Case Of Thrombophlebitis Research Articles

Percutaneous surgery with balloon for tibial plateau fractures, results with a minimum of 5 years of follow-up

Tibial plateau fracture is a frequent entity for which surgical management is difficult both surgically and postoperatively, with multiple complications and often delayed recovery. The challenge lies in the anatomical reduction of the joint, the limitation of complications and the rapid functional recovery. Tuberoplasty appears to be an innovative technique that meets current expectations.The objective is to evaluate the reliability of tuberoplasty in reducing surgical risks and improving postoperative clinical results.This single-centre retrospective study included 30 patients with depressed tibial plateau fractures who underwent tuberoplasty from September 2011 to March 2014. Reduction analysis was performed by comparing pre-operative and post-operative depression from computed tomography (CT) data. Clinical outcomes were assessed by measuring flexion joint ranges, time to weight-bearing, KOOS questionnaire and a pangonogram.The mean depression was 7.4mm pre-operatively and 2.6mm [0;9] post-operatively, with 47% (14/30) having a residual depression of 2mm or less. Mean flexion at 6 weeks was 103° [30; 130]. Partial and total weight-bearing were allowed on day 47 [3; 150] and day 58 [20; 150], respectively. The mean KOOS score was 25.43 [1.15; 62.30] at a minimum of 5 years after surgery and the mean axis was 176.54° [172; 180]. There was one case of thrombophlebitis and one sensory-motor deficit in the common fibular nerve territory.The reduction of the tibial plateau observed in our study from tuberoplasty is in line with the literature results obtained from a conventional approach. Our results indicate that tuberoplasty is stable in the long term, has good functional results and early recovery with few complications. This preliminary study presents results that need to be investigated in a prospective randomised double-blind study.

Hemorrhagic Septic Thrombophlebitis in Horses

Background: Thrombophlebitis represents the main disease of the cardiovascular system of horses, its occurrence is strongly associated with the use of inappropriate materials and techniques. Its clinical presentation varies according to the degree of vessel obstruction and the appearance of complications, in the diagnosis it is essential to assess the extent of damage and the severity of the case. Establishing appropriate treatments, it should be noted that these are mostly clinical, reserving surgical interventions for severe cases, so the aim of the study is report a case of hemorrhagic septic thrombophlebitis treated by partial phlebectomy of the left jugular vein.Case: A 9-year-old male castrated equine, with no defined racial pattern, weighing 345 kg, used in the practice of vaquejada was attended at the Veterinary Hospital (HV) of the Federal University of Campina Grande (UFCG), Campus Patos (PB). During the anamnesis, it was reported that the animal presented colic a month ago, it was treated, recovered and since then, it started presenting an area with increase in volume in the neck region that ruptured the day before the HV attendance, where blood and pus came from. On physical exam, slight edema was noted in the left masseteric region, a volume rise involving the middle and cranial third of the neck with firm consistency in the left jugular sulcus, sensitivity to palpation and little drainage of purulent bloody secretion was observed. Additionally, tachycardia, tachypnea and intestinal hypomotility were found. In turn, in the ultrasound exam, a hypoechoic structure was seen, causing partial obstruction of the vessel, proximal to the fistulated region and total obstruction distal to it. With this information, antibiotic therapy was prescribed, a warm compress followed by the use of anti-inflammatory gel every 8 hours. By choice of the owner, the animal returned to the farm, in the next day returned to the Veterinary Hospital, due to extensive bleeding observed on the estate, immediately tried to stanch the bleeding by compressive banding, without success, we opted for the surgical intervention aiming to perform ligation and partial resection of the jugular vein. Pre-anesthetic medication was performed and under general anesthesia a rectilinear incision was made over the left jugular vein of the neck caudal region to bifurcation of lingual and facial veins, blunt dissection aiming to loosen the vessel and hemostasis of the installed neovascularization, transfixing proximal ligation with 1-0 nylon thread, diaeresis, removal of the vessel, reduction of the subcutaneous space, application of drain, dermorrhaphy in simple continuous pattern and use of compressive curative. For the postoperative period, maintenance of the initial antibiotic therapy was prescribed, adding flunixin meglumine 1.1 mg/kg, i.m, SID, 4 applications, tetanus serum 5000 UI/IM, antiphlogistic massage in the masseter region and wound treatment by washing with hypersaturated solution, use of sugar, healing pomade and repellent. One month after surgery, the animal received medical release with satisfactory healing, recovery from anemic and infectious condition, without circulatory complications.Discussion: The present report shows the feasibility of unilateral partial phlebectomy of the jugular vein as a therapeutic option in complicated cases of thrombophlebitis. In which thrombectomy techniques are contraindicated and ineffective clinical treatments, another alternative is vascular transplantation, which encounters many logistical difficulties in the routine. Despite the interruption of blood flow being pointed out as an aggravating factor, it should be noted that often thrombophlebitis itself leads to this condition, and the development of collateral circulation secondary to venous flow obstruction has been observed.

Surgical treatment of osteoporotic thoraco-lumbar compressive fractures: the use of pedicle screw with augmentation PMMA.

The osteoporosis prevalence in population is age related. The aim of this single-center observational study was evaluate the middle- to long-term performance of cement (PMMA) augmented fenestrated pedicle screws in elderly patients with thoraco-lumbar compressive fractures by osteoporosis. From 2011 to 2015 we treated 52 patients (20 males and 32 females) suffering from somatic osteoporotic fractures (T10-L2). The average age was 73.4years, with an age range between 65 and 82years. The treatment consisted of stabilization with pedicle screw augmentation with PMMA cement. Patients were clinically evaluated with Visual Analyzing System scale (VAS scale) and with low back disability questionnaire Oswestry, in pre and post surgery and during the follow up at 12 and 24months. A total of 410 fenestrated pedicle screws with PMMA augmentation were implanted. No cases of loosening or pulling out of screws were recorded. There have been n 3 cases of thrombophlebitis, treated with oral anticoagulant drugs and 1 case of post-operative death due to ventricular fibrillation. No neurological complications occurred during the study. The mean VAS score decreased from 8.5 to 4.8 and the result remained stable during follow up. Oswestry questionnaire showed a mean decrease of low back pain of 24% in post-op period. Fenestrated screws with PMMA augmentation offers a possibility to treat patients with reduced bone quality due to severe osteoporosis.

Safety of parenteral nutrition in newborns: Results from a nationwide prospective cohort study

Limited or delayed availability of parenteral nutrition (PN) solutions, as well as difficulties in ordering are often identified as reasons for non-compliance with international guidelines in newborns. This study aims at assessing the modality of use and safety of premixed standardized PN solutions in a nationwide prospective cohort of newborns treated in clinical practice. Two premixed fixed formulations with respective osmolarity of 715 and 790mOsm/L specifically designed for neonates were made available throughout the country for clinical use from birth onwards. Descriptive data and modality of use were prospectively collected in a case report form, whereas all related and unrelated adverse events were recorded on a separate adverse event form. A total of 14,167 infants were prospectively included and 16,640 parenteral nutrition periods were analyzed. Mean age was 33 weeks of gestation, and mean weight was 2086g. The majority of infants (81%) started the parenteral nutrition the first day of life or the day after. The route of parenteral nutrition delivery was peripheral in 47% of the parenteral nutrition periods. During the whole study, a total of 72 adverse events occurring in 68 infants were reported. Of these adverse events, 59 (0.37% of the nutrition periods), among which 19 serious adverse events, were reported as related to the parenteral nutrition solutions. The events related to parenteral nutrition solutions were general disorders and administration site conditions (n=42 including 9 cases of cutaneous necrosis), and nutrition and metabolism disorders (n=17). There was no case of thrombophlebitis. Six of the 19 serious events related to the parenteral nutrition solutions (32%) were due to the misuse of the infusion bag. These data support the concept that ready-to-use parenteral nutrition formulations can safely provide parenteral nutrition from birth onwards. They further support that parenteral solutions with an osmolarity up to 800mOsm/L are well-tolerated when infused on a peripheral vein. Considering the potential risk of errors and misuses, this study also highlights the need for nutrition practice care guidelines for neonates and for regular campaigns providing information and strategies for a safe use of parenteral nutrition solutions.

Polymicrobial Bacteremia With Actinomyces odontolyticus , Fusobacterium and Atopobium parvulum Secondary to Septic Thrombophlebitis in an Immunocompetent Patient

A 25-year-old immunocompetent man was found to have polymicrobial bacteremia secondary to a right arm septic thrombus. His blood cultures grew Actinomyces odontolyticus , Fusobacterium and Atopobium parvulum . Co-infections with these three bacteria are rarely documented and this is the first known reported case of thrombophlebitis associated with these bacteria. J Med Cases. 2016;7(11):515-517 doi: http://dx.doi.org/10.14740/jmc2685w

Venous Thromboembolism Prophylaxis with Aspirin for Multiple Myeloma Patients Receiving Thalidomide Combination As First-Line Treatment

Introduction: Despite the increase in overall survival in patients with multiple myeloma (MM) over the last decade as a result of the use of new chemotherapeutic agents, the immunomodulators (thalidomide and lenalidomide) are associated with a higher rate of venous thromboembolism (VTE), principally when associated with other chemotherapeutic drugs and erythropoietin (EPO). The incidence of VTE with isolated thalidomide is 3 to 4%, similar to the risk of the disease itself. The association of thalidomide with corticoids or anthracycline agents has led to an increase in the incidence of VTE to 12 and 34%, respectively. The introduction of low-dose aspirin, vitamin K inhibitors or low molecular weight heparin prophylaxis, according to the risk factors present upon diagnosis reduced the risk of thrombosis to 3 to 7%.Objectives: The objectives were to evaluate thrombotic events during the use of thalidomide as first-line treatment in symptomatic MM patients and the effectiveness of low-dose aspirin prophylaxis.Casuistic and Methods: This is a descriptive study of thrombotic events by means of a retrospective survey of patient files for MM patients who had been followed up on at the gammopathies outpatient unit at Santa Casa de Misericórdia de São Paulo from January 2009 to April 2014. The following induction therapy schedules with thalidomide for patients eligible or not for bone marrow transplantation were performed: thalidomide + dexamethasone (TD), cyclophosphamide + thalidomide + dexamethasone (CTD) and melphalan + prednisone + thalidomide (MPT). All of the patients received a dose of 100mg/day of the antiplatelet agent (aspirin) as prophylaxis.Results: In the aforementioned period, 219 patients had been diagnosed with symptomatic MM and of these, 149 patients had received thalidomide-based chemotherapy. The thalidomide group had a median age of 61 years (40 to 88). In the DS IIIA-IIIB stage, there were 131 (87.9%), 14 (9.4%) IIA-IIB, 1 (0.7%) IA and 3 (2%) had not been evaluated. According to the ISS Classification, 36 (24.2%) were ISS I, 41 (27.5%) II and 58 (38.9%) III, with 9.4% not evaluated. The most frequent isotope was IgG (56%). In relation to chemotherapy, 34 (22.8%) received TD, 98 (65.8%) CTD, 17 (11.4%) MPT. We identified 10 (6.7%) cases of thrombotic events in patients using thalidomide, thus distributed: 8 deep vein thrombosis (DVT), one case of DVT/ pulmonary embolism and one case of thrombophlebitis. Only one patient with thrombosis did not follow the prophylactic treatment at the service, which was 100mg/day of aspirin. The events occurred on average 72 days after initiating thalidomide use. Five cases were related to mobility reduction, 2 cases to obesity, 2 to smoking, 3 being ex-smokers, 3 to infection concomitant with the thrombotic event, 2 to diabetes and 1 case of previously treated breast cancer. All of the cases presented some associated risk factor.Conclusion and Discussion: The use of aspirin as prophylaxis in the group of MM patients being treated with thalidomide demonstrated efficacy in the control of risk for thrombosis. We observed 6.7% of VTE with the prophylactic use of low-dose aspirin in recently diagnosed MM patients without a history of thrombotic events, as described in the literature. Thalidomide is made available free of charge for MM treatment by the Brazilian public health system. Therefore, it is the main drug used in the MM treatment in Brazil. A better understanding of adequate thrombophylaxis according to the present risk factors is important for the optimization of the treatment of MM patients. DisclosuresNo relevant conflicts of interest to declare.

A Case of Thrombophlebitis Caused by Carbamazepine

Objective: To present a male patient with focal epilepsy and Glanzmann’s thrombasthenia who experienced Thrombophlebitis (TP) after oral administration of Carbamazepine (CBZ). Methods: In an epileptic patient with malacia from intracerebral hemorrhage in left parietal and occipital lobes due to thrombasthenia, TP occurred following treatment of antiepileptic drug CBZ. Based on the dynamic changes of clinical manifestation and dosage of CBZ, in combination with the test results of D-Dimer, fibrinogen, prothrombin degradation products, and other laboratory tests, especially of Adenosine Diphosphate (ADP) and Arachidonic Acid (AA) evoked platelet aggregation tests, the etiology and pathophysiology of TP was explored. Results: Six months after CBZ application with 200 mg bid, TP in the right lower extremity appeared. TP occurred in the left leg after another 3 months. The comfortlessness lightened when CBZ dosage was decreased to 100 mg bid. Furthermore, the inflammation disappeared after 4 months of cutting CBZ to 50 mg bid. However, inflammation emerged again in both legs following 100 mg bid of CBZ. D-Dimer, fibrinogen and prothrombin degradation products were 2357 ng/mL, 100 mg/dL, and 34.2 μg/mL, respectively. ADP and AA evoked platelet aggregation tests showed 4% and 26% (normal range: 71%-88%), respectively. These results demonstrated that there may be definite correlation between TP in lower extremity and CBZ administration. Conclusion: CBZ might result in reversible peripheral TP which was associated with its dosage, but the mechanism is still not clear. Practice implications: This case report reminds of physicians to pay more attention to the rare side effect of CBZ.

Catheter-directed foam sclerotherapy treatment of saphenous vein incompetence

The aim of this study is to report the short-term results of catheter-directed foam sclerotherapy (CDFS) in the treatment of axial saphenous vein incompetence. Data of all patients undergoing CDFS for symptomatic primary incompetence of the great or small saphenous vein were prospectively collected. Treatment results in terms of occlusion rate and patients' grade of satisfaction were analysed. All successfully treated patients underwent clinical and duplex follow-up examinations one year postoperatively. Between September 2006 and September 2010, 357 limbs (337 patients) were treated with CDFS at our institution. Based on the CEAP classification, 64 were allocated to clinical class C3 , 128 to class C4, 102 to class C5 and 63 to class C6. Of the 188 patients who completed the one year follow up examination, 67 % had a complete and 14 % a near complete obliteration of the treated vessel. An ulcer-healing rate of 54 % was detected. 92 % of the patients were satisfied with the results of treatment. We registered six cases of thrombophlebitis and two cases of venous thromboembolism, all requiring treatment. The short-term results of CDFS in patients with axial vein incompetence are acceptable in terms of occlusion and complications rates.

Vascular access devices in leukemia: a retrospective review amongst patients treated at The Ottawa Hospital with induction chemotherapy for acute leukemia

Patients with acute leukemia require reliable central vascular access to ensure delivery of intravenous therapy. Peripherally inserted central catheters (PICCs) and Hickman® catheters are two commonly inserted central vascular catheters (CVCs), providing access to the central vascular space. While there have been reports describing individual center experiences, no one has compared the two devices, retrospectively or prospectively. We analyzed patients diagnosed with acute leukemia between September 1996 and April 2009, who had a PICC or Hickman®, received induction chemotherapy and survived at least 20 days. Prior to 1 January 2007, PICCs were inserted by palpation (PICC-palp) and Hickman® catheters were inserted surgically (H-Surg). After this date, PICCs were inserted by ultrasound (PICC-U/S) and Hickman“ catheters were inserted by interventional radiology (H-IR). Fifty-five patients had a Hickman® catheter (18 H-Surg, 37 H-IR) and 92 patients had a PICC (69 PICC-palp, 23 PICC-U/S). Significant improvements from H-Surg to H-IR catheters include the reduction in exit-site inflammation and infection (27.8% to 5.4%) and in bacteremic episodes (72.2% to 27.0%). Compared to PICC-U/S, H-IR had fewer cases of thrombophlebitis (0.0% vs. 8.7%); H-IR also required fewer instillations of a thrombolytic agent than the PICC-U/S (8.1% vs. 69.6%). Both CVCs have shown improvements from pre- to post-2007 insertion methods. Our data suggest that there were fewer complications with post-2007 Hickman® catheters compared to PICCs, suggesting that Hickman® catheters provide a more reliable central vascular access in these patients.

Moderne Ultraschalldiagnostik der Beinvenenthrombose bei unklarer Genese der Lungenembolie

We compared innovative ultrasound techniques such as tissue harmonic imaging (THI) and cross-beam technique with speckle reduction imaging (SRI) to conventional fundamental B scan in the diagnosis of deep vein thrombosis. We investigated a total number of 185 patients with clinical symptoms of acute vein thrombosis. We documented the thrombosis in the patients using multifrequency ultrasound probes (5-7 MHz, 6-9 MHz, 9-14 MHz, Logig 9, GE) and recorded ultrasound sequences in fundamental B scan, THI, and cross-beam technique with SRI (grade 2). Three blinded ultrasound investigators ranked the marking of the thrombosis in each of these image modalities and graded them with the numbers 5 = weak, 4 = moderate, 3 = satisfactory, 2 = good, and 1 = excellent. We calculated the median and a t-test for each of these image modalities. We diagnosed 115 thromboses (62%) in 185 investigated patients. This group could be divided as follows: 11 patients (6%) with three-level thrombosis, 37 patients (20%) with two-level thrombosis, and 67 (36%) with one-level thrombosis. The one-level thrombosis group included five (3%) patients with muscle vein thromboses, seven (4%) cases of thrombophlebitis without involvement of the deep vein system, and three (2%) cases of thrombophlebitis with involvement of the deep vein system. The t-test for unconnected samples showed significant differences (p <0.05) in iliac veins and highly significant differences (p <0.001) in the veins of the lower extremity due to the superior capabilities for detection of thrombosis using the cross-beam technique with SRI compared to THI and the fundamental B scan. The use of high-resolution linear ultrasound probes with the concomitant application of THI and cross-beam technique with SRI facilitates the diagnosis of deep vein thrombosis. The employment of these new ultrasound modalities is an advantage in distinguishing the veins from the surrounding tissue structures and helps in evaluating the compressibility of venous vessels.

Tratamiento hormonal de reasignación de sexo en España: nuestra experiencia en 236 casos

Introduction In recent decades, demand for gender reassignment therapy (psychological, hormonal and surgical) has significantly increased. In Spain, this type of therapy has not generally been provided in public hospitals. Consequently, endocrinologists and other health professionals have insufficient experience of this treatment and transsexuals have to resort to self therapy or to private hospitals. Patients and methods During an 8-year period (1997-2004), 236 individuals with gender identity disorder (GID) were evaluated. There were 129 male-to-female transsexuals and 107 female-tomale transsexuals, aged between 19 and 54 years (mean age 34 years), with distinct educational levels (primary education in 23%, secondary education in 41%, and higher education in 36%). All patients underwent diagnostic evaluation by a psychiatrist and received psychological support. After clinical and biochemical evaluation, 4 patients were rejected for hormone therapy due to distinct organic disorders. The remaining patients were selected for distinct hormone treatments and were followed-up every 6 months. Results During the follow-up period, hyperprolactinemia occurred in 65% of female-to-male transsexuals and liver enzyme alterations in 8%. There were no cases of thrombophlebitis. In male-to-female transsexuals, liver enzyme alterations were found in 24% and hyperprolactinemia in 13%. After 2 years of hormone therapy, 43 patients underwent complete gender reassignment surgery. There were no severe adverse effects, although 5 patients reported different degrees of sexual dissatisfaction. Conclusions GID are increasingly frequent. Consequently, to prevent the adverse effects of hormone self treatment, these disorders should be managed by the Spanish national health service, which should create specific multidisciplinary units for this purpose.

Thrombophlebitis of Aneurysmal Antecubital Vein causing Pulmonary Embolism: A Case Report

The authors report a case of thrombophlebitis arising in an antecubital fossa vein resulting in a pulmonary embolism. Thrombophlebitis occurred in a vein with aneurysmal dilatation (27mm dia) and was confirmed on duplex ultrasonography. A pulmonary embolism was suspected clinically and was confirmed by ventilation-perfusion scanning. The patient was managed by anticoagulation with warfarin. Two months later she developed features of a cerebro-vascular accident secondary to bleeding into cerebral hygromas following which anticoagulation was discontinued.

Outcome of Tunneled Infusion Catheters Inserted via the Right Internal Jugular Vein

Purpose: To assess the outcome of tunneled central venous catheter placement via the right internal jugular vein. Materials and Methods: Between June 2001 and May 2002, 670 consecutive Hickman catheters were placed in 654 patients via the right internal jugular vein. The procedural complications arising and follow-up data obtained from May to July 2002 were evaluated. Results: The technical success rate for catheter placement was 99.9% (669/670). Procedural complications were limited to eight cases (1.2%), including three pneumothoraces, one early migration of the catheter, one clinically unimportant air embolism, one catheter injury, one catheter kinking and one primary malpositioning in the azygos vein. Catheter dwelling time ranged from 1 to 407 (mean 107.1) days. During the follow-up period, 416 catheters were removed for various reasons: treatment had ended (n=334), patients declined treatment or their drug regimen was changed (n=16), late complications arose (n=53), or other circumstances intervened (n=13). Late complications included 44 cases of catheter-related infection (6.6%), five of catheter migration (0.7%), two of catheter occlusion (0.3%), one of thrombophlebitis (0.15%), and one of catheter-related right atrial thrombosis (0.15%). Only one instance of symptomatic venous thrombosis or stenosis was noted , namely the one case of thrombophlebitis. Conclusion: Because the incidence of subsequent symptomatic venous thrombosis or stenosis is lower, the preferred route for tunneled central venous catheter placement is the right internal jugular vein.

Effect of oral contraceptive on ovarian function in young females undergoing neoadjuvant chemotherapy treatment for osteosarcoma

We compared the residual ovarian function and the fertility of two groups of female patients treated at different times at the authors' institution by neoadjuvant chemotherapy for localized osteosarcoma of the extremities. From 1997 to 2000, one group of 31 females received neoadjuvant treatment according to the IOR 6 protocol, which included high-dose ifosfamide, high-dose methotrexate, adryamycin, and cis-platinum. In this group of patients an oral contraceptive (OC) was given in an attempt to prevent post-chemotherapy ovarian failure. Another group of 90 patients was treated between 1974 to 1995 with the same antiblastic drugs according to similar protocols (IOR 1-IOR 5). These patients did not receive OC or other treatment to protect ovarian function. There were no significant differences between the two groups of patients. Early chemotherapy-induced menopause occurred in 3 out of 19 postpubertal patients who received the OC and in 3 out of 71 postpubertal patients in the control group. In the OC group there were 2 cases of thrombophlebitis. No delay in menarche was seen in prepubertal patients. From statistical evaluation we underline that age and alkylant doses are the most important predictive factors for early menopause and that oral contraceptives during chemotherapy do not protect ovarian function in patients receiving high-dose alkylant based chemotherapy.

Clinical results of single-level posterior lumbar interbody fusion using the Brantigan I/F carbon cage filled with a mixture of local morselized bone and bioactive ceramic granules.

A retrospective study to evaluate the results of single-level posterior lumbar interbody fusion (PLIF) using the Brantigan I/F cage (DePuy AcroMed Corp., Raynham, MA) filled with a mixture of local morselized autologous bone and bioactive ceramic granules. To report the clinical and radiologic results of PLIF using the Brantigan I/F cage for lumbar degenerative pathologies with instability. The Brantigan I/F cage for PLIF was designed to improve the fusion success of interbody fusion by separating the mechanical and biologic functions of PLIF using an implant device and autologous bone from the iliac crest. Although high fusion rates have been reported, donor site morbidity caused by bone harvest from the iliac crest remains a concern. The possibility of accomplishing cage PLIF using a mixture of local morselized bone and a bone extender was studied. A total of 25 patients underwent single-level PLIF using the Brantigan I/F cage filled with a mixture of local morselized bone and bioactive ceramic granules. All patients were observed for more than 2 years (average 2 years 7 months) and evaluated by clinical rating and radiograph. Preoperative Japanese Orthopedic Association clinical scores were significantly improved in all patients at the time of follow-up. The average improvement rate was 83.1%. There were no serious complications. Minor complications included two dural tears and two cases of thrombophlebitis. No patient required blood transfusion. All patients achieved radiographic fusion and radiographic stability, although two patients fused in a collapsed position. Regional alignment of the operated segments was restored at surgery and maintained at the time of final follow-up. There were statistical improvements in percent slip and percent posterior disc height in patients with spondylolisthesis. Posterior lumbar interbody fusion using the Brantigan I/F cage with a mixture of local morselized bone and bioactive ceramic granules can yield a solid union with satisfactory regional alignment and adequate disc height without harvest of iliac crest bone.

Low-molecular-weight heparins in pregnancy.

We conducted a systematic review, with MEDLINE and Cochrane Library data base searches and bibliographic reviews, of English-language reports describing therapy with low-molecular-weight heparin (LMWH) in pregnancy. Altogether 40 citations, excluding abstracts, were identified. When the quality of evidence was categorized according to the method outlined by the U.S. Preventive Services Task Force, 2 articles were level I, 3 were level II-1, 3 were level II-2, 4 were level II-3, 9 were level III, and the remaining 19 were classified as other (i.e., below level III). Of the 728 pregnant women and 1 postpartum woman described in the 40 citations, 340 (47%) received dalteparin, 192 (26%) enoxaparin, 108 (15%) certoparin, 54 (7%) nadroparin, 30 (4%) other LMWH, and 6 (< 1%) unspecified. The indication for LMWH in most patients (606 pregnancies, 83%) was for thromboprophylaxis. Daily doses ranged from 2500-22,000 U for dalteparin, 20 mg (2000 U)-80 mg (8000 U) for enoxaparin, 3000 U for certoparin, and 2050-15,000 U for nadroparin. Regimens included fixed dosages, increasing dosages as pregnancy progressed, dosages based on body weight, and dosages titrated according to anti-Xa levels. Duration of therapy ranged from a single dose to 476 days. Maternal anti-Xa levels were reported for 255 pregnancies. Target anti-Xa levels ranged from 0.1-0.6 U/ml and measured values from 0.0-0.7 U/ml. Major maternal findings were 18 local and generalized skin reactions, 27 bleeding complications, 9 thromboembolic events, 8 deep vein thromboses, 1 bilateral renal vein thrombosis, 4 pulmonary emboli, 1 hepatic infarction, 4 cases of thrombophlebitis, 12 cases of preeclampsia, 1 placental abruption, and 2 osteoporotic vertebral fractures. A major fetal finding was lack of anti-Xa activity in fetal or cord blood. Published experience suggests that LMWHs are generally safe and effective when administered for thromboprophylaxis during pregnancy. Until prospective, randomized, controlled trials comparing them with unfractionated heparin are performed, their benefits in pregnancy will remain inconclusive.

Regional intravenous guanethidine blocks in algodystrophy

Five-hundred-thirteen regional intravenous guanethidine blocks were carried out in 125 cases of algodystrophy (118 adults), after failure of other treatments in 120 cases (Group I) and without previous treatments in 5 (Group II). A positive result occurred in 85 cases of Group I (71%) and in the 5 cases of Group II, after 4.5 +/- 1.7 blocks. In Group I the results did not differ significantly between upper (33 cases) and lower (87 cases) limb or in regard to sex, age, duration of disease, nature of previous treatments. The presence of psychic disorders was accompanied by less frequent (p less than 0.02) positive results. The tolerance was satisfactory in 85.6% of cases: 22 moderate side effects authorized a continuation of the blocks, 22 serious ones indicated interruption, especially one case of thrombophlebitis and another one of very transitory acute ischaemia. The risk of intolerance was significantly raised (p less than 0.02) by age. The regional guanethidine blocks seemed to be a good treatment for algodystrophy after failure of other treatments.

Femoral Head Autografting With Total Hip Arthroplasty for Lateral Acetabular Dysplasia

The use of a lateral femoral head autograft with total hip arthroplasty is an effective method to treat moderate to severe acetabular dysplasia with an excellent chance of satisfactory results. The operation was performed on 42 hips in 37 patients over a 12-year period. The average follow-up period was 5.7 years, with none shorter than two years. A posterior approach was used with no trochanteric osteotomy in 38 hips. Average operative time was 133 minutes and average blood replacement was 435 ml. All grafts united. Average Harris hip ratings increased from a preoperative 39.1 points to a postoperative 89.8 points. Complications included three loose femoral components (one definite, one probable, and one possible), two loose acetabular components (one definite and one possible), one Class IV heterotopic ossification, and two cases of thrombophlebitis. Two patients required revision surgery for loosening. To date, there are no infections, dislocations, pulmonary emboli, nerve palsies, or deaths.

Cardiovascular and Bacteremic Manifestations of Campylobacter fetus Infection: Case Report and Review

A case of bacteremia due to Campylobacter fetus subspecies fetus with concomitant pleuropericarditis in a previously healthy patient is presented. The organism is ubiquitous, but most commonly causes infection in patients with chronic underlying illnesses. The pathogenesis of human infection has not been definitively elucidated. Bacteremia is the most common clinical manifestation of this infection, although cases of thrombophlebitis, mycotic aneurysm, endocarditis, and pericarditis have also been reported. The treatment of choice for most infections is gentamicin, with chloramphenicol recommended for infection involving the central nervous system. Tetracyclines and erythromycin are alternative agents. Prolonged therapy is essential to the prevention of relapse. A high index of suspicion is necessary for the recognition of this organism in the appropriate clinical settings.

Intravenous nicardipine hydrochloride: Treatment of patients with severe hypertension

Nicardipine hydrochloride, a dihydropyridine calcium entry-blocking drug, was administered to 66 patients with severe hypertension during three protocols designed to examine the efficacy and safety of this investigation drug. It was shown that nicardipine was uniformly effective in lowering blood pressure to a therapeutic goal of 95 mm Hg. Time to achieve therapeutic effect was dose dependent, and steady-state blood levels were achieved after 8 to 12 hours. Reductions in both systolic and diastolic blood pressure but not changes in heart rate were correlated with plasma concentrations of nicardipine. In dose-ranging studies, the minimal effective dose of nicardipine appeared to be 2 mg/hr; 1 mg/hr was an ineffective dose, and little additional effect was seen above 4 mg/hr. Side effects were modest and consisted of those associated with vasodilation--headache, flushing, and feelings of warmth. In the initial group of patients studied, local thrombophlebitis occurred in a substantial number of patients. This was seen only after 14 hours of infusion. In subsequent studies, the infusion site was changed after 12 hours, and no further cases of thrombophlebitis were seen. Nicardipine appears to be therapeutic agent for parenteral use that shows promise in the treatment of severe hypertension.