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Lippi G.,Laboratory of Clinical Chemistry and Hematology | Favaloro E.J.,Institute of Clinical Pathology and Medical Research ICPMR | Cervellin G.,Academic Hospital of Parma
Seminars in Thrombosis and Hemostasis

Recurrent thrombosis is a relatively frequent complication of venous thromboembolism (VTE) and represents an important cause of clinical and economic issues for health care systems worldwide. Rates of thrombosis increase with increasing age, with aging recognized to be a risk factor for thrombosis. Although D-dimer is now regarded as the biochemical gold standard for assisting the diagnosis of VTE and predicting the recurrent risk of thrombosis, the interpretation of D-dimer values with increasing age remains challenging due to many factors. These include the development of age-related changes in both the microcirculation and blood coagulation, which ultimately contribute to generate a hypercoagulable state and a gradual increase of D-dimer concentration with aging. Convincing evidence has now been provided that while D-dimer values may be effectively utilized for predicting the risk of recurrent thrombosis with increasing age, conventional cutoff values are inappropriate for older populations. In summary, analysis of the current scientific literature suggests that the adoption of age-dependent thresholds may increase the diagnostic effectiveness of this biomarker with increasing age. © 2014 by Thieme Medical Publishers, Inc. Source

Danese E.,University of Verona | Montagnana M.,University of Verona | Cervellin G.,Academic Hospital of Parma | Lippi G.,Laboratory of Clinical Chemistry and Hematology
Annals of Medicine

Atrial fibrillation (AF) is the most common among the severe cardiac arrhythmias and carries a significant risk of mortality and morbidity in the general population. The most important complication is represented by development of one or more thrombi in the left atrium of the dyskinetic heart, and their successive cerebral and peripheral embolization. The pathophysiological basis of the thromboembolic complications in AF entails the presence of a hypercoagulable state, which is mirrored by increased concentrations of a variety of prothrombotic markers. D-dimer is universally considered the gold standard among the various biomarkers that reflect activation of coagulation, fibrinolysis, or both, and several studies have assessed its diagnostic and prognostic role in AF. With a few exceptions and despite a broad heterogeneity in the study designs, published data seem to demonstrate that D-dimer values may be associated with the presence of atrial thrombosis, may be predictive of primary adverse outcomes and death, may be correlated with cerebral infarction volume, and may also be a useful parameter for assessing the degree of hypercoagulability of AF patients after cardioversion. If larger prospective studies confirm these findings, D-dimer assessment may hence become an integral part of the clinical decision-making in patients with AF. © 2014 Informa UK, Ltd. Source

Cervellin G.,Academic Hospital of Parma | Borghi L.,University of Parma | Lippi G.,Laboratory of Clinical Chemistry and Hematology
Internal and Emergency Medicine

Clinical judgment is a foundation of medical practice and lies at the heart of a physician's knowledge, expertise and skill. Although clinical judgment is an active part of all medical fields, thus including diagnosis and therapy, communication and decision making, it is still poorly defined. It can be considered a synthesis of intuition (mainly based on Gestalt principles) and an analytical approach. Gestalt perception finds its rationale in the evidence that perception of any given object or experience exhibits intrinsic qualities that cannot be completely reduced to visual, auditory, tactile, olfactory, or gustatory components. Thus, perceptions are not constructed in a "bottom-up" fashion from such elements, but are instead globally perceived, in a more "top-down" fashion. Gestalt perception, if cautiously and carefully combined with structured (techno)logical tools, would permit one to defoliate the often too-many-branches built diagnostic trees, and help physicians to better develop their competency. On the other hand, the practice of evidence-based medicine lies in the integration of individual clinical expertise and judgment with the best available external clinical evidence from systematic research. This article is aimed at providing some general concepts about Gestalt perception, and to discuss some aspects of clinical practice potentially influenced by this approach. © 2014 SIMI. Source

Lippi G.,Laboratory of Clinical Chemistry and Hematology | Franchini M.,Carlo Poma Hospital | Cervellin G.,Academic Hospital of Parma
Seminars in Thrombosis and Hemostasis

Ischemic heart disease (IHD) is the leading cause of death and disability worldwide. An early and accurate diagnosis of IHD is necessary to improve outcomes. According to recent guidelines, the diagnosis of acute myocardial infarction (AMI) is based on increased or decreased value of cardiospecific troponins with one measure exceeding the 99th percentile upper reference limit, associated with symptoms suggestive for myocardial ischemia, indicative electrocardiogram abnormalities, and evidence of recent myocardial functional impairment or intracoronary thrombosis. The recent advent of highly sensitive troponin immunoassays has represented a paradigm shift, wherein the improved analytical sensitivity has increased the negative predictive value, while contextually decreasing the diagnostic specificity of these tests. Although several additional biomarkers have been proposed as surrogate or in combination with troponins, there is little evidence that any of these will substantially improve AMI diagnosis. With regard to therapy, early mechanical (i.e., percutaneous coronary intervention, PCI) or pharmacological reperfusion should be performed early in ST-segment elevation myocardial infarction (STEMI) within 12 h of symptom onset, whereas fibrinolysis may be considered in all other circumstances. Patients undergoing primary PCI should also receive a combination of double antiplatelet therapy (i.e., aspirin and adenosine diphosphate receptor blocker), associated with parenteral anticoagulation, preferably with low-molecular-weight heparin. In analogy with STEMI, a wealth of data shows that primary early invasive strategy (i.e., PCI) and antiplatelet therapy remains the cornerstone of management of patients with non-ST segment elevation acute coronary syndrome. Stem cell-based therapy has also emerged as a potentially therapeutic option, and there are ongoing efforts among several investigators to translate basic research into clinical practice.Copyright © 2013 by Thieme MedicalPublishers, Inc. Source

Cervellin G.,Academic Hospital of Parma | Lippi G.,Laboratory of Clinical Chemistry and Hematology
Seminars in Thrombosis and Hemostasis

The history of myocardial infarction (MI) diagnostics has gone through a continuous evolution over the past century, when several new discoveries have contributed to remarkably increase the number of patients appropriately diagnosed with this condition. The tale of MIs and Men displays rather a long history, since atherosclerosis was found to be present in humans several centuries before modern civilization and the identification of the most prevalent risk factors. It was only at the end of the 19th century and at the beginning of the 20th century that the physicians acknowledged that MI is principally sustained by coronary thrombosis, and that the clinical picture of MI could be subsequently confirmed at autopsy. With the first description of the electrocardiogram (ECG) in the 1910s and 1920s, the history of modern MI diagnostics really began. Additional important discoveries followed, which are mainly represented by radiography, echocardiography, computed tomography, and magnetic resonance imaging of the heart. Another major breakthrough occurred at the down of the third millennium, with the development of commercial immunoassays for the measurement of cardiac troponin I and T, which represent now the cornerstones for identifying any kind of myocardial injury, thus including MI. The major advancements in the understanding of MI pathophysiology and the progressive introduction of efficient diagnostic tools will be described and discussed in this narrative historical review. © 2014 by Thieme Medical Publishers, Inc. Source

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