Search

Immune thrombocytopenia, also known as immune thrombocytopenic purpura (ITP), has emerged as a significant COVID-19-associated complication. This study analyzes the published literature of case reports and case series regarding COVID-19 infection associated with ITP.In this systematic review and meta-analysis, a systematic search was conducted through PubMed, Web of Science, and Medline through Clarivate and EBSCO to include the eligible studies. The authors utilized Review Manager 5.4 to conduct quantitative data synthesis for the condition of interest analysis.A total of 13 eligible case reports and case series with 42 patients were included in this study; 54.8% of them were male. The pooled mean age of all participants was (59.5 ± 19) years with a median age of 63 years. The estimated mean time from diagnosis with COVID-19 to ITP development was 18.1 ± 21 days and the mean time to recovery from ITP was 5.8 ± 4.8 days. The pooled random effect of mean platelet count in the included six studies was 14.52, CI [8.79, 20.25].Our analysis shows that ITP secondary to COVID-19 infection is slightly more prevalent among males (54.8%). Elderly patients were more vulnerable to the disease. Most cases developed ITP within 2-3 weeks after COVID-19 infection and recovered in less than one week from ITP.

Background: Several studies have found a link between stress and thyroid disorder, the majority of evidence supporting stress contributing to the start and progression of autoimmune illness is circumstantial, and the mechanisms by which stress impacts thyroid is not fully understood. Study aims to summarize the current evidence regarding relation between thyroid disorders and stress. Methodology: MEDLINE, Embase, CINAHL, Psyc Info, and ASSIA were searched and reference lists of included studies were searched. Studies were included that described relation between stress and thyroid disorders. No software has been utilized to analyze the data. The data was extracted based on specific form that contains (Author’s name, publication year, country, methodology and results). Results: The search of the mentioned databases returned a total of 87 studies that were included for title screening. 54 of them were included for abstract screening, which lead to the exclusion of 32 articles. The remaining 22 publications full-texts were reviewed. The full-text revision lead to the exclusion of 13 studies, and 9 were enrolled for final data extraction. Conclusion: There is evidence regarding the association of thyroid disorders with stress. These findings add to the growing literature suggesting that thyroid function changes may be associated with stress.

Purpose: There is increasing interest in using administrative data to examine treatment-related complications that lead to emergency department (ED) visits or hospitalizations (H). The purpose of this study was to evaluate the reliability of billing codes for identifying chemotherapy-related acute care visits (CRVs) among women with early-stage breast cancer. Materials and Methods: The cohort was identified by using deterministically linked health databases and consisted of women who were diagnosed with early-stage breast cancer who started adjuvant chemotherapy between 2007 and 2009 in Ontario, Canada. A random sample of 496 patient cases was chosen as the validation cohort. Sensitivity (SN) and specificity (SP) were calculated for three scenarios: chemotherapy-related ED visit, chemotherapy-related H, and febrile neutropenia (FN)–related visit. For FN-related visits, three definitions were considered: general, moderate, and strict. Results: The administrative cohort consisted of 8,359 patients, 43.4% of whom had at least one ED or H, including 1,496 women who had multiple visits that resulted in 6,293 unique visits. Of these, 73.1% were considered CRVs. The algorithm performed well in identifying CRVs that included H either from ED (SN, 90%; SP, 100%) or directly from home (SN, 91%; SP, 93%), but less well for ED visits that did not result in H (SN, 65%; SP, 80%). Depending on which FN algorithm was used, 4.8% to 24% of visits were considered related. The moderate FN algorithm provided the best tradeoff between SN (69% to 97%) and SP (83% to 98%). Conclusion: Administrative data can be valuable in evaluating chemotherapy-related serious events. Algorithm validation in other cohorts is needed.

Treatment with doxorubicin (DOX) is a common treatment for different types of cancer. DOX-NP is one of a well established marketed liposomal formulation for DOX. It has advantages over free DOX in reducing the cardiac toxicity and increasing the efficacy. Gold nanoparticles (GNPs), have been widely used in biomedical applications such as medical imaging and biosensors. Mice bearing Ehrlich tumor were injected with saline, free doxorubicin (DOX) in solution, gold nanoparticles loaded liposomes and commercial liposomal encapsulated doxorubicin (DOX-NP). The results showed that GNPs loaded liposomes could enhance the antitumor activity of commercial liposomal formulation (DOX-NP) and displayed significantly decreased systemic toxicity compared with free DOX and commercial liposomal formulation (DOX-NP) at the equivalent dose. So the injection of GNPs and DOX-NP is expected to increase the cell killing and make it a promising approach to cancer treatment.

To determine if early recovery from severe post-operative anemia is accelerated by iv iron therapy alone or in combination with recombinant erythropoietin (EPO).In this double-blinded, placebo-controlled randomized study, consenting adult patients without preoperative anemia whose hemoglobin concentration (Hb) was 70 to 90 g x L(-1) on the first day after cardiac or orthopedic surgery (POD 1) were assigned to one of three groups: control, iv iron alone (200 mg of iron sucrose on POD 1, 2, and 3) or in combination with EPO (600 U x kg(-1) on POD 1 and 3). The primary outcome was increase in Hb (adjusted for red blood cell transfusions) from POD 1 to 7. Analysis was by intention-to-treat in patients for whom the primary outcome was available. Group effect was analyzed by the ANOVA test, and between-group differences were specified with a Duncan multiple-range test.The primary outcome was available in 31 of 38 randomized patients. The average POD 1 Hb was 84 +/- 4 g x L(-1). There were no between-group differences in outcomes except for higher reticulocyte counts on POD-7 in the combination group. The average adjusted one-week increases in Hb were 7 +/- 8 g x L(-1) in the control group (n = 10), 9 +/- 9 g x L(-1) in the iv iron group (n = 11), and 10 +/- 14 g x L(-1) in the combination group (n = 10). The average adjusted six-week increases in Hb were 37 +/- 14 g x L(-1) in the control group, 40 +/- 7 g x L(-1) in the iv iron group, and 45 +/- 12 g x L(-1) in the combination group.Early postoperative treatment with iv iron alone or in combination with EPO does not appear to accelerate early recovery from postoperative anemia.

Massive blood transfusion (MBT) remains a serious and common occurrence in liver transplantation surgery. This retrospective cohort study was undertaken to identify preoperative predictors of MBT and to develop a risk index for MBT in liver transplantation. Data were retrospectively collected on all liver transplantations carried out at a single institution between January 1998 and March 2004. Multivariable logistic regression analysis was used to identify independent predictor variables of MBT, defined as/=6 units of red blood cell concentrate (RBC) in the first 24 hours of surgery. The model was internally validated by bootstrapping. Of the 460 liver transplant recipients, 193 (42%) received/=6 units of RBC within 24 hours of surgery. Unadjusted analyses identified 12 preoperative predictors of MBT: age, height, gender, repeat transplantation, etiology of liver failure, and preoperative laboratory values (hemoglobin concentration, platelet count, international normalized ratio for prothrombin activity [INR], albumin, total bilirubin, and creatinine). In multivariable logistic regression, 7 independent predictors of MBT were identified: age (40 years), hemoglobin concentration (/=10.0 g/dL), INR (1.2-1.99, and2.0), platelet count (/=70 x 10(9)/L), creatinine (/=110 micromol/L for female subjects and/=120 micromol/L for male subjects), albumin (28 g/L), and repeat transplantation. The area under the receiver-operating characteristic curve (ROC) for the model was 0.82. By using the regression beta coefficients to derive weights for each of these predictors, a risk index was developed that assigned each patient a score between 0 and 8. The ROC for this risk index was 0.79. MBT in liver transplantation surgery can be accurately predicted by 7 readily available preoperative predictors.

Efficacy trials of preoperative erythropoietin therapy (PET) recommend a dosing schedule that cannot always be adhered to in everyday clinical practice. Consequently, we instituted a flexible dosing schedule and routinely offered it to anemic patients [hemoglobin (Hb)] # 130 g.L1) undergoing total joint arthroplasty (TJA). The purpose of this observational, cohort study was to assess the effectiveness of this practice in reducing red blood cell (RBC) transfusion. After obtaining Institutional Ethics Board approval, data were collected prospectively on all patients who underwent TJA at our institution from July 1999 to June 2003. Patients with baseline Hb # 130 g.L1 were offered PET as follows: one to three sc injections (20,000 IU for those # 70 kg, and 40,000 IU for those > 70 kg) every three to seven days before surgery. Since treatment was not randomly assigned, multivariable logistic regression analysis and propensity score case-control matching were used to adjust for baseline differences in patient demographics and perioperative risk factors for RBC transfusion. The adjusted relationship between PET and RBC transfusion was then determined. Of the 1,782 patients that underwent TJA during the study period, 770 (47.9%) had a Hb 70 kg) tous les trois a sept jours avant l’operation. Le traitement n’etant pas assigne au hasard, une analyse de regression logistique multivariee et un appariement sujettemoin du score de propension ont ete utilises pour ajuster les differences dans les caracteristiques des patients et les facteurs de risque perioperatoires de transfusion de CG. La relation ajustee entre le TPE et la transfusion de CG a ensuite ete determinee. Des 1 782 patients qui ont subi une AAT pendant la periode etudiee, 770 (47,9 %) avaient une Hb < 130 g.L1. De ces patients, 214 ont recu le TPE et leur taux de transfusion de CG a ete de 16,4 %, tandis qu’il a ete de 56,1 % chez ceux qui n’ont pas recu de TPE (P < 0,0001). Le risque relatif ajuste de transfusion de CG avec le TPE etait de 0,33 (intervalle de confiance de 95 % = 0,21-0,49). Le TPE utilise dans le cadre d’une pratique clinique courante est une modalite efficace de conservation du sang.

BACKGROUND: Cardiac surgery is occasionally complicated by massive blood loss that is refractory to standard hemostatic interventions. Recombinant factor VIIa (rF-VIIa) is being increasingly used as rescue therapy in such cases, but little information is available on its safety and efficacy for this indication. STUDY DESIGN AND METHODS: The outcomes of the first 51 cardiac surgery patients who received rF-VIIa for intractable blood loss (from November 2002 to February 2004) at a single institution according to a standardized clinical guideline were compared to 51 matched control patients, with the control patients identified from a large database and matched based on the propensity for massive blood loss. RESULTS: Blood loss and blood product usage were significantly decreased after 2.4 to 4.8 mg of rF-VIIa. In those treated after sternal closure (n = 32), there was a significant reduction in blood loss from the hour before to the hour after treatment: 100 (70, 285) mL (median [25th, 75th percentiles]; p < 0.0001). Except for a slower postoperative recovery and higher incidence of acute renal dysfunction, the adverse event rates were similar between the rF-VIIa-treated patients and their matched controls. CONCLUSIONS: These results suggest that rF-VIIa may be an effective rescue therapy for patients with intractable hemorrhage after cardiac surgery. A clinically important risk of stroke or other major thrombotic complications could not be ruled out by our study. Controlled clinical trials with adequate power to detect the impact of rF-VIIa therapy on morbidity and mortality therefore are necessary before one can recommend its routine use in patients undergoing cardiac surgery who have excessive bleeding. assive blood loss is a serious complication of cardiac surgery that occurs when standard hemostatic interventions, which include surgical intervention, local hemostatic agents, and transfusion of blood products, fail to stop hemorrhage after surgery. There has recently been a great deal of interest in the use of recombinant factor VIIa (rF-VIIa)—a novel hemostatic agent that is currently approved only for patients with hemophilia with antibodies against specific coagulation factors (anti-FVIII or antiF IX)—for control of refractory hemorrhage after cardiac surgery. There are now multiple case reports and small case series that have described the successful use of rFVIIa in cardiac surgery. 1-10 Owing to their small sample sizes and lack of comparison groups, however, these reports can confirm neither the efficacy nor the safety of rF-VIIa for this indication. The high rate of serious adverse events in these reports has raised concerns about the safety of rF-VIIa in cardiac surgery.

tion by a member of the Society. The Richard Knill competition was instituted in memory of Dr. Richard Knill, a foremost researcher in anesthesiology and prominent collaborator to the Canadian Journal of Anesthesia (CJA). The Annual Meeting Committee selects the top abstracts submitted for presentation by members of the Society at the Annual Meeting. The authors are invited to present their results at the Richard Knill competition. Presentations are marked by a jury composed of the members of the Editorial Board of the CJA. In 2004, the Richard Knill Award was presented to Dr. David C. Campbell for his work on Patient Controlled Epidural Analgesia during labour.

BACKGROUND: Although the association between massive perioperative blood loss (MBL) and adverse outcomes is well recognized, it is unclear whether MBL is an independent risk factor or, instead, simply a marker for other adverse events or severity of illness. The objective of this cohort study was to quantify the independent association of MBL in cardiac surgery with all-cause in-hospital mortality. STUDY DESIGN AND METHODS: Data were prospectively collected on consecutive patients who underwent cardiac surgery with cardiopulmonary bypass at a quaternary-care academic center from 1999 to 2003. The number of red blood cell (RBC) units transfused within 1 day of surgery was used as a surrogate measure of perioperative blood loss. Receiver-operating characteristic curve analyses were employed to identify the most appropriate cutoff for defining MBL. The independent association of MBL with mortality was determined with multivariable logistic regression analyses. Bootstrapping and sensitivity analyses were used to confirm the validity of the results. RESULTS: MBL was defined as receiving at least 5 units of RBCs within 1 day of surgery. Of 9215 patients analyzed, 1.8 percent (n = 169) died and 9.7 percent (n = 890) had MBL. After adjusting for multiple potential confounders (including perioperative adverse events), MBL was associated with an 8.1-fold (95% confidence interval, 3.9-17.0) increase in the odds of death. This risk estimate was stable across different modeling conditions as well as in bootstrap sampling. CONCLUSION: MBL after cardiac surgery has a strong, independent association with in-hospital mortality.

BACKGROUND: Cardiac surgery with cardiopulmonary bypass may result in excessive fibrinolysis and platelet (PLT) dysfunction, resulting in impaired hemostasis and excessive blood loss. Prophylactic use of the antifibrinolytic drugs aprotinin and tranexamic acid is thought to prevent these hemostatic defects. Their relative clinical utility and safety in high-transfusion-risk cardiac surgery, however, is not known. STUDY DESIGN AND METHODS: Using propensity scores, 449 patients who received aprotinin for high-transfusion-risk cardiac surgery were matched to 449 patients who received tranexamic acid from a pool of 10,870 consecutive patients who underwent cardiac surgery at a single center, 586 of whom received aprotinin and the remainder of whom received tranexamic acid. RESULTS: The two matched groups were well balanced in terms of measured perioperative variables. Blood product transfusion rates were similar in the aprotinin and tranexamic acid groups: red blood cells, 79 percent versus 76 percent (p = 0.3); PLTs, 56 percent versus 50 percent (p = 0.06); and plasma, 66 percent versus 61 percent (p = 0.1). Adverse events rates were comparable in the two groups, except for renal dysfunction (defined as a greater than 50% increase in creatinine concentration during the first postoperative week to >100 µmol/L in women and >110 µmol/L in men or a new requirement for dialysis support), which occurred in 24 percent (107/449) of aprotinin patients and 17 percent (75/449) of tranexamic acid patients (p = 0.01). CONCLUSIONS: Aprotinin and tranexamic acid have similar hemostatic effectiveness in high-transfusion-risk cardiac surgery. Within the confines of propensity score matching, our results suggest that aprotinin may be associated with renal dysfunction.

Efficacy trials of preoperative erythropoietin therapy (PET) recommend a dosing schedule that cannot always be adhered to in everyday clinical practice. Consequently, we instituted a flexible dosing schedule and routinely offered it to anemic patients [hemoglobin (Hb)]or = 130 g x L(-1)) undergoing total joint arthroplasty (TJA). The purpose of this observational, cohort study was to assess the effectiveness of this practice in reducing red blood cell (RBC) transfusion.After obtaining Institutional Ethics Board approval, data were collected prospectively on all patients who underwent TJA at our institution from July 1999 to June 2003. Patients with baseline Hbor = 130 g x L(-1) were offered PET as follows: one to three sc injections (20,000 IU for thoseor = 70 kg, and 40,000 IU for those70 kg) every three to seven days before surgery. Since treatment was not randomly assigned, multivariable logistic regression analysis and propensity score case-control matching were used to adjust for baseline differences in patient demographics and perioperative risk factors for RBC transfusion. The adjusted relationship between PET and RBC transfusion was then determined.Of the 1,782 patients that underwent TJA during the study period, 770 (47.9%) had a Hb130 g x L(-1). Of these patients, 214 received PET and their RBC transfusion rate was 16.4%, whereas the transfusion rate was 56.1% in those who did not receive PET (P0.0001). The adjusted odds ratio of RBC transfusion with PET was 0.33 (95% confidence interval = 0.21-0.49).PET, used as part of routine clinical practice, is an effective blood conservation modality.

Although the association between massive perioperative blood loss (MBL) and adverse outcomes is well recognized, it is unclear whether MBL is an independent risk factor or, instead, simply a marker for other adverse events or severity of illness. The objective of this cohort study was to quantify the independent association of MBL in cardiac surgery with all-cause in-hospital mortality.Data were prospectively collected on consecutive patients who underwent cardiac surgery with cardiopulmonary bypass at a quaternary-care academic center from 1999 to 2003. The number of red blood cell (RBC) units transfused within 1 day of surgery was used as a surrogate measure of perioperative blood loss. Receiver-operating characteristic curve analyses were employed to identify the most appropriate cutoff for defining MBL. The independent association of MBL with mortality was determined with multivariable logistic regression analyses. Bootstrapping and sensitivity analyses were used to confirm the validity of the results.MBL was defined as receiving at least 5 units of RBCs within 1 day of surgery. Of 9215 patients analyzed, 1.8 percent (n = 169) died and 9.7 percent (n = 890) had MBL. After adjusting for multiple potential confounders (including perioperative adverse events), MBL was associated with an 8.1-fold (95% confidence interval, 3.9-17.0) increase in the odds of death. This risk estimate was stable across different modeling conditions as well as in bootstrap sampling.MBL after cardiac surgery has a strong, independent association with in-hospital mortality.

185 Background: Administrative data is increasingly being used to study treatment related complications that lead to acute care visits such as emergency department visits or hospitalizations (ED+H). We evaluated the accuracy of diagnosis codes for identifying chemotherapy related acute care visits (CRVs) among women with breast cancer. Methods: We prospectively developed algorithms to identify CRVs from administrative data in women receiving adjuvant chemotherapy for breast cancer in Ontario, Canada. Sensitivity (SN) and specificity (SP) were calculated for 3 scenarios: chemotherapy related ED visit, chemotherapy related H, and febrile neutropenia (FN) related visit using the chart as the gold standard. Since there is no specific diagnosis code for FN, three definitions of FN were considered: general (defined as fever or infection or neutropenia as main reason for visit), moderate (neutropenia as main reason for visit) or strict (fever or infection plus neutropenia). The population based cohort was generated by linking several health databases to identify women who had at least one ED+H during adjuvant chemotherapy for breast cancer between 2007-2009. The validation cohort consisted of 490 randomly selected cases from this cohort. Results: The population-based cohort consisted of 8,359 patients of whom 43.4% had at least one ED+H including 1,496 women who had multiple visits resulting in 6,293 unique ED+H. Of these, 73.1% were considered CRVs based on our algorithm. The algorithm performed well in identifying CRVs that included an H either from ED (SN 90%, SP 100%) or directly from home (SN 91%, SP 93%) but less well for ED visits that did not result in H (SN 65%, SP 80%). Depending on which FN algorithm was used, 1.4-24% of visits were considered FN related. The general FN algorithm had excellent SN regardless of whether the visit involved H (94-98%) but SP was moderate (66-80%). The strict FN algorithm had good SP (78-99%) but SN was highly variable (13-89%). The moderate FN algorithm provided the best tradeoff between SN (69-97%) and SP (76-98%). Conclusions: CRVs can be identified from administrative data with reasonable confidence, obviating the need for chart abstraction to evaluate chemotherapy related serious events.

The aim of the present study was to identify patients who were at particular risk of violent behaviour, over a period of one month in a psychiatric high dependency unit, and to examine whether particular patients could be identified at admission who would subsequently be violent. Medical records, and other documents for 52 inpatients were included. Demographic, historical and clinical data available at admission were noted. All violent incidents were recorded and classified. Seventeen of 52 patients committed physical violence, usually to the staff. Most incidents were carried out by a small number of individuals. Identifying the violent, using variables available at admission, was not possible. The ward admitted a group with a subsequent high rate of violence. Prediction within this high-risk group was not possible. Measures aimed at preventing violence on a local secure ward should apply to all patients and should not be targeted just at those that would appear to be the most likely to be violent.

115 Background: Over use of routine surveillance imaging to detect recurrence in women with EBC was recently identified as one of the top five opportunities to improve the quality of cancer care by the American Society of Clinical Oncology. We undertook a population level assessment of the current practice of surveillance imaging in EBC women treated in Ontario Canada. Methods: Incident EBC patients diagnosed 01/07 – 12/09 in Ontario, Canada were identified from the Ontario Cancer Registry. Patient records were linked deterministically to provincial health care databases to provide comprehensive medical follow-up. Basic (chest x-ray, abdominal x-ray and abdominal ultrasound) and advanced (computed tomography [CT] or bone scans) surveillance imaging scans completed during the first and second year of follow-up (starting 6 months after surgery or upon completion of chemotherapy) were identified. Logistic regression models were used to identify covariates associated with advanced surveillance imaging. Results: 16,981 EBC patients were included in the analysis of which 7,907(46.6%) received chemotherapy. In the first year of follow up care, 8,311 (48.9%) had at least 1 basic imaging test, while 4,916 (29.0%) had advanced imaging. This fell to 45.7% (basic) and 25.1% (advanced) in the second year of follow-up. Bone scans were the most common advanced imaging test (14.5%), followed by CT thorax (10.8%). On multivariable analysis age, stage, the use of chemotherapy and comorbidity were associated with increased use of advanced surveillance imaging (Table). Conclusions: Surveillance imaging was common in the first two years of follow-up for EBC patients. While appropriate for symptom driven investigation, the high rate of advanced imaging scans suggests an opportunity for improvement with the Ontario cancer system. [Table: see text]

6628 Background: Over use of routine surveillance imaging to detect recurrence in women with EBC was recently identified as one of the top five opportunities to improve the quality of cancer care by the American Society of Clinical Oncology. We undertook a population level assessment of the current practice of surveillance imaging in EBC women treated in Ontario Canada. Methods: Incident early breast cancer patients diagnosed 01/07 – 12/09 in Ontario, Canada were identified from the Ontario Cancer Registry. Patient records were linked deterministically to provincial health care databases to provide comprehensive medical follow-up. Basic (chest x-ray, abdominal x-ray and abdominal ultrasound) and advanced (computed tomography [CT] or bone scans) surveillance imaging scans completed during the first and second year of follow-up care (starting 6 months after surgery or upon completion of adjuvant chemotherapy) were identified. Logistic regression models were used to identify covariates associated with advanced surveillance imaging. Results: 16,981 EBC patients were included in the analysis of which 7,907(46.6%) received chemotherapy. In the first year of follow up care, 8,311 (48.9%) had at least 1 basic imaging test, while 4,916 (29.0%) had advanced imaging. This fell to 45.7% (basic) and 25.1% (advanced) in the second year of follow-up. Bone scans were the most common advanced imaging test (14.5%), followed by CT thorax (10.8%). On multivariable analysis age, stage, the use of chemotherapy and comorbidity were associated with increased use of advanced surveillance imaging (Table). Significant geographic variation was also demonstrated. Conclusions: Surveillance imaging was common in the first two years of follow-up for EBC patients. While appropriate for symptom driven investigation, attention should be paid to the routine use of surveillance imaging in EBC women during follow-up care. [Table: see text]