Deep vein thrombosis also known as deep venous thrombosis [medicine] is caused by formation of blood clot in the deep veins of the body. It mostly occurs in the deep veins of the legs. In most cases, the blood clots usually dissolve on their own without any medical intervention. However deep vein thrombosis can become fatal if the blood clot formed breaks loose and then through the blood stream it is transported to the lungs causing pulmonary embolism.
This paper is a focus on the risk the risk factors of deep vein thrombosis in South African population. Dr.Virchrows in early 2005 spent time in South Africa and observed that prevalence of deep vein thrombosis in patients grew at a rate of 18%.Most of these patients were also HIV positive(1097). He conducted a systematic study and in the end of his study, he outlined several principal factors risking deep vein thrombosis in South Africa.
Introduction
Background / Literature review
Dr.Virchrows in early 2005 spent time in South Africa and observed that prevalence of deep vein thrombosis in patients grew at a rate of 18%.Most of these patients were also HIV positive. He conducted a systematic study and in the end of his study, he outlined several principal factors risking deep vein thrombosis in South Africa(542).
Prolonged Inactivity: Lack of leg movement up to four hours or more due to driving for long hours or long flights causes calf muscles in the legs be unable to contract. Contraction of muscles is necessary for facilitating smooth blood circulation in the veins of the legs hence lack of blood circulation enhances the risk of blood clotting in the veins. This can also occur to patients in bed rest or patients with paralysis.
Genetic disorder: Deep vein thrombosis could be as a result of a genetic disorder causing blood clots in the veins.
Pregnancy: Deep vein thrombosis is high in pregnant women suffering from genetic blood clotting disorders and could be a risk up to six weeks after delivery. Pressure in pelvis, legs and veins rises hence risking a high chance of developing deep vein thrombosis.
Surgery: During surgery general anesthesia used tends to dilate veins raising the risk of blood clotting. Injury to veins could also slow down blood circulation hence formation of blood clots. Surgeries that could risk deep vein thrombosis are: orthopedic operations involving the hip and knees, neurological procedures, major pelvic or abdominal surgery caused by malignant like cancer.
Heart failure: Poor heart conditions slacken blood flow and this may lead to blood clots causing deep vein thrombosis.
Obesity: Excess weight puts pressure on the legs and pelvic thus reducing blood circulation in the lower limbs. This could cause blood clots
Smoking: Smoking slows down blood circulation in the body and could also cause blood clots especially in the case of heavy smoking.
Contraceptives: Deep vein thrombosis could be as a result of side effects of contraceptives.
Well over 200,000 South Africans suffer from DVT each year,4 but, because most DVT is occult, the true incidence is unknown (493). Approximately 50,000 patients per year require hospitalization for 5-10 days of intravenous heparin therapy. In addition to those with acute thrombosis, thousands more suffer from sequelae such as stasis dermatitis and venous ulcers. While the degree of morbidity is significant, mortality rates are equally problematic. Thromboembolic disease is annually responsible for 20,000 deaths in South Africa. The elderly are in greatest jeopardy; DVT is associated with around 20% annual mortality in this age group. Many in this subgroup die from associated PE, while others succumb from comorbid disease, especially cancer. Even children are at risk for venous thrombosis. Pediatric patients at risk include those with spinal mechanism that propels blood into the central circulation. Stasis plays a role in thrombosis encountered in the morbidly obese
and in individuals with cardiac disease. Limb paralysis from stroke or spinal cord injury is associated with a difficult to evaluate syndrome of painless or occult thrombosis (493). Surgery and trauma are responsible for up to 40% of all Thromboembolic disease, which results from both a hypercoagulable state and immobility. These insults activate the clotting cascade, and indices of thrombosis and fibrinolysis rise rapidly.
DVT Condition
Questions heparin for DVT, interestingly, this practice is not justified by the literature. For patients not on warfarin, assessment of the PTT will almost never affect management. Obviously, a PTT should be obtained six hours after standard heparin in begun(129). If a patient with acute DVT is currently on warfarin, an International Normalized Ratio (INR) is essential for management. It is now well documented that the prothrombin time (PT) is both antiquated and inaccurate, primarily because the sensitivity of thromboplastin reagents differs from batch to batch. Fortunately, the INR adjusts for this lack of standardization by comparing each batch with an International Sensitivity Index. Measurement of the PT could be eliminated from clinical practice if replaced by the INR. Adequate anticoagulation for DVT is reflected by an INR between two and three. If a patient with a sub-therapeutic INR develops a DVT, they will require more aggressive anticoagulation- first with heparin, and then an increased dose of warfarin. However, a patient who is on warfarin, but sustains an acute clot and has a therapeutic INR, requires a Greenfield filter. Emergency Medicine Reports 17 chest pain or shortness of breath should have a VQ CT scan to expedite the diagnosis (697). Two blood tests are valuable in the management of Thromboembolic disease: the D-dimer and the INR. Current D-dimer assays have predictive value for DVT, and the INR is useful for guiding the management of patients with known DVT who are on warfarin (Coumadin). While no blood test can conclusively rule in or rule out venous thrombosis, a normal D-dimer in a patient with no risk factors for thrombosis makes proximal DVT extremely unlikely. Despite the fact that it is frequently ordered, a complete blood count (CBC) rarely provides useful information in patients with leg signs or symptoms. The leukocyte count cannot distinguish between DVT and cellulitis and is neither sensitive nor specific for either condition. Coagulation studies rarely are required as part of the initial evaluation of venous thrombosis (853). Occasionally, these studies may be valuable after Doppler demonstrates an acute clot, and in patients who develop a clot while on warfarin.
Physical Examination
A caveat that is nearly 20 years old remains valid today. "A combination of clinical signs and symptoms that included tenderness, swelling, redness, and the assessment of Homans' sign [can] not adequately differentiate patients with or without DVT (663)."This is not to imply that physical examination is useless, but that a number of physical findings in combination with risk factors assist in the diagnosis of a patient with leg complaints. Occasionally, a rectal temperature can help distinguish cellulitis from DVT. While patients with DVT may have a low grade fever due to a systemic inflammatory response, this fever rarely exceeds 102°F. To help make this differentiation, it is essential to completely undress the patient with leg symptoms and inspect for lymphangitis, erythema, and ulcerations. Clots may become infected, especially in patients with intravenous drug abuse. Remember to examine the entire limb for abnormalities, as lymphangitis may have large "skip" areas. Be alert for psychiatric patients or prisoners who may tie a tourniquet around their thigh to produce factitious
DVT. Lack of discrepancy in calf size does not rule out DVT. Some researchers have standardized calf measurements at 10 cm below the tibial tuberosity. While asymmetry of the calves of 1 cm or more is abnormal, such asymmetry does not definitively distinguish between patients with Thromboembolic disease and that without (437). However, asymmetric calf swelling of greater than 3 cm is almost always a significant finding. Examine the legs for pitting edema; extremities affected by acute thrombosis are frequently warmer than the opposite limb. Palpation includes a search for "cords," which are very specific, although insensitive for thrombosis. Cords are most often detected in the popliteal fossa. Palpate distal pulses and evaluate capillary refill to assess limb perfusion. Pulses may also be diminished in long-standing arterial disease. The presence of pain with passive range of motion of the toes or ankle is an important clue to compartment syndrome. Move and palpate all joints to detect acute arthritis or other joint pathology. Neurologic evaluation may detect nerve root irritation; sensory, motor, and reflex deficits should be noted. Search for a thrill or bruit which is associated with arteriovenous (AV) fistulas. Patients with large fistulas have abnormally high cardiac output, and manual compression of the fistula reflexively slows the heart by reducing the shunt (Branham's sign). Patients with a remote history of a gunshot wound to the extremity are most likely to present with a fistula (89). Bony tenderness does not rule out DVT. Indeed, up to 65% of patients with DVT will have pain with percussion of the medial tibia. Bancroft or Moses' sign is pain with compression of the calf against the tibia. Some patients with DVT will have more pain with this maneuver than with transverse compression of the gastrocnemius. A review of venous thrombosis would not be complete without mention of Homans sign: pain in the posterior calf or knee with forced dorsiflexion of the foot. It is often present in patients with sciatica. Despite numerous references to Homans sign in the medical literature, this finding is inaccurate and unreliable. Examination of the patient with DVT does not end with evaluation of the extremity. Search for stigmata of PE such as tachycardia (common), tachypnea or chest findings (rare), and exam for signs suggestive of underlying malignancy. Diffuse swelling can indicate the presence of an upper extremity DVT. Effort-induced thrombosis occurs in young, active males, while catheter-related thrombosis is limited to patients with prior instrumentation or intravenous drug abuse. Dilated collateral veins are frequent, but these are more easily seen in Caucasians(655). Look for arm discoloration and palpable axillary veins. Diagnostic Studies Clinical examination alone is able to confirm only 20-30% of cases of DVT. Because of the limitations associated with the physical examination and history, the diagnosis of DVT must be pursued in any patient who presents with unexplained extremity pain or swelling. A patient, who presents with symptoms in both arms and both legs, usually will not be suffering from bilateral thrombosis. Patients with risk factors for bilateral thrombosis, however, who present with bilateral findings, need careful examination. Patients with unilateral complaints and no clear explanation, such as a direct blow to the extremity, twisted ankle, etc., require further evaluation. The presence of risk factors for DVT must decrease the threshold for obtaining imaging studies. Accordingly, nearly all patients with complaints compatible with venous thrombosis, and who have no typical alternative diagnosis, require an imaging study
Therapy
This Clinical Pathway is a suggested approach for suspected DVT patients, and is intended to supplement rather than substitute for professional judgment(749). The physician may change this plan at any time depending upon the patient's individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. 18 January 18, 1999/Emergency Medicine Reports dimer measured by the whole-blood agglutination assay almost rules out the diagnosis (i.e., there will be less than a 1% chance of proximal DVT). While some physicians may opt to forgo imaging studies in patients with a negative D-dimer, others may be reluctant to rely entirely upon a blood test. It seems reasonable that a negative D-dimer may obviate the need for off-hour Doppler studies in low-risk patients. If a patient presents at night with a swollen leg and a negative red cell agglutination test, imaging usually can be safely postponed until the morning.
Imaging Studies
Imaging studies include both invasive (venography, radiolabeled fibrinogen) and noninvasive (ultrasound, plethysmography, MRI) techniques. Current options are discussed in the next sections. While venography aspires to be the "gold standard" modality for the diagnosis of DVT, it is a "gold-plated" standard at best(1109). First, radiologists disagree on interpretation in at least 10% of cases, and 5-15% of all studies are technically inadequate. Moreover, side effects are significant and 2-5% of patients develop phlebitis from this painful procedure. The rare case of anaphylaxis remains a significant clinical concern. For the most part, ultrasound has supplanted venography for the initial evaluation of the patient with suspected DVT. If the ultrasound is equivocal or unavailable, venography may be useful. Venography is also useful if the patient has a high clinical probability of thrombosis and a negative ultrasound, and it is also valuable in symptomatic patients with a history of prior thrombosis in whom the ultrasound is non-diagnostic(295). In these patients, it usually can distinguish between acute events and chronic changes seen on ultrasound. A contrast study can delineate occlusion, recanalization, and collateral channels. Since neither ultrasound nor
impedance plethysmography (IPG) is accurate for clot in Up to 10% of patients with DVT have an underlying coagulation disorder such as antiphospholipid syndrome or protein 'S,' protein 'C,' or antithrombin III deficiency. However, measurements of these levels usually are not necessary for emergency management. On occasion, the admitting internist may screen young adults with unexplained thrombosis for more common coagulation disorders. D-dimer. If an emergency physician wishes to use a single blood test in order to exclude the diagnosis of DVT, the Ddimer assay would be that test. Only 2% of patients with a negative
D-dimer (measured by the whole blood agglutination assay) will have DVT. In patients with a low pretest probability, the negative predictive value is 99.4%. D-dimer is a specific degradation product of cross-linked fibrin (58). Because concurrent production and breakdown of clot characterize thrombosis, patients with Thromboembolic disease have elevated levels of D-dimer. There are three major approaches for measuring D-dimer. The two older tests include the sensitive, but time consuming, enzyme-linked immunoabsorbent assay (ELISA) and a rapid, but less sensitive, latex agglutination. These tests suffered from a specificity
of as low as 15-38% in DVT and PE. Currently, the most useful assay is the whole blood agglutination test (SimpliRED). This five minute, bedside test is both rapid and sensitive. In one study, this technique had a sensitivity of 93% for proximal DVT, 70% for calf DVT, and an overall specificity of 77%.69 All D-dimer tests, regardless of the process, are more sensitive for proximal than distal clot, and may miss as many as 30% of calf DVTs. False-positive D-dimers occur in patients with recent (within 10 days) surgery or trauma, recent myocardial infarction or stroke, acute infection, disseminated intravascular coagulation, pregnancy or recent delivery, active collagen vascular disease, or metastatic cancer.69 In a patient with no risk factors for DVT, a negative DTEST.
Motivation
The motivation of this paper is found in the fact that the risk factors of DVT in South Africa have already been identified. Virchow first elucidated the causes of deep venous thrombosis with a description of a classical triad: stasis, hypercoagulability, and endothelial injury. While at least 50% of patients with DVT have risk factors the strongest risk factor for venous thrombosis is prior Thromboembolic disease. Moreover, risk factors are additive in nature(1824).
Research Question: Is conducting research on DVT necessary?
The necessity to do the research based on the current health implications of DVT to South Africans. Scientists have shown through practical and theoretical arguments the clear effects of DVT to humans (1798). When a condition affects too many people and hits them with severe effects, then necessity arises for research to contain the issue. Further, the research is aimed at making reliable recommendations for future DVT prevention and treatment procedures on basis of its findings.
Research Hypothesis: Tomorrow's implications of DVT in South Africa are depended on research conducted today
The findings of this research shall enable the laying of preventive measures/ procedures for of DVT in South Africa. Further, the research findings are aimed at making reliable recommendations for future treatment procedures on basis of its findings(199).
Aim: The main aim of conducting this research is to identify the risk factors for Deep Vein Thrombosis (DVT) in South African population. This is attained through:
Conducting a literature review on DVT in South Africa
Proposing research
Conducting research and
Reporting Research findings
Methodology
The main methodology for use in this research is based Rajit (2005) Research structure. According to Rajit, reliable research is based on an eight step structure. Each step is a process in itself as described below.
Formulating a research problem. This step involves literature review, formulation of a research problem, identification of variables and formulation of possible hypothesis.
Conceptualizing of a research design: In this step, only two activities are involved. First is identifying a research design and second is selecting a study design for the research.
Construction of an instrument for data collection: In this step, selection of a data collection method is done, then data is collected using attitudinal scales and last, a test to establish the validity of the data collection instrument is done.
Sample selection: this is a brief step as it only involves the selection of a sample.
Writing a research proposal: this is literary the most important step in the research process. Its success determines whether or not the research is to take place and how reliable its outcome is going to be. With reference to this research, it wouldn't be an overstatement to note that the research proposal was successful and that the outcome of the completed research is undoubtedly going to be a success.
Data collection: This step marks the initial stage of the research process in the field. It simply involves collecting data as depicted by the name.
Data analysis: During this second last step, data collected is processed and prepared for display and presentation.
Report writing: This marks the end of the research. It compiles the research process in detail and provides conclusions of findings and recommendations.
This structure as designed by Kumar in 2005 is the research methodology applied in this research.
Ethical and Legal Considerations
For a just and fair research in this research, ethical and legal issues ought to be considered. The legal issues expected are in form of, collaborative partnerships with all stakeholders, social or clinical relevance, scientific merit, fair selection of subjects, favourable risk-benefit assessment, informed consent, independent ethical review and respect for participants.
On the other hand, ethical issues to be considered can be considered as outlined in the Principles for ethical research(14). These are: respect for persons through, autonomy (informed consent), privacy and confidentiality; beneficence to do well and protect from harm and lastly justice as in through fair distribution of benefits and burdens.
Reporting and implementation of results
Previous researches used quantitative approach to provide solutions to the already existing crisis in DVT. The quantitative approach applied was sound enough to include numerical and chronological factual records. Contrastingly, this research uses a qualitative approach in addressing the same problem. Logical analysis and reasoning is heavily employed in this paper which clearly links means to ends in accordance to research the question and purpose. As highlighted earlier, a qualitative approach answers the questions of why and how in a reasonable order (92).
The basic method used in this quantitative form of research is the use of graphs, pie charts, tables among other means of definite data analysis. However, this being a qualitative research, the most preferred method is content analysis. Content analysis is a method of data analysis that involves the consideration of content obtained from the field, most probably verbal or written data. It involves reasoning of why or how a situation is the way it is. By applying this method in this research, a more reliable conclusion is attainable since satisfaction being the key problem in this research is an immeasurable factor. It most revolves the feelings and views of a person towards the subject matter.
The advantage of content analysis discussed above is that the factor of personal views and feeling towards a subject is catered for. Unlike majority other methods such as logical analysis which involves mathematical representation of issues, content analysis accommodates numerically immeasurable forces around the question of satiability in nursing profession.
Limitations
First and foremost, any research is faced with a challenge of imperfection. However data collection, analysis and presentation may be accurate, there always exist measures of tendency in which deviations are expected to occur. This research is limited in such consideration. Second challenge is of bias rooting from misinterpretation of meanings of phrases. Third, the field research always has perverse conditions than those planned for, this could limit the research process in terms of resource availability.
However, to decrease the impact of the above limitations, this research has taken intensive planning measures and created regulative measures(695).
Budget
The budget of this research is set from the cost of key requirements necessary for the success of this research. In this case, funds represent the required materials necessary to facilitate the recording, presentation and report of the research findings. Moreover, the funds are representative of the wages and salaries of personnel of this research. The question of the funds brings in the necessity of funders. These could be the individual donors, cooperates or even the government. This party comes in to facilitate and help in mobilization of necessary resources for the research to be conducted successfully (1109).
Second requirement is the personnel and subjects involved in the research process. The people to strategize this research, the researchers themselves, and the subjects of the research, research writers and data analysts are part of the onboard research crew required. Most important in this list are the proficient personnel who understand data collection methods well. Data collection methods in research are distinct. The same commonly known collection methods are to be employed here. One of the methods is interviews in which a person questions a subject verbally. Another method would be questionnaire filling. In questionnaire filling, subjects are given questions to answer on hard copy. The questions in this form could either be open or closed ended. One advantage of questionnaire method is that data collected is not altered at any moment and that first hand data is available for future consultation in its original state. A third method of data collection would be content analysis. This is method involves reviewing past records of research findings and collecting any relevant from them. Such among other methods are the kind proposed for data collection in this research. This kind of personnel is almost obviously found with people in this field of academics. Preferably, the research should be conducted by qualified personnel.
Research personnel preferable in this research would be medics themselves while on the side of the subjects, those infected together with current practicing medics would be a major consideration in this research. adults presenting to Emergency Units of GF Jooste (GFJ) , Tygerberg hospital (TBH) Victoria hospitals(VWH), Groote schuur Hospital (GSH), Paarl Hospital And Newsomerset Hospital (NSH) or admitted in these hospitals who diagnosed as DVT by formal ultrasounds.
For reliable research writing, experienced research writers come in handy to fill this gap. These can be found locally within the regions of research or at lack, such writers can also be easily found online. Last but not least is the willingness of the relevant authorities in implementing the findings of the research and paving way for carrying out recommendations of this research.
BUDGET
ITEM
QUANTITY
AMOUNT ($)
Posters ( to create awareness)
600 @ $ 1
600
Research Committee pay( 10 members)
$120 per day for 120 days
144000
Field researchers pay (19)
$60 per day for 100 days
114000
Stationery ( pens, writing pads etc.)
general
200
Miscellaneous and allowances
general
35000
TOTAL
293800
