Haematologica
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Pulmonary embolism (PE), with an incidence of 23 per 100,000 patients per year, is a frequent clinical problem, responsible for 200,000 deaths each year in the United States. Pulmonary angiography, the gold standard for diagnosing PE, is invasive, costly and not universally available. Moreover, PE is confirmed in only approximately 30% of patients in whom it is suspected, rendering noninvasive screening tests necessary. Several strategies have been recently proposed to reduce the need for pulmonary angiography in the diagnostic workup of pulmonary embolism. The objective of this article is to analyze the individual performance of the new diagnostic instruments and their combination in rational diagnostic strategies. ⋯ Even though PE remains a difficult diagnostic challenge, the availability of novel noninvasive tests (plasma D-dimer and ultrasonography of the lower limbs) and the rehabilitation of clinical assessment allow a more rational and sparse prescription of pulmonary angiography. More work needs to be done to assess test performances and refine diagnostic strategies in distinct patient subgroups, particularly those hospitalized. Screening patients with plasma D-dimer and ultrasonography of the lower limbs may be the most cost-effective strategy, at least in outpatients.
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Patients with hematologic malignancies and a history of an invasive fungal infection are considered to be at high risk of suffering reactivation of the infection during subsequent intensive chemotherapy. ⋯ Despite lack of definite evidence, administration of an active antifungal drug before, during and after the period of neutropenia appears to be useful. In IPA, residual masses, nodules or cavities in the lung usually contain viable invasive fungal elements and should be resected whenever possible. On the other hand, the risk of reactivation and progression of an active fungal infection during intensive chemoradiotherapy is very high, and novel therapeutic strategies appear warranted in this setting.