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Unser Chapter, vor allem die Pittsburgher Sektion, ist leider zur Zeit im Schrumpfen begriffen, da einige Foscherkollegen nach Österreich zurückgekehrt sind beziehungsweile Berufungen an andere Institutionen erhalten haben. Besonders bedauern wir den Verlust von Robert Gasser, unseren Kieferspezialisten, der samt Familie zurück nach Innsbruck zurückging. Unsere Treffen hatten daher ausschliesslich sozialen Charakter. Mit einiger Wehmut sehen wir auch dem Abschied von Javid Kamal und Dagmar Rühig entgegen, die beide nach Albuquerque übersiedeln. David war hier am University of Pittsburgh Medical Center as Internist beschäftigt, während Dagmar in der Graduate School of Public and International Affairs ihren zweiten Masters in International Development machte. Wir wüschen beiden alles Gute für ihren neuen Karriereabschnitt in New Mexico.
Bei den Eastern Regionals der Mediziner im März hat unser Javid, für seine Forschungsarbeit und Präsentation einen Preis erhalten sowie eine Einladung zum Kongress in Chicago. Für all jene, die diese Arbeit interessiert, geben wir hier eine engl. Zusammenfassung der Forschungsarbeit samt Case-Beschreibung wieder. Eine Power-Point Präsentation ist hier erhaeltlich.
Forschungsarbeit und Präsentation – Dr. J. Kamali und M. Elnicki: – Zusammenfassung FOR PULMONARY EMBOLISM IS D-DIMER REALLY A SNOUT? J. Kamali; M. Elnicki University of Pittsburgh, Pittsburgh, PA. (Tracking ID # 116489)
LEARNING OBJECTIVES: 1) To recognize the importance of pre-test probability of disease in the interpretation of diagnostic test results, 2) To recognize limitations in the use of the D-Dimer test to rule out pulmonary embolism (PE). CASE: A 46 year-old woman with a history of hypertension, type 2 diabetes mellitus and obesity presented with a sudden onset of right-sided pleuritic chest pain of 10 hours duration. The pain began at rest and was sharp, 8/10 in severity and nonradiating. There were no alleviating factors. The patient denied any trauma, recent operations, fever or chills but had a sedentary life style. She was nonsmoker and denied alcohol or illicit drug use. No family history of coagulopathy. Vital signs were normal except respiration rate of 22/minute. Pulse oximetry was 99% on room air. Heart, lung and extremities were unremarkable, but there was moderate right chest wall tenderness on palpation. Laboratory data were notable for normal electrolytes, cardiac enzymes and electrocardiogram. D-Dimer test was negative and a V/Q Scan was read as low probability for PE. Lower extremity dopplers were negative for deep venous thrombosis (DVT). Due to the continued high clinical suspicion of a PE, a pulmonary angiogram was performed which demonstrated filling defects in 3 segmental branches of the right lower lobe pulmonary artery consistent with PE. Subsequent evaluation revealed the presence of the Factor V Leiden mutation. DISCUSSION: Tests with high sensitivity rule out (Snout) and high specifity rule in (Spin) diseases. These, however, are strongly influenced by the prevalence of the disease in the studied population. Using published clinical prediction rules, this patient has a high pre-test probability of a PE (70-90%). The sensitivity of the D-Dimer ranges from 85%-99% and the specifity from 45%-68%. Based on these, the negative likelihood ratio (LR-) would range from 0.33-0.015 and the post test probability from 35%-3%, respectively. Given the potential risk of mortality from a PE (26% if untreated), applying an invasive gold standard test (pulmonary angiography) is appropriate. The case illustrates the limitations of the D-Dimer assay in this particular diagnostic strategy. D-Dimer is the primary product of the enzymatic degradation of cross-linked fibrin by plasmin and is elevated in the presence of thrombosis. However elevated D-Dimer levels are not limited to PE or DVT, and the absence of elevated D-Dimer levels does not always rule out PE. While the D-Dimer assay has a high sensitivity, its negative predictive value depends upon the pre-test probability of disease, and must be evaluated within the clinical context.