Establecimiento de un protocolo para el uso de la heparina en pacientes con características especiales / Set up of a protocol for heparin use in special patients

Las HBPMs (heparina de bajo peso molecular) tienen numerosas ventajas sobre la heparina no fraccionada (HNF) como seguridad, eficacia, biodisponibilidad, menor monitorización y una respuesta anticoagulante persistente. Pero, existe cierta preocupación en su manejo para determinados pacientes que requieren un control especial como en insuficiencia renal, mayores de 75 años, obesidad y embarazo. El objetivo de este estudio fue la realización de un protocolo consensuado entre los Servicios de Farmacia, Hematología y Medicina Interna, para el seguimiento y monitorización de HBPM en pacientes que requieren un especial control. Para ello, llevamos a cabo una revisión bibliográfica de las distintas heparinas en las situaciones comentadas. Basándonos en la evidencia disponible y en el consenso entre los miembros del grupo de trabajo, elaboramos el protocolo, recomendando unas dosis para profilaxis, tratamiento y monitorización, mediante la determinación del factoranti-Xa. Además, recogemos unas orientaciones sobre los valores terapéuticos del anti-Xa y unas pautas posológicas para la obtención de un anti-Xa en rango. La heparina seleccionada fue la enoxaparina, por su evidencia y disponibilidad en nuestro centro (AU)

Low-molecular weight (LMW) heparins bring a series of advantages as compared to non-fractionated heparin (NFH), such as safety, efficacy, bioavailability, fewer monitoring, and persistent anti-coagulant response. There exist, however, a concern about their use in particular patients that may require a special control, such as those with renal failure, age over 75 years, obesity, and pregnancy. The aim of this study was the set up between the department of Pharmacy, Hematology, and Internal Medicine of a consensus protocol for the follow-up ad monitoring of LMWH in patients requiring a special control. For this purpose, we carried out a bibliographical review of the different heparins used under de above mentioned conditions. Based on the evidence available and the consensus among the members of the working group, we established a protocol that contained recommendations on prophylaxis, management and monitoring by means of the determination of anti-Xa factor. Besides,we included some clues on the therapeutic figures of anti-Xa and administration schedules for obtaining anti-Xa values within the range. Enoxaparin was the selected heparin given the evidence and its availability at our center (AU)

[Set up of a protocol for heparin use in special patients]. / Establecimiento de un protocolo para el uso de la heparina en pacientes con características especiales.

Low-molecular weight (LMW) heparins bring a series of advantages as compared to non-fractionated heparin (NFH), such as safety, efficacy, bioavailability, fewer monitoring, and persistent anti-coagulant response. There exist, however, a concern about their use in particular patients that may require a special control, such as those with renal failure, age over 75 years, obesity, and pregnancy. The aim of this study was the set up between the department of Pharmacy, Hematology, and Internal Medicine of a consensus protocol for the follow-up ad monitoring of LMWH in patients requiring a special control. For this purpose, we carried out a bibliographical review of the different heparins used under de above mentioned conditions. Based on the evidence available and the consensus among the members of the working group, we established a protocol that contained recommendations on prophylaxis, management and monitoring by means of the determination of anti-Xa factor. Besides, we included some clues on the therapeutic figures of anti-Xa and administration schedules for obtaining anti-Xa values within the range. Enoxaparin was the selected heparin given the evidence and its availability at our center.

Las HBPMs (heparina de bajo peso molecular) tienen numerosas ventajas sobre la heparina no fraccionada (HNF) como seguridad, eficacia, biodisponibilidad, menor monitorización y una respuesta anticoagulante persistente. Pero, existe cierta preocupación en su manejo para determinados pacientes que requieren un control especial como en insuficiencia renal, mayores de 75 años, obesidad y embarazo. El objetivo de este estudio fue la realización de un protocolo consensuado entre los Servicios de Farmacia, Hematología y Medicina Interna, para el seguimiento y monitorización de HBPM en pacientes que requieren un especial control. Para ello, llevamos a cabo una revisión bibliográfica de las distintas heparinas en las situaciones comentadas. Basándonos en la evidencia disponible y en el consenso entre los miembros del grupo de trabajo, elaboramos el protocolo, recomendando unas dosis para profilaxis, tratamiento y monitorización, mediante la determinación del factor anti-Xa. Además, recogemos unas orientaciones sobre los valores terapéuticos del anti-Xa y unas pautas posológicas para la obtención de un anti-Xa en rango. La heparina seleccionada fue la enoxaparina, por su evidencia y disponibilidad en nuestro centro.

Aplasia pura de serie roja con cambios mielodisplásicos / No disponible

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[Thrombogenic and endothelial damage markers in patients with ischemic systolic impairment]. / Marcadores de hipercoagulabilidad y daño endotelial en pacientes con disfunción sistólica de origen isquémico.

INTRODUCTION: Anticoagulation is rarely indicated in patients with left ventricular dysfunction who show an increased risk for thromboembolism. In theory, the three arms of the Virchow' triad may be present: abnormal blood flow, endothelial damage and prothrombotic markers. The aim of this study was to identify the last two arms. PATIENTS AND METHOD: We studied 82 consecutive patients with demonstrated ischaemic heart disease and sinus rhythm, and compared them with a control group comprised of 32 healthy subjects matched for age and sex. None or the patients had had an acute coronary event or hemodynamic decompensation within the 3 months prior to inclusion in the study. The plasma concentration or von Willebrand factor and fibrin d-dimer and fibrinogen were determined as endothelial damage and prothrombotic markers, respectively. A fractional shortening less than 29% by echography was defined as ventricular systolic dysfunction. RESULTS: The patients showed significantly higher levels of von Willebrand factor with respect to the control group (109.2 31.9 vs 85.5 32.6%, p < 0.01), with no differences in fibrinogen and fibrin d-dimer values. Twenty-six patients fulfilled criteria of left ventricular systolic dysfunction. Patients with left ventricular dysfunction showed higher fibrinogen (386 118 vs 322 102 mg/dl, p = 0.03) and fibrin d-dimer (0.36 0.22 vs 0.26 0.10 g/ml; p = 0.04) levels, with no differences in von Willebrand factor levels. CONCLUSIONS: After acute coronary events, patients with ischaemic heart disease show markers of endothelial damage. However, patients with left ventricular dysfunction show a hypercoagulable state.

Hipercoagulabilidad y cardiopatía isquémica: potencial interacción entre los anticuerpos antifosfolípidos y elementos celulares implicados en la hemostasia / Hipercoagulability and ischemic cardiopathy: potential interaction between antiphospholipid antibodies and cellular elements related with haemosthasis

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Ectodermal ablation of the third branchial arch in chick embryos and the morphogenesis of the parathyroid III gland.

The parathyroid glands have been classically considered to be derivatives of the third and fourth pharyngeal pouches in most species, including humans. Furthermore, the presence of neural crest-derived cells in the parathyroid glands connective tissue has been apparently established. However, our previous studies have provided a new hypothesis on the origin of these glands in human and chick embryos. To determine the origin of the parathyroid III (P3) gland, ectoderm of the third branchial arch was cauterized in chick embryos at Hamburger and Hamilton's stage 19 (embryonic day 3). Cauterization of the ventral half of the ectoderm was followed by the non-formation, on the same side, of the P3 gland. When the dorsal half of the ectoderm was cauterized, both the right and left P3 glands formed. Our observations suggest that the ectoderm of the ventral half of the third branchial arch is necessary for the organization of the P3 gland.

[Improvement in fibrinolytic function following anticoagulant treatment in chronic rheumatic atrial fibrillation]. / Mejoría de la función fibrinolítica tras el tratamiento anticoagulante en la fibrilación auricular reumática crónica.

INTRODUCTION AND OBJECTIVES: Patients with rheumatic atrial fibrillation are considered at high risk of systemic embolism and require oral anticoagulation. Fibrinolytic function has been little studied. We evaluated fibrinolytic activation markers before starting anticoagulation, at 1 and 6 months following the introduction of oral anticoagulation therapy. We analyzed the relationship with left atrial diameter and mitral area. METHODS: Tissue plasminogen activator (tPA), its inhibitor (PAI-1), plasmin-antiplasmin complexes (PAP) and D-dimer were measured in 13 patients with rheumatic atrial fibrillation. Basal levels were compared with those found in plasma of 20 healthy subjects matched by sex and age. Transthoracic echocardiography was made. RESULTS: A significant increase for PAI-1 and D-dimer levels were detected in patients with atrial fibrillation group (p < 0.05), with no differences in tPA and PAP concentrations. Significant correlation between left atrial diameter and basal t-PA levels was found. Levels of t-PA, PAI-1 and D-dimer decreased significantly under anticoagulation therapy, whereas PAP levels were significantly increased. CONCLUSIONS: Patients with rheumatic atrial fibrillation show a relative hypofibrinolytic state due to elevated PAI-1 levels with no increase in PAP concentration. At six months of anticoagulation therapy, an improvement of fibrinolytic function markers was observed. This is consistent with the prophylactic effect of oral anticoagulants therapy against thromboembolic risk.

Acute leukemias after treatment with radioiodine for thyroid cancer.

Leukemia is an uncommon complication of exposure to radioiodine (131I), used in treatment of thyroid cancer, because low doses are now used. We report two cases of acute myelogenous leukemia developed after the treatment of a thyroid carcinoma with a small dose of 131I.

[Safety of oral anticoagulation in aged patients with heart diseases]. / Seguridad en la anticoagulación oral en ancianos con cardiopatía.

BACKGROUND: Anticoagulation therapy in the elderly poses some doubts on the possible increase in hemorrhagic risk. The hemorrhagic complications in a population of patients over 70 years of age anticoagulated with acenocoumarol by heart disease were studied. MATERIALS AND METHODS: A study was made of seventy-two patients (43 females and 29 males; mean age: 73 years) anticoagulated for one year and controlled on an outpatient basis by means of INR (international normalized ratio) measurement with a maximal interval of four weeks. INR values above 4.5 or below 2.0 were considered out of range. RESULTS: Nineteen patients had an INR above the recommended value on one occasion and eleven patients on two or more occasions. Sixteen patients had hemorrhagic complications, five were admitted on account of hemorrhages although none of them required transfusional therapy. No cases of brain hemorrhage or peripheral embolism occurred. CONCLUSIONS: Most anticoagulated elderly patients were within their therapeutic range. The percentage of severe hemorrhagic complications was low. Advanced age had did not prove to be a factor against therapy with oral anticoagulants.

Grafts of the third branchial arch in chick embryos.

The parathyroid glands have been classically considered derivatives of the third and fourth pharyngeal pouches in most species, including humans. The presence of neural crest-derived cells in parathyroid glands connective tissue has apparently been established. However, our previous studies have provided a new hypothesis on the origin of these glands in human and chick embryos. To determine the true origin of the third parathyroid (parathyroid III) gland in the chick embryo, pieces of the third branchial arch from donor chick embryos at Hamburger and Hamilton's stage 19 (embryonic day 3) were grafted to host chick embryos at the same stage of development. Starting from Hamburger and Hamilton's stage 27 (embryonic day 5), a structure identified as the parathyroid III appeared in the ectodermal (epipharyngeal) placode of the third branchial arch graft, from which it subsequently became separated at Hamburger and Hamilton's stage 28 (embryonic day 5.5) and continued to develop and mature. Our findings suggest the conclusion that the parathyroid III gland begins to develop from the epipharyngeal placode, so that this gland, from our point of view, could be considered ectodermal in nature.

Development of the human submandibular salivary gland.

The development and morphogenetic timetable of the submandibular gland was studied in 37 human embryos and human fetuses. The medial paralingual groove constituted the anlage of the submandibular gland: Its anterior three-quarters gave rise to Wharton's duct, and its posterior quarter to the submandibular gland proper. The sublingual process of the submandibular gland originated from a lateral ectodermal bud of the anlage of the submandibular gland, in the posterior quarter of the medial paralingual groove.

Developmental differences in the ossification process of the human corpus and ramus mandibulae.

A correlation was sought between the organization of the dental crest and the ossification of the corpus mandibulae in 14 human embryos and 13 human fetuses. The different types of ossification between the corpus and the ramus mandibulae suggest that the cartilago mandibularis (meckeliensis) guides the formation of the mandibula, while the dental crest acts as a coorganizer. In the area of the foramen mentale, the lamina dentalis begins to invaginate (to give rise to the dental crest), and at this level intramembranous ossification of the corpus mandibulae commences. These findings, together with the presence of the cartilago mandibularis before the appearance of the dental crest, and the fact that the former is seen along the entire length of the mandibula (from the symphysis mandibulae to the capsula otica), support the hypothesis that the dental crest, rather than the cartilago mandibularis, acts as the coorganizer in the corpus mandibulae.