Pulmonary embolism: an unsuspected killer

Late onset of pulmonary embolism caused by lymphocyst following pelvic lymphadenectomy

Herein is reported a case of late-onset pulmonary embolism following pelvic surgery, despite prophylactic measures in the perioperative period. Twenty-six days after hysterectomy and pelvic lymphadenectomy for endometrial carcinoma, an 83-year-old woman developed a pulmonary embolism. This was caused by pelvic lymphocyst, which, in turn, led to chronic compression of the right external iliac vein. This case strongly suggests that prolonged postoperative thromboembolic prophylaxis should be considered in elderly patients undergoing lymphocyst following pelvic surgery.

Bayes pulmonary embolism assisted diagnosis: a new expert system for clinical use

BACKGROUND

The diagnosis of pulmonary embolism demands flexible decision models, both for the presence of clinical confounders and for the variability of local diagnostic resources. As Bayesian networks fully meet this requirement, Bayes Pulmonary embolism Assisted Diagnosis (BayPAD), a probabilistic expert systems focused on pulmonary embolism, was developed.

METHODS

To quantitatively validate and improve BayPAD, the system was applied to 750 patients from a prospective study done in an Italian tertiary hospital where the true pulmonary embolism status was confirmed using pulmonary angiography or ruled out with a lung scan. The proportion of correct diagnoses made by BayPAD (accuracy) and the correctness of the pulmonary embolism probabilities predicted by the model (calibration) were calculated. The calibration was evaluated according to the Cox regression-calibration model.

RESULTS

Before refining the model, accuracy was 88.6%. Once refined, accuracy was 97.2% and 98%, respectively, in the training and validation samples. According to Cox analysis, calibration was satisfactory, despite a tendency to exaggerate the effect of the findings on the probability of pulmonary embolism. The lack of some investigations (like Spiral computed tomographic scan and Lower limbs doppler ultrasounds) in the pool of available data often prevents BayPAD from reaching the diagnosis without invasive procedures.

CONCLUSIONS

BayPAD offers clinicians a flexible and accurate strategy to diagnose pulmonary embolism. Simple to use, the system performs case-based reasoning to optimise the use of resources available within a particular hospital. Bayesian networks are expected to have a prominent role in the clinical management of complex diagnostic problems in the near future.

Natural Death in the Forensic Setting

Although unexpected natural deaths comprise a large proportion of the cases seen in the forensic setting, the investigation of these cases remains a unique challenge. Some cases are straightforward; however, others require special examination and dissections, as well as the use of special dissections and ancillary studies. For the forensic investigator to accurately assign a cause and manner of death, one must be aware of the differential diagnoses, common scenarios, and typical victim. The authors reviewed all forensic cases referred to the Forensic Section of the Medical University of South Carolina over a 15-year period from January 1989-December 2003. The number of natural deaths occurring in adults (age 18 years and older) was 6932, compared with the overall number of 13,227 cases. The natural deaths were then analyzed as to autopsy findings, cause of death, cardiac versus noncardiac, age, race, and gender. Current techniques, special dissections, and ancillary studies that can assist in the classification of these deaths in the forensic setting are reviewed.

Pulmonary embolism in patients with chronic obstructive pulmonary disease or congestive heart failure

BACKGROUND

The diagnosis of pulmonary embolism (PE) is often unreliable in patients with chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF).

SUBJECTS AND METHODS

Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) is an ongoing registry of consecutive patients with acute venous thromboembolism. In this study, the clinical characteristics, laboratory findings, and clinical outcomes of all enrolled patients with acute PE, with or without underlying cardiopulmonary diseases, were compared and contrasted. In addition, the performance of 2 clinical models for the diagnosis of PE was retrospectively evaluated.

RESULTS

As of January 2005, 4444 patients with symptomatic PE have been enrolled in RIETE. Of those, 632 patients (14%) had COPD and 422 (9.5%) had CHF. Significant differences were found in clinical presentation and 3-month outcomes among the 3 groups. With the Geneva model, there was a lower percentage of PE patients with COPD (relative risk [RR] 0.82; 95% confidence interval [CI], 0.66-1.02) or CHF (RR 0.73; 95% CI, 0.56-0.95) who fell into the low pretest probability category, compared with patients with neither. Besides, the percentage of patients with high probability of PE was similar among the 3 patient groups. The frequency of COPD (61%) and CHF (72%) patients with a high pretest probability for PE increased when using the Pisa score, but the percentage of COPD patients into the high probability group was lower (RR 0.60; 95% CI, 0.51-0.71).

CONCLUSIONS

Significant differences exist in PE patients with and without underlying cardiopulmonary diseases. The performance of the 2 clinical prediction models varied according to the presence or absence of underlying COPD or CHF.

Identifying Chest Pain Emergencies in the Primary Care Setting

The majority of patients presenting to a primary care physician with acute chest pain will have non-life-threatening etiologies. Nevertheless, catastrophic cause of chest pain such as ACS, AD, PE, esophageal perforation, and pericarditis must be considered in the differential diagnosis. Often, these deadly conditions have atypical clinical presentations that must be recognized. Furthermore, the physical examination can be deceptively benign in patients harboring a catastrophic etiology of chest pain. By identifying these atypical presentations, recognizing the utility of the physical examination, and understanding of the limitations of traditional diagnostic imaging, primary care physicians can effectively diagnose patients who have life-threatening cause of acute chest pain.

Incidental Pulmonary Emboli in Oncology Patients: Prevalence, CT Evaluation, and Natural History

PURPOSE

To retrospectively determine the prevalence and natural history of incidental pulmonary emboli in oncology patients, the number of such cases reported at initial thoracic computed tomographic (CT) image interpretation, and the factors that contribute to underdiagnosis.

MATERIALS AND METHODS

Institutional review board approval, which included HIPAA-compliant access to protected health information and waived patient consent requirements, was obtained for this retrospective study. Four hundred three consecutive oncology patients (199 male, 204 female; age range, 14-87 years; mean age, 55 years) in whom adequate-quality multidetector thoracic CT was performed within a 10-day period for indications other than pulmonary emboli assessment were identified. There were 31 (7.7%) inpatients at the time of imaging. Each imaging case was reviewed by two independent radiologists, and all pulmonary emboli were confirmed by a panel of three thoracic radiologists. Clinical charts were reviewed for demographic data, embolus detection, and outcomes up to 2 years after the initial examination. Patient groups were compared by using chi2 and one-sided binomial tests.

RESULTS

Sixteen (4.0%) of the 403 patients had pulmonary emboli. The highest prevalences were in patients with gynecologic malignancies (two of 13, 15%) and in those with melanoma (four of 41, 10%). Four (25%) of the 16 patients with emboli were identified at initial clinical CT image interpretation, and all had multiple emboli involving at least the lobar arteries. Missed emboli typically were solitary and involved smaller arteries; no other confounding factors were identified. Six (60%) of 10 patients with emboli who underwent any lower extremity imaging had deep vein thrombosis. With the exception of one patient, who was transferred back to the referring physician and lost to follow-up, all patients with reported pulmonary emboli were treated. Two patients had subsequent embolic events: one death despite treatment and one recurrent embolus in a nontreated patient.

CONCLUSION

Incidental pulmonary emboli were seen in 16 (4%) oncology patients but were initially reported in only four of them. The small size of involved arteries contributes to the failed detection at initial CT image interpretation, and patients with emboli in these small vessels may have deep vein thrombosis or recurrent emboli.

Initial approach to the patient who has chest pain

The last decade has seen extraordinary advances in the cardiovascular arena, particularly in the evaluation and management of the patient who has acute coronary syndromes. From bedside markers of myocardial damage to drug-eluting stents, technical advances are proliferating. Efforts in developing an international registry for acute aortic dissection have helped elucidate the acute presentation, management, and prognosis of this uncommon but lethal disease. Finally, the multiple research efforts in coordinating clinical decision-making with serologic markers and advanced imaging for the diagnosis of pulmonary embolism is changing the approach to the patient at risk for thromboembolic disease.

Chest Pain: A Clinical Assessment

Chest pain is one of the most common presentations in emergency medicine. The initial evaluation should always consider life-threatening causes such as aortic dissection, pulmonary embolism, pneumothorax, pneumomediastinum, pericarditis, and esophageal perforation. Radiographic imaging is performed in tandem with the initial clinical assessment and stabilization of the patient. Radiologic findings are key to diagnosis and management of this entity.

Nontraumatic Thoracic Emergencies

Acute chest pain is one of the most common complaints of patients who present to an emergency department, and accounts for up to 5% of all visits. It also is one of the most complex issues in an emergency setting because, although clinical signs and symptoms often are nonspecific, rapid diagnosis and therapy are of great importance. The chest radiograph remains an important component of the evaluation of chest pain, and usually is the first examination to be obtained. Nevertheless, cross-sectional imaging has added greatly to the ability to characterize the wide constellation of clinical findings into a distinct etiology. This article reviews how the various entities that can present as nontraumatic chest pain can manifest radiographically.

Initial Evaluation of Chest Pain

Chest pain is among the most frequently evaluated presenting complaints in the emergency department (ED). Diagnostic etiologies range from benign to life-threatening. Failure to diagnose the life-threatening chest emergencies-specifically acute coronary syndrome, aortic dissection, and pulmonary embolism-can lead to catastrophic medical and legal outcomes for the patient and physician respectively. This article focuses on clinical and risk management strategies to minimize misdiagnosis and produce favorable medical and medicolegal outcomes.

Pulmonary emboli: the differential diagnosis dilemma

Pulmonary embolism is a rare but serious medical condition, with an estimated mortality of 5% to 20%. Many patients receiving physical therapy may be at risk for developing pulmonary embolism, especially after periods of immobilization or surgery. Patients presenting with dyspnea, chest pain, or tachypnea, particularly after trauma or surgery, have an increased likelihood of pulmonary embolism. Clinical prediction rules have been developed, which can aid the practitioners in assessing the risk a patient has for developing pulmonary embolism. The present clinical commentary discusses the existing evidence for screening patients for pulmonary embolism. To illustrate the importance of the screening examination, a patient is presented who was referred to physical therapy 5 days after cervical discectomy and fusion. This patient was subsequently referred for medical evaluation and a confirmatory diagnosis of pulmonary embolism.