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Query: UMLS:C0034065 (pulmonary embolism)
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The clinical diagnosis of acute deep vein thrombosis (DVT) is but 50% accurate when compared to the results of contrast venography. This clinical inaccuracy had led to the dependence of the physician upon laboratory diagnosis. Whereas contrast venography is the gold standard of diagnosis, its expense, special equipment, personnel, and discomfort make it unsuitable for evaluating large numbers of patients. For this reason, numerous noninvasive tests utilizing plethysmographic and Doppler techniques have been developed to evaluate patients with suspected venous disease, and when expertly performed have a degree of accuracy of approximately 90%. This degree of accuracy coincides with the experience of our peripheral vascular laboratory using the Doppler venous examination. Based on these statistics, our current practice is to evaluate patients suspected of having DVT with a Doppler venous examination (Figure 1). If the test is abnormal or equivocal, contrast venography is usually obtained and anticoagulation recommended. Contrariwise, if the Doppler venous examination is normal, venography is not obtained, and anticoagulation treatment is not recommended. This practice should reduce the number of venograms in a patient population that is not at an increased risk of pulmonary embolism or repeated deep venous thrombosis. To evaluate the validity and safety of this practice, one hundred eighty-six patients with normal Doppler venous examinations in whom contrast venography was not obtained were evaluated and form the basis of this report.
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PMID:The normal Doppler venous examination. 683 18

Congenital antithrombin III deficiency is a rare but well-documented abnormality. A young man presented with pulmonary embolism and was found to be suffering from this condition. His family history revealed numerous members with venous disease and its complications. Treatment of the acute episode and prophylaxis are discussed.
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PMID:Familial thrombosis associated with antithrombin III deficiency in a young adult male. A case report. 742 87

The purpose of this study was to characterize the long-term safety and efficacy of the stainless-steel Greenfield filter. All patients who underwent Greenfield filter placement at three institutions during tenure of the senior author (L.J.G.) were entered prospectively into a filter registry and followed on an annual basis. Follow-up consisted of clinical examination to evaluate the status of venous disease or recurrence of pulmonary embolism, abdominal radiographs to determine the stability of the filter and an evaluation of the patency of the inferior vena cava and lower extremities. This report summarizes the 20-year experience. The rate of recurrent pulmonary embolism was 4% and the caval patency rate was 96%. Some filter movement of no clinical significance was seen in 8% of cases. There was no procedural mortality and morbidity was minimal. Greenfield filter insertion provides long-term protection from pulmonary embolism while preserving caval patency.
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PMID:Twenty-year clinical experience with the Greenfield filter. 760 7

At the request of the Ad Hoc Committee on Reporting Standards of the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery, this report updates and modifies "Reporting standards in venous disease" (J Vasc Surg 1988;8:172-81). As in the initial document, reporting standards for publications dealing with (1) acute lower extremity venous thrombosis, (2) chronic lower extremity venous insufficiency, (3) upper extremity venous thrombosis, and (4) pulmonary embolism are presented. Numeric grading schemes for disease severity, risk factors, and outcome criteria present in the original document have been updated to reflect increased knowledge of venous disease and advances in diagnostic techniques. Certain recommendations of necessity remain arbitrary. These standards are offered as guidelines whose observance will in our opinion improve the clarity and precision of communications in the field of venous disorders.
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PMID:Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. 880 76

Although less frequent than that of the lower limbs, venous thrombosis of the upper limbs may cause pulmonary embolism. This embolism is usually moderate and facilitated by the delay or absence of anticoagulant treatment. We report the case of a young man who had multiple and recurrent embolism consecutive to thrombosis of the axillary and subclavian veins and who rapidly developed pulmonary arterial hypertension on previously healthy lungs. There was no venous disease of the lower limb. After a more than 2 years' period, the pulmonary arterial hypertension is still moderate, but the patient remains under long-term antivitamin K therapy, this being the only available treatment capable of preventing a deterioration that would result in post-embolic cor pulmonale and ultimately require lung transplantation.
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PMID:[Unusual complication of venous thrombosis of the upper limb: pulmonary hypertension]. 829 44

Our purpose was to determine the incidence of deep-vein thrombosis (DVT) in patients who have had early operative fixation of fractures of the lower extremity distal to the hip. There is a high incidence of distal thrombosis in patients who have undergone early operative fixation of lower-extremity fractures. The incidence of DVT is higher with proximal extremity fractures than with distal extremity fractures. Most clots are occult and do not progress clinically. Given the high incidence of DVT with femoral and tibial plateau fractures, older age, and longer operating times, anticoagulation prophylaxis may be indicated. Ours was a prospective incidence study. All patients who had had early operative fixation of lower-extremity fractures were eligible (n = 176). Seventy-four were excluded based on specific criteria. The remaining 102 patients underwent lower-extremity venography an average of 9 days after operative fixation of their fractures (range 3-22 days). Eight patients had bilateral lower-extremity fractures. The patients were followed clinically for 6 weeks to identify complications related to venous disease. The overall incidence of clinically occult DVT was 28%. Of the represented fractures, 40% were of the femoral shaft (eight of 20), 43% of the tibial plateau (12 of 28), 22% of the tibial shaft (12 of 54), and 12.5% of the tibial plafond (one of eight). Four of the thrombi were proximal to the popliteal fossa. Four of the patients had clinical evidence of pulmonary embolism while in the hospital. One of them had objective confirmation on further testing. No patient had clinical evidence of pulmonary emboli as an outpatient by follow-up criteria. The incidence of DVT has not been determined for patients with early stabilization of lower-extremity fractures. This study suggests a higher DVT incidence in more proximal fractures, but little risk of embolization. Thrombus formation proximal to the popliteal fossa is rare. Older age, longer operating times, and longer times before fracture fixation all correlate with an increased incidence of DVT.
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PMID:Incidence of deep-vein thrombosis in patients with fractures of the lower extremity distal to the hip. 872

There are few conditions in medicine as difficult to diagnose as pulmonary embolism. This is certainly not due to the rarity of the disease which is probably as common as myocardial infarction in France. The circumstances surrounding pulmonary embolism and the risk factors of deep venous thrombosis have been well identified. The risk of thromboembolic venous disease has been assessed for each type of surgery. The methods of treatment and prevention have progressed over a number of years. However, in practice, these advances have not "transformed" the frequency of the disease or reduced its mortality. Further progress could come from improved identification of patients at risk, especially by biological tests and new abnormalities of blood coagulation.
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PMID:[Epidemiology of pulmonary embolism]. 881 27

The Prevalence of Early Atherosclerosis study aims to define the prevalence of subclinical atherosclerosis in a typical population of central Italy. A concomitant study evaluates the prevalence of venous diseases. The prevalence of superficial and deep venous disease, the prevalence of venous thrombosis and pulmonary embolism, and the prevalence of the most common venous malformations were studied through use of medical history, a questionnaire, and noninvasive investigations. The costs of venous problems were also considered. Of some 2000 inhabitants, 746 (379 women; mean age 46.3 +/- 7 years; range eight to ninety-four) have been screened. No significant difference in trend increase of the relationship age/percent of subjects with venous problems was observed for superficial venous disease. The increase in the proportion of subjects with lipodermatosclerosis and venous ulcerations appeared to be correlated with age (r = 0.543). Evidence accepted for pulmonary embolisms was pulmonary angiogram or evidence on ventilation+perfusion lung scans. According to these criteria the number of documented deep vein thromboses and pulmonary embolisms was very limited with a larger number of suspected disease entities. There was no significant correlation between age and pulmonary embolism or deep venous thrombosis distribution. The number of venous and/or arteriovenous malformations was comparable along the age axis in the different age groups. Only a limited number of these malformations (in less that 1% of subjects) had caused a clinical problem. The treatments used for venous problems have been reported in a questionnaire and subdivided into occasional treatments and chronic treatments (when used for periods longer than twelve months). The percent of subjects using different treatment was also studied. Treatments were divided in: (1) over-the-counter products (or any treatment not requiring prescription); (2) specialized drug (for venous diseases); (3) compression; (4) surgery (any type of surgical treatment); (5) sclerotherapy; (6) combined treatments (ie, sclerotherapy and surgery); (7) alternative treatments (herbal products etc). Finally, the average costs per year for treatment, for investigations, and the costs due to lost working days were recorded. In conclusion some 12% of the evaluated population sample (male population 46%) had or had been affected in the past by a venous problem and 50% of them had received some type of treatment.
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PMID:Epidemiology and costs of venous diseases in central Italy. The San Valentino Venous Disease Project. 924 56

Pulmonary embolus is a significant aspect of thromboembolic venous disease which globally is the third most important cardiovascular disorder. There are several methods of primary prevention to decrease morbidity and mortality related to this disease. This article consists of a review of the most current methods of prophylaxis followed by practical recommendations for surgical, medical and obstetric patients.
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PMID:[Strategies for prevention of pulmonary embolism during at-risk surgeries and in the medical environment]. 1090 43

Pulmonary emboli are frequent during pregnancy and the post partum period and represent one of the major causes of maternal mortality during this period. It is estimated that there is an increased risk of thromboembolic venous disease during pregnancy at 1:1000 to 1:2000 pregnancies. This is explained by changes in the physiology and biology of coagulation factors and fibrinolysis. The risk is increased in those aged more than 35, the presence of a past history of thromboembolic venous disease; hereditary or acquired thrombophilia or delivery by caesarean section. The diagnosis should be confirmed with the same rigor as outside pregnancy. No diagnostic examination is contraindicated in those pregnant but the diagnostic strategy should be in favor of non-invasive examinations with ultrasonic venography of the lower limbs and/or pulmonary scintigraphy being the investigations of choice. The treatment of pulmonary emboli during pregnancy rests on heparin, coumarin being strictly contraindicated due to the risk of fetal malformation. Low molecular weight heparin is not currently used during pregnancy but initial data in the literature suggests that they may be used during pregnancy without increased risk compared to non-fractionated heparin. The indications for anticoagulant prophylaxis remains poorly characterized.
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PMID:[Pulmonary embolism and pregnancy]. 1090 52


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