Thrombolysis in massive and submassive pulmonary embolism during pregnancy and the puerperium: a systematic review.

Thrombolysis in high-risk pulmonary embolism (PE) patients is recommended worldwide; however, the evidence for thrombolysis during pregnancy and the immediate puerperium remains unclear. We conducted a systematic review from 1950 to 2019 through PubMed, Ovid/Willey, and Cochrane Library to assess the safety and effectiveness of thrombolysis during pregnancy and the immediate puerperium. Additionally, we characterized the clinical presentation, risk stratification, and diagnostic approach. We have communicated our results according to the PRISMA statement. We collected 141 records and, after critical assessment, included 47 case reports of 54 patients, including 43 and 11 patients during pregnancy and puerperium, respectively. During pregnancy, alteplase was the most frequent systemic thrombolytic agent used (67%), but only nine patients received the approved FDA regimen. With catheter-directed thrombolysis, low-dose thrombolytics and fragmentation were the most common regimens. Major bleeding occurred in 18% of cases, but there was no intracranial bleeding. One maternal death occurred secondary to refractory cardiogenic shock. Fetal mortality was 20%. During the immediate puerperium, nine patients received "off-label" first-, second-, and third-generation thrombolytic regimens, and four cases underwent catheter-directed thrombolysis. We observed nine major bleeding events, seven of which were from the uterine location and none of which were intracranial. In conclusion, overall, these data do not suggest prohibitive risk associated with thrombolysis for PE in pregnancy. Management of massive and high-risk submassive PE in pregnancy should be individualized to each patient. In the data presented, no fatal bleeding or intracranial bleeding was observed. Finally, future efforts should systematically collect and report data on high-risk PE in pregnancy and peripartum patients to improve the evidence-base clinical practice.

Factor Xa inhibition and sPESI failure in intermediate-high-risk pulmonary embolism.

We report the case of a 61-year-old man who presented at the Emergency Department (ED), complaining of sudden-onset dyspnea and chest pain after a long flight from Tokyo to Houston. Considering his clinical stability and sPESI 0, enoxaparin 1 mg/kg BID was started for 24 h, and the patient was then considered for early discharge with apixaban 10 mg BID. Direct-factor Xa inhibition did not improve extensive thrombus burden and right ventricular dysfunction despite D-dimer measurement reduction. Because of the treatment failure, we considered thrombolysis. Currently, recommendations to use thrombolysis in patients under non-vitamin K antagonist oral anticoagulants (NOACs) do not exist. Hence, the one dose of apixaban was stopped, and 12 h later, we performed successful thrombolysis. A systematic review from 2007 to 2017 did not identify any cases related to NOACs failure to reduce thrombus burdens in patients with PE and persistent right ventricular dysfunction. We also did not find any evidence of cases that reported strategies for urgent thrombolysis in PE patients on NOACs. To the best of our knowledge, apixaban's failure to reduce thrombus burden, persistent right ventricular dysfunction, and a NOACs-thrombolysis bridge in patients with PE on apixaban has not been previously described. Both the bedside risk stratification and the therapeutic failures should alert clinicians in the ED to the potential limitations of low-molecular-weight heparin, NOACs therapy, and sPESI in the setting of intermediate-high-risk PE.

Quality of life and persistence of COVID-19 symptoms 90 days after hospital discharge.

OBJECTIVE: We aimed to describe the persistence of symptoms in coronavirus disease 2019 (COVID-19) and quality of life (QoL) among patients 90 days after their discharge from the hospital for infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and to determine differences in QoL domains concerning the absence or presence of persistent symptoms. METHODS: To measure QoL, we used a validated Spanish version of the 36-item Short Form Health Survey (SF-36). RESULTS: We included 141 patients. Ninety days after discharge, COVID-19 symptoms persisted in 107 patients (75.9%), with fatigue (55.3%) and joint pain (46.8%) being the most frequent. According to the SF-36, the role-physical score was the dimension with the lowest values (median score, 25; interquartile range, 0-75). Patients with joint pain, fatigue, and dyspnea had lower scores than patients without those symptoms, with 10 of the 13 evaluated SF-36 scales showing lower levels. CONCLUSION: Ninety days after hospital discharge from COVID-19 reference centers, most patients had persistent symptoms and had lower SF-36 scores than patients without symptoms. It is important to follow-up patients discharged from the hospital after SARS-CoV-2 infection, ideally through a post-COVID-19 health care clinic and rehabilitation program, to improve QoL in these patients.

Main Bronchus Stenosis Due to Tuberculosis and Ogilvie's Syndrome: A Case Report of Two Unusual Diseases in the Same Patient.

Main bronchus stenosis as a sequel of pulmonary tuberculosis is infrequent and should raise suspicion of other presentations of the infection. Given its non-specific symptomatology and the absence of a specific diagnostic method, tracheobronchial tuberculosis is usually not suspected and diagnosed despite its great impact on quality of life due to the high incidence of stenosis as a consequence. Ogilvie's syndrome, an uncommon condition, requires careful management and surveillance given the risk of ischemia and colonic perforation intrinsic to the disease. We present a case of a patient with main bronchus stenosis secondary to tuberculosis infection and Ogilvie's syndrome post-surgery.

Phase II clinical trial testing the safety of a humanised monoclonal antibody anti-CD20 in patients with heart failure with reduced ejection fraction, ICFEr-RITU2: study protocol.

INTRODUCTION: Chronic heart failure with reduced ejection fraction (HFrEF) treatment targets neurohormonal inhibition; however, our experimental observations and the recent clinical evidence in myocardial infarction and heart transplant patients support the anti-inflammatory pathway as a potential novel therapeutic target. Therefore, we aimed to assess the safety of human monoclonal antibody-CD20 (rituximab) in patients with HFrEF. METHODS AND ANALYSIS: We designed this protocol according to the Standard Protocol Items: Recommendations for Interventional Trials guidelines as a phase II, single-centred, single group and prospective clinical trial. We hypothesise that the use of a monoclonal antibody, rituximab, could be a potentially safe new agent in HFrEF management. We will include patients with EF≤40%, New York Heart Association functional class III/IV and unresponsive to standard treatment. We will use a dosing regimen (1000 mg) previously applied to post-transplant patients and patients with rheumatoid arthritis with favourable results, aiming to provide supplementary evidence of safety in patients with HFrEF. We designed strategies tailored to preserving the integrity of patient safety. The date of study initiation will be 29th of May 2019. ETHICS AND DISSEMINATION: The following protocol was approved by IRB committees, and as a requirement, all patients need to sign an informed consent form before being subjected to any procedure prior to the initiation of the study. We are aware that the trial will be run in patients who due to their cardiovascular functional class, have reserved prognosis, with no known therapy that leads to improvement. Hence, this trial searches to establish the safety of an alternative strategy in ameliorating prognosis. Regardless of the study outcomes, whether favourable or not, they will be published. If a favourable outcome is evidenced, it will prompt performing a phase III, efficacy-based study. TRIAL REGISTRATION NUMBER: The trial was approved by the IRB (CONBIOÉTICA-19-CEI-011-20161017 and COFEPRIS-17-CI-19-039-003), and registered at Clinicaltrials.gov (NCT03332888; Pre-Results).