Superficial venous disease and combined hormonal contraceptives: a systematic review

AbstractBackgroundSuperficial venous disease, which includes superficial venous thrombosis (SVT) and varicose veins, may be associated with a higher risk of venous thromboembolism (VTE). Use of combined hormonal contraceptives (CHCs) has been associated with an increased risk of VTE compared with nonuse. Little is known about whether use of CHCs by women with superficial venous disease may further elevate the risk of VTE.ObjectivesTo investigate evidence regarding risk of VTE in women with SVT or varicose veins who use CHCs compared with non-CHC users.MethodsWe searched the PubMed database for all English-language articles published from database inception through September 2014. We included primary research studies that examined women with SVT or varicose veins who used CHCs compared to women with these conditions who did not use CHCs. Outcomes of interest included VTE (among women with SVT or varicose veins) and SVT (for those with varicose veins).ResultsTwo studies were identified that met inclusion criteria. One fair-quality case–control study reported an odds ratio (OR) for VTE of 43.0 (95% confidence interval [CI] 15.5–119.3) among women with SVT using oral contraceptives (OCs) compared with nonusers without SVT. The OR for VTE was also increased for women with SVT not using OCs (OR 5.1; 95% CI 2.8–9.5) and for women without SVT using OCs (OR 4.0; 95% CI 3.3–4.7), compared with nonusers without SVT. One fair-quality cohort study demonstrated that women with varicose veins had an increased rate of VTE with use of OCs (1.85 per 1000 women-years [WY]), compared with users without varicose veins (0.84 per 1000 WY), nonusers with varicose veins (0.31 per 1000 WY) and nonusers without varicose veins (0.19 per 1000 WY). This study also demonstrated that women with varicose veins had an increased rate of SVT with use of OCs (10.63 per 1000 WY), compared with nonusers with varicose veins (7.59 per 1000 WY), users without varicose veins (1.89 per 1000 WY) and nonusers without varicose veins (0.77 per 1000 WY).ConclusionTwo studies suggest increased risk of VTE among OC users with superficial venous disease; however, no definitive conclusions can be made due to the limited number of studies and limitations in study quality. Theoretical concerns need to be clarified with further research on whether the risk of significant sequelae from superficial venous disease among CHC users is related to clinical severity of disease and underlying factors

Radiation osteitis of the clavicle

The bone alterations in the region of the clavicle (3 cases) are similar to those we have observed and described elsewhere in the skeleton i.e., the mandible, maxillary and ethmoid bones. Rarefaction is the result of three different types of bone destruction: osteoclasia, a kind of osteocytic osteolysis only observed after irradiation and obviously related with infection, and a pure demineralization of the osseous tissue by contact with pus. Reconstruction processes, although unable to prevent spontaneous fracture, are also present and correspond to islets of chondroid tissue surrounded by lamellar bone. However, these recently deposited calcified tissues are already necrotic since most of their lacunae are empty.Les modifications osseuses dans la région de la clavicule (3 observations) sont semblables à celles observées ailleurs dans le squelette, par exemple la mandibule, le maxillaire et l’os ethmoïde. La raréfaction osseuse est le résultat de trois types différents de destruction: l’ostéoclasie, une espèce d’ostéolyse ostéocytaire observée après irradiation, en rapport certain avec une infection et une déminéralisation pure du tissu osseux en contact avec du pus. Les phénomènes de reconstruction, bien qu’incapables d’éviter une fracture spontanée, sont également présents et ils correspondent à des îlots de tissu chondroïde au sein de travées d’os lamellaire. Cependant ces tissus calcifiés récemment déposés sont déjà nécrosés puisque les ostéoplastes sont vides

Value of venous color flow duplex scan as initial screening test for geriatric inpatients with clinically suspected pulmonary embolism

Raghid Kreidy1, Elias Stephan2, Pascale Salameh3, Mirna Waked4 1Department of Vascular Surgery, Saint George Hospital, University Medical Center, University of Balamand, Beirut, Lebanon; 2Department of Geriatrics, Saint George Hospital, University Medical Center, University of Balamand, Beirut, Lebanon; 3Laboratory of Clinical and Epidemiological Research, Faculty of Pharmacy, Lebanese University, 4Department of Pulmonary Medicine, Saint George Hospital, University Medical Center, University of Balamand, Beirut, Lebanon Aim: The contribution of lower extremity venous duplex scan to the diagnostic strategy for pulmonary embolism has been demonstrated by many authors. However, the positive diagnostic value of this noninvasive test in clinically suspected pulmonary embolism is not very high (10%–18%). Since thromboembolic risks increase considerably in hospitalized patients with advanced age, this study aims to determine the importance of lower extremity venous color flow duplex scan in this particular subgroup of patients with clinically suspected pulmonary embolism. The effects of clinical presentation and risk factors on the results of duplex scan have been also studied. Methods: Between July 2007 and January 2010, 95 consecutive Lebanese geriatric ($60 years of age) inpatients with clinically suspected pulmonary embolism assessed in an academic tertiary-care center for complete lower extremity venous color flow duplex scan were retrospectively reviewed. Age varied between 60 and 96 years (mean, 79.9 years). Forty patients were males and 55 females. Absence of compressibility was the most important criteria for detecting acute venous thrombosis. Results: Out of 95 patients, 33 patients (34.7%) were diagnosed with recent deep venous thrombosis of lower extremities (14 proximal and 19 distal) using complete venous ultrasound. Nine of these 33 patients (27.2%) had a history of venous thromboembolism and eleven (33.3%) presented with edema of lower extremities. A total of 28 patients (84.8%) with positive duplex scan had associated risk factors for venous thromboembolism. Conclusion: Lower extremity venous color flow duplex scan appears to be a reasonable initial screening test in the diagnostic algorithm of pulmonary embolism in geriatric inpatients with clinically suspected pulmonary embolism. This is particularly true in patients with a history of venous thromboembolism, in patients with a clinical presentation suggesting venous thrombosis, in uremic patients and in patients with altered general and mental status who are not candidates for chest computed tomography. Keywords: venous thrombosis, lower extremities, geriatri

Tratamento médico da tromboflebite superficial do membro inferior: heparina ou anti-inflamatórios?

Trata-se de uma primeira versão de uma Revisão que foi aperfeiçoada posteriormente, com apresentação noutro evento científico e com publicação em revista científica.Introdução e objectivo: A tromboflebite superficial (TVS) é uma condição clínica frequente, afectando predominantemente os membros inferiores (MI). O especialista de Medicina Geral e Familiar deve ter conhecimentos sobre a sua abordagem e as complicações que podem surgir. É uma entidade clínica pouco estudada, existindo controvérsia sobre a melhor terapêutica. O objectivo desta revisão é tentar clarificar qual a melhor terapêutica da TVS do MI, no que diz respeito aos anti-inflamatórios (AINEs) ou heparina de baixo peso molecular (HBPM). Metodologia: Foi realizada pesquisa bibliográfica de normas de orientação clínica (NOC), revisões baseadas na evidência (RBE) e artigos originais nas bases de dados National Guideline Clearinghouse, Guidelines Finder, Canadian Medical Association Infobase, Cochrane Library, Clinical Evidence, Database of Abstracts of Reviews of Effectiveness, Uptodate, Pubmed e nos sites portugueses da Direcção Geral de Saúde, Associação Portuguesa de Médicos de Clínica Geral, MGFamiliar.net e no Índex de Revistas Médicas Portuguesas. Os termos MeSH utilizados foram: venous thrombosis; heparin, low-molecular-weight; anti-inflammatory agents. Seleccionaram-se artigos publicados entre 2008-2011, em concordância com o objectivo e aplicando critérios de exclusão: artigos repetidos; TVS em internamento ou em zonas que não o MI; TVS em idade pediátrica; Profilaxia de TVS; TVS complicada ou associada a factores de risco. Classificou-se o nível de evidência/força de recomendação pela escala SORT. Resultados: Foram encontrados 215 artigos. Depois da aplicação dos critérios de exclusão obteve-se 1 NOC, 2 RBE e 1 ensaio clínico randomizado. A evidência suporta que existe melhoria dos sintomas dos doentes com TVS tratados com HBPM ou AINEs em comparação com placebo, reduzindo a incidência de recorrências e complicações, sem diferenças no perfil de segurança a curto prazo (SORT B). Anticoagulação durante pelo menos 4 semanas, está indicada sobretudo quando se indentificam critérios de gravidade (SORT B). A utilização simultânea de HBPM e AINEs revelou maior eficácia no alívio sintomático do que a HBPM isolada (nível de evidência 2). Discussão: As evidências apontam a anticoagulação como a opção terapêutica mais indicada, reservando-se os AINEs para quando não existem sinais de gravidade. São necessários mais ensaios clínicos aleatorizados, sobretudo no que se relaciona com a opção por AINEs ou HBPM ou a sua utilização simultânea, doses e duração de tratamento

Manejo de la tromboflebitis superficial en la mujer embarazada

Superficial vein thrombosis (SVT) has traditionally been considered a benign condition. However, current evidence suggests that thrombosis will spread into the deep vein system in a significant proportion of cases, particularly when the thrombus occupies the proximal long saphenous vein. Its presentation in pregnancy is an added difficulty. This case represents the complex management of a condition for which diagnostic prediction tools are lacking. Ultrasound examination plays a key role, especially in pregnant patients, for whom evidence supporting the diagnosis and treatment of venous thromboembolic disease is weaker than for the rest of patients. We present the case of a pregnant woman of 9 weeks with SVT and we discussed her management.La trombosis venosa superficial se ha considerado tradicionalmente como una afección benigna. Sin embargo, la evidencia actual sugiere que una proporción significativa de casos se propagará al sistema venoso profundo, particularmente cuando el trombo ocupa la vena safena larga proximal. Su presentación en el embarazo supone una dificultad añadida. Este caso representa la complejidad en el manejo de una patología sobre la que no hay herramientas de predicción diagnóstica, y donde la ecografía juega un papel clave, en especial en pacientes embarazadas, en quienes las evidencias que soportan el diagnóstico y tratamiento de la enfermedad tromboembólica venosa son más débiles que en el resto de los pacientes. Presentamos el caso de una gestante de 9 semanas con trombosis venosa superficial y discutimos su manejo

Obesity and risk of venous thromboembolism among postmenopausal women: differential impact of hormone therapy by route of estrogen administration. The ESTHER Study.

BACKGROUND: Oral estrogen use and elevated body mass index (BMI) increase the risk of venous thromboembolism (VTE). Recent data suggest that transdermal estrogen might be safe with respect to thrombotic risk. However, the impact of transdermal estrogen on the association between overweight (25 kg m(-2) 30 kg m(-2)) and VTE risk has not been investigated. METHODS: We carried a multicenter case-control study of VTE among postmenopausal women aged 45-70 years, between 1999 and 2005, in France. Case population consisted of women with a first documented idiopathic VTE. We recruited 191 hospital cases matched with 416 hospital controls and 62 outpatient cases matched with 181 community controls. RESULTS: The odds ratio (OR) for VTE was 2.5 [95% confidence interval (CI):1.7-3.7] for overweight and 3.9 (95% CI: 2.2-6.9) for obesity. Oral, not transdermal, estrogen was associated with an increased VTE risk (OR = 4.5; 95% CI: 2.6-7.7 and OR = 1.1; 95% CI: 0.7-1.7, respectively). Compared with non-users with normal weight, the combination of oral estrogen use and overweight or obesity further enhanced VTE risk (OR = 10.2; 95% CI: 3.5-30.2 and OR = 20.6; 95% CI: 4.8-88.1, respectively). However, transdermal users with increased BMI had similar risk as non-users with increased BMI (OR = 2.9; 95% CI: 1.5-5.8 and OR = 2.7; 95% CI: 1.7-4.5 respectively for overweight; OR = 5.4; 95% CI: 2.1-14.1 and OR = 4.0; 95% CI: 2.1-7.8 respectively for obesity). CONCLUSIONS: In contrast to oral estrogen, transdermal estrogen does not confer an additional risk of idiopathic VTE in women with increased BMI. The safety of transdermal estrogen on thrombotic risk has to be confirmed

Elevated D-dimer Level in the Differential Diagnosis of Venous Malformations

Objective: To evaluate if elevated D-dimer level is specific for venous malformations (VMs) and thus useful for differential diagnosis, which can be problematic even in specialized interdisciplinary centers. Localized intravascular coagulopathy, characterized by elevated D-dimer levels, has been observed in approximately 40% of patients with VMs. Design: Prospective convenience sample accrued from 2 interdisciplinary sites. Setting: Two interdisciplinary centers for vascular anomalies in Brussels, Belgium, and Caen, France Participants: The study population comprised 280 patients with clinical data, Doppler ultrasonograms (for 251 patients), and coagulation parameter measurements. Main Outcome Measure: Measurement of D-dimer levels. Results: A VM was diagnosed in 195 of 280 patients (69.6%), and 83 of them had elevated D-dimer levels; the sensitivity of D-dimer dosage was 42.6% (95% confidence interval, 35.6%-49.5%). Among the 85 patients without VM, D-dimer levels were elevated only in 3 patients; the specificity of the dosage was 96.5% (95% confidence interval, 92.5%-100%). Conclusions: Elevated D-dimer level is highly specific for VMs (pure, combined, or syndromic), and therefore this easy and inexpensive biomarker test should become part of the clinical evaluation of vascular anomalies. It can detect hidden VMs and help differentiate glomuvenous malformation (normal D-dimer levels) from other multifocal venous lesions. Elevated D-dimer level also differentiates a VM from a lymphatic malformation. Moreover, slow-flow Klippel-Trenaunay syndrome (capillaro-lymphatico-venous malformation with limb hypertrophy) can be distinguished from fast-flow Parkes Weber syndrome (capillary malformation with underlying multiple microfistulas and limb hypertrophy). For these reasons, D-dimer level measurement is a useful complementary tool for diagnosing vascular anomalies in everyday practice

Association of localized intravascular coagulopathy with venous malformations

OBJECTIVE: To determine which venous malformations (VMs) are at risk for coagulopathy. Venous malformations are slow-flow vascular malformations present at birth, and localized intravascular coagulopathy (LIC) causes pain and thrombosis within a lesion and severe bleeding during surgical procedures. DESIGN: Prospective convenience sample accrued from 2 multidisciplinary sites in Brussels, Belgium, and Caen, France. PARTICIPANTS: The study population comprised 140 patients with clinical data and coagulation parameters. Magnetic resonance imaging was performed for 110 patients. MAIN OUTCOME MEASURE: Measurement of D-dimer levels. RESULTS: Of the 140 participants, 59 (42%) showed high D-dimer levels, 36 (61%) of whom had levels higher than 1.0 microg/mL. Six of the participants had low fibrinogen levels. In univariate analysis, large surface, presence of palpable phleboliths, and truncal localization were associated with high D-dimer levels. In the multivariate analysis, only large surface area and presence of phleboliths remained independently associated with high D-dimer levels. Severe LIC, characterized by concomitant low fibrinogen level, was associated with extensive venous malformations of the extremities. CONCLUSIONS: Localized intravascular coagulopathy is statistically significantly associated with large and/or deep venous malformations that affect any location, which can have a palpable phlebolith. These patients are at risk of local pain due to thrombosis. Lesions with elevated D-dimer levels associated with low fibrinogen levels (severe LIC) commonly affect an extremity and have a high risk of hemorrhage. Low-molecular-weight heparin can be used both to treat the pain caused by LIC and to prevent decompensation of severe LIC to disseminated intravascular coagulopathy