Diurnal changes of lower leg volume in obese and non-obese subjects.

BACKGROUND/AIM: Obesity is a risk factor for chronic venous disease. However, the mechanisms behind this association are poorly understood. We tested the hypothesis that obese subjects have a higher diurnal leg volume increase compared with non-obese subjects. METHODS: In this prospective cohort study including obese (body mass index, BMI ≥30 kg m(-)(2)) and non-obese (BMI ≤25 kg m(-)(2)) subjects without venous insufficiency, lower leg volume was assessed by optoelectronic volumetry in the morning and in the evening. All subjects underwent duplex ultrasound and light reflection rheography (venous pump power and venous refill time, VRT) to investigate lower extremity venous function. A pedometer was carried between the morning and evening visit to assess the daily number of footsteps. A backward multivariable linear regression model was used to determine factors associated with diurnal lower leg volume increase. RESULTS: Forty-two limbs in 24 obese subjects and 29 limbs in 15 non-obese subjects were analyzed. Obese subjects had larger common femoral vein diameters (17.1±2.4 vs 15.5±2.4 mm, P<0.01) and slower peak, mean and minimal velocities (25.1±10.6 vs 44.3±14.3 cm s(-1); 6.8±2.4 vs 12.7±5.6 cm s(-1); -0.2±6.4 vs -6.3±11.9 cm s(-1); P<0.01 for all) than non-obese subjects. VRT was shorter in obese subjects (40.5±15.0 vs 51.0±12.1 s, P<0.01) and decreased significantly in the course of the day only in obese subjects (P<0.01). Obesity, male gender, CEAP (Clinical-Etiology-Anatomy-Pathophysiology) class, total time between the two visits and difference between morning and evening VRT were positively associated with higher lower leg volume increase; morning VRT and the total number of footsteps showed a negative association (P<0.04 for all). CONCLUSION: Obesity was found to be an independent predictor of higher diurnal leg volume increase. One potential mechanism is a progressive failure of venous valve function in the course of the day in obese subjects.

Case report: Isolated dissection of the left gastric artery: an unusual cause of acute abdominal pain.

Spontaneous and isolated dissection of the left gastric artery is a rare occurrence, with only a handful of cases reported in the medical literature. Clinical presentation may mimic more common intra-abdominal pathologies; however, it is imperative to identify this condition promptly due to its potential serious consequences. This underscores the importance of maintaining a high level of clinical suspicion and including this pathology in the differential diagnosis of patients presenting with acute abdominal symptoms. Hence, this case report aims to increase awareness among clinicians about the importance of identifying and treating this rare condition promptly. A 69-year-old female experienced severe epigastric pain while attending a yoga class, prompting her admission to the emergency department 24 h later due to the persistence of her symptoms. Following imaging work-up utilizing computed tomography angiography (CTA), she was diagnosed with a dissection of the left gastric artery. Notably, there was no associated aneurysm or any evidence of ischemia in the esophageal or gastric wall. Conservative management, including low-dose aspirin and blood pressure control, was implemented. After 6 months of follow-up, CTA demonstrated expansion of the true lumen and the absence of secondary aneurysm formation, leading to discontinuation of aspirin. The management of spontaneous dissection of visceral arteries is primarily determined by the presence of complications and organ ischemia. In the case of uncomplicated visceral artery dissections, first-line treatment comprises surveillance and antiaggregation. Nevertheless, the optimal duration of antiplatelet therapy and the necessity for long-term follow-up remain unclear. Endovascular or surgical interventions should be reserved for patients exhibiting deteriorating symptoms or complications, and the decision to pursue these interventions should be made on a case-by-case basis.

Enhanced diastolic reflections on arterial pressure pulse during exercise recovery.

During recovery from a maximal or submaximal aerobic exercise, augmentation of central (aortic) systolic pressure by reflected pressure waves is blunted in healthy humans. However, the extent to which reflected pressure waves modify the central pulse in diastole in these conditions remains unknown. We evaluated systolic and diastolic central reflected waves in 11 endurance-trained athletes on recovery from a maximal running test on a treadmill (treadmill-max) and a 4000 m run in field conditions. On both occasions in each subject, the radial pulse was recorded with applanation tonometry in the resting preexercise state and then 5, 15, 25, 35, and 45 min after exercise termination. From the central waveform, as reconstructed by application of a generalized transfer function, we computed a systolic (AIx) and a diastolic index (AId) of pressure augmentation by reflections. At 5 min, both indices were below preexercise. At further time-points, AIx remained low, while AId progressively increased, to overshoot above preexercise at 45 min. The same behavior was observed with both exercise types. Beyond the first few minutes of recovery following either maximal or submaximal aerobic exercise, reflected waves selectively augment the central pressure pulse in diastole, at least in endurance-trained athletes.

Electronic alert system for improving appropriate thromboprophylaxis in hospitalized medical patients: a randomized controlled trial.

Essentials Venous thromboembolism (VTE) prophylaxis in hospitalized medical patients remains inconsistent. We implemented an electronic alert system featuring a validated risk assessment model for VTE. In this randomized controlled study, the e-alert system did not improve VTE prophylaxis. Many electronic alerts were ignored by ordering physicians. SUMMARY: Background The use of thromboprophylaxis among acutely ill hospitalized medical patients remains inconsistent. Objective To improve thromboprophylaxis use by implementing a computer-based alert system combined with a Geneva Risk Score calculation tool in the electronic patient chart and order entry system. Patients/Methods Consecutive patients admitted to the general internal medicine wards of the University Hospital Bern, Switzerland were randomized to the alert group, in which an alert and the Geneva Risk Score calculation tool was issued in the electronic patient chart, or to the control group, in which no alert was issued. The primary endpoint was the rate of appropriate thromboprophylaxis during hospital stay. Results Overall, 1593 patients (alert group, 804; control group, 789) were eligible for analysis. The median age was 67 years (interquartile range, 53-79 years) and 47% were female. Appropriate thromboprophylaxis was administered to 536 (66.7%) patients from the alert group and to 526 (66.7%) patients from the control group. Among the 804 patients from the alert group, a total of 446 (55.5%) either had no score calculation by the physician in charge (n = 348) or had a calculated score result that was inconsistent with information from the patient chart (n = 98). Appropriate thromboprophylaxis was less often administered to patients with no score or an inconsistent score result than to 358 patients with a consistent score result (62.6% versus 71.8%). Conclusions The electronic alert (e-alert) system did not improve appropriate thromboprophylaxis, most likely because many e-alerts were ignored by ordering physicians. The use of appropriate thromboprophylaxis in the control group was higher than expected.

Ultrasound-assisted versus conventional catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis: 1-year follow-up data of a randomized-controlled trial.

Essentials Acute iliofemoral deep vein thrombosis can be treated with catheter-directed thrombolysis (CDT). We performed a randomized trial comparing conventional CDT versus ultrasound-assisted CDT (USAT). Clinical and duplex sonographic outcomes at 12 months were similar in the CDT and USAT groups. In both groups, incidence of postthrombotic syndrome was very low with good quality of life. SUMMARY: Background In patients with acute iliofemoral deep vein thrombosis (IFDVT), catheter-directed thrombolysis (CDT) aims to prevent the postthrombotic syndrome (PTS). Adding intravascular high-frequency, low-power ultrasound energy to CDT does not seem to improve the immediate thrombolysis results but its impact on clinical outcomes at 12 months is not known. Patients/Methods In this randomized-controlled trial, 48 patients (mean age 50 ± 21 years; 52% women) with acute IFDVT were randomized to conventional CDT (n = 24) or ultrasound-assisted CDT (USAT; n = 24). In both groups, a fixed-dose thrombolysis regimen (20 mg r-tPA over 15 h) was used, followed by routine stenting of residual venous obstruction. At 12 months, PTS and venous disease severity (Villalta score and revised Venous Clinical Severity Score [rVCSS]), disease-specific quality of live (QOL; CIVIQ-20) and duplex-sonographic outcomes were assessed. Results Among the 45 surviving patients, 40 (89%; 95% confidence interval [CI] 76-96%) patients were free from PTS (defined as Villalta score < 5 points; 83%, 95% CI 61-95% in the USAT and 96%, 95% CI 77-100% in the CDT group), with a similar mean total Villalta score of 2.3 ± 2.9 vs. 1.7 ± 1.6, and a mean total rVCSS of 3.0 ± 3.5 vs. 2.7 ± 2.9 in the USAT and the CDT groups, respectively. Both groups had good disease-specific QOL with a CIVIQ-20 score of 29.4 ± 11.8 vs. 26.1 ± 7.8, respectively. Primary (100% vs. 92%) and secondary (100% vs. 96%) iliofemoral patency rates and presence of femoro-popliteal venous reflux (39% vs. 33%) were similar in both groups. Conclusion The addition of intravascular ultrasound energy to conventional CDT for the treatment of acute IFDVT did not have any impact on relevant clinical or duplex sonographic outcomes, which were favorable in both study groups. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier:NCT01482273.