Asymptomatic DVT may be regarded as a reliable surrogate endpoint for clinical outcome in studies investigating thromboprophylaxis in general surgery. LMWH seems to be as effective and safe as UFH. Determination of the optimal dose regimen of LMWH for this indication requires further investigation.

et al. Br J Surg 2010;97:650-6.Conclusion: There are no differences between sclerotherapy results in patients treated for truncal varices with foam sclerotherapy regardless of whether compression therapy after the procedure is used for 1 or 5 days.Summary: There are no data on the optimal bandaging regimen after foam sclerotherapy for truncal varices. In Great Britain, 80% of the members of the Vascular Society of Great Britain and Ireland responding to a questionnaire, and who treated patients with sclerotherapy, indicated they used compression bandages, and 90% subsequently used compression stockings after compression bandaging. Duration of treatment ranged from 1 to 7 days for initial bandages, with compression stockings used for 7 to 14 days, with some surgeons recommending compression stockings for up to 3 months. The authors sought to determine whether duration of bandaging could be reduced after foam sclerotherapy for truncal varices.Patients with primary uncomplicated varicose veins were randomized after foam sclerotherapy treatment to wearing compression bandaging for 24 hours or 5 days. In each case after compression bandages were removed, thromboembolism deterrent (TED) stockings then used for a total of 14 days of compression after foam sclerotherapy. The primary end point of the study was the 6-week Aberdeen Varicose Vein Severity Score (AVVSS) and Buford pain score. The study randomized 124 legs, of which 61 were randomized to 24 hours of compression bandaging and 63 to 5 days of compression bandaging. Venous occlusion rates at 6 weeks were 90% and 89%, respectfully (P ϭ .842). There were no differences in phlebitis after 2 weeks (P ϭ .445), skin discoloration after 6 weeks (46% vs 40%; P ϭ .546). There were no differences between groups in the AVVSS from baseline to 2 weeks (-0.29 vs -0.80; P ϭ .717) or to 6 weeks (-5.89 vs -5.14; 95% confidence interval [CI] for the difference, -3.29 to 1.8; P ϭ .563). There were also no differences between groups in changes in the Buford pain score from baseline to 2 weeks (-9.04 vs -2.80, P ϭ .248) or to 6 weeks (-17.32 vs -8.46; 95% CI for the difference, -19.06 to 1.33; P ϭ .088). Finally, the two groups also did not demonstrate any differences in changes in the Short Form-36 score from baseline to 6 weeks (2.02 vs. 1.74; P ϭ .903).Comment: Foam sclerotherapy is replacing liquid sclerotherapy as the preferred method of sclerotherapy for patients with truncal varicosities. Compression after treatment is essential to optimal results. However, as the authors point out with respect to foam sclerotherapy, the optimal duration of compression after treatment has not been adequately studied. This study is good news for patients. Compression bandages are not comfortable, and the results indicate that 24 hours of compressive bandaging, followed by a TED stocking for a total of 2 weeks, is just as efficacious as 5 days of compressive bandaging, followed by a TED stocking for a total of 2 weeks. The study provides practical guidance for post-therapy bandaging of patients...

Summary. Background: The benefit-to-risk ratio of vitamin K antagonists (VKA), relative to active comparators, especially low-molecular-weight heparins (LMWH), for preventing venous thromboembolism in patients undergoing major orthopedic surgery is debated. Objectives: We performed a meta-analysis of all randomized trials in orthopedic surgery comparing adjusted doses of VKA to control treatments. Patients and methods: An exhaustive literature search, both manual and computer-assisted, was performed. Studies were selected on the basis of randomization procedure (VKA vs. a control group). At least one of the following outcome measures was to be evaluated: deep vein thrombosis (DVT), pulmonary embolism (PE), death, major hemorrhage or wound hematoma. Four reviewers assessed each article to determine eligibility for inclusion and outcome measures. Results: VKAs were more effective than placebo or no treatment in reducing DVT [567 patients, relative risk (RR) ¼ 0.56, 95% confidence interval (CI) 0.37, 0.84, P < 0.01] and clinical PE (651 patients, RR ¼ 0.23, 95% CI 0.09, 0.59, P < 0.01). These results were obtained at the cost of a higher rate of wound hematoma (162 patients, RR ¼ 2.91, 95% CI 1.09, 7.75, P ¼ 0.03). VKAs were also more effective than intermittent pneumatic compression (534 patients, RR ¼ 0.46, 95% CI 0.25, 0.82, P ¼ 0.009) in preventing proximal DVT. In contrast, VKAs were less effective than LMWH in preventing total DVT and proximal DVT (9822 patients, RR ¼ 1.51, 95% CI 1.27, 1.79, P < 0.001; and 6131 patients, RR ¼ 1.51, 95% CI 1.04, 2.17, P ¼ 0.028, respectively). The differences between VKA and LMWH in major hemorrhage and wound hematoma were not significant. Conclusions: In patients undergoing major orthopedic surgery, VKAs are less effective than LMWH, without any significant difference in the bleeding risk.

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The literature suggests that variations in anticoagulant effect occur when acenocoumarol is administrated in a daily dose. We assessed the anticoagulant effects of acenocoumarol with INR, factors VII and X and protein C in 12 randomly selected hospitalised patients with deep-vein thrombosis, six of them receiving a daily dose of acenocoumarol, the other six receiving twice daily doses. When the drug effect had been at a steady-state for at least 72 h, five blood samples were drawn per patient over a period of 24 h. No nycthemeral significant variations were noted for INR, factor X and protein C in the two groups (P > 0.10). Nycthemeral significant variation in factor VII when acenocoumarol was administered once daily was noted (P = 0.02), but the clinical relevance of factor VII variation at steady-state is uncertain. In spite of the short pharmacokinetic half-life of acenocoumarol, a stable nycthemeral pharmacodynamic activity was observed after once daily administration; twice-daily administration of acenocoumarol does not appear to be justified.

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Heparin was measured, with respect to standard curves prepared with normal pooled plasma, by five methods, APTT, (Auto-APTT), thrombin time (Thromboquik), one (Heptest) and two-stage (Hepaclot) coagulation, anti-factor Xa and chromogenic anti-factor Xa after addition at three concentrations (0.2, 0.4, 0.6iu/ml) to plasma prepared from three groups of ten individuals: normal young volunteers, hospitalized patients with malignancy and hospitalized geriatric patients. By the APTT and TT, differences in sensitivity were observed, for example, at 0.4iu heparin/ml corresponding to an apparent difference in heparin level of 10- and 14-fold between high and low responding individuals. All low responders, by APTT and TT, were in the older hospitalized group, tending to overheparinization when monitoring by these methods. Such large differences were not apparent by any of the anti-factor Xa assays. A circadian difference (1.9 and 1.8 fold) in sensitivity was also observed in the patient group such that in samples taken at night (12 pm), heparin levels were 30-50% higher than those taken during the morning on average when measured in the APTT and TT (p,0.001, analysis of variance). Again, such large differences were notapparent by anti-factor Xa methods. In light of recent findings about the usefulness of anti-factor Xa methods for efficient monitoring of heparin, it issuggested that this conclusion may arise from the tendency for anti-factor Xa methods to determine actual concentrations of heparin.

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