Guidelines for the treatment of antiphospholipid syndrome

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized
by arterial and venous thrombosis, gestational morbidity and presence of elevated and
persistently positive serum titers of antiphospholipid antibodies. The treatment of APS is
still controversial, because any therapeutic decision potentially faces the risk of an insuffi cient or excessive antithrombotic coverage associated with anticoagulation and its major
adverse effects. This guideline was elaborated from nine relevant clinical questions related
to the treatment of APS by the Committee of Vasculopathies of the Brazilian Society of
Rheumatology. Thus, this study aimed at establishing a guideline that included the most
relevant and controversial questions in APS treatment, based on the best scientifi c evidence available. The questions were structured by use of the PICO (patient, intervention or
indicator, comparison and outcome) process, enabling the generation of search strategies
for evidence in the major primary scientifi c databases (MEDLINE/PubMed, Embase, Lilacs,
Scielo, Cochrane Library, Premedline via OVID). A manual search for evidence and theses
was also conducted (BDTD and IBICT). The evidence retrieved was selected based on critical assessment by using discriminatory instruments (scores) according to the category of
the therapeutic question (JADAD scale for randomized clinical trials and Newcastle-Ottawa
scale for non-randomized studies). After defining the potential studies to support the recommendations, they were selected according to level of evidence and grade of recommendation, according to the Oxford classification.
http://www.scielo.br/pdf/rbr/v53n2/en_v53n2a05.pdf

Thromboprophylaxis for Orthopedic patients in Turkey

Fracture neck of femur surgery, total hip replacement, total knee replacement patients are at high risk of developing VTE as seen in western population. In India, there are still mixed opinions among the orthopedic surgeons about the increased risk of VTE in Indian population going for orthopedic surgeries.

It is interesting to note the results of the study from Turkey given below. this is a large study and worth to note their findings.

J Bras Pneumol. 2013 Jun;39(3). 

Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery?Akpinar EE, Hosgün D, Akan B, Ates C, Gülhan M. Source  Ufuk University, Department of Chest Diseases, Ankara, Turkey.Abstract

OBJECTIVE:

Pulmonary embolism (PE) is an important complication of major orthopedic surgery. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) and factors influencing the development of VTE in patients undergoing major orthopedic surgery in a university hospital.

METHODS:

Patients who underwent major orthopedic surgery (hip arthroplasty, knee arthroplasty, or femur fracture repair) between February of 2006 and June of 2012 were retrospectively included in the study. The incidences of PE and deep vein thrombosis (DVT) were evaluated, as were the factors influencing their development, such as type of operation, age, and comorbidities.

RESULTS:

We reviewed the medical records of 1,306 patients. The proportions of knee arthroplasty, hip arthroplasty, and femur fracture repair were 63.4%, 29.9%, and 6.7%, respectively. The cumulative incidence of PE and DVT in patients undergoing major orthopedic surgery was 1.99% and 2.22%, respectively. Most of the patients presented with PE and DVT (61.5% and 72.4%, respectively) within the first 72 h after surgery. Patients undergoing femur fracture repair, those aged ≥ 65 years, and bedridden patients were at a higher risk for developing VTE.

CONCLUSIONS:

Our results show that VTE was a significant complication of major orthopedic surgery, despite the use of thromboprophylaxis. Clinicians should be aware of VTE, especially during the perioperative period and in bedridden, elderly patients (≥ 65 years of age).

RIETE registry and COPD with PE

Pulmonary embolism is a life threatening complication and it is known to recur in some patients. The diagnosis of pulmonary embolism is difficult in chronic pulmonary obstructive disease patients. There can be delay or difficulty due to overlap of the clinical symptoms in these conditions. If the PE is recurrent then also it can be missed in some patients. So, the morbidity and mortality in COPD patients with PE or recurrent PE is higher than those with Leg DVT. So, it is mandatory to look after patients of COPD with PE more closely to avoid the mortality.

Respir Res. 2013 Jul 18;14:75. doi: 10.1186/1465-9921-14-75.

Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease: data from the RIETE registry. Bertoletti L, Quenet S, Laporte S, Sahuquillo JC, Conget F, Pedrajas JM, Martin M, Casado I, Riera-Mestre A, Monreal M; RIETE Investigators. Thrombosis Research Group, EA3065, University Saint-Etienne, Jean Monnet, Saint-Etienne F-42023, France. laurent.bertoletti@gmail.com.

Abstract: Patients with chronic obstructive pulmonary disease (COPD) have a modified clinical presentation of venous thromboembolism (VTE) but also a worse prognosis than non-COPD patients with VTE. As it may induce therapeutic modifications, we evaluated the influence of the initial VTE presentation on the 3-month outcomes in COPD patients.

COPD patients included in the on-going world-wide RIETE Registry were studied. The rate of pulmonary embolism (PE), major bleeding and death during the first 3 months in COPD patients were compared according to their initial clinical presentation (acute PE or deep vein thrombosis(DVT)).

Of the 4036 COPD patients included, 2452 (61%; 95% CI: 59.2-62.3) initially presented with PE. PE as the first VTE recurrence occurred in 116 patients, major bleeding in 101 patients and mortality in 443 patients (Fatal PE: first cause of death). Multivariate analysis confirmed that presenting with PE was associated with higher risk of VTE recurrence as PE (OR, 2.04; 95% CI: 1.11-3.72) and higher risk of fatal PE (OR, 7.77; 95% CI: 2.92-15.7).

COPD patients presenting with PE have an increased risk for PE recurrences and fatal PE compared with those presenting with DVT alone. More efficient therapy is needed in this subtype of patients. 

PE recurrences according to initial presentation as DVT or PE.

Mortality according to initial presentation as DVT or PE

Pinjala R K

Delays in the management of venous thromboembolism

Delays in diagnosis and treatment of venous thromboembolism in a developing country setting

It is important to promptly suspect, confirm the diagnosis of venous thrombosis to avoid or reduce the risk of venous thrombosis and its complications. Every physician would generally make an effort to achieve the early anticoagulation in these patients as soon as the diagnosis is confirmed. In a recent paper published from the Iran it was observed that the delay in the diagnosis and treatment is related to the delayed presentation of the patient to the clinics and hospitals. Probably it is the same reason in many other countries where the general awareness of the problem is not there in the public and peripheral medical centers.


Tuberk Toraks. 2013 Jun;61(2):96-102. Rahimi-Rad MH, Rahimi-Rad S, Zarrin S. Source Department of Respiratory Medicine, Faculty of Medicine, Urmia University, Urmia, Iran. rahimirad@hotmail.com.Abstract : Introduction: Rapid diagnosis and treatment of deep vein thrombosis and pulmonary thromboembolism reduce mortality and morbidity. The aim of this study is to investigate delays in treatment of deep vein thrombosis and pulmonary thromboembolism and related factor in a developing country. Materials and Methods: We prospectively investigated 353 patients with diagnosis deep vein thrombosis and/or pulmonary thromboembolism in Urmia, Iran. We recorded dates of symptom onset, initial visit by a clinician, initiation of treatment, and confirmation of diagnosis. We also analyzed relation with some factors. Results: The mean interval from symptoms onset to initiation of treatment was 4.70 days, 89% of this interval was between onset of symptoms to first medical evaluation (mean= 4.19 days). Mean time from onset of symptoms to confirmation of diagnosis was 6.29 days. Of 353 patients with venous thromboembolism 185 (52.4%) visited by a physician within two days of onset of symptoms and 168 (47.6%) patients after two days. Factors that was associated with earlier seeking with p value < 0.05 were pulmonary thromboembolism patients earlier than deep veinthrombosis, higher education, recent surgery, presence of cast, entire leg swelling. There was no association between age, gender, number of symptoms, and presence familial history of venous thromboembolism (all p value > 0.05). The delays time from first visit to final diagnosis was significantly shorter in patients with high probability score. Conclusion: Most patients with venous thromboembolism received anti-coagulation and diagnosis with delay. The main cause of delay is related to patient's delays. There is a need to improve people awareness about venous-thromboembolism and to develop strategies to reduce delays.

Vasculo-Behcet's Disease

Successful Treatment of Vasculo-Behcet's Disease Presenting as Recurrent Pseudoaneurysms: the Importance of Medical Treatment.

Li S, Chen AJ, Huang K, Li H.

Source

The Department of Dermatology, The First Affiliated Hospital, Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016 China.

Abstract

INTRODUCTION:

Vasculo-Behcet's disease is a subtype of Behcet's disease, characterized by cases in which vascular complications are present and often dominate the clinical features. In this disease, there are four different vascular complications: arterial occlusion, arterial aneurysm or pseudoaneurysm, venous thrombosis, and variceal formation. It is rare that arterial lesions are multiple, but without venous involvement. So far, the optimal treatment of the disease has not been established.

CASE REPORT:

The authors report a rare case of vasculo-Behcet's disease with multiple and recurrent pseudoaneurysms in large arteries, but without affecting the venous system. The patient underwent three rounds of surgery, but developed a new pseudoaneurysm after each operation in short term. However, the patient was successfully treated with a combination of prednisone and immunosuppressive agents.

CONCLUSION:

For Vasculo-Behcet's disease, surgical and endovascular interventions alone increased the incidence of pseudoaneurysm. Early diagnosis and early initiation of prednisone in combination with immunosuppressive therapy are critical for inhibiting the progression of vascular lesions and provide a good prognosis.