D-dimer testing as the initial test for suspected pulmonary embolism. Appropriateness of prescription and physician compliance to guidelines.

OBJECTIVES: Recent studies have shown that strategies for pulmonary embolism diagnosis which have included D-dimer testing have been most cost effective. The objective of this study is to evaluate the impact of a new strategy for pulmonary embolism diagnosis based on D-dimer results. METHODS: A prospective survey was conducted in the emergency ward and three medical departments of a university teaching hospital. Guidelines for diagnosis of PE were established and implemented through an educational intervention and a specific order form. D-dimer (ELISA) was required for all patients suspected of having PE. A result above 500 ng/ml was to be followed by an a pulmonary imaging procedure. Appropriateness of prescription of D-dimer and non-compliance with guidelines (absence of diagnostic imaging procedure following D-dimer results above 500 ng/ml) were evaluated. RESULTS: One-hundred sixty patients were studied. D-dimer test was performed in 154 patients (96.3%) suspected of PE during a two-month period. Test results were above 500 ng/ml in 111 cases. PE was confirmed in 20 cases. Twenty percent (31/154) of the D-dimer prescriptions were inappropriate. Among those with D-dimer results above 500 ng/ml, 45% (50/111) of the patients experienced no imaging procedure. CONCLUSIONS: Despite implementation of clinical guidelines for its use, D-dimer was excessively prescribed. A large proportion of results was not taken in consideration by prescribers. Often new technologies have good experimental results, but behave differently when used routinely in ordinary care settings. It is important that field studies be developed to evaluate the effectiveness of new technologies.

Intravascular lymphomatosis (neoplastic angioendotheliosis) of the central nervous system: case report and literature review.

A 63-year-old woman developed gradual slowness, recurrent multifocal deficits, severe constitutional symptoms and hypopituitarism which progressed to death over 2.5 months. Elevation in lactico dehydrogenases was the main biological abnormality. Necropsy showed an intravascular malignant proliferation which proved to be a lymphoma of B-lineage. In order to better define diagnostic criteria, we reviewed previously reported cases of intravascular lymphomatosis of the central nervous system. A strategy for establishing the diagnosis is proposed.

[Acute sphenoid sinusitis in adults]. / Les sinusites sphénoïdales aiguës de l'adulte.

Seven cases of acute sphenoid sinusitis were reviewed. Two happened after deep sea diving. Headache of variable location and fever were the most predominant presenting symptoms (5/7). Purulent discharge in the cavum was present in three. Correct diagnosis was delayed from six to twenty-four days after beginning of symptoms, when a neurologic deficit became apparent : mainly paralysis of the sixth and third cranial nerves. Computed axial tomography was the most useful radiologic procedure for demonstrating sinus opacification in every patient. Two patients died, three had complete recovery, one had persistent epileptic focus after brain abscess. Last patient had paraparesis and incontinence of urine after study of cerebrospinal fluid (C. S. F.) flow with methylene blue. Cannulation of the sphenoid sinus was performed in two patients and surgical drainage in three. Gram negative microorganisms and Staphylococcus aureus were isolated from the sphenoid sinus of only three patients. Blood cultures were negatives in every cases and C. S. F. in six. First choice antibiotics was an association of aminoglucosides and broad-spectrum penicillin in six cases. It always had to be changed.

[Septicemia in cirrhotic patients]. / Septicémies chez le cirrhotique.

The clinical features of 22 patients with cirrhosis of the liver complicated by septicaemia were studied retrospectively and compared with a control group of 52 patients with septicaemia without cirrhosis. The incidence of septicaemia was higher in the cirrhotic group (4.25 p. 100) than in the control group (0.64 p. 100). The overall incidence of cirrhosis in patients with septicaemia was 19 p. 100. Nine of the 22 cirrhotic patients and 16 patients in the control group died. Prognostic factor common to both groups of patients were: shock, coma, delayed apyrexia and the isolation of more than one infecting organism on blood culture. Poor prognostic factors specific to the cirrhotic patients were the presence of ascites, especially if infected, and signs of hepatocellular failure.

[Carcinoid tumor of the ampulla of Vater and Recklinghausen's neurofibromatosis]. / Tumeur carcinoïdienne vatéro-duodénale et neurofibromatose de Recklinghausen.

We report the fifth case of carcinoid tumour of Vater ampulla with Von Recklinghausen's neurofibromatosis. We have reviewed the literature and discussed the significance of such an association which seems fortuitous.

[Osteoarthritis caused by dematiaceous fungi. Apropos of 3 cases]. / Ostéoarthrites à champignons noirs (dématiés). A propos de 3 observations.

Three cases of osteoarthritis due to dematiaceous fungi are reported. The first case, a Drechslera longirostrata spondylitis complicating prosthetic valve fungal endocarditis responded only to the association of Amphotericin B and Ketoconazole. The second patient had chronic osteoarthritis of the knee due to Phialophora parasitica resistant to medical and surgical treatment after renal transplantation. These two cases are the first and the second known reports of clinical infection with these fungi. The third patient had osteoarthritis of the patella complicating a skin infection by a thorn prick. This was cured by surgical excision and 3 months' medical treatment. These cases of infections osteoarthritis of the knee followed subcutaneous abscesses. Deep tissue infections with dematiaceous fungi with osteoarthritic involvement are very rare (6 cases of Drechslera and 8 cases of Phialophora have been reported). These fungi are opportunist saprophytes of plants in subtropical regions. They are characterised on culture by their brown and black pigmentation and microscopy shows septated filaments. Cutaneous effraction is the usual portal of entry in man; patients commonly have depression of their immune systems. Osteoarthritis is generally due to local extension of a subcutaneous abscess. The functional sequellae can be very serious. Treatment comprises surgical excision of the infected tissues with antifungal drugs which may have to be given in association.

[Chronic pneumonia caused by paraffin oil and pleural modifications: mesothelial hyperplasia and mesothelioma]. / Pneumopathie chronique à l'huile de paraffine et modifications pleurales: hyperplasie mésothéliale et mésothéliome.

A 82 years old woman with no past history of cardiac or pulmonary disease or asbestos exposure, but with chronic administration of paraffin oil as laxative, had lipid pneumonia and a primary neoplasic pleural effusion. From the reported case, the authors discuss the possible part of mineral oil as pleural carcinogenic factor (mesothelioma).