Search

Background: The performance of different diagnostic strategies for pulmonary embolism (PE) in patient subgroups is unclear.Purpose: To evaluate and compare the efficiency and safety of the Wells rule with fixed or age-adjusted d-dimer testing overall and in inpatients and persons with cancer, chronic obstructive pulmonary disease, previous venous thromboembolism, delayed presentation, and age 75 years or older.Data Sources: MEDLINE and EMBASE from 1 January 1988 to 13 February 2016.Study Selection: 6 prospective studies in which the diagnostic management of PE was guided by the dichotomized Wells rule and quantitative d-dimer testing.Data Extraction: Individual data of 7268 patients; risk of bias assessed by 2 investigators with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool.Data Synthesis: The proportion of patients in whom imaging could be withheld based on a "PE-unlikely" Wells score and a negative d-dimer test result (efficiency) was estimated using fixed (≤500 µg/L) and age-adjusted (age × 10 µg/L in patients aged >50 years) d-dimer thresholds; their 3-month incidence of symptomatic venous thromboembolism (failure rate) was also estimated. Overall, efficiency increased from 28% to 33% when the age-adjusted (instead of the fixed) d-dimer threshold was applied. This increase was more prominent in elderly patients (12%) but less so in inpatients (2.6%). The failure rate of age-adjusted d-dimer testing was less than 3% in all examined subgroups.Limitation: Post hoc analysis, between-study differences in patient characteristics, use of various d-dimer assays, and limited statistical power to assess failure rate.Conclusion: Age-adjusted d-dimer testing is associated with a 5% absolute increase in the proportion of patients with suspected PE in whom imaging can be safely withheld compared with fixed d-dimer testing. This strategy seems safe across different high-risk subgroups, but its efficiency varies.Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Background: Although well-established for suspected lower limb deep venous thrombosis, an algorithm combining a clinical decision score, d-dimer testing, and ultrasonography has not been evaluated for suspected upper extremity deep venous thrombosis (UEDVT).Objective: To assess the safety and feasibility of a new diagnostic algorithm in patients with clinically suspected UEDVT.Design: Diagnostic management study. (ClinicalTrials.gov: NCT01324037) SETTING: 16 hospitals in Europe and the United States.Patients: 406 inpatients and outpatients with suspected UEDVT.Measurements: The algorithm consisted of the sequential application of a clinical decision score, d-dimer testing, and ultrasonography. Patients were first categorized as likely or unlikely to have UEDVT; in those with an unlikely score and normal d-dimer levels, UEDVT was excluded. All other patients had (repeated) compression ultrasonography. The primary outcome was the 3-month incidence of symptomatic UEDVT and pulmonary embolism in patients with a normal diagnostic work-up.Results: The algorithm was feasible and completed in 390 of the 406 patients (96%). In 87 patients (21%), an unlikely score combined with normal d-dimer levels excluded UEDVT. Superficial venous thrombosis and UEDVT were diagnosed in 54 (13%) and 103 (25%) patients, respectively. All 249 patients with a normal diagnostic work-up, including those with protocol violations (n = 16), were followed for 3 months. One patient developed UEDVT during follow-up, for an overall failure rate of 0.4% (95% CI, 0.0% to 2.2%).Limitations: This study was not powered to show the safety of the substrategies. d-Dimer testing was done locally.Conclusion: The combination of a clinical decision score, d-dimer testing, and ultrasonography can safely and effectively exclude UEDVT. If confirmed by other studies, this algorithm has potential as a standard approach to suspected UEDVT.Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Background: Although well-established for suspected lower limb deep venous thrombosis, an algorithm combining a clinical decision score, D-dimer testing, and ultrasonography has not been evaluated for suspected upper extremity deep venous thrombosis (UEDVT). Objective: To assess the safety and feasibility of a new diagnostic algorithm in patients with clinically suspected UEDVT. Design: Diagnostic management study. (ClinicalTrials.gov: NCT01324037) Setting: 16 hospitals in Europe and the United States. Patients: 406 inpatients and outpatients with suspected UEDVT. Measurements: The algorithm consisted of the sequential application of a clinical decision score, Ddimer testing, and ultrasonography. Patients were first categorized as likely or unlikely to have UEDVT; in those with an unlikely score and normal Ddimer levels, UEDVT was excluded. All other patients had (repeated) compression ultrasonography. The primary outcome was the 3-month incidence of symptomatic UEDVT and pulmonary embolism in patients with a normal diagnostic work-up. Results: The algorithm was feasible and completed in 390 of the 406 patients (96%). In 87 patients (21%), an unlikely score combined with normal Ddimer levels excluded UEDVT. Superficial venous thrombosis and UEDVT were diagnosed in 54 (13%) and 103 (25%) patients, respectively. All 249 patients with a normal diagnostic work-up, including those with protocol violations (n = 16), were followed for 3 months. One patient developed UEDVT during follow-up, for an overall failure rate of 0.4% (95% CI, 0.0% to 2.2%). Limitations: This study was not powered to show the safety of the substrategies. DDimer testing was done locally. Conclusion: The combination of a clinical decision score, Ddimer testing, and ultrasonography can safely and effectively exclude UEDVT. If confirmed by other studies, this algorithm has potential as a standard approach to suspected UEDVT. [ABSTRACT FROM AUTHOR]

Background: Several clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared. Objective: To directly compare the performance of 4 CDRs (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with n-dimer testing to exclude PE. Design: Prospective cohort study. Setting: 7 hospitals in the Netherlands. Patients: 807 consecutive patients with suspected acute PE. Intervention: The clinical probability of PE was assessed by using a computer program that calculated all CDRs and indicated the next diagnostic step. Results of the CDRs and D-dimer tests guided clinical care. Measurements: Results of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up. Results: Prevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal D-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and D-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% Cl, 2.9% to 3.1 %]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal D-dimer result. Limitation: Management was based on a combination of decision rules and o-dimer testing rather than only 1 CDR combined with D-dimer testing. Conclusion: All 4 CDRs show similar performance for exclusion of acute PE in combination with a normal o-dimer result. This prospective validation indicates that the simplified scores may be used in clinical practice. Primary Funding Source: Academic Medical Center, VU University Medical Center, Rijnstate Hospital, Leiden University Medical Center, Maastricht University Medical Center, Erasmus Medical Center, and Maasstad Hospital. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about the role of computed tomographic pulmonary angiography in suspected pulmonary embolism.

The article focuses on the findings of two studies regarding the efficacy of anticoagulant thromboprophylaxis with rivaroxaban or enoxaparin in hip anthroplasty. Randomized controlled trials were conducted on patients 18 to 93 years of age and revealed that thromboprophylaxis with rivaroxaban or enoxaparin did not differ for major bleeding in total hip arthroplasty. It states that neither rivaroxaban nor enoxaparin groups differ for abnormalities in liver enzymes in hip anthroplasty.

The article focuses on efficacy of anticoagulants thromboprophylaxis with rivaroxaban or enoxaparin in preventing bleeding in knee anthroplasty. Hip and knee arthroplasty are associated with a high risk for venous thromboembolism and the use of anticoagulants like warfarin with thromboprophylaxis poses the need for anticoagulant monitoring and subcutaneous administration. It states that neither rivaroxaban nor enoxaparin group differ for major bleeding in knee anthroplasty.