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Overutilisation of imaging studies for diagnosis of pulmonary embolism: are we following the guidelines?
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    Overuse of imaging might be attributable to suboptimal clinical decision rules

    The judgment that imaging studies were over-utilised (1) should not be based on the degree of compliance with the Wells clinical decision rule (CDR), given the fact that the Wells score is not necessarily the optimal one for PE. In a study which compared 7 CDRs, namely, the Wells score, simplified Wells score, original Geneva score, revised Geneva score, Charlotte score and the Pisa model, diagnostic accuracy amounted to 0.44, 0.61, and 0.76 for simplified Wells score, Wells score, and Pisa model, respectively (2). The Wells score was tested in 598 primary care patients presenting with symptoms including cough, unexpected or sudden dyspnoea, deterioration in existing dyspnoea, and pleuritic pain, singly or in combination. These patients were referred to secondary care with suspected PE, where they were subsequently rigorously evaluated and investigated according to hospital guidelines. The diagnosis of PE was subsequently confirmed in 73 cases. However, in as many as 44 of those cases where PE was ruled out, the presenting Wells score amounted to >4 points (3), a score that is taken to signify "PE likely" in the simplified Wells score. In the evaluation of PE diagnostic confusion is compounded by the fact that PE can be an incidental finding, for example, during CT imaging in the oncological context (4). In the latter study, 25% of 52 patients with incidental PE had no PE-related symptoms (4). In the entire group of 52 patients with incidental PE, eight had m...

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