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Kang SY, Jo IJ, Heo S, Chang H, Lee G, Park JE, Kim T, Lee SU, Kim MJ, Yoon H. Emergency medicine residents' learning curve in diagnosing deep vein thrombosis with 3-point venous point-of-care ultrasound. Int J Emerg Med 2024; 17:75. [PMID: 38886639 PMCID: PMC11181670 DOI: 10.1186/s12245-024-00645-x] [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: 01/12/2024] [Accepted: 05/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Many cases of deep vein thrombosis (DVT) are diagnosed in the emergency department, and abbreviated lower extremity venous point-of-care ultrasound (POCUS) has already shown an accuracy comparable to that of specialists. This study aimed to identify the learning curve necessary for emergency medicine (EM) residents to achieve expertise-level accuracy in diagnosing DVT through a 3-point lower extremity venous POCUS. METHODS This prospective study was conducted at an emergency department between May 2021 and October 2022. Four EM residents underwent a one-hour POCUS training session and performed DVT assessments in participants with DVT symptoms or confirmed pulmonary embolism. POCUS was performed at three proximal lower extremity sites to evaluate the thrombi presence and vein compressibility, with results validated by specialized radiology ultrasound. Cumulative sum (CUSUM) and the Bush and Mosteller models were used to analyze the learning curve, while generalized estimating equations were used to identify factors affecting diagnostic accuracy. RESULTS 91 POCUS scans were conducted in 49 patients, resulting in 22% DVT confirmed by specialized venous ultrasound. In the CUSUM analysis, all four EM residents attained a 90% success rate at the common femoral vein, whereas only half achieved this rate when all three sites were considered. According to Bush and Mosteller models, 13-18 cases are required to attain 90-95% diagnostic accuracy. After 10-16 cases, the examination time for each resident decreased, and a 20% increase in examiner confidence was linked to a 2.506-fold increase in the DVT diagnosis accuracy. CONCLUSION EM residents generally required 13-18 cases for 90-95% DVT diagnostic accuracy, but proficiency varied among individuals, particularly requiring more cases for regions outside the common femoral vein.
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Affiliation(s)
- Soo Yeon Kang
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, Chung- Ang University School of Medicine, Gwangmyeong, Gyeonggi-do, 14353, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon-do, 24341, Republic of Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sejin Heo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hansol Chang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Guntak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Min Ji Kim
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, 06351, Republic of Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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2
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Townsend Reeves M, Lahil H, Gold A, Danckers M, Dubensky L, Slesinger TL. Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report. J Emerg Med 2024; 66:e694-e700. [PMID: 38763838 DOI: 10.1016/j.jemermed.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. CASE REPORT A 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.
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Affiliation(s)
- M Townsend Reeves
- Department of Emergency Medicine, HCA Florida Aventura Hospital, Aventura, Florida
| | - Harjeev Lahil
- Department of Emergency Medicine, HCA Florida Aventura Hospital, Aventura, Florida
| | - Aaron Gold
- Department of Radiology, HCA Florida Aventura Hospital, Aventura, Florida
| | - Mauricio Danckers
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, Florida
| | - Laurence Dubensky
- Department of Emergency Medicine, HCA Florida Aventura Hospital, Aventura, Florida
| | - Todd L Slesinger
- Department of Emergency Medicine, HCA Florida Aventura Hospital, Aventura, Florida
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3
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Okoli ML, Rao P, Kavuma S, Bulusu RV, Hanna-Moussa S, Vahdat K. POCUS for Thrombus: Emphasizing the Importance of Initial Point-of-Care Ultrasound in the Management of Pulmonary Thromboembolism. Cureus 2024; 16:e58272. [PMID: 38752077 PMCID: PMC11094530 DOI: 10.7759/cureus.58272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/18/2024] Open
Abstract
Pulmonary embolism (PE) constitutes a substantial health burden among individuals in the United States. It ranks as the third most common cause of cardiovascular death aside from stroke and myocardial infarction. Diagnostic errors are common with PE as patients can present with non-specific symptoms or could be completely asymptomatic with PE being an incidental finding. Diagnostic errors can result in missed or late diagnosis of PE, which, in turn, increases health care costs, morbidity, and mortality rates. Hence, early diagnosis is crucial. Computed tomography pulmonary angiography (CTPA) remains the gold standard in PE diagnosis, despite exposure to high doses of radiation. Point-of-care ultrasound (POCUS) is an underutilized, non-invasive technique that aids in the early diagnosis of PE and can safely reduce the radiation from CTPA in cases where contraindication exists. POCUS has been shown to have a high sensitivity and specificity for early diagnosis of PE.
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Affiliation(s)
| | - Poonam Rao
- Internal Medicine, CHRISTUS Health/Texas A&M College of Medicine, Longview, USA
| | - Siima Kavuma
- Internal Medicine, CHRISTUS Health/Texas A&M College of Medicine, Longview, USA
| | - Ravi Vijay Bulusu
- Internal Medicine, CHRISTUS Health/Texas A&M College of Medicine, Longview, USA
| | | | - Khashayar Vahdat
- Cardiology, CHRISTUS Health/Texas A&M College of Medicine, Longview, USA
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4
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Rössler J, Cywinski JB, Argalious M, Ruetzler K, Khanna S. Anesthetic management in patients having catheter-based thrombectomy for acute pulmonary embolism: A narrative review. J Clin Anesth 2024; 92:111281. [PMID: 37813080 DOI: 10.1016/j.jclinane.2023.111281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/25/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
Pulmonary embolism is the third leading cause of cardiovascular death. Novel percutaneous catheter-based thrombectomy techniques are rapidly becoming popular in high-risk pulmonary embolism - especially in the presence of contraindications to thrombolysis. The interventional nature of these procedures and the risk of sudden cardiorespiratory compromise requires the presence of an anesthesiologist. Facilitating catheter-based thrombectomy can be challenging since qualifying patients are often critically ill. The purpose of this narrative review is to provide guidance to anesthesiologists for the assessment and management of patients having catheter-based thrombectomy for acute pulmonary embolism. First, available techniques for catheter-based thrombectomy are reviewed. Then, we discuss definitions and application of common risk stratification tools for pulmonary embolism, and how to assess patients prior to the procedure. An adjudication of risks and benefits of anesthetic strategies for catheter-based thrombectomy follows. Specifically, we give guidance and rationale for use monitored anesthesia care and general anesthesia for these procedures. For both, we review strategies for assessing and mitigating hemodynamic perturbations and right ventricular dysfunction, ranging from basic monitoring to advanced inodilator therapy. Finally, considerations for management of right ventricular failure with mechanical circulatory support are discussed.
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Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jacek B Cywinski
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sandeep Khanna
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiothoracic and Vascular Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
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5
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Popat A, Harikrishnan S, Seby N, Sen U, Patel SK, Mittal L, Patel M, Vundi C, Patel Y, Babita, Kumar A, Nakrani AA, Patel M, Yadav S. Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e52371. [PMID: 38694948 PMCID: PMC11062642 DOI: 10.7759/cureus.52371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 05/04/2024] Open
Abstract
Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion, POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.
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Affiliation(s)
- Apurva Popat
- Internal Medicine, Marshfield Clinic Health System, Marshfield, USA
| | | | - Niran Seby
- Internal Medicine, Tbilisi State Medical University, Tbilisi, GEO
| | - Udvas Sen
- Internal Medicine, Agartala Government Medical College, Agartala, IND
| | - Sagar K Patel
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj, IND
| | - Lakshay Mittal
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Mitkumar Patel
- Internal Medicine, Mahatma Gandhi Mission (MGM) Medical College, Navi Mumbai, IND
| | - Charitha Vundi
- Internal Medicine, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, IND
| | - Yashasvi Patel
- Internal Medicine, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Babita
- Internal Medicine, Uzhhorod National University, Uzhhorod, UKR
| | - Ashish Kumar
- General Practice, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
| | - Akash A Nakrani
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Surat, IND
| | - Mahir Patel
- Medical School, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Sweta Yadav
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
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6
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Allena N, Khanal S. The Algorithmic Lung Detective: Artificial Intelligence in the Diagnosis of Pulmonary Embolism. Cureus 2023; 15:e51006. [PMID: 38259362 PMCID: PMC10803098 DOI: 10.7759/cureus.51006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/24/2024] Open
Abstract
Pulmonary embolism (PE) poses a significant threat as the third leading cause of cardiovascular death, prompting the widespread use of CT pulmonary angiogram for rapid detection. Despite its prevalence, diagnostic accuracy remains variable among radiologists. The emergence of artificial intelligence (AI), notably through convolutional neural networks and deep learning reconstruction, offers a promising avenue to enhance PE detection. AI demonstrates superior sensitivity and negative predictive values, reducing the risk of missed diagnoses. Implementation of AI-based worklist prioritization substantially shortens detection and notification times, streamlining radiological workflows. However, it is crucial to underscore that AI acts as a complement, not a replacement, for radiologists, synergizing with human expertise. As AI integration progresses, it holds the potential to significantly improve diagnostic accuracy and efficiency in pulmonary embolism detection while maintaining the essential role of human judgment in medical decision-making.
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Affiliation(s)
| | - Sneha Khanal
- Internal Medicine, BronxCare Health System, Bronx, USA
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7
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Lian TY, Cao Y. Prediction of recurrent venous thromboembolism: The writing is on the wall. J Thromb Haemost 2023; 21:1420-1422. [PMID: 37179071 DOI: 10.1016/j.jtha.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Tian-Yu Lian
- Medical Science Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunshan Cao
- Department of Cardiology, Pulmonary Vascular Disease Center, Gansu Provincial Hospital, Lanzhou, China.
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8
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Incidence and Prognostic Role of Pleural Effusion in Patients with Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12062315. [PMID: 36983315 PMCID: PMC10058137 DOI: 10.3390/jcm12062315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 03/19/2023] Open
Abstract
Background: Pleural effusion is a common pulmonary embolism (PE) complication, which has been documented to increase the risk of death in PE and relate to disease progression. However, the incidence of pleural effusion varies among studies and its association with PE outcome is still unclear. This study sought to determine the pooled incidence and prognostic value of pleural effusion events in patients with PE. Methods: We systematically searched the PubMed, EMBASE, SCOPE, Web of Science, Cochrane, LILACS, CINAHL, EBSCO, AMED, and OVID databases from the inception of each database to 7 September 2022 with a restriction on human studies, to identify studies assessing the association between pleural effusion and PE including all prospective and retrospective clinical studies. An exploratory meta-analysis was performed using a random-effects model. We evaluated the heterogeneity and performed subgroup analyses. Results: The final meta-analysis included 29 studies involving 13,430 PE patients. The pooled incidence of pleural effusion in PE patients was 41.2% (95% CI: 35.7–46.6%), which tended to be unilateral (pooled incidence: 60.8%, 95% CI: 45.7–75.8%) and small (pooled incidence: 85.9%, 95% CI: 82.6–89.1%). Pooled analysis using a random-effects model (I2 = 53.2%) showed that pleural effusion was associated with an increased risk of 30-day mortality (RR 2.19, 95% CI: 1.53–3.15, p < 0.001, I2 = 67.1%) and in-hospital mortality (RR 2.39, 95% CI: 1.85–3.09, p < 0.001, I2 = 37.1%) in patients with PE. Conclusions: Our meta-analysis found that PE patients had a high incidence of pleural effusion, which was usually unilateral and small. Pleural effusion generally increases 30-day and in-hospital mortality in patients with PE, and it is recommended that physicians be aware of the risk of death from PE, especially when patients have pleural effusion. Further investigations focusing on PE with pleural effusion are warranted.
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9
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Oleksiuk-Bójko M, Lisowska A. Venous thromboembolism: Why is it still a significant health problem? Adv Med Sci 2023; 68:10-20. [PMID: 36368288 DOI: 10.1016/j.advms.2022.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/08/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) remains the third leading cause of acute cardiovascular syndrome following myocardial infarction and ischemic stroke. The global burden of disease worldwide is high and shows a steady upward trend in recent years with an incidence of 1-2 per 1000 adults per year. The overarching goal of the initial management of VTE is to prevent early and late adverse outcomes. Rapid evaluation and therapeutic intervention is vital to improving prognosis. METHODS We searched PubMed, Science Direct and Scopus databases for articles published in the last 10 years. Additionally, some earlier articles were analyzed. RESULTS For the purposes of this review, we discussed how understanding the epidemiology of VTE and the current knowledge of early and late complications of this disease have shaped the current approach to VTE prevention. We also analyzed the current knowledge and the most up-to-date information about VTE in COVID-19 infection. Contemporary perspective presented in this article on mortality in VTE, the incidence of recurrences, the risk of major bleeding during therapy and the chronic complications indicate why this is a major challenge for today's medicine and a current target for further research. CONCLUSIONS Understanding the interaction between environmental and genetic factors appears to be crucial in the diagnostic process. It can provide insight into the pathophysiology of VTE, potentially identifying options for targeted prevention and treatment. However, due to differences in clinical presentation, diagnosing pulmonary embolism may not be an easy task which perfectly illustrates the scale and complexity of the disease.
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Affiliation(s)
- Monika Oleksiuk-Bójko
- Department of Cardiology, University Clinical Hospital in Bialystok, Bialystok, Poland
| | - Anna Lisowska
- Department of Cardiology, University Clinical Hospital in Bialystok, Bialystok, Poland.
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10
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Xu H, Li H, Xu Q, Zhang Z, Wang P, Li D, Guo L. Automatic detection of pulmonary embolism in computed tomography pulmonary angiography using Scaled-YOLOv4. Med Phys 2023. [PMID: 36633186 DOI: 10.1002/mp.16218] [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: 07/24/2022] [Revised: 11/10/2022] [Accepted: 12/24/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a common but fatal clinical condition and the gold standard of diagnosis is computed tomography pulmonary angiography (CTPA). Prompt diagnosis and rapid treatment can dramatically reduce mortality in patients. However, the diagnosis of PE is often delayed and missed. METHODS In this study, we identified a deep learning model Scaled-YOLOv4 that enables end-to-end automated detection of PE to help solve these problems. A total of 307 CTPA data (Tianjin 142 cases, Linyi 133 cases, and FUMPE 32 cases) were included in this study. The Tianjin dataset was divided 10 times in the ratio of training set: validation set: test set = 7:2:1 for model tuning, and both the Linyi and FUMPE datasets were used as independent external test sets to evaluate the generalization of the model. RESULTS Scaled-YOLOv4 was able to process one patient in average 3.55 s [95% CI: 3.51-3.59 s]. It also achieved an average precision (AP) of 83.04 [95% CI: 79.36-86.72] for PE detection on the Tianjin test set, and 75.86 [95% CI: 75.48-76.24] and 72.74 [95% CI: 72.10-73.38] on Linyi and FUMPE, respectively. CONCLUSIONS This deep learning algorithm helps detect PE in real time, providing radiologists with aided diagnostic evidence without increasing their workload, and can effectively reduce the probability of delayed patient diagnosis.
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Affiliation(s)
- Haijun Xu
- School of Medical Imaging, Tianjin Medical University, Tianjin, China
| | - Huiyao Li
- Department of MR, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Qifei Xu
- Department of Radiology, Linyi people's Hospital, Linyi, Shandong, China
| | - Zewei Zhang
- Department of Nuclear Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping Wang
- School of Medical Imaging, Tianjin Medical University, Tianjin, China
| | - Dong Li
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Li Guo
- School of Medical Imaging, Tianjin Medical University, Tianjin, China
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11
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Serebriakoff P, Cafferkey J, de Wit K, Horner DE, Reed MJ. Pulmonary embolism management in the emergency department: part 2. J Accid Emerg Med 2023; 40:69-75. [PMID: 35383107 DOI: 10.1136/emermed-2021-212001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/20/2022] [Indexed: 01/10/2023]
Abstract
Pulmonary embolism (PE) can present with a range of severity. Prognostic risk stratification is important for efficacious and safe management. This second of two review articles discusses the management of high-, intermediate- and low-risk PE. We discuss strategies to identify patients suitable for urgent outpatient care in addition to identification of patients who would benefit from thrombolysis. We discuss specific subgroups of patients where optimal treatment differs from the usual approach and identify emerging management paradigms exploring new therapies and subgroups.
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Affiliation(s)
| | - John Cafferkey
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Daniel E Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK .,Acute Care Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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12
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Thomas Z, Banks J, Eaton AA, Ward LM. 25 years of psychology research on the “strong black woman”. SOCIAL AND PERSONALITY PSYCHOLOGY COMPASS 2022. [DOI: 10.1111/spc3.12705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Zharia Thomas
- Department of Psychology Florida International University Miami Florida USA
| | - Jasmine Banks
- Department of Psychology University of Michigan Ann Arbor Michigan USA
| | - Asia A. Eaton
- Department of Psychology Florida International University Miami Florida USA
| | - L. Monique Ward
- Department of Psychology University of Michigan Ann Arbor Michigan USA
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13
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Karimialavijeh E, Khaksar A, Pishgahi G, Sadat Hashemi M, Jalali A. Tricuspid Annular Plane Systolic Excursion (TAPSE) Measurement by Emergency Medicine Residents in Patients Suspected of Pulmonary Emboli. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2079-2085. [PMID: 34825725 DOI: 10.1002/jum.15892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/21/2021] [Accepted: 10/29/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES We aimed to evaluate the ability of emergency medicine (EM) residents to measure tricuspid annular plane systolic excursion (TAPSE) by M-Mode ultrasound. METHODS Four EM residents with prior focused cardiac ultrasound (FOCUS) experience participated in 10 hours of hands-on training and then performed TAPSE measurements in adult patients at high risk of having pulmonary emboli (PE) between December 2020 and April 2021. Patients underwent bedside echocardiography by cardiology residents, and a CT pulmonary angiogram (CTPA) was performed to confirm the diagnosis. The agreement between EM and cardiology residents was assessed by intraclass correlation coefficient (ICC). RESULTS Sixty-six patients were included (mean age = 58.7 ± 16.7 years), of which 28 patients (42.8%) had positive CTPA. The mean TAPSE, measured by EM residents was 16.36 ± 1.59 mm in the PE positive group and 21.68 ± 2.87 mm in the PE negative group (P-value = <.0001). The mean ± SD TAPSE, measured by cardiology residents, was 17.7 ± 1.98 mm in the PE group and 22.5 ± 3.6 mm in the PE negative group (P-value = <.0001). There was significant agreement between EM and cardiology residents in terms of measuring TAPSE (ICC = 0.91, 95% confidence interval [CI] = 0.80-0.95). The receiver operating characteristic (ROC) curves of TAPSE for diagnosing PE revealed that TAPSE, measured by EM residents, had a high level of accuracy (area under the ROC curve [AUC] = 0.93, 95% CI, 0.878-0.99). CONCLUSIONS EM residents can perform M-Mode TAPSE measurement in suspected PE cases after 10 hours of hands-on training. TAPSE measurement should be added to routine FOCUS protocols, especially when there is suspicion of PE.
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Affiliation(s)
- Ehsan Karimialavijeh
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Afshin Khaksar
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghasem Pishgahi
- Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Mozhgan Sadat Hashemi
- Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Jalali
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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14
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Affiliation(s)
- Susan R Kahn
- From Lady Davis Institute at Jewish General Hospital and the Department of Medicine, McGill University, Montreal (S.R.K.), the Department of Emergency Medicine, Queen's University, Kingston, ON (K.W.), and the Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (K.W.) - all in Canada
| | - Kerstin de Wit
- From Lady Davis Institute at Jewish General Hospital and the Department of Medicine, McGill University, Montreal (S.R.K.), the Department of Emergency Medicine, Queen's University, Kingston, ON (K.W.), and the Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (K.W.) - all in Canada
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Rozykhodzhaeva GA, Zhuraev ZA. Comparative retrospective analysis of the prevalence of deep vein thrombosis detected by duplex ultrasound in primary health care facilities. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To identify the incidence of deep vein thrombosis (DVT) as determined by compressive duplex ultrasound in primary health care facilities before and during the pandemic of a coronavirus disease 2019 (COVID-19).Material and methods. This retrospective analysis of 1492 duplex ultrasound examinations in 2018 and 1710 examinations in 2020-2021 in patients with suspected lower limb DVT was performed. The studies were carried out in 4 primary health care institutions in different cities of the Republic of Uzbekistan. Each patient underwent duplex ultrasound of lower limb deep veins. Most patients had complaints (swelling, leg pain) (symptomatic patients), while some individuals underwent preventive screening before various surgical interventions and had no complaints (asymptomatic patients).Results. According to the data obtained, the prevalence of DVT increased significantly during the pandemic — from 3,9 to 15,1% (χ2=113,23, p<0,001). During the pandemic, there was a trend towards a relative increase in lower limb DVT among the elderly and young people — by 8,7 and 3,8%, respectively (χ2=1,66, p=0,19 and χ2=0,64, p=0,42, respectively). No dependence of the prevalence of lower limb DVT on the sex was found (χ2=0,02, r=0,9).Conclusion. The study results showed an increase in the prevalence of lower limb DVT during the COVID-19 pandemic. Further clinical studies are needed to analyze the lower limb DVT during this period.
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Affiliation(s)
| | - Z. A. Zhuraev
- Center of Development of Professional Qualification of Health Workers
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16
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How artificial intelligence improves radiological interpretation in suspected pulmonary embolism. Eur Radiol 2022; 32:5831-5842. [PMID: 35316363 PMCID: PMC8938594 DOI: 10.1007/s00330-022-08645-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 12/29/2021] [Accepted: 02/04/2022] [Indexed: 11/05/2022]
Abstract
Objectives To evaluate and compare the diagnostic performances of a commercialized artificial intelligence (AI) algorithm for diagnosing pulmonary embolism (PE) on CT pulmonary angiogram (CTPA) with those of emergency radiologists in routine clinical practice. Methods This was an IRB-approved retrospective multicentric study including patients with suspected PE from September to December 2019 (i.e., during a preliminary evaluation period of an approved AI algorithm). CTPA quality and conclusions by emergency radiologists were retrieved from radiological reports. The gold standard was a retrospective review of CTPA, radiological and clinical reports, AI outputs, and patient outcomes. Diagnostic performance metrics for AI and radiologists were assessed in the entire cohort and depending on CTPA quality. Results Overall, 1202 patients were included (median age: 66.2 years). PE prevalence was 15.8% (190/1202). The AI algorithm detected 219 suspicious PEs, of which 176 were true PEs, including 19 true PEs missed by radiologists. In the cohort, the highest sensitivity and negative predictive values (NPVs) were obtained with AI (92.6% versus 90% and 98.6% versus 98.1%, respectively), while the highest specificity and positive predictive value (PPV) were found with radiologists (99.1% versus 95.8% and 95% versus 80.4%, respectively). Accuracy, specificity, and PPV were significantly higher for radiologists except in subcohorts with poor-to-average injection quality. Radiologists positively evaluated the AI algorithm to improve their diagnostic comfort (55/79 [69.6%]). Conclusion Instead of replacing radiologists, AI for PE detection appears to be a safety net in emergency radiology practice due to high sensitivity and NPV, thereby increasing the self-confidence of radiologists. Key Points • Both the AI algorithm and emergency radiologists showed excellent performance in diagnosing PE on CTPA (sensitivity and specificity ≥ 90%; accuracy ≥ 95%). • The AI algorithm for PE detection can help increase the sensitivity and NPV of emergency radiologists in clinical practice, especially in cases of poor-to-moderate injection quality. • Emergency radiologists recommended the use of AI for PE detection in satisfaction surveys to increase their confidence and comfort in their final diagnosis. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-022-08645-2.
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Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year Single-Center Observational Study. J Interv Cardiol 2021; 2021:9923440. [PMID: 34803526 PMCID: PMC8572623 DOI: 10.1155/2021/9923440] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/27/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To describe our institution's experience with the AngioVac system. Background Intracardiac and intravascular masses previously required surgical excision, but now, there are a number of minimally invasive options. With the advent of vacuum aspiration, more specifically the AngioVac System (AngioDynamics, NY, USA), there exists a system with both low mortality and minor complications. However, the number of retrospective studies remains limited. Outcome data for high-risk patients are also limited. Methods Data were collected and analyzed in patients who underwent AngioVac therapy at our tertiary care center from January 2014 to December 2020. Results Our results demonstrated a 93.3% intraoperative success rate and a 100% intraoperative survival rate. However, a number of complications, including but not limited to hematomas, anemia, and hypotension, occurred, as described below. Conclusions Our experiences demonstrated good outcomes and continue to support the usefulness of the AngioVac System. The data also support the use of AngioVac as a treatment option for the debulking or removal of right heart masses in critically ill patients.
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Affiliation(s)
- Neeraja Murali
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Sahar Morkos El Hayek
- Washington University in Saint Louis, 660 S Euclid Avenue CB 8072, St Louis, MO 63110, USA
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19
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CT pulmonary angiography appropriateness in a single emergency department: does the use of revised Geneva score matter? Radiol Med 2021; 126:1544-1552. [PMID: 34518985 PMCID: PMC8702417 DOI: 10.1007/s11547-021-01416-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE To assess the percentage of computed tomography pulmonary angiography (CTPA) procedures that could have been avoided by methodical application of the Revised Geneva Score (RGS) coupled with age-adjusted D-dimer cut-offs rather than only clinical judgment in Emergency Department patients with suspected pulmonary embolism (PE). MATERIAL AND METHODS Between November 2019 and May 2020, 437 patients with suspected PE based on symptoms and D-dimer test were included in this study. All patients underwent to CTPA. For each patient, we retrospectively calculated the age-adjusted D-dimer cut-offs and the RGS in the original version. Finally, CT images were retrospectively reviewed, and the presence of PE was recorded. RESULTS In total, 43 (9.84%) CTPA could have been avoided by use of RGS coupled with age-adjusted D-dimer cut-offs. Prevalence of PE was 14.87%. From the analysis of 43 inappropriate CTPA, 24 (55.81%) of patients did not show any thoracic signs, two (4.65%) of patients had PE, and the remaining patients had alternative thoracic findings. CONCLUSION The study showed good prevalence of PE diagnoses in our department using only physician assessment, although 9.84% CTPA could have been avoided by methodical application of RGS coupled with age-adjusted D-dimer cut-offs.
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Varrias D, Palaiodimos L, Balasubramanian P, Barrera CA, Nauka P, Melainis AA, Zamora C, Zavras P, Napolitano M, Gulani P, Ntaios G, Faillace RT, Galen B. The Use of Point-of-Care Ultrasound (POCUS) in the Diagnosis of Deep Vein Thrombosis. J Clin Med 2021; 10:3903. [PMID: 34501350 PMCID: PMC8432124 DOI: 10.3390/jcm10173903] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022] Open
Abstract
Acute lower extremity proximal deep venous thrombosis (DVT) requires accurate diagnosis and treatment in order to prevent embolization and other complications. Point-of-care ultrasound (POCUS), a clinician performed, and clinician interpreted bedside ultrasound examination has been increasingly used for DVT evaluation mainly in the urgent and critical care setting, but also in the ambulatory clinics and the medical wards. Studies have demonstrated that POCUS has excellent diagnostic accuracy for acute proximal DVT when performed by well-trained users. However, there is significant heterogeneity among studies on the necessary extent of training and universally acceptable standardized education protocols are needed. In this review, we summarize the evidence that supports the use of POCUS to diagnose acute proximal DVT and focus on methodology and current technology, sensitivity and specificity, pre-test probability and the role of D-dimer, time and resources, education, limitations, and future directions.
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Affiliation(s)
- Dimitrios Varrias
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Leonidas Palaiodimos
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Prasanth Balasubramanian
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Christian A Barrera
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Peter Nauka
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
- Department of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
| | - Angelos Arfaras Melainis
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Christian Zamora
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Phaedon Zavras
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Marzio Napolitano
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Perminder Gulani
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - George Ntaios
- Department of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece;
| | - Robert T. Faillace
- Department of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 3N1, Bronx, NY 10461, USA; (P.B.); (C.A.B.); (A.A.M.); (C.Z.); (P.Z.); (M.N.); (P.G.); (R.T.F.)
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
| | - Benjamin Galen
- Albert Einstein College of Medicine, Bronx, NY 10461, USA; (P.N.); (B.G.)
- Department of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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Müller-Peltzer K, Kretzschmar L, Negrão de Figueiredo G, Crispin A, Stahl R, Bamberg F, Trumm CG. Present Limitations of Artificial Intelligence in the Emergency Setting - Performance Study of a Commercial, Computer-Aided Detection Algorithm for Pulmonary Embolism. ROFO-FORTSCHR RONTG 2021; 193:1436-1444. [PMID: 34352914 DOI: 10.1055/a-1515-2923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Since artificial intelligence is transitioning from an experimental stage to clinical implementation, the aim of our study was to evaluate the performance of a commercial, computer-aided detection algorithm of computed tomography pulmonary angiograms regarding the presence of pulmonary embolism in the emergency room. MATERIALS AND METHODS This retrospective study includes all pulmonary computed tomography angiogram studies performed in a large emergency department over a period of 36 months that were analyzed by two radiologists experienced in emergency radiology to set a reference standard. Original reports and computer-aided detection results were compared regarding the detection of lobar, segmental, and subsegmental pulmonary embolism. All computer-aided detection findings were analyzed concerning the underlying pathology. False-positive findings were correlated to the contrast-to-noise ratio. RESULTS Expert reading revealed pulmonary embolism in 182 of 1229 patients (49 % men, 10-97 years) with a total of 504 emboli. The computer-aided detection algorithm reported 3331 findings, including 258 (8 %) true-positive findings and 3073 (92 %) false-positive findings. Computer-aided detection analysis showed a sensitivity of 47 % (95 %CI: 33-61 %) on the lobar level and 50 % (95 %CI 43-56 %) on the subsegmental level. On average, there were 2.25 false-positive findings per study (median 2, range 0-25). There was no significant correlation between the number of false-positive findings and the contrast-to-noise ratio (Spearman's Rank Correlation Coefficient = 0.09). Soft tissue (61.0 %) and pulmonary veins (24.1 %) were the most common underlying reasons for false-positive findings. CONCLUSION Applied to a population at a large emergency room, the tested commercial computer-aided detection algorithm faced relevant performance challenges that need to be addressed in future development projects. KEY POINTS · Computed tomography pulmonary angiograms are frequently acquired in emergency radiology.. · Computer-aided detection algorithms (CADs) can support image analysis.. · CADs face challenges regarding false-positive and false-negative findings.. · Radiologists using CADs need to be aware of these limitations.. · Further software improvements are necessary ahead of implementation in the daily routine.. CITATION FORMAT · Müller-Peltzer K, Kretzschmar L, Negrão de Figueiredo G et al. Present Limitations of Artificial Intelligence in the Emergency Setting - Performance Study of a Commercial, Computer-Aided Detection Algorithm for Pulmonary Embolism. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1515-2923.
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Affiliation(s)
- Katharina Müller-Peltzer
- Klinik für Diagnostische und Interventionelle Radiologie, Albert-Ludwigs-Universität Freiburg Medizinische Fakultät, Freiburg, Deutschland
| | - Lena Kretzschmar
- Klinik und Poliklinik für Radiologie, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Alexander Crispin
- Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Klinikum der Universität München-Großhadern, München, Deutschland
| | - Robert Stahl
- Institut für Diagnostische und Interventionelle Neuroradiologie, Klinikum der Universität München-Großhadern, München, Deutschland
| | - Fabian Bamberg
- Klinik für Diagnostische und Interventionelle Radiologie, Albert-Ludwigs-Universität Freiburg Medizinische Fakultät, Freiburg, Deutschland
| | - Christoph Gregor Trumm
- Institut für Diagnostische und Interventionelle Neuroradiologie, Klinikum der Universität München-Großhadern, München, Deutschland
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Al-Zaher N, Vitali F, Neurath MF, Goertz RS. The Positive Rate of Pulmonary Embolism by CT Pulmonary Angiography Is High in an Emergency Department, Even in Low-Risk or Young Patients. Med Princ Pract 2021; 30:37-44. [PMID: 32911479 PMCID: PMC7923846 DOI: 10.1159/000511464] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 09/09/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The clinical presentation of pulmonary embolism (PE) can be various and misleading. We analyzed patients with suspicion of PE and subsequently performed computed tomography pulmonary angiography (CTPA) in an emergency department of Internal Medicine, focusing on patient groups in which PE might be underestimated in the emergency setting, such as young patients and patients with low clinical probability. MATERIAL AND METHODS In 2016 and 2017, all patients receiving a CTPA for investigation of PE were retrospectively evaluated for clinical parameters (age, symptoms, and vital parameters) and D-dimers. The Wells score was calculated. RESULTS CTPA was performed in 323 patients (158 female and 165 male; mean age 62 years). The leading symptoms for admission were dyspnea or chest pain; 62% showed intermediate or high risk for PE, calculated by applying the Wells score. In 123 (38%) of all patients, a PE was proved and pathologic age-adjusted D-dimers were found in 97.6%. Thirty of 121 (25%) patients with low risk according to Wells score had a PE. Deep vein thrombosis was verified in 67/123 (55%) patients; 43% (15/35) of all suspicions for PE in patients <40 years were positive with 4/15 (26%), showing a central PE. Younger patients (<40 years) with PE presented more often with tachycardia or tachypnea and chest pain or dyspnea than elderly patients with PE. CONCLUSION CTPA frequently proves a PE in patients with suspicion of PE in an emergency department of Internal Medicine. If PE is suspected and CTPA performed accordingly, the presence of PE is quite common even in low-risk patient groups (Wells score) or in young patients <40 years with chest pain or dyspnea.
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Affiliation(s)
- Nizam Al-Zaher
- Department of Internal Medicine 1, Friedrich-Alexander-University Erlangen-Nurnberg, Erlangen, Germany
| | - Francesco Vitali
- Department of Internal Medicine 1, Friedrich-Alexander-University Erlangen-Nurnberg, Erlangen, Germany
| | - Markus F Neurath
- Department of Internal Medicine 1, Friedrich-Alexander-University Erlangen-Nurnberg, Erlangen, Germany
| | - Ruediger S Goertz
- Department of Internal Medicine 1, Friedrich-Alexander-University Erlangen-Nurnberg, Erlangen, Germany,
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Challenging anticoagulation cases: A case of acute pulmonary embolism in a patient with chronic thrombocytopenia. Thromb Res 2020; 198:83-85. [PMID: 33302211 DOI: 10.1016/j.thromres.2020.11.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/06/2020] [Accepted: 11/27/2020] [Indexed: 01/08/2023]
Abstract
We present a case of acute pulmonary embolism in a patient with myelofibrosis and thrombocytopenia. The patient had a history of portal vein thrombosis and had taken warfarin for the past six years. At the time of his pulmonary embolism diagnosis, his INR was 1.5 and platelet count 58 × 109/L. This article discusses how to balance the risk of thrombosis against the risk of bleeding, and reviews the options for pulmonary embolism treatment including transition to low-molecular-weight heparin, direct oral anticoagulants and/or inferior vena cava filters.
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de Winter MA, van Bergen EDP, Welsing PMJ, Kraaijeveld AO, Kaasjager KHAH, Nijkeuter M. The Prognostic Value of Syncope on Mortality in Patients With Pulmonary Embolism: A Systematic Review and Meta-analysis. Ann Emerg Med 2020; 76:527-541. [PMID: 32461009 DOI: 10.1016/j.annemergmed.2020.03.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/18/2020] [Accepted: 03/25/2020] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE Syncope is a presenting symptom in 10% to 20% of patients with pulmonary embolism. We perform a meta-analysis to clarify the prognostic value of syncope on short-term mortality in pulmonary embolism patients and its association with hemodynamic instability. METHODS PubMed, EMBASE, and the Cochrane Library were searched up until January 7, 2020. Studies reporting inhospital or 30-day mortality of adults with pulmonary embolism with and without syncope were included. Quality of included studies was evaluated with the Quality in Prognosis Studies tool. Meta-analysis was conducted to derive pooled odds ratios (ORs) and risk differences for the relation of syncope with mortality and hemodynamic instability. To study the influence of hemodynamic instability on the association between syncope and mortality, meta-regression was performed. RESULTS Search and selection resulted in 26 studies, of which 20 were pooled, involving 9,419 of 335,120 patients (3%) with syncope. Syncope was associated with higher mortality (OR 1.82; 95% confidence interval [CI] 1.14 to 2.90; I2 88%; risk difference 4% [95% CI 1% to 8%]) and higher prevalence of hemodynamic instability (OR 4.36; 95% CI 2.27 to 8.37; I2 93%; risk difference 12% [95% CI 7% to 18%]). OR for mortality in patients with pulmonary embolism with syncope versus without it was higher in the presence of a larger difference in hemodynamic instability between groups (coefficient 0.05; 95% CI 0.01 to 0.09). CONCLUSION The association between syncope and short-term mortality in patients with pulmonary embolism is explained by a difference in hemodynamic instability. This emphasizes the importance of risk stratification by hemodynamic status in pulmonary embolism patients with and without syncope.
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Affiliation(s)
- Maria A de Winter
- Department of Internal Medicine, UMC Utrecht, Utrecht, the Netherland.
| | | | - Paco M J Welsing
- Department of Internal Medicine, UMC Utrecht, Utrecht, the Netherland
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Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy. Blood Adv 2020; 3:3770-3779. [PMID: 31770442 DOI: 10.1182/bloodadvances.2019000369] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.
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Mortality risk associated with venous thromboembolism: a systematic review and Bayesian meta-analysis. LANCET HAEMATOLOGY 2020; 7:e583-e593. [PMID: 32735837 DOI: 10.1016/s2352-3026(20)30211-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Venous thromboembolism is associated with increased mortality risk in some populations, but how frequently it is a direct cause of death is unclear. We used data from venous thromboembolism prevention trials to evaluate the causal effect of venous thromboembolism reduction on mortality. METHODS We did a systematic review and meta-analysis of randomised controlled trials (RCTs) evaluating venous thromboembolism prevention. We searched MEDLINE, Embase, PubMed, and Web of Science starting from Jan 1, 1993, to March 19, 2018. We included studies of patients who were at elevated risk of venous thromboembolism and were randomly assigned to either anticoagulant or antiplatelet therapy versus placebo or no treatment. We excluded studies with an active control agent (which might mitigate the lethality of venous thromboembolism) and those for which mortality data were unavailable. We modelled heterogeneity in a Bayesian framework, taking overall mortality as a primary endpoint, and pulmonary embolism, fatal pulmonary embolism, and major bleeding as secondary endpoints. We focused our analyses on studies reporting statistically significant effects of prevention on venous thromboembolism endpoints. We report treatment effects as median risk ratios (RRs), wherein a null effect equals 1, with 95% credible intervals (CrIs). This meta-analysis was registered with PROSPERO, CRD42018089697. FINDINGS From 4229 studies screened, we identified 86 eligible RCTs; 52, with data from over 70 000 patients, were positive, with significantly increased venous thromboembolism risk in patients in control groups versus treatment groups (RR 2·74, 95% CrI 2·32-3·31, p<0·0001). The meta-analysis established that the causal effect of venous thromboembolism prevention on mortality was null (control group mortality was 3391 [9·8%] of 34 537 patients; treatment group mortality was 3498 [9·8%] of 35 795 patients [RR 1·01, 95% CrI 0·97-1·06; p=0·58]) with low heterogeneity (τ 0·02, 95% CrI 0·00-0·07, p=0·89). Patients in control groups had more pulmonary embolism (RR 2·22, 95% CrI 1·78-2·89, p<0·0001) and fatal pulmonary embolism (1·58, 1·14-2·19, p=0·01), but less major bleeding (0·60, 0·47-0·75, p<0·0001) than those in treatment groups. A meta-analysis with the additional 34 negative studies yielded similar results for all endpoints except fatal pulmonary embolism, where evidence of an effect was weaker (1·42, 1·05-1·91, p=0·02). INTERPRETATION The perception that venous thromboembolism is a common cause of mortality should be revised considering the null effect of venous thromboembolism prevention on mortality. Our findings call into question the use of composite endpoints in venous thromboembolism-prevention trials and provide rationale for de-escalation trials. FUNDING None.
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Kreft D, Keiler J, Grambow E, Kischkel S, Wree A, Doblhammer G. Prevalence and Mortality of Venous Leg Diseases of the Deep Veins: An Observational Cohort Study Based on German Health Claims Data. Angiology 2020; 71:452-464. [PMID: 32166953 DOI: 10.1177/0003319720905751] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study estimates the prevalence and mortality of diseases of the deep veins of the legs such as deep vein thrombosis (DVT), postthrombotic syndrome (PTS), and venous leg ulceration (VLU). We used a random sample of 250 000 patients at age 50+ years of the register of the Allgemeine Ortskrankenkasse from 2004 to 2015. Selected manifestations of venous diseases assumed as risk factors for mortality were analyzed using Cox models while adjusting for various basic demographic and health characteristics. The prevalence in 2004 was 0.05% for DVT of the femoral veins, 0.50% for DVT of any deep veins, 0.86% for PTS, and 0.91% for VLU. The mortality rate in 2004 to 2015 was 20.40 deaths/100 person-years for DVT of the femoral veins, 10.69 for DVT of any deep veins, 4.34 for PTS, and 7.02 for VLU. The model revealed a 35% higher risk (p < .001) in patients with any DVT, an 88% higher mortality (p < .001) for femoral DVT, a 23% higher risk (p < .001) for VLU, and no health disadvantage in persons with PTS. Our study revealed an increased mortality for patients with VLU and DVT. Even after adjustment for embolic events and infections of the venous ulcers mortality remained significantly higher.
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Affiliation(s)
- Daniel Kreft
- Institute for Sociology and Demography, University of Rostock, Rostock, Germany.,Rostock Center for the Study of Demographic Change, Rostock, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Jonas Keiler
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
| | - Eberhard Grambow
- Department of General, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
| | - Sabine Kischkel
- Institute for Biomedical Engineering, Rostock University Medical Center, Rostock, Germany
| | - Andreas Wree
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
| | - Gabriele Doblhammer
- Institute for Sociology and Demography, University of Rostock, Rostock, Germany.,Rostock Center for the Study of Demographic Change, Rostock, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
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Alshami A, Alhillan A, Varon J. Computed Tomographic Angiography in Pulmonary Embolism: Diagnostic or a Screening Tool. CURRENT RESPIRATORY MEDICINE REVIEWS 2020. [DOI: 10.2174/1573398x1503191125144633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Abbas Alshami
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center Neptune, NJ, United States
| | - Alsadiq Alhillan
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center Neptune, NJ, United States
| | - Joseph Varon
- The University of Texas Health Science Center at Houston Chief of Staff and Chief of Critical Care Services United Memorial Medical Center Houston, Texas, United States
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29
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Canty D, Mufti K, Bridgford L, Denault A. Point-of-care ultrasound for deep venous thrombosis of the lower limb. Australas J Ultrasound Med 2019; 23:111-120. [PMID: 34760590 DOI: 10.1002/ajum.12188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The incidence and morbidity of deep venous thrombosis (DVT) and pulmonary embolus are high. Although efforts to increase screening for DVT have been recommended, this is limited by resources. Venous duplex ultrasound has replaced venography as the first-line investigation of choice for DVT, increasing availability and reducing patient exposure to radiation and intravenous contrast. Furthermore, an abbreviated ultrasound where DVT is inferred from incomplete venous compressibility has an equivalent accuracy to venous duplex, requiring less time and training enabling its widespread use by emergency, critical care and anaesthesia clinicians. In this review, the evolution and method of lower limb venous compression ultrasound is described along with evidence for its use in patients at high risk for DVT in these clinical settings.
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Affiliation(s)
- David Canty
- Department of Surgery (Royal Melbourne Hospital) University of Melbourne Level 6 Centre for Medical Research, PO Box 2135 Melbourne Victoria 3050 Australia.,Department of Anaesthesia and Pain Management Royal Melbourne Hospital 300 Grattan Street, Parkville Melbourne Victoria 3050 Australia.,Department of Medicine, Nursing and Health Sciences Monash University Wellington Rd Clayton Victoria 3800 Australia.,Department of Anaesthesia and Perioperative Medicine Monash Health 246 Clayton Rd Clayton Victoria 3168 Australia
| | - Kavi Mufti
- Department of Medicine, Nursing and Health Sciences Monash University Wellington Rd Clayton Victoria 3800 Australia.,Intensive Care Unit Frankston Hospital 2 Hastings Road Frankston Victoria 3199 Australia
| | - Lindsay Bridgford
- Department of Surgery (Royal Melbourne Hospital) University of Melbourne Level 6 Centre for Medical Research, PO Box 2135 Melbourne Victoria 3050 Australia.,Department of Emergency Medicine Maroondah Hospital 1-15 Davey Dr Ringwood East Victoria 3135 Australia
| | - André Denault
- Department of Anesthesiology and Critical Care Faculty of Medicine University of Montreal 2900 Edouard Montpetit Blvd Montreal Quebec H3T 1J4 Canada.,Department of Anesthesiology and Critical Care Montreal Heart Institute 5000 Rue Bélanger Montreal Quebec QC H1T 1C8 Canada
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30
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Al-Samkari H, Connors JM. Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:71-79. [PMID: 31808892 PMCID: PMC6913483 DOI: 10.1182/hematology.2019000369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA; and
| | - Jean M Connors
- Harvard Medical School, Boston, MA; and
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
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31
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Hosein AS, Mahabir VSD, Konduru SKP, Giddings SL. Pulmonary embolism: an often forgotten differential diagnosis for abdominal pain. QJM 2019; 112:689-690. [PMID: 31173142 DOI: 10.1093/qjmed/hcz138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- A S Hosein
- Department of Medicine, San Fernando Teaching Hospital, San Fernando, Trinidad and Tobago
| | - V S D Mahabir
- Department of Medicine, San Fernando Teaching Hospital, San Fernando, Trinidad and Tobago
| | - S K P Konduru
- Department of Radiology, Sangre Grande General Hospital, Sangre Grande, Trinidad and Tobago
| | - S L Giddings
- Department of Clinical Medical Sciences, University of the West Indies at Saint Augustine, Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
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32
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Tajbakhsh N, Shin JY, Gotway MB, Liang J. Computer-aided detection and visualization of pulmonary embolism using a novel, compact, and discriminative image representation. Med Image Anal 2019; 58:101541. [PMID: 31416007 DOI: 10.1016/j.media.2019.101541] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 01/15/2023]
Abstract
Diagnosing pulmonary embolism (PE) and excluding disorders that may clinically and radiologically simulate PE poses a challenging task for both human and machine perception. In this paper, we propose a novel vessel-oriented image representation (VOIR) that can improve the machine perception of PE through a consistent, compact, and discriminative image representation, and can also improve radiologists' diagnostic capabilities for PE assessment by serving as the backbone of an effective PE visualization system. Specifically, our image representation can be used to train more effective convolutional neural networks for distinguishing PE from PE mimics, and also allows radiologists to inspect the vessel lumen from multiple perspectives, so that they can report filling defects (PE), if any, with confidence. Our image representation offers four advantages: (1) Efficiency and compactness-concisely summarizing the 3D contextual information around an embolus in only three image channels, (2) consistency-automatically aligning the embolus in the 3-channel images according to the orientation of the affected vessel, (3) expandability-naturally supporting data augmentation for training CNNs, and (4) multi-view visualization-maximally revealing filling defects. To evaluate the effectiveness of VOIR for PE diagnosis, we use 121 CTPA datasets with a total of 326 emboli. We first compare VOIR with two other compact alternatives using six CNN architectures of varying depths and under varying amounts of labeled training data. Our experiments demonstrate that VOIR enables faster training of a higher-performing model compared to the other compact representations, even in the absence of deep architectures and large labeled training sets. Our experiments comparing VOIR with the 3D image representation further demonstrate that the 2D CNN trained with VOIR achieves a significant performance gain over the 3D CNNs. Our robustness analyses also show that the suggested PE CAD is robust to the choice of CT scanner machines and the physical size of crops used for training. Finally, our PE CAD is ranked second at the PE challenge in the category of 0 mm localization error.
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Affiliation(s)
- Nima Tajbakhsh
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ, USA
| | - Jae Y Shin
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ, USA
| | | | - Jianming Liang
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ, USA.
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Lee JH, Lee SH, Yun SJ. Comparison of 2-point and 3-point point-of-care ultrasound techniques for deep vein thrombosis at the emergency department: A meta-analysis. Medicine (Baltimore) 2019; 98:e15791. [PMID: 31145304 PMCID: PMC6709014 DOI: 10.1097/md.0000000000015791] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND To our knowledge, so far, no studies have comprehensively examined the performance of 2-point and 3-point point-of-care compression ultrasound (POCUS) in the diagnosis of lower extremity deep vein thrombosis (DVT). The aim of this meta-analysis was to compare the performance of 2-point and 3-point POCUS techniques for the diagnosis of DVT and evaluate the false-negative rate of each POCUS method. METHODS A computerized search of the PubMed, EMBASE, and Cochrane library databases was performed to identify relevant original articles. Bivariate modeling and hierarchical summary receiver operating characteristic modeling were performed to compare the diagnostic performance of 2-point and 3-point POCUS. The pooled proportions of the false-negative rate for each POCUS method were assessed using a DerSimonian-Laird random-effects model. Meta-regression analyses were performed according to the patient and study characteristics. RESULTS Seventeen studies from 16 original articles were included (2-point, 1337 patients in 9 studies; 3-point, 1035 patients in 8 studies). Overall, 2-point POCUS had similar pooled sensitivity [0.91; 95% confidence interval (95% CI), 0.68-0.98; P = .86) and specificity (0.98; 95% CI, 0.96-0.99; P = .60) as 3-point POCUS (sensitivity, 0.90; 95% CI, 0.83-0.95 and specificity, 0.95; 95% CI, 0.83-0.99). The false-negative rates of 2-point (4.0%) and 3-point POCUS (4.1%) were almost similar. Meta-regression analysis showed that high sensitivity and specificity tended to be associated with an initial POCUS performer (including attending emergency physician > only resident) and separate POCUS training for DVT (trained > not reported), respectively. CONCLUSION Both 2-point and 3-point POCUS techniques showed excellent performance for the diagnosis of DVT. We recommend that POCUS-trained attending emergency physicians perform the initial 2-point POCUS to effectively and accurately diagnose DVT.
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Affiliation(s)
- Ju Hyung Lee
- Department of Medical Service, 8311 unit, the Republic of Korea Air Force, Chungcheongnam-do
| | - Sun Hwa Lee
- Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine
| | - Seong Jong Yun
- Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Republic of Korea
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Sickle cell disease and venous thromboembolism: A retrospective comparison of the rate of positive CT pulmonary angiography in the emergency department. Eur J Radiol 2019; 110:256-259. [PMID: 30599869 DOI: 10.1016/j.ejrad.2018.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/19/2018] [Accepted: 11/27/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Previous authors have reported an increased incidence of acute pulmonary embolism (PE) in patients with sickle cell disease (SCD) based on retrospective analysis of ICD codes. It is unknown whether patients with SCD have higher rates of positive CT pulmonary angiogram (CTPA) in the emergency department (ED). METHODS The institutional review board (IRB) approved this retrospective study; informed consent was waived. Between January 1, 2005 and May 31, 2015, 28 patients with SCD underwent a total of 78 CTPA studies in the ED. A control group of 75 non-SCD patients matched for age, gender and race underwent 78 consecutive CTPA studies in the emergency department. Modified Wells' (mWells') scores were calculated for each CTPA study performed. The studies for both groups were blind read by two fellowship trained body radiologists. Descriptive statistics were performed, with significance considered if p < 0.05. RESULTS The rate of positive CT pulmonary angiogram in patients with SCD was 6.4% (5/78), compared with 12.8% (10/78) in non-SCD matched controls. There was no significant difference in the rate of positive CTPA (p = 0.277). There was also no difference in the mean mWells' score between the two groups (2.44 for SCD vs. 1.95 for controls, p = 0.120). CONCLUSION SCD patients did not have a significantly different rate of acute PE when compared with matched controls undergoing CTPA in the ED.
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35
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Hachem LD, Mansouri A, Scales DC, Geerts W, Pirouzmand F. Anticoagulant prophylaxis against venous thromboembolism following severe traumatic brain injury: A prospective observational study and systematic review of the literature. Clin Neurol Neurosurg 2018; 175:68-73. [PMID: 30384119 DOI: 10.1016/j.clineuro.2018.09.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 09/16/2018] [Accepted: 09/23/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Venous thromboembolism (VTE) is a serious complication following severe traumatic brain injury (TBI), however, anticoagulant prophylaxis remains controversial due to concerns of intracranial hemorrhage (ICH) progression. We examined anticoagulant prophylaxis practice patterns at a major trauma centre and determined risk estimates for VTE and ICH progression classified by timing of anticoagulant initiation. PATIENTS AND METHODS A 1-year prospective analysis of consecutive patients with severe TBI admitted to a Level-I trauma centre was conducted. In addition, we systematically reviewed the literature to identify studies on VTE and anticoagulant prophylaxis after severe TBI. RESULTS 64 severe TBI patients were included. 83% of patients received anticoagulant prophylaxis, initiated ≥3d post-TBI in 67%. The in-hospital VTE incidence was 16% and there was no significant difference between patients who received early (<3d) versus late (≥3d) prophylaxis (10% vs. 16%). Rates of ICH progression (0% vs. 7%) were similar between groups. Our systematic review identified 5 studies with VTE rates ranging from 5 to 10% with prophylaxis, to 11-30% without prophylaxis. The effect of timing of anticoagulant prophylaxis initiation on ICH progression was not reported in any study. CONCLUSION VTE is a common complication after severe TBI. Anticoagulant prophylaxis is often started late (≥3d) post-injury. Randomized trials are justifiable and necessary to provide practice guidance with regards to optimal timing of anticoagulant prophylaxis.
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Affiliation(s)
- Laureen D Hachem
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - William Geerts
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Farhad Pirouzmand
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Division of Neurosurgery, Sunnybrook Health Science Centre, Toronto, Canada.
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van der Pol LM, Dronkers CEA, van der Hulle T, den Exter PL, Tromeur C, Heringhaus C, Mairuhu ATA, Huisman MV, van den Hout WB, Klok FA. The YEARS algorithm for suspected pulmonary embolism: shorter visit time and reduced costs at the emergency department. J Thromb Haemost 2018; 16:725-733. [PMID: 29431911 DOI: 10.1111/jth.13972] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Indexed: 08/31/2023]
Abstract
Essentials The YEARS algorithm was designed to simplify the diagnostic workup of suspected pulmonary embolism. We compared emergency ward turnaround time of YEARS and the conventional algorithm. YEARS was associated with a significantly shorter emergency department visit time of ˜60 minutes. Treatment of pulmonary embolism was initiated 53 minutes earlier with the YEARS algorithm SUMMARY: Background Recently, the safety of the YEARS algorithm, designed to simplify the diagnostic work-up of pulmonary embolism (PE), was demonstrated. We hypothesize that by design, YEARS would be associated with a shorter diagnostic emergency department (ED) visit time due to simultaneous assessment of pre-test probability and D-dimer level and reduction in number of CT scans. Aim To investigate whether implementation of the YEARS diagnostic algorithm is associated with a shorter ED visit time compared with the conventional algorithm and to evaluate the associated cost savings. Methods We selected consecutive outpatients with suspected PE from our hospital included in the YEARS study and ADJUST-PE study. Different time-points of the diagnostic process were extracted from the to-the-minute accurate electronic patients' chart system of the ED. Further, the costs of the ED visits were estimated for both algorithms. Results All predefined diagnostic turnaround times were significantly shorter after implementation of YEARS: patients were discharged earlier from the ED; 54 min (95% CI, 37-70) for patients managed without computed tomography pulmonary angiography (CTPA) and 60 min (95% CI, 44-76) for the complete study population. Importantly, patients diagnosed with PE by CTPA received the first dose of anticoagulants 53 min (95% CI, 22-82) faster than those managed according to the conventional algorithm. Total costs were reduced by on average €123 per visit. Conclusion YEARS was shown to be associated with a shorter ED visit time compared with the conventional diagnostic algorithm, leading to faster start of treatment in the case of confirmed PE and savings on ED resources.
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Affiliation(s)
- L M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - C E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - T van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - P L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Heringhaus
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - A T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - W B van den Hout
- Department of Medical Decision Making and Quality of CareLeiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Coombs M, Fox B. Outpatient Treatment of Pulmonary Embolism: a Practical Guide. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0144-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pomero F, Borretta V, Bonzini M, Melchio R, Douketis JD, Fenoglio LM, Dentali F. Accuracy of emergency physician–performed ultrasonography in the diagnosis of deep-vein thrombosis. Thromb Haemost 2017; 109:137-45. [DOI: 10.1160/th12-07-0473] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 09/14/2012] [Indexed: 11/05/2022]
Abstract
SummaryDuplex ultrasound is the first-line diagnostic test for detecting lower limb deep-vein thrombosis (DVT) but it is time consuming, requires patient transport, and cannot be interpreted by most physicians. The accuracy of emergency physician–performed ultrasound (EPPU) for the diagnosis of DVT, when performed at the bedside, is unclear. We did a systematic review and meta-analysis of the literature, aiming to provide reliable data on the accuracy of EPPU in the diagnosis of DVT. The MEDLINE and EMBASE databases (up to August 2012) were systematically searched for studies evaluating the accuracy of EPPU compared to either colour-flow duplex ultrasound performed by a radiology department or vascular laboratory, or to angiography, in the diagnosis of DVT. Weighted mean sensitivity and specificity and associated 95% confidence intervals (CIs) were calculated using a bivariate random-effects regression approach. There were 16 studies included, with 2,379 patients. The pooled prevalence of DVT was 23.1% (498 in 2,379 patients), ranging from 7.4% to 47.3%. Using the bivariate approach, the weighted mean sensitivity of EPPU compared to the reference imaging test was 96.1% (95%CI 90.6–98.5%), and with a weighted mean specificity of 96.8% (95%CI:94.6–98.1%). Our findings suggest that EPPU may be useful in the management of patients with suspected DVT. Future prospective studies are warranted to confirm these findings.
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Buchanan I, Teeples T, Carlson M, Steenblik J, Bledsoe J, Madsen T. Pulmonary Embolism Testing Among Emergency Department Patients Who Are Pulmonary Embolism Rule-out Criteria Negative. Acad Emerg Med 2017; 24:1369-1376. [PMID: 28787100 DOI: 10.1111/acem.13270] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/25/2017] [Accepted: 07/29/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Previous studies have demonstrated that rates of pulmonary embolism (PE) testing have increased without a concomitant decrease in PE-related mortality. The Pulmonary Embolism Rule-out Criteria (PERC) intend to reduce testing for PE in the emergency department (ED) by identifying low-risk patients ("PERC-negative") who do not require D-dimer, computed tomography pulmonary angiogram (CTPA), or ventilation/perfusion (VQ) scan for PE. This study assesses PE testing rates among PERC-negative patients presenting to an urban academic ED. METHODS We prospectively enrolled a convenience sample of ED patients with chest pain and/or shortness of breath presenting between June 2010 and December 2015. We recorded baseline variables at the time of ED presentation, information on testing performed in the ED, and the diagnosis of acute PE during the ED visit. We classified patients as PERC-positive or PERC-negative utilizing baseline variables and clinical characteristics. RESULTS Of the 3,024 study patients, 54.8% (95% confidence interval = 53%-56.5%) were female and the mean age was 51.7 (51.1-52.3) years. A total of 17.5% (16.2%-18.9%) of study patients were PERC-negative and 33.7% (32%-35.4%) of all patients underwent testing for PE. A total of 25.5% (22%-29.4%) of PERC-negative patients had PE testing compared to 35.4% (33.6%-37.3%) of PERC-positive patients (p < 0.001). A total of 7.2% (5.3%-9.7%) of PERC-negative patients had advanced imaging without a D-dimer compared to 19.2% (17.8%-20.8%) of PERC-positive patients (p < 0.001). In multivariate analysis, factors associated with PE testing in PERC-negative patients included age, white non-Hispanic race/ethnicity, pleuritic chest pain, and a complaint of both chest pain and shortness of breath. Two PERC-negative patients (0.4%) were diagnosed with an acute PE in the ED compared to 2.2% of PERC-positive patients (p = 0.008). The overall testing yield for PE was 1.6% (0.4%-9.2%) among PERC-negative patients versus 6.3% (4.9%-8.1%) among PERC-positive patients (p = 0.017). CONCLUSION In an academic ED, a significant proportion of PERC-negative patients underwent testing for PE, including CT or VQ scan without D-dimer risk stratification. Future areas of research may include evaluating factors that lead clinicians to pursue PE testing in PERC-negative patients and implementing clinical pathways to minimize practice variability among these patients.
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Affiliation(s)
- Ian Buchanan
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
| | - Troy Teeples
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
| | - Margaret Carlson
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
| | - Jacob Steenblik
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
| | - Joseph Bledsoe
- Emergency Department; Intermountain Medical Center; Murray UT
| | - Troy Madsen
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
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Abstract
Venous thromboembolism (VTE) can present in a variety of different clinical settings and in a diverse, comorbid patient population, both of which will guide the clinician toward the appropriate therapeutic response. Patients who present with pulmonary embolism are at risk for hemodynamic instability, recurrence of VTE, cardiac comorbidities, and increased risk of overall mortality. Prognostication models have been clinically validated for risk stratification and prediction of mortality. Similar to pulmonary embolism, patients with deep vein thrombosis carry a higher risk of VTE recurrence and cardiac comorbidities. Consequently, VTE can be treated by a variety of methods such as anticoagulants or inferior vena cava filters, which bear their own risks and benefits. It is imperative that clinicians monitor patients for complications from VTE and the chosen therapy.
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Ge L, He X, Zhang Y, Zhang Y, Chai F, Jiang L, Webster TJ, Zheng C. A dabigatran etexilate phospholipid complex nanoemulsion system for further oral bioavailability by reducing drug-leakage in the gastrointestinal tract. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2017; 14:S1549-9634(17)30156-9. [PMID: 28842377 DOI: 10.1016/j.nano.2017.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/07/2017] [Accepted: 08/11/2017] [Indexed: 02/06/2023]
Abstract
Dabigatran etexilate (DE) is insoluble at neutral pH values but soluble at low pH values due to protonation, which is the major cause for the poor bioavailability of commercial DE products. Here, we first developed a DE nanoemulsion system and improved dissolution in simulated intestinal fluids by encapsulating DE into an oil phase, but 35.8% of the drug still leaked out. Further, we prepared a DE-phospholipid complex (DE-PC) to enhance lipophilicity and solubility of DE. The resulting DE-PC nanoemulsions significantly (P<0.05) reduced drug leakage and subsequent precipitation. As a result, the relative bioavailability of DE-PC nanoemulsions increased to 147.3% and 606.6% compared to DE nanoemulsions and commercial DE products, respectively. Thus, the presently developed drug-phospholipid complex nanoemulsion system is a promising drug delivery system for improving the oral bioavailability of pH-dependent soluble drugs.
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Affiliation(s)
- Liang Ge
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing, China
| | - Xinyi He
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing, China
| | - Yajie Zhang
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing, China
| | - Yuan Zhang
- Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Fujuan Chai
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing, China
| | - Liqun Jiang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, School of Pharmacy, Xuzhou Medical University, Xuzhou, China
| | - Thomas J Webster
- Department of Chemical Engineering, Northeastern University, Boston, MA, USA.
| | - Chunli Zheng
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing, China.
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Pulmonary CTA in sickle cell patients: quantitative assessment of enhancement quality. Emerg Radiol 2017; 24:667-674. [PMID: 28801805 DOI: 10.1007/s10140-017-1541-3] [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: 05/04/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to validate the observation that pulmonary artery (PA) enhancement is often decreased in sickle cell disease (SCD) patients imaged with MDCT for suspected pulmonary embolism and determine whether contrast infusion parameters are accountable for lower enhancement levels. MATERIALS AND METHODS Retrospective comparison of 35 adult SCD patients imaged for suspected pulmonary embolism (PE) in our emergency department using 128-slice dual source MDCT scanner to 34 age and weight matched adult controls. Bolus tracking data was recorded, and enhancement levels of the main PA and descending aorta were measured. Electronic records were reviewed for demographics, imaging and lab correlation, and infusion parameters. RESULTS Age, weight, contrast infusion rate, and contrast volume were similar for both SCD and control patients. SCD patients had significantly lower main PA enhancement (mean 233 HU, range 151-361 HU) than the control subjects (mean 290 HU, range 138-487 HU) (p < 0.001). Most (74%) SCD subjects had PA enhancement that was <250 HU, while most (68%) control patients had PA enhancement ≥250 HU. Change in PA enhancement per second during bolus tracking was lower in SCD patients (12 HU/s, range -24 to 91 HU/s) than control patients (mean 30 HU/s, range -37 to 138 HU/s), although the difference was not statistically significant (p = 0.08). Hemoglobin levels were significantly lower in the SCD cohort (p < 0.001). CONCLUSION In this series of adult SCD patients with suspected PE imaged with MDCT, main PA enhancement level was lower than controls. Quality improvement investigations should focus on protocol optimization to improve enhancement quality and likelihood of a definitive diagnosis.
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Mason J, Herbert M, Schriger DL. Pulmonary Embolism Prevalence in Admitted Syncope Patients: 1 in 6 Really? Ann Emerg Med 2017; 70:257-260. [DOI: 10.1016/j.annemergmed.2017.04.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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van Mens TE, Scheres LJJ, de Jong PG, Leeflang MMG, Nijkeuter M, Middeldorp S. Imaging for the exclusion of pulmonary embolism in pregnancy. Cochrane Database Syst Rev 2017; 1:CD011053. [PMID: 28124411 PMCID: PMC6464730 DOI: 10.1002/14651858.cd011053.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pulmonary embolism is a leading cause of pregnancy-related death. An accurate diagnosis in pregnant patients is crucial to prevent untreated pulmonary embolism as well as unnecessary anticoagulant treatment and future preventive measures. Applied imaging techniques might perform differently in these younger patients with less comorbidity and altered physiology, who largely have been excluded from diagnostic studies. OBJECTIVES To determine the diagnostic accuracy of computed tomography pulmonary angiography (CTPA), lung scintigraphy and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism during pregnancy. SEARCH METHODS We searched MEDLINE and Embase until July 2015. We used included studies as seeds in citations searches and in 'find similar' functions and searched reference lists. We approached experts in the field to help us identify non-indexed studies. SELECTION CRITERIA We included consecutive series of pregnant patients suspected of pulmonary embolism who had undergone one of the index tests (computed tomography (CT) pulmonary angiography, lung scintigraphy or MRA) and clinical follow-up or pulmonary angiography as a reference test. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction and quality assessment. We contacted investigators of potentially eligible studies to obtain missing information. In the primary analysis, we regarded inconclusive index test results as a negative reference test, and treatment for pulmonary embolism after an inconclusive index test as a positive reference test. MAIN RESULTS We included 11 studies (four CTPA, five lung scintigraphy, two both) with a total of 695 CTPA and 665 lung scintigraphy results. Lung scintigraphy was applied by different techniques. No MRA studies matched our inclusion criteria.Overall, risk of bias and concerns regarding applicability were high in all studies as judged in light of the review research question, as was heterogeneity in study methods. We did not undertake meta-analysis. All studies used clinical follow-up as a reference standard, none in a manner that enabled reliable identification of false positives. Sensitivity and negative predictive value were therefore the only valid test accuracy measures.The median negative predictive value for CTPA was 100% (range 96% to 100%). Median sensitivity was 83% (range 0% to 100%).The median negative predictive value for lung scintigraphy was 100% (range 99% to 100%). Median sensitivity was 100% (range 0% to 100%).The median frequency of inconclusive results was 5.9% (range 0.9% to 36%) for CTPA and 4.0% (range 0% to 23%) for lung scintigraphy. The overall median prevalence of pulmonary embolism was 3.3% (range 0.0% to 8.7%). AUTHORS' CONCLUSIONS Both CTPA and lung scintigraphy seem appropriate for exclusion of pulmonary embolism during pregnancy. However, the quality of the evidence mandates cautious adoption of this conclusion. Important limitations included poor reference standards, necessary assumptions in the analysis regarding inconclusive test results and the inherent inability of included studies to identify false positives. It is unclear which test has the highest accuracy. There is a need for direct comparisons between diagnostic methods, including MR, in prospective randomized diagnostic studies.
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Affiliation(s)
- Thijs E van Mens
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Luuk JJ Scheres
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Paulien G de Jong
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mariska MG Leeflang
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsP.O. Box 22700AmsterdamNetherlands1100 DE
| | - Mathilde Nijkeuter
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
- University Medical Centre UtrechtDepartment of Internal MedicineHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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Starosta RT, Rivero R, de Oliveira FH, Lopes E, Cerski MR. Misdiagnosis of Streptococcus gallolyticus endocarditis. AUTOPSY AND CASE REPORTS 2016; 6:29-33. [PMID: 27818956 PMCID: PMC5087981 DOI: 10.4322/acr.2016.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/17/2016] [Indexed: 11/23/2022] Open
Abstract
Death certificate inaccuracy is of major concern both in the public health domain and in individual health care, since it may yield untruthful data on the incidence, prevalence, and lethality of medical entities, and may hamper prophylactic measures among those who share, with the deceased, the common genetic, environmental, or behavioral risk factors. An effective way to settle this haziness relies on the increase of autopsy performance, increasing manifold the exactitude as well as facing surprising diagnoses. In this report, the authors present the case of a middle-aged woman who sought medical care because of back pain accompanied by weight loss. She died suddenly and unexpectedly in the Emergency Room. In this case, due to the unusual clinical presentation and the patient's unexpected death, the causa mortis would not have been elucidated if the autopsy had not been undertaken.
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Affiliation(s)
| | - Raquel Rivero
- Service of Surgical Pathology - Hospital de Clínicas de Porto Alegre - Universidade Federal do Rio Grande do Sul, Porto Alegre/RS - Brazil
| | - Francine Hehn de Oliveira
- Service of Surgical Pathology - Hospital de Clínicas de Porto Alegre - Universidade Federal do Rio Grande do Sul, Porto Alegre/RS - Brazil
| | - Eron Lopes
- Service of Surgical Pathology - Hospital de Clínicas de Porto Alegre - Universidade Federal do Rio Grande do Sul, Porto Alegre/RS - Brazil
| | - Marcelle Reesink Cerski
- Service of Surgical Pathology - Hospital de Clínicas de Porto Alegre - Universidade Federal do Rio Grande do Sul, Porto Alegre/RS - Brazil
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Bates DDB, Tkacz JN, LeBedis CA, Holalkere N. Suboptimal CT pulmonary angiography in the emergency department: a retrospective analysis of outcomes in a large academic medical center. Emerg Radiol 2016; 23:603-607. [DOI: 10.1007/s10140-016-1425-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 07/14/2016] [Indexed: 10/21/2022]
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Stojanovska J, Carlos RC, Kocher KE, Nagaraju A, Guy K, Kelly AM, Chughtai AR, Kazerooni EA. CT Pulmonary Angiography: Using Decision Rules in the Emergency Department. J Am Coll Radiol 2016; 12:1023-9. [PMID: 26435116 DOI: 10.1016/j.jacr.2015.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/01/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to assess the appropriateness of utilization and diagnostic yields of CT pulmonary angiography (CTPA), comparing two commonly applied decision rules, the pulmonary embolism (PE) rule-out criteria (PERC) and the modified Wells criteria (mWells), in the emergency department (ED) setting. METHODS Institutional review board approval was obtained for this HIPAA-compliant, prospective-cohort, academic single-center study. Six hundred two consecutive adult ED patients undergoing CTPA for suspected PE formed the study population. The outcome was positive or negative for PE by CTPA and at 6-month follow-up. PERC and mWells scores were calculated. A positive PERC score was defined as meeting one or more criteria and a positive mWells score as >4. The percentage of CT pulmonary angiographic examinations that could have been avoided and the diagnostic yield of CTPA using PERC, mWells, and PERC applied to a negative mWells score were calculated. RESULTS The diagnostic yield of CTPA was 10% (61 of 602). By applying PERC, mWells, and PERC to negative mWells score, 17.6% (106 of 602), 45% (273 of 602), and 17.1% (103 of 602) of CT pulmonary angiographic examinations, respectively, could have been avoided. The diagnostic yield in PERC-positive patients was higher than in mWells-positive patients (10% [59 of 602] vs 8% [49 of 602], P < .0001). Among PERC-negative and mWells-negative patients, the diagnostic yields for PE were 1.9% (2 of 106) and 4% (12 of 273), respectively (P = .004). The diagnostic yield of a negative PERC score applied to a negative mWells score was 1.9% (2 of 103). CONCLUSIONS The use of PERC in the ED has the potential to significantly reduce the utilization of CTPA and misses fewer cases of PE compared with mWells, and it is therefore a more efficient decision tool.
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Affiliation(s)
- Jadranka Stojanovska
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan.
| | - Ruth C Carlos
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Keith E Kocher
- Emergency Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Arun Nagaraju
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Karen Guy
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Aine M Kelly
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Aamer R Chughtai
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Ella A Kazerooni
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
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Mulcare MR, Lee RW, Pologe JI, Clark S, Borda T, Sohn Y, Sacco DL, Riley DC. Interrater reliability of emergency physician-performed ultrasonography for diagnosing femoral, popliteal, and great saphenous vein thromboses compared to the criterion standard study by radiology. JOURNAL OF CLINICAL ULTRASOUND : JCU 2016; 44:360-367. [PMID: 26890934 DOI: 10.1002/jcu.22338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/12/2016] [Accepted: 01/13/2016] [Indexed: 06/05/2023]
Abstract
PURPOSE To assess the interrater reliability and test characteristics of lower limb sonographic examination for the diagnosis of deep venous and proximal great saphenous vein thrombosis when performed by Emergency Physicians (EPs) as compared to that by the Department of Radiology (Radiology). The secondary objective was to assess the effects of patient body mass index and EP satisfaction with bedside ultrasound on sensitivity and specificity. METHODS A prospective study was conducted for patients with clinical suspicion for lower extremity thrombus. EPs evaluated for venous thrombosis in the common femoral vein, femoral vein of the thigh, popliteal vein, and proximal great saphenous vein. Subsequently, all patients received ultrasounds by Radiology, the criterion standard. RESULTS One hundred ninety-seven patients (257 individual legs) were evaluated. There was 90-95% agreement between EP and Radiology, moderate kappa agreement for common femoral vein, and femoral vein of the thigh and fair kappa agreement for great saphenous vein and popliteal vein. The sensitivity and specificity of EP ultrasounds compared with criterion standard were lower than previously reported. There was no trend in patient body mass index or provider satisfaction influencing the test characteristics. CONCLUSIONS Our study suggests that point-of-care sonography should not replace Radiology-performed scans. The required amount of training for EPs to be competent in this examination needs further investigation. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:360-367, 2016.
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Affiliation(s)
- Mary R Mulcare
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York
- Emergency Medicine Residency, New York-Presbyterian Hospital, New York, New York
| | - Randall W Lee
- Division of Emergency Medicine, Columbia University Medical Center, New York, New York
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Jonas I Pologe
- Division of Emergency Medicine, Columbia University Medical Center, New York, New York
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Sunday Clark
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York
- Emergency Medicine Residency, New York-Presbyterian Hospital, New York, New York
| | - Tomas Borda
- Department of Family Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Youdong Sohn
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Gyeonggi-do, South Korea
| | - Dana L Sacco
- Emergency Medicine Residency, New York-Presbyterian Hospital, New York, New York
- Division of Emergency Medicine, Columbia University Medical Center, New York, New York
| | - David C Riley
- Emergency Medicine Residency, New York-Presbyterian Hospital, New York, New York
- Division of Emergency Medicine, Columbia University Medical Center, New York, New York
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50
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Beroud S. Embolie pulmonaire de présentation abdominale. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0626-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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