The impact of using different age-adjusted cutoffs of D-dimer in the diagnosis of pulmonary thromboembolism

Abstract Background Although the incidence of symptomatic pulmonary thromboembolism after elective surgery for degenerative musculoskeletal disorders is comparatively low, it is extremely detrimental to both patients and health-care providers. Therefore, its prevention is mandatory. We aimed to perform a cross-sectional analysis of deep venous thrombosis (DVT) before elective surgery for degenerative musculoskeletal disorders, including total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery, and identify the factors associated with the incidence of preoperative DVT. Methods The clinical data of patients aged ≥ 30 years who underwent TKA or THA, and spine surgery for lumbar or cervical degenerative disorders at our institution were retrospectively collected. D-dimer levels were measured preoperatively in all the patients scheduled for surgery. For the patients with D-dimer levels ≥ 1 µg/mL or who were determined by their physicians to be at high risk of DVT, the lower extremity vein was preoperatively examined for DVT on ultrasonography. Results Overall, we retrospectively evaluated 1236 consecutive patients, including 701 men and 535 women. Of the patients, 431 and 805 had D-dimer levels ≥ 1 and < 1 µg/mL, respectively. Of 683 patients who underwent lower extremity ultrasonography, 92 had proximal (n = 7) and distal types (n = 85) of DVT. The preoperative prevalence of DVT was 7.4 %. No patient had the incidence of postoperative symptomatic venous thromboembolism. A multivariate analysis revealed that age ≥ 80 years (odds ratio [OR], 95 % confidence interval [CI]: 2.8, 1.1–7.3), knee surgery (2.1, 1.1–4.0), American Society of Anesthesiologists (ASA) grade 2 (2.8, 1.2–6.8), ASA grades 3 or 4 (3.1, 1.0–9.4), and malignancy (1.9, 1.1–3.2) were significantly associated with DVT incidence. Conclusions This is the first study to conduct a cross-sectional analysis of preoperative DVT data of patients scheduled for elective surgery for degenerative musculoskeletal disorders. Although whether screening for preoperative DVT is needed to prevent postoperative symptomatic pulmonary thromboembolism remains to be clarified, our data suggested that DVT should be noted before surgery in the patients with advanced age, knee surgery, high ASA physical status, and malignancy.

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The impact of COVID‐19 on the sensitivity of D‐dimer for pulmonary embolism

Academic Emergency Medicine ◽

10.1111/acem.14348 ◽

2021 ◽

Author(s):

Samuel J. Elberts ◽

Ryan Bateman ◽

Alexandra Koutsoubis ◽

Kory S. London ◽

Jennifer L. White ◽

...

Keyword(s):

Pulmonary Embolism ◽

The Impact ◽

D Dimer

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368. Clinical Characteristics of Hospitalized COVID-19 American Indian Patients in Rural Arizona

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.563 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S253-S254

Author(s):

Amy Nham ◽

Ryan M Close

Keyword(s):

American Indians ◽

Median Number ◽

Clinic Visit ◽

Contact Tracing ◽

Shortness Of Breath ◽

Early Referral ◽

Increased Risk ◽

Wbc Count ◽

The Impact ◽

D Dimer

Abstract Background American Indians have an increased risk of serious complications from COVID-19 due to the high prevalence of comorbidities such as diabetes, heart disease, obesity, and asthma. To date, there has been limited analysis of COVID-19 in the AI population. This study describes the characteristics of hospitalized COVID-19 patients from a well-defined AI population in eastern Arizona. Additionally, we explored the impact of early referral via contact tracing versus those who self-presented. Methods Retrospective chart reviews were completed for patients hospitalized for COVID from March 29 to May 16, 2020. Summary statistics were used to describe demographics, symptoms, pre-existing conditions, and hospitalization data. Results We observed 447 laboratory-confirmed cases of COVID-19, resulting in 71 (15.9%) hospitalizations over a 7-week period and a hospitalization rate of 159 per 1,000 persons. Of the 50 hospitalizations reviewed sequentially, 56% were female, median age of 55 (IQR 44–65). Median number of days hospitalized was 4 (2–6), with 16% requiring intensive care unit support, 15% intubated, 12% readmitted, and 10% deceased. 67% had an epidemiological link, and 32% had an emergency department or outpatient clinic visit within 7 days of hospitalization. All patients were symptomatic; the most common symptoms were cough (90%), shortness of breath (78%), and subjective fever (66%). 86% of patients had a pre-existing condition; the most common pre-existing conditions were diabetes (66%), obesity (58%), and hypertension (52%, Figure 1). All patients had elevated LDH, 94% had elevated CRP, 86% had elevated d-dimer, and 40% had lymphopenia; only 10% had an elevated WBC count and 26% had thrombocytopenia (Table 1). 26% of the patients were referred in by the tracing team (Table 2). Analysis of 500 hospitalizations will be available in October 2020. Conclusion Most AI patients hospitalized had a pre-existing condition, symptoms of cough or shortness of breath, and elevated LDH, CRP, and d-dimer. More research is needed to understand the patterns of COVID-19 related disease in vulnerable populations, like AI/AN, and to examine the utility of early referral by contact tracing teams in rural settings which may guide future tracing strategies. Disclosures All Authors: No reported disclosures

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Use of heparin in patients with severe COVID-19: What is the evidence?

Research Society and Development ◽

10.33448/rsd-v10i6.15820 ◽

2021 ◽

Vol 10 (6) ◽

pp. e28910615820

Author(s):

Vitória Ribeiro Dantas Marinho ◽

Camila Vilar Oliveira Villarim ◽

Laura Cristina Costa e Silva ◽

André Luiz Costa e Silva ◽

Irami Araújo-Neto ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Web Of Science ◽

Pulmonary Thromboembolism ◽

Cytokine Release ◽

Beneficial Effects ◽

Heparin Administration ◽

Rapid Spread ◽

New Research ◽

D Dimer

The rapid spread of coronavirus disease (COVID-19) worldwide urges the need for studies on the illness and its management. The COVID-19 infection leads to hypercoagulation due to inflammatory cytokine release and D-dimer increase in critically ill patients, resulting in pulmonary thromboembolism (PE) and venous thromboembolism (VTE) evolving to sepsis and death. The study evaluated the currently existing evidence on heparin administration in patients with severe COVID-19. An integrative literature review was done by searching for scientific studies in the PubMed, Scopus, Embase, and Web of Science databases. The analyzed studies showed that heparin use in critically ill patients could efficiently prevent thrombotic events and reduce the exacerbated inflammatory process. However, further investigation on the effect on patients is still needed. The use of heparin in critically ill COVID-19 patients has been prescribed increasingly by doctors. But its use has not yet had its outcomes well established in the literature. Therefore, deeper investigations and new research development are needed to clarify potential beneficial effects.

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Validation and impact of a simplified clinical decision rule for diagnosing pulmonary embolism in primary care: design of the PECAN prospective diagnostic cohort management study

BMJ Open ◽

10.1136/bmjopen-2019-031639 ◽

2019 ◽

Vol 9 (10) ◽

pp. e031639 ◽

Cited By ~ 4

Author(s):

Rosanne van Maanen ◽

Frans H Rutten ◽

Frederikus A Klok ◽

Menno V Huisman ◽

Jeanet W Blom ◽

...

Keyword(s):

Primary Care ◽

Pulmonary Embolism ◽

False Negative ◽

Diagnostic Algorithm ◽

Clinical Decision ◽

Final Diagnosis ◽

Hospital Environment ◽

Diagnostic Study ◽

The Impact ◽

D Dimer

IntroductionCombined with patient history and physical examination, a negative D-dimer can safely rule-out pulmonary embolism (PE). However, the D-dimer test is frequently false positive, leading to many (with hindsight) ‘unneeded’ referrals to secondary care. Recently, the novel YEARS algorithm, incorporating flexible D-dimer thresholds depending on pretest risk, was developed and validated, showing its ability to safely exclude PE in the hospital environment. Importantly, this was accompanied with 14% fewer computed tomographic pulmonary angiography than the standard, fixed D-dimer threshold. Although promising, in primary care this algorithm has not been validated yet.Methods and analysisThe PECAN (DiagnosingPulmonaryEmbolism in the context ofCommonAlternative diagNoses in primary care) study is a prospective diagnostic study performed in Dutch primary care. Included patients with suspected acute PE will be managed by their general practitioner according to the YEARS diagnostic algorithm and followed up in primary care for 3 months to establish the final diagnosis. To study the impact of the use of the YEARS algorithm, the primary endpoints are the safety and efficiency of the YEARS algorithm in primary care. Safety is defined as the proportion of false-negative test results in those not referred. Efficiency denotes the proportion of patients classified in this non-referred category. Additionally, we quantify whether C reactive protein measurement has added diagnostic value to the YEARS algorithm, using multivariable logistic and polytomous regression modelling. Furthermore, we will investigate which factors contribute to the subjective YEARS item ‘PE most likely diagnosis’.Ethics and disseminationThe study protocol was approved by the Medical Ethical Committee Utrecht, the Netherlands. Patients eligible for inclusion will be asked for their consent. Results will be disseminated by publication in peer-reviewed journals and presented at (inter)national meetings and congresses.Trial registrationNTR 7431.

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Concordance between clinical diagnosis of pulmonary thromboembolism at hospital discharge and anatomopathological diagnosis

International Journal of Immunopathology and Pharmacology ◽

10.1177/2058738420942390 ◽

2020 ◽

Vol 34 ◽

pp. 205873842094239

Author(s):

Benjamín Rubio-Jurado ◽

Rocío Concepción Albores-Arguijo ◽

Antonio Guerra-Soto ◽

Teresita Plasencia-Ortiz ◽

Gerónimo Tavarez-Macías ◽

...

Keyword(s):

Hospital Discharge ◽

Clinical Diagnosis ◽

Pulmonary Thromboembolism ◽

Developed Countries ◽

Hospital Discharges ◽

Postmortem Diagnosis ◽

Autopsy Diagnosis ◽

The Mean ◽

D Dimer ◽

Similar Incidence

Half of the cases of pulmonary thromboembolism (PTE) are not diagnosed because of its unspecific clinical presentation; in Mexico, autopsy data reveal a similar incidence to that of developed countries. The objective of this work was to know the concordance between the clinical diagnosis of PTE at hospital discharge and its autopsy diagnosis. The method used was a retrospective cohort study of cases with PTE diagnosis who attended from January 2005 to December 2013. Information was obtained from the autopsies registry and clinical charts. From 177,368 hospital discharges, there were 412 (6.74%) with PTE diagnosis. There were 13,559 deaths, with PTE diagnosis in 139 (1%) patients. There were 479 autopsies, and in 66 (14%) of whom PTE diagnosis was documented, the mean age was 55 years (range, 18–89 years). The premortem diagnosis of PTE at discharge was confirmed in 412 cases. Postmortem diagnosis of principal disease was medical in 49 (74%) and medical-surgical in 17 (26%) patients. We found that nine patients had the clinical diagnosis of PTE, unlike the postmortem diagnosis, which was reported in 66 autopsies. The above allows establishing a 1:7 ratio that represents 14%. D-dimer was determined in 11 cases (16%) and was positive in 8 (73%). Thromboprophylaxis was applied in 15 cases (23%). The study of necropsies and identification of discrepancies is needed to improve the diagnostic accuracy and healthcare quality. The evaluation of hemostasis biomarkers besides D-dimer can better describe the pro-thrombotic state, the risk of thrombosis, and its association with morbidity and mortality.

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Prothrombotic State Induced by Middle-Distance Endurance Exercise in Middle-Aged Athletes

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0038-1667115 ◽

2018 ◽

Vol 44 (08) ◽

pp. 747-755 ◽

Cited By ~ 2

Author(s):

Gian Salvagno ◽

Cantor Tarperi ◽

Matteo Gelati ◽

Martina Montagnana ◽

Elisa Danese ◽

...

Keyword(s):

Blood Coagulation ◽

Blood Group ◽

Thrombin Generation ◽

Area Under The Curve ◽

Abo Blood Group ◽

Middle Aged ◽

Endurance Running ◽

Von Willebrand ◽

The Impact ◽

D Dimer

AbstractSince the impact of possible prothrombotic factors on blood coagulation resulting from exercise remains elusive, this study investigated the acute effects of middle-distance endurance running on blood coagulation parameters in middle-aged athletes. The study population consisted of 33 male endurance runners who were engaged in a 21.1 km run under competitive conditions. Blood samples were collected before the run, immediately after the run, and 3 hours after run completion. Samples were assessed for activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen, D-dimer, factor VIII (FVIII), von Willebrand factor antigen (VWF:Ag), endogenous thrombin potential (area under the curve of thrombin generation [TGA-AUC]), and peak thrombin generation (TGA-PK). Post-run variations were expressed as delta (Δ). At baseline, APTT was found to be significantly associated with ABO blood group, VWF:Ag, and FVIII; fibrinogen with age; VWF:Ag with BMI, training regimen, and ABO blood group; APTT with FVIII; FVIII with VWF:Ag and ABO blood group; APTT with VWF:Ag; and TGA-PK with ABO blood group, PT, and TGA-AUC. Immediately after the run, statistically significant increases were observed for PT, D-dimer, VWF:Ag, and FVIII, while statistically significant reductions could be observed for APTT, TGA-AUC, and TGA-PK. Fibrinogen values remained unchanged. Significant correlations were observed between Δ VWF:Ag and Δ FVIII, Δ APTT and Δ VWF:Ag, Δ APTT and Δ FVIII, Δ TGA-AUC and Δ TGA-PK, and between Δ D-dimer and Δ TGA-AUC and Δ TGA-PK. No Δ variation was associated with running time. The results of this study seemingly suggest that middle-distance competitive running may evoke several prothrombotic changes in blood coagulation.

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Diabetes does not influence activation of coagulation, fibrinolysis or anticoagulant pathways in Gram-negative sepsis (melioidosis)

Thrombosis and Haemostasis ◽

10.1160/th11-07-0504 ◽

2011 ◽

Vol 106 (12) ◽

pp. 1139-1148 ◽

Cited By ~ 10

Author(s):

Joost Meijers ◽

Rapeephan Maude ◽

Direk Limmathurotsakul ◽

Nicholas Day ◽

Sharon Peacock ◽

...

Keyword(s):

Protein C ◽

Burkholderia Pseudomallei ◽

Blood Donors ◽

Protein S ◽

Admission Diagnosis ◽

Procoagulant Effect ◽

Multiple Abnormalities ◽

The Impact ◽

D Dimer

SummaryDiabetes is associated with a disturbance of the haemostatic balance and is an important risk factor for sepsis, but the influence of diabetes on the pathogenesis of sepsis remains unclear. Melioidosis (Burkholderia pseudomallei infection) is a common cause of community-acquired sepsis in Southeast Asia and northern Australia. We sought to investigate the impact of pre-existing diabetes on the coagulation and fibrinolytic systems during sepsis caused by B. pseudomallei. We recruited a cohort of 44 patients (34 with diabetes and 10 without diabetes) with culture-proven melioidosis. Diabetes was defined as a pre-admission diagnosis of diabetes or an HbA1c>7.8% at enrolment. Thirty healthy blood donors and 52 otherwise healthy diabetes patients served as controls. Citrated plasma was collected from all subjects; additionally in melioidosis patients follow-up specimens were collected seven and ≥28 days after enrolment where possible. Relative to uninfected healthy controls, diabetes per se (i.e. in the absence of infection) was Characterised by a procoagulant effect. Melioidosis was associated with activation of coagulation (thrombin-antithrombin complexes (TAT), prothrombin fragment F1+2 and fibrinogen concentrations were elevated; PT and PTT prolonged), suppression of anti-coagulation (antithrombin, protein C, total and free protein S levels were depressed) and abnormalities of fibrinolysis (D-dimer and plasmin-antiplasmin complex [PAP] were elevated). Remarkably, none of these haemostatic alterations were influenced by pre-existing diabetes. In conclusion, although diabetes is associated with multiple abnormalities of coagulation, anticoagulation and fibrinolysis, these changes are not detectable when superimposed on the background of larger abnormalities attributable to B. pseudomallei sepsis.

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The Impact of COVID-19 Disease on Platelets and Coagulation

Pathobiology ◽

10.1159/000512007 ◽

2020 ◽

pp. 1-13 ◽

Cited By ~ 7

Author(s):

Geoffrey D. Wool ◽

Jonathan L. Miller

Keyword(s):

Degradation Products ◽

Severe Bleeding ◽

Bleeding Events ◽

Current State ◽

Venous Thromboembolic Events ◽

Venous Thromboembolic ◽

Intravascular Coagulopathy ◽

Vascular Beds ◽

The Impact ◽

D Dimer

Coronavirus disease 2019 (COVID-19) causes a spectrum of disease; some patients develop a severe proinflammatory state which can be associated with a unique coagulopathy and procoagulant endothelial phenotype. Initially, COVID-19 infection produces a prominent elevation of fibrinogen and D-dimer/fibrin(ogen) degradation products. This is associated with systemic hypercoagulability and frequent venous thromboembolic events. The degree of D-dimer elevation positively correlates with mortality in COVID-19 patients. COVID-19 also leads to arterial thrombotic events (including strokes and ischemic limbs) as well as microvascular thrombotic disorders (as frequently documented at autopsy in the pulmonary vascular beds). COVID-19 patients often have mild thrombocytopenia and appear to have increased platelet consumption, together with a corresponding increase in platelet production. Disseminated intravascular coagulopathy (DIC) and severe bleeding events are uncommon in COVID-19 patients. Here, we review the current state of knowledge of COVID-19 and hemostasis.

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