Blood clots in lower leg symptoms. Deep Vein Thrombosis (DVT): Symptoms, Risks, and Treatment Options
What are the symptoms of Deep Vein Thrombosis. How is DVT diagnosed and treated. Who is at higher risk of developing DVT. What can you do to prevent Deep Vein Thrombosis.
Understanding Deep Vein Thrombosis: A Comprehensive Guide
Deep Vein Thrombosis (DVT) is a serious medical condition characterized by the formation of blood clots in deep veins, typically in the legs. These clots can pose significant health risks if left untreated, potentially leading to life-threatening complications such as pulmonary embolism. Recognizing the symptoms and understanding the risk factors associated with DVT is crucial for early detection and prompt treatment.
Identifying the Telltale Signs of DVT
DVT symptoms can vary, but they often manifest in one leg and may include:
- Throbbing or cramping pain, particularly in the calf or thigh
- Swelling in the affected leg
- Warm skin around the painful area
- Redness or discoloration of the skin
- Swollen veins that are tender to the touch
Can DVT occur in other parts of the body? While less common, DVT can also develop in the arms or abdomen, presenting similar symptoms in these areas.
Risk Factors: Who’s More Susceptible to DVT?
Several factors can increase an individual’s likelihood of developing DVT:
- Age (over 60)
- Obesity
- Smoking
- Previous history of DVT
- Use of contraceptive pills or hormone replacement therapy
- Cancer or heart failure
- Presence of varicose veins
Are there specific situations that elevate DVT risk? Certain circumstances can temporarily increase the chances of developing DVT, including:
- Recent hospitalization or surgery, especially with limited mobility
- Extended periods of bed rest
- Long-distance travel (over 3 hours) by plane, car, or train
- Pregnancy and the postpartum period (up to 6 weeks after delivery)
- Dehydration
It’s important to note that DVT can sometimes occur without any apparent cause.
Diagnosing DVT: From Symptoms to Confirmation
When DVT is suspected, prompt medical evaluation is crucial. The diagnostic process typically involves:
- Physical examination and assessment of symptoms
- Referral to a hospital within 24 hours for further testing
- Ultrasound scan to evaluate blood flow in the affected vein
- In some cases, a venogram (X-ray of the vein) using a special dye to highlight the blood clot
How quickly should one seek medical attention for suspected DVT? If you experience symptoms of DVT, it’s important to consult a healthcare provider or seek urgent care as soon as possible to prevent potential complications.
Treatment Approaches for Deep Vein Thrombosis
The management of DVT focuses on preventing the clot from growing, reducing the risk of pulmonary embolism, and minimizing long-term complications. Treatment options may include:
- Anticoagulant medications (blood thinners) such as heparin, warfarin, or rivaroxaban
- Surgical interventions to remove blood clots or prevent their formation
- Specialized treatment plans for pregnant women, involving injections throughout pregnancy and early postpartum period
What is the typical duration of DVT treatment? Most patients require anticoagulation therapy for at least three months, but the exact duration may vary based on individual circumstances and risk factors.
Recovery and Rehabilitation After DVT
Recovering from DVT involves a combination of medical management and lifestyle adjustments. Post-hospital care recommendations often include:
- Regular walking to promote circulation
- Elevating the affected leg while sitting
- Postponing long-distance travel for at least two weeks after starting anticoagulation therapy
How can patients support their recovery at home? In addition to following medical advice, patients can aid their recovery by maintaining a healthy diet, staying hydrated, and gradually increasing physical activity as recommended by their healthcare provider.
Preventive Measures: Reducing Your Risk of DVT
While not all cases of DVT are preventable, several strategies can help reduce the risk:
- Maintaining a healthy weight
- Staying physically active with regular walks
- Ensuring proper hydration
- Avoiding prolonged periods of immobility
- Refraining from crossing legs while sitting
- Quitting smoking
- Limiting alcohol consumption
Are there specific precautions for long-distance travelers? For journeys lasting 3 hours or more, consider the following:
- Wear loose, comfortable clothing
- Stay well-hydrated
- Avoid alcohol during travel
- Take opportunities to walk and stretch when possible
DVT Prevention in Hospital Settings
Healthcare providers play a crucial role in assessing and mitigating DVT risk for hospitalized patients. Preventive measures in clinical settings may include:
- Risk assessment upon admission
- Prescription of prophylactic anticoagulants when appropriate
- Use of compression stockings or intermittent pneumatic compression devices
- Early mobilization of patients when medically feasible
How does hospitalization impact DVT risk? Extended hospital stays, particularly those involving surgery or periods of immobility, can significantly increase the likelihood of developing DVT. Therefore, healthcare teams implement tailored prevention strategies based on individual patient risk factors.
The Importance of Early Detection and Intervention
Recognizing the signs of DVT and seeking prompt medical attention can be life-saving. The potential complications of untreated DVT, such as pulmonary embolism, underscore the critical nature of early diagnosis and treatment. Individuals with risk factors or those experiencing symptoms should not hesitate to consult healthcare professionals for evaluation and guidance.
Advances in DVT Research and Treatment
Ongoing research in the field of thrombosis continues to enhance our understanding of DVT and improve treatment modalities. Recent advancements include:
- Development of novel oral anticoagulants with improved safety profiles
- Enhanced imaging techniques for more accurate diagnosis
- Exploration of personalized treatment approaches based on genetic factors
- Investigation of new preventive strategies for high-risk populations
How are these advancements shaping the future of DVT management? As research progresses, patients can expect more targeted and effective treatments, potentially reducing the burden of DVT and its associated complications.
Living with DVT: Long-term Considerations
For individuals who have experienced DVT, long-term management and lifestyle adjustments may be necessary to prevent recurrence and manage potential complications such as post-thrombotic syndrome. Key considerations include:
- Adherence to prescribed anticoagulation therapy
- Regular follow-up appointments with healthcare providers
- Wearing compression stockings as recommended
- Maintaining an active lifestyle within medical guidelines
- Being vigilant for signs of recurrence or new clot formation
Can individuals fully recover from DVT? While many people recover well from DVT with proper treatment, some may experience long-term effects. The outlook depends on factors such as the extent of the clot, timely treatment, and individual health status.
The Role of Diet and Nutrition in DVT Prevention
While diet alone cannot prevent DVT, certain nutritional choices may contribute to overall vascular health and potentially reduce risk:
- Maintaining adequate hydration
- Consuming foods rich in omega-3 fatty acids
- Incorporating vitamin K-rich foods (for those not on warfarin)
- Limiting sodium intake to manage blood pressure
- Avoiding excessive alcohol consumption
Is there a specific “DVT prevention diet”? While no singular diet has been proven to prevent DVT, a balanced, heart-healthy eating plan can support overall cardiovascular health and may indirectly reduce DVT risk.
Exercise and DVT: Finding the Right Balance
Physical activity plays a crucial role in DVT prevention and recovery, but it’s essential to approach exercise cautiously, especially for those with a history of DVT or current risk factors:
- Gradual introduction of low-impact activities
- Focus on exercises that promote circulation, such as walking or swimming
- Avoiding high-impact or contact sports during initial recovery phases
- Incorporating regular stretching and mobility exercises
- Consulting with healthcare providers before starting new exercise regimens
How soon after DVT can one resume exercise? The timing for resuming physical activity varies depending on individual circumstances. It’s crucial to follow medical advice and gradually increase activity levels under professional guidance.
Psychological Impact of DVT: Addressing Mental Health
The experience of DVT can have significant psychological effects on individuals, including:
- Anxiety about recurrence or complications
- Depression related to lifestyle changes or physical limitations
- Fear of travel or situations perceived as high-risk
- Stress associated with ongoing medical management
How can patients cope with the emotional aspects of DVT? Strategies for managing the psychological impact may include:
- Seeking support from mental health professionals
- Joining support groups for individuals with DVT or clotting disorders
- Practicing stress-reduction techniques such as mindfulness or meditation
- Educating oneself about DVT to feel more in control of the condition
DVT in Special Populations: Pregnancy and Cancer Patients
Certain groups face unique challenges and considerations when it comes to DVT risk and management:
Pregnancy-Associated DVT:
- Increased risk during pregnancy and up to 6 weeks postpartum
- Careful anticoagulation management to balance maternal and fetal health
- Importance of early mobility after delivery
- Potential need for extended prophylaxis in high-risk cases
Cancer-Related DVT:
- Higher incidence of DVT in cancer patients due to various factors
- Challenges in balancing anticoagulation with cancer treatments
- Potential need for long-term anticoagulation
- Importance of coordinated care between oncology and thrombosis specialists
How does management differ for these special populations? Treatment approaches for pregnant women and cancer patients with DVT often require specialized protocols and close monitoring to address their unique risk factors and health considerations.
The Future of DVT Prevention and Treatment
As medical science advances, the landscape of DVT management continues to evolve. Emerging areas of research and development include:
- Gene therapy approaches to target underlying clotting disorders
- Development of more sophisticated risk assessment tools
- Exploration of novel anticoagulants with improved safety profiles
- Integration of artificial intelligence in DVT diagnosis and risk prediction
- Investigation of personalized medicine approaches for tailored treatment plans
What potential breakthroughs are on the horizon for DVT care? While specific outcomes are difficult to predict, ongoing research holds promise for more effective prevention strategies, faster diagnosis, and more targeted treatments that could significantly improve outcomes for individuals at risk of or affected by DVT.
Global Perspectives on DVT: Awareness and Healthcare Disparities
DVT awareness and management vary significantly across different regions and healthcare systems worldwide. Key considerations include:
- Disparities in access to diagnostic tools and treatments
- Variations in clinical guidelines and practices among countries
- Cultural differences affecting risk factors and prevention strategies
- Economic impacts of DVT on healthcare systems and individuals
How can global collaboration improve DVT outcomes? International research partnerships, standardization of care protocols, and efforts to increase global awareness of DVT can contribute to improved prevention and management strategies worldwide.
DVT (deep vein thrombosis) – NHS
DVT (deep vein thrombosis) is a blood clot in a vein, usually in the leg. DVT can be dangerous. Get medical help as soon as possible if you think you have DVT.
Symptoms of DVT (deep vein thrombosis)
Symptoms of DVT (deep vein thrombosis) in the leg are:
- throbbing pain in 1 leg (rarely both legs), usually in the calf or thigh, when walking or standing up
- swelling in 1 leg (rarely both legs)
- warm skin around the painful area
- red or darkened skin around the painful area – this may be harder to see on brown or black skin
- swollen veins that are hard or sore when you touch them
These symptoms can also happen in your arm or tummy if that’s where the blood clot is.
Credit:
DR P. MARAZZI/SCIENCE PHOTO LIBRARY https://www.sciencephoto.com/media/440619/view
Urgent advice: Ask for an urgent GP appointment or get help from NHS 111 if:
Immediate action required: Call 999 or go to A&E if:
You have symptoms of DVT (deep vein thrombosis), such as pain and swelling, and:
- breathlessness
- chest pain
DVT can be very serious because blood clots can travel to your lungs. This is called a pulmonary embolism.
A pulmonary embolism can be life-threatening and needs treatment straight away.
Who is more likely to get DVT (deep vein thrombosis)
A DVT (deep vein thrombosis) is more likely to happen if you:
- are over 60
- are overweight
- smoke
- have had DVT before
- take the contraceptive pill or HRT
- have cancer or heart failure
- have varicose veins
There are also some times when you have a higher chance of getting DVT.
These include if you:
- are staying in or recently left hospital – especially if you cannot move around much (like after an operation)
- are confined to bed
- go on a long journey (more than 3 hours) by plane, car or train
- are pregnant or if you’ve had a baby in the previous 6 weeks
- are dehydrated
Sometimes DVT can happen for no obvious reason.
How DVT (deep vein thrombosis) is diagnosed
If a doctor thinks you have DVT (deep vein thrombosis), you should be referred to hospital within 24 hours for an ultrasound scan. The scan shows whether blood is flowing normally through the vein.
You may also have an X-ray of the vein (venogram). For this, you’ll be injected with a dye to show where the blood clot is.
Treatment of DVT (deep vein thrombosis)
You may have an injection of a blood-thinning medicine called heparin while you’re waiting for an ultrasound scan to see if you have a DVT (deep vein thrombosis).
The main treatments include:
- blood-thinning medicines, such as warfarin or rivaroxaban – you’ll probably need to take these for at least 3 months
- surgery to remove blood clots or stop them forming
If you get a DVT when you’re pregnant, you’ll have injections for the rest of the pregnancy and until your baby is 6 weeks old.
Recovery from DVT (deep vein thrombosis)
There are things you can do to help you recover from DVT (deep vein thrombosis).
After you leave hospital, you’ll be encouraged to:
- walk regularly
- keep your affected leg raised when you’re sitting
- delay any flights or long journeys until at least 2 weeks after you start taking blood-thinning medicine
How to prevent DVT (deep vein thrombosis)
There are things you can do to lower your chance of getting DVT (deep vein thrombosis).
Do
stay a healthy weight
stay active – taking regular walks can help
drink plenty of fluids to avoid dehydration – DVT is more likely if you’re dehydrated
Don’t
do not sit still for long periods of time – get up and move around every hour or so
do not cross your legs while you’re sitting
do not smoke
do not drink lots of alcohol
Going on a long journey
If you’re travelling for 3 hours or more by plane, train or car, there are things you can do during the journey to lower your chances of getting DVT.
These include:
- wearing loose clothing
- drinking plenty of water
- avoiding alcohol
- walking around when possible
Going into hospital
If you go into hospital, your healthcare team should check if there’s a higher chance you’ll get DVT.
If they think you’re more likely to get DVT, you may be given treatment to prevent it, such as medicine or compression stockings (knee-high elastic socks that help your blood circulation), while you’re in hospital.
You may continue treatment after you leave hospital because a blood clot can happen weeks later.
You can also help protect yourself against DVT while you’re in hospital by:
- staying active and walking around if you can
- moving your toes (up and down) and ankles (in circles) if you have to stay in bed – your healthcare team may give you some exercises to do
Page last reviewed: 22 March 2023
Next review due: 22 March 2026
Symptoms in Legs, Lungs, and More
Written by WebMD Editorial Contributors
- Arms, Legs
- Heart
- Lungs
- Brain
- Belly
- Kidneys
- More
Ever get a paper cut or nick yourself while shaving? When that happens, a blood clot saves the day. It quickly stops the bleeding, and when it’s done its job, it usually breaks up. Sometimes, though, things can go wrong.
When blood clots don’t fall apart, they can be dangerous and lead to serious medical conditions. You can get them in blood vessels in just about any part of your body. They’re most likely to affect a leg, especially if you sit for long periods of time.
You might get a clot in your arteries, which carry oxygen in your blood from your heart to all the cells of your body. The result can be really serious. It can keep oxygen from getting to your heart, lungs, or brain, and cause a life-threatening emergency, like a heart attack or stroke.
You could also get a clot in the veins that carry blood back to your heart. When that happens, symptoms usually come on more gradually, but can still mean trouble.
If you learn the warning signs, you’re more likely to get quick medical help that can make a huge difference in keeping you out of the danger zone. But it’s important to know that in some cases, clots can happen with few symptoms or none at all. .
See More: Dos and Don’ts of a Blood Clot
When a blood clot forms in one of the deep veins in your arm or leg, way beneath your skin’s surface, it could be something called a deep vein thrombosis (DVT). That’s dangerous because the clot could travel to your heart or lungs.
You’re more likely to get a DVT if you haven’t moved around for a long time, say after surgery or during a long plane trip. Get medical help right away if you notice any of these symptoms:
- Swelling. This can happen in the exact spot where the blood clot forms, or your entire leg or arm could puff up.
- Change in color. You might notice that your arm or leg takes on a red or blue tinge, or gets itchy.
- Pain. As the clot gets worse, you may hurt or get sore. The feeling can range from a dull ache to intense pain. You may notice the pain throbs in your leg, belly, or even your arm.
- Warm skin. The skin around painful areas or in the arm or leg with the DVT may feel warmer than other skin.
- Trouble breathing. If this happens, it could mean that the clot has moved from your arm or leg to your lungs. You may also get a bad cough, and might even cough up blood. You may get pain in your chest or feel dizzy. Call 911 to get medical help right away.
- Lower leg cramp. If the clot is in your calf or lower leg, you may feel like you have a cramp or charley horse.
- Pitting edema. DVT can cause fluid buildup (edema) in the arms or legs. It typically happens quite quickly with DVT. When you press on the swollen area, it can cause a dimple or “pit” (pitting) that remains for a few seconds.
- Swollen, painful veins. The pain may increase with touch.
A blood clot that forms in or around your ticker may cause a heart attack. Watch out for symptoms like these:
- Severe pain in your chest and arm
- Sweating
- Trouble breathing
A blood clot in your lung usually starts out in a deep vein in your arm or leg, then breaks off and travels to your lung. When this happens, you get what’s called a pulmonary embolism, an extremely dangerous condition.
Get medical help right away if you:
- Feel short of breath or have problems breathing
- Get pain in your chest
- Start to cough
- Begin to sweat
- Feel dizzy
Blood clots here may be caused by fatty deposits in the walls of the blood vessels that bring blood to your brain. Or sometimes, they may form because of a blow to your head that leads to a concussion.
In other cases, a clot that starts out in a different part of your body, like your chest or neck, might enter your bloodstream and travel to your brain, where it can cause a stroke.
Watch out for these symptoms:
- Problems with your vision or speech
- A seizure
- General feeling of weakness
Blood clots can happen in the veins that drain blood from your intestines. They can be caused by conditions like diverticulitis or liver disease, or even by birth control pills.
How will you know if this is going on? Check with your doctor if you have problems like these:
- Nausea or vomiting
- Severe pain in your belly, which may be worse after you eat
- Diarrhea
- Bloody stools
- A bloated feeling
A blood clot in your kidneys can keep them from removing waste from your body. That can cause high blood pressure or even kidney failure.
This is dangerous, so look out for these symptoms:
- Pain in the side of your belly, legs, or thighs
- Blood in your urine
- Fever
- Nausea or vomiting
- High blood pressure
- Sudden severe leg swelling
- Trouble breathing
Top Picks
Blood clots.
Signs Not to Ignore
Blood clots can basically be divided into two main groups – dormant clots and clots that travel through the body. When or while the clots are at rest, we speak of thrombosis. For example, deep vein thrombosis is known, which is usually associated with clots in the leg, but can also occur in other parts of the body, such as the arm. On the other hand, we can also talk about embolism. This condition is characterized by the fact that the clot splits off and then moves through the body. When it comes to pulmonary embolism, it can be fatal.
Blood clots: symptoms of deep vein thrombosis.
Deep vein thrombosis is not necessarily associated with very obvious signs, so the problem can go unrecognized for quite some time, increasing the risk of more serious complications. One of the most typical symptoms is pain in the leg or arm in which a blood clot has formed, or increased sensitivity of this limb. Also, the condition is characterized by warm skin in the clot area. Some also observe swelling of the affected limb. In addition, the skin near the clot may turn red or turn purple. Symptoms characteristic of deep vein thrombosis are sometimes similar to the sensations that accompany a tense muscle. For example, those who are more active may mistake signs of deep vein thrombosis for a classic sports injury.
How to determine the risk of pulmonary embolism?
Even with deep vein thrombosis, it is necessary to be able to recognize it quickly and then take action as soon as possible. This is especially important if there is a risk of PE or if the blood clot travels to the lungs. One of the most common symptoms that occurs when a blood clot enters the lungs is chest pain accompanied by difficulty breathing, especially when trying to take a deep breath. At the same time, increased sweating may occur, accompanied by increased heart rate, fever, and a feeling of dizziness. However, sometimes the risk of pulmonary embolism is also indicated by blood-stained cough discharge. Therefore, if you notice any of these signs, or if a person near you has these signs, you need to seek medical attention as soon as possible.
Groups in which the risk of blood clots is particularly high.
Blood clots can occur for a variety of reasons and in almost anyone. However, there are groups of people in whom the risk of such complications is particularly high. Therefore, individuals at risk should pay special attention to any symptoms of blood clots. One of the increased risk factors is the use of oral hormonal contraceptives. There is also an increased risk of blood clots in pregnant women, smokers, overweight people, diabetics, people with chronic inflammatory diseases, and some cancer patients.
We can also talk about a higher likelihood of blood clots in older people, especially people over sixty. Lack of physical activity can also contribute to the risk of blood clots. Genetic factors may also be at the root – if blood clotting problems are very common in your family, then special care is required.
Signs and symptoms of deep vein thrombosis
- July 13, 2021
Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more deep veins in your body, usually in your legs. Deep vein thrombosis can cause leg pain or swelling, but may be asymptomatic.
- Symptoms of deep vein thrombosis
- Causes of deep vein thrombosis
- Risk factors
- DVT complications
- Thrombosis prophylaxis
DVT may be associated with diseases that affect the blood clotting process. A blood clot in your legs can also form if you don’t move for a long time, such as after surgery or an accident. But walking extremely long distances can lead to blood clots.
Deep vein thrombosis is a serious condition because blood clots in your veins can travel through the bloodstream and get stuck in your lungs, blocking blood flow (pulmonary embolism). However, pulmonary embolism may occur without evidence of DVT.
When DVT and pulmonary embolism occur at the same time, it is called venous thromboembolism (VTE).
Symptoms
Signs and symptoms of DVT:
- Swelling of the affected leg. In rare cases, swelling appears on both legs.
- Pain in the leg. The pain often starts in the calf and may feel like spasms or soreness.
- Red or discolored skin on the leg.
- Feeling of warmth in the affected leg.
Deep vein thrombosis may occur without noticeable symptoms.
When to see a doctor
If you have signs or symptoms of DVT, see your doctor.
If you have signs or symptoms of pulmonary embolism (PE), a life-threatening complication of deep vein thrombosis, seek emergency medical attention.
Call 103
Warning signs and symptoms of pulmonary embolism include:
- Sudden shortness of breath
- Pain or discomfort in the chest that is aggravated by taking a deep breath or coughing.
- Feeling dizzy or dizzy or fainting
- Rapid pulse
- Fast breathing
- Cough with blood
Suspect deep vein thrombosis? Contact the professionals.
Causes
Anything that interferes with the normal flow or clotting of blood can cause blood clots.
The main causes of DVT are damage to the vein due to surgery or trauma, and due to inflammation from infection or trauma.
Risk factors
Many factors can increase the risk of developing DVT, which include:
- Age. The risk of DVT increases at age 60, although it can occur at any age.
- Sitting for long periods of time, such as while driving or flying. When your legs remain motionless for several hours, your calf muscles do not contract. Muscle contractions promote blood circulation.
- Prolonged bed rest, such as during a long hospital stay or paralysis. Blood clots can form in the calves if the calf muscles are not used for a long time.
- Injury or surgery. Injury to the veins or surgery may increase the risk of blood clots.
- Pregnancy. Pregnancy increases pressure in the veins of the pelvis and legs. Women with an inherited bleeding disorder are at particular risk. The risk of blood clots as a result of pregnancy may remain up to six weeks after the baby is born.
- Birth control pills (oral contraceptives) or hormone replacement therapy. Both factors can increase the blood’s ability to clot.
- Exposure to drugs or chemicals. Certain drugs may cause blood clots. Before use, consult your doctor.
- Overweight or obese. Excess weight increases pressure in the veins of the pelvis and legs.
- Smoking. Smoking affects clotting and circulation, which may increase the risk of DVT.
- Cancer. Some forms of cancer increase blood levels of substances that cause blood clotting. Some forms of cancer treatment also increase the risk of blood clots.
- Heart failure. Increases the risk of deep vein thrombosis and pulmonary embolism. Because people with heart failure have limited heart and lung function, symptoms caused by even a small pulmonary embolism are more noticeable.
- Inflammatory bowel disease. Bowel disease, such as Crohn’s disease or ulcerative colitis, increases the risk of DVT.
- Personal or family history of DVT or PE. If you or someone in your family has had one or both of these, you may be at greater risk of developing DVT.
- Genetics. Some people inherit genetic risk factors or disorders, such as factor V Leiden, that make their blood clot more easily. The hereditary disease itself may not cause blood clots unless it is combined with one or more other risk factors.
- Risk factor unknown. Sometimes a blood clot in a vein can occur without an obvious underlying risk factor. This is called unprovoked VTE.
Complications
DVT complications may include:
- Pulmonary embolism (PE). PE is a potentially life-threatening complication associated with DVT. This happens when a blood vessel in your lung is blocked by a clot that travels to your lung from another part of your body, usually your leg.
If you have signs and symptoms of PE, it is important to seek immediate medical attention. Sudden shortness of breath, chest pain when inhaling or coughing, rapid breathing, rapid pulse, feeling weak or faint, and coughing up blood can occur with PE. - Post-phlebitic syndrome. Damage to the veins by a thrombus reduces blood flow to the affected areas, causing leg pain and swelling, skin discoloration and skin ulcers.
- Complications of treatment.