Validation of the diagnostic utility of D-dimer measurement in patients with acute aortic syndrome.

OBJECTIVE: The objective of this study was to evaluate the validity of D-dimer measurements for the diagnosis of acute aortic syndrome in patients admitted to hospital with acute chest pain. METHODS: A retrospective observational study design was used. Consecutive patients ( n=887) admitted to a tertiary hospital with acute chest pain (acute aortic syndrome, 123; acute pulmonary embolism, 29; and other disease, 735) from the emergency department between January 2011 and April 2014 were assessed to validate the diagnostic value of D-dimer measurements. RESULTS: The D-dimer level was significantly increased in patients with acute aortic syndrome (median (interquartile range) 4.9 (2.0-17.4) µg/ml) compared with control patients (median (interquartile range) 0.6 (0.3-1.4) µg/ml; p<0.001). At a cut-off point of 0.5 µg/ml, the sensitivity for acute aortic syndrome was 0.97 (95% confidence interval 0.92-0.99) and was similar to that for acute pulmonary embolism (0.97 (0.82-0.99)). The age-adjusted D-dimer cut-off point, defined as age × 0.01 µg/ml in patients ⩾50 years, successfully reduced the number of false-positive diagnoses by 13%, while still retaining a high sensitivity (0.96 (0.91-0.99)). The five false-negative diagnoses of acute aortic syndrome included three patients with intramural haematoma, one patient with a penetrating aortic ulcer and one patient with an impending aortic rupture. A combination of probability assessment and the D-dimer approach reduced the number of false-negatives from five patients to two patients. CONCLUSIONS: This study demonstrated that the D-dimer test can distinguish acute aortic syndrome from other diseases presenting with acute chest pain with high sensitivity and modest specificity. Using the D-dimer approach presents limitations with some subtypes of acute aortic syndrome, such as intramural haematoma.

[Purpura fulminans (symmetric peripheral gangrene): 7-year consecutive case review in Japan].

BACKGROUND: Acute infectious purpura fulminans (AIPF), a rare syndrome of infection-induced ischemic necrosis of the extremities (symmetric peripheral gangrene), is due most often to Neisseria meningitidis in the US and the UK, but is not endemic to Japan. PURPOSE: We reviewed clinical AIPF manifestations in Japan. METHODS: (A) We retrospectively analyzed six cases of AIPF in the last seven years. (B) We reviewed the medical literature up to 2008 using PubMed search and Japana Centra Revuo Medicina (Igakuchuozasshi) findings. RESULTS: (A) None of the 6 subjects-5 men and 1 woman aged 44 to 69 old- had a history of splenectomy. Except for one case, their disease was community-acquired and immunocompetent. Causative organisms were Streptococcus pneuomoniae (66.7%), Gram negative rods, and Legionella pneumophilla. No localized infectious focus was apparent except for one of Legionella pneumonia. Systemic purpura progressed rapidly within 12 to 96 hours of initial fever or influenza-like symptoms. Main AIPF manifestations are shock and disseminated intervascular coagulation, but not all subjects had both. Six-month mortality was 33.3%, with death within two days of admission. Survivors all required at least two limbs to be amputated. (B) The Japanese literature reported AIPF occurring in 64 cases- 11 neonatal due to congenital protein C deficiency, seven pediatric, and 46 adults. Organisms most commonly involved were S. pneumoniae at 41.3%, and Neisseria meningitidis at 15.2%. The most common pathogen reported in a PubMed search was Neisseria meningitidis. CONCLUSIONS: In Japan, S. pneumoniae is the most frequent isolate associated with AIPF, and progression to AIPF occurs mainly in adults, who commonly suffer frequent amputations and high mortality. Rapid progressing systemic purpura following common-cold-like symptoms is the key to early diagnosis, even if the patient is immunocompetent, not splenectomized, or has no apparent infectious foci.

[Six-year review of cigarette ingestion in children--gastric lavage versus medical observation].

During 2006, the Japan Poison Information Center received 2583 inquiries about ingestion of cigarette, which is the most frequent household products ingested by children in Japan. During 2001-2006, two hundred and seventy-six children under seven years of age ingesting cigarettes and its related substances presented to the emergency department in Japan Red Cross Hospital Wakayama Center. The peak age was one year and younger, so-called "ingestion age". Patients were frequently detected chewing cigarettes and the situation of cases varied individually. It was impossible to estimate the amount of ingested cigarette based on the medical interview. Eighty-three percent of the patients were asymptomatic. Treatment strategy has been changed into a noninvasive one. Gastric lavage has not been performed by emergency physicians since 2001, and by pediatricians since 2006. After the medical observation for two hours following ingestion, all the children except one (who was hospitalized because of his family's request) were discharged from the emergency department. Independent of doing gastric lavage, all the 276 children had good prognosis. We conluded that ingestion of cigarette in children is generally benign. No gastric lavage, but medical observation for two hours following ingestion in emergency department is our recommendation of management.