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N Engl J Med ; Several diagnostic strategies using ultrasound imaging, measurement of D-dimer, and assessment of clinical probability of disease have proved safe in patients with suspected tiefe Venenthrombose shin thrombosis, but they have not been compared in randomized trials. Full Text of Background Outpatients presenting with suspected lower-extremity deep-vein thrombosis were potentially eligible. Using a clinical model, physicians evaluated the patients and categorized them as likely or unlikely to have deep-vein thrombosis.
The patients were then randomly assigned to undergo ultrasound imaging alone control tiefe Venenthrombose shin or to undergo D-dimer testing D-dimer group followed by ultrasound imaging unless the D-dimer test was negative and the patient was considered clinically unlikely to have deep-vein thrombosis, tiefe Venenthrombose shin which case ultrasound imaging was not performed. Full Text of Methods Five hundred thirty patients were randomly assigned to the control group, and tiefe Venenthrombose shin the D-dimer group.
The overall prevalence of deep-vein thrombosis or pulmonary embolism was Among patients for whom deep-vein thrombosis had been ruled out by the initial diagnostic strategy, there were two confirmed venous thromboembolic events in the D-dimer group 0. The use of D-dimer testing resulted in a significant tiefe Venenthrombose shin in the use of ultrasonography, from a mean of 1.
Two hundred eighteen patients 39 percent in the D-dimer group did tiefe Venenthrombose shin require ultrasound imaging. Full Text of Results Deep-vein thrombosis can be ruled out in a patient who is judged clinically unlikely to have deep-vein thrombosis and who has a negative D-dimer test. Ultrasound testing can be safely omitted in such patients. Full Блестящая, trophischen Geschwüren Hunger Добро tiefe Venenthrombose shin Discussion Suspected deep-vein thrombosis is a common condition, with a lifetime cumulative incidence of 2 to 5 percent.
Untreated deep-vein thrombosis can result in pulmonary embolism, a potentially fatal outcome. Anticoagulant therapy reduces both morbidity and mortality from venous thromboembolism, and early diagnosis is therefore important. Accurate diagnosis of deep-vein thrombosis minimizes the risk of thromboembolic complications and averts the exposure of patients without thrombosis to the risks of anticoagulant therapy.
We tiefe Venenthrombose shin determined that the use of a clinical model allows physicians to categorize accurately the probability that a patient has deep-vein thrombosis before tests are performed. D-dimer is a marker of endogenous fibrinolysis and should therefore be detectable in patients with deep-vein thrombosis. Several studies have shown the D-dimer assay to have a high negative predictive value and D-dimer to be a sensitive but nonspecific marker of deep-vein thrombosis.
We hypothesized that the use of D-dimer testing in patients with suspected deep-vein tiefe Venenthrombose shin would reduce the need for ultrasound imaging and rule out deep-vein thrombosis in a higher proportion of patients on the day of presentation, while not compromising safety, as reflected by a small number of thromboembolic events during three months of follow-up.
Consecutive outpatients with suspected deep-vein thrombosis were potentially eligible for the study. The patients were recruited from the thrombosis units of five academic health centers. Lungenembolie, wie sie und zu verhindern, were also recruited from our emergency departments in the last quarter six months tiefe Venenthrombose shin the study.
The research ethics committee of each institution approved the study, and all participants gave written informed consent. Patients with a score of less than two were considered unlikely, and those with a score of two or more were considered likely, to have deep-vein thrombosis. Consecutive patients were randomly assigned either to undergo ultrasound imaging alone control group or to undergo D-dimer testing; those tiefe Venenthrombose shin the latter group then underwent ultrasound imaging if they had been judged clinically likely to have deep-vein thrombosis or if they were judged clinically unlikely but the D-dimer test was positive Figure 1 Figure 1 Diagnostic Read more and Patient Outcomes in the Group Judged Clinically Unlikely to Have Deep-Vein Thrombosis DVT.
Two patients refused follow-up, and three were lost to follow-up. All patients in the control group underwent ultrasound tiefe Venenthrombose shin of the proximal veins. For patients who had been judged clinically unlikely to have deep-vein thrombosis, the diagnosis of deep-vein thrombosis was excluded if the ultrasound test was negative.
For those who had been judged likely to have deep-vein thrombosis, a second ultrasound examination was performed one week later if the first test was negative. For the SimpliRED test, the result was considered negative if no agglutination was seen. All other patients underwent an ultrasound test.
A second test was performed only in the patients judged clinically likely to have deep-vein thrombosis who had an initial negative ultrasound test and a positive D-dimer test. Ultrasonography was performed with a high-resolution 5- or 7. The deep veins were evaluated for compressibility at 1-cm intervals from the common femoral vein to the point tiefe Venenthrombose shin the popliteal vein joins the calf veins.
In patients with no history of deep-vein thrombosis, deep-vein thrombosis was diagnosed if the vein was noncompressible. In patients with a history of deep-vein thrombosis, deep-vein thrombosis was diagnosed if there was a new noncompressible site or if the tiefe Venenthrombose shin of a clot had increased by at least 4 mm from a previous measurement.
If the clot diameter had increased by 1. Randomization was performed in computer-generated blocks, with block source ranging from 4 to 12 and with stratification according to the history of previous deep-vein thrombosis and according to center.
The randomization assignments were concealed in opaque envelopes. The study nurse opened the envelopes sequentially after the patient consent form had been signed and tiefe Venenthrombose shin clinical probability of deep-vein thrombosis had been determined. Patients receiving a diagnosis of deep-vein thrombosis were treated with conventional anticoagulant therapy. Other patients were asked to report to or call the study center if they had symptoms compatible with venous tiefe Venenthrombose shin, and their condition was reviewed one week and three months after presentation.
On the basis of our previous studies, we expected a rate of thromboembolic complications of 0. An increase of 0. The primary analysis compared the rates of proximal deep-vein thrombosis and pulmonary embolism during the three-month follow-up among patients in the control and D-dimer groups in whom deep-vein thrombosis had initially been ruled out.
Statistical significance was considered to have been achieved if the two-tailed P value was less than 0. The binomial distribution was used to determine 95 percent confidence intervals for proportions SPSS, version A total of outpatients were screened, of whom were eligible, provided informed consent, and were randomized Figure 3 Figure 3 Profile of the Trial.
Of these, were assigned to the control group and to the D-dimer group. The base-line characteristics of the two groups were similar Table 2 Table 2 Demographic and Clinical Characteristics of the Patients. The difference in the numbers of patients in the two groups was due to stratification and to the loss of randomization envelopes in the emergency departments of our institutions.
Of the patients who completed follow-up, 83 Four hundred ninety-five Five hundred eighty-seven These rates include events that click the following article during the three-month follow-up. Of the control patients who completed follow-up, were categorized as unlikely tiefe Venenthrombose shin as likely to have deep-vein thrombosis.
Sixteen patients in the former group had venous thromboembolic events 5. Sixteen patients returned during follow-up: The four events seen on follow-up were all pulmonary emboli that were confirmed by high-probability ventilation perfusion scanning on days 10, 59, 65, and 70 after initial presentation. In two patients, the pulmonary embolism developed during a subsequent hospitalization.
Of the control patients tiefe Venenthrombose shin as likely to have deep-vein thrombosis, 67 Twelve patients returned during follow-up: In two patients, pulmonary embolism was confirmed on days 14 and 21 of follow-up.
In one of these cases, the diagnosis was equivocal, even after spiral computed tomography and pulmonary angiography, but the patient was treated with anticoagulant therapy. Overall, in the control group 6 of the patients 1. Of the patients randomly assigned to the D-dimer group who completed follow-up, were categorized as unlikely and as likely to have deep-vein thrombosis. Two hundred eighteen patients Seventeen of these patients returned during follow-up: Two of these patients 0.
Tiefe Venenthrombose shin had a positive D-dimer test and underwent ultrasound imaging, which confirmed proximal deep-vein thrombosis in 14 patients and was negative in 83, none of whom subsequently had deep-vein thrombosis.
The negative predictive value of the D-dimer test was Of the patients in the Свидетельств Varizen in Blagoweschtschensk понимала group who were categorized as likely to have deep-vein thrombosis, 71 None had deep-vein thrombosis or pulmonary embolism during follow-up 95 percent confidence interval, 0 Net Krampf 2.
Nine patients returned during follow-up: Among all patients who underwent D-dimer learn more here, two 0. In the entire D-dimer group, the negative predictive value was There was no significant difference between the rates of various thromboembolic events on follow-up in the D-dimer and control groups 0. The 95 percent confidence interval for the observed difference of 0.
The mean number of ultrasound tests per patient was 1. Venography was performed in 11 patients, 5 of whom had tiefe Venenthrombose shin deep-vein thrombosis and an abnormal ultrasound test at tiefe Venenthrombose shin but no base-line ultrasound test for comparison; venography showed evidence of previous deep-vein thrombosis and ruled out acute thrombosis in all 5. Among patients categorized as likely to have deep-vein thrombosis, 74 percent of control patients and only 40 percent of patients in the D-dimer group had a repeated ultrasound examination.
Twenty patients died during the study, 10 of whom initially received a diagnosis of deep-vein thrombosis. Sixteen deaths were due to metastatic cancer, two to renal failure, one to sepsis, and one to ischemic cardiac disease. None of the deaths were due to pulmonary embolism. We have demonstrated that in patients presenting with suspected deep-vein thrombosis, a diagnostic strategy using D-dimer testing and clinical judgment to tiefe Venenthrombose shin patients for ultrasound imaging is as safe and feasible as a strategy combining clinical judgment with ultrasound imaging for all patients.
The addition of D-dimer testing to tiefe Venenthrombose shin diagnostic algorithm has the potential to make the diagnosis of deep-vein thrombosis in outpatients more convenient and economical. In patients who are considered clinically unlikely to tiefe Venenthrombose shin deep-vein thrombosis tiefe Venenthrombose shin who have a negative D-dimer test, the diagnosis of deep-vein thrombosis can safely be excluded without the need for further diagnostic testing.
Use of the D-dimer test here reduces tiefe Venenthrombose shin need for repeated ultrasound testing in patients who are likely to have deep-vein thrombosis and establishes a definitive diagnosis on the day of presentation in a larger proportion of patients.
Diagnostic strategies that have proved safe in patients with suspected deep-vein thrombosis have used repeated ultrasound testing, ultrasonography combined with D-dimer testing, and clinical probability estimation combined with ultrasonography. Several previous studies have suggested that the high negative predictive value of D-dimer testing in outpatients with suspected deep-vein thrombosis may be used as part of a diagnostic algorithm.
Our study demonstrates that the use of D-dimer testing to rule out deep-vein thrombosis benefits from consideration of clinical probability. First, the negative D-dimer result in patients who were unlikely to have deep-vein thrombosis eliminated the need for ultrasound testing in over 38 percent of the patients in the D-dimer group.
In the group judged likely to have deep-vein thrombosis, we were able to limit the need for a repeated test to the patients with positive D-dimer results. This strategy has the additional advantage of increasing the proportion of patients who will have a positive result on the repeated test.