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.

Eficácia, segurança e tolerabilidade da Enoxaparina para prevenção de tromboembolismo venoso nas cirurgias eletivas de abdome, pelve e varizes: revisão rápida de evidências / Seffectiveness,safety and tolerability of Enoxaparin for the prevention of venous thromboembolism in elective surgery of the abdomen, pelvis and varices: quick evidence review

Tecnologia: Enoxaparina comparada à profilaxia mecânica e/ou outros medicamentos disponíveis ou não no SUS. Indicação: Profilaxia de Tromboembolismo Venoso (TEV) em pacientes submetidos a cirurgia de abdome, pelve e varizes. Pergunta: Há superioridade em eficácia e segurança da enoxaparina (heparina de baixo peso molecular - HBPM) comparada à profilaxia mecânica e a outros medicamentos disponíveis ou não no SUS para prevenção de TEV em pacientes acima de 18 anos, não gestantes, em pós-operatório de cirurgias eletivas de abdome, pelve e varizes? Métodos: Revisão rápida de evidências (overview) de revisões sistemáticas, com levantamento bibliográfico realizado na base de dados PUBMED, utilizando estratégia estruturada de busca. A qualidade metodológica das revisões sistemáticas foi avaliada com AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews). Resultados: Foram selecionadas quatro e incluídas duas revisões sistemáticas com metanálise. Conclusão: HBPM no pós-operatório de cirurgia abdominal e pelve reduziu a incidência de TEV geral e TEV sintomático, sem aumentar risco de sangramento e mortalidade. Nas cirurgias de veias varicosas, foi observado uma redução de todos os eventos trombóticos e risco de TVP, sem aumentar risco de sangramento

Technology: Enoxaparin compared to mechanical prophylaxis and/or other drugs available or not in the SUS. Indication: Prophylaxis of Venous Thromboembolism (VTE) in patients undergoing surgery of the abdomen, pelvis and varicose veins. Question: There is superiority in efficacy and safety of enoxaparin, compared to mechanical prophylaxis and other drugs available or not in the SUS, for the prevention of VTE for patients over 18 years old, non-pregnant in the postoperative period of elective surgeries of the abdomen, pelvis and varicose veins? Methods: Rapid review of evidence (overview) from systematic reviews, with a bibliographic search in the PUBMED database, using a structured strategy. The methodological quality of systematic reviews was assessed with AMSTAR-2 (Methodological Quality Assessment of Systematic Reviews). Results: Four were selected and two systematic reviews with meta-analysis were included. Conclusion: LMWH in the postoperative period of abdominal and pelvic surgery reduced the incidence of general VTE and symptomatic VTE, without increasing the risk of bleeding and mortality. In varicose vein surgeries, a reduction in all thrombotic events and risk of DVT was observed, without increasing the risk of bleeding

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.

Enfermedad tromboembólica venosa en hemopatías malignas: un enfoque desde la prevención / Venous thromboembolic disease in hematologic malignancies: a preventive approach

Introducción: La enfermedad tromboembólica venosa es una complicación frecuente en las hemopatías malignas, con incidencia similar a la observada en tumores sólidos de alto riesgo trombótico. Objetivo: Describir la influencia de factores de riesgo y biomarcadores de la enfermedad tromboembólica venosa asociada a hemopatías malignas y su aplicación en el diseño de modelos de evaluación de riesgo para la prevención de esta enfermedad. Métodos: Se realizó una revisión exhaustiva en la literatura especializada de artículos publicados sobre la temática a través de las bases de datos: PubMed, SciELO, ScienceDirect, Medline y el motor de búsqueda Google académico. Análisis y síntesis de la información: En pacientes con hemopatías malignas han sido descritos múltiples factores de riesgo para la ocurrencia de eventos tromboembólicos venosos: moleculares, relacionados con el paciente, la enfermedad y el tratamiento, así como biomarcadores de riesgo. Basados en ellos, varias investigaciones han sido desarrolladas para elaborar y validar modelos predictivos de enfermedad tromboembólica venosa que guíen la estratificación del riesgo y el tratamiento profiláctico de esta enfermedad en hemopatías malignas, aunque aún son insuficientes. Enfermedades como los linfomas y el mieloma múltiple tienen más investigaciones en esta área que el resto de las hemopatías malignas. Conclusión: Se necesita diseñar nuevos modelos de riesgo y validar los existentes en un mayor número de casos; así como desarrollar estudios prospectivos en pacientes con riesgo de eventos tromboembólicos y hemopatías malignas, para realizar una estrategia de prevención primaria personalizada con estratificación de la tromboprofilaxis(AU)

Introduction: Venous thromboembolic disease is a frequent complication in hematologic malignancies with incidence similar to that observed in solid tumors with high thrombotic risk. Objective: To describe the influence of risk factors and biomarkers of venous thromboembolic disease associated with hematologic malignancies and their application in the design of risk assessment models for the prevention of this disease. Methods: An exhaustive review was carried out in the specialized literature of articles published on the subject using the following databases: PubMed, SciELO, ScienceDirect, Medline and the academic Google search engine. Analysis and synthesis of the information: Multiple risk factors for the occurrence of venous thromboembolism have been described in patients with hematologic malignancies: patient-related, disease-related, treatment-related and molecular, as well as biomarkers of risk. Based on these, several investigations have been developed to elaborate and validate predictive venous thromboembolism models to guide risk stratification and prophylactic treatment of venous thromboembolic disease in hematologic malignancies, although they are still insufficient. Lymphomas and multiple myeloma have more research in this area than other hematologic malignancies. Conclusion: There is a need to design new risk models and validate existing ones in a larger number of cases, as well as to develop prospective studies in patients at risk of thromboembolic events and hematologic malignancies, to carry out a personalized primary prevention strategy with thromboprophylaxis stratification(AU)

Profilaxia pré-exposição de tromboembolia venosa e enfermagem: A realidade de um hospital público universitário / Profilaxis preexposición de la tromboembolia venosa y enfermería: La realidad de un hospital público universitario / Pre-exposure prophylaxis of venous thromboembolism and nursing: The reality of a university public hospital

Objetivo: caracterizar o risco de tromboembolismo venoso e uso de profilaxia em pacientes clínicos e cirúrgicos, avaliando a conformidade ou não-conformidade da prescrição de profilaxia medicamentosa. Método: estudo transversal, com 3341 pacientes clínicos e cirúrgicos com protocolo de profilaxia de tromboembolismo venoso preenchido aprovado pelo Comitê de Ética em Pesquisa CAAE 62055616.7.00005411, com dados extraídos de relatório personalizado gerado automaticamente do prontuário eletrônico do paciente em planilha Excel®, do período de março/2017 a dezembro 2017. As análises iniciais foram obtidas a partir de medidas descritivas para as variáveis quantitativas e frequências e percentuais para variáveis categorizadas. Resultados: A taxa global de conformidade foi de 70% e os pacientes clínicos apresentaram maior conformidade de prescrição de profilaxia em relação aos pacientes cirúrgicos. Conclusão: A profilaxia medicamentosa para tromboembolismo venoso é subutilizada, principalmente em pacientes cirúrgicos. Os pacientes clínicos receberam mais profilaxia que os cirúrgicos, predominando a indicação da enoxaparina sódica.(AU)

Objective: to characterize the risk of venous thromboembolism and the use of prophylaxis in clinical and surgical patients, evaluating the compliance or non-compliance with the prescription of drug prophylaxis. Method: a cross-sectional study with 3341 clinical and surgical patients with a completed venous thromboembolism prophylaxis protocol approved by the Research Ethics Committee CAAE 62055616.7.00005411, with data extracted from a personalized report automatically generated from the patient's electronic medical record in an Excel® spreadsheet, from the period from March/2017 to December 2017. The initial analyzes were obtained from descriptive measures for quantitative variables and frequencies and percentages for categorized variables. Results: The overall compliance rate was 70% and clinical patients showed greater compliance with prophylaxis prescriptions compared to surgical patients. Conclusion: Drug prophylaxis for venous thromboembolism is underused, especially in surgical patients. Clinical patients received more prophylaxis than surgical patients, with the indication of enoxaparin sodium predominating.(AU)

Objetivo: caracterizar el riesgo de tromboembolismo venoso y el uso de profilaxis en pacientes clínicos y quirúrgicos, evaluando el cumplimiento o incumplimiento de la prescripción de profilaxis farmacológica. Método: estudio transversal con 3341 pacientes clínicos y quirúrgicos con protocolo completo de profilaxis de tromboembolismo venoso aprobado por el Comité de Ética en Investigación CAAE 62055616.7.00005411, con datos extraídos de un informe personalizado generado automáticamente a partir de la historia clínica electrónica del paciente en un Excel® hoja de cálculo, del período de marzo/2017 a diciembre de 2017. Los análisis iniciales se obtuvieron a partir de medidas descriptivas para variables cuantitativas y frecuencias y porcentajes para variables categorizadas. Resultados: La tasa de cumplimiento global fue del 70% y los pacientes clínicos mostraron un mayor cumplimiento de las prescripciones de profilaxis en comparación con los pacientes quirúrgicos. Conclusión: La profilaxis farmacológica del tromboembolismo venoso está infrautilizada, especialmente en pacientes quirúrgicos. Los pacientes clínicos recibieron más profilaxis que los pacientes quirúrgicos, predominando la indicación de enoxaparina sódica.(AU)

Morbi-mortalidad de la enfermedad tromboembólica venosa en el Hospital Universitario "Arnaldo Milián Castro" / Morbi-mortality of venous thromboembolic disease at "Arnaldo Milián Castro" University Hospital

Introducción: La enfermedad tromboembólica venosa es un proceso grave y mortal, considerado un problema de salud a escala mundial. Objetivo: Caracterizar la morbi-mortalidad por enfermedad tromboembólica venosa en el Hospital Universitario "Arnaldo Milián Castro". Métodos: Se realizó un estudio descriptivo retrospectivo de corte transversal a una muestra de 290 casos atendidos en el Hospital Universitario "Arnaldo Milián Castro" de Villa Clara, entre febrero de 2014 y febrero de 2016. Las variables fueron: edad, sexo, factores de riesgo, forma de presentación de la enfermedad y tipo de diagnóstico. Resultados: Se observó un predominio del sexo femenino y de los pacientes mayores de 70 años, independientemente del sexo y la inmovilidad como factor de riesgo. La trombosis venosa profunda del sector íleo-femoral fue la forma de presentación más común. El diagnóstico clínico primó, aunque el tromboembolismo pulmonar, como la complicación principal, se diagnosticó por necropsia. La mayor cantidad de trombosis venosa profunda se registró en el Servicio de Angiología, mientras que las muertes por embolia pulmonar predominaron en el Servicio de Terapia Intensiva. El tratamiento médico más utilizado fue la heparina sódica más warfarina; el profiláctico se realizó solo en el 24,7 por ciento de los casos. La heparina sódica se utilizó más en los servicios de Terapia Intensiva. Conclusiones: La enfermedad tromboembólica venosa fue la principal causa de muerte prevenible en el hospital, lo que sugiere que la profilaxis antitrombótica debe resultar una práctica esencial en los pacientes hospitalizados(AU)

Introduction: Venous thromboembolic disease is a serious and fatal process considered a health problem on a global scale. Objective: Characterize morbidity and mortality due to venous thromboembolic disease at "Arnaldo Milián Castro" University Hospital. Methods: A retrospective descriptive cross-sectional study was conducted on a sample of 290 cases treated at "Arnaldo Milián Castro" University Hospital in Villa Clara between February 2014 and February 2016. The variables were: age, sex, risk factors, form of presentation of the disease and type of diagnosis. Results: A predominance of the female sex and patients over 70 years of age was observed, regardless of sex and immobility as risk factors. Deep vein thrombosis of the ileus-femoral sector was the most common form of presentation. Clinical diagnosis prevailed, although pulmonary thromboembolism, as the main complication, was diagnosed by necropsy. The highest amount of deep vein thrombosis was recorded in the Angiology Service, while deaths from pulmonary embolism predominated in the Intensive Care Service. The most commonly used medical treatment was sodium heparin plus warfarin; prophylaxis was performed only in 24.7 percent of cases. Sodium heparin was more used in Intensive Care services. Conclusions: Venous thromboembolic disease was the leading cause of preventable death in the hospital, suggesting that antithrombotic prophylaxis should be an essential practice in hospitalized patients.

Low molecular weight heparin is useful in adult COVID-19 inpatients. Experience during the first Spanish wave: observational study

ABSTRACT BACKGROUND: The intensity of the thromboprophylaxis needed as a potential factor for preventing inpatient mortality due to coronavirus disease-19 (COVID-19) remains unclear. OBJECTIVE: To explore the association between anticoagulation intensity and COVID-19 survival. DESIGN AND SETTING: Retrospective observational study in a tertiary-level hospital in Spain. METHODS: Low-molecular-weight heparin (LMWH) status was ascertained based on prescription at admission. To control for immortal time bias, anticoagulant use was analyzed as a time-dependent variable. RESULTS: 690 patients were included (median age, 72 years). LMWH was administered to 615 patients, starting from hospital admission (89.1%). 410 (66.7%) received prophylactic-dose LMWH; 120 (19.5%), therapeutic-dose LMWH; and another 85 (13.8%) who presented respiratory failure, high D-dimer levels (> 3 mg/l) and non-worsening of inflammation markers received prophylaxis of intermediate-dose LMWH. The overall inpatient-mortality rate was 38.5%. The anticoagulant nonuser group presented higher mortality risk than each of the following groups: any LMWH users (HR 2.1; 95% CI: 1.40-3.15); the prophylactic-dose heparin group (HR 2.39; 95% CI, 1.57-3.64); and the users of heparin dose according to biomarkers (HR 6.52; 95% CI, 2.95-14.41). 3.4% of the patients experienced major hemorrhage. 2.8% of the patients developed an episode of thromboembolism. CONCLUSIONS: This observational study showed that LMWH administered at the time of admission was associated with lower mortality among unselected adult COVID-19 inpatients. The magnitude of the benefit may have been greatest for the intermediate-dose subgroup. Randomized controlled trials to assess the benefit of heparin within different therapeutic regimes for COVID-19 patients are required.

Profilaxia do tromboembolismo venoso nas cirurgias ortopédicas / Venous thromboprophylaxis in orthopedic surgeries

A trombose venosa profunda (TVP) e o tromboembolismo pulmonar (TEP) são as principais manifestações clínicas do tromboembolismo venoso (TEV). O TEV é uma complicação comum e potencialmente grave das cirurgias ortopédicas, uma vez que pode levar à limitação funcional e morte pós-operatória. O uso da tromboprofilaxia reduz acentuadamente a incidência de TEV relacionado às intervenções ortopédicas, e seu uso é recomendado por diversas diretrizes. Entretanto, a indicação e o tipo de tromboprofilaxia para algumas intervenções ortopédicas, assim como o uso de ferramentas de predição de risco, ainda não estão bem estabelecidos e constituem pontos de debate. Os objetivos deste trabalho foram identificar os fatores de risco para TEV e suas interações nas cirurgias ortopédicas e avaliar a aplicabilidade do escore de risco de Caprini na predição de TEV em pacientes ortopédicos. Além disso, devido à escassez de conhecimento e recomendações sobre tromboprofilaxia nas intervenções ortopédicas de tornozelo e pé, realizaram-se uma revisão narrativa e uma enquete internacional sobre o assunto. Para analisar a interação de fatores de risco de TEV e a aplicabilidade preditiva do escore de Caprini nas cirurgias ortopédicas, foram utilizados os dados do Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA), um estudo caso-controle holandês de base populacional cujo desfecho de interesse é o TEV. Neste, 263 indivíduos que tiveram TEV e 94 controles foram submetidos à cirurgia ortopédica. O risco de TEV foi maior nos primeiros 30 dias após a cirurgia [odds ratio ajustada (ORadj) 17,5; intervalo de confiança (IC) 95%, 9,2-33,4] e manteve-se aumentado até 90 dias (ORadj 11,5; IC 95%, 7,3-17,7). Houve interação entre cirurgia ortopédica e mutação fator V Leiden (ORadj 17,5; IC 95%, 4,1-73,6), tipo de sangue não-O (ORadj 11,2; 95% IC, 3,4-34,0) e níveis séricos de fator VIII maiores que 150 mg/dl (ORadj 18,6; IC, 7,4-46,9). Quanto ao escore de Caprini, foram avaliados 357 indivíduos com TEV submetidos à cirurgia ortopédica. Um total de 20,9% dos casos e 41,5% dos controles foram classificados no grupo de menor risco (Caprini < 5 pontos). Pacientes com um escore de Caprini maior que 11 pontos tiveram um risco de TEV seis vezes maior (OR 6,3; IC 95%, 1,7-22,9), e pacientes com um escore de 9 a 10 tiveram um risco três vezes maior (OR 3,5; IC 95% 1,2-10,3). A área sob a curva (AUC) do escore de Caprini foi de 0,64, evidenciando uma discriminação de predição de TEV moderada. Na enquete internacional sobre tromboprofilaxia de pé e tornozelo, 693 cirurgiões ortopédicos de pé e tornozelo de 49 países participaram. Aproximadamente 50% informaram prescrever tromboprofilaxia durante a imobilização do paciente. Quando utilizada, as escolhas preferidas em ordem decrescente foram ácido acetilsalicílico (AAS), heparina de baixo peso molecular (HBPM) e anticoagulantes orais diretos. AAS e HBPM foram predominantemente prescritos na América do Norte e Europa, respectivamente. TVP prévia, imobilidade, obesidade e trombofilia hereditária foram considerados os principais fatores de risco indicativos do uso de tromboprofilaxia. Concluiu-se que: houve risco aumentado de TEV e interação entre os fatores de risco fator V Leiden, níveis elevados de fator VIII e grupo sanguíneo não- O com cirurgia ortopédica; o escore de Caprini é uma ferramenta que pode auxiliar os cirurgiões ortopédicos a classificarem o risco de TEV no pós-operatório, embora seu desempenho preditivo discriminativo tenha sido moderado; apesar de a maioria dos cirurgiões ortopédicos de tornozelo e pé considerarem que a tromboprofilaxia está indicada para cirurgias de tornozelo e pé (principalmente na presença de fatores de risco como TVP prévia, imobilidade, obesidade e trombofilia hereditária), a prescrição, o tipo e a duração apresentam grande discrepância intercontinental. Assim, este trabalho contribui para a identificação de pacientes sob alto risco de TEV, ponto estratégico para o uso individualizado e seguro da tromboprofilaxia como ferramenta para redução do risco de TEV relacionado às cirurgias ortopédicas.

Deep vein thrombosis (DVT) and pulmonary embolism are the main clinical manifestations of venous thromboembolism (VTE). VTE is a common and potentially serious complication of orthopedic surgeries, as it can lead to functional limitation and postoperative death. The use of thromboprophylaxis markedly reduces the incidence of VTE related to orthopedic interventions, and its use is recommended by several guidelines. However, the indication and type of thromboprophylaxis for some orthopedic interventions, as well as the use of risk prediction tools are still not well established and is debatable. The objectives of this study were to identify risk factors for VTE and their interactions in orthopedic surgeries and to evaluate the applicability of the Caprini risk score in predicting VTE in orthopedic patients. In addition, due to the lack of knowledge and recommendations on thromboprophylaxis in foot and ankle surgeries, a narrative review and an international survey on the subject were carried out. Data from the MEGA Study (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis) which is a Dutch population-based case-control study whose outcome of interest is VTE were used. A total of 263 subjects who had VTE and 94 controls underwent orthopedic surgery. The risk of VTE was the highest in the first 30 days after surgery (adjusted odds ratio [ORadj] 17.5; 95% CI [confidence interval], 9.2-33.4) and remained increased up to 90 days (ORadj, 11.5; 95% CI, 7.3- 17.7). There was interaction between orthopedic surgery and factor V Leiden mutation (ORadj 17.5, 95%CI 4.1-73.6), non-O blood type (ORadj 11.2; 95%CI 3.4-34.0) and factor VIII plasma levels greater than 150 mg/dl (ORadj 18.6; CI 7.4-46.9). To assess the applicability of the Caprini Score, 357 individuals with VTE undergoing orthopedic surgery in the MEGA were evaluated. A total of 20.9% of cases and 41.5% of controls were classified in the lowest risk group (Caprini <5 points). Patients with a Caprini score greater than 11 points had a six-fold increased risk of VTE (OR 6.3, 95% CI 1.7- 22.9) and patients with a score of 9-10 had about three-fold increased risk (OR 3.5, 95% CI 1.2-10.3). The area under curve for the Caprini score was 0.64, evidencing a moderate VTE prediction discrimination. In the international survey on foot and ankle thromboprophylaxis, 693 orthopedic foot and ankle surgeons from 49 countries participated. Approximately 50% reported prescribing thromboprophylaxis during patient immobilization that, when used, the preferred choice, in descending order, was acetylsalicylic acid (ASA), low molecular weight heparin (LMWH) and direct oral anticoagulants. ASA and LMWH were predominantly prescribed in North America and Europe, respectively. Previous DVT, immobility, obesity and hereditary thrombophilia were considered the main risk factors indicative of the use of thromboprophylaxis. It is concluded that there was increased risk of VTE and interaction between factor V Leiden, high plasma levels of factor VIII or non-O blood group and orthopedic surgery; that the Caprini score is a tool that can help orthopedic surgeons to classify the risk of postoperative VTE, although its discriminative predictive performance was moderate and that although most ankle and foot orthopedic surgeons consider that thromboprophylaxis is indicated for ankle and foot surgeries (especially in the presence of risk factors such as previous DVT, immobility, obesity and hereditary thrombophilia), the prescription, type and duration present a large intercontinental discrepancy. Thus, this work contributed to the identification of patients at high risk of VTE, a strategic point for the individualized and safe use of thromboprophylaxis as a tool to reduce the risk of VTE related to orthopedic surgeries.

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.

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.

Trastornos de la coagulación en cirrosis hepática: artículo de revisión / Coagulation disorders in liver cirrhosis: a review article

Los eventos fisiopatológicos de la cirrosis hepática alteran drásticamente los procesos de hemostasia primaria, secundaria y fibrinólisis. Antiguamente se conceptuaba que dichas alteraciones predisponían exclusivamente a un estado de hipocoagulabilidad, debido a la baja producción hepática de factores procoagulantes y a la trombocitopenia característica. Actualmente existe evidencia de mecanismos de compensación que llevan a un reequilibrio hemostático, que es inestable y fácilmente desregulado ante comorbilidades, complicaciones y progresión de la enfermedad, conduciendo a fenómenos prohemorrágicos o protrombóticos, como trombosis venosa portal, tromboembolismo venoso, etc. Para determinar eficazmente si un paciente cirrótico tiene riesgo de sangrado, no son de utilidad las pruebas de coagulación convencionales. El tratamiento dependerá del estado hipo o hipercoagulable del paciente. Para ello desarrollamos una revisión de los fenómenos hemostáticos en la cirrosis, con el fin de dar a conocer sus características, el método de diagnóstico más eficaz y los tratamientos disponibles.

The pathophysiological events of liver cirrhosis drastically alter the processes of primary and secondary hemostasis and fibrinolysis. Previously, it was conceptualized that these alterations exclusively predisposed to hypocoagulation, due to the low hepatic production of procoagulant factors and the characteristic thrombocytopenia. Currently, there is evidence of compensation mechanisms that lead to a hemostatic rebalancing, which is unstable and easily dysregulated in the presence of comorbidities, complications and progression of the disease, leading to prohemorrhagic or prothrombotic phenomena, such as portal vein thrombosis, venous thromboembolism, etc. To effectively determine whether a cirrhotic patient is at risk for bleeding, conventional coagulation tests are not helpful. Treatment will depend on the hypo or hypercoagulable state of the patient. In this manuscript, we review the hemostatic phenomena in cirrhosis, to reveal its characteristics, effective diagnostic methods and treatment.

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.

Venous thromboembolism risk assessment and prophylaxis in hospitalised medical patients in the Cape Town metropole, South Africa

Background. Venous thromboembolism (VTE) is regarded as the most preventable cause of inpatient death in hospital settings globally. VTE can be prevented through the provision of non-pharmacological and/or pharmacological thromboprophylaxis following individualised risk screening. The Caprini risk assessment model (RAM) offers a validated and well-established approach for VTE risk assessment in medical inpatients. Literature findings describe a trend towards inappropriate and under-prescribing of thromboprophylaxis in this population. Together with concerns regarding clinicians' perceived importance of VTE risk assessment, the need to clarify these aspects of practice is evident. Objectives. To describe VTE risk assessment and prophylaxis practices of medical practitioners in public sector hospitals in Western Cape Province, South Africa (SA). Methods. A retrospective, cross-sectional study design was employed in the medical wards of two district hospitals and one regional hospital in the Cape Town metropole, Western Cape. Medical folders of adult medical inpatients admitted between January and July 2020 were reviewed to assess VTE risk using the Caprini RAM. Thromboprophylaxis therapy prescribed and contraindications to chemoprophylaxis were also evaluated. Results. Of 380 patients included in the review, 51.6% were female, and the average age was 52.1 years (range 18 - 96); 21.3% had their weight recorded, while none had their height documented. Infectious disease was the predominant diagnosis (49.2%) detected in the sample. Common VTE risk factors identified included bed rest/restricted mobility for <72 hours (76.3%) and serious infection (67.4%). A total of 97.1% of patients (n=369) were found to be at moderate or higher risk of VTE (Caprini score ≥2). Of this at-risk group, 24.1% were eligible to receive chemoprophylaxis, yet no prescription for thromboprophylaxis was identified. Seventy percent of patients (n=266) were prescribed chemoprophylaxis, with enoxaparin accounting for 98.5% of regimens. Contraindications to chemoprophylaxis were recorded in 13.4% of patients. Conclusions. Although rates of VTE prophylaxis in medical inpatients may be improving, thromboprophylaxis still remains critically underutilised in this population. This study highlighted a consequence of this trend, with inappropriate chemoprophylaxis prescribing becoming more evident. Mechanical prophylaxis prescribing in medical inpatients is lacking, despite the associated benefits. RAMs should be adapted for the SA setting, where infectious diseases are prevalent. Future research should assess RAM use by clinicians, as this could provide insight into improving RAM uptake and thromboprophylaxis prescribing.

Complications des prothèses valvulaires mécaniques: à propos de cinq cas au service de cardiologie du Centre Hospitalier de Libreville / Complications of mechanical prothetic heart valves : about five cases in the cardiology Department of the Libreville University Hospital Center

Introduction : La présence de matériel prothétique intracardiaque expose au risque thromboembolique, infectieux et/ou hémorragique. L'objectif de ce travail était de décrire les particularités cliniques et étiologiques des complications de prothèses valvulaires mécaniques.Cas cliniques : Il s'agit d'une série de cinq observations de patients présentant une complication de prothèses valvulaires mécaniques colligées au service de cardiologie du Centre Hospitalier Universitaire de Libreville durant la période allant de Janvier 2017 à Décembre 2021. Les complications rapportées étaient deux cas de thrombose obstructive de prothèse, un accident vasculaire cérébral sur microthrombose, une endocardite infectieuse et un accident hémorragique sous antivitamines K. Ce dernier était responsable d'un décès. Conclusion : Ces cas cliniques mettent en exergue les difficultés liées au suivi de l'anticoagulation au long cours chez les patients porteurs de prothèse valvulaire mécanique dans notre contexte. La mise en place d'un programme d'éducation thérapeutique pourrait diminuer ces complications parfois létales

Introduction: The presence of intracardiac prosthetic material exposes to thromboembolic, infectious and/or hemorrhagic risk. The objective of this study was to describe the clinical and etiological particularities of mechanical valve prostheses complications. Clinical cases: five observations of patients presenting with a complication of mechanical valve prostheses collected in the cardiology department of the Libreville University Hospital Center during the period from January 2017 to December 2021, were reported. Complications observed were two cases of obstructive prosthesis thrombosis, a cerebrovascular stroke coming from microthrombosis, an infective endocarditis and a hemorrhagic accident under vitamin K antagonists. This last was responsible for the one death. Conclusion: These clinical cases highlight the difficulties related to the monitoring of long-term anticoagulation in patients with mechanical valve prosthesis in our context. The development of a therapeutic education program could reduce these potentially lethal complications

Manifestations cardiovasculaires au cours de l'infection à VIH à Libreville: étude comparative de patients séropositifs et séronégatifs / Cardiovascular Manifestations during HIV infection in Libreville: Comparative study of seropositive and seronegative patients

Introduction. Le spectre des atteintes cardiovasculaires au cours de l'infection à VIH a été modifi é par la trithérapie antirétrovirale. L'objectif de ce travail était de décrire le profi l des manifestations cardiovasculaires chez les patients vivants avec le VIH en le comparant à celui de patients séronégatifs. Méthodes. Il s'est agi d'une étude cas-témoins des dossiers de patients respectivement séropositifs et séronégatifs hospitalisés pour une pathologie cardiovasculaire au service de cardiologie du Centre Hospitalier Universitaire de Libreville de janvier 2015 à décembre 2018. L'analyse statistique a été réalisée à l'aide du logiciel Statview 5.0. Lestests de Chi-2 de Pearson ou Exact de Ficher ont été utilisés pour la comparaison des proportions. Résultats. L'étude a porté sur sur l'analyse de 82 et 150 dossiers de patients respectivement séropositifs et séronégatifs. Un âge inférieur à 50 ans était retrouvé chez 70,7% des séropositifs et 43,3% des séronégatifs (p<0,01). Le taux de CD4 moyen des séropositifs était de 189±170/mm3 et 45,1% d'entre eux étaient sous trithérapie antiretrovirale.La cardiomyopathie dilatée était l'atteinte cardiaque la plus fréquente chez les séropositifs (42,7%) et chez les séronégatifs (52,7%) (p=0,14). La maladie thromboembolique veineuse était relevée chez 7(8,5%) séropositifs et 14 (8,8%) séronégatifs (p=0,93). Une péricardite était diagnostiquée chez 25,6% des séropositifs avec une étiologie tuberculeuse dans 85,7% des cas. Les pathologies vasculaires athéromateuses étaient plus fréquentes chez les séronégatifs (23,1%) comparés aux séropositifs (6,1%) (p<0,01). La mortalité des séropositifs était principalement due aux péricardites (71,4%). Conclusion. les manifestations cardiovasculaires liées à l'immunodépression persistent chez les personnes vivant avec le VIH à Libreville. Un dépistage précoce de ces atteintes permettrait de réduire la mortalité.

Introduction. The spectrum of cardiovascular damage during HIV infection has been modified by triple antiretroviral therapy. The objective of this study was to describe the profile of cardiovascular manifestations in patients living with HIV by comparing it to the one of seronegative patients. Methods. This was a case-control study which focused on the files of patients hospitalized for a cardiovascular pathology in the cardiology department of the Center Hospitalier Universitaire de Libreville from january 2015 to december. 2018. Results. In total, there was on the analysis of the files of 82 seropositive patients and 150 seronegative patients. The age found was less than 50 years old in 70.7% of seropositives and 43.3% of seronegatives (p <0.01). The mean CD4 count in seropositives was 189 ± 170 /mm3 and 45.1% of them were on triple antiretroviral therapy. Dilated cardiomyopathy was the most common cardiac disease in HIVpositive (42.7%) and HIV-negative (52.7%) (p = 0.14). Venous thromboembolic disease was noted in 7 (8.5%) seropositives and 14 (8.8%) seronegatives (p=0.93).Pericarditis was diagnosed in 25.6% of seropositives patients with a tuberculous etiology in 85.7% of cases. Atheromatous vascular pathologies were more frequent in seronegative (23.1%) compared to seropositive (6.1%) (p <0.01). Mortality among seropositive was mainly due to pericarditis (71.4%)