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Luu IHY, Mostard GJM, van Mil D, van Berlo MHW, Lobbes MBI, Külcü K, Cate HT, Peeters J, Palmen J, Buijs J, Jie KSG, van Kampen RJW, van Twist DJL. Deferring diagnostic evaluation for suspected deep venous thrombosis using a single dose of anticoagulant: Real-world data from a regionwide care pathway. Eur J Intern Med 2024; 122:54-60. [PMID: 38151419 DOI: 10.1016/j.ejim.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/01/2023] [Accepted: 12/20/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Patients with suspected deep venous thrombosis (DVT) are typically referred to the emergency department (ED) for immediate evaluation. However, this often contributes to ED overcrowding and necessitates round-the-clock sonographic examinations. Therefore, we implemented a regionwide care pathway for deferring diagnostic workup of suspected DVT until the following day. Patients receive a single anticoagulant dose from their general practitioner (GP) to prevent progression of DVT in the interval between referral and diagnostic evaluation. The next day, patients undergo comprehensive evaluation at our outpatient DVT clinic, including venous ultrasound. This retrospective study aims to provide real-world data on the safety of this care pathway regarding the occurrence of bleeding complications and pulmonary embolism (PE). METHODS We included all GP-referred patients with suspected DVT in 2018 and 2019. Patients with absolute contraindications to deferred evaluation or anticoagulation were excluded. The primary endpoint was the occurrence of bleeding complications. Secondary endpoints included PE events and all-cause mortality within seven days following DVT evaluation. RESULTS Among 1,024 included patients, DVT was confirmed in 238 patients (23.2%) and superficial thrombophlebitis in 98 patients (9.6%). No bleeding events were recorded in patients in whom DVT was ruled out. PE was confirmed in eight patients on the same day as DVT evaluation (0.8%, 95%CI 0.4-1.6) and in six patients within seven days following DVT evaluation (0.6%, 0.2-1.3%). No deaths occurred during this timeframe. CONCLUSION This real-world study observed a very low incidence of bleeding complications and PE events, indicating that this care pathway of deferred DVT workup is safe and may offer a more streamlined diagnostic approach for patients with suspected DVT.
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Affiliation(s)
- Inge H Y Luu
- Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Guy J M Mostard
- Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Dominique van Mil
- Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Marlon H W van Berlo
- Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Marc B I Lobbes
- Department of Medical Imaging, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Kemal Külcü
- Department of Medical Imaging, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jos Peeters
- General practice Overhoven-Hoogveld, Huisartsen Coöperatie Westelijke Mijnstreek, Sittard, the Netherlands
| | - Jan Palmen
- General practice Aarveld Medical Center, Huisartsen Oostelijk Zuid-Limburg, Heerlen, the Netherlands
| | - Jacqueline Buijs
- Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Kon-Siong G Jie
- Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Roel J W van Kampen
- Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
| | - Daan J L van Twist
- Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands.
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Willems JIA, Tummers-de Lind van Wijngaarden RFA, Dubelaar IJM, De Kruif MD, Leers MPG, Luu IHY, Peeters RP, van Twist DJL. Thyroid and adrenal incidentalomas on chest CT: Prevalence, diagnostic work-up and outcomes in a cohort of COVID-19 suspected patients. Eur J Intern Med 2023:S0953-6205(23)00444-2. [PMID: 38123419 DOI: 10.1016/j.ejim.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Due to increased use of computed tomography (CT), prevalence of thyroid and adrenal incidentalomas is rising. Yet, previous studies on the outcomes of diagnostic work-up of incidentalomas are subjected to inclusion bias. Therefore, we aimed to investigate prevalence and outcomes of diagnostic work-up of thyroid and adrenal incidentalomas detected on chest CT in a less selected population of COVID-19 suspected patients. DESIGN A retrospective, observational cohort study. METHODS We included all COVID-19 suspected patients who underwent chest CT between March 2020 and March 2021. Radiology reports and medical records were reviewed for the presence and subsequent diagnostic work-up of thyroid and adrenal incidentalomas. RESULTS A total of 1,992 consecutive COVID-19 patients were included (59.4% male, median age 71 years [IQR: 71-80]). Thyroid and adrenal incidentalomas were identified in 95 (4.8%) and 133 (6.7%) patients, respectively. Higher prevalence was observed with increasing age, among female patients and in patients with malignancy. Forty-four incidentalomas were further analyzed, but no malignancies were found. Only three lesions were hormonally active (1 thyrotoxicosis and 2 mild autonomous cortisol secretion). Diagnostic work-up did not lead to any change in clinical management in 97.7% of the analyzed patients. CONCLUSION Prevalence rates of thyroid and adrenal incidentalomas on chest CT in a less selected COVID-19 cohort were 4.8% and 6.7%, respectively. Yet, as all incidentalomas turned out to be benign and only three lesions were (mildly) hormonally active, this raises the question whether intensive diagnostic work-up of incidentalomas is necessary in all patients.
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Affiliation(s)
- Jeresa I A Willems
- Department of Internal Medicine, Zuyd Thyroid Center, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | | | - Ivo J M Dubelaar
- Department of Radiology, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | - Martijn D De Kruif
- Department of Pulmonology, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | - Math P G Leers
- Department of Clinical Chemistry and Hematology, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | - Inge H Y Luu
- Department of Internal Medicine, Zuyd Thyroid Center, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | - Robin P Peeters
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Daan J L van Twist
- Department of Internal Medicine, Zuyd Thyroid Center, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands.
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van Twist DJL, Luu IHY, Ten Cate H. Aspirin for Thromboprophylaxis after a Fracture. N Engl J Med 2023; 388:e57. [PMID: 37075155 DOI: 10.1056/nejmc2301925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Affiliation(s)
| | - Inge H Y Luu
- Zuyderland Medical Center, Sittard, the Netherlands
| | - Hugo Ten Cate
- Maastricht University Medical Center, Maastricht, the Netherlands
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Luu IHY, Frijns T, Buijs J, Krdzalic J, de Kruif MD, Mostard GJM, Ten Cate H, Martens RJH, Mostard RLM, Leers MPG, van Twist DJL. Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department. PLoS One 2023; 18:e0283459. [PMID: 36952456 PMCID: PMC10035852 DOI: 10.1371/journal.pone.0283459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 03/03/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Diagnosing concomitant pulmonary embolism (PE) in COVID-19 patients remains challenging. As such, PE may be overlooked. We compared the diagnostic yield of systematic PE-screening based on the YEARS-algorithm to PE-screening based on clinical gestalt in emergency department (ED) patients with COVID-19. METHODS We included all ED patients who were admitted because of COVID-19 between March 2020 and February 2021. Patients already receiving anticoagulant treatment were excluded. Up to April 7, 2020, the decision to perform CT-pulmonary angiography (CTPA) was based on physician's clinical gestalt (clinical gestalt cohort). From April 7 onwards, systematic PE-screening was performed by CTPA if D-dimer level was ≥1000 ug/L, or ≥500 ug/L in case of ≥1 YEARS-item (systematic screening cohort). RESULTS 1095 ED patients with COVID-19 were admitted. After applying exclusion criteria, 289 were included in the clinical gestalt and 574 in the systematic screening cohort. The number of PE diagnoses was significantly higher in the systematic screening cohort compared to the clinical gestalt cohort: 8.2% vs. 1.0% (3/289 vs. 47/574; p<0.001), even after adjustment for differences in patient characteristics (adjusted OR 8.45 (95%CI 2.61-27.42, p<0.001) for PE diagnosis). In multivariate analysis, D-dimer (OR 1.09 per 1000 μg/L increase, 95%CI 1.06-1.13, p<0.001) and CRP >100 mg/L (OR 2.78, 95%CI 1.37-5.66, p = 0.005) were independently associated with PE. CONCLUSION In ED patients with COVID-19, the number of PE diagnosis was significantly higher in the cohort that underwent systematic PE screening based on the YEARS-algorithm in comparison with the clinical gestalt cohort, with a number needed to test of 7.1 CTPAs to detect one PE.
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Affiliation(s)
- Inge H Y Luu
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Tim Frijns
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Jacqueline Buijs
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Jasenko Krdzalic
- Department of Radiology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Martijn D de Kruif
- Department of Pulmonology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Guy J M Mostard
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Remy J H Martens
- Department of Clinical Chemistry and Haematology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Remy L M Mostard
- Department of Pulmonology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Math P G Leers
- Department of Clinical Chemistry and Haematology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Daan J L van Twist
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
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Luu IHY, Kroon FPB, Buijs J, Krdzalic J, de Kruif MD, Leers MPG, Mostard GJM, Martens RJH, Mostard RLM, van Twist DJL. Systematic screening for pulmonary embolism using the YEARS algorithm in patients with suspected COVID-19 in the Emergency Department. Thromb Res 2021; 207:113-115. [PMID: 34601306 PMCID: PMC8461006 DOI: 10.1016/j.thromres.2021.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/05/2021] [Accepted: 09/14/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Inge H Y Luu
- Department of Internal Medicine, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Féline P B Kroon
- Department of Internal Medicine, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Jacqueline Buijs
- Department of Internal Medicine, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Jasenko Krdzalic
- Department of Radiology, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Martijn D de Kruif
- Department of Pulmonology, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Math P G Leers
- Department of Clinical Chemistry and Hematology, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Guy J M Mostard
- Department of Internal Medicine, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Remy J H Martens
- Department of Clinical Chemistry and Hematology, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Remy L M Mostard
- Department of Pulmonology, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
| | - Daan J L van Twist
- Department of Internal Medicine, Zuyderland Medical Centre, PO-box 5500, 6130 MB Sittard, the Netherlands.
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Affiliation(s)
| | | | | | - Rémy L M Mostard
- and Pulmonology Zuyderland Medical Centre, PO Box 5500, 6130 MB Sittard, the Netherlands
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