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This study was undertaken to survey the current practice for venous thromboembolism (VTE) prophylaxis in Irish hospitals. A questionnaire was completed by 293 Irish consultant hospital doctors for the period October 1991 to December 1992 regarding their policy for VTE prophylaxis. Of the doctors surveyed, 36.85% are physicians, 27.3% are surgeons, 20.1% obstetricians and gynaecologists and 15.7% anaesthetists. 94% of physicians initiated DVT prophylaxis in their 'at risk' patients. 94% of the surgeons and 92% of the obstetricians/gynaecologists had used VTE prophylaxis and usage in both groups was more common in high risk patients. Anaesthetists reported VTE prophylaxis being used in an average of 20% of operations. Physicians considered the most important risk factors to be immobility, the period post myocardial infarction and a history of previous DVT. Other factors considered important by surgeons included advancing patient age and malignancy while obstetricians thought obesity to be a major risk factor. The most favoured prophylactic measures used by all doctors surveyed were subcutaneous heparin and elastic (TED) stockings.
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PMID:Prophylaxis of venous thromboembolism in Irish hospitals. 810 28

Little is known about the pattern of Deep Vein Thrombosis in Saudi Arabia. Over 4 year period, 62 cases with strong evidence of venous thrombosis were studied in King Abdulaziz University and King Fahad Hospitals to learn the pattern of deep vein thrombosis in Jeddah, Western Saudi Arabia. There were 32 females and 30 males. The mean age of the group was 36.0 years (range 6-90 years). One or more risk factors was/were detected in 40 patients. Among these 14 factors, age more than 50 years, obesity, vasculitis, malignancy and postpartum were the common factors encountered. In other 22 patients, no risk factor was found. However, extensive laboratory search diagnosed 9 rare disorders out of these 22 cases. Antithrombin III, protein C, protein S deficiencies in 5, 2, 1 patients, consecutively. The last patient had significantly shortened PTT. The other 13 (21.0%) patients were considered real idiopathic DVT. Extremities were involved in 54 patients compared to only 8 cases with inferior vena cava or visceral thrombosis. The upper limb was affected in only 10 patients unlike the lower limb which was more commonly affected n = 37.
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PMID:Pattern of deep venous thrombosis in Jeddah area, western Saudi Arabia. 837 13

In an open, randomized, prospective, interindividual trial, the incidence of thrombosis with (n = 126) and without (n = 127) LMWH prophylaxis once a day was determined in 253 outpatients immobilized in a plaster cast due to an injury of the lower limb. Furthermore, the influence of possible risk factors on the thrombus formation was determined. The histories of the patients were comparable. The average period of plaster cast immobilization was 15.7 days and did not differ between treatment groups. Thrombosis was diagnosed by compression ultrasound; patients with positive findings were investigated by means of ascending phlebography. There were 21 cases of thrombosis in the group without prophylaxis (16.5%) and only six cases of thrombosis (4.8%) with LMWH. This difference is statistically significant (2p < 0.01). Crucial risk factors were age over 30 years, obesity, varicose veins, and fractures. Patients without prophylaxis who had fractures developed DVT in 29% in contrast to 11.3% in patients with soft-tissue injuries. This study shows that LMWH prophylaxis should be mandatory for plaster cast immobilized patients regardless of preexisting risk factors for thromboembolism.
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PMID:Low molecular weight heparin for the prevention of thromboembolism in outpatients immobilized by plaster cast. 839 16

The European Concerted Action on Thrombosis (ECAT) DVT Study was a collaborative study of preoperative haemostatic tests in prediction of DVT (diagnosed by routine bilateral venography) after elective hip replacement. 480 patients were recruited in 11 centres across Europe. Clinical risk factors were assessed, and stored citrated plasma aliquots were centrally assayed for 29 haemostatic factors according to the ECAT methodology. 120 (32%) of 375 evaluable patients had DVT, and 41 (11%) had proximal DVT. Among clinical variables, DVT was significantly associated with increased age, obesity, and possibly non-use of stockings. Of the 29 haemostatic factors, mean preoperative levels were significantly higher in patients with subsequent DVT (on univariate analyses) for factor VIII activity, prothrombin fragment F1+2, thrombin-antithrombin complexes, and fibrin D-dimer; and significantly lower for APTT and APC sensitivity ratio. Factor V Leiden was also associated with DVT. Most of these variables were also associated with age, while D-dimer was higher in patients with varicose veins. On multivariate analyses including clinical variables, only a shorter APTT (locally but not centrally performed) and APC resistance showed a statistically significant association with DVT. We conclude that (a) DVT is common after elective hip replacement despite prophylaxis; (b) the study provides some evidence that DVT is associated with a preoperative hypercoaguable state; and (c) preoperative haemostatic tests do not add significantly to prediction of DVT from clinical variables, with the possible exception of APC resistance.
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PMID:Prediction of deep vein thrombosis after elective hip replacement surgery by preoperative clinical and haemostatic variables: the ECAT DVT Study. European Concerted Action on Thrombosis. 1040 61

From the information presented in this article, it can be concluded that clinical suspicion of VTE should be increased in patients with a history of VTE, recent surgery, spinal cord injury, trauma, or malignancy. A variety of medical illnesses also increase the risk of venous thrombosis, including congestive heart failure, myocardial infarction, stroke with paresis, nephrotic syndrome, cigarette smoking, and obesity. Hypercoagulable states, such as antithrombin III deficiency, protein C deficiency, protein S deficiency, or factor V Leiden mutation should be considered in those patients who develop VTE in the absence of known risk factors. Additionally, the presence of vena caval filters does not exclude the possibility of PE or recurrent DVT. With a careful assessment of risk, physicians can hope to increase the diagnostic yield of VTE and decrease the significant morbidity and mortality of caused by this disease.
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PMID:Epidemiology of venous thromboembolic disease. 1176 74

The present article focuses on the prevalence and risk factors for varicose veins and the severe stage of chronic venous insufficiency (CVI). The evaluation was made by reviewing the results of specific well-designed studies performed on the general population (case-control studies, cross-sectional studies, and large case series). Data from the literature were compared with the results of a recent multicenter cross-sectional study in Poland, in which 40,095 individuals from 803 registers of primary care physicians were clinically examined and assigned a clinical CEAP class. Analysis of the associations between varicose veins or severe CVI prevalence and factors that are usually considered as representing a risk for the development of CVI was performed. In Poland, a prevalence of varicose veins and severe CVI (skin changes, leg ulcer) similar to that observed in the other developed countries was reported. It was more common in women, but female sex was not found to be a strong risk factor. Among the risk factors most closely associated with CVI were age, family history of varicose veins, and constipation, whatever the sex. This is in keeping with findings from recent epidemiologic studies. Obesity and lack of physical activity were strongly associated with CVI in women, more so than in men. The number of pregnancies (more than 2 pregnancies) significantly distinguished between women with and without CVI. Regarding these latter risk factors, the Polish results do not contradict the commonly held beliefs that are found in the literature. A modest association was found with female sex, previous injury in legs (DVT), and remaining in the standing position for a long time, although these parameters are usually among those mostly agreed as being risk factors. The role of the prolonged sitting position was not established. The Polish epidemiologic survey provided updated figures on the prevalence of and risk factors for varicose veins and severe CVI, using clear and globally accepted clinical definitions for the venous disease based on the CEAP classification.
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PMID:The influence of environmental factors in chronic venous insufficiency. 1293 54

The presented thromboprophylactic concept includes weight bearing and ankle motion as well as breathing therapy and drug prophylaxis (antiphlogistics, analgesic drugs, heparin). Routinely performed ultrasound screening of the deep veins (legs and pelvis) before release showed a low DVT incidence of 2.5% in a prospective clinical observation of 841 inpatients. Obesity, venous insufficiency, and a history of previous thromboembolic events were associated with a significantly increased risk of thrombosis (relative risk 4.1, 4,9, and 5.8, respectively) The duration of immobilization also had a relevant influence indicating that early postoperative physiotherapy in traumatology and orthopedic surgery has a widely underestimated thromboprophylactic effect.
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PMID:[Stationary thromboprophylaxis in casualty surgery. Relevance of postoperative mobility and preexisting risk factors]. 1499 70

Bilateral prophylactic mastectomy can reduce the incidence of breast cancer by 87 to 93% in high-risk individuals and is an appealing option for many patients if reconstruction can be provided with acceptable morbidity and outstanding esthetic results. Autogenous breast reconstruction techniques have evolved over the last 20 years to meet this goal. Familiarity with the deep inferior epigastric perforator (DIEP) flap led us to carry out simultaneous bilateral breast reconstruction with acceptable morbidity and superior esthetic outcome in 3 patient groups: (1) after bilateral prophylactic mastectomy, (2) after therapeutic and contralateral prophylactic mastectomy, and (3) after explantation of bilateral implant failures. A retrospective review of our experience with 280 flaps in 140 patients was performed. Average operating times, including time for implant removal or mastectomy and reconstruction, was 7.3 hours. Average hospitalization was 3.9 days. Significant perioperative complications occurred in 9 patients (6.4%); all returned to the operating room. This included 7 microvascular complications, 1 hematoma, 1 seroma, and 1 DVT. Less significant complications were divided into early and late. The early complications included 1.8% partial flap necrosis, 4.2% abdominal apron necrosis greater than 5 cm2, 2.9% seromas that required intervention, and 5.7% partial breast flap dehiscence. Late complications included 12.5% fat necrosis of any size and 2.1% hernia formation. Smoking, obesity, age, history of chest wall radiation, and flap size were evaluated as risk factors for increased morbidity.
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PMID:Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps. 1515 76

Maternal pregravid obesity is a significant risk factor for adverse outcomes during pregnancy. In early pregnancy there is an increased risk of spontaneous abortion and congenital anomalies. In later gestation maternal metabolic manifestations of the metabolic syndrome, such as gestational hypertensive disorders and diabetes, become clinically recognized because of the increased insulin resistance in obese compared with nonobese women. In women with pregestational glucose intolerance, hypertension, central obesity, and lipid disorders, the physiologic changes in pregnancy increase the risk of problems previously not routinely encountered during pregnancy. These include chronic cardiac dysfunction, proteinuria, sleep apnea, and nonalcoholic fatty liver disease. At parturition the obese patient is at an increased risk of cesarean delivery and associated complications of anesthesia, wound disruption, infection, and deep venous thrombophlebitis. For the fetus there are short-term risks of fetal macrosomia, more specifically obesity, and long-term risks of adolescent components of the metabolic syndrome. Although preliminary results of bariatric surgery are encouraging, the procedure is expensive and not for all obese women, and we recognize that long-term follow-up data on offspring of obese women who have undergone bariatric surgery before pregnancy are lacking. In the interim, we need to encourage obese women to lose weight before conception, using lifestyle changes if possible. During pregnancy, weight gain should be limited to Institute of Medicine guidelines (currently under review) and encouragement given for physical activity.
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PMID:Management of obesity in pregnancy. 1726 45

Almost two billion people use commercial aircraft annually. Long-haul flights are taken by over 300 million people. A serious complication of long-distance travel (or prolonged time of flight) is thromboembolism. The real incidence of the problem is difficult to evaluate since there is no consensus about the diagnostic tests or limitation of time after landing connected to the VTE complication. A direct relation between VTE incidence and long-distance flights has been documented. The risk for DVT is 3-12% in a long-haul flight. The pathophysiologic changes that increase VTE risk at flight are stasis (sitting in crowded condition), hypoxia in the airplane cabin, and dehydration. Individual risk factors for air travel-related VTE include age over 40 years, gender (female), women who use oral contraceptives, varicose veins in lower limbs, obesity and genetic thrombophilia. Prevention measures include environmental protection such as keeping the pressure inside the airplane cabinet in hypobaric condition, avoiding dehydration and prolonged sitting. For individuals at increased risk, venous blood stasis can be reduced by wearing elastic stockings and prophylactic use of low-molecular-weight heparin.
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PMID:Air travel and the risk of thromboembolism. 2105 84


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