Utility and limitations of patient-adjusted D-dimer cut-off levels for diagnosis of venous thromboembolism-A systematic review and meta-analysis.

PURPOSE: To systematically assess test performance of patient-adapted D-dimer cut-offs for the diagnosis of venous thromboembolism (VTE). METHODS: Systematic review and analysis of articles published in PubMed, Embase, ClinicalTrials.gov, and Cochrane Library databases. Investigations assessing patient-adjusted D-dimer thresholds for the exclusion of VTE were included. A hierarchical summary receiver operating characteristic model was used to assess diagnostic accuracy. Risk of bias was assessed by Quality Assessment of Diagnostic Accuracy Studies 2 score. RESULTS: A total of 68 studies involving 141,880 patients met the inclusion criteria. The standard cut-off revealed a sensitivity of 0.99 (95% confidence interval [CI] 0.98-0.99) and specificity of 0.23 (95% CI 0.16-0.31). Sensitivity was comparable to the standard cut-off for age-adjustment (0.97 [95% CI 0.96-0.98]) and YEARS algorithm (0.98 [95% CI 0.91-1.00]) but lower for pretest probability (PTP)-adjusted (0.95 [95% CI 0.89-0.98) and COVID-19-adapted thresholds (0.93 [95% CI 0.82-0.98]). Specificity was significantly higher across all adjustment strategies (age: 0.43 [95% CI 0.36-0.50]; PTP: 0.63 [95% CI 0.51-0.73]; YEARS algorithm: 0.65 [95% CI 0.39-0.84]; and COVID-19: 0.51 [95% CI 0.40-0.63]). The YEARS algorithm provided the best negative likelihood ratio (0.03 [95% CI 0.01-0.15]), followed by age-adjusted (both 0.07 [95% CI 0.05-0.09]), PTP (0.08 [95% CI 0.04-0.17), and COVID-19-adjusted thresholds (0.13 [95% CI 0.05-0.32]). CONCLUSIONS: This study indicates that adjustment of D-dimer thresholds to patient-specific factors is safe and embodies considerable potential for reduction of imaging. However, robustness, safety, and efficiency vary considerably among different adjustment strategies with a high degree of heterogeneity.

Tram, rail, bicycle: An unhappy triad? Rising incidence and resource consumption of tramline-associated bicycling accidents in Bern, Switzerland.

Bicycle traffic and the number of accidents have been increasing in Switzerland in recent years. However, little is known about specific types of bicycling accidents - such as tramline-associated bicycling accidents (TABA) - that are potentially avoidable. This retrospective single center study of emergency department (ED) consultations analyzed TABA in the city of Bern, Switzerland. We analyzed the medical records of adult patients who presented to the ED after any bicycle accident. Patient and consultation characteristics were extracted. Incidence, important characteristics and ED resource consumption of TABA were compared with bicycle accidents that did not involve tramlines (BA). Furthermore, injury patterns and predictors of resource consumption were determined in TABA. We included a total of 298 TABA and 2351 BA over the 5.6-year study period. TABA accounted for 11.2 % of all bicycling accidents. Descriptive analysis revealed a significant increase between 2013 (lowest) and 2016 (highest) of 33.0 % in the total number of BA and 132 % in the total number of TABA. Compared to BA, TABA patients were significantly older, more often female, had a less urgent triage, and less often needed resuscitation bay treatment, hospitalization or ICU-admission (all p < 0.05). In multivariable analysis, TABA were associated with greater needs for ED resources. Most TABA injuries were to limbs (70.5 %) or the head (53.0 %), including intracranial hemorrhage (2.3 %). The radiological work-up consumed most of the resources (37.5 %), followed by physicians' work (25.8 %). Statistically significant predictors of ED resource consumption in TABA were age, triage, resuscitation bay treatment, injuries to head/clavicle, and intoxication. One out of ten patients was intoxicated. Although TABA is associated with less severe trauma than BA, it bears the risk of significant morbidity and high ED resource needs. Intoxications contribute to this problem. Our findings underline the need for preventive measures to reduce TABA in the future.

Increased S-100 B levels are associated with fractures and soft tissue injury in multiple trauma patients.

BACKGROUND: S-100 B protein was identified as a biomarker for traumatic brain injury, but studies suggest that extracranial injuries may also lead to increased S-100 B serum levels. In this study, we aim to quantify the impact of injury patterns on S-100 B levels in patients with suspected multiple trauma. METHODS: Patients with suspected multiple trauma treated at a Level 1 Trauma centre in Switzerland were included in this retrospective patient chart review. Extent of injuries and severity was assessed and S-100 B levels on admission measured. Potential predictors of increased S-100 B levels (>0.2 µg/L) were identified through uni- and multivariable analyses. RESULTS: In total, 1,338 patients with suspected multiple trauma were included. Multivariable logistic regression showed a significant association with increased S-100 B levels in long bone fracture (OR 2.3, 95% CI: 1.3-4.1, p = 0.004), non-long bone fracture (OR 3.0, 95% CI: 2.2-4.3, p<0.001), thoracic injury (OR 2.6, 95% CI: 1.6-4.2, p<0.001), and deep tissue injury/wounds (OR 1.9, 95% CI: 1.4-2.6, p<0.001). Head trauma with intracerebral bleeding was only weakly associated (OR 2.0, 95% CI 1.2-3.5, p = 0.01) and head trauma without intracranial bleeding was not associated with an increased S-100 B protein level (p = 0.71). Trauma severity was also related to increased S-100 B levels (OR per ISS: 1.1, 95% CI 1.0-1.1, p<0.001). S-100 B levels <0.57 µg/L had a high diagnostic value to rule out in-hospital mortality (negative predictive value: 1.0, 95% CI: 0.98-1.00). CONCLUSION: Fractures and thoracic injuries appeared as main factors associated with increased S-100 B levels. Head injury may only play a minor role in S-100 B protein elevation in multiple trauma patients. A normal S-100 B has a good negative predictive value for in-hospital mortality. S100-B levels were associated with trauma severity and might thus be of use as a prognostic marker in trauma patients.

Renal Function-Adjusted D-Dimer Levels in Critically Ill Patients With Suspected Thromboembolism.

OBJECTIVES: Diagnosing thromboembolic disease typically includes D-dimer testing and use of clinical scores in patients with low to intermediate pretest probability. However, renal dysfunction is often observed in patients with thromboembolic disease and was previously shown to be associated with increased D-dimer levels. We seek to validate previously suggested estimated glomerular filtration rate-adjusted D-dimer cutoff levels. Furthermore, we strive to explore whether the type of renal dysfunction affects estimated glomerular filtration rate-adjusted D-dimer test characteristics. DESIGN: Single-center retrospective data analysis from electronic healthcare records of all emergency department patients admitted for suspected thromboembolic disease. SETTING: Tertiary care academic hospital. SUBJECTS: Exclusion criteria were as follows: age less than 16 years old, patients with active bleeding, and/or incomplete records. INTERVENTIONS: Test characteristics of previously suggested that estimated glomerular filtration rate-adjusted D-dimer cutoff levels (> 333 µg/L [estimated glomerular filtration rate, > 60 mL/min/1.73 m], > 1,306 µg/L [30-60 mL/min/1.73 m], and > 1,663 µg/L [< 30 mL/min/1.73 m]) were validated and compared with the conventional D-dimer cutoff level of 500 µg/L. MAIN RESULTS: A total of 14,477 patients were included in the final analysis, with 467 patients (3.5%) diagnosed with thromboembolic disease. Renal dysfunction was observed in 1,364 (9.4%) of the total population. When adjusted D-dimer levels were applied, test characteristics remained stable: negative predictive value (> 99%), sensitivity (91.2% vs 93.4%), and specificity (42.7% vs 50.7%) when compared with the conventional D-dimer cutoff level to rule out thromboembolic disease (< 500 µg/L). Comparable characteristics were also observed when adjusted D-dimer cutoff levels were applied in patients with acute kidney injury (negative predictive value, 98.8%; sensitivity, 95.8%; specificity, 39.2%) and/or "acute on chronic" renal dysfunction (negative predictive value, 98.0%; sensitivity, 92.9%; specificity, 48.5%). CONCLUSIONS: D-Dimer cutoff levels adjusted for renal dysfunction appear feasible and safe assessing thromboembolic disease in critically ill patients. Furthermore, adjusted D-dimer cutoff levels seem reliable in patients with acute kidney injury and "acute on chronic" renal dysfunction. In patients with estimated glomerular filtration rate less than 60 mL/min/1.73 m, the false-positive rate can be reduced when estimated glomerular filtration rate-adjusted D-dimer cutoff levels are applied.

[Sequelae of hernia repair: What are the key issues?] / Folgezustände nach Hernienchirurgie: Was ist zu beachten?

Sequelae of hernia repair: What are the key issues? Abstract. Since hernia repair is increasingly performed as day case surgery, general practitioners are becoming progressively involved in postoperative care. Early sequelae must be differentiated from late sequelae of hernia repair. Hematomas, seromas and acute pain are frequent early postoperative problems, while at a later stage recurrence and potentially chronifying pain are of importance. The focus of this review is on aftercare, frequent postoperative problems and their therapeutic options.