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PubMed2003

Reliability of bleeding and non-bleeding on probing to gingival histological features.

Given the extensive use in periodontal diagnosis of the clinical sign of bleeding on probing, the reliability of the technique in relation to gingival histological features and the need for a better understanding of its significance was investigated. Bleeding (B) and non-bleeding (NB) buccal gingival tissues, were measured through manual probing during gingivectomy procedures. The histological evidence of inflammation was used as the gold standard. The established histological descriptive patterns showed statistically significant differences between B and NB sites (chi2 = 20.842, p < 0.05). The reliability scores were found to be of high sensitivity (90.9%) and negative predictive value (89.5%) as well as of fair specificity (77.3%) and positive predictive value (80%). The accuracy was found to be 84.1%. The histological quantitative analysis showed no statistically significant difference for any HGI (Histological Gingival Index). B sites presented HGI = 1 in 72.8%, close to the NB sites, which showed 63.4% for the same histological score. Furthermore, Pearson's analysis showed a low correlation between the studied clinical signs and the histological quantitative analysis (r = 0.265, p > 0.05). We conclude that the clinical parameter of bleeding on probing is a reliable tool for diagnosing gingival inflammation, whereas the clinical sign of non-bleeding on probing is not a safe criteria for evaluating gingival health.

Adult↗

PubMedDate not supplied

Propranolol for prophylaxis of bleeding in cirrhotic patients with large varices: a multicenter, randomized clinical trial. The Italian Multicenter Project for Propranolol in Prevention of Bleeding.

To assess if propranolol prevents the first bleeding in cirrhosis, we randomly assigned 174 patients with large varices to either propranolol in doses reducing the resting heart rate by 25% (85 patients) or to a placebo (oral vitamin K, 89 patients). Sixty-nine patients had alcoholic cirrhosis, 24 posthepatitis cirrhosis and 81 cryptogenic cirrhosis. At the time of inclusion, 75 patients (43%) had ascites and according to the Child-Pugh classification, 103 (59%) had Class A disease, 60 (34%) Class B and 11 (7%) Class C. We report here an interim analysis of the study when all patients had been followed for at least 1 year (mean follow-up = 22 months). At this time, the cumulative proportion of patients free of bleeding was 74% (both differences not significant), respectively. A retrospective analysis showed that the cumulative percentage of patients free of bleeding was significantly higher in the propranolol- than in the control-group in the subsets of patients without ascites or in Child-Pugh Class A: respectively, 87 vs. 64% (p = 0.023) and 88 vs. 64% (p = 0.01). No differences in bleeding incidence were found in patients with ascites or in Child-Pugh Class B or C. Propranolol treatment did not affect survival in any subgroup. Twenty-five patients had to be withdrawn from propranolol because of side effects (n = 23) or low compliance (n = 2). If confirmed on a longer follow-up, these results suggest that propranolol could prevent the first bleeding in patients with well-compensated cirrhosis.

Clinical Trials as Topic↗

PubMed1980

Bleeding duodenal varices demonstrated by transhepatic portography. Report of a case misinterpreted as Bleeding duodenal Ulcer.

Bleeding duodenal varices are a rare complication of portal hypertension. Upper gastrointestinal bleeding from other sources than varices is common in patients with cirrhosis. Most often the bleeding is misinterpreted as bleeding from duodenal ulcer, and the diagnosis is first apparent during emergency operation. From our experience with a case of bleeding duodenal varices we suggest that the diagnostic procedure of choice is percutaneous transhepatic portography.

Aged↗

PubMed1986

Effect of alternate-day regular and enteric-coated aspirin on platelet aggregation, bleeding time, and thromboxane A2 levels in bleeding-time blood.

The effectiveness of low-dose aspirin for primary prevention of cardiovascular mortality is being assessed among the nearly 22,000 United States physicians currently participating in the Physicians' Health Study. Because of occasional reports of gastric irritation among study participants, two enteric-coated aspirin preparations were tested as possible alternatives to regular compressed aspirin for platelet inhibition. Thirty-three volunteers were assigned randomly to one of four treatment groups: regular aspirin (325 mg), placebo, and two enteric-coated aspirin preparations (325 mg). Pills were administered every other day, duplicating the regimen used in the Physicians' Health Study. Bleeding times, platelet aggregation, and thromboxane A2 levels produced by aggregating platelets in vitro, as well as in collected bleeding-time blood, were determined. Measurements were taken before and after a single dose as well as after seven alternate-day doses. Regular and enteric-coated aspirin preparations were equally efficacious in prolonging the bleeding time, inhibiting platelet aggregation, and suppressing thromboxane A2 production. There was virtually complete suppression of thromboxane A2 production (over 99 percent), by platelets in vitro and in collected bleeding-time blood. The levels were still profoundly reduced (89 percent) 48 hours after the last dose. Enteric-coated aspirin may provide an alternative to regular aspirin in a low-dose regimen designed to inhibit platelet activity.

Adult↗

PubMed1985

Effect of high-dose ampicillin and cloxacillin on bleeding time and bleeding in open-heart surgery.

To determine if platelet dysfunction caused by high doses of penicillin compounds is of practical importance in patients with additional haemostatic defects perioperatively, a study was made of patients undergoing open-heart surgery. They were randomly assigned to prophylactic treatment with ampicillin 8 g plus cloxacillin 4 g daily for three days, or with cephalothin 8 g daily for three days. Fifty patients in each group were evaluated. The median bleeding time preoperatively and on days 1 and 4 postoperatively did not differ between the groups. The bleeding time was prolonged beyond the normal range in eight patients of the ampicillin/cloxacillin group and in three of the cephalothin group (p less than 0.05). Prolonged bleeding time was not associated with lower platelet count or greater blood loss. The total blood loss and the amounts of transfused blood, platelets and cryoprecipitate were all greater in the ampicillin/cloxacillin group, but the difference was not statistically significant. Combined use of ampicillin and cloxacillin in open-heart surgery is associated with increased bleeding, but the increase is without practical importance.

Adolescent↗

PubMed1995

Vampire bat salivary plasminogen activator evokes minimal bleeding relative to tissue-type plasminogen activator as assessed by a rabbit cuticle bleeding time model.

Cuticle bleeding time (CBT) measurements in anesthetized rabbits were performed to assess the potential bleeding risks which may accompany the administration of tissue-type plasminogen activator (tPA) or vampire bat salivary plasminogen activator (BatPA). The dose of BatPA or tPA used in this study, 42 nmol/kg, was previously shown to be efficacious using a rabbit femoral artery thrombosis model (Gardell et al, Circulation 84:244, 1991). CBT was determined by severing the apex of the nail cuticle and monitoring the time to cessation of blood flow. CBT was minimally elevated (1.6-fold, p = NS) following bolus intravenous administration of BatPA; in contrast, bolus intravenous administration of tPA dramatically elevated CBT (6.2-fold, p < 0.05). Rabbits treated with tPA, but not BatPA, displayed profound activation of systemic plasminogen and consequent degradation of Factor VIII and fibrinogen. Elevations in CBT after the administration of tPA were reversed by the replenishment of plasma Factor VIII activity to 40% of control, but were unaffected by complete replenishment of plasma fibrinogen. The results of this study suggest that the administration of BatPA, at a dose that promotes thrombolysis, may evoke a minimal bleeding risk, relative to an equi-efficacious dose of tPA. In addition, the tPA-provoked proteolytic consumption of Factor VIII may be a key contributor to the heightened bleeding risk.

Animals↗

PubMed1992

Epidemiology of AIDS in females with hemophilia and other chronic bleeding disorders in the United States: comparisons with males with chronic bleeding disorders and AIDS and with nonhemophilic female blood-transfusion recipients with AIDS.

From January 1, 1981 through June 30, 1990, 32 females with chronic bleeding disorders were diagnosed with acquired immunodeficiency syndrome (AIDS) in the United States. Most (81.3%) were white and greater than or equal to 30 years of age, with a median age of 37.5 years. Eighteen (56.3%) had von Willebrand's disease. Pneumocystis carinii pneumonia was reported for 16 (50%). None had Kaposi sarcoma. The median survival time was 10.8 months, with a cumulative probability of survival at 1 year of 47.3% and at 2 years of 27.6%. We compared the demographic data and survival times of these females with those of males with a chronic bleeding disorder and AIDS, and with those of nonhemophilic females with AIDS whose exposure to the human immunodeficiency virus (HIV) was through receipt of blood transfusions, blood components, or tissue. The principal demographic difference was age distribution. The females with chronic bleeding disorders tended to be younger than the transfused, nonhemophilic females, but older than the males. The survival time from AIDS diagnosis to death for the females with chronic bleeding disorders did not differ statistically from that of the other two groups, although older nonhemophilic females whose exposure was transfusion may progress more rapidly to AIDS.

Acquired Immunodeficiency Syndrome↗

PubMed1987

Angiodysplasia--an uncommon cause of colonic bleeding: colonoscopic evaluation of 1,050 patients with rectal bleeding and anaemia.

Angiodysplasia of the colon was diagnosed in 31 out of 1,050 patients (3%) presenting with rectal bleeding or anaemia, among 10,000 colonoscoped at St. Mark's Hospital. The lesions were identified in 16 out of 879 (2%) patients with rectal bleeding, in 15 out of 171 (9%) patients with anaemia, and in a further three patients without features of blood loss. The angiodysplasia lesions were predominantly in the right colon (76%) and occurred with a similar frequency (12%) in the transverse and the left colon. Affected patients (59% male and 41% female) were in the older age group (53-89 years; mean age 69.5 years) but only one patient had known aortic valve disease. Angiodysplasia is an important diagnosis to consider in patients presenting with colonic bleeding or anaemia because it can be treated in the majority of cases by endoscopic electrocoagulation. However in our experience it is less common (3%) than previously suggested by other authors (40-67%). Endoscopic over-diagnosis is possible when intramucosal capillaries with no bleeding tendency on local traumatisation or biopsy are included in the diagnosis but these lesions are not true angiodysplasia.

Aged↗

PubMed1993

Self-treatment with desmopressin intranasal spray in patients with bleeding disorders: effect on bleeding symptoms and socioeconomic factors.

Desmopressin (1-desamino-8-D-arginine vasopressin), an established hemostatic agent for the treatment of bleeding in mild hemophilia A, von Willebrand's disease, or platelet disorders, has mostly been given parenterally as intravenous or subcutaneous injections. Intranasal administration by spray has been shown to yield significant and highly reproducible increases in the plasma concentrations of factor VIII and von Willebrand factor and platelet adhesiveness, and to be suitable for self-administration at home, as it is easy to handle and does not involve the use of needles. This paper presents data from a questionnaire answered by 78 patients with mild hemophilia A, von Willebrand's disease, or platelet disorders, who had used the spray at home to treat bleeding symptoms. The patients experienced decreased blood loss and shortened duration of epistaxis, menorrhagia, tissue bleeding, and bleeding in connection with minor surgery or tooth extraction. The use of factor VIII concentrates was diminished, as were the number of visits to outpatient care and absence from school or work.

Adult↗

PubMed2004

Management of massive lower gastrointestinal bleeding: should there be surgical intervention without initial endoscopy and radiological evidence of the source of bleeding?

We report two case histories of patients with massive rectal blood loss. Endoscopic and radiological investigations could not identify the source of bleeding at admission. Initially, both patients recovered without surgical intervention, receiving a large number of blood transfusions only. Extensive subsequent radiological analysis showed that the bleeding was due to a pathological part of the proximal jejunum in one case and of the colon transversum in the other. Although immediate surgical intervention was not needed at presentation, both patients underwent resection of a part of the bowel some time thereafter. Surgery was performed after hemodynamic stabilization in the first case. However, in the second case, emergency surgical intervention was needed due to persistent bleeding 4 days after admission. Both patients are still doing well half a year after this massive gastrointestinal (GI) hemorrhage. Aside from a small area of chronic inflammation and fibrosis of the jejunum in one patient, histopathological evaluation of the surgical resection specimens revealed no specific cause for these massive gastrointestinal bleedings. We discuss the general approach of gastrointestinal hemorrhage and the several (dis)advantages of the various imaging techniques and the order in which they should be used.

Journal Article↗

PubMed2001

Practical management of anticoagulation, bleeding and blood product support for cardiac surgery. Part one: bleeding and anticoagulation issues.

There are many challenging problems related to bleeding and anticoagulation in cardiac surgery. Practical guidelines, which are based on available evidence, can help to direct management issues of post-bypass bleeding, perioperative anticoagulation and the use of haemostatic agents. The patient's bleeding history is the most useful preoperative screening test of haemostasis. The input of a haematologist is often valuable in a number of areas, such as preoperative assessment of patients with a significant history of bleeding, or past history of heparin-induced thrombocytopenia, a lupus anticoagulant, or recent venous thromboembolism. Cardiothoracic surgeons, anaesthetists, perfusionists and haematologists can ensure 'best practice' by being actively involved in the development of 'local' transfusion and anticoagulation guidelines, hospital transfusion committee policies, and audits.

Journal Article↗

PubMed1999

Secondary prevention of upper gastrointestinal bleeding associated with maintenance acid-suppressing treatment in patients with peptic ulcer bleed.

We studied the recurrence of upper gastrointestinal bleeding (UGIB) in a cohort of patients who had an episode of peptic ulcer bleed, and we investigated the effect of maintenance treatment with cimetidine, omeprazole, and ranitidine. We identified 952 patients with a hospitalization for an episode of peptic ulcer bleed by searching the General Practice Research Database in the United Kingdom. The mean follow-up time was 33 months. Less than 10% of the cohort presented with a new episode of UGIB. We calculated incidence rates of recurrent UGIB and estimated the relative risk (RR) of UGIB associated with use of the various acid-suppressing drugs. The greatest protection for recurrent UGIB associated with maintenance acid-suppressing treatment was seen with omeprazole (relative risk 0.2; 95% CI, 0.02-1.0). The corresponding estimates with cimetidine and ranitidine were 0.9 (0.3-2.3) and 0.9 (0.5-1.8). Among nonsteroidal anti-inflammatory drug users, concomitant use of omeprazole afforded protection against a new bleed (RR 0.0; 0.0-1.0), and there was a suggestion of a protective effect with misoprostol, 0.4 (0.01-3.2). The degree of lowered risk of recurrent UGIB in patients on omeprazole maintenance therapy compared with cimetidine or ranitidine therapy is comparable with the protection provided through profound reduction of gastric acidity achieved with proton-pump inhibitors.

Adult↗

PubMed2005

Effect of famotidine on recurrent bleeding after successful endoscopic treatment of bleeding peptic ulcer.

AIM: We investigated the effect of acid suppression therapy on recurrent bleeding after successful endoscopic treatment of bleeding peptic ulcer. METHODS: A total of 400 patients with bleeding peptic ulcer received either intravenous infusion of famotidine (40 mg/day) (n = 207, 163 males, 44 females, mean age 61.5 years) or drip infusion of omeprazole (40 mg/day; n = 193, 134 males, 59 females, mean age 59.8 years) after successful endoscopic treatment. The fasting duration, hospital stay, volume of transfused blood, incidence of rebleeding and mortality were compared between the two groups. RESULTS: The incidence of rebleeding did not differ significantly between the famotidine group (9%) and the omeprazole group (8%). The mean hospital stay was significantly shorter in the omeprazole group (18.4 days) than in the famotidine group (21.5 days, P = 0.009). However, there was no statistically significant difference in fasting duration, volume of transfused blood or mortality. CONCLUSION: Our findings indicate that intravenous infusion of famotidine after successful endoscopic treatment is equivalent to drip infusion of omeprazole for prevention of recurrent bleeding.

Adolescent↗

PubMed2001

Comparison of transvaginal ultrasound, saline infusion sonography and hysteroscopy to investigate postmenopausal bleeding and unscheduled bleeding on HRT.

A study was conducted to compare transvaginal ultrasound (TVS), saline infusion sonography (SIS) and outpatient hysteroscopy for examining the uterine cavity in women with postmenopausal bleeding and unscheduled bleeding on hormone replacement therapy (HRT). Fourty Subjects agreed to undergo TVS, SIS and hysteroscopy in addition to endometrial sampling. The abnormalities detected by each imaging method were recorded together with the discomfort (visual analogue scale). Thirty women completed all three imaging procedures. In 18 cases TVS suggested an abnormal cavity. SIS and hysteroscopy were of similar efficacy in clarifying the nature of this, and confirmed an abnormality in 12 cases (40%). TVS was significantly less painful than the other procedures (p < 0.001). SIS and hysteroscopy were associated with pain scores similar to endometrial sampling. These findings justify the need for a large randomised trial of TVS, SIS, hysteroscopy and endometrial sampling, in order to develop the most appropriate strategy for investigating postmenopausal bleeding and unscheduled bleeding on HRT.

Endometrium↗

PubMed2004

[Vagotomy in the treatment of bleeding reflux-esophagitis and gastroduodenal bleedings].

Fifteen-year experience in the treatment of 588 patients with esophageal and gastroduodenal bleedings is analyzed. Surgery was performed in 286 patients, 302 patients were treated conservatively including 71 patients who underwent endoscopic procedures. Principles of differentiated treatment policy are developed. Selective proximal vagotomy in combination with fundoplication (if indicated, with surgeries draining the stomach) is surgery of choice in bleeding reflux-esophagitis and gastroduodenal ulcerous bleedings. These methods eliminate pathogenetic factors of bleeding gastro-esophageal reflux, lower acidity of gastric juice.

Esophagitis, Peptic↗

PubMed2006

Critical bleeding in pregnancy: a novel therapeutic approach to bleeding.

AIM: In the developed countries the frequency of life threatening post-partum hemorrhages (PPH) is 1 in 1,000 deliveries with a risk of death of 1-2/100,000 deliveries. Hysterectomies for intractable bleeding are carried out in approximately 50% of the cases. The majority of PPH have obstetrical causes, most frequently atony of the uterus. Hereditary and acquired hemostatic defects are very rare. Guidelines of standard surgical and medical measures are available. In this paper we focus on the use of activated recombinant factor VII (rFVIIa) in PPH. METHODS: A computerized literature search was carried out in PubMed and Ovid for papers published between 2001 and 2005 in the English literature reporting on life-threatening PPH treated with rFVIIa after failure of conventional therapy, including hysterectomy. RESULTS: We identified 11 papers including 39 patients; in 18 of them the laboratory data were indicative for disseminated intravascular coagulation and in 24 hysterectomy was carried out. Controlled or reduced bleeding was reported in 38 out of 39 treated patients. CONCLUSIONS: The bleeding can occur in a series of events conductive to metabolic complications, hypoxia, disseminate intravascular coagulation, organ damage and multiorgan failure, progressively exhaustive. The therapeutic intervention must be instituted as early as possible before successive complications ensue. These preliminary reports in PPH after failure of conventional standard therapy suggest that rFVIIa is an active agent but should be administered as early as possible before the consequences of severe and intractable bleeding.

Critical Illness↗

PubMed1995

[Prediction of bleeding risks and death in cirrhosis based on hemodynamic and metabolic variables. A study of patients with esophageal varices without previous bleeding].

As identification of patients with liver cirrhosis who are at risk of bleeding or death is essential in terms of prophylaxis, we have determined the prognostic influence of various patient characteristics on risk of bleeding and death. Fifty-five cirrhotic patients with oesophageal varices without previous bleeding were included in the study and followed up after a medium observation period of 446 days (range:5-1211 days). A total of 55 clinical, biochemical, haemodynamic, and endoscopic variables were classified as either systemic haemodynamic, portal haemodynamic, or metabolic. Using univariate analysis the following variables showed a significant relation to an increased risk of bleeding or death: high plasma volume (p < 0.02), high azygos blood flow (p < 0.004), high hepatic venous pressure gradient (p < 0.02), marked prominence of varices (p < 0.05), poor nutritional status (p < 0.0001), low clotting factor 2, 7, 10 (p < 0.002), low incapacitation index (p < 0.004), low serum albumin (p < 0.005), high bilirubin (p = 0.05), high alkaline phosphatases (p < 0.02), low arterial oxygen saturation (p = 0.02), and encephalopathy (p < 0.007). In a Cox regression model poor nutritional status (p < 0.00005), serum bilirubin (p < 0.001), short central circulation time (p < 0.03), low serum albumin (p < 0.02), and low index of clotting factor 2, 7, 10 (p < 0.05) were independently associated with higher risk. In conclusion, the results support the prognostic value of metabolic variables as earlier described. The prognostic significance of central circulation time stresses the importance of the hyperdynamic systemic circulation in the increased risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2005

Screening women with menorrhagia for underlying bleeding disorders: the utility of the platelet function analyser and bleeding time.

Menorrhagia is a very common clinical problem among women of reproductive age and recent studies have suggested that underlying bleeding disorders, particularly von Willebrand's deficiency and platelet function defects, are prevalent in women presenting with menorrhagia. The objective of this study was to determine the utility of the platelet function analyser (PFA-100) and bleeding time (BT) as initial screening tests for underlying bleeding disorders in women with menorrhagia. In this study, 81 women with a physician diagnosis of menorrhagia underwent PFA-100 testing, BT and comprehensive haemostatic testing. The effectiveness of the PFA-100 and BT as screening tools in women with menorrhagia was assessed using results of haemostatic testing for von Willebrand's disease (VWD) and platelet dysfunction. In women presenting with menorrhagia, the PFA-100 had a sensitivity 80%, specificity 89%, positive predictive value (PPV) 33%, negative predictive value (NPV) 98% and efficiency 88% for VWD. For platelet aggregation defects, the PFA-100 closure time had a sensitivity 23%, specificity 92%, PPV of 75%, NPV of 52% and efficiency 55%. The data suggest that the PFA-100 may be useful in stratifying women with menorrhagia for further von Willebrand testing; however, neither the PFA-100 nor the BT tests are effective for purposes of classifying women for standard platelet aggregometry testing in women presenting with menorrhagia.

Adolescent↗