Incidence and impact of anticoagulation-associated abnormal menstrual bleeding in women after venous thromboembolism.

Preliminary data and clinical experience have suggested an increased risk of abnormal uterine bleeding (AUB) in women of reproductive age treated with anticoagulants, but solid data are lacking. The TEAM-VTE study was an international multicenter prospective cohort study in women aged 18 to 50 years diagnosed with acute venous thromboembolism (VTE). Menstrual blood loss was measured by pictorial blood loss assessment charts at baseline for the last menstrual cycle before VTE diagnosis and prospectively for each cycle during 3 to 6 months of follow-up. AUB was defined as an increased score on the pictorial blood loss assessment chart (>100 or >150) or self-reported AUB. AUB-related quality of life (QoL) was assessed at baseline and the end of follow-up using the Menstrual Bleeding Questionnaire. The study was terminated early because of slow recruitment attributable to the COVID-19 pandemic. Of the 98 women, 65 (66%) met at least one of the 3 definitions of AUB during follow-up (95% confidence interval [CI], 57%-75%). AUB occurred in 60% of women (36 of 60) without AUB before VTE diagnosis (new-onset AUB; 95% CI, 47%-71%). Overall, QoL decreased over time, with a mean Menstrual Bleeding Questionnaire score increase of 5.1 points (95% CI, 2.2-7.9), but this decrease in QoL was observed only among women with new-onset AUB. To conclude, 2 of every 3 women who start anticoagulation for acute VTE experience AUB, with a considerable negative impact on QoL. These findings should be a call to action to increase awareness and provide evidence-based strategies to prevent and treat AUB in this setting. This was an academic study registered at www.clinicaltrials.gov as #NCT04748393; no funding was received.

Diagnostic accuracy of combining C-Reactive protein and Alvarado Score among 2-to-20-year-old patients with acute appendicitis suspected presenting to Emergency Departments.

OBJECTIVE: Main objective was whether the combination of C-Reactive Protein (CRP) and Alvarado Score (AS) increase the diagnosis accuracy of AS among 2-to-20-year-old patients with suspected acute appendicitis presenting to Emergency Departments. METHODS: This is a secondary analysis of prospective cohort study consecutively including all patients from 2 to 20 years of age attended for suspected acute appendicitis in 4 Spanish Emergency Departments during 6-month period. We collected demographic, clinical, analytic and radiographic, and surgical data. AS categories were retrospectively calculated as low (0-4 points), intermediate (5-6 points) or high (7-10 points). The cut-off levels were >0.5 mg/dl for CRP. The outcome was diagnosis of acute appendicitis within 14 days of the index visit. RESULTS: A total of 331 patients with suspected of acute appendicitis (mean age 11.8 (SD 3.8) years; 52.9% males) were recruited. According to AS, 108 (32.6%) were at low risk, 76 at (23.0%) intermediate risk and 147 (44.4%) at high risk of acute appendicitis. One hundred and sixteen (35.0%) cases had confirmed histopathological diagnosis of acute appendicitis. The AUCs of ROC were 0.76 (0.70-0.81) for AS and 0.79 (95% CI 0.75-0.84) for CRP-AS being the difference statistically significant (p=0.003). The CRP for diagnosis acute appendicitis in low risk AS group had negative predictive value of 95.8% (95%CI 87.3-98.9) and likelihood ratio negative of 0.4 (95%CI 0.2-1.0).. CONCLUSIONS: CRP-AS has shown to increase the diagnostic accuracy of AS for acute appendicitis. This approach may be useful to rule out the diagnosis of acute appendicitis in paediatric patients attended for abdominal pain suggestive of acute appendicitis.

FOTROCAN Delphi consensus statement regarding the prevention and treatment of cancer-associated thrombosis in areas of uncertainty and low quality of evidence

Introduction. Decision-making in cancer-related venous thromboembolism (VTE) is often founded on scant lines of evidence and weak recommendations. The aim of this work is to evaluate the percentage of agreement surrounding a series of statements about complex, clinically relevant, and highly uncertain aspects to formulate explicit action guidelines. Materials and methods. Opinions were based on a structured questionnaire with appropriate scores and were agreed upon using a Delphi method. Questions were selected based on a list of recommendations with low evidence from the Spanish Society of Oncology Clinical Guideline for Thrombosis. The questionnaire was completed in two iterations by a multidisciplinary panel of experts in thrombosis. Results. Of the 123 statements analyzed, the panel concurred on 22 (17%) and another 81 (65%) were agreed on by qualified majority, including important aspects of long-term and prolonged anticoagulation, major bleeding and rethrombosis management, treatment in special situations, catheter-related thrombosis and thromboprophylaxis. Among them, the panelists agreed the incidental events should be equated to symptomatic ones, long-term and extended use of full-dose low-molecular weight heparin, and concluded that the Khorana score is not sensitive enough to uphold an effective thromboprophylaxis strategy. Conclusion. Though the level of consensus varied depending on the scenario presented, overall, the iterative process achieved broad agreement as to the general treatment principles of cancer-associated VTE. Clinical validation of these statements in genuine practice conditions would be useful (AU)

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FOTROCAN Delphi consensus statement regarding the prevention and treatment of cancer-associated thrombosis in areas of uncertainty and low quality of evidence.

INTRODUCTION: Decision-making in cancer-related venous thromboembolism (VTE) is often founded on scant lines of evidence and weak recommendations. The aim of this work is to evaluate the percentage of agreement surrounding a series of statements about complex, clinically relevant, and highly uncertain aspects to formulate explicit action guidelines. MATERIALS AND METHODS: Opinions were based on a structured questionnaire with appropriate scores and were agreed upon using a Delphi method. Questions were selected based on a list of recommendations with low evidence from the Spanish Society of Oncology Clinical Guideline for Thrombosis. The questionnaire was completed in two iterations by a multidisciplinary panel of experts in thrombosis. RESULTS: Of the 123 statements analyzed, the panel concurred on 22 (17%) and another 81 (65%) were agreed on by qualified majority, including important aspects of long-term and prolonged anticoagulation, major bleeding and rethrombosis management, treatment in special situations, catheter-related thrombosis and thromboprophylaxis. Among them, the panelists agreed the incidental events should be equated to symptomatic ones, long-term and extended use of full-dose low-molecular weight heparin, and concluded that the Khorana score is not sensitive enough to uphold an effective thromboprophylaxis strategy. CONCLUSION: Though the level of consensus varied depending on the scenario presented, overall, the iterative process achieved broad agreement as to the general treatment principles of cancer-associated VTE. Clinical validation of these statements in genuine practice conditions would be useful.

Valor pronóstico de un ingreso previo médico o quirúrgico en pacientes con embolia pulmonar sintomática ambulatoria / Prognostic value of a previous medical or surgical admission in outpatients with symptomatic pulmonary embolism

Objetivo. Determinar si el antecedente de un ingreso, médico (IM) o quirúrgico (IQ), en los 3 meses previos es un factor asociado a la mortalidad a los 30 días en pacientes con embolia pulmonar aguda sintomática ambulatoria. Método. Estudio observacional de cohortes retrospectivo que incluyó a pacientes adultos con el diagnóstico de embolia pulmonar aguda sintomática en un hospital terciario durante 6 años. Resultados. Se incluyeron 870 pacientes con una edad media de 72,7 años. Un 10,6% (92) tuvieron un IM previo y un 4,9% (43) un IQ. Ciento doce (12,9%) fallecieron en los primeros 30 días. En el grupo de IM se documentó mayor frecuencia de Pulmonary Embolism Severity Index (PESI) simplificada de alto riesgo (≥1) (IM 90,2% vs. IQ 65,1% vs. sin ingreso previo 67%; p<0,001) y de mortalidad a los 30 días (IM 20,7% vs. IQ 7% vs. sin ingreso previo 12,9%; p=0,038). Tras un análisis de regresión logística la PESI simplificada≥1 fue el único factor independiente de mortalidad a 30 días. Conclusiones. La gravedad del episodio agudo, valorada por la escala PESI simplificada, se asocia de forma independiente con la mortalidad a 30 días en los pacientes con embolia pulmonar aguda sintomática ambulatoria. El antecedente de un IM en los 3 meses previos suele conllevar mayor gravedad en el episodio agudo (AU)

Objective. To determine whether an earlier medical (MA) or surgical (SA) admission in the previous three months is a factor associated with mortality at 30 days in outpatients with acute symptomatic pulmonary embolism. Method. Observational, retrospective cohort study on adult patients diagnosed with acute symptomatic pulmonary embolism in a tertiary hospital over a period of 6 years. Results. The study included 870 patients with a mean age of 72.7 years: 10.6% (92) had a prior MA, 4.9% (43) had a SA and 12.9% (112) died within the first 30 days. The MA group showed a higher frequency of simplified Pulmonary Embolism Severity Index (PESI) of high risk (≥1) (MA 90.2% vs SA 65.1% vs no prior admission 67.0%; p<0.001) and mortality at 30 days (MA 20.7% vs SA 7.0% vs no prior admission 12.9%; p=0.038). The logistic regression analysis demonstrated that a simplified PESI≥1 was the only independent risk factor for mortality at 30 days. Conclusions. The severity of the acute episode, as assessed by the simplified PESI scale, is independently associated with mortality at 30 days in outpatients with acute symptomatic pulmonary embolism. An earlier MA in the previous 3 months usually involves greater severity in the acute episode (AU)

Prognostic value of a previous medical or surgical admission in outpatients with symptomatic pulmonary embolism.

OBJECTIVE: To determine whether an earlier medical (MA) or surgical (SA) admission in the previous three months is a factor associated with mortality at 30 days in outpatients with acute symptomatic pulmonary embolism. METHOD: Observational, retrospective cohort study on adult patients diagnosed with acute symptomatic pulmonary embolism in a tertiary hospital over a period of 6 years. RESULTS: The study included 870 patients with a mean age of 72.7 years: 10.6% (92) had a prior MA, 4.9% (43) had a SA and 12.9% (112) died within the first 30 days. The MA group showed a higher frequency of simplified Pulmonary Embolism Severity Index (PESI) of high risk (≥1) (MA 90.2% vs SA 65.1% vs no prior admission 67.0%; p<0.001) and mortality at 30 days (MA 20.7% vs SA 7.0% vs no prior admission 12.9%; p=0.038). The logistic regression analysis demonstrated that a simplified PESI≥1 was the only independent risk factor for mortality at 30 days. CONCLUSIONS: The severity of the acute episode, as assessed by the simplified PESI scale, is independently associated with mortality at 30 days in outpatients with acute symptomatic pulmonary embolism. An earlier MA in the previous 3 months usually involves greater severity in the acute episode.

Coinfección por VIH/VHB: estrategias terapéuticas y control serológico / HIV/HBV coinfection: Serological control and therapeutic strategies

Objetivos. La evolución y pronóstico de los pacientes coinfectados por el virus de la inmunodeficiencia humana (VIH) y el de la hepatitis B (VHB) no es bien conocida. Este estudio describe el tratamiento y el control serológico, virológico, bioquímico y elastográfico de los pacientes coinfectados por VIH/VHB. Pacientes y métodos. Estudio descriptivo, retrospectivo, de la totalidad de pacientes coinfectados por VIH/VHB seguidos en una consulta monográfica de VIH entre el 1 de enero de 2007 y el 30 de noviembre de 2008. A los pacientes se les realizaron determinaciones virológicas y serológicas para el VHB y el VIH, así como linfocitos CD4 y transaminasas, antes de comenzar el tratamiento antirretroviral y en el momento del análisis. Resultados. Se identificaron 54 (5,4%) pacientes coinfectados por VIH/VHB. Las medianas de CD4 nadir y actual fueron de 179 y 437 células/μl, respectivamente. El 70% tenían RNA-VIH indetectable. Cincuenta y dos pacientes (96,3%) seguían terapia con fármacos activos frente al VHB. Un 68,8% presentaron negativización del antígeno «e» del VHB, con un 81,6% de respuesta virológica. El antígeno de superficie del VHB se negativizó en el 10,4%. La alanina aminotransferasa era normal en el75,5%. Se realizó FibroScan® a 30 (55,6%) pacientes, obteniéndose una mediana de 7.0 KPa. Conclusiones. Los resultados obtenidos sugieren un buen control serológico, virológico, bioquímico y elastográfico de los pacientes coinfectados por VIH/VHB con los tratamientos recomendados por las guías clínicas(AU)

Objectives. The evolution and prognosis of patients co-infected by human immunodeficiency virus (HIV) and hepatitis B (HBV) is not well know. This study describes the treatment and serological, virological and biochemical and elastographic responses of HIV and HBV-coinfected patients. Patients and methods. A descriptive, retrospective study of all the HIV/HBV-coinfected patients seen in a specialized HIV department between 1 January 2007 and 30 November 2008 was performed. Virological and serological determinations of HIV and HBV infections as well as CD4 lymphocytes and transaminases prior to antiretroviral treatment and at the time of analysis were obtained. Results. A total of 54 (5.4%) cases of HIV/HBV coinfection were identified. The median nadir and current CD4 were 179 and 437 cells/L, respectively. There was undetectable RNA-HIV in 70%. There were 52 patients (96.3%) who followed active drugs treatment against HBV. After treatment, 68.8% had HBeAg negative result, with 81.6% virologic response. The HBsAg became negative in 10.4%. ALT was normal in 75.5%. FibroScan® was performed in 30 (55.6%) patients, yielding a median of 7.0kPa. Conclusions. The results obtained suggest a good serological, virological and biochemical control of HIV/HBV-coinfected patients with treatments recommended by clinical guidelines(AU)

HIV/HBV coinfection: serological control and therapeutic strategies.

OBJECTIVES: The evolution and prognosis of patients co-infected by human immunodeficiency virus (HIV) and hepatitis B (HBV) is not well know. This study describes the treatment and serological, virological and biochemical and elastographic responses of HIV and HBV-coinfected patients. PATIENTS AND METHODS: A descriptive, retrospective study of all the HIV/HBV-coinfected patients seen in a specialized HIV department between 1 January 2007 and 30 November 2008 was performed. Virological and serological determinations of HIV and HBV infections as well as CD4 lymphocytes and transaminases prior to antiretroviral treatment and at the time of analysis were obtained. RESULTS: A total of 54 (5.4%) cases of HIV/HBV coinfection were identified. The median nadir and current CD4 were 179 and 437 cells/L, respectively. There was undetectable RNA-HIV in 70%. There were 52 patients (96.3%) who followed active drugs treatment against HBV. After treatment, 68.8% had HBeAg negative result, with 81.6% virologic response. The HBsAg became negative in 10.4%. ALT was normal in 75.5%. FibroScan(®) was performed in 30 (55.6%) patients, yielding a median of 7.0kPa. CONCLUSIONS: The results obtained suggest a good serological, virological and biochemical control of HIV/HBV-coinfected patients with treatments recommended by clinical guidelines.

HIV/HBV coinfection: Serological control and therapeutic strategies. / Coinfección por VIH/VHB: estrategias terapéuticas y control serológico.

OBJECTIVES: The evolution and prognosis of patients co-infected by human immunodeficiency virus (HIV) and hepatitis B (HBV) is not well know. This study describes the treatment and serological, virological and biochemical and elastographic responses of HIV and HBV-coinfected patients. PATIENTS AND METHODS: A descriptive, retrospective study of all the HIV/HBV-coinfected patients seen in a specialized HIV department between 1 January 2007 and 30 November 2008 was performed. Virological and serological determinations of HIV and HBV infections as well as CD4 lymphocytes and transaminases prior to antiretroviral treatment and at the time of analysis were obtained. RESULTS: A total of 54 (5.4%) cases of HIV/HBV coinfection were identified. The median nadir and current CD4 were 179 and 437 cells/L, respectively. There was undetectable RNA-HIV in 70%. There were 52 patients (96.3%) who followed active drugs treatment against HBV. After treatment, 68.8% had HBeAg negative result, with 81.6% virologic response. The HBsAg became negative in 10.4%. ALT was normal in 75.5%. FibroScan(®) was performed in 30 (55.6%) patients, yielding a median of 7.0kPa. CONCLUSIONS: The results obtained suggest a good serological, virological and biochemical control of HIV/HBV-coinfected patients with treatments recommended by clinical guidelines.