Use of non-invasive scales for detecting esophageal varices in paediatric patients with portal vein thrombosis. / Utilización de escalas no invasivas en la detección de varices esofágicas en pacientes con trombosis venosa portal.

INTRODUCTION: Portal vein thrombosis (PVT) is the most frequent cause of portal hypertension in paediatric population. Baveno VI Consensus considers endoscopic variceal ligation as the second therapeutic option after meso-Rex bypass (surgical shunt). AIM: Analyse the diagnostic profitability of non-invasive scales in order to predict the risk of oesophageal varices (OV) in children with PVT. MATERIAL AND METHODS: Descriptive retrospective study where every upper gastrointestinal endoscopy (UGE) carried on patients <15 years old with non-cirrhotic PVT were included. There were divided according to the presence of OV and sex, cause, age, previous gastrointestinal bleeding or treatments, results of UGE and scales (Clinical Prediction Rule - CPR), Varices Prediction Rule - VPR), King's Variceal Prediction Score - K-VaPS) and Platelet count/Spleen diameter Ratio - PSR). Qualitative variables were expressed as absolute frequency and percentage, and quantitative variables as median and interquartile range. U Mann-Whitney and Hanley-McNeil tests were used for comparisons. RESULTS: Forty-five UGE were analysed. 80% (n=36) presented OV: median of 3 (2-3) and 33.3% (n=12) required endoscopic variceal ligation. Statistical differences were demonstrated between both groups: CPR (142.39 [132.22-166.53] vs. 122.75 [115.24-133.15]; p=0.003), VPR (9.91 [9.36-11.75] vs. 5.6 [3.34-8.39]; p=0.001), K-VaPS (117.86 [99.66-126.58] vs. 99.64 [94.88-10.18]; p=0.019), PSR (2384.62 [1902.22-3201.63] vs. 1252.5 [579.6-2144.42]; p=0.05), with and area under the curve AUROC>75%, without statistical differences between scales. CONCLUSIONS: In paediatric patients with non-cirrotic PVT non-invasive scales can be used as a tool to predict the presence of OV and raise the indication of UGE.

Thromboembolic and hemorrhagic complications in patients with prosthetic heart valves cared for in a tertiary care center. What have we learned?

BACKGROUND: Heart valve replacement surgery with mechanical or biological prostheses entails a risk of thromboembolism and bleeding complications. OBJECTIVE: To determine the complications related to complementary anticoagulation therapy and the probability of risk. METHODS: One-hundred and sixty-three patients who underwent heart valve replacement between 2002 and 2016 with either mechanical or biological prostheses, and who received vitamin K antagonists after hospital discharge, were studied. Anticoagulation therapy was categorized into optimal and non-optimal according to INR values prior to the development of complications. Patients with comorbidities and other risk factors for thrombosis and/or bleeding were excluded. RESULTS: In total, 68.7 % of patients received mechanical prostheses, and 31.3 %, biological prostheses (p ≤ 0.001); 25.2 % experienced the complications that motivated the study (p ≤ 0.001), which were hemorrhagic in 48.8 %, thromboembolic in 26.8 %, and of both types in 24.4 % (relative risk = 4.229). Among the patients with complications, 95.1 % received mechanical prostheses, and 4.9 %, biological (p = 0.005); non-optimal INR was identified in 49.7 % (p ≤ 0.001). CONCLUSIONS: Given the high risk of thromboembolic and hemorrhagic complications, valve prostheses must be carefully chosen, and care priorities should include prevention and follow-up, especially in those patients who require anticoagulation therapy.

ANTECEDENTES: El reemplazo valvular por prótesis mecánicas o biológicas implica riesgo de tromboembolismo y complicaciones hemorrágicas. OBJETIVO: Determinar las complicaciones relacionadas con la terapia de anticoagulación complementaria y la probabilidad de riesgo en pacientes portadores de prótesis valvulares del corazón. MÉTODOS: Se estudiaron 163 pacientes entre 2002 y 2016, portadores de prótesis mecánicas y biológicas, quienes recibieron antagonistas de la vitamina K posterior al egreso hospitalario. La terapia de anticoagulación se categorizó en óptima y no óptima conforme a los valores de INR previos a las complicaciones. Fueron excluidos los pacientes con comorbilidades y otros factores de riesgo de trombosis y/o sangrado. RESULTADOS: a 68.7 % de los pacientes se les colocó prótesis mecánica y a 31.3 %, biológica (p ≤ 0.001); 25.2 % presentó las complicaciones motivo de estudio (p ≤ 0.001), hemorrágicas en 48.8 %, tromboembólicas en 26.8 % y de ambos tipos en 24.4 % (riesgo relativo = 4.229); a 95.1 % de los pacientes con complicaciones se les colocó prótesis mecánica y a 4.9 %, biológica (p = 0.005); 49.7 % presentó INR no óptimo (p ≤ 0.001). CONCLUSIONES: Ante riesgo alto de complicaciones tromboembólicas y hemorrágicas, la elección de las prótesis valvulares, la prevención y el seguimiento son prioridades, principalmente en quienes requieren terapia de anticoagulación.

Plasma markers of COVID-19 severity: a pilot study.

BACKGROUND: SARS-CoV-2 infected patients show heterogeneous clinical presentations ranging from mild symptoms to severe respiratory failure and death. Consequently, various markers reflect this wide spectrum of disease presentations. METHODS: Our pilot cohort included moderate (n = 10) and severe (n = 10) COVID-19 patients, and 10 healthy controls. We determined plasma levels of nine acute phase proteins (APPs) by nephelometry, and full-length (M65), caspase-cleaved (M30) cytokeratin 18, and ADAMTS13 (a disintegrin-like and metalloprotease with thrombospondin type-1 motif 13) by ELISA. In addition, we examined whole plasma N-glycosylation by capillary gel electrophoresis coupled to laser-induced fluorescence detection (CGE-LIF). RESULTS: When compared to controls, COVID-19 patients had significantly lower concentrations of ADAMTS13 and albumin (ALB) but higher M30, M65, α1-acid glycoprotein (AGP), α1-antitrypsin (AAT), ceruloplasmin (CP), haptoglobin (HP), and high-sensitivity C-reactive protein (hs-CRP). The concentrations of α1-antichymotrypsin (ACT), α2-macroglobulin (A2MG) and serum amyloid A (SAA) proteins did not differ. We found significantly higher levels of AAT and M65 but lower ALB in severe compared to moderate COVID-19 patients. N-glycan analysis of the serum proteome revealed increased levels of oligomannose- and sialylated di-antennary glycans and decreased non-sialylated di-antennary glycan A2G2 in COVID-19 patients compared to controls. CONCLUSIONS: COVID-19-associated changes in levels and N-glycosylation of specific plasma proteins highlight complexity of inflammatory process and grant further investigations.

Pregnancy in myeloproliferative neoplasms.

Myeloproliferative neoplasms (MPN) are associated with a significant risk of thrombosis and the hypercoagulable environment of pregnancy increases this risk. The most frequent gestational complications consist of spontaneous abortion, thrombosis, bleeding, and hypertensive disease of pregnancy. Treatment depends on thrombotic risk, gestational trimester, and myeloproliferative neoplasm.

Las neoplasias mieloproliferativas (NMP) están asociadas a un riesgo notable de trombosis y el entorno de hipercoagulabilidad propio del embarazo aumenta este riesgo. Las complicaciones gestacionales más frecuentes consisten en: aborto espontáneo, trombosis, sangrado y enfermedad hipertensiva del embarazo. El tratamiento depende del riesgo trombótico, trimestre gestacional y neoplasia mieloproliferativa.

Risks in invasive procedures.

Patients with myeloproliferative neoplasms have an increased risk of thrombosis and bleeding. This risk must be identified, as well as individualizing the therapeutic strategy before invasive procedures; adequate cytoreduction reduces the risk of complications.

Los pacientes con neoplasias mieloproliferativas tienen un riesgo incrementado de trombosis y sangrado. Se debe identificar dicho riesgo, así como individualizar la estrategia terapéutica previo a los procedimientos invasivos; una adecuada citorreducción disminuye el riesgo de complicaciones.

Thrombotic events.

Major thrombotic complications in myeloproliferative neoplasms (MPNs) represent an important clinical problem due to their high morbidity, the complexity of their management, and their associated mortality. The appearance of a thrombosis implies a high thrombotic risk stratification of the MPN and determines the initiation or optimization of cytoreductive treatment and the use of antiplatelet or anticoagulant therapy as secondary prophylaxis. The incidence of thrombosis at the time of diagnosis is higher than during the course of the disease, being located in the arterial territory in 60-70% of cases. Once thrombosis has occurred, up to 20-33% of patients experience thrombotic recurrence in the same initial vascular territory.

Las complicaciones trombóticas mayores en las neoplasias mieloproliferativas (NMP) representan un importante problema clínico debido a su elevada morbilidad, la complejidad de su manejo y su mortalidad asociada. La aparición de una trombosis comporta una estratificación de alto riesgo trombótico de la NMP y determina el inicio o la optimización del tratamiento citorreductor y el uso de terapia antiplaquetaria o anticoagulante como profilaxis secundaria. La incidencia de trombosis en el momento del diagnóstico es mayor que durante la evolución de la enfermedad, localizándose en territorio arterial en el 60-70% casos. Una vez se ha producido una trombosis, hasta el 20-33% de los pacientes sufre una recurrencia trombótica en el mismo territorio vascular inicial.

Coronary stent and prolonged dual antiplatelet therapy. A longitudinal study.

INTRODUCTION: In current European guidelines for the management of myocardial infarction after coronary stent placement, there is no consensus on dual antiplatelet therapy (DAPT) ideal duration to prevent stent thrombosis-restenosis without significantly increasing the bleeding risk. OBJECTIVE: To report the percentage of major bleeding and presence of major cardiovascular events associated with prolonged DAPT in patients recruited at the National Institute of Cardiology, treated with primary percutaneous coronary intervention and stent. METHODS: A longitudinal, prospective, observational, non-experimental, descriptive study was carried out. Patients were recruited from November 2016 to December 2017. RESULTS: One hundred and thirty-five patients with a mean age of 57 ± 10 years who completed the three-year follow-up were selected. Obesity and hypertension stood out as the main risk factors. After using DAPT for three years, 3.7% of mortality, 1.48% of major bleeding, and 4.4% of thrombosis-restenosis were recorded. CONCLUSIONS: Prolonged use of DAPT would be justified by the high incidence of thrombosis-restenosis, without a significant increase in bleeding risk, as well as a decrease in major cardiovascular events.

INTRODUCCIÓN: En las guías actuales europeas para el manejo del infarto de miocardio posterior a la colocación de endoprótesis coronaria (stent), no existe consenso sobre la duración ideal de la terapia antiagregante plaquetaria dual (DAPT, dual antiplatelet therapy) para prevenir la trombosis-reestenosis del stent sin aumentar el riesgo significativo de sangrado. OBJETIVO: Reportar el porcentaje de sangrado mayor y de eventos cardiovasculares mayores asociados a la DAPT prolongada en pacientes atendidos en el Instituto Nacional de Cardiología y tratados con intervención coronaria percutánea primaria y stent. MÉTODOS: Se realizó un estudio longitudinal, prospectivo observacional y descriptivo no experimental. Los pacientes fueron captados de noviembre de 2016 a diciembre de 2017. RESULTADOS: Fueron seleccionados 135 pacientes con una media de edad de 57 ± 10 años, quienes cumplieron un seguimiento clínico por tres años. La obesidad y la hipertensión destacaron como principales factores de riesgo. Posterior al uso de DAPT durante tres años, se registró 3.7 % de mortalidad, 1.48 % de sangrado mayor y 4.4 % de trombosis-reestenosis. CONCLUSIONES: El uso prolongado de DAPT estaría justificado por la alta incidencia de trombosis-reestenosis, sin incremento significativo en el riesgo de sangrado y con disminución de los eventos cardiovasculares mayores.

The outcomes of interventional treatment for Budd-Chiari Syndrome complicated by inferior vena cava thrombosis: Systematic review and meta-analysis.

PURPOSE: The aim of this study was to perform a systematic review and meta-analysis to assess the safety and efficacy of interventional treatment for Budd-Chiari syndrome (BCS) complicated by Inferior Vena Cava thrombosis (IVCT) patients. METHODS: We evaluated the published studies on interventional treatment for BCS complicated by IVCT. Meta-analysis was used to calculate the combined effect size and their 95% confidence intervals (CI) based on random effect. The publication bias was assessed by Begg's test. RESULTS: Sixteen studies on interventional treatment for BCS complicated by IVCT patient were selected for meta-analysis, a total of 767 BCS complicated by IVCT patients were included. The combined effect size (95% CI) were 99% (98-100%) for the total successful rate of IVC recanalization, 15% (11-21%) for the rate of IVC restenosis after initial operation, 92.0% (86-97%) for the rate of clinical improvement, 76% (68-84%) for the rate of thrombus clearance and 0.00% (0-1%) for the incidence of pulmonary embolism (PE). Through subgroup meta-analysis about the rate of thrombus clearance, we got the pooled results (95% CI) of individualized treatment strategy (ITS) group and non-individualized treatment strategy (non-ITS) group, were 81% (71-92%) and 73% (63-83%), respectively. CONCLUSIONS: The interventional treatment for BCS complicated by IVCT patients is safe and effective with low incidence of PE, high thrombus clearance rate, high technically successful rate, good patency, and high clinical improvement rate. Moreover, subgroup analysis indicated that management based on the type and extent of the thrombus is proposed.

Placental pathology and perinatal risk during the COVID-19 pandemic.

BACKGROUND: Respiratory and immune changes during pregnancy can lead to viral infections. In coronavirus disease 2019 (COVID-19), clinical characteristics and perinatal risks are difficult to assess and are relatively unknown. OBJECTIVE: To review placental pathology in asymptomatic women with COVID-19, and to evaluate effects on perinatal outcomes. MATERIAL AND METHOD: Retrospective, observational, cross-sectional study that included 29 pregnant women in 2020. The women underwent COVID-19 tests and were divided in two groups: 1) control, COVID-19-negative patients, and 2) asymptomatic COVID-19-positive patients; the placentas were studied at the pathology department, and clinical data were retrieved from the electronic medical record; in addition, a literature review was carried out. RESULTS: When the groups were compared, no differences were observed in general data and clinical characteristics. On the day of delivery, patients 2, 4, 5, 6, 8 and 9 of the COVID-19 group were between day 0 and 10.5 after having tested positive; only patients 1, 3 and 7 had overcome the infection. There was a decrease in weeks of gestation in the COVID-19 group (37.8 ± 1.8 vs. 39 ± 0.8; p ≤ 0.05). COVID-19-positive patients' placental histopathology showed a higher prevalence of thrombotic alterations in placental villi (55.5 vs. 0%). CONCLUSIONS: COVID-19 asymptomatic infection potentiates preexisting prothrombotic profile, thus increasing the risk of placental thrombosis and, potentially, of thrombosis in pregnant women.

ANTECEDENTES: Los cambios respiratorios e inmunitarios en el embarazo pueden conducir a infecciones virales. En la enfermedad por coronavirus 2019 (COVID-19) las características clínicas y riesgos perinatales son difíciles de evaluar y son relativamente desconocidos. OBJETIVO: Revisar patología placentaria en mujeres asintomáticas con COVID-19 y evaluar efectos en datos perinatales. MATERIAL Y MÉTODO: Estudio retrospectivo, observacional y transversal, incluye 29 mujeres embarazadas en 2020. Se realizaron prueba COVID-19 y dividieron en dos grupos: 1) control, pacientes COVID-19 negativas y 2) COVID-19 asintomáticas con COVID-19 positivo; las placentas se estudiaron en patología y los datos clínicos se tomaron del expediente electrónico; asimismo, se realizó revisión de literatura. RESULTADOS: Al comparar grupos no se observó diferencia en datos generales y características clínicas. El día del parto, las pacientes 2, 4, 5, 6, 8 y 9 del grupo COVID-19 se encontraban entre día 0 y 10.5 después de positividad; únicamente las pacientes 1, 3 y 7 habían superado la infección. Se presentó disminución de semanas de gestación en el grupo COVID-19 (37.8 ± 1.8 vs. 39 ± 0.8; p ≤ 0.05). La histopatología placentaria en COVID-19 mostró mayor prevalencia de alteraciones trombóticas en vellosidades placentarias (55.5 vs. 0%). CONCLUSIONES: La infección asintomática por COVID-19, potencializa perfil protrombótico preexistente, incrementando riesgo de trombosis placentaria y trombosis en mujeres embarazadas.

Tyrame [N-(3-hydroxy-1:3:5(10)-estratrien-17ß-yl)-4-hydroxy-phenethylamine], antithrombotic aminoestrogen that decreases microvesicle formation.

BACKGROUND: Estrogens that are used as contraceptives or in replacement therapy are associated with an increase in the risk for developing thrombosis, mainly during the first year of treatment and in women with associated risk factors. OBJECTIVE: To synthesize, characterize and identify the anticoagulant, antiplatelet aggregation and microvesicle-reducing effect of the new aminoestrogen Tyrame. MATERIAL AND METHODS: CD1 strain mice were used, which had Tyrame (0, 1 and 2 mg/100 g) subcutaneously administered. At 24 h, a blood sample was obtained to determine whole-blood clotting time, microvesicles concentration and inhibitory effect on platelet aggregation. RESULTS: Blood clotting time increased up to 1.5 times in comparison with the control. Platelet aggregation inhibition had different magnitude depending on the agonist agent employed, and was complete with collagen. Both effects had a dose-dependent relationship. The microvesicles decreased up to six times with respect to the control. CONCLUSIONS: Tyrame reduces platelet aggregation and microvesicle formation, which emphasizes its potential therapeutic utility as an estrogen free of thrombotic effects.

ANTECEDENTES: Los estrógenos empleados como anticonceptivos o en la terapia de sustitución se asocian a un incremento en el riesgo de desarrollar trombosis, principalmente durante el primer año de tratamiento y en mujeres con factores de riesgo asociados. OBJETIVO: Sintetizar, caracterizar e identificar el efecto anticoagulante, antiagregante plaquetario y reductor de las microvesículas del nuevo aminoestrógeno tyrame. MATERIAL Y MÉTODOS: Se emplearon ratones cepa CD1 a los que se les administró por vía subcutánea tyrame (0, 1 y 2 mg/100 g). A las 24 h se tomó una muestra de sangre para determinar el tiempo de coagulación en sangre total, la concentración de microvesículas y el efecto inhibidor de la agregación plaquetaria. RESULTADOS: El tiempo de coagulación en sangre se incrementó hasta 1.5 veces con respecto al control. La inhibición de la agregación plaquetaria tuvo diferente magnitud dependiendo del agente agonista, siendo completa con colágena. Ambos efectos siguieron una relación dependiente de la dosis. Las microvesículas disminuyeron hasta seis veces con respecto al control. CONCLUSIONES: el tyrame disminuye la agregación plaquetaria y la formación de microvesículas, lo que acentúa su posible utilidad terapéutica como un estrógeno sin efectos trombóticos.

Analysis of the quality of anticoagulation with vitamin K antagonists in three clinical scenarios in Mexico.

INTRODUCTION: Vitamin K antagonists (VKA) are a therapeutic alternative in patients with venous thromboembolic disease; however, numerous factors affect their pharmacology. OBJECTIVE: To evaluate the quality of VKA anticoagulation at three different time periods in Mexico. METHODS: Prospective study, nested in patient cohorts at three different clinical scenarios between 2013 and 2019. Outpatients with indication for treatment with VKAs for at least 12 months were included. Patients were managed according to the criteria of the treating physician. RESULTS: Patient general characteristics were similar between groups, except for the VKA indication. The results of 4,148 patients and 38,548 INR assessments were analyzed. The times in therapeutic range during the three phases of the study and pooled data were significantly higher for the anticoagulation clinic. Only the number of patient visits was significantly associated with the results, unlike age, gender, and type of VKA. CONCLUSIONS: VKAs are widely used, but it is difficult for therapeutic goals to be achieved, especially in non-specialized clinical services. Creation of anticoagulation clinics is an urgent need for the Mexican health system.

INTRODUCCIÓN: Los antagonista de la vitamina K (AVK) son una alternativa terapéutica en los pacientes con enfermedad tromboembólica venosa; sin embargo, numerosos factores afectan su farmacología. OBJETIVO: Evaluar la calidad de la anticoagulación AVK durante tres diferentes periodos en México. MÉTODOS: Estudio prospectivo, anidado en cohortes de pacientes en tres escenarios clínicos entre los años 2013-2019. Se incluyeron pacientes no hospitalizados con indicación para recibir AVK por al menos 12 meses, quienes fueron manejados de acuerdo con el criterio del médico tratante. RESULTADOS: Las características generales de los pacientes fueron similares entre los grupos, excepto por la indicación para usar los AVK. Se analizaron los resultados de 4148 pacientes y 38 548 evaluaciones de INR. Los tiempos en rango terapéutico durante las tres fases del estudio y los datos acumulados fueron significativamente mayores en la clínica de anticoagulación. Solo el número de visitas de control de los pacientes se asoció significativamente con los resultados, a diferencia de la edad, el sexo y el tipo de AVK. CONCLUSIONES: Los AVK se utilizan ampliamente, pero es difícil alcanzar la meta terapéutica, sobre todo en servicios clínicos no especializados. La creación de clínicas de anticoagulación es una necesidad urgente en el sistema mexicano de salud.

Bayesian network analysis of plasma microRNA sequencing data in patients with venous thrombosis.

MicroRNAs (miRNAs) are small regulatory RNAs participating to several biological processes and known to be involved in various pathologies. Measurable in body fluids, miRNAs have been proposed to serve as efficient biomarkers for diseases and/or associated traits. Here, we performed a next-generation-sequencing based profiling of plasma miRNAs in 344 patients with venous thrombosis (VT) and assessed the association of plasma miRNA levels with several haemostatic traits and the risk of VT recurrence. Among the most significant findings, we detected an association between hsa-miR-199b-3p and haematocrit levels (P = 0.0016), these two markers having both been independently reported to associate with VT risk. We also observed suggestive evidence for association of hsa-miR-370-3p (P = 0.019), hsa-miR-27b-3p (P = 0.016) and hsa-miR-222-3p (P = 0.049) with VT recurrence, the observations at the latter two miRNAs confirming the recent findings of Wang et al. Besides, by conducting Genome-Wide Association Studies on miRNA levels and meta-analyzing our results with some publicly available, we identified 21 new associations of single nucleotide polymorphisms with plasma miRNA levels at the statistical significance threshold of P < 5 × 10-8, some of these associations pertaining to thrombosis associated mechanisms. In conclusion, this study provides novel data about the impact of miRNAs' variability in haemostasis and new arguments supporting the association of few miRNAs with the risk of recurrence in patients with venous thrombosis.

Los micro-ARN (miARN) son pequeñas moléculas de ARN reguladoras que participan en varios procesos biológicos y están implicados en diversas patologías. Mensurables en los líquidos corporales, se ha planteado que los miARN pueden ser biomarcadores eficaces para el diagnóstico de enfermedades y/o características asociadas. Aquí hemos llevado a cabo un análisis de miARN plasmático con tecnología de secuenciación de última generación en 344 pacientes con trombosis venosa (TV) y hemos evaluado la asociación de los niveles de miARN con distintas características hemostáticas y el riesgo de recidiva de TV. Entre los hallazgos más significativos, hemos detectado una asociación entre hsa-miR-199b-3p y los niveles de hematocritos (p = 0,0016); dos marcadores que se habían asociado de forma independiente con el riesgo de sufrir TV. Asimismo, hemos observado una evidencia indicativa de asociación entre hsa-miR-370-3p (p = 0,019), hsa-miR-27b-3p (p = 0,016) y hsa-miR-222-3p (p = 0,049) y la recidiva de TV; los resultados los dos últimos miARN confirman los hallazgos recientes de Wang et al. (Clin Epigenetics, 2019). Además, al efectuar estudios de asociación del genoma completo sobre los niveles de miARN y al metaanalizar nuestros resultados con otros disponibles públicamente, hemos identificado 21 asociaciones nuevas de polimorfismos de un solo nucleótido (PSN) con niveles de miARN plasmático con un umbral de significación estadística de p < 5 × 10−8; algunas de estas asociaciones pertenecen a los mecanismos patogénicos de la trombosis.Como conclusión, en este estudio se proporcionan nuevos datos sobre el impacto de la variabilidad de miARN en la hemostasia y nuevos argumentos que apoyan la asociación de algunas secuencias de miARN con el riesgo de recidiva en pacientes con trombosis venosa.

Neutrophils as instigators of thrombosis: Beyond antimicrobial protection. / Neutrófilos como instigadores de trombosis: más allá de la protección antimicrobiana.

When activated, neutrophils release structures (NETs) composed of DNA, histones and granular proteins that provide an ideal matrix for platelet activation and coagulation mechanisms, thereby contributing to the pathogenesis of thrombosis in venous and arterial territories, as well as cancer-associated thrombosis. NETs play a key role in immunothrombosis, a term that describes the relationship between the immune response and coagulation.

Treatment of deep vein thrombosis of the lower extremities. / Tratamiento de la trombosis venosa profunda de extremidades inferiores.

Deep vein thrombosis of the lower extremities is a common condition that should be treated appropriately given the possibility that it could lead to an ultimately fatal complication, as well as to a post-thrombotic syndrome that is in some cases disabling. The current treatment for this condition is differentiated into an acute phase, a long-term therapy and occasionally an extended therapy, which not only has defined objectives but also uses various drugs and even varying dosages for each drug. We describe the therapeutic anticoagulation options in each of these treatment phases and some of the treatments (thrombolysis, insertion of an inferior vena cava filter, surgery) that can play a role in certain conditions.

Prophylaxis of venous thromboembolism disease in patients with cancer. / Profilaxis de la enfermedad tromboembólica venosa en pacientes con cáncer.

Thrombotic risk should always be assessed in the various clinical scenarios of patients with cancer. Thromboprophylaxis with low-molecular-weight heparin is recommended above other anticoagulants for most patients with cancer who are hospitalised. However, the safety of primary thromboprophylaxis in this context is unknown; however, thromboprophylaxis can be completed with mechanical methods. Thromboprophylaxis in outpatients who are treated with chemotherapy is not indicated, except for outpatients who have other factors that determine a high thrombotic risk. In these cases, prophylaxis such as apixaban, rivaroxaban and low-molecular-weight heparin may be employed, provided there are no significant risk factors for bleeding or drug interactions. In patients undergoing oncologic surgery, thromboprophylaxis should be started before the surgery, continuing for at least 7 to 10 days and, in cases of major surgery, even up to 4 weeks. Drug prophylaxis is not routinely recommended to prevent upper extremity thrombosis in patients who carry central venous catheters.

Diagnosis of deep vein thrombosis. / Diagnóstico de la trombosis venosa profunda.

Deep vein thrombosis (DVT) is part of the clinical spectrum of venous thromboembolism disease (VTE), whose estimated annual incidence rate is 1-2 episodes per 1000 individuals and represents the third leading cause of cardiovascular mortality in developed countries. Establishing an accurate diagnosis of DVT is essential for preventing acute complications (such as pulmonary embolism) and chronic complications associated with post-thrombotic syndrome. Currently, there are well-established diagnostic algorithms for lower extremity DVT, which include clinical probability models that help establish the risk of experiencing the disease based on the patients' history, clinical findings, D dimer measurements, fibrin degradation product tests with a high negative predictive value and imaging tests to confirm the diagnosis. Venous compression ultrasonography is currently the technique of choice because it is a non-invasive, easy-to-administer test that can make serial evaluations. There is much accumulated evidence that DVT can be safely ruled out in patients with a low or intermediate clinical probability and a negative D dimer (<500 ng/mL) without performing additional examinations. The consensus is not as clear about the need for a proximal or complete examination of the entire extremity. Other techniques may also be employed, such as magnetic resonance venography and venous phase computed axial tomography, although these should not be a substitute for compression ultrasonography as the initial diagnostic test. There are other special circumstances in which the diagnosis is more problematic and there are no diagnostic algorithms as consolidated, such as DVT during pregnancy, diagnosing rethrombosis and DVT that affects the upper extremities.

Prophylaxis in nonorthopaedic surgery. / Profilaxis en cirugía no ortopédica.

Surgery increases the risk (by 20-fold) of venous thromboembolism (VTE), but there are prophylaxis methods (mechanical, pharmaceutical or combined) that safely reduce the incidence rate of VTE. The administration of prophylaxis requires a prior assessment of the risks associated with the patient and with the type of surgery. The Caprini and Rogers scales classify patients into four VTE risk categories (very low, low, moderate and high). In pharmacological prophylaxis, the risk of bleeding should also be assessed. At this time, the recommendation is to administer prophylaxis to all patients: mechanical prophylaxis for low, moderate or high risk with contraindications for the administration of heparin; combined with heparin for very high risk; and with drugs such as low-molecular-weight heparin, unfractionated heparin and fondaparinux for moderate to high risk. These measurements should be kept until full ambulation, discharge, or at least seven days (for major oncologic and bariatric surgery, maintain for four weeks).

Coagulopathy associated with COVID-19.

Infection with a new type of coronavirus surprised with the diversity of its clinical symptoms. The disease may be asymptomatic, with only mild symptoms in the form of olfactory loss, general weakness or flu-like symptoms. However, in some patients, COVID-19 infection can be severe, with hypercoagulation being a common finding, with vascular endothelial damage and the consequent risk of venous and arterial thrombotic complications. Coa-gulopathy subsequently significantly worsens the prognosis of patients and increases overall mortality. Recently, a new term has been introduced to indicate the presence of activated hemostasis in SARS-CoV-2 infection - coagulopathy associated with COVID-19 (CAC). The current global pandemic of COVID-19 has triggered intensive research on the disease, which has clarified a number of findings about the infection, but we still have many unanswered questions, especially regarding possible treatment.

Efficacy and safety of anticoagulation in non-malignant portal vein thrombosis in patients with liver cirrhosis.

BACKGROUND AND AIM: Treatment for portal vein thrombosis (PVT) is not well established. Nevertheless, anticoagulation therapy can seemingly be used as first-line therapy. However, there are limited data on the role of this treatment in patients with PVT and cirrhosis. We sought to assess the safety and efficacy of anticoagulation therapy in a series of patients with non-malignant PVT and liver cirrhosis. METHODS: We analyzed the data of 32 patients with cirrhosis and PVT between March 2009 and September 2015. All patients received anticoagulation treatment. PVT was diagnosed within the context of biannual hepatocellular carcinoma screening in these patients. RESULTS: Recanalisation was achieved in 23 patients: complete in 17 patients (53.1%) and partial in 6 patients (18.7%). The median time for achieving a complete response was 7 months (95% CI: 6-8). We did not discover any risk factors associated with repermeation (partial or complete). None of the patients presented with thrombosis progression while receiving anticoagulation. Nine patients who achieved complete recanalisation and stopped anticoagulation therapy suffered rethrombosis (52%). There were no differences between the patients who achieved complete or partial recanalisation (35%) and those who did not (33%) in relation to the onset of hepatic events during follow-up. Three patients (9%) presented with bleeding complications: two variceal bleeding episodes and one brain hemorrhage. CONCLUSIONS: In cirrhotic patients with non-malignant PVT, anticoagulation therapy led to partial or complete recanalisation in 70% of patients, with a broad safety profile. Due to the existing rethrombosis rate, long-term anticoagulation should be considered.