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1.
Medicine (Baltimore) ; 100(37): e27053, 2021 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-34664830

RESUMO

ABSTRACT: For patients with ischemic stroke, intravenous (IV) thrombolysis with Urokinase within 6 hours has been accepted as beneficial, but its application is limited by high risk of hemorrhagic complications after thrombolysis. This study aimed to analyze the risk factors of hemorrhagic complications after intravenous thrombolysis using Urokinase in acute cerebral infarction (ACI) patients.Total 391 consecutive ACI patients were enrolled and divided into 2 groups: the hemorrhagic complications group and the non-hemorrhagic complications group. The related data were collected and analyzed.Univariate analysis showed significant differences in prothrombin time, atrial fibrillation (AF), Mean platelet volume, large platelet ratio (L-PLR), triglyceride (TG), Lactate dehydrogenase, alanine aminotransferase (ALT), high-density lipoprotein, and baseline National Institute of Health Stroke Scale score between the hemorrhagic complications and the non-hemorrhagic complications group (P < .1). Multivariate logistic regression analysis indicated that AF (odds ratio [OR] = 2.91, 95% confidence interval [CI] = 1.06-7.99 P = .039) was the risk factor of hemorrhagic complications, while ALT (OR = 0.27, 95% CI = 0.10-0.72 P = .009) and TG (OR = 0.16, 95% CI = 0.06-0.45 P = .000) were protective factors of hemorrhagic complications.For patients with AF and lower levels of ALT or TG, the risk of hemorrhagic complications might increase after ACI.


Assuntos
Hemorragia/etiologia , Terapia Trombolítica/efeitos adversos , Trombose/tratamento farmacológico , Administração Intravenosa/efeitos adversos , Administração Intravenosa/métodos , Idoso , Idoso de 80 Anos ou mais , China/epidemiologia , Feminino , Hemorragia/epidemiologia , Hemorragia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Terapia Trombolítica/estatística & dados numéricos , Trombose/epidemiologia , Ativador de Plasminogênio Tipo Uroquinase/efeitos adversos , Ativador de Plasminogênio Tipo Uroquinase/uso terapêutico
2.
Int J Mol Sci ; 22(17)2021 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-34502548

RESUMO

Toxins from Bothrops venoms targeting hemostasis are responsible for a broad range of clinical and biological syndromes including local and systemic bleeding, incoagulability, thrombotic microangiopathy and macrothrombosis. Beyond hemostais disorders, toxins are also involved in the pathogenesis of edema and in most complications such as hypovolemia, cardiovascular collapse, acute kidney injury, myonecrosis, compartmental syndrome and superinfection. These toxins can be classified as enzymatic proteins (snake venom metalloproteinases, snake venom serine proteases, phospholipases A2 and L-amino acid oxidases) and non-enzymatic proteins (desintegrins and C-type lectin proteins). Bleeding is due to a multifocal toxicity targeting vessels, platelets and coagulation factors. Vessel damage due to the degradation of basement membrane and the subsequent disruption of endothelial cell integrity under hydrostatic pressure and tangential shear stress is primarily responsible for bleeding. Hemorrhage is promoted by thrombocytopenia, platelet hypoaggregation, consumption coagulopathy and fibrin(ogen)olysis. Onset of thrombotic microangiopathy is probably due to the switch of endothelium to a prothrombotic phenotype with overexpression of tissue factor and other pro-aggregating biomarkers in association with activation of platelets and coagulation. Thrombosis involving large-caliber vessels in B. lanceolatus envenomation remains a unique entity, which exact pathophysiology remains poorly understood.


Assuntos
Transtornos da Coagulação Sanguínea/fisiopatologia , Venenos de Crotalídeos/metabolismo , Hemorragia/fisiopatologia , Hemostasia/fisiologia , Trombose/fisiopatologia , Animais , Antivenenos/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Coagulação Sanguínea/fisiologia , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Plaquetas/efeitos dos fármacos , Plaquetas/fisiologia , Venenos de Crotalídeos/antagonistas & inibidores , Humanos
3.
Anesthesiology ; 135(4): 673-685, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34370811

RESUMO

BACKGROUND: Life-threatening bleeding requires prompt reversal of the anticoagulant effects of factor Xa inhibitors. This study investigated the effectiveness of four-factor prothrombin complex concentrate in treating trauma-related hemorrhage with rivaroxaban-anticoagulation in a pig polytrauma model. This study also tested the hypothesis that the combined use of a low dose of prothrombin complex concentrate plus tranexamic acid and fibrinogen concentrate could improve its subtherapeutic effects. METHODS: Trauma (blunt liver injury and bilateral femur fractures) was induced in 48 anesthetized male pigs after 30 min of rivaroxaban infusion (1 mg/kg). Animals in the first part of the study received prothrombin complex concentrate (12.5, 25, and 50 U/kg). In the second part, animals were treated with 12.5 U/kg prothrombin complex concentrate plus tranexamic acid or plus tranexamic acid and fibrinogen concentrate. The primary endpoint was total blood loss postinjury. The secondary endpoints (panel of coagulation parameters and thrombin generation) were monitored for 240 min posttrauma or until death. RESULTS: The first part of the study showed that blood loss was significantly lower in the 25 U/kg prothrombin complex concentrate (1,541 ± 269 ml) and 50 U/kg prothrombin complex concentrate (1,464 ± 108 ml) compared with control (3,313 ± 634 ml), and 12.5 U/kg prothrombin complex concentrate (2,671 ± 334 ml, all P < 0.0001). In the second part of the study, blood loss was significantly less in the 12.5 U/kg prothrombin complex concentrate plus tranexamic acid and fibrinogen concentrate (1,836 ± 556 ml, P < 0.001) compared with 12.5 U/kg prothrombin complex concentrate plus tranexamic acid (2,910 ± 856 ml), and there were no early deaths in the 25 U/kg prothrombin complex concentrate, 50 U/kg prothrombin complex concentrate, and 12.5 U/kg prothrombin complex concentrate plus tranexamic acid and fibrinogen concentrate groups. Histopathologic analyses postmortem showed no adverse events. CONCLUSIONS: Prothrombin complex concentrate effectively reduced blood loss, restored hemostasis, and balanced thrombin generation. A multimodal hemostatic approach using tranexamic acid plus fibrinogen concentrate enhanced the effect of low doses of prothrombin complex concentrate, potentially reducing the prothrombin complex concentrate doses required for effective bleeding control.


Assuntos
Anticoagulantes/toxicidade , Modelos Animais de Doenças , Inibidores do Fator Xa/toxicidade , Hemostasia/efeitos dos fármacos , Traumatismo Múltiplo/tratamento farmacológico , Rivaroxabana/toxicidade , Animais , Fatores de Coagulação Sanguínea/farmacologia , Fatores de Coagulação Sanguínea/uso terapêutico , Terapia Combinada/métodos , Relação Dose-Resposta a Droga , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Hemorragia/fisiopatologia , Hemostasia/fisiologia , Masculino , Traumatismo Múltiplo/induzido quimicamente , Traumatismo Múltiplo/fisiopatologia , Suínos
4.
Br J Radiol ; 94(1127): 20210753, 2021 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-34464549

RESUMO

Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.


Assuntos
Doenças das Glândulas Suprarrenais/diagnóstico por imagem , Diagnóstico por Imagem/métodos , Hemorragia/diagnóstico por imagem , Doenças das Glândulas Suprarrenais/fisiopatologia , Glândulas Suprarrenais/diagnóstico por imagem , Glândulas Suprarrenais/fisiopatologia , Hemorragia/fisiopatologia , Humanos
5.
PLoS One ; 16(8): e0255721, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34375347

RESUMO

AIMS: To evaluate factors influencing the length of stay in patients undergoing percutaneous left atrial appendage occlusion (LAAO). METHODS AND RESULTS: Patient characteristics, procedural data and the occurrence of serious adverse events were analyzed from the AmplatzerTM AmuletTM Occluder Observational Study. Patients were divided into three groups: same day (S, 0day, n = 60, 5.6%) early (E, 1day, n = 526, 48.9%), regular (R, 2-3days, n = 338, 31.4%) and late (L, ≥4days, n = 152, 14.1%) discharge and followed up for 60 days. Procedure and device related SAE during the in-hospital stay (S: 0.0% vs. E: 1.0% vs. R: 2.1% vs. L: 23%, p<0.0001) were a major trigger for a prolonged in-hospital stay. Of the 37 subjects in the late discharge group with an SAE prior to discharge, cardiac or bleeding complications were the most common underlying conditions, occurring in 26 subjects. Multinomial logistic analysis only identified HAS-BLED score as an independent influencing factor (p = 0.04) for a late discharge. After 60 days, mortality tended to be greatest in the late discharge group (S: 0.0% vs. E: 1.0% vs. R: 1.2% vs. L: 3.3%, p = 0.1066). CONCLUSION: Over half of the subjects receiving an Amplatzer Amulet occluder were discharged within 1 day of the implant procedure. Serious adverse events were a major trigger for a late discharge after LAAO. Increased HAS-BLED score was associated with a prolonged in-hospital stay.


Assuntos
Apêndice Atrial/fisiopatologia , Fibrilação Atrial/terapia , Hemorragia/terapia , AVC Isquêmico/terapia , Dispositivo para Oclusão Septal , Idoso , Fibrilação Atrial/fisiopatologia , Cateterismo Cardíaco/métodos , Feminino , Fatores de Risco de Doenças Cardíacas , Hemorragia/complicações , Hemorragia/fisiopatologia , Humanos , AVC Isquêmico/complicações , AVC Isquêmico/fisiopatologia , Tempo de Internação , Masculino , Resultado do Tratamento
6.
Transfusion ; 61 Suppl 1: S167-S173, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269439

RESUMO

INTRODUCTION: We conducted a prospective observational study on 205 trauma patients at a level I trauma facility to test the hypothesis that a compensatory reserve measurement (CRM) would identify higher risk for progression to shock and/or need a life-saving interventions (LSIs) earlier than systolic blood pressure (SBP) and blood lactate (LAC). METHODS: A composite outcome metric included blood transfusion, procedural LSI, and mortality. Discrete measures assessed as abnormal (ab) were SBP <90 mmHg, CRM <60%, and LAC >2.0. A graded categorization of shock was defined as: no shock (normal [n] SBP [n-SBP], n-CRM, n-LAC); sub-clinical shock (ab-CRM, n-SBP, n-LAC); occult shock (n-SBP, ab-CRM, ab-LAC); or overt shock (ab-SBP, ab-CRM, ab-LAC). RESULTS: Three patients displayed overt shock, 53 displayed sub-clinical shock, and 149 displayed no shock. After incorporating lactate into the analysis, 86 patients demonstrated no shock, 25 were classified as sub-clinical shock, 91 were classified as occult shock, and 3 were characterized as overt shock. Each shock subcategory revealed a graded increase requiring LSI and transfusion. Initial CRM was associated with progression to shock (odds ratio = 0.97; p < .001) at an earlier time than SBP or LAC. CONCLUSIONS: Initial CRM uncovers a clinically relevant subset of patients who are not detected by SBP and LAC. Our results suggest CRM could be used to more expeditiously identify injured patients likely to deteriorate to shock, with requirements for blood transfusion or procedural LSI.


Assuntos
Transfusão de Sangue , Hemorragia/terapia , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Pressão Sanguínea , Feminino , Hemorragia/sangue , Hemorragia/diagnóstico , Hemorragia/fisiopatologia , Humanos , Lactatos/sangue , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Choque Hemorrágico/sangue , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/fisiopatologia , Triagem , Ferimentos e Lesões/sangue , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/fisiopatologia
8.
Surg Radiol Anat ; 43(10): 1735-1743, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33890143

RESUMO

BACKGROUND: Standart interventional procedures such as screw instrumentation, aortic arch endovascular surgery and cervical nerve blockade may be of fatal risk due to anatomic reason of variations in the proximal part of the vertebral artery (VA). The aim of this study is to study the VA variations of the extracranial segments to evaluate the frequency of the incident to demonstrate the importance of clinical condition strategy. METHODS: The prevalence of variations and morphometric measurements of the VA in three-dimensional computed tomographic angiography (3D-CTA) scans were studied. Total 400 VA was investigated for the aortic arch origin of the VA, diameter of the VA, its level of entry into the transverse foramen, the dominance sides, and related basilar artery course. RESULTS: 3D-CTA radiographs of 200 Anatolian patients (120 men and 80 women with age range 17-90 years). In most cases (approximately 94%), both sides of VA were the first branch of subclavian artery. While all the right VAs was branched from the subclavian artery, 6% of the left VAs were branched from the aortic arch. 2/3 of them originated from the proximal of the subclavian artery and 1/3 from the distal. The VA which were originating from the proximal of the classical anatomic pattern tended to enter the transverse foramen more distally than C6 level. VAs with a different level of entry than C6 are left-sided and aortic arch originated (out of 8 cases 3 had a level of entry at C5 and 2 at C4). The outer diameter ranges of the prevertebral part of the VA of subclavian origin and left VA of aortic arch origin were 3.2-3.6 mm and 3.2-3.6 mm, respectively. While the diameters of the right and left VAs were almost the same in approximately 20% cases, the left VA was dominant in up to 60% of cases. A significant relationship was found between the side of the dominant VA and in the course of the basilar artery. CONCLUSIONS: The relationship between the dominant side of VA and the course of the basilar artery of its own vessel has never been reported elsewhere. Such anatomical variations, routine preoperative 3D-CTA evaluation is mandatory to prevent the VA injury when C5-C2 instrumentation, anterior cervical decompression, cervical nerve blockade and aortic arch surgery are planned.


Assuntos
Variação Anatômica , Angiografia por Tomografia Computadorizada/métodos , Hemorragia/fisiopatologia , Imageamento Tridimensional/métodos , Artéria Vertebral/anormalidades , Artéria Vertebral/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Turquia , Artéria Vertebral/fisiopatologia , Adulto Jovem
9.
CMAJ ; 193(4): E117-E123, 2021 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-33667180

RESUMO

BACKGROUND: Little is known about the association between alcohol consumption and risk of cardiovascular events in patients with established atrial fibrillation (AF). The main aim of the current study was to investigate the associations of regular alcohol intake with incident stroke or systemic embolism in patients with established AF. METHODS: To assess the association between alcohol consumption and cardiovascular events in patients with established AF, we combined data from 2 comparable prospective cohort studies that followed 3852 patients with AF for a median of 3.0 years. Patients were grouped into 4 categories of daily alcohol intake (none, > 0 to < 1, 1 to < 2 and ≥ 2 drinks/d). The primary outcome was a composite of stroke and systemic embolism. Secondary outcomes were all-cause mortality, myocardial infarction, hospital admission for acute heart failure, and a composite of major and clinically relevant nonmajor bleeding. Associations were assessed using time-updated, multivariable-adjusted Cox proportional hazards models. RESULTS: Mean age (± standard deviation) was 71 ± 10 years (28% were women and 84% were on oral anticoagulants). We observed 136 confirmed strokes or systemic emboli. Compared with nondrinkers, adjusted hazard ratios for the primary outcome event were 0.87, 95% confidence interval (CI) 0.55-1.37 for > 0 to < 1 drinks/d; 0.70, 95% CI 0.39-1.25 for 1 to < 2 drinks/d; and 0.96, 95% CI 0.56-1.67 for ≥ 2 drinks/d (p for linear [quadratic] trend 0.71 [0.22]). There was no significant association between alcohol consumption and bleeding, but there was a nonlinear association with heart failure (p for quadratic trend 0.01) and myocardial infarction (p for quadratic trend 0.007). INTERPRETATION: In patients with AF, we did not find a significant association between low to moderate alcohol intake and risk of stroke or other cardiovascular events. Our findings do not support special recommendations for patients with established AF with regard to alcohol consumption. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT02105844.


Assuntos
Consumo de Bebidas Alcoólicas/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Hemorragia/etiologia , Idoso , Idoso de 80 Anos ou mais , Consumo de Bebidas Alcoólicas/epidemiologia , Consumo de Bebidas Alcoólicas/fisiopatologia , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Fibrilação Atrial/fisiopatologia , Estudos de Coortes , Feminino , Fatores de Risco de Doenças Cardíacas , Hemorragia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Varfarina/efeitos adversos , Varfarina/uso terapêutico
10.
Anesth Analg ; 133(4): 1060-1069, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33755645

RESUMO

BACKGROUND: Intraoperative hypotension is a common event, and a recent study suggests that maintenance of blood pressure may reduce complications. The splanchnic circulation provides a reservoir of blood that can be mobilized during hemorrhage; hence, intestinal microcirculation is sensitive to volume changes. The aim of this study was to assess the impact of hemorrhage on intestinal microcirculation and hemodynamics, and the effects of phenylephrine on these parameters. METHODS: Eight anesthetized, mechanically ventilated Yorkshire/Landrace crossbreed pigs were studied. Graded hemorrhage was performed with the removal of 20% of blood volume in 5% increments. Hemodynamic and intestinal microcirculatory measurements were performed at each stage with side-stream dark field microscopy, following which mean arterial pressure (MAP) was corrected with phenylephrine to baseline values and measurements repeated. A repeated measurement 1-way analysis of variance (ANOVA) was used to compared changes from baseline measurements. RESULTS: The mean baseline microcirculation score was 42 (standard deviation [SD] = 5). A 5% hemorrhage decreased the microcirculation score by a mean difference of 19 (95% confidence interval [CI], 12-27; P < .0001), and an additional 5% hemorrhage further reduced the microcirculation score by a mean difference of 12 (95% CI, 4-19; P = .0001). Subsequent hemorrhage or administration of phenylephrine did not significantly change the microcirculation scores except when phenylephrine was administered at the 15% hemorrhage stage, which increased the microcirculation score by a mean difference of 7 (95% CI, 1-13; P = .003). All hemodynamic variables were returned to baseline values following hemorrhage by the phenylephrine infusion. CONCLUSIONS: Intestinal microcirculatory flow is reduced early in hemorrhage and is uncorrected by phenylephrine infusion. Hemodynamic changes associated with hemorrhage are corrected by phenylephrine and do not reflect microcirculatory flow status.


Assuntos
Hemodinâmica/efeitos dos fármacos , Hemorragia/tratamento farmacológico , Intestinos/irrigação sanguínea , Microcirculação/efeitos dos fármacos , Fenilefrina/farmacologia , Circulação Esplâncnica/efeitos dos fármacos , Vasoconstritores/farmacologia , Animais , Modelos Animais de Doenças , Feminino , Hemorragia/fisiopatologia , Sus scrofa , Fatores de Tempo
11.
Am J Kidney Dis ; 77(5): 796-809, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33771393

RESUMO

Since maintenance hemodialysis (HD) first became available in the United States in 1962, there has been tremendous growth in the population of patients with kidney failure. HD has become a routine treatment carried out in outpatient clinics, hospitals, nursing facilities, and in patients' homes. Although it is a complex procedure, HD is quite safe. Serious complications are uncommon due to the use of modern HD machines and water treatment systems as well as the development of strict protocols to monitor various aspects of the HD treatment. The practicing nephrologist must be knowledgeable about life-threatening complications that can occur during HD and be able to recognize, manage, and prevent them. This installment in the AJKD Core Curriculum in Nephrology reviews the pathogenesis, management, and prevention of 9 HD emergencies. The HD emergencies covered include dialyzer reactions, dialysis disequilibrium syndrome, uremic/dialysis-associated pericarditis, air embolism, venous needle dislodgement, vascular access hemorrhage, hemolysis, dialysis water contamination, and arrhythmia episodes.


Assuntos
Emergências , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/fisiopatologia , Arritmias Cardíacas/terapia , Edema Encefálico , Descontaminação , Soluções para Diálise/normas , Embolia Aérea/etiologia , Embolia Aérea/fisiopatologia , Embolia Aérea/terapia , Deslocamentos de Líquidos Corporais , Hemólise , Hemorragia/etiologia , Hemorragia/fisiopatologia , Hemorragia/terapia , Humanos , Hipersensibilidade/etiologia , Hipersensibilidade/fisiopatologia , Hipersensibilidade/terapia , Rins Artificiais/efeitos adversos , Agulhas , Nefrologia , Pericardite/etiologia , Pericardite/fisiopatologia , Pericardite/terapia , Falha de Prótese , Esterilização , Uremia/complicações , Purificação da Água/normas
12.
Cardiovasc Intervent Radiol ; 44(6): 943-951, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33608760

RESUMO

PURPOSE: To evaluate the safety and efficacy of superselective vesical artery embolization (SVAE) in the treatment of intractable hemorrhagic cystitis (HC) following hematopoietic stem cell transplantation (HSCT). METHODS: From January 2010 to December 2018, 26 patients with hematologic malignancy who underwent SVAE for treatment of intractable HC following HSCT were retrospectively reviewed. SVAE was performed with 300-500 µm gelatin-sponge particles initially. Technical success was defined as achieving bilateral SVAE for all the prominent vesical arteries. Therapeutic efficacy was defined as: Complete response (CR): macroscopic hematuria completely disappeared on more than 2 consecutive days after SVAE; Partial response (PR): macroscopic hematuria reduced after SVAE or briefly disappeared after SVAE but reappeared soon within 2 days; No response: no response to SVAE or hematuria aggravated after SVAE; Recurrence: macroscopic hematuria relapsed on follow-up after achieving an initial CR. Adverse events were also registered. RESULTS: There was a mean follow-up of 11.4 months (range, 0.5-83.7). The mean interval for the onset of HC after HSCT was 39.7 ± 19.0 days, and mean duration of hematuria before embolization was 14.9 ± 15.7 days. SVAE was technically successful in all patients. After embolization, macroscopic hematuria regressed within 48 h for all patients. The mean urine erythrocyte counts dropped from 14,213.2 ± 20,999.0/uL before SVAE to 6072.9 ± 12,720.7/uL on 3d after SVAE (P = 0.002) and 3720.2 ± 8988.9/uL on 7 d after SVAE (P = 0.001), respectively. Hematuria completely disappeared prior to discharge in 23 (88.5%) patients (including 20 with one embolization and 3 with 2 embolizations) and remainder 3 patients had PR. No major procedure-related complications were noted, except for post-embolization syndrome in 8 patients, which resolved with symptomatic treatment. On follow-up monthly, hematuria recurrence was seen in 4/23 patients (17.4%) and was managed conservatively in 2 patients and with repeat embolization in the remainder 2 patients. CONCLUSION: For fragile patients with hematologic malignancy, SVAE is safe and effective to treat HC following HSCT, even though repeat embolization may be required to achieve a sustained complete remission of the hematuria.


Assuntos
Cistite/terapia , Embolização Terapêutica/métodos , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Hemorragia/terapia , Adolescente , Adulto , Artérias/fisiopatologia , Cistite/etiologia , Cistite/fisiopatologia , Hemorragia/etiologia , Hemorragia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Bexiga Urinária/irrigação sanguínea , Adulto Jovem
13.
Anesthesiology ; 134(4): 607-616, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33635950

RESUMO

BACKGROUND: Measuring fluid status during intraoperative hemorrhage is challenging, but detection and quantification of fluid overload is far more difficult. Using a porcine model of hemorrhage and over-resuscitation, it is hypothesized that centrally obtained hemodynamic parameters will predict volume status more accurately than peripherally obtained vital signs. METHODS: Eight anesthetized female pigs were hemorrhaged at 30 ml/min to a blood loss of 400 ml. After each 100 ml of hemorrhage, vital signs (heart rate, systolic blood pressure, mean arterial pressure, diastolic blood pressure, pulse pressure, pulse pressure variation) and centrally obtained hemodynamic parameters (mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure, cardiac output) were obtained. Blood volume was restored, and the pigs were over-resuscitated with 2,500 ml of crystalloid, collecting parameters after each 500-ml bolus. Hemorrhage and resuscitation phases were analyzed separately to determine differences among parameters over the range of volume. Conformity of parameters during hemorrhage or over-resuscitation was assessed. RESULTS: During the course of hemorrhage, changes from baseline euvolemia were observed in vital signs (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) after 100 ml of blood loss. Central hemodynamic parameters (mean pulmonary artery pressure and pulmonary capillary wedge pressure) were changed after 200 ml of blood loss, and central venous pressure after 300 ml of blood loss. During the course of resuscitative volume overload, changes were observed from baseline euvolemia in mean pulmonary artery pressure and central venous pressure after 500-ml resuscitation, in pulmonary capillary wedge pressure after 1,000-ml resuscitation, and cardiac output after 2,500-ml resuscitation. In contrast to hemorrhage, vital sign parameters did not change during over-resuscitation. The strongest linear correlation was observed with pulmonary capillary wedge pressure in both hemorrhage (r2 = 0.99) and volume overload (r2 = 0.98). CONCLUSIONS: Pulmonary capillary wedge pressure is the most accurate parameter to track both hemorrhage and over-resuscitation, demonstrating the unmet clinical need for a less invasive pulmonary capillary wedge pressure equivalent.


Assuntos
Soluções Cristaloides/administração & dosagem , Hidratação/efeitos adversos , Hemodinâmica , Hemorragia/fisiopatologia , Animais , Volume Sanguíneo , Modelos Animais de Doenças , Feminino , Ressuscitação , Suínos , Sinais Vitais
14.
J Trauma Acute Care Surg ; 90(5): 838-844, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33496551

RESUMO

BACKGROUND: Noncompressible torso hemorrhage (NCTH) of the abdomen is a challenge to rapidly control and treat in the prehospital and emergency department settings. In this pilot study, we developed a novel intraperitoneal hemostasis device (IPHD) prototype and evaluated its ability for slowing NCTH and prolonging survival in a porcine model of lethal abdominal multiorgan hemorrhage. METHODS: Yorkshire male swine (N = 8) were instrumented under general anesthesia for monitoring of hemodynamics and blood sampling. Animals were subjected to a 30% controlled arterial hemorrhage followed by lacerating combinations of the liver, spleen, and kidney. The abdomen was closed and after 2 minutes of NCTH, and the IPHD was inserted into the peritoneal cavity via an introducer (n = 5). The balloon was inflated and maintained for 60 minutes. At 60 minutes postdeployment, the balloon was deflated and removed, and blood resuscitation was initiated followed by gauze packing for hemostasis. The remaining animals (n = 3) were used as controls and subjected to the same injury without intervention. RESULTS: All animals managed with IPHD intervention (5 of 5 swine) survived the duration of the intervention period (60 minutes), while all control animals (3 of 3 swine) died at a time range of 15 to 43 minutes following organ injury (p = 0.0042). Animals receiving IPHD remained hemodynamically stable with a mean arterial pressure range of 44.86 to 55.10 mm Hg and experienced increased cardiac output and decreased shock index after treatment. Controls experienced hemodynamic decline in all parameters until endpoints were met. Upon IPHD deflation and removal, all treated animals began to hemorrhage again and expired within 2 to 132 minutes despite packing. CONCLUSION: Our data show that the IPHD concept is capable of prolonging survival by temporarily stanching lethal NCTH of the abdomen. This device may be an effective temporary countermeasure to NCTH of the abdomen that could be deployed in the prehospital environment or as a bridge to more advanced therapy.


Assuntos
Traumatismos Abdominais/terapia , Oclusão com Balão/instrumentação , Hemorragia/terapia , Traumatismos Abdominais/fisiopatologia , Animais , Modelos Animais de Doenças , Hemodinâmica , Hemorragia/fisiopatologia , Hemostasia , Masculino , Projetos Piloto , Pressão , Ressuscitação/métodos , Taxa de Sobrevida , Suínos
15.
Nutr Rev ; 79(9): 964-975, 2021 08 09.
Artigo em Inglês | MEDLINE | ID: mdl-33517432

RESUMO

CONTEXT: The World Health Organization set the recommended daily vitamin C intake, henceforth referred to as ascorbic acid (AA), on the basis of scurvy prevention. Double-blind AA depletion-repletion studies suggest that this recommended AA dose may be too low to prevent microvascular fragility. OBJECTIVES: (1) To conduct a systematic review and meta-analysis of controlled clinical trials on whether AA supplementation leads to a reduced gingival bleeding tendency, a manifestation of microvascular fragility; and (2) to relate AA plasma levels to retinal hemorrhaging, another manifestation of microvascular fragility. DATA SOURCES: Data were reviewed from 15 trials conducted in 6 countries with 1140 predominantly healthy participants with measures of gingival bleeding tendency, and from the National Health and Nutrition Examination Survey (NHANES) III of 8210 US residents with measures of retinal hemorrhaging. RESULTS: In clinical trials, AA supplementation reduced gingival bleeding tendency when estimated baseline AA plasma levels were < 28 µmol/L (standardized mean difference [SMD], -0.83; 95%CI, -1.16 to -0.49; P < 0.002). Supplementation with AA did not unequivocally reduce gingival bleeding tendency when baseline estimated AA plasma levels were >48 µmol/L or unknown (respective standardized mean differences: -0.23, 95%CI, -0.45 to -0.01, P < 0.05; and -0.56; 95%CI: -1.19 to 0.06, P < 0.08). In NHANES III, prevalence of both retinal hemorrhaging and gingival bleeding tendency increased when AA plasma levels were within the range that protects against scurvy (11-28 µmol/L; respective prevalence ratios adjusted for age and sex: 1.47; 95%CI: 1.22-1.77; and 1.64; 95%CI: 1.32-2.03; P < 0.001 for both). CONCLUSION: Consistent evidence from controlled clinical trials indicates that setting human AA requirements based on scurvy prevention leads to AA plasma levels that may be too low to prevent an increased gingival bleeding tendency. Gingival bleeding tendency and retinal hemorrhaging coincide with low AA plasma levels and thus may be reflective of a systemic microvascular pathology that is reversible with an increased daily AA intake.


Assuntos
Ácido Ascórbico , Gengiva , Hemorragia , Ácido Ascórbico/uso terapêutico , Gengiva/patologia , Hemorragia/fisiopatologia , Hemorragia/prevenção & controle , Humanos , Inquéritos Nutricionais , Ensaios Clínicos Controlados Aleatórios como Assunto
16.
Eur J Med Res ; 26(1): 10, 2021 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-33478582

RESUMO

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in severely injured patients with uncontrollable bleeding. However, zone-dependent effects of REBOA are rarely described. We compared the short-term zone- and organ-specific microcirculatory changes in abdominal organs and the extremity during occlusion of the aorta in a standardized porcine model. METHODS: Male pigs were placed under general anesthesia, for median laparotomy to expose intra-abdominal organs. REBOA placement occurred in Zone 1 (from origin left subclavian artery to celiac trunk), Zone 2 (between the coeliac trunk and most caudal renal artery) and Zone 3 (distal most caudal renal artery to aortic bifurcation). Local microcirculation of the intra-abdominal organs were measured at the stomach, colon, small intestine, liver, and kidneys. Furthermore, the right medial vastus muscle was included for assessment. Microcirculation was measured using oxygen-to-see device (arbitrary units, A.U). Invasive blood pressure measurements were recorded in the carotid and femoral artery (ipsilateral). Ischemia/Reperfusion (I/R)-time was 10 min with complete occlusion. RESULTS: At baseline, microcirculation of intra-abdominal organs differed significantly (p < 0.001), the highest flow was in the kidneys (208.3 ± 32.9 A.U), followed by the colon (205.7 ± 36.2 A.U.). At occlusion in Zone 1, all truncal organs showed significant decreases (p < 0.001) in microcirculation, by 75% at the colon, and 44% at the stomach. Flow-rate changes at the extremities were non-significant (n.s). During occlusion in Zone 2, a significant decrease (p < 0.001) in microcirculation was observed at the colon (- 78%), small intestine (- 53%) and kidney (- 65%). The microcirculatory changes at the extremity were n.s. During occlusion in Zone 3, truncal and extremity microcirculatory changes were n.s. CONCLUSION: All abdominal organs showed significant changes in microcirculation during REBOA. The intra-abdominal organs react differently to the same occlusion, whereas local microcirculation in extremities appeared to be unaffected by short-time REBOA, regardless of the zone of occlusion.


Assuntos
Oclusão com Balão/métodos , Hemorragia/terapia , Traumatismo por Reperfusão/terapia , Animais , Aorta Abdominal/fisiopatologia , Aorta Abdominal/cirurgia , Modelos Animais de Doenças , Hemorragia/fisiopatologia , Hemorragia/prevenção & controle , Humanos , Masculino , Microcirculação/fisiologia , Pessoa de Meia-Idade , Traumatismo por Reperfusão/fisiopatologia , Traumatismo por Reperfusão/prevenção & controle , Ressuscitação/métodos , Suínos
18.
Mar Drugs ; 19(2)2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33499020

RESUMO

In the current study, hemostatic compositions including a combination of chitosan and kaolin have been developed. Chitosan is a marine polysaccharide derived from chitins, a structural component in the shells of crustaceans. Both chitosan and kaolin have the ability to mediate a quick and efficient hemostatic effect following immediate application to injury sites, and thus they have been widely exploited in manufacturing of hemostatic composites. By combining more than one hemostatic agent (i.e., chitosan and kaolin) that act via more than one mechanism, and by utilizing different nanotechnology-based approaches to enhance the surface areas, the capability of the dressing to control bleeding was improved, in terms of amount of blood loss and time to hemostasis. The nanotechnology-based approaches utilized to enhance the effective surface area of the hemostatic agents included the use of Pluronic nanoparticles, and deposition of chitosan micro- and nano-fibers onto the carrier. The developed composites effectively controlled bleeding and significantly improved hemostasis and survival rates in two animal models, rats and rabbits, compared to conventional dressings and QuikClot® Combat Gauze. The composites were well-tolerated as demonstrated by their in vivo biocompatibility and absence of clinical and biochemical changes in the laboratory animals after application of the dressings.


Assuntos
Quitosana/administração & dosagem , Desenho de Fármacos , Hemostasia/efeitos dos fármacos , Hemostáticos/administração & dosagem , Caulim/administração & dosagem , Nanocompostos/administração & dosagem , Animais , Bandagens , Quitosana/síntese química , Avaliação Pré-Clínica de Medicamentos/métodos , Feminino , Hemorragia/tratamento farmacológico , Hemorragia/fisiopatologia , Hemostasia/fisiologia , Hemostáticos/síntese química , Caulim/síntese química , Masculino , Nanocompostos/química , Coelhos , Ratos , Ratos Sprague-Dawley
19.
Am J Cardiol ; 145: 151-159, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33460602

RESUMO

Despite the monumental advances in the diagnoses and therapeutics of malignancy, several cancer patients have presented with pericardial involvement, including acute pericarditis, constrictive pericarditis, and pericardial effusion. Multiple factors can contribute to acute pericarditis, including direct metastasis to the heart, pericardial hemorrhage, infections due to immunosuppression, and cancer therapies that include chemotherapy, immunotherapy, and radiation. Pericardial effusion, either due to cancer invasion or cancer treatment, is one of the most common incidental findings in cancer patients, which significantly worsens morbidity and mortality. If left untreated, pericardial effusion is known to cause complications such as pericardial tamponade. Constrictive pericarditis can be due to radiation exposure, chemotherapy, or is a sequela of a previous episode of acute pericarditis. In conclusion, early detection, prompt treatment, and understanding of pericardial diseases are necessary to help improve the quality of life of cancer patients, and we aim to summarize the knowledge of pericardial involvement in patients with cancer.


Assuntos
Antineoplásicos/efeitos adversos , Hemorragia/fisiopatologia , Neoplasias/terapia , Derrame Pericárdico/fisiopatologia , Pericardite Constritiva/fisiopatologia , Lesões por Radiação/fisiopatologia , Radioterapia/efeitos adversos , Hemorragia/diagnóstico , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Hospedeiro Imunocomprometido , Infecções/etiologia , Infecções/imunologia , Infecções/fisiopatologia , Metástase Neoplásica , Neoplasias/complicações , Derrame Pericárdico/diagnóstico , Derrame Pericárdico/etiologia , Derrame Pericárdico/terapia , Pericardite/diagnóstico , Pericardite/etiologia , Pericardite/fisiopatologia , Pericardite/terapia , Pericardite Constritiva/diagnóstico , Pericardite Constritiva/etiologia , Pericardite Constritiva/terapia , Pericárdio , Lesões por Radiação/diagnóstico , Lesões por Radiação/etiologia , Lesões por Radiação/terapia
20.
Am J Hematol ; 96(2): 199-207, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33107998

RESUMO

Immune thrombocytopenia (ITP) has a substantial, multifaceted impact on patients' health-related quality of life (HRQoL). Data describing which aspects of ITP physicians and patients perceive as having the greatest impact are limited. The ITP World Impact Survey (I-WISh) was a cross-sectional survey, including 1507 patients and 472 physicians, to establish the impact of ITP on HRQoL and productivity from patient and physician perspectives. Patients reported that ITP reduced their energy levels (85% of patients), capacity to exercise (77%), and limited their ability to perform daily tasks (75%). Eighty percent of physicians reported that ITP symptoms reduced patient HRQoL, with 66% reporting ITP-related fatigue substantially reduced patient HRQoL. Patients believed ITP had a substantial impact on emotional well-being (49%) and 63% worried their condition would worsen. Because of ITP, 49% of patients had already reduced, or seriously considered reducing their working hours, and 29% had considered terminating their employment. Thirty-six percent of patients employed at the time of the survey felt ITP decreased their work productivity, while 51% of patients with high/very high symptom burden reported that ITP affected their productivity. Note, I-WISh demonstrated substantive impact of ITP on patients' HRQoL both directly for patients and from the viewpoint of their physicians. Patients reported reduced energy levels, expressed fears their condition might worsen, and those who worked experienced reduced productivity. Physicians should be aware not only of platelet counts and bleeding but also the multi-dimensional impact of ITP on patients' lives as an integral component of disease management.


Assuntos
Hemorragia/fisiopatologia , Púrpura Trombocitopênica Idiopática/fisiopatologia , Qualidade de Vida , Estudos Transversais , Feminino , Hemorragia/diagnóstico , Hemorragia/terapia , Humanos , Masculino , Púrpura Trombocitopênica Idiopática/diagnóstico , Púrpura Trombocitopênica Idiopática/terapia
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