Postthrombotic syndrome

Despite considerable progress in the diagnosis and treatment of deep vein thrombosis (DVT) of the lower extremities, one of every three patients will develop postthrombotic sequelae within 2 years; these sequelae are severe in approximately 20% of cases and produce considerable socioeconomic consequences. Among factors potentially related to the development of the postthrombotic syndrome (PTS) are older age, obesity, insufficient oral anticoagulant therapy, and recurrent ipsilateral thrombosis. Whether the extent and location of the initial thrombosis are associated with the development of PTS is controversial. Based on recent findings, the lack of vein recanalization within the first 6 months appears to be an important predictor of PTS, whereas the development of transpopliteal venous reflux is not. The diagnosis of PTS can be made on clinical grounds for patients with a history of DVT. The combination of a standardized clinical evaluation with the results of compression ultrasonography and Doppler ultrasound helps diagnose or exclude a previous proximal vein thrombosis. According to the results of recent clinical studies, the prompt administration of adequate compression elastic stockings in patients with symptomatic DVT has the potential to reduce the frequency of late PTS development by half. The management of this condition is demanding and often frustrating. However, when carefully supervised and instructed to wear proper elastic stockings, more than 50% of patients will either remain stable or improve during long-term follow-up. Clinical presentation helps predict the prognosis; the outcome of patients who refer with initially severe manifestations is more favorable than that of patients whose symptoms deteriorate progressively over time.     

Postthrombotic syndrome in children

The postthrombotic syndrome (PTS) is a clinical condition of limb pain along with physical findings that range from swelling to stasis ulcers following one or more episodes of deep vein thrombosis (DVT). While venous thromboembolism has recently gained increased recognition in children, the sequelae of limb thrombi are being recognized in a substantial proportion of affected children, and with varying degrees of severity. PTS is caused by both obstructed as well as refluxed venous blood flow, with combined effects of obstruction and reflux resulting in earlier, and more extensive symptoms. PTS can be diagnosed using an evaluation tool adapted from an international adult scale. Certain risk factors predispose children to PTS including elevations in factor VIII activity and D-dimer, clot occlusiveness, clot persistence, number of venous segments involved and duration of observation following DVT. Optimal prevention and treatment have not yet been determined, although antithrombotic therapy to facilitate rapid clot resolution, elevation, compression, moderate exercise and achievement of optimal body weight are likely to improve outcome.     

Travellers' thrombosis and economy class syndrome: incidence,aetiology and prevention

In this article we review economy class syndrome or travellers' thrombosis as it should be more appropriately described. We review the evidence for and against the existence of this condition. Much of the evidence included in this article has been justifiably criticised but it is the best evidence available to date. We conclude that there is a probable link between thrombosis and long distance travel. However this association is confined to individuals with additional risk factors and fatal pulmonary embolus is very rare. The probable aetiology of this association is prolonged immobilisation in cramped conditions. Other factors are likely to play a minor role. When considering preventative measures, for the majority of individuals the risk is very small. Simple advise can be given with no requirement for additional intervention. Compression stockings should be considered for high-risk patients. In individuals planning prolonged travel with multiple risk factors for thrombosis low dose low molecular weight heparin should be considered. The criteria for defining risk groups remains unclear and we outline our recommendations. There is conflicting evidence with regard to the use of aspirin but considering the latest evidence we do not recommend it.     

Travellers’ thrombosis and economy class syndrome: incidence,aetiology and prevention

Summary In this article we review economy class syndrome or travellers’ thrombosis as it should be more appropriately described. We review the evidence for and against the existence of this condition. Much of the evidence included in this article has been justifiably criticised but it is the best evidence available to date. We conclude that there is a probable link between thrombosis and long distance travel. However this association is confined to individuals with additional risk factors and fatal pulmonary embolus is very rare. The probable aetiology of this association is prolonged immobilisation in cramped conditions. Other factors are likely to play a minor role. When considering preventative measures, for the majority of individuals the risk is very small. Simple advise can be given with no requirement for additional intervention. Compression stockings should be considered for high‐risk patients. In individuals planning prolonged travel with multiple risk factors for thrombosis low dose low molecular weight heparin should be considered. The criteria for defining risk groups remains unclear and we outline our recommendations. There is conflicting evidence with regard to the use of aspirin but considering the latest evidence we do not recommend it.     

Postthrombotic syndrome after hip or knee arthroplasty: a cross-sectional study

BACKGROUND: Although the incidence of the postthrombotic syndrome (PTS) has been addressed in patients with symptomatic deep vein thrombosis (DVT), less information is available on the incidence in patients who develop asymptomatic DVT after major hip or knee arthroplasty. OBJECTIVES: To determine whether symptomatic PTS occurs more frequently in patients who develop DVT after hip or knee arthroplasty than those who are free of DVT and to provide an estimate of the incidence of PTS in patients who had undergone major hip or knee arthroplasty and had proximal DVT, distal (calf) DVT, or no DVT. DESIGN AND SETTING: A cross-sectional study conducted at the Hamilton Health Sciences Corporation, Hamilton, Ontario, and the Academic Medical Centre, Amsterdam, the Netherlands. SUBJECTS AND METHODS: Two hundred fifty-five subjects who had undergone major hip or knee arthroplasty 2 to 7 years previously and had routine predischarge venography showing proximal DVT (n = 25), distal DVT (n = 66), or no DVT (n = 164) were enrolled from March 1993 through December 1998. The presence of symptomatic PTS confirmed by the presence of objectively confirmed venous valvular incompetence was ascertained. RESULTS: The rates of PTS were low and not significantly different among the 3 subgroups: 1 (4.0%, 95% confidence interval [CI] = 0.1%-20.4%) of 25 patients with proximal DVT, 4 (6.1%, 95% CI = 1.7%-14.8%) of 66 patients with distal DVT, and 7 (4.3%, 95% CI = 1.7%-8.6%) of 164 patients with no DVT. CONCLUSIONS: Symptomatic PTS is an uncommon complaint after major hip or knee arthroplasty. Patients who develop postoperative proximal or distal DVT and who receive 6 to 12 weeks of anticoagulant therapy are not predisposed to PTS.     

The postphlebitic syndrome. Pathophysiology, prevention and management

Chronic deep venous insufficiency of the lower extremity, usually the result of antecedent venous thrombosis, represents a problem of considerable magnitude for both patient and physician. While the fully developed postphlebitic syndrome is immediately recognized by the most inexperienced medical student, the exact underlying pathogenetic mechanisms remain controversial, available therapeutic options are limited, and the value of surgery is uncertain.     

Postthrombotic syndrome complicating a case of May-Thurner syndrome despite endovascular therapy: case report and review

External compression of the left iliac vein is a common finding in the general population. It may predispose patients to the development of deep vein thrombosis (DVT) of the left leg and may also lead to a more complicated course than in other types of DVT. This entity has been well-described by other authors. External compression of the left iliac vein should be suspected in cases of complicated DVT or in cases of DVT with no predisposing factors. We describe a case of May-Thurner syndrome that involved a complicated treatment course, and a review of current options for diagnosis and therapy.     

AIDS in India: incidence, prevalence, and prevention,

With 3.7 million human immunodeficiency virus (HIV)-positive in India, many predict that this nation of 1 billion people will soon see infection rates soar if successful prevention programs are not implemented. The majority of infections occur through sexual contact, with blood banks, intravenous drug use, and mother-to-child transmission also spreading the virus. Those in India who are HIV-positive are highly stigmatized and often have difficulty finding physicians who are willing to treat them. Nongovernment organizations provide various services, including physician referrals and legal help for those who are HIV-positive and programs to raise awareness and education. Although the Government of India has designed various programs to help prevent the further spread of HIV, lack of funding and poor regulatory systems are further barriers to their implementation. India is also at war with poverty, illiteracy, and gender inequality, all of which make the fight against acquired immune deficiency syndrome (AIDS) a more difficult battle. India's AIDS control strategy must take these issues into account in order to design successful programs to prevent infection rates from multiplying rapidly.     

Radial artery spasm during transradial cardiac catheterization and percutaneous coronary intervention: incidence,predisposing factors,prevention, and management

Transradial cardiac catheterization and percutaneous coronary intervention are increasingly being performed worldwide in elective and emergency procedures, with many centers adopting the transradial route as their first choice of arterial access. One of the most common complications encountered during transradial procedures is radial artery spasm. This article reviews the current literature on the incidence, predisposing factors, preventive, and treatment measures for radial artery spasm.     

Red man syndrome: incidence, etiology, and prophylaxis

The red man syndrome (RMS) is the most common toxicity of vancomycin therapy. A prospective trial to investigate the frequency, causation, and possible prophylaxis of this syndrome was conducted. Thirty-three patients were observed during their first two doses (1 g/60 min) of vancomycin. Before dose 1, they were randomized to double-blinded pretreatment with either diphenhydramine (50 mg) or placebo. Patients were examined frequently, and histamine levels were obtained at 0, 30, and 60 min during dose 1. Those with first-dose reactions were rerandomized for pretreatment and had histamine levels drawn during a second infusion. Of 17 patients with placebo pretreatment, 8 (47%) had RMS. None of the 16 pretreated with diphenhydramine had a first-dose reaction (P = .003). Three of the eight first-dose reactors had a second-dose RMS reaction; in one of these three, it was more severe than the dose 1 RMS despite diphenhydramine pretreatment. RMS events were associated with elevated plasma histamine; this was especially true of severe reactions.     

Post-dural-puncture headache: Characteristics, management, and prevention

Post-dural-puncture headache is a common complication after both diagnostic and therapeutic procedures. Prompt recognition of the clinical syndrome, followed by supportive and corrective actions, can decrease the morbidity in those afflicted. The most useful preventive measure during dural puncture in adult patients is the use of smaller cannulae with the bevel aimed parallel to the long axis of the spine.     

Dog bites: Bacteriology, management, and prevention

Dog bites are among the most frequent causes of nonfatal injuries in the United States. Most dog bites involve children and young adults. Infected wounds are polymicrobial in nature; the most prevalent organisms are Pasteurella, streptococci, staphylococci, and Fusobacterium, Bacteroides, and Porphyromonas species. Musculoskeletal and neurovascular injuries, as well as systemic infections, can be complications of dog-bite wounds. Treatment includes thorough cleansing of the wound, with copious irrigation. Abscesses, when present, should undergo incision and drainage. Suitable antibiotics for the initial empiric and expectant therapy include amoxicillin-potassium clavulanate, a penicillin with a first generation cephalosporin, or clindamycin and a fluoroquinolone (eg, for patients allergic to penicillins). Preventive strategies should be aimed at public awareness of basic animal safety and responsible pet ownership.     

Hemorrhoidectomy failures: causes,prevention and management

Summary Despite the accessibility of the anorectum, 20 per cent of hemorrhoidectomies fail to attain satisfactory anatomic and functional end results. Late disabling complications of hemorrhoidectomy include anal stenosis, anal fissure,re-formed hemorrhoids, prolapse of rectal mucosa, excessive tags and, occasionally, suture granulomas and perianal epidural cysts. The causes, prevention and management of such lesions have been discussed. Read at the meeting of the American Proctologic Society, New Orleans, Louisiana, April 17 to 19, 1967.     

Hypoplastic myelodysplastic syndrome: incidence,morphology, cytogenetics,and prognosis

Summary The present study, based upon the retrospective evaluation of 352 patients with primary myelodysplastic syndrome (pMDS), revealed hypoplastic MDS in 42 patients (11.9%). Median age is similar in hypo- and normo-/hypercellular MDS (72.6 versus 70.7 versus 72.4 years). Hypoplastic MDS occurred significantly more often in women compared with normo- and hypercellular MDS. Sequential biopsies were performed in 14 patients, showing a persistence of hypoplasia over a period of up to 43 months. The proportion of patients showing mesenchymal reaction, especially an increase of mast cells, was significantly higher in hypoplastic MDS, whereas dysplastic features of hematopoiesis occurred less frequently and were of lower grade in comparison to normo-/hyperplastic MDS. Among the subgroup with hypoplastic bone marrow, the classification according to FAB criteria revealed 28 patients with RA (66.7%), three with RARS (7.1%), and eight with RAEB (19.0%), as well as one patient each with RAEB-T and CMMol (2.4% each), and one case which had to be reckoned among the category of unclassifiable MDS (2.4%). Median survival was 21.8 months for hypoplastic MDS, 26.9 months for normoplastic MDS, and 14.2 months for hyperplastic MDS. During follow-up, 14 patients (33%) with hypoplastic MDS developed acute nonlymphatic leukemia. Although not a constant finding, karyotype abnormalities involving particularly chromosome 7 seem to be associated with hypoplastic MDS. The results confirm the existence of a hypoplastic variant of MDS which seems to more frequently affect female patients, and which requires bone marrow biopsy for its accurate diagnosis.Supported by grants from theDeutsche Krebshilfe, Bonn, Germany