Download PDF
Semin Thromb Hemost 2014; 40(07): 812-824
DOI: 10.1055/s-0034-1394108
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Dangers in the Practice of Defensive Medicine in Hemostasis Testing for Investigation of Bleeding or Thrombosis: Part I—Routine Coagulation Testing

Giuseppe Lippi
1   Laboratory of Clinical Chemistry and Hematology, Academic Hospital of Parma, Parma, Italy
,
Emmanuel J. Favaloro
2   Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Pathology West, Westmead Hospital, Westmead, New South Wales, Australia
,
Massimo Franchini
3   Department of Hematology and Transfusion Medicine, C. Poma Hospital, Mantova, Italy
› Author Affiliations
Further Information

Publication History

Publication Date:
14 October 2014 (online)

    Permissions and Reprints

Abstract

Defensive medicine is a term conventionally used for defining the medical (mal)practice of ordering medically questionable diagnostic testing, procedures, or visits, or to avoid high-risk patients or procedures. The practice of defensive medicine may primarily be aimed to reduce exposure to malpractice liability, to avoid patient criticism regarding “medical inaction,” or to avoid “missing” some otherwise potential identifiable defect(s). Although the precise impact of defensive medicine in the field of laboratory testing is difficult to estimate from the current literature, the overuse or inappropriate use of laboratory resources ranges from 23 to 67%, and a large part of this can be attributed to medical liability concerns, with apparently little clinical awareness of the adverse consequences that may be associated with this practice. Essentially, performing inappropriate testing remarkably increases the risk of obtaining false-positive results due to statistical, preanalytical, and analytical reasons, thus triggering further and potentially even more invasive follow-up testing, inappropriate patient management, along with incremental increases of expenditure due to misuse of health care resources. As routine coagulation testing is commonly performed for the screening of patients with bleeding or thrombotic disorders, either a false-negative or a false-positive result may significantly impact on clinical outcomes and health care resources. The aim of this article is to describe the leading causes of physiological, pathological, therapeutic, and spurious variations of the prothrombin time, activated partial thromboplastin time, and D-dimer, as well as the potential clinical consequences emerging from the generation of false-negative and false-positive results with these tests.

Keywords

defensive medicine - inappropriateness - prothrombin time - activated partial thromboplastin time - D-dimer
 

  • References

  • 1 Passmore K, Leung W-C. Defensive practice among psychiatrists: a questionnaire survey. Postgrad Med J 2002; 78 (925) 671-673
    CrossrefPubMedGoogle Scholar
  • 2 Studdert DM, Mello MM, Sage WM , et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005; 293 (21) 2609-2617
    CrossrefPubMedGoogle Scholar
  • 3 Sloan FA, Shadle JH. Is there empirical evidence for “Defensive Medicine”? A reassessment. J Health Econ 2009; 28 (2) 481-491
    CrossrefPubMedGoogle Scholar
  • 4 Studdert DM, Mello MM, Gawande AA , et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 2006; 354 (19) 2024-2033
    CrossrefPubMedGoogle Scholar
  • 5 Kessler D, McClellan M. Do doctors practice defensive medicine?. Q J Econ 1996; 111: 353-390
    CrossrefPubMedGoogle Scholar
  • 6 Kessler D, McClellan M. Malpractice law and health care reform: optimal liability policy in an era of managed care. J Public Econ 2002; 84: 175-197
    CrossrefPubMedGoogle Scholar
  • 7 Lippi G, Plebani M. Biomarker research and leading causes of death worldwide: a rather feeble relationship. Clin Chem Lab Med 2013; 51 (9) 1691-1693
    PubMedGoogle Scholar
  • 8 Lippi G, Mattiuzzi C. Testing volume is not synonymous of cost, value and efficacy in laboratory diagnostics. Clin Chem Lab Med 2013; 51 (2) 243-245
    PubMedGoogle Scholar
  • 9 Lippi G, Plebani M. False myths and legends in laboratory diagnostics. Clin Chem Lab Med 2013; 51 (11) 2087-2097
    PubMedGoogle Scholar
  • 10 DeKay ML, Asch DA. Is the defensive use of diagnostic tests good for patients, or bad?. Med Decis Making 1998; 18 (1) 19-28
    CrossrefPubMedGoogle Scholar
  • 11 Lippi G, Cervellin G, Plebani M. The ten commandments of laboratory testing for emergency physicians. Clin Chem Lab Med 2014; 52 (2) 183-187
    PubMedGoogle Scholar
  • 12 Clinical and Laboratory Standards Institute; . Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory; Approved Guideline—Third Edition. CLSI document C28–A3c. Wayne, PA: Clinical and Laboratory Standards Institute; 2008
  • 13 Lippi G, Franchini M, Cervellin G. Diagnosis and management of ischemic heart disease. Semin Thromb Hemost 2013; 39 (2) 202-213
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Lakos G, Favaloro EJ, Harris EN , et al. International consensus guidelines on anticardiolipin and anti-β2-glycoprotein I testing: report from the 13th International Congress on Antiphospholipid Antibodies. Arthritis Rheum 2012; 64 (1) 1-10
    CrossrefPubMedGoogle Scholar
  • 15 Rang M. The Ulysses syndrome. Can Med Assoc J 1972; 106 (2) 122-123
    PubMedGoogle Scholar
  • 16 Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S. Overuse of health care services in the United States: an understudied problem. Arch Intern Med 2012; 172 (2) 171-178
    CrossrefPubMedGoogle Scholar
  • 17 Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS ONE 2013; 8 (11) e78962
    CrossrefPubMedGoogle Scholar
  • 18 Summerton N. Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. BMJ 1995; 310 (6971) 27-29
    CrossrefPubMedGoogle Scholar
  • 19 Van Boven K, Dijksterhuis P, Lamberts H. Defensive testing in Dutch family practice. Is the grass greener on the other side of the ocean?. J Fam Pract 1997; 44 (5) 468-472
    PubMedGoogle Scholar
  • 20 Collins MF, Kneeland MD, Campion FX , et al. Massachusetts Risk Management Survey (MaRMS) of teaching hospital physicians. J Healthc Risk Manag 1997; 17 (2) 3-11
    PubMedGoogle Scholar
  • 21 Hiyama T, Yoshihara M, Tanaka S , et al. Defensive medicine practices among gastroenterologists in Japan. World J Gastroenterol 2006; 12 (47) 7671-7675
    PubMedGoogle Scholar
  • 22 Nahed BV, Babu MA, Smith TR, Heary RF. Malpractice liability and defensive medicine: a national survey of neurosurgeons. PLoS ONE 2012; 7 (6) e39237
    CrossrefPubMedGoogle Scholar
  • 23 Sathiyakumar V, Jahangir AA, Mir HR , et al. The prevalence and costs of defensive medicine among orthopaedic trauma surgeons: a national survey study. J Orthop Trauma 2013; 27 (10) 592-597
    CrossrefPubMedGoogle Scholar
  • 24 Quick AJ. The thromboplastin reagent for the determination of prothrombin. Science 1940; 92 (2379) 113-114
    PubMedGoogle Scholar
  • 25 Hood JL, Eby CS. Evaluation of a prolonged prothrombin time. Clin Chem 2008; 54 (4) 765-768 , discussion 768–769
    CrossrefPubMedGoogle Scholar
  • 26 Lippi G, Plebani M, Favaloro EJ. Technological advances in the hemostasis laboratory. Semin Thromb Hemost 2014; 40 (2) 178-185
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Favaloro EJ, Lippi G, Koutts J. Laboratory testing of anticoagulants: the present and the future. Pathology 2011; 43 (7) 682-692
    CrossrefPubMedGoogle Scholar
  • 28 Franchini M. Haemostasis and pregnancy. Thromb Haemost 2006; 95 (3) 401-413
    PubMedGoogle Scholar
  • 29 Franchini M. Hemostasis and aging. Crit Rev Oncol Hematol 2006; 60 (2) 144-151
    CrossrefPubMedGoogle Scholar
  • 30 Lippi G, Maffulli N. Biological influence of physical exercise on hemostasis. Semin Thromb Hemost 2009; 35 (3) 269-276
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Vescovi PP, Favaloro EJ, Lippi G , et al. The spectrum of coagulation abnormalities in thyroid disorders. Semin Thromb Hemost 2011; 37 (1) 7-10
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Franchini M, Lippi G. Recombinant activated factor VII: mechanisms of action and current indications. Semin Thromb Hemost 2010; 36 (5) 485-492
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Kamal AH, Tefferi A, Pruthi RK. How to interpret and pursue an abnormal prothrombin time, activated partial thromboplastin time, and bleeding time in adults. Mayo Clin Proc 2007; 82 (7) 864-873
    CrossrefPubMedGoogle Scholar
  • 34 Peterson CE, Kwaan HC. Current concepts of warfarin therapy. Arch Intern Med 1986; 146 (3) 581-584
    CrossrefPubMedGoogle Scholar
  • 35 Lippi G, Becan-McBride K, Behúlová D , et al. Preanalytical quality improvement: in quality we trust. Clin Chem Lab Med 2013; 51 (1) 229-241
    PubMedGoogle Scholar
  • 36 Lippi G, Salvagno GL, Montagnana M, Lima-Oliveira G, Guidi GC, Favaloro EJ. Quality standards for sample collection in coagulation testing. Semin Thromb Hemost 2012; 38 (6) 565-575
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Adcock Funk DM, Lippi G, Favaloro EJ. Quality standards for sample processing, transportation, and storage in hemostasis testing. Semin Thromb Hemost 2012; 38 (6) 576-585
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Lippi G, Salvagno GL, Montagnana M, Guidi GC. Short-term venous stasis influences routine coagulation testing. Blood Coagul Fibrinolysis 2005; 16 (6) 453-458
    CrossrefPubMedGoogle Scholar
  • 39 Lippi G, Ippolito L, Favaloro EJ. Technical evaluation of the novel preanalytical module on instrumentation laboratory ACL TOP: advancing automation in hemostasis testing. J Lab Autom 2013; 18 (5) 382-390
    CrossrefPubMedGoogle Scholar
  • 40 Lippi G, Rossi R, Ippolito L , et al. Influence of residual platelet count on routine coagulation, factor VIII, and factor IX testing in postfreeze-thaw samples. Semin Thromb Hemost 2013; 39 (7) 834-839
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Da Rin G, Lippi G. Total laboratory automation of routine hemostasis testing. J Lab Autom 2013; 19 (4) 419-422
    PubMedGoogle Scholar
  • 42 Da Rin G, Lippi G. Sample rerun after short-term refrigerated storage: impact on routine coagulation testing. Int J Lab Hematol 2014; 36 (5) e71-e73
    CrossrefPubMedGoogle Scholar
  • 43 Lippi G, Montagnana M, Salvagno GL, Guidi GC. Interference of blood cell lysis on routine coagulation testing. Arch Pathol Lab Med 2006; 130 (2) 181-184
    PubMedGoogle Scholar
  • 44 Daves M, Giacomuzzi K, Tagnin E , et al. Influence of centrifuge brake on residual platelet count and routine coagulation tests in citrated plasma. Blood Coagul Fibrinolysis 2014; 25 (3) 292-295
    CrossrefPubMedGoogle Scholar
  • 45 Lima-Oliveira G, Lippi G, Salvagno GL, Montagnana M, Picheth G, Guidi GC. Sodium citrate vacuum tubes validation: preventing preanalytical variability in routine coagulation testing. Blood Coagul Fibrinolysis 2013; 24 (3) 252-255
    CrossrefPubMedGoogle Scholar
  • 46 Lippi G, Plebani M. Primary blood tubes mixing: time for updated recommendations. Clin Chem Lab Med 2012; 50 (4) 599-600
    CrossrefPubMedGoogle Scholar
  • 47 Chuang J, Sadler MA, Witt DM. Impact of evacuated collection tube fill volume and mixing on routine coagulation testing using 2.5-ml (pediatric) tubes. Chest 2004; 126 (4) 1262-1266
    CrossrefPubMedGoogle Scholar
  • 48 Lippi G, Salvagno GL, Montagnana M, Guidi GC. Influence of primary sample mixing on routine coagulation testing. Blood Coagul Fibrinolysis 2007; 18 (7) 709-711
    PubMedGoogle Scholar
  • 49 Parenmark A, Landberg E. To mix or not to mix venous blood samples collected in vacuum tubes?. Clin Chem Lab Med 2011; 49 (12) 2061-2063
    CrossrefPubMedGoogle Scholar
  • 50 Lima-Oliveira G, Lippi G, Salvagno GL , et al. Processing of diagnostic blood specimens: is it really necessary to mix primary blood tubes after collection with evacuated tube system?. Biopreserv Biobank 2014; 12 (1) 53-59
    CrossrefPubMedGoogle Scholar
  • 51 Lippi G, Favaloro EJ. Activated partial thromboplastin time: new tricks for an old dogma. Semin Thromb Hemost 2008; 34 (7) 604-611
    Article in Thieme ConnectPubMedGoogle Scholar
  • 52 Bonar RA, Favaloro EJ, Marsden K. External quality assurance for heparin monitoring. Semin Thromb Hemost 2012; 38 (6) 632-639
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 Lippi G, Ardissino D, Quintavalla R, Cervellin G. Urgent monitoring of direct oral anticoagulants in patients with atrial fibrillation: a tentative approach based on routine laboratory tests. J Thromb Thrombolysis 2014; 38 (2) 269-274
    CrossrefPubMedGoogle Scholar
  • 54 Liu J, Yuan E, Lee L. Gestational age-specific reference intervals for routine haemostatic assays during normal pregnancy. Clin Chim Acta 2012; 413 (1-2) 258-261
    CrossrefPubMedGoogle Scholar
  • 55 Lippi G, Meschi T, Borghi L. Variation of activated partial thromboplastin time according to age and sex in a large population study: analytical and clinical implications. Blood Coagul Fibrinolysis 2012; 23 (2) 177-178
    CrossrefPubMedGoogle Scholar
  • 56 Lippi G, Franchini M, Brazzarola P, Manzato F. Preoperative screening: the rationale of measuring APTT in risk assessment. Haematologica 2001; 86 (3) 328
    PubMedGoogle Scholar
  • 57 Renné T, Schmaier AH, Nickel KF, Blombäck M, Maas C. In vivo roles of factor XII. Blood 2012; 120 (22) 4296-4303
    CrossrefPubMedGoogle Scholar
  • 58 Lippi G, Salvagno GL, Ippolito L, Franchini M, Favaloro EJ. Shortened activated partial thromboplastin time: causes and management. Blood Coagul Fibrinolysis 2010; 21 (5) 459-463
    CrossrefPubMedGoogle Scholar
  • 59 Lippi G, Franchini M, Targher G , et al. Epidemiological association between fasting plasma glucose and shortened APTT. Clin Biochem 2009; 42 (1-2) 118-120
    CrossrefPubMedGoogle Scholar
  • 60 Lippi G, Targher G, Favaloro EJ, Franchini M. Venous thromboembolism in chronic liver disease. Semin Thromb Hemost 2011; 37 (1) 66-76
    Article in Thieme ConnectPubMedGoogle Scholar
  • 61 Mielicki WP, Tenderenda M, Rutkowski P, Chojnowski K. Activation of blood coagulation and the activity of cancer procoagulant (EC 3.4.22.26) in breast cancer patients. Cancer Lett 1999; 146 (1) 61-66
    CrossrefPubMedGoogle Scholar
  • 62 Mina A, Favaloro EJ, Mohammed S, Koutts J. A laboratory evaluation into the short activated partial thromboplastin time. Blood Coagul Fibrinolysis 2010; 21 (2) 152-157
    CrossrefPubMedGoogle Scholar
  • 63 van Veen JJ, Spahn DR, Makris M. Routine preoperative coagulation tests: an outdated practice?. Br J Anaesth 2011; 106 (1) 1-3
    CrossrefPubMedGoogle Scholar
  • 64 Telgt DS, Macik BG, McCord DM, Monroe DM, Roberts HR. Mechanism by which recombinant factor VIIa shortens the aPTT: activation of factor X in the absence of tissue factor. Thromb Res 1989; 56 (5) 603-609
    CrossrefPubMedGoogle Scholar
  • 65 Mina A, Favaloro EJ, Koutts J. Relationship between short activated partial thromboplastin times, thrombin generation, procoagulant factors and procoagulant phospholipid activity. Blood Coagul Fibrinolysis 2012; 23 (3) 203-207
    CrossrefPubMedGoogle Scholar
  • 66 Favaloro EJ. Laboratory testing in disseminated intravascular coagulation. Semin Thromb Hemost 2010; 36 (4) 458-467
    Article in Thieme ConnectPubMedGoogle Scholar
  • 67 Lippi G, Favaloro EJ. Laboratory hemostasis: milestones in clinical chemistry and laboratory medicine. Clin Chem Lab Med 2013; 51 (1) 91-97
    PubMedGoogle Scholar
  • 68 Lima-Oliveira G, Lippi G, Salvagno GL , et al. Effects of vigorous mixing of blood vacuum tubes on laboratory test results. Clin Biochem 2013; 46 (3) 250-254
    CrossrefPubMedGoogle Scholar
  • 69 Salvagno GL, Lippi G, Montagnana M, Franchini M, Poli G, Guidi GC. Influence of temperature and time before centrifugation of specimens for routine coagulation testing. Int J Lab Hematol 2009; 31 (4) 462-467
    CrossrefPubMedGoogle Scholar
  • 70 Franchini M, Mannucci PM. The history of hemophilia. Semin Thromb Hemost 2014; 40 (5) 571-576
    Article in Thieme ConnectPubMedGoogle Scholar
  • 71 Favaloro EJ. Trials and tribulations in lupus anticoagulant testing. Clin Chem Lab Med 2013; 51 (2) 253-256
    PubMedGoogle Scholar
  • 72 Favaloro EJ, Wong RC. Antiphospholipid antibody testing for the antiphospholipid syndrome: a comprehensive practical review including a synopsis of challenges and recent guidelines. Pathology 2014; 46 (6) 481-495
    CrossrefPubMedGoogle Scholar
  • 73 Lippi G, Franchini M, Targher G, Favaloro EJ. Help me, Doctor! My D-dimer is raised. Ann Med 2008; 40 (8) 594-605
    CrossrefPubMedGoogle Scholar
  • 74 Lippi G, Cervellin G, Casagranda I, Morelli B, Testa S, Tripodi A. D-dimer testing for suspected venous thromboembolism in the emergency department. Consensus document of AcEMC, CISMEL, SIBioC, and SIMeL. Clin Chem Lab Med 2014; 52 (5) 621-628
    PubMedGoogle Scholar
  • 75 Bates SM. D-dimer assays in diagnosis and management of thrombotic and bleeding disorders. Semin Thromb Hemost 2012; 38 (7) 673-682
    Article in Thieme ConnectPubMedGoogle Scholar
  • 76 Danese E, Montagnana M, Cervellin G, Lippi G. Hypercoagulability, D-dimer and atrial fibrillation: an overview of biological and clinical evidence. Ann Med 2014; 46 (6) 364-371
    CrossrefPubMedGoogle Scholar
  • 77 Cervellin G, Bonfanti L, Picanza A, Lippi G. Relation of D-dimer and troponin I in patients with new-onset atrial fibrillation. Am J Cardiol 2014; 114 (7) 1129-1130
    CrossrefPubMedGoogle Scholar
  • 78 Bergmann F, Pingel N, Czwalinna A, Koch M. D-Dimer in normal pregnancy: determination of reference values for three commercially available assays. Clin Chem Lab Med 2014; (e-pub ahead of print). doi: 10.1515/cclm-2014-0054
    PubMedGoogle Scholar
  • 79 Lippi G, Bonfanti L, Saccenti C, Cervellin G. Causes of elevated D-dimer in patients admitted to a large urban emergency department. Eur J Intern Med 2014; 25 (1) 45-48
    CrossrefPubMedGoogle Scholar
  • 80 Lippi G, Favaloro EJ, Cervellin G. A review of the value of D-dimer testing for prediction of recurrent venous thromboembolism with increasing age. Semin Thromb Hemost 2014; (e-pub ahead of print). doi: 10.1055/s-0034-1384630
    PubMedGoogle Scholar
  • 81 Knecht MF, Heinrich F, Spanuth E. Evaluation of plasma D-dimer in the diagnosis and in the course of fibrinolytic therapy of deep vein thrombosis and pulmonary embolism. Thromb Res 1992; 67 (2) 213-220
    CrossrefPubMedGoogle Scholar
  • 82 Lippi G, Veraldi GF, Fraccaroli M, Manzato F, Cordiano C, Guidi G. Variation of plasma D-dimer following surgery: implications for prediction of postoperative venous thromboembolism. Clin Exp Med 2001; 1 (3) 161-164
    CrossrefPubMedGoogle Scholar
  • 83 Lippi G, Favaloro EJ. D-dimer measurement and laboratory feedback. J Emerg Med 2009; 37 (1) 82-83 , author reply 83
    CrossrefPubMedGoogle Scholar
  • 84 Lippi G, Ippolito L, Tondelli MT, Favaloro EJ. Interference from heterophilic antibodies in D-dimer assessment. A case report. Blood Coagul Fibrinolysis 2014; 25 (3) 277-279
    CrossrefPubMedGoogle Scholar
  • 85 Robier C, Edler E, Klescher D, Neubauer M. False-positive D-dimer result in a latex-enhanced immunoassay caused by interfering human anti-mouse antibodies. Clin Chem Lab Med 2014; (e-pub ahead of print). doi: 10.1515/cclm-2014-0496
    PubMedGoogle Scholar
  • 86 Lippi G, Avanzini P, Zobbi V, Ippolito L. Influence of mechanical hemolysis of blood on two D-dimer immunoassays. Blood Coagul Fibrinolysis 2012; 23 (5) 461-463
    CrossrefPubMedGoogle Scholar
  • 87 Earls JP, White RD, Woodard PK , et al. ACR Appropriateness Criteria® chronic chest pain—high probability of coronary artery disease. J Am Coll Radiol 2011; 8 (10) 679-686
    CrossrefPubMedGoogle Scholar
  • 88 Jackson BR. The dangers of false-positive and false-negative test results: false-positive results as a function of pretest probability. Clin Lab Med 2008; 28 (2) 305-319 , vii
    CrossrefPubMedGoogle Scholar
  • 89 Cuker A. Clinical and laboratory diagnosis of heparin-induced thrombocytopenia: an integrated approach. Semin Thromb Hemost 2014; 40 (1) 106-114
    Article in Thieme ConnectPubMedGoogle Scholar
  • 90 Verstappen WH, van der Weijden T, Sijbrandij J , et al. Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial. JAMA 2003; 289 (18) 2407-2412
    CrossrefPubMedGoogle Scholar
  • 91 Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J 2006; 82 (974) 823-829
    CrossrefPubMedGoogle Scholar
  • 92 Feldman LS, Shihab HM, Thiemann D , et al. Impact of providing fee data on laboratory test ordering: a controlled clinical trial. JAMA Intern Med 2013; 173 (10) 903-908
    CrossrefPubMedGoogle Scholar
  • 93 Chu KH, Wagholikar AS, Greenslade JH, O'Dwyer JA, Brown AF. Sustained reductions in emergency department laboratory test orders: impact of a simple intervention. Postgrad Med J 2013; 89 (1056) 566-571
    CrossrefPubMedGoogle Scholar
  • 94 Lippi G, Cervellin G, Plebani M. Less is more, but do not throw out the baby with the bathwater either!. Diagnosis 2014; 1 (3) 199-201
    PubMedGoogle Scholar
  • 95 Kottke-Marchant K. Algorithmic approaches to hemostasis testing. Semin Thromb Hemost 2014; 40 (2) 195-204
    Article in Thieme ConnectPubMedGoogle Scholar
  • 96 Cervellin G, Borghi L, Lippi G. Do clinicians decide relying primarily on Bayesians principles or on Gestalt perception? Some pearls and pitfalls of Gestalt perception in medicine. Intern Emerg Med 2014; 9 (5) 513-519
    CrossrefPubMedGoogle Scholar