CT venography for deep vein thrombosis using a low tube voltage (100 kVp) setting could increase venous enhancement and reduce the amount of administered iodine

Objective

To investigate the validity of the 100 kVp setting in CT venography (CTV) in the diagnosis of deep vein thrombosis (DVT), and to evaluate the feasibility of reducing the amount of administered iodine in this setting.

Materials and Methods

After receiving the contrast medium (CM) of 2.0 mL/kg, 88 patients underwent CTV of the pelvis and lower extremities by using one of four protocols: Group A, 120 kVp setting and 370 mgI/mL CM; group B, 120 kVp and 300 mgI/mL; group C, 100 kVp and 370 mgI/mL; group D, 100 kVp and 300 mgI/mL. The groups were evaluated for venous attenuation, vein-to-muscle contrast-to-noise ratio (CNR_VEIN), DVT-to-vein contrast-to-noise ratio (CNR_DVT), and subjective degree of venous enhancement and image quality.

Results

Venous attenuation and CNR_VEIN were significantly higher in group C (144.3 Hounsfield unit [HU] and 11.9), but there was no significant difference between group A (118.0 HU and 8.2) and D (122.4 HU and 7.9). The attenuation value of DVT was not significantly different among the four groups, and group C had a higher absolute CNR_DVT than the other groups. The overall diagnostic image quality and venous enhancement were significantly higher in group C, but there was no difference between groups A and D.

Conclusion

The 100 kVp setting in CTV substantially help improve venous enhancement and CNR_VEIN. Furthermore, it enables to reduce the amount of administered iodine while maintaining venous attenuation, as compared with the 120 kVp setting.

Pulmonary embolism in a patient with eosinophilic esophagitis: causal or coincidental?

Eosinophilic esophagitis is a chronic immune-mediated disease characterized by infiltration of the esophageal mucosa with eosinophils and concomitant esophageal dysfunction. Though there are well-described associations between certain chronic inflammatory conditions and venous thromboembolism, there have been no reports of venous thromboembolism occurring in eosinophilic esophagitis. We report the case of a 33-year-old man with severe eosinophilic esophagitis resulting in recurrent esophageal strictures who was unresponsive to oral viscous budesonide therapy, and who developed an isolated pulmonary embolism in the absence of risk factors for venous thromboembolism. We then discuss potential mechanisms for venous thromboembolism in eosinophilic esophagitis, such as inflammation-mediated hypercoagulability, hypereosinophilia, and immunoglobulin E-mediated platelet activation.

Activated protein C anticoagulant system dysfunction and thrombophilia in Asia

Thrombophilia that is common among Caucasians is caused by genetic polymorphisms of coagulation factor V Leiden (R506Q) and prothrombin G20210A. Unlike that in Caucasians, thrombophilia that is common in the Japanese and Chinese involve dysfunction of the activated protein C (APC) anticoagulant system caused by abnormal protein S and protein C molecules. Approximately 50% of Japanese and Chinese individuals who develop venous thrombosis have reduced activities of protein S. The abnormal sites causing the protein S molecule abnormalities are distributed throughout the protein S gene, PROS1. One of the most common abnormalities is protein S Tokushima (K155E), which accounts for about 30% of the protein S molecule abnormalities in the Japanese. Whether APC dysfunction occurs in other Asian countries is an important aspect of mapping thrombophilia among Asians. International surveys using an accurate assay system are needed to determine this.

Variations in risk assessment models may contribute to the existing gap between venous thromboembolism prophylaxis guidelines and adherence

BACKGROUND

Risk assessment models (RAMs) may allow the clinician to determine need for deep vein thrombosis (DVT) prophylaxis. Individual healthcare facilities often develop their own RAMs. The purpose of this study was to determine: 1.) inter-RAM variability in DVT risk factors and contraindications; 2.) inter-rater variability and inter-RAM variability when applying a RAM to a standard case; and 3.) inter-rater and inter-RAM variability in outcome as far as type of prophylaxis. A convenience sample of RAMs was obtained from various institutions and ten reviewers were recruited to apply the RAMs to three patient cases.

FINDING

The review resulted in 390 separate assessments. Patient 1 did not receive any chemoprophylaxis in 67% of the evaluations, patient 2 in 27% of the evaluations and patient 3 in 2.3% of the evaluations. There was statistically significant variation in the provision of chemoprophylaxis per RAM for patient 1 (p=0.001) and no significant variation for patients 2 and 3. When analyzing the rate of chemoprophylaxis per reviewer, there was statistically significant variation for patients 1 and 2 (p=0.026 and <0.0001 respectively) but not for patient 3 (p=0.123).

CONCLUSION

There may be significant inter-RAM and inter-reviewer variability when utilizing RAMs for assessing DVT risk.

Acute osteomyelitis associated with Deep vein thrombosis in a patient of acute abdomen: A diagnostic dilemma

Deep vein thrombosis associated with acute osteomyelitis is a rare presentation. Such a presentation can lead to delay in diagnosis especially due to overlapping clinical presentation and usually has a poor prognosis. Only a high level of clinical suspicion can help in diagnosis. We present such case which patient presented with acute abdomen with swelling in lower limb.

Results of post-laparoscopic cholecystectomy duplex scan without deep vein thrombosis prophylaxis prior to surgery

BACKGROUNDS

There are controversies among surgeons about prophylaxis of deep vein thrombosis (DVT) in laparoscopic cholecystectomy. The aim of this study was the assessment of patients' condition after laparoscopic cholecystectomy without any prophylactic measure.

METHODS

100 cases of laparoscopic cholecystectomy without DVT prophylaxis were followed by duplex scanning in the first postoperative day and by physical examination and patient history at the first to second postoperative week however no clinical sign was found for DVT.

RESULTS

Only one case of partially thrombosis (1%) was found by duplex scanning which was managed conservatively.

CONCLUSION

Laparoscopic cholecystectomy may consider as a low-risk procedure and routine prophylaxis may not be justified in the absence of other risk factor.

Deep venous thromboembolism after a trauma in a football player double heterozygous for factor V Leiden and prothrombin G20210A mutation: The role of genetic testing in sport

Traumatic vascular injuries to the lower limb are frequent in athletes, particularly in sports characterized by high-speed collisions. However, the diagnosis is not always straightforward, for the lack of clearly visible abnormalities without provocative testing or appropriate imaging. The failure of an early diagnosis can lead to devastating consequences. In these subjects, it may be useful to investigate the personal susceptibility to thrombotic events such as the presence of a hereditary hypercoagulable state. We experienced a case of a soccer player with progressive swelling and severe pain of the calf after a trauma during a football match 3 days previously, who came to our hospital for suspected deep vein thrombosis, confirmed by echo-Doppler ultrasound. A thrombophilia screening detected a double heterozygosity for factor V Leiden and prothrombin G20210A mutation in the presence of a strong family history for thromboembolism. Immediate treatment with elastic stocking compression and enoxaparin was started. The patient was discharged on warfarin therapy maintained for six months, with the warning to avoid trauma activities during anticoagulation. Thrombotic genetic testing in athletes who experience episodes of deep vein thrombosis might offer important opportunities for patient management, such as prolonged anticoagulant therapy or avoidance of risk factors such as trauma-related sports.

Thrombotic risk assessment questionary helps increase the use of thromboprophylaxis for patients with pelvic and acetabular fractures

BACKGROUND

Pelvic and acetabular fractures have been known as one of the high risk factors for developing deep vein thrombosis (DVT), but thromboprophylaxis for patients with such fractures remains underused despite its widely accepted benefits. Current guidelines have not been universally adopted in clinical practice. The purpose of this study is to introduce a Thrombotic Risk Assessment Questionary (assessment table) according to evidence-based guidelines and evaluate its impact on the use of thromboprophylaxis for patients with pelvic and acetabular fractures.

MATERIALS AND METHODS

We retrospectively reviewed 305 consecutive patients with pelvic and acetabular fractures from August 1, 2008 through September 30, 2010. The control group without using the assessment table included 153 patients admitted during the first 13 months, and the assessment group using the assessment table included 152 patients admitted during the following months. Data on clinical outcomes of DVT, the number of patients receiving prophylaxis, and the time of the first dose of anticoagulant were collected.

RESULTS

Compared with the control group, Patients using the assessment table were more likely to be given DVT prophylaxis (84.2% vs. 37.3%, P < 0.05) and the time of the first dose of anticoagulant was reduced (4.32 days ± 4.78 days vs. 6.6 days ± 5.96 days, P < 0.05). Patients in the assessment group had lower risk of developing DVT (8.6% vs. 20.3%, P < 0.05).

CONCLUSION

The assessment table can significantly improve the use of thromboprophylaxis after pelvic and acetabular fractures, which will likely reduce the incidence of DVT. Developing individual hospital prophylaxis strategy is an effective way to determine whether hospitalized patients should receive pharmacologic and/or mechanical prophylaxis or not.

Recurrent Deep Vein Thrombosis due to Thrombophilia

Deep vein thrombosis (DVT) is a common condition that is often under-diagnosed. Acquired or hereditary defects of coagulation or a combination of these defects may facilitate the development of DVT. Recurrent DVT, a positive family history or unusual presentation may warrant investigation for hereditary thrombophilia. Investigations are best when conducted at least one month after completion of a course of anticoagulant therapy. Most patients are managed with heparin in the acute stage overlapped by warfarin. The case presented here describes a 40-year old man undergoing three episodes of DVT. Investigations revealed protein C and protein S deficiency. Protein C, protein S and antithrombin deficiency either singly or in combination, are relatively common causes of hereditary thrombophilia. The case presented here serves as a reminder of the need to look into the underlying cause of venous thromboembolism.

Hospital versus home treatment of deep vein thrombosis in a tertiary care hospital in Saudi Arabia: Are we ready?

AIM/BACKGROUND

Treatment of DVT with LMWHs has been shown recently to be as effective as UFH with suggested lower costs. This study was conducted to determine and compare the cost of in-patient hospital treatment versus outpatient hospital treatment of patients with DVT.

METHOD

All adult patients with acute proximal DVT referred to the Emergency Department of King Khalid University Hospital, Riyadh, Saudi Arabia between August 2009 and August 2010 were invited to the study. An economic analysis was performed to compare the cost impact of outpatients versus hospital treatment.

RESULTS

Sixty-one patients were included in the study, 31 were followed in the outpatient setting and 30 as the control group (inpatients). There were no significant differences in the outcome between the outpatient and inpatient group; three patients (9.7%) in the outpatient group and four patients (13.3%) in the inpatient group had recurrent DVT. Mean nursing cost was $55 for the outpatient group and $215 for the inpatient group, mean laboratory monitoring cost was $638 for outpatient group and $1511 for the inpatient group. Hospital stay and doctor's fees amounted to a mean of $1000 for outpatient treatment and $2387 for inpatient treatment, p < 0.0001. The mean outpatient cost was significantly lower than the inpatient cost ($1750 vs. $4338, p < 0.0001).

CONCLUSION

Outpatient treatment of patients with DVT using LMWHs is cost-effective with no significant differences in the outcome of patients. OPD treatment of DVT is feasible in Saudi Arabia provided there is enough logistic support from thrombosis clinics and those involved in DVT care.

Risk factors for delayed recanalization of calf vein thrombosis

PURPOSE

To determine the risk factors of delayed recanalization of isolated calf vein thrombosis (CVT).

METHODS

One hundred fifty limbs of 110 patients with CVT between September 2007 and April 2010 were enrolled. We used ultrasonography for the diagnosis and follow-up examinations of CVT. We calculated recanalization rates at 1 and 3 months after initial diagnosis and analyzed the risk factors associated with delayed recanalization of CVT.

RESULTS

CVTs were located in the muscular calf vein in 110 (73.3%), in the deep calf vein in 18 (12%), and in both in 22 cases (14.7%). Among all CVTs, 94 limbs (63%) were symptomatic. Major risk factors for CVT were orthopedic surgery (87.3%), malignancy (21.3%), and immobilization (15.3%). Sixty-seven patients (60.9%) were treated with oral anticoagulation therapy, while 43 patients by low molecular weight heparin (n = 19) or by conservative methods including elastic compression stockings and ambulation (n = 21). The cumulative recanalization rate at 1 and 3 months was 23% and 82% and it was significantly higher in patients who underwent oral anticoagulation therapy compared with patients without oral anticoagulation therapy (84% vs. 65%, P = 0.008 by log-rank test). Malignancy (odds ratio [OR], 2.789; P = 0.043) and immobilization (OR, 4.191; P = 0.029) were independent risk factors for delayed recanalization of CVT and oral anticoagulation (OR, 0.300; P = 0.020) was an independent factor in promoting recanalization in multivariate analysis.

CONCLUSION

For patients with isolated CVT, no oral anticoagulation resulted in higher rates of delayed recanalization compared to oral anticoagulation treatment. Immobilization and having malignancy were independent risk factors for delayed recanalization.

Incidence of venous thromboembolism using 64 channel multidetector row computed tomography-indirect venography and anti-coagulation therapy after total knee arthroplasty in Korea

Purpose

This study evaluated the incidence of a venous thromboembolism (VTE) after total knee arthroplasty (TKA) using multidetector row computed tomography-indirect venography (MDCT-indirect venography) and assessed the efficacy of anti-coagulation therapy.

Materials and Methods

We enrolled 118 patients with 126 cases of TKA. The average age of the patients was 68.4 years. We used 64 channel MDCT-indirect venography for the detection of VTE. We treated selectively proximal deep vein thrombosis (DVT) or pulmonary thromboembolism (PTE) cases according to the results of MDCT-indirect venography. We re-evaluated the change in VTE using follow-up MDCT-indirect venography after 3 months.

Results

We identified VTE in 35.7%. DVT only was identified in 22.2% including 8 cases of proximal DVT and 20 cases of distal DVT. PTE without DVT was identified in 4.8%, and combined DVT and PTE in 8.7%. All patients with PTE were asymptomatic, but 4 DVT patients had signs of leg swelling. After anti-coagulation therapy, 20 patients showed complete resolution in 16 cases, improvement in 3 cases and one case showed a new distal DVT.

Conclusions

The incidence of VTE after primary TKA was 35.7% in Korea. Furthermore, anti-coagulation therapy for proximal DVT and PTE patients may be a useful method for preventing the occurrence of a fatal PTE.

Iliofemoral-popliteal deep vein thrombosis at 35(th) week of pregnancy: treated with cesarean section and vena cava blockage plus thrombectomy

Pregnancy, due to its adaptive physiological changes, is a risk factor for deep vein thrombosis. Incidence of thromboembolic complications during pregnancy ranges from 0.76 to 1.72 per 1000 births. We present in this case report a pregnant woman with iliofemoral-popliteal deep vein thrombosis diagnosed at the 35(th) week of her pregnancy, who was treated with vena cava blockage and thrombectomy followed by cesarean section. Unfortunately, a rethrombosis developed in the patient after three days. We determined that the a-v fistula was blocked and not working. We found additionally that the deep vein thrombosis was closing the iliac vein completely on the left side and the blockage descending down through the inferior vena cava inlet with MRI. The patient underwent insertion of a retrievable vena cava filter, two stent implantation to the venous narrowings and surgical iliofemoral venous thrombectomy with concomitant re-creation of a temporary femoral arterio-venous fistula. Anticoagulation therapy with enoxaparine was started after the operation. The patient was discharged with warfarin under control of the INR value, and also with additional compression therapy (compression stockings) from the clinic. Without jeopardizing the mother and the baby, planning a combined surgical procedure, with a multidisciplinary approach is the best way to eliminate the risks of serious complications such as pulmonary embolism and mortality.

Is thromboprophylaxis effective in reducing the pulmonary thromboembolism?

BACKGROUND

Deep vein thrombosis (DVT) is a relatively prevalent disease which causes high costs due to the required diagnostic tests, specialized treatments, and hospital admission. In recent decades, implementation of thromboprophylaxis protocols has significantly reduced the incidence of thromboembolism in hospitals. The present study aimed to compare the incidence of venous thromboembolism before and after implementation of the mentioned protocol in hospital with identified risk factors and underlying diseases.

METHODS

In this case-control group, 385 patients at the risk of DVT, some before and some after implementation of the protocol were studied. Therefore, the level of thromboprophylaxis and the incidence of venous thromboembolism were compared before and after the protocol. Data was entered into SPSS(15) and analyzed by chi-square and t tests

RESULTS

Out of 385 patients, 34 patients (8.8%) had venous thromboembolism while 351 (91.2%) were not affected. The incidence of venous thromboembolism was significantly different before and after the implementation of the protocol (17.7% vs. 5.9%; P < 0.001). The incidence of venous thromboembolism in patients not receiving thromboprophylaxis was almost 5 times higher than those who received it (20.7% vs. 5.1%). The frequency distribution of thromboembolism had a significant difference in the two above mentioned groups (P < 0.001).

CONCLUSION

Thromboprophylaxis protocol reduced venous thromboembolism incidence in patients with underlying diseases which increase the risk of the complication.

Role of calf muscle stimulation in the prevention of DVT in Indian patients undergoing surgeries for fractures around the hip

BACKGROUND

The venous stasis of soleal vein during surgery may be an important factor in the development of deep vein thrombosis (DVT). The stimulation of calf muscle during surgery may help in preventing DVT. The present study is conducted to evaluate the role of peroperative calf muscle electrostimulation in prevention of DVT in patients undergoing surgeries around the hip joint.

MATERIALS AND METHODS

The study comprised 200 patients undergoing surgeries around the hip joint. The patients having risk factors (such as previous myocardial infarction, malignancies, paraplegia or lower limb monoplegia, previous history of DVT or varicose veins, etc.) for the development of DVT were excluded. They were randomized into two groups: 100 cases were given peroperative calf muscle electrostimulation for DVT prophylaxis (Group A) and the remaining 100 patients were taken as controls without any prophylaxis (Group B). The color Doppler ultrasound was performed to exclude pre-existing DVT and on 7(th) day postoperative to find out the incidence of DVT in both the groups.

RESULTS

Two patients among Group A and six patients among Group B demonstrated DVT on ultrasonography, but the difference was not found to be statistically significant (P=0.279). None of the patients had any clinical evidence of DVT.

CONCLUSION

The role of peroperative calf muscle electrostimulation for DVT prophylaxis remains controversial. The risk of developing DVT in patients undergoing surgeries around the hip joint is very less in patients analysed in our series.

Acute pulmonary embolism induced by renal obstruction with benign prostatic hyperplasia: Case report

Background

We report a rare case of acute pulmonary embolism (PE) induced by urinary retention and bladder distention with benign prostatic hyperplasia (BPH).

Case report

A 76-year-old male with BPH presented to the hospital with anuria of 24 h duration and abdominal distention. Physical examination revealed tenderness and distention of the lower abdomen and a swollen right leg. Echocardiography after urethral catheterization showed a large free-floating thrombus traversing back and forth through the tricuspid orifice. Computed tomographic angiography demonstrated filling defects at the level of the right inter lobar pulmonary artery and the segmental branches of both pulmonary arteries, indicating acute PE. The patient was treated with heparin and warfarin for three weeks to ensure the resolution of the pulmonary embolus. After the resolution of all symptoms, the patient was discharged without further complication.

Conclusion

This case suggested that a distended bladder is a potential risk factor for the development of deep vein thrombosis and PE.

Detection and Prevention of Post-Operative Deep Vein Thrombosis [DVT] Using Nadroparin Among Patients Undergoing Major Abdominal Operations in India; a Randomised Controlled Trial

Deep vein thrombosis [DVT] is one of the most dreaded complications in post-operative patients as it is associated with considerable morbidity and mortality. Majority of patients with postoperative DVT are asymptomatic. The pulmonary embolism, which is seen in 10% of the cases with proximal DVT, may be fatal. Therefore it becomes imperative to prevent DVT rather than to diagnose and treat. Only one randomized trial has been reported from India to assess the effectiveness of low molecular weight heparin in preventing post-operative DVT. To assess the risk of DVT in North Indian patients following major abdominal operations and to evaluate the effectiveness of Nadroparin, A Low Molecular Weight Heparin (LMWH) therapy in preventing post-operative DVT. Sixty five patients were randomised preoperatively into Group-I; Nadroparin prophylaxis and Group-II: No prophylaxis. The primary outcome was the occurrence of DVT, diagnosed by bilateral lower limb venogram performed, seven to ten days after operation. Secondary outcome measures included adverse effects of radio-opaque dye, intra-operative blood loss, operating time, postoperative platelet count, intraoperative blood transfusion requirements and the total duration of postoperative bed rest. No case of DVT occurred in either group. There was no statistical difference in the risk of secondary outcome measures in the two groups. DVT was not observed in any of the patients, even with several high risk factors indicating a possible protective mechanism in the North Indian population.

Percutaneous options for acute deep vein thrombosis

Anticoagulant therapy is associated with poor late limb outcomes in many patients with deep vein thrombosis (DVT). Because systemic thrombolysis and surgical thrombectomy have inherent limitations, image-guided percutaneous thrombus removal is currently favored. Pharmacologic thrombolysis is effective in removing thrombus, but long-term benefit has not been conclusively demonstrated and major bleeding rates appear to be higher than those observed with anticoagulation alone. Percutaneous mechanical thrombectomy is limited as a stand-alone DVT treatment method by inability to clear large thrombosed veins completely and by pulmonary embolism. Pharmacomechanical thrombolysis represents the most promising currently available method to treat DVT. Randomized trials with long-term follow-up are needed to determine the appropriate indications for these procedures. In the meantime, a highly individualized approach to selection of patients is recommended, taking into account the chronicity and anatomic extent of DVT, the presence of circulatory compromise, the patient's bleeding risk profile, life expectancy, and anticipated activity level.

Predictors of a positive duplex scan in patients with a clinical presentation compatible with deep vein thrombosis or cellulitis

BACKGROUND

Deep vein thrombosis (DVT) and cellulitis are common conditions whose symptoms lead patients to seek medical attention in the emergency department (ED). Distinguishing between these two conditions quickly and accurately is important.

OBJECTIVES

To determine the yield of duplex scanning among ED patients whose clinical presentation is compatible with DVT or cellulitis. In addition, to determine whether baseline clinical variables are predictive of the final diagnosis among ED patients with an initial clinical impression of 'DVT versus cellulitis' who underwent duplex scanning.

METHODS

In this historical cohort study, patients with a final diagnosis of DVT (positive duplex) were compared on several baseline variables with patients with a final diagnosis of cellulitis (negative duplex and antibiotics prescribed) .

RESULTS

One hundred-nine of 542 ED patients referred for a duplex scan were initially diagnosed as 'DVT versus cellulitis', 17% of whom had DVT confirmed by a positive duplex scan. Comparing patients with DVT versus those with cellulitis, 0% versus 15.3% had rigors (P=0.06); 0% versus 8.3% had distinct margins of erythema (P<0.01); 5.3% versus 22.2% were currently on antibiotics (P=0.09); and 50% versus 21.3% had an elevated white blood cell count (P=0.04).

CONCLUSION

There are differences in a number of baseline characteristics of 'DVT versus cellulitis' patients who went on to have either positive or negative duplex scans, some of which were statistically significant despite the limited sample size. These findings should be confirmed prospectively in a larger study sample since they may have the potential to aid in the clinical differentiation between DVT and cellulitis.

Venous thromboembolism prophylaxis for hospitalized medical patients, current status and strategies to improve

Venous thromboembolism (VTE), comprising life-threatening pulmonary embolism (PE) and its precursor deep-vein thrombosis (DVT), is commonly encountered problem. Although most patients survive DVT, they often develop serious and costly long-term complications. Both unfractionated heparin and low molecular weight heparins significantly reduce the incidence of VTE and its associated complications. Despite the evidence demonstrating significant benefit of VTE prophylaxis in acutely ill medical patients, several registries have shown significant underutilization. This underutilization indicates the need for educational and audit programs in order to increase the number of medical patients receiving appropriate prophylaxis. Many health advocacy groups and policy makers are paying more attention to VTE prophylaxis; the National Quality Forum and the Joint Commission recently endorsed strict VTE risk assessment evaluation for each patient upon admission and regularly thereafter. In the article, all major studies addressing this issue in medical patients have been reviewed from the PubMed. The current status of VTE prophylaxis in hospitalized medical patients is addressed and some improvement strategies are discussed.

Improving adherence to venous thromoembolism prophylaxis using multiple interventions

OBJECTIVE:

In hospital, deep vein thrombosis (DVT) increases the morbidity and mortality in patients with acute medical illness. DVT prophylaxis is well known to be effective in preventing venous thromoembolism (VTE). However, its use remains suboptimal. The objective of this study was to evaluate the impact of quality improvement project on adherence with VTE prophylaxis guidelines and on the incidence of hospital-acquired VTEs in medical patients.

METHODS:

The study was conducted at Saudi Aramco Medical Services Organization from June 2008 to August 2009. Quality improvement strategies included education of physicians, the development of a protocol, and weekly monitoring of compliance with the recommendations for VTE prophylaxis as included in the multidisciplinary rounds. A feedback was provided whenever a deviation from the protocol occurs.

RESULTS:

During the study period, a total of 560 general internal medicine patients met the criteria for VTE prophylaxis. Of those, 513 (91%) patients actually received the recommended VTE prophylaxis. The weekly compliance rate in the initial stage of the intervention was 63% (14 of 22) and increased to an overall rate of 100% (39 of 39) (P = 0.002). Hospital-acquired DVT rate was 0.8 per 1000 discharges in the preintervention period and 0.5 per 1000 discharges in the postintervention period, P = 0.51. However, there was a significant increase in the time-free period of the VTE and we had 11 months with no single DVT.

CONCLUSION:

In this study, the use of multiple interventions increased VTE prophylaxis compliance rate.

Extended venous thromboembolism prophylaxis for high-risk patients undergoing surgery for malignancy

Background

In surgical patients with known malignancy, the odds ratio for an episode of a venous thromboembolism is approximately 6.5 compared to a group of patients without malignancy undergoing the same procedure [Heit et al.: Arch Intern Med 2000;160:809–815].

Case Report

We present a case of a 46-year-old Caucasian male with a history of adenocarcinoma of the rectum. The patient received neoadjuvant treatment prior to low anterior resection with diverting colostomy. He received short-term prophylaxis for venous thrombosis, but unfortunately developed a blood clot in a lower extremity several weeks after surgery.

Conclusion

There is a well-defined role in carefully selected patients for the use of extended prophylaxis to prevent venous thromboembolic complications following cancer surgery.

A cross-sectional study to detect the prevalence of hyperhomocysteinemia in cases of deep vein thrombosis

Hyperhomocysteinemia is a known risk factor for the development of deep vein thrombosis (DVT). Various studies have been conducted in the western countries to know the prevalence of hyperhomocysteinemia in patients with DVT and in general population. There is no documented literature of the prevalence of hyperhomocysteinemia in Indian population. Thus the aim of this study was to determine the prevalence of hyperhomocysteinemia in cases of DVT in our population. To evaluate the prevalence of hyperhomocysteinemia, a prospective cross sectional study done on a total of 70 patients admitted in KLES Dr Prabhakar Kore hospital, Belgaum, India. DVT was confirmed by Doppler examination. Serum homocysteine was measured and the data analysed. Statistical significance was calculated using chi square test. A total of 70 patients were studied of which 53 were males and 17 were females. The prevalence of hyperhomocysteinemia among the cases of DVT was 31.428%.The prevalence among males was 35.85% and among females was 17.64%.There was statistically significant association between hyperhomocysteinemia and presence of ischaemic heart disease with a p value of 0.005 on chi square analysis. The prevalence of hyperhomocysteinemia in cases of deep vein thrombosis in our population was 31.428%. There was a statistically significant association between hyperhomocysteinemia and ischaemic heart disease.

A Case with Upper Extremity Deep Vein Thrombosis after in vitro Fertilization

Deep vein thrombosis (DVT) is a predisposing condition of pulmonary embolism which can be fatal. Usually, DVT is found in the lower extremities. However, DVT can be occurred in the upper extremities. The usual predisposing conditions of the upper extremity DVT include insertion of central venous catheters and pacemaker wires. Here, we report a case of upper extremity DVT after in vitro fertilization and embryo transfer. The patient was successfully controlled with subcutaneous administration of low molecular weight heparin.

Venous thromboembolic disease in colorectal patients

Venous thromboembolic disease, which includes deep vein thromboses as well as pulmonary emboli, can be a significant complication in the postoperative patient. In particular, colorectal patients often carry a higher risk for venous thromboembolism when compared with patients undergoing other operative procedures. Features unique to colorectal patients are the high incidence of inflammatory bowel disease or malignancy. Typically, these patients will undergo lengthy pelvic procedures, which also contribute to a cumulative risk of venous thrombosis. It is critical that all patients and the proposed operative procedure are appropriately risk stratified. Risk stratification allows for easier implementation of an appropriate prophylactic strategy. There are a wide range of safe and effective mechanical and pharmacologic measures available. The authors provide very specific recommendations, but note that clinical judgment plays a significant role.

Recent advances in the management of venous thromboembolism

Venous thromboembolism (VTE) is a spectrum of diseases that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Anticoagulant treatment is the mainstay of therapy for VTE. Unfractionated heparin (UFH) or low molecular weight heparin (LMWH) followed by vitamin K antagonists have been the treatment of choice for most patients with VTE, with the aim to prevent thrombus extension or embolization and recurrent VTE. Fondaparinux, a selective, indirect, parenteral factor Xa inhibitor, is now also approved for the initial treatment of VTE and represents an important alternative to UFH or LMWH. Secondary prevention of VTE with vitamin K antagonists is usually prescribed for a minimum of three months, with the duration of treatment based on the presence or absence of major identifiable risk factors for the index event. Patients with permanent risk factors or patients with recurrent DVT or PE require life long secondary prevention. Over the last years, new oral anticoagulant agents have been developed and are now undergoing extensive clinical evaluation in several settings, including the treatment of VTE. New oral anticoagulants include selective, direct thrombin inhibitors, such as dabigatran etexilate, and selective, direct factor Xa inhibitos, such as rivaroxaban, apixaban or edoxaban. All these drugs are admistered at fixed daily doses and do not require laboratory monitoring. The positive results of the first completed clinical trials suggest that a new era in the management of VTE is about to begin.

A re-appraisal of warfarin control in the treatment of deep vein thrombosis and / or pulmonary embolism

BACKGROUND

Warfarin is commonly used for management of deep vein thrombosis (DVT) and pulmonary embolism (PE), controlling therapy by means of the International Normalized Ratio (INR).

OBJECTIVES

To identify differences in INR results between patients with thromboembolic and haemorrhagic complications and controls.

METHODS

Two nested case-control studies from within a controlled trial of the duration of warfarin therapy (47 thrombotic and 16 haemorrhagic complications).

RESULTS

Patients whose thromboembolism failed to resolve during treatment or recurred during or after treatment had non-significantly lower INR levels than matched controls (geometric mean 2.2 versus 2.3, p = 0.12). Patients with haemorrhage also had not statistically significant lower INR levels than their matched controls (2.1 versus 2.3, p = 0.22). The variability of INR levels was similar in both case groups and controls. The mean percentage of INR levels in the therapeutic range 2 - 3 was almost identical in thrombotic cases and controls (56.5% versus 56.1%). Compared to the haemorrhagic group, better control was achieved in controls (61.5% versus 43.0%, p=0.01), but controls had slightly more INR values above the therapeutic range (12.1% versus 10.5%, p = 0.74) whilst haemorrhagic cases had more INR values below the therapeutic range (46.6% versus 26.4%, p = 0.03).

CONCLUSION

In this study, higher INR levels were not associated with haemorrhage suggesting that, for patients being treated for DVT/PE, a modest increase in the target therapeutic range could be considered.

Inferior vena cava thrombosis in young adults--a review of two cases

We present two cases of clinically extensive bilateral DVTs associated with inferior vena caval thrombosis. Young patients presenting with symptoms of DVT should be investigated not only to establish any thrombophilic pre-disposition, but to ascertain the proximal extent of thrombus which may itself influence treatment.

Endovascular treatment for iliac vein compression syndrome: a comparison between the presence and absence of secondary thrombosis

Objective

To evaluate the value of early identification and endovascular treatment of iliac vein compression syndrome (IVCS), with or without deep vein thrombosis (DVT).

Materials and Methods

Three groups of patients, IVCS without DVT (group 1, n = 39), IVCS with fresh thrombosis (group 2, n = 52) and IVCS with non-fresh thrombosis (group 3, n = 34) were detected by Doppler ultrasonography, magnetic resonance venography, computed tomography or venography. The fresh venous thrombosis were treated by aspiration and thrombectomy, whereas the iliac vein compression per se were treated with a self-expandable stent. In cases with fresh thrombus, the inferior vena cava filter was inserted before the thrombosis suction, mechanical thrombus ablation, percutaneous transluminal angioplasty, stenting or transcatheter thrombolysis.

Results

Stenting was performed in 111 patients (38 of 39 group 1 patients and 73 of 86 group 2 or 3 patients). The stenting was tried in one of group 1 and in three of group 2 or 3 patients only to fail. The initial patency rates were 95% (group 1), 89% (group 2) and 65% (group 3), respectively and were significantly different (p = 0.001). Further, the six month patency rates were 93% (group 1), 83% (group 2) and 50% (group 3), respectively, and were similarly significantly different (p = 0.001). Both the initial and six month patency rates in the IVCS patients (without thrombosis or with fresh thrombosis), were significantly greater than the patency rates of IVCS patients with non-fresh thrombosis.

Conclusion

From the cases examined, the study suggests that endovascular treatment of IVCS, with or without thrombosis, is effective.

Perioperative pulmonary embolism

Pulmonary thromboembolism (PTE) is a perioperative complication that requires prompt diagnosis and treatment to minimize mortality. Detection of deep vein thrombosis (DVT) suggests the presence of PTE. The clinical presentation of PTE is mainly hemodynamic and gas exchange abnormalities. Diagnostic tools include ventilation/perfusion scan, pulmonary angiography, spiral CT, and echocardiography. Therapeutic options include hemodynamic support with inotropics, anticoagulation, systemic thrombolysis, surgical embolectomy and an inferior vena cava filter. DVT prophylaxis should be considered in all operative patients with high risk. Anesthesiologists should consider the appropriate anticoagulant management before and after surgery to optimize anesthetic choices.

Lethal pulmonary thromboembolism misdiagnosed as pneumonia: A case report

Although pulmonary thromboembolism (PTE) is not rare, unfortunately for anesthesiologists, the signs and symptoms of PTE are unreliable and nonspecific. PTE is a potentially lethal condition without an accurate diagnosis and prompt treatment. We report a case of PTE misdiagnosed as simple pneumonia. A 60-year-old female, not receiving prophylactic anticoagulant therapy, underwent elective surgery for a left proximal tibial fracture. During induction of general anesthesia, a temporary bronchospasm occurred and subsided quickly. Because vital signs were stable and patient monitoring was normal, we did not identify a serious hypercarbic condition. After surgery, a massive hemoptysis occurred and the patient expired due to cardiopulmonary collapse. According to autopsy, the cause of death was a PTE originating in deep vein thrombosis.

Utility of manjisthadi lepa in soft tissue inflammation

In the context of Bhagna (fractures), Chikitsa sthana of Sushruta Samhita, a classical treatise of Ayurveda the entire protocol for management of different kinds of injuries is elaborated. Manjisthadi Lepa according to the mode of application either Ushna or Sita can facilitate the healing of soft tissue injury like Deep vein thrombosis, Cellutitis, Synovitis and Thrombophlebitis. It is proposed that symptomatic relief can be achieved with Sheeta Lepa in Acute conditions of Abhighata (injury)were Rakta and Pitta are mainly vitiated and UshnaLepa in Chronic conditions were Vata Kapha are vitiated.

Venous thromboembolism in acute spinal cord injury patients

BACKGROUND

The western literature on deep vein thrombosis (DVT) and pulmonary embolism (PE) following spinal cord injury (SCI) report an alarmingly high incidence, necessitating thromboprophylaxis. The literature on incidence from the Asian subcontinent is scanty and from India is almost nonexistent.

MATERIALS AND METHODS

Seventy hospitalized acute SCI patients presenting within five days of the injury were included in the present analysis. Forty-two cases were subjected to color Doppler studies and 28 cases had to be subjected to venography due to lack of facility at some point of time. The clinical course of the patients was closely observed during the period of hospitalization. All except 14 were managed nonoperatively. Thromboprophylaxis was not given to any patient at any stage; however, treatment was instituted in those showing the features of DVT on investigations.

RESULTS

Twelve patients died during the period of hospitalization. Deep vein thrombosis could be detected in seven patients only, three in the proximal and four in the distal segment of the lower limb and of these three died. Based on the clinical course and positive investigation report in favor of DVT, we presumed that the cause of death in these three patients was pulmonary embolism. In the other nine, in the absence of an autopsy report, the cause of deaths was considered as pulmonary infection, asphyxia, diaphragmatic paralysis, hematemesis, cervicomedullary paralysis etc. Clinical features to diagnose DVT were of little help.

CONCLUSIONS

There is a much lower incidence (10%) of DVT and PE following spinal cord injury (SCI) in India than what is reported from the western countries. Higher age group and quadriplegia were the only factors which could be correlated. Deep vein thrombosis extending proximal to the knee was significant. In the absence of autopsy and other screening tests like D-dimer test or 125I fibrogen uptake study, the true incidence of venous thromboembolism remains uncertain. Noninvasive screening of all patients for the detection of deep vein thrombosis in SCI patients is strongly recommended.

Current Clinical Practice: Low-Molecular-Weight Heparins in The Prophylaxis and Treatment of Thrombo-Embolic Disease

Low-Molecular-Weight Heparin (LMWH) fractions are prepared from standard unfractionated heparin (UFH) and are thus similar to it in many aspects. The major advantages of LMWH are improved efficacy and safety, longer half-life and reduced need for laboratory monitoring. In addition, the dangers of UFH administered by continuous infusion in the hospital setting are often not fully appreciated and the necessary monitoring and dosage adjustment poorly carried out resulting in inadequate doses being given. LMWHs are the drug of choice in many clinical situations. Four LMWHs are now licensed in the UK for prophylaxis of venous thrombo-embolism during or after surgery (Certoparin, Dalteparin [Fragmin], Enoxaparin [Lovenox/Clexane] and Tinzaparin [Inno-hep]; a fifth is licensed but not currently available in the UK. Dalteparin, Enoxaparin and Tinzaparin are licensed for the treatment of Deep Vein Thrombosis (DVT), and Tinzaparin additionally for the treatment of Pulmonary Embolism (PE), but so far none is licensed for use in pregnancy or paediatrics.