Profilaxia do tromboembolismo venoso em cirurgia ortopédica

A importância da profilaxia do tromboembolismo venoso e de suas complicações em cirurgia ortopédica é cada vez mais significativa. Esta revisão aborda as bases fisiopatológicas da formação dos trombos em geral e em cirurgia ortopédica, sua incidência, fatores predisponentes e complicações. Apresenta, ainda, uma abordagem atualizada e crítica dos meios de profilaxia atualmente disponíveis em nosso meio.

Infective endocarditis with left to right intracardiac fistula due to Streptococcus anginosus - a rare complication caused by an even rarer bacterium

Although infective endocarditis (IE) has been described in reports dating from the Renaissance, the diagnosis still challenges and the outcome often surprises. In the course of time, diagnostic criteria have been updated and validated to reduce misdiagnosis. Some risk factors and epidemiology have shown dynamic changes since degenerative valvular disease became more predominant in developed countries, and the mean age of the affected population increased. Despite streptococci have been being well known as etiologic agents, some groups, although rare, have been increasingly reported (e.g., Streptococcus milleri.) Intracardiac complications of IE are common and have a worse prognosis, frequently requiring surgical treatment. We report a case of a middle-aged diabetic man who presented with prolonged fever, weight loss, and ultimately severe dyspnea. IE was diagnosed based on a new valvular regurgitation murmur, a positive blood culture for Streptococcus anginosus, an echocardiographic finding of an aortic valve vegetation, fever, and pulmonary thromboembolism. Despite an appropriate antibiotic regimen, the patient died. Autopsy findings showed vegetation attached to a bicuspid aortic valve with an associated septal abscess and left ventricle and aortic root fistula connecting with the pulmonary artery. A large thrombus was adherent to the pulmonary artery trunk and a pulmonary septic thromboemboli were also identified.

Compressão pneumática intermitente na prevenção de trombose venosa profunda em pacientes cirúrgicos: revisão sistemática e metanálise

Introdução: Trombose Venosa Profunda (TVP) é o resultado de inúmeros fatores, incluindo estase venosa, injuria endotelial e hipercoagulação do sangue. O embolismo pulmonar é a maior complicação da TVP e ocorre quando um trombo ou um coágulo sangüíneo desloca-se em direção aos pulmões. O tromboembolismo é um sério problema de saúde e é responsável por um considerável número de mortes súbitas e por significantes custos de hospitalizações em todo o mundo. Entre os métodos profiláticos usados na prevenção da TVP, há os classificados como mecânicos e os farmacológicos. Ambos são efetivos e podem ser usados sempre que necessário, tendo sido recomendados por consenso internacional. Objetivos: Avaliar a incidência da TVP em pacientes cirúrgicos através da Compressão pneumática Intermitente CPI (coxa/perna ou perna/pé) contra nenhuma forma de profilaxia ou contra fármacos. Métodos: Revisão sistemática de ensaios clínicos randomizados, utilizando a metodologia Cochrane, através de buscas eletrônica e manual. Foram incluídos pacientes cirúrgicos, de ambos os sexos, cuja intervenção foi o uso de aparelhos de compressão pneumática intermitente. Resultados: 4269 pacientes cirúrgicos investigados por 31 ensaios submetidos a um número de intervenções cirúrgicas, incluindo cirurgia ortopédica (joelho e quadris), geral, ginecológica, urológica e neurológica. Dados combinados demonstraram efeitos de tratamento virtualmente iguais entre CPI e abordagens farmacológicas [0.95 (95%CI 0.82, 1.10)], em relação à incidência de TVP. Entretanto, o risco de hemorragia foi maior e estatisticamente significante em pacientes tratados com intervenções farmacológicas [0.37(95%CI 0.20, 0.69)]. Conclusão: Comparações entre as estratégias farmacológicas e mecânicas indicam que ambas são similares na prevenção de trombose venosa profunda. Entretantio, a evidência atual suportaria a escolha das abordagens mecâncias, uma vez que o risco de eventos hemorrágicos favorece os métodos mecânicos.

Proteinuria e sindrome nefrosica nel cane: studio reptrospettivo di 338 casi

La sindrome nefrosica (SN) è definita come la presenza concomitante di una proteinuria maggiore di 3.5g/24 h, ipoalbuminemia, ipercolesterolemia e presenza di edemi. I pazienti con SN sono più a rischio di quelli che presentano una nefropatia glomerulare non nefrosica (NNGD) per lo sviluppo di ipertensione, ipernatremia, complicazioni tromboemboliche e comparsa di insufficienza renale. In Medicina Veterinaria, la Letteratura riguardante l’argomento è molto limitata e non è ben nota la correlazione tra SN e gravità della proteinuria, ipoalbuminemia e sviluppo di tromboembolismo. L’obiettivo del presente studio retrospettivo è stato quello di descrivere e caratterizzare le alterazioni cliniche e clinicopatologiche che si verificano nei pazienti con rapporto proteine urinarie:creatinina urinaria (UPC) >2 con lo scopo di inquadrare con maggiore precisione lo stato clinico di questi pazienti e individuare le maggiori complicazioni a cui possono andare incontro. In un periodo di nove anni sono stati selezionati 338 cani e suddivisi in base ad un valore cut-off di UPC≥3.5. Valori mediani di creatinina, urea, fosforo, albumina urinaria, proteina C reattiva (CRP) e fibrinogeno sono risultati al di sopra del limite superiore dell’intervallo di riferimento, valori mediani di albumina sierica, ematocrito, antitrombina al disotto del limite inferiore di riferimento. Pazienti con UPC≥3.5 hanno mostrato concentrazioni di albumine, ematocrito, calcio, Total Iron Binding Capacity (TIBC), significativamente minori rispetto a quelli con UPC<3.5, concentrazioni di CRP, di urea e di fosforo significativamente maggiori. Nessuna differenza tra i gruppi nelle concentrazioni di creatinina colesterolo, trigliceridi, sodio, potassio, cloro, ferro totale e pressione sistolica. I pazienti con UPC≥3.5 si trovano verosimilmente in uno “stato infiammatorio” maggiore rispetto a quelli con UPC<3.5, questa ipotesi avvalorata dalle concentrazioni minori di albumina, di transferrina e da una concentrazione di CRP maggiore. I pazienti con UPC≥3.5 non presentano concentrazioni di creatinina più elevate ma sono maggiormente a rischio di anemia.

Untersuchung zur Therapie akuter venöser Thromboembolien mit niedermolekularen Heparinen (NMH)

Über einen Zeitraum von 14 Monaten wurden Patienten mit akuter, duplexsonographisch nachgewiesener tiefer Beinvenenthrombose erfasst und im initialen Behandlungszeitraum mit niedermolekularem Heparin (Enoxaparin) sowie im weiteren Verlauf überlappend mit Marcumar® therapiert. Erhoben wurden eine ausführliche, standardisierte Eigen- sowie Familienanamnese und die Risikofaktoren für eine TVT. Desweiteren wurde eine klinische Untersuchung inklusive Duplexsonographie der Venen und eine Thrombophiliediagnostik durchgeführt. Täglich erfolgte die Bestimmung diverser Laborparameter (INR, APTT, D-Dimere, CRP, kleines Blutbild). Am ersten und fünften Tag wurden zusätzlich die Transaminasen bestimmt. Nach 30 Tagen erfolgte eine klinische Verlaufskontrolle, nach drei Monaten eine ambulante Kontrollduplexsonographie. Diskutiert werden Enoxaparin-Nebenwirkungen, Verläufe der duplexsonographisch erhobenen Befunde und klinischen Symptome, die Thrombophiliediagnostik sowie Laborverläufe der Infekt- und Gerinnungsparameter (APTT, INR, D-Dimere). Die D-Dimerverläufe und die Bedeutung der sinnvollen D-Dimerbestimmung wurden bereits auf mehreren Tagungen vorgestellt.

Impact of obesity on venous hemodynamics of the lower limbs

Obesity is a risk factor for chronic venous insufficiency and venous thromboembolism. The aim of this study was to compare venous flow parameters of the lower limbs assessed by duplex ultrasound scanning in obese and nonobese individuals according to body mass index (BMI).

American Society of Clinical Oncology/American Society of Hematology clinical practice guideline update on the use of epoetin and darbepoetin in adult patients with cancer

Purpose To update American Society of Clinical Oncology/American Society of Hematology recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. Methods An Update Committee reviewed data published between January 2007 and January 2010. MEDLINE and the Cochrane Library were searched. Results The literature search yielded one new individual patient data analysis and four literature-based meta-analyses, two systematic reviews, and 13 publications reporting new results from randomized controlled trials not included in prior or new reviews. Recommendations For patients undergoing myelosuppressive chemotherapy who have a hemoglobin (Hb) level less than 10 g/dL, the Update Committee recommends that clinicians discuss potential harms (eg, thromboembolism, shorter survival) and benefits (eg, decreased transfusions) of ESAs and compare these with potential harms (eg, serious infections, immune-mediated adverse reactions) and benefits (eg, rapid Hb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. The Committee cautions against ESA use under other circumstances. If used, ESAs should be administered at the lowest dose possible and should increase Hb to the lowest concentration possible to avoid transfusions. Available evidence does not identify Hb levels � 10 g/dL either as thresholds for initiating treatment or as targets for ESA therapy. Starting doses and dose modifications after response or nonresponse should follow US Food and Drug Administration–approved labeling. ESAs should be discontinued after 6 to 8 weeks in nonresponders. ESAs should be avoided in patients with cancer not receiving concurrent chemotherapy, except for those with lower risk myelodysplastic syndromes. Caution should be exercised when using ESAs with chemotherapeutic agents in diseases associated with increased risk of thromboembolic complications. Table 1 lists detailed recommendations. This guideline was developed through a collaboration between the American Society of Clinical Oncology and the American Society of Hematology and has been published jointly by invitation and consent in both Journal of Clinical Oncology and Blood.

American Society of Hematology/American Society of Clinical Oncology clinical practice guideline update on the use of epoetin and darbepoetin in adult patients with cancer

Purpose: To update American Society of Hematology/American Society of Clinical Oncology recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. Methods: An Update Committee reviewed data published between January 2007 and January 2010. MEDLINE and the Cochrane Library were searched. Results: The literature search yielded one new individual patient data analysis and four literature-based meta-analyses, two systematic reviews, and 13 publications reporting new results from randomized controlled trials not included in prior or new reviews. Recommendations: For patients undergoing myelosuppressive chemotherapy who have a hemoglobin (Hb) level less than 10 g/dL, the Update Committee recommends that clinicians discuss potential harms (eg, thromboembolism, shorter survival) and benefits (eg, decreased transfusions) of ESAs and compare these with potential harms (eg, serious infections, immune-mediated adverse reactions) and benefits (eg, rapid Hb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. The Committee cautions against ESA use under other circumstances. If used, ESAs should be administered at the lowest dose possible and should increase Hb to the lowest concentration possible to avoid transfusions. Available evidence does not identify Hb levels 10 g/dL either as thresholds for initiating treatment or as targets for ESA therapy. Starting doses and dose modifications after response or nonresponse should follow US Food and Drug Administration-approved labeling. ESAs should be discontinued after 6 to 8 weeks in nonresponders. ESAs should be avoided in patients with cancer not receiving concurrent chemotherapy, except for those with lower risk myelodysplastic syndromes. Caution should be exercised when using ESAs with chemotherapeutic agents in diseases associated with increased risk of thromboembolic complications. Table 1 lists detailed recommendations.

The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism

We compared the test characteristics of the shock index (SI) and the simplified pulmonary embolism severity index (sPESI) for predicting 30-day outcomes in a cohort of 1,206 patients with objectively confirmed pulmonary embolism (PE). The primary outcome of the study was all-cause mortality. The secondary outcome was nonfatal symptomatic recurrent venous thromboembolism (VTE) or nonfatal major bleeding. Overall, 119 (9.9%) out of 1,206 patients died (95% CI 8.2-11.5%) during the first month of follow-up. The sPESI classified fewer patients as low-risk (369 (31%) out of 1,206 patients, 95% CI 28-33%) compared to the SI (1,024 (85%) out of 1,206 patients, 95% CI 83-87%) (p<0.001). Low-risk patients based on the sPESI had a lower 30-day mortality than those based on the SI (1.6% (95% CI 0.3-2.9%) versus 8.3% (95% CI 6.6-10.0%)), while the 30-day rate of nonfatal recurrent VTE or major bleeding was similar (2.2% (95%CI 0.7-3.6%) versus 3.3% (95%CI 2.2-4.4%)). The net reclassification improvement with the sPESI was 13.4% (p = 0.07). The integrated discrimination improvement was estimated as 1.8% (p<0.001). The sPESI quantified the prognosis of patients with PE better than the SI.

Rivaroxaban: Quantification by anti-FXa assay and influence on coagulation tests A study in 9 Swiss laboratories

INTRODUCTION: Rivaroxaban (RXA) is licensed for prophylaxis of venous thromboembolism after major orthopaedic surgery of the lower limbs. Currently, no test to quantify RXA in plasma has been validated in an inter-laboratory setting. Our study had three aims: to assess i) the feasibility of RXA quantification with a commercial anti-FXa assay, ii) its accuracy and precision in an inter-laboratory setting, and iii) the influence of 10mg of RXA on routine coagulation tests. METHODS: The same chromogenic anti-FXa assay (Hyphen BioMed) was used in all participating laboratories. RXA calibrators and sets of blinded probes (aim ii.) were prepared in vitro by spiking normal plasma. The precise RXA content was assessed by high-pressure liquid chromatography-tandem mass spectrometry. For ex-vivo studies (aim iii), plasma samples from 20 healthy volunteers taken before and 2 - 3hours after ingestion of 10mg of RXA were analyzed by participating laboratories. RESULTS: RXA can be assayed chromogenically. Among the participating laboratories, the mean accuracy and the mean coefficient of variation for precision of RXA quantification were 7.0% and 8.8%, respectively. Mean RXA concentration was 114±43?g/L .RXA significantly altered prothrombin time, activated partial thromboplastin time, factor analysis for intrinsic and extrinsic factors. Determinations of thrombin time, fibrinogen, FXIII and D-Dimer levels were not affected. CONCLUSIONS: RXA plasma levels can be quantified accurately and precisely by a chromogenic anti-FXa assay on different coagulometers in different laboratories. Ingestion of 10mg RXA results in significant alterations of both PT- and aPTT-based coagulation assays.

Prospective comparison of clinical prognostic scores in elderly patients with pulmonary embolism

Background: The Geneva Prognostic Score (GPS), the Pulmonary Embolism Severity Index (PESI), and its simplified version (sPESI) are well known clinical prognostic scores for pulmonary embolism (PE).Objectives: To compare the prognostic performance of these scores in elderly patients with PE. Patients/Methods: In a multicenter Swiss cohort of elderly patients with venous thromboembolism, we prospectively studied 449 patients aged ≥65 years with symptomatic PE. The outcome was 30-day overall mortality. We dichotomized patients as low- vs. higher-risk in all three scores using the following thresholds: GPS scores ≤2 vs. >2, PESI risk classes I-II vs. III-V, and sPESI scores 0 vs. ≥1. We compared 30-day mortality in low- vs. higher-risk patients and the areas under the receiver operating characteristic curve (ROC). Results: Overall, 3.8% of patients (17/449) died within 30 days. The GPS classified a greater proportion of patients as low risk (92% [413/449]) than the PESI (36.3% [163/449]) and the sPESI (39.6% [178/449]) (P<0.001 for each comparison). Low-risk patients based on the sPESI had a mortality of 0% (95% confidence interval [CI] 0-2.1%) compared to 0.6% (95% CI 0-3.4%) for low-risk patients based on the PESI and 3.4% (95% CI 1.9-5.6%) for low-risk patients based on the GPS. The areas under the ROC curves were 0.77 (95%CI 0.72-0.81), 0.76 (95% CI 0.72-0.80), and 0.71 (95% CI 0.66-0.75), respectively (P=0.47). Conclusions: In this cohort of elderly patients with PE, the GPS identified a higher proportion of patients as low-risk but the PESI and sPESI were more accurate in predicting mortality.

Acute cardiac disorder or pneumonia and concomitant presence of pulmonary embolism

Purpose To determine the frequency of apparent acute pulmonary embolism (PE) and of concomitant disease in computed tomography pulmonary angiography (CTPA); to compare the frequency of PE in patients with pneumonia or acute cardiac disorder (acute coronary syndrome, tachyarrhythmia, acute left ventricular heart failure or cardiogenic shock), with the frequency of PE in patients with none of these alternative chest pathologies (comparison group). Methods Retrospective analysis of all patients who received a CTPA at the emergency department (ED) within a period of four years and 5 months. Results Of 1275 patients with CTPA, 28 (2.2%) had PE and concomitant radiologic evidence of another chest disease; 3 more (0.2%) had PE and an acute cardiac disorder without radiological evidence of heart failure. PE was found in 11 of 113 patients (10%) with pneumonia, in 5 of 154 patients (3.3%) with an acute cardiac disorder and in 186 of 1008 patients (18%) in the comparison group. After adjustment for risk factors for thromboembolism and for other relevant patient’s characteristics, the proportion of CTPAs with evidence of PE in patients with an acute cardiac disorder or pneumonia was significantly lower than in the comparison group (OR 0.13, 95% CI 0.05–0.33, p<0.001 for patients with an acute cardiac disorder, and OR 0.45, 95% CI 0.23–0.89, p = 0.021 for patients with pneumonia). Conclusion The frequency of PE and a concomitant disease that can mimic PE was low. The presence of an acute cardiac disorder or pneumonia was associated with decreased odds of PE.

Therapeutic approaches to patients with hypereosinophilic syndromes

Hypereosinophilic syndromes (HES) are a heterogeneous group of disorders that range from asymptomatic eosinophilia > 1,500/mL to aggressive disease complicated by life-threatening end organ involvement, including endomyocardial fibrosis and thromboembolism. To complicate matters further, similar clinical manifestations can occur in the setting of marked eosinophilia due to helminth infection, drug hypersensitivity, and other causes. In the past, therapy was guided only by the exclusion of these secondary causes of eosinophilia and the severity of the clinical manifestations. More recently, the availability of novel targeted therapies and a better understanding of the etiologies of some subtypes of HES have necessitated a more structured approach.

Activated coagulation during open and endovascular abdominal aortic aneurysm repair

OBJECTIVE: The study was conducted to determine activation of coagulation in patients undergoing open and endovascular infrarenal abdominal aortic aneurysm repair (EVAR). METHODS: In a prospective, comparative study, 30 consecutive patients undergoing open repair (n = 15) or EVAR (n = 15) were investigated. Blood samples to determine fibrinopeptide A, fibrin monomer, thrombin-antithrombin complex, and D-dimer were taken up to 5 days postoperatively. Routine hematologic and hematochemical parameters as well as clinical data were collected. RESULTS: Both groups showed comparable demographic variables. Operating time was longer in open repair (249 +/- 77 minutes vs 186 +/- 69 minutes, P < .05). Perioperatively elevated markers of coagulation were measured in both groups. Fibrinopeptide A levels did not differ significantly between the groups (P = .55). The levels of fibrin monomer and thrombin-antithrombin complex were significantly higher in patients undergoing EVAR (P < .0001), reflecting increased thrombin activity and thrombin formation compared with open surgery. The D-dimer level did not differ significantly between the groups. These results were also valid after correction for hemodilution. CONCLUSION: These data suggest increased procoagulant activity in EVAR compared with open surgery. A procoagulant state may favor possible morbidity derived from micro- and macrovascular thrombosis, such as in myocardial infarction, multiple organ dysfunction, venous thrombosis and thromboembolism, or disseminated intravascular coagulation.

[Tooth extraction under medication with acetylsalicylic acid.]

PURPOSE: The purpose of this prospective study was to show and analyze the bleeding complications after teeth extraction under therapy with 100 mg acetylsalicylic acid (ASA) and to compare them to bleeding complications after teeth extraction in patients with a healthy blood profile.PATIENTS AND METHODS: In 65 patients under medication with 100 mg ASA and in 252 healthy patients, 151/ 543 teeth were extracted and the bleeding complications monitored.RESULTS: The postoperative bleeding frequency was 1.54% in the ASA 100 group and 1.59% in the healthy control group without any medication. No serious or uncontrollable postoperative bleedings arose in either group. All bleedings could be easily handled. No obvious difference concerning the bleeding frequency between the two groups was observed. The small number of bleeding events and the complexity of affecting parameters did not permit statistical tests.CONCLUSION: It is not necessary to interrupt the medication of 100 mg acetylsalicylic acid given to prevent thromboembolism before tooth extractions.