ObjectivesTo investigate how many general practitioner (GP)-referred venous thromboembolic events (VTEs) are diagnosed during 1 year in one geographical region and to investigate the (urgent) referral pathway of VTE diagnoses, including the role of laboratory D-dimer testing.DesignHistorical cohort study.SettingGP patients of 47 general practices in a demarcated geographical region of 161 503 inhabitants in the Netherlands.ParticipantsWe analysed all 895 primary care patients in whom either the GP determined a D-dimer value or who had a diagnostic work-up for suspected VTE in a non-academic hospital during 2015.Primary and secondary outcome measuresThe primary outcomes of this study were the total number of VTEs per year and the diagnostic pathways—including the role of GP determined D-dimer testing—of patients urgently referred to secondary care for suspected VTE. Additionally, we explored the use of an age-adjusted D-dimer cut-off.ResultsThe annual VTE incidence was 0.9 per 1000 inhabitants. GPs annually ordered 5.1 D-dimer tests per 1000 inhabitants. Of 470 urgently GP-referred patients, 31.3% had a VTE. Of those urgently referred based on clinical assessment only (without D-dimer testing), 73.8% (96/130) had a VTE; based on clinical assessment and laboratory D-dimer testing yielded 15.0% (51/340) VTE. Applying age-adjusted D-dimer cut-offs to all patients aged 50 years or older resulted in a reduction of positive D-dimer results from 97.9% to 79.4%, without missing any VTE.ConclusionsAlthough D-dimer testing contributes to the diagnostic work-up of VTE, GPs have a high detection rate for VTE in patients who they urgently refer to secondary care based on clinical assessment only.
The work-up and management of patients with acute liver failure in paediatric critical care are often challenging. This chapter takes the readers through definitions, grading of severity, and diagnostic work-up of acute liver failure in children. General principles underlying the management of acute liver failure, including immediate resuscitation and retrieval; organ support, including renal replacement therapy; and the management of complications, including bleeding, are discussed. In particular, this chapter focuses on neuromonitoring and neuroprotection strategies in children with hepatic encephalopathy as a complication. The role of liver transplantation in fulminant liver failure and a brief overview of complications are also discussed.
The optimal management of hypertensive patients requires accurate evaluation of cardiovascular risk factors and co-morbidities. The therapeutic approach to hypertension may, in fact, be significantly different according to associated conditions. Among them, the presence of coronary heart disease, heart failure, cerebrovascular disease, chronic kidney disease, and specific age groups deserve special attention. In this chapter, the initial diagnostic work-up, the thresholds and targets for treatment, and the preferred drugs in specific conditions/co-morbidities will be briefly discussed.
General practitioner use of D-dimer in suspected venous thromboembolism: historical cohort study in one geographical region in the Netherlands