Management of primary care patients with suspected deep vein thrombosis: use of a therapeutic dose of low-molecular-weight heparin to avoid urgent ultrasonographic evaluation.

BACKGROUND: Out of hospital management of patients with suspected deep vein thrombosis (DVT) can be problematic. The accuracy of clinical prediction rules in the primary care setting may be inadequate, D-dimer testing may not be available, and the cost-effectiveness of urgent ultrasonographic evaluation is uncertain. OBJECTIVE: The purpose of this study was to determine the efficacy and safety of an empiric single therapeutic dose of low-molecular weight heparin (LMWH) in the time interval preceding ultrasound investigation in patients presenting to primary care physicians (PCPs) for suspicion of DVT. METHODS: Consecutive patients with suspected DVT who presented to the office of a PCP outside regular thrombosis center working hours were enrolled. All eligible patients received a single therapeutic dose of LMWH (100 anti-Xa IU kg(-1) weight) and were scheduled to undergo clinical and instrumental evaluation at the thrombosis center the morning after. Clinical events were documented after a 3-month follow-up. RESULTS: A total of 534 consecutive patients with suspected DVT were included in this study; of these 102 patients had subsequent diagnosis of DVT. We detected no episodes of pulmonary embolism, major bleeding, or death during the 18-h window between the administration of LMWH and objective evaluation. Of the 432 patients in whom diagnosis of DVT was subsequently excluded, only three (0.7%; CI: 0.2-2.0%) developed venous thromboembolic events during the 3-month follow-up period. CONCLUSIONS: Empiric treatment with a single therapeutic dose of LMWH is effective and safe for outpatients with suspected DVT initially managed in a primary care setting. This strategy has the potential to reduce the need for urgent diagnostic imaging.

Retroperitoneal hemorrhage following bone marrow biopsy.

We report the case of an elderly woman with polycythemia vera submitted to bone marrow biopsy who developed retroperitoneal hemorrhage as a result of direct penetration of the needle through the iliac crest, with damage to the iliolumbar artery, the first branch of the hypogastric artery.

[Myelography in obstetrical paralysis of the brachial plexus]. / La mielografia nelle paralisi ostetriche del plesso brachiale.

The use of myelography in obstetric palsies of brachial plexus is aimed at diagnosing root avulsion. This kind of lesion appears as the disappearance of the slightly transparent nerve roots which might be combined either with pseudomeningocele or with deformation of radicular pouch. In our study we considered 69 operated patients who had previously undergone myelography. In 74.2% of cases myelographic findings were confirmed at surgery. False positives and false negatives were 9.7% and 3.2%, respectively. Incorrect diagnoses were made in 12.9% of cases, because of misread lesions and incorrect evaluation of their location, usually at the cervico-dorsal junction. No side-effects were observed. Myelography appears thus to be extremely useful for both the preoperative evaluation and the choice of surgery in newborn children with obstetric palsy of the brachial plexus.

[Hematologic changes in renal neoplasms]. / Alterazioni ematologiche in corso di neoplasia renale.

The main haematological parameters, particularly haemoglobin concentration and the numbers of leukocytes and platelets, were studied in 146 kidney tumour patients. Only 119 of the subjects studied later underwent nephrectomy. In 66 patients the tumours were limited to within the renal capsule (group I) while in 39 other subjects the tumours had gone beyond this limit and had invaded the perirenal tissue (group II). 27 patients had metastasis in one or more sites (group III). In the remaining 14 subjects (group IV) without proven metastasis, the surgical staging was not available since because of cachexia they were not undergone nephrectomy. More frequent signs were: anaemia (Hb less than 12 g/dl), mainly normochromic, found in a high percentage of cases (41% in group I, 59% in group II, 74% in group III, 79% in group IV); leukocytosis (G.B. greater than 8000/mm3: 38% in group I, 51% in group II, 37% in group III, 50% in group IV). Mild thrombocytosis (P = 350-500 X 10(3)/mm3) was found with notable frequency mainly in groups II and III (20% and 18% respectively). On the other hand leukopenia (G.B. less than 3500 per mm3) and thrombocytopenia (P less than 140 X 10(3) per mm3) were rather rare. The results of our study are also discussed in relation to the main findings in the literature.