient, 55 years old, who experienced severe bleeding four times and had three SRAE procedures and one laparoscopic procedure after PCNL. The presence of a renal artery pseudoaneurysm was not initially identified during the first two attempts of angiography due to arterial spasm and a small, undeveloped lesion. This case report is intended to enhance awareness of tiny pseudoaneurysms, emphasizing the importance of avoiding oversight to improve the success rate of embolization.

Pulmonary haemorrhage and haemoptysis associated with bevacizumab-related treatment regimens: a retrospective, pharmacovigilance study using the FAERS database.

Background: Bevacizumab (BV) is widely used in routine cancer treatment and clinical therapy in combination with many other agents. This study aims to describe and analyse post-market cases of pulmonary haemorrhage and haemoptysis reported with different BV treatment regimens by mining data from the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database. Methods: Data were collected from the FAERS database between 2004 Q1 and 2023 Q1. Disproportionality analysis including the reporting odds ratio (ROR) was employed to quantify the signals of disproportionate reporting of pulmonary haemorrhage and haemoptysis adverse events (AEs) associated with BV-related treatment regimens. The demographic characteristics, time to onset and outcomes were further clarified. Results: A total of 55,184 BV-associated reports were extracted from the FAERS database, of which 497 reports related to pulmonary haemorrhage and haemoptysis. Overall, the median onset time of pulmonary haemorrhage and haemoptysis AEs was 43 days (interquartile range (IQR) 15-117 days). In the subgroup analysis, BV plus targeted therapy had the longest median onset time of 90.5 days (IQR 34-178.5 days), while BV plus chemotherapy had the shortest of 40.5 days (IQR 14-90.25). BV plus chemotherapy disproportionately reported the highest percentage of death (148 deaths out of 292 cases, 50.68%). Moreover, the BV-related treatments including four subgroups in our study demonstrated the positive signals with the association of disproportionate reporting of pulmonary haemorrhage and haemoptysis. Notably, BV plus chemotherapy showed a significant higher reporting risk in pulmonary haemorrhage and haemoptysis signals of disproportionate reporting in comparison to BV monotherapy (ROR 5.35 [95% CI, 4.78-6.02] vs. ROR 4.19 [95% CI, 3.56-4.91], p = 0.0147). Conclusion: This study characterized the reporting of pulmonary haemorrhage and haemoptysis, along with the time to onset and demographic characteristics among different BV-related treatment options. It could provide valuable evidence for further studies and clinical practice of BV.

Widespread haemorrhages in infants post-shunting (WHIPS): clinical features, risk factors and neuroimaging characteristics of a rare and under-recognised phenomenon.

PURPOSE: Infants undergoing CSF shunting procedures face a rare complication which we propose to rename "Widespread Haemorrhages in Infants Post-Shunting" (WHIPS) to better capture this unique phenomenon specific to infants undergoing CSF diversion. Our objective is to analyse the risk factors for WHIPS development and provide a detailed neuroradiological description of these haemorrhages. MATERIALS AND METHODS: A radiology information system (RIS) was searched using the search terms "shunt" and/or "catheter" and/or "drain" and/or "ventriculoperitoneal" and/or "VP" between September 2008 to January 2021 for patients < 12 months of age. Clinical data was compiled for each patient meeting the inclusion criteria. Included cases were reviewed by three radiologists for the presence of WHIPS with calculation of the bifrontal ratio and documenting haemorrhage number, morphology, location and lobar distribution. RESULTS: 51 patients met inclusion criteria, 8 WHIPS patients and 43 controls. There was a statistically significant correlation between a larger post-op head circumference and WHIPS (p = 0.04). WHIPS was associated with post-haemorrhagic hydrocephalus and post-infectious hydrocephalus (p = 0.009). WHIPS were identified in the cortico-subcortical regions, periventricular white matter, and deep white matter. Haemorrhages were either punctate, ovoid or confluent. Haemorrhages ranged from single to innumerable. CONCLUSIONS: WHIPS represent a rare and under-recognised complication of CSF shunting unique to the infantile population. We postulate deep and superficial medullary venous haemorrhage as an underlying mechanism related to disordered intracranial hydrodynamics which are exacerbated in the infantile population due to underdeveloped arachnoid granulations and a compliant skull.

Pre-treatment radiological factors associated with poor functional outcome in an Asian cohort of large vessel occlusion acute ischemic stroke patients undergoing mechanical thrombectomy.

Background and aims: Endovascular thrombectomy (EVT) is the current standard of care for large vessel occlusion (LVO) acute ischemic stroke (AIS); however, up to two-thirds of EVT patients have poor functional outcomes despite successful reperfusion. Many radiological markers have been studied as predictive biomarkers for patient outcomes in AIS. This study seeks to determine which clinico-radiological factors are associated with outcomes of interest to aid selection of patients for EVT for LVO AIS. Methods: A retrospective study of patients who underwent EVT from 2016 to 2020 was performed. Data on various radiological variables, such as anatomical parameters, clot characteristics, collateral status, and infarct size, were collected alongside traditional demographic and clinical variables. Univariate and multivariate analysis was performed for the primary outcomes of functional independence at 3 months post-stroke (modified Rankin Scale 0-2) and secondary outcomes of in-hospital mortality and symptomatic intracranial hemorrhage. Results: The study cohort comprised 325 consecutive patients with anterior circulation LVO AIS (54.5% male) with a median age of 68 years (interquartile range 57-76). The median NIHSS was 19. Age, hypertension, hyperlipidaemia, National Institutes of Health Stroke Scale (NIHSS), Alberta mCTA score, ASPECTS, clot length, thrombus HU and mTICI score and the angle between ICA and CCA were associated with functional outcomes at 3 months on univariate analysis. On multivariate analysis, age, Alberta mCTA collaterals and NIHSS were significantly associated with functional outcomes, while ASPECTS approached significance. Conclusion: Among the many proposed radiological markers for patients in the hyperacute setting undergoing EVT, the existing well-validated clinico-radiological measures remain strongly associated with functional status.

Pathogenicity and virulence of African swine fever virus.

African swine fever (ASF) is a devastating disease with a high impact on the pork industry worldwide. ASF virus (ASFV) is a very complex pathogen, the sole member of the family Asfaviridae, which induces a state of immune suppression in the host through infection of myeloid cells and apoptosis of lymphocytes. Moreover, haemorrhages are the other main pathogenic effect of ASFV infection in pigs, related to the infection of endothelial cells, as well as the activation and structural changes of this cell population by proinflammatory cytokine upregulation within bystander monocytes and macrophages. There are still many gaps in the knowledge of the role of proteins produced by the ASFV, which is related to the difficulty in producing a safe and effective vaccine to combat the disease, although few candidates have been approved for use in Southeast Asia in the past couple of years.

Sex differences in risk factor relationships with subarachnoid haemorrhage and intracranial aneurysms: A Mendelian Randomisation study.

Background: The prevalence of intracranial aneurysms (IAs) and incidence of aneurysmal subarachnoid haemorrhage (aSAH) is higher in women than in men. Although several cardiometabolic and lifestyle factors have been related to the risk of IAs or aSAH, it is unclear whether there are sex differences in causal relationships of these risk factors. Aims: The aim of this study was to determine sex differences in causal relationships between cardiometabolic and lifestyle factors and risk of aSAH and IA. Methods: We conducted a sex-specific two-sample Mendelian randomisation study using summary-level data from genome-wide association studies. We analysed low-density lipoprotein cholesterol, high-density lipoprotein cholesterol [HDL-C], triglycerides, non-HDL-C, total cholesterol, fasting glucose, systolic and diastolic blood pressure, smoking initiation, and alcohol use as exposures, and aSAH and IA (i.e., aSAH and unruptured IA combined) as outcomes. Results: We found statistically significant sex differences in the relationship between genetically proxied non-HDL-C and aSAH risk, with odds ratios (ORs) of 0.72 (95% confidence interval 0.58, 0.88) in women and 1.01 (0.77, 1.31) in men (P-value for sex difference 0.044). Moreover, genetic liability to smoking initiation was related to a statistically significantly higher risk of aSAH in men compared to women (P-value for sex difference 0.007) with ORs of 3.81 (1.93, 7.52) and 1.12 (0.63, 1.99), respectively, and to a statistically significantly higher IA risk in men compared to women (P-value for sex difference 0.036) with ORs of 3.58 (2.04, 6.27) and 1.61 (0.98, 2.64), respectively. In addition, higher genetically proxied systolic and diastolic blood pressure were related to a higher risk of aSAH and IA in both women and men. Conclusions: Higher genetically proxied non-HDL-C was related to a lower risk of aSAH in women compared to men. Moreover, genetic liability to smoking initiation was associated with a higher risk for aSAH and IA in men compared to women. These findings may help improve understanding of sex differences in the development of aSAH and IA.

Single-centre real-life observational study on mortality and outcomes: decompressive craniectomy and brain death in traumatic brain injury, haemorrhage, and other cerebral diseases.

BACKGROUND: Decompressive hemicraniectomy (DHC) is used after severe brain damages with elevated, refractory intracranial pressure (ICP). In a non age-restricted population, mortality rates and long-term outcomes following DHC are still unclear. This study's objectives were to examine both, as well as to identify predictors of unfavourable outcomes. METHODS: We undertook a retrospective observational analysis of patients aged 18 years and older who underwent DHC at the University Hospital of Bonn between 2018 and 2020, due to traumatic brain injury (TBI), haemorrhage, tumours or infections. Patient outcomes were assessed by conducting telephone interviews, utilising questionnaires for modified Rankin Scale (mRS) and extended Glasgow Outcome scale (GOSE). We evaluated the health-related quality of life using the EuroQol (EQ-5D-5L) scale. RESULTS: A total of 144 patients with a median age of 58.5 years (range: 18 to 85 years) were evaluated. The mortality rate was 67%, with patients passing away at a median of 6.0 days (IQR [1.9-37.6]) after DHC. Favourable outcomes, as assessed by the mRS and GOSE were observed in 10.4% and 6.3% of patients, respectively. Cox regression analysis revealed a 2.0% increase in the mortality risk for every year of age (HR = 1.017; 95% CI [1.01-1.03]; p = 0.004). Uni- and bilateral fixed pupils were associated with a 1.72 (95% CI [1.03-2.87]; p = 0.037) and 3.97 (95% CI [2.44-6.46]; p < 0.001) times higher mortality risk, respectively. ROC-analysis demonstrated that age and pupillary reactivity predicted 6-month mortality with an AUC of 0.77 (95% CI [0.69-0.84]). The only parameter significantly associated with a better quality of life was younger age. CONCLUSIONS: Following DHC, mortality remains substantial, and favourable outcomes occur rarely. Particularly in elderly patients and in the presence of clinical signs of herniation, mortality rates are notably elevated. Hence, the indication for DHC should be set critically.

Andexanet alpha versus four-factor prothrombin complex concentrate in DOACs anticoagulation reversal: an updated systematic review and meta-analysis.

BACKGROUND: There is currently a lack of evidence for the comparative effectiveness of Andexanet alpha and four-factor prothrombin complex concentrate (4F-PCC) in anticoagulation reversal of direct oral anticoagulants (DOACs). The primary aim of our systematic review was to verify which drug is more effective in reducing short-term all-cause mortality. The secondary aim was to determine which of the two reverting strategies is less affected by thromboembolic events. METHODS: A systematic review and meta-analysis was performed. RESULTS: Twenty-two studies were analysed in the systematic review and quantitative synthesis. In all-cause short-term mortality, Andexanet alpha showed a risk ratio (RR) of 0.71(95% CI 0.37-1.34) in RCTs and PSMs, compared to 4F-PCC (I2 = 81%). Considering the retrospective studies, the pooled RR resulted in 0.84 (95% CI 0.69-1.01) for the common effects model and 0.82 (95% CI 0.63-1.07) for the random effects model (I2 = 34.2%). Regarding the incidence of thromboembolic events, for RCTs and PSMs, the common and the random effects model exhibited a RR of 1.74 (95% CI 1.09-2.77), and 1.71 (95% CI 1.01-2.89), respectively, for Andexanet alpha compared to 4F-PCC (I2 = 0%). Considering the retrospective studies, the pooled RR resulted in 1.21 (95% CI 0.87-1.69) for the common effects model and 1.18 (95% CI 0.86-1.62) for the random effects model (I2 = 0%). CONCLUSION: Considering a large group of both retrospective and controlled studies, Andexanet alpha did not show a statistically significant advantage over 4F-PCC in terms of mortality. In the analysis of the controlled studies alone, Andexanet alpha is associated with an increased risk of thromboembolic events. CLINICAL TRIAL REGISTRATION: PROSPERO: International prospective register of systematic reviews, 2024, CRD42024548768.

Pathogenicity associated with an infestation of the marine leech parasite Pterobdella arugamensis in farmed fish.

The marine leech Pterobdella arugamensis is a hematophagous parasite, and the extent of injury to the host largely depends on the number of attached leeches. This study aimed to assess the pathogenicity of marine leeches in Asian seabass (Lates calcarifer) and tiger grouper (Epinephelus fuscoguttatus) fingerlings under laboratory conditions. Five groups of healthy Asian seabass and tiger grouper were exposed to varying numbers of marine leeches (0, 1, 10, 30, or 70 per fish) for 7 d. Infested Asian seabass and tiger grouper both showed pathological changes even with only 1 leech, manifesting as clinical signs like haemorrhages. The cumulative mortality at 7 d post-exposure (dpe) was 11 or 33% for Asian seabass infested with 1 or 10 marine leeches, respectively. Fish with 30 or 70 marine leeches showed higher rates of mortality (56%). A similar trend was seen in tiger grouper, with mortality rates reaching 78% in fish with 30 or 70 marine leeches, and 56 or 33% in fish with 10 leeches or 1 leech, respectively. Factorial analysis of mortality after 7 dpe between both species showed significant differences (2-way ANOVA p = 0.001) when exposed to varying numbers of marine leeches. The haematocrit values differed significantly between Asian seabass or tiger grouper infested with either 0 or 1 marine leech and those infested with 10, 30, or 70 marine leeches (1-way ANOVA, p = 0.0001). This suggests that marine leech infestation has a measurable impact on both species. Consequently, fish farmers should promptly address leech infestation upon discovery in their cages.

Identification of mitophagy and ferroptosis-related hub genes associated with intracerebral haemorrhage through bioinformatics analysis.

BACKGROUND: Mitophagy and ferroptosis occur in intracerebral haemorrhage (ICH) but our understanding of mitophagy and ferroptosis-related genes remains incomplete. AIM: This study aims to identify shared ICH genes for both processes. METHODS: ICH differentially expressed mitophagy and ferroptosis-related genes (DEMFRGs) were sourced from the GEO database and literature. Enrichment analysis elucidated functions. Hub genes were selected via STRING, MCODE, and MCC algorithms in Cytoscape. miRNAs targeting hubs were predicted using miRWalk 3.0, forming a miRNA-hub gene network. Immune microenvironment variances were assessed with MCP and TIMER. Potential small molecules for ICH were forecasted via CMap database. RESULTS: 64 DEMFRGs and ten hub genes potentially involved in various processes like ferroptosis, TNF signalling pathway, MAPK signalling pathway, and NF-kappa B signalling pathway were discovered. Several miRNAs were identified as shared targets of hub genes. The ICH group showed increased infiltration of monocytic lineage and myeloid dendritic cells compared to the Healthy group. Ten potential small molecule drugs (e.g. Zebularine, TWS-119, CG-930) were predicted via CMap. CONCLUSION: Several shared genes between mitophagy and ferroptosis potentially drive ICH progression via TNF, MAPK, and NF-kappa B pathways. These results offer valuable insights for further exploring the connection between mitophagy, ferroptosis, and ICH.

Cerebral haemorrhage in the patient with atrial fibrillation: do we employ the direct oral anticoagulants without waiting too long?

Intracranial haemorrhage (ICH) is the most feared haemorrhagic complication of oral anticoagulant therapy (OAT), although the risk is significantly lower with direct oral anticoagulants (DOACs) compared with warfarin. Intracranial haemorrhage is generally considered, by clinicians, to be an absolute contraindication to starting or resuming OAT in patients with atrial fibrillation (AF). On the other hand, the pivotal trials with DOACs excluded patients with previous ICH. Observational studies actually indicate a net clinical benefit in favour of DOAC in patients with AF and previous ICH. This benefit is confirmed by randomized clinical trials which, however, have the limitation of the small number of cases, but larger clinical trials comparing DOACs vs. aspirin or no therapy are underway. While OAT is certainly contraindicated in patients with lobar ICH and cerebral amyloid angiopathy, in other cases, the decision must be made in the individual patient through an accurate balance between thromboembolic risk and haemorrhagic risk and a multidisciplinary cardio-neurological evaluation.

Long-term survival of traumatic brain injury and intra-cerebral haemorrhage patients: A multicentric observational cohort.

PURPOSE: Mortality is often assessed during ICU stay and early after, but rarely at later stage. We aimed to compare the long-term mortality between TBI and ICH patients. MATERIALS AND METHODS: From an observational cohort, we studied 580 TBI patients and 435 ICH patients, admitted from January 2013 to February 2021 in 3 ICUs and alive at 7-days post-ICU discharge. We performed a Lasso-penalized Cox survival analysis. RESULTS: We estimated 7-year survival rates at 72.8% (95%CI from 67.3% to 78.7%) for ICH patients and at 84.9% (95%CI from 80.9% to 89.1%) for TBI patients: ICH patients presenting a higher mortality risk than TBI patients. Additionally, we identified variables associated with higher mortality risk (age, ICU length of stay, tracheostomy, low GCS, absence of intracranial pressure monitoring). We also observed anisocoria related with the mortality risk in the early stage after ICU stay. CONCLUSIONS: In this ICU survivor population with a prolonged follow-up, we highlight an acute risk of death after ICU stay, which seems to last longer in ICH patients. Several variables characteristic of disease severity appeared associated with long-term mortality, raising the hypothesis that the most severe patients deserve closer follow-up after ICU stay.

Interventional radiology for prevention and management of postpartum haemorrhage: a single centre retrospective cohort study.

PURPOSE: Postpartum haemorrhage (PPH) remains a leading cause of maternal death despite current medical management. Surgical interventions are still needed for refractory bleeding. Interventional radiology (IR) can be a successful intermediary that avoids the need for hysterectomy. Nevertheless, IR outcome data in a peripartum setting are limited. The objective of this study is to document the efficacy and safety of IR. METHODS: Retrospective study reviewed the records of consecutive patients who underwent peripartum IR from 01/01/2010 until 31/12/2020 in a tertiary academic centre. Patients were divided in a prophylactic and a therapeutic group. Information about interventions before and after IR, and IR specific complications was retrieved. Efficacy was defined by the number of transfusions and additional surgical interventions needed after IR, and safety was assessed by the incidence of IR related complications. RESULTS: Fifty-four patients, prophylactic group (n = 24) and therapeutic group (n = 30), were identified. In both groups, IR was successful with 1.5 ± 2.9 packed cells transfused post-IR (1.0 ± 2.1 prophylactic vs 1.9 ± 3.3 therapeutic; p = 0.261). Additional surgical interventions were required in n = 5 patients (9.2%), n = 1 (4.2%) in the prophylactic vs. n = 4 (13.3%) in the therapeutic group. Complications were reported in n = 12 patients (22.2%), n = 2 (8.3%) prophylactic vs. n = 10 (33.3%) in therapeutic group. Mostly minor complications, as puncture site hematoma or bleeding, were reported in n = 4 (7.4%). Severe complications as necrosis and metabolic complications were reported in n = 2 patients (3.9%). CONCLUSION: IR for prevention and treatment of PPH was highly successful and associated with minor complications.

Millard-Gubler Syndrome in a Patient with Preeclampsia. Case Report and Review of Combined Intra- and Extra-Axial Facial and Abducens Nerve Injuries.

Millard-Gubler syndrome is a pontine syndrome caused by a lesion in the lower pons region. It is characterised by ipsilateral facial paralysis and VI paresis and contralateral brachiocrural palsy. We present the case of a female patient, G4P2A1, at 21 weeks of gestation, with preeclampsia, complaints of blurred vision, diplopia, and right hemiparesis, in whom a clinical diagnosis of Millard-Gubler syndrome was made. Neuroimaging showed an intraparenchymal haemorrhage towards the central portion of the bulbopontine junction. An extensive aetiological study was carried out to determine the cause of the hypertensive disorder syndrome during pregnancy. The patient improved satisfactorily from the neurological deficit after delivery of an early stillbirth.

A retrospective analysis of postpartum red blood cell transfusions at a tertiary care obstetric centre.

BACKGROUND AND OBJECTIVES: Postpartum anaemia is a prevalent health problem. We aimed to determine the compliance rate for red blood cell (RBC) transfusion indication among postpartum women in a single tertiary care centre in Quebec, Canada. MATERIALS AND METHODS: Retrospective cohort study including all women ≥6 h postpartum who received ≥1 RBC transfusion during their delivery hospitalization between January 2005 and February 2022. We determined our centre's compliance rate by indication as compared to current society guidelines, all published after 2015 (Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis [NATA], Royal College of Obstetricians and Gynaecologists [RCOG], American College of Obstetricians and Gynecologists [ACOG]). We then explored predictors of guideline non-compliance and described transfusion practices in our centre. RESULTS: A total of 171 women were included. Our centre's compliance rate was 79.5% (95% confidence interval [CI] 72.7-84.8). Predictors of guideline non-compliance were maternal medical comorbidity or abnormal placentation, both limited by large CIs (odds ratio [OR] 2.26, CI 1.02-4.94, p = 0.04; OR 4.00, CI 1.31-12.06, p = 0.01, respectively). Postpartum haemorrhage was diagnosed among 68% of the cohort, mostly due to uterine atony (73.3%). Mean baseline and nadir haemoglobin were 111 g/L (±18) and 62 g/L (±7.7), respectively. Multiple unit initial transfusion was found in a majority of patients (63.7%). Iron therapy was administered to 51.5% of women in-hospital and 81.9% received an oral iron prescription at discharge. There were no differences in primary or secondary outcomes subsequent to relevant guideline publication. CONCLUSION: Our centre's compliance rate for RBC transfusion indication meets current practice guidelines. Areas for improvement include single-unit initial transfusion protocols and adjuvant iron treatment. Antenatal optimization of haemoglobin and ferritin stores may limit postpartum transfusions.