General practitioner use of D-dimer in suspected venous thromboembolism: historical cohort study in one geographical region in the Netherlands

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.

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Stroke masquerading as cardiac arrest: the artery of Percheron

BMJ Case Reports ◽

10.1136/bcr-2020-238681 ◽

2021 ◽

Vol 14 (1) ◽

pp. e238681

Author(s):

Megan Quetsch ◽

Sureshkumar Nagiah ◽

Stephen Hedger

Keyword(s):

Cardiac Arrest ◽

Clinical Assessment ◽

Altered Consciousness ◽

Cognitive Changes ◽

Consciousness Level ◽

Artery Of Percheron ◽

Conscious Level ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

The artery of Percheron (AOP) is a rare arterial variant of the thalamic blood supply. Due to the densely packed collection of nuclei it supplies, an infarction of the AOP can be devastating. Here we highlight a patient who had an AOP stroke in the community, which was initially managed as cardiac arrest. AOP strokes most often present with vague symptoms such as reduced conscious level, cognitive changes and confusion without obvious focal neurology, and therefore are often missed at the initial clinical assessment. This case highlights the importance of recognising an AOP stroke as a cause of otherwise unexplained altered consciousness level and the use of MRI early in the diagnostic work-up.

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Ruling out deep venous thrombosis in primary care

Thrombosis and Haemostasis ◽

10.1160/th04-12-0829 ◽

2005 ◽

Vol 94 (07) ◽

pp. 200-205 ◽

Cited By ~ 64

Author(s):

Karel G. M. Moons ◽

Arno W. Hoes ◽

Ruud Oudega

Keyword(s):

Primary Care ◽

Health Care ◽

Decision Rule ◽

Cross Sectional ◽

Diagnostic Decision ◽

Number Of Patients ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up ◽

D Dimer

SummaryIn primary care, the physician has to decide which patients have to be referred for further diagnostic work-up. At present, only in 20% to 30% of the referred patients the diagnosis DVT is confirmed. This puts a burden on both patients and health care budgets. The question arises whether the diagnostic work-up and referral of patients suspected of DVT in primary care could be more efficient. A simple diagnostic decision rule developed in primary care is required to safely exclude the presence of DVT in patients suspected of DVT, without the need for referral. In a cross-sectional study, we investigated the data of 1295 consecutive patients consulting their primary care physician with symptoms suggestive of DVT, to develop and validate a simple diagnostic decision rule to safely exclude the presence of DVT. Independent diagnostic indicators of the presence of DVT were male gender, oral contraceptive use, presence of malignancy, recent surgery, absence of leg trauma, vein distension, calf difference and D-dimer test result. Application of this rule could reduce the number of referrals by at least 23% while only 0·7% of the patients with a DVT would not be referred. We conclude that by using eight simple diagnostic indicators from patient history, physical examination and the result of D-dimer testing, it is possible to safely rule out DVT in a large number of patients in primary care, reducing unnecessary patient burden and health care costs.

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Role of colonoscopy in the diagnostic work-up of bowel endometriosis

World Journal of Gastroenterology ◽

10.3748/wjg.v21.i16.4997 ◽

2015 ◽

Vol 21 (16) ◽

pp. 4997 ◽

Cited By ~ 10

Author(s):

Marco Milone

Keyword(s):

Bowel Endometriosis ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

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Acute liver failure

Challenging Concepts in Paediatric Critical Care ◽

10.1093/med/9780198794592.003.0008 ◽

2020 ◽

pp. 89-104

Author(s):

Andrew Jones ◽

Akash Deep

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Organ Support ◽

Fulminant Liver Failure ◽

Management Of Complications ◽

Diagnostic Work ◽

Work Up ◽

Paediatric Critical Care ◽

Diagnostic Work Up

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.

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