The BMJ Today: Bleeding anticoagulants and guerrilla warfare

rich_hurleyCan we better quantify the risk of upper gastrointestinal and intracranial bleeding among patients who are taking long term oral anticoagulants for venous thromboembolism, systemic embolism, or stroke prevention? This information would help inform treatment, further investigation, or monitoring.

A research paper published yesterday on describes the newly devised “QBleed algorithms.” The researchers, from the University of Nottingham, found that these calculations “provided valid measures of absolute risk . . . in patients with and without anticoagulation.”

They carried out a large open cohort study, using routinely collected data from UK general practice linked to hospital episode statistics and mortality data from 2008 to 2013. They included data about 4.4 million patients with 16.4 million person years of follow-up, during which 21 641 patients had an incident upper gastrointestinal bleed, and 9040 had an intracranial bleed.

“This is among the largest of the outpatient derivation cohorts used in this specialty to date and provides extra power to develop more robust predictive models using more candidate covariates than other scores,” said Benjamin A Steinberg in a linked Editorial.

The algorithms made use of 21 variables, including patients’ age, sex, Townsend deprivation score, ethnicity, smoking, alcohol intake, chronic diseases, prescribed drugs, body mass index, systolic blood pressure, haemoglobin, platelets, and previous bleeding before the study.

“Further research is needed to evaluate the clinical outcomes and the cost effectiveness of using these algorithms in primary care,” wrote Steinberg. “What magnitude of risk is too high? Is the threshold the same for every patient and every indication?”

Bleeding risks can be calculated online, at, with open source software available to download.

Meanwhile, in a very different vein, Jeph Mathias, a former Médecins Sans Frontières doctor turned environmental crusader in northern India, reflects on a time in the Colombian jungle when he shared a beer and a chat with a rebel leader, in a recently published Personal View article.

“A hand fell on my shoulder just as I was pulling my hammock’s last knot tight,” he wrote. “He was just a boy . . . I was being kidnapped. ‘Medico,’ he said, ‘the boss wants to talk.’”

After fixing a child’s severed extensor tendon, Mathias wrote, “An MSF doctor and FARC [the Revolutionary Armed Forces of Colombia] guerrilla met and connected.”

He concludes that the guerrilla, Che, “must be long dead—malaria, leishmaniasis, a bullet, a knife—but with me still are those eyes as grey as cold ash, a velvet voice, and his implied farewell: ‘I failed. Hermano [brother] . . . Yes, heal diseases and injuries, but Medico, also heal people.’”

And vote in our latest poll on “Should boys be vaccinated against HPV as well as girls?” We’re publishing two articles on this issue tonight. We’re keen to know what you think about these or any other articles we’ve published. Leave us a rapid response: we republish the most interesting and useful as formal letters to the editor.

Richard Hurley is deputy magazine editor for The BMJ.