Diffuse microscopic angiodysplasia and nodular lymphoid hyperplasia in an infant with obscure massive lower gastrointestinal bleeding: a diagnostic challenge

The authors report a rare case of diffuse microscopic angiodysplasia and nodular lymphoid hyperplasia involving the distal ileum and total colon in a 13-month-old girl who had recurrent episodes of massive lower gastrointestinal bleeding of obscure origin. Colonoscopy showed multiple nodular hyperplasia and mucosal erosions, and all other diagnostic studies were negative. At laparotomy, intraoperative transluminal endoscopic transillumination was of benefit in identifying the bleeding foci but could not detect every angiodysplastic lesion.     

The immune thrombocytopenic purpura (ITP) bleeding score: assessment of bleeding in patients with ITP

A method for objective quantification of bleeding symptoms in immune thrombocytopenic purpura (ITP) has not been established. The ITP Bleeding Scale (IBLS) is a novel bleeding assessment system comprising 11 site-specific grades. Implementation of the IBLS on 100 patient visits revealed that although platelet count and large platelet count correlated well with bleeding symptoms overall, this relationship disappeared in marked thrombocytopenia. The IBLS is a useful clinical tool for monitoring bleeding and may be used to aid the development of laboratory parameters that correlate with underlying bleeding propensity in thrombocytopenia.     

Nonprocedural bleeding after left atrial appendage closure versus direct oral anticoagulants: A subanalysis of the randomized PRAGUE-17 trial

Introduction

Observational studies have shown low bleeding rates in patients with atrial fibrillation (AF) treated by left atrial appendage closure (LAAC); however, data from randomized studies are lacking. This study compared bleeding events among patients with AF treated by LAAC and nonvitamin K anticoagulants (NOAC).

Methods

The Prague-17 trial was a prospective, multicenter, randomized trial that compared LAAC to NOAC in high-risk AF patients. The primary endpoint was a composite of a cardioembolic event, cardiovascular death, and major and clinically relevant nonmajor bleeding (CRNMB) defined according to the International Society on Thrombosis and Hemostasis (ISTH).

Results

The trial enrolled 402 patients (201 per arm), and the median follow-up was 3.5 (IQR 2.6–4.2) years. Bleeding occurred in 24 patients (29 events) and 32 patients (40 events) in the LAAC and NOAC groups, respectively. Six of the LAAC bleeding events were procedure/device-related. In the primary intention-to-treat analysis, LAAC was associated with similar rates of ISTH major or CRNMB (sHR 0.75, 95% CI 0.44–1.27, p = 0.28), but with a reduction in nonprocedural major or CRNMB (sHR 0.55, 95% CI 0.31–0.97, p = 0.039). This reduction for nonprocedural bleeding with LAAC was mainly driven by a reduced rate of CRNMB (sHR for major bleeding 0.69, 95% CI 0.34–1.39, p = .30; sHR for CRNMB 0.43, 95% CI 0.18–1.03, p = 0.059). History of bleeding was a predictor of bleeding during follow-up. Gastrointestinal bleeding was the most common bleeding site in both groups.

Conclusion

During the 4-year follow-up, LAAC was associated with less nonprocedural bleeding. The reduction is mainly driven by a decrease in CRNMB.     

Left atrial appendage occlusion for atrial fibrillation and bleeding diathesis

Background

Patients with atrial fibrillation (AF) and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. Short-term anti-thrombotic drugs are used postprocedure to offset the risk of device-related thrombus, evidence for this practice is limited.

Objectives

To investigate optimal postimplant antithrombotic strategy in high bleeding-risk patients.

Methods

Patients with AF and high-risk for both stroke and bleeding undergoing LAAO were advised their perioperative drug therapy by a multidisciplinary physician panel. Those deemed to be at higher risk of bleeding from anti-thrombotic drugs were assigned to minimal treatment with no antithrombotics or Aspirin-alone. The remaining patients received standard care (STG) with a 12 week course of dual-antiplatelets or anticoagulation postimplant. We compared mortality, device-related thrombus, ischemic stroke, and bleeding events during the 90 days postimplant and long-term. Event-free survival was assessed using Kaplan−Meier survival analysis, with logrank testing for statistical significance.

Results

Seventy-five patients underwent LAAO of whom 63 patients (84%) had a prior serious bleeding event. The 42 patients on minimal treatment were older (74.3 ± 7.7 vs. 71.2 ± 7.2) with higher HASBLED score (3.6 ± 0.9 vs. 3.3 ± 1.2) than the 33 patients having standard care. There were no device-related thrombi or strokes in either group at 90 days postprocedure; STG had more bleeding events (5/33 vs. 0/42, p = 0.01) with associated deaths (3/33 vs. 0/42, p = 0.05). During long-term follow-up (median 2.2 years), all patients transitioned onto no antithrombotic drugs (43 patients [61%]) or a single-antiplatelet (29 patients [39%]). There was no evidence of early minimal treatment adversely affecting long-term outcomes.

Conclusions

Short-term anti-thrombotic drugs may not be needed after LAAO implant in patients with high bleeding risk and could be harmful. Larger, prospective studies would be warranted to test these findings.     

Efficacy of water flossing on clinical parameters of inflammation and plaque: A 4-week randomized controlled trial

Background

The primary prevention of periodontitis is controlling gingivitis daily. The study objective was to compare the efficacy of a pulsating water flosser to a pulsating water flosser infused with air microbubbles on clinical signs of inflammation and plaque.

Methods

One hundred and five participants were enrolled in this single-blind, single-centre, parallel, 4-week, IRB/IEC-approved clinical trial. Participants were randomly assigned to one of three groups: water flosser (WF) plus manual toothbrush, water flosser infused with microbubbles of air (MBWF) plus manual toothbrush, or dental floss (DF) plus manual toothbrush. Bleeding on probing (BOP), Modified Gingival Index (MGI) and Rustogi Modification Navy Plaque Index (RMNPI) scores were recorded at baseline, 2 and 4 weeks.

Results

All participants completed the study (n = 105). All groups showed a statistically significant reduction for BOP, MGI and RMNPI at 4 weeks (p < 0.05, except DF marginal RMNPI). The WF group showed a statistically significant greater reduction in whole mouth BOP (0.41) compared to MBWF (0.32) and DF (0.19). This was also true for MGI (0.37, 0.30 and 0.20, respectively) and RMNPI (0.13, 0.11 and 0.06, respectively; p < 0.05 for all comparisons). No adverse events were reported.

Conclusion

This study demonstrates that a manual toothbrush and water flosser, with or without microbubbles, is an effective oral care regimen for controlling gingivitis over 4 weeks.     

卡络磺钠联合雷贝拉唑治疗溃疡性上消化道出血的临床研究

目的 探讨卡络磺钠联合雷贝拉唑治疗溃疡性上消化道出血的临床疗效。方法 选取2018年1月—2021年12月在梧州市工人医院住院治疗的74例溃疡性上消化道出血患者,按照随机数字法将所有患者分为对照组和治疗组,每组各37例。对照组早晨口服雷贝拉唑钠肠溶胶囊,20 mg/次,1次/d。治疗组在对照组的基础上静滴滴注注射用卡络磺钠,60 mg加入0.9%氯化钠注射液250 mL中稀释,1次/d。两组均连续用药7 d。观察两组的临床疗效,比较两组腹胀、腹痛、头晕、烧心症状缓解时间及治疗前后血清丙二醇（MDA）、抗利尿激素（ADH）、皮质醇（COR）、白细胞介素6（IL-6）、白细胞介素17（IL-17）、肿瘤坏死因子α（TNF-α）、C反应蛋白（CRP）水平的变化情况和不良反应。结果 治疗后,治疗组总有效率是97.29%,显著高于对照组的81.08%（P＜0.05）。经治疗,治疗组腹胀、腹痛、头晕、烧心症状缓解时间均显著短于对照组（P＜0.05）。治疗后,两组MDA、ADH、COR水平均较治疗前显著降低（P＜0.05）,且治疗后治疗组MDA、ADH、COR水平低于对照组（P＜0.05）。治疗后,两组血清IL-6、IL-17、TNF-α、CRP水平均较治疗前显著降低（P＜0.05）,且治疗后,治疗组血清学指标水平低于对照组（P＜0.05）。治疗组患者不良反应发生率是8.11%,显著低于对照组患者的18.92%（P＜0.05）。结论 卡络磺钠联合雷贝拉唑治疗溃疡性上消化道出血可有效提高治疗效果,并能极大地缓解患者临床症状,改善机体氧化应激反应,降低炎性因子水平,具有一定的临床推广应用价值。