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The purpose of this project was to provide national guidance on the optimal use of 99mTc during a situation of reduced supply. To accomplish this, our objective at CADTH was:

Optimal Use Report - Canadian Agency for Drugs and Technologies in Health.

Version: 2012

Of the total population of patients who are evaluated for suspected PE, few are confirmed to have the condition, indicating a low diagnostic yield of current evaluation methods. Studies report a range of values for the diagnostic yield of CTPA, ranging from less than 5% to 30%, depending on the clinical characteristics of the patient pool, and use of risk stratification strategies. False-positive test results, which, depending on pretest probability, can occur in approximately 10% to 42% of patients who undergo CT scanning, can lead to unnecessary anticoagulation therapy, which carries substantial risk of adverse effects including hemorrhage (occasionally devastating or fatal), interactions with other medications, inconvenience in terms of attendance for repeated blood tests (possibly requiring time off work), implications for future dental and medical procedures, and costs (both to the patient and society). False-negative CT results, which also occur at high frequency (e.g., 1% to 11%), can lead to bypass of necessary treatment, complications, and death. The uncertain benefit of increased testing and the significant expense of PE could suggest that current CT utilization patterns for the diagnosis of PE are not cost-effective. This is reflected in the increased diagnosis of mild PEs, which, if treated, may increase costs and possible harms, and may not reduce mortality. In light of these concerns, it is important to assess whether there are other cost-effective and safe alternatives.

CADTH Optimal Use Report - Canadian Agency for Drugs and Technologies in Health.

Version: September 29, 2016

The purpose of this report is to review the clinical evidence on safety and the evidence based guidelines on the use of ionizing radiation in pregnant women.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: June 9, 2015

The objective of this report is to perform a systematic review of the beneficial and harmful effects of rivaroxaban 15 mg and 20 mg for the treatment of deep vein thrombosis (DVT) and/or pulmonary embolism (PE).

Common Drug Review - Canadian Agency for Drugs and Technologies in Health.

Version: August 2015

Study found that the post D-dimer model performed strongly and could be useful to predict individuals’ risk of recurrence of venous thromboembolism at any time up to 2–3 years, thereby aiding patient counselling and treatment decisions.

Health Technology Assessment - NIHR Journals Library.

Version: February 2016

This is an evidence report prepared by the University of Connecticut/Hartford Hospital Evidence-based Practice Center (EPC) examining the comparative efficacy and safety of prophylaxis for venous thromboembolism in major orthopedic surgery (total hip replacement [THR], total knee replacement [TKR], and hip fracture surgery [HFS]) and other nonmajor orthopedic surgeries (knee arthroscopy, injuries distal to the hip requiring surgery, and elective spine surgery).

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: March 2012

Patients subjected to major surgery of the abdomen are at considerable risk of developing blood clots in the veins of the lower limbs. These clots may detach and develop clots in the lungs and cause sudden death. Clots in the limbs may impaire the venous function leading to a life‐long tendency to swollen legs and leg ulceration. In order to avoid these complications patients are often offered protective medicine during the first week after surgery, but patients are probably at risk of developing clots up to one month after surgery. This review suggests that prophylaxis should be administered for at least one month after surgery.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: January 21, 2009

Venous thromboembolism (VTE) is a condition in which a blood clot (a thrombus) forms in a vein and then dislodges to travel in the blood (an embolus). A venous thrombus most commonly occurs in the deep veins of the legs or pelvis; this is then called a deep vein thrombosis (DVT). Blood flow through the affected vein can be limited by the clot, and it can cause swelling and pain in the leg. If it dislodges and travels to the lungs, to the pulmonary arteries, it is called a pulmonary embolism (PE), which in some cases may be fatal. VTE as a term includes both DVT and PE. Major risk factors for VTE include a prior history of DVT, age over 60 years, surgery, obesity, prolonged travel, acute medical illness, cancer, immobility, thrombophilia (an abnormal tendency for the blood to clot) and pregnancy.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: June 2012

This guideline covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA). Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions of up to 2 weeks are covered as well. This guideline is a stand-alone document, but is designed to be read alongside the Intercollegiate Stroke Working Party guideline ‘National clinical guideline for stroke’ which considers evidence for interventions from the acute stage into rehabilitation and life after stroke. The Intercollegiate Stroke Working Party guideline is an update of the 2004 2nd edition and includes all the recommendations contained within this guideline. This acute stroke and TIA guideline is also designed to be read alongside the Department of Health’s (DH) ‘National stroke strategy’ (NSS). Where there are differences between the recommendations made within this acute stroke and TIA guideline and the NSS, the Guideline Development Group (GDG) members feel that their recommendations are derived from systematic methodology to identify all of the relevant literature.

NICE Clinical Guidelines - National Collaborating Centre for Chronic Conditions (UK).

Version: 2008

There are widespread concerns within Veterans Affairs (VA) healthcare and in non-VA US healthcare that the costs of healthcare are rising at unsustainable rates. One driver of cost is the increasing use of radiology imaging procedures, particularly advanced imaging techniques such as computed tomography (CT) scanning, magnetic resonance imaging (MRI), and CT angiography. Most authorities agree that more appropriate use of certain imaging tests could both improve quality and save costs.

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: January 2015

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious potential complication in hospitalized patients. Thromboprophylaxis regimens include pharmacological and mechanical options such as intermittent pneumatic compression devices (IPCDs). There are a wide variety of IPCDs available, but it is uncertain if they vary in effectiveness or ease of use.

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: June 2015

Effectiveness and Comparative Effectiveness Reviews, systematic reviews of existing research on the effectiveness, comparative effectiveness, and comparative harms of different medical tests, are intended to provide relevant evidence to inform real-world health care decisions for patients, providers, and policymakers. In an effort to improve the transparency, consistency, and scientific rigor of the work of the Effective Health Care (EHC) Program, the Agency for Healthcare Research and Quality (AHRQ), the Scientific Resource Center, and the Evidence-based Practice Centers (EPCs), have developed this Methods Guide for Medical Test Reviews (also referred to as the Medical Test Methods Guide). We intend it to serve as a resource for the EPCs as well as for other investigators interested in conducting systematic reviews on medical tests. We hope it will be a practical guide both for those who prepare the systematic reviews and those who use them in clinical practice, research development, and in making policy decisions.

Agency for Healthcare Research and Quality (US).

Version: June 2012

The study found that the use of novel oral anticoagulants has advantages over warfarin in patients with atrial fibrillation, but there was no strong evidence that they should replace warfarin or low-molecular-weight heparin in the primary prevention, treatment or secondary prevention of venous thromboembolic disease.

Health Technology Assessment - NIHR Journals Library.

Version: March 2017

Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease subtype of pulmonary hypertension. It is a progressive disease characterized by the presence of non-resolving or recurrent thrombi distributed within the pulmonary arteries. This can obstruct or occlude the luminal space, eventually leading to increased pulmonary vascular resistance (PVR), pulmonary hypertension, and right-sided heart failure. Although the exact etiology of CTEPH remains poorly understood, it may arise following an initial episode of acute pulmonary embolism (PE); however, up to 60% of CTEPH patients have not had any antecedent episode of acute PE. The epidemiology of CTEPH is likewise not well established. Some surveillance data estimate CTEPH to occur in 0.1% to 0.5% of patients surviving an initial episode of acute PE; however, the true incidence of CTEPH is likely to be higher, owing to an unknown number of undetected cases either presenting occultly or latently in the setting of acute PE or through non-venous thromboembolism etiologies.

Common Drug Review - Canadian Agency for Drugs and Technologies in Health.

Version: July 2015

The authors concluded that pharmacological prophylaxis significantly reduced risk of thromboembolism without any increased risk of major bleeding and that unfractionated heparin and low molecular weight heparin were equally effective. This was a well-conducted study and the authors' conclusions are likely to be reliable for at-risk populations; applicability to all general medicine patients was less clear.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

This study investigated the accuracy of clinical gestalt compared with clinical prediction rules for estimating the pre-test probability of pulmonary embolism. The authors concluded that clinical gestalt of experienced clinicians and clinical prediction rules used by experienced and less-experienced clinicians have similar accuracy. Given that the extent of differences between the combined studies and the quality of the included studies are unknown, the conclusions may not be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2003

This review found that in patients with haemodynamically stable pulmonary embolus, recombinant tissue plasminogen activator did not reduce rates of objective recurrent pulmonary embolism or pulmonary embolism-related mortality compared to heparin. The review was limited by the small amount of evidence available and questionable study quality. The authors’ conclusions may require cautious interpretation.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

This review concluded that the time within the International Normalised Ratio target range (TTR) varied from 56% to 75% depending on whether data for the first three months were included. Substantial variation in treatment regimen, method to calculate TTR, and the possibility for TTR to be higher in clinical practice, means the generalisability of the overall results is uncertain.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2012

This review assessed the combined negative VIDAS D-dimer result and a non-high pre-test probability to exclude pulmonary embolism. The authors concluded that this method can safely and effectively exclude pulmonary embolism in outpatients with a suspected event. This was a largely well-conducted review, although a lack of clarity regarding study quality limited the interpretation of reliability.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

Systematic Reviews in PubMed

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