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1.
N Engl J Med ; 381(14): 1309-1320, 2019 Oct 03.
Artigo em Inglês | MEDLINE | ID: mdl-31475798

RESUMO

BACKGROUND: Patients with stable coronary artery disease and diabetes mellitus who have not had a myocardial infarction or stroke are at high risk for cardiovascular events. Whether adding ticagrelor to aspirin improves outcomes in this population is unclear. METHODS: In this randomized, double-blind trial, we assigned patients who were 50 years of age or older and who had stable coronary artery disease and type 2 diabetes mellitus to receive either ticagrelor plus aspirin or placebo plus aspirin. Patients with previous myocardial infarction or stroke were excluded. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major bleeding as defined by the Thrombolysis in Myocardial Infarction (TIMI) criteria. RESULTS: A total of 19,220 patients underwent randomization. The median follow-up was 39.9 months. Permanent treatment discontinuation was more frequent with ticagrelor than placebo (34.5% vs. 25.4%). The incidence of ischemic cardiovascular events (the primary efficacy outcome) was lower in the ticagrelor group than in the placebo group (7.7% vs. 8.5%; hazard ratio, 0.90; 95% confidence interval [CI], 0.81 to 0.99; P = 0.04), whereas the incidence of TIMI major bleeding was higher (2.2% vs. 1.0%; hazard ratio, 2.32; 95% CI, 1.82 to 2.94; P<0.001), as was the incidence of intracranial hemorrhage (0.7% vs. 0.5%; hazard ratio, 1.71; 95% CI, 1.18 to 2.48; P = 0.005). There was no significant difference in the incidence of fatal bleeding (0.2% vs. 0.1%; hazard ratio, 1.90; 95% CI, 0.87 to 4.15; P = 0.11). The incidence of an exploratory composite outcome of irreversible harm (death from any cause, myocardial infarction, stroke, fatal bleeding, or intracranial hemorrhage) was similar in the ticagrelor group and the placebo group (10.1% vs. 10.8%; hazard ratio, 0.93; 95% CI, 0.86 to 1.02). CONCLUSIONS: In patients with stable coronary artery disease and diabetes without a history of myocardial infarction or stroke, those who received ticagrelor plus aspirin had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. (Funded by AstraZeneca; THEMIS ClinicalTrials.gov number, NCT01991795.).


Assuntos
Aspirina/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Ticagrelor/uso terapêutico , Idoso , Aspirina/efeitos adversos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/mortalidade , Método Duplo-Cego , Quimioterapia Combinada/efeitos adversos , Feminino , Seguimentos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/prevenção & controle , Inibidores da Agregação de Plaquetas/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Ticagrelor/efeitos adversos , Resultado do Tratamento
2.
Am Surg ; 85(8): 904-908, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560311

RESUMO

Delayed splenic bleeding (DSB) is a poorly understood complication of blunt splenic injury. Treatment for splenic bleeding may involve splenectomy, but angioembolization is becoming a widely used adjuvant for management. Using the North Carolina Trauma Registry, this study aimed to evaluate the incidence, mortality, and risk factors for DSB in North Carolina. Using ICD-9 and ICD-10 codes, patients were stratified into two cohorts, those who underwent immediate splenectomy and those who were initially managed nonoperatively. DSB was then defined as splenectomy at greater than 24 hours after presentation. Of the 1688 patients included in the study, 269 patients (16%) underwent immediate splenectomy and 1419 (84%) were managed nonoperatively initially, with 32 (2%) having delayed splenectomy. Older age (≥30 years) was associated with increased odds of having delayed splenectomy (odds ratio 4.30; 95% confidence interval 1.08, 17.17; P = 0.04). Four per cent of patients managed nonoperatively and undergoing an angioembolization procedure eventually required splenectomy. Risk factors for DSB remain elusive. Splenic artery embolization may be used as an adjuvant to splenectomy for stable patients, but it is not always a definitive treatment, and patients may still require splenectomy.


Assuntos
Embolização Terapêutica , Hemorragia/etiologia , Hemorragia/terapia , Baço/lesões , Esplenectomia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/terapia , Adulto , Fatores Etários , Feminino , Hemorragia/mortalidade , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Sistema de Registros , Fatores de Risco , Artéria Esplênica/lesões , Centros de Traumatologia , Ferimentos não Penetrantes/mortalidade
3.
BMJ ; 365: l2222, 2019 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-31253632

RESUMO

OBJECTIVE: To evaluate the efficacy and safety of standard term (12 months) or long term (>12 months) dual antiplatelet therapy (DAPT) versus short term (<6 months) DAPT after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Relevant studies published between June 1983 and April 2018 from Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, ClinicalTrials.gov, and Clinicaltrialsregister.eu. REVIEW METHODS: Randomised controlled trials comparing two of the three durations of DAPT (short term, standard term, and long term) after PCI with DES were included. The primary study outcomes were cardiac or non-cardiac death, all cause mortality, myocardial infarction, stent thrombosis, and all bleeding events. RESULTS: 17 studies (n=46 864) were included. Compared with short term DAPT, network meta-analysis showed that long term DAPT resulted in higher rates of major bleeding (odds ratio 1.78, 95% confidence interval 1.27 to 2.49) and non-cardiac death (1.63, 1.03 to 2.59); standard term DAPT was associated with higher rates of any bleeding (1.39, 1.01 to 1.92). No noticeable difference was observed in other primary endpoints. The sensitivity analysis revealed that the risks of non-cardiac death and bleeding were further increased for ≥18 months of DAPT compared with short term or standard term DAPT. In the subgroup analysis, long term DAPT led to higher all cause mortality than short term DAPT in patients implanted with newer-generation DES (1.99, 1.04 to 3.81); short term DAPT presented similar efficacy and safety to standard term DAPT with acute coronary syndrome (ACS) presentation and newer-generation DES placement. The heterogeneity of pooled trials was low, providing more confidence in the interpretation of results. CONCLUSIONS: In patients with all clinical presentations, compared with short term DAPT (clopidogrel), long term DAPT led to higher rates of major bleeding and non-cardiac death, and standard term DAPT was associated with an increased risk of any bleeding. For patients with ACS, short term DAPT presented similar efficacy and safety with standard term DAPT. For patients implanted with newer-generation DES, long term DAPT resulted in more all cause mortality than short term DAPT. Although the optimal duration of DAPT should take personal ischaemic and bleeding risks into account, this study suggested short term DAPT could be considered for most patients after PCI with DES, combining evidence from both direct and indirect comparisons. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018099519.


Assuntos
Clopidogrel/uso terapêutico , Stents Farmacológicos/normas , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/cirurgia , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Humanos , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombose/epidemiologia , Trombose/mortalidade
4.
BMC Vet Res ; 15(1): 169, 2019 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-31126342

RESUMO

BACKGROUND: Pulmonary hemorrhage is a rare cause of death in horses. Hemorrhage within the respiratory tract has many causes, including mycosis of the guttural pouch, invasive procedures causing serious trauma to nasal conchae, or lung biopsy. We report on a rare case of a fatal pulmonary hemorrhage in a horse after a severe cough during bronchoalveolar lavage. To the best of our knowledge, this is the first report of spontaneous hemorrhage in a horse during bronchoalveolar lavage. CASE PRESENTATION: A 21-year-old mare which belonged to the didactic herd of The Faculty of Veterinary Medicine underwent BAL procedure for training purposes. Clinical examination prior to the procedure did not reveal any abnormalities and the horse had been classified as healthy. The horse was sedated with 0.01 mg/kg of detomidine and 0.01 mg/kg of butorphanol. The silicon BAL catheter was passed through the nasal passage into the trachea and then into the bronchus. Before catheter was wedged, the mare began to cough heavily and massive haemorrhage from mouth and nostrils occurred. Despite fluid therapy, shock occurred within 15 min and the mare was euthanized. Upon necropsy, site of hemorrhage was identified in the left lobar caudal bronchi, from a large blood vessel running directly beneath the bronchial wall. Upon histology, a chronic lympho-plasmocytic inflammatory process in left bronchi was identified. Moreover, Masson's trichrome staining revealed severe, perivascular fibrosis. CONCLUSION: Although BAL is a relatively safe procedure, and such complications should be treated as extremely rare, this case indicates that, in some individuals with specific subclinical problems, even mild physical force such as a cough can lead to rupture of the artery.


Assuntos
Lavagem Broncoalveolar/veterinária , Hemorragia/veterinária , Doenças dos Cavalos/mortalidade , Animais , Brônquios/irrigação sanguínea , Lavagem Broncoalveolar/efeitos adversos , Lavagem Broncoalveolar/mortalidade , Tosse/veterinária , Feminino , Fibrose/veterinária , Hemorragia/mortalidade , Cavalos , Inflamação/veterinária , Pneumopatias/veterinária
5.
BMC Infect Dis ; 19(1): 451, 2019 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-31113404

RESUMO

BACKGROUND: The emergence of leptospirosis-associated severe pulmonary hemorrhagic syndrome (SPHS) with high case fatality has been reported from many countries. Understanding of clinical disease and sequel of SPHS needs larger studies with adequate numbers. The purpose of this study was to describe the characteristics and sequel by different therapeutic approaches for SPHS in Leptospirosis in Sri Lanka. METHODS: This study was conducted at Teaching Hospital-Karapitiya (THK), Galle, Sri Lanka from June 2015 to December 2017. THK is the main tertiary care center for the Southern Province. All confirmed-cases of leptospirosis who presented during this period and were admitted to five medical units of THK were included in this study. SPHS was defined as a patient presenting; haemoptysis, arterial hypoxemia (Acute Lung Injury Score < 2.5), haemoglobin drop (10% from the previous value), or diffused alveolar shadows in the chest radiograph, without alternative explanation other than leptospirosis. RESULTS: Of the 128 MAT confirmed cases of leptospirosis, 111 (86.7%) had acute kidney injury (AKI) whilst SPHS was seen in 80 (62.5%). Patients typically developed SPHS within the first week of illness, mostly on days 4 and 5. The case fatality rate of this study sample was 28.1% (n = 36), while for patients with SPHS, it was 41.5%. Most of the deaths (n = 19) were within the first 3 days of admission (on the same day 8, and within next 48 h 11). Among SPHS patients, 59 received therapeutic plasma exchange (TPE). The survival rate was higher (n = 35, 74.5%) when the TPE was performed within the first 48 h of detecting SPHS compared to patients in whom the procedure was done after 48 h (n = 5, 54.5%). Of the 19 leptosprosis patients with SPHS who did not receive TPE, 17 died (89.5%). However, the group of patients who received TPE was primarily the patients survived beyond day 3. CONCLUSIONS: We observed that during the study period, SPHS was common and the mortality rate was higher in the study area. The treatment modalities tested need further evaluation and confirmation.


Assuntos
Hemorragia/etiologia , Leptospirose/complicações , Pneumopatias/etiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Adulto , Feminino , Hemorragia/mortalidade , Hemorragia/terapia , Hospitais de Ensino/estatística & dados numéricos , Humanos , Imunoglobulinas/uso terapêutico , Leptospirose/mortalidade , Leptospirose/terapia , Pneumopatias/mortalidade , Pneumopatias/terapia , Masculino , Pessoa de Meia-Idade , Mortalidade , Troca Plasmática , Sri Lanka/epidemiologia , Síndrome
6.
Transfusion ; 59(S2): 1474-1478, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980747

RESUMO

BACKGROUND: The short shelf-life of fresh platelets limits their efficient inventory management and availability during a massive transfusion protocol. Risk of insufficient availability can be mitigated by building an inventory of cryopreserved platelets (CPs). METHODS: A comparative study of fresh apheresis platelets (FAPs) and CPs was performed. Type-O CPs were processed with DMSO frozen at -80°C and reconstituted in thawed AB plasma. All patients enrolled in the study had the following parameters evaluated on admission: vital signs (body temperature, heart rate, mean arterial pressure), blood count, prothrombin time, activated partial thromboplastin time, fibrinogen level, and, in trauma patients, international severity score. Several outcomes were evaluated: 30-day survival, adverse events, quantity of administered blood products, fibrinogen concentrate and thromboxane (TXA), and laboratory parameters after transfusion (blood count, prothrombin time, activated partial thromboplastin time, fibrinogen level). RESULTS: Twenty-five (25) patients in the study group received transfusions totaling 81 units of CPs. Twenty-one (21) patients in the control group received a total of 67 units of FAPs. There were no significant differences in patient characteristics (p > 0.05) between groups. Both groups were comparable in clinical outcomes (30-day survival, administered blood products, fibrinogen concentrate, TXA, and adverse events). Among posttransfusion laboratory parameters, platelet count was higher in the group transfused with FAPs (97.0 ×109 /L) than in the group transfused with CPs (41.5 ×109 /L), p = 0.02025. Other parameters were comparable in both groups. CONCLUSION: The study suggests that CPs are tolerable and a feasible alternative to FAPs. However, larger randomized studies are needed to draw definitive conclusions.


Assuntos
Plaquetas , Criopreservação , Fibrinogênio/administração & dosagem , Hemorragia , Traumatismo Múltiplo , Transfusão de Plaquetas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia/sangue , Hemorragia/mortalidade , Hemorragia/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/sangue , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/terapia , Tempo de Tromboplastina Parcial , Plaquetoferese , Tempo de Protrombina
7.
Transfusion ; 59(S2): 1423-1428, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980749

RESUMO

The majority of potentially preventable deaths after trauma are related to hemorrhage and occur early after injury, with the largest number of deaths occurring before hospital arrival. Approximately one-fourth of trauma deaths may be potentially preventable through early medical and surgical interventions. Interventions dedicated to bleeding control and hemostatic resuscitation have demonstrated merit in decreasing hemorrhagic injury mortality. Advancing these novel strategies to the casualty in the prehospital phase of care, particularly in tactical or austere environments, may prove beneficial for hemorrhage mitigation to temporize the window of survival to definitive care. Future studies of resuscitation and survival after traumatic injury must include analysis of prehospital deaths to fully understand the outcomes of early interventions.


Assuntos
Serviços Médicos de Emergência/métodos , Hemorragia/terapia , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Hemorragia/mortalidade , Humanos , Ferimentos e Lesões/mortalidade
8.
Transfusion ; 59(S2): 1429-1438, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980748

RESUMO

BACKGROUND: Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured. MATERIALS AND METHODS: Our regional trauma network (Southwest Texas Regional Advisory Council) developed and implemented a multiphased approach toward facilitating remote damage control resuscitation. This approach required placing low-titer O+ whole blood (LTO+ WB) at helicopter emergency medical service bases, transitioning hospital-based trauma resuscitation from component therapy to the use of whole blood, modifying select ground-based units to carry and administer whole blood at the scene of an accident, and altering the practices of our blood bank to support our new initiative. In addition, we had to provide information and training to an entire large urban emergency medical system regarding changes in policy. RESULTS: Through a thorough, structured program we were able to successfully implement point-of-injury resuscitation with LTO+ WB. Preliminary evaluation of our first 25 patients has shown a marked decrease in mortality compared to our historic rate using component therapy or crystalloid solutions. Additionally, we have had zero transfusion reactions or seroconversions. CONCLUSION: Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.


Assuntos
Bancos de Sangue , Preservação de Sangue/normas , Transfusão de Sangue/normas , Redes Comunitárias , Serviços Médicos de Emergência , Hemorragia/terapia , Ressuscitação , Centros de Traumatologia , Sistema do Grupo Sanguíneo ABO , Bancos de Sangue/organização & administração , Bancos de Sangue/normas , Redes Comunitárias/organização & administração , Redes Comunitárias/normas , Soluções Cristaloides/administração & dosagem , Serviços Médicos de Emergência/organização & administração , Serviços Médicos de Emergência/normas , Feminino , Hemorragia/mortalidade , Humanos , Masculino , Texas , Centros de Traumatologia/organização & administração , Centros de Traumatologia/normas
9.
Scand J Trauma Resusc Emerg Med ; 27(1): 48, 2019 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-31014373

RESUMO

BACKGROUND: Prothrombin complex concentrate (PCC) is widely used to reverse the action of direct oral anticoagulants (DOACs) in accordance with current guidelines and because of a lack of specific reversal agents. Indications, clinical characteristics and patient outcomes of patients might differ in comparison to reversal of vitamin K antagonists where reversal with PCC is well established. METHODS: Our cohort study explores patient characteristics, indications and clinical outcomes for reversal of all DOAC patients receiving PCC at our university emergency department from 01.06.2012 to 01.07.2017, in comparison with patients on VKA. RESULTS: Out of 199,982 consultations, we studied 346 patients who were given PCC for reversal of either DOAC (n = 74) or VKA (n = 272). The most common reason for treatment was acute bleeding; in 86.7% of both groups. 37.3% of bleeding was traumatic (p = 0.666). The most frequent bleeding location was intracranial (61.6%, p = 0.881). Gastrointestinal bleeding was more often found in the DOAC group (18.9% vs. 8.8%, p = 0.014). More erythrocyte concentrates (ECs) were given to DOAC patients with blood transfusion (p = 0.014). Tranexamic acid was used more often in DOAC patients than in VKA patients (28.4% vs. 7.4%, p < 0.001). No significant group differences were found for the following patient outcomes: in-hospital mortality, ICU stay, and length of stay at the ICU or in hospital. CONCLUSION: In DOAC treated patients, PCC was applied more often because of gastrointestinal bleeding and patients received higher numbers of ECs as well as tranexamic acid. No differences were observed with regard to important clinical outcomes.


Assuntos
Anticoagulantes/administração & dosagem , Fatores de Coagulação Sanguínea/administração & dosagem , Hemorragia/tratamento farmacológico , Vitamina K/antagonistas & inibidores , Doença Aguda , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Feminino , Seguimentos , Hemorragia/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Masculino , Conduta do Tratamento Medicamentoso , Estudos Retrospectivos , Suíça/epidemiologia , Resultado do Tratamento
10.
Vox Sang ; 114(4): 355-362, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30900267

RESUMO

BACKGROUND: We investigated changes to transfusion practices over time in paediatric liver transplant centre and evaluated the effect of transfusion practice to mortality. METHODS: A pilot retrospective study included two cohorts each with 101 sequential paediatric LT recipients: an Early group (1994-1998) and a Recent group (2009-2013). Demographic characteristics and data on the intraoperative transfusion of red blood cells (RBC), fresh-frozen plasma (FFP), platelets and cryoprecipitate were collected. Postoperative laboratory results were also obtained, together with donor and data regarding 1- and 5-year survival. Appropriate intergroup comparisons, univariate and multivariate analysis were made and P ≤ 0·05 was considered statistically significant. RESULTS: There were no significant group differences in demographic data (except patient height). Despite the fact that median total blood loss did not differ between groups (111 ml/kg in both groups), the Early group had greater levels of intraoperative RBC transfusion (75 vs. 59 ml/kg, respectively, P = 0·04) and less use of FFP (53 vs. 62 ml/kg, respectively, P = 0·01). Overall we noted a lower 1- and 5-year survival in the Early group (88·2% vs. 96%, P = 0·04 and 82·4% vs. 89·1%, P = 0·01, respectively). Univariate, but not multivariate regression analyses demonstrated that higher PELD score, RBC and FFP transfusion, and inclusion in the Early group were contributing factors to 1-year higher mortality. CONCLUSIONS: This retrospective analysis of blood loss and replacement in paediatric LT patients demonstrates that the majority of our patients suffer major haemorrhage and require large-volume RBC and FFP replacements. In our pilot study, large volume of RBC and FFP replacement did not contribute to mortality. Paediatric LT involves a number of multidisciplinary teams. Thus, all care-related factors and combinations thereof that may contribute to outcome and should be evaluated in the future.


Assuntos
Transfusão de Sangue/tendências , Transplante de Fígado/tendências , Pediatria/tendências , Transfusão de Plaquetas/tendências , Adolescente , Transfusão de Componentes Sanguíneos/tendências , Plaquetas/citologia , Criança , Pré-Escolar , Coleta de Dados , Contagem de Eritrócitos , Transfusão de Eritrócitos/tendências , Feminino , Hemorragia/mortalidade , Humanos , Lactente , Masculino , Análise Multivariada , Projetos Piloto , Plasma , Sistema de Registros , Estudos Retrospectivos , Índice de Gravidade de Doença
11.
Clin Appl Thromb Hemost ; 25: 1076029619839154, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30919654

RESUMO

We examined the institutional variations in anticoagulation therapy for sepsis-induced disseminated intravascular coagulation (DIC) and their effects on patient outcomes. This post hoc analysis of a cohort study included 3195 patients with severe sepsis across 42 intensive care units. To evaluate differences in the intensity of anticoagulation therapy, the proportion of patients receiving anticoagulation therapy and the total number of patients with sepsis-induced DIC were compared. Predicted in-hospital mortality for each patient was calculated using logistic regression analysis. To evaluate survival outcomes, the actual/mean predicted in-hospital mortality ratio in each institution was calculated. Thirty-eight institutions with 2897 patients were included. Twenty-five institutions treated 60% to 100% (high-intensity institutions), while the rest treated 0% to 50% (low-intensity institutions) of patients with sepsis-induced DIC having anticoagulant therapy. Every 10-unit increase in the intensity of anticoagulant therapy was associated with lower in-hospital mortality (odds ratio: 0.904). A higher number of high-intensity institutions (compared to low-intensity institutions) had lower in-hospital mortality and fewer bleeding events than predicted. In conclusion, institutional variations existed in the use of anticoagulation therapy in patients with sepsis-induced DIC. High-intensity anticoagulation therapy was associated with better outcomes.


Assuntos
Anticoagulantes/administração & dosagem , Coagulação Intravascular Disseminada , Mortalidade Hospitalar , Unidades de Terapia Intensiva , Sepse , Idoso , Anticoagulantes/efeitos adversos , Intervalo Livre de Doença , Coagulação Intravascular Disseminada/tratamento farmacológico , Coagulação Intravascular Disseminada/mortalidade , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sepse/tratamento farmacológico , Sepse/mortalidade , Taxa de Sobrevida
12.
Curr Opin Anaesthesiol ; 32(2): 200-205, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817396

RESUMO

PURPOSE OF REVIEW: Uncontrolled bleeding in trauma secondary to a combination of surgical bleeding and trauma-induced complex coagulopathy is a leading cause of death. Prothrombin complex concentrates (PCCs), recombinant activated factor seven (rFVIIa) and recombinant human prothrombin act as procoagulants by increasing thrombin generation and fibrinogen concentrate aids stable clot formation. This review summarizes the current evidence for procoagulant use in the management of bleeding in trauma, and data and evidence gaps for routine clinical use. RECENT FINDINGS: Retrospective and prospective studies of PCCs (±fibrinogen concentrate) have demonstrated a decreased time to correction of trauma coagulopathy and decreased red cell transfusion with no obvious effect on mortality or thromboembolic outcomes. PCCs in a porcine model of dilutional coagulopathy demonstrated a sustained increase in thrombin generation, unlike recombinant human prothrombin which showed a transient increase and has been studied only in animals. In other retrospective studies, there is a suggestion that lower doses of PCCs may be effective in the setting of acquired coagulopathy. SUMMARY: There is increasing evidence that early correction of coagulopathy has survival benefits, and the use of procoagulants as first-line therapy has the potential benefit of rapid access and timely treatment. This requires confirmation in prospective studies.


Assuntos
Coagulantes/uso terapêutico , Hemorragia/tratamento farmacológico , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/complicações , Coagulação Sanguínea/efeitos dos fármacos , Fatores de Coagulação Sanguínea/farmacologia , Fatores de Coagulação Sanguínea/uso terapêutico , Coagulantes/farmacologia , Relação Dose-Resposta a Droga , Fator VIIa/farmacologia , Fator VIIa/uso terapêutico , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Protrombina/farmacologia , Protrombina/uso terapêutico , Proteínas Recombinantes/farmacologia , Proteínas Recombinantes/uso terapêutico , Fatores de Tempo , Resultado do Tratamento , Ferimentos não Penetrantes/tratamento farmacológico , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/tratamento farmacológico , Ferimentos Penetrantes/mortalidade
13.
Curr Opin Anaesthesiol ; 32(2): 206-212, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817397

RESUMO

PURPOSE OF REVIEW: Anticoagulants in general, but especially the relatively new direct oral anticoagulants and platelet inhibitors, pose a great challenge for physicians in the hemorrhaging patient. The aim of the present review is to provide an overview on recent studies dealing with the reversal of anticoagulation in the hemorrhaging patient and to describe our therapeutic emergency strategy for those patients. RECENT FINDINGS: A specific antidote for dabigatran is already on the market and antidotes for the direct and indirect factor Xa inhibitors are in development. Moreover, bleeding under platelet inhibitors remains critical with very little evidence on effective reversal strategies. SUMMARY: To reverse anticoagulation in the hemorrhaging patient, specific antidotes should be the first option if available, followed by four-factor prothrombin complex concentrate (PCC), activated PCC and recombinant activated factor seven as the emergency strategy. Fibrinogen concentrate, antifibrinolytics and oral charcoal, respectively, can be considered as an additional measure. Massive blood loss and thrombocytopenia should be treated independently according to the respective, local guidelines for (massive) transfusion of blood and blood products.


Assuntos
Antifibrinolíticos/uso terapêutico , Antitrombinas/efeitos adversos , Hemorragia/terapia , Inibidores da Agregação de Plaquetas/efeitos adversos , Administração Oral , Antifibrinolíticos/farmacologia , Antifibrinolíticos/normas , Antitrombinas/administração & dosagem , Coagulação Sanguínea/efeitos dos fármacos , Testes de Coagulação Sanguínea , Transfusão de Sangue/normas , Carvão Vegetal/administração & dosagem , Terapia Combinada/métodos , Terapia Combinada/normas , Relação Dose-Resposta a Droga , Hemorragia/induzido quimicamente , Hemorragia/diagnóstico , Hemorragia/mortalidade , Humanos , Inibidores da Agregação de Plaquetas/administração & dosagem , Guias de Prática Clínica como Assunto , Diálise Renal/normas , Resultado do Tratamento
14.
J Thromb Thrombolysis ; 47(4): 495-504, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30859370

RESUMO

In patients with active cancer and acute venous thromboembolism (VTE), the low-molecular-weight-heparin (LMWH) dalteparin is more effective than vitamin K antagonist (VKA) in reducing the risk of recurrent venous thromboembolism (rVTE) without increasing the risk of bleeding. However, the relative benefit of LMWH versus VKA in patients with active cancer at high or low risk of rVTE and bleeding is unclear. This post hoc analysis used data from the CLOT study to explore the efficacy and safety of LMWH versus VKA in preventing recurrent thrombosis in high- and low-risk patients with active cancer. High-risk patients were defined by metastatic disease and/or antineoplastic treatment at baseline; low-risk patients presented with neither. Among high-risk patients, rVTE occurred in 25/318 (8%) (LMWH) versus 53/314 (17%) (VKA) (hazard ratio, 0.44; p = 0.001). No significant difference was detected in the rate of major or any bleeding. The 6-month mortality rate was 40% (LMWH) versus 41% (VKA). In low-risk patients, 2/20 (10%) (LMWH) had rVTE versus 0/24 (0%) (VKA) (hazard ratio, not estimable; p = 0.998). No significant difference was detected in the rate of major or any bleeding. The 6-month mortality rate was 20% (LMWH) versus 29% (VKA). In patients with cancer-associated thrombosis at high risk of rVTE and bleeding, the LMWH dalteparin was more effective than VKA in reducing the risk of rVTE without increasing the risk of bleeding. No difference in rate of rVTE or bleeding was observed between LMWH and VKA among low-risk patients.


Assuntos
Cumarínicos/administração & dosagem , Dalteparina/administração & dosagem , Neoplasias/tratamento farmacológico , Trombose/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológico , Idoso , Cumarínicos/efeitos adversos , Dalteparina/efeitos adversos , Intervalo Livre de Doença , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/mortalidade , Neoplasias/patologia , Taxa de Sobrevida , Trombose/mortalidade , Trombose/patologia , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/patologia
15.
J Forensic Leg Med ; 63: 52-55, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30870725

RESUMO

Clinical and pathological case files of lethal snakebites were reviewed from the Magway Region General Hospital, Magway, Myanmar, over a five-year period (January 2013 December 2017). A total of 2069 postmortem examinations were performed which included 84 cases of lethal snake bite (4.1%). The annual numbers ranged from 10 out of a total of 268 autopsies in 2013 (3.7%), to 31 out of a total of 501 autopsies in 2016 (6.2%). There were 54 males (64%) and 30 females (36%) (M:F = 1.9:1; age range 5-75yrs, mean 33yrs). The most common time for lethal envenomation was August (16/84-19%), the middle of the monsoon season. 45/84 (54%) had acute renal failure, 27/84 (32%) were shocked, and the remaining 12/84 (14%) had disseminated intravascular coagulation. Twenty cases (24%) died within 24 h after envenomation. Fang marks were identified on the legs (either right or left) in 73/84 cases (87%) and on the arms in five cases (6%). The predominant findings at autopsy were of acute renal injury (82/84-98%), pituitary haemorrhage/necrosis (36/84-43%), and adrenal gland haemorrhage (30/84-36%). Despite the reduction in fatalities over the years snakebite from Russell's viper in particular remains an important contributor to mortality in central Myanmar despite the availability of antivenom.


Assuntos
Mordeduras de Serpentes/mortalidade , Venenos de Serpentes/envenenamento , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/mortalidade , Adolescente , Doenças das Glândulas Suprarrenais/induzido quimicamente , Doenças das Glândulas Suprarrenais/mortalidade , Adulto , Distribuição por Idade , Idoso , Animais , Criança , Pré-Escolar , Coagulação Intravascular Disseminada/induzido quimicamente , Coagulação Intravascular Disseminada/mortalidade , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Mianmar/epidemiologia , Necrose , Doenças da Hipófise/induzido quimicamente , Doenças da Hipófise/mortalidade , Hipófise/patologia , Estudos Retrospectivos , Distribuição por Sexo , Choque/induzido quimicamente , Choque/mortalidade , Adulto Jovem
16.
Transfus Med ; 29(1): 20-22, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30859640

RESUMO

CLINICAL QUESTION: Does transfusing platelets to preterm infants (< 34 weeks) at a higher platelet count threshold count (< 50 x 109 /L) reduce the risk of major bleeding or death compared to only transfusing platelets when the platelet count drops below 25 x 109 /L. EVIDENCE FROM TRIAL: Preterm infants with a low platelet count who were transfused platelets at the higher platelet count threshold had a higher risk of dying or having a major bleed than those who were not. The reasons why this occurred are currently unclear.


Assuntos
Hemorragia/mortalidade , Hemorragia/terapia , Recém-Nascido Prematuro , Transfusão de Plaquetas , Trombocitopenia/mortalidade , Trombocitopenia/terapia , Feminino , Humanos , Recém-Nascido , Masculino
17.
J Pediatr Surg ; 54(5): 975-979, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30765151

RESUMO

PURPOSE: The purpose of this study was to identify an optimal definition of massive transfusion (MT) in civilian pediatric trauma. METHODS: Severely injured children (age ≤18 years, injury severity score ≥25) in the Trauma Quality Improvement Program research datasets 2014-2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Early mortality was defined as death within 24 h and delayed mortality as death after 24 h from hospital admission. Receiver operating curves and sensitivity and specificity analysis identified an MT threshold. Continuous variables are presented as median [IQR]. RESULTS: Of the 270 included children, the overall mortality was 27% (N = 74). There were no differences in demographics or mechanism of injury between children that lived or died. Sensitivity and specificity for early mortality was optimized at a 4-h transfusion volume of 37 ml/kg. After controlling for other significant variables, a threshold of 37 ml/kg/4 h predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25-17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96-9.16; p < 0.01). CONCLUSION: An MTP threshold of 37 mL/kg/4 h of transfused blood products predicted the need for hemorrhage control procedures and early mortality. This threshold may provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization. TYPE OF STUDY: Diagnostic Test. LEVEL OF EVIDENCE: III.


Assuntos
Transfusão de Sangue , Hemorragia/terapia , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Adolescente , Criança , Bases de Dados Factuais , Feminino , Hemorragia/mortalidade , Humanos , Escala de Gravidade do Ferimento , Masculino , Curva ROC , Fatores de Tempo , Estados Unidos/epidemiologia
18.
J Pediatr Hematol Oncol ; 41(2): e72-e78, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30608491

RESUMO

BACKGROUND: Recombinant activated factor VII (rFVIIa) has been used off-label to treat or prevent severe bleeding in patients for whom conventional treatments are unsuccessful. However, studies in children remain limited. PROCEDURE: To examine the efficacy and safety of rFVIIa, we performed a retrospective analysis of rFVIIa off-label use in a pediatric hematology/oncology cohort at a single center from 2006 to 2014. RESULTS: Of 58 patients identified, 46 (79.3%) received rFVIIa to treat bleeding and 12 (20.7%) to prevent bleeding. Thirty-three (71.7%) patients had life-threatening bleeding. In the treatment group, 63.0% patients were responders (ie, bleeding decreased or stopped) and 37.0% were nonresponders (ie, bleeding did not change). Blood products usage was similar between responders and nonresponders. After rFVIIa administration, prothrombin time, partial thromboplastin time and lactate were significantly lower, but fibrinogen was significantly higher in responders than nonresponders. Venous thromboembolism developed in 5.2% (3/58) patients, but its relation to rFVIIa remains unclear. Responders had significantly lower mortality than nonresponders (17.2% vs. 82.4%, P<0.0001). CONCLUSIONS: rFVIIa controlled most bleeding events in this cohort, despite predominance of life-threatening bleeding, suggesting good efficacy. Venous thromboembolism rate was low. Further studies are warranted to identify predictors of favorable response to rFVIIa in similar patients.


Assuntos
Fator VIIa/administração & dosagem , Hemorragia/prevenção & controle , Neoplasias/tratamento farmacológico , Adolescente , Criança , Pré-Escolar , Fator VIIa/efeitos adversos , Feminino , Hemorragia/sangue , Hemorragia/mortalidade , Humanos , Masculino , Neoplasias/sangue , Neoplasias/mortalidade , Tempo de Tromboplastina Parcial , Tempo de Protrombina , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos
19.
Diagn Interv Radiol ; 25(1): 71-80, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30644369

RESUMO

PURPOSE: Percutaneous tissue biopsy is a mainstay of diagnostic and interventional radiology, providing a minimally invasive method for diagnosing malignant and benign disease. The purpose of this review was to collect and summarize the best available evidence regarding the risk factors associated with bleeding complications in image-guided liver biopsy. METHODS: A literature review was performed, searching Medline, EMBASE, CINAHL, the Cochrane Library, the National Institute for Health and Care Excellence (NICE) and Canadian Agency for Drugs and Technology in Health (CADTH) databases for any studies evaluating bleeding complications in image-guided liver biopsy. A total of 68 articles, published between January 1994 and April 2015, were reviewed in full, with 34 ultimately eligible for inclusion in the review. RESULTS: Bleeding of any kind occurred in up to 10.9% of image-guided liver biopsies, with major bleeding episodes ranging from 0.1% to 4.6% and minor bleeding events occurring in up to 10.9% of biopsies. The overall rate of bleeding was, however, found to be less than 2%. Several risk factors (patient, operator, and procedure-related) were identified as potentially indicative of an increased risk of post-biopsy bleeding. Patient-related risk factors included patient age (>50 years or <2 years), inpatient status (8/12 vs. 4/12, P < 0.001), comorbidities and/or concurrent diagnoses and coagulation status (rate of bleeding was 3.3% for international normalized ratio [INR] 1.2-1.5 vs. 7.1% for INR >1.5, P < 0.001). There was no consensus on impact of operator experience (>200 biopsies/year vs. <50/year) on post-biopsy bleeding rate. Procedure-related risk factors included needle size (cutting biopsy vs. fine needle aspiration, P < 0.001) and the presence of a patent track on post-biopsy ultrasound (P < 0.001). Lastly there was no difference found between targeted vs. nontargeted biopsies and number of needle passes. CONCLUSION: Reported rate of post-biopsy bleeding ranges between 0% and 10.9%, although the vast majority of studies reported bleeding rates under 2%. Several patient, operator, and procedure-related risk factors are associated with a higher risk of bleeding following liver biopsy.


Assuntos
Biópsia por Agulha Fina/efeitos adversos , Hemorragia/complicações , Biópsia Guiada por Imagem/métodos , Fígado/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha Fina/métodos , Criança , Pré-Escolar , Hemorragia/mortalidade , Humanos , Lactente , Recém-Nascido , Fígado/patologia , Pessoa de Meia-Idade , Agulhas/tendências , Radiologia Intervencionista/métodos , Radiologia Intervencionista/estatística & dados numéricos , Fatores de Risco , Ultrassonografia de Intervenção/métodos , Adulto Jovem
20.
World Neurosurg ; 123: 351-356, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30590211

RESUMO

BACKGROUND: Colloid cysts of the third ventricle are rare, slow-growing lesions of neuroepithelial origin. Although histopathologically benign, third ventricular colloid cysts are a well-known cause of sudden, unexpected coma and death. Several theories have been proposed to describe the rare, sudden onset of severe symptomatology and rapid clinical decline due to colloid cysts. Moreover, there is currently no clear consensus regarding the most suitable neurosurgical technique or the most effective approach for resection, nor do guidelines or standardized clinical indications exist to recommend observation versus intervention and/or resection in the asymptomatic patient. To highlight this conundrum, we present a clinical case of a hemorrhagic colloid cyst that resulted in fatality and discuss the relevant literature. CASE DESCRIPTION: A 21-year-old male presented to an outside hospital with an acute onset of a severe headache, nausea, and vomiting, which started while jogging. A few hours later, he precipitously declined into a comatose state. Radiographic imaging demonstrated a hemorrhagic third ventricular colloid cyst causing acute obstructive hydrocephalus, severe increased intracranial pressure, and downward herniation. He was then transferred to our institution for neurosurgical intervention. Despite aggressive cerebrospinal fluid drainage and medical management, he was declared brain dead several days later. CONCLUSIONS: To our knowledge, this is the only case report to describe sudden-onset coma and death due to a hemorrhagic third ventricular colloid cyst occurring after exercising. We review the literature on fatal colloid cysts emphasizing the proposed mechanisms of sudden death and current neurosurgical management in both asymptomatic and symptomatic patients.


Assuntos
Cistos Coloides/complicações , Morte Súbita , Exercício , Hemorragia/complicações , Cistos Coloides/diagnóstico por imagem , Cistos Coloides/mortalidade , Angiografia por Tomografia Computadorizada , Hemorragia/diagnóstico por imagem , Hemorragia/mortalidade , Humanos , Imagem por Ressonância Magnética , Masculino , Terceiro Ventrículo/diagnóstico por imagem , Adulto Jovem
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