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Gonzalez-Hermosillo LM, Cueto-Robledo G, Navarro-Vergara DI, Garcia-Cesar M, Torres-Rojas MB, Graniel-Palafox LE, Castro-Escalante KY, Castro-Diaz AM. Post-pulmonary embolism syndrome: A reminder for clinicians. Asian Cardiovasc Thorac Ann 2024; 32:336-344. [PMID: 39135401 DOI: 10.1177/02184923241272913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2024]
Abstract
Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular emergencies and the third leading cause of death. Although efforts focus on treating the acute event, patients who survive APE may develop long-term sequelae. Research reveals that approximately half of patients who have suffered an APE do not regain their previous level of function and experience a reduction in their quality of life for several years after the episode. Acute pulmonary embolism can be classified according to the risk of short-term mortality, with most mortality and morbidity concentrated in high-risk and intermediate-risk cases. The first-line treatment for APE is systemic anticoagulation. However, identifying and more aggressively treating people with intermediate to high risk, who have a more favorable risk profile for reperfusion treatments, could reduce short-term mortality and mitigate post-pulmonary embolism syndrome (PPES). Post-pulmonary embolism syndrome refers to a variety of persistent symptoms and functional limitations that occur after an APE. The presence of persistent dyspnea, functional limitations, and/or decreased quality of life after an APE has been recently termed "PPES," although this entity encompasses different manifestations. The most severe cause of persistent dyspnea is chronic thromboembolic pulmonary hypertension, where increased pulmonary artery pressure is due to the fibrotic organization of unresolved APE. Post-PE Syndrome is not always systematically addressed in management guidelines, and its prevalence may be underestimated. More research is needed to fully understand its causes and risk factors. Interventions such as cardiopulmonary rehabilitation have been suggested to improve the quality of life of patients with PPES. A comprehensive, evidence-based approach is essential to effectively prevent and manage PPES and improve the long-term outcomes and well-being of affected patients.
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Affiliation(s)
| | - Guillermo Cueto-Robledo
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
- Pulmonary Circulation Clinic, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
- Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Dulce-Iliana Navarro-Vergara
- Doctorate Program in Biomedical Sciences, Postgraduate Unit, National Autonomous University of Mexico, Mexico City, Mexico
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
| | - Marisol Garcia-Cesar
- Doctorate Program in Biomedical Sciences, Postgraduate Unit, National Autonomous University of Mexico, Mexico City, Mexico
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
| | - Maria-Berenice Torres-Rojas
- Doctorate Program in Biomedical Sciences, Postgraduate Unit, National Autonomous University of Mexico, Mexico City, Mexico
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
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Rook B, van Rijn MJE, Jansma EP, van Montfrans C. Effect of exercise after a deep venous thrombosis: A systematic review. J Eur Acad Dermatol Venereol 2024; 38:289-301. [PMID: 37731155 DOI: 10.1111/jdv.19523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
Post-thrombotic syndrome (PTS) is a common complication after deep vein thrombosis (DVT) and has a major impact on physical symptoms, quality of life (QoL) and economic costs. Relatively simple lifestyle interventions as physical exercise might reduce PTS severity and increase QoL. To evaluate the direct and long-term effects of physical activity in patients with an acute or previous DVT. We conducted a systematic review through an additional search from 2007 up to March 2022, to complement the comprehensive systematic review of Kahn et al. Articles evaluating the effect of exercise after a DVT including symptoms, QoL and the incidence and severity of PTS, were included. Quality of the studies was assessed using a GRADE-like checklist and results were reported according to the PRISMA Statement. Ten studies were included, seven randomized controlled trials and three cohort studies. We identified three types of physical activity based on timing and duration; (1) early mobilisation in the acute phase of the DVT; (2) short duration exercise 1 year after DVT and (3) prolonged exercise during follow-up after a previous DVT. Early mobilisation showed improvement in QoL and pain reduction and after 2 years it resulted in a significant reduction of PTS severity. Prolonged supervised exercise resulted in improvement of QoL. In addition, positive effects on symptoms of venous insufficiency and muscle functions were observed. None of the included studies reported an increased risk of PTS or worsening of symptoms due to physical activity. Physical exercise after a DVT is safe, improves QoL, reduces pain and decreases PTS severity. Lifestyle intervention such as guided individualized training programs can be a useful supplementary therapy for patients after a DVT or for PTS patients. Optimal training programs may be identified by further studies that improve patient-oriented outcomes for both adults and children after a DVT.
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Affiliation(s)
- B Rook
- Emergency Department, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - M J E van Rijn
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - E P Jansma
- Head of Medical Information Specialists, Leiden University, Leiden, The Netherlands
| | - C van Montfrans
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Partridge JA, Anton PM, Wallace JP, Lake LL. Exercise social support, barriers, and instructions in venous thromboembolism survivors: a descriptive study. Res Pract Thromb Haemost 2023; 7:102147. [PMID: 37601020 PMCID: PMC10439440 DOI: 10.1016/j.rpth.2023.102147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/13/2023] [Accepted: 06/17/2023] [Indexed: 08/22/2023] Open
Abstract
Background Diagnosis of venous thromboembolism (VTE) can be a significant life event that leads to changes in physical activity and exercise. Currently, little is known about the psychosocial experiences of survivors including perceived sources of social support, exercise barriers, and instructions for exercise from medical providers. Objectives This study aimed to explore psychosocial characteristics associated with VTE survivors' postdiagnosis exercise. Specifically, 1) what are the main sources of social support utilized by VTE survivors for exercise, 2) what are the most significant exercise barriers (eg, physical, social, and psychological) faced by VTE survivors, and 3) what specific information relative to exercise is provided by medical professionals following diagnosis? Methods VTE survivors (n = 472) were recruited through social media groups to participate in open-ended questions about psychosocial characteristics pertaining to postdiagnosis exercise. Results VTE survivors reported multiple forms of exercise social support, although almost 1 in 4 participants reported having no support for exercise. Several postdiagnosis exercise barriers were noted, and the data indicated a wide variety of information from their medical providers regarding engaging in exercise following their diagnosis, suggesting that the unique benefits and drawbacks to these instructions should be examined in more detail. Conclusion Although VTE survivors identified numerous categories of social support, there also exist numerous barriers, including a lack of standardized instructions for exercise. Further exploration of these characteristics is needed to better serve this population to encourage postdiagnosis exercise.
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Affiliation(s)
| | - Philip M. Anton
- Southern Illinois University Carbondale, Carbondale, Illinois, USA
| | | | - Leslie L. Lake
- National Blood Clot Alliance, Philadelphia, Pennsylvania, USA
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4
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A bidirectional Mendelian randomized study of classical blood lipids and venous thrombosis. Sci Rep 2023; 13:3904. [PMID: 36890190 PMCID: PMC9995644 DOI: 10.1038/s41598-023-31067-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/06/2023] [Indexed: 03/10/2023] Open
Abstract
There is still some controversy about the relationship between lipids and venous thrombosis (VTE). A bidirectional Mendelian randomization (MR) study was conducted to clarify the causal relationship between three classical lipids (low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglycerides (TGs)) and venous thromboembolism (VTE) (deep venous thrombosis (DVT) and pulmonary embolism (PE)). Three classical lipids and VTE were analysed by bidirectional Mendelian randomization (MR). We used the random effect inverse variance weighted (IVW) model as the main analysis model and the weighted median method, simple mode method, weighted mode method and MR-Egger methods as supplementary methods. The leave-one-out test was used to determine the influence of outliers. The heterogeneity was calculated by using Cochran Q statistics in the MR-Egger and IVW methods. The intercept term in the MR‒Egger regression was used to indicate whether horizontal pleiotropy affected the results of the MR analysis. In addition, MR-PRESSO identified outlier single-nucleotide polymorphisms (SNPs) and obtained a stable result by removing outlier SNPs and then performing MR analysis. When we used three classical lipids (LDL, HDL and TGs) as exposure variables, no causal relationship between them and VTE (DVT and PE) was found. In addition, we did not find significant causal effects of VTE on the three classical lipids in reverse MR analysis. There is no significant causal relationship between three classical lipids (LDL, HDL and TGs) and VTE (DVT and PE) from a genetic point of view.
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Hillegass E, Lukaszewicz K, Puthoff M. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022. Phys Ther 2022; 102:6585463. [PMID: 35567347 DOI: 10.1093/ptj/pzac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.
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Affiliation(s)
- Ellen Hillegass
- Department of Physical Therapy, Mercer University, Atlanta, Georgia, USA
| | | | - Michael Puthoff
- Physical Therapy Department, St Ambrose University, Davenport, Iowa, USA
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Brennan FH. Diagnosis, Management of, and Return to Play Guidance for Venous Thromboembolism in Athletes. Curr Sports Med Rep 2022; 21:129-136. [PMID: 35394954 DOI: 10.1249/jsr.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Venous thromboembolism (VTE) is not rare and is becoming more recognized in our athletic population. This diagnosis can be elusive. A provider must have a high clinical suspicion and use pretest probabilities to order the appropriate studies and accurately diagnose a VTE. Treatment using direct oral anticoagulants for 3 months is recommended in most cases. Gradual return to play can be achieved after treatment is complete. Some athletes, however, may require lifelong anticoagulation. Return to collision sports may be possible using a timed dose strategy if long-term anticoagulation is needed. The management of an athlete with a VTE should include an individualized treatment plan and involve shared decision making with the athlete, team physicians, and hematologic specialists.
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Affiliation(s)
- Fred H Brennan
- BayCare Family Medicine Residency and Sports Medicine, University of South Florida, Morton Plant; Department of Family Medicine, University of South Florida Morsani College of Medicine; and Tampa Bay Buccaneers, Tampa, FL
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Pally A, Tennison J. Rehabilitation in the Setting of Untreated Cancer-Associated Acute Deep Vein Thrombosis. Integr Cancer Ther 2022; 21:15347354221074349. [PMID: 35112579 PMCID: PMC8819757 DOI: 10.1177/15347354221074349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Research is needed to guide the timing and safety of rehabilitation (physical and occupational therapy) in patients with acute deep venous thrombosis (DVT) that is untreated due to contraindications. CASE DESCRIPTION A 21-year-old man with Hodgkin lymphoma was admitted to the hospital for neutropenic fever. He developed gastrointestinal bleeding, diffuse alveolar hemorrhage, and bilateral lower-extremity DVT. He was not a candidate for chemical anticoagulation or placement of an inferior vena cava filter owing to thrombocytopenia. Rehabilitation was initially deferred because of concern that the thrombus could travel to the lungs, causing a pulmonary embolism. Rehabilitation was, however, started 4 days after the initial diagnosis of lower-extremity DVT to assess functional mobility and activities of daily living skills to prepare for discharge from the hospital. RESULTS The patient experienced no bleeding events during rehabilitation, and his acute, untreated DVT did not propagate based on clinical assessment. His Activity Measure for Post-Acute Care (AM-PAC) "6 Clicks" Basic Mobility score improved from 30.25 to 35.55 over the period of 11 days while he received rehabilitation. CONCLUSION Despite having an acute bilateral lower-extremity DVT that was untreatable owing to thrombocytopenia, the patient successfully participated in rehabilitation and improved his physical functional status without an adverse event. Untreated acute venous thromboembolism in the setting of recent history of major bleeding raise concerns about physical activity restrictions. It is critical to consider both the risks and benefits of mobilizing patients and prescribing exercises in patients with these conditions.
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Affiliation(s)
| | - Jegy Tennison
- The University of Texas MD Anderson Cancer Center, Houston, USA
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De la Fuente C, Henriquez H, Carmont MR, Huincahue J, Paredes T, Tapia M, Araya JP, Díaz N, Carpes FP. Do the heel-rise test and isometric strength improve after Achilles tendon repair using Dresden technique? Foot Ankle Surg 2022; 28:37-43. [PMID: 33509663 DOI: 10.1016/j.fas.2021.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 01/11/2021] [Accepted: 01/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Achilles' tendon ruptures result in impaired plantar flexion strength and endurance. It is interesting to know the plantar flexion strength, the number of heel-rise repetitions, and the maximal calf circumference following Achilles' tendon ruptures repair. METHODS Both the injured and non-injured legs of thirty male patients with Achilles' tendon ruptures treated with the percutaneous Dresden technique were compared with the ankle function of 30 healthy participants. Rehabilitation involved partial weight-bearing for three weeks and then increased to full weight-bearing and ankle exercises. RESULTS The injured legs had weaker plantar flexion strength (1.64 ± 0.17 Nm/kg) compared with the non-injured legs (1.91 ± 0.24 Nm/kg; p = 0.002) and the healthy participants' legs (1.93 ± 0.32 Nm/kg; p < 0.001). The non-injured leg had greater ability in doing heel-rise repetitions (39.4 ± 6.1 rep.) compared with the injured legs (37.2 ± 5.7 rep.; p < 0.023) and the healthy participants' legs (31.0 ± 13.0 rep.; p < 0.001). CONCLUSIONS The injured leg had not recovered full isometric strength but had improved heel-rise repetition.
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Affiliation(s)
- Carlos De la Fuente
- Laboratory of Neuromechanics, Universidade Federal do Pampa #97500-970, Campus Uruguaiana, Uruguaiana, Brazil; Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile; Clinica MEDS, Santiago #7691236, Santiago, Chile; Centro de Salud Deportiva, Clinica Santa Maria, Santiago #7520380, Santiago, Chile
| | - Hugo Henriquez
- Centro de Salud Deportiva, Clinica Santa Maria, Santiago #7520380, Santiago, Chile; Traumatologia, Facultad de Medicina, Instituto Traumatológico-Universidad de Chile, Universidad de Chile, Santiago #8340220, Chile
| | - Michael R Carmont
- Department of Trauma and Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust #TF16TF, Shropshire, UK
| | - Javiera Huincahue
- Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile
| | - Tamara Paredes
- Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile
| | - María Tapia
- Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile
| | - Juan Pablo Araya
- Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile
| | - Nicolás Díaz
- Interno de Medicina, Facultad de Medicina #8340220, Universidad de Chile, Santiago, Chile
| | - Felipe P Carpes
- Laboratory of Neuromechanics, Universidade Federal do Pampa #97500-970, Campus Uruguaiana, Uruguaiana, Brazil.
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Gastaldi G, Pannier F, Roztočil K, Lugli M, Mansilha A, Haller H, Rabe E, VAN Rijn MJ. Chronic venous disease and diabetic microangiopathy: pathophysiology and commonalities. INT ANGIOL 2021; 40:457-469. [PMID: 34547884 DOI: 10.23736/s0392-9590.21.04664-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic venous disease and diabetes mellitus are highly prevalent and debilitating conditions affecting millions of individuals globally. Although these conditions are typically considered as separate entities, they often co-exist which may be important in both understanding their pathophysiology and determining the best treatment strategy. Diabetes mellitus is twice as common in patients with chronic venous disease compared with the general population. Notably, a large proportion of patients with diabetes mellitus present with venous disorders, although this is often overlooked. The etiology of chronic venous disease is multifactorial, involving hemodynamic, genetic, and environmental factors which result in changes to the venous endothelium and structural wall as well as inflammation. Inflammation, endothelial dysfunction and hyperfiltration or leakage, are commonly observed in diabetes mellitus and cause various diabetic microvascular complications. Both diseases are also influenced by the increased expression of adhesion molecules, chemokines, and cytokines, and are characterized by the presence of vessel hypertension. Consequently, despite differences in etiology, the pathophysiology of both chronic venous disease and diabetic microangiopathy appears to be driven by endothelial dysfunction and inflammation. Treatment strategies should take the co-existence of chronic venous disease and diabetic microangiopathy into account. Compression therapy is recommended in inflammatory conditions that have an edema component as seen in both chronic venous disease and diabetes mellitus. Lifestyle changes like weight loss and exercise, will improve metabolic state and lower inflammation and should be promoted in these patients. Additionally, both patient populations may benefit from venoactive drugs.
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Affiliation(s)
- Giacomo Gastaldi
- Division of Endocrinology Diabetology Nutrition and Patient Education, Geneva University Hospitals, Geneva, Switzerland
| | - Felizitas Pannier
- Private Clinic Phlebology and Dermatology, Bonn, Germany.,Department of Dermatology, University of Cologne, Cologne, Germany
| | - Karel Roztočil
- Department of Transplantational and Vascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Marzia Lugli
- Unit of Vascular Surgery, Cardiovascular Department, Hesperia Hospital, Modena, Italy
| | - Armando Mansilha
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. João, Porto, Portugal
| | - Hermann Haller
- Hannover Medical School, Department of Nephrology and Hypertension, Hannover, Germany
| | - Eberhard Rabe
- Department of Dermatology (Emeritus), University of Bonn, Bonn, Germany
| | - Marie Josee VAN Rijn
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands -
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Rauch B, Salzwedel A, Bjarnason-Wehrens B, Albus C, Meng K, Schmid JP, Benzer W, Hackbusch M, Jensen K, Schwaab B, Altenberger J, Benjamin N, Bestehorn K, Bongarth C, Dörr G, Eichler S, Einwang HP, Falk J, Glatz J, Gielen S, Grilli M, Grünig E, Guha M, Hermann M, Hoberg E, Höfer S, Kaemmerer H, Ladwig KH, Mayer-Berger W, Metzendorf MI, Nebel R, Neidenbach RC, Niebauer J, Nixdorff U, Oberhoffer R, Reibis R, Reiss N, Saure D, Schlitt A, Völler H, von Känel R, Weinbrenner S, Westphal R. Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1. J Clin Med 2021; 10:2192. [PMID: 34069561 PMCID: PMC8161282 DOI: 10.3390/jcm10102192] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/20/2021] [Accepted: 03/23/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. METHODS The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. RESULTS Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs. CONCLUSIONS These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.
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Affiliation(s)
- Bernhard Rauch
- Institut für Herzinfarktforschung Ludwigshafen, D-67063 Ludwigshafen, Germany
- Zentrum für Ambulante Rehabilitation, ZAR Trier GmbH, D-54292 Trier, Germany
| | - Annett Salzwedel
- Department of Rehabilitation Medicine, Faculty of Health Sciences Brandenburg, University of Potsdam, D-14469 Potsdam, Germany; (A.S.); (S.E.); (H.V.)
| | - Birna Bjarnason-Wehrens
- Institut für Kreislaufforschung und Sportmedizin, Abt. Präventive und rehabilitative Sport- und Leistungsmedizin, Deutsche Sporthochschule Köln, D-50937 Köln, Germany;
| | - Christian Albus
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine, University Hospital, D-50937 Köln, Germany;
| | - Karin Meng
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, D-97078 Würzburg, Germany;
| | | | | | - Matthes Hackbusch
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, D-69120 Heidelberg, Germany; (M.H.); (K.J.); (D.S.)
| | - Katrin Jensen
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, D-69120 Heidelberg, Germany; (M.H.); (K.J.); (D.S.)
| | - Bernhard Schwaab
- Curschmann Klinik Dr. Guth GmbH & Co KG, D-23669 Timmendorfer Strand, Germany;
| | | | - Nicola Benjamin
- Zentrum für Pulmonale Hypertonie, Thorax-Klinik am Universitätsklinikum Heidelberg, D-69126 Heidelberg, Germany; (N.B.); (E.G.)
| | - Kurt Bestehorn
- Institut für Klinische Pharmakologie, Technische Universität Dresden, Fiedlerstraße 42, D-01307 Dresden, Germany;
| | - Christa Bongarth
- Klinik Höhenried gGmbH, Rehabilitationszentrum am Starnberger See, D-82347 Bernried, Germany; (C.B.); (H.-P.E.)
| | - Gesine Dörr
- Alexianer St. Josefs-Krankenhaus Potsdam-Sanssouci, D-14471 Potsdam, Germany;
| | - Sarah Eichler
- Department of Rehabilitation Medicine, Faculty of Health Sciences Brandenburg, University of Potsdam, D-14469 Potsdam, Germany; (A.S.); (S.E.); (H.V.)
| | - Hans-Peter Einwang
- Klinik Höhenried gGmbH, Rehabilitationszentrum am Starnberger See, D-82347 Bernried, Germany; (C.B.); (H.-P.E.)
| | - Johannes Falk
- Deutsche Rentenversicherung Bund (DRV-Bund), D-10709 Berlin, Germany; (J.F.); (S.W.)
| | - Johannes Glatz
- Reha-Zentrum Seehof der Deutschen Rentenversicherung Bund, D-14513 Teltow, Germany;
| | - Stephan Gielen
- Klinikum Lippe, Standort Detmold, D-32756 Detmold, Germany;
| | - Maurizio Grilli
- Universitätsbibliothek, Universitätsmedizin Mannheim, D-68167 Mannheim, Germany;
| | - Ekkehard Grünig
- Zentrum für Pulmonale Hypertonie, Thorax-Klinik am Universitätsklinikum Heidelberg, D-69126 Heidelberg, Germany; (N.B.); (E.G.)
| | - Manju Guha
- Reha-Zentrum am Sendesaal, D-28329 Bremen, Germany;
| | - Matthias Hermann
- Klinik für Kardiologie, Universitätsspital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland;
| | - Eike Hoberg
- Wismarstraße 13, D-24226 Heikendorf, Germany;
| | - Stefan Höfer
- Universitätsklinik für Medizinische Psychologie und Psychotherapie, Medizinische Universität Innsbruck, A-6020 Innsbruck, Austria;
| | - Harald Kaemmerer
- Klinik für Angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Klinik der Technischen Universität München, D-80636 München, Germany;
| | - Karl-Heinz Ladwig
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technische Universität München (TUM) Langerstraße 3, D-81675 Munich, Germany;
| | - Wolfgang Mayer-Berger
- Klinik Roderbirken der Deutschen Rentenversicherung Rheinland, D-42799 Leichlingen, Germany;
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice (ifam), Medical Faculty of the Heinrich-Heine University, Werdener Straße. 4, D-40227 Düsseldorf, Germany;
| | - Roland Nebel
- Hermann-Albrecht-Klinik METTNAU, Medizinische Reha-Einrichtungen der Stadt Radolfzell, D-73851 Radolfzell, Germany;
| | - Rhoia Clara Neidenbach
- Institut für Sportwissenschaft, Universität Wien, Auf der Schmelz 6 (USZ I), AU-1150 Wien, Austria;
| | - Josef Niebauer
- Universitätsinstitut für Präventive und Rehabilitative Sportmedizin, Uniklinikum Salzburg Paracelsus Medizinische Privatuniversität, A-5020 Salzburg, Austria;
| | - Uwe Nixdorff
- EPC GmbH, European Prevention Center, Medical Center Düsseldorf, D-40235 Düsseldorf, Germany;
| | - Renate Oberhoffer
- Lehrstuhl für Präventive Pädiatrie, Fakultät für Sport- und Gesundheitswissenschaften, Technische Universität München, D-80992 München, Germany;
| | - Rona Reibis
- Kardiologische Gemeinschaftspraxis Am Park Sanssouci, D-14471 Potsdam, Germany;
| | - Nils Reiss
- Schüchtermann-Schiller’sche Kliniken, Ulmenallee 5-12, D-49214 Bad Rothenfelde, Germany;
| | - Daniel Saure
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, D-69120 Heidelberg, Germany; (M.H.); (K.J.); (D.S.)
| | - Axel Schlitt
- Paracelsus Harz-Klinik Bad Suderode GmbH, D-06485 Quedlinburg, Germany;
| | - Heinz Völler
- Department of Rehabilitation Medicine, Faculty of Health Sciences Brandenburg, University of Potsdam, D-14469 Potsdam, Germany; (A.S.); (S.E.); (H.V.)
- Klinik am See, D-15562 Rüdersdorf, Germany
| | - Roland von Känel
- Klinik für Konsiliarpsychiatrie und Psychosomatik, Universitätsspital Zürich, CH-8091 Zürich, Switzerland;
| | - Susanne Weinbrenner
- Deutsche Rentenversicherung Bund (DRV-Bund), D-10709 Berlin, Germany; (J.F.); (S.W.)
| | - Ronja Westphal
- Herzzentrum Segeberger Kliniken, D-23795 Bad Segeberg, Germany;
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12
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Physical activity in children at risk of postthrombotic sequelae: a pilot randomized controlled trial. Blood Adv 2021; 4:3767-3775. [PMID: 32780844 DOI: 10.1182/bloodadvances.2020002096] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/02/2020] [Indexed: 11/20/2022] Open
Abstract
Increased physical activity is protective against worsening of postthrombotic syndrome (PTS) in adults. We assessed patient eligibility, consent, adherence, and retention rates in a pilot trial of prescribed physical activity following venous thromboembolism (VTE) in children. Secondary objectives were to describe the within-subject changes in PTS, quality of life, and coagulation biomarkers before and after the intervention in each group. We enrolled and randomized patients between 7 and 21 years of age to the physical activity group or the standard care (education-only) group in a 1:1 allocation ratio. The physical activity group wore a Fitbit for 4 weeks to determine habitual activity and then increased activity over an 8-week "active" period, followed by a 4-week "do-as-you-wish" period. Two hundred thirty-five children were diagnosed with VTE; 111 patients were screened, of whom 40 (36%) met study eligibility criteria. Of these, 23 (57%) consented to participate and were randomized (Fitbit,11; standard group, 12). The trial was of greater interest to overweight and obese children, as they comprised 83% of consented patients. Only 33% adhered to the activity prescription, and 65% (15/23) completed the trial. The PTS scores (P = .001) improved in the physical activity group compared with the education-only group. It is feasible to enroll and randomize pediatric VTE patients to a prescribed physical activity regimen 3 months following VTE. Metrics for adherence to enhanced physical activity and retention were not met. These results provide the rationale to explore low adherence and retention rates before moving forward with a larger trial of exercise training following VTE. This trial was registered at www.clinicaltrials.gov as #NCT03075761.
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13
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Xu L, Fu C, Zhang Q, He C, Wei Q. The effectiveness of exercise training in treating venous thromboembolism: a systematic review. PHYSICIAN SPORTSMED 2021; 49:1-11. [PMID: 32643517 DOI: 10.1080/00913847.2020.1786746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This study aims to (1) evaluate the clinical safety of an exercise-based rehabilitation intervention for patients with venous thromboembolism (VTE); (2) separately summarize the effects of exercise training in deep vein thrombosis (DVT), pulmonary embolism (PE) and postthrombotic syndrome (PTS) survivors; and (3) identify commonly used exercise prescriptions and describe treatment progression. The Medline, Cochrane Library, and Embase databases were searched for randomized control trials and cohort studies published prior to February 2020 comparing exercise training interventions with non-exercise interventions for patients with VTE. Two reviewers independently reviewed and appraised the risk of bias of each study. Nine articles were included for review, five of which were randomized clinical trials, while three were prospective cohort studies, and one was a retrospective cohort trial. The results showed that exercise-based rehabilitation training was safe for patients diagnosed with VTE, including patients with DVT, PE, and PTS, but offered limited evidence to support the use of regular exercise as an intervention to improve exercise capacity in patients with VTE. Exercise-based rehabilitation in VTE survivors is clearly an emerging field with a lack of large, adequately powered randomized controlled trials. Existing evidence suggests that exercise is safe, but evidence to support exercise therapy as a replacement for standard care in all VTE patients is insufficient. Prescription and progression patterns should be tailored for individuals based on health conditions and functional deficits.
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Affiliation(s)
- Lin Xu
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University , Chengdu, Sichuan, PR China.,Key Laboratory of Rehabilitation Medicine in Sichuan Province , Chengdu, Sichuan, PR China
| | - Chenying Fu
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University , Chengdu, Sichuan, China
| | - Qing Zhang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University , Chengdu, Sichuan, PR China.,Key Laboratory of Rehabilitation Medicine in Sichuan Province , Chengdu, Sichuan, PR China
| | - Chengqi He
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University , Chengdu, Sichuan, PR China.,Key Laboratory of Rehabilitation Medicine in Sichuan Province , Chengdu, Sichuan, PR China
| | - Quan Wei
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University , Chengdu, Sichuan, PR China.,Key Laboratory of Rehabilitation Medicine in Sichuan Province , Chengdu, Sichuan, PR China
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14
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Evans CR, Hong CP, Folsom AR, Heckbert SR, Smith NL, Wiggins K, Lutsey PL, Cushman M. Lifestyle Moderates Genetic Risk of Venous Thromboembolism: The ARIC Study. Arterioscler Thromb Vasc Biol 2020; 40:2756-2763. [PMID: 32878478 PMCID: PMC8498945 DOI: 10.1161/atvbaha.120.314668] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/17/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a common disease that has a genetic basis. Lifestyle factors contribute to risk, but it is unknown whether healthy lifestyle can mitigate the genetic risk. We studied whether greater adherence to the American Heart Association's cardiovascular health metric, Life's Simple 7 (LS7), is associated with lower incidence of VTE in individuals across categories of a genetic risk score (GRS) for VTE. Approach AND RESULTS: We followed 9026 White participants from the ARIC (Atherosclerosis Risk in Communities) Study, a prospective cohort enrolled in 1987 to 1989 until 2015. We tested the joint associations with VTE of a validated VTE GRS comprising 5 well-known gene variants and baseline LS7 categories. There were 466 incident VTE events over 22.8 years. Participants with an optimal LS7 score had a lower incidence of VTE (3.9%) than those with inadequate LS7 (5.7%). Compared with the high GRS and inadequate LS7 group (hazard ratio=1), those with high GRS and optimal LS7 indeed had a reduced hazard ratio of VTE: 0.65 (95% CI, 0.48-0.89). The group with low GRS and optimal LS7 had the lowest hazard ratio of VTE (0.39 [95% CI, 0.25-0.61]). Of the LS7 components, in all GRS groups, the factor most strongly protective for VTE was normal weight. CONCLUSIONS Among people at low or high genetic risk for VTE, healthier lifestyle factors, particularly normal weight, were associated with a lower incidence of VTE. Further studies should determine the impact of lifestyle changes among patients at high genetic risk of VTE, such as in thrombophilic families.
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Affiliation(s)
- Christina R Evans
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (C.R.E.)
| | - Ching-Ping Hong
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (C.-P.H., A.R.F., P.L.L.)
| | - Aaron R Folsom
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (C.-P.H., A.R.F., P.L.L.)
| | - Susan R Heckbert
- Cardiovascular Health Research Unit, Department of Epidemiology (S.R.H., N.L.S.), University of Washington, Seattle
| | - Nicholas L Smith
- Cardiovascular Health Research Unit, Department of Epidemiology (S.R.H., N.L.S.), University of Washington, Seattle
- Kaiser Permamente Washington Health Research Institute, Kaiser Permanente Washington, Seattle (N.L.S.)
- Seattle Epidemiologic Research and Information Center, Office of Research and Development, Department of Veterans Affairs, Seattle, WA (N.L.S.)
| | - Kerri Wiggins
- Cardiovascular Health Research Unit, Department of Medicine (K.W.), University of Washington, Seattle
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (C.-P.H., A.R.F., P.L.L.)
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington (M.C.)
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15
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Edmunds K, Tuffaha H, Scuffham P, Galvão DA, Newton RU. The role of exercise in the management of adverse effects of androgen deprivation therapy for prostate cancer: a rapid review. Support Care Cancer 2020; 28:5661-5671. [PMID: 32699997 DOI: 10.1007/s00520-020-05637-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Prostate cancer (PCa) is the most commonly diagnosed cancer in Australia, accounting for one quarter of all new cancer diagnoses for males. Androgen deprivation therapy (ADT) is the standard first-line therapy for metastatic PCa but is also used across much of the spectrum of disease. Unfortunately, debilitating adverse effects are a significant and largely unavoidable feature of ADT. A recent systematic review of adverse effects of ADT identified 19 sub-groups classified according to the Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0. The potential for multiple simultaneous adverse effects, their associated management and the impact of adverse effects on cancer outcomes and quality of life are important considerations in the treatment and supportive care of men with PCa. Exercise is increasingly being recognized as an efficacious strategy in managing these adverse effects. METHODS A rapid review was undertaken to examine the role of exercise in the management of the most commonly reported ADT adverse effects classified according to the CTCAE sub-groups. A systematic search was conducted in Medline, PsycINFO, Google Scholar and Google for the years 2010 to September 2019 to identify the benefits of exercise in managing the adverse effects of ADT for PCa. RESULTS There is strong evidence for exercise as medicine in addressing several of the adverse effects of PCa such as loss of muscle mass and strength, fatigue and declining physical function. Moderate level evidence for PCa exists for exercise-induced improvements in depression and anxiety, bone loss, and sexual dysfunction. While evidence of the effectiveness of exercise is lacking for many adverse effects of ADT for PCa, evidence in the cancer population as a whole or other clinical populations is strong, and many clinical guidelines recommend exercise as a fundamental part of their clinical management. With the exception of gynaecomastia and breast pain, there is increasing evidence (PCa, cancer or other clinical populations) to suggest that exercise has the potential to reduce and even prevent many of the adverse effects of ADT, thus improving survivorship outcomes for men with PCa. CONCLUSION Exercise has the potential to reduce and even prevent many of the adverse effects of ADT, thus improving survivorship outcomes for men with PCa. The use of exercise for PCa management has the potential to translate into health and economic benefits in improved quality of life and fewer complications, resulting in savings to the health care system, enhanced productivity and reduced patient and carer burden. Exercise thus has the potential to improve quality of life for this population as well as generate significant cost savings.
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Affiliation(s)
- Kim Edmunds
- Centre for Applied Health Economics, Griffith University, Brisbane, Australia. .,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.
| | - Haitham Tuffaha
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia
| | - Paul Scuffham
- Centre for Applied Health Economics, Griffith University, Brisbane, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Daniel A Galvão
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Australia
| | - Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Australia.,School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Australia
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16
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Romano S, Salustri E, Robles AG, Calò L, Penco M, Sciarra L. Non-vitamin K antagonist oral anticoagulants and sport. Minerva Cardioangiol 2020; 68:98-109. [PMID: 32429628 DOI: 10.23736/s0026-4725.20.05177-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Physical activity is worldwide recommended for its benefits on cardiovascular system. There is an increasing number of people of all ages that approach sport activity both as leisure time physical activity and as competitive sport. It is always more frequent the request even from older subjects and cardiac patients to be allowed to practice physical activity. Some problems could arise when these subjects present or develop pathologic conditions that require specific pharmacological treatment, in particular an anticoagulation therapy. This review focalizes on the management of oral anticoagulant therapy (OAT) in patients practicing sport activity, especially due to atrial fibrillation and deep vein thrombosis, which represent two highly prevalent conditions, particularly with increasing age. Official recommendations in this field may appear limiting for patients, forbidding in the majority of cases sports at risk of trauma and consequent bleeding. These recommendations still resent the heritage of the "traditional" management of OAT, mainly represented by vitamin-K antagonists (VKAs). The non-vitamin K antagonist oral anticoagulants, with their more favorable pharmacokinetic-pharmacodynamic profile compare to VKAs, may now represent an opportunity to modify the approach to sport activity in patients with an indication to OAT. This review of the literature deals with possible strategies to overcome the present limitations for OAT subjects willing to pursue a healthy lifestyle, that include sport activity, minimizing at the same time their risk of bleeding.
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Affiliation(s)
- Silvio Romano
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Elisa Salustri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy -
| | - Antonio G Robles
- Department of Cardiology, Casilino Polyclinic Hospital, Rome, Italy
| | - Leonardo Calò
- Department of Cardiology, Casilino Polyclinic Hospital, Rome, Italy
| | - Maria Penco
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Luigi Sciarra
- Department of Cardiology, Casilino Polyclinic Hospital, Rome, Italy
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17
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Kunutsor SK, Mäkikallio TH, Seidu S, de Araújo CGS, Dey RS, Blom AW, Laukkanen JA. Physical activity and risk of venous thromboembolism: systematic review and meta-analysis of prospective cohort studies. Eur J Epidemiol 2019; 35:431-442. [PMID: 31728878 PMCID: PMC7250794 DOI: 10.1007/s10654-019-00579-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/05/2019] [Indexed: 12/19/2022]
Abstract
The inverse association between physical activity and arterial thrombotic disease is well established. Evidence on the association between physical activity and venous thromboembolism (VTE) is divergent. We conducted a systematic review and meta-analysis of published observational prospective cohort studies evaluating the associations of physical activity with VTE risk. MEDLINE, Embase, Web of Science, and manual search of relevant bibliographies were systematically searched until 26 February 2019. Extracted relative risks (RRs) with 95% confidence intervals (CIs) for the maximum versus minimal amount of physical activity groups were pooled using random effects meta-analysis. Twelve articles based on 14 unique prospective cohort studies comprising of 1,286,295 participants and 23,753 VTE events were eligible. The pooled fully-adjusted RR (95% CI) of VTE comparing the most physically active versus the least physically active groups was 0.87 (0.79–0.95). In pooled analysis of 10 studies (288,043 participants and 7069 VTE events) that reported risk estimates not adjusted for body mass index (BMI), the RR (95% CI) of VTE was 0.81 (0.70–0.93). The associations did not vary by geographical location, age, sex, BMI, and methodological quality of studies. There was no evidence of publication bias among contributing studies. Pooled observational prospective cohort studies support an association between regular physical activity and low incidence of VTE. The relationship does not appear to be mediated or confounded by BMI.
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Affiliation(s)
- Setor K Kunutsor
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Timo H Mäkikallio
- Division of Cardiology, Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - Samuel Seidu
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4WP, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4WP, UK
| | | | | | - Ashley W Blom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Jari A Laukkanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyvaskyla, Finland
- Department of Medicine, Central Finland Health Care District, Jyvaskyla, Finland
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18
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Paluch Ł, Nitek Ż, Sklinda K, Zakrzewski J, Walecki J, Noszczyk B. Factors Influencing Elastographically Determined Remodeling of Venous Thrombi. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2643-2650. [PMID: 30719742 DOI: 10.1002/jum.14965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/21/2018] [Accepted: 01/17/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To verify whether elastographically determined remodeling of venous obliterating material formed during sclerotherapy is influenced by patient-specific factors. METHODS The study included 60 patients who underwent sclerotherapy for venous insufficiency. Elastographic parameters of obliterating material, including relative vascular cross sections (percent) with the highest (red), intermediate (green), and lowest elasticity (blue), determined 7 ± 1, 14 ± 2, and 21 ± 2 days after sclerotherapy, were analyzed against the patients' ages, sexes, physical activity levels, and pain severities. RESULTS The patients included 45 women and 15 men with a mean age ± SD of 51.2 ± 14.7 years. A significant correlation was observed between the age of the patients and the relative area of the vessel highlighted in red during the third control visit (R = 0.289; P = .025). The proportion of men in whom the elastographic structure of venous obliterating material during the second visit was classified as mixed was higher than that of women (66.7% versus 28.9%; P = .032). During the third visit, the proportion of patients with low physical activity in whom the elastographic structure of venous obliterating material was classified as fibrous turned out to be lower than the respective percentages of patients with moderate and high activity levels (12.0% versus 35.0% versus 46.7%; P = .045). However, none of these effects was observed systematically throughout the whole follow-up period. CONCLUSIONS The time to complete organization of venous obliterating material may be longer in older patients, women, and patients with lower levels of physical activity, but these factors seem to influence the thrombus structure solely at specific time points in its evolution. Nevertheless, they should be considered during elastographic assessments of thrombus age.
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Affiliation(s)
- Łukasz Paluch
- Department of Radiology, Gruca Orthopedic and Trauma Teaching Hospital, Center of Postgraduate Medical Education, Otwock, Poland
| | - Żaneta Nitek
- Department of Radiology, Gruca Orthopedic and Trauma Teaching Hospital, Center of Postgraduate Medical Education, Otwock, Poland
| | - Katarzyna Sklinda
- Department of Radiology, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Jakub Zakrzewski
- Department of Radiology, Gruca Orthopedic and Trauma Teaching Hospital, Center of Postgraduate Medical Education, Otwock, Poland
| | - Jerzy Walecki
- Department of Radiology, Gruca Orthopedic and Trauma Teaching Hospital, Center of Postgraduate Medical Education, Otwock, Poland
| | - Bartłomiej Noszczyk
- Department of Plastic Surgery, Orłowski Hospital, Center of Postgraduate Medical Education, Warsaw, Poland
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19
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Sarkies MN, Maloney S, Symmons M, Haines TP. Video strategies improved health professional knowledge across different contexts: a helix counterbalanced randomized controlled study. J Clin Epidemiol 2019; 112:1-11. [DOI: 10.1016/j.jclinepi.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/30/2019] [Accepted: 04/09/2019] [Indexed: 01/14/2023]
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20
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Witmer CM. How I approach managing student athletes at risk for bleeding. Pediatr Blood Cancer 2019; 66:e27523. [PMID: 30362247 DOI: 10.1002/pbc.27523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/04/2018] [Accepted: 10/04/2018] [Indexed: 01/19/2023]
Abstract
Frequently, pediatric hematologists need to provide guidance regarding sports participation for children with congenital coagulopathies, immune thrombocytopenia, and those receiving anticoagulation. Although sports participation has clear health and psychosocial benefits, it can be associated with harm secondary to bleeding from injury. Decision-making for sports involvement should be individualized, patient centered, and well informed. This review focuses on the current data regarding the benefit as well as risks for sports participation and provides a framework for advising and supporting the student athlete who is at risk for bleeding.
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Affiliation(s)
- Char M Witmer
- The Children's Hospital of Philadelphia, Division of Hematology, Philadelphia, Pennsylvania
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21
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Amoury M, Noack F, Kleeberg K, Stoevesandt D, Lehnigk B, Bethge S, Heinze V, Schlitt A. Prognosis of patients with pulmonary embolism after rehabilitation. Vasc Health Risk Manag 2018; 14:183-187. [PMID: 30214219 PMCID: PMC6121757 DOI: 10.2147/vhrm.s158815] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Pulmonary embolism (PE) is a life-threatening disease; in Germany, therefore, rehabilitation after PE is recommended in patients with intermediate- and high-risk PE. However, no prospective data on PE after inpatient rehabilitation have been published so far. PATIENTS AND METHODS For this monocentric study, 70 patients with PE were prospectively recruited between November 2013 and November 2014 after giving written informed consent. This study was approved by the ethics committee of the Medical Association of Saxony-Anhalt. Inclusion criteria were as follows: age ≥18 years and a stay at the Paracelsus-Harz Clinic in Bad Suderode, Germany, with the main indication of PE. During the hospital stay, history-relevant medical data and diagnostic findings were collected and documented. Furthermore, we recorded whether patients were rehospitalized or died during the treatment period in the rehabilitation clinic or during the 12-month follow-up. RESULTS The mean age was 64.5 ± 13.0 years, the mean body mass index (BMI) was 30.4 ± 6.0 kg/m2, and 54.3% were women. During rehabilitation, two patients (3.9%) were transferred to a primary care hospital; no patient died. However, four patients died (5.7%) in the 12-month follow-up period. A total of 20 patients were hospitalized in the 12-month follow-up period (hospitalization rate during the 12-month follow-up period: 28.6%). Of these 20 patients, one patient was rehospitalized with a newly diagnosed PE (1.4%) and two patients were rehospitalized for bleeding events (2.8%). CONCLUSION PE is a life-threatening disease, and therefore it seems reasonable to recommend rehabilitation at least in patients with an intermediate- or high-risk PE. In this study, death and other serious event rates were low during the in-hospital rehabilitation and in the 12-month follow-up period, which underlined the safety and importance of a standardized rehabilitation program after survived PE.
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Affiliation(s)
- Mroawan Amoury
- Department of Emergency Medicine, University Clinic Halle-Saale, Halle, Germany
| | - Frank Noack
- Department of Emergency Medicine, University Clinic Halle-Saale, Halle, Germany
- Department of Medicine I, University Clinic Halle-Saale, Halle, Germany
| | - Kathleen Kleeberg
- Medical Faculty, Martin Luther-University Halle-Wittenberg, Halle, Germany,
| | - Dietrich Stoevesandt
- Department of Diagnostic Radiology, University Clinic Halle-Saale, Halle, Germany
| | - Burghart Lehnigk
- Department of Cardiology and Pulmology, Paracelsus-Harz Clinic Bad Suderode, Quedlinburg, Germany,
| | - Steffi Bethge
- Department of Cardiology and Pulmology, Paracelsus-Harz Clinic Bad Suderode, Quedlinburg, Germany,
| | - Viktoria Heinze
- Department of Cardiology and Pulmology, Paracelsus-Harz Clinic Bad Suderode, Quedlinburg, Germany,
| | - Axel Schlitt
- Medical Faculty, Martin Luther-University Halle-Wittenberg, Halle, Germany,
- Department of Cardiology and Pulmology, Paracelsus-Harz Clinic Bad Suderode, Quedlinburg, Germany,
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22
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Kim J, Kraft P, Hagan KA, Harrington LB, Lindstroem S, Kabrhel C. Interaction of a genetic risk score with physical activity, physical inactivity, and body mass index in relation to venous thromboembolism risk. Genet Epidemiol 2018. [PMID: 29520861 DOI: 10.1002/gepi.22118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is highly heritable. Physical activity, physical inactivity and body mass index (BMI) are also risk factors, but evidence of interaction between genetic and environmental risk factors is limited. METHODS Data on 2,134 VTE cases and 3,890 matched controls were obtained from the Nurses' Health Study (NHS), Nurses' Health Study II (NHS II), and Health Professionals Follow-up Study (HPFS). We calculated a weighted genetic risk score (wGRS) using 16 single nucleotide polymorphisms associated with VTE risk in published genome-wide association studies (GWAS). Data on three risk factors, physical activity (metabolic equivalent [MET] hours per week), physical inactivity (sitting hours per week) and BMI, were obtained from biennial questionnaires. VTE cases were incident since cohort inception; controls were matched to cases on age, cohort, and genotype array. Using conditional logistic regression, we assessed joint effects and interaction effects on both additive and multiplicative scales. We also ran models using continuous wGRS stratified by risk-factor categories. RESULTS We observed a supra-additive interaction between wGRS and BMI. Having both high wGRS and high BMI was associated with a 3.4-fold greater risk of VTE (relative excess risk due to interaction = 0.69, p = 0.046). However, we did not find evidence for a multiplicative interaction with BMI. No interactions were observed for physical activity or inactivity. CONCLUSION We found a synergetic effect between a genetic risk score and high BMI on the risk of VTE. Intervention efforts lowering BMI to decrease VTE risk may have particularly large beneficial effects among individuals with high genetic risk.
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Affiliation(s)
- Jihye Kim
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Peter Kraft
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kaitlin A Hagan
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Laura B Harrington
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sara Lindstroem
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Christopher Kabrhel
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Hsu N, Wang T, Friedman O, Barjaktarevic I. Medical Management of Pulmonary Embolism: Beyond Anticoagulation. Tech Vasc Interv Radiol 2017; 20:152-161. [PMID: 29029709 DOI: 10.1053/j.tvir.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pulmonary embolism (PE) is a common medical condition that carries significant morbidity and mortality. Although diagnosis, anticoagulation, and interventional clot-burden reduction strategies represent the focus of clinical research and care in PE, appropriate risk stratification and supportive care are crucial to ensure good outcomes. In this chapter, we will discuss the medical management of PE from the time of presentation to discharge, focusing on the critical care of acute right ventricular failure, anticoagulation of special patient populations, and appropriate follow-up testing after acute PE.
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Affiliation(s)
- Nancy Hsu
- Division of Pulmonary and Critical Care, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Tisha Wang
- Division of Pulmonary and Critical Care, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Oren Friedman
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Berkowitz JN, Moll S. Athletes and blood clots: individualized, intermittent anticoagulation management. J Thromb Haemost 2017; 15:1051-1054. [PMID: 28301715 DOI: 10.1111/jth.13676] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Indexed: 11/30/2022]
Abstract
Essentials Athletes on anticoagulants are typically prohibited from participation in contact sports. Short-acting anticoagulants allow for reconsideration of this precedent. An individualized pharmacokinetic/pharmacodynamics study can aid patient-specific management. Many challenges and unresolved issues exist regarding such tailored intermittent dosing. SUMMARY Athletes with venous thromboembolism (VTE) are typically prohibited from participating in contact sports during anticoagulation therapy, but such mandatory removal from competition can cause psychological and financial detriments for athletes and overlooks patient autonomy. The precedent of compulsory removal developed when options for anticoagulation therapy were more limited, but medical advances now allow for rethinking of the management of athletes with VTE. We propose a novel therapeutic approach to the treatment of athletes who participate in contact sports and require anticoagulation. A personalized pharmacokinetic/pharmacodynamics study of a direct oral anticoagulant can be performed for an athlete, which can inform the timing of medication dosing. Managed carefully, this can allow athletic participation when plasma drug concentration is minimal (minimizing bleeding risk) and prompt resumption of treatment after the risk of bleeding sufficiently normalizes (maximizing therapeutic time).
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Affiliation(s)
- J N Berkowitz
- Departments of Orthopaedics and Sports Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - S Moll
- Department of Medicine, Division of Hematology-Oncology, Hemophilia and Thrombosis Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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25
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López JM, Fortuny G, Puigjaner D, Herrero J, Marimon F, Garcia-Bennett J. Effects of walking in deep venous thrombosis: a new integrated solid and fluid mechanics model. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2017; 33:e2819. [PMID: 27505011 DOI: 10.1002/cnm.2819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 07/01/2016] [Accepted: 07/10/2016] [Indexed: 06/06/2023]
Abstract
Deep venous thrombosis (DVT) is a common disease. Large thrombi in venous vessels cause bad blood circulation and pain; and when a blood clot detaches from a vein wall, it causes an embolism whose consequences range from mild to fatal. Walking is recommended to DVT patients as a therapeutical complement. In this study the mechanical effects of walking on a specific patient of DVT were simulated by means of an unprecedented integration of 3 elements: a real geometry, a biomechanical model of body tissues, and a computational fluid dynamics study. A set of computed tomography images of a patient's leg with a thrombus in the popliteal vein was employed to reconstruct a geometry model. Then a biomechanical model was used to compute the new deformed geometry of the vein as a function of the fiber stretch level of the semimembranosus muscle. Finally, a computational fluid dynamics study was performed to compute the blood flow and the wall shear stress (WSS) at the vein and thrombus walls. Calculations showed that either a lengthening or shortening of the semimembranosus muscle led to a decrease of WSS levels up to 10%. Notwithstanding, changes in blood viscosity properties or blood flow rate may easily have a greater impact in WSS.
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Affiliation(s)
- Josep M López
- Departament d'Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Av Països Catalans 26, Tarragona, Catalunya, Spain
| | - Gerard Fortuny
- Departament d'Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Av Països Catalans 26, Tarragona, Catalunya, Spain
| | - Dolors Puigjaner
- Departament d'Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Av Països Catalans 26, Tarragona, Catalunya, Spain
| | - Joan Herrero
- Departament d'Enginyeria Química, Universitat Rovira i Virgili, Av Països Catalans 26, Tarragona, Catalunya, Spain
| | - Francesc Marimon
- Departament de Medicina i Cirurgia, Universitat Rovira i Virgili, Hospital Sant Joan, Reus, Catalunya, Spain
| | - Josep Garcia-Bennett
- Servei de Radiologia i Diagnòstic per la Imatge, Hospital Sant Joan, Reus, Catalunya, Spain
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26
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Physical Therapist Clinical Reasoning and Action for Individuals With Undiagnosed Lower Extremity Tumors: A Report of 3 Cases. J Orthop Sports Phys Ther 2017; 47:359-366. [PMID: 28355977 DOI: 10.2519/jospt.2017.7037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Resident's case problem. Background Although rare in the general population, bone and soft tissue tumors may be more frequently encountered in patients seeking physical therapy because of the propensity of their initial symptoms to mimic those of commonly treated musculoskeletal disorders. Screening for tumors requires the physical therapist to be attentive to unexpected findings. The purpose of this paper was to describe the clinical-reasoning and screening processes of physical therapists who facilitated the timely recognition of bone and soft tissue tumors in 3 patients referred through medical channels. Diagnosis The referral diagnoses were lumbar spinal stenosis, calcaneal bursitis, and postexcisional quadriceps weakness. When comprehensively examined, each of the patients had either atypical examination findings or failed to respond to physical therapy treatment. After the physical therapists alerted the appropriate medical providers of the examination findings, diagnoses of high-grade osteosarcoma of the pelvis, chondroma of the knee, and liposarcoma of the thigh followed. Discussion Tumors of the lower extremity can initially mimic common musculoskeletal pathology. Physical therapists must remain alert for red flags, atypical signs and symptoms, and poor responses to treatment, even when patients are referred through medical channels. Particular attention is necessary in the case of unusual symptoms in the lower extremity, where over half of primary malignant tumors occur. Level of Evidence Differential diagnosis, level 5. J Orthop Sports Phys Ther 2017;47(5):359-366. Epub 29 Mar 2017. doi:10.2519/jospt.2017.7037.
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27
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Streiff MB, Agnelli G, Connors JM, Crowther M, Eichinger S, Lopes R, McBane RD, Moll S, Ansell J. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis 2016; 41:32-67. [PMID: 26780738 PMCID: PMC4715858 DOI: 10.1007/s11239-015-1317-0] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This guidance document focuses on the diagnosis and treatment of venous thromboembolism (VTE). Efficient, cost effective diagnosis of VTE is facilitated by combining medical history and physical examination with pre-test probability models, D dimer testing and selective use of confirmatory imaging. Clinical prediction rules, biomarkers and imaging can be used to tailor therapy to disease severity. Anticoagulation options for acute VTE include unfractionated heparin, low molecular weight heparin, fondaparinux and the direct oral anticoagulants (DOACs). DOACs are as effective as conventional therapy with LMWH and vitamin K antagonists. Thrombolytic therapy is reserved for massive pulmonary embolism (PE) or extensive deep vein thrombosis (DVT). Inferior vena cava filters are reserved for patients with acute VTE and contraindications to anticoagulation. Retrievable filters are strongly preferred. The possibility of thoracic outlet syndrome and May-Thurner syndrome should be considered in patients with subclavian/axillary and left common iliac vein DVT, respectively in absence of identifiable triggers. The optimal duration of therapy is dictated by the presence of modifiable thrombotic risk factors. Long term anticoagulation should be considered in patients with unprovoked VTE as well as persistent prothrombotic risk factors such as cancer. Short-term therapy is sufficient for most patients with VTE associated with transient situational triggers such as major surgery. Biomarkers such as D dimer and risk assessment models such the Vienna risk prediction model offer the potential to customize VTE therapy for the individual patient. Insufficient data exist to support the integration of bleeding risk models into duration of therapy planning.
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Affiliation(s)
- Michael B Streiff
- Division of Hematology, Department of Medicine and Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Giancarlo Agnelli
- Stroke Unit, Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Mark Crowther
- Departments of Medicine and Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Sabine Eichinger
- Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Renato Lopes
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Robert D McBane
- Cardiovascular Division, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephan Moll
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jack Ansell
- Department of Medicine, Hofstra North Shore/LIJ School of Medicine, Hempstead, NY, USA
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Mao Y, Wu L, Ding W. The efficacy of preoperative administration of gabapentin/pregabalin in improving pain after total hip arthroplasty: a meta-analysis. BMC Musculoskelet Disord 2016; 17:373. [PMID: 27577678 PMCID: PMC5004259 DOI: 10.1186/s12891-016-1231-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/23/2016] [Indexed: 11/17/2022] Open
Abstract
Background The purpose of this systematic review and meta-analysis of randomised controlled trials (RCTs) was to evaluate the pain control by gabapentin or pregabalin administration versus placebo after total hip arthroplasty (THA). Methods In January 2016, a systematic computer-based search was conducted in the Medline, Embase, PubMed, CENTRAL (Cochrane Controlled Trials Register), Web of Science and Google databases. This systematic review and meta-analysis were performed according to the PRISMA statement criteria. The primary endpoint was the cumulative morphine consumption and visual analogue scale (VAS) scores at 24 and 48 h with rest or mobilisation. The complications of vomiting, nausea, dizziness and pruritus were also compiled to assess the safety of gabapentin and pregabalin. Stata 12.0 software was used for the meta-analysis. After testing for publication bias and heterogeneity across studies, the data were aggregated for random-effects modelling when necessary. Results Seven studies involving 769 patients met the inclusion criteria. The meta-analysis revealed that treatment with gabapentin or pregabalin can decrease the cumulative morphine consumption at 24 h (mean difference (MD) = −7.82; 95 % CI −0.95 to −0.52; P < 0.001) and 48 h (MD = −6.90; 95 % CI −0.95 to −0.57; P = 0.118). Gabapentin or pregabalin produced no better outcome than placebo in terms of VAS score with rest at 24 h (SMD = 0.15; 95 % CI −0.17 to −0.48; P = 0.360) and with rest at 48 h (SMD = 0.22; 95 % CI −0.25 to 0.69; P = 0.363). There was no statistically significant difference between the groups with respect to the VAS score at 24 h postoperatively (SMD = 0.46; 95 % CI −0.19 to 1.11; P = 0.164) and at 48 h postoperatively (SMD = 1.15; 95 % CI −0.58 to 2.89; P = 0.193). Gabapentin decreased the occurrence of nausea (relative risk (RR), 0.49; 95 % CI 0.27–0.92, P = 0.025), but there was no significant difference in the incidence of vomiting, dizziness and pruritus. Conclusions On the basis of the current meta-analysis, gabapentin or pregabalin can decrease the cumulative morphine consumption and decrease the occurrence of nausea; however, further trials are needed to assess the efficacy of pain control by gabapentin or pregabalin. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1231-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yingdelong Mao
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, 318 Chaowang Road, Hangzhou, Zhejiang, 310005, People's Republic of China
| | - Lianguo Wu
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, 318 Chaowang Road, Hangzhou, Zhejiang, 310005, People's Republic of China
| | - Weiguo Ding
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, Zhejiang, 310012, People's Republic of China.
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Izcovich A, Popoff F, Rada G. Early mobilization versus bed rest for deep vein thrombosis. Medwave 2016; 16 Suppl 2:e6478. [PMID: 27391009 DOI: 10.5867/medwave.2016.6478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Aiming to prevent thromboembolic events, bed rest was historically considered in the management of patient with deep vein thrombosis. Nevertheless early ambulation could have beneficial effects. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified seven systematic reviews including 10 randomized trials answering this question. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded early ambulation is probably effective in reducing deep vein thrombosis progression and improving limb pain, and might not increase the risk of thromboembolism.
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Affiliation(s)
- Ariel Izcovich
- Servicio de Clínica Médica, Hospital Alemán, Buenos Aires, Argentina; Programa de Medicina Basada en Pruebas, Hospital Alemán, Buenos Aires, Argentina. Address: Hospital Alemán de Buenos Aires, Av. Pueyrredon 1640, CP C118AAT, +54114827700.
| | - Federico Popoff
- Servicio de Clínica Médica, Hospital Alemán, Buenos Aires, Argentina; Programa de Medicina Basada en Pruebas, Hospital Alemán, Buenos Aires, Argentina
| | - Gabriel Rada
- Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; GRADE working group; The Cochrane Collaboration; Fundación Epistemonikos, Santiago, Chile
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30
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Kasawara KT, Cotechini T, Macdonald-Goodfellow SK, Surita FG, Pinto e Silva JL, Tayade C, Othman M, Ozolinš TRS, Graham CH. Moderate Exercise Attenuates Lipopolysaccharide-Induced Inflammation and Associated Maternal and Fetal Morbidities in Pregnant Rats. PLoS One 2016; 11:e0154405. [PMID: 27124733 PMCID: PMC4849647 DOI: 10.1371/journal.pone.0154405] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 04/13/2016] [Indexed: 12/21/2022] Open
Abstract
Fetal growth restriction (FGR) and coagulopathies are often associated with aberrant maternal inflammation. Moderate-intensity exercise during pregnancy has been shown to increase utero-placental blood flow and to enhance fetal nutrition as well as fetal and placental growth. Furthermore, exercise is known to reduce inflammation. To evaluate the effect of moderate-intensity exercise on inflammation associated with the development of maternal coagulopathies and FGR, Wistar rats were subjected to an exercise regime before and during pregnancy. To model inflammation-induced FGR, pregnant rats were administered daily intraperitoneal injections of E. coli lipopolysaccharide (LPS) on gestational days (GD) 13.5–16.5 and sacrificed at GD 17.5. Control rats were injected with saline. Maternal hemostasis was assessed by thromboelastography. Moderate-intensity exercise prevented LPS-mediated increases in white blood cell counts measured on GD 17.5 and improved maternal hemostasis profiles. Importantly, our data reveal that exercise prevented LPS-induced FGR. Moderate-intensity exercise initiated before and maintained during pregnancy may decrease the severity of maternal and perinatal complications associated with abnormal maternal inflammation.
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Affiliation(s)
- Karina T. Kasawara
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
- Department of Obstetrics and Gynaecology, University of Campinas, Campinas, SP, Brazil
| | - Tiziana Cotechini
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | | | - Fernanda G. Surita
- Department of Obstetrics and Gynaecology, University of Campinas, Campinas, SP, Brazil
| | - João L. Pinto e Silva
- Department of Obstetrics and Gynaecology, University of Campinas, Campinas, SP, Brazil
| | - Chandrakant Tayade
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | - Terence R. S. Ozolinš
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | - Charles H. Graham
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
- * E-mail:
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Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline. Phys Ther 2016; 96:143-66. [PMID: 26515263 DOI: 10.2522/ptj.20150264] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/24/2015] [Indexed: 02/09/2023]
Abstract
The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular & Pulmonary and Acute Care sections of APTA, have developed this clinical practice guideline to assist physical therapists in their decision-making process when treating patients at risk for venous thromboembolism (VTE) or diagnosed with a lower extremity deep vein thrombosis (LE DVT). No matter the practice setting, physical therapists work with patients who are at risk for or have a history of VTE. This document will guide physical therapist practice in the prevention of, screening for, and treatment of patients at risk for or diagnosed with LE DVT. Through a systematic review of published studies and a structured appraisal process, key action statements were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms, based on the key action statements, were developed that can assist with clinical decision making. Physical therapists, along with other members of the health care team, should work to implement these key action statements to decrease the incidence of VTE, improve the diagnosis and acute management of LE DVT, and reduce the long-term complications of LE DVT.
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Wang Z, Chen Q, Ye M, Shi GH, Zhang B. Active Ankle Movement May Prevent Deep Vein Thrombosis in Patients Undergoing Lower Limb Surgery. Ann Vasc Surg 2016; 32:65-72. [PMID: 26802300 DOI: 10.1016/j.avsg.2015.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 06/26/2015] [Accepted: 10/06/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our aim is to investigate the effect of active ankle movement to prevent deep vein thrombosis (DVT) in patients who received lower limb surgery, and to provide a theory of evidence for rehabilitation nursing of patients after orthopedic surgery. METHODS Between January 2012 and December 2013, a total of 174 patients were randomized as case group (n = 96) and control group (n = 78). Case group received routine nursing and active ankle movement (30 times/min, 1-7 days after surgery), while control group only received routine nursing. The symptoms and signs of DVT were in real-time observation during the experiment. Thigh and crus circumference, maximum venous outflow (MVO), maximum venous capacity (MVC), and MVO ratio (MVO ratio = MVO/MVC) in the two groups were measured 1-7 days after surgery. Six-month follow-up study was also conducted to observe the occurrence of DVT. RESULTS Our study revealed that thigh circumference in the case group decreased compared with the control group in 5-7 days (fifth day: 39.98 ± 3.25 vs. 41.01 ± 3.38, P = 0.043; sixth day: 38.21 ± 3.81 vs. 39.49 ± 3.79, P = 0.029; seventh day: 37.13 ± 3.15 vs. 38.76 ± 3.31, P = 0.001), and crus circumference in the case group also decreased compared with the control group in 5-7 days (fifth day: 26.35 ± 2.11 vs. 27.01 ± 2.19, P = 0.045; sixth day: 25.99 ± 2.31 vs. 26.88 ± 3.12, P = 0.032; seventh day: 25.56 ± 1.99 vs. 26.38 ± 2.89, P = 0.028). MVO and MVC in the case group increased compared with the control group 7 days after surgery (MVO: 15.01 ± 2.56 vs. 14.12 ± 2.56, P = 0.024; MVC: 10.18 ± 3.15 vs. 8.91 ± 2.78, P = 0.006). Significant difference in the incidence of thrombus and DVT were found between the case group and the control group 1-7 days after surgery (thrombus: 1.0% and 7.7%, P = 0.027; DVT: 7.6% and 18.4%, P = 0.032). CONCLUSION Our result manifested that active ankle movement can relieve the swelling of patients after lower limb surgery, and improve the MVO and MVC of patients to prevent formation of DVT after lower limb surgery.
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Affiliation(s)
- Zhe Wang
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, P.R. China.
| | - Qian Chen
- Department of Ultrasound, Renmin Hospital of Wuhan University, Wuhan, P.R. China
| | - Mao Ye
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, P.R. China
| | - Guang-Hui Shi
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, P.R. China
| | - Bo Zhang
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, P.R. China
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33
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Noack F, Schmidt B, Amoury M, Stoevesandt D, Gielen S, Pflaumbaum B, Girschick C, Völler H, Schlitt A. Feasibility and safety of rehabilitation after venous thromboembolism. Vasc Health Risk Manag 2015. [PMID: 26203256 PMCID: PMC4508081 DOI: 10.2147/vhrm.s81411] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Venous thromboembolism is a life-threatening disease. In survivors, different degrees of functional complaints need to be restored or prevented (eg, post-thrombotic syndrome, pulmonary hypertension). Therefore, rehabilitation after venous thromboembolism is recommended in Germany. However, a structured rehabilitation program has not been defined for this indication. Here, we present the experience of a single rehabilitation center. METHODS Data from consecutive pulmonary embolism (PE) patients who were referred for a 3-week inpatient rehabilitation program from 2006 to 2014 were retrospectively evaluated. RESULTS In all, 422 patients were identified. The mean age was 63.9±13.5 years, the mean body mass index (BMI) was 30.6±6.2 kg/m2, and 51.9% were female. Deep vein thrombosis according to PE was known for 55.5% of all patients. We applied a wide range of therapeutic interventions such as bicycle training with monitored heart rate in 86.7%, respiratory training in 82.5%, aquatic therapy/swimming in 40.1%, and medical training therapy in 14.9% of all patients. Adverse events (AEs) occurred in 57 patients during the 3-week rehabilitation period. The most common AEs were cold (n=6), diarrhea (n=5), and infection of the upper or lower respiratory tract that was treated with antibiotics (n=5). However, three patients under anticoagulation therapy suffered from bleeding, which was clinically relevant in one. Four patients (0.9%) had to be transferred to a primary care hospital for non-PE-associated reasons (acute coronary syndrome, pharyngeal abscess, and acute abdominal problems). No influence of any of the physical activity interventions on the incidence of any AE was found. CONCLUSION Since PE is a life-threatening disease, it seems reasonable to recommend rehabilitation at least in PE patients with an intermediate or high risk. It is shown for the first time in this study that a standard rehabilitation program after PE is safe. However, efficacy and safety in the long term need to be studied prospectively.
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Affiliation(s)
- Frank Noack
- Department of Medicine I, University Clinic Halle (Saale), Halle, Germany ; Department of Emergency Medicine, University Clinic Halle (Saale), Halle, Germany
| | - Bernd Schmidt
- Department of Medicine I, University Clinic Halle (Saale), Halle, Germany
| | - Mroawan Amoury
- Department of Emergency Medicine, University Clinic Halle (Saale), Halle, Germany
| | - Dietrich Stoevesandt
- Department of Diagnostic Radiology, University Clinic Halle (Saale), Halle, Germany
| | - Stephan Gielen
- Department of Medicine III, University Clinic Halle (Saale), Halle, Germany
| | - Birgit Pflaumbaum
- Department of Cardiology and Pulmology, Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany
| | - Christiane Girschick
- Department of Cardiology and Pulmology, Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany
| | | | - Axel Schlitt
- Department of Cardiology and Pulmology, Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany ; Medical Faculty, Martin Luther University Halle, Wittenberg, Germany
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Abstract
This issue provides a clinical overview of deep venous thrombosis, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.
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35
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Liu Z, Tao X, Chen Y, Fan Z, Li Y. Bed rest versus early ambulation with standard anticoagulation in the management of deep vein thrombosis: a meta-analysis. PLoS One 2015; 10:e0121388. [PMID: 25860350 PMCID: PMC4393252 DOI: 10.1371/journal.pone.0121388] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/15/2015] [Indexed: 12/05/2022] Open
Abstract
Introduction Bed rest has been considered as the cornerstone of management of deep vein thrombosis (DVT) for a long time, though it is not evidence-base, and there is growing evidence favoring early ambulation. Methods Electronic databases including Medline, PubMed, Cochrane Library and three Chinese databases were searched with key words of “deep vein thrombosis”, “pulmonary embolism”, “venous thrombosis”, “bed rest”, “immobilization”, “mobilization” and “ambulation”. We considered randomized controlled trials, prospective or retrospective cohort studies that compared the outcomes of acute DVT patients managed with early ambulation versus bed rest, in addition to standard anticoagulation. Meta-analysis pertaining to the incidence of new pulmonary embolism (PE), progression of DVT, and DVT related deaths were conducted, as well as the extent of remission of pain and edema. Results 13 studies were included with a total of 3269 patients. Compared to bed rest, early ambulation was not associated with a higher incidence of new PE, progression of DVT, or DVT related deaths (RD −0.03, 95% CI −0.05∼ −0.02; Z = 1.24, p = 0.22; random effect model, Tau2 = 0.01). Moreover, if the patients suffered moderate or severe pain initially, early ambulation was related to a better outcome, with respect to remission of acute pain in the affected limb (SMD 0.42, 95%CI 0.09∼0.74; Z = 2.52, p = 0.01; random effect model, Tau2 = 0.04). Meta-analysis of alleviation of edema cannot elicit a solid conclusion because of significant heterogeneity among the few studies. Conclusions Compared to bed rest, early ambulation of acute DVT patients with anticoagulation was not associated with a higher incidence of new PE, progression of DVT, and DVT related deaths. Furthermore, for the patients suffered moderate or severe pain initially, a better outcome can be seen in early ambulation group, regarding to the remission of acute pain in the affected limb.
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Affiliation(s)
- Zhenlei Liu
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Xixi Tao
- Department of Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Zhongjie Fan
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yongjun Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
- * E-mail:
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Kline JA, Nordenholz KE, Courtney DM, Kabrhel C, Jones AE, Rondina MT, Diercks DB, Klinger JR, Hernandez J. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost 2014; 12:459-68. [PMID: 24484241 DOI: 10.1111/jth.12521] [Citation(s) in RCA: 174] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/26/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) can worsen quality of life due to persistent dyspnea or exercise intolerance. OBJECTIVE Test if tenecteplase increases the probability of a favorable composite patient-oriented outcome after submassive PE. METHODS Normotensive patients with PE and right ventricular (RV) strain (by echocardiography or biomarkers) were enrolled from eight hospitals. All patients received low-molecular-weight heparin followed by random assignment to either a single weight-based bolus of tenecteplase or placebo, administered in a double-blinded fashion. The primary composite outcome included: (i) death, circulatory shock, intubation or major bleeding within 5 days or (ii) recurrent PE, poor functional capacity (RV dysfunction with either dyspnea at rest or exercise intolerance) or an SF36(®) Physical Component Summary (PCS) score < 30 at 90-day follow-up. RESULTS Eighty-three patients were randomized; 40 to tenecteplase and 43 to placebo. The trial was terminated prematurely. Within 5 days, adverse outcomes occurred in three placebo-treated patients (death in one and intubation in two) and one tenecteplase-treated patient (fatal intracranial hemorrhage). At 90 days, adverse outcomes occurred in 13 unique placebo-treated patients and five unique tenecteplase-treated patients Thus, 16 (37%) placebo-treated and six (15%) tenecteplase-treated patients had at least one adverse outcome (exact two-sided P = 0.017). CONCLUSIONS Treatment of patients with submassive pulmonary embolism with tenecteplase was associated with increased probability of a favorable composite outcome.
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Affiliation(s)
- J A Kline
- Departments of Emergency Medicine and Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
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Azarbal A, Santo V, Moneta G. How should we treat May–Thurner syndrome and other causes of iliac vein obstruction? Examining the evidence. Interv Cardiol 2014. [DOI: 10.2217/ica.13.85] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Kline JA, Hernandez J, Hogg MM, Jones AE, Courtney DM, Kabrhel C, Nordenholz KE, Diercks DB, Rondina MT, Klinger JR. Rationale and methodology for a multicentre randomised trial of fibrinolysis for pulmonary embolism that includes quality of life outcomes. Emerg Med Australas 2013; 25:515-26. [PMID: 24224521 DOI: 10.1111/1742-6723.12159] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Submassive pulmonary embolism (PE) has a low mortality rate but can degrade functional capacity. OBJECTIVE The present study aims to provide rationale, methodology, and initial findings of a multicentre, randomised trial of fibrinolysis for PE that used a composite end-point, including quality of life measures. METHODS This investigator-initiated study was funded by a contract between a corporate partner and the investigator's hospital (the prime site). The investigator was the Food and Drug Administration (FDA) sponsor. The prime site subcontracted, indemnified, and trained consortia members. Consenting, normotensive patients with PE and right ventricular strain (by echocardiography or biomarkers) received low-molecular-weight heparin and random assignment to a single bolus of tenecteplase or placebo in double-blinded fashion. The outcomes were: (i) in-hospital rate of intubation, vasopressor support, and major haemorrhage, or (ii) at 90 days, death, recurrent PE, or composite that defined poor quality of life (echocardiography, 6 min walk test and surveys). The planned sample size was n = 200. RESULTS Eight sites enrolled 87 patients over 5 years. The ratio of patients screened for each enrolled was 7.4 to 1, equating to 11 h screening time per patient enrolled. Primary barrier to enrolment was the cost of screening. Two patients died (2.5%, 95%CI [0-8%]), one developed shock, but 18 (22%, 95%CI: [13-30%]) had a poor quality of life. CONCLUSIONS An investigator-initiated, FDA-regulated, multicentre trial of fibrinolysis for submassive PE was conducted, but was limited by screening costs and a low mortality rate. Quality of life measurements might represent a more important patient-centred end-point.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Singh L, Stevens EE. Leg Pain and Gynecologic Malignancy. Am J Hosp Palliat Care 2013; 30:594-600. [DOI: 10.1177/1049909112460422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Gynecologic malignancies affect more than 83 000 women in the United States, each year. Because the disease involves the pelvis, many patients have side effects distal to this area in their lower extremities. The differential diagnosis of leg pain can be divided into vascular, neurologic, and musculoskeletal causes. In this review article, we address numerous etiologies of leg pain, reviewing the prevalence of disease, physical examination findings, diagnostic as well as treatment modalities.
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Affiliation(s)
- Lilly Singh
- Department of Obstetrics & Gynecology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Erin E. Stevens
- Department of Obstetrics & Gynecology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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Abstract
This article describes the risk factors, diagnostic tools, and therapeutic approaches for venous thromboembolism (VTE), which includes primarily deep vein thrombosis and pulmonary embolism, as well as VTE occurring at other sites. Outpatient management strategies are emphasized.
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Affiliation(s)
- Bruce Burnett
- Park Nicollet Health Services, Thrombosis Clinic, 6600 Excelsior Boulevard, St Louis Park, MN 55426, USA.
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Mayer K, Keese M, Schmandra TC, Meyn M, Schmitz-Rixen T. [Diagnosis and therapy of deep vein thrombosis]. MMW Fortschr Med 2012; 154 Spec No 3:79-84. [PMID: 23724724 DOI: 10.1007/s15006-012-1300-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Kerstin Mayer
- Klinik für Gefäss- und Endovascularchirugie, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main
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Lv W, Wu XJ, Collins M, Han ZL, Jin X. Analysis of a series of patients with varicose vein recurrence. J Int Med Res 2012; 40:1156-65. [PMID: 22906290 DOI: 10.1177/147323001204000336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Varicose veins of the lower extremities is a common clinical condition. Although surgical treatment is often successful, the recurrence rate remains high. This retrospective study evaluated the reasons for postoperative recurrence of varicose veins by analysing ultrasonography and venography findings in patients with recurrent disease. METHODS A series of consecutive cases of recurrent varicose veins of the lower limbs was reviewed. Data collected included clinical characteristics, symptoms and vascular imaging. RESULTS The study included 109 legs with recurrent varicose veins (92 patients): 101/109 legs (92.7%) showed perforating vein insufficiency and 86/109 (78.9%) showed reflux of the superficial femoral vein, of varying degrees of severity. Residual saphenous vein was recorded for 82 legs (75.2%), while 19 (17.4%) had blocked iliac veins due to post-thrombotic syndrome. CONCLUSIONS Several factors that may contribute to varicose vein recurrence have been identified. These include failure to ligate perforating veins and initial failure to perform the appropriate surgical intervention. Prevention of varicose vein recurrence after surgical correction requires a more extensive use of preoperative imaging, to tailor surgical intervention to suit individual patients.
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Affiliation(s)
- W Lv
- Department of Vascular Surgery, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, China
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Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S-e496S. [PMID: 22315268 PMCID: PMC3278049 DOI: 10.1378/chest.11-2301] [Citation(s) in RCA: 2482] [Impact Index Per Article: 206.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This article addresses the treatment of VTE disease. METHODS We generated strong (Grade 1) and weak (Grade 2) recommendations based on high-quality (Grade A), moderate-quality (Grade B), and low-quality (Grade C) evidence. RESULTS For acute DVT or pulmonary embolism (PE), we recommend initial parenteral anticoagulant therapy (Grade 1B) or anticoagulation with rivaroxaban. We suggest low-molecular-weight heparin (LMWH) or fondaparinux over IV unfractionated heparin (Grade 2C) or subcutaneous unfractionated heparin (Grade 2B). We suggest thrombolytic therapy for PE with hypotension (Grade 2C). For proximal DVT or PE, we recommend treatment of 3 months over shorter periods (Grade 1B). For a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B; Grade 2B if provoked by a nonsurgical risk factor and low or moderate bleeding risk); that is unprovoked, we suggest extended therapy if bleeding risk is low or moderate (Grade 2B) and recommend 3 months of therapy if bleeding risk is high (Grade 1B); and that is associated with active cancer, we recommend extended therapy (Grade 1B; Grade 2B if high bleeding risk) and suggest LMWH over vitamin K antagonists (Grade 2B). We suggest vitamin K antagonists or LMWH over dabigatran or rivaroxaban (Grade 2B). We suggest compression stockings to prevent the postthrombotic syndrome (Grade 2B). For extensive superficial vein thrombosis, we suggest prophylactic-dose fondaparinux or LMWH over no anticoagulation (Grade 2B), and suggest fondaparinux over LMWH (Grade 2C). CONCLUSION Strong recommendations apply to most patients, whereas weak recommendations are sensitive to differences among patients, including their preferences.
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Affiliation(s)
- Clive Kearon
- Department of Medicine and Clinical Epidemiology and Biostatistics, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Medicine, Family Medicine, and Social and Preventive Medicine, State University of New York at Buffalo, Buffalo, NY.
| | | | - Paolo Prandoni
- Department of Cardiothoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Henri Bounameaux
- Department of Medical Specialties, University Hospitals of Geneva, Geneva, Switzerland
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael E Nelson
- Department of Medicine, Shawnee Mission Medical Center, Shawnee Mission, KS
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michael K Gould
- Department of Medicine and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Mark Crowther
- Department of Medicine, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Susan R Kahn
- Department of Medicine and Clinical Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 21:575-98. [PMID: 22072093 DOI: 10.1007/s00586-011-2045-6] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 09/14/2011] [Accepted: 10/07/2011] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The effect size for exercise therapy in the treatment of chronic non-specific low back pain (cLBP) is only modest. This review aims to analyse the specificity of the effect by examining the relationship between the changes in clinical outcome (pain, disability) and the changes in the targeted aspects of physical function (muscle strength, mobility, muscular endurance) after exercise therapy. METHODS We searched for exercise therapy trials for cLBP published up to 15 April 2010 in Medline, Embase, Cochrane Library, Cinahl, and PEDro. Two independent reviewers selected studies according to the inclusion criteria. DATA EXTRACTION one author extracted the data of the articles. RESULTS DATA SYNTHESIS 16 studies with a total of 1,476 participants met the inclusion criteria. There was little evidence supporting a relationship between the changes in pain or physical function and the changes in performance for the following measures: mobility (no correlation in 9 studies, weak correlation in 1 study), trunk extension strength (7 and 2, respectively), trunk flexion strength (4 and 1, respectively) and back muscle endurance (7 and 0, respectively). Changes in disability showed no correlation with changes in mobility in three studies and a weak correlation in two; for strength, the numbers were four (no correlation) and two (weak correlation), respectively. CONCLUSIONS The findings do not support the notion that the treatment effects of exercise therapy in cLBP are directly attributable to changes in the musculoskeletal system. Future research aimed at increasing the effectiveness of exercise therapy in cLBP should explore the coincidental factors influencing symptom improvement.
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Affiliation(s)
- F Steiger
- Institute of Human Movement Sciences and Sport, ETH Zürich, Zurich, Switzerland
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Seok SJ, Kim SJ, Gil HW, Yang JO, Lee EY, Hong SY. Tissue plasminogen activator and plasminogen activator inhibitor-1 levels in patients with acute paraquat intoxication. J Korean Med Sci 2011; 26:474-81. [PMID: 21468253 PMCID: PMC3069565 DOI: 10.3346/jkms.2011.26.4.474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 02/08/2011] [Indexed: 11/20/2022] Open
Abstract
To investigate the effects of reactive oxygen species (ROS) on tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) plasma levels, and their possible implications on clinical outcome, we measured tPA and PAI-1 levels in 101 patients with acute paraquat (PQ) intoxication. The control group consisted of patients who ingested non-PQ pesticides during the same period. tPA and PAI-1 levels were higher in the PQ group than in the controls. PQ levels were significantly correlated with ingested amount, timelag to hospital, tPA level, and hospitalization duration. tPA levels were correlated with PAI-1, fibrin degradation product (FDP), and D-dimer. D-dimer levels were lower in the PQ group than in the controls. Univariate analysis indicated the following significant determinants of death: age, ingested amount, PQ level, timelag to hospital, serum creatinine, lipase, pH, pCO(2), HCO(3) (-), WBC, FDP, PAI-1, and tPA. However, multivariate analysis indicated that only PQ level was significant independent factor predicting death. In conclusion, tPA and PAI-1 levels were higher, while D-dimer levels were lower in the PQ group than in the controls, implying that ROS stimulate tPA and PAI-1, but PAI-1 activity overrides tPA activity in this setting. Decreased fibrinolytic activity appears to be one of the clinical characteristics of acute PQ intoxication.
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Affiliation(s)
- Su-Jin Seok
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Su-Ji Kim
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Hyo-Wook Gil
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Jong-Oh Yang
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Eun-Young Lee
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Sae-Yong Hong
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
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Lowe GDO. Management of deep vein thrombosis to reduce the incidence of post-thrombotic syndrome. Phlebology 2011; 25 Suppl 1:9-13. [PMID: 20870814 DOI: 10.1258/phleb.2010.010s02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The post-thrombotic syndrome (PTS) is the major chronic sequel of deep vein thrombosis (DVT) of the leg, and is a major socioeconomic challenge. In addition to systematic prophylaxis of DVT in hospitalized patients, effective management of DVT is important to reduce the incidence of PTS. Thrombolysis and thrombectomy are not indicated routinely. Optimal anticoagulation, usually with heparins initially and then with oral warfarin, is important to prevent recurrent DVT, which is a major risk factor for PTS. Following a routine three-month period of anticoagulation, patients with proximal idiopathic DVT should be individually assessed for the benefits and risks of continued oral anticoagulation, including patient preferences. Risk factors for recurrent DVT include active cancer, pregnancy, continued use of oral oestrogens, male sex, obesity, recurrent thrombosis, established PTS, permanent inferior vena caval filters, residual DVT, high fibrin d-dimer and other thrombophilias. Early walking, continued high levels of physical activity and wearing compression stockings for up to two years may also reduce the risk of PTS.
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Affiliation(s)
- G D O Lowe
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
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Sasaki K, Senda M, Matsuyama Y, Ota H. Can Clinical Findings Predict the Complications Associated with Acute-phase Deep Venous Thrombosis after Total Hip Arthroplasty? J Phys Ther Sci 2011. [DOI: 10.1589/jpts.23.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Masuo Senda
- Division of Physical Medicine and Rehabilitation, Okayama University Hospital
| | - Yoshiyuki Matsuyama
- Division of Physical Medicine and Rehabilitation, Okayama University Hospital
| | - Haruyuki Ota
- Division of Physical Medicine and Rehabilitation, Okayama University Hospital
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Kahn SR, Shrier I, Shapiro S, Houweling AH, Hirsch AM, Reid RD, Kearon C, Rabhi K, Rodger MA, Kovacs MJ, Anderson DR, Wells PS. Six-month exercise training program to treat post-thrombotic syndrome: a randomized controlled two-centre trial. CMAJ 2010; 183:37-44. [PMID: 21098066 DOI: 10.1503/cmaj.100248] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Exercise training may have the potential to improve post-thrombotic syndrome, a frequent, chronic complication of deep venous thrombosis. We conducted a randomized controlled two-centre pilot trial to assess the feasibility of a multicentre-based evaluation of a six-month exercise training program to treat post-thrombotic syndrome and to obtain preliminary data on the effectiveness of such a program. METHODS Patients were randomized to receive exercise training (a six-month trainer-supervised program) or control treatment (an education session with monthly phone follow-ups). Levels of eligibility, consent, adherence and retention were used as indicators of study feasibility. Primary outcomes were change from baseline to six months in venous disease-specific quality of life (as measured using the Venous Insufficiency Epidemiological and Economic Study Quality of Life [VEINES-QOL] questionnaire) and severity of post-thrombotic syndrome (as measured by scores on the Villalta scale) in the exercise training group versus the control group, assessed by t tests. Secondary outcomes were change in generic quality of life (as measured using the Short-Form Health Survey-36 [SF-36] questionnaire), category of severity of post-thrombotic syndrome, leg strength, leg flexibility and time on treadmill. RESULTS Of 95 patients with post-thrombotic syndrome, 69 were eligible, 43 consented and were randomized, and 39 completed the study. Exercise training was associated with improvement in VEINES-QOL scores (exercise training mean change 6.0, standard deviation [SD] 5.1 v. control mean change 1.4, SD 7.2; difference 4.6, 95% CI 0.54 to 8.7; p = 0.027) and improvement in scores on the Villalta scale (exercise training mean change -3.6, SD 3.7 v. control mean change -1.6, SD 4.3; difference -2.0, 95% CI -4.6 to 0.6; p = 0.14). Most secondary outcomes also showed greater improvement in the exercise training group. INTERPRETATION Exercise training may improve post-thrombotic syndrome. It would be feasible to definitively evaluate exercise training as a treatment for post-thrombotic syndrome in a large multicentre trial.
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Affiliation(s)
- Susan R Kahn
- Department of Medicine, McGill University, Ottawa, Ont., Canada.
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