Trombocitopenia inducida por heparinas, revisión de los mecanismos implicados, diagnóstico y manejo de un evento adverso complejo

Heparin induced thrombocytopenia (HIT) is an immune mediated disorder caused by antibodies that recognize complexes of platelet factor 4 and heparin. Thrombosis is a central and unpredictable feature of this syndrome. Despite optimal management, disease morbidity and mortality from thrombosis remain high. The hypercoagulable state in HIT is biologically distinct from other thrombophilic disorders in that clinical complications are directly attributable to circulating ultra-large immune complexes (ULIC). In some individuals, ULIC elicit unchecked cellular procoagulant responses that culminate in thrombosis. To date, the clinical and biologic risk factors associated with thrombotic risk in HIT remain elusive. This review will summarize our current understanding of thrombosis in HIT with attention to its clinical features, cellular mechanisms, and its managementLa trombocitopenia inducida por heparina (TIH) es un trastorno mediado por el sistema inmunitario causado por anticuerpos que reconocen complejos del factor plaquetario 4 y la heparina. La trombosis es una característica central e impredecible de este síndrome. A pesar del manejo óptimo, la morbilidad y la mortalidad de la enfermedad por trombosis siguen siendo altas. El estado hipercoagulable en TIH es biológicamente distinto de otros trastornos trombofílicos en que las complicaciones clínicas son directamente atribuibles a los complejos inmunes ultra grandes (CIUG) circulantes. En algunos individuos, los CIUG provocan respuestas procoagulantes celulares no controladas que culminan en trombosis. Hasta la fecha, los factores de riesgo clínicos y biológicos asociados con el riesgo trombótico en TIH siguen siendo esquivos. Esta revisión resumirá nuestra comprensión actual de la trombosis en TIH con atención a sus características clínicas, mecanismos celulare

Hernia diafragmática post traumática e infección por Covid-19 en adulto mayor

Traumatic diaphragmatic hernia is a rare and life-threatening injury that can occur after closed or penetrating thoracoabdominal trauma. The case of an older adult patient institutionalized in a nursing home with a history of chest trauma is presented, who consulted for respiratory symptoms and a contagion link for Sars-Cov-2. On admission, she was haemodynamically unstable, on chest examination with dullness to percussion and decreased vesicular murmur on auscultation of lung bases, chest X-ray showed left pleural effusion and gastrointestinal content in the right hemithorax. The objective of this case is to show a rare entity in which the joint presentation of post-traumatic diaphragmatic hernia and Covid-19 was confirmed, however, a timely consultation was not carried out, the diagnosis of diaphragmatic injury was incidental and the patient had a torpid progression with subsequent death.La hernia diafragmática de origen traumático es una lesión poco frecuente y potencialmente mortal que puede presentarse posterior a un trauma toracoabdominal cerrado o penetrante. Se presenta el caso de una paciente adulta mayor institucionalizada en hogar geriátrico con antecedente traumático en tórax, quien consultó por síntomas respiratorios y nexo de contagio para Sars-Cov-2. A su ingreso se encontraba con inestabilidad hemodinámica, a la exploración torácica con matidez a la percusión y disminución del murmullo vesicular en la auscultación de bases pulmonares, la radiografía de tórax mostró derrame pleural izquierdo y contenido gastrointestinal en hemitórax derecho. El objetivo de este caso es mostrar una entidad poco común en quien se confirmó la presentación conjunta de hernia diafragmática post traumática y Covid-19, sin embargo, no se realizó una consulta oportuna, el diagnóstico de lesión diafragmática fue incidental y la paciente tuvo una progresión tórpida con posterior deceso

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)