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Pretest Probability (pretest + probability)

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Medical Sciences	100%

Selected Abstracts

Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

ACADEMIC EMERGENCY MEDICINE, Issue 8 2009
Abhinav Chandra MD
Abstract Objectives:, The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event. Methods:, This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina. Results:, Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2). Conclusions:, In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes. [source]

Potential Impact of Adjusting the Threshold of the Quantitative D-dimer Based on Pretest Probability of Acute Pulmonary Embolism

ACADEMIC EMERGENCY MEDICINE, Issue 4 2009
Christopher Kabrhel MD
Abstract Objectives:, The utility of D-dimer testing for suspected pulmonary embolism (PE) can be limited by test specificity. The authors tested if the threshold of the quantitative D-dimer can be varied according to pretest probability (PTP) of PE to increase specificity while maintaining a negative predictive value (NPV) of >99%. Methods:, This was a prospective, observational multicenter study of emergency department (ED) patients in the United States. Eligible patients had a diagnostic study ordered to evaluate possible PE. PTP was determined by the clinician's unstructured estimate and the Wells score. Five different D-dimer assays were used. D-dimer test performance was measured using 1) standard thresholds and 2) variable threshold values: twice (for low PTP patients), equal (intermediate PTP patients), or half (high PTP patients) of standard threshold. Venous thromboembolism (VTE) within 45 days required positive imaging plus decision to treat. Results:, The authors enrolled 7,940 patients tested for PE, and clinicians ordered a quantitative D-dimer for 4,357 (55%) patients who had PTPs distributed as follows: low (74%), moderate (21%), or high (4%). At standard cutoffs, across all PTP strata, quantitative D-dimer testing had a test sensitivity of 94% (95% confidence interval [CI] = 91% to 97%), specificity of 58% (95% CI = 56% to 60%), and NPV of 99.5% (95% CI = 99.1% to 99.7%). If variable cutoffs had been used the overall sensitivity would have been 88% (95% CI = 83% to 92%), specificity 75% (95% CI = 74% to 76%), and NPV 99.1% (95% CI = 98.7% to 99.4%). Conclusions:, This large multicenter observational sample demonstrates that emergency medicine clinicians currently order a D-dimer in the majority of patients tested for PE, including a large proportion with intermediate PTP and high PTP. Varying the D-dimer's cutoff according to PTP can increase specificity with no measurable decrease in NPV. [source]

The performance of the Japanese version of the K6 and K10 in the World Mental Health Survey Japan

INTERNATIONAL JOURNAL OF METHODS IN PSYCHIATRIC RESEARCH, Issue 3 2008
Toshi A. Furukawa
Abstract Two new screening scales for psychological distress, the K6 and K10, have been developed using the item response theory and shown to outperform existing screeners in English. We developed their Japanese versions using the standard backtranslaton method and included them in the World Mental Health Survey Japan (WMH-J), which is a psychiatric epidemiologic study conducted in seven communities across Japan with 2436 participants. The WMH-J used the WMH Survey Initiative version of the Composite International Diagnostic Interview (CIDI) to assess the 30-day Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition (DSM-IV). Performance of the two screening scales in detecting DSM-IV mood and anxiety disorders, as assessed by the areas under receiver operating characteristic curves (AUCs), was excellent, with values as high as 0.94 (95% confidence interval = 0.88 to 0.99) for K6 and 0.94 (0.88 to 0.995) for K10. Stratum-specific likelihood ratios (SSLRs), which express screening test characteristics and can be used to produce individual-level predicted probabilities of being a case from screening scale scores and pretest probabilities in other samples, were strikingly similar between the Japanese and the original versions. The Japanese versions of the K6 and K10 thus demonstrated screening performances essentially equivalent to those of the original English versions. Copyright © 2008 John Wiley & Sons, Ltd. [source]

Accuracy of Very Low Pretest Probability Estimates for Pulmonary Embolism Using the Method of Attribute Matching Compared with the Wells Score

ACADEMIC EMERGENCY MEDICINE, Issue 2 2010
Jeffrey A. Kline MD
Abstract Objectives:, Attribute matching matches an explicit clinical profile of a patient to a reference database to estimate the numeric value for the pretest probability of an acute disease. The authors tested the accuracy of this method for forecasting a very low probability of venous thromboembolism (VTE) in symptomatic emergency department (ED) patients. Methods:, The authors performed a secondary analysis of five data sets from 15 hospitals in three countries. All patients had data collected at the time of clinical evaluation for suspected pulmonary embolism (PE). The criterion standard to exclude VTE required no evidence of PE or deep venous thrombosis (DVT) within 45 days of enrollment. To estimate pretest probabilities, a computer program selected, from a large reference database of patients previously evaluated for PE, patients who matched 10 predictor variables recorded for each current test patient. The authors compared the outcome frequency of having VTE [VTE(+)] in patients with a pretest probability estimate of <2.5% by attribute matching, compared with a value of 0 from the Wells score. Results:, The five data sets included 10,734 patients, and 747 (7.0%, 95% confidence interval [CI] = 6.5% to 7.5%) were VTE(+) within 45 days. The pretest probability estimate for PE was <2.5% in 2,975 of 10,734 (27.7%) patients, and within this subset, the observed frequency of VTE(+) was 48 of 2,975 (1.6%, 95% CI = 1.2% to 2.1%). The lowest possible Wells score (0) was observed in 3,412 (31.7%) patients, and within this subset, the observed frequency of VTE(+) was 79 of 3,412 (2.3%, 95% CI = 1.8% to 2.9%) patients. Conclusions:, Attribute matching categorizes over one-quarter of patients tested for PE as having a pretest probability of <2.5%, and the observed rate of VTE within 45 days in this subset was <2.5%. ACADEMIC EMERGENCY MEDICINE 2010; 17:133,141 © 2010 by the Society for Academic Emergency Medicine [source]

Sensitivity of superficial cultures in lower extremity wounds,

JOURNAL OF HOSPITAL MEDICINE, Issue 7 2010
Chayan Chakraborti MD
Abstract BACKGROUND: Superficial wound cultures are routinely used to guide therapy, despite a lack of clear supporting evidence. PURPOSE: To conduct a systematic review of the correlation between superficial wound cultures and the etiology of skin and soft tissue infections. DATA SOURCES: Medline, EMBASE, CINAHL, Scopus. STUDY SELECTION: Articles published between January 1960 and August 2009 involving superficial wound cultures and deeper comparison cultures. DATA EXTRACTION: Two reviewers independently searched for abstracted information pertaining to the microbiology of lower extremity wounds sufficient to calculate the sensitivity and specificity of superficial wound cultures versus comparison cultures. DATA SYNTHESIS: Data pooled using a random-effects meta-analysis model. RESULTS: Of 9032 unique citations, 8 studies met all inclusion criteria. Inter-rater reliability was substantial (Kappa = 0.78). Pooled test sensitivity for superficial wound swabs was 49% (95% confidence interval [CI], 37-61%], and specificity was 62% (95% CI, 51-74%). The pooled positive and negative likelihood ratios (LRs) were 1.1 (95% CI, 0.71-1.5) and 0.67 (95% CI, 0.52-0.82). The median number of isolates for surface cultures (2.7, interquartile range [IQR] 1.8-3.2) was not significantly different than that for comparison cultures, (2.2, IQR 1.7-2.9) (P = 0.75). CONCLUSION: Few studies show a strong relationship between superficial wound swabs and deep tissue cultures, and the current data demonstrate poor overall sensitivity and specificity. The positive and negative LRs were found to provide minimal utility in influencing pretest probabilities. Results of this analysis show that wound cultures should not be used in lieu of local antibiograms to guide initial antibiotic therapies. Journal of Hospital Medicine 2010;5:415,420. © 2010 Society of Hospital Medicine. [source]

The Contribution of the Subjective Component of the Canadian Pulmonary Embolism Score to the Overall Score in Emergency Department Patients

ACADEMIC EMERGENCY MEDICINE, Issue 10 2005
Christopher Kabrhel MD
Abstract Background: Clinicians frequently use their experience to determine the pretest probability of pulmonary embolism (PE), although scoring systems are promoted as being more reliable. The Canadian Pulmonary Embolism Score (CPES) combines six objective questions and one subjective question. The CPES has been validated and appears to be useful for risk-stratifying patients. However, research suggests that subjective gestalt performs similarly to the CPES, and the influence of the subjective question on the predictive value of the CPES is not clear. Objectives: To determine the test characteristics of the CPES, its subjective question, and the degree to which the predictive value of the CPES is influenced by its individual questions. Methods: The authors performed a prospective observational study on a cohort of emergency department patients suspected of having PE. The authors compared patients' CPES results with the diagnosis of PE, calculated the test characteristics of the CPES, and determined the contribution of individual CPES questions to the score's overall predictive value. Results: Of 607 patients, 61 (10%) had PE. Of low-risk patients (CPES ,4), 5.54% (n= 449; 95% confidence interval [95% CI] = 3.64% to 8.11%) had PE. The sensitivity (59.0%; 95% CI = 47.4% to 69.8%) and the negative predictive value (94.4%; 95% CI = 92.8% to 95.9%) of the CPES were similar to the sensitivity (53.2%; 95% CI = 40.2% to 65.8%) and negative predictive value (93.5%; 95% CI = 90.7% to 95.5%) of the subjective question alone. In multivariable analysis, nearly all of the predictive value of the CPES was derived from the subjective question. Conclusions: The predictive value of the CPES appears to be derived primarily from its subjective component. [source]

Accuracy of Very Low Pretest Probability Estimates for Pulmonary Embolism Using the Method of Attribute Matching Compared with the Wells Score

Differences in clinical presentation of deep vein thrombosis in men and women

JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 10 2008
E. ROSEANN ANDREOU
Summary.,Background:,As assessment of clinical pretest probability is the first step in the diagnostic evaluation of deep vein thrombosis (DVT), it is important to know if the clinical features of DVT are the same in men and women. Objectives:,To compare the prevalence and clinical characteristics of DVT, and the accuracy of clinical pretest probability assessment, between men and women with suspected DVT. Methods:,A retrospective analysis of individual patient data from three prospective studies by our group that evaluated diagnostic tests for a suspected first episode of DVT. Clinical characteristics, clinical pretest probability for DVT, and prevalence and extent of DVT was assessed in a total of 1838 outpatients. Results:,The overall prevalence of DVT was higher in men than in women (14.4% vs. 9.4%) (P = 0.001). The prevalence of DVT was higher in men than in women who were categorized as having a clinical pretest probability that was low (6.9% vs. 3.5%; P = 0.025) or moderate (16.9% vs. 8.7%; P = 0.04), but similar in patients in the high category (40.2% vs. 44.0%; P = 0.6). In patients diagnosed with DVT, swelling of the entire leg occurred more often (41.5% vs. 15.7%; P < 0.001), and thrombosis was more extensive (involvement of both popliteal and common femoral veins in 47.9% vs. 21.6%), in women than in men. Conclusions:,In outpatients with suspected DVT, the overall prevalence of thrombosis and the prevalence of thrombosis in those with a low or a moderate clinical pretest probability were higher in men than in women. [source]

Combined use of clinical pretest probability and D-dimer test in cancer patients with clinically suspected deep venous thrombosis

JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 1 2006
M. DI NISIO
Summary.,Background: The value of the D-dimer (DD) test in combination with the clinical pretest probability (PTP) has not been evaluated in cancer patients with suspected deep vein thrombosis (DVT), whereas this group of patients usually accounts for 10,25% of clinically suspected DVT. Methods: A cohort of 2066 consecutive patients with clinically suspected DVT was investigated. Patients were judged to be positive or negative for DVT according to the outcomes of serial compression ultrasound and a 3-month follow-up period with imaging test verification of the symptomatic cases. Diagnostic accuracy indices of the DD test according to the PTP score were assessed in patients with and without cancer. Results: Of the cohort, 244 (11%) were known to have cancer at presentation. A venous thromboembolic event was diagnosed in 41% of the patients with cancer and in 22% of the patients without malignancy. Among the cancer patients, 17% were considered to have a low PTP, 35% a moderate and 41% a high PTP. The negative predictive value (NPV) of the DD test was 100% (95%CI, 85,100) and 97% (95% CI, 88,99) among cancer patients with low PTP or low-moderate PTP. In the absence of malignancy, the corresponding NPV were 98% and 97%, respectively. The specificity of the DD test progressively decreased moving from the low to the higher PTP. Conclusions: In cancer patients with clinically suspected DVT, a negative DD might be useful in excluding the diagnosis within the low or low-moderate PTP groups. More studies are warranted to confirm these findings. [source]

The utility of pretest probability assessment in patients with clinically suspected venous thromboembolism

JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 9 2003
J. Kelly
Summary. ,The assessment of pretest probability (PTP), with stratification into low-, intermediate- and high-risk groups is an essential initial step in the current diagnostic management of patients with suspected venous thromboembolism (VTE). In combination with additional information, it reduces the need for initial and supplementary imaging, and allows considerable refinement of the posterior probability of VTE following non-invasive imaging. PTP may be assessed either empirically or by using various decision rules or scoring systems, the best known of which are the simplified Wells scores for suspected deep vein thrombosis (DVT) and pulmonary embolism (PE), and the Geneva score for suspected PE. Each of these approaches shows similar directional and categorical accuracy, and has been validated as facilitating clinically useful classification of the PTP, although an overview of data suggests that fewer patients tend to be classified as low PTP when assessed empirically. This group is the most important to identify, as several outcome studies have shown that imaging and treatment are safely obviated in outpatients with suspected DVT or PE who have a low PTP in combination with negative d -dimer testing, a subgroup accounting for up to half of all patients studied. Hence, while probably not of critical importance, the explicit approach offered by scoring systems might be preferred over empirical assessment, particularly when used by more junior staff. [source]

An age-adapted approach for the use of D-dimers in the exclusion of deep venous thrombosis,

AMERICAN JOURNAL OF HEMATOLOGY, Issue 8 2009
Fred J.L.M. Haas
A normal D-dimer (DD) concentration for the exclusion of deep venous thrombosis (DVT) has a low specificity in older patients and compression ultrasonography is often required. Three D-dimer assays, STA Liatest, Tina-quant, and Innovance, are evaluated in symptomatic outpatients suspected for DVT with emphasis on its performance in older patients by using different cut-off levels. This study includes 466 outpatients suspected for having DVT. The diagnostic accuracy, measured as sensitivity and area under the curve of the receiver operation characteristic curve is good for all DD assays. The specificity of the DD assays combined with a low pretest probability varies from 42.6 to 51.5%. The specificity of the three DD assays in patients ,60 years varies, however, between 24.6 and 40.9%. Several cut-off values in different age-subgroups are studied. For patients <60 years, the most accurate cut-off value is 500 ,g/L for all DD assays. For patients ,60 years, a threshold of 750 ,g/L has the best results with NPV of 100% for all assays and specificity of 48.5% (STA Liatest), 60.6% (Tina-quant), and 49.2% (Innovance), respectively. For the three assays, the number needed to test (NNT) decreases in both subgroups of patients compared to the standard algorithm. A cut-off level of 750 ,g/L for patients ,60 years improves the clinical performance of DD assays in combination with the PTP score without the loss of NPV. The NNT improves substantially with an age-adapted algorithm. Am. J. Hematol., 2009. © 2009 Wiley-Liss, Inc. [source]

Sputum carcinoembryonic antigen, neuron-specific enolase and cytokeratin fragment 19 levels in lung cancer diagnosis

RESPIROLOGY, Issue 1 2004
Ioannis Kalomenidis
Objective: The aim of the present study was to examine the impact of sputum carcinoembryonic antigen (CEA), neuron-specific enolase (NSE) and cytokeratin fragment 19 (CYFRA 21-1) levels in lung cancer diagnosis and to compare the diagnostic usefulness of sputum assays with that of serum assays. Methodology: Forty-seven patients with lung cancer and 62 with benign lung disease were studied. Tumour marker levels in sputum (sp.) and serum (ser) were measured by immunoradiometric assays. Results: Sputum and serum tumour marker levels were significantly higher in lung cancer than in benign disease. When the specificity was 95%, the sensitivity was 57%, 43%, 36%, 30%, 28% and 19%, for spCEA, serCYFRA 21-1, spCYFRA 21-1, serCEA, serNSE, and spNSE, respectively. Bayesian analysis showed that the best predictive values correspond to spCEA and serCYFRA 21-1. The maximum overall gain was obtained in pretest probability of 0.35 for both spCEA and serCYFRA 21-1, with predictive values of 84% and 80% for spCEA and serCYFRA 21-1, respectively. Conclusion: Sputum tumour marker levels were no more useful than the serum levels in lung cancer diagnosis. SpCEA offered the best predictive values but these were still not sufficiently satisfactory for spCEA to be proposed for routine use. [source]

What is the optimal approach for using a direct amplification test in the routine diagnosis of pulmonary tuberculosis?

RESPIROLOGY, Issue 4 2002
A preliminary assessment
Objective: The aim of this study was to determine the most appropriate strategy for the rapid diagnosis of pulmonary tuberculosis (PTB) using a nucleic acid amplification (NAA) test. Methodology: This was a prospective study of 128 adult patients in whom respiratory secretions were tested for Mycobacterium tuberculosis by the AMPLICOR assay. The basis for starting PTB treatment was noted for each patient. The optimal approach was determined by using Bayes' theorem to compare different combinations of pretest probability, smear results with the AMPLICOR test. Results: The incidence of PTB was 15.6%. In only one patient was treatment for PTB commenced because of a positive AMPLICOR result. The rest were managed according to the conventional approach which relied upon clinical judgment and direct smear. The optimal approach was to treat patients with high or intermediate pretest risk for PTB who returned positive AMPLICOR tests. The overall accuracies of the conventional approach, AMPLICOR test and optimal approach were 89.8, 95.3 and 96.1%, respectively. Conclusion: This small study suggests that NAA testing be limited to patients with high or intermediate pretest risk of PTB. In this group, positive results demand treatment while the management of those with negative results still relies on clinical judgment. [source]

Simultaneous use of serum IgG and IgM for risk scoring of suspected early Lyme borreliosis: graphical and bivariate analyses

APMIS, Issue 4 2010
RAM B. DESSAU
Dessau RB, Ejlertsen T, Hilden J. Simultaneous use of serum IgG and IgM for risk scoring of suspected early Lyme borreliosis: graphical and bivariate analyses. APMIS 2010; 118: 313,23. The laboratory diagnosis of early disseminated Lyme borreliosis (LB) rests on IgM and IgG antibodies in serum. The purpose of this study was to refine the statistical interpretation of IgM and IgG by combining the diagnostic evidence provided by the two immunoglobulins and exploiting the whole range of the quantitative variation in test values. ELISA assays based on purified flagella antigen were performed on sera from 815 healthy Danish blood donors as negative controls and 117 consecutive patients with confirmed neuroborreliosis (NB). A logistic regression model combining the standardized units of the IgM and IgG ELISA assays was constructed and the resulting disease risks graphically evaluated by receiver operating characteristic and ,predictiveness' curves. The combined model improves the discrimination between NB patients and blood donors. Hence, it is possible to report a predicted risk of disease graded for each individual patient, as is theoretically preferable. The predictiveness curve, when adapted to the local pretest probability of LB, allows high-risk and low-risk thresholds to be defined instead of cut-offs based on the laboratory characteristics only, and it allows the extent of under- and over-treatment to be assessed. It is shown that an example patient with low ELISA results in IgM and IgG, considered negative by the conventional cut-off, has a relatively high risk of belonging to the truly diseased population and a low risk of being false positive. Using a 20% high-risk threshold for advising the clinician to consider treatment, the sensitivity of the assay is increased from 76% to 85%, while the specificity is maintained at around 95%. [source]

Potential Impact of Adjusting the Threshold of the Quantitative D-dimer Based on Pretest Probability of Acute Pulmonary Embolism

The management of heparin-induced thrombocytopenia

BRITISH JOURNAL OF HAEMATOLOGY, Issue 3 2006
David Keeling
Abstract The Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology has produced a concise practical guideline to highlight the key issues in the management of heparin-induced thrombocytopenia (HIT) for the practicing physician in the UK. The guideline is evidence-based and levels of evidence are included in the body of the article. All patients who are to receive heparin of any sort should have a platelet count on the day of starting treatment. For patients who have been exposed to heparin in the last 100 d, a baseline platelet count and a platelet count 24 h after starting heparin should be obtained. For all patients receiving unfractionated heparin (UFH), alternate day platelet counts should be performed from days 4 to 14. For surgical and medical patients receiving low-molecular-weight heparin (LMWH) platelet counts should be performed every 2,4 d from days 4 to 14. Obstetric patients receiving treatment doses of LMWH should have platelet counts performed every 2,4 d from days 4 to 14. Obstetric patients receiving prophylactic LMWH are at low risk and do not need routine platelet monitoring. If the platelet count falls by 50% or more, or falls below the laboratory normal range and/or the patient develops new thrombosis or skin allergy between days 4 and 14 of heparin administration HIT should be considered and a clinical assessment made. If the pretest probability of HIT is high, heparin should be stopped and an alternative anticoagulant started at full dosage unless there are significant contraindications while laboratory tests are performed. Platelet activation assays using washed platelets have a higher sensitivity than platelet aggregation assays but are technically demanding and their use should be restricted to laboratories experienced in the technique. Non-expert laboratories should use an antigen-based assay of high sensitivity. Only IgG class antibodies need to be measured. Useful information is gained by reporting the actual optical density, inhibition by high concentrations of heparin, and the cut-off value for a positive test rather than simply reporting the test as positive or negative. In making a diagnosis of HIT the clinician's estimate of the pretest probability of HIT together with the type of assay used and its quantitative result (enzyme-linked immunosorbent assay, ELISA, only) should be used to determine the overall probability of HIT. Clinical decisions should be made following consideration of the risks and benefits of treatment with an alternative anticoagulant. For patients with strongly suspected or confirmed HIT, heparin should be stopped and full-dose anticoagulation with an alternative, such as lepirudin or danaparoid, commenced (in the absence of a significant contraindication). Warfarin should not be used until the platelet count has recovered. When introduced in combination with warfarin, an alternative anticoagulant must be continued until the International Normalised Ratio (INR) is therapeutic for two consecutive days. Platelets should not be given for prophylaxis. Lepirudin, at doses adjusted to achieve an activated partial thromboplastin time (APTT) ratio of 1·5,2·5, reduces the risk of reaching the composite endpoint of limb amputation, death or new thrombosis in patients with HIT and HIT with thrombosis (HITT). The risk of major haemorrhage is directly related to the APTT ratio, lepirudin levels and serum creatinine levels. The patient's renal function needs to be taken into careful consideration before treatment with lepirudin is commenced. Severe anaphylaxis occurs rarely in recipients of lepirudin and is more common in previously exposed patients. Danaparoid in a high-dose regimen is equivalent to lepirudin in the treatment of HIT and HITT. Danaparoid at prophylactic doses is not recommended for the treatment of HIT or HITT. Patients with previous HIT who are antibody negative (usually so after >100 d) who require cardiac surgery should receive intraoperative UFH in preference to other anticoagulants that are less validated for this purpose. Pre- and postoperative anticoagulation should be with an anticoagulant other than UFH or LMWH. Patients with recent or active HIT should have the need for surgery reviewed and delayed until the patient is antibody negative if possible. They should then proceed as above. If deemed appropriate early surgery should be carried out with an alternative anticoagulant. We recommend discussion of these complex cases requiring surgery with an experienced centre. The diagnosis must be clearly recorded in the patient's medical record. [source]

Hypopituitarism is uncommon after aneurysmal subarachnoid haemorrhage

CLINICAL ENDOCRINOLOGY, Issue 1 2010
Marianne Klose
Summary Objective, Aneurysmal subarachnoid haemorrhage (SAH) has recently been reported as a common cause of chronic hypopituitarism, and introduction of routine neuroendocrine screening has been advocated. We aimed at estimating the risk of hypopituitarism after SAH using strict criteria including confirmatory testing in case of suggested insufficiency. Design, Cross-sectional evaluation with a nested prospective subgroup. Patients and measurements, Endocrine evaluation was performed at a median of 14 months (range 11,26) post-SAH in 62 patients with SAH and 30 healthy controls. Twenty-six patients were followed prospectively (median 7 days, and 12 months post-SAH). Endocrine evaluation included baseline evaluation, which was combined with an insulin tolerance test (ITT) or, if contraindicated, GHRH + arginine tests and a standard ACTH test at evaluation 1,2 years post-SAH. Pituitary insufficiencies were confirmed by re-evaluation. Results, Early post-SAH hormone alterations mimicking central hypogonadism were present in 58% of the patients and associated with a worse clinical state (P < 0·05). One to 2 years post-SAH, initial neuroendocrine evaluation identified seven patients (11%) with abnormal results; three had free T4 and TSH suggestive of central hypothyroidism, three men had testosterone below 10 nm, and one had an insufficient GH and cortisol response to the ITT. None of these abnormalities was confirmed upon confirmatory testing. Conclusion, In the largest reported cohort of patients with SAH to date, with early and late endocrine evaluation, none of the patients had chronic hypopituitarism. Based on these findings, the introduction of routine neuroendocrine screening is not justified, and the data suggest the importance of using strict diagnostic criteria in patients with a low pretest probability of hypopituitarism. [source]