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CONTEXT: Pulmonary computed tomography angiography (CTA) and the Wells criteria both have interobserver variability in the assessment of pulmonary embolism (PE). Quantitative D-dimer assay findings have been shown to have a high negative predictive value in patients with low pretest probability of PE. OBJECTIVE: Evaluate roles for clinical probability and CTA in Emergency Department (ED) patients suspected of acute PE but having a low serum D-dimer level. DESIGN: Prospective observational study of ED patients with possible PE who underwent pulmonary CTA and had D-dimer levels =1.0 mug/mL. MAIN OUTCOME: Clinical probability of PE determined by ED physicians using standard published criteria; pulmonary CTAs read by initial and study radiologists kept unaware of D-dimer results. RESULTS: In 16 months, 744 patients underwent pulmonary CTA, with 347 study participants who had a D-dimer level = 1.0 mug/mL. In one participant, CTA showed a PE that was agreed on by both the initial and study radiologists. In six participants, the initial findings were reported as positive for PE but were not interpreted as positive by the study radiologist. In none of these participants was PE diagnosed on the basis of clinical probability, of findings on ancillary studies and three-month follow-up examination, or by another radiologist, unaware of findings, acting as a tiebreaker. CONCLUSION: Pulmonary CTA findings positive for acute embolism should be viewed with caution, especially if the suspected PE is in a distal segmental or subsegmental artery in a patient with a serum D-dimer level of =1.0 mug/mL. Furthermore, the Wells criteria may be of limited additional value in this group of patients with low D-dimer levels because most will have low or intermediate clinical probability of PE.
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PURPOSE: A prospective study was designed to determine if a screening quantitative serum D-dimer measurement of 1.0 microg/mL or less precludes pulmonary computed tomographic (CT) angiography in patients with possible acute pulmonary embolism (PE). MATERIALS AND METHODS: Over a period of 16 months, every patient seen in the emergency department in whom there was clinical suspicion of PE sufficient to warrant pulmonary CT angiography was also requested to have a quantitative serum D-dimer level measurement taken. All pulmonary CT angiography procedures were performed on a four-slice scanner and every examination was overread by a radiologist who was blinded to the D-dimer assay results. Three-month medical record and telephone follow-up was carried out for all participants who had a serum D-dimer level of 1.0 microg/mL or less to verify no new diagnosis or death from PE. RESULTS: In this prospective study, 361 consecutive patients who received pulmonary CT angiography had a D-dimer level of 1.0 microg/mL or less. There were 310 patients who had negative pulmonary CT angiography results and 50 patients who had indeterminate CT angiography results. Only one patient had positive pulmonary CT angiography findings. Minimum 3-month follow-up information was available for 349 patients, none of whom reported subsequent PE, including those with indeterminate pulmonary CT angiography results. CONCLUSION: The use of a screening D-dimer measurement of 1.0 microg/mL or less precludes pulmonary CT angiography in patients with possible acute PE. The use of this quantitative D-dimer assay would decrease radiation exposure, contrast medium toxicity, cost, and time for patients seen in the emergency medicine department.
Assuntos
Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia , Biomarcadores/sangue , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Prevalência , Estudos Prospectivos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios XRESUMO
100 teens ranked pain experienced for their most recent "shot"on three different scales: casual 0-10 scale (mean 3.3), faces scale (mean 2.8), and 10 cm visual analog scale (mean 2.4). All pain scores showed wide variation (poor validity). Pain severity values were not equivalent across the different pain scales with the casual 10 scale most likely to overestimate pain values.