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Background Recent publications have increasingly demonstrated a link between superficial-vein thrombosis (SVT) and deep-vein thrombosis (DVT) in the adult population and have led to changes in SVT treatment considerations. A similar relationship between SVT and DVT in pediatric populations, however, is not currently well established. Objectives We sought to evaluate the temporal and anatomic relationship between SVT and DVT among pediatric inpatients in order to determine to what degree SVT is associated with DVT. Methods We first retrospectively reviewed our institution's local prospective hospital-acquired VTE (HA-VTE) registry to identify all children (age 0–21 years, inclusive) admitted to Children's Hospital Colorado for more than 48 h between January 2012 and September 2017 who developed a DVT while hospitalized. We then reviewed each patient's electronic health record for evidence of SVT to identify SVT + DVT cases. Afterwards, we utilized a list of ICD codes to identify all patients during this time frame who developed an SVT and removed patients whom we previously identified as SVT + DVT cases to obtain the number of patients with isolated SVT. Results Of 59,910 patients admitted during the study period, 438 (0.7%) developed a thrombosis while hospitalized - 197 (0.3%) with isolated SVT, 161 (0.3%) with isolated DVT, and 80 (0.1%) with both SVT + DVT. These 80 SVT + DVT patients represent 33% of the 241 total DVT patients and 29% of the 277 total SVT patients. Of the 12 SVT + DVT patients in whom the SVT was diagnosed before the DVT, the subsequent DVT occurred within a mean of 6.4 (range 1–22) days and at the same anatomic site in 6 (50%). The age breakdown for this cohort was: 0 (0%) 0–1 months, 2 (17%) 1 month-2 years, 3 (25%) 2–12 years, 3 (25%) 12–16 years, and 4 (33%) 16–21 years. Conclusions Our results indicate a temporal and anatomic relationship between SVT and DVT in hospitalized children, particularly those with central venous catheters.

BACKGROUND Concern for deep vein thrombosis (DVT) is the most common reason for emergency department (ED) referral after total joint arthroplasty (TJA) at our institution. We aim to investigate the referral pathway, together with the cost and outcomes associated with patients who access an ED because of concern for DVT after TJA. METHODS We reviewed a consecutive series of all primary hip and knee arthroplasty patients who accessed the ED for concern for DVT within 90 days of surgery over a one-year period. The referral source and costs associated with the ED visit were collected. A propensity-matched control cohort (n = 252) that was not referred to the ED for DVT was used to compare patient-reported outcomes measures. RESULTS In 2018, 108/10,445 primary TJA patients (1.0%) accessed the ED for concern about DVT. The most common reason for accessing the ED was self-referral (69, 64%), followed by orthopaedic on-call referral (21, 19%). Only 15 patients (14%) were found to have ultrasonography evidence of DVT. The mean cost for accessing the ED for DVT for patients with public insurance was $834 (range $394-$2,877). When compared with the control cohort, patients who accessed the ED for DVT had significantly lower postoperative functionality scores (52.5 versus 65.9, P < 0.001). DISCUSSION At our institution, 1% of patients who undergo primary TJA accessed the ED for concern for DVT at substantial cost, with only a small portion testing positive for DVT. Self-referral is by far the most common pathway. Additional investigations will be aimed at determining better pathways for DVT work-up, while ensuring appropriate management.

BACKGROUND COVID-19 is a novel disease caused due to infection from the respiratory pathogen SARS CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) It originated from the city of Wuhan in China in December 2019, and spread to become a pandemic in most of the world The World Health Organization (WHO) declared COVID-19 to be a `public health emergency of international concern' on January 30, 2020 Since then there have been countless cases and associated fatalities In this article we focus on one aspect of the underlying conditions that may prove to be fatal in critically ill patients of COVID-19, namely hypercoagulative states and their associated thrombotic complications We analyse data-driven studies that outline the manifold increase in instances of COVID-19 related thrombotic events and the patient demography that is most affected by it There are several reflections and critical enumerations of the specific clinical features that patients with COVID-19 associated coagulopathies present with We analyse and comment on several anecdotal instances of patients presenting with new-onset symptoms of severe large-vessel ischemic strokes and other coagulopathies We determine how laboratory findings and specific markers can help identify patients most at risk of thrombotic events These events may range from deep vein thromboses to fatal cerebrovascular accidents There is an increased stress on how these coagulation problems may relate to other infectious conditions through presentation with similar markers We also analyse the radiological investigations that such patients yield and identify peculiarities in them There is further emphasis on the importance and efficacy of thrombotic prophylaxis and anticoagulant therapy in the management and reduction of fatalities We also attempt to educate clinicians and intensive care providers regarding better management practices to mitigate fatal outcomes, including both pharmacological and supportive interventions

Summary. Isolated distal deep vein thromboses (IDDVT) represent up to 50 % of legs deep vein thromboses (DVT). However, since their natural history is to date unknown, the need to diagnose and treat them is a matter of debate. The diagnostic strategy based on the assessment of pre-test probability and D-dimer demonstrated a scarse efficiency for IDDVT. The choice between a proximal and a complete ultrasonographic approach should be guided by the clinical context, the local expertise and the patient characteristics. Randomized and observational studies have analyzed the need of therapy and compared different regimens of anticoagulation, with conflicting results. Systematic reviews and meta-analyses tend to support the usefulness of an anticoagulant treatment, even if the optimal dose and duration are not still defined. A careful stratification of the patient’s profile, taking into account risk factors for proximal extension, recurrence and bleeding should address the therapeutic approach, which must always be discussed with an adequately informed patient. Further studies aimed to clarify the natural history of IDDVT, and to assess safety and efficacy of lower intensity and shorter duration protocols are urgently needed.

Recent studies have demonstrated patients with rheumatoid arthritis (RA) have deranged coagulation parameters predisposing them to venous thromboembolisms (VTEs). Therefore, the purpose of this study was to investigate whether patients who have RA undergoing primary TKA have higher rates of (1) VTEs; (2) readmission rates; and (3) costs of care.Patients who have RA undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and comorbidities. Exclusions included patients with a history of VTEs and hypercoagulable states. Primary outcomes analyzed included rates of 90-day VTEs, along with lower extremity deep vein thromboses and pulmonary embolisms, 90-day readmission rates, in addition to day of surgery, and 90-day costs of care. A P-value less than .05 was considered statistically significant.Patients who have RA were found to have significantly higher incidence and odds (OR) of VTEs (1.9 vs 1.3%; OR: 1.51, P.0001), deep vein thromboses (1.6 vs 1.1%; OR: 1.55, P.0001), and pulmonary embolisms (0.4 vs 0.3%; OR: 1.26, P= .0001). Study group patients also had significantly higher incidence and odds of readmissions (21.6 vs 14.1%; OR: 1.67, P.0001) compared to controls. In addition, RA patients incurred significantly higher day of surgery ($12,475.17 vs $11,428.96; P.0001) and 90-day costs of care ($15,937.34 vs $13,678.85; P.0001).After adjusting for age, sex, and comorbidities, the study found patients who have RA undergoing primary TKA had significantly higher rates of VTEs, readmissions, and costs.

Background AngioJet® is an increasingly used method of percutaneous mechanical thrombectomy for the treatment of patients with arterial and venous thromboses. AngioJet® has been shown to cause intravascular haemoylsis universally. We report the case of a 29 year old patient who underwent AngioJet® thrombectomy and post-procedure developed a stage 3 Acute kidney injury (AKI.) requiring renal replacement therapy (RRT), secondary to intravascular haemolysis. We aim to explore the mechanism and potential risk factors associated with developing AKI in these patients and suggest steps to optimise patient management. Case presentation A 29 year old Caucasian male who developed a stage 3 AKI, requiring RRT, following AngioJet® thrombectomy for an occluded femoral vein stent. Urine and laboratory investigations showed evidence of intravascular haemolysis, which was the likely cause of AKI. Following a brief period of RRT he completely recovered renal function. Conclusions AKI is an increasingly recognised complication following AngioJet® thrombectomy, but remains underappreciated in clinical practice. AKI results from intravascular haemolysis caused by the device. Up to 13% of patients require RRT, but overall short-term prognosis is good. Pre-procedural risk factors for the development of AKI include recent major surgery. Sodium bicarbonate should be administered to those who develop renal impairment. Renal biopsy is high risk and does not add to management. Increased clinician awareness and vigilance for AKI post-procedure can allow for early recognition and referral to nephrology services for ongoing management.

Subacute cutaneous lupus erythematosus (SCLE) is a rare cutaneous lupus erythematosus (CLE) subtype manifesting in middle-aged Caucasians with photo-distributed papulosquamous or annular lesions. Drug-induced SCLE (DI-SCLE) forms present in a similar manner but direct oral anticoagulants are rarely implicated. We report an unusual case of SCLE in a 37-year-old African American patient with a history of unprovoked deep vein thromboses (DVT) who presented with new-onset photoprotected polymorphic lesions two months after the initiation of apixaban anticoagulation therapy. Our case demonstrates the heterogeneous nature of SCLE presentation and highlights the possibility of apixaban as a potential causative agent of DI-SCLE in immunogenetically susceptible individuals. Moreover, we hypothesize on the etiopathogenesis of our patient’s atypical presentation.

Background Isolated distal deep vein thromboses (IDDVT) are frequently diagnosed; however, their natural history and real risk of complications are still uncertain. Though treatment is still not well standardized, international guidelines recommend no more than 3 months of anticoagulation therapy. We investigated how Italian clinicians treat IDDVT patients in their real life in our country. Methods Baseline characteristics and clinical history of the patients enrolled in the prospective, observational, multicenter START-Register for a first IDDVT or proximal DVT (PDVT) were analyzed. Results Overall, 412 IDDVT patients were significantly younger, with better renal function, and more frequent major transient risk factors, when compared with 1,173 PDVT patients. The anticoagulation duration was >180 days in 52.7% of IDDVT patients (70.7% in PDVT). During treatment, bleeding occurred in 5.6 and 2.8% patient-years in IDDVT and PDVT, respectively (p = 0082). Bleeding was more frequent in IDDVT than PDVT patients treated with warfarin (6.8 vs. 3.2 patient-years, p = 0.0228, respectively). Thrombotic complications occurred in 1.1 and 2.4% patient-years in IDDVT and PDVT patients, respectively. Analyzing together the two groups, 66.1% of bleeds and 86.1% thrombotic complications occurred after 90 days anticoagulation treatment. Conclusion The large majority of IDDVT patients received anticoagulation for more than 3 months. Most bleeding and thrombotic complications occurred after the first 90 days of anticoagulation therapy. These results indicate that an extended anticoagulation beyond 90 days in IDDVT patients is associated with increased risk of complications. Whether an extended treatment may lower recurrences after anticoagulation withdrawal should be assessed by specifically designed studies.

Summary. Deep vein thromboses lead to post thrombotic syndrome in up to 50% of patients, which entails significant morbidity and socioeconomic costs. Endovascular treatment of iliofemoral deep vein thrombosis aims to reduce the development and the severity of post thrombotic syndrome. This case series of four cases demonstrates that acute and chronic thrombotic stenoses or occlusions can be safely managed by ultrasound guided endovascular treatment minimizing the number of interventions, bleeding risk and radiation exposure.

Acute pancreatitis complicated with pulmonary embolism has been described in literature, however, hyperlipidaemic acute pancreatitis complicated with pulmonary embolism and deep vein thrombosis has rarely been reported. We reported here a rare case of hyperlipidaemic acute pancreatitis. Although he had undergone plasmapheresis and his TG level reduced to normal range with symptoms relieved, he developed pulmonary embolism and multiple deep vein thromboses. The patient was diagnosed early and successfully salvaged by interventional radiology and oral anticoagulants. The patient was a 51-year-old man, he experienced a sudden upper abdomen pain for 24 h before being admitted to a local hospital where diagnosis of acute pancreatitis was made, and he had no relief of the symptoms after treatment. The patient was a non-smoker and did not consume alcohol. He had no history of diabetes, gallstones or cholelithasis. After transferring to our unit, the patient was treated with plasmapheresis along with low molecular weight heparin, insulin, antibiotics and proton pump inhibitors and the abdomen pain was alleviated gradually. However, 8 days after admission, the patient developed a sudden chest tightness and shortness of breath. Examination revealed a high level of D-dimer (16700 ug/L), a computer tomography angiography of chest revealed pulmonary embolism. Urokinase was started intravenously. Pulmonary angiography and venography demonstrated pulmonary embolism and extensive lower limb deep vein thrombosis. Catheter directed thrombolysis and urokinase was initiated through catheter followed by an IVC filter implantation. Dyspnea of the patient got well with thrombolytic treatment and anticoagulation therapy. This is a rare case of hyperlipidaemic acute pancreatitis complicated pulmonary embolism and Deep vein thrombosis even after treated with plasmapheresis. The case we present here will aid in its early recognition, interventional radiology hence the prevention for this rare but catastrophic complication.

Case Presentation A woman in her late 40s with a history of recurrent deep vein thromboses and hypersensitivity pneumonitis (HP) presented to the ED with progressive exertional dyspnea and productive cough. She recently had started oral corticosteroids after HP was confirmed via transbronchial lung cryobiopsy from both the right upper and lower lobes, which showed poorly formed granulomas with mild interstitial and perivascular lymphocytic infiltrates. A causative antigen for her HP was never clearly identified.

Upper extremity deep vein thrombosis (UEDVT) accounts for 5% of all deep vein thromboses (DVTs). UEDVT may be complicated by post thrombotic syndrome and pulmonary embolism, and early recognition and prompt start of anticoagulant treatment are key. Primary UEDVT, also known as Paget-von Schrötter syndrome, is associated with repeated or sudden physical activity of the upper arm and venous outflow obstruction due to anatomical variations. Secondary UEDVT is often associated with malignancy or use of intravenous devices, such as central venous catheters or pacemaker leads. Although the diagnosis and treatment of UEDVT have many similarities with DVT of the lower extremities, knowledge of specific aspects regarding UEDVT is important to guide optimal management. In this review, we will discuss the epidemiology, diagnosis, and treatment of UEDVT based on the current literature.

Introduction For acute venous thromboembolism (VTE), a biomarker with higher specificity than D-dimer would be of great clinical use. Thrombin generation and overall hemostatic potential (OHP) reflect the hemostatic balance by globally assessing multiple coagulation factors and inhibitors. These tests discriminate between healthy controls and patients with a prothrombotic tendency but have yet to be established as clinical biomarkers of VTE. Objective This study compares endogenous thrombin potential (ETP) and OHP to D-dimer and fibrin monomers (FM) in outpatients with suspected VTE. Methods A cross-sectional diagnostic study where 954 patients with suspected pulmonary embolism or deep venous thrombosis were recruited consecutively from the medical emergency department at Karolinska University Hospital. D-dimer, FM, OHP, and ETP were analyzed in a subpopulation of 60 patients with VTE and 98 matched controls without VTE. VTE was verified either by ultrasonography or computed tomography and clinical data were collected from medical records. Results Compared with healthy controls, both VTE and non-VTE patients displayed prothrombotic profiles in OHP and ETP. D-dimer, FM, ETP area under the curve (AUC), and ETP T lag were significantly different between patients with VTE and non-VTE. The largest receiver-operating characteristic AUCs for discrimination between VTE and non-VTE, were found in D-dimer with 0.94, FM 0.77, and ETP AUC 0.65. No useful cutoff could be identified for the ETP or the OHP assay. Conclusion Compared with D-dimer, neither ETP nor OHP were clinically viable biomarkers of acute venous thrombosis. The data indicated that a large portion of the emergency patients with suspected VTE were in a prothrombotic state. Funding agencies: Foundation for Coagulation Research at Karolinska Institutet, the ScandinavianResearch Foundation for Varicose Veins and other Venous Diseases, FoU Region Stockholm, the Swedish Society onThrombosis and Haemostasis with Leo Pharma.

Background: The 2016 Infusion Therapy Standards of Practice no longer require that low pH ( Purpose: To demonstrate the safety and efficacy of intravenous vancomycin administration through a short and long term midline catheter. Methodology: A retrospective chart review was performed on 1086 patients who received intravenous vancomycin through a midline catheter. Results: There were no catheter-associated bloodstream infections and no deep vein thromboses. Phlebitis occurred rarely (0.6%), as did benign infiltrations (1.2%). There were no extravasation injuries. Conclusions: These outcomes summarize more than 5 years of experience administering intravenous vancomycin (4 mg/mL) safely and cost-efficiently through a nontrimmable midline catheter.

Presented herein is a literature review considering the problems of using antithrombotic therapy after venous stenting. Described herein are the literature data according to which the authors give preference to anticoagulant therapy (low-molecular-weight heparins, vitamin K antagonists, direct oral anticoagulants). This is followed by considering the problems of duration of treatment depending on various clinical situations. According to the presented data, the problem of prescribing disaggregants in a combination with anticoagulants after stenting of veins remains disputable, finding however many supporters. Analysed in the article are the results of the first International Delphi Consensus dedicated to antithrombotic therapy after venous stenting. Participating in the study were 106 independent experts practicing stenting in 78 centres of 28 countries of the world. Nonthrombotic iliac vein lesions, having appeared as May-Thurner syndrome due to extravasal compression and residual obstruction after thrombolysis, as well as the presence of postthrombotic syndrome were the main 'scenarios' for our study. The study resulted in working out provisions considering the policy of antithrombotic therapy in various obstructive lesions of deep veins. According to the presented data, anticoagulant therapy is preferable during 6-12 months after stenting in nonthrombotic iliac vein lesions. Low-molecular-weight heparins appear to be a method of choice in treatment during the first 2-6 weeks. Life-long administration of anticoagulants is recommended after multiple deep vein thromboses. Discontinuation of anticoagulants after 6-12 months is indicated after venous stenting in one episode of deep vein thrombosis. No consensus was achieved regarding the role of prolonged disaggregant therapy. Underlined in the article is the importance of a meticulous individual approach to choosing optimal policy of antithrombotic therapy and determining therapeutic policy together with a haematologist.Представлен обзор литературы, в котором рассматриваются вопросы применения антитромботической терапии после венозного стентирования. Приводятся литературные данные, согласно которым авторы отдают предпочтение антикоагулянтной терапии (низкомолекулярные гепарины, антагонисты витамина К, прямые оральные антикоагулянты). Рассматриваются вопросы длительности лечения в зависимости от различных клинических ситуаций. Согласно представленным данным вопрос назначения дезагрегантов в сочетании с антикоагулянтами после стентирования вен остается дискутабельным, хотя и находит немало сторонников. В статье проанализированы результаты первого международного консенсуса Delphi, посвященного антитромботической терапии после венозного стентирования. В исследовании принимали участие 106 независимых экспертов, практикующих стентирование в 78 центрах 28 стран мира. Нетромботические поражения подвздошных вен, которые проявились в виде синдрома May–Thurner вследствие экстравазальной компрессии и резидуальной обструкции после тромболизиса, а также наличие посттромботического синдрома явились основными 'сценариями' для нашего исследования. В результате разработаны положения, рассматривающие тактику антитромботической терапии при различных обструктивных поражениях глубоких вен. Согласно представленным данным антикоагулянтная терапия предпочтительна на протяжении 6–12 месяцев после стентирования при нетромботических поражениях подвздошных вен. Низкомолекулярные гепарины являются методом выбора в лечении в течение первых 2–6 недель. Пожизненное применение антикоагулянтов рекомендовано после множественных тромбозов глубоких вен. Отмена антикоагулянтов через 6–12 месяцев показана после венозного стентирования при одном эпизоде тромбоза глубоких вен. Не достигнуто соглашение относительно роли длительной дезагрегантной терапии. В статье подчеркивается важность тщательного индивидуального подхода к выбору оптимальной стратегии антитромботической терапии и определения тактики лечения в сложных случаях совместно с гематологом.

Medical institutions use quality metrics to track complications seen in hospital admissions. Similarly, morbidity and mortality (MM) conferences are held to peer review complications. The purpose of this study was to compare the complications identified in a cohort of patients within 30 days of neurosurgical intervention with those captured in a cohort of MM conferences.All complications that occurred within 30 days of surgery were obtained for patients admitted to the neurosurgical service between May and September 2013. All patients discussed in MM conference between August 2012 and February 2015 were included in a second data set. Complications were subdivided into 4 categories and compared between the 2 cohorts.A total of 749 postoperative complications were identified, including 52 urinary tract infections, 52 pneumonias, 15 deep vein thromboses, 19 strokes, 75 seizures, 25 wound infections, 6 cardiac arrests, and 162 reoperations. Eighty-five MM cases were reviewed, identifying 9 strokes, 3 seizures, 8 wound infections, 13 hematomas, 7 intraoperative errors, and 11 postoperative deaths. The MM cohort showed higher rates of neurologic complications (P 0.0001) and surgical complications (P0.0001). The neurosurgical admission cohort showed higher rates of general medical adverse events (P = 0.0118) and infectious complications (not surgical wound related, P = 0.0002).Both neurosurgical service inpatient complications and complications discussed in MM provide valuable opportunities for identifying areas in need of quality improvement. As the United States moves toward an outcomes reimbursement model, neurosurgical programs should adjust MM conferences to reflect both technical operative complications as well as more common complications.

Non-vitamin K antagonist oral anticoagulants (NOACs) have been widely used for the prevention of ischemic strokes in patients with nonvalvular atrial fibrillation (AF). At present, NOACs have been evaluated for the treatment of deep vein thrombosis (DVT). We examined the efficacy of dabigatran, the first NOAC for anticoagulation of AF in Japan, in outpatients who suffered from DVTs under a deteriorated general condition.Thirty-six consecutive outpatients diagnosed with DVT at our institute were enrolled. Not all patients could be hospitalized due to other clinical problems; 15 (42%) had malignant tumors, 9 (25%) psychological disorders, and 6 (17%) postoperative orthopedic disease. Dabigatran was administered at a dose of 110-150 mg once or twice daily, depending on the renal function and age. The mean dosage of dabigatran was 211.7 ± 36.6 mg per day. In 18 (50%) patients, the DVTs were completely dissolved and disappeared over a treatment term of 4.3 ± 4.3 months. In 9 patients (25%), the DVTs partly dissolved, but in the remaining 9 (25%) patients, dabigatran was totally ineffective. During a follow-up of 30.5 ± 5.3 months, DVTs did not recur with dabigatran in 18 patients with an effective efficacy. In a multivariate analysis, patients with small sized thromboses and those without malignant tumors were significantly associated with the DVTs dissolving (P = 0.003 and P = 0.006, respectively).Dabigatran was effective for dissolving DVTs in outpatients with a poor condition, particularly when the size of the DVT was small and malignant tumors were absent.

Cases of sudden death due to pulmonary thromboembolism (PTE) following laparoscopic surgery are very rare. The risk factors for PTE include sex, operation duration, age, obesity, and underlying diseases. The development of thromboprophylaxis according to specific risk factors has contributed to the decrease in postoperative mortality. Here, we describe the case of a 50-year-old patient with sudden death due to PTE at 24 hours after laparoscopic cholecystectomy. The origin of the thrombi were bilateral deep vein thromboses in both the lower extremities. No severe risk factors for PTE were detected in the patient, and pneumatic compression devices were used during the surgery for thromboprophylaxis. We believe that the accumulation of minor risk factors may have contributed to the onset of PTE. Hence, a more cautious assessment of the risk factors for PTE prior to surgery is required in such cases.

We present the case of a patient with a deep vein thrombosis (DVT) who failed rivaroxaban therapy. Our patient initially presented with left lower extremity edema, erythema, and pain. He was subsequently started on rivaroxaban therapy for a combined treatment period of 12 months, during and after which he persisted to have evidence of a DVT. The patient’s prescribed drug regimen was changed from rivaroxaban to warfarin, which demonstrated a rapid resolution of the DVTs as determined by ultrasound assessment of our patient’s lower extremity veins. Rivaroxaban, a factor Xa inhibitor, is a well-known oral anticoagulant that is used for a variety of indications and has become a mainstay in the treatment of deep vein thrombosis. With the introduction and emergence of this medication in the clinic, postmarketing reports of efficacy or lack thereof are important to review. In conclusion, we anticipate that it is likely that there are other patients with DVTs who may not respond to rivaroxaban and for whom alternative anticoagulation therapies should be explored.

The purpose of this study was to determine whether an association exists between cutting or trimming peripherally inserted central catheters (PICCs) and the development of deep vein thromboses (DVTs). An observational, retrospective study was conducted on 634 patients who had a PICC inserted between 2011 and 2012. Patients who had a reverse-taper PICC inserted were assigned into 1 of 2 groups. The first group included patients with a reverse-taper PICC that was cut/trimmed (PC) before insertion (n = 224). The second group was made up of patients whose PICC was not cut/trimmed (PNC) before insertion (n = 410). All PICC-associated DVTs were confirmed by a positive venous Doppler result and recorded. A statistically significant difference (P < .001) was found between patients in the PC group who developed a DVT (9.82%) and patients in the PNC group in which PICCs were not trimmed (1.95%). There is evidence to suggest that altering the reverse-taper PICC by cutting or trimming the tip before insertion may be associated with increased DVTs. Further study is required to determine whether PICCs should be reduced in length or whether there is an appropriate method of trimming the catheter to ensure its stability after insertion.

In this issue of Blood , Cieslik et al have added assessments of clot structure as a potentially new and important way to predict recurrent deep vein thromboses (DVT) after withdrawal of anticoagulant therapy. 1 Their work represents a departure from the standard approach to understanding blood coagulation, which is typically viewed through the lens of biochemistry as regulated pathways governed by specific clotting factor concentrations and activities. However, as Cieslik et al demonstrate, regulation of enzyme activity through proteolysis represents only 1 aspect of thrombosis and hemostasis. The final product of blood coagulation (ie, the clot) does not exist merely as a result of a ratio between activating and inhibiting enzymes; rather, it is a tangible, complex, and unique biological material.

Patient safety indicators (PSIs) use inpatient administrative data to flag cases with potentially preventable adverse events (AEs) attributable to hospital care. This study explored how many AEs the PSIs identified in the 30 days post discharge. PSI software was run on Veterans Health Administration 2003-2007 administrative data for 10 recently validated PSIs. Among PSI-eligible index hospitalizations not flagged with an AE, this study evaluated how many AEs occurred within 1 to 14 and 15 to 30 days post discharge using inpatient and outpatient administrative data. Considering all PSI-eligible index hospitalizations, 11 141 postdischarge AEs were identified, compared with 40 578 inpatient-flagged AEs. More than 60% of postdischarge AEs were detected within 14 days of discharge. The majority of postdischarge AEs were decubitus ulcers and postoperative pulmonary embolisms or deep vein thromboses. Extending PSI algorithms to the postdischarge period may provide a more complete picture of hospital quality. Future work should use chart review to validate postdischarge PSI events.

ACADEMIC EMERGENCY MEDICINE 2011; 18:22–31 © 2011 by the Society for Academic Emergency Medicine Abstract Background: Computed tomography angiograms (CTAs) for patients with suspected pulmonary embolism (PE) are being ordered with increasing frequency from the emergency department (ED). Strategies are needed to safely decrease the utilization of CTs to control rising health care costs and minimize the associated risks of anaphylaxis, contrast-induced nephropathy, and radiation-induced carcinogenesis. The use of compression ultrasonography (US) to identify deep vein thromboses (DVTs) in hemodynamically stable patients with signs and symptoms suggestive of PE is highly specific for the diagnosis of PE and may represent a cost-effective alternative to CT imaging. Objectives: The objective was to analyze the cost-effectiveness of a selective CT strategy incorporating the use of compression US to diagnose and treat DVT in patients with a high pretest probability of PE. Methods: The authors constructed a decision analytic model to evaluate the scenario of an otherwise healthy 59-year-old female in whom PE was being considered as a diagnosis. Two strategies were used. The selective CT strategy began with a screening compression US. Negative studies were followed up with a CTA, while patients with positive studies identifying a DVT were treated as though they had a PE and were anticoagulated. The universal CT strategy used CTA as the initial test, and anticoagulation was based on the CT result. Costs were estimated from the 2009 Medicare data for hospital reimbursement, and professional fees were obtained from the 2009 National Physician Fee Schedule. Clinical probabilities were obtained from existing published data, and sensitivity analyses were performed across plausible ranges for all clinical variables. Results: In the base case, the selective CT strategy cost $1,457.70 less than the universal CT strategy and resulted in a gain of 0.0213 quality-adjusted life-years (QALYs). Sensitivity analyses confirm that the selective CT strategy is dominant above both a pretest probability for PE of 8.3% and a compression US specificity of 87.4%. Conclusions: A selective CT strategy using compression US is cost-effective for patients provided they have a high pretest probability of PE. This may reduce the need for, and decrease the adverse events associated with, CTAs.

Paget-Schroetter's syndrome (PSS) is an effort-related syndrome involving upper extremity deep vein thromboses (UEDVTs) that usually occur in the subclavian or axillary veins. The aetiology is distinct from that of lower extremity DVTs (LEDVTs). Although rare, the syndrome can occur in young, otherwise healthy people who participate in upper extremity activity (Roche-Nagle et al 2007) such as footballer Gary Cahill, a defender at Bolton Wanderers, whose hopes of playing football at international level this season have diminished as a result of developing a UEDVT (BBC Sport 2010). This article discusses the incidence and aetiology, and provides a case study, of the syndrome.

Deep vein thromboses (DVT) are often associated with post-thrombotic syndrome (PTS) and long term side effects such as chronic venous insufficiency or venous stasis ulcers, but these symptoms typically develop months-to-years after presentation of the DVT. Here, we report a case of severe lower extremity bullae and ulcers one week after diagnosis and treatment of DVT.

Cementless acetabular components gained popularity because of the increased rate of loosening associated with cemented cups after intermediate and long-term follow-up. There are few long-term follow-up studies of cementless acetabular components. This study aims to evaluate the clinical and radiological long-term results of the press-fit standard Wagner Cup. Between January 1, 1994 and June 30, 1994, 118 implantations of a standard Wagner Cup were performed, and 102 implants were clinically and radiographically followed-up after a mean of 12.0 years. The Merle d’Aubigné score improved from a preoperative mean of 9.5 to 17.2 at latest follow-up. Early postoperative complications included two deep haematomata requiring needle aspiration, two deep vein thromboses, one pulmonary embolism, two temporary lesions of the sciatic nerve, one single event of THR dislocation and one recurrent dislocation. Two isolated cup revisions and five more complete total hip replacements were performed for aseptic loosening. The overall survival rate at 12 years was 93.1% (95/102). The standard Wagner cup yields very good long-term results.

The authors consider isolated distal deep-vein thrombosis (DVT) to be significant and recommend treating isolated symptomatic distal DVT in the same way as proximal lower-limb DVT. There is no guidance for the treatment of asymptomatic isolated distal DVT; however, certain triggers could be used to guide therapy. Our policy is as follows: all patients with distal DVT (asymptomatic and symptomatic) are given graduated compression stockings and early ambulation. We use anticoagulant therapy to treat asymptomatic distal DVT greater than 10 cm in length, or more proximal ones that are near the confluence of the venous trifurcation that forms the popliteal vein. Those patients with asymptomatic thrombi of 5–10 cm and with ongoing risk factors for propagation, for example immobilization or malignancy, generally receive treatment. We generally do not anticoagulate asymptomatic soleal vein and other small isolated distal DVT. We empirically watch untreated patients more closely, with repeat compression ultrasound...

Objective To determine the effectiveness and safety of an expanded perioperative venous thromboembolism (VTE) prophylaxis strategy in women undergoing complex gynecologic surgery. Methods We performed a cohort study of 527 patients undergoing major surgery at a single institution over a thirty-month interval during which the gynecologic oncology service implemented an expanded approach to VTE prophylaxis. We compared rates of VTE pre- and post-intervention as well as bleeding and infectious complications. Results Prior to the intervention, there were 23 VTE events in 345 patients (rate of 6.67%): 8 deep vein thromboses (DVTs) and 15 pulmonary emboli (PEs). Post-intervention, there were 5 VTE events in 182 patients (2.7%): 3 DVTs and 2 PEs (RR=0.4, p=0.056). Time-to-event analysis showed a significantly higher incidence of VTE events in the pre-intervention time frame compared to the post-intervention period (p=0.049). There were no significant differences in bleeding or infection complications between groups. Conclusions Implementation of a perioperative VTE prophylaxis protocol was safe, feasible and resulted in a clinically significant reduction in symptomatic VTE. Preoperative single-dose unfractionated heparin for all patients, combined with two weeks of thromboprophylaxis in gynecologic cancer patients, may decrease VTE events without increasing bleeding or infection.

Background The introduction of central venous catheters has advanced medical care, particularly in hemato-oncology. However these can be associated with an increased thrombotic risk. Previous studies have compared the rate of thrombotic events between peripherally- inserted (PICCs) and long term skin tunneled catheters (LTSTCs) noting fewer complications associated with the latter, though this has rarely translated into clinical practice. The objectives of our study was to compare the cumulative incidence of thrombotic events between peripherally-inserted and long term skin tunneled venous catheters. Patients/methods We performed a retrospective, single center cohort analysis of patients with hematological malignancies who had either a PICC or LTSTC line inserted between January 2010 through January 2013. Cumulative incidences of thrombotic events were compared between the two groups, and post-thrombotic complications were also examined. Results 346 patients had a PICC inserted with cumulative incidence of symptomatic thrombosis of 5.8%, while 237 patients had a LTSTC inserted with a cumulative incidence of 1.7% (p = 0.003). Post-thrombotic complication rates, particularly infection, were higher in the PICC group compared to the LTSTC group (p = 0.597). Conclusions Our study showed that the incidence of thrombotic events in hemato-oncology patients was significantly lower in those who had a LTSTC compared to PICC line. As the use of central venous lines increases in hemato-oncology patient care, a randomized trial comparing PICCs and LTSTCs is necessary to address which venous access is most appropriate in this cohort of patients, with minimal risk of morbidity and mortality.

The majority of fatal pulmonary emboli arise from deep vein thromboses in the lower limb. Pulmonary embolism continues to be a major cause of death in hospitalized patients. The classification, history, epidemiology, pathophysiology and prognosis are disclosed. An overview of the current recommendations for venous thromboembolism in surgical and medical patients and the failure of its application are discussed. The use of adequate thromboprophylaxis in approximately only one-third of patients is a familiar account. Prophylaxis guidelines use risk stratification systems, which lend to confusion by clinicians with the inevitable consequence of failed prophylaxis implementation. The National Institute of Health and Clinical Excellence are due to provide national prophylactic guidelines in May 2007. Simplified guidelines, a national consensus, and continued education of patients and health care professions to maintain compliance, is the solution to thromboprophylaxis.

The original description and definition of the antiphospholipid syndrome (APS) included predominantly thromboses of large veins and large arteries (deep vein thromboses [DVT] and strokes), fetal losses and thrombocytopenia (mild to moderate). The thromboses and fetal losses were often recurrent. Small vessel occlusions did occur (affecting renal and retinal skin vessels, etc.) but these did not dominate the clinical picture. The systemic nature of the syndrome was recognized in 1992 and is referred to as Hughes’ Syndrome. In 1992, a new subset consisting predominantly of small vessel microangiopathy, with considerably less large vessel occlusive disease, was defined as the catastrophic antiphospholipid syndrome (CAPS) and the eponym Asherson’s Syndrome has been attached. Severe thrombocytopenia and features of the systemic inflammatory response syndrome appear to accompany this very often fatal condition. Recurrences were very rare. A new subset is highlighted and reviewed in this paper and is termed the ...

We present a differentiated scheme for prophylaxis of thromboembolism using mostly the low molecular weight heparin dalteparin (LMWH) and in some cases unfractionated heparin (UFH). We report our clinical results of applying this scheme over a 5 year period in a traumatological center. In 11905 operatively treated patients 122 deep vein thromboses (DVT) of the lower extremities (rate 0.98 %) and 19 pulmonary embolisms (PE) (rate 0.16%) were clinically diagnosed. The DVT were phlebographically verified. 59.8 % of the DVT were limited to the calf. The time between trauma/operation and diagnosis of the DVT was in average 10.7 days (1-42). A heparin-induced thrombocytopenia type II was diagnosed in 12 cases (only 1 × with LMWH). The highest diagnosis-related rates of DVT we found in fractures of the tibial head (12.4%), total knee arthroplasty (6.7%), polytraumata (6.5%) and total hip arthroplasty (2.6%), The number of proximal DVT was highest in polytraumata. Our scheme proved to be of good practical use. Our results show, that also in daily clinical practice the prophylaxis of DVT/PE with LMWH is favourable and more attention has to be drawn to the fractures especially of the knee.

Cases of airline passengers developing deep vein thromboses and contracting infectious diseases during flights have led to airlines' provision of in-flight customer health advice coming under increased scrutiny. By means of a manifest content analysis of the information provided in 50 international airlines’ in-flight magazines, this paper examines the nature and presentation of the health advice that is supplied and comments on the different approaches individual airlines adopt.

This report describes a case of a collegiate baseball player who presented with 3 weeks of worsening right shoulder pain and mild swelling and faint discoloration of the right arm and hand. He was found to have a nonocclusive clot on his brachial vein and was treated with anticoagulants. This was his second lifetime thrombosis. A hematologic workup revealed no evidence of a hereditary origin, and thrombosis was believed to be related to recent exertion (baseball throwing). Upper extremity deep vein thromboses are extremely uncommon. However, because they can have potentially life-threatening consequences, deep vein thromboses must be on the differential for any athlete who presents with increased pain, swelling, or discoloration of an extremity.

The first four years of a community based podiatric surgery service are reviewed. During that period 5553 new referrals were received and 2335 surgical procedures were performed. The outcome of first ray, lesser digit, and lesser metatarsal surgery was measured using the American Orthopaedic Foot and Ankle Society clinical rating system and foot pathology was shown to be markedly improved by podiatric surgery. Two hundred and forty seven adverse events/complications occurred including 31 bacterial infections, 9 deep vein thromboses, 3 complex regional pain syndromes and 53 adverse reactions to analgesia. Patient satisfaction with the service was high with 93% of patients surveyed agreeing that they would opt for the podiatric surgery route if they had to have another foot operation. This study indicates that podiatric surgery is both effective and safe.

Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique for varicose vein removal that addresses some limitations of traditional procedures. The study objective was to analyze perioperative and follow-up outcomes after TIPP and present modifications gleaned over 9 years of performing the technique. Four hundred and thirty-one patients who underwent TIPP performed between June 2002 and April 2011 were included in this retrospective review. Descriptive statistics were used to describe demographic, treatment, and outcome data. The mean procedure time was 20.2 minutes. The majority (50.5%) of cases involved 10 to 20 incisions. No significant varicosities were reported at a follow-up of 12 weeks. Postoperative complications included 2 (0.5%) deep vein thromboses, 8 (1.9%) cellulitis episodes, 16 (3.7%) hemosiderin staining cases, 2 (0.5%) abscesses, and 2 (0.5%) cases of excessive or hypertrophic scarring. All but one patient reported good outcomes and were satisfied with the procedure. With proper training and experience, TIPP with a lower oscillation frequency and secondary tumescence results in good outcome and high patient satisfaction.

The American College of Chest Physicians use strict evidence-based medicine methodology to make recommendations regarding deep vein thromboses prophylaxis. The highest level recommendations (1-A) involve routine pharmacoprophylaxis for all total joint patients with protocols that are aggressive by the standards of many arthroplasty specialists. A high incidence of complications has been reported at some centers using 1-A protocols, whereas centers using less aggressive protocols have achieved low complication rates and are also successful in effectively minimizing the incidence of symptomatic thromboembolic events.

I first met Steve Bell in the fall of 1970. I was a junior medical student at Southwestern Medical School rotating on the internal medicine ward at Parkland Memorial Hospital. I was the student on the case of a Mr. Wilson, a man who drove one-quarter-mile dragsters (nitro fuel) for a living. Mr. Wilson's car had disintegrated during a race at the International Drag Strip in Lewisville, Texas, off of Interstate 35. With fractures in the spine, pelvis, femurs, ribs, and upper arms, he was in a cast from his upper body to the bottom of both legs and both arms were in casts. Mr. Wilson had been on the orthopedic ward until he developed deep vein thromboses and pulmonary emboli, which had necessitated transfer to the medical service for anticoagulation. Regrettably, Mr. Wilson developed a pneumothorax and required a chest tube. As the lowest man on the team, I was left during noon conference to meet the thoracic surgery fellow who was coming to place the chest tube for Mr. Wilson. I was sitting with Mr. Wilson when Steve Bell came into the room. We made acquaintance and then Dr. Bell asked me, “Do you know how to place a chest tube?” I said, “No, I am just ajunior medical student.” Dr. Bell's reply: “Well, you're going to become a doctor, so you need to know how to place a chest tube.” We made a list of the equipment we needed and we assembled the equipment. Then I was given a detailed lecture on how to place anterior and posterior chest tubes. Under Dr. Bell's watchful eye, I placed my first chest tube anteriorly on the left. A chest x-ray was performed to confirm proper placement. When the team returned from conference, all was well with Mr. Wilson. The resident in charge took a big gulp when Mr. Wilson told him that the student had placed the chest tube. Amazingly, Mr. Wilson left the hospital some weeks later. I never did see or hear of him driving dragsters after that. In the 37 years since, I have placed three chest tubes during emergencies. It is remarkable how I remember the equipment list and the techniques given me that fall day in 1970.

The aim of this study is to describe the hospitalization and regional distribution of selected cardiovascular and thrombo-embolic events (cardiac infarction, cerebral strokes, deep vein thromboses, pulmonary embolism) of young women in Austria in the years 1993 and 1994, and to collect basic epidemiologic data for the study of the side effects of oral contraceptives. The calculated hospitalization rates are based on the Austrian hospitals' discharge records of 1993 and 1994. The persons concerned are women aged between 15 and 44 who live in Austria. The results of the study reveal that--in 1993--of the above mentioned group 51 out of 100,000 inhabitants were hospitalized because of the selected cardiovascular and thromboembolic events: 4/100,000 had a cardiac infarction, 5/100,000 had a stroke, 17/100,000 had a pulmonary embolism, and 27/100,000 suffered a deep vein thrombosis. In 1994 the counted cases per 100,000 inhabitants were 48, out of which 4/100,000 where cardiac infarcts, 5/100,000 strokes, 16/100,000 pulmonary embolism, and 25/100,000 deep vein thromboses.

Quality improvement has mitigated the occurrence of postoperative deep vein thromboses (DVTs); however, despite adherence to protocols, they continue to occur. This study aimed to characterize their rate and distribution at our institution, and appropriate use of thromboprophylaxis.Local American College of Surgeons National Surgical Quality Improvement Program data were queried for general surgery cases complicated by DVT from 2009 to 2011. Medical records were evaluated to ascertain the following: classify DVTs by site, ascertain if appropriate prophylactic measures were instituted, evaluate treatment instituted, evaluate the occurrence of a PE if the DVT was line-associated, and if so, the indication for the central line.Of 1,857 patients, 39 had postoperative DVTs (2.1%). Fourteen lower-extremity (35.9%) DVTs, 4 central (10%) DVTs, and 21 upper-extremity (53.8%) DVTs (UEDVTs) were captured. All but 2 had appropriate thromboprophylaxis. All but one UEDVT was line-associated. Diagnoses were prompted by symptoms in 72% of the patients. Pulmonary emboli developed in 3 of 39 patients.An unexpected finding was that line-associated UEDVTs comprised over half of all DVTs, mostly in patients without cancer. This analysis highlights the need for more selective central-line use; choosing peripheral access may reduce DVT rates further. Improved pharmacoprophylaxis protocols would likely benefit this population.