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Vásquez V, Orozco J. Detection of COVID-19-related biomarkers by electrochemical biosensors and potential for diagnosis, prognosis, and prediction of the course of the disease in the context of personalized medicine. Anal Bioanal Chem 2023; 415:1003-1031. [PMID: 35970970 PMCID: PMC9378265 DOI: 10.1007/s00216-022-04237-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/30/2022] [Accepted: 07/18/2022] [Indexed: 02/07/2023]
Abstract
As a more efficient and effective way to address disease diagnosis and intervention, cutting-edge technologies, devices, therapeutic approaches, and practices have emerged within the personalized medicine concept depending on the particular patient's biology and the molecular basis of the disease. Personalized medicine is expected to play a pivotal role in assessing disease risk or predicting response to treatment, understanding a person's health status, and, therefore, health care decision-making. This work discusses electrochemical biosensors for monitoring multiparametric biomarkers at different molecular levels and their potential to elucidate the health status of an individual in a personalized manner. In particular, and as an illustration, we discuss several aspects of the infection produced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a current health care concern worldwide. This includes SARS-CoV-2 structure, mechanism of infection, biomarkers, and electrochemical biosensors most commonly explored for diagnostics, prognostics, and potentially assessing the risk of complications in patients in the context of personalized medicine. Finally, some concluding remarks and perspectives hint at the use of electrochemical biosensors in the frame of other cutting-edge converging/emerging technologies toward the inauguration of a new paradigm of personalized medicine.
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Affiliation(s)
- Viviana Vásquez
- Max Planck Tandem Group in Nanobioengineering, Institute of Chemistry, Faculty of Natural and Exact Sciences, University of Antioquia, Complejo Ruta N, Calle 67 N° 52-20, Medellín, 050010, Colombia
| | - Jahir Orozco
- Max Planck Tandem Group in Nanobioengineering, Institute of Chemistry, Faculty of Natural and Exact Sciences, University of Antioquia, Complejo Ruta N, Calle 67 N° 52-20, Medellín, 050010, Colombia.
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Tsai LC, Liu KL, Lin WY, Lin YC, Huang NE, Lee JCI, Linacre A, Hsieh HM. Evaluation of three commercial kits effective identification of menstrual blood based on the D-dimer. Forensic Sci Int 2022; 338:111389. [PMID: 35849993 DOI: 10.1016/j.forsciint.2022.111389] [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: 05/28/2022] [Revised: 07/04/2022] [Accepted: 07/11/2022] [Indexed: 11/28/2022]
Abstract
Blood or bloodstains are encountered frequently in forensic investigations. Presumptive and more confirmatory tests for peripheral blood are well established, however, similar methods for menstrual blood identification are less so. D-dimer is a fibrin degradation product that occurs at high concentration in menstrual blood and therefore a potential target to screen for this body fluid. We evaluated three rapid tests to determine if they can discriminate menstrual blood from peripheral remote from a laboratory setting. Their sensitivity, specificity and robustness were also assessed. The assays were: a latex agglutination (Dade Dimertest Latex Assay), SERATEC PMB test and OneStep D-dimer RapidCard InstaTest, both of which are based on lateral flow immunochromatographic analysis. Of the three, greater sensitivity was observed using the OneStep D-dimer RapidCard InstaTest, regardless of whether liquid or a stain was used. This test also detected a result using the smallest volume of menstrual blood, 0.003125 μL. Specificity testing was based on six different body fluids (urine, saliva, peripheral blood, semen, sweats and vaginal fluid) resulting in all 30 samples testing negative for the D-dimer using the OneStep D-dimer RapidCard InstaTest. Mixtures at ratios 1:1, 1:3 and 1:9 (menstrual blood: the other biofluid or PBS) were tested and the results showed that D-dimer could be detected for all samples using either the Dade Dimertest Latex Assay or the OneStep D-dimer RapidCard InstaTest. The body fluids were exposed to environmental stresses such as various temperature (-20 °C, 4 °C, room temperature and 37 °C for 30, 90, 180 and 360 days) and fluctuations in humidity (42%, 76% and 100% humidity at room temperature for 1, 3, 5, 10 and 20 days): all samples were D-dimer positive using the OneStep D-dimer RapidCard InstaTest though the strength decreased relative to the increase of storage time and temperature or humidity. All 6 postmortem blood samples gave a positive result for D-dimer using the OneStep D-dimer RapidCard InstaTest and 2 samples gave a positive response using the Dade Dimertest Latex Assay and the SERATEC PMB test; peripheral blood postmortem samples can show an increase in D-dimer. Menstrual blood was recovered from the pads under the sample wells after testing using the two immunochromatographic assays from which STR alleles could be amplified successfully. The results presented here support the application of these commercial kits for effective identification of menstrual blood.
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Affiliation(s)
- Li-Chin Tsai
- Department of Forensic Science, Central Police University, No.56 Shu-Jen Road, Kwei-San, Taoyuan 333322, Taiwan, ROC
| | - Kuo-Lan Liu
- Forensic Examination Division, Criminal Investigation Bureau, National Police Agency, No.5 Lane 553, Chung Hsiao East Road Section 4, Xinyi District, Taipei 110055, Taiwan, ROC
| | - Wan-Ying Lin
- Department of Forensic Science, Central Police University, No.56 Shu-Jen Road, Kwei-San, Taoyuan 333322, Taiwan, ROC
| | - Yu-Chih Lin
- Taichung City Government Police Department, No.500 Fengxing Road Section 1, Tanzi District, Taichung City 427003, Taiwan, ROC
| | - Nu-En Huang
- Forensic Biology Division, Criminal Investigation Bureau, National Police Agency, No.5 Lane 553, Chung Hsiao East Road Section 4, Xinyi District, Taipei 110055, Taiwan, ROC
| | - James Chun-I Lee
- Department of Forensic Medicine, College of Medicine, National Taiwan University, No.1 Jen-Ai Road Section 1, Taipei 100233, Taiwan, ROC
| | - Adrian Linacre
- College of Science & Engineering, Flinders University, Adelaide 5001, Australia
| | - Hsing-Mei Hsieh
- Department of Forensic Science, Central Police University, No.56 Shu-Jen Road, Kwei-San, Taoyuan 333322, Taiwan, ROC.
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A Hemagglutination-Based Semiquantitative Test for Point-of-Care Determination of SARS-CoV-2 Antibody Levels. J Clin Microbiol 2021; 59:e0118621. [PMID: 34469185 PMCID: PMC8601214 DOI: 10.1128/jcm.01186-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Serologic point-of-care tests to detect antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are an important tool in the COVID-19 pandemic. The majority of current point-of-care antibody tests developed for SARS-CoV-2 rely on lateral flow assays, but these do not offer quantitative information. To address this, we developed a novel antibody test leveraging hemagglutination, employing a dry card format currently used for typing ABO blood groups. Two hundred COVID-19 patient and 200 control plasma samples were reconstituted with O-negative red blood cells (RBCs) to form whole blood and added to dried viral-antibody fusion protein, followed by a stirring step and a tilting step, 3-min incubation, and a second tilting step. The sensitivities of the hemagglutination test, Euroimmun IgG enzyme-linked immunosorbent assay (ELISA), and receptor binding domain (RBD)-based CoronaChek lateral flow assay were 87.0%, 86.5%, and 84.5%, respectively, using samples obtained from recovered COVID-19 individuals. Testing prepandemic samples, the hemagglutination test had a specificity of 95.5%, compared to 97.3% and 98.9% for the ELISA and CoronaChek, respectively. A distribution of agglutination strengths was observed in COVID-19 convalescent-phase plasma samples, with the highest agglutination score (4) exhibiting significantly higher neutralizing antibody titers than weak positives (2) (P < 0.0001). Strong agglutinations were observed within 1 min of testing, and this shorter assay time also increased specificity to 98.5%. In conclusion, we developed a novel rapid, point-of-care RBC agglutination test for the detection of SARS-CoV-2 antibodies that can yield semiquantitative information on neutralizing antibody titer in patients. The 5-min test may find use in determination of serostatus prior to vaccination, postvaccination surveillance, and travel screening.
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Kruse RL, Huang Y, Lee A, Zhu X, Shrestha R, Laeyendecker O, Littlefield K, Pekosz A, Bloch EM, Tobian AAR, Wang ZZ. A hemagglutination-based, semi-quantitative test for point-of-care determination of SARS-CoV-2 antibody levels. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 33972952 DOI: 10.1101/2021.05.01.21256452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Serologic, point-of-care tests to detect antibodies against SARS-CoV-2 are an important tool in the COVID-19 pandemic. The majority of current point-of-care antibody tests developed for SARS-CoV-2 rely on lateral flow assays, but these do not offer quantitative information. To address this, we developed a new method of COVID-19 antibody testing employing hemagglutination tested on a dry card, similar to that which is already available for rapid typing of ABO blood groups. A fusion protein linking red blood cells (RBCs) to the receptor-binding domain (RBD) of SARS-CoV-2 spike protein was placed on the card. 200 COVID-19 patient and 200 control plasma samples were reconstituted with O-negative RBCs to form whole blood and added to the dried protein, followed by a stirring step and a tilting step, 3-minute incubation, and a second tilting step. The sensitivity for the hemagglutination test, Euroimmun IgG ELISA test and RBD-based CoronaChek lateral flow assay was 87.0%, 86.5%, and 84.5%, respectively, using samples obtained from recovered COVID-19 individuals. Testing pre-pandemic samples, the hemagglutination test had a specificity of 95.5%, compared to 97.3% and 98.9% for the ELISA and CoronaChek, respectively. A distribution of agglutination strengths was observed in COVID-19 convalescent plasma samples, with the highest agglutination score (4) exhibiting significantly higher neutralizing antibody titers than weak positives (2) (p<0.0001). Strong agglutinations were observed within 1 minute of testing, and this shorter assay time also increased specificity to 98.5%. In conclusion, we developed a novel rapid, point-of-care RBC agglutination test for the detection of SARS-CoV-2 antibodies that can yield semi-quantitative information on neutralizing antibody titer in patients. The five-minute test may find use in determination of serostatus prior to vaccination, post-vaccination surveillance and travel screening.
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Tasić N, Paixão TRLC, Gonçalves LM. Biosensing of D-dimer, making the transition from the central hospital laboratory to bedside determination. Talanta 2019; 207:120270. [PMID: 31594601 DOI: 10.1016/j.talanta.2019.120270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/13/2019] [Accepted: 08/14/2019] [Indexed: 12/20/2022]
Abstract
Since the disclosure of the fibrinogen degradation mechanism, around half a century ago, a significant number of papers have been published related to the clinical relevance of D-dimer, a molecule immune to additional enzymatic decomposition by plasmin. Due to the obliquity of regulating blood coagulation in pathological events, the number of diseases and conditions associated with abnormal levels of D-dimer includes deep vein thrombosis, pulmonary embolism, sepsis, myocardial infarction, disseminated intravascular coagulation, among many others. D-dimer not only is an important player in medical diagnosis but also its role as a prognosis biomarker is being revealed. However, the number of analytical alternative methods has not accompanied this trend, even though novel simple point-of-care devices would certainly boost the relevance of D-dimer in emergency medicine. Some reasons for that could be related to the fact that D-dimer is a challenging analyte present in complex samples like blood. In this manuscript, subsequent to a fibrinogen degradation process introduction, it is provided a historical overview of the early D-dimer assays, followed by an extended focus on innovative solutions, with a spotlight on the electrochemical bioanalytical devices. The discussion is accompanied with a critical analysis and concluding thoughts concerning future perspectives.
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Affiliation(s)
- Nikola Tasić
- Departamento de Química Fundamental, Instituto de Química, Universidade de São Paulo, Av. Prof. Lineu Prestes, 748, São Paulo, SP, Brazil
| | - Thiago R L C Paixão
- Departamento de Química Fundamental, Instituto de Química, Universidade de São Paulo, Av. Prof. Lineu Prestes, 748, São Paulo, SP, Brazil.
| | - Luís Moreira Gonçalves
- Departamento de Química Fundamental, Instituto de Química, Universidade de São Paulo, Av. Prof. Lineu Prestes, 748, São Paulo, SP, Brazil.
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Kearon C, Parpia S, Spencer FA, Schulman S, Stevens SM, Shah V, Bauer KA, Douketis JD, Lentz SR, Kessler CM, Connors JM, Ginsberg JS, Spadafora L, Julian JA. Long-term risk of recurrence in patients with a first unprovoked venous thromboembolism managed according to d-dimer results; A cohort study. J Thromb Haemost 2019; 17:1144-1152. [PMID: 31033194 DOI: 10.1111/jth.14458] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/17/2019] [Indexed: 11/26/2022]
Abstract
Essentials Long-term recurrence risk after a first unprovoked VTE with negative d-dimer levels is uncertain. Anticoagulation was stopped if d-dimer was negative, and was continued if d-dimer was positive. Five years after stopping anticoagulants, recurrent VTE was 30% in men and 17% in women. Negative d-dimers do not justify stopping anticoagulants in most men but appear to in most women. BACKGROUND The long-term risk of recurrence in patients with a first unprovoked venous thromboembolism (VTE) who have negative d-dimer results is uncertain. OBJECTIVES To determine this risk, including in subgroups based on sex. PATIENTS AND METHODS ln a prospective interventional cohort study of 410 patients with a first unprovoked VTE, anticoagulants were stopped if d-dimer was negative on therapy and 1 month after stopping therapy. Other patients remained on anticoagulant therapy. We previously reported findings after a mean of 2.2 years. The current report includes 3 years of additional follow-up in 293 of these patients. RESULTS During a median follow-up of 5.0 years, recurrent VTE after stopping therapy in response to negative d-dimer testing was 5.1% (95% confidence interval [CI], 3.6-6.5) per patient-year overall, 7.5% (95% CI, 5.5-10.0) in men, 3.8% (95% CI, 2.0-6.6) in women with VTE not associated with estrogens, and 0.4% (95% CI, 0.0-2.3) in women with VTE associated with estrogens (P < 0.001 for three-group comparison). Risk of recurrence at 5 years was 21.5% (95% CI, 16.4-26.5) overall, 29.7% (95% CI, 22.1-37.3) in men, 17.0% (95% CI, 8.1-25.9) in non-estrogen women, and 2.3% (95% CI, 0.0-6.8) in estrogen women. CONCLUSION The long-term risk of recurrence in patients with a first unprovoked VTE who have negative d-dimer results is not low enough to justify stopping anticoagulant therapy in men, but appears to be low enough in women for many to choose stopping therapy (ClinicalTrials.gov; NCT00720915).
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Affiliation(s)
- Clive Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Murray, Utah
| | - Vinay Shah
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Kenneth A Bauer
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Steven R Lentz
- Department of Medicine, University of Iowa, Iowa City, Iowa
| | - Craig M Kessler
- Department of Medicine, Georgetown University, Washington, District of Columbia
| | - Jean M Connors
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Jim A Julian
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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Antiphospholipid antibodies and recurrent thrombosis after a first unprovoked venous thromboembolism. Blood 2018; 131:2151-2160. [PMID: 29490924 DOI: 10.1182/blood-2017-09-805689] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 02/18/2018] [Indexed: 01/23/2023] Open
Abstract
It is uncertain whether antiphospholipid antibodies (APAs) increase the risk of recurrence after a first unprovoked venous thromboembolism (VTE). We tested for anticardiolipin antibodies, anti-β2 glycoprotein 1 antibodies, and lupus anticoagulant on 2 occasions ∼6 months apart in 307 patients with a first unprovoked VTE who were part of a prospective cohort study. We then determined if APAs were associated with recurrent thrombosis in the 290 patients who stopped anticoagulant therapy in response to negative D-dimer results. Compared with those without an APA, the hazard ratios for recurrent VTE were 1.8 (95% confidence interval [CI], 0.9-3.7; P = .09) in the 25.9% of patients with an APA on ≥1 occasions, 2.7 (95% CI, 1.1-.7; P = .03) in the 9.0% of patients with the same APA on 2 occasions, and 4.5 (95% CI, 1.5-13.0; P = .006) in the 3.8% of patients with 2 or 3 different APA types on either the same or different occasions. There was no association between having an APA and D-dimer levels. We conclude that having the same type of APA on 2 occasions or having >1 type of APA on the same or different occasions is associated with recurrent thrombosis in patients with a first unprovoked VTE who stop anticoagulant therapy in response to negative D-dimer tests. APA and D-dimer levels seem to be independent predictors of recurrence in patients with an unprovoked VTE. This trial was registered at www.clinicaltrials.gov as #NCT00720915.
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Osaki T, Sugiyama D, Magari Y, Souri M, Ichinose A. Rapid immunochromatographic test for detection of anti-factor XIII A subunit antibodies can diagnose 90 % of cases with autoimmune haemorrhaphilia XIII/13. Thromb Haemost 2017; 113:1347-56. [DOI: 10.1160/th14-09-0745] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/10/2015] [Indexed: 11/05/2022]
Abstract
SummaryAutoimmune haemorrhaphilia XIII/13 (AH13) is an acquired lifethreatening bleeding disorder due to anti-factor XIII (FXIII) autoantibodies (auto-Abs). AH13 patients may die of haemorrhage without correct diagnosis and proper treatment because of lack of awareness and the absence of rapid easy-to-use tests specific for this disease. Currently, the definitive diagnosis is established by cumbersome and time-consuming laboratory tests such as dot-blot assays and enzymelinked immunosorbent assays (ELISA), and therefore these tests are generally not carried out. To save AH13 patients’ lives, there is an urgent necessity for developing a rapid test for FXIII auto-Abs. We first generated and characterised mouse monoclonal antibodies (mAb) against human FXIII A subunit (FXIII-A), and then developed a rapid immunochromatographic test (ICT) for detection of anti-FXIII-A auto- Abs using one mAb with a dissociation constant of 9.3 × 10-11 M. The auto-Ab-FXIII-A complex was captured by the mAb on a nitrocellulose membrane and visualised by Au-conjugated anti-human IgG Ab. Mixing with healthy control plasma improved the detection of auto-Abs in patients having extremely low levels of FXIII-A. The specificity and sensitivity of the ICT were 87% and 94%, respectively. We also detected auto-Abs against activated FXIII (FXIIIa) in three patients by pre-converting FXIII to FXIIIa by thrombin treatment. ICT values were significantly inversely correlated with FXIII activity levels, indicating an association between the quantity of anti-FXIII autoantibodies and AH13. This reliable rapid ICT assay can be applied to a point-of-care test to detect anti-FXIII-A auto-Abs, and will contribute to early diagnosis and treatment of AH13.
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Bernardi E, Camporese G. Diagnosis of deep-vein thrombosis. Thromb Res 2017; 163:201-206. [PMID: 29050648 DOI: 10.1016/j.thromres.2017.10.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/17/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
The diagnostic approach to suspected symptomatic deep-vein thrombosis of the lower extremities is usually based on non-invasive methods, including the estimation of clinical probability, the measurement of D-dimer levels, and ultrasonography. The present review discusses the evidence available from the literature about the management of the first episode of suspected deep-vein-thrombosis.
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Affiliation(s)
- Enrico Bernardi
- Emergency Unit, Department of Critical Care, aULSS2 "Marca Trevigana", distretto di Pieve di Soligo, via Brigata Bisagno, 4, 31015 Conegliano, Treviso, Italy.
| | - Giuseppe Camporese
- Unit of Angiology, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, via Giustiniani, 2, 35128 Padova, Italy.
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Kearon C, Parpia S, Spencer F, Baglin T, Stevens S, Bauer K, Lentz S, Kessler C, Douketis J, Moll S, Kaatz S, Schulman S, Connors J, Ginsberg J, Spadafora L, Liaw P, Weitz J, Julian J. D-dimer levels and recurrence in patients with unprovoked VTE and a negative qualitative D-dimer test after treatment. Thromb Res 2016; 146:119-125. [DOI: 10.1016/j.thromres.2016.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/17/2016] [Accepted: 06/18/2016] [Indexed: 11/28/2022]
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GAO YZ, ZHANG L, HUO WS, SHI S, LIAN J, GAO YH. An Integrated Giant Magnetoresistance Microfluidic Immuno-sensor for Rapid Detection and Quantification of D-dimer. CHINESE JOURNAL OF ANALYTICAL CHEMISTRY 2015. [DOI: 10.1016/s1872-2040(15)60827-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kearon C, Spencer FA, O'Keeffe D, Parpia S, Schulman S, Baglin T, Stevens SM, Kaatz S, Bauer KA, Douketis JD, Lentz SR, Kessler CM, Moll S, Connors JM, Ginsberg JS, Spadafora L, Julian JA. D-dimer testing to select patients with a first unprovoked venous thromboembolism who can stop anticoagulant therapy: a cohort study. Ann Intern Med 2015; 162:27-34. [PMID: 25560712 DOI: 10.7326/m14-1275] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Normal D-dimer levels after withdrawal of anticoagulant therapy are associated with a reduced risk for recurrence in patients with unprovoked venous thromboembolism (VTE) and may justify stopping treatment. OBJECTIVE To determine whether patients with a first unprovoked VTE and negative D-dimer test result who stop anticoagulant therapy have a low risk for recurrence. DESIGN Prospective management study with blinded outcome assessment. (ClinicalTrials.gov: NCT00720915). SETTING 13 university-affiliated clinical centers. PATIENTS 410 adults aged 75 years or younger with a first unprovoked proximal deep venous thrombosis or pulmonary embolism who had completed 3 to 7 months of anticoagulant therapy. INTERVENTION Anticoagulant therapy was stopped if D-dimer test results were negative and was not restarted if results were still negative after 1 month. MEASUREMENTS Recurrent VTE during an average follow-up of 2.2 years. RESULTS In 319 patients (78%) who had 2 negative D-dimer results and did not restart anticoagulant therapy, rates of recurrent VTE were 6.7% (95% CI, 4.8% to 9.0%) per patient-year overall (42 of 319), 9.7% (CI, 6.7% to 13.7%) per patient-year in men (33 of 180), 5.4% (CI, 2.5% to 10.2%) per patient-year in women with VTE not associated with estrogen therapy (9 of 81), and 0.0% (CI, 0.0% to 3.0%) per patient-year in women with VTE associated with estrogen therapy (0 of 58) (P = 0.001 for the 3-group comparison). LIMITATIONS Imprecision in female subgroups. Results may not be generalizable to different D-dimer assays from the one used in the study. CONCLUSION The risk for recurrence in patients with a first unprovoked VTE who have negative D-dimer results is not low enough to justify stopping anticoagulant therapy in men but may be low enough to justify stopping therapy in women. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Clive Kearon
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Frederick A. Spencer
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Denis O'Keeffe
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Sameer Parpia
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Sam Schulman
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Trevor Baglin
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Scott M. Stevens
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Scott Kaatz
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Kenneth A. Bauer
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - James D. Douketis
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Steven R. Lentz
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Craig M. Kessler
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Stephan Moll
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Jean M. Connors
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Jeffrey S. Ginsberg
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Luciana Spadafora
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Jim A. Julian
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
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Hendriksen JMT, Geersing GJ, van Voorthuizen SC, Oudega R, ten Cate-Hoek AJ, Joore MA, Moons KGM, Koffijberg H. The cost–effectiveness of point-of-care D-dimer tests compared with a laboratory test to rule out deep venous thrombosis in primary care. Expert Rev Mol Diagn 2014; 15:125-36. [DOI: 10.1586/14737159.2015.976202] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Tenna AMS, Kappadath S, Stansby G. Diagnostic tests and strategies in venous thromboembolism. Phlebology 2012; 27 Suppl 2:43-52. [DOI: 10.1258/phleb.2012.012s35] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Venous thromboembolism (VTE) is a term including deep vein thrombosis (DVT) and pulmonary embolism (PE). Timely and accurate diagnosis of both is essential as delayed or missed diagnoses can result in death or longer term complications. Patients with suspected DVT should initially undergo a pretest probability Wells score. Depending on pretest probability Wells score they should then either proceed to two-point ultrasound scanning or D-dimer testing. Likewise, patients suspected of PE should undergo a two-level PE Wells score, and, if scored likely, a computed tomography pulmonary angiogram (CTPA), or, if there is a low pretest probability score, D-dimer testing. If positive, patients should undergo CTPA. Ventilation perfusion scanning (V/Q scan) or V/Q SPECT should be considered in place of CTPA if there is allergy to contrast media or renal impairment.
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Affiliation(s)
- A M S Tenna
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - S Kappadath
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - G Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
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Zafren K, Feldman J, Becker RJ, Williams SR, Weiss EA, Deloughery T. D-dimer is not elevated in asymptomatic high altitude climbers after descent to 5340 m: the Mount Everest Deep Venous Thrombosis Study (Ev-DVT). High Alt Med Biol 2012; 12:223-7. [PMID: 21962065 DOI: 10.1089/ham.2010.1101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We performed this study to determine the prevalence of elevated D-dimer, a marker for deep venous thrombosis (DVT), in asymptomatic high altitude climbers. On-site personnel enrolled a convenience sample of climbers at Mt. Everest Base Camp (Nepal), elevation 5340 m (17,500 ft), during a single spring climbing season. Subjects were enrolled after descent to base camp from higher elevation. The subjects completed a questionnaire to evaluate their risk factors for DVT. We then performed a D-dimer test in asymptomatic individuals. If the D-dimer test was negative, DVT was considered ruled out. Ultrasound was available to perform lower-extremity compression ultrasounds to evaluate for DVT in case the D-dimer was positive. We enrolled 76 high altitude climbers. None had a positive D-dimer test. The absence of positive D-dimer tests suggests a low prevalence of DVT in asymptomatic high altitude climbers.
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Affiliation(s)
- Ken Zafren
- Division of Emergency Medicine, Stanford University Medical Center, Stanford, California, USA.
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Geersing GJ, Toll DB, Janssen KJM, Oudega R, Blikman MJC, Wijland R, de Vooght KMK, Hoes AW, Moons KGM. Diagnostic Accuracy and User-Friendliness of 5 Point-of-Care D-Dimer Tests for the Exclusion of Deep Vein Thrombosis. Clin Chem 2010; 56:1758-66. [DOI: 10.1373/clinchem.2010.147892] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Point-of-care D-dimer tests have recently been introduced to enable rapid exclusion of deep venous thrombosis (DVT) without the need to refer a patient for conventional laboratory-based D-dimer testing. Before implementation in practice, however, the diagnostic accuracy of each test should be validated.
METHODS
We analyzed data of 577 prospectively identified consecutive primary care patients suspected to have DVT, who underwent 5 point-of-care D-dimer tests—4 quantitative (Vidas®, Pathfast™, Cardiac®, and Triage®) and 1 qualitative (Clearview Simplify®)—and ultrasonography as the reference method. We evaluated the tests for the accuracy of their measurements and submitted a questionnaire to 20 users to assess the user-friendliness of each test.
RESULTS
All D-dimer tests showed negative predictive values higher than 98%. Sensitivity was high for all point-of-care tests, with a range of 0.91 (Clearview Simplify) to 0.99 (Vidas). Specificity varied between 0.39 (Pathfast) and 0.64 (Clearview Simplify). The quantitative point-of-care tests showed similar and high discriminative power for DVT, according to calculated areas under the ROC curves (range 0.88–0.89). The quantitative Vidas and Pathfast devices showed limited user-friendliness for primary care, owing to a laborious calibration process and long analyzer warm-up time compared to the Cardiac and Triage. For the qualitative Clearview Simplify assay, no analyzer or calibration was needed, but interpretation of a test result was sometimes difficult because of poor color contrast.
CONCLUSIONS
Point-of-care D-dimer assays show good and similar diagnostic accuracy. The quantitative Cardiac and Triage and the qualitative Clearview Simplify D-dimer seem most user-friendly for excluding DVT in the doctor's office.
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Affiliation(s)
- Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Diane B Toll
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kristel JM Janssen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ruud Oudega
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marloes JC Blikman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - René Wijland
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Karen MK de Vooght
- Department for Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Karel GM Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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17
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Ten Cate-Hoek AJ, Toll DB, Büller HR, Hoes AW, Moons KGM, Oudega R, Stoffers HEJH, van der Velde EF, van Weert HCPM, Prins MH, Joore MA. Cost-effectiveness of ruling out deep venous thrombosis in primary care versus care as usual. J Thromb Haemost 2009; 7:2042-9. [PMID: 19793189 DOI: 10.1111/j.1538-7836.2009.03627.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Referral for ultrasound testing in all patients suspected of DVT is inefficient, because 80-90% have no DVT. OBJECTIVE To assess the incremental cost-effectiveness of a diagnostic strategy to select patients at first presentation in primary care based on a point of care D-dimer test combined with a clinical decision rule (AMUSE strategy), compared with hospital-based strategies. PATIENTS/METHODS A Markov-type cost-effectiveness model with a societal perspective and a 5-year time horizon was used to compare the AMUSE strategy with hospital-based strategies. Data were derived from the AMUSE study (2005-2007), the literature, and a direct survey of costs (2005-2007). RESULTS OF BASE-CASE ANALYSIS Adherence to the AMUSE strategy on average results in savings of euro138 ($185) per patient at the expense of a very small health loss (0.002 QALYs) compared with the best hospital strategy. The iCER is euro55 753($74 848). The cost-effectiveness acceptability curves show that the AMUSE strategy has the highest probability of being cost-effective. RESULTS OF SENSITIVITY ANALYSIS Results are sensitive to decreases in sensitivity of the diagnostic strategy, but are not sensitive to increase in age (range 30-80), the costs for health states, and events. CONCLUSION A diagnostic management strategy based on a clinical decision rule and a point of care D-dimer assay to exclude DVT in primary care is not only safe, but also cost-effective as compared with hospital-based strategies.
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Affiliation(s)
- A J Ten Cate-Hoek
- Department of Clinical Epidemiology, Maastricht University Medical Center, Maastricht, The Netherlands
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Tan M, van Rooden CJ, Westerbeek RE, Huisman MV. Diagnostic management of clinically suspected acute deep vein thrombosis. Br J Haematol 2009; 146:347-60. [DOI: 10.1111/j.1365-2141.2009.07732.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Toulon P, Lecourvoisier C, Meyniard O. Evaluation of a rapid qualitative immuno-chromatography D-dimer assay (Simplify D-dimer) for the exclusion of pulmonary embolism in symptomatic outpatients with a low and intermediate pretest probability. Comparison with two automated quantitative assays. Thromb Res 2009; 123:543-9. [DOI: 10.1016/j.thromres.2008.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Revised: 05/19/2008] [Accepted: 05/29/2008] [Indexed: 10/21/2022]
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20
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Righini M, Perrier A, De Moerloose P, Bounameaux H. D-Dimer for venous thromboembolism diagnosis: 20 years later. J Thromb Haemost 2008; 6:1059-71. [PMID: 18419743 DOI: 10.1111/j.1538-7836.2008.02981.x] [Citation(s) in RCA: 198] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Twenty years after its first use in the diagnostic workup of suspected venous thromboembolism (VTE), fibrin D-dimer (DD) testing has gained wide acceptance for ruling out this disease. The test is particularly useful in the outpatient population referred to the emergency department because of suspected deep vein thrombosis (DVT) or pulmonary embolism (PE), in which the ruling out capacity concerns every third patient clinically suspected of having the disease. This usefulness is based on the high sensitivity of the test to the presence of VTE, at least for some assays. Due to its poor specificity precluding its use for ruling in VTE, DD testing must be integrated in comprehensive, sequential diagnostic strategies that include clinical probability assessment and imaging techniques such as lower limb venous compression ultrasonography for suspected DVT or multi-slice helical computed tomography for suspected PE. The present narrative review updates the data available on the use of the various commercially available DD assays in the diagnostic approach of clinically suspected VTE in distinct patient populations or situations, including outpatients and inpatients, patients with cancer, older age, pregnancy, a suspected recurrent event, limited thrombus burden, and patients already on anticoagulant treatment.
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Affiliation(s)
- M Righini
- Division of Angiology and Hemostasis, Department of Internal Medicine, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
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Van Der Velde EF, Wichers IM, Toll DB, Van Weert HCPM, Büller HR. Feasibility and accuracy of a rapid 'point-of-care' D-dimer test performed with a capillary blood sample. J Thromb Haemost 2007; 5:1327-30. [PMID: 17403085 DOI: 10.1111/j.1538-7836.2007.02567.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Subramaniam RM, Heath R, Cox K, Chou T, Stewart J, Sleigh J. Does an immunochromatographic D-dimer exclude acute lower limb deep venous thrombosis? Emerg Med Australas 2006; 18:457-63. [PMID: 17083634 DOI: 10.1111/j.1742-6723.2006.00866.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND A pre-test probability score and D-dimer may reduce the need for ultrasound examinations for excluding lower limb deep venous thrombosis (DVT). OBJECTIVE To establish the accuracy of an immunochromatographic D-dimer assay called 'Simplify' for diagnosis of acute DVT by complete (calf veins included) lower limb ultrasound examination. METHODS A total of 453 consecutive patients presented to the ED of a tertiary centre with suspected first episode of DVT, were prospectively recruited. A pre-test probability score (Hamilton Score), an immunochromatographic D-dimer and a complete, single, unilateral lower limb ultrasound examination were performed in all patients. All patients with a negative ultrasound examination were followed up for 3 months. RESULTS There were 159 men and 294 women with a mean age of 55.8 years (SD 20.3). Of the 227 patients with a negative D-dimer, 214 patients had negative ultrasound examinations and 13 patients had isolated calf DVT. Among the 226 patients with a positive D-dimer, 74 patients had DVT and 152 patients had negative ultrasound examinations. The sensitivity, specificity, positive and negative predictive values were 85.1% (75.8-91.8), 58.5% (53.4-63.5), 32.7% (26.6-38.9) and 94.3% (90.4-96.9), respectively. One hundred and sixty-five patients had an unlikely Hamilton Score and a negative D-dimer. The negative predictive value of the immunochromatographic D-dimer in an unlikely Hamilton Score population was 98.8% (95.7-99.8%). CONCLUSION An unlikely probability Hamilton Score and a negative immunochromatographic D-dimer reliably exclude both proximal and isolated calf DVT.
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Subramaniam RM, Snyder B, Heath R, Tawse F, Sleigh J. Diagnosis of lower limb deep venous thrombosis in emergency department patients: performance of Hamilton and modified Wells scores. Ann Emerg Med 2006; 48:678-85. [PMID: 17112931 DOI: 10.1016/j.annemergmed.2006.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Revised: 04/04/2006] [Accepted: 04/13/2006] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE We validate and compare the Hamilton score for assessment of lower limb deep venous thrombosis with the modified Wells score. METHODS Consecutive patients presenting to the emergency department of a tertiary center for suspected lower limb deep venous thrombosis were prospectively recruited. Hamilton score and modified Wells score calculations, D-dimer, and complete (calf veins included), single lower limb ultrasonographic examination were performed for all patients. All patients with a negative ultrasonographic examination result for deep venous thrombosis were followed up for 3 months. RESULTS The study population consisted of 116 men and 193 women, with an average age of 55.6 years (SD 20.1). A total of 67 (21.7%) patients were diagnosed with deep venous thrombosis. Forty (59.7%) of these patients had isolated calf deep venous thrombosis, and the other 27 (40.3%) patients had proximal deep venous thrombosis. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for an unlikely Hamilton score (score < or = 2) and D-dimer were 99% (95% confidence interval [CI] 92% to 99.96%), 42 % (95% CI 36% to 49%), 32% (95% CI 26% to 39%), 99% (95% CI 95% to 99.98%), 1.7 (95% CI 1.52% to 1.9%), and 0.04 (95% CI 0.01 to 0.25), respectively. The sensitivity, specificity, PPV, NPV, LR+ and LR- for an unlikely modified Wells score (score < or = 1) and D-dimer were 99% (95% CI 92% to 99.96%), 33 % (95% CI 27% to 39%), 29% (95% CI 23% to 35%), 99% (95% CI 93% to 99.97%), 1.47 (95% CI 1.34 to 1.62), and 0.05 (95% CI 0.01 to 0.32), respectively. CONCLUSION An unlikely probability of Hamilton score and a negative D-dimer may effectively exclude a lower limb deep venous thrombosis. Hamilton and modified Wells scores have similar performance characteristics.
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Hogg K, Dawson D, Mackway-Jones K. The emergency department utility of Simplify D-dimer to exclude pulmonary embolism in patients with pleuritic chest pain. Ann Emerg Med 2006; 46:305-10. [PMID: 16187460 DOI: 10.1016/j.annemergmed.2005.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Pleuritic chest pain is a common presenting complaint in the emergency department (ED) and a symptom of pulmonary embolism. Patients with pleuritic chest pain would benefit from a simple and rapid way of screening for pulmonary embolism. The aim of this study is to assess the utility of Simplify D-dimer as a rule-out tool for pulmonary embolism in ED patients with pleuritic chest pain. METHODS This was a prospective diagnostic study in a large city-center ED. Four hundred twenty-five patients with pleuritic chest pain were prospectively recruited between February 2002 and June 2003. Simplify D-dimer testing was performed on each patient in the ED. All patients followed an independent reference standard diagnostic algorithm for pulmonary embolism. Each patient was followed up clinically for 3 months. RESULTS The calculated sensitivity of Simplify D-dimer for pulmonary embolism was 81.8% (95% confidence interval [CI] 61.4% to 92.7%), and specificity was 74.2% (95% CI 69.6% to 78.4%). The negative predictive value was 98.6% (95% CI 96.6% to 99.6%), positive predictive value 15.0% (95% CI 9.1% to 22.7%), negative likelihood ratio 0.25 (95% CI 0.10 to 0.52) and positive likelihood ratio 3.17 (95% CI 2.30 to 3.97). The study cohort pretest probability was 5.3%. A negative Simplify result reduced the posttest probability to 1.3% (95% CI 0.5% to 3.4%). CONCLUSION The Simplify D-dimer is not sufficiently sensitive to exclude the diagnosis of pulmonary embolism in all patients presenting to the ED with pleuritic chest pain.
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Affiliation(s)
- Kerstin Hogg
- Emergency Department, Manchester Royal Infirmary, Manchester, United Kingdom.
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Subramaniam RM, Chou T, Heath R, Allen R. Importance of Pretest Probability Score and D-Dimer Assay Before Sonography for Lower Limb Deep Venous Thrombosis. AJR Am J Roentgenol 2006; 186:206-12. [PMID: 16357403 DOI: 10.2214/ajr.04.1398] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of our study was to develop and validate a clinical score (the Hamilton score) for the assessment of lower limb deep venous thrombosis (DVT) and to determine the usefulness of this score and a D-dimer assay before a complete lower limb sonographic examination. SUBJECTS AND METHODS Five hundred forty-two consecutive ambulatory patients presenting to the emergency department were prospectively recruited, of whom 16 patients were excluded from the study. Eighteen history and examination variables were collected by the emergency department physicians. The Simplify D-dimer assay and a complete, single lower limb sonographic examination were performed in all patients. All patients with a negative sonographic examination for DVT were followed up for 3 months, and all those with a positive sonographic examination were given anticoagulation therapy. The Hamilton score was developed using the data from the first 214 patients and was prospectively validated in the next 312 patients. RESULTS The most significant factors associated with a diagnosis of DVT were immobilization of the lower limb, active malignancy, and a strong clinical suspicion of DVT without other diagnostic possibilities by the emergency department physicians. Other factors were bed rest or recent surgery, male sex, calf circumference difference greater than 3 cm, and erythema. The Hamilton score was developed with the following weights: immobilization of the lower limb (2 points), active malignancy (2 points), strong clinical suspicion of DVT without other diagnostic possibilities by the emergency physicians (2 points), bed rest or recent surgery (1 point), male sex (1 point), calf circumference difference greater than 3 cm (1 point), and erythema (1 point). A score of 3 or greater indicates a likely probability for DVT, and a score of 2 or less represents an unlikely probability for DVT. Of the 103 patients with an unlikely probability Hamilton score and a negative D-dimer assay, only one patient had isolated calf DVT. A combined diagnostic strategy of unlikely-probability Hamilton score and a negative D-dimer would have a negative predictive value of 99% (95% confidence interval, 94.7-100%). CONCLUSION An unlikely-probability Hamilton score and a negative Simplify D-dimer assay effectively exclude lower limb DVT, and a sonographic examination is unnecessary in this group of ambulatory emergency department patients.
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Affiliation(s)
- Rathan M Subramaniam
- Academic and Research Division, Department of Radiology, Waikato Hospital, Hamilton, New Zealand.
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