What exactly is DVT and am I at risk?

Deep vein thrombosis, or deep venous thrombosis (DVT), is the formation of a blood clot (thrombus) within a deep vein,[a] most commonly the legs. Nonspecific signs may include pain, swelling, redness, warmness, and engorged superficial veins. Pulmonary embolism, a potentially life-threatening complication, is caused by the detachment (embolization) of a clot that travels to the lungs. Together, DVT and pulmonary embolism constitute a single disease process known as venous thromboembolism. Post-thrombotic syndrome, another complication, significantly contributes to the health-care cost of DVT.

In 1856, German pathologist Rudolf Virchow postulated the interplay of three processes resulting in venous thrombosis, now known as Virchow’s triad: a decreased blood flow rate (venous stasis), increased tendency to clot (hypercoagulability), and changes to the blood vessel wall. DVT formation typically begins inside the valves of the calf veins, where the blood is relatively oxygen deprived, which activates certain biochemical pathways. Several medical conditions increase the risk for DVT, including cancer, trauma, and antiphospholipid syndrome. Other risk factors include older age, surgery, immobilization (as with bed rest, orthopedic casts, and sitting on long flights), combined oral contraceptives, pregnancy, the postnatal period, and genetic factors. Those genetic factors include deficiencies with antithrombin, protein C, and protein S, the mutation of factor V Leiden, and the property of having a non-O blood type.

Individuals suspected of having DVT may be assessed using a clinical prediction rule such as the Wells score. A D-dimer test may also be used to assist with excluding the diagnosis (because of its high sensitivity) or to signal a need for further testing. Diagnosis is most commonly done with ultrasound of the suspected veins.

Prevention options for at-risk individuals include early and frequent walking, calf exercises, anticoagulants, aspirin, graduated compression stockings, and intermittent pneumatic compression. Anticoagulation is the standard treatment; typical medications include low-molecular-weight heparin or a vitamin K antagonist. Wearing graduated compression stockings appears to reduce the risk of post-thrombotic syndrome. The rate of DVTs increases from childhood to old age; in adulthood, about one in 1000 adults is affected per year.

Intermittent Pneumatic Compression: The New Standard of Care for Preventing VTE in Stroke Patients?

By GA Wardle
Reviewed by Alan S. Weinstein, MD, FACP, Senior Physician Advisor, Virtua Fox Chase
Cancer Program, Marlton, NJ

Physical methods for prevention of deep vein thrombosis (DVT)—including intermittent
pneumatic compression (IPC)—have documented efficacy in surgical patients. As recently as
2010, however, a Cochrane review found insufficient evidence to recommend IPC in stroke
patients, calling for larger randomized trials to assess potential risks and benefits in this
population.1 One such study is CLOTS 3, the results from which were presented at the European
Stroke Conference (ESC) in May 2013 and published simultaneously in The Lancet.2

Although venous thromboembolism (VTE) is a common complication of hospitalized medical
and surgical patients, VTE prevention measures are persistently underutilized, especially in
medical patients, in whom the risk-benefit ratio is less certain.2,3 In the UK alone, there are an
estimated 80,000 stroke patients at risk for DVT because they are immobilized. Among these,
10% will experience DVT and 1.5% will have a pulmonary embolus within the first month after
a stroke.4 Hence, the clinical and economic costs of not treating VTE in at-risk patients are
considerable.

Here’s a brief review of the history of the Clots in Legs Or sTockings after Stroke study: CLOTS
1 failed to show a benefit for thigh-length graduated compression stockings (GCS) in stroke
patients.5 CLOTS 2, which compared thigh-length to calf-length GCS, also failed to find any
benefit for GCS and was halted before enrollment was completed to avoid exposing study
subjects to the discomfort and risk of thigh-length GCS.6 IPC, which includes sleeves that are
inflated one leg at a time to compress the legs at intervals and stimulate venous flow, is thought
to lessen the risk of DVT both by reducing stasis and stimulating release of fibrinolytic factors.2

CLOTS 3 was a large randomized, controlled, multicenter trial that enrolled immobile patients
(N=2876) admitted following stroke.2 Within 3 days of hospitalization, patients were randomly
assigned not to receive IPC or to receive open-label IPC for a minimum of 30 days, or until
restoration of mobility, discharge, or death. The primary outcome was asymptomatic DVT
discovered in the proximal veins by compression duplex ultrasound at 7 to 10 days and 25 to 30
days, or symptomatic DVT in the proximal veins confirmed on imaging within 30 days of
enrollment.

IPC resulted in an absolute risk reduction of 3.6% (95% confidence interval [CI] 1.4 to 4.8). A
somewhat unexpected finding was a nonsignificant reduction in mortality in the IPC group (11%
versus 13%; P=.057). Benefit was found across all patient subgroups, including both
hemorrhagic and ischemic stroke patients. On the negative side, the IPC-treated group had an
increased risk of skin breaks (3% versus 1%, P=.002) and there was a minimal nonsignificant
increase in the risk of falls with injury (33 versus 24, 2% in each group, P=.221).2

“At last we have a simple, safe, and affordable treatment that reduces the risk of DVT and even
appears to reduce the risk of dying after a stroke,” commented Professor Martin Dennis of the
University of Edinburgh, who presented the study at ESC on behalf of the CLOTS Trials
Collaboration.7

This favorable risk-benefit profile is especially encouraging since issues surrounding the use of
anticoagulant prophylaxis include bleeding risk and uncertain benefit in medical patients.2
Despite a long list of potential study limitations—from the nonblinded nature of the trial to the
method of detecting symptomatic DVT to the lack of IPC adherence—the results of CLOTS 3
appear both valid and generalizable to stroke populations and perhaps to other medical patients
as well.2,3

“Finding a way of preventing blood clots from developing in the legs after stroke has been a huge
challenge, with all the research up until now failing to identify a safe and effective treatment to
this common and dangerous complication,” said Professor Tony Rudd, chair of the
Intercollegiate Stroke Working Party at the UK Royal College of Physicians in London. “This
study is a major breakthrough, showing how a simple and safe treatment can save lives. It is one
of the most important research studies to emerge from the field of stroke in recent years.”7
References:

Naccarato M, Chiodo Grandi F, Dennis M, et al. Physical methods for preventing deep vein
thrombosis in stroke. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD001922.
CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration. Effectiveness of
intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who
have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet.
2013;382:516-524.
Stevens SM, Woller SC. Intermittent pneumatic compression in patients with stroke. Lancet.
2013;382:484-486.
Dennis M, Sandercock P, Reid J, et al; CLOTS Trials Collaboration. Does intermittent
pneumatic compression reduce the risk of post stroke deep vein thrombosis? The CLOTS 3 trial:
study protocol for a randomized controlled trial. Trials. 2012;13:26.
CLOTS Trials Collaboration. Effectiveness of thigh-length graduated compression stockings to
reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised
controlled trial. Lancet. 2009;373:1958-1965.
CLOTS Trials Collaboration. Thigh-length versus below-knee stockings for deep venous
thrombosis prophylaxis after stroke: a randomized trial. Ann Intern Med. 2010;153:553-562.
Hope for stroke patients [press release]. The University of Edinburgh College of Medicine and
Veterinary Medicine. June 3, 2013.
http://www.ed.ac.uk/schools-departments/medicine-vet-medicine/news-events/all-news/hopefors
trokepatients310513. Accessed September 3, 2013.

Antidepressant use increases hip fracture risk among elderly

from: Medical New Today .com

Antidepressant use nearly doubles the risk of hip fracture among community-dwelling persons with Alzheimer’s disease, according to a new study from the University of Eastern Finland. The increased risk was highest at the beginning of antidepressant use and remained elevated even 4 years later. The findings were published in the International Journal of Geriatric Psychiatry.

For each person with Alzheimer’s disease, two controls without the disease were matched by age and sex. Antidepressant use was associated with two times higher risk of hip fracture among controls. However, the relative number of hip fractures was higher among persons with Alzheimer’s disease compared to controls.

The increased risk was associated with all of the most frequently used antidepressant groups, which were selective serotonin reuptake inhibitors (SSRI drugs), mirtazapine and selective noradrenaline reuptake inhibitors (SNRI drugs). The association between antidepressant use and the increased risk of hip fracture persisted even after adjusting the results for use of other medication increasing the risk of fall, osteoporosis, socioeconomic status, history of psychiatric diseases, and chronic diseases increasing the risk of fall or fracture.

Antidepressants are used not only for the treatment of depression, but also for the treatment of chronic pain and behavioral and psychological symptoms of dementia, including insomnia, anxiety and agitation. If antidepressant use is necessary, researchers recommend that the medication and its necessity be monitored regularly. In addition, other risk factors for falling should be carefully considered during the antidepressant treatment.

The study was based on the register-based MEDALZ cohort comprising data on all community-dwelling persons diagnosed with Alzheimer’s disease in Finland between 2005-2011, and their matched controls. The study population included 50,491 persons with and 100,982 persons without the disease. The follow-up was 4 years from the date of Alzheimer’s disease diagnosis or a corresponding date for controls. The mean age of the study population was 80 years.

Public Wants Well-Rested Medical Residents to Ensure Safe Patient Care

A new national poll shows that the vast majority of the American public favors restricting the
work shifts of medical residents (also known as resident physicians) to no more than 16 straight
hours without sleep, according to a press release from Public Citizen. Importantly, 86% of the
public is opposed to lifting the 16-hour cap for first-year residents – a proposal being
aggressively pushed by physician groups. Moreover, 80% of the public supports implementing
the 16-hour cap for all residents, not just first-year residents. “Sleep-deprived doctors must make
life-or-death decisions while dealing with long overnight shifts,” said Arianna Huffington, author
of “The Sleep Revolution.” “This latest poll shows that the American people want well-rested
doctors treating them. When we take care of ourselves, we are more effective at taking care of
others.” The national poll, commissioned by Public Citizen and conducted by Lake Research
Partners, was unveiled today during a telephone press conference. The poll comes as the
Accreditation Council for Graduate Medical Education (ACGME) – the private organization that
sets the rules on resident work hours that are intended to protect the health and safety of both
residents and patients – is facing intense pressure from dozens of physician organizations to lift
the current 16-hour shift cap for first-year medical residents and allow them to work 28 or more
hours in a row without sleep, the press release notes. “Rarely do we see such striking bipartisan
consensus over any health care issue,” said Celinda Lake, president of Lake Research Partners.
“The American public’s opinion toward medical resident work hours remains consistent and
overwhelming: The vast majority of people do not want doctors-in-training treating patients after
working grueling shifts of more than 16 hours without sleep.”
(Read more at
http://health-system-management.advanceweb.com/public-wants-well-rested-medical-residents-t
o-ensure-safe-patient-care/?utm_term=Read%20More&utm_campaign=HSM_DB_091916&utm
_content=email&utm_source=Act-On+Software&utm_medium=email&cm_mmc=Act-On%20S
oftware-_-email-_-Daily%20Brief%3A%20U.N.%20to%20Address%20Antibiotic%20Resistanc
e-_-Read%20More

 

Rapid-Inflation Intermittent Pneumatic Compression for Prevention of Deep Venous Thrombosis

Eisele R, Kinzl L, Koelsch T:J Bone Joint Surg Am. 89:1050-6, 2007

Over 1800 consecutive inpatients were enrolled in this randomized prospective clinical study. A total of 902 patients were managed with chemoprophylaxis alone and 901 patients received chemoprophylaxis augmented with [VenaFlow] intermittent pneumatic compression (IPC). All patients were Dopplered for evidence of symptomatic and nonsymptomatic deep vein thrombosis (DVT) at discharge. In the chemoprophylaxis-only group, fifteen patients (1.7%) were diagnosed with a DVT; three thromboses were symptomatic. In the IPC group, four patients (0.4%) were diagnosed with DVT; one thrombosis was symptomatic. The difference was significant. In addition, patients who wore the IPC device more than six hours per day had no deep vein thromboses. The results demonstrate that the multimodal approach of using a rapid inflation intermittent pneumatic compression device as an adjunct to low-molecular-weight heparin is significantly more effective in preventing DVTs than using low-molecular-weight heparin alone.

Studies have shown that carefully controlled exercise is safe for patients with lymphedema.

INFORMATION FROM THE NATIONAL CANCER INSTITUTE

Exercise does not increase the chance that lymphedema will develop in patients who are at risk for lymphedema. In the past, these patients were advised to avoid exercising the affected limb. Studies have now shown that slow, carefully controlled exercise is safe and may even help keep lymphedema from developing. Studies have also shown that, in breast-cancer survivors, upper-body exercise does not increase the risk that lymphedema will develop. Some studies with breast cancer survivors show that upper-body exercise is safe in women who have lymphedema or who are at risk for lymphedema. Weight-lifting that is slowly increased may keep lymphedema from getting worse. Exercise should start at a very low level, increase slowly over time, and be overseen by the lymphedema therapist. If exercise is stopped for a week or longer, it should be started again at a low level and increased slowly. If symptoms (such as swelling or heaviness in the limb) change or increase for a week or longer, talk with the lymphedema therapist. It is likely that exercising at a low level and slowly increasing it again over time is better for the affected limb than stopping the exercise completely.

AMA Blasts Medicare Part B Drug Price Plan

Votes to ask CMS to withdraw proposal

by Joyce Frieden
News Editor, MedPage Today

 

CHICAGO — A proposal by the Centers for Medicare & Medicaid Services (CMS) to change the way Medicare pays for drugs under the Part B program would hurt physician practices, the American Medical Association said at its annual meeting here.
“This is a patient care issue and an access issue,” said Heather Smith, MD, an ob/gyn in Bronx, N.Y., who spoke on behalf of the American Congress of Obstetricians and Gynecologists. “This will impact care of our patients, especially those with ovarian cancer.”

The AMA House of Delegates passed a resolution Wednesday asking that CMS withdraw its proposal and, if that doesn’t happen, that the AMA lobby Congress block the proposal’s implementation. The proposal, if put into place, “would significantly undermine the ability of physician practices to meet the significant administrative and financial burdens associated with the rapidly evolving healthcare environment,” according to the resolution.
The CMS plan would replace the current Medicare reimbursement — the average sales price of the drug plus a 6% add-on fee to cover costs — with a rate of the average sales price plus 2.5%, plus a flat fee of $16.80 per drug per day. The flat fee would be adjusted at the beginning of each year.

For full story go to: http://www.medpagetoday.com/MeetingCoverage/AMA/58630

Low Level Laser Combine with Pneumatic Compression May Prove More Effective In Treatment Of Lymphedema

by Erkan Kozanoglu, et al, Faculty of Medicine, Cukurova University, Adana, Turkey

Abstract

Objective: To compare the long-term efficacy of pneumatic compression and low-level laser therapies in the management of postmastectomy lymphoedema.

Design: Randomized controlled trial.

Setting: Department of Physical Medicine and Rehabilitation of Cukurova University, Turkey.

Subjects: Forty-seven patients with postmastectomy lymphoedema were enrolled in the study.

Interventions: Patients were randomly allocated to pneumatic compression (group I, n=24) and low-level laser (group II, n=23) groups. Group I received 2 hours of compression therapy and group II received 20 minutes of laser therapy for four weeks. All patients were advised to perform daily limb exercises.

Main measures: Demographic features, difference between sum of the circumferences of affected and unaffected limbs (▵C), pain with visual analogue scale and grip strength were recorded.

Results: Mean age of the patients was 48.3 (10.4) years. ▵C decreased significantly at one, three and six months within both groups, and the decrease was still significant at month 12 only in group II (P = 0.004). Improvement of group II was greater than that of group I post treatment (P = 0.04) and at month 12 after 12 months (P = 0.02). Pain was significantly reduced in group I only at posttreatment evaluation, whereas in group II it was significant post treatment and at follow-up visits. No significant difference was detected in pain scores between the two groups. Grip strength was improved in both groups, but the differences between groups were not significant.

Conclusions: Patients in both groups improved after the interventions. Group II had better long-term results than group I. Low-level laser might be a useful modality in the treatment of postmastectomy lymphoedema.

SEXUALITY AND DEMENTIA

Balancing resident rights and safety.

Excerpted from an article by Lee Ann Griffen in the Florida Health Care Association’s newsletter
“Pulse”.

“Competent residents engaging in consensual sexual activity is not a cause for undue concern in
assisted living, especially considering many residents have their own rooms which they call
home. CMS’ interpretation of Home and Community-Based Characteristics for assisted living
clients who receive Medicaid services takes this further, providing individuals the right to have
visitors of their choosing at any time.

Assisted living communities may specialize in accommodating residents who have cognitive
impairments. It’s important to recognize that cognitive impairments do not necessarily make a
person ineligible for sexual activity. However, administrators and professional staff must try to
differentiate between intimacy and abuse. There is no one-size-fits-all approach to sexuality and
dementia.

A clinical assessment must occur in order to determine consent. Guidance may be found at
www.nih.gov/ ; search Intimacy and Sexuality. It should be noted that a person’s right to make
choices is not invalidated solely because the staff does not agree. Staff should be educated on
distinguishing between their own values and the values of the residents.

New Study Reveals Concerns About Lymphedema and Other Complications As Cancer Survivors Increase

A new study in the journal Cancer Epidemiology, Biomarkers & Prevention shows that during the next 10 years there will be a 42 percent increase of cancer survivors who are older than 65 years old. Health care professionals will need to become aware of some of the distinct challenges these types of patients face to give them high-quality care. In particular, some cancer patients deal with lymphedema as a result of surgery or radiation therapy that causes a mechanical alteration of the lymphatic system. This chronic disorder can greatly affect an individual’s quality of life. It is critical that treatment for lymphedema occurs early on, as the disorder can worsen over time. “Health care professionals need to do everything possible to keep the skin integrity and prevent further infection,” said Greg Grambor, president of Vascular PRN, a company that helps healthcare professionals nationwide with lymphedema pumps and lymphedema boots. “Compression therapy can keep fluid from repooling so that other complications do not occur.” Over time, lymphedema can lead to cellulitis, disability, and psychosocial issues. Swollen tissues can create an environment where infections can reappear and cause irreversible damage to the tissues. Pain and difficulty moving can lead to a diminished quality of life, and affect other areas of a person’s social and intimate relations. “With a doctor’s guidance, extremity pump systems and physical therapy can do a lot of good to regain comfort and lessen the issues that can ensue,” said Grambor.