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Purpose To evaluate a new noninvasive diagnostic strategy for ruling out deep vein thrombosis consisting of either a combination of low clinical probability and normal ultrasonography or a combination of moderate-to-high clinical probability, normal ultrasonography, and a normal D-dimer test. Subjects and methods We studied 811 patients with clinically suspected deep vein thrombosis using a diagnostic management strategy that combined clinical probability, ultrasonography, and measurement of D-dimers. The primary endpoint was venous thromboembolism occurring during a 3-month follow-up. Results Of the 280 patients (35%) with a low clinical probability, 30 (11%) had an abnormal initial ultrasonography and were treated. Of the other 250 untreated patients with low clinical probability and a normal ultrasonography, 5 (2%; 95% confidence interval [CI]: 1% to 5%) developed a nonfatal venous thromboembolism during follow-up. Of the 531 patients (65%) with a moderate-to-high clinical probability, 300 (56%) had an abnormal ultrasonography. Of the remaining 231 patients with a normal ultrasonography, 148 had a normal D-dimer test; none of these patients developed deep vein thrombosis during follow-up (0%; 95% CI: 0% to 3%). Of the 83 patients with an abnormal D-dimer test, 77 underwent repeat ultrasonography about 1 week later; none of the 64 patients with a second normal ultrasound developed symptomatic deep vein thrombosis during follow-up (0%; 95% CI: 0% to 6%). Conclusion This management strategy, which combines clinical probability, ultrasonography, and D-dimer measurements, is practical and safe in ruling out deep vein thrombosis in patients with clinically suspected thrombosis and reduces the need for repeat ultrasonography.

The first case report describes an extremely prolonged activated partial thromboplastin time (APTT) in a patient with no history of increased bleeding tendency. Heparin use was excluded. The APTT mixing study combined with the medical history suggests a deficiency in one of the non-essential coagulation factors. This was confirmed by factor XII activity of1%. The second case report describes a prolonged APTT in a patient with no history of increased bleeding tendency. The negative bleeding tendency in combination with a failure of the mixing study to correct the coagulation assay results suggests a factor inhibitor, most probably lupus anticoagulant. Indeed, the lupus anticoagulant was positive and the anti-cardiolipin antibody titre was also positive. Aberrations in the process of haemostasis can be efficiently screened using a platelet count, an APTT, a PT and a thorough physical examination combined with a thorough medical history taking. Common causes of prolonged PT and/or APTT are the use of oral anticoagulants or heparin, vitamin K deficiency and liver disease. Other causes include coagulation factor deficiencies, coagulation factor inhibitors and diffuse intravascular coagulation.

Background: We designed a diagnostic strategy, based on clinical probability and D-dimer concentration, to select patients who were unlikely to have pulmonary embolism (PE), before further diagnostic workup was performed. The utility and safety of this strategy were evaluated in a prospective management study. Methods: Consecutive patients with suspected PE had D-dimer testing and clinical probability assessment with a clinical decision rule. Patients with a low probability and a normal D-dimer concentration (

We describe two patients, a father and a son, presenting with erythrocytosis. Evaluation showed no pulmonal or cardial disorders. Owing to an elevated erythropoietin level after phlebotomy, a physiological secondary polycythaemia was suspected. A haemoglobin electrophoresis showed that our patients have a haemoglobinopathy with high affinity for oxygen, called Hb-Malmö (exon 3: c.294 C>G p.His98Gln). Hb-Malmö is a congenital disorder located on a gene at chromosome 11, in the B-chain on codon 97, decoding the α-subunit and β-subunit of the haemoglobin. Through a mutation (CAC→CAG), histidine is replaced by glutamine. The mutation causes a disorder in the connection between the α1-subunit and β2-subunit of the haemoglobin structure. These connections are important sites for binding oxygen. Mutated haemoglobin has a preference for an oxygenated status, which implicates that there is an increased binding and decreased release of oxygen. To compensate, there will be an erythrocytosis to transport sufficient oxygen to the peripheral tissues.

A patient was admitted to the internal medicine ward because of hypercalcaemia. Additional diagnostic testing led to the diagnosis multiple myeloma. During admission, she gradually developed confusion and a left hemiparesis. Brain imaging revealed a large tumour mass extending into the brain (figure 1). The patient was treated with chemotherapy consisting of melphalan and bortezomib in combination with dexamethason, because the cognitive condition was too bad to treat …

Background: Pulmonary embolism is a common clinical disorder that is associated with high morbidity and mortality if untreated. It is important to confirm or rule out the diagnosis in patients with clinical suspicion of the disease. Purpose: To evaluate various diagnostic strategies for excluding pulmonary embolism. Data Sources: MEDLINE (1966 to February 2003), EMBASE, and DARE; study investigators; and reference lists. Study, Selection: Prospective clinical outcome studies. Data Extraction: The researchers recorded the frequency of symptomatic venous thromboembolism over 3 months of follow-up in patients in whom pulmonary embolism had been excluded according to various strategies. Strategies were divided into three categories according to the number of rounds of diagnostic tests needed to exclude pulmonary embolism. Data Synthesis: 25 studies involving more than 7000 patients were included. In all referred patients, two strategies-normal results on pulmonary angiography or lung scintigraphy and normal D-dimer levels combined with low clinical probability-safely excluded pulmonary embolism (failure rates less than or equal to 3%). In the second round of diagnostic tests, in patients who had had a nondiagnostic lung scan, both pulmonary angiography and serial leg testing for venous thrombosis were accurate and safe. When D-dimer testing combined with clinical probability was inconclusive, a normal perfusion lung scan safely excluded pulmonary embolism. Accumulating evidence shows that normal results on spiral computed tomography may also safely exclude the disease. Conclusions: Many diagnostic strategies to exclude pulmonary embolism have been evaluated in consecutive patients. Interest is likely to increase in a simple, fast strategy, starting with a normal perfusion lung scan or a combination of normal D-dimer levels and low clinical probability. After the initial round of testing, a reliable diagnostic method, such as angiography or lung scintigraphy, is warranted