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Abstract
Purpose of review Decision-making on resuming oral anticoagulant (OAC) after intracerebral hemorrhage (ICH) evokes significant debate among clinicians. Such patients have been excluded from randomized clinical trials. This review article provides a comprehensive summary of the evidence on anticoagulation resumption after ICH. Recent findings OAC resumption does not increase the risk of recurrent ICH and can also reduce the risk of all-cause mortality. OAC cessation exposes patients to a significantly higher risk of thromboembolism, which could be reduced by resumption. The optimal timing of anticoagulation resumption after ICH is still unknown. Both early (< 2 weeks) and late (> 4 weeks) resumption should be reached only after very careful assessment of risks for ICH recurrence and thromboembolism. The introduction of new oral anticoagulants and other interventions, such as left atrial appendage closure, has provided some patients with more alternatives. Summary Given the lack of high-quality evidence to guide clinical decision-making, clinicians must carefully balance the risks of thromboembolism and recurrent ICH in individual patients. We propose a management approach which would facilitate the decision-making process on whether anticoagulation is appropriate, as well as when and how to restart anticoagulation after ICH.
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Cronin P, Dwamena BA. A Clinically Meaningful Interpretation of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II and III Data. Acad Radiol 2018; 25:561-572. [PMID: 29337091 DOI: 10.1016/j.acra.2017.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 08/01/2017] [Accepted: 11/21/2017] [Indexed: 12/21/2022]
Abstract
RATIONALE AND OBJECTIVES This study aimed to calculate the multiple-level likelihood ratios (LRs) and posttest probabilities for a positive, indeterminate, or negative test result for multidetector computed tomography pulmonary angiography (MDCTPA) ± computed tomography venography (CTV) and magnetic resonance pulmonary angiography (MRPA) ± magnetic resonance venography (MRV) for each clinical probability level (two-, three-, and four-level) for the nine most commonly used clinical prediction rules (CPRs) (Wells, Geneva, Miniati, and Charlotte). The study design is a review of observational studies with critical review of multiple cohort studies. The settings are acute care, emergency room care, and ambulatory care (inpatients and outpatients). MATERIALS AND METHODS Data were used to estimate pulmonary embolism (PE) pretest probability for each of the most commonly used CPRs at each probability level. Multiple-level LRs (positive, indeterminate, negative test) were generated and used to calculate posttest probabilities for MDCTPA, MDCTPA + CTV, MRPA, and MRPA + MRV from sensitivity and specificity results from Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II and PIOPED III for each clinical probability level for each CPR. Nomograms were also created. RESULTS The LRs for a positive test result were higher for MRPA compared to MDCTPA without venography (76 vs 20) and with venography (42 vs 18). LRs for a negative test result were lower for MDCTPA compared to MRPA without venography (0.18 vs 0.22) and with venography (0.12 vs 0.15). In the three-level Wells score, the pretest clinical probability of PE for a low, moderate, and high clinical probability score is 5.7, 23, and 49. The posttest probability for an initially low clinical probability PE for a positive, indeterminate, and negative test result, respectively, for MDCTPA is 54, 5 and 1; for MDCTPA + CTV is 52, 2, and 0.7; for MRPA is 82, 6, and 1; and for MRPA + MRV is 72, 3, and 1; for an initially moderate clinical probability PE for MDCTPA is 86, 22, and 5; for MDCTPA + CTV is 85, 10, and 4; for MRPA is 96, 25, and 6; and for MRPA + MRV is 93, 14, and 4; and for an initially high clinical probability of PE for MDCTPA is 95, 47, and 15; for MDCTPA + CTV is 95, 27, and 10; for MRPA is 99, 52, and 17; and for MRPA + MRV is 98, 34, and 13. CONCLUSIONS For a positive test result, LRs were considerably higher for MRPA compared to MDCTPA. However, both a positive MRPA and MDCTPA have LRs >10 and therefore can confirm the presence of PE. Performing venography reduced the LR for a positive and negative test for both MDCTPA and MRPA. The nomograms give posttest probabilities for a positive, indeterminate, or negative test result for MDCTPA and MRPA (with and without venography) for each clinical probability level for each of the CPR.
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Affiliation(s)
- Paul Cronin
- Department of Radiology, University of Michigan Health System, B1 132G Taubman Center/5302, 1500 East Medical Center, Ann Arbor, MI 48109.
| | - Ben A Dwamena
- Department of Radiology, University of Michigan Health System, B1 132G Taubman Center/5302, 1500 East Medical Center, Ann Arbor, MI 48109; Nuclear Medicine Service, VA Ann Arbor Health Care System, Ann Arbor, Michigan
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Ye F, Stalvey C, Khuddus MA, Winchester DE, Toklu HZ, Mazza JJ, Yale SH. A systematic review of mobility/immobility in thromboembolism risk assessment models for hospitalized patients. J Thromb Thrombolysis 2018; 44:94-103. [PMID: 28484939 DOI: 10.1007/s11239-017-1501-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hospitalized patients are at risk of venous thromboembolism (VTE) and prophylaxis is often suboptimal due to difficulty in identifying at-risk patients. Simple and validated risk-assessment models (RAMs) are available to assist clinicians in identifying patients who have a high risk for developing VTE. Despite the well-documented association of immobility with increased risk of thrombosis, immobility is not consistently defined in clinical studies. We conducted a systematic review of published VTE RAMs and used objective criteria to determine how the term immobility is defined in RAMs. We identified 17 RAMs with six being externally validated. The concept of immobility is vaguely described in different RAMs, impacting the validity of these models in clinical practice. The wide variability in defining mobility in RAMs precluded its accurate clinical application, further limiting generalization of published RAMs. Externally validated RAMs with clearly defined qualitative or quantitative terms of immobility are needed to assess VTE risk in real-time at the point-of-care.
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Affiliation(s)
- Fan Ye
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA.,College of Medicine, University of Central Florida, Orlando, FL, 32827, USA
| | - Carolyn Stalvey
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Matheen A Khuddus
- North Florida Regional Medical Center, The Cardiac and Vascular Institute, Gainesville, FL, 32605, USA
| | - David E Winchester
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Hale Z Toklu
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA
| | - Joseph J Mazza
- Marshfield Clinic Research Foundation, Marshfield, WI, 54449, USA
| | - Steven H Yale
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA. .,College of Medicine, University of Central Florida, Orlando, FL, 32827, USA. .,Department of Internal Medicine, North Florida Regional Medical Center, 6500 Newberry Road, Gainesville, FL, 32614, USA.
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Choi H, Krishnamoorthy D. The diagnostic utility of D-dimer and other clinical variables in pregnant and post-partum patients with suspected acute pulmonary embolism. Int J Emerg Med 2018; 11:10. [PMID: 29504087 PMCID: PMC5835486 DOI: 10.1186/s12245-018-0169-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 02/08/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) during pregnancy remains one of the leading causes of maternal morbidity and mortality in the developed world. However, there is a paucity of high-quality evidence resulting in a lack of consensus in managing this group of patients. The aims of the study were to address the diagnostic utility of D-dimer for suspected PE in pregnant and post-partum patients and to identify any clinical presentation variables that are predictors of PE in this group of patients. METHODS A retrospective case note review of 152 pregnant and post-partum patients who underwent diagnostic imaging (ventilation/perfusion (V/Q) or computed tomographic pulmonary angiography (CTPA)) for suspected PE at a tertiary teaching hospital from 2007 to 2011 was conducted. The reference range for D-dimer was less than 0.5 mg/L as being normal. The following variables were also assessed in terms of their predictive capability for PE diagnosis in pregnancy: heart rate (HR), mean arterial pressure (MAP), shock index (SI) and A-a gradient. RESULTS The application of D-dimer testing for suspected PE in this study population had a sensitivity of 100% (95% CI, 73-100%), specificity of 42% (95% CI, 31-53%) and a likelihood negative ratio of 0. None of the clinical variables were significant predictors of PE according to regression analyses. CONCLUSIONS There is supportive evidence that a negative D-dimer result is useful as a means of ruling out PE in pregnant and post-partum patients. However, we need a larger prospective observational study to collaborate the findings.
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Affiliation(s)
- Hyun Choi
- Emergency Department, University Hospital Lewisham, Lewisham High Street, London, UK.
| | - Dinesh Krishnamoorthy
- St George's School of Medicine, University of London, Cranmer Terrace, London, SW17 0RE, UK
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55
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Riopel C, Bounameaux H. Doppler ultrasound and D-dimer. Hamostaseologie 2017; 32:28-36. [DOI: 10.5482/ha-1182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 11/07/2011] [Indexed: 01/16/2023] Open
Abstract
SummaryThe diagnosis of venous thromboembolism has evolved considerably with the development of standardized diagnostic algorithms that include clinical probability assessment, D-dimer measurement and the use of non-invasive imaging modalities such as compression ultrasonography and computed tomography angiography. The implementation of these strategies aims to improve resource allocation and patient outcome. The judicious use of these diagnostic tools requires a thorough knowledge of the appropriate clinical setting in which every test and strategy is efficient and can be used safely. For this purpose, D-dimer measurement and compression ultrasonography are complementary: the former is mainly used to exclude VTE in selected patients, while the latter is used to confirm the presence of an underlying DVT.This review provides an appraisal of the features and use of D-dimer and compression ultrasonography in the context of suspected venous thromboembolism.
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Narbey D, Habibi A, Chadebech P, Mekontso-Dessap A, Khellaf M, Lelièvre JD, Godeau B, Michel M, Galactéros F, Djoudi R, Bartolucci P, Pirenne F. Incidence and predictive score for delayed hemolytic transfusion reaction in adult patients with sickle cell disease. Am J Hematol 2017; 92:1340-1348. [PMID: 28924974 DOI: 10.1002/ajh.24908] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 09/14/2017] [Indexed: 01/20/2023]
Abstract
Delayed hemolytic transfusion reaction (DHTR) is a life-threatening complication of transfusion in sickle cell disease (SCD). The frequency of DHTR is underestimated because its symptoms mimic those of vaso-occlusive crisis and antibodies (Abs) are often not detectable. No predictive factors for identifying patients likely to develop DHTR have yet been defined. We conducted a prospective single-center observational study over 30 months in adult sickle cell patients. We included 694 transfusion episodes (TEs) in 311 patients, divided into occasional TEs (OTEs: 360) and chronic transfusion program (CTEs: 334). During follow-up, 15 cases of DHTR were recorded, exclusively after OTEs. DHTR incidence was 4.2% per OTE (95% CI [2.6; 6.9]) and 6.8% per patient during the 30 months of the study (95% CI [4.2; 11.3]). We studied 11 additional DHTR cases, to construct a predictive score for DHTR. The DHTR mortality is high, 3 (11.5%) of the 26 DHTR patients died. The variables retained in the multivariate model were history of DHTR, number of units previously transfused and immunization status before transfusion. The resulting DHTR-predictive score had an area under the ROC curve of 0.850 [95% CI: 0.780-0.930], a negative-predictive value of 98.4% and a positive-predictive value of 50%. We report in our study population, for the first time, the incidence of DHTR, and, its occurrence exclusively in occasionally transfused patients. We also describe a simple score for predicting DHTR in patients undergoing occasional transfusion, to facilitate the management of blood transfusion in SCD patients.
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Affiliation(s)
- David Narbey
- Etablissement Français du Sang; Créteil 94000 France
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
| | - Anoosha Habibi
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
- Reference Center for Sickle Cell Disease, Hôpital Henri Mondor; Créteil France
| | - Philippe Chadebech
- Etablissement Français du Sang; Créteil 94000 France
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
| | - Armand Mekontso-Dessap
- Intensive Care Unit, Hôpital Henri Mondor; Créteil France
- IMRB, Groupe de recherche clinique CARMAS; Créteil France
- Université Paris Est Créteil, Faculté de Médecine
| | - Mehdi Khellaf
- Université Paris Est Créteil, Faculté de Médecine
- Emergency Unit, Hôpital Henri Mondor; Créteil France
| | - Jean-Daniel Lelièvre
- Université Paris Est Créteil, Faculté de Médecine
- Clinical Immunology Department; Hôpital Henri Mondor; Créteil France
| | - Bertrand Godeau
- Intensive Care Unit, Hôpital Henri Mondor; Créteil France
- Internal Medicine Department; Hôpital Henri Mondor; Créteil France
| | - Marc Michel
- Université Paris Est Créteil, Faculté de Médecine
- Internal Medicine Department; Hôpital Henri Mondor; Créteil France
| | - Frédéric Galactéros
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
- Reference Center for Sickle Cell Disease, Hôpital Henri Mondor; Créteil France
- Université Paris Est Créteil, Faculté de Médecine
| | - Rachid Djoudi
- Etablissement Français du Sang; Créteil 94000 France
| | - Pablo Bartolucci
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
- Reference Center for Sickle Cell Disease, Hôpital Henri Mondor; Créteil France
- Université Paris Est Créteil, Faculté de Médecine
| | - France Pirenne
- Etablissement Français du Sang; Créteil 94000 France
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
- Université Paris Est Créteil, Faculté de Médecine
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Le Gal G, Bounameaux H, Righini M. Venous thromboembolism diagnosis: unresolved issues. Thromb Haemost 2017; 113:1184-92. [DOI: 10.1160/th14-06-0530] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/22/2014] [Indexed: 11/05/2022]
Abstract
SummaryRecent advances in the management of patients with suspected VTE have both improved diagnostic accuracy and made management algorithms safer, easier to use and well standardised. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-dimer measurement and imaging tests, mainly represented by compression ultrasound (CUS) for suspected DVT and computed tomography pulmonary angiography (CTPA) or lung ventilationperfusion scan for pulmonary embolism. These diagnostic algorithms allow a safe and cost-effective diagnosis for most patients with suspected VTE. In this review, we focus on the challenge of diagnosing VTE in special patient populations, such as elderly patients, pregnant women, or patients with a prior VTE. Some additional challenges are arising that might require adjustments to current diagnostic strategies, such as the reduced clinical suspicion threshold, resulting in a lower proportion of VTE among suspected patients; the overdiagnosis and overtreatment of VTE, especially regarding calf deep-vein thrombosis (DVT) and subsegmental pulmonary embolism (SSPE).
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Marschner C, Kristensen A, Rozanski E, McEvoy F, Kühnel L, Taeymans O, de Laforcade A, Sato A, Wiinberg B. Diagnosis of canine pulmonary thromboembolism by computed tomography and mathematical modelling using haemostatic and inflammatory variables. Vet J 2017; 229:6-12. [DOI: 10.1016/j.tvjl.2017.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/19/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
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Barcan A, Tarta D, Tarta C. Clinical Update. Clinical Presentations of Pulmonary Embolism in the Emergency Department. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2017. [DOI: 10.1515/jce-2017-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Pulmonary embolism (PE) is one of the most severe conditions encountered in the emergency department (ED) and one of the leading causes of cardiovascular morbidity and mortality, especially in patients presenting with hemodynamic instability, right ventricular dysfunction, or necessitating cardiopulmonary resuscitation. The early recognition and treatment of PE is essential, as many studies demonstrated that mortality rates drop significantly if adequate therapy is administered from the early stages. The aim of this update is to summarize the various patterns of PE presentations in the ED.
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Affiliation(s)
- Andreea Barcan
- Clinic of Cardiology, Municipal Hospital, Mediaș , Romania
| | - Dorin Tarta
- Clinic of Cardiology, Municipal Hospital, Mediaș , Romania
| | - Cristina Tarta
- Clinic of Cardiology, Municipal Hospital, Mediaș , Romania
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Robert-Ebadi H, Mostaguir K, Hovens MM, Kare M, Verschuren F, Girard P, Huisman MV, Moustafa F, Kamphuisen PW, Buller HR, Righini M, Le Gal G. Assessing clinical probability of pulmonary embolism: prospective validation of the simplified Geneva score. J Thromb Haemost 2017; 15:1764-1769. [PMID: 28688113 DOI: 10.1111/jth.13770] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Indexed: 01/10/2023]
Abstract
Essentials The simplified Geneva score allows easier pretest probability assessment of pulmonary embolism (PE). We prospectively validated this score in the ADJUST-PE management outcome study. The study shows that it is safe to manage patients with suspected PE according to this score. The simplified Geneva score is now ready for use in routine clinical practice. SUMMARY Background Pretest probability assessment by a clinical prediction rule (CPR) is an important step in the management of patients with suspected pulmonary embolism (PE). A limitation to the use of CPRs is that their constitutive variables and corresponding number of points are difficult to memorize. A simplified version of the Geneva score (i.e. attributing one point to each variable) has been proposed but never been prospectively validated. Aims Prospective validation of the simplified Geneva score (SGS) and comparison with the previous version of the Geneva score (GS). Methods In the ADJUST-PE study, which had the primary aim of validating the age-adjusted D-dimer cut-off, the SGS was prospectively used to determine the pretest probability in a subsample of 1621 study patients. Results Overall, PE was confirmed in 294 (18.1%) patients. Using the SGS, 608 (37.5%), 980 (60.5%) and 33 (2%) were classified as having a low, intermediate and high clinical probability. Corresponding prevalences of PE were 9.7%, 22.4% and 45.5%; 490 (30.1%) patients with low or intermediate probability had a D-dimer level below 500 μg L-1 and 653 (41.1%) had a negative D-dimer test according to the age-adjusted cut-off. Using the GS, the figures were 491(30.9%) and 650 (40.9%). None of the patients considered as not having PE based on a low or intermediate SGS and negative D-dimer had a recurrent thromboembolic event during the 3-month follow-up. Conclusions The use of SGS has similar efficiency and safety to the GS in excluding PE in association with the D-dimer test.
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Affiliation(s)
- H Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - K Mostaguir
- Clinical Research Center, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M M Hovens
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - M Kare
- Emergency room, Centre Hospitalier d'Agen, Agen, France
| | - F Verschuren
- Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - P Girard
- Département Thoracique, L'Institut Mutualiste Montsouris, Paris, France
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - F Moustafa
- Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - P W Kamphuisen
- Department of Vascular Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - H R Buller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - M Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - G Le Gal
- Ottawa Hospital Research Institute, Ottawa, Canada
- CIC1412, Université de Brest, Brest, France
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Schulman S, Ageno W, Konstantinides SV. Venous thromboembolism: Past, present and future. Thromb Haemost 2017; 117:1219-1229. [PMID: 28594049 DOI: 10.1160/th16-10-0823] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/02/2016] [Indexed: 12/28/2022]
Abstract
Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, is associated with a considerable disease burden which continues to grow along with the longer life expectancy of the population worldwide. In the past century, parenteral heparin prophylaxis was established for hospitalised patients at elevated risk of VTE. More recently, non-vitamin K antagonist oral anticoagulants (NOACs) with a direct inhibiting effect on factor Xa or thrombin, underwent extensive testing in clinical trials and have been approved for patients undergoing hip or knee replacement. Clinical investigation is ongoing in further areas of thromboprophylaxis, including medical prophylaxis in patients and high-risk situations in the outpatient setting. The diagnostic approach to suspected VTE is now based on advanced imaging techniques and robust diagnostic algorithms which ensure high sensitivity and specificity. Nevertheless, the role of clinical, or pre-test, probability assessment remains crucial to avoid overdiagnosis and treatment errors. Advances in reperfusion strategies, along progressive establishment of the NOACs as the new standard of anticoagulation treatment, have simplified the management of VTE, improving outcomes and particularly safety. While new molecular targets for anticoagulation are being investigated in the quest to further reduce bleeding risk, adjusting the initial regimen to the patient's risk and finding the optimal duration of anticoagulation after an index VTE event will be some of the top priorities in the years to come. Importantly, and in parallel to new drugs and technical advances in imaging, incentives such as hospital accreditation and funding based on evidence-based practice need to be implemented to increase guideline adherence.
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Affiliation(s)
- Sam Schulman
- Sam Schulman, MD, PhD, Thrombosis Service, HHS-General Hospital, 237 Barton St E, Hamilton, ON, L8L 2X2, Canada, Tel. : +1 905 5270271, ext 44479, Fax: +1 905 5211551, E-mail
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Ban JW, Wallace E, Stevens R, Perera R. Why do authors derive new cardiovascular clinical prediction rules in the presence of existing rules? A mixed methods study. PLoS One 2017; 12:e0179102. [PMID: 28591223 PMCID: PMC5462434 DOI: 10.1371/journal.pone.0179102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/24/2017] [Indexed: 12/26/2022] Open
Abstract
Background Researchers should examine existing evidence to determine the need for a new study. It is unknown whether developers evaluate existing evidence to justify new cardiovascular clinical prediction rules (CPRs). Objective We aimed to assess whether authors of cardiovascular CPRs cited existing CPRs, why some authors did not cite existing CPRs, and why they thought existing CPRs were insufficient. Method Derivation studies of cardiovascular CPRs from the International Register of Clinical Prediction Rules for Primary Care were evaluated. We reviewed the introduction sections to determine whether existing CPRs were cited. Using thematic content analysis, the stated reasons for determining existing cardiovascular CPRs insufficient were explored. Study authors were surveyed via e-mail and post. We asked whether they were aware of any existing cardiovascular CPRs at the time of derivation, how they searched for existing CPRs, and whether they thought it was important to cite existing CPRs. Results Of 85 derivation studies included, 48 (56.5%) cited existing CPRs, 33 (38.8%) did not cite any CPR, and four (4.7%) declared there was none to cite. Content analysis identified five categories of existing CPRs insufficiency related to: (1) derivation (5 studies; 11.4% of 44), (2) construct (31 studies; 70.5%), (3) performance (10 studies; 22.7%), (4) transferability (13 studies; 29.5%), and (5) evidence (8 studies; 18.2%). Authors of 54 derivation studies (71.1% of 76 authors contacted) responded to the survey. Twenty-five authors (46.3%) reported they were aware of existing CPR at the time of derivation. Twenty-nine authors (53.7%) declared they conducted a systematic search to identify existing CPRs. Most authors (90.7%) indicated citing existing CPRs was important. Conclusion Cardiovascular CPRs are often developed without citing existing CPRs although most authors agree it is important. Common justifications for new CPRs concerned construct, including choice of predictor variables or relevance of outcomes. Developers should clearly justify why new CPRs are needed with reference to existing CPRs to avoid unnecessary duplication.
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Affiliation(s)
- Jong-Wook Ban
- Evidence-Based Health Care Programme, Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, Medical Science Division, University of Oxford, Oxford, United Kingdom
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, Medical Science Division, University of Oxford, Oxford, United Kingdom
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At-risk and intervention thresholds of occupational stress using a visual analogue scale. PLoS One 2017; 12:e0178948. [PMID: 28586383 PMCID: PMC5460813 DOI: 10.1371/journal.pone.0178948] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 05/22/2017] [Indexed: 01/15/2023] Open
Abstract
Background The visual analogue scale (VAS) is widely used in clinical practice by occupational physicians to assess perceived stress in workers. However, a single cut-off (black-or-white decision) inadequately discriminates between workers with and without stress. We explored an innovative statistical approach to distinguish an at-risk population among stressed workers, and to establish a threshold over which an action is urgently required, via the use of two cut-offs. Methods Participants were recruited during annual work medical examinations by a random sample of workers from five occupational health centres. We previously proposed a single cut-off of VAS stress in comparison with the Perceived Stress Scale (PSS14). Similar methodology was used in the current study, along with a gray zone approach. The lower limit of the gray zone supports sensitivity (“at-risk” threshold; interpreted as requiring closer surveillance) and the upper limit supports specificity (i.e. “intervention” threshold–emergency action required). Results We included 500 workers (49.6% males), aged 40±11 years, with a PSS14 score of 3.8±1.4 and a VAS score of 4.0±2.4. Using a receiver operating characteristic curve and the PSS cut-off score of 7.2, the optimal VAS threshold was 6.8 (sensitivity = 0.89, specificity = 0.87). The lower and upper thresholds of the gray zone were 5 and 8.2, respectively. Conclusions We identified two clinically relevant cut-offs on the VAS of stress: a first cut-off of 5.0 for an at-risk population, and a second cut-off of 8.2 over which an action is urgently required. Future investigations into the relationships between this upper threshold and deleterious events are required.
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Challenges in Quality Improvement: Appropriate Utilization of Computed Tomography Angiograms for Evaluation of Pulmonary Embolism. Am J Med 2017; 130:652-656. [PMID: 28192088 DOI: 10.1016/j.amjmed.2017.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 01/30/2017] [Accepted: 01/30/2017] [Indexed: 11/22/2022]
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Cronin P, Dwamena BA. A Clinically Meaningful Interpretation of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) Scintigraphic Data. Acad Radiol 2017; 24:550-562. [PMID: 28262522 DOI: 10.1016/j.acra.2017.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
Abstract
RATIONALE AND OBJECTIVES Pulmonary embolism (PE) is a common condition associated with significant morbidity and mortality. Diagnostic test characteristics reported in terms of sensitivity and specificity are difficult to translate at the clinical level. More relevant measures are likelihood ratios (LRs), which can convert a pretest into a posttest probability. The aim of our study was to calculate the LRs and posttest probabilities for multiple-level test result for ventilation/perfusion (V/Q) lung scintigraphy and for perfusion scintigraphy combined with chest radiography using modified Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II and the Prospective Investigative Study of Pulmonary Embolism Diagnosis (PISAPED) criteria for each clinical probability level for the most commonly used clinical prediction rules (CPR) using the PIOPED data. MATERIALS AND METHODS PE pretest probability was estimated for the most commonly used CPRs (Wells, Geneva, Miniati, and Charlotte) at each clinical probability level (two-, three-, and four-level). Multiple-level LRs (high, indeterminate, low, very low probability, and normal) and the positive, indeterminate, and negative results for V/Q scintigraphy, and the positive, indeterminate, and negative results for perfusion scintigraphy were generated and used to calculate posttest probabilities based on the sensitivity and specificity data from PIOPED for each clinical probability level (low, intermediate, and high) for each CPR. Nomograms were also created. RESULTS The LRs for a positive V/Q and perfusion scintigraphy test using modified PIOPED II and PISAPED criteria were 20.6, 11, and 23.7, and for a negative test result were 0.15, 0.16, and 0.2, respectively. In the three-level Wells score, the posttest probability for an initial low clinical probability PE for a positive, indeterminate, and negative test result, respectively, for V/Q scintigraphy is 56, 5, and 0.9; for perfusion scintigraphy with modified PIOPED 40, 7, and 0.9, and with PISAPED 59, not available (N/A), and 1.2; for an initial moderate clinical probability PE for V/Q scintigraphy 86, .22, and 4; for perfusion scintigraphy with modified PIOPED 77, 26, and 5, and with PISAPED 88, N/A, and 6; for an initial high clinical probability of PE for V/Q scintigraphy 95, 48, and 13; and for perfusion scintigraphy with modified PIOPED 92, 53, and 13, and with PISAPED 96, N/A, and 16. CONCLUSIONS With LRs >10, a positive test result for V/Q and perfusion scintigraphy can confirm the presence of PE. Only a normal test result has low enough LR to exclude PE.
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A Novel Scoring System for Diagnosing Acute Mesenteric Ischemia in the Emergency Ward. World J Surg 2017; 41:1966-1974. [DOI: 10.1007/s00268-017-3984-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ruggiero A, Screaton NJ. Imaging of acute and chronic thromboembolic disease: state of the art. Clin Radiol 2017; 72:375-388. [PMID: 28330686 DOI: 10.1016/j.crad.2017.02.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/23/2017] [Accepted: 02/07/2017] [Indexed: 01/31/2023]
Abstract
Acute pulmonary embolism (PE) is a life-threatening condition that requires prompt diagnosis and treatment. Recent advances in imaging allow acute and rapid recognition even by the non-specialist radiologist. Most acute emboli resolve on anticoagulation without sequelae; however, some emboli fail to fully resolve becoming endothelialised with the development of chronic thromboembolic disease (CTED). Increased pulmonary vascular resistance arising from CTED may lead to chronic thromboembolic pulmonary hypertension (CTEPH) a debilitating disease affecting up to 5% of survivors of acute PE. Diagnostic evaluation is more complex in CTEPH/CTED than acute PE with subtle imaging features often being overlooked or misinterpreted. Differentiation of acute from chronic PE and from other forms of pulmonary hypertension has profound therapeutic implications. Diverse imaging techniques are available to diagnose and monitor PEs both in the acute and chronic setting. Broadly they include techniques that provide data on lung parenchymal perfusion (ventilation-perfusion [VQ] scintigraphy), angiographic techniques (computed tomography [CT], magnetic resonance imaging [MRI], and invasive angiography) or a combination of both (MR angiography and time-resolved angiography or dual-energy CT angiography). This review aims to describe state of the art imaging highlighting the strength and weaknesses of individual techniques in the diagnosis of acute and chronic PE.
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Affiliation(s)
- A Ruggiero
- Department of Radiology, Papworth Hospital, Cambridge, UK
| | - N J Screaton
- Department of Radiology, Papworth Hospital, Cambridge, UK.
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Karamat A, Awan S, Hussain MG, Al Hameed F, Butt F, Wahla AS. Usefulness of Clinical Prediction Rules, D-dimer, and Arterial Blood Gas Analysis to Predict Pulmonary Embolism in Cancer Patients. Oman Med J 2017; 32:148-153. [PMID: 28439386 DOI: 10.5001/omj.2017.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Pulmonary embolism (PE) is seven times more common in cancer patients than non-cancer patients. Since the existing clinical prediction rules (CPRs) were validated predominantly in a non-cancer population, we decided to look at the utility of arterial blood gas (ABG) analysis and D-dimer in predicting PE in cancer patients. METHODS Electronic medical records were reviewed between December 2005 and November 2010. A total of 177 computed tomography pulmonary angiograms (CTPAs) were performed. We selected 104 individuals based on completeness of laboratory and clinical data. Patients were divided into two groups, CTPA positive (patients with PE) and CTPA negative (PE excluded). Wells score, Geneva score, and modified Geneva score were calculated for each patient. Primary outcomes of interest were the sensitivities, specificities, positive, and negative predictive values for all three CPRs. RESULTS Of the total of 104 individuals who had CTPAs, 33 (31.7%) were positive for PE and 71 (68.3%) were negative. There was no difference in basic demographics between the two groups. Laboratory parameters were compared and partial pressure of oxygen was significantly lower in patients with PE (68.1 mmHg vs. 71 mmHg, p = 0.030). Clinical prediction rules showed good sensitivities (88-100%) and negative predictive values (93-100%). An alveolar-arterial (A-a) gradient > 20 had 100% sensitivity and negative predictive values. CONCLUSIONS CPRs and a low A-a gradient were useful in excluding PE in cancer patients. There is a need for prospective trials to validate these results.
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Affiliation(s)
- Asifa Karamat
- Department of Internal medicine, Sahukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Shazia Awan
- Department of Internal medicine, Sahukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Muhammad Ghazanfar Hussain
- Department of Internal medicine, Sahukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Fahad Al Hameed
- Department of Intensive Care, King Abdul Aziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Faheem Butt
- Department of Internal medicine, Sahukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Ali Saeed Wahla
- Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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Role of Clinical Decision Tools in the Diagnosis of Pulmonary Embolism. AJR Am J Roentgenol 2017; 208:W60-W70. [DOI: 10.2214/ajr.16.17206] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Colomina M, Koo M, Basora M, Pizones J, Mora L, Bagó J. Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial † †This Article is accompanied by Editorial Aew470. Br J Anaesth 2017; 118:380-390. [DOI: 10.1093/bja/aew434] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
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Nazerian P, Volpicelli G, Gigli C, Becattini C, Sferrazza Papa GF, Grifoni S, Vanni S. Diagnostic Performance of Wells Score Combined With Point-of-care Lung and Venous Ultrasound in Suspected Pulmonary Embolism. Acad Emerg Med 2017; 24:270-280. [PMID: 27859891 DOI: 10.1111/acem.13130] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 10/20/2016] [Accepted: 11/02/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Lung and venous ultrasound are bedside diagnostic tools increasingly used in the early diagnostic approach of suspected pulmonary embolism (PE). However, the possibility of improving the conventional prediction rule for PE by integrating ultrasound has never been investigated. METHODS We performed lung and venous ultrasound in consecutive patients suspected of PE in four emergency departments. Conventional Wells score (Ws) was adjudicated by the attending physician, and ultrasound was performed by one of 20 investigators. Signs of deep venous thrombosis (DVT) at venous ultrasound and signs of pulmonary infarcts or alternative diagnoses at lung ultrasound were considered to recalculate two items of the Ws: signs and symptoms of DVT and alternative diagnosis less likely than PE. The diagnostic performances of the ultrasound-enhanced Ws (USWs) and Ws were then compared after confirmation of the final diagnosis. RESULTS A total of 446 patients were studied. PE was confirmed in 125 patients (28%). USWs performed significantly better than Ws, with a sensitivity of 69.6% versus 57.6% and a specificity of 88.2% versus 68.2%. In combination with D-dimer, USWs showed an optimal failure rate (0.8%) and a significantly superior efficiency than Ws (32.3% vs. 27.2%). A strategy based on lung and venous ultrasound combined with D-dimer would allow to avoid CT pulmonary angiography in 50.5% of patients with suspected PE, compared to 27.2% when the rule without ultrasound is applied. CONCLUSIONS A pretest risk stratification enhanced by ultrasound of lung and venous performs better than Ws in the early diagnostic process of PE.
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Affiliation(s)
- Peiman Nazerian
- Department of Emergency Medicine Careggi University Hospital Firenze
| | - Giovanni Volpicelli
- Department of Emergency Medicine San Luigi Gonzaga University Hospital Torino
| | - Chiara Gigli
- Department of Emergency Medicine Careggi University Hospital Firenze
| | - Cecilia Becattini
- Department of Internal Medicine University Hospital of Perugia Perugia
| | - Giuseppe Francesco Sferrazza Papa
- Respiratory Unit Dipartimento Scienze della Salute San Paolo Hospital Università degli Studi di Milano Milano
- Casa di Cura del Policlinico Dipartimento di Scienze Neuroriabilitative Milano Italy
| | - Stefano Grifoni
- Department of Emergency Medicine Careggi University Hospital Firenze
| | - Simone Vanni
- Department of Emergency Medicine Careggi University Hospital Firenze
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Abstract
D-dimer has become one of the commonly requested coagulation tests, especially in the venous thromboembolism rule out setting. Appropriate D-dimer testing has significantly decreased the number of radiological investigations in this clinical scenario. D-dimer testing also plays an important role in the diagnostic process of the systemic coagulation disorders, especially disseminated intravascular coagulation in conjunction with other coagulation tests. However, widespread D-dimer testing without good understanding of the technical issues related to the test has recently caused some concerns. This review aims to address the basic physiology of D-dimer formation, the different methods available for its routine assessment, the current problems that both clinicians and laboratory scientists face with this test, and the important need for harmonization of commercial immunoassays.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Oxford Road, M13 9WL, Manchester, UK.
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Emmanuel J Favaloro
- Haematology Department, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, NSW Health Pathology, Westmead, NSW, 2145, Australia
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Doğan H, de Roos A, Geleijins J, Huisman MV, Kroft LJM. The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism. Diagn Interv Radiol 2016; 21:307-16. [PMID: 26133321 DOI: 10.5152/dir.2015.14403] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pulmonary embolism (PE) is a potentially life threatening condition requiring adequate diagnosis and treatment. Computed tomography pulmonary angiography (CTPA) is excellent for including and excluding PE, therefore CT is the first-choice diagnostic imaging technique in patients suspected of having acute PE. Due to its wide availability and low invasiveness, CTPA tends to be overused. Correct implementation of clinical decision rules in diagnostic workup for PE improves adequate use of CT. Also, CT adds prognostic value by evaluating right ventricular (RV) function. CT-assessed RV dysfunction and to lesser extent central emboli location predicts PE-related mortality in normotensive and hypotensive patients, while PE embolic obstruction index has limited prognostic value. Simple RV/left ventricular (LV) diameter ratio measures >1.0 already predict risk for adverse outcome, whereas ratios <1.0 can safely exclude adverse outcome. Consequently, assessing the RV/LV diameter ratio may help identify patients who are potential candidates for treatment at home instead of treatment in the hospital. A minority of patients develop chronic thromboembolic pulmonary hypertension (CTEPH) following acute PE, which is a life-threatening condition that can be diagnosed by CT. In proximal CTEPH, involving the more central pulmonary arteries, thrombectomy usually results in good outcome in terms of both functional status and long-term survival rate. CT is becoming the imaging method of choice for diagnosing CTEPH as it can identify patients who may benefit from thrombectomy. New CT developments such as distensibility measurements and dual-energy or subtraction techniques may further refine diagnosis and prognosis for improved patient care.
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Affiliation(s)
- Halil Doğan
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
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Abstract
Pulmonary embolism covers a wide spectrum of presentation from an asymptomatic individual to a life-threatening medical emergency. It is of paramount importance to appropriately risk stratify patients with pulmonary embolism, particularly with those who present without hypotension. Right ventricular dysfunction can evolve after a patient has received a diagnosis of pulmonary embolism, necessitating aggressive measures rather than simple anticoagulation. In this review, we discuss definition, risk stratification, pathogenesis, diagnostic approach, and management, with particular focus on massive pulmonary embolism.
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Giannitsis E, Mair J, Christersson C, Siegbahn A, Huber K, Jaffe AS, Peacock WF, Plebani M, Thygesen K, Möckel M, Mueller C, Lindahl B. How to use D-dimer in acute cardiovascular care. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:69-80. [PMID: 26450781 DOI: 10.1177/2048872615610870] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
D-dimer testing is important to aid in the exclusion of venous thromboembolic events (VTEs), including deep venous thrombosis and pulmonary embolism, and it may be used to evaluate suspected aortic dissection. D-dimer is produced upon activation of the coagulation system with the generation and subsequent degradation of cross-linked fibrin by plasmin. Many different assays for D-dimer testing are currently used in routine care. However, these tests are neither standardized nor harmonized. Consequently, only clinically validated assays and assay specific decision limits should be used for routine testing. For the exclusion of pulmonary embolism/deep vein thrombosis, age-adjusted cut-offs are recommend. Clinicians must be aware of the validated use of their hospital's D-dimer assay to avoid inappropriate use of this biomarker in routine care.
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Affiliation(s)
| | - Johannes Mair
- 2 Department of Internal Medicine III, Medical University Innsbruck, Austria
| | | | | | - Kurt Huber
- 5 Department of Medicine, Wilhelminen Hospital, Austria
| | | | | | - Mario Plebani
- 8 Department of Laboratory Medicine, University Hospital, Italy
| | | | - Martin Möckel
- 10 Division of Emergency Medicine, Charité-Universitätsmedizin Berlin, Germany
| | | | - Bertil Lindahl
- 12 Department of Medical Sciences, Uppsala University, Sweden
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John G, Platon A, Poletti PA, Perrier A, Bendjelid K. Contrast Circulation Time to Assess Right Ventricular Dysfunction in Pulmonary Embolism: A Retrospective Pilot Study. PLoS One 2016; 11:e0159674. [PMID: 27551831 PMCID: PMC4994948 DOI: 10.1371/journal.pone.0159674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/06/2016] [Indexed: 11/18/2022] Open
Abstract
Objective To optimize enhancement of pulmonary arteries and facilitate diagnosis of pulmonary embolism (PE), modern computed tomography angiography (CTA) contains a contrast bolus tracking system. We explored the diagnostic accuracy of the time-intensity curves given by this automated system to identify right ventricular dysfunction (RVD) in acute PE. Methods 114 CTAs with a diagnosis of PE were reviewed. RVD was defined as right-to-left ventricular diameter ratio of 1 or greater. Four parameters on time-intensity curves were identified. Parameters between CTAs with and those without RVD were compared with the Wilcoxon rank-sum test. The ability of the four parameters to discriminate patients with RVD was explored by compiling the area under the operating curves (AUC). Results The time needed by the contrast media to reach the pulmonary artery [8 seconds (IQR: 7–9) versus 7 seconds (IQR: 6–8), p<0.01], the time needed to reach 40 Hounsfield units (HU) [11 seconds (IQR: 8.5–14) versus 9.5 seconds (IQR: 8–10.5), p<0.01], and the contrast intensity reached after 10 seconds [19 HU (IQR: 4–67) versus 53 HU (IQR: 32–80), p<0.05] were all statistically different between CTA with and CTA without RVD. Those three parameters changed gradually across severity categories of RVD (p<0.05 for trend). Their AUC to identify RVD ranged from 0.63 to 0.66. The slope of contrast intensity over time was not informative: [31 HU/s (IQR: 20–57) in CTA with, compared to 36 HU/s (IQR: 22.5–53) in CTA without RVD, p = 0.60]. Conclusion Several parameters of the time-intensity curve obtained by the bolus tracking system are associated with RVD assessed on CTA images. Of those, the time needed to reach a predefined threshold seems to be the easiest to obtain in any CTA without additional processing time or contrast injection. However, the performance of those parameters is globally low.
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Affiliation(s)
- Gregor John
- Department of Internal medicine, Hôpital neuchâtelois, Chasseral 20, 2300 La Chaux-de-Fonds, Switzerland
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals (HUG), Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
- * E-mail:
| | - Alexandra Platon
- Department of radiology, Emergency-room radiology unit, Geneva University Hospitals (HUG), Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Pierre-Alexandre Poletti
- Department of radiology, Emergency-room radiology unit, Geneva University Hospitals (HUG), Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Arnaud Perrier
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals (HUG), Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
- Geneva Faculty of Medicine, Michel-Servet 1, 1206 Geneva, Switzerland
| | - Karim Bendjelid
- Intensive Care Service, Geneva University Hospitals, and Geneva Faculty of Medicine, Gabrielle Perret-Gentil 4, 1211 Geneva, Switzerland
- Geneva Hemodynamic Research Group, Geneva Faculty of Medicine, Michel-Servet 1, 1206 Geneva, Switzerland
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Mandatory Assignment of Modified Wells Score Before CT Angiography for Pulmonary Embolism Fails to Improve Utilization or Percentage of Positive Cases. AJR Am J Roentgenol 2016; 207:442-9. [DOI: 10.2214/ajr.15.15394] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Morreau M, Lyon A. How common standards can diminish collective intelligence: a computational study. J Eval Clin Pract 2016; 22:483-9. [PMID: 27338114 DOI: 10.1111/jep.12585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 05/15/2016] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
Abstract
Making good decisions depends on having accurate information - quickly, and in a form in which it can be readily communicated and acted upon. Two features of medical practice can help: deliberation in groups and the use of scores and grades in evaluation. We study the contributions of these features using a multi-agent computer simulation of groups of physicians. One might expect individual differences in members' grading standards to reduce the capacity of the group to discover the facts on which well-informed decisions depend. Observations of the simulated groups suggest on the contrary that this kind of diversity can in fact be conducive to epistemic performance. Sometimes, it is adopting common standards that may be expected to result in poor decisions.
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Affiliation(s)
| | - Aidan Lyon
- University of Maryland, College Park, MD, United States
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Theunissen J, Scholing C, van Hasselt WE, van der Maten J, Ter Avest E. A retrospective analysis of the combined use of PERC rule and Wells score to exclude pulmonary embolism in the Emergency Department. Emerg Med J 2016; 33:696-701. [PMID: 27287004 DOI: 10.1136/emermed-2016-205687] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/16/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND The pulmonary embolism rule-out criteria (PERC) rule is an eight-factor decision rule to support the decision not to order a diagnostic test when the gestalt-based clinical suspicion on pulmonary embolism (PE) is low. METHODS In a retrospective cohort study, we determined the accuracy of a negative PERC (0) in patients with a low Wells score (<2) to rule-out PE, and compared this to the accuracy of the default algorithm used in our hospital (a low Wells score in combination with a negative D-dimer). RESULTS During the study period, 377 patients with a Wells score <2 were included. CT pulmonary angiography (CTPA) was performed in 86 patients, and V/Q scintigraphy in one patient. PE was diagnosed in 18 patients. 78 patients (21%) had a negative PERC score. When further diagnostic studies would have been omitted in these patients, two (subsegmental) PEs would have been missed, resulting in a sensitivity of 89% (64%-98%) and a negative likelihood ratio (LR-) of 0.52 (0.14-1.97). The default algorithm missed one (subsegmental) PE, resulting in a sensitivity of 95% (71%-99%) and an LR- of 0.25 (0.04-1.73). CONCLUSIONS The combination of a Wells score <2 and a PERC rule of 0 had a suboptimal sensitivity for excluding PE in our sample of patients presenting in the ED. Further studies are warranted to test this algorithm in larger populations.
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Affiliation(s)
- Jmg Theunissen
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - C Scholing
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - W E van Hasselt
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - J van der Maten
- Department of Pulmonology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - E Ter Avest
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Hendriksen JMT, Lucassen WAM, Erkens PMG, Stoffers HEJH, van Weert HCPM, Büller HR, Hoes AW, Moons KGM, Geersing GJ. Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule. Ann Fam Med 2016; 14:227-34. [PMID: 27184993 PMCID: PMC4868561 DOI: 10.1370/afm.1930] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 01/20/2016] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Diagnostic prediction models such as the Wells rule can be used for safely ruling out pulmonary embolism (PE) when it is suspected. A physician's own probability estimate ("gestalt"), however, is commonly used instead. We evaluated the diagnostic performance of both approaches in primary care. METHODS Family physicians estimated the probability of PE on a scale of 0% to 100% (gestalt) and calculated the Wells rule score in 598 patients with suspected PE who were thereafter referred to secondary care for definitive testing. We compared the discriminative ability (c statistic) of both approaches. Next, we stratified patients into PE risk categories. For gestalt, a probability of less than 20% plus a negative point-of-care d-dimer test indicated low risk; for the Wells rule, we used a score of 4 or lower plus a negative d-dimer test. We compared sensitivity, specificity, efficiency (percentage of low-risk patients in total cohort), and failure rate (percentage of patients having PE within the low-risk category). RESULTS With 3 months of follow-up, 73 patients (12%) were confirmed to have venous thromboembolism (a surrogate for PE at baseline). The c statistic was 0.77 (95% CI, 0.70-0.83) for gestalt and 0.80 (95% CI, 0.75-0.86) for the Wells rule. Gestalt missed 2 out of 152 low-risk patients (failure rate = 1.3%; 95% CI, 0.2%-4.7%) with an efficiency of 25% (95% CI, 22%-29%); the Wells rule missed 4 out of 272 low-risk patients (failure rate = 1.5%; 95% CI, 0.4%-3.7%) with an efficiency of 45% (95% CI, 41%-50%). CONCLUSIONS Combined with d-dimer testing, both gestalt using a cutoff of less than 20% and the Wells rule using a score of 4 or lower are safe for ruling out PE in primary care. The Wells rule is more efficient, however, and PE can be ruled out in a larger proportion of suspected cases.
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Affiliation(s)
- Janneke M T Hendriksen
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Wim A M Lucassen
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
| | - Petra M G Erkens
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Henri E J H Stoffers
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Henk C P M van Weert
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Arno W Hoes
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Karel G M Moons
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
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2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol 2016; 13:e1-e29. [PMID: 26810814 DOI: 10.1016/j.jacr.2015.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 01/02/2023]
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Rybicki FJ, Udelson JE, Peacock WF, Goldhaber SZ, Isselbacher EM, Kazerooni E, Kontos MC, Litt H, Woodard PK. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016; 67:853-79. [PMID: 26809772 DOI: 10.1016/j.jacc.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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83
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Madsen PH, Hess S. Symptomatology, Clinical Presentation and Basic Work up in Patients with Suspected Pulmonary Embolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:33-48. [DOI: 10.1007/5584_2016_104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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Bruno RR, Donner-Banzhoff N, Söllner W, Frieling T, Müller C, Christ M. The Interdisciplinary Management of Acute Chest Pain. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:768-79; quiz 780. [PMID: 26585188 PMCID: PMC4660855 DOI: 10.3238/arztebl.2015.0768] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/10/2015] [Accepted: 09/10/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute chest pain of non-traumatic origin is a common reason for presentation to physician's offices and emergency rooms. Coronary heart disease is the cause in up to 25% of cases. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goal-oriented management is mandatory. METHODS This review is based on pertinent articles and guidelines retrieved by a selective search in PubMed. RESULTS History-taking, physical examination, and a 12-lead electrocardiogram (ECG) are the first steps in the differential diagnostic process and generally allow the identification of features signifying a high risk of lifethreatening illness. If the ECG reveals ST-segment elevation, cardiac catheterization is indicated. The timedependent measurement of highly sensitive troponin values is a reliable test for the diagnosis or exclusion of acute myocardial infarction. A wide variety of other potential causes (e.g., vascular, musculoskeletal, gastroenterologic, or psychosomatic) must be identified from the history if they are to be treated appropriately. Elderly patients need special attention. CONCLUSION Acute chest pain is a major diagnostic challenge for the physician. Common errors are traceable to non-recognition of important causes and to an inadequate diagnostic work-up. Future studies should be designed to help optimize the interdisciplinary management of patients with chest pain.
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Affiliation(s)
- Raphael R Bruno
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuernberg
| | | | - Wolfgang Söllner
- Department of Psychosomatics and Psychotherapeutic Medicine, Paracelsus Medical University, Nuernberg
| | - Thomas Frieling
- Department of Gastroenterology, Hepatology, Neurogastroenterology, Infectiology, Hematology and Oncology, HELIOS Hospital Krefeld
| | - Christian Müller
- Department of Cardiology, University Hospital Basel, Switzerland
| | - Michael Christ
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuernberg
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Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 163:701-11. [PMID: 26414967 DOI: 10.7326/m14-1772] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
DESCRIPTION Pulmonary embolism (PE) can be a severe disease and is difficult to diagnose, given its nonspecific signs and symptoms. Because of this, testing patients with suspected acute PE has increased dramatically. However, the overuse of some tests, particularly computed tomography (CT) and plasma d-dimer measurement, may not improve care while potentially leading to patient harm and unnecessary expense. METHODS The literature search encompassed studies indexed by MEDLINE (1966-2014; English-language only) and included all clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for the diagnosis of PE. This document is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available evidence and recent guidelines. The target audience for this paper is all clinicians; the target patient population is all adults, both inpatient and outpatient, suspected of having acute PE. BEST PRACTICE ADVICE 1 Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered. BEST PRACTICE ADVICE 2 Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria. BEST PRACTICE ADVICE 3 Clinicians should obtain a high-sensitivity d-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all Pulmonary Embolism Rule-Out Criteria. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE. BEST PRACTICE ADVICE 4 Clinicians should use age-adjusted d-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted. BEST PRACTICE ADVICE 5 Clinicians should not obtain any imaging studies in patients with a d-dimer level below the age-adjusted cutoff. BEST PRACTICE ADVICE 6 Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation-perfusion scans for patients who have a contraindication to CTPA or if CTPA is not available. Clinicians should not obtain a d-dimer measurement in patients with a high pretest probability of PE.
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Affiliation(s)
- Ali S. Raja
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Jeffrey O. Greenberg
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Amir Qaseem
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Thomas D. Denberg
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Nick Fitterman
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Jeremiah D. Schuur
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
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Hale G, Brenner M. Risks and benefits of low molecular-weight heparin and target-specific oral anticoagulant use for thromboprophylaxis in medically ill patients. Am J Cardiovasc Drugs 2015; 15:311-22. [PMID: 25957095 DOI: 10.1007/s40256-015-0122-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Venous thromboembolism is the third most common cardiovascular disease and a major cause of inpatient mortality as over 50 % of deep vein thrombosis and pulmonary embolism are undetected in medically treated patients. Several agents are approved for thromboprophylaxis, including warfarin, unfractionated heparin, low molecular-weight heparins, fondaparinux, and target-specific oral anticoagulants. The purpose of this literature review is to discuss the increased risk of venous thromboembolism in medically ill patients and the literature surrounding the efficacy and tolerability of low molecular-weight heparins and target-specific oral anticoagulants for this indication. PubMed, MEDLINE, EBSCOhost, and clinicaltrials.gov were used as search engines in the literature review. Search limits included articles containing human subjects, scholarly (peer-reviewed) journals written in English, and publication dates from 2004 to 2014. Animal studies, non-English articles, and publications dated prior to 2004 were excluded. Recurrent venous thromboembolism remains an ongoing problem affecting thousands of people in the non-surgical population annually. With limited data, it is not likely that target-specific oral anticoagulants will soon replace low molecular-weight heparins or even be considered an alternative until efficacy and tolerability have been established. Until further evidence is disclosed, low molecular-weight heparins and fondaparinux (in the absence of renal dysfunction and low body weight) should continue to be utilized as first-line agents for thromboprophylaxis in medically ill patients. The use of apixaban and rivaroxaban is discouraged for thromboprophylaxis in medically ill patients.
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Guo DJ, Zhao C, Zou YD, Huang XH, Hu JM, Guo L. Values of the Wells and revised Geneva scores combined with D-dimer in diagnosing elderly pulmonary embolism patients. Chin Med J (Engl) 2015; 128:1052-7. [PMID: 25881599 PMCID: PMC4832945 DOI: 10.4103/0366-6999.155085] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) can be difficult to diagnose in elderly patients because of the coexistent diseases and the combination of drugs that they have taken. We aimed to compare the clinical diagnostic values of the Wells score, the revised Geneva score and each of them combined with D-dimer for suspected PE in elderly patients. METHODS Three hundred and thirty-six patients who were admitted for suspected PE were enrolled retrospectively and divided into two groups based on age (≥65 or <65 years old). The Wells and revised Geneva scores were applied to evaluate the clinical probability of PE, and the positive predictive values of both scores were calculated using computed tomography pulmonary arteriography as a gold standard; overall accuracy was evaluated by the area under the curve (AUC) of receiver operator characteristic curve; the negative predictive values of D-dimer, the Wells score combined with D-dimer, and the revised Geneva score combined with D-dimer were calculated. RESULTS Ninety-six cases (28.6%) were definitely diagnosed as PE among 336 cases, among them 56 cases (58.3%) were ≥65 years old. The positive predictive values of Wells and revised Geneva scores were 65.8% and 32.4%, respectively (P < 0.05) in the elderly patients; the AUC for the Wells score and the revised Geneva score in elderly was 0.682 (95% confidence interval [CI]: 0.612-0.746) and 0.655 (95% CI: 0.584-0.722), respectively (P = 0.389). The negative predictive values of D-dimer, the Wells score combined with D-dimer, and the revised Geneva score combined with D-dimer were 93.7%, 100%, and 100% in the elderly, respectively. CONCLUSIONS The diagnostic value of the Wells score was higher than the revised Geneva score for the elderly cases with suspected PE. The combination of either the Wells score or the revised Geneva score with a normal D-dimer concentration is a safe strategy to rule out PE.
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Affiliation(s)
- Dan-Jie Guo
- Department of Cardiology, Peking University People's Hospital, Beijing 100044, China
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Hendriksen JMT, Geersing GJ, Lucassen WAM, Erkens PMG, Stoffers HEJH, van Weert HCPM, Büller HR, Hoes AW, Moons KGM. Diagnostic prediction models for suspected pulmonary embolism: systematic review and independent external validation in primary care. BMJ 2015; 351:h4438. [PMID: 26349907 PMCID: PMC4561760 DOI: 10.1136/bmj.h4438] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To validate all diagnostic prediction models for ruling out pulmonary embolism that are easily applicable in primary care. DESIGN Systematic review followed by independent external validation study to assess transportability of retrieved models to primary care medicine. SETTING 300 general practices in the Netherlands. PARTICIPANTS Individual patient dataset of 598 patients with suspected acute pulmonary embolism in primary care. MAIN OUTCOME MEASURES Discriminative ability of all models retrieved by systematic literature search, assessed by calculation and comparison of C statistics. After stratification into groups with high and low probability of pulmonary embolism according to pre-specified model cut-offs combined with qualitative D-dimer test, sensitivity, specificity, efficiency (overall proportion of patients with low probability of pulmonary embolism), and failure rate (proportion of pulmonary embolism cases in group of patients with low probability) were calculated for all models. RESULTS Ten published prediction models for the diagnosis of pulmonary embolism were found. Five of these models could be validated in the primary care dataset: the original Wells, modified Wells, simplified Wells, revised Geneva, and simplified revised Geneva models. Discriminative ability was comparable for all models (range of C statistic 0.75-0.80). Sensitivity ranged from 88% (simplified revised Geneva) to 96% (simplified Wells) and specificity from 48% (revised Geneva) to 53% (simplified revised Geneva). Efficiency of all models was between 43% and 48%. Differences were observed between failure rates, especially between the simplified Wells and the simplified revised Geneva models (failure rates 1.2% (95% confidence interval 0.2% to 3.3%) and 3.1% (1.4% to 5.9%), respectively; absolute difference -1.98% (-3.33% to -0.74%)). Irrespective of the diagnostic prediction model used, three patients were incorrectly classified as having low probability of pulmonary embolism; pulmonary embolism was diagnosed only after referral to secondary care. CONCLUSIONS Five diagnostic pulmonary embolism prediction models that are easily applicable in primary care were validated in this setting. Whereas efficiency was comparable for all rules, the Wells rules gave the best performance in terms of lower failure rates.
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Affiliation(s)
- Janneke M T Hendriksen
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
| | - Geert-Jan Geersing
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
| | - Wim A M Lucassen
- Department of General Practice, Academic Medical Center, Amsterdam, Netherlands
| | - Petra M G Erkens
- Department of Family Medicine, CAHPRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Henri E J H Stoffers
- Department of Family Medicine, CAHPRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | | | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Arno W Hoes
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
| | - Karel G M Moons
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
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Ingber S, Selby R, Lee J, Geerts W, Brnjac E. Combination pretest probability assessment and D-dimer did not reduce outpatient imaging for venous thromboembolism in a tertiary care hospital emergency department. CAN J EMERG MED 2015; 16:53-62. [PMID: 24424001 DOI: 10.2310/8000.2013.130986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is difficult to diagnose yet potentially life threatening. A low-risk pretest probability (PTP) assessment combined with a negative D-dimer can rule out VTE in two-thirds of outpatients, reducing the need for imaging. Real-life implementation of this strategy is associated with several challenges. METHODS We evaluated the impact of introducing a standardized diagnostic algorithm including a mandatory PTP assessment and D-dimer on radiologic test use for VTE in our emergency department (ED). A retrospective review of all ED visits for suspected VTE in the year prior to and following the introduction of this algorithm was conducted. VTE diagnosis was based on imaging. Guideline compliance was also assessed. RESULTS ED visits were investigated for suspected VTE in the pre- and postintervention periods (n = 1,785). Most D-dimers (95%) ordered were associated with a PTP assessment, and 50% of visits assigned a low PTP had a negative D-dimer. The proportion of imaging tests ordered for VTE in all ED visits was unchanged postintervention (1.9% v. 2.0%). The proportion of patients with suspected VTE in whom VTE was confirmed on imaging decreased postintervention (10.2% v. 14.1%). CONCLUSION In spite of excellent compliance with our algorithm, we were unable to reduce imaging for VTE. This may be due to a lower threshold for suspecting VTE and an increase in investigation for VTE combined with a high false positive rate of our D-dimer assay in low-pretest probability patients. This study highlights two common real-life challenges with adopting this strategy for VTE investigation.
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Abstract
Pulmonary embolism (PE) is a common diagnosis in critical care. Depending on the severity of clot burden, the clinical picture ranges from nearly asymptomatic to cardiovascular collapse. The signs and symptoms of PE are nonspecific. The clinician must have a high index of suspicion to make the diagnosis. PE is risk stratified into 3 categories: low-risk, submassive, and massive. Submassive PE remains the most challenging with regard to initial and long-term management. Little consensus exists as to the appropriate tests for risk stratification and therapy. This article reviews the current literature and a suggested approach to these patients.
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Affiliation(s)
- Laurence W Busse
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Jason S Vourlekis
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
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Bauld RA, Patterson C, Naylor J, Rooms M, Bell D. Deep vein thrombosis and pulmonary embolism in the military patient. J ROY ARMY MED CORPS 2015; 161:288-95. [PMID: 26246348 DOI: 10.1136/jramc-2015-000502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, is a common, potentially lethal condition and a cause of long-term morbidity and functional limitation. This paper is a clinical review focused on military epidemiology, evidence-based recommendations for prevention, diagnosis and management of VTE and occupational considerations in a military population. METHODS A literature review was conducted through Pubmed and Embase for systematic reviews, meta-analyses and clinical trials relating to VTE. Guidelines from the National Institute for Health and Care Excellence, British Thoracic Society and the American College of Chest Physicians were reviewed and recommendations considered. RESULTS Acute morbidity from VTE can range from limb pain and swelling to life-threatening cardiovascular compromise. Long-term sequelae include postthrombotic syndrome, chronic thrombosis and pulmonary hypertension. Diagnosis should follow a validated pathway depending on the patient's prerest probability. The management of the condition should vary with attention to risk stratification. DISCUSSION Prompt initiation of anticoagulation reduces symptoms, rates of recurrent VTE and death but treatment must be balanced against the risk of major haemorrhage. Military operations expose personnel to a unique combination of risk factors for VTE and operating in austere environments can increase the challenge of diagnosis, prognostication and management. Furthermore, there are implications for troop attrition, operational readiness and return to work.
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Affiliation(s)
- Richard A Bauld
- Emergency Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - J Naylor
- Peterborough and Stamford Hospitals Trust, Peterborough, UK
| | - M Rooms
- 9 Regt Army Air Corps, Thirsk, UK
| | - D Bell
- Imperial College London, London, UK
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Ambulatory vital signs in the workup of pulmonary embolism using a standardized 3-minute walk test. CAN J EMERG MED 2015; 17:270-8. [PMID: 26034913 DOI: 10.1017/cem.2014.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonary embolism. METHODS This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessed ambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism. RESULTS We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) for pulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0). CONCLUSION In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules.
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Piovella F, Iosub DI. Acute pulmonary embolism: risk assessment, risk stratification and treatment options. CLINICAL RESPIRATORY JOURNAL 2015; 10:545-54. [PMID: 25619266 DOI: 10.1111/crj.12264] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 12/19/2014] [Accepted: 01/20/2015] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a potentially life-threatening cardiovascular emergency with a high mortality rate. Rapid diagnosis and treatment are important in optimising clinical outcomes in patients with PE, and anticoagulants are the mainstay of treatment. Traditionally, anticoagulant therapy involves parenteral anticoagulants, overlapping with and followed by oral vitamin K antagonists. Direct oral anticoagulants (DOACs), including the factor Xa inhibitors rivaroxaban, apixaban and edoxaban, and the direct thrombin inhibitor dabigatran etexilate, have been developed to address limitations associated with traditional anticoagulant therapy. Apixaban, dabigatran and rivaroxaban have recently been approved for the treatment of acute deep vein thrombosis (DVT) and PE and prevention of recurrent DVT or PE. Edoxaban is approved in the United States but not currently in the European Union for the treatment of DVT and PE; approval of edoxaban in Europe is anticipated in the near future. OBJECTIVE To summarise the management of patients with suspected PE in accordance with recent guidelines, and to discuss the evidence behind the recent approvals of the DOACs for the treatment of PE. DISCUSSION Diagnosis and treatment of PE is guided by clinical probability scoring systems and tools for prognostic stratification and early mortality risk evaluation. Anticoagulants remain the mainstay of treatment. Successful phase III trials have demonstrated the efficacy of the DOACs for the treatment of DVT and PE, with a potentially improved safety profile, leading to their recent approval in this indication, and giving the clinician greater choice of anticoagulant therapies in this setting. CONCLUSIONS DOACs offer an alternative and potentially simplified option for anticoagulation therapy in patients with PE compared with traditional anticoagulants and are likely to assist physicians in optimising management of patients with PE and improve clinical outcomes.
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Affiliation(s)
- Franco Piovella
- Area di Ricerca in Emostasi e Trombosi, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale 'Casimiro Mondino', Pavia, Italy.
| | - Diana Irina Iosub
- Dipartimento Cardiotoracovascolare, Fondazione I.R.C.C.S. Policlinico 'San Matteo', Pavia, Italy
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Evaluation of serum endothelial cell specific molecule-1 (endocan) levels as a biomarker in patients with pulmonary thromboembolism. Blood Coagul Fibrinolysis 2015; 25:272-6. [PMID: 24509328 DOI: 10.1097/mbc.0000000000000071] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this study was to investigate the relationship between pulmonary thromboembolism (PTE) and serum endocan levels. The study included 46 patients with a diagnosis of PTE and control group (25 healthy individuals). Serum endocan levels in all participants' blood samples were measured. The average age of the individuals was 61.76 ± 16.39 years. There was a significant difference in the serum endocan levels between the patients and those of the control group [321.93 ng/l (111.35-2511.33) and 192.77 ng/l (118.30-309.02), respectively; P < 0.030]. The serum endocan levels in the submassive [469.41 ng/l (258.13-800.54)] and the massive PTE groups [719.18 ng/l (319.84-2511.33)] were statistically higher than those in the control group [192.77 ng/l (118.30-309.02)] (P < 0.001 and P < 0.001, respectively). In addition, there was a statistically significant difference between the serum endocan levels of the nonmassive PTE group [188.57 ng/l (111.35-685.56)] and the submassive PTE group (P < 0.01). The serum endocan levels correlated with the international normalization ratio (INR), right ventricular dilatation (RVD) and SBP (r = 0.418, P = 0.004; r = 0.659, P < 0.001; r = -0.425, P = 0.003, respectively). In conclusion, serum endocan levels can be considered a practicable biomarker to determine the severity of PTEs and follow-up thrombolytic therapy.
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95
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Yetgin GO, Aydin SA, Koksal O, Ozdemir F, Mert DK, Torun G. Clinical probability and risk analysis of patients with suspected pulmonary embolism. World J Emerg Med 2014; 5:264-9. [PMID: 25548599 DOI: 10.5847/wjem.j.issn.1920-8642.2014.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 09/06/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is one of the most frequent diseases that could be missed in overcrowded emergency departments as in Turkey. Early and accurate diagnosis could decrease the mortality rate and this standard algorithm should be defined. This study is to find the accurate, fast, non-invasive, cost-effective, easy-to-access diagnostic tests, clinical scoring systems and the patients who should be tested for clinical diagnosis of PE in emergency department. METHODS One hundred and forty patients admitted to the emergency department with the final diagnosis of PE regarding to anamnesis, physical examination and risk factors, were included in this prospective, cross-sectional study. The patients with a diagnosis of pulmonary embolism, acute coronary syndrome or infection and chronic obstructive pulmonary disease (COPD) were excluded from the study. The demographics, risk factors, radiological findings, vital signs, symptoms, physical-laboratory findings, diagnostic tests and clinical scoring systems of patients (Wells and Geneva) were noted. The diagnostic criteria for pulmonary emboli were: filling defect in the pulmonary artery lumen on spiral computed tomographic angiography and perfusion defect on perfusion scintigraphy. RESULTS Totally, 90 (64%) of the patients had PE. Age, hypotension, having deep vein thrombosis were the risk factors, and oxygen saturation, shock index, BNP, troponin and fibrinogen levels as for the biochemical parameters were significantly different between the PE (+) and PE (-) groups (P<0.05). The Wells scoring system was more successful than the other scoring systems. CONCLUSION Biochemical parameters, clinical findings, and scoring systems, when used altogether, can contribute to the diagnosis of PE.
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Affiliation(s)
| | - Sule Akkose Aydin
- Emergency Department, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Ozlem Koksal
- Emergency Department, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Fatma Ozdemir
- Emergency Department, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Dilek Kostak Mert
- Emergency Department, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Gokhan Torun
- Emergency Department, Uludag University Faculty of Medicine, Bursa, Turkey
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96
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Nazerian P, Giachino F, Vanni S, Veglio MG, Castelli M, Lison D, Bitossi L, Moiraghi C, Grifoni S, Morello F. Diagnostic performance of the aortic dissection detection risk score in patients with suspected acute aortic dissection. EUROPEAN HEART JOURNAL: ACUTE CARDIOVASCULAR CARE 2014; 3:373-381. [DOI: 10.1177/2048872614527010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Peiman Nazerian
- Emergency Department, Careggi University Hospital, Firenze, Italy
| | | | - Simone Vanni
- Emergency Department, Careggi University Hospital, Firenze, Italy
| | - Maria G Veglio
- Emergency Department, Molinette University Hospital, Torino, Italy
| | - Matteo Castelli
- Emergency Department, Careggi University Hospital, Firenze, Italy
| | - Davide Lison
- Emergency Department, Molinette University Hospital, Torino, Italy
| | - Luca Bitossi
- Emergency Department, Careggi University Hospital, Firenze, Italy
| | - Corrado Moiraghi
- Emergency Department, Molinette University Hospital, Torino, Italy
| | - Stefano Grifoni
- Emergency Department, Careggi University Hospital, Firenze, Italy
| | - Fulvio Morello
- Emergency Department, Molinette University Hospital, Torino, Italy
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97
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Abstract
BACKGROUND Pulmonary embolism (PE) can be a life-threatening emergency. Accurate diagnostic techniques and patient-specific management strategies are necessary to ensure favorable clinical outcomes. METHODS Relevant guidelines, articles, reviews, and abstracts were identified using a narrative approach in PubMed/MEDLINE, Google Scholar, clinicaltrials.gov and nice.org.uk. English-language articles published in 2000-2014 were initially identified using the search terms: novel OAC, pulmonary embolism, venous thromboembolism, diagnosis, treatment, rivaroxaban, apixaban, dabigatran, and edoxaban. The initial literature search was supported by a 'snowballing' style literature search, and relevant articles were included based on a professional judgment of relevance. SCOPE We discuss the diagnosis of PE and the categorization of risk for subgroups, which may assist with making treatment decisions. We review current guidance on acute and long-term treatment, possible limitations of traditional anticoagulant therapy, and the development of direct oral anticoagulants, which may significantly alter the management of patients with PE. Finally, we discuss special considerations in high-risk and hard-to-treat subpopulations that may benefit from the improved benefit-risk profile offered by these newer agents. CONCLUSIONS The direct oral anticoagulants may overcome several of the limitations associated with traditional anticoagulant therapy, potentially improving the standard of care for PE patients, including high-risk and hard-to-manage subgroups.
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Affiliation(s)
- Robert J Walter
- Walter Reed National Military Medical Center , Bethesda, MD , USA
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98
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Palla A, Marconi L, Bigazzi F, Pistolesi M. Lung scintigraphy in the diagnosis of pulmonary embolism: pathophysiological and practical evidence. Clin Transl Imaging 2014. [DOI: 10.1007/s40336-014-0083-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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99
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Poleto FZ, Paulino CD, Singer JM, Molenberghs G. Semi-parametric Bayesian analysis of binary responses with a continuous covariate subject to non-random missingness. STAT MODEL 2014. [DOI: 10.1177/1471082x14549290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Missingness in explanatory variables requires a model for the covariates even if the interest lies only in a model for the outcomes given the covariates. An incorrect specification of the models for the covariates or for the missingness mechanism may lead to biased inferences for the parameters of interest. Previously published articles either use semi-/non-parametric flexible distributions for the covariates and identify the model via a missing at random assumption, or employ parametric distributions for the covariates and allow a more general non-random missingness mechanism. We consider the analysis of binary responses, combining a missing not at random mechanism with a non-parametric model based on a Dirichlet process mixture for the continuous covariates. We illustrate the proposal with simulations and the analysis of a dataset.
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Affiliation(s)
- Frederico Z Poleto
- Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Daniel Paulino
- Instituto Superior Técnico, Universidade de Lisboa (and CEAUL-FCUL), Av. Rovisco Pais, Lisboa, Portugal
| | - Julio M Singer
- Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Geert Molenberghs
- I-BioStat, Universiteit Hasselt, Diepenbeek, Belgium, and Katholieke Universiteit Leuven, Leuven, Belgium
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100
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Javadrashid R, Mozayan M, Tarzamni MK, Ghaffari MR, Fouladi DF. Spiral computed tomographic pulmonary angiography in patients with acute pulmonary emboli and no pre-existing comorbidity: a prospective prognostic panel study. Eur Radiol 2014; 25:147-54. [DOI: 10.1007/s00330-014-3383-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 06/21/2014] [Accepted: 08/05/2014] [Indexed: 01/22/2023]
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