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1.
BMJ Case Rep ; 14(1)2021 Jan 11.
Artigo em Inglês | MEDLINE | ID: mdl-33431458

RESUMO

A 55-year-old man presented with severe right upper quadrant abdominal pain and hypertension up to 231/171 mm Hg on a background of a known adrenal mass, intravenous drug use and recurrent anxiety attacks. CT showed heterogenous lesion of the right adrenal gland but the sudden severe pain remained unexplained. After correction of the blood pressure with analgesia and antihypertensives, the patient developed a type 2 non-ST-elevation myocardial infarction that was treated with aspirin and therapeutic enoxaparin. This resulted in worsening pain and a repeat CT angiogram showed a haemoretroperitoneum around the right adrenal lesion. On review, an occult intra-adrenal haemorrhage was identified on the initial CT scan. Presumably this concealed haemorrhage caused the initial pain crisis and later decompressed into the retroperitoneal space. Raised metanephrine levels confirmed the diagnosis of pheochromocytoma and after preoperative optimisation with phenoxybenzamine, an open right adrenalectomy was performed.


Assuntos
Dor Abdominal/etiologia , Neoplasias das Glândulas Suprarrenais/diagnóstico , Hemorragia/diagnóstico , Hipertensão/etiologia , Infarto do Miocárdio/diagnóstico , Feocromocitoma/diagnóstico , Dor Abdominal/diagnóstico , Neoplasias das Glândulas Suprarrenais/sangue , Neoplasias das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/cirurgia , Glândulas Suprarrenais/diagnóstico por imagem , Glândulas Suprarrenais/patologia , Glândulas Suprarrenais/cirurgia , Adrenalectomia , Anti-Hipertensivos/administração & dosagem , Angiografia por Tomografia Computadorizada , Eletrocardiografia , Hemorragia/sangue , Hemorragia/etiologia , Hemorragia/cirurgia , Humanos , Hipertensão/sangue , Hipertensão/tratamento farmacológico , Masculino , Metanefrina/sangue , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/etiologia , Medição da Dor , Feocromocitoma/sangue , Feocromocitoma/complicações , Feocromocitoma/cirurgia , Espaço Retroperitoneal , Tomografia Computadorizada por Raios X
2.
Medicine (Baltimore) ; 99(44): e23025, 2020 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-33126388

RESUMO

RATIONALE: Pulmonary hemorrhage is a rare but fatal complication of Henoch-Schönlein purpura (HSP), and more easily ignored in children than in adults due to the absence of clinically evident hemoptysis. Moreover, despite being sporadically reported, given that pulmonary hemorrhage may develop after regression and even disappearance of skin rash, the asynchronous progression of skin and lung lesions poses escalating challenges in the timely diagnosis. We herein presented a delayed diagnosis of late-onset pulmonary hemorrhage in a child with HSP after regression of purpuric rash. PATIENT CONCERNS: A 6-year and 3-month child with a history of self-resolved purpuric rash three weeks ago, presented acutely with cough and dyspnea but without fever. DIAGNOSES: The decreased hemoglobin and diffuse ground-glass opacities of both lungs on CT scan weren't comprehensively evaluated. The child was initially misdiagnosed as pneumonia. INTERVENTIONS: Antibiotic treatment was initiated. However, no improvement of respiratory status was found following aggressive combination therapy. Bronchoscopy was subsequently performed. OUTCOMES: An diffuse alveolar hemorrhage with low inflammatory profile was noted after a bronchoscopy. Considering the history of HSP, the diagnosis of HSP-associated pulmonary hemorrhage was ultimately confirmed and the patient received corticosteroids with satisfactory results. LESSONS: Pulmonary hemorrhage could occur in children with HSP at late onset of disease after regression of skin rash. New-onset respiratory symptoms in patients with a history of HSP should heighten suspicion for pulmonary hemorrhage, particularly if presenting with lack of fever, sudden drop of hemoglobin, new pulmonary infiltrates and unresponsiveness to antibiotics therapy. Bronchoscopy should be performed early to confirm the diagnosis, specifically for children.


Assuntos
Exantema , Hemorragia/diagnóstico , Pneumopatias/diagnóstico , Púrpura de Schoenlein-Henoch , Criança , Tosse/etiologia , Diagnóstico Tardio , Hemorragia/complicações , Hemorragia/diagnóstico por imagem , Humanos , Pneumopatias/complicações , Pneumopatias/diagnóstico por imagem , Masculino , Tomografia Computadorizada por Raios X
3.
Medicine (Baltimore) ; 99(43): e22926, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120848

RESUMO

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


Assuntos
Coagulantes/uso terapêutico , Fator VIII/uso terapêutico , Hemofilia A/etiologia , Lúpus Eritematoso Sistêmico/complicações , Administração Intravenosa , Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/uso terapêutico , Testes de Coagulação Sanguínea/métodos , Coagulantes/administração & dosagem , Terapia Combinada , Ciclofosfamida/administração & dosagem , Ciclofosfamida/uso terapêutico , Equimose/diagnóstico , Equimose/etiologia , Fator VIII/administração & dosagem , Feminino , Hematúria/diagnóstico , Hematúria/etiologia , Hemofilia A/terapia , Hemorragia/diagnóstico , Hemorragia/etiologia , Humanos , Imunossupressores/administração & dosagem , Imunossupressores/uso terapêutico , Metilprednisolona/administração & dosagem , Metilprednisolona/uso terapêutico , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial/métodos , Tempo de Tromboplastina Parcial/estatística & dados numéricos , Plasma , Plasmaferese/métodos , Resultado do Tratamento
4.
Can J Surg ; 63(5): E422-E430, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33009903

RESUMO

BACKGROUND: Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS: We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS: We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION: A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.


Assuntos
Hemorragia/diagnóstico , Modelos Biológicos , Triagem/métodos , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/complicações , Adulto , Transfusão de Sangue/estatística & dados numéricos , Canadá/epidemiologia , Tomada de Decisão Clínica , Embolização Terapêutica/estatística & dados numéricos , Feminino , Hemorragia/epidemiologia , Hemorragia/etiologia , Hemorragia/terapia , Hemostasia Cirúrgica/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco/métodos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia
5.
Wilderness Environ Med ; 31(3): 337-343, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32830028

RESUMO

The objective of this case series was to describe 2 patients presenting with subarachnoid hemorrhage with hydrocephalus and hemoventricle after a snakebite caused by presumed Bothrops ssp. Both cases occurred in the municipality of Guajará (Amazonas state), Western Brazilian Amazon. Both cases featured delay in administration of serum therapy, which may have contributed to the emergence of complications such as stroke. Patient 1 was admitted to hospital 16 h after the snakebite occurred. Before receiving antivenom, testing showed the patient as having unclottable blood. She developed hemorrhagic stroke (a subarachnoid hemorrhage with hydrocephalus and hemoventricle). On the seventh day, she was discharged from hospital. Patient 2 arrived at the hospital 3 d after the snakebite occurred and presented with unclottable blood. He had a stroke (right frontoparietal hemorrhage, intraparenchymal hemorrhage already open to the ventricle) and died on the eighth day after the snakebite. Delay in seeking health care after snake envenomation can result in worse outcome.


Assuntos
Bothrops , Mordeduras de Serpentes/complicações , Acidente Vascular Cerebral/terapia , Idoso , Animais , Antivenenos/administração & dosagem , Brasil , Diagnóstico Tardio , Evolução Fatal , Feminino , Hemorragia/diagnóstico , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Masculino , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento , Adulto Jovem
6.
Vasc Endovascular Surg ; 54(8): 665-669, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32720585

RESUMO

PURPOSE: To evaluate the efficacy, safety, and feasibility of transradial approach (TRA) for endovascular management of traumatic bleeding. MATERIALS AND METHODS: A retrospective review was performed at a single level 1 trauma institution from August 2018 to July 2019. Patients presented to the interventional radiology department who were intended to be treating using TRA for the management of trauma-induced bleeding were selected. Demographics, indication for embolization, embolization site, preprocedural labs, hemodynamic stability, technical success, and complications were recorded. RESULTS: Transradial approach was attempted in 29 (74.4%) of the 39 patients identified by operators who prefer TRA. Four patients received treatment using TRA on 2 separate occasions, for a total of 33 procedures completed with a technical success of 97% (32/33). Transradial approach was safely completed in 9 patients (27.3%) with preprocedural hemodynamically unstable status. For the 10 patients who received treatment via a transfemoral approach (TFA), traumatic disfiguration of the left upper extremity, preexisting arterial lines placed by the trauma team, and external iliac artery injuries requiring covered stent placement were the most common indications for TFA over TRA. There were no procedural or access site-related complications. CONCLUSION: Transradial approach for the endovascular management of bleeding in a trauma setting is safe and effective with a high technical success rate and no complications.


Assuntos
Cateterismo Periférico , Embolização Terapêutica , Procedimentos Endovasculares , Hemorragia/terapia , Artéria Radial , Lesões do Sistema Vascular/terapia , Adulto , Idoso , Cateterismo Periférico/efeitos adversos , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Estudos de Viabilidade , Feminino , Hemodinâmica , Hemorragia/diagnóstico , Hemorragia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , New Jersey , Punções , Artéria Radial/diagnóstico por imagem , Radiografia Intervencionista , Estudos Retrospectivos , Stents , Centros de Traumatologia , Resultado do Tratamento , Serviços Urbanos de Saúde , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/fisiopatologia , Adulto Jovem
7.
Am J Trop Med Hyg ; 103(3): 1156-1157, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32682452

RESUMO

A 70-year-old Dominican Republic man presented with lower back pain for 10 days. Fifteen days before pain onset, he had low-grade fever, chills, and asthenia, and 4 days before admission, he had constipation, malaise, generalized weakness, anorexia, nausea, and vomiting. On admission, the patient was afebrile and hypotensive, with a heart rate of 105 and an oxyhemoglobin saturation on room air of 95%. Hyponatremia, lymphopenia, elevated C-reactive protein, and ferritin were observed in complementary tests. Computed tomography (CT) scan showed findings consistent with COVID-19 bilateral bronchopneumonia, and an increase in size and blurring (loss of the Y shape) of both adrenals indicative of acute bilateral adrenal hemorrhage. The patient tested negative by reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal swab, yet positive for IgG and IgM by ELISA, suggesting COVID-19 diagnosis.


Assuntos
Doenças das Glândulas Suprarrenais/etiologia , Betacoronavirus , Infecções por Coronavirus/complicações , Hemorragia/etiologia , Pneumonia Viral/complicações , Doenças das Glândulas Suprarrenais/diagnóstico , Idoso , Hemorragia/diagnóstico , Humanos , Masculino , Pandemias
8.
Med. clín (Ed. impr.) ; 155(2): 51-56, jul. 2020. graf, tab
Artigo em Inglês | IBECS | ID: ibc-195696

RESUMO

AIMS: The association of on-admission CRP and early adverse outcomes in acute venous thromboembolism (VTE) has not been investigated. We hypothesized that increased on-admission CRP levels would correlate with adverse outcomes in patients with acute VTE. METHOD: In this prospective observational study, consecutive patients with acute VTE were enrolled and CRP levels were measured within the first 24h after diagnosis. Mortality, bleeding and recurrence were recorded during a 30-day follow-up. RESULTS: 586 patients were included. Higher CRP levels were found in patients with mortality (7.5 vs 4.0mg/dL; p = 0.01) and bleeding (7.8 vs 3.9mg/dL; p = 0.03). Multivariable logistic regression showed that CRP levels >5mg/dL were associated with higher mortality (OR 6.25; 95% CI, 2.1-18.6) and bleeding (OR 2.7; CI 95% 1.3-5.7). These results were independent to ESC risk score and simplified PESI score for mortality prediction. The predictive capacity of CRP showed an area under the ROC curve - AUC - of .7 (CI 95% .56-.85) for mortality and .65 (CI 95% .54-.75) for bleeding. The prognostic capacity of the ESC risk score and simplified PESI score was improved after adding the CRP cutoff of 5mg/dL (AUC of .87 CI 95% .79-.95). CONCLUSION: Our findings suggest that on-admission CRP level may be a simple, widely available and valuable biomarker to identify high-risk VTE patients for early mortality and bleeding. CRP ≥5mg/dL was independently associated with 30-day VTE related death and bleeding


OBJETIVOS: La asociación de la medición de PCR al ingreso y las complicaciones precoces en la enfermedad tromboembólica venosa (ETV) aguda no ha sido evaluado. Nuestra hipótesis es que los niveles elevados de PCR al ingreso podrían estar correlacionados con complicaciones precoces en pacientes con ETV aguda. MÉTODOS: Estudio observacional prospectivo, en el que se incluyeron pacientes consecutivos con ETV aguda en los que se midió la PCR en las primeras 24h del diagnóstico. La mortalidad, el sangrado y la recurrencia fueron registrados durante el seguimiento a 30 días. RESULTADOS: Se incluyeron 586 pacientes. Se encontraron niveles más elevados de PCR en pacientes que fallecieron (7,5 vs. 4mg/dl; p = 0,01) y que sangraron (7,8 vs. 3,9mg/dl; p = 0,03). Una regresión logística multivariante mostró que niveles de PCR>5mg/dl se asociaron significativamente con mayor mortalidad (OR: 6,25; IC 95%: 2,1-18,6) y sangrado (OR: 2,7; IC 95%: 1,3-5,7). Estos resultados fueron independientes de las escalas pronósticas de mortalidad ESC y PESI simplificada. La capacidad predictiva de la PCR mostró un área bajo la curva (ABC) ROC de 0,7 (IC 95%: 0,56-0,85) para mortalidad y 0,65 (IC 95%: 0,54-0,75) para sangrado. La capacidad pronóstica de las escalas pronósticas ESC y PESI simplificada mejoró de forma significativa al añadir el punto de corte de PCR>5mg/dl (ABC de 0,87; IC 95%: 0,79-0,95). CONCLUSIÓN: La medición de PCR al ingreso puede ser un marcador sencillo y ampliamente disponible para identificar a pacientes con ETV aguda y alto riesgo de mortalidad y sangrado precoces. Niveles de PCR≥5mg/dl se asociaron de forma independiente con mayor mortalidad y sangrado a 30 días en pacientes con ETV aguda


Assuntos
Humanos , Reação em Cadeia da Polimerase , Tromboembolia Venosa/complicações , Hemorragia/diagnóstico , Valor Preditivo dos Testes , Estudos de Coortes , Hemorragia/complicações , Hemorragia/mortalidade , Estudos Prospectivos , Modelos Logísticos , Biomarcadores , Sensibilidade e Especificidade
10.
PLoS One ; 15(6): e0231565, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32479502

RESUMO

OBJECTIVE: To evaluate the level of agreement between cardiologists regarding the management of oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (NVAF) in Spain. MATERIALS AND METHODS: A two-round Delphi study was performed using an online survey. In round 1, panel members rated their level of agreement with the questionnaire items on a 9-point Likert scale. Item selection was based on acceptance by ≥66.6% of panellists and the agreement of the scientific committee. In round 2, the same panellists evaluated those items that did not meet consensus in round 1. RESULTS: A total of 238 experts participated in round 1; of these, 217 completed the round 2 survey. In round 1, 111 items from 4 dimensions (Thromboembolic and bleeding risk evaluation for treatment decision-making: 18 items; Choice of OAC: 39 items; OAC in specific cardiology situations: 12 items; Patient participation and education: 42 items) were evaluated. Consensus was reached for 92 items (83%). Over 80% of the experts agreed with the use of DOACs as the initial anticoagulant treatment when OAC is indicated. Panellists recommended the use of DOACs in patients at high risk of thromboembolic complications (CHA2DS2-VASc ≥3) (83%), haemorrhages (HAS-BLED ≥3) (89%) and poor quality of anticoagulation control (SAMe-TT2R2 >2) (76%), patients who fail to achieve an optimal therapeutic range after 3 months on VKA treatment (93%), and those who are to undergo cardioversion (80%). Panellists agreed that the efficacy and safety profile of each DOAC (98%), the availability of a specific reversal agent (72%) and patient's preference (85%) should be considered when prescribing a DOAC. A total of 97 items were ultimately accepted after round 2. CONCLUSIONS: This Delphi panel study provides expert-based recommendations that may offer guidance on clinical decision-making for the management of OAC in NVAF. The importance of patient education and involvement has been highlighted.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Administração Oral , Adulto , Anticoagulantes/efeitos adversos , Fibrilação Atrial/patologia , Técnica Delfos , Feminino , Hemorragia/diagnóstico , Hemorragia/etiologia , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Preferência do Paciente , Médicos/psicologia , Espanha , Inquéritos e Questionários , Tromboembolia/diagnóstico , Tromboembolia/etiologia
12.
Thromb Haemost ; 120(5): 737-746, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32369845

RESUMO

Long-term safety and efficacy data of extended half-life factor IX (FIX) prophylaxis in children with hemophilia B (HB) are sparse. paradigm 5 is a multinational, open-label, single-arm, phase III trial assessing once-weekly (40 IU/kg) prophylactic nonacog beta pegol (N9-GP) in previously treated patients (PTPs) aged ≤ 12 years with HB (FIX activity ≤ 2%). Primary endpoint: incidence of anti-FIX inhibitory antibodies (≥ 0.6 Bethesda Units). We present a 5-year analysis (N = 25, including remaining patients with ≥ 5 years' follow-up) and compare with a 1-year analysis (≥ 52 weeks' exposure). The main phase enrolled 25 children; 22 entered the extension phase; 17 remained in trial at data cutoff. Median treatment period: 5.6 years/patient; median total number of N9-GP exposure days: 290.0/patient. No patients developed anti-FIX inhibitory antibodies. No other safety concerns, including thromboembolic events, were reported. Neurological examinations have not revealed any new abnormal findings. Sixteen (64.0%) patients remained free from spontaneous bleeds; all bleeds were mild/moderate in severity; 93.0% were controlled with 1 to 2 N9-GP injections. No intracranial hemorrhages were reported. Annualized bleeding rates (ABRs) were very low at 5 years (median/Poisson-estimated mean overall ABR: 0.66/0.99), having decreased from the 1-year analysis (1.00/1.44). Median/Poisson-estimated mean spontaneous ABRs for the 1- and 5-year analyses: 0.00/0.45 and 0.00/0.33. Mean FIX trough activity at 5 years: 17.9%. Mean polyethylene glycol plasma concentration reached steady state at 6 months, increasing slightly over time, in line with increased FIX trough activity. N9-GP administered for ≥ 5 years shows favorable long-term safety and efficacy in PTPs with HB (FIX activity ≤ 2%).


Assuntos
Fator IX/administração & dosagem , Hemofilia B/tratamento farmacológico , Hemostáticos/administração & dosagem , Polietilenoglicóis/administração & dosagem , Adolescente , Fatores Etários , Ásia , Criança , Pré-Escolar , Esquema de Medicação , Europa (Continente) , Fator IX/efeitos adversos , Fator IX/farmacocinética , Hemofilia B/sangue , Hemofilia B/diagnóstico , Hemorragia/sangue , Hemorragia/diagnóstico , Hemorragia/prevenção & controle , Hemostáticos/efeitos adversos , Hemostáticos/sangue , Hemostáticos/farmacocinética , Humanos , Lactente , América do Norte , Segurança do Paciente , Polietilenoglicóis/efeitos adversos , Polietilenoglicóis/farmacocinética , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/sangue , Proteínas Recombinantes/farmacocinética , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
13.
Medicine (Baltimore) ; 99(20): e20167, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32443333

RESUMO

The purpose of this study is to analyze the risk factors of sporadic renal hamartoma and establish a risk scoring system, and to intervene in patients with high-risk sporadic renal hamartoma who are prone to rupture and bleeding as soon as possible.Retrospective univariate and multivariate logistic analyzes were conducted for clinical data of 332 sporadic renal hamartoma patients to screen out independent risk factors of tumor rupture. Score of each independent risk factor was calculated. (Calculation formula: the risk coefficient of each factor = the beta regression coefficient of each factor/the minimum value of the beta regression coefficient of all factors, the value of the smallest beta regression coefficient corresponding to all the factors was assigned 1 point. The score of each factor was equal to the risk coefficient of each variable was taken as an integer value by rounding.) The total score was equal to the sum of all factors. Then the area under the receiver operating characteristics (AUC) curve was compared between high risk factors and scoring system. Finally, the scoring system was evaluated by the area under the curve (AUC) and the Hosmer-Lemeshow method in an independent cohort of 130 patients.Factors such as symptoms at presentation, tumor size, tumor blood supply, and tumor growth pattern were significant predictors of sporadic renal angiomyolipoma rupture in both the univariate and multivariate analyses; these predictors were included in the scoring system to predict sporadic renal angiomyolipoma rupture. There were no significant differences in AUCs between high risk factors and scoring system (z = 0.6434, P = .583, AUC = 0.913, and 0.903 for high risk factors and scoring system, respectively). The sporadic renal angiomyolipoma patients who scored >6 points were prone to rupture. AUROC of the scoring system in the validation set was 0.854(95%CI:0.779, 0.928). Using the Hosmer-Lemeshow method, the value of X was 2.916, P = .893, suggesting the scoring system fitted well.A scoring system based on clinical features is simple and effective in predicting sporadic angiolipoma rupture and hemorrhage. When the score is higher than 6 points, the probability of hamartoma rupture and hemorrhage is significantly increased and early intervention is needed.


Assuntos
Angiomiolipoma/complicações , Hamartoma/complicações , Hemorragia/diagnóstico , Neoplasias Renais/patologia , Ruptura/diagnóstico , Adulto , China/epidemiologia , Regras de Decisão Clínica , Feminino , Hemorragia/etiologia , Humanos , Neoplasias Renais/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Projetos de Pesquisa/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Ruptura/etiologia , Carga Tumoral/fisiologia
14.
BMC Womens Health ; 20(1): 66, 2020 04 03.
Artigo em Inglês | MEDLINE | ID: mdl-32245454

RESUMO

BACKGROUND: Müllerianosis is a very rare neoplasm composed of two or three Müllerian derived tissues (endosalpinx, endometrium and endocervix). We report the first case of concurrent müllerianosis of the urinary bladder and the umbilicus presenting with umbilical bleeding. CASE PRESENTATION: A 43-year-old Asian premesopausal female, gravida 1, para 1, presented with intermittent umbilical bleeding. An umbilical nodule and a bladder tumor on the posterior wall of the urinary bladder were identified. She underwent transurethral resection of the bladder tumor and excision of the umbilical nodule successively. Diagnosis of müllerianosis was confirmed by the histological and immunological features. No tumor recurrence was noted at 6 months of follow-up. CONCLUSIONS: Müllerianosis is extremely rare and mainly reported in the urinary bladder, and generally affects women of reproductive age. Despite the common presentations of müllerianosis of the urinary bladder including irritative voiding symptoms, abdominal/pelvic pain and gross hematuria, our rare case had no symptom except umbilical bleeding. The possibility of concurrent bladder müllerianosis should be considered when müllerianosis is found at other location. We suggest a surgical intervention to establish the correct pathological diagnosis because it is essential to exclude malignant neoplasms of the urinary bladder. The majority of patients have a favorable prognosis.


Assuntos
Hemorragia/etiologia , Ductos Paramesonéfricos/patologia , Umbigo/irrigação sanguínea , Doenças da Bexiga Urinária/patologia , Bexiga Urinária/patologia , Adulto , Biópsia , Cesárea , Endométrio , Feminino , Hemorragia/diagnóstico , Hemorragia/cirurgia , Humanos , Pré-Menopausa , Doenças Raras , Resultado do Tratamento , Umbigo/patologia , Umbigo/cirurgia , Bexiga Urinária/cirurgia , Doenças da Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/cirurgia
15.
Pediatr Pulmonol ; 55(6): 1481-1486, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32293809

RESUMO

OBJECTIVE: Combined methylmalonic acidemia and homocysteinemia is a genetically heterogeneous disorder of cobalamin (cbl; vitamin B12) metabolism, which consists of five subtypes including cblC, cblD, cblF, cblJ, and cblX deficiencies. The purpose of this study is to summarize new clinical features mainly diffuse alveolar hemorrhage (DAH) in cblC deficiency. METHODS: We made a retrospective analysis of four pediatric patients diagnosed with DAH and pulmonary microangiopathy due to cblC deficiency between January 2017 and December 2018 in Beijing Children's Hospital. RESULTS: This study describes four patients with their ages ranging from 4 years 2 months to 7 years 6 months with cblC deficiency who developed late-onset diffuse lung disease (DLD). Of these, the first three patients presented predominantly with DAH, and the last patient with pulmonary microangiopathy confirmed by thoracoscopic lung biopsy. All patients were accompanied by pulmonary arterial hypertension (PAH), two accompanied by respiratory failure, and two accompanied by moderate megaloblastic anemia. Diffuse ground-glass opacification and poorly defined ground-glass centrilobular nodules were seen on high-resolution computed tomography in one patient and three patients, respectively. All patients were suspected of having idiopathic pulmonary hemosiderosis or interstitial lung disease at other hospitals. All of them received treatment with corticosteroid before admission, but the symptoms did not improve. Moreover, all patients carried compound heterozygous mutations (c.80A>G, c.609G>A) in MMACHC and improved significantly after being treated for cblC deficiency and PAH. CONCLUSIONS: CblC deficiency should be considered in the differential diagnosis of DAH especially with PAH, and pulmonary microangiopathy be the main reason of DLD in these patients.


Assuntos
Hemorragia/diagnóstico , Hemossiderose/diagnóstico , Pneumopatias/diagnóstico , Deficiência de Vitamina B 12/diagnóstico , Criança , Pré-Escolar , Diagnóstico Diferencial , Feminino , Hemorragia/etiologia , Hemorragia/genética , Hemossiderose/etiologia , Hemossiderose/genética , Humanos , Pneumopatias/etiologia , Pneumopatias/genética , Masculino , Mutação , Oxirredutases/genética , Deficiência de Vitamina B 12/complicações , Deficiência de Vitamina B 12/genética
17.
Anesth Analg ; 130(5): 1176-1187, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32287125

RESUMO

BACKGROUND: Individualized hemodynamic monitoring approaches are not well validated. Thus, we evaluated the discriminative performance improvement that might occur when moving from noninvasive monitoring (NIM) to invasive monitoring and with increasing levels of featurization associated with increasing sampling frequency and referencing to a stable baseline to identify bleeding during surgery in a porcine model. METHODS: We collected physiologic waveform (WF) data (250 Hz) from NIM, central venous (CVC), arterial (ART), and pulmonary arterial (PAC) catheters, plus mixed venous O2 saturation and cardiac output from 38 anesthetized Yorkshire pigs bled at 20 mL/min until a mean arterial pressure of 30 mm Hg following a 30-minute baseline period. Prebleed physiologic data defined a personal stable baseline for each subject independently. Nested models were evaluated using simple hemodynamic metrics (SM) averaged over 20-second windows and sampled every minute, beat to beat (B2B), and WF using Random Forest Classification models to identify bleeding with or without normalization to personal stable baseline, using a leave-one-pig-out cross-validation to minimize model overfitting. Model hyperparameters were tuned to detect stable or bleeding states. Bleeding models were compared use both each subject's personal baseline and a grouped-average (universal) baseline. Timeliness of bleed onset detection was evaluated by comparing the tradeoff between a low false-positive rate (FPR) and shortest time to bleed detection. Predictive performance was evaluated using a variant of the receiver operating characteristic focusing on minimizing FPR and false-negative rates (FNR) for true-positive and true-negative rates, respectively. RESULTS: In general, referencing models to a personal baseline resulted in better bleed detection performance for all catheters than using universal baselined data. Increasing granularity from SM to B2B and WF progressively improved bleeding detection. All invasive monitoring outperformed NIM for both time to bleeding detection and low FPR and FNR. In that regard, when referenced to personal baseline with SM analysis, PAC and ART + PAC performed best; for B2B CVC, PAC and ART + PAC performed best; and for WF PAC, CVC, ART + CVC, and ART + PAC performed equally well and better than other monitoring approaches. Without personal baseline, NIM performed poorly at all levels, while all catheters performed similarly for SM, with B2B PAC and ART + PAC performing the best, and for WF PAC, ART, ART + CVC, and ART + PAC performed equally well and better than the other monitoring approaches. CONCLUSIONS: Increasing hemodynamic monitoring featurization by increasing sampling frequency and referencing to personal baseline markedly improves the ability of invasive monitoring to detect bleed.


Assuntos
Análise de Dados , Monitorização Hemodinâmica/métodos , Hemodinâmica/fisiologia , Hemorragia/diagnóstico , Hemorragia/fisiopatologia , Animais , Pressão Arterial/fisiologia , Débito Cardíaco , Feminino , Monitorização Fisiológica/métodos , Suínos
18.
BMC Surg ; 20(1): 69, 2020 Apr 10.
Artigo em Inglês | MEDLINE | ID: mdl-32276609

RESUMO

BACKGROUND: Various techniques are used to detect intraoperative bleeding points in thyroid surgery. We aimed to assess the effect of increasing peak airway pressure to 30, 40 and 50 cm H2O manually in detecting intraoperative bleeding points. METHODS: One hundred and 34 patients scheduled for total thyroidectomy were included to this prospective randomised controlled clinical study. We randomly assigned patients to increase peak airway pressure to 30, 40 and 50 cm H2O manually intraoperatively just before surgical closure during hemostasis control. The primary endpoint was the rate of bleeding points detected by the surgeon during peak airway pressure increase. RESULTS: The rate of detection of the bleeding points was higher in 50 cm H2O Group than the other two groups (15.9 vs 25.5 vs 40%, P = 0.030), after pressure administration, the HR, SpO2, and P peak were similar between groups (P = 0.125, 0.196, 0.187, respectively). The median duration of the bleeding point detection after the pressure application was 21.82 s in 30 cm H2O, 25 s in 40 cm H2O, and 22.50 s in 50 cm H2O groups. Postoperative subcutaneous hematomas or hemorrhages requiring surgery were not seen in any patient. CONCLUSIONS: Manually increasing peak airway pressure to 50 cm H2O during at least 22.50 s may be used as an alternative way to detect intraoperative bleeding points in thyroid surgery. CLINICAL TRIAL REGISTRATION: NCT03547648. Registered 6 June2018.


Assuntos
Hemorragia/diagnóstico , Tireoidectomia/métodos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
19.
Cardiovasc Ther ; 2020: 8647837, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32190122

RESUMO

Background: Anemia following acute myocardial infarction (AMI) is associated with poor outcomes. While previous studies in patients with AMI have focused on anemia at admission, we hypothesized that hemoglobin (Hb) decline during hospitalization and lower discharge Hb would be associated with greater long-term mortality in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Methods: We analyzed records of 983 STEMI patients who were treated with primary PCI. The primary end point was all-cause mortality at 1 year and 2 years. The relationship between discharge Hb levels, decline in Hb levels, bleeding event classification, and all-cause mortality was determined. Results: Overall, 16.4% of patients had bleeding events, which were classified by the Thrombolysis in Myocardial Infarction (TIMI) score as 7% minimal, 8.6% minor, and 0.9% major. No significant gastrointestinal bleed and cerebral hemorrhage occurred in hospitals among these patients. The incidence rate of the 2-year all-cause mortality increased with severity of the bleeding event score (8.78% for no bleeding vs. 11.59% for minimal bleeding vs. 20.24% for minor bleeding vs. 55.56% for major bleeding, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006-1.034, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006-1.034, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006-1.034. Conclusions: In this population of patients hospitalized for STEMI, all-cause mortality increased with lower discharge Hb, and discharge Hb was a significant predictor of mortality risk.


Assuntos
Anemia/sangue , Hemoglobinas/metabolismo , Hemorragia/sangue , Alta do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Anemia/diagnóstico , Anemia/mortalidade , Biomarcadores/sangue , Causas de Morte , Feminino , Hemorragia/diagnóstico , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento
20.
Cardiovasc J Afr ; 31(4): 185-189, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32181794

RESUMO

INTRODUCTION: Mechanical heart valve (MHV) prostheses increase the risk of thromboembolic complications. While warfarin anticoagulation reduces this risk, its use increases the risk of bleeding. We sought to estimate the rate of thromboembolic and bleeding complications among patients with MHVs at a tertiary hospital in Botswana. Factors associated with bleeding and thromboembolic complications are also described. METHODS: This retrospective cohort study involved a cohort of patients with MHV at Princess Marina Hospital who were operated on before September 2017. The study documented bleeding and thromboembolic events since the valve replacement, patients' demographic information, co-existing medical conditions, drug history and details of valve replacement. Using the recent international normalised ratio (INR) results, each patient's time in therapeutic range (TTR) was calculated to assess the level of anticoagulation control. RESULTS: The study enrolled 142 patients with a mean (SD) age of 42 (12) years and a median (IQR) duration since valve replacement of four years (1.8-10.0). The median (IQR) TTR was 29.8% (14.1-51.0) and only 14.8% of the patients had an optimal anticoagulation control. The rates of major bleeding and thromboembolic complications were 1.5 per 100 person-years and 2.80 per 100 person-years, respectively. A longer duration of warfarin use was associated with an increased risk of both bleeding (p = 0.008) and thromboembolic complications (p = 0.01). CONCLUSIONS: Bleeding and thromboembolic complications were common in MHV prosthesis patients in this study. Long duration of anticoagulation, albeit sub-optimal control, was a risk factor for bleeding and thromboembolic complications in these patients. Therefore, long-term efforts are necessary to address these complications and possibly improve the quality of life of these patients.


Assuntos
Anticoagulantes/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Hemorragia/induzido quimicamente , Tromboembolia/prevenção & controle , Varfarina/efeitos adversos , Administração Oral , Adulto , Anticoagulantes/administração & dosagem , Botsuana/epidemiologia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Hemorragia/diagnóstico , Hemorragia/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tromboembolia/diagnóstico , Tromboembolia/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Varfarina/administração & dosagem
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