Background: Although increasingly recognized as a major clinical problem, most reported estimates of the attack rates of venous thromboembolism (VTE) are based on studies enrolling patients more than a decade ago. Given changes in patient characteristics, risk factor profiles, and prophylaxis strategies over time, more current estimates are needed if we are to better target high-risk patients and allocate limited health care resources. The purpose of this study was to describe crude, as well as age and gender adjusted, attack rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) in residents of the Worcester Statistical Metropolitan Area (SMSA) during the year 1999. Methods: The medical records of all male and female residents from the Worcester SMSA (2000 census = 478,000) diagnosed with ICD-9 codes consistent with possible DVT and/or PE at all 11 greater Worcester hospital during 1999 were reviewed by trained data abstractors. Characterization of each case of VTE was classified as definite, probable, or possible using prespecified criteria. For purposes of this analysis we approximated attack rates for the total Worcester SMSA population. However, for several specific analyses we have excluded 15 cases of validated VTE occurring in patients < 25 years of age. Age and sex-specific attack rates were calculated in a standard manner. Attack estimates were based on 2000 Massachusetts Census data for the Worcester SMSA which reported 287,631 residents 25 years of age or older. Results: There were a total of 590 recognized episodes of VTE in residents of the Worcester SMSA yielding an approximate attack rate of 123/100,000 population. Approximately one quarter of patients developed VTE during hospitalization for another indication while the remaining three quarters presented to the hospital with VTE. Excluding 15 cases of VTE occurring in patients < 25 years of age yields an attack rate of 200 per 100,000 population (95% C.I. 184, 216). Our study sample included 420 cases of isolated DVT (146/100,000 population), 140 cases of PE with or without DVT (49/100,000 population), and 74 cases of recurrent DVT (26/100,000 population). Overall, attack rates of DVT and PE for females were similar to those of men (DVT 152/100,000 vs 139/100,000; PE 51/100,000 vs 45/100,000). However attack rates in females age 75 years and older were significantly greater than those in men of the same age. The age and specific attack rates of clinically recognized VTE are shown in Figure 1. Conclusions: The annual overall attack rate of VTE in this community based study was slightly higher than that reported in the initial Worcester DVT study of 1985/1986 (107/100,000). In addition, if one excludes the small number of cases of VTE occurring in the young, attack rates/100,000 are almost doubled and increase rapidly with age particularly in women. These data have important implications for targeting of VTE prophylaxis and utilization of health care resources. Attack rate of clinical recognized VTE per 100,000 population: The Worcester Venous Thromboembolism Study 1999 Attack rate of clinical recognized VTE per 100,000 population: The Worcester Venous Thromboembolism Study 1999

We present a case of a patient with acute colonic pseudo obstruction (Ogilvie’s Syndrome) in a 63-year-old Hispanic male with multiple co morbidities, sent from the Nursing Home for evaluation of progressive abdominal distention. Clinical examination and diagnostic workup confirmed massive colonic dilatation, without mechanical obstruction.

International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations.IJCRI publishes Review Articles, Case Series, Case Reports, Case in Images, Clinical Images and Letters to Editor. Website: www.ijcasereportsandimages.comSyphilitic paroxysmal cold hemoglobinuria associated with peripheral gangrene: A diagnostic dilemma Segun P Adeoye, Seema Tayal, Apar Bains, Prabhjot Manes ABSTRACT Introduction: Paroxysmal cold hemoglobinuria is a rare clinical entity; syphilitic association is even rarer. The lack of awareness amongst healthcare providers, and its fleeting course often mean that many a time, paroxysmal cold hemoglobinuria is not diagnosed. Case Report: Herein, we present a case of syphilitic paroxysmal cold hemoglobinuria with peripheral gangrene that necessitated amputation. We describe the atypical presentation, emphasize or diagnostic dilemma and report our therapeutic considerations. Conclusion:The report raises two important points (i) the lack of awareness of the clinical entity amongst healthcare providers (ii) the sub-optimal work-up done for late-onset dementia. We conclude by making the case for including the screen for syphilis in their work-up of patients presenting with aortic valvular disease, chronic dementia (especially of the early-onset type) and hemolytic anemia of the cold antibody variety.

Background: Recent observations suggest that upper extremity deep vein thrombosis (DVT) has become more common over the last few decades. However the prevalence of this disorder within the community has not been established. The purpose of this study was to compare the occurrence rate, risk factor profile, management strategies, and hospital outcomes in patients with upper versus lower extremity DVT in a cohort of all Worcester residents diagnosed with venous thromboembolism (VTE) in 1999. Methods: The medical records of all residents from the Worcester, MA statistical metropolitan area (2000 census=478,000) diagnosed with ICD-9 codes consistent with possible DVT and/or pulmonary embolism at all 11 Worcester hospitals during the years 1999, 2001, and 2003 are being reviewed by trained data abstractors. Validation of each case of VTE is performed using prespecified criteria. Results: A total of 483 cases have been validated as acute DVT events - this represents all cases of DVT occurring in residents of the Worcester SMSA in 1999. For purposes of this analysis we have excluded 4 patients with both upper and lower extremity DVT. Upper extremity DVT was diagnosed in 68 (14.2%) of patients versus 411 (85.8%) cases of lower extremity DVT. Patients with upper extremity DVT were younger, more likely to be Hispanic, more likely to have renal disease and more likely to have had a recent central venous catheter, infection, surgery, ICU stay, or chemotherapy than patients with lower extremity DVT. They were less likely to have had a prior DVT or to have developed their current DVT as an outpatient. Although less likely to be treated with heparin, LMWH, or warfarin they were more likely to suffer major bleeding complications. Recurrence rates of VTE during hospitalization were very low in both groups. Conclusions: Patients with upper extremity DVT comprise a small but clinically important proportion of all patients with DVT in the community setting. Their risk profiles differs from patients with lower extremity DVT suggesting strategies for DVT prophylaxis and treatment for this group may need to be tailored. Characteristics of Patients with Upper versus Lower Extremity DVT Upper extremity (n=68) Lower extremity (n=417) P value *Recent = < 3 months Demographics Mean Age, yrs 59.3 66.5 <0.001 Male (%) 51.5 45 NS Race (%) <0.05 White 86.6 91.6 Black 1.5 3.2 Hispanic 9.0 2.0 VTE Setting (%) <0.001 Community 53.8 76.2 Hospital Acquired 46.2 23.8 Risk Factors (%) Recent Central Venous Catheter 61.8 11.9 <0.001 Recent Infection 48.5 32.4 <0.01 Recent Surgery 47.8 28.1 <0.001 Cancer 44.1 32.6 0.06 Recent Immobility 38.2 47.0 NS Recent chemotherapy 25 9.5 <0.001 Renal disease 23.5 1.7 <0.0001 Recent ICU discharge 23.5 15.1 0.07 Recent CHF 19.1 16.6 NS Previous DVT 3.0 18.7 <0.01 Anticoagulant prophylaxis (%) During hospital admission (n=125) 76.7 71.6 NS During recent prior hospital admission (n=188) 73.7 54.7 <0.05 During recent surgery (n=146) 62.5 55.3 NS Hospital therapy - treatment doses (%) Any heparin/LMWH 66.2 82 <0.01 Warfarin at discharge 53.1 71.2 <0.01 Hospital Outcomes (%) Length of stay (mean, d) 11.2 6.8 <0.01 Major bleeding 11.8 4.9 <0.05 Recurrent DVT 1.5 1.0 NS Recurrent PE 0 0.2 NS Hospital Mortality 4.5 4.1 NS