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* When compared to African Americans and Caucasians, the incidence of DVT is noted to be two to four times lower in Hispanics and Asian-Pacific Islanders.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
* When compared to African Americans and Caucasians, the incidence of DVT is noted to be two to four times lower in Hispanics and Asian-Pacific Islanders.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
* Lower thrombosis incidences in non-Caucasians may be related to a lower prevalence of disorders like [[Factor V Leiden]] or [[Thrombin#Prothrombin 20210a mutation|Prothrombin 20210A mutation]].<ref name="pmid9109469">{{cite journal| author=Ridker PM, Miletich JP, Hennekens CH, Buring JE| title=Ethnic distribution of factor V Leiden in 4047 men and women. Implications for venous thromboembolism screening. | journal=JAMA | year= 1997 | volume= 277 | issue= 16 | pages= 1305-7 | pmid=9109469 | doi= | pmc= | url= }} </ref><ref name="pmid9415695">{{cite journal| author=Gregg JP, Yamane AJ, Grody WW| title=Prevalence of the factor V-Leiden mutation in four distinct American ethnic populations. | journal=Am J Med Genet | year= 1997 | volume= 73 | issue= 3 | pages= 334-6 | pmid=9415695 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9415695  }} </ref>
* Lower thrombosis incidences in non-Caucasians may be related to a lower prevalence of disorders like [[Factor V Leiden]] or [[Thrombin#Prothrombin 20210a mutation|Prothrombin 20210A mutation]].<ref name="pmid9109469">{{cite journal| author=Ridker PM, Miletich JP, Hennekens CH, Buring JE| title=Ethnic distribution of factor V Leiden in 4047 men and women. Implications for venous thromboembolism screening. | journal=JAMA | year= 1997 | volume= 277 | issue= 16 | pages= 1305-7 | pmid=9109469 | doi= | pmc= | url= }} </ref><ref name="pmid9415695">{{cite journal| author=Gregg JP, Yamane AJ, Grody WW| title=Prevalence of the factor V-Leiden mutation in four distinct American ethnic populations. | journal=Am J Med Genet | year= 1997 | volume= 73 | issue= 3 | pages= 334-6 | pmid=9415695 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9415695  }} </ref>
===Hospitalization for VTE===
* During 2007–2009, an estimated annual average of 547,596 hospitalizations had a diagnosis of VTE for adults aged ≥18 years. Estimates for DVT and PE diagnoses were not mutually exclusive. An estimated annual average of 348,558 adult hospitalizations had a diagnosis of DVT, and 277,549 adult hospitalizations had a diagnosis of PE. An estimated annual average of 78,511 adult hospitalizations (14% of overall VTE hospitalizations) had diagnoses of both DVT and PE.<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
* The estimated average annual number of hospitalizations with VTE was successively greater among older age groups: 54,034 for persons aged 18–39 years; 143,354 for persons aged 40–59 years; and 350,208 for persons aged ≥60 years. The estimated average annual number of hospitalizations with VTE was comparable for men (250,973) and women (296,623). Shown below is an image depicting the estimated average annual number of hospitalization with a diagnosis of DVT, PE, or VTE by age and sex.<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
[[Image:Estimated average annual number of hospitalization VTE.gif|frame|center|Estimated average annual number of hospitalizations with a diagnosis of deep thrombosis (DVT), pulmonary embolism (PE), or venous thromboembolism (VTE), by patient sex and age group — National Hospital Discharge Survey, United States, 2007–2009 - [https://www.cdc.gov/mmwr/pdf/wk/mm6122.pdf Source:CDC]]]
* The average annual rates of hospitalizations with a discharge diagnosis of DVT, PE, or VTE among adults were 152, 121, and 239 per 100,000 population, respectively. For VTE, the average annual rates were 60 per 100,000 population aged 18–39 years, 143 for persons aged 40–49 years, 200 for persons aged 50–59 years, 391 for persons aged 60–69 years, 727 for persons aged 70–79 years, and 1,134 for persons aged ≥80 years. The rates of hospitalization were similar for men and women, and the point estimates increased for both sexes by age.<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
* On average, 28,726 hospitalized adults with a VTE diagnosis died each year. Of these patients, an average of 13,164 had a DVT diagnosis and 19,297 had a PE diagnosis; 3,735 had both DVT and PE diagnoses.<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>


===Recurrence of VTE===
===Recurrence of VTE===

Revision as of 13:31, 20 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Classification

Classification of hyperparathyridism
Features Primary hyperparathyroidism Secondary hyperparathyroidism Tertiary hyperparathyroidism
Pathology Hyperfunction of parathyroid cells due to hyperplasia, adenoma or carcinoma. Physiological stimulation of parathyroid in response to hypocalcaemia. Following long term physiological stimulation leading to hyperplasia.
Cause
Associations May be associated with multiple endocrine neoplasia. Usually due to chronic renal failure or other causes of Vitamin D deficiency. Seen in chronic renal failure.
Serum calcium High Low/Normal High
Serum phosphate Low/Normal High High
Management Usually surgery if symptomatic. Cincacalcet can be considered in those not fit for surgery. Treatment of underlying cause. Usually cinacalcet or surgery in those that don't respond.

Epidemiology PE & DVT

Incidence

  • The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.[1]
  • Subjects who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.[2]
  • In the United States, the annual incidence of VTE is estimated to be approximately 100 per 100,000 persons.[1]

Age

  • The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.[1]
  • Subjects who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.[2]

Gender

  • Studies about differences in the incidence of VTE by gender have mixed results.
    • Some reported a higher incidence of DVT among young females[3]
    • Some reported it higher among either older females[4]
    • Some reported it higher in men.[2][5]
  • In addition, the risk for DVT was reported to consistently increase with age across both genders.[2]

Race

  • There is a significant difference in the incidence of DVT as it relates to race. African Americans characteristically have the highest incidence of DVT while Caucasians rank as the second highest incidence of DVT.[1]
  • When compared to African Americans and Caucasians, the incidence of DVT is noted to be two to four times lower in Hispanics and Asian-Pacific Islanders.[1]
  • Lower thrombosis incidences in non-Caucasians may be related to a lower prevalence of disorders like Factor V Leiden or Prothrombin 20210A mutation.[6][7]

Recurrence of VTE

  • One-third (about 33%) of people with VTE will have a recurrence within 10 years.[8][9]
  • The risk of recurrence of VTE in patients diagnosed with first-time VTE is estimated to be around 7-8 percent per year during an average follow up period of 2.2 years of subsequent observation of 265 patients.[2]
  • Among patients with a first episode of VTE, the risk of recurrence of VTE is particularly elevated in the first 6 to 12 months following the first episode of VTE. The risk of recurrent VTE remains up to 10 years, with a estimated cumulative incidence of first overall VTE recurrence of 30 %. Predictors for recurrence of VTE include malignancy, neurological diseases, and paresis.[10]
  • In recent years, the increase in thrombosis incidence may be related to improved diagnostic modalities and increased awareness by clinicians.[1]

Complications of VTE

  • Estimates suggest that 60,000-100,000 Americans die of VTE, 10 to 30% of which will die within one month of diagnosis.[8][9]
  • Among people who have had a DVT, one-half will have long-term complications (post-thrombotic syndrome) such as swelling, pain, discoloration, and scaling in the affected limb.[8][9]
  • Hospitalized medical patients:
    • Increased risk of thrombosis
      • Anticoagulant thromboprophylaxis with low-molecular-weight heparin [LMWH], low-dose unfractionated heparin (LDUH) bid, LDUH tid, or fondaparinux
    • Low risk of thrombosis
      • Use of pharmacological prophylaxis or mechanical prophylaxis is not recommended
    • Bleeding or at high risk of bleeding
      • Anticoagulant thromboprophylaxis is not recommended
    • Increased risk of thrombosis who are bleeding or at high risk for major bleeding
      • Optimal use of mechanical thromboprophylaxis with graduated compression stockings (GCS) or intermittent pneumatic compression (IPC)
      Note: When bleeding risk decreases, and if risk persist, pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis.
    • Who receive an initial course of thromboprophylaxis
      • Extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay is not recommended.
  • Routine ultrasound screening for DVT is not recommended
  • Using LMWH or LDUH thromboprophylaxis over no prophylaxis is recommended
  • Patients with bleeding, or are at high risk for major bleeding
    • Mechanical thromboprophylaxis with GCS or IPC until the bleeding risk decreases, rather than no mechanical thromboprophylaxis
    • Note: When bleeding risk decreases, and if VTE risk persist, pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis.
  • Outpatients with cancer
    • No additional risk factors for VTE
      • Routine prophylaxis with LMWH or LDUH and the prophylactic use of vitamin K antagonists is not recommended
    • Indwelling central venous catheters
    • Routine prophylaxis with LMWH or LDUH and the prophylactic use of vitamin K antagonists is not recommended
  • Outpatients with solid tumors
    • Additional risk factors for VTE and at low risk of bleeding
      • Prophylactic-dose LMWH or LDUH over no prophylaxis is recommended
    • Note: Additional risk factors for venous thrombosis in cancer outpatients include previous venous thrombosis, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, and lenalidomide.
  • Routine use of thromboprophylaxis
  • At increased risk of VTE
    • Frequent ambulation, calf muscle exercise, or sitting in an aisle seat if feasible
    • Use of properly fitted, below-knee GCS providing 15 to 30 mm Hg of pressure at the ankle during travel
    • Note: Increased risk implies including previous VTE, recent surgery or trauma, active malignancy, pregnancy, estrogen use, advanced age, limited mobility, severe obesity, or known thrombophilic disorder.
  • Not at increased risk of VTE
    • Use of GCS is not recommended
  • Use of aspirin or anticoagulants to prevent VTE
  • The long-term daily use of mechanical or pharmacologic thromboprophylaxis to prevent VTE

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 White RH (2003). "The epidemiology of venous thromboembolism". Circulation. 107 (23 Suppl 1): I4–8. doi:10.1161/01.CIR.0000078468.11849.66. PMID 12814979.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P; et al. (2004). "Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology". Am J Med. 117 (1): 19–25. doi:10.1016/j.amjmed.2004.01.018. PMID 15210384.
  3. ↑ Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ (1998). "Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study". Arch Intern Med. 158 (6): 585–93. PMID 9521222.
  4. ↑ Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA (1994). "The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly". Arch Intern Med. 154 (8): 861–6. PMID 8154949.
  5. ↑ "Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009". Retrieved 2012-10-06.
  6. ↑ Ridker PM, Miletich JP, Hennekens CH, Buring JE (1997). "Ethnic distribution of factor V Leiden in 4047 men and women. Implications for venous thromboembolism screening". JAMA. 277 (16): 1305–7. PMID 9109469.
  7. ↑ Gregg JP, Yamane AJ, Grody WW (1997). "Prevalence of the factor V-Leiden mutation in four distinct American ethnic populations". Am J Med Genet. 73 (3): 334–6. PMID 9415695.
  8. ↑ 8.0 8.1 8.2 Beckman MG, Hooper WC, Critchley SE, Ortel TL (2010). "Venous thromboembolism: a public health concern". Am J Prev Med. 38 (4 Suppl): S495–501. doi:10.1016/j.amepre.2009.12.017. PMID 20331949.
  9. ↑ 9.0 9.1 9.2 CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein
  10. ↑ Heit JA, Mohr DN, Silverstein MD, Petterson TM, O'Fallon WM, Melton LJ (2000). "Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study". Arch Intern Med. 160 (6): 761–8. PMID 10737275.
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