Statement of Principles

concerning

DEEP VEIN THROMBOSIS

Instrument No. 5 of 2001 as amended

made under section 196B(2) of the

This compilation was prepared on 5 October 2005
taking into account Amendment of Statement of Principles concerning DEEP VEIN THROMBOSIS (Instrument No. 38 of 2004)

Prepared by the Repatriation Medical Authority Secretariat, Brisbane

Revocation and Determination

of

Statement of Principles

concerning

DEEP VEIN THROMBOSIS

ICD-10-AM CODES: I80.1, I80.2, I80.8, I82.2, I82.8

Veterans’ Entitlements Act 1986

1.         The Repatriation Medical Authority under subsection 196B(2) of the Veterans’ Entitlements Act 1986 (the Act):

(a)       revokes Instrument No.43 of 1998; and

(b)       determines in its place the following Statement of Principles.

Kind of injury, disease or death

2.        (a)       This Statement of Principles is about deep vein thrombosis and death from deep vein thrombosis.

            (b)       For the purposes of this Statement of Principles, “deep vein thrombosis” means an aggregation of blood factors, primarily platelets and fibrin with entrapment of cellular elements, present in the deep venous system, and causing vascular obstruction at the point of its formation, but excluding retinal, cerebral, pulmonary, hepatic, renal, portal and mesenteric thrombosis, attracting ICD-10-AM code I80.1, I80.2, I80.8, I82.2 or I82.8.

Basis for determining the factors

3.         The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that deep vein thrombosis and death from deep vein thrombosis can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces.

Factors that must be related to service

4.         Subject to clause 6, at least one of the factors set out in clause 5 must be related to any relevant service rendered by the person.

Factors

5.         The factors that must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting deep vein thrombosis or death from deep vein thrombosis with the circumstances of a person’s relevant service are:

(a)       undergoing surgery requiring a general, spinal or epidural anaesthetic within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(b)       suffering trauma to the affected vein within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(c)       experiencing immobilisation for at least four consecutive hours within the 30 days immediately before the clinical onset of deep vein thrombosis; or

(d)       undergoing non-surgical hospitalisation within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(e)       suffering from:

(i)                a significant head injury,

(ii)             a spinal cord injury,

(iii)           a fracture to the spinal column, pelvic bone, femur, or tibia, or

(iv)            an injury to the lower extremity requiring treatment with a cast

within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(f)               suffering from congestive cardiac failure within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(g)              suffering from a malignant neoplasm at the time of the clinical onset of deep vein thrombosis; or

(h)       for deep vein thrombosis in a lower limb or the pelvis only, suffering from paralysis of either or both lower limbs at the time of the clinical onset of deep vein thrombosis; or

(j)        suffering from a space occupying lesion causing venous compression of:

(i)        the affected vein, or

(ii)       a vein draining the affected vein

at the time of the clinical onset of deep vein thrombosis; or

(k)       being obese at the time of the clinical onset of deep vein thrombosis; or

(m)      for deep vein thrombosis in a lower limb only, suffering from varicose veins in the affected lower limb within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(n)        for deep vein thrombosis in a lower limb only, suffering superficial vein thrombosis of the affected lower limb within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(o)       undergoing a course of the combined oral contraceptive pill for a period of at least three weeks within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(p)       undergoing a course of hormone replacement therapy for a period of at least three weeks within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(q)       being pregnant or being within the 90 days immediately postpartum at the time of the clinical onset of deep vein thrombosis; or

(r)        undergoing treatment with a cytotoxic agent for a malignant or proliferative disease within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(s)        undergoing treatment with tamoxifen within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(t)        suffering from a myeloproliferative disease at the time of the clinical onset of deep vein thrombosis; or

(u)       suffering from systemic lupus erythematosus at the time of the clinical onset of deep vein thrombosis; or

(v)       suffering from dysfibrinogenaemia at the time of the clinical onset of deep vein thrombosis; or

(w)      suffering from Buerger’s disease at the time of the clinical onset of deep vein thrombosis; or

(x)       suffering from Behçet’s disease at the time of the clinical onset of deep vein thrombosis; or

(y)       suffering from hyperhomocystinaemia at the time of the clinical onset of deep vein thrombosis; or

(z)        suffering from protein C deficiency, protein S deficiency, antithrombin III deficiency or activated protein C resistance at the time of the clinical onset of deep vein thrombosis; or

(za)      suffering from paroxysmal nocturnal haemoglobinuria at the time of the clinical onset of deep vein thrombosis; or

(zb)      suffering from antiphospholipid antibody syndrome at the time of the clinical onset of deep vein thrombosis; or

(zc)      suffering from a myocardial infarction within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(zd)      suffering from an aneurysm of the affected vein at the time of the clinical onset of deep vein thrombosis; or

(ze)      undergoing treatment with an anti-psychotic drug within the 90 days immediately before the clinical onset of deep vein thrombosis; or

(zf)      inability to obtain appropriate clinical management for deep vein thrombosis.

Factors that apply only to material contribution or aggravation

6.         Paragraph 5(zf) applies only to material contribution to, or aggravation of, deep vein thrombosis where the person’s deep vein thrombosis was suffered or contracted before or during (but not arising out of) the person’s relevant service; paragraph 8(1)(e), 9(1)(e), 70(5)(d) or 70(5A)(d) of the Act refers.

Inclusion of Statements of Principles

7.         In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles.

Other definitions

8.         For the purposes of this Statement of Principles:

“activated protein C resistance” means a condition where there is a reduced response to the anticoagulant activity of activated protein C and is characterised by reduced prolongation of the activated partial thromboplastin time in response to added protein C;

“an anti-psychotic drug” means clozapine or a drug from one of the following classes of chemical agents:

phenothiazines;

thioxanthines;

butyrophenones;

benzamides;

diphenylbutylpiperidines; or

dibenzoxazepines;

“antiphospholipid antibody syndrome” means the presence of antiphospholipid antibodies or lupus anticoagulant antibodies plus one or more of the following clinical manifestations: venous thrombosis, arterial thrombosis, foetal loss or thrombocytopaenia;

“antithrombin III” means a protein of normal plasma and extravascular sites that inactivates thrombin and thus inhibits blood coagulation;

“Behçet’s disease” means a chronic, inflammatory, multi system, autoimmune disorder presenting with recurrent oral and genital ulcerations as well as ocular involvement;

“being obese” means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of 30 or greater.

The BMI = W/H² and where:

W is the person’s weight in kilograms and

H is the person’s height in metres;

“Buerger’s disease” also known as thromboangiitis obliterans, means a nonatherosclerotic, segmental, inflammatory, occlusive vascular disease affecting the small and medium-sized arteries and veins;

“congestive cardiac failure” means a clinical syndrome due to heart disease, resulting in congestion in the peripheral circulation with or without congestion of the lungs;

“death from deep vein thrombosis” in relation to a person includes death from a terminal event or condition that was contributed to by the person’s deep vein thrombosis;

“dysfibrinogenaemia” means a condition where there is both normal and mutant fibrinogen in the blood plasma;

“hormone replacement therapy” means administration of oestrogen preparations often in combination with progesterone to offset a hormone deficiency following surgically induced or naturally occurring menopause;

“hospitalisation” means inpatient hospitalisation or residence in a nursing home where assistance with activities of daily living is required;

“hyperhomocystinaemia” means a condition characterised by an excess of homocystine in the blood;

“ICD-10-AM code” means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th revision, Australian Modification (ICD-10-AM), Second Edition, effective date of 1 July 2000, copyrighted by the National Centre for Classification in Health, Sydney, NSW, and having ISBN 1 86487 271 3;

“immobilisation” means at least gross diminution of movement of a lower limb associated with sitting or reclining;

“malignant neoplasm” means a cancer of any part of the body, excluding non-metastatic non melanotic malignant neoplasm of the skin.  The cancer may be present but undiagnosed at the time of the clinical onset of deep vein thrombosis;

“myeloproliferative disease” means a family of disorders, including chronic myelogenous leukaemia, polycythaemia vera, idiopathic myelofibrosis and essential thrombocytosis, characterised by increased blood cell production which arise in a clonal manner from abnormalities at the level of the haematopoietic stem cell;

“paralysis of either or both lower limbs” means loss or impairment of motor function of either or both lower limbs, occurring in conditions such as stroke or spinal cord injury;

“paroxysmal nocturnal haemoglobinuria” means a chronic acquired blood cell dysplasia in which there is proliferation of a clone of stem cells producing erythrocytes, platelets and granulocytes that are abnormally susceptible to lysis by complement; it is characterised by the presence of free haemoglobin in the urine, intravascular haemolysis and venous thrombosis;

“protein C deficiency” means a deficiency of a vitamin K dependent plasma protein that, when activated, inhibits the clotting cascade at the levels of factor V and factor VIII;

“protein S deficiency” means a deficiency of a vitamin K dependent plasma protein that inhibits blood clotting by serving as a cofactor for activated protein C;

“relevant service” means:

(a)       operational service; or

(b)       peacekeeping service; or

(c)       hazardous service;

“significant head injury” means trauma to the head resulting in:

(a)              a skull fracture; or

(b)              loss of consciousness with retrograde amnesia; or

(c)              leakage of blood and/or cerebrospinal fluid from the external auditory canal or from the nostril;

“spinal cord injury” means an injury to the long tracts of the spinal cord resulting in permanent motor or sensory deficits below the level of the lesion;

“superficial vein thrombosis” means thrombosis of the greater or lesser saphenous veins or their tributaries;

“systemic lupus erythematosus” means a connective tissue disease in which cells are damaged by pathogenic autoantibodies and immune complexes;

“tamoxifen” means a nonsteroidal anti-oestrogen used in the prevention or treatment of malignant neoplasms or to stimulate ovulation in infertility;

“terminal event” means the proximate or ultimate cause of death and includes:

(a)       pneumonia;

(b)       respiratory failure;

(c)       cardiac arrest;

(d)       circulatory failure; or

(e)       cessation of brain function;

“trauma to the affected vein” means injury to the affected vein by:

(a)               injection, cannulation or incision of the affected vein; or

(b)               therapeutic radiation of the part of the body surrounding the affected vein; or

(c)               a crush injury to the affected vein;

“varicose veins” means dilatation, lengthening and tortuosity of a subcutaneous superficial vein or veins of the lower limb such as the saphenous veins and perforating veins and does not include telangiectasis (intradermal venectasis).

Application

9.         This Instrument applies to all matters to which section 120A of the Act applies.

Notes to Statement of Principles concerning deep vein thrombosis (Instrument No. 5 of 2001)

The Statement of Principles concerning deep vein thrombosis (Instrument No. 5 of 2001) in force under section 196B(2) of the Veterans’ Entitlements Act 1986, as shown in this compilation is amended as indicated in the Tables below.

Table of Instruments

Table of Amendments