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In This Issue of JAMA |

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JAMA. 2014;311(11):1087-1089. doi:10.1001/jama.2013.279388.
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D-dimer levels are commonly assessed in patients suspected of having an acute pulmonary embolism (PE); however, D-dimer levels increase with age, reducing clinical utility in elderly patients. In a prospective cohort of 3346 patients who presented to the emergency department with clinically suspected PE, Righini and colleagues found that compared with a fixed D-dimer cutoff (500 μg/L), combining an age-adjusted D-dimer cutoff (age × 10 in patients ≥50 years) with a clinical probability assessment score resulted in a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical PE.

Reports of an increased incidence of neonatal invasive Haemophilus influenzae infection raises the possibility that pregnant women may have a greater susceptibility to invasive H influenzae infection. In an analysis of national surveillance data for invasive H influenza disease among women of child-bearing age in England and Wales, Collins and colleagues found that women who were pregnant had an increased risk of invasive H influenzae infection, which was associated with poor pregnancy outcomes. In an Editorial, Edwards discusses maternal infection and adverse fetal outcomes.

To assess the burden of psychiatric illness prior to and following a critical illness, Wunsch and colleagues analyzed Danish health registry data from 24 179 patients admitted to an intensive care unit (ICU) and requiring mechanical ventilation and 2 matched comparison cohorts—20 466 hospitalized patients and 120 844 individuals from the general population. Among the authors’ findings were that prior psychiatric diagnoses were more common among the critically ill patients and that new psychiatric diagnoses and psychoactive medication use were increased following ICU discharge.

Clinical Review & Education

Prostate cancer screening with the prostate-specific antigen (PSA) test remains controversial. To assess the association between PSA screening and prostate cancer–specific mortality and to develop an approach to screening that balances potential benefits and harms, Hayes and Barry considered the evidence from 5 randomized trials of prostate cancer screening with the PSA test and 4 related modeling studies that varied the screening strategy or extended the follow-up period. The authors report the available evidence favors discussion of the pros and cons of PSA screening with men aged 55 to 69 years who are at average risk. Only those men who express a strong preference for screening should have PSA testing.

In this JAMA Clinical Evidence Synopsis, Bruins Slot and Berge summarize the results of a Cochrane review (10 randomized trials; 42 084 patients) that examined the safety and efficacy of treatment with factor Xa inhibitors vs vitamin K antagonists (warfarin) to prevent stroke and other systemic embolic events in patients with atrial fibrillation. The authors report that compared with warfarin, factor Xa inhibitors were associated with a lower risk of stroke and other embolic events and with lower rates of intracranial hemorrhage and mortality.

A 22-year-old woman presents with oral ulcers and a rash on her palms. She takes no medications and a review of systems is noncontributory. Examination reveals shallow erosions with hemorrhagic crusts on the lips and widespread targetoid macules with dusky centers on the palms. What would you do next?



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