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2.
J Stroke Cerebrovasc Dis ; 30(1): 105428, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33161349

RESUMO

The SARS-CoV-2 virus causing Coronavirus Disease 2019 (COVID-19) is a global pandemic with almost 30 million confirmed worldwide cases. Prothrombotic complications arising from those affected with severe symptoms have been reported in various medical journals. Currently, clinical trials are underway to address the questions regarding anticoagulation dosing strategies to prevent thrombosis for these critically ill patients. However, given the increasing use of therapeutic anticoagulation in patients admitted with COVID-19 to curtail this prothrombotic state, our institution has witnessed six cases of devastating intracranial hemorrhage as well as thrombosis leading to five fatalities and we examine their hospital course and anticoagulation used.


Assuntos
Anticoagulantes/efeitos adversos , Fibrinolíticos/efeitos adversos , Hospitalização , Hemorragias Intracranianas/induzido quimicamente , Trombose/prevenção & controle , Idoso , /diagnóstico , Evolução Fatal , Feminino , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Trombose/diagnóstico , Trombose/etiologia , Resultado do Tratamento
3.
Eur J Clin Invest ; 51(1): e13433, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33053206

RESUMO

BACKGROUND: COVID-19 patients are considered at high risk of venous thromboembolism (VTE). The real nature of pulmonary artery occlusions (PAO) in COVID-19 has been questioned, suggesting that it is caused also by in situ thrombi, rather than only by emboli (PE) from peripheral thrombi. METHODS: We searched MEDLINE for studies published until 6 June 2020 that included COVID-19 patients or non-COVID-19 medical patients at VTE risk, treated with heparins, in whom VTE (PE and deep vein thrombosis, DVT) had been reported. Systematic review and results reporting were conducted in accordance with PRISMA guidelines. Data were independently extracted by two observers, and estimates were pooled using random-effects meta-analysis. RESULTS: We identified 17 studies including 3224 COVID-19 patients and 7 including 11 985 non-COVID-19 patients. Two analyses were performed: in all COVID-19 patients and only in those (n = 515) who, like non-COVID-19 patients, were screened systematically for DVT. The latter analysis revealed that the prevalence of DVT was 15.43% (95%CI, 4.08-31.77) in COVID-19 and 4.21% (2.27-6.68) in non-COVID-19 patients (P = .0482). The prevalence of PE was 4.85% (40.33-13.01) in COVID-19 patients and 0.22% (0.03-0.55) in non-COVID-19 patients (P = .0128). The percentage of PE among VTE events was 22.15% (5.31-44.60) in COVID-19 and 6.39% (3.17-10.41) in non-COVID-19 patients (P = .0482). Differences were even more marked when all COVID-19 patients were analysed. CONCLUSIONS: The results of our meta-analysis highlight a disproportion in the prevalence of PE among all VTE events in COVID 19 patients, likely reflecting PAO by pulmonary thrombi, rather than emboli from peripheral vein thrombi.


Assuntos
/epidemiologia , Artéria Pulmonar , Embolia Pulmonar/epidemiologia , Trombose/epidemiologia , Trombose Venosa/epidemiologia , Anticoagulantes/uso terapêutico , Estudos de Casos e Controles , Heparina/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Prevalência , Embolia Pulmonar/prevenção & controle , Trombose/prevenção & controle , Trombose Venosa/prevenção & controle
4.
Ann Vasc Surg ; 70: 123-130, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32416311

RESUMO

BACKGROUND: Management of antithrombotic therapy with warfarin in patients undergoing fistulograms and possible interventions is controversial and difficult because of lack of adequate outpatient bridging options. Our goal was to assess periprocedural outcomes in patients managed using different anticoagulation strategies. METHODS: A retrospective, single-institution analysis of all patients on chronic anticoagulation with warfarin undergoing fistulograms from 2011 to 2017 was performed. Anticoagulation management strategies were classified as suspended warfarin (SW), continued warfarin (CW), and a heparin bridge with suspended warfarin (HB). Periprocedural outcomes were analyzed. RESULTS: There were 87 patients on chronic anticoagulation with warfarin who underwent 175 fistulograms. Median age was 63 years, and 43.4% were women. Indications for warfarin included atrial fibrillation (53%), prior pulmonary embolism/deep vein thrombosis (29%), and hypercoagulable state (14%). Distribution was SW (60%), CW (26%), and HB (14%). Approximately half (53%) were same-day procedures, 30% occurred during access-related admissions, and 14% were performed during nonaccess-related admissions. Common indications for a fistulogram included difficulty with dialysis (63.4%), access thrombosis (20.6%), and poor maturation (10.3%). Interventions included angioplasty (82.9%), thrombectomy/embolectomy (20.6%), and stenting (8.6%). Thirty-day outcomes for SW versus CW versus HB were similar for bleeding complications (5.7%, 6.5%, 8.3%; P = 0.89), systemic thrombotic complications (3.8%, 2.2%, 0%; P = 0.569), access rethrombosis (7.6%, 13%, 12.5%; P = 0.517), and tunneled dialysis catheter placement (11.4%, 13%, 12.5%; P = 0.958). After excluding procedures performed during a nonaccess-related admission, length of stay (LOS) was highest among HB (9.6 ± 7.8 days) compared with SW (2.6 ± 5.9 days) and CW (1 ± 2.8 days), (P < 0.0001). CONCLUSIONS: CW therapy in patients undergoing fistulograms was not associated with increased morbidity and was associated with shorter LOS. Bridging with heparin is not associated with improved outcomes, warranting a thorough consideration of continuing warfarin is safe and may streamline preservation of dialysis accesses without significantly increasing resource utilization.


Assuntos
Anticoagulantes/administração & dosagem , Derivação Arteriovenosa Cirúrgica , Substituição de Medicamentos , Heparina/administração & dosagem , Falência Renal Crônica/terapia , Diálise Renal , Trombose/prevenção & controle , Varfarina/administração & dosagem , Adulto , Idoso , Anticoagulantes/efeitos adversos , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Esquema de Medicação , Feminino , Heparina/efeitos adversos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Complicações Pós-Operatórias/etiologia , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Varfarina/efeitos adversos
5.
Cardiol Rev ; 29(1): 43-47, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32947478

RESUMO

The novel coronavirus (severe acute respiratory syndrome CoV-2 [SARS-CoV-2]), also known as COVID-19, is a single-stranded enveloped RNA virus that created a Public Health Emergency of International Concern in January 2020, with a global case burden of over 15 million in just 7 months. Infected patients develop a wide range of clinical manifestations-typically presenting with fever, cough, myalgia, and fatigue. Severely ill patients may fall victim to acute respiratory distress syndrome, acute heart injuries, neurological manifestations, or complications due to secondary infections. These critically ill patients are also found to have disrupted coagulation function, predisposing them to consumptive coagulopathies, and both venous and thromboembolic complications. Common laboratory findings include thrombocytopenia, elevated D-dimer, fibrin degradation products, and fibrinogen, all of which have been associated with greater disease severity. Many cases of pulmonary embolism have been noted, along with deep vein thrombosis, ischemic stroke, myocardial infarction, and systemic arterial embolism. The pathogenesis of coronavirus has not been completely elucidated, but the virus is known to cause excessive inflammation, endothelial injury, hypoxia, and disseminated intravascular coagulation, all of which contribute to thrombosis formation. These patients are also faced with prolonged immobilization while staying in the hospital or intensive care unit. It is important to have a high degree of suspicion for thrombotic complications as patients may rapidly deteriorate in severe cases. Evidence suggests that prophylaxis with anticoagulation may lead to a lower risk of mortality, although it does not eliminate the possibility. The risks and benefits of anticoagulation treatment should be considered in each case. Patients should be regularly evaluated for bleeding risks and thrombotic complications.


Assuntos
Transtornos da Coagulação Sanguínea/sangue , Embolia/sangue , Trombose/sangue , Anticoagulantes/uso terapêutico , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/metabolismo , /tratamento farmacológico , Síndrome da Liberação de Citocina/sangue , Síndrome da Liberação de Citocina/complicações , Síndrome da Liberação de Citocina/metabolismo , Coagulação Intravascular Disseminada/sangue , Coagulação Intravascular Disseminada/etiologia , Coagulação Intravascular Disseminada/metabolismo , Coagulação Intravascular Disseminada/prevenção & controle , Embolia/etiologia , Embolia/metabolismo , Embolia/prevenção & controle , Endotélio Vascular/metabolismo , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Fibrinogênio/metabolismo , Humanos , Hipóxia/sangue , Hipóxia/etiologia , Hipóxia/metabolismo , Imobilização , Inflamação/sangue , Inflamação/etiologia , Inflamação/metabolismo , /etiologia , /prevenção & controle , Infarto do Miocárdio/sangue , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/metabolismo , Infarto do Miocárdio/prevenção & controle , Guias de Prática Clínica como Assunto , Embolia Pulmonar/sangue , Embolia Pulmonar/etiologia , Embolia Pulmonar/metabolismo , Embolia Pulmonar/prevenção & controle , Índice de Gravidade de Doença , Trombocitopenia/sangue , Trombocitopenia/etiologia , Trombose/etiologia , Trombose/metabolismo , Trombose/prevenção & controle , Trombose Venosa/sangue , Trombose Venosa/etiologia , Trombose Venosa/metabolismo
6.
Med Hypotheses ; 144: 110218, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33254525

RESUMO

Covid-19, caused by SARS-CoV-2, has major world-wide health-related and socio-economic consequences. There are large disparities in the burden of Covid-19 with an apparent lower risk of poor outcomes in East Asians compared to populations in the West. A recent study suggested that Covid-19 leads to a severe extrahepatic vitamin K insufficiency, which could lead to impaired activation of extrahepatic proteins like endothelial anticoagulant protein S in the presence of normal hepatic procoagulant activity. This would be compatible with the enhanced thrombogenicity in severe Covid-19. The same study showed that vitamin K antagonists (VKA) that inhibit vitamin K recycling, had a greater impact on procoagulant activity than on the activation of extrahepatic vitamin K-dependent proteins during SARS-CoV-2 infections. A genetic polymorphism in the vitamin K epoxide reductase complex 1, VKORC1 -1639A, is particularly prevalent in East Asia and associates with low vitamin K recycling rates. Carriage of the allele may be regarded as bioequivalent to low-dose VKA use. We speculate that VKORC1 -1639A confers protection against thrombotic complications of Covid-19 and that differences in its allele frequency are partially responsible for the differences in Covid-19 severity between East and West.


Assuntos
/genética , Vitamina K Epóxido Redutases/genética , América/epidemiologia , /enzimologia , Europa (Continente)/epidemiologia , Extremo Oriente/epidemiologia , Frequência do Gene , Humanos , Modelos Biológicos , Pandemias , Polimorfismo de Nucleotídeo Único , Índice de Gravidade de Doença , Trombose/etiologia , Trombose/genética , Trombose/prevenção & controle , Vitamina K/antagonistas & inibidores , Deficiência de Vitamina K/etiologia
7.
Am J Cardiovasc Drugs ; 20(6): 559-570, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33145698

RESUMO

In patients with coronavirus disease 2019 (COVID-19), the prevalence of pre-existing cardiovascular diseases is elevated. Moreover, various features, also including pro-thrombotic status, further predispose these patients to increased risk of ischemic cardiovascular events. Thus, the identification of optimal antithrombotic strategies in terms of the risk-benefit ratio and outcome improvement in this setting is crucial. However, debated issues on antithrombotic therapies in patients with COVID-19 are multiple and relevant. In this article, we provide ten questions and answers on risk stratification and antiplatelet/anticoagulant treatments in patients at risk of/with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection based on the scientific evidence gathered during the pandemic.


Assuntos
Anticoagulantes/farmacologia , Anticoagulantes/uso terapêutico , Trombose/etiologia , Trombose/prevenção & controle , Fatores Etários , Anti-Inflamatórios não Esteroides/farmacologia , Anticoagulantes/administração & dosagem , Anticoagulantes/classificação , Antivirais/farmacologia , Fibrilação Atrial/tratamento farmacológico , Quimioprevenção/efeitos adversos , Quimioprevenção/métodos , Coagulação Intravascular Disseminada/tratamento farmacológico , Interações Medicamentosas , Humanos , Itália , Pandemias , Fatores de Risco , Gestão de Riscos , Índice de Gravidade de Doença , Fatores Sexuais , Trombose/tratamento farmacológico , Trombose/fisiopatologia
8.
Mayo Clin Proc ; 95(11): 2467-2486, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33153635

RESUMO

A higher risk of thrombosis has been described as a prominent feature of coronavirus disease 2019 (COVID-19). This systematic review synthesizes current data on thrombosis risk, prognostic implications, and anticoagulation effects in COVID-19. We included 37 studies from 4070 unique citations. Meta-analysis was performed when feasible. Coagulopathy and thrombotic events were frequent among patients with COVID-19 and further increased in those with more severe forms of the disease. We also present guidance on the prevention and management of thrombosis from a multidisciplinary panel of specialists from Mayo Clinic. The current certainty of evidence is generally very low and continues to evolve.


Assuntos
Anticoagulantes/uso terapêutico , Guias de Prática Clínica como Assunto , Trombose/prevenção & controle , /complicações , Humanos , Minnesota , Trombose/etiologia
9.
Crit Care ; 24(1): 653, 2020 11 23.
Artigo em Inglês | MEDLINE | ID: mdl-33225952

RESUMO

BACKGROUND: A substantial proportion of critically ill COVID-19 patients develop thromboembolic complications, but it is unclear whether higher doses of thromboprophylaxis are associated with lower mortality rates. The purpose of the study was to evaluate the association between initial dosing strategy of thromboprophylaxis in critically ill COVID-19 patients and the risk of death, thromboembolism, and bleeding. METHOD: In this retrospective study, all critically ill COVID-19 patients admitted to two intensive care units in March and April 2020 were eligible. Patients were categorized into three groups according to initial daily dose of thromboprophylaxis: low (2500-4500 IU tinzaparin or 2500-5000 IU dalteparin), medium (> 4500 IU but < 175 IU/kilogram, kg, of body weight tinzaparin or > 5000 IU but < 200 IU/kg of body weight dalteparin), and high dose (≥ 175 IU/kg of body weight tinzaparin or ≥ 200 IU/kg of body weight dalteparin). Thromboprophylaxis dosage was based on local standardized recommendations, not on degree of critical illness or risk of thrombosis. Cox proportional hazards regression was used to estimate hazard ratios with corresponding 95% confidence intervals of death within 28 days from ICU admission. Multivariable models were adjusted for sex, age, body mass index, Simplified Acute Physiology Score III, invasive respiratory support, and initial dosing strategy of thromboprophylaxis. RESULTS: A total of 152 patients were included: 67 received low-, 48 medium-, and 37 high-dose thromboprophylaxis. Baseline characteristics did not differ between groups. For patients who received high-dose prophylaxis, mortality was lower (13.5%) compared to those who received medium dose (25.0%) or low dose (38.8%), p = 0.02. The hazard ratio of death was 0.33 (95% confidence intervals 0.13-0.87) among those who received high dose, and 0.88 (95% confidence intervals 0.43-1.83) among those who received medium dose, as compared to those who received low-dose thromboprophylaxis. There were fewer thromboembolic events in the high (2.7%) vs medium (18.8%) and low-dose thromboprophylaxis (17.9%) groups, p = 0.04. CONCLUSIONS: Among critically ill COVID-19 patients with respiratory failure, high-dose thromboprophylaxis was associated with a lower risk of death and a lower cumulative incidence of thromboembolic events compared with lower doses. TRIAL REGISTRATION: Clinicaltrials.gov NCT04412304 June 2, 2020, retrospectively registered.


Assuntos
Anticoagulantes/administração & dosagem , Estado Terminal/mortalidade , Dalteparina/administração & dosagem , Trombose/mortalidade , Trombose/prevenção & controle , Tinzaparina/administração & dosagem , APACHE , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Suécia/epidemiologia
10.
Ned Tijdschr Tandheelkd ; 127(11): 617-624, 2020 Nov.
Artigo em Holandês | MEDLINE | ID: mdl-33252603

RESUMO

The clinical guidelines on antithrombotics, published by the Dutch Institute of Expertise for Oral Healthcare, give advice on policy to be followed in cases of dental procedures involving bleeding. The guidelines allow room for professional assessment of bleeding risks, for which background knowledge about haemostasis, thrombosis and antithrombotic processes is necessary. Normal haemostasis can be divided in several steps: vasoconstriction, primary haemostasis by aggregation of thrombocytes, and secondary haemostasis by the formation of fibrin out of coagulation factors. In the case of thrombosis, a blood clot forms inside a blood vessel, causing obstruction of blood flow to the underlying tissue. Various antithrombotics are prescribed for the prevention and treatment of thrombosis. Thrombocyte aggregation inhibitors only have an effect on primary haemostasis. Vitamin K antagonists influence secondary haemostasis by lowering the production of several coagulation factors. The direct oral anticoagulants have an immediate effect on an activated coagulation factor, and are currently prescribed in large quantities [in the Netherlands]. Low-molecular-weight heparin also inhibits activated coagulation factors, but is not used for long-term antithrombotic therapy since it is administrated subcutaneously.


Assuntos
Fibrinolíticos , Trombose , Anticoagulantes/farmacologia , Fibrinolíticos/farmacologia , Fibrinolíticos/uso terapêutico , Hemostasia , Humanos , Países Baixos , Trombose/tratamento farmacológico , Trombose/prevenção & controle
11.
Z Gastroenterol ; 58(11): 1099-1106, 2020 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-33197951

RESUMO

In emergency medicine and intensive care the key to control active bleeding - besides definitive therapy (endoscopy, therapeutic angiography or operation) - often is to improve the patients clotting and thrombus formation. Knowledge about routine laboratory testing, their strength and weaknesses as well as indications and dosing of pro-coagulants and blood products remains pivotal in these situations. Achieving hemostasis can be especially challenging in patients with liver cirrhosis, innate or acquired coagulation disorders. This review summarizes the principles of hemostasis diagnostics and management in acute bleeding for gastroenterologists and hepatologists including novel available antidotes and innovative tools for patients with advanced liver disease such as thromboelastometry.


Assuntos
Gastroenterologia , Cirrose Hepática/complicações , Trombose/etiologia , Cuidados Críticos , Hemostasia , Humanos , Cirrose Hepática/sangue , Trombose/prevenção & controle
12.
Trials ; 21(1): 920, 2020 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-33176886

RESUMO

OBJECTIVES: The primary objective is to test if heparin added to a standard regional anticoagulation protocol based on citrate is able to reduce dialysis circuit losses by clotting without increasing the risk of thrombocytopenia or bleeding, in patients with COVID-19 with acute kidney injury requiring dialysis. TRIAL DESIGN: Randomized, parallel-group, open-label trial, with two arms (ratio 1:1) comparing different continuous renal replacement therapy anticoagulation strategies. PARTICIPANTS: Eligibility conditions: All ICU patients of University of Sao Paulo General Hospital (Hospital das Clínicas), Brazil will be screened for eligibility conditions. Adults (> 18 years old) with confirmed COVID-19 and acute kidney injury requiring dialysis with agreement between ICU and nephrology teams for the introduction of renal continuous replacement therapy in daily ICU rounds. Continuous renal replacement therapy will be prescribed by consulting nephrologists based on standard clinical guidelines, including acute kidney injury with hemodynamic instability plus hyperkalemia, severe acidosis, volume overload, respiratory distress, multiorgan failure or some combination of these factors. DATA COLLECTION: Patients demographics and associated clinical data and comorbidities will be recorded at ICU entry. Demographic information will include the patient's age, sex, and admission dates. Clinical data comprise comorbidities, APACHE 2, SAPS 3, need for mechanical ventilation, and use of vasopressor drugs. Physiological data collected by the day of CRRT start will be vital signs, the arterial oxygen tension/fraction of inspired oxygen (PaO2/FiO2) index, and serum creatinine, blood urea nitrogen, bilirubin, hemoglobin, hematocrit, platelets, white blood cell count levels and Peak D-dimer levels. Patients will be analyzed for the first 72h of CRRT, and they will be evaluated regarding clinical variables, filter patency and any adverse events that could be related to the anticoagulation choice, as bleeding (mild or major) or low platelets counts (<100.000 ui/uL) during treatment period. Mild and major bleeding will be defined by hemorrhagic event without clinical impact or hemoglobin (Hb) fall lesser than 1g/dL and hemorrhagic event with clinical impact or Hb fall higher than 1g/dL, respectively. EXCLUSION CRITERIA: Hypersensitivity to any of the substances going to be used in the study (Citric acid dextrosol 2.2% and unfractionated heparin); Previous diagnosis of coagulopathy or thrombophilia; Contraindication to the use of unfractionated heparin; Risk of citrate poisoning - (Lactate> 30 mg/dL, international normalized ratio > 2.5, Total bilirubin> 15 mg/dL); Pregnancy; Patients unlikely to survive for more than 24 hours. The trial is being undertaken at the University of Sao Paulo General Hospital (Hospital das Clinicas), Brazil. INTERVENTION AND COMPARATOR: Group A (control) - Patients on continuous renal replacement therapy (blood flow 150 ml/min, dose of 30 mL/Kg/h) receiving anticoagulation with sodium citrate at 4 mmol/L Group B (experiment): Patients on continuous hemodialysis (blood flow 150 mL/min, dose of 30 mL/Kg/h) receiving anticoagulation with sodium citrate at 4 mmol/L associated with unfractionated heparin at 10 U/Kg/h. MAIN OUTCOMES: The percentage of clotted dialyzers within 72 hours in each of the studied groups (Primary outcome) Secondary outcomes: Number of dialyzers used in the first 72 hours of dialysis protocol, Mortality in the first 72 h of dialysis protocol, Bleeding events (Major or minor) in the first 72 h of dialysis protocol, Thrombocytopenia (less than 50.000 platelets) proportion in the first 72 h of dialysis protocol, Dialysis efficiency (Urea sieving) - variation in urea sieving between the first, second and third days of dialysis protocol, Continuous renal replacement therapy pressures (Arterial, Venous, dialysate and pre-filter pressure) in the first 72 h of dialysis protocol, in-hospital mortality. RANDOMIZATION: RedCap→ randomization - 2 blocks randomization by D-dimer level (5000ng/dL cut-off) and catheter site (Right Internal Jugular versus other sites) with 1:1 allocation ratio. BLINDING (MASKING): No blinding - Open label format NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): Total number of patients 90 (45 per group) TRIAL STATUS: Trial version 2.0 - ongoing recruitment. First recruitment: June 29, 2020 Estimated date for last recruitment: December 31, 2020 TRIAL REGISTRATION: Responsible Party: University of Sao Paulo General Hospital (Hospital das Clinicas) ClinicalTrials.gov Identifier: NCT04487990 , registered July 27, 2020, ReBec www.ensaiosclinicos.gov.br/rg/RBR-45kf9p/ Other Study ID Numbers: U1111-1252-0194 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1) In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.


Assuntos
Lesão Renal Aguda , Infecções por Coronavirus , Monitoramento de Medicamentos/métodos , Heparina , Pandemias , Pneumonia Viral , Diálise Renal , Trombose/prevenção & controle , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Adulto , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Coagulação Sanguínea/efeitos dos fármacos , Infecções por Coronavirus/sangue , Infecções por Coronavirus/complicações , Infecções por Coronavirus/tratamento farmacológico , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hemoglobinas/análise , Hemorragia/etiologia , Hemorragia/prevenção & controle , Heparina/administração & dosagem , Heparina/efeitos adversos , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Pneumonia Viral/sangue , Pneumonia Viral/complicações , Pneumonia Viral/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Risco Ajustado/métodos , Trombocitopenia/etiologia , Trombocitopenia/prevenção & controle , Trombose/complicações
13.
ASAIO J ; 66(10): 1069-1072, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33136589

RESUMO

Extracorporeal membrane oxygenation (ECMO) is recognized as organ support for potentially reversible acute respiratory distress syndrome (ARDS). However, limited resource during the outbreak and the coagulopathy associated with coronavirus disease 2019 (COVID-19) make the utilization of venovenous (VV) ECMO highly challenging. We herein report specific considerations for cannulation configurations and ECMO management during the pandemic. High blood flow and anticoagulation at higher levels than usual practice for VV ECMO may be required because of thrombotic hematologic profile of COVID-19. Among our first 24 cases (48.8 ± 8.9 years), 17 patients were weaned from ECMO after a mean duration of 19.0 ± 10.1 days and 16 of them have been discharged from ICU.


Assuntos
Infecções por Coronavirus/terapia , Oxigenação por Membrana Extracorpórea/métodos , Pneumonia Viral/terapia , Anticoagulantes/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/complicações , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Trombose/etiologia , Trombose/prevenção & controle
14.
Semergen ; 46(7): 479-486, 2020 Oct.
Artigo em Espanhol | MEDLINE | ID: mdl-33046353

RESUMO

The new coronavirus (SARS-CoV-2) is responsible for a severe acute respiratory syndrome. Among its manifestations, it can develop a thrombotic disease, both venous and arterial, due to excessive inflammation that affects the vascular system, with platelet activation and endothelial dysfunction, among other mechanisms. Thrombosis is associated with SARS-CoV-2 infection, increasing its severity and conferring a worse prognosis. Our performance as Family Physicians can contribute important actions in the management and control of this severe complication. Considering that many of our patients already receive antithrombotic or anticoagulant therapy, the fact that they may develop a COVID-19 infection will have implications for the choice, dosage and control of their treatment. In this document we review, with the information currently available, the relationship between disease caused by SARS-CoV-2 and thrombosis, as well as its management with a focus on Primary Care.


Assuntos
Anticoagulantes/administração & dosagem , Infecções por Coronavirus/complicações , Infecções por Coronavirus/terapia , Medicina de Família e Comunidade/métodos , Pneumonia Viral/complicações , Pneumonia Viral/terapia , Atenção Primária à Saúde/métodos , Trombose/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/diagnóstico , Humanos , Pandemias , Pneumonia Viral/diagnóstico , Medição de Risco , Trombose/virologia , Tromboembolia Venosa/virologia
17.
BMC Surg ; 20(1): 251, 2020 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-33092570

RESUMO

BACKGROUND: Excisional haemorrhoidectomy is the gold standard technique in patients with III and IV degree haemorrhoidal disease (HD). However, it is associated with a significant rate of post-operative pain. The aim of our study was to evaluate the efficacy of mesoglycan in the post-operative period of patients who underwent open excisional diathermy haemorrhoidectomy (OEH). METHODS: This was a retrospective multicentre observational study. Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled. All patients were followed-up on the first post-operative day (T1) and after 1 week (T2), 3 weeks (T3) and 6 weeks (T4). BMI, habits, SF-12 questionnaire, VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated. RESULTS: In the mesoglycan group, post-operative thrombosis was significantly reduced at T2 (p < 0.05) and T3 (p < 0.005), and all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003). There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding. There was an early recovery of autonomy in the mesoglycan group in all three follow-up periods (T2 p = 0.016; T3 p = 0.002; T4 p = 0.007). CONCLUSIONS: The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain with consequent early resumption of autonomy. Trial registration NCT04481698-Mesoglycan for Pain Control After Open Excisional HAEMOrrhoidectomy (MeHAEMO) https://clinicaltrials.gov/ct2/show/NCT04481698?term=Mesoglycan+for+Pain+Control+After+Open+Excisional+HAEMOrrhoidectomy+%28MeHAEMO%29&draw=2&rank=1.


Assuntos
Fibrinolíticos/uso terapêutico , Glicosaminoglicanos/uso terapêutico , Hemorroidectomia , Hemorroidas , Dor Pós-Operatória , Trombose , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorroidectomia/efeitos adversos , Hemorroidectomia/métodos , Hemorroidas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Estudos Retrospectivos , Trombose/etiologia , Trombose/prevenção & controle , Resultado do Tratamento , Adulto Jovem
20.
Arterioscler Thromb Vasc Biol ; 40(12): 2990-3003, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33028101

RESUMO

OBJECTIVE: Arterial thrombosis leading to ischemic injury worsens the prognosis of many patients with cardiovascular disease. PZ-128 is a first-in-class pepducin that reversibly inhibits PAR1 (protease-activated receptor 1) on platelets and other vascular cells by targeting the intracellular surface of the receptor. The TRIP-PCI (Thrombin Receptor Inhibitory Pepducin in Percutaneous Coronary Intervention) trial was conducted to assess the safety and efficacy of PZ-128 in patients undergoing cardiac catheterization with intent to perform percutaneous coronary intervention. Approach and Results: In this randomized, double-blind, placebo-controlled, phase 2 trial, 100 patients were randomly assigned (2:1) to receive PZ-128 (0.3 or 0.5 mg/kg), or placebo in a 2-hour infusion initiated just before the start of cardiac catheterization, on top of standard oral antiplatelet therapy. Rates of the primary end point of bleeding were not different between the combined PZ-128 doses (1.6%, 1/62) and placebo group (0%, 0/35). The secondary end points of major adverse coronary events at 30 and 90 days did not significantly differ but were numerically lower in the PZ-128 groups (0% and 2% in the PZ-128 groups, 6% and 6% with placebo, p=0.13, p=0.29, respectively). In the subgroup of patients with elevated baseline cardiac troponin I, the exploratory end point of 30-day major adverse coronary events + myocardial injury showed 83% events in the placebo group versus 31% events in the combined PZ-128 drug groups, an adjusted relative risk of 0.14 (95% CI, 0.02-0.75); P=0.02. CONCLUSIONS: In this first-in-patient experience, PZ-128 added to standard antiplatelet therapy appeared to be safe, well tolerated, and potentially reduced periprocedural myonecrosis, thus providing the basis for further clinical trials. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02561000.


Assuntos
Síndrome Coronariana Aguda/terapia , Plaquetas/efeitos dos fármacos , Cateterismo Cardíaco , Peptídeos Penetradores de Células/administração & dosagem , Doença da Artéria Coronariana/terapia , Lipopeptídeos/administração & dosagem , Miocárdio/patologia , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/administração & dosagem , Receptor PAR-1/agonistas , Trombose/prevenção & controle , Síndrome Coronariana Aguda/diagnóstico por imagem , Idoso , Plaquetas/metabolismo , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Peptídeos Penetradores de Células/efeitos adversos , Peptídeos Penetradores de Células/farmacocinética , Doença da Artéria Coronariana/diagnóstico por imagem , Método Duplo-Cego , Feminino , Humanos , Infusões Intravenosas , Lipopeptídeos/efeitos adversos , Lipopeptídeos/farmacocinética , Masculino , Pessoa de Meia-Idade , Necrose , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/farmacocinética , Estudo de Prova de Conceito , Estudos Prospectivos , Receptor PAR-1/metabolismo , Recidiva , Stents , Trombose/sangue , Trombose/etiologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
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