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Abstract
Evidence-based medicine underpins modern practice of medicine. This paper describes a fictional consultation between Santa Claus and a doctor regarding deep vein thrombosis (DVT) prophylaxis, giving a
review of the evidence for DVT prophylaxis in travellers while exposing the difficulty in applying evidence
to atypical clinical encounters. Medline and the Cochrane Library were searched, and guidelines
reviewed. Keywords used were DVT, thromboembolism, deep vein thrombosis and air travel-related
venous thromboembolism. All relevant studies found, have been included in this review, with additional
studies identified from the references in these articles. In conclusion, compression stockings, with or
without a one-off dose of either aspirin or heparin, are the most evidence-based approaches for prophylaxis in someone with established risk factors for DVT prior to a long-haul flight. Simple exercises
should also be encouraged.
Keywords: DVT, thromboembolism, deep vein thrombosis, air travel-related venous thromboembolism,
Santa
Introduction
Approaching Christmas, travel health consultations will
involve patients with a range of intentions: city-breaks,
snow-sports and Christmas sunshine. Most will be low
risk and have an evidence-base for advice.
Yet what if Santa presented for advice on deep vein
thrombosis (DVT) risk during his long-haul flight? A
link between air travel and venous thromboembolism
(ATVT) is accepted1, with a symptomatic frequency of
1%2 and a symptomless frequency of 10%.3 DVT can be
complicated by venous thromboembolism (VTE) to the
lung, pulmonary embolus (PE), and in the context of airtravel is referred to by some authorities as ATVT; for simplicity this paper will refer to DVT, as this is the accepted
aetiology.
Santa is a statistical outlier. Even adjusting for his
demographics and establishing his baseline coagulation
risk may not enable us to use aviation data accurately, as
a flying sleigh is a different physiological environment to
a pressurized cabin. Regardless, there remains relatively
little data on coagulation in extreme environments.
Scenario
Dr Van Testatus, during his travel clinic, had just convinced a patient that typhoid was unlikely in Chamonix
during December, when an elderly jolly gentleman
entered and introduced himself as Santa. He reported
that he was self-employed and therefore did not have
access to an occupational health department but was due
DOI: 10.1258/smj.2011.011154
184
Nunn et al.
Table 1 Factors that may increase the risk of DVT in airline travellers
above the baseline population (adapted from Clarke et al. 5)
Individual risk factors
Hereditary or acquired
prothrombotic clotting
disorders
Previous DVT/VTE
Older age
Pregnancy and the postpartum
state (not relevant to Santa)
Recent surgery or trauma
Malignancy
Smoking status
Chronic heart disease (other
chronic disease, especially
cardiovascular diseases)
Obesity
Medication (oral contraceptive,
hormone replacement)
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Risk factor
Cautions
Dermatitis
Final considerations
The evidence suggests that it is vital to establish previous
DVT as a risk factor. Unfortunately for Santa, studies
suggest that continuous flight and multiple flights are
equal risk factors.25 Distance may be important as there
is risk in long distance flights with stopovers.8 However,
unless Santa flies to Charles de Gaulle, he would not
have been included in this data.
Why are there limited data? The usabilty of data
depends upon study design, cohort, validity and the population to which one wishes to apply the findings. Complex
studies often raise questions in ethical review and this
delays research.60 The NZATT study excluded patients
with a positive D-dimer, which mainly excluded elderly
patients.2 People with risk factors are often excluded.61
The greatest, common, problem facing us is a lack of
evidence. Research has been done on flight DVT, but
approaches are inconsistent, making it impossible to
collate data. We need a consensus on the definition of
long-haul flights because ,2 hours,8 .3 hours,23 .4
Scottish Medical Journal
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Nunn et al.
Recommendations
Van Testatus could recommend stockings following the
Cochrane review. However, in the trials used for this
analysis there were no symptomatic DVTs, PEs or deaths,
and so the effect of stockings on these endpoints was undetermined.5 However, these data may not apply to the
seated position.
Therefore Van Testatus could advise compression
hosiery and encourage movement on the flight. He could
consider a one-off dose of 150 mg aspirin, if he was satisfied
with establishing gastrointestinal-bleed risk and providing
adequate gastric protection, or a single-dose of prophylactic low molecular weight heparin prior to departure. Dr VT
will need to update his opinion as further WRIGHT and
CLOTS data become available.
Provenance statement: KN and MB are both Academic
Foundation Programme (a recent initiative in the UK to
promote development of future academic clinicians) clinical doctors. KN suggested this clinical problem, and MB
thought this was essential, so KN and MB prepared the
manuscript. They then sought mentorship from MW and
expert opinion from IW, who critiqued the structure,
format and evidence base. Professor Michael Greaves
(Faculty of Medicine, University of Aberdeen) provided
editorship and local peer review, critically contributing
to the text. The final decision to submit was made by
KN and MB, and both act as guarantors. KN and MB contributed equally to the text.
Conflict of interest: Both KN and MB report having
received gifts from Santa but do not feel able to accurately
declare the net value, they advocate Santas work but
receive no direct reward, nor travel reimbursement for
doing so. There is no known financial or other relationship
between the hospitals, University and Santa. KN and MB
also report having left mince pies, carrots and a wee tipple
out for Santa and his reindeer in the past. They do not
believe that their interest in Santa has any direct bearing
on their clinical or academic practice. MW, IW and MG
deny any interest in Santa that would jeopardize their professional autonomy.
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