Jama-Journal of the American Medical Association最新文献

Importance: Superficial vein thrombosis (SuVT) is characterized by thrombus in the superficial veins, typically in the lower or upper extremities, and has an estimated annual incidence of 64 to 131 per 100 000 person-years. Approximately 10% of patients with SuVT progress to deep vein thrombosis (DVT) or pulmonary embolism (PE).

Observations: Endothelial injury (caused by infection or intravenous devices), venous stasis (such as from chronic venous insufficiency or prolonged immobility), and hypercoagulability (due to cancer or pregnancy) are pathophysiologic factors associated with SuVT. Clinical risk factors for lower extremity SuVT are similar to those of DVT and PE and include pregnancy, varicose veins, and active cancer. The incidence of SuVT is greater in females than males (78-167 compared with 49-116 per 100 000 person-years). In contrast with lower extremity SuVT, upper extremity SuVT is primarily caused by indwelling intravenous catheters. Patients typically present with a tender, red, palpable cord under the skin in the upper or lower extremity. D-dimer testing has a sensitivity of approximately 48% to 74.3% and, therefore, is not reliable for excluding SuVT. Approximately 25% of patients with lower extremity SuVT present with concomitant DVT, likely because risk factors for SuVT and DVT are similar and because SuVT can extend into deep veins. In people without classic symptoms and signs of SuVT, ultrasonography can establish the presence and extent of the thrombus. Management may include elastic compression stockings and nonsteroidal anti-inflammatory drugs. For patients with SuVTs that are at least 5 cm long or those with persistent or worsening symptoms despite several days of conservative therapy, treatment includes anticoagulation with fondaparinux 2.5 mg. Alternative anticoagulation treatment includes rivaroxaban 10 mg once daily and low-molecular-weight heparins (eg, enoxaparin 40 mg once daily), which may reduce subsequent venous thromboembolic events. SuVT located within 3 cm of a deep vein should be treated with therapeutic doses of anticoagulation such as direct oral anticoagulants.

Conclusions and relevance: SuVT typically presents as a tender, painful, palpable cord under the skin. Management may include elastic compression stockings, nonsteroidal anti-inflammatory drugs, and systemic anticoagulation with fondaparinux 2.5 mg or rivaroxaban 10 mg. SuVTs within 3 cm of a deep vein should be treated with therapeutic dose anticoagulation.

Importance: Syphilis is an infectious disease caused by Treponema pallidum, a gram-negative, spirochete bacterium. Worldwide, an estimated 8 million adults aged 18 to 49 years acquired syphilis in 2022. From 2019 to 2023, US syphilis cases increased by 61% overall, with diagnoses among females increasing by 112% and congenital syphilis cases increasing by 106%.

Observations: Syphilis is transmitted via contact with infectious lesions during vaginal, anal, or oral sex or via the placenta during pregnancy. Individuals at increased risk for syphilis include people with HIV, those engaging in condomless sex with multiple partners, and men who have sex with men (MSM)-who comprised one-third (32.7%) of all males with primary and secondary syphilis in 2023. Early syphilis is defined as syphilis in the first year after infection and includes symptomatic (primary and secondary) and asymptomatic (early latent) stages. Primary syphilis is characterized by painless anogenital lesions. Secondary syphilis is associated with a diffuse rash, mucocutaneous lesions, and lymphadenopathy. Syphilis diagnosed more than a year after infection is referred to as late syphilis and includes asymptomatic (late latent) and symptomatic (tertiary) stages. Neurosyphilis, which can occur at any stage, can lead to meningitis, uveitis, hearing loss, or stroke. In pregnancy, up to 40% of fetuses with in-utero exposure to syphilis are stillborn or die from their infection during infancy. The diagnosis of syphilis relies on serologic reactivity along with a clinical history and presentation consistent with active or latent syphilis infection. The recommended treatment for syphilis is benzathine penicillin G administered as intramuscular doses of 2.4 million units: a single injection for early stage and 3 weekly injections for late latent stage syphilis. Strategies to identify and prevent syphilis infections include (1) screening of sexually active people aged 15 to 44 years at least once and at least annually for those at increased risk, (2) screening 3 times in pregnant individuals (at the first prenatal visit, during the third trimester, and at delivery), (3) counseling about condom use, and (4) offering doxycycline postexposure prophylaxis (200-mg doxycycline taken within 72 hours after sex as postexposure prophylaxis) to MSM and transgender women with a history of a sexually transmitted infection in the past year.

Conclusions and relevance: Syphilis infections, including congenital syphilis, have increased in the US and worldwide over the past decade. First-line treatment for syphilis is benzathine penicillin G. Routine syphilis screening of all pregnant patients and all sexually active people aged 15 to 44 years and use of doxycycline postexposure prophylaxis in individuals at risk for syphilis infection are recommended strategies to decrease syphilis transmission.