1
|
Ten Cate V, Koeck T, Panova-Noeva M, Rapp S, Prochaska JH, Lenz M, Schulz A, Eggebrecht L, Hermanns MI, Heitmeier S, Krahn T, Laux V, Münzel T, Leineweber K, Konstantinides SV, Wild PS. A prospective cohort study to identify and evaluate endotypes of venous thromboembolism: Rationale and design of the Genotyping and Molecular Phenotyping in Venous ThromboEmbolism project (GMP-VTE). Thromb Res 2019; 181:84-91. [PMID: 31374513 DOI: 10.1016/j.thromres.2019.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/17/2019] [Accepted: 07/21/2019] [Indexed: 01/02/2023]
Abstract
Several clinical, genetic and acquired risk factors for venous thromboembolism (VTE) have been identified. However, the molecular pathophysiology and mechanisms of disease progression remain poorly understood. This is reflected by uncertainties regarding the primary and secondary prevention of VTE and the optimal duration of antithrombotic therapy. A growing body of literature points to clinically relevant differences between VTE phenotypes (e.g. deep vein thrombosis (DVT) versus pulmonary embolism (PE), unprovoked versus provoked VTE). Extensive links to cardiovascular, inflammatory and immune-related morbidities are testament to the complexity of the disease. The GMP-VTE project is a prospective, multi-center cohort study on individuals with objectively confirmed VTE. Sequential data sampling was performed at the time of the acute event and during serial follow-up investigations. Various data levels (e.g. clinical, genetic, proteomic and platelet data) are available for multi-dimensional data analyses by means of advanced statistical, bioinformatic and machine learning methods. The GMP-VTE project comprises n = 663 individuals with acute VTE (mean age: 60.3 ± 15.9 years; female sex: 42.8%). In detail, 28.4% individuals (n = 188) had acute isolated DVT, whereas 71.6% subjects (n = 475) had PE with or without concomitant DVT. In the study sample, 28.9% (n = 129) of individuals with PE and 30.1% (n = 55) of individuals with isolated DVT had a recurrent VTE event at the time of study enrolment. The systems-oriented approach for the comprehensive dataset of the GMP-VTE project may generate new biological insights into the pathophysiology of VTE and refine our current understanding and management of VTE.
Collapse
Affiliation(s)
- V Ten Cate
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - T Koeck
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - M Panova-Noeva
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - S Rapp
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - J H Prochaska
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - M Lenz
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Institute of Organismic and Molecular Evolution, Johannes Gutenberg University Mainz, Mainz, Germany
| | - A Schulz
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - L Eggebrecht
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - M I Hermanns
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; School of Chemistry, Biology and Pharmacy, Fresenius University of Applied Sciences, Idstein, Germany
| | | | - T Krahn
- Bayer AG, Wuppertal, Germany
| | - V Laux
- Bayer AG, Wuppertal, Germany
| | - T Münzel
- Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - S V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, University General Hospital, Greece
| | - P S Wild
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Germany.
| | | |
Collapse
|
3
|
Carpenter CR, Raja AS, Brown MD. Overtesting and the Downstream Consequences of Overtreatment: Implications of "Preventing Overdiagnosis" for Emergency Medicine. Acad Emerg Med 2015; 22:1484-92. [PMID: 26568269 DOI: 10.1111/acem.12820] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/03/2015] [Accepted: 07/07/2015] [Indexed: 12/15/2022]
Abstract
Overtesting, the downstream consequences of overdiagnosis, and overtreatment of some patients are topics of growing debate within emergency medicine (EM). The "Preventing Overdiagnosis" conference, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, with sponsorship from consumer organizations, medical journals, and academic institutions, is evidence of an expanding interest in this topic. However, EM represents a compellingly unique environment, with increased decision density tied to high stakes for patients and providers with missed or delayed diagnoses in a professional atmosphere that does not tolerate mistakes. This article reviews the relevance of this reductionist paradigm to EM, provides a first-hand synopsis of the first "Preventing Overdiagnosis" conference, and assesses barriers to moving the concept of less test ordering to reality.
Collapse
Affiliation(s)
- Christopher R. Carpenter
- Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Ali S. Raja
- Department of Emergency Medicine; Brigham & Women's Hospital; Boston MA
| | - Michael D. Brown
- Emergency Medicine; Michigan State University College of Medicine; Grand Rapids MI
| |
Collapse
|
5
|
Cervellin G, Borghi L, Lippi G. Do clinicians decide relying primarily on Bayesians principles or on Gestalt perception? Some pearls and pitfalls of Gestalt perception in medicine. Intern Emerg Med 2014; 9:513-9. [PMID: 24610565 DOI: 10.1007/s11739-014-1049-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
Abstract
Clinical judgment is a foundation of medical practice and lies at the heart of a physician's knowledge, expertise and skill. Although clinical judgment is an active part of all medical fields, thus including diagnosis and therapy, communication and decision making, it is still poorly defined. It can be considered a synthesis of intuition (mainly based on Gestalt principles) and an analytical approach. Gestalt perception finds its rationale in the evidence that perception of any given object or experience exhibits intrinsic qualities that cannot be completely reduced to visual, auditory, tactile, olfactory, or gustatory components. Thus, perceptions are not constructed in a "bottom-up" fashion from such elements, but are instead globally perceived, in a more "top-down" fashion. Gestalt perception, if cautiously and carefully combined with structured (techno)logical tools, would permit one to defoliate the often too-many-branches built diagnostic trees, and help physicians to better develop their competency. On the other hand, the practice of evidence-based medicine lies in the integration of individual clinical expertise and judgment with the best available external clinical evidence from systematic research. This article is aimed at providing some general concepts about Gestalt perception, and to discuss some aspects of clinical practice potentially influenced by this approach.
Collapse
Affiliation(s)
- Gianfranco Cervellin
- Emergency Department, Academic Hospital of Parma, Via Gramsci, 14, 43126, Parma, Italy,
| | | | | |
Collapse
|