Anti-phosphatidylserine/prothrombin antibodies in patients with polyarteritis nodosa.

INTRODUCTION: Anti-phospatidylserine/prothrombin (aPS/PT) antibodies have been described in cutaneous Polyarteritis Nodosa (PAN) in association with specific manifestations. OBJECTIVES: To determine aPS/PT antibodies in patients with PAN and its correlation with clinical manifestations. METHODS: Cross-sectional comparative study including PAN patients and 20 controls (10 Microscopic Polyangiitis [MPA] and 10 Behçet's disease [BD]). Clinical and demographic variables, treatment, serologic markers, prognosis, activity and damage indexes were evaluated. aPS/PT, anti-cardiolipin (aCL), anti-beta 2 glycoprotein 1 (anti-B2GP1) antibodies, and lupus anticoagulant (LA) were determined. RESULTS: Fourteen patients with PAN were included, 11 (79%) women, with disease duration of 207 months, and mostly inactive disease. Only one patient with PAN and one with BD were positive for aPS/PT IgG. LA was the most frequent antibody identified. One patient with MPA and one with BD were positive for aCL IgM; one with MPA for anti-B2GP1 IgG, and one with PAN for anti-B2GP1 IgM. CONCLUSIONS: aPS/PT antibodies are not frequent in patients with longstanding inactive PAN.

Anticuerpos antifosfatidilserina/protrombina en pacientes con poliarteritis nodosa / Anti-Phosphatidylserine/Prothrombin antibodies in patients with Polyarteritis Nodosa

Antecedentes: Anticuerpos antifosfatidilserina/protrombina (aPS/PT) han sido descritos en poliarteritis nodosa (PAN) cutánea, en asociación con manifestaciones específicas. Objetivos: Determinar anticuerpos aPS/PT en pacientes con PAN y analizar su correlación con manifestaciones clínicas. Métodos: Estudio transversal comparativo de pacientes con PAN y 20 controles (10 con poliangitis microscópica [PAM] y 10 con enfermedad de Behçet [EB]). Se evaluaron variables demográficas, clínicas, serológicas y tratamiento; índices de pronóstico, actividad y daño. Se determinaron anticuerpos aPS/PT, anticardiolipina (aCL), anti-beta 2 glicoproteína 1 (anti-B2GP1) y anticoagulante lúpico (AL). Resultados: Fueron incluidos 14 pacientes con PAN, 11 (79%) mujeres, con duración de la enfermedad de 207 meses, y principalmente enfermedad inactiva. Sólo un paciente con PAN y uno con EB fueron positivos para aPS/PT IgG. El anticuerpo antifosfolípido más frecuente fue AL. Un paciente con PAM y uno con EB fueron positivos para aCL IgM; uno con PAM para anti-B2GP1 IgG, uno con PAN para anti-B2GP1 IgM. Conclusiones: Los anticuerpos aPS/PT son infrecuentes en pacientes con PAN inactiva de larga evolución.(AU)

Introduction: Anti-phosphatidylserine/prothrombin (aPS/PT) antibodies have been described in cutaneous Polyarteritis Nodosa (PAN) in association with specific manifestations. Objectives: To determine aPS/PT antibodies in patients with PAN and its correlation with clinical manifestations.Methods: Cross-sectional comparative study including PAN patients and 20 controls (10 Microscopic Polyangiitis [MPA] and 10 Behçet's disease [BD]). Clinical and demographic variables, treatment, serological markers, prognosis, activity and damage indexes were evaluated. aPS/PT, anti-cardiolipin (aCL), anti-beta 2 glycoprotein 1 (anti-B2GP1) antibodies, and lupus anticoagulant (LA) were determined. Results: Fourteen patients with PAN were included, 11 (79%) women, with disease duration of 207 months, and mostly inactive disease. Only one patient with PAN and one with BD were positive for aPS/PT IgG. LA was the most frequent antibody identified. One patient with MPA and one with BD were positive for aCL IgM; one with MPA for anti-B2GP1 IgG, and one with PAN for anti-B2GP1 IgM. Conclusions: aPS/PT antibodies are not frequent in patients with longstanding inactive PAN.(AU)

Cirugías más frecuentes en el Centro Médico Naval en un período de 5 años / Most frequent surgeries at the Naval Medical Center in a 5-year period

Resumen: Introducción: El objetivo de este estudio es determinar los procedimientos quirúrgicos más frecuentemente realizados en el Centro Médico Naval, un Centro Médico de Tercer Nivel. Material y métodos: Se realizó un estudio observacional, exploratorio, descriptivo, trasversal y retrospectivo incluyendo todas las cirugías realizadas del 01 de enero de 2015 al 31 de julio de 2019, consultando los registros del quirófano y los expedientes electrónicos. Resultados: Se registraron 25,114 cirugías, con un promedio anual de 5,527 procedimientos y de 16 procedimientos diarios (rango de 2 a 25). Las especialidades que más cirugías realizaron fueron cirugía general, ortopedia, ginecoobstetricia y oftalmología. Las principales cirugías realizadas fueron la facoemulsificación de catarata con colocación de lente intraocular, endoscopías, cesáreas, colecistectomía laparoscópica, atención del trabajo de parto, reducción abierta con fijación interna de fracturas, apendicectomía abierta, hernioplastía inguinal y lavados quirúrgicos. El 59% de las cirugías se realizó en mujeres. El rango de edad de los pacientes fue desde recién nacido hasta los 101 años, estando la mayoría entre los 53 y 72 años. Conclusiones: El Centro Médico Naval destina la mayoría de los recursos de su quirófano para la atención obstétrica (cesárea y trabajo de parto), la atención de padecimientos crónico-degenerativos (cirugía de catarata, y endoscopías), atención de accidentes (reducción de fracturas y lavados quirúrgicos) y la resolución de padecimientos abdominales agudos como la apendicitis y la colecistitis.

Abstract: Introduction: The study objective was to determine the most frequently surgical procedures at the Naval Medical Center, a third level medical center. Material and methods: An observational, exploratory, descriptive, cross-sectional and retrospective study was conducted including all surgeries performed from January 1, 2015 to July 31, 2019, reviewing the surgical records and patient electronic files. Results: 25,114 surgeries were registered, with an annual average of 5,527 procedures and 16 daily procedures (range from 2 to 25). General surgery, orthopedics, gynecoobstetrics and ophthalmology were the specialties with the most amount of surgeries. The main surgeries were cataract phacoemulsification with intraocular lens placement, endoscopies, caesarean sections, laparoscopic cholecystectomy, labor delivery, open reduction with internal fracture fixation, open appendectomy, inguinal hernioplasty and surgical washes. 59% of the surgeries were performed in women. The age range of the patients was from newborn to 101 years, with most patients between 53 and 72 years. Conclusions: The naval medical center spend surgical resources for obstetric care (caesarean section and labor), care of chronic degenerative diseases (cataract surgery, and endoscopy), accident care (fracture reduction and surgical washes) and the resolution of acute abdominal conditions such as appendicitis and cholecystitis.

Anti-Phosphatidylserine/Prothrombin antibodies in patients with Polyarteritis Nodosa. / Anticuerpos antifosfatidilserina/protrombina en pacientes con poliarteritis nodosa.

INTRODUCTION: Anti-phosphatidylserine/prothrombin (aPS/PT) antibodies have been described in cutaneous Polyarteritis Nodosa (PAN) in association with specific manifestations. OBJECTIVES: To determine aPS/PT antibodies in patients with PAN and its correlation with clinical manifestations. METHODS: Cross-sectional comparative study including PAN patients and 20 controls (10 Microscopic Polyangiitis [MPA] and 10 Behçet's disease [BD]). Clinical and demographic variables, treatment, serological markers, prognosis, activity and damage indexes were evaluated. aPS/PT, anti-cardiolipin (aCL), anti-beta 2 glycoprotein 1 (anti-B2GP1) antibodies, and lupus anticoagulant (LA) were determined. RESULTS: Fourteen patients with PAN were included, 11 (79%) women, with disease duration of 207 months, and mostly inactive disease. Only one patient with PAN and one with BD were positive for aPS/PT IgG. LA was the most frequent antibody identified. One patient with MPA and one with BD were positive for aCL IgM; one with MPA for anti-B2GP1 IgG, and one with PAN for anti-B2GP1 IgM. CONCLUSIONS: aPS/PT antibodies are not frequent in patients with longstanding inactive PAN.

Isoantibodies, prevalence and risk factors in two hospitals in Mexico / Isoanticuerpos, prevalencia y factores de riesgo en dos hospitales de México

Background: Erythrocyte isoimmunization or alloimmunization is a late complication of transfusion, in which antibodies against erythrocyte antigens other than the ABO system are developed. Its prevalence is variable, groups of patients with low prevalence (2%) and others of high risk with more than 50% have been described. These antibodies can have serious clinical repercussions in transfused patients. Objective: To know the prevalence of erythrocyte isoimmunization, the risk factors for its development and the types of antibodies developed in the user population of two hospitals in Mexico. Methods: Retrospective study. The database of the Blood Bank and the Transfusion Service of two hospitals was analyzed for the search of transfused patients who developed isoantibodies from 2012 to 2016, analyzing their background to determine the risk factors, prevalence and type of antibodies. Results: An isoimmunization prevalence of 0.97% was found in 5 years; the main antibodies found were: anti-E, anti-K, anti-C, anti-Dia, anti-c, anti-D and anti-Fya. The associated risk factors for the development of isoimmunization were: transfusion history, pregnancy and female sex, as a finding it was found that group O is a protective factor. Conclusions: Erythrocyte alloimmunization in the population studied corresponded to a low prevalence. The main antibodies found were against Rh, Kell and Diego system antigens, with a different distribution than published in other international series. No previous report was found about the finding on group O as a protective factor for isoimmunization.

Introducción: la isoinmunización o aloinmunización eritrocitaria es una complicación tardía de la transfusión, en la cual se desarrollan anticuerpos contra antígenos eritrocitarios diferentes al sistema ABO. Su prevalencia es variable, se han descrito grupos de pacientes con baja prevalencia (2%) y otros de alto riesgo con más del 50%. Estos anticuerpos pueden tener repercusiones clínicas graves en los pacientes transfundidos. Objetivo: conocer la prevalencia de la isoinmunización eritrocitaria, los factores de riesgo para su desarrollo y los tipos de anticuerpos desarrollados en la población usuaria de dos hospitales en México. Métodos: estudio retrospectivo. Se analizó la base de datos del banco de sangre y del servicio de transfusión de dos hospitales para la búsqueda de pacientes transfundidos que desarrollaron isoanticuerpos del año 2012 al 2016, analizando sus antecedentes para determinar los factores de riesgo, prevalencia y tipo de anticuerpos. Resultados: se encontró una prevalencia de isoinmunización del 0.97% en 5 años; los principales anticuerpos encontrados fueron: anti-E, anti-K, anti-C, anti-Dia, anti-c, anti-D y anti-Fya. Los factores de riesgo asociados para el desarrollo de isoinmunización fueron: antecedentes transfusionales, embarazo y el sexo femenino, como hallazgo se encontró que el grupo O es un factor protector. Conclusiones: la aloinmunización eritrocitaria en la población estudiada correspondió a una prevalencia baja. Los principales anticuerpos encontrados fueron contra antígenos del sistema Rh, Kell y Diego, con una distribución diferente a lo publicado en otras series internacionales. No se encontró reporte previo acerca del hallazgo sobre el grupo O como factor protector para isoinmunización.

Anti-RNP/Sm antibodies in patients with systemic lupus erythematosus and its role in thrombosis: a case-control study.

OBJECTIVE: To validate the association of thrombotic events with positive lupus anticoagulant (LA) and co-presence of anti-RNP/Sm, as well as the diagnostic accuracy of this combination of antibodies for thrombosis. METHODS: Case-control study of patients with systemic lupus erythematosus (SLE) who presented thrombosis after SLE diagnosis and controls with SLE without thrombosis. Comorbidities, traditional risk factors, clinical variables, and treatment were evaluated. Antiphospholipid (aPL) and anti-RNP/Sm antibodies were determined. RESULTS: Sixty-three cases and 63 controls were studied, 88% women, median age of 40 years, and disease duration of 135 months at study inclusion. No differences were found between groups regarding age, comorbidities, or clinical characteristics at SLE diagnosis. Patients with thrombosis were more frequently positive for anti-RNP/Sm (p = 0.001), IgG aCL (p = 0.02), IgG anti-B2GPI (p = 0.02), IgM anti-B2GPI (p = 0.02), LA (p < 0.001), the combination of anti-RNP/Sm + LA (p < 0.001), and aPL triple marker (p = 0.002), compared to controls. The combination of anti-RNP/Sm + LA, SLEDAI-2 K, and prednisone dose was associated with thrombosis (p < 0.05). The combination of anti-RNP/Sm + LA showed 56% sensitivity, 79% specificity, 73% positive predictive value, 64% negative predictive value, positive likelihood ratio (LR) 2.69, and negative LR 0.56 for predicting thrombosis. No difference was found in the comparison of area under the curve between LA alone and the combination of anti-RNP/Sm + LA (p = 0.73). CONCLUSION: Thrombosis was associated with disease activity, dose of prednisone, and the combination of anti-RNP/Sm antibodies and LA. This combination of antibodies could be useful in the identification of SLE patients at risk of thrombosis.

Venous and Arterial Thrombotic Events in Systemic Lupus Erythematosus.

OBJECTIVE: The incidence of thrombosis in patients with systemic lupus erythematosus (SLE) is 25 to 50-fold higher than in the general population; we aimed to define the characteristics of venous thrombotic events (VTE) and arterial thrombotic events (ATE) to identify the patients at highest risk. METHODS: The study included 219 patients with recent-onset SLE. At baseline, standardized medical history and laboratory tests were done. Followup visits occurred quarterly, and information about damage accrual, comorbidities, and cardiovascular risk factors was updated annually. Main outcome was development of TE after SLE diagnosis. RESULTS: Thirty-five patients (16%) developed TE (27 VTE, 8 ATE) during 5.21 years of followup; incidence rate 31/1000 patient-years. Most events (57%) developed within the first year of diagnosis, and 69% were not associated with lupus anticoagulant (LAC), determined with 1 method. VTE developed earlier than ATE (2.0 vs 57.5 mos, p = 0.02). In the multivariate analysis, variables preceding VTE included cutaneous vasculitis, nephrotic syndrome, dose of prednisone, and LAC in combination with anti-RNP/Sm antibodies (p < 0.03). Patients with ATE were older (median age 44 vs 29 yrs, p = 0.04), smokers, and had hypertension, diabetes mellitus, dyslipidemia, at least 2 traditional risk factors, nephrotic syndrome, chronic damage, and a higher cumulative dose of prednisone (p < 0.05). LAC in combination with anti-RNP/Sm antibodies was associated with VTE and improved the accuracy for predicting it. CONCLUSION: Our study suggests that in SLE, VTE and ATE have different risk factors. Understanding these differences is helpful for identifying patients at highest risk. The use of LAC plus anti-RNP/Sm for predicting VTE deserves further study.

Thrombosis in leukemia: incidence, causes, and practical management.

In patients with acute leukemia (AL), coagulation disorders, which include both thrombotic and hemorrhagic events, are part of the clinical spectrum both at diagnosis and during its evolution. The incidence of these events has been reported by several authors in the range of 1-36 %. This heterogeneity appears to be related to the type of patients included, the study design, and patient-related factors as well as the treatment used. The pathophysiology of thrombosis in AL is complex and multifactorial and includes a myriad of factors that contribute to cancer procoagulant state: synthesis of procoagulant factors by circulating blasts, cellular microparticles, use of endovascular devices (catheters), type of chemotherapy used (L-asparaginase) to name a few. Currently, treatment relies in the use of heparin, followed by vitamin K antagonists for 3 to 6 months. However, randomized controlled studies are required in patients with AL and thrombosis to confirm its safety, duration, and effectiveness.

[Hemophilia.] / Hemophilia.

Hemophilia is a genetic disease in which the clinical manifestation is mainly the presence of hemorrhage. There are two known types of hemophilia: hemophilia A and B, which have a deficiency of factor VIII or IX clotting, respectively. The intensity of bleeding in hemophilia depends on the plasma levels of factor VIII or IX and has traditionally been classified as mild (> 5 % activity), moderate (1-5 % activity) and severe (< 1 % activity). In laboratory tests, isolated prolongation of activated partial thromboplastin time (aPTT) can be found, but it is necessary to determine the plasma levels of factor VIII or IX to establish the diagnosis of hemophilia A or B. The treating of this disease involves replacing exogenous factor VIII or IX concentrates. Gene therapy could be an option in the future to achieve the cure of the disease. Complications of hemophilia are the risk of transfusion-associated infections, pseudotumor hemophilic, hemophilic arthropathy and the presence of serum inhibitors.

La hemofilia es una enfermedad genética en la que las manifestaciones clínicas consisten básicamente en la presencia de hemorragias. Se conocen dos tipos de hemofilia: A y B, las cuales se originan por la deficiencia de los factores VIII y IX de la coagulación, respectivamente. La intensidad de la hemorragia en la hemofilia depende de los niveles plasmáticos del factor VIII o IX y tradicionalmente se ha clasificado como leve (> 5 % de actividad), moderada (de 1 a 5 % de actividad) y severa (< 1 % de actividad). En las pruebas se identifica prolongación aislada del tiempo de tromboplastina parcial activada (TTPa), pero es necesario determinar los niveles plasmáticos del factor VIII o IX para establecer el diagnóstico de hemofilia A o B. El tratamiento de esta enfermedad consiste en la reposición exógena con concentrados del factor VIII o IX. En el futuro, la terapia genética podría ser una opción para lograr la curación de la enfermedad. Las complicaciones de la hemofilia son el riesgo de infecciones relacionadas con las transfusiones, el pseudotumor hemofílico, la artropatía hemofílica y la presencia de inhibidores.

[Treatment of cancer and thrombosis: practical approach]. / Tratamiento de cáncer y trombosis: enfoque práctico.

Individuals with cancer are at increased risk of developing thrombosis. The prevalence of thrombosis depends on tumor-related factors such as histological type, stage, the use of central venous catheters, or treatment with surgery, chemotherapy or radiotherapy, as well as general prothrombotic factors including advanced age, immobility, obesity, hereditary thrombophilias and comorbidities. Prophylactic or therapeutic treatment of thrombosis should be individualized and will depend on both the risk of thrombosis and bleeding. In this review we intend to update concepts that have changed substantially such as green food-free diet, or the indication of absolute bed rest in patients with recent thrombosis. We propose evidence-based therapeutic strategies regarding the most prevalent clinical problems encountered in patients with cancer and thrombosis.

[Therapeutic response and survival in patients with hairy cell leukemia in a third level institution]. / Respuesta terapéutica y supervivencia en pacientes con leucemia de células peludas en un hospital de tercer nivel.

BACKGROUND: in Mexico published casuistry concerning hairy cell leukemia (HCL) is limited. OBJECTIVE: to describe the therapeutic response and survival of patients with HCL attended in a third level public institution. METHODS: patient's data with HCL diagnosis registered between January 1989 - December 2009 were analyzed. RESULTS: twenty three patients fulfilled HCL diagnosis criteria. Median age was 44 years (range 23-75 years) and median follow-up of the cohort was 1,877 days (range 1-8,462 days). First line treatment varied along time finding complete response (CR) and partial response (PR) rates of 77.3 and 18.2%, respectively. Of all therapeutic modalities employed cladribine induced the highest response rate. Survival at 1,877 days was 82.6%. At last follow-up 65.2% of patients remain alive, 13 in CR and 2 in PR; 4 died (CR = 2, PR = 1, active disease = 1) and 4 were lost during follow-up. CONCLUSION: this study which included more patients than previous single-institution Mexican series confirm the chronic clinical behavior of HCL and that purine analogs are corner stone in the treatment of patients suffering HCL.

[Preoperative hemostasis evaluation]. / Evaluación preoperatoria de la hemostasia.

Identify which patients are going to bleed during a surgery or invasive procedure is desirable. The coagulation tests as the prothrombin time (PT), the activated partial thromboplastin time (aPTT), bleeding time (BT) and platelet count are routinely made with this purpose in the preoperative evaluation. But, really these laboratory tests can predict what patients are going to bleed? The answer with the current knowledge is: No. The most efficient method for prediction of bleeding is the clinical history, but still, most surgical bleeding are not by coagulopathy, they are caused by factors related to surgical technique, and therefore are not susceptible to be predicted. This article describes the recommendations for the assessment of bleeding risk prior to surgery or invasive procedures and discusses the value of preoperative coagulation tests.

[New anticoagulants: dabigatran, rivaroxaban and apixaban]. / Nuevos anticoagulantes: dabigatrán, rivaroxabán y apixabán.

To date, the most widely used drugs in our anticoagulation clinics are acenocoumarin and warfarin, which belong to the category of vitamin K antagonists (VKA). They have about 70 years of use in the clinic, with proven efficacy for various thrombotic diseases, but also with known problems of variability and dietary and drug interactions. In hospital thromboprophylaxis, the most widely used anticoagulant is enoxaparin, a low molecular weight heparin (LMWH). A new generation of anticoagulants are available, the direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban and apixaban), with obvious advantages over conventional anticoagulants. This paper summarizes what has been published to date for these new antithrombotics.