User:NikosGouliaros/sandbox3

Comments from NikosGouliaros]

Congratulations and thanks for the obvious hard work that has been put to this article. Please read what follows as a humble, well-meaning, good-faith review. It will be updated section by section.

Background

• The medical manual of style (MEDMOS) does not include such a section. Moreover, the information it currently contains can easily be included in other sections, like Pathophysiology. The second paragraph hardly includes any "background" information; it would better be classified under Classification, Complications, and Epidemiology. A section on classification can include not only what subtypes a condition like DVT can comprise, but also what groups of conditions DVT is a part of, e.g. the spectrum of VTE. My humble opinion is that the article would benefit from removing the whole section and repositioning the information it contains in the respective sections, as delineated in MEDMOS.
• If one paragraph is collectively supported by one source, it is sufficient for the inline citation to appear once at the end of the paragraph.
• Source [21] is inappropriate for the information it supports. Itself it cites: ISTH Steering Committee for World Thrombosis Day (2014). "Thrombosis: a major contributor to the global disease burden". J Thromb Haemost. 12 (10): 1580–90. doi:10.1111/jth.12698. PMID 25302663.. (More on that under Epidemiology.)
• [22] cites a possibly predatory journal, that is not indexed in MEDLINE. A more appropriate source is: Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P; et al. (2019). "European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism". EuroIntervention. 14 (13): 1389–1402. doi:10.4244/EIJ-D-18-00622. PMID 30141306.{{cite journal}}: CS1 maint: multiple names: authors list (link).
• The last paragraph, on unusual, non-deep, vein thrombosis, is perhaps unnecessary. NikosGouliaros (talk) 23:49, 16 April 2021 (UTC)

Signs and symptoms

• The text starting from "Signs and symptoms alone are not sufficiently..." until the end, with info on diagnostic pathways and differential diagnosis, belongs to Diagnosis.
• What remains would benefit from more details. It's a type of medical content that is difficult to source only from journal articles, without also citing a textbook. The ones on my bookshelves are a bit old and therefore not ideal, but literature on signs and symptoms doesn't change so fast as to demand the most recent citations; so I'm attempting a rewrite:
  "DVT affects the legs approximately 10 times more often than the arms. People with DVT complain of pain, tightness, or a sense of fulness of the affected limb; if it is a leg, symptoms are worsened by standing and walking. The leg or arm may be swollen, and when pressure is applied to a small area, the indentation persists after its release ("pitting edema"); it may also be warm and reddened, cyanotic or discolored. Tenderness is another sign, especially along the affected vein, which may be palpable as a cord. Distented superficial veins and prominent venous collaterals may be noted, and vein distention is not reversable by raising the member. The presence of inflammation of the vein walls, which may precede or follow clot formation and is termed thrombophlebitis, may cause the skin above them to become red and hot. They patient may have fever and complain of cramps in the adjoining muscles.
  DVT located at the calf may have fewer manifestations, especially if only one vein is obstructed, allowing venous blood return to continue through the rest. On the other hand, proximal DVT located at the femoral or iliac veins can produce intense pain and massive leg edema, as well as pallor from reduced arterial flow (due to arterial spasm, or the interstitial pressure from the edema surpassing the capillary perfusion pressure). This condition is referred to as phlegmasia alba dolens (painful white inflammation). Total obstruction of venous outflow can cause fluid to accumulate and increase interstitial pressures further, collapsing the arteries and producing limb ischemia that gives it a cyanotic hue (phlegmasia cerulea dolens, painful blue inflammation). Interstitial fluid accumulation can reduce intravascular fluid volume, and cause the blood pressure to drop, along with other manifestations of hypovolemia. " This paragraph is not complete, as it lacks info on what changes with different sites of DVT, eg femoral vs saphenous veins, and with the presence of inflammation; I can come back with more. (I seem to have become a writer instead of a reviewer, so another reviewer, of what I myself write, is needed.) Note that StatPearls, from what I read in archived discussions in WikiProject Medicine, is not the best of sources, but I consider it acceptable for simple information on signs and symptoms, and pathophysiology. It's obvious that I too, unfortunately, lack a good vascular medicine textbook.
  • I think this is a great idea, and I totally agree with you on the need to find other sources that might not have been published in the last several years. I like the text you propose. The only thing I'd add is that I've heard that "palpable cords" are actually superficial vein thrombosis (SVT) (or was it superficial thrombophlebitis?), thus why you can feel them (they aren't deep), and because an association with SVT and DVT raises suspicion for DVT.

(We have been editing at the same time). I don't mind removing the palpable cords, it's probably one of the things that physicians read in books but never encounter in real life.NikosGouliaros (talk) 18:13, 18 April 2021 (UTC)

• Skimming source [19] I cannot find support for asymptomatic DVT, and I couldn't find it in a quick search through PubMed either. The source can be changed to, and the text may be expanded as: People with DVT may experience no symptoms, especially if they are staying recumbent because of some other condition. This source is not ideal, as its 13 years of age may be challenged in a Featured Article Review, but the statement it sources in my opinion doesn't necessarily need a very recent publication.
• Phlegmasia cerulea dolens, and also phlegmasia alba dolens, probably merit a mention in this section, and perhaps only in this section. I can come back with more. In a sense, they too are complications of DVT.
  • I think phlegmasia cerulea dolens merits a mention here, good idea. I spent a fair amount of time in the literature looking up phlegmasia cerulea dolens and phlegmasia alba dolens last year because I was confused on this point (how much they should be covered in the DVT article). I concluded that term phlegmasia alba dolens was not used in the current DVT literature and that the profile of phlegmasia cerulea dolens was rising in the current literature. That's why I mention it in several places, because management of iliofemoral DVT can overlap with phlegmasia cerulea dolens. Phlegmasia cerulea dolens is simply a severe form of DVT and because it is DVT it should be discussed throughout where it merits mention, in my opinion.

While you were writing this I was adding material on the two types of phlegmasia dolens. On the white one, I have no strong feelings. However, although I have no access to the full text, searching in the Google Books Preview I see it is mentioned in Rutherford's vascular surgery and endovascular therapy, which is a major surgical textbook. NikosGouliaros (talk) 18:13, 18 April 2021 (UTC)

• According to MEDMOS, Complications should be included in this section. They can be described in a subsection, as in Dengue fever, or (more commonly) simply mentioned along with their clinical presentation as separate paragraphs, as in Influenza. I propose adding one or two paragraphs, with symptoms and signs of pulmonary embolism, paradoxic embolism, and post thrombotic syndrome. Doing so will eliminate most of the content of a section on Complications, which is not allowed for in the MEDMOS. The information on recurrent DVT, that is currently also included in Complications, may be moved to prognosis. 22:26, 17 April 2021 (UTC) 22:26, 17 April 2021 (UTC) Edited: 18:03, 18 April 2021 (UTC)

Classification

• This section can have various positions, but this one is fine.
• As I wrote earlier, I think it's better of pulmonary embolism (PE) is described briefly as a complication of DVT in Signs and symptoms; therefore, I would move the first sentence of this section there (if no other source is at hand, Braunwald (2019) can be cited). The second sentence contains the info that I prefer this section to start with (i.e., that DVT and PE constitute the entity of venous thromboembolism); the source is fine.
• About two-thirds of VTE manifests as DVT, with one-third manifesting as PE.: A more recent source would be: Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A; et al. (2020). "American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism". Blood Adv. 4 (19): 4693–4738. doi:10.1182/bloodadvances.2020001830. PMC 7556153. PMID 33007077.{{cite journal}}: CS1 maint: multiple names: authors list (link). To be more specific, it should read "About two-thirds of VTE manifests as DVT without PE; one-third manifests as PE (with or without DVT).
• Up to one-forth of PE cases cause sudden death: I would move this to to the PE section of Signs and symptoms. More recent source same as above.
• The next paragraph could begin with a phrasing like "DVT is classified as provoked etc", and later "It is also classified as acute...", to better justify the title of the section.
• Ortel (2020) could be used for the definition of provoked and unprovoked DVT, as more recent. On provoked and unprovoked DVT, one could add "This distinction has important implications to therapy".
• Acute DVT is characterized by pain and swelling and is usually occlusive, which means that it obstructs blood flow, whereas non-occlusive DVT is less symptomatic.: The distinction between occlusive and non-occlusive DVT is self-evident, and seems to attract little attention in literature; I haven't been able to find a direct mention in it in a source more recent than the two cited ones [Scarvelis (2009) quotes a 1992 paper}. I propose deleting this sentence (but this is getting outside my field of expertise, so my proposal is weak).

References