Immediate mobilisation in acute vein thrombosis reduces post-thrombotic syndrome

AIM

To investigate the effect of compression and immediate ambulation in the acute stage of deep vein thrombosis (DVT) on the development of postthrombotic syndrome (PTS).

METHODS

DESIGN

follow-up study of patients who previously have been enrolled in a randomized controlled trial.

SETTING

outpatient department of a municipial hospital.

SUBJECTS AND INTERVENTIONS

a follow-up was performed 2 years after 53 patients with acute proximal DVT had been enrolled into a randomized controlled trial, comparing bed rest and no compression (n=17), Unna boot bandages plus walking (n=18) and compression stockings plus walking (n=18). Telephone interviews could be conducted with 11 patients, 37 patients could be reinvestigated by independent observers (11 from the bed-rest group, 13 from the bandage group and 13 from the stocking group). Compression stockings up to the time of the follow-up were worn by 8/11 (73%) of the bed-rest patients and by 13/26 (50%) of the mobile patients.

MAIN OUTCOME MEASURES

clinical and venous duplex investigation, pain assessment using visual analogue scale and Lowenberg test, leg circumference, clinical ''PTS-score'' combining 5 subjective symptoms with 6 objective signs (Villalta-Prandoni-scale).

RESULTS

Duplex investigation of the deep veins and pain assessment by visual analogue scale showed no significant differences between the groups. Nine out of 11 patients after bed rest, but only 16/26 in the mobile groups showed a larger calf circumference on the diseased leg (n.s.). Judged by the Villalta-Prandoni-scale a significantly better outcome could be found in the mobile group (mean score 5.1) than in the bed-rest group (mean score 8.2), (p<0.01). (''Mild PTS'' = score 5-14, ''severe PTS'' score = or > 15). Eighteen out of 26 mobile patients, but only 2/11 bed-rest patients had a score = or < 5 (''no PTS'').

CONCLUSIONS

Immediate mobilisation with compression in the acute stage of DVT reduces the incidence and the severity of PTS.

Results of a questionnaire regarding improvement of 'C' in the CEAP classification

BACKGROUND

One of the shortcomings of the CEAP classification is that some of the clinical conditions in the original version were not defined and, therefore, were used in different ways by those who work with CEAP.

AIM

To clarify the definitions of the seven clinical classes in the CEAP classification and to improve universal understanding of these in phlebology.

METHODS

The authors prepared a short questionnaire regarding the 'C' part of CEAP with five main questions, dealing with definitions of clinical items: telangiectases, corona phlebectatica, reticular veins, varicose veins and the use of CEAP. The questionnaire was translated into 11 different languages and sent around the world by means of International Venous Digest by fax. Two hundred and six answers were received from 67 countries out of 3681 faxes sent (5.6%).

RESULTS

There were a wide variety of opinions returned thus demonstrating that the same term is used with various meanings by different physicians. All physicians classify telangiectases of thigh and foot as class C1, but discrepant answers were obtained concerning the differences between reticular veins and reticular varicose veins as well as the diameter of small and large varicose veins. Sixty per cent of physicians answering this survey use the CEAP classification.

CONCLUSION

Further clarification and refinement of the CEAP classification are necessary. The authors hope that this will result in broader acceptance of CEAP.

Leg compression and ambulation is better than bed rest for the treatment of acute deep venous thrombosis

AIM

Treatment of acute deep venous thrombosis (DVT) with low-molecular-weight heparin and vitamin K-antagonists reduces the risk of thrombus progression and pulmonary embolism but has no immediate effect on signs and symptoms. We addressed the question whether adding compression and walking would lead to a more rapid clinical improvement than bed rest.

METHODS

Fifty-three symptomatic outpatients with proximal DVT were randomly treated, in addition to dalteparin and phenprocoumon, with either firm inelastic bandages (n=18), elastic compression stockings (n=18), both combined with immediate deliberate ambulation, or bed rest without any compression (n=17). We assessed daily walking distance, well-being, quality of life, pain, swelling and clinical scores over a period of 9 days. Lung scans and ultrasound of the leg were performed on days 0 and 9.

RESULTS

In the compression groups the walking distance increased with time to 4 km/day on average. Improvement of well-being and DVT-related quality of life was significantly faster and more pronounced with compression than with bed rest (p<0.05 for stockings, p<0.001 for bandages). Pain monitored by visual analogue scale decreased with time in a linear pattern in all groups (p<0.001). There was a significant difference between the groups (p<0.01), the best effect being achieved with bandages. Pain assessed by a provocation test was reduced by half on day 3 with bed rest but remained constantly present over the subsequent 6 days. With compression it was reduced to near baseline on day 3. Swelling was almost completely removed with compression and clinical scores also improved more than with bed rest (p<0.001). Thrombus progression, as studied with ultrasound, was less frequent and less pronounced in the compression groups than with bed rest. There was no difference of new pulmonary embolism on repeat lung scans.

CONCLUSION

Leg compression combined with walking is the better alternative to bed rest for the treatment of symptomatic outpatients with proximal DVT.

Die Antistase, ein vernachlässigtes Therapieprinzip bei der tiefen Beinvenenthrombose

Antikoagulation ist die Basis der konservativen Behandlung der tiefen Venenthrombose (TVT). Die phlebographischen Ergebnisse mit konventionellen intravenösen Infusionen von unfraktioniertem Heparin, die Bettruhe erforderten, waren nicht sehr zufriedenstellend, konnten aber durch die Einführung von niedermolekularen Heparinen (NMH) verbessert werden. NMH werden subkutan verabreicht. Die Bettruhe kann entfallen, sogar eine Heimtherapie wird möglich. Die besseren Ergebnisse sind wohl auch durch die frühe Mobiliserung der Patienten entsprechend den Prinzipien der Antistase zu erklären. Eine ambulatorische Behandlung der proximalen TVT mit NMH und Kompression führt nicht zu einem erhöhten Risiko von klinisch relevanten Lungenembolien. Gehübungen mit guter Kompression (Verbände oder Kompressionsstrümpfe) bewirken eine raschere und effektivere Reduktion von Schmerzen und Schwellung als Bettruhe.

Wenn ein TVT-Patient kommt, liegen sehr häufig szintigraphisch nachweisbare Lungenembolien vor, die meistens klinisch stumm sind. Unter therapeutischer NMHDosierung, fester Kompression und Gehübungen sind neue Pulmonalembolien selten. Die Inzidenz einer tödlichen Pulmonalembolie betrug 3 von 1289 bei so behandelten, konsekutiven Patienten. Zusätzliche antistatische Maßnahmen zur Antikoagulation ergeben bessere Resultate als alleinige Antikoagulation, ohne dabei die Gefahr einer gefährlichen Lungenembolie zu erhöhen. Deshalb sollten mobile TVT-Patienten exakt antikoaguliert werden (in der Initialphase bevorzugt beginnend mit NMH) und mit guter Beinkompression angehalten werden, möglichst viel zu gehen, unabhängig davon, ob sie zu Hause oder im Krankenhaus behandelt werden.

[Diagnosis and therapy of thrombophlebitis with special consideration of low molecular weight heparin]

The clinical diagnosis of superficial thrombophlebitis is characterized by the occurrence of painful and inflamed cords along superficial veins and varices. Duplex sonography is recommended to rule out asymptomatic deep vein thrombosis which may be present in about 20% and to check potential sources of entrance of the thrombotic process into deep veins, like the junctions of great and small saphenous veins. Classic therapy is based on firm compression therapy and walking exercises. Incisions with expression of clots and anti-inflammatory drugs may reduce pain and inflammation. When phlebitis involves also the thigh and especially the proximal part of the great saphenous vein surgical ligation of the junction and local thrombectomy can be considered, preferably on an outpatient basis. Recent data from one randomised controlled trial demonstrate the efficacy of unfractionated heparin in a dose of 12,500 I.U. s. c. twice a day in this indication. According to another randomised controlled trial low molecular weight heparin (LMWH) may reduce the development of thromboembolic complications and also the relatively frequent extension of the thrombi in the superficial veins. Therapeutic doses seem to be more effective than prophylactic doses. While conventional therapy with compression and walking is sufficient for the majority of cases, the additional use of low molecular heparin is recommended in increased thromboembolic risk and when the thigh is involved. In the few studies available treatment time of 6-12 days is reported. More studies with special focus on indication, dosage and duration of therapy with LMWH are needed for the recommendation of clear therapeutic guidelines.

[Periarterial sympathectomy of the radial and ulnar arteries in Raynaud's phenomenon--a preliminary study]

PURPOSE

Assessment of the post-operative results of peripheral sympathectomy in Raynaud's phenomenon.

METHODS

Six patients with therapy refractory Raynaud's phenomenon underwent a 4 cm long adventitial stripping of the radial and ulnar arteries proximal to the wrist. The nerve of Henle was followed up to the surface of the palmar arch and resected. The pre- and postoperative examinations were performed using the help of a questionnaire, telethermography and infra-red laser reflexion rheography.

RESULTS

All but two patients (two hands) were free of complaints (four patients, six hands), the three ulcers on the finger tips healed well. According to the questionnaire there was a dramatic improvement in the quality of life of the patients.

CONCLUSION

In the follow-up period of two years, there was no recurrence. Adventitial stripping of the radial and ulnar arteries and resection of the nerve of Henle proximal to the wrist have demonstrated favourable results in the treatment of therapy-resistant complaints in Raynaud's phenomenon.

Adventitial stripping of the radial and ulnar arteries in Raynaud's disease

Adventitial stripping of the palmar arch, the palmar common digital arteries, or the proper digital arteries is a last resort in the treatment of refractory primary or secondary Raynaud's phenomenon. Seven patients who had adventitial stripping of the ulnar and radial arteries proximal to the wrist and resection of the nerve of Henle, if identifiable, are presented. All of them were evaluated by telethermography, acral rheography, and a questionnaire before and after surgery. All were asymptomatic after surgery with satisfactory healing of the ulcers at the fingertips. None of them relapsed during the follow-up time of 1.5 years.

The efficacy and safety of a coumarin-/troxerutin-combination (SB-LOT) in patients with chronic venous insufficiency: a double blind placebo-controlled randomised study

BACKGROUND

The objective was to evaluate the oedema-protective effect of a vasoactive drug (coumarin/troxerutin [SB-LOT]) plus compression stockings in patients suffering from chronic venous insufficiency after decongestion of the legs as recommended by the new guidelines.

PATIENTS AND METHODS

231 patients were randomly assigned medical compression stockings plus SB-LOT (90 mg coumarin and 540 mg troxerutin per day) or medical compression stockings plus placebo for the first 4 weeks and SB-LOT or placebo for the second 12 weeks of the study. The primary efficacy endpoint was the lower leg volume measured by well-established water plethysmometry.

RESULTS

226 patients were evaluated. After ceasing compression stockings, an edema protective effect was detected in the SB-LOT-group but not in the controls. Recurrence of leg volume increase was by 6.5 +/- 12.1 ml and by 36.7 +/- 12.1 ml in the SB-LOT and placebo group, respectively (p = 0.0402). The local complaint score and general aspects of quality of life were also superior for the SB-LOT-group (p = 0.0041). Significant differences were also observed with regard to clinical global impression and therapeutic effect. No serious adverse drug reaction or clinically relevant impairment of laboratory parameters occur.

CONCLUSION

This study confirms the oedema-protective effect of SB-LOT in chronic venous insufficiency and provides a treatment option for patients who discontinue compression after a short time.

Lupus anticoagulant and venous leg ulceration

BACKGROUND

Most leg ulcers occur in patients with venous insufficiency. However, not all patients with venous insufficiency develop leg ulcers. Recent studies have found that factors causing clotting abnormalities, e.g. anticardiolipin antibody (ACA), are associated with leg ulcers. Although lupus anticoagulant, like ACA, belongs to the group of antiphospholipid antibodies, its presence in patients with venous leg ulceration has not been previously reported.

OBJECTIVES

To determine the presence of lupus anticoagulant in patients with venous leg ulceration.

METHODS

We investigated the presence of lupus anticoagulant in 27 patients with venous leg ulcers and compared these data with controls. Lupus anticoagulant was evaluated in all subjects by the Russell's viper venom test.

RESULTS

Of 27 patients with venous leg ulceration, 16 (59%) were shown to have lupus anticoagulant, while only one of 32 controls (3%) was found to have lupus anticoagulant. Thus, lupus anticoagulant was significantly more frequent in patients with venous leg ulcers than in controls (P < 0.001).

CONCLUSIONS

We suggest that lupus anticoagulant could be a hitherto unknown factor contributing to the development of venous leg ulcers.

Diagnostik und Therapie der Thrombophlebitis unter besonderer Berücksichtigung niedermolekularer Heparine

Die klinische Diagnose der oberflächlichen Thrombophlebitis ist charakterisiert durch das Auftreten von schmerzhaften und entzündeten Strängen im Bereich von oberflächlichen Venen und Varizen. Eine Duplexsonographie wird empfohlen, um eine asymptomatische tiefe Venenthrombose auszuschließen, die in ca. 20% vorliegen kann, und um potentielle Eintrittspforten des thrombotischen Prozesses in tiefe Venen (z. B. Mündung von Vena saphena magna und parva) abzuklären. Die klassische Behandlung basiert auf einer festen Kompression sowie Gehübungen. Inzisionen mit Expression von Gerinnseln sowie entzündungshemmende Medikamente können Schmerzen und Entzündung lindern. Wenn die Phlebitis auch den Oberschenkel und besonders die proximalen Anteile der Vena saphena magna betrifft, kann eine Mündungsligatur und eine lokale Thrombektomie überlegt werden, bevorzugt unter ambulanten Bedingungen. Neue Daten einer randomisierten kontrollierten Studie beweisen die Wirksamkeit von unfraktioniertem Heparin in der Dosierung von zweimal 12 500 I.E. s. c. bei dieser Indikation.

Aufgrund einer weiteren randomisierten kontrollierten Studie kann niedermolekulares Heparin (NMH) die Entwicklung von thromboembolischen Komplikationen und die relativ häufige Ausbreitung der Thromben in den oberflächlichen Venen verzögern. Therapeutische Dosen scheinen effektiver zu sein als prophylaktische. Während die herkömmliche Behandlung mit Kompression und Gehübungen für die meisten Fälle ausreicht, wird die zusätzliche Gabe von niedermolekularen Heparinen bei erhöhtem Thromboembolierisiko und bei Oberschenkelmitbeteiligung empfohlen. Die wenigen Studien berichten von einer Behandlungszeit von 6-12 Tagen. Mehr Studien speziell im Hinblick auf Indikation, Dosierung und Therapiedauer von NMH sind erforderlich, um klare Therapierichtlinien geben zu können.

[Mondor phlebitis associated with hepatitis C]

Mondor's disease in association with hepatitis C. We report a case of a 40 years old patient suffering from Mondor's disease. Neither a malignancy nor a disturbance of the clotting system was found. This case is remarkable for the association with hepatitis C.

Therapy of deep vein thrombosis with low molecular weight heparin, leg compression and immediate ambulation

BACKGROUND

Traditionally, patients with acute deep vein thrombosis (DVT) are treated with strict bed rest for several days to avoid clots from breaking off and causing pulmonary emboli. The purpose of this study is to give a precise estimate of short term complications like pulmonary embolism, bleeding, heparin-induced thrombocytopenia (HIT) and death in a cohort of consecutive patients who were admitted because of acute symptomatic DVT, all treated by compression and walking exercises instead of conventional bed-rest and nearly all by low-molecular-weight heparin.

PATIENTS AND METHODS

In 1289 consecutive patients the following five endpoints were registered for the period of hospital-stay: 1. Frequency of pulmonary embolism (PE) at admission (V/Q lung scan), 2. Frequency of new PE's after 10 days (second lung scan), 3. Fatal events (autopsy), 4. Frequency of malignant disease, 5. Bleeding complications and HIT.

RESULTS

1. 190/356 (53.4% of iliofemoral, 355/675 (52.6%) of femoral and 84/239 (35.1%) of lower leg vein thrombosis showed PE (difference iliofemoral and femoral versus lower leg DVT p < 0.001). Two thirds of these PE were asymptomatic. 2. New PE after 10 days in comparison to the baseline scan occurred in 7.4%, 6.4% and 3.4% respectively. 3. Fatal events, all investigated by autopsy, were caused by PE in 3 patients aged over 76 years (0.23%), by malignant diseases in 12 (0.9%) and due to other causes in 2 (0.15%). 4. 232 patients (18%) had associated malignant diseases, from which 33% were detected by our screening. 5. Non-fatal bleeding complications were seen in 3.3%, including 5 patients (0.4%) with major bleeding. Three patients (0.2%) suffered from HIT II.

CONCLUSION

The low incidence of recurrent and fatal pulmonary emboli in this series affirms the value of early ambulation with heavy leg compression in patients with symptomatic acute leg deep venous thrombosis. In addition, the presence of pulmonary emboli in one-third of those with calf vein thrombi emphasizes the importance of fully diagnosing and treating calf clots.

Multicentre, randomised controlled trial of four-layer bandaging versus short-stretch bandaging in the treatment of venous leg ulcers

BACKGROUND

Aim of the study was to compare the healing rates of venous ulcers obtained with four-layer bandages (4LB) versus short stretch bandages (SSB).

DESIGN

Multicentre, randomised controlled trial performed in 5 centres of the Netherlands and in 2 centres in Austria ("PADS-study" = Profore Austrian Dutch Study).

PATIENTS AND METHODS

112 patients (53 treated with 4LB and 59 treated with SSB) completed at least one post-treatment follow-up, 90 completed the study. Bandaging and ulcer assessment was performed at weekly intervals. Randomisation was carried out for each centre and was stratified according to the size (more or less than 10 cm2) of the ulcerated area. Local therapy consisted of plain absorbing, non-adherent dressings. Time to complete healing was recorded up to a maximum of 16 weeks. The two treatment-groups were comparable regarding their baseline-characteristics.

RESULTS

In total 33/53 (62%) of ulcer-patients were healed in the 4LB group, compared with 43/59 (73%) in the SSB group (difference 11%, 95% CI -28% to 7%). 77% of the ulcers with an initial area less than 5 cm2 healed as compared with 33% of the larger ulcers. The different healing rates in the centres could be explained by the different sizes of the treated ulcers. Based on Kaplan-Meier estimates the median healing time was 57 days for the 4LB (95% CI 47-85 days) and 63 days for the SSB (95% CI 43-70 days).

CONCLUSION

The ulcer healing rate and the median healing time did not differ among the two types of bandages. The main discriminant criterion for healing was the initial ulcer size. In centres who are experienced users of short-stretch bandages, no statistically significant different healing rates of venous ulcers could be found after 4LB or SSB.

Reisethrombose 2001

Anlässlich einer Tagung in Wien im Juni 2001 hat eine Gruppe von Experten aus Deutschland, der Schweiz und aus Österreich ein Dokument ausgearbeitet, in welchem eine Definition der Reisethrombose gegeben und Vorbeugemaßnahmen vorgeschlagen wurden, die an drei Risikogruppen angepasst sind.

Compression and walking versus bed rest in the treatment of proximal deep venous thrombosis with low molecular weight heparin

OBJECTIVE

The purpose of this randomized controlled trial was to evaluate the benefits of compression and walking exercises in comparison with bed rest in the acute stage of proximal deep venous thrombosis (DVT).

METHODS

Forty-five patients with proximal DVT that was proved with compression ultrasound scan or phlebography were randomized into three groups. Group A consisted of 15 patients who received inelastic compression bandages (Unna boots on the lower leg, adhesive bandages on the thigh), and group B consisted of 15 patients who received thigh-length compression stockings, class II. Group C consisted of 15 patients who underwent bed rest and no compression. All patients received dalteparin, 200 IU/kg per body weight, subcutaneously every 24 hours. The clinical characteristics of the three groups were comparable. Primary end points were the reduction of pain assessed daily with the Visual Analogue Scale and the Lowenberg test, the reduction of leg circumference at the ankle and calf levels, and the improvement of clinical scores. The daily walking distance was measured with a pedometer. Safety parameters were ventilation-perfusion scans and duplex ultrasound scans performed on days 0 and 9.

RESULTS

The daily walking distance was between 600 and 12,000 m in the compression groups and averaged 66 m in the bed rest group. The pain level showed a statistically significant reduction starting after the second day in the compression groups (A and B) and after 9 days in the bed rest group C (P <.05). The same was true for the measurement of leg circumference. Improvement of the clinical scores was significantly better in the compression groups compared with the bed rest group (P <.01). There was no significant difference concerning the occurrence of new pulmonary emboli and regression of thrombus diameter. Progression of thrombi in the femoral vein was greater and occurred more frequently in the bed rest group than in the other two groups (P = not significant).

CONCLUSION

Mobile patients with acute proximal DVT treated with low molecular weight heparin should be encouraged to walk with compression bandages or medical compression stockings. The rate of resolution of pain and swelling is significantly faster when the patient ambulates with compression. The risk of pulmonary embolism is not significantly increased by this approach.

Factors influencing pain outcome in herpes zoster: an observational study with valaciclovir. Valaciclovir International Zoster Assessment Group (VIZA)

AIM OF THE STUDY

An observational study with valaciclovir was conducted to assess clinical outcome in herpes zoster, especially pain and associated neurological signs and symptoms in relation to a series of demographic and disease characteristics discernible at presentation. The safety and acceptability of valaciclovir for treatment of zoster was assessed in a wide variety of primary care and clinic referral settings.

METHODS

In total, 1897 immunocompetent adults with clinically diagnosed, localized acute herpes zoster were enrolled in this international, open-label study of valaciclovir. All subjects received treatment with oral valaciclovir (1000 mg three times daily) for 7 days from entry to the study and were asked to record the presence of zoster-associated pain and abnormal sensations throughout treatment and 6 months' follow-up. They were seen frequently in clinic to verify subjective assessments and for evaluation of rash healing. Safety and tolerability were assessed by adverse event monitoring.

RESULTS

Overall, 1191 subjects (63%) were aged > or = 50 years, and 203 (11%) had ophthalmic zoster. Cessation of zoster-associated pain was significantly faster in the younger age group; median times to loss of zoster-associated pain were 23 days and 9 days in the > or = 50 and < 50 years age groups, respectively. Similarly, abnormal sensations resolved significantly more rapidly in the younger subjects; the median duration of abnormal sensations was 31 days in the > or = 50 year olds and 16 days in those aged < 50 years. In cases of ophthalmic zoster, the rate of pain resolution was not different from those with zoster in other dermatomes (median duration of pain 18 vs. 16 days). However, abnormal sensations persisted significantly longer in subjects with ophthalmic zoster than in those with zoster at other sites (47 vs. 22 days). In addition to advancing age, subjects suffering moderate to severe prodromal pain or acute pain during the rash phase were at significantly greater risk of zoster-associated pain and abnormal sensations persisting for longer. Subjects with concomitant neurological disorders were also more likely to develop prolonged abnormal sensations. Valaciclovir treatment was well tolerated, and adverse events were rare and generally mild.

CONCLUSION

This study confirmed the prognostic importance of advancing age and the intensity of prodromal or acute pain as risk factors for prolonged zoster-associated pain and persisting abnormal sensations in the affected dermatome. Ophthalmic zoster and pre-existing neurological disorders are also identified as highly significant risk factors for prolonged abnormal sensations in herpes zoster.

Erythema migrans and serodiagnosis by enzyme immunoassay and immunoblot with three borrelia species

There is wide divergence of opinion between physicians regarding the use of serological measures for the diagnosis and treatment of erythema migrans, the hallmark of Lyme borreliosis. We studied the outcome of an enzyme immunoassay and immunoblot (Western blot) used on the sera of patients who had suffered tick bite and erythema migrans, and had been subsequently treated with various antibiotics. Ninety-nine consecutive patients presenting with erythema migrans after tick bite were prospectively recruited at the outpatient department of two Vienna City hospitals and at the consultation office for Lyme borreliosis of the Institute of Hygiene. University Vienna. Blood samples were taken before antibiotic treatment and 3 and 6 months thereafter. Blood samples from 100 blood donors served as controls. Antibodies against Borrelia burgdorferi sensu lato were determined by enzyme immunoassay (IgG and IgM EIA) and by IgG immunoblot. The latter was performed with isolates of B. alzelii (H2) B. burgdorferi sensu stricto (Le) and B. garinii (W) from Austrian patients. The 4 interpretation criteria for immunoblot results were: A (3 bands out of 8), B (2 bands out of 9), C and D (1 band out of 6). In all patients, the erythema resolved within the treatment period. No complications secondary to the borrelia infection were registered. After treatment there was no significant change in titre, nor was there a difference in the immunoblot pattern between the first, second and third serum samples. Serum antibodies to B. burgdorferi were positive by EIA in 22.9% (IgG) and 2.5% (IgM). Immunoblot results offered by borrelia species and by the interpretation criteria, ranging between 8.3% (criterion A, strain Le) and 44.2% (criterion D, strain H2). By EIA, control samples were IgG and IgM positive in 5% and 1%, respectively. Positive immunoblot results with strain H2 were found in 9%, 13%, 18%, and 20% by the criteria A through D respectively. After antibiotic treatment of erythema migrans the immunological response appears to be abrogated. Thus, serological results are not supportive for the diagnosis of erythema migrans, not will they retrospectively prove successful antibiotic treatment of borrelia infection.

Inelastic leg compression is more effective to reduce deep venous refluxes than elastic bandages

BACKGROUND

Deep venous refluxes play an important triggering role for the development of venous leg ulcers. Compression therapy is able to reduce these refluxes depending on pressure and the kind of material being used.

OBJECTIVE

To compare the efficacy of compression bandages of varying pressure and material (elastic, long-stretch versus inelastic, short-stretch bandages, four-layer bandages).

METHODS

Venous volume (VV) and venous filling index (VFI) as a quantitative parameter of venous reflux were measured using an airplethysmograph (APG) in a total of 21 patients presenting with venous leg ulcers and deep venous refluxes. Bandage pressure was measured in every experiment. The influence of elastic and inelastic bandages with increasing pressure and the changes in these parameters using different bandages with the same pressure were investigated.

RESULTS

The initial median value of VFI without compression was 8.45 ml/sec. VV and VFI were significantly reduced by increasing external pressure, more strongly with inelastic than with elastic material. With a pressure of 25 mmHg inelastic bandages diminished VFI to a median of 3.25 ml/sec while the elastic material did not even approach this value with a pressure of 40 mmHg (4.25 ml/sec). Applying bandages of different material with the same pressure of 30 mmHg, the most intense reduction of VV and VFI was obtained by inelastic and by four-layer bandages. The effect on venous reflux was statistically significantly superior with inelastic compared to elastic material.

CONCLUSION

Using the same bandage pressure, inelastic material is more effective at reducing deep venous refluxes than elastic bandages in patients with venous ulcers. Four-layer bandages show similar efficacy to inelastic bandages.

[Thrombophlebitis: bed rest or walking exercise?]

It is a common tradition to admit patients with deep vein thrombosis (DVT) to the hospital and put them to bed for several days because of fear from pulmonary embolism, even if they are mobile. Between May 1994 and December 1997 929 patients were admitted to our department who were treated by subcutaneous injections of low-molecular-weight heparin (mainly 200 IU dalteparin per kilogram body-weight per 24 hours), got firm compression bandages and were encouraged to walk as much as possible. On admission DVT propagated into the pelvis in 268 patients, into the thigh in 480 and below the popliteal level in 181 patients. V/Q-lung scans were performed at baseline and repeated after 10 days on average. In these three groups primary pulmonary embolism was diagnosed in 49.4%, 50% and 34% respectively, new emboli after 10 days were found in 6.1%, 5.7% and 3.9%. Only one third of the patients with embolism on admission and 5 from 50 patients who developed new emboli showed some dyspnoea. 12 patients died and underwent autopsy, 3 fatal events were caused by pulmonary embolism. With out management the incidence of thromboembolic complications is statistically significantly lower than data from the literature. Preliminary results from an ongoing randomised trial comparing bed-rest, compression bandages and compression stockings in the acute phase of proximal DVT demonstrate faster improvement of swelling and of pain in the compression-groups. Low-molecular-weight heparin has greatly facilitated therapy of DVT since effective anticoagulation can be obtained by subcutaneous injections of fixed doses without the need of laboratory monitoring. For the future development of conservative management mechanical prophylaxis of thrombus extension by acceleration of venous flow using leg compression and walking will probably become as important as exact anticoagulation.