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EVIDENCE-BASED-HEALTH  April 1999

EVIDENCE-BASED-HEALTH April 1999

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Subject:

Re: DVT diagnostic accuracy and GPs

From:

"Chris Burton" <[log in to unmask]>

Reply-To:

Chris Burton

Date:

Sat, 24 Apr 1999 13:15:15 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (101 lines)

These any help? - have included a couple of abstracts and starting point for
the search if you want to follow links etc

PubMed Search on Wells PS (name cribbed from ref to the Lancet article in
the about-to-be-released SIGN Antithrombotic Therapy Guideline)

includes

JAMA 1998 Apr 8;279(14):1094-9

Published errata appear in JAMA 1998 May 27;279(20):1614 and 1998 Jul
22-29;280(4):328


Does this patient have deep vein thrombosis?

Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
[log in to unmask]

OBJECTIVE: To review the validity of the clinical assessment and diagnostic
tests in patients with suspected deep vein thrombosis (DVT). METHODS: A
comprehensive review of the literature was conducted by searching MEDLINE
from 1966 to April 1997. RESULTS: Individual symptoms and signs alone do not
reliably predict which patients have DVT. Overall, the diagnostic properties
of the clinical examination are poor; the sensitivity of the clinical
examination ranges from 60% to 96%, and the specificity ranges from 20% to
72%. However, using specific combinations of risk factors, symptoms, and
physical signs for DVT, clinicians can reliably stratify patients with
suspected DVT into low, moderate, or high pretest probability categories of
actually suffering from DVT. This stratification process in combination with
noninvasive testing, such as compression ultrasonography, simplifies the
management strategies for patients with suspected DVT. CONCLUSIONS: Use of a
clinical prediction guide that includes specific factors from both the
history and physical examination in combination with noninvasive tests
simplifies management strategies for patients with suspected DVT.

Comments:


Comment in: ACP J Club 1998 Sep-Oct;129(2):47
Comment in: JAMA 1998 Dec 2;280(21):1828-9

____________

Lancet 1997 Dec 20-27;350(9094):1795-8



Value of assessment of pretest probability of deep-vein thrombosis in
clinical management.

Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, Clement C,
Robinson KS, Lewandowski B
Department of Medicine, University of Ottawa, Ontario, Canada.

BACKGROUND: When ultrasonography is used to investigate deep-vein
thrombosis, serial testing is recommended for those who test negative
initially. Serial testing is inconvenient for patients and costly. We aimed
to assess whether the calculation of pretest probability of deep-vein
thrombosis, with a simple clinical model, could be used to improve the
management of patients who present with suspected deep-vein thrombosis.
METHODS: Consecutive outpatients with suspected deep-vein thrombosis had
their pretest probability calculated with a clinical model. They then
underwent compression ultrasound imaging of proximal veins of the legs.
Patients at low pretest probability underwent a single ultrasound test. A
negative ultrasound excluded the diagnosis of deep-vein thrombosis whereas a
positive ultrasound was confirmed by venography. Patients at moderate
pretest probability with a positive ultrasound were treated for deep-vein
thrombosis whereas patients with an initial negative ultrasound underwent a
single follow-up ultrasound 1 week later. Patients at high pretest
probability with a positive ultrasound were treated whereas those with
negative ultrasound underwent venography. All patients were followed up for
3 months for thromboembolic complications. FINDINGS: 95 (16.0%) of all 593
patients had deep-vein thrombosis; 3%, 17%, and 75% of the patients with
low, moderate, and high pretest probability, respectively, had deep-vein
thrombosis. Ten of 329 patients with low pretest probability had the
diagnosis confirmed, nine at initial testing and one at follow-up. 32 of 193
patients with moderate pretest probability had deep-vein thrombosis, three
diagnosed by the serial (1 week) test, and two during follow-up. 53 of 71
patients with high pretest probability had deep-vein thrombosis (49 by the
initial ultrasound and four by venography). Only three (0.6%) of all 501
(95% CI 0.1-1.8) patients diagnosed as not having deep-vein thrombosis had
events during the 3-month follow-up. Overall only 33 (5.6%) of 593 patients
required venography and serial testing was limited to 166 (28%) of 593
patients. INTERPRETATION: Management of patients with suspected deep-vein
thrombosis based on clinical probability and ultrasound of the proximal deep
veins is safe and feasible. Our strategy reduced the need for serial
ultrasound testing and reduced the rate of false-negative or false-positive
ultrasound studies.



Dr Chris Burton
GP, Sanquhar, Dumfriesshire
Member of WestNet, the West of Scotland Primary Care Research Network
http://www.btinternet.com/~chrisburton/heart.htm



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