Optimal duration of anticoagulant treatment of venous thromboembolism

RECURRENT THROMBOSIS VERSUS ANTICOAGULANT-RELATED BLEEDING: The optimal duration of anticoagulation for venous thromboembolism depends on the balance between the risk of thrombosis if anticoagulation is stopped, and the risk of bleeding if patients remain on treatment. In the past decade, five large well designed trials have been completed which have compared different durations of anticoagulation for the treatment of various categories of patients with venous thrombosis. In conjunction with the findings of a number of other prospective studies, these trials have helped to identify risk factors for recurrent venous thrombosis and anticoagulant-related bleeding, and have led to a better understanding of the optimal duration of therapy for individual patients. RISK OF RECURRENT THROMBOSIS: The risk of recurrent thrombosis is low if thrombosis was precipitated by a major reversible risk factor such as surgery. Patients with idiopathic thrombosis (no apparent risk factor) and those with persistent risk factors (e.g., cancer), have a high risk of recurrence. Some hereditary (e.g., protein C, S or antithrombin deficiency) and acquired (e.g., antiphospholipid antibodies) thrombophilic states are risk factors for recurrence independently of whether thrombosis was, or was not, provoked by a major risk factor. DURATION OF THERAPY: Patients with a low risk of recurrence should be anticoagulated for three months. Others should be treated from 6 months to indefinitely, depending on the balance between the risk of recurrence and the risk of bleeding in each individual patient.     

Thromboembolism and venous thrombosis of the deep veins in surgical children--an increasing challenge?

Children share many known predisposing risk factors for venous thromboembolism and deep venous thrombosis but appears less common and is probably underestimated. Fatal pulmonary embolism is rare but may also be missed because of low level of clinical awareness. The aim of this study was to investigate children with thromboembolism of deep veins to evaluate risk factors and highlight their danger.

Methods

This was a retrospective review of all children (<13 years old) diagnosed with a venous thromboembolism (1993-2009). Clinical and radiologic features and any risk factors were documented. Venous thromboembolism was diagnosed on clinical suspicion together with compressive Doppler studies, spiral computed tomography, or magnetic resonance scan.

Results

Eighteen children with a consistent clinical picture were identified (painful unilateral limb swelling). Their mean age was 9.3 years with a male/female ratio of 3.5:1. Predisposing factors were identified in 17 (95%). These included infective conditions (n = 11), previous femoral line (n = 3), trauma (n = 2), and complicated appendicitis (n = 2). Chronic infective and inflammatory conditions included tuberculosis (n = 4), HIV (n = 3), staphylococcal septicemia (n = 2), and Takayasu arteritis (n = 1). Pulmonary embolism occurred in 5 (28%), and 1 presented later with a post-phlebitic leg. Elevated factor VIII was seen in 3.

Conclusion

This study identified an association with known risk factors in most children with venous thromboembolism and suggests that those with femoral venous access or ongoing chronic infective states (eg, TB/HIV) are particularly at risk.     

胰腺癌MUC4的表达及其临床相关影响因素的分析

目的:研究胰腺癌组织中MUC4的表达及其与临床相关因素间的关系。方法:采用免疫组织化学法检测53例胰腺导管腺癌和对应癌旁组织,以及9例慢性胰腺炎组织MUC4的表达,分析胰腺癌MUC4的表达与肿瘤分化、分期、病人生存时间等临床因素之间的关系。结果:53例胰腺癌组织中MUC4蛋白阳性表达43例(81.1%),对应癌旁组织中MUC4蛋白均为阴性表达,9例慢性胰腺炎中MUC4蛋白阳性表达2例(22.2%)。MUC4蛋白在胰腺癌组织中阳性表达率显著高于癌旁组织及慢性胰腺炎组织(P0.05)。单因素及多因素生存分析显示,淋巴结转移、临床TNM分期和MUC4的表达是胰腺癌预后相关的重要独立因素,MUC4的高表达组预后较差(P<0.05)。结论:MUC4可能是一个特异的胰腺癌肿瘤相关标志物,在胰腺癌中有较高的表达率,MUC4的检测有助于胰腺癌的诊断,并可作为鉴别胰腺癌和慢性胰腺炎的一个重要参考指标;同时MUC4的检测还有助于判断手术病人的预后。     

Hypercoagulable states

A prethrombotic or hypercoagulable state is one in which the hemostatic balance is disturbed, with increasing procoagulant activity or decreasing activity of intrinsic anticoagulant properties. A basic problem in the study of hypercoagulable states is that it cannot be determined with certainty whether changes in hemostatic variables are causative or consequences of thromboses that have already occurred. This chapter discusses the ways in which various physiologic and pathologic states may be associated with alterations in hemostatic systems and, by weighting the balance in favor of readier coagulability, may predispose to thrombosis. Physiologic conditions discussed include stress, cold, pregnancy, oral contraceptives (OCs), aging, and smoking. It is noted that major alterations in blood coagulability, rheology, and flow during pregnancy combine to increase the risk of thrombosis, especially venous. The risk that venous thromboembolism will occur is increased 10-fold in OC users. The increased risk may be related to alterations in hemostatic variables that occur gradually over the 1st year of use, with no further subsequent increase. At present, no individual laboratory test is capable of identifying patients at risk of thrombosis, but a number of variables in combination (e.g., obesity, age, presence of varocose veins, euglobulin lysis time, level of fibrinogen degradation products) may provide a useful indication. In the absence of reliable predictive indicators, assessment and management efforts should be directed in 3 ways. 1st, simple tests should be undertaken in all individuals in whom thromboembolism has occurred to diagnose treatable predisposing factors. 2nd, efforts should be directed toward refining a safe, effective prophylactic regimen. 3rd, a few selected patients (e.g., those who have their 1st thrombotic episode before age 30 years) should be investigated in greater detail.     

Primary axillary-subclavian venous thrombosis: is aggressive surgical intervention justified?

Multimodal (thrombolysis, surgical decompression, venous reconstruction, oral anticoagulation) treatment of primary axillary-subclavian venous thrombosis was reviewed to assess the impact of venous patency on functional outcome. Since 1996, 7 patients (6 men, 1 woman) of ages 16-53 years (mean 33 years) presented with symptomatic acute axillosubclavian venous thrombosis as a result of a recent athletic or strenuous arm activity. Five patients had undergone previous (>2 weeks) catheter-directed thrombolysis and venous angioplasty. Diagnostic contrast venography followed by repeat catheter-directed thrombolysis demonstrated abnormal (residual stenosis [n=6] or occlusion [n=1]) axillosubclavian venous segments in all patients. Surgical intervention was performed at a mean interval of 7 days (range 1-19 days) after thrombolysis and consisted of thoracic outlet decompression with scalenectomy and 1st rib resection via a paraclavicular (n=4) or supraclavicular (n=3) approach. Medial claviculectomy or cervical rib resection was performed in 2 patients. Concomitant venous surgery was performed in all patients to restore normal venous patency by circumferential venolysis (n=7) and balloon catheter thrombectomy (n=3), or vein-patch angioplasty (n=2), or endovenectomy (n=5), or internal jugular transposition (n=2). Postoperative venous duplex testing beyond 1 month identified recurrent thrombosis in 4 patients despite therapeutic oral anticoagulation. Subsequent venous recanalization was documented in 3 patients. Poor functional outcome was associated with an occluded venous repair and extensive venous thrombosis on initial presentation. A patent or recanalized venous repair present in 6 of 7 patients was associated with good functional outcome and may justify multimodal intervention in patients with primary axillosubclavian effort thrombosis presenting with recurrent thrombosis and significant residual disease after thrombolysis.     

Chronic pancreatitis

Chronic pancreatitis (CP) is a progressive, disabling, fibro-inflammatory disease of the pancreas of variable clinical course and is usually associated with permanent loss of exocrine and endocrine function over a period of time. The incidence is increasing. There are various aetiological risk factors that cause CP, chronic alcoholism being the most common risk factor. The TIGAR-O classification identifies all the risk factors and aetiology. Most susceptible patients have a sentinel acute pancreatitis event which initiates chronic progressive inflammation, scarring and fibrosis, though some may present insidiously with symptoms of functional loss – diabetes or steatorrhoea. Intractable abdominal pain, steatorrhoea, weight loss and (type 3c) diabetes mellitus are late manifestations of the disease. Diagnosis is made with a combination of clinical history, examination, cross sectional imaging combined with pancreatic function tests (in equivocal cases). Complications include gastric and biliary obstruction, pseudocyst formation, pancreatic ascites, pseudoaneurysms and venous thrombosis. Patients with CP have increased risk of developing pancreatic adenocarcinoma. Management includes making the diagnosis, identifying the aetiology, instituting life-style changes to abstain from alcohol and smoking, and involving the specialist multidisciplinary team (including pain team, dietician, clinical psychologist, endoscopist, gastrointestinal physician and pancreatic surgeon) if initial steps do not control the symptoms.     

Epidemiologie der ven?sen Thromboembolie

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are still a common cause of mortality and morbidity. A large proportion of venous thromboembolisms (VTE) occur spontaneously but many would be preventable by implementation of standard prophylactic measures especially in high risk patients. Venous thrombosis occurs at an annual incidence of about 1 per 1,000 adults but this increases with age. About two thirds of thromboembolic episodes manifest as DVT and one third as PE. Thrombosis impairs the quality of life, especially in patients with postthrombotic syndrome and VTE sharply increases mortality. Mortality rates are highest in cancer patients. Tumors activate coagulation and the tumor itself might compress veins and therefore induce venous stasis. In addition immobilization with hospitalization, surgery and chemotherapy increase the risks. Several studies have shown incidences of thromboembolisms of more than 12 per 1,000 even in the first 6 months after cancer has been diagnosed. There are differences in incidences of diagnosed venous thrombosis among ethnic groups with blacks having the highest rates, followed by whites and then Hispanics and Asians. The major risk factors for thromboembolism include endogenous patient characteristics, such as obesity and genetic factors and triggering factors such as surgery, immobility or pregnancy. Obesity as a risk factor is nowadays a worldwide problem and the incidence has more than doubled in many countries with an estimated prevalence as high as 30% in many geographical areas. Patients who experience venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) are more than twice as likely to die within the next 8 years than similar individuals without venous thrombosis or pulmonary embolism.     

Chronic pancreatitis

Chronic pancreatitis (CP) is a complex progressive fibro-inflammatory disease of the pancreas with a variable clinical course often progressing to a permanent loss of exocrine and endocrine function. Over the last 20 years the incidence has continued to increase. CP has multifactorial aetiological risk factors with chronic alcoholism being the most common. The updated TIGAR-O_V2 classification identifies the pertinent risk factors and aetiology. The most susceptible patients to develop CP have a sentinel acute pancreatitis event which initiates the chronic progressive inflammation, scarring and fibrosis of the pancreas. Symptomatically CP presents as intractable abdominal pain, with weight loss and functional loss (steatorrhoea and type 3c diabetes mellitus) being late manifestations of the disease. Diagnosis is made by a combination of clinical history, examination and cross sectional imaging, combined with pancreatic function tests (only in equivocal cases). Complications include gastric and biliary obstruction, pseudocyst formation, pancreatic ascites, pseudoaneurysms, venous thrombosis and an increased risk of developing pancreatic adenocarcinoma. Management includes: diagnosis and identifying the aetiology, instituting life-style changes to abstain from alcohol and smoking, and involving the specialist multidisciplinary team (including pain team, dietician, clinical psychologist, endoscopist, GI physician and pancreatic surgeon) in patients with on-going symptoms or when there is doubt in the diagnosis.     

Fungal pseudotumor masquerading as pancreatic cancer—A sequela of new technology?

Fungal infection resulting in chronic pancreatitis is rare. We report a case of chronic pancreatitis due to fungal infection causing common bile duct obstruction and abdominal pain mimicking pancreatic cancer. Treatment included resection to cure the pain and rule out malignancy. Long-term effects of fungal infection may be seen more frequently as total parenteral nutrition, antibiotics, and foreign bodies (e.g., stents, drains, central venous catheters) are more often being used in the treatment of many diseases.     

Risk factors for mortality in patients with upper extremity and internal jugular deep venous thrombosis

OBJECTIVE: To elucidate the natural history of upper extremity deep venous thrombosis (UEDVT), we examined factors that may contribute to the high mortality associated with UEDVT. METHODS: Five hundred forty-six patients were diagnosed with acute internal jugular/subclavian/axillary deep venous thrombosis from January 1992 to June 2003 by duplex scanning at our institution. There were 329 women (60%). The mean age +/- SD was 68 +/- 17 years (range, 1-101 years). Risk factors for UEDVT were the presence of a central venous catheter or pacemaker in 327 patients (60%) and a history of malignancy in 119 patients (22%). Risk factors for mortality within 2 months of the diagnosis of UEDVT that were analyzed included age, sex, presence of a central venous catheter or pacemaker, history of malignancy, location of UEDVT, concomitant lower extremity deep venous thrombosis, systemic anticoagulation, placement of a superior vena caval filter, and pulmonary embolism. RESULTS: The overall mortality rate at 2 months was 29.6%. The number of patients diagnosed with pulmonary embolism by positive ventilation/perfusion scan or computed tomographic scan was 26 (5%). The presence of a central venous catheter or pacemaker ( P < .001), concomitant lower extremity deep venous thrombosis ( P = .04), not undergoing systemic anticoagulation ( P = .002), and the placement of a superior vena caval filter ( P = .02) were associated with mortality within 2 months of the diagnosis of UEDVT by univariate analysis. Pulmonary embolism ( P = .42), sex ( P = .65), and a history of malignancy ( P = .96) were not. CONCLUSIONS: These data suggest that the high associated mortality of UEDVT may be due to the underlying characteristics of the patients' disease process and may not be a direct consequence of the UEDVT itself.     

胰十二指肠切除术治疗远端胆管癌和胰头癌的临床效果分析

目的比较胰十二指肠切除术治疗远端胆管癌和胰头癌的临床效果。方法回顾性分析2016年1月至2020年12月于南京医科大学第一附属医院胰腺中心行胰十二指肠切除术且术后病理学检查结果为远端胆管癌或胰头癌的1 005例患者的临床和病理学资料。其中远端胆管癌组112例, 男性71例, 女性 41例, 年龄为[M(IQR)]65(15)岁(范围:40～87岁);胰头癌组893例, 男性534例, 女性359例, 年龄为64(13)岁(范围:16～91岁)。通过χ2检验、Fisher确切概率法、秩和检验或Log-rank检验分析两组患者临床病理学特征和术后生存时间之间的差异。采用倾向性评分匹配的方法, 按1∶1匹配后, 通过Kaplan-Meier法比较两组患者术后总体生存时间的差异。结果与胰头癌组相比, 远端胆管癌组手术时间短[240.0(134.0)min比261.0(97.0)min;Z=2.712, P=0.007], 联合静脉切除比例低[4.5%(5/112)比19.4%(173/893);χ2=15.177, P<0.01], 肿瘤最大径小[2.0(1.0)cm比3.0(1.5)c...     

Incidence of benign inflammatory disease in patients undergoing Whipple procedure for clinically suspected carcinoma: a single-institution experience

Background

We evaluated the incidence of chronic pancreatitis and chronic bile duct inflammation in patients undergoing pancreaticoduodenectomy (PD) for suspected periampullary cancer.

Methods

Differences between clinical presentation, surgical management, and outcomes were compared between patients with malignancy and benign inflammatory disease.

Results

The incidence of chronic inflammatory disease was 12.9% (21/162). Patients with chronic inflammatory disease were associated with a higher incidence of smoking (75.0% versus 64.7%) and chronic alcohol use (66.7% versus 46.2%). Jaundice was significantly more frequent in patients with malignant disease (83.6% versus 42.9%, P < .05). Surgery for chronic inflammatory disease was associated with significantly more intraoperative bleeding (P < .05).

Conclusions

The finding of chronic inflammatory disease after PD for suspected carcinoma is justifiable because (1) none of the available diagnostic modalities are infallible, (2) early treatment of pancreatic cancer is crucial for achieving cure, and (3) PD may relieve clinical symptoms in patients with chronic pancreatitis or pancreatic cancer.     

Factors predictive of venous thrombotic complications in patients with isolated superficial vein thrombosis

OBJECTIVE: Superficial vein thrombosis may be complicated with venous thromboembolism. We examined factors predictive of venous thromboembolism in superficial vein thrombosis, which, to our knowledge, had not been prospectively studied before. DESIGN AND METHODS: We performed post hoc analysis of the STENOX trial, a prospective randomized controlled trial that investigated various antithrombotic therapies in 427 hospitalized patients with objectively confirmed symptomatic isolated superficial vein thrombosis. The value of various baseline characteristics as predictive factors of venous thrombotic complications at 3 months was studied with logistic regression. Venous thrombotic complications were defined as deep vein thrombosis or pulmonary embolism, or recurrence or proximal extension of superficial vein thrombosis. RESULTS: Venous thrombotic complications occurred in 78 patients. Independent predictive factors for complications were superficial vein thrombosis of recent onset (odds ratio [OR], 3.01; 95% confidence interval [CI], 1.44-6.27), severe chronic venous insufficiency (OR, 2.75; CI, 1.10-6.89), male gender (OR, 2.17; CI, 1.28-3.68), and history of venous thromboembolism (OR, 2.07; CI 1.06-4.04). Deep vein thrombosis or pulmonary embolism occurred in 19 patients. Only severe chronic venous insufficiency was an independent predictor of this complication (OR, 4.50; CI, 1.30-15.61). CONCLUSIONS: After symptomatic isolated superficial vein thrombosis, venous thrombotic complications are relatively frequent, and are more likely to occur in men, in patients with a history of venous thromboembolism or with severe chronic venous insufficiency, or in whom superficial vein thrombosis is recent. Knowledge of such predictive factors may be useful for determining appropriate treatment in patients with superficial vein thrombosis and for designing future phase III clinical trials.     

vascular endothelial growth factor and DPC4 predict adjuvant therapy outcomes in resected pancreatic cancer

Angiogenesis is important for pancreatic cancer progression, but its role in predicting response to therapy is not known. We investigated the association of various angiogenic factors and intratumoral microvessel density (IMD) with adjuvant therapy and survival in resected pancreatic cancer. Tissue cores from a multi-institutional retrospective series of resected patients were used to build a pancreatic cancer tissue microarray. Vascular endothelial growth factor (VEGF), platelet-derived endothelial cell growth factor (PD-ECGF), CD31 (for IMD), and DPC4 expression were determined using immunohistochemistry. Expression of VEGF and PD-ECGF, both proangiogenic factors, was observed in 70 (56%) and 75 (59%) of 124 tumors, respectively. Expression of DPC4, an angiogenesis inhibitor, was observed in 59 of 124 (48%) tumors. VEGF expression correlated significantly with increased IMD (P = .03), as did loss of antiangiogenic DPC4 (P =.05). PD-ECGF expression did not correlate with IMD. Use of adjuvant therapy was associated with increased survival in patients with VEGF-positive tumors (18.8 [treated] versus 11.2 [untreated] months; hazard ratio [HR] = 0.38, 95% confidence interval [CI], 0.19-0.76; P = .005), but not in patients with VEGF-negative tumors. Similarly, improved survival was observed in patients with high IMD (16.3 [treated] versus 11.2 [untreated] months; HR = 0.44, 95% CI, 0.23-0.87; P = .02) and in patients with loss of DPC4 (20.3 [treated] versus 11.2 [untreated] months; HR = 0.31, 95% CI, 0.14-0.67; P = .002), but not in those with low IMD or normal DPC4 expression. VEGF (stimulator) and DPC4 (inhibitor) are important regulators of pancreatic tumor angiogenesis and predictive of benefit from adjuvant therapy. Adjuvant therapy may have both antiangiogenic and cytotoxic effects. Addition of anti-VEGF agents to adjuvant regimens may further improve outcomes. Presented at the Fifth Biennial Meeting of the American Hepato-Pancreato-Biliary Association, Fort Lauderdale, Florida, April 14–17, 2005. Dr. Khorana is supported by the James P. Wilmot Cancer Research Fellowship.     

Portal vein thrombosis after splenectomy in pediatric hematologic disease: risk factors, clinical features, and outcome

Background/Purpose

A retrospective study was performed to evaluate risk factors, clinical features, and treatment modalities of portal vein thrombosis (PVT) after splenectomy in pediatric hematologic disease.

Methods

Sixty-eight patients who underwent splenectomy for various hematologic diseases were evaluated with regard to age, sex, blood count, and splenic mass. Patients who developed PVT were also reviewed for clinical features, treatment modalities, and outcome.

Results

Patients with PVT (n = 4, 5.88%) and without PVT (n = 64, 94.2%) had a mean age and female/male ratio of 13.2 years (range, 10-16 years) and 4:0, and 10.2 years (range, 1-16 years) and 29:35, respectively. Postoperative thrombocyte levels and splenic mass with and without PVT was 804 × 10³/mm³ and 752.5 g, and 465.2 × 10³/mm³ and 441g, respectively. Three patients with PVT presented with abdominal pain, fever, and vomiting. The diagnosis of PVT was made by Doppler ultrasonography in all patients including the asymptomatic case. Protein C, protein S, and antithrombin III levels were mostly decreased and/or normal and di-dimer levels were increased and/or normal after the development of PVT. Antiplatelet (acetylsalicylic acid) and antithrombotic therapy (low molecular weight heparin) were treatment agents. None of the patients needed surgery. During a mean follow-up period of 55.5 months, by Doppler ultrasonography, 1 patient was found to be free of thrombosis, whereas 1 had partial thrombosis. Two patients developed cavernomatous transformation leading to portal hypertension.

Conclusions

Portal vein thrombosis is a rare but significant complication of splenectomy done for hematologic diseases. According to our results, female gender and decreased levels of coagulation inhibitors seem to be risk factors in addition to previously mentioned thrombocytosis and greater splenic mass. Doppler ultrasonography may be performed in all patients after splenectomy to screen PVT. In the presence of well-known risk factors, prophylactic antiplatelet and antithrombotic therapy should be considered after splenectomy.     

Novel aspects in regulated expression of the renal type IIa Na/Pi-cotransporter

Proximal tubular phosphate (P(i)) reabsorption is a key element in overall phosphate homeostasis; physiologic/pathophysiologic alterations are related to the control of brush border membrane expression (regulated endocytosis) of the type IIa sodium (Na)/phosphate(P(i))-cotransporter (NaPi-IIa). The carboxy terminus of NaPi-IIa contains sequences important for its apical delivery/expression; the last three amino acids are involved in PSD95/DglA/ZO-1 (PDZ) interactions involving NaPi-IIa, Na/H exchanger-regulatory factor 1 (NHERF1/2), and PDZK1/2 (apical scaffold). Regulated endocytosis of NaPi-IIa [e.g., parathyroid hormone (PTH)-induced] is reduced in megalin-deficient mice; internalization occurs via clathrin-coated structures, early endosomes, and finally leads to lysosomal degradation. NaPi-IIa contains, in the third intracellular loop, a sequence motif required for internalization. Different hormonal [e.g., PTH, atrial natriuretic peptide (ANP), also nitric oxide (NO)] and nonhormonal factors activate a variety of intracellular signaling cascades [protein kinase A (PK-A), protein kinase C (PK-C), protein kinase G (PK-G), extracellular receptor kinase (ERK)-1/2] leading (by unknown mechanisms) to NaPi-IIa internalization. Different phosphatonins [e.g., fibroblast growth factor (FGF)-23, frizzled related protein (FRP)-4, matrix extracellularphosphoglycoprotein (MEPE)], associated with different pathophysiologic states of renal P(i)-handling, seem also to control apical expression of NaPi-IIa. Internalization of NaPi-IIa first requires its removal from the apical scaffold. This scaffold can also be considered as a regulatory scaffold containing also protein kinase A (PK-A)-anchoring proteins (AKAPs, ezrin) and the apical PTH receptor. The role of the different components of the regulatory scaffold in regulated endocytosis of NaPi-IIa is at present unknown.     

Deep vein thrombosis and malignancy: a surgical oncologist's perspective

Oncology patients are at increased risk of developing deep vein thrombosis (DVT) and its potentially fatal sequel, pulmonary embolism. This is due to multiple factors, including the presence of the malignancy itself, comorbid factors and therapy-related interventions. Issues that are peculiar to venous thrombosis in the oncology setting are discussed, based on a MEDLINE search of the English literature. These include the need to screen for malignancy in idiopathic DVT, a high index of suspicion for venous thrombosis in the cancer patient, the use of vena cava filters, and the anti-neoplastic effects of heparin. Asian patients appear to have a lower incidence of DVT compared to Caucasians. A recommended regimen for prophylaxis of DVT must take into account the varying thrombosis risk associated with different malignancies. Cancer patients not undergoing abdominal, pelvic or orthopaedic surgery (e.g. mastectomy) should use elastic compression stockings and be mobilized early, whereas low-molecular-weight heparin should be given to those undergoing more major surgery. In advanced malignancy, treatment of DVT palliates symptoms. These patients may need long-term anticoagulation with warfarin.     

Ancrod: a practical alternative to heparin

To rapidly start systemic anticoagulation there are few alternatives to heparin; those that may be used are often less effective and are impractical substitutes for various reasons. We report the cases of seven patients in whom anticoagulant therapy was begun with ancrod instead of heparin for one or more of the following reasons: (1) failure to achieve systemic anticoagulation in response to heparin (e.g., antithrombin III deficiency), (2) heparin-associated complications (e.g., thrombocytopenia, thrombosis, or both), and (3) combined anticoagulation and improved blood rheology considered to be potentially more beneficial than anticoagulation alone (e.g., massive thrombosis). In the cases reported, ancrod permitted systemic anticoagulation equal to that of heparin; this was achieved without bleeding complications. In contrast to streptokinase or urokinase, ancrod does not degrade preformed, fully cross-linked thrombin fibrin; consequently hemorrhagic complications are uncommon. Ancrod appears to be an appropriate alternative to heparin and may be preferable to it in certain circumstances.     

急性胰腺炎外周循环和胰腺微循环血小板内皮细胞粘附分子-1的表达

目的　探讨急性胰腺炎 (AP)外周循环和胰腺微循环中血小板内皮细胞粘附分子 1(PECAM 1)表达的变化规律。方法　Wistar大鼠 48只 ,诱发AP动物模型 ,用流式细胞仪分析脾静脉和下腔静脉血中多形核白细胞 (PMN )PECAM 1的表达。结果　 ( 1)在急性水肿性胰腺炎(AEP)动物模型中 ,外周循环和胰腺微循环PMNPECAM 1的表达水平在AEP 2、4h组相近 ,自 4h开始 ,外周循环PMNPECAM 1的表达上调直至 8h ;胰腺微循环PMNPECAM 1的表达下调直至 8h ,在AEP 8h组 ,差异有显著性 ( P <0 .0 5 )。 ( 2 )在急性坏死性胰腺炎 (ANP)模型中 ,胰腺微循环PMNPECAM 1的表达下调 ;外周循环组PMNPECAM 1的表达未见明显变化 ,在ANP 4、6h组 ,差异有显著性 (P <0 .0 5 )。结论　AEP胰腺微循环和外周循环PMNPECAM 1的表达呈逆向性 ,在胰腺微循环呈下调趋势 ,在外周循环呈上调趋势 ;ANP胰腺微循环PMNPECAM 1的表达呈加速性下调 ,该结果显示 ,在ANP早期 ,抑制PMNPECAM 1的过度表达可能有助于改善AP病理改变。     

Update moderne Kompressionstherapie

Compression therapy can be conducted with various medical bandages or stocking systems and is a basic procedure in phlebologic and lymphologic therapy. Compression can be carried out as alone or as a combined treatment with interventional or surgical therapy. There is good evidence for the efficacy of compression in advanced chronic venous insufficiency of CEAP (clinical condition, etiology, anatomic location and pathophysiology) grades C4-C6, in the therapy of deep venous thrombosis, post-thrombotic syndrome and lymphedema. Despite a poor level of evidence compression is recommended by the current guidelines for initial chronic venous insufficiency of CEAP grades C1-C3, superficial venous thrombosis and lipedema. In recent years the side effects and compliance with compression treatment in particular have come into the focus of scientific interest.. A differentiated consideration of the characteristics and possibilities of modern compression devices (e.g. pressure, stiffness, type of weave) allows a more individual treatment.