scholarly journals P117: Does an age-adjusted D-dimer threshold provide adequate sensitivity in ED patients investigated for pulmonary embolism?

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S117-S117
Author(s):  
K.D. Senior ◽  
K. Burles ◽  
D. Grigat ◽  
D. Wang ◽  
G. Innes ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Predictive Value ◽  
Older Patients ◽  
False Positive Rate ◽  
High Sensitivity ◽  
Ct Imaging ◽  
Administrative Database ◽  
Positive Rate ◽  
Sensitivity Specificity ◽  
D Dimer

Introduction: The D-dimer assay is a high sensitivity, low specificity test used to rule out pulmonary embolism (PE) in low risk ED patients. Patients with a positive D-dimer result will likely undergo CT imaging to confirm the diagnosis. Given the time, cost, and radiation exposure associated with CT, and the higher false-positive rate in older patients, an age-adjusted D-dimer threshold may be preferred. Our objective was to evaluate the sensitivity and specificity of an age-adjusted D-dimer and approximate the downstream effect on CT imaging utilization. Methods: This was a retrospective cohort study conducted using administrative data from Calgary emergency departments between July 2013 and January 2015. Eligible patients were individuals aged 50 and older who were undergoing PE workup including D-dimer testing. Outcomes were ascertained using CT imaging reports and by searching the regional administrative database for subsequent diagnosis of PE within 30 days of the index visit. These data were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value of the D-dimer test using the standard threshold (500 ng/mL) and an age-adjusted threshold (10 ng/mL x patient age as an integer). From this, the potential reduction in CT imaging use and missed PE diagnoses were modeled. Results: Of 6669 patients aged 50 or older who had D-dimer testing for possible PE, 1504 (22.6%) underwent a CT scan, and 217 (14.4% of CT) received a discharge diagnosis of pulmonary embolism, which was confirmed on chart review. When test results were re-interpreted using an age-adjusted threshold, D-dimer specificity increased from 63.9% to 75.4%, while sensitivity decreased from 96.5% to 89.9%. This translates to 888 new true negatives, representing CT scans potentially avoided (a 59% reduction in CT utilization), but with 18 new missed PE diagnoses. Conclusion: The age-adjusted threshold may reduce use of CT imaging among older patients suspected of PE, but at the cost of more missed PE diagnoses.

Evidence for Age-Adjusted D-Dimer to Rule out Pulmonary Embolism: An Institutional Study

2020 ◽  
Vol 154 (Supplement_1) ◽  
pp. S5-S5
Author(s):  
Ridin Balakrishnan ◽  
Daniel Casa ◽  
Morayma Reyes Gil
Keyword(s):  
Pulmonary Embolism ◽  
False Positive ◽  
False Positive Rate ◽  
Moderate Risk ◽  
Older Population ◽  
Statistical Measures ◽  
Positive Rate ◽  
Risk Patients ◽  
D Dimer ◽  
Rule Out

Abstract The diagnostic approach for ruling out suspected acute pulmonary embolism (PE) in the ED setting includes several tests: ultrasound, plasma d-dimer assays, ventilation-perfusion scans and computed tomography pulmonary angiography (CTPA). Importantly, a pretest probability scoring algorithm is highly recommended to triage high risk cases while also preventing unnecessary testing and harm to low/moderate risk patients. The d-dimer assay (both ELISA and immunoturbidometric) has been shown to be extremely sensitive to rule out PE in conjunction with clinical probability. In particularly, d-dimer testing is recommended for low/moderate risk patients, in whom a negative d-dimer essentially rules out PE sparing these patients from CTPA radiation exposure, longer hospital stay and anticoagulation. However, an unspecific increase in fibrin-degradation related products has been seen with increase in age, resulting in higher false positive rate in the older population. This study analyzed patient visits to the ED of a large academic institution for five years and looked at the relationship between d-dimer values, age and CTPA results to better understand the value of age-adjusted d-dimer cut-offs in ruling out PE in the older population. A total of 7660 ED visits had a CTPA done to rule out PE; out of which 1875 cases had a d-dimer done in conjunction with the CT and 5875 had only CTPA done. Out of the 1875 cases, 1591 had positive d-dimer results (>0.50 µg/ml (FEU)), of which 910 (57%) were from patients older than or equal to fifty years of age. In these older patients, 779 (86%) had a negative CT result. The following were the statistical measures of the d-dimer test before adjusting for age: sensitivity (98%), specificity (12%); negative predictive value (98%) and false positive rate (88%). After adjusting for age in people older than 50 years (d-dimer cut off = age/100), 138 patients eventually turned out to be d-dimer negative and every case but four had a CT result that was also negative for a PE. The four cases included two non-diagnostic results and two with subacute/chronic/subsegmental PE on imaging. None of these four patients were prescribed anticoagulation. The statistical measures of the d-dimer test after adjusting for age showed: sensitivity (96%), specificity (20%); negative predictive value (98%) and a decrease in the false positive rate (80%). Therefore, imaging could have been potentially avoided in 138/779 (18%) of the patients who were part of this older population and had eventual negative or not clinically significant findings on CTPA if age-adjusted d-dimers were used. This data very strongly advocates for the clinical usefulness of an age-adjusted cut-off of d-dimer to rule out PE.

scholarly journals Predictive value of high-sensitivity troponin I and D-dimer assays for adverse outcome in patients with acute pulmonary embolism

2012 ◽  
Vol 5 (2) ◽  
pp. 586-590 ◽  
Author(s):  
THOMAS WALTER ◽  
PAUL APFALTRER ◽  
FRANK WEILBACHER ◽  
MATHIAS MEYER ◽  
STEFAN O. SCHOENBERG ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Predictive Value ◽  
Acute Pulmonary Embolism ◽  
Troponin I ◽  
Adverse Outcome ◽  
High Sensitivity ◽  
High Sensitivity Troponin ◽  
D Dimer

scholarly journals Early Radiologic Diagnosis of Pulmonary Infection in Febrile Neutropenic Patients: A Comparison of Serial Chest Radiography and Single CT Chest

2021 ◽  
Vol 2021 ◽  
pp. 1-7
Author(s):  
Wanaporn Burivong ◽  
Thanatorn Sricharoen ◽  
Apichart Thachang ◽  
Sunsiree Soodchuen ◽  
Panitpong Maroongroge ◽  
...  
Keyword(s):  
Febrile Neutropenia ◽  
Positive Predictive Value ◽  
Absolute Neutrophil Count ◽  
Predictive Value ◽  
Pulmonary Infection ◽  
False Positive Rate ◽  
Radiologic Diagnosis ◽  
Chest Film ◽  
Positive Rate ◽  
Sensitivity Specificity

Objective. The purpose of this study is to compare the early radiologic diagnosis of pulmonary infection between serial chest radiography (chest film) and single chest computed tomography (CT chest) in the first seven days of febrile neutropenia. Methods. This study included 78 patients with hematologic malignancies who developed 107 episodes of febrile neutropenia from January 2012 to October 2017 and had a chest film performed within the first seven days. Demographic and radiographic data were retrospectively reviewed. Three radiologists independently and blindly evaluated chest films and CT chests. The sensitivity, specificity, and correlation of chest film with absolute neutrophil count were carried out. Results. A total of 222 chest films were performed during this period and found thirty-nine episodes (36.4%) of radiographic active pulmonary infection. The diagnosis of clinical positive for pulmonary infection is 44.8% (48/107). Sensitivity, specificity, positive predictive value, and negative predictive value of serial chest film in the early radiologic diagnosis of pulmonary infection are 50%, 74%, 61%, and 64%, respectively. The false-positive rate was 14%, and the false-negative rate was 22%. For single CT chest examinations, twenty-six studies were assessed, and 42.3% was indicative of radiographic active pulmonary infection. Sensitivity, specificity, positive predictive value, and negative predictive value of CT chest in the early radiologic diagnosis of pulmonary infection are 91%, 40%, 53%, and 86%, respectively. The false-positive rate was 60%. The absolute neutrophil count was not useful for predicting radiographic active pulmonary infection. Conclusion. Serial chest film for early radiologic diagnosis of pulmonary infection within the first seven days of febrile neutropenia has lower sensitivity with higher specificity as compared to a single CT chest. Conversely, CT chest may not only have a higher sensitivity in determining early pulmonary infection but also has a higher rate of false-positives.

Is D2 surgery necessary for clinical T1 gastric cancer with nodal swelling?

2020 ◽  
Vol 38 (4_suppl) ◽  
pp. 288-288
Author(s):  
Takeyuki Wada ◽  
Takaki Yoshikawa ◽  
Ayako Kamiya ◽  
Keichi Date ◽  
Tsutomu Hayashi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Gastric Cancer ◽  
Positive Predictive Value ◽  
Predictive Value ◽  
False Positive ◽  
False Positive Rate ◽  
False Positivity ◽  
Positive Rate ◽  
D2 Surgery ◽  
Sensitivity Specificity

288 Background: D2 surgery is required for clinical T1 gastric cancer with nodal swelling, however, D2 has a higher risk for morbidity than D1/D1+. Moreover, previous study demonstrated that the false positive rate for nodal diagnosis in clinical T1 was very high. To select optimal surgery with high probability, we explored risk factors for false positivity in clinical T1 disease. Methods: Patients who underwent radical gastrectomy for clinical T1 gastric cancer between April 2015 and June 2019 were enrolled. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive values for nodal diagnosis were retrospectively investigated. The risk factors for false positivity were also analyzed by the following factors; age, sex, histological type, tumor size, tumor depth, location, tumor type, presence of ulcer, and timing of CT that is (1) the patients who underwent primary endoscopic mucosal dissection (ESD) but resulted in non-curative resection, then received CT to proceed to surgery (delayed CT group) or (2) the other patients who had received CT before primary surgery or before non-curative ESD (primary CT group). Results: A total of 679 patients were examined in the present study. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 83.5% (567/679), 14.3% (13/91), 94.2% (554/588), 27.7% (13/47), and 87.7% (554/632), respectively. The false positive rate was 72.3% (34/47). In univariate analysis, differentiated tumor ( p= 0.012) and delayed CT (p < 0.001) were associated with the false positivity. Multivariate analysis revealed that delayed CT (OR, 4.534; p < 0.001) was a sole significant risk factor for false positivity. False positive rate was 100% (13/13) in the delayed CT group and 61.8% (21/34) in the primary CT group ( p= 0.009). Conclusions: False positive rate was high in clinical T1 disease, especially when the patients received delayed CT after non-curative ESD. D2 surgery would be unnecessary even though nodal swelling was detected in CT after non-curative ESD.

scholarly journals Role of complementary cytology, colposcopy and histopathology in detecting premalignant and malignant lesions of cervix

2016 ◽  
Author(s):  
Akanksha Mangla ◽  
Renuka Sinha
Keyword(s):  
Predictive Value ◽  
False Positive Rate ◽  
False Negative ◽  
False Negative Rate ◽  
Cross Sectional Study ◽  
High Grade ◽  
Cervical Lesions ◽  
Cross Sectional ◽  
Positive Rate ◽  
Sensitivity Specificity

Objective: Cervical cancer is the second most common gynecologic malignancy worldwide. India alone accounts for one fifth of total number of cases worldwide. The aim of our study was to calculate sensitivity, specificity, positive predictive value, negative predictive value, false positive rate and false negative rate of complementary cytology and colposcopy with histopathology as gold standard for detection of premalignant and malignant cervical lesions. Methods: A cross sectional study was conducted at Vardhman Mahavir Medical College and Safdarjung hospital, Delhi, India. 100 non pregnant females with complaint of post coital or irregular vaginal bleeding and those who had unhealthy cervix on visual inspection were included in study. Results: Colposcopy exhibited a high degree of accuracy in diagnosis of high grade lesions. Overall sensitivity of cytology was 50% whereas that of colposcopy was 83.3%. Cytology had specificity of 93.4% whereas colposcopy had specificity of 89.4%. 100% of high grade and invasive cancers on colposcopy were associated with similar findings on histology. The degree of agreement between cytology and colposcopy with histology was significant (p<0.001). Conclusion: Colposcopy is sensitive method as compared to cytology, especially in the higher grade lesions and combination of both methods appears to be of higher diagnostic importance.

scholarly journals Diagnostic performance of D-dimer in predicting pulmonary embolism in tuberculous pleural effusion patients

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Xiaoming Li ◽  
Yajing Qin ◽  
Wenjing Ye ◽  
Xi Chen ◽  
Dezhi Sun ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pleural Effusion ◽  
Predictive Value ◽  
Diagnostic Performance ◽  
Characteristic Curve ◽  
Pulmonary Angiography ◽  
Potential Mechanism ◽  
Tuberculous Pleural Effusion ◽  
Sensitivity Specificity ◽  
D Dimer

Abstract Background Tuberculous pleural effusion (TPE) patients usually have elevated D-dimer levels. The diagnostic performance of D-dimer in predicting pulmonary embolism (PE) in the TPE population is unclear. This study aimed to assess the diagnostic performance of D-dimer for PE in the TPE population and explore its potential mechanism. Methods We retrospectively analysed patients who were admitted to Xinhua Hospital and Weifang Respiratory Disease Hospital with confirmed TPE between March 2014 and January 2020. D-dimer levels were compared between patients with and without PE. To test the diagnostic performance of D-dimer in predicting PE, receiver operating characteristic curve analysis was performed. Positive predictive value (PPV) and negative predictive value (NPV) were also reported. To explore the potential mechanism of PE in TPE, inflammatory biomarkers were compared between PE and non-PE patients. Results This study included 248 patients (170 males and 78 females) aged 43 ± 20.6 years. Elevated D-dimer levels (≥ 0.5 mg/L) were detected in 186/248 (75%) patients. Of the 150 patients who underwent computed tomography pulmonary angiography, 29 were diagnosed with PE. Among the TPE population, the PE patients had significantly higher D-dimer levels than the non-PE patients (median, 1.06 mg/L vs. 0.84 mg/L, P < 0.05). The optimal cut-off value for D-dimer in predicting PE in TPE was 1.18 mg/L, with a sensitivity of 89.7% and a specificity of 77.8% (area under curve, 0.893; 95% confidence interval 0.839–0.947; P < 0.01). The PPV was 49.1%, while the NPV was 96.9% at a D-dimer cut-off of 1.18 mg/L for PE. PE patients had lower median WBC and interleukin (IL)-8 values (5.14 × 109/L vs. 6.1 × 109/L, P < 0.05; 30.2 pg/ml vs. 89.7 pg/ml, P < 0.05) but a higher median IL-2 receptor value (1964.8 pg/ml vs. 961.2 pg/ml, P < 0.01) than those in the non-PE patients. Conclusions D-dimer is an objective biomarker for predicting PE in patients with TPE. A D-dimer cut-off of 1.18 mg/L in the TPE population may reduce unnecessary radiological tests due to its excellent sensitivity, specificity, and NPV for PE. The imbalance of prothrombotic and antithrombotic cytokines may partly be attributed to the formation of pulmonary emboli in patients with TPE.

scholarly journals Efficacy of D-Dimer Assay in Pulmonary Venous Thromboembolism: Study of 76 Cases

2021 ◽  
Author(s):  
Shubhi Saxena ◽  
Nishant Saxena ◽  
Richa Jain ◽  
Jasmin Jasani
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Venous Thrombosis ◽  
Predictive Value ◽  
Wide Spectrum ◽  
Pulmonary Angiography ◽  
Retrospective Case ◽  
One Year ◽  
Sensitivity Specificity ◽  
D Dimer

Introduction: Venous Thromboembolism (VTE) encompasses a wide spectrum consisting predominantly of deep venous thrombosis and pulmonary embolism. The value of Fibrin Degradation Product (FDP) of which, most common is D-dimer which is most commonly deployed to pre-diagnose venous thrombosis. Diagnosing it has always been a hard effort. It is produced when cross-linked fibrin is broken down; among patient who is suspected of having pulmonary embolism, blood D-dimer levels correlate with the probability of having pulmonary embolism. Aim: This study was done to analyse the sensitivity of plasma D-dimer for VTE. Materials and Methods: Retrospective case study of 76 patients with VTE in form of pulmonary embolism done at the Dhiraj Hospital, Sumandeep Vidyapeeth Deemed University, Vadodara from January 2019 to January 2020 for a period of one year. Prethrombolytic plasma was withdrawn and D-dimer quantification were measured using fully automatic stago coagulometer instruement (STA Compact Max). Sensitivity, Specificity, Negative Predictive Value (NPV) and Positive Predictive Value (PPV) was calculated and formulated in tables and graphs. Results: The sensitivity, NPV, specificity and PPV of the D-dimer was 95.65%, 76.92%, 66.66% and 92.95%, respectively. CT pulmonary angiography had a specificity of 80%, sensitivity of 92.75%, a NPV of 70.58% and a PPV of 95.52%. Conclusion: D-dimer is mostly the go to test for ruling out VTE especially pulmonary embolism, if the pre-test probability is intermediate. Rationale use of this test does help in prognostification and helps to achieve therapeutics faster and more effectively.

scholarly journals Use of SimpliRED D-dimer assay and computerised tomography in the diagnosis of acute pulmonary embolism

2009 ◽  
Vol 8 (2) ◽  
pp. 85-87
Author(s):  
Deepak Subedi ◽  
◽  
Derek Bell ◽  
Shazad Aslam ◽  
Marina J Brochwitz Lewinski ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Predictive Value ◽  
Acute Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Predictive Values ◽  
Computed Tomographic ◽  
Unselected Patient ◽  
Risk Scoring ◽  
Sensitivity Specificity ◽  
D Dimer

Background: The utility of D-dimer in the diagnostic workup of pulmonary embolism has been established. Several D-dimer tests are available with different sensitivities and specificities. SimpliRED D-dimer is a rapid qualitative whole blood D-dimer assay suitable for bedside use. Objective: To assess the utility of the SimpliRED D-dimer test in patients with suspected acute pulmonary embolism in the absence of formal ‘risk scoring’. Design: A prospective study measuring SimpliRED D-dimer in unselected patients undergoing computed tomographic pulmonary angiography (CTPA) examination for suspected acute pulmonary embolism. Main outcome measures: D-dimer and CTPA results were compared. Sensitivity, specificity, and positive and negative predictive values of SimpliRED D-dimer were calculated for the unselected patient group. Results: Forty-seven patients underwent D-dimer testing and CTPA. SimpliRED D-dimer was positive in 23 and negative in 24 patients. D-dimer was positive in only 6 (50%) of the 12 patients with positive CTPA. Of the 35 with negative CTPA, 17 had positive D-dimer. The positive predictive value of the D-dimer was 26.1 % and the negative predictive value 75.0%. Conclusion: SimpliRED D-dimer should not be used in the diagnosis of pulmonary embolism in the absence of risk scoring.

Tissue plasminogen activator as a novel diagnostic aid in acute pulmonary embolism

VASA ◽  
2014 ◽  
Vol 43 (6) ◽  
pp. 450-458 ◽  
Author(s):  
Julio Flores ◽  
Ángel García-Avello ◽  
Esther Alonso ◽  
Antonio Ruíz ◽  
Olga Navarrete ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Negative Predictive Value ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Predictive Value ◽  
Acute Pulmonary Embolism ◽  
Enzyme Linked Immunosorbent Assay ◽  
Diagnostic Utility ◽  
Tissue Plasminogen ◽  
D Dimer

Background: We evaluated the diagnostic efficacy of tissue plasminogen activator (tPA), using an enzyme-linked immunosorbent assay (ELISA) and compared it with an ELISA D-dimer (VIDAS D-dimer) in acute pulmonary embolism (PE). Patients and methods: We studied 127 consecutive outpatients with clinically suspected PE. The diagnosis of PE was based on a clinical probability pretest for PE and a strict protocol of imaging studies. A plasma sample to measure the levels of tPA and D-dimer was obtained at enrollment. Diagnostic accuracy for tPA and D-dimer was determined by the area under the receiver operating characteristic (ROC) curve. Sensitivity, specificity, predictive values, and the diagnostic utility of tPA with a cutoff of 8.5 ng/mL and D-dimer with a cutoff of 500 ng/mL, were calculated for PE diagnosis. Results: PE was confirmed in 41 patients (32 %). Areas under ROC curves were 0.86 for D-dimer and 0.71 for tPA. The sensitivity/negative predictive value for D-dimer using a cutoff of 500 ng/mL, and tPA using a cutoff of 8.5 ng/mL, were 95 % (95 % CI, 88–100 %)/95 % (95 % CI, 88–100 %) and 95 % (95 % CI, 88–100 %)/94 %), respectively. The diagnostic utility to exclude PE was 28.3 % (95 % CI, 21–37 %) for D-dimer and 24.4 % (95 % CI, 17–33 %) for tPA. Conclusions: The tPA with a cutoff of 8.5 ng/mL has a high sensitivity and negative predictive value for exclusion of PE, similar to those observed for the VIDAS D-dimer with a cutoff of 500 ng/mL, although the diagnostic utility was slightly higher for the D-dimer.

scholarly journals Use of β-D-glucan in diagnosis of suspected Pneumocystis jirovecii pneumonia in adults with HIV infection

2021 ◽  
pp. 095646242110222
Author(s):  
Thomas Juniper ◽  
Chris P Eades ◽  
Eliza Gil ◽  
Harriet Fodder ◽  
Killian Quinn ◽  
...  
Keyword(s):  
Predictive Value ◽  
Diagnostic Tests ◽  
Elevated Serum ◽  
Clinical Information ◽  
High Sensitivity ◽  
Pneumocystis Pneumonia ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Alternative Diagnosis ◽  
Positive Threshold ◽  
Sensitivity Specificity

Objectives: An elevated serum (1-3)-β-D-glucan (BDG) concentration has high sensitivity for a diagnosis of Pneumocystis pneumonia (PCP) in people with HIV (PWH). At the current manufacturer-recommended positive threshold of 80 pg/mL (Fungitell), specificity for PCP is variable and other diagnostic tests are required. We evaluated the utility of serum BDG for diagnosis of suspected PCP in PWH at three inner-London hospitals to determine BDG concentrations for diagnosis and exclusion of PCP. Methods: From clinical case records, we abstracted demographic and clinical information and categorised patients as having confirmed or probable PCP, or an alternative diagnosis. We calculated sensitivity, specificity and positive predictive value (PPV) of serum BDG concentrations >400 pg/mL and negative predictive value (NPV) of BDG <80 pg/mL. Results: 76 patients were included; 29 had laboratory-confirmed PCP, 17 had probable PCP and 30 had an alternative diagnosis. Serum BDG >400 pg/mL had a sensitivity of 83%, specificity of 97% and PPV 97% for diagnosis of PCP; BDG <80 pg/mL had 100% NPV for exclusion of PCP. Conclusions: In PWH with suspected PCP, BDG <80 pg/mL excludes a diagnosis of PCP, whereas BDG concentrations >400 pg/mL effectively confirm the diagnosis. Values 80–400 pg/mL should prompt additional diagnostic tests.

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