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Láinez-Ramos-Bossini A, Moreno-Suárez S, Pérez-García M, Gálvez-López R, Garrido Sanz F, Rivera-Izquierdo M. Acute pulmonary embolism: Appropriateness of emergency department management according to clinical guidelines. RADIOLOGIA 2022; 64:291-299. [PMID: 36030076 DOI: 10.1016/j.rxeng.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/26/2020] [Indexed: 10/18/2022]
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Láinez-Ramos-Bossini AJ, Moreno-Suárez S, Pérez-García MC, Gálvez-López R, Sanz FG, Rivera-Izquierdo M. Acute pulmonary embolism: appropriateness of emergency department management according to clinical guidelines. RADIOLOGIA 2020; 64:S0033-8338(20)30111-9. [PMID: 33008620 DOI: 10.1016/j.rx.2020.06.004] [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: 03/25/2020] [Revised: 06/11/2020] [Accepted: 06/26/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS To evaluate the frequency of acute pulmonary embolism, the use of clinical probability scores, and the appropriateness of the management of patients for whom computed tomography angiography (CTA) was requested from the emergency department for suspected acute pulmonary embolism. MATERIALS AND METHODS This was a retrospective observational study of CTA studies requested from the emergency department to rule out acute pulmonary embolism. We analyzed clinical variables and the explicit use of clinical probability scores. We determined the appropriateness of management according to the Wells Score and Geneva Score and the simplified versions of these two scores, calculated retrospectively. RESULTS We included 534 patients (52.8% women; mean age, 73 years). The frequency of acute pulmonary embolism was 23.0% and the Wells Score was explicitly used in 15.2%. The appropriateness of the management varied depending on the clinical probability score used to assess it (54.5%-75.8%) and on whether the standard D-dimer or age-adjusted D-dimer was used. CONCLUSIONS The failure to use the Wells Scores in all cases does not necessarily imply inappropriate management, and the performance of global clinical judgment can be similar to that of clinical probability scores; however, specific studies are necessary to confirm this hypothesis.
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Affiliation(s)
- A J Láinez-Ramos-Bossini
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España; Programa de Doctorado en Medicina Clínica y Salud Pública, Universidad de Granada, Granada, España.
| | - S Moreno-Suárez
- Servicio de Urgencias, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M C Pérez-García
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - R Gálvez-López
- Servicio de Urgencias, Hospital Universitario Virgen de las Nieves, Granada, España
| | - F Garrido Sanz
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Rivera-Izquierdo
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España; Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario San Cecilio, Granada, España
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Ozdemir M, Sonmez BM, Yilmaz F, Yilmaz A, Duyan M, Komut S. Is Bedside End-Tidal CO 2 Measurement a Screening Tool to Exclude Pulmonary Embolism in Emergency Department? J Clin Med Res 2019; 11:696-702. [PMID: 31636784 PMCID: PMC6785277 DOI: 10.14740/jocmr3941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/24/2019] [Indexed: 12/23/2022] Open
Abstract
Background Pulmonary embolism (PE) is among the most difficult conditions to diagnose in emergency department. The majority of patients thought to have PE are tested positive for D-dimer and subsequently tested with advanced diagnostic modalities. Novel noninvasive tests capable of excluding PE may obviate the need for advanced imaging tests. We studied the role of combined clinical probability assessment and end-tidal carbon dioxide (ETCO2) measurement for diagnosis of possible PE in emergency department. Methods We included 100 consecutive subjects suspected to have PE and a positive D-dimer test to study clinical probability of PE and ETCO2 levels. ETCO2 > 34 mm Hg was found to be the best cut-off point for diagnosing PE. PE was ultimately eliminated or diagnosed by spiral computed tomography (CT). Results Diagnostic performances of tests were as follows: ETCO2 and D-dimer had a sensitivity of 100% and a negative predictive value (NPV) of 100% at the cut-off levels of 34 mm Hg and 500 ng/mL, respectively; Wells score had a sensitivity of 80% and NPV of 69.7% at a score of 4. Conclusions ETCO2 alone cannot reliably exclude PE. Combining it with clinical probability, however, reliably and correctly eliminates or diagnoses PE and prevents further testing to be done.
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Affiliation(s)
- Metin Ozdemir
- Department of Emergency Medicine, Istanbul Esenyurt Necmi Kadioglu State Hospital, Istanbul, Turkey
| | - Bedriye Muge Sonmez
- Department of Emergency Medicine, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Fevzi Yilmaz
- Department of Emergency Medicine, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Aykut Yilmaz
- Department of Cardiology, Siirt State Hospital, Siirt, Turkey
| | - Murat Duyan
- Department of Emergency Medicine, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Seval Komut
- Department of Emergency Medicine, Erol Olcok Education and Research Hospital, Hitit University, Corum, Turkey
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El Yaagoubi A, Michelet P, Vaïsse B, Deharo JC, Morange P, Sarlon-Bartoli G. [Evaluation of an "Emergency Thrombosis" care system in a university-hospital department of general emergencies]. JOURNAL DE MÉDECINE VASCULAIRE 2019; 44:184-193. [PMID: 31029272 DOI: 10.1016/j.jdmv.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
Abstract
GOAL Describe the use of diagnostic, prognostic and therapeutic algorithms for venous thromboembolism (VTE), derived from the 2014 European guidelines, in a teaching hospital's emergencies department and compare two groups: the 2015 group "without a care path" and the 2017 group "with a care path". METHOD Comparative and retrospective study of the characteristics of emergencies department patients admitted for VTE from January to June 2015 for the 2015 group and from January to June 2017 for the 2017 group. RESULTS Seventy-nine patients were included in the 2015 group and 62 patients in the 2017 group. In 24% of cases a clinical probability rule was calculated in the 2017 group (vs. no score in 2015, P<0.05). In the 2015 group, 10% of patients did not have a D-Dimer measurement in case of low clinical probability (vs. 0% in 2017, P<0.05). For both groups, the severity score sPESI was not noted in the medical record. All patients with pulmonary embolism were hospitalized in both groups. A total of 36% of patients with deep vein thrombosis (DVT) were hospitalized in the 2015 group (vs. none in 2017, P<0.05). A total of 52.5% of patients were treated with direct oral anticoagulants (DOAS) in the 2017 group vs. 32.5% in the 2015 group (P<0.05). In 18% of cases DOAS were prescribed by emergency physicians in the 2017 group vs. 2.5% in the 2015 group (P<0.05). Mean hospital stay was 7.4 days in the 2017 group and 9.4 days in the 2015 group (P<0.05). CONCLUSION We observed a change in clinical practices and prescriptions after the establishment of an "Emergency Thrombosis" care system. Indeed, improvement in the calculation of the clinical probability score, increase in the outpatient management of DVT, increase in prescribing DOAS and reducing the length of hospital stay were the main revisions. The implementation of standardized digitally calculated clinical and prognostic probability scores would optimize this care path, as well as allow a better distribution of the post-emergency consultations created for outpatients.
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Affiliation(s)
- A El Yaagoubi
- Unité d'hypertension artérielle et de médecine vasculaire, hôpital de la Timone, CHU de la Timone, AP-HM, 264, rue Saint-pierre, 13385 Marseille cedex 05, France; UMR MD2, Aix Marseille Université, 27 boulevard Jean-Moulin 13005 Marseille, France
| | - P Michelet
- Service d'accueil des urgences de la Timone, CHU de la Timone, AP-HM, 13385 Marseille cedex 05, France; UMR MD2, Aix Marseille Université, 27 boulevard Jean-Moulin 13005 Marseille, France
| | - B Vaïsse
- Unité d'hypertension artérielle et de médecine vasculaire, hôpital de la Timone, CHU de la Timone, AP-HM, 264, rue Saint-pierre, 13385 Marseille cedex 05, France; UMR MD2, Aix Marseille Université, 27 boulevard Jean-Moulin 13005 Marseille, France
| | - J C Deharo
- Unité d'hypertension artérielle et de médecine vasculaire, hôpital de la Timone, CHU de la Timone, AP-HM, 264, rue Saint-pierre, 13385 Marseille cedex 05, France; UMR MD2, Aix Marseille Université, 27 boulevard Jean-Moulin 13005 Marseille, France
| | - P Morange
- UMR MD2, Aix Marseille Université, 27 boulevard Jean-Moulin 13005 Marseille, France; Laboratoire d'hématologie, CHU de la Timone, AP-HM, 13385 Marseille cedex 05, France; Unité Inserm C2VN, AMU, faculté de médecine de Marseille, 27 boulevard Jean-Moulin 13005 Marseille, France
| | - G Sarlon-Bartoli
- Unité d'hypertension artérielle et de médecine vasculaire, hôpital de la Timone, CHU de la Timone, AP-HM, 264, rue Saint-pierre, 13385 Marseille cedex 05, France; UMR MD2, Aix Marseille Université, 27 boulevard Jean-Moulin 13005 Marseille, France; Unité Inserm C2VN, AMU, faculté de médecine de Marseille, 27 boulevard Jean-Moulin 13005 Marseille, France.
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Nakayama Y, Shimizu T, Mochizuki Y, Hayashi K, Matsuda C, Nagao M, Watabe K, Kawata A, Oyanagi K, Isozaki E, Nakano I. Predictors of impaired communication in amyotrophic lateral sclerosis patients with tracheostomy-invasive ventilation. Amyotroph Lateral Scler Frontotemporal Degener 2015; 17:38-46. [PMID: 26121169 DOI: 10.3109/21678421.2015.1055276] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Predictors of communication impairment in patients with amyotrophic lateral sclerosis (ALS) using tracheostomy-invasive ventilation (TIV) were investigated. Seventy-six ALS patients using TIV were enrolled and classified into three subgroups of communication ability: patients who could communicate with communication devices (Stage I), patients who had difficulty with communication (Stage II, III, or IV), and patients who could not communicate by any means (Stage V). Predictors of communication impairment were analysed by the Cox proportional hazard model. Results demonstrated that there were no significant differences in disease duration between subgroups. Within 24 months after disease onset, patients who needed TIV and tube feeding, developed oculomotor impairment or became totally quadriplegic and progressed from Stage I to II and V significantly earlier. Multivariate analyses revealed that within 24 months from onset, the need for TIV and progression to total quadriplegia were significant events in patients who progressed to Stage II, whereas the development of oculomotor limitation was significant in patients who progressed to Stage V. In conclusion, TIV, impaired oculomotor movement and total quadriplegia are predictors of severe communication impairment. Rapid disease progression might indicate future communication impairment after the use of TIV. We highly recommend early detection of impaired communication and identification of the best methods of communication.
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Affiliation(s)
- Yuki Nakayama
- a Laboratory of Nursing Research for Intractable Disease, Tokyo Metropolitan Institute of Medical Science , Tokyo , Japan
| | - Toshio Shimizu
- b Department of Neurology , Tokyo Metropolitan Neurological Hospital , Tokyo , Japan
| | - Yoko Mochizuki
- c Department of Pathology , Tokyo Metropolitan Neurological Hospital , Tokyo , Japan.,d Department of Neurology , Tokyo Metropolitan Kita Medical and Rehabilitation Center for the Disabled
| | - Kentaro Hayashi
- b Department of Neurology , Tokyo Metropolitan Neurological Hospital , Tokyo , Japan
| | - Chiharu Matsuda
- a Laboratory of Nursing Research for Intractable Disease, Tokyo Metropolitan Institute of Medical Science , Tokyo , Japan
| | - Masahiro Nagao
- b Department of Neurology , Tokyo Metropolitan Neurological Hospital , Tokyo , Japan
| | - Kazuhiko Watabe
- e ALS and Neuropathy Project, Tokyo Metropolitan Institute of Medical Science , Tokyo , Japan
| | - Akihiro Kawata
- b Department of Neurology , Tokyo Metropolitan Neurological Hospital , Tokyo , Japan
| | - Kiyomitsu Oyanagi
- f Department of Brain Disease Research , Shinshu University School of Medicine , Nagano , Japan
| | - Eiji Isozaki
- b Department of Neurology , Tokyo Metropolitan Neurological Hospital , Tokyo , Japan
| | - Imaharu Nakano
- b Department of Neurology , Tokyo Metropolitan Neurological Hospital , Tokyo , Japan
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