Factores de riesgo, complicaciones y evaluación del manejo de los pacientes con trombosis venosa superficial de miembros inferiores atendidos en servicios de urgencias españoles

Objectives: Three main objectives were evaluated: To describe the characteristics of patients diagnosed with isolated superficial venous thrombosis (SVT) of the lower limbs in hospital emergency departments (ED), and to evaluate adherence to clinical practice guidelines (first objective) in diagnostic (performance of venous ultrasound) and therapeutic management (initiation of anticoagulant therapy). To describe the therapeutic management of patients with isolated SVT of the lower limbs in the ED (second objective) and to evaluate the impact of the treatment established in the ED on the evolution (third objective), in terms of complications of venous thromboembolic disease (VTE), and to know the characteristics of the patients who suffer complications. Method: To respond to the first objective, a retrospective cohort study was conducted in 18 EDs. All patients seen in EDs with a final diagnosis of TVS in MMII, aged ≥18 years, from January 2016 to May 2017 were included. To assess non-adherence to clinical practice guideline recommendations, a backward stepwise multiple logistic regression model was fitted. To answer the second and third main objective, patients with an objective diagnosis of isolated SVT were selected. VTE complications [deep vein thrombosis (DVT), pulmonary thromboembolism (PE) and extension or recurrence of SVT)], clinically relevant bleeding and death at 180 days were collected. Variables associated with complications were assessed using Cox regression. Results: To meet the objectives of the study, two main sections were classified: a total patients (first main objective) and a subgroup of patients with an objective diagnosis of SVT (second and third main objectives). Regarding the total patients, 1166 patients were included. The mean age was 59.6 years, 67.9% were women. Twenty-four.4% had a history of VTE. 8.9% had some complication at 180 days. There were 17 patients (1.5%) with hemorrhage and 16 (1.4%) deaths. Venous ultrasound was performed in 703 (60.3%) patients. A total of 898 (77%) received anticoagulation treatment, with a median of 27.3 days. The variables associated with the decision to anticoagulate were: history of VTE (OR 1.60; 95% CI: 1.12-2.30), vari¬ces (OR 1.40; 95% CI: 1.12-2.30), limb pain (OR 1.44; 95% CI: 1.08-191), painful cord (OR 1.30; 95% CI: 0.97-1.73) and performance of venous ultrasound (OR 1.60; 95% CI: 1.94-3.45). As for the subgroup of patients with an objective diagnosis of SVT, 703 patients were included. A total of 84.1% received anticoagulation for 30 days (interquartile range 15-42), 81.3% with low-molecular-weight heparin (48% prophylactic doses, 52% intermediate-therapeutic). In 180 days, 64 patients (9.1%) had VTE complications, 12 (1.7%) had clinically relevant bleeding, and 4 died (0.6%). Patients in whom anticoagulation was instituted in the ED took longer to develop complications (66 vs. 11 days, p = 0.009). Of those who developed complications, 76.6% were not anticoagulated at the time. Previous VTE was independently associated with the development of complications (adjusted hazard ratio 2.20; 95% confidence interval: 1.34-3.62). Conclusions: Adherence to clinical practice guidelines for the diagnosis and treatment of isolated lower-limb SVT is low in Spanish emergency departments. Ultrasound imaging is not ordered for 1 out of every 2 to 3 patients, and anticoagulant treatment is not started in 1 out of 4 patients. There is great room for improvement. ED treatment of SVT varies and is often suboptimal. The incidence of thromboembolic complications after SVT is high. Starting anticoagulation in the ED delays the development of complications. Patients with a history of thromboembolic disease are more at risk of complications.Objetivo: Se evaluaron tres objetivos principales: Describir las características de los pacientes diagnosticados de trombosis venosa superficial (TVS) aislada de miembros inferiores (MMII) en servicios de urgencias hospitalarios (SUH), y evaluar la adherencia a las guías de práctica clíni¬ca (primer objetivo) en el manejo diagnóstico (realización de ecografía venosa) y terapéutico (instauración de tratamiento anticoagulante). Describir el manejo terapéutico de los pacientes con TVS aislada de MMII en SUH (segundo objetivo) y evaluar el impacto del tratamiento instaurado en urgencias en la evolución (tercer objetivo), en términos de complicaciones de enfermedad tromboembólica venosa (ETV), y conocer las características de los pacientes que sufren complicaciones. Método: Para responder al primer objetivo se realizó un estudio de cohortes retrospectivo en 18 SUH. Se incluyeron todos los pacientes atendidos en los SUH con diagnóstico final de TVS en MMII, con edad ≥18 años, de enero de 2016 a mayo de 2017. Para evaluar la no adherencia a las recomendaciones de las guías de práctica clínica se ajustó un modelo de regresión logística múltiple por pasos hacia atrás. Para responder al segundo y tercer objetivo principal, se seleccionaron a los pacientes con diagnóstico objetivo de TVS aislada. Se recogieron las complicaciones de ETV [trombosis venosa profunda (TVP), tromboembolia pulmonar (TEP) y extensión o recurrencia de TVS)], sangrados clínicamente relevantes y defunciones a 180 días. Se evaluaron las variables asociadas a las complicaciones mediante una regresión de Cox. Resultados: Para responder a los objetivos del estudio, se clasificaron dos grandes apartados: una muestra general de pacientes (primer objetivo principal) y un subgrupo de pacientes con diagnóstico objetivo de TVS (segundo y tercer objetivo principal). En cuanto a la muestra general, 1166 pacientes fueron incluidos. La edad media fue de 59,6 años, el 67,9% eran mu¬jeres. El 24,4% tenían antecedentes de ETV. El 8,9% tuvieron alguna complica¬ción a 180 días. Hubo 17 pacientes (1,5%) con hemorragia y 16 (1,4%) muertes. Se realizó ecografía venosa a 703 (60,3%) pacientes. Recibieron tratamiento anticoagulante 898 (77%), con una mediana de 27,3 días. Las variables asociadas con la decisión de anticoagular fueron: antecedentes ETV (OR 1,60;IC 95%: 1,12-2,30), vari¬ces (OR 1,40;IC 95%:1,12-2,30), dolor extremidad (OR1,44; IC 95%: 1,08-191), cordón doloro¬so (OR 1,30;IC 95%:0,97-1,73) y realización de ecografía venosa (OR 1,60;IC 95%: 1,94-3,45). En cuanto al subgrupo de pacientes con diagnóstico objetivo de TVS, se incluyeron 703 pacientes. El 84,1% recibieron anticoagulación durante 30 días (rango intercuartil 15-42), 81,3% con heparina de bajo peso molecular (48% dosis profilácticas, 52% intermedias-terapéuticas). En 180 días, 64 pacientes (9,1%) tuvieron complicación de ETV, 12 (1,7%) tuvieron sangrado clínicamente relevante, y 4 fallecieron (0,6%). Los pacientes en que se instauró anticoagulación en urgencias tardaron más tiempo en desarrollar complicaciones (66 vs 11 días, p = 0,009). El 76,6% de los que se complicaron no estaban anticoagulados en ese momento. La ETV previa se asoció de forma independiente con el desarrollo de complicaciones (hazard ratio ajustada 2,20; intervalo de confianza del 95%:1,34-3,62). Conclusión: Existe una baja adherencia a las recomendaciones de las guías de práctica clínica en el manejo diagnósti¬co y terapéutico de los pacientes con diagnóstico de TVS aislada de MMII en los SUH españoles: no se realiza ecografía venosa en uno de cada 2-3 pacientes, y no se instaura tratamiento anticoagulante en 1 de cada 4. Esto constituye un margen de mejora muy relevante. El tratamiento en urgencias de la TVS aislada es heterogéneo y con frecuencia subóptimo. La incidencia de complicaciones de ETV es elevada. El tratamiento anticoagulante iniciado en urgencias supone un retraso en el desarrollo de complicaciones. Los pacientes con ETV previa tienen más riesgo de complicaciones.Escuela de DoctoradoDoctorado en Investigación en Ciencias de la Salu

Convalescent Plasma Therapy, Therapeutic Formulations of Repurposed Drugs in 20th Century Epidemics against COVID-19: A Systematic Review

Coronavirus 2019 disease (COVID-19) represents one of the largest pandemics the world has faced, and it is producing a global health crisis. To date, the availability of drugs to treat COVID-19 infections remains limited to supportive care although therapeutic options are being explored. Some of them are old strategies for treating infectious diseases. convalescent plasma (CP) therapy has been used successfully in other viral outbreaks in the 20th century. In this study, we systematically evaluated the effect and safety of CP therapy on hospitalized COVID-19 patients. A structured search was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines using Medline (PubMed), SciELO, Cochrane Library Plus, Web of Science, and Scopus. The search included articles published up to January 2022 and was restricted to English- and Spanish-language publications. As such, investigators identified six randomized controlled trials that met the search criteria. The results determined that in hospitalized COVID-19 patients the administration of CP therapy with a volume between 200–500 mL and a single transfusion performed in 1–2 h, compared to the control group, decreased viral load, symptomatology, the period of infection, and mortality, without serious adverse effects. CP did influence clinical outcomes and may be a possible treatment option, although further studies will be necessary

Clinical Presentation and Short- and Long-term Outcomes in Patients With Isolated Distal Deep Vein Thrombosis vs Proximal Deep Vein Thrombosis in the RIETE Registry

International audienceImportance: Insufficient data exist about the clinical presentation, short-term, and long-term outcomes of patients with isolated distal deep vein thrombosis (IDDVT), that is, thrombosis in infrapopliteal veins without proximal extension or pulmonary embolism (PE).Objective: To determine the clinical characteristics, short-term, and 1-year outcomes in patients with IDDVT and to compare the outcomes in unadjusted and multivariable adjusted analyses with patients who had proximal DVT.Design, setting, and participants: This was a multicenter, international cohort study in participating sites of the Registro Informatizado Enfermedad Tromboembólica (RIETE) registry conducted from March 1, 2001, through February 28, 2021. Patients included in this study had IDDVT. Patients with proximal DVT were identified for comparison. Patients were excluded if they had a history of asymptomatic DVT, upper-extremity DVT, coexisting PE, or COVID-19 infection.Main outcomes and measures: Primary outcomes were 90-day and 1-year mortality, 1-year major bleeding, and 1-year venous thromboembolism (VTE) deterioration, which was defined as subsequent development of proximal DVT or PE.Results: A total of 33 897 patients were identified with isolated DVT (without concomitant PE); 5938 (17.5%) had IDDVT (mean [SD] age, 61 [17] years; 2975 male patients [50.1%]), and 27 959 (82.5%) had proximal DVT (mean [SD] age, 65 [18] years; 14 315 male patients [51.2%]). Compared with individuals with proximal DVT, those with IDDVT had a lower comorbidity burden but were more likely to have had recent surgery or to have received hormonal therapy. Patients with IDDVT had lower risk of 90-day mortality compared with those with proximal DVT (odds ratio [OR], 0.47; 95% CI, 0.40-0.55). Findings were similar in 1-year unadjusted analyses (hazard ratio [HR], 0.52; 95% CI, 0.46-0.59) and adjusted analyses (HR, 0.72; 95% CI, 0.64-0.82). Patients with IDDVT had a lower 1-year hazard of VTE deterioration (HR, 0.83; 95% CI, 0.69-0.99). In 1-year adjusted analyses of patients without an adverse event within the first 3 months, IDDVT was associated with lower risk of VTE deterioration (adjusted HR, 0.48; 95% CI, 0.24-0.97). By 1-year follow-up, symptoms or signs of postthrombotic syndrome were less common in patients with IDDVT (47.6% vs 60.5%).Conclusions and relevance: Results of this cohort study suggest that patients with IDDVT had a less ominous prognosis compared with patients with proximal DVT. Such differences were likely multifactorial, including the differences in demographics, risk factors, comorbidities, particularly for all-cause mortality, and a potential association of thrombus location with VTE deterioration and postthrombotic syndrome. Randomized clinical trials are needed to assess the optimal long-term management of IDDVT