Suspicion Of Deep Vein Thrombosis Research Articles

Mortality and Deep Vein Thrombosis in the Gamma Variant of Covid 19 and Lung Injury.

The SARS-CoV-2 disease predisposes infected individuals to thrombosis, the underlying mechanisms of which are not fully understood. The balance between pro-coagulant factors and natural coagulation inhibitors in critically ill patients with Covid-19 is fundamental to the prevention and treatment of complications. The aim of the present study was to investigate the pulmonary injury patterns in Covid-19 having higher mortality in the presence of deep vein thrombosis in comparison to patients without venous thrombosis and determine the Gamma variant. A retrospective study was conducted involving the evaluation of 200 medical records of patients with Covid-19 and a clinical suspicion of deep vein thrombosis (DVT) at the intensive care unit of a public hospital. The sample was divided into two groups of patients were formed - those positive and those negative for DVT. Statistical analysis involved the use of Fisher's exact test, the paired t-test and chi-square test. Patients with DVT had more severe lung injuries (greater than 70%) compared to those without DVT (p = 0.003). Lesions affecting 50% to 70% of the lung area occurred in little more half of the group with DVT and just under half in the group without DVT (p = 0.5). Pulmonary lesions affecting less than 50% of the lung occurred more in patients without DVT (p = 0.0001). The Gamma variant increased prevalence of the both DVT and mortality (p=0.0001). Deep vein thrombosis is an aggravating factor of mortality in patients with SARS-CoV-2, and the Gamma variant is an aggravating factor of both thrombotic events and mortality.

Is it sufficient to evaluate COVID‐19 infected critically ill patients only in terms of VTE risk factors? What about disease severity?

Dear Editor, We read with great interest the study by Wang et al.1 which was published online and being ahead of print in the Clinical Respiratory Journal. At the beginning of the corona virus disease 2019 (COVID-19) pandemia in their single-centre retrospective, observational study, they retrospectively analysed 138 COVID-19 patients and researched the factors for in-hospital venous thromboembolism (VTE) and bleeding. They found that 16.7% of patients with COVID-19 had high risk for VTE according to Pauda Prediction Score; 6.5% of patients had high risk of bleeding for VTE prophylaxis according to Improve Prediction Score. They identified thrombotic events in four patients (2.9%), all of them had deep vein thrombosis (DVT). They found the incidence of VTE as 20% and one major haemorrhage was happened in critically ill patients during VTE treatment. They defined critically ill patients as those admitted to intensive care unit (ICU) who required mechanical ventilation or had a fraction of inspired oxygen (FIO2) of at least 60% or more. They used lower extremity compression ultrasound to detect DVT for all critically ill patients with a high risk of VTE and high level of D-dimer. If ultrasound was positive, patients underwent computed tomography pulmonary angiogram.1 This is an important issue, but there are some practical questions to be answered for a proper clinical extrapolation. First, COVID-19 leads coagulation disorders that are triggered by increased level of procoagulant substances. Sepsis-induced coagulopathy (SIC) and disseminated intravascular coagulation (DIC) are the main causes of coagulation associated mortality in critically ill patients. The SIC criteria established by the International Society on Thrombosis and Haemostasis (ISTH) is often used to guide anticoagulant therapy in hospitalised patients.2 Nevertheless, DVT occurs in majority of patients with critically ill COVID-19. COVID-19 is an acute viral infection which primarily affects respiratory system and if it progresses to acute respiratory distress syndrome (ARDS) and leads other organ failures, as well. Although Wang et al.1 used Padua Prediction Score and found 16.7% of the patients were at high risk for VTE, VTE was determined in 20% of the patients. According to Padua Prediction Score, patients with chronic conditions such as malignancy, reduced mobility, and thrombophilia get higher risk scores whereas common disorders during COVID-19 course such as heart and respiratory failure, acute myocardial infarction, or ischaemic stroke result in minor score increase. This is the most likely reason of low prediction rate which is reported in the previous study.1 Moreover, apart from thromboembolic situation such as DVT, in patients with COVID-19, pulmonary inflammation may lead susceptibility to embolism.2 Therefore, not only suspicion for DVT, presence of ARDS, elevated D-dimer levels, or worsening in oxygenation should make clinicians consider pulmonary thrombosis and perform chest imaging. Second, it has shown by many studies that severity of COVID-19 is a risk factor for VTE and elevated ferritin, C-reactive protein, D-dimer, and interleukin-6 levels are associated with thromboembolic events and poor prognosis.3 In the previous study by Wang et al.,1 there is not enough data on duration and severity of disease. We believe that considering these factors together with Padua Prediction Score provides better prediction rates for VTE. Third, to determine COVID-19 associated thromboembolism, Sequential Organ Failure Assessment (SOFA) score that is one of the disease severity and organ failure scores has been evaluated by some previous studies.4, 5 These studies suggest that in critically ill COVID-19 patients, higher SOFA scores are associated with higher DVT frequency, D-dimer levels, duration of disease, hypoalbuminemia, and duration of disease.4 Other previous study5 reported that higher ISTH SIC scores which include SOFA score, prothrombin time–international normalised ratio (PT-INR), and platelet levels are associated with higher mortality and patients with ISTH SIC score higher than 3 had 3.05-fold increased mortality risk. Both haemodynamic situation and arterial oxygen partial pressure to fractional inspired oxygen ratio (PaO2/FIO2) are components of SOFA score. PaO2/FIO2 ratio is a main determinator of ARDS severity and also reflects the severity of COVID-19. Finally, we believe that further prospective clinical trials need to develop an effectual risk prediction score including disease severity to determine VTE earlier in COVID-19 patients. The authors declare that the letter was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All authors contributed equally to the letter. Data sharing is not applicable to this article as no new data were created or analyzed in this study. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Asymptomatic deep vein thromboses in prolonged hospitalized COVID-19patients.

High incidence of venous thromboembolic (VTE) events in coronavirus disease 2019 (COVID-19) patients has been reported despite pharmacologic thromboprophylaxis. We performed prospective bilateral lower extremity ultrasound evaluation of prolonged hospitalized COVID-19 ward patients from our institution without clinical suspicion of deep vein thrombosis (DVT).A total of 102 patient were included in the study. All patients were receiving pharmacologic thromboprophylaxis, the majority in intermediate or therapeutic doses. Asymptomatic DVT was detected in 26/102 (25.5%) patients: 22 had distal and four had proximal DVT, six had bilateral leg involvement. Pulmonary embolism was highly prevalent (17/70, 24.3%) but similarly grouped among patients with and without asymptomatic DVT. In total 37.2% of patients included in the study were recognized as having VTE.Asymptomatic DVT events were more common in intensive care unit (ICU) survivors (60% in postmechanically ventilated ICU survivors, 21.2% in ward patients, 22% in high-flow oxygen treated patients; P = 0.031), in patients with higher modified International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk-score (median 3 vs. 2 points with and without DVT; P = 0.021) and higher body temperature on admission (median 38.7 °C vs. 37.7 °C with and without DVT; P = 0.001). No clear associations with Padua VTE risk score, demographic and other clinical characteristics, intensity of thromboprophylaxis, severity of other COVID-19 symptoms, degree of systemic inflammation or D‑dimers on admission were found (P > 0.05 for all analyses).Systematic ultrasound assessment in prolonged hospitalized severe COVID-19 patients prior to hospital discharge is needed, especially in ICU survivors, to timely recognize and appropriately treat patients with asymptomatic DVT.Supplementary InformationThe online version of this article (10.1007/s00508-021-01973-1) contains supplementary material, which is available to authorized users.

Incidence of venous thromboembolism in Asian patients undergoing anterior cruciate ligament reconstruction without the use of mechanical or chemical prophylaxis

Background:Venous thromboembolism (VTE) is a clinically relevant complication of major orthopedic surgeries. The prevalence of VTE and the indications for VTE thromboprophylaxis in Asian patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction are not clear. This study aims to evaluate the prevalence of clinically significant venous thromboembolic events (VTE) in Asian patients undergoing arthroscopic ACL reconstruction without mechanical or chemical thromboprophylaxis.Methods:All patients who underwent ACL reconstruction by a single surgeon from 2006 to 2018 in a single tertiary institution were reviewed. The inclusion criteria for the study included Asian patients of common ethnic groups in Singapore (Chinese, Malay, Indian) and underwent primary or revision ACL reconstruction, or ACL reconstruction combined with meniscal surgery. The exclusion criteria were patients with incomplete medical records, pre-existing anticoagulant treatment within 1 year prior to the surgery and additional procedures that altered the standard rehabilitation protocol, less than 6 months of follow-up duration. All patients received general anesthesia. The single-bundle ACL technique with autologous hamstring tendon reconstruction was performed. No chemical DVT prophylaxis was given. The patients were screened for clinically for VTE. Symptomatic patients were referred for ultrasonography.Results:Of the 581 patients reviewed, 3 patients had a clinical suspicion of deep vein thrombosis, but subsequent ultrasonography showed no thrombosis. Hence, the prevalence of clinically significant VTE was 0%.Conclusion:Given the low prevalence of clinically significant VTE, there is no need for routine mechanical or chemical thromboprophylaxis or radiologic screening in Asian patients undergoing arthroscopic ACL reconstruction.

A comparative study of colour doppler findings in diabetic and non-diabetic lower limb deep vein thrombosis patients attending tertiary care hospital

Introduction: Diabetes mellitus (DM) has been shown to be associated with increased coagulability, endothelial damage, and decreased fibrinolysis function [1], which can result in deep vein thrombosis (DVT). The present study was aimed at comparing the clinical characteristics of DVT patients with and without DM. Methodology: We included 100 diabetic and 100 non-diabetic controls, who were was admitted in the indoor ward of medical and surgical departments and were referred to our department with suspicion of DVT. They underwent examination for DVT detection using ultrasonography machine on B-mode and colour Doppler study. Results: Of the 100 diabetics and 100 non-diabetics, 21% and 15% had DVT respectively. Most of the thrombi were chronic, complete, proximal and single left sided. Common iliac vein (n = 10/21 vs 2/15; p value

Lower extremities Duplex-Doppler ultrasonography for the detection of suspected deep venous thrombosis: A preliminary report from Sokoto

Background: There is a paucity of reports on the deep vein thrombosis in our environment.Aims and Objective: The aim of this study is to document the role of Doppler ultrasound in detecting deep vein thrombosis in our environment.Methods and Materials: Between Januarys to December 2014 forty six in patients with suspicion of DVT were evaluated prospectively. All patients presented with symptoms of single or bilateral disease, and a high probability of the disease. Two trained radiologists performed all duplex scan examinations. The patients were scanned using Mindray DC-3/DC-3T Diagnostic ultrasound scanner (Mindray Bio- Medical Electronics Co., LTD) linear (7-12MHz) transducers was used.Results: A total of 46 patients had duplex-Doppler scan examination carried out between January-December 2014. There were 30(65.2%) males and 16(38.8%) females subjects recruited for the study. The mean age was 48.9±SD17.3 with range of 18-85 years. A total of 21 patients (45.6%) were found to have deep vein thrombosis (DVTs) on duplex-Doppler examination. Proximal DVTs was seen in 6(12.9%) and 14(30.3%) for right and left lower limbs respectively. Distal DVTs was seen in 1(2.2%) in the right lower limb and 25(54.4%) show normal findings bilaterally. Diffused DVTs was seen in 2(4.3%) patients involving external, through popliteal veins on the right lower limb. In 3(6.5%) of the patients only the common femoral, superficial femoral and popliteal shows diffuse DVTs.Conclusion: With availability of Doppler ultrasound in our environment the diagnosis of DVT is now easier. Duplex scanning techniques are faster, safer, and less expensive. Because of its noninvasive nature, venous duplex is repeatable, allowing for continued follow up after the diagnosis. Asian Journal of Medical Sciences Vol.7(6) 2016 53-57

Clinical Application of Technetium-99m-Labeled Red Blood Cells Subcutaneous Radionuclide Venography and Abdominal/Pelvic Hybrid SPECT/CT Imaging in Patients with Suspicion of Proximal Deep Vein Thrombosis

Technetium-99m-labeled red blood cells subcutaneous radionuclide venography can apply to evaluate deep venous flow of lower extremities. We introduce additional abdominal/pelvic hybrid SPECT/CT (single-photon emission computed tomography with computed tomography) to scrutinize the proximal deep venous flow defects in the iliac vein. SPECT/CT imaging is collected when disturbed or asymmetrical iliac venous flow is noted on the planar imaging of Tc-99m-labeled red blood cells subcutaneous radionuclide venography. The region of SPECT/CT imaging includes abdominal aorta, inferior vena cava and bilateral iliac vessels. We present three cases with suspicion of deep vein thrombosis in the iliac vein. Tc-99m-labeled red blood cells subcutaneous radionuclide venography with SPECT/CT revealed not only provides us the venous flow but also other information including abnormal vessel structure, space-occupying lesion and abnormality in other organs. In conclusion, if disturbed or asymmetrical iliac venous flow and abnormal collateral venous drainage in the abdomen are noted on the Tc-99mlabeled red blood cells subcutaneous radionuclide venography, SPECT/CT imaging may arrange for further information and differential diagnosis of lower extremities swelling; not only in detecting deep vein thrombosis.

Noninvasive cardiac output monitoring during anaesthetic management for caesarean delivery in parturient with severe mitral stenosis: A more relaxed look.

Noninvasive cardiac output monitoring during anaesthetic management for caesarean delivery in parturient with severe mitral stenosis: A more relaxed look.

Pre-diagnostic management of patients suspicious of deep vein thrombosis

Background: We analysed the feasibility of the 9th ACCP-guidelines recommendation of starting therapeutic anti- coagulation in patients with a high suspicion of deep vein thrombosis (DVT) and tried to answer the question as to whether it generates a relevant over- or under-use of anti-coagulants in the period prior to the definitive diagnosis. Patients and methods: From March to May 2013 we included 98 consecutive out-patients (mean age 63 ± 17 years, 39 males) suspected of DVT, classifying them according to the 9th ACCP-guidelines recommendations into two groups with high and low clinical suspicion. Those with a high suspicion (Wells Score ≥ 2 and elevated DDimer concentration) initially received Rivaroxaban 15 mg orally. Results: Out of the 80 patients with a high clinical suspicion, 15 (19%) received therapeutic anti-coagulation without any medical necessity because DVT was finally excluded. Out of the 10 patients with a low clinical suspicion, 2 (20%) with a finally proven DVT might have benefited from initial therapeutic anti-coagulation. Females were at a slightly higher risk of receiving therapeutic anti-coagulation unnecessarily. Out of the 45 females with a high clinical suspicion, who received therapeutic anti-coagulation, DVT was excluded in 9 (20%). In males it was 6 (17%) out of 35 patients. The costs for those 80 patients accepting initial anti-coagulation by taking Rivaroxaban 15 mg were €312. By using Certoparin 8000 I.E. the cost would have been €792, which is 150% higher compared to Rivaroxaban within in the same period. Conclusion: Defining patients to have a high suspicion for DVT by Wells score and DDimer is associated with an over-use of therapeutic anticoagulation in almost every fifth patients.

Point-of-care ultrasound in patients with suspected deep vein thrombosis (DVT)

Background Suspicion of Deep vein thrombosis (DVT) is a frequent cause of presentation in emergency departments (EDs). Traditionally at Holbaek University Hospital, patients presenting with suspected lower-extremity DVT are commonly assessed and treated as out-patients in the Quick Diagnostic Unit (QDU), a part of our Emergency Department. The patients undergo D-dimer testing and Wells score followed by ultrasound (US) only if the D-dimer is positive, or the patient is judged clinically to have DVT (Wells score>2). Unfortunately, the limited availability of radiologist-performed ultrasound outside banker’s hours delay the diagnosis by more than 24 hours and may expose the patient to inappropriate anticoagulation treatment. The safety, ease of use, rapid time of diagnosis, low cost and accessibility makes bedside ultrasound for DVT especially useful for emergency physicians. The aim of this pilot study is to assess the time-todiagnosis and the accuracy of emergency physician performed bedside ultrasound (EPUS) in the detecting of pathological findings (Hematoma, Baker’s cyst and Thrombosis), in comparison with the traditional settings involving a radiologist-performed ultrasound.

Imaging Tests in the Diagnosis of Pulmonary Embolism

Imaging modalities play an essential role in diagnosing pulmonary embolism (PE). Clinical outcome studies demonstrated that PE can be safely ruled out in patients with unlikely clinical probability in combination with a normal D-dimer test result; in all other patients additional imaging is needed. The aim is to accurately confirm or rule out the diagnosis of PE, after which, if indicated, anticoagulant treatment can be initiated. Various diagnostic tests are available, and this article reviews the different imaging techniques in patients with suspected PE. Computed tomographic pulmonary angiography (CTPA) is the imaging test of choice because of its high sensitivity and specificity. Compression ultrasonography and ventilation perfusion scintigraphy are reserved for patients with concomitant suspicion of deep vein thrombosis or contraindication for CTPA. Furthermore the diagnostic process in patients with clinically suspected recurrent PE, PE during pregnancy, and PE in the elderly and in patients with malignancy are discussed.

Active cytomegalovirus infection in patients with acute venous thrombosis: A case‐control study

Infectious diseases have been associated with venous thrombosis (VT) [1]. Several case-studies described active cytomegalovirus infection in patients with VT [2-6]. In this case-control study, we detected five cases with active cytomegalovirus infection and VT, and none in the control group. All were female, below 37 years of age, and had another acquired risk factor for VT. This may imply that active cytomegalovirus infection contributes to a procoagulant state in young subjects with other mild risk factors for VT.

Alternative sonographische Diagnosen bei klinischem Thromboseverdacht

Unclear extremity complaints are common symptoms of inpatients. In a subset of these patients, a clinical suspicion of deep vein thrombosis (DVT) results; this needs to be quickly and definitively clarified by a vascular physician. The question arose of how often a clinical suspicion of DVT was confirmed in an inpatient population and which alternative diagnoses were able to be made by angiologists. In a retrospective analysis, all inpatients in the Angiologic Vascular Diagnostics Center of the University Hospital Halle, Germany, examined in 2007 for a suspicion of DVT were evaluated with respect to the definitively made diagnosis. In 213 (28.6%) of 745 suspected cases of DVT, a DVT was confirmed. In 532 patients (71.4%), DVT was excluded. In 314 of these patients, 436 alternative diagnoses were recorded in the diagnostic reports of angiologic examinations. In 38.6% (n = 168), other venous causes could be confirmed as the most common alternative diagnosis. There were chronic venous diseases in 28% (n = 122), superficial thrombophlebitis (n = 27), and tumor-related pelvic vein compression (n = 19). 17.4% (n = 76) exhibited lymphedema. In 13.3% (n = 58), a generalized edema was diagnosed. Arthrogenic causes followed with 12.8% (n = 56). Lipedema (5.3%) and hematoma (5%) could be verified as other important differential diagnoses. Rare causes were symptomatic or ruptured Baker's cysts (2.5%), erysipelas (2.5%), abscess, aneurysm, muscle tears, and tumors. The variety of alternative diagnoses in patients with clinical suspicion of DVT is high. The knowledge and systematic examination of potential, even rare differential diagnoses after exclusion of DVT are part of the repertoire of the vascular physician. Unnecessary and expensive, as well as onerous, diagnostic procedures on the patient can be avoided. Anticoagulation that was begun as a result of the suspicion of DVT can quickly be stopped.

A Cost-effectiveness Analysis of Diagnostic Algorithms of Deep Vein Thrombosis at the Emergency Department

Introduction Suspected cases of deep vein thrombosis are common at emergency departments and they often require extensive and costly diagnostic testing. The objective of this study was to evaluate whether a diagnostic algorithm based upon pre-test probability and D-dimer in diagnosing deep vein thrombosis may be cost-effective from a societal perspective in a Swedish setting. Material and Methods The cost-effectiveness of two alternative diagnostic algorithms were calculated using decision analysis. An algorithm which out ruled deep vein thrombosis among low probability patients with negative D-dimer was compared to a traditional algorithm including compression ultrasonography and/or contrast venography for all patients. For sensitivity analysis, a third reversed algorithm, where D-dimer was followed by pre-test probability, was analyzed. Estimates of probabilities were obtained from a prospective management study, including 357 outpatients with clinical suspicion of deep vein thrombosis. Direct costs were estimated using prices from Scania, Sweden. Indirect costs were estimated using time spent at the local emergency department and gross average wages in Sweden. Results The total cost of the pre-test probability and D-dimer algorithm was estimated to €406 per patient and the traditional algorithm was estimated to €581 per patient. Reversing the order of the score and test resulted in an estimate of €421 per patient. Conclusion At no significant difference in diagnostic efficacy the algorithm based upon pre-test probability and D-dimer was cost-effective, while the reversed algorithm and diagnostic imaging for all patients were not.

Thrombus vaporization by excimer laser angioplasty

A 70-year-old woman, with no traditional cardiovascular risk factor, came to our attention because of a non-STsegment myocardial infarction. Her cardiac history was uneventful, except the recent onset of episodes of waxing and waning epigastric pain. Of note, 2 weeks earlier, she began therapy with enoxaparin due to the suspicion of deep vein thrombosis. At admission, the patient complained of sharp, persisting pain referred to the epigastrium. Physical examination and routine blood test results were normal. Cardiac enzymes were raised (CK-MB 22.8 ng/ml) and ECG showed diffuse repolarization abnormalities. At echocardiography, mild depression of left ventricle function was found, with hypokinesis of its anterior and lateral walls. Coronary angiography (Fig. 1) revealed a critical stenosis of the ramus intermedius with a high thrombus burden downward the lesion (Panel A), thus prompting for percutaneous revascularization in the same session. After wiring of the culprit vessel, excimer laser angioplasty was performed (Panel B). Thrombus vaporization and underlying plaque debulking

Ultraschalluntersuchung der extremitätenversorgenden Gefäße

Ultrasound investigation of the vascular supply to legs and arms has become a standard procedure and is performed in all kinds of both arterial occlusive disease and venous disease. On the arterial side the most common disease is atherosclerosis in which stenoses and occlusions can be identified and characterized with respect to the functional significance. Sensitivity und specificity for the detection of symptomatic occlusions and stenoses are approximately 90% and 99%, respectively. This is the basis for planning invasive procedures, catheter interventions as well as operations. The short term success can be assessed and long term follow-up can be performed by ultrasound. In addition all other kinds of arterial disease (embolisms, aneurysms, inflammation and mechanical alterations) can be examined. On the venous side, the most common indication for ultrasound is the suspicion of deep vein thrombosis. Compression ultrasound of the leg veins allows a reliable diagnosis in almost all cases. The diagnostic failure rate in a 3-month follow up is around 0.5%. The present review summarizes the indications and examination details for leg arteries, arm arteries, leg veins and arm veins. A separate paragraph deals with dialysis shunts, a growing field in vascular medicine.

Diagnostic issues of VTE in pregnancy

Venous thromboembolism is a major cause of maternal morbidity and mortality, and accurate diagnostic workup upon suspicion of deep vein thrombosis or pulmonary embolism in a pregnant woman is of utmost importance. The diagnostic repertoire for venous thromboembolism is, however, less well studied in pregnant women. The clinical assessment is influenced by common symptoms of pregnancy such as leg swelling or shortness of breath. The role of D-Dimer is limited, since — even during uncomplicated pregnancy — D-Dimer levels increase with gestational age. Preliminary data indicate that a normal D-Dimer in a healthy pregnant woman with a low clinical probability may exclude deep vein thrombosis. Compression ultrasonography and ventilation perfusion scanning or helical computed tomography are the imaging techniques of choice in a pregnant woman with suspected deep vein thrombosis or pulmonary embolism, respectively. The role of magnetic resonance imaging for the diagnosis of venous thromboembolism during pregnancy is uncertain and contraindications particularly to contrast media have to be considered.

Venous ultrasonography in symptomatic and asymptomatic patients: an updated review

Venous ultrasound is a major tool in both routine clinical care and clinical research. Since the last review, major attempts have been made to improve its methodological strength, and therefore, its value in assessing diagnostic criteria, risks, and outcomes in venous thromboembolism. In symptomatic patients, further evidence has been provided that the approach of a single examination of the entire venous system is feasible and safe. This holds true for patients with suspicion of deep vein thrombosis as well as of pulmonary embolism. In asymptomatic patients, several attempts have been made to validate venous ultrasound against venography. Even if no direct comparison has been made, the results seem to be more promising in medically ill patients than in those early after major orthopaedic surgery. For routine clinical use, the single examination strategy still awaits full recognition and implementation into practice. For clinical trials, there is insufficient data about the accuracy of centrally read ultrasound. This fact directly points to the unmet need of a consensus of standardization of venous ultrasound as an endpoint measure in clinical trials regarding the examination procedure itself, its documentation, and the adjudication process.

Sonographie bei Lungenembolie: drei Fliegen auf einen Streich

Pulmonary embolism remains a great diagnostic challenge. The value of different ultrasound methods is presented in this review. Regarding the accuracy of echocardiography, it shows a sensitivity of 41 - 50 % and a specifity of 90 % for unselected patients with suspicion of PE as a result. On the other hand, the sensitivity of echocardiography in cases of hemodynamic instable patients is very high. In a recent multicenter trial of thoracic ultrasound in diagnosis of pulmonary embolism on 352 patients the sensitivity amounts to 74 %, the specifity to 95 %, the positive predictive value to 95 %, negative predictive value to 75 % and accuracy to 84 %. Colour Doppler sonography with compression is a save modality ensuring the source of embolism in deep vein thrombosis. With suspicion of deep vein thrombosis the median sensitivity made up 95 % (38 - 100 %) and median specifity was 97 % (81 - 100 %). The combination of chest sonography, echocardiography and compression sonography of leg vein thrombosis enhances the sensitivity of sonography to 92 %, while this accuracy can not be reached with any other method.

The Value of Clinical Findings and D-Dimer Tests in Diagnosing Deep Vein Thrombosis in Primary Care

In primary care, the physician has to decide which patients with a suspicion of deep vein thrombosis (DVT) have to be referred for further diagnostic work-up. Accurate referral is of utmost importance because unrecognized and therefore untreated DVT may cause pulmonary embolism. The classic clinical findings are not sufficiently accurate for the diagnosis of DVT. The majority of the referred patients, 70 to 80%, do not have DVT and this puts a burden on both patients and health care budgets. Diagnosis in primary care is different from that in secondary care caused by the referral mechanism or spectrum difference. Diagnostic tests derived in secondary care, therefore, cannot simply be generalized to primary-care patients. The well-known diagnostic rule for DVT, the Wells rule, does not adequately rule out DVT in primary-care patients. A proper diagnostic rule for use in primary care is lacking; therefore, we investigated the data of 1,295 patients in primary care suspected of having DVT. We developed and validated a simple diagnostic decision rule to exclude the presence of DVT safely in primary care. 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 circumference difference, and D-dimer test result. Application of this rule could reduce the number of referrals by at least 23%, whereas only 0.7% of the patients with a DVT would not be referred. A diagnosis strategy is given, together with a practical flow diagram.