Guidelines for the management of coagulation disorders in patients with cirrhosis.

Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients. These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation.

Dynamic assessment of CHA2DS2-VASc and HAS-BLED scores for predicting ischemic stroke and major bleeding in atrial fibrillation patients.

INTRODUCTION AND OBJECTIVES: Stroke and bleeding risks in atrial fibrillation (AF) are often assessed at baseline to predict outcomes years later. We investigated whether dynamic changes in CHA2DS2-VASc and HAS-BLED scores over time modify risk prediction. METHODS: We included patients with AF who were stable while taking vitamin K antagonists. During a 6-year follow-up, all ischemic strokes/transient ischemic attacks (TIAs) and major bleeding events were recorded. CHA2DS2-VASc and HAS-BLED were recalculated every 2-years and tested for clinical outcomes at 2-year periods. RESULTS: We included 1361 patients (mean CHA2DS2-VASc and HAS-BLED 4.0±1.7 and 2.9±1.2). During the follow-up, 156 (11.5%) patients had an ischemic stroke/TIA and 269 (19.8%) had a major bleeding event. Compared with the baseline CHA2DS2-VASc, the CHA2DS2-VASc recalculated at 2 years had higher predictive ability for ischemic stroke/TIA during the period from 2 to 4 years. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) showed improvements in sensitivity and better reclassification. The CHA2DS2-VASc recalculated at 4 years had better predictive performance than the baseline CHA2DS2-VASc during the period from 4 to 6 years, with an improvement in IDI and an enhancement of the reclassification. The recalculated HAS-BLED at 2-years had higher predictive ability than the baseline score for major bleeding during the period from 2 to 4 years, with significant improvements in sensitivity and reclassification. A slight enhancement in sensitivity was observed with the HAS-BLED score recalculated at 4 years compared with the baseline score. CONCLUSIONS: In AF patients, stroke and bleeding risks are dynamic and change over time. The CHA2DS2-VASc and HAS-BLED scores should be regularly reassessed, particularly for accurate stroke risk prediction.

Uterotonics, magnesium sulphate and antibiotics during childbirth and peripartum: Important obstetric drugs for the anaesthesiologist.

The main causes of maternal mortality are comorbidities, hypertensive pregnancy syndrome, obstetric haemorrhage, and maternal sepsis. For this reason, uterotonics, magnesium sulphate, and antibiotics are essential tools in the management of obstetric patients during labour and in the peripartum period. These drugs are widely used by anaesthesiologists in all departments, and play a crucial role in treatment and patient safety. For the purpose of this narrative review, we performed a detailed search of medical databases and selected studies describing the use of these drugs in patients during pregnancy, delivery and the pospartum period. Uterotonics, above all oxytocin, play an important role in the prevention and treatment of pospartum haemorrhage, and various studies have shown that in obstetric procedures, such as scheduled and emergency caesarean section, they are effective at lower doses than those hitherto accepted. We also discuss the use of carbetocin as an effective alternative that has a therapeutic advantage in certain clinical circumstances. Magnesium sulphate is the gold standard in the prevention and treatment of eclampsia, and also plays a neuroprotective role in preterm infants. We describe the precautions to be taken during magnesium administration. Finally, we discuss the importance of understanding microbiology and the pharmacology of antibiotics in the management of obstetric infection and endometritis, and draw attention to the latest trends in antibiotic regimens in labour and caesarean section.

Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage.

INTRODUCTION: Subarachnoid haemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts. METHODS: This study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients' clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analysed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration. RESULTS: A total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25.3%. 66.3% of the total of patients with SAH were due to intracranial aneurysm rupture (n = 238). 45.3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11.7% (n = 28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26.1 days. The mean rate of reoperation of patients after shunt was 17.7%, mostly due to infection. CONCLUSIONS: The most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain.

INTRODUCTION AND OBJECTIVES: The optimal timing of coronary angiography in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. METHODS: This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. RESULTS: Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). CONCLUSIONS: In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.

Diagnostic accuracy of the Oakland score versus haemoglobin for predicting outcomes in lower gastrointestinal bleeding.

BACKGROUND: Acute lower gastrointestinal bleeding (ALGIB) is a common cause of hospitalization. Recent guidelines recommend the use of prognostic scales for risk stratification. However, it remains unclear whether risk scores are more accurate than some simpler prognostic variables. OBJECTIVE: To compare the predictive values of haemoglobin alone and the Oakland score for predicting outcomes in ALGIB patients. DESIGN: Single-centre, retrospective study at a University Hospital. Data were extracted from the hospital's clinical records. The Oakland score was calculated at admission. Study outcomes were defined according to the original article describing the Oakland score: safe discharge (the primary Oakland score outcome), transfusion, rebleeding, readmission, therapeutic intervention and death. Area under the receiver operating characteristics (AUROC) curve and accuracy using haemoglobin and the Oakland score were calculated for each outcome. RESULTS: Two hundred and fifty-eight patients were included. Eighty-four (32.6%) needed transfusion, 50 (19.4%) presented rebleeding, 31 (12.1%) required therapeutic intervention, 20 (7.8%) were readmitted and six (2.3%) died. There were no differences in the AUROC curve values for haemoglobin versus the Oakland score with regard to safe discharge (0.82 (0.77-0.88) vs 0.80 (0.74-0.86), respectively) or to therapeutic intervention and death. Haemoglobin was significantly better for predicting transfusion and rebleeding, and the Oakland score was significantly better for predicting readmission. CONCLUSION: In our study, the Oakland score did not perform better than haemoglobin alone for predicting the outcome of patients with ALGIB. The usefulness of risk scores for predicting outcomes in clinical practice remains uncertain.

Tranexamic acid in patients with traumatic brain injury: a meta-analysis.

BACKGROUND: We performed a meta-analysis to assess the effectiveness and safety of tranexamic acid in patients with traumatic brain injury (TBI). METHODS: We searched the literature for articles evaluating the effectiveness and safety of tranexamic acid (TXA) in TBI published between January 2012 and January 2021, and identified 8 studies with a total of 10860 patients: 5660 received TXA and 5200 served as controls. We used a dichotomous or continuous approach with a random or fixed-effect model to assess the efficacy and safety of TXA in TBI, and calculated the mean difference (MD) and odds ratio (OR) with the corresponding 95% confidence interval. RESULTS: In patients with TBI, early administration of TXA was associated with a greater relative benefit (MD -2.45; 95% CI = -4.78 to -0.12; p=0.04) and less total haematoma expansion (MD - 2.52; 95% CI = -4.85 to -0.19; p=0.03) compared to controls. There were no statistically significant differences in mortality (OR 0.94; 95% CI=0.85-1.03; p=0.18), presence of progressive haemorrhage (OR 0.75; 95% CI=0.56-1.01; p=0.06), need for neurosurgery (OR 1.15; 95% CI=0.66-1.98; p=0.63), high Disability Rating Scale score (OR 0.90; 95% CI=0.56-1.45; p=0.68), and incidence of ischaemic or thromboembolic complications (OR 1.34; 95% CI=0.33-5.46; p=0.68) between TBI patients treated with TXA and controls. CONCLUSIONS: Early administration of TXA in TBI patients may have a greater relative benefit and may inhibit haematoma expansion. There were no significant differences in mortality, presence of progressive haemorrhage, need for neurosurgery, high Disability Rating Scale score, and incidence of ischaemic or thromboembolic complications between TBI patients treated with TXA and controls. Further studies are needed to validate these results.

Systematic review of clinical trials on antithrombotic therapy with factor XI inhibitors.

INTRODUCTION AND OBJECTIVE: Data from phase 2 clinical trials suggest that factor XI inhibitors may exhibit a more favorable efficacy/safety profile compared to current antithrombotic therapies. The aim of this systematic review is to analyze the available evidence derived from these studies. METHODS: A literature search in the PubMed, Cochrane Library, Scopus, EMBASE databases, and clinical trial registration platforms Clinical Trials and Cochrane Central Register of Controlled was conducted. In accordance with the PRISMA statement, results were reported. RESULTS: A total of 18 completed or ongoing clinical trials addressing multiple scenarios, including atrial fibrillation, stroke, myocardial infarction, and venous thromboembolism, were identified. Evidence from 8 studies with available results was analyzed. Phase 2 studies with factor XI inhibitors, overall, demonstrated an acceptable efficacy and safety profile. The benefit-risk balance, in terms of reducing venous thromboembolism in patients undergoing total knee arthroplasty, was more favorable. For this scenario, factor XI inhibitors showed a 50% reduction in the overall rate of thrombotic complications and a 60% reduction in the rate of bleeding compared to enoxaparin. Modest results in studies involving patients with atrial fibrillation, stroke, and myocardial infarction were observed. CONCLUSIONS: Factor XI inhibitors offer new prospects in antithrombotic treatment and prophylaxis. Ongoing phase 3 studies will help define the most suitable drugs and indications.

Evaluation of the last 2 decades in the characteristics of presentation, management and prognosis of serious spontaneous intracerebral hemorrhage in a third level hospital.

OBJECTIVE: To analyze the change in the characteristics of presentation, evolution and treatment in the ICU, as well as the functional evolution at 12 months of spontaneous intracranial hemorrhages (ICHs) treated in an ICU reference center. PATIENT AND METHODS: Descriptive, retrospective study in a Neurocritical Reference Hospital. All admissions of patients with HICE during three periods are studied: 1999-2001 (I), 2015-2016 (II) and 2020-2021 (III). Evolution in the three periods of demographic variables, baseline characteristics of the patients, clinical variables and characteristics of bleeding, evolutionary data in the ICU are studied. At one year we assessed the GOS scale (Glasgow Outcome Score) according to whether they had a poor (GOS 1-3) or good (GOS 4-5) prognosis. RESULTS: 300 admitted patients, distributed in periods: I: 28.7%, II: 36.3% and III: 35%. 56.7% were males aged 66 (55.5-74) years; ICH score 2 (1-3). The ICU stay was 5 (2-14) days with a mortality of 36.8%. GOS 1-3 a year in 67.3% and GOS 4-5 in 32.7%. Comparing the three periods, we observed a higher prevalence in women, and the presence of cardiovascular factors; no changes in etiology; in relation to the location, it increases cerebellar hemorrhage and in the brainstem. Although the severity was greater, the stay in the ICU, the use of invasive mechanical ventilation and tracheostomy were lower. Open surgery has decreased its use by 50%. Mortality continues to be high, stagnating in the ICU at 35% and entails a high degree of disability one year after assessment. CONCLUSIONS: Severe ICH is a complex pathology that has changed some characteristics in the last two decades, with more severe patients, with more cardiovascular history and a greater predominance of brainstem and cerebellar hemorrhage. Despite the increase in severity, better parameters during the ICU stay, with open surgery used 50% less. Mortality remains stagnant at 35% with high disability per year.

Umbral crítico de administración en pacientes con trauma severo y reanimación endovascular: ¿Un concepto útil? / Critical Administration Threshold in severe trauma patients and endovascular resuscitation: A useful concept?

Introducción. Se describe la utilidad del umbral crítico de administración (CAT por su denominación en inglés) como herramienta para la reanimación hemostática en pacientes con trauma severo y oclusión endovascular aórtica. Métodos. Revisión retrospectiva de pacientes adultos con hemorragia por trauma, con o sin oclusión endovascular aórtica (REBOA), atendidos entre enero de 2015 y junio de 2020, en un centro de trauma nivel I en Cali, Colombia. Se registraron variables demográficas, severidad del trauma, estado clínico, requerimiento transfusional, tiempo hasta CAT+ y CAT alcanzado (1, 2 ó 3). Resultados. Se incluyeron 93 pacientes, se utilizó REBOA en 36 y manejo tradicional en 57. El grupo REBOA presentó mayor volumen de sangrado (mediana de 3000 ml, RIC: 1950-3625 ml) frente al grupo control (mediana de1500 ml, RIC: 700-2975ml) (p<0,001) y mayor cantidad de glóbulos rojos transfundidos en las primeras 6 horas (mediana de 5, RIC:4-9); p=0,015 y en las primeras 24 horas (mediana de 6, RIC: 4-11); p=0,005. No hubo diferencias estadísticamente significativas en número de pacientes CAT+ entre grupos o tiempo hasta alcanzarlo. Sin embargo, el estado CAT+ durante los primeros 30 minutos de la cirugía fue mayor en grupo REBOA (24/36, 66,7 %) frente al grupo control (17/57, 29,8 %; p=0,001), teniendo este mayor tasa de mortalidad intrahospitalaria frente a los pacientes CAT-. Conclusión. El umbral crítico de administración es una herramienta útil en la reanimación hemostática de pacientes con trauma y REBOA, que podría predecir mortalidad precoz.

Introduction. The objective is to describe the utility of the Critical Administration Threshold (CAT) as a tool in hemostatic resuscitation in patients with severe trauma and REBOA. Methods. Retrospective review between January 2015 and June 2020 of adult patients with hemorrhage secondary to trauma with or without REBOA in a level I trauma center in Cali, Colombia. Demographic variables, trauma severity, clinical status, transfusion needs, time to CAT+ and number of CAT achieved (1, 2 or 3) were recorded. Results. Ninety-three patients were included, in which REBOA was used in 36 and traditional management in 57. The REBOA group had a higher bleeding volume (3000 ml), IQR: 1950-3625 ml vs the control group (1500 ml, IQR: 700-2975 ml) (p<0.001) and a higher rate of PRBC units transfused in the first 6 hours (median 5, IQR: 4-9); p=0.015 and in the first 24 hours (median 6, IQR: 4-11); p=0.005. There were no statistically significant differences in the number of CAT+ patients between groups or time to CAT+. However, CAT+ status during the first 30 minutes of surgery was higher in the REBOA Group (24/36, 66.7%) vs. the control group (17/57, 29.8%; p=0.001), having this group a higher in-hospital mortality rate vs. CAT- patients. Conclusion. CAT is a useful tool in the hemostatic resuscitation of patients with trauma and REBOA that could predict early mortality.

Cohorte descriptiva de pacientes adultos con hipertensión portal en una institución de tercer nivel en Colombia / Descriptive cohort of adult patients with portal hypertension at a tertiary care institution in Colombia

Introducción. La hipertensión portal (HTP) se define como una elevación anormal de la presión venosa en el sistema portal que lleva al desarrollo de vías colaterales para desviar el flujo sanguíneo de la zona. Dentro de su etiología están las relacionadas con la cirrosis hepática y otras causas denominadas no cirróticas. El objetivo de este estudio fue evaluar los principales hallazgos demográficos, clínicos y paraclínicos en un grupo de pacientes con HTP, y determinar el uso de ayudas invasivas y no invasivas, y su disponibilidad para el diagnóstico y seguimiento de los pacientes en los centros que no cuentan con laboratorio de hemodinamia hepática, reflejando la dinámica de múltiples escenarios en Colombia. Metodología. Se realizó un estudio descriptivo de corte transversal, retrospectivo, en pacientes atendidos en una institución de tercer nivel del sur de Colombia, entre enero del año 2015 y diciembre del año 2020. Resultados. Se obtuvo una muestra de 61 pacientes en donde la mayoría de casos correspondían a hombres en la séptima década de la vida, procedentes del área urbana. La principal causa de consulta fue el sangrado digestivo (39,3 %), asociado a la presencia de telangiectasias (arañas vasculares) en el 37,2 %, seguido de circulación colateral (31,3 %) e ictericia (19,7 %). En la ecografía abdominal (realizada en el 57,4 % de los pacientes) predominaron la cirrosis (68 %) y la presencia de esplenomegalia (14,2 %), y en lospacientes con Doppler portal (realizado en el 16,4 %) se encontró hígado cirrótico (80 %) y dilatación portal (40 %). Con respecto a los hallazgos en la esofagogastroduodenoscopia predominó la presencia de várices esofágicas y gastritis crónica. Conclusión. El principal motivo de consulta fue el sangrado digestivo, en tanto que la cirrosis fue el antecedente y el hallazgo imagenológico más frecuente, seguido de las várices esofágicas. Se encontró que el uso de paraclínicos, ecografía abdominal, ecografía con Doppler portal y esofagogastroduodenoscopia fueron los más utilizados en el contexto clínico de los pacientes con el diagnóstico de HTP.

Introduction. Portal hypertension (PHT) is defined as an abnormal elevation of venous pressure in the portal system that leads to the development of collateral pathways to divert blood flow from the area. Within its etiology are those related to liver cirrhosis and other so-called non cirrhotic causes. The aim of this study was to evaluate the main demographic, clinical and paraclinical findings in a group of patients with PHT, and to determine the use of invasive and non-invasive aids, and their availability for the diagnosis and follow-up of patients in centers that do not have a hepatic hemodynamics laboratory, reflecting the dynamics of multiple scenarios in Colombia. Methodology. A descriptive, retrospective, cross-sectional, retrospective study was conducted in patients attended in a third level institution in Southern Colombia, between January 2015 and December 2020. Results. A sample of 61 patients was obtained where the majority of cases corresponded to men in the seventh decade of life, from the urban area. The main cause of consultation was digestive bleeding (39.3%), associated with the presence of telangiectasias (spider veins) in 37.2%, followed by collateral circulation (31.3%) and jaundice (19.7%). In abdominal ultrasound (performed in 57.4% of the patients), cirrhosis (68%) and the presence of splenomegaly (14.2%) predominated, and in patients with portal Doppler (performed in 16.4%), cirrhotic liver (80%) and portal dilatation (40%) were found. With respect to the findings in the esophagogastroduodenoscopy, esophageal varices and chronic gastritis were predominant. Conclusion. The main reason for consultation was gastrointestinal bleeding, while cirrhosis was the most frequent history and imaging finding, followed by esophageal varices. It was found that the use of paraclinics, abdominal ultrasound, ultrasound with portal Doppler and esophagogastroduodenoscopy were the most used in the clinical context of patients diagnosed with PHT.

Twelve controversial questions in aneurysmal subarachnoid hemorrhage.

Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains a major challenge. Despite the recent publication of guidelines from the American Heart Association/American Stroke Association and the Neurocritical Care Society, there are many controversial questions in the intensive care unit (ICU) management of this population. The authors provide an analysis of common issues in the ICU and provide guidance on the daily management of this specific population of neurocritical care patients.

Prognostic value of scales for aneurysmal subarachnoid hemorrhage: Report of a reference center in Peru.

INTRODUCTION: Multiple scales have been designed to stratify the severity and predict the prognosis in the initial evaluation of patients with aneurysmal subarachnoid hemorrhage (aSAH). Our study aimed to validate the most commonly used prognostic scales for aSAH in our population: Hunt-Hess, modified Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH), and Barrow Aneurysm Institute (BAI) scales. METHODS: This study includes all aSAH cases treated at our institution between June 2019 and December 2020. We developed a retrospective cohort by reviewing medical records and radiologic images performed during hospitalization. The outcome was evaluated using the modified Rankin scale (mRS). It was defined as a poor outcome (mRS 4-5) and mortality (mRS 6). The ROC curves and the area under the curve (AUC) of each of the prognostic scales were calculated to evaluate their prognostic prediction capacity. RESULTS: A total of 142 patients were diagnosed with aSAH. A poor outcome occurred in 52.1% of the patients, whereas mortality was 27.5%. The AUC of the scales studied was similar and no significant difference was found between them for predicting a poor outcome (P = .709) or mortality (P = .715). CONCLUSION: We determined that the prognostic scales for aSAH had a similar predictive value for poor clinical outcomes and mortality in our institution, with no significant difference. Thus, we recommend the most simple and well-known scale used institutionally.

Intracerebral hemorrhage after deep brain stimulation surgery guided with microelectrode recording: analysis of 297 procedures.

OBJECTIVES: Report the incidence of symptomatic and asymptomatic intracerebral hemorrhage (ICH) in patients submitted to deep brain stimulation (DBS) guided with microelectrode recording (MER) with further analysis of potential risk factors, both inherent to the patient and related to the pathology and surgical technique. METHODS: We performed a retrospective observational study. 297 DBS procedures were concluded in 277 patients in a single hospital centre between January 2010 and December 2020. All surgeries were guided with MER. We analysed the incidence of symptomatic and asymptomatic ICH and its correlation to age, sex, diagnosis, hypertension and perioperative hypertension, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, and number of MER trajectories. RESULTS: There were a total of 585 electrodes implanted in 277 patients. 16 ICH were observed, of which 6 were symptomatic and 10 asymptomatic, none of which incurred in permanent neurological deficit. The location of the hemorrhage varied between cortical and subcortical plans, always in relation with the trajectory or the final position of the electrode. The incidence of symptomatic ICH per lead-implantation was 1%, and the CT-scan demonstrated asymptomatic ICH in 1.7% more patients. Male patients or with hypertension are 2.7 and 2.2 times more likely to develop ICH, respectively. However, none of these characteristics has been shown to have a statistically significant association with the occurrence of ICH, as well as age, diagnosis, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, number of MER trajectories and perioperative hypertension. CONCLUSIONS: MER-guided DBS is a safe technique, with low incidence of ICH and no permanent deficits in our study. Hypertension and male sex seem to be risk factors for the development of ICH in this surgery. Nevertheless, no statistically significant factors were found for the occurrence of this complication.

Single antiplatelet therapy after left atrial appendage closure in patients with AF: safety and effectiveness.

INTRODUCTION AND OBJECTIVES: The optimal antithrombotic strategy following left atrial appendage closure (LAAC) is poorly defined in patients with nonvalvular atrial fibrillation. We assessed the safety and effectiveness of a single antiplatelet treatment (SAPT) strategy after LAAC in a population at high risk of ischemic and bleeding events. METHODS: This single-center, observational, prospective study included a consecutive cohort of patients who underwent LAAC using the LAmbre device (Lifetech Scientific, China) and who were discharged with SAPT. The primary outcome was a composite of stroke, systemic embolism, and device-related thrombosis during follow-up. Secondary endpoints were cardiovascular mortality and major bleeding events (BARC ≥3a). Clinical follow-up was performed at 1, 6, and 12 months and subsequently on an annual basis. Transesophageal echocardiography was performed at 1 and 12 months of follow-up. RESULTS: The study comprised 74 patients. The median age was 77 [72-83] years and 43% were women. The cohort exhibited a high prevalence of comorbidities and cardiovascular risk factors. The median CHA2DS2-VASc and HAS-BLED scores were 4 [3-6] and 4 [4-5], respectively. The median length of follow-up was 2.5 years (188 patients-year). During follow-up, device-related thrombosis occurred in 3 patients (4%). Ischemic stroke occurred in 1 patient (1.3%, rate 0.5%/y), representing a 90.9% relative risk reduction compared with the risk predicted by CHA2DS2-VASc. Major bleeding events occurred in 12 patients (16%, 6.4%/y), with a relative risk reduction of 26.4% of that predicted by HAS-BLED. Cardiovascular-related mortality was observed in 2 patients (2.7%). CONCLUSIONS: SAPT appears to be a safe and effective treatment following LAAC in patients at high ischemic and hemorrhagic risk. Further studies are needed to confirm our findings.

[Neurological evolution in traumatic spinal cord injury according to the size of the intraparenchymal hemorrhage]. / Evolución neurológica en la lesión medular traumática en función del tamaño de la hemorragia intraparenquimatosa.

INTRODUCTION AND OBJECTIVES: The presence of spinal cord hemorrhage is considered as a poor prognostic factor in traumatic spinal cord injury (SCI). However, it has been suggested in published works that the prognosis of small hemorrhages is not so negative. The aim of this paper is to assess the neurological evolution in individuals with intraparenchymal hemorrhage according to its size. MATERIAL AND METHODS: Retrospective observational study. Selected all the patients admitted for acute traumatic SCI between 2010 and 2018 with early magnetic resonance study and spinal cord hemorrhage. Two groups were established depending on the size of the bleeding: microhemorrhages (less than 4mm) and macrohemorrhages (greater than 4mm). The neurological examination at admission and discharge was compared according to the AIS grade and the motor score (MS). RESULTS: Forty-six cases collected, 17 microhemorrhages and 29 macrohemorrhages. 70.6% of the microhemorrhages were AIS A while among macrohemorrhages the percentage was 89.6%. At the time of discharge, an improvement in the AIS grade was observed in 40.0% of the microhemorrhages compared to 4.0% of the macrohemorrhages (P=.008). Initial MS was similar, 45.2±22.2 in the microhemorrhages and 40.9±20.4 in the macrohemorrhages (P=.459), but at discharge it was higher in the first group: 60.4±20.5 for 42.7±22.8 (P=.033). Eight patients (17.4%) died during admission. CONCLUSIONS: There is a relationship between the size of the intraparenchymal hemorrhage and the neurological prognosis of SCI, with hemorrhages smaller than 4mm presenting a better evolution.

Aneurysmal subarachnoid haemorrhage: Volumetric quantification of the blood distribution pattern to accurately predict the ruptured aneurysm location.

BACKGROUND: In spontaneous subarachnoid haemorrhage (SAH) accurate determination of the bleeding source is paramount to guide treatment. Traditionally, the bleeding pattern has been used to predict the aneurysm location. Here, we have tested a software-based tool, which quantifies the volume of intracranial blood and stratifies it according to the regional distribution, to predict the location of the ruptured aneurysm. METHODS: A consecutive series of SAH patients admitted to a single tertiary centre between 2012-2018, within 72 h of onset, harbouring a single intracranial aneurysm. A semi-automatized method of blood quantification, based on the relative density increase, was applied to initial non-contrast CTs. Five regions were used to define the bleeding patterns and to correlate them with aneurysm location: perimesencephalic, interhemispheric, right/left hemisphere and intraventricular. RESULTS: 68 patients were included for analysis. There was a strong association between the distribution of blood and the aneurysm location (p < 0.001). In particular: ACom and interhemispheric fissure (p < 0.001), MCA and ipsilateral hemisphere (p < 0.001), ICA and ipsilateral hemisphere and perimesencephalic cisterns (p < 0.001), PCom and hemispheric, perimesencephalic and intraventricular (p = 0.019), and PICA and perimesencephalic and intraventricular (p < 0.001). The internal diagnostic value was high (AUROC ≥ 0.900) for these locations. CONCLUSION: Regional automatised volumetry seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid spaces. This tool accurately predicts the location of the ruptured aneurysm; its use may be prospectively considered in the emergency setting when speed and simplicity are attained.

Bundle para quantificação de perda sanguínea pós-parto vaginal / Bundle para la cuantificación de pérdida sanguínea posparto vaginal / Bundle for quantifying vaginal blood loss after childbirth

Resumo Objetivo Construir e validar o conteúdo de um bundle para quantificação da perda sanguínea pós-parto vaginal. Métodos Estudo metodológico desenvolvido de fevereiro a agosto de 2022, em três etapas: levantamento bibliográfico, construção do instrumento e validação de conteúdo por 14 experts. O instrumento para validação foi composto por 11 itens selecionados a partir de revisão sistemática. Para cada item do bundle aplicou-se escala Likert e para verificar a concordância entre experts, calculou-se o Índice de Concordância. Consideraram-se válidos os itens com concordância acima de 80%. A validação de conteúdo foi realizada em uma única rodada de avaliação. Resultados A versão final do bundle foi composta por nove itens. Os cuidados propostos estão relacionados à quantificação direta do sangramento pós-parto e seu registro, observação da puérpera, a utilização de protocolos institucionais em casos de hemorragia pós-parto, assim como a capacitação da equipe. Conclusão O estudo permitiu construir e validar bundle para quantificação da perda sanguínea pós-parto vaginal, com vistas à melhora do diagnóstico de hemorragia pós-parto.

Resumen Objetivo Elaborar y validar el contenido de un bundle para la cuantificación de pérdida sanguínea posparto vaginal. Métodos Estudio metodológico, llevado a cabo de febrero a agosto de 2022, en tres etapas: análisis bibliográfico, construcción del instrumento y validación de contenido por 14 expertos. El instrumento para validación consistió en 11 ítems seleccionados a partir de revisión sistemática. Se aplicó la escala Likert para cada ítem del bundle; y para verificar la concordancia entre expertos, se calculó el Índice de Concordancia. Se consideraron válidos los ítems con concordancia superior a 80 %. La validación de contenido se realizó en una única ronda de evaluación. Resultados La versión final del bundle consistió en nueve ítems. Los cuidados propuestos están relacionados con la cuantificación directa del sangrado posparto y su registro, la observación de la puérpera, la utilización de protocolos institucionales en casos de hemorragia posparto, así como también la capacitación del equipo. Conclusión El estudio permitió elaborar y validar un bundle para la cuantificación de pérdida sanguínea posparto vaginal, con el fin de mejorar el diagnóstico de hemorragia posparto.

Abstract Objective To construct and validate the content of a bundle to quantify vaginal blood loss after childbirth. Methods This is a methodological study developed from February to August 2022, divided into bibliographic survey, instrument construction and content validity, by 14 experts. The instrument for validity consisted of 11 items selected from a systematic review. For each item in the bundle, a Likert scale was applied, and to check agreement among experts, the Concordance Index was calculated. Items with agreement above 80% were considered valid. Content validity was carried out in a single round of assessment. Results The final version of the bundle consisted of nine items. The proposed care is related to direct quantification of postpartum bleeding and its recording, observation of postpartum women, use of institutional protocols in cases of postpartum hemorrhage as well as team training. Conclusion The study allowed constructing and validating a bundle for quantifying vaginal blood loss after childbirth, with a view to improving postpartum hemorrhage diagnosis.

Homocysteine serum levels in patients with ruptured and unruptured intracranial aneurysms: a case-control study / Homocisteína sérica em pacientes com aneurismas rotos e não rotos: um estudo caso-controle

Abstract Background There is very few data regarding homocysteine's influence on the formation and rupture of intracranial aneurysms. Objective To compare homocysteine levels between patients with ruptured and unruptured intracranial aneurysms, and to evaluate possible influences of this molecule on vasospasm and functional outcomes. Methods This is a retrospective, case-control study. We evaluated homocysteinemia differences between patients with ruptured and unruptured aneurysms; and the association of homocysteine levels with vasospasm and functional outcomes. Logistic regressions were performed. Results A total of 348 participants were included: 114 (32.8%) with previous aneurysm rupture and 234 (67.2%) with unruptured aneurysms. Median homocysteine was 10.75μmol/L (IQR = 4.59) in patients with ruptured aneurysms and 11.5μmol/L (IQR = 5.84) in patients with unruptured aneurysms. No significant association was detected between homocysteine levels and rupture status (OR = 0.99, 95% CI = 0.96-1.04). Neither mild (>15μmol/L; OR = 1.25, 95% CI 0.32-4.12) nor moderate (>30μmol/L; OR = 1.0, 95% CI = 0.54-1.81) hyperhomocysteinemia demonstrated significant correlations with ruptured aneurysms. Neither univariate (OR = 0.86; 95% CI 0.71-1.0) nor multivariable age-adjusted (OR = 0.91; 95% CI = 0.75-1.05) models evidenced an association between homocysteine levels and vasospasm. Homocysteinemia did not influence excellent functional outcomes at 6 months (mRS≤1) (OR = 1.04; 95% CI = 0.94-1.16). Conclusion There were no differences regarding homocysteinemia between patients with ruptured and unruptured intracranial aneurysms. In patients with ruptured aneurysms, homocysteinemia was not associated with vasospasm or functional outcomes.

RESUMO Antecedentes Existem poucos dados sobre a influência da homocisteína na formação e rotura de aneurismas intracranianos (AI). Objetivo Comparar os níveis de homocisteína entre pacientes com AI rotos e não rotos e influências no vasoespasmo e resultados funcionais. Métodos Estudo caso-controle, que avaliou as diferenças de homocisteinemia entre pacientes com aneurismas rotos e não rotos, além da associação entre níveis de homocisteína, vasoespasmo e estado funcional. Regressões logísticas foram realizadas. Resultados Um total de 348 participantes foram incluídos: 114 (32,8%) com aneurismas rotos e 234 (67,2%) não rotos. A homocisteína mediana foi de 10,75μmol/L (IQR = 4,59) nos rotos e 11,5μmol/L (IQR = 5,84) nos não rotos. Não houve associação significativa entre os níveis de homocisteína e o status de ruptura (OR = 0,99, 95% CI = 0,96-1,04). Nem a hiperhomocisteinemia leve (>15μmol/L; OR = 1,25, 95% CI = 0,32-4,12) nem a moderada (>30μmol/L; OR = 1,0, 95% CI = 0,54-1,81) mostraram correlações significativas com aneurismas rotos. Modelos univariados (OR = 0,86; 95% CI = 0,71-1,0) e multivariados ajustados por idade (OR = 0,91; 95% CI = 0,75-1,05) não evidenciaram associação entre homocisteína e vasoespasmo. A homocisteinemia não influenciou resultados funcionais excelentes em seis meses (mRS ≤ 1) (OR = 1,04; 95% CI = 0,94-1,16). Conclusão Não houve diferenças em relação à homocisteinemia entre pacientes com aneurismas intracranianos rotos e não rotos. Em pacientes com aneurismas rotos, a homocisteinemia não foi associada ao vasoespasmo ou resultados funcionais.

Early-onset neonatal sepsis as a risk factor for peri-intraventricular hemorrhage in premature infants / Sepse precoce como fator de risco para hemorragia peri-intraventricular em prematuros

ABSTRACT Objective: To assess early-onset sepsis as a risk factor of peri-intraventricular hemorrhage in premature infants born at less than or equal to 34 weeks' gestation and admitted to a neonatal intensive care unit (NICU). Methods: This retrospective cohort study included premature patients born at less than or equal to 34 weeks' gestation who were admitted to the NICU of a tertiary hospital in southern Brazil, and born from January 2017 to July 2021. Data were collected from patients' medical records. Early-onset sepsis was measured according to the presence or absence of diagnosis within the first 72 hours of life, whereas the outcome, peri-intraventricular hemorrhage, was described as the presence or absence of hemorrhage, regardless of its grade. Results: Hazard ratios were calculated using Cox regression models. A total of 487 patients were included in the study, of which 169 (34.7%) had some degree of peri-intraventricular hemorrhage. Early-onset sepsis was present in 41.6% of the cases of peri-intraventricular hemorrhage, which revealed a significant association between these variables, with increased risk of the outcome in the presence of sepsis. In the final multivariate model, the hazard ratio for early-onset sepsis was 1.52 (95% confidence interval 1.01-2.27). Conclusion: Early-onset sepsis and the use of surfactants showed to increase the occurrence of the outcome in premature children born at less than or equal to 34 weeks' gestation. Meanwhile, factors such as antenatal corticosteroids and gestational age closer to 34 weeks' gestations were found to reduce the risk of peri-intraventricular hemorrhage.

RESUMO Objetivo: O objetivo do presente trabalho foi avaliar a sepse precoce como fator de risco para hemorragia peri-intraventricular (HPIV) em prematuros com 34 semanas ou menos, admitidos em Unidade de Terapia Intensiva (UTI) Neonatal. Métodos: Este estudo de coorte retrospectivo incluiu pacientes prematuros com 34 semanas ou menos, que receberam alta da UTI Neonatal de hospital terciário, no sul do Brasil, nascidos no período de janeiro de 2017 a julho de 2021. Os dados foram coletados por meio dos prontuários desses pacientes. A sepse precoce foi mensurada conforme a presença ou a ausência do diagnóstico nas primeiras 72 horas de vida. Já o desfecho, hemorragia peri-intraventricular, foi descrito conforme a presença ou ausência da hemorragia, independentemente do grau. Resultados: Hazard ratios (HR) foram calculados por meio de modelos de regressão de Cox. Foram incluídos no estudo 487 pacientes. Destes, 169 (34,7%) apresentaram algum grau de hemorragia peri-intraventricular. A sepse precoce esteve presente em 41,6% dos casos de hemorragia peri-intraventricular e apresentou associação significativa, elevando o risco do desfecho quando presente. No modelo multivariável final, o HR para a sepse precoce foi de 1,52 (intervalo de confiança de 95% — IC95% 1,01-2,27). Conclusão: Sepse precoce e uso de surfactante demonstraram aumentar a ocorrência do desfecho em crianças prematuras até 34 semanas, enquanto fatores como corticoide antenatal e idades gestacionais mais próximas a 34 semanas mostraram reduzir o risco de ocorrência hemorragia peri-intraventricular.