New and known predictors of the postthrombotic syndrome: A subanalysis of the ATTRACT trial

Introduction: Postthrombotic syndrome (PTS) remains associated with significant clinical and economic burden. This study aimed to investigate known and novel predictors of the development of PTS in participants of the ATTRACT (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) trial. Methods: We used multivariable logistic regression to identify baseline and postbaseline factors that were predictive of the development of PTS during study follow-up, as defined by a Villalta score of 5 or greater or the development of a venous ulcer from 6 to 24 months after enrollment. Results: Among 691 patients in the study cohort (all had proximal deep vein thrombosis [DVT] that extended above the popliteal vein, of which 57% had iliofemoral DVT), 47% developed PTS. Further, we identified that Villalta score at baseline (odds ratio [OR], 1.09 [95% confidence interval [CI], 1.05-1.13] per one-unit increase) and employment status (unemployed due to disability: OR, 3.31 [95% CI, 1.72-6.35] vs. employed more than 35 hours per week) were predictive of PTS. In terms of postbaseline predictors, leg pain severity at day 10 (OR, 1.28 [95% CI, 1.13-1.45] per 1-point increase in a 7-point scale) predicted PTS. Also, patients receiving rivaroxaban on day 10 following randomization had lower rates of PTS (OR, 0.53 [95% CI, 0.33-0.86]) than patients on warfarin. Conclusions: Novel predictors for PTS identified in our study include baseline Villalta score, leg pain severity at 10 days, and unemployed due to disability. Our findings also suggest that the initial choice of anticoagulant to treat DVT may have an impact on the development of PTS

Guidance for the prevention and treatment of the post-thrombotic syndrome

The post-thrombotic syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations include symptoms and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening and in severe cases, leg ulcers. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20–30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of post-thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children

A Clinical Trial of Venous Stent Placement for Post-thrombotic Syndrome: Current Status and Pandemic-related Changes

Patients with post-thrombotic syndrome (PTS) and iliac vein obstruction have lower extremity symptoms, activity limitation and impairment of health-related quality of life. Preliminary studies suggest that iliac vein stent placement, which eliminates venous outflow obstruction, may reduce the clinical severity of PTS. However, stent placement is associated with patient risk, inconvenience and cost. Therefore, the Chronic Venous Thrombosis – Relief with Adjunctive Catheter-directed Therapy (C-TRACT) trial was launched to rigorously assess the risk–benefit ratio of stent placement for the treatment of moderate or severe PTS. In the trial, patients in both treatment groups receive a high quality of multi-modality PTS care that includes medical, compressive, and ulcer therapies. Due to the COVID-19 pandemic, the trial protocol and practices were modified to enhance the study feasibility while preserving its ability to answer its primary question. This review summarises the current status of the trial and the potential impact of the pandemic-related adaptations to future venous clinical practice and research

Exploring the Villalta scale to capture postthrombotic syndrome using alternative approaches: A subanalysis of the ATTRACT trial

BACKGROUND: Clinical trials that evaluated interventions to prevent postthrombotic syndrome (PTS) used the Villalta scale (VS) to define PTS, but there is a lack of consistency in its use. OBJECTIVES: This study aimed to improve the ability to identify patients with clinically meaningful PTS after DVT in participants of the ATTRACT trial. METHODS: We conducted a post hoc exploratory analysis of 691 patients from the ATTRACT study, a randomized trial evaluating the effectiveness of pharmacomechanical thrombolysis to prevent PTS in proximal deep vein thrombosis. We compared 8 VS approaches to classify patients with or without PTS in terms of their ability to discriminate between those with poorer vs better venous disease-specific quality of life (Venous Insufficiency Epidemiological and Economic Study Quality of Life [VEINES-QOL]) between 6- and 24-months follow-up. The difference in the average area under the fitted curve of VEINES-QOL scores between PTS and no PTS ( RESULTS: For any PTS (a single VS score ≥5), approaches 1 to 3 had similar CONCLUSION: A single VS score of ≥ 5 reliably distinguishes patients with clinically meaningful PTS as assessed by impact on QOL and is preferred because of greater convenience (only one assessment needed). Alternative methods to define PTS (ie, adjusting for CVI) do not improve the scale\u27s ability to identify clinically meaningful PTS

More: A Mobile Open Rich Media Environment

‘Rich media ’ is a term that implies the integration of all of the ad-vances we have made in the mobile space delivering music, speech, text, graphics and video. This is true, but it is more than the sum of its parts. Rich media is the ability to deliver these modalities, to interact with these modalities, and to do it in a way that allows for the construction, delivery and use of compelling mobile services in an effective and economic manner. In this paper, we introduce a sys-tem called Mobile Open Rich-media Environment (‘MORE’) that helps realize such mobile rich media services, combining various technologies of W3C, OMA, 3GPP and IETF standards. The differ-ent components of the system include formatting, packaging, trans-porting, rendering and interacting with rich media files and streams. 1

Extracorporeal photopheresis to attenuate decline in lung function due to refractory obstructive allograft dysfunction

BACKGROUND: This study was designed to prospectively evaluate the efficacy of extracorporeal photopheresis (ECP) to attenuate the rate of decline of FEV STUDY DESIGN AND METHODS: Subjects from 10 lung transplant centres were assigned to ECP treatment or to observation based on spirometric criteria, with potential crossover for those under observation. The primary endpoint of this study was to assess response to ECP (i.e., greater than a 50% decrease in the rate of FEV RESULTS: Of 44 enrolled subjects, 31 were assigned to ECP treatment while 13 were initially assigned to observation on a non-random basis using specific spirometric inclusion criteria (seven of the observation patients subsequently crossed over to receive ECP). Of evaluable patients, 95% of patients initially assigned to treatment responded to ECP with rates of FEV CONCLUSIONS: These analyses suggest that earlier detection and treatment of BOS should be considered to appreciate improved outcomes with ECP