Preferences and Practices of Brazilian Orthopedists for Thromboprophylaxis Techniques in Total Knee Arthroplasty: Survey Among Members of the Brazilian Society of Knee Surgery (SBCJ) / Preferências e práticas de ortopedistas brasileiros por técnicas de tromboprofilaxia na artroplastia total do joelho: Levantamento entre membros da Sociedade Brasileira de Cirurgia do Joelho (SBCJ)

Abstract Objective The present study describes the preferences and current practices of a sample of knee surgeons in Brazil regarding thromboprophylaxis in total knee arthroplasty (TKA). Method In the present internet survey, surgeons from the Brazilian Knee Surgery Society (SBCJ, in the Portuguese acronym) voluntarily answered an anonymous questionnaire including time of personal surgical experience, perceptions about the best thromboprophylaxis options, and actual practices in their work environment. Results From December 2020 to January 2021, 243 participants answered the questionnaire. All, except for 3 (1.2%), reported using thromboprophylaxis, and most (76%) combined pharmacological and mechanical techniques. The most prescribed drug was enoxaparin (87%), which changed to rivaroxaban (65%) after discharge. The time of thromboprophylaxis initiation varied according to the length of training of the knee surgeon (p ≤ 0.03), and their preferences and practices differed according to the Brazilian region (p< 0.05) and the health system in which the surgeons work (public or private sector; p= 0.024). The option for mechanical thromboprophylaxis also depended on the training time of the surgeon. Conclusion Thromboprophylaxis preferences and practices in TKA are diverse across Brazilian regions and health systems (public or private sectors). Given the lack of a national clinical guideline, most orthopedists follow either their hospital guidelines or none. The mechanical prophylaxis method and the little use of aspirin are the points that most diverge from international guidelines and practices.

Resumo Objetivo Descrever as preferências e práticas atuais de uma amostra de cirurgiões de joelho do Brasil quanto à forma de tromboprofilaxia na artroplastia total do joelho (ATJ). Método presente pesquisa realizada pela internet, cirurgiões associados à Sociedade Brasileira de Cirurgia do Joelho (SBCJ) foram convidados a responder voluntariamente a um questionário anônimo incluindo o tempo de experiência cirúrgica pessoal, percepções sobre as melhores opções de tromboprofilaxia e as reais práticas no ambiente onde trabalham. Resultados Entre dezembro de 2020 e janeiro de 2021, 243 participantes responderam ao questionário completo. Exceto por 3 (1,2%) participantes, todos declararam praticar tromboprofilaxia, a maioria (76%) combinando as formas farmacológica e mecânica. A droga mais prescrita é a enoxaparina (87%), com modificação para rivaroxabana (65%) após a alta. O momento de início da tromboprofilaxia variou conforme o tempo de formação do cirurgião de joelho (p ≤ 0,03) e as preferências e práticas variaram conforme a região do país (p< 0,05) e o sistema de saúde no qual trabalham os cirurgiões (público ou privado; p= 0,024). A opção por tromboprofilaxia mecânica também dependeu do tempo de formação do cirurgião. Conclusão As preferências e práticas de tromboprofilaxia na ATJ são diversas nas regiões do Brasil e sistemas de saúde (público ou privado). Dada a inexistência de uma diretriz clínica nacional, a maior parte dos ortopedistas segue ou a diretriz de seu próprio hospital ou nenhuma. O método de profilaxia mecânica e a pouca utilização do ácido acetilsalicílico são os pontos que mais destoam das diretrizes e práticas internacionais.

Influência do sexo e da idade sobre o diâmetro da cava inferior e implicações para o implante de filtros de veia cava / Influence of sex and age on inferior vena cava diameter and implications for the implantation of vena cava filters

Resumo Contexto A aferição do diâmetro venoso e a escolha de um filtro de veia cava compatível são fundamentais para diminuir o risco de complicações decorrentes do implante desses dispositivos. Entretanto, são escassas as informações sobre como o diâmetro da cava inferior varia de acordo com o sexo e a idade. Objetivos Determinar a influência do sexo e da idade dos pacientes sobre o diâmetro da cava inferior e a adequação dos diferentes modelos de filtro disponíveis. Métodos Estudo analítico retrospectivo, realizado a partir de imagens de tomografia computadorizada. O diâmetro no segmento infrarrenal da veia cava inferior foi aferido em três pontos (cranial, médio e caudal). Os resultados foram classificados de acordo com o sexo e as faixas etárias. Resultados Foram analisadas tomografias de 417 pacientes: 245 mulheres e 172 homens. Os diâmetros nos pontos médio e caudal foram, respectivamente, 19,1 mm e 20,6 mm em mulheres de 81 a 92 anos, sendo estatisticamente menores (p < 0,05) quando comparados aos de mulheres com idade entre 19 e 40 anos (diâmetro no ponto médio: 22,7 mm; diâmetro no ponto caudal: 23 mm). Resultados semelhantes foram observados em homens. Os diâmetros venosos nos pontos cranial e caudal foram estatisticamente maiores em homens (ponto cranial: 24,4 mm; ponto caudal: 22,3 mm) do que em mulheres (ponto cranial: 22,6 mm; ponto caudal: 20,8 mm) em pacientes com idade entre 51 e 70 anos (p < 0,05). Conclusões O diâmetro da veia cava inferior foi menor em pacientes com idade mais avançada em ambos os sexos, e a taxa de variação do diâmetro foi semelhante entre homens e mulheres.

Abstract Background Measuring the venous diameter and choosing a compatible vena cava filter are essential to reduce the risk of complications resulting from implantation of these devices. However, there is little information on how the diameter of the inferior vena cava varies with sex and age. Objectives To determine the influence of patients' gender and age on their inferior vena cava diameter and the suitability of the different models of available filters. Methods Retrospective analytical study based on computed tomography images. The diameter of the inferior vena cava was measured at 3 points: above the confluence of the common iliac veins, below the renal veins, and midway between these two points (cranial point, caudal point, and midpoint) using Arya® and Carestream PACS® software. The results were classified by sex and age groups. Results CT scans of 417 patients were analyzed: 245 women and 172 men. The diameters at the midpoint and caudal point were, respectively, 19.1 mm and 20.6 mm in women from 81 to 92 years old and were statistically smaller (p< 0.05) when compared to women aged 19 to 40 years (midpoint: 22.7 mm; caudal point: 23 mm). Similar results were seen in men. Venous diameters at the cranial and caudal points in patients aged from 51 to 70 years were statistically larger in men (cranial point: 24.4 mm; caudal point:22.3 mm) than in women (cranial point: 22.6 mm; caudal point:20.8 mm) (p< 0.05). Conclusions A smaller diameter was found for the inferior vena cava in older patients of both sexes and the rate of diameter change was similar among men and women.

Análise dos desfechos maternos e fetais relacionados à COVID-19 durante a gestação / Analysis of maternal and fetal outcomes related to COVID-19 during pregnancy

O SARS-CoV-2 é um vírus RNA transmitido pelo contato direto ou indireto por gotículas infectadas. No que se refere à COVID-19 e à gestação, referências apontam que nesse período as mulheres possuem maior susceptibilidade a complicações obstétricas e perinatais. O presente estudo objetiva compreender e compilar aspectos da infecção e os principais desfechos negativos maternos e fetais documentados na literatura atual, relacionados à infecção pelo novo coronavírus durante a gestação. Trata-se de uma revisão integrativa de literatura embasada pela análise de 2.441 artigos no total, dos quais 62 foram incluídos na pesquisa, sendo 38 deles da base de dados PubMed e 24 da BVS (Biblioteca Virtual em Saúde), nos idiomas inglês e português. Em conclusão, mulheres grávidas com diagnóstico da patologia podem precisar de assistência de alta complexidade. A associação à doença pode apresentar riscos ou complicações como coagulopatias, pré-eclâmpsia, prematuridade e outros desfechos negativos que serão abordados neste artigo.(AU)

SARS-CoV-2 is an RNA virus, transmitted by direct or indirect contact by infected droplets. Regarding to COVID-19 and pregnancy, references indicate that during this period, women are more susceptible to obstetric and perinatal complications. This study aims to understand and compile aspects of infection and the main negative maternal and fetal outcomes documented in the current literature, related to the infection by the new coronavirus during pregnancy. This is an integrative literature review based on the analysis of 2,441 articles in total, of which 62 were included in the survey, 38 from the PubMed database and 24 from BVS (Biblioteca Virtual em Saúde) in English and Portuguese languages. In conclusion, pregnant women diagnosed with the pathology may need highly complex assistance. The association with the disease may present risks for complications such as coagulopathies, pre-eclampsia, prematurity and other negative outcomes that will be addressed in this article.(AU)

Trombose de veia porta não associada à cirrose - desafio terapêutico / Non-cirrhotic portal vein thrombosis - therapeutic challenge

Resumo A trombose de veia porta (TVP) é uma doença na qual ocorre trombose desde os ramos intra-hepáticos da veia porta, podendo se estender até a veia esplênica e/ou veia mesentérica superior, estando associada, na maioria das vezes, à cirrose hepática. A TVP não associada a cirrose é rara. O objetivo deste artigo foi relatar dois casos de TVP não associados à cirrose, que foram tratados com anticoagulação e tiveram evolução clínica satisfatória.

Abstract Portal vein thrombosis (PVT) is a disease in which thrombosis occurs from the intrahepatic branches of the portal vein, and may extend to the splenic vein and/or superior mesenteric vein. It is most often associated with liver cirrhosis. PVT not associated with cirrhosis is rare. The aim of this article is to report two cases of PVT in which it was not associated with cirrhosis. Both were treated with anticoagulation and clinical progress afterwards was good.

Trousseau′s syndrome with cerebral infarction:report of one case with literature review / 中华全科医师杂志

Trousseau′s syndrome(TS) is a complication of cancer-associated thrombosis caused by hypercoagulability. A 58-years female patient admitted to the Affiliated Hospital of Qingdao University on October 2020 and diagnosed with Trousseau′s syndrome was reported. This was a patient with pancreatic malignant tumor. On the second day of admission, the mouth angle was distorted and the speech was vague. Craniocerebral MR showed multiple DWI high signals in the brain parenchyma, and brain MR enhancement showed no abnormal enhancement in the brain parenchyma. The patient was considered to be Trousseau′s syndrome. Using "Trousseau′s syndrome" and "cerebral infarction" as key words, the relevant literature was searched in CNKI, Wanfang and PubMed databases from January 2011 to June 2021, total of 76 cases of Trousseau′s syndrome complicated with cerebral infarction were reported in the literature. Among 77 cases (including one in this study) 36 were males and 41 were females, with a median age of 63 years old. The most common tumor type was lung adenocarcinoma (24 cases, 31.2 %). The mean D-dimer level was (17.3±12.8) mg/L, Craniocerebral CT or MRI showed that 57 cases (74.0 %) had bilateral multiple lesions; and 56 cases received anticoagulant therapy. A total of 68 patients were followed up, with a median survival time of 90 days, and one year overall survival rate was 32.6 %. The study indicates that for cerebral infarction with significantly elevated D-dimer level and multiple vascular involvement, malignant tumors should be considered.

Atrial fibrillation with low cardioembolic risk and ischemic cerebrovascular accidents / Fibrilación auricular con riesgo cardioembólico bajo y accidente cerebrovascular isquémico

Abstract Atrial fibrillation is the most prevalent disease in hypertensive patients over the age of 60. Although a large proportion of patients have symptoms related to this arrhythmia, some asymptomatic patients may experience cerebrovascular accidents as the only clinical manifestation. It is very important for clinicians to have a clear understanding of the tools, scales and specific information required for performing an appropriate assessment of patients with atrial fibrillation, in order to prevent its complications. We present the case of a male patient with atrial fibrillation and a low risk of ischemic cardiovascular accidents, whose implanted event monitor showed no evidence of arrhythmias for over one year, and who developed an ischemic CVA in multiple cerebral territories, with subsequent documentation of a thrombus in the left atrial appendage. (Acta Med Colomb 2021; 46. DOI:https://doi.org/10.36104/amc.2021.2006).

Resumen La fibrilación auricular es la enfermedad más prevalente en pacientes hipertensos mayores de 60 años. Si bien una gran proporción de pacientes tiene síntomas relacionados con esta arritmia, algunos pacientes asintomáticos pueden desarrollar accidentes cerebrovasculares como única manifestación clínica. Para el clínico es importante tener un conocimiento claro sobre las herramientas, escalas e información específica para realizar una correcta valoración del paciente con fibrilación auricular, con el objetivo de prevenir las complicaciones relacionadas con esta arritmia. Se presenta el caso de un paciente de sexo masculino con fibrilación auricular y riesgo bajo de accidente cerebrovascular isquémico, portador de monitor de eventos, sin evidencia de arritmia por más de un año, quien desarrolló un ACV isquémico en múltiples territorios cerebrales, con posterior documentación de trombo en la auriculilla izquierda. (Acta Med Colomb 2021; 46. DOI:https://doi.org/10.36104/amc.2021.2006).

Consenso Colombiano para la prevención, diagnóstico y manejo de condiciones trombóticas en pacientes adultos con COVID-19: aplicando el Marco de la Evidencia a la Decisión (EtD) GRADE / Colombian consensus for the prevention, diagnosis and treatment of thrombotic conditions in adult patients with COVID-19: applying GRADE Evidence to Decision (EtD) Frameworks

resumen está disponible en el texto completo

Abstract Recent studies have reported the occurrence of thrombotic phenomena or coagulopathy in patients with COVID-19. There are divergent positions regarding the prevention, diagnosis, and treatment of these phenomena, and current clinical practice is based solely on deductions by extension from retrospective studies, case series, observational studies, and international guidelines developed prior to the pandemic. In this context, the aim was to generate a group of recommendations on the prevention, diagnosis and management of thrombotic complications associated with COVID-19. Methods: A rapid guidance was carried out applying the GRADE Evidence to Decision (EtD) frameworks and an iterative participation system, with statistical and qualitative analysis. Results: 31 clinical recommendations were generated focused on: a) Coagulation tests in symptomatic adults with suspected infection or confirmed SARS CoV-2 infection; b) Thromboprophylaxis in adults diagnosed with COVID-19 (Risk scales, thromboprophylaxis for outpatient, in-hospital management, and duration of thromboprophylaxis after discharge from hospitalization), c) Diagnosis and treatment of thrombotic complications, and d) Management of people with previous indication of anticoagulant agents. Conclusions: Recommendations of this consensus guide clinical decision-making regarding the prevention, diagnosis, and treatment of thrombotic phenomena in patients with COVID-19, and represent an agreement that will help decrease the dispersion in clinical practices according to the challenge imposed by the pandemic.

Cardioembolic stroke: risk factors, clinical features, and early outcome in 956 consecutive patients

ABSTRACT Background: There is little information about the early clinical features of cardioembolic stroke before complementary examinations. Objective: The aim of this study was to identify risk factors, clinical features, and early outcomes of cardioembolic stroke. Methods: Retrospective study based on prospectively collected data available from a university medical center hospital-based stroke registry. Consecutive patients diagnosed with cardioembolic infarction were selected and compared to those diagnosed with an atherothrombotic stroke. Predictors of cardioembolic infarction were assessed by multivariate analysis. Results: From a cohort of 4597 consecutive patients, we studied 956 patients diagnosed with cardioembolic infarction (80 years [standard deviation (SD) 9.14]; 63% women) and 945 with atherothrombotic infarction (77.01 years [SD 9.75]; 49.8% women). The univariate comparative analysis reported that advanced age (≥ 85 years), female gender, atrial fibrillation (AF), ischemic heart disease, and congestive heart failure were significantly more frequent in the cardioembolic group, whereas hypertension, diabetes, peripheral vascular disease, heavy smoking, hyperlipidemia, and previous transient ischemic attack were significant in the atherothrombotic group. In the logistic regression model, AF (odds ratio [OR] 15.75, 95% confidence interval [CI]: 12.14-20.42), ischemic heart disease (OR 3.12, 95% CI: 2.16-4.5), female gender (OR 1.56, 95% CI: 1.22-2.00), and sudden-onset (OR 1.97, 95% CI: 1.54-2.51), were independent significant predictors of cardioembolic stroke. Conclusions: Potential cardioembolic stroke requires a comprehensive evaluation, since early classification and identification through predictors would improve effective management. (REV INVEST CLIN. 2021;73(1):23-30)

Accidente cerebrovascular de la arteria basilar: cannabis como factor de riesgo en jóvenes / Cerebrovascular accident of basilar artery: Cannabis as a risk factor in young people / Acidente Vascular Cerebral (AVC) da artéria basilar: cannabis como fator de risco em jovens

Introducción. La arteria basilar se forma de las arterias vertebrales, cursa sobre el puente y se bifurca originando las arterias cerebrales posteriores. Irriga parte del tronco encefálico, cerebelo, tálamo y los lóbulos occipitales y temporales cerebrales. Su obstrucción es rara (1% de los accidentes isquémicos), puede ocurrir en cualquier parte de su trayecto, con cuadro clínico diverso. En jóvenes se añaden otros factores de riesgo distintos a los cardiovasculares, se incluye el consumo de sustancias psicoactivas. El objetivo de este artículo es presentar el caso de un adulto joven, su evolución posterior a la intervención endovascular y la asociación, pasada por alto, al consumo de cannabinoides. Caso clínico. Individuo de 23 años con 14 horas de parálisis facial periférica derecha, diplopía, disartria, hemiparesia e hiperreflexia izquierda, disfagia, náuseas y emesis. Tomografía Axial Computarizada de cráneo simple sin alteraciones. Posteriormente, al realizarse resonancia magnética nuclear, se evidencia isquemia pontomesencefálica y focos isquémicos agudos lacunares en lóbulos cerebelosos. Se consideró comprometido el territorio de la arteria basilar, por lo que se realizó angiotomografía que evidenció una obstrucción crítica de dicho vaso a nivel del tercio distal. Se realizó trombectomía con stent-retriever con recanalización total de la arteria basilar con flujo en toda su extensión. Al egreso fue clasificado como TOAST idiopático. Conclusiones. Las escalas etiológicas para stroke creadas para adultos mayores sobreestiman la etiología idiopática en pacientes jóvenes, lo cual puede ocasionar que el consumo de cannabis sea pasado por alto como causante pese a la asociación reportada por la literatura.

Introduction. The basilar artery is formed from the vertebral arteries, runs over the pons and bifurcates, originating the posterior cerebral arteries. It irrigates part of the brainstem, cerebellum, thalamus, and the occipital and temporal lobes of the brain. Its obstruction is rare (1% of ischemic accidents), it can occur in any part of its path, with a diverse clinical condition. In young people, other risk factors other than cardiovascular ones are added; psychoactive substance use is included. The objective of this article is to present the case of a young adult, his evolution after endovascular intervention and the association, overlooked, to the consumption of cannabinoids. Clinical case. 23-year-old man with 14 hours of right peripheral facial paralysis, diplopia, dysarthria, left hyperreflexia and hemiparesis, dysphagia, nausea and emesis. Simple skull Computerized Axial Tomography without alterations. Subsequently, when a nuclear magnetic resonance was performed, pontomesencephalic ischemia and acute lacunar ischemic foci in the cerebellar lobes were evidenced. The basilar artery territory was considered compromised, so a CT angiography was performed, which revealed a critical obstruction of said artery at the level of the distal third. A stent-retriever thrombectomy was performed with total recanalization of the basilar artery with flow in its entirety. Upon discharge, he was classified as "idiopathic" according to the TOAST classification. Conclusions. The etiological scales for stroke created for older adults overestimate idiopathic etiology in young patients, which may cause cannabis use to be overlooked as a cause despite the association reported in the literature.

Introdução. A artéria basilar é formada pelas artérias vertebrais, passa pela ponte e se bifurca, originando as artérias cerebrais posteriores. Irriga parte do tronco cerebral, cerebelo, tálamo e os lobos occipital e temporal do cérebro. Sua obstrução é rara (1% dos acidentes isquêmicos), podendo ocorrer em qualquer parte de seu trajeto, com quadro clínico diverso. Nos jovens, são adicionados outros fatores de risco além dos cardiovasculares, incluindo o consumo de substâncias psicoativas. O objetivo deste artigo é apresentar o caso de um adulto jovem, sua evolução após a intervenção endovascular e a associação, despercebida, ao consumo de canabinoides. Caso clínico. Indivíduo de 23 anos com 14 horas de paralisia facial periférica direita, diplopia, disartria, hemiparesia e hiperreflexia esquerda, disfagia, náuseas e vômitos. Tomografia axial computadorizada de crânio simples sem alterações. Posteriormente, quando foi realizada a ressonância magnética nuclear, foram evidenciados isquemia pontomesencefálica e focos agudos de isquemia lacunar nos lobos cerebelares. O território da artéria basilar foi considerado comprometido, por isso foi realizada uma angiotomografia, que revelou uma obstrução crítica do referido vaso no terço distal. Foi realizada trombectomia stent-retriever com recanalização total da artéria basilar com fluxo em sua totalidade. No momento da alta, foi classificado como TOAST idiopática. Conclusões.As escalas etiológicas para AVC criadas para idosos superestimam a etiologia idiopática em pacientes jovens, o que pode fazer com que o uso de cannabis seja negligenciado como causa, apesar da associação relatada na literatura.

SARS-CoV-2 vaccines-induced thrombotic thrombocytopenia: should we consider immuno-hypersensitivity?

ABSTRACT The coronavirus disease 2019 (COVID-19) pandemic is significantly causing unprecedented clinical, socioeconomic, and public health challenges globally. The successful global administration of effective, safe and sustainable vaccine(s) is widely believed to be crucial in mitigating as well as preventing COVID-19. However, the rising cases of severe adverse events following immunization (AEFI) with COVID-19 vaccines including thrombosis, thrombocytopenia, and in some instances, death have created serious global concerns and could enormously contribute to vaccine hesitancy. Although the complete underlying pathophysiology and immunopathology of the COVID-19 vaccines related to AEFI, including thrombosis and/or anaphylaxis, are yet to be determined, exploring possible immuno-hypersensitivity could be crucial in the mechanisms associated with these reactions, thereby mitigating their occurrences as well as restoring confidence in vaccine administration for a COVID-19 free world.

Is routine screening for silent pulmonary embolism justified in patients with deep vein thrombosis? / Existe justificativa para o rastreio de embolia pulmonar silenciosa em pacientes com trombose venosa profunda?

Abstract The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase.

Resumo A ocorrência de embolia pulmonar assintomática em pacientes com trombose venosa profunda tem uma incidência que excede 70%, mesmo nos casos de trombose venosa profunda distal. Relatamos o caso de um paciente com diagnóstico de trombose venosa profunda no membro inferior esquerdo associado a embolia pulmonar assintomática, que apresentou sintomas tardios devido a essa mesma embolia. A ausência de sintomas agudos e o surgimento de sintomas tardios pode suscitar dúvidas quanto ao tratamento mais adequado e resultar em intervenções desnecessárias, se o diagnóstico tomográfico de embolia pulmonar não tiver sido feito anteriormente. No presente caso, demonstramos que uma angiotomografia realizada no momento do diagnóstico de trombose venosa profunda detectou a embolia pulmonar e evitou uma interpretação incorreta de um evento trombótico recorrente na vigência de anticoagulação, o que por engano demonstraria uma falha na terapia anticoagulante. Essa situação pode levar a intervenções desnecessárias, como o implante de filtro de veia cava inferior. Entendemos que apenas um relato de caso não deve mudar uma conduta médica já estabelecida; no entanto, fomenta a discussão e estimula estudos que avaliem a necessidade de um exame diagnóstico pulmonar no momento do diagnóstico de trombose venosa profunda.

Consenso colombiano para la prevención, el diagnóstico y el tratamiento de condiciones trombóticas en adultos con COVID-19: aplicando el Marco de la Evidencia a la Decisión (EtD) GRADE / Colombian consensus for the prevention, diagnosis and treatment of thrombotic conditions in adults with COVID-19: applying GRADE Evidence to Decision (EtD) Frameworks

Introducción estudios recientes han reportado fenómenos trombóticos o coagulopatía en pacientes con COVID-19. Hay posiciones divergentes en cuanto a la prevención, el diagnóstico y el tratamiento de estos fenómenos, y la práctica clínica actual está basada únicamente en deducciones por extensión a partir de estudios retrospectivos, series de casos, estudios observacionales y guías internacionales desarrolladas previas a la pandemia. Objetivo establecer una serie de recomendaciones sobre prevención, diagnóstico y manejo de las complicaciones trombóticas asociadas a COVID-19. Métodos se desarrolló una guía rápida en la que se aplicó el marco de la evidencia a la decisión (EtD) de GRADE y un sistema de participación iterativo, con análisis estadísticos y cualitativos de sus resultados. Resultados se generaron 31 recomendaciones clínicas enfocadas a: a) Pruebas de coagulación en adultos sintomáticos con sospecha de infección o infección confirmada por SARS-CoV-2; b) Tromboprofilaxis en personas adultas con diagnóstico de COVID-19 (escalas de riesgo, tromboprofilaxis de manejo ambulatorio, intrahospitalario y duración de tromboprofilaxis después del egreso de hospitalización), c) Diagnóstico y tratamiento de las complicaciones trombóticas y d) Manejo de personas con indicación previa a usar agentes anticoagulantes. Conclusiones las recomendaciones clínicas de este consenso orientan la toma de decisiones clínicas respecto a prevención, diagnóstico y tratamiento de fenómenos trombóticos en pacientes con COVID-19, y representan un acuerdo que ayudará a disminuir la dispersión en las prácticas clínicas acorde con el desafío que impone la pandemia.

Abstract Introduction: recent studies have reported the occurrence of thrombotic phenomena or coagulopathy in patients with COVID-19. There are divergent positions regarding the prevention, diagnosis, and treatment of these phenomena, and current clinical practice is based solely on deductions by extension from retrospective studies, case series, observational studies, and international guidelines developed prior to the pandemic. Objective: to generate a group of recommendations on the prevention, diagnosis and management of thrombotic complications associated with COVID-19. Methods: a rapid guidance was carried out applying the GRADE Evidence to Decision (EtD) frameworks and an iterative participation system, with statistical and qualitative analysis. Results: 31 clinical recommendations were generated focused on: a) Coagulation tests in symptomatic adults with suspected infection or confirmed SARS CoV-2 infection; b) Thromboprophylaxis in adults diagnosed with COVID-19 (Risk scales, thromboprophylaxis for outpatient, in-hospital management, and duration of thromboprophylaxis after discharge from hospitalization), c) Diagnosis and treatment of thrombotic complications, and d) Management of people with previous indication of anticoagulant agents. Conclusions: recommendations of this consensus guide clinical decision-making regarding the prevention, diagnosis, and treatment of thrombotic phenomena in patients with COVID-19, and represent an agreement that will help decrease the dispersion in clinical practices according to the challenge imposed by the pandemic.

Isquemia arterial aguda de las extremidades: ¿cómo abordarla? / Acute arterial limb ischemia: ¿How to approach it?

La isquemia arterial aguda de las extremidades se define como la interrupción abrupta del flujo sanguíneo a determinado tejido, lo cual afecta la integridad, la viabilidad de la extremidad, o ambas. Las causas son múltiples y pueden resumirse en dos procesos fisiopatológicos, trombóticos o embólicos, con lo que se puede establecer el pronóstico y el tratamiento según su causa. El cuadro sindrómico es variable, y típicamente, se identifica con las cinco "P" de Pratt (pain, pallor, pulselessness,paralysisand paresthesia); se cuenta con múltiples ayudas diagnósticas, pero la arteriografía sigue siendo el método estándar para el diagnóstico. Con el advenimiento de los avances tecnológicos y los procedimientos vasculares, el salvamento de las extremi-dades ha venido en aumento y ha disminuido la extensión de las amputaciones, lo cual conlleva una mayor tasa de rehabilitación y de reincorporación a la vida social

Acute arterial ischemia of the extremities is defined as the abrupt interruption of blood flow to certain tissue which affects the integrity and/or viability of the limb. The causes are multiple and can be summarized in two pathophysiological processes, thrombotic or embolic, with which the prognosis and management can be established depending on the cause. The syndromic picture is variable, typically identified with the Pratt's five "P" (pain, pallor, pulselessness, paralysis and paresthesia); there is an arsenal of diagnostic tools but arteriography remains the gold standard for diagnosis. With the advent of technological advances and vascular procedures, limb salvage has been increasing with a decrease in the extent of amputations represented by a higher rate of rehabilitation and reincorporation into social life

Ischemic stroke as an initial presentation of primary bone marrow lymphoma

@#Various cancer types have been associated with cancer-related cerebral infarction. In this study, we describe the first case of cancer-related cerebral infarction in which the underlying disease was primary bone marrow lymphoma (PBML). A 79-year-old man presented with abruptly developed bilateral lower extremity weakness and confusion. Diffusion-weighted imaging on admission showed multiple cortical and subcortical embolic infarction lesions in multiple vascular territories. Diagnostic evaluations to determine the embolic source revealed no abnormalities. Laboratory testing demonstrated elevated D-dimer (2.59 μg/mL) but no other prothrombotic abnormalities. In suspicion of cancer-related stroke, we performed chest CT, abdomen CT, and FDG-PET to detect the hidden malignancy. Findings revealed no evidence of cancer; however, they did reveal signs of anemia (hemoglobin 9.0 g/dL). Bone marrow aspiration biopsy showed large atypical B cell involvement suggestive of high-grade B cell lymphoma. The patient was diagnosed with primary bone marrow diffuse large B-cell lymphoma initially presenting with ischemic stroke. Our case suggests that primary bone marrow cancer may be a candidate for the differential diagnosis of hidden malignancy in patients with suspected cancer-related stroke. Bone marrow biopsy may be essential for establishing an appropriate differential diagnosis in patients with abnormal hematologic findings.

Retrospective analysis of clinical features of chronic obstructive pulmonary disease complicated with pulmonary thromboembolism / 中国基层医药

Objective@#To analyze the clinical features of patients with chronic obstructive pulmonary disease(COPD) complicated with pulmonary thromboembolism(PTE).@*Methods@#The clinical data of 21 patients with COPD and PTE and 26 patients with acute exacerbation of COPD(AECOPD) from June 2015 to March 2018 in Taiyuan Central Hospital were retrospectively analyzed.The SSPS 22.0 statistical software was used to analyze the clinical data.General data, blood gas analysis results, lung function, hemoglobin, coagulation parameters, combined disease were analyzed.@*Results@#There were no statistically significant differences in age, gender and lung function grading between the COPD complicated with PTE group and AECOPD group (all P>0.05). The incidence rates of chest pain(8 cases, 38.1%) and syncope(2 cases, 10.5%) in the COPD complicated with PTE group were higher than those in the AECOPD group[chest pain(3 cases, 11.5%), syncope(1 case, 3.8%)](χ2=7.645, 9.413, all P<0.05). There was no statistically significant difference in carbon dioxide partial pressure(PaCO2)retention between the two groups(P>0.05). The blood oxygen partial pressure(PaO2) of the COPD complicated with PTE group was (62.86±15.10)mmHg, which was lower than that of the AECOPD group [(74.83±17.59)mmHg](t=4.642, P<0.05). The hemoglobin, activated partial thromboplastin time(APTT), fibrinogen(FIB), D-dimer levels in the COPD complicated with PTE group were (146.78±21.40)g/L, (35.62±5.93)s, (4.34±1.18)g/L, (5.02±3.63)mg/L, respectively, which were higher than those in the AECOPD group [(137.45±15.15)g/L, (29.38±3.16)s, (3.62±1.08)g/L, (0.92±0.42)mg/L] (t=4.375, 4.654, 3.869, 18.653, all P<0.05). There were no statistically significant differences in the proportion of comorbidities such as diabetes, hypertension, hyperlipidemia and lower extremity(all P>0.05).@*Conclusion@#COPD patients complicated with PTE have the following characteristics: elderly and male patients accounted for a high proportion, chest pain and syncope symptoms occurred in a high proportion, severe hypoxia, hemoglobin and D-dimer increased significantly.

Endovascular Strategies in the Management of Acute Limb Ischemia

Acute limb ischemia (ALI) represents one of the most common emergent scenarios encountered by a vascular specialist. Despite expedient revascularization, high rates of limb loss are reported along with high mortality rates which are second only to ruptured abdominal aortic aneurysms. Surgical revascularization is standard of care. Endovascular techniques as an alternative have emerged to be appropriate first line therapy when addressing the threatened limb. We review the etiology and classification of ALI and current endovascular techniques and evidence to date in the management of patients acutely presenting with extremity ischemia.

Retrospective analysis of clinical features of chronic obstructive pulmonary disease complicated with pulmonary thromboembolism / 中国基层医药

Objective To analyze the clinical features of patients with chronic obstructive pulmonary disease (COPD) complicated with pulmonary thromboembolism (PTE).Methods The clinical data of 21 patients with COPD and PTE and 26 patients with acute exacerbation of COPD(AECOPD) from June 2015 to March 2018 in Taiyuan Central Hospital were retrospectively analyzed.The SSPS 22.0 statistical software was used to analyze the clinical data.General data,blood gas analysis results,lung function,hemoglobin,coagulation parameters,combined disease were analyzed.Results There were no statistically significant differences in age,gender and lung function grading between the COPD complicated with PTE group and AECOPD group (all P ＞ 0.05).The incidence rates of chest pain(8 cases,38.1％) and syncope(2 cases,10.5％) in the COPD complicated with PTE group were higher than those in the AECOPD group [chest pain (3 cases,11.5 ％),syncope (1 case,3.8 ％)] (x2 =7.645,9.413,all P ＜0.05).There was no statistically significant difference in carbon dioxide partial pressure (PaCO2)retention between the two groups(P＞0.05).The blood oxygen partial pressure(PaO2) of the COPD complicated with PTE group was (62.86 ± 15.10)mmHg,which was lower than that of the AECOPD group [(74.83 ± 17.59)mmHg] (t =4.642,P ＜ 0.05).The hemoglobin,activated partial thromboplastin time (APTT),fibrinogen (FIB),D-dimer levels in the COPD complicated with PTE group were (146.78 ± 21.40) g/L,(35.62 ± 5.93) s,(4.34 ± 1.18) g/L,(5.02 ± 3.63)mg/L,respectively,which were higher than those in the AECOPD group [(137.45 ± 15.15)g/L,(29.38 ±3.16) s,(3.62 ± 1.08) g/L,(0.92 ±0.42) mg/L] (t =4.375,4.654,3.869,18.653,all P ＜0.05).There were no statistically significant differences in the proportion of comorbidities such as diabetes,hypertension,hyperlipidemia and lower extremity (all P ＞ 0.05).Conclusion COPD patients complicated with PTE have the following characteristics:elderly and male patients accounted for a high proportion,chest pain and syncope symptoms occurred in a high proportion,severe hypoxia,hemoglobin and D-dimer increased significantly.

Role of Computed Tomography in Evaluation of Cerebrovascular Accidents in a Tertiary Care Centre in Northern Kerala

Background: Cerebrovascular accident is one of the leading causes of death and disability throughout the world. It is the third most common cause of death after heart disease and cancer in India. Early diagnosis can improve the morbidity and mortality rates, as more advanced therapies are currently being instituted. Computed tomography imaging having wider availability, being cost effective and less time consuming, plays the role of first-line imaging modality. Many studies have been done all over the world to demonstrate the usefulness of computed tomography in management of cerebrovascular accident. Our study is aimed to establish the role of computed tomography in clinically suspected cases of cerebrovascular accident. The purpose of this study is to document the presence or absence of hemorrhage or infarcts, to find the location and reasonably assess the blood vessels involved and to spot the incidence of negative cases of clinically suspected stroke. Methods: A prospective study of 250 cases admitted to Academy of medical sciences, Pariyaram, Kannur with the clinical diagnosis of acute stroke were taken up for the study. Results: Out of 250 patients clinically suspected of CVA submitted for CT scan study of the brain. 150 patients i.e., 60% had infarcts. 70 patients i.e., 28% had haemorrhage,5 patients i.e., 2% had S.D.H.,5 patients i.e., 2% had C.V.T., 5 patients i.e., 2% had tumor and 15 patients i.e.,6% had normal scans. Infarcts formed the major group of the CVA cases i.e., 60%, involving most commonly the R.M.C.A. territory in patients i.e., 33.34%. Hemorrhage formed the second major group of the CVA cases i.e., 28.5%, involving most commonly the R.M.C.A. territory in patients i.e., 28.5%. Conclusions: The study showed that there is a preponderance of ischemic over hemorrhagic CVA. There is also a male preponderance in the occurrence of both hemorrhagic and ischemic CVA. C.T. Scanning is the “Gold Standard” technique for the diagnosis of acute stroke. And management of stroke depends upon “accurate diagnosis”. Hence, CT scan should be ideally done in all cases.