Long-term outcomes of cancer-related isolated distal deep vein thrombosis: the OPTIMEV study.

Essentials Clinical significance of cancer-related isolated distal deep vein thrombosis (iDDVT) is unknown. We studied patients with iDDVT, with and without cancer, and proximal DVT with cancer. Cancer-related iDDVT patients have a much poorer prognosis than iDDVT patients without cancer. Cancer-related iDDVT patients have a similar prognosis to cancer-related proximal DVT patients. SUMMARY: Background Isolated distal deep vein thrombosis (iDDVT) (infra-popliteal DVT without pulmonary embolism [PE]) is a frequent event and, in the absence of cancer, is usually considered to be a minor form of venous thromboembolism (VTE). However, the clinical significance of cancer-related iDDVT is unknown. Methods Using data from the observational, prospective multicenter OPTIMEV cohort, we compared, at 3 years, the incidences of death, VTE recurrence and major bleeding in patients with cancer-related iDDVT with those in cancer patients with isolated proximal DVT (matched 1:1 on age and sex) and patients with iDDVT without cancer (matched 1:2 on age and sex). Results As compared with patients with cancer-related isolated proximal DVT (n = 92), those with cancer-related iDDVT (n = 92) had a similar risk of death (40.8% per patient-year (PY) vs. 38.3% per PY; aHR = 1.0, 95% CI[0.7-1.4]) and of major bleeding (3.8% per PY vs. 3.6% per PY, aCHR = 0.9 [0.3-3.2]) and a higher risk of VTE recurrence (5.4% per PY vs. 11.5% per PY; aCHR = 1.8 [0.7-4.5]). As compared with patients with iDDVT without cancer (n = 184), those with cancer-related iDDVT had a nine times higher risk of death (3.5% per PY vs. 38.3% per PY; aHR = 9.3 [5.5-15.9]), a higher risk of major bleeding (1.8% per PY vs. 3.6% per PY; aCHR = 2.0 [0.6-6.1]) and a higher risk of VTE recurrence (5.0% per PY vs. 11.5% per PY; aCHR = 2.0 [1.0-3.7]). The results remained similar in the subgroup of patients without history of VTE. Conclusion Patients with cancer-related iDDVT seem to have a prognosis that is similar to that of patients with cancer-related isolated proximal DVT and a dramatically poorer prognosis than patients with iDDVT without cancer. This underlines the high clinical significance of cancer-related iDDVT and the need for additional studies.

Long-term risk of venous thromboembolism recurrence after isolated superficial vein thrombosis.

Essentials Long-term risk of recurrence of isolated superficial vein thrombosis (SVT) is under-studied. We analyzed data from a cohort of first SVT and proximal deep vein thrombosis (DVT) without cancer. The risk of recurrence as DVT or pulmonary embolism is twice lower in SVT patients. However, overall risk of recurrence is similar between SVT and proximal DVT patients. Click to hear Dr Decousus' perspective on superficial vein thrombosis SUMMARY: Background Isolated superficial vein thrombosis (iSVT) (without concomitant deep vein thrombosis [DVT] or pulmonary embolism [PE]) is a frequent event, but available data on long-term outcomes are scarce and retrospective. Therefore, we aimed to determine prospectively the risk and type of venous thromboembolism (VTE) recurrence after iSVT and compare them with those of proximal DVT. Methods Using data from the prospective, multicenter, observational, OPTIMEV study, we assessed, at 3 years and after anticoagulants were stopped, the incidence and the type of VTE recurrence (iSVT/DVT/PE) of patients with a first objectively confirmed iSVT without cancer (n = 285), and compared these with those of patients with a first proximal DVT without cancer (n = 262). Results As compared with proximal DVT patients, iSVT patients had a similar overall incidence of VTE recurrence (5.4% per patient-year [PY] versus 6.5% per PY, adjusted hazard ratio [aHR] 0.9, 95% confidence interval [CI] 0.5-1.6), but iSVT recurred six times more often as iSVT (2.7% versus 0.6%, aHR 5.9, 95% CI 1.3-27.1) and 2.5 times less often as deep-VTE events (2.5% versus 5.9%, aHR 0.4, 95% CI 0.2-0.9). Varicose vein status did not influence the risk or the type of VTE recurrence. Saphenian junction involvement by iSVT was not associated with a higher risk of recurrence (5.2% per PY versus 5.4% per PY), but was associated with recurrence exclusively as deep-VTE events. Conclusion In patients with a first iSVT without cancer, after stopping anticoagulants, the incidence of deep-VTE recurrence is half that of DVT patients, but the overall risk of recurrence is similar. Ssaphenian junction involvement seems to influence the risk of deep-VTE recurrence, whereas varicose vein status has no impact or a low impact on VTE recurrence.

Low incidence of cancer after venous thromboembolism: An update from the French OPTIMEV Cohort.

BACKGROUND: Recent studies have shown lower rates of cancer following venous thromboembolism (VTE) than previously described. OBJECTIVES: To reassess the risk of cancer in patients with clinical symptoms of VTE with or without confirmed VTE. PATIENTS: We used data from OPTIMEV, a French prospective multicenter observational study of patients presenting to hospital and community vascular medicine specialists with suspected VTE. Patients with confirmed VTE (1565) and matched controls without VTE (1847) were followed for 3 years (2006-2009). The main outcome was occurrence of cancer at 3 years, and death was a censoring event. RESULTS: A total of 5.0% [4.0-6.3] of patients with VTE and 3.8% [3.0-4.9] without VTE developed cancer during follow-up. The adjusted hazard ratio (HR) was 1.2 [0.9-1.8] for patients with confirmed VTE (P=0.22). The overall standardized incidence ratio (SIR) was 1.4 [1.1-1.6] for our population, VTE+ and VTE-, compared with the general population, statistically significant (P<0.05). CONCLUSIONS: We found a lower occurrence of cancer after VTE than previously described, with no significant difference between patients whether VTE was confirmed or not. Our results (low incidence and no difference between patients VTE+ or VTE-) provide no argument in favor of an extensive screening for cancer in case of VTE.

Reduced mortality by meeting guideline criteria before using recombinant activated factor VII in severe trauma patients with massive bleeding.

BACKGROUND: Management of trauma patients with severe bleeding has led to criteria before considering use of recombinant activated factor VII (rFVIIa), including haemoglobin >8 g dl-1, serum fibrinogen ≥1.0 g l-1, platelets >50,000 x 109 l-1, arterial pH ≥ 7.20, and body temperature ≥34 °C. We hypothesized that meeting these criteria is associated with improved outcomes. METHODS: In this prospective cohort study of 26 French trauma centres, subjects were included if they received rFVIIa for persistent massive bleeding despite appropriate care after severe blunt and/or penetrating trauma. RESULTS: After surgery and/or embolization as haemostatic interventions, 112 subjects received a first dose of 103 µg kg-1 rFVIIa (82-200) (median, 25th-75th percentile) at 420 min (285-647) post-trauma. Of these, 71 (63%) "responders" were still alive at 24h post-trauma and had their transfusion requirements reduced by > 2 packed red blood cell units after rFVIIa treatment. Mortality was 54% on day 30 post-trauma. There were 21%, 44% and 35% subjects who fulfilled 0-1, 2-3 or 4-5, respectively, of the guidelines before receiving rFVIIa. Survival at day 30 was 13%, 49% and 64% and the proportion of responders was 39%, 64% and 82%, when subjects fulfilled 0-1, 2-3 or 4-5 conditions, respectively (both P <0.01). CONCLUSIONS: In actively bleeding trauma patients, meeting guideline criteria before considering rFVIIa was associated with lower mortality and a higher proportion of responders to the rFVIIa.

Increased CRP levels may be a trait marker of suicidal attempt.

Suicide is a leading cause of death worldwide. Identifying biomarkers will help enhance our understanding of suicidal pathophysiology and improve its prevention. Therefore, we investigated CRP levels in 600 depressed inpatients: 520 patients had a lifetime history of suicide attempts and 80 patients did not have any history of suicide attempts. For all patients, we assessed socio-demographic features, lifetime Axis I DSM-IV diagnoses, depression intensity, suicidal ideation, characteristics of suicidal history, and history of childhood trauma. The day following admission, fasting blood tests yielded samples collected for the measurement of high sensitivity hs-CRP. CRP levels were associated with a history of suicide attempts. The risk of suicide attempts increased with higher levels of CRP in a dose-response way before and after adjustments for age, gender, chronic diseases, addiction and anxiety comorbidities, antidepressants use, smoking status and sexual abuse. Noteworthy, the association between CRP levels and history of suicide attempts remained significant after having excluded patients with chronic diseases. There was no significant difference in CRP levels between patients who attempted suicide more or less than a week before plasma sampling, and no significant difference in CRP levels was evidenced between high vs low suicidal ideation. In conclusion, this is the first study suggesting that CRP may be a trait marker for suicidal vulnerability by associating CRP levels and a lifetime history of suicide attempts in depressed inpatients. Therefore, determining the inflammatory marker profile of individuals exhibiting suicidal behaviors could be relevant for anticipating behaviors and refining new therapeutic opportunities.

Sinus floor elevation with a crestal approach using a press-fit bone block: a case series.

This prospective study aimed to provide detailed clinical information on a sinus augmentation procedure, i.e., transcrestal sinus floor elevation with a bone block using the press-fit technique. A bone block is harvested with a trephine burr to obtain a cylinder. This block is inserted into the antrum via a crestal approach after creation of a circular crestal window. Thirty-three patients were treated with a fixed prosthesis supported by implants placed on 70 cylindrical bone blocks. The mean bone augmentation was 6.08±2.87 mm, ranging from 0 to 12.7 mm. Only one graft failed before implant placement. During surgery and the subsequent observation period, no complications were recorded, one implant was lost, and no infection or inflammation was observed. This proof-of-concept study suggests that the use of a bone block inserted into the sinus cavity via a crestal approach can be an alternative to the sinus lift procedure with the creation of a lateral window. It reduces the duration of surgery, cost of treatment, and overall discomfort.

Prone position affects stroke volume variation performance in predicting fluid responsiveness in neurosurgical patients.

BACKGROUND: Stroke volume variation (SVV) during mechanical ventilation predicts preload responsiveness. We hypothesized that the prone position would alter the performance of this dynamic indicator. METHODS: Two parallel groups of ventilated neurosurgical patients with low tidal volume (6-8 ml.kg-1) were studied before surgical incision. SVV was measured at T0, T15 and T30 min during a fluid volume expansion (250 mL hetastarch 6% over 30 min) with patients in either the supine (N.=29; Supine group) or prone position (N.=23; Prone group). Fluid responsiveness was defined as an increase in the stroke volume index (SVI) of ≥20% at T30. Receiver-operating characteristics (ROC) curves were generated for SVV. RESULTS: Prone positioning significantly increased SVV. Volume expansion in the Prone group increased SVI but led to a decline in SVV from 16% (12-22; median, 25-75th percentile) at T0 to 9% (8-13%) at T30. These effects on SVI and SVV were more pronounced compared to those obtained in the Supine group (P ≤0.05). Fluid responsiveness was predicted by SVV >12% at T0 (sensitivity 88%, specificity 62%) in the Supine group. In the Prone group, the area under the ROC curve of SVV (0.53; 95% confidence interval 0.27-0.79) did not allow the determination of a threshold SVV value. CONCLUSION: In ventilated patients with low tidal volume, a prone position may have a direct effect on the heart that alters the performance of SVV in predicting fluid responsiveness. External factor such as prone position renders difficult the interpretation of SVV as a dynamic indicator of cardiac preload.

Impact of anatomical location of lower limb venous thrombus on the risk of subsequent cancer.

After a proximal deep-vein thrombosis (P-DVT), the risk of diagnosis of a previously unsuspected cancer is high. Isolated distal DVT (iD-DVT; i.e. infra-popliteal DVT without pulmonary embolism [PE]) and isolated superficial-vein thrombosis (iSVT; i.e. without concomitant DVT and PE) are at least as frequent as P-DVT but their association with subsequent cancer is uncertain. We exploited data from the OPTIMEV prospective, observational, multicentre study to i) compare the risk of subsequent cancer three years after a first objectively confirmed iSVT, iD-DVT and iP-DVT in patients without a prior history of cancer or of venous thromboembolism, ii) assess predictors of subsequent cancer in cases of iD-DVT. The overall cumulative rates of cancer among the 304 patients with iSVT, 536 patients with iD-DVT, and 327 patients with iP-DVT were similar (3.4% 95% confidence interval [1.8-6.2], 3.9% [2.5-5.9] and 3.9% [2.3-6.8], respectively), regardless of whether the index venous thromboembolic event was unprovoked or associated with a major transient risk factor. Neither anatomical (muscular vs deep-calf DVT) nor ultrasound scan characteristics (number of thrombosed veins, clot diameter under compression) seemed strongly associated with the risk of cancer in cases of iD-DVT. In patients managed in routine practice, all the different clinical expressions of lower limb venous thromboembolism are associated with a similar risk of subsequent cancer. From a clinical practice point of view, this suggests that cancer screening, without discussing the necessity, or not, of such screening, should not differ between a deep-proximal, deep-distal or superficial location of thrombosis.

Increased severity of suicidal behavior in impulsive aggressive patients exposed to familial adversities.

BACKGROUND: The mechanisms by which childhood abuse and family history of suicidal behavior (FHS) lead to an increased risk of suicidal behavior are still unknown. Impulsive aggression may play an intermediate role. We investigated whether greater scores for aggression and impulsivity might be associated with the effects of FHS and/or childhood abuse on the severity of suicidal behavior. METHOD: We examined the scores of three scales measuring impulsive aggression in a sample of 696 suicide attempters. We compared the highest and lowest scores with regard to reports of childhood abuse and FHS using adjusted multinomial regression models. Genetic polymorphisms of the serotonergic system known to be associated with impulsive aggression were also analyzed. RESULTS: Patients with high impulsive aggressive scores showed significant differences in sociodemographic, clinical and suicidal features compared with patients with low impulsive aggressive scores. Adjusted results showed that combinations of some types of childhood abuse and FHS, particularly emotional abuse and emotional neglect, are associated with high impulsivity and hostility scores. The SS genotype of the serotonin transporter gene (5-HTTLPR) was associated with high levels of impulsivity when the subjects reported emotional abuse [odds ratio (OR) 5.55, 95% confidence interval (CI) 1.75-17.5] or physical abuse (OR 5.03, 95% CI 1.50-16.9) in their childhood. CONCLUSIONS: Our results support the role of impulsive aggression as one of the links that may connect childhood abuse and FHS with severity of suicidal behavior.

Crenobalneotherapy (spa therapy) in patients with knee and generalized osteoarthritis: a post-hoc subgroup analysis of a large multicentre randomized trial.

OBJECTIVE: To determine whether the addition of spa therapy to home exercises provides any benefit over exercises and the usual treatment alone in the management of generalised osteoarthritis associated with knee osteoarthritis. METHODS: This study was a post-hoc subgroup analysis of our randomised multicentre trial (www.clinicaltrial.gov: NCT00348777). Participants who met the inclusion criteria of generalized osteoarthritis (Kellgren, American College of Rheumatology, or Dougados criteria) were extracted from the original randomised controlled trial. They had been randomised using Zelen randomisation. The treatment group received 18days of spa treatment in addition to a home exercise programme. Main outcome was number of patients achieving minimal clinically important improvement at six months (MCII) (≥-19.9mm on the VAS pain scale and/or ≥-9.1 points in a WOMAC function subscale), and no knee surgery. Secondary outcomes included the "patient acceptable symptom state" (PASS) defined as VAS pain ≤32.3mm and/or WOMAC function subscale ≤31 points. RESULTS: From the original 462 participants, 214 patients could be categorized as having generalised osteoarthritis. At sixth month, 182 (88 in control and 94 in SA group) patients, were analysed for the main criteria. MCII was observed more often in the spa group (n=52/94 vs. 38/88, P=0.010). There was no difference for the PASS (n=19/88 vs. 26/94, P=0.343). CONCLUSIONS: This study indicates that spa therapy with home exercises may be superior to home exercise alone in the management of patients with GOA associated with knee OA.

Incidence and predictors of venous thromboembolism recurrence after a first isolated distal deep vein thrombosis.

BACKGROUND: Isolated distal deep vein thrombosis (iDDVT) (i.e. without proximal DVT or pulmonary embolism) represents half of all cases of lower limb DVT. Its clinical significance and management are controversial. Data on long-term follow-up are scarce, especially concerning risk and predictors of venous thromboembolism (VTE) recurrence. METHODS: Using data from the OPTIMEV (OPTimisation de l'Interrogatoire dans l'évaluation du risque throMbo-Embolique Veineux) study, a prospective, observational, multicenter study, we compared, 3 years after an index VTE event and after discontinuation of anticoagulants, (i) the incidence and type of recurrence in patients without cancer with a first iDDVT vs. a first isolated proximal DVT (iPDVT) and (ii) predictors of recurrence after iDDVT. RESULTS: Compared with patients with iPDVT (n = 259), patients with an iDDVT (n = 490) had a lower annualized incidence of overall VTE recurrence (5.2% [95% confidence interval 3.6-7.6] vs. 2.7% [1.9-3.8], respectively; P = 0.02) but a similar incidence of pulmonary embolism recurrence (1.0% [0.5-2.3] vs. 0.9% [0.5-1.6], respectively; P = 0.83). An age of > 50 years, unprovoked character of index iDDVT, and involvement of more than one vein in one or both legs each independently tripled the risk of recurrence, with the latter then being ≥ 3% per patient-year. Neither muscular vein nor deep-calf vein location of iDDVT nor clot diameter with compression influenced the risk of recurrence. CONCLUSIONS: After stopping anticoagulants, patients with iDDVT have a significantly lower risk of overall VTE recurrence than did patients with iPDVT but a similar risk of serious recurrent VTE. Age > 50 years, unprovoked iDDVT, and number of thrombosed veins (more than one) influenced the risk of recurrence and may help to define patients at significant risk of recurrence.

[Identification of patients at high risk of cancer after a venous thromboembolic disease]. / Identification des patients à haut risque de cancer au décours d'une maladie thromboembolique veineuse.

OBJECTIVE: Assessment of cancer screening in the context of venous thromboembolic disease (VTE) remains controversial. We tried to characterize a population at high risk of developing cancer among patients suffering from VTE. METHOD: We conducted a retrospective ancillary case-control study among patients with VTE who later had a positive diagnosis of cancer. We assessed the association of cancer with characteristic features of VTE and with the results for four biological markers. RESULTS: Our population included 142 patients (53% men, median age 71 years). Two years after VTE, 24 patients (17%) had cancer. Median values for D-dimers, fibrin monomers and SP-selectin were significantly higher among patients who developed cancer. Logistic regression enabled us to identify two parameters targeting patients with a high risk of cancer: bilateral venous thrombosis (OR: 4.41, 95%CI: 1.41-13.78, P=0.01) and D-dimers superior to 3.8 µg/mL (OR: 3.68, 95%CI: 1.36-9.94, P=0.01). The information provided by these two characteristics was additive; 58% of patients in our population who had both factors developed cancer. CONCLUSION: Bilateral venous thrombosis and D-dimers superior to 3.8 µg/mL are highly associated with carcinoma. This result requires a prospective validation. It could be useful in limiting the screening process to the population most at risk.

Suicidal phenotypes associated with family history of suicidal behavior and early traumatic experiences.

BACKGROUND: Family history of suicidal behavior and personal history of childhood trauma are risk factors for suicidal behaviors. We hypothesize that subjects with any of these risk factors will show differential features and that subjects with both of them will display more severe phenotypes. METHODS: This study compares three groups of suicide attempters (n=878): subjects with a family history of suicidal behavior and a personal history of early traumatic experiences, subjects with a family history of suicidal behavior or a personal history of early traumatic experiences, and subjects with neither of these two risk factors, with regards to psychopathology, personality traits and suicidal behavior. RESULTS: Subjects with a family history of suicidal behavior and childhood trauma were younger at their first suicide attempt and made more frequent, severe and violent attempts when compared with the other groups. Differences in number and precocity of attempts remained after adjustments in a multinomial regression model. Finally, personality profiles were also substantially different in the group with higher impulsiveness, novelty seeking, affective lability and hopelessness. LIMITATIONS: The information provided by subjects regarding childhood abuse and family history of suicidal behavior was not confirmed by other sources. CONCLUSIONS: Suicide attempters with a family history of suicidal behavior and childhood trauma show specific characteristics that might be used to prevent future suicidal behaviors in this population. Both risk factors should be routinely investigated when assessing the suicidal risk of a patient.

[Compression therapy and deep-vein thrombosis: a clinical practice survey]. / Compression veineuse et thrombose veineuse profonde. Enquête de pratique en médecine vasculaire.

BACKGROUND: Compression therapy constitutes the cornerstone of prevention of post-thrombotic syndrome in patients with deep-vein thrombosis (DVT). However, no consensus has been reached regarding the optimal timing for initiation, duration, and strength of compression therapy. OBJECTIVE: To document prescribing practices of compression therapy in case of DVT by French Vascular Medicine physicians. METHODS: E-mail survey sent in 2009 to all physicians members of the French Society of Vascular Medicine. RESULTS: Seven hundred and sixty-one vascular medicine physicians (56.6% private practice, 19.8% hospital-based and 23.6% both private practice and hospital-based physicians) responded. At diagnosis, 94.3% (n=707) systematically prescribed compression therapy. The initial compression consisted in elastic compression stockings (ECS) for 57.3% of patients (n=426) and in bandages for 42.7% (n=317). When physicians initially prescribed bandages, in 92.3% of cases they later switched to elastic compression stockings (ECS). Finally, 95.8% (n=712) of vascular medicine physicians reported prescribing ECS during DVT follow-up. The ECS ankle pressure gradient was 15-20 mmHg in 64.3% of cases and 20-36 mmHg in 35.5%. Most physicians (85.9%, n=631) modulated the duration of compression therapy according to the results of follow-up compression ultrasonographic explorations. Only a limited proportion of physicians took into account thrombus localization or its initial extention. CONCLUSION: In case of DVT, French vascular medicine physicians systematically prescribed compression therapy. However, the strength of compression was lower than recommended by international guidelines. Efficacy and benefits (potential better compliance) of this common practice should be assessed with a randomized controlled trial.

Superficial vein thrombosis and recurrent venous thromboembolism: a pooled analysis of two observational studies.

BACKGROUND: The management strategies for symptomatic isolated superficial vein thrombosis (SVT) (without concomitant deep vein thrombosis [DVT] or pulmonary embolism [PE]) have yet to achieve widespread consensus. Concerns have been raised regarding the usefulness of prescribing anticoagulant treatments to all patients with isolated SVT. Determining the isolated SVT subgroups who have the highest risks of venous thromboembolism (VTE) recurrence (composite of DVT, PE, and new SVT) may facilitate the identification of patients who are likely to benefit from anticoagulant treatment. DESIGN AND METHODS: We performed a pooled analysis on individual data from two observational, multicenter, prospective studies, to determine predictors for VTE recurrence and their impact in an unselected population of symptomatic isolated SVT patients. RESULTS: One thousand and seventy-four cases of symptomatic isolated SVT were followed up at 3 months. VTE recurrence was observed in 3.9% of the patients; 16.2% of the patients did not receive anticoagulants, and 0.6% experienced a VTE recurrence. Cancer, personal history of VTE and saphenofemoral/popliteal involvement significantly increased the risk of subsequent VTE or DVT/PE in univariate analyses. Only male sex significantly increased the risk of VTE or DVT/PE recurrence in multivariate analyses. Twelve percent of the patients had cancer or saphenofemoral junction involvement, and were at higher risk of DVT/PE recurrence than patients without those characteristics (4.7% vs. 1.9%, P= 0.06). CONCLUSIONS: In patients with symptomatic SVT, only male sex significantly and independently increased the risk of VTE recurrence. Cancer or saphenofemoral junction involvement defined a population at high risk for deep VTE recurrence. Some SVTs might be safely managed without anticoagulants.

[Validation of a deep vein thrombosis prediction rule in primary care]. / Validation d'un score de probabilité clinique de thrombose veineuse profonde des membres inférieurs spécifique à la médecine générale.

OBJECTIVE: Suspected deep vein thrombosis (DVT) of lower limbs (LL) may require different tools to rule out or confirm the diagnosis. Clinical probability provides help to select useful tests, interpret their results, and decide to treat the patient meanwhile. Clinical prediction rules that risk stratify patients with suspected DVT can be established from inpatients, but no prediction rule not requiring laboratory tests has been established from primary care patients. We previously derived and internally validated such a prediction rule. The aim of this study is to externally validate this score. PATIENTS AND METHODS: The score was applied to Optimev outpatients with suspected LL-DVT, and without suspected pulmonary embolism. Sensitivity and specificity were calculated for proximal and distal DVT, according to each score. The area under the ROC curve was calculated for each kind of DVT, in order to assess the validity of the score on predicting the presence or absence of DVT. RESULTS: Among 3523 outpatients prospectively included in the Optimev study for suspected LL DVT, overall prevalence of DVT was 29.7% (n=1046), ranging from 21.7% in the non-high score probability, to 61.4% in the high score probability. The area under the ROC curve was 0.79 [CI 95%, 0.77-0.80]. With subgroup analysis, the area under curve was 0.83 [CI 95%, 0.82-0.85] for proximal DVT, and 0.75 [CI 95%, 0.73-0.77] for distal DVT. CONCLUSION: This score reliably identifies primary care patients with LL DVT, whether proximal or distal.

Clinical presentation and mortality in pulmonary embolism: the Optimev study.

AIMS: To describe the clinical presentation and 3-month mortality in recognized forms of venous thromboembolism (VTE). METHODS: All 8256 patients referred to 359 vascular physicians for clinical suspicion of VTE were included over a 15-month period in France. Subjects without a confirmed diagnosis of VTE served as controls. Risk factors, clinical presentation and estimated 3-month survival for each form of VTE were evaluated. RESULTS: Of 5889 patients, 426 had pulmonary embolism (PE) with deep vein thrombosis (DVT), 148 had PE without DVT, and 5315 had no VTE. 2350 patients with other VTE events (DVT and superficial vein thrombosis) and 17 other patients were excluded of the analysis. PE without DVT patients presented differently for risk factors in the univariate analysis. Three-month mortality was 4.0% for controls, 12.9% for PE with DVT, and 4.6% for PE without DVT. Compared with controls, only PE with DVT patients (adjusted hazard ratio: 2.6 95% CI [1.4-4.7]) were at increased risk of mortality. CONCLUSIONS: PE without DVT is not associated with a higher 3-month mortality compared to controls, in contrast to PE with DVT. When diagnosing PE in patients, the clinical significance of an associated DVT is important.

Chronic lateral ankle instability surgical repairs: the long term prospective.

UNLABELLED: The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction. MATERIAL AND METHODS: A multicenter retrospective review was performed on 310 lateral ankle ligament reconstructions, with a mean 13-year-follow-up (minimum FU: 5 years). Male subjects (53%) and sports trauma (78%) predominated. Mean duration of instability was 92 months; mean age at surgery was 28 years. Twenty-eight percent of cases showed subtalar joint involvement. Four classes of surgical technique were distinguished: C1, direct capsular ligamentous complex reattachment; C2, augmented repair; C3, ligamentoplasty using part of the peroneus brevis tendon and C4, ligamentoplasty using the whole peroneus brevis tendon. Clinical and functional assessment used Karlsson and Good-Jones-Livingstone scores; radiologic assessment combined centered AP and lateral views, hindfoot weight-bearing Méary views and dynamic views (manual technique, Telos or self-imposed varus). RESULTS: The majority of results (92%) were satisfactory. The mean Karlsson score of 90 [19-100] (i.e., 87% good and very good results) correlated with the subjective assessment, and did not evolve over time. Postoperative complications (20%), particularly when neurologic, were associated with poorer results. Control X-ray confirmed the very minor progression in degenerative changes, with improved stability; there was, however, no correlation between functional result and residual laxity on X-ray. Unstable and painful ankles showed poorer clinical results and more secondary osteoarthritis. Analysis by class of technique found poorer results in C4-type plasties and poorer control of laxity on X-ray in C1-type tension restoration. DISCUSSION: The present results confirm the interest of lateral ankle ligamentoplasty in the management of instability and protection against secondary osteoarthritis, and of precise lesion assessment (CT-scan/MRI) to adapt surgery to the ligamentary and associated lesions. LEVEL OF EVIDENCE: Level IV. Retrospective therapeutic study.