UNASSIGNED: To investigate the pivotal determinants contributing to the adverse prognosis in patients afflicted with traumatic lung injury (TLI), with an aim to mitigate the elevated mortality rate associated with this condition.
UNASSIGNED: A retrospective analysis was carried out on 106 TLI patients who were admitted to the intensive care unit of a comprehensive hospital from March 2018 to November 2022. The patients were categorized into two groups based on their 28-day outcome: the survival group (n = 88) and the death group (n = 18). Random forest model, least absolute shrinkage and selection operator (LASSO) regression and support vector machine recursive feature elimination (SVM-RFE) were utilized to pinpoint the primary factors linked to poor prognosis in TLI patients. The Receiver Operating Characteristic (ROC) curve analysis was utilized to ascertain the predictive value of INR in forecasting the prognosis of TLI patients. Based on the cut-off value of INR, patients were categorized into two groups: INR ≥ 1.36 group (n = 35) and INR < 1.36 group (n = 71). The 28-day survival rate was then compared using Kaplan-Meier analysis.
UNASSIGNED: Random forest model, LASSO, and SVM-RFE jointly identified International standardization ratio (INR) as a risk factor for TLI patients. The area under the ROC curve for INR in predicting the 28-day mortality of TLI patients was 0.826 (95% CI 0.733-0.938), with a cut-off value of 1.36. The 28-day mortality risk for TLI patients with an INR ≥ 1.36 was 8.5 times higher than those with an INR < 1.36.
UNASSIGNED: Traumatic lung injury patients with elevated INR have a poor prognosis. An INR of ≥1.36 can be used as an early warning indicator for patients with traumatic lung injury.

Correction of coagulation is a crucial aspect of trauma care. While there are reports highlighting the effectiveness of fibrinogen concentrate in severe trauma cases with coagulopathic complications, literature on its use in pediatric cases remains limited. This paper discusses the case of a 5-year-old male presenting with a splenic injury and associated coagulopathy. We administered fibrinogen concentrate to enhance his coagulability prior to performing transcatheter arterial embolization utilizing gelatin sponges, aiming for optimal hemostasis. Post-administration, the patient\'s fibrinogen levels improved significantly, leading to successful hemostasis and a positive clinical outcome.

Hepatitis E virus (HEV) is typically asymptomatic in developed countries but can be more severe in certain populations. We aim to describe the epidemiology of HEV-associated hospitalisations from 1998 to 2020 in the United States, investigate risk factors for inpatient mortality and describe outcomes in pregnant women. We utilised the National Inpatient Sample and extracted cases of HEV-associated hospitalisations using ICD-9/10 diagnostic codes. Demographic, clinical and pregnancy data were extracted and analysed by chi-square and logistic regression. We identified 3354 cases of HEV-associated hospitalisations; 1689 (50.4%) were female and 1425 (42.5%) were non-Hispanic White. The median age was 50 (IQR: 37-59) years. Hospitalisation rates for HEV ranged from 2.5 per 10,000,000 in 2008 to a peak of 9.6 per 10,000,000 people in the general U.S. population in 2004. The mortality rate was 5.2%. Age ≥ 40 years (OR: 7.73; 95% CI: 1.57-38.09; p = 0.012), HIV infection (OR: 4.63; 95% CI: 1.26-16.97; p = 0.021), and coagulopathy (OR: 7.22; 95% CI: 2.81-18.57; p < 0.001) were associated with increased odds of mortality within the HEV cohort. There were 226 pregnant women with HEV. Rates of maternal death, stillbirth and preterm birth were similar between HEV and non-HEV pregnant cohorts. Hepatitis B and hepatitis C co-infection were significantly more common in the HEV pregnant cohort (p < 0.05). HEV-associated hospitalisations are uncommon in the United States, but likely underdiagnosed. Certain risk factors can be used to predict prognosis of these hospitalised patients. Pregnant women with HEV appear to have favourable maternal and fetal outcomes despite hepatitis B and C co-infection.

Cytokine storm syndrome (CSS) is a severe life-threatening condition characterized by a clinical phenotype of overwhelming systemic inflammation, hyperferritinemia, hemodynamic instability, and multiple organ failure (MOF), and, if untreated, it can potentially lead to death. The hallmark of CSS is an uncontrolled and dysfunctional immune response involving the continual activation and expansion of lymphocytes and macrophages, which secrete large amounts of cytokines, causing a cytokine storm. Many clinical features of CSS can be explained by the effects of pro-inflammatory cytokines, such as interferon (IFN)-γ, tumor necrosis factor (TNF), interleukin (IL)-1, IL-6, and IL-18 [1-7]. These cytokines are elevated in most patients with CSS as well as in animal models of CSS [8, 9]. A constellation of symptoms, signs, and laboratory abnormalities occurs that depends on the severity of the syndrome, the underlying predisposing conditions, and the triggering agent.

Postoperative surgical site infection in the lumbar spine is one of the serious complications that sometimes results in death. Herein, we describe a case in which a patient was found to have coagulopathy due to vitamin K deficiency when he was transferred to a hospital for treatment for a postoperative infection of the lumbar spine. The coagulation disorder was caused by antimicrobial agents administered to the patient, who was suffering from hyponutrition. The patient was a 70-year-old man with a history of diabetes mellitus. He was diagnosed with lumbar spinal canal stenosis and underwent posterior decompression of the L2-L5 and S1 laminae at a previous hospital five months before transfer to our hospital. Four months before transfer, purulent discharge was observed from the wound, and methicillin-susceptible Staphylococcus aureus was detected in the wound culture. Cefazolin was administered for two weeks, resulting in initial improvement. However, one month before the transfer, the wound infection recurred, accompanied by bacteremia and a psoas abscess. He had been treated with cefazolin, levofloxacin, rifampicin, trimethoprim, and sulfamethoxazole, but the antibiotics\' effects were insufficient. Upon transfer for debridement surgery due to uncontrolled infection, his coagulation parameters were as follows: prothrombin time (PT) 74.0 sec, PT-international normalized ratio (INR) 6.69, PT% 9.0, activated partial thromboplastin time (APTT) 138 sec, fibrinogen (FIB) 664 mg/dl, fibrin degradation products (FDP) 7.1 μg/ml, and protein induced by vitamin K absence-II (PIVKA-II) 34400 mAU/ml. Because we suspected vitamin K deficiency, vitamin K 40 mg was administered as a test dose, and coagulation function improved to PT 16.4 sec, PT-INR 1.30, PT% 65.2, and APTT 79 sec after four hours. The diagnosis of vitamin K deficiency was confirmed, vitamin K was administered for four days, and the coagulation status normalized five days after transfer. Debridement was performed for the left psoas abscess. Cefazolin was administered for eight weeks, and administration was completed. The coagulation abnormality did not recur due to careful attention to his nutrition. We experienced a case of coagulopathy due to vitamin K deficiency caused by antimicrobial agents administered to a hyponourished patient with a postoperative infection of the lumbar spine. The cause of vitamin K deficiency, in this case, was thought to be low nutrition, suppression of vitamin K-producing bacteria by cefazolin and rifampicin, and the use of cefazolin with a methyl-thiadiazole thiol group. It should be kept in mind that severe coagulopathy due to vitamin K deficiency caused by antimicrobial treatment with hyponutrition can occur in postoperative infections.

OBJECTIVE: SARS-CoV-2 (COVID) induces systemic thrombotic complications including acute ischemic stroke. In this case series, we report markers of inflammation, coagulation factors including von Willebrand factor antigen, and rotational thromboelastometry (ROTEM) data.
METHODS: Retrospective case series of COVID patients seen at a single comprehensive stroke center between 2020 - 2022. For patients undergoing mechanical thrombectomy (MT), ROTEM data was collected during the procedure and analyzed on ROTEM delta system.
RESULTS: Fifteen patients (33.3% female) median age 65-years-old presented with COVID and acute ischemic stroke. Thirteen had LVO. The mean NIHSS was 15 (range 0 - 35) on admission and 18 (0 - 42) at discharge. Most were cryptogenic (N=7, 46.7%), followed by cardioembolic (N=6, 40%) and large artery-to-artery embolization (N=2, 13.3%). mRS was < 3 in 8 (53%) patients at discharge. None of the patients were on anticoagulation, and five were on antiplatelet therapy pre-hospitalization. Seven received thrombolytics with alteplase (tPA), and 10 had MT. Baseline platelet count was 102 K/uL (range 102 - 291 K/uL). vWF was measured in 12 patients, all elevated, with seven having levels >400 (180%). ROTEM data was collected in six patients. Three who received tPA had abnormal EXTEM and FIBTEM data (CT extem > 85secs, A10 EXTEM < 45mm, and A10 FIBTEM < 10mm). Notably, INTEM (CT INTEM >208secs) was abnormal in five of the six patients, two of whom did not receive tPA.
CONCLUSIONS: Elevated vWF antigen levels with abnormal ROTEM data suggests that COVID induces changes in the clotting cascade. More robust research is needed to investigate these findings. Thrombolytics, MT, and antiplatelet agents should be utilized to treat COVID-related ischemic stroke based on current clinical guidelines.

BACKGROUND: This study aimed to clarify the characteristics and survival prediction value of transcranial Doppler microembolic signals (MES) in patients with acute cerebral infarction and active cancer.
RESULTS: Between 2017 and 2022, 1089 cases of acute cerebral infarction were recorded within 7 days of disease onset. Among them, transcranial Doppler was successful in 33 patients who had active cancer, and these data were analyzed in this study. The primary outcomes were stroke recurrence and mortality at 3 months. The study population had the following characteristics [median (interquartile range)]: age, 70 years (63-78); body mass index, 21.6 (20-24), National Institutes of Health Stroke Scale 3 (1-6), and modified Rankin Scale score at discharge 1 (1-4). The most common cancer types were lung (24%), pancreatic (24%), and intestinal (18%). MES was present in 16 of 33 patients (48.5%). The presence and number of MES were significantly associated with the levels of D-dimer (P <0.001) and C-reactive protein (P=0.012). Moreover, the presence of MES was associated with multiple ischemic lesions and the 3-territory sign on magnetic resonance imaging. Of the 33 patients, 9 died at 3 months, and 1 had stroke recurrence. On Cox multivariate analysis, using the MES-negative group as a reference, the presence of MES was significantly associated with all-cause death (adjusted hazard ratio, 12.19 [95% CI, 1.45-216.85]; P=0.020).
CONCLUSIONS: In patients with acute ischemic stroke and active cancer, the presence of MES was associated with D-dimer and C-reactive protein levels and multiple and 3-territory ischemic lesions, and was predictive of short-term survival.

Cardiopulmonary bypass and extracorporeal membrane oxygenation have many similarities, but there are significant differences in managing hemostasis. Cardiopulmonary bypass includes shorter mechanical circulatory support times, blood stasis, higher flows, and an increased blood-air interface. These factors cause differences in the risk of coagulopathy, management of anticoagulation, monitoring of the hemostatic system, and management of coagulopathy. This article aims to identify these key differences in the hemostatic system between patients on cardiopulmonary bypass and those on extracorporeal membrane oxygenation.

Background: Thromboelastometry like ROTEM® is a point-of-care method used to assess the coagulation status of patients in a rapid manner being particularly useful in critical care settings, such as trauma, where quick and accurate assessment of coagulation can guide timely and appropriate treatment. Currently, this method is not yet comprehensively available with sparse data on its effectiveness in resuscitation rooms. The aim of this study was to assess the effect of early thromboelastometry on the probability of mass transfusions and mortality of severely injured patients. Methods: The TraumaRegister DGU® was retrospectively analyzed for severely injured patients (2011 until 2020) with information available regarding blood transfusions and Trauma-Associated Severe Hemorrhage (TASH) score components. Patients with an estimated risk of mass transfusion >2% were included in a matched-pair analysis. Cases with and without use of ROTEM® diagnostic were matched based on risk categories for mass transfusion. A total of 1722 patients with ROTEM® diagnostics could be matched with a non-ROTEM® patient with an identical risk category. Adult patients (≥16) admitted to a trauma center in Germany, Austria, or Switzerland with Maximum Abbreviated Injury Scale severity ≥3 were included. Results: A total of 83,798 trauma victims were identified after applying the inclusion and exclusion criteria. For 7740 of these patients, the use of ROTEM® was documented. The mean Injury Severity Score (ISS) in patients with ROTEM® was 24.3 compared to 19.7 in the non-ROTEM® group. The number of mass transfusions showed no significant difference (14.9% ROTEM® group vs. 13.4% non-ROTEM® group, p = 0.45). Coagulation management agents were given significantly more often in the ROTEM® subgroup. Mortality in the ROTEM® group was 4.1% less than expected (estimated mortality based on RISC II 34.6% vs. observed mortality 30.5% (n = 525)). In the non-ROTEM® group, observed mortality was 1.6% less than expected. Therefore, by using ROTEM® analysis, the expected mortality could be reduced by 2.5% (number needed to treat (NNT) 40; SMR of ROTEM® group: 1:0.88; SMR of non-ROTEM® group: 1:0.96; p = 0.081). Conclusions: Hemorrhage is still one of the leading causes of death of severely injured patients in the first hours after trauma. Early thromboelastometry can lead to a more targeted coagulation management, but is not yet widely available. This study demonstrated that ROTEM® was used for the more severely injured patients and that its use was associated with a less than expected mortality as well as a higher utilization of hemostatic products.

UNASSIGNED: Anticoagulant rodenticide toxicity is commonly encountered in veterinary practice that can result in internal bleeding. We have observed dogs with retroperitoneal hemorrhage secondary to anticoagulant rodenticide toxicity. However, abdominal radiographic changes in dogs with rodenticide toxicity have not been studied and retroperitoneal hemorrhage secondary to rodenticide toxicity has rarely been reported.
UNASSIGNED: The objective is to describe abdominal radiographic features of anticoagulant rodenticide toxicity and concurrent thoracic radiographic changes in dogs and cats.
UNASSIGNED: Dogs and cats diagnosed with rodenticide toxicity and with available abdominal radiographs were included in this retrospective analysis. Board-certified radiologists reviewed the abdominal and thoracic radiographs. Evaluation of abdominal radiographic changes included assessment of peritoneal or retroperitoneal effusion, subcutaneous hemorrhage, and internal hemorrhage of abdominal organs.
UNASSIGNED: Fourteen dogs and two cats with confirmed rodenticide toxicity were included in the study. In dogs, retroperitoneal effusion (28.6%) was the most commonly observed abdominal radiographic change, followed by peritoneal effusion (14.3%). Thoracic radiographic changes in dogs included pleural effusion (63.6%) and mediastinal widening (63.6%) as the most common findings, followed by pulmonary hemorrhage (36.4%) and tracheal narrowing (36.4%). Subcutaneous hemorrhage or edema (9.1%) was also noted. No abdominal radiographic changes consistent with hemorrhage secondary to rodenticide toxicity were noted in the two cats.
UNASSIGNED: Based on our findings, it is suggested that rodenticide toxicity may result in retroperitoneal effusion even in the absence of thoracic disease. Therefore, abdominal radiographs may be valuable when suspecting hemorrhage due to coagulopathy. However, abdominal radiographic changes associated with rodenticide toxicity are considered rare in cats.