Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study

OBJECTIVE: To evaluate the safety of withholding anticoagulant treatment from patients with clinically suspected deep vein thrombosis but normal findings on compression ultrasonography. DESIGN: Compression ultrasonography was done with a simplified diagnostic procedure limited to the common femoral vein in the groin and the popliteal vein extending down to the trifurcation of the calf veins. Patients with normal ultrasonography findings at presentation were retested 1 week later. MAIN OUTCOME MEASURE: The incidence of venous thromboembolic complications during follow up for 6 months in patients in whom anticoagulant treatment was withheld on the basis of normal results on two ultrasonography tests 1 week apart. SETTING: University research centres in four hospitals. RESULTS: A total of 1702 patients were included in the study. Abnormal results on compression ultrasonography at presentation or at 1 week were found in 400 and 12 patients, respectively, for a prevalence of deep vein thrombosis of 24%. None of the patients were lost to follow up. Venous thromboembolic complications during the week of serial testing occurred in a single patient and in eight patients during 6 months' follow up, resulting in a cumulative rate of venous thromboembolic complications of 0.7% (95% confidence interval 0.3% to 1.2%). The mean number of extra hospital visits and additional tests required per initially referred patient was 0.8. CONCLUSION: It is safe to withhold anticoagulant treatment from patients with clinically suspected deep vein thrombosis who have a normal result on compression ultrasonography at the time of presentation and at 1 week.     

Varicose vein surgery and deep vein thrombosis

A questionnaire was sent to 363 members of the Vascular Surgical Society of Great Britain and Ireland about their use of deep vein thrombosis (DVT) prophylaxis at the time of varicose vein surgery. Replies were received from 289 surgeons (80 percent), of whom only 29 percent regarded varicose veins as an important risk factor for DVT. Only 12 percent used subcutaneous heparin prophylaxis routinely, while 71 percent did so selectively, being influenced by a history of thromboembolism (95 percent), obesity (47 percent), age (35 percent), recurrent varicose veins (22 percent) and inpatient status (16 percent). At the end of the operation 52 percent applied crepe bandages, 25 percent other bandages, 13 percent stockings and 10 percent Tubigrip. Subsequently, antiembolism stockings were prescribed by 55 percent. There is a wide variation in opinion regarding DVT prophylaxis for patients having varicose vein surgery, which has both clinical and medicolegal implications.     

Outpatient management of deep vein thrombosis

OBJECTIVE: To assess whether patients with deep vein thrombosis (DVT) could be satisfactorily treated on an outpatient basis with low molecular weight (LMW) heparin and warfarin. DESIGN: A 22 month prospective study of adults attending St Peter's Hospital accident and emergency department with DVT. RESULTS: 1093 patients were referred and assessed; 160 were venogram positive, of which 159 patients between the ages of 22 and 89 years of age have now been treated with LMW heparin as outpatients. Direct liaison with community nurses has minimised the impact on general practitioner workload. CONCLUSIONS: 1272 bed days were saved during this period (an estimated 320,000 pounds). The outpatient treatment of thromboembolism has been shown to be effective and safe.     

Sulfinpyrazone and postoperative deep vein thrombosis

Small doses of subcutaneous heparin and infusions of dextran both reduce the incidence of fatal pulmonary embolism after elective general surgery. But both methods have disadvantages. Therefore, the protection against deep vein thrombosis afforded by sulfinpyrazone, a drug which can be taken by mouth as well as by injection, was assessed in a prospective study of 119 patients undergoing elective general or urological surgery. The prophylactic administration of sulfinpyrazone was compared with the effects of small doses of sodium heparin and infusions of dextran-70. The 125I-fibrinogen test was carried out in all patients during their hospitalization. Deep vein thrombosis was diagnosed in 13 of 30 patients (43%) who received sulfinpyrazone, in 9 of 29 (31%) receiving dextran-70 and in 2 of 22 (9%) having subcutaneous heparin. The difference between the sulfinpyrazone and heparin groups was statistically significant (p less than 0.01). Sulfinpyrazone in the dose used in this trial was not effective in reducing the incidence of deep vein thrombosis during elective general surgery.     

A case of deep vein thrombosis

The case of a woman admitted to hospital various times because of the onset of a mantle-like oedematous syndrome is reported. Observations revealed a narrowing at the level of the internal jugular and right subclavian veins with total obliteration of the right anonymous vein caused by previous thrombosis induced by intravenous implantation of a pace-maker.     

Preoperative prediction of postoperative deep vein thrombosis

A range of clinical data was obtained from 124 patients about to undergo operation and several coagulation tests were performed. No patient received prophylaxis for deep vein thrombosis, and isotopic scanning after operation showed that 20 patients had developed thrombosis. a simiple prognostic index for predicting which patients would develop postoperative deep vein thrombosis was constructed using the clinical and coagulation data obtained before operation. The five variables with the best predictive power-euglobulin lysis time, age, presence of varicose veins, fibrin related antigen, and percentage overweight-produced an equation that identfied 95% of those who developed deep vein thrombosis and misallocated only 28% of those who did not develop thrombosis. In view of the complications that low-dose heparin and dextran can cause, giving prophylaxis to under a third of the patients who will not develop deep vein thrombosis is clearly better than giving it to all.     

Light-reflection rheography and acute deep vein thrombosis

The authors examined 47 subjects affected by acute phlebothrombosis of the lower limbs by means of light-reflection-rheography (LRR). The diagnosis was based on the results of clinical, Doppler, and duplex scanner evaluations. The results were compared with those obtained in 30 healthy subjects (control group). The LRR examinations were performed by two methods: the one consisting of a passive execution of postural movements of the limb, the other using the technique of plethysmographic venous occlusion. The pathological LRR curves were characteristic for each type of disease and for the site of thrombosis and were different from the normal ones. The results obtained show the usefulness of the method and it potential in studying the collateral circulation and the effects of different therapies.     

Prospective screening for deep vein thrombosis in high risk patients

Closed chest cardiac massage is simple and usually a safe procedure for cardiac resuscitation. However, it is not innocuous and is occasionally associated with serious and even fatal complications. A case is reported in which fracture of the upper part of the left half of the sternum occurred following midline sternotomy. The sternum was re-approximated in the usual manner by interrupted wire sutures, but the fracture was not specifically repaired, because it was thought to be adequatley stabilized by this closure. Postoperatively, the patient required closed chest cardiac massage which caused a fatal laceration of the outflow tract of the right ventricle due to penetration of the sharp edges of fractured fragments. We believe fracture of the sternum which occurs while retracting it with sternotomy retractor during open heart surgery should be deliberately repaired to avoid this serious complication.     

Does this patient have deep vein thrombosis?

OBJECTIVE: To review the validity of the clinical assessment and diagnostic tests in patients with suspected deep vein thrombosis (DVT). METHODS: A comprehensive review of the literature was conducted by searching MEDLINE from 1966 to April 1997. RESULTS: Individual symptoms and signs alone do not reliably predict which patients have DVT. Overall, the diagnostic properties of the clinical examination are poor; the sensitivity of the clinical examination ranges from 60% to 96%, and the specificity ranges from 20% to 72%. However, using specific combinations of risk factors, symptoms, and physical signs for DVT, clinicians can reliably stratify patients with suspected DVT into low, moderate, or high pretest probability categories of actually suffering from DVT. This stratification process in combination with noninvasive testing, such as compression ultrasonography, simplifies the management strategies for patients with suspected DVT. CONCLUSIONS: Use of a clinical prediction guide that includes specific factors from both the history and physical examination in combination with noninvasive tests simplifies management strategies for patients with suspected DVT.     

Diagnosis of deep vein thrombosis, an overview

This article reviews the role of dendritic cells in cutaneous immunity. Langerhans cells (LC) found in the epidermis are the best-characterized dendritic cell population. They have the ability to process antigen in the periphery, transport it to the draining lymph nodes (DLN) where they are able to cluster with, and activate, antigen-specific naive T cells. During migration LC undergo phenotypic and functional changes which enable them to perform this function. There are other less well-characterized dendritic cells including dendritic epidermal T cells, dermal dendrocytes and dermal "LC-like' cells. Although there is no evidence that dendritic epidermal T cells (DETC) can present antigen or migrate to lymph nodes, they do influence the intensity of cutaneous immune responses to chemical haptens. Antigen-presenting cells (APC) in the dermis may provide alternative routes of antigen presentation which could be important in the regulation of skin immune responses. Therefore, dendritic cells are vital for the induction of immune responses to antigens encountered via the skin. LC are particularly important in primary immune responses due to their ability to activate naive T cells. The faster kinetics of secondary responses, and the ability of nonprofessional APC to induce effector function in previously activated cells, suggest that antigen presentation in the DLN may be less important in responses to previously encountered antigens. In these secondary responses, dendritic and nondendritic APC in the skin may directly induce effector functions from antigen-specific recirculating cells.     

Diagnosis of deep vein thrombosis of the extremities

Working on a Nursing Home Demonstration Project seeking alternative forms of care for this "abandoned" population, and testing the cost-effectiveness of these forms, is the vantage point from which the social worker involved assessed how her professional skills meshed with patient needs. How patients' levels of functioning and behavior were improved through the exercise of administrative, educational and practice skills is defined.