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ZorgDomein als oplossing bij inclusieproblemen. HUISARTS EN WETENSCHAP 2023; 66:35-37. [PMID: 36876157 PMCID: PMC9961297 DOI: 10.1007/s12445-023-2184-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
De inclusie van deelnemers voor wetenschappelijke onderzoeken in de eerstelijnszorg valt bijna altijd zwaar tegen. Dit artikel beschrijft hoe een onderzoek naar een nieuwe diagnostische strategie daardoor bijna mislukte. Een alternatieve inclusieprocedure bleek echter wonderwel te werken.
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Cafferkey J, Serebriakoff P, de Wit K, Horner DE, Reed MJ. Pulmonary embolism diagnosis: clinical assessment at the front door. J Accid Emerg Med 2022; 39:945-951. [PMID: 35868848 DOI: 10.1136/emermed-2021-212000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 07/09/2022] [Indexed: 11/03/2022]
Abstract
This first of two practice reviews addresses pulmonary embolism (PE) diagnosis considering important aspects of PE clinical presentation and comparing evidence-based PE testing strategies. A companion paper addresses the management of PE. Symptoms and signs of PE are varied, and emergency physicians frequently use testing to 'rule out' the diagnosis in people with respiratory or cardiovascular symptoms. The emergency clinician must balance the benefit of reassuring negative PE testing with the risks of iatrogenic harms from over investigation and overdiagnosis.
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Affiliation(s)
- John Cafferkey
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | | | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Medicine, McMaster University, Ontario, Canada
| | - Daniel E Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Matthew James Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK .,Acute Care Group, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
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Heerink JS, Gemen E, Oudega R, Geersing GJ, Hopstaken R, Kusters R. Performance of C-Reactive Protein, Procalcitonin, TAT Complex, and Factor VIII in Addition to D-Dimer in the Exclusion of Venous Thromboembolism in Primary Care Patients. J Appl Lab Med 2021; 7:444-455. [PMID: 34597379 DOI: 10.1093/jalm/jfab094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/28/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND In primary care, D-dimer-combined with a clinical assessment-is recommended for ruling-out venous thromboembolism (VTE). However, D-dimer testing frequently yields false-positive results, notably in the elderly, and the search for novel biomarkers thus continues. We assessed the added diagnostic value of 4 promising laboratory tests. METHODS Plasma samples from 256 primary care patients suspected of VTE were collected. We explored added value (beyond D-dimer) of C-reactive protein (CRP), procalcitonin (PCT), thrombin-antithrombin III complex (TAT-c), and factor VIII (FVIII). Diagnostic performance of these biomarkers was assessed univariably and by estimating their area under the receiver operating curve (AUC). Added diagnostic potential beyond D-dimer testing was assessed using multivariable logistic regression. RESULTS Plasma samples of 237 VTE-suspected patients were available for analysis-36 patients (25%) confirmed deep vein thrombosis, 11 patients (12%) pulmonary embolism. Apart from D-dimer, only CRP, and FVIII levels appeared to be higher in patients with VTE compared to patients without VTE. The AUCs for these 3 markers were 0.76 (95% CI: 0.69-0.84) and 0.75 (95% CI: 0.68-0.83), respectively, whereas the AUC for D-dimer was 0.90 (95% CI: 0.86-0.94). Combining these biomarkers in a multivariable logistic model with D-dimer did not improve these AUCs meaningfully. CONCLUSIONS In our dataset, we were unable to demonstrate any added diagnostic performance beyond D-dimer testing of novel biomarkers in patients suspected of VTE in primary care. As such, D-dimer testing appears to remain the best choice in the exclusion of clinically suspected VTE in this setting. TRIAL REGISTRATION Netherlands Trial Register NL5974. (METC protocol number: 16-356/M; NL56475.041.16.).
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Affiliation(s)
- Jorn S Heerink
- 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
| | - 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 General Practice, University Medical Centre Utrecht, the Netherlands
| | - Geert-Jan Geersing
- Julius Centre for Health Sciences and General Practice, University Medical Centre 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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The authors reply. Crit Care Med 2021; 48:e1378-e1379. [PMID: 33255145 DOI: 10.1097/ccm.0000000000004701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van Maanen R, Kingma AEC, Oudega R, Rutten FH, Moons K, Geersing GJ. Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study. BMJ Open 2020; 10:e039913. [PMID: 33372074 PMCID: PMC7772307 DOI: 10.1136/bmjopen-2020-039913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/22/2020] [Accepted: 11/17/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Clinical prediction rules (CPRs) followed by D-dimer testing were shown to safely rule out venous thromboembolism (VTE) in about half of all suspected patients in controlled and experienced study settings. Yet, its real-life impact in primary care is unknown. The aim of this study was to determine the real-life impact of CPRs for suspected VTE in primary care. DESIGN Cross-sectional cohort study. SETTING Primary care in the Netherlands. PARTICIPANTS Patients with suspected deep venous thrombosis (n=993) and suspected pulmonary embolism (n=484). INTERVENTIONS General practitioners received an educational instruction on how to use CPRs in suspected VTE. We did not rectify incorrect application of the CPR in order to mimic daily clinical care. MAIN OUTCOME MEASURES Primary outcomes were the diagnostic failure rate, defined as the 3-month incidence of VTE in the non-referred group, and the efficiency, defined as the proportion of non-referred patients in the total study population. Secondary outcomes were determinants for and consequences of incorrect application of the CPRs. RESULTS In 267 of the included 1477 patients, VTE was confirmed. When CPRs were correctly applied, the failure rate was 1.51% (95% CI 0.77 to 2.86), and the efficiency was 58.1% (95% CI 55.2 to 61.0). However, the CPRs were incorrectly applied in 339 patients, which resulted in an increased failure rate of 3.31% (95% CI 1.07 to 8.76) and a decreased efficiency of 35.7% (95% CI 30.6 to 41.1). The presence of concurrent heart failure increased the likelihood of incorrect application (adjusted OR 3.26; 95% CI 1.47 to 7.21). CONCLUSIONS Correct application of CPRs for VTE in primary care is associated with an acceptable low failure rate at a high efficiency. Importantly, in nearly a quarter of patients, the CPRs were incorrectly applied that resulted in a higher failure rate and a considerably lower efficiency.
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Affiliation(s)
- Rosanne van Maanen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Annelieke E C Kingma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ruud Oudega
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karel Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Brüggemann RAG, Spaetgens B, Gietema HA, Brouns SHA, Stassen PM, Magdelijns FJ, Rennenberg RJ, Henry RMA, Mulder MMG, van Bussel BCT, Schnabel RM, van der Horst ICC, Wildberger JE, Stehouwer CDA, Ten Cate H. The prevalence of pulmonary embolism in patients with COVID-19 and respiratory decline: A three-setting comparison. Thromb Res 2020; 196:486-490. [PMID: 33091701 PMCID: PMC7557291 DOI: 10.1016/j.thromres.2020.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/30/2020] [Accepted: 10/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The risk of pulmonary embolism (PE) in patients with Coronavirus Disease 2019 (COVID-19) is recognized. The prevalence of PE in patients with respiratory deterioration at the Emergency Department (ED), the regular ward, and the Intensive Care Unit (ICU) are not well-established. OBJECTIVES We aimed to investigate how often PE was present in individuals with COVID-19 and respiratory deterioration in different settings, and whether or not disease severity as measured by CT-severity score (CTSS) was related to the occurrence of PE. PATIENTS/METHODS Between April 6th and May 3rd, we enrolled 60 consecutive adult patients with confirmed COVID-19 from the ED, regular ward and ICU who met the pre-specified criteria for respiratory deterioration. RESULTS A total of 24 (24/60: 40% (95% CI: 28-54%)) patients were diagnosed with PE, of whom 6 were in the ED (6/23: 26% (95% CI: 10-46%)), 8 in the regular ward (8/24: 33% (95% CI: 16-55%)), and 10 in the ICU (10/13: 77% (95% CI: 46-95%)). CTSS (per unit) was not associated with the occurrence of PE (age and sex-adjusted OR 1.06 (95%CI 0.98-1.15)). CONCLUSION The number of PE diagnosis among patients with COVID-19 and respiratory deterioration was high; 26% in the ED, 33% in the regular ward and 77% in the ICU respectively. In our cohort CTSS was not associated with the occurrence of PE. Based on the high number of patients diagnosed with PE among those scanned we recommend a low threshold for performing computed tomography angiography in patients with COVID-19 and respiratory deterioration.
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Affiliation(s)
- Renée A G Brüggemann
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Bart Spaetgens
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Hester A Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands; Grow school of Oncology and Developmental biology, Maastricht, the Netherlands
| | - Steffie H A Brouns
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Patricia M Stassen
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Fabienne J Magdelijns
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Roger J Rennenberg
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ronald M A Henry
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark M G Mulder
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Coen D A Stehouwer
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands; Thrombosis Expert Centre Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
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Lafleur J, Rutenberg A. An unusual cause of chest pain in a 33 year old male: neurofibromatosis. Am J Emerg Med 2020; 38:1963.e1-1963.e3. [DOI: 10.1016/j.ajem.2020.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022] Open
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Vinson DR, Aujesky D, Geersing GJ, Roy PM. Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review. Perm J 2020; 24:19.163. [PMID: 32240089 DOI: 10.7812/tpp/19.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. OBJECTIVE To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). METHODS We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. RESULTS We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. DISCUSSION We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. CONCLUSION Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA.,Kaiser Permanente Division of Research, Oakland, CA.,Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, CA
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, UMR (CNRS 6015 - INSERM 1083) Institut Mitovasc, Université d'Angers, France
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