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Burggraaf-van Delft JLI, la Roi-Teeuw HM, de Wit J, Klok FA, Cannegieter SC, Geersing GJ. [When to suspect pulmonary embolism: a balancing act]. Ned Tijdschr Geneeskd 2024; 168:D7788. [PMID: 38661169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Pulmonary embolism (PE) is a common disease, which can present with a variety of symptoms. Optimal use of diagnostics is challenging given the tight and delicate balance between underdiagnosis and over-testing or overdiagnosis. Diagnostic delay occurs in a substantial part of patients, and seems more common in those with known cardiopulmonary disease or non-specific signs and symptoms. At the other end of the spectrum, the amount of diagnostic imaging increases. Increased use of diagnostic imaging in general leads to more harmful exposures and might result in overtreatment, as may be the case in subsegmental PE. Correct use of clinical prediction rules reduces the need for diagnostic imaging while PE can still be ruled out safely. This clinical lesson describes three cases of PE and provides an overview of factors that contribute to underdiagnosis or overdiagnosis. We provide recommendations to improve our balancing act for this challenging disease.
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Affiliation(s)
| | - Hannah M la Roi-Teeuw
- Universitair Medisch Centrum Utrecht, afd. Huisartsgeneeskunde en verplegingswetenschap, Utrecht
| | - J de Wit
- Leids Universitair Medisch Centrum
| | - F A Klok
- Leids Universitair Medisch Centrum, afd. Interne Geneeskunde - Trombose en Hemostase, Leiden
| | - S C Cannegieter
- Leids Universitair Medisch Centrum, afd. Klinische epidemiologie en afd. Trombose en Hemostase, Leiden
| | - G J Geersing
- Universitair Medisch Centrum Utrecht, afd. Huisartsgeneeskunde en verplegingswetenschap, Utrecht
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2
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Goedegebuur J, Abbel D, Accassat S, Achterberg WP, Akbari A, Arfuch VM, Baddeley E, Bax JJ, Becker D, Bergmeijer B, Bertoletti L, Blom JW, Calvetti A, Cannegieter SC, Castro L, Chavannes NH, Coma-Auli N, Couffignal C, Edwards A, Edwards M, Enggaard H, Font C, Gava A, Geersing GJ, Geijteman ECT, Greenley S, Gregory C, Gussekloo J, Hoffmann I, Højen AA, van den Hout WB, Huisman MV, Jacobsen S, Jagosh J, Johnson MJ, Jørgensen L, Juffermans CCM, Kempers EK, Konstantinides S, Kroder AF, Kruip MJHA, Lafaie L, Langendoen JW, Larsen TB, Lifford K, van der Linden YM, Mahé I, Maiorana L, Maraveyas A, Martens ESL, Mayeur D, van Mens TE, Mohr K, Mooijaart SP, Murtagh FEM, Nelson A, Nielsen PB, Ording AG, Ørskov M, Pearson M, Poenou G, Portielje JEA, Raczkiewicz D, Rasmussen K, Trinks-Roerdink E, Schippers I, Seddon K, Sexton K, Sivell S, Skjøth F, Søgaard M, Szmit S, Trompet S, Vassal P, Visser C, van Vliet LM, Wilson E, Klok FA, Noble SIR. Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool. Thromb Res 2023; 228:54-60. [PMID: 37276718 DOI: 10.1016/j.thromres.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs. METHODS The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe. RESULTS SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life. CONCLUSIONS We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.
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Affiliation(s)
- J Goedegebuur
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Abbel
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - S Accassat
- Department of Vascular and Therapeutical Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France
| | - W P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A Akbari
- Swansea University, Swansea, Wales, United Kingdom
| | - V M Arfuch
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - E Baddeley
- Cardiff University, Cardiff, United Kingdom
| | - J J Bax
- Department of Medicine - Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Becker
- University Medical Center Mainz, Mainz, Germany
| | | | - L Bertoletti
- Department of Vascular and Therapeutical Medicine, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - J W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A Calvetti
- Assistance Publique-Hopitaux de Paris, Paris, France
| | - S C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - L Castro
- Vall d'Hebron Research Institute, Barcelona, Spain
| | - N H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - N Coma-Auli
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - C Couffignal
- Hôpital Louis Mourier, APHP, Assistance Publique-Hopitaux de Paris, Paris, France
| | - A Edwards
- Cardiff University, Cardiff, United Kingdom
| | - M Edwards
- Cardiff University, Cardiff, United Kingdom
| | - H Enggaard
- Aalborg University Hospital, Aalborg, Denmark
| | - C Font
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - A Gava
- Societa per l'Assistenza al Malato Oncologico Terminale Onlus (S.A.M.O.T.) Ragusa Onlus, Ragusa, Italy
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, the Netherlands
| | - E C T Geijteman
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - S Greenley
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - C Gregory
- Cardiff University, Cardiff, United Kingdom
| | - J Gussekloo
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - I Hoffmann
- Hôpital Bichat, APHP, Assistance Publique-Hopitaux de Paris, Paris, France
| | - A A Højen
- Aalborg University Hospital, Aalborg, Denmark
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S Jacobsen
- Aalborg University Hospital, Aalborg, Denmark
| | - J Jagosh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - M J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - L Jørgensen
- Aalborg University Hospital, Aalborg, Denmark
| | - C C M Juffermans
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - E K Kempers
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - A F Kroder
- Todaytomorrow, Rotterdam, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L Lafaie
- Department of Geriatrics and Gerontology, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | | | - T B Larsen
- Aalborg University Hospital, Aalborg, Denmark
| | - K Lifford
- Cardiff University, Cardiff, United Kingdom
| | - Y M van der Linden
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands; Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - I Mahé
- Department of Innovative Therapies in Haemostasis, Hôpital Louis Mourier, APHP, Paris, France
| | - L Maiorana
- Societa per l'Assistenza al Malato Oncologico Terminale Onlus (S.A.M.O.T.) Ragusa Onlus, Ragusa, Italy
| | - A Maraveyas
- Clinical Sciences Centre Hull York Medical School University of Hull, Hull, United Kingdom
| | - E S L Martens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - D Mayeur
- Centre Georges-François Leclerc, Dijon, France
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - K Mohr
- University Medical Center Mainz, Mainz, Germany
| | - S P Mooijaart
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - F E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - A Nelson
- Cardiff University, Cardiff, United Kingdom
| | - P B Nielsen
- Aalborg University Hospital, Aalborg, Denmark
| | - A G Ording
- Aalborg University Hospital, Aalborg, Denmark
| | - M Ørskov
- Aalborg University Hospital, Aalborg, Denmark
| | - M Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - G Poenou
- Department of Vascular and Therapeutical Medicine, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - J E A Portielje
- Department of Medicine - Internal medicine and Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Raczkiewicz
- Department of Medical Statistics, School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - K Rasmussen
- Aalborg University Hospital, Aalborg, Denmark
| | - E Trinks-Roerdink
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - K Seddon
- Wales Cancer Research Centre, Cardiff, UK
| | - K Sexton
- Cardiff University, Cardiff, United Kingdom
| | - S Sivell
- Cardiff University, Cardiff, United Kingdom
| | - F Skjøth
- Aalborg University Hospital, Aalborg, Denmark
| | - M Søgaard
- Aalborg University Hospital, Aalborg, Denmark
| | - S Szmit
- Department of Cardio-Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - S Trompet
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - P Vassal
- Department of Vascular and Therapeutical Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France
| | - C Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L M van Vliet
- Department of Health, Medicine and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - E Wilson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Trinks-Roerdink EM, Geersing GJ, Hemels M, van Gelder IC, Klok FA, van Smeden M, Rutten FH, van Doorn S. External validation and updating of prediction models of bleeding risk in patients with cancer receiving anticoagulants. Open Heart 2023; 10:openhrt-2023-002273. [PMID: 37055175 PMCID: PMC10106080 DOI: 10.1136/openhrt-2023-002273] [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: 02/02/2023] [Accepted: 03/27/2023] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVE Patients with cancer are at increased bleeding risk, and anticoagulants increase this risk even more. Yet, validated bleeding risk models for prediction of bleeding risk in patients with cancer are lacking. The aim of this study is to predict bleeding risk in anticoagulated patients with cancer. METHODS We performed a study using the routine healthcare database of the Julius General Practitioners' Network. Five bleeding risk models were selected for external validation. Patients with a new cancer episode during anticoagulant treatment or those initiating anticoagulation during active cancer were included. The outcome was the composite of major bleeding and clinically relevant non-major (CRNM) bleeding. Next, we internally validated an updated bleeding risk model accounting for the competing risk of death. RESULTS The validation cohort consisted of 1304 patients with cancer, mean age 74.0±10.9 years, 52.2% males. In total 215 (16.5%) patients developed a first major or CRNM bleeding during a mean follow-up of 1.5 years (incidence rate; 11.0 per 100 person-years (95% CI 9.6 to 12.5)). The c-statistics of all selected bleeding risk models were low, around 0.56. Internal validation of an updated model accounting for death as competing risk showed a slightly improved c-statistic of 0.61 (95% CI 0.54 to 0.70). On updating, only age and a history of bleeding appeared to contribute to the prediction of bleeding risk. CONCLUSIONS Existing bleeding risk models cannot accurately differentiate bleeding risk between patients. Future studies may use our updated model as a starting point for further development of bleeding risk models in patients with cancer.
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Affiliation(s)
- E M Trinks-Roerdink
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - G J Geersing
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - Mew Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - I C van Gelder
- Department of Cardiology, UMCG, Groningen, The Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, LUMC, Leiden, The Netherlands
| | - M van Smeden
- Department of Epidemiology & Health Economics, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - F H Rutten
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - S van Doorn
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
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Abstract
Background Diagnostic delay in patients with pulmonary embolism (PE) is typical, yet the proportion of patients with PE that experienced delay and for how many days is less well described, nor are determinants for such delay. Objectives This study aimed to assess the prevalence and extent of delay in diagnosing PE. Methods A systematic literature search was performed to identify articles reporting delays in diagnosing PE. The primary outcome was mean delay (in days) or a percentage of patients with diagnostic delay (defined as PE diagnosis more than seven days after symptom onset). The secondary outcome was determinants of delay. Random-effect meta-analyses were applied to calculate a pooled estimate for mean delay and to explore heterogeneity in subgroups. Results The literature search yielded 10,933 studies, of which 24 were included in the final analysis. The pooled estimate of the mean diagnostic delay based on 12 studies was 6.3 days (95% prediction interval 2.5 to 15.8). The percentage of patients having more than seven days of delay varied between 18% and 38%. All studies assessing the determinants of coughing (n = 3), chronic lung disease (n = 6) and heart failure (n = 8) found a positive association with diagnostic delay. Similarly, all studies assessing recent surgery (n = 7) and hypotension (n = 6), as well as most studies assessing chest pain (n = 8), found a negative association with diagnostic delay of PE. Conclusion Patients may have symptoms for almost one week before PE is diagnosed and in about a quarter of patients, the diagnostic delay is even longer.
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Affiliation(s)
- R van Maanen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - E M Trinks-Roerdink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - F H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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5
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Seelig J, Trinks-Roerdink EM, Chu G, Pisters R, Theunissen LJHJ, Trines SA, Pos L, Kirchhof CJHJ, de Jong SFAMS, den Hartog FR, van Alem AP, Polak PE, Tieleman RG, van der Voort PH, Lenderink T, Otten AM, de Jong JSSG, Gu YL, Luermans JGLM, Kruip MJHA, Timmer SAJ, de Vries TAC, Cate HT, Geersing GJ, Rutten FH, Huisman MV, Hemels MEW. Determinants of label non-adherence to non-vitamin K oral anticoagulants in patients with newly diagnosed atrial fibrillation. European Heart Journal Open 2022; 2:oeac022. [PMID: 35919339 PMCID: PMC9242063 DOI: 10.1093/ehjopen/oeac022] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/12/2022] [Accepted: 03/24/2022] [Indexed: 11/15/2022]
Abstract
Abstract
Aims
To evaluate the extent and determinants of off-label non-vitamin K oral anticoagulant (NOAC) dosing in newly diagnosed Dutch AF patients.
Methods and results
In the DUTCH-AF registry, patients with newly diagnosed AF (<6 months) are prospectively enrolled. Label adherence to NOAC dosing was assessed using the European Medicines Agency labelling. Factors associated with off-label dosing were explored by multivariable logistic regression analyses. From July 2018 to November 2020, 4500 patients were registered. The mean age was 69.6 ± 10.5 years, and 41.5% were female. Of the 3252 patients in which NOAC label adherence could be assessed, underdosing and overdosing were observed in 4.2% and 2.4%, respectively. In 2916 (89.7%) patients with a full-dose NOAC recommendation, 4.6% were underdosed, with a similar distribution between NOACs. Independent determinants (with 95% confidence interval) were higher age [odds ratio (OR): 1.01 per year, 1.01–1.02], lower renal function (OR: 0.96 per ml/min/1.73 m2, 0.92–0.98), lower weight (OR: 0.98 per kg, 0.97–1.00), active malignancy (OR: 2.46, 1.19–5.09), anaemia (OR: 1.73, 1.08–2.76), and concomitant use of antiplatelets (OR: 4.93, 2.57–9.46). In the 336 (10.3%) patients with a reduced dose NOAC recommendation, 22.9% were overdosed, most often with rivaroxaban. Independent determinants were lower age (OR: 0.92 per year, 0.88–0.96) and lower renal function (OR: 0.98 per ml/min/1.73 m2, 0.96–1.00).
Conclusion
In newly diagnosed Dutch AF patients, off-label dosing of NOACs was seen in only 6.6% of patients, most often underdosing. In this study, determinants of off-label dosing were age, renal function, weight, anaemia, active malignancy, and concomitant use of antiplatelets.
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Affiliation(s)
- J Seelig
- Department of Cardiology, Hospital Rijnstate, Rijnstate, Arnhem, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University , Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Centre , Nijmegen, the Netherlands
| | - EM Trinks-Roerdink
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University , Utrecht, the Netherlands
| | - G Chu
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre , Leiden, the Netherlands
| | - R Pisters
- Department of Cardiology, Hospital Rijnstate, Rijnstate, Arnhem, the Netherlands
| | - LJHJ Theunissen
- Department of Cardiology, Maxima Medical Centre , Eindhoven, the Netherlands
| | - SA Trines
- Willem Einthoven Centre for Cardiac Arrhythmia Research and Management, Department of Cardiology, Leiden University Medical Centre , Leiden, the Netherlands
| | - L Pos
- Department of Cardiology, Hospital Group Twente , Hengelo, the Netherlands
| | - CJHJ Kirchhof
- Department of Cardiology, Alrijne Hospital Leiderdorp , Leiderdorp, the Netherlands
| | - SFAMS de Jong
- Department of Cardiology, Elkerliek Hospital , Helmond, the Netherlands
| | - FR den Hartog
- Department of Cardiology, Hospital Gelderse Vallei , Ede, the Netherlands
| | - AP van Alem
- Department of Cardiology, Haaglanden Medical Centre , The Hague, the Netherlands
| | - PE Polak
- Department of Cardiology, St. Anna Hospital , Geldrop, the Netherlands
| | - RG Tieleman
- Department of Cardiology, Martini Hospital , Groningen, the Netherlands
| | - PH van der Voort
- Department of Cardiology, Catharina Hospital , Eindhoven, the Netherlands
| | - T Lenderink
- Department of Cardiology, Zuyderland Medical Centre , Heerlen, the Netherlands
| | - AM Otten
- Department of Cardiology, Gelre Hospitals , Apeldoorn-Zutphen, the Netherlands
| | - JSSG de Jong
- Department of Cardiology, onze lieve vrouwe gasthuis , Amsterdam, the Netherlands
| | - YL Gu
- Department of Cardiology, Hospital Nij Smellinghe, Nij Smellinghe , Drachten, the Netherlands
| | - JGLM Luermans
- Department of Cardiology, Maastricht University Medical Centre , Maastricht, the Netherlands
| | - MJHA Kruip
- Anticoagulation Clinic , Star-shl, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus University Medical Centre , Rotterdam, the Netherlands
| | - SAJ Timmer
- Department of Cardiology, Northwest Clinics , Alkmaar, the Netherlands
| | - TAC de Vries
- Department of Cardiology, Hospital Rijnstate, Rijnstate, Arnhem, the Netherlands
- Department of Cardiology, Amsterdam University Medical Centres location Academic Medical Centre , Amsterdam, the Netherlands
| | - H ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University , Maastricht, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre , Maastricht, the Netherlands
| | - GJ Geersing
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University , Utrecht, the Netherlands
| | - FH Rutten
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University , Utrecht, the Netherlands
| | - MV Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre , Leiden, the Netherlands
| | - MEW Hemels
- Department of Cardiology, Hospital Rijnstate, Rijnstate, Arnhem, the Netherlands
- Department of Cardiology, Radboud University Medical Centre , Nijmegen, the Netherlands
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6
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Khan F, Rahman A, Tritschler T, Carrier M, Kearon C, Weitz JI, Schulman S, Couturaud F, Becattini C, Agnelli G, Brighton T, Lensing AW, Pinede L, Parpia S, Geersing GJ, Takada T, Bradbury C, Andreozzi GM, Palareti G, Prandoni P, Buller HR, Mallick R, Hutton B, Thavorn K, Le Gal G, Rodger M, Fergusson DA. Long-term risk of major bleeding after discontinuing anticoagulation for unprovoked venous thromboembolism: a systematic review and meta-analysis. Thromb Haemost 2021; 122:1186-1197. [PMID: 34753191 DOI: 10.1055/a-1690-8728] [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] [Indexed: 10/19/2022]
Abstract
BACKGROUND The long-term risk of major bleeding after discontinuing anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. OBJECTIVES To determine the incidence of major bleeding up to 5 years after discontinuing anticoagulation for a first unprovoked VTE. METHODS We searched MEDLINE, EMBASE, and Cochrane CENTRAL (from inception to January 2021) to identify relevant randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding after discontinuing anticoagulation in patients with a first unprovoked VTE who had completed ≥3 months of initial treatment. Unpublished data on major bleeding events and person-years were obtained from authors of included studies to calculate study-level incidence rates. Random-effects meta-analysis was used to pool results across studies. RESULTS Of 1123 records identified by the search, 20 studies (17 RCTs) and 8740 patients were included in the analysis. During 13 011 person-years of follow-up after discontinuing anticoagulation, the pooled incidence of major bleeding (n=41) and fatal bleeding (n=7) per 100 person-years was 0.35 (95% confidence interval [CI], 0.20-0.54) and 0.09 (95% CI, 0.05-0.15). The 5-year cumulative incidence of major bleeding was of 1.0% (95% CI, 0.4%-2.4%). The case-fatality rate of major bleeding after discontinuing anticoagulation was 19.9% (95% CI, 10.6%-31.1%). CONCLUSIONS Patients with a first unprovoked VTE have a non-trivial risk of major bleeding once anticoagulants are discontinued. Estimates from this study can help clinicians counsel patients about the incremental risk of major bleeding with extended anticoagulation to guide decision making about treatment duration for unprovoked VTE.
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Affiliation(s)
- Faizan Khan
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Tobias Tritschler
- Department of General Internal Medicine, Bern University Hospital, Bern, Switzerland
| | - Marc Carrier
- Department of Medicine. University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada.,The Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
| | | | - Francis Couturaud
- Department of internal medicine and chest diseases, Brest University Hospital Centre, Brest, France
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Timothy Brighton
- Prince of Wales Hospital and Community Health Services, Randwick, Australia
| | | | - Laurent Pinede
- Infirmerie Protestante de Lyon, Caluire et Cuire, France
| | | | | | | | - Charlotte Bradbury
- University of Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland
| | | | | | | | - H R Buller
- Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kednapa Thavorn
- ICES @uOttawa, University of Ottawa Faculty of Medicine, Ottawa, Canada
| | - Grégoire Le Gal
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Canada.,Université de Bretagne Occidentale, Brest, France.,INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, Saint Etienne, France
| | - Marc Rodger
- Medicine, McGill University, Montreal, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada
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7
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van Royen FS, van Smeden M, Moons KGM, Rutten FH, Geersing GJ. Management of superficial venous thrombosis based on individual risk profiles: protocol for the development and validation of three prognostic prediction models in large primary care cohorts. Diagn Progn Res 2021; 5:15. [PMID: 34404480 PMCID: PMC8371853 DOI: 10.1186/s41512-021-00104-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/13/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Superficial venous thrombosis (SVT) is considered a benign thrombotic condition in most patients. However, it also can cause serious complications, such as clot progression to deep venous thrombosis (DVT) and pulmonary embolism (PE). Although most SVT patients are encountered in primary healthcare, studies on SVT nearly all were focused on patients seen in the hospital setting. This paper describes the protocol of the development and external validation of three prognostic prediction models for relevant clinical outcomes in SVT patients seen in primary care: (i) prolonged (painful) symptoms within 14 days since SVT diagnosis, (ii) for clot progression to DVT or PE within 45 days and (iii) for clot recurrence within 12 months. METHODS Data will be used from four primary care routine healthcare registries from both the Netherlands and the UK; one UK registry will be used for the development of the prediction models and the remaining three will be used as external validation cohorts. The study population will consist of patients ≥18 years with a diagnosis of SVT. Selection of SVT cases will be based on a combination of ICPC/READ/Snowmed coding and free text clinical symptoms. Predictors considered are sex, age, body mass index, clinical SVT characteristics, and co-morbidities including (history of any) cardiovascular disease, diabetes, autoimmune disease, malignancy, thrombophilia, pregnancy or puerperium and presence of varicose veins. The prediction models will be developed using multivariable logistic regression analysis techniques for models i and ii, and for model iii, a Cox proportional hazards model will be used. They will be validated by internal-external cross-validation as well as external validation. DISCUSSION There are currently no prediction models available for predicting the risk of serious complications for SVT patients presenting in primary care settings. We aim to develop and validate new prediction models that should help identify patients at highest risk for complications and to support clinical decision making for this understudied thrombo-embolic disorder. Challenges that we anticipate to encounter are mostly related to performing research in large, routine healthcare databases, such as patient selection, endpoint classification, data harmonisation, missing data and avoiding (predictor) measurement heterogeneity.
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Affiliation(s)
- F S van Royen
- Dept. General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.
| | - M van Smeden
- Dept. Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - K G M Moons
- Dept. Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - F H Rutten
- Dept. General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - G J Geersing
- Dept. General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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8
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Harskamp RE, de Meij MA, Cals JWL, Reesink HJ, Geersing GJ. [COVID-19: care at home or in hospital? Considerations in primary care]. Ned Tijdschr Geneeskd 2020; 164:D5045. [PMID: 32420705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
COVID-19 is a treacherous disease, in which infected patients who appear to fare well can deteriorate rapidly, mostly due to respiratory failure. For general practitioners (and other first-line responders), a clinical evaluation at any given time merely provides a snapshot of the patient's condition. Therefore, frequent monitoring is warranted in at-risk patients. However, there is no one-size-fits-all approach for monitoring, treatment and referral decisions. This is particularly the case in patients with advanced age. In this article, through the use of case examples, we aim to provide guidance when facing difficult management decisions in patients with (suspected) COVID-19.
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Affiliation(s)
- R E Harskamp
- Amsterdam UMC - locatie AMC, Afd. Huisartsgeneeskunde Amsterdam
| | - M A de Meij
- OLVG, afd. Ondersteunende en palliatieve zorg, Amsterdam
| | - J W L Cals
- Universiteit van Maastricht, Vakgroep Huisartsgeneeskunde, CAPHRI, Maastricht
| | - H J Reesink
- OLVG, afd. Ondersteunende en palliatieve zorg, Amsterdam
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9
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Mulder BA, Ten Berg J, Ten Cate H, van Es N, Hemels MEW, Kappelle LJ, Bearda Bakker HB, de Borst GJ, Drenth DJ, Geersing GJ, Rienstra M. Complex clinical scenarios with the use of direct oral anticoagulants in patients with atrial fibrillation: a multidisciplinary expert advisory board. Neth Heart J 2020; 28:504-513. [PMID: 32394366 PMCID: PMC7494714 DOI: 10.1007/s12471-020-01424-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The risk of developing atrial fibrillation (AF) and the risk of stroke both increase with advancing age. As such, many individuals have, or will develop, an indication for oral anticoagulation to reduce the risk of stroke. Currently, a large number of anticoagulants are available, including vitamin K antagonists, direct thrombin or factor Xa inhibitors (the last two also referred to as direct oral anticoagulants or DOACs), and different dosages are available. Of the DOACs, rivaroxaban can be obtained in the most different doses: 2.5 mg, 5 mg, 15 mg and 20 mg. Many patients develop co-morbidities and/or undergo procedures that may require the temporary combination of anticoagulation with antiplatelet therapy. In daily practice, clinicians encounter complex scenarios that are not always described in the treatment guidelines, and clear recommendations are lacking. Here, we report the outcomes of a multidisciplinary advisory board meeting, held in Utrecht (The Netherlands) on 3 June 2019, on decision making in complex clinical situations regarding the use of DOACs. The advisory board consisted of Dutch cardiovascular specialists: (interventional) cardiologist, internist, neurologist, vascular surgeon and general practitioners invited according to personal title and specific field of expertise.
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Affiliation(s)
- B A Mulder
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - J Ten Berg
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - H Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - N van Es
- Department of Internal Medicine, University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate, Arnhem, The Netherlands
| | - L J Kappelle
- Department of Neurology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - G J Geersing
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - M Rienstra
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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10
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van Doorn S, Rutten FH, Geersing GJ. [Towards 'the best DOAC'?]. Ned Tijdschr Geneeskd 2019; 163:D3524. [PMID: 30945829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Direct oral anticoagulants (DOACs) are increasingly being prescribed for stroke prevention in patients with atrial fibrillation or for treating venous thromboembolism. In this short overview, we provide some guidance on possible differences between available DOACs as well as a comparison with traditional treatments using vitamin K antagonists. In the absence of head-to-head trials comparing different DOACs with each other, this is predominantly based on indirect meta-analysis and observational evidence. Thus, this should be interpreted with caution and considered as expert consensus.
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Affiliation(s)
- Sander van Doorn
- UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijns Geneeskunde
| | - Frans H Rutten
- UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijns Geneeskunde
| | - G J Geersing
- UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijns Geneeskunde
- Contact: G.J. Geersing
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11
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Folkeringa RJ, Geersing GJ, Cate HT. [Frameworks for responsible anticoagulation care: a contribution to a collective view]. Ned Tijdschr Geneeskd 2018; 162:D2811. [PMID: 30570924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Until recently, vitamin K antagonists (VKAs) were the only form of anticoagulation for the prevention of thromboembolic complications in patients with atrial fibrillation or venous thromboembolisms. Various caregivers are involved in anticoagulation care. Criticism of the support by the thrombosis department focused mainly on the lack of guarantees regarding the interinstitutional anticoagulation chain of care. Initiatives have now been deployed to improve this support, as described in the national integrated anticoagulation care standard (LSKA, Landelijke Standaard Ketenzorg Antistolling) and the national primary care anticoagulation agreement (LESA, Landelijke Eerstelijns Samenwerkingsafspraken). However, rapidly increasing use of direct oral anticoagulants (DOACs) has dramatically altered anticoagulation care. Patients and caregivers are more often confronted with uncertainty about treatment coordination. This article aims to sketch frameworks for responsible anticoagulation care. We examine different topics, such as coordination, organisation of follow-up, availability for answering questions and switching from VKA to DOAC.
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Affiliation(s)
| | - G J Geersing
- Onze Lieve Vrouwe Gasthuis, Huisartspraktijk Buitenhof, Amsterdam
| | - Hugo Ten Cate
- Maastricht Universitair Medisch Centrum, Cardiovasculair Research Institute Maastricht (CARIM) en Trombose Expertise Centrum
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12
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Geersing GJ. [Cancer detection following unprovoked VTE; case history and physical examination are still of foremost importance]. Ned Tijdschr Geneeskd 2018; 162:D2401. [PMID: 29303099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The relation between cancer and thrombosis is well known. In fact, the presence of an occult malignancy in patients with unprovoked venous thromboembolism (VTE) is named after a famous 19th century French physician; it is called Trousseau's sign. In this commentary, I elaborate upon findings from a recent individual patient data meta-analysis on Trousseau's sign. This study demonstrated that extensive screening to unmask an occult malignancy in unprovoked VTE is no better than 'simple' history taking and physical examination, alongside age-specific and gender-specific national cancer screening e.g. for colorectal carcinoma, breast cancer and/or prostate cancer. Listening to what the patient has to say and a good physical examination remain the cornerstone for modern medicine, a finding Trousseau would no doubt have appreciated.
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Affiliation(s)
- G J Geersing
- UMC Utrecht, afd. Julius Centrum voor Gezondheidswetenschappen en Eerstelijns Geneeskunde, Utrecht
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13
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van Doorn S, Debray TPA, Kaasenbrood F, Hoes AW, Rutten FH, Moons KGM, Geersing GJ. Predictive performance of the CHA2DS2-VASc rule in atrial fibrillation: a systematic review and meta-analysis. J Thromb Haemost 2017; 15:1065-1077. [PMID: 28375552 DOI: 10.1111/jth.13690] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Indexed: 11/29/2022]
Abstract
Essentials The widely recommended CHA2DS2-VASc shows conflicting results in contemporary validation studies. We performed a systematic review and meta-analysis of 19 studies validating CHA2DS2-VASc. There was high heterogeneity in stroke risks for different CHA2DS2-VASc scores. This was not explained by differences between setting of care, or by performing meta-regression. SUMMARY Background The CHA2DS2-VASc decision rule is widely recommended for estimating stroke risk in patients with atrial fibrillation (AF), although validation studies show ambiguous and conflicting results. Objectives To: (i) review existing studies validating CHA2DS2-VASc in AF patients who are not (yet) anticoagulated; (ii) meta-analyze estimates of stroke risk per score; and (iii) explore sources of heterogeneity across the validation studies. Methods We performed a systematic literature review and random effects meta-analysis of studies externally validating CHA2DS2-VASc in AF patients not receiving anticoagulants. To explore between-study heterogeneity in stroke risk, we stratified studies to the clinical setting in which patient enrollment started, and performed meta-regression. Results In total, 19 studies were evaluated, with over two million person-years of follow-up. In studies recruiting AF patients in hospitals, stroke risks for scores of 0, 1 and 2 were 0.4% (approximate 95% prediction interval [PI] 0.2-3.2%), 1.2% (95% PI 0.1-3.8%), and 2.2% (95% PI 0.03-7.8%), respectively. These were consistently higher than those in studies recruiting patients from the open general population, with risks of 0.2% (95% PI 0.0-0.9%), 0.7% (95% PI 0.3-1.2%) and 1.5% (95% PI 0.4-3.3%) for scores of 0, 1, and 2, respectively. Heterogeneity, as reflected by the wide PIs, could not be fully explained by meta-regression. Conclusions Studies validating CHA2DS2-VASc show high heterogeneity in predicted stroke risks for different scores.
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Affiliation(s)
- S van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - T P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F Kaasenbrood
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - K G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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14
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van Doorn S, Brakenhoff TB, Moons KGM, Rutten FH, Hoes AW, Groenwold RHH, Geersing GJ. The effects of misclassification in routine healthcare databases on the accuracy of prognostic prediction models: a case study of the CHA2DS2-VASc score in atrial fibrillation. Diagn Progn Res 2017; 1:18. [PMID: 31093547 PMCID: PMC6460749 DOI: 10.1186/s41512-017-0018-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Research on prognostic prediction models frequently uses data from routine healthcare. However, potential misclassification of predictors when using such data may strongly affect the studied associations. There is no doubt that such misclassification could lead to the derivation of suboptimal prediction models. The extent to which misclassification affects the validation of existing prediction models is currently unclear.We aimed to quantify the amount of misclassification in routine care data and its effect on the validation of the existing risk prediction model. As an illustrative example, we validated the CHA2DS2-VASc prediction rule for predicting mortality in patients with atrial fibrillation (AF). METHODS In a prospective cohort in general practice in the Netherlands, we used computerized retrieved data from the electronic medical records of patients known with AF as index predictors. Additionally, manually collected data after scrutinizing all complete medical files were used as reference predictors. Comparing the index with the reference predictors, we assessed misclassification in individual predictors by calculating Cohen's kappas and other diagnostic test accuracy measures. Predictive performance was quantified by the c-statistic and by determining calibration of multivariable models. RESULTS In total, 2363 AF patients were included. After a median follow-up of 2.7 (IQR 2.3-3.0) years, 368 patients died (incidence rate 6.2 deaths per 100 person-years). Misclassification in individual predictors ranged from substantial (Cohen's kappa 0.56 for prior history of heart failure) to minor (kappa 0.90 for a history of type 2 diabetes). The overall model performance was not affected when using either index or reference predictors, with a c-statistic of 0.684 and 0.681, respectively, and similar calibration. CONCLUSION In a case study validating the CHA2DS2-VASc prediction model, we found substantial predictor misclassification in routine healthcare data with only limited effect on overall model performance. Our study should be repeated for other often applied prediction models to further evaluate the usefulness of routinely available healthcare data for validating prognostic models in the presence of predictor misclassification.
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Affiliation(s)
- S. van Doorn
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - T. B. Brakenhoff
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - K. G. M. Moons
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - F. H. Rutten
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - A. W. Hoes
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - R. H. H. Groenwold
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - G. J. Geersing
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
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15
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Lucassen WAM, Erkens PMG, Geersing GJ, Büller HR, Moons KGM, Stoffers HEJH, van Weert HCPM. Qualitative point-of-care D-dimer testing compared with quantitative D-dimer testing in excluding pulmonary embolism in primary care. J Thromb Haemost 2015; 13:1004-9. [PMID: 25845618 DOI: 10.1111/jth.12951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 03/29/2015] [Indexed: 08/31/2023]
Abstract
BACKGROUND General practitioners can safely exclude pulmonary embolism (PE) by using the Wells PE rule combined with D-dimer testing. OBJECTIVE To compare the accuracy of a strategy using the Wells rule combined with either a qualitative point-of-care (POC) D-dimer test performed in primary care or a quantitative laboratory-based D-dimer test. METHODS We used data from a prospective cohort study including 598 adults suspected of PE in primary care in the Netherlands. General practitioners scored the Wells rule and carried out a qualitative POC test. All patients were referred to hospital for reference testing. We obtained quantitative D-dimer test results as performed in hospital laboratories. The primary outcome was the prevalence of venous thromboembolism in low-risk patients. RESULTS Prevalence of PE was 12.2%. POC D-dimer test results were available in 582 patients (97%). Quantitative test results were available in 401 patients (67%). We imputed results in 197 patients. The quantitative test and POC test missed one (0.4%) and four patients (1.5%), respectively, with a negative strategy (Wells ≤ 4 points and D-dimer test negative) (P = 0.20). The POC test could exclude 23 more patients (4%) (P = 0.05). The sensitivity and specificity of the Wells rule combined with a POC test were 94.5% and 51.0% and, combined with a quantitative test, 98.6% and 47.2%, respectively. CONCLUSIONS Combined with the Wells PE rule, both tests are safe to use in excluding PE. The quantitative test seemed to be safer than the POC test, albeit not statistically significant. The specificity of the POC test was higher, resulting in more patients in whom PE could be excluded.
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Affiliation(s)
- W A M Lucassen
- Department of Family Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - P M G Erkens
- Department of Family Medicine, University of Maastricht, Maastricht, the Netherlands
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - K G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H E J H Stoffers
- Department of Family Medicine, University of Maastricht, Maastricht, the Netherlands
| | - H C P M van Weert
- Department of Family Medicine, Academic Medical Center, Amsterdam, the Netherlands
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16
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Geersing GJ, Zuithoff NPA, Kearon C, Anderson DR, ten Cate-Hoek AJ, Elf JL, Bates SM, Hoes AW, Kraaijenhagen RA, Oudega R, Schutgens REG, Stevens SM, Woller SC, Wells PS, Moons KGM. Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis. BMJ 2014; 348:g1340. [PMID: 24615063 PMCID: PMC3948465 DOI: 10.1136/bmj.g1340] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the accuracy of the Wells rule for excluding deep vein thrombosis and whether this accuracy applies to different subgroups of patients. DESIGN Meta-analysis of individual patient data. DATA SOURCES Authors of 13 studies (n = 10,002) provided their datasets, and these individual patient data were merged into one dataset. ELIGIBILITY CRITERIA Studies were eligible if they enrolled consecutive outpatients with suspected deep vein thrombosis, scored all variables of the Wells rule, and performed an appropriate reference standard. MAIN OUTCOME MEASURES Multilevel logistic regression models, including an interaction term for each subgroup, were used to estimate differences in predicted probabilities of deep vein thrombosis by the Wells rule. In addition, D-dimer testing was added to assess differences in the ability to exclude deep vein thrombosis using an unlikely score on the Wells rule combined with a negative D-dimer test result. RESULTS Overall, increasing scores on the Wells rule were associated with an increasing probability of having deep vein thrombosis. Estimated probabilities were almost twofold higher in patients with cancer, in patients with suspected recurrent events, and (to a lesser extent) in males. An unlikely score on the Wells rule (≤ 1) combined with a negative D-dimer test result was associated with an extremely low probability of deep vein thrombosis (1.2%, 95% confidence interval 0.7% to 1.8%). This combination occurred in 29% (95% confidence interval 20% to 40%) of patients. These findings were consistent in subgroups defined by type of D-dimer assay (quantitative or qualitative), sex, and care setting (primary or hospital care). For patients with cancer, the combination of an unlikely score on the Wells rule and a negative D-dimer test result occurred in only 9% of patients and was associated with a 2.2% probability of deep vein thrombosis being present. In patients with suspected recurrent events, only the modified Wells rule (adding one point for the previous event) is safe. CONCLUSION Combined with a negative D-dimer test result (both quantitative and qualitative), deep vein thrombosis can be excluded in patients with an unlikely score on the Wells rule. This finding is true for both sexes, as well as for patients presenting in primary and hospital care. In patients with cancer, the combination is neither safe nor efficient. For patients with suspected recurrent disease, one extra point should be added to the rule to enable a safe exclusion.
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Affiliation(s)
- G J Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands
| | - N P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands
| | - C Kearon
- Division of Haematology and Thromboembolism, Department of Medicine, McMaster University Hamilton, Hamilton, Canada
| | - D R Anderson
- Division of Haematology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - A J ten Cate-Hoek
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - J L Elf
- Vascular Center, Skane University Hospital, Malmö, Sweden
| | - S M Bates
- Division of Haematology and Thromboembolism, Department of Medicine, McMaster University Hamilton, Hamilton, Canada
| | - A W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands
| | - R A Kraaijenhagen
- Department of Medicine, Academic Medical Center Amsterdam, Netherlands
| | - R Oudega
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands
| | - R E G Schutgens
- Van Creveld Clinic, University Medical Center Utrecht, Utrecht, Netherlands
| | - S M Stevens
- Thrombosis Clinic, Intermountain Medical Center, Murray, UT, USA
| | - S C Woller
- Thrombosis Clinic, Intermountain Medical Center, Murray, UT, USA
| | - P S Wells
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Canada
| | - K G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands
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17
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Abstract
Risk prediction models can be used to estimate the probability of either having (diagnostic model) or developing a particular disease or outcome (prognostic model). In clinical practice, these models are used to inform patients and guide therapeutic management. Examples from the field of venous thrombo-embolism (VTE) include the Wells rule for patients suspected of deep venous thrombosis and pulmonary embolism, and more recently prediction rules to estimate the risk of recurrence after a first episode of unprovoked VTE. In this paper, the three phases that are recommended before a prediction model may be used in daily practice are described: development, validation, and impact assessment. In the development phase, the focus is on model development commonly using a multivariable logistic (diagnostic) or survival (prognostic) regression analysis. The performance of the developed model is expressed by discrimination, calibration and (re-) classification. In the validation phase, the developed model is tested in a new set of patients using these same performance measures. This is important, as model performance is commonly poorer in a new set of patients, e.g. due to case-mix or domain differences. Finally, in the impact phase the ability of a prediction model to actually guide patient management is evaluated. Whereas in the development and validation phase single cohort designs are preferred, this last phase asks for comparative designs, ideally randomized designs; therapeutic management and outcomes after using the prediction model is compared to a control group not using the model (e.g. usual care).
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Affiliation(s)
- J M T Hendriksen
- Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center (UMC), Utrecht, the Netherlands
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Schouten HJ, Geersing GJ, Koek HL, Zuithoff NPA, Janssen KJM, Douma RA, van Delden JJM, Moons KGM, Reitsma JB. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ 2013; 346:f2492. [PMID: 23645857 PMCID: PMC3643284 DOI: 10.1136/bmj.f2492] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To review the diagnostic accuracy of D-dimer testing in older patients (>50 years) with suspected venous thromboembolism, using conventional or age adjusted D-dimer cut-off values. DESIGN Systematic review and bivariate random effects meta-analysis. DATA SOURCES We searched Medline and Embase for studies published before 21 June 2012 and we contacted the authors of primary studies. STUDY SELECTION Primary studies that enrolled older patients with suspected venous thromboembolism in whom D-dimer testing, using both conventional (500 µg/L) and age adjusted (age × 10 µg/L) cut-off values, and reference testing were performed. For patients with a non-high clinical probability, 2 × 2 tables were reconstructed and stratified by age category and applied D-dimer cut-off level. RESULTS 13 cohorts including 12,497 patients with a non-high clinical probability were included in the meta-analysis. The specificity of the conventional cut-off value decreased with increasing age, from 57.6% (95% confidence interval 51.4% to 63.6%) in patients aged 51-60 years to 39.4% (33.5% to 45.6%) in those aged 61-70, 24.5% (20.0% to 29.7% in those aged 71-80, and 14.7% (11.3% to 18.6%) in those aged >80. Age adjusted cut-off values revealed higher specificities over all age categories: 62.3% (56.2% to 68.0%), 49.5% (43.2% to 55.8%), 44.2% (38.0% to 50.5%), and 35.2% (29.4% to 41.5%), respectively. Sensitivities of the age adjusted cut-off remained above 97% in all age categories. CONCLUSIONS The application of age adjusted cut-off values for D-dimer tests substantially increases specificity without modifying sensitivity, thereby improving the clinical utility of D-dimer testing in patients aged 50 or more with a non-high clinical probability.
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Affiliation(s)
- Henrike J Schouten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508GA Utrecht, Netherlands
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Bruins Slot MHE, Rutten FH, van der Heijden GJMG, Geersing GJ, Glatz JFC, Hoes AW. Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule. Fam Pract 2011; 28:323-8. [PMID: 21239470 DOI: 10.1093/fampra/cmq116] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians. OBJECTIVE We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP. METHODS In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly. RESULTS Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk. CONCLUSIONS The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.
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Affiliation(s)
- M H E Bruins Slot
- Department of General practice and Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands.
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Geersing GJ, Janssen KJM, Oudega R, Bax L, Hoes AW, Reitsma JB, Moons KGM. Excluding venous thromboembolism using point of care D-dimer tests in outpatients: a diagnostic meta-analysis. BMJ 2009; 339:b2990. [PMID: 19684102 PMCID: PMC2727580 DOI: 10.1136/bmj.b2990] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To review the evidence on the diagnostic accuracy of the currently available point of care D-dimer tests for excluding venous thromboembolism. DESIGN Systematic review of research on the accuracy of point of care D-dimer tests, using bivariate regression to examine sources of variation and to estimate sensitivity and specificity. DATA SOURCES Studies on the diagnostic accuracy of point of care D-dimer tests published between January 1995 and September 2008 and available in either Medline or Embase. Review methods The analysis included studies that compared point of care D-dimer tests with predefined reference criteria for venous thromboembolism, enrolled consecutive outpatients, and allowed for construction of a 2x2 table. RESULTS 23 studies (total number of patients 13 959, range in mean age 38-65 years, range of venous thromboembolism prevalence 4-51%) were included in the meta-analysis. The studies reported two qualitative point of care D-dimer tests (SimpliRED D-dimer (n=12) and Clearview Simplify D-dimer (n=7)) and two quantitative point of care D-dimer tests (Cardiac D-dimer (n=4) and Triage D-dimer (n=2)). Overall sensitivity ranged from 0.85 (95% confidence interval 0.78 to 0.90) to 0.96 (0.91 to 0.98) and overall specificity from 0.48 (0.33 to 0.62) to 0.74 (0.69 to 0.78). The two quantitative tests Cardiac D-dimer and Triage D-dimer scored most favourably. CONCLUSIONS In outpatients suspected of venous thromboembolism, point of care D-dimer tests can contribute important information and guide patient management, notably in low risk patients (that is, those patients with a low score on a clinical decision rule).
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Affiliation(s)
- G J Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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Heeren PA, van Westreenen HL, Geersing GJ, van Dullemen HM, Plukker JT. Influence of tumor characteristics on the accuracy of endoscopic ultrasonography in staging cancer of the esophagus and esophagogastric junction. Endoscopy 2004; 36:966-71. [PMID: 15520913 DOI: 10.1055/s-2004-825956] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic ultrasonography (EUS) is the most accurate method of assessing the locoregional extent of cancer of the esophagus and esophagogastric junction. The aim of this study was to evaluate the influence of tumor-related factors such as length and location on the accuracy of EUS in staging these tumors. PATIENTS AND METHODS Between January 1997 and September 2002, 280 consecutive patients underwent preoperative EUS for staging cancer of the esophagus and esophagogastric junction. The influence of histopathology, the presence of Barrett's dysplasia or stenosis, and the location and length of the primary tumor on the accuracy of EUS for T, N, and M staging were studied. RESULTS The overall accuracy rates of EUS for assessing the T, N, and M stages were 73 %, 80 %, and 78 %, respectively. The influence of the tumor's histopathology and the presence of Barrett's dysplasia or stenosis was minimal. The accuracy of EUS was greater in tumors 5 cm or less in size than in tumors larger than 5 cm (82 % vs. 52 % for the T stage, P < 0.05; 88 % vs. 59 % for the N stage, P < 0.05; and 92 % vs. 56 % for the M stage, P < 0.001). The low accuracy of T staging in larger tumors may be due to the exclusion of patients with local unresectability or distant metastases. EUS was also significantly better in esophageal tumors, particularly for identifying celiac trunk metastases (93 % vs. 63 %; P < 0.001). CONCLUSIONS The accuracy of EUS for staging esophageal cancer is lower in tumors larger than 5 cm and in esophagogastric junction tumors than in tumors 5 cm in size or less and in esophageal tumors. These findings should be considered when treatment decisions are being taken.
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Affiliation(s)
- P A Heeren
- Dept. of Surgical Oncology, Groningen University Hospital, Groningen, The Netherlands
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