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Resumen El tratamiento del infarto agudo de miocardio con elevación del segmento ST tiene barreras dependiendo de la región geográfica. La angioplastia coronaria primaria es el tratamiento de elección, siempre y cuando sea realizada dentro de tiempo y por operadores experimentados. Sin embargo, cuando no está disponible, la administración de fibrinólisis y el envío para angioplastia de rescate, en caso de reperfusión negativa, es la mejor estrategia. De la misma manera, la angioplastia coronaria, como parte de una estrategia farmacoinvasiva, es la mejor alternativa cuando hay reperfusión positiva. El desarrollo de redes de tratamiento del infarto aumenta el número de pacientes reperfundidos dentro de los tiempos recomendados y mejora los desenlaces. En América Latina, los programas nacionales para el tratamiento del infarto deben centrarse en mejorar los resultados y el éxito a largo plazo depende de trabajar hacia objetivos definidos y obtener métricas de rendimiento, por lo tanto, estos deben desarrollar métricas para cuantificar su desempeño. El siguiente documento discute todas estas alternativas y sugiere oportunidades de mejora.

Abstract The treatment of ST-segment elevation myocardial infarction has barriers depending on the geographic region. Primary coronary angioplasty is the treatment of choice, if it is performed on time and by experienced operators. However, when it is not available, the administration of fibrinolysis and referral for rescue angioplasty, in case of negative reperfusion, is the best strategy. In the same way, coronary angioplasty, as part of a pharmacoinvasive strategy, is the best alternative when there is positive reperfusion. The development of infarct treatment networks increases the number of patients reperfused within the recommended times and improves outcomes. In Latin America, national myocardial infarction treatment programs should focus on improving outcomes, and long-term success depends on working toward defined goals and enhancing functionality, therefore programs should develop capacity to measure their performance. The following document discusses all of these alternatives and suggests opportunities for improvement.

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Although primary percutaneous coronary intervention (pPCI) is the treatment of choice in ST-elevation myocardial infarction (STEMI), challenges may arise in accessing this intervention for certain geodemographic groups. Pharmacoinvasive strategy (PIs) has demonstrated comparable outcomes when delays in pPCI are anticipated, but real-world data on long-term outcomes are limited. The aim of the present study was to compare long-term outcomes among real-world patients with STEMI who underwent either PIs or pPCI. This was a prospective registry including patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary objective was cardiovascular mortality at 12 months according to the reperfusion strategy (pPCI vs PIs) and major cardiovascular events (cardiogenic shock, recurrent myocardial infarction, and congestive heart failure), and Bleeding Academic Research Consortium type 3 to 5 bleeding events were also evaluated. A total of 799 patients with STEMI were included; 49.1% underwent pPCI and 50.9% received PIs. Patients in the PIs group presented with more heart failure on admission (Killip-Kimbal >I 48.1 vs 39.7, p = 0.02) and had a lower proportion of pre-existing heart failure (0.2% vs 1.8%, p = 0.02) and atrial fibrillation (0.25% vs 1.2%, p = 0.02). No statistically significant difference was observed in cardiovascular mortality at the 12-month follow-up (hazard ratio for PIs 0.74, 95% confidence interval 0.42 to 1.30, log-rank p = 0.30) according to the reperfusion strategy used. The composite of major cardiovascular events (hazard ratio for PIs 0.98, 95% confidence interval 0.75 to 1.29, p = 0.92) and Bleeding Academic Research Consortium type 3 to 5 bleeding rates were also comparable. A low socioeconomic status, Killip-Kimball >2, age >60 years, and admission creatinine >2.0 mg/100 ml were predictors of the composite end point after multivariate analysis. In conclusion, this prospective real-world registry provides additional support that long-term major cardiovascular outcomes and bleeding are not different between patients who underwent PIs versus primary PCI.

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The treatment of ST-segment elevation myocardial infarction has barriers depending on the geographic region. Primary coronary angioplasty is the treatment of choice, if it is performed on time and by experienced operators. However, when it is not available, the administration of fibrinolysis and referral for rescue angioplasty, in case of negative reperfusion, is the best strategy. In the same way, coronary angioplasty, as part of a pharmacoinvasive strategy, is the best alternative when there is positive reperfusion. The development of infarct treatment networks increases the number of patients reperfused within the recommended times and improves outcomes. In Latin America, national myocardial infarction treatment programs should focus on improving outcomes, and long-term success depends on working toward defined goals and enhancing functionality, therefore programs should develop capacity to measure their performance. The following document discusses all of these alternatives and suggests opportunities for improvement.

El tratamiento del infarto agudo de miocardio con elevación del segmento ST tiene barreras dependiendo de la región geográfica. La angioplastia coronaria primaria es el tratamiento de elección, siempre y cuando sea realizada dentro de tiempo y por operadores experimentados. Sin embargo, cuando no está disponible, la administración de fibrinólisis y el envío para angioplastia de rescate, en caso de reperfusión negativa, es la mejor estrategia. De la misma manera, la angioplastia coronaria, como parte de una estrategia farmacoinvasiva, es la mejor alternativa cuando hay reperfusión positiva. El desarrollo de redes de tratamiento del infarto aumenta el número de pacientes reperfundidos dentro de los tiempos recomendados y mejora los desenlaces. En América Latina, los programas nacionales para el tratamiento del infarto deben centrarse en mejorar los resultados y el éxito a largo plazo depende de trabajar hacia objetivos definidos y obtener métricas de rendimiento, por lo tanto, estos deben desarrollar métricas para cuantificar su desempeño. El siguiente documento discute todas estas alternativas y sugiere oportunidades de mejora.

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ABSTRACT Objective: To identify how pediatric surgeons manage children with pneumonia and parapneumonic pleural effusion in Brazil. Methods: An online cross-sectional survey with 27 questions was applied to pediatric surgeons in Brazil through the Brazilian Association of Pediatric Surgery. The questionnaire had questions about type of treatment, exams, hospital structure, and epidemiological data. Results: A total of 131 respondents completed the questionnaire. The mean age of respondents was 44 ± 11 years, and more than half (51%) had been practicing pediatric surgery for more than 10 years. The majority of respondents (33.6%) reported performing chest drainage and fibrinolysis when facing a case of fibrinopurulent parapneumonic pleural effusion. A preference for video-assisted thoracic surgery instead of chest drainage plus fibrinolysis was noted only in the Northeast region. Conclusions: Chest drainage plus fibrinolysis was the treatment adopted by most of the respondents in this Brazilian sample. There was a preference for large drains; in contrast, smaller drains were preferred by those who perform chest drainage plus fibrinolysis. Respondents would rather change treatment when facing treatment failure or in critically ill children.

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Cancer is a leading cause of death, and the fibrinolytic system shows cooperative effects that facilitate the growth of tumors and the appearance of metastases. This prospective study aimed to evaluate the fibrinolytic potential in cancer patients and its association with mortality outcomes using the fluorometric method of simultaneous thrombin and plasmin generation. The study included 323 cancer patients and 148 healthy individuals. During the 12-month follow-up, 68 patients died. Compared to the control group, cancer patients showed alterations in thrombin production consistent with a hypercoagulability profile, and an increase in plasmin generation. Mortality risk was associated with two parameters of thrombin in both univariate and multivariable analysis: maximum amplitude (Wald 11.78, p < 0.001) and area under the curve (Wald 8.0, p < 0.005), while such associations were not observed for plasmin. In conclusion, this was the first study able to demonstrate the simultaneous evaluation of thrombin and plasmin generation in newly diagnosed untreated cancer patients. Patients with cancer have been observed to exhibit a hypercoagulable profile. During the study, two parameters linked to thrombin generation, MA and AUC, were identified and found to have a potential association with mortality risk. However, no associations were found with parameters related to plasmin generation.

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Hemostasis preserves blood fluidity and prevents its loss after vessel injury. The maintenance of blood fluidity requires a delicate balance between pro-coagulant and fibrinolytic status. Endothelial cells (ECs) in the inner face of blood vessels maintain hemostasis through balancing anti-thrombotic and pro-fibrinolytic activities. Dyslipidemias are linked to hemostatic alterations. Thus, it is necessary a better understanding of the underlying mechanisms linking hemostasis with dyslipidemia. Statins are drugs that decrease cholesterol levels in the blood and are the gold standard for treating hyperlipidemias. Statins can be classified into natural and synthetic molecules, approved for the treatment of hypercholesterolemia. The classical mechanism of action of statins is by competitive inhibition of a key enzyme in the synthesis pathway of cholesterol, the HMG-CoA reductase. Statins are frequently administrated by oral ingestion and its interaction with other drugs and food supplements is associated with altered bioavailability. In this review we deeply discuss the actions of statins beyond the control of dyslipidemias, focusing on the actions in thrombotic modulation, vascular and cardiovascular-related diseases, metabolic diseases including metabolic syndrome, diabetes, hyperlipidemia, and hypertension, and chronic diseases such as cancer, chronic obstructive pulmonary disease, and chronic kidney disease. Furthermore, we were prompted to delved deeper in the molecular mechanisms by means statins regulate coagulation acting on liver, platelets, and endothelium. Clinical evidence show that statins are effective regulators of dyslipidemia with a high impact in hemostasis regulation and its deleterious consequences. However, studies are required to elucidate its underlying molecular mechanism and improving their therapeutical actions.

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Catecholamine stimulation over adrenergic receptors results in a state of hypercoagulability. Chronic stress involves the release and increase in circulation of catecholamines and other stress related hormones. Numerous observational studies in human have related stressful scenarios to several coagulation variables, but controlled stimulation with agonists or antagonists to adrenergic receptors are scarce. This systematic review is aimed at presenting an updated appraisal of the effect of adrenergic receptor modulation on variables related to human hemostasis by systematically reviewing the effect of adrenergic receptor-targeting drugs on scale variables related to hemostasis. By searching 3 databases for articles published between January 1st 2011 and February 16th, 2022 reporting effects on coagulation parameters from stimulation with α- or ß-adrenergic receptor targeting drugs in humans regardless of baseline condition, excluding records different from original research and those not addressing the main aim of this systematic review. Risk of bias assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2). Tables describing a pro-thrombotic anti-fibrinolytic state induced after ß-adrenergic receptor agonist stimulation and the opposite after α1-, ß-adrenergic receptor antagonist stimulation were synthesized from 4 eligible records by comparing hemostasis-related variables to their baseline. Notwithstanding this low number of records, experimental interventions included were sound and mostly unbiased, results were coherent, and outcomes were biologically plausible. In summary, this systematic review provides a critical systematic assessment and an updated elaboration, and its shortcomings highlight the need for further investigation in the field of hematology.

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ST-segment elevation myocardial infarction (STEMI) is a clinical entity whose adequate treatment will depend on its prompt recognition, accurate diagnosis, and management in reperfusion networks. The first contact with these patients is generally done in centers without reperfusion capacity, attended by non-cardiologist doctors, and in centers far from hospitals with greater resolution capacity, something that is well known in our country. This manuscript proposes a strategy for the diagnosis and treatment of STEMI in centers without percutaneous coronary intervention capacity of the public health system in Peru, emphasizing not losing sight of electrocardiographic patterns compatible with coronary artery occlusion, adequate fibrinolysis and management of its complications, the treatment of infarction in special populations and highlighting the importance of the pharmacoinvasive strategy as the main form of reperfusion treatment in our country.

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Introducción: La inflamación de la pleura desencadenada por bacterias y mediada por citocinas, aumenta la permeabilidad vascular y produce vasodilatación, lo cual genera desequilibrio entre la producción de líquido pleural y su capacidad de reabsorción por eficientes mecanismos fisiológicos. La condición anterior conduce al desarrollo de derrame pleural paraneumónico. Objetivo: Exponer la importancia de la correlación fisiopatológica y diagnóstica con los pilares fundamentales de actuación terapéutica en el derrame pleural paraneumónico. Métodos: Revisión en PubMed y Google Scholar de artículos publicados hasta abril de 2021 que abordaran el derrame pleural paraneumónico, su fisiopatología, elementos diagnósticos, tanto clínicos como resultados del estudio del líquido pleural, pruebas de imágenes, y estrategias terapéuticas. Análisis y síntesis de la información: El progreso de una infección pulmonar y la producción de una invasión de gérmenes al espacio pleural favorece la activación de mecanismos que conllevan al acúmulo de fluido, depósito de fibrina y formación de septos. Este proceso patológico se traduce en manifestaciones clínicas, cambios en los valores citoquímicos y resultados microbiológicos en el líquido pleural, que acompañados de signos radiológicos y ecográficos en el tórax, guían la aplicación oportuna de los pilares de tratamiento del derrame pleural paraneumónico. Conclusiones: Ante un derrame pleural paraneumónico, con tabiques o partículas en suspensión en la ecografía de tórax, hallazgo de fibrina, líquido turbio o pus en el proceder de colocación del drenaje de tórax, resulta necesario iniciar fibrinólisis intrapleural. Cuando el tratamiento con fibrinolíticos intrapleurales falla, la cirugía video-toracoscópica es el procedimiento quirúrgico de elección(AU)

Introduction: The inflammation of the pleura triggered by bacteria and mediated by cytokines, increases vascular permeability and produces vasodilation, which generates imbalance between the production of pleural fluid and its resorption capacity by efficient physiological mechanisms. The above condition leads to the development of parapneumonic pleural effusion. Objective: To expose the importance of the pathophysiological and diagnostic correlation with the fundamental pillars of therapeutic action in parapneumonic pleural effusion. Methods: Review in PubMed and Google Scholar of articles published until April 2021 that addressed parapneumonic pleural effusion, its pathophysiology, diagnostic elements, both clinical and results of the pleural fluid study, imaging tests, and therapeutic strategies. Analysis and synthesis of information: The progress of a lung infection and the production of an invasion of germs into the pleural space favors the activation of mechanisms that lead to the accumulation of fluid, fibrin deposition and formation of septa. This pathological process results in clinical manifestations, changes in cytochemical values and microbiological results in the pleural fluid, which accompanied by radiological and ultrasound signs in the chest, guide the timely application of the pillars of treatment of parapneumonic pleural effusion. Conclusions: In the event of a parapneumonic pleural effusion, with septums or particles in suspension on chest ultrasound, finding fibrin, turbid fluid or pus in the procedure of placement of the chest drain, it is necessary to initiate intrapleural fibrinolytic. When treatment with intrapleural fibrinolytics fails, video-thoracoscopic surgery is the surgical procedure of choice(AU)

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Introducción: El derrame pleural paraneumónico resulta la complicación más frecuente de la neumonía bacteriana, de manejo complejo y muchas veces quirúrgico. No existen publicaciones en Cuba provenientes de ensayos clínicos controlados y aleatorizados ni del uso de la estreptoquinasa recombinante (Heberkinasa®) en el derrame pleural. Objetivo: Evaluar la eficacia y la seguridad de la Heberkinasa® en el tratamiento del derrame pleural paraneumónico complicado complejo y el empiema en niños. Métodos: Ensayo clínico fase III, abierto, aleatorizado (2:1), en grupos paralelos y controlado. Se concluyó la inclusión prevista de 48 niños (1-18 años de edad), que cumplieron los criterios de selección. Los progenitores otorgaron el consentimiento informado. Los pacientes se distribuyeron en dos grupos: I- experimental: terapia estándar y administración intrapleural diaria de 200 000 UI de Heberkinasa® durante 3-5 días y II-control: tratamiento estándar. Las variables principales: necesidad de cirugía y la estadía hospitalaria. Se evaluaron los eventos adversos. Resultados: Ningún paciente del grupo I-experimental requirió cirugía, a diferencia del grupo II-control en el que 37,5 por ciento necesitó cirugía video-toracoscópica, con diferencia altamente significativa. Se redujo la estadía hospitalaria (en cuatro días), las complicaciones intratorácicas y las infecciones asociadas a la asistencia sanitaria en el grupo que recibió Heberkinasa®. No se presentaron eventos adversos graves atribuibles al producto. Conclusiones: La Heberkinasa® en el derrame pleural paraneumónico complicado complejo y empiema resultó eficaz y segura para la evacuación del foco séptico, con reducción de la necesidad de tratamiento quirúrgico, de la estadía hospitalaria y de las complicaciones, sin eventos adversos relacionados con su administración(AU)

Introduction: Paraneumonic pleural effusion is the most frequent complication of bacterial pneumonia, with complex and often surgical management. There are no publications in Cuba from randomized controlled clinical trials or the use of recombinant streptokinase (Heberkinase®) in pleural effusion. Objective: To evaluate the efficacy and safety of Heberkinase® in the treatment of complex complicated parapneumonic pleural effusion and empyema in children. Methods: Phase III, open-label, randomized (2:1), parallel-group, controlled clinical trial. The planned inclusion of 48 children (1-18 years of age), who met the selection criteria, was completed. Parents gave informed consent. The patients were divided into two groups: I-experimental: standard therapy and daily intrapleural administration of 200,000 IU of Heberkinase® for 3-5 days; and II-control: standard treatment. The main variables: need for surgery and hospital stay. Adverse events were evaluated. Results: No patient in group I-experimental required surgery, unlike group II-control in which 37.5 percent required video-assisted thoracoscopic surgery, with a highly significant difference. Hospital stay (to 4 days), intrathoracic complications and infections associated to healthcare in the group that received Heberkinase® was reduced. No serious adverse events attributable to the product occurred. Conclusions: Heberkinase® in complex complicated parapneumonic pleural effusion and empyema was effective and safe for the draining of the septic focus, with reduction of the need for surgical treatment, hospital stay and complications, with no adverse events related to its administration(AU)

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Introdução: A doença arterial coronariana multiarterial é um desafio na prática clínica. Uma abordagem individualizada deve considerar não apenas as características do paciente, mas também um enfoque multidisciplinar, com o Heart Team. Diversos escores angiográficos foram propostos com o objetivo de quantificar o risco associado à doença arterial coronariana multiarterial. O escore SYNTAX residual foi proposto como um método para caracterizar e quantificar a doença coronariana residual, de forma sistemática, após intervenção coronária percutânea. Existem poucos dados na literatura que correlacionam o escore SYNTAX residual em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST submetidos a uma estratégia farmacoinvasiva. O objetivo deste estudo foi avaliar o escore SYNTAX e o escore SYNTAX residual como preditores de desfechos intra-hospitalares e de médio prazo (180 a 380 dias), em pacientes com doença coronária multiarterial no contexto de infarto do miocárdio com supradesnivelamento do segmento ST, após terapia fibrinolítica bem-sucedida. Métodos: Em um estudo transversal, analítico e prospectivo, avaliamos o escore SYNTAX residual como preditor de desfechos intra-hospitalares e de médio prazo (6 meses a 1 ano), em pacientes com doença arterial coronariana multiarterial, no contexto de infarto do miocárdio com supradesnivelamento do segmento ST após estratégia farmacoinvasiva. Resultados: Entre agosto de 2019 e dezembro de 2020, foram analisados 108 pacientes com infarto do miocárdio com supradesnivelamento do segmento ST após fibrinólise, com critérios de reperfusão. O escore SYNTAX médio foi 13,98 (±4,87) e o escore SYNTAX residual médio foi 7,56 (±4,47). O escore SYNTAX residual elevado foi associado à nefropatia induzida por contraste e evento cardíaco adverso maior. Também foi um preditor independente de evento cardíaco adverso maior, com risco aumentado 9,69 vezes (p=0,0274). Conclusão: O escore SYNTAX residual elevado confere pior prognóstico em pacientes com infarto do miocárdio com elevação do segmento ST após estratégia farmacoinvasiva.

Background: Multivessel coronary artery disease is a challenge in clinical practice. An individualized approach should consider not only the patient characteristics, but also a multidisciplinary approach, together with the Heart Team. Multiple angiographic scores have been proposed with the aim of quantifying the risk associated with multivessel coronary artery disease. Residual SYNTAX score has been proposed as a method to systematically characterize and quantify residual coronary disease after percutaneous coronary intervention. There are few data in the literature correlating the residual SYNTAX score in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive strategy. The objective of this study was to evaluate the SYNTAX score and residual SYNTAX score as predictors of in-hospital and medium-term outcomes (180 to 380 days) in patients with multivessel coronary artery disease in the setting of ST-segment elevation myocardial infarction, after successful fibrinolytic therapy. Methods: In a cross-sectional, analytical, and prospective study, we evaluated residual SYNTAX score as predictor of in-hospital and medium-term outcomes (6 months to 1 year), in patients with multivessel coronary artery disease, in the setting of ST-segment elevation myocardial infarction after pharmacoinvasive strategy. Results: Between August 2019 and December 2020, 108 patients with ST-segment elevation myocardial infarction after fibrinolysis, with reperfusion criteria, were analyzed. The mean SYNTAX score was 13.98 (±4.87) and the mean residual SYNTAX score was 7.56 (±4.47). High residual SYNTAX score was associated with contrast-induced nephropathy and major adverse cardiac event. It was also an independent predictor of major adverse cardiac event with a 9.69-fold increased risk (p=0.0274). Conclusion: High residual SYNTAX score confers worse prognosis in patients with ST-segment elevation myocardial infarction after pharmacoinvasive strategy.

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La regulación del sistema de la fibrinólisis está mediada por interacciones moleculares específicas entre sus principales componentes y por la síntesis y posterior liberación a partir de las células endoteliales de los activadores e inhibidores del plasminógeno. Por tanto, un incremento de la actividad del sistema de la fibrinólisis favorece la aparición de trastornos hemorrágicos, mientras que el defecto de la actividad fibrinolítica puede predisponer a la trombosis. En los pacientes con SARS-CoV-2 también se han reportado alteraciones en la fibrinólisis. La atenuación del sistema de activación del plasminógeno conduce a un recambio anormal de fibrina en el espacio alveolar con la aparición de trombosis. Se ha informado que los niveles plasmáticos de PAI-1 son un factor de riesgo de mal pronóstico y mortalidad en los pacientes con COVID-19.

The regulation of the fibrinolysis system is mediated by specific molecular interactions between its main components and by the synthesis and subsequent release from endothelial cells of plasminogen activators and inhibitors. Therefore, an increase in the activity of the fibrinolysis system favors the appearance of bleeding disorders, while a defect in fibrinolytic activity may predispose to thrombosis. Alterations in fibrinolysis have also been reported in patients with SARS-CoV-2. Attenuation of the plasminogen activation system leads to abnormal fibrin turnover in the alveolar space with the development of thrombosis. Plasma PAI-1 levels have been reported to be a risk factor for poor prognosis and mortality in patients with Covid-19.

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Background: Acute coronary syndromes (ACS) include ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). The leading cause of mortality in Guatemala is acute myocardial infarction (AMI) and there is no established national policy nor current standard of care. Objective: Describe the factors that influence ACS outcome, evaluating the national healthcare system's quality of care based on the Donabedian health model. Methods: The ACS-Gt study is an observational, multicentre, and prospective national registry. A total of 109 ACS adult patients admitted at six hospitals from Guatemala's National Healthcare System were included. These represent six out of the country's eight geographic regions. Data enrolment took place from February 2020 to January 2021. Data was assessed using chi-square test, Student's t-test, or Mann-Whitney U test, whichever applied. A p-value < 0.05 was considered statistically significant. Results: One hundred and nine patients met inclusion criteria (80.7% STEMI, 19.3% NSTEMI/UA). The population was predominantly male, (68%) hypertensive (49.5%), and diabetic (45.9%). Fifty-nine percent of STEMI patients received fibrinolysis (alteplase 65.4%) and none for primary Percutaneous Coronary Intervention (pPCI). Reperfusion success rate was 65%, and none were taken to PCI afterwards in the recommended time period (2-24 hours). Prognostic delays in STEMI were significantly prolonged in comparison with European guidelines goals. Optimal in-hospital medical therapy was 8.3%, and in-hospital mortality was 20.4%. Conclusions: There is poor access to ACS pharmacological treatment, low reperfusion rate, and no primary, urgent, or rescue PCI available. No patient fulfilled the recommended time period between successful fibrinolysis and PCI. Resources are limited and inefficiently used.

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Introducción: La embolia pulmonar aguda es una de las causas más frecuentes de mortalidad y morbilidad grave durante el embarazo, sin embargo, no existe un consenso para su diagnóstico definitivo. Objetivo: Exponer las consideraciones más importantes para el diagnóstico y tratamiento de gestantes con sospecha de embolia pulmonar. Material y Métodos: Revisión de la literatura sobre el tema, publicada desde 2012 y hasta la actualidad que incluyó las bases de datos PubMed/MEDLINE, EMBASE, Lilacs y SciELO. Desarrollo: Las guías actuales muestran controversias en relación con el uso de reglas de predicción de riesgo, la cuantificación del dímero D y la indicación de estudios de imagen. La evaluación clínica continúa siendo el principal sustrato diagnóstico, pero se ha señalado que tanto una gammagrafía de ventilación-perfusión normal como una angio TC negativa excluyen con precisión la embolia pulmonar durante el embarazo. El uso de heparinas es el tratamiento de elección, mientras que los nuevos anticoagulantes orales no están recomendados en el embarazo a falta de estudios que avalen su seguridad. La fibrinólisis se puede considerar ante gestantes de alto riesgo (hipotensión grave, shock o parada cardiorespiratoria). Conclusiones: El manejo de las pacientes debe ser por un equipo multidisciplinario, lo que permitirá obtener mejores resultados maternos y perinatales.

Introduction: Acute pulmonary embolism is one of the most frequent causes of mortality and serious morbidity during pregnancy; however, there is no consensus on its definitive diagnosis. Objective: To expose the most important considerations for the diagnosis and treatment of pregnant women with suspected pulmonary embolism. Material and Methods: Literature review on the subject, published from 2012 to the present, which included the PubMed/MEDLINE, EMBASE, Lilacs and SciELO databases. Development: The current guidelines show controversies in relation to the use of risk prediction rules, the quantification of D-dimer and the indication of imaging studies. Clinical evaluation continues to be the main diagnostic substrate, but it has been pointed out that both a normal ventilation-perfusion scintigraphy and a negative CT angiography accurately exclude pulmonary embolism during pregnancy. The use of heparins is the treatment of choice, while the new oral anticoagulants are not recommended in pregnancy due to the lack of studies that support their safety. Fibrinolysis can be considered in high-risk pregnant women (severe hypotension, shock, or cardiorespiratory arrest). Conclusions: The management of these patients should be undertaken by a multidisciplinary team, which will allow better maternal and perinatal results.

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Las orugas del género Lonomia, del orden Lepidoptera y familia Saturnidae, son de interés médico en Sudamérica por ser causantes del lonomismo, tipo de envenenamiento que aumenta cada vez más en Colombia, con tasas de mortalidad de 2,5 %. La severidad es variable y los casos no son de notificación obligatoria, lo que lleva a un subregistro de estos eventos. Se presenta el caso de una mujer adulta joven, quien acude a urgencias por la picadura de 20 orugas Lonomia en la palma de la mano izquierda; presentó signos locales inflamatorios, dolor y limitación de la movilidad de la mano. Se hospitalizó por tres días, se clasificó como leve y se trató con analgesia y antihistamínico endovenoso, lo que logró favorable evolución. El envenenamiento por oruga Lonomia es una urgencia que puede ser mortal, por tanto, es importante que se conozcan estos eventos en la literatura para su adecuado abordaje.

Caterpillars of the genus Lonomia, of the order Lepidoptera, family Saturnidae are of medical interest in South America for being the cause of lonomism, poisoning that is increasing more and more in Colombia, with mortality rates of 2.5%, the severity is variable and they are not mandatory notification, which leads to an underreporting of these events. We present the case of a young adult woman, who went to the emergency room due to the bite of 20 Lonomia caterpillars in the palm of her left hand, generating local inflammatory signs, pain and limitation of hand mobility. She was hospitalized for 3 days, classified as mild and treated with analgesia and intravenous antihistamine; which achieved favorable evolution. Therefore, it was concluded that Lonomia caterpillar poisoning is an emergency, which can be fatal. It is important that these events are known in the literature for their proper approach.

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OBJECTIVES: We sought to determine the relationship between in-hospital mortality and the neutrophil-to-lymphocyte ratio (NLR) in patients with ST-elevation myocardial infarction (STEMI) undergoing with pharmaco-invasive strategy (PIS). BACKGROUND: Increased levels of white blood cells have been associated with adverse clinical outcomes in patients with (STEMI). NLR has recently emerged as a potent and more specific prognostic marker in predicting short- and long-term mortalityin patients undergoing primary percutaneous coronary intervention. This association has never been reported in patients managed with PIS. METHODS: Between March 2010 and October 2016, 1860 STEMI patients managed with PIS were consecutively included in a dedicated database. The study population was divided into tertiles based on the admission NLR values (lower: <4.0, intermediate: 4.0 to <7.3, and upper: ≥7.3). Co-primary endpoints were in-hospital mortality and MACE (death, non-fatal reinfarction or stent thrombosis). RESULTS: Patients in the upper NLR tertile had significantly higher in-hospital mortality (9.0% vs. 4.8% versus. 1.8%, p < 0.001) and MACE (11.6% vs. 8.0% versus 2.9%, p < 0.001) than patients with intermediate or low NLR. By multivariable logistic regression analysis, the upper NLR tertile was an independent predictor of MACE (odds radio [OR] 4.19, 95% confidence interval [95% CI] 2.23-7.88, p < 0.001) and in-hospital mortality [OR 3.32, 95% CI 1.19-9.28, p = 0.02]. CONCLUSION: High NLR values were independently associated with in-hospital MACE and death in STEMI patients submitted to a PIS. NLR might be a simple and useful risk stratification tool in this high-risk population.

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Snake venom serine proteases (SVSPs) are chymotrypsin-like proteins found in some venoms of the Viperidae family. These enzymes affect physiological processes of their prey and victims, acting mainly in the hemostatic, fibrinolytic and kinin systems. SVSPs belong to the PA clan, PA (S) subclan, S1 family and A subfamily of proteolytic enzymes. This work, describes a SVSP (Lmr-PA) isolated from the venom of Lachesis muta rhombeata which activates plasminogen. The proteinase was purified by combination of gel filtration and anionic exchange chromatographies. Its homogeneity was demonstrated by SDS-PAGE, reverse-phase HPLC, and two-dimensional electrophoresis. Lmr-PA is a 30-kDa single chain glycoprotein. Its amino acid sequence (61%) was determined by mass spectrometry on nLC-MS/MS. Lmr-PA activates plasminogen to release plasmin and degrades the plasmin substrate S-2251 as well as dimethylcasein. PMSF, the specific inhibitor of serine proteases completely blocked Lmr-PA activity. The proteinase cleaves the Aα chain and partially the Bβ and γ chains of fibrinogen. In addition the protease degrades laminin, nidogen and type IV collagen from Matrigel. The enzyme digests fibrin in presence of plasminogen in vitro. Deglycosylated Lmr-PA loses approximately 26% of its activity. In addition, Lmr-PA activity is inhibited by α2-macroglobulin at a ratio of 2:1 (α2-M:E) and α2-antiplasmin inhibits plasmin generated from plasminogen. Lmr-PA does not induce aggregation of washed human platelets but, aggregates platelets in presence of exogenous fibrinogen and binds to the platelet receptors glycoproteins (GP) GPIb and GPVI. Our data indicate that Lmr-PA is a plasminogen activating serine protease, like to previously reported LV-PA from Lachesis muta muta venom. These results suggested that Lmr- PA play a role in the pathology of snake envenomation and could be a useful model to study hemostatic disorders caused by snake bites.

As serinoproteases do veneno de serpentes (SVSPs) são proteínas semelhantes à quimotripsina presentes encontradas em alguns venenos da família Viperidae. Essas enzimas afetam os processos fisiológicos de suas presas e vítimas, atuando principalmente nos sistemas hemostático, fibrinolítico e cinina. As SVSPs pertencem ao clã PA, subclan PA (S), família S1 e subfamília A de enzimas proteolíticas. Este trabalho descreve uma SVSP (Lmr-PA) isolada do veneno de Lachesis muta rhombeata que ativa o plasminogênio. A proteinase foi purifica por combinação de cromatografias de filtração em gel e troca aniônica. Sua homogeneidade foi demonstrada por SDS-PAGE, HPLC de fase reversa e eletroforese bidimensional. Lmr-PA é uma glicoproteína de cadeia simples de 30 kDa. A sua sequência de aminoácidos (61%) foi determinada por espectrometria de massa em nLC-MS/MS. Lmr-PA ativa o plasminogênio para liberar plasmina e degrada o substrato de plasmina S-2251, bem como a dimetilcaseína. PMSF, um inibidor específico de serinoproteases bloqueou completamente a atividade da Lmr-PA. A proteinase cliva a cadeia Aα e parcialmente as cadeias Bβ e γ do fibrinogênio. Além disso, a protease degrada laminina, nidogênio e colágeno tipo IV de Matrigel. A enzima digere a fibrina na presença de plasminogênio in vitro. Lmr-PA desglicosilada perde aproximadamente 26% da sua atividade. Além disso, a atividade da Lmr-PA é inibida pela α2-macroglobulina em uma proporção de 2:1 (α2-M:E) e a α2-antiplasmina inibe a plasmina gerada a partir do plasminogênio. Lmr-PA não induz a agregação de plaquetas humanas lavadas, mas agrega plaquetas na presença de fibrinogênio exógeno e se liga às glicoproteínas dos receptores plaquetários (GP) GPIb e GPVI. Nossos dados indicam que a Lmr-PA é uma serinoprotease ativadora do plasminogênio semelhante a LV-PA relatada anteriormente do veneno de Lachesis muta muta. Esses resultados sugerem que a Lmr-PA desempenha um papel na patologia do envenenamento por serpentes e pode ser um modelo útil para estudar distúrbios hemostáticos causados por acidentes ofídicos.

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Abstract The new coronavirus 2019-nCov or SARS-Cov-2 is responsible for the most important pandemic in the 21st century: the coronavirus disease (COVID-19). The 2019-nCov infection elicits a hyper-coagulable state, conditioning a worse outcome in these patients. The pathophysiology of the exaggerated coagulation activation in these patients is still unknown, and probably involves several mechanisms, different from those involved in sepsis-associated coagulopathy. This article discusses the case of a patient with no remarkable medical history, who after 7 days of fever, diarrhea and epigastric pain was diagnosed with COVID-19 bilateral pneumonia, further aggravated by severe Acute Respiratory Distress Syndrome. In this context, the patient experienced a massive acute pulmonary thromboembolism accompanied by an acute thrombus in the heart's right ventricle, leading to hemodynamic instability. For the first time in our center in these patients, systemic fibrinolysis was successfully performed, with resolution of the intracavitary thrombus and the acute hemodynamic shock.

Resumen El nuevo coronavirus 2019-nCov o SARS-Cov-2 es responsable de la pandemia más importante del siglo XXI: la enfermedad del coronavirus (COVID-19). La infección por 2019-nCov produce un estado de hipercoagulabilidad, que promueve peores desenlaces en estos pacientes. La fisiopatología de la exagerada activación de la coagulación en estos pacientes aún se desconoce y posiblemente involucre varios mecanismos, diferentes a los participan en la coagulopatía asociada a sepsis. El presente artículo presenta el caso de un paciente sin antecedentes médicos y quien luego de 7 días de fiebre, diarrea y dolor epigástrico, fue diagnosticado con neumonía bilateral por COVID-19, agravada por la presencia de Síndrome de Dificultad Respiratoria Aguda. En este contexto, el paciente desarrolla un tromboembolismo pulmonar agudo masivo, acompañado de un trombo agudo en el ventrículo derecho, produciéndole inestabilidad hemodinámica. Por primera vez en nuestro centro, se realizó exitosamente una fibrinólisis sistémica, con resolución del trombo intracavitario y del shock hemodinámico agudo.

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RESUMEN Introducción: El tratamiento de reperfusión es la terapéutica de mayor eficacia para reducir la mortalidad del infarto agudo de miocardio con elevación del segmento ST (IAMCEST) , y su efectividad es inversamente proporcional al tiempo total de isquemia. El mayor desafío es instrumentar su aplicación en la vida real y corregir en forma continua los desvíos o las barreras que se presentan en la práctica cotidiana. Objetivos: Evaluar la mortalidad con las diferentes modalidades de reperfusión, su relación con el tiempo de tratamiento y su efectividad en un registro prospectivo multicéntrico del mundo real de Argentina. Material y Métodos: estudio prospectivo, multicéntrico de carácter nacional, incluidos los pacientes con IAMCEST hasta las 36 h del comienzo de los síntomas (ARGEN-IAM-ST registro continuo). Resultados: participaron 2464 pacientes de 78 centros entre 2015 y 2019. El 88,5% recibió tratamiento de reperfusión. La mortalidad fue de 8,68%. Los pacientes tratados con reperfusión tuvieron una mortalidad de 7,81% versus 15,38% sin tratamiento (p <0,001). La mortalidad con angioplastia primaria fue 7,51%, con trombolíticos 9,03%, con estrategia farmacoinvasiva 2,99% y con angioplastia de rescate 9,40%, sin diferencia estadísticamente significativa entre angioplastia primaria y trombolíticos (OR 0,81 IC 95% 0,56-1,18, p = ns). Los pacientes fallecidos fueron de mayor edad, con mayor proporción de mujeres e insuficiencia cardíaca. El tratamiento de reperfusión e ingreso a la institución dentro de 3 horas del comienzo de los síntomas se asoció a menor mortalidad. Los pacientes fallecidos con angioplastia primaria tuvieron mayor tiempo total de isquemia (378 minutos versus 285 minutos, p < 0,001). Conclusiones: La mortalidad por IAMCEST se relacionó con el acceso a la reperfusión y su precocidad. Fue mucho mayor en los pacientes no reperfundidos, y menor cuando la reperfusión se efectuó en forma precoz dentro de las primeras tres horas del comienzo de los síntomas. En los pacientes tratados con angioplastia primaria la mortalidad se incrementó con mayor tiempo total de isquemia. Este registro de la práctica real del tratamiento del IAMCEST refuerza la necesidad de una mejor articulación del sistema de atención para bajar los tiempos y utilizar la estrategia mejor y más oportuna.

ABSTRACT Background: reperfusion treatment is the most effective therapy in reducing mortality from acute ST elevation myocardial infarction and its effectiveness is inversely proportional to the total time of ischemia. The greatest challenge is to implement its application in real life and continuously correct the deviations or barriers that arise in daily practice. Objectives: to evaluate mortality with the different reperfusion modalities, its relationship with treatment time and to evaluate its effectiveness. Methods: a prospective, multicenter national study, including patients with STEMI up to 36 h after symptoms began (ARGENAMI-ST continuous registry). Results: 2464 patients were included from 2015 to 2019 in 78 centers. 88.5% received reperfusion treatment. Mortality was 8.68%. The patients treated with reperfusion had a mortality of 7.81% versus 15.38% without treatment (p <0.001). Mortality with primary angioplasty was 7.51%, thrombolytics 9.03%, pharmacoinvasive strategy 2.99%, and rescue angioplasty 9.40%, with no statistically significant difference between primary angioplasty and thrombolytics (OR 0.81; 95% CI 0.56-1.18, p = ns). The deceased patients were older, a higher proportion of women, and heart failure. Reperfusion treatment and admission to the institution within 3 hours of starting symptoms were associated with lower mortality. Patients who died with primary angioplasty had a longer total ischemia time (378 minutes versus 285 minutes, p <0.001). Conclusions: mortality from STEMI was related to access to reperfusion and its earliness. It was much higher in non-reperfused patients, and lower when reperfusion was carried out early within the first three hours of the onset of symptoms. In patients treated with primary angioplasty, mortality increased with a longer total ischemia time. This record of the actual practice of the treatment of infarction reinforces the need for a better articulation of the care system to reduce times and use the best timely strategy.