Acute pulmonary embolism as a complication in a young male patient with a left popliteal venous aneurysm / Embolia pulmonar aguda como complicação em paciente masculino jovem com aneurisma venoso poplíteo esquerdo

Abstract Venous aneurysms are rare and have a prevalence of 0.1 to 0.2% in the reported series. Typically, patients do not present any symptoms, but are prone to develop deep venous thrombosis (DVT) and the most feared complication, pulmonary embolism (PE). We present the case of a previously healthy 36-year-old man who presented at the emergency department with tachycardia, dyspnea, and pleuritic pain. A thoracic computed tomography angiography (CTA) confirmed the diagnosis of acute pulmonary embolism. He was treated with systemic thrombolysis and anticoagulation. In the further workup of the cause of the embolism, computed tomography revealed a fusiform dilation of the left popliteal vein measuring 3 by 3 centimeters (cm) with an incomplete filling defect because of thrombus presence. The patient underwent open surgical repair. At one month follow-up, he was asymptomatic, and an ultrasound revealed complete patency of the popliteal vein without dilatation or thrombus.

Resumo Aneurismas venosos são raros, tendo uma prevalência de 0,1 a 0,2% nas séries relatadas. Os pacientes não costumam manifestar sintomas; entretanto, são propensos a desenvolver trombose venosa profunda e a complicação mais temida, embolia pulmonar. Apresentamos o caso de um homem de 36 anos previamente hígido que chegou ao serviço de emergência queixando-se de taquicardia, dispneia e dor pleurítica. Uma angiotomografia computadorizada confirmou o diagnóstico de embolia pulmonar aguda. O paciente foi tratado com trombólise sistêmica e anticoagulantes. Em exames posteriores para investigar a causa da embolia, uma tomografia computadorizada revelou dilatação fusiforme da veia poplítea esquerda medindo 3x3 cm, com enchimento incompleto devido à presença de um trombo. O paciente foi submetido a reparo cirúrgico aberto. No seguimento de 1 mês, ele estava assintomático, e uma ultrassonografia revelou a patência completa da veia poplítea, sem dilatação ou trombo.

Incidence of thrombotic events and complications associated to inferior vena cava filters in patients with and without anticoagulation therapy / Incidencia de eventos trombóticos y complicaciones asociadas al uso de filtros de vena cava en pacientes en pacientes con o sin terapia anticoagulante

Abstract Objective: Anticoagulation is the primary management to prevent venous thromboembolism; inferior vena cava filters (IVCFs) provide a mechanical prophylactic alternative when anticoagulation is contraindicated. The aim of this study was to evaluate in IVCF patients, whether the initiation of anticoagulation therapy is associated with decreased rates of recurrent thrombotic events and device-related complications. Methods: This was a retrospective review of patients that underwent insertion of IVCF. Subjects with IVCF were studied in two groups: those initiated on anticoagulation (A) and without anticoagulation (NA). Variables as indications for IVCF, anticoagulation, recurrence of thrombosis, complications, and reinterventions were examined. Results: From April 2007 to March 2014, 54 patients underwent IVCF placement; (61% of females), with mean age of 54 years (standard deviation ± 19). 28 (52%) were initiated on anticoagulation, during a mean follow-up period of 28 months, five experienced recurrent thrombosis and three were on the A group (p=0.5); when comparing patients that developed post-thrombotic syndrome, seven were in the A group and seven in the NA. Two patients with IVC rupture were in the A group (p=0.5), and the only case of IVCF migration occurred in the A group. 11 (20%) patients died from comorbidities nonrelated to the device or procedure (four in the A cohort). Conclusions: Patients with IVCF on anticoagulation have equivalent rates of thrombotic events and device-related complications than those patients NA.

Resumen Objetivo: La anticoagulación es la terapia de elección para la prevención de tromboembolismo venoso; los filtros de vena cava inferior (FVCI) proveen una alternativa mecánica profiláctica cuando la anticoagulación está contraindicada. El objetivo de este estudio fue evaluar si la terapia anticoagulante se asocia con una tasa menor de eventos trombóticos recurrentes y complicaciones relacionadas con el dispositivo. Métodos: Los pacientes fueron categorizados en dos grupos: Aquellos a los que se les inicio anticoagulación (A) y aquellos que no (NA). Variables tales como indicación de la colocación del filtro, anticoagulación, recurrencia de trombosis y complicaciones fueron examinadas. Resultados: De abril de 2007 a marzo 2014, a 54 pacientes se les coloco un filtro (61% fueron mujeres), con una media de edad de 54 años [Desviación estándar (DE) ±19. Veintiocho (52%) fueron iniciados en anticoagulación y durante un seguimiento de 28 meses, 5 pacientes experimentaron recurrencia de trombosis, 3 en el grupo A (p=0.5). Al comparar los pacientes que desarrollaron síndrome posflebítico, 7 pertenecieron al grupo A y 7 al grupo NA. Dos pacientes con ruptura de vena cava pertenecieron al grupo A (p=0.5) y el único caso de migración del dispositivo ocurrió en el grupo A. Once (20%) pacientes fallecieron debido a comorbilidades no relacionadas con el dispositivo o el procedimiento. Conclusión: Pacientes con FVCI en anticoagulación tienen tasas de eventos trombóticos y complicaciones asociadas a los dispositivos equivalentes a aquellos pacientes sin anticoagulación.

II. The research ethics involving vulnerable groups

Abstract Vulnerability in research occurs when the participant is incapable of protecting his or her interests and therefore, has an increased probability of being intentionally or unintentionally harmed. This manuscript aims to discuss the conditions that make a group vulnerable and the tools and requirements that can be used to reduce the ethical breaches when including them in research protocols. The vulnerability can be due either to an inability to understand and give informed consent or to unequal power relationships that hinder basic rights. Excluding subjects from research for the only reason of belonging to a vulnerable group is unethical and will bias the results of the investigation. To consider a subject or group as vulnerable depends on the context, and the investigator should evaluate each case individually.

I. The role of research ethics committees in observational studies: epidemiological registries, case reports, interviews, and retrospective studies

Abstract It is often unclear to the clinical investigator whether observational studies should be submitted to a research ethics committee (REC), mostly because, in general, no active or additional interventions are performed. Moreover, obtaining an informed consent under these circumstances may be challenging, either because these are very large epidemiological registries, or the subject may no longer be alive, is too ill to consent, or is impossible to contact after being discharged. Although observational studies do not involve interventions, they entail ethical concerns, including threats such as breaches in confidentiality and autonomy, and respect for basic rights of the research subjects according to the good clinical practices. In this context, in addition to their main function as evaluators from an ethical, methodological, and regulatory point of view, the RECs serve as mediators between the research subjects, looking after their basic rights, and the investigator or institution, safeguarding them from both legal and unethical perils that the investigation could engage, by ensuring that all procedures are performed following the international standards of care for research. The aim of this manuscript is to provide information on each type of study and its risks, along with actions to prevent such risks, and the function of RECs in each type of study.

Revisión sistemática de procedimientos quirúrgicos usados para tratar patología aórtica en México / Systematic review of surgical procedures used to treat aortic pathology in Mexico

Resumen Introducción: En México no se cuentan con estadísticas adecuadas acerca de la enfermedad aórtica, que puede ser tratada mediante manejo médico o cirugía abierta o endovascular. Objetivo: Identificar la literatura en bases de datos electrónicas relativa al manejo invasivo de la patología aórtica en México. Método: Se realizó búsqueda sistemática y revisión narrativa de la literatura disponible en diferentes bases de datos electrónicas: PubMed, Imbiomed, Clinical Key, Bibliat, Scielo, Sage Journals, Sciencedirect y con el motor de búsqueda de Google Académico. Resultados: Se encontraron 90 artículos, de los cuales 50 reunían los criterios de inclusión. Fueron seleccionados estudios observacionales y reportes de casos, con énfasis en los datos demográficos de los pacientes, resultados clínicos y la supervivencia posoperatoria a 30 días. Conclusión: Se reporta elevada tasa de complicaciones de las enfermedades aórticas debido al infradiagnóstico de estas, que deriva en manejo más complejo y pronóstico desfavorable. La creación de un registro nacional de patología aórtica es crucial para la estandarización en el abordaje y la optimación de los resultados.

Abstract Introduction: In Mexico, there are no appropriate statistical data on aortic disease, which can be treated with medical management or open or endovascular surgical approach. Objective: To carry out a systematic search and review of the literature in electronic databases with regard to invasive management of aortic pathology in Mexico. Method: A systematic search and narrative review of available literature was carried out using different electronic databases: PubMed, Imbiomed, Clinical Key, Bibliat, Scielo, Sage Journals and Sciencedirect, as well as with the Google Scholar search engine. Results: Ninety articles were found, out of which only 53 met the inclusion criteria. Observational studies and case reports were selected, emphasizing on patient demographics, clinical results, and 30-day postoperative survival. Conclusion: An elevated rate of complications is reported for aortic pathologies due to underdiagnosis, which results in management being more complicated and prognosis unfavorable. The creation of a national aortic disease registry is crucial to standardization in the approach and optimization of results.

Evaluación de 20 años de experiencia y calidad de vida en pacientes con tratamiento quirúrgico para la enfermedad quística del hígado / Evaluation of 20 years of experience and quality of life in surgically treated patients with cystic liver disease

El tratamiento quirúrgico en la enfermedad quística del hígado, debe ser reservado para pacientes con sintomatología importante. El tipo de tratamiento quirúrgico depende del tamaño y localización del o de los quistes. En pacientes con hígado poliquístico y hepatomegalia masiva puede estar indicado el trasplante hepático, con buenos resultados en la supervivencia y calidad de vida (CV). Objetivo: observar la evolución en un periodo de 20 años, en tres grupos de pacientes con Enfermedad Quística del Hígado (EQ), que se sometieron a tratamiento quirúrgico y determinar la calidad de vida de los mismos. Material y método: en un periodo de 20 años fueron operados 44 pacientes. Los casos se distribuyeron en quistes simples (24 casos), hígado poliquístico (13 casos), cistadenomas (siete casos). Mediante el cuestionario SF-36 (de un año) se evaluó la autopercepción de la CV a través de ocho dominios, agrupados en dos categorías mayores: subescalas de salud física (PCS) y de salud mental (MCS). Resultados: el dolor abdominal fue el principal síntoma e indicación de cirugía. La fenestración fue el procedimiento quirúrgico que con mayor frecuencia se realizó. Respecto a la calidad de vida, no se reportaron diferencias significativas en la distribución por diagnóstico y se consideró como buena en todo el grupo. El seguimiento promedio postoperatorio fue de 39 meses. Conclusión: el manejo quirúrgico en la EQ debe ser reservado para pacientes con síntomas secundarios a un crecimiento exagerado o complicaciones, como ruptura, infección y hemorragia. Las opciones terapéuticas se deben individualizar en cada paciente. Los resultados de calidad de vida son buenos después del tratamiento quirúrgico.