Comparisons of oncological and functional outcomes among radical retropubic prostatectomy, high dose rate brachytherapy, cryoablation and high-intensity focused ultrasound for localized prostate cancer: A prospective, controlled, nonrandomized trial

Background: Several clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared. Objective: To directly compare the performance of 4 CDRs (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with D-dimer testing to exclude PE. Design: Prospective cohort study. Setting: 7 hospitals in the Netherlands. Patients: 807 consecutive patients with suspected acute PE. Intervention: The clinical probability of PE was assessed by using a computer program that calculated all CDRs and indicated the next diagnostic step. Results of the CDRs and D-dimer tests guided clinical care. Measurements: Results of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up. Results: Prevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal D-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and D-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% CI, 2.9% to 3.1%]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal D-dimer result. Limitation: Management was based on a combination of decision rules and D-dimer testing rather than only 1 CDR combined with D-dimer testing. Conclusion: All 4 CDRs show similar performance for exclusion of acute PE in combination with a normal D-dimer result. This prospective validation indicates that the simplified scores may be used in clinical practice. Primary Funding Source: Academic Medical Center, VU University Medical Center, Rijnstate Hospital, Leiden University Medical Center, Maastricht University Medical Center, Erasmus Medical Center, and Maasstad Hospital. © 2011 American College of Physicians

Quel rôle peut-on imputer aux banques à charte canadiennes dans la transmission des chocs monétaires des années quatre-vingt?

Cette recherche s’inscrit dans la foulée de nombreux travaux entrepris suite aux publications de Bernanke et Blinder (1988, 1992) ayant remis à l’avant-plan le rôle joué par le système bancaire dans la transmission de la politique monétaire. Nous proposons d’examiner la dynamique inhérente à certains postes du bilan des banques à charte canadiennes suite aux mouvement des principaux taux d’intérêt, habituellement jugés révélateurs des conditions monétaires du moment. Pour ce faire, nous avons recours à un modèle VAR hebdomadaire comportant à la fois, des éléments de l’actif et du passif des banques ainsi que les taux de rendement associés à divers instruments financiers. Cependant, dans le but de bien encadrer cette analyse, nous développons un modèle formel du comportement d’une banque où les seuls changements aux postes de son bilan suite aux mouvements de taux d’intérêt sont dictés par des ajustements de portefeuille visant à tirer avantage des écarts se creusant entre ceux-ci. Ce modèle théorique est soumis aux variations de taux d’intérêt issues du modèle empirique VAR. Les mouvements observés aux postes du bilan de cette banque « témoin » fournissent un guide utile permettant d’interpréter de façon éclairée les résultats empiriques obtenus. À cet égard, l’exercice proposé montre qu’il est possible d’établir un parallèle assez étroit entre l’évolution des postes du bilan de la banque hypothétique et celle captée par le modèle VAR et ainsi apporte un certain support à l’approche traditionnelle sur le rôle joué par les banques dans la transmission des chocs monétaires.This paper can be seen as a contribution to a growing literature initiated by Bernanke and Blinder (1988, 1992) which have examined the role played by the banking system in the transmission of monetary policy. We propose to study the dynamic behaviour of the balance sheet of Canadian chartered banks following a shock to some key interest rates which are good indicators of the prevailing monetary conditions. More specifically, we estimate a weekly VAR model which comprises key asset and liabilities elements as well as rates of return on major financial instruments. However, to guide this empirical inquiry, we set up a model of a representative bank which adjusts its balance sheet elements according to the interest rate spreads arising in the financial markets. This theoretical model is then subjected to the same interest rate shocks than those imposed on the VAR model: the adjustments observed in this laboratory will prove quite useful to assess the significance of the empirical results uncovered by the VAR model. Overall, we find that both approaches give rise to quite similar dynamic responses which tends to support the traditional role of the banking sector in the transmission of monetary policy

Qualitative point-of-care D-dimer testing compared with quantitative D-dimer testing in excluding pulmonary embolism in primary care

General practitioners can safely exclude pulmonary embolism (PE) by using the Wells PE rule combined with D-dimer testing. To compare the accuracy of a strategy using the Wells rule combined with either a qualitative point-of-care (POC) D-dimer test performed in primary care or a quantitative laboratory-based D-dimer test. We used data from a prospective cohort study including 598 adults suspected of PE in primary care in the Netherlands. General practitioners scored the Wells rule and carried out a qualitative POC test. All patients were referred to hospital for reference testing. We obtained quantitative D-dimer test results as performed in hospital laboratories. The primary outcome was the prevalence of venous thromboembolism in low-risk patients. Prevalence of PE was 12.2%. POC D-dimer test results were available in 582 patients (97%). Quantitative test results were available in 401 patients (67%). We imputed results in 197 patients. The quantitative test and POC test missed one (0.4%) and four patients (1.5%), respectively, with a negative strategy (Wells ≤ 4 points and D-dimer test negative) (P = 0.20). The POC test could exclude 23 more patients (4%) (P = 0.05). The sensitivity and specificity of the Wells rule combined with a POC test were 94.5% and 51.0% and, combined with a quantitative test, 98.6% and 47.2%, respectively. Combined with the Wells PE rule, both tests are safe to use in excluding PE. The quantitative test seemed to be safer than the POC test, albeit not statistically significant. The specificity of the POC test was higher, resulting in more patients in whom PE could be exclude

Co-occurrence of metabolic factors and the risk of coronary heart disease: A prospective cohort study in the Netherlands

Background -Prevalence of metabolic factors such as diabetes, hypertension, obesity, HDL and total cholesterol that are associated with an increased risk of coronary heart disease (CHD) is increasing worldwide. However, less is known about combinations of these factors that are associated with the highest CHD risk. Therefore, the associations between combinations of these metabolic factors and the incidence of CHD, acute myocardial infarction (AMI), and unstable angina pectoris (UAP) were studied in the Cardiovascular Registry Maastricht (CAREMA) cohort study. Methods - The CAREMA study consists of 21,148 participants, born in 1927–1977 and randomly sampled from Maastricht and surrounding communities in 1987–1997. At baseline, all participants completed a self-administered questionnaire. Height, weight, blood pressure, total and HDL cholesterol levels were measured during a physical examination. After follow-up of maximally 16.9 years, 780 CHD, 437 AMI, and 286 UAP cases of first occurrence were registered. Incidence rate ratios (RRs) were estimated using Cox proportional hazards models adjusted for age, sex, smoking, and alcohol consumption. Results - Compared with subjects without any of the metabolic factors, the RRs of CHD were 2.37, 4.34, and 7.36 for subjects with 1, 2, or = 3 metabolic factors, respectively. These RRs were higher for AMI but lower for UAP. Especially combinations of metabolic factors that included diabetes or both a low HDL (= 0.9 mmol/L in men; = 1.0 mmol/L in women) and high total cholesterol (= 6.21 mmol/L) were associated with increased risks. Conclusion - The risk of total CHD, AMI, and UAP varies considerably between different combinations of metabolic factors

Diagnostic prediction models for suspected pulmonary embolism: systematic review and independent external validation in primary care

OBJECTIVE To validate all diagnostic prediction models for ruling out pulmonary embolism that are easily applicable in primary care. DESIGN Systematic review followed by independent external validation study to assess transportability of retrieved models to primary care medicine. SETTING 300 general practices in the Netherlands. PARTICIPANTS Individual patient dataset of 598 patients with suspected acute pulmonary embolism in primary care. MAIN OUTCOME MEASURES Discriminative ability of all models retrieved by systematic literature search, assessed by calculation and comparison of C statistics. After stratification into groups with high and low probability of pulmonary embolism according to pre-specified model cut-offs combined with qualitative D-dimer test, sensitivity, specificity, efficiency (overall proportion of patients with low probability of pulmonary embolism), and failure rate (proportion of pulmonary embolism cases in group of patients with low probability) were calculated for all models. RESULTS Ten published prediction models for the diagnosis of pulmonary embolism were found. Five of these models could be validated in the primary care dataset: the original Wells, modified Wells, simplified Wells, revised Geneva, and simplified revised Geneva models. Discriminative ability was comparable for all models (range of C statistic 0.75-0.80). Sensitivity ranged from 88% (simplified revised Geneva) to 96% (simplified Wells) and specificity from 48% (revised Geneva) to 53% (simplified revised Geneva). Efficiency of all models was between 43% and 48%. Differences were observed between failure rates, especially between the simplified Wells and the simplified revised Geneva models (failure rates 1.2% (95% confidence interval 0.2% to 3.3%) and 3.1% (1.4% to 5.9%), respectively; absolute difference -1.98% (-3.33% to -0.74%)). Irrespective of the diagnostic prediction model used, three patients were incorrectly classified as having low probability of pulmonary embolism; pulmonary embolism was diagnosed only after referral to secondary care. CONCLUSIONS Five diagnostic pulmonary embolism prediction models that are easily applicable in primary care were validated in this setting. Whereas efficiency was comparable for all rules, the Wells rules gave the best performance in terms of lower failure rates

Detecting and Diagnosing Atrial Fibrillation (D2AF): study protocol for a cluster randomised controlled trial

Background: Atrial fibrillation is a common cause of stroke and other morbidity. Adequate treatment with anticoagulants reduces the risk of stroke by 60 %. Early detection and treatment of atrial fibrillation could prevent strokes. Atrial fibrillation is often asymptomatic and/or paroxysmal. Case-finding with pulse palpation is an effective screening method, but new methods for detecting atrial fibrillation have been developed. To detect paroxysmal atrial fibrillation ambulatory rhythm recording is needed. This study aims to determine the yield of case-finding for atrial fibrillation in primary care patients. In addition, it will determine the diagnostic accuracy of three different case-finding methods. Methods/Design: In a multicenter cluster randomised controlled trial, we compare an enhanced protocol for case-finding of atrial fibrillation with usual care. We recruit 96 practices. We include primary care patients aged 65 years or older not diagnosed with atrial fibrillation. Within each practice, a cluster of 200 patients is randomly selected and marked. Practices are evenly randomised to intervention or control group. The allocation is not blinded. When a marked patient visits an intervention practice, the case-finding protocol starts, consisting of: pulse palpation, sphygmomanometer with automated atrial fibrillation detection and handheld single-lead electrocardiogram (ECG). All patients with at least 1 positive test and a random sample of patients with negative tests receive a 12-lead ECG. Patients without atrial fibrillation on the 12-lead ECG, undergo additional continuous Holter and use the handheld single-lead ECG at home for 2 weeks. Control practices provide care as usual. The study runs for 1 year in each cluster. The primary outcomes are the difference in detection rate of new AF between intervention and control practices and the accuracy of three index tests to diagnose AF. We are currently recruiting practices. The 'Detecting and Diagnosing Atrial Fibrillation' (D(2)AF) study will determine the yield of an intensive case-finding strategy and the diagnostic accuracy of three index tests to diagnose atrial fibrillation in a primary care setting

Opportunistic screening versus usual care for detection of atrial fibrillation in primary care: cluster randomised controlled trial.

Objective To investigate whether opportunistic screening in primary care increases the detection of atrial fibrillation compared with usual care. Design Cluster randomised controlled trial. Setting 47 intention-to-screen and 49 usual care primary care practices in the Netherlands, not blinded for allocation; the study was carried out from September 2015 to August 2018. Participants In each practice, a fixed sample of 200 eligible patients, aged 65 or older, with no known history of atrial fibrillation in the electronic medical record system, were randomly selected. In the intention-to-screen group, 9218 patients eligible for screening were included, 55.0% women, mean age 75.2 years. In the usual care group, 9526 patients were eligible for screening, 54.3% women, mean age 75.0 years. Interventions Opportunistic screening (that is, screening in patients visiting their general practice) consisted of three index tests: pulse palpation, electronic blood pressure measurement with an atrial fibrillation algorithm, and electrocardiography (ECG) with a handheld single lead electrocardiographic device. The reference standard was 12 lead ECG, performed in patients with at least one positive index test and in a sample of patients (10%) with three negative tests. If 12 lead ECG showed no atrial fibrillation, patients were invited for more screening by continuous monitoring with a Holter electrocardiograph for two weeks. Main outcome measures Difference in the detection rate of newly diagnosed atrial fibrillation over one year in intention-to-screen versus usual care practices. Results Follow-up was complete for 8874 patients in the intention-to-screen practices and for 9102 patients in the usual care practices. 144 (1.62%) new diagnoses of atrial fibrillation in the intention-to-screen group versus 139 (1.53%) in the usual care group were found (adjusted odds ratio 1.06 (95% confidence interval 0.84 to 1.35)). Of 9218 eligible patients in the intention-to-screen group, 4106 (44.5%) participated in the screening protocol. In these patients, 12 lead ECG detected newly diagnosed atrial fibrillation in 26 patients (0.63%). In the 266 patients who continued with Holter monitoring, four more diagnoses of atrial fibrillation were found. Conclusions Opportunistic screening for atrial fibrillation in primary care patients, aged 65 and over, did not increase the detection rate of atrial fibrillation, which implies that opportunistic screening for atrial fibrillation is not useful in this setting

Diagnostic outcome management study in patients with clinically suspected recurrent acute pulmonary embolism with a structured algorithm

Introduction: The value of diagnostic strategies in patients with clinically suspected recurrent pulmonary embolism (PE) has not been established. The aim was to determine the safety of a simple diagnostic strategy using the Wells clinical decision rule (CDR), quantitative D-dimer testing and computed tomography pulmonary angiography (CTPA) in patients with clinically suspected acute recurrent PE. Materials and Methods: Multicenter clinical outcome study in 516 consecutive patients with clinically suspected acute recurrent PE without using anticoagulants. Results: An unlikely clinical probability (Wells rule 4 points or less) was found in 182 of 516 patients (35%), and the combination of an unlikely CDR-score and normal D-dimer result excluded PE in 88 of 516 patients (17%), without recurrent venous thromboembolism (VTE) during 3 month follow-up (0%; 95% CI 0.0-3.4%). CTPA was performed in all other patients and confirmed recurrent PE in 172 patients (overall prevalence of PE 33%) and excluded PE in the remaining 253 patients (49%). During follow-up, seven of these 253 patients returned with recurrent VTE (2.8%; 95% CI 1.2-5.5%), of which in one was fatal (0.4 %; 95 % CI 0.02-1.9%). The diagnostic algorithm was feasible in 98% of patients. Conclusions: A diagnostic algorithm consisting of a clinical decision rule, D-dimer test and CTPA is effective in the management of patients with clinically suspected acute recurrent PE. CTPA provides reasonable safety in excluding acute recurrent PE in patients with a likely clinical probability or an elevated D-dimer test for recurrent PE, with a low risk for fatal PE at follow-up