Evaluation of the International Society on Thrombosis & Haemostasis scoring system & its modifications in diagnosis of disseminated intravascular coagulation: A pilot study from southern India

Background & objectives: Diagnosis of disseminated intravascular coagulation (DIC) rests primarily on the clinical profile along with supportive laboratory tests. The International Society on Thrombosis and Haemostasis (ISTH) had proposed a scoring system for the diagnosis of overt DIC. However, fibrinogen values which are supposed to be low are often found to be elevated due to the associated inflammation seen in some cases. Moreover, peripheral smear is known to show schistocytes, which is also not included in the score. This study was done to evaluate ISTH scoring system and its modifications in suspected DIC. Methods: Fifty-six patients were enrolled for the present study of whom; in four, fibrinogen assay could not be done. Modifications in the ISTH scoring with the exclusion of fibrinogen, i.e. modified ISTH (MI) score and subsequent inclusion of schistocytes, i.e. modified ISTH with schistocytes (MIS) score, were used. The modified scores were analyzed for diagnostic accuracy parameters and agreement with ISTH score. Results: Amongst 56 cases, 9/52 (17.3%), 22 (39.3%) and 17 (30.4%) were diagnosed as positive for overt DIC by ISTH, MI and MIS scores and mortality was 33, 22.7 and 17.6 per cent, respectively. The sensitivity, specificity, positive and negative predictive values for the MI score were 100, 74.4, 45 and 100 per cent and for MIS score were 100, 86, 60 and 100 per cent, respectively. The agreement between MI score and MIS score with ISTH score was moderate [?=0.502, 95% confidence interval (CI): 0.272-0.732, P<0.001] and substantial (?=0.681, 95% CI: 0.45-0.91, P<0.001). Interpretation & conclusions: In the present study, the calculated mortality was highest by ISTH score. Best agreement was between MIS score and ISTH score. In a resource-constrained setup where fibrinogen assay and therefore ISTH score is difficult, it is suggested that MIS score can be considered.

Diagnosis of non-overt disseminated intravascular coagulation made according to the International Society on Thrombosis and Hemostasis criteria with some modifications

BACKGROUND: An early diagnosis of disseminated intravascular coagulation (DIC) before its progression to an overt stage is necessary for early treatment and positive outcomes. In 2001, the Scientific and Standardization Committee (SCC) of the International Society on Thrombosis and Hemostasis (ISTH) proposed new criteria for the preclinical diagnosis of overt and non-overt DICs. We investigated the clinical usefulness of the modified ISTH criteria for non-overt DIC diagnosis. METHODS: We enrolled 296 DIC patients (170 males and 126 females) admitted and evaluated at the Gangnam Severance Hospital, Seoul, Korea, between March 2006 and April 2007. Hemostatic tests, including platelet counts, prothrombin time (PT), D-dimer levels with antithrombin, and protein-C levels, were evaluated by excluding negative scores with clinical signs, in which more than 5 points of interest denoted non-overt DIC. Mortality rates were also evaluated. RESULTS: There were 289 patients with increased D-dimer levels and significant parametric changes suggesting DIC progression. Protein C and antithrombin levels were lower (99.2% each) and appeared earlier in patients with non-overt DIC than in patients with overt DIC. In all, 125 (43.3%) patients had non-overt DIC and, of which 27 died (mortality rate, 21.6%). The sensitivity and specificity for mortality were 73.0% and 55.9%, respectively, which were same as those for the original ISTH criteria. CONCLUSION: The modified ISTH criteria can be used for the early detection of non-overt DIC, and may be useful for the improvement of outcomes of non-overt DIC patients.

Comparison between Diagnostic Criteria for Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Hemostasis (ISTH) and the Korean Society on Thrombosis and Hemostasis (KSTH) / 대한혈액학회지

BACKGROUND: The criteria set by the International Society on Thrombosis and Hemostasis (ISTH) with the criteria of the Korean Society on Thrombosis and Hemostasis (KSTH) for the diagnosis of DIC was compared to evaluate the agreement between two criteria and the characteristics of each criteria. METHODS: Two hundred ninety-six adult patients with sepsis (57 pneumonia, 75 hepatobiliary and gastrointestinal infection, 25 urinary tract infection, 51 infection associated with malignant diseases and 84 other causes) were studied. The rate of agreement in the diagnosis of DIC by the two diagnostic systems was analyzed. Characteristics of each criteria was also analyzed by the comparison of laboratory criteria. RESULTS: The kappa coefficient and concordance rate, agreement parameters in the diagnosis of DIC by the two diagnostic systems was 0.78 and 89.5%, respectively. The median platelet count was lower and FDP level was higher in the patients diagnosed by ISTH criteria than in patients diagnosed by KSTH criteria. CONCLUSION: The agreement between ISTH and KSTH criteria was significantly high.