A decision model to estimate a risk threshold for venous thromboembolism prophylaxis in hospitalized medical patients.

Essentials Low risk patients don't require venous thromboembolism (VTE) prophylaxis; low risk is unquantified. We used a Markov model to estimate the risk threshold for VTE prophylaxis in medical inpatients. Prophylaxis was cost-effective for an average medical patient with a VTE risk of ≥ 1.0%. VTE prophylaxis can be personalized based on patient risk and age/life expectancy. SUMMARY: Background Venous thromboembolism (VTE) is a common preventable condition in medical inpatients. Thromboprophylaxis is recommended for inpatients who are not at low risk of VTE, but no specific risk threshold for prophylaxis has been defined. Objective To determine a threshold for prophylaxis based on risk of VTE. Patients/Methods We constructed a decision model with a decision-tree following patients for 3 months after hospitalization, and a lifetime Markov model with 3-month cycles. The model tracked symptomatic deep vein thromboses and pulmonary emboli, bleeding events and heparin-induced thrombocytopenia. Long-term complications included recurrent VTE, post-thrombotic syndrome and pulmonary hypertension. For the base case, we considered medical inpatients aged 66 years, having a life expectancy of 13.5 years, VTE risk of 1.4% and bleeding risk of 2.7%. Patients received enoxaparin 40 mg day-1 for prophylaxis. Results Assuming a willingness-to-pay (WTP) threshold of $100 000/ quality-adjusted life year (QALY), prophylaxis was indicated for an average medical inpatient with a VTE risk of ≥ 1.0% up to 3 months after hospitalization. For the average patient, prophylaxis was not indicated when the bleeding risk was > 8.1%, the patient's age was > 73.4 years or the cost of enoxaparin exceeded $60/dose. If VTE risk was < 0.26% or bleeding risk was > 19%, the risks of prophylaxis outweighed benefits. The prophylaxis threshold was relatively insensitive to low-molecular-weight heparin cost and bleeding risk, but very sensitive to patient age and life expectancy. Conclusions The decision to offer prophylaxis should be personalized based on patient VTE risk, age and life expectancy. At a WTP of $100 000/QALY, prophylaxis is not warranted for most patients with a 3-month VTE risk below 1.0%.

Synergism between metformin and statins in modifying the risk of biochemical recurrence following radical prostatectomy in men with diabetes.

BACKGROUND: To determine the effect of statins and metformin in combination on biochemical recurrence (BCR) among diabetic men undergoing radical prostatectomy (RP). METHODS: Diabetic men undergoing RP at our institution from January 1995 to March 2012 were retrospectively reviewed. Recipients of adjuvant radiation or hormonal therapy were excluded. Statin and/or metformin use was determined through review of electronic records. BCR-free survival was plotted using Kaplan-Meier analysis, and the effect of statins and metformin on BCR was assessed via a multivariate Cox proportional hazards model. RESULTS: Seven hundred and sixty-seven men met the inclusion criteria. Seventy-six (9.9%) were users of statins only, 56 (7.3%) were users of metformin only and 42 (5.5%) were dual users. Median follow-up time was 27 months. Dual users were less likely than nonusers or users of either medication alone to have a biopsy Gleason sum of 8-10 (P=0.033), and tended towards a lower rate of pathological T stage of pT3 or higher (P=0.064). Dual users had the highest 2-year and 5-year BCR-free survival, although this was not statistically significant (P=0.205). On multivariate regression, neither statin nor metformin use alone was significantly associated with BCR-free survival. However, their interaction led to a significantly lower BCR risk than would be expected from each medication's independent effects (hazard ratio=0.2; P=0.037). CONCLUSIONS: The combination of statins and metformin in men undergoing RP for prostate cancer (PCa) may be associated with a lower BCR risk than would be predicted based on the independent effects of both medications. A synergism between these two agents is biologically plausible based on our current understanding of their diverse molecular pathways of action. The results of future clinical trials involving the use of either medication in men with PCa should be carefully assessed for confirmatory evidence of such a relationship.

2009 pandemic H1N1-associated myocarditis in a previously healthy adult.

Influenza infection most commonly affects the upper and lower respiratory tracts, but can involve extrapulmonary sites, including the myocardium. We report on a case of myocarditis caused by documented 2009 pandemic H1N1 influenza in a previously healthy adult, and review the literature on influenza myocarditis.

Nicotine and 3-ethenylpyridine concentrations as markers for environmental tobacco smoke in restaurants.

The Finnish Tobacco Act has restricted smoking in public places since 1976, and in 1994 the Act was amended to include workplaces as well. In 2000, the Tobacco Act will be expanded further to restaurants. In Finland, the exposure of clients and employees to the vapor phase environmental tobacco smoke (ETS) in restaurants has not been systematically studied before by measuring ETS markers in indoor air. However, in these establishments the concentrations of ETS are expected to be much higher than in other workplaces. Gaseous nicotine and 3-ethenylpyridine were used as indicators of ETS in three different types of restaurants. Mean concentrations of nicotine ranged from 1.4-42.2 micrograms/m3 and 3-ethenylpyridine 1.4-6.3 micrograms/m3. In addition, concentrations of total volatile organic compounds (TVOC), CO and CO2 were measured and concentrations were 183-2215 micrograms/m3, 0.9-3.1 mg/m3 and 600-880 ppm, respectively. The concentrations of ETS markers were highest in discos and nightclubs and lowest in restaurants. The concentrations of total volatile organic compounds were highest in discos and nightclubs, especially when smoke generators were used.

Thoracoscopic surgery: historical perspectives.

Recent technical advances have revolutionized the fields of surgical endoscopy, laparoscopy, thoracoscopy, and microsurgical spinal endoscopy. The authors discuss the rich history and recent evolution of these techniques. Thoracoscopy had been widely used for the treatment of pleural conditions associated with tuberculosis. It was largely abandoned in the 1950s when effective antituberculosis medications were introduced. In the 1980s the development of video-assisted endoscopic procedures in the fields of general surgery, orthopedics, and otolaryngology provided new impetus to revive thoracoscopy. As a result of these advances thoracoscopy replaced open thoracotomy in many cardiothoracic procedures. These improvements led to the application of these techniques to treat disorders of the spine. By the mid-1990s microsurgical endoscopy was being used effectively to treat thoracic disc disease, perform anterior surgical release procedures for scoliosis, resect tumors, and even to conduct complex spinal fusions and reconstructions. As technology continues to improve, there is no doubt that thoracoscopic surgery will find a permanent place in the armamentarium of techniques used to treat pathological entities of the spine.

Measurement and analysis of nicotine and other VOCs in indoor air as an indicator of passive smoking.

In Finland the Tobacco Act was amended in 1994 to include workplaces. The developed method for estimating passive smoking, or environmental tobacco smoke utilised the widely used measurement of volatile organic compounds in indoor air quality surveys. The method is based on active sorbent sampling, thermal desorption and gas chromatography/mass selective detection (GC/MS) analysis and it has been tested in a chamber and in field conditions. The method can be used simultaneously to measure volatile organic compounds and exposure to tobacco smoke. We recommend nicotine, collected by active sampling, as an indicator for the evaluation of the exposure to environmental tobacco smoke spreading from smoking areas.

Primary PTCA in a Rural Hospital.

The results of primary percutaneous transluminal coronary angioplasty (PTCA) to treat patients with acute myocardial infarction in a rural hospital were reviewed. Thirty-five patients presenting with acute myocardial infarction, including 40% considered high risk, were treated using the strategy of primary angioplasty. Following cardiac catheterization, two patients were found to have anatomy deemed unsuitable for primary angioplasty and subsequently underwent urgent coronary artery bypass graft (CABG) surgery. Thirty-three patients underwent primary angioplasty with a procedural success rate of 94%. Procedural success was defined as reduction of the infarct arteries stenosis to less then 50% and the establishment of TIMI-III flow. Six percent of these patients required urgent CABG surgery because of unsuccessful angioplasty. In-hospital cardiac mortality was 3%. Six month follow-up was achieved for all patients. There were no cardiac deaths following hospital discharge. Recurrent ischemia occurred in 17% of the patients. Favorable in-hospital and late results were achieved. This review indicates that the strategy of primary angioplasty to treat myocardial infarction may be successfully applied in a rural setting.

Traumatic thoracobiliary fistula.

Thoracobiliary fistulas are a commonly reported complication of subphrenic or liver abscesses and biliary tract obstruction. However, they are a rare and unusual complication of traumatic thoracoabdominal wounds. Due to their rarity, the experience of any one surgeon is minimal, and there is a paucity of information available in the literature regarding their treatment. We describe a case of a traumatic thoracobiliary fistula, review the existing literature, and discuss the proper management of this potentially lethal sequela of trauma.

Simple method for cardioplegia retrieval in patients with chronic renal failure.

A case in which a retrograde cardioplegia catheter was inserted into the coronary sinus for retrieval of antegrade cardioplegia in a patient with chronic renal failure is described. Potassium levels were maintained within normal limits throughout the procedure.

Solitary pulmonary nodules: detection of malignancy with PET with 2-[F-18]-fluoro-2-deoxy-D-glucose.

It is estimated that nearly one-third of solitary pulmonary nodules (SPNs) may represent bronchogenic carcinoma. The noninvasive imaging methods used currently (ie, plain radiography, computed tomography) are not reliable for accurate detection of malignancy in most SPNs. The authors prospectively evaluated use of positron emission tomography (PET) with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) for identification of malignancy in 20 patients with noncalcific, radiographically indeterminate SPNs. PET-FDG imaging demonstrated focal hypermetabolism in 13 biopsy-proved malignant nodules, whereas no increased FDG uptake was seen in the seven benign SPNs. Semiquantitative analysis with computation of differential uptake ratios also helped clearly differentiate benign nodules (mean +/- standard deviation, 0.56 +/- 0.27) from malignant nodules (mean +/- standard deviation, 5.63 +/- 2.38) (P less than .001). Thus, PET-FDG imaging may be a potentially useful noninvasive technique for accurate differentiation of benign and malignant SPNs that are radiographically indeterminate.

Airway obstruction following transhiatal esophagogastrectomy.

A 79 year old man suffered acute respiratory distress secondary to delayed gastric emptying several months following esophagogastrostomy. No drainage procedure was performed at the time of the procedure. The need for a drainage procedure is controversial. Symptoms of gastric stasis have reportedly improved with a drainage procedure and the risk of concomitant pyloromyotomy or pyloroplasty has been shown to be minimal and may prevent a potentially catastrophic complication as described in this report.

Surgery and the management of peripheral lung tumors adherent to the parietal pleura.

Among 37 patients with peripheral T3 lung lesions, preoperative clinical and imaging evidence was suggestive of T3 disease in 28 and of T2 disease in nine. Intraoperatively, the T2 designation was changed to T3 on the basis of adherence of the tumor to the parietal pleura. All had mediastinoscopy followed by resection and complete lymph node dissection. There were 17 lobectomies and 20 pneumonectomies. The chest wall was resected in continuity with the lung in 21 patients, and in 16 only an extrapleural resection was done. Follow-up was completed in all patients (range 2 to 14 years, median 7 years). The 5-year actuarial survival rate for all patients was 30%. As expected, the presence of lymph node metastasis affected the 5-year actuarial survival rate: N0 = 41%; N1 = 29%, and N2 = 0%. Histologic examination of the resected specimen confirmed a T3 lesion in 30 patients. The tumor was removed completely in 100% of patients whose chest wall was resected in continuity with the lung but in only 31% in whom an extrapleural resection was done. In the absence of lymph node metastasis, the 5-year survival rate of patients after en bloc resection of the chest wall was 50% compared with 33% for those with extrapleural resection (p less than 0.05). The finding of a peripheral lung tumor adherent to the parietal pleura indicates, in most instances, extension through the parietal pleura. When tumor is firmly adherent to the parietal pleura, an en bloc resection of the chest wall rather than an extrapleural dissection should be performed. This assures complete tumor removal and improves the probability of long-term survival.

Lyme disease of the CNS: MR imaging findings in 14 cases.

The MR images of 14 patients with clinical diagnoses of Lyme disease, CNS complaints, and positive Lyme titers were reviewed. MR examinations were abnormal in 43%. Areas of abnormal signal were identified within the cerebral white matter as well as within the brainstem.

Injections for joint and soft tissue disorders: when and how to use them.

Joint and soft tissue injections may be the only way to differentiate various arthritic disorders, accurately identify a septic joint, and apply focused treatment. Certain considerations can make these injections safer and more effective. This article reviews the principles of diagnostic and therapeutic use of joint and soft tissue injections and makes specific recommendations for common injection sites. Also described are appropriate aseptic techniques for aspirating and injecting joints, bursae, and soft tissue, as well as the judicious use of corticosteroid injections in this age group.

Chronic mucocutaneous candidiasis-thymoma syndrome. A case report.

A 69-year-old woman sought treatment with a history of persistent debilitating intraoral ulcerations and recurrent oral and vaginal candidiasis. The medical history included thymoma, breast cancer, and lip cancer. The oral lesions were consistent with bullous lichen planus. Laboratory studies showed severe hypogammaglobulinemia. The chronic mucocutaneous candidiasis-thymoma syndrome is now recognized as a distinct form of primary immunodeficiency.

Management of simple renal cysts during percutaneous nephrostolithotomy.

Simple renal cysts can coexist with renal stones. Percutaneous removal of these stones requires special considerations. We describe the management of 2 patients with this problem and propose a simple logarithm.