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• W2028757835 abstract "In 2001, the International Society on Thrombosis and Haemostasis (ISTH) Sub-Committee of the Scientific and Standardisation Committee (SSC) on Disseminated Intravascular Coagulation (DIC) proposed that the working definition of DIC be delineated into two phases. Non-overt DIC would represent subtle hemostatic dysfunction while overt DIC recognized its decompensated phase [1]. Central to the diagnosis is a scoring system rooted in rapid and readily available tests. This would then enable the diagnosis to be utilized widely and serve as the reference standard for diagnostic and therapeutic purposes. For overt DIC, a cumulative score of 5 or more from prolonged prothrombin time (PT), reduced platelets and fibrinogen, and elevated fibrin-related markers was proposed (Table 1). This required prospective confirmation. For non-overt DIC, scoring would incorporate abnormal trends and results in both simple global tests and molecular markers of coagulation (Table 2). Studies were required to establish feasibility and to derive a prognostic score. We examined all articles citing the 2001 communication. Searching on MEDLINE and EMBASE (December 2001 to June 2006) also included the terms ‘DIC’ and ‘diagnosis’, ‘ISTH’, ‘overt’, ‘non-overt’ plus related links. Selection was based on use of the scoring systems in DIC diagnosis and prognosis. In the absence of a reference ‘gold’ standard for the ISTH overt DIC score, comparisons with the Japanese Ministry of Health and Welfare (JMHW) score were important as the best-evidenced working diagnosis to date. Studies in the 1990s closely correlated increasing JMHW scores with increasing mortality [2]. In 1284 patients, Wada et al. found the rate of agreement between both ISTH and JMHW scores at 67.4% [3]. Discordance was primarily in the JMHW sensitivity to DIC in hematologic malignancies with high fibrinolytic activity. Without such patients, a further comparative study showed 93% concordance [4]. Although these were mainly in patients with infection, Gando et al. found mortality to be also high in the DIC of non-infected patients diagnosed using ISTH criteria [5]. Using a different approach with blinded ‘expert’ assessments, Bakhtiari et al. found sensitivity of 91% and specificity of 97% with the ISTH DIC score [6]. Increasing scores strongly correlated with mortality. Others have similarly confirmed this independent prediction of mortality by the ISTH DIC score and its added prognostic value to the Acute Physiology and Chronic Health Evaluation (APACHE) II system [7-9]. In relation to therapeutic relevance, retrospective analyses from two large treatment trials in sepsis [10, 11] utilizing data that did not include fibrinogen levels also highlighted the prognostic power of the ISTH DIC score. In the PROWESS study, the DIC score separated those with favorable responses to recombinant activated protein C from those with less impressive effects [10]. Comparable results were shared by the KyberSept cohort of patients treated with antithrombin without concomitant heparin [11]. Studies have also addressed specific differences in reporting laboratory results. In laboratories where the PT in seconds is not reported, the prothrombin index has been used with 0 for >70%, 1 for 40%–70% and 2 for <40% [9]. Studies have also attempted to define D-dimer cutoff levels. One approach assigned scores for moderate and strong increases on 25% and 75% quartiles derived from over 1000 samples in intensive care [12]. Dempfle et al. [12] found this to be approximately 1 μg mL−1 and approximately 3 μg mL−1, respectively, with good concordance between two D-dimer assays. In a Dutch intensive care cohort, 0.4–4 μg mL−1 and > 4μg mL−1 D-dimer was used for moderate and strong increases, respectively [6]. As issues remain on the accuracy of high D-dimer estimations with ongoing work to standardize reagents, precise cutoff recommendations remain to be defined. For non-overt DIC, Toh and Downey demonstrated that the proposed template was workable [13]. In addition, a score of 5 or greater could diagnostically define patients with a poor prognosis from haemostatic dysfunction, independent of developing overt DIC. Although the scoring system allowed for PC and AT measurements, the combination of scoring abnormal trends and results in the PT, platelet count, and D-dimer provided sufficient robustness without recourse to the molecular markers. Indeed, studies of simplified scoring variations that include longitudinal observations show promise. An evolving score based on PT and platelet count in the first 48 h of intensive care reflected clinical severity [14]. Worsening coagulopathy during the first day of severe sepsis was also associated with increased development of new organ failure [15]. Notably, it was PT and D-dimer changes but not PC or AT that were significantly related to mortality when analyzed as continuous variables. A score of 5 or greater can identify overt DIC by the system proposed in the 2001 communication of the ISTH SSC on DIC. Using a different template whereby abnormal trends are scored alongside abnormal results, non-overt DIC can be diagnosed from a score of 5 or greater. There appears to be no added value in including PC or AT estimations. Further prospective validation and similar approaches of capturing evolving coagulopathy through readily available assays are recommended. The authors state that they have no conflict of interest." @default.
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• W2028757835 date "2007-03-01" @default.
• W2028757835 modified "2023-10-14" @default.
• W2028757835 title "The scoring system of the Scientific and Standardisation Committee on Disseminated Intravascular Coagulation of the International Society on Thrombosis and Haemostasis: a 5‐year overview" @default.
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• W2028757835 doi "https://doi.org/10.1111/j.1538-7836.2007.02313.x" @default.
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