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      Assessment of limb edema in pediatric post‐thrombotic syndrome


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          Pediatric tools for diagnosis of post‐thrombotic syndrome ( PTS) include the assessment of limb edema as a symptom (patient/proxy‐reported) and as a sign. However, it is unclear whether these two approaches refer to the same clinical aspect of PTS. This could result in overestimation of disease severity. We sought to evaluate the correlation among different techniques to assess limb edema as a sign and as a symptom in children who sustained upper extremity ( UE) or lower extremity ( LE) deep vein thrombosis ( DVT) and were, therefore, at risk of PTS.


          Limb edema was cross‐sectionally measured as a symptom (ie, patient‐ or proxy‐reported) and as a sign (ie, clinician‐assessed limb circumference difference, limb volume ratio, bioimpedance spectroscopy ratio ( BIS), and durometry ratio) in 140 children at risk of PTS (n = 70 UEDVT, n = 70 LEDVT). Item‐item correlations were estimated using Pearson or Spearman correlation coefficients, as appropriate, and separately for the UE and LE groups.


          In the UEDVT group, proxy‐reported swelling correlated weakly to moderately with circumference difference and with volume ratio, but not with BIS ratio. In the LEDVT group, proxy‐reported swelling correlated moderately with thigh circumference difference and volume ratio, and patient‐reported swelling correlated moderately with BIS ratio.


          Our findings suggest that patient/proxy‐reported and clinician‐assessed limb edema measure slightly different aspects of PTS, justifying their inclusion in pediatric PTS tools. In addition, proxy‐reported swelling was in closer agreement with clinician‐assessed total limb size (ie, observed edema), and patient‐reported swelling in the LE seemed to reflect limb fluid content (ie, perceived edema).

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          Most cited references18

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          Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.

          Post-thrombotic syndrome varies from mild oedema to incapacitating swelling with pain and ulceration. We investigated the rate of post-thrombotic syndrome after a first episode of deep-vein thrombosis and assessed the preventive effect of direct application of a sized-to-fit graded compression stocking. Patients with a first episode of venogram-proven proximal deep-vein thrombosis were randomly assigned no stockings (the control group) or made-to-measure graded compression elastic stockings for at least 2 years. Post-thrombotic syndrome was assessed with a standard scoring system that combined clinical characteristics and objective leg measurements. Patients were assessed every 3 months during the first 2 years, and every 6 months thereafter for at least 5 years. The cumulative incidence of mild-to-moderate post-thrombotic syndrome was the primary outcome measure. Of the 315 consecutive outpatients considered for inclusion, 44 were excluded and 77 did not consent to take part. 194 patients were randomly assigned compression stockings (n = 96) or no stockings (n = 98). The median follow-up was 76 months (range 60-96) in both groups. Mild-to-moderate post-thrombotic syndrome (score > or = 3 plus one clinical sign) occurred in 19 (20%) patients in the stocking group and in 46 (47%) control-group patients (p or = 4), compared with 23 (23%) patients in the control group (p < 0.001). In both groups, most cases of post-thrombotic syndrome occurred within 24 months of the acute thrombotic event. About 60% of patients with a first episode of proximal deep-vein thrombosis develop post-thrombotic syndrome within 2 years. A sized-to-fit compression stocking reduced this rate by about 50%.
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            Early diagnosis of lymphedema using multiple frequency bioimpedance.

            Multiple frequency bioelectrical impedance analysis (MFBIA) has previously been shown to provide accurate relative measures of lymphedema in the upper limb of patients (1). This paper reports the results of a three year prospective study to evaluate the efficacy of MFBIA to predict the early onset of lymphedema in patients following treatment for breast cancer. Bioelectrical impedance measurements and circumferential measurements of each upper limb were recorded in healthy control subjects (n = 60) to determine the normal range of the ratio (dominant/non-dominant) of extracellular and total limb volumes respectively. Patients undergoing surgery for the treatment of breast cancer were recruited as the study group; MFBIA and circumferential measurements were recorded pre-surgery, one month post-surgery and then at two month intervals for 24 months. One hundred and two patients were recruited into the study. Twenty patients developed lymphedema in the 24 months follow up period of this study. In each of these 20 cases MFBIA predicted the onset of the condition up to 10 months before the condition could be clinically diagnosed. Estimates of the sensitivity and specificity were both approximately 100%. At the time of detection by MFBIA, only one of the patients returned a positive test result from the total limb volumes determined from the circumferential measures. These results confirmed the suitability of the MFBIA technique as a reliable diagnostic procedure for the early detection of lymphedema.
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              A cross-sectional study evaluating post-thrombotic syndrome in children.

              Post-thrombotic syndrome (PTS) in adults, characterized by swelling, skin pigmentation, pain, and ulceration of the limb, is secondary to deep vein thrombosis (DVT). In contrast to the extensive documentation on PTS in adults, little is known about the risk of PTS in children. To determine the incidence, clinical characteristics, and predictors of PTS in children. A cross-sectional study in 153 nonselected children with objectively confirmed DVT. All children were assessed for PTS using a standardized score. As per the PTS score, severity was classified as: absent, mild, moderate, or severe. Post-thrombotic syndrome was present in 96/153 children (63%), in which 80 (83%) were mild and 16 (17%) were moderate. Swelling was the most frequently recorded subjective symptom (43%) while increased limb circumference (71%) and presence of collateral circulation (53%) were the most frequently recorded objective symptoms. Risk factors for development of PTS were: lack of resolution of the DVT by radiographic assessment (OR 3.96, 95% CI 1.68-9.30), number of vessels involved in the initial DVT (OR 2.05, 95% CI 1.52-2.77), and length of follow-up (OR 1.22, 95% CI 1.08-1.39). These findings demonstrate that PTS is a clinically significant disease in children with previous DVT.

                Author and article information

                Res Pract Thromb Haemost
                Res Pract Thromb Haemost
                Research and Practice in Thrombosis and Haemostasis
                John Wiley and Sons Inc. (Hoboken )
                17 April 2018
                July 2018
                : 2
                : 3 ( doiID: 10.1002/rth2.2018.2.issue-3 )
                : 591-595
                [ 1 ] Department of Pediatrics The Hospital for Sick Children Toronto ON Canada
                [ 2 ] Institute of Health Policy, Management and Evaluation University of Toronto Toronto ON Canada
                [ 3 ] Child Health Evaluative Sciences The Hospital for Sick Children University of Toronto Toronto ON Canada
                [ 4 ] School of Chemistry and Molecular Biosciences The University of Queensland St. Lucia, Brisbane Australia
                [ 5 ] Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto ON Canada
                [ 6 ] Department of Research Design and Biostatistics Sunnybrook Health Sciences Centre Toronto ON Canada
                Author notes
                [*] [* ] Correspondence

                Leonardo R. Brandão, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.

                Email: leonardo.brandao@ 123456sickkids.ca

                © 2018 The Authors. Research and Practice in Thrombosis and Haemostasis published by Wiley Periodicals, Inc on behalf of International Society on Thrombosis and Haemostasis.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                : 17 October 2017
                : 12 January 2018
                Page count
                Figures: 0, Tables: 2, Pages: 5, Words: 3756
                Funded by: Physicians’ Services Incorporated Foundation
                Brief Report
                Online‐only Articles
                Original Articles: Thrombosis
                Custom metadata
                July 2018
                Converter:WILEY_ML3GV2_TO_NLMPMC version:version=5.4.3 mode:remove_FC converted:16.07.2018

                child,deep vein thrombosis,lower extremity,signs and symptoms,upper extremity


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