Up to 90% of patients referred for ultrasonography with suspected deep venous thrombosis (DVT) of the leg do not have the disease.
To evaluate the safety and efficiency of using a clinical decision ...rule that includes a point-of-care d-dimer assay at initial presentation in primary care to exclude DVT.
A prospective management study.
Approximately 300 primary care practices in 3 regions of the Netherlands (Amsterdam, Maastricht, and Utrecht).
1028 consecutive patients with clinically suspected DVT.
Patients were managed on the basis of the result of the clinical decision rule, which included a d-dimer result. Patients with a score of 3 or less were not referred for ultrasonography and received no anticoagulant treatment; patients with a score of 4 or more were referred for ultrasonography.
The primary outcome was symptomatic, objectively confirmed, venous thromboembolism during 3-month follow-up.
The mean age of the 1028 study patients was 58 years, and 37% of patients were men. A valid score was obtained in 1002 patients (98%). In 500 patients (49%), with a score of 3 or less, 7 developed venous thromboembolism within 3 months (incidence, 1.4% 95% CI, 0.6% to 2.9%). A total of 502 patients (49%) had a score of 4 or more; 3 did not have ultrasonography. Ultrasonography showed DVT in 125 patients (25%), for an overall prevalence in evaluable patients of 13% (125 of 1002). Of the 374 patients who had normal ultrasonography results, 4 developed venous thromboembolism within 3 months (1.1% CI, 0.3% to 2.7%).
The study lacked a randomized design and relied on clinical follow-up to detect missed thrombotic disease.
A diagnostic management strategy in primary care by using a simple clinical decision rule and a point-of-care d-dimer assay reduces the need for referral to secondary care of patients with clinically suspected DVT by almost 50% and is associated with a low risk for subsequent venous thromboembolic events.
The Netherlands Organization for Scientific Research.
Recently, a diagnostic score was developed to safely exclude deep-vein thrombosis (DVT) in primary care. A large prospective study, in which general practitioners used this diagnostic score to decide ...which patients needed referral, revealed that the number of referrals for ultrasound measurements was reduced by almost 50%, at the cost of an acceptably low risk (1.4%, 95% confidence interval CI 0.6% to 2.9%) of venous thromboembolic events in non-referred patients. However, simple adjustments to the diagnostic score (so-called updating) might further improve the accuracy; i.e. reduce the proportion of missed diagnoses (safety) or increase the proportion of patients who do not need to be referred (efficiency). We applied two updating methods to determine whether adjusting the weights of the predictors or adding new predictors could further improve the accuracy of the diagnostic score. The weights of the predictors did not need to be adjusted, but inclusion of ‘history of DVT’ and ‘prolonged travelling’ significantly added predictive value (p-values 0.014 and 0.023, respectively). However, adding these predictors to the diagnostic score did not improve the safety and efficiency: at equal safety (1.4% missed diagnoses among the non-referred patients), the efficiency was lower (43.5%, 95% CI 40.4% to 46.6% compared to 49.4%, 95% CI 46.3% to 52.5%). The diagnostic score for excluding DVT in primary care has good accuracy in its original form and could not be improved by including additional predictors. This suggests that the original diagnostic score can be used to safely exclude clinically suspected DVT in primary care.
Abstract Purpose The association of spontaneous venous thromboembolism with occult malignancy is well established. Less clear is the incidence of subsequent cancer in patients with superficial ...thrombophlebitis. We wanted to determine the incidence of cancer after an episode of spontaneous superficial thrombophlebitis in a large general practice population. Methods The objective of this study was to assess the incidence of newly diagnosed malignancies in patients within 2 years after the diagnosis of a spontaneous episode of superficial thrombophlebitis and to compare this incidence with nonexposed matched control patients and the Dutch population. The patients and their controls were identified by a search in the electronic patient records of 5 primary health care centers in Amsterdam, the Netherlands. A standardized morbidity ratio was calculated using data of the Dutch cancer registry. Results A total number of 277 patients with superficial thrombophlebitis were identified, of which 250 patients had no cancer at study entry. In 5 of these 250 patients (2%; 95% confidence interval CI, 1%-5%), a new malignancy was diagnosed within 2 years after their superficial thrombophlebitis compared with 2% (95% CI, 1%-4%) in the control group. The standardized morbidity ratio was 1.1 (95% CI, 0.5-2.7). A recurrent episode of superficial thrombophlebitis was observed in 18 of the 250 patients, and in 1 patient cancer was diagnosed within 24 months after the first episode of superficial thrombophlebitis. Conclusion We conclude that a single episode of unprovoked superficial thrombophlebitis diagnosed by a family physician is not associated with an increased risk of subsequent cancer.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Abstract Purpose The Wells rule is widely used for clinical assessment of patients with suspected deep vein thrombosis (DVT), especially in the secondary care setting. Recently a new clinical ...decision rule for primary care patients (the primary care rule) has been proposed, because the Wells rule is not sufficient to rule out DVT in this setting. The objective was to compare the ability of both rules to safely rule out DVT and to efficiently reduce the number of referrals for leg ultrasound investigation that would result in a negative finding. Methods Family physicians collected data on 1,086 patients to calculate the scores for both decision rules before leg ultrasonography was performed. In all patients D-dimer (dimerized plasmin fragment D) testing was performed using a rapid point-of-care assay. Patients were stratified into risk categories defined by each rule and the D-dimer result. Outcomes were DVT (diagnosed by ultrasonography) and venous thromboembolic complications or death caused by a possible thromboembolic event during a 90-day follow-up period. We calculated the differences between the 2 rules in the number of missed diagnoses and the proportions of patients that needed ultrasound testing. Results Data from 1,002 eligible patients were used for this analysis. A venous thromboembolic event occurred during follow-up in 7 patients with a low score and negative D-dimer finding, both with the Wells rule (7 of 447; 1.6%; 95% confidence interval CI, 0.7%-3.3%) and the primary care rule (7 of 495; 1.4%; 95% CI, 0.6%-3.0%). Using the Wells rule, 447 patients (45%) would not need referral for further testing compared with 495 patients (49%) when using the primary care rule (McNemar P <.001). Conclusions In primary care, suspected DVT can safely be ruled out using either of the 2 rules in combination with a point-of-care D-dimer test. Both rules can reduce unnecessary referrals for compression ultrasonography by about 50%, though the primary care rule reduces it slightly more.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Launched in January 2015, the National Aeronautics and Space Administration (NASA) Soil Moisture Active Passive (SMAP) observatory was designed to provide frequent global mapping of high-resolution ...soil moisture and freeze-thaw state every two to three days using a radar and a radiometer operating at L-band frequencies. Despite a hardware mishap that rendered the radar inoperable shortly after launch, the radiometer continues to operate nominally, returning more than two years of science data that have helped to improve existing hydrological applications and foster new ones.
Beginning in late 2016 the SMAP project launched a suite of new data products with the objective of recovering some high-resolution observation capability loss resulting from the radar malfunction. Among these new data products are the SMAP Enhanced Passive Soil Moisture Product that was released in December 2016, followed by the SMAP/Sentinel-1 Active-Passive Soil Moisture Product in April 2017.
This article covers the development and assessment of the SMAP Level 2 Enhanced Passive Soil Moisture Product (L2_SM_P_E). The product distinguishes itself from the current SMAP Level 2 Passive Soil Moisture Product (L2_SM_P) in that the soil moisture retrieval is posted on a 9km grid instead of a 36km grid. This is made possible by first applying the Backus-Gilbert optimal interpolation technique to the antenna temperature (TA) data in the original SMAP Level 1B Brightness Temperature Product to take advantage of the overlapped radiometer footprints on orbit. The resulting interpolated TA data then go through various correction/calibration procedures to become the SMAP Level 1C Enhanced Brightness Temperature Product (L1C_TB_E). The L1C_TB_E product, posted on a 9km grid, is then used as the primary input to the current operational SMAP baseline soil moisture retrieval algorithm to produce L2_SM_P_E as the final output. Images of the new product reveal enhanced visual features that are not apparent in the standard product. Based on in situ data from core validation sites and sparse networks representing different seasons and biomes all over the world, comparisons between L2_SM_P_E and in situ data were performed for the duration of April 1, 2015–October 30, 2016. It was found that the performance of the enhanced 9km L2_SM_P_E is equivalent to that of the standard 36km L2_SM_P, attaining a retrieval uncertainty below 0.040m3/m3 unbiased root-mean-square error (ubRMSE) and a correlation coefficient above 0.800. This assessment also affirmed that the Single Channel Algorithm using the V-polarized TB channel (SCA-V) delivered the best retrieval performance among the various algorithms implemented for L2_SM_P_E, a result similar to a previous assessment for L2_SM_P.
•SMAP enhanced passive product validation covered diversified spatial scales.•Product retrieval accuracy is found to be below 0.040m3/m3 with good correlation.•Single channel algorithm using v-polarized TB channel showed the best performance.•Descending 6:00am retrieval is more accurate than ascending 6:00pm retrieval.•First project-level publication on this new product
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