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Diagnostic approach to patients with suspected pulmonary embolism
  1. Department of Medicine for the Elderly, Tameside General Hospital, Ashton under Lyne OL6 9RW, UK

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    Sir,The observation that patients with indeterminate isotope lung scans received anticoagulant therapy without the benefit of validation or refutation of pulmonary thrombo-embolic disease through the use of investigative modalities for lower limb deep vein thrombosis,1 resonates with my own observation that there is widespread underutilisation of the principle of a ‘one stop’ facility for streamlining investigation and treatment of common disorders. A ‘one stop’ facility for investigation of pulmonary thrombo-embolic disease would have ensured that patients with indeterminate isotope lung scans could proceed to an investigative evaluation of the lower limbs for deep vein thrombosis at the same sitting. The generalisability of this principle is exemplified by the investigation of the underlying cause of iron deficiency anaemia in a ‘one stop’ facility utilising upper gastrointestinal endoscopy and colonoscopy at the same sitting, resulting in one of the highest yields for identification of multiple pathology as the aetiopathogenetic basis of this disorder,2 and also reducing the likelihood of delayed recognition of ‘clinically silent’ underlying causes such as left-sided colonic cancer.3 The authors also addressed the issue of suboptimal concordance between contrast venography and ultrasonography for detection of lower limb deep vein thrombosis, including above knee involvement.1 A related issue is that of the strength of the negative predictive value of compression ultrasonography of lower limb veins. According to a recent study in which 62 pulmonary arteriograms were performed in suspected pulmonary embolism despite a low-probability isotope lung scan and negative lower limb ultrasonography, the latter does not necessarily rule out the probability of pulmonary embolism, since five of the 62 patients tested positive for pulmonary embolism on pulmonary arteriography.4 Ancillary tests such as D-dimer testing,5 might prove to be a useful alternative to pulmonary arteriography in the context of the association of low probability scintigraphy and negative lower limb ultrasonography.


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