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Current Challenges in Diagnosis of Venous Thromboembolism. J Clin Med 2020; 9:jcm9113509. [PMID: 33138326 PMCID: PMC7693569 DOI: 10.3390/jcm9113509] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/17/2020] [Accepted: 10/27/2020] [Indexed: 02/05/2023] Open
Abstract
In patients with suspected venous thromboembolism, the goal is to accurately and rapidly identify those with and without thrombosis. Failure to diagnose venous thromboembolism (VTE) can lead to fatal pulmonary embolism (PE), and unnecessary anticoagulation can cause avoidable bleeding. The adoption of a structured approach to VTE diagnosis, that includes clinical prediction rules, D-dimer testing and non-invasive imaging modalities, has enabled rapid, cost-effective and accurate VTE diagnosis, but problems still persist. First, with increased reliance on imaging and widespread use of sensitive multidetector computed tomography (CT) scanners, there is a potential for overdiagnosis of VTE. Second, the optimal strategy for diagnosing recurrent leg deep venous thrombosis remains unclear as is that for venous thrombosis at unusual sites. Third, the conventional diagnostic approach is inefficient in that it is unable to exclude VTE in high-risk patients. In this review, we outline pragmatic approaches for the clinician faced with difficult VTE diagnostic cases. In addition to discussing the principles of the current diagnostic framework, we explore the diagnostic approach to recurrent VTE, isolated distal deep-vein thrombosis (DVT), pregnancy associated VTE, subsegmental PE, and VTE diagnosis in complex medical patients (including those with impaired renal function).
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202
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Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis. Blood Adv 2020; 4:5002-5010. [PMID: 33057634 DOI: 10.1182/bloodadvances.2020002173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/23/2020] [Indexed: 11/20/2022] Open
Abstract
Guidelines for the diagnostic workup of deep vein thrombosis (DVT) recommend assessing the clinical pretest probability before proceeding to D-dimer testing and/or compression ultrasonography (CUS) if the patient has high pretest probability or positive D-dimer. Referring only patients with positive D-dimer for whole-leg CUS irrespective of pretest probability may simplify the workup of DVT. In this prospective management outcome study, we assessed the safety of such a strategy. We included consecutive outpatients referred to the Emergency Department at Østfold Hospital, Norway, with suspected DVT between February 2015 and November 2018. STA-Liatest D-Di Plus D-dimer was analyzed for all patients, and only patients with levels ≥0.5 µg/mL were referred for CUS. All patients with negative D-dimer or negative CUS were followed for 3 months to assess the venous thromboembolic rate. One thousand three hundred ninety-seven patients were included. Median age was 64 years (interquartile range, 52-73 years), and 770 patients (55%) were female. D-dimer was negative in 415 patients (29.7%) and positive in 982 patients (70.3%). DVT was diagnosed in 277 patients (19.8%). Six patients in whom DVT was ruled out at baseline were diagnosed with DVT within 3 months of follow-up for a thromboembolic rate of 0.5% (95% confidence interval, 0.2-1.2). A simple diagnostic approach with initial stand-alone D-dimer followed by a single whole-leg CUS in patients with positive D-dimer safely ruled out DVT. We consider this strategy to be a valuable alternative to the conventional workup of DVT in outpatients. This trial was registered at www.clinicaltrials.gov as #NCT02486445.
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Abstract
Focusing on the current state of the art, this article (a) describes recent advances in the understanding of the pathogenesis of venous thromboembolism (VTE), (b) discusses current approaches for the prevention, diagnosis and treatment of VTE, (c) outlines the role of aspirin for VTE prevention and treatment, and (d) highlights the unmet needs in VTE management and describes novel approaches to address them.
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Affiliation(s)
- Noel C Chan
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
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204
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Piggott T, Baldeh T, Akl EA, Junek M, Wiercioch W, Schneider R, Langendam MW, Meerpohl J, Brozek JL, Schünemann HJ. Supporting effective participation in health guideline development groups: The Guideline Participant Tool. J Clin Epidemiol 2020; 130:42-48. [PMID: 32987163 DOI: 10.1016/j.jclinepi.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 07/18/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Health guidelines are a key knowledge translation tool produced and used by numerous stakeholders worldwide. Effective participation in guideline development groups or development groups is crucial for guideline success, yet little guidance exists for members of these groups. In this study, we present the Guideline Participant Tool (GPT) to support effective participation in guideline groups, in particular those using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. STUDY DESIGN AND SETTING We used a mixed methods and iterative approach to develop a tool to support guideline participation. We used the findings of a published systematic review to develop an initial list of items for considerations for guideline participants. Then, we refined this list through key informant interviews with guideline chairs, sponsors, and participants. Finally, we validated the GPT in three guideline groups with 26 guideline group members. RESULTS The initial list of items based on 37 articles from the existing systematic review included 15 themes and 61 items for a draft tool. Ten key informant interviews helped us refine the list to include the following themes: selection of participants, guideline group process, and tool format. 26 respondents completed the validation survey from three guideline groups. Refinement of the tool ultimately generated a GPT with 33 items for participant consideration before, during, and in follow-up to guideline group meetings. CONCLUSION The GPT contains helpful guidance for all guideline participants, particularly those without previous guideline experience. Future research should further explore the need for additional tools to support guideline participants and identify and develop strategies for improving guideline members' participation in guideline groups. This work will be incorporated into INGUIDE.org guideline training and credentialing efforts by the Guidelines International Network and McMaster University.
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Affiliation(s)
- Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Mats Junek
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada
| | - Rita Schneider
- Department of Nuclear Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Miranda W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
| | - Joerg Meerpohl
- Institute for Evidence in Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany; Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Jan L Brozek
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada; Institute for Evidence in Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Medicine, McMaster University, Hamilton, Canada.
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205
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Piera Carbonell A, Frías Vargas M, García Vallejo O, García Lerín A, Cabrera Ferriols MA, Peiró Morant J, Carrasco Carrasco E. [COVID-19 and thromboprophylaxis: Recommendations for our clinical practice in Primary Care]. Semergen 2020; 46:479-486. [PMID: 33046353 PMCID: PMC7500906 DOI: 10.1016/j.semerg.2020.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/16/2020] [Accepted: 07/30/2020] [Indexed: 12/14/2022]
Abstract
El nuevo coronavirus (SARS-CoV-2) es el responsable de un síndrome respiratorio agudo severo (SARS). Entre sus manifestaciones puede desarrollar una enfermedad trombótica, tanto venosa como arterial, debido a la inflamación excesiva que afecta al sistema vascular, con activación plaquetaria y disfunción endotelial, entre otros mecanismos. La trombosis se asocia a la infección producida por el SARS- CoV-2, aumentando su gravedad y confiriendo un peor pronóstico. Nuestra actuación como Médicos de Familia puede aportar acciones importantes en el manejo y control de esta severa complicación. Teniendo en cuenta que muchos de nuestros pacientes ya reciben terapia antitrombótica o anticoagulante, el hecho de que puedan desarrollar una infección por COVID-19 tendrá implicaciones para la elección, la dosificación y el control en su tratamiento. En este documento, revisamos, con la información actualmente disponible, la relación entre enfermedad producida por el SARS-CoV-2 y trombosis, así como su manejo con un enfoque centrado en Atención Primaria.
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Affiliation(s)
| | | | | | | | - M A Cabrera Ferriols
- Centro de Salud San Vicente del Raspeig, San Vicente del Raspeig, Alicante, España
| | - J Peiró Morant
- Centro de Salud Ponent, Andratx, Mallorca, Illes Balears, España
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206
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Shi S, Cheng J, Chen H, Zhang Y, Zhao Y, Wang B. Preoperative and intraoperative predictors of deep venous thrombosis in adult patients undergoing craniotomy for brain tumors: A Chinese single-center, retrospective study. Thromb Res 2020; 196:245-250. [PMID: 32919179 DOI: 10.1016/j.thromres.2020.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/28/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Brain tumor resection by craniotomy is associated with a high risk of deep vein thrombosis (DVT). This study evaluated the incidence and preoperative and intraoperative risk factors for DVT within 30 days of surgery. METHODS The analysis included: 1) basic clinical variables (patient age, sex, body mass index [BMI], tumor location, and tumor histology); 2) blood test results before operation, such as leukocytes, platelets, and coagulation parameters; and 3) surgical factors (total amount of blood lost, anesthesia mode, and surgery duration). RESULTS Of the 1670 patients, 206 (12.34%) had DVT and nine (0.54%) had both DVT and pulmonary embolism (PE) after surgery. Preoperative and intraoperative factors independently associated with DVT/PE were: older age 46-55 years (odds ratio [OR]: 2.87; 95% confidence interval [CI]: 1.83-4.50; P < 0.001), age 56-65 years (OR: 5.24; 95% CI: 3.27-8.40; P < 0.001), age > 65 years (OR: 6.00; 95% CI: 3.45-10.45; P < 0.001), BMI (OR: 1.03; 95% CI: 1.00-1.05; P = 0.029), activated partial thromboplastin time [APTT] (OR: 0.91; 95% CI: 0.86-0.95; P = 0.000), D-dimer (OR: 1.69; 95% CI: 1.23-2.34; P = 0.001), high-grade glioma (OR: 2.09; 95% CI: 1.28-3.40; P = 0.003), glio-neuronal (OR: 3.30; 95% CI: 1.28-8.47; P = 0.013), craniopharyngioma (OR: 2.16; 95% CI: 1.13-4.10; P = 0.019), and surgery duration (OR: 1.82; 95% CI: 1.27-2.60; P = 0.001). CONCLUSIONS Older age, BMI, preoperative APTT, D-dimer, tumor histology, and surgery duration independently increased the risk of developing postoperative DVT/PE. These findings provide prognostic information that will guide therapies aimed at minimizing the development of DVT/PE during hospitalization.
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Affiliation(s)
- Shuhai Shi
- Department of Critical Care Medicine, Sanbo Brain Hospital, Capital Medical University, 100093 Beijing, China
| | - Jingli Cheng
- Department of Neurosurgery, First Affiliated Hospital of Baotou Medical College, 014010 Baotou, Inner Mongolia Autonomous Region, China
| | - Haoliang Chen
- Department of Medical Information, Sanbo Brain Hospital, Capital Medical University, 100093 Beijing, China
| | - Yunxin Zhang
- Department of Critical Care Medicine, Sanbo Brain Hospital, Capital Medical University, 100093 Beijing, China
| | - Ying Zhao
- Department of Critical Care Medicine, Sanbo Brain Hospital, Capital Medical University, 100093 Beijing, China
| | - Baoguo Wang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, 100093 Beijing, China.
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207
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Robert-Ebadi H, Righini M. D-dimer: Well beyond diagnosis! JOURNAL DE MEDECINE VASCULAIRE 2020; 45:239-240. [PMID: 32862979 PMCID: PMC7343641 DOI: 10.1016/j.jdmv.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 06/11/2023]
Affiliation(s)
- H Robert-Ebadi
- Division of angiology and hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - M Righini
- Division of angiology and hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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208
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Controversy and Debate Series on Core Outcome Sets: The SOLAR (Standardized Outcomes Linking Across StakeholdeRs) system and hub and spokes model for direct core outcome measures in health care and its relation to GRADE. J Clin Epidemiol 2020; 125:216-221. [DOI: 10.1016/j.jclinepi.2020.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/05/2020] [Indexed: 01/06/2023]
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209
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van Dam LF, Gautam G, Dronkers CEA, Ghanima W, Gleditsch J, von Heijne A, Hofstee HMA, Hovens MMC, Huisman MV, Kolman S, Mairuhu ATA, Nijkeuter M, van de Ree MA, van Rooden CJ, Westerbeek RE, Westerink J, Westerlund E, Kroft LJM, Klok FA. Safety of using the combination of the Wells rule and D-dimer test for excluding acute recurrent ipsilateral deep vein thrombosis. J Thromb Haemost 2020; 18:2341-2348. [PMID: 32613731 PMCID: PMC7497055 DOI: 10.1111/jth.14986] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/20/2020] [Accepted: 06/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnostic accuracy of clinical probability assessment and D-dimer testing for clinically suspected recurrent deep vein thrombosis (DVT) is largely unknown. AIM To evaluate the safety of ruling out acute recurrent DVT based on an unlikely Wells score for DVT and a normal D-dimer test. METHODS This was a predefined endpoint of the Theia study in which the diagnostic accuracy of magnetic resonance direct thrombus imaging in acute recurrent ipsilateral DVT was validated. The Wells rule and D-dimer test, performed as part of the study protocol, were not used for management decisions. The primary outcome of this analysis was the incidence of recurrent DVT at baseline or during 3-month follow-up for patients with an unlikely Wells score and a normal D-dimer test. RESULTS Results of both Wells score and D-dimer tests were available in 231 patients without anticoagulant treatment. The recurrent DVT prevalence was 45% (103/231). Forty-nine patients had an unlikely Wells score and normal D-dimer test, of whom 3 (6.1%, 95% confidence interval [CI] 1.3%-18%) had recurrent DVT at baseline/follow-up, yielding a sensitivity of 97% (95% CI 92%-99%) and specificity of 36% (95% CI 28%-45%). Thus, if clinical probability scoring and D-dimer testing would have been applied, radiological imaging could have been omitted in 21% of patients with a diagnostic failure rate of 6.1%. CONCLUSION By applying clinical probability scoring and D-dimer testing, radiological imaging could be spared in one fifth of patients with suspected recurrent ipsilateral DVT. However, the high failure rate does not support implementation of this strategy in daily practice.
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Affiliation(s)
- Lisette F. van Dam
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Gargi Gautam
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Charlotte E. A. Dronkers
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineHaaglanden Medical CenterThe Haguethe Netherlands
| | - Waleed Ghanima
- Department of Internal MedicineØstfold Hospital TrustØstfoldNorway
- Department of HaematologyInstitute of Clinical MedicineUniversity of OsloOsloNorway
| | | | - Anders von Heijne
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Herman M. A. Hofstee
- Department of Internal MedicineHaaglanden Medical CenterThe Haguethe Netherlands
| | | | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Stan Kolman
- Department of Vascular MedicineDiakonessenhuisUtrechtthe Netherlands
| | | | - Mathilde Nijkeuter
- Department of Vascular MedicineUniversity Medical Center UtrechtUtrechtthe Netherlands
| | | | | | | | - Jan Westerink
- Department of Vascular MedicineUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Eli Westerlund
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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210
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Abstract
Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.
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Affiliation(s)
- Lisa Duffett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lana A Castellucci
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Melissa A Forgie
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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211
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Yamagata K, Fukuzawa S, Ishibashi-Kanno N, Uchida F, Yanagawa T, Bukawa H. The Association between D-Dimer and Prognosis in the Patients with Oral Cancer. Dent J (Basel) 2020; 8:dj8030084. [PMID: 32756384 PMCID: PMC7558716 DOI: 10.3390/dj8030084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022] Open
Abstract
D-dimer levels are reported to relate with tumor stage, prognosis, and lymph node involvement, as well as overall survival (OS) in patients with solid tumors. The purpose of this study was to investigate association between the value of D-dimer and the prognosis of oral cancer (OC). We designed a retrospective cohort study and enrolled a sample of patients who were diagnosed with OC and treated with surgery and/or radiotherapy. The predictor was the D-dimer and outcome variable was OS. Other variables included age, neutrocyte count, neutrophil lymphocyte ratio (NLR), C-reactive protein (CRP), and management. Differences in OS rate were analyzed by log-rank test. A Cox proportional hazards model was used to adjust for the effects of potential confounders. Differences with a P value less than 0.05 were considered statistically significant. In 88 patients with OC, D-dimer median value for the predicting OS was 0.7 µg/mL. There was a significant difference in OS when patients were stratified according to D-dimer, with an OS rate of 77.8% for patients with low D-dimer (<0.7), and 57.3% with high D-dimer (≥0.7) (p = 0.035). Univariate analyses revealed close correlations between OS and age, neutrocyte count, NLR, CRP, and D-dimer (<0.7 and ≥0.7). Cox multivariate analysis identified management (mainly surgery vs. radiotherapy) (HR 3.274, 95% CI 1.397–7.676; p = 0.006) as independent predictive factors for OS. There was a significant difference in OS when patients were stratified according to D-dimer with low (<0.7) and high D-dimer (≥0.7) (p = 0.035). Though, as a predictive factor, management was associated with OS.
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212
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Elmi G, Rinaldi ER, Domanico A, Aluigi L. Calf deep vein thrombosis – clinical relevance, diagnostic approaches and therapeutic options. VASA 2020; 49:359-366. [DOI: 10.1024/0301-1526/a000869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Summary. Isolated distal deep vein thromboses (IDDVT) represent up to 50 % of legs deep vein thromboses (DVT). However, since their natural history is to date unknown, the need to diagnose and treat them is a matter of debate. The diagnostic strategy based on the assessment of pre-test probability and D-dimer demonstrated a scarse efficiency for IDDVT. The choice between a proximal and a complete ultrasonographic approach should be guided by the clinical context, the local expertise and the patient characteristics. Randomized and observational studies have analyzed the need of therapy and compared different regimens of anticoagulation, with conflicting results. Systematic reviews and meta-analyses tend to support the usefulness of an anticoagulant treatment, even if the optimal dose and duration are not still defined. A careful stratification of the patient’s profile, taking into account risk factors for proximal extension, recurrence and bleeding should address the therapeutic approach, which must always be discussed with an adequately informed patient. Further studies aimed to clarify the natural history of IDDVT, and to assess safety and efficacy of lower intensity and shorter duration protocols are urgently needed.
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Affiliation(s)
- Giovanna Elmi
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
| | - Elisa Rebecca Rinaldi
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
| | - Andrea Domanico
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
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213
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Li J, Wang D, Wang W, Jia J, Kang K, Zhang J, Zhao X. In-hospital venous thromboembolism is associated with poor outcome in patients with spontaneous intracerebral hemorrhage: A multicenter, prospective study. J Stroke Cerebrovasc Dis 2020; 29:104958. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104958] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 10/24/2022] Open
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214
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Ono K, Takedani H. Risk of deep venous thrombosis after total knee arthroplasty in patients with haemophilia A. Haemophilia 2020; 26:867-872. [DOI: 10.1111/hae.14095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/06/2020] [Accepted: 06/11/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Kumiko Ono
- Department of Joint Surgery Research Hospital The Institute of Medical Science The University of Tokyo Tokyo Japan
| | - Hideyuki Takedani
- Department of Joint Surgery Research Hospital The Institute of Medical Science The University of Tokyo Tokyo Japan
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215
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Vidali S, Morosetti D, Cossu E, Luisi MLE, Pancani S, Semeraro V, Consales G. D-dimer as an indicator of prognosis in SARS-CoV-2 infection: a systematic review. ERJ Open Res 2020; 6:00260-2020. [PMID: 32685436 PMCID: PMC7357271 DOI: 10.1183/23120541.00260-2020] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023] Open
Abstract
Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) stimulates pro-thrombotic changes. This, combined with its tropism for endothelium and lung structures, may explain its association with thrombotic events, reduction of pulmonary gas exchange, acute respiratory distress syndrome (ARDS) and a composite end-point (intensive care unit, invasive ventilation, death). This study aims to highlight the correlation between elevated D-dimer (an indirect thrombosis marker) and the increased rate of poor prognosis-associated conditions, and to introduce D-dimer-labelled anticoagulant administration as a potentially useful tool to prevent complications and positively influence coronavirus disease 2019 (COVID-19) course. Methods An online database search (PubMed, Google Scholar, Scopus, Web of Science and Cochrane) was performed between 13 March and 10 April 2020. The most relevant keywords were "D-dimer", "SARS-CoV-2", "COVID-19", "thrombosis" and "ARDS". Selection was independently conducted by three reviewers. References and previews of accepted articles were evaluated. Data inclusion/extraction inaccuracy was limited by the work of three reviewers. Selection bias reduction was addressed by thoughtfully designing the search protocol. Quality assessment was performed with the Newcastle-Ottawa Scale. The systematic review protocol was not registered because we anticipated the very limited available evidence on the topic and due to the urgency of the study. Results 16 studies were evaluated. Good-quality criteria were reached in 13 out of 16 studies. D-dimer was increased and significantly higher in COVID-19 patients compared with healthy controls, in COVID-19 patients with severe disease or a composite end-point compared with non-severe disease, in ARDS compared with non-ARDS patients and in deceased ARDS patients compared with ARDS patients who survived (all p<0.001). COVID-19 patients treated with anticoagulants demonstrated lower mortality compared with those not treated (p=0.017). Conclusions Correlations exist between COVID-19 infection, severe elevation of D-dimer levels, and increase in the rate of complications and composite end-point. The appropriateness of early and continuous D-dimer monitoring and labelled anticoagulation as management tools for COVID-19 disease deserves accurate investigation, to prevent complications and reduce interventions.
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Affiliation(s)
- Sofia Vidali
- Diagnostic and Interventional Imaging, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Daniele Morosetti
- Diagnostic and Interventional Imaging, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Elsa Cossu
- Diagnostic and Interventional Imaging, University Hospital Policlinico Tor Vergata, Rome, Italy
| | | | | | - Vittorio Semeraro
- Diagnostic and Interventional Imaging, Santissima Annunziata Hospital, Taranto, Italy
| | - Guglielmo Consales
- Anesthesiology and Resuscitation, Santo Stefano Hospital, Prato, Italy.,Anesthesiology and Resuscitation, Azienda USL Toscana Centro, Florence, Italy
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216
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Robert-Ebadi H, Righini M. The 2019 ESC guidelines on pulmonary embolism: some further insights. Eur J Intern Med 2020; 77:6-8. [PMID: 32446816 DOI: 10.1016/j.ejim.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 04/28/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
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217
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Muñoz Rodríguez FJ. Diagnosis of deep vein thrombosis. Rev Clin Esp 2020; 220:S0014-2565(20)30132-6. [PMID: 32600570 DOI: 10.1016/j.rce.2020.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/10/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
Deep vein thrombosis (DVT) is part of the clinical spectrum of venous thromboembolism disease (VTE), whose estimated annual incidence rate is 1-2 episodes per 1000 individuals and represents the third leading cause of cardiovascular mortality in developed countries. Establishing an accurate diagnosis of DVT is essential for preventing acute complications (such as pulmonary embolism) and chronic complications associated with post-thrombotic syndrome. Currently, there are well-established diagnostic algorithms for lower extremity DVT, which include clinical probability models that help establish the risk of experiencing the disease based on the patients' history, clinical findings, D dimer measurements, fibrin degradation product tests with a high negative predictive value and imaging tests to confirm the diagnosis. Venous compression ultrasonography is currently the technique of choice because it is a non-invasive, easy-to-administer test that can make serial evaluations. There is much accumulated evidence that DVT can be safely ruled out in patients with a low or intermediate clinical probability and a negative D dimer (<500 ng/mL) without performing additional examinations. The consensus is not as clear about the need for a proximal or complete examination of the entire extremity. Other techniques may also be employed, such as magnetic resonance venography and venous phase computed axial tomography, although these should not be a substitute for compression ultrasonography as the initial diagnostic test. There are other special circumstances in which the diagnosis is more problematic and there are no diagnostic algorithms as consolidated, such as DVT during pregnancy, diagnosing rethrombosis and DVT that affects the upper extremities.
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218
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Al-Khafaji RA, Schierbeck L. Deep Venous Thrombosis in a Patient with a Moderate Pretest Probability and a Negative D-Dimer Test: A Review of the Diagnostic Algorithms. J Blood Med 2020; 11:173-184. [PMID: 32581617 PMCID: PMC7266946 DOI: 10.2147/jbm.s244773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Modern diagnostic strategies of venous thromboembolism (VTE) have been developed. In this review, the diagnostic algorithms for deep-vein thrombosis (DVT) and their parameters are discussed individually in the context of reporting a case of DVT in a 43-year-old Caucasian female with a moderate pretest probability stratified by Wells’ score and a negative high quality D-dimer test. The patient was on treatment with Xarelto (rivaroxaban), 20 mg PO daily at the time of presentation. The diagnosis was verified through a complete lower limb ultrasound (US). This case highlights the diagnostic challenges and pitfalls of the current algorithms, especially those seen in a subgroup of patients such as patients with cancer, pregnancy, recurrent VTE or are on anticoagulation therapy at the time of presentation. The diagnosis of DVT is less plausible in a patient who is on anticoagulation therapy, but physicians should be aware of such a possibility. Physicians should also know in advance the numerous clinically relevant limitations of D-dimer testing before interpreting the results. Unifying the current diagnostic strategies, modifying the current Wells’ score and using the protocol of a whole-leg compression US instead of the limited US protocol are among the several cautious suggestions that have been proposed based on this review to possibly decrease the incidence of missed DVT.
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Affiliation(s)
- Rasha A Al-Khafaji
- Cardiology Department, Nordsjælland (North Zealand) University Hospital, Hillerød, Denmark.,Endocrinology and Nephrology Department, Nordsjælland (North Zealand) University Hospital, Hillerød, Denmark
| | - Louise Schierbeck
- Cardiology Department, Nordsjælland (North Zealand) University Hospital, Hillerød, Denmark
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219
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Rollins-Raval MA, Marlar RA, Goodwin AJ. Age-Adjusted D-dimer Cutoffs: A Warning From the Laboratory. Ann Emerg Med 2020; 75:783-784. [PMID: 32471582 DOI: 10.1016/j.annemergmed.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Indexed: 10/24/2022]
Affiliation(s)
| | - Richard A Marlar
- Department of Pathology, University of New Mexico, Albuquerque, NM
| | - Andrew J Goodwin
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine, Burlington, VT
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220
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Montes Santiago J, Argibay Filgueira AB. Home treatment of venous thromboembolism disease. Rev Clin Esp 2020; 220:S0014-2565(20)30130-2. [PMID: 32560918 DOI: 10.1016/j.rce.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/08/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Abstract
Despite the potential benefits of outpatient care, most patients with pulmonary embolisms are treated in hospitals for fear of possible adverse events. However, there is a wealth of scientific evidence from studies covering more than 4000 outpatients, which has led the current clinical practice guidelines to recommend early discharge or outpatient treatment when a low risk of death or complications has been confirmed, when there are no comorbidities or aggravating processes present to warrant hospitalisation and when appropriate monitoring and treatment are observed. This approach minimises the complications that can arise in hospitals and represents considerable cost savings. When selecting these patients, the use of prognostic tools such as the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI) and the Hestia Criteria are of paramount importance. Using these tools, the short-term outcomes (30-90days) show low mortality (in general <3%) and a low incidence of other complications (rate of recurrence and major bleeding <2%). Based on the available evidence, outpatient treatment can be considered the most appropriate strategy at this time for most hemodynamically stable patients with pulmonary embolisms.
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Affiliation(s)
- J Montes Santiago
- Departamento de Medicina Interna, Complejo Hospital Universitario, Vigo, Pontevedra, España.
| | - A B Argibay Filgueira
- Departamento de Medicina Interna, Complejo Hospital Universitario, Vigo, Pontevedra, España
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221
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Chez les sujets ambulatoires avec embolie pulmonaire suspectée, une nouvelle stratégie diagnostique utilisant les D-dimères ajustés en fonction de la probabilité clinique permet-elle d’exclure de façon sécuritaire ce diagnostic sans avoir recours à l’imagerie ? Rev Med Interne 2020; 41:429-430. [DOI: 10.1016/j.revmed.2020.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/06/2020] [Indexed: 11/24/2022]
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222
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Stevens SM, Fazili M, Woller SC. Choosing ultrasound technique for suspected deep vein thrombosis: which is best? Quant Imaging Med Surg 2020; 10:1418-1421. [PMID: 32550148 DOI: 10.21037/qims-2020-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Scott M Stevens
- Intermountain Healthcare, Murray, UT, USA.,School of Medicine, University of Utah, Murray, UT, USA
| | | | - Scott C Woller
- Intermountain Healthcare, Murray, UT, USA.,School of Medicine, University of Utah, Murray, UT, USA
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223
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Heerink JS, Gemen E, Oudega R, Hopstaken R, Geersing GJ, Kusters R. Analytical performance and user-friendliness of five novel point-of-care D-dimer assays. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:433-440. [PMID: 32459511 DOI: 10.1080/00365513.2020.1768586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
D-dimer testing combined with a clinical assessment has become a standard pathway for ruling-out venous thromboembolism (VTE). Recently, novel Point-of-Care (POC) D-dimer assays have been introduced, enabling low-volume blood sampling for rapid exclusion of VTE in a one-step procedure. We assessed the analytical validity and user-friendliness of a set of these novel POC D-dimer assays, and compared the results with a standard laboratory assay. Plasma samples were run on our reference assay (STA-Liatest D-di PLUS®) and five POC assays: Nano-Checker 710®, AFIAS-1®; iChroma-II®; Standard F200® and Hipro AFS/1®). After evaluating imprecision, Pearson Product-Moment correlation coefficients were calculated, Passing Bablok regression was performed and Bland-Altman plots were generated. User-friendliness was evaluated using the System Usability Scale (SUS). A set of 238 plasma samples of patients clinically suspected of VTE in general practice was available for analysis. Only one POC D-dimer assay (Nano-Checker 710) demonstrated an insufficient degree of imprecision. Pearson correlation coefficients and mean biases ranged from 0.68 to 0.93 and -165 to -53 μg/L respectively, and concordance with our reference assay varied from 71.8% to 89.5% using a 500 μg/L cut-off point. While we found considerable variation in overall user-friendliness, most devices were judged easy to use. In view of our findings regarding analytical performance and user-friendliness, we consider most of the novel POC D-dimer assays can be used in settings outside of the laboratory such as general practice, combining the possibility of multi-testing with low-volume capillary blood sampling and processing times of less than 15 min.
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Affiliation(s)
- Jorn S Heerink
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Eugenie Gemen
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Ruud Oudega
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.,Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Geert-Jan Geersing
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ron Kusters
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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224
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Wiercioch W, Nieuwlaat R, Akl EA, Kunkle R, Alexander KE, Cuker A, Rajasekhar A, Alonso-Coello P, Anderson DR, Bates SM, Cushman M, Dahm P, Guyatt G, Iorio A, Lim W, Lyman GH, Middeldorp S, Monagle P, Mustafa RA, Neumann I, Ortel TL, Rochwerg B, Santesso N, Vesely SK, Witt DM, Schünemann HJ. Methodology for the American Society of Hematology VTE guidelines: current best practice, innovations, and experiences. Blood Adv 2020; 4:2351-2365. [PMID: 32453843 PMCID: PMC7252554 DOI: 10.1182/bloodadvances.2020001768] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Methods for the development of clinical guidelines have advanced dramatically over the past 2 decades to strive for trustworthiness, transparency, user-friendliness, and rigor. The American Society of Hematology (ASH) guidelines on venous thromboembolism (VTE) have followed these advances, together with application of methodological innovations. OBJECTIVE In this article, we describe methods and methodological innovations as a model to inform future guideline enterprises by ASH and others to achieve guideline standards. Methodological innovations introduced in the development of the guidelines aim to address current challenges in guideline development. METHODS We followed ASH policy for guideline development, which is based on the Guideline International Network (GIN)-McMaster Guideline Development Checklist and current best practices. Central coordination, specialist working groups, and expert panels were established for the development of 10 VTE guidelines. Methodological guidance resources were developed to guide the process across guidelines panels. A methods advisory group guided the development and implementation of methodological innovations to address emerging challenges and needs. RESULTS The complete set of VTE guidelines will include >250 recommendations. Methodological innovations include the use of health-outcome descriptors, online voting with guideline development software, modeling of pathways for diagnostic questions, application of expert evidence, and a template manuscript for publication of ASH guidelines. These methods advance guideline development standards and have already informed other ASH guideline projects. CONCLUSIONS The development of the ASH VTE guidelines followed rigorous methods and introduced methodological innovations during guideline development, striving for the highest possible level of trustworthiness, transparency, user-friendliness, and rigor.
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Affiliation(s)
- Wojtek Wiercioch
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Robby Nieuwlaat
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | | | | | - Adam Cuker
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau-Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública), Barcelona, Spain
| | - David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mary Cushman
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Philipp Dahm
- Urology Section, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Nephrology and Hypertension, Department of Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Thomas L Ortel
- Department of Medicine and
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nancy Santesso
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK; and
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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225
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Tal S, Spectre G, Kornowski R, Perl L. Venous Thromboembolism Complicated with COVID-19: What Do We Know So Far? Acta Haematol 2020; 143:417-424. [PMID: 32396903 PMCID: PMC7270063 DOI: 10.1159/000508233] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus disease (COVID-19) is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is responsible for the ongoing 2019-2020 pandemic. Venous thromboembolism (VTE), a frequent cardiovascular and/or respiratory complication among hospitalized patients, is one of the known sequelae of the illness. Hospitalized COVID-19 patients are often elderly, immobile, and show signs of coagulopathy. Therefore, it is reasonable to assume a high incidence of VTE among these patients. Presently, the incidence of VTE is estimated at around 25% of patients hospitalized in the intensive care unit for COVID-19 even under anticoagulant treatment at prophylactic doses. In this review, we discuss present knowledge of the topic, the unique challenges of diagnosis and treatment of VTE, as well as some of the potential mechanisms of increased risk for VTE during the illness. Understanding the true impact of VTE on patients with COVID-19 will potentially improve our ability to reach a timely diagnosis and initiate proper treatment, mitigating the risk for this susceptible population during a complicated disease.
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Affiliation(s)
- Shir Tal
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Galia Spectre
- Hematology Department, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leor Perl
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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226
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Mehdipoor G, Jimenez D, Bertoletti L, Fidalgo Á, Sanchez Muñoz-Torrero JF, Gonzalez-Martinez JP, Blanco-Molina Á, Ángel Aibar M, Bonnefoy PB, Khorasani R, Prince MR, Bikdeli B, Monreal M, Adarraga MD, Agud M, Azcarate-Agüero P, Aibar J, Alfonso J, Amado C, Ignacio Arcelus J, Ballaz A, Barba R, Barrón CBM, Barrón-Andrés B, Camon AM, Cañas I, Criado J, Ancos CD, Miguel JD, del Toro J, Demelo-Rodríguez P, Díaz-Pedroche C, Díaz-Peromingo JA, Díaz-Simón R, Díez-Sierra J, Milagros Domínguez I, Escribano JC, Farfán AI, Fernández-Capitán C, Fernández-Reyes JL, Flores K, Font C, Font L, Francisco I, Gabara C, Galeano-Valle F, Ángeles García M, García-Bragado F, García-García M, García-Raso A, Gavín-Blanco O, Gavín-Sebastián O, Carmen Gayol M, Gil-Díaz A, Gómez-Cuervo C, Grau E, Gutiérrez-Guisado J, Hernández-Blasco L, Iglesias M, Jara-Palomares L, Jesús Jaras M, Joya MD, Jou I, Lacruz B, Lalueza A, Lecumberri R, Lima J, Llamas P, Luis Lobo J, López-Jiménez L, López-Miguel P, José López-Núñez J, López-Reyes R, Bosco López-Sáez J, Alejandro Lorente M, Lorenzo A, Loring M, Lumbierres M, Madridano O, Maestre A, Javier Marchena P, Martín-Fernández M, Miguel Martín-Guerra J, Martín-Martos F, Mellado M, Mercado MI, Moisés J, del Valle Morales M, Muñoz-Blanco A, Muñoz-Guglielmetti D, Antonio Nieto J, Jesús Núñez M, Ortega-Michel MCOC, Dolores Ortega-Recio M, Osorio J, Otero R, Paredes D, Parra P, Parra V, Pedrajas JM, Pellejero G, Pérez-Ductor C, Asunción Pérez-Jacoíste M, Pesántez D, Porras JA, Portillo J, Reig L, Riera-Mestre A, Rivas A, Rodríguez-Cobo A, Rodríguez-Galán I, Rodríguez-Matute C, Rosa V, María Rubio C, Ruiz-Artacho P, Ruiz-Giménez N, Ruiz-Ruiz J, Ruiz-Sada P, Ruiz-Torregrosa P, Carles Sahuquillo J, Salgueiro G, Sampériz Á, Sancho T, Soler S, Suárez S, María Suriñach J, Tiberio G, Isabel Torres M, Tolosa C, Trujillo-Santos J, Uresandi F, Usandizaga E, Valle R, Ramón Vela J, Vidal G, Villares P, Zamora C, Gutiérrez P, Javier Vázquez F, Vanassche T, Vandenbriele C, Verhamme P, Hirmerova J, Malý R, Salgado E, Benzidia I, Bura-Riviere A, Crichi B, Debourdeau P, Farge-Bancel D, Helfer H, Mahé I, Moustafa F, Poenou G, Schellong S, Braester A, Brenner B, Tzoran I, Amitrano M, Bilora F, Bortoluzzi C, Brandolin B, Bucherini E, Ciammaichella M, Colaizzo D, Dentali F, Micco PD, Giammarino E, Grandone E, Maggi F, Mangiacapra S, Mastroiacovo D, Maida R, Pace F, Pesavento R, Pomero F, Prandoni P, Quintavalla R, Rocci A, Siniscalchi C, Tiraferri E, Tufano A, Visonà A, Hong NV, Zalunardo B, Kalejs RV, Kigitovica D, Skride A, Ferreira M, Meireles J, Reis A, Bosevski M, Krstevski G, Zdraveska M, Bounameaux H, Mazzolai L, Caprini JA, Tafur AJ, Weinberg I, Wilkins H, My Bui H. Patient-Level, Institutional, and Temporal Variations in Use of Imaging Modalities to Confirm Pulmonary Embolism. Circ Cardiovasc Imaging 2020; 13:e010651. [PMID: 32418452 DOI: 10.1161/circimaging.120.010651] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The choice of the imaging modality for diagnosis of pulmonary embolism (PE) could be influenced by provider, patient or hospital characteristics, or over time. However, little is known about the choice of the diagnostic modalities in practice. The aim of this study was to evaluate the variations in the use of imaging modalities for patients with acute PE.
Methods:
Using the data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective international registry of patients with venous thromboembolism (March 2001–January 2019), we explored the imaging modalities used in patients with acute PE. The imaging modalities included computed tomography pulmonary angiography, ventilation/perfusion scanning, pulmonary angiography, a combination of these tests, or PE signs and symptoms plus imaging-confirmed proximal deep vein thrombosis but no chest imaging.
Results:
Among 38 025 patients with confirmed PE (53.1% female, age: 67.3±17 years), computed tomography pulmonary angiography was the dominant modality of diagnosis in all RIETE enrollees (78.2% [99% CI, 77.6–78.7]); including pregnant patients (58.9% [99% CI, 47.7%–69.4%]) and patients with severe renal insufficiency (62.5% [99% CI, 59.9–65.0]). A greater proportion of patients underwent ventilation/perfusion scanning in larger hospitals compared with smaller hospitals (13.1% versus 7.3%,
P
<0.001). The use of computed tomography pulmonary angiography varied between 13.3% and 98.3% across the countries, and its use increased over time (46.5% in 2002 to 91.7% in 2018,
P
<0.001).
Conclusions:
In a large multinational PE registry, variations were observed in the use of imaging modalities according to patient or institutional factors and over time. However, computed tomography pulmonary angiography was the dominant modality of diagnosis, even in pregnancy and severe renal insufficiency. The safety, costs, and downstream effects of these tests on PE-related and non-PE-related outcomes warrant further investigation.
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Affiliation(s)
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain (D.J.)
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Hôpital Nord, CHU de Saint-Etienne and INSERM U1059 SAINBIOSE - CIC 1408, Université Jean-Monnet, Saint-Etienne, France (L.B.)
| | - Ángeles Fidalgo
- Department of Internal Medicine, Hospital Universitario de Salamanca, Spain (A.F.)
| | | | - José Pedro Gonzalez-Martinez
- Department of Internal Medicine, Hospital Universitari St Joan de Deu Manresa (Barcelona) Fundació Althaia (J.P.G.-M.)
| | - Ángeles Blanco-Molina
- Department of Internal Medicine, Hospital Universitario Reina Sofía, Córdoba, Spain (A.B.-M.)
| | - Miguel Ángel Aibar
- Internal Medicine Department and IIS Aragón, Hospital Clínico Universitario, Zaragoza, Spain (M.A.A.)
| | - Pierre-Benoît Bonnefoy
- Service de médecine nucléaire, Hôpital Nord, CHU de St-Etienne, Saint-Etienne, France (P.-B.B.)
| | - Ramin Khorasani
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.K.)
| | - Martin R. Prince
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital (M.R.P.)
- Columbia University College of Physicians and Surgeons, New York, NY (M.R.P.)
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital (B.B.)
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (B.B.)
- Cardiovascular Research Foundation (CRF), New York, NY (B.B.)
| | - Manuel Monreal
- Department of Internal Medicine, Hospital de Badalona Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain (M.M.)
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D-dimer as a stand-alone test to rule out deep vein thrombosis. Thromb Res 2020; 191:134-139. [PMID: 32447095 DOI: 10.1016/j.thromres.2020.04.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Current guidelines recommend the use of clinical decision rules, such as Wells score, in combination with D-dimer to assess the need for objective imaging to rule out deep vein thrombosis (DVT). However, the clinical decision rule has limitations, and use of D-dimer as a stand-alone test has been suggested. OBJECTIVE We aimed to assess the safety and efficiency of D-dimer as a stand-alone test to rule out DVT in outpatients referred with suspected DVT. METHODS We collected data from consecutive outpatients referred to our hospital with suspected DVT in 2008-2018. D-dimer levels were analyzed using STA® Liatest® D-Di assay. D-dimer as a stand-alone test was theoretically applied in retrospect, and the number of misdiagnosed events were estimated as if such an approach had been initially used. All patients were followed for three months. RESULTS Of 1765 included patients, 293 (16.6%) were diagnosed with DVT. A total of 491 patients (27.8%) had a negative D-dimer (<500 ng/mL). Of these, nine were diagnosed with DVT, yielding a failure rate for D-dimer as a stand-alone test of 1.8% (95% CI 0.8%-3.5%). The majority of the misdiagnosed patients had distal DVT. In analyses restricted to proximal DVTs, the failure rate was 0.6% (95% CI 0.1%-1.8%). D-dimer as a stand-alone approach reduced the proportion of required ultrasounds from 81.8% to 72.2%. CONCLUSION D-dimer as a stand-alone test may be safe for excluding proximal DVT and reduce the proportion of required ultrasounds. Prospective management studies are needed to confirm our findings.
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Peripherally inserted central catheters lead to a high risk of venous thromboembolism in children. Blood 2020; 135:220-226. [PMID: 31909784 DOI: 10.1182/blood.2019002260] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/28/2019] [Indexed: 11/20/2022] Open
Abstract
Venous thromboembolism (VTE) incidence in children has sharply increased with the majority of cases secondary to central venous catheters (CVCs). Among CVCs, the number of peripherally inserted central catheters (PICCs) placed has risen significantly. In this multicenter, prospective, observational cohort study, we enrolled patients aged 6 months to 18 years with newly placed PICCs or tunneled lines (TLs). We evaluated the incidence of VTE, central line-associated bloodstream infections (CLABSIs), and catheter malfunctions in PICCs and TLs, and risk factors of CVC-related VTE. A total of 1967 CVCs were included in the analysis. The incidence of CVC-related VTE was 5.9% ± 0.63%. The majority of the cases, 80%, were in subjects with PICCs, which had a significantly higher risk of catheter-related VTE than subjects with TLs (hazard ratio [HR] = 8.5; 95% confidence interval [CI], 3.1-23; P < .001). PICCs were significantly more likely to have a CLABSI (HR = 1.6; 95% CI, 1.2-2.2; P = .002) and CVC malfunction (HR = 2.0; 95% CI, 1.6-2.4; P < .001). Increased risk of CVC-related VTE was found in patients with a prior history of VTE (HR = 23; 95% CI, 4-127; P < .001), multilumen CVC (HR = 3.9; 95% CI, 1.8-8.9; P = .003), and leukemia (HR = 3.5; 95% CI, 1.3-9.0; P = .031). Children with PICCs had a significantly higher incidence of catheter-related VTE, CLABSI, and CVC malfunction over TLs. The results suggest that pause be taken prior to placing CVCs, especially PICCs, due to the serious complications they have been shown to cause.
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Stals MAM, Klok FA, Huisman MV. Diagnostic management of acute pulmonary embolism in special populations. Expert Rev Respir Med 2020; 14:729-736. [DOI: 10.1080/17476348.2020.1753505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Milou A. M. Stals
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
PURPOSE OF REVIEW Patients with pulmonary embolism commonly undergo thrombophilia evaluation for a variety of reasons including risk stratification for recurrent venous thromboembolism (VTE) and treatment planning. However, the utility of thrombophilia testing in many clinical scenarios remains unclear. This review evaluates current recommendations for thrombophilia testing described in consensus VTE guidelines, recent literature on the clinical application of these recommendations, novel genetic assessments for hereditary thrombophilias, and studies evaluating use of direct oral anticoagulants (DOACs) in VTE patients with thrombophilias. RECENT FINDINGS Current VTE guidelines advise limited use of thrombophilia testing, recognizing that testing may be misinterpreted and frequently does not lead to a change in management. Testing and test results are not necessarily benign, are frequently misinterpreted, and can lead to increased anxiety in both patients and clinicians. Recent studies have offered innovative techniques to better align clinical practice with these recommendations as well as expanded genomic assessments to improve the scope and predictive value of thrombophilia testing. There is also emerging literature on the appropriateness of direct oral anticoagulant therapy for VTE patients with hereditary thrombophilias or antiphospholipid syndrome. SUMMARY Thrombophilia testing in its current form does not significantly impact clinical management or improve outcomes for most VTE patients. Therefore, it should be employed judiciously and only in patients for whom it is likely to alter clinical management. Novel expanded genomic thrombophilia testing approaches and additional studies evaluating optimal anticoagulant treatment in various thrombophilia subpopulations will make thrombophilia testing more useful for patients moving forward.
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231
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Blondon M, Le Gal G, Meyer G, Righini M, Robert-Ebadi H. Age-adjusted D-dimer cutoff for the diagnosis of pulmonary embolism: A cost-effectiveness analysis. J Thromb Haemost 2020; 18:865-875. [PMID: 31925875 DOI: 10.1111/jth.14733] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/18/2019] [Accepted: 01/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with suspected pulmonary embolism (PE) and a non-high pretest probability, the use of an age-adjusted D-dimer cutoff (AADD, <500 ng/mL up to 50 years, then METHODS We created a decision tree to compare the use of the AADD with the standard D-dimer cutoff. The model included short-term venous thromboembolism-related events and long-term complications, their associated morbidity/mortality, and costs. Probabilities were derived from published literature and the ADJUST-PE study, and costs from US estimates. The time horizon was lifetime, with a health care system perspective. RESULTS Using the AADD cutoff, compared with the standard cutoff, was associated with a loss of 0.0001 quality-adjusted life-years (QALY) and an average cost reduction of $33.4. The decremental cost-effectiveness ratio (DCER) was +$282 881/lost QALY (95% confidence interval from +$43 209/lost QALY to a dominant strategy). The probability that the use of the AADD cutoff was either dominant or gained >$200 000/lost QALY was 79.4%. In sensitivity analyses, the DCER became <+$200 000/lost QALY only if, among patients with D-dimer below the AADD cutoff, the mortality of an undiagnosed PE was >6% or the prevalence of PE was >0.6%. CONCLUSIONS The AADD cutoff results in a clinically nonsignificant decrease in QALY but important costs reductions. It is a decrementally cost-effective innovation, with a potential of cost savings of >$80 million per year for the United States health care system.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Haemostasis, Faculty of Medicine and Geneva University Hospitals, Geneva, Switzerland
| | - Gregoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Guy Meyer
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Université Paris Descartes, Paris, France
| | - Marc Righini
- Division of Angiology and Haemostasis, Faculty of Medicine and Geneva University Hospitals, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Haemostasis, Faculty of Medicine and Geneva University Hospitals, Geneva, Switzerland
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Jafarzadeh-Esfehani R, Mostafa Parizadeh S, Sabeti Aghabozorgi A, Yavari N, Sadr-Nabavi A, Alireza Parizadeh S, Ghandehari M, Javanbakht A, Rezaei-Kalat A, Mahdi Hassanian S, Vojdanparast M, Ferns GA, Khazaei M, Avan A. Circulating and tissue microRNAs as a potential diagnostic biomarker in patients with thrombotic events. J Cell Physiol 2020; 235:6393-6403. [PMID: 32198752 DOI: 10.1002/jcp.29639] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 01/30/2020] [Indexed: 12/13/2022]
Abstract
Venous and arterial thrombosis are conditions that have a considerable burden if left untreated. The hypoxia-induced by the occluded vessel can disrupt the circulation of any organ, the cornerstone of treating thrombosis is rapid diagnosis and appropriate treatment. Diagnosis of thrombosis may be made by using laboratory tests or imaging techniques in individuals who have clinical manifestations of a thrombotic event. The use of serum micro ribonucleic acids (RNAs) has recently been applied to the diagnosis of thrombosis. These small RNA molecules are emerging as new diagnostic markers but have had very limited applications in vascular disease. Most of the articles provided various microRNAs with different levels of accuracy. However, there remains a lack of an appropriate panel of the most specific microRNA in the literature. The purpose of the present review was to summarize the existing data on the use of microRNAs as a diagnostic biomarker for venous thrombosis.
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Affiliation(s)
- Reza Jafarzadeh-Esfehani
- Department of Medical Genetics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Mostafa Parizadeh
- Department of Physiology, Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Physiology, Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Negar Yavari
- Department of Physiology, Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ariane Sadr-Nabavi
- Department of Medical Genetics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Alireza Parizadeh
- Department of Physiology, Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Ghandehari
- Department of Physiology, Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Physiology, Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afsane Javanbakht
- Department of Physiology, Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Physiology, Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afsaneh Rezaei-Kalat
- Department of Psychiatry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Mahdi Hassanian
- Department of Physiology, Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Vojdanparast
- Department of Cardiovascular Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gordon A Ferns
- Division of Medical Education, Brighton & Sussex Medical School, Brighton, UK
| | - Majid Khazaei
- Department of Physiology, Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Physiology, Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Avan
- Department of Physiology, Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Physiology, Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
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Corona G, Goulis DG, Huhtaniemi I, Zitzmann M, Toppari J, Forti G, Vanderschueren D, Wu FC. European Academy of Andrology (EAA) guidelines on investigation, treatment and monitoring of functional hypogonadism in males: Endorsing organization: European Society of Endocrinology. Andrology 2020; 8:970-987. [PMID: 32026626 DOI: 10.1111/andr.12770] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Evidence regarding functional hypogonadism, previously referred to as 'late-onset' hypogonadism, has increased substantially during the last 10 year. OBJECTIVE To update the European Academy of Andrology (EAA) guidelines on functional hypogonadism. METHODS Expert group of academicians appointed by the EAA generated a series of consensus recommendations according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. RESULTS The diagnosis of functional hypogonadism should be based on both the presence of clinical symptoms supported by repeatedly low morning fasting serum total testosterone (T) measured with a well-validated assay, after exclusion of organic causes of hypogonadism. Lifestyle changes and weight reduction should be the first approach in all overweight and obese men. Whenever possible, withdrawal/modification of drugs potentially interfering with T production should be advised. Testosterone replacement therapy (TRT) is contraindicated in men with untreated prostate or breast cancer, as well as severe heart failure. Severe low urinary tract symptoms and haematocrit >48%-50% represent relative contraindications for TRT. Prostate-specific antigen and digital rectal examination of the prostate should be undertaken in men >40 years of age before initiating TRT to exclude occult prostate cancer. Transdermal T should be preferred for initiation of TRT, whereas gonadotrophin therapy is only recommended when fertility is desired in men with secondary hypogonadism. TRT is able to improve sexual function in hypogonadal men. Other potential positive outcomes of TRT remain uncertain and controversial. CONCLUSION TRT can reliably improve global sexual function in men with hypogonadism in the short term. Long-term clinical benefits, and safety of TRT in functional hypogonadism, remain to be fully documented. Clinicians should therefore explicitly discuss the uncertainties and benefits of TRT and engage them in shared management decision-making.
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Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ilpo Huhtaniemi
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, UK.,Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland
| | - Michael Zitzmann
- Institute of Reproductive Medicine, University Clinic Muenster, Muenster, Germany
| | - Jorma Toppari
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland.,Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Gianni Forti
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Frederick C Wu
- Division of Endocrinology, Diabetes and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, UK
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234
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Etxeandia-Ikobaltzeta I, Zhang Y, Brundisini F, Florez ID, Wiercioch W, Nieuwlaat R, Begum H, Cuello CA, Roldan Y, Chen R, Ding C, Morgan RL, Riva JJ, Zhang Y, Charide R, Agarwal A, Balduzzi S, Morgano GP, Yepes-Nuñez JJ, Rehman Y, Neumann I, Schwab N, Baldeh T, Braun C, Rodríguez MF, Schünemann HJ. Patient values and preferences regarding VTE disease: a systematic review to inform American Society of Hematology guidelines. Blood Adv 2020; 4:953-968. [PMID: 32150612 PMCID: PMC7065473 DOI: 10.1182/bloodadvances.2019000462] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 01/24/2020] [Indexed: 12/17/2022] Open
Abstract
Values and preferences relate to the importance that patients place on health outcomes (eg, bleeding, having a deep venous thrombosis) and are essential when weighing benefits and harms in guideline recommendations. To inform the American Society of Hematology guidelines for management of venous thromboembolism (VTE) disease, we conducted a systematic review of patients' values and preferences related to VTE. We searched Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature from inception to April of 2018 (PROSPERO-CRD42018094003). We included quantitative and qualitative studies. We followed Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance for rating the certainty and presenting findings for quantitative research about the relative importance of health outcomes and a grounded theory approach for qualitative thematic synthesis. We identified 14 quantitative studies (2465 participants) describing the relative importance of VTE-related health states in a widely diverse population of patients, showing overall small to important impact on patients' lives (certainty of the evidence from low to moderate). Additionally, evidence from 34 quantitative studies (6424 participants) and 15 qualitative studies (570 participants) revealed that patients put higher value on VTE risk reduction than on the potential harms of the treatment (certainty of evidence from low to moderate). Studies also suggested a clear preference for oral medication over subcutaneous medication (moderate certainty). The observed variability in health state values may be a result of differences in the approaches used to elicit them and the diversity of included populations rather than true variability in values. This finding highlights the necessity to explore the variability induced by different approaches to ascertain values.
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Affiliation(s)
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Francesca Brundisini
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ivan D Florez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Housne Begum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Carlos A Cuello
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Health Quality Improvement, School of Medicine, Tecnologico de Monterrey, Monterrey, Mexico
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ru Chen
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chengyi Ding
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rana Charide
- GRADE Center, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sara Balduzzi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena, Modena, Italy
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Yasir Rehman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicole Schwab
- SickKids Hospital and University of Toronto, Toronto, ON, Canada
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Cody Braun
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University Health Sciences Centre, Hamilton, ON, Canada
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Diagnostic accuracy of three ultrasonography strategies for deep vein thrombosis of the lower extremity: A systematic review and meta-analysis. PLoS One 2020; 15:e0228788. [PMID: 32045437 PMCID: PMC7012434 DOI: 10.1371/journal.pone.0228788] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/23/2020] [Indexed: 02/01/2023] Open
Abstract
Background Compression ultrasonography (CUS) is the first-line imaging test in the diagnostic management of suspected deep vein thrombosis (DVT) of the lower extremity. Three CUS strategies are used in clinical practice. However, their relative diagnostic accuracy is uncertain. Objectives This systematic review and meta-analysis aimed to summarize and compare the diagnostic accuracy of single limited, serial limited, and whole-leg CUS for DVT. Methods MEDLINE, Embase, and CENTRAL were searched from January 1st, 1989 to July 23rd, 2019 for studies assessing at least one of the CUS strategies in adults with suspected DVT of the lower extremity, using clinical follow-up for venous thromboembolism or contrast venography as the reference standard. Study selection, data extraction, and risk of bias assessment were performed in duplicate by independent authors. A bivariate random-effects model was used to compute diagnostic accuracy summary estimates. Results Forty studies (n = 21,250) were included. The venous thromboembolic event rate after a negative CUS (failure rate) of single limited (1.4%; 95% CI, 0.83–2.5), serial limited (1.9%; 95% CI, 1.4–2.5), and whole-leg CUS (1.0%; 95% CI, 0.6–1.6) did not differ significantly. The proportion of positive results was lower with single limited CUS, as was DVT prevalence in this group. Conclusions The failure rates of single limited, serial limited, and whole-leg CUS for DVT appeared to be quite comparable. The relative failure rate of single limited CUS remains uncertain, as the DVT prevalence was lower in these studies. Therefore, this CUS strategy may only be safe in a selected group of low-risk patients. Preference for one of the strategies may be based on pretest probability assessment, feasibility, expertise, and perceived clinical relevance of isolated distal DVT.
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236
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Javaudin F, Seon J, Le Bastard Q, Cabiot A, Pes P, Arnaudet I, Allain M, Le Conte P. Evaluation of short training session for venous limited compression ultrasonography: prospective multicenter study. Ultrasound J 2020; 12:5. [PMID: 32016592 PMCID: PMC6997306 DOI: 10.1186/s13089-020-0155-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous limited compression ultrasonography (VLCU) is recommended in case of suspicion of deep venous thrombosis (DVT). Current training pathways are rather long and include experiential phase. This aim of this study was to investigate the efficacy of a short training session for VLCU without experiential phase. The training session was applied in residents without previous ultrasound skills. Program included operation of ultrasound device and interpretation of venous images. Included patients were older than 18 years and had a suspicion of DVT. After realization of VLCU using usual technique, residents reported the dynamic compressibility of the femoral and popliteal veins, the presence or not of a visible thrombus, self-reported difficulty and duration. Patients then underwent a whole leg ultrasonography (WLCU) in the local laboratory which was blinded to VLCU results. The main criterion was the negative-predictive value (NPV) of VLCU for the absence of proximal DVT diagnosed with WLCU. Secondary criteria were VLCU diagnostic performances, rate of inability to conclude, difficulty and duration. For a NPV of 95 ± 6%, the needed number of patients was 96. This study was approved by the ethical committee. RESULTS 102 patients were analyzed. 46 residents were trained. A DVT was diagnosed by WLCU in 18 patients (prevalence of 17.6% [95% CI 11-26%]). VLCU detected 15 DVT (NPV of 96% [95% CI 89-99%]). The positive likelihood ratio was 9.9, the negative likelihood ratio 0.19 and Cohen's Kappa 0.62 [95% CI 0.52-0.71]. The sensitivity was 83% [CI 95% 60-94%] and specificity 88% [CI 95% 79-93%]. The mean number of VLCU by residents was 2.3 ± 2.1, median 2 (minimum 1, maximum 8). Mean duration was 3.4 min, difficulty was 3.7 ± 2. CONCLUSION The principal objective, NPV 96% [95% CI 89-99%], was achieved. However, this short training session was inadequate to allow ruling-out a DVT with sufficient security. Thus, the experiential phase seems to be essential.
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Affiliation(s)
- François Javaudin
- Emergency Department, Departmental Hospital, La Roche Sur Yon, 44035, Nantes Cedex 01, France
| | - Julie Seon
- Emergency Department, University Hospital, Nantes, France
| | - Quentin Le Bastard
- Emergency Department, Departmental Hospital, La Roche Sur Yon, 44035, Nantes Cedex 01, France
| | - Astrid Cabiot
- Emergency Department, University Hospital, Nantes, France
| | - Philippe Pes
- Emergency Department, Departmental Hospital, La Roche Sur Yon, 44035, Nantes Cedex 01, France
| | - Idriss Arnaudet
- Emergency Department, Departmental Hospital, La Roche Sur Yon, 44035, Nantes Cedex 01, France
| | - Milena Allain
- Emergency Department, Departmental Hospital, La Roche Sur Yon, 44035, Nantes Cedex 01, France
| | - Philippe Le Conte
- Emergency Department, Departmental Hospital, La Roche Sur Yon, 44035, Nantes Cedex 01, France.
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Vedovati MC, Giustozzi M, Franco L. Beyond the guidelines: Novelties, changes and unsolved issues from the 2019 ESC guidelines on pulmonary embolism. Eur J Intern Med 2020; 72:1-4. [PMID: 31744660 DOI: 10.1016/j.ejim.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Cristina Vedovati
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
| | - Michela Giustozzi
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Laura Franco
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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Kline JA, Garrett JS, Sarmiento EJ, Strachan CC, Courtney DM. Over-Testing for Suspected Pulmonary Embolism in American Emergency Departments: The Continuing Epidemic. Circ Cardiovasc Qual Outcomes 2020; 13:e005753. [PMID: 31957477 DOI: 10.1161/circoutcomes.119.005753] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND No recent data have investigated rates of diagnostic testing for pulmonary embolism (PE) in US emergency departments (EDs), and no data have examined computed tomographic pulmonary angiography (CTPA) rates in subgroups at high risk for adverse imaging outcomes, including young women and children. We hypothesized that over-testing for PE remains a problem. METHODS AND RESULTS We used electronic health record and billing data for 16 EDs in Indiana and 11 hospitals in the Dallas-Fort Worth area from 2016 to 2019 to locate ED patients who had any of the following: D-dimer, CTPA, scintillation ventilation perfusion lung scanning or formal pulmonary angiography. The primary outcomes were ED encounter volume-adjusted CTPA rate, PE yield rate with subgroup reporting for children (<18 years) and women under 45 years. We also examined the most frequent diagnoses. From a total visit volume of 1 828 010 patient encounters, 97 125 (5.3% of the total volume) had a diagnostic test for PE, including 25 870 patients who had CTPA order without D-dimer (59% of all tests for PE). The yield rate for PE from CTPA scans was 1.3% (1.1%-1.5%) in Indiana and 4.8% (4.2%-5.1%) in Dallas-Fort Worth (pooled rate 3.1%). Linear regression showed that increased D-dimer ordering correlated with increased PE yield rate (Pearson's R2=0.43; P<0.001). From the pooled sample, 59% of CTPAs done were in women, with 21% of all CTPAs performed on women under 45 years of age, and 1.4% (1.3%-1.5%) on children. The most frequent diagnoses were symptom-based descriptions of chest pain (34%) and shortness of breath (6.5%) and the condition-based diagnosis of pneumonia (4.1%). CONCLUSIONS Over-testing for PE in American EDs remains a major public health problem. Centers with higher D-dimer ordering had higher yield of PE on CTPA. These data suggest the potential for implementation of D-dimer based protocols to reduce low-yield CTPA ordering.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - John S Garrett
- Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX (J.S.G.)
| | - Elisa J Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - Christian C Strachan
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX (D.M.C.)
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Diversifying study design in pediatrics. Blood 2020; 135:156-157. [DOI: 10.1182/blood.2019004198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gibbs L, Moulton J, Tichenor V. Venous Thromboembolism. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_88-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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241
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Liem RI, Lanzkron S, D Coates T, DeCastro L, Desai AA, Ataga KI, Cohen RT, Haynes J, Osunkwo I, Lebensburger JD, Lash JP, Wun T, Verhovsek M, Ontala E, Blaylark R, Alahdab F, Katabi A, Mustafa RA. American Society of Hematology 2019 guidelines for sickle cell disease: cardiopulmonary and kidney disease. Blood Adv 2019; 3:3867-3897. [PMID: 31794601 PMCID: PMC6963257 DOI: 10.1182/bloodadvances.2019000916] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/01/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Prevention and management of end-organ disease represent major challenges facing providers of children and adults with sickle cell disease (SCD). Uncertainty and variability in the screening, diagnosis, and management of cardiopulmonary and renal complications in SCD lead to varying outcomes for affected individuals. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about screening, diagnosis, and management of cardiopulmonary and renal complications of SCD. METHODS ASH formed a multidisciplinary guideline panel that included 2 patient representatives and was balanced to minimize potential bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including performing systematic evidence reviews up to September 2017. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 10 recommendations for screening, diagnosis, and management of cardiopulmonary and renal complications of SCD. Recommendations related to anticoagulation duration for adults with SCD and venous thromboembolism were also developed. CONCLUSIONS Most recommendations were conditional due to a paucity of direct, high-quality evidence for outcomes of interest. Future research was identified, including the need for prospective studies to better understand the natural history of cardiopulmonary and renal disease, their relationship to patient-important outcomes, and optimal management.
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Affiliation(s)
- Robert I Liem
- Division of Hematology, Oncology and Stem Cell Transplant, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sophie Lanzkron
- Division of Adult Hematology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Thomas D Coates
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Laura DeCastro
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ankit A Desai
- Krannert Institute of Cardiology, School of Medicine, Indiana University, Indianapolis, IN
| | - Kenneth I Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
| | - Robyn T Cohen
- Division of Pediatric Pulmonary and Allergy, Boston Medical Center, School of Medicine, Boston University, Boston, MA
| | - Johnson Haynes
- Division of Pulmonary Disease, College of Medicine, University of South Alabama, Mobile, AL
| | - Ifeyinwa Osunkwo
- Division of Hematology, The Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Jeffrey D Lebensburger
- Division of Pediatric Hematology/Oncology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - James P Lash
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Theodore Wun
- Division of Hematology and Oncology, School of Medicine, University of California Davis, Sacramento, CA
| | - Madeleine Verhovsek
- Division of Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada
| | | | | | - Fares Alahdab
- Division of General Internal Medicine, Mayo Medical School, Rochester, MN; and
| | - Abdulrahman Katabi
- Division of General Internal Medicine, Mayo Medical School, Rochester, MN; and
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, School of Medicine, University of Kansas, Kansas City, KS
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Peterson EA, Lee AYY. Update from the clinic: what's new in the diagnosis of cancer-associated thrombosis? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:167-174. [PMID: 31808866 PMCID: PMC6913437 DOI: 10.1182/hematology.2019000024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Malignancy is associated with a high risk of venous thromboembolism (VTE), and treatment with anticoagulant therapy is associated with a high risk of bleeding. Thus, accurate and timely VTE diagnosis in cancer patients is essential for identifying individuals who would benefit from anticoagulant therapy and for avoiding unnecessary treatment that can cause anticoagulant-related bleeding. The approach to the diagnosis of VTE in non-cancer patients involves a stepwise process beginning with an assessment of the pretest probability (PTP) of VTE using a validated clinical prediction rule (CPR) followed by D-dimer testing and/or diagnostic imaging. In patients with a low PTP and a negative D-dimer result, VTE can be excluded without additional imaging. However, published data suggest that CPRs and D-dimer testing may not be as accurate or as useful in patients with cancer. Studies have shown that the combination of a low PTP and negative D-dimer result is not efficient for exclusion of deep vein thrombosis (DVT) or pulmonary embolism (PE) in the cancer patient population because the vast majority of patients still require radiologic imaging. We propose that cancer patients with suspected VTE should proceed directly to radiologic imaging to confirm or exclude a diagnosis of DVT or PE.
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Affiliation(s)
- Erica A Peterson
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Kearon C, de Wit K, Parpia S, Schulman S, Afilalo M, Hirsch A, Spencer FA, Sharma S, D'Aragon F, Deshaies JF, Le Gal G, Lazo-Langner A, Wu C, Rudd-Scott L, Bates SM, Julian JA. Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med 2019; 381:2125-2134. [PMID: 31774957 DOI: 10.1056/nejmoa1909159] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP. METHODS We performed a prospective study in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for 3 months to detect venous thromboembolism. RESULTS A total of 2017 patients were enrolled and evaluated, of whom 7.4% had pulmonary embolism on initial diagnostic testing. Of the 1325 patients who had a low C-PTP (1285 patients) or moderate C-PTP (40 patients) and a negative d-dimer test (i.e., <1000 or <500 ng per milliliter, respectively), none had venous thromboembolism during follow-up (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%). Of all 1863 patients who did not receive a diagnosis of pulmonary embolism initially and did not receive anticoagulant therapy, 1 patient (0.05%; 95% CI, 0.01 to 0.30) had venous thromboembolism. Our diagnostic strategy resulted in the use of chest imaging in 34.3% of patients, whereas a strategy in which pulmonary embolism is considered to be ruled out with a low C-PTP and a d-dimer level of less than 500 ng per milliliter would result in the use of chest imaging in 51.9% (difference, -17.6 percentage points; 95% CI, -19.2 to -15.9). CONCLUSIONS A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up. (Funded by the Canadian Institutes of Health Research and others; PEGeD ClinicalTrials.gov number, NCT02483442.).
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Affiliation(s)
- Clive Kearon
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Kerstin de Wit
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sameer Parpia
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sam Schulman
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Marc Afilalo
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Andrew Hirsch
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Frederick A Spencer
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sangita Sharma
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Frédérick D'Aragon
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Jean-François Deshaies
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Gregoire Le Gal
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Alejandro Lazo-Langner
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Cynthia Wu
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Lisa Rudd-Scott
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Shannon M Bates
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Jim A Julian
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
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Genetic risk assessment towards warfarin application: Saudi Arabia study with a potential to predict and prevent side effects. Saudi J Biol Sci 2019; 27:456-459. [PMID: 31889870 PMCID: PMC6933267 DOI: 10.1016/j.sjbs.2019.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 12/31/2022] Open
Abstract
Warfarin doses are greatly affected by polymorphism altering cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase complex subunit 1 (VKORC1) gene. This study evaluated the prevalence of alleles (either single or double) and carriers of single nucleotide polymorphisms (SNPs) in both genotypes CYP2C9 and VKORC1 in alkharj area, Saudi Arabia and its association with warfarin use risk. Total 112 samples were collected and genotyped using FlexiGene DNA Kit for isolation and StepOnePlus Real-Time PCR System by TaqMan allelic discrimination methods. The results indicated the frequency of 11%, 8% and 45% for CYP2C9 *2 *3 and VKORC1-1639 G > A polymorphism. And as a combination genotype it was 15.18% For both CYP2C9 and VKORC1 polymorphism, 27.67% for CYP2C9 and 42.86% for VKORC1. Non-carriers rate came to be at 30.3%. According to previously published dosing changes in warfarin for polymorphism carriers (single-double-triple). The predicted warfarin doses reduction in order of 1–1.6, 2–2.9, 2.9–3.7 mg/day. It was found that 72.3% of the study population was carrier of a type of polymorphism, 15.18% for two types of polymorphisms. These findings predict changes in warfarin metabolism and eventually dosing alteration among patients on warfarin. Both genotypes (CYP2C9 and VKORC1) require different dosing of warfarin than non-carriers in order to minimize the risk of warfarin overdosing and avoidance of the drug-related problems (DRPs).
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Viau-Lapointe J, Arsenault MP. New evidence in diagnosis of pulmonary embolism during pregnancy. Obstet Med 2019; 13:120-124. [PMID: 33093863 DOI: 10.1177/1753495x19875589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/19/2019] [Indexed: 12/28/2022] Open
Abstract
Diagnosis of pulmonary embolism (PE) in pregnancy is notoriously difficult and lacking high quality evidence. Three studies (DiPEP, ARTEMIS and CT-PE-Pregnancy) evaluating a systematic approach to PE diagnosis have recently been published. DiPEP is a retrospective case-control study that found a poor utility of clinical decision rules or D-dimer testing for PE diagnosis in pregnancy. ARTEMIS and CT-PE-Pregnancy are well conducted prospective management studies that proposed two algorithms with different clinical decision rules and D-dimer criteria for the diagnosis of PE in pregnancy. They included few events in high risk patients, which makes difficult the assessment of both algorithm's safety in women with a high probability of PE. Considering this new evidence, D-dimer testing might be useful to avoid radiation imaging in pregnant women considered at low risk for PE. In contrast, a negative D-dimer cannot be considered sufficiently safe to rule out PE when clinicians estimate that PE is the most likely diagnosis.
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Affiliation(s)
- Julien Viau-Lapointe
- Département de médecine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Canada
| | - Marie-Pier Arsenault
- Département de médecine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Canada
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Signorelli SS, Scuto S, Marino E, Giusti M, Xourafa A, Gaudio A. Anticoagulants and Osteoporosis. Int J Mol Sci 2019; 20:ijms20215275. [PMID: 31652944 PMCID: PMC6862478 DOI: 10.3390/ijms20215275] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 12/20/2022] Open
Abstract
Anticoagulant agents are widely used in the treatment of thromboembolic events and in stroke prevention. Data about their effects on bone tissue are in some cases limited or inconsistent (oral anti-vitamin K agents), and in others are sufficiently strong (heparins) to suggest caution in their use in subjects at risk of osteoporosis. This review analyses the effects of this group of drugs on bone metabolism, on bone mineral density, and on fragility fractures. A literature search strategy was developed by an experienced team of specialists by consulting the MEDLINE platform, including published papers and reviews updated to March 2019. Literature supports a detrimental effect of heparin on bone, with an increase in fracture rate. Low molecular weight heparins (LMWHs) seem to be safer than heparin. Although anti-vitamin K agents (VKAs) have a significant impact on bone metabolism, and in particular, on osteocalcin, data on bone mineral density (BMD) and fractures are contrasting. To date, the new direct oral anticoagulants (DOACs) are found to safe for bone health.
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Affiliation(s)
| | - Salvatore Scuto
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
| | - Elisa Marino
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
| | - Michele Giusti
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
| | - Anastasia Xourafa
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
| | - Agostino Gaudio
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
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Dehbozorgi A, Damghani F, Mousavi-Roknabadi RS, Sharifi M, Sajjadi SM, Hosseini-Marvast SR. Accuracy of three-point compression ultrasound for the diagnosis of proximal deep-vein thrombosis in emergency department. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:80. [PMID: 31620179 PMCID: PMC6788177 DOI: 10.4103/jrms.jrms_1057_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/05/2019] [Accepted: 06/03/2019] [Indexed: 11/08/2022]
Abstract
Background: This study aimed to assess the accuracy of three-point compression ultrasonography (3PCUS) performed for the diagnosis of proximal deep-vein thrombosis (DVT) in Emergency Department (ED) compared with the results of duplex US (DUS) (whole-leg compression ultrasound). Materials and Methods: The current prospective cross-sectional study with diagnostic test assessment was conducted on adult patients who were referred to the ED of a general teaching hospital in Shiraz, southern part of Iran (September 2016–May 2017), suspected of lower-extremity DVT, using a convenience sampling. The results of 3PCUS performed by ED residents were compared with the results of DUS performed by the radiology residents, which was considered as a criterion standard. Results: A total of 240 patients were enrolled, with a mean (standard deviation) age of 59.46 (16.58). 3PCUS has a sensitivity and a specificity of 100% (95% confidence interval [CI], 96.55%–100%) and 93.33% (95% CI, 87.72%–96.91%), respectively, in comparison with DUS (whole-leg compression ultrasound). Negative predictive value and positive predictive value were 100% and 92.11% (95% CI, 86.12%–95.64%), respectively, with an accuracy of 96.25% (95% CI, 93%–98.27%). Conclusion: The results of this study showed that 3PCUS of the lower extremities with a portable US machine, performed by the ED's residents, can accurately identify the presence or absence of lower-extremity DVT.
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Affiliation(s)
- Afsaneh Dehbozorgi
- Department of Emergency Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Damghani
- Department of Emergency Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mehrdad Sharifi
- Department of Emergency Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Mahmoudreza Sajjadi
- Department of Emergency Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Kokosi M, Lams B, Agarwal S. Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome. Clin Chest Med 2019; 40:519-529. [DOI: 10.1016/j.ccm.2019.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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250
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Gottenborg E, Misky GJ. The Management of Anticoagulation for Venous Thromboembolism in the Hospitalized Adult. J Hosp Med 2019; 14:499-500. [PMID: 31386616 DOI: 10.12788/jhm.3271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/24/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Emily Gottenborg
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Gregory J Misky
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
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