Distal DVT may not require treatment with anticoagulation. If leg symptoms worsen, or if there is an extension of distal DVT on the follow-up scan, treatment with anticoagulation is recommended.

Hyperhomocysteinemia is a rare condition which predisposes to atherothrombosis. Recurrent venous thromboembolism (VTE) with hyperhomocysteinemia is known but extremely uncommon. Homocysteine levels of more than 22 umol/L can predispose to VTE in a middle-aged women. We describe a case of a middle-aged woman, community ambulant with recurrent VTE with intermediately high homocysteine levels. She had no other risk factors for recurrent venous thrombosis. In our article, we also discuss hyperhomocysteinemia and its link to VTE.

Portal vein thrombosis (PVT) in a setting of liver metastasis is not easy to treat as it may be portal vein tumor thrombus (PVTT). A 77-year-old male patient was diagnosed as ascending colon carcinoma, underwent right hemicolectomy in 1991 with a recurrence in July 2009. In August 2009, he underwent computed tomography (CT) scan of the abdomen which showed evidence of superior mesenteric vein thrombosis with no liver metastasis. He was started with anticoagulation and decision was to treat long term. He was admitted with mesenteric artery ischemic symptoms in February 2012 on anticoagulation. CT scan abdomen and pelvis in February 2012 showed tumor thrombus involving the superior mesenteric vein, portal vein, and splenic vein with hepatic metastasis. His tumor marker chorioembryonic antigen was 34 ?g/L. He was continued on anticoagulation. A repeat CT scan abdomen after 2 years (in January 2014) showed, increase in size of hepatic metastasis, extensive thrombus involving the superior mesenteric vein, portal vein, and splenic vein with collaterals. Mesentery was congested due to extensive superior mesenteric vein thrombus. He finally succumbed in June 2014. It is very important to differentiate PVT from PVTT as the prognosis is different. PVTT progresses despite of long-term anticoagulation with poor prognosis.

C entral aortic systolic pressure (CASP) is a very wellrecognized tool to assess the end organ damage in patients with hypertension, and is now considered superior to peripheral brachial pressure. CASP is measured noninvasively by tonometry or a BPro watch (HealthSTATS, Singapore) ( Figure 1) (1-3). It is known that angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers and calcium channel blockers reduce CASP more than some antihypertensives such as beta-blockers. White coat hypertension with CASP has not been described and validated. We describe a very anxious young patient on telmisartan (an angiotensin receptor blocker) with a very high CASP compared with his peripheral blood pressure (BP). Case presentationA 24-year-old male hypertensive patient was diagnosed on 24 h ambulatory BP monitoring as having definite hypertension. He had a strong family history of hypertension, and was investigated for secondary causes of hypertension. His electrocardiogram results showed evidence of left ventricular hypertrophy. His renin level was 11.69 ng/mL/h (normal 0.15 ng/mL/h to 2.33 ng/mL/h), and his aldosterone level was 89 pmol/L (normal 28 pmol/L to 445 pmol/L). The patient's renal Doppler ultrasound did not show any evidence of renal artery stenosis; his urine catecholamines and metanephrines were negative for pheochromocytoma. His lipid panel showed a low-density lipoprotein cholesterol level of 4.8 mmol/L, high-density lipoprotein cholesterol level of 0.9 mmol/L, cholesterol level of 6.3 mmol/L and triglyceride level of 1.4 mmol/L. He was diagnosed with primary hypertension. As a result, 80 mg/day telmisartan and 10 mg/day atorvastatin were prescribed as treatment.He was fairly well controlled on telmisartan 80 mg/day, with his BP ranging from 125/80 mmHg to 130/85 mmHg (home BP monitoring). In May 2009, he underwent routine CASP at Tan Tock Seng Hospital (Singapore), and ambulatory BP measurements (ABPM) using a BPro watch. Central aortic systolic pressure (CASP) is a very well-recognized tool to assess the end organ damage in patients with hypertension. It is known that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and calcium channel blockers reduce CASP more than some antihypertensives such as beta-blockers. White coat hypertension with CASP has not been described and validated. The present report describes a very anxious 24-year-old patient on telmisartan (an angiotensin receptor blocker), with a very high CASP compared with his peripheral blood pressure (BP). He had a strong family history of hypertension, and was fairly well controlled on 80 mg/day telmisartan, with his BP ranging from 125/80 mmHg to 130/85 mmHg (home BP monitoring). In May 2009, he underwent routine CASP at Tan Tock Seng Hospital (Singapore), and ambulatory BP measurements using a BPro watch (HealthSTATS, Singapore). The patient had a CASP of 132 mmHg at the hospital, but his calculated CASP by ambulatory BP measurement at 1 pm was 120 mmHg. His ambulatory BPs were 137/94 mmHg; thus, hydrochlo...

The purpose of this study was to assess the risk of venous thromboembolism (VTE) in patients admitted to the Tan Tock Seng Hospital (TTSH), Singapore during October and November 2009. The primary outcome assessed was mortality due to VTE, or development of deep vein thrombosis or pulmonary embolism (PE) within 3 months from the day of admission. Both univariate and multivariate analyses were performed for allcause mortality and deaths associated with PE. Seven hundred twenty-one patients admitted to the 5th floor of the General Medicine Department, TTSH, during the 2 months were analyzed. There were 368 (51.04%) female patients and 353 (48.96%) male patients. As per race distribution, 566 (78.50%) patients were Chinese, 100 (13.86%) patients were Malaysians, 46 (6.38%) patients were Indians, and 9 (1.26%) were other races. Four hundred ninety-two (68.24%) were independent for activities of daily living (ADL) and 229 (31.76%) were dependent for all ADL. There were in all 42 deaths. There were definite PE deaths in 2 (4.76%) patients, probable PE deaths in 3 (7.14%) patients, and suspected PE deaths in 8 (19.05%) patients. Twenty (47.62%) deaths were due to pneumonia, 3 (7.14%) deaths were due to urinary tract infections, and 4 (9.52%) deaths were due to other infections. Two (4.76%) deaths were due to myocardial infarction. The risk of VTE was high in acutely ill patients admitted to the General Medicine Department, TTSH, Singapore. The factors that predispose patients to a very high risk are ADL dependence, acute heart failure, past history of VTE, or if they are clinically dehydrated and have acute renal failure. This warrants increased awareness and need for VTE prophylaxis.

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Patients with human immunodeficiency virus (HIV) are at risk of developing thrombosis and are 8 to 10 times more likely to develop thrombosis than the general population. Moreover, if they have hypercoagulable state they can have severe thrombosis and life-threatening thrombotic events. The purpose of this retrospective study is to analyze hypercoagulable state in HIV-seropositive patients who have been diagnosed with venous thromboembolism (VTE). This study is a subgroup study of a larger cohort group of HIV-seropositive patients with VTE followed up with our vascular medicine outpatient clinic. The patients included for this study were HIV-seropositive patients with hypercoagulable state, analyzed over the past 3 years, and followed prospectively. HIV-seropositive patients with arterial thrombosis were excluded. These patients had minimum, regular follow-up of 3 months, with a Doppler scan in the beginning and last follow-up. All the patients were analyzed for hypercoagulable state and the patients selected in this study were those who were tested positive for hypercoagulable state. All patients were analyzed for age, gender, race, site of thrombosis, coagulation factors, lipid panel, type of antiretroviral treatment, past or present history of infections or malignancy, CD4 absolute and helper cell counts at the beginning of thrombosis, and response to treatment and outcome. Patients with HIV with arterial thrombosis were excluded. The study was approved by the ethics committee. Five patients were included in this study. The mean age was 47.8 years (range 38 to 58 years). All were male patients with lower limb thrombosis. Most common venous thrombosis was popliteal vein thrombosis, followed by common femoral, superficial femoral, and external iliac thrombosis. Two patients had deficiency of protein S, two had high homocysteine levels, one had deficiency of antithrombin 3, and one had increase in anticardiolipin immunoglobulin G antibody. All the patients were taking nucleoside and nonnucleoside inhibitors but only one patient was taking protease inhibitors. There was no history of malignancy but two patients had past history of tuberculosis. The mean absolute CD4 counts were 244 cells/UL (range 103 to 392 cells/UL) and helper CD4 counts were 19.6 cells/UL (range 15 to 30 cells/UL). All were anticoagulated with warfarin or enoxaparin. There was complete resolution of deep vein thrombosis only in one patient on long-term anticoagulation but there was no resolution of thrombosis in the other four patients despite of therapeutic anticoagulation for more than 6 months. All the patients are alive and on regular follow-up. Thrombosis in HIV patients is seen more commonly in middle aged, community ambulant male patients. The most common hypercoagulable state was noted as deficiency of protein S and hyperhomocysteinemia. Eighty percent of the patients did not respond to therapeutic anticoagulation.

Objective:Arterial stiffness in Moyamoya disease (MMD) has not been described before in literature. We describe a young 42 year-old lady who initially presented as hypertensive urgency and recurrent stroke and was later diagnosed with MMD. We would like to highlight increased arterial stiffness as a cause of hypertension in patients with MMD.Design and method:This is a case report of a 42 year old lady 42 year Singaporean lady presented in 2015 with headache and transient ischemic attack(TIA) and systolic blood pressure was 200mmHg. She was diagnosed with hypertension at the age 28 years and started on telmisartan 40 mg OD.There was no end organ damage and secondary hypertension work up was negative. She has recurrent TIAs and was started on T. atorvastatin 40 mg ON and T clopidogrel 75 mg OD in Feb 2017.She presented with stroke in March 2019, and MRI revealed left posterior temporal-parietal infarct, MRA revealed severe stenosis of left terminal internal carotid artery(ICA).She presented with recurrent stroke in April 2019 and MRI/MRA revealed scattered acute infarcts in left MCA and ACA territories and severe steno-occlusive disease involving left ICA. She underwent left external carotid –internal carotid bypass in June 2019. In light of these findings, MMD was diagnosed.Results:She was started on T spironolactone and her blood pressure was kept in stable range of 130–150/80–95mmHg. An arterial stiffness study by SphygmoCor in June 2020 showed markedly increased arterial stiffness with markedly increased augmentation index, aortic augmentation pressure, aortic systolic pressure and aortic pulse pressure for the patient’s age.Conclusions:We present an interesting and rare case of hypertension in a young patient with MMD associated with increased arterial stiffness, with no renovascular disease. This is one of the first cases reported in MMD with increased arterial stiffness. We also highlighted genetic studies and case reports that have suggested that the histopathological process underlying Moyamoya vessels may also affect systemic vessels. We hope that this article will inspire more research on the relationship between MMD and hypertension, particularly in terms of how systemic vasculature is affected.