Topical vs. intravenous administration of tranexamic acid in knee arthroplasty and prevalence of deep venous thrombosis: a randomized clinical trial / Uso tópico versus intravenoso de ácido tranexâmico na artroplastia de joelho e prevalência de trombose venosa profunda: estudo clínico randomizado

BACKGROUND: Tranexamic acid (TXA) is widely used in orthopedic surgery to reduce perioperative bleeding. Since TXA inhibits fibrinolysis, there is concern that it may increase the risk of thromboembolic events. OBJECTIVES: To verify the prevalence of deep venous thrombosis (DVT) in patients receiving TXA during total knee arthroplasty and to compare topical with intravenous administration of the drug. METHODS: All patients admitted for total knee arthroplasty due to primary arthrosis between June and November of 2014 were recruited consecutively. Thirty patients were randomized to a "topical group&" (1.5 g TXA diluted in 50ml saline sprayed over the area operated, before tourniquet release), 30 to an intravenous; (20mg/kg TXA in 100 ml of saline, given at the same time as anesthesia), and 30 to a control group (100 ml of saline, given at the same time as anesthesia). All patients had duplex ultrasound scans of the legs on the 15th postoperative day. RESULTS: Deep venous thrombosis events occurred in five of the 90 patients operated (one out of 30 in the topical group [3.3%], four out of 30 in the control group [13.3%], and zero in the intravenous group). All were confirmed by duplex ultrasound scans and all were asymptomatic. Prevalence rates of DVT were similar between groups (p = 0.112 for control vs. intravenous; p = 0.353 for control vs. topical; and p =1.000 for intravenous vs. topical, according to two-sided exact tests). CONCLUSIONS: Both topical and intravenous administration of TXA are safe with regard to occurrence of DVT, since the number of DVT cases in patients given TXA was not different to the number in those given placebo.

CONTEXTO: O ácido tranexâmico é amplamente utilizado em cirurgia ortopédica para reduzir a hemorragia perioperatória. Como o ácido tranexâmico inibe a fibrinólise, há uma preocupação de que ele possa aumentar o risco de eventos tromboembólicos. OBJETIVOS: Verificar se o uso do ácido tranexâmico é seguro em relação à prevalência de trombose venosa profunda em pacientes submetidos a artroplastia total do joelho, e comparar as administrações tópica e intravenosa desse medicamento. MÉTODOS: Todos os pacientes consecutivamente admitidos para artroplastia total do joelho devido a artrose primária entre junho e novembro de 2014 foram recrutados. Os pacientes foram randomizados em um "grupo tópico" (1,5 g de ácido tranexâmico diluído em 50 ml de solução salina cobrindo toda a área operada antes de liberar o torniquete), um "grupo intravenoso" (20 mg/kg de ácido tranexâmico em 100 ml de solução salina no momento da anestesia) e um "grupo controle" (100 ml de solução salina com a anestesia). No 15º dia de pós-operatório, todos os pacientes foram submetidos a ultrassonografia vascular com Doppler de membros inferiores, independentemente de sintomas. RESULTADOS: Dos 90 pacientes operados, apenas cinco apresentaram trombose venosa profunda (um no grupo tópico e quatro no grupo controle). CONCLUSÕES: Tanto a administração tópica quanto a intravenosa de ácido tranexâmico são seguras em termos de ocorrência de trombose venosa profunda, pois o número de casos de trombose venosa profunda foi semelhante quando comparamos os pacientes que receberam ácido tranexâmico e os que receberam placebo. Novos estudos, com amostras maiores, são necessários para confirmar esse achado.

Recanalization after acute deep vein thrombosis / Recanalizacao apos trombose venosa profunda aguda

The process of recanalization of the veins of the lower limbs after an episode of acute deep venous thrombosis is part of the natural evolution of the remodeling of the venous thrombus in patients on anticoagulation with heparin and vitamin K inhibitors. This remodeling involves the complex process of adhesion of thrombus to the wall of the vein, the inflammatory response of the vessel wall leading to organization and subsequent contraction of the thrombus, neovascularization and spontaneous lysis of areas within the thrombus. The occurrence of spontaneous arterial flow in recanalized thrombosed veins has been described as secondary to neovascularization and is characterized by the development of flow patterns characteristic of arteriovenous fistulae that can be identified by color duplex scanning. In this review, we discuss some controversial aspects of the natural history of deep vein thrombosis to provide a better understanding of its course and its impact on venous disease.

O processo de recanalização das veias dos membros inferiores, após um episódio de trombose venosa profunda aguda em pacientes anticoagulados com heparina e inibidores da vitamina K, faz parte da evolução natural da remodelagem do trombo venoso. Esse complexo processo de remodelagem envolve a adesão do trombo à parede da veia, à resposta inflamatória da parede do vaso, levando à organização e subsequente contração do trombo, à neovascularização e à lise espontânea de áreas no interior do trombo. A presença de fluxo arterial espontâneo em veias com trombose recanalizada tem sido descrita como secundária à neovascularização e se caracteriza pelo desenvolvimento de fluxo com padrão de fístulas arteriovenosas, identificadas por meio de mapeamento dúplex colorido. Nesta revisão, são discutidos alguns aspectos controversos da história natural da trombose venosa profunda, para uma melhor compreensão da sua evolução e do seu impacto sobre a doença venosa.

Did Rubens' Delilah have Mondor's disease?

BACKGROUND: Rubens was a master of European Baroque painting and a practitioner of realism. A female model for his paintings of Samson and Delilah and the Three Graces has apparent right-sided breast abnormalities. METHOD AND RESULTS: Examination of the images shows persistent changes. The clinical scenario suggests Mondor's disease, possibly related to rheumatoid arthritis or chronic infection. DISCUSSION: Visible breast changes such as distortion, skin retraction and nipple deviation warrant concern and require investigation.

Mondor's disease: what's new since 1939?

Mondor's disease (MD) is a rare and self-limited benign disease first described in 1939. Originally its clinical presentation was a superficial vein thrombosis (SVT) without contiguous skin inflammation of the chest wall veins. Over time its definition has evolved and now also includes subcutaneous thrombosis of the dorsal vein of the penis but also retractile scarring of the fascia after breast surgery without concomitant SVT. In all cases clinical examination constitutes the first step of diagnostic management. It is followed by an ultrasound exploration (US) to search for a thrombus. In about half of all cases the disease is considered as idiopathic and cancer is rare. Whatever the location considered, the follow-up is usually uneventful with low rates of recurrence and of subsequent cancer. Treatment is debated and ranges from therapeutic abstention to anticoagulants or even surgery. It is likely that the new locations and mechanisms (without thrombosis) of the MD have lead to the constitution of a heterogeneous entity precluding from a consensual mode of care.

Risk factors and prophylaxis for deep venous thrombosis in neurosurgery.

Acceptance is increasing for pharmacological prophylaxis against deep vein thrombosis (DVT) and pulmonary embolism (PE) for most types of surgery, but its use remains controversial in neurosurgical patients because of the threat of catastrophic hemorrhage. Consequently, mechanical measures such as sequential calf compression and graduated compression stockings are currently the preferred prophylaxis for neurosurgical patients. However, some patients remain at high risk despite these measures and may require prophylaxis with low molecular weight heparins or unfractionated heparin. In neurosurgical patients, known risk factors for DVT or PE include advanced age, malignancy, limb weakness, prolonged surgery, and cranial as opposed to spinal surgery. Using comprehensive neurosurgery databases, the authors identify more specific neurosurgical diagnoses and procedures as risk factors for DVT and PE, and show increases in the frequency of DVT and PE for the wider neurosurgery population and for glioma patients over time. DVT prophylaxis is compared in public and private hospital settings. This chapter contributes to the changing picture of DVT and PE in neurosurgical patients over the last two decades.

Armand Trousseau--some of his contributions to neurology.

Trousseau made a remarkably large number of original clinical contributions to medicine and neurology. Best known are Trousseau's syndrome, the combination of venous thrombosis with visceral carcinoma; tache cérébrale, the red streak seen on scratching the skin in acute meningitis; and Trousseau's sign, the cardinal physical sign in tetany. His pioneering work in tracheostomy in diphtheria, haemochromatosis, Parkinson's disease, aphasia and chorea are but a few of his outstanding clinical studies. Based on his famously comprehensive text, Clinique Médicale de l'Hôtel Dieu, this paper highlights a few of his discoveries. The name of Armand Trousseau must stand alongside those of Charcot, Oppenheim, Jackson and Gowers in the annals of neurology.