Comparación de cambios clínicos y hemodinámicos en pacientes con insuficiencia venosa mixta según tipo de manejo.

Existen varias causas de la insuficiencia venosa profunda, la insuficiencia venosa superficial es una de ellas; por tal motivo, una intervención activa de la insuficiencia superficial ya sea cirugía convencional, esclerosis o radiofrecuencia mejora el reflujo del sistema venoso profundo. En nuestro medio no se acostumbra a intervenir los pacientes con insuficiencia venosa mixta bajo la creencia de exacerbar la enfermedad o generar complicaciones. Se pretende documentar los cambios clínicos y hemodinámicos en pacientes con insuficiencia venosa mixta según tipo de manejo, médico vs quirúrgico

Hallazgos radiológicos de la enfermedad pulmonar en pacientes Colombianos con esclerodermia

La esclerosis sistémica (ES) es una enfermedad autoinmune multisistémica que afecta principalmente la piel, los pulmones, el tracto gastrointestinal, el corazón y los riñones. La enfermedad pulmonar, presente en casi el 100% de los casos, es el factor con mayor influencia en la mortalidad. El propósito de este estudio es realizar un análisis detallado de la enfermedad pulmonar por tomografía computarizada de alta resolución(TCAR) en pacientes Colombianos con ES, para lo cual se realizó un estudio de prevalencia analítica en 44 pacientes con ES valorados en el Hospital Universitario Mayor Méderi en los últimos 7 años. Los resultados mostraron características demográficas y clínicas similares a las previamente descritas. La prevalencia de enfermedad pulmonar intersticial fue alta, y los hallazgos de fibrosis pulmonar como vidrio esmerilado y panal de abejas se asociaron con la presencia del autoanticuerpo antiSCL70. La medida del diámetro esofágico por TCAR fue mayor en los pacientes con disfagia, antiSCL 70 y linfopenia, los cuales son marcadores de mal pronóstico.

Who, when and where? Identification of patients at risk of an in-hospital adverse event: Implications for nursing practice

Patients who suffer an adverse event (AE) are more likely to die or suffer permanent disability. Many AEs are preventable. Nurses have long played a pivotal role in the prevention of AEs. Much of the literature to date pertains to the role of nurses in the prevention of AEs such as falls, pressure areas and deep vein thrombosis. Prominent risk factors for AEs are the presence of physiological abnormality, failure to recognize or correct physiological abnormality, advanced patient age and location of patient room. Ongoing physiological assessment of patients is a nursing responsibility and the assessment findings of nurses underpin many patient care decisions. The early recognition and correction of physiological abnormality can improve patient outcomes by reducing the incidence of AEs, making nurses' ability to identify, interpret and act on physiological abnormality a fundamental factor in AE prediction and prevention. This paper will examine the role of nurses in AE prevention, using cardiac arrest as an example, from the perspective of physiological safety; that is, accurate physiological assessment and the early correction of physiological abnormality.

Cost-effectiveness of dalteparin vs unfractionated heparin for the prevention of venous thromboembolism in critically ill patients

Venous thromboembolism (VTE) is a common complication of acute illness, and its prevention is a ubiquitous aspect of inpatient care. A multicenter blinded, randomized trial compared the effectiveness of the most common pharmocoprevention strategies, unfractionated heparin (UFH) and the low-molecular-weight heparin (LMWH) dalteparin, finding no difference in the primary end point of leg deep-vein thrombosis but a reduced rate of pulmonary embolus and heparin-induced thrombocytopenia among critically ill medical-surgical patients who received dalteparin.

Ximelagatran versus warfarin for prophylaxis of venous thromboembolism in major orthopedic surgery: systematic review of randomized controlled trials

INTRODUÇÃO: O ximelagatrano foi recentemente estudada para profilaxia do tromboembolismo venoso (TEV). OBJETIVO: Avaliar se o ximelagatrano comparado com a varfarina melhora a profilaxia do TEV em pacientes submetidos à cirurgia ortopédica do joelho. FONTE DE DADOS: Estudos randomizados identificados por pesquisa eletrônica na literatura médica, até 2006, cujos dados foram compilados no programa Review Manager, versão 4.2.5. RESULTADOS: Foram incluídos três estudos randomizados bem conduzidos envolvendo 4.914 participantes. Foram definidos dois sub-grupos com dosagens diferentes de ximelagatrano (24 mg and 36 mg, duas vezes ao dia). O tratamento com ximelagatrano mostrou freqüência significantemente menor de TEV que o tratamento com varfarina, mas somente na dosagem de 36-mg [risco relativo, RR 0.72 ([intervalo de confiança, IC, 95% 0.64, 0.81), p < 0.00001]. A freqüência de TEV no sub-grupo de 24-mg foi similar a da varfarina [RR 0.86 (IC 95% 0.73, 1.01), p = 0.06]. Para TEV maior, embolia pulmonar, sangramento e sangramento maior não houve diferença entre varfarina e a ximelagatrano. Ao final do tratamento, a elevação da alanino-aminotransferase (ALT) foi menos freqüente no sub-grupo de 24 mg de ximelagatrano que no grupo da varfarina [RR 0.33 (IC 95% 0.12, 0.91) p = 0.03], mas no período de acompanhamento essa elevação foi maior com 36 mg de ximelagatrano [RR 6.97 (IC 95% 1.26, 38.50) p = 0.03]. CONCLUSÃO: O ximelagatrano foi mais efetivo que a varfarina quando usado em dosagens maiores (36 mg, 2 vezes ao dia), mas às expensas de aumento de enzimas hepáticas no período de acompanhamento.

Trombose venosa profunda de membros superiores: estudo coorte retrospectivo de 52 casos

OBJETIVO: Rever os fatores predisponentes e a evolução em série de casos de trombose venosa profunda dos membros superiores de nossa instituição. MÉTODOS: Cinqüenta e dois pacientes consecutivos, com trombose venosa profunda dos membros superiores (29 homens e 23 mulheres), idade média de 52,3 anos, documentados por mapeamento dúplex (71,1%), flebografia (11,1%) ou clinicamente (15,6%), foram incluídos no presente estudo. RESULTADOS: As manifestações clínicas foram: dor no antebraço (24 casos - 46,1%), dor no braço (27 casos - 51,9%), edema do membro superior (45 casos - 86,5%), dor à compressão do membro superior (36 casos - 70,2%) e dor à movimentação do mesmo (32 casos - 61,7%). Os principais fatores de risco foram: punção ou acesso venoso (20 casos - 39,1%) e câncer (16 casos - 32,6%). As veias envolvidas foram: umeral (n = 18), axilar (n = 27), subclávia (n = 15) e jugular (n = 11). A embolia pulmonar estava inicialmente presente em quatro casos (7,6%). O tratamento inicial foi feito com heparina não-fracionada intravenosa (64,3%), subcutânea (16,7%), ou heparina de baixo peso molecular (17,1%), seguido de varfarina. Doze pacientes morreram antes da alta, em função de causas não relacionadas à embolia pulmonar. Foram acompanhados os 40 pacientes restantes por período de 3 meses a 10 anos, sendo que dois morreram de causas não relacionadas à embolia pulmonar, um paciente desenvolveu seqüelas pós-trombóticas, como edema residual e limitações aos movimentos, e seis ficaram com discretos sintomas residuais (edema e dor). CONCLUSÕES: A trombose venosa profunda dos membros superiores foi mais freqüente em pacientes submetidos a acessos venosos e com neoplasia em atividade. Comparando com dados da literatura, a evolução dos pacientes sob tratamento exclusivo com anticoagulantes foi, no mínimo, similar a outros tratamentos propostos.

O papel do mapeamento dúplex no diagnóstico da trombose venosa profunda assintomática dos membros inferiores

O diagnóstico da trombose venosa profunda sintomática está bem estabelecido com o uso do mapeamento dúplex, que apresenta sensibilidade de 100% e especificidade de 98%, para trombose venosa profunda proximal, e sensibilidade de 94% e especificidade de 75%, para distal. Na trombose venosa profunda recente e assintomática, o diagnóstico com o mapeamento dúplex ainda não está bem estabelecido, mostrando uma queda na acurácia desse método diagnóstico. Essa queda é devida ao fato de o trombo recente não ser oclusivo, apresentar a mesma ecogenicidade do sangue e uma consistência diminuída, prejudicando o teste da compressibilidade, que é o mais sensível para diagnóstico da trombose venosa profunda. Nesta revisão, serão revistos artigos publicados que avaliaram a acurácia do mapeamento dúplex no diagnóstico da trombose venosa profunda assintomática.

Estudo comparativo entre protocolos para profilaxia da trombose venosa profunda: uma nova proposta

INTRODUÇÃO: O artigo compara os protocolos Davison-Caprini (americano) e Sandri (brasileiro) para profilaxia da trombose venosa profunda (TVP), buscando a elaboração de um novo protocolo, mais abrangente e aplicável. MÉTODO: Foi realizado um estudo prospectivo, durante um ano, abrangendo 212 pacientes, comparando os protocolos quanto à estratificação de risco de TVP, e ao tipo de profilaxia indicado. Um novo protocolo foi proposto, aplicado e comparado aos anteriores. RESULTADOS: Obteve-se um novo protocolo, denominado Sandri modificado, que restringe a heparina a um grupo seleto de pacientes, semelhante ao americano, mantendo-se adequado tanto para cirurgias estéticas quanto reparadoras. CONCLUSÕES: A baixa adesão, por parte dos cirurgiões plásticos, ao uso rotineiro da profilaxia de TVP, espelha a escassez de informação sobre o tema. O protocolo Sandri modificado busca melhorar a compreensão e a aplicabilidade da profilaxia da TVP na cirurgia plástica.

Intermolecular interactions and characterization of the novel factor Xa exosite involved in macromolecular recognition and inhibition: Crystal structure of human Gla-domainless factor Xa complexed with the anticoagulant protein NAPc2 from the hematophagous nematode Ancylostoma caninum

NAPc2, an anticoagulant protein from the hematophagous nematode Ancylostoma caninum evaluated in phase-II/IIa clinical trials, inhibits the extrinsic blood coagulation pathway by a two step mechanism, initially interacting with the hitherto uncharacterized factor Xa exosite involved in macromolecular recognition and subsequently inhibiting factor VIIa (K-i = 8.4 pM) of the factor VIIa/tissue factor complex. NAPc2 is highly flexible, becoming partially ordered and undergoing significant structural changes in the C terminus upon binding to the factor Xa exosite. In the crystal structure of the ternary factor Xa/NAPc2/selectide complex, the binding interface consists of an intermolecular antiparallel beta-sheet formed by the segment of the polypeptide chain consisting of residues 74-80 of NAPc2 with the residues 86-93 of factor Xa that is additional maintained by contacts between the short helical segment (residues 67-73) and a turn (residues 26-29) of NAPc2 with the short C-terminal helix of factor Xa (residues 233-243). This exosite is physiologically highly relevant for the recognition and inhibition of factor X/Xa by macromolecular substrates and provides a structural motif for the development of a new class of inhibitors for the treatment of deep vein thrombosis and angioplasty. (c) 2006 Elsevier Ltd. All rights reserved.

Abordagem diagnóstica dos pacientes com suspeita de trombose venosa profunda dos membros inferiores

Deep venous thrombosis is a relatively common disease, which can present pulmonary embolism as a complication in its acute phase, and later the post-thrombotic syndrome. Thus, diagnosis should be made as soon as possible, in order to prevent or minimize such complications. Several studies have shown that the symptoms and the clinical signs are inaccurate for the deep venous thrombosis diagnosis and that complementary exams are necessary. As an attempt to simplify the patients' assessment, Well et al., in 1997, developed a clinical prediction index that combines symptoms, signs and risk factors for deep venous thrombosis and managed to make a simpler approach through an association of this index with the complementary exams. Phlebography has been considered the gold standard of complementary exams. However, since it is an invasive exam and thus subject to complications, other diagnostic methods were introduced aiming at making the diagnostic approach simpler and less invasive. Doppler ultrasound, duplex scan, impedance plethysmography, computed tomography, and blood tests such as the D-dimer are some of the available methods for assessing the patient with suspicion of deep venous thrombosis. Among them, duplex scan has shown excellent accuracy and it is currently widely accepted as the first choice test for approaching the patient with deep venous thrombosis. Several authors have suggested an association of diagnostic methods to simplify and make the assessment of such patients more cost-effective, leading to the introduction of a wide range of diagnostic strategies. The different diagnostic methods used for assessing deep venous thrombosis are discussed, as well as a review of the literature on the accuracy, advantages and disadvantages of these methods. Copyright © 2005 by Sociedade Brasileira de Angiologia e Cirurgia Vascular.

Risk-assessment algorithm and recommendations for venous thromboembolism prophylaxis in medical patients

The risk for venous thromboembolism (VTE) in medical patients is high, but risk assessment is rarely performed because there is not yet a good method to identify candidates for prophylaxis. Purpose: To perform a systematic review about VTE risk factors (RFs) in hospitalized medical patients and generate recommendations (RECs) for prophylaxis that can be implemented into practice. Data sources: A multidisciplinary group of experts from 12 Brazilian Medical Societies searched MEDLINE, Cochrane, and LILACS. Study selection: Two experts independently classified the evidence for each RF by its scientific quality in a standardized manner. A risk-assessment algorithm was created based on the results of the review. Data synthesis: Several VTE RFs have enough evidence to support RECs for prophylaxis in hospitalized medical patients (eg, increasing age, heart failure, and stroke). Other factors are considered adjuncts of risk (eg, varices, obesity, and infections). According to the algorithm, hospitalized medical patients ≥40 years-old with decreased mobility, and ≥1 RFs should receive chemoprophylaxis with heparin, provided they don't have contraindications. High prophylactic doses of unfractionated heparin or low-molecular-weight-heparin must be administered and maintained for 6-14 days. Conclusions: A multidisciplinary group generated evidence-based RECs and an easy-to-use algorithm to facilitate VTE prophylaxis in medical patients. © 2007 Rocha et al, publisher and licensee Dove Medical Press Ltd.

The Ped-APS registry: The antiphospholipid syndrome in childhood

In recent years, antiphospholipid syndrome (APS) has been increasingly recognised in various paediatric autoimmune and nonautoimmune diseases, but the relatively low prevalence and heterogeneity of APS in childhood made it very difficult to study in a systematic way. The project of an international registry of paediatric patients with APS (the Ped-APS Registry) was initiated in 2004 to foster and conduct multicentre, controlled studies with large number of paediatric APS patients. The Ped-APS Registry is organised as a collaborative project of the European Forum on Antiphospholipid Antibodies and Juvenile Systemic Lupus Erythematosus Working Group of the Paediatric Rheumatology European Society. Currently, it documents a standardised clinical, laboratory and therapeutic data of 133 children with antiphospholipid antibodies (aPL)-related thrombosis from 14 countries. The priority projects for future research of the Ped-APS Registry include prospective enrolment of new patients with aPL-related thrombosis, assessment of differences between the paediatric and adult APS, evaluation of proinflammatory genotype as a risk factor for APS manifestations in childhood and evaluation of patients with isolated nonthrombotic aPL-related manifestations. © The Author(s), 2009.

Significância clínica de tromboembolismo venoso recorrente

Recurrent venous thromboembolism is a significant problem leading to increased morbidity and mortality. It has a high impact on patients' quality of life and imposes a great financial burden on society. Cumulative recurrence has been reported as 40% at 10 years, while the chance of developing postthrombotic signs and symptoms in the lower extremities almost quadruples when ipsilateral. There is also a higher chance of developing pulmonary hypertension. Important factors for recurrence are unprovoked episodes of deep vein thrombosis, malignancy and older age. The evidence for other factors is controversial. Accurate diagnosis and treatment tailored to the patients' history, thrombotic events and risk factors are necessary to optimize management and prevent recurrence.

Systematic review of randomized controlled trials of new anticoagulants for venous thromboembolism prophylaxis in major orthopedic surgeries, compared with enoxaparin

Background: In the past 10 years, new anticoagulants (NACs) have been studied for venous thromboembolism (VTE) prophylaxis. Objective: To evaluate the risk/benefit profile of NACs versus enoxaparin for VTE prophylaxis in major orthopedic surgery. Methods: A systematic review of double-blind randomized phase III studies was performed. The search strategy was run from 2000 to 2011 in the main medical electronic databases in any language. Independent extraction of articles was performed by 2 authors using predefined data fields, including study quality indicators. Results: Fifteen published clinical trials evaluating fondaparinux, rivaroxaban, dabigatran, and apixaban were included. Primary efficacy (any deep vein thrombosis [DVT], nonfatal pulmonary embolism, or all-cause mortality) favored fondaparinux (relative risk [RR] 0.50; 95% CI, 0.39, 0.63) and rivaroxaban (RR, 0.50; 95% CI, 0.34, 0.73) over enoxaparin, although significant heterogeneity was observed in both series. The primary efficacy of dabigatran at 220 mg, apixaban, and bemiparin were similar, with RRs of 1.02 (95% CI, 0.86, 1.20), 0.63 (95% CI, 0.39, 1.01), and 0.87 (95% CI, 0.65, 1.17), respectively. The primary efficacy of dabigatran at 150 mg (RR, 1.20; 95% CI, 1.03, 1.41), was inferior to enoxaparin. The incidence of proximal DVT favored apixaban (RR, 0.45; 95% CI, 0.27, 0.75) only. Rivaroxaban (RR, 0.45; 95% CI, 0.27, 0,77) and apixaban (RR, 0.38; 95% CI, 0.16, 0.90) produced significantly lower frequencies of symptomatic DVT. The incidence of major VTE favored rivaroxaban (RR, 0.44; 95% CI, 0.25, 0.81), only. Bleeding risk was similar for all NACs, except fondaparinux (RR, 1.27; 95% CI, 1.04, 1.55), which exhibited a significantly higher any-bleeding risk compared with enoxaparin, and apixaban (RR, 0.88; 95% CI, 0.79, 0.99), which was associated with a reduced risk of any bleeding. Alanine amino transferase was significantly lower with 220 mg of dabigatran, (RR, 0.67; 95% CI, 0.79, 0.99) than with enoxaparin. Conclusions: NACs can be considered alternatives to conventional thromboprophylaxis regimens in patients undergoing elective major orthopedic surgery, depending on clinical characteristics and cost-effectiveness. The knowledge of some differences concerning efficacy or safety profile, pointed out in this systematic review, along with the respective limitations, may be useful in clinical practice. © 2013 Elsevier Inc. All rights reserved.