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Validation of helical computed tomography for suspected pulmonary embolism: a near miss?

Division of General Internal Medicine, Department of Internal Medicine, Geneva Faculty of Medicine and Geneva University Hospital, Geneva, Switerland.
Journal of Thrombosis and Haemostasis (Impact Factor: 5.55). 02/2005; 3(1):14-6. DOI: 10.1111/j.1538-7836.2004.01073.x
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    ABSTRACT: Objective.  To determine the utility of high quantitative D-dimer levels in the diagnosis of pulmonary embolism.Methods.  D-dimer testing was performed in consecutive patients with suspected pulmonary embolism. We included patients with suspected pulmonary embolism with a high risk for venous thromboembolism, i.e. hospitalized patients, patients older than 80 years, with malignancy or previous surgery. Presence of pulmonary embolism was based on a diagnostic management strategy using a clinical decision rule (CDR), D-dimer testing and computed tomography.Results.  A total of 1515 patients were included with an overall pulmonary embolism prevalence of 21%. The pulmonary embolism prevalence was strongly associated with the height of the D-dimer level, and increased fourfold with D-dimer levels greater than 4000 ng mL−1 compared to levels between 500 and 1000 ng mL−1. Patients with D-dimer levels higher than 2000 ng mL−1 and an unlikely CDR had a pulmonary embolism prevalence of 36%. This prevalence is comparable to the pulmonary embolism likely CDR group. When D-dimer levels were above 4000 ng mL−1, the observed pulmonary embolism prevalence was very high, independent of CDR score.Conclusion.  Strongly elevated D-dimer levels substantially increase the likelihood of pulmonary embolism. Whether this should translate into more intensive diagnostic and therapeutic measures in patients with high D-dimer levels irrespective of CDR remains to be studied.
    Journal of Internal Medicine 07/2008; 264(2):195 - 200. DOI:10.1111/j.1365-2796.2008.01972.x · 5.79 Impact Factor
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    ABSTRACT: Objective. To determine the utility of high quantitative D-dimer levels in the diagnosis of pulmonary embolism. Methods. D-dimer testing was performed in consecutive patients with suspected pulmonary embolism. We included patients with suspected pulmonary embolism with a high risk for venous thromboembolism, i.e. hospitalized patients, patients older than 80 years, with malignancy or previous surgery. Presence of pulmonary embolism was based on a diagnostic management strategy using a clinical decision rule (CDR), D-dimer testing and computed tomography. Results. A total of 1515 patients were included with an overall pulmonary embolism prevalence of 21%. The pulmonary embolism prevalence was strongly associated with the height of the D-dimer level, and increased fourfold with D-dimer levels greater than 4000 ng mL(-1) compared to levels between 500 and 1000 ng mL(-1). Patients with D-dimer levels higher than 2000 ng mL(-1) and an unlikely CDR had a pulmonary embolism prevalence of 36%. This prevalence is comparable to the pulmonary embolism likely CDR group. When D-dimer levels were above 4000 ng mL(-1), the observed pulmonary embolism prevalence was very high, independent of CDR score. Conclusion. Strongly elevated D-dimer levels substantially increase the likelihood of pulmonary embolism. Whether this should translate into more intensive diagnostic and therapeutic measures in patients with high D-dimer levels irrespective of CDR remains to be studied.
    Journal of Internal Medicine 01/2008; · 5.79 Impact Factor
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    ABSTRACT: Thromboembolic events are an increasingly commonly recognized secondary complications in children treated for serious, life-threatening primary diseases. Nevertheless the incidence of venous thromboembolic disease remains 100 times less frequent in hospitalized children than hospitalized adults, as recent data suggest an incidence of 5,3/10.000 pediatric patients compared to an incidence of 2,5-5/100 in adult patients. Diseases usually associated with thromboembolic events in children are neoplasia, autoimmune or cardiac malformative disease. Contrarily to what is observed in the adult, the majority of deep vein thrombosis events occur at the upper limbs veins, usually at the place where devices for venous access like port-a-cath or central venous lines are inserted. Because of the relatively low incidence of venous thromboembolic events in children, the diagnostic approach used are largely extrapolated from guidelines obtained from adult studies. However, the diagnostic performances of some diagnostic tools like Doppler-Ultrasound are probably diminished in children. Moreover, the concept of developmental hemostasis, which stresses the point that the hemostatic system in children is quite different from the adult one, is widely accepted and clearly suggests that the diagnostic and therapeutic approach in pediatric patients may not be simply extrapolated from data obtained in adult studies.From a more practical point of view, the fact that the hemostatic system in children is a dynamic and evolving system, renders the therapeutic approach quite complex. In particular, doses of anticoagulants vary markedly across the pediatric age. The absence of adapted formulations of commonly used anticoagulants, for example the absence of liquid formulations of anti-vitamin K drugs, further complicates the administration and the correct monitoring of anticoagulation in children, and may diminish observance in adolescent patients. Even though the concept that “children are not little adults” is nowadays widely accepted, there is an urgent need for prospective studies to better assess the modalities of diagnosis and treatment of venous thromboembolic disease in this particular population. (J Mal Vasc 2006; 31: 135-142)
    Journal des Maladies Vasculaires 07/2006; 31(3):135-142. DOI:10.1016/S0398-0499(06)76532-5 · 0.24 Impact Factor

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