Istodobna duboka venska tromboza i plućna embolija udružena s hipertireozom: prikaz slučaja

Numerous disorders of coagulation and fibrinolysis have been reported in patients with thyroid diseases, especially with hyperthyroidism. Most articles are focused on deep vein thrombosis risk, however, few of them describe association between hyperthyroidism and pulmonary embolism. We report a case of a 43-year-old woman with long-term uncontrolled hyperthyroidism complicated by venous thromboembolism. The potential mechanisms could be endothelial dysfunction, decreased fibrinolytic activity, and increased levels of coagulation factors. Thyroid evaluation should be recommended in patients with unprovoked venous thromboembolic events.Različiti poremećaji koagulacije ponekad se povezuju s bolestima štitnjače, najčešće hipertireozom. Većina dosadašnjih radova je usredotočena na rizik duboke venske tromboze kod takvih bolesnika, dok je u vrlo malom broju radova opisana povezanost hipertireoze i plućne embolije. Prikazuje se slučaj 43-godišnje bolesnice s dugogodišnjom nekontroliranom hipertireozom i posljedičnim akutnim venskim tromboembolizmom. Vjerojatni patofiziološki mehanizam uključuje oštećenje endotela, smanjenje fibrinolitičke aktivnosti i povećanu razinu faktora koagulacije. Klinička i laboratorijska evaluacija štitnjače preporučljiva je u bolesnika s neprovociranim tromboembolijskim događajem

Pre-existing chronic thromboembolic pulmonary hypertension in acute pulmonary embolism

BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is considered a complication of pulmonary embolism (PE). However, signs of CTEPH may exist in patients with a first symptomatic PE. RESEARCH QUESTION Which radiologic findings on computed tomography pulmonary angiography (CTPA) at the time of acute PE could indicate the presence of a pre-existing CTEPH? RESULTS We included unselected patients with acute PE who were prospectively followed for 2 years with a structured visit schedule. Two expert radiologists independently assessed patients' baseline CTPAs for pre-existing CTEPH; in case of disagreement, a decision was reached by 2:1 majority with a third expert. In addition, the radiologists checked for predefined individual parameters suggesting chronic PE and pulmonary hypertension. Signs of chronic PE or CTEPH at baseline were identified in 46 (15%) of 303 included patients. Intravascular webs, arterial narrowing or retraction, dilated bronchial arteries and right ventricular hypertrophy were the main drivers of the assessment. Five (1.7%) patients were diagnosed with CTEPH during follow-up. All four patients diagnosed with CTEPH early (83-108 days after acute PE) could be found in enriched subgroups based on the experts' overall assessment or fulfilling a minimum number of the predefined radiologic criteria at baseline. The specificity of pre-existing CTEPH diagnosis and the level of radiologists' agreement improved as the number of required criteria increased. INTERPRETATION Searching for predefined radiologic parameters suggesting pre-existing CTEPH at the time of acute PE diagnosis may allow for targeted follow-up strategies and risk-adapted CTEPH screening, thus facilitating earlier CTEPH diagnosis

Importancia del ultrasonido a la cabecera del paciente en el manejo urgente de la disnea

Point-of-care ultrasonography (POCUS) is an important tool in the initial assessment of critical patients. In this report, we describe the case of an 83-year-old woman admitted to the emergency room due to a sudden unclear change of consciousness. She was confused, hypoxemic, tachycardic, and had signs of poor perfusion. The POCUS showed dilatation of the right ventricle, raising a solid suspicion of pulmonary thromboembolism. This case supports the importance of including POCUS in the assessment of critically ill patients, as it reduces the time for diagnosis and treatment, improving the patient's prognosis.El ultrasonido a la cabecera del paciente (UCP) es una herramienta esencial en la evaluación inicial del paciente crítico. Presentamos el caso de una mujer de 83 años que ingresó por un cuadro de alteración súbita del estado de consciencia. A su llegada estaba confusa, con hipoxemia, taquicardia y signos de mala perfusión periférica. El UCP mostró dilatación del ventrículo derecho compatible con la fuerte sospecha clínica de tromboembolismo pulmonar. Este caso demuestra la importancia de incluir el UCP en la evaluación de pacientes críticos, pues permite reducir el tiempo para el diagnóstico y tratamiento, mejorando su pronóstico

Akutna plućna tromboembolija – primjena fibrinolitičke terapije u liječenju hemodinamski nestabilnog bolesnika u doba pandemije bolesti COVID-19: prikaz slučaja

Pulmonary embolism (PE) is a common and potentially fatal condition. Despite advances in diagnostic procedures, late detection and non-detection of this condition is also not uncommon. In patients with PE, recurrent embolisms and death can be prevented with prompt diagnosis and adequate treatment. Due to presentation with a non-specific clinical picture and symptomatology, unfortunately almost one third of the patients remain undiagnosed and untreated. We know that there is a large difference in outcome between treated and untreated patients with PE (25-30% mortality in untreated and 2-8% in treated patients). We present a case of PE in the era of the COVID-19 pandemic in an adult patient with acute dyspnea, vomiting, presyncope, chest pain, and shock.Plućna embolija (PE) često je i potencijalno smrtonosno stanje. Usprkos napretku u dijagnostičkim postupcima, takvo se stanje često otkriva kasno ili se uopće ne otkriva. Opetovane embolije i smrt u bolesnika s PE-om mogu se spriječiti brzom dijagnozom i primjerenim liječenjem. S obzirom na to da PE ima nespecifičnu kliničku sliku i simptomatolgiju, oko trećine bolesnika nije niti dijagnosticirano niti liječeno. Znamo da postoji velika razlika u ishodima između liječenih i neliječenih bolesnika s PE-om (25 – 30 % smrtnosti u neliječenih i 2 – 8 % u liječenih bolesnika). Prikazujemo slučaj PE-a u odraslog bolesnika s akutno nastalom zaduhom, povraćanjem, presinkopom, boli u prsima i šokom u doba pandemije bolesti COVID-19

Vanhuksiin kohdistettavat pakko- ja rajoitustoimenpiteet laitoshoidossa

Tutkielma tarkastelee vanhuksiin kohdistettavia pakko- ja rajoitustoimenpiteitä ja niiden edellytyksiä sosiaali- ja terveydenhuollon järjestämässä laitoshoidossa. Pakko- ja rajoitustoimenpiteet puuttuvat vanhuksen perusoikeuksiin, kuten henkilökohtaiseen koskemattomuuteen ja vapauteen. Vanhustenhuollossa pakon käyttöä ei ole säännelty, minkä vuoksi perusoikeuksiin puuttuvat rajoitukset toteutetaan ilman laissa säädettyä toimivaltaa ja ilman tarkempaa sääntelyä niiden käytön edellytyksistä tai rajoituksista. Pakon käyttö on katsottu somaattisessa hoidossa sallituksi silloin, kun se on välttämätöntä potilaan hoidon ja hoivan turvaamiseksi. Rajoitustoimenpiteisiin voidaan joutua turvautumaan myös silloin, kun vanhus on vaaraksi itselleen tai muille. Tutkielman tavoitteena on luoda katsaus vanhuksen oikeudelliseen asemaan laitoshoidossa sekä tuoda esiin niitä haasteita, joita lakiaukkotilanne muodostaa perusoikeuksiin puuttuvien rajoitustoimenpiteiden suhteen. Perus- ja ihmisoikeudet muodostavat tutkielman teoreettisen perustan, joka saa vahvaa tukea myös sosiaali- ja lääkintäoikeuden yleisistä opeista ja periaatteista. Rajoitustoimenpiteissä korostuvat eri intressien, periaatteiden ja perusoikeuksien kollisiotilanteet, jotka ratkaistaan lainopin mukaisesti punninnan avulla. Tutkielmassa tarkastellaan perusoikeusrajoituksia sekä vanhuksiin kohdistettavien pakko- ja rajoitustoimenpiteiden taustalla vaikuttavien periaatteiden välistä punnintaa. Tutkielman lopussa esitellään kokoavasti premissejä, joihin vanhuksien perusoikeusrajoitukset kiinnittyvät sekä lähitulevaisuuden näkymiä sosiaali- ja terveydenhuollon muuttuvassa kentässä, erityisesti ajankohtaisen lainsäädäntömuutoksen kautta

The celiac axis compression syndrome (CACS): critical review in the laparoscopic era Síndrome de compresión del tronco celiaco: Revisión crítica en la era de la cirugía laparoscópica

The celiac axis compression syndrome (CACS) due to median arcuate ligament (MAL) was first described by Harjola in 1963; originating postpandrial abdominal pain, weight loss, epigastric bruit and celiac axis stenosis > 75% in angiographic studies. This clinical condition has been the origin of controversies about its pathogenesis, diagnosis and its long term clinical results. Advances in diagnostic imaging as 64 multidetector-row CT (MDCT), 3-D reconstruction, magnetic resonance (MR) and color duplex ultrasonography, provide better understanding of the syndrome and allow to identify the best candidates for surgical division of MAL fibers. Since the introduction of laparoscopic approach, and also endovascular procedures, in 2000, a new perspective has established in this challenging syndrome. With the occasion of our own experience, a critical review of the syndrome is presented.El síndrome de compresión del tronco celiaco fue descrito por Harjola en 1963 como la compresión extrínseca del tronco celiaco por las fibras tendinosas del ligamento arcuato; causando un cuadro de dolor intenso post-pandrial en epigastrio, pérdida de peso, soplo epigástrico y estenosis mayor del 75% en la angiografía selectiva. Desde entonces, dicho síndrome ha sido motivo de múltiples controversias relacionadas con su patogenia y la variabilidad de los resultados obtenidos con la cirugía. Debido a la proliferación y accesibilidad de técnicas de imagen más precisas y menos invasivas (angio-TAC multicorte, angio-RMN, eco-doppler), el diagnóstico de dicho síndrome puede realizarse con mayor precisión y sentar las bases de la indicación quirúrgica con mayor seguridad y eficacia. La introducción, en el año 2000, de técnicas laparoscópicas en la liberación del tronco celiaco, junto con procedimientos endovasculares complementarios, ha representado un notable avance en el tratamiento del síndrome. Basados en nuestra experiencia personal, presentamos una revisión crítica y propuesta terapéutica del síndrome

The celiac axis compression syndrome (CACS): critical review in the laparoscopic era

The celiac axis compression syndrome (CACS) due to median arcuate ligament (MAL) was first described by Harjola in 1963; originating postpandrial abdominal pain, weight loss, epigastric bruit and celiac axis stenosis > 75% in angiographic studies. This clinical condition has been the origin of controversies about its pathogenesis, diagnosis and its long term clinical results. Advances in diagnostic imaging as 64 multidetector–row CT (MDCT), 3-D reconstruction, magnetic resonance (MR) and color duplex ultrasonography, provide better understanding of the syndrome and allow to identify the best candidates for surgical division of MAL fibers. Since the introduction of laparoscopic approach, and also endovascular procedures, in 2000, a new perspective has established in this challenging syndrome. With the occasion of our own experience, a critical review of the syndrome is presented