Indicación de profilaxis post exposición al VIH (PPE) en caso de relaciones sexuales sin preservativo o violencia sexual

Folleto elaborado en base a "Profilaxis Post Exposición para el VIH en personas adultas", del Ministerio de Salud de la Nación, Argentina.Se presenta un diagrama con posibles opciones de profilaxis.

Lower Mortality and Morbidity with Low-Molecular-Weight Heparin for Venous Thromboembolism Prophylaxis in Spine Trauma.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: The objective of this study was to evaluate outcomes between patients receiving LMWH versus UH in a retrospective cohort of patients with spine trauma. SUMMARY OF BACKGROUND DATA: Although multiple clinical trials have been conducted, current guidelines do not have enough evidence to suggest low-molecular-weight heparin (LMWH) or unfractionated heparin (UH) for venous thromboembolism (VTE) prophylaxis in spine trauma. METHODS: Patients with spine trauma in the Trauma Quality Improvement Program datasets were identified. Those who died, were transferred within 72 hours, were deemed to have a fatal injury, were discharged within 24 hours, suffered from polytrauma, or were missing data for VTE prophylaxis were excluded. A propensity score was created using age, sex, severity of injury, time to prophylaxis, presence of a cord injury, and altered mental status or hypotension upon arrival, and inverse probability weighted logistic regression modeling was used to evaluate mortality, venous thromboembolic, return to operating room, and total complication rates. E values were used to calculate the likelihood of unmeasured confounders. RESULTS: Those receiving UH (n = 7172) were more severely injured (P < 0.0001), with higher rates of spinal cord injury (32.26% vs. 25.32%, P < 0.0001) and surgical stabilization (29.52% vs. 22.94%, P < 0.0001) compared to those receiving LMWH (n = 20,341). Patients receiving LMWH had lower mortality (odds ratio [OR]: 0.47; 95% CI: 0.42-0.53; P < 0.001; E = 3.68), total complication (OR: 0.92; 95% CI: 0.88-0.95; P < 0.001; E = 1.39), and VTE event (OR: 0.80; 95% CI: 0.72-0.88; P < 0.001; E = 1.81) rates than patients receiving UH. There were no differences in rates of unplanned return to the operating room (OR: 1.01; 95% CI: 0.80-1.27; P = 0.93; E = 1.11). CONCLUSION: There is an association between lower mortality and receiving LMWH for VTE prophylaxis in patients with spine trauma. A large randomized clinical trial is necessary to confirm these findings. LEVEL OF EVIDENCE: 3.

Prophylactic levetiracetam-induced pancytopenia with traumatic extra-dural hematoma: Case report.

BACKGROUND: Pancytopenia has only rarely been reported with Levetiracetam use. It is a potentially life threatening adverse effect that requires cessation of therapy. CASE DESCRIPTION: We describe a case of an otherwise well thirty-two-year-old man who underwent an emergent craniotomy for evacuation of a traumatic extra-dural haematoma. Post-operatively, he developed pancytopenia which corrected with cessation of levetiracetam. CONCLUSION: This report aims to increase awareness of this rare side effect and reiterates the judicious use of prophylactic levetiracetam in brain trauma.

Anthrax prevention through vaccine and post-exposure therapy.

INTRODUCTION: Vaccines and therapeutic antibodies are the most crucial components of anthrax prophylaxis (pre- and post-exposure) and treatment. The improvement in the availability and safety profile of vaccines and the therapeutic antibodies has helped immensely in reducing the worldwide burden of anthrax. AREAS COVERED: Current recommendations for anthrax prophylaxis and control, vaccines and therapeutic antibodies, the recent endeavors, particularly, made after 2010 toward making them safer and more efficacious along with our opinion on its future course. Primarily, PubMed and Europe PMC were searched to cover the recent developments in the above-indicated areas. EXPERT OPINION: Some key existing lacunae in our understanding of the working of biologicals-based anthrax-control measures, i.e., vaccines and therapeutic antibodies, should be addressed to improve their overall stability, safety profile, and efficacy. The identification of novel inhibitors targeting different key-molecules and vital-steps contributing to the overall anthrax pathophysiology could make a difference in anthrax control.

Evaluation of dosing and safety outcomes of low-dose prophylactic warfarin in children after cardiothoracic surgery.

PURPOSE: Prophylactic warfarin with an International Normalized Ratio (INR) goal of 1.5 to 2.0 is one antithrombotic therapy utilized in children after cardiothoracic surgery (CTS); published sources suggest a dose of 0.1 mg/kg per day to achieve this goal. However, few studies have evaluated dosing in this population. The purpose of this study was to evaluate dosing and safety outcomes in children receiving warfarin after CTS. METHODS: A descriptive, retrospective review was conducted to evaluate warfarin dosing and INR outcomes in patients 18 years of age or younger who underwent CTS and received prophylactic warfarin with an INR goal of 1.5 to 2.0 from January 2014 through December 2018. The primary objective was to determine the median initial warfarin dose. Secondary objectives included identifying the percentage of documented INR values that were outside the therapeutic range, the percentage of patients with therapeutic INRs at discharge, and the 30-day readmission rate. RESULTS: Twenty-six patients were included in the review. The median initial warfarin dosage was 0.07 mg/kg/d (interquartile range [IQR], 0.05-0.10 mg/kg/d). Of the total of 177 INR values collected during the entire study period, 67 (37.9%) were therapeutic, 64 (36.2%) were subtherapeutic, and 46 (26.0%) were supratherapeutic. Eighteen patients (69.2%) had at least 1 supratherapeutic INR at any point during the study period, most frequently on days 2 through 4 of therapy. At discharge, 11 patients (42.3%) had therapeutic INRs. Four patients (15.4%) were readmitted within 30 days, with bleeding documented in 2 patients during their readmission. CONCLUSION: The majority of patients received an initial warfarin dose less than that specified in published recommendations but still had a supratherapeutic INR at least once during the study period. When initiating warfarin after CTS, a dosage of <0.1 mg/kg per day and frequent monitoring may be needed to achieve an INR goal of 1.5 to 2.0.

CE: HIV Update: An Epidemic Transformed.

: The field of HIV treatment and prevention has evolved rapidly over the past four decades. New therapies that are more potent and streamlined have transformed HIV into a chronic disease, while the use of such preventive strategies as preexposure prophylaxis and postexposure prophylaxis provide effective options for reducing the risk of HIV infection. These medical breakthroughs have enabled more people living with HIV (PLWH) to reach older adulthood. But they also mean that nurses are seeing more PLWH who have developed long-term complications of living with HIV or of exposure to antiretroviral therapy, as well as concurrent chronic conditions associated with advanced age. Nurses play a critical role in caring for PLWH and those at risk for HIV infection. This article discusses HIV epidemiology, describes the current state of HIV treatment and prevention, and highlights common comorbidities often seen in PLWH who are over age 50.

Increased Transfusion Requirements with Pharmacologic Thromboembolism Prophylaxis During Inflammatory Bowel Disease Exacerbation.

BACKGROUND: Inflammatory bowel disease (IBD) exacerbation requiring hospitalization increases the risk of venous thromboembolism (VTE), and current guidelines recommend pharmacologic VTE prophylaxis (PVTEP). AIMS: Bleeding risks with PVTEP in this population are poorly defined, and no study has investigated packed red blood cell (PRBC) transfusion requirements in this population. METHODS: We conducted a chart review of all adult hospitalizations for IBD exacerbation within the Northwell Healthcare system. Patient characteristics recorded included demographics, disease type ulcerative colitis or Crohn's disease, severe disease defined by inpatient corticosteroid or biologic use, and admission hemoglobin. Inpatient use of PVTEP and anti-platelet therapies were identified. The primary outcome was the occurrence of any packed red blood cell (PRBC) transfusion. RESULTS: In total, 717 patients met inclusion criteria, accounting for 891 admissions. PVTEP was used during 60.4% of admissions, and 11.1% of patient admissions included a transfusion event. Severe disease patients receiving PVTEP had an 18.6% transfusion risk, versus 11.1% for those not receiving PVTEP, OR 1.82, CI (1.04-3.17). One multivariable analysis transfusion was associated with PVTEP, OR 2.11, 95% CI 1.18, 3.77, p = 0.0120, disease severity OR 3.17, 95% CI 1.81,5.54, p < 0.0001, anti-platelet therapies OR 2.46, 95% CI 1.23-4.90, p = 0.0107, bowel resection OR 3.88, 95% CI 1.97,7.63, p < 0.0001 and decreased admission hemoglobin OR 2.01, 95% CI 1.73-2.32, p < 0.0001, but not disease type ulcerative colitis OR 0.71, 95% CI 0.42-1.20. CONCLUSION: PVTEP during IBD exacerbation is associated with increased PRBC transfusions. Our findings do not constitute a contraindication to PVTEP, but may be incorporated into patient counseling during inpatient IBD management.

Human rabies post exposure prophylaxis at the Pasteur Institute of Dakar, Senegal: trends and risk factors.

BACKGROUND: Rabies remains a major public health problem in developing countries. Most fatal rabies cases, especially in children, result from dog bites and occur in low-income countries, such as those in Sub-Saharan Africa. Rabies can be controlled through mass dog vaccination and human deaths prevented through timely and appropriate post-exposure prophylaxis (PEP). As access to appropriate PEP remains a serious challenge for bite-victims, the aim of this study was to understand the use of PEP, to evaluate the knowledge, attitudes and practices with respect to rabies and to identify risk factors related to non-compliance with PEP to define recommendations for improving PEP in Senegal. METHODS: This study included patients with suspicion of rabies exposure who sought PEP at the Pasteur Institute of Dakar from April 2013 to March 2014. Patients with rabies clinical symptoms, those who had already started PEP and those with exposure outside Senegal or for more than 3 months were excluded. Data on risk factors and propensity to seek and complete PEP were collected using questionnaires and phone interviews. The association between acceptability and compliance with PEP and other independent variables were evaluated using multivariate regression analysis. RESULTS: Among the 905 patients enrolled into the study, 67% were male (sex ratio M/F, 2) and 46%, children under 15 years of age. Exposures by animal bites represented 87%, whereas the remainder were due to scratches or contact; 76% were classified as WHO category III and 88% were due to dogs. Among these patients, 7% refused to start PEP and 54.5% completed the full schedule. Main factors reported by non-compliant patients were vaccine costs and affordability, and knowledge on status of biting animal. CONCLUSION: This study shows that despite the awareness about rabies dangers and prevention, only half of the patients completed the full PEP schedule. The following recommendations, such as free of charge prophylaxis or intradermal regimens as an alternative to intramuscular regimens, should be considered to increase the adherence to PEP at the Pasteur Institute of Dakar and in Senegal.

Updates on HIV nonoccupational postexposure prophylaxis.

PURPOSE OF REVIEW: Adolescents and young adults continue to contribute to new HIV infections despite improved antiretroviral regimens and HIV preexposure and postexposure prophylaxis (PrEP and PEP). Knowledge about nonoccupational HIV PEP (nPEP) is relevant and important for all pediatricians as adolescents present under a variety of circumstances disclosing past sexual activity. RECENT FINDINGS: nPEP is effective in preventing HIV infection, and newer regimens have been shown to increase compliance amongst users, have less side effects, and lead to less HIV resistance. Yet, research on physician prescription practices shows a lack of knowledge regarding appropriate HIV nPEP medication regimens, dosing, and follow-up recommendations. Updated national guidelines are available to providers who may be unfamiliar with indications and drug regimens for nPEP. Studies also provide different strategies to increase nPEP use and compliance among patients as well as ways to increase provider awareness of appropriate nPEP prescription. SUMMARY: Research of HIV nPEP shows that it is effective when used correctly, but there needs to be increased education and awareness to increase provider prescription and patient use as well as institutional changes to help patients complete the full course of medication.

Timing of Prophylactic Anticoagulation and Its Effect on Thromboembolic Events After Surgery for Metastatic Tumors of the Spine.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate the effect of timing of initiation of prophylactic anticoagulation (AC) on the incidence of venous thromboembolism (VTE) after surgery for metastatic tumors of the spine. SUMMARY OF BACKGROUND DATA: VTE is a known complication in patients undergoing surgery for metastatic spine disease. However, there is limited data on the use of prophylactic AC in this population and its impact on the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as the risk of epidural hematoma. METHODS: A retrospective review of our institutional neurosurgical spine database for the years 2012 through 2018 was performed. Patients who underwent surgery for metastatic tumors were identified. The development of VTE within 30 days was examined, as well as the occurrence of epidural hematoma. The incidence of VTE was compared between patients receiving "early" (within postoperative days 1-3) and "delayed" prophylactic AC (on or after postoperative day 4). RESULTS: Sixty-five consecutive patients were identified (mean age 57, 62% male). The overall rate of VTE was 16.9%-all of whom had DVTs with a 3.1% rate of nonfatal PE (two patients also developed PE). From the overall cohort, 36 of 65 (56%) received prophylactic AC in addition to mechanical prophylaxis-22 in the early group (61.1%) and 14 in the delayed group (38.9%). The risk of VTE was 9.1% in the early group and 35.7% in the delayed group (26.6% absolute risk reduction; P = 0.049); there was one case of epidural hematoma (1.5%). On multivariate analysis, delayed prophylactic AC was found to significantly increase the odds of VTE development (OR 6.43; 95% CI, 1.01-41.2; P = 0.049). CONCLUSION: The findings of this study suggest that administration of prophylactic AC between days 1 and 3 after surgery for metastatic tumors of the spine may significantly reduce the risk of postoperative thromboembolic events. LEVEL OF EVIDENCE: 4.

Prophylactic Effect of Amiodarone Infusion on Reperfusion Ventricular Fibrillation After Release of Aortic Cross-Clamp in Patients with Left Ventricular Hypertrophy Undergoing Aortic Valve Replacement: ARandomized Controlled Trial.

OBJECTIVE: To investigate whether prophylactic amiodarone infusion prevents ventricular fibrillation after aortic cross-clamp release and attenuates cytokine production in patients with left ventricular hypertrophy undergoing cardiac surgery. DESIGN: Prospective, randomized controlled trial. SETTING: A public hospital. PARTICIPANTS: The study comprised 68 patients undergoing aortic valve replacement for severe aortic stenosis. INTERVENTIONS: Patients were randomly assigned to receive a 150mg bolus then 30mg/h continuous infusion of amiodarone (amiodarone group) or a 1 mg/kg bolus then 1 mg/kg/h continuous infusion of lidocaine (lidocaine group). The primary outcome was the ventricular fibrillation incidence rate after aortic cross-clamp release. Secondary outcomes included perioperative serum interleukin-6 and tumor necrosis factor-alpha levels. MEASUREMENTS AND MAIN RESULTS: The ventricular fibrillation incidence rate was significantly lower in the amiodarone than in the lidocaine group (20.6% v 50%, relative risk 0.41; 95% confidence interval [CI] 0.20-0.86; p = 0.021). Interleukin-6 levels 1hour after aortic cross-clamp release and at intensive care unit admission were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 117.4pg/mL [87.1-158.4] v 339.5pg/mL [210.6-547.2]; p < 0.01 and 211.1pg/mL [162.8-73.6] v 434.1pg/mL [293.7-641.5]; p < 0.01, respectively). Tumor necrosis factor-alpha levels 1hour after aortic cross-clamp release were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 1.624pg/mL [1.359-1.940] v 2.283pg/mL [1.910-2.731]; p = 0.02). CONCLUSIONS: Amiodarone prevented reperfusion ventricular fibrillation in patients with left ventricular hypertrophy undergoing aortic valve replacement to a greater extent than did lidocaine. Furthermore, amiodarone inhibited postoperative interleukin-6 and tumor necrosis factor-alpha production.

Recent advances in the development of monoclonal antibodies for rabies post exposure prophylaxis: A review of the current status of the clinical development pipeline.

Despite successful control in many parts of the world, rabies virus continues to result in tens of thousands of deaths each year. Death from rabies can be prevented by timely and appropriate post exposure prophylaxis including wound cleaning and administration of vaccine and rabies immunoglobulin. Currently, rabies immunoglobulin is derived from the blood plasma of horses or humans and has several limitations relating to supply, cost and quality. Monoclonal antibodies produced through recombinant DNA technologies could potentially overcome these limitations. The first anti-rabies monoclonal antibody has recently gained regulatory approval in India and there are several other candidates being evaluated in clinical trials. Given the advances in the field, rabies monoclonal antibodies have been recently considered by the World Health Organization's Strategic Advisory Group of Experts on Immunization and included in updated WHO immunization policy recommendations for rabies published in April 2018. This article reviews the current landscape of the clinical trial development of anti-rabies monoclonal antibodies and the historical clinical trial pathways followed for blood-derived rabies immunoglobulin before discussing challenges in the clinical evaluation, regulatory approval, uptake and monitoring of these products.

Pneumocystis jiroveci pneumonia in kidney and simultaneous pancreas kidney transplant recipients in the present era of routine post-transplant prophylaxis: risk factors and outcomes.

BACKGROUND: The goal of this study was to identify predictors for development of Pneumocystis jirovecii pneumonia (PJP) in kidney and simultaneous kidney and pancreas transplant recipients in the present era of universal primary prophylaxis. METHODS: We reviewed adult recipients of kidney transplant or simultaneous pancreas and kidney transplant at the University of Wisconsin between January 1, 1994 and December 31, 2016. Patients diagnosed with PJP during this time frame were included. Controls were randomly selected from among those whose post-transplant course was not complicated by PJP, matched on time since transplant through incidence density sampling with a 3:1 ratio. RESULTS: 28 (0.45%) of 6270 recipients developed PJP between 1994 and 2016. Median time since transplant was 4.6 years (interquartile range (IQR): 1.4-9.6 years). Affected recipients were older, had more HLA mismatches, and were more likely to have had BK viremia, CMV viremia and invasive fungal infections than matched controls. CMV viremia remained the only significant risk factor in multivariate analysis, and was a strong predictor (OR 6.27; p = 0.002). Ninety percent of the cases with prior CMV viremia had been diagnosed in the year preceding the diagnosis of PJP; among these, median time from diagnosis of CMV to diagnosis of PJP was 3.4 months (IQR: 1.74-11.5 months) and median peak CMV viral load prior to diagnosis of PJP was 3684.5 IU/mL (IQR: 1034-93,300 IU/mL). Additionally, 88.9% of patients with CMV in the preceding year had active infection at time of PJP diagnosis. Patient and graft survival were significantly worse at 2 years in recipients with PJP than our control group (42.4% vs. 88.5, and 37.9% vs. 79.9%; p < 0.001). CONCLUSIONS: Despite the low overall incidence of PJP in the era of universal prophylaxis, outcomes are poor. We suggest extending or re-initiating PJP prophylaxis for at least 6 months in the setting of CMV viremia due to the relatively low risk of therapy and potential significant impact on disease prevention.

Incidence of akathisia after postoperative nausea and vomiting prophylaxis with droperidol and ondansetron in outpatient surgery: A multicentre controlled randomised trial.

BACKGROUND: Akathisia, a distressing movement disorder induced by butyrophenones, has been described with low doses of droperidol used for postoperative nausea and vomiting (PONV) prophylaxis, but the incidence remains unclear. OBJECTIVES: To determine the incidence of akathisia after PONV prophylaxis with two doses of droperidol in comparison with ondansetron, in patients undergoing ambulatory surgery. We hypothesised that the incidence of akathisia is higher with droperidol than that with ondansetron. DESIGN: Randomised controlled double blind trial. SETTING: Two University Hospital Centres and two private Clinics from January to September 2014. PATIENTS: Patients (n=297) undergoing general anaesthesia for ambulatory surgery were randomly allocated to receive PONV prophylaxis with droperidol (0.625 or 1.25 mg) or ondansetron 4 mg; patients of the three groups also received 4 mg of dexamethasone. Exclusion criteria were contraindication to droperidol and ondansetron, use of psychotropic medications or benzodiazepines or history of psychotic illness. INTERVENTIONS: Participants received droperidol (0.625 or 1.25 mg) or ondansetron 4 mg during general anaesthesia. After discharge from the postanaesthesia care unit presence and severity of akathisia were assessed using the Barnes Akathisia Rating Scale at 4 h postoperatively. MAIN OUTCOME MEASURES: Score of the Global Clinical Assessment of Akathisia of Barnes Akathisia Rating Scale. RESULTS: The number of akathisia observed was 1/118 (0.8%) in the ondansetron group, 1/84 (1.2%) in droperidol 0.625 mg group, and 3/87 (3.4%) in droperidol 1.25 mg group. The akathisia rate difference among the three groups was not significant (P = 0.52). We could not demonstrate significant differences in the incidence of akathisia between the two doses of droperidol. The only case of marked akathisia treated with benzodiazepines was observed after droperidol 1.25 mg. CONCLUSION: The use of droperidol or ondansetron for PONV prophylaxis is associated to a low incidence of akathisia (0.8 to 3.4%) after general anaesthesia for ambulatory surgery. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01942343.

Length of Thromboprophylaxis in Patients Operated on for a High-Grade Glioma: A Retrospective Study.

OBJECTIVE: High-grade gliomas are associated with venous thromboembolism (VTE). This retrospective study with a parallel cohort design investigated influence of continuing prophylactic anticoagulation after discharge on rate of VTE and intracranial hemorrhage (ICH) in patients operated on for high-grade glioma. METHODS: Consecutive adult patients who underwent subtotal or gross total resection for high-grade glioma at a single institution were included. Multivariable logistic regression analysis was used to investigate the association between duration of thromboprophylaxis (dalteparin administered 21 days vs. 0-7 days) and occurrence of VTE and ICH within 21 or 90 days after surgery, corrected for known risk factors. RESULTS: Of 301 included patients, 166 received short-term thromboprophylaxis, and 135 received prolonged thromboprophylaxis. In multivariable analysis, prolonged thromboprophylaxis was not significantly associated with occurrence of VTE within 21 days (3.0% vs. 1.2%; P = 0.24) or 90 days (8.9% vs. 4.8%; P = 0.09) after surgery; however, prolonged prophylaxis was associated with occurrence of ICH (5.9% vs. 0.6%; P = 0.03). Additionally, immobility (P = 0.03) and high body mass index (P = 0.02) were associated with occurrence of VTE. CONCLUSIONS: Prophylactic anticoagulation for 21 days postoperatively was not associated with a decreased rate of VTE compared with thromboprophylaxis until discharge. ICH was more common with prolonged thromboprophylaxis. These results provide insufficient evidence to extend duration of prophylaxis beyond hospitalization. Large-scale randomized prospective studies are needed to clarify safety, efficacy, and optimal timing of postoperative thromboprophylaxis in patients with high-grade glioma.

Current Practice Trends for Use of Early Venous Thromboembolism Prophylaxis After Intracerebral Hemorrhage.

BACKGROUND: Venous thromboembolism (VTE) is common after intracerebral hemorrhage (ICH). Guidelines recommend early VTE prophylaxis. OBJECTIVE: To determine characteristics associated with early chemoprophylaxis (CP) after ICH in the Get With The Guidelines-Stroke registry. METHODS: In this observational cohort study, we identified patients with ICH between January 1, 2009 and September 30, 2013, who (1) were non-ambulatory and/or not comfort care measures by hospital day 2; (2) were not transferred to another acute care facility; and (3) had known VTE prophylaxis status at end of hospital day 2. Categories for VTE prophylaxis were as follows: (1) mechanical non-CP or (2) CP with or without mechanical prophylaxis. Early prophylaxis was defined as occurring by hospital day 2. Using multivariable logistic regression, we assessed patient, hospital, and geographic factors independently associated with early CP use. RESULTS: Among 74 283 patients with ICH from 1358 hospitals, 5929 (7.9%) received early CP, 66 444 (89.4%) received early mechanical/non-CP, and 1910 (2.6%) had no prophylaxis, mechanical or CP, within the first 2 days. There was no increase in early CP use over the study period; 60% of hospitals provided early CP to <9% of patients. In multivariable analysis, female sex, atrial fibrillation, diabetes, coronary, carotid, and peripheral artery disease, prior ischemic stroke or transient ischemic attack, hospital size >500 beds, and geographic region were independently associated with early vs no early CP use. CONCLUSION: Nationwide, the large majority of ICH patients receive early mechanical VTE prophylaxis only, without CP. Patient comorbidities and hospital characteristics such as geographic location are determinants of higher use of early CP.

Comparison of different therapeutic strategies for complete hydatidiform mole in women at least 40 years old: a retrospective cohort study.

BACKGROUND: There are three main therapeutic strategies, namely expectant management (dilation and curettage only), prophylactic chemotherapy and prophylactic total hysterectomy for treating older women with complete hydatidiform mole (CHM). However, the scientific community has so far, not unanimously accepted the above-mentioned methods. The objective of this study was to evaluate the effectiveness of these therapeutic strategies in preventing post-molar gestational trophoblastic neoplasia (GTN) pertaining to patients with CHM who were at least 40 years old. METHODS: Hundred and seventy-one patients from our hospital who had histologically been diagnosed of CHM and underwent treatment from January 2004 to December 2013 were included. All patients were followed continuously for a minimum of 2 years after which relevant clinical data were extracted and analysed. RESULTS: All patients were divided to three groups. Group 1 consisted of 124 patients, treated by expectant management, and the incidence of post-molar GTN was 37.1%. Group 2 included 12 patients who received prophylactic chemotherapy, with an incidence of 41.7%. The remaining 35 patients, Group 3, underwent prophylactic total hysterectomy, with the lowest incidence of 11.4%. A significantly lower incidence was noted in group 3 as compared to group 1 (P = 0.004). GTN patients who received prophylactic chemotherapy required, on average, longer time to be diagnosed of GTN and had higher probability of chemotherapy resistance (P = 0.031 and P = 0.024). CONCLUSIONS: This retrospective analysis showed that prophylactic total hysterectomy was the most effective therapeutic strategy for treating CHM in women at least 40 years old of age.

The National Practice Patterns of Venous Thromboembolism Prophylaxis Post-Cardiothoracic Surgery.

BACKGROUND: The rates of venous thromboembolism (VTE) post-cardiothoracic surgery are not well understood. The american college of chest physicians (CHEST) guidelines report weak recommendations for starting VTE prophylaxis post-cardiothoracic surgery. It is suspected that due to the increase in bleed risk, postsurgery initiation of pharmacologic VTE prophylaxis is limited. OBJECTIVE: The study sought to investigate the use of VTE prevention in US hospitals performing cardiac surgery and the use of mechanical/chemical prophylaxis postoperatively. METHODS: This is a multicenter survey distributed to cardiac hospitals in the United States. The survey was distributed through 3 separate listservs. Data were analyzed utilizing descriptive statistics. RESULTS: The majority of the hospitals were academic and/or community and completed coronary artery bypass graft (CABG), valve replacement (mitral/aortic/tricuspid), and aortic repair. It was common for hospitals to start mechanical and pharmacologic prophylaxis post-cardiothoracic surgery on postoperative day (POD) 1 to 2. The anticoagulation most commonly used consisted of unfractionated heparin. CONCLUSIONS: The majority of the institutions are initiating therapy POD 1 to 2 with both mechanical and chemical prophylaxis. The full impact of early initiation of VTE prophylaxis is unknown, and more studies are needed to assess the true risks/benefits of these practices.