Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist.

Heavy menstrual bleeding (HMB) is frequently reported by adolescents. The role of the hematologist is threefold in the evaluation of such patients: 1) perform a clinical and laboratory evaluation for an underlying bleeding disorder based on the degree of clinical suspicion, 2) identify and manage any concomitant iron deficiency, and 3) provide input to the referring provider regarding the management of HMB, particulary for patients with identified hemostatic defects. Several clues in the menstrual history should raise suspicion for an underlying bleeding disorder, such as menses lasting >7 days, menstrual flow which soaks >5 products daily or requires product change during the night, passage of large blood clots, or failure to respond to conventional therapies. A detailed personal and family history of other bleeding symptoms should also be obtained. Iron deficiency with and without anemia is commonly found in young women with HMB. Therefore, it is important to obtain not only a hemoglobin, but also a ferritin level, when evaluating these patients. Iron supplementation is often a key component of management in the adolescent with heavy menses, and is still needed even in those who have received packed red cell transfusions due to severe anemia. Strategies for decreasing menstrual blood flow are similar between adults and adolescents with heavy menses, with combined hormonal contraceptives recommended as first-line therapy. However, adolescent-specific considerations exist for many of these agents, and must be incorporated into shared decision making when selecting the most appropriate treatment.

Laser prostatectomy in patients on anticoagulant therapy or with bleeding disorders.

PURPOSE: Bleeding disorders or the use of anticoagulant medication are contraindications to transurethral prostate resection in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Laser prostatectomy has proved to be adequate surgical therapy with less blood loss than transurethral prostate resection. MATERIALS AND METHODS: A prospective, controlled study was done in patients at high risk (HR) with LUTS suggestive of BPH. They were treated with contact laser prostatectomy (CLP) or the combination of CLP with visual laser ablation prostatectomy (VLAP). HR was defined as bleeding disorders or anticoagulants use. As a control, men at normal risk with LUTS suggestive of BPH were treated with CLP. Patients completed validated questionnaires and underwent urodynamics at baseline and 6 months postoperatively. RESULTS: A total of 75 patients were included, namely 19 in the HR-CLP group, 11 in the HR-CLP-VLAP group and 45 in the normal risk CLP group. Obstruction relief, and symptomatic and subjective improvement were equal in all 3 groups. Effective capacity (maximum cystometric capacity minus post-void residual volume) also improved significantly in all except the HR-CLP group. Maximum urine flow improved in all groups but not significantly in the HR-CLP group. Intraoperative and postoperative complications were slightly higher in HR cases. However, blood transfusion was never necessary and there was no mortality. CONCLUSIONS: CLP and especially CLP-VLAP perform almost as well in HR cases compared with CLP in those at normal risk. These procedures are safe for men at HR with LUTS suggestive of BPH.

Seudotrombocitopenia dependiente de EDTA / EDTA-dependent pseudothrombocytopenia

Introducción. La seudotrombocitopenia dependiente de etilendiaminotetracetato (EDTA) es un fenómeno conocido consistente en la formación de agregados de plaquetas in vitro en muestras de sangre anticoaguladas con EDTA y que puede conducir a diagnósticos erróneos de trombocitopenia. Es poco frecuente entre la población pediátrica y carece de significación patológica. Su correcta identificación puede evitar estudios innecesarios y tratamientos potencialmente peligrosos. Caso clínico. Niña de 10 años que ingresó en nuestro centro para estudio de trombopenia sin episodios previos ni clínica actual sugestiva de diátesis hemorrágica. El recuento de plaquetas fue de 31 x 109/L. En el examen microscópico de la sangre se observaron frecuentes agregados plaquetarios. Al realizar un hemograma de una muestra anticoagulada con heparina se evidenció un recuento de plaquetas normal, emitiéndose el diagnóstico de seudotrombocitopenia dependiente de EDTA. Discusión. La mayoría de casos de seudotrombopenia dependiente de EDTA obedecen a aglutininas de tipo IgM o IgG con máxima actividad entre 4 y 20 °C. Se desconoce el mecanismo íntimo de interacción con las plaquetas, pero se supone que en presencia de EDTA ocurre un cambio conformacional de la superficie plaquetaria que induce la exposición de un neoantíngeno al que se unirían las aglutininas (AU)

[Chronic, hemorrhage-induced iron deficiency anemia in Osler disease]. / Chronische, blutungsbedingte Eisenmangelanämie bei Morbus Osler.

We report the history of a 77-year-old man with Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia) who suffered from recurrent epistaxis and chronic bleeding anemia for many years. Hereditary hemorrhagic telangiectasia is a rare congenital disease, that is characterized by telangiectases of the nasal and oral mucosa, the gastrointestinal tract and the skin. Arteriovenous malformations of the lung and the brain may be present. The genetic and pathologic features, the clinical manifestations and the differential diagnosis are shortly presented. The management is not validated by controlled studies and is mainly based on clinical experience. It involves supportive therapy with iron supplementation and erythrocyte transfusions, if needed, for chronic bleeding anemia, aminocaproic acid, tranexamic acid or oestrogen-progesterone therapy to prevent mucosal bleeding, cauterisation, photocoagulation, transcatheter embolotherapy or surgery to treat the vascular abnormalities.

[Intracranial hematoma accompanying bleeding tendency: therapeutic practice and analysis of literature].

Therapies and prognoses covering fifteen cases of intracranial hematoma (ICrH) accompanying various types of bleeding tendency (BTD) were studied along with a secondary analysis of the pertinent references. Fifteen cases were divided into two groups, Group A comprising 11 cases of ICrH accompanying primary BTD, and Group B comprising four cases of ICrH accompanying secondary BTD caused by various underlying diseases. Group A included four cases of hemophilia A (Hp-A), two cases of factor XIII deficiency (FXIII-d), three cases of thrombocytopenia (Th-p) and two cases of vitamin K deficiency (VK-d). The four cases of Hp-A responded favorably, with good prognoses, to a supplementary therapy alone. This result was endorsed by the development of therapy as documented in the references. The combined five cases of FXIII-d and Th-p tended without exception, to show good prognoses in the wake of a combination therapy of supplementary treatment and surgical procedure. As regards FXIII-d, there was an inter-reference difference in supplementary doses. Many references shared the view that splenectomy was essential to the treatment of Th-p in general, and idiopathic thrombocytopenic purpura in particular. The current study also suggested that gammaglobulin in large doses would serve as an effective therapy. The two cases of VK-d suffered from a serious degree of lingering neurologic manifestations, although their lives were saved. Even though there is an established therapy for it, VK-d was found to be a problem with poor functional prognosis showing the importance of the preventive approach. Group B was classified into the acute type and the subacute type depending on the rate of pathologic development. As underlying diseases DIC and myelofibrosis due to acute myeloblastic leukemia, and Th-p due to aplastic anemia were noted in two cases in each group. Of these, two cases of the subacute type were able to be saved, while two cases of the acute type followed poor prognostic courses resulting, eventually, in death. The following were found to be responsible fatal factors: 1) causes of BTD which involved both mechanisms of coagulation and hemostasis, 2) non-removal of the underlying disease, in which case supplementary therapy tended to be futile, and 3) the underlying disease per se as a danger to the life of the patient. In conclusion, therapeutic rationale and prognosis in ICrH accompanying primary type of BTD will benefit from the implementation of an adequate augmentative therapy as in the ordinary type of ICrH.(ABSTRACT TRUNCATED AT 400 WORDS)