A case report of Budd-Chiari syndrome with cardiac complications and low SPO2 successfully managed by an integrated-approach

Budd-Chiari syndrome [BCS] is a rare, potentially life-threatening condition characterized by the triad of abdominal pain, ascites, and hepatomegaly (with or without jaundice). There will be an underlying disorder in most cases. The diagnosis, as well as management of the case, requires a multidisciplinary approach. The treatment should aim at reducing the presenting symptoms as well as removing the underlying pathology. Here we explain a case report of a 21-year-old male patient in the subacute stage of BCS with its complications and considered as a candidate for liver transplantation. His liver enzymes, PT/INR, D- dimer, and homocysteine values were above normal levels. The arterial oxygen saturation level was subnormal, and he was on supportive oxygen supplement. Inferior venacava [IVC] Doppler revealed a non-obstructive intrahepatic thrombus. The patient was treated with Homoeopathic medicine Arsenicum album and Arnica montana, given as an adjuvant to conventional treatment.

Removal of Shield Needles from Graphene Oxide Thrombus and Preparation / 中国医疗器械杂志

Atherosclerosis is a chronic inflammatory disease commonly seen in clinical practice. It can lead to thickening of vascular intima, occlusion of lumen stenosis and thrombosis, leading to angina pectoris, hypertension, myocardial infarction and other diseases, posing a serious threat to human life and health. This study provides a method for removing shield needles from graphene oxide thrombus and its preparation. The graphene oxide shield needle mainly includes flexible rotating shaft, radial flexible rod, rotating needle, adsorption main pipe and dosing main pipe, laser measuring device, high definition camera and other structures, which has the following advantages:firstly, it achieves multi-angle rotation grinding thrombosis, precise rotation grinding, avoids vascular damage and infection; secondly, thrombolytic drugs can be applied in the process of rotary grinding and small thrombus can be adsorbed to effectively avoid secondary embolization of blood vessels; thirdly, it a coating of graphene oxide on a rotating needle, which protects against bacteria and infection. This study has practical reference value for the development of thrombotherapy and the application of graphene in the medical field.

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.

Limb ischemia in patients with COVID-19 / Isquemia de membros em pacientes com COVID-19

Abstract This narrative review covers the life-threatening thromboembolic events associated with SARS-CoV-2 infection/COVID-19. It addresses the physical changes that cause vascular and arterial damage to limbs, laboratory management of coagulation, and management of anticoagulation. COVID-19's relationship with deep venous thrombosis and arterial thrombosis is also emphasized. The main thromboembolic events described in the literature are illustrated with examples from our experience with COVID-19 patients.

Resumo Esta revisão narrativa abrange os eventos tromboembólicos com risco de vida associados a infecção por SARS-CoV-2/COVID-19. Aborda as mudanças físicas que causam danos vasculares e arteriais aos membros, o manejo laboratorial da coagulação e o manejo da anticoagulação. A relação de COVID-19 com trombose venosa profunda e trombose arterial também é enfatizada. Os principais eventos tromboembólicos descritos na literatura são ilustrados a partir de nossa experiência com pacientes COVID-19.

Coagulopatía por SARS-CoV-2 / SARS-COV-2 COAGULOPATHY

En diciembre de 2019 se descubrió un nuevo coronavirus, asociado a pacientes que sufrían un cuadro de neumonía en Hubei provincia de China, desde ese momento se estudia las características del virus, como también de la patología que produce. En los pacientes graves, se observó un estado proinflamatorio y procoagulante que provocó la disfunción multiorgánica, y, en muchos de ellos, la muerte. El objetivo de este trabajo consiste en describir la fisiopatología de la coagulopatía que esta infección, sorprendentemente, provoca. Es importante remarcar la relación que existe entre los estados inflamatorios y la cascada de la coagulación, cuyas disfunciones ocurren en situaciones de gravedad, como es la sepsis. El SARS-CoV-2 entrara a la célula mediante el receptor de la enzima convertidora de angiotensinógeno. En los estadios avanzados o críticos de la enfermedad, el estímulo hiperinflamatorio y el ambiente protrombótico provocarán un daño multiorgánico. El enfoque de los pacientes en estadios avanzados o críticos debe ser de soporte vital, junto a una terapia anticoagulante completa

In December 2019, a new coronavirus, SARS-CoV-2, was discovered in patients suffering from pneumonia. In critically ill patients, a proinflammatory and procoagulant state was observed: this led to multiorgan dysfunction, and, in many patients, to death. The objective of this work is to describe the pathophysiology of coagulopathy that this infection, surprisingly, causes. It is important to highlight the cross-talk between inflammation and coagulation in serious situations, such as sepsis. SARS-CoV-2 will enter the cell via the angiotensinogen converting enzyme receptor. In the advanced or critical stages of the disease, the hyperinflammatory stimulus and the prothrombotic environment will cause multi-organ damage. The approach of patients in advanced or critical stages should be life support, together with full anticoagulant therapy.

Thrombin generation and thromboelastometry tests in dogs with chronic kidney disease / Testes de geração de trombina e tromboelastometria em cães com doença renal crônica

Patients with chronic kidney disease (CKD) have paradoxical hemostatic potential because they have bleeding episodes but are also prone to thrombosis. Few studies have evaluated blood viscoelastic properties in dogs with kidney disease; on the other hand, hypercoagulability has been observed in these patients. It is also emphasized that the platelet function and its participation in this process have not yet been fully understood. The objective of this study was to evaluate and compare the Thrombin Generation Test (TGT) and also viscoelastic properties of the blood measured by thromboelastometry (TEM) in dogs with proteinuria in CKD. Twenty healthy dogs (Control Group) and 19 dogs with CKD in stage III or IV, classified according to International Renal Interest Society - IRIS, were selected, and the reference test of urine protein:creatinine ratio (UPCR) should be greater than one (CKD group). Blood samples for TEM, thrombin generation, Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT), and fibrinogen concentration was collected at a single time for both groups after inclusion criteria being confirmed. Statistical analysis was performed according to the distribution of variables at 5% significance level. Differences were observed between healthy dogs and those with proteinuria in CKD noted in TEM. The TGT was unable to differentiate between sick and healthy groups. However, when the nephropathy was stratified, increases in TTP and peak thrombin concentration by TGT were observed in females and dogs over 30 days of diagnosis of CKD. Both tests signaled a discrete state of hypercoagulability. In fact, TEM is more sensitive to detect hypercoagulability in dogs with CKD. However, the TGT has potential clinical application by allowing long-term sample storage.(AU)

Os pacientes com doença renal crônica (DRC) apresentam um potencial hemostático paradoxal, pois apresentam episódios de sangramento, mas também são propensos à trombose. Poucos estudos avaliaram as propriedades viscoelásticas sanguíneas em cães com doenças renais, entretanto, a hipercoagulabilidade já foi observada nestes pacientes. Ressalta-se ainda que a função plaquetária e sua participação neste processo ainda não foram totalmente esclarecidas. O objetivo foi avaliar e comparar o teste de geração de trombina (TGT) e as propriedades viscoelásticas sanguíneas medidas pela tromboelastometria (TEM) em cães com DRC proteinúrica. Foram selecionados 20 cães saudáveis (grupo controle) e 19 cães com DRC em estágios III ou IV classificados segundo o IRIS e a relação proteína/creatinina urinária maior que um (grupo DRC). As amostras de sangue para a realização da tromboelastometria (TEM), geração de trombina, tempo de protrombina (TP), tempo de tromboplastina parcial ativada (TTPA) e concentração de fibrinogênio foram colhidas em momento único para ambos os grupos após os critérios de inclusão confirmados. A análise estatística foi realizada de acordo com a distribuição das variáveis, ao nível de 5% de significância. Foi observada diferença entre os cães saudáveis e os com DRC proteinúrica observados na TEM. O teste de geração de trombina não foi capaz de diferenciar os grupos doente e saudável. Entretanto, quando os nefropatas foram analisados de forma estratificada, foram observados aumentos do ETP e da concentração máxima de trombina (peak) pelo TGT em fêmeas e em cães com mais de 30 dias de diagnóstico da DRC. Ambos os testes sinalizando para um discreto estado de hipercoagulabiliade. A tromboelastometria é mais sensível para detectar a hipercoagulabilidade em cães com DRC. Entretanto, o teste de geração de trombina tem melhor aplicabilidade por permitir o armazenamento da amostra em longo prazo.(AU)

Tromboembolismo venoso na mulher: novos desafios para uma velha doença / Venous thromboembolism in women: new challenges for an old disease

Resumo Nos países que controlaram as causas clássicas de óbito materno, como eclâmpsia e hemorragia, o tromboembolismo venoso (TEV) passou a ser a principal preocupação. A prevenção do TEV na gestação e no puerpério, por meio de diretrizes e da instituição de farmacoprofilaxia, é ainda a melhor estratégia para reduzir essa complicação. Os contraceptivos hormonais e a terapia de reposição hormonal também aumentam o risco de TEV; porém, as mulheres não podem ser privadas dos benefícios dessas terapias, que as tornam mais livres na idade fértil e menos sintomáticas na menopausa. Tanto o uso indiscriminado quanto a proibição imotivada são inadequados. A escolha dos métodos contraceptivos e de reposição deve ser feita por criteriosa seleção, avaliando as contraindicações, os critérios de elegibilidade e a autonomia das pacientes. O presente artigo apresenta uma revisão não sistemática da literatura recente visando a avaliar e resumir a associação entre TEV e situações clínicas peculiares ao sexo feminino.

Abstract In countries that have controlled classic causes of maternal death, such as eclampsia and hemorrhage, venous thromboembolism (VTE) has become the major concern. Prevention of VTE during pregnancy and postpartum by applying guidelines and implementing pharmacoprophylaxis is still the best strategy to reduce occurrence of this complication. Hormonal contraceptives and hormone replacement therapy also increase the risk of VTE, but women cannot be deprived of their benefits, which increase their freedom at childbearing age and reduce their symptoms at menopause. Both indiscriminate use and unmotivated prohibition are inappropriate. Contraceptive and hormone replacement methods should be chosen with care, evaluating the patients' contraindications, eligibility criteria, and autonomy. This article presents a nonsystematic review of recent literature with the aim of evaluating and summarizing the associations between VTE and clinical situations peculiar to women.

Podemos atuar preventivamente para evitar que os pacientes portadores de COVID-19 evoluam de forma mais grave? / Can we manage prophylactic therapy in COVID-19 patients to prevent severe illness complications?

Resumo Muitos pacientes com COVID-19 apresentam complicações tromboembólicas que acabam piorando seu prognóstico. Os autores propõem uma modificação no escore CHA2DS2-VASc, incluindo 1 ponto para COVID-19, para, desse modo, indicar profilaxia de eventos tromboembólicos antes do agravamento do quadro. As vantagens dessa modificação seriam evitar a piora do paciente por problemas tromboembólicos, bem como a necessidade de internação em unidade de tratamento intensivo e de ventilação mecânica, e diminuir a mortalidade.

Abstract Many patients with COVID-19 have thromboembolic complications that worsen their prognosis. Herein, the authors propose a modified version of the CHA2DS2-VASc score, including 1 point for COVID-19, so that prophylaxis to protect against thromboembolic events would be indicated before the condition becomes severe. The advantages of this modification would be prevention of the patient's condition worsening due to thromboembolic problems and reduction of the likelihood of a need for intensive care and mechanical ventilation, reducing mortality.

Técnicas e procedimentos de controle de infecções de cateteres venosos em onco-hematologia infantil: aspectos clínico-epidemiológicos e microbiológicos e prevalência de Corynebacterium spp. - Instituto Nacional de Câncer, RJ / Techniques and procedures central line infections control in childhood cancer patients: clinical and epidemiological aspects, microbiological and prevalence of Corynebacterium spp. - Instituto Nacional de Câncer, RJ

Estudo descritivo retrospectivo realizado no Instituto Nacional do Câncer José Alencar Gomes da Silva, HCI-Rio de Janeiro, Brasil, (INCA-HCI-RJ), no qual foram avaliadas infecções relacionadas aos acessos venosos para tratamento oncológico, nos setores Onco-Hematológicos pediátricos. A infecção representa uma importante complicação em pacientes oncológicos em tratamento. Devido ao tratamento oncológico que envolve: procedimentos cirúrgicos muitas vezes mutilantes, tratamento com quimioterápicos que ocasionam períodos de imunossupressão e neutropenia, e tratamento radioterápico com radiação e lise celular. O uso de dispositivos venosos associados a períodos de imunossupressão pode levar a infecção da corrente sanguínea e outras complicações (por exemplo trombose). No presente estudo foram investigados aspectos clínico-epidemiológicos das infecções e da susceptibilidade antimicrobiana em amostras clínicas obtidas de processos infecciosos associados ao uso de cateteres venosos de longa permanência no tratamento oncológico em pacientes do Hospital do Câncer José de Alencar Gomes da Silva, HCI/INCA, Rio de Janeiro Brasil. Foram avaliadas: a) prevalência das espécies diversas relacionadas aos quadros infecciosos identificados nestes pacientes oncológicos; b) prevalência de casos de complicações e outras infecções invasivas relacionadas ao uso de cateteres de longa permanência; c) perfis de susceptibilidade a antimicrobianos e ocorrência de multirresistência. O desenvolvimento deste projeto de pesquisa possibilitou a observação análise e validação da evolução dos processos envolvidos nos quadros de infecções nosocomiais em pacientes oncológicos pediátricos na prevenção de complicações que envolvem todo o sistema de saúde, além de contribuir na escolha de antimicrobianos e estratégias terapêuticas mais efetivas para o tratamento de infecções em cateteres por espécies multirresistentes de Corynebacterium.

Retrospective descriptive study conducted at the National Cancer Institute José Alencar Gomes da Silva, INCA / HCI-Rio de Janeiro, Brazil, (INCA-HCI-RJ). Infection represents an important complication in cancer patients. This group is more prone to infections due to the cancer treatment that involves: surgical procedures often mutilating, treatment with chemotherapy that cause periods of immunosuppression even with neutropenia, and radiotherapy treatment with radiation and cell lysis. The vascular devices associated with these periods can lead to bloodstream infection besides others complication as thrombosis. The number of reports of infections in hospitalized cancer patients increases morbidity and mortality rates. In the present study clinical and epidemiological aspects of infections were identified and antimicrobial susceptibility were investigated in clinical exams and samples from blood patients and venous catheter in children oncological patients at the José de Alencar Gomes da Silva, HCI / INCA, Rio de Janeiro Brazil. It was possible evaluate a) prevalence of various species infections in cancer patients; b) prevalence of cases of complications and other invasive infections related to the use of long-term catheters; c) antimicrobial susceptibility profiles and occurrence of multidrug resistance. The development of this research project in nosocomial infections in pediatric cancer patients was enabled analysis and validation of some process involved to prevent vascular complications that involve entire health system. In addition to contributing to the choice of antimicrobials and the most effective therapeutic strategies for the treatment of multi-resistant Corynebacterium sp.

Evolução no tratamento da doença coronária estável - mais fisiológico, menos invasivo / Evolution of treatment for stable coronary artery disease - more physiological, less invasive

Ao longo das décadas, alguns conceitos mudaram radicalmente a respeito do tratamento clínico da doença arterial coronariana (DAC). Inicialmente focado na redução dos sintomas isquêmicos, hoje a otimização da terapêutica clínica é fundamental para a redução de eventos cardiovasculares. No mesmo período, houve um grande desenvolvimento das técnicas de revascularização. A angioplastia coronária tornou-se uma das intervenções terapêuticas mais frequentemente realizadas e as técnicas de revascularização miocárdica vêm sendo objeto de mais ensaios clínicos randomizados, do que qualquer outra intervenção em Medicina. Ainda mais, várias modalidades de imagem invasivas e não invasivas foram desenvolvidas, permitindo estudar com maior precisão a doença arterial coronariana, reconhecer novos marcadores prognóstico, avaliar mais claramente os pacientes e indicar mais acertadamente o tratamento

Some concepts regarding the clinical management of coronary artery disease (CAD) have radically changed over the past decades. Initially focused on improving ischemic symptoms, today, optimal medical therapy is fundamental for reducing cardiovascular events. In the same time frame, there has been an immense development in revascularization treatment. Coronary angioplasty has become one of the most frequently performed therapeutic interventions, and myocardial revascularization techniques have been the subject of more randomized clinical trials than any other intervention in medicine. Furthermore, several invasive and non-invasive imaging modalities have been developed, enabling more accurate study of coronary artery disease, recognition of prognostic markers, clearer patient evaluation, and earlier treatment indications

Evaluación de la estrategia de terapia antitrombótica posterior al cambio valvular aórtico con válvulas biológicas en pacientes de bajo riesgo trombótico / Evaluation of the antithrombotic strategy in low thrombotic risk patients who underwent aortic valve replacement with a bioprosthesis

Resumen De acuerdo a las guías actuales, aún es materia de debate el uso de anticoagulación en los primeros 3 meses en pacientes de bajo riesgo trombótico sometidos a cambio valvular aórtico con prótesis biológicas. En base a la evidencia actual, la aspirina a dosis bajas es razonable como alternativa a los antagonistas de la vitamina K (AVK) durante el posquirúrgico temprano en pacientes con prótesis biológicas en posición aórtica. Se comparó la incidencia de complicaciones trombóticas o hemorrágicas de acuerdo a la estrategia de terapia antitrombótica en los pacientes de bajo riesgo trombótico sometidos a cambio valvular aórtico con válvulas biológicas en el Instituto Nacional de Cardiología Ignacio Chávez. La hipótesis: la aspirina como monoterapia antitrombótica tiene un efecto benéfico comparado con los AVK. Se estudiaron los pacientes de bajo riesgo trombótico sometidos a cambio valvular aórtico con válvulas biológicas en el Instituto Nacional de Cardiología Ignacio Chávez. Se incluyeron los pacientes operados del año 2011 al 2015. Se identificó en el seguimiento a un año la presencia de complicaciones trombóticas o hemorrágicas y si se manejaron con cualquiera de las siguientes: aspirina únicamente, AVK solo y la combinación aspirina más AVK. Se analizaron 231 pacientes. Solo se presentó una complicación hemorrágica en un paciente tratado con AVK. No hubo complicaciones trombóticas. No se presentaron complicaciones trombóticas en pacientes que no recibieron anticoagulación oral formal durante los primeros 3 meses posquirúrgicos, lo que indica que es seguro el uso de aspirina como monoterapia en estos pacientes de bajo riesgo trombótico.

Abstract According to current guidelines, in patients without additional risk factors who have undergone aortic valve replacement with a bioprosthesis, anticoagulation in the first 3 months after surgery is still a matter of debate. According to current evidence, aspirin in low doses is a reasonable alternative to vitamin K antagonists (VKA). A comparison is made between the incidence of thrombotic and haemorrhagic complications in patients with low thrombotic risk who underwent aortic valve replacement with a bioprosthesis in the National Institute of Cardiology of Ignacio Chávez of Mexico. The hypothesis: aspirin as monotherapy has a beneficial effect compared to VKA. The studied patients were the low thrombotic risk patients who underwent aortic valve replacement with a bioprosthesis in the National Institute of Cardiology of Ignacio Chávez of Mexico from 2011 to 2015. The groups studied were: aspirin only, VKA only, and the combination of VKA plus aspirin. The patients were retrospectively followed-up for 12 months, and the thrombotic and haemorrhagic complications were documented. Of the 231 patients included in the study, only one patient in the VKA only group presented with a haemorrhagic complication. No thrombotic complications were observed. In the present study no thrombotic complications were observed in patients who did not receive anticoagulation in the first 3 months after an aortic valve replacement with a bioprosthesis after a follow up period of 12 months. This suggests that the use of aspirin only is safe during this period.

Catheter directed thrombolysis in treatment of acute iliofemoral deep venous thrombosis: determinants of outcome

Background: Acute deep vein thrombosis [DVT] of the lower limbs occurs in about 1.0 person per 1000 population per year and is associated with substantial morbidity. Although anticoagulation effectively prevents thrombus extension, pulmonary embolism, death, and recurrence may occur. Moreover, many patients develop venous dysfunction resulting in post-thrombotic syndrome [PTS]. PTS is associated with reduced individual health-related quality of life and a substantially increased economic burden. Hence, additional and more aggressive treatment, including systemic thrombolysis, thrombectomy, and catheter- directed thrombolysis [CDT], has been introduced to accelerate thrombus removal. Numerous studies suggest that additional CDT may provide highly effective clot lysis. There is little doubt that the overall benefit of thrombolysis depends on multiple factors, including predisposing risks, symptom duration, thrombus extension, and technical approaches and interventional success

Aim of the Work: This study aimed to define predictors of immediate and mid-long-term anatomic and clinical failures to guide patient selection and to set a standard for patient and physician expectations

Patients and Methods: This is a prospective observational cohort study that enrolled 20 patients [22 limbs] who presented to the Ain Shams University hospitals in the period from 7/2015 to 7/2017 with acute iliofemoral deep venous thrombosis [IFDVT] and fulfilled the inclusion criteria [mentioned below]. Intrathrombus catheter directed thrombolysis [CDT] was done. Assessments of predictors of immediate periprocedural success was based on degree of clot lysis and resolution of symptoms and signs. Incidence of postthrombotic syndrome [PTS] was calculated at 6 months postoperative using Villalta score [>/=5 vs <5]

Results: During the study duration, 20 patients [22 limbs] were recruited. The mean age was 40.95 +/- 12.35 years old, 11 patients [12 limbs] were women. The indication for CDT was severe progressive pain/swelling [18 limbs], and phlegmasia cerulea dolens [4 limbs]. 5 patients [7 limbs] had IVC thrombosis at the initial venography. 5 limbs had balloon dilatation only while iliac stenting was done in 12 limbs. 15 patients received CDT for 48 hours while 5 patients [7 limbs] received CDT for 24 hours [mean duration of CDT was 1.68 days]. As regards bleeding, only 2 cases of those who had CDT for 24 hours had bleeding, while bleeding occurred in 12 cases of those who had CDT for 48 hours. There were no recurrent DVT, intra or postoperative pulmonary embolism nor death within the study population till the end of the follow up period [6months]. 6 months post intervention, 7 limbs were free of PTS [Villalta score < 5], 15 limbs had mild to moderate PTS, and no patients had severe PTS. The mean Villalta score was 5.14 +/- 1.859

Conclusion: In our study, determinants of outcome following CDT for acute IFDVT were: 1] access site, 2] dose of thrombolytic agent used, 3] duration of thrombolysis, and 4] thrombus score at the end of the procedure. More studies should be done comparing not only the effect of CDT on incidence of PTS but also its effect on its severity [e.g. Villalta score] on short and long term

Uso de varfarina em pediatria: características clínicas e farmacológicas / Use of warfarin in pediatrics: clinical and pharmacological characteristics

RESUMO Objetivo: Descrever como as crianças respondem à anticoagulação oral com varfarina, verificando a influência da idade, da condição clínica, da via de administração da varfarina e do uso de Nutrição Parenteral Total (NPT), e apresentar a presença de fatores de risco para eventos tromboembólicos (TE). Métodos: Estudo transversal retrospectivo com pacientes ≤18 anos que iniciaram o uso da varfarina em um hospital universitário. Os pacientes foram divididos conforme condição clínica, idade, forma de administração do medicamento e uso de NPT. Foram utilizados os dados dos prontuários dos pacientes, considerando os fatores de risco para TE já descritos na literatura, o tempo e a dose necessária para atingir a primeira Razão Normalizada Internacional (INR) no alvo e eventos adversos nesse período. No período posterior ao alcance de INR, foi verificada a manutenção da anticoagulação, por meio da dose prescrita e dos exames de INR. Resultados: Vinte e nove pacientes foram incluídos no estudo. O principal fator de risco para TE foi o uso de cateter venoso central, em 89,6% dos pacientes. Os pacientes com síndrome do intestino curto e em uso de NPT necessitaram de doses significativamente maiores (p≤0,05) para atingir e manter a INR no alvo. Os pacientes com ≤1 ano levaram mais tempo e necessitaram de uma dose maior para anticoagular e para manter o INR no alvo que os pacientes mais velhos. A mediana de exames de INR abaixo do alvo foi de 48,2% nos grupos estudados. Conclusões: A complexidade da terapia anticoagulante reforça a necessidade da elaboração de protocolos que orientem a prática clínica.

ABSTRACT Objective: To describe how children respond to oral anticoagulation with warfarin, verifying the influence of age, clinical condition, route of administration of warfarin and use of total parenteral nutrition (TPN), as well as to describe risk factors for the occurrence of thrombotic events (TE) in childhood. Methods: A retrospective descriptive study including all patients ≤18 years old for whom warfarin was prescribed in a university hospital. Patients were divided according to clinical condition, age, route of medication administration and use of TPN. Data was collected from the patients' medical records and the analysis considered the risk factors for TE already described in the literature, the time and the dose required in order to reach the first International Normalized Ratio (INR) in the target and the adverse events in this period. After reaching the INR, the maintenance of anticoagulation was verified by the prescribed dose and INR tests. Results: Twenty-nine patients were included in the study. The major risk factor for TE was the use of a central venous catheter in 89.6% of the patients. Patients with short bowel syndrome and total parenteral nutrition required significantly higher doses (p≤0.05) to achieve and maintain the INR in the target. Patients ≤1 year old needed longer periods and required an increased dose of anticoagulation and maintenance than older patients. The mean number of INR examinations below the target was 48.2% in the groups studied. Conclusions: The observed complexity of anticoagulant therapy reinforces the need to develop protocols that guide clinical practice.

Thromboprophylaxis and maternal-fetal outcomes of women with serum markers for hereditary thrombophilia and previous obstetric complications / Tromboprofilaxia e desfechos materno-fetais de mulheres com marcadores séricos para trombofilias hereditárias e antecedentes de complicações obstétricas

Abstract Objectives: to evaluate the maternalfetal outcomes of thromboprophylaxis with enoxa parin based on scoring system in women with serum markers for hereditary thrombophilia and previous obstetric complications. Methods: a retrospective study was undertaken based on data collected from clinical records. We included 54 pregnant women with serum markers for hereditary thrombophilia undergoing therapeutic intervention with enoxaparin in the period from November 2009 to December 2013. The initial dose of low molecular weight heparin was guided by a scoring system. The maternalfetal outcomes of previous pregnancies and, subsequently, the treatment were compared using the chisquare (χ2) test with the Yates correction and Fisher's Exact Test; p<0.05 was considered significant. Results: we observed significant reduction in fetal/perinatal deaths (p<0.05) and spontaneous abortions (p<0.001) after intervention. The live births at fullterm delivery (p<0.001) and live births at preterm delivery (p<0.05) increased significantly after intervention. Conclusions: the therapeutic intervention with enoxaparin based on scoring system during pregnancy seems to improve the fetal prognosis.

Resumo Objetivos: avaliar os desfechos maternosfetais da tromboprofilaxia com enoxaparina com base em sistema de pontuação em mulheres com marcadores séricos para trombofilia hereditária e antecedentes de complicações obstétricas. Métodos: realizouse estudo retrospectivo com base em dados coletados de prontuários. Foram Incluídas 54 mulheres grávidas com marcadores séricos de trombofilia hereditária submetidos à intervenção terapêutica com enoxaparina no período de novembro de 2009 a dezembro de 2013. A dose inicial de heparina de baixo peso molecular foi norteada por um sistema de pontuação. Os resultados maternosfetais de gestações anteriores e subsequentes ao tratamento foram comparados utilizando Teste quiquadrado com correção de Yates ou Exato de Fisher; p<0,05 foi considerado significativo. Resultados: observouse significativa redução de mortes fetais / perinatais (p<0,05) e abortos espontâneos (p<0,001) após intervenção. Os nascidos vivos com parto a termo (p<0,001) e nascidos vivos no parto prematuro (p<0,05) elevaramse significativamente após a intervenção. Conclusão: a intervenção terapêutica com enoxaparina com base no sistema de pontuação durante a gravidez parece melhorar o prognóstico fetal.

Evaluación de una intervención para el uso de tromboprofilaxis basada en el envío de alertas electrónicas a médicos residentes de primer año de dos hospitales de Lima, Perú / Evaluation of an intervention for the use of thromboprophylaxis based on electronic alert transmission to first-year medical residents from two hospitals of Lima, Peru

RESUMEN Objetivos. Evaluar la aplicación de una intervención basada en el envío de mensajes de texto y correos electrónicos dirigido a médicos residentes de medicina interna para lograr el incremento de la prescripción de tromboprofilaxis acorde a Guías de Práctica Clínica (GPC). Materiales y métodos. Se realizó un estudio tipo cuasiexperimental en los servicios de hospitalización de medicina interna de dos hospitales generales de Lima, Perú, uno seleccionado para aplicar la intervención y el otro como control. La unidad de análisis fue la hoja de prescripción médica. Se consideró que la intervención debería incrementar la prescripción acorde a GPC con respecto a la evaluación inicial y también respecto al hospital control. Resultados. Se evaluaron 394 hojas de prescripción médica, 227 (57,4%) procedentes del servicio intervenido y 167 (42,4%) correspondieron del control. En el servicio intervenido, inicialmente el 64,5% tuvo una prescripción acorde a GPC, para disminuir a 54,4% luego de la intervención; el sobreuso aumentó de 13,6 a 26,8%. Conclusiones. La intervención basada en el envío de mensajes de texto y correos electrónicos no tuvo impacto, observándose una tendencia al sobreuso de tromboprofilaxis posintervención.

ABSTRACT Objectives. To assess the implementation of an intervention based on the sending of text messages and e-mails to internal medicine residents in order to achieve an increase in the prescription of thromboprophylaxis according to Clinical Practice Guidelines (CPG). Materials and methods. A quasi-experimental study was conducted in the inpatient units of internal medicine at two general hospitals in Lima, Peru: one selected to implement the intervention and the other as control. The unit of analysis was the therapeutic order sheet. It was considered that the intervention should increase the order of thromboprophylaxis according to CPG with respect to the initial assessment and also in relation to the control hospital. Results. Atotal of 394 therapeutic order sheets, 227 (57.4%) from the intervention hospital and 167 (42.4%) from the control, were evaluated. In the intervention hospital, 64.5% initially had an order of thromboprophylaxis according to CPG, which decreased to 54.4% after the intervention; overuse increased from 13.6 to 26.8%. Conclusions. Intervention based on sending text messages and e-mails had no impact, showing a tendency to overuse of thromboprophylaxis post-intervention.

Lumbar puncture in patients using anticoagulants and antiplatelet agents / Punção lombar em pacientes usando anticoagulantes e agentes antiplaquetários

ABSTRACT The use of anticoagulants and antiplatelet agents has largely increased. Diagnostic lumbar puncture in patients taking these drugs represents a challenge considering the opposing risks of bleeding and thrombotic complications. To date there are no controlled trials, specific guidelines, nor clear recommendations in this area. In the present review we make some recommendations about lumbar puncture in patients using these drugs. Our recommendations take into consideration the pharmacology of these drugs, the thrombotic risk according to the underlying disease, and the urgency in cerebrospinal fluid analysis. Evaluating such information and a rigorous monitoring of neurological symptoms after lumbar puncture are crucial to minimize the risk of hemorrhage associated neurological deficits. An individualized patient decision-making and an effective communication between the assistant physician and the responsible for conducting the lumbar puncture are essential to minimize potential risks.

RESUMO O uso de anticoagulantes e de agentes antiplaquetários tem aumentado nos últimos anos. A realização de punção lombar diagnóstica em pacientes utilizando tais medicamentos representa um desafio, em função dos riscos de complicações hemorrágicas ou trombóticas, estas últimas em pacientes que interrompem o tratamento para a realização do procedimento. Não há ainda estudos controlados nem diretrizes específicas nesta área. Neste artigo de revisão, algumas recomendações são feitas, levando-se em conta aspectos farmacológicos destas medicações, o risco de complicações trombóticas de acordo com a doença de base, e a urgência na coleta do líquor. A avaliação cuidadosa destas informações e uma monitorização neurológica rigorosa visando a detecção e o tratamento precoce de complicações podem reduzir o risco de sequelas neurológicas decorrentes de hemorragia. Uma decisão individualizada e uma efetiva comunicação entre o médico assistente e o responsável pela realização da punção lombar é essencial para minimizar potenciais riscos.

Trombocitopenia inducida por heparina: Nuevas opciones terapéuticas / Heparin-induced thrombocytopenia. New therapeutical options

La trombocitopenia inducida por heparina (TIH) es una reacción adversa inmunológica mediada por la formación de anticuerpos contra el complejo heparina-factor plaquetario 4 (FP4), caracterizada por la presencia de trombocitopenia y la asociación paradojal de trombosis arterial o venosa. Es una complicación poco frecuente pero grave del uso de cualquier tipo de heparina. En tratados con procedimientos cardiovasculares como intervención coronaria percutánea y cirugía de revascularización cardiaca, la prevalencia de anticuerpos es significativamente mayor que en otros escenarios clínicos. El reconocimiento de las características clínicas y de laboratorio permite la suspensión inmediata de la heparina y la instauración de tratamiento anticoagulante alternativo, para evitar la progresión y formación de nuevos trombos y sus complicaciones. En la presente revisión se resumen las diferentes alternativas terapéuticas para la TIH, en particular los anticoagulantes orales directos (DOACS) como el dabigatran, rivaroxaban y apixaban que pueden proporcionar una nueva opción para el tratamiento de TIH.

Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse reaction due to antibodies to a multimolecular complex of heparin and platelet factor 4 (PF4) characterized by moderate thrombocytopenia and paradoxical arterial or venous thrombosis. It is a relatively infrequent complication related to the administration of any type of heparin. In patients undergoing percutaneous coronary revascularization or coronary artery by-pass graft the prevalence of HIT is higher than in other clinical settings. Recognizing clinical and laboratory features of HIT allow immediate discontinuation of heparin and the use of alternative anticoagulants to avoid serious thrombotic complications. In this review, we summarize different therapeutic options for the treatment of HIT with special emphasis on direct oral anticoagulants (DOACS) such as dabigatran, rivaroxaban and apixaban. DOACS might represent a therapeutic alternative for HIT treatment.

Factores de riesgo para la formación de trombos sobre el dispositivo ULTRASEPT®, en pacientes con fibrilación auricular sometidos a cierre percutáneo de orejuela izquierda / Risk factors for thrombus formation on the ULTRASEPT® device in patiens with atrial fibrillation being submitted to left atrial appendage closure

Introducción: El cierre percutáneo de orejuela izquierda con dispositivos percutáneos (CPOI) ha demostrado ser útil en la prevención de embolia arterial como alternativa al tratamiento anticoagulante (TACO) en pacientes con fibrilación auricular no valvular (FANV). Sin embargo, en las primeras semanas post implante, existe el riesgo de formación de trombos sobre el dispositivo. Objetivos: Describir e Identificar los factores de riesgo para la formación de trombos sobre el dispositivo posterior al cierre de orejuela izquierda. Métodos: Se incluyeron 15 pacientes con FANV y alto riesgo hemorrágico, sometidos a CPOI con dispositivo Ultrasept (Cardia Inc., Eagan, MN), en el Hospital Clínico de la Universidad Católica, entre Abril 2013 y Junio 2014. A todos se les realizó eco-cardiograma transesofágico (ETE) al primer, tercer y sexto mes post implante. Todos los pacientes recibieron aspirina en forma permanente y TACO por 45 días el que se reemplazó por clopidogrel hasta el sexto mes post implante. Se analizaron parámetros clínicos y ecocardiográficos en forma retrospectiva para identificar los factores de riesgo asociados a la formación de trombos sobre el dispositivo. Resultados: La edad promedio de los pacientes fue 77± 8 años, 73% de sexo masculino. El 80% tenía FA permanente y 20% FA paroxística. EL Score de CHA2DS2VASc promedio fue de 5 (mínimo 3, máximo 8 puntos). En 4 pacientes (26.6%), encontramos trombos en el dispositivo en el seguimiento con ETE (1 paciente al primer mes y 3 al tercer mes), sin consecuencias clínicas. Al comparar los pacientes que formaron trombos con el resto, no hubo diferencias en las variables clínicas (edad, sexo, Hipertensión arterial (HTA), Diabetes Mellitus (DM), Dislipidemia, Tabaquismo, Insuficiencia Renal, AVE previos), ni en las variables ecocardiográficas estudiadas, como el área de la aurícula izquierda (AI), contraste espontáneo en la AI, insuficiencia mitral ni cierre incompleto de orejuela (medida por la existencia de flujo peridispositivo). Sin embargo, los pacientes con trombos presentaron CHA2DS2VASc score más alto (7.1 vs 4.7; p= 0.001) y fracción de eyección (FE) más baja (43% vs 55%; p= 0.001). En la curva ROC de CHA2DS2VASc para predecir una mayor probabilidad de formación de trombos, un valor > 6 obtiene una sensibilidad de un 100% y una especificidad de un 80%. En nuestro seguimiento clínico de 2 años ± 5.7 meses posterior al implante, 1 paciente tuvo un AVE isquémico identificando como fuente enfermedad carotidea (no tenía trombos en el dispositivo). El resto de los pacientes se mantienen asintomáticos. Conclusiones: En nuestra experiencia, el CHA2DS-2VASc score (> 6) y la fracción de eyección baja, fueron factores de riesgo para la formación de trombos sobre el dispositivo de cierre de orejuela. Este hallazgo debería confirmarse en series más grandes dado que podría cambiar la estrategia de anticoagulación post implante.

Background: Percutaneous closure of the left atrial appendage (LAA) has been shown to be useful in the prevention of arterial embolism as an alternative to oral anticoagulants in patients with non valvular atrial fibrillation. However, thrombus formation may develop in the first weeks following device implantation/ Aim: to identify risk factors for thrombus development on devices used for LAA closure. Methods: 15 patients with non valvular AF and high risk for anticoagulant treatment were included. Patients received an Ultrasept (Cardia Inc., Eagan, MN) between April 2013 and June 2014. Transesophageal echocardiography was performed in all patients 1, 3 and 6 months post implant. All patients received aspirin permanently and acenocumarol for 45 days, followed by clopidogrel until 6 months post implant. Results: Mean age was 77 years old (SD 8). 73% were males. AF was permanent in 80% and paroxysmal in 20%. Mean CHA2DS2VASC was 8 (range 3 to 8). Thrombus were revealed by TEE in 4 patients (26.6%), at 1 month (1 patient) and at 3 months post implant (3 patients). No complications occurred in these patients. Clinical variables (age, sex, hyper-tension, diabetes, dyslipidemia, smoking habit, renal failure and prior strokes) were no different in patients with or without thrombus. The same was true for left atrial size, mitral insufficiency or incomplete closure of LAA. In contrast, patients with thrombus formation had a higher CHA2DS2VASc score (7.1 vs 4.7, p=0.001 and a lower LV ejection fraction (43% vs 55%, p=0.001). A CHA2DS2VASc score > 6 was 100% sensible and 80% specific for thrombus formation (ROC curve). After a follow-up of 24 ± 5 months only 1 patients had and ischemic cerebro-vascular event which was attributed to carotid artery disease (the patient had no evidence of device thrombus). All other patients remain asymptomatic. Conclusion: A CHA2DS2VASc score > 6 and a low ejection fraction were risk factors for thrombus formation on LAA closing device. Confirmation of these findings in a larger series of patients could lead to a change in anticoagulant strategy following the implantation of devices to close the LAA.