Incidence and predictors of serious bleeding during long-term follow-up after acute coronary syndrome in a population-based cohort study

Progress in decreasing ischemic complications in acute coronary syndrome (ACS) has come at the expense of increased bleeding risk. We estimated the long-term, post-discharge incidence of serious bleeding, characterized bleeding type, and identified predictors of bleeding and its impact on mortality in an unselected cohort of patients with ACS. In this population-based study, we included 1379 patients identified with an ACS, 2010–2014. Serious bleeding was defined as intracranial hemorrhage (ICH), bleeding requiring hospital admission, or bleeding requiring transfusion or surgery. During a median 4.6-year follow-up, 85 patients had ≥ 1 serious bleed (cumulative incidence, 8.6%; 95% confidence interval (CI) 8.3–8.9). A subgroup of 557 patients, aged ≥ 75 years had a higher incidence (13.4%) than younger patients (6.0%). The most common bleeding site was gastrointestinal (51%), followed by ICH (27%). Sixteen percent had a recurrence. Risk factors for serious bleeding were age ≥ 75 years, lower baseline hemoglobin (Hb) value, previous hypertension or heart failure. Serious bleeding was associated with increased mortality. Bleeding after ACS was fairly frequent and the most common bleeding site was gastrointestinal. Older age, lower baseline Hb value, hypertension and heart failure predicted bleeding. Bleeding did independently predict mortality.

A life-threatening spontaneous ascending aortic rupture due to a small penetrating aortic ulcer

We reported a rare case of spontaneous frank rupture of a small (4 mm) penetrating aortic ulcer in the ascending aorta resulted in catastrophic bleeding. The ulcer only created a pinhole wound in the adventitia without saccular aneurysms, intramural hematomas, or aortic dissections. Notably, the wound could be directly closed because the aortic wall was intact only 5 mm away from the bleeding site. The postoperative course was uneventful, and the patient was discharged on the 11th postoperative day. After 8 months, follow-up computed tomography showed no abnormality of the aortic wall at the repair site.

Development and Validation of a Computable Phenotype for Bleeding in Hospitalized Patients: The Medical Inpatients Thrombosis and Hemostasis (MITH) Study

Introduction: Bleeding is an uncommon event but it is causes significant increase in morbidity and mortality. Identifying bleeding events using electronic health record data (both resulting from hospitalization and causing hospitalization) would allow the development of risk assessment models (RAM) to identify those at most risk. Traditional prospective cohorts for rare events are time consuming and expensive. We suggest a more efficient method using the electronic health record (EHR) data by developing and validating an algorithm to detect bleeding in hospitalized patients, ie, a "computable phenotype". Methods: We captured all admissions to the University of Vermont (UVM) Medical Center between 2010-19, a tertiary care medical center in northwest Vermont. Using International Classification of Disease (ICD) 9 and 10 discharge diagnoses, "present on admission" flags, problem lists, laboratory values, vital signs, current procedure terminology (CPT) codes, medication administration, and flowsheet data for transfusion support, we developed computable phenotypes for bleeding. Classification was based on the gold standard International Society of Thrombosis and Haemostasis definitions for clinically relevant non-major bleeding (CRNMB) and major bleeding (MB) and validated by medical record review. To improve sensitivity and specificity, algorithms were developed by bleeding site (intracerebral, intraspinal, pericardial, retroperitoneal, orbital, intramuscular, gastrointestinal, genitourinary, gynecologic, pulmonary, nasal, post-procedure, or miscellaneous). We preliminary validated the computable phenotype by randomly abstracting 10 medical records from each bleeding site. Results: Among 62,468 admissions, our computable phenotype for bleeding identified 10,202 bleeding events associated with hospitalization; 4,650 were CRNMB and 5,552 were MB. On chart abstraction, 135 of 153 hospitalizations had either a MB or CRNMB (88%, Figure). For MB, 95 of 119 (80%) of the computed MB phenytope events were validated. Of the 24 of 119 (20%) not validated, 14% (16) were CRNMB and 7% (8) the bleeding was present on coding but was not detected by chart review. Only 29%(10/34) of the CRNMB were validated. The most common error in the CRNMB computable phenotype was misclassification of 14 MB as CRNMB (41% of CRNMB. For individual bleeding sites, (figure), the algorithms performed well for most sites including intracerebral hemorrhage, gastrointestinal, and intramuscular bleeding, but performed less well for unusual and rarer bleeding sites (i.e. nasal). Conclusion: We developed a computable phenotype for bleeding which can be applied to our EHR system. The computable phenotype was specific for MB, but underestimated the severity of potential CRNMB. Importantly, we correctly classified specific important bleeding sites such as intracerebral, gastrointestinal, and retroperitoneal. This computable phenotype forms the basis for further refinement, and provides a road map for future studies on epidemiology of hospital-acquired bleeding and hospitalization for bleeding. Figure: Major and Clinically relevant non-major bleeding as detected by Electronic Health Record compared to the chart validation Figure 1 Disclosures No relevant conflicts of interest to declare.

Management of a life-threatening intercostal artery bleeding, difficult to visualize in open surgery: a case report

Life-threatening bleeding from an intercostal artery is a rare and challenging event. A 74-year-old patient with a right-sided pleural effusion was treated by a pigtail pleural drain. He developed a large haemothorax, initially addressed by a large bore chest tube. As he became haemodynamically unstable, he required an emergency anterolateral right thoracotomy. It was difficult to visualize and reach the bleeding vessel during open surgery. A 30° laparoscopy camera was introduced and the bleeding site was identified. An incision was made directly over the bleeding site and the two ends of the lacerated intercostal artery were ligated by two externally placed figure-of-eight sutures. The patient survived and recovered fully. As most general surgeons, even at smaller hospitals, are familiar with laparoscopy, the technique described here may be useful for other surgeons to employ if a life-threatening intercostal artery injury occurs.

Surgery-associated acquired hemophilia A: a report of 2 cases and review of literature

Background Acquired Hemophilia A (AHA) is a rare bleeding diathesis in patients with no previous personal or family bleeding history. The diagnosis of this disease often delays due to unfamiliarity of physicians with it, which leads to its high mortality rate. Case presentation Two cases (one 12 years old female and another 18 years old male) were admitted for right upper abdominal mass and right upper abdominal pain respectively at different times. Pre-operative diagnosis of both cases was congenital choledochal cyst. They suffered continuous gastrointestinal bleeding (hematemesis and melena) with reduced hemoglobin to 54 g/L and 60 g/L after Roux-en-Y anastomosis respectively. To investigate the exact bleeding site, Digital subtraction angiography (DSA) of case 1 showed contrast overflow at small branch of proper hepatic artery but had unremarkable result for case 2, whereas gastroscopy of both cases showed unremarkable results. Multiple surgeries were also performed for hemostatic purpose but each time no active bleeding site was found. Finally, hematologists consultation was mandated in both cases and they were diagnosed as acquired haemophilia A. However, unfortunately case 1 patient could not survive because of sever hemorrhage and infection while Case 2 of 18 years old male survived after proper haemophilia treatment catalog. Conclusion Awareness about surgery associated acquired haemophilia A (SAHA) can facilitate quick diagnosis and lifesaving management because the mortality rate in SAHA is high due to lake of knowledge or late recognition of the disease. Bleeding always occurs at surgical sites and it can occur immediately within few hours after surgery in some cases. Hemorrhage may be severe or even life threatening and it presents a special challenge for diagnosis and treatment in a patient who has just undergone a surgical procedure. The treatment strategies for AHA include resumption of hemostasis with either recombinant porcine factor VIII (rpFVIII) or bypassing agents and immunosuppressive therapy to suppress the production of the factor VIII inhibitor.