[Ambulatory management of thrombophlebitis].
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Ambulatory Care↗
Biomedical subjects
H Partsch
Publications and source records attributed to H Partsch.
Factors influencing pain outcome in herpes zoster: an observational study with valaciclovir. Valaciclovir International Zoster Assessment Group (VIZA).
AIM OF THE STUDY: An observational study with valaciclovir was conducted to assess clinical outcome in herpes zoster, especially pain and associated neurological signs and symptoms in relation to a series of demographic and disease characteristics discernible at presentation. The safety and acceptability of valaciclovir for treatment of zoster was assessed in a wide variety of primary care and clinic referral settings. METHODS: In total, 1897 immunocompetent adults with clinically diagnosed, localized acute herpes zoster were enrolled in this international, open-label study of valaciclovir. All subjects received treatment with oral valaciclovir (1000 mg three times daily) for 7 days from entry to the study and were asked to record the presence of zoster-associated pain and abnormal sensations throughout treatment and 6 months' follow-up. They were seen frequently in clinic to verify subjective assessments and for evaluation of rash healing. Safety and tolerability were assessed by adverse event monitoring. RESULTS: Overall, 1191 subjects (63%) were aged > or = 50 years, and 203 (11%) had ophthalmic zoster. Cessation of zoster-associated pain was significantly faster in the younger age group; median times to loss of zoster-associated pain were 23 days and 9 days in the > or = 50 and < 50 years age groups, respectively. Similarly, abnormal sensations resolved significantly more rapidly in the younger subjects; the median duration of abnormal sensations was 31 days in the > or = 50 year olds and 16 days in those aged < 50 years. In cases of ophthalmic zoster, the rate of pain resolution was not different from those with zoster in other dermatomes (median duration of pain 18 vs. 16 days). However, abnormal sensations persisted significantly longer in subjects with ophthalmic zoster than in those with zoster at other sites (47 vs. 22 days). In addition to advancing age, subjects suffering moderate to severe prodromal pain or acute pain during the rash phase were at significantly greater risk of zoster-associated pain and abnormal sensations persisting for longer. Subjects with concomitant neurological disorders were also more likely to develop prolonged abnormal sensations. Valaciclovir treatment was well tolerated, and adverse events were rare and generally mild. CONCLUSION: This study confirmed the prognostic importance of advancing age and the intensity of prodromal or acute pain as risk factors for prolonged zoster-associated pain and persisting abnormal sensations in the affected dermatome. Ophthalmic zoster and pre-existing neurological disorders are also identified as highly significant risk factors for prolonged abnormal sensations in herpes zoster.
Acyclovir↗
Compression and walking versus bed rest in the treatment of proximal deep venous thrombosis with low molecular weight heparin.
OBJECTIVE: The purpose of this randomized controlled trial was to evaluate the benefits of compression and walking exercises in comparison with bed rest in the acute stage of proximal deep venous thrombosis (DVT). METHODS: Forty-five patients with proximal DVT that was proved with compression ultrasound scan or phlebography were randomized into three groups. Group A consisted of 15 patients who received inelastic compression bandages (Unna boots on the lower leg, adhesive bandages on the thigh), and group B consisted of 15 patients who received thigh-length compression stockings, class II. Group C consisted of 15 patients who underwent bed rest and no compression. All patients received dalteparin, 200 IU/kg per body weight, subcutaneously every 24 hours. The clinical characteristics of the three groups were comparable. Primary end points were the reduction of pain assessed daily with the Visual Analogue Scale and the Lowenberg test, the reduction of leg circumference at the ankle and calf levels, and the improvement of clinical scores. The daily walking distance was measured with a pedometer. Safety parameters were ventilation-perfusion scans and duplex ultrasound scans performed on days 0 and 9. RESULTS: The daily walking distance was between 600 and 12,000 m in the compression groups and averaged 66 m in the bed rest group. The pain level showed a statistically significant reduction starting after the second day in the compression groups (A and B) and after 9 days in the bed rest group C (P <.05). The same was true for the measurement of leg circumference. Improvement of the clinical scores was significantly better in the compression groups compared with the bed rest group (P <.01). There was no significant difference concerning the occurrence of new pulmonary emboli and regression of thrombus diameter. Progression of thrombi in the femoral vein was greater and occurred more frequently in the bed rest group than in the other two groups (P = not significant). CONCLUSION: Mobile patients with acute proximal DVT treated with low molecular weight heparin should be encouraged to walk with compression bandages or medical compression stockings. The rate of resolution of pain and swelling is significantly faster when the patient ambulates with compression. The risk of pulmonary embolism is not significantly increased by this approach.
Acute Disease↗
Erythema migrans and serodiagnosis by enzyme immunoassay and immunoblot with three borrelia species.
There is wide divergence of opinion between physicians regarding the use of serological measures for the diagnosis and treatment of erythema migrans, the hallmark of Lyme borreliosis. We studied the outcome of an enzyme immunoassay and immunoblot (Western blot) used on the sera of patients who had suffered tick bite and erythema migrans, and had been subsequently treated with various antibiotics. Ninety-nine consecutive patients presenting with erythema migrans after tick bite were prospectively recruited at the outpatient department of two Vienna City hospitals and at the consultation office for Lyme borreliosis of the Institute of Hygiene. University Vienna. Blood samples were taken before antibiotic treatment and 3 and 6 months thereafter. Blood samples from 100 blood donors served as controls. Antibodies against Borrelia burgdorferi sensu lato were determined by enzyme immunoassay (IgG and IgM EIA) and by IgG immunoblot. The latter was performed with isolates of B. alzelii (H2) B. burgdorferi sensu stricto (Le) and B. garinii (W) from Austrian patients. The 4 interpretation criteria for immunoblot results were: A (3 bands out of 8), B (2 bands out of 9), C and D (1 band out of 6). In all patients, the erythema resolved within the treatment period. No complications secondary to the borrelia infection were registered. After treatment there was no significant change in titre, nor was there a difference in the immunoblot pattern between the first, second and third serum samples. Serum antibodies to B. burgdorferi were positive by EIA in 22.9% (IgG) and 2.5% (IgM). Immunoblot results offered by borrelia species and by the interpretation criteria, ranging between 8.3% (criterion A, strain Le) and 44.2% (criterion D, strain H2). By EIA, control samples were IgG and IgM positive in 5% and 1%, respectively. Positive immunoblot results with strain H2 were found in 9%, 13%, 18%, and 20% by the criteria A through D respectively. After antibiotic treatment of erythema migrans the immunological response appears to be abrogated. Thus, serological results are not supportive for the diagnosis of erythema migrans, not will they retrospectively prove successful antibiotic treatment of borrelia infection.
Adolescent↗
Inelastic leg compression is more effective to reduce deep venous refluxes than elastic bandages.
BACKGROUND: Deep venous refluxes play an important triggering role for the development of venous leg ulcers. Compression therapy is able to reduce these refluxes depending on pressure and the kind of material being used. OBJECTIVE: To compare the efficacy of compression bandages of varying pressure and material (elastic, long-stretch versus inelastic, short-stretch bandages, four-layer bandages). METHODS: Venous volume (VV) and venous filling index (VFI) as a quantitative parameter of venous reflux were measured using an airplethysmograph (APG) in a total of 21 patients presenting with venous leg ulcers and deep venous refluxes. Bandage pressure was measured in every experiment. The influence of elastic and inelastic bandages with increasing pressure and the changes in these parameters using different bandages with the same pressure were investigated. RESULTS: The initial median value of VFI without compression was 8.45 ml/sec. VV and VFI were significantly reduced by increasing external pressure, more strongly with inelastic than with elastic material. With a pressure of 25 mmHg inelastic bandages diminished VFI to a median of 3.25 ml/sec while the elastic material did not even approach this value with a pressure of 40 mmHg (4.25 ml/sec). Applying bandages of different material with the same pressure of 30 mmHg, the most intense reduction of VV and VFI was obtained by inelastic and by four-layer bandages. The effect on venous reflux was statistically significantly superior with inelastic compared to elastic material. CONCLUSION: Using the same bandage pressure, inelastic material is more effective at reducing deep venous refluxes than elastic bandages in patients with venous ulcers. Four-layer bandages show similar efficacy to inelastic bandages.
Adult↗
Classification of chronic venous insufficiency.
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Disability Evaluation↗
Compression therapy of venous ulcers.
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Arteries↗
["Ambulatory" therapy of deep venous thrombosis of the leg--definition].
The central problem in connection with "ambulatory treatment" of deep vein thrombosis is the degree of mobility. In future trials it will be essential not only to register carefully anticoagulant therapy but also to define and to measure walking activities and adjuvant compression.
Ambulatory Care↗
[Thrombophlebitis: bed rest or walking exercise?].
It is a common tradition to admit patients with deep vein thrombosis (DVT) to the hospital and put them to bed for several days because of fear from pulmonary embolism, even if they are mobile. Between May 1994 and December 1997 929 patients were admitted to our department who were treated by subcutaneous injections of low-molecular-weight heparin (mainly 200 IU dalteparin per kilogram body-weight per 24 hours), got firm compression bandages and were encouraged to walk as much as possible. On admission DVT propagated into the pelvis in 268 patients, into the thigh in 480 and below the popliteal level in 181 patients. V/Q-lung scans were performed at baseline and repeated after 10 days on average. In these three groups primary pulmonary embolism was diagnosed in 49.4%, 50% and 34% respectively, new emboli after 10 days were found in 6.1%, 5.7% and 3.9%. Only one third of the patients with embolism on admission and 5 from 50 patients who developed new emboli showed some dyspnoea. 12 patients died and underwent autopsy, 3 fatal events were caused by pulmonary embolism. With out management the incidence of thromboembolic complications is statistically significantly lower than data from the literature. Preliminary results from an ongoing randomised trial comparing bed-rest, compression bandages and compression stockings in the acute phase of proximal DVT demonstrate faster improvement of swelling and of pain in the compression-groups. Low-molecular-weight heparin has greatly facilitated therapy of DVT since effective anticoagulation can be obtained by subcutaneous injections of fixed doses without the need of laboratory monitoring. For the future development of conservative management mechanical prophylaxis of thrombus extension by acceleration of venous flow using leg compression and walking will probably become as important as exact anticoagulation.
Adolescent↗
[Isotope lymphography--possibilities and limits in evaluation of lymph transport].
Quantitative isotopic lymphscintigraphy is based on a combination of transmission- and emission scintigraphy correcting the different depths of lymph nodes. This method allows an exact estimation of lymph-transport in legs during standardised stress. The depth-corrected uptake in the lymph nodes expressed in percentage of the injected dose (D%) reflects the lymph-transport. After s.c. injection of 1 mCi of 99 m Tc-microcolloid (Nanocoll) the prefascial lymph-transport and after intramuscular (i.m.) injection the subfascial lymph-transport can be assessed. The stress consists of 15 minutes walking on a horizontal treadmill at a speed of 3.2 km/h. After s.c. injection all types of lymphedema can be diagnosed (average uptake in lymphedema 2.0 +/- 2.5 D%, in normal legs 14.3 +/- 4.2 D%; p < 0.001). The subfascial transport is much lower, only 7.7% of the prefascial transport. In healthy legs the uptake after i.m. injections is 1.1 +/- 0.8 D%, in postthrombotic syndrome the uptake decreases to 0.2 +/- 0.16 D% (p < 0.02). Lymphscintigraphy after i.c. injection of the colloid reveals contradictory results. The uptake is very low only in lymphedema with involvement of the whole leg. In distal and in secondary lymphedema the uptake is near the normal range. The clearance rate of the tracer from the depot is not reliable for diagnosing lymphedema. Information may be gained concerning the following points: quantitative measurement of lymph transport, routine diagnosis of lymphedema, follow-up in lymphedema, assessment of pre- and subfascial lymph-transport in patients with venous diseases, angiodysplasias etc., documentation of therapeutic effects.
Exercise Test↗
Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management. Summary of an evidence-based report of the VEINES task force. Venous Insufficiency Epidemiologic and Economic Studies.
BACKGROUND: To critically review the classification, epidemiology, outcomes, diagnosis and treatment of chronic venous disorders of the leg (CVDL), to issue evidence-based recommendations, and to identify areas requiring further research. METHODS: Articles identified by an extensive literature search were scored by members of an international task force. Only those articles with a moderate or strong rating for internal validity were retained. RESULTS: A scoring system weighing CVDL severity according to the probability of ulcer occurrence is proposed. Epidemiological data on the frequency of CVDL and its risk factors are reviewed. The following items are evaluated: costs associated with treatment; clinical outcomes related to CVDL and its treatment; available generic and disease-specific measures of quality of life; diagnostic procedures used to detect venous reflux; and efficacy of available treatments. CONCLUSIONS: CVDL is an important public health problem, based on its prevalence, cost and impact on quality of life. High-priority areas for research on CVDL are identified.
Chronic Disease↗
[Deep vein thrombosis--diagnosis and therapy].
For diagnosis of deep vein thrombosis an objective visualising method is indispensable (Duplex sonography, phlebography, MRI). The approval of several preparations of low-molecular-weight heparin made therapy easy: subcutaneous injections of fixed doses which are mainly adjusted to body-weight allow safe and effective anticoagulation without the need of special laboratory testing. Mobile patients should be kept walking with compression of their legs. Secondary prophylaxis consists of oral anticoagulation or alternatively in low-molecular-weight heparin and compression stockings.
Anticoagulants↗
Whole-blood immunoassay (SimpliRED) versus plasma immunoassay (NycoCard) for the diagnosis of clinically suspected deep vein thrombosis.
BACKGROUND: The level of D-dimer in the blood reflects the level of lysed, cross-linked fibrin, and is a useful diagnostic marker in patients with clinically suspected deep vein thrombosis (DVT). In this study, two assays for the measurement of D-dimer levels were compared: the new, whole-blood immunoassay, SimpliRED, which can be performed at the patient's bedside in two minutes; and the plasma immunoassay, NycoCard. PATIENTS AND METHODS: D-dimer levels were determined using these two techniques in 108 patients with clinically suspected DVT. To ascertain or rule out the diagnosis of DVT compression ultrasonography using a colour coded Duplex instrument was done. 8 doubtful cases were diagnosed by ascending phlebography. By these procedures DVT was confirmed in 33 patients and ruled out in the remaining 75 cases. RESULTS: The SimpliRED assay exhibited a sensitivity of 1.0 (CI 0.89-1.0) and a specificity of 0.75 (CI 0.63-0.84); negative predictive value 1.0 (CI 0.94-1.0), positive predictive value 0.63 (CI 0.49-1.0). By contrast, the NycoCard assay displayed a sensitivity of 0.85 (CI 0.68-0.95) and a specificity of 0.65 (CI 0.53-0.76); negative predictive value 0.91 (CI 0.80-0.97), positive predictive value of 0.52 (CI 0.38-0.66). CONCLUSION: The results show that the SimpliRED assay is a valuable tool in the diagnosis of clinically suspected DVT, especially when laboratory facilities are not accessible.
Adult↗
The effect of mobilisation of patients during treatment of thromboembolic disorders with low-molecular-weight heparin.
OBJECTIVE: To elucidate the risk of pulmonary embolism (PE) in patients with deep vein thrombosis (DVT) who are kept walking with compression bandages. EXPERIMENTAL DESIGN: Perfusion/ventilation scanning of the lungs was performed at admission and after 10 days of treatment. SETTING: General community hospital. PATIENTS: A total of 631 consecutive patients were studied (upper limit of the thrombi: iliofemoral vein, n=212; femoral or popliteal vein, n=302; lower leg, n=117). The patients received different dose regimens of low-molecular-weight heparin (dalteparin) subcutaneously. RESULTS: The study revealed that the prevalence of PE at baseline was between 45.1% and 51% (95% CI 38.2-55.2 and 45.2-56.8% respectively) in patients with proximal DVT, and 31.9% (95% CI 23.6-41.2%) in those with DVT restricted to the lower leg. The majority of these cases of PE were completely asymptomatic. The incidence of a new PE, revealed by a second lung scan on day 10 after admission, was 7.0% (95% CI 3.9-11.4%) in patients with iliofemoral DVT, 5.5% (95% CI 3.2-8.7%) in those with femoropopliteal DVT and 2.7% (95% CI 0.6-7.6%) in those with lower-leg DVT. These incidence rates for new PEs were significantly lower than the rates previously reported (p<0.01). The fatality rate was also lower compared with the literature: one patient suffered a fatal PE (0.2%; 95% CI 0-0.9%), four patients died from malignant tumours, and one from pneumonia. The frequency of malignant tumours was greater in this study than in the literature (23% in patients with iliofemoral DVT, 14% in those with femoropopliteal DVT and 9% in those with DVT of the lower leg). CONCLUSION: Mobile patients with DVT do not need bed-rest. Low-molecular-weight heparin s.c., compression bandages and walking exercises make home-treatment of DVT feasible.
Aged↗
Frequency of pulmonary embolism in patients who have iliofemoral deep vein thrombosis and are treated with once- or twice-daily low-molecular-weight heparin.
PURPOSE: The purpose of this study was to compare the efficacy and safety of treating mobile iliofemoral patients with deep venous thrombosis (DVT) with subcutaneous low-molecular-weight heparin (dalteparin sodium) either 200 IU/kg once-daily (group 1) or 100 IU/kg twice-daily (group 2). METHODS: Consecutive patients with suspected iliofemoral DVT diagnosed by duplex ultrasonography and verified by radionuclide venography were randomized to one of the two low-molecular-weight heparin (LMWH) regimens. Perfusion and when necessary ventilation scans were performed for diagnosis of pulmonary emboli (PE) in all patients immediately after admission and were repeated after approximately 10 days, whereupon oral anticoagulation was started unless contraindicated. Minimal and maximal anti-factor Xa activity was measured after 2 to 3 days of therapy. All patients were kept mobile with compression bandages. The primary end point was reduction in frequency of PE as assessed on the second lung scan. RESULTS: A total of 140 patients with confirmed DVT were randomized, 76 to group 1 and 64 to group 2. The two groups were comparable in their baseline clinical characteristics. In the initial lung scans 36 (47.4%) patients in group 1 and 29 (45.3%) patients in group 2 had objectively verified PE, but only 11 (14.5%) and 8 (12.5%) patients, respectively, had symptoms. After dalteparin treatment PE disappeared in two patients in group 1, but in two other cases new PEs occurred, (NS). In group 2 a resolution of PEs was observed in eight patients, whereas only one new PE could be detected. This change reflects the efficacy of therapy as defined by resolution of existing PEs and by the occurrence of new PEs and is statistically significant according to McNemar's chi-square test with the exact binomial method pair procedure (p < 0.05). Symptomatic PE was reduced from 14.5% to 5.3% in group 1 (96% to CI for the difference, -1.5% to +17.3%) and from 12.5% to 1.6% in group 2 (95% CI for the difference 0.7% to 18%, p < 0.05). There was one single fatal PE, one serious and three minor bleeding episodes in group 1, and one minor bleeding episode in group 2 (95% CI for the difference: -3.6% to +8.1%). CONCLUSIONS: Treatment of ambulant iliofemoral patients with DVT with 100 IU/kg dalteparin twice-daily appears to be moe safe and effective than 200 IU/kg given once-daily. Bed rest is not necessary for treating mobile patients.
Aged↗
Classification and grading of chronic venous disease in the lower limbs. A consensus statement.
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Chronic Disease↗
Ultrastructural study of the dermal microvasculature in patients undergoing retrograde intravenous pressure infusions.
BACKGROUND: Retrograde intravenous pressure infusion (RIPI) of drugs, e.g. antibiotics, under arterial occlusion (Bier's block) allows high local tissue concentrations in the extremities. This technique is of particular value in the antibiotic treatment of infected diabetic foot lesions. OBJECTIVE: The aim of our study was to look for morphological changes of the dermal microvasculature induced by RIPI. METHODS: In 7 patients with infected diabetic foot lesions, punch biopsies were taken from the calf skin before and at the end of RIPI and studied by light and electron microscopy. RESULTS: RIPI induced a dilatation of venous capillaries and postcapillary venules, loosening of contacts between endothelial cells (EC) with focal formation of small gaps in the vessel wall and a widening of the space between EC and pericytes. Lymphatic vessels were markedly dilated. In contrast, arterioles did not exhibit signs of morphological alteration. RIPI did not produce cellular damage of blood and lymphatic vessels. CONCLUSIONS: The morphological changes of dermal vessels induced by RIPI are presumably due to a rapid rise in venous pressure. Our morphological observations support results of previous hemodynamic and nuclear medical investigations, which showed that RIPI enhances the filtration and diffusion of molecules into the interstitium, leading to high local tissue concentrations. The venous capillaries and postcapillary venules are involved in this process in particular.
Aged↗
[Artificial edema of the extremity].
Our report describes a 46-year-old woman with self-inflicted oedema of the left leg and the left arm. She induced leg oedema by an elastic bandage tourniquet and arm oedema by holding her arm dependent and immobile. A preexisting disorder of the affected leg (postthrombotic syndrome) and of the affected arm (hypoesthesia subsequent to surgical injury of the plexus brachialis) delayed the diagnostic proceedings. Our case report shows that: Confirmed presence of organic disease does not exclude limb oedema of self-inflicted origin. Oedema resulting from a tourniquet and "hysterical oedema" can be developed by one and the same patient. Effective care of such patients is only possible if dermatologist and psychiatrist work together all the time (liaison psychiatry).
Diagnosis, Differential↗