Efecto de un equipo multidisciplinar (código TEP) en el pronóstico de los pacientes con tromboembolia de pulmón aguda sintomática / Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism

Antecedentes No se han aclarado suficientemente los beneficios del manejo multidisciplinar (código TEP) de los pacientes con tromboembolia de pulmón (TEP) aguda sintomática. El objetivo de este estudio fue evaluar el efecto sobre la mortalidad a corto plazo del código TEP comparado con la atención habitual. Métodos Realizamos un estudio retrospectivo que incluyó a todos los pacientes con diagnóstico de TEP aguda sintomática ingresados en un hospital terciario universitario entre los años 2007 y 2022. Mediante un análisis de emparejamiento exacto 1:1, los pacientes atendidos por un equipo multidisciplinar para el manejo de la TEP (código TEP) fueron emparejados con otros que recibieron la atención habitual (es decir, no multidisciplinar) para la TEP. El evento primario de eficacia fue la mortalidad por cualquier causa durante los 30 primeros días después del diagnóstico. El evento secundario de eficacia fue la mortalidad por la propia TEP durante el mismo período de tiempo. Resultados De los 2.902 pacientes con diagnóstico de TEP aguda sintomática incluidos en este estudio, 223 (7,7%; intervalo de confianza [IC] del 95%: 6,7-8,7%) fueron manejados por el código TEP. Se emparejaron 207 pacientes manejados por el código TEP con 207 pacientes manejados de forma habitual. En la cohorte emparejada, la atención multidisciplinar a los pacientes con TEP aguda sintomática no se asoció a una reducción significativa de la mortalidad por cualquier causa (odds ratio [OR]: 1,09; IC del 95%: 0,63-1,89) o por la propia TEP (OR: 1,30; IC del 95%: 0,47-3,62) en el mes posterior al diagnóstico de la TEP. Conclusiones La atención multidisciplinar a los pacientes con TEP aguda sintomática no se asoció a una reducción significativa de la mortalidad precoz. (AU)

Background The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE. Methods We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality. Results Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE. Conclusions Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality. (AU)

Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism.

BACKGROUND: The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE. METHODS: We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality. RESULTS: Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE. CONCLUSIONS: Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality.

[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.

Impacto del confinamiento durante la pandemia de COVID-19 en la prevalencia de la enfermedad tromboembólica venosa / Impact of strict confinement during the COVID-19 pandemic on the prevalence of venous thromboembolic disease

Objetivo: comparar la frecuencia de eventos tromboembólicos agudos en pacientes atendidos en urgencias de un hospital comarcal durante las primeras semanas de la pandemia de COVID-19 del año 2020 respecto al año anterior.Material y métodos: estudio retrospectivo en pacientes mayores de 40 años atendidos en urgencias del Hospital de Riotinto (Huelva) desde el 15 de marzo al 30 de abril de los años 2019 y 2020. La recogida de información se llevó a cabo a partir de una revisión de historias clínicas y el cuestionario de recogida de datos contenía variables clínicas y sociodemográficas.Resultados: se incluyeron 1.245 pacientes. Edad media: 71,2 años (desviación estándar [DE]: 13,7) y un 51,1% eran mujeres. En 2019 se atendieron a 797 mayores de 40 años y en 2020 fueron 448, suponiendo un descenso del 43,79%. La prevalencia de embolismo pulmonar fue superior en 2020 respecto a 2019 (1,6% frente a 0,4%; p = 0,024). La frecuencia de eventos trombóticos venosos fue superior también en 2020 respecto a 2019 (1,35% frente a 0,4%; p = 0,054). La prevalencia global de la enfermedad tromboembólica venosa con variable compuesta (tromboembolismo pulmonar + trombosis venosa) fue significativamente superior en 2020 frente a 2019 (2,9% frente a 0,8%; p = 0,003). Ningún paciente fue diagnosticado de COVID-19 y tromboembolismo.Conclusiones: en el período de confinamiento durante la pandemia hubo un incremento del número de eventos tromboembólicos agudos en adultos, tanto de tromboembolia pulmonar como de trombosis venosa profunda respecto al año previo. (AU)

Aim: to compare the frequency of acute thromboembolic events in patients visited in the casualty department of a regional hospital during the first few weeks of the COVID-19 pandemic in 2020 with the same period of previous year.Material and methods: retrospective study of patients aged over 40 years of age treated in the casualty department of Hospital de Riotinto (Huelva) from 15 March to 30 April 2019 and same period of 2020. The information was collected from a review of medical records. The data collection questionnaire contained clinical and sociodemographic variables.Results: a total of 1245 patients were included. Mean age was 71.2 (SD:13.7) years old and 51.1% were women. In 2019, 797 patients aged over 40 years of age were treated, while in 2020, the patients seen were 448, which represented a decrease of 43.79%. The prevalence of pulmonary embolism was higher in 2020 compared to 2019 (1.6% vs. 0.4%; P=0.024). The frequency of venous thrombotic events was also higher in 2020 compared to 2019 (1.35% vs. 0.4%; P=0.054). The overall prevalence of venous thromboembolic disease with composite variable (pulmonary thromboembolism + venous thrombosis) was statistically significantly higher in 2020 versus 2019 (2.9% versus 0.8%; P=0.003). None of our patients were diagnosed with COVID-19 and thromboembolism.Conclusions: during the period of confinement during the pandemic there was an increase in the number of acute thromboembolic events in adults, both PE and VTE compared to the previous year.(AU)

Randomized clinical trial of aspirin as prophylaxis for thromboembolism in hip arthroplasty / Ensaio randomizado da aspirina na profilaxia do tromboembolismo em artroplastia do quadril

ABSTRACT Objective: This study aims to evaluate aspirin as a chemical prophylaxis (200 mg) in total hip arthroplasty. Methods: the study compared two groups and used ultrasonography (USG) to screen for low-deep venous thrombosis. Group 1 received 600 mg (control), and Group 2 received 200 mg of (intervention), associated with the use of elastic compression stockings and early walking Results: fourteen patients were allocated to Group A (200mg), and 16 to Group B (600mg); in group A (200mg), 3 cases with thrombus below the popliteal vein were detected at the first USG examination. All of them are in the left lower limb (21.4%). In group B (600 mg), 5 cases were identified after the first exam (31.2%). All cases were asymptomatic and followed the protocol with prophylaxis only with Aspirin. Conclusion: In the statistical data, there were no differences in the presence of thrombus between the 200- and 600 mg groups, which is credited to using low-dose aspirin in low doses (200mg). Hematimetric levels returned to baseline levels and suggested there was no chronic or acute bleeding related to the use of aspirin. The manuscript was prepared according to the CONSORT guideline 2010. Level of Evidence I; Longitudinal Randomized Comparative Clinical Study.

RESUMO Objetivo: Este estudo pretende avaliar a aspirina como profilaxia química (200 mg) na artroplastia total do quadril. Métodos: estudo comparando dois grupos com diferentes doses de aspirina e utilizando a ultrassonografia (USG) para rastreamento da trombose venosa profunda baixa. O grupo 1, 650 mg ao dia de aspirina (controle) e o grupo 2, 200 mg de aspirina ao dia na mesma posologia (intervenção) e associados ao uso de meias elásticas de compressão e deambulação precoce. Resultados: quatorze pacientes foram alocados no grupo A (200 mg) e 16 no grupo B (650 mg). No grupo A foram detectados 3 casos com trombos abaixo da veia poplítea ao USG sendo 21,4%. Já no grupo B, 5 casos foram identificados após o primeiro exame (31,2%). Todos assintomáticos e sem sinais de sangramento ativo ou queda da hematimetria no momento da detecção dos trombos. Conclusão: os dados sugerem não haver diferença na incidência de trombo em ambos os grupos, não sendo a profilaxia com a aspirina dose-dependente. Os níveis hematimétricos retornaram aos níveis iniciais o que sugere não ter havido sangramento crônico ou agudo relacionado ao uso. Nível de Evidência I; Estudo Clínico Randomizado Longitudinal Comparativo.

Optic neuropathy following COVID-19 vaccine / Neuropatia óptica após a vacina contra a COVID-19

ABSTRACT This case series describes four patients who presented with retinal and optic nerve vascular occlusions after administration of different COVID-19 vaccines. The first patient received the ChAdOx1 nCoV-19 vaccine (AZD1222; Oxford/AstraZeneca) and 42 days later developed central retinal artery occlusion. The second patient developed a painless visual impairment in the left eye and was diagnosed with anterior ischemic optic neuropathy 6 days after receiving the Sinovac-CoronaVac vaccine. The third patient presented with the same condition 22 days after receiving the third dose of the COVID-19 Pfizer (Comirnaty®) vaccine. The fourth patient developed bilateral retrobulbar optic neuritis after receiving the Oxford/AstraZeneca vaccine. The purpose of this case series is to discuss the possibility of a causal association between ischemic eye alterations and COVID-19 virus vaccination. Long-term follow-up and evaluation of similar cases will help elucidate the degree of the association between the vaccine and ischemic ocular events.

RESUMO Esta série de casos descreve quatro casos de pacientes que apresentaram oclusões vasculares de retina e nervo óptico após a administração de tipos diferentes de vacinas contra COVID-19. O primeiro paciente tomou a vacina ChAdOx1 nCoV-19 (AZD1222; Oxford/AstraZeneca) e 42 dias depois desenvolveu oclusão da artéria central da retina. O segundo paciente teve défice visual indolor no olho esquerdo após 6 dias da vacina Sinovac (CoronaVac) e foi diagnosticado com neuropatia óptica isquêmica anterior. O terceiro paciente apresentou o mesmo quadro após 22 dias da terceira dose da vacina COVID-19 Pfizer (Comirnaty®). O quarto paciente desenvolveu neurite óptica retrobulbar bilateral após vacina Oxford/AstraZeneca. O objetivo da nossa série de casos é discutir a possibilidade de correlação entre os quadros oculares isquêmicos e a vacinação contra a COVID-19. Nossos pacientes receberam vacinas contra COVID-19 com tecnologias diferentes e apresentaram quadros isquêmicos oculares relacionados temporalmente à vacinação. O acompanhamento e a avaliação a longo prazo de novos estudos semelhantes elucidarão o grau de associação entre a vacina e esse possível evento adverso.

Anticoagulación precoz con warfarina en pacientes sometidos a sustitución valvular aórtica por bioprótesis: ensayo prospectivo randomizado: análisis interino / Early anticoagulation with warfarin in patients undergoing bioprosthetic aortic valve replacement: randomized prospective trial: interim analysis / Anticoagulação precoce com varfarina em pacientes submetidos à troca valvar aórtica por bioprótese: ensaio prospectivo randomizado: análise provisória

Introducción: aunque las bioprótesis son menos trombogénicas que las válvulas mecánicas; la trombosis de estas es una entidad cada vez más reconocida como causa de disfunción protésica potencialmente reversible. No está definido el beneficio de la anticoagulación rutinaria versus antiagregación plaquetaria luego de la sustitución valvular aórtica (SVA) por bioprótesis. La anticoagulación precoz podría asociarse a menores gradientes transprotésicos con similar riesgo de complicaciones. Objetivos: el objetivo primario es determinar si existe una diferencia significativa en la variación del gradiente transprotésico medio al año de la SVA entre las dos estrategias de tratamiento antitrombótico. Los objetivos secundarios son la comparación de la variación del gradiente máximo y del área valvular aórtica, y parámetros clínicos que incluyen la Clase Funcional de la New York Heart Association, las tasas de sangrado mayor y menor y la incidencia de eventos embólicos. Este trabajo representa el análisis interino a 3 meses de un proyecto a más largo plazo, y se propone mostrar los resultados preliminares de los puntos finales previamente definidos. Métodos: se presenta el análisis interino de un ensayo randomizado multicéntrico. Todos los pacientes sometidos a SVA por bioprótesis porcinas fueron sucesivamente reclutados en dos centros de cirugía cardíaca desde el 01/01/2019 hasta el 01/09/2019. El grupo anticoagulación recibió warfarina durante los primeros 3 meses y ambos recibieron aspirina a largo plazo. Se realizaron instancias de seguimiento clínicas y ecocardiográficas antes del alta, a los 3 meses y al año. Resultados: se reclutaron 107 pacientes; 46% de ellos fueron randomizados al grupo anticoagulación y 54% al grupo control. No existieron diferencias en las características basales. Tampoco existieron diferencias significativas entre ambos grupos en la variación entre el alta y los 3 meses del área valvular protésica, coeficiente de obstrucción, gradiente máximo ni gradiente medio ni en la clase funcional. En cuanto a las complicaciones, no existieron eventos embólicos y los sangrados no difirieron significativamente entre ambos grupos. Conclusiones: la anticoagulación no modificó la variación de los gradientes transprotésicos a los 3 meses. Asimismo, no produjo mayor incidencia de efectos adversos. Todavía no está dilucidado si la anticoagulación precoz con warfarina luego de la SVA tiene impacto en los resultados a largo plazo.

Introduction: although bioprostheses are less thrombogenic than mechanical valves, bioprosthesis valve thrombosis is an increasingly recognized entity that can cause potentially reversible prosthetic valve dysfunction. There is a lack of consensus whether to use anticoagulation after aortic valve replacement (AVR) or antiplatelet therapy. Our hypothesis is that early anticoagulation is associated with lower transprosthetic gradients with similar risk of complications. Objective: primary objective is to determine if there is a significant difference in the variation of the mean transprosthetic gradient (ΔGm) one year after SVA between the two antithrombotic treatment strategies. Secondary objectives are the comparison of the variation of maximum gradient and aortic valve area, and clinical parameters including NYHA functional class, major and minor bleeding rates, and the incidence of embolic events. This work represents the 3-month interim analysis of a longer-term project, and is intended to show the preliminary results of the previously defined end points. Methods: this is an interim analysis of a multicenter randomized trial. All patients who underwent AVR by porcine bioprostheses were successively recruited in two cardiac surgery centers in Montevideo between 01/01/2019 and 01/09/2019. The anticoagulation group received warfarin for 3 months. Both groups received aspirin. Clinical and echocardiographic follow-up consultations were performed before discharge, at 3 months, and at 1 year. Results: 107 patients were recruited, 46% were randomized to the anticoagulation group and 54% to the control group. There were no differences in baseline characteristics. There were no significant differences between the two groups in the variation between discharge and 3 months of effective orifice area, doppler velocity index, peak gradient and mean gradient. There were also no differences between both groups in functional class. Regarding complications, there were no embolic events and bleeding did not differ significantly. Conclusions: in this study, anticoagulation did not modify the variation of transprosthetic gradients at 3 months. Likewise, it did not produce a higher incidence of adverse effects. It remains unclear whether early anticoagulation with warfarin after AVR has an impact on long-term outcomes.

Introdução: embora as biopróteses sejam menos trombogênicas que as mecânicas, a trombose de biopróteses é uma entidade cada vez mais reconhecida como causa de disfunção protética potencialmente reversível. A anticoagulação de rotina após a substituição da valva aórtica por bioprótese (SVA) não está definida. Nossa hipótese é que a anticoagulação precoce está associada a menores gradientes transprotéticos com risco semelhante de complicações. Objetivo: o objetivo principal é determinar se há uma diferença significativa na variação do gradiente transprotético médio (ΔGm) um ano após SVA entre as duas estratégias de tratamento antitrombótico. Os objetivos secundários são a comparação da variação do gradiente máximo e da área valvar aórtica e parâmetros clínicos, incluindo NYHA CF, taxas de sangramento maior e menor e incidência de eventos embólicos. Este trabalho representa a análise intercalar de 3 meses de um projeto de longo prazo, e pretende mostrar os resultados preliminares dos pontos finais previamente definidos. Métodos: apresenta-se a análise interina de um estudo multicêntrico randomizado. Todos os pacientes submetidos a SVA por biopróteses suínas foram sucessivamente recrutados em dois centros de cirurgia cardíaca em Montevidéu, durante um período de recrutamento de 1/1/2019 a 1/9/2019. O grupo de anticoagulação recebeu warfarina por 3 meses. Ambos os grupos receberam aspirina. Foram realizadas consultas médicas clínicas e ecocardiográficas antes da alta, aos 3 meses e ao 1 ano. Resultados: foram recrutados 107 pacientes, 46% foram randomizados para o grupo anticoagulação e 54% para o grupo controle. Não houve diferenças nas características basais. Não houve diferenças significativas entre os dois grupos da variação entre alta e 3 meses na área valvar, coeficiente de obstrução, gradiente máximo ou gradiente médio. Também não houve diferenças entre os dois grupos na classe funcional. Em relação às complicações, não houve eventos embólicos e sangramentos não diferiram significativamente. Conclusões: neste estudo, a anticoagulação não modificou a variação dos gradientes transprotéticos aos 3 meses. Da mesma forma, não produziu maior incidência de efeitos adversos. Ainda não está claro se a anticoagulação precoce com varfarina após SVA tem impacto nos resultados a longo prazo.

Pulmonary embolism rule-out decision-making tools for patients aged 35 years or younger in hospital emergency departments: a post-hoc analysis of performance in 3 prospective cohorts. / Capacidad de diferentes reglas de decisión clínica para descartar tromboembolismo pulmonar en pacientes de 35 o menos años atendidos en servicios de urgencias: análisis post-hoc de tres cohortes prospectivas.

OBJECTIVES: To assess the performance of the Pulmonary Embolism Rule-out Criteria (PERC) and the age-modified PERC-35 tool in hospital emergency departments (EDs) for evaluating patients aged 35 years or younger. A secondary aim was to assess other decision-making criteria. MATERIAL AND METHODS: Post-hoc analysis of 3 European cohort studies. We included data for patients aged 35 years or younger suspected of PE who were followed for 3 months. The safety and efficacy of applying the PERC and PERC-35 were assessed with the diagnostic error rate (failure to detect PE) and the proportion of patients in whom a diagnosis of PE was ruled out. We also assessed the safety and efficacy of applying the YEARS and PEGeD criteria. RESULTS: Data for 1235 patients aged 35 years or younger were analyzed. Twenty-two (1.8%; 95% CI, 1.2%-2.7%) PE cases were diagnosed at 3 months. Six (1.0%; 95% CI, 0.5%-2.2%) and 5 (0.9%; 95% CI, 0.4%-2.1%) PE cases were not diagnosed by the PERC and PERC-35 tools, respectively. These tools allowed PE to be ruled out in 591 (48.2%; 95% CI, 45.4%-51.0%) and 554 (46.2%; 95% CI, 43.4%-49.0%) cases, respectively. The error rates of the YEARS and PEGeD criteria, respectively, were 0.4% (95% CI, 0.1%-1.1%) and 0.5% (95% CI, 0.2%-1.2%); their efficacy was similar. CONCLUSION: The safety and efficacy profiles of the PERC and PERC-35 algorithms were similar in patients aged 35 years or younger. However, the large confidence intervals we report do not allow us to confirm the safety of using the tools in patients in this age group.

OBJETIVO: Evaluar la capacidad de la regla PERC (Pulmonary Embolism Rule-out Criteria) y la regla modificada por edad (PERC-35) para descartar tromboembolia pulmonar (TEP) en servicios de urgencias hospitalarios (SUH) en pacientes 35 años. El objetivo secundario fue analizar otras reglas de decisión clínica. METODO: Análisis post-hoc de 3 estudios de cohorte europeos (PROPER, PERCEPIC y MODIGLIANI). Se incluyeron pacientes 35 años con sospecha de TEP en SUH y con seguimiento a 3 meses. La seguridad y eficacia de PERC y PERC-35 se evaluaron con su tasa de error -no detectar TEP- y la proporción de pacientes con diagnóstico de TEP descartado. Se evaluó la seguridad y eficacia de las reglas YEARS y PEGeD. RESULTADOS: Se analizaron 1.235 pacientes 35 años. Hubo 22 (1,8%, IC 95%: 1,2-2,7) TEP diagnosticados a los 3 meses. Hubo 6 (1,0%, IC 95%: 0,5-2,2) y 5 (0,9%, IC 95%: 0,4-2,1) TEP no diagnosticados con las reglas PERC y PERC-35 respectivamente. Estas reglas permitieron descartar TEP en 591 (48,2%, IC 95%: 45,4- 51,0) y 554 (46,2%, IC 95%: 43,4- 49,0) respectivamente. La tasa de error de YEARS y PEGeD fue del 0,4% (IC 95%: 0,1- 1,1) y 0,5% (IC 95%: 0,2-1,2), con una eficacia similar. CONCLUSIONES: En pacientes 35 años, las reglas PERC y PERC-35 mostraron perfiles de seguridad y eficacia similares. Sin embargo, el amplio intervalo de confianza comunicado en este estudio no permite confirmar su seguridad.

Capacidad de diferentes reglas de decisión clínica para descartar tromboembolismo pulmonar en pacientes de 35 o menos años atendidos en servicios de urgencias: análisis post-hoc de tres cohortes prospectivas / Pulmonary embolism rule-out decision-making tools for patients aged 35 years or younger in hospital emergency departments: a post-hoc analysis of performance in 3 prospective cohorts

Objetivos: Evaluar la capacidad de la regla PERC (Pulmonary Embolism Rule-out Criteria) y la regla modificada por edad (PERC-35) para descartar tromboembolia pulmonar (TEP) en servicios de urgencias hospitalarios (SUH) en pacientes # 35 años. El objetivo secundario fue analizar otras reglas de decisión clínica. Método: Análisis post-hoc de 3 estudios de cohorte europeos (PROPER, PERCEPIC y MODIGLIANI). Se incluyeron pacientes # 35 años con sospecha de TEP en SUH y con seguimiento a 3 meses. La seguridad y eficacia de PERC yPERC-35 se evaluaron con su tasa de error -no detectar TEP- y la proporción de pacientes con diagnóstico de TEP descartado. Se evaluó la seguridad y eficacia de las reglas YEARS y PEGeD. Resultados: Se analizaron 1.235 pacientes # 35 años. Hubo 22 (1,8%, IC 95%: 1,2-2,7) TEP diagnosticados a los 3 meses. Hubo 6 (1,0%, IC 95%: 0,5-2,2) y 5 (0,9%, IC 95%: 0,4-2,1) TEP no diagnosticados con las reglas PERC y PERC-35 respectivamente. Estas reglas permitieron descartar TEP en 591 (48,2%, IC 95%: 45,4- 51,0) y 554 (46,2%, IC 95%: 43,4- 49,0) respectivamente. La tasa de error de YEARS y PEGeD fue del 0,4% (IC 95%: 0,1- 1,1) y 0,5% (IC 95%: 0,2-1,2), con una eficacia similar. Conclusiones: En pacientes # 35 años, las reglas PERC y PERC-35 mostraron perfiles de seguridad y eficacia similares. Sin embargo, el amplio intervalo de confianza comunicado en este estudio no permite confirmar su seguridad. (AU)

Objectives: To assess the performance of the Pulmonary Embolism Rule-out Criteria (PERC) and the age-modified PERC-35 tool in hospital emergency departments (EDs) for evaluating patients aged 35 years or younger. A secondary aim was to assess other decision-making criteria. Method: Post-hoc analysis of 3 European cohort studies. We included data for patients aged 35 years or younger suspected of PE who were followed for 3 months. The safety and efficacy of applying the PERC and PERC-35 were assessed with the diagnostic error rate (failure to detect PE) and the proportion of patients in whom a diagnosis of PE was ruled out. We also assessed the safety and efficacy of applying the YEARS and PEGeD criteria. Results: Data for 1235 patients aged 35 years or younger were analyzed. Twenty-two (1.8%; 95% CI, 1.2%-2.7%) PE cases were diagnosed at 3 months. Six (1.0%; 95% CI, 0.5%-2.2%) and 5 (0.9%; 95% CI, 0.4%-2.1%) PE cases were not diagnosed by the PERC and PERC-35 tools, respectively. These tools allowed PE to be ruled out in 591 (48.2%; 95% CI, 45.4%-51.0%) and 554 (46.2%; 95% CI, 43.4%-49.0%) cases, respectively. The error rates of the YEARS and PEGeD criteria, respectively, were 0.4% (95% CI, 0.1%-1.1%) and 0.5% (95% CI, 0.2%-1.2%); their efficacy was similar. Conclusions: The safety and efficacy profiles of the PERC and PERC-35 algorithms were similar in patients aged 35 years or younger. However, the large confidence intervals we report do not allow us to confirm the safety of using the tools in patients in this age group. (AU)

Manejo de la fibrilación auricular en los servicios de urgencias hospitalarios: actualización a 2023 del consenso de la Sociedad Española de Medicina de Urgencias (SEMES), la Sociedad Española de Cardiología (SEC) y la Sociedad Española de Trombosis y Hem / Emergency department management of atrial fibrillation: 2023 consensus from the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Thrombosis and Hemostasis (SETH)

La fibrilación auricular (FA) es la arritmia sostenida de mayor prevalencia en los servicios de urgencias (SU), y en España presenta una frecuentación elevada y creciente. Esta arritmia es una enfermedad grave, que incrementa la mortalidad y asocia una relevante morbilidad e impacto en la calidad de vida de los pacientes y en el funcionamiento de los servicios sanitarios. La diversidad de aspectos clínicos a considerar y el elevado número de opciones terapéuticas posibles justifican la implementación de estrategias de actuación coordinadas entre los diversos profesionales implicados, con el fin de incrementar la adecuación del tratamiento y optimizar el uso de recursos. Este documento, realizado por un grupo multidisciplinario de expertos en arritmias cardiacas miembros de la Sociedad Española de Medicina de Urgencias y Emergencias, la Sociedad Española de Cardiología y la Sociedad Española de Trombosis y Hemostasia, recoge las recomendaciones para el manejo de la FA en los SU hospitalarios, basadas en la evidencia disponible y adaptadas a las especiales circunstancias de los mismos. En él se analizan con detalle las estrategias de profilaxis tromboembólica, control de frecuencia y control del ritmo, y los aspectos logísticos y diagnósticos relacionados. (AU)

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia managed in emergency departments, and the already high prevalence of this arrhythmia is increasing in Spain. This serious condition associated with increased mortality and morbidity has a negative impact on patient quality of life and the functioning of the health care system. The management of AF requires consideration of diverse clinical variables and a large number of possible therapeutic approaches, justifying action plans to coordinate the work of several medical specialties in the interest of providing appropriate care and optimizing resources. This consensus statement brings together recommendations for emergency department management of AF based on available evidence adapted to special circumstances. The statement was drafted by a multidisciplinary team of specialists from the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Thrombosis and Hemostasis (SETH). Strategies for stroke prophylaxis, measures to bring heart rate and heart rhythm under control, and related diagnostic and logistic issues are discussed in detail. (AU)

Diferencias de sexo en los beneficios de la anticoagulación en pacientes ancianos con fibrilación auricular: un subanálisis del estudio EMERG-AF / Sex-related differences in benefits of anticoagulation therapy in elderly patients with atrial fibrillation: a subanalysis of the EMERG-AF study

Objetivos: Analizar los beneficios y seguridad a largo plazo de la anticoagulación oral (ACO) prescrita en los servicios de urgencias (SU) a pacientes mayores con fibrilación auricular (FA) y las diferencias en función del sexo. Método: Se trata de un análisis post-hoc del estudio EMERG-AF. Se incluyeron pacientes consecutivos $ 75 años, que consultaron en 62 SU por FA. Se recogieron datos clínicos y ACO. La variable principal estuvo compuesta por muerte, tromboembolia o sangrado mayor en 1 año. Resultados: Se incluyeron 690 pacientes, 386 mujeres (55,9%). Al alta, 575 pacientes (83,3%) estaban con ACO. En 96 de ellos se inició en el SU. Tras 1 año, la variable principal sucedió en 158 pacientes (22,9%): 118 (17,1%) fallecieron, 22 (2,7%) tuvieron una complicación tromboembólica y 34 (4,9%) una hemorragia mayor. Tras ajustar por las principales características clínicas, la ACO se asoció a una reducción en la variable principal (HR: 0,372, IC 95%: 0,236-0,587, p < 0,001), pero no se asoció con la hemorragia mayor. En las mujeres, la ACO se asoció con una reducción en la variable principal (HR: 0,372, IC 95%: 0,236-0,587, p < 0,001) y una menor mortalidad (HR: 0,281, IC 95%: 0,168-0,469, p < 0,001), incluidos pacientes con nueva prescripción y en aquellos dados de alta. Esta asociación no alcanzó significación en los hombres. (AU)

Objectives: To analyze the long-term benefits and safety of oral anticoagulation therapy prescribed in emergency departments for elderly patients with atrial fibrillation, and to detect any sex-related differences present. Material and methods: Post-hoc analysis of data compiled by the EMERG-AF group (Spanish acronym for Emergency Department Stroke Prophylaxis and Guidelines Implementation in Atrial Fibrillation). Consecutive patients aged 75 years or older with atrial fibrillation who were treated in 62 EDs were included. We recorded clinical data and anticoagulants prescribed. Patients were followed for 1 year. The main outcome variable was a composite of death, thromboembolism, or major bleeding within 1 year. Results: Data for 690 patients were registered; 386 (55.9%) were women. At discharge, 575 patients (83.3%) were on anticoagulants; therapy was started in the ED for 96 of them. A total of 158 patients (22.9%) had experienced at least 1 component of the main outcome within 1 year: 118 (17.1%) died, 22 (2.7%) had thromboembolic complications, and 34 (4.9%) had major bleeding. After adjustment for main clinical characteristics, hazard ratios (HRs) showed that anticoagulation therapy was associated with a reduction in the composite outcome (HR, 0.372; 95% CI, 0.236-0.587; P .001) but not specifically with major bleeding overall. When data for women were analyzed separately, anticoagulant therapy was again associated with a reduction in the composite outcome (HR, 0.372; 95% CI, 0.236-0.587; P .001) and also with death (HR, 0.281; 95% CI, 0.168-0.469; P .001), even in patients with anticoagulant prescriptions initiated on discharge from the ED. These associations did not reach statistical significance in men. (AU)

Deep Vein Thrombosis after a Supracondylar Fracture of the Humerus in a Child - A Rare Complication / Trombose venosa profunda após uma fratura supracondilar do úmero em uma criança - Uma complicação rara

Abstract Deep vein thrombosis in the upper extremities is uncommon, especially in the pediatric population and in the trauma setting. The diagnosis is challenging, due to its rarity, requiring a high degree of suspicion. We describe a rare case of humeral vein thrombosis after a displaced supracondylar fracture of the humerus in a 7-year-old girl. The risk factors for thromboembolism and sequelae are also discussed. The early detection and treatment are mandatory to prevent poor outcomes, such as fatal thromboembolism.

Resumo Trombose venosa profunda nas extremidades superiores é incomum, especialmente na população pediátrica e no ambiente do trauma. O diagnóstico é desafiador, devido a sua raridade, exigindo alto grau de suspeita. Descrevemos um caso raro de trombose venosa úmera após uma fratura supracondilar deslocada do úmero em uma menina de 7 anos. Os fatores de risco para tromboembolismo e sequelas também são discutidos. A detecção e o tratamento precoces são obrigatórios para evitar desfechos ruins, como tromboembolismo fatal.

Tromboembolia pulmonar masiva en un paciente con enfermedad de Crohn y tuberculosis latente tratada con ustekinumab

La enfermedad inflamatoria intestinal (EII) es un espectro de enfermedades crónicas inmunomediadas que afectan tanto el tracto gastrointestinal, como otros sistemas extraintestinales, comportándose como una enfermedad sistémica. Los fenómenos tromboembólicos son una complicación frecuente en la EII, como consecuencia de los estados de hipercoagulabilidad que se asocian con la actividad de la enfermedad, y su aparición tiene un impacto negativo tanto en el pronóstico como en la sobrevida de los pacientes. Debido a ello, el control de la actividad inflamatoria de la EII es uno de los pilares en el control de los eventos tromboembólicos. Los medicamentos biológicos se asocian al control rápido del cuadro inflamatorio, sin embargo, siempre se discute el tema de seguridad para la reactivación de infecciones latentes, en particular tuberculosis. Presentamos el caso de un paciente de 37 años que debutó con trombosis venosa profunda en el miembro inferior izquierdo y posteriormente con tromboembolismo pulmonar masivo. Luego de investigar la etiología y ampliar la historia clínica se le diagnosticó Enfermedad de Crohn (EC). Al realizar los estudios previos al uso de biológicos, las pruebas de PPD y quantiferon resultaron positivas, luego de la discusión del caso se decidió iniciar tratamiento con ustekinumab.

Inflammatory bowel disease (IBD) is a spectrum of chronic immune-mediated diseases that affect the gastrointestinal tract and other extraintestinal systems, behaving as a systemic disease. Thromboembolic phenomena are a frequent complication in IBD, because of hypercoagulability states associated with disease activity, and their presence has a negative impact on prognosis and patient survival. Due to this, the control of the inflammatory activity of IBD is one of the pillars in the control of thromboembolic events. Biological drugs are associated with rapid control of the inflammatory process, however, the security profile for the reactivation of latent infections, particularly tuberculosis, is always discussed. We present the case of a 37-year-old patient who presented with deep vein thrombosis in the left lower limb and later with massive pulmonary thromboembolism. During his evaluation, he was diagnosed with Crohn's disease (CD). When carrying out the studies prior to the use of biologics, PPD and quantiferon tests were positive. After discussing the case, we decided to start treatment with ustekinumab.

Angio-TC pulmonar durante la pandemia de COVID-19: comparación en pacientes con y sin la infección y con una serie prepandémica / Pulmonary CT angiography in the first wave of the COVID-19 pandemic: comparison between patients with and without infection and with a pre-pandemic series

Antecedentes y objetivo: Analizar el rendimiento diagnóstico de la angio-TC pulmonar y comparar distintos valores de corte del dímero-D para el diagnóstico de tromboembolia pulmonar (TEP) aguda en pacientes con y sin infección por SARS-CoV-2.Materiales y métodos: Análisis retrospectivo de todas las angio-TC pulmonares realizadas consecutivamente por sospecha de TEP en un hospital de tercer nivel durante 2 periodos distintos. El primero de diciembre del 2020 a febrero del 2021 y el segundo de diciembre del 2017 a febrero del 2018. Se recogieron los resultados del dímero-D durante las 24h previas a la realización de las angio-TC pulmonares, así como el resultado de estas últimas para todos los pacientes incluidos. Se analizaron la sensibilidad, especificidad, valores predictivos, área bajo la curva (AUC) y patrón de tromboembolia para 6 valores distintos del dímero-D y la extensión del tromboembolia. Durante el periodo de la pandemia se registró si los pacientes tenían enfermedad por SARS-CoV-2. Resultados: Tras desestimar 29 estudios de baja calidad, se incluyeron 492 para el análisis. De ellos, 352 fueron realizados durante la pandemia; 180 en enfermos con COVID-19 y 172 sin la enfermedad. La frecuencia absoluta de TEP diagnosticados durante la pandemia fue mayor (34 durante el periodo previo a la pandemia y 85 durante la pandemia, correspondiendo 47 de este último grupo a pacientes con COVID-19). No se encontraron diferencias significativas al comparar el AUC para los valores del dímero-D. Los valores óptimos calculados a partir de las curvas ROC fueron distintos (2.200, 4.800 y 3.200μg/l en pacientes con COVID-19, sin COVID-19 y en diagnosticados durante el periodo prepandemia, respectivamente).(AU)

Background and aims: To analyze the diagnostic performance of pulmonary CT angiography and to compare different D-dimer cutoffs for the diagnosis of acute pulmonary embolism in patients with and without SARS-CoV-2 infections. Materials and methods: We retrospectively analyzed all consecutive pulmonary CT angiography studies done for suspected pulmonary embolism in a tertiary hospital during two time periods: the first December 2020 through February 2021 and the second December 2017 through February 2018. D-dimer levels were obtained less than 24hours before the pulmonary CT angiography studies. We analyzed the sensitivity, specificity, positive and negative predictive values, area under the receiver operating curve (AUC), and pattern of pulmonary embolism for six different values of D-dimer and the extent of the embolism. During the pandemic period, we also analyzed whether the patients had COVID-19. Results: After excluding 29 poor-quality studies, 492 studies were analyzed; 352 of these were done during the pandemic, 180 in patients with COVID-19 and 172 in patients without COVID-19. The absolute frequency of pulmonary embolism diagnosed was higher during the pandemic period (34 cases during the prior period and 85 during the pandemic; 47 of these patients had COVID-19). No significant differences were found in comparing the AUCs for the D-dimer values. The optimum values calculated for the receiver operating characteristic curves differed between patients with COVID-19 (2200 mcg/L), without COVID-19 (4800 mcg/L), and diagnosed in the prepandemic period (3200 mcg/L). Peripheral distribution of the emboli was more common in patients with COVID-19 (72%) than in those without COVID-19 and than in those diagnosed before the pandemic [OR 6.6, 95% CI:1.5?24.6, p<0.05 when compared to central distribution].(AU)

Retirada difícil de filtro de vena cava inferior (FVCI). Consideraciones técnicas y variables asociadas / Difficult withdrawal of an inferior vena cava filter: technical considerations and associated variables

Objetivo: Analizar la eficacia del procedimiento de retirada de los filtros de la vena cava inferior (FVCI), así como los factores clínico-radiológicos asociados a una retirada difícil. Material y método: Estudio retrospectivo, observacional y unicéntrico de pacientes tratados mediante retirada de FVCI entre mayo del 2015 y mayo del 2021. Se recogieron variables clínico-demográficas, del procedimiento y radiológicas: tipo de FVCI, angulación respecto a la vena cava inferior (VCI) >15°, gancho contra la pared y patas del dispositivo incrustadas en la pared de VCI> 3mm. Las variables de eficacia fueron: tiempo de fluoroscopia, éxito en la retirada del FVCI y número de intentos hasta la retirada. Como variables de seguridad: presencia de complicaciones, retirada quirúrgica y mortalidad. La variable principal fue la retirada difícil, definida como más de 5min de fluoroscopia o más de un intento de retirada. Resultados: Se incluyó a 109 pacientes, 54 (49,5%) fueron considerados retirada difícil. Las variables radiológicas gancho contra la pared (33,3% vs. 9,1%; p=0,027), patas incrustadas (20,4% vs. 3,6%; p=0,008) y> 45 días desde la colocación (51,9% vs. 25,5%; p=0,006) fueron significativamente más frecuentes en el grupo de retirada difícil. Estas variables mantienen la asociación al analizar los FVCI Optease®. En los FVCI Celect® solo se asoció con retirada difícil la inclinación del FVCI> 15° (25% vs. 0%; p=0,029).Conclusión: Se ha encontrado asociación entre una retirada difícil y las siguientes variables: tiempo desde colocación del FVCI, patas incrustadas y contacto del gancho con la pared de VCI. Al analizar según el tipo de FVCI, estas variables se mantienen en el tipo Optease®, en cambio, la inclinación de más de 15° dificulta la retirada de los dispositivos de morfología cónica (Celect®).(AU)

Objective: To analyze the efficacy of the procedure for withdrawing an inferior vena cava (IVC) filter and the clinical and radiological factors associated with difficult withdrawal. Material and methods: This retrospective observational study included patients who underwent IVC filter withdrawal at a single center between May 2015 and May 2021. We recorded demographic, clinical, procedural, and radiological variables: type of IVC filter, angle with the IVC> 15°, hook against the wall, and legs embedded in the IVC wall> 3mm. The efficacy variables were fluoroscopy time, success of IVC filter withdrawal, and number of attempts to withdraw the filter. The safety variables were complications, surgical removal, and mortality. The main variable was difficult withdrawal, defined as more than 5minutes fluoroscopy or more than 1 attempt at withdrawal. Results: A total of 109 patients were included; withdrawal was considered difficult in 54 (49.5%). Three radiological variables were more common in the difficult withdrawal group: hook against the wall (33.3% vs. 9.1%; p=0.027), embedded legs (20.4% vs. 3.6%; p=0.008), and>45 days since IVC filter placement (51.9% vs. 25.5%; p=0.006). These variables remained significant in the subgroup of patients with OptEase IVC filters; however, in the group of patients with Celect IVC filters, only the inclination of the IVC filter>15° was significantly associated with difficult withdrawal (25% vs 0%; p=0.029). Conclusion: Difficult withdrawal was associated with time from IVC placement, embedded legs, and contact between the hook and the wall. The analysis of the subgroups of patients with different types of IVC filters found that these variables remained significant in those with OptEase filters; however, in those with cone-shaped devices (Celect), the inclination of the IVC filter>15° was significantly associated with difficult withdrawal.(AU)

Riesgo de recurrencia de la trombosis en pacientes con tromboembolia venosa asociada a COVID-19 y a cirugía / Risk of thrombosis recurrence among patients with COVID-19- and surgery-associated venous thromboembolism

Introducción La cirugía reciente es un factor de riesgo transitorio mayor y conocido de tromboembolia venosa (TEV) debido al bajo riesgo de recurrencia de la TEV una vez suspendida la anticoagulación. Por otro lado, se desconoce el riesgo de recurrencia de la TEV en los pacientes con TEV asociada a COVID-19. El objetivo de este estudio consistió en comparar el riesgo de recurrencia de la TEV entre pacientes con TEV asociada a COVID-19 y a cirugía. Método Se realizó un estudio prospectivo, observacional y unicéntrico en el que participaron pacientes consecutivos diagnosticados de TEV en un hospital terciario entre enero de 2020 y mayo de 2022 y que fueron objeto de seguimiento durante un mínimo de 90 días. Se evaluaron las características iniciales, el cuadro clínico y los resultados clínicos. Se compararon las incidencias de recurrencia de la TEV, hemorragias y muertes entre ambos grupos. Resultado En el estudio se incluyó a un total de 344 pacientes: 111 con TEV asociada a cirugía y 233 con TEV asociada a COVID-19. Entre los pacientes con TEV asociada a COVID-19 hubo una mayor frecuencia de varones (65,7 vs. 48,6%, p = 0,003). La recurrencia de la TEV fue de 3% en los pacientes con COVID-19 y de 5,4% en los pacientes quirúrgicos, sin diferencias significativas (p = 0,364). La tasa de incidencia de TEV recurrente fue de 1,25 y 2,29 por 1.000 personas-meses en los pacientes con COVID-19 y quirúrgicos, respectivamente, sin diferencias significativas (p = 0,29). En el análisis multifactorial, la COVID-19 se asoció a una mayor mortalidad (HR = 2,34; IC 95%, 1,19-4,58), pero no a un mayor riesgo de recurrencia (HR = 0,52; IC 95%, 0,17-1,61). En el análisis multifactorial de riesgos competitivos no se observaron diferencias en cuanto a recurrencias (SHR = 0,82; IC 95%, 0,40-2,05). Conclusiones El riesgo de recurrencia fue bajo en los pacientes con TEV asociada a COVID-19 y a cirugía, sin diferencias entre ambos grupos (AU)

Introduction Recent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE. Methods A prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups. Result A total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p = 0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences (p = 0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences (p = 0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19-4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17-1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40 – 2.05). Conclusions In patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups (AU)

Complicaciones hemorrágicas y trombóticas del embarazo: diagnóstico, prevención y tratamiento

Las hemorragias y la enfermedad tromboembólica venosa (ETEV) figuran entre las cinco causas más frecuentes de morbilidad y mortalidad materna en el mundo. Revisamos la evaluación y el manejo actualizado de las causas obstétricas de la hemorragia posparto (HPP), así como el diagnóstico y manejo de condiciones hematológicas que pueden causar o agravar la HPP, por ejemplo: coagulación intravascular diseminada, enfermedad de von Willebrand, trombocitopenia autoinmune y las microangiopatías trombóticas. Revisamos el rol del síndrome antifosfolípido y las trombofilias hereditarias como factores predisponentes a pérdidas fetales recurrentes y la ETEV en el embarazo y las recomendaciones actuales para la prevención de ambas complicaciones. Asimismo, repasamos el abordaje diagnóstico y líneas de manejo de la ETEV. Un objetivo adicional fue enfatizar la importancia del trabajo colaborativo multidisciplinario para lograr el manejo exitoso de las gestantes con las complicaciones obstétricas y hematológicas descritas.

Bleeding and venous thromboembolism (VTE) are among the five most common causes of morbidity and mortality in pregnant women worldwide. This review describes the current evaluation and management of the obstetric causes of postpartum hemorrhage (PPH), as well as the diagnosis and management of hematologic conditions which can cause or worsen PPH, such as disseminated intravascular coagulation, von Willebrand disease, autoimmune thrombocytopenia and the thrombotic microangiopathies. It also describes the role of the antiphospholipid syndrome and inherited thrombophilia as predisposing factors for recurrent pregnancy loses and VTE, and the current recommendations for the prevention of both complications. As well, the current diagnostic approach and management of ETEV are described. An additional objective of this Review is to emphasize the importance of a collaborative multidisciplinary approach for the successful management of the obstetric and hematologic complications herein described.

Eficácia, segurança e tolerabilidade da Enoxaparina para prevenção de tromboembolismo venoso nas cirurgias eletivas de abdome, pelve e varizes: revisão rápida de evidências / Seffectiveness,safety and tolerability of Enoxaparin for the prevention of venous thromboembolism in elective surgery of the abdomen, pelvis and varices: quick evidence review

Tecnologia: Enoxaparina comparada à profilaxia mecânica e/ou outros medicamentos disponíveis ou não no SUS. Indicação: Profilaxia de Tromboembolismo Venoso (TEV) em pacientes submetidos a cirurgia de abdome, pelve e varizes. Pergunta: Há superioridade em eficácia e segurança da enoxaparina (heparina de baixo peso molecular - HBPM) comparada à profilaxia mecânica e a outros medicamentos disponíveis ou não no SUS para prevenção de TEV em pacientes acima de 18 anos, não gestantes, em pós-operatório de cirurgias eletivas de abdome, pelve e varizes? Métodos: Revisão rápida de evidências (overview) de revisões sistemáticas, com levantamento bibliográfico realizado na base de dados PUBMED, utilizando estratégia estruturada de busca. A qualidade metodológica das revisões sistemáticas foi avaliada com AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews). Resultados: Foram selecionadas quatro e incluídas duas revisões sistemáticas com metanálise. Conclusão: HBPM no pós-operatório de cirurgia abdominal e pelve reduziu a incidência de TEV geral e TEV sintomático, sem aumentar risco de sangramento e mortalidade. Nas cirurgias de veias varicosas, foi observado uma redução de todos os eventos trombóticos e risco de TVP, sem aumentar risco de sangramento

Technology: Enoxaparin compared to mechanical prophylaxis and/or other drugs available or not in the SUS. Indication: Prophylaxis of Venous Thromboembolism (VTE) in patients undergoing surgery of the abdomen, pelvis and varicose veins. Question: There is superiority in efficacy and safety of enoxaparin, compared to mechanical prophylaxis and other drugs available or not in the SUS, for the prevention of VTE for patients over 18 years old, non-pregnant in the postoperative period of elective surgeries of the abdomen, pelvis and varicose veins? Methods: Rapid review of evidence (overview) from systematic reviews, with a bibliographic search in the PUBMED database, using a structured strategy. The methodological quality of systematic reviews was assessed with AMSTAR-2 (Methodological Quality Assessment of Systematic Reviews). Results: Four were selected and two systematic reviews with meta-analysis were included. Conclusion: LMWH in the postoperative period of abdominal and pelvic surgery reduced the incidence of general VTE and symptomatic VTE, without increasing the risk of bleeding and mortality. In varicose vein surgeries, a reduction in all thrombotic events and risk of DVT was observed, without increasing the risk of bleeding

Evidence-based pharmacological prophylaxis recommendations for venous thromboembolism in hospitalized acutely ill medical patients: a systematic review of clinical practice guidelines / Recomendações baseadas em evidências científicas de profilaxia farmacológica para tromboembolismo venoso em pacientes hospitalizados com doenças agudas: uma revisão sistemática de diretrizes clínicas

Abstract Venous thromboembolism is a complex multifactorial disease considered the most common cause of preventable deaths in hospitalized patients. Recommendations about pharmacological venous thromboembolism prophylaxis in adult hospitalized patients are available in clinical practice guidelines for optimization of healthcare delivery and improvement of patient outcomes. We conducted a systematic review of clinical practice guidelines using ADAPTE to synthesize recommendations for pharmacological prophylaxis of venous thromboembolism in hospitalized medical patients at a medium complexity university hospital. Recommendations for pharmacological prophylaxis were extracted from seven clinical practice guidelines considered of high quality after assessment with the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. These recommendations will support discussion with specialists and implementation of practices in the setting of the hospital studied.

Resumo O tromboembolismo venoso é uma doença multifatorial complexa, considerada uma causa comum de óbitos evitáveis em pacientes hospitalizados. Recomendações sobre profilaxia farmacológica de tromboembolismo venoso em pacientes adultos hospitalizados estão disponíveis em diretrizes clínicas para otimizar os cuidados à saúde e contribuir com a melhora do desfecho do paciente. Dessa forma, foi conduzida uma revisão sistemática de diretrizes clínicas utilizando a metodologia ADAPTE para sintetizar as recomendações para profilaxia farmacológica de tromboembolismo venoso em pacientes clínicos adultos hospitalizados em um hospital universitário de média complexidade. As recomendações para profilaxia farmacológica foram extraídas de sete diretrizes clínicas consideradas de alta qualidade após avaliação pelo Appraisal of Guidelines for Research and Evaluation (AGREE II). Essas recomendações servirão de apoio para discussão com especialistas e implementação de práticas dentro do contexto do hospital estudado.