Massive Epistaxis Revealing a Post-Traumatic Aneurysm of the Internal Carotid Artery: A Clinical Case and Review of the Literature

Internal carotid artery (ICA) aneurysms are an unusual but serious cause of epistaxis. This epistaxis is massive and sometimes uncontrollable threatening the vital prognosis of patients. We report the case of a 16-year-old adolescent received in emergency with severe bilateral epistaxis, asthenia and grade-3 left exophthalmos. In his history, the subject had been the victim of an assault six months before consultation. He had received blows on the cephalic extremity with light but repeated epistaxis. The treatment consisted to blood products transfusion and local compression by sterile gazes. An ICA aneurysm in sphenoid sinus has been confirmed in a craniofacial CT scan coupled to vascular opacification. Although the ICA has a variable course in contact with the sphenoid sinus, massive epistaxis would be the consequence of a pronounced dehiscence of the ICA in the sphenoid sinus, particularly in a traumatic context. In front of this type of epistaxis in our context, general practitioners must be able to suspect a ruptured ICA aneurysm in the presence of exophthalmos and a notion of old or recent cranio-encephalic injury. Additionally, due to the high morbidity and mortality of this condition, a monitoring algorithm is necessary for patients with head trauma to facilitate early detection.

ON101 Cream Increases the Wound Healing Rate in Diabetic Patients with Uremia—Cases Report

Diabetic patients who underwent long-term dialysis may increase the prevalence of foot ulceration. In addition, diabetic foot ulcer (DFUs) patients with end-stage renal disease (ESRD) do not heal well, and the amputation rate is 6.5 - 10 times higher compared to the non-nephropathic diabetic population. Thus, a suitable therapeutic agent was needed. ON101 is a topical cream that promotes diabetic wound healing through a unique macrophage-regulating ability. In this case series, we included 5 diabetes patients (mean age 54.6 ± 8.7 years, 4 mal) with ESRD (mean eGFR 7.4 ± 3.35 mL/min/1.73m2) and had experienced dialysis for at least 4.5 years. These patients also have UT (University of Texas) grade 2A DFUs that have existed for at least 1.5 months (mean ulcer duration 8.3 ± 8.97 months). These subjects were applied ON101 twice daily for up to 20 weeks, and wound size was recorded during treatment. Among these subjects, three ulcers (patient No. 1, 2, and 3) completely healed within 10 weeks upon ON101 application, and one ulcer was 99% reduced at 20th weeks (patient No. 4). Only one ulcer didn’t show an obvious response that may due to poor compliance in wound care and glucose control. In summary, the overall healing rate was 60%, suggesting ON101 performed equivalence healing efficacy in dialysis patients compared with those who did not have dialysis.

Impact of COVID-19 lockdown on hospital admissions for epistaxis in Germany

BACKGROUND Reports of a decrease in hospital admissions during the coronavirus disease 2019(COVID-19)lockdown period have raised concerns about delayed or missed diagnoses and treatments for non-COVID-19-related illnesses.AIM To investigate the impact of the COVID-19 pandemic-induced lockdown and its end on hospital admissions of patients with epistaxis in Germany.METHODS A retrospective analysis based on the national database of the Hospital Remuneration System was used to compare hospital admissions during defined time periods between 2019 and 2022 with the lockdown period as the reference period.This was done on a weekly basis before,during,and after the lockdown.An Interrupted Time Series was used as the analysis method.RESULTS In our analysis,we included 26183 patients.The implementation of the lockdown led to a substantial reduction in the overall occurrence of epistaxis among patients(P<0.05).This effect was most pronounced in the age group of 0-39 years,where the decrease was highly significant(P<0.001).However,there was no change observed in patients aged 80 years and older(not significant).With the end of the lockdown period,the overall number of patients,especially in the youngest age group,increased abruptly and significantly(P<0.01).CONCLUSION During the lockdown period,there was a decrease in hospital admissions for younger patients with epistaxis,possibly due to the fear of COVID-19 exposure.We also conclude that the severity of epistaxis was not underestimated in the elderly during the pandemic.

Evaluation of the Application Effect of Psychological Nursing Intervention on Maintenance Hemodialysis Patients with Uremia

Objective:To evaluate the application effect of psychological nursing intervention on maintenance hemodialysis(MHD)patients with uremia.Methods:Sixty cases of uremic patients admitted to the hospital between May 2023 and May 2024 were selected for MHD treatment and divided using the random number table method into 30 cases in each group.The observation group implemented psychological nursing intervention,while the reference group received conventional nursing intervention,after which the nursing effects were compared.Results:After nursing,the psychological state score of the observation group was lower than that of the reference group;the treatment compliance of the observation group was higher than that of the reference group;the self-care ability score of the observation group was higher than that of the reference group,and the quality-of-life score of the observation group was higher than that of the reference group(P<0.05).Conclusion:Psychological nursing intervention for uremic MHD patients can improve their negative psychology,enhance treatment compliance,and comprehensively improve patients’self-care ability and quality of life.

Epistaxis in end stage liver disease masquerading as severe upper gastrointestinal hemorrhage

AIM: To describe the prevalence, diagnosis, treatment, and outcomes of end stage liver disease (ESLD) patients with severe epistaxis thought to be severe upper gastrointestinal hemorrhage (UGIH).

Cost Effective Trend in Epistaxis Management

Background: Epistaxis affects much of the population and is a common medical complaint seen across a variety of medical settings. Current standard of care treatment includes a range of options from topical therapy to invasive intranasal device insertion in the absence of on-demand specialist involvement. Aim: The aim of this article is to not only highlight superior outcomes in patients with acute nontraumatic epistaxis that are treated with noninvasive nebulized tranexamic acid instead of more invasive options, but also monetary benefit to the community through reduced costs. Case Presentation: this case report highlights a successful epistaxis resolution with use of tranexamic acid in a 64-year-old female after she was subjected to intranasal device insertion that did not resolve bleeding. Conclusion: Nebulized tranexamic acid is a cost-effective medication that not only reduces rates of recurrence, but it also increases patient satisfaction while minimizing overall healthcare costs, and therefore should be the first choice therapy in uncomplicated epistaxis management.

Traumatic Middle Meningeal Artery Pseudoaneurysms Presenting with Intractable Epistaxis: A Rare Case Report and Review of Literature

Middle meningeal artery (MMA) pseudoaneurysms are very rare and are most often traumatic. They may present as an epidural or intraparenchymal hematoma. This study reports a rare case in which a patient suffered from intractable epistaxis because of a pseudoaneurysm in middle meningeal artery and skull base fracture after craniocerebra trauma. Pseudoaneurysm and the feeding artery were embolized by using Onyx-18 liquid embolic system. Complete cessation of bleeding was achieved in this case immediately after the endovascular therapies. In this study, clinical manifestation, diagnostic imaging and endovascular treatment are described. Formation mechanisms and the treatment of traumatic pseudoaneurysm of middle meningeal artery are discussed.

Aging and uremia:Is there cellular and molecular crossover?

Many observers have noted that the morphological changes that occur in chronic kidney disease(CKD) patients resemble those seen in the geriatric population, with strikingly similar morbidity and mortality profiles and rates of frailty in the two groups, and shared characteristics at a pathophysiological level especially in respect to the changes seen in their vascular andimmune systems. However, whilst much has been documented about the shared physical characteristics of aging and uremia, the molecular and cellular similarities between the two have received less attention. In order to bridge this perceived gap we have reviewed published research concerning the common molecular processes seen in aging subjects and CKD patients, with specific attention to altered proteostasis, mitochondrial dysfunction, post-translational protein modification, and senescence and telomere attrition. We have also sought to illustrate how the cell death and survival pathways apoptosis, necroptosis and autophagy are closely interrelated, and how an understanding of these overlapping pathways is helpful in order to appreciate the shared molecular basis behind the pathophysiology of aging and uremia. This analysis revealed many common molecular characteristics and showed similar patterns of cellular dysfunction. We conclude that the accelerated aging seen in patients with CKD is underpinned at the molecular level, and that a greater understanding of these molecular processes might eventually lead to new much needed therapeutic strategies of benefit to patients with renal disease.

Effect of high-flux and low-flux hemodialysis on the side metabolites and cytokines in patients with uremia

Objective:To study the effect of high-flux and low-flux hemodialysis on the side metabolites and cytokines in patients with uremia.Methods: A total of 50 patients with uremia who accepted high-flux hemodialysis and 140 patients with uremia who accepted low-flux hemodialysis in our hospital between March 2015 and March 2016 were selected and included in high-flux group and low-flux group respectively. Before and after dialysis, serum was collected respectively to determine the levels of side metabolites, calcium-phosphorus metabolism indexes and cytokines.Results: 3 months after dialysis, serum Ca levels of two groups of patients were not significantly different from those before dialysis while BUN, Scr,β2-MG, sTfR, P, PTH and AKP levels were significantly lower than those before dialysis;3 months after dialysis, serum BUN, Scr and Ca levels of high-flux group were not significantly different from those of low-flux group whileβ2-MG, sTfR, P, PTH, AKP, TNF-α, IL-1β, IL-6, IL-8 and IL-10 levels were significantly lower than those of low-flux group.Conclusion:Compared with low-flux hemodialysis, high-flux hemodialysis treatment of uremia can more effectively remove middle molecular and macromolecular toxins, correct calcium-phosphorus metabolism disorder and relieve micro-inflammatory state.

Analysis of Endoscopic Sphenopalatine Artery Surgery for Refractory Epistaxis

Background: This study aimed to determine the safety and efficacy of sphenopalatine artery (SPA) surgery in patients with refractory epistaxis and to identify factors associated with the indications for surgery to assist clinicians in making prompt and appropriate decisions regarding SPA surgery for refractory epistaxis. Methods: We analyzed 97 consecutive patients with nasal bleeding hospitalized in our institution between April 2009 and March 2018. Clinicopathological characteristics and clinical outcomes were analyzed from retrospective chart reviews. Results: Of the 97 patients, 28 (29 sides) required SPA surgery. There were no differences in sex, anti-coagulant drug or antiplatelet use, hemoglobin concentration, or platelet count between Group A (patients who required surgery) and Group B (patients who did not require surgery). Age (58 vs. 67 years, p = 0.038) and severity of comorbidity (0 vs. 1, p = 0.039) were significantly lower in the surgery group. Patients who were younger and had lower Charlson Comorbidity Index (CCI) scores had more requirements for surgery than those who were older and had higher CCI scores. There was no significant difference between the groups with respect to the proportion of patients receiving blood transfusions;however, the length of hospitalization was significantly longer in Group A than in Group B (8.9 vs. 8 days, p = 0.038). Success rate (non-rebleeding rate) was 89%, comparable to that reported in previous studies. Conclusions: Endoscopic SPA surgery was found safe and effective method with few complications. Younger patients with lower CCI scores were found appropriate for SPA surgery for refractory epistaxis due in part to a lower risk of anesthesia.

Effect of hemodialysis in combined with hemoperfusion on the toxin clearance rate and carotid intima in patients with uremia

Objective:To explore the effect of hemodialysis (HD) in combined with hemoperfusion (HP) on the toxin clearance rate and carotid intima in patients with uremia.Methods: A total of 40 patients with uremia who were admitted in our hospital from May, 2015 to February, 2017 were included in the study and randomized into the control group (n=20) and the study group (n=20). The patients in the two groups were given routine HD treatment. On the above basis, the patients in the study group were given HP treatment, continuously for 3 months. The toxin content, clearance rate, and serum inflammatory cytokines before and after treatment in the two groups were detected and compared. The ultrasound diagnostic apparatus was used to detect the carotid IMT before and after treatment in the two groups. Results: Scr and BUN after treatment in the two groups, and PTH andβ2-MG contents in the study group were significantly reduced when compared with before treatment. PTH andβ2-MG contents after treatment in the study group were significantly lower than those in the control group, while PTH andβ2-MG clearance rate was significantly higher than that in the control group. The serum MDA, hs-CRP, IL-6, and TNF-α levels after treatment in the two groups were significantly reduced when compared with before treatment. The serum hs-CRP, IL-6, and TNF-α levels after treatment in the study group were significantly lower than those in the control group. IMT and plaque area after treatment in the control group were significantly increased when compared with before treatment, while IMT and plaque area in the study group were not significantly changed. The plaque area after treatment in the study group was significantly less than that in the control group.Conclusions: HD in combined with HP can significantly enhance the toxin clearance rate of large molecules in patients with uremia, alleviate the inflammatory reaction, and meanwhile effectively delay the occurrence of atherosclerosis and other cardiovascular complications.

Teachers’ Awareness Regarding Emergency Management of Epistaxis inside the School;Alahssa, Saudi Arabia

Background: Epistaxis is one of the commonest emergencies encountered by ENT physicians as well as to family and emergency physicians. It is common among school children as they are easily injured during different school activities. Objective: The aim of this study was to assess the level of knowledge and attitude regarding first aid management of epistaxis among school teachers in Al-Ahsa, Saudi Arabia. Method: A cross sectional study was conducted in November 2017 among Saudi school teachers in AlAhssa region, Kingdom of Saudi Arabia. The data were collected by a well-structured online questionnaire which was designed including questions about the biographical data of the teacher, questions about the past knowledge of the emergency management of epistaxis and questions assessing the awareness of the method applied as a management of epistaxis. Result: We received 485 valid responses. 76% of teachers were female, 93% worked in public and 40% were in primary schools. 54% of participants had received information about first aid to stop nose bleeding or hemorrhage. 67% said that their students experienced epistaxis before. Interestingly, 15% said they would not try to stop the bleeding, and only 25% said they would press on the cartilaginous part of nose. However, a higher percentage (57%) knew that they should tilt the head forward.

Angiographic embolization for refractory epistaxis

Objective:To assesstheroleof angiographicembolizationin treatmentof refractoryepistaxis.Methods:The diagnosticandtherapeuticroleof digitalsubtractionangiography(DSA)in13patientswithrefractoryepistaxiswereretro-spectivelystudied.Results:Pseudoaneurysmof carotidarterywasconfirmedin3of the13patientswithrefractoryepis-taxiswithangiography.Selectiveangiographicembolizationwasperformedin12/13patients.Thesuccessratewas91.67%(11/12).Patientsweretolerantto theuseof DSAwithoutseverecomplications.Conclusion:Selectiveangiographicem-bolizationis a safeandeffectivemethodintreatmentof refractoryepistaxis.In caseof traumaticepistaxiswithineffective conservativetreatmentor recurrentepistaxis,preoperativeangiographyshouldbe performedto ruleoutpseudoaneurysmof carotidartery.

Clinico-Epidemiological Pattern and Treatment of Epistaxis in a Tertiary Hospital in South Western Nigeria

Background/Objectives: Epistaxis is a common presentation and may constitute a major challenge to the parents and the health care givers. This study aimed at determining the clinico-epidemiological pattern, presentation and etiology of epistaxis. Materials and Methods: This prospective study of all patients that presented with epistaxis via the Ear, Nose and Throat department of a tertiary institution in Nigeria. The study was carried out between June 2012 and July 2017. Data were obtained from patients who gave consent by using pre-tested interviewer assisted questionnaire. All the data obtained were analyzed using SPSS version 16.0. Results: The prevalence of epistaxis in this study was 12.2%. The peak age group was 1-10 years with epistaxis prevalence of 36.4%. The male to female ratio was 1.5:1. Anterior epistaxis was more common than posterior epistaxis accounted for 80.1% and 7.4% respectively. Single episode of epistaxis was seen in 78.4% of the patients while recurrent epistaxis occurred in 21.6%. Unilateral epistaxis was 62.5%, bilateral epistaxis was 37.5% while right nasal bleeding accounted for 35.8%. The main local causes of epistaxis were trauma 29.5%, infective rhinosinusitis 18.8% and sinonasal tumours 12.5%. Severe epistaxis requiring blood transfusion was seen in 2.8% of the patients and death was recorded in 2.3%. Majority 110 (62.5%) were managed by observation alone, 20 (11.4%) by conservative therapy and 22 (12.5%) had surgical excision. Blood transfusion was given in 5. The outcome of treatment was good recovery in 79.0% while patients’ satisfaction with treatment was noted in 84.1%. Conclusion: Epistaxis is a common sinonasal presentation with effect on quality of life. In our center commonest site of nose bleeds was local mainly from traumatic, inflammatory and neoplastic aetiology.

Hereditary hemorrhagic telangiectasia presenting as a recurrent epistaxis in an adolescent:A case report

BACKGROUND Epistaxis can be an isolated finding or a manifestation of a systemic disease.Some of the potential etiologies are usage of anticoagulants,bleeding disorders,vascular aneurysms,nasal neoplasm,hypertension and nasal steroids.Hereditary hemorrhagic telangiectasia(HHT)as a cause of recurrent epistaxis is uncommon.CASE SUMMARY In this report,we describe an 18-year-old adolescent with recurrent epistaxis,mucocutaneous telangiectasia and family history of HHT,consistent with HHT.CONCLUSION Timely diagnosis is needed not only to treat the epistaxis but also to be vigilant for other serious manifestations of this condition.

Diagnosis of uremia patients based on color space

Since traditional nail diagnosis is susceptible to objective factors such as illumination,medical experience,etc.,a nail diagnosis system of traditional Chinese medicine which combines objective nail image acquisition with information analysis is proposed and applied to the clinical research of nail diagnosis of uremia patients.Fifteen nail pictures of uremic patients were collected and segmented.The color information of nails was extracted.The relationship between the hemoglobin values of uremic patients and the values of color space before and after maintenance hemodialysis was analyzed by correlation analysis and multiple regression analysis.The experimental results show that the hemoglobin value of uremic patients have certain correlations with multiple color channels;before and after dialysis,there are significant changes in multiple channels;and the related multiple regression equation is established.

左旋卡尼汀和rhEPO对尿毒症贫血的疗效观察

目的观察左旋卡尼汀对重组人红细胞生成素(rhEPO)纠正尿毒症贫血的促进作用。方法尿毒症维持性血透患者62例,其中30例透析后皮下注射rhEPO50～150IU/kg,每周1～2次;32例透析后静脉注射左旋卡尼汀1g,每周2次,并根据患者贫血程度给于rhEPO。治疗开始时和治疗后4、8、12周,分别检测血红蛋白、红细胞压积和血浆白蛋白。结果左旋卡尼汀联合rhEPO组血红蛋白、红细胞压积和血浆白蛋白水平均显著高于单用rhEPO组(P<0.01);联合用药组rhEPO用量明显减少(P<0.01),血压升高发生率(11%)显著低于单用rhEPO组(33%)(P<0.05)。结论左旋卡尼汀能加强rhEPO纠正贫血的疗效;因用量减少,降低了rhEPO引起高血压的发生率。

Effect of hemodialysis combined with hemoperfusion on dialysis efficiency, lipid metabolism and atherosclerosis in patients with uremia

Objective:To study the effect of hemodialysis (HD) combined with hemoperfusion (HP) on dialysis efficiency, lipid metabolism and atherosclerosis in patients with uremia.Methods:A total of 70 patients with uremia who were treated in our hospital between March 2013 and October 2015 were collected and divided into observation group and control group (n=35) according to double-blind randomized control method. Observation group of patients received hemodialysis combined with hemoperfusion, control group of patients received hemodialysis alone, and the treatment lasted for 6 months. After 6 months of intervention, automatic biochemical analyzer was used to detect renal function indexes and lipid metabolism indexes, and the two-dimensional ultrasound was used to quantitatively determine the carotid atherosclerosis parameters.Results:Before intervention, differences in renal function, lipid metabolism and atherosclerosis levels were not statistically significant between two groups of patients;after 6 months of intervention, renal function indexes blood urea nitrogen (BUN), serum creatinine (Scr),β2-microglobulin (β2-MG) and blood uric acid (BUA) levels of observation group were lower than those of control group, lipid metabolism indexes total cholesterol (TC), triglyceride (TG), apolipoprotein A1 (ApoA1) and apolipoprotein B (ApoB) levels were lower than those of control group, and differences between groups were statistically significant;quantitative carotid ultrasound parameters gray-scale median (GSM) of observation group was higher than that of control group, enhanced intensity (EI) and enhanced density (ED) were lower than those of control group, and differences between groups were statistically significant.Conclusion:Hemodialysis combined with hemoperfusion can improve the dialysis efficiency, also reduce lipid metabolism disturbance and delay the formation of atherosclerosis in patients with uremia.

尿毒症血液透析并发医院感染61例临床分析

目的了解尿毒症血透患者并发医院感染情况,探讨其相关的危险因素及预防措施。方法回顾分析我院2000-01～2004-07间61例尿毒症血透患者中符合医院感染诊断标准临床资料。结果61例血透患者发生感染30例,49例次,医院感染率49.18%,例次感染率80.33%。感染部位依次为呼吸道感染(64.10%),中心静脉置管相关感染(25.64%),尿路感染及肠道感染(各5.13%)。贫血越严重,白蛋白越低,医院感染率越高,差异均有显著意义(P<0.01)。原发病为糖尿病肾病较非糖尿病肾病医院感染率高,差异有显著意义(P<0.01)。且随着年龄增长及住院时间延长,感染率升高。结论尿毒症血透患者并发医院感染与住院时间、原发病、贫血、营养状况有关,同时年龄也是其危险因素。

Propranolol-Induced Epistaxis in a Woman with Multiple Obstetric Complications: Case Report

Epistaxis is a common complaint which is rarely life-threatening, as most cases are self-limited and as such unreported. However, it may be a significant cause for concern if it becomes recurrent. Although a number of medications including topical antihistamines and non-steroidal anti-inflammatory drugs are known aetiological factors for epistaxis due to their antiplatelet effects, beta blockers are not being widely reported as a possible cause. This report presents the case of a 34-year-old G2P0+1, who was diagnosed with hyperthyroidism in pregnancy and subsequently reported epistaxis twice at different occasion and different hospital settings when propranolol was introduced for her treatment, with resolution of epistaxis after withdrawal of propranolol. The report aims to highlight and sensitize physicians to the possible risk of bleeding in patients placed on beta blockers especially propranolol for a wide range of medical condition due to its thrombocytopathic effect.