The role of risk factors in delayed diagnosis of pulmonary embolism

Comparison of Dual-Energy Computed Tomography Pulmonary Angiography-Derived Contrast Enhancement with Standard Dual-Energy Pulmonary Angiography in Diagnosing Subsegmental Pulmonary Embolism: A Prospective Study

Objective  In this study, we compare the diagnostic accuracy of dual-energy (DE) computed tomography pulmonary angiography (CTPA) derived contrast enhancement (DECTPA, CTPA images with iodine maps) with standard dual-energy pulmonary angiography (SCTPA) for diagnosis of subsegmental pulmonary embolism in the cases with clinical suspicion of acute pulmonary embolism (APE). Materials and Methods  We included 50 cases with clinical suspicion of APE that were referred for CTPA. All the patients underwent CTPA in the dual-energy protocol. Two radiologists evaluated the images. The first radiologist interpreted the SCTPA images (vascular images) and the second radiologist interpreted the DECTPA (CTPA images with iodine maps) for findings of APE. We calculated the sensitivity, specificity, and negative predictive value of DECTPA vis-à-vis SCTPA images. Results  The DECTPA with the advantage of iodine map utilization yielded higher detection of thrombi in peripheral subsegmental arteries (72 vs. 99; p  = - 0.001) as compared to the SCTPA images by identification of 18 new perfusion defects (interquartile range [IQR]: 0-1) that were consistent with APE. Filling defects were identified in 27 (IQR: 0-4) more subsegmental arteries supplying these 18 areas, which were not detected on SCTPA alone. These 18 perfusion defects were identified in 13 cases. In these 13 cases, 4 new cases were diagnosed that were negative on CTPA ( p  = -0.125). In the evaluation of the APE, sensitivity and specificity were calculated and it was found that DECTPA showed 100% sensitivity and 86% specificity with 100% negative predictive value in the detection of thrombi as compared to the routine CTPA. Conclusion  DECTPA has higher sensitivity and negative predictive value in the detection of the subsegmental perfusion defect identification as compared to SCTPA.

A systematic review and meta-analysis of diagnostic delay in pulmonary embolism

Background

Diagnostic delay in patients with pulmonary embolism (PE) is typical, yet the proportion of patients with PE that experienced delay and for how many days is less well described, nor are determinants for such delay.

Objectives

This study aimed to assess the prevalence and extent of delay in diagnosing PE.

Methods

A systematic literature search was performed to identify articles reporting delays in diagnosing PE. The primary outcome was mean delay (in days) or a percentage of patients with diagnostic delay (defined as PE diagnosis more than seven days after symptom onset). The secondary outcome was determinants of delay. Random-effect meta-analyses were applied to calculate a pooled estimate for mean delay and to explore heterogeneity in subgroups.

Results

The literature search yielded 10,933 studies, of which 24 were included in the final analysis. The pooled estimate of the mean diagnostic delay based on 12 studies was 6.3 days (95% prediction interval 2.5 to 15.8). The percentage of patients having more than seven days of delay varied between 18% and 38%. All studies assessing the determinants of coughing (n = 3), chronic lung disease (n = 6) and heart failure (n = 8) found a positive association with diagnostic delay. Similarly, all studies assessing recent surgery (n = 7) and hypotension (n = 6), as well as most studies assessing chest pain (n = 8), found a negative association with diagnostic delay of PE.

Conclusion

Patients may have symptoms for almost one week before PE is diagnosed and in about a quarter of patients, the diagnostic delay is even longer.

Allergic rhinitis is associated with thromboembolic disease in pregnancy

Finding the risk factors for thromboembolic (TE) disease and preventing its development in pregnant women is important. Allergic rhinitis (AR) is a common chronic disease. We aim to find if AR is a risk factor. From 2004 to 2011, 55,057 pregnant women were recruited from a Taiwan database. They were grouped into AR and non-AR groups. The rate of TE and venous complications during pregnancy and 60 days after childbirth were compared between non-AR and the AR group. Those with AR diagnosed both before and after childbirth, meaning AR was not changed during pregnancy, the rates of TE (OR 2.64) and venous complications (OR 1.35) were higher compared to non-AR subjects. In those who underwent cesarean delivery, the rate was also higher in group 3 (OR 4.14). Those with AR before childbirth, without after, meaning AR was well controlled during pregnancy, the rate of TE was not higher than that of the non-AR subjects. Pregnant women with AR have an increased rate of TE. An increased rate of venous complications in these subjects might explain the increase in TE. If AR is well controlled during pregnancy, the rate of TE does not appear to increase.

Diagnostic Delay of Pulmonary Embolism in COVID-19 Patients

Pulmonary embolism (PE) is a frequent, life-threatening COVID-19 complication, whose diagnosis can be challenging because of its non-specific symptoms. There are no studies assessing the impact of diagnostic delay on COVID-19 related PE. The aim of our exploratory study was to assess the diagnostic delay of PE in COVID-19 patients, and to identify potential associations between patient- or physician-related variables and the delay. This is a single-center observational retrospective study that included 29 consecutive COVID-19 patients admitted to the San Matteo Hospital Foundation between February and May 2020, with a diagnosis of PE, and a control population of 23 non-COVID-19 patients admitted at our hospital during the same time lapse in 2019. We calculated the patient-related delay (i.e., the time between the onset of the symptoms and the first medical examination), and the physician-related delay (i.e., the time between the first medical examination and the diagnosis of PE). The overall diagnostic delay significantly correlated with the physician-related delay (p < 0.0001), with the tendency to a worse outcome in long physician-related diagnostic delay (p = 0.04). The delay was related to the presence of fever, respiratory symptoms and high levels of lactate dehydrogenase. It is important to rule out PE as soon as possible, in order to start the right therapy, to improve patient's outcome and to shorten the hospitalization.

Case Report: Successful revascularization in massive pulmonary embolism with a large protruding thrombus and dilated cardiomyopathy

Pulmonary embolism is a potentially life-threatening condition. Despite advances in diagnostics, lack of consensus and delays in determining the diagnosis of pulmonary embolism are still important problems. We report the diagnosis and management of a 37-year-old man suffering from massive pulmonary embolism, a large protruding thrombus, and dilated cardiomyopathy. Echocardiography showed dilatation of all cardiac chambers, a large protruding thrombus in the right atrium to the inferior vena cava, impaired left and right ventricular systolic function, and global hypokinetic of the left ventricle with eccentric left ventricular hypertrophy. A thoracic computerized tomography scan showed pulmonary embolism with infarction. The patient's blood pressure was 60/40 mmHg and heart rate was 110 bpm. The patient was diagnosed with high-risk acute pulmonary embolism. We gave him hemodynamic support and reperfusion therapy with a loading dose of 250,000 units of Streptokinase followed by 100,000 units/hour for 24 hours. After revascularization, the patient's hemodynamic condition improved. The diagnosis of acute pulmonary embolism is based on clinical symptoms, hemodynamic changes, or radiological examination. Unstable hemodynamic underlies high-risk stratification. Hypotension or shock results from obstruction of the pulmonary artery which causes increased right ventricular afterload and acute right ventricular dysfunction. Reperfusion with thrombolysis therapy could provide good outcomes in this patient. Prolonged anticoagulation should be given to prevent the recurrence of venous thromboembolism.

Case Report: Successful revascularization in massive pulmonary embolism with a large protruding thrombus and dilated cardiomyopathy

Pulmonary embolism is a potentially life-threatening condition. Despite advances in diagnostics, lack of consensus and delays in determining the diagnosis of pulmonary embolism are still important problems. We report the diagnosis and management of a 37-year-old man suffering from massive pulmonary embolism, a large protruding thrombus, and dilated cardiomyopathy. Echocardiography showed dilatation of all cardiac chambers, a large protruding thrombus in the right atrium to the inferior vena cava, impaired left and right ventricular systolic function, and global hypokinetic of the left ventricle with eccentric left ventricular hypertrophy. A thoracic computerized tomography scan showed pulmonary embolism with infarction. The patient's blood pressure was 60/40 mmHg and heart rate was 110 bpm. The patient was diagnosed with high-risk acute pulmonary embolism. We gave him hemodynamic support and reperfusion therapy with a loading dose of 250,000 units of Streptokinase followed by 100,000 units/hour for 24 hours. After revascularization, the patient's hemodynamic condition improved. The diagnosis of acute pulmonary embolism is based on clinical symptoms, hemodynamic changes, or radiological examination. Unstable hemodynamic underlies high-risk stratification. Hypotension or shock results from obstruction of the pulmonary artery which causes increased right ventricular afterload and acute right ventricular dysfunction. Reperfusion with thrombolysis therapy could provide good outcomes in this patient. Prolonged anticoagulation should be given to prevent the recurrence of venous thromboembolism.

Case Report: Successful revascularization in massive pulmonary embolism with a large protruding thrombus and dilated cardiomyopathy

Pulmonary embolism is a potentially life-threatening condition. Despite advances in diagnostics, lack of consensus and delays in determining the diagnosis of pulmonary embolism are still important problems. We report the diagnosis and management of a 37-year-old man suffering from massive pulmonary embolism, a large protruding thrombus, and dilated cardiomyopathy. Echocardiography showed dilatation of all cardiac chambers, a large protruding thrombus in the right atrium to the inferior vena cava, impaired left and right ventricular systolic function, and global hypokinetic of the left ventricle with eccentric left ventricular hypertrophy. A thoracic computerized tomography scan showed pulmonary embolism with infarction. The patient's blood pressure was 60/40 mmHg and heart rate was 110 bpm. The patient was diagnosed with high-risk acute pulmonary embolism. We gave him hemodynamic support and reperfusion therapy with a loading dose of 250,000 units of Streptokinase followed by 100,000 units/hour for 24 hours. After revascularization, the patient's hemodynamic condition improved. The diagnosis of acute pulmonary embolism is based on clinical symptoms, hemodynamic changes, or radiological examination. Unstable hemodynamic underlies high-risk stratification. Hypotension or shock results from obstruction of the pulmonary artery which causes increased right ventricular afterload and acute right ventricular dysfunction. Reperfusion with thrombolysis therapy could provide good outcomes in this patient. Prolonged anticoagulation should be given to prevent the recurrence of venous thromboembolism.

Elevated D-Dimers and Right Ventricular Dysfunction on Echocardiography for Diagnosis of Pulmonary Embolism: A Validation Study

Background

There is an increasing need to explore other non-invasive techniques for the diagnosis of pulmonary embolism in resource-limited countries.

Objective

To assess the validity of elevated D-dimer levels and right ventricular (RV) dysfunction on echocardiography in predicting definite massive pulmonary embolism among patients diagnosed with massive pulmonary embolism using computed tomography (CT) pulmonary angiography as the gold standard.

Methods

The patients with acute massive pulmonary embolism on CT pulmonary angiography were included. The participants underwent 12-lead electrocardiography, assessment of D-dimer levels, and bedside echocardiography to determine right ventricular dysfunction. The data were recorded on a proforma and analyzed using IBM SPSS software version 26.0 (IBM Corp., Armonk, NY).

Results

There were 160 patients in the study. The mean age was 49.19 ± 14.89 years. Elevated D-dimer levels were seen in 80.60% of the patients whereas ventricular dysfunction on echocardiography was seen in 90.00% of the patients. The sensitivity and specificity of elevated D dimer levels were 78.99% and 14.60%, respectively. The positive predictive values (PPV) and negative predictive values (NPV) for elevated D-dimer levels were 72.87% and 19.35%, respectively. In contrast, the sensitivity of ventricular dysfunction was 94.96% and specificity 24.39%. PPV was found to be 78.47% and NPV was 62.50%.

Conclusion

Positive D-dimer levels and ventricular dysfunction on echocardiography are sensitive enough to consider the diagnosis of massive pulmonary embolism but lack adequate specificity, thus, necessitating the presence of other noninvasive tests.

Determinants and prognostic implication of diagnostic delay in patients with a first episode of pulmonary embolism

Signs and symptoms of pulmonary embolism (PE) are not specific and this can lead to a diagnostic delay. Little is known about the determinants of this delay and its prognostic implication. We conducted a retrospective analysis of a prospective cohort involving 514 patients with a first episode of PE. The diagnostic delay was defined as a time from first symptom onset to diagnosis of >3 days, corresponding of the median time in the population. Multivariable logistic regression analysis was performed to identify determinants of diagnostic delay. Prognostic implication was measured as the occurrence of 30-day all-cause mortality, haemodynamic collapse or recurrent PE. A total of 240 (47%) among 514 patients had a time from first symptom to diagnosis > 3 days. Previous deep vein thrombosis (OR 0.55, 95% Confidence Interval (CI), 0.32-0.93), immobilization (OR 0.52, 95% CI, 0.28-0.96), surgery (OR 0.31, 95% CI, 0.16-0.62), chest pain (OR 0.58, 95% CI, 0.39-0.86), syncope (OR 0.48, 95% CI, 0.23-1.01), dyspnea (OR 2.48, 95% CI, 1.57-3.91) and hemoptysis (OR 3.57, 95% CI, 1.40-9.07) were associated with diagnostic delay. Twenty-two patients (4.3%, 95%CI, 2.8-6.5) experienced an outcome event within 30 days. Among them, 15 patients (6.2% 95%CI, 3.7-10.3) had a diagnostic delay and 7 (2.6%, 95% CI 1.1-5.4) did not (p = 0.039). In this cohort, diagnostic delay is associated with the absence of major risk factors for PE or clinical features such as chest pain or syncope and the presence of dyspnea or hemoptysis. Diagnostic delay is associated with a worse 30-day prognosis.

Referral Patterns and Diagnostic Yield of Lung Scintigraphy in the Diagnosis of Acute Pulmonary Embolism

Introduction. The purpose of this study is to assess referral patterns and the yield of ventilation-perfusion (V/Q) scintigraphy in patients referred for acute pulmonary embolism (PE). Methods. We retrospectively reviewed the charts of all patients who underwent V/Q studies between April 1, 2008, and March 31, 2010. Patients were subdivided into 4 groups based on their referral source: emergency department (ED), hospital inpatient ward, outpatient thrombosis clinic, and all other outpatient sources. Results. A total of 1008 patients underwent V/Q scintigraphy to exclude acute PE. The number of ED, inpatient, thrombosis clinic, and outpatient studies was 43 (4.3%), 288 (28.6%), 351 (34.8%), and 326 (32.3%). Proportion of patients with contrast contraindication varied significantly among the different groups. Of the 1,008 studies, 331 (32.8%) were interpreted as normal, 408 (40.5%) as low, 158 (15.7%) as intermediate, and 111 (11.0%) as high probability for PE. 68 (6.7%) patients underwent CTPA within 2 weeks following V/Q. Conclusion. The rate of nondiagnostic studies is lower than that reported in previously published data, with a relatively low rate of intermediate probability studies. Only a small fraction of patients undergoing a V/Q scan will require a CTPA.

Clinical characteristics associated with diagnostic delay of pulmonary embolism in primary care: a retrospective observational study

OBJECTIVES

To evaluate the extent of delay in the diagnosis of pulmonary embolism (PE) in primary care, and to identify determinants that are associated with such diagnostic delay.

DESIGN

Retrospective observational study.

SETTING

6 primary care practices across the Netherlands.

PARTICIPANTS

Data from patients with an objectively confirmed diagnosis of PE (International Classification of Primary Care (ICPC) code K93) up to June 2015 were extracted from the electronic medical records. For all these PE events, we reviewed all consultations with their general practitioner (GP) and scored any signs and symptoms that could be attributed to PE in the 3 months prior to the event. Also, we documented actual comorbidity and the diagnosis considered initially.

PRIMARY AND SECONDARY OUTCOME MEASURES

Delay was defined as a time gap of >7 days between the first potentially PE-related contact with the GP and the final PE diagnosis. Multivariable logistic regression analysis was performed to identify independent determinants for delay.

RESULTS

In total, 180 incident PE cases were identified, of whom 128 patients had 1 or more potential PE-related contact with their GP within the 3 months prior to the diagnosis. Based on our definition, in 33 of these patients (26%), diagnostic delay was observed. Older age (age >75 years; OR 5.1 (95% CI 1.8 to 14.1)) and the absence of chest symptoms (ie, chest pain or pain on inspiration; OR 5.4 (95% CI 1.9 to 15.2)) were independent determinants for diagnostic delay. A respiratory tract infection prior to the PE diagnosis was reported in 13% of cases without delay, and in 33% of patients with delay (p=0.008).

CONCLUSIONS

Diagnostic delay of more than 7 days in the diagnosis of PE is common in primary care, especially in the elderly, and if chest symptoms, like pain on inspiration, are absent.

A systematic review of patient-related risk factors for catheter-related thrombosis

To identify patient-related risk factors for venous thrombosis in patients with central venous catheters (CVC) or peripherally inserted central catheters (PICC). We performed a systematic review of the literature assessing patient-related risk factors for thrombosis related to CVC or PICC. The databases PubMed, Ovid and the Cochrane library were searched for observational studies pertaining to patient-related risk factors for CVC and PICC-related thrombosis. The initial search through PubMed, Ovid and the Cochrane library yielded 516 results. After 71 duplicates were removed, 445 articles were assessed for eligibility based on title and abstract. Four hundred and eleven articles were then excluded and 33 full text articles were manually assessed for eligibility. Eight articles were eliminated as they did not contain content relevant to the review. Twenty-five studies were then selected to assess 20 risk factors. There were no consistent significant associations for catheter-related thrombosis across the twenty-five studies. Multiple studies identified age, malignancy, diabetes, obesity, chemotherapy, thrombophilia and a history of thrombosis as significant risk factors for catheter-related thrombosis. Inconsistent findings among studies make it difficult to establish which patient-related risk factors are associated with catheter-related thrombosis. Future studies could include larger sample sizes and more cases of catheter-related thrombosis to produce more significant results. Identification of patient-related risk factors could lead to early recognition of upper limb deep vein thrombosis in patients with catheters, thereby preventing complications.

Benefits of texture analysis of dual energy CT for Computer-Aided pulmonary embolism detection

Pulmonary embolism is an avoidable cause of death if treated immediately but delays in diagnosis and treatment lead to an increased risk. Computer-assisted image analysis of both unenhanced and contrast-enhanced computed tomography (CT) have proven useful for diagnosis of pulmonary embolism. Dual energy CT provides additional information over the standard single energy scan by generating four-dimensional (4D) data, in our case with 11 energy levels in 3D. In this paper a 4D texture analysis method capable of detecting pulmonary embolism in dual energy CT is presented. The method uses wavelet-based visual words together with an automatic geodesic-based region of interest detection algorithm to characterize the texture properties of each lung lobe. Results show an increase in performance with respect to the single energy CT analysis, as well as an accuracy gain compared to preliminary work on a small dataset.

Right ventricular function and thrombus load in patients with pulmonary embolism and diagnostic delay

INTRODUCTION

It has been reported that the time between symptom onset and objective diagnosis of pulmonary embolism (PE) does not affect patients' prognosis with regard to re-thrombosis and mortality risk. However, this observation is contra-intuitive and poorly understood. We further elaborated on this paradox by evaluating thrombus load and right ventricular function in patients with and without diagnostic delay.

MATERIALS AND METHODS

We performed a post hoc analysis of a previously published observational prospective outcome study in 113 consecutive PE patients. Qanadli-score and RV/LV ratio were scored in all patients, as was the duration from symptom onset to clinical presentation and diagnosis. Diagnostic delay was defined as a period of more than 7 days between symptom onset and clinical presentation. Further endpoints were mortality and hospital readmission in a 6-week follow-up period.

RESULTS

Twenty patients with and 93 patients without delay were studied, who had comparable baseline characteristics and co-morbidities. In linear analyses, Qanadli-score (R² of 0.021; P = 0.130) and RV/LV ratio (R² < 0.001; P = 0.991) were not associated with diagnostic delay. Likewise, longer delay was not predictive of 6-week mortality (odds ratio, 0.65; 95% CI, 0.08-5.57) or hospital readmission (odds ratio, 0.75; 95% CI, 0.15-3.65).

CONCLUSION

In our patient cohort, diagnostic delay was not associated with higher thrombus load or right ventricular dysfunction. This provides a possible explanation for the lack of prognostic relevance of diagnostic delay.

Study of clinical profile and management of patients with pulmonary embolism - single center study

OBJECTIVE

To study the clinical profile, diagnostic methods and management in patients with symptomatic pulmonary embolism (PE).

METHODS

Retrospective assessment of clinical features and management of patients presenting with symptomatic pulmonary embolism from January 2005 to March 2012.

RESULTS

35 patients who were newly diagnosed to have pulmonary embolism with a mean age of 52.1 years were included in the study. Dyspnea (91.4%) and syncope (22.8%) were the predominant symptoms. Echocardiography was done in all patients. 30 patients (85.7%) had pulmonary arterial hypertension, 31 patients (88.5%) had evidence of RV dysfunction and 4 patients (16.7%) had evidence of thrombus in PA, RV. Out of 35 patients, 34 patients (97.14%) showed positive d-dimer reports. Among 35 patients, 24 (68.5%) had positive troponin values. V/Q scan was done in 14 patients (40%) and CT pulmonary angiogram (CTPA) was done in 24 patients (68.5%.). Thrombolysis was done is 24 patients (68.5%). All patients received low molecular weight heparin followed by warfarin. Of the 35 patients, 34 (97.1%) were discharged and were under regular follow up for 6 months and one patient died during the hospital stay.

CONCLUSION

Pulmonary embolism is a common problem and can be easily diagnosed provided it is clinically suspected. Early diagnosis and aggressive management is the key to successful outcome.

Effect of delay in hospital presentation on clinical and imaging findings in acute pulmonary thromboembolism

BACKGROUND

There is limited information on the extent and clinical importance of the delay in hospital presentation of acute pulmonary thromboembolism (PTE).

OBJECTIVE

The aim of this study was to investigate the delay in hospital presentation of PTE and its association with clinical and imaging findings in PTE.

METHODS

This prospective study was conducted on patients admitted to our hospital with a diagnosis of acute PTE between September 2007 and September 2011. Relationships between delay in hospital presentation and clinical findings, risk factors, imaging findings, and in-hospital mortality were analyzed.

RESULTS

Of the 195 patients enrolled, 84 (43.1%) patients presented 3 days after the onset of symptoms. Patients with chest pain, history of immobility for more than 3 days, recent surgery, and estrogen use had significantly less delayed presentation. Right ventricular dysfunction was significantly more frequent in patients with delayed presentation (odds ratio [OR] = 2.38; 95% confidence interval [CI] 1.27-4.44; p = 0.006); however, no relationship was found between delay in presentation and pulmonary computed tomographic angiography or color Doppler sonography findings. Patients with delayed presentation were at higher risk of in-hospital mortality (OR = 4.32; 95% CI 1.12-16.49; p = 0.021).

CONCLUSIONS

Our study showed that a significant portion of patients with acute PTE had delayed presentation. Also, patients with delayed presentation had worse echocardiographic findings and higher in-hospital mortality.

Enhanced visualization of pulmonary perfusion in 4D dual energy CT images

Pulmonary embolism (PE) affects up to 600,000 patients and contributes to at least 100,000 deaths every year in the United States alone. Diagnosis of PE can be difficult as most symptoms are unspecific. Computed Tomography (CT) angiography is the reference for diagnosing PE. CT angiography produces grayscale images with darker areas representing any mass filling defects, making the analysis of the images difficult. This article demonstrates a method using the combination of energy levels in Dual Energy CT images to highlight the presence of PE in the lung. The results show that pairing different energy levels from 40 to 140 keV can increase the contrast between well perfused areas and underperfused areas of the lung. In addition, the visualization used in the current study complies with the window/level settings usually employed by radiologists.

Clinical features of patients inappropriately undiagnosed of pulmonary embolism

PURPOSES

The objective of this study was to identify clinical factors associated with delayed diagnosis of acute pulmonary embolism (PE) in the emergency department (ED).

BASIC PROCEDURES

A retrospective observational study was performed at three University affiliated Hospitals; 436 consecutive patients who presented to the ED with an acute PE confirmed by chest computed tomography from 2008 to 2011 were included. Patients were divided into 3 groups: group 1, PE was diagnosed while the patient was still in the ED; group 2, PE was diagnosed during hospitalization; group 3, patients who were sent home with a wrong alternative diagnosis and returned to the ED and were diagnosed of PE.

MAIN FINDINGS

One hundred forty-six patients (33.5%) had a delayed diagnosis of PE--21.5% belong to group 2 and 11.9% to Group 3. Chronic coexisting medical conditions like asthma or chronic obstructive pulmonary disease were independent predictors of a delayed diagnosis in patients who were admitted to hospital whereas non-specific and less severe symptoms like the presence of pleuro-mechanic thoracic pain, fever, hemoptysis, or the presence of a pulmonary infiltrate in chest x-ray were independent predictors of a delayed diagnosis in patients who were sent home.

PRINCIPAL CONCLUSIONS

Delay in diagnosis of acute PE is frequent despite current diagnostic strategies. Patients are sent home or admitted to hospital with a wrong diagnosis depending on clinical presentation or coexisting medical conditions.

Factor V leiden thrombophilia in a female collegiate soccer athlete: a case report

OBJECTIVE

To raise awareness among health care providers caring for an active population to an uncommon genetic mutation that increases the risk for a potentially fatal venous thromboembolism.

BACKGROUND

A 19-year-old previously healthy female collegiate soccer athlete complained of coughing and progressively decreased exercise tolerance, which were attributed to a recent illness and lack of sleep. Later that evening, she complained of dyspnea and pleuritic pain and was referred to the emergency department. Bilateral pulmonary emboli were identified with computed tomography, and a hypercoagulable panel revealed that the patient was heterozygous for the factor V Leiden mutation.

DIFFERENTIAL DIAGNOSIS

Pneumonia, pneumothorax, pericarditis, pleuritis, gastroesophageal reflux disease, pulmonary embolism.

TREATMENT

Intravenous heparin therapy was initiated immediately in the emergency department. This was followed by inpatient anticoagulant therapy for 5 days and outpatient anticoagulant therapy for an additional 12 months. During this time, the patient was unable to participate in soccer drills or return to competition and was limited to conditioning activities due to the risk of increased bleeding time.

UNIQUENESS

Documented cases of pulmonary embolism in a young athletic population are rare and are usually associated with genetic risk factors. Factor V Leiden is a relatively uncommon genetic mutation that dramatically increases the risk for venous thromboembolism. Although the fatality rate in this population is low, fatality is preventable if the condition is recognized early and managed properly.

CONCLUSIONS

Athletes should be encouraged to communicate with their athletic trainers regarding any changes in health status or medication usage. When an athlete presents with nonspecific symptoms such as dyspnea and chest pain, athletic trainers should consider the possibility of pulmonary embolism. A high degree of suspicion results in early diagnosis and treatment and may prevent a fatal event.

Delay in diagnosis of pulmonary thromboembolism in emergency department: is it still a problem?

BACKGROUND AND AIM

Pulmonary embolism (PE) is a common and serious disease that can result in death unless emergent diagnosis is made and treatment is initiated. In this study, we aimed to identify whether there is still a delay in the diagnosis of PE and to identify the time to delay in diagnosis and factors leading to this delay.

METHODS

This is a prospective observational cohort study performed in an emergency department (ED) of a tertiary care university hospital between September 2008 and September 2010. The rate and cause of delay in diagnosis were analyzed among patients with PE. The "delay" was defined as diagnosing after first 24 hours of symptom onset.

RESULTS

Among the 53 patients who were diagnosed with PE, a delay in diagnosis was present in 49 (93%) of them. Total delay time was 6.8 ± 7.7 days. In 33 (62%) patients, there was a delay of 4.6 ± 6.5 days due to patient-related factors. Delay in diagnosis after admission to hospital was 2.2 ± 2.9 days in 40 (75%) patients. In multivariate regression analysis, being female and having chest pain and cough were identified as significant factors causing patient-related delay. Unilateral leg edema, recent operation, and previous venous thromboembolism (VTE) history were the significant factors causing PE diagnosis without a delay. On the other hand, systemic hypertension as comorbidity was the only factor leading to physician-related delay.

CONCLUSION

The delay in diagnosis of PE in EDs still remains as an important problem. While being female and having chest pain and cough are significantly and independently associated with patient delay in diagnosis, the unilateral leg edema, recent operation, and previous VTE history cause physicians to diagnose on time. On the other hand, having hypertension as comorbidity may lead to physician delay. In order to prevent the delay in diagnosis, hospital-associated factors must be elucidated totally and more interventions must be made to increase public and professional awareness of the disease.

LR-PED rule: low risk pulmonary embolism decision rule - a new decision score for low risk pulmonary embolism

INTRODUCTION

When accurately diagnosed, non-massive Pulmonary embolism (PE) has a low mortality rate. However, some patients initially considered to be low risk show progressive deterioration. This research aims at developing a preliminary score that allows detection of low risk patients potentially eligible for outpatient treatment.

MATERIALS AND METHODS

Retrospective cohort study involving 142 asymptomatic/mildly symptomatic and hemodynamically stable patients with PE and no clinical/echocardiographic signs of right ventricular dysfunction. Collected data: risk factors, analytic/gasometric parameters, admission echocardiogram, thoracic CT angiography. Patients followed for 6months. Primary endpoint: 1-month all-cause mortality. Secondary endpoints: Intrahospital and 6-month all-cause mortality. A score designed for identification of very low risk patients eligible for outpatient treatment was developed and its prognostic accuracy compared to that of the Geneva and simplified PESI models.

RESULTS

A score for predicting 1-month mortality (Low Risk Pulmonary Embolism Decision [LR-PED] rule) was obtained using Binary Logistic Regression, including: age, atrial fibrillation at admission, previous heart failure, admission heart rate, creatinine, glycaemia, troponin I and C-reactive protein at admission. ROC curve analysis assessed its overall accuracy for predicting 1-month, intrahospital and 6-month mortality (AUC=0.756, 0.763 and 0.854, respectively). Compared to Geneva and simplified PESI, the LR-PED rule showed higher sensitivity and negative predictive value for the detection of the lowest risk patients. The net reclassification improvement index revealed significant successful upward risk reclassification by the LR-PED model of patients reaching primary or secondary outcomes.

CONCLUSIONS

LR-PED rule seems more attractive than Geneva or simplified PESI in its ability to identify patients at very low mortality risk who would be potentially eligible for outpatient treatment. Prospective validation of this score in larger cohorts is mandatory before its potential implementation.

The Impact of Age on the Delay in Diagnosis in Patients With Acute Pulmonary Embolism

It has been speculated that the atypical clinical presentation of acute pulmonary embolism (PE) in older patients leads to a late diagnosis and therefore contributes to a worse prognosis. Therefore, we prospectively evaluated the delay in diagnosis and its relation to the in-hospital mortality in 202 patients with acute PE. Patients >65 years presented more often with hypoxia ( P = .017) and with a history of syncope ( P = .046). Delay in diagnosis was not statistically different in both age groups. Older age was significantly associated with an increased risk for in-hospital mortality (OR 4.36, 95% CI 0.93-20.37, P = .043), whereas the delay in diagnosis was not associated with an increase of in-hospital mortality. We therefore conclude that the clinical presentation of acute PE in older patients cannot be considered as a risk factor for late diagnosis and is not responsible for their higher in-hospital death rate.