scholarly journals THE MANAGEMENT OF VENOUS THROMBOEMBOLIC DISORDERS

2013 ◽  
Vol 3 (3) ◽  
Author(s):  
Diana S. Purwanto
Keyword(s):  
Venous Thromboembolism ◽  
Thrombotic Event ◽  
Venous Stasis ◽  
Initial Management ◽  
Clinical Probability ◽  
Venous Thromboembolic ◽  
Life Threatening ◽  
Diagnostic Work ◽  
Work Up ◽  
D Dimer

Abstrak: Tromboemboli vena (VTE) mengacu pada semua bentuk trombosis patologis yang terjadi di sirkulasi vena, yang paling umum adalah trombosis vena dalam (DVT) pada ekstremitas bawah, namun manifestasi VTE yang paling mengancam nyawa adalah embolisasi trombi vena dalam ke sirkulasi paru, yang disebut emboli paru (PE). Banyak faktor baik yang diturunkan atau didapat, bisa menyebabkan VTE karena faktor-faktor tersebut mempengaruhi stasis vena, kerusakan pembuluh dan hiperkoagulabilitas, sebagai pemicu peristiwa trombotik. Sebuah kombinasi dari tes D-dimer dan probabilitas klinis diperkenalkan oleh Wells sebagai langkah pertama dalam diagnosis. Agen antikoagulan biasanya UFH atau LMWH, harus diberikan untuk menghindari pembentukan bekuan lebih lanjut ketika gangguan VTE dikonfirmasi. Pada saat efek antitrombotik yang memadai dicapai dengan heparin, antikoagulan oral seperti warfarin digunakan untuk mengurangi kemungkinan VTE berulang. Kata kunci: Tromboemboli vena, DVT, PE, D-dimer, antikoagulan.     Abstract: Venous thromboembolism (VTE) refers to all forms of pathologic thrombosis occurring on the venous side of the circulation, the most common of which is deep venous thrombosis (DVT) of the lower extremities. The most life-threatening manifestation of VTE is embolization of venous thrombi to the pulmonary circulation, called pulmonary embolism (PE). Many factors, either inherited or acquired, can cause VTE, since these factors influence the venous stasis, vessel damage and hypercoagulability, as the trigger of thrombotic event.   A combination of a D-dimer assay and clinical probability as a first step in diagnostic work-up was introduced by Wells et al. An initial management of anticoagulant agents usually UFH or LMWH, should be administered to avoid further clot formation when VTE disorder is confirmed. At some point an adequate antithrombotic effect is achieved with heparin, oral anticoagulant such as warfarin is started to reduce the probability of recurrent VTE. Keywords: Venous thromboembolism, DVT, PE, D-dimer, anticoagulant.

D-dimer Assays for the Exclusion of Venous Thromboembolism: Which Test for which Diagnostic Strategy?

2000 ◽  
Vol 83 (02) ◽  
pp. 180-181 ◽  
Author(s):  
P. de Moerloose
Keyword(s):  
Venous Thromboembolism ◽  
Diagnostic Strategy ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Lung Scan ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up ◽  
D Dimer

SummaryD-dimer measurement has proven to be very useful to rule out deep vein thrombosis (DVT) and pulmonary embolism (PE) in symptomatic outpatients (1). The problem faced by many physicians is the choice and the position of the D-Dimer tests in the diagnostic work-up of patients suspected of venous thromboembolism (VTE). In the last and present issues of Thrombosis and Haemostasis, two very interesting studies addressing these questions were published.In the first paper (2), de Groot and colleagues evaluated, in a management study, the clinical utility of incorporating the SimpliRED assay in the diagnostic work-up of patients with suspected PE. Of the 245 study subjects, 59 did not receive anticoagulant therapy on the basis of a nondiagnostic lung scan, a normal D-dimer and a non-high clinical probability of PE. In the follow-up, only one patient experienced a thromboembolic event (which can be compared with the 6% of subsequent rate of VTE in the follow-up of the 54 patients with a normal perfusion lung scan). However, if SimpliRED D-dimer would have been used alone as a first exclusion step, 6 of 61 patients with proven PE had been missed (9.8%, 95% CI 3.7-20.2).

scholarly journals Clinical applicability of D-dimer assay in the diagnosis of pulmonary embolism reduces with aging

2007 ◽  
Vol 1 (4) ◽  
pp. 153-164
Author(s):  
Luca Masotti ◽  
Giancarlo Landini ◽  
Fabio Antonelli ◽  
Elio Venturini ◽  
Roberto Cappelli ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Elderly Patients ◽  
Case Reports ◽  
High Morbidity ◽  
Clinical Probability ◽  
Clinical Applicability ◽  
Diagnostic Management ◽  
Diagnostic Work ◽  
Work Up ◽  
D Dimer

Despite modern algorithms have been proposed for diagnosis of pulmonary embolism (PE), it remains understimed and often missed in clinical practice, especially in elderly patients, resulting in high morbidity and mortality when early and correctly untreated. One of the main controversial issue is represented by the role and applicability of D-dimer in the diagnostic work up of geriatric patients. Most recent guidelines in young-adult patients suggest to perform D-dimer assay by ELISA or immunoturbidimetric methods only in non high pre-test clinical probability (PTP) patients; in these patients negative D-dimer can safely rule out the diagnosis of PE. This strategy is safe also in elderly patients; however the percentage of patients with non high PTP and negative D-dimer reduces progressively with age, making difficult its clinical applicability. The Authors, starting from two case reports, up date the diagnostic management of PE underling the limitations of D-dimer assay in elderly patients.

Problem solving in clinical practice: the sick infant with low sodium and high potassium

2020 ◽  
pp. edpract-2019-317756
Author(s):  
Yincent Tse ◽  
Nidhi Singhal ◽  
Leigh McDonald ◽  
Milan Gopal ◽  
Anupam Lall ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Problem Solving ◽  
High Potassium ◽  
Initial Management ◽  
Low Sodium ◽  
Life Threatening ◽  
Diagnostic Work ◽  
Work Up ◽  
Term Management ◽  
Diagnostic Work Up

Many paediatricians will be faced with a sick infant who on investigation is found to have hyponatraemia and hyperkalaemia at some time in their career. The focus of initial management includes the treatment of potentially life-threatening hyperkalaemia with concurrent investigation aiming to elucidate whether the underlying cause reflects a primarily renal or endocrine pathology. We describe the presentation of two infants who each presented with one of the more common underlying diagnoses that led to this biochemical disturbance and discuss the approach to immediate treatment, diagnostic work-up and longer term management.

Venous thromboembolism: Contemporary diagnostic and therapeutic aspects

VASA ◽  
2008 ◽  
Vol 37 (3) ◽  
pp. 211-226 ◽  
Author(s):  
Bounameaux ◽  
Righini ◽  
Perrier
Keyword(s):  
Computed Tomography ◽  
Venous Thromboembolism ◽  
Vitamin K Antagonists ◽  
The Elderly ◽  
Helical Computed Tomography ◽  
Diagnostic Tools ◽  
Oral Anticoagulant Treatment ◽  
Clinical Probability ◽  
Work Up ◽  
D Dimer

To discuss new features that were published during the past few years on diagnosis and treatment of venous thromboembolism (VTE). Progress has been made in assessing clinical probability of pulmonary embolism (PE), in addressing the particular aspects of PE diagnosis in the elderly, in evaluating the diagnostic performance of single- and multi-detector row helical computed tomography (hCT), and in looking at the role of D-dimer measurement and lower limb venous compression ultrasonography in the diagnostic work-up of PE. New therapeutic options have also been proposed. Diagnosing VTE depends upon several, mainly non-invasive diagnostic tools that must be used sequentially, depending on the clinical situation and the local expertise. In the vast majority of patients, a noninvasive work-up is feasible and the diagnostic algorithms are becoming simpler. We focused on new developments of clinical probability assessment, PE in the elderly, potential new uses of D-dimer measurement, advent of multidetector row helical computed tomography and utility of ultrasonography to detect deep vein thrombosis in PE suspected patients. Treatment of acute venous thromboembolism consists of parenteral administration of heparin (usually low-molecular-weight heparin or, more recently, fondaparinux) overlapped and followed by oral vitamin K antagonists that will be administered for a certain period of time (usually 3 to 12 months), depending upon the estimated risks of recurrence and bleeding in each individual patient. Contemporary features include the controversial possibility of reducing the intensity of oral anticoagulant treatment (INR 1.5–2) after an initial full-intensity treatment (INR 2–3) period of 3 to 12 months, and the emergence of new anticoagulant drugs such as direct oral synthetic inhibitors of thrombin or factor Xa.

The role of fibrin monomers in optimizing the diagnostic work-up of deep vein thrombosis

2007 ◽  
Vol 97 (05) ◽  
pp. 807-813 ◽  
Author(s):  
Fred Haas ◽  
Mariette Agterof ◽  
Marike Vos ◽  
Douwe Biesma ◽  
Roger Schutgens
Keyword(s):  
Deep Vein Thrombosis ◽  
Clinical Score ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Diagnostic Work ◽  
Additional Value ◽  
Deep Vein ◽  
Work Up ◽  
Fibrin Monomers ◽  
D Dimer

SummaryDespite the use of a clinical score and D-dimers to exclude deep vein thrombosis (DVT), the majority of patients still need repeated ultrasound (US).The aim of the study was to investigate whether fibrin monomers (FMs), as markers of thrombin generation, have additional value in the diagnosis of DVT. This is a posthoc analysis of 464 outpatients, participants in a management study using D-dimers (Tina-Quant® ) and a clinical score in the exclusion of DVT. Two new FM assays (Auto LIA-FM® and IATRO SF®, Japan) were performed. Overall sensitivity, negative predictive value (NPV) and specificity of the D-dimer test were 98%, 98% and 42%.The optimal cut-off point for the Auto LIAFM test was ≤ 3 µ g/ml with values of 88%, 88% and 59%, respectively. The IATRO SF test had an optimal cut-off point of ≤ 2 µ g/ ml with values of 92%, 81 and 22%, respectively.The NPV of a non-high clinical score and a normal D-dimer (n=97) was 100%. In patients with a high clinical score (n=160), the NPV of the D-dimer was 88%. In these patients, a single US combined with a normal D-dimer or FM test had an equal NPV as serial US (100 versus 98%, respectively) and lead to a reduction in the need for US by 36–53%, respectively. In patients with abnormal D-dimer concentrations (n=343), a normal US combined with a normal Auto LIA-FM test had a NPV of 97%,which was also true for serial US.This could lead to a reduction in the need for US by 45%. The present studied FMs are inferior to theTina-Quant D-dimer test when used as primary screening tool to exclude DVT.Adding these FMs to patients with a normal Tina-Quant D-dimer has no benefit. In patients with a high pretest clinical probability score, a single US in combination with a normal D-dimer or FM test might be as safe as serial US. In patients with abnormal D-dimer concentrations and a normal US, a normal FM test might be able to replace the second US.

Travel and the risk of symptomatic venous thromboembolism

2003 ◽  
Vol 89 (03) ◽  
pp. 499-505 ◽  
Author(s):  
Marije ten Wolde ◽  
Roderik Kraaijenhagen ◽  
Jan Schiereck ◽  
Petronella Hagen ◽  
Joost Mathijssen ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Odds Ratio ◽  
Case Control Studies ◽  
Long Distance ◽  
Vein Thrombosis ◽  
Increased Risk ◽  
Venous Thromboembolic ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

SummaryWhether long-distance travel and symptomatic venous thromboembolism (VTE) are associated is debated. On the basis of the available literature a fair risk estimate cannot be obtained. We estimated an accurate odds ratio for the relationship between recent travelling and symptomatic VTE.From three case-control studies consisting of 788 and 170 patients with clinically suspected deep vein thrombosis (DVT) and 989 patients with clinically suspected pulmonary embolism (PE) referred for diagnostic work-up, a pooled odds ratio for the relation between travel and symptomatic VTE was calculated. Cases were patients in whom the diagnosis was confirmed according to a diagnostic management strategy, whereas controls were patients in whom the diagnosis was excluded and who had an uneventful clinical follow-up. Patients were seen in the period April 1997 to September 2000. Travel history was recorded prior to diagnostic work-up.The pooled odds ratio for the association between any travel and symptomatic venous thromboembolism was 0.9 (95% CI: 0.6-1.4). The median travel time was 7 h (quartile range 4 to 10 h). Separate analyses performed for different types of transport (plane, car, bus or train) yielded comparable odds ratios. The analysis for duration of travelling showed an increased odds ratio of 2.5 (95% CI: 1.0-6.2) in the category of 10-15 h of travelling.This study shows that the average traveller does not have an increased risk for symptomatic venous thromboembolism. Only very long travelling (more than 10 h) may be associated with venous thromboembolic disease.

Ruling out clinically suspected pulmonary embolism by assessment of clinical probability and D-dimer levels: a management study

2003 ◽  
Vol 89 (01) ◽  
pp. 97-103 ◽  
Author(s):  
Johan Lutisan ◽  
Marinus Marwijk Kooy ◽  
Bart Kuipers ◽  
Ad Oostdijk ◽  
Jef van der Leur ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Probability Assessment ◽  
Suspected Pulmonary Embolism ◽  
Thromboembolic Risk ◽  
Management Study ◽  
Entire Cohort ◽  
Clinical Probability ◽  
Diagnostic Work ◽  
Work Up ◽  
D Dimer

SummaryD-dimer test combined with clinical probability assessment has been proposed as the first step in the diagnostic work-up of patients with suspected pulmonary embolism (PE). In a prospective management study we investigated the safety and efficiency of excluding PE by a normal D-dimer combined with a low or moderate clinical probability. Of the 202 study patients this combination ruled out PE in 64 (32%) patients. The 3-month thromboembolic risk in these patients was 0% (95% CI, 0.0-5.6%).The prevalence of PE in the entire cohort was 29% (59 patients), whereas in the low, moderate and high clinical probability groups this was 25%, 26% and 50%, respectively. We conclude that ruling out suspected PE by a normal D-dimer combined with a low or moderate clinical probability appears to be a safe and efficient strategy. The accuracy of the clinical probability assessment is modest.

scholarly journals Death of unknown cause? Post-mortem diagnosis of fulminant course of an EBV-associated secondary hemophagocytic lymphohistiocytosis

2021 ◽  
Author(s):  
Josia Fauser ◽  
Stefan Köck ◽  
Eberhard Gunsilius ◽  
Andreas Chott ◽  
Andreas Peer ◽  
...  
Keyword(s):  
Immune Response ◽  
Case Report ◽  
Macrophage Activation ◽  
Post Mortem ◽  
Life Threatening ◽  
Appropriate Therapy ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up ◽  
Secondary Hemophagocytic Lymphohistiocytosis

SummaryHLH is a life-threatening disease, which is characterized by a dysregulated immune response with uncontrolled T cell and macrophage activation. The often fulminant course of the disease needs a fast diagnostic work-up to initiate as soon as possible the appropriate therapy. We present herein the case of a 71-year-old patient with rapidly progressive hyperinflammatory syndrome, which post mortem resulted in the diagnosis of EBV-associated HLH. With this case report, we intend to highlight the relevance of the HScore in the diagnosis of HLH, to create a greater awareness for EBV as a trigger of HLH, and to demonstrate the importance of treating EBV-associated HLH as early as possible.

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