A ruptured omental pseudoaneurysm is a rare cause of intra-abdominal hemorrhage. Herein, we present a case of bleeding ruptured omental pseudoaneurysm in a patient on systemic anticoagulation and ...successful treatment with surgery. A 72-year-old female on warfarin for atrial fibrillation presented with worsening abdominal pain. Cross-sectional imaging was obtained and was consistent with a large omental pseudoaneurysm (measuring 2.2 cm) as well as blood products within the abdomen. The patient was taken to the operating room where a pseudoaneurysm with evidence of active bleeding was identified. A diagnostic laparoscopy converted to exploratory laparotomy with partial omentectomy was performed. An omental pseudoaneurysm is a rare but potentially life-threatening cause of intra-abdominal hemorrhage. Given the risk of re-bleed, these lesions should be addressed promptly. In a facility that has the expertise, a catheter based approach with embolization may be considered, however, the mainstay of therapy should remain surgical resection.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Background Plasma-first resuscitation attenuates trauma-induced-coagulopathy (TIC), however, the logistics of plasma-first resuscitation require thawed plasma (TP) be readily available due ...to the obligatory thawing time of FFP. The current standard is storage of TP for up to 5 days at 4°C, based on factor levels at outdate, for use in patients at risk for TIC, but there remains a 2.2% outdated wastage rate. However, the multitude of plasma proteins in attenuating TIC remain unknown. We hypothesize that TP retains the ability to enhance clotting and reduce tPA-induced fibrinolysis at 14 days storage. Methods FFP was thawed and stored at 4°C at the following intervals: 14, 10, 7, 5, 3, and 1-day prior to the experiment. Healthy volunteers underwent blood draws followed by 50% dilution with above TP stored intervals as well as FFP, normal saline (NS), albumin, and whole blood (WB) control. Samples underwent tPA-modified (75ng/ml) thrombelastography (TEG) with analysis of R-time, angle, maximum amplitude (MA), and LY30. Results TEG properties did not change significantly over the thawed storage. 14-day TP retained the ability to inhibit tPA-induced hyperfibrinolysis (median LY30% 9.6%) similar to FFP (5.6%), WB (14.6%) and superior to albumin (59.3%) and NS (58.1%). 14-day TP also retained faster clot formation (median angle, 66.2°) and superior clot strength (MA, 61.5mm) to albumin (34.8°, 21.6mm) and NS (41.6°, 32.2mm). Conclusion TP plasma stored for 14 days retains clot enhancing ability and resistance to clot degradation similar to FFP. A clinical trial is needed to validate these in vitro results.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Introduction
High alcohol consumption has been associated with decreased fibrinolysis and enhanced thrombosis risk in cardiovascular disease. In trauma, alcohol has been associated with poor clot ...formation; however, its effect on fibrinolysis has not been fully investigated. We assessed the association of blood alcohol levels and fibrinolysis in trauma activation patients.
Methods
We queried our prospective registry of trauma activations from 2014 to 2016. Associations between viscoelastic measurements rapid thrombelastography (rTEG) and blood alcohol level (BAL) were determined and adjusted for confounders by a multinomial logistic regression. Lysis phenotypes were defined by the % lysis in 30 min (LY30) as follows: hyperfibrinolysis ≥ 3%, physiologic 0.9–2.9%, and fibrinolysis shutdown < 0.9%.
Results
Overall, 191 (43.8%) had BAL measured. There were 65 (34%) patients that had no detectable BAL, 32 (16.8%) had BAL of 10–150 mg/dL, and 94 (49.2%) patients had BAL > 150 mg/dL. BAL had a moderate, but significant inverse correlation with LY30 (Rho = − 0.315,
p
< 0.001), while there were no significant correlations between BAL and other TEG values. The distribution of fibrinolysis phenotypes varied significantly by BAL levels (
p
< 0.009, with high BAL having more shutdown and less hyperfibrinolysis than the other two BAL level groups. Multinomial logistic regression showed that after adjustment for confounders, BAL levels > 150 mg/dL were independently associated with a threefold increase in the odds of shutdown compared to undetectable BAL (OR 3.37, 95% CI 1.04–8.05,
p
= 0.006). High BAL was also significantly associated with higher odds of shutdown compared to low BAL (OR 2.63, 95% CI 1.15–6.06). Compared to physiologic fibrinolysis, fibrinolysis shutdown was associated with increased mortality (OR 2.87, 95% CI 1.41–5.83) and VFD < 28 (OR 2.54, 95% CI 1.47–4.39).
Conclusion
In the injured patient, high blood alcohol levels are associated with increased incidence of fibrinolysis shutdown. This finding has implications for postinjury hemostatic resuscitation as these patients may be harmed by anti-fibrinolytics. Further research is needed to assess whether the association with fibrinolysis is modified by the chronicity and type of alcohol consumed and whether anti-fibrinolytic therapy in intoxicated patients produces adverse effects.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Abstract Introduction Traumatic arterial injuries have a high degree of morbidity if left untreated. Frequently, arterial injuries are found soon after injury due to either subjective complaints or ...objective findings. Opportunity for delayed repair of vascular injury is a rare event as irreversible ischemia occurs at such early time points. Case report We report a case of delayed presentation of complete arterial transection of the brachial artery due to penetrating trauma, but without classical hard signs of vascular injury. Trajectory, symptoms, and pulse exam prompted further evaluation. Successful reverse saphenous vein interposition grafting of the transected artery returned normal blood flow to the affected extremity with preserved function. Conclusion This case of delayed presentation of arterial transection is significant as delayed identification of arterial injury is rare. Furthermore, it demonstrates the need for clinicians to have a high index of suspicion in patients with traumatic limb injuries who present in a subacute or delayed fashion with increasing pain and worsening of initial physical exam findings.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Elevated clot strength (maximum amplitude MA) measured by thrombelastography (TEG) is associated with thrombotic complications. However, it remains unclear how MA translates to thrombotic risks, as ...this measurement is independent of time, blood flow, and clot degradation. We hypothesize that under flow conditions, increased clot strength correlates to time-dependent measurements of coagulation and resistance to fibrinolysis.
Surgical patients at high risk of thrombotic complications were analyzed with TEG and total thrombus-formation analysis system (T-TAS). TEG hypercoagulability was defined as an r <10.2 min, angle >59, MA >66 or LY30 <0.2% (based off of healthy control data, n = 141). The T-TAS AR and PL chips were used to measure clotting at arterial shear rates. T-TAS measurements include occlusion start time, occlusion time (OT), occlusion speed (OSp), and total clot generation (area under the curve). These measurements were correlated to TEG indices (R time, angle, MA, and LY30). Both T-TAS and TEG assays were challenged with tissue plasminogen activator (t-PA) to assess clot resistance to fibrinolysis.
Thirty subjects were analyzed, including five controls. TEG-defined hypercoagulability by MA was detected in 52% of the inflammatory bowel disease/cancer patients; 0% was detected in the controls. There were no TEG measurements that significantly correlated with T-TAS AR and PL chip. However, in the presence of t-PA, T-TAS AR determined OSp to have an inverse relationship with TEG angle (−0.477, P = 0.012) and LY30 (−0.449, P = 0.019), and a positive correlation with R time (0.441 P = 0.021). In hypercoagulability determined by TEG MA, T-TAS PL had a significantly reduced OT (4:07 versus 6:27 min, P = 0.043). In hypercoagulability defined by TEG LY30, T-TAS PL had discordant findings, with a significantly prolonged OT (6:36 versus 4:30 min, P = 0.044) and a slower OSp (10.5 versus 19.0 kPa/min, P = 0.030).
Microfluidic coagulation assessment with T-TAS has an overall poor correlation with most TEG measurements in a predominantly hypercoagulable patient population, except in the presence of t-PA. The one anticipated finding was an elevated MA having a shorter time to platelet-mediated microfluidic occlusion, supporting the role of platelets and hypercoagulability. However, hypercoagulability defined by LY30 had opposing results in which a low LY30 was associated with a longer PL time to occlusion and slower OSp. These discordant findings warrant ongoing investigation into the relationship between clot strength and fibrinolysis under different flow conditions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
...chronic anemia and thrombocytosis are two common characteristics of patients with chronic kidney disease, and those two factors have been shown to be associated with increased final clot strength ...on TEG parameters. ...in the current cost-conscious environment, would you and your co-authors recommend that we must draw TEG assay and fibrinogen level in all patients who undergo hemodialysis access surgery? With this, we'll include pre- and post-dialysis samples for these patients to see what dialysis does to their clotting factors, to their platelet function, and eventually the goal is to perform randomized control trials to see if we can identify certain patients that would benefit from antiplatelet therapy and anti-fibrinogen therapy to prevent thrombotic complications.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
The emergence of functional genomics and proteomics has added to the growing need for improved analysis methods that can detect and distinguish between protein variants resulting from allelic ...variation, mutation, or post-translational modification. Aptamers, single-stranded DNA or RNA molecules that fold into three-dimensional structures conducive to binding targets, have become an attractive alternative to antibodies for this type of analysis. Although aptamers have been developed for a wide range of target species, very few sequences have been identified that bind selectively to proteins with specific post-translational modifications. Using capillary electrophoresis-based selection, we have developed DNA aptamer sequences that selectively bind an
N
-glycosylated peptide fragment of vascular endothelial growth factor (VEGF). The selection method incorporates alternating positive- and counter-selection steps in free solution in order to obtain aptamers with both high affinity toward the glycosylated target and high selectivity
versus
a non-glycosylated variant. Affinity capillary electrophoresis and surface plasmon resonance binding assays indicate these sequences have low-µM dissociation constants and preferentially bind the glycosylated peptide with as much as 50-fold specificity. Such aptamers could serve as tools for rapid and simple monitoring of disease-linked functional changes in proteins, with potential applications in drug screening and disease diagnosis.
A new strategy for on-capillary counter-selection in CE-SELEX enables development of aptamers selective for glycosylated peptide variants.
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