All family physicians should know that when
a patient has any sudden chest episode, if the D-Dimer test
is negative and troponin levels are normal by 12 hours, pulmonary
embolism and myocardial infarction may be safely excluded. The
difficulty arises, when these blood levels are raised.
Unfortunately, there are a number of other conditions, where
both these tests show high levels. A few examples of such conditions
are:
- after accidents, 2. post operative cases, 3. patients in
shock, 4. sepsis, 5. cardiac failure, 6. renal failure, 7.
hepatic failure and 8. iatrogenic causes.
Fortunately, all these conditions are seen in serious or hospitalised
patients and do not apply to patients seen by a family physician
during home visits, where he is called for an episode of chest
pain or chest discomfort with or without slight dyspnoea. The
only thing worth noting is that in addition to raised D-Dimer
levels, the troponin levels may also slightly rise in a patient
of pulmonary embolism. D-Dimer levels may also be raised in
patients having deep calf vein thrombosis and should not be
given any importance, if there are no chest symptoms. |
IMMEDIATE
ADENOTONSILLECTOMY IS NOT ALWAYS NEEDED
Children with mild symptoms of throat infection or
adenotonsillar hypertrophy may not require immediate
adenotonsillectomy. Van Staaij and colleagues randomised
300 children aged 2-8 years with these symptoms to adenotonsillectomy
or watchful waiting and found that immediate surgery
did not reduce episodes of fever, throat infections,
upper respiratory tract infections, and health related
quality of life. Adenotonsillectomy was more effective
in children who had three to six throat infections than
in those who had up to two. Twelve children had complications
after surgery. In a commentary Little points out that
a third of children initially treated medically required
surgery. This study shows that immediate surgery is
not effective, not that tonsillectomy in itself is ineffective,
but more data are needed to optimise treatment.
BMJ,
2004; 329 : 654.
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