Correspondence / American Journal of Emergency Medicine 33 (2015) 290–304
301
Table Ages, genders, accurate diagnoses and requirements for invasive procedures and intensive care units among the non-dengue patients
Adult (7)
Pediatric (3)
Gender (age)
Diagnosis
F (48) F (55) M (67) M (72) M (72) F (85) M (32) M (8) F (3) M (4)
Systemic lupus erythematosus Systemic lupus erythematosus Perforated gastric ulcer Cholecystitis, Bacteremia (Escherichia coli) Pyelonephritis, Bacteremia (Escherichia coli) Pyelonephritis, Bacteremia (Escherichia coli) Urinary tract infection Kawasaki disease Tonsillitis Tonsillitis
However, a study of travelers revealed that a single positive IgM is associated with a 42.5% false-positive rate, and the authors suggested the use of a more specific diagnostic technique to confirm dengue infection [2]. Based on our experience, we found that a single positive dengue IgM provided only 50% specificity for the diagnosis of dengue, and a significant portion of the misdiagnosed patients (6/10) required either invasive interventions or immunosuppressive therapy. Additionally, a retrospective study conducted in Taiwan regarding dengue patients with acute abdomen revealed that invasive procedures or surgeries increased the requirements of blood transfusion and prolonged hospital stays [7]. Therefore, the early detection of the actual disease and the confirmation of the dengue infection are crucial for suspected patients with positive dengue IgM. Levy et al. performed a study that included 36 dengue patients. These authors found the CRP levels are mildly elevated and seldom exceed 15 mg/L [8]. This finding is in line with our result that the majority of the CRP levels in the dengue patients were below 15 mg/L; the only two cases that exceed this value had CRP levels of 26.5 and 28.4 mg/L. Accordingly, a markedly increased CRP level might indicate either a serious infectious or the presence of an inflammatory disease in the involved patient. Thrombocytopenia, leucopenia and elevated hematocrit are all common hematologic abnormalities in dengue patients [2,6]. In our institution, thrombocytopenia and fever are the dominant triggers for physicians to order a dengue IgM. Consequently, the platelet counts of the dengue and non-dengue patients were similar. Leukocytosis is more common than leucopenia in infectious diseases and Kawasaki disease [9]. Regarding the hematocrit level, anemia is typically present in patients with SLE and Kawasaki disease [10]. Therefore, marked elevations in CRP level, leukocytosis and low levels of hematocrit are practical markers that should remind physicians to search for either a misdiagnosed illness or the combination of dengue and other diseases. A single dengue IgM does not indicate the diagnosis of dengue infection with certainty. Various infectious and inflammatory diseases can produce positive results. We advocate the performance of an additional confirmatory diagnostic test in suspected cases, particularly those with marked elevations in CRP level, leukocytosis and decreased level of hematocrit.
Invasive procedures
Intensive care unit 7 days
Surgery for perforated gastric ulcer Cholecystectomy Nephrectomy
12 days 4 days
Kuo-Tai Chen, MD Emergency Department, Chi-Mei Medical Center Department of Emergency Medicine, Taipei Medical University, Taipei Corresponding author. Emergency Department, Chi-Mei Medical Center 901 Chung-Hwa Road, Yung Kang, Tainan 710, Taiwan Tel: 886-6-2812811 ext. 57196; Fax: 886-6-2816161. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.11.035 References [1] Guzman MG, Kouri G. Dengue diagnosis, advances and challenges. Int J Infect Dis 2004;8:69–80. [2] Wichmann O, Stark K, Shu PY, Niedrig M, Frank C, Huang JH, et al. Clinical features and pitfalls in the laboratory diagnosis of dengue in travelers. BMC Infect Dis 2006;6:120. [3] Sopontammarak S, Promphan W, Roymanee S, Phetpisan S. Positive serology for dengue viral infection in pediatric patients with Kawasaki disease in southern Thailand. Circ J 2008;72:1492–4. [4] Santosa A, Poh Z, Teng GG. Delayed diagnosis of systemic lupus erythematosus due to misinterpretation of dengue serology. Scand J Rheumatol 2014;41:77–9. [5] Arya SC, Agarwal N. Dengue and concurrent urinary infection in a tertiary care hospital in Delhi. Trans R Soc Trop Med Hyg 2009;103:642–3. [6] World Health Organization. Dengue hemorrhagic fever: diagnosis, treatment, prevention and control. 2nd ed. Geneva: World Health Organization; 1997. [7] Khor BS, Liu JW, Lee IK, Yang KD. Dengue hemorrhagic fever patients with acute abdomen: clinical experience of 14 cases. Am J Trop Med Hyg 2006;74:901–4. [8] Levy A, Valero N, Espina LM, Anez G, Arias J, Mosquera J. Increment of interleukin 6, tumor necrosis factor alpha, nitric oxide, C-reactive protein and apoptosis in dengue. Trans R Soc Trop Med Hyg 2010;104:16–23. [9] Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health progessionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young. Am Heart Assoc Pediatr 2004;114:1708–33. [10] Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, et al. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982;25:1271–7.
Is red blood cell distribution width enough to predict prognosis of necrotizing fasciitis? ☆
To the Editor, Po-An Su, MD Division of infection disease, Department of Medicine, Chi-Mei Medical Center Che-Kim Tan, MD Department of Intensive Care Medicine, Chi-Mei Medical Center Chien-Chin Hsu, MD, PhD Emergency Department, Chi-Mei Medical Center Department of Biotechnology, Southern Tainan University of Technology, Tainan, Taiwan
We read with great interest the recently published article by Weng et al [1] in which the authors aimed to assess the association of elevated red blood cell distribution width (RDW) with in-hospital mortality due to necrotizing fasciitis (NF) retrospectively. They concluded that elevated RDW is a significant and independent predictor of in-hospital
☆ Conflict of interests: The authors state that there is no conflict of interests regarding the publication of this manuscript.
302
Correspondence / American Journal of Emergency Medicine 33 (2015) 290–304
mortality for patients with NF. However, we think that there are some points that should be emphasized about this study. First, considering lack of data on the levels of serum iron, folic acid, or vitamin B12, which may affect RDW values, as stated as one of the limitations of the original study, assessing RDW will not be sufficient to predict inflammation. On the other hand, platelet-tolymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) were introduced as potential markers to determine inflammation in various disorders [2,3]. Because NLR and PLR were readily available at no additional cost, they should be evaluated as inflammatory markers in the current study. Second, in discussion section of the original study, elevated RDW was claimed to indicate the presence of a severe systemic inflammatory state. Although RDW, an inexpensive, noninvasive but powerful indicator, overlooked on whole blood analysis, itself, without other inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, etc) may not accurately provide information about progression of NF [4,5]. Therefore, it would be better to assess RDW with other inflammation markers to predict the impact of inflammatory and preinflammatory processes on the prognosis of the patient group. Third, 14.5% cut-off level was taken as the normal upper limit in the original study. This cut-off value was probably determined and being used for the evaluation of the anemia in the laboratory analysis conducted. However, this use of RDW is not currently standard practice, and cut-off values for RDW are instrument specific and must be known by the ordering clinician [6]. Moreover, use of the same value in the evaluation of the inflammatory process is not appropriate in the current study. Therefore, it should be more valuable to detect the optimum RDW cutoff value, highest sensitivity, and specificity, with receiver operating characteristic curve analysis, to predict the prognosis of patients with NF. In conclusion, the use of new hematologic parameters (NLR, PLR, etc) that are simple and readily available at no additional cost, assessing all parameters affecting RDW and determining the optimum RDW cutoff value would provide more reliable results and improve the credibility of the whole article in this study population. Erdim Sertoglu, MD Ankara Mevki Military Hospital, Anittepe Dispensary Biochemistry Laboratory, Ankara, Turkey Corresponding author. Tel.: +90 507 140 3616; fax: +90 312 304 3300 E-mail address: [email protected] Metin Uyanik, MD Corlu Military Hospital, Biochemistry Laboratory, Tekirdag, Turkey Huseyin Kayadibi, MD Adana Military Hospital, Biochemistry Laboratory, Adana, Turkey The author responds:
1. The PLR and NLR were mostly use in chronic inflammatory process, such as lymphoma, leukemia, and tuberculosis. There was little literature talking about sepsis and NLR/PLR. 2. There were many other laboratory markers such as procalcitonin, soluble triggering receptor expressed on myeloid cells 1, D -dimer, soluble CD 14 subtype, heart-type fatty acid-binding protein, mean platelet volume, interleukin 6, and brain natriuretic peptide.
Hong-Mo Shih, MD
http://dx.doi.org/10.1016/j.ajem.2014.11.021
References [1] Weng CL, Wang CH, Chen IC, Hsiao KY, Chang KP, Wu SY, et al. Red cell distribution width is an independent predictor of mortality in necrotizing fasciitis. Am J Emerg Med 2014;32:1259–62. [2] McMillan DC. Systemic inflammation, nutritional status and survival in patients with cancer. Curr Opin Clin Nutr Metab Care 2009;12:223–6. [3] Abakay O, Abakay A, Sen HS, Tanrikulu AC. The relationship between inflammatory marker levels and pulmonary tuberculosis severity. Inflammation 2014 http://dx. doi.org/10.1007/s10753-014-9978-y [Epub ahead of print]. [4] Lancerotto L, Tocco I, Salmaso R, Vindigni V, Bassetto F. Necrotizing fasciitis: classification, diagnosis, and management. J Trauma Acute Care Surg 2012;72:560–6. [5] Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool to distinguish necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004;32:1535–41. [6] Riedl J, Posch F, Königsbrügge O, Lötsch F, Reitter EM, Eigenbauer E, et al. Red cell distribution width and other red blood cell parameters in patients with cancer: association with risk of venous thromboembolism and mortality. PLoS One 2014;9:e111440 http://dx.doi.org/10.1371/journal.pone.0111440.
Pulmonary embolism in 2014—the mosaic seems completing ☆
To the Editor, In pulmonary thromboembolism (PTE), there is a high-risk subgroup of patients with a fatal outcome. Most patients (almost onequarter of all PTE patients) die suddenly within 1 hour of presentation, most commonly without a proper diagnosis [1,2]. At the other end of the spectrum, low-risk patients (around one-third of all admitted to hospital) can be safely treated at home [3]. As an illustration, the risk of fatal PTE is “5.42-fold higher (P b .001)” in patients who are presented with a symptomatic nonmassive PTE in comparison with patients who have deep vein thrombosis (DVT) but who do not have symptomatic PTE [4]. In addition to differences in mortality risk, for patients with venous thromboembolism (VTE), there are also a number of the other differences: in the presentation (eg,“PTE, the great masquerader”), in the age of patients (from a few weeks to N100 years old), in the number and severity of comorbidities, and in the prognosis—as far as postthrombotic syndrome is regarded after DVT and chronic thromboembolic pulmonary hypertension after PTE. With the exception of PTE patients in shock/hypotension (~5% of all PTE patients) [5], who should be treated using fibrinolytic, almost all other VTE patients receive similar medicaments (anticoagulant therapy), despite such pronounced (up to 5.42-fold) differences in mortality risk [6]. Such variabilities in age, comorbidities, mortality risk, etc, together with a lack of pathognomonic symptoms, have been some of the reasons why many diagnostic and therapeutic dilemmas have persisted and will persist in PTE [7]. A frustrating lack of a valid, evidence-based tool to better risk stratify a large subgroup of PTE patients at intermediate risk (most hospitalized PTE patients), has lasted for a long period [3]. In parallel, considerable effort has been exercised in the past to investigate whether intermediate-risk PTE patients should receive fibrinolytic treatment, again without a clear and a persuasive answer for years. Therefore, the treatment was insufficiently guided by recommendations in a large subgroup of PTE patients with intermediate mortality risk. Thus, crucial and difficult therapeutic choices have been liberally left to the physician [8] (such as whether to give fibrinolytic, with its imminent risk of major hemorrhage or to withhold from fibrinolytic, leaving a patient at risk for sudden deterioration and hemodynamic compromise, with the eventual need for the escalation of therapy and an uncertain outcome). Furthermore, refinement in individualization of anticoagulant therapy has been absent (“one size for all” approach)
☆ This work has been supported by the Serbian Ministry of Education and Science, Belgrade, Serbia, grant no. 175092.
301
Table Ages, genders, accurate diagnoses and requirements for invasive procedures and intensive care units among the non-dengue patients
Adult (7)
Pediatric (3)
Gender (age)
Diagnosis
F (48) F (55) M (67) M (72) M (72) F (85) M (32) M (8) F (3) M (4)
Systemic lupus erythematosus Systemic lupus erythematosus Perforated gastric ulcer Cholecystitis, Bacteremia (Escherichia coli) Pyelonephritis, Bacteremia (Escherichia coli) Pyelonephritis, Bacteremia (Escherichia coli) Urinary tract infection Kawasaki disease Tonsillitis Tonsillitis
However, a study of travelers revealed that a single positive IgM is associated with a 42.5% false-positive rate, and the authors suggested the use of a more specific diagnostic technique to confirm dengue infection [2]. Based on our experience, we found that a single positive dengue IgM provided only 50% specificity for the diagnosis of dengue, and a significant portion of the misdiagnosed patients (6/10) required either invasive interventions or immunosuppressive therapy. Additionally, a retrospective study conducted in Taiwan regarding dengue patients with acute abdomen revealed that invasive procedures or surgeries increased the requirements of blood transfusion and prolonged hospital stays [7]. Therefore, the early detection of the actual disease and the confirmation of the dengue infection are crucial for suspected patients with positive dengue IgM. Levy et al. performed a study that included 36 dengue patients. These authors found the CRP levels are mildly elevated and seldom exceed 15 mg/L [8]. This finding is in line with our result that the majority of the CRP levels in the dengue patients were below 15 mg/L; the only two cases that exceed this value had CRP levels of 26.5 and 28.4 mg/L. Accordingly, a markedly increased CRP level might indicate either a serious infectious or the presence of an inflammatory disease in the involved patient. Thrombocytopenia, leucopenia and elevated hematocrit are all common hematologic abnormalities in dengue patients [2,6]. In our institution, thrombocytopenia and fever are the dominant triggers for physicians to order a dengue IgM. Consequently, the platelet counts of the dengue and non-dengue patients were similar. Leukocytosis is more common than leucopenia in infectious diseases and Kawasaki disease [9]. Regarding the hematocrit level, anemia is typically present in patients with SLE and Kawasaki disease [10]. Therefore, marked elevations in CRP level, leukocytosis and low levels of hematocrit are practical markers that should remind physicians to search for either a misdiagnosed illness or the combination of dengue and other diseases. A single dengue IgM does not indicate the diagnosis of dengue infection with certainty. Various infectious and inflammatory diseases can produce positive results. We advocate the performance of an additional confirmatory diagnostic test in suspected cases, particularly those with marked elevations in CRP level, leukocytosis and decreased level of hematocrit.
Invasive procedures
Intensive care unit 7 days
Surgery for perforated gastric ulcer Cholecystectomy Nephrectomy
12 days 4 days
Kuo-Tai Chen, MD Emergency Department, Chi-Mei Medical Center Department of Emergency Medicine, Taipei Medical University, Taipei Corresponding author. Emergency Department, Chi-Mei Medical Center 901 Chung-Hwa Road, Yung Kang, Tainan 710, Taiwan Tel: 886-6-2812811 ext. 57196; Fax: 886-6-2816161. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.11.035 References [1] Guzman MG, Kouri G. Dengue diagnosis, advances and challenges. Int J Infect Dis 2004;8:69–80. [2] Wichmann O, Stark K, Shu PY, Niedrig M, Frank C, Huang JH, et al. Clinical features and pitfalls in the laboratory diagnosis of dengue in travelers. BMC Infect Dis 2006;6:120. [3] Sopontammarak S, Promphan W, Roymanee S, Phetpisan S. Positive serology for dengue viral infection in pediatric patients with Kawasaki disease in southern Thailand. Circ J 2008;72:1492–4. [4] Santosa A, Poh Z, Teng GG. Delayed diagnosis of systemic lupus erythematosus due to misinterpretation of dengue serology. Scand J Rheumatol 2014;41:77–9. [5] Arya SC, Agarwal N. Dengue and concurrent urinary infection in a tertiary care hospital in Delhi. Trans R Soc Trop Med Hyg 2009;103:642–3. [6] World Health Organization. Dengue hemorrhagic fever: diagnosis, treatment, prevention and control. 2nd ed. Geneva: World Health Organization; 1997. [7] Khor BS, Liu JW, Lee IK, Yang KD. Dengue hemorrhagic fever patients with acute abdomen: clinical experience of 14 cases. Am J Trop Med Hyg 2006;74:901–4. [8] Levy A, Valero N, Espina LM, Anez G, Arias J, Mosquera J. Increment of interleukin 6, tumor necrosis factor alpha, nitric oxide, C-reactive protein and apoptosis in dengue. Trans R Soc Trop Med Hyg 2010;104:16–23. [9] Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health progessionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young. Am Heart Assoc Pediatr 2004;114:1708–33. [10] Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, et al. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982;25:1271–7.
Is red blood cell distribution width enough to predict prognosis of necrotizing fasciitis? ☆
To the Editor, Po-An Su, MD Division of infection disease, Department of Medicine, Chi-Mei Medical Center Che-Kim Tan, MD Department of Intensive Care Medicine, Chi-Mei Medical Center Chien-Chin Hsu, MD, PhD Emergency Department, Chi-Mei Medical Center Department of Biotechnology, Southern Tainan University of Technology, Tainan, Taiwan
We read with great interest the recently published article by Weng et al [1] in which the authors aimed to assess the association of elevated red blood cell distribution width (RDW) with in-hospital mortality due to necrotizing fasciitis (NF) retrospectively. They concluded that elevated RDW is a significant and independent predictor of in-hospital
☆ Conflict of interests: The authors state that there is no conflict of interests regarding the publication of this manuscript.
302
Correspondence / American Journal of Emergency Medicine 33 (2015) 290–304
mortality for patients with NF. However, we think that there are some points that should be emphasized about this study. First, considering lack of data on the levels of serum iron, folic acid, or vitamin B12, which may affect RDW values, as stated as one of the limitations of the original study, assessing RDW will not be sufficient to predict inflammation. On the other hand, platelet-tolymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) were introduced as potential markers to determine inflammation in various disorders [2,3]. Because NLR and PLR were readily available at no additional cost, they should be evaluated as inflammatory markers in the current study. Second, in discussion section of the original study, elevated RDW was claimed to indicate the presence of a severe systemic inflammatory state. Although RDW, an inexpensive, noninvasive but powerful indicator, overlooked on whole blood analysis, itself, without other inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, etc) may not accurately provide information about progression of NF [4,5]. Therefore, it would be better to assess RDW with other inflammation markers to predict the impact of inflammatory and preinflammatory processes on the prognosis of the patient group. Third, 14.5% cut-off level was taken as the normal upper limit in the original study. This cut-off value was probably determined and being used for the evaluation of the anemia in the laboratory analysis conducted. However, this use of RDW is not currently standard practice, and cut-off values for RDW are instrument specific and must be known by the ordering clinician [6]. Moreover, use of the same value in the evaluation of the inflammatory process is not appropriate in the current study. Therefore, it should be more valuable to detect the optimum RDW cutoff value, highest sensitivity, and specificity, with receiver operating characteristic curve analysis, to predict the prognosis of patients with NF. In conclusion, the use of new hematologic parameters (NLR, PLR, etc) that are simple and readily available at no additional cost, assessing all parameters affecting RDW and determining the optimum RDW cutoff value would provide more reliable results and improve the credibility of the whole article in this study population. Erdim Sertoglu, MD Ankara Mevki Military Hospital, Anittepe Dispensary Biochemistry Laboratory, Ankara, Turkey Corresponding author. Tel.: +90 507 140 3616; fax: +90 312 304 3300 E-mail address: [email protected] Metin Uyanik, MD Corlu Military Hospital, Biochemistry Laboratory, Tekirdag, Turkey Huseyin Kayadibi, MD Adana Military Hospital, Biochemistry Laboratory, Adana, Turkey The author responds:
1. The PLR and NLR were mostly use in chronic inflammatory process, such as lymphoma, leukemia, and tuberculosis. There was little literature talking about sepsis and NLR/PLR. 2. There were many other laboratory markers such as procalcitonin, soluble triggering receptor expressed on myeloid cells 1, D -dimer, soluble CD 14 subtype, heart-type fatty acid-binding protein, mean platelet volume, interleukin 6, and brain natriuretic peptide.
Hong-Mo Shih, MD
http://dx.doi.org/10.1016/j.ajem.2014.11.021
References [1] Weng CL, Wang CH, Chen IC, Hsiao KY, Chang KP, Wu SY, et al. Red cell distribution width is an independent predictor of mortality in necrotizing fasciitis. Am J Emerg Med 2014;32:1259–62. [2] McMillan DC. Systemic inflammation, nutritional status and survival in patients with cancer. Curr Opin Clin Nutr Metab Care 2009;12:223–6. [3] Abakay O, Abakay A, Sen HS, Tanrikulu AC. The relationship between inflammatory marker levels and pulmonary tuberculosis severity. Inflammation 2014 http://dx. doi.org/10.1007/s10753-014-9978-y [Epub ahead of print]. [4] Lancerotto L, Tocco I, Salmaso R, Vindigni V, Bassetto F. Necrotizing fasciitis: classification, diagnosis, and management. J Trauma Acute Care Surg 2012;72:560–6. [5] Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool to distinguish necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004;32:1535–41. [6] Riedl J, Posch F, Königsbrügge O, Lötsch F, Reitter EM, Eigenbauer E, et al. Red cell distribution width and other red blood cell parameters in patients with cancer: association with risk of venous thromboembolism and mortality. PLoS One 2014;9:e111440 http://dx.doi.org/10.1371/journal.pone.0111440.
Pulmonary embolism in 2014—the mosaic seems completing ☆
To the Editor, In pulmonary thromboembolism (PTE), there is a high-risk subgroup of patients with a fatal outcome. Most patients (almost onequarter of all PTE patients) die suddenly within 1 hour of presentation, most commonly without a proper diagnosis [1,2]. At the other end of the spectrum, low-risk patients (around one-third of all admitted to hospital) can be safely treated at home [3]. As an illustration, the risk of fatal PTE is “5.42-fold higher (P b .001)” in patients who are presented with a symptomatic nonmassive PTE in comparison with patients who have deep vein thrombosis (DVT) but who do not have symptomatic PTE [4]. In addition to differences in mortality risk, for patients with venous thromboembolism (VTE), there are also a number of the other differences: in the presentation (eg,“PTE, the great masquerader”), in the age of patients (from a few weeks to N100 years old), in the number and severity of comorbidities, and in the prognosis—as far as postthrombotic syndrome is regarded after DVT and chronic thromboembolic pulmonary hypertension after PTE. With the exception of PTE patients in shock/hypotension (~5% of all PTE patients) [5], who should be treated using fibrinolytic, almost all other VTE patients receive similar medicaments (anticoagulant therapy), despite such pronounced (up to 5.42-fold) differences in mortality risk [6]. Such variabilities in age, comorbidities, mortality risk, etc, together with a lack of pathognomonic symptoms, have been some of the reasons why many diagnostic and therapeutic dilemmas have persisted and will persist in PTE [7]. A frustrating lack of a valid, evidence-based tool to better risk stratify a large subgroup of PTE patients at intermediate risk (most hospitalized PTE patients), has lasted for a long period [3]. In parallel, considerable effort has been exercised in the past to investigate whether intermediate-risk PTE patients should receive fibrinolytic treatment, again without a clear and a persuasive answer for years. Therefore, the treatment was insufficiently guided by recommendations in a large subgroup of PTE patients with intermediate mortality risk. Thus, crucial and difficult therapeutic choices have been liberally left to the physician [8] (such as whether to give fibrinolytic, with its imminent risk of major hemorrhage or to withhold from fibrinolytic, leaving a patient at risk for sudden deterioration and hemodynamic compromise, with the eventual need for the escalation of therapy and an uncertain outcome). Furthermore, refinement in individualization of anticoagulant therapy has been absent (“one size for all” approach)
☆ This work has been supported by the Serbian Ministry of Education and Science, Belgrade, Serbia, grant no. 175092.
