scholarly journals Coagulopathy and its effect on treatment and mortality in patients with traumatic intracranial hemorrhage

2021 ◽  
Author(s):  
Janne Kinnunen ◽  
Jarno Satopää ◽  
Mika Niemelä ◽  
Jukka Putaala
Keyword(s):  
Intracranial Hemorrhage ◽  
Multivariable Analysis ◽  
International Normalized Ratio ◽  
University Hospital ◽  
Lower Mortality ◽  
Traumatic Intracranial Hemorrhage ◽  
Hemorrhage Volume ◽  
Anticoagulant Medication ◽  
Admission Glasgow Coma Scale

Abstract Background The role of coagulopathy in patients with traumatic brain injury has remained elusive. In the present study, we aim to assess the prevalence of coagulopathy in patients with traumatic intracranial hemorrhage, their clinical features, and the effect of coagulopathy on treatment and mortality. Methods An observational, retrospective single-center cohort of consecutive patients with traumatic intracranial hemorrhage treated at Helsinki University Hospital between 01 January and 31 December 2010. We compared clinical and radiological parameters in patients with and without coagulopathy defined as drug- or disease-induced, i.e., antiplatelet or anticoagulant medication at a therapeutic dose, thrombocytopenia (platelet count < 100 E9/L), international normalized ratio > 1.2, or thromboplastin time < 60%. Primary outcome was 30-day all-cause mortality. Logistic regression analysis allowed to assess for factors associated with coagulopathy and mortality. Results Of our 505 patients (median age 61 years, 65.5% male), 206 (40.8%) had coagulopathy. Compared to non-coagulopathy patients, coagulopathy patients had larger hemorrhage volumes (mean 140.0 mL vs. 98.4 mL, p < 0.001) and higher 30-day mortality (18.9% vs. 9.7%, p = 0.003). In multivariable analysis, older age, lower admission Glasgow Coma Scale score, larger hemorrhage volume, and conservative treatment were independently associated with mortality. Surgical treatment was associated with lower mortality in both patients with and without coagulopathy. Conclusions Coagulopathy was more frequent in patients with traumatic intracranial hemorrhage presenting larger hemorrhage volumes compared to non-coagulopathy patients but was not independently associated with higher 30-day mortality. Hematoma evacuation, in turn, was associated with lower mortality irrespective of coagulopathy.

Endovascular stroke therapy may be safe in patients with elevated international normalized ratio

2016 ◽  
Vol 9 (12) ◽  
pp. 1187-1190 ◽  
Author(s):  
Sibu Mundiyanapurath ◽  
Anne Tillmann ◽  
Markus Alfred Möhlenbruch ◽  
Martin Bendszus ◽  
Peter Arthur Ringleb
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Tertiary Care ◽  
Multivariable Analysis ◽  
International Normalized Ratio ◽  
Unfavorable Outcome ◽  
Favorable Outcome ◽  
University Hospital ◽  
Increased Risk

IntroductionEndovascular therapy in acute ischemic stroke is safe and efficient. However, patients receiving oral anticoagulation were excluded in the larger trials.ObjectiveTo analyze the safety of endovascular therapy in patients with acute ischemic stroke and elevated international normalized ratio (INR) values.MethodsRetrospective database review of a tertiary care university hospital for patients with anterior circulation stroke treated with endovascular therapy. Patients with anticoagulation other than vitamin K antagonists were excluded. The primary safety endpoint was defined as symptomatic intracranial hemorrhage (sICH; ECASS II definition). The efficacy endpoint was the modified Rankin scale (mRS) score after 3 months, dichotomized into favorable outcome (mRS 0–2) and unfavorable outcome (mRS 3–6).Results435 patients were included. 90% were treated with stent retriever. 27 (6.2%) patients with an INR of 1.2–1.7 and 21 (4.8%) with an INR >1.7. 33 (7.6%) had sICH and 149 patients (34.3%) had a favorable outcome. Patients with an elevated INR did not have an increased risk for sICH or unfavorable outcome in multivariable analysis. The additional use of IV thrombolysis in patients with an INR of 1.2–1.7 did not increase the risk of sICH or unfavorable outcome. These results were replicated in a sensitivity analysis introducing an error of the INR of ±5%. They were also confirmed using other sICH definitions (Safe Implementation of Thrombolysis in Stroke (SITS), National Institute of neurological Disorders and Stroke (NINDS), Heidelberg bleeding classification).ConclusionsEndovascular therapy in patients with an elevated INR is safe and efficient. Patients with an INR of 1.2–1.7 may be treated with combined IV thrombolysis and endovascular therapy.

scholarly journals POS0582 RHEUMATOID ARTHRITIS AND ORAL MICROBIOME: PREDICTORS OF DISTURBANCES AND ITS IMPLICATIONS. RESULTS FROM A COHORT AT TREATMENT WITH cs/b/tsDMARD

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 524.2-524
Author(s):  
R. Dos-Santos ◽  
F. Otero ◽  
E. Perez-Pampín ◽  
A. Mera Varela
Keyword(s):  
Rheumatoid Arthritis ◽  
Periodontal Disease ◽  
Disease Activity ◽  
Multivariable Analysis ◽  
Oral Microbiome ◽  
University Hospital ◽  
Disease Course ◽  
Univariable Analysis ◽  
Multiple Species

Background:Oral microbiome (OM) seems to be significant in the pathogenesis of some immune-mediated diseases, such as rheumatoid arthritis (RA), psoriasis or inflammatory bowel disease.1 Some microorganisms, as Porphyromonas gingivalis have been related with the production of autoantibodies. Also it has been suggested that composition of OM could change RA disease course, being more difficult-to-treat and having higher disease activity scores.2Objectives:To identify which variables could predict the appearance of altered OM and its implications in clinical practice.Methods:Patients were recruited if they were diagnosed of RA and were at active treatment (biological, classical or targeted synthetic disease modifying anti-rheumatic drugs [b/cs/tsDMARDs]). Patients performed a dental review with a specialized odontologist that made an OM test (semiquantitative PCR), and oral health standards were instructed (following criteria of American Academy of Periodontology). Recruitment was made during 2020 in the Clinical University Hospital in Santiago de Compostela, Spain. Disease activity reevaluation was made 2 months later.Treatment, demographic and clinical data were collected from participants.Univariable logistic and linear regression were performed to identify predictors of OM. Variables with p<0.20 were selected for multivariable analysis.Stata 15.1 was used to perform statistical analysis.Results:47 patients were selected of whom 40 were female. Mean age was 55.43 years (SD 14.42). 30.77% were current or ex-smokers. Mean time since RA diagnosis was 14.89 years (SD 8.47). 63.83% were anti-citrullinated peptide autoantibody (ACPA) positive and 70.21% were rheumatoid factor (RF) positive, letting only 6 patients double negative. 46.81% had moderate/severe periodontal disease (PD). 32.61% of patients had any comorbidity. Mean DAS28 at the OM test was 2.67 (SD 1.28) and after 2 months 2.37 (SD 1.03). Mean C-reactive protein (CRP) was 0.64 mg/dl (SD 1.48) and median erythrocyte sedimentation rate (ESR) was 13 mm (IQR 7;27). All patients were under glucocorticoid treatment, 46 with bDMARD, 1 with tsDMARD and 46 with csDMARD. Treponema denticola was detected in 44.68% of patients, P. gingivalis in 29.79%, Actinomyces spp in 8.51%, Tanerella forsythia in 36.17% and Prevotella intermedia in 25.53%. Only 15 patients were full-negative for OM test.Univariable analysis identified RF positive, double autoantibody positive (RF and ACPA) and moderate/severe PD as potential predictors of the presence of at least one oral microorganism (p<0.20). Multivariable testing pointed out moderate/severe PD as predictor of the presence of at least one oral microorganism (OR 22.91 [CI95% 2.38-220.4] p=0.007).Univariable analysis identified higher age, presence of any comorbidity, RF positive, higher CRP, treatment with anti-tumour necrosis alpha (aTNF) and moderate/severe PD as potential predictors of the presence of multiple species in OM (p<0.20). Multivariable testing pointed out moderate/severe PD as predictor of the presence of multiple species in OM (ß 0.39 [95%CI 0.19-0.58] p=0.000).Conclusion:Oral microbiome is closely related with periodontal disease, added to our results, a relationship between OM and disease activity has been exposed. In this analysis the role of OM and autoantibody profile is manifest, as being double positive or RF positive is associated with the presence of altered OM. Also patients with high acute-phase reactants, active disease and under aTNF treatment could delineate a specific RA population under risk of altered OM, where intensive strategies for changing oral microbiome could have any repercussion in the disease course.References:[1]Chen, B., Zhao, Y., Li, S. et al. Variations in oral microbiome profiles in rheumatoid arthritis and osteoarthritis with potential biomarkers for arthritis screening. Sci Rep8, 17126 (2018).[2]R Bodkhe, B Balakrishnan, V Taneja. The role of microbiome in rheumatoid arthritis treatment. Ther Adv Musculoskelet Dis. 2019;11:1759720.Disclosure of Interests:None declared

scholarly journals A risk-stratified therapy for infants with acute lymphoblastic leukemia: a report from the JPLSG MLL-10 trial

Blood ◽  
2020 ◽  
Vol 136 (16) ◽  
pp. 1813-1823 ◽  
Author(s):  
Daisuke Tomizawa ◽  
Takako Miyamura ◽  
Toshihiko Imamura ◽  
Tomoyuki Watanabe ◽  
Akiko Moriya Saito ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Multivariable Analysis ◽  
Risk Groups ◽  
University Hospital ◽  
High Dose ◽  
Pediatric Leukemia ◽  
Hematopoietic Stem

Abstract The prognosis for infants with acute lymphoblastic leukemia (ALL), particularly those with KMT2A gene rearrangement (KMT2A-r), is dismal. Continuous efforts have been made in Japan to investigate the role of hematopoietic stem cell transplantation (HSCT) for infants with KMT2A-r ALL, but improvement in outcome was modest. In the Japanese Pediatric Leukemia/Lymphoma Study Group MLL-10 trial, infants with ALL were stratified into 3 risk groups (low risk [LR], intermediate risk [IR], and high risk [HR]) according to KMT2A status, age, and presence of central nervous system leukemia. Children’s Oncology Group AALL0631 modified chemotherapy with the addition of high-dose cytarabine in early intensification was introduced to KMT2A-r patients, and the option of HSCT was restricted to HR patients only. The role of minimal residual disease (MRD) was also evaluated. Ninety eligible infants were stratified into LR (n = 15), IR (n = 19), or HR (n = 56) risk groups. The 3-year event-free survival (EFS) rate for patients with KMT2A-r ALL (IR + HR) was 66.2% (standard error [SE], 5.6%), and for those with germline KMT2A (KMT2A-g) ALL (LR), the 3-year EFS rate was 93.3% (SE, 6.4%). The 3-year EFS rate was 94.4% (SE, 5.4%) for IR patients and 56.6% (SE, 6.8%) for HR patients. In multivariable analysis, female sex and MRD ≥0.01% at the end of early consolidation were significant factors for poor prognosis. Risk stratification and introduction of intensive chemotherapy in this study were effective and were able to eliminate HSCT for a subset of infants with KMT2A-r ALL. Early clearance of MRD seems to have translated into favorable outcomes and should be incorporated into risk stratifications in future trials. This trial was registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) as #UMIN000004801.

scholarly journals Vitamin K antagonist has a higher impact than heparin in preventing circuit clotting in chronic haemodialysis patients

2019 ◽  
Vol 13 (4) ◽  
pp. 647-653
Author(s):  
Pierre-Yves Charles ◽  
Yannick Le Meur ◽  
Tugdual Tanquerel ◽  
Hubert Galinat
Keyword(s):  
Vitamin K ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
Protective Role ◽  
University Hospital ◽  
Chronic Haemodialysis ◽  
Heparin Dose ◽  
Thrombosis Risk ◽  
The Mean

Abstract Background In dialysis sessions, some data suggest that decreasing or even avoiding additional anticoagulation by heparin is possible among patients already treated with oral anticoagulation. However, the required dose of heparin may actually depend on the pre-dialysis international normalized ratio (INR), which varies from one session to another. The aim of our study was to determine the respective role of INR and heparin dosing in the risk of circuit clotting during chronic haemodialysis. Methods From early 2012 to July 2016, we analysed the totality of dialysis sessions performed at Brest University Hospital among haemodialysis patients treated by vitamin K antagonists (VKA). We established a prediction of circuit clotting on the basis of a simplified score obtained by combining INR and heparin dosing. Results In total, 7184 dialysis sessions among chronic haemodialysis patients under VKA were identified, including 233 with clotting events. The mean INR without clotting events was 2.5 versus 1.8 with clotting events (P &lt; 0.001). Frequencies of circuit clotting were different according to INR group (INR &lt;2.0, INR 2.0–3.0, INR &gt;3.0; P &lt; 0.0001). The protective role of VKA was higher than heparin, as shown by discriminant factor analysis (P &lt; 0.0001). Conclusion. Our study established a predictive model of thrombosis risk of dialysis circuits in patients treated by VKA for a given heparin dose and a given INR. This model shows a marginal contribution of heparin to protect against the risk of thrombosis compared with VKA. Moreover, heparin would not appear to be necessary for patients with an INR &gt;2.2.

scholarly journals Clinical role of low hemoglobin ratio in poor neurologic outcomes in infants with traumatic intracranial hemorrhage

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
En-Pei Lee ◽  
Shao-Hsuan Hsia ◽  
Oi-Wa Chan ◽  
Chia-Ying Lin ◽  
Jainn-Jim Lin ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Clinical Role ◽  
Neurologic Outcomes ◽  
Traumatic Intracranial Hemorrhage

scholarly journals Safety of endovascular treatment in acute stroke patients taking oral anticoagulants

2016 ◽  
Vol 12 (4) ◽  
pp. 412-415 ◽  
Author(s):  
Timo Uphaus ◽  
Oliver C Singer ◽  
Joachim Berkefeld ◽  
Christian H Nolte ◽  
Georg Bohner ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Hemorrhage ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Multivariate Logistic Regression Analysis ◽  
International Normalized Ratio ◽  
Acute Cerebral Ischemia ◽  
Male Patients

Background The endovascular treatment of acute cerebral ischemia has been proven beneficial without major safety concerns. To date, the role of endovascular treatment in patients treated with oral anticoagulants, which may be associated with periprocedural intracranial bleeding, remains uncertain. Aims The objective of the current analysis is to evaluate the safety of endovascular treatment in patients treated with oral anticoagulants. Methods The ENDOSTROKE-Registry is a commercially independent, prospective observational study in 12 stroke centers in Germany and Austria collecting pre-specified variables about endovascular stroke therapy. Results Data from 815 patients (median age 70 (interquartile range (IQR) 20), 57% male) undergoing endovascular treatment with known anticoagulation status were analyzed. A total of 85 (median age 76 (IQR 8), 52% male) patients (10.4%) took vitamin-K-antagonists prior to endovascular treatment. Anticoagulation status as measured with international normalized ratio was above 2.0 in 31 patients. Intracranial hemorrhage occurred in 11.8% of patients taking vitamin-K-antagonists compared to no-vitamin-K-antagonists (12.2%, p = 0.909). After adjustment for confounding factors which were unbalanced at univariate level such as NIHSS and age, anticoagulation status was not found to significantly influence clinical outcome (modified Rankin Scale 3–6) and occurrence of intracranial hemorrhage in a multivariate logistic regression analysis. Conclusion Prior use of vitamin-K-antagonists was not associated with a higher rate of periprocedural intracranial hemorrhage after endovascular treatment or worse outcome. Endovascular treatment should be considered as an important treatment option in patients taking vitamin-K-antagonists.

scholarly journals Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin

2018 ◽  
Vol 8 (4) ◽  
pp. 311-317 ◽  
Author(s):  
Heidi Lehtola ◽  
Antti Palomäki ◽  
Pirjo Mustonen ◽  
Päivi Hartikainen ◽  
Tuomas Kiviniemi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Intracranial Hemorrhage ◽  
Significant Proportion ◽  
International Normalized Ratio ◽  
Intracranial Hemorrhages ◽  
Spontaneous Hemorrhage ◽  
Traumatic Intracranial Hemorrhage ◽  
Subdural Hemorrhages ◽  
Intracerebral Hemorrhages ◽  
Traumatic Hemorrhage

BackgroundIntracranial hemorrhage is the most devastating complication in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC). It can be either spontaneous or caused by head trauma. We sought to address the prevalence, clinical characteristics, and prognosis of traumatic and spontaneous intracranial hemorrhages in AF patients on OAC.MethodsMulticenter FibStroke registry of 5,629 patients identified 592 intracranial hemorrhages during warfarin treatment between 2003 and 2012.ResultsA large proportion (40%) of intracranial hemorrhages were traumatic. Of these, 64% were subdural hemorrhages (SDHs) and 20% intracerebral hemorrhages (ICHs). With respect to the spontaneous hemorrhages, 25% were SDHs and 67% ICHs. Patients with traumatic hemorrhage were older (81 vs 78 years, p = 0.01) and more often had congestive heart failure (30% vs 16%, p < 0.01) and anemia (7% vs 3%, p = 0.03) compared to patients with spontaneous hemorrhage. Admission international normalized ratio (INR) values (2.7 vs 2.7, p = 0.79), as well as CHA2DS2-VASc (median 4 vs 4, p = 0.08) and HAS-BLED (median 2 vs 2, p = 0.05) scores, were similar between the groups. The 30-day mortality after traumatic hemorrhage was significantly lower than after spontaneous hemorrhage (25% vs 36%, p < 0.01).ConclusionsA significant proportion of intracranial hemorrhages in anticoagulated AF patients were traumatic. Traumatic hemorrhages were predominantly SDHs and less often fatal when compared to spontaneous hemorrhages, which were mainly ICHs. Admission INR values as well as CHA2DS2-VASc and HAS-BLED scores were similar in patients with spontaneous and traumatic intracranial hemorrhage.Clinicaltrials.gov identifierNCT02146040.

Neurological consultations and diagnoses in a large, dedicated COVID-19 university hospital

2020 ◽  
Vol 78 (8) ◽  
pp. 494-500 ◽  
Author(s):  
Adalberto STUDART-NETO ◽  
Bruno Fukelmann GUEDES ◽  
Raphael de Luca e TUMA ◽  
Antonio Edvan CAMELO FILHO ◽  
Gabriel Taricani KUBOTA ◽  
...  
Keyword(s):  
Neurological Diseases ◽  
Neuromuscular Disorders ◽  
Neurological Symptoms ◽  
University Hospital ◽  
Special Treatment ◽  
Nasal Swabs ◽  
Neurological Exam ◽  
Neurological Conditions ◽  
De Medicina

ABSTRACT Background: More than one-third of COVID-19 patients present neurological symptoms ranging from anosmia to stroke and encephalopathy. Furthermore, pre-existing neurological conditions may require special treatment and may be associated with worse outcomes. Notwithstanding, the role of neurologists in COVID-19 is probably underrecognized. Objective: The aim of this study was to report the reasons for requesting neurological consultations by internists and intensivists in a COVID-19-dedicated hospital. Methods: This retrospective study was carried out at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, a 900-bed COVID-19 dedicated center (including 300 intensive care unit beds). COVID-19 diagnosis was confirmed by SARS-CoV-2-RT-PCR in nasal swabs. All inpatient neurology consultations between March 23rd and May 23rd, 2020 were analyzed. Neurologists performed the neurological exam, assessed all available data to diagnose the neurological condition, and requested additional tests deemed necessary. Difficult diagnoses were established in consensus meetings. After diagnosis, neurologists were involved in the treatment. Results: Neurological consultations were requested for 89 out of 1,208 (7.4%) inpatient COVID admissions during that period. Main neurological diagnoses included: encephalopathy (44.4%), stroke (16.7%), previous neurological diseases (9.0%), seizures (9.0%), neuromuscular disorders (5.6%), other acute brain lesions (3.4%), and other mild nonspecific symptoms (11.2%). Conclusions: Most neurological consultations in a COVID-19-dedicated hospital were requested for severe conditions that could have an impact on the outcome. First-line doctors should be able to recognize neurological symptoms; neurologists are important members of the medical team in COVID-19 hospital care.

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