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Research ArticleOriginal Research

General Practitioner–Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study

Nicola Mumoli, Josè Vitale, Matteo Giorgi-Pierfranceschi, Silvia Sabatini, Renato Tulino, Marco Cei, Eugenio Bucherini, Carlo Bova, Daniela Mastroiacovo, Alberto Camaiti, Gerardo Palmiero, Luca Puccetti and Francesco Dentali; for the PRACTICUS Study Investigators
The Annals of Family Medicine November 2017, 15 (6) 535-539; DOI: https://doi.org/10.1370/afm.2109
Nicola Mumoli
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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  • For correspondence: nimumoli@tiscali.it
Josè Vitale
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Matteo Giorgi-Pierfranceschi
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Silvia Sabatini
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Renato Tulino
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Marco Cei
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Eugenio Bucherini
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Carlo Bova
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Daniela Mastroiacovo
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Alberto Camaiti
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Gerardo Palmiero
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Luca Puccetti
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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Francesco Dentali
Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy (Mumoli, Cei, Camaiti, Palmiero); Department of Internal Medicine, Ospedale Beata Vergine di Mendrisio, Ticino, Switzerland (Vitale); Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy (Giorgi-Pierfranceschi); Primary Ambulatory Care, Livorno, Italy (Sabatini); Primary Care, Porto Santo Stefano, Grosseto, Italy (Tulino); Department of Vascular Medicine, ASL Di Romagna, Ravenna, Italy (Bucherini); Department of Internal Medicine, Azienda Ospedaliera, Cosenza, Italy (Bova); Angiology Unit, ASL 1 Avezzano Sulmona L’Aquila, Avezzano (AQ), Italy (Mastroiacovo); Primary Ambulatory Care, Pisa, Italy (Puccetti); Department of Internal Medicine, Ospedale di Circolo, Varese, Varese, Italy (Dentali).
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    Figure 1

    Patient screening and study inclusion.

    VTE=venous thromboembolism

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    Table 1

    Patient Demographic and Clinical Characteristics (N = 1,107)

    CharacteristicsDVT (n=200)No DVT (n=907)
    Age, mean (SD), [range], y63.6 (±15.2) [20–101]63.8 (±14.9) [19–98]
    Men, No. (%)104 (52)587 (53)
    Site of DVT
     Femoral vein, No. (%)104 (52)n/a
     Popliteal vein, No. (%)152 (76)n/a
     Both, No. (%)56 (28)n/a
    • DVT=deep vein thrombosis; n/a=not applicable.

    • View popup
    Table 2

    Diagnostic Performance of General Practitioner–Performed Compression US for Proximal DVT

    DVT SiteSensitivity, % (95% CI)Specificity, % (95% CI)PPV, % (95% CI)NPV, % (95% CI)Accuracy, % (95% CI)Cohen κ, % (95% CI)
    Overall90.0 (88.2–91.8)97.1 (96.2–98.1)87.4 (85.4–89.3)97.8 (96.9–98.6)95.8 (94.7–97.0)0.86 (0.84–0.88)
    Femoral95.2 (93.9–96.5)98.8 (98.2–99.4)89.2 (87.4–91.0)99.5 (99.1–99.9)98.5 (97.7–99.2)0.91 (0.89–0.93)
    Popliteal89.5 (87.7–91-3)98.4 (97.7–99.2)90.1 (88.3–91.8)98.3 (97.6–99.1)97.2 (96.2–98.2)0.88 (0.86–0.90)
    Both98.7 (98.0–99.3)100 (99.9–100)100 (99.9–100)99.9 (99.7–100)99.9 (99.7–100)0.99 (0.98–0.99)
    • DVT = deep vein thrombosis; NPV = negative predictive value; PPV = positive predictive value; US = ultrasound.

    • Note: Diagnosis of physician expert in vascular US was the reference test.

Additional Files

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    Supplemental Appendix

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    • Supplemental data: Appendix - PDF file
  • The Article in Brief

    General Practitioner-Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study

    Nicola Mumoli , and colleagues

    Background Compression ultrasonography has many advantages as a tool to identify deep-vein thrombosis. This study assesses the diagnostic accuracy of compression ultrasonography performed by general practitioners who receive vascular ultrasound training in diagnosing suspected deep vein thrombosis of the lower limbs.

    What This Study Found General practitioners trained in compression ultrasonography have excellent accuracy and agreement in diagnosing symptomatic proximal deep vein thrombosis. In a study of more than 1,000 outpatients with clinically suspected deep vein thrombosis, diagnosis was performed by physician experts in vascular ultrasonography and GPs trained in the technique. Expert physicians diagnosed deep vein thrombosis in 200 patients, corresponding to an overall prevalence of 18 percent. Compression ultrasonography performed by GPs had sensitivity of 90 percent and specificity of 97 percent with diagnostic accuracy for deep vein thrombosis of 96 percent. Because sensitivity achieved by GPs appeared suboptimal, the authors call for future studies to evaluate the implementation of proper training strategies to maximize skill.

    Implications

    • The authors suggest that more rapid diagnosis, directly obtained by GPs in primary care, could improve appropriate management of deep vein thrombosis and help address the growing need for professionals trained in compression ultrasonography.
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The Annals of Family Medicine: 15 (6)
The Annals of Family Medicine: 15 (6)
Vol. 15, Issue 6
November/December 2017
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General Practitioner–Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study
Nicola Mumoli, Josè Vitale, Matteo Giorgi-Pierfranceschi, Silvia Sabatini, Renato Tulino, Marco Cei, Eugenio Bucherini, Carlo Bova, Daniela Mastroiacovo, Alberto Camaiti, Gerardo Palmiero, Luca Puccetti, Francesco Dentali
The Annals of Family Medicine Nov 2017, 15 (6) 535-539; DOI: 10.1370/afm.2109

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General Practitioner–Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study
Nicola Mumoli, Josè Vitale, Matteo Giorgi-Pierfranceschi, Silvia Sabatini, Renato Tulino, Marco Cei, Eugenio Bucherini, Carlo Bova, Daniela Mastroiacovo, Alberto Camaiti, Gerardo Palmiero, Luca Puccetti, Francesco Dentali
The Annals of Family Medicine Nov 2017, 15 (6) 535-539; DOI: 10.1370/afm.2109
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