What went wrong? The flawed concept of cerebrospinal venous insufficiency

In 2006, Zamboni reintroduced the concept that chronic impaired venous outflow of the central nervous system is associated with multiple sclerosis (MS), coining the term of chronic cerebrospinal venous insufficiency ('CCSVI'). The diagnosis of 'CCSVI' is based on sonographic criteria, which he found exclusively fulfilled in MS. The concept proposes that chronic venous outflow failure is associated with venous reflux and congestion and leads to iron deposition, thereby inducing neuroinflammation and degeneration. The revival of this concept has generated major interest in media and patient groups, mainly driven by the hope that endovascular treatment of 'CCSVI' could alleviate MS. Many investigators tried to replicate Zamboni's results with duplex sonography, magnetic resonance imaging, and catheter angiography. The data obtained here do generally not support the 'CCSVI' concept. Moreover, there are no methodologically adequate studies to prove or disprove beneficial effects of endovascular treatment in MS. This review not only gives a comprehensive overview of the methodological flaws and pathophysiologic implausibility of the 'CCSVI' concept, but also summarizes the multimodality diagnostic validation studies and open-label trials of endovascular treatment. In our view, there is currently no basis to diagnose or treat 'CCSVI' in the care of MS patients, outside of the setting of scientific research

An Educational Intervention on the Clinical Utility of Point-Of-Care Ultrasound (POCUS) in the Timely Detection of Perioperative Thromboembolic Complications in COVID-19 Patients Undergoing Noncardiac Surgery

Background: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a rare but most likely fatal perioperative complication associated with increased patient morbidity and mortality. COVID-19-positive patients with VTE who present for surgery are predominantly asymptomatic and do not meet the conventional definition and traditional diagnostic criteria. This presents a challenge in identifying VTE in this patient population without proper surveillance and monitoring. Objectives: The purpose of this study is to improve anesthesia providers’ knowledge of the value of POCUS modality in preventing perioperative VTE in patients with COVID-19 undergoing noncardiac surgical procedures and improve recognition of associated risk factors that predispose patients to the development of VTE. Investigators used CINAHL, MEDLINE, and EMBASE databases to answer the PICO (i.e., population, intervention, comparison, outcome) question: “In the adult patients with COVID-19 (P), does the use of the POCUS modality as an adjunct to preoperative screening for DVT (I), compared to its non-use (C), improve the early identification of perioperative VTE ( O)? The literature review provides the educational framework to improve provider knowledge. The overall objective of the project is to increase the quality of healthcare delivery to improve healthcare outcomes for patients with COVID-19 undergoing noncardiac surgery. Methodology: The primary methodology of the proposed project is to administer an online educational intervention to providers which focuses on the benefits of perioperative POCUS utilization in the early identification of VTEs. Pre- and post-assessment surveys will be used to measure the improvement of provider knowledge before and after the intervention. Results: Overall, there was an improvement in provider knowledge following the education intervention. Additionally, the likelihood of utilizing the perioperative POCUS modality increased among anesthesia providers. Conclusion: The perioperative incorporation of the POCUS modality has been shown to accurately assess the presence of DVT. The educational intervention provided effectively improved anesthesia provider knowledge on the value of POCUS modality in preventing perioperative VTE in patients with COVID-19 undergoing noncardiac surgical procedures and improving recognition of associated risk factors that predispose patients to the development of these events. Increasing awareness of the high incidence of thromboembolic events in patients with COVID-19 and the role of POCUS in their early detection can reduce mortality and improve postoperative outcomes

The incidence and prevention of Postoperative Venous Thrombosis

In the last few years a very high incidence of deep vein thrombosis has been reported in the literature. Venous thrombosis and its sequel, pulmonary embolus account for 12. 5% of all postoperative deaths and is the single greatest threat to recovery after surgical operations. This study was undertaken to investigate the incidence of postoperative deep vein thrombosis occurring at Groote Schuur Hospital using the newer methods of diagnosis. No previous similar study has been conducted in South Africa. The high-risk factors predisposing to venous thrombosis have been assessed and the techniques of diagnosis using Radio-active fibrinogen, Doppler ultrasound and Venography have been studied. The local findings reported in this study confirmed the high reported incidence. Methods of prevention of venous thrombosis using low doses heparin and sodium pentosan polysulphate have been assessed

The comparative hemodynamic efficacy of lower limb muscles using transcutaneous electrical stimulation.

Circulation in the limbs can be augmented using transcutaneous electrical stimulation devices. The optimum muscle stimulation sites for enhancement of vascular hemodynamic parameters have not been identified.Seven suitable anatomic sites were identified within the right leg. Twelve healthy participants were recruited (mean age, 23.1 ± 3 years; body mass index, 23.1 ± 3 kg/m(2)). Muscles were stimulated by transcutaneous bipolar electrodes at a current twice their motor threshold, at 1 Hz, for 5 minutes. Hemodynamic ultrasound measurements were taken from the right femoral vein. Laser Doppler measurements from the feet of the stimulated and nonstimulated sides were obtained. Baseline measurements were compared with readings after 5 minutes of stimulation, with device active. Discomfort experienced for stimulation of each muscle was rated out of 100.Hemodynamic changes displayed large intersubject variation, with no muscle statistically superior to the others. All muscles increased peak velocity; contraction of medial gastrocnemius increased time-averaged maximum velocity and volume flow. All muscles increased foot fluximetry (P < .05). Discomfort correlated weakly with current applied. Tibialis anterior and vastus lateralis were most tenable.Transcutaneous stimulation increases hemodynamic parameters significantly, locally and systemically. No optimum stimulation site has been identified, and it is limited by comfort and variability in the subjects response. Gastrocnemius, tibialis anterior, and vastus lateralis all provoke large changes in hemodynamic parameters, but clinical efficacy in disease prevention and management has not been explored

The Anticoagulation of Calf Thrombosis (ACT) project: study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Half of all lower limb deep vein thrombi (DVT) in symptomatic ambulatory patients are located in the distal (calf) veins. While proximal disease warrants therapeutic anticoagulation to reduce the associated risks, distal DVT often goes untreated. However, a proportion of untreated distal disease will undoubtedly propagate or embolize. Concern also exists that untreated disease could lead to long-term post thrombotic changes. Currently, it is not possible to predict which distal thrombi will develop such complications. Whether these potential risks outweigh those associated with unrestricted anticoagulation remains unclear. The Anticoagulation of Calf Thrombosis (ACT) trial aims to compare therapeutic anticoagulation against conservative management for patients with acute symptomatic distal deep vein thrombosis.</p> <p>Methods</p> <p>ACT is a pragmatic, open-label, randomized controlled trial. Adult patients diagnosed with acute distal DVT will be allocated to either therapeutic anticoagulation or conservative management. All patients will undergo 3 months of clinical and assessor blinded sonographic follow-up, followed by 2-year final review. The project will commence initially as an external pilot study, recruiting over a 16-month period at a single center to assess feasibility measures and clinical event rates. Primary outcome measures will assess feasibility endpoints. Secondary clinical outcomes will be collected to gather accurate data for the design of a definitive clinical trial and will include: (1) a composite endpoint combining thrombus propagation to the popliteal vein or above, development of symptomatic pulmonary embolism or sudden death attributable to venous thromboembolic disease; (2) the incidence of major and minor bleeding episodes; (3) the incidence of post-thrombotic leg syndrome at 2 years using a validated screening tool; and (4) the incidence of venous thromboembolism (VTE) recurrence at 2 years.</p> <p>Discussion</p> <p>The ACT trial will explore the feasibility of comparing therapeutic anticoagulation to conservative management in acute distal DVT, within a modern cohort. We also aim to provide contemporary data on clot propagation, bleeding rates and long-term outcomes within both groups. These results will inform the conduct of a definitive study if feasibility is established.</p> <p>Trial registration</p> <p>Current Controlled Trials <a href="http://www.controlled-trials.com/ISRCTN75175695">ISRCTN75175695</a></p

Compression stockings for preventing deep vein thrombosis (DVT) in airline passengers

Background Air travel might increase the risk of deep vein thrombosis (DVT). It has been suggested that wearing compression stockings might reduce this risk. This is an update of the review first published in 2006. Objectives To assess the effects of wearing compression stockings versus not wearing them for preventing DVT in people travelling on flights lasting at least four hours. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 April 2020. We also checked the bibliographies of relevant studies and reviews identified by the search to check for any additional trials. Selection criteria Randomised trials of compression stockings versus no stockings in passengers on flights lasting at least four hours. Trials in which passengers wore a stocking on one leg but not the other, or those comparing stockings and another intervention were also eligible. Data collection and analysis Two review authors independently selected trials for inclusion and extracted data. We sought additional information from trialists where necessary. Main results One new study that fulfilled the inclusion criteria was identified for this update. Twelve randomised trials (n = 2918) were included in this review: ten (n = 2833) compared wearing graduated compression stockings on both legs versus not wearing them; one trial (n = 50) compared wearing graduated compression tights versus not wearing them; and one trial (n = 35) compared wearing a graduated compression stocking on one leg for the outbound flight and on the other leg on the return flight. Eight trials included people judged to be at low or medium risk of developing DVT (n = 1598) and two included high‐risk participants (n = 1273). All flights had a duration of more than five hours. Fifty of 2637 participants with follow‐up data available in the trials of wearing compression stockings on both legs had a symptomless DVT; three wore stockings, 47 did not (odds ratio (OR) 0.10, 95% confidence interval (CI) 0.04 to 0.25, P Authors' conclusions There is high‐certainty evidence that airline passengers similar to those in this review can expect a substantial reduction in the incidence of symptomless DVT and low‐certainty evidence that leg oedema is reduced if they wear compression stockings. The certainty of the evidence was limited by the way that oedema was measured. There is moderate‐certainty evidence that superficial vein thrombosis may be reduced if passengers wear compression stockings. We cannot assess the effect of wearing stockings on death, pulmonary embolism or symptomatic DVT because no such events occurred in these trials. Randomised trials to assess these outcomes would need to include a very large number of people

Clinical Practice Guideline for Venous Thromboembolism

Background: The morbidity associated with venous thromboembolism often goes unrecognized. Identifying patient populations at risk for venous thromboembolism and implementing evidence-based guidelines can decrease the number of untoward effects of this disease. Clinical pathway guidelines are valuable tools needed by nurses in the prevention and treatment of disorders for patients. Education of the guideline can increase knowledge and understanding of what prevention, interventions, and treatment are available for the orthopaedic patient and how to apply this knowledge to everyday patient care.;Objective: To educate orthopaedic nurses on the clinical practice guidelines of thromboembolism.;Method: Incorporate the education of thromboembolism in an orthopaedic class intended for registered nurses studying for the national orthopaedic exam.;Population: Twenty-three registered nurses from the Mid-Ohio Valley employed at Selby General Hospital.;Expected Outcome: To calculate a statistically difference in the scores of a pre test and a post test given to the nurses enrolled in the class on the prevention and treatment of thromboembolism