Luca Calanca

Comparison of the diagnostic performance of the original and modified Wells score in inpatients and outpatients with suspected deep vein thrombosis

INTRODUCTION The original and modified Wells score are widely used prediction rules for pre-test probability assessment of deep vein thrombosis (DVT). The objective of this study was to compare the predictive performance of both Wells scores in unselected patients with clinical suspicion of DVT. METHODS Consecutive inpatients and outpatients with a clinical suspicion of DVT were prospectively enrolled. Pre-test DVT probability (low/intermediate/high) was determined using both scores. Patients with a non-high probability based on the original Wells score underwent D-dimers measurement. Patients with D-dimers < 500 μg/L did not undergo further testing, and treatment was withheld. All others underwent complete lower limb compression ultrasound, and those diagnosed with DVT were anticoagulated. The primary study outcome was objectively confirmed symptomatic venous thromboembolism within 3 months of enrollment. RESULTS 298 patients with suspected DVT were included. Of these, 82 (27.5%) had DVT, and 46 of them were proximal. Compared to the modified score, the original Wells score classified a higher proportion of patients as low-risk (53 vs 48%; p < 0.01) and a lower proportion as high-risk (17 vs 15%; p = 0.02); the prevalence of proximal DVT in each category was similar with both scores (7-8% low, 16-19% intermediate, 36-37% high). The area under the receiver operating characteristic curve regarding proximal DVT detection was similar for both scores, but they both performed poorly in predicting isolated distal DVT and DVT in inpatients. CONCLUSION The study demonstrates that both Wells scores perform equally well in proximal DVT pre-test probability prediction. Neither score appears to be particularly useful in hospitalized patients and those with isolated distal DVT.

Prevalence and risk factors for venous thromboembolic complications in the Swiss Inflammatory Bowel Disease Cohort.

Abstract Objective: Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is associated with the occurrence of venous thromboembolism (VTE) such as deep vein thrombosis (DVT) and pulmonary embolism (PE). We aimed to assess the prevalence and associated risk factors for VTE in a large national cohort of IBD patients. Material and methods: Data from patients of the Swiss IBD Cohort Study (SIBDCS) enrolled between 2006 and 2013 were analyzed. Results: A total of 2284 IBD patients were analyzed of which 1324 suffered from CD and 960 from UC. VTE prevalence was 3.9% (90/2284) overall and 3.4% (45/1324) in CD patients (whereof 2.4% suffered from DVT and 1.5% from PE) and 4.7% (45/960) in UC patients (whereof 3.2% suffered from DVT and 2.4% from PE). Median disease duration in CD patients with VTE was 12 years [IQR 8–23] compared to eight years [3–16] in CD patients without VTE (p = 0.001). Disease duration in UC patients with VTE was seven years [4–18] compared to six years [2–13] in UC patients without VTE (p = 0.051). Age at CD diagnosis ≥40 years (OR 1.851, p = 0.073) and disease duration >10 years (OR 1.771, p = 0.088) showed a trend to be associated with VTE. In UC patients, IBD-related surgery (OR 3.396, p = 0.004) and pancolitis (OR 1.927, p = 0.050) were significantly associated with VTE. Conclusions: VTE are prevalent in CD and UC patients. Pancolitis and UC-related surgery are significantly associated with VTE in UC patients.

Exercise Training Modalities in Lower Limb Peripheral Artery Disease

Walking performance is reduced in lower limb peripheral artery disease (LLPAD) patients. This may lead to reduced daily life activities and quality of life, and contribute to increased mortality risk. Regular exercise training is recommended as one of the primary baseline measures to reduce cardiovascular risk and improve walking performance, physical functioning, aerobic fitness, and quality of life in LLPAD patients. Walking and lower extremity aerobic training are the most common modes of training. However, by reason of more severe claudication pain, lower pain tolerance, increased risk of fall linked with an impaired balance, and/or other comorbidities, elderly LLPAD patients cannot always complete a walking training session. Therefore, alternative modes of training (e.g., arm crank ergometer, resistance training, Nordic pole walking, cycling) have also been evaluated, and promising results were found. These different training modalities (other than walking) are safe and effective and allow elderly LLPAD patients to benefit from rehabilitation programs taking into account their specific needs.

Anticoagulation and Renal Insufficiency

Abstract. In patients with chronic renal disease vitamin K antagonists are a valid anticoagulant treatment with vigilant monitoring of international normalized ratio and bleeding risk assessment. Direct oral anticoagulants are contraindicated in stage 5 chronic kidney disease. Some studies have proposed empirical dose adjustments according to level of renal impairment. In stage 4 chronic kidney disease (CrCl 15 – 30 ml/min) a lower dose of rivaroxaban (15 mg) and edoxaban (30 mg) is proposed, but data are limited. In patients with worsening renal function and treated with rivaroxaban studies have shown lower rates of stroke and systemic embolism, without significant difference in major or non-major clinically relevant bleeding events, compared to patients treated with warfarin. Concerning injectable agents, unfractionated heparin is the anticoagulant of choice in patients with severe renal impairment, but some low-molecular-weight heparins can also be used with appropriate monitoring and subsequent dose a...