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Hao W, Liu X, Feng J, Qian Y, An S, Tian Y, Quan W, Sun J, Wei Y, Zhang X, Jiang R. Age-adjusted D-Dimer Thresholds Combined with the Modified Wells Score as a Predictor of Lower Extremity Deep Venous Thrombosis. Clin Appl Thromb Hemost 2023; 29:10760296231221141. [PMID: 38099820 PMCID: PMC10725659 DOI: 10.1177/10760296231221141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Neurosurgical patients are at an increased risk of deep venous thrombosis (DVT), which, if not properly managed, can lead to pulmonary embolism. This study aimed to investigate the accuracy of age-adjusted D-dimer thresholds combined with the modified Wells score as a predictor for lower extremity DVT diagnosis. METHODS We conducted a study among patients aged >50 years with suspected lower extremity DVT in the neurosurgery intensive care unit between December 2019 and December 2020. Receiver operating characteristic curve analysis was performed to examine the diagnostic capacity of age-adjusted D-dimer combined with the modified Wells score. RESULTS A total of 233 participants, with an average age of 71.81 ± 12.59 years, were enrolled in the study. The mean D-dimer levels were 0.73 ± 0.39 mg/L. Among the participants, 57 (57.9%, 33 males) were diagnosed with DVT. The age-adjusted D-dimer combined with the modified Wells score had the highest area under the curve for diagnosing lower extremity DVT compared to D-dimer and age-adjusted D-dimer alone, with an AUC of 0.858. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the age-adjusted D-dimer combined with the modified Wells score for DVT diagnosis were 78.95%, 80.68%, 57%, 92.2%, and 80.26%, respectively. When analyzing subgroups, the accuracy was 79.55% for participants with cerebral hemorrhage, 81.69% for those with craniocerebral injury, 74.99% for participants with intracranial infection, and 88.89% for those with craniocerebral tumor. CONCLUSION The combination of the age-adjusted D-dimer thresholds with the modified Wells score might effectively predict lower extremity DVT.
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Affiliation(s)
- Wei Hao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Ordos Central Hospital, Ordos, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Jiancheng Feng
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Yu Qian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Shuo An
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Jian Sun
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Yingsheng Wei
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury, Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
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Iwuji K, Almekdash H, Nugent KM, Islam E, Hyde B, Kopel J, Opiegbe A, Appiah D. Age-Adjusted D-Dimer in the Prediction of Pulmonary Embolism: Systematic Review and Meta-analysis. J Prim Care Community Health 2021; 12:21501327211054996. [PMID: 34814782 PMCID: PMC8640977 DOI: 10.1177/21501327211054996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Pulmonary embolism (PE), depending on the severity, carries a high mortality and morbidity. Proper evaluation, especially in patients with low probability for PE, is important to avoid unnecessary diagnostic testing. Objective: To review the diagnostic utility of conventional versus age-adjusted D-dimer cutoff values in patients 50 years and older with suspected pulmonary embolism. Methods: Systematic review with univariant and bivariant meta-analysis. Data sources: We searched PubMed, MEDLINE, and EBSCO for studies published before September 20th, 2020. We cross checked the reference list of relevant studies that compares conventional versus age-adjusted D-dimer cutoff values in patients with suspected pulmonary embolism. Study selection: We included primary published studies that compared both conventional (500 µg/L) and age-adjusted (age × 10 µg/L) cutoff values in patients with non-high clinical probability for pulmonary embolism. Results: Nine cohorts that included 47 720 patients with non-high clinical probability were included in the meta-analysis. Both Age-adjusted D-dimer and conventional D-dimer have high sensitivity. However, conventional D-dimer has higher false positive rate than age-adjusted D-dimer. Conclusion: Age-adjusted D-dimer cutoffs combined with low risk clinical probability assessment ruled out PE diagnosis in suspected patients with a decreased rate of false positive tests.
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Affiliation(s)
- Kenneth Iwuji
- Texas Tech University Health Sciences Center Lubbock, Lubbock, TX, USA
| | - Hasan Almekdash
- Texas Tech University Health Sciences Center Lubbock, Lubbock, TX, USA
| | - Kenneth M Nugent
- Texas Tech University Health Sciences Center Lubbock, Lubbock, TX, USA
| | - Ebtesam Islam
- Texas Tech University Health Sciences Center Lubbock, Lubbock, TX, USA
| | - Briget Hyde
- Texas Tech University Health Sciences Center Lubbock, Lubbock, TX, USA
| | - Jonathan Kopel
- Texas Tech University Health Sciences Center Lubbock, Lubbock, TX, USA
| | - Adaugo Opiegbe
- University of Benin, Edo State, Benin City, Edo, Nigeria
| | - Duke Appiah
- Texas Tech University Health Sciences Center Lubbock, Lubbock, TX, USA
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Role of a new age-adjusted D-dimer cutoff value for preoperative deep venous thrombosis exclusion in elderly patients with hip fractures. J Orthop Surg Res 2021; 16:649. [PMID: 34717681 PMCID: PMC8557539 DOI: 10.1186/s13018-021-02801-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/18/2021] [Indexed: 11/20/2022] Open
Abstract
Objective This study aimed to describe the characteristics of plasma D-dimer level with increasing age and establish a new age-adjusted D-dimer cutoff value for excluding preoperative lower limb deep vein thrombosis (DVT) in elderly patients with hip fractures. Methods This was a retrospective study of elderly patients who presented with acute hip fracture in our institution between June 2016 and June 2019. All patients underwent D-dimer test and duplex ultrasound. Patients were divided into six 5-year-apart age groups. The optimal cutoff value for each group was calculated by using receiver operating characteristic (ROC) curves, whereby the new age-adjusted D-dimer cutoff value was determined. The sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) were calculated and compared when different D-dimer cutoff values were applied, i.e., conventional 0.5 mg/L, previously well-established age-adjusted cutoff value (age × 0.01 mg/L) and the new age-adjusted D-dimer cutoff value herein. Results There were 2759 patients included, 887 males and 1872 females, with an average age of 78 years. In total, 280 patients were diagnosed with preoperative DVT. The optimal cutoff values for the six age groups were 0.715 mg/L, 1.17 mg/L, 1.62 mg/L, 1.665 mg/L, 1.69 mg/L and 1.985 mg/L, respectively, and the calculated age-adjusted coefficient was 0.02 mg/L. With this new coefficient applied, the specificity was 61%, clearly higher than those for conventional threshold (0.5 mg/L, 37%) or previously established age-adjusted D-dimer threshold (age × 0.01 mg/L, 22%). In contrast, the sensitivity was lower than that (59% vs 85% or 77%) when D-dimer threshold of 0.5 mg/L or age-adjusted cutoff value (age × 0.01 mg/L) was used. The other indexes as PPV (15%, 11% and 12%) and NPV (93%, 93% and 94%) were comparable when three different D-dimer thresholds were applied. Conclusions We developed a new age-adjusted D-dimer cutoff value (age × 0.02 mg/L) for a specified high-risk population of patients aged 65 years or older with hip fractures, and demonstrated the improved utility of the D-dimer test for exclusion of DVT. This formula can be considered for use in elderly hip fracture patients who meet the applicable standards as preoperative DVT screening, after its validity is confirmed by more well-evidenced studies.
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Villacorta H, Pickering JW, Horiuchi Y, Olim M, Coyne C, Maisel AS, Than MP. Machine learning with D-dimer in the risk stratification for pulmonary embolism: a derivation and internal validation study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 11:13-19. [PMID: 34697635 DOI: 10.1093/ehjacc/zuab089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022]
Abstract
AIM To develop a machine learning model to predict the diagnosis of pulmonary embolism (PE). METHODS AND RESULTS We undertook a derivation and internal validation study to develop a risk prediction model for use in patients being investigated for possible PE. The machine learning technique, generalized logistic regression using elastic net, was chosen following an assessment of seven machine learning techniques and on the basis that it optimized the area under the receiver operator characteristic curve (AUC) and Brier score. Models were developed both with and without the addition of D-dimer. A total of 3347 patients were included in the study of whom, 219 (6.5%) had PE. Four clinical variables (O2 saturation, previous deep venous thrombosis or PE, immobilization or surgery, and alternative diagnosis equal or more likely than PE) plus D-dimer contributed to the machine learning models. The addition of D-dimer improved the AUC by 0.16 (95% confidence interval 0.13-0.19), from 0.73 to 0.89 (0.87-0.91) and decreased the Brier score by 14% (10-18%). More could be ruled out with a higher positive likelihood ratio than by the Wells score combined with D-dimer, revised Geneva score combined with D-dimer, or the Pulmonary Embolism Rule-out Criteria score. Machine learning with D-dimer maintained a low-false-negative rate at a true-negative rate of nearly 53%, which was better performance than any of the other alternatives. CONCLUSION A machine learning model outperformed traditional risk scores for the risk stratification of PE in the emergency department. However, external validation is needed.
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Affiliation(s)
- Humberto Villacorta
- Division of Cardiology, Department of Clinical Medicine, Fluminense Federal University, Rua Marquês do Paraná 303, Niterói, Rio de Janeiro CEP 24033-900, Brazil
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Riccarton Avenue, Christchurch 8011, New Zealand.,Department of Medicine, University of Otago, Christchurch, 2 Riccarton Road, Christchurch 8011, New Zealand
| | - Yu Horiuchi
- Division of Cardiology, Department of Medicine, Mitsui Memorial Hospital, Kanda-Izumicho 1, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Moshe Olim
- Brainstorm Medical, Inc., 2235 Montgomery Ave Cardiff By The Sea, San Diego, CA, 92007-1913, USA
| | - Christopher Coyne
- Emergency Medicine, Department of Medicine, University of California San Diego, 200 W. Arbor Drive 8676, San Diego, CA, 92103, USA
| | - Alan S Maisel
- Brainstorm Medical, Inc., 2235 Montgomery Ave Cardiff By The Sea, San Diego, CA, 92007-1913, USA.,Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92037-7411
| | - Martin P Than
- Emergency Department, Christchurch Hospital, Riccarton Avenue, Christchurch 8011, New Zealand
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Khan M, Alter SM, Clayton LM, Hughes PG, Shih RD, Solano JJ. Age adjusted D-dimer cutoffs for pulmonary embolism in a geriatric population utilizing a D-dimer unit assay. Am J Emerg Med 2021; 51:103-107. [PMID: 34735966 DOI: 10.1016/j.ajem.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/24/2021] [Accepted: 10/04/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Age adjusted serum d-dimer (AADD) with clinical decision rules have been utilized to rule out pulmonary embolism (PE) in low-risk patients; however, its use in the geriatric population has been questioned and the use of d-dimer unit (DDU) assay is uncommon. OBJECTIVE The present study aims to compare the test characteristics of the AADD (age × 5) measured in DDU with the standard cutoff (DDU < 250) and study hospital laboratory's d-dimer cutoff (DDU < 600) in geriatric patients presenting with suspected PE. METHODS This retrospective study enrolled patients ≥65 years old with suspected PE and d-dimer performed between January 1, 2019 and December 31, 2019 who presented to the emergency department (ED). Charts were reviewed for CTA chest and ventilation perfusion imaging results for PE. Diagnostic parameters for each cutoff were calculated for the primary outcome. RESULTS 510 patients were included, 20 with PE. There was no significant difference between the sensitivities of AADD (100%, 95% CI: 80-100), standard cutoff (100%, 95% CI: 80-100), and hospital cutoff (90%, 95% CI: 66.9-98.2). The hospital cutoff specificity (22.7%, 95% CI: 17.1-29.3) was significantly greater than the AADD (13.4%, 95% CI: 9.1-19.2) and standard cutoff (10.8%, 95% CI: 7.0-16.3) specificities. CONCLUSIONS In geriatric patients presenting to the ED with suspected PE, the AADD measured in DDUs maintained sensitivity with improved specificity compared to standard cutoff. In this population, the AADD would have safely reduced imaging by 19% without missing any PEs. AADD remains a valid tool with high sensitivity and negative predictive value in ruling out PE in geriatric patients.
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Affiliation(s)
- Mohsin Khan
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, FL 33431, USA.
| | - Scott M Alter
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, FL 33431, USA.
| | - Lisa M Clayton
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, FL 33431, USA.
| | - Patrick G Hughes
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, FL 33431, USA.
| | - Richard D Shih
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, FL 33431, USA.
| | - Joshua J Solano
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, FL 33431, USA.
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Goulden R, Rowe BH, Abrahamowicz M, Strumpf E, Tamblyn R. Association of Intravenous Radiocontrast With Kidney Function: A Regression Discontinuity Analysis. JAMA Intern Med 2021; 181:767-774. [PMID: 33818606 PMCID: PMC8022267 DOI: 10.1001/jamainternmed.2021.0916] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Radiocontrast has long been thought of as nephrotoxic; however, a number of recent observational studies found no evidence of an association between intravenous contrast and kidney injury. Because these studies are at high risk of confounding and selection bias, alternative study designs are required to enable more robust evaluation of this association. OBJECTIVE To determine whether intravenous radiocontrast exposure is associated with clinically significant long-term kidney impairment, using a study design that permits stronger causal interpretation than existing observational research. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all emergency department patients aged 18 years or older undergoing D-dimer testing between 2013 and 2018 in the Canadian province of Alberta. A fuzzy regression discontinuity design was used, exploiting the fact that individuals just either side of the eligibility cutoff for computed tomographic pulmonary angiogram (CTPA)-typically 500 ng/mL-have markedly different probabilities of contrast exposure, but should otherwise be similar with respect to potential confounders. EXPOSURES Intravenous contrast in the form of a CTPA. MAIN OUTCOMES AND MEASURES Estimated glomerular filtration rate (eGFR) up to 6 months following the index emergency department visit. RESULTS During the study period 156 028 individuals received a D-dimer test. The mean age was 53 years, 68 206 (44%) were men and 87 822 (56%) were women, and the mean baseline eGFR level was 86 mL/min/1.73 m2. Patients just above and below the CTPA eligibility cutoff were similar in terms of measured confounders. There was no evidence for an association of contrast with eGFR up to 6 months later, with a mean change in eGFR of -0.4 mL/min/1.73 m2 (95% CI, -4.9 to 4.0) associated with CTPA exposure. There was similarly no evidence for an association with need for kidney replacement therapy (risk difference [RD], 0.07%; 95% CI, -0.47% to 0.61%), mortality (RD, 0.3%; 95% CI, -2.9% to 3.2%), and acute kidney injury (RD, 4.3%; 95% CI, -2.7% to 12.9%), though the latter analysis was limited by missing data. Subgroup analyses were potentially consistent with harm among patients with diabetes (mean eGFR change -6.4 mL/min/1.73 m2; 95% CI, -15.4 to 0.2), but not among those with other reported risk factors for contrast-induced nephropathy; these analyses, however, were relatively underpowered. CONCLUSIONS AND RELEVANCE Using a cohort study design and analysis that permits stronger causal interpretation than existing observational research, we found no evidence for a harmful effect on kidney function of intravenous contrast administered for CTPA in an emergency setting.
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Affiliation(s)
- Robert Goulden
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry and School of Public Health, both at the University of Alberta, Edmonton, Alberta, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Erin Strumpf
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Economics, Faculty of Arts, McGill University, Montreal, Quebec, Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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De Pooter N, Brionne-François M, Smahi M, Abecassis L, Toulon P. Age-adjusted D-dimer cut-off levels to rule out venous thromboembolism in patients with non-high pre-test probability: Clinical performance and cost-effectiveness analysis. J Thromb Haemost 2021; 19:1271-1282. [PMID: 33638267 DOI: 10.1111/jth.15278] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/22/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND As aging was found to be associated with increased D-dimer levels, the question arose whether D-dimer measurement was useful in the diagnostic strategy of venous thromboembolism (VTE) in elderly patients. AIM OF THE STUDY To compare retrospectively the performance of six diagnostic strategies based on the three-level Wells scores and various cut-off levels for D-dimer, evaluated using the HemosIL D-Dimer HS 500 assay, in a derivation cohort of 644 outpatients with non-high pretest probability (PTP) of VTE. The clinical usefulness of the best-performing strategy was then confirmed in a multicenter validation study involving 1255 consecutive outpatients with non-high PTP. RESULTS The diagnostic strategy based on the age-adjusted cut-off level calculated by multiplying the patient's age by 10 above 50 years was found to perform the best in the derivation study with a better sensitivity-to-specificity ratio than the conventional strategy based on the fixed cut-off level (500 ng/ml), a higher specificity and a negative predictive value (NPV) above 99%. Such an increase in test specificity was confirmed in the validation cohort, with the NPV remaining above 99%. Taking into account the local reimbursement rates of diagnostic tests, using this strategy led to a 6.9% reduction of diagnostic costs for pulmonary embolism and a 5.1% reduction for deep vein thrombosis, as imaging tests would be avoided in a higher percentage of patients. CONCLUSION The diagnostic strategy of VTE based on the age-adjusted cut-off level for D-dimer in patients over 50 years was found to be safe, with NPV above 99%, and cost-effective.
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Affiliation(s)
- Neila De Pooter
- Hematology Laboratory, Emile Müller Regional Hospital, Mulhouse, France
- Hematology Laboratory, Grasse Hospital, Grasse, France
| | | | - Motalib Smahi
- Hematology Laboratory, Simone Veil Hospital, Eaubonne, France
| | - Lien Abecassis
- Hematology Laboratory, Jean Verdier Hospital, Aulnay-sous-Bois, France
| | - Pierre Toulon
- Hematology Department, Côte d'Azur University, Pasteur University Hospital, Nice, France
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8
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Uzel Şener M, Şahin Duyar S, Saral Öztürk Z, Şener A. The impact of using different age-adjusted cutoffs of D-dimer in the diagnosis of pulmonary thromboembolism. Am J Emerg Med 2021; 43:118-122. [PMID: 33550102 DOI: 10.1016/j.ajem.2021.01.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 01/25/2021] [Accepted: 01/25/2021] [Indexed: 10/22/2022] Open
Abstract
Background This study was conducted to evaluate the relationship of age-adjusted D-dimer value with different coefficients in diagnosis of pulmonary embolism (PE) in geriatric patients. Methods The emergency admissions of the patients aged 65 and over with suspected PE during 2018 were reviewed retrospectively. The demographic characteristics, laboratory tests and radiologic findings of computed tomography pulmonary angiogram (CTPA) or single photon emission computed tomography ventilation/perfusion scintigraphy (V/Q) were recorded. The characteristics of the patients with PE were statistically compared with the patients without PE. The specificity and sensitivity for higher cut-off levels (age × 10-15) were presented. Results PE was detected in 39.2% (n = 246) of 628 patients aged 65 years and older included in the study. The multivariate analysis revealed that higher D-dimer level (OR = 1,00011; p < 0.001) and BUN level (OR = 1.025; p = 0.013) were independent risk factors for PE diagnosis in elderly patients. Diagnostic statistics for D-dimer cut-off levels selected from ROC analysis and calculated values as 10-15 times of age showed that if the D-dimer cut-off value used is chosen higher, lower sensitivity rates are obtained. Our results also indicated that the patients with malignancy, renal failure, central PE on CTPA and PE with high probability on SPECT VQ were presented with higher D-dimer values. Conclusion Our results do not support the use of higher D-dimer cut-off levels such as 15 times the age in geriatric population. The impact of the location of PE and comorbidities on the outcomes of these patients must be clarified for determining cut-offs with higher specificity.
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Affiliation(s)
- Melahat Uzel Şener
- Department of Chest Disease, Ankara Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, University of Health Sciences, Ankara, Turkey.
| | - Sezgi Şahin Duyar
- Department of Chest Disease, Ankara Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Zeynep Saral Öztürk
- Department of Emergency Medicine, Ankara Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Alp Şener
- Faculty of Medicine, Department of Emergency Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkey; Department of Emergency Medicine, Ministry of Health Ankara City Hospital, Ankara, Turkey
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Ghobadi A, Lin B, Musigdilok VV, Park SJ, Palmer‐Toy DE, Gould MK, Vinson DR, Hutchison DM, Sharp AL. Effect of Using an Age-adjusted D-dimer to Assess for Pulmonary Embolism in Community Emergency Departments. Acad Emerg Med 2021; 28:60-69. [PMID: 33206443 DOI: 10.1111/acem.14175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/20/2020] [Accepted: 11/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the effect of changing the laboratory-reported D-dimer reference intervals to age-adjusted reference intervals on the use of advanced chest imaging and 30-day adverse events among emergency department (ED) encounters. METHODS A retrospective interrupted time-series analysis of ED encounters for patients > 50 years evaluated for suspected pulmonary embolism (PE) from April 2014 to April 2016. The primary outcome was use of advanced diagnostic imaging, and the secondary outcome was 30-day mortality or PE diagnosis. Secondary analyses also quantified delayed PE diagnoses pre- and postintervention. A generalized estimating equation segmented logistic regression model, adjusting for patient and facility characteristics, was used to determine changes in odds of diagnostic imaging and 30-day mortality or PE diagnoses. RESULTS A total of 10,534 (5,153 pre- and 5,381 postimplementation) ED encounters were included. Advanced imaging was obtained in 35.9% of pre- versus 33% of postimplementation encounters. Age-adjusted D-dimer (AADD) showed a small and nonsignificant decrease in month-to-month trends of advanced chest imaging postimplementation (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.96 to 1.00). Use of advanced imaging in patients with D-dimer values lower than 500 ng/mL fibrinogen-equivalent units (FEU) was similar in the preintervention (5.8%) and postintervention (6.8%) periods. However, imaging was obtained in 30% of patients postintervention with a D-dimer result less than AADD reference interval , but more than the historical 500 ng/mL FEU reference interval. Implementing an AADD threshold demonstrated no change in the rate of 30-day adverse events (missed PE or mortality). CONCLUSION Changing the laboratory-reported D-dimer reference intervals for evaluation of PE was not associated with reduction in advanced chest imaging and did not increase 30-day adverse events. However, there was substantial noncompliance with the age-adjusted reference intervals in the postintervention period likely blunting the impact of this intervention.
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Affiliation(s)
- Ali Ghobadi
- From the Department of Clinical Science Kaiser Permanente Bernard J. Tyson School of Medicine PasadenaCAUSA
- the Anaheim Medical Center Kaiser Permanente Southern California Anaheim CAUSA
| | - Bryan Lin
- the Department of Research and Evaluation Kaiser Permanente PasadenaCAUSA
| | | | - Stacy J. Park
- the Department of Research and Evaluation Kaiser Permanente PasadenaCAUSA
| | - Darryl E. Palmer‐Toy
- the Southern California Permanente Medical Group Regional Reference Laboratories North Hollywood and Chino Hills CAUSA
| | - Michael K. Gould
- the Department of Research and Evaluation Kaiser Permanente PasadenaCAUSA
- the Department of Health Systems Science Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena CAUSA
| | - David R. Vinson
- the Department of Research, and The Permanente Medical Group Kaiser Permanente Northern California Oakland CAUSA
- the Kaiser Permanente Roseville Medical Center Roseville CAUSA
| | | | - Adam L. Sharp
- the Department of Research and Evaluation Kaiser Permanente PasadenaCAUSA
- the Department of Health Systems Science Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena CAUSA
- and the Los Angeles Medical Center Kaiser Permanente Southern California Los Angeles CA USA
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