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Delgado F, Hajibonabi F, Hislop J, Johnson JO, Naeem M, Hanna T. Optimizing emergency department imaging utilization for pulmonary emboli: A study on the effects of IV contrast rationing. Clin Imaging 2024; 107:110090. [PMID: 38271900 DOI: 10.1016/j.clinimag.2024.110090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 01/07/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE To study the impact of a contrast mitigation protocol on imaging utilization for pulmonary embolism (PE) in the emergency department (ED). MATERIAL AND METHODS Medical records of ED patients with suspected PE who underwent CT pulmonary angiography (CTPA) or ventilation-perfusion (VQ) scans were analyzed in control (3/15/22-4/15/22) and test (5/15/22-6/15/22) periods. The test period included a contrast mitigation protocol due to a global iodinated contrast shortage (05/2022-06/2022). Out of 610 scans, 28 were excluded for non-PE indications. Patient demographics, time metrics, and imaging reports were recorded. RESULTS Among 11,019 ED visits, there were 582 imaging events for suspected PE. The test period exhibited a significantly lower imaging rate of 4.16 % compared to 6.54 % in the control period (p < 0.001). CTPA usage decreased by 47.73 %, while VQ scan usage increased by 775.00 % during the test period. Test period positivity rate was 0.82 %, with CTPA at 0.58 % (1/173) and VQ scan at 1.43 % (1/70). In the control period, the positivity rate was 0.29 %, with CTPA at 0.30 % (1/331) and VQ scan at 0.00 % (0/8). Previous hospitalization history was significantly higher in the test period (70/243 vs. 39/339, p < 0.001). The positivity rates between the two periods showed no significant difference (p = 0.57). There were no significant differences in ED length of stay and image acquisition times. CONCLUSION The contrast mitigation protocol reduced CTPA use, increased VQ scans, and maintained positivity rates and image acquisition times. However, concerns persist about unnecessary imaging and low positivity rates, necessitating further research to optimize PE diagnostic algorithms.
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Affiliation(s)
- Francisco Delgado
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Farid Hajibonabi
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Jada Hislop
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Muhammad Naeem
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Tarek Hanna
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
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Who should get long-term anticoagulant therapy for venous thromboembolism and with what? Blood Adv 2019; 2:3081-3087. [PMID: 30425073 DOI: 10.1182/bloodadvances.2018020230] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 05/24/2018] [Indexed: 12/27/2022] Open
Abstract
After an initial 3 to 6 months of anticoagulation for venous thromboembolism (VTE), clinicians and patients face an important question: "Do we stop anticoagulants or continue them indefinitely?" The decision is easy in some scenarios (eg, stop in VTE provoked by major surgery). In most scenarios, which are faced on a day-to-day basis in routine practice, it is a challenging decision because of uncertainty in estimates in the long-term risks (principally major bleeding) and benefits (reducing recurrent VTE) and the tight trade-offs between them. Once the decision is made to continue, the next question to tackle is "Which anticoagulant?" Here again, it is a difficult decision because of the uncertainty with regard to estimates of efficacy and the safety of anticoagulant options and the tight trade-offs between choices. We conclude with the approach that we take in our clinical practice.
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Klok FA, Presles E, Tromeur C, Barco S, Konstantinides SV, Sanchez O, Pernod G, Raj L, Robin P, Le Roux P, Hoffman C, Mélac S, Bertoletti L, Girard P, Laporte S, Mismetti P, Meyer G, Leroyer C, Couturaud F. Evaluation of the predictive value of the bleeding prediction score VTE-BLEED for recurrent venous thromboembolism. Res Pract Thromb Haemost 2019; 3:364-371. [PMID: 31294323 PMCID: PMC6611364 DOI: 10.1002/rth2.12214] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 04/06/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION VTE-BLEED is a validated score for identification of patients at increased risk of major bleeding during extended anticoagulation for venous thromboembolism (VTE). It is unknown whether VTE-BLEED high-risk patients also have an increased risk for recurrent VTE, which would limit the potential usefulness of the score. METHODS This was a post hoc analysis of the randomized, double-blind, placebo-controlled PADIS-PE trial that randomized patients with a first unprovoked pulmonary embolism (PE) initially treated during 6 months to receive an additional 18-month of warfarin vs. placebo. The primary outcome of this analysis was recurrent VTE during 2-year follow-up after anticoagulant discontinuation, that is, after the initial 6-month treatment in the placebo arm and after 24 months of anticoagulation in the active treatment arm. This rate, adjusted for study treatment allocation, was compared between patients in the high- vs. low-risk VTE-BLEED group. RESULTS In complete case analysis (n = 308; 82.4% of total population), 89 (28.9%) patients were classified as high risk; 44 VTE events occurred after anticoagulant discontinuation during 668 patient-years. The cumulative incidence of recurrent VTE was 16.4% (95% confidence interval [CI], 10.0%-26.1%; 14 events) and 14.6% (95% CI, 10.4%-20.3%; 30 events) in the high-risk and low-risk VTE-BLEED groups, respectively, for an adjusted hazard ratio of 1.16 (95% CI, 0.62-2.19). CONCLUSION In this study, patients with unprovoked PE classified at high risk of major bleeding by VTE-BLEED did not have a higher incidence of recurrent VTE after cessation of anticoagulant therapy, supporting the potential yield of the score for making management decisions on the optimal duration of anticoagulant therapy.
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Affiliation(s)
- Frederikus A. Klok
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Emilie Presles
- Unité de Recherche CliniqueInnovation et PharmacologieCentre Hospitalo‐Universitaire de Saint‐EtienneINSERM U1059 SAINBIOSEUniversité Jean MonnetF‐CRIN INNOVTESaint‐EtienneFrance
| | - Cecile Tromeur
- Département de Médecine Interne et PneumologieCentre Hospitalo‐Universitaire de BrestUniversité de Bretagne OccidentaleEA 3878, CIC INSERM 1412, F‐CRIN INNOVTEBrestFrance
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Olivier Sanchez
- Université Paris DescartesUniversité Sorbonne Paris CitéParisFrance
- Service de Pneumologie et de Soins IntensifsHôpital Européen Georges PompidouAP‐HPParisFrance
- Université Paris DescartesSorbonne Paris CitéINSERM UMR S 1140F‐CRIN INNOVTEParisFrance
| | - Gilles Pernod
- Département de Médecine VasculaireCentre Hospitalo‐Universitaire de GrenobleUniversité de Grenoble 1F‐CRIN INNOVTEGrenobleFrance
| | - Leela Raj
- Département de Médecine Interne et PneumologieCentre Hospitalo‐Universitaire de BrestUniversité de Bretagne OccidentaleEA 3878, CIC INSERM 1412, F‐CRIN INNOVTEBrestFrance
| | - Philippe Robin
- Service de Médecine Nucléaire and EA 3878Centre Hospitalo‐Universitaire de BrestUniversité de Bretagne OccidentaleF‐CRIN INNOVTEBrestFrance
| | - Pierre‐Yves Le Roux
- Service de Médecine Nucléaire and EA 3878Centre Hospitalo‐Universitaire de BrestUniversité de Bretagne OccidentaleF‐CRIN INNOVTEBrestFrance
| | - Clément Hoffman
- Service d'Echo‐doppler VasculaireEA 3878, CIC INSERM 1412Centre Hospitalo‐Universitaire de BrestUniversité de Bretagne OccidentaleF‐CRIN INNOVTEBrestFrance
| | - Solen Mélac
- Département de Médecine Interne et PneumologieCentre Hospitalo‐Universitaire de BrestUniversité de Bretagne OccidentaleEA 3878, CIC INSERM 1412, F‐CRIN INNOVTEBrestFrance
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et ThérapeutiqueUnité de Pharmacologie CliniqueCIC1408Centre Hospitalo‐Universitaire de Saint‐EtienneINSERM U1059 SAINBIOSEUniversité Jean MonnetF‐CRIN INNOVTESaint‐EtienneFrance
| | - Philippe Girard
- Département ThoraciqueInstitut Mutualiste MontsourisF‐CRIN INNOVTEParisFrance
| | - Silvy Laporte
- Unité de Recherche CliniqueInnovation et PharmacologieCentre Hospitalo‐Universitaire de Saint‐EtienneINSERM U1059 SAINBIOSEUniversité Jean MonnetF‐CRIN INNOVTESaint‐EtienneFrance
| | - Patrick Mismetti
- Service de Médecine Vasculaire et ThérapeutiqueUnité de Pharmacologie CliniqueCIC1408Centre Hospitalo‐Universitaire de Saint‐EtienneINSERM U1059 SAINBIOSEUniversité Jean MonnetF‐CRIN INNOVTESaint‐EtienneFrance
| | - Guy Meyer
- Université Paris DescartesUniversité Sorbonne Paris CitéParisFrance
- Service de Pneumologie et de Soins IntensifsHôpital Européen Georges PompidouAP‐HPParisFrance
- Université Paris DescartesSorbonne Paris CitéINSERM UMR S 1140F‐CRIN INNOVTEParisFrance
| | - Christophe Leroyer
- Département de Médecine Interne et PneumologieCentre Hospitalo‐Universitaire de BrestUniversité de Bretagne OccidentaleEA 3878, CIC INSERM 1412, F‐CRIN INNOVTEBrestFrance
| | - Francis Couturaud
- Département de Médecine Interne et PneumologieCentre Hospitalo‐Universitaire de BrestUniversité de Bretagne OccidentaleEA 3878, CIC INSERM 1412, F‐CRIN INNOVTEBrestFrance
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Nishimoto Y, Yamashita Y, Morimoto T, Saga S, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Shiomi H, Kato T, Makiyama T, Ono K, Sato Y, Kimura T. Clinical Characteristics and Outcomes of Venous Thromboembolisms According to an Out-of-Hospital vs. In-Hospital Onset - From the COMMAND VTE Registry. Circ J 2019; 83:1377-1384. [PMID: 30930347 DOI: 10.1253/circj.cj-18-1314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Differences in the clinical characteristics and outcomes of venous thromboembolisms (VTEs) based on different clinical situations surrounding the onset might be important for directing appropriate treatment strategies, but have not yet been appropriately evaluated. Methods and Results: The COMMAND VTE Registry is a multicenter registry enrolling 3,027 consecutive patients with acute symptomatic VTEs in Japan between January 2010 and August 2014. We divided the study population into 3 groups: Out-of-hospital onset (n=2,308), In-hospital onset with recent surgery (n=310), and In-hospital onset without recent surgery (n=374). Active cancer was most prevalent in the In-hospital onset without recent surgery group, and least in the Out-of-hospital onset group (Out-of-hospital onset group: 20%, In-hospital onset with recent surgery group: 26%, and In-hospital onset without recent surgery group: 38%, P<0.001). The cumulative 5-year incidence of recurrent VTEs did not significantly differ across the 3 groups (11.4%, 5.8%, and 8.7%, respectively; P=0.11). The cumulative 5-year incidences of major bleeding and all-cause death were highest in the In-hospital onset without recent surgery group (11.1%, 8.5%, and 23.3%, P<0.001; 26.8%, 24.9%, and 48.4%, P<0.001, respectively). CONCLUSIONS In the real-world VTE registry, the clinical characteristics and long-term outcomes substantially differed according to the clinical situation of VTE onset, suggesting the need for different treatment strategies for VTEs in different clinical settings.
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Affiliation(s)
- Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital
| | | | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital
| | | | | | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital
| | | | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine
| | | | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Stowell SR, Stowell CP. Biologic roles of the ABH and Lewis histo-blood group antigens part II: thrombosis, cardiovascular disease and metabolism. Vox Sang 2019; 114:535-552. [PMID: 31090093 DOI: 10.1111/vox.12786] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 12/14/2022]
Abstract
The ABH and Lewis antigens were among the first of the human red blood cell polymorphisms to be identified and, in the case of the former, play a dominant role in transfusion and transplantation. But these two therapies are largely twentieth-century innovations, and the ABH and related carbohydrate antigens are not only expressed on a very wide range of human tissues, but were present in primates long before modern humans evolved. Although we have learned a great deal about the biochemistry and genetics of these structures, the biological roles that they play in human health and disease are incompletely understood. This review and its companion, which appeared in a previous issue of Vox Sanguinis, will focus on a few of the biologic and pathologic processes which appear to be affected by histo-blood group phenotype. The first of the two reviews explored the interactions of two bacteria with the ABH and Lewis glycoconjugates of their human host cells, and described the possible connections between the immune response of the human host to infection and the development of the AB-isoagglutinins. This second review will describe the relationship between ABO phenotype and thromboembolic disease, cardiovascular disease states, and general metabolism.
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Affiliation(s)
- Sean R Stowell
- Center for Apheresis, Center for Transfusion and Cellular Therapies, Emory Hospital, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Christopher P Stowell
- Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, USA.,Department of Pathology, Harvard Medical School, Boston, MA, USA
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Abstract
Venous thromboembolism (VTE) is categorized by the U.S. Surgeon General as a major public health problem. VTE is relatively common and associated with reduced survival and substantial health-care costs, and recurs frequently. VTE is a complex (multifactorial) disease, involving interactions between acquired or inherited predispositions to thrombosis and VTE risk factors, including increasing patient age and obesity, hospitalization for surgery or acute illness, nursing-home confinement, active cancer, trauma or fracture, immobility or leg paresis, superficial vein thrombosis, and, in women, pregnancy and puerperium, oral contraception, and hormone therapy. Although independent VTE risk factors and predictors of VTE recurrence have been identified, and effective primary and secondary prophylaxis is available, the occurrence of VTE seems to be relatively constant, or even increasing.
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Affiliation(s)
- John A Heit
- Division of Cardiovascular Diseases (JAH), Mayo Clinic, Hematology Research-Stabile 660, 200 First Street SW, Rochester, MN, 55905, USA.
| | | | - Richard H White
- Division of General Internal Medicine (RHW), University of California, Davis, Sacramento, CA, USA
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Fahrni J, Husmann M, Gretener SB, Keo HH. Assessing the risk of recurrent venous thromboembolism--a practical approach. Vasc Health Risk Manag 2015; 11:451-9. [PMID: 26316770 PMCID: PMC4544622 DOI: 10.2147/vhrm.s83718] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Recurrent venous thromboembolism (VTE) is associated with increased morbidity and mortality. This risk is lowered by anticoagulation, with a large effect in the initial phase following the venous thromboembolic event, and with a smaller effect in terms of secondary prevention of recurrence when extended anticoagulation is performed. On the other hand, extended anticoagulation is associated with an increased risk of major bleeding and thus leads to morbidity and mortality. Therefore, it is necessary to assess the risk of recurrence for VTE on an individual basis, and a recommendation for secondary prophylaxis should be specifically based on risk calculation of recurrence of VTE and bleeding. In this review, we provide a comprehensive summary of relevant risk factors for recurrent VTE and a practical approach for assessing the risk of recurrence in daily practice.
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Affiliation(s)
- Jennifer Fahrni
- Division of Angiology, Medical University Clinic, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Marc Husmann
- Clinic for Angiology, University Hospital, University of Zurich, Zürich, Switzerland
| | | | - Hong H Keo
- Division of Angiology, Medical University Clinic, Kantonsspital Aarau AG, Aarau, Switzerland
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Abstract
Thrombosis can affect any venous circulation. Venous thromboembolism (VTE) includes deep-vein thrombosis of the leg or pelvis, and its complication, pulmonary embolism. VTE is a fairly common disease, particularly in older age, and is associated with reduced survival, substantial health-care costs, and a high rate of recurrence. VTE is a complex (multifactorial) disease, involving interactions between acquired or inherited predispositions to thrombosis and various risk factors. Major risk factors for incident VTE include hospitalization for surgery or acute illness, active cancer, neurological disease with leg paresis, nursing-home confinement, trauma or fracture, superficial vein thrombosis, and-in women-pregnancy and puerperium, oral contraception, and hormone therapy. Although independent risk factors for incident VTE and predictors of VTE recurrence have been identified, and effective primary and secondary prophylaxis is available, the occurrence of VTE seems to be fairly constant, or even increasing.
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Heit JA. Predicting the risk of venous thromboembolism recurrence. Am J Hematol 2012; 87 Suppl 1:S63-7. [PMID: 22367958 DOI: 10.1002/ajh.23128] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 01/16/2012] [Accepted: 01/17/2012] [Indexed: 11/07/2022]
Abstract
Venous thromboembolism (VTE) is a chronic disease with a 30% ten-year recurrence rate. The highest incidence of recurrence is in the first 6 months. Active cancer significantly increases the hazard of early recurrence, and the proportions of time on standard heparin with an APTT ≥ 0.2 anti-X(a) U/mL, and on warfarin with an INR ≥ 2.0, significantly reduce the hazard. The acute treatment duration does not affect recurrence risk after treatment is stopped. Independent predictors of late recurrence include increasing patient age and body mass index, leg paresis, active cancer and other persistent VTE risk factors, idiopathic VTE, antiphospholipid antibody syndrome, antithrombin, protein C or protein S deficiency, hyperhomocysteinemia and a persistently increased plasma fibrin D-dimer. A recommendation for secondary prophylaxis should be individualized based on the risk for recurrent VTE (especially fatal pulmonary embolism) and bleeding. The appropriateness of secondary prophylaxis should be continuously reevaluated, and the prophylaxis stopped if the benefit no longer exceeds the risk.
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Affiliation(s)
- John A Heit
- Division of Cardiovascular Diseases, Department of Internal Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Tichelaar YIGV, Knol HM, Mulder AB, Kluin-Nelemans JC, Lijfering WM. Association between deep vein thrombosis and transient inflammatory signs and symptoms: a case-control study. J Thromb Haemost 2010; 8:1874-6. [PMID: 20546126 DOI: 10.1111/j.1538-7836.2010.03939.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
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