[Inflammatory bowel diseases and pregnancy]

Inflammatory bowel disease (IBD) affects women during their reproductive years and 25% become pregnant after an initial diagnosis of IBD. Many choose voluntary infertility due to concerns on the influence of disease and medical therapy on pregnancy outcome. We suggest that a multidisciplinary approach may lessen the risks involved. Pre-pregnancy consultation, with conception during the IBD remission allows a pregnancy outcome similar to the general population. During pregnancy, the continuation of regular medications (except MTX and thalidomide) and nutritional support is crucial. IBD flares during pregnancy are best treated with steroidal or anti-TNF agents, until 30-32 weeks. Breastfeeding should be encouraged. Postpartum follow-up of patients by an integrated team ensures an optimal future perinatal outcome.

From airway inflammation to inflammatory bowel disease: eotaxin-1, a key regulator of intestinal inflammation

Eotaxin-1 (CCL-11) is a potent eosinophil chemoattractant that is considered a major contributor to tissue eosinophilia. Elevated eotaxin-1 levels have been described in various pathologic conditions, ranging from airway inflammation, to Hodgkin lymphoma, obesity and coronary artery disease. The main receptor for eotaxin-1 is CCR3; however, recent evidence indicates that eotaxin-1 may also bind to other receptors expressed by various cell types, suggesting a more widespread regulatory role for eotaxin-1 beyond the recruitment of eosinophils. Eotaxin-1 is also strongly associated with various gastrointestinal (GI) disorders. Although the etiology of inflammatory bowel disease (IBD) is still unknown, eotaxin-1 may play a key role in the development of mucosal inflammation. In this review, we summarize the biological context and effects of eotaxin-1, as well as its potential role as a therapeutic target, with a special focus on gastrointestinal inflammation.

Maternal inflammatory bowel disease has short and long-term effects on the health of their offspring: a multicenter study in Israel

BACKGROUND

There are concerns about the effect of inflammatory bowel diseases (IBD) on fertility, pregnancy and pregnancy outcomes, but no long-term data on the health of offspring born to IBD mothers. The aims were to assess the short- and long-term effects of maternal IBD on the morbidity and development of their offspring.

METHODS

Female IBD patients and controls completed questionnaires on their pregnancy outcome, and their offspring's short- and long-term health and development.

RESULTS

IBD and control mothers (159 and 175, respectively) were recruited. Medical data of 412 IBD and 417 control offspring were recorded. IBD mothers had significantly more singleton pregnancies, their offspring's birth weight was significantly lower, and they breastfed significantly less compared to controls (P=0.028, 0.007, and <0.0001, respectively). There were significantly more congenital anomalies (mainly limb deformities) among the IBD offspring (P<0.035). Offspring born post-maternal IBD diagnosis, compared to pre-diagnosis, tended to have more neurodevelopmental problems (e.g., gross motor delay, P=0.03). IBD was significantly more prevalent in the offspring of IBD mothers, while allergies and atopic dermatitis were more frequent in offspring of control mothers. More offspring of IBD mothers taking medications during pregnancy were born preterm and had lower birth weights compared to offspring of IBD mothers not taking medications during pregnancy. Children of mothers taking steroids had the lowest birth weights, compared to those of IBD mothers taking 5ASAs or immunomodulators.

CONCLUSIONS

Maternal IBD affects pregnancy and the offspring's immediate and long-term morbidity, specifically, congenital anomalies and neurodevelopmental problems.

Fecal calprotectin as a predictor of abnormal colonic histology

PURPOSE

Gastroenterologists have been seeking reliable noninvasive indices of inflammatory and malignant bowel disease. This prospective study was to assess the value of fecal calprotectin in predicting abnormal histologic findings in patients undergoing colonoscopy.

METHODS

Stool specimens supplied before colonoscopy by 72 consecutive patients were measured for calprotectin levels, and the findings correlated with the colonoscopy results and other fecal and blood parameters. Receiver operating characteristics curve analysis was used to determine the predictive value of fecal calprotectin for abnormal colonic histology.

RESULTS

Patients with abnormal histologic findings had significantly higher calprotectin levels (218 +/- 125 mg percent) than patients with normal colonoscopy (77 +/- 100 mg percent). There was a highly significant correlation between calprotectin levels and erythrocyte sedimentation rate (r = 0.45, P = 0.008), positive fecal occult blood test (r = 0.57, P = 0.0001), and abnormal colonic histology (r = 0.54, P = 0.0001). Patients with active inflammatory bowel disease had higher calprotectin levels than the rest of the study patients (r = 0.3; P = 0.01). On multivariate analysis, calprotectin was a significant predictor of abnormal colonic histology (P = 0.005; odds ratio, 1.007; 95 percent confidence interval, 1.002-1.012). The area under the receiver operating characteristics curve was 0.79. A fecal calprotectin concentration of 150 microg/ml had a sensitivity of 75 percent, specificity of 84 percent, positive predictive value of 80 percent, and negative predictive value of 75 percent in predicting abnormal colonic histology.

CONCLUSIONS

Fecal calprotectin may serve as a simple, noninvasive surrogate marker of abnormal histologic findings in patients scheduled for colonoscopy.

Endobronchial metastases from colon cancer without liver metastases: report of eight cases

PURPOSE

The liver is the most common site of hematogenous spread from colon tumors. Pulmonary metastases from colon cancer result, in most of the cases, from hepatic metastases.

METHODS

We describe eight cases of colorectal cancers in which endobronchial metastases have been developed without any evidence of liver involvement.

RESULTS

Median age was 62 years old. In most of the patients, the primary cancer developed in the left side. The median time from colorectal presentation to pulmonary onset was four years. Dyspnea was the major symptom in all cases. Pulmonary involvement included endobronchial metastasis in all cases. CT scan of the chest showed bilateral, diffuse, large, nodular infiltrates without lymph nodes enlargement and without pleural effusion. Endobronchial therapy brought symptomatic relief in all cases; however, two-year follow-up showed only 50 percent survival rate.

CONCLUSIONS

Endobronchial metastasis should be suspected in patients with colon cancer with respiratory symptoms, even without known liver metastasis. To the best of our knowledge, such a case series has not been published yet.

The role of enzyme-linked immunosorbent assay D-dimer in patients with acute coronary syndrome presenting with normal cardiac enzymes

Plasma D-dimer levels, the primary degradation product of cross-linked fibrin, are elevated in acute coronary syndrome (ACS). However, the role of D-dimer in patients presenting to the Emergency Department with ACS and normal cardiac enzymes is unknown. We conducted a prospective, observational study in the Emergency Department of a major tertiary university-affiliated center. The study included 124 patients presented to the Emergency Department with ACS and normal cardiac enzymes. Blood samples were collected and assayed for D-dimer levels with the enzyme-linked immunosorbent assay (ELISA) test. The D-dimer values were correlated with the clinical, laboratory and electrocardiographic findings on admission, as well as with the catheterization findings and with hospital length of stay. ELISA D-dimer levels positively correlated with sex, hypertension and smoking (r = -0.27, P = 0.002; r = 0.33, P = 0.0002; and r = -0.24, P = 0.007, respectively). Significant correlation was also observed between ELISA D-dimer and cardiac medications including beta-blocker (r = 0.22, P = 0.01), aspirin (r = 0.18, P = 0.04), nitrate (r = 0.20, P = 0.002), acute phase reactants fibrinogen (r = 0.45, P = 0.0001) and C-reactive protein (r = 0.29, P = 0.004), ischemic electrocardiographic changes (r = 0.21, P = 0.02) and length of stay (r = 0.29, P = 0.001). The catheterization findings were also correlated with the ELISA D-dimer levels (r = 0.31, P = 0.02). The ELISA D-dimer test may add important clinical data concerning patients with ACS and normal cardiac enzymes.

Lamivudine prophylaxis for hepatitis B virus infection after lung transplantation

BACKGROUND

Several reports have shown the efficacy of prophylactic lamivudine treatment for hepatitis B virus (HBV) infection in liver and renal transplantations. No data are available, however, after lung transplantation. We report our experience with prophylactic lamivudine treatment in lung transplant recipients with HBV infection or when the donor was HBc antibody positive.

METHODS

All our 120 lung transplant recipients and their donors were routinely screened for HBV markers. All recipients who tested positive for hepatitis B surface antigen and negative for HBV-DNA, or had organs from donors who tested positive for hepatitis B core antibody, were treated prophylactically with lamivudine for 12 months after lung transplantation. Patients whose liver functions became abnormal during follow-up were tested for HBV serology and HBV-DNA.

RESULTS

Eleven of 120 lung transplant recipients (9.2%) were treated with prophylaxis lamivudine. Four recipients were hepatitis B surface antigen positive, and 7 recipients received organs from donors positive for HBc antibodies. Median follow-up after treatment was 24 months. All patients had normal alanine transaminase and undetectable levels of HBV-DNA before treatment. No side effects of lamivudine therapy were reported by any of the patients. Reactivation with alanine transaminase elevation and high HBV-DNA levels occurred in 2 patients. Both of them were recipients positive for hepatitis B surface antigen. In the first patient, lamivudine-resistant strain was detected and adefovir dipivoxil was started. In the other, reactivation developed 2 months after the end of lamivudine treatment. Lamivudine treatment was resumed, with rapid normalization of the HBV-DNA.

CONCLUSIONS

Use of lamivudine is considered safe for suppressing HBV infection after lung transplantation.

Pulmonary Mycobacterium kansasii Infection in Israel, 1999–2004

BACKGROUND

Mycobacterium kansasii infection is one of the most common causes of nontuberculous mycobacterial lung disease in world. However, little is known about its background characteristics or drug sensitivity in nonendemic areas.

DESIGN

We assessed the clinical features, radiologic findings, and drug sensitivity associated with M kansasii infection in Israel.

METHODS

Patients with a culture-positive diagnosis of M kansasii infection between April 1999 and April 2004 were identified from a clinic database of tuberculosis centers. Mycobacterial cultures were performed with standard methods. Data on patient background and clinical features were collected from the medical files.

RESULTS

Mean age (+/- SD) of the 56 patients was 58 +/- 18 years, and 64% were men; 59% had associated lung disease. Fifteen percent were receiving immunosuppressive medications. None had HIV infection. Systemic comorbid diseases were noted in 27%. The most common clinical presentations were chest pain, cough, hemoptysis, fever, and night sweats. Cavitation was noted only in 54%. Older patients had more noncavitary disease than younger patients (p = 0.01, r = 0.35). Lower-lobe predominance was very rare (4%). None of the patients presented with pleural effusion or lymphadenopathy. Only seven patients (11%) underwent bronchoscopy for diagnosis. M kansasii isolates showed the highest sensitivity to rifampin, ethambutol, clarithromycin, and ofloxacin, and the highest resistance to ciprofloxacin and capreomycin. The mean duration of treatment was 21 +/- 7.2 months. There were no disease-related deaths.

CONCLUSIONS

M kansasii disease in Israel has no association with HIV, more systemic comorbid diseases and associated lung disease, and fewer cavitations. Following appropriate treatment, patients with M kansasii disease have an excellent prognosis.

Role of Soluble Interleukin-2 Receptor Levels in Patients with Latent Tuberculosis

Serum soluble interleukin-2 receptor (sIL-2R) serves as a marker of disease activity in patients with tuberculosis (TB). However, little is known about its role in latent TB. The aim of this study was to assess the levels of sIL-2R in patients with latent TB and correlate them with the purified protein derivate (PPD) test results. Patients with a diagnosis of latent TB were divided into three subgroups by induration size: <10 mm, 10-20 mm, >20 mm. Blood was collected for sIL-2R assay. Findings were compared to a healthy control group. The study group consisted of 44 patients (68% male) of mean ( +/- SD) age 20 +/- 10 years, and the control group consisted of 41 subjects (42% male) aged 31 +/- 11 years. Comparison of the two groups yielded a significantly higher serum sIL-2R level in the patients (450 +/- 224 U/ml vs. 374 +/- 30 U/ml, p = 0.03). Mean sIL-2R levels were significantly correlated with the presence of latent TB (p = 0.03), and with purified protein derivative (PPD) subgroups: 387 +/- 177 U/ml for induration size <10 mm, NS; 450 +/- 238 U/ml for 10-20 mm, p = 0.04, and 605 +/- 235 U/ml for >20 mm, p < 0.0001. sIL-2R assay may serve as an additional tool to estimate the extent of the immune response in patients with latent TB.

The role of routine culture for tuberculosis during bronchoscopy in a nonendemic area: analysis of 300 cases and review of the literature

BACKGROUND

Many centers routinely culture bronchoscopy samples for mycobacteria, even when tuberculosis (TB) is not strongly suspected. The value of this practice is poorly defined in areas with a low prevalence of TB.

METHODS

A retrospective observational study was conducted in tertiary care, university-affiliated medical center and included 300 consecutive patients who underwent a bronchoscopy examination. The findings for acid-fast bacillus (AFB) staining and culture were reviewed, and data on demographic characteristics, presenting symptoms, old TB, autoimmune status, and chest x-ray results were collected from the files.

RESULTS

The study included 175 men (58%) and 125 women, with a mean age of 62 +/- 25 years. Eight cultures (2.67%) grew mycobacteria: 4 (1.33%) Mycobacterium tuberculosis and 4 (1.33%) nontuberculous mycobacteria (NTM). Thus, the incidence of TB was 4 of 300 (1.33%) patients. There were no cases of positive AFB smear or culture in patients with atelectasis, pulmonary mass, or hemoptysis with normal chest x-ray. One of the 22 patients (5%) with diffuse pulmonary nodules had active TB as did 3 of the 134 patients (2.24%) with pulmonary infiltrates. All 4 patients with NTM had pulmonary infiltrates. The use of a cost-effective diagnostic strategy in our series, wherein testing would have been ruled out for patients without a clinical suspicion of TB and radiologic findings of a pulmonary mass (n = 107, 35.6%), would have saved the system US $5350.

CONCLUSION

The findings highlight the importance of an effective strategy for routine TB cultures during bronchoscopy in patients from nonendemic areas in whom TB is not suspected, especially those with pulmonary mass.

The role of routine culture for tuberculosis during bronchoscopy examination of lung masses

BACKGROUND

Many centers routinely culture bronchoscopy samples for mycobacteria even when tuberculosis (TB) is not strongly suspected. The value of this practice has hardly been investigated.

OBJECTIVE

The aim of this retrospective study was to assess the utility of routine culture of bronchoscopy samples of lung masses for mycobacteria in a region where TB is not endemic.

PATIENTS AND METHODS

The study group consisted of 168 patients who underwent bronchoscopy for investigation of lung masses in a major tertiary-care, university-affiliated facility in central Israel. The findings on acid-fast bacillus staining and culture were reviewed, and data on demographic characteristics were collected from the files.

RESULTS

There were 97 men (58%) and 71 women with a mean age of 62 +/- 25 years. One culture (0.6%) grew Mycobacterium tuberculosis. There were no cases of positive acid-fast bacillus smear or positive nontuberculous mycobacteria culture. Sixty USD (5.45%) would be saved per patient without clinical suspicion of TB.

CONCLUSIONS

These findings highlight the need to formulate new guidelines for the performance of mycobacterial cultures of bronchoscopy specimens in areas with a low prevalence of TB.

Gastrointestinal involvement of posttransplant lymphoproliferative disorder in lung transplant recipients: report of a case

PURPOSE

Lymphoproliferative disorder is a well-recognized complication of lung transplantation. Risk factors include Epstein-Barr virus infection and immunosuppression. The gastrointestinal manifestations of post-transplant lymphoproliferative disorder in lung transplant recipients have not been fully characterized.

METHODS

Case presentation and 16 previously reported cases of post-transplant lymphoproliferative disorder with gastrointestinal involvement are reviewed.

RESULTS

Patient ages ranged from 25 to 65 (median, 52) years. Median time from lung transplantation to onset of posttransplant lymphoproliferative disorder was 36 (range, 1-109) months; 35 percent of cases (6/17) occurred within 18 months; Eighty-eight percent of patients (15/17) had positive Epstein-Barr virus serology before transplantation. In five patients (29 percent), the posttransplant lymphoproliferative disorder also involved sites other than the gastrointestinal tract. The most common gastrointestinal site of posttransplant lymphoproliferative disorder was the colon, followed by the small intestine and stomach. Clinical features included abdominal pain, nausea, and bloody diarrhea. Diagnosis was based on typical pathologic changes on gastrointestinal tract biopsy obtained mainly by colonoscopy. Treatment included a reduction in the immunosuppressive regimen in 15 of 17 cases (88 percent) and surgical resection in 10 (59 percent). One patient was untreated. Seven of 16 patients (44 percent) responded to treatment and 9 patients died. Median time from onset of posttransplant lymphoproliferative disorder to death was 70 (range, 10-85) days.

CONCLUSIONS

Posttransplant lymphoproliferative disorder with gastrointestinal involvement is a unique entity that should be considered in all Epstein-Barr-Virus-positive lung transplant recipients who present with abdominal symptoms. Although immunosuppressive modulation and resection can lead to remission, the risk of death is 50 percent.

An association between oxygen desaturation and D-dimer in patients with obstructive sleep apnea syndrome

D-dimer, a degradation product of fibrin, is being increasingly used as a marker and prognostic factor in various thrombotic diseases. Previous reports have shown that obstructive sleep apnea is associated with platelet activation and hypercoagulability. The aim of the study was to assess the potential role of the plasma D-dimer test in patients with obstructive sleep apnea. We designed a prospective group comparison study in a tertiary-care, university-affiliated medical center. One hundred and three patients of mean age 57 years (range 50-76 years) with symptoms suggestive of obstructive sleep apnea were included. Polysomnography was performed in all cases, and blood was collected for plasma D-dimer measurement by MiniQuant turbidmetric assay. The demographic and polysomnograph data were compared between patients with normal and high (> 250 ng/ml) D-dimer levels. The group with higher D-dimer values had lower mean minimal oxygen saturation (72.1 +/- 16.4 vs. 81.7 +/- 11.6%, p = 0.008) and a longer mean period of oxygen saturation below 90% (84.1 +/- 86.2 vs. 38.5 +/- 70.8 minutes, p = 0.032). There was no correlation of respiratory disturbance index and sleep architecture with D-dimer values. We concluded that sleep apnea syndrome is associated with fibrinolytic activity. Oxygen desaturation seems to be one of the mediatory factors in the putative connection between obstructive sleep apnea and hypercoagulability state.

Hepatic production of insulin-like growth factors in normal and diseased liver

BACKGROUND/AIMS

IGF-I levels are reduced in cirrhotic patients. However, it is not known whether this decreased level is the result of reduced hepatic production or modified bioavailability secondary to decreased binding proteins. We determined the hepatic production of IGF-I and IGF-II and their receptors in normal and diseased liver.

METHODOLOGY

Twenty-five patients included, 11 controls with normal liver and 14 with either chronic hepatitis or cirrhosis. mRNA for IGF-1, IGF-II and their receptors were measured. Immunohistochemical staining was performed to localize the IGF-producing cells.

RESULTS

In 11 normal livers, the IGF-I mRNA levels were 4.95 +/- 1.8; in the 14 diseased livers, the levels were 1.22 +/- 0.69 (p < 0.001). IGF-II mRNA levels were 3.78 +/- 1.45 for the control and 5.11 +/- 2.15 in the diseased livers (NS). IGF-I receptor levels were 1.15 +/- 0.83 in the normal and 0.31 +/- 0.22 in the liver disease group (p < 0.05). There was no statistical difference between the two groups for IGF-II receptor.

CONCLUSIONS

Patients with chronic liver disease have a significant reduction in their hepatic production of IGF-I, whereas IGF-II tends to be elevated. Treatment with recombinant IGF-I in patients with metabolic or endocrine complications of cirrhosis might prove useful.

Diagnostic value of CYFRA 21-1, CEA, CA 19-9, CA 15-3, and CA 125 assays in pleural effusions: analysis of 116 cases and review of the literature

Levels of tumor markers in pleural effusions may help to establish the diagnosis of pleural malignancy, but the precise diagnostic value of each marker remains unclear. The aim of this study was to assess the diagnostic value of five common pleural fluid tumor markers, carcinoembryonic antigen (CEA), cytokeratin fragment (CYFRA) 21-1, cancer antigen (CA) 15-3, CA 19-9, and CA 125, and to review the literature from the past 15 years. Pleural fluid samples were collected prospectively from 116 patients and assayed for CEA, CYFRA 21-1, CA 15-3, CA 19-9, and CA 125 levels. A MEDLINE search of the English-language literature from the past 15 years was also done. Effusions were classified as benign or malignant on the basis of their definitive pathologic or cytologic diagnoses. The levels of all pleural tumor markers were statistically significantly higher in the malignant group than in the benign group. The marker with the highest accuracy was CEA (85.3%); CA 15-3, CYFRA 21-1, and CA 19-9 had similar accuracies (75.2%, 72.4%, and 71.5%, respectively), and CA 125 had the lowest accuracy (40.5%). On univariate analysis, tumor-marker combinations did not result in a greater accuracy than that of CEA alone. On multivariate logistic regression, CA 15-3 and CYFRA 21-1 were significant predictors of malignancy. Among the nine reports in the literature comparing 11 different tumor markers, CEA, CA 15-3, and CYFRA 21-1 yielded the best results. We conclude that pleural fluid analysis should include CEA for the diagnosis of malignancy. CA 15-3 and CYFRA 21-1 may serve as alternative options.

Successful steroid withdrawal in lung transplant recipients: result of a pilot study

OBJECTIVE

Corticosteroids play a key role in immunosuppression after transplantation. However, because chronic steroid treatment may cause significant morbidity and mortality, steroid-free immunosuppression remains a desirable goal. To the best of our knowledge, there are no reports on successful steroid withdrawal (SW) in lung transplant recipients.

METHODS

The study group included 35 patients who underwent heart-lung, double-lung or single-lung transplantation. Criteria for initiation of SW were stable pulmonary function tests and absence of clinical or bronchoscopic evidence of acute or chronic rejection in the last 6 months. Pulmonary function, blood pressure and metabolic parameters were compared between the patients who underwent SW and those who did not.

RESULTS

Eight patients (23%) underwent SW. Median follow-up was 19 months (range 11-23 months). Compared to the non-withdrawal group, the withdrawal group was older (60+/-6 vs. 52+/-13 years, P=0.01, r=0.49), had higher rates of emphysema (88% vs. 18%, P=0.01) and use of a cyclosporine-based regimen (62% vs. 26%, P=0.0001), and had longer time from transplantation to the withdrawal attempt (70+/-13 vs. 29+/-26 months, P=0.0002). The SW group showed no adverse effects in graft function and no deterioration on pulmonary function tests. SW had a beneficial metabolic effect, with a decrease in mean cholesterol level from 229+/-45 to 194+/-25 mg/dl (P=0.02) and no significant change in weight, systolic blood pressure or glucose level. In the non-withdrawal group, mean cholesterol levels increased from 175+/-34 to 209+/-57 mg/dl (P=0.0005), weight increased from 72+/-15 to 80+/-14 kg (P=0.0001), and systolic blood pressure increased from 125+/-15 to 139+/-16 mmHg (P=0.001); glucose levels did not change. There was a significant correlation between total cholesterol level and weight in both groups (P=0.0006, r=-0.56 and P=0.01, r=-0.46, respectively).

CONCLUSIONS

Late SW is safe in stable patients after lung transplantation. There was no evidence of rejection or a deterioration in pulmonary function. Lipid profile improvement and blood pressure stabilization accompanied the termination of steroid therapy.

Role of ELISA D-dimer test in patients with unstable angina pectoris presenting at the emergency department with a normal electrocardiogram

Patients with unstable angina pectoris and acute myocardial infarction have higher than normal D-dimer levels. The aim of the study was to determine the value of the D-dimer test in patients with unstable angina pectoris and a normal electrocardiogram on presentation at the emergency department. The study sample included 81 patients who met these criteria. Blood samples collected at admission were subjected to ELISA D-dimer. Findings were correlated with coronary risk factors, use of cardiac medications, blood levels of acute phase reactants (fibrinogen and C-reactive protein), cardiac enzymes levels, length of hospital stay, and catheterization findings. ELISA D-dimer levels were statistically significantly correlated with cardiac risk factors, namely male sex, older age, smoking, and hypertension (r = 0.25, P = 0.02; r = 0.43, P = 0.0001; r = 0.26, P = 0.03; r = 0.35, P = 0.002, respectively), in addition to use of cardiac medications (beta blockers, aspirin, nitrates), levels of acute phase reactants, length of stay, and catheterization findings. On multivariate analysis, only D-dimer level, age, and sex were predictors of length of stay (P = 0.018). The study suggests that D-dimer levels at admission to the emergency department may serve as an additional tool to predict the magnitude of unstable angina pectoris in patients with a normal electrocardiogram.

Determinants of ELISA D-dimer sensitivity for unstable angina pectoris as defined by coronary catheterization

Unstable angina pectoris is associated with elevated D-dimer levels. However, the operating characteristics (sensitivity, specificity, positive and negative predictive value) of the D-dimer assay for the diagnosis of coronary artery disease (CAD) are unknown. Using a prospective, observational design, we collected blood from 54 patients with unstable angina pectoris at admission and assayed for ELISA D-dimer levels. The sensitivity, specificity, and negative and positive prediction values for angiographically determined coronary artery disease were calculated at multiple discriminate levels. All patients underwent coronary catheterization. A statistically significant correlation was noted between ELISA D-dimer levels and age, male sex, hypertension, use of beta-blocker, fibrinogen levels and catheterization findings. No correlation was noted between ELISA D-dimer levels and degree of the coronary artery disease. Best results were provided at a discriminate level of 270 ng/ml, with sensitivity 70%, negative predictive value 72%, and overall accuracy 67%. All discriminate levels, however, provided values too low for diagnosis. In conclusion, ELISA D-dimer assay is a non-sensitive, non-specific test for coronary artery disease as defined by coronary catheterization. However, the assay adds information regarding the severity of disease in patients presenting with acute coronary syndrome.

Prognostic value of a new quantitative D-dimer test in critically ill patients 24 and 48 h following admission to the intensive care unit

A D-dimer assay may predict mortality in medical critically ill patients, although no consensus on the clinical utility of this diagnostic test has been reached. A prospective single-center study was designed to evaluate whether D-dimer levels, as measured by a new, rapid assay, correlate with poor outcome in critically ill patients. A total of 95 blood samples were collected from medical and surgical adult patients 24 and 48 h following admission to the intensive care unit (ICU). D-dimer was assayed by the Miniquant quantitative test and correlated to the ICU length of stay, the hospital length of stay, the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Simplified Acute Physiology Score (SAPS) 24 and 48 h following admission to the ICU, organ system failure index and hospital mortality. The 24-h D-dimer level correlated with the 48 h APACHE II and SAPS scores (r = 0.41, P = 0.01; and r = 0.39, P = 0.01, respectively). The 48-h D-dimer level correlated with the APACHE II and SAPS scores at 48 h and with the organ system failure index (number of organ failure) (r = 0.54, P = 0.0008; r = 0.60, P = 0.0001; and r = 0.37, P = 0.02, respectively). Neither the 24-h nor the 48-h D-dimer levels were predictive of in-hospital mortality in a multivariate model. We conclude that this simple and new laboratory test may serve as an additional tool to predict the clinical severity of patients admitted to the ICU.

A rapid quantitative D-dimer assay at admission correlates with the severity of community acquired pneumonia

Previous research has shown a link between infectious inflammatory processes and hemostatic abnormalities. No data exist, however, on whether coagulation markers correlate with the severity of community-acquired pneumonia (CAP) at admission. We conducted a prospective, observational study in an Emergency Medicine Department of a primary care hospital. Sixty-eight patients admitted with CAP were included. Blood samples were collected at admission and assayed for D-dimer levels. D-dimers were correlated with the Pneumonia Patient Outcome Research Team (PORT) score and Acute Physiology and Chronic Health Evaluation II score on admission, with length of hospital stay, number of organ failures, time to defervescence and hospital mortality. D-dimer levels were positively correlated with the Acute Physiology and Chronic Health Evaluation II score (r = 0.44, P = 0.0002), the PORT score (r = 0.36, P = 0.002) and the length of hospital stay (r = 0.24, P = 0.046). Mean D-dimer levels of patients for whom hospitalization is recommended, according to PORT guidelines, were significantly higher than D-dimer levels of patients for whom hospitalization is not recommended (1.47 +/- 1.05 microg/ml and 0.71 +/- 0.79 microg/ml respectively; P = 0.006). The correlation between D-dimer levels and time to defervescence, development of organ system failure and outcome was not statistically significant. We conclude that D-dimer levels at admission may predict the severity of CAP.