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Kafeza M, Shalhoub J, Salooja N, Bingham L, Spagou K, Davies AH. A systematic review of clinical prediction scores for deep vein thrombosis. Phlebology 2016; 32:516-531. [PMID: 27885107 DOI: 10.1177/0268355516678729] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective Diagnosis of deep vein thrombosis remains a challenging problem. Various clinical prediction rules have been developed in order to improve diagnosis and decision making in relation to deep vein thrombosis. The purpose of this review is to summarise the available clinical scores and describe their applicability and limitations. Methods A systematic search of PubMed, MEDLINE and EMBASE databases was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance using the keywords: clinical score, clinical prediction rule, risk assessment, clinical probability, pretest probability, diagnostic score and medical Subject Heading terms: 'Venous Thromboembolism/diagnosis' OR 'Venous Thrombosis/diagnosis'. Both development and validation studies were eligible for inclusion. Results The search strategy returned a total of 2036 articles, of which 102 articles met a priori criteria for inclusion. Eight different diagnostic scores were identified. The development of these scores differs in respect of the population included (hospital inpatients, hospital outpatients or primary care patients), the exclusion criteria, the inclusion of distal deep vein thrombosis and the use of D-dimer. The reliability and applicability of the scores in the context of specific subgroups (inpatients, cancer patients, elderly patients and those with recurrent deep vein thrombosis) remains controversial. Conclusion Detailed knowledge of the development of the various clinical prediction scores for deep vein thrombosis is essential in understanding the power, generalisability and limitations of these clinical tools.
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Affiliation(s)
- Marina Kafeza
- 1 Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Joseph Shalhoub
- 1 Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,2 Imperial College Healthcare NHS Trust, London, UK
| | - Nina Salooja
- 2 Imperial College Healthcare NHS Trust, London, UK
| | - Lucy Bingham
- 2 Imperial College Healthcare NHS Trust, London, UK
| | - Konstantina Spagou
- 3 Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alun H Davies
- 1 Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,2 Imperial College Healthcare NHS Trust, London, UK
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Al-Hameed F, Al-Dorzi HM, Shamy A, Qadi A, Bakhsh E, Aboelnazar E, Abdelaal M, Al Khuwaitir T, Al-Moamary MS, Al-Hajjaj MS, Brozek J, Schünemann H, Mustafa R, Falavigna M. The Saudi clinical practice guideline for the diagnosis of the first deep venous thrombosis of the lower extremity. Ann Thorac Med 2015; 10:3-15. [PMID: 25593601 PMCID: PMC4286842 DOI: 10.4103/1817-1737.146849] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/16/2014] [Indexed: 11/04/2022] Open
Abstract
The diagnosis of deep venous thrombosis (DVT) may be challenging due to the inaccuracy of clinical assessment and diversity of diagnostic tests. On one hand, missed diagnosis may result in life-threatening conditions. On the other hand, unnecessary treatment may lead to serious complications. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia (KSA), an expert panel led by the Saudi Association for Venous Thrombo-Embolism (SAVTE; a subsidiary of the Saudi Thoracic Society) with the methodological support of the McMaster University Working Group, produced this clinical practice guideline to assist healthcare providers in evidence-based clinical decision-making for the diagnosis of a suspected first DVT of the lower extremity. Twenty-four questions were identified and corresponding recommendations were made following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. These recommendations included assessing the clinical probability of DVT using Wells criteria before requesting any test and undergoing a sequential diagnostic evaluation, mainly using highly sensitive D-dimer by enzyme-linked immunosorbent assay (ELISA) and compression ultrasound. Although venography is the reference standard test for the diagnosis of DVT, its use was not recommended.
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Affiliation(s)
- Fahad Al-Hameed
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs Jeddah, Saudi Arabia
| | - Hasan M Al-Dorzi
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs Jeddah, Saudi Arabia
| | - Abdulrahman Shamy
- Department of Radiology, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Abdulelah Qadi
- Department of Medicine, King Fahad General Hospital, Jeddah, Saudi Arabia
| | - Ebtisam Bakhsh
- Department of Medicine, King Fahad Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Essam Aboelnazar
- Department of Surgery, Um Al Qura University, Makkah, Saudi Arabia
| | - Mohamad Abdelaal
- Department of Pathology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Tarig Al Khuwaitir
- Department of Medicine, King Fahad General Hospital, Jeddah, Saudi Arabia
| | - Mohamed S Al-Moamary
- Department of Medicine, King Abdulaziz Medical City, Riyadh, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia
| | | | - Jan Brozek
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada ; Department of Medicine, McMaster University, Hamilton, Canada
| | - Holger Schünemann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada ; Department of Medicine, McMaster University, Hamilton, Canada
| | - Reem Mustafa
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada ; Department of Internal Medicine and Nephrology, University of Missouri-Kansas City, Kansas City, Missouri, United States
| | - Maicon Falavigna
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada ; Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
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Tan Y, Christensen M. Pulmonary embolism in the emergency department: a Singaporean nursing case review. Intensive Crit Care Nurs 2012; 29:48-56. [PMID: 22622095 DOI: 10.1016/j.iccn.2012.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 03/28/2012] [Accepted: 04/04/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The presentation of pulmonary embolism to the emergency department (ED) can prove challenging because of the myriad of potential disease processes that mimic its signs and symptoms. The incidence of pulmonary embolism and indeed the mortality associated with it is relatively high. Early diagnosis and treatment is crucial in off-setting the potential deleterious effects associated with this condition. The aim of this article is to present a nursing case review of a patient presenting to the ED with a diagnosis of pulmonary embolism. METHOD We chose to use a case review to highlight the nursing and medical care that was provided for a patient who presented to the emergency department acutely with dyspnoea, chest pain and pyrexia. The use of case reviews are useful in reporting unusual or rare cases and this format is typically seen more in medicine than in nursing. They can naturally take one of two formats-a single case report or a series of case reports; in this case we opted to report on a single case. DISCUSSION The gentleman in question was an ambulance admission to the ED with a three day history of chest pain, shortness of breath and one episode of syncope which brought him to the ED. Over the course of his admission a variety of treatment modalities were used successfully to alleviate the problem. More notable from a nursing perspective was the use of diagnostic tools as an interpretation to guide his care and provide a platform from which a deeper understanding and appreciation of the intricacies the critically ill patient often presents. CONCLUSION We found the use of case review very enlightening in understanding the disease process and the decision-making that accompanies this. Whilst our patient was successfully rehabilitated home, we learnt a lot from the experience which has been most beneficial in supporting our understanding of pulmonary embolism.
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Affiliation(s)
- Yvonne Tan
- Emergency Department, Tan Tock Seng Hospital, Singapore
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Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e351S-e418S. [PMID: 22315267 DOI: 10.1378/chest.11-2299] [Citation(s) in RCA: 404] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Objective testing for DVT is crucial because clinical assessment alone is unreliable and the consequences of misdiagnosis are serious. This guideline focuses on the identification of optimal strategies for the diagnosis of DVT in ambulatory adults. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that clinical assessment of pretest probability of DVT, rather than performing the same tests in all patients, should guide the diagnostic process for a first lower extremity DVT (Grade 2B). In patients with a low pretest probability of first lower extremity DVT, we recommend initial testing with D-dimer or ultrasound (US) of the proximal veins over no diagnostic testing (Grade 1B), venography (Grade 1B), or whole-leg US (Grade 2B). In patients with moderate pretest probability, we recommend initial testing with a highly sensitive D-dimer, proximal compression US, or whole-leg US rather than no testing (Grade 1B) or venography (Grade 1B). In patients with a high pretest probability, we recommend proximal compression or whole-leg US over no testing (Grade 1B) or venography (Grade 1B). CONCLUSIONS Favored strategies for diagnosis of first DVT combine use of pretest probability assessment, D-dimer, and US. There is lower-quality evidence available to guide diagnosis of recurrent DVT, upper extremity DVT, and DVT during pregnancy.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
| | - Roman Jaeschke
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Murray, UT
| | - Steven Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew D Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Clive Kearon
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Holger J Schunemann
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Stephen G Pauker
- Department of Medicine, Tufts New England Medical Center, Boston, MA
| | | | - Gordon H Guyatt
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Melby V, Gillespie M, Martin S. Emergency nurse practitioners: the views of patients and hospital staff at a major acute trust in the UK. J Clin Nurs 2010; 20:236-46. [DOI: 10.1111/j.1365-2702.2010.03333.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Siau K, Davies A, Laversuch CJ. Is there still a role for computerized strain gauge plethysmography in the assessment of patients with suspected deep vein thrombosis? QJM 2010; 103:259-64. [PMID: 20185536 DOI: 10.1093/qjmed/hcq007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Although deep vein thromboses (DVTs) are common, only a minority of patients referred with suspected DVT will have the condition. Various strategies exist to allow rapid and safe discharge of low-risk patients, thus precluding the need for imaging. AIMS AND OBJECTIVES We aimed to investigate the accuracy of clinical risk assessment, D-Dimer analysis, computerized strain gauge plethysmography (CSGP) or a combination of the above in the assessment of outpatients with suspected DVT. METHODS We performed a prospective cohort study on outpatients referred with suspected DVT to our medical assessment unit. Patients systematically underwent clinical risk assessment, D-Dimer analysis, CSGP and imaging with ultrasonography and/or venography. RESULTS One hundred and eighty patients with suspected DVT were included in the analysis. Using a threshold of 0.6 mg/l, D-Dimer had a sensitivity and negative predictive value (NPV) of 100% for detecting DVT. Incorporating D-Dimer analysis with clinical risk assessment increased the specificity of the test. The sensitivity and NPV of CSGP were poor at 52.8 and 86.7%, respectively. Incorporating CSGP with D-Dimer did not influence decision making. Although the sensitivity of CSGP was higher for above knee (73.7%) than below knee DVT (29.4%), neither was sufficient for use as a screening tool. CONCLUSION Our study did not support the role of CSGP either as a stand-alone screening tool or in conjunction with clinical risk scoring. As the evidence base for CSGP is conflicting, its accuracy should first be assessed before being incorporated into hospital algorithms as a DVT exclusion tool. However, our results support the current practice for D-Dimer use either alone or in conjunction with clinical assessment tool in the assessment of lower limb DVT.
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Affiliation(s)
- K Siau
- Department of Medicine, Great Western Hospital, Swindon SN3 6BB, UK.
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Otero Candelera R, Elías Hernández T, González Vergara D. Tratamiento domiciliario de la enfermedad tromboembólica venosa (ETV). Med Clin (Barc) 2009; 133:272-6. [DOI: 10.1016/j.medcli.2008.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 11/26/2008] [Indexed: 10/20/2022]
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Buchan JC, Ashiq A, Kitson N, Dixon J, Cassels-Brown A, Bradbury JA. Nurse specialist treatment of eye emergencies: five year follow up study of quality and effectiveness. Int Emerg Nurs 2009; 17:149-54. [PMID: 19577201 DOI: 10.1016/j.ienj.2008.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 10/30/2008] [Accepted: 12/04/2008] [Indexed: 11/28/2022]
Abstract
The role of specialist nurses in triage, diagnosis and management of emergency eye conditions is well established, and encouraging reports of the safety and effectiveness of such services have been published. Specialist nurses in an emergency eye clinic in the UK seeing >7000 patients per year had been found at initial evaluation to treat 22% of the 1976 patients seen over a three month period without referring on to an ophthalmologist. A repeat of this evaluation five years later found this proportion had dropped to 17% (chi(2) = 16.7, p<0.01). In addition, the initial evaluation had found no incident of any patient having been treated and discharged by the specialist nurses returning to the department due to incorrect diagnosis or mismanagement. By contrast, from the sample 5 years later, 3 patients were identified who returned to the department due to possible misdiagnosis or sub-optimal management. We suggest that provision must be made for continuing professional development of nurses in this type of extended role, and the commitment to ongoing education should be backed up by a system of monitoring and critical incident reporting to facilitate skill maintenance and the life long learning process for specialist nurses.
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Affiliation(s)
- John Cameron Buchan
- Department of Ophthalmology, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom.
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