Home versus in-patient treatment for deep vein thrombosis.

BACKGROUND: Deep vein thrombosis (DVT) affects 1-2/1,000 of the adult population per annum in western societies. It may be associated with pulmonary embolism (PE) which carries a 10% fatality rate. Sufferers may develop post-thrombotic syndrome with swelling of the leg, secondary varicose veins and ulceration. In the initial stages of treatment for DVT patients are traditionally admitted to hospital for intravenous treatment with unfractionated heparin (UH) for three to five days. The dose of UH required to provide a therapeutic level of anticoagulation is unpredictable, so the blood must be closely monitored. Fractionated, or low molecular weight heparin (LMWH), is given subcutaneously once daily and requires no monitoring, so can be given in hospital or at home. OBJECTIVES: To collate all randomised controlled trials (RCTs) comparing a home treatment regime (LMWH) with hospital treatment (LMWH or UH) for the initial phase of treatment for DVT, and to compare the safety, efficacy, patient acceptability and cost implications of home versus in-patient treatment. SEARCH STRATEGY: All published reports of home treatment were traced through MEDLINE, and EMBASE (up to and including December 2000) using the search strategy described by the Cochrane Peripheral Vascular Diseases Group. Additional searches included the Cochrane CCTR/CENTRAL database, handsearching non-listed journals, and personal communication with researchers. SELECTION CRITERIA: RCTs of home versus hospital treatment for DVT in which DVT was clinically confirmed and treated with either LMWH or UH. DATA COLLECTION AND ANALYSIS: One reviewer selected the material for inclusion (IGS): the other (AAM) reviewed the literature and selection of trials. Outcomes included PE, recurrent DVT, gangrene, heparin complications, and death. MAIN RESULTS: Only two major RCTs with comparable treatment arms were found. Both had fundamental problems including high exclusion rates, partial hospital treatment of many in the LMWH arms, and comparison of UH in hospital with LMWH at home. The trials showed that home treatment was no more liable to complications than hospital treatment. Initial results from a smaller RCT comparing LMWH treatment in both home and hospital arms came to the same conclusion. REVIEWER'S CONCLUSIONS: The limited evidence suggests that home management is cost effective, and likely to be preferred by patients. Further large trials comparing these treatments are unlikely to be held. Therefore, home treatment is likely to become the norm, and further research will be directed to resolving practical issues.

Intraluminal stenting in the management of adhesional intestinal obstruction.

Intraluminal stenting of the small bowel has been advocated as a method of reducing the risk of recurrent adhesional obstruction in patients requiring adhesolysis. We reviewed the complications and efficacy of this technique in 25 patients undergoing surgery for relief of intestinal obstruction due to complex, extensive and dense adhesions. Five patients developed minor and three patients major complications. Three (13%) of 23 patients alive after mean follow-up of 4 years had had episodes of recurrent intestinal obstruction, but none had required reoperation. Intraluminal stenting remains of unproven efficacy. It may find a place as an adjunct to adhesolysis in patients requiring repeated operations for the relief of obstruction due to extensive and dense adhesions; but, in view of the high rate of complications, careful case selection will be necessary.

Oxpentifylline treatment of venous ulcers of the leg.

OBJECTIVE: To determine the effect of oxpentifylline on the healing of venous ulcers of the leg. DESIGN: Double blind, randomised, prospective, placebo controlled, parallel group study. SETTING: Four outpatient clinics treating leg ulcers in England and the Republic of Ireland. PATIENTS: 80 Consecutive patients with clinical evidence of venous ulceration of the leg in whom appreciable arterial disease was excluded by the ratio of ankle to brachial systolic pressure being greater than 0.8. INTERVENTIONS: All patients received either oxpentifylline 400 mg three times a day by mouth or a matching placebo for six months (or until their reference ulcer healed if this occurred sooner) in addition to a locally standardised method of compression bandaging. MAIN OUTCOME MEASURES: The primary end point was complete healing of the reference ulcer within six months. The secondary end point was the change in the area of the ulcer over the six month observation period. RESULTS: Complete healing of the reference ulcer occurred in 23 of the 38 patients treated with oxpentifylline and in 12 of the 42 patients treated with a placebo. Life table analysis showed that the proportion of ulcers healed at six months was 64% in the group treated with oxpentifylline compared with 34% in the group treated with a placebo (log rank test chi 2 = 4.78, p = 0.03), which was significant (odds ratio = 1.81, 95% confidence interval 1.20 to 2.71). CONCLUSION: Oxpentifylline used in conjunction with compression bandaging improves the healing of venous ulcers of the leg.

The significance of beta-haemolytic streptococci in chronic leg ulcers.

beta-Haemolytic streptococci were identified in 18.8% of bacterial isolates from 91 legs of patients with leg ulcers swabbed routinely. This previously unreported high incidence is ascribed to selective culture methods. In view of its sensitivity to simple antibiotics and its reputed proclivity for skin destruction, the beta-haemolytic streptococcus should be sought and, if found, energetically treated.

Colonoscopic surveillance after diagnosis of carcinoma of the colon and rectum.

Routine colonoscopic surveillance was undertaken in 63 patients after resection of colonic cancer. Recurrence at the anastomotic site was never shown visually or histologically. Despite this, local or metastatic progression occurred in 8 patients; thus, the stade of the mucosa is no guide to the progression of the disease. However, colonoscopy was useful in detecting polyps and second carcinomas. A plan of follow-up is advocated, based on the likelihood of development of further tumours.

Nutritional status of patients with leg ulcers.

A group of 30 consecutive patients from a leg ulcer clinic were compared with age- and sex-matched controls in respect of 11 indices which may reflect nutritional deficiency. Twenty-one controls and 23 patients showed a total of 92 abnormalities, of which 48 were classified as severe. Mean indices were not significantly different in the two groups apart from a lower haemoglobin in patients and raised serum ferritin in controls.

Clinical comparison of elastic supports for venous diseases of the lower limb.

Compression garments for the lower limb were tested in two groups--general support garments and anti-embolism supports. A total of 98 patients was examined. The method used was by the interposition of partly fluid-filled pressure sensors between garment and skin. A combination of roller bandage with shaped tubigrip (SBB--Seton) and Sigvaris stockings afforded effective pressure in the general support group but only the roller bandage plus pressure garment (Seton) did so in the anti-embolism group, both in the acute and prolonged studies.

Clinical comparison of elastic supports for venous diseases of the lower limb and thrombosis prevention.

There is little objective evidence available when prescribing aids and appliances such as elastic supports for the leg. Doctors are generally ill-informed about effectiveness, fitting and costs of these garments. The claims of competing suppliers cannot be applied to clinical situations because the garments are tested in vitro on rigid forms. Elastic support for the lower limb is required in the treatment of varicose veins and gravitational disease and has been found effective in prevention of deep venous thrombosis. This study examined the in vivo effectiveness of four commercially purchased garments for these two purposes. The legs of 40 patients with varicose veins, 12 with gravitational disease and 20 patients admitted for elective operations were studied. Pressure exerted by the garment was detected by partly fluid filled bags between garment and limb. The results in patients with varicose veins and gravitational disease were similar. Only two garments exerted effective pressure and of these two the combination of a roller bandage and tapered tubigrip is recommended on grounds of least expense and ease of application. Of the four anti-embolism supports only the roller bandage plus tapered tubigrip produced effective compression: two garments produced reversed flow gradients in the majority of tests. Elastic supports should be double tested, firstly by the manufacturer for basic stretch and regain characteristics and secondly in vivo by clinicians to provide objective evidence of cost effectiveness.