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Introduction Hospital-acquired thrombosis (HAT) is defined as any venous thromboembolism (VTE)-related event during a hospital admission or occurring up to 90 days post discharge, and is associated with significant morbidity, mortality and healthcare-associated costs. Although surgery is an established risk factor for VTE, operations with a short hospital stay (, National Institute for Health Research (NIHR) NIHR133776

Although esophagectomy remains the preferred treatment for esophageal cancer, it is still associated with a number of complications, including post-operative venous thromboembolism (VTE). The aim of this study was to summarize the reported incidence of VTE after esophagectomy, its risk factors, and prevention strategies. We conducted a systematic search of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Fourteen studies met our inclusion criteria and were selected in the present review. Overall, we identified 9768 patients who underwent esophagectomy, with a post-operative VTE rate of 4% (440 patients). The reported risk factors for VTE included advanced age, American Society of Anesthesiologists (ASA) class III or IV, a history of cardiovascular or pulmonary disease, and the implementation of preoperative chemo-radiotherapy. Postoperative acute respiratory distress syndrome was also associated with VTE. No universally applied prevention strategies for VTE after esophagectomy were identified in the literature. Despite advances in perioperative care, VTE after esophagectomy still represents a source of morbidity for about 4% of patients. Low molecular weight heparin is suggested as the routine standard prophylactic regimen after esophageal cancer surgery.

Medicina Interna, Vol. 25 N.º 3 (2018): Julho/Setembro

IntroductionPatients with lower limb trauma requiring orthopaedic immobilisation may be at risk of venous thromboembolism but opinions differ about who may benefit from thromboprophylactic anticoagulant treatment.The aim of this CASTING study is to demonstrate the safety of thromboprophylaxis based on the Thrombosis Risk Prediction for patients with cast immobilisation (TRiP(cast) score with regards to the 3-month incidence of symptomatic venous thromboembolism events in low-risk patients not receiving thromboprophylaxis, as well as the usefulness of this strategy on the rate of patients receiving anticoagulant treatment in comparison to current practice.Methods and analysisCASTING will be a stepped-wedge cluster randomised controlled clinical trial, performed in 15 emergency departments in France and Belgium. With their informed consent, outpatients admitted to one of the participating emergency departments for a lower limb trauma requiring orthopaedic immobilisation without surgery will be included. All centres will begin the trial with the ‘observational period’ and, every 2 weeks, 1 centre will be randomly assigned to switch to the ‘interventional period’ and to apply the TRiP(cast) score, in which only patients with a score ≥7 will receive thromboprophylactic anticoagulant treatment. The primary endpoint is the rate of clinical thromboembolic events within 90 days following the inclusion of low-risk patients not receiving thromboprophylaxis.Ethics and disseminationThe protocol has been approved by the Comité de Protection des Personnes Sud I (Ethics Review ID-RCB: 2019-A01829-48) for France and the Comité d’éthique hôpital-facultaire Saint Luc (N° B403201941338) for Belgium. It is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this study will be disseminated in peer-reviewed journals and at scientific conferences.Trial registration numberNCT04064489.

SUMMARY OBJECTIVES The outbreak of coronavirus disease (COVID-19) is a public health emergency of international concern. Inflammatory changes are part of COVID-19 pathophysiology and this might generate a higher thromboembolic risk in patients using combined hormonal contraception and menopausal hormone therapy. We aimed to discuss the main aspects related to this issue and propose management strategies for women affected by COVID-19. METHODS This narrative review collected information from several articles published since the beginning of the outbreak of the new coronavirus disease about the pathophysiology, stage of the disease, the occurrence of thrombotic events, and the risk of thromboembolism in users of contraception and hormonal therapy. RESULTS This article consolidates clinical parameters about the risk of venous thromboembolism in users of contraception and menopausal hormone therapy emphasizing the probable increase of that risk in women with suspected or confirmed COVID-19 and bringing safer recommendations. CONCLUSIONS In this scenario, apart from the fundamental orientations of preventive measures, like social isolation and hygiene, it is important that all female health professionals have knowledge of the new rules and adopt safety measures, especially on the prescription of hormonal therapy and contraception. RESUMO OBJETIVOS A pandemia da COVID-19 é um problema de saúde pública emergente e que tem repercussão internacional. As alterações inflamatórias fazem parte da fisiopatologia da COVID-19 e isso pode acarretar um maior risco tromboembólico em mulheres que fazem uso de contracepção e terapia hormonal da menopausa. Discutimos os principais aspectos relacionados a esse risco e propomos uma estratégia de seguimento das mulheres acometidas da COVID-19. MÉTODOS Esta revisão narrativa coletou informações de vários artigos publicados desde o início da pandemia do novo coronavírus, no que tange à sua fisiopatologia, estágios da doença e ocorrência de eventos trombóticos, bem como sobre o risco de tromboembolismo venoso em usuárias de contracepção e terapia hormonal da menopausa. RESULTADOS Este artigo consolida alguns parâmetros clínicos sobre o risco de tromboembolismo em usuárias de contracepção e terapia hormonal na menopausa, enfatizando o provável aumento desse risco em mulheres com suspeita ou confirmação do novo coronavírus, e traz uma recomendação de uma conduta mais segura. CONCLUSÃO Nesse cenário, além das fundamentais orientações de medidas preventivas, como o isolamento social e a higiene, é importante que os profissionais que trabalham na atenção à saúde feminina tenham conhecimentos da nova realidade e adotem condutas seguras, especialmente na prescrição de THM e contracepção.

Background. Coronavirus disease 2019 (COVID-19) can result in profound changes in blood coagulation. The aim of the study was to determine the incidence and predictors of venous thromboembolic events (VTE) among patients with COVID-19 requiring hospital admission. Subjects and Methods. We performed a retrospective study at the Lausanne University Hospital with patients admitted because of COVID-19 from February 28 to April 30, 2020. Results. Among 443 patients with COVID-19, VTE was diagnosed in 41 patients (9.3%; 27 pulmonary embolisms, 12 deep vein thrombosis, one pulmonary embolism and deep vein thrombosis, one portal vein thrombosis). VTE was diagnosed already upon admission in 14 (34.1%) patients and 27 (65.9%) during hospital stay (18 in ICU and nine in wards outside the ICU). Multivariate analysis revealed D-dimervalue>3,120 ng/ml(P<0.001; OR 15.8, 95% CI 4.7-52.9) and duration of 8 days or more from COVID-19 symptoms onset to presentation (P0.020; OR 4.8, 95% CI 1.3-18.3) to be independently associated with VTE upon admission. D-dimervalue≥3,000 ng/lcombined with a Wells score forPE≥2was highly specific (sensitivity 57.1%, specificity 91.6%) in detecting VTE upon admission. Development of VTE during hospitalization was independently associated with D-dimervalue>5,611 ng/ml(P<0.001; OR 6.3, 95% CI 2.4-16.2) and mechanical ventilation (P<0.001; OR 5.9, 95% CI 2.3-15.1). Conclusions. VTE seems to be a common COVID-19 complication upon admission and during hospitalization, especially in ICU. The combination ofWells≥2score andD−dimer≥3,000 ng/lis a good predictor of VTE at admission.

RESUMO A artroplastia total do joelho é um procedimento eletivo, realizado em indivíduos relativamente saudáveis. Porém, devido ao risco inerente de tromboembolismo venoso, são utilizados fármacos para sua profilaxia. O objetivo do presente trabalho foi conduzir uma revisão sistemática da literatura para comparar a eficácia da enoxaparina e da rivaroxabana na prevenção desta complicação e no risco de sangramento intraoperatório. Foi feita uma revisão no site SciELO, Pubmed e Cochrane através dos descritores, artroplastia de joelho, rivaroxabana e enoxaparina através da estratégia de busca PICO. Os critérios de inclusão foram os artigos no período estudado, que comparavam ambas as drogas em cirurgias de artroplastia do joelho. Os critérios de relevância para tornar o estudo elegível foram definidos como: somente artigos publicados a partir 2010 e com casuística com mais de 20 pacientes foram considerados; somente estudos obtidos em sua íntegra foram analisados; somente estudos com seguimento maior do que 12 meses foram considerados relevantes. As variáveis utilizadas para a comparação dos artigos foram as complicações mais comuns no pós-operatório de artroplastias do joelho: tromboembolismo venoso e sangramento. Foi utilizado o Review Man 5.3 para estruturação da revisão. Os autores observaram que nos estudos analisados, considerando tromboembolismo venoso sintomático, a rivaroxabana resultou em maiores benefícios quando comparada com a enoxaparina. ABSTRACT Total knee arthroplasty is an elective procedure performed on relatively healthy individuals. However, due to the inherent risk of venous thromboembolism, drugs are used for its prophylaxis. The objective of the present study was to conduct a systematic review of the literature to compare the efficacy of enoxaparin and rivaroxaban in preventing this complication and the risk of intraoperative bleeding. We reviewed the SciELO, Pubmed and Cochrane databases with the descriptors knee arthroplasty, rivaroxaban and enoxaparin through the PICO search strategy. Inclusion criteria were the articles during the study period comparing both drugs in knee arthroplasty. Relevant criteria to study eligibility were articles published since 2010 and with a sample of more than 20 patients; studies obtained in their entirety; and studies with follow-up of more than 12 months. The variables used to compare the articles were the most common postoperative complications of knee arthroplasties: venous thromboembolism and bleeding. We used the Review Man software, version 5.3, for structuring the review. In the studies analyzed, considering symptomatic venous thromboembolism, rivaroxaban resulted in higher benefits when compared to enoxaparin.

La maladie thromboembolique veineuse (MTEV), regroupant la thrombose veineuse profonde et l'embolie pulmonaire, est une complication potentiellement grave rencontrée en chirurgie gynécologique. En l'absence de thromboprophylaxie, elle est fréquente et peut entraîner une morbi-mortalité conséquente. À l'inverse, une prophylaxie mal adaptée peut s'avérer délétère. Des facteurs de risque liés aux patientes mais également aux types de chirurgie ont été identifiés, permettant d'adapter la prophylaxie périopératoire. Diverses recommandations ont été proposées, sans véritable consensus. Cet article rappelle la physiopathologie ainsi que les facteurs de risque de la MTEV et propose des recommandations cohérentes et pratiques sur la thromboprophylaxie périopératoire en chirurgie gynécologique, se basant sur les diverses recommandations internationales.

BACKGROUND: Low-molecular-weight heparins (LMWHs) have been shown to accumulate in patients with renal insufficiency, especially in therapeutic dosages. Although no appropriate studies have been conducted for prophylactic dosages of nadroparin, dose reduction is sometimes recommended, especially for high prophylactic dosages. We assessed accumulation of a prophylactic dose of 5700 IU subcutaneous nadroparin once daily in patients with renal insufficiency. METHODS: We conducted a prospective cohort study and measured peak anti-Xa activity four hours after subcutaneous nadroparin injection on day 1, 3, 5 and if possible day 10 in adults with and without renal insufficiency defined as a glomerular filtration rate (GFR) below or above 50 ml/min/1.73 m2. Patients with a GFR below 10 ml/min/1.73 m2 were excluded. RESULTS: We included 14 patients in each group. In the group with renal failure 12 patients had a GFR between 30 and 50 ml/min/1.73 m2. Peak anti-Xa activity showed a high interindividual variability, but was fairly constant within each patient. There was no rise in peak anti-Xa activity on day 3 and 5 after consecutive administration. In the group with normal renal function, peak anti-Xa activity declined on day 5 compared with day 1 (p = 0.005). CONCLUSION: Prophylactic dosages of nadroparin showed no accumulation in patients with a GFR between 30-50 ml/min/1.73 m2. Dose reduction in this group could lead to suboptimal thromboprophylaxis. Due to underrepresentation of patients with a GFR < 30 ml/min/1.73 m2 (n = 2), we cannot give recommendations for this group.

Background: although many patients with venous thromboembolism require extended treatment, it is uncertain whether it is better to use full- or lower-intensity anticoagulation therapy or aspirin. Methods: in this randomized, double-blind, phase 3 study, we assigned 3396 patients with venous thromboembolism to receive either once-daily rivaroxaban (at doses of 20 mg or 10 mg) or 100 mg of aspirin. All the study patients had completed 6 to 12 months of anticoagulation therapy and were in equipoise regarding the need for continued anticoagulation. Study drugs were administered for up to 12 months. The primary efficacy outcome was symptomatic recurrent fatal or nonfatal venous thromboembolism, and the principal safety outcome was major bleeding. Results: a total of 3365 patients were included in the intention-to-treat analyses (median treatment duration, 351 days). The primary efficacy outcome occurred in 17 of 1107 patients (1.5%) receiving 20 mg of rivaroxaban and in 13 of 1127 patients (1.2%) receiving 10 mg of rivaroxaban, as compared with 50 of 1131 patients (4.4%) receiving aspirin (hazard ratio for 20 mg of rivaroxaban vs. aspirin, 0.34; 95% confidence interval [CI], 0.20 to 0.59; hazard ratio for 10 mg of rivaroxaban vs. aspirin, 0.26; 95% CI, 0.14 to 0.47; P

Helia Robert-Ebadi, Grégoire Le Gal, Marc RighiniDivision of Angiology and Hemostasis (HRE, MR), Department of Internal Medicine, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland, and Department of Internal Medicine and Chest Diseases, EA 3878 (GETBO), Brest University Hospital, Brest, France (GLG)Abstract: Elderly people represent a patient population at high thromboembolic risk, but also at high hemorrhagic risk. There is a general tendency among physicians to underuse anticoagulants in the elderly, probably both because of underestimation of thromboembolic risk and overestimation of bleeding risk. The main indications for anticoagulation are venous thromboembolism (VTE) prophylaxis in medical and surgical settings, VTE treatment, atrial fibrillation (AF) and valvular heart disease. Available anticoagulants for VTE prophylaxis and initial treatment of VTE are low molecular weight heparins (LMWH), unfractionated heparin (UFH) or synthetic anti-factor Xa pentasaccharide fondaparinux. For long-term anticoagulation vitamin K antagonists (VKA) are the first choice and only available oral anticoagulants nowadays. Assessing the benefit-risk ratio of anticoagulation is one of the most challenging issues in the individual elderly patient, patients at highest hemorrhagic risk often being those who would have the greatest benefit from anticoagulants. Some specific considerations are of utmost importance when using anticoagulants in the elderly to maximize safety of these treatments, including decreased renal function, co-morbidities and risk of falls, altered pharmacodynamics of anticoagulants especially VKAs, association with antiplatelet agents, patient education. Newer anticoagulants that are currently under study could simplify the management and increase the safety of anticoagulation in the future.Keywords: anticoagulation, elderly patients, venous thromboembolism, hemorrhagic risk, atrial fibrillation, thrombin inhibitors, factor Xa inhibitor

The purpose of these recommendations is to provide a community based on current scientific evidence tool, patient-centered, which may be useful in clinical practice and contribute to the appropriate, systematic and cross-implementation of prophylaxis of venous thromboembolism in the adult patient. With the support of the Portuguese Society of Anesthesiology were approved by National Multidisciplinary Consensus between specialties: Anesthesiology, Cardiology, Cardiothoracic Surgery; General Surgery - Bariatric Surgery; Aesthetic, Plastic and Reconstructive Surgery; Vascular Surgery; Gynecology and Obstetrics; Immuno-Haematherapy; Neurosurgery; Oncology; Orthopedics and Urology. Venous thromboembolism is a serious public health problem. In perioperative venous thromboembolic risk associated with individual factors of the patient, type of surgery, type of anesthesia and length of stay. Previous venous thrombosis, oncologic disease, advanced age, major orthopedic surgery, bariatric surgery and immobilization in bed, are some of the risk factors for thromboembolic events. The neuraxial blockade is associated with reduction in these events. The ENDORSE study evaluating the international implementation of the recommendations of the 7th Consensus of the American College of Chest Physicians on venous thromboembolism prophylaxis in Portugal, revealed that the rate of appropriate prophylaxis in the surgical patient at risk was inferior to many other European countries. In this study, among patients who have been prescribed thromboprophylaxis, some did not meet indication criteria, being exposed to unnecessary risks. The gaps identified in the prophylaxis of venous thromboembolism are related to the lack of effective inter-disciplinary communication, ignorance of recommendations and pharmacokinetics and pharmacodynamics of agents and the fear of bleeding complications. The lack of risk assessment models validated and easy to apply has hampered the standardization of criteria. These recommendations consider the Caprini risk assessment model. The assessment of the risk of venous thromboembolism is indicated to all offered surgery patients and should be recorded in the clinical process. Thromboprophylaxis is a multidisciplinary responsibility, should be based on a consideration of the risks of venous thromboembolism and bleeding and take into account the patient's values and preferences. The thromboprophylaxis should begin 6-12 hours after surgery (with exceptions)., O propósito destas recomendações é fornecer uma ferramenta fundamentada na evidência científica atual, centrada no doente, que possa ser útil na prática clínica e que contribua para a implementação adequada, sistemática e transversal da profilaxia do tromboembolismo venoso no doente adulto. Foram aprovadas, com o apoio da Sociedade Portuguesa de Anestesiologia, por Consenso Nacional Multidisciplinar entre as especialidades de: Anestesiologia, Cardiologia; Cirurgia Cardiotorácica; Cirurgia Geral - Cirurgia da Obesidade; Cirurgia Plástica, Reconstrutiva e Estética; Cirurgia Vascular; Ginecologia e Obstetrícia; Imuno-Hemoterapia; Neurocirurgia; Oncologia; Ortopedia e Urologia. O tromboembolismo venoso constitui um grave problema de saúde pública. No período peri-operatório o risco de tromboembolismo está relacionado com fatores individuais do doente, tipo de cirurgia e de anestesia e tempo de internamento. Trombose venosa prévia, doença oncológica, idade avançada, cirurgia major ortopédica, cirurgia bariátrica e imobilização no leito, constituem alguns dos principais fatores de risco de eventos tromboembólicos. O bloqueio do neuro-eixo está associado a redução destes eventos. O estudo ENDORSE que avaliou o cumprimento internacional das recomendações do 7º Consenso do American College of Chest Physicians sobre profilaxia do tromboembolismo venoso, revelou que em Portugal a taxa de profilaxia adequada no doente cirúrgico em risco era inferior à de outros países europeus. Neste estudo, alguns dos doentes a quem foi prescrita tromboprofilaxia não preenchiam critérios de indicação, ficando expostos a riscos desnecessários. Os hiatos identificados na profilaxia do TEV relacionam-se com a falta de comunicação interdisciplinar efetiva, desconhecimento das recomendações e da farmacologia dos agentes e o receio de complicações hemorrágicas. A falta de modelos de avaliação de risco validados e fáceis de aplicar tem dificultado a uniformização de critérios. Estas recomendações consideram o modelo de avaliação de risco de Caprini. A avaliação do risco de tromboembolismo venoso está indicada em todos os doentes propostos para cirurgia, devendo ser registada no processo clínico. A tromboprofilaxia é uma responsabilidade multidisciplinar, deve basear-se na ponderação dos riscos de tromboembolismo venoso e de hemorragia e ter em conta os valores e preferências do doente. A tromboprofilaxia deve iniciar-se 6-12 horas após a cirurgia (com exceções).

The First Nordic Conference in Obesity in Gynecology and Obstetrics (NOCOGO) took place in Billund, Denmark between 22(nd) and 24(th) October 2012. The goal of the meeting was to encourage attendance and interaction between obstetricians, gynecologists, nurses and midwives with regard to obesity, because it's worsening global nature. The University of Southern Denmark has a special interest and expertise in this area and the members of the organising and scientific committees were from the university and/orOdense University Hospital.. Financial support for the Conference was provided solely by the Region of South Denmark. Approximately 200 delegates and speakers attended from 11 countries, mainly the Nordic countries but also from Australia, Belgium, Dominica, Israel, Spain, UK and the USA. This article is protected by copyright. All rights reserved.

Background: Venous thromboembolism (VTE) prophylaxis among hospitalized patients remains underutilized. We investigated the use of appropriate prophylaxis and predictors for using prophylaxis prior to the onset of acute VTE. Methods: In 14 academic and non-academic Swiss hospitals, 567 consecutive patients (306 medical and 261 surgical patients) with objectively confirmed acute VTE and hospitalization within 30 days prior to the VTE event were enrolled. Data on acute and chronic comorbidities, VTE risk factors, and prophylaxis use prior to VTE were prospectively recorded. Results: Among the 567 patients (62±16 years), deep vein thrombosis (DVT) alone was diagnosed in 222 (39%), acute pulmonary embolism (PE) in 218 (38%), and PE plus DVT in 127 (22%). Overall, prophylaxis was used in 329 (58%) patients prior to the VTE event. Among the medical patients, 146 (48%) received prophylaxis, and among the surgical patients, 183 (70%) received prophylaxis (p 3 days (OR 2.12, 95% CI 1.45–3.09), obesity (OR 2.01, 95% CI 1.03–3.90), prior DVT (OR 1.71, 95% CI 1.31–2.24), and prior PE (OR 1.54, 95% CI 1.05–2.26) were independent predictors of prophylaxis. In contrast, cancer (OR 1.06, 95% CI 0.89–1.25), age (OR 0.99, 95% CI 0.98–1.01), acute heart failure (OR 1.13, 95% CI 0.79–1.63), and acute respiratory failure (OR 1.19, 95% CI 0.89–1.59) were not predictive of prophylaxis. Conclusions: Although an indication for prophylaxis was present in most patients who suffered acute VTE as a complication during or shortly after hospitalization, almost half did not receive any form of prophylaxis. Future effort should focus on the improvement of prophylaxis in hospitalized patients, particularly in patients with cancer, acute heart or respiratory failure, and in the elderly.

Background: Low-molecular-weight heparins (LMWHs) have been shown to accumulate in patients with renal insufficiency, especially in therapeutic dosages. Although no appropriate studies have been conducted for prophylactic dosages of nadroparin, dose reduction is sometimes recommended, especially for high prophylactic dosages. We assessed accumulation of a prophylactic dose of 5700 IU subcutaneous nadroparin once daily in patients with renal insufficiency. Methods: We conducted a prospective cohort study and measured peak anti-Xa activity four hours after subcutaneous nadroparin injection on day 1, 3, 5 and if possible day 10 in adults with and without renal insufficiency defined as a glomerular filtration rate (GFR) below or above 50 ml/min/1.73 m(2). Patients with a GFR below 10 ml/min/1.73 m(2) were excluded. Results: We included 14 patients in each group. In the group with renal failure 12 patients had a GFR between 30 and 50 ml/min/1.73 m(2). Peak anti-Xa activity showed a high interindividual variability, but was fairly constant within each patient. There was no rise in peak anti-Xa activity on day 3 and 5 after consecutive administration. In the group with normal renal function, peak anti-Xa activity declined on day 5 compared with day 1 (p = 0.005). Conclusion: Prophylactic dosages of nadroparin showed no accumulation in patients with a GFR between 30-50 ml/min/1.73 m(2). Dose reduction in this group could lead to suboptimal thromboprophylaxis. Due to underrepresentation of patients with a GFR < 30 ml/min/1.73 m(2) (n = 2), we cannot give recommendations for this group.