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1.
BMC Pulm Med ; 21(1): 102, 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-33761886

RESUMO

BACKGROUND: Coronavirus Disease 2019 (COVID-19) is a pandemic affecting all countries in the world. Italy has been particularly afflicted by the health emergency, and since the peak phase has passed, major concern regarding medium to long term complications due to COVID-19 is arising. Little is known in literature regarding thromboembolic complications once healed after COVID-19. CASE PRESENTATION: A 51-year-old patient recovered from COVID-19 pneumonia complicated by pulmonary embolism (PE) came to the hospital for palpitations and chest pain. Although he was on treatment dose of direct oral anticoagulation (DOAC), massive recurrent PE was diagnosed. CONCLUSION: In the early post COVID-19 era, the question remains regarding the efficacy of DOACs in COVID-19 patients.


Assuntos
Anticoagulantes/administração & dosagem , Dabigatrana/administração & dosagem , Heparina/administração & dosagem , Embolia Pulmonar/prevenção & controle , Embolia Pulmonar/virologia , Varfarina/administração & dosagem , Administração Oral , Anticoagulantes/uso terapêutico , Dabigatrana/uso terapêutico , Quimioterapia Combinada , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/tratamento farmacológico , Recidiva , Varfarina/uso terapêutico
2.
Acute Med ; 20(1): 15-17, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33749690

RESUMO

We assessed the efficacy of thrombolysis in avoiding long-term complications. Notes of patients thrombolysed for PE in the 2-year period were reviewed. The initial CTPA and echocardiogram results before thrombolysis were compared to the results of follow up imaging repeated after 6 months. Twenty-two patients were thrombolysed for PE. 14 patients had sub-massive PE and 8 patients had massive PE. The right ventricle (RV) was dilated on pre-thrombolysis echocardiogram in 16 patients. On follow up echocardiography all patients with massive PE (6 studies) had a normal RV size, with pulmonary artery pressures (PAP) of 29mmHg. Follow up echocardiography of patients with submassive PE (13 studies) showed 11 patients with a normal RV, with PAP of 28 mmHg.


Assuntos
Embolia Pulmonar , Terapia Trombolítica , Ecocardiografia , Humanos , Embolia Pulmonar/tratamento farmacológico , Estudos Retrospectivos , Resultado do Tratamento
3.
Medicine (Baltimore) ; 100(11): e25216, 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33726018

RESUMO

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs) have been widely used for stroke prevention in atrial fibrillation (AF) and the treatment and prevention of venous thromboembolism. There is an issue with safety, especially in clinically relevant bleeding. We performed a network meta-analysis to evaluate the risk of major gastrointestinal (GI) bleeding associated with NOACs. METHODS: Interventions were warfarin, enoxaparin, apixaban, dabigatran, edoxaban, and rivaroxaban. The primary outcome was the incidence of major GI bleeding. A subgroup analysis was performed according to the following indications: AF, deep venous thrombosis/pulmonary embolism, and postsurgical prophylaxis. RESULTS: A total of 29 randomized controlled trials (RCTs) and 4 large observation population studies were included. Compared with warfarin, apixaban showed a decreased the risk of major GI bleeding (relative risk [RR] 0.54, 95% confidence interval [CI] 0.25-0.76), and rivaroxaban tended to increase this risk (RR 1.40, 95% CI 1.06-1.85). Dabigatran (RR 1.25, 95% CI 0.98-1.60), edoxaban (RR 1.07, 95% CI 0.69-1.65), and enoxaparin (RR 1.24, 95% CI 0.63-2.43) did not significantly increase the risk of GI bleeding than did warfarin. In the subgroup analysis, according to indications, apixaban showed a decreased risk of major GI bleeding (RR 0.50, 95% CI 0.34-0.74) than did warfarin in AF studies. Dabigatran (RR 2.36, 95% CI 1.55-3.60, and rivaroxaban (RR 1.75, 95% CI 1.10-6.41) increased the risk of major GI bleeding than did apixaban. An analysis of studies on venous thromboembolism or pulmonary embolism showed that no individual NOAC or enoxaparin was associated with an increased risk of major GI bleeding compared to warfarin. CONCLUSION: Individual NOACs had varying profiles of GI bleeding risk. Results of analyses including only RCTs and those including both RCTs and population studies showed similar trends, but also showed several differences.


Assuntos
Anticoagulantes/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Hemorragia Gastrointestinal/induzido quimicamente , Embolia Pulmonar/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológico , Administração Oral , Adulto , Idoso , Fibrilação Atrial/complicações , Dabigatrana/efeitos adversos , Enoxaparina/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Metanálise em Rede , Estudos Observacionais como Assunto , Embolia Pulmonar/complicações , Pirazóis/efeitos adversos , Piridinas/efeitos adversos , Piridonas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Rivaroxabana/efeitos adversos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Tiazóis/efeitos adversos , Tromboembolia Venosa/complicações , Varfarina/efeitos adversos
5.
JAMA Netw Open ; 4(2): e2036304, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33533929

RESUMO

Importance: It is unclear whether the clinical benefits associated with non-vitamin K antagonist oral anticoagulants (NOACs) are similar to those associated with low-molecular-weight heparins (LMWHs) in Asian individuals with cancer and acute venous thromboembolism (VTE). Objective: To compare the risk of recurrent thromboembolic events and bleeding associated with use of a NOAC vs use of the LMWH enoxaparin in Asian individuals with cancer-associated VTE. Design, Setting, and Participants: This cohort study was conducted using data from the Chang Gung Research Database, a multi-institutional electronic medical records database in Taiwan. A cohort of 1109 patients with cancer-associated VTE were identified between January 1, 2012, and January 31, 2019. Data were analyzed from March 2019 through December 2020. Exposures: Receiving a NOAC (including rivaroxaban, apixaban, edoxaban, or dabigatran) or the LMWH enoxaparin. Main Outcomes and Measures: The primary outcomes were composite recurrent VTE or major bleeding. Stabilized inverse probability of treatment weighting was used to balance baseline covariates. We compared risks of recurrent VTE or major bleeding between groups using Cox proportional hazards models. In addition, we conducted an analysis using a Fine and Gray subdistribution hazard model that considered death as a competing risk. Results: Among 1109 patients with cancer and newly diagnosed VTE, 578 (52.1%) were women and the mean (SD) age at index date was 66.0 (13.0) years; 529 patients (47.7%) received NOACs and 580 patients (52.3%) received the LMWH enoxaparin. Composite recurrent VTE or major bleeding occurred in 75 patients (14.1%) in the NOAC group and 101 patients (17.4%) in the enoxaparin group (weighted hazard ratio [HR], 0.77; 95% CI, 0.56-1.07; P = .11). The groups had similar risk of VTE recurrence (HR, 0.62; 95% CI, 0.39-1.01; P = .05) and major bleeding (HR, 0.80; 95% CI, 0.52-1.24; P = .32) at 12 months of follow-up. However, taking a NOAC was associated with a significantly lower risk of gastrointestinal bleeding compared with receiving enoxaparin (10 patients [1.9%] vs 41 patients [7.1%]; HR, 0.29; 95% CI, 0.15-0.59; P < .001). Findings for both primary outcomes were consistent with competing risk analyses (recurrent VTE: HR, 0.68; 95% CI, 0.45-1.01; P = .05; major bleeding: HR, 0.77; 95% CI, 0.51-1.16; P = .21). Conclusions and Relevance: This cohort study found that in real-world practice, among Asian patients with cancer-associated VTE, use of a NOAC was associated with a similar risk for recurrent VTE or major bleeding compared with use of the LMWH enoxaparin. Nonetheless, use of a NOAC was associated with a significantly lower rate of gastrointestinal bleeding. Further prospective studies are needed to confirm these findings.


Assuntos
Inibidores do Fator Xa/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Neoplasias/complicações , Tromboembolia Venosa/tratamento farmacológico , Idoso , Anticoagulantes/uso terapêutico , Grupo com Ancestrais do Continente Asiático , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/etiologia , Recidiva , Taiwan/epidemiologia , Resultado do Tratamento , Tromboembolia Venosa/etiologia , Trombose Venosa/tratamento farmacológico , Trombose Venosa/etiologia
6.
BMJ Case Rep ; 14(2)2021 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-33541993

RESUMO

Acute pulmonary embolism is a frequent potentially reversible cause of sudden cardiac arrest. The early diagnosis is challenging but essential for further treatment. New therapeutic options in resuscitation, such as extracorporeal resuscitation, are leading to frequent transports of patients to emergency rooms with ongoing resuscitation. A transoesophageal echo performed during resuscitation can give hints for reversible causes for the cardiac arrest. We present a case of a 40-year-old female patient who was transferred to our department with ongoing resuscitation and received a transoesophageal echo immediately on arrival. The examination showed a massive intracardiac thrombus. The subsequent thrombolysis and following resuscitation were observed and documented via transoesophageal echo.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca/terapia , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica , Trombose/complicações , Adulto , Reanimação Cardiopulmonar/efeitos adversos , Ecocardiografia Transesofagiana , Feminino , Humanos
7.
Medicina (Kaunas) ; 57(2)2021 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-33530544

RESUMO

Traditionally, the management of patients with pulmonary embolism has been accomplished with anticoagulant treatment with parenteral heparins and oral vitamin K antagonists. Although the administration of heparins and oral vitamin K antagonists still plays a role in pulmonary embolism management, the use of these therapies are limited due to other options now available. This is due to their toxicity profile, clearance limitations, and many interactions with other medications and nutrients. The emergence of direct oral anticoagulation therapies has led to more options now being available to manage pulmonary embolism in inpatient and outpatient settings conveniently. These oral therapeutic options have opened up opportunities for safe and effective pulmonary embolism management, as more evidence and research is now available about reversal agents and monitoring parameters. The evolution of the pharmacological management of pulmonary embolism has provided us with better understanding regarding the selection of anticoagulants. There is also a better understanding and employment of anticoagulants in pulmonary embolism in special populations, such as patients with liver failure, renal failure, malignancy, and COVID-19.


Assuntos
Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Administração Oral , Anticoagulantes/administração & dosagem , Fibrinolíticos/administração & dosagem , Humanos , Falência Hepática/complicações , Neoplasias/complicações , Insuficiência Renal/complicações , Fatores de Risco
9.
Medicine (Baltimore) ; 100(1): e24230, 2021 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-33429821

RESUMO

INTRODUCTION: Although venous thromboembolism (VTE) is relatively rare after unicompartmental knee arthroplasty (UKA), symptomatic pulmonary embolism (PE) can be fatal. Whether routine thromboprophylaxis or thrombolytic treatment is necessary for patients undergoing UKA remains unclear. Here, we present a case of delayed pulmonary embolism after UKA. PATIENT CONCERNS: A 57-year-old women underwent cemented UKA for left localized medial knee pain. There were no risk factors of VTE besides high BMI before surgery. 2 months after surgery, the patient presented with dyspnea and palpitation, and these symptoms could not be alleviated after rest. DIAGNOSIS: An arterial blood gas analysis showed decreased PO2, SO2 and PCO2. Pulmonary CTA showed multiple pulmonary embolism in the trunk of the right lower pulmonary artery and the branch of the left lower pulmonary arteries. The final diagnosis was delayed pulmonary embolism after UKA. INTERVENTIONS: Urokinase thrombolysis was administered intravenously. Low molecular weight heparin and warfarin were prescribed for anticoagulation. OUTCOMES: The patient's symptoms abated, and chest CTA showed that the pulmonary embolism had dissolved. No further thrombosis has been observed for more than 6 years. CONCLUSIONS: We presented an unusual case of delayed pulmonary embolism after UKA. Despite the low incidence, its life-threatening nature makes it imperative for surgeons to be well-informed about thrombosis and pay more attention to its prevention strategies.


Assuntos
Artroplastia do Joelho/efeitos adversos , Osteoartrite do Joelho/cirurgia , Embolia Pulmonar/diagnóstico , Anticoagulantes/uso terapêutico , Angiografia por Tomografia Computadorizada , Diagnóstico Diferencial , Feminino , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Infusões Intravenosas , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/etiologia , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem , Varfarina/uso terapêutico
10.
Int J Infect Dis ; 104: 568-571, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33486013

RESUMO

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), a novel coronavirus, originated as an epidemic respiratory illness in Wuhan, China. COVID-19 eventually spread to almost all countries and has now been declared a global pandemic disease by the World Health Organisation. A plethora of research has explored the dynamics of different clinical entities related to SARS-COV-2, in particular, COVID-19 associated coagulopathy. A large scale of patients have been reported to have developed pulmonary embolism without any other standard triggers or risk factors, leading to speculation that COVID-19 is an independent risk factor for venous thromboembolism. In addition to the development of thromboembolic complications such as pulmonary embolism, COVID-19 has also been reported to have triggered disseminated intravascular coagulation (DIC); however, it is unclear whether pulmonary embolism was due to COVID-19-induced thrombosis or a result of coagulopathy secondary to DIC. We describe a unique case of a COVID-19 associated coagulopathy in a patient with confirmed pulmonary embolism along with an overt DIC. Following diagnosis, the challenge was to identify the appropriate treatment modality for this unique situation. The patient was treated with anticoagulants and steroids along with blood products. The patient's condition markedly improved and was clinically stable on discharge.


Assuntos
/complicações , Coagulação Intravascular Disseminada/etiologia , Embolia Pulmonar/etiologia , Idoso , Anticoagulantes/uso terapêutico , Coagulação Intravascular Disseminada/tratamento farmacológico , Feminino , Humanos , Embolia Pulmonar/tratamento farmacológico , Fatores de Risco
11.
Clin Appl Thromb Hemost ; 27: 1076029620979575, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33471574

RESUMO

This study assessed epidemiologic data and clinical outcomes, including venous thromboembolism (VTE) recurrence and bleeding events, in patients with cancer-associated VTE, and assessed factors associated with clinical outcomes. Data were extracted from retrospective medical-chart review of adult patients diagnosed with cancer-associated deep vein thrombosis or pulmonary embolism who received anticoagulation treatment for ≥3 months. Patients were classified by: low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs), and other anticoagulants. First VTE recurrence and bleeding events, and factors associated with their occurrence, were assessed during the initial 6 months of treatment. Overall, 623 patients (age: 63.7 ± 11.3 years, 49.3% male) were included (119, 132, and 372 patients in LMWH, DOACs and other anticoagulants groups, respectively). The cumulative 6-month incidence of VTE recurrence was 16.6% (total), 8.3% (LMWH), 16.7% (DOACs), and 20.7% (other); respective bleeding events were 22.5%, 11.0%, 12.3%, and 30.7%). VTE recurrence and bleeding rates differed only between LMWH and other anticoagulants (HR 2.4, 95% CI: 1.2-5.0 and 3.6, 1.9-6.8, respectively). These results highlight the importance of initial VTE treatment choice for preventing VTE recurrence and bleeding events. LMWH or DOACs for ≥3 months can be considered for effective VTE management in cancer patients.


Assuntos
Neoplasias/complicações , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/etiologia , Administração Oral , Idoso , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Estudos de Coortes , Feminino , Hemorragia/etiologia , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/etiologia , Recidiva , República da Coreia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
14.
BMJ Case Rep ; 14(1)2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509878

RESUMO

We present a case of a 38-year-old man with a history of chronic thromboembolic pulmonary hypertension on therapeutic anticoagulation and recent hospitalisation for COVID-19 disease who was hospitalised for recurrent acute pulmonary embolism despite therapeutic anticoagulation with warfarin (International Normalized Ratio (INR) of 3.0). Our case highlights the hypercoagulable state associated with COVID-19 disease and the absence of standardised approaches to anticoagulation treatment for this population.


Assuntos
Anticoagulantes/uso terapêutico , Embolia Pulmonar/complicações , Embolia Pulmonar/tratamento farmacológico , Varfarina/uso terapêutico , Adulto , Doença Crônica , Diagnóstico Diferencial , Humanos , Masculino , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos
15.
BMJ Case Rep ; 14(1)2021 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-33472803

RESUMO

Granulicatella adiacens, which occurs as part of the oral microflora, is an uncommon cause of infection. However, it can cause serious bloodstream infections including infective endocarditis. Although oral bacteria, most commonly the Fusobacterium spp, can cause internal jugular vein (IJV) thrombophlebitis, there are no reported cases of IJV thrombosis caused by G. adiacens Here we report a patient with septic IJV thrombosis with G. adiacens bacteraemia. A middle-aged man presented to our hospital with fever and altered mental status. Blood cultures were positive for G. adiacens, and pan-scan CT with contrast showed left IJV thrombosis, pulmonary embolism and abscesses in the gluteal muscles. The patient was successfully treated with antibiotics. When confronted with G. adiacens bacteraemia in patients with poor oral hygiene, it is necessary to be cautious of the fact that this organism can cause IJV thrombophlebitis.


Assuntos
Abscesso/diagnóstico por imagem , Carnobacteriaceae , Infecções por Bactérias Gram-Positivas/diagnóstico , Veias Jugulares , Embolia Pulmonar/diagnóstico por imagem , Tromboflebite/diagnóstico por imagem , Abscesso/terapia , Antibacterianos/uso terapêutico , Hemocultura , Nádegas , Drenagem , Duração da Terapia , Inibidores do Fator Xa/uso terapêutico , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/etiologia , Piridinas/uso terapêutico , Tiazóis/uso terapêutico , Tromboflebite/tratamento farmacológico , Tomografia Computadorizada por Raios X
16.
Rev Med Suisse ; 17(720-1): 20-23, 2021 Jan 13.
Artigo em Francês | MEDLINE | ID: mdl-33443825

RESUMO

Direct oral anticoagulants (DOAC) represent commonly prescribed drugs in everyday clinical practice for indications such as atrial fibrillation, prevention of venous thromboembolic disease (VTE) after major orthopaedic surgery, treatment of deep vein thrombosis and pulmonary embolism, and long term prevention of VTE recurrence. More recently, the efficacy of DOAC has been demonstrated in new clinical situations, such as heparin-induced thrombocytopenia, cancer-associated VTE and secondary prevention of cardiovascular events in patients with atherothrombotic arterial disease. This article's aims is to present the recent data on which these new indications are based.


Assuntos
Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Embolia Pulmonar/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/tratamento farmacológico , Administração Oral , Humanos , Tromboembolia Venosa/tratamento farmacológico
17.
Ann Pharmacother ; 55(1): 25-35, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32578433

RESUMO

BACKGROUND: Numerous equations are used for estimation of renal function, and many electronic medical records report multiple clearance estimates to assist with drug dosing. It is unknown whether the presence of multiple clearance estimates affects clinical decision-making. OBJECTIVE: To determine whether the presence of multiple renal clearance estimates affects pharmacist drug dosing decisions. METHODS: A randomized trial in the form of an electronic survey including 4 clinical vignettes was delivered to hospital pharmacists. Vignettes consisted of a patient presenting with an acute pulmonary embolism requiring enoxaparin therapy. Pharmacists were randomized to receive a single estimate of renal function or multiple estimates for all vignettes. The primary outcome was deviation from approved recommendations on at least 1 vignette. The χ2 test was used to detect differences in deviation rates between groups. Logistic regression was performed to adjust for the effects of potentially confounding variables. RESULTS: A total of 154 studies were completed (73 in the multiple-estimate group and 81 in the single-estimate group). Pharmacists presented with multiple renal estimates were significantly more likely to deviate from recommended dosing regimens than pharmacists presented with a single estimate (54.7% vs 38.2%; P = 0.04). The results were driven primarily by the 2 vignettes that included discordance among Cockcroft-Gault equation creatinine clearance estimates. Logistic regression identified multiple estimates as the only independent predictor of deviation (P = 0.04). CONCLUSION AND RELEVANCE: Pharmacists provided with a single renal clearance estimate were more likely to adhere to approved dosing recommendations than pharmacists provided with multiple estimates.


Assuntos
Enoxaparina/administração & dosagem , Farmacêuticos/normas , Guias de Prática Clínica como Assunto/normas , Doença Aguda , Idoso , Tomada de Decisão Clínica , Creatinina/urina , Registros Eletrônicos de Saúde , Enoxaparina/urina , Feminino , Taxa de Filtração Glomerular , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Farmacêuticos/psicologia , Embolia Pulmonar/tratamento farmacológico
18.
Am J Hematol ; 96(3): 320-329, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33326124

RESUMO

IgG-specific and polyspecific PF4-dependent enzyme-immunoassays (EIAs) have exceptionally high sensitivity (≥99%) for diagnosis of heparin-induced thrombocytopenia (HIT), a drug reaction caused by platelet-activating antibodies detectable by serotonin-release assay (SRA). The IgG-specific EIAs are recommended for screening, as their high sensitivity is accompanied by relatively high specificity vis-à-vis polyspecific EIAs. We investigated the frequency of SRA-positive/EIA-negative (SRA+/EIA-) HIT, prompted by referral to our reference HIT laboratory of serial blood samples from a patient ("index case") with false-negative IgG-specific EIAs. Despite initial clinical suspicion for HIT, repeat negative IgG-specific EIAs prompted heparin resumption, which triggered recurrent thrombocytopenia and near-fatal cardiac arrest, indicating likely post-heparin HIT-associated anaphylactoid reaction. Further investigations revealed a strong-positive SRA, whether performed with heparin alone, PF4 alone, or PF4/heparin, with inhibition by Fc receptor-blocking monoclonal antibody (indicating IgG-mediated platelet activation); however, five different IgG-specific immunoassays yielded primarily negative (or weak-positive) results. To investigate the frequency of SRA+/EIA- HIT, we reviewed the laboratory and clinical features of patients with this serological profile during a 6-year period in which our reference laboratory investigated for HIT using both SRA and IgG-specific EIA. Although ~0.2% of 8546 patients had an SRA+/EIA- profile, further review of 15 such cases indicated clerical/laboratory misclassification or false-positive SRA in all, with no SRA+/EIA- HIT case identified. We conclude that while SRA+/EIA- HIT is possible-as shown by our index case-this clinical picture is exceptionally uncommon. Moreover, the requirement for a positive EIA is a useful quality control maneuver that reduces risk of reporting a false-positive SRA result.


Assuntos
Anafilaxia/induzido quimicamente , Anticoagulantes/efeitos adversos , Autoanticorpos/sangue , Autoantígenos/imunologia , Plaquetas/metabolismo , Heparina/efeitos adversos , Técnicas Imunoenzimáticas/métodos , Imunoglobulina G/sangue , Ativação Plaquetária/imunologia , Fator Plaquetário 4/imunologia , Serotonina/sangue , Trombocitopenia/diagnóstico , Adulto , Anticoagulantes/uso terapêutico , Autoanticorpos/imunologia , Quimioterapia Combinada , Reações Falso-Negativas , Feminino , Parada Cardíaca , Heparina/uso terapêutico , Humanos , Imunoglobulina G/imunologia , Imunoglobulina M/sangue , Imunoglobulina M/imunologia , Erros Médicos , Obesidade/complicações , Embolia Pulmonar/complicações , Embolia Pulmonar/tratamento farmacológico , Recidiva , Sensibilidade e Especificidade , Trombocitopenia/induzido quimicamente , Trombose Venosa/complicações , Trombose Venosa/tratamento farmacológico , Varfarina/uso terapêutico
19.
Vnitr Lek ; 66(6): 386-390, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33380145

RESUMO

The new guidelines on the diagnosis and management of pulmonary embolism developed in collaboration with the European Respiratory Society were presented on the congress od European society of cardiology in 2019. Are internists concerned, when these guidelines were presented at the congress of cardiologic society? Management of acute pulmonary embolism is less „cathlab dependent“than management of acute coronary syndromes - and pulmonary embolism patients are often treated by internists. Moreover, differential diagnosis of dyspnoea is a everyday problem solved by internists. What is new in the updated guidelines? Refinements in interpretation of Ddimer testing will help us to avoid unnecessary pulmonary angiograms. Nonvitamin K antagonist oral anticoagulants (NOACs) are now the preferred agents for treating the majority of patients with PE, both in the acute phase and over the long term, including selected patients with malignancy. Further important updates include recurrence scores and guidance on extended anticoagulation after PE. A new comprehensive algorithm is proposed for patient followup after acute PE to prevent, detect and treat late sequelae of venous thromboembolism.


Assuntos
Embolia Pulmonar , Tromboembolia Venosa , Administração Oral , Anticoagulantes/uso terapêutico , Coagulação Sanguínea , Humanos , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/terapia , Tromboembolia Venosa/tratamento farmacológico
20.
J Extra Corpor Technol ; 52(4): 327-331, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33343036

RESUMO

Saddle pulmonary embolism (PE) remains a challenge to diagnose and manage in pediatric patients. Current literature encourages early consideration of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in high-risk PE patients with impending right ventricular failure. We present a 17-year-old patient who was admitted to a pediatric cardiac intensive care unit with saddle PE requiring emergent VA-ECMO support because of cardiovascular collapse. Despite anticoagulation with bivalirudin and receiving systemic thrombolysis with alteplase, the clot burden was persistent with minimal improvement in right ventricular function. We proceeded to catheter thrombolysis while on VA-ECMO. This ultimately led to a successful resolution of the PE and allowed for weaning off VA-ECMO. PE is rare in children compared with adults, and pediatricians may be unaware of therapies becoming increasingly used in adults such as the use of VA-ECMO, with systemic and local thrombolysis. The concurrent use of a direct thrombin inhibitor for ECMO anticoagulation alongside the thrombolysis is a novel combination in this condition and age-group.


Assuntos
Oxigenação por Membrana Extracorpórea , Embolia Pulmonar , Adolescente , Adulto , Criança , Hirudinas , Humanos , Fragmentos de Peptídeos , Embolia Pulmonar/tratamento farmacológico , Proteínas Recombinantes , Ativador de Plasminogênio Tecidual/uso terapêutico
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