Assistência ginecológica aos transgênero / Gynecological care for transgenders

Transgênero (trans) é um termo que alberga toda a diversidade de gênero. A incongruência de gênero faz parte desse espectro e refere-se à pessoa cuja identidade de gênero é oposta ao sexo que lhe foi atribuído no nascimento. A terapia hormonal de afirmação de gênero, bem como a cirurgia de afirmação de gênero, é necessária para adequar o corpo ao gênero ao qual a pessoa se identifica. Os homens trans necessitam da terapia com testosterona, que visa reduzir as concentrações de estradiol e incrementar a testosterona circulante para níveis fisiológicos masculinos, resultando em masculinização. A mulher trans receberá o estradiol, associado ou não a um antiandrogênico, visando reduzir a testosterona e incrementar o estrogênio para níveis femininos, resultando em feminização. A cirurgia de afirmação de gênero é, frequentemente, requerida para completar as modificações fenotípicas para o homem e a mulher trans. O ginecologista e obstetra tem um papel crucial no provimento de cuidados a essa população. O presente artigo visa sistematizar algumas ações que o ginecologista e obstetra pode oferecer e que têm potencial para melhorar a qualidade de vida dos homens e mulheres trans. (AU)

Transgenero (trans) is an umbrella term that encompasses all gender diversity. Gender Incongruity is part of this spectrum and refers to the person whose gender identity is opposed to the sex assigned to them at birth. Gender-affirming hormone therapy as well as gender-affirming surgery are necessary to adapt the body to the gender to which the person identifies. Trans men require testosterone therapy to reduce estradiol concentrations and increase circulating testosterone to male physiological levels resulting in masculinization. Trans women will receive estradiol associated or not with an antiandrogenic to reduce testosterone and increase estrogen to female levels resulting in feminization. gender-affirming surgery is often required to complete phenotypic modifications for trans men and women. The gynecologist and obstetrician plays a crucial role in to provide care to this population. This article aims to systematize some actions that the gynecologist and obstetrician can offer to improve the quality of life of trans men and women. (AU)

Contracepção pós-parto e pós-abortamento: um compilado das evidências atuais / Postpartum and post-abortion contraception: a compilation of current evidences

Idealmente, a contracepção deve ser iniciada o mais precocemente possível após o parto ou após o abortamento, permitindo que as mulheres sejam protegidas contra uma gravidez não programada subsequente. O objetivo desta revisão é discutir a contracepção no pós-parto e pós-aborto, por meio da análise de ensaios clínicos e metanálises, além das principais diretrizes internacionais, com ênfase nas indicações e contraindicações, tempo de início do uso dos métodos contraceptivos e possíveis complicações. Nesta revisão não sistemática, são discutidos os principais métodos contraceptivos: dispositivos intrauterinos, métodos somente de progestagênios, métodos hormonais combinados, métodos de barreira, método de amenorreia lactacional e esterilização. O aconselhamento contraceptivo pós-parto deve começar durante o pré-natal e, em pacientes após abortamento, durante a internação hospitalar. Todas as mulheres devem ter acesso a informações claras sobre cada método contraceptivo, e o processo de tomada de decisão deve ser compartilhado com o médico assistente. Idealmente, métodos de contracepção reversíveis de longa duração devem ser priorizados em relação aos outros. Em conjunto, todas as evidências demonstram que o melhor método para cada paciente é aquele que combine altas taxas de segurança com o desejo da paciente de iniciá-lo e mantê-lo pelo tempo que desejar.

Contraception should ideally be started as early as possible after childbirth or abortion to allow women to be protected against a subsequent unplanned pregnancy. The aim of this review is to discuss postpartum and postabortion contraception, through the analysis of clinical trials and meta-analyses, in addition to the main international guidelines, with emphasis on indications and contraindications, time to start contraceptive method and possible complications. In this review, the main contraceptive methods are discussed: intrauterine devices, progestin-only methods, combined hormonal methods, barrier methods, lactational amenorrhea method and sterilization. Postpartum contraceptive counseling should start during prenatal care and during hospital stay in post-abortion patients. All women should have access to clear information about each contraceptive method and the decision-making process must be shared. Ideally, long acting reversible contraception methods should be prioritized over others. Taken together, all the evidence shows that the best method for each patient is the one that combines high safety rates with the patient's desire to start and maintain it for as long as she wants.

Expert consensus on the prevention of venous thromboembolism for elderly patients with critical illness in China (2023) / 中华危重病急救医学

Patients with critical illness are at the high risk of venous thromboembolism (VTE), and the older the patient, the higher the incidence of VTE. Despite its poor prognosis, VTE is preventable. At present, although there are many consensus or guidelines on the prevention of VTE at home and abroad, there is still a lack of consensus or guidelines for the prevention of VTE in elderly patients with critical illness. In order to standardize the prevention of VTE in elderly patients with critical illness in China, Expert consensus on the prevention of venous thromboembolism for elderly patients with critical illness in China (2023) was developed by Critical Care Medicine Division of Chinese Geriatric Society and Zhejiang Provincial Clinical Research Center for Critical Care Medicine. Members of the working group consulted relevant domestic and foreign guidelines, integrated evidence-based medical evidence and clinical experience, formed the draft consensus, submitted it to the expert group for discussion for many times, revised it for many times, and finally sent it to the expert group in the form of electronic questionnaire, and the expert gave a comprehensive score according to the theoretical basis, scientific nature and feasibility of the consensus items. The recommendation strength of each item was determined, and 21 recommendations were finally formed to provide reference for the prevention of VTE in elderly patients with critical illness.

Postoperative subacute static progressive stretch does not increase the risk of distal lower limb venous thromboembolism / 中华创伤杂志(英文版)

PURPOSE@#Static progressive stretch (SPS) can be applied to treat chronic joint stiffness. However, the impacts of subacute application of SPS to the distal lower limbs, where deep vein thrombosis (DVT) is common, on venous thromboembolism remain unclear. This study aims to explore the risk of venous thromboembolism events following subacute application of SPS.@*METHODS@#A retrospective cohort study was conducted on patients diagnosed with DVT following a lower extremity orthopedic surgery before being transferred to the rehabilitation ward from May 2017 to May 2022. Patients with unilateral lower limb comminuted para-articular fractures, transferred to rehabilitation ward for further treatment within 3 weeks after operation, followed up more than 12 weeks since initial manual physiotherapy, and diagnosed DVT by ultrasound before rehabilitation course were included in the study. Patients with polytrauma, without evidence of previous peripheral vascular disease or incompetence, had medication for thrombosis treatment or prophylaxis before the operation, detected with paralysis due to nervous system impairment, infected after operation during the regime, or with acute progression of DVT were excluded. The included patients were randomized to the standard physiotherapy and the SPS integrated groups for observation. Associated DVT and pulmonary embolism data were collected during the physiotherapy course to compare the groups. SSPS 28.0 and GraphPad Prism 9 were used for data processing. A p < 0.05 was set significant difference.@*RESULTS@#In total of 154 patients with DVT participating in this study, 75 of them were treated with additional SPS for postoperative rehabilitation. The participants in the SPS group showed improved range of motion (12.3° ± 6.7°). However, in the SPS group, there was no difference in thrombosis volume between the start and termination (p = 0.106, p = 0.787, respectively), although difference was seen intra-therapy (p < 0.001). Contingency analysis revealed the pulmonary embolism incidence (OR = 0.703) in the SPS group compared to the mean physiotherapy.@*CONCLUSION@#The SPS technique is a safe and reliable option to prevent potential joint stiffness without aggravating the risk of distal DVT for postoperative patients suffering from relevant trauma.

Aspirin versus Rivaroxaban to Prevent Venous Thromboembolism after Total Knee Arthroplasty: A Double-blinded, Randomized Controlled Trial / Aspirina versus rivaroxabana na prevenção do tromboembolismo venoso após artroplastia total do joelho: Um ensaio clínico randomizado, controlado e duplo-cego

Abstract Objective Aspirin (acetylsalicylic acid, ASA) and rivaroxaban are anticoagulants that have increased in popularity due to ease of use in the prevention of venous thromboembolism (VTE) after total knee arthroplasty (TKA). The present study aimed to evaluate the efficacy of ASA compared with that of rivaroxaban on VTE prophylaxis in patients who underwent TKA. Method Forty patients who had primary knee osteoarthritis and would undergo TKA were randomized into two groups. In total, 20 patients in the ASA group used oral aspirin, at a dose of 300 mg/day, for VTE prophylaxis after TKA, while 20 patients in the rivaroxaban group received oral rivaroxaban, at a dose of 10 mg/day. On days 4 and 14 after the operation, deep vein thrombosis (DVT) in the lower limbs on the operated side was detected through duplex ultrasonography. Other complications were recorded for 14 days. Results There were no positive findings of DVT detected with duplex ultrasonography in the groups of patients, and the occurrence of pulmonary embolism was not observed. In total, 4 patients had subcutaneous ecchymosis on the fourth postoperative day (2 patients in the ASA group and 2 patients in the rivaroxaban group; p= 1.0), and another 4 patients on the fourteenth postoperative day (1 patient in the ASA group and 3 patients in the rivaroxaban group; p= 0.292). No cases of wound hematoma, major organ bleeding, wound infection, or reoperation were observed in the sample. Conclusion Aspirin and rivaroxaban had comparable efficacy to prevent VTE, without increasing the incidence of wound complications and bleeding after TKA.

Resumo Objetivo A aspirina (ácido acetilsalicílico, AAS) e a rivaroxabana são anticoagulantes que vêm ganhando popularidade devido à facilidade de uso na prevenção do tromboembolismo venoso (TEV) após artroplastia total do joelho (ATJ). Este estudo teve como objetivo avaliar a eficácia do AAS em comparação com a da rivaroxabana na profilaxia de TEV em pacientes submetidos a ATJ. Método Quarenta pacientes com osteoartrite primária do joelho, que seriam submetidos a ATJ, foram randomizados em dois grupos. No total, 20 pacientes do grupo AAS usaram aspirina oral, na dose de 300 mg/dia, para a profilaxia do TEV após ATJ; e 20 pacientes do grupo rivaroxabana receberam uma dose oral de 10 mg/dia. No 4° e 14° dias do pós-operatório, trombose venosa profunda (TVP) dos membros inferiores no lado da cirurgia foi detectada por meio de ultrassonografia duplex. Foram registradas outras complicações durante catorze dias. Resultados Não foram detectados achados positivos de TVP com a ultrassonografia duplex nos grupos de pacientes, e não se observou a ocorrência de embolia pulmonar. No total, 4 pacientes apresentaram equimose subcutânea no 4° dia do pós-operatório (2 pacientes no grupo AAS e 2 pacientes no grupo rivaroxabana; p= 1,0), e outros 4 pacientes, no 14° dia do pós-operatório (1 paciente no grupo AAS e 3 pacientes no grupo rivaroxabana; p= 0,292). Nenhum paciente da amostra apresentou hematoma da ferida cirúrgica, sangramento de órgão importante, infecção da ferida, ou necessidade de nova cirurgia. Conclusão A aspirina e a rivaroxabana apresentaram eficácia comparável na prevenção do TEV, sem aumentar a incidência de complicações da ferida e sangramento após ATJ.

Concordancia entre dos escalas para evaluar la clasificación del riesgo de eventos tromboembólicos y el requerimiento de profilaxis farmacológica en el posparto / Agreement between two scales used for assessing risk classification for thromboembolic events and the requirement of postpartum pharmacological prophylaxis

RESUMEN Objetivos: Establecer la concordancia para evaluar el requerimiento de profilaxis farmacológica en el puerperio entre la escala del Rojal College Obstetricians and Gynaecologists y la escala de la guía colombiana en una institución de cuarto nivel en Bogotá, Colombia. Materiales y métodos: Estudio de concordancia diagnóstica ensamblado sobre un estudio transversal. Se incluyeron mujeres embarazadas con 24 o más semanas de gestación que ingresaron para inducción de trabajo de parto, en trabajo de parto activo, para cesárea electiva, o que requirieron cesárea de urgencia, hospitalizadas entre el 1 de marzo y 30 de abril de 2021 en una institución privada de alta complejidad en Bogotá, Colombia. Se realizó un muestreo por conveniencia. Se midieron variables demográficas, factores de riesgo, clasificación del riesgo y profilaxis farmacológica según las dos escalas. Se calculó la prevalencia de los factores de riesgo por cada escala y la concordancia en la indicación de la profilaxis entre las dos escalas por medio del valor de kappa ponderado. Resultados: Se incluyeron 320 pacientes. La escala del Royal College Obstetricians and Gynaecologists clasificó al 54,7 % de las pacientes en riesgo bajo, riesgo intermedio al 42,5 % y riesgo alto al 2,8 %. La escala colombiana clasificó al 80 % de las pacientes en riesgo bajo, 17,2 % riesgo intermedio, 2,2 % riesgo alto y 0,6 % con riesgo muy alto. El valor kappa ponderado para la concordancia para indicación fue de 0,47 (IC 95 %: 0,38-0,56). Conclusiones: La concordancia de las dos escalas para definir requerimiento de profilaxis farmacológica en el posparto tiene un acuerdo moderado. Se considera es necesario validar los criterios de clasificación del riesgo de la escala colombiana en una segunda cohorte, además evaluar la capacidad predictiva de la herramienta de la guía colombiana en diferentes puntos de corte en términos de las consecuencias de falsos positivos y negativos.

ABSTRACT Objectives: To determine agreement in assessing the need for postpartum pharmacological prophylaxis between the scale of the Royal College of Obstetricians and Gynaecologists and the Colombian guideline scale in a Level IV institution in Bogota, Colombia. Material and methods: Diagnostic agreement study assembled on a cross-sectional study. The included population consisted of pregnant women with 24 or more weeks of pregnancy admitted between March 1 and April 30 of 2021 to a high complexity private institution in Bogotá, Colombia, for labor induction, in active labor, for elective cesarean section, or who required urgent cesarean section. Convenience sampling was used. Measured variables included demographics, risk factors, risk classification and pharmacological prophylaxis according to the two scales. The prevalence of risk factors for each scale was estimated and agreement regarding prophylaxis indication between the two scales was measured using the weighted kappa value. Results: Overall, 320 patients were included. According to the scale of the Royal College Obstetricians and Gynaecologists, 54.7 % patients were classified as low risk, 42.5 % as intermediate risk and 2.8 % as high risk. The Colombian scale classified 80 % of patients as low risk, 17.2 % as intermediate risk, 2.2 % as high risk, and 0.6 % as very high risk. The weighted kappa value for agreement regarding the indication was 0.47 (95 % CI: 0.38-0.56). Conclusions: Agreement between the two scales to determine the need for postpartum pharmacological prophylaxis is moderate. Risk classification criteria for the Colombian scale should be validated in a second cohort. Moreover, the predictive ability of the Colombian guideline tool should be assessed at different cut-off points in terms of the consequences of false positive and false negative results.

Trauma-induced pulmonary thromboembolism: What's update? / 中华创伤杂志(英文版)

Trauma-induced pulmonary thromboembolism is the second leading cause of death in severe trauma patients. Primary fibrinolytic hyperactivity combined with hemorrhage and consequential hypercoagulability in severe trauma patients create a huge challenge for clinicians. It is crucial to ensure a safe anticoagulant therapy for trauma patients, but a series of clinical issues need to be answered first, for example, what are the risk factors for traumatic venous thromboembolism? How to assess and determine the status of coagulation dysfunction of patients? When is the optimal timing to initiate pharmacologic prophylaxis for venous thromboembolism? What types of prophylactic agents should be used? How to manage the anticoagulation-related hemorrhage and to determine the optimal timing of restarting chemoprophylaxis? The present review attempts to answer the above questions.

Observation of preventive effect of intervention strategy based on Caprini risk evaluation model on venous thromboembolism after total knee arthroplasty / 中国骨伤

OBJECTIVE@#To observe preventive effect of Caprini based thrombosis risk evaluation model on venous thromboembolism (VTE) after total knee replacement (TKA).@*METHODS@#Totally 257 TKA patients were admitted from May 2017 to December 2021 were selected. They were divided into conventional intervention strategies (121 patients in control group) and intervention strategies based on Caprini thrombosis risk evaluation model (136 patients in observation group), based on whether Caprini thrombosis risk evaluation model was introduced in May 2019. In normal gourp, there were 79 males and 42 females aged from 50 to 78 years old with an average of (63.10±11.86) years old;body mass index (BMI) ranged from 19 to 32 with an average of (25.21±4.95) kg/m2;55 patients on the left side and 66 on the right side. In observation group, there were 81 males and 55 females aged from 50 to 78 years old with an average of (64.35±10.54) years old;BMI ranged from 19 to 32 with an average of (24.43±5.18) kg/m2;87 patients on the left side and 49 on the right side. The incidence of VTE, visual analogue scale (VAS), Hospital for Special Surgery (HSS) score, affected limb swelling, mean velocity(Vm), peak velocity (PV), D-dimer (D-D), prothrombin time(PT), and incidence of complications were analyzed and compared.@*RESULTS@#The incidence of VTE in observation group was 1.47%(2/136), and 9.09%(11/121) in control group, and there was statistically difference between two groups (χ2=6.976, P=0.008). At 7 days after operation, VAS, HSS score and the difference in circumference of the affected limb in observation group were significantly better than those in control group, and had statistically differences (P<0.05). Blood flow Vm and PV levels between two groups were significantly increased (P<0.001), and blood flow Vm and PV levels in observation group were significantly higher than those in control group on the 7th day after operation, and had differences (P<0.001). The serum D-D level in observation group was significantly lower than that of in control group on the 7th day after operation, and PT level was significantly higher than that of in control group, and had difference(P<0.05). There was no difference in total incidence of complications between two groups (χ2=4.488, P=0.034).@*CONCLUSION@#Intervention strategy based on caprini thrombus risk evluation model could effectively reduce incidence of VTE and complications in TKA patients, improve swelling, hemodynamics and coagulation function of the affected limbs, and contribute to recovery of knee joint function.

Tromboprofilaxia na cirurgia de varizes dos membros inferiores no Brasil / Thromboprophylaxis in lower limb varicose vein surgery in Brazil

Resumo Contexto Apesar de todo o investimento na profilaxia primária do tromboembolismo venoso (TEV) em pacientes cirúrgicos nos últimos anos, ainda não existem diretrizes específicas para aqueles que serão submetidos a procedimentos para tratamento de varizes de membros inferiores. Objetivos Avaliar o perfil de conduta de profilaxia do TEV pelos cirurgiões vasculares brasileiros para procedimentos de tratamento de varizes de membros inferiores. Métodos Pesquisa de levantamento por envio de questionário eletrônico a cirurgiões vasculares brasileiros. Os respondentes foram divididos entre os que realizam tratamento de veias safenas por cirurgia convencional e os que realizam termoablação para fim de comparação entre os grupos. Resultados Entre os 765 respondentes, o tratamento de escolha das veias safenas foi a cirurgia convencional para 405 (53%), espuma ecoguiada para 44 (6%) e termoablação (endolaser ou radiofrequência) para 199 (26%). Os cirurgiões que realizam termoablação prescrevem mais farmacoprofilaxia após o procedimento que aqueles que preferem cirurgia convencional (67/199, 34% vs. 112/405, 28%; p = 0,002). O grupo termoablação estratifica o paciente quanto ao risco de TEV com mais frequência que o grupo cirurgia convencional (102/199, 51% vs. 179/405, 44%; p =0,004). Ambos os grupos usam mais frequentemente enoxaparina como medicação para profilaxia, porém o grupo termoablação usa mais anticoagulantes orais diretos proporcionalmente que o grupo cirurgia convencional (26% vs. 10%, p < 0,001). Conclusões Cirurgiões vasculares brasileiros que fizeram o tratamento de veias safenas por termoablação prescrevem farmacoprofilaxia com maior frequência e por um período mais prolongado do que os que realizaram o tratamento por cirurgia convencional.

Abstract Background Despite all the investment in primary venous thromboembolism (VTE) prophylaxis for surgical patients in recent years, there are still no specific guidelines for those who undergo procedures to treat lower limb varicose veins. Objectives To evaluate the profile of VTE prophylaxis practices among Brazilian vascular surgeons conducting lower limb varicose vein procedures. Methods Survey design, sending an electronic questionnaire to Brazilian vascular surgeons. Respondents were divided between those who perform saphenous vein treatment with conventional surgery and those who perform thermoablation for the purpose of comparison between groups. Results Of 765 respondents, 405 (53%) treat saphenous veins with conventional surgery for, 44 (6%) with foam, and 199 (26%) with thermoablation (endolaser or radiofrequency). Surgeons who perform thermoablation prescribed more pharmacoprophylaxis after varicose vein surgery than those who perform conventional surgery (67/199, 34% vs. 112/405, 28%; p = 0.002). The thermoablation group stratifies patients for thromboembolism risk more frequently than the conventional surgery group (102/199, 51% vs. 179/405, 44%; p = 0.004). Both groups use enoxaparin as the most frequent drug for prophylaxis, but the thermoablation group uses proportionally more direct oral anticoagulants than the conventional surgery group (26% vs. 10%, p<0.001). Conclusions Brazilian vascular surgeons who perform saphenous vein treatment by thermoablation prescribe pharmacoprophylaxis more frequently and for a longer period than those who use conventional surgery.

Desafios da profilaxia estendida do tromboembolismo venoso em pacientes clínicos e cirúrgicos / Challenges of extended venous thromboembolism prophylaxis in medical and surgical patients

Resumo Pacientes hospitalizados por doenças clínicas e cirúrgicas agudas estão sob risco de desenvolvimento de tromboembolismo venoso (TEV) durante a hospitalização e após a alta. A profilaxia farmacológica estendida além do período da hospitalização é recomendada para pacientes submetidos a cirurgias de alto risco de TEV e para grupos selecionados de pacientes clínicos hospitalizados. Diversos desafios envolvem essa prática, desde o reconhecimento das populações de risco elegíveis para a extensão da profilaxia até a escolha do anticoagulante mais adequado e a definição do tempo ideal de utilização. Os principais modelos de avaliação de risco de TEV em pacientes clínicos e cirúrgicos hospitalizados, as recomendações atuais para uso da profilaxia estendida e suas limitações e benefícios serão apresentados nesta revisão.

Abstract Patients hospitalized for acute medical and surgical illnesses are at risk of developing venous thromboembolism (VTE) during hospitalization and after discharge. Extended pharmacological prophylaxis beyond the hospital stay is recommended for patients undergoing surgeries at high risk for VTE and for selected groups of hospitalized medical patients. This practice involves several challenges, from identification of at-risk populations eligible for extended prophylaxis to choice of the most appropriate anticoagulant and definition of the ideal duration of use. This review will present the main VTE risk assessment models for hospitalized medical and surgical patients, the current recommendations for use of extended prophylaxis, and its limitations and benefits.

Adherencia a las recomendaciones de tromboprofilaxis post-cesárea: estudio de corte transversal / Compliance with post-cesarean section thromboprophylaxis recommendations. A cross sectional study in 233 women

Background: Cesarean section increases four times the risk of venous thromboembolism compared to vaginal delivery. The Royal College of Obstetricians and Gynecologists guidelines are used at our service. A written alert was designed to stratify patients at high, intermediate or low risk making a suggestion for thromboprophylaxis. Aim: To assess the compliance with the guidelines and to evaluate the impact of a written alert in the thromboprophylaxis compliance in women subjected to caesarean section. Patients and Methods: Review of medical records of 233 women aged 19 to 32 years, subjected to a caesarean section in a Gynecology Service, between 2016-2017. Results: Compliance with recommendations was observed in 29% of patients (68/233), 86% in the low-risk group, 26% in the intermediate risk group and 100% in the high risk group. In 41/233 (18%) of patients, a written alert was included in the medical record. Compliance with recommendations in the presence of the written alert was 61% (25/41 women) compared to 22% (43/192) in those lacking the alert (p < 0.01). In women whose emergency caesarean section was the only risk factor, the compliance with the recommendation was 8%, compared with 30% among those who had at least one thrombotic risk factor associated with caesarean section (p < 0.01). Conclusions: In this cross-sectional study, we observed a low compliance with thromboprophylaxis guidelines in cesarean women. We observed that the use of a written alert improved the compliance with thromboprophylaxis.

Meias elásticas de compressão graduada como medida profilática de tromboembolismo venoso e edema de membros inferiores desencadeados por viagens aéreas: uma revisão sistemática de ensaios clínicos / Graduated compression stockings as a prophylactic measure in venous thromboembolism and edema of lower limbs triggered by air travel: a systematic review of clinical trials

Resumo Com o aumento da duração e frequência das viagens aéreas, observou-se um aumento da prevalência de tromboembolismo venoso nos passageiros. Este estudo avaliou a eficácia do uso de meias elásticas de compressão graduada para a prevenção de tromboembolismo venoso desencadeado por viagens aéreas com duração maior que 3 horas de voo. Trata-se de uma revisão sistemática de ensaios clínicos. A qualidade metodológica dos estudos e o nível de evidência científica foram avaliados pelo Consolidated Standards of Reporting Trials e Grading of Recommendations Assessment, Development and Evaluation. Foram identificados 34 artigos, entretanto apenas oito atenderam aos critérios de elegibilidade. Os desfechos incidência de tromboembolismo venoso e edema foram avaliados em 2.022 e 1.311 passageiros, respectivamente. Os estudos demonstraram evidências de alta qualidade para a prevenção de edema e de moderada qualidade para a redução da incidência de tromboembolismo venoso com o uso de meias elásticas de compressão graduada durante viagens aéreas.

Abstract The increase in duration and frequency of flights has led to an increase in the prevalence of venous thromboembolism among airline passengers. This study assesses the efficacy of graduated compression stockings for prevention of venous thromboembolism triggered by flights lasting more than 3 hours. The design is a systematic review of clinical trials. The methodological quality of studies and the level of scientific evidence were evaluated using the Consolidated Standards of Reporting Trials and Grading of Recommendations Assessment, Development and Evaluation standards. A total of 34 articles were identified, but only eight met the eligibility criteria. The outcomes incidence of venous thromboembolism and edema were assessed in 2,022 and 1,311 passengers, respectively. The studies presented high quality evidence demonstrating prevention of edema and moderate quality evidence of reduced incidence of venous thromboembolism associated with wearing graduated compression stockings during flights.

Avaliação do risco de sangramento na profilaxia do tromboembolismo venoso / Bleeding risk assessment for venous thromboembolism prophylaxis

Resumo O tromboembolismo venoso (TEV) é uma das principais causas preveníveis de morbimortalidade em pacientes hospitalizados, sendo a embolia pulmonar (EP) fatal possivelmente a sua primeira manifestação. Diretrizes nacionais e internacionais recomendam o uso de modelos de avaliação de risco para a prescrição de profilaxia do TEV em pacientes hospitalizados. Apesar das evidências e diretrizes de apoio, o uso da tromboprofilaxia permanece abaixo do ideal, o que pode resultar da baixa conscientização dos benefícios da profilaxia, mas também pode refletir o medo de complicações hemorrágicas, justificando a subutilização da tromboprofilaxia em todo o mundo. A avaliação do risco de sangramento é, portanto, necessária para a adequação de profilaxia e deve ser realizada de forma concomitante à avaliação do risco de trombose. O objetivo desta revisão é salientar a importância da avaliação conjunta do risco de TEV e do risco de sangramento em pacientes hospitalizados.

Abstract Venous thromboembolism (VTE) is one of the main preventable causes of morbidity and mortality in hospitalized patients and fatal pulmonary embolism (PE) may be its first manifestation. Several national and international guidelines recommend using risk assessment models for prescription of VTE prophylaxis in hospitalized patients. Despite evidence and guidelines supporting VTE prevention, use of VTE prophylaxis in hospitalized patients remains suboptimal, which may be because of low awareness of the benefits of VTE prophylaxis, but might also reflect fear of bleeding complications in these patients, since this constitutes one of the main reasons for underutilization of thromboprophylaxis worldwide. Bleeding risk assessment is therefore necessary for adequate prophylaxis prescription and should be carried out concurrently with assessment of the risk of thrombosis. The purpose of this review is to highlight the importance of jointly assessing risk of VTE and risk of bleeding in hospitalized patients.

Comparable efficacy of 100 mg aspirin twice daily and rivaroxaban for venous thromboembolism prophylaxis following primary total hip arthroplasty: a randomized controlled trial / 中华医学杂志(英文版)

BACKGROUND@#Aspirin has demonstrated safety and efficacy for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA); however, inconsistent dose regimens have been reported in the literature. This study aimed to evaluate and compare the safety and efficacy of 100 mg aspirin twice daily with rivaroxaban in VTE prophylaxis following THA.@*METHODS@#Patients undergoing elective unilateral primary THA between January 2019 and January 2020 were prospectively enrolled in the study and randomly allocated to receive 5 weeks of VTE prophylaxis with either oral enteric-coated aspirin (100 mg twice daily) or rivaroxaban (10 mg once daily). Medication safety and efficacy were comprehensively evaluated through symptomatic VTE incidence, deep vein thrombosis (DVT) on Doppler ultrasonography, total blood loss (TBL), laboratory bloodwork, Harris hip score (HHS), post-operative recovery, and the incidence of other complications.@*RESULTS@#We included 70 patients in this study; 34 and 36 were allocated to receive aspirin and rivaroxaban prophylaxis, respectively. No cases of symptomatic VTE occurred in this study. The DVT rate on Doppler ultrasonography in the aspirin group was not significantly different from that in the rivaroxaban group (8.8% vs. 8.3%, χ2 = 0.01, P = 0.91), confirming the non-inferiority of aspirin for DVT prophylaxis (χ2 = 2.29, P = 0.01). The calculated TBL in the aspirin group (944.9 mL [658.5-1137.8 mL]) was similar to that in the rivaroxaban group (978.3 mL [747.4-1740.6mL]) (χ2 = 1.55, P = 0.12). However, there were no significant inter-group differences in HHS at post-operative day (POD) 30 (Aspirin: 81.0 [78.8-83.0], Rivaroxaban: 81.0 [79.3-83.0], χ2 = 0.43, P = 0.67) and POD 90 (Aspirin: 90.0 [89.0-92.0], Rivaroxaban: 91.5 [88.3-92.8], χ2 = 0.77, P = 0.44), the incidence of bleeding events (2.9% vs. 8.3%, χ2 = 0.96, P = 0.33), or gastrointestinal complications (2.9% vs. 5.6%, χ2 = 1.13, P = 0.29).@*CONCLUSION@#In terms of safety and efficacy, the prophylactic use of 100 mg aspirin twice daily was not statistically different from that of rivaroxaban in preventing VTE and reducing the risk of blood loss following elective primary THA. This supports the use of aspirin chemoprophylaxis following THA as a less expensive and more widely available option for future THAs.@*TRIAL REGISTRATION@#Chictr.org, ChiCTR18000202894; http://www.chictr.org.cn/showproj.aspx?proj=33284.

Guidance on diagnosis, prevention and treatment of thromboembolic complications in COVID-19: a position paper of the Brazilian Society of Thrombosis and Hemostasis and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy

ABSTRACT Hemostatic abnormalities and thrombotic risk associated with coronavirus disease 2019 (COVID-19) are among the most discussed topics in the management of this disease. The aim of this position paper is to provide the opinion of Brazilian experts on the thromboprophylaxis and management of thrombotic events in patients with suspected COVID-19, in the sphere of healthcare in Brazil. To do so, the Brazilian Society of Thrombosis and Hemostasis (BSTH) and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy (ABHH) have constituted a panel of experts to carefully review and discuss the available evidence about this topic. The data discussed in this document was reviewed by May 9, 2020. Recommendations and suggestions reflect the opinion of the panel and should be reviewed periodically as new evidence emerges.

SBA 2020: Regional anesthesia guideline for using anticoagulants update / SBA 2020: Atualização na diretriz da anestesia regional em uso de anticoagulantes

Abstract The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative review, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

Resumo Os padrões evolutivos para a prevenção do tromboembolismo venoso perioperatório e a introdução de medicações antitrombóticas cada vez mais potentes resultaram em preocupações com o aumento do risco de sangramento neuroaxial. Após o consenso da Sociedade Brasileira de Anestesiologia em 2014, novos medicamentos anticoagulantes orais foram aprovados pelas instituições reguladoras internacionais, assim como pela ANVISA. As sociedades que buscam abordar o manejo perioperatório desses fármacos apresentam recomendações conflitantes. Em resposta a essas questões e à necessidade de uma abordagem mais racional, as condutas foram atualizadas nesta revisão narrativa e feitas declarações de consenso. Elas foram projetadas para encorajar a assistência ao paciente de forma segura e de qualidade, mas não podem garantir um resultado específico. Tal como acontece com qualquer recomendação de orientação clínica, estas estão sujeitas a revisão com o conhecimento de avanços específicos de complicações. O objetivo foi avaliar aspectos da segurança em anestesia e analgesia regional em pacientes em uso de medicações antitrombóticas, tais como: possíveis complicações decorrentes da técnica; fatores de risco associados ao hematoma espinhal, estratégias de prevenção, diagnóstico e tratamento; intervalo seguro para suspensão e reinício da medicação após o bloqueio regional.

Recomendaciones para el uso de tromboprofilaxis en pacientes hospitalizados por COVID-19 en la Argentina / Recommendations for the use of thromboprophylaxis in hospitalized patients with COVID-19 in Argentina

Si bien la incidencia es incierta, algunos reportes de caso sugieren que la infección por COVID 19 se asocia con un aumento del riesgo de tromboembolismo venoso. Sugerimos iniciar tromboprofilaxis a todos los pacientes hospitalizados por síntomas asociados con una infección por COVID-19, a menos que esté contraindicado, con enoxaparina 40 mg SC diariamente si el clearance de creatinina es mayor a 30 ml/min.

Although the incidence is uncertain, some case reports suggest that COVID 19 infection is associated with an increased risk of venous thromboembolism. We suggest starting prophylactic anticoagulant therapy for all patients hospitalized with a symptomatic infection with COVID-19, unless contraindicated, with enoxaparin 40 mg SC daily if creatinine clearance is greater than 30 ml/min.

Prevention of pulmonary and venous thromboembolism post coronary artery bypass graft surgery - literature review

Abstract Objective: The current review evaluates recent literature on the different aspects of prophylaxis in postoperative pulmonary and venous thromboembolism and their main risk factors. Methods: The literature survey was carried out based on the PubMed data using the keywords "coronary artery bypass graft" and "venous thromboembolism" as components of the search field title. Results: Studies reported several risk factors for postoperative thromboembolism including advanced age, postoperative immobilization, type of thromboprophylaxis, obesity, and location of the surgery. Conclusion: According to the studies, tailored prophylaxis could be easily adapted to decrease the intensity and duration of postoperative thromboembolism in a patient with several disorders and comorbidities, especially in cardiovascular disease.