Related Articles

Mycosis fungoides.

Crit Rev Oncol Hematol. 2008 Feb;65(2):172-82

Authors: Zinzani PL, Ferreri AJ, Cerroni L

Mycosis fungoides (MF) constitutes the most frequent cutaneous T-cell lymphoma. Sezary syndrome is considered by some authors to be an erythrodermic leukemic variant of MF, but is classified separately in the new WHO-EORT classification of cutaneous lymphomas. MF usually occurs in old adults with a 2:1 male to female ratio. Its prognosis is variable and strongly conditioned by the extent and type of skin involvement and presence of extracutaneous disease. Patients with stage IA-disease have an excellent prognosis with an overall long-term life expectancy that is similar to an age-, sex-, and race-matched control population. Almost all patients with stage IA MF will die from causes other than MF, with a median survival >33 years. Only 9% of these patients will progress to more extended disease. Patients with stage IB or IIA have a median survival greater than 11 years. These patients with T2 disease have a likelihood of disease progression of 24% and nearly 20% die of MF. Subgroups with stage IB or IIA have similar prognosis. Patients with cutaneous tumors or generalized erythroderma have a median survival of 3 and 4.5 years, respectively. The majority of these patients will die of MF. Extracutaneous dissemination is observed in less than 10% of patients with patch or plaque disease and in 30-40% of patients with tumors or generalized erythrodermatous involvement. Extracutaneous involvement is directly correlated to the extent of cutaneous disease. The most commonly involved organs are lung, spleen, liver, and gastrointestinal tract. Patients with extracutaneous disease at presentation involving either lymph nodes or viscera have a median survival of <1.5 years. Patients with plaque-type or erythrodermic MF may develop cutaneous tumors with large cell histology, often expressing CD30, which share a common clonal origin as observed in their preexisting MF and are associated with a less favourable outcome.

PMID: 17950613 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Acute myocardial infarction in sickle cell disease: a systematic review.

Crit Pathw Cardiol. 2008 Jun;7(2):133-8

Authors: Pannu R, Zhang J, Andraws R, Armani A, Patel P, Mancusi-Ungaro P

Myocardial infarction in young adults is, in practice, a diagnosis of exclusion. Given the fact that most of the patients with sickle cell disease are young and have predisposition to painful crisis, they are often overlooked for myocardial infarction. These patients often have few or no traditional risk factors for coronary artery disease, and risk stratification tools such as the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) models place these patients at low risk. Nonspecific changes on electrocardiogram are of little diagnostic value. Myocardial infarction is very often a missed diagnosis in patients with sickle cell disease. Diagnostic criteria, potential mechanisms, and management for acute myocardial infarction in patients with sickle cell disease are discussed.

PMID: 18520531 [PubMed - indexed for MEDLINE]

[Read more →]

Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry.

Thromb Haemost. 2008 Jul;100(1):26-31

Authors: Ruíz-Giménez N, Suárez C, González R, Nieto JA, Todolí JA, Samperiz AL, Monreal M,

A score that can accurately determine the risk of major bleeding during anticoagulant therapy may help to make decisions on anticoagulant use. RIETE is an ongoing registry of consecutive patients with acute venous thromboembolism (VTE). We composed a score to predict the risk for major bleeding within three months of anticoagulant therapy. Of 19,274 patients enrolled, 13,057 (67%) were randomly assigned to the derivation sample, 6,572 to the validation sample. In the derivation sample 314 (2.4%) patients bled (fatal bleeding, 105). On multivariate analysis, age >75 years, recent bleeding, cancer, creatinine levels >1.2 mg/dl, anemia, or pulmonary embolism at baseline were independently associated with an increased risk for major bleeding. A score was composed assigning 2 points to recent bleeding, 1.5 to abnormal creatinine levels or anemia, 1 point to the remaining variables. In the derivation sample 2,654 (20%) patients scored 0 points (low risk); 9,645 (74%) 1-4 points (intermediate); 758 (5.8%) >4 points (high risk). The incidences of major bleeding were: 0.3% (95% confidence interval [CI]: 0.1-0.6), 2.6% (95% CI: 2.3-2.9), and 7.3% (95% CI: 5.6-9.3), respectively. The likelihood ratio test was: 0.14 (95% CI: 0.07-0.27) for patients at low risk;2.96 (95% CI: 2.18-4.02) for those at high risk. In the validation sample the incidence of major bleeding was: 0.1%, 2.8%, and 6.2%, respectively. In conclusion, a risk score based on six variables documented at entry can identify VTE patients at low, intermediate, or high risk for major bleeding during the first three months of therapy.

PMID: 18612534 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Prognostic value of plasma N-terminal probrain natriuretic peptide levels in the acute respiratory distress syndrome.

Crit Care Med. 2008 Aug;36(8):2322-7

Authors: Bajwa EK, Januzzi JL, Gong MN, Thompson BT, Christiani DC

OBJECTIVE: Patients with acute respiratory distress syndrome suffer from profound cardiac and pulmonary derangement, including right ventricular strain and noncardiogenic pulmonary edema, which may potentially alter concentrations of cardiac natriuretic peptides. We sought to determine whether N-terminal probrain natriuretic peptide (NT-proBNP) levels are elevated in acute respiratory distress syndrome and whether they can serve as a marker of prognosis in this setting. DESIGN: Prospective study. SETTING: Tertiary-care academic medical center. PATIENTS: One hundred seventy-seven acute respiratory distress syndrome subjects enrolled in a prospective intensive care unit cohort. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: NT-proBNP was measured from blood taken within 48 hrs of acute respiratory distress syndrome onset. Patients were followed for the primary outcome of 60-day mortality and secondary outcomes of organ dysfunction and ventilator-free days. Seventy patients died (40%). Median NT-proBNP level was 3181 ng/L (interquartile range 723-9246 ng/L). NT-proBNP levels were significantly higher among nonsurvivors (p < .0001). Receiver operating curve analysis revealed an optimal NT-proBNP cut-point of 6813 ng/L for predicting death. Patients with levels above the cut-point had significantly higher odds of mortality on multivariable analysis (odds ratio 2.36, 95% confidence interval 1.11-4.99, p = .02) than those with levels below the cut-point. Kaplan-Meier survival analysis showed that this difference emerged early and was sustained (p < .0001). Patients with elevated NT-proBNP also had higher organ dysfunction scores (p < .0001) and fewer ventilator free days (p = .03) than those with lower NT-proBNP levels. CONCLUSIONS: NT-proBNP levels are elevated among acute respiratory distress syndrome patients and parallel the severity of the syndrome and likelihood for morbidity and mortality. This demonstrates the potential utility of this biomarker for prognosis in this disease.

PMID: 18596623 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Doubt and belief in physicians’ ability to prognosticate during critical illness: the perspective of surrogate decision makers.

Crit Care Med. 2008 Aug;36(8):2341-7

Authors: Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, Luce JM, White DB

OBJECTIVES: Although discussing a prognosis is a duty of physicians caring for critically ill patients, little is known about surrogate decision-makers’ beliefs about physicians’ ability to prognosticate. We sought to determine: 1) surrogates’ beliefs about whether physicians can accurately prognosticate for critically ill patients; and 2) how individuals use prognostic information in their role as surrogate decision-makers. DESIGN, SETTING, AND PATIENTS: Multicenter study in intensive care units of a public hospital, a tertiary care hospital, and a veterans’ hospital. We conducted semistructured interviews with 50 surrogate decision-makers of critically ill patients. We analyzed the interview transcripts using grounded theory methods to inductively develop a framework to describe surrogates’ beliefs about physicians’ ability to prognosticate. Validation methods included triangulation by multidisciplinary analysis and member checking. MEASUREMENTS AND MAIN RESULTS: Overall, 88% (44 of 50) of surrogates expressed doubt about physicians’ ability to prognosticate for critically ill patients. Four distinct themes emerged that explained surrogates’ doubts about prognostic accuracy: a belief that God could alter the course of the illness, a belief that predicting the future is inherently uncertain, prior experiences where physicians’ prognostications were inaccurate, and experiences with prognostication during the patient’s intensive care unit stay. Participants also identified several factors that led to belief in physicians’ prognostications, such as receiving similar prognostic estimates from multiple physicians and prior experiences with accurate prognostication. Surrogates’ doubts about prognostic accuracy did not prevent them from wanting prognostic information. Instead, most surrogate decision-makers view physicians’ prognostications as rough estimates that are valuable in informing decisions, but are not determinative. Surrogates identified the act of prognostic disclosure as a key step in preparing emotionally and practically for the possibility that a patient may not survive. CONCLUSIONS: Although many surrogate decision-makers harbor some doubt about the accuracy of physicians’ prognostications, they highly value discussions about prognosis and use the information for multiple purposes.

PMID: 18596630 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Corticosteroids for recurrent pericarditis: high versus low doses: a nonrandomized observation.

Circulation. 2008 Aug 5;118(6):667-71

Authors: Imazio M, Brucato A, Cumetti D, Brambilla G, Demichelis B, Ferro S, Maestroni S, Cecchi E, Belli R, Palmieri G, Trinchero R

BACKGROUND: Corticosteroid use is widespread in recurrent pericarditis, even if rarely indicated, and high doses (eg, prednisone 1.0 to 1.5 mg . kg(-1) . d(-1)) are generally recommended, although only weak evidence supports their use with possible severe side effects. The aim of this work was to compare side effects, recurrences and other complications, and hospitalizations of a low- versus high-dose regimen of prednisone for recurrent pericarditis. METHODS AND RESULTS: A retrospective review of all cases of recurrent pericarditis treated with corticosteroids according to different regimens from January 1996 to June 2004 was performed in 2 Italian referral centers. One hundred patients with recurrent pericarditis (mean age, 50.1+/-15.8 years; 57 females) were included in the study; 49 patients (mean age, 47.5+/-16.0; 25 females) were treated with low doses of prednisone (0.2 to 0.5 mg . kg(-1) . d(-1)), and 51 patients (mean age, 52.6+/-15.3; 32 females) were treated with prednisone 1.0 mg . kg(-1) . d(-1). Baseline demographic and clinical characteristics were well balanced across the groups. Each initial dose was maintained for 4 weeks and then slowly tapered. After adjustment for potential confounders (age, female gender, nonidiopathic origin), only high doses of prednisone were associated with severe side effects, recurrences, and hospitalizations (hazard ratio, 3.61; 95% confidence interval, 1.96 to 6.63; P<0.001). CONCLUSIONS: Use of higher doses of prednisone (1.0 mg . kg(-1) . d(-1)) for recurrent pericarditis is associated with more side effects, recurrences, and hospitalizations. Lower doses of prednisone should be considered when corticosteroids are needed to treat pericarditis.

PMID: 18645054 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Nontuberculous mycobacterial infections.

Arch Pathol Lab Med. 2008 Aug;132(8):1333-41

Authors: Jarzembowski JA, Young MB

CONTEXT: Nontuberculous mycobacteria include numerous acid-fast bacilli species, many of which have only recently been recognized as pathogenic. The diagnosis of mycobacterial disease is based on a combination of clinical features, microbiologic data, radiographic findings, and histopathologic studies. OBJECTIVE: To provide an overview of the clinical and pathologic aspects of nontuberculous mycobacteria infection, including diagnostic laboratory methods, classification, epidemiology, clinical presentation, and treatment. DATA SOURCES: Review of the pertinent literature and published methodologies. CONCLUSIONS: Nontuberculous mycobacteria include numerous acid-fast bacilli species, many of which are potentially pathogenic, and are classified according to the Runyon system based on growth rates and pigment production. Their slow growth hinders cultures, which require special medium and prolonged incubation. Although such methods are still used, newer nucleic acid-based technologies (polymerase chain reaction and hybridization assays) can rapidly detect and speciate some mycobacteria–most notably, distinguishing Mycobacterium tuberculosis from other species. Infections caused by these organisms can present as a variety of clinical syndromes, not only in immunocompromised patients but also in immunocompetent hosts. Most common among these are chronic pulmonary infections, superficial lymphadenitis, soft tissue and osteoarticular infections, and disseminated disease. Treatment of nontuberculous mycobacterial infections is difficult, requiring extended courses of multidrug therapy with or without adjunctive surgical intervention.

PMID: 18684037 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Percutaneous valve procedures: an update.

Curr Probl Cardiol. 2008 Aug;33(8):417-57

Authors: Tops LF, Kapadia SR, Tuzcu EM, Vahanian A, Alfieri O, Webb JG, Bax JJ

Valvular heart disease is an important cause of morbidity and mortality. Aortic stenosis and mitral regurgitation account for the majority of patients with native valve disease. Although surgical treatment provides satisfactory outcome, a large proportion of patients do not undergo a surgical intervention, because of the high estimated operative risk and multiple comorbidities. Recently, new techniques that enable percutaneous treatment of valvular heart disease have been developed and their feasibility has been reported in several studies. All techniques target a minimal invasive procedure with a low risk of procedure-related complications. In this article, an overview of the various percutaneous procedures for mitral and aortic valve disease is provided. In addition, an update on the ongoing trials in percutaneous valve procedures is presented. Finally, the role of imaging in performing percutaneous valve procedures will be discussed.

PMID: 18620099 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Evidence-based standards for cancer pain management.

J Clin Oncol. 2008 Aug 10;26(23):3879-85

Authors: Dy SM, Asch SM, Naeim A, Sanati H, Walling A, Lorenz KA

High-quality management of cancer pain depends on evidence-based standards for screening, assessment, treatment, and follow-up for general cancer pain and specific pain syndromes. We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel. Providers should routinely screen for the presence or absence and intensity of pain and should perform descriptive pain assessment for patients with a positive screen, including assessment for likely etiology and functional impairment. For treatment, providers should provide pain education, offer breakthrough opioids in patients receiving long-acting formulations, offer bowel regimens in patients receiving opioids chronically, and ensure continuity of opioid doses across health care settings. Providers should also follow up on patients after treatment for pain. For metastatic bone pain, providers should offer single-fraction radiotherapy as an option when offering radiation, unless there is a contraindication. When spinal cord compression is suspected, providers should treat with corticosteroids and evaluate with whole-spine magnetic resonance imaging scan or myelography as soon as possible but within 24 hours. Providers should initiate definitive treatment (radiotherapy or surgical decompression) within 24 hours for diagnosed cord compression and should follow up on patients after treatment. These standards provide an initial framework for high-quality evidence-based management of general cancer pain and pain syndromes.

PMID: 18688056 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Simplified criteria for the diagnosis of autoimmune hepatitis.

Hepatology. 2008 Jul;48(1):169-76

Authors: Hennes EM, Zeniya M, Czaja AJ, Parés A, Dalekos GN, Krawitt EL, Bittencourt PL, Porta G, Boberg KM, Hofer H, Bianchi FB, Shibata M, Schramm C, Eisenmann de Torres B, Galle PR, McFarlane I, Dienes HP, Lohse AW,

Diagnosis of autoimmune hepatitis (AIH) may be challenging. However, early diagnosis is important because immunosuppression is life-saving. Diagnostic criteria of the International Autoimmune Hepatitis Group (IAIHG) were complex and purely meant for scientific purposes. This study of the IAIHG aims to define simplified diagnostic criteria for routine clinical practice. Candidate criteria included sex, age, autoantibodies, immunoglobulins, absence of viral hepatitis, and histology. The training set included 250 AIH patients and 193 controls from 11 centers worldwide. Scores were built from variables showing predictive ability in univariate analysis. Diagnostic value of each score was assessed by the area under the receiver operating characteristic (ROC) curve. The best score was validated using data of an additional 109 AIH patients and 284 controls. This score included autoantibodies, immunoglobulin G, histology, and exclusion of viral hepatitis. The area under the curve for prediction of AIH was 0.946 in the training set and 0.91 in the validation set. Based on the ROC curves, two cutoff points were chosen. The score was found to have 88% sensitivity and 97% specificity (cutoff > or =6) and 81% sensitivity and 99% specificity (cutoff > or =7) in the validation set. CONCLUSION: A reliable diagnosis of AIH can be made using a very simple diagnostic score. We propose the diagnosis of probable AIH at a cutoff point greater than 6 points and definite AIH 7 points or higher.

PMID: 18537184 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries.

Int J Med Inform. 2008 Sep;77(9):613-20

Authors: Callen JL, Alderton M, McIntosh J

BACKGROUND: Hospital discharge summaries have traditionally been paper-based (handwritten or dictated), and deficiencies have often been reported. On the increase is the utilisation of electronic summaries, which are considered of higher quality than paper-based summaries. However, comparisons between electronic and paper-based summaries regarding documentation deficiencies have rarely been made and there have been none in recent years. OBJECTIVES: (1) To study the hospital discharge summaries, which were either handwritten or electronic, of a population of inpatients, with regard to documentation of information required for ongoing care; and (2) to compare the electronic with the handwritten summaries concerning documentation of this information. METHODS: The discharge summaries of 245 inpatients were examined for documentation of the items: discharge date; additional diagnoses; summary of the patient's progress in hospital; investigations; discharge medications; and follow-up (instructions to the patient's general practitioner). One hundred and fifty-one (62%) discharge summaries were electronically created and 94 (38%) were handwritten. Odds ratios (ORs) with their confidence intervals (CI) were estimated to show strength of association between the electronic summary and documentation of individual study items. RESULTS: Across all items studied, the electronic summaries contained a higher number of errors and/or omissions than the handwritten ones (OR 1.74, 95% CI 1.26-2.39, p<0.05). Electronic summaries more commonly documented a summary of the patient's progress in hospital (OR 18.3, 95% CI 3.33-100, p<0.05) and less commonly recorded date of discharge and additional diagnoses (respective ORs 0.17 (95% CI 0.09-0.31, p<0.05) and 0.33 (95% CI 0.15-0.89, p<0.05). CONCLUSION: It is not necessarily the case that electronic discharge summaries are of higher quality than handwritten ones, but free text items such as summary of the patient's progress may less likely be omitted in electronic summaries. It is unknown what factors contributed to incompleteness in creating the electronic discharge summaries investigated in this study. Possible causes for deficiencies include: insufficient training; insufficient education of, and thus realisation by, doctors regarding the importance of accurate, complete discharge summaries; inadequate computer literacy; inadequate user interaction design, and insufficient integration into routine work processes. Research into these factors is recommended. This study suggests that not enough care is taken by doctors when creating discharge summaries, and that this is independent of the type of method used. The importance of the discharge summary as a chief means of transferring patient information from the hospital to the primary care provider needs to be strongly emphasised.

PMID: 18294904 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

ERCP as an outpatient treatment: a review.

Gastrointest Endosc. 2008 Jul;68(1):118-23

Authors: Jeurnink SM, Poley JW, Steyerberg EW, Kuipers EJ, Siersema PD

BACKGROUND: ERCP on an outpatient basis could be as safe as on an inpatient basis and may also reduce medical costs. OBJECTIVE: To review the available literature to determine the safety of an ERCP performed on an outpatient basis. DESIGN: A review of the published literature was performed by searching PubMed, the Cochrane Library, EMBASE, and the Web of Science. PATIENTS: Patients who were undergoing an ERCP. INTERVENTIONS: An ERCP on an inpatient or outpatient basis. MAIN OUTCOME MEASUREMENTS: Patient and treatment characteristics, complications, and prolonged hospital admissions and readmissions. RESULTS: Eleven studies were included in this review, of which 5 were comparative studies, 5 were prospective studies, and 1 was a retrospective study. In these series, a total of 2483 patients underwent an ERCP on an outpatient basis and 2320 patients were admitted overnight after an ERCP. Complications were seen in 184 of 2483 outpatients (7%), of which 72% of complications (107/149) presented within 2 to 6 hours, 10% (15/149) within 6 to 24 hours, and 18% (27/149) more than 24 hours after the ERCP. Three percent of the inpatients (82/2320) developed a complication, of which 95% of complications (78/82) presented within 24 hours and 5% (4/82) presented more than 24 hours after the ERCP. A prolonged hospital stay after an ERCP was indicated in 6% of the designated outpatients (148/2483), whereas 3% of outpatients (74/2149) and <1% of inpatients (4/2320) were readmitted after discharge. LIMITATIONS: Limited data available. CONCLUSIONS: This review shows that, with a selective policy, an ERCP on an outpatient basis seems as safe as when performed on an inpatient basis.

PMID: 18308308 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Simple and accurate prediction of the clinical probability of pulmonary embolism.

Am J Respir Crit Care Med. 2008 Aug 1;178(3):290-4

Authors: Miniati M, Bottai M, Monti S, Salvadori M, Serasini L, Passera M

RATIONALE: Clinical probability assessment is a fundamental step in the diagnosis of pulmonary embolism. OBJECTIVES: To develop a predictive model for pulmonary embolism based on clinical symptoms, signs, and the interpretation of the electrocardiogram. METHODS: The model was developed from a database of 1,100 patients with suspected pulmonary embolism, of whom 440 had the disease confirmed by angiography or autopsy findings. It was validated in an independent sample of 400 patients with suspected pulmonary embolism (71% were inpatients). Easy-to-use software was developed for computing the clinical probability on palm computers and mobile phones. MEASUREMENTS AND MAIN RESULTS: The model comprises 16 variables of which 10 (older age, male sex, prolonged immobilization, history of deep vein thrombosis, sudden-onset dyspnea, chest pain, syncope, hemoptysis, unilateral leg swelling, electrocardiographic signs of acute cor pulmonale) are positively associated, and 6 (prior cardiovascular or pulmonary disease, orthopnea, high fever, wheezes, or crackles on chest auscultation) are negatively associated with pulmonary embolism. In the validation sample, 165 (41%) of 400 patients had pulmonary embolism confirmed by angiography. The prevalence of pulmonary embolism was 2% when the predicted clinical probability was slight (0 to 10%), 28% when moderate (11 to 50%), 67% when substantial (51 to 80%), and 94% when high (81 to 100%). There was no significant difference between inpatients and outpatients with respect to the prevalence of pulmonary embolism in the four probability categories. CONCLUSIONS: The proposed model is simple and accurate, and it may aid physicians when assessing the clinical probability of pulmonary embolism.

PMID: 18436792 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

CT angiography in the evaluation of acute pulmonary embolus.

AJR Am J Roentgenol. 2008 Aug;191(2):471-4

Authors: Costantino MM, Randall G, Gosselin M, Brandt M, Spinning K, Vegas CD

OBJECTIVE: The purpose of this study was to assess the appropriate use of CT angiography (CTA) in the diagnostic evaluation of acute pulmonary embolism (PE). MATERIALS AND METHODS: We reviewed a total of 575 CT angiograms obtained to evaluate for PE at a large level 1 trauma teaching hospital from January 2004 through March 2005. Various clinical settings were used for 267 inpatient (46%), 258 emergency department (45%), and 50 outpatient (9%) studies. We excluded CTA performed for other reasons, repeated CTA, and patient records with incomplete clinical data. On the basis of chart review in which the investigators were blinded to final diagnoses, pretest probability of PE according to the Wells criteria was retrospectively assigned to each patient. D-dimer values, when obtained, also were reviewed. The diagnosis of PE was based on final CTA reports. RESULTS: PE was diagnosed in 9.57% of 575 patients. Positivity rates by location were 32 (12%) of the 267 inpatients, 22 (8.5%) of the 258 emergency department patients, and one (2.0%) of the 50 outpatients. Three (< 1%) of the 575 patients had high probability of PE, even though 351 patients had gone directly to CTA. Of the other 572 patients, 158 (28%) had intermediate and 414 (72%) low probability of PE. In the high, intermediate, and low probability groups, two (67%), 24 (15%), and 29 (7%), respectively, of the patients had PE. A D-dimer assay was performed for 224 (39%) of the 575 patients. Thirty-nine (17%) of the 224 patients had normal results (< 0.5 microg/mL); 107 (48%), intermediate results (0.6-2.0 microg/mL); and 78 (35%), abnormal results (> 2.0 microg/mL). In the emergency department cohort, 151 (59%) of 258 patients underwent a D-dimer assay. Thirty-two (21%) of the 151 patients had normal results; 81 (54%), intermediate results; and 38 (25%), abnormal results. Only one patient with a normal D-dimer level and three patients with intermediate D-dimer levels had PE, the equivalent of 3% of each group. The number of CTA examinations ordered for patients with normal and intermediate D-dimer results was 146 (25% of the 575 total studies). Twenty-two (8%) of the 258 emergency department patients had PE, and clinical suspicion of PE was high for 11 (50%), intermediate for 10 (45%), and low for one (5%) of those patients. CONCLUSION: Our data showed suboptimal use of the Wells criteria and subjective overestimation of the probability of PE before ordering of CTA. Although a definitive acceptable PE positivity rate for CTA has not been established, the 10% yield represents overuse of CTA as a screening rather than a diagnostic examination.

PMID: 18647919 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Evidence-based recommendations for cancer nausea and vomiting.

J Clin Oncol. 2008 Aug 10;26(23):3903-10

Authors: Naeim A, Dy SM, Lorenz KA, Sanati H, Walling A, Asch SM

The experience of patients living with cancer and being treated with chemotherapy often includes the symptoms of nausea and vomiting. To provide a framework for high-quality management of these symptoms, we developed a set of key targeted evidence-based standards through an iterative process of targeted systematic review, development, and refinement of topic areas and standards and consensus ratings by a multidisciplinary expert panel as part of the RAND Cancer Quality-Assessing Symptoms Side Effects and Indicators of Supportive Treatment Project. For nausea and vomiting, key clinical standards included screening at the initial outpatient and inpatient visit, prophylaxis for acute and delayed emesis in patients receiving moderate to highly emetic chemotherapy, and follow-up after treatment for nausea and vomiting symptoms. In addition, patients with cancer and small bowel obstruction were examined as a special subset of patients who present with nausea and vomiting. The standards presented here for preventing and managing nausea and vomiting in cancer care should be incorporated into care pathways and should become the expectation rather than the exception.

PMID: 18688059 [PubMed - indexed for MEDLINE]

[Read more →]