Long-term monitoring and treatment of venous thromboembolic disease: recommendations of the Thromboembolic Disease Group of the Spanish Society of Internal Medicine 2024.

Venous thromboembolim (VTE) is a highly prevalent condition that requires long-term monitoring and treatment. This monitoring includes: 1) completing the etiological study and determining the risk of VTE recurrence; 2) establishing the optimal duration of anticoagulant treatment, as well as the type of therapy and its dosage; 3) estimating the risk of bleeding, and 4) identifying the occurrence of chronic complications. This consensus document, prepared by the VTE Group of the Spanish Society of Internal Medicine (SEMI), aims to update and establish consensus recommendations on these aspects. The document focuses on four aspects of management: the first includes risk factors for VTE recurrence after an unprovoked VTE episode and describes the predictive scores of VTE recurrence; the second focuses on risk factors for bleeding; the third provides recommendations for long-term follow-up in VTE, addressing specific considerations for screening chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome of the lower limbs; and the fourth provides guidance on the optimal duration of extended anticoagulant treatment, as well as the type of therapy and its dosage. For each area, an exhaustive literature review was conducted, analyzing the updated VTE clinical guidelines and recent studies. This document is intended to be a guide in the long-term management of VTE based on the most current knowledge.

Cerebral venous thrombosis in children an 18-year review of a Portuguese hospital.

INTRODUCTION: Cerebral venous thrombosis (CVT) is an uncommon and clinically heterogeneous cerebrovascular particularly in children, only a few published case series focused in the pediatric population. PATIENTS AND METHODS: Retrospective single-center observational and analytical study of consecutive pediatric patients admitted in a level II Portuguese hospital with a confirmed diagnosis of CVT, from 2003 to 2021. Clinical presentation, neuroimaging findings, prothrombotic factors, treatment strategies, outcome and recanalization were documented. RESULTS: Twelve children were included (58% female). Mean age was 7.3 years. The most frequent symptoms were vomiting, headache and behavioral alterations. Infection was the triggering factor in 50% of the cases. The diagnosis of CVT was made based on imaging evidence of thrombosis through magnetic imaging resonance (MRI) with venography and/or computed tomography (CT) with venography. In 67% of cases there were multiples sinuses involved; the transverse sinus was the most affected, followed by the sigmoid sinus. In 83% of cases anticoagulant therapy was initiated with low molecular weight heparin (LMWH) and associated prothrombotic factors were investigated, with no major prothrombotic factors identified. No deaths occurred, but 30% had long-term neurological sequelae. One patient recurred 18 years later. CONCLUSION: The results of this study are consistent with data from other published studies. MRI is the preferred imaging method for diagnosis in children by avoiding ionizing radiation and allowing identification of subjacent causes. Anticoagulation with LMWH is recommended and important to reduce mortality and sequelae. Infectious diseases are the most common trigger for CVT and can also be the cause for high morbidity and poor outcomes.

Anti-Xa activity below range is related to thrombosis in patients with severe COVID-19.

OBJECTIVE: We aimed to anlayse the relationship between anti-Xa activity below range and thomboembolic events. DESIGN: Single center prospective observational longitudinal cohort study (February-November 2021). SETTING: Patients admitted to the ICU of a University Hospital. PARTICIPANTS: Patients with severe COVID-19 pneumoniae. INTERVENTIONS: Enoxaparin was used for prophylactic and therapeutic anticoagulation. Enoxaparin dosing and dose adjustment were based on anti-Xa activity according to the hospital protocol. MAIN VARIABLES OF INTEREST: Target: thomboembolic events. PREDICTORS: demographics, pharmacotherapy, anti-Xa measurements, clinical data, and laboratory results. Logistic regression was used to identify independent risk factors for thomboembolic events. RESULTS: Data were available for 896 serum anti-Xa measurements from 228 subjects. Overall, 71.9% were male, with a median age of 62. Most patients needed invasive mechanical ventilation (87.7%) and mortality was 24.1%. A total of 28.9% new thomboembolic events were diagnosed. There were 27.1% anti-Xa measesurements below range. When multivariable logistic regression analysis was performed anti-Xa activity below range (RR, 4.2; p = 0.000), C-reactive protein (25 mg/L increase) (RR, 1.14; p = 0.005) and D-dimer (1000 ng/L increase) (RR, 1.06; p = 0.002) were the independent factors related to new thomboembolic events in patients with severe COVID-19. CONCLUSIONS: Anti-Xa activity below range, C-reactive protein and D-dimer were the independent factors related to thomboembolic events in patients with severe COVID-19. Purposely designed clinical trials should be carried out to confirm the benefit of an anti-Xa monitoring.

Bariatric and general surgical procedures in obese patients with a history of venous thromboembolism and concurrent anticoagulation therapy.

OBJECTIVE: The objective of this study was to examine the use and outcomes of perioperative anticoagulation (AC) in obese patients with a known history of venous thromboembolism event (VTE). METHOD: A retrospective review of a prospective database for patients with a VTE history undergoing bariatric and general surgery at a single center (1/2008-12/2017) was performed. Factors assessed included demographics, surgical details, and outcomes. RESULTS: Sixty-five patients underwent 76 procedures: 46 females (71%); mean age 51 years (range 26-73), mean weight 284 pounds (range 110-558), mean body mass index 45 (range 19-87). Comorbidities include hypertension (60%), gastroesophageal reflux disease (54%), osteoarthritis (49%), obstructive sleep apnea (45%), and diabetes (37%). Operations: 22 general surgeries (29%), 20 sleeve gastrectomies (26%), 12 revisions/conversions (16%), 12 Roux-en-Y gastric bypasses (16%), and 10 gastric bands (13%). Modalities: 67% laparoscopic, 28% robotic, and 5% open. Twenty-two patients (34%) had a pre-operative inferior vena cava filter placed with no complications. The mean length of stay was 4.4 days (range 1-31). Complications: seven 30-day readmissions (9%), one 30-day reoperation (1%), and two 90-day VTEs (3%). Thirty-day readmissions: four for inability to tolerate PO, two for small bowel obstruction, and one for symptomatic anastomotic ulcer. CONCLUSIONS: In our patients, post-operative AC could be started without an increased risk of bleeding in patients with a history of VTE undergoing bariatric surgery.

OBJETIVO: Examinar el uso y los resultados de la anticoagulación perioperatoria en pacientes bariátricos con antecedentes de tromboembolia venosa (TEV). MÉTODO: Revisión retrospectiva (base de datos prospectiva) de pacientes sometidos a cirugía general y bariátrica (1/2008-12/2017). Se evaluaron datos demográficos, detalles quirúrgicos y resultados. RESULTADOS: Sesenta y cinco pacientes se sometieron a 76 procedimientos: 46 mujeres (71%), edad media 51 años (rango: 26-73), peso medio 284 libras (rango: 110-558), índice de masa corporal medio 45 (rango: 19-87). Comorbilidad: hipertensión (60%), enfermedad por reflujo gastroesofágico (54%), osteoartritis (49%), apnea obstructiva del sueño (45%), diabetes (37%). Operaciones: 22 cirugía general (29%), 20 gastrectomías en manga (26%), 12 revisiones/conversiones (16%), 12 Y-de-Roux (16%), 10 bandas gástricas (13%). Modalidades: 67% laparoscópica, 28% robótica, 5% abierta. A 22 pacientes (34%) se les colocó un filtro de vena cava inferior preoperatorio sin complicaciones. La estancia media fue de 4.4 días (rango: 1-31). Complicaciones: 7 reingresos a los 30 días (9%), 1 reoperación a los 30 días (1%), 2 TEV a los 90 días (3%). Reingresos a los 30 días: 4 por incapacidad para tolerar la vía oral, 2 obstrucciones de intestino delgado y 1 úlcera anastomótica sintomática. CONCLUSIONES: En nuestros casos, la anticoagulación posoperatoria pudo iniciarse sin aumento del riesgo de sangrado en pacientes con antecedentes de TVE sometidos a cirugía bariátrica.

Thrombotic Event Prevention in Patients Undergoing Posterior Lumbar Arthrodesis: our experiencie. A retrospective case series study. / Prevención de eventos trombóticos en pacientes sometidos a cirugía de artrodesis lumbar por vía posterior: experiencia en nuestro centro. Estudio retrospectivo de casos.

INTRODUCTION: There is no generalized consensus regarding perioperative prophylaxis of venous thromboembolism (VTE), either on using or timing it in patients undergoing spine surgery. VTE is a current concern because, even though being an uncommon event, it can cause serious complications. The aim of the present study is to propose guidelines for the prevention of thrombotic events in posterior spinal surgery, either as deep vein thrombosis or pulmonary thromboembolism. If the number of patients getting prophylaxis drugs is reduced a subsequent reduction of the incidence of epidural hematoma can be expected. MATERIALS AND METHODS: A number of 235 patients who had undergone posterior spinal arthrodesis in the previous five years were studied. Mechanical thromboprophylaxis measures consisting of compression stockings were applied in all of them. Anticoagulant drugs were also applied whenever risk factors for thrombosis were observed. Early weight-bearing was resumed immediately after surgery. Demographic, clinical, and surgical variables were collected, as well as complications appearing during the follow-up period, that was scheduled at one, two, four, six and twelve months after the surgery. Thrombotic events, if present, were diagnosed by clinical and imaging tests such as ultrasound and CT angiography. RESULTS: From the total 235 patients of this series, one hundred and fifty-three cases met the study inclusion criteria. A total of four thrombotic events appeared, one in the form of deep vein thrombosis and other three in the form of pulmonary thromboembolism. These last patients suffering an embolism died because of it. None of the variables studied had statistical significance for the occurrence of a thrombotic event. All four patients who suffered thrombotic events were receiving anticoagulant drugs, in addition to mechanical compression stockings, because of the presence of risk factors for thrombosis. CONCLUSIONS: By applying the fore mentioned protocol, adequate prevention of thromboembolic events was achieved in this study population of patients undergoing posterior spinal surgery.

Primary hyperparathyroidism in pregnancy: a case report highlighting uncommon complication / Hiperparatiroidismo primario en el embarazo: reporte de caso destacando una complicación infrecuente

Abstract Primary hyperparathyroidism (PHPT) is characterized by elevated levels of calcium and parathyroid hormone (PTH). However, the interpretation of diagnostic tests, such as serum calcium and PTH levels, is complex in pregnant women. The aim of this report is to present a case of PHTP in a pregnant adolescent, with a special emphasis on an uncommon complication, as well as diagnostic and treatment strategies. A 17-year-old pregnant female presented with hyper emesis gravidarum and neurological symptoms, leading to the diagnosis of cerebral venous thrombosis. Further investigations revealed hypercalcemia and persistently elevated PTH levels, consistent with PHPT. After local ization studies, the patient underwent an emergency parathyroidectomy with a diagnosis of parathyroid ad enoma. During follow-up, intrauterine growth restric tion and severe preeclampsia developed, necessitating an emergency cesarean section. Both the mother and neonate had favorable outcomes. PHPT is an infrequent condition in the pregnant population, and its diagnosis can be challenging due to the overlap of symptoms with normal physiological changes during pregnancy. The occurrence of uncom mon complications, such as thrombotic phenomena, highlights the need for a comprehensive approach to ensure early detection and management. In most cases, parathyroidectomy is the treatment of choice.

Resumen El hiperparatiroidismo primario (HPTP) se caracteriza por niveles elevados de calcio y hormona paratiroidea (PTH). Sin embargo, la interpretación de pruebas diag nósticas, como los niveles de calcio sérico y PTH, es compleja en mujeres embarazadas. El objetivo de este re porte es presentar un caso de HPTP en una adolescente embarazada, con especial hincapié en una complicación infrecuente, así como en las estrategias diagnósticas y de tratamiento. Una mujer embarazada de 17 años presentó hiperé mesis gravídica y síntomas neurológicos, lo que llevó al diagnóstico de trombosis venosa cerebral. Posterio res investigaciones revelaron hipercalcemia y niveles persistentemente elevados de PTH, consistentes con HPTP. Tras la realización de estudios de localización, la paciente fue sometida a una paratiroidectomía de emergencia con diagnóstico de adenoma de paratiroi des. Durante el seguimiento, se desarrolló restricción del crecimiento intrauterino y preeclampsia grave, lo que resultó en la necesidad de realizar una cesárea de emergencia. Tanto la madre como el neonato evolucio naron favorablemente. El HPTP es una condición infrecuente en la población embarazada y su diagnóstico puede ser desafiante por la superposición de síntomas con los cambios fisiológicos normales del embarazo. La aparición de complicaciones infrecuentes, como fenómenos trombóticos, resalta la necesidad de un abordaje integral para garantizar la detección y el manejo temprano. En la mayoría de los casos, la paratiroidectomía es el tratamiento de elección.

Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the venous thromboembolism group of the Spanish Society of Internal Medicine.

Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25-40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI). PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).

Teratoma gástrico. Caso clínico

Introducción: Reportamos los hallazgos clínicos, quirúrgicos, imagenológicos e histopatológicos de un paciente con Teratoma Gástrico. Materiales y Método: Se recopilaron variables clínico demográficas, imagenológicas, quirúrgicas y post operatorias, analizándolas de forma descriptiva. Resultados: Paciente masculino de 33 años que presenta cuadro de TVP (trombosis venosa profunda) que se decide complementar con Angiotc donde se constata aumento de volumen nodular en relación a la curvatura menor del estómago. Se complementa estudio con endoscopía digestiva alta que muestra lesión infiltrante, extensa en curvatura menor. Se decide realizar gastrectomía total laparoscópica. Estudio histopatológico muestra en curvatura menor, histopatología compatible con teratoma maduro. Paciente con evolución satisfactoria post operatoria se decide alta médica, control a los 7 meses post operado sin complicaciones. Discusión: El teratoma gástrico es un tumor infrecuente, se caracteriza por su composición heterogénea. Se diagnostica comúnmente en niños pequeños, aunque puede ocurrir a cualquier edad. La causa exacta del teratoma gástrico es desconocida, pero se cree que se desarrolla debido a anomalías durante el desarrollo embrionario. Su diagnóstico de teratoma implica una combinación de estudios. Histológicamente, los teratomas gástricos están compuestos de tejidos de diferentes capas de células germinales, incluyendo ectodermo, mesodermo y endodermo. Conclusión: los teratomas gástricos son tumores extremadamente inusuales, que pueden ser difíciles de diagnosticar y manejar, se requiere un enfoque multidisciplinario para un manejo óptimo.

Introduction: to present the clinical, surgical, imaging, and histopathological findings of a patient with a gastric teratoma. Materials and Methods: Descriptive analysis was conducted on clinical, demographic, imaging, surgical, and postoperative variables collected. Results: A 33-year-old male patient was diagnosed with deep vein thrombosis (DVT), and an angiotc scan revealed an increase in nodular volume in the lesser curvature of the stomach. Upper digestive endoscopy showed an infiltrating lesion extensively affecting the lesser curvature. Laparoscopic total gastrectomy was performed, and histopathological examination confirmed the presence of a mature teratoma in the lesser curvature. The patient experienced a satisfactory postoperative recovery and was discharged. Follow-up at 7 months postoperatively showed no complications. Discussion: Gastric teratoma is a rare tumor characterized by its heterogeneous composition. While it is typically diagnosed in young children, it can occur at any age. The exact cause of gastric teratoma is unknown, but it is believed to result from embryonic developmental anomalies. Diagnosis of teratoma involves a combination of diagnostic tests. Histologically, gastric teratomas consist of tissues derived from different layers of germ cells, including ectoderm, mesoderm, and endoderm. Conclusion: Gastric teratomas are extremely uncommon tumors that pose challenges in terms of diagnosis and management. An interdisciplinary approach is necessary for optimal management.

Cerebral venous thrombosis.

Cerebral venous thrombosis is part of the so-called thrombosis in unusual sites. It is defined as an occlusion in the cerebral venous territory. Its incidence is progressively increasing, especially in developing countries. It is more frequently observed in young women, with hormonal factors such as pregnancy or hormonal contraception being significant risk factors in the development of this condition. The clinical presentation will depend fundamentally on the topography of the thrombosis, with a confirmatory diagnosis based mainly on imaging tests. The treatment generally consists of anticoagulation, and other options may be considered depending on the severity of the case. Overall, the prognosis is better than that of other intracranial vascular disorders. This review describes the current evidence available regarding cerebral venous thrombosis.

[Portosinusoidal vascular disorder: A paradigm shift]. / Enfermedad vascular portosinusoidal: un cambio de paradigma.

The term portosinusoidal vascular disorder (PSVD) refers to a clinical-pathological entity that encompasses those patients with intrahepatic vascular damage without cirrhosis at risk of developing severe complications of portal hypertension. Numerous systemic diseases, genetic disorders, and toxic agents have been associated with this pathology, making its diagnosis an important clinical challenge. The recent description of uniform diagnostic criteria and a better understanding of its pathophysiology will allow for better identification of patients, even in early stages of the disease. Although there is currently no effective etiological treatment available, early diagnosis allows for the development of preventive strategies for some severe complications of portal hypertension.

[Translated article] Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis.

INTRODUCTION: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analysed. Mortality, risk of bleeding and surgical wound complications was also analysed. RESULTS: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR=0.93; 95% CI: 0.69-1.26; p=0.64), DVT (OR=0.72; 95% CI: 0.43-1.20; p=0.21) or PE (OR=1.13; 95% CI: 0.86-1.49; p=0.38) between both groups. No significant differences were found in mortality (p=0.30), bleeding (p=0.22), or complications in the surgical wound (p=0.85) between both groups. These same findings were found in the sub-analysis of only randomised clinical trials (p>0.05). CONCLUSIONS: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Efectividad de una estrategia educativa en la prescripción de la tromboprofilaxis adecuada en un servicio de Medicina Interna de un hospital general / Effectiveness of an educational strategy in increasing the prescription of adequate thromboprophylaxis in the internal medicine service of general hospital

RESUMEN Objetivo Determinar el impacto de una intervención educativa sobre la frecuencia de prescripciones médicas adecuadas de tromboprofilaxis en un servicio de medicina de un hospital general. Material y métodos Estudio quasi experimental, en el cual en la fase pre-intervención se obtuvieron las frecuencias de indicación de tromboprofilaxis adecuada por parte de los médicos del servicio de medicina. Se realizó una intervención educativa de 8 semanas a este mismo grupo de médicos. En la fase post intervención se midió la frecuencia de la tromboprofilaxis adecuada a los 2 y 4 meses después de la intervención. Resultados La intervención educativa se implementó en 112 médicos residentes de las especialidades de medicina. La totalidad de prescripciones fueron hechas por los médicos residentes de primer año y refrendadas por su médico supervisor. Previamente a la intervención se obtuvieron 47 (44,35%) prescripciones adecuadas, 13 (12,26%) subóptimas, 4 (3,77%) inadecuadas y 42 (39, 62%) ausencia de prescripción. Luego de la intervención se obtuvieron a los 2 meses subsiguientes: 78 (75,72%) prescripciones adecuadas, 7 (6,79%) subóptimas, 4 (2,91%) inadecuadas y 15 (14,58%) ausencias de prescripción, habiendo diferencia significativa con el nivel basal. A los 4 meses subsiguientes postintervención se obtuvieron: 86 (83,49%) adecuada, 5(4,85%) subóptima, 2 (1,94%) inadecuada y 10 (9,72%) ausencia de prescripción, habiendo diferencia significativa con el nivel basal. No hubo aumento en la frecuencia de sobre uso. Conclusiones La aplicación de una estrategia educativa al personal médico fue efectiva en el incremento de las prescripciones de tromboprofilaxis correctamente indicadas en un servicio de medicina. No se encontró sobreuso de la tromboprofilaxis luego de la intervención.

SUMMARY Objective To determine whether an educational intervention strategy would improve the frequency of medical prescriptions for adequate thromboprophylaxis in a medicine service. Methods Quasi-experimental study, in which in the pre-intervention phase the frequencies of indication of appropriate thromboprophylaxis by physicians from the medicine service were obtained. An 8-week educational intervention was carried out with this same group of doctors. In the post-intervention phase, the frequency of adequate thromboprophylaxis was measured at 2 and 4 months after the intervention. Results The educational intervention was implemented in 112 resident physicians in medicine specialties. All prescriptions were made by the first-year resident physicians and endorsed by their supervising physician. Prior to the intervention, 47 (44.35%) adequate prescriptions were obtained, 13 (12.26%) suboptimal, 4 (3.77%) inadequate, and 42 (39, 62%) no prescription. After the intervention, the following 2 months were obtained: 78 (75.72%) adequate prescriptions, 7 (6.79%) suboptimal, 4 (2.91%) inadequate and 15 (14.58%) no prescriptions, there being a significant difference with the baseline level. At the subsequent 4 months post-intervention, the following were obtained: 86 (83.49%) adequate, 5 (4.85%) suboptimal, 2 (1.94%) inadequate and 10 (9.72%) no prescription, with a difference significant with the baseline level. There was no increase in the frequency of overuse. Conclusions The application of an educational strategy to medical personnel was effective in increasing correctly indicated thromboprophylaxis prescriptions in a medical service. No overuse of thromboprophylaxis was found after the intervention.

Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study.

INTRODUCTION: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications. OBJECTIVE: The aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain. METHODS: We conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 10 Spanish centres. RESULTS: We included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3 to 6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P =  .03), focal deficits (P = .001), and encephalopathy (P < .001) showing a statistically significant association with poor prognosis (mRS > 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%. CONCLUSION: The diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.

Sobreexpresión del factor VIII, riesgo de trombosis y tratamiento / Overexpression of factor VIII: risk for thrombosis and treatment

Introducción: la trombosis venosa profunda (TVP) es una enfermedad multifactorial, la cual se ha relacionado con estados de hipercoagulabilidad, alteraciones del flujo sanguíneo y lesiones vasculares endoteliales. Se ha estimado una tasa de incidencia de 1 a 2 casos por mil habitantes año, y casi 2 millones de nuevos casos anuales en Estados Unidos. Existen factores de riesgo establecidos y las trombofilias parecen ocupar un lugar importante en su etiología y los estados de hipercoagulabilidad secundarios a niveles elevados de factor de coagulación VIII asociado a disfunción endotelial, y al incremento de adhesión plaquetaria confieren también una gran predisposición a la aparición de trombosis. Presentación del caso: paciente de 24 años de edad, sin antecedentes de importancia. Consulta por una masa indurada en región axilar derecha, que resultó ser TVP de la vena yugular externa, confluente yugulosubclavio, vena supraclavicular axilar y humeral con alto riesgo de embolización; a su vez se documentó tromboembolia pulmonar y se sospechó trombosis cerebral. La búsqueda de estados procoagulantes no arrojó ningún resultado, posteriormente se mide Factor VIII con sobreexpresión de 223% del valor normal y tras una revisión literaria del tratamiento documentada en el presente artículo se determina que el tratamiento más adecuado es warfarina

Introduction: Deep vein thrombosis (DVT) is a multifactorial medical condition that has been related to hypercoagulable states, alterations in blood flow and lesions in vessel endothelium. The incidence of DVT ranges between 1 and 2 cases per 1000 people and almost two million new cases per year in the United States. Some risk factors have been identified. Thrombophilias seem to play an important role in DVT etiology. Hypercoagulability states secondary to high blood coagulation factor VIII levels associated with endothelial dysfunction and increased platelet adhesion, pose a higher predisposition for thrombosis. Case report: we present the case of a 24-year-old male patient, with no relevant past history, who presented with an indurated mass in the right axillary region, which turned out to be a DVT of the external jugular vein, jugulo-subclavian confluence, supraclavicular, axillary and humeral veins with high risk of embolism. Pulmonary thromboembolism was documented and cerebral venous thrombosis was suspected. The search for procoagulant states yielded no results. Factor VIII levels were measured revealing an overexpression of factor VIII at 223% [normal range 50 ­ 200%]. A literature review determined warfarin to be the proper treatment

Trombosis venosa mesentérica y portal como causa infrecuente de obstrucción e isquemia intestinal en paciente joven. Reporte de caso / Mesenteric and Portal Venous Thrombosis as an infrequent cause of intestinal Obstruction and Ischemia in young patients. A case report

Resumen La isquemia mesentérica aguda se asocia a una mortalidad de entre el 50 y el 100%, la causa más rara de esta es la trombosis venosa de los vasos mesentéricos (5%) y portal (1%). Las manifestaciones clínicas son diversas, siendo el dolor abdominal el principal síntoma. La tomografía computarizada con contraste intravenoso en fase portal es la imagen más precisa para el diagnóstico. El tratamiento en fase aguda se basa en anticoagulación, fluidos intravenosos, antibióticos profilácticos, descanso intestinal y descompresión. La laparotomía de control de daños, incluida la resección intestinal y el abdomen abierto, pueden estar justificados en última instancia para pacientes con necrosis intestinal y sepsis. Caso clínico: Hombre de 35 años, sin antecedentes de importancia, solo tabaquismo desde hace 15 años. Refirió que 5 días previos comenzó a presentar dolor en el epigastrio tipo cólico, de intensidad moderada, posteriormente refirió que el dolor se generalizó y aumentó de intensidad, acompañado de náusea, vómito, intolerancia a la vía oral y alza térmica. Al examen físico tuvo datos de respuesta inflamatoria sistémica, estaba consciente y orientado, con abdomen doloroso a la palpación superficial y profunda a nivel generalizado, pero acentuado en el flanco derecho, rebote positivo con resistencia, timpanismo generalizado, peristalsis ausente. Se ingresó a quirófano a laparotomía exploradora, encontrando lesión a intestinal isquémica-necrótica a 190-240 cm del ángulo de Treitz, y 400 cc de líquido hemático; se realizó resección de la parte intestinal afectada, con entero-enteroanastomosis término-terminal manual. Se envió pieza a patología, y se reportó un proceso inflamatorio agudo con necrosis transmural y congestión vascular. Ante estos hallazgos se realizó angiotomografía abdominal que reportó defecto de llenado en la vena mesentérica superior, secundario a trombosis que se extendía hasta la confluencia y la vena porta. Conclusión: La trombosis venosa mesentérica y portal es una patología muy infrecuente en pacientes jóvenes sin factores de riesgo en los que se presenta dolor abdominal. El diagnóstico es complejo debido a que los datos clínicos y de laboratorio son poco específicos. Sin embargo, debemos tenerla en cuenta en el diagnóstico diferencial de etiologías de dolor abdominal.

Abstract Acute Mesenteric Ischemia is associated with a mortality rate between 50% and 100%; the rarest cause of this is venous thrombosis of the mesenteric (5%) and portal (1%) vessels. The clinical manifestations are diverse, with abdominal pain being the main symptom. Computed tomography with intravenous contrast in the portal phase is the most accurate image for diagnosis. Treatment in the acute phase is based on anticoagulation, intravenous fluids, prophylactic antibiotics, intestinal rest, and decompression. Damage control laparotomy, including bowel resection and open abdomen, may ultimately be warranted for patients with bowel necrosis and sepsis. Clinical case: 35-year-old man, with no significant history, only smoking for 15 years. For 5 days before, he reported crampy epigastric pain of moderate intensity. He subsequently reported that the pain became generalized and increased in intensity, accompanied by nausea, vomiting, oral intolerance, and temperature rise. The physical examination showed signs of a systemic inflammatory response, conscious and oriented, abdomen painful on superficial and deep palpation at a generalized level but accentuated on the right flank, positive rebound with resistance, generalized tympanism, absent peristalsis. The operating room was entered for exploratory laparotomy, finding an ischemic-necrotic intestinal lesion at 190 - 240 cm from the angle of Treitz, and 400cc of blood fluid. Resection of the affected intestinal part is performed, with entire manual terminal end anastomosis. The specimen was sent to pathology, reporting an acute inflammatory process with transmural necrosis and vascular congestion. Given these findings, abdominal CT angiography was performed, which reported a filling defect in the superior mesenteric vein, secondary to thrombosis that extended to the confluence and the portal vein. Conclusion: Mesenteric and portal venous thrombosis is a very rare pathology in young patients without risk factors in whom abdominal pain occurs. The diagnosis is complex because the clinical and laboratory data are not very specific. However, we must take it into account in the differential diagnosis of abdominal pain etiologies.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy.

INTRODUCTION: Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC. MATERIALS AND METHODS: Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed. RESULTS: Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization. CONCLUSION: In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Trombosis venosa y de senos cerebrales en recién nacidos y niños / Venous and cerebral sinus thrombosis in newborns and children

Resumen Introducción : La trombosis de venas y senos venosos cerebrales (TVSC) constituye una causa conocida, aun que subestimada de ictus en la infancia. Su diagnóstico requiere un alto índice de sospecha, una correcta in terpretación de la neuroimagen e interrelación entre el clínico y el radiólogo. Objetivo : Analizar las manifestaciones clínicas, fac tores de riesgo y neuroimagen de recién nacidos (RN) y niños menores de 15 años con TVSC. Métodos: Estudio descriptivo, retrospectivo, multi céntrico, de una serie consecutiva de casos de menores de 15 años que ingresaron por TVSC entre el 1 de enero del 2010 y el 1 de marzo de 2022. Resultados : El estudio incluyó 51 pacientes: 39% con síntomas agudos y 59% subagudos. En los RN predomi naron síntomas encefalopáticos y convulsiones, mien tras en los niños elementos de hipertensión endocranea na (HTEC). Se identificaron factores de riesgo en el 90% de los casos. La resonancia magnética con angiografía en tiempo venoso confirmó el diagnóstico en el 80%, siendo el seno recto el más afectado en RN y el seno lateral en niños. Se encontraron complicaciones hemorrágicas en 30.5%, siendo más frecuentes en los RN. Se inició anti coagulación en el 82% sin complicaciones. Las secuelas estuvieron presentes en 44.4% de RN y 37.9% de niños, siendo más frecuentes y graves en los RN. Conclusiones : Para realizar un diagnóstico precoz es fundamental pensar en TVSC en RN con síntomas en cefalopáticos y/o convulsiones y en mayores con clínica de HTEC en presencia de enfermedades predisponentes o desencadenantes.

Abstract Introduction : Cerebral venous sinus thrombosis (CVST) is a well-known, although underestimated, cause of stroke in childhood. Its diagnosis requires a high index of suspicion, a correct interpretation of neuroim aging studies and an interrelation between clinicians and radiologists. The clinical features, risk factors and neuroimaging of children under 15 years of age with CVST were analyzed. Methods : multicenter, retrospective, descriptive, study of a consecutive series of cases of children under 15 years of age, who were admitted due to CVST between January 1st, 2010, and March 1st, 2022. Results : The study included 51 patients: 39% with acute symptoms and 59% with subacute symptoms. Newborns predominantly presented encephalopathic symptoms and seizures, while children exhibited signs of intracranial hypertension (ICH). Risk factors were 96 identified in 90% of the cases. Magnetic resonance with angiography in venous time confirmed the diagnosis in 80% of the patients, with the straight sinus being the most affected in newborns and the lateral sinus in chil dren. Hemorrhagic complications were found in 30.5%, being more frequent in newborns. Anticoagulation was initiated in 82% without complications. Sequelae were present in 44.4% of newborns and 37.9% of children, being more frequent and severe in newborns. Conclusions : To make an early diagnosis, it is essen tial to consider CVST in newborns with encephalopathic symptoms and/or seizures, and in children with signs of ICH in the presence of predisposing or triggering conditions.

Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. / Riesgo de tromboembolismo venoso en la tromboprofilaxis entre aspirina y heparinas de bajo peso molecular tras una artroplastia total de cadera o artroplastia total de rodilla. Revisión sistemática y metaanálisis.

INTRODUCTION: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed. RESULTS: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05). CONCLUSIONS: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Serum PLA2R antibody as a predictive biomarker for venous thromboembolism risk in primary membranous nephropathy.

BACKGROUND: Patients with nephrotic syndrome are at high risk of venous thromboembolism (VTE), especially for primary membranous nephropathy (PMN). The phospholipase A2 receptor (PLA2R) is a marker of primary membranous nephropathy activity. This study investigated the predictive value of PLA2R antibodies in PMN for VTE. METHODS: In this retrospective study, we included 97 PMN patients and evaluated the predictive value of serum PLA2R antibodies for VTE risk. Lower extremity venous ultrasound, renal vein ultrasound, or spiral computed tomography pulmonary arteriography were used to assess VTE events. Serum anti-PLA2R antibodies were detected by enzyme-linked immunosorbent assay (ELISA). The risk of VTE was stratified according to serum albumin levels. RESULTS: Twenty PMN patients (21%) had thromboembolic events. Eight (15%) of patients with serum albumin >25g/l developed VTE, 6 of whom were positive for serum PLA2R antibodies. Positive serum PLA2R antibodies were significantly associated with VTE events in patients with serum albumin >25g/l (p=0.01). Age, sex, blood creatinine, serum albumin, and 24-h urine protein levels were not statistically different between the two groups. Kaplan-Meier analysis using the log-rank test revealed anti-PLA2R positive membranous nephropathy patients had more probability of VTE events than anti-PLA2R negative patients. Univariate Cox proportional hazards analysis revealed that lnPLA2R-Ab is an unfavorable predictor for VTE events in patients with serum albumin >25g/l (hazard ratio (HR) 2.1, p=0.01). CONCLUSIONS: The PLA2R antibody was a risk predictor for thromboembolic events in patients with primary membranous nephropathy with serum albumin >25g/l.