The specificity of D-dimer testing in patients with suspected pulmonary embolism and impaired renal function is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.
Abstract
Background
Determination of pretest probability and D-dimer tests are the first diagnostic steps in patients with suspected pulmonary embolism, which can be ruled out when clinical probability is unlikely and D-dimerlevel is normal. We evaluated the utility of D-dimer testing in patients with impaired renal function.
Methods
D-dimer tests were performed in consecutive patients with suspected pulmonary embolism and an unlikely clinical probability. Creatinine levels were assessed as clinical routine. Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Correlation between D-dimer level and renal function and proportions of patients with normal D-dimer in different categories of estimated glomerular filtration rate (eGFR) were assessed. Different categories of decreasing eGFR were defined as: normal renal function (eGFR >89 mL/min), mild decrease in eGFR (eGFR 60-89 mL/min), and moderate decrease in eGFR (eGFR 30-59 mL/min).
Results
Creatinine levels were assessed in 351 of 385 patients (91%). D-dimer levels significantly increased in 3 categories of decreasing eGFR (P = .027 and P = .021 for moderate renal impairment compared with mild renal impairment and normal renal function, respectively). Normal D-dimer levels were found in 58% of patients with eGFR >89 mL/min, in 54% with eGFR 60-89 mL/min, and in 28% with eGFR 30-59 mL/min.
Conclusions
The specificity of D-dimer testing in patients with suspected pulmonary embolism and decreased GFR is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.
To read this article in its entirety, please visit our website.
-- Reza Karami-Djurabi, MD, Frederikus A. Klok, MD, Judith Kooiman, Sophie I. Velthuis, Mathilde Nijkeuter, MD, PhD, Menno V. Huisman, MD, PhD
This article was originally published in the November 2009 issue of The American Journal of Medicine.
Kamis, 10 Desember 2009
The Obesity Paradox, Weight Loss, and Coronary Disease
Although an obesity paradox exists, in that coronary heart disease patients with higher body mass index or higher percent body fat have lower mortality than those with less obesity, the results of this study support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.
Abstract
Purpose
Because obesity is a cardiovascular risk factor but is associated with a more favorable prognosis among cohorts of cardiac patients, we assessed this “obesity paradox” in overweight and obese patients with coronary heart disease enrolled in a cardiac rehabilitation and exercise training (CRET) program, making this assessment in patients classified as overweight/obese using both traditional body mass index (BMI) and percent body fat assessments. Additionally, we assessed the efficacy and safety of purposeful weight loss in overweight and obese coronary patients.
Patients and Methods
We retrospectively studied 529 consecutive CRET patients following major coronary events before and after CRET, and compared baseline and post program data in 393 overweight and obese patients (body mass index [BMI] ≥25 kg/m2) divided by median weight change (median = −1.5%; mean +2% vs −5%, respectively). In addition, we assessed 3-year total mortality in various baseline BMI categories as well as compared mortality in those with high baseline percent fat (>25% in men and >35% in women) versus those with low baseline fat.
Results
Following CRET, the overweight and obese with greater weight loss had improvements in BMI (−5%; P<.0001), percent fat (−8%; P <.0001), peak oxygen consumption (+16%; P <.0001), low-density lipoprotein cholesterol (−5%; P <.02), high-density lipoprotein cholesterol (+10%; P <.0001), triglycerides (−17%; P<.0001), C-reactive protein (−40%; P <.0001), and fasting glucose (−4%; P = .02), as well as marked improvements in behavioral factors and quality-of-life scores. Those with lower weight loss had no significant improvements in percent fat, low-density lipoprotein cholesterol, triglycerides, C-reactive protein, and fasting glucose. During 3-year follow-up, overall mortality trended only slightly lower in those with baseline overweightness/obesity who had more weight loss (3.1% vs 5.1%; P = .30). However, total mortality was considerably lower in the baseline overweight/obese (BMI ≥25 kg/m2) than in 136 CRET patients with baseline BMI <25 kg/m2 (4.1% vs 13.2%; P <.001), as well as in those with high baseline fat compared with those with low fat (3.8% vs 10.6%; P <.01).
Conclusions
Purposeful weight loss with CRET in overweight/obese coronary patients is associated with only a nonsignificant trend for lower mortality but is characterized by marked improvements in obesity indices, exercise capacity, plasma lipids, and inflammation, as well as behavioral factors and quality of life. Although an “obesity paradox” exists using either baseline BMI or baseline percent fat criteria, these results support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.
To read this article in its entirety, please visit our website.
-- Carl J. Lavie, MD, Richard V. Milani, MD, Surya M. Artham, MD, MPH, Dharmendrakumar A. Patel, MD, MPH, Hector O. Ventura, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Abstract
Purpose
Because obesity is a cardiovascular risk factor but is associated with a more favorable prognosis among cohorts of cardiac patients, we assessed this “obesity paradox” in overweight and obese patients with coronary heart disease enrolled in a cardiac rehabilitation and exercise training (CRET) program, making this assessment in patients classified as overweight/obese using both traditional body mass index (BMI) and percent body fat assessments. Additionally, we assessed the efficacy and safety of purposeful weight loss in overweight and obese coronary patients.
Patients and Methods
We retrospectively studied 529 consecutive CRET patients following major coronary events before and after CRET, and compared baseline and post program data in 393 overweight and obese patients (body mass index [BMI] ≥25 kg/m2) divided by median weight change (median = −1.5%; mean +2% vs −5%, respectively). In addition, we assessed 3-year total mortality in various baseline BMI categories as well as compared mortality in those with high baseline percent fat (>25% in men and >35% in women) versus those with low baseline fat.
Results
Following CRET, the overweight and obese with greater weight loss had improvements in BMI (−5%; P<.0001), percent fat (−8%; P <.0001), peak oxygen consumption (+16%; P <.0001), low-density lipoprotein cholesterol (−5%; P <.02), high-density lipoprotein cholesterol (+10%; P <.0001), triglycerides (−17%; P<.0001), C-reactive protein (−40%; P <.0001), and fasting glucose (−4%; P = .02), as well as marked improvements in behavioral factors and quality-of-life scores. Those with lower weight loss had no significant improvements in percent fat, low-density lipoprotein cholesterol, triglycerides, C-reactive protein, and fasting glucose. During 3-year follow-up, overall mortality trended only slightly lower in those with baseline overweightness/obesity who had more weight loss (3.1% vs 5.1%; P = .30). However, total mortality was considerably lower in the baseline overweight/obese (BMI ≥25 kg/m2) than in 136 CRET patients with baseline BMI <25 kg/m2 (4.1% vs 13.2%; P <.001), as well as in those with high baseline fat compared with those with low fat (3.8% vs 10.6%; P <.01).
Conclusions
Purposeful weight loss with CRET in overweight/obese coronary patients is associated with only a nonsignificant trend for lower mortality but is characterized by marked improvements in obesity indices, exercise capacity, plasma lipids, and inflammation, as well as behavioral factors and quality of life. Although an “obesity paradox” exists using either baseline BMI or baseline percent fat criteria, these results support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.
To read this article in its entirety, please visit our website.
-- Carl J. Lavie, MD, Richard V. Milani, MD, Surya M. Artham, MD, MPH, Dharmendrakumar A. Patel, MD, MPH, Hector O. Ventura, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Nailing the Diagnosis!
Physical examination plays a crucial role in patient evaluation by confirming the hypotheses during history taking, suggesting new clues, and directing investigations. We describe how the recognition of a nail abnormality led us to the recognition of the cause of long-standing lymphedema and pleural effusion.
To read this article in its entirety, please visit our website.
-- Srinivas Rajagopala, MD, Navneet Singh, MD, DM, Dheeraj Gupta, MD, DM, FCCP
This article was originally published in the December 2009 issue of The American Journal of Medicine.
To read this article in its entirety, please visit our website.
-- Srinivas Rajagopala, MD, Navneet Singh, MD, DM, Dheeraj Gupta, MD, DM, FCCP
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Commentary: The Bottom Line
Consideration of the forgoing will lead you to realize that the practice of medicine is predominantly a humanistic act. Physicians must care about their patients, and they must constantly improve their scientific knowledge about disease. To care and not know is dangerous. To know and not care is even worse. Caring and knowing must be combined to succeed in doctoring.
-- J. Willis Hurst, MD1
The thin thread that holds our existence in this life is broken every time we become sick. We seek medical care to restore our homeostasis through remedies and drugs provided by medical healers. Nonetheless, there is an untold and intense connection between the patient and the clinician that has been traditionally upheld as the key element of the therapeutic patient–physician relationship. In fact, more than the remedies, as patients, we expect to be listened to and cared for by compassionate and competent physicians. A listening and caring physician may turn out to be a more effective healer than the most scientifically updated physician who has little empathy. However, the major threat to this sacred connection between the provider and the patient is the growing practice of the business of medicine where care is sacrificed to see a greater number of “clients,” and thus increased billing.
The practice of clinical medicine is rapidly transforming with the current worldwide economic crisis. Although no one denies the importance of running a practice in a fiscally responsible way, the core ideals behind “physicianhood” and its mission also seem to be faltering.
To read this article in its entirety, please visit our website.
-- Carlos Franco-Paredes, MD, MPH, Phyllis Kozarsky, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
-- J. Willis Hurst, MD1
The thin thread that holds our existence in this life is broken every time we become sick. We seek medical care to restore our homeostasis through remedies and drugs provided by medical healers. Nonetheless, there is an untold and intense connection between the patient and the clinician that has been traditionally upheld as the key element of the therapeutic patient–physician relationship. In fact, more than the remedies, as patients, we expect to be listened to and cared for by compassionate and competent physicians. A listening and caring physician may turn out to be a more effective healer than the most scientifically updated physician who has little empathy. However, the major threat to this sacred connection between the provider and the patient is the growing practice of the business of medicine where care is sacrificed to see a greater number of “clients,” and thus increased billing.
The practice of clinical medicine is rapidly transforming with the current worldwide economic crisis. Although no one denies the importance of running a practice in a fiscally responsible way, the core ideals behind “physicianhood” and its mission also seem to be faltering.
To read this article in its entirety, please visit our website.
-- Carlos Franco-Paredes, MD, MPH, Phyllis Kozarsky, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Selasa, 01 Desember 2009
An Aberrant Internal Carotid Artery in the Mouth
The cervical internal carotid artery normally runs straight to the skull base without branching.(1) However, aberrant courses of the extracranial internal carotid artery are not rare and may place the vessel in close relationship with the pharyngeal wall.(2, 3) We present this clinical observation to draw the readers' attention on a probably underappreciated anatomic variation.
A 77-year-old woman had long-standing moderate dysphagia and right-sided foreign body sensations in the throat. She had no history of alcohol or tobacco abuse. On examination, smooth irritation-free mucous membranes were found, but a funicular pulsatile mass was detected on the posterior pharyngeal wall on the right. Endoscopy displayed that the mass continued down to the hypopharynx. It was finally attributed to an aberrant course of the internal carotid artery. The patient was instructed to advise every treating physician of this anatomic variation and to abstain from sharp-edged food such as chicken bones and fish.
Pronounced extracranial aberrations of the internal carotid artery have a calculated incidence of 5% in the general population and can often be found bilaterally. They result from embryologic maldevelopment and age-related loss of elasticity in the vessel wall. These anatomic variations remain asymptomatic in the majority of cases but can also become apparent with dysphagia, pharyngeal foreign body sensations, intraoral pulsations, or signs of cerebrovascular insufficiency in case of sharp vessel bends.1, 2, 3 If placed in close opposition with the pharyngeal wall (Figure 1A and B), an aberrant internal carotid artery is at risk of injury during intubation, endoscopy, and routine pharyngeal or dental procedures. It may also be misdiagnosed as a parapharyngeal tumor.2, 3 Therefore, the awareness of extracranial aberrations of the internal carotid artery is essential for every clinician.
References
1. Paulsen F, Tillmann B, Christofides C, et al. Curving and looping of the internal carotid artery in relation to the pharynx: frequency, embryology and clinical implications. J Anat. 2000;197:373–381.
2. Hertzanu Y, Tovi F. Radiology case of the month (Aberrant internal carotid artery manifesting as a pharyngeal mass). J Otolaryngol. 1992;21:294–296.MEDLINE
3. Ricciardelli E, Hillel AD, Schwartz AN. Aberrant carotid artery (Presentation in the near midline pharynx). Arch Otolaryngol Head Neck Surg.1989;115:519–522. MEDLINE
-- Jens Pfeiffer, MD, Gerd J. Ridder, MD
This article was originally published in the March 2009 issue of The American Journal of Medicine.
A 77-year-old woman had long-standing moderate dysphagia and right-sided foreign body sensations in the throat. She had no history of alcohol or tobacco abuse. On examination, smooth irritation-free mucous membranes were found, but a funicular pulsatile mass was detected on the posterior pharyngeal wall on the right. Endoscopy displayed that the mass continued down to the hypopharynx. It was finally attributed to an aberrant course of the internal carotid artery. The patient was instructed to advise every treating physician of this anatomic variation and to abstain from sharp-edged food such as chicken bones and fish.
Pronounced extracranial aberrations of the internal carotid artery have a calculated incidence of 5% in the general population and can often be found bilaterally. They result from embryologic maldevelopment and age-related loss of elasticity in the vessel wall. These anatomic variations remain asymptomatic in the majority of cases but can also become apparent with dysphagia, pharyngeal foreign body sensations, intraoral pulsations, or signs of cerebrovascular insufficiency in case of sharp vessel bends.1, 2, 3 If placed in close opposition with the pharyngeal wall (Figure 1A and B), an aberrant internal carotid artery is at risk of injury during intubation, endoscopy, and routine pharyngeal or dental procedures. It may also be misdiagnosed as a parapharyngeal tumor.2, 3 Therefore, the awareness of extracranial aberrations of the internal carotid artery is essential for every clinician.
References
1. Paulsen F, Tillmann B, Christofides C, et al. Curving and looping of the internal carotid artery in relation to the pharynx: frequency, embryology and clinical implications. J Anat. 2000;197:373–381.
2. Hertzanu Y, Tovi F. Radiology case of the month (Aberrant internal carotid artery manifesting as a pharyngeal mass). J Otolaryngol. 1992;21:294–296.MEDLINE
3. Ricciardelli E, Hillel AD, Schwartz AN. Aberrant carotid artery (Presentation in the near midline pharynx). Arch Otolaryngol Head Neck Surg.1989;115:519–522. MEDLINE
-- Jens Pfeiffer, MD, Gerd J. Ridder, MD
This article was originally published in the March 2009 issue of The American Journal of Medicine.
Langganan:
Komentar (Atom)