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BACKGROUND & AIMS: Despite several recent international guidelines, no consensus exists on the bleeding risk nor haemostatic parameter thresholds that define the safety of invasive procedures in patients with cirrhosis. The aim of this study was to establish a position paper on the bleeding risk associated with invasive procedures in patients with cirrhosis among the experts involved in various guidelines. METHODS: All experts involved in recent guidelines on the management of invasive procedures in patients with cirrhosis were invited to classify 80 procedures as high risk or low risk with respect to bleeding. Procedures were considered high risk when the estimated risk of major bleeding was 1.5% or more, or when even minor bleeding might lead to significant morbidity or death. The experts were also asked to choose safety thresholds for laboratory test values at which elective invasive procedures could be safely performed. The predetermined threshold considered as consensus was ≥75% agreement. RESULTS: Fifty-two experts participated in the study. Out of 80 procedures, a consensus opinion was reached for 52 procedures (65%): 17 procedures were classified as high risk, primarily interventional endoscopic procedures, percutaneous organ biopsies, or procedures involving the central nervous system; and 35 as low risk, primarily diagnostic procedures. The lowest platelet counts at which performance of a low-risk procedure or a high-risk procedure/surgery were deemed acceptable were 30 × 109/L and 50 × 109/L, respectively. Experts did not believe that international normalised ratio should be considered before performing low-risk procedures; 71% also indicated that it should not be considered before performing high-risk procedures. CONCLUSIONS: This experience-based classification may be helpful to refine future study designs and to guide clinical decision making regarding invasive procedures in patients with cirrhosis. IMPACT AND IMPLICATIONS: Several risk classifications and management guidelines for invasive procedures in patients with cirrhosis have been proposed, but with conflicting recommendations. By providing a position paper, based on the opinion of a broad panel of experts, on the bleeding risk associated with 52 invasive procedures in patients with cirrhosis, this survey will help to provide a framework for future study design. The consensus on platelet count, international normalised ratio, fibrinogen and activated partial thromboplastin time identified in this survey will inform physicians regarding the laboratory test values considered acceptable by the experts prior to the performance of an elective invasive procedure in patients with cirrhosis.

Purpose: Our aim was to develop new evidence-based and consensus-based recommendations for bleeding control in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. Methods: MEDLINE and Embase were systematically searched until June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared interventions for bleeding control in the prehospital setting using manual pressure, haemostatic agents, tourniquets, pelvic stabilisation, or traction splints in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality and bleeding control. Transfusion requirements and haemodynamic stability were surrogate outcomes. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. Results: Fifteen studies were identified. Interventions covered were pelvic binders (n = 4 studies), pressure dressings (n = 1), tourniquets (n = 6), traction splints (n = 1), haemostatic agents (n = 3), and nasal balloon catheters (n = 1). Fourteen new recommendations were developed. All achieved strong consensus. Conclusion: Bleeding control is the basic objective of treatment. This can be easily justified based on empirical evidence. There is, however, a lack of reliable and high-quality studies that assess and compare methods for bleeding control in patients with multiple and/or severe injuries. The guideline provides reasonable and practical recommendations (although mostly with a low grade of recommendation) and also reveals several open research questions that can hopefully be answered when the guideline is revised again. [ABSTRACT FROM AUTHOR]

Major bleeding is a life-threatening condition with high morbidity and mortality. Trauma, gastrointestinal bleeding, haemoptysis, intracranial haemorrhage or other causes of bleeding represent major concerns in the Emergency Department (ED), especially when complicated by haemodynamic instability. Severity and source of bleeding, comorbidities, and prior use of anticoagulants are pivotal factors affecting both the clinical status and the patients' differential response to haemorrhage. Thus, risk stratification is fundamental in the initial assessment of patients with bleeding. Aggressive resuscitation is the principal step for achieving haemodynamic stabilization of the patient, which will further allow appropriate interventions to be made for the definite control of bleeding. Overall management of major bleeding in the ED should follow a holistic individualized approach which includes haemodynamic stabilization, repletion of volume and blood loss, and reversal of coagulopathy and identification of the source of bleeding. The aim of the present practical guide is to provide an update on recent epidemiological data about the most common etiologies of bleeding and summarize the latest evidence regarding the bundles of care for the management of patients with major bleeding of traumatic or non-traumatic etiology in the ED. [ABSTRACT FROM AUTHOR]

Background: Haemorrhage remains the leading cause of preventable mortality following trauma, often aggravated by the acidosis, hypothermia and coagulopathy-the lethal triad of trauma. However, the impact of trauma-induced hypocalcemia on the haemorrhage remains unclear. It is intuitive to consider perturbations of ionised calcium early during trauma resuscitation in acutely injured patients given its pathophysiological significance for an improved outcome. Thus, we conducted a prospective study to analyse the role of ionized calcium ion levels during trauma resuscitation and its association with the need for blood transfusion(s) requirement and mortality. Methods: A prospective study was conducted on acutely injured patients with haemorrhage getting admitted to a Level 1 trauma center in India between September 2020 and June 2022. Ionised calcium was measured on arrival, after 6 h, and on day two of the injury to assess the prevalence. The amount of blood transfusion received by the patient was noted along with other demographic and in-hospital details. The association of hypocalcemia with blood transfusion and mortality was also evaluated. Results: Of the 1961 patients screened for eligibility, 200 patients were recruited and analysed. 72.5% of patients were hypocalcaemic on emergency department (ED) admission. Ionized hypocalcaemia was significantly associated with the need for blood transfusion(s) (p-value < 0.01). A significant association was also noted between ionized hypocalcaemia and mortality (p-value: 0.0085). On the univariate and multivariable analysis, ionized hypocalcaemia was a significant predictor of mortality. Conclusions: Ionized hypocalcaemia is widely prevalent among acutely injured. Trauma-induced hypocalcaemia at admission is associated with increased need for blood transfusions and increased mortality. [ABSTRACT FROM AUTHOR]

Purpose: Our aim was to update evidence-based and consensus-based recommendations for the inhospital endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. Methods: MEDLINE and Embase were systematically searched to June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared endovascular interventions for bleeding control such as embolisation, stent or stent-graft placement, or balloon occlusion against control interventions in patients with polytrauma and/or severe injuries in the hospital setting. The diagnosis of pelvic haemorrhage was added post-hoc as an additional clinical question. We considered patient-relevant clinical outcomes such as mortality, bleeding control, haemodynamic stability, transfusion requirements, complications, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. Results: Forty-three new studies were identified. Interventions covered were resuscitative endovascular balloon occlusion of the aorta (REBOA) (n = 20), thoracic endovascular aortic repair (TEVAR) (n = 9 studies), pelvic trauma (n = 6), endovascular aortic repair (EVAR) of abdominal aortic injuries (n = 3), maxillofacial and carotid artery injuries (n = 2), embolisation for abdominal organ injuries (n = 2), and diagnosis of pelvic haemorrhage (n = 1). Five recommendations were modified, and one additional recommendation was developed. All achieved strong consensus. Conclusion: The following key recommendations are made. Whole-body contrast-enhanced computed tomography should be used to detect bleeding and vascular injuries. Blunt thoracic and abdominal aortic injuries should be managed using TEVAR/EVAR. If possible, endovascular treatment should be delayed beyond 24 h after injury. Bleeding from parenchymatous abdominal organs should be controlled using transarterial catheter embolisation. Splenic injuries that require no immediate intervention can be managed with observation. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the long-term impact of superselective renal artery embolization (SRAE) on renal function in cases of severe post-percutaneous nephrolithotomy (PCNL) haemorrhage, and to identify the factors associated with the long-term outcome of renal function. Methods: Patients treated with SRAE for post-PCNL hemorrhage between September 2016 and September 2021 were included. Patients' demographic and clinical data were recorded. Multiple linear regression and logistic regression were used to identify the factors related to the percentages of estimated glomerular filtration rate (eGFR) change and the risk factors of worsening renal function (WRF), respectively. Result: A total of 80 patients were included. There was no significant change in eGFR before and after SRAE immediately within 1.45 ± 1.66 days (66.37 ± 28.45 vs. 63.86 ± 29.26 mL/min/1.73 m², p = 0.202). Patient's eGFR increased significantly from 66.37 ± 28.45 to 70.94 ± 30.48 mL/min/1.73 m² (p = 0.044) with a mean follow-up of 30.4 months after SRAE, especially in patients with compromised renal function before SRAE (β = 0.297, p = 0.039). However, BMI > 24 kg/m2 was significantly associated with the decrease of eGFR (β = -0.343, p = 0.016). 12 (15.0%) patients developed WRF, logistic regression analysis showed that BMI > 24.0 kg/m2 (OR = 4.144, p = 0.045) and atrophic renal cortex (OR = 4.180, p = 0.040) were independent risk factors of WRF. Conclusion: SRAE is an effective treatment for post-PCNL severe haemorrhage, and is not deleterious to long term renal function. Notably, BMI > 24.0 kg/m2 and atrophic renal cortex were significant predictors of long-term WRF in SRAE patients. [ABSTRACT FROM AUTHOR]

Introduction: Obstetric emergencies are sudden, unexpected life-threatening medical conditions that occur during pregnancy, labour, delivery or puerperium and are challenging moments because of frightening and traumatic experiences. Obstetric emergencies, which threaten the well-being of the woman and the unborn child, account for the majority of causes of maternal death. Objective: The study sought to explore Midwives' experiences in obstetric emergencies in the Kwahu West Municipality of Ghana Methods: A phenomenological study design with a qualitative approach was employed to explore the midwives' experiences in the management of obstetrics. Participants were selected using purposive sampling. The sample size of 13 was reached upon data saturation. A semi-structured interview guide was used to interview midwives who have experienced and managed obstetric emergencies. The obtained data was transcribed and analysed using a thematic analysis approach. Results: Overall, five themes and 13 subthemes emerged. The emerging themes encompass factors influencing midwives' experiences in managing obstetric emergencies, Reactions of midwives during obstetric emergencies, Challenges of midwives in managing obstetric emergencies, Healthcare challenging factors, and Client-centred limitations. Conclusion: It is evident that midwives play a critical role in addressing obstetric emergencies, often being the frontline healthcare providers in such situations. Their experiences shed light on both the challenges they face and the strategies they employ to provide effective care under demanding circumstances. The findings highlight the need for further investment in training and resources for midwives, particularly in rural areas where access to healthcare services may be limited. [ABSTRACT FROM AUTHOR]

Background and Aims The bleeding risk of using non-steroidal anti-inflammatory drugs (NSAIDs) in patients treated with oral anticoagulants for venous thromboembolism (VTE) remains unclear. Methods A nationwide cohort study of 51 794 VTE patients initiating oral anticoagulants between 1 January 2012 and 31 December 2022 was conducted. Time-dependent multivariate cause-specific Cox regression was used to compute adjusted hazard ratios between NSAID use and hospital-diagnosed bleeding episodes. Results Event rates for any bleeding per 100 person-years were 3.5 [95% confidence interval (CI), 3.4–3.7] during periods without NSAID use and 6.3 (95% CI, 5.1–7.9) during periods with NSAID use (number needed to harm = 36 patients treated for 1 year). Compared with non-use, the adjusted hazard ratios for any bleeding associated with NSAID use were 2.09 (95% CI, 1.67–2.62) overall, 1.79 (95% CI, 1.36–2.36) for ibuprofen, 3.30 (95% CI, 1.82–5.97) for diclofenac, and 4.10 (95% CI, 2.13–7.91) for naproxen. Compared with non-use, the adjusted hazard ratios associated with NSAID use were 2.24 (95% CI, 1.61–3.11) for gastrointestinal bleeding, 3.22 (95% CI, 1.69–6.14) for intracranial bleeding, 1.36 (95% CI,.67–2.77) for thoracic and respiratory tract bleeding, 1.57 (95% CI,.98–2.51) for urinary tract bleeding, and 2.99 (95% CI, 1.45–6.18) for anaemia caused by bleeding. Results were consistent for anticoagulant and VTE subtypes. Conclusions Patients treated with oral anticoagulants for VTE had a more than two-fold increased bleeding rate when using NSAIDs. This increased bleeding rate was not restricted to the gastrointestinal tract. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction Aim Methods Results Conclusions Maintaining the balance between procoagulant and anticoagulant factors is essential for effective haemostasis. Emerging evidence suggests a modulation of bleeding tendency by factors in the anticoagulant and fibrinolytic systems.This study investigates the clinical and laboratory characteristics of a family with combined von Willebrand disease (VWD) and antithrombin (AT) deficiency.The study focused on a 38‐year‐old female index patient (IP) with severe type 3 VWD and a history of bleeding disorders. Coagulation assays included VWF antigen, platelet‐dependent VWF activity, factor VIII activity, thrombin generation assay (TGA) and AT activity. Molecular genetic analyses were conducted by a targeted DNA custom next generation sequencing (NGS) panel.The IP and one of her sisters suffered type 3 VWD. While the IP presents with a classical severe bleeding phenotype, the sister (II‐2) exhibited less severe bleeding symptoms. Extended family members showed type 1 VWD with mild presentations. NGS revealed a homozygous deletion of exon 6 in the VWF gene in the IP and her sister (II‐2). All other family members carry this genetic variant in a heterozygous state. Additionally, II‐2 has a heterozygous variant in the SERPINC1 gene (c.133C>T, p.Arg45Trp). Both IP and II‐2 carry a homozygous prothrombin G20210A variant. TGA results indicated reduced thrombin generation in severe VWD patients, with a pronounced thrombin burst in those with the AT and prothrombin G20210A variant.AT deficiency appears to modulate bleeding symptoms in severe VWD. This study emphasizes the importance of comprehensive genetic and phenotypic evaluation in managing complex coagulation disorders. [ABSTRACT FROM AUTHOR]

[Display omitted] • Nanoparticle-based drug delivery systems enhance targeted therapy for ischemic stroke by improving drug bioavailability. • Advances in thrombolytic therapy using rtPA-loaded nanoparticles improve clot dissolution and reduce hemorrhagic risks in ischemic stroke. • Metal and metal oxide nanoparticles, such as cerium oxide and platinum, provide neuroprotection by scavenging reactive oxygen species. • pH-responsive nanosystems enable controlled drug release in the acidic environment of ischemic brain tissue. • Nanoparticle-enhanced imaging techniques, including MRI and CT offer better diagnostic precision. A stroke, also known as cerebrovascular accident, is a medical emergency that occurs when the blood supply to the brain is interrupted. This disruption can happen in two main ways: through a hemorrhagic stroke, where a blood vessel in the brain bursts, or through an ischemic stroke, where a blood clot blocks an artery. Both types of stroke cause damage to brain cells, leading to a range of health complications. Globally, stroke ranks as the second leading cause of death and disability. This review provides an overview of stroke, focusing on its early detection, current treatment options, and emerging therapies. We discuss the complex mechanisms that contribute to stroke development, including the roles of cells, biomolecules, and blood vessels. Additionally, the review explores recent advances in the use of nanoparticles to enhance the efficacy of the pharmacotherapy of stroke, particularly ischemic stroke. Ongoing clinical trials in stroke management are also highlighted. Timely diagnosis and prompt intervention are critical for improving patient outcomes. We aim to increase awareness and understanding of stroke among researchers and healthcare professionals, ultimately improving patient care. [ABSTRACT FROM AUTHOR]

Objectives: We seek to describe the current practice pattern use of prothrombin complex concentrate (PCC) and fibrinogen concentrate (FC) in trauma patients. Background: Trauma‐induced coagulopathy (TIC) and endotheliopathy of trauma (EOT) contribute significantly to mortality from traumatic haemorrhage. FC, and 4‐factor PCC are potential treatments for EOT and TIC, respectively. Materials and Methods: We obtained data from the Trauma Quality Improvement Program (TQIP) registry and identified patients who received either PCC or FC using procedural codes. We used descriptive statistics to characterise practice patterns of these products. Results: There were 6 714 002 total encounters within the TQIP from 2017 to 2022, of which 10 589 received PCC and 3009 received FC. Of the recipients, there were 35 that received both products. There were 44 that received both. The median age of PCC recipients was 77 (69–84) with 19 patients <15 years of age with the youngest being 2 years of age. There was a general upward trend in the number of facilities with documented use of PCC: 155/744, 168/766, 189/764, 206/780, 234/795, and 235/816, respectively. The median age of FC recipients was 57 (32–75) with 48 patients <15 years of age with the youngest being 1 year of age. There was a minor downward trend in the number of facilities that had documented use of FC: 55, 44, 39, 32, 38 and 40. Conclusions: The administration of PCC and FC remains uncommon, although there appears to be an upward trend of PCC use. Most PCC use appeared to be for anticoagulation reversal in the setting of head trauma. Data guiding the use of these products are necessary as these products become more recognised as adjuncts to traumatic haemorrhage control. [ABSTRACT FROM AUTHOR]

Purpose: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a controversial haemorrhage control intervention often touted as the bridge to definitive haemorrhage control. This review summarizes the evolution of REBOA from its inception to the latest applications with an emphasis on clinical outcomes. Methods: This is a narrative review based on a selective review of the literature. Results: REBOA remains a rarely utilized intervention in trauma patients. Complications have remained consistent over time despite purported improvements in catheter technology. Ischemia-reperfusion injuries, end-organ dysfunction, limb ischemia, and amputations have all been reported. Evidence-based guidelines are lacking, and appropriate indications and the ideal patient population for this intervention are yet to be defined. Conclusion: Despite the hype, purported technological advancements, and the mirage of high-quality studies over the last decade, REBOA has failed to keep up to its expectations. The quest to find the solution for uncontrolled NCTH remains unsolved. [ABSTRACT FROM AUTHOR]

A haematoma is a collection of blood and blood components under the skin’s subcutaneous layer. An acute wound to the blood vessel wall is a frequent cause of haematomas. Focal swelling, taut skin and soreness are associated with blood expanding and pooling beneath the skin. It can be difficult to diagnose if there is an underlying discolouration. The authors report a case of an eight-year-old female patient with the chief complaint of swelling on the face for two days due to a fall from a height of 10 feet. She reported a history of blood from the mouth and avulsed upper lateral incisors immediately after the fall. Bilateral diffuse swelling was observed in the submandibular region, measuring 7×7 cm extraorally, extending from the inferior border across the midline and from the chin to the hyoid bone, accompanied by facial asymmetry. The final diagnosis was post-traumatic haematoma and a conservative approach was the treatment of choice. The present case highlights the importance of correct diagnosis and early intervention.

Abstract Background The IBS® Tissue Removal Device, as a new technology, currently lacks a systematic evaluation of its effectiveness in treating endometrial polyps. Furthermore, the exact cause of polyps recurrence is not yet clear. The purpose of this article is to compare the efficacy of the IBS® Tissue Removal Device with hysteroscopic cold knife resection for the treatment of endometrial polyps and analyze the recurrence factors of endometrial polyps. Methods 202 patients with endometrial polyps who were admitted to Changzhou Maternal and Child Health Care Hospital from January 2019 to December 2022 were included in the retrospective studies. Based on the surgical technique, these patients were categorized into two groups: the IBS group (n = 100) and the cold knife group (n = 102). Following surgery, both groups underwent a year of follow-up. Data from the perioperative period (operation time, intraoperative blood loss, intraoperative rehydration, intraoperative complications, length of hospital stay), follow-up data (postoperative endometrial thickness, postoperative vaginal bleeding time, complication rate, menstrual recovery time, pregnancy rate, and recurrence rate) and general clinical data (age, BMI(Body mass index, BMI), number of pregnancies or miscarriages, number of hysteroscopic operations, preoperative white blood cells, fasting blood glucose, polyp diameter) were compared between the two groups. Results The recurrence rate of the IBS group was 6% (6/100), which was lower than that of the cold knife group (14.7% (15/102), and the difference was statistically significant (P 0.05). There was also no significant difference between IBS group and cold knife group in intraoperative rehydration, intraoperative complications and postoperative hospital stay, intermenstrual bleeding, recovery of menstruation and endometrial thickness and postoperative pregnancy between the IBS group and the cold knife group (P > 0.05). Conclusion The IBS® Tissue Removal Device can reduce the recurrence rate of endometrial polyps after surgery, improve the perioperative indexes, and reduce the postoperative vaginal bleeding time, which is better than that of hysteroscopic cold knife resection.

Abstract Background Bleeding events are common complications in critically ill patients with haematological malignancies. The objective of this study was to assess the incidence and identify determinants of ICU-acquired severe bleeding events in critically ill patients with haematological malignancies. We conducted a single-center retrospective study including all adult patients with a history of haematological malignancy requiring unplanned ICU admission over a 12-year period (2007–2018). The primary endpoint was the occurrence of ICU-acquired (i.e. after the first 24 h in the ICU) severe bleeding events, as defined as grades 3 or 4 of the World Health Organization classification. Results A total of 1012 patients were analysed, mainly with a diagnosis of lymphoma (n = 434, 42.9%) and leukaemia or myelodysplastic syndrome (n = 266, 26.3%). Most patients were recently diagnosed (n = 340, 33.6%) and under active cancer treatment within the last 3 months (n = 604, 59.7%). The main cause for admission was infection (n = 479, 47.3%), but a significant proportion of patients were admitted for a primary haemorrhage (n = 99, 10%). ICU-acquired severe bleeding events occurred in 109 (10.8%) patients after 3.0 days [1.0–7.0] in the ICU. The main source of bleeding was the gastrointestinal tract (n = 44, 40.3%). Patients experiencing an ICU-acquired severe bleeding event displayed prolonged in-ICU length of stay (9.0 days [1.0–6.0] vs. 3.0 [3.5–15.0] in non-bleeding patients, p

Tenggao Chen,1,&ast; Wanlin Lei,2,&ast; Maofeng Wang2 1Department of Colorectal Surgery, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China; 2Department of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Maofeng Wang, Department of Biomedical Sciences Laboratory, No. 60 Wuning West Road, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, 322100, People’s Republic of China, Email wzmcwmf@wmu.edu.cnObjective: This study aimed to develop a predictive model for assessing internal bleeding risk in elderly aspirin users using machine learning.Methods: A total of 26,030 elderly aspirin users (aged over 65) were retrospective included in the study. Data on patient demographics, clinical features, underlying diseases, medical history, and laboratory examinations were collected from Affiliated Dongyang Hospital of Wenzhou Medical University. Patients were randomly divided into two groups, with a 7:3 ratio, for model development and internal validation, respectively. Least absolute shrinkage and selection operator (LASSO) regression, extreme gradient boosting (XGBoost), and multivariate logistic regression were employed to develop prediction models. Model performance was evaluated using area under the curve (AUC), calibration curves, decision curve analysis (DCA), clinical impact curve (CIC), and net reduction curve (NRC).Results: The XGBoost model exhibited the highest AUC among all models. It consisted of six clinical variables: HGB, PLT, previous bleeding, gastric ulcer, cerebral infarction, and tumor. A visual nomogram was developed based on these six variables. In the training dataset, the model achieved an AUC of 0.842 (95% CI: 0.829– 0.855), while in the test dataset, it achieved an AUC of 0.820 (95% CI: 0.800– 0.840), demonstrating good discriminatory performance. The calibration curve analysis revealed that the nomogram model closely approximated the ideal curve. Additionally, the DCA curve, CIC, and NRC demonstrated favorable clinical net benefit for the nomogram model.Conclusion: This study successfully developed a predictive model to estimate the risk of bleeding in elderly aspirin users. This model can serve as a potential useful tool for clinicians to estimate the risk of bleeding in elderly aspirin users and make informed decisions regarding their treatment and management.Keywords: aspirin, bleeding, haemorrhage, predictive model, extreme gradient boosting, nomogram

Abstract Background Haemorrhage is a leading cause of preventable mortality in high-income countries and emergency management presents unique challenges in the prehospital setting. The study aimed to determine incidence and characteristics of fatalities from prehospital haemorrhage in Sweden. Methods A nationwide retrospective cohort study 2012–2021 was conducted using data from the Swedish National Board of Health and Welfare. Prehospital fatality from haemorrhage was defined as a cause of death related to haemorrhage (Appendix 1) without a hospital admission on the same day. Primary outcome was age-standardized mortality rate per 100,000 inhabitants. Results A total of 9801 prehospital fatalities from haemorrhage were identified. Annual age-standardized mortality rate decreased from 10.97 to 8.18 per 100,000 population (coefficient = − 0.28, r2 = 0.85, p =

Background Aims Methods Results Conclusion Abdominal paracentesis is a frequently performed procedure in hospitalised patients with ascites. Concurrently, most hospitalised adult patients receive pharmacologic anticoagulation, either for therapeutic purposes or prophylactically to prevent venous thromboembolism. Despite this, minimal evidence exists to guide management of anticoagulant therapy pre‐ and post‐paracentesis.The authors aimed to investigate the safety of abdominal paracentesis in hospitalised patients receiving therapeutic or prophylactic anticoagulation, including in patients for whom these medications were withheld periprocedurally.TriNetX, an electronic health record data set, was queried to identify patients between the ages of 18 and 80 years who received an abdominal paracentesis while hospitalised at the authors' institution between September 2017 and June 2022. Patients receiving prophylactic anticoagulation (137), therapeutic anticoagulation (74) and no anticoagulation because of coagulopathy or thrombocytopenia (15) were compared. Rates of withholding anticoagulation, performing service, pre‐ and post‐paracentesis haemoglobin, bleeding complications, thrombotic complications and need for red blood cell transfusion were analysed.Procedure‐related bleeding complications occurred in two (1.4%) patients in the prophylactic group and 0 (0%) patients in the therapeutic group (P = 0.54). No thrombotic complications occurred. Rates of red blood cell transfusions post‐paracentesis were similar between groups. Analysis of secondary end‐points identified significant differences in rates of withholding anticoagulation and mean change in haemoglobin between performing services.Performance of abdominal paracentesis in patients receiving therapeutic or prophylactic anticoagulation appears to be safe regardless of whether anticoagulation was interrupted periprocedurally, with low rates of bleeding complications, thrombotic complications or need for red blood cell transfusions post‐paracentesis. [ABSTRACT FROM AUTHOR]

Background: Radical cystectomy is typically recommended for managing bladder cancer, with ileal conduit diversion being a prevalent form of urinary diversion. Stomal variceal haemorrhage is a rare complication of ileal bladder diversion and poses diagnostic and therapeutic challenges that can escalate to life-threatening circumstances. Hepatic cirrhosis and cancer liver metastasis-induced portal hypertension are considered the main causes of stomal varices. However, the real-world expertise in the pathophysiology of, diagnostic approach to, and overall management strategy for stomal variceal haemorrhage in ileal conduit diversion is limited. Case presentation: Herein, we present a rare case of a 77-year-old man with bladder cancer who developed stomal variceal haemorrhage after undergoing radical cystectomy and ileal conduit urinary diversion. Imaging revealed that the peristomal varices communicated with the subcutaneous veins of the abdominal wall without apparent portal hypertension. Transhepatic coil embolization of bleeding stomal varices was successfully performed via a transhepatic antegrade approach. No complications or stomal variceal haemorrhage occurred during a 6-month follow-up period. Conclusion: Transhepatic coil embolization may be considered an initial therapeutic option for patients who experience stomal variceal haemorrhage. Comprehensive management of underlying liver disease and portal hypertension is needed at follow-up visits. We describe successful experience with the precise treatment of this rare and atypical disease, conduct a thorough review of the pertinent literature, and deliberate on optimized diagnostic and therapeutic procedures. [ABSTRACT FROM AUTHOR]

Introduction: One of the many challenges in diagnosing bleeding disorders is distinguishing between normal and abnormal bleeding symptoms. Letstalkperiod.ca is an educational website that includes an online self‐administered bleeding assessment tool (Self‐BAT) which is a validated screening tool that enables patients to independently determine their bleeding scores (BS). Aim: The aim of this study was to evaluate patient outcomes for those referred with an abnormal Self‐BAT BS compared to those referred without the prior use of the Self‐BAT. Methods: This was a retrospective, observational study. After obtaining REB approval, chart review was performed for patients evaluated for a suspected bleeding disorder in a tertiary care centre between 2016 and 2023. Results: 351 patients (310 female) were identified for inclusion with a mean age of 41 years. Of these patients, 30 were referred for a positive/abnormal Self‐BAT BS and the remainder were referred for other reasons. Patients referred for a positive Self‐BAT BS required interventions for their bleeding symptoms more often (73.3% vs. 36.7%, p ≤.001). Though they were not diagnosed with an inherited bleeding disorder more often (6.7% vs. 10.7%, p =.754), patients referred for a positive self‐BAT were more likely to be diagnosed with a bleeding disorder when the definition was expanded to include bleeding disorder of unknown cause (56.7% vs. 31.9%, p =.008). Conclusion: Results of this study suggest that the Self‐BAT at letstalkperiod.ca can be a useful tool for patients and physicians to identify those needing referral to tertiary haematology clinics for evaluation and management of bleeding symptoms. [ABSTRACT FROM AUTHOR]

Background: Bleeding events are common complications in critically ill patients with haematological malignancies. The objective of this study was to assess the incidence and identify determinants of ICU-acquired severe bleeding events in critically ill patients with haematological malignancies. We conducted a single-center retrospective study including all adult patients with a history of haematological malignancy requiring unplanned ICU admission over a 12-year period (2007–2018). The primary endpoint was the occurrence of ICU-acquired (i.e. after the first 24 h in the ICU) severe bleeding events, as defined as grades 3 or 4 of the World Health Organization classification. Results: A total of 1012 patients were analysed, mainly with a diagnosis of lymphoma (n = 434, 42.9%) and leukaemia or myelodysplastic syndrome (n = 266, 26.3%). Most patients were recently diagnosed (n = 340, 33.6%) and under active cancer treatment within the last 3 months (n = 604, 59.7%). The main cause for admission was infection (n = 479, 47.3%), but a significant proportion of patients were admitted for a primary haemorrhage (n = 99, 10%). ICU-acquired severe bleeding events occurred in 109 (10.8%) patients after 3.0 days [1.0–7.0] in the ICU. The main source of bleeding was the gastrointestinal tract (n = 44, 40.3%). Patients experiencing an ICU-acquired severe bleeding event displayed prolonged in-ICU length of stay (9.0 days [1.0–6.0] vs. 3.0 [3.5–15.0] in non-bleeding patients, p < 0.001) and worsened outcomes with increased in-ICU and in-hospital mortality rates (55% vs. 18.3% and 65.7% vs. 33.1%, respectively, p < 0.001). In multivariate analysis, independent predictors of ICU-acquired severe bleeding events were chronic kidney disease (cause-specific hazard 2.00 [1.19–3.31], p = 0.008), a primary bleeding event present at the time of ICU admission (CSH 4.17 [2.71–6.43], p < 0.001), non-platelet SOFA score (CSH per point increase 1.06 [1.01–1.11], p = 0.02) and prolonged prothrombin time (CSH per 5-percent increase 0.90 [0.85–0.96], p = 0.001) on the day prior to the event of interest. Conclusions: Major bleeding events are common complications in critically ill patients with haematological malignancies and are associated with a worsened prognosis. We identified relevant risk factors of bleeding which may prompt closer monitoring or preventive measures. [ABSTRACT FROM AUTHOR]

Purpose: Infants undergoing CSF shunting procedures face a rare complication which we propose to rename "Widespread Haemorrhages in Infants Post-Shunting" (WHIPS) to better capture this unique phenomenon specific to infants undergoing CSF diversion. Our objective is to analyse the risk factors for WHIPS development and provide a detailed neuroradiological description of these haemorrhages. Materials and methods: A radiology information system (RIS) was searched using the search terms "shunt" and/or "catheter" and/or "drain" and/or "ventriculoperitoneal" and/or "VP" between September 2008 to January 2021 for patients < 12 months of age. Clinical data was compiled for each patient meeting the inclusion criteria. Included cases were reviewed by three radiologists for the presence of WHIPS with calculation of the bifrontal ratio and documenting haemorrhage number, morphology, location and lobar distribution. Results: 51 patients met inclusion criteria, 8 WHIPS patients and 43 controls. There was a statistically significant correlation between a larger post-op head circumference and WHIPS (p = 0.04). WHIPS was associated with post-haemorrhagic hydrocephalus and post-infectious hydrocephalus (p = 0.009). WHIPS were identified in the cortico-subcortical regions, periventricular white matter, and deep white matter. Haemorrhages were either punctate, ovoid or confluent. Haemorrhages ranged from single to innumerable. Conclusions: WHIPS represent a rare and under-recognised complication of CSF shunting unique to the infantile population. We postulate deep and superficial medullary venous haemorrhage as an underlying mechanism related to disordered intracranial hydrodynamics which are exacerbated in the infantile population due to underdeveloped arachnoid granulations and a compliant skull. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy and safety of Nd:YAG laser hyaloidotomy in the treatment of premacular subhyaloid haemorrhage (SHH) Material and Methods: The study analyzed the medical records of 37 patients who underwent Nd:YAG hyaloidotomy for premacular SHH between 2014 and 2022. Patients were evaluated based on age, gender, etiology, symptom duration, visual acuity, laser energy, number of shots, complications, and need for additional procedures. The main success criteria were drainage and absorption of SHH, increased visual acuity, need for additional procedures, and post-procedural complications. Results: A study of 37 patients with 39 eyes, with a mean age of 52.03 ± 20.51 years and symptom duration of 10.51 ± 7.43 days, found common etiologies such as proliferative diabetic retinopathy, retinal vein occlusion, retinopathy of valsalva, leukemia, retinal macroaneurysm, hypertensive crisis, choroidal neovascular membrane, and Terson syndrome. The mean laser energy performed was 7.38 ± 2.08 mJ, and the mean number of shots was 4.28 ± 1.87. Nd:YAG laser hyaloidotomy was successful in 87.17% of cases but failed in 2 patients with proliferative diabetic retinopathy, one patient with Terson syndrome, and one patient with leukemia. Visual acuity improved significantly in the 6th month. Conclusion: Nd:YAG laser hyaloidotomy is a cheap, effective, safe, and noninvasive treatment method for the treatment of premacular SHH. It prevents the need for invasive vitreoretinal surgery and its complications. Visual prognosis depends on the etiology of SHH and associated macular changes. [ABSTRACT FROM AUTHOR]

Objective. This article was composed to review the profile of giant splenic artery aneurysm as reported in the recent literature. Methodology. A systematic literature search was conducted through electronic databases and scientific networking sites, including PubMed, Scopus, and Google Scholar, using the key words and terms "giant splenic artery aneurysm", "large splenic artery aneurysm", and "huge splenic artery aneurysm". Only literature in English was considered for inclusion in this study, and the time frame was fixed between 2014 and 2024. Results. 16 cases, including 9 (56.25%) females and 7 (43.75%) males, ranging in age from 35 to 84 years (mean 60.4±13.4 years). Years were included in the review. The size of aneurysm varied from 10 cm to 30.68 cm (mean 12.54±5.32 cm). Upper abdominal pain was the commonest presentation, along with shock and palpable lumps. The majority of the cases (n = 11; 68.7%) were managed by laparotomy, and an endovascular approach was adopted in 4 (25%) cases. Conclusion. Giant splenic artery aneurysm (GSAA) is a rare but potentially life-threatening condition. Physicians need to be aware of this condition so that a diagnosis is made promptly. There is no role of conservative management, and all giant aneurysms need appropriate treatment after detection. Open surgical aneurysmectomy is the mainstay of management. [ABSTRACT FROM AUTHOR]

Purpose: Trauma has the potential to cause haemorrhage, tissue damage, pain, visceral manipulation and psychological distress. Each of these consequences of trauma can cause changes in autonomic outflow, which dictates a patient's vital signs. Patients who are hypotensive and bradycardic due to a vagally mediated parasympathetic response to pain, psychological distress and visceral manipulation may be confused with those who exhibit bradycardia and hypotension following significant blood volume loss. Methods: This review summarises literature that describes specific stimuli, patterns of injury and patient characteristics that are associated with a non-haemorrhagic vagal response to trauma. Results: Twenty-six records described predominantly parasympathetic responses to trauma (both blunt and penetrating) and surgery ("iatrogenic trauma"). Such a non-haemorrhagic vagal response occurs following a wide variety of injury patterns. Patient age and sex are poor predictors of the likelihood of a non-haemorrhagic vagal response. The development and resolution of a non-haemorrhagic vagal response occurs over a heterogenous time period. It is unclear whether speed of onset and resolution is linked to the pattern of injury or other factors causing a predominantly parasympathetic response following non-haemorrhagic trauma. Conclusion: The pattern of injury, patient demographic and speed of onset / resolution associated with the non-haemorrhagic vagal response to trauma may is heterogenous. It is therefore challenging to clinically distinguish between the hypotensive bradycardia due to hypovolaemia secondary to haemorrhage, or a parasympathetic response to trauma in the absence of bleeding. [ABSTRACT FROM AUTHOR]

Background: Haemorrhage is a leading cause of preventable mortality in high-income countries and emergency management presents unique challenges in the prehospital setting. The study aimed to determine incidence and characteristics of fatalities from prehospital haemorrhage in Sweden. Methods: A nationwide retrospective cohort study 2012–2021 was conducted using data from the Swedish National Board of Health and Welfare. Prehospital fatality from haemorrhage was defined as a cause of death related to haemorrhage (Appendix 1) without a hospital admission on the same day. Primary outcome was age-standardized mortality rate per 100,000 inhabitants. Results: A total of 9801 prehospital fatalities from haemorrhage were identified. Annual age-standardized mortality rate decreased from 10.97 to 8.18 per 100,000 population (coefficient = − 0.28, r2 = 0.85, p = < 0.001). Trauma was the most common cause (3512, 35.83%) with intentional self-harm (X60–X84), transport accidents (V01–V99) and assault (X85–Y09) being the most common mechanisms of injury. Traumatic fatalities were younger and a larger proportion were male compared to non-traumatic causes (p < 0.001). Overall median Charlson Comorbidity Index (Quan) was 0 [0–2] with a lower index noted for traumatic causes (p < 0.001). Trauma resulted in a median of 26.1 [3.65–49.22] years of life lost per patient compared to 0 [0–3.65] for non-traumatic causes (p < 0.001). Regional variations in mortality rate were observed with lower population density correlating with higher mortality rate (ρ = − 0.64, p = 0.002). Conclusions: Prehospital mortality from haemorrhage decreased between 2012 and 2021. Trauma was the most common cause which resulted in many years of life lost in a population with a low burden of comorbidities. There were considerable regional differences with low population density associated with higher mortality rate from prehospital haemorrhage. [ABSTRACT FROM AUTHOR]

Background: Bleeding following cardiac surgery is common and serious, yet a gap persists in understanding how experienced intensive care nurses identify and respond to such complications. Aim: To describe the clinical decision‐making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery. Study Design: This qualitative study adopted the Recognition‐Primed Decision Model as its theoretical framework. Thirty‐nine experienced nurses from four adult intensive care units participated in semi‐structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory. Results: Participants maintained consistent vigilance towards post‐cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision‐making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability. Conclusions: Nurses' decision‐making was shaped by their personal attributes, the patient's condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision‐making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation. Relevance to Clinical Practice: This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability‐focused educational programmes, and understanding decision‐making intricacies are crucial for informing nursing education and decision‐support systems. [ABSTRACT FROM AUTHOR]

Background and aims: Patients with cirrhosis of the liver are in a delicate state of rebalanced haemostasis and are at risk of developing both bleeding and thrombotic complications. Conventional haemostatic tests are unable to predict bleeding and thrombosis in these patients. We aimed to explore the role of Rotational Thromboelastometry (ROTEM) in predicting bleeding and thrombotic events in patients with cirrhosis. Methods: We conducted a prospective cohort study of patients with cirrhosis at two metropolitan hospitals. All patients underwent ROTEM analysis and were then followed to record any bleeding and thrombotic events. Univariate and multivariate logistic regression analyses were performed to explore associations with bleeding and thrombotic events. Results: Nineteen of the 162 patients recruited experienced a bleeding event within one year of ROTEM analysis. On univariate analysis, maximum clot firmness (MCF) using both EXTEM and INTEM tests was significantly reduced in patients who had a bleeding event, compared to those who did not (50 mm vs. 57 mm, p < 0.01 and 48 mm vs. 54 mm, p < 0.01, respectively). In addition, on univariate analysis, clotting time (CT) in the INTEM test was prolonged in the bleeding group (214 s vs. 198 s, p = 0.01). On multivariate analysis, only MCFEX was a significant predictor of bleeding events. In contrast, there was no association found between ROTEM parameters and development of thrombosis within a one-year period. Conclusions: ROTEM may provide a useful tool in predicting future bleeding events in patients with cirrhosis. Larger studies are required to further validate this finding and explore its application in clinical practice. [ABSTRACT FROM AUTHOR]

Trauma to the cervical region may result in critical injury to the airway, the neck vasculature, and the pharynx or oesophagus. These three systems should be systematically assessed, alongside ATLS protocols, in all patients presenting with blunt or penetrating trauma to the head and neck region. The majority of trauma centres now have a policy of selective neck exploration based on clinical and radiological findings. It is therefore essential to be aware of the symptoms and clinical signs of injury of key neck structures, so that neck exploration can be performed promptly in patients who require it. [ABSTRACT FROM AUTHOR]

We report on a previously healthy zoo specimen of an adult budgerigar (Melopsittacus undulatus, obtainedwithpermission fromSouthwick'sZoo) founddeceased in its enclosure. To assess cause of death and ensure the absence of an infectious neoplasia, we used an integrated multiscale brain-imaging workflow, previously only used on mammals. The specimen was imaged with microcomputed tomography before and after enhancing soft-tissue contrast with diffusible iodine-based contrast-enhanced microcomputed tomography. Scans revealed an orbital blowout fracture and an unidentified large mass across majority of the diencephalon, striatum and midbrain caudal to the right orbit. After destaining, neural pathohistology confirmed the mass as a brain haemorrhage with no evidence of neoplasia or inflammation. We conclude that this specimen died of head trauma, likely from a head-on collision within its enclosure. This multiscale imaging workflow (diffusible iodine-based contrast-enhanced microcomputed tomography followed by destaining and pathohistology) can improve our evaluation of differential diagnoses in avian specimens. [ABSTRACT FROM AUTHOR]

African swine fever (ASF) is a devastating disease with a high impact on the pork industry worldwide. ASF virus (ASFV) is a very complex pathogen, the sole member of the family Asfaviridae, which induces a state of immune suppression in the host through infection of myeloid cells and apoptosis of lymphocytes. Moreover, haemorrhages are the other main pathogenic effect of ASFV infection in pigs, related to the infection of endothelial cells, as well as the activation and structural changes of this cell population by proinflammatory cytokine upregulation within bystander monocytes and macrophages. There are still many gaps in the knowledge of the role of proteins produced by the ASFV, which is related to the difficulty in producing a safe and effective vaccine to combat the disease, although few candidates have been approved for use in Southeast Asia in the past couple of years.

A haematoma is a collection of blood and blood components under the skin's subcutaneous layer. An acute wound to the blood vessel wall is a frequent cause of haematomas. Focal swelling, taut skin and soreness are associated with blood expanding and pooling beneath the skin. It can be difficult to diagnose if there is an underlying discolouration. The authors report a case of an eight-year-old female patient with the chief complaint of swelling on the face for two days due to a fall from a height of 10 feet. She reported a history of blood from the mouth and avulsed upper lateral incisors immediately after the fall. Bilateral diffuse swelling was observed in the submandibular region, measuring 7x7 cm extraorally, extending from the inferior border across the midline and from the chin to the hyoid bone, accompanied by facial asymmetry. The final diagnosis was post-traumatic haematoma and a conservative approach was the treatment of choice. The present case highlights the importance of correct diagnosis and early intervention. [ABSTRACT FROM AUTHOR]

Wunderlich syndrome (WS) is a spontaneous, non-traumatic retroperitoneal haemorrhage confined to the subcapsular or perinephric spaces. Various neoplastic and non-neoplastic pathologies can cause this entity, renal angiomyolipoma being the most common. Early accurate diagnosis and timely intervention are required for a favourable outcome. We present the case of a 37-year-old female with no previous comorbidities who developed severe pain in the left loin since 1 day after a fall from a chair. Ultrasonography abdomen done in outside hospital revealed massive splenomegaly with perisplenic haematoma and moderate haemoperitoneum. Contrast-enhanced computed tomography abdomen showed bilateral renal angiomyolipomas with intralesional aneurysms and active bleeding on the left side. In view of active contrast leak and fall in haemoglobin %, endovascular embolisation was done through right transfemoral arterial access. The patient was discharged in stable condition. During 1-month follow-up, the patient is asymptomatic.

Abstract Background Exercise-induced pulmonary haemorrhage (EIPH) in athletic horses is characterized by the presence of blood from the lungs in the tracheobronchial tree after intense exercise. Despite the high prevalence of EIPH in horses, the primary aetiology remains unknown. Variants in the genes encoding CD39 and CD39L1 (ENTPD1 and ENTPD2, respectively) were previously reported as potential genetic causes involved in EIPH pathogenesis. However, the role of these variants in haemostatic functions is unknown. Results To investigate the association between EIPH and missense variants in the ENTPD1 (rs1152296272, rs68621348, and rs68621347) and ENTPD2 genes (rs782872967), 76 Thoroughbred horses diagnosed with EIPH and 56 without clinical signs of EIPH (control group) by trachea-bronchial endoscopy were genotyped. The rs1152296272 and rs68621347 variants were linked, which explained why the same results were found in all horses. Approximately 96% and 95% of the EIPH and control horses, respectively, carried at least one nonreference allele for these variants. In contrast, 100% of the control horses and 96% of the EIPH horses were homozygous for the reference allele for the rs68621348 variant. In the EIPH group, 1.5% of the horses were homozygotes and 24% were heterozygous for the nonreference allele of the rs782872967 variant. In the control group, the nonreference allele of this variant was observed only in heterozygotes (16%). There were no significant differences between groups for any of the variants. Conclusions The variants previously described in the genes encoding the CD39 and CD39L1 enzymes were highly present in the studied population. However, no association was found between the occurrence of EIPH and the presence of these variants in Thoroughbred horses in this study.

Liang Hu,1 Han Wu,1 Jiamin Wang,2 Yang Hu1 1Department of Urology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People’s Republic of China; 2Department of Intervention, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People’s Republic of ChinaCorrespondence: Yang Hu, Department of Urology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People’s Republic of China, Email yanghu2024@126.comAbstract: Minimally invasive percutaneous nephrolithotomy (mini-PCNL) maintains a stone clearance rate similar to standard PCNL while reducing blood loss. Bleeding is a complex and serious complication that can arise after PCNL surgery. Pseudoaneurysm (PA) is an uncommon type of delayed bleeding problem, which affects less than 1% of patients after PCNL. The most effective treatment for severe post-PCNL hemorrhage is super-selective renal angiographic embolization (SRAE), but it can fail in some patients and require additional surgical intervention. This report details the case of a male patient, 55 years old, who experienced severe bleeding four times and had three SRAE procedures and one laparoscopic procedure after PCNL. The presence of a renal artery pseudoaneurysm was not initially identified during the first two attempts of angiography due to arterial spasm and a small, undeveloped lesion. This case report is intended to enhance awareness of tiny pseudoaneurysms, emphasizing the importance of avoiding oversight to improve the success rate of embolization.Keywords: super-selective renal angiographic embolization, percutaneous nephrolithotomy, haemorrhage, case

Dengue infection can take on many different forms, ranging from no symptoms to a mild fever, all the way to a severe condition known as dengue shock syndrome. Although the typical symptoms of dengue are well known, the virus can also cause rare neurological complications. Dengue encephalitis is a severe form of neuroinvasive dengue that can be fatal as the virus directly affects the central nervous system. This case series provides a comprehensive overview of dengue, its clinical spectrum, and the potential for severe neurological complications such as dengue encephalitis. It highlights the importance of considering dengue as a possible diagnosis in patients with encephalitis, particularly during a dengue epidemic.