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Retinal vein occlusion is a frequent cause of visual loss for which few effective therapies are available. Anticoagulation with low molecular weight heparin might be of value in its treatment. We conducted a systematic review and meta analysis of randomized trials evaluating the effect of low molecular weight heparin in patients with retinal vein occlusion. Data sources included MEDLINE, EMBASE, HealthSTAR, the Cochrane Library, Lilacs, the Investigative Ophthalmology and Visual Science database and gray literature. Main outcome was the mean difference between the visual acuity measured at baseline and at six months expressed in the logMAR scale. Secondary outcome was a composite of any adverse ocular outcome including: worsening of visual acuity, visual fields or fluorescein angiography, or development of iris neovascularization, any neovascularization or neovascular glaucoma. Subgroup analyses for branch versus central retinal vein occlusion were conducted. We identified 1,084 references of which 3 studies comparing low molecular weight heparin with aspirin (229 evaluable patients) were included. Overall, the pooled mean visual acuity difference was -0.23 logMAR (95% CI -0.38, -0.09; P=0.002) in favor of low molecular weight heparin. Low molecular weight heparin was associated with a 78% risk reduction for developing any adverse ocular outcome (pooled RR 0.22; 95% CI 0.10, 0.46; P<0.001). In subgroup analyses benefits seemed lower in branch retinal vein occlusion. No increased vitreous hemorrhages were observed. In patients with retinal vein occlusion treatment with low molecular weight heparin seems to be associated with improvement in the visual acuity and less adverse ocular outcomes. These benefits might differ in patients with central as opposed to branch retinal vein occlusion. Further studies are required to confirm these findings and clarify its benefits in specific subgroups of patients before definitive recommendations can be made.

Background and Objectives: Outpatient treatment of deep vein thrombosis (DVT) has become a common practice. However, in some centers cancer patients with DVT are excluded from home treatment because they have a higher risk of both bleeding and recurrent DVT. We performed a retrospective review of clinical practice patterns to assess the rate of cancer patients who were deemed eligible for outpatient treatment of their DVT., Design and Methods: The charts of patients from the Thrombosis Units at two tertiary care institutions were reviewed. All patients with objectively documented DVT at our institutions are treated through the Thrombosis Units. Patients are treated as outpatients unless they require admission for other medical problems, are actively bleeding or have pain that requires parenteral narcotics. Outpatient treatment was with low molecular weight heparin (LMWH) followed by warfarin or with LMWH alone., Results: Over a period of almost four years there were 321 patients with cancer, 167 (52.5%) of whom had metastatic disease. The most frequent sites of cancer were genitourinary tract (21.2%), breast (20.5%), and gastrointestinal system (18.4%). Treatment with LMWH and warfarin was prescribed to 67% and LMWH alone to 33%. One hundred and ninety-seven patients (61.4%) were entirely treated at home. There were no differences between patients treated at home and hospitalized patients with regard to gender, mean age, site of cancer, presence of metastases, and treatment. After 3 months, recurrent thromboembolism occurred in 6.1% of patients treated at home and in 4.8% of hospitalized patients (p=0.64), and major bleeding in 1.0% and 4.8%, respectively (p=0.03). One hundred and sixty patients died (49.8%), 100 (50.7%) in the home treatment group and 60 (48.4%) of the hospitalized patients., Interpretation and Conclusions: Home treatment of DVT in cancer patients is safe and feasible in almost two-thirds of cases. Outpatient management of antithrombotic treatment did not increase the rate of adverse events, even if the stage of the disease was advanced.

Background and Objectives: Excessive anticoagulation is a frequent complication of anticoagulant therapy. The risk of hemorrhage approximately doubles for each one point increase in the International Normalized Ratio (INR) above 3.0. Reducing a prolonged INR to within the desired therapeutic range requires that oral anticoagulants be withheld. In addition, vitamin K may be administered. Since this latter treatment can produce rapid reductions in the INR, it must be carefully tailored to meet individual needs, balancing the risk of bleeding against the potential risk of causing thromboembolism., Methods: To review available literature on the management of coumarin-associated coagulopathy in asymptomatic patients, a Medline search was carried out and papers published in English from 1966 and 2003 were identified. All available information on the management of asymptomatic patients presenting with coumarin-associated coagulopathy was analyzed., Results: Following the results of clinical studies that only used an elevated INR as a surrogate end-point for the risk of bleeding, low dose oral vitamin K appears as the preferable strategy for rapidly restoring therapeutic INR levels in asymptomatic patients who present with an excessively prolonged INR due to warfarin therapy. For the treatment of patients with asymptomatic acenocoumarol-induced coagulopathy, vitamin K does not add any benefit to the strategy of simply withholding oral anticoagulant treatment., Interpretation and Conclusions: Large randomized trials using clinical end-points are now required to provide evidence-based treatment recommendations for patients with coumarin-associated coagulopathy.

Background and Objectives: The risk of venous thromboembolism in medical patients is comparable to the risk in general surgical patients. Thromboprophylaxis is recommended for specific medical patients, but its use in clinical practice is unknown., Design and Methods: We conducted a retrospective review of the charts of consecutive patients discharged from 2 departments of Internal Medicine, one in the teaching hospital of Varese and one in the non-teaching hospital of Angera, Italy, from October to December 2000. We selected the charts of patients with clinical conditions at increased risk of venous thromboembolism requiring thromboprophylaxis according to consensus statements. The use of antithrombotic drugs and contraindications to prophylaxis were documented., Results: We screened a total of 516 charts, 265 in Varese and 251 in Angera and we identified 165 patients (103 and 62, respectively) at risk of venous thromboembolism because of malignancy (53), heart failure (34), stroke (33), acute infections (23), acute respiratory failure (18), acute rheumatic disorders (3), and inflammatory bowel disease (1). Forty-two patients had contraindications to antithrombotic drugs and 11 were already on long-term oral anticoagulant treatment. Among the 112 remaining patients, prophylaxis was prescribed to 52 patients (46.4%), 35 of 60 in Varese (58.3%) and 17 of 52 in Angera (32.7%, p=0.0067). Patients with stroke and heart failure were significantly more likely to receive thromboprophylaxis than other groups of patients., Interpretation and Conclusions: Prophylaxis of venous thromboembolism is underused in medical patients and the proportion of patients receiving antithrombotic drugs varies with the medical condition which precipitated hospital admission. The low rate of usage of prophylaxis suggests that preventable cases of thromboembolism are occurring and that better education of physicians is required to increase the usage of thromboprophylaxis.

Background and Objectives: Patients with deep vein thrombosis are selected for home treatment on the basis of their clinical and social condition. Cancer is frequently associated with venous thromboembolism and is often considered an exclusion criterion for outpatient treatment. We investigated the impact of cancer on the outpatient management of venous thrombosis., Design and Methods: We performed a prospective, cohort study on consecutive patients with objectively documented deep vein thrombosis. All were assessed for home treatment. Hospital admission was recommended in the presence of common exclusion criteria. All patients were treated with low molecular weight heparin and warfarin. Information on previous, active, or suspected cancer was collected. Recurrent thrombosis, bleeding and mortality were documented at a 3-month follow-up., Results: One hundred patients were included; 72 were entirely treated at home (mean age: 61.2 years). There were 22 patients with known cancer: 12 (55%) were managed as outpatients (16.5% of the outpatient population) and 10 were hospitalized (36% of the inpatient population), 6 because of a poor clinical condition, 4 because further investigation of their malignancy was required. The presence of cancer and the likelihood of poor compliance were the most frequent reasons cited for in-hospital treatment. Overall, event rates at 3 months were comparable to those reported in previous studies in the outpatient population and slightly higher in the inpatient population (recurrent thrombosis 1.5% and 7%; bleeding 5.5% and 10.7%; mortality 4% and 18%, respectively)., Interpretation and Conclusions: Cancer was the most common reason cited for in-hospital treatment. Nevertheless, more than half of the patients with known cancer were safely and effectively treated at home.