Venous Thrombosis: Risk Factors and Management

During the past 2 decades, the diagnostic and therapeutic approach to deep vein thrombosis (DVT) has greatly evolved. First, the assessment of the clinical probability has gained wide acceptance. Second, novel noninvasive diagnostic tools such as venous compression ultrasonography and D-dimer measurement have become available, drastically reducing the need for invasive tools such as phlebography. Third, new anticoagulant drugs, in particular low-molecular-weight heparins (LMWHs), have become available and have made DVT treatment a lot easier by allowing out-ofhospital management. Several diagnostic algorithms, based on the assessment of clinical probability, D-dimer measurement and venous compression ultrasonography, have shown to be safe in management studies. In addition to improvements in diagnostic algorithms and anticoagulant treatment, compression therapy by elastic stockings to diminish the prevalence of the postthrombotic syndrome has been validated in prospective studies. The dilemma of the need or no need for looking for and treating isolated calf DVT with anticoagulants remains a controversial issue, as do the optimal length and intensity of anticoagulation. In the near future, the emergence of several new, totally synthetic, orally active anticoagulant compounds, such as direct thrombin or factor Xa inhibitors that are presently being tested in clinical studies, could profoundly change the therapeutic approach to DV

Use of anticoagulants in elderly patients: practical recommendations

Elderly people represent a patient population at high thromboembolic risk, but also at high hemorrhagic risk. There is a general tendency among physicians to underuse anticoagulants in the elderly, probably both because of underestimation of thromboembolic risk and overestimation of bleeding risk. The main indications for anticoagulation are venous thromboembolism (VTE) prophylaxis in medical and surgical settings, VTE treatment, atrial fibrillation (AF) and valvular heart disease. Available anticoagulants for VTE prophylaxis and initial treatment of VTE are low molecular weight heparins (LMWH), unfractionated heparin (UFH) or synthetic anti-factor Xa pentasaccharide fondaparinux. For long-term anticoagulation vitamin K antagonists (VKA) are the first choice and only available oral anticoagulants nowadays. Assessing the benefit-risk ratio of anticoagulation is one of the most challenging issues in the individual elderly patient, patients at highest hemorrhagic risk often being those who would have the greatest benefit from anticoagulants. Some specific considerations are of utmost importance when using anticoagulants in the elderly to maximize safety of these treatments, including decreased renal function, co-morbidities and risk of falls, altered pharmacodynamics of anticoagulants especially VKAs, association with antiplatelet agents, patient education. Newer anticoagulants that are currently under study could simplify the management and increase the safety of anticoagulation in the future

Diffuse fibromuscular dysplasia successfully treated with scoring balloon angioplasty in a 3-year-old boy

In children, up to 10% of the cases of arterial hypertension may be caused by a renovascular disease. The etiology of this renovascular disease is most of the time due to a fibromuscular dysplasia (FMD), which causes a noninflammatory intimal-medial fibroplasia leading to luminal compromise. Percutaneous transluminal angioplasty of FMD is a worldwide-accepted treatment modality for this serious arterial disease with, so far, good safety and long-term efficacy data. Once FMD involves several arterial compartments leading to symptoms the outcomes are poor. Herein we report the case of a 3½-year-old boy with severe arterial hypertension and abdominal angina due to a diffuse multivisceral FMD involvement, successfully managed by a percutaneous angioplasty approach using a new balloon catheter for plaque modulatio

Prognostic stratification of acute pulmonary embolism: Focus on clinical aspects, imaging, and biomarkers

Pulmonary embolism (PE) represents a common disease in emergency medicine and guidelines for diagnosis and treatment have had wide diffusion. However, PE morbidity and mortality remain high, especially when associated to hemodynamic instability or right ventricular dysfunction. Prognostic stratification to identify high risk patients needing to receive more aggressive pharmacological and closer monitoring is of utmost importance. Modern guidelines for management of acute PE are based on risk stratification using either clinical, radiological, or laboratory findings. This article reviews the modern treatment of acute PE, which is customized upon patient prognosis. Accordingly the current risk stratification tools described in the literature such as clinical scores, echocardiography, helical computer tomography, and biomarkers will be reviewed

Mortality rate related to peripheral arterial disease: A retrospective analysis of epidemiological data (years 2008-2019).

BACKGROUND AND AIMS Peripheral arterial disease (PAD) is one of the most prevalent cardiovascular diseases with more than 230 million people being affected worldwide. As highlighted by the recent European Society of Cardiology guidelines, data on the epidemiology of PAD is urgently needed. METHODS AND RESULTS We accessed the vital registration data of the Veneto region (Northern Italy, approximately five millions inhabitants) covering the period 2008-2019. We computed annual age-standardized rates for PAD reported as the underlying cause of death (UCOD) or as one of multiple causes of death (MCOD). Age-adjusted odds ratios (OR) served to study the association between PAD and cardiovascular comorbidities. The age-standardized mortality rate for PAD as MCOD slightly declined from 19.6 to 17.8 in men and from 10.8 to 9.1 deaths per 100,000 population-years in women. The age-standardized PAD-specific mortality rate (UCOD) remained stable: 3.1 to 3.7 per 100,000 person-years in women (Average Annual Percent Change 1.3, 95% CI -0.8; 3.4%) and 4.4 to 4.3 per 100,000 person-years (Average Annual Percent Change -0.2, 95% CI -3.6; 3.4%) in men. PAD contributed to 1.6% of all deaths recorded in the region. Ischemic heart disease, diabetes mellitus and neoplasms were the most prevalent UCOD among PAD patients. PAD was associated with diabetes mellitus (OR 3.79, 95%CI 3.55-4.06) and chronic kidney diseases (OR 2.73, 95%CI 2.51-2.97) in men, and with atrial fibrillation (OR 2.26, 95%CI 2.10-2.44) in women. CONCLUSION PAD remains a substantial cause of death in the general population of this high-income region of Western Europe with marked sex-specific differences

Pulmonary embolism in the elderly: a review on clinical, instrumental and laboratory presentation

OBJECTIVE: Diagnosis of pulmonary embolism (PE) remains difficult and is often missed in the elderly due to nonspecific and atypical presentation. Diagnostic algorithms able to rule out PE and validated in young adult patients may have reduced applicability in elderly patients, which increases the number of diagnostic tools use and costs. The aim of the present study was to analyze the reported clinical presentation of PE in patients aged 65 and more. MATERIALS AND METHODS: Prospective and retrospective English language studies dealing with the clinical, instrumental and laboratory aspects of PE in patients more than 65 and published after January 1987 and indexed in MEDLINE using keywords as pulmonary embolism, elderly, old, venous thromboembolism (VTE) in the title, abstract or text, were reviewed. RESULTS: Dyspnea (range 59%-91.5%), tachypnea (46%-74%), tachycardia (29%-76%), and chest pain (26%-57%) represented the most common clinical symptoms and signs. Bed rest was the most frequent risk factor for VTE (15%-67%); deep vein thrombosis was detected in 15%-50% of cases. Sinus tachycardia, right bundle branch block, and ST-T abnormalities were the most frequent ECG findings. Abnormalities of chest X-ray varied (less than 50% in one-half of the studies and more than 70% in the other one-half). Arterial blood gas analysis revealed severe hypoxemia and mild hypocapnia as the main findings. D-Dimer was higher than cut-off in 100% of patients in 75% of studies. Clinical usefulness of D-Dimer measurement decreases with age, although the strategies based on D-Dimer seem to be cost-effective at least until 80 years. CONCLUSION: Despite limitations due to pooling data of heterogeneous studies, our review could contribute to the knowledge of the presentation of PE in the elderly with its diagnostic difficulties. A diagnostic strategy based on reviewed data is proposed

Brain activations in speech recovery process after intra-oral surgery: an fMRI study

International audienceThis study aims at describing cortical and subcortical activation patterns associated with functional recovery of speech production after reconstructive mouth surgery. Our ultimate goal is the understanding of how the brain deals with altered relationships between motor commands and auditory/orosensory feedback, and establishes new inter-articulatory coordination to preserve speech communication abilities. A longitudinal sparse-sampling fMRI study involving orofacial, vowel and syllable production tasks on 9 patients and in three different sessions (one week before, one month and three months after surgery) was conducted. Healthy subjects were recorded in parallel. Results show that for patients in the pre-surgery session, activation patterns are in good agreement with the classical speech production network. Crucially, lower activity in sensorimotor control brain areas during orofacial and speech production movements is observed for patients in all sessions. One month after surgery, the superior parietal lobule is more activated for simple vowel production suggesting a strong involvement of a multimodal integration process to compensate for loss of tongue motor control. Altogether, these results indicate both altered and adaptive sensorimotor control mechanisms in these patients. Index Terms: Neurophonetics, fMRI, speech recovery, motor control, glossectomy, whole-brain analysis, sparse-sampling

Evolution des activations cérébrales lors de la production de parole après exérèse au niveau de la cavité orale

International audienceUsing functional MRI, acoustic data and motor oral assessment, brain correlates of speech recovery after dramatic structural changes in the vocal tract have been investigated during three tasks: orofacial movements and speech production (vowels and syllables). Eleven patients were recorded during three sessions, preoperatively and postoperatively, 1 month and 3 months after surgery (for seven of them also 9 months after surgery). Eleven healthy subjects were recorded in parallel. A "whole brain" group analysis (patients/healthy subjects) reveals a specific activation pattern for patients, in particular during vowel task, which is session-dependent. Moreover, global lower brain activation compared to healthy subjects was found for all tasks in primary, secondary and integrative sensorimotor regions. Differences are interpreted in relation with the emergence of new speech motor goals and changes in the internal models.A partir de données d'IRM fonctionnelle, acoustiques et praxiques, nous avons étudié les corrélats cérébraux de l'adaptation de la parole après une modification structurelle importante du conduit vocal lors de trois tâches : mouvements oro-faciaux silencieux, voyelles et syllabes. Onze patients ont été enregistrés lors de trois sessions, pré-opératoire et post-opératoire à 1 mois et 3 mois (pour sept d'entre eux aussi à 9 mois). Onze sujets contrôles ont été enregistrés en parallèle. Une analyse de groupe (patients/contrôles) " cerveau entier " révèle des patrons d'activation spécifiques aux patients au cours des différentes sessions en particulier pour la tâche de production de voyelles. De plus, une moindre activation cérébrale par rapport aux sujets sains a été observée pour toutes les tâches dans des régions motrices, sensorielles et d'intégration sensori-motrice. Nous interprétons ces résultats en relation avec la redéfinition des buts de parole et l'adaptation de modèles internes du système moteur périphérique

Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts

Objectives In older patients, the the D-dimer test for pulmonary embolism has reduced specificity and is therefore less useful. In this study a new, age dependent cut-off value for the test was devised and its usefulness with older patients assessed

ESVM Guideline on peripheral arterial disease

International audienc