Incidence and outcomes of thromboembolic events in plastic surgery infirmary patients.

INTRODUCTION: This study was developed to determine the incidence and outcome of thromboembolic events in a plastic surgery infirmary. METHODS: In a retrospective study, using the hospital's software of statistics and database, we selected the patients admitted to the plastic surgery infirmary of Hospital São João, Porto- Portugal, from 2006 to the end of 2015. Using software diagnosis codification that is the same as the International Classification of Diseases, Ninth Revision (ICD-9), we selected patients that suffered a deep venous thrombosis or pulmonary embolism and reviewed their medical records - collected the number of patients submitted to abdominoplasty, head and neck cancer patients, and breast cancer patients. RESULTS: Of the 10,473 patients of the data set, nine patients were diagnosed with a venous thromboembolism (VTE) event, leading to a rate of 0.09% over the 10 years. During that period, 1728 abdominoplasties were performed, and there were three cases of VTE (0.17%); 338 head and neck cancer patients, three VTE events (0.9%), and one VTE (0.2%) in 506 breast cancer patients. CONCLUSION: This study suggests that in plastic surgery, VTE risk assessment and corresponding prophylaxis cannot be neglected.

INTRODUCCIÓN: Este estudio fue desarrollado para determinar la incidencia y el resultado de tromboembólicos eventos (TEV) en una enfermería de cirugía plástica. MÉTODOS: En un estudio retrospectivo, utilizando el software del hospital de estadísticas y base de datos, seleccionamos a los pacientes ingresados a la cirugía plástica enfermería del Hospital São João, Portugal, desde 2006 hasta finales de 2015. Usando una codificación de diagnóstico de software que es la misma que la Clasificación Internacional de Enfermedades, Novena Revisión (CIE-9), pacientes seleccionados que sufrieron una trombosis venosa profunda o embolia pulmonar y revisó sus registros médicos, recopilados el número de pacientes sometidos a abdominoplastia, cabeza y cuello pacientes con cáncer y pacientes con cáncer de mama. RESULTADOS: De los 10473 pacientes del conjunto de datos, nueve pacientes fueron diagnosticados con un evento de TEV, lo que lleva a una tasa de 0,09% durante los diez años. Durante Eso período, se realizaron 1728 abdominoplasties, y hubo 3 casos de TEV (0,17%); 338 pacientes con cáncer de cabeza y cuello, 3 eventos de TEV (0,9%) y un TEV (0,2%) en 506 pacientes con cáncer de mama. CONCLUSIÓN: Este estudio sugiere que en la cirugía plástica, la evaluación del riesgo de TEV y la profilaxis correspondiente no puede ser descuidada.

Thromboembolic Events Related to Treatment with Checkpoint Inhibitors: Report of Two Cases.

Despite the significant clinical benefits, checkpoint inhibition is associated with a unique spectrum of immune-related adverse events. It is sometimes difficult to distinguish some rare adverse effects from a cancer progression; thus, such effects should be reported in clinical trials to be diagnosed by physicians. Only a few cases of arterial embolic events have been described in studies related to patients treated by immunotherapy. In this article, we report the cases of 2 patients who presented rare and severe thromboembolic events after using checkpoint inhibitors. The first case describes multiple organ embolism at the same time, associated with other autoimmune symptoms. In the second case, distal digital necrosis emerged after the initiation of immunotherapy. There is insufficient data about the real incidence of thromboembolic and rheumatological events related to checkpoint inhibition. Future trials should be done to establish preventive strategies.

Deep Vein Thrombosis as Initial Manifestation of Whipple Disease.

INTRODUCTION: Wipple disease (WD) is a rare chronic disease caused by the bacillus Tropheryma whipplei. Constitutive, rheumatologic, gastrointestinal, cardiac, cerebral, lymphatic, cutaneous, and ophthalmological signs are possible systemic symptoms. However, thrombotic manifestations are rarely described as "stroke-like syndrome" or arterial thrombosis. Diagnosis is based on clinical manifestations and pathological examination. Laboratory findings may include anemia, leukocytosis, and thrombocytosis. OBJECTIVE: We report a case of venous thrombosis as initial manifestation of WD. CASE REPORT: We describe the case of a 53-year-old male with iliofemoral vein thrombosis followed by intermittent diarrhea, loss of appetite, abdominal distension, and bloating. A mild malnutrition state with a weight loss of 13 kg, pallor (+/4 +), presence of lower-limb edema (+/4 +), and hypertympanic distended abdomen occurred. Laboratory tests on admission revealed anemia, positive inflammatory activity tests, and normal coagulation. Endoscopic examination showed villous edema with white dotted infiltrates in the second duodenal portion and intestinal lymphangiectasia in the terminal ileum. Pathological examination revealed numerous macrophages with positive periodic acid-Schiff inclusions. Venous Doppler ultrasound showed extensive deep thrombosis on the left lower limb and recanalization of the femoral vein in the right lower limb. The patient was treated with ceftriaxone and enoxaparin sodium, which led to an improvement of gastrointestinal and thrombosis symptoms. COMMENTS: Hypercoagulability, endothelial damage, vasculitis, and blood stasis are present in T. whipplei infection, which are associated with the activation of inflammatory mechanisms as well as procoagulant and thromboembolic events. WD should be part of the differential diagnosis of diseases that cause venous thrombosis of unknown origin.

Breast cancer-associated venous thromboembolism: A case-control study.

Breast cancer is frequently associated with venous thromboembolism (VTE). VTE may result in significant morbidity, a substantial economic burden and even leads to patients' death. Risk factor identification and management of VTE in breast cancer patients remains poorly studied. We evaluated breast cancer patients' baseline and treatment characteristics in predicting VTE occurrence as well as its prognosis. We conducted a case-control study of all breast cancer patients with a VTE diagnosed between January 2007 and December 2011 at the Instituto Nacional de Câncer (INCA) in Brazil. Two hundred and twenty five patients developed VTE and were compared with 225 controls, in the 5-year study period. The bulk of the thrombotic events were unilateral (94.2%) VTEs of the lower extremity (78.7%), largely proximally located (78%). VTE occurred more often within the first 3 years after the diagnosis of cancer (66.2%), being more common in the first 6 months (21.8%). Significant predictors of developing VTE were age 50 years and over (OR 1.85, 95% CI: 1.16-2.95), PS equal to or above 3 (OR 2.01, 95% CI: 1.24-3.26), and the presence of a CVC (OR 2.56, 95% CI: 1.42-4.62). This large retrospective analysis of VTE in breast cancer patients confirms that most events occur early in the treatment course. The incidence of VTE was associated with patients' age, PS, and the presence of CVC. Prospective studies are needed to evaluate outpatient thromboprophylaxis for selected groups of patients.

Absence of in vitro Procoagulant Activity in Immunoglobulin Preparations due to Activated Coagulation Factors.

BACKGROUND: Immunoglobulin (IG) products, including intravenous (IVIG) or subcutaneous (SCIG) immunoglobulins are considered safe and effective for medical therapy; however, a sudden and unexpected increase in thromboembolic events (TE) after administration of certain batches of IVIG products has been attributed to the presence of activated coagulation factors, mainly factor XIa. Our aims were to examine the presence of enduring procoagulant activity during the manufacturing process of IGs, with special focus on monitoring factor XIa, and to evaluate the presence of in vitro procoagulant activity attributed to coagulation factors in different lots of IVIG and SCIG. METHODS: Samples of different steps of IG purification, 19 lots of IVIG and 9 of SCIG were analyzed and compared with 1 commercial preparation of IVIG and 2 of SCIG, respectively. Factors II, VII, IX, XI and XIa and non-activated partial thromboplastin time (NAPTT) were assayed. RESULTS: The levels of factors II, VII, IX, X and XI were non-quantifiable once fraction II had been re-dissolved and in all analyzed lots of IVIG and SCIG. The level of factor XIa at that point was under the detection limits of the assay, and NAPTT yielded values greater than the control during the purification process. In SCIG, we detected higher concentrations of factor XIa in the commercial products, which reached values up to 5 times higher than the average amounts found in the 9 batches produced by UNC-Hemoderivados. Factor XIa in commercial IVIG reached levels slightly higher than those of the 19 batches produced by UNC-Hemoderivados. CONCLUSION: IVIG and SCIG manufactured by UNC-Hemoderivados showed a lack of thrombogenic potential, as demonstrated not only by the laboratory data obtained in this study but also by the absence of any reports of TE registered by the post marketing pharmacovigilance department.

Recombinant factor VIIa is associated with an improved 24-hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients

OBJECTIVE: To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications. INTRODUCTION: Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use. METHODS: Consecutive massively transfused (> 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival. RESULTS: Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events. CONCLUSIONS: Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients.

Terapia antitrombótica en la fibrilación auricular no valvular, a la luz de la medicina basada en la evidencia / Antithrombotic therapy in non-valvular atrial fibrillation

La fibrilación auricular (FA) afecta a más de dos millones de personas en Estados Unidos y se calcula que afectará a más de tres millones para el año 2020. Se caracteriza por la presencia en el electrocardiograma de ondas rápidas e irregulares sobre la línea de base, que varían de tamaño, morfología y tiempo. Es particularmente frecuente en los ancianos. Se produce por múltiples circuitos de microrreentrada que salen de la aurícula, colisionan, se extinguen y reaparecen; es necesaria una masa critica de tejido auricular para sostener un mínimo de circuitos que permitan perpetuar la arritmia. Dos estudios recientes permiten concluir que la terapia dirigida solamente al control de la respuesta ventricular es igualmente efectiva para el control del ritmo cardíaco, lo que desvirtúa la conducta de intentar restablecer el ritmo sinusal en todos los pacientes con FA.Una de las complicaciones más severas de la FA son los eventos tromboembólicos sistémicos que se presentan principalmente al sistema nervioso central; a la FA se le atribuye ser el factor causal en el 15 por ciento de todos los casos y en el 30 por ciento de los que ocurren en personas mayores de 80 años. Se revisan y analizan diferentes estudios de prevención tanto primaria como secundaria en pacientes con FA no valvular, los cuales sustentan las recomendaciones de consensos internacionales para su tratamiento basado en anticoagulación o antiagregación

The number of people with atrial fibrillation (AF) in the United States has been projected to increase from the current 2.2 million to 3 million in 2020. It is characterized by the presence of rapid and irregular waves on the base line that vary in size, shape and timing. It is particularly frequent in the elderly. In AF multiple, small microreentrant circuits are constantly arising in the atria, colliding, being extinguished, and arising again; a critical mass of atrial tissue is required to sustain the minimal number of simultaneous circuits necessary for the perpetuation of the arrhythmia. Two recent studies permit to conclude that the rhythm control strategy offers no survival advantage over the rate control strategy, and there are potential advantages, such as the lower risk of adverse drug effects, with the rate control strategy. One of the most severe complications of AF are the thromboembolic events mainly to the central nervous system. AF is an important independent risk factor for the embolic stroke, responsible for as many as 15% of strokes and for 30% in the group 80 to 89 years old. We analyzed different primary and secondary prevention studies in patients with non-valvular FA, which support the recommendations of guidelines developed by the American College of Cardiology, the American Heart Association, the European Society of Cardiology and ACCP.