Natural history of venous thromboembolism.

Most deep vein thromboses (DVTs) start in the calf, and most probably resolve spontaneously. Thrombi that remain confined to the calf rarely cause leg symptoms or symptomatic pulmonary embolism (PE). The probability that calf DVT will extend to involve the proximal veins and subsequently cause PE increases with the severity of the initiating prothrombotic stimulus.

Duration of therapy for acute venous thromboembolism.

Prospective studies are providing a better understanding of the relative risk for recurrent thrombosis and anticoagulant-related bleeding in subgroups of patients with VTE, particularly during the extended phase of therapy. These findings in conjunction with the results of randomized trials evaluating specific anticoagulant and nonanticoagulant therapies are resulting in improvements in the management of VTE (Box 1). It is anticipated that ongoing studies will continue to identify clinical and biochemical risk factors for recurrent thrombosis and bleeding.

Diagnosis of pulmonary embolism.

No single noninvasive test for pulmonary embolism is both sensitive and specific. Some tests are good for "ruling in" pulmonary embolism (e.g.

Using evidence in practice. Foot care in diabetes.

Foot ulceration and amputation remain all too common complications for people with diabetes mellitus. Overcoming this, however, requires considerable effort. Improved implementation of patient education programs is essential, along with increased access to resources to support optimal foot care and the acquisition of optimal footwear for patients at highest risk of these complications.

Perfect balance in total knee arthroplasty: the elusive compromise.

A Tensor/Balancer device (Stryker Howmedica Osteonics, Allendale, NJ) was used to restore optimal stability and alignment during 83 consecutive total knee arthroplasties with a minimum of 6-week clinical and radiographic follow-up. The surgical technique is described. Mean flexion-extension symmetry was restored to within 1 degrees.

Acute colonic pseudo-obstruction after elective total joint arthroplasty.

A retrospective review of 31 patients who developed acute colonic pseudo-obstruction (ACPO) after total joint arthroplasty was undertaken to determine predisposing factors related to, and outcomes following, therapeutic intervention. Comparison with all patients who underwent total joint arthroplasty revealed an overall 1.2% incidence of ACPO.

Management of suspected deep venous thrombosis in outpatients by using clinical assessment and D-dimer testing.

Background: When deep venous thrombosis is suspected, objective testing is required to confirm or refute the diagnosis.

Objective: To determine whether the combination of a low clinical suspicion and a normal D -dimer result rules out deep venous thrombosis.

Design: Prospective cohort study.

Fibrinolytic variables in patients with recurrent venous thrombosis: a prospective cohort study.

To determine whether fibrinolytic testing predicts recurrent venous thrombosis, we have performed a prospective cohort study in which 303 patients with a first episode of venous thromboembolism underwent comprehensive fibrinolytic testing while receiving oral anticoagulants, and after anticoagulants had been discontinued. They were then followed for up to 3 years for recurrent venous thrombosis. No systematic differences in the levels or activity of type 1 plasminogen activator inhibitor (PAI-1), tissue plasminogen activator (tPA) or euglobulin clot lysis times were detected between patients who did, or did not, suffer recurrent thrombosis.

Arteriovenous malformation mimicking femoral osteolysis after total hip arthroplasty.

We encountered a case of apparent progressive femoral osteolysis around a well-fixed cementless implant in a young patient. At the time of revision arthroplasty, massive hemorrhaging occurred during exposure and attempted femoral component extraction. Urgent packing of the exposed endosteum with polymethyl methacrylate controlled the bone bleeding.

Noninvasive diagnosis of deep vein thrombosis in postoperative patients.

The accuracy of noninvasive testing for the diagnosis of deep vein thrombosis (DVT) generally is less in asymptomatic patients than it is in those with symptoms suggestive of thrombosis. This is because asymptomatic DVT often is confined to the distal veins and, when it involves the proximal veins, the thrombi usually are smaller than in symptomatic patients with proximal thrombosis. Because the positive predictive value of noninvasive tests for asymptomatic DVT generally is 80% or less, abnormal results should be confirmed by venography.

Antimicrobial safety and tolerability: differences and dilemmas.

The adverse drug reactions associated with antimicrobials have become a topic of major importance and concern in the last few years. Antimicrobial toxicity may take many forms, varying from mild, transient phenomena to dramatic, life-threatening events such as seizures or cardiac arrhythmias. We review the toxicity of antimicrobials in general and of the fluoroquinolones in particular and attempt to explain the adverse events by use of structure-adverse event relationships where possible.

Relationship of Penicillin Resistance to Mortality in Pneumococcal Pneumonia.

Clinical management of community-acquired pneumonia (CAP)--and Streptococcus pneumoniae infection in general--are controversial. Multiple sets of guidlines exist. This article reviews CAP, S.

Management of patients with hereditary hypercoagulable disorders.

The inherited hypercoagulable states can be divided into those that are common and associated with a modest risk of thrombosis (i.e. factor V Leiden and G20210A prothrombin gene) and those that are uncommon but associated with a high risk of thrombosis.

Antibiotic therapy for community-acquired pneumonia.

This article takes a broad perspective of community-acquired pneumonia (CAP). The arguments and data that support or refute the current approaches to initial antimicrobial treatment of CAP as outlined in the American Thoracic Society and Infectious Disease Society of America documents are provided. The complex issues involved in the decision of how to properly treat CAP are addressed.

The use of intravenous contrast in postoperative MR imaging of pituitary macroadenomas.

In this study we reviewed 23 postoperative magnetic resonance (MR) imaging examinations of patients with pituitary macroadenomas to determine if intravenous contrast is of value in this setting. The addition of contrast enhanced images to noncontrast T1-weighted images changed the radiologist's assessment in 4/5 early postoperative examinations and in 0/18 late postoperative examinations. Intravenous contrast is of value in distinguishing residual tumor from packing material on early postoperative MR examinations but is less useful in later postoperative examinations.

Low-dose oral vitamin K reliably reverses over-anticoagulation due to warfarin.

Background: Patients receiving long-term warfarin frequently develop asymptomatic excessive prolongation of their international normalized ratio (INR) results. The most appropriate management strategy in these patients is unknown. This prospective cohort study was designed to address whether 1 mg of oral vitamin K effectively reduces the INR value of such patients.

Antimicrobial approaches to therapy for pneumonia.

Pneumonia remains a serious illness with significant associated morbidity and mortality. Parallelling our increased understanding of the etiology, epidemiology, and pathogenesis of pneumonia and the development of new antibiotics has been the frightening increase in the rate and extent of bacterial resistance. The prevalence of resistance has reached unprecedented levels in many countries, and we are facing the specter of infection by pathogens for which we have no effective treatment.

Antimicrobial activity of ceftriaxone compared with cefotaxime in the presence of serum albumin.

The effect of serum albumin on the antimicrobial activity of ceftriaxone, cefotaxime, and a 1:1 ratio of cefotaxime and its desacetyl metabolite against nonpseudomonal Gram-negative bacilli was determined. Antimicrobial activity of drugs was evaluated by measuring minimum inhibitory (mic) and bactericidal (mbc) concentrations in broth with and without human serum albumin. The analysis of logarithmically transformed mean mics and mbcs showed that there was a highly significant interaction between drug and serum albumin (P<0.

Drug risk factors associated with a sustained outbreak of Clostridium difficile diarrhea in a teaching hospital.

A case-control study was undertaken to identify and quantify antimicrobial and nonantimicrobial drug risk factors associated with a sustained outbreak of Clostridium difficile diarrhea on two medical (teaching and nonteaching) units and an oncology unit. In total, 80 cases associated with an endemic clone of toxigenic C difficile were compared with controls. Eighty controls were selected from a group of 290 controls randomly chosen from the outbreak period.

Magnetic resonance imaging and computed tomography of hyperacute spinal epidural hematoma.

The authors report a case of hyperacute spinal epidural hematoma, an uncommon condition, imaged by both magnetic resonance imaging and computed tomography. The relative specificity of these two imaging methods for this abnormality is discussed, and recommendations for emergent imaging in this setting are given.