Arnaud Perrier

..The perception of physicians, who witness the effects of these strategies, may provide useful insights regarding the impact of system-wide priority setting on access to care...

..Finally, a few limitations of randomised controlled trials are discussed...

..This paper reviews the performance of clinical evaluation and diagnostic tests for venous thromboembolism, and recently validated diagnostic schemes...

..We evaluated whether the use of D-dimer measurement and multidetector-row CT, without lower-limb ultrasonography, might safely rule out pulmonary embolism...

..In summary, including helical CT in diagnostic strategies for pulmonary embolism is cost-effective provided that it is combined with DD and US. In contrast, helical CT as a single test is not cost-effective...

..Clinical prediction rules or scores are instruments that allow to quantify the respective contributions of medical history, clinical examination and laboratory tests to a diagnosis or a prognosis in a given patient...

..Helical computed tomography (CT) is commonly used to diagnose pulmonary embolism, although its operating characteristics have been insufficiently evaluated...

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..Finally, the limitations of evidence-based medicine and its main instruments, i.e. randomised controlled trials and meta-analyses, are briefly discussed...

..In patients with a low clinical probability of pulmonary embolism (PE) and a nondiagnostic lung scan, the prevalence of PE is theoretically very low. We assessed the safety and usefulness of this association for ruling out PE...

..However, such a conclusion awaits the validation of algorithms including CTscan by clinical outcome trials, in which the therapeutic decision would rest on the result of the spiral CTscan...

..What is meant by collaboration should be better defined to allow developing strategies for training health care professionals to collaborate efficiently and for evaluating their impact on health care quality...

..Moreover, they propose a training track individualized according to the trainee's future practice environment (hospital-based, urban or suburban outpatient practice)...

..A simple prognostic model could help identify patients with pulmonary embolism who are at low risk of death and are candidates for outpatient treatment...

..To evaluate a diagnostic strategy for pulmonary embolism that combined clinical assessment, plasma D-dimer measurement, lower limb venous ultrasonography, and helical computed tomography (CT)...

..An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment...

..We compared this combination with a strategy in which both a negative venous ultrasonography of the leg and MSCT were needed to exclude pulmonary embolism...

..Therefore, a rational diagnostic approach to PE in older people should rest mainly on the sequential use of those tests that have demonstrated strong diagnostic yield, accuracy, and safety in this population...

..Increasing the cut-off value of D-dimer in cancer patients might increase the test's clinical usefulness...

..Serial ultrasonography is less cost-effective...

..Standard CRP tests alone or combined with clinical probability assessment cannot safely exclude PE...

..OBJECTIVE, DESIGN: Prospective, observational study, to determine the respective contribution of clinical experience and data collection features to diagnostic accuracy...

..The objective of this study was to compare the risks and benefits of bid low-molecular-weight heparin vs no treatment in patients with suspected PE...

..Whether this score remains accurate and useful in clinical practice should be determined in a prospective multicentre validation study...

..This review gives a critical appraisal of the sequential steps of the diagnostic work-up in suspected DVT or PE...

..Whether making teachers explicitly conscious about their own reasoning processes may help them better model and explain their diagnostic approach to specific cases should be assessed in follow-up studies...

..Our decision analysis suggests that the benefits of LMWH after cesarean delivery exceed the risks. This benefit is, however, very low in women with no risk factors...

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..The results indicate that they should now be implemented in daily practice taking into account local facilities and expertise. The exact place of helical computed tomography in such sequential algorithms remains to be established...

..There is an urgent need for randomised trials assessing the usefulness of anticoagulant treatment in distal DVT...

..Its contribution to extend the competence of learners in clinical settings should be further evaluated...

..To attempt to develop a prediction guide for PE in this population in order to identify the patients in whom PE should be investigated...

..Finally, clinical assessment contributes significantly to the cost savings associated with modern noninvasive strategies...

..This selective review describes some recent studies that provide insight in various areas such as cardiovascular disease, heart failure, renovascular disease, venous thromboembolic disease, pneumonia, as well as acute pancreatitis...

..Prognostic scores have also been developed in order to stratify patients for the different therapeutic options: outpatient or inpatient treatment, anticoagulant treatment or thrombolysis or surgical or endovascular mechanical treatment...

..Thus, to be efficient, the design of a workshop should consider not only individual tutors' needs, but also the background of their teaching units, with special attention to their internal organization and tutor group functioning...

..Such support services may also need to be more proactive in making their help available...

..Some data stimulating our reflection on the integration of medical education in health care centres and on the validity of some scientific publications are also presented...

..At 400 ng/ml, three results were false-negative, one with both devices and two with the Stratus D-dimer only. Stratus D-dimer appears to be suitable for the exclusion of venous thromboembolism in the emergency room setting...

..The risk of recurrence of pulmonary embolism (PE) is higher in men than in women. Differences in clinical presentation of deep vein thrombosis (DVT) have been reported between the two genders but comparative data on PE are lacking...

..The cause of acute exacerbation of chronic obstructive pulmonary disease (COPD) is often difficult to determine. Pulmonary embolism may be a trigger of acute dyspnoea in patients with COPD...

..The Geneva rule appears to be more accurate when combined with clinical judgment, although it does not apply to inpatients...

..5% (88.9, 98.8) and 47.8% (40.8, 54.9) at a cutt-off value of 1.1 microg/ml. This assay appears promising and should be validated in clinical practise to assess its place in the work-up schemes of thromboembolism...

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..To discuss reports published in 2005 on the diagnosis of clinically suspected nonmassive pulmonary embolism...

..Troponin I (cTnI), myoglobin, heart-type fatty acid binding protein (H-FABP), and natriuretic peptides (BNP, NTproBNP) were all reported to be elevated in patients with pulmonary embolism (PE)...

..The use of data elicited by experts solving problems independently has been advocated as a method of setting performance standards...

..How medical decisions are made in real-life situations is largely unexplored. We explored patients' perceptions of decision-making during a hospitalization and examined the conformity of the decision process with expert recommendations...

..Our data suggest that age does not have a marked influence on the diagnostic performances of hCT in clinically suspected pulmonary embolism...

..In conclusion, this is the first study suggesting the interest of this Fibrin Monomer test to rule out PE; these results, however, need to be confirmed by other studies...

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..Early discussion with a competent patient and establishment of advance directives is therefore extremely important...

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..5-2) after an initial full-intensity treatment (INR 2-3) period of 3 to 12 months, and the emergence of new anticoagulant drugs such as direct oral synthetic inhibitors of thrombin or factor Xa...

..Moreover, standardization of the cut-off and of the time of blood sampling in relation to cessation of anticoagulation is warranted...

..Recent studies suggested a limited yield of proximal US when multislice computed tomography (MSCT) was used...

..Troponins (cTnI and cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP), myoglobin, heart-type fatty acid-binding protein (H-FABP) and fibrin D-Dimer are emergent candidates for risk stratification in pulmonary embolism (PE)...

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..More extensive use of D-dimer in clinical practice requires more rapid and equally reliable unitary tests as the ELISA...

..Applying this score to emergency ward patients suspected of having PE could allow a more effective diagnostic process...

..6-99.4). This new assay is fast and fully automated, and its performance is suitable to exclude venous thromboembolism. Management studies should be performed to assess its utility...

..Little is known about the performance of search strategies when they are applied to answer specific clinical questions...

..Methadone dose, presence of cytochrome P-450 3A4 inhibitors, potassium level, and liver function contribute to QT prolongation. Long QT syndrome can occur with low doses of methadone...

..Patients with obvious alternative diagnoses such as acute left heart failure, pneumonia or acute coronary syndrome should not be investigated for PE...

..To validate the Pulmonary Embolism Severity Index (PESI), a clinical prognostic model which identifies low-risk patients with pulmonary embolism (PE)...

..The results indicate that they should now be implemented in daily practice, taking into account local facilities and expertise...

..Whether a more precise characterization of chest pain might allow an accurate identification of such patients deserves further study...

..Low fat-free mass may be an independent risk factor for malnutrition that results in an increased length of hospital stay (LOS)...

..The prevalence of physician bedside rationing, which presents physicians with difficult moral dilemmas, highlights the importance of discussions regarding how to ration care in the most ethically justifiable manner...

..The presurgical evaluation of lung cancer, the level of glucose control to be achieved in the intensive care unit, and novel methods of teaching medicine are also discussed...

..The objective of this article is to give an overview of the current diagnostic tools for the evaluation of the iron metabolism and to provide a practical diagnostic algorithm for the evaluation of iron-deficient anemia...

..To assess residents' difficulties during the first year of residency. In contrast to previous studies that mainly used structured questionnaires, a qualitative procedure was applied...

..Furthermore, initial revascularization in patients with stable coronary heart disease, and no high risk lesions or disabling angina, has no benefit over medical management of CVRF...

..Other topics include pneumonia prognosis, the management of ascitis fluid or of septic shock, and methodology...

..This benefit seems to be related to an inhibitory effect on tumoral progression. LMWH seems promising in an eventual routine clinical use. However, their type, dose and duration and in which cancers has to be further defined...

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..We conclude that spectrum effect is more common than spectrum bias and that clinical decisions are affected only under certain conditions...

..Clinical epidemiology and statistics skills of clinical researchers are often limited. We assessed methodological skills of medical researchers and identified factors associated with higher skill levels...

..Despite theses results, evidence of using D-dimer for tailoring duration of anticoagulation is still sparse...

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..Pretest probability assessment is necessary to identify patients in whom pulmonary embolism (PE) can be safely ruled out by a negative D-dimer without further investigations...

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..Results are encouraging but preliminary, therefore procalcitonine measurement should be restricted to patients with criteria of severe infection for the time being...

..Finally, spiral computed tomography (CT) seems promising and might modify the diagnostic work-up of PE in the near future. However, it is insufficiently validated, and its place in a rational diagnostic algorithm is not defined...

..In the absence of further large scale studies with relevant endpoints, which are now unlikely to be conducted, nesiritide is rapidly disappearing from the therapeutic armamentarium...

..It allows ruling in the diagnosis of PE without further invasive and/or expensive testing in suspected patients...