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Our experience with 101 consecutive T.H.A.'s in 91 patients was examined in an attempt to identify preoperative risk factors for postoperative medical complications, especially pulmonary embolism and thrombophlebitis. Six per cent of patients developed postoperative clinical thrombophlebitis, and 8% a pulmonary embolism. Advancing age and previous venous thrombosis served as predictors for pulmonary embolism and thrombophlebitis, respectively (p less than 0.01), but obesity, venous varicosities, diabetes mellitus, cigarette smoking, previous pulmonary embolism, and length of surgery did not, for either. Fifty per cent of the patients with preoperative abnormal kidney function developed some form of medical complication postoperatively, a significant increase in risk (p less than 0.05) over patients with normal kidney function. We were unable to identify an increase in postoperative atelectasis or pneumonia associated with smoking or obesity in these patients. No consistent decrease in post-operative medical morbidity could be assigned to preoperative medical consultations, suggesting that we have not yet identified all significant risk factors. A thorough preoperative preparation and improvement in intra- and postoperative techniques and management may account for differences found in this study from traditionally held risk factors.
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PMID:Risk factor assessment in 101 total hip arthroplasties: a medical perspective. 47 24

The most important side effects of oral contraceptives (OCs) and their incidence, together with advice and monitoring of the patient at risk, are pointed out. There is a mild increase in blood pressure in longterm contraceptive use caused by increased angiotensinogen production by the liver. It is significant only for women with a history of familial hypertension, diabetes mellitus, or pre-eclampsia. Smoking increases this risk. Urinary tract infections are 25-50% more frequent in pill users. Glucose tolerance is slightly decreased. Contraceptives' diabetogenic effect is higher in women with hereditary tendency for diabetes, latent diabetes, and/or obesity. They are contraindicated in latent diabetes. Findings are contradictory in their effects on cholesterol and triglyceride serum level, but the pill is contraindicated in lipid metabolism disorders. There is an increased incidence in cholecystitis and cholelithiasis in pill-users (70-80 additional cases/100,000 user years). Liver diseases, intrahepatic cholestasis, occur rarely and benign liver tumors have not conclusively been proved to be caused by the pill. A variety of laboratory findings have been related to contraceptive use and drug interactions occur with barbiturates, rifampicin, hydantoin, and phenylbutazone. Blood coagulation is increased, partially by increased production of various blood coagulation factors; but more importantly, by a decreased synthesis of antithrombin III, a natural protective mechanism against intravascular coagulation. This increases thrombosis risk. Risk doubles with simultaneous cigarette smoking. Various epidemiological studies indicate a 5-10 fold increase in thromboembolism and thrombophlebitis, deep vein thrombosis, and pulmonary embolism. There is a correlation between contraceptive use and cerebrovascular disorders and myocardial infarction. This risk increases with age and years of pill use. The pill is contraindicated with symptoms of thrombophlebitis and thromboembolism, sickle cell anemia, proposed surgery, and longterm immobilization. Overall risk factors are not too high. Recommendations for rational pill use related to age are given and further contraindications are mentioned.
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PMID:[Adverse effects of oral contraceptives]. 55 52

A case of chorea in a woman taking oral contraceptives, without a previous history of chorea or rheumatic fever, is presented. All laboratory findings were normal except for a considerable increase in triglyceride levels. Complete recovery occurred within 4 months after discontinuing the contraceptive treatment, without any other treatment. It is suggested that the contraceptive steroids may cause some metabolic disorders, which produce secondary vascular disorders. It is emphasized that oral contraceptives should be prescribed only to patients whose anamesis rules out precedents of or predisposition to vascular diseases (thrombophlebitis of the lower limbs, obesity, arterial hypertension, hyperlipidemia, diabetes, tabagism, migraine, or temporary ictus).
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PMID:[Chorea and the use of contraceptives]. 100 33

The postphlebitic syndrome is a significant management problem that affects a large number of patients. Primary prophylaxis of deep-vein thrombophlebitis would reduce the risk of developing the postphlebitic syndrome and should be considered in high-risk patients. Patients who have had a phlebitis should be monitored with noninvasive tests of the deep venous circulation for the development of venous valve incompetence. Patients with venous hypertension should be placed in compression stockings to prevent the postphlebitic syndrome. In patients who progress to venous ulceration, several aggressive measures must be undertaken. Systemic treatment includes management of obesity, edema, immobility, poor nutrition, and comorbid illnesses. Some patients may require a short hospitalization of bed rest, lower limb elevation, and daily dressings and wound care. Outpatient therapy requires sustained compression of 35 to 40 mmHg at the ankle for many months to allow the ulcer to heal. The standard bandage material is Unna's boots, which is applied every one to two weeks by a trained nurse. Cadexomer iodide is an effective local treatment that helps debride the ulcer and accelerate healing. Finally, pentoxifylline therapy has also been shown to significantly improve the healing of venous ulcers.
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PMID:Contemporary treatment of venous lower limb ulcers. 147 73

The complications of surgical treatment for lumbar disc herniation (LDH) are important to know, but hard to measure because of their low incidence and varied pattern. Using data from the National Hospital Discharge Survey, which codes discharges and procedures according to the ICD-9-CM, we assessed acute complication rates for 3,289 surgically treated LDH patients and 4,025 nonoperative LDH patients, identifying complications from codiagnoses. The complication rates were significantly correlated with the postoperative length of stay and with the risk factors of obesity, hypertension, and diabetes. We found fewer instances of thrombophlebitis (0.3/1,000) and slightly lower mortality (0.9/1,000) than previously reported. Although the frequency of the cauda equina syndrome in the literature approximates our findings of 5/1,000, our data did not allow correction for the fraction of preexistent cauda equina syndromes. Our any-complication-rate is 3.7%. Even though LDH surgery is relatively safe, its complications should not be overlooked.
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PMID:Acute complications in patients with surgical treatment of lumbar herniated disc. 213 9

We examined 182 patients (257 knees) who had had a total knee arthroplasty two to five six years earlier. The patients were grouped into five weight classes. Eighteen patients (twenty-seven knees) were considered moderately obese and twelve patients (twenty-seven knees), severely obese. The results in all but four knees were rated excellent or good. One patient needed a revision procedure for late infection, and the result was rated poor. Three results were rated fair. There was no discernible difference in the over-all scores among the five weight groups. However, 30 per cent of the knees of the moderately and severely obese patients had patellofemoral symptoms, whereas the incidence was 14 per cent in the other groups (p less than 0.03). No clear-cut association was found between obesity and either thrombophlebitis or complications related to the wound.
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PMID:Total knee arthroplasty in obese patients. 222 20

Obesity is assumed to be a risk factor in the occurrence of thrombophlebitis. We studied 168 consecutive patients retrospectively; 33 were men and 135 women, with an average age of 34 (range 27 to 41) years. All patients had a gastric bypass because of obesity, with a minimum of 100 lb over normal weight. The mean weight was 279.2 lb (range 191 to 500). Only three patients had a history of deep vein thrombophlebitis, with no thromboembolism. Eighty-four of the patients were studied preoperatively by noninvasive means (Doppler, impedance plethysmography [IPG], phleborheography [PRG]); 12 had evidence of old disease, and two had a history of treated deep vein thrombophlebitis. No patient had prophylactic therapy. The incidence of clinical deep vein thrombophlebitis was zero; noninvasive evaluation in 64 patients demonstrated no abnormality. Postoperative thromboembolism, which occurred in three of 168 (1.8%) patients, was confirmed by ventilation-perfusion scan and pulmonary angiogram. The mortality from thromboembolism was less than 1% (1/168 patients). Extreme obesity may not necessarily constitute a major risk factor in the occurrence of postoperative deep vein thrombophlebitis and thromboembolism. Prophylactic medications and therapy may add inappropriate risk, undue cost, and unnecessary discomfort, and must be weighed against a mortality of less than 1%.
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PMID:Obesity: is it really a risk factor in thrombophlebitis? 331 Feb 49

In acute thrombosis of deep veins of the lower extremities, post-thrombotic syndrome develops in 75% of cases and leads to premature debilitation in 1/3 of the patients. Besides known thrombogenic causes, hormonal preparations more and more often are factors in occurrence of acute thrombosis. There is no doubt that hormonal contraceptive agents are the most reliable method of preventing pregnancy. Their widespread use has resulted in a significant decrease in septic abortions with serious consequences. The purpose of this article is not to discredit this method of preventing pregnancy, but merely to ascertain the presence or lack of a link between thromboembolic diseases and the use of hormonal contraceptive agents. Disturbance of the balance between clotting and anti-clotting systems contributes to development of thrombosis. Etiological factors include changes in vascular walls and functional impairment of hemodynamics. A decrease in the level of antithrombin III in the blood and also in the amount of heparinocytes after using hormonal contraceptive agents has also been proven. Postoperative and postnatal hypodynamics, thrombophlebitis with chronic venous insufficiency, neoplastic syndrome and trauma are causes of acute thrombosis. Age, obesity, hypertonic disease and smoking serve as other risk factors. From 1975 to 1981, 72 women were in the surgical clinic of the Mardeburg Medical Academy for treatment of acute thromboembolic diseases: 34 were using hormonal contraceptive agents before onset of the disease; 19 smoked up to 10 cigarettes a day; and 5 smoked occasionally. After operative intervention, 20 women developed acute thrombosis; only 2 of them were using hormonal contraceptives. No clear causes of thrombosis were found in 35 women, but 32 of them were using hormonal contraceptives. Trauma was the cause in 1 woman with thrombosis of the cartoid artery. On the average, the women used hormonal contraceptives for 4.1 years before onset of the disease (3.1 years in thrombosis of veins of the lower extremities and pelvis; 5.1 in arterial thrombosis). In 28 of 34 women with acute thromboses, they were localized in the veins of the lower extremities and pelvis after taking hormonal contraceptives. Women with thromboembolic diseases after taking hormonal contraceptives had general examinations at periods from 6 months to 5 years. Development of post-thrombotic syndrome was observed in 12 women with thrombosis of veins in the lower extremities and pelvis. Thromboses without any thrombogenic causes were observed in women under 30 after taking hormonal contraceptives. Although a direct link between the use of hormonal contraceptive agents and thromboembolic diseases cannot be proven presently, taking these preparations is believed to be 1 of the risk factors in the development of these diseases.
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PMID:[Hormonal contraceptive agents as a risk factor in the development of acute thromboembolic diseases]. 382 Oct 1

Oral contraceptives (OCs) were first introduced more than 30 years ago. OC manufacturers have reduced the dosage of synthetic estrogens (e.g., ethinyl estradiol, 100-150 mcg to 20-35 mcg) and progestins to limit their metabolic effects on lipoproteins, carbohydrates, and hemostasis. In addition to protection from pregnancy, OC benefits include lower incidence of painful periods, excessive bleeding, and iron deficiency anemia; reduction of ovarian cysts, benign breast tumors, and pelvic inflammatory disease; and protection against endometrial and ovarian cancers. The risk of a cardiovascular event (myocardial infarction, cerebrovascular events, venous thromboembolism, and deep vein thrombophlebitis) in OC users is 1-2/100,000 women years. Cardiovascular risk factors include smoking, hypertension, lipid disorders, severe obesity, diabetes mellitus, and cardiovascular events in first degree relatives before age 40. Thus, women with any of these risk factors should not use OCs. OCs do not increase the risk of breast cancer in women less than 59 years old. They may increase this risk if used over a long duration before the first fullterm pregnancy. OCs may cause a modest increase in cervical neoplasia. Low-dose OCs have a small effect on lipid metabolism. OCs increase serum triglycerides 30-50%. OCs increase insulin secretion and hyperinsulinemia increases the cardiovascular risk. Practitioners should evaluate clients before prescribing OCs. They should not prescribe OCs to women with hypertension, diabetes mellitus, lipid disorders, gynecological cancers, and previous cardiovascular disorders. Practitioners should tell clients that smoking is a leading risk factor and about OC's side effects (e.g., menstrual disturbances). The physical exam should include a cervical PAP smear, gynecological exam of the uterus and the ovaries, and a breast exam. Practitioners should test cholesterol and triglycerides before and during OC use. Premenopausal healthy women with no risk factors can use low-dose OCs.
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PMID:Update on oral contraception. 836 2

The pattern of postoperative pyrexia in Khartoum was prospectively studied in 260 patients who underwent a variety of surgical operations. Ninety four patients (36.1%) developed postoperative pyrexia. The commonest causes of pyrexia encountered were wound sepsis (10%), malaria (9.6%) and respiratory tract infection (7.3%). Less frequent causes were urinary tract infection, thrombophlebitis, intra-abdominal sepsis and deep vein thrombosis. In 14.6% of the patients, the cause of pyrexia was undetermined. The risk factors for postoperative pyrexia were the patient's age, diabetes mellitus, obesity, preoperative chest infection, smoking, duration of surgery, operator's surgical experience and urethral catheterisation. The postoperative pyrexia was associated with 7.4% mortality rate which was due to intra-abdominal sepsis and pulmonary embolism. The incidence of postoperative pyrexia can be minimised by adequate preoperative preparation, meticulous surgical technique and good postoperative care.
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PMID:Pattern of postoperative pyrexia in Khartoum. 862 71


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