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PubMed2005

Electronic alerts to prevent venous thromboembolism among hospitalized patients.

BACKGROUND: Prophylaxis against deep-vein thrombosis in hospitalized patients remains underused. We hypothesized that the use of a computer-alert program to encourage prophylaxis might reduce the frequency of deep-vein thrombosis among high-risk hospitalized patients. METHODS: We developed a computer program linked to the patient database to identify consecutive hospitalized patients at risk for deep-vein thrombosis in the absence of prophylaxis. The program used medical-record numbers to randomly assign 1255 eligible patients to an intervention group, in which the responsible physician was alerted to a patient's risk of deep-vein thrombosis, and 1251 patients to a control group, in which no alert was issued. The physician was required to acknowledge the alert and could then withhold or order prophylaxis, including graduated compression stockings, pneumatic compression boots, unfractionated heparin, low-molecular-weight heparin, or warfarin. The primary end point was clinically diagnosed, objectively confirmed deep-vein thrombosis or pulmonary embolism at 90 days. RESULTS: More patients in the intervention group than in the control group received mechanical prophylaxis (10.0 percent vs. 1.5 percent, P<0.001) or pharmacologic prophylaxis (23.6 percent vs. 13.0 percent, P<0.001). The primary end point occurred in 61 patients (4.9 percent) in the intervention group, as compared with 103 (8.2 percent) in the control group; the Kaplan-Meier estimates of the likelihood of freedom from deep-vein thrombosis or pulmonary embolism at 90 days were 94.1 percent (95 percent confidence interval, 92.5 to 95.4 percent) and 90.6 percent (95 percent confidence interval, 88.7 to 92.2 percent), respectively (P<0.001). The computer alert reduced the risk of deep-vein thrombosis or pulmonary embolism at 90 days by 41 percent (hazard ratio, 0.59; 95 percent confidence interval, 0.43 to 0.81; P=0.001). CONCLUSIONS: The institution of a computer-alert program increased physicians' use of prophylaxis and markedly reduced the rates of deep-vein thrombosis and pulmonary embolism among hospitalized patients at risk.

Adolescent↗
PubMed1994

[Paradoxical embolism of the aortic arch diagnosed by transesophageal echocardiography. Surgical treatment].

The authors report the case of a woman who presented with a pulmonary embolism followed by systemic embolism. Transoesophageal echocardiography showed a persistent foramen ovale compatible with a possible paradoxical embolism. In addition, a mobile embolism in the aortic arch was demonstrated. This embolism was extracted under cardiopulmonary bypass to avoid a recurrence of embolism. Transoesophageal echocardiography is the only reliable, non-invasive method allowing simultaneous diagnosis of a right to left shunt and visualisation of the thoracic aorta.

Aged↗
PubMed2002

[Very long-term outcome of 68 vena cava filters percutaneously implanted].

Between January 1987 and December 1991, 68 consecutive patients aged 71.5 +/- 12.0 years underwent percutaneous implantation of a vena caval filter, mainly the LGM (N = 64). Fifty seven patients had pulmonary embolism, 61 had deep vein thrombosis of the lower limbs. The average follow-up interval was 4.9 +/- 3.3 years (7.0 +/- 2.7 years for the patients still alive). The follow-up included a telephonic enquiry to determine the date and cause of death, recurrent deep vein thrombosis and/or pulmonary embolism; surviving patients underwent clinical examination, plain abdominal X-ray with a lateral decubitus view and duplex ultrasonography of the lower limb veins to assess the patency of the filter. Fifty three per cent of the patients died. Four predictive factors for mortality were identified: a contra-indication to anticoagulant therapy, chronic post-embolic cor pulmonale, an indication of prophylactic implantation in the elderly and the presence of underlying malignant disease. There were 5.8% recurrences of pulmonary embolism, 26.1% of lower limb deep vein thrombosis and 25% of filter thrombosis. The only predictive factor of thrombosis was a proximal venous thrombus and was associated in 50% of filter thrombosis. Seventy per cent of the plain abdominal X-rays were abnormal with 9 displacements. 9 migrations and 10 closures of the filters. There was a significant correlation between closure on plain abdominal X-ray and caval thrombosis and between recurrent deep vein thrombosis and caval thrombosis. The frequency of long-term complications after implantation of a caval filter in this study suggests that interruption of the vena cava should be reserved for the only validated indications in the presence of a formal contra-indication to or failure of anticoagulant therapy. Other indications require evaluation with prospective randomised trials.

Adult↗
PubMed1992

Occurrence of arterial thrombosis in a cohort of patients with hereditary deficiency of clotting inhibitors.

Hereditary deficiency of protein C, protein S or antithrombin III has been associated with an increased incidence of venous thrombosis or pulmonary embolism. The relationship between these deficiencies and the development of arterial thrombosis is a matter of current investigation. We retrospectively studied the occurrence of arterial thrombosis in 92 symptomatic patients belonging to a group of 160 with a confirmed diagnosis of hereditary deficiency of one of the physiologic clotting inhibitors. Seventeen of them experienced at least one arterial thrombotic event. This indicates that about one out of five of the symptomatic patients had experienced arterial thrombosis. The control group consisted of 92 sex and age matched (+/- 5 years) patients with no clotting deficiency who had experienced in the same period at least one episode of deep vein thrombosis or pulmonary embolism. Only one of them had developed arterial thrombosis. Ischemic stroke, myocardial infarction, upper and lower limb arterial thrombosis, and mesenteric artery occlusion occurred regardless of the type of defect taken into account; mean age of about 37.05 +/- 23 years (mean +/- SD). In some cases, arterial thrombosis was fatal. The overall number of venous thrombotic events in the 92 symptomatic patients of this study was much higher than that of arterial thrombosis, with a ratio of 24 to 1. The use of long-term anticoagulant therapy in our group of patients seemed to be able to prevent recurrences of both arterial and venous thrombosis.

Adolescent↗
PubMed1990

Venous thromboembolic disease: diagnosis and use of antithrombotic therapy.

Several invasive and noninvasive tests are available to aid the clinician in the diagnosis of deep venous thrombosis and pulmonary embolism. Contrast venography remains the standard for diagnosing deep venous thrombosis of the lower extremity, while impedance plethysmography is sensitive, specific, and noninvasive. Compressive duplex ultrasonography is useful for deep venous thrombosis of the thigh down to the popliteal vein. The ventilation-perfusion lung scan is the most common test for diagnosing pulmonary embolism, but pulmonary angiography remains the standard. Heparin is the mainstay of treatment for deep venous thrombosis and pulmonary embolism, with an important role played by warfarin therapy.

Heparin↗
PubMed2003

Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study.

BACKGROUND: The benefit of thromboprophylaxis for 1 month has never been evaluated in patients undergoing hip fracture surgery, a setting in the highest risk category for postoperative venous thromboembolism (VTE). METHODS: In a double-blind multicenter trial, 656 patients undergoing hip fracture surgery were randomly assigned to receive prophylaxis with a once-daily subcutaneous injection of either 2.5 mg of fondaparinux sodium or placebo for 19 to 23 days. Before randomization, all patients had received fondaparinux for 6 to 8 days. The primary efficacy outcome was VTE occurring during the double-blind period (deep vein thrombosis detected by mandatory bilateral venography or documented symptomatic deep vein thrombosis or pulmonary embolism). The main safety outcome was major bleeding. RESULTS: The primary efficacy outcome was assessed in 428 patients. Fondaparinux reduced the incidence of VTE compared with placebo from 35.0% (77/220) to 1.4% (3/208), with a relative reduction in risk of 95.9% (95% confidence interval, 87.2%-99.7%; P<.001). Similarly, the incidence of symptomatic VTE was significantly lower with fondaparinux (1/326; 0.3%) than with placebo (9/330; 2.7%). The relative reduction in risk was 88.8% (P =.02). Although there was a trend toward more major bleeding in the fondaparinux group than in the placebo group (P =.06), there were no differences between the 2 groups in the incidence of clinically relevant bleeding (leading to death, reoperation, or critical organ bleeding). CONCLUSIONS: Extended prophylaxis with fondaparinux for 3 weeks after hip fracture surgery reduced the risk of VTE by 96% and was well tolerated.

Adult↗
PubMed1992

Vena caval occlusion after Simon nitinol filter placement: identification with MR imaging in patients with malignancy.

The prevalence of inferior vena caval occlusion associated with the Simon nitinol filter (SNF) was studied at two institutions in the follow-up of filters placed over a 13-month period. Twenty-four consecutive patients with defined indications (contraindication to anticoagulation with pulmonary embolism or deep venous thrombosis [DVT], recurrent pulmonary embolism despite anticoagulation, or extensive DVT [eg, iliofemoral]) underwent placement of a SNF. This patient group includes a high proportion with pelvic or renal malignancy (54%, 13 of 24) or a history of other malignancy. Of these 24, physical examination at follow-up identified 10 symptomatic patients with unilateral or bilateral leg swelling. Of these 10, magnetic resonance imaging, with spin-echo and gradient-echo techniques, demonstrated IVC occlusion in five patients (50%). These data suggest that vena caval occlusion following SNF placement occurs more commonly than previously recognized. Possible contributing factors include reduced venous inflow in patients with prior nephrectomy or pelvic neoplasms, pelvic venous compression by tumor mass, and hypercoagulable states.

Adult↗
PubMed2006

The challenges of Proteus syndrome: diagnosis and management.

Proteus syndrome (PS) is a disorder of patchy or mosaic postnatal overgrowth of unknown etiology. The onset of overgrowth typically occurs in infancy and can involve any tissue of the body. Commonly involved tissues include connective tissue and bone, skin, central nervous system, the eye, but it apparently can affect any tissue. Diagnosing of PS is difficult and the diagnostic criteria are controversial. Our group advocates stringent diagnostic criteria to facilitate research and appropriate clinical care. The benefit of strict criteria is that they define a clinical group that is reasonably homogenous with respect to manifestations and prognosis. The overgrowth of PS is progressive and can be difficult to manage. The progressive overgrowth most commonly causes severe orthopaedic complications, but it can cause many other complications. One of the most common complications in patients with PS is deep venous thrombosis and pulmonary embolism, which can cause premature death. Effective management requires knowledge of the wide array of manifestations and complications of the disorder and a team approach that includes the geneticist, surgeons, and other specialists.

Female↗