Target sign in COVID-19, radiological interpretation and diagnostic contribution of digital thoracic tomosynthesis.

INTRODUCTION: Our objectives are: To describe the radiological semiology, clinical-analytical features and prognosis related to the target sign (TS) in COVID-19. To determine whether digital thoracic tomosynthesis (DTT) improves the diagnostic ability of radiography. MATERIAL AND METHODS: Retrospective, descriptive, single-centre, case series study, accepted by our ethical committee. Radiological, clinical, analytical and follow-up characteristics of patients with COVID-19 and TS on radiography and DTT between November 2020 and January 2021 were analysed. RESULTS: Eleven TS were collected in 7 patients, median age 35 years, 57% male. All TS presented with a central nodule and a peripheral ring, and in at least 82%, the lung in between was of normal density. All TS were located in peripheral, basal regions and 91% in posterior regions. TS were multiple in 43%. Contiguous TS shared the peripheral ring. Other findings related to pneumonia were associated in 86% of patients. DTT detected 82% more TS than radiography. Only one patient underwent a CT angiography of the pulmonary arteries, positive for acute pulmonary thromboembolism. Seventy-one per cent presented with pleuritic pain. No distinctive laboratory findings or prognostic worsening were detected. CONCLUSIONS: TS in COVID-19 predominates in peripheral and declining regions and can be multiple. Pulmonary thromboembolism was detected in one case. It occurs in young people, frequently with pleuritic pain and does not worsen the prognosis. DTT detects more than 80 % of TS than radiography.

Guidelines for the management of coagulation disorders in patients with cirrhosis.

Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients. These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation.

SER recommendations on treatment of refractory Behçet's syndrome.

OBJECTIVE: To develop multidisciplinary recommendations based on available evidence and expert consensus for the therapeutic management of patients with refractory Behçet's syndrome (BS) (difficult to treat, severe resistant, severe relapse) to conventional treatment. METHODS: A group of experts identified clinical research questions relevant to the objective of the document. These questions were reformulated in PICO format (patient, intervention, comparison and outcome). Systematic reviews of the evidence were conducted, the quality of the evidence was evaluated following the methodology of the international working group Grading of Recommendations Assessment, Development, and Evaluation (GRADE). After that, the multidisciplinary panel formulated the specific recommendations. RESULTS: 4 PICO questions were selected regarding the efficacy and safety of systemic pharmacological treatments in patients with BS with clinical manifestations refractory to conventional therapy related to mucocutaneous and/or articular, vascular, neurological parenchymal and gastrointestinal phenotypes. A total of 7 recommendations were made, structured by question, based on the identified evidence and expert consensus. CONCLUSIONS: The treatment of most severe clinical manifestations of BS lacks solid scientific evidence and, besides, there are no specific recommendation documents for patients with refractory disease. With the aim of providing a response to this need, here we present the first official Recommendations of the Spanish Society of Rheumatology for the management of these patients. They are devised as a tool for assistance in clinical decision making, therapeutic homogenisation and to reduce variability in the care of these patients.

Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the thromboembolic disease 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).

Trombosis venosa cerebral / Cerebral venous thrombosis

La trombosis venosa cerebral forma parte de las llamadas trombosis en sitios inusuales. Se define como una oclusión en el territorio venoso cerebral. Su incidencia se encuentra en aumento progresivo, especialmente en países en vías de desarrollo. Se observa con más frecuencia en mujeres jóvenes, siendo los factores hormonales, como el embarazo o la anticoncepción hormonal, factores de riesgo principales en el desarrollo de esta afección. La clínica va a depender fundamentalmente de la topografía de la trombosis, con un diagnóstico de confirmación basado principalmente en las pruebas de imagen. El tratamiento consiste generalmente en la anticoagulación, pudiendo plantearse otras opciones según la gravedad del cuadro. En general, el pronóstico es mejor que el de otros trastornos vasculares intracraneales. En esta revisión se describe la evidencia actual disponible acerca de la trombosis venosa cerebral.(AU)

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.(AU)

Recomendaciones SER sobre el tratamiento del síndrome de Behçet refractario / SER recommendations on treatment of refractory Behçet's syndrome

Objetivo: Elaborar recomendaciones multidisciplinares, basadas en la evidencia disponible y el consenso de expertos, para el manejo terapéutico de los pacientes con síndrome de Behçet refractario (difícil de tratar, resistente grave, recidivante grave) al tratamiento convencional. Métodos: Un panel de expertos identificó preguntas clínicas de investigación relevantes para el objetivo del documento. Estas preguntas fueron reformuladas en formato PICO –paciente, intervención, comparación, outcome o desenlace–. A continuación, se realizaron revisiones sistemáticas; la evaluación de la calidad de la evidencia se realizó siguiendo la metodología del grupo internacional de trabajo Grading of Recommendations, Assessment, Development, and Evaluation. Tras esto, el panel multidisciplinar formuló las recomendaciones. Resultados: Se seleccionaron 4 preguntas PICO relativas a la eficacia y seguridad de los tratamientos farmacológicos sistémicos en los pacientes con síndrome de Behçet con manifestaciones clínicas refractarias a terapia convencional, relacionadas con los fenotipos mucocutáneo y/o articular, vascular, neurológico-parenquimatoso y gastrointestinal. Se formularon un total de 7 recomendaciones estructuradas por pregunta, con base en la evidencia encontrada y el consenso de expertos. Conclusiones: El tratamiento de las manifestaciones clínicas más graves del síndrome de Behçet carece de evidencia científica sólida y no existen documentos de recomendaciones específicas para los pacientes con enfermedad refractaria a la terapia convencional. Con el fin de aportar una respuesta a esta necesidad, se presenta el primer documento de recomendaciones de la Sociedad Española de Reumatología específicas para el abordaje terapéutico de estos pacientes, que servirá de ayuda en la toma de decisiones clínica y la reducción de la variabilidad en la atención.(AU)

Objective: To develop multidisciplinary recommendations based on available evidence and expert consensus for the therapeutic management of patients with refractory Behçet's syndrome (difficult to treat, severe resistant, severe relapse) to conventional treatment. Methods: A group of experts identified clinical research questions relevant to the objective of the document. These questions were reformulated in PICO format –patient, intervention, comparison and outcome–. Systematic reviews of the evidence were conducted; the quality of the evidence was evaluated following the methodology of the international working group Grading of Recommendations, Assessment, Development, and Evaluation. After that, the multidisciplinary panel formulated the specific recommendations. Results: Four PICO questions were selected regarding the efficacy and safety of systemic pharmacological treatments in patients with Behçet's syndrome with clinical manifestations refractory to conventional therapy related to mucocutaneous and/or articular, vascular, neurological parenchymal and gastrointestinal phenotypes. A total of 7 recommendations were made, structured by question, based on the identified evidence and expert consensus. Conclusions: The treatment of most severe clinical manifestations of Behçet's syndrome lacks solid scientific evidence and, besides, there are no specific recommendation documents for patients with refractory disease. With the aim of providing a response to this need, here we present the first official recommendations of the Spanish Society of Rheumatology for the management of these patients. They are devised as a tool for assistance in clinical decision making, therapeutic homogenisation and to reduce variability in the care of these patients.(AU)

Manejo de la trombosis venosa cerebral en España: estudio descriptivo MOTIVATE / Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study

Introducción: La trombosis venosa cerebral (TVC) es una causa poco común de ictus que afecta principalmente a adultos jóvenes. Un diagnóstico precoz y preciso puede reducir la tasa y gravedad de las complicaciones. Objetivo: Analizar las características clínicas, manejo y tratamiento de la TVC en diferentes centros de nuestro país. Métodos: Estudio descriptivo retrospectivo multicéntrico de pacientes hospitalizados por TVC entre 2008 y 2017 en 11 centros sanitarios en nuestro país. Resultados: Se incluyeron 256 pacientes, edad media 49,8 ± 18,7 años y el 51% fueron mujeres. Los síntomas más frecuentes fueron: cefalea (73%), déficits focales (50%), crisis epilépticas (33%) y encefalopatía (21%). Las localizaciones más frecuentes fueron: seno longitudinal superior (12,5%), transverso (10,9%) y afectación de dos o más senos o venas (66,4%). La etiología conocida más frecuente fue la trombofilia (24%), siendo la mutación de la protrombina G20210A la más común (19%). El 46% fue tratado con antitrombóticos durante 3-6 meses, el 21% durante un año y un 22,6% de los pacientes requirieron anticoagulación indefinida. En un 5% de los sujetos fue preciso terapia endovascular y un 33% requirió neurocirugía. En relación al pronóstico, el 75% fueron independientes a los 3 meses con una puntuación en la escala de Rankin modificada (mRS) ≤ 2 y la presencia de papiledema (p = 0,03), déficit focal (p = 0,001) y encefalopatía (p < 0,001) se relacionaron significativamente con mal pronóstico (mRS > 3). La tasa de mortalidad intrahospitalaria fue del 4,3% y el 6,3% de los pacientes fallecieron a los 3 meses. Conclusión:La diversidad de factores de riesgo y la presentación variable suponen un desafío en el diagnóstico y tratamiento de la TVC. Para mejorar el pronóstico y reducir la mortalidad es fundamental la instauración de protocolos en el manejo de esta patología.(AU)

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 11 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 3-6 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.(AU)

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.

Trombo en tránsito izquierdo intraoperatorio en trasplante bipulmonar diagnosticado por ecocardiografía transesofágica: ¿qué es lo siguiente? / Left side clot in transit in double-lung transplantation diagnosticated by transesophageal echocardiography: What's next?

Un varón de 61 años sin predisposición trombótica es sometido a trasplante bipulmonar como último tratamiento para su EPOC terminal sin soporte de ECMO. Tras el implante y la reperfusión de ambos pulmones, se realizó un examen ecocardiográfico transesofágico completo para comprobar principalmente las anastomosis de las venas pulmonares. En este estudio se identificó una gran masa móvil, hiperecogénica, densa y heterogénea en la aurícula izquierda, compatible con un trombo en tránsito desde la circulación venosa pulmonar. Este hallazgo fue comunicado al equipo quirúrgico inmediatamente para reabrir la anastomosis y retirar el coágulo antes de mayores consecuencias. No hubo manifestaciones clínicas cuando se despertó al paciente.(AU)

61-year-old man without any thrombotic predisposition was undergone double sequential lung transplantation due to terminal stage of COPD without extracorporeal membrane oxygenation (ECMO) support. After implantation and reperfusion of both lungs, a complete transoesophageal echocardiography exam was performed to check especially the pulmonary venous anastomosis. In this exam, a large heterogenous, dense, hyperechoic mobile mass was identified in the LA, which was compatible with a thrombus in transit from pulmonary veins circulation. This finding was communicated to the surgical team to reopen the anastomosis and remove the clot before further consequences. There were no clinical manifestations when the patient was awakened.(AU)

Alta frecuencia de trombo endoluminal en pacientes con ictus isquémico tras la infección por coronavirus 2019 / High frequency of endoluminal thrombus in patients with ischaemic stroke following SARS-CoV-2 infection

Introducción El ictus isquémico puede ser una complicación grave en los pacientes con infección por SARS-CoV-2. Estudiar y caracterizar los diferentes subtipos etiológicos, las características clínicas y el pronóstico funcional podrá resultar útil en la selección de pacientes para un manejo y tratamiento óptimos. Métodos La recogida de variables se hizo de forma retrospectiva en pacientes consecutivos con infección por SARS-CoV-2 que desarrollaron un episodio de isquemia cerebral focal (entre el 1 de marzo del 2020 y el 19 de abril del 2020). Se llevó a cabo en un hospital universitario de tercer nivel en la Comunidad de Madrid (España). Resultados Durante el período de estudio 1.594 pacientes fueron diagnosticados de infección por SARS-CoV-2. Identificamos a 22 pacientes con ictus isquémico (1,38%); de estos, no cumplieron los criterios de inclusión 6. Un total de 16 pacientes con isquemia cerebral focal constituyeron la serie del estudio (15 con ictus isquémico y uno con accidente isquémico transitorio). En la valoración basal en el National Institutes of Health Stroke Scale la mediana fue de 9 (rango intercuartil: 16), la edad media ± desviación estándar fue de 73 ± 12,8 años; 12 pacientes fueron varones (75%). El tiempo desde los síntomas de COVID-19 hasta el ictus fue de 13 días. Se encontró oclusión de gran vaso en 12 pacientes (75%). El dímero-D estuvo elevado en el 87,5% y la proteína C reactiva en el 81,2% de los casos. La etiología más frecuente del ictus isquémico fue la aterotrombosis (9 pacientes, 56,3%) con un subtipo predominante que fue el trombo endoluminal sobre placa de ateroma (5 pacientes, 31,2%), 4 de ellos en la arteria carótida interna y uno de ellos en el arco aórtico. La mortalidad en nuestra serie fue del 44% (7 de 16 pacientes). Conclusiones En los pacientes con ictus y COVID-19 la etiología más frecuente fue la aterotrombótica, con una elevada frecuencia de trombo endoluminal sobre placa de ateroma... (AU)

Background Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. Methods Data were collected retrospectively on consecutive patients with SARS-CoV-2 infection who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). Results During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). Conclusions In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19–associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients. (AU)

Efectividad y seguridad de una estrategia de antiagregación plaquetaria simple tras cierre percutáneo de orejuela izquierda en pacientes con FA / Single antiplatelet therapy after left atrial appendage closure in patients with AF: safety and effectiveness

Introduction and objectives The optimal antithrombotic strategy following left atrial appendage closure (LAAC) is poorly defined in patients with nonvalvular atrial fibrillation. We assessed the safety and effectiveness of a single antiplatelet treatment (SAPT) strategy after LAAC in a population at high risk of ischemic and bleeding events. Methods This single-center, observational, prospective study included a consecutive cohort of patients who underwent LAAC using the LAmbre device (Lifetech Scientific, China) and who were discharged with SAPT. The primary outcome was a composite of stroke, systemic embolism, and device-related thrombosis during follow-up. Secondary endpoints were cardiovascular mortality and major bleeding events (BARC ≥3a). Clinical follow-up was performed at 1, 6, and 12 months and subsequently on an annual basis. Transesophageal echocardiography was performed at 1 and 12 months of follow-up. Results The study comprised 74 patients. The median age was 77 [72-83] years and 43% were women. The cohort exhibited a high prevalence of comorbidities and cardiovascular risk factors. The median CHA2DS2-VASc and HAS-BLED scores were 4 [3-6] and 4 [4-5], respectively. The median length of follow-up was 2.5 years (188 patients-year). During follow-up, device-related thrombosis occurred in 3 patients (4%). Ischemic stroke occurred in 1 patient (1.3%, rate 0.5%/y), representing a 90.9% relative risk reduction compared with the risk predicted by CHA2DS2-VASc. Major bleeding events occurred in 12 patients (16%, 6.4%/y), with a relative risk reduction of 26.4% of that predicted by HAS-BLED. Cardiovascular-related mortality was observed in 2 patients (2.7%). Conclusions SAPT appears to be a safe and effective treatment following LAAC in patients at high ischemic and hemorrhagic risk. Further studies are needed to confirm our findings (AU)

Introducción y objetivos Se desconoce cuál es la terapia antitrombótica óptima tras el cierre percutáneo de la orejuela izquierda (CPOI) en pacientes con fibrilación auricular no valvular. El objetivo de este estudio es analizar la efectividad y la seguridad de un régimen de tratamiento antiagregante plaquetario simple (TAPS) tras el CPOI en una población con alto riesgo isquémico y hemorrágico. Métodos Estudio observacional prospectivo que incluyó una cohorte consecutiva de pacientes a los que se realizó CPOI con dispositivo LAmbre (Lifetech Scientific, China) y que recibieron TAPS al alta. El evento primario fue un combinado de ictus, embolia sistémica y trombosis del dispositivo. Los eventos secundarios fueron mortalidad cardiovascular y hemorragia mayor (BARC ≥ 3a). Se realizó seguimiento clínico al mes y a los 6 y 12 meses y cada año después. Se realizó ecocardiograma transesofágico al mes y a los 12 meses. Resultados Se incluyó a 74 pacientes (el 43% mujeres) con una mediana de edad de 77 [intervalo intercuartílico, 72-83] años, que presentaban gran comorbilidad y factores de riesgo cardiovascular. Los valores de CHA2DS2-VASc y HAS-BLED fueron una mediana de 4 [3-6] y 4 [4-5] respectivamente. Durante el seguimiento (mediana, 2,5 años), 3 pacientes (4%) presentaron trombosis del dispositivo. Uno sufrió ictus isquémico (1,3%, 0,5%/año), lo que supone, según la incidencia esperada por CHA2DS2-VASc, una reducción del riesgo relativo del 90,9%. Sufrieron eventos hemorrágicos 12 pacientes (16%; 6,4%/año), una tasa el 26,4% menor que el riesgo HAS-BLED predicho. Se produjo la muerte cardiovascular de 2 pacientes (2,7%). Conclusiones Una estrategia de TAPS tras el CPOI parece ser una opción efectiva y segura para los pacientes con altos riesgos isquémico y hemorrágico. Se necesitan más estudios que corroboren nuestros resultados (AU)

[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.

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.

Alta frecuencia de trombo endoluminal en pacientes con ictus isquémico tras la infección por coronavirus 2019 / High frequency of endoluminal thrombus in patients with ischaemic stroke following SARS-CoV-2 infection

Introducción El ictus isquémico puede ser una complicación grave en los pacientes con infección por SARS-CoV-2. Estudiar y caracterizar los diferentes subtipos etiológicos, las características clínicas y el pronóstico funcional podrá resultar útil en la selección de pacientes para un manejo y tratamiento óptimos. Métodos La recogida de variables se hizo de forma retrospectiva en pacientes consecutivos con infección por SARS-CoV-2 que desarrollaron un episodio de isquemia cerebral focal (entre el 1 de marzo del 2020 y el 19 de abril del 2020). Se llevó a cabo en un hospital universitario de tercer nivel en la Comunidad de Madrid (España). Resultados Durante el período de estudio 1.594 pacientes fueron diagnosticados de infección por SARS-CoV-2. Identificamos a 22 pacientes con ictus isquémico (1,38%); de estos, no cumplieron los criterios de inclusión 6. Un total de 16 pacientes con isquemia cerebral focal constituyeron la serie del estudio (15 con ictus isquémico y uno con accidente isquémico transitorio). En la valoración basal en el National Institutes of Health Stroke Scale la mediana fue de 9 (rango intercuartil: 16), la edad media ± desviación estándar fue de 73 ± 12,8 años; 12 pacientes fueron varones (75%). El tiempo desde los síntomas de COVID-19 hasta el ictus fue de 13 días. Se encontró oclusión de gran vaso en 12 pacientes (75%). El dímero-D estuvo elevado en el 87,5% y la proteína C reactiva en el 81,2% de los casos. La etiología más frecuente del ictus isquémico fue la aterotrombosis (9 pacientes, 56,3%) con un subtipo predominante que fue el trombo endoluminal sobre placa de ateroma (5 pacientes, 31,2%), 4 de ellos en la arteria carótida interna y uno de ellos en el arco aórtico. La mortalidad en nuestra serie fue del 44% (7 de 16 pacientes). Conclusiones En los pacientes con ictus y COVID-19 la etiología más frecuente fue la aterotrombótica, con una elevada frecuencia de trombo endoluminal sobre placa de ateroma... (AU)

Background Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. Methods Data were collected retrospectively on consecutive patients with SARS-CoV-2 infection who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). Results During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). Conclusions In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19–associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients. (AU)

TIPS en pacientes cirróticos con trombosis venosa portal: una revisión de la literatura / TIPS in cirrhotic patients with portal vein thrombosis: A review of the literature

En los últimos años, la trombosis de la vena porta entre los pacientes cirróticos se ha comportado como una entidad reconocida y cada vez más estudiada, no solo por su creciente incidencia, sino por la asociación con gravedad y mal pronóstico en cirrosis. Asimismo, se hacen objeto de estudio las terapias disponibles para el manejo tanto médico como quirúrgico de estos pacientes, lo que ha dado un papel importante a la derivación portosistémica transyugular intrahepática (TIPS). El uso de TIPS en esta población se posiciona como una alternativa de manejo aceptable, no solo por brindar mejoría en las complicaciones derivadas de la hipertensión portal, sino también por sus resultados prometedores en diferentes estudios sobre el flujo y la recanalización portal, y por su perfil de seguridad. Sin embargo, la eficacia, los efectos adversos a largo plazo y el pronóstico de dicha intervención en la compleja fisiopatología de la cirrosis deben continuar en estudio. El objetivo de este artículo es revisar los avances del uso de TIPS en el manejo de pacientes con cirrosis hepática y trombosis portal.

In recent years, portal vein thrombosis among cirrhotic patients has been a well-recognized and continuously studied entity, not only because of its increasing incidence but also because of its association with severity and poor prognosis in cirrhosis. Likewise, therapies available for both medical and surgical management in these patients are being studied, which has given an important role to the transjugular intrahepatic portosystemic shunt (TIPS). The use of TIPS in this population is positioned as an acceptable management alternative, not only because it provides improvement in complications derived from portal hypertension, but also because of its promising results in different studies on portal flow and recanalization upgrade, and for its safety. However, the efficacy, long-term adverse effects, and prognosis of this intervention in the complex pathophysiology of cirrhosis must continue to be studied. The objective of this article is to review the advances in the use of TIPS in the management of patients with liver cirrhosis and portal vein thrombosis.

Single antiplatelet therapy after left atrial appendage closure in patients with AF: safety and effectiveness.

INTRODUCTION AND OBJECTIVES: The optimal antithrombotic strategy following left atrial appendage closure (LAAC) is poorly defined in patients with nonvalvular atrial fibrillation. We assessed the safety and effectiveness of a single antiplatelet treatment (SAPT) strategy after LAAC in a population at high risk of ischemic and bleeding events. METHODS: This single-center, observational, prospective study included a consecutive cohort of patients who underwent LAAC using the LAmbre device (Lifetech Scientific, China) and who were discharged with SAPT. The primary outcome was a composite of stroke, systemic embolism, and device-related thrombosis during follow-up. Secondary endpoints were cardiovascular mortality and major bleeding events (BARC ≥3a). Clinical follow-up was performed at 1, 6, and 12 months and subsequently on an annual basis. Transesophageal echocardiography was performed at 1 and 12 months of follow-up. RESULTS: The study comprised 74 patients. The median age was 77 [72-83] years and 43% were women. The cohort exhibited a high prevalence of comorbidities and cardiovascular risk factors. The median CHA2DS2-VASc and HAS-BLED scores were 4 [3-6] and 4 [4-5], respectively. The median length of follow-up was 2.5 years (188 patients-year). During follow-up, device-related thrombosis occurred in 3 patients (4%). Ischemic stroke occurred in 1 patient (1.3%, rate 0.5%/y), representing a 90.9% relative risk reduction compared with the risk predicted by CHA2DS2-VASc. Major bleeding events occurred in 12 patients (16%, 6.4%/y), with a relative risk reduction of 26.4% of that predicted by HAS-BLED. Cardiovascular-related mortality was observed in 2 patients (2.7%). CONCLUSIONS: SAPT appears to be a safe and effective treatment following LAAC in patients at high ischemic and hemorrhagic risk. Further studies are needed to confirm our findings.

High frequency of endoluminal thrombus in patients with ischaemic stroke following AARS-CoV-2 infection.

BACKGROUND: Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. METHODS: Data were collected retrospectively on consecutive patients with COVID-19 who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). RESULTS: During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). CONCLUSIONS: In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19-associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients.

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

Left side clot in transit in double-lung transplantation diagnosticated by transesophageal echocardiography: what's next?

A 61-year-old man with no predisposition to thrombosis underwent sequential double lung transplantation without extracorporeal membrane oxygenation (ECMO) support due to terminal stage COPD. After implantation and reperfusion of both lungs, a complete transoesophageal echocardiography study was performed to check the pulmonary venous anastomosis. The study showed a large, heterogeneous, dense, hyperechoic free-floating mass in the left atrium compatible with a clot in transit from the pulmonary circulation. The surgical team were notified of this finding so that they could reopen the anastomosis and remove the clot to prevent a major complication. There were no clinical manifestations when the patient was awakened.

Cuando los vómitos no son causados por un virus / When vomiting is not caused by a virus

La otitis media aguda (OMA) es un diagnóstico muy frecuente en Atención Primaria, a veces se complica con supuración y, en otras ocasiones, menos frecuentemente, con mastoiditis. Se presenta el caso de una niña de 6 años que, tras ser diagnosticada de OMA supurada e instaurarse tratamiento antibiótico, comienza con vómitos, mareos y cefalea, así como con un mal control del dolor con la analgesia habitual y posterior fotofobia. Tras varias visitas, acaba por diagnosticarse una mastoiditis con trombosis del seno transverso, sigmoideo y yugular. La importancia del caso radica en una rápida sospecha de las posibles complicaciones de una otitis media para realizar un diagnóstico y tratamiento precoz de las mismas. (AU)

Acute otitis media (AOM) is a very frequent diagnosis in Primary Care, sometimes complicated with suppuration, and less frequently, with mastoiditis. We present the case of a 6-year-old girl who, after being diagnosed with suppurative AOM and starting antibiotic treatment, began with vomiting, dizziness and headache, as well as poor pain control with the usual analgesia and subsequent photophobia. After several visits, a mastoiditis with thrombosis of the transverse, sigmoid and jugular sinuses was finally diagnosed. The importance of the case lies in a rapid suspicion of possible complications of otitis media in order to diagnose and treat them early. (AU)