Comparison of clinical prediction scores for the diagnosis of deep vein thrombosis in unselected population of outpatients and inpatients.

OBJECTIVES: The aim of this research was to compare the accuracy of the modified Wells, the Wells, the Kahn, the St. André, and the Constans score for the diagnosis of deep vein thrombosis of the lower limb in unselected population of outpatients and inpatients. METHOD: The pretest of probability score was employed in consecutive 500 outpatients and inpatients with suspicion of deep vein thrombosis. All patients were examined with compression ultrasonography. RESULTS: Deep vein thrombosis was confirmed in 26.4%. In the unselected population of outpatients and inpatients, the accuracy of the modified Wells score and the Constans score was higher than other scores. Both scores were more accurate for the outpatients. There was no accurate score for the inpatient subgroup. CONCLUSIONS: The modified Wells and the Constans score appear to be useful in the unselected population of outpatients and inpatients and particularly in the outpatient subgroup.

Outcomes of permanent inferior vena cava filters: experiences in Thai patients.

INTRODUCTION: We aimed to study the outcomes of permanent inferior vena cava (IVC) filter implantation in Thai patients. METHODS: This was a retrospective study of 28 patients with deep vein thrombosis (DVT) who underwent prophylactic implantation of IVC filters for fatal pulmonary embolism (PE) between January 2005 and June 2008. The patients' operative records, protocol and follow-up data were analysed. 11 (39%) patients had PE at the initial diagnosis. The mean age of the patients was 62.1 (range 33-83) years. Indications for IVC filter implantation included contraindications to and complications of anticoagulant therapy and floating thrombi in the iliofemoral veins. RESULTS: No significant technical complication was noted, except for malposition in one patient (3.5%) and failure of the permanent IVC filter to open fully in another. During the follow-up period (mean 17.5 ± 10.9 months), no patients had any episode of PE and nine (32%) died of unrelated causes. Two patients were lost to follow-up. Among the 17 survivors, six (35.2%) had non-recanalised thrombosis vein, four (23.5%) had clinical evidence of chronic venous insufficiency, two (11.7%) had recurrent DVT in the contralateral limb and one (5.8%) developed IVC thrombosis. There was no evidence of migration of the caval filters. No statistical significance was observed in the effects of post-filter anticoagulation drug on current DVT and in the relation between PE at initial diagnosis and death during follow-up. CONCLUSION: Permanent IVC filter implantation may be effective for preventing symptomatic PE in Thai patients, with no significant sequelae in the lower extremities.

Inappropriate use of protein C, protein S, and antithrombin testing for hereditary thrombophilia screening: an experience from a large university hospital.

INTRODUCTION: Deficiencies of protein C, protein S, and antithrombin are the main inherited risk factors in Thai patients with venous thromboembolism, although the prevalence is not high. METHODS: To evaluate the appropriate use of the testing for these proteins, the test orders of 503 patients were retrospectively reviewed using the proposed guidelines. Inter-rater reliability between two investigators was also calculated. RESULTS: Of 503, 459 (91%; 95% confidence interval 88-93%) of the test orders were inappropriate. The most common cause of inappropriateness was testing during acute thrombosis (42.5%). Results were inconclusive in 105 (20.9%) patients who had isolated decrease in one of the proteins, mostly owing to lack of confirmation of the abnormal results. Kappa index for the reliability of two investigators was 0.79. CONCLUSION: To enhance the appropriate use of hereditary thrombophilia screening tests, physician education concerning the patient selection, suitable timing for testing and repetition of the tests with abnormal results should be emphasized.

Transcutaneous oxygen tension: a useful predictor of ulcer healing in critical limb ischaemia.

OBJECTIVE: To investigate the threshold of transcutaneous oxygen tension (TcPO(2)) values in predicting ulcer healing in patients with critical limb ischaemia in a prospective study. METHOD: 50 patients suffering from critical limb ischaemia with chronic ischemic ulcers or gangrenous toes were enrolled in this study between January and December 2008. Their demographic data and ankle brachial pressure index (ABPI) were collected. Baseline ulcers were measured with a wound measurement system (Visitrak, Smith & Nephew). TcPO(2) was measured at rest in the supine position and with 30 degrees leg elevation. The patients with infective and ischemic ulcers underwent debridement and gangrenous toes were amputated. Ulcer outcome was classified as either: (1) A healing ulcer, showing good epithelialisation or granulation at both base and edges, or a decrease in ulcer area during the study; or (2) A non-healing ulcer, showing poor granulation tissue formation or a pale base and necrotic edges, or deterioration in an ischaemic ulcer. RESULTS: The mean age of the patients was 67.6 + or - 10.8 years. The most common risk factor was hypertension (90%). Mean ABPI was 0.75 + or - 0.39. 13 patients (26%) had a TcPO(2) of less than 20 mmHg, of which none showed any improvement in ulcer healing (p<0.001). 15 patients (30%) had a TcPO(2) of more than 40 mmHg, of which all progressed to complete ulcer healing (p<0.001). In the borderline group (20-40 mmHg, 22 patients, 44%), 10 patients (45%) had a TcPO2 drop of <10 mmHg with 30 degrees leg elevation, of which 8 achieved complete ulcer healing (p<0.001). 12 patients (55%) had a TcPO(2) drop of >10 mmHg with 30 degrees leg elevation, of which 11 showed no ulcer healing (p<0.001). CONCLUSION: TcPO(2) measurement is an accurate, non-invasive, and good predictor of ischemic ulcer healing, for cut-off TcPO(2) values of less than 20 mmHg and more than 40 mmHg. In addition, the leg elevation method for TcPO(2) might provide an important adjunct in the assessment of patients with borderline values.

Malignant carcinoid tumor of the appendix with liver and lung metastasis: report of a case with a high level of serum carcinoembryonic antigen.

We report elevated serum carcinoembryonic antigen (CEA) in a case of malignant carcinoid tumor of the appendix with liver and lung metastasis. A 55-year-old Thai man was found to have multiple nodules in the liver by ultrasonography. Serum CEA was 7,387.9 ng/mL (normal 0-4.1 ng/mL) leading to a clinical impression of colonic carcinoma with liver metastasis. During the investigation, he developed acute abdomen caused by ruptured acute appendicitis. Malignant carcinoid tumor of the appendix, 1 cm in diameter and located proximal to the ruptured acute appendicitis, was identified. The tumor cells showed trabecular or insular growth pattern, some nuclear pleomorphism but typically fine nuclear chromatin, frequent mitoses and focal necrosis. They were immunoreactive for antibody to chromogranin, neuron-specific enolase, CEA, and cytokeratin. Tumor metastases were discovered in the liver, right lung, mediastinal and right supraclavicular lymph nodes. Electron microscopic study demonstrated pleomorphic neurosecretory granules of the midgut type of carcinoid tumor.