Background: Direct oral anticoagulants (DOACs) are widely used among hospitalized patients, yet real-world inpatient bleeding data remains relatively sparse. Most evidence derives from randomized trials enrolling ambulatory, clinically stable patients, or those being treated for a single specific indication such as acute venous thromboembolism (VTE), which may not reflect the risk profile of acutely ill inpatients with multimorbidity, procedural exposures, and fluctuating renal function. This study describes the incidence and types of bleeding events in a real-world inpatient cohort receiving apixaban or rivaroxaban at a single tertiary care center. Methods: We conducted a single-center, retrospective cohort study of 867 hospital encounters involving apixaban (n = 722, 83.3%) or rivaroxaban (n = 145, 16.7%) between 2019 and 2021. The primary outcome was a non-adjudicated, non-standardized composite of any documented bleeding (gastrointestinal bleeding, hematuria, intracranial hemorrhage, vaginal bleeding, or epistaxis) during the index hospitalization; International Society on Thrombosis and Haemostasis (ISTH) major bleeding or clinically relevant non-major (CRNM) bleeding definitions were not applied. Secondary outcomes included individual bleeding subtypes, hemoglobin drop ≥2 g/dL, transfusion requirement, ICU/CCU admission, vasopressor use, and bleeding-related mortality. All comparisons are unadjusted and descriptive. Between-group comparisons used Fisher's exact test and the Mann-Whitney U test. Results: Bleeding was documented in 13 encounters (1.5% overall; apixaban 1.39%, rivaroxaban 2.07%); given reliance on clinical documentation rather than systematic adjudication, true incidence may be higher. The composite outcome was driven predominantly by gastrointestinal bleeding (n = 10, 76.9% of events). No hemoglobin drop ≥2 g/dL, transfusion, ICU/CCU admission, vasopressor use, or bleeding-related mortality occurred in either group. No statistically significant between-agent difference was observed (p = 0.47); all comparisons are unadjusted and descriptive. Median length of stay (LOS) differed between drug groups (8.6 vs. 6.2 days; p = 0.006), an exploratory finding confounded by patient class imbalance. Conclusions: In this single-center, retrospective cohort, bleeding was documented in 1.5% of encounters; ascertainment limitations mean true incidence may be higher. Non-adjudicated, non-standardized outcome definitions and the small number of events limit comparability with the literature and preclude definitive inference. The absence of a statistically significant between-agent difference should not be interpreted as evidence of equivalence. These findings are hypothesis-generating and should not be used for comparative inference. Prospective, multicenter studies using ISTH-standardized outcomes, indication-level data, and formal adjudication are needed.

Background: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant vascular disorder primarily caused by pathogenic variants in the ENG and ACVRL1 genes. Although genotype-phenotype correlations are well established at the population level, the degree of phenotypic similarity among relatives sharing the same variant is poorly characterized. Objective: to explore differences in expressivity and quantify the degree of phenotypic variability among individuals with HHT carrying the same pathogenic variant. Methods: We evaluated 60 patients from a reference center with recurrent ENG and ACVRL1 variants, to quantify intra-familial phenotypic heterogeneity using Shannon entropy indices, Jaccard distances, and a latent variable liability-threshold approach. Results: There was substantial phenotypic variability among individuals and families, with cutaneous telangiectasia being the most frequent manifestation. Shannon entropy and Jaccard analyses indicated broadly high variability. The shared variant accounted for only 3.3% of total variance. Age was significantly associated with disease manifestations (β = 0.027, p = 0.002; OR = 1.028, 95% CI 1.010-1.045), with each additional year increasing the odds of severe symptoms by 2.7%, particularly bleeding severity and skin telangiectasias. Conclusions: These findings suggest that the variable expressivity in HHT is predominantly driven by individual-level factors other than the specific pathogenic variant carried by each patient.

Acute anterior epistaxis is frequently managed with multiple nonoperative interventions, but comparative evidence regarding their effectiveness remains uncertain. This systematic review and meta-analysis evaluated the effectiveness and safety of nonoperative treatments for acute anterior epistaxis in emergency and otolaryngology settings. PubMed/MEDLINE, Scopus, and Web of Science were searched from inception through 3 July 2026 for randomized controlled trials (RCTs) comparing nonoperative hemostatic interventions in adults with acute anterior epistaxis. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and random-effects meta-analysis was performed when sufficient clinical comparability was present. Nine RCTs including 1,124 participants were identified, with three trials contributing to quantitative synthesis. Topical tranexamic acid reduced rebleeding within 24 hours compared with matched vehicle controls (RR, 0.39; 95% CI, 0.17-0.89), with an absolute risk reduction of 19.1 percentage points. However, topical tranexamic acid was not associated with a significant reduction in further hemostatic intervention (RR, 0.59; 95% CI, 0.22-1.59). Other nonoperative strategies showed variable effects across heterogeneous outcomes. Overall, topical tranexamic acid may reduce early rebleeding in acute anterior epistaxis, but evidence regarding broader clinical outcomes remains limited by the small number of comparable trials, heterogeneous protocols, and inconsistent outcome definitions. Further high-quality randomized trials with standardized outcomes are required to clarify the optimal role of these interventions.

Background and Clinical Significance: Carbimazole is a widely used medication to treat Graves' disease, although it can rarely cause acquired aplastic anemia, a complication that happens in less than 0.01% of people. Case Presentation: We report a 36-year-old woman treated with supratherapeutic dose carbimazole who, after approximately six months of treatment, developed high grade fever, severe menorrhagia, spontaneous epistaxis, and pancytopenia. Her bone marrow biopsy showed severe bone marrow failure with only 5% cellularity and trilineage hypoplasia. Other potential causes were ruled out. Immediate discontinuation of carbimazole was done, and supportive care, including blood transfusions, broad-spectrum antibiotics, G-CSF, and eltrombopag, was started. The patient deteriorated during her hospital stay, developed neutropenic sepsis and acute respiratory failure from diffuse alveolar hemorrhage, which required intubation and pulse steroid therapy. She was stabilized and discharged, with a referral to a tertiary medical center for starting antithymocyte globulin (ATG) immunosuppressive therapy, which she subsequently completed; two months after discharge she was transfusion independent with near-normalization of her blood counts. Conclusions: This case serves as a stark reminder of how lethal thionamide-induced bone marrow failure can be, highlighting the vital need for immediate drug cessation, swift intensive care, and thorough patient education on early warning signs.

Carcinomas are the second most common feline intranasal neoplasm. Various treatment options, including radiotherapy, surgery or a combination of both, have been described, but data on medical therapy efficacy are lacking. This retrospective study evaluated the outcome of cats with nasal carcinoma (NC) treated with antineoplastic treatment. Cats with a histopathological or cytopathological diagnosis of NC were included. Patients receiving antineoplastic treatment were compared to patients receiving palliative treatment alone. Response to therapy, median time to progression (MTTP) and median survival time (MST) were described and compared for both groups. Analysed clinical variables included the presence of epistaxis, facial deformity, stage, use of NSAIDs and previous surgical debulking. Thirty-three cats were included in the study: 18 in the antineoplastic treatment group and 15 in the palliative treatment group. Forty-eight percent of the entire population had worsening of the clinical signs, 36% remained stable and 16% showed clinical benefit. MTTP of the entire population was 104 days and MST was 178 days. No statistically significant differences were found between groups for either MTTP (96 vs. 111 days; p = 0.95) or MST (197 vs. 262; p = 0.77). None of the evaluated clinical variables was associated with outcome. In this retrospective study, antineoplastic treatment was not associated with a detectable survival advantage over palliative treatment alone. These findings should be interpreted cautiously given the small sample size and heterogeneity of treatments administered.

Cerebrospinal fluid (CSF) leak during endonasal dacryocystorhinostomy is a rare, life-threatening, and underreported complication. We present 3 cases of 2 males and 1 female with an age range of 48 to 79 years. All cases involved patients with narrow nasal passages and were performed by early career surgeons. No intraoperative complications were noted in 2 cases, while severe epistaxis occurred in 1 case during superior osteotomy. All patients developed a headache within the first 48 hours, and cerebrospinal fluid rhinorrhea occurred in 1 case. Two patients developed bacterial meningitis and required intubation and ventilatory support, with 1 fatality. Imaging revealed pneumocephalus in all cases and a transverse venous sinus thrombosis in one. A break in the fovea ethmoidalis was identified in all cases, located posterior to the lacrimal sac. These defects were either at the vertical insertion of the middle turbinate or in association with an extended osteotomy superoposteriorly to the sac.

Background Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant, multisystem vascular disorder characterized by mucocutaneous telangiectasias and visceral arteriovenous malformations (AVMs). Pathogenic variants in ENG (endoglin), ACVRL1 (activin receptor-like kinase 1, ALK1), and SMAD4 (SMAD family member 4) disrupt signaling in the bone morphogenetic protein (BMP) 9/10 and transforming growth factor-beta (TGF-β) pathways, resulting in dysregulated angiogenesis and excess vascular endothelial growth factor (VEGF) activity. Clinically, HHT most commonly presents with recurrent epistaxis and chronic gastrointestinal (GI) bleeding, frequently leading to iron deficiency anemia and reduced quality of life (QoL). Complications from visceral AVMs involving the lungs, brain, and liver may also occur. Early diagnosis and systematic screening are essential to reduce preventable morbidity. Methods This narrative review synthesizes current primary literature on the diagnosis, screening, and treatment of HHT, with particular emphasis on evolving systemic therapies, supportive care strategies, and procedural interventions. Evidence from international guidelines, randomized trials, observational cohort studies, and narrowly focused systematic reviews was evaluated to summarize contemporary management approaches. Results HHT diagnosis is made with the Curaçao clinical criteria, genetic testing, and targeted imaging to identify visceral vascular malformations. Screening recommendations emphasize early detection of pulmonary and cerebral AVMs and ongoing surveillance for anemia and other complications. Therapeutic strategies increasingly prioritize systemic therapy over repeated local procedures. Antiangiogenic agents including intravenous bevacizumab, pomalidomide, thalidomide, and oral pazopanib have demonstrated efficacy in reducing bleeding severity, improving hemoglobin levels, and decreasing transfusion requirements in moderate-to-severe disease. Supportive care remains foundational and includes iron replacement, selective blood transfusion, routine monitoring, and assessment of patient-reported QoL. In patients with refractory epistaxis, surgical interventions such as septodermoplasty or nasal closure may provide durable bleeding control. Endovascular and neurosurgical management may also be required for selected vascular complications. Conclusions Management of HHT is undergoing a paradigm shift toward mechanism-based systemic therapy integrated with multidisciplinary care. Advances in antiangiogenic and precision-medicine approaches are improving bleeding control and long-term outcomes. Early recognition, comprehensive screening, individualized therapy, and coordinated management across specialties are critical for optimizing care in this complex multisystem disease.

Here, we describe a case of Exserohilum rostratum rhinitis in a cow and review the literature on diseases caused by Exserohilum spp. and dematiaceous fungi historically classified morphologically as Helminthosporium, Drechslera, or Bipolaris in domestic ruminants. In March 2024, an adult Holstein cow from a dairy herd in Uruguay developed bilateral nodules in the nasal mucosa, resulting in dyspnea, snoring, nasal discharge, and weight loss. Histologically, severe chronic eosinophilic granulomatous rhinitis was found, with giant cells and intra- and extracellular fungi. Exserohilum rostratum was identified by PCR and sequencing of the extended 28S rDNA region. Our literature search retrieved ~40 bovine cases in the United States, Australia, South Africa, Namibia, and Uruguay, 1 caprine case in Brazil, and no ovine cases. Clinical signs included chronic dyspnea, stertor, mucopurulent nasal discharge, epistaxis, and weight loss, generally affecting adult beef cattle. The lesions usually affected the nasal mucosa and submucosa, rarely involved the skin or regional lymph nodes, and occasionally were restricted to the skin. Bilateral, raised, 0.1-5-cm granulomatous nasal nodules resulted in restriction of airflow. The hallmark microscopic lesion is chronic eosinophilic granulomatous inflammation with giant cells and intralesional fungal structures, including ~5-30-µm, round-to-ovoid chlamydospores and short ~2-6-µm-wide septate hyphae, which may have brown-pigmented walls. Definitive fungal identification requires molecular testing, which is rarely pursued.

Delayed severe epistaxis after closed reduction of a nasal bone fracture is uncommon, and postoperative nasal synechia is rarely considered as a bleeding source. A 19-year-old woman developed recurrent severe epistaxis 5 weeks after closed reduction and intranasal packing. Bleeding recurred immediately after pack removal despite repeated packing. Emergency endoscopic exploration showed bilateral adhesions between the septum and inferior turbinate, with active bleeding directly visualized from right-sided synechial tissue. Suction coagulation and synechiolysis achieved hemostasis. Hemoglobin decreased from 13.7 to 7.9 g/dL, but transfusion was not required, and no recurrence occurred during 159 days of follow-up. Postoperative nasal synechia should be considered in unexplained delayed epistaxis after nasal fracture management, particularly when bleeding repeatedly recurs after pack removal; early endoscopic evaluation may identify and control a focal structural source.