Recurrent deep vein thrombosis: long-term incidence and natural history.

OBJECTIVE: To determine the long-term incidence, risk factors, and associated morbidity and mortality of recurrent deep vein thrombosis (DVT). SUMMARY BACKGROUND DATA: Few studies have examined the long-term natural history and impact of recurrent DVT. METHODS: We conducted a prospective observational study that followed 153 consecutive patients with an acute first episode of DVT. Clinical examination and ultrasound were performed serially for at least 5 years. Location and extent of the initial DVT, recurrence, pulmonary embolism, cause of mortality, signs and symptoms of post thrombotic syndrome (PTS), and the risk factors were recorded. RESULTS: The incidence of recurrence at 5 years was 26.1%. Patients with both proximal and distal DVT had a higher recurrence rate than proximal (17/48 35% vs. 12/49, 24%, P = 0.27) or calf alone (11/56, 20%, P = 0.08). Unprovoked DVT and age >65 years were associated with higher recurrence rates (P < 0.001; relative risk [RR]: 2.9, 95% confidence interval [CI]: 1.5-5.7) and (P = 0.025; RR: 1.5, 95% CI: 1-2.3), respectively. Thrombophilia was not associated with increased risk of recurrence (P = 0.21). Patients with DVT due to surgery or trauma had a lower recurrence (P < 0.001). Ipsilateral recurrence was associated with increased severity of PTS (P < 0.001; RR: 1.6, 95% CI: 1.4-2.2). PE occurred 47 times, 12 (25%) of which were fatal events. CONCLUSIONS: Factors associated with a higher rate of recurrence included unprovoked DVT and age >65. Elevated thrombus burden had a trend towards higher risk. Patients with surgery and trauma had low recurrence rates. Ipsilateral recurrence was strongly associated with PTS. PE occurred frequently and was a common cause of death.

A Case of Evan's Syndrome Induced by Vedolizumab.

Vedolizumab is a monoclonal antibody against the ɑ4ß7 integrin receptor used for the treatment of ulcerative colitis and Crohn's disease. Clinical trials have shown vedolizumab to be a safe and highly effective therapy in treating inflammatory bowel disease. Its unique gut-specific mechanism of action has made it an attractive agent in recent years. However, vedolizumab's side effect profile and long-term effects are not fully understood. We report a patient with ulcerative colitis who presented with epistaxis 1 week after receiving the first induction dose of vedolizumab found to have a severe immune-mediated thrombocytopenia and hemolytic anemia, otherwise known as Evan's syndrome.

Escalation of Immunosuppressive Therapy for Inflammatory Bowel Disease Is Not Associated With Adverse Outcomes After Infection With Clostridium difficile.

BACKGROUND: Clostridium difficile infection (CDI) is common in patients with inflammatory bowel disease (IBD), often leading to diagnostic confusion and delays in IBD therapy escalation. This study sought to assess outcomes after CDI in IBD patients exposed to new or escalated immunosuppressive therapy. METHODS: This multicenter retrospective cohort study included IBD patients with documented CDI at 4 academic medical centers. Data were abstracted from clinical databases at each institution. Outcomes at 30 and 90 days were compared between patients undergoing new or intensified immunosuppressive therapy and those without therapy escalation. Continuous variables were compared using t tests, and proportions using chi-square tests. Multivariable logistic regression was used to determine the association of individual variables with severe outcomes (including death, sepsis, and/or colectomy) within 90 days. Secondary outcomes included CDI recurrence, rehospitalization, worsening of IBD, and severe outcomes within 30 days. RESULTS: A total of 207 adult patients with IBD and CDI were included, of whom 62 underwent escalation to biologic or corticosteroid therapy (median time to escalation, 13 days). Severe outcomes within 90 days occurred in 21 (15.6%) nonescalated and 1 (1.8%) therapy-escalated patients. Serum albumin <2.5 mg/dL, lactate >2.2 mg/dL, intensive care unit admission, hypotension, and comorbid disease were associated with severe outcomes. Likelihood of severe outcomes was decreased in patients undergoing escalation of IBD therapy after CDI (adjusted odds ratio [aOR], 0.12) and increased among patients aged >65 years (aOR, 4.55). CONCLUSIONS: Therapy escalation for IBD within 90 days of CDI was not associated with worse clinical outcomes. Initiation of immunosuppression for active IBD may therefore be appropriate in carefully selected patients after treatment of CDI.