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Harry R Buller - One of the best experts on this subject based on the ideXlab platform.
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Deep Vein Thrombosis and pulmonary embolism
The Lancet, 2016Co-Authors: Marcello Di Nisio, Nick Van Es, Harry R BullerAbstract:Summary Deep Vein Thrombosis and pulmonary embolism, collectively referred to as venous thromboembolism, constitute a major global burden of disease. The diagnostic work-up of suspected Deep Vein Thrombosis or pulmonary embolism includes the sequential application of a clinical decision rule and D-dimer testing. Imaging and anticoagulation can be safely withheld in patients who are unlikely to have venous thromboembolism and have a normal D-dimer. All other patients should undergo ultrasonography in case of suspected Deep Vein Thrombosis and CT in case of suspected pulmonary embolism. Direct oral anticoagulants are first-line treatment options for venous thromboembolism because they are associated with a lower risk of bleeding than vitamin K antagonists and are easier to use. Use of thrombolysis should be limited to pulmonary embolism associated with haemodynamic instability. Anticoagulant treatment should be continued for at least 3 months to prevent early recurrences. When venous thromboembolism is unprovoked or secondary to persistent risk factors, extended treatment beyond this period should be considered when the risk of recurrence outweighs the risk of major bleeding.
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risk of Deep Vein Thrombosis and pulmonary embolism in asthma
European Respiratory Journal, 2013Co-Authors: Christof J Majoor, Harry R Buller, Pieter Willem Kamphuisen, Aeilko H Zwinderman, Anneketen Brinke, Marijke Amelink, Lucia H Rijssenbeeknouwens, Peter J Sterk, Elisabeth H BelAbstract:Increasing evidence suggests that patients with asthma have activated coagulation within the airways. Whether this leads to an increase in venous thromboembolic events is unknown. We therefore assessed the incidence of venous thromboembolic events in patients with mild-to-moderate and severe asthma as compared with an age- and sex-matched reference population. 648 patients with asthma (283 with severe and 365 patients with mild-to-moderate asthma) visiting three Dutch outpatient asthma clinics were studied. All patients completed a questionnaire about a diagnosis of Deep Vein Thrombosis and pulmonary embolism in the past, their risk factors, history of asthma and medication use. All venous thromboembolic events were objectively verified. In total, 35 venous thromboembolic events (16 Deep Vein Thrombosis and 19 pulmonary embolism) occurred at a median age of 39 (range 20-63) years. The incidence of pulmonary embolism in patients with severe asthma was 0.93 (95% CI 0.42-1.44) per 1000 person-years, 0.33 (95% CI 0.07-0.60) in mild-to-moderate asthma and 0.18 (95% CI 0.03-0.33) in the general population, respectively. Severe asthma and oral corticosteroid use were independent risk factors of pulmonary embolism (hazard ratios 3.33 (1.16-9.93) and 2.82 (1.09-7.30), respectively). Asthma was not associated with Deep Vein Thrombosis. Severe asthma greatly enhances the risk of pulmonary embolism, particularly if chronic corticosteroids are used.
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Deep Vein Thrombosis
The Lancet, 1999Co-Authors: Anthonie W A Lensing, Martin H Prins, Paolo Prandoni, Harry R BullerAbstract:Summary Deep-Vein Thrombosis is an important complication of several inherited and acquired disorders, but may also occur spontaneously. Prevention of recurrent venous Thrombosis and pulmonary embolism is the main reason for accurate diagnosis and adequate treatment. This seminar discusses only symptomatic Deep-Vein Thrombosis. The diagnosis can be confirmed by objective tests in only about 30% of patients with symptoms. Venous thromboembolic complications happen in less than 1% of untreated patients in whom the presence of venous Thrombosis is rejected on the basis of serial ultrasonography or ultrasonography plus either D-dimer or clinical score. Initial anticoagulant treatment (intravenous or subcutaneous heparin) should continue until oral anticoagulant treatment, started concurrently, increases the international normalised ratio above 2·0 for more than 24 h. The optimum duration of oral anticoagulant treatment is unresolved, but may be guided by the presence of temporary or persistent risk factors or presentation with recurrent venous thromboembolism.
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compression ultrasonography for diagnostic management of patients with clinically suspected Deep Vein Thrombosis prospective cohort study
Obstetrical & Gynecological Survey, 1998Co-Authors: Annalisa Cogo, Philip S Wells, Anthonie W A Lensing, Harry R Buller, Franco Piovella, Maria M W Koopman, Alexander G G Turpie, Sergio Siragusa, Sabina Villalta, Paolo PrandoniAbstract:Abstract Objective: To evaluate the safety of withholding anticoagulant treatment from patients with clinically suspected Deep Vein Thrombosis but normal findings on compression ultrasonography. Design: Compression ultrasonography was done with a simplified diagnostic procedure limited to the common femoral Vein in the groin and the popliteal Vein extending down to the trifurcation of the calf Veins. Patients with normal ultrasonography findings at presentation were retested 1 week later. Main outcome measure: The incidence of venous thromboembolic complications during follow up for 6 months in patients in whom anticoagulant treatment was withheld on the basis of normal results on two ultrasonography tests 1 week apart. Setting: University research centres in four hospitals. Results: A total of 1702 patients were included in the study. Abnormal results on compression ultrasonography at presentation or at 1 week were found in 400 and 12 patients, respectively, for a prevalence of Deep Vein Thrombosis of 24%. None of the patients were lost to follow up. Venous thromboembolic complications during the week of serial testing occurred in a single patient and in eight patients during 6 months9 follow up, resulting in a cumulative rate of venous thromboembolic complications of 0.7% (95% confidence interval 0.3% to 1.2%). The mean number of extra hospital visits and additional tests required per initially referred patient was 0.8. Conclusion: It is safe to withhold anticoagulant treatment from patients with clinically suspected Deep Vein Thrombosis who have a normal result on compression ultrasonography at the time of presentation and at 1 week. Key messages Clinical diagnosis of suspected Deep Vein Thrombosis is notoriously unreliable and objective diagnostic tests are indicated to confirm or refute the presence of this condition Ultrasonography with Vein compressibility of the common femoral and popliteal Vein is the non-invasive test of choice for the diagnostic management of patients with suspected Deep Vein Thrombosis It is safe to withhold anticoagulant treatment from patients with suspected Deep Vein Thrombosis who have normal results on compression ultrasonography on presentation and on a single repeat test 1 week later With the simplified compression ultrasound strategy the number of repeat tests can be safely reduced to a single test performed a week after presentation Most patients with Deep Vein Thrombosis can be identified at presentation, making this strategy convenient to patients and less costly
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a comparison of real time compression ultrasonography with impedance plethysmography for the diagnosis of Deep Vein Thrombosis in symptomatic outpatients
The New England Journal of Medicine, 1993Co-Authors: H Heijboer, Anthonie W A Lensing, Harry R Buller, Alexander G G Turpie, L P Colly, J Ten W CateAbstract:Background Impedance plethysmography performed serially over a one-week period has been shown to be an effective diagnostic strategy for patients with clinically suspected acute Deep-Vein Thrombosis. Compression ultrasonography has a high sensitivity and specificity for the detection of proximal-Vein Thrombosis. The clinical value of repeated ultrasonography in the management of symptomatic Deep-Vein Thrombosis is unknown. Methods We conducted a randomized trial in 985 consecutive outpatients with clinically suspected Deep-Vein Thrombosis to compare the diagnostic value of serial impedance plethysmography (494 patients) and serial compression ultrasonography (491 patients). We compared the positive predictive values of both tests for the diagnosis of venous Thrombosis, using contrast venography as a reference. The frequencies of venous thromboembolism during a six-month follow-up period were also compared in patients with repeatedly normal results in order to evaluate the safety of withholding anticoagula...
J Ten W Cate - One of the best experts on this subject based on the ideXlab platform.
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a comparison of real time compression ultrasonography with impedance plethysmography for the diagnosis of Deep Vein Thrombosis in symptomatic outpatients
The New England Journal of Medicine, 1993Co-Authors: H Heijboer, Anthonie W A Lensing, Harry R Buller, Alexander G G Turpie, L P Colly, J Ten W CateAbstract:Background Impedance plethysmography performed serially over a one-week period has been shown to be an effective diagnostic strategy for patients with clinically suspected acute Deep-Vein Thrombosis. Compression ultrasonography has a high sensitivity and specificity for the detection of proximal-Vein Thrombosis. The clinical value of repeated ultrasonography in the management of symptomatic Deep-Vein Thrombosis is unknown. Methods We conducted a randomized trial in 985 consecutive outpatients with clinically suspected Deep-Vein Thrombosis to compare the diagnostic value of serial impedance plethysmography (494 patients) and serial compression ultrasonography (491 patients). We compared the positive predictive values of both tests for the diagnosis of venous Thrombosis, using contrast venography as a reference. The frequencies of venous thromboembolism during a six-month follow-up period were also compared in patients with repeatedly normal results in order to evaluate the safety of withholding anticoagula...
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Deep Vein Thrombosis and the incidence of subsequent symptomatic cancer
The New England Journal of Medicine, 1992Co-Authors: Paolo Prandoni, Annalisa Cogo, Anthonie W A Lensing, Martin H Prins, Harry R Buller, A M Cattelan, S Cuppini, Franco Noventa, J Ten W CateAbstract:Abstract Background. In contrast to the established relation between overt cancer and subsequent venous thromboembolism, it is unclear whether symptomatic Deep-Vein Thrombosis is associated with a risk of subsequent overt malignant disease. Methods. Two hundred sixty consecutive patients with symptomatic, venographically proved Deep-Vein Thrombosis were enrolled in a study, of whom 250 were followed during a two-year period. Among those assessed during follow-up, the incidence of subsequently detected cancer in the 105 patients with secondary venous Thrombosis (i.e., Thrombosis associated with a well-recognized risk factor other than cancer) was compared with the incidence of cancer in the 145 patients with idiopathic venous Thrombosis. Results. Routine examination at the time of diagnosis of the venous Thrombosis revealed cancer in 5 of the 153 enrolled patients with idiopathic venous Thrombosis (3.3 percent) and in none of the 107 enrolled patients with secondary venous Thrombosis. During follow-up, ove...
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prevention of Deep Vein Thrombosis following total hip replacement by low molecular weight heparinoid
Thrombosis and Haemostasis, 1992Co-Authors: J A Hoek, Harry R Buller, M T Nurmohamed, K J Hamelynck, R K Marti, H C Knipscheer, Ten H Cate, H N Magnani, J Ten W CateAbstract:Abstract We assessed the safety and efficacy of the novel low molecular weight heparinoid Lomoparan (Org 10172) for the prevention of Deep-Vein Thrombosis in patients undergoing elective total hip replacement in a randomized, placebo-controlled, double-blind trial in 197 consecutive patients. The heparinoid (750 anti-factor Xa-units, s.c., b.i.d.) was administered to 97 patients and 99 patients received placebo. Study medication was started preoperatively and continued for 10 days. Efficacy was assessed by bilateral phlebography at day 10, postoperatively. The incidence of Deep-Vein Thrombosis was 56.6% and 15.5% respectively in the placebo and heparinoid treated patients (incidence reduction: 74%; P less than 0.001). This reduction was observed both for proximal-Vein Thrombosis (25% to 8%; P less than 0.005) and isolated calf-Vein Thrombosis (31% to 7%; P less than 0.001). No major hemorrhage was observed. The number of red-cell units transfused and drain-fluid loss were comparable for the two study groups. Six patients in the heparinoid group and none in the control group developed minor wound hematomas (P less than 0.05). During an 8-week post-discharge follow-up period three patients with a normal venogram at day 10 developed clinically apparent venous thromboembolism, which was confirmed by objective testing. All three patients belonged to the heparinoid-treated group. We conclude that 750 anti-factor Xa units Org 10172 s.c. twice daily starting preoperatively is safe and effectively reduces early Deep-Vein Thrombosis following elective total hip replacement. Further studies on the incidence of post-discharge thromboembolism are required.
Paolo Prandoni - One of the best experts on this subject based on the ideXlab platform.
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Deep Vein Thrombosis
The Lancet, 1999Co-Authors: Anthonie W A Lensing, Martin H Prins, Paolo Prandoni, Harry R BullerAbstract:Summary Deep-Vein Thrombosis is an important complication of several inherited and acquired disorders, but may also occur spontaneously. Prevention of recurrent venous Thrombosis and pulmonary embolism is the main reason for accurate diagnosis and adequate treatment. This seminar discusses only symptomatic Deep-Vein Thrombosis. The diagnosis can be confirmed by objective tests in only about 30% of patients with symptoms. Venous thromboembolic complications happen in less than 1% of untreated patients in whom the presence of venous Thrombosis is rejected on the basis of serial ultrasonography or ultrasonography plus either D-dimer or clinical score. Initial anticoagulant treatment (intravenous or subcutaneous heparin) should continue until oral anticoagulant treatment, started concurrently, increases the international normalised ratio above 2·0 for more than 24 h. The optimum duration of oral anticoagulant treatment is unresolved, but may be guided by the presence of temporary or persistent risk factors or presentation with recurrent venous thromboembolism.
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compression ultrasonography for diagnostic management of patients with clinically suspected Deep Vein Thrombosis prospective cohort study
Obstetrical & Gynecological Survey, 1998Co-Authors: Annalisa Cogo, Philip S Wells, Anthonie W A Lensing, Harry R Buller, Franco Piovella, Maria M W Koopman, Alexander G G Turpie, Sergio Siragusa, Sabina Villalta, Paolo PrandoniAbstract:Abstract Objective: To evaluate the safety of withholding anticoagulant treatment from patients with clinically suspected Deep Vein Thrombosis but normal findings on compression ultrasonography. Design: Compression ultrasonography was done with a simplified diagnostic procedure limited to the common femoral Vein in the groin and the popliteal Vein extending down to the trifurcation of the calf Veins. Patients with normal ultrasonography findings at presentation were retested 1 week later. Main outcome measure: The incidence of venous thromboembolic complications during follow up for 6 months in patients in whom anticoagulant treatment was withheld on the basis of normal results on two ultrasonography tests 1 week apart. Setting: University research centres in four hospitals. Results: A total of 1702 patients were included in the study. Abnormal results on compression ultrasonography at presentation or at 1 week were found in 400 and 12 patients, respectively, for a prevalence of Deep Vein Thrombosis of 24%. None of the patients were lost to follow up. Venous thromboembolic complications during the week of serial testing occurred in a single patient and in eight patients during 6 months9 follow up, resulting in a cumulative rate of venous thromboembolic complications of 0.7% (95% confidence interval 0.3% to 1.2%). The mean number of extra hospital visits and additional tests required per initially referred patient was 0.8. Conclusion: It is safe to withhold anticoagulant treatment from patients with clinically suspected Deep Vein Thrombosis who have a normal result on compression ultrasonography at the time of presentation and at 1 week. Key messages Clinical diagnosis of suspected Deep Vein Thrombosis is notoriously unreliable and objective diagnostic tests are indicated to confirm or refute the presence of this condition Ultrasonography with Vein compressibility of the common femoral and popliteal Vein is the non-invasive test of choice for the diagnostic management of patients with suspected Deep Vein Thrombosis It is safe to withhold anticoagulant treatment from patients with suspected Deep Vein Thrombosis who have normal results on compression ultrasonography on presentation and on a single repeat test 1 week later With the simplified compression ultrasound strategy the number of repeat tests can be safely reduced to a single test performed a week after presentation Most patients with Deep Vein Thrombosis can be identified at presentation, making this strategy convenient to patients and less costly
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accuracy of clinical assessment of Deep Vein Thrombosis
The Lancet, 1995Co-Authors: Philip S Wells, Gary Foster, Annalisa Cogo, R Dovidio, Anthonie W A Lensing, Clive Kearon, Jeffrey I Weitz, Jack Hirsh, D.r. Anderson, Paolo PrandoniAbstract:Abstract The clinical diagnosis of Deep-Vein Thrombosis is generally thought to be unreliable. From experience, we hypothesised that this widely held view might be incorrect. We developed a clinical model and prospectively tested its ability in three tertiary care centres to stratify symptomatic outpatients with suspected Deep-Vein Thrombosis into groups with high, moderate, or low probability groups of Deep-Vein Thrombosis. We evaluated our clinical model in combination with venous ultrasonography to determine the potential for an improved and simplified diagnostic approach in patients with suspected Deep-Vein Thrombosis. All patients were clinically assessed to determine the probability for Deep-Vein Thrombosis before they had ultrasonography and venography. All tests were performed and interpreted by independent observers. In 529 patients, the clinical model predicted prevalence of Deep-Vein Thrombosis in the three categories: 85% in the high pretest probability category, 33% in the moderate, and 5% in the low category. There was no statistical difference in the performance of the model in the three centres. The model demonstrated excellent interobserver reliability (Kappa=0.85). There were important differences with ultrasonography between the high and low pretest probability groups for both positive predictive values (100% (95% Cl, 94-100%) vs (63% [35-85%], respectively). Thus, use of the clinical model combined with ultrasonography would decrease the number of false positive and negative diagnosis if venography were done when the ultrasound result and pretest probability were discordant. The diagnostic process could be simplified by excluding those patients with low pretest probability and normal ultrasound results from serial testing.
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Deep Vein Thrombosis and the incidence of subsequent symptomatic cancer
The New England Journal of Medicine, 1992Co-Authors: Paolo Prandoni, Annalisa Cogo, Anthonie W A Lensing, Martin H Prins, Harry R Buller, A M Cattelan, S Cuppini, Franco Noventa, J Ten W CateAbstract:Abstract Background. In contrast to the established relation between overt cancer and subsequent venous thromboembolism, it is unclear whether symptomatic Deep-Vein Thrombosis is associated with a risk of subsequent overt malignant disease. Methods. Two hundred sixty consecutive patients with symptomatic, venographically proved Deep-Vein Thrombosis were enrolled in a study, of whom 250 were followed during a two-year period. Among those assessed during follow-up, the incidence of subsequently detected cancer in the 105 patients with secondary venous Thrombosis (i.e., Thrombosis associated with a well-recognized risk factor other than cancer) was compared with the incidence of cancer in the 145 patients with idiopathic venous Thrombosis. Results. Routine examination at the time of diagnosis of the venous Thrombosis revealed cancer in 5 of the 153 enrolled patients with idiopathic venous Thrombosis (3.3 percent) and in none of the 107 enrolled patients with secondary venous Thrombosis. During follow-up, ove...
Philip S Wells - One of the best experts on this subject based on the ideXlab platform.
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evaluation of d dimer in the diagnosis of suspected Deep Vein Thrombosis
The New England Journal of Medicine, 2003Co-Authors: Philip S Wells, Bernard Lewandowski, Melissa Forgie, Jonathan Dreyer, Clive Kearon, Marc A Rodger, George Kovacs, Michael Mitchell, D.r. Anderson, Michael J KovacsAbstract:background Several diagnostic strategies using ultrasound imaging, measurement of d -dimer, and assessment of clinical probability of disease have proved safe in patients with suspected Deep-Vein Thrombosis, but they have not been compared in randomized trials. methods Outpatients presenting with suspected lower-extremity Deep-Vein Thrombosis were potentially eligible. Using a clinical model, physicians evaluated the patients and categorized them as likely or unlikely to have Deep-Vein Thrombosis. The patients were then randomly assigned to undergo ultrasound imaging alone (control group) or to undergo d -dimer testing ( d -dimer group) followed by ultrasound imaging unless the d -dimer test was negative and the patient was considered clinically unlikely to have Deep-Vein Thrombosis, in which case ultrasound imaging was not performed. results Five hundred thirty patients were randomly assigned to the control group, and 566 to the d -dimer group. The overall prevalence of Deep-Vein Thrombosis or pulmonary embolism was 15.7 percent. Among patients for whom Deep-Vein Thrombosis had been ruled out by the initial diagnostic strategy, there were two confirmed venous thromboembolic events in the d -dimer group (0.4 percent; 95 percent confidence interval, 0.05 to 1.5 percent) and six events in the control group (1.4 percent; 95 percent confidence interval, 0.5 to 2.9 percent; P=0.16) during three months of follow-up. The use of d -dimer testing resulted in a significant reduction in the use of ultrasonography, from a mean of 1.34 tests per patient in the control group to 0.78 in the d -dimer group (P=0.008). Two hundred eighteen patients (39 percent) in the d- dimer group did not require ultrasound imaging. conclusions Deep-Vein Thrombosis can be ruled out in a patient who is judged clinically unlikely to have Deep-Vein Thrombosis and who has a negative d -dimer test. Ultrasound testing can be safely omitted in such patients.
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compression ultrasonography for diagnostic management of patients with clinically suspected Deep Vein Thrombosis prospective cohort study
Obstetrical & Gynecological Survey, 1998Co-Authors: Annalisa Cogo, Philip S Wells, Anthonie W A Lensing, Harry R Buller, Franco Piovella, Maria M W Koopman, Alexander G G Turpie, Sergio Siragusa, Sabina Villalta, Paolo PrandoniAbstract:Abstract Objective: To evaluate the safety of withholding anticoagulant treatment from patients with clinically suspected Deep Vein Thrombosis but normal findings on compression ultrasonography. Design: Compression ultrasonography was done with a simplified diagnostic procedure limited to the common femoral Vein in the groin and the popliteal Vein extending down to the trifurcation of the calf Veins. Patients with normal ultrasonography findings at presentation were retested 1 week later. Main outcome measure: The incidence of venous thromboembolic complications during follow up for 6 months in patients in whom anticoagulant treatment was withheld on the basis of normal results on two ultrasonography tests 1 week apart. Setting: University research centres in four hospitals. Results: A total of 1702 patients were included in the study. Abnormal results on compression ultrasonography at presentation or at 1 week were found in 400 and 12 patients, respectively, for a prevalence of Deep Vein Thrombosis of 24%. None of the patients were lost to follow up. Venous thromboembolic complications during the week of serial testing occurred in a single patient and in eight patients during 6 months9 follow up, resulting in a cumulative rate of venous thromboembolic complications of 0.7% (95% confidence interval 0.3% to 1.2%). The mean number of extra hospital visits and additional tests required per initially referred patient was 0.8. Conclusion: It is safe to withhold anticoagulant treatment from patients with clinically suspected Deep Vein Thrombosis who have a normal result on compression ultrasonography at the time of presentation and at 1 week. Key messages Clinical diagnosis of suspected Deep Vein Thrombosis is notoriously unreliable and objective diagnostic tests are indicated to confirm or refute the presence of this condition Ultrasonography with Vein compressibility of the common femoral and popliteal Vein is the non-invasive test of choice for the diagnostic management of patients with suspected Deep Vein Thrombosis It is safe to withhold anticoagulant treatment from patients with suspected Deep Vein Thrombosis who have normal results on compression ultrasonography on presentation and on a single repeat test 1 week later With the simplified compression ultrasound strategy the number of repeat tests can be safely reduced to a single test performed a week after presentation Most patients with Deep Vein Thrombosis can be identified at presentation, making this strategy convenient to patients and less costly
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value of assessment of pretest probability of Deep Vein Thrombosis in clinical management
The Lancet, 1997Co-Authors: Philip S Wells, Cathy Clement, Sue K Robinson, Lisa Gray, Janis Bormanis, David Anderson, Michael Mitchell, Bernard LewandowskiAbstract:Summary Background When ultrasonography is used to investigate Deep-Vein Thrombosis, serial testing is recommended for those who test negative initially. Serial testing is inconvenient for patients and costly. We aimed to assess whether the calculation of pretest probability of Deep-Vein Thrombosis, with a simple clinical model, could be used to improve the management of patients who present with suspected Deep-Vein Thrombosis. Methods Consecutive outpatients with suspected Deep-Vein Thrombosis had their pretest probability calculated with a clinical model. They then underwent compression ultrasound imaging of proximal Veins of the legs. Patients at low pretest probability underwent a single ultrasound test. A negative ultrasound excluded the diagnosis of Deep-Vein Thrombosis whereas a positive ultrasound was confirmed by venography. Patients at moderate pretest probability with a positive ultrasound were treated for Deep-Vein Thrombosis whereas patients with an initial negative ultrasound underwent a single follow-up ultrasound 1 week later. Patients at high pretest probability with a positive ultrasound were treated whereas those with negative ultrasound underwent venography. All patients were followed up for 3 months for thromboembolic complications. Findings 95 (16 ·'0%) of all 593 patients had Deep-Vein Thrombosis; 3%, 17%, and 75% of the patients with low, moderate, and high pretest probability, respectively, had Deep-Vein Thrombosis. Ten of 329 patients with low pretest probability had the diagnosis confirmed, nine at initial testing and one at follow-up. 32 of 193 patients with moderate pretest probability had Deep-Vein Thrombosis, three diagnosed by the serial (1 week) test, and two during follow-up. 53 of 71 patients with high pretest probability had Deep-Vein Thrombosis (49 by the initial ultrasound and four by venography). Only three (0 ·6%) of all 501 (95% Cl 0 ·1–1 ·8) patients diagnosed as not having Deep-Vein Thrombosis had events during the 3-month follow-up. Overall only 33 (5 ·6%) of 593 patients required venography and serial testing was limited to 166 (28%) of 593 patients. Interpretation Management of patients with suspected Deep-Vein Thrombosis based on clinical probability and ultrasound of the proximal Deep Veins is safe and feasible. Our strategy reduced the need for serial ultrasound testing and reduced the rate of false-negative or false-positive ultrasound studies.
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accuracy of clinical assessment of Deep Vein Thrombosis
The Lancet, 1995Co-Authors: Philip S Wells, Gary Foster, Annalisa Cogo, R Dovidio, Anthonie W A Lensing, Clive Kearon, Jeffrey I Weitz, Jack Hirsh, D.r. Anderson, Paolo PrandoniAbstract:Abstract The clinical diagnosis of Deep-Vein Thrombosis is generally thought to be unreliable. From experience, we hypothesised that this widely held view might be incorrect. We developed a clinical model and prospectively tested its ability in three tertiary care centres to stratify symptomatic outpatients with suspected Deep-Vein Thrombosis into groups with high, moderate, or low probability groups of Deep-Vein Thrombosis. We evaluated our clinical model in combination with venous ultrasonography to determine the potential for an improved and simplified diagnostic approach in patients with suspected Deep-Vein Thrombosis. All patients were clinically assessed to determine the probability for Deep-Vein Thrombosis before they had ultrasonography and venography. All tests were performed and interpreted by independent observers. In 529 patients, the clinical model predicted prevalence of Deep-Vein Thrombosis in the three categories: 85% in the high pretest probability category, 33% in the moderate, and 5% in the low category. There was no statistical difference in the performance of the model in the three centres. The model demonstrated excellent interobserver reliability (Kappa=0.85). There were important differences with ultrasonography between the high and low pretest probability groups for both positive predictive values (100% (95% Cl, 94-100%) vs (63% [35-85%], respectively). Thus, use of the clinical model combined with ultrasonography would decrease the number of false positive and negative diagnosis if venography were done when the ultrasound result and pretest probability were discordant. The diagnostic process could be simplified by excluding those patients with low pretest probability and normal ultrasound results from serial testing.
Samuel Z Goldhaber - One of the best experts on this subject based on the ideXlab platform.
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pharmacomechanical catheter directed thrombolysis for Deep Vein Thrombosis
The New England Journal of Medicine, 2017Co-Authors: Suresh Vedantham, David J. Cohen, Elizabeth A. Magnuson, Anthony J. Comerota, Samuel Z Goldhaber, Susan R. Kahn, Michael R. Jaff, Jim A. Julian, Mahmood K Razavi, Heather L GornikAbstract:BackgroundThe post-thrombotic syndrome frequently develops in patients with proximal Deep-Vein Thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter “pharmacomechanical thrombolysis”) rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome. MethodsWe randomly assigned 692 patients with acute proximal Deep-Vein Thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up. ResultsBetween 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% ...
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pulmonary embolism and Deep Vein Thrombosis
The Lancet, 2012Co-Authors: Samuel Z Goldhaber, Henri BounameauxAbstract:Summary Pulmonary embolism is the third most common cause of death from cardiovascular disease after heart attack and stroke. Sequelae occurring after venous thromboembolism include chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Venous thromboembolism and atheroThrombosis share common risk factors and the common pathophysiological characteristics of inflammation, hypercoagulability, and endothelial injury. Clinical probability assessment helps to identify patients with low clinical probability for whom the diagnosis of venous thromboembolism can be excluded solely with a negative result from a plasma D-dimer test. The diagnosis is usually confirmed with compression ultrasound showing Deep Vein Thrombosis or with chest CT showing pulmonary embolism. Most patients with venous thromboembolism will respond to anticoagulation, which is the foundation of treatment. Patients with pulmonary embolism should undergo risk stratification to establish whether they will benefit from the addition of advanced treatment, such as thrombolysis or embolectomy. Several novel oral anticoagulant drugs are in development. These drugs, which could replace vitamin K antagonists and heparins in many patients, are prescribed in fixed doses and do not need any coagulation monitoring in the laboratory. Although rigorous clinical trials have reported the effectiveness and safety of pharmacological prevention with low, fixed doses of anticoagulant drugs, prophylaxis remains underused in patients admitted to hospital at moderate risk and high risk for venous thromboembolism. In this Seminar, we discuss pulmonary embolism and Deep Vein Thrombosis of the legs.
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Deep Vein Thrombosis in patients with chronic kidney disease
Thrombosis and Haemostasis, 2008Co-Authors: Leon H Daneschvar, Ali Seddighzadeh, Gregory Piazza, Samuel Z GoldhaberAbstract:Deep Vein Thrombosis (DVT) is a poorly understood complication of chronic kidney disease (CKD). The objective of our analysis was to profile DVT patients with and without CKD. We defined CKD as patients requiring dialysis or patients having nephrotic syndrome. We compared 268 patients with CKD (184 patients with dialysis-dependent renal disease and 84 with nephrotic syndrome) to 4,307 patients with preserved renal function from a prospective United States multicenter Deep venous Thrombosis (DVT) registry. Compared with non-CKD patients, CKD patients with DVT were younger (median age 62 vs. 69 years, p
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upper extremity Deep Vein Thrombosis
Circulation, 2002Co-Authors: Hylton V Joffe, Samuel Z GoldhaberAbstract:Background— Upper-extremity Deep Vein Thrombosis (UEDVT) occurs spontaneously or sometimes develops as a complication of pacemaker use, long-term use of a central venous catheter (CVC), or cancer. Methods and Results— To improve our understanding of UEDVT, we compared the demographics, symptoms, risk factors, prophylaxis, and initial management of 324 (6%) patients with central venous catheter (CVC)–associated UEDVT, 268 (5%) patients with non–CVC-associated UEDVT, and 4796 (89%) patients with lower-extremity DVT from a prospective US multicenter DVT registry. The non–CVC-associated UEDVT patients were younger (59.2±18.2 versus 64.2±16.9 years old; P<0.0001), less often white (65% versus 73%; P<0.01), leaner (body mass index [BMI] 26.8±7.1 versus 28.5±7.3 kg/m2; P<0.001), and more likely to smoke (19% versus 13%; P=0.02) than the lower-extremity DVT patients. By way of propensity analysis and multivariable logistic regression analysis, we determined that an indwelling CVC was the strongest independent pre...
