Validity of International Classification of Diseases, Ninth Revision, Clinical Modification codes for estimating the prevalence of venous ulcer.

BACKGROUND: The American Venous Forum issued a call to reduce the prevalence of venous ulcers (VUs) by 50% in 10 years. The objectives of this study were to determine the validity of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for VU and to estimate the prevalence of VU in a well-defined geographic population (Olmsted County, Minn). METHODS: Rochester Epidemiology Project resources and 18 VU ICD-9-CM codes were used to identify residents with possible VUs during the 2-year period 2010-2011 (n = 1551). The complete medical records in the community were reviewed for a 15% random sample (n = 227) of these residents, and on the basis of prespecified criteria, patients were categorized as a VU or non-VU case. Continuous and categorical variables were compared between groups by the two-sample t-test and χ(2) test. RESULTS: Ninety-three patients (41%) had active or healed VUs, 83 had non-VUs, and 51 never had ulcers but had stasis skin changes or skin infection. ICD-9-CM code 454.0 best identified VU cases (sensitivity, 24%; specificity, 100%). VU patients were older and heavier and more frequently had bilateral ulcers. On the basis of the random sample review, an estimated 635 patients had healed or active VUs during the 2-year period of the study. The prevalence of VUs in the Olmsted County population was estimated to be 210 per 100,000 person-years, with VU incidence (newly diagnosed ulcers) of 85 per 100,000 person-years. CONCLUSIONS: ICD-9-CM VU codes operated poorly for VU identification. VU surveillance for estimating trends in incidence and prevalence of VUs will require better methods. The estimated prevalence of VUs in Olmsted County is 210 per 100,000 person-years. New ulcers developed each year in 85 of 100,000 people, an incidence that seems to be higher than in the previous epidemiologic study in this population.

Severe case and literature review of primary erythromelalgia: novel SCN9A gene mutation.

Erythromelalgia is a rare clinical syndrome characterized by intermittent heat, redness, swelling and pain more commonly affecting the lower extremities. Symptoms are mostly aggravated by warmth and are eased by a cold temperature. In some cases, symptoms can be very severe and disabling. Erythromelalgia can be classified as either familial or sporadic, with the familial form inherited in an autosomal dominant manner. Recently, there has been a lot of progress in studying Na(v)1.7 sodium channels (expressed mostly in the sympathetic and nociceptive small-diameter sensory neurons of the dorsal root ganglion) and different mutations affecting the encoding SCN9A gene that leads to channelopathies responsible for some disorders, including primary erythromelalgia. We present a severe case of progressive primary erythromelalgia caused by a new de novo heterozygous missense mutation (c.2623C>G) of the SCN9A gene which substitutes glutamine 875 by glutamic acid (p.Q875E). To our knowledge, this mutation has not been previously reported in the literature. We also provided a short literature review about erythromelalgia and Na(v) sodium channelopathies.

Care of the adult Hodgkin lymphoma survivor.

Of those individuals diagnosed with Hodgkin lymphoma, 85% will survive and may be affected by residual effects of their cancer and its therapy (chemotherapy, radiation therapy, stem cell transplantation). Hodgkin lymphoma survivors are at risk of developing secondary malignancies, cardiovascular disease, pulmonary disease, thyroid disease, infertility, premature menopause, chronic fatigue, and psychosocial issues. These conditions usually have a long latency and therefore present years or decades after Hodgkin lymphoma treatment, when the patient's care is being managed by a primary care provider. This review summarizes these unique potential medical and psychologic sequelae of Hodgkin lymphoma, and provides screening and management recommendations.

The association of active cancer with venous thromboembolism location: a population-based study.

OBJECTIVE: To test active cancer for an association with venous thromboembolism (VTE) location. PATIENTS AND METHODS: Using the resources of the Rochester Epidemiology Project, we identified all Olmsted County, MN, residents with incident VTE during the 35-year period 1966-2000 (N = 3385). We restricted analyses to residents with objectively diagnosed VTE during the 17-year period from January 1, 1984, to December 31, 2000 (N = 1599). For each patient, we reviewed the complete medical records in the community for patient age, gender, and most recent body mass index at VTE onset; VTE event type and location; and previously identified independent VTE risk factors (ie, surgery, hospitalization for acute medical illness, active cancer, leg paresis, superficial venous thrombosis, and varicose veins). Using logistic regression we tested active cancer for an association with each of 4 symptomatic VTE locations (arm or intra-abdominal deep venous thrombosis [DVT], intra-abdominal DVT, pulmonary embolism, and bilateral leg DVT), adjusted for age, gender, body mass index, and other VTE risk factors. RESULTS: In multivariate analyses, active cancer was independently associated with arm or intra-abdominal DVT (odds ratio [OR], 1.76; P = .01), intra-abdominal DVT (OR, 2.22; P = .004), and bilateral leg DVT (OR, 2.09; P = .02), but not pulmonary embolism (OR, 0.93). CONCLUSION: Active cancer is associated with VTE location. Location of VTE may be useful in decision making regarding cancer screening.

Fibrin d-dimer concentration, deep vein thrombosis symptom duration, and venous thrombus volume.

INTRODUCTION: To determine the relationship between fibrin D-dimer levels, symptom duration, and thrombus volume, consecutive patients with incident deep venous thrombosis (DVT) were evaluated. METHODS: In a cross-sectional study design, patient symptom onset was determined by careful patient questioning. Venous thrombosis was confirmed by compression duplex ultrasonography. Thrombus volume was estimated based on patient's femur length using a forensic anthropology method. Fibrin D-dimer was measured by latex immunoassay. RESULTS: 72 consecutive patients with confirmed leg DVT agreed to participate. The median symptom duration at the time of diagnosis was 10 days. The median D-dimer concentration was 1050 ng/dL. The median thrombus volume was 12.92 cm(3). D-Dimer levels correlated with estimated thrombus volume (P < .0006 CI 0.12-0.41; R(2) (adjusted) = .15) but not symptom duration, patient's age, or gender. CONCLUSIONS: Despite varying symptom duration prior to diagnosis, fibrin D-dimer remains a sensitive measure of venous thrombosis and correlates with thrombus volume.

Predicting left atrial thrombi in atrial fibrillation.

BACKGROUND: The aim of the study was to determine whether CHADS(2) score is predictive of left atrial appendage thrombus (LAAT) in nonvalvular atrial fibrillation (AF). Strategies for effective stroke prevention in AF require tools capable of identifying those patients at greatest risk for embolization of LAAT and most likely to benefit from warfarin. Nearly half of strokes in AF are due to noncardioembolic mechanisms for which antiplatelet therapy would be more appropriate. Previous attempts to develop such tools have been limited by including patients without proven cardioembolism. METHODS: Nonanticoagulated, nonvalvular AF patients with (cases) or without (controls) LAAT by transesophageal echocardiography were identified using Mayo Clinic Echocardiography and Cardioversion Unit Databases (Rochester, MN). Type and duration of AF, CHADS(2) score, and echocardiography measures were compared to determine variables predictive of LAAT. RESULTS: The CHADS(2) score was significantly higher for cases (n = 110, mean +/- SD 2.8 +/- 1.6) compared to controls (n = 387, 1.6 +/- 1.3). By multivariate analysis, independent predictors of LAAT included heart failure (HR 5.78, P < 0001), prior stroke/transient ischemic attack (HR 3.94, P < .0001), diabetes mellitus (HR 1.98, P = .015), permanent AF (HR 3.02, P < .05), AF duration (HR 2.24, P < .05), and spontaneous echocardiographic contrast (HR 4.35, P = .005). Using these elements, a new scoring system provided cleaner case-control separation (C-index 0.90) and higher predictive power compared to CHADS(2) (C-index 0.71). CONCLUSIONS: The CHADS(2) score predicts the presence of LAAT in AF patients. Some, but not all, variables within this score are predictive of LAAT. By including only echo and clinical variables predictive of LAAT, our novel scoring system better identified those AF patients at greatest cardioembolic risk.

Hibernating kidney - a case report.

A 75-year-old woman presented with a two-month history of progressive dyspnea on exertion. On physical examination, her blood pressure was 148/90 mmHg, jugular venous pressure was 10 cmH(2)O with a prominent V wave, right ventricular heave was present and she had a systolic murmur at the right upper sternal border that varied with inspiration. The patient had a pulsatile liver, mild ascites and systolic bruits over both kidneys, with the diastolic component on the left side.

Effect of carotid atherosclerosis screening on risk stratification during primary cardiovascular disease prevention.

We investigated the effect that carotid plaque area (CPA) and intima media thickness (IMT) measurements have on risk stratification in 95 patients with intermediate Framingham scores (6% to 19%). The risk status of each patient was adjusted to be low, intermediate, or high based on the results of carotid ultrasound. After carotid testing, 44% (IMT) and 45% (CPA) of the intermediate-risk patients were stratified as low risk, and 22% (IMT) and 40% (CPA) were stratified as high risk. Using the threshold values derived from our laboratory, 28% (IMT) and 45% (CPA) of patients were stratified as low risk, and 35% (IMT) and 27% (CPA) were identified as high risk. These tests adjust the risk strata of >/=63% of patients deemed as having intermediate risk by Framingham scores.