Editorial
Authors:   University Hospital Southampton Foundation Trust Tremona Road, Roseveare Chris 
Published: June 2021

There are times when I still believe that D-dimer is helpful in the investigation of thromboembolic disease – but also plenty when I wish the test had never been invented. The low specificity of the test is well recognised, and this inevitably raises the dilemma of how far to investigate the patient with a positive d-dimer for whom pulmonary embolism is clinically unlikely. However, the article by Subedi and colleagues on p…. of this edition provides a salutary reminder of the dangers in assuming that a negative test can reliably exclude PE. In this, albeit small study, simplired d-dimer was negative in 50% of unselected patients whose CTPA subsequently showed evidence of pulmonary embolism. The reminder only to use the test following formal risk scoring is timely: Increasingly, the pressure to achieve emergency access targets leads to blood being sent to the laboratory before any clinician has clapped eyes on the patient. However, clinical assessment must be untainted. The Wells score, commonly used in the pre-test probability assessment of PE, requires the clinician to consider whether an ‘alternative diagnosis is more likely than PE’. If not, the score rises dramatically. If the D-dimer has already been measured before calculation of the score there is a real danger that this might influence this judgement. The message is clear – don’t use D-dimer badly…and be prepared to ignore the result, whether positive or negative, if it does not correspond to your clinical judgement. Thromboembolic disease is also the focus of the two review articles in this journal; the first article by Jason Mainwaring gives a haematologist’s perspective on the investigation and management of deep vein thrombosis, providing a detailed summary of the evidence behind some of the most commonly used anticoagulant regimens. Cheema and colleagues from Ipswich have examined the much more specific problem of iliofemoral thrombus, illustrated by a case in their practice treated by catheter directed thrombolysis. The images provided show impressive dissolution of the clot, with rtPA being delivered directly into the affected area. However, the jury remains out on whether we should be recommending this treatment for all patients as a means of preventing the long term complication of post-thrombotic syndrome. Regular readers of this journal will note the return of the section entitled ‘How we do it here…’, which is intended to provide acute physicians with the opportunity to share examples of good practice. The first of this series of articles describes the well-established multi-disciplinary approach to patients with complex needs incorporating a Primary Care physician in Edinburgh. Further submissions to this section are invited for future editions. John Ho, acute medicine consultant in Bristol has submitted a summary of some of the recently guidelines relevant to acute physicians; if readers find this helpful we will consider making this a regular feature. Suggestions for future inclusion in this section should be emailed directly to him at the address provided with the article. I also hope to extend the ‘correspondence’ section in future, so if any of the articles included in this edition stimulate you to put your fingers to the keyboard, my email inbox is ready and waiting!