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PubMed2000

[Thromboembolic diseases in children].

The incidence of thromboembolic diseases in children is increasing, probably as a consequence of medical progress and modern intensive care. Due to lack of scientific evidence, clinical recommendations for treatment of children are mainly based on opinions and extrapolations from adult medicine. This article presents current concepts of thromboembolic diseases in children, based on a review of the literature. Characteristic features are presented and differences between the disease in adults and children are outlined. Guidelines for antithrombotic treatment are provided. We suggest that screening for thrombophilic disorders should be performed on wide indications, and that modern principles of treatment in adult medicine should also be applied for children with thromboembolic diseases.

Adult↗
PubMed2000

A comparative double-blind, randomised trial of a new second generation LMWH (bemiparin) and UFH in the prevention of post-operative venous thromboembolism. The Bemiparin Assessment group.

A randomised, prospective, double-blind trial was performed, to compare the safety and efficacy of a new low-molecular-weight heparin (LMWH) Bemiparin and standard unfractionated heparin (UFH), for the prophylaxis of postoperative venous thromboembolism. 300 patients scheduled to undergo elective hip arthroplasty were included. The principal outcome measures were the incidence of thromboembolic events and bleeding complications. 149 patients received 3,500 anti-Xa IU of bemiparin plus a placebo injection daily and 149 patients received 5,000 IU of UFH twice a day. The two groups were similar with respect to factors likely to affect the risk of developing post-operative venous thromboembolism (VTE) and risk of bleeding events. During the post-operative period, 34 patients developed VTE complications; 9 (7.2%) in the bemiparin group and 25 (18.7%) in the UFH group. VTE in the two groups was statistically significant (OR of 2.96; 95% CI 1.32-6.62 and p = 0.01). There were no significant differences in the frequency of bleeding complications: major bleeding requiring discontinuation of prophylaxis, (OR 1.21; 95% CI 0.36-4.05; p = 1.00), the measured median operative blood loss (p = 0.77) or the median postoperative drain loss (p = 0.97), and the number of patients who developed wound haematoma (OR 0.87; 95% CI 0.31-2.46; p = 1.00). A comparison of coagulation parameters on the preoperative day with post-operative day 2 +/- 1, day 6 +/- 1 and day of discharge showed a significantly higher AT concentration, anti-factor Xa activity and TFPI levels in the bemiparin group when compared with UFH. This study demonstrates that bemiparin, in a single daily subcutaneous dose of 3,500 anti-Xa IU in high risk patients undergoing hip arthroplasty is more effective than UFH administered twice daily at a dose of 5,000 IU in the prevention of postoperative VTE. Both agents are equally safe.

Aged↗
PubMed2000

Peripartum cardiomyopathy presenting as lower extremity arterial thromboembolism. A case report.

BACKGROUND: Although venous thromboembolism has been associated with peripartum cardiomyopathy, there have been no prior reports of lower extremity arterial thromboembolism complicating cardiac failure. CASE: A 38-year-old woman, gradiva 5, para 5, presented on postpartum day 9 with left pedal parasthesia. Lower extremity angiography found acute thrombotic emboli in the left popliteal artery, right tibial artery and right peroneal artery. When respiratory decompensation ensued, a transthoracic echocardiogram revealed global hypokinesis and a left ventricular ejection fraction of 30%. The patient had an uneventful recovery after treatment with digoxin, furosemide and intravenous heparin. CONCLUSION: Lower extremity arterial thromboembolism may be the initial manifestation of peripartum cardiomyopathy.

Adult↗
PubMedDate not supplied

The damage to a person caused by venous thromboembolism in the civil responsibility.

The venous thromboembolism can clinically show itself as deep venous thrombosis or as pulmonary embolism. Both serious and potentially fatal, for this high incidence, they assume importance in social economic sphere. The authors take into account the medicolegal diagnostics methodology of the deep venous thrombosis and of the pulmonary embolism, the traumatic and post traumatic etiology, to determine the connection of causality and the estimating parameters of the damage to a person in the sphere of civil responsibility. To attain to a certain diagnosis of thromboembolism, since its difficult cause of paucisymtomaticity or asymtomaticity of the pathology after an attentive evaluation of symptoms, clinic manifestations and factors of risk, it can't be disregarded to utilize scientific diagnostic criteria, and instrumental ascertainments, serial too, helped by conventional means of standardization, such as the new American system of classification CEAP. The following phases of medicolegal ascertainment consist in identifying the causal connection between disease and event and in estimating of the damage to a person, with rigorous and objective methodology and using tabular orientation guides, that have to indicate the percentage incidence of the undergone disablement on the person's validity for indemnity. It is showed the particular delicacy of the medical examiner's evaluation in thromboembolic disease, in the sphere of civil responsibility, both for the difficulties of the diagnostic identification of the deep venous thrombosis, and of the pulmonary embolism, and for the determination of the connection of causality with traumatic events and with following operation of orthopedics-traumatology and neurosurgery (sector on which the most difficult problems of professional responsibility can connect) and finally for the real evaluation of the consequent damage to a persons, in order to its indemnity.

Diagnostic Errors↗
PubMed2000

Nomograms for the administration of unfractionated heparin in the initial treatment of acute thromboembolism--an overview.

Despite the availability of low-molecular-weight heparins, unfractionated heparin (UFH) still remains the drug of choice for the initial treatment of acute venous thromboembolism in many countries. When appropriately employed, UFH treatment results in a degree of efficacy and safety that is fully comparable with that obtained with the use of heparin derivatives. The use of nomograms for the intravenous or subcutaneous administration of UFH assures that virtually all patients will promptly achieve adequate levels of anticoagulation, thus decreasing the likelihood of recurrent venous thromboembolism without extra bleeding-risk. In this article we reviewed clinical studies on the implementation and validation of UFH dosing nomograms, and attempted a quantitative analysis of their performance. According to the results of our analysis, a statistically significantly higher proportion of patients treated on the basis of a nomogram reached a therapeutic anticoagulant level within 24 h of treatment, as compared to patients treated following the standard practice (odds ratio, 3.6; 95% CI, 2.6 to 4.9). The rate of recurrent thromboembolic events was significantly lower for patients treated according to a nomogram (odds ratio, 0.3; 95% CI, 0.1 to 0.8), while no significant differences in terms of either major or minor bleedings were detected between nomogram patients and controls.

Algorithms↗
PubMedDate not supplied

Prevention of thromboembolic complications in the rehabilitation center: diagnostic and risk factor stratification tools.

Patients who present "at risk" to physical medicine and rehabilitation centers for venous thromboembolic disease are often challenging if a management strategy is not preestablished. There are many recommendations in the medical literature, with guidelines on prophylaxis techniques and methods that can be used in the physical medicine and rehabilitation patient population. It is important that management strategies be used that further promote the quality of medical care while providing an economic justification. In our institution, we regularly follow a process for stratifying the risk of developing deep venous thrombosis complications in the acute care setting and then continuing appropriate prophylaxis management into the rehabilitation facility. The purpose of this report is to present one method of stratifying patient risk for thromboembolic complications and maintaining appropriate thromboembolic prophylaxis during the risk period. In addition, this report aims to provide practical management recommendations for the PM&R provider.

Algorithms↗
PubMed2001

Silent thromboembolic events associated with the treatment of unruptured cerebral aneurysms by use of Guglielmi detachable coils: prospective study applying diffusion-weighted imaging.

BACKGROUND AND PURPOSE: Aneurysm embolization using Guglielmi detachable coils (GDC) is gaining increasing acceptance as a viable alternative to surgery in the treatment of cerebral aneurysms. Although recent reports describe a significant rate of symptomatic thromboembolic complications with GDC use, many of the neurologic deficits are transient. We sought to determine the incidence of silent thromboembolic events with the use of diffusion-weighted imaging and to correlate radiologic findings with the results of neurologic examinations. METHODS: Diffusion-weighted MR imaging was performed within 48 hours in 14 consecutive elective GDC aneurysm treatments. Embolizations were performed under systemic heparinization; all flush solutions were heparinized, and both guiding catheters and microcatheters were placed for continuous heparinized infusions. Neurologic examination, including the National Institutes of Health Stroke Scale determination, was performed by a stroke neurologist before the coiling procedures were performed, immediately after the procedures were performed, and before discharge. MR imaging examinations were reviewed by a stroke neurologist and an interventional neuroradiologist, with determination and characterization of diffusion-weighted imaging abnormalities. RESULTS: Small areas of restricted diffusion, presumed to represent procedure-related embolic infarctions, were noted on the images of eight of 14 patients. All except one of the areas were located ipsilateral to the side of the catheterization. Six patients had evidence of multiple infarcts. Most lesions were small (<2 mm); one patient with coil stretch and herniation into the parent vessel had numerous infarcts with a dominant posterior frontal infarct. Pre- and posttreatment National Institutes of Health Stroke Scale scores were unchanged for 13 of 14 patients. Overall, the rate of asymptomatic emboli was 61% (eight of 13 treatments) in uncomplicated treatments. Strokes occurred independently of the number of coils used; the mean number of coils used for patients with strokes was 7.6 (range, two to 13) and for patients without evidence of infarcts was 10.2 (range, one to 30). This was not a significant difference (P > .5). CONCLUSION: Silent thromboembolic events related to the use of the GDC system are a common occurrence, despite meticulous technique and systemic anticoagulation. Although clinical sequelae are rare, the high rate of occurrence suggests that alterations in the technique, such as the addition of antiplatelet agents, should be considered.

Adult↗
PubMed2000

[Comparative efficacy of low molecular heparin (fraxiparine), non-fractionized heparin and anti-aggregate therapy in the prophylaxis complex for thromboembolic complications after surgical interventions performed for oncological disease].

Thromboembolism is one of the most frequent postoperative complications, which lead to exitus letalis in many of the patients. The thromboembolism occurrence is the most frequent in oncological diseases. Anticoagulants of direct action the nonfractionized heparin and low molecular weight heparins are applied for prophylaxis of thromboembolic complications. Their usage in combination with antiaggregative preparations is undesirable because of the bleeding occurrence threat. Comparative studying of prophylactic action and the haemorrhagic complications frequency under the usage of heparin, fraxiparin and antiaggregative preparations was performed in 462 patients. Maximal activity of low molecular weight heparins vs such of nonfractionized heparin and antiaggregative preparations was proved. The trustworthy enhancement of the bleeding frequency and of the blood coagulating system was not noted in the combined application of fraxiparin and antiaggregative preparations.

Adult↗
PubMed2001

[Thromboembolic complications in the use of oral estrogen-gestagen contraceptives].

Deep vein thrombosis is a serious complication of oral contraception. The most serious complication, pulmonary embolism, could be lethal. The relative risk of thromboembolic disease is four time higher in women using oral contraception. Both the amount of estrogen and the type of gestagen can increase the relative risk of thromboembolic disease. Oral contraceptives influence procoagulants, fibrinolytic system and inhibitors of coagulation. The choice of oral contraceptive should be very careful. It is advised to use preparations with less then 50 micrograms of ethinyl-estradiol and the type of gestagen that has minimal metabolic side effects, including minimal effect on coagulation. It is not recommended to perform screening of trombophilia before prescribing oral contraception. Family history of thrombosis is indication for more detailed investigation. However in the case of positive history of thromboembolic disease use of oral contraception is contraindicated. Oral contraception users should be informed about increased risk of deep vein trombosis, and what to do to prevent deep vein thrombosis.

Blood Coagulation↗
PubMed2001

Venous thromboembolism and melanoma.

The association between venous thromboembolism and cancer has been known for many years. The clotting system may be activated because of enhanced platelet aggregation and adhesion or by stimulation from the endothelial cells or the tumour cells themselves. Furthermore, thrombosis may develop as a result of prolonged immobilization, surgery, chemotherapy or hormone therapy. We present a case of a patient who underwent surgery for excision of a Clark level II melanoma on the back who developed pulmonary metastasis four years after the operation. The metastasis manifested with very severe venous thromboembolism which, despite anticoagulant therapy and the placement of a vena caval filter, led to the patient's death from pulmonary embolism. The case is uncommon, in terms of both the rarity with which venous thromboembolism is associated to melanoma, and the severity with which it manifested.

Humans↗
PubMed2001

[Prevention of thromboembolism in non-rheumatic atrial fibrillation: an update].

Randomized clinical trials have demonstrated the efficacy and safety of oral anticoagulants in the prevention of systemic thromboembolism in nonrheumatic atrial fibrillation. The benefit of this treatment is particularly evident in patients in whom atrial fibrillation is associated with a major risk factor for systemic thromboembolism (patients > 75 years of age, history of hypertension, previous left ventricular failure or previous systemic thromboembolism) or those in whom two minor risk factors are present (patients between 65 and 75 years of age, diabetes, ischemic heart disease). According to these recommendations, all the patients > 75 years of age with chronic or paroxysmal atrial fibrillation should receive oral anticoagulant treatment to maintain an INR between 2.0 and 3.0. However, as the risk of bleeding during oral anticoagulant treatment increases with age, the benefit/risk ratio should always be evaluated in elderly patients. Although high risk patients do not benefit from aspirin treatment, aspirin or other antiplatelet agents might be indicated in medium risk patients or in those in whom the risk of bleeding with oral anticoagulants is considered too high. New antithrombotic regimens will be tested in the near future.

Administration, Oral↗
PubMed2001

[Prevention of thromboembolic complications in laparoscopic surgery].

The rate of thromboembolic complications was studied in 6672 patients who underwent laparoscopic intervention. The effectiveness of preventive use of low-molecular weight heparin fraxiparine was evaluated. 5 patients (0.075%) developed deep veins thrombosis, 2 patients (0.03%)--pulmonary thromboembolis. The general rate of thromboembolic complications was 0.11%. Specific prevention by fraxiparine together with decrease of mean duration of operation, maintaining insufflation pressure equal or less than 1.6 kPa (12 mm Hg), periodical exsufflation every 30-40 min and turning of the patient into Trendelenburg's position permitted to reduce the rate of thromboembolic complications to 0.045%.

Adolescent↗
PubMed1975

Platelets, hemostasis, and thromboembolism during treatment of acute respiratory insufficiency with extracorporeal membrane oxygenation.

Twenty-eight patients were supported with long-term extracorporeal membrane oxygenation as a treatment for acute respiratory insufficiency. Clinical, laboratory, and autopsy data concerning platelets, hemostasis, and thromboembolic disease are presented for the periods during and after bypass. During bypass, a "foreign-surface coagulopathy" was encountered which consisted of abnormal bleeding plus frequent, generalized, small and large vessel thromboembolic events. The abnormal bleeding is attributed to heparin, thrombocytopenia, and a qualitative platelet defect. Possible causes of the thromboembolic events including disseminated intravascular coagulation are also discussed, and speculations are offered concerning clinical management and directions for future investigation.

Adolescent↗
PubMed2001

[Thromboembolism in travelers].

The association between long haul travel and the risk of venous thromboembolism are suspected for long time. Mostly air travel related thrombosis series have been reported in the literature. Risk factors can be classified as: 1. travel related factors (coach position, immobilization, prolonged air travel, narrow seat and room, diuretic effect of alcohol, insufficient fluid intake, dehydration, direct pressure on leg veins, rare inspiration). 2. air plane related risk factors (low humidity, relative hypoxia, stress). 3. patient related factors (hereditary and acquired thrombophylia, previous deep venous thrombosis, age over 40, recent surgery or trauma, gravidity, puerperium, oestrogen containing pills, varicosity, chronic heart disease, obesity, fever, diarrhoea, vomiting, smoking). No patient related factors were found in some cases. To reduce the hazards air travellers are rightly concerned to know the level of the risk and the airlines should be responsible for this information. People should discuss with their physician what prophlylactic measures should be taken, such as compression stockings or low molecular weight heparin. Not only flight but car, bus and train travellers are also at risk of developing venous thromboembolism. Long haul travel alone is a separate risk factor for venous thromboembolism.

Humans↗
PubMed2001

[Thromboembolism complications in tumor diseases: pathophysiology, risk factors and preventive approaches].

Thromboembolic complications are among the most common causes of death in cancer patients and result in considerable reduction in quality of life in patients affected. Besides immobilization therapeutical interventions such as surgery, chemotherapy and insertion of an indwelling central venous line have been identified as additional risk factors for thromboembolism. While postoperative prophylaxis is recommended, anticoagulation in presence of other risk factors, especially concerning cost-benefit ratio, is still a matter of debate. Evaluation of genetic risk factors for thromboembolism may add in the near future to the decision-making process to provide cancer patients with antithrombotic prophylaxis. With the introduction of low molecular weight heparin to clinical practice clinicians now face an alternative option to oral anticoagulants for long-term therapy and prophylaxis. Suggestive evidence that low molecular weight heparin reduce mortality of cancer patients independent of cardiovascular causes have stimulated intensive clinical efforts to reinvestigate anticoagulation in cancer patients.

Anticoagulants↗
PubMed2002

Use of managed care claims data in the risk assessment of venous thromboembolism in outpatients.

BACKGROUND: Deep vein thrombosis (DVT) is a complication of immobilizing illness in both inpatient and outpatient settings and can lead to serious complications such as pulmonary embolism (PE). DVT and PE are collectively referred to as venous thromboembolism. OBJECTIVE: To develop DVT and PE risk assessment models that can be used in office-based practice and for population-based disease management efforts. METHODS: Data were culled from integrated medical and pharmacy claims paid by 37 health plans in the United States (the PharMetrics Integrated Outcomes Database, PharMetrics Inc., Watertown, MA), and included information on adult plan members enrolled during 1998 and 1999. Patients hospitalized for DVT or PE in 1999 were identified, and potential risk factors were assessed by reviewing claims for the entire study population in 1998 to document prior DVT or immobilizing illness. The contribution of each potential risk factor to the probability of the occurrence of DVT or PE was determined by means of multiple logistic regression analysis. A risk-scoring algorithm based on regression coefficients was then developed. RESULTS: Fifty-two percent of the study population of 2.8 million plan members were women. DVT or PE occurred in 1330 of those 2.8 million individuals (47 per 100,000). Logistic regression results confirmed the role of risk factors previously reported in the literature and revealed additional risk factors that have not been reported previously, including diabetes, renal failure, rheumatoid arthritis, cellulitis, use of warfarin, use of systemic corticosteroids, and use of potassium chloride. When risk scores were applied to the study population, the 1% identified as being at highest risk had a probability for the development of venous thromboembolism that was 10 times greater than that of the population average. CONCLUSIONS: This study confirms the feasibility of using managed care claims data to develop a risk assessment tool for venous thromboembolism that can be used in office-based practice and for population-based disease management.

Adult↗
PubMed2002

[Relation between left atrial spontaneous echocontrast and pulmonary venous flow in nonvalvular atrial fibrillation: implications for stratification of thromboembolic risk].

BACKGROUND: The links between pulmonary venous flow (PVF) and left atrial stasis have not been adequately defined in nonvalvular atrial fibrillation. In this setting, we aimed to study the relationship between PVF and the occurrence of left atrial spontaneous echocontrast (SEC) in order to evaluate its clinical relevance in the assessment of the cardioembolic risk. METHODS: We studied by echocardiography 109 patients with nonvalvular atrial fibrillation (65 males, 44 females, mean age 66 +/- 9 years). The left ventricular end-diastolic and end-systolic diameters, the left ventricular fractional shortening, the left ventricular mass, and the left atrial volume were measured by transthoracic approach. The systolic and diastolic peak velocities of PVF, their ratio (pS/pD) and the velocity-time integrals were assessed by means of transesophageal investigation; furthermore, the presence of left atrial SEC or thrombi was recorded. Among clinical data, thromboembolic events occurring within 15 days before the echocardiographic study, history of hypertension and duration of atrial fibrillation were also collected. RESULTS: Left atrial SEC showed a significant correlation with left atrial volume (p < 0.001), detection of thrombi (p < 0.001), thromboembolic events (p = 0.002) and pS/pD ratio (p < 0.001). By multivariate analysis, pS/pD ratio was independently correlated with left atrial volume, age and left ventricular fractional shortening (r2 = 0.29, p < 0.001). The sensitivity and specificity of pS/pD ratio to predict the presence of severe SEC was 73.9 and 62.5%, respectively. CONCLUSIONS: In patients with nonvalvular atrial fibrillation, pS/pD ratio is significantly related to the occurrence of left atrial SEC and seems to be a useful parameter concurring to assess left atrial stasis and thromboembolic risk.

Aged↗
PubMed2002

[Venous thromboembolism in Cameroon (report of 18 cases)].

The purpose of this report was to describe clinical and ultrasound findings associated with venous thromboembolism of the lower extremities and pulmonary embolism observed in our department with special emphasis on the utility of venous ultrasound in the diagnosis of venous thromboembolism. Between January 1, 1998 and December 31, 1999, a total of 47 venous ultrasound procedures were carried out according to the standard technique using a Logic 400 MD system (General Electric). Deep venous thrombosis was diagnosed in 18 cases (38.3%). There were 10 men and 8 women with a mean age of 46 years (range, 24 to 71 years). Thrombosis involved the internal saphenous, popliteal, or sural vein in 12 cases, the common or deep femoral vein in 4, and the external iliac vein in 2. The most common risk factors observed in our series were surgery, predisposing conditions, history of venous thrombosis and morbid obesity (66.8% of case). Prolonged periods of bed confinement and neoplasm (lower extremity Kaposi's disease) were more uncommon (22.2%). Pulmonary embolism occurred during the observation period in six cases (33.3%) including 3 (50%) that were fatal. Based on these findings it can be concluded that although its incidence is relatively low in black African patients at risk, thromboembolic disease is often fatal and requires routine preventive treatment using heparin.

Adult↗