scholarly journals A Review of Inappropriate D-Dimer Ordering at a Canadian Tertiary Care Centre

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 5778-5778
Author(s):  
Monika Oliver ◽  
Mohammad Karkhaneh ◽  
Jacqueline Karathra ◽  
Mariam Goubran ◽  
Cynthia M. Wu
Keyword(s):  
Tertiary Care ◽  
Retrospective Chart Review ◽  
High Sensitivity ◽  
Pulmonary Angiography ◽  
Tertiary Care Centre ◽  
University Of Alberta ◽  
Vein Thrombosis ◽  
Wells Score ◽  
Test Probability ◽  
D Dimer

Introduction The D-dimer has been validated for use in the diagnosis of venous thromboembolism (VTE). The high sensitivity of the assay allows for safe exclusion of VTE in patients with low pre-test probability. Pre-test probability scores such as the Wells score for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) have been established to help guide physicians on when to order a D-dimer in patients with suspected VTE. We sought to explore the landscape of D-dimer ordering at our institution and what clinical circumstances trigger D-dimer ordering. Methods We conducted a retrospective chart review of 237 patients in whom a D-dimer has been ordered over a 3-month period from January to March 2018 at the University of Alberta Hospital, Edmonton, Canada. Charts were reviewed for the following parameters: Specialty of ordering physician, apparent indication for ordering, patient risk factors for VTE and evidence of pre-test probability calculation. If no pre-test probability was recorded, we retrospectively calculated Wells DVT or PE scores depending on the apparent indication. We then reviewed subsequent investigations thought to be influenced by interpretation of the D-dimer. These included ventilation/perfusion scans (V/Q scan), ultrasound Doppler studies and Computerized Tomography pulmonary angiography (CTPA). Results Of the 237 charts reviewed, 84.4% of D-dimers were ordered in the Emergency Department while only 14.3% were drawn on admitted patients. Sixty-nine percent of the patients were identified as having at least one risk factor for the development of VTE with prolonged hospitalization (5.5%) and personal history of VTE (4.2%) being the most common. Indication for ordering was suspected VTE in 76.3% of patients while the indications was unclear in 12.7% of patients. An initial pre-test probability score was recorded for only 3 patients. Of the D-dimers ordered, 47.7% were above the upper limit of normal (≥ 0.50 mg/L) and considered a positive test. Forty five CTPAs and 27 V/Q scans were performed with only 4 (1.69%) and 6 (2.53%) confirming the presence of pulmonary emboli, respectively. Doppler ultrasounds were performed on 18 patients (7.6%) with only one confirming a DVT. Conclusions Our data shows that the majority of physicians at our institution fail to utilize pre-test probability tools prior to ordering a D-dimer. This leads to unnecessary costs, overuse of imaging studies and results in low rates of positive scans. Disclosures Wu: Bayer: Other: Local PI for trial ; BMS-Pfizer: Other: Local PI for trial ; Daiichi-Sankyo: Other: Local PI for trial .

A Retrospective Review of the Appropriateness of D-Dimer Ordering and Interpretation Using Wells' Clinical Probability Criteria

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 28-29
Author(s):  
Monika Oliver ◽  
Mariam Goubran ◽  
Jacqueline Karathra ◽  
Mohammad Karkhaneh ◽  
Cynthia M. Wu
Keyword(s):  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Improve Patient Care ◽  
High Sensitivity ◽  
Advisory Board ◽  
Multivariable Logistic Regression Analysis ◽  
Prolonged Contact ◽  
Wells Score ◽  
Test Probability ◽  
D Dimer

Introduction The D-dimer has been validated in diagnostic venous thromboembolism (VTE) algorithms. The high sensitivity of the assay allows for safe exclusion of VTE in patients with low clinical pre-test probability and a negative D-dimer. The Wells score for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) are validated pre-test probability tools which help guide physicians on when to order a D-dimer in patients with suspected VTE. However, we suspect these scoring tools are often under-utilized by physicians leading to inappropriate D-dimer ordering and subsequent interventions. We sought to explore the landscape of D-dimer ordering at our institution. Methods We conducted a retrospective chart review of 482 patients in whom a D-dimer had been ordered over a 3-month period at the University of Alberta Hospital, a tertiary care teaching hospital in Edmonton, Canada. Charts were reviewed for patient demographics, specialty of ordering physician, apparent indication for ordering, patient risk factors for VTE and evidence of a pre-test probability (PTP) calculation. WIf no PTP score was documented, we retrospectively calculated Wells DVT or PE scores. VTE was deemed likely with a calculated Wells score for DVT ≧2 or Wells score for PE >4. In the case of high PTP for PE, patients should go directly to imaging and a D-dimer should not be performed. A cut off of ≥ 0.50 mg/L was deemed a positive D-dimer (STA-LIATEST). We also reviewed subsequent investigations thought to be influenced by interpretation of the D-dimer including: ventilation/perfusion (V/Q) and pulmonary angiography (CTPA) scans, and upper and lower extremity doppler ultrasound studies. We then used multivariable logistic regression analysis to evaluate the proportion of patients who received imaging despite a low PTP and negative D-dimer. Results Seventy eight percent of D-dimers were ordered by Emergency physicians while 15.3% were drawn on admitted patients, and 5.8% in the outpatient setting. The indication for ordering was unknown in 87 (17.5%) of cases. Pre-test probability scores were documented in only 8 (1.6%) of cases. All of those documented were the Wells PE score. When Wells DVT and PE scores were calculated retrospectively, 30.0% and 17.1% (87 cases) were deemed 'likely' for VTE, respectively. However, imaging was performed in 172 cases (34.6%), including in 36 cases despite a negative D-dimer result and low PTP. In contrast, 68 cases (17.2%) had a D-dimer performed with a high Wells PTP for PE despite the recommendation to proceed directly to imaging. VTE (either DVT or PE) was confirmed by imaging in 32 (18.6%) of cases, the majority (53.1%) had a high retrospective PTP. Conclusions Inappropriate ordering and interpretation of D-dimers remains a significant problem despite the implementation of clinical guidelines and pre-test probability algorithms, namely the Wells score for DVT and PE meant to guide physicians. This leads to unnecessary cost, radiation exposure, and prolonged contact with the health care system for patients. This suggests the need for quality improvement initiatives which draw physician's attention to pre-test probability tools which can curbing subsequent inappropriate investigations and improve patient care. Disclosures Wu: Servier: Other: advisory board; BMS-pfizer: Honoraria, Other: advisory board; leo pharma: Other: advisory board; Pfizer: Honoraria.

Performance of five D-dimer assays for the exclusion of symptomatic distal leg vein thrombosis

2012 ◽  
Vol 107 (02) ◽  
pp. 369-378 ◽  
Author(s):  
Jan Schwonberg ◽  
Carola Hecking ◽  
Marc Schindewolf ◽  
Dimitrios Zgouras ◽  
Susanne Lehmeyer ◽  
...  
Keyword(s):  
High Sensitivity ◽  
Diagnostic Value ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Wells Score ◽  
Deep Vein ◽  
Test Result ◽  
D Dimer ◽  
Rule Out ◽  
Compression Ultrasonography

SummaryThe diagnostic value of D-dimer (DD) in the exclusion of proximal deep-vein thrombosis (DVT) is well-established but is less well-known in the exclusion of distal (infrapopliteal) DVT. Therefore, we evaluated the diagnostic abilities of five DD assays (Vidas-DD, Liatest-DD, HemosIL-DD, HemosIL-DDHS, Innovance-DD) for excluding symptomatic proximal and distal leg DVT. A total of 243 outpatients whose symptoms were suggestive of DVT received complete compression ultrasonography (cCUS) of the symptomatic leg(s). The clinical probability of DVT (PTP) was assessed by Wells score. Thirty-eight proximal and 31 distal DVTs (17 tibial/fibular DVTs, 14 muscle DVTs) were diagnosed by cCUS. Although all assays showed high sensitivity for proximal DVT (range 97–100%), the sensitivity was poor for distal DVT (range 78–93%). None of the assays were individually able to rule out all DVTs as a stand-alone test (negative predictive value [NPV] 91–96%). However, a negative DD test result combined with a low PTP exhibited a NPV of 100% for all DVTs (including proximal, tibial/fibular, and muscle DVTs) with the HemosIL-DDHS and Innovance-DD. All proximal and tibial/fibular DVTs, but not all muscle DVTs, could be ruled out with this strategy using the Liatest-DD and Vidas-DD. The HemosIL-DD could not exclude distal leg DVT, even in combination with a low PTP. The combination of a negative DD with a low PTP showed a specificity of 32–35% for all DVTs. In conclusion, our study shows that when used in conjunction with a low PTP some DD assays are useful tools for the exclusion of distal leg DVT.

scholarly journals Advances in the Diagnosis of Venous Thromboembolism: A Literature Review

Diagnostics ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. 365 ◽  
Author(s):  
Harish Patel ◽  
Haozhe Sun ◽  
Ali N. Hussain ◽  
Trupti Vakde
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Valsalva Maneuver ◽  
Imaging Modality ◽  
Diagnostic Algorithm ◽  
Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Compression Ultrasound ◽  
Test Probability ◽  
D Dimer

The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.

scholarly journals Safety of D-Dimer As a Stand-Alone Test for the Exclusion of Deep Vein Thrombosis Compared to Other Strategies

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 2517-2517
Author(s):  
Synne Fronas ◽  
Hilde Skuterud Wik ◽  
Anders EA Dahm ◽  
Camilla Tøvik Jørgensen ◽  
Jostein Gleditsch ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
Financial Support ◽  
Probability Assessment ◽  
Regional Health ◽  
Vein Thrombosis ◽  
Wells Score ◽  
Deep Vein ◽  
Eastern Norway ◽  
Test Probability ◽  
D Dimer

Abstract Background Together with clinical decision rules, D-dimer testing has long been the mainstay of diagnostic work-up of suspected deep vein thrombosis (DVT). Advantages of D-dimer measurement include wide availability, low costs and high sensitivity. Age-adjusted D-dimer cut-off values have been suggested to improve specificity of D-dimer testing, defining a positive D-dimer as age multiplied by 0.01 mg/L at or over fifty years of age. Age-adjusted cut-off values have been found to increase specificity without compromising safety in the setting of acute pulmonary embolism, but have not been extensively evaluated in DVT. In this study, we aimed to evaluate and compare the diagnostic performance of fixed versus age-adjusted D-dimer thresholds in patients with suspected DVT, as a stand-alone test or in combination with pre-test probability assessment. Methods We included 973 consecutive outpatients referred to Østfold Hospital, Norway, with suspected first or recurrent lower extremity DVT, between 2015 and 2017. STA®-Liatest® Plus D-Dimer assay was performed and Wells clinical score assessed in all patients. Patients with positive fixed D-dimer (≥0.5 mg/L) were referred for whole-leg compression ultrasonography (CUS), whereas patients with negative D-dimer were not, irrespective of the clinical pre-test probability. Failure rate was defined as patients with negative D-dimer at baseline remaining untreated and diagnosed with symptomatic venous thromboembolism during 3-month follow-up. We compared diagnostic indices of both D-dimer thresholds with or without initial pre-test probability assessment. Results DVT was diagnosed in 177 out of 973 patients (18%).The fixed D-dimer cut-off was associated with a sensitivity of 99.4% (95% CI 96.9 to 99.9%) for one diagnostic failure (0.3%) (not adjudicated as of print). Adding the Wells score would have detected this one case at a cost of 90 additional CUS examinations. Age-adjusted D-dimer as a stand-alone test was associated with 6 diagnostic failures (1.5%) for a sensitivity of 96.6% (95% CI 92.8 to 98.8%). Age-adjusted D-dimer combined with Wells score yielded a sensitivity of 99.4% (95% CI 96.9 to 99.9%), with one diagnostic failure (0.4%) and 714 patients referred for CUS. Conclusion Our results suggest that the fixed D-dimer as a stand-alone test without Wells score is a safe and efficient diagnostic strategy. Combining age-adjusted D-dimer with Wells score was equally safe, but was not associated with a lower number of necessary CUS examinations. Disclosures Fronas: Bayer AG: Other: Bayer AG contributed with financial support in conducting the study; South-Eastern Norway Regional Health Authority: Other: Grant in conducting the study. Tøvik Jørgensen:Bayer AG: Other: Bayer AG contributed with financial support in conducting the study; South-Eastern Norway Regional Health Authority: Other: Grant for conducting the study. Ghanima:Bayer, BMS, Novartis: Research Funding; Amgen, Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees.

D-Dimers, Thrombin Antithrombin III Complexes and Prothrombin Fragments 1 + 2: Diagnostic value in Clinically Suspected Deep Vein Thrombosis

1991 ◽  
Vol 65 (01) ◽  
pp. 028-032 ◽  
Author(s):  
B Boneu ◽  
G Bes ◽  
H Pelzer ◽  
P Sié ◽  
H Boccalon
Keyword(s):  
Deep Vein Thrombosis ◽  
Antithrombin Iii ◽  
High Sensitivity ◽  
Diagnostic Value ◽  
Predictive Values ◽  
Vein Thrombosis ◽  
High Negative Predictive Value ◽  
Deep Vein ◽  
D Dimer ◽  
Mercury Strain Gauge

SummaryThis study was performed to determine the accuracy of D-Dimer fibrin derivatives, thrombin-antithrombin III (TAT) complexes and prothrombin fragments 1 + 2 (F 1 + 2) determinations for the diagnosis of deep vein thrombosis (DVT). One hundred and sixteen consecutive patients referred to the angiology unit of our hospital for a clinically suspected DVT were investigated. They were submitted to mercury strain gauge plethysmography and to ultrasonic duplex scanning examination; in cases of inconclusive results or of proximal DVT (n = 35), an ascending phlebography was performed. After these investigations were completed, the diagnosis of DVT was confirmed in 34 and excluded in 82. One half of the patients were already under anticoagulant therapy at the time of investigation. The 3 biological markers were assayed using commercially available ELISA techniques and the D-Dimer was also assayed with a fast latex method. The normal distribution of these markers was established in 40 healthy blood donors. The most accurate assay for the diagnosis of DVT was the D-Dimer ELISA which had both a high sensitivity (94%) and a high negative predictive value (95%). The D-Dirner latex, TAT complexes and F 1 + 2 were far less sensitive and provided negative predictive values which ranged between 78 and 85%. In spite of positive and significant correlations between the levels of ihe 3 markers, their association did not improve their overall accuracy for detecting D\/L Therefore, with the exception of the D-Dimer ELISA, these markers were of little value for the diagnosis of DVT in this specific population.

scholarly journals Characteristics of infective endocarditis in a cancer population

Open Heart ◽  
2021 ◽  
Vol 8 (2) ◽  
pp. e001664
Author(s):  
Cullen Grable ◽  
Syed Yusuf ◽  
Juhee Song ◽  
George M Viola ◽  
Owais Ulhaq ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Mortality Data ◽  
Limited Information ◽  
Tertiary Care Centre ◽  
Indwelling Catheters ◽  
Patients With Cancer ◽  
Duke Criteria ◽  
Immunocompromised State

BackgroundInfective endocarditis (IE) is more common in patients with cancer as compared with the general population. Due to an immunocompromised state, the need for invasive procedures, hypercoagulability and the presence of indwelling catheters, patients with cancer are particularly predisposed to the development of IE.ObjectivesLimited information exists about IE in patients with cancer. We aimed to evaluate the characteristics of patients with cancer and IE at our tertiary care centre, including a comparison of the microorganisms implicated and their association with mortality.MethodsA retrospective chart review of patients with cancer who had echocardiography for suspicion of endocarditis was conducted. A total of 56 patients with a confirmed diagnosis of cancer and endocarditis, based on the modified Duke criteria, were included in the study. Baseline demographics, risk factors for developing IE, echocardiography findings, microbiology and mortality data were analysed.ResultsFollowing the findings of vegetations by echocardiography, the median survival time was 8.5 months. Staphylococcus aureus was the most common organism identified as causing endocarditis. The mitral and aortic valves were the most commonly involved sites of endocarditis. Patients with S. aureus endocarditis (SAE) had a significantly poorer survival when compared with patients without SAE (p=0.0217) over the 12-month period from diagnosis of endocarditis.ConclusionsOverall survival of patients with cancer and endocarditis is poor, with a worse outcome in patients with SAE.

Performance of the Wells score in predicting deep vein thrombosis in medical and surgical hospitalized patients with or without thromboprophylaxis: The R-WITT study

2021 ◽  
pp. 1358863X2199467
Author(s):  
Jean-Eudes Trihan ◽  
Michael Adam ◽  
Sara Jidal ◽  
Isabelle Aichoun ◽  
Sarah Coudray ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
Risk Stratification ◽  
Hospitalized Patients ◽  
Operating Characteristics ◽  
Vein Thrombosis ◽  
Ultrasound Study ◽  
Wells Score ◽  
Deep Vein ◽  
The Impact ◽  
Test Probability

The Wells score had shown weak performance to determine pre-test probability of deep vein thrombosis (DVT) for inpatients. So, we evaluated the impact of thromboprophylaxis on the utility of the Wells score for risk stratification of inpatients with suspected DVT. This bicentric cross-sectional study from February 1, 2018 to January 31, 2019 included consecutive medical and surgical inpatients who underwent lower limb ultrasound study for suspected DVT. Wells score clinical predictors were assessed by both ordering and vascular physicians within 24 h after clinical suspicion of DVT. Primary outcome was the Wells score’s accuracy for pre-test risk stratification of suspected DVT, accounting for anticoagulation (AC) treatment (thromboprophylaxis for ⩾ 72 hours or long-term anticoagulation). We compared prevalence of proximal DVT among the low, moderate and high pre-test probability groups. The discrimination accuracy was defined as area under the receiver operating characteristics (ROC) curve. Of the 415 included patients, 30 (7.2%) had proximal DVT. Prevalence of proximal DVT was lower than expected in all pre-test probability groups. The prevalence in low, moderate and high pre-test probability groups was 0.0%, 3.1% and 8.2% ( p = 0.22) and 1.7%, 4.2% and 25.8% ( p < 0.001) for inpatients with or without AC, respectively. Area under ROC curves for discriminatory accuracy of the Wells score, for risk of proximal DVT with or without AC, was 0.72 and 0.88, respectively. The Wells score performed poorly for discrimination of risk for proximal DVT in hospitalized patients with AC but performed reasonably well among patients without AC; and showed low inter-rater reliability between physicians. ClinicalTrials.gov Identifier: NCT03784937.

scholarly journals Prevalence and characteristics of venous thromboembolism in severe exacerbation of chronic obstructive pulmonary disease in a tertiary care hospital in India

2021 ◽  
Author(s):  
Soibam Pahel Meitei ◽  
Sudheer Tale ◽  
Arjun Kumar Negi ◽  
Ruchi Dua ◽  
Rohit Walia ◽  
...  
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Venous Thromboembolism ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Lower Limbs ◽  
Chronic Obstructive ◽  
Care Hospital ◽  
Obstructive Pulmonary Disease ◽  
Test Probability ◽  
D Dimer

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) carries a high risk of venous thromboembolism (VTE). Pulmonary embolism (PE) and AECOPD increase the mortality and morbidity risk associated with each other. Racial and ethnic differences in VTE risk have been documented in multiple studies. However, there is a dearth of reliable Indian data on the same. This study was planned to find the prevalence of VTE in the setting of severe AECOPD in a tertiary care hospital in India and to identify the clinical, laboratory and radiological characteristics of VTE in severe AECOPD. A total of 156 consecutive patients admitted with severe AECOPD and meeting the specified inclusion and exclusion criteria were recruited. Thorough workup of all patients was done including ABG, serum D dimer, ECG, compression ultrasound of lower limbs and 2-D echocardiography. Patients with high pre-test probability score, or intermediate pre-test probability score at presentation with serum D dimer above the age adjusted cut-off underwent computerised tomography pulmonary angiography (CTPA).  Results were analysed using SPSS version 23.  Sixteen (10.3%) patients had VTE, 15 (93.75%) of them being cases of isolated PE. Female gender, higher cumulative past exposure to corticosteroid, higher alveolar-arterial gradient, right ventricular dysfunction, and higher mean pulmonary artery pressure were associated with increased risk for VTE. The prevalence of VTE in AECOPD in this study among an Indian population is higher than among other Asians, but lower than among the Blacks, the Caucasians and the Middle-East ethnicities. Since a vast majority of VTE presents as PE without DVT in the setting of AECOPD, the absence of deep vein thrombosis of lower limbs does not rule PE in the setting.

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