Recurrent venous thromboembolism in patients with and without anticoagulation after inferior vena caval filter placement.

AIM: The aim of this study was to compare the rate of recurrent venothromboembolic (VTE) events and factors contributing to VTE events in patients with inferior vena caval (IVC) filters on chronic anticoagulation to those in whom anticoagulation was discontinued. METHODS: Retrospective cohort study of 353 patients who received IVC filters between 1986 and 2002. RESULTS: Anticoagulation status was available for 304 patients (132 on coumadin anticoagulation therapy and 172 who did not receive any anticoagulation therapy) whose IVC filters were placed within 30 days of their qualifying thromboembolic event. Two-year event-free survival for the anticoagulated group was 80.6% (95% confidence interval--CI--76.9, 84.3] and was 67.8% (95% CI 63.2, 72.3) for the non-anticoagulated group. Patients who had Greenfield filter had a higher, but not statistically significant different, rate of recurrence compared to those with other types of filters (hazard ratio 1.4; 95% CI 0.9, 2). The rate of recurrent VTE events was independent of age, gender, smoking status, or underlying medical condition. CONCLUSIONS: Among those with IVC filters, long-term anticoagulation therapy prolonged event-free survival for up to 2 years but did not prevent recurrent VTE events.

Risk assessment model for venothromboembolism in post-hospitalized patients.

AIM: Venothromboembolism (VTE) is an important condition in hospitalized patients accounting for significant morbidity and mortality, and the risk of VTE often continues post-hospitalization. Although risk assessment models have been developed to predict the risk of deep venous thrombosis (DVT) in hospitalized patients, no models have been developed that determine the risk of DVT during the post-hospitalization period. The objective of this study was to create a risk profile using risk factor assessment that could be used to predict which patients are at highest risk of developing DVT within 60 days following hospital discharge. METHODS: The computerized medical records of 380 patients (190 with DVT and 190 without DVT) who received care from 1995-2002 and were subsequently re-hospitalized within 60 days of discharge were retrospectively reviewed. Univariate and multivariate logistic regression analyses were conducted to identify risk variables related to VTE. A novel risk assessment model was created using risk factors from the logistic regression analyses. RESULTS: The prevalence of VTE was found to be 93.2% (69/74) in the high-risk category, 52.9% (109/206) in the moderate-risk category, and 12% (12/100) in the low-risk category. CONCLUSIONS: Once validated, this risk assessment model may be applied to identify patients who may be at increased risk of developing VTE post-hospitalization. Those at high risk should be considered for anticoagulation therapy during the post-hospitalization period. Availability of a risk profile using risk factor assessment to guide decisions related to anticoagulation therapy will have important ramifications relative to patient outcomes including morbidity, mortality, and reductions in VTE-associated cost.

Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy.

OBJECTIVE: To determine the clinical spectrum of immunosuppressive conditions and systemic corticosteroid therapy associated with the development of Pneumocystis carinii pneumonia in a consecutive series of patients without acquired immunodeficiency syndrome (AIDS). DESIGN: We retrospectively analyzed a consecutive series of 116 patients without AIDS who were assessed at Mayo Medical Center for a first episode of P. carinii pneumonia between 1985 and 1991. METHODS: Medical records were examined to determine underlying immunosuppressive disorders, premorbid corticosteroid dosage and duration of therapy, associated infections, and subsequent respiratory failure and in-hospital mortality. RESULTS: Conditions associated with a first episode of P. carinii pneumonia were hematologic malignant disorders (30.2%), organ transplantation (25.0%), inflammatory disorders (22.4%), solid tumors (12.9%), and miscellaneous conditions (9.5%). Regardless of the associated underlying disease, corticosteroids had been administered systemically in 105 patients (90.5%) within 1 month before the diagnosis of P. carinii pneumonia. The median daily corticosteroid dose was equivalent to 30 mg of prednisone; however, 25% of patients had received as little as 16 mg of prednisone daily. The median duration of corticosteroid therapy was 12 weeks before the development of pneumonia; however, P. carinii pneumonia developed after 8 weeks or less of corticosteroid therapy in 25% of these patients. Respiratory failure occurred in 43%, and in-hospital mortality was 34% for patients with P. carinii pneumonia in conditions other than AIDS. CONCLUSION: Although these results do not suggest that premorbid administration of corticosteroids is the only factor that contributes to the development of P. carinii pneumonia in these patients, they show that, in this large consecutive series, systemic corticosteroid therapy, even in moderate doses, was administered to most patients during the month preceding the onset of P. carinii pneumonia. Consideration should be given to instituting P. carinii prophylaxis (when not contra-indicated) in patients for whom prolonged systemic corticosteroid therapy is prescribed.

Unusual aspects of acute Q fever-associated hepatitis.

We describe a 37-year-old farmer with a 3-week history of fevers and hepatitis, in whom Q fever was diagnosed. The diagnosis was based on the findings of characteristic "ring" granulomas on a bone marrow biopsy specimen and confirmed by complement-fixation antibody tests to Coxiella burnetii. Unusual aspects of this case included (1) relatively low complement-fixation antibody titers, (2) prolonged prothrombin time, (3) false-positive results of a serologic test for the human immunodeficiency virus (HIV), and (4) ring granulomas that progressed to atypical granulomas in biopsy specimens.

Bronchiolitis obliterans organizing pneumonia caused by Plasmodium vivax malaria.

A 64-year-old woman developed a relapse of Plasmodium vivax malaria followed by a rapidly progressive diffuse patchy pulmonary process. Open lung biopsy specimen showed bronchiolitis obliterans organizing pneumonia (BOOP). After corticosteroid therapy was initiated, there was both clinical and radiographic improvement. This is believed to be the first reported association of BOOP with malaria.

Preventive control of AIDS by the dental profession: a survey of practices in a large urban area.

The purpose of this study was threefold: (1) to report the proportion of dental practitioners adhering to the 1987 Centers for Disease Control (CDC) procedures for using infection control techniques (ICTs); (2) to identify attitudes toward infection control and disease; and (3) to establish whether certain practitioner characteristics or use of certain ICTs were related to willingness to treat HIV-positive patients, willingness to volunteer for an HIV specialty clinic outside of regular practice, vaccination against hepatitis B, and a felt need for a specialty clinic within the practice to treat HIV patients effectively. A survey of approximately 3,800 members of a major metropolitan dental society found that 89 percent of respondents regularly used at least one CDC ICT beyond routine medical histories. Ninety-one percent indicated a moderate to extreme change in attitude toward the risks of infectious diseases and the regular use of ICTs (80.2% identified AIDS as the major factor in this change). Twenty-seven percent indicated that they would knowingly treat HIV-positive patients. No differences were found among practitioners willing to treat HIV-infected patients and those unwilling to treat these patients in terms of adherence to the CDC ICT recommendations for dentists. Statistical association between ICT use and other practitioner response variables are discussed.

Acute chest syndrome in sickle cell disease. Crucial considerations in adolescents and adults.

Rapid recognition of acute chest syndrome is essential in patients with sickle cell disease. The condition can be particularly severe in adolescents and adults and often leads to death. In this article, the authors review the challenges of evaluating the syndrome and outline current treatment and supportive care.

Approach to diagnosing lower extremity edema.

Edema, a sign of a localized or systemic disease process, results from a disruption in the normal physiological forces controlling extracellular fluid volume. This review utilizes an anatomical approach in discussing the various causes of edema.

Comparative radiography of artificially created mandibular condyle defects.

This study was designed to evaluate the effectiveness of four radiographic techniques in demonstrating the TMJ. Mandibular condyles of a variety of sizes, as well as horizontal and vertical angulation, were selected. The location and size of the defects also varied. The mandibular condyles, in which 12 defects were created, were divided into two groups of six large and six small each. On examination of the condyles with the different defects, using each of the four radiographic techniques, the defects were localized with silver amalgam and reexamined with the radiographic techniques. The visualization of the defects was compared using the radiographs.

Hemorrhagic pleural effusion and pleural thickening as a complication of chronic lymphocytic leukemia.

We report a case of pleural thickening and hemothorax in a 56-year-old male with B-cell chronic lymphocytic leukemia (CLL). The association of this entity with CLL has not been previously reported. Awareness of this occurrence is essential to appropriate therapy for similar patients with CLL.

Approach to the vaso-occlusive crisis in adults with sickle cell disease.

The vaso-occlusive crisis, or sickle cell crisis, is a common painful complication of sickle cell disease in adolescents and adults. Acute episodes of severe pain (crises) are the primary reason that these patients seek medical care in hospital emergency departments. Frequently, however, the pain is incompletely treated. Despite advances in pain management, physicians are often reluctant to give patients adequate dosages of narcotic analgesics because of concerns about addiction, tolerance and side effects. It is important to recognize a pain crisis early, correct the inciting causes, control pain, maintain euvolemia and, when necessary, administer adequate hemoglobin to decrease the hemoglobin S level. The family physician and the hematologist must work together to treat acute pain episodes promptly and effectively, manage the long-term sequelae of chronic pain and prevent future vaso-occlusive crises.