International angiology : a journal of the International Union of Angiology
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Review
Exclusion and diagnosis of deep vein thrombosis in outpatients by sequential noninvasive tools.
Phlebography is the reference gold standard for the diagnosis of deep vein thrombosis (DVT), but due to its invasive nature and associated side effects it has been replaced by compression ultrasonography (CUS). Patients suspected of DVT are subjected to leg vein CUS that actually confirms DVT in only 16 to 28% of outpatients in large prospective management studies. CUS has a high positive predictive value of more than 98% for proximal DVT but usually misses calf vein thrombosis. ⋯ The combination of a negative CUS, a low clinical score and a positive ELISA D-dimer but <1000 ng/ml excludes DVT with a negative predictive value of >99% without the need to repeat CUS. Patients with a negative CUS, scan but a positive ELISA D-dimer, and a moderate or high clinical score are still at risk with a probability of DVT of 3-5% and 20-30%, respectively and are thus candidates for repeated ultrasound scanning. The rapid ELISA D-dimer first followed by risk-based no, single or repeated CUS will be the most cost-effective strategy.
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Even though low molecular weight heparins (LMWHs) have become the standard for venous thromboembolism (VTE) prophylaxis in most European countries and Canada, it was not until recently that LMWHs were approved for use in the United States. The main objective of this study was to assess the current preferences and attitudes of United States surgeons toward the prevention of VTE with particular reference to LMWH. ⋯ North American general surgeons have substantially modified their approach to VTE prevention in the last 4 years. Physical methods and unfractionated heparin remain the preferred prophylactic modalities, but LMWHs have gained rapid acceptance since their approval for use for VTE prevention in North America. Even though the results of this survey must be interpreted with caution because of the limited response rate and possible sampling bias, they still reflect the current preferences and attitudes of North American surgeons toward prophylaxis.
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Iloprost given in a standard dose regimen (0.5-2 ng/kg/min for 6 hours daily over 21-28 days) has proven to be effective and safe in hospitalized patients with critical limb ischemia. Major drawbacks of the standard regimen are the high frequency of side effects, the long duration of the daily infusion, and a hospital stay of 3 to 4 weeks. Recently, the efficacy of low doses of iloprost (25 mg/day) was demonstrated. This open pilot study was undertaken to identify a more practical and cost-effective regimen with less side effects. The feasibility, efficacy and safety of an individually adapted, intermittently applied low-dose iloprost regimen in an outpatient setting were evaluated. ⋯ In a limited number of patients with severe peripheral ischemia of various etiologies, long-term outpatient treatment with an individually adapted low-dose iloprost regimen was feasible and safe. Our data suggest that flexible treatment modalities might be as effective as rigid standard treatment regimens, the former being more advantageous in terms of greater practicability and cost-effectiveness due to outpatient management. Further studies are needed to confirm the efficacy of this individually adapted, low-dose outpatient iloprost treatment regimen in a larger number of patients.