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Biomedical subjects

M Nijkeuter

Publications and source records attributed to M Nijkeuter.

7 recordsLinked to original sources
PubMed2006

A simple diagnostic strategy in hospitalized patients with clinically suspected pulmonary embolism.

OBJECTIVES: Diagnostic strategies in patients with suspected pulmonary embolism have been extensively studied in outpatients; their value in hospitalized patients has not been well established. Our aim was to determine the safety and clinical utility of a simple diagnostic strategy in hospitalized patients with suspected pulmonary embolism. DESIGN: Prospective management study. SETTING: Twelve teaching hospitals (five academic, seven general hospitals). SUBJECT: A total of 605 hospitalized patients with clinically suspected pulmonary embolism. All patients completed the study. INTERVENTIONS: First the clinical decision rule (CDR)-score was calculated. An unlikely CDR-score in combination with a normal D-dimer excluded pulmonary embolism. All other patients underwent helical computed tomography (CT). CT either diagnosed or excluded pulmonary embolism, in which case anticoagulants were started or withheld. All patients were instructed to report symptoms of venous thrombosis. Objective tests were performed to confirm venous thromboembolism. The primary outcome was the incidence of symptomatic venous thrombosis during 3-month follow-up. RESULTS: The combination of an unlikely CDR-score and a normal D-dimer excluded pulmonary embolism in 60 patients (10% of all patients); no venous thromboembolic event occurred during follow-up (0%; 95% CI 0-6.7%). CT excluded pulmonary embolism in 380 patients; during follow-up venous thromboembolism occurred in five patients (1.4%; 95% CI 0.4-3.1%). CONCLUSIONS: An unlikely CDR-score in combination with a normal D-dimer appears to exclude pulmonary embolism safely in hospitalized patients. Before clinical implementation it is important this safety is confirmed by others. CT testing was obviated in only 10% of patients. CT can safely exclude pulmonary embolism in hospitalized patients.

Algorithms↗
PubMed2006

Accuracy of clinical decision rule, D-dimer and spiral computed tomography in patients with malignancy, previous venous thromboembolism, COPD or heart failure and in older patients with suspected pulmonary embolism.

BACKGROUND: The diagnostic work-up of patients with suspected pulmonary embolism (PE) has been optimized and simplified by the use of clinical decision rules (CDR), D-dimer (DD) testing and spiral computed tomography (s-CT). Whether this strategy is equally safe and efficient in specific subgroups of patients is evaluated in this study. METHODS: A diagnostic strategy including a CDR, DD test and s-CT was evaluated in patients with malignancy, previous venous thromboembolism (VTE), chronic obstructive pulmonary disease or heart failure and in older patients. PE was ruled out by either an unlikely CDR and a normal DD or a s-CT negative for PE. The safety of these tests was assessed by the 3-month incidence rate of symptomatic VTE in those without PE at baseline. The efficiency was evaluated by calculating the numbers needed to test for the different subgroups. RESULTS: The venous thromboembolic incidence rate after the combination of an unlikely CDR and a normal DD varied from 0% (95% CI: 0-7.9%) in the 482 patients older than 75 years of age to 2% (95% CI: 0.05-10.9%) in the 474 patients with a malignancy. For s-CT these incidences varied from 0.3% to 1.8%. The number needed to test in order to rule out one patient from PE with the studied strategy was highest in cancer patients and in the elderly patients (approximately 10). CONCLUSION: It appears to be safe to rule out PE by either the combination of an unlikely CDR and a normal DD or by a negative s-CT in various subgroups of patients with suspected PE. However, the clinical usefulness of the CDR in combination with the DD as the initial step in the diagnostic process varied among these patient groups.

Adult↗
PubMed2005

Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy: a systematic review.

INTRODUCTION: Diagnosing deep vein thrombosis (DVT) and pulmonary embolism (PE) in pregnancy is challenging. Many of the common diagnostic tests, including compression ultrasonography (CUS), ventilation-perfusion scintigraphy (VQ scan) and helical computed tomography (hCT) that have been extensively investigated in non-pregnant patients, have not been appropriately validated in pregnancy. Extrapolating results of diagnostic studies of DVT and PE in non-pregnant patients to those who are pregnant may not be correct because during pregnancy, physiologic and anatomic changes may affect diagnostic test results, presentation and natural history of VTE. METHODS: We performed a systematic analysis of published studies addressing accurate diagnostic testing for DVT and PE in pregnancy to determine the accuracy of these tests in pregnancy. RESULTS: Our initial search yielded 530 articles of which four remained for inclusion, three studies investigating diagnostic testing in patients with a clinical suspicion of DVT or PE and one study in patients with a clinical suspicion of PE. CONCLUSIONS: From our systematic analysis of published studies investigating diagnostic testing for a clinical suspicion of DVT in pregnancy we conclude that; (i) two studies support withholding anticoagulant therapy in pregnant women with a clinical suspicion of DVT and normal results on serial IPG (impedance plethysmography), however, IPG is no longer used; (ii) one study demonstrated that a normal CUS at presentation combined with a normal D-dimer test or an abnormal D-dimer test combined with normal serial CUS appears promising for safely excluding DVT in pregnant patients, but too few patients were included in this pilot-study to draw firm conclusions; and (iii) one study investigated pregnant patients with a clinical suspicion of PE and this study concluded that in patients with normal or non-diagnostic VQ scans, withholding anticoagulant therapy might be safe, but this needs confirmation in larger studies. Recommendations on diagnostic testing of pregnant patients with a clinically suspected DVT or PE are provided.

Female↗
PubMed2005

Diagnostic methods in pulmonary embolism.

Diagnosing pulmonary embolism (PE) is challenging since clinical signs and symptoms are non-specific. The diagnostic tests available for demonstrating PE all have their drawbacks and are often costly and consume considerable amounts of resources. Simple tools that have become available in the last several years include clinical prediction rules and D-dimer testing. Assessment of the clinical probability, combined with a D-dimer test, can limit the need for additional diagnostic tests by 30%. For outpatients with a normal, sensitive ELISA D-dimer test and a low-to-moderate clinical probability, PE can safely be ruled out. Pulmonary angiography, though still the gold standard, is rarely used nowadays because of its invasiveness, its high costs and limited availability, and the declining experience of radiologists with the technique. Two imaging techniques--lung scintigraphy and helical CT--are the diagnostic methods of choice. A normal perfusion lung scan can safely exclude PE. However, 55-65% of patients have indeterminate lung scan results, making additional imaging tests necessary. Helical CT is increasingly being used as the first-line test because it can directly visualize a thromboembolus, it can suggest an alternative diagnosis, and there is excellent inter-observer agreement. A normal helical CT, followed by compression ultrasonography of the leg veins, can safely rule out PE. Finally, the safety of withholding anticoagulant treatment from patients with a normal multi-row detector helical CT as the sole test has not yet been demonstrated.

Journal Article↗
PubMed2004

Pentasaccharides in the prophylaxis and treatment of venous thromboembolism: a systematic review.

PURPOSE OF REVIEW: The aim of this review is to perform a critical analysis of all completed studies evaluating pentasaccharides-synthetically derived, selective inhibitors of activated factor X-in prophylaxis in major orthopedic surgery and the treatment of venous thromboembolism. RECENT FINDINGS: Venous thromboembolism is a disorder with considerable morbidity when left untreated. New antithrombotic agents have been developed that selectively inhibit components of the coagulation system, thereby avoiding the difficulties associated with current anticoagulants. The pentasaccharides fondaparinux and idraparinux are the first of a new class of synthetic selective inhibitors of activated factor X. Fondaparinux has been extensively investigated in two areas: orthopedic surgery and venous thromboembolism. It is clear from four thromboprophylaxis studies in major orthopedic surgery that fondaparinux is 50% more effective in reducing venous thromboembolism than enoxaparin. This superior efficacy led to an overall increase in major bleeding, which was however primarily due to more fondaparinux-treated patients with bleeding indexes of 2 or greater. The incidence of fatal bleeding, critical organ bleeding, or bleeding leading to reoperation did not differ significantly between the two groups. In the initial treatment of patients with proximal vein thrombosis and pulmonary embolism, fondaparinux was equally effective as low molecular weight heparins and unfractionated heparin, respectively, without a different incidence in major bleeding in fondaparinux and comparator heparin groups. SUMMARY: Fondaparinux, one of the first of a new class of synthetic selective factor Xa inhibitors, is overall 50% more effective in reducing venous thromboembolism than enoxaparin in major orthopedic surgery, with an overall 1% increased rate of major bleeding, when compared with enoxaparin. The incidence of fatal bleeding, critical organ bleeding, or bleeding leading to reoperation did not differ significantly between the two treatment groups. Fondaparinux is equally effective as low molecular weight heparins and unfractionated heparin in the initial treatment of patients with proximal vein thrombosis and pulmonary embolism, respectively. Finally, as with any new drug, fondaparinux should be used cautiously and only in patients who reflect the population of the clinical trials in which the drug was evaluated.

Clinical Trials as Topic↗
PubMedDate not supplied

The role of helical CT in the diagnosis of pulmonary embolism.

Diagnosing pulmonary embolism is problematic since clinical signs and symptoms of PE are aspecific. Diagnostic algorithms have been developed to rationalize the use of imaging tests in patients with a clinical suspicion of PE. An algorithm based on helical CT has gained widespread interest due to the availability of helical CT. However, these algorithms have often been implemented without appropriate assessment in clinical practice. If one is to implement helical CT as a first line diagnostic test for patients with clinically suspected pulmonary embolism it is important to note that a) CT is sensitive to larger emboli b) single slice technology may miss smaller subsegmental pulmonary emboli and c) outcome studies using a combination of normal single slice helical CT and normal compression ultrasonography rules out safely pulmonary embolism. In view of recent developments in multi row detector CT technology, large, well-designed studies are needed to determine the exact role of multi row helical CT in diagnosing PE.

Humans↗