Management of bleeding in patients hospitalized in the intensive cardiac care unit: expert opinion of the Association of Intensive Cardiac Care and Section of Cardiovascular Pharmacotherapy of the Polish Cardiac Society in cooperation with specialists in other fields of medicine

ABSTRACT Nowadays, the intensive cardiac care unit (ICCU) provides care for patients with acute coronary syndrome, acute and exacerbated chronic heart failure, cardiogenic shock, sudden cardiac arrest, electrical storm, as well as with indications for urgent cardiac surgical treatment. Most of these patients require the use of 1, 2, or frequently even 3 drugs that act on the blood coagulation pathway. While antithrombotic drugs prevent thromboembolic events, they are associated with a higher risk of bleeding. In this population of patients, bleeding may often have a worse impact on prognosis than the primary disease. In this expert opinion of the Association of Intensive Cardiac Care, we presented practical guidelines on the management of bleeding in patients hospitalized at the ICCU, including bleeding risk reduction and treatment recommendations. Because of multiple comorbidities and diverse organs that may be the source of bleeding, we provided also recommendations from specialists in other fields of medicine. We hope that this document will facilitate the management of one of the most challenging populations at the ICCU

Postępowanie w krwawieniach u pacjentów hospitalizowanych na oddziale intensywnej terapii kardiologicznej

Współczesny Oddział Intensywnej Terapii Kardiologicznej (OITK) to miejsce, gdzie leczeni są pacjenci z ostrymi zespołami wieńcowymi, z ostrą i zaostrzoną przewlekłą niewydolnością serca, wstrząsem kardiogennym, po nagłym zatrzymaniu krążenia, z burzą elektryczną, a także z pilnymi wskazaniami do leczenia kardiochirurgicznego. Większość tych chorych wymaga stosowania jednego, dwóch, a nierzadko trzech leków wpływających na układ krzepnięcia. Leki przeciwzakrzepowe, zabezpieczając pacjentów przed zdarzeniami zakrzepowo‑zatorowymi, zwiększają jednocześnie ryzyko krwawień. Krwawienia w tej grupie pacjentów mogą mieć niejednokrotnie gorszy wpływ na rokowanie niż choroba podstawowa. Niniejsza opinia ekspertów Asocjacji Intensywnej Terapii Kardiologicznej ma za zadanie przedstawić praktyczne wskazówki postępowania z pacjentami na OITK w celu zmniejszenia ryzyka krwawień i sposobu ich leczenia. Ze względu na liczne choroby współistniejące w tej grupie chorych, jak również różne organy, w których obrębie może dochodzić do krwawień, w niniejszym dokumencie opieramy się też na zaleceniach przygotowanych przez specjalistów innych dziedzin medycyny. Mamy nadzieję, że niniejszy dokument okaże się przydatny w postępowaniu z tą jedną z najtrudniejszych grup pacjentów na OITK.Współczesny Oddział Intensywnej Terapii Kardiologicznej (OITK) to miejsce, gdzie leczeni są pacjenci z ostrymi zespołami wieńcowymi, z ostrą i zaostrzoną przewlekłą niewydolnością serca, wstrząsem kardiogennym, po nagłym zatrzymaniu krążenia, z burzą elektryczną, a także z pilnymi wskazaniami do leczenia kardiochirurgicznego. Większość tych chorych wymaga stosowania jednego, dwóch, a nierzadko trzech leków wpływających na układ krzepnięcia. Leki przeciwzakrzepowe, zabezpieczając pacjentów przed zdarzeniami zakrzepowo‑zatorowymi, zwiększają jednocześnie ryzyko krwawień. Krwawienia w tej grupie pacjentów mogą mieć niejednokrotnie gorszy wpływ na rokowanie niż choroba podstawowa. Niniejsza opinia ekspertów Asocjacji Intensywnej Terapii Kardiologicznej ma za zadanie przedstawić praktyczne wskazówki postępowania z pacjentami na OITK w celu zmniejszenia ryzyka krwawień i sposobu ich leczenia. Ze względu na liczne choroby współistniejące w tej grupie chorych, jak również różne organy, w których obrębie może dochodzić do krwawień, w niniejszym dokumencie opieramy się też na zaleceniach przygotowanych przez specjalistów innych dziedzin medycyny. Mamy nadzieję, że niniejszy dokument okaże się przydatny w postępowaniu z tą jedną z najtrudniejszych grup pacjentów na OITK

A Quarter of Century in Artificial Intelligence and Law: Projects, Personal Trajectories, a Subjective PerspectiveLanguage, Culture, Computation. Computing of the Humanities, Law, and Narratives

This article describes projects in the domain of artificial intelligence and law, which resulted from the research of the five authors listed, when they formed teams (of the first author named and each one of the other authors). Therefore, the present paper offers a subjective perspective, from the viewpoint of personal trajectories within AI & Law. Several, though not all, of the projects concerned dealt with facets of legal evidence. These projects include: ALIBI (an AI planner generating exonerating accounts); a representation of Italy’s regional constitutions in a nested-relation representation (a precursor of XML); the application of kappa calculus and a probabilistic interpretation to a Scandinavian approach to evidential strength; the application of Petri Nets for representing temporal relations in mutual wills; Daedalus (Judge Asaro’s software assisting Italy’s examining magistrates with inquiries, and then when they turn prosecutors); a study in occurrences in court of allegations echoing the pretext archetype “The dog ate my homework” (even when the claim was not pretextuous); an application of Wigmore Charts to an analysis of both the argumentation and the rhetoric of an Italian arringa (final submissions to the court) from a real court case; editorial projects which promoted the emergence of evidence as a conspicuous field within AI & Law (thus overturning previous neglect); and a magnum opus (Nissan 2012a) which presents the state of the art of computational applications to legal evidence, police inquiries, or argumentation

Safety and outcome of revascularization treatment in patients with acute ischemic stroke and COVID-19: the Global COVID-19 Stroke Registry

Background and ObjectivesCOVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19.MethodsThis was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT).ResultsOf a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60).DiscussionPatients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis.Paroxysmal Cerebral Disorder

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry.

COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry.

BACKGROUND AND OBJECTIVES COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. METHODS Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry

BACKGROUND AND OBJECTIVES: COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. METHODS: Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS: Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION: Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis