Safety of infraorbital hyaluronic acid injections: Outcomes of a meta-analysis on prospective clinical trials.

BACKGROUND: Hollowing of the infraorbital region represents a common concern among aesthetic patients. In the past decade, an increasing number of patients have resorted to noninvasive aesthetic procedures to treat these concerns. The objective of this study was to evaluate the safety profile of infraorbital hyaluronic acid injections for aesthetic rejuvenation. METHODS: Through a systematic review and meta-analysis of prospective clinical trials, investigators sought to answer the research question "Does the use of needle versus cannula during infraorbital HA injections result in the same incidence rate of adverse events?" The primary outcomes of interest were the incidence rates of ecchymosis and edema in subject groups treated with a needle or cannula. RESULTS: Subjects treated with needles had a statistically significant greater incidence rate of ecchymosis, compared to those treated with cannula. Conversely, subjects treated with cannula had a statistically significant greater incidence rate of edema, compared to those treated with needles. CONCLUSIONS: The incidence rates of adverse events following the administration of hyaluronic acid injections in the infraorbital region vary depending on whether a needle or cannula is used; with needles being associated with a greater risk of ecchymosis and cannulas being associated with a greater risk of edema. These findings should be discussed with patients prior to treatment consultation. Finally, as with most techniques, it is usually prudent to develop expertise with one technique before using a second, especially in cases where both approaches can be used and have different adverse event profiles.

A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery.

BACKGROUND: Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients. OBJECTIVES: This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes. METHODS: A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed. RESULTS: Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, -40.0 to -12.7 mL; P < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (odds ratio, 0.280; 95% CI, 0.076-1.029; P = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, 3 studies found statistically significant reductions in postoperative drain output, and 1 study reported significantly improved surgical site quality for patients who received TXA (P = 0.001). CONCLUSIONS: TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation.

A spontaneous retropharyngeal haematoma: a suspected side-effect of indomethacin.

BACKGROUND: Retropharyngeal haematomas are most commonly associated with trauma and anti-coagulant use. This paper describes the first reported case of a spontaneous retropharyngeal haematoma suspected to be due to indomethacin use. CASE REPORT: It is proposed that the combination of indomethacin affecting platelet aggregation, alongside the patient coughing, may have led to this retropharyngeal haematoma. CONCLUSION: The complexities of management are discussed and the current literature reviewed. In the absence of airway compromise or a rapidly enlarging haematoma, patients can be managed conservatively with observation and close discussion with the haematology department. Follow-up imaging is not necessary if the patient's symptoms settle; however, any increase in parathyroid hormone levels must be investigated to exclude a parathyroid adenoma.

Extreme ecchymoses in a migraine patient using concomitant treatment with calcitonin gene-related peptide receptor antibodies and fish oil supplements: a case report.

BACKGROUND: Erenumab, a monoclonal antibody against the calcitonin gene-related peptide (CGRP) receptor, is registered for migraine prevention. Compared to other conventional migraine prevention medicines (i.e. topiramate, betablockers and amitriptyline) erenumab has better tolerability. Impaired hemostasis has not been reported previously. Here, we report the first case of an increased tendency to bruise in a migraine patient treated with erenumab. CASE PRESENTATION: A 41-year old female migraine patient was treated with erenumab for 12 months, which led to a significant reduction of headache and migraine days. Three months after treatment start, she experienced increased tendency to bruise leading to extreme ecchymosis after 4 months treatment. Platelet counts and aggregation, thromboelastography, activated partial thromboplastin time (APTT) and international normalized ratio (INR) were all normal. Thorough interview revealed intake of fish oil supplements for many years prior to treatment. The increased tendency to bruise subsided after discontinuation of fish oil supplements. CONCLUSION: The combination of fish oil supplements and erenumab may cause increased tendency to bruise. Erenumab has no effect on the platelets per se but may cause impaired wound healing by suppression of CGRP. Thus, small and unnoticeable bruises may be aggravated instead in patients with tendency to bruise caused by for instance fish oil supplements.

Risk factors for ecchymosis in patients receiving rivaroxaban for thromboprophylaxis after total knee arthroplasty: a retrospective cohort study.

WHAT IS KNOWN AND OBJECTIVE: Ecchymosis of the limb is commonly seen after total knee arthroplasty (TKA) when using anticoagulants for thromboprophylaxis, but it is unknown which factors may predispose patients to an increased risk. The aim of this study was to evaluate risk factors for ecchymosis in patients receiving rivaroxaban after TKA. METHODS: A retrospective, single-centre cohort analysis was conducted. The electronic medical records of patients admitted to the Department of Orthopedics during January 2018 to December 2019 and who received rivaroxaban 10 mg daily after TKA were reviewed for documentation of ecchymosis. Baseline demographics, laboratory values and surgical information were included for analysing their relationship with ecchymosis. RESULTS AND DISCUSSION: A total of 227 patients were included in the study. Among them, 54 patients (23.8%) developed ecchymosis, and 173 did not. The ecchymosis group had a higher proportion of patients with a body weight >60 kg [83.33% vs. 50.00%, p = 0.0004] and hypertension [61.11% vs 41.46%, p = 0.0304]. The ecchymosis group also had a higher BMI [26.04 ± 2.71 kg/m2 vs 24.52 ± 3.18 kg/m2 , p = 0.0066] mean arterial pressure (MAP) recorded from post-operation day 1 to day 3 [105.21 mmHg vs 91.52 mmHg, p = 0.0003]. However, serum albumin concentrations before surgery [3.85 g/dL vs. 4.20 g/dL, p = 0.0225] and on post-operation day 3 [3.50 g/dL vs. 3.91 g/dL, p = 0.0370] were lower in the ecchymosis group. Serum haemoglobin on post-operation day 3 was also lower [10.07 g/dL vs. 11.57 g/dL, p = 0.0459]. Five risk factors for ecchymosis were identified by binary logistic regression: mean MAP (from POD1 to POD3) (OR=2.901, 95% CI: 2.522-3.293, p < 0.001), BMI (OR=2.513, 95% CI: 1.929-3.011, p < 0.001), history of hypertension (OR=2.661, 95% CI: 1.272-4.535, p = 0.032), post-surgery serum albumin level (OR=0.848, 95% CI: 0.735-0.977, p = 0.023) and post-surgery serum haemoglobin level (OR=0.943; 95% CI: 0.898-0.990, p = 0.018). WHAT IS NEW AND CONCLUSION: The present analyses identified that BMI, history of hypertension, mean MAP (POD1 to POD3), post-surgery serum albumin level and post-surgery serum haemoglobin level were independent risk factors for rivaroxaban-related ecchymosis in patients who underwent TKA. These factors should be considered and optimized before starting rivaroxaban therapy.

A 50-Year-Old Woman With Confusion and Facial Rash.

CASE PRESENTATION: A 50-year-old woman presented to the ED with a 3-day history of increasing confusion. Prior to her presentation, the patient had been in her usual state of health as reported by her family. She had a history of bipolar disorder and attention-deficit/hyperactivity disorder but had stopped her psychiatric medications for the past 4 days secondary to loss of insurance coverage. History was limited due to the patient's altered state and confusion, and was obtained from family. There was no history of headache, loss of consciousness, weakness of extremities, seizures, fever, or recent trauma. The patient's medical history also included cocaine abuse. The patient's family believed she had been abstinent from cocaine use for several years.

Management of Lip Complications.

This article discusses complications that may occur after procedures on the lips, specifically focusing on injectable fillers. Evidence-based guidelines and suggested methods to manage these complications are presented in a systematic format.

Is it required to routinely check fibrinogen level in patients with rheumatic diseases on tocilizumab? Case-based review.

Tocilizumab (TCZ) may rarely cause hematological side effects including neutropenia and thrombocytopenia. TCZ is essentially expected to lower the fibrinogen levels to stay within the normal range, but TCZ-induced hypofibrinogenemia has been rarely reported in literature. Although it may remain asymptomatic, hypofibrinogenemia has clinical significance owing to the tendency of the condition to result in bleeding. A 65-year-old female patient with known polymyositis was, approximately 20 years after the diagnosis was made, examined due to elevated acute phase reactants leading to the diagnosis of giant cell arteritis (GCA) and TCZ treatment was initiated as she had former steroid-induced osteoporotic fractures. 1 month after the initial dose of intravenous (IV) TCZ, she presented with ecchymosis and was detected to have hypofibrinogenemia. Following the administration of the second dose, hypofibrinogenemia was detected again. In this review, we have analyzed this patient in addition to the cases in six other articles of TCZ induced hypofibrinogenemia which we found out based on our search strategy. Our aim is to point out a rare side effect of TCZ, hypofibrinogenemia, thus to emphasize a possible bleeding disorder and discuss probable underlying mechanisms.

Comparison of abdominal and arm areas in patients receiving subcutaneous heparin in terms of development of pain, hematoma, and ecchymosis.

The purpose of this study was to compare the abdominal and arm areas in the patients using subcutaneous heparin in terms of pain, hematoma, and ecchymosis development. As a result of subcutaneous heparin injections, complications such as pain, ecchymosis, and hematoma may develop in the injection site. The injection site chosen for injection is one of the factors that are effective on complications. This quasi-experimental study was conducted with 54 patients at orthopedics-traumatology and cardiothoracic surgery clinics of a university hospital. The data were collected using a patient description and follow-up form, visual analog scale, transparent film, and a chronometer. Ecchymosis and hematoma were evaluated at the 48th hour after injection, whereas the pain level was evaluated right after the injection, and the pain duration was evaluated during the injection. The rate of pain in the arm area was statistically higher. Differences between the areas in terms of level and duration of pain and development and size of ecchymosis and hematoma were not significant. More pain developed due to heparin injection in the arm area than in the abdominal area. No differences were observed between the areas in terms of level and duration of pain, development and size of ecchymosis, or development and size of hematoma.

Possible Drug-nutraceutical Interaction leading to Unexpected Sequelae after Inguinal Hernia Repair.

BACKGROUND Nutraceutical formulations are an area in which physicians should be increasingly aware of their side effects. This case study shows the adverse effects that ginkgo biloba can have when combined with tadalafil following an inguinal hernia repair. CASE REPORT A 74-year-old male presented for repair of a recurrent inguinal hernia and for which the procedure was performed without complication. Upon follow-up, it was noted that he had significant ecchymosis not only in the inguinal region but in the ventral aspect of his penis. Upon further questioning, he reported that he had been taking ginkgo biloba that was stopped 5 days prior to the operation and restarted postoperative day 1. This, combined with tadalafil, was thought to be the reason for the unexpected induration and ecchymosis at the shaft of the penis. After discontinuing both medications, the ecchymosis and induration did resolve. CONCLUSIONS While ecchymosis and induration are expected in the inguinal region, the appearance of significant ecchymosis and induration down the shaft of the penis was unexpected in this case, and therefore we thought it could be due to nutraceutical use of ginkgo biloba combined with tadalafil, which were started postoperatively.

Formación de equimosis y/o hematoma tras la administración profiláctica de enoxaparina subcutánea en abdomen o brazo en pacientes críticos / Ecchymosis and/or haematoma formation after prophylactic administration of subcutaneous enoxaparin in the abdomen or arm of the critically ill patient

Introducción: Los eventos adversos más frecuentes de la administración subcutánea de heparina de bajo peso molecular son la equimosis y/o el hematoma. No existe una fuerte recomendación sobre la zona de punción. Objetivo: Evaluar los eventos adversos, equimosis y/o hematoma, tras administración de enoxaparina subcutánea profiláctica en abdomen vs. brazo, en pacientes críticos. Metodología: Ensayo clínico aleatorizado en dos ramas (inyección abdomen vs. brazo), entre julio de 2014 y enero de 2017, en una unidad de cuidados intensivos polivalente de 18 camas. Incluidos pacientes con enoxaparina profiláctica, ingreso >72h, sin hepatopatías o enfermedades hematológicas, con índice de masa corporal (IMC)>18,5, no embarazadas, mayores de edad y sin lesiones cutáneas que impidan la valoración. Excluidos fallecimientos o traslados de hospital antes de finalizar la valoración. Recogidas variables demográficas, clínicas y aparición de equimosis y/o hematoma en lugar de inyección a las 12, 24, 48 y 72h. Análisis descriptivo, comparación de grupos y regresión logística. Aprobado por la comité de ética, con consentimiento firmado de pacientes/familiares. Resultados: Un total de 301 casos (11 excluidos): 149 en abdomen vs. 141 en brazo. Sin diferencias significativas en variables demográficas, clínicas, IMC, dosis de enoxaparina y administración de antiagregantes. Equimosis en el 48% de los pacientes y hematoma en el 8%, sin diferencias estadísticas abdomen vs. brazo [equimosis, abdomen vs. brazo, n(%): 66(44) vs. 72(51), p=0,25] [hematoma abdomen vs. brazo, n(%):9(6) vs. 14(10), p=0,2]. Se halla significación estadística en el tamaño del hematoma a las 72h: [área de hematoma (mm2) abdomen vs. brazo, mediana (RIC): 2(1-5,25) vs. 20(5,25-156), p=0,027]. Conclusiones: En nuestra cohorte de pacientes, la enoxaparina subcutánea profiláctica administrada en el abdomen produce menos hematomas, a las 72h, que administrada en el brazo. La tasa de incidencia de equimosis y hematomas es menor a la publicada en pacientes críticos, advirtiéndose que pacientes con antiagregantes presentan mayor riesgo de presentar lesiones, no observándose relación de su aparición con el IMC (AU)

Introduction: Ecchymosis and/or haematoma are the most common adverse events after subcutaneous administration of low molecular weight heparin. There is no strong recommendation as to the puncture site. Objective: To evaluate the adverse events, ecchymosis and/or haematoma after the administration of prophylactic subcutaneous enoxaparin in the abdomen vs the arm in the critically ill patient. Methodology: A randomised, two-arm clinical trial (injection in the abdomen vs the arm), performed between July 2014 and January 2017, in an 18-bed, polyvalent intensive care unit. Patients receiving prophylactic enoxaparin, admitted >72h, with no liver or haematological disorders, a body mass index (BMI) >18.5, not pregnant, of legal age and with no skin lesions which would impede assessment were included. We excluded patients who died or who were transferred to another hospital before completing the evaluation. We gathered demographic and clinical variables, and the onset of ecchymosis and/or haematomas at the injection site after 12, 24, 48 and 72hours. A descriptive analysis was undertaken, with group comparison and logistic regression. The study was approved by the ethics committee with the signed consent of patients/families. Results: 301 cases (11 excluded): 149 were injected in the abdomen vs 141 in the arm. There were no significant differences in demographic and clinical variables, BMI, enoxaparin dose or antiplatelet administration [ecchymosis, abdomen vs arm, n(%): 66(44) vs 72(51), P=.25] [haematoma abdomen vs arm, n(%): 9(6) vs 14(10), P=.2]. Statistical significance was found in the size of the haematomas after 72h: [area of haematoma (mm2) abdomen vs arm, median (IQR): 2(1-5.25) vs 20(5.25-156), P=.027]. Conclusions: In our patient cohort, prophylactic subcutaneous enoxaparin administered in the abdomen causes fewer haematomas after 72hours, than when administered in the arm. The incidence rate of ecchymosis and haematoma was lower than the published incidence in critically ill patients, although patients receiving anti-platelet agents present a higher risk of injury. No relationship was observed in relation to BMI (AU)

Ecchymosis and/or haematoma formation after prophylactic administration of subcutaneous enoxaparin in the abdomen or arm of the critically ill patient. / Formación de equimosis y/o hematoma tras la administración profiláctica de enoxaparina subcutánea en abdomen o brazo en pacientes críticos.

INTRODUCTION: Ecchymosis and/or haematoma are the most common adverse events after subcutaneous administration of low molecular weight heparin. There is no strong recommendation as to the puncture site. OBJECTIVE: To evaluate the adverse events, ecchymosis and/or haematoma after the administration of prophylactic subcutaneous enoxaparin in the abdomen vs the arm in the critically ill patient. METHODOLOGY: A randomised, two-arm clinical trial (injection in the abdomen vs the arm), performed between July 2014 and January 2017, in an 18-bed, polyvalent intensive care unit. Patients receiving prophylactic enoxaparin, admitted >72h, with no liver or haematological disorders, a body mass index (BMI) >18.5, not pregnant, of legal age and with no skin lesions which would impede assessment were included. We excluded patients who died or who were transferred to another hospital before completing the evaluation. We gathered demographic and clinical variables, and the onset of ecchymosis and/or haematomas at the injection site after 12, 24, 48 and 72hours. A descriptive analysis was undertaken, with group comparison and logistic regression. The study was approved by the ethics committee with the signed consent of patients/families. RESULTS: 301 cases (11 excluded): 149 were injected in the abdomen vs 141 in the arm. There were no significant differences in demographic and clinical variables, BMI, enoxaparin dose or antiplatelet administration [ecchymosis, abdomen vs arm, n(%): 66(44) vs 72(51), P=.25] [haematoma abdomen vs arm, n(%): 9(6) vs 14(10), P=.2]. Statistical significance was found in the size of the haematomas after 72h: [area of haematoma (mm2) abdomen vs arm, median (IQR): 2(1-5.25) vs 20(5.25-156), P=.027]. CONCLUSIONS: In our patient cohort, prophylactic subcutaneous enoxaparin administered in the abdomen causes fewer haematomas after 72hours, than when administered in the arm. The incidence rate of ecchymosis and haematoma was lower than the published incidence in critically ill patients, although patients receiving anti-platelet agents present a higher risk of injury. No relationship was observed in relation to BMI.

Acquired haemophilia A complicating alemtuzumab therapy for multiple sclerosis.

Alemtuzumab is a highly efficacious therapy used in the treatment of multiple sclerosis (MS), but uncoupling of T and B cell repopulation during immune reconstitution associates with an increasing range of secondary B cell-mediated autoimmune complications. A 34-year-old woman developed Graves' disease 11 months following an initial course of alemtuzumab treatment for MS. Nine months following the second treatment with alemtuzumab, the patient presented with spontaneous intramuscular and subcutaneous haemorrhage due to development of an inhibitory autoantibody to coagulation factor VIII. Acquired haemophilia A (AHA) is an extremely rare complication in patients treated with alemtuzumab. Treatment with rituximab may induce a rapid remission of AHA; however, the patient's high John Cunningham virus (JCV) antibody index and alemtuzumab-induced T cell lymphopenia may lead to an increased risk of progressive multifocal leucoencephalopathy, a potential complication which was unacceptable to the patient.