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JAMA ; 324(17): 1765-1776, 2020 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-33141212


Importance: Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event. Observations: PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin. Conclusions and Relevance: Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.

Extremidade Inferior/irrigação sanguínea , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/terapia , Fatores Etários , Biomarcadores/sangue , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Estilo de Vida , Ilustração Médica , Síndrome Pós-Trombótica/etiologia , Valor Preditivo dos Testes , Fatores de Risco , Fatores Sexuais , Avaliação de Sintomas , Trombectomia/métodos , Trombofilia/complicações , Trombofilia/genética , Ultrassonografia , Filtros de Veia Cava , Tromboembolia Venosa/sangue , Tromboembolia Venosa/etiologia , Varfarina/uso terapêutico
Clin Dermatol ; 38(4): 489-493, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32972608


Lam Qua, a Chinese artist who painted in the Western style, was hired by American ophthalmologist and missionary Peter Parker to paint Parker's Chinese patients. Most of Lam Qua's paintings depict patients with rather large tumors located in various areas across the body; there are a few that are also of dermatologic interest. This contribution explores Lam Qua's paintings that depict a cutaneous horn, gangrenous necrosis, and an ulcerating tumor.

Cirurgia Geral/história , Ilustração Médica , Missionários , Oftalmologia/história , Pinturas , China , História do Século XIX , Humanos
Pediatrics ; 146(3)2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32868470


Pediatric care providers, pediatricians, pediatric subspecialty physicians, and other health care providers should be able to recognize children with abnormal head shapes that occur as a result of both synostotic and deformational processes. The purpose of this clinical report is to review the characteristic head shape changes, as well as secondary craniofacial characteristics, that occur in the setting of the various primary craniosynostoses and deformations. As an introduction, the physiology and genetics of skull growth as well as the pathophysiology underlying craniosynostosis are reviewed. This is followed by a description of each type of primary craniosynostosis (metopic, unicoronal, bicoronal, sagittal, lambdoid, and frontosphenoidal) and their resultant head shape changes, with an emphasis on differentiating conditions that require surgical correction from those (bathrocephaly, deformational plagiocephaly/brachycephaly, and neonatal intensive care unit-associated skill deformation, known as NICUcephaly) that do not. The report ends with a brief discussion of microcephaly as it relates to craniosynostosis as well as fontanelle closure. The intent is to improve pediatric care providers' recognition and timely referral for craniosynostosis and their differentiation of synostotic from deformational and other nonoperative head shape changes.

Craniossinostoses/diagnóstico , Acrocefalossindactilia/genética , Fenótipo de Síndrome de Antley-Bixler/genética , Suturas Cranianas/anatomia & histologia , Disostose Craniofacial , Craniossinostoses/classificação , Craniossinostoses/etiologia , Craniossinostoses/cirurgia , Cabeça/anormalidades , Humanos , Lactente , Hipertensão Intracraniana/etiologia , Ilustração Médica , Microcefalia/etiologia , Osteogênese/fisiologia , Fenótipo , Fotografação , Polidactilia/genética , Receptores de Fatores de Crescimento de Fibroblastos/metabolismo , Procedimentos Cirúrgicos Reconstrutivos , Crânio/anatomia & histologia , Crânio/diagnóstico por imagem , Crânio/crescimento & desenvolvimento , Sinostose/complicações , Sinostose/diagnóstico por imagem