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Rehman A, Singh A, Sridhar P, Wang HY, Velo A, Nguyen D, Ehrlich M, Lookstein R, Steiger DJ. Association of race, ethnicity and insurance status with outcomes for patients with acute pulmonary embolism treated by PERT: a retrospective observational study. Respir Res 2024; 25:259. [PMID: 38915033 PMCID: PMC11197331 DOI: 10.1186/s12931-024-02872-5] [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: 04/13/2024] [Accepted: 06/07/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Management of PE has become streamlined with the implementation of PE Response Teams (PERT). Race, ethnicity and insurance status are known to influence the outcomes of patients with acute PE. However, whether the implementation of PERT-based care mitigates these racial and ethnic disparities remains unknown. Our aim was to assess the association of race, ethnicity and insurance with outcomes for patients with acute PE managed by PERT. METHODS We performed a retrospective chart review of 290 patients with acute PE, who were admitted to one of three urban teaching hospitals in the Mount Sinai Health System (New York, NY) from January 2021 to October 2023. A propensity score-weighted analysis was performed to explore the association of race, ethnicity and insurance status with overall outcomes. RESULTS Median age of included patients was 65.5 years and 149 (51.4%) were female. White, Black and Asian patients constituted 56.2% (163), 39.6% (115) and 3.5% [10] of the cohort respectively. Patients of Hispanic or Latino ethnicity accounted for 8.3% [24] of the sample. The 30-day rates of mortality, major bleeding and 30-day re-admission were 10.3%, 2.1% and 12.8% respectively. Black patients had higher odds of major bleeding (odds ratio [OR]: 1.445; p < 0.0001) when compared to White patients. Patients of Hispanic or Latino ethnicity had lower odds of receiving catheter-directed thrombolysis (OR: 0.966; p = 0.0003) and catheter-directed or surgical embolectomy (OR: 0.906; p < 0.0001) when compared to non-Hispanic/Latino patients. Uninsured patients had higher odds of receiving systemic thrombolysis (OR: 1.034; p = 0.0008) and catheter-directed thrombolysis (OR: 1.059; p < 0.0001), and lower odds of receiving catheter-directed or surgical embolectomy (OR: 0.956; p = 0.015) when compared to insured patients, although the odds of 30-day mortality and 30-day major bleeding were not significantly different. CONCLUSION Within a cohort of PE patients managed by PERT, there were significant associations between race, ethnicity and overall outcomes. Hispanic or Latino ethnicity and uninsured status were associated with lower odds of receiving catheter-directed or surgical embolectomy. These results suggest that disparities related to ethnicity and insurance status persist despite PERT-based care of patients with acute PE.
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Affiliation(s)
- Abdul Rehman
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ, 07103, USA
| | - Avinash Singh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, 10029, USA
| | - Priyanka Sridhar
- Department of Medicine, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, 10029, USA
| | - Hong Yu Wang
- Department of Medicine, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, 10029, USA
| | - Agostina Velo
- Department of Medicine, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, 10029, USA
| | - Destiny Nguyen
- Department of Medicine, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, 10029, USA
| | - Madeline Ehrlich
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, 10029, USA
| | - Robert Lookstein
- Department of Radiology, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, 10029, USA
| | - David J Steiger
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, 10029, USA.
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Rehman A, Bahk J, Baloch HNU, Salman S, Sharma V, Singh A, Steiger DJ. Association of Different Anticoagulation Strategies With Outcomes in Patients Hospitalized With Acute Pulmonary Embolism. Cureus 2024; 16:e61545. [PMID: 38962644 PMCID: PMC11219246 DOI: 10.7759/cureus.61545] [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: 06/02/2024] [Indexed: 07/05/2024] Open
Abstract
Background Therapeutic anticoagulation is the cornerstone of treatment for pulmonary embolism (PE), but the impact of different anticoagulation strategies on patient outcomes remains unclear. In this study, we assessed the association of different anticoagulation strategies with the outcomes of patients with acute PE. Methods A retrospective chart review of 207 patients with acute PE who were admitted to one of three urban teaching hospitals in the Mount Sinai Health System (in New York City) from January 2020 to September 2022 was performed. Demographic, clinical, and radiographic data were recorded for all patients. Multivariate regression analyses were performed to assess the association of different outcomes with the approach of therapeutic anticoagulation used. Results The median age of the included patients was 65 years, and 50.2% were women. The most common approach (n = 153, 73.9%) to therapeutic anticoagulation was initial treatment with unfractionated or low molecular weight heparin followed by a direct-acting oral anticoagulant (DOAC), while heparin alone (either unfractionated or low molecular weight heparin) was used in 37 (17.9%) patients, and another 17 (8.2%) patients were treated with heparin followed by bridging to warfarin. Hospital length of stay was longer for patients in the "heparin to warfarin" group (risk-adjusted incidence rate ratio of 2.52). The rates of in-hospital bleeding, all-cause 30-day mortality, and all-cause 30-day re-admissions did not have any significant association with the therapeutic anticoagulation approach used. Conclusion Patients with acute PE who were initially treated with heparin and subsequently bridged to warfarin had a longer hospital stay. Rates of in-hospital bleeding, 30-day mortality, and 30-day re-admission were not associated with the strategy of therapeutic anticoagulation employed.
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Affiliation(s)
- Abdul Rehman
- Internal Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Jeeyune Bahk
- Internal Medicine, Mount Sinai Hospital, New York City, USA
| | | | - Sidra Salman
- Internal Medicine, Mount Sinai Hospital, New York City, USA
| | - Venus Sharma
- Internal Medicine, Mount Sinai Hospital, New York City, USA
| | - Avinash Singh
- Pulmonary and Critical Care Medicine, Mount Sinai Hospital, New York City, USA
| | - David J Steiger
- Pulmonary and Critical Care Medicine, Mount Sinai Hospital, New York City, USA
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Brand J, McGowan R, Nimunkar A. Review of pulmonary emboli and techniques for their mechanical removal to inform device design. J Med Eng Technol 2020; 44:255-265. [PMID: 32657668 DOI: 10.1080/03091902.2020.1791985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Pulmonary emboli present a significant burden of disease, with limited treatment options for some patients. Mechanical devices for pulmonary emboli removal are becoming increasingly prevalent though more work remains to be done. This paper briefly discusses the mechanical properties of pulmonary emboli, the disease state they cause, and the existing embolectomy devices. The goal of this paper is to aid the design of minimally invasive mechanical pulmonary emboli removal devices, by providing a review of this topic as well as some key design specifications.
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Affiliation(s)
- Jessica Brand
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Roger McGowan
- Research and Development, Boston Scientific, Maple Grove, MN, USA
| | - Amit Nimunkar
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
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Forgerini M, Varallo FR, de Oliveira ARA, de Nadai TR, de Carvalho Mastroianni P. Assessment of the adherence to and costs of the prophylaxis protocol for venous thromboembolism. Clinics (Sao Paulo) 2019; 74:e1143. [PMID: 31433043 PMCID: PMC6691834 DOI: 10.6061/clinics/2019/e1143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/29/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Evaluate adherence to the therapeutic prophylaxis protocol for venous thromboembolism (VTE) as well as the costs of this practice. METHODS A descriptive and cross-sectional study was conducted at a State General Hospital in Brazil through reports of drug dispensions, prescriptions and risk stratification of patients. Adherence to the VTE prophylaxis protocol was monitored. The tests for VTE diagnosis measured the adherence to therapeutic prophylaxis treatment, and the purchase prices of the drugs went into the calculation of drug therapy costs. The level of adherence to prescriptions for VTE prophylaxis in the hospital was classified as "adherence", "non-adherence" and "justified non-adherence" when compared with the protocol. RESULTS Protocol adherence was observed for 50 (30.9%) patients, and non-adherence was observed for 63 (38.9%) patients, generating an additional cost of $180.40/month. Justified non-adherence in 49 (30.2%) patients generated $514.71/month in savings due to a reduction in the number of daily administrations of unfractionated heparin while still providing an effective method for preventing VTE. Twenty-six patients stratified as having medium to high risk of VTE who did not receive prophylaxis were identified, generating $154.41 in savings. However, these data should be evaluated with caution since the risks and outcomes associated with not preventing VTE outweigh the economy achieved from not prescribing a drug when a patient needs it. The only case of VTE identified during the study period was related to justified non-adherence to the protocol. CONCLUSION The protocol is based on scientific evidence that describes an effective therapy to prevent VTE. However, the protocol should be updated because the justifications for non-adherence are based on scientific evidence, and this justified non-adherence generates savings and yields effective disease prevention.
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Affiliation(s)
- Marcela Forgerini
- Departamento de Farmacos e Medicamentos, Faculdade de Ciencias Farmaceuticas, Universidade Estadual de Sao Paulo (UNESP), Araraquara, SP, BR
| | - Fabiana Rossi Varallo
- Departamento de Ciencias Farmaceuticas, Faculdade de Ciencias Farmaceuticas de Ribeirao Preto, Universidade de Sao Paulo, Ribeirao Preto, SP, BR
| | - Alice Rosa Alves de Oliveira
- Departamento de Farmacos e Medicamentos, Faculdade de Ciencias Farmaceuticas, Universidade Estadual de Sao Paulo (UNESP), Araraquara, SP, BR
| | - Tales Rubens de Nadai
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo, Ribeirao Preto, SP, BR
| | - Patrícia de Carvalho Mastroianni
- Departamento de Farmacos e Medicamentos, Faculdade de Ciencias Farmaceuticas, Universidade Estadual de Sao Paulo (UNESP), Araraquara, SP, BR
- *Corresponding author. E-mail:
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Zhao Y, Wu Y, Zuo Z, Suo H, Zhao S, Zhang H. CT pulmonary angiography using different noise index values with an iterative reconstruction algorithm and dual energy CT imaging using different body mass indices: Image quality and radiation dose. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2017; 25:79-91. [PMID: 27802249 DOI: 10.3233/xst-160608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate the differences in imaging quality and radiation dose in CT pulmonary angiography (CTPA) by using fast-kV switching dual energy CT imaging and 3D Smart mA modulation at different body mass indices (BMIs) and at different noise index (NI) values with an adaptive statistical iterative reconstruction (ASIR) algorithm. METHODS Four hundred patients who underwent CTPA were equally divided into two groups: A (18.5 kg/m2 ≦ BMI <24.9 kg/m2) and B (24.9 kg/m2 ≦ BMI ≦ 4.9 kg/m2). The groups were randomly subdivided into four subgroups (n = 50): A1-A4 and B1-B4. The patients in subgroups A1 and B1 underwent fast-kV switching dual energy CT imaging. The other patients underwent 3D Smart mA modulation with the ASIR algorithm at NI values 26, 36, and 46 for A2/B2, A3/B3, and A4/B4, respectively. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of all images were calculated after CTPA. Images were then subjectively evaluated using a 5-point scale. The volume CT dose index and dose-length product (DLP) were recorded and their means calculated. The DLP was converted to the effective dose (ED). RESULTS In group A, the SNR, CNR, and subjective image scores showed no statistical differences (P > 0.05). The ED in subgroup A4 was 67.12% and 31.53% lower than that in A1 and A2, respectively. In group B, the variables showed no significant differences between the subgroups B3, B1, and B2 (P > 0.05). The ED in subgroup B3 was 50.12% and 35.95% lower than that in B1 and B2, respectively. CONCLUSIONS Setting different NI values according to BMIs and applying the ASIR algorithm can more effectively reduce the radiation dose in CTPA than in fast-kV switching dual energy CT, while maintaining image quality. Imaging may be performed at NI = 46 in patients with lower BMI (group A) and at NI = 36 in patients with higher BMI (group B).
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Affiliation(s)
- Yongxia Zhao
- The Affiliated Hospital of Hebei University, Baoding, China
| | - Yanmin Wu
- The Affiliated Hospital of Hebei University, Baoding, China
| | - Ziwei Zuo
- The Affiliated Hospital of Hebei University, Baoding, China
| | - Hongna Suo
- Medicine School of Hebei University, Baoding, China
| | - Sisi Zhao
- The Affiliated Hospital of Hebei University, Baoding, China
| | - Haisong Zhang
- The Affiliated Hospital of Hebei University, Baoding, China
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A Comparison of the Image Quality and Radiation Dose Using 100-kVp Combination of Different Noise Index and 120-kVp in Computed Tomography Pulmonary Angiography. J Comput Assist Tomogr 2016; 40:784-90. [DOI: 10.1097/rct.0000000000000488] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Santos JG, Carmona S, Sequeira JA, Prata A, Santos AI. Pulmonary ventilation/perfusion single photon emission tomography--Initial experience of a Nuclear Medicine Department. REVISTA PORTUGUESA DE PNEUMOLOGIA 2016; 22:27-33. [PMID: 26298531 DOI: 10.1016/j.rppnen.2015.06.011] [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: 02/23/2015] [Revised: 06/14/2015] [Accepted: 06/27/2015] [Indexed: 06/04/2023] Open
Abstract
INTRODUCTION Lung ventilation/perfusion scintigraphy with planar images (V/QS-planar) is very useful for the diagnosis and follow-up of pulmonary thromboembolism (PTE). Acquiring tomographic images (V/QS-SPECT) is a recent development with potential to increase the technique's accuracy. The purpose of this work is to evaluate the added benefits of V/QS-SPECT studies as opposed to traditional planar imaging. PATIENTS AND METHODS We prospectively revised 53 V/QS-planar and V/QS-SPECT exams, performed according to the European Association of Nuclear Medicine guidelines. We evaluated the exams independently, by consensus of two Nuclear Medicine physicians. For both methods, we gave each lung a score expressing the dimension and extension of perfusion defects with normal ventilation. For each lung, we compared the scores with the paired Wilcoxon test, estimating the 95% confidence interval (95 CI) for the respective difference. RESULTS We performed V/QS-SPECT exams without technical difficulties. The paired Wilcoxon test estimated the score difference to be -0.75 (95 CI of -1.0 to -0.5; p-value=9.6 × 10(-7)), expressing a statistically significant difference of about 1 subsegmental defect between both methods, with V/QS-SPECT detecting more defects. DISCUSSION The results demonstrate that V/QS-SPECT identifies a slightly larger number of perfusion defects than V/QS-planar, suggesting a higher sensitivity of this technique. However, more studies are necessary to evaluate the clinical meaning of this fact. CONCLUSION V/QS-SPECT demonstrates a higher capability to identify perfusion defects. This method looks promising, allowing for a greater role of this exam in pulmonary thromboembolism diagnosis and follow-up.
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Affiliation(s)
- J G Santos
- Serviço de Medicina Nuclear, Hospital Garcia de Orta, EPE, Av. Torrado da Silva, 2805-267 Almada, Portugal.
| | - S Carmona
- Serviço de Medicina Nuclear, Hospital Garcia de Orta, EPE, Av. Torrado da Silva, 2805-267 Almada, Portugal
| | - J A Sequeira
- Serviço de Medicina Nuclear, Hospital Garcia de Orta, EPE, Av. Torrado da Silva, 2805-267 Almada, Portugal
| | - A Prata
- Serviço de Medicina Nuclear, Hospital Garcia de Orta, EPE, Av. Torrado da Silva, 2805-267 Almada, Portugal
| | - A I Santos
- Serviço de Medicina Nuclear, Hospital Garcia de Orta, EPE, Av. Torrado da Silva, 2805-267 Almada, Portugal
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Chen WJ, Lin CC, Lin CY, Chang YJ, Sung FC, Kao CH, Yeh JJ. Pulmonary embolism in chronic obstructive pulmonary disease: a population-based cohort study. COPD 2015; 11:438-43. [PMID: 25010753 DOI: 10.3109/15412555.2013.813927] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND To evaluate the incidence of pulmonary embolism (PE) in patients with chronic obstructive pulmonary disease (COPD) in Taiwan. METHODS This was a retrospective population-based cohort study using data retrieved from Taiwan's National Health Insurance Research Database (2000 to 2008), which contains 99% of Taiwanese healthcare data. The evaluations included 355,878 COPD patients and 355,878 non-COPD patients for comparison. RESULTS The incidence of PE in the COPD cohort was 12.31 per 10,000 person-years (1.37/10,000 persons/y), which was approximately 4-times higher than in the comparison cohort (0.35/10,000 persons/y). In the COPD cohort, risk of PE was higher in the young age group (20-59 y, HR 4.64, 95% CI 3.06-7.03) than in other age groups. Risk of PE was higher in patients with COPD combined with hypertension, coronary artery disease, and cancer, or those with previous operation (HR 4.16, 4.75, 4.56, and 4.50 respectively) than in those with COPD and no comorbidity. CONCLUSIONS The overall incidence of PE is lower in Taiwan than in western countries. However, the prevalence of PE in COPD patients is higher than in non-COPD patients and increases with age. It is crucial to incorporate PE into the differential diagnosis of COPD exacerbation for clinical physicians.
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Affiliation(s)
- Wei-Ji Chen
- 1From the Chest Division, Department of Internal Medicine, Mackay Memorial Hospital , Taipei , Taiwan
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García-Sanz M, Pena-Álvarez C, López-Landeiro P, Bermo-Domínguez A, Fontúrbel T, González-Barcala F. Symptoms, location and prognosis of pulmonary embolism. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:194-9. [DOI: 10.1016/j.rppneu.2013.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/05/2013] [Accepted: 09/21/2013] [Indexed: 10/25/2022] Open
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DeMeulenaere S. Critical Hospital Event Caused by Uncontrolled Diabetes. J Nurse Pract 2014. [DOI: 10.1016/j.nurpra.2013.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wang X, Palasubramaniam J, Gkanatsas Y, Hohmann JD, Westein E, Kanojia R, Alt K, Huang D, Jia F, Ahrens I, Medcalf RL, Peter K, Hagemeyer CE. Towards effective and safe thrombolysis and thromboprophylaxis: preclinical testing of a novel antibody-targeted recombinant plasminogen activator directed against activated platelets. Circ Res 2014; 114:1083-93. [PMID: 24508759 DOI: 10.1161/circresaha.114.302514] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
RATIONALE Fibrinolysis is a valuable alternative for the treatment of myocardial infarction when percutaneous coronary intervention is not available in a timely fashion. For acute ischemic stroke, fibrinolysis is the only treatment option with a very narrow therapeutic window. Clinically approved thrombolytics have significant drawbacks, including bleeding complications. Thus their use is highly restricted, leaving many patients untreated. OBJECTIVE We developed a novel targeted fibrinolytic drug that is directed against activated platelets. METHODS AND RESULTS We fused single-chain urokinase plasminogen activator (scuPA) to a small recombinant antibody (scFvSCE5), which targets the activated form of the platelet-integrin glycoprotein IIb/IIIa. Antibody binding and scuPA activity of this recombinant fusion protein were on par with the parent molecules. Prophylactic in vivo administration of scFvSCE5-scuPA (75 U/g body weight) prevented carotid artery occlusion after ferric chloride injury in a plasminogen-dependent process compared with saline (P<0.001), and blood flow recovery was similar to high-dose nontargeted urokinase (500 U/g body weight). Tail bleeding time was significantly prolonged with this high dose of nontargeted urokinase, but not with equally effective targeted scFvSCE5-scuPA at 75 U/g body weight. Real-time in vivo molecular ultrasound imaging demonstrates significant therapeutic reduction of thrombus size after administration of 75 U/g body weight scFvSCE5-scuPA as compared with the same dose of a mutated, nontargeting scFv-scuPA or vehicle. The ability of scFvSCE5-scuPA to lyse thrombi was lost in plasminogen-deficient mice, but could be restored by intravenous injection of plasminogen. CONCLUSIONS Targeting of scuPA to activated glycoprotein IIb/IIIa allows effective thrombolysis and the potential novel use as a fibrinolytic agent for thromboprophylaxis without bleeding complications.
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Affiliation(s)
- Xiaowei Wang
- From Atherothrombosis and Vascular Biology Laboratory (X.W., J.P., Y.G., J.D.H., E.W., K.A., D.H., F.J., I.A., K.P.), and Vascular Biotechnology Laboratory (R.K., K.A., C.E.H.), Baker IDI, Melbourne, Australia; Department of Cardiology and Angiology, University Hospital Freiburg, Germany (I.A.); Fibrinolysis and Gene Regulation Laboratory, Australian Centre for Blood Diseases, Melbourne, Australia (R.L.M.); and Central Clinical School, Monash University, Melbourne, Australia (R.L.M., K.P., C.E.H.)
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Kanaan Y, Knoepp UD, Kelly AM. The influence of education on appropriateness rates for CT pulmonary angiography in emergency department patients. Acad Radiol 2013; 20:1107-14. [PMID: 23931424 DOI: 10.1016/j.acra.2013.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 05/04/2013] [Accepted: 05/04/2013] [Indexed: 02/03/2023]
Abstract
RATIONALE AND OBJECTIVES To evaluate appropriate utilization rates for computed tomography (CT) pulmonary angiography (CTPA) in a tertiary center emergency department (ED), before and after a health care provider educational intervention. MATERIALS AND METHODS Institutional Review Board-approved retrospective study. Records for 100 consecutive CTPA studies ordered by the ED were retrieved from a radiology database. Appropriateness rates for the studies were determined using information from existing literature (clinical decision rules and society guidelines). Where pretest probability was not performed, it was calculated by the authors. After ED health care provider education regarding appropriateness guidelines through a dedicated lecture and question-and-answer session, appropriateness rates for another 100 consecutive CTPA ordered by the ED were calculated. RESULTS In the preeducational intervention, 1% of patients had Wells scores performed, 65% were women, and 29% were age <40 years. Before CTPA, 40% patients had d-dimer testing, 15% of patients had a "negative" d-dimer, 17% had alternative explanations for chest pain, and 76% had low or intermediate pretest probability. Appropriateness rates for CTPA was 7%, and 8% of studies were positive. Postintervention, no Wells scores were performed, 59% were women, and 34% <40 years. Before CTPA, 32% of patients had d-dimer, 16% had a "negative" d-dimer, 22% had alternative explanations for chest pain, and 84% had low or intermediate pretest probability. The appropriateness rate for CTPA was 6% and 10% of studies were positive. CONCLUSION A single educational intervention had no effect on appropriate utilization rates for CTPA. Repeated and sustained educational interventions may help improve imaging ordering pathways through the ED and other departments.
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Hedner C, Sundgren PC, Kelly AM. Associations between presence of relevant information in referrals to radiology and prevalence rates in patients with suspected pulmonary embolism. Acad Radiol 2013; 20:1115-21. [PMID: 23931425 DOI: 10.1016/j.acra.2013.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 04/20/2013] [Accepted: 05/02/2013] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to assess if the presence of information including the pretest probability (Wells score), other known risk factors, and symptoms given on referrals for computed tomography (CT) pulmonary angiography correlated with prevalence rates for pulmonary embolism (PE). Also, to evaluate for differences between a university and a regional hospital setting regarding patient characteristics, amount of relevant information provided on referrals, and prevalence rates for pulmonary embolism. MATERIALS AND METHODS Retrospective review of all consecutive referrals (emergency room, inpatient, and outpatient) for CT performed on children and adults for suspected PE from two sites: a tertiary (university) hospital (site 1) and a secondary (regional) hospital (site 2) over a 5-year period. RESULTS The overall prevalence rate was 510/3641 or 14% of all referrals. Significantly higher number of males had a positive CT compared to women (18% versus 12%, P < .001). Although no statistically significant relationship between a greater amount of relevant information on the referral and the probability for positive finding existed, a slight trend was noted (P = .09). In two categories, "hypoxia" and "signs of deep vein thrombosis," the presence of this information conferred a higher probability for pulmonary embolism, P < .001. In the categories, "chest pain," "malaise," and "smoker/chronic obstructive pulmonary disease", the absence of information conferred a higher probability for pulmonary embolism. CONCLUSIONS The amount of relevant clinical information on the request did not correlate with prevalence rates, which may reflect a lack of documentation on the part of emergency physicians who may use a "gestalt" approach. Request forms likely did not capture all relevant patient risks and many factors may interact with each other, both positively and negatively. Pretest probability estimations were rarely performed, despite their inclusion in major society guidelines.
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Affiliation(s)
- Charlotta Hedner
- Center for Medical Imaging and Physiology, Skåne University Hospital, Lund University, Lund, Sweden
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Nicolaides A, Fareed J, Kakkar AK, Comerota AJ, Goldhaber SZ, Hull R, Myers K, Samama M, Fletcher J, Kalodiki E, Bergqvist D, Bonnar J, Caprini JA, Carter C, Conard J, Eklof B, Elalamy I, Gerotziafas G, Geroulakos G, Giannoukas A, Greer I, Griffin M, Kakkos S, Lassen MR, Lowe GDO, Markel A, Prandoni P, Raskob G, Spyropoulos AC, Turpie AG, Walenga JM, Warwick D. Diagnosis and Anticoagulant Treatment. Clin Appl Thromb Hemost 2013; 19:187-98. [DOI: 10.1177/1076029612474840n] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Monn MF, Haut ER, Lau BD, Streiff M, Wick EC, Efron JE, Gearhart SL. Is venous thromboembolism in colorectal surgery patients preventable or inevitable? One institution's experience. J Am Coll Surg 2013; 216:395-401.e1. [PMID: 23312467 DOI: 10.1016/j.jamcollsurg.2012.12.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 12/05/2012] [Accepted: 12/05/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The rate of venous thromboembolism (VTE) in colorectal surgery patients is reportedly high. Herein, we describe characteristics of patients developing VTE in the early postoperative period. STUDY DESIGN A retrospective cohort analysis was conducted using institutional comprehensive data on colorectal surgery patients from the National Surgical Quality Improvement Program. All patients from July 2009 to July 2011 were included. Multivariable logistic regression was used to assess which factors were associated with increased risk of developing VTE within 30 days of operation. RESULTS There were 615 patients who underwent colorectal surgery. Twenty-five (4.1%) developed VTE; 16 (2.6%) deep venous thrombosis (DVT), 4 (0.7%) pulmonary embolus (PE), and 5 (0.8%) developed both DVT and PE. Among VTE patients, 23 (92%) were ordered risk-appropriate VTE prophylaxis. On multivariable analysis, risk factors associated with VTE included postoperative infection (odds ratio [OR] 4.21, 95% CI 1.79, 9.89; p = 0.001), disseminated cancer (OR 4.38, 95% CI 1.24, 15.42; p = 0.022), and emergent status (OR 2.80, 95% CI 1.15, 6.85; p = 0.024). Fourteen (56.0%) of the 25 VTE patients also developed infectious complications compared with 168 (28.5%) of patients without VTE (p = 0.001). Organ space surgical site infections were the most common infection, present in 7 VTE patients. The infectious complications in 9 (64.3%) of the 14 patients occurred before or the same day as the VTE. CONCLUSIONS Most VTE events occurred in colorectal surgery patients ordered current best practice prophylaxis for VTE. Further investigation is warranted to identify patients at increased risk for VTE and to develop new strategies to further reduce the incidence of postoperative VTE.
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Stein PD, Matta F, Alrifai A, Rahman A. Trends in case fatality rate in pulmonary embolism according to stability and treatment. Thromb Res 2012; 130:841-6. [DOI: 10.1016/j.thromres.2012.07.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 06/27/2012] [Accepted: 07/12/2012] [Indexed: 10/28/2022]
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18
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Ji S, Fang W, Dong N, He Z, Ruan C. Detection of Thromboembolism with 99mTc-labeled F(ab)2 Fragment of Anti-glycoprotein IIIa Chimeric Monoclonal Antibody in Beagle Canines. Thromb Res 2012; 130:703-8. [DOI: 10.1016/j.thromres.2012.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/29/2012] [Accepted: 07/04/2012] [Indexed: 01/15/2023]
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Stein PD, Matta F. Noninvasive Imaging in Pulmonary Embolism According to Age and Gender. Clin Appl Thromb Hemost 2012; 20:143-6. [DOI: 10.1177/1076029612462763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Some now recommend a lung scan if the plain chest radiograph is normal instead of computed tomographic (CT) angiography to minimize the risks of radiation in younger patients with suspected pulmonary embolism. The purpose of this investigation is to determine practice standards according to age and gender in regard to noninvasive imaging. Data are from the Nationwide Inpatient Patient, 1998 to 2009. In 2006 to 2009, the proportion of females with pulmonary embolism imaged with CT angiography was 275 (90%) of 305 among teenagers and girls, 3990 (87%) of 4570 among women 20 to 40 years, and 25 650 (85%) of 30 160 among women >40 years. Among males the proportion imaged with CT angiography was 175 (92%) of 190 among teenagers and boys, 3000 (89%) of 3370 among men 20 to 40 years, and 21 280 (86%) of 24 800 among men >40 years. In conclusion, contrary to the recommendations of some, CT angiography is usually obtained in young patients.
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Affiliation(s)
- Paul D. Stein
- Department of Research, St. Mary Mercy Hospital, Livonia, MI, USA
- Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Fadi Matta
- Department of Research, St. Mary Mercy Hospital, Livonia, MI, USA
- Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
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Viteri-Ramírez G, García-Lallana A, Simón-Yarza I, Broncano J, Ferreira M, Pueyo J, Villanueva A, Bastarrika G. Low radiation and low-contrast dose pulmonary CT angiography: Comparison of 80 kVp/60 ml and 100 kVp/80 ml protocols. Clin Radiol 2012; 67:833-9. [PMID: 22683247 DOI: 10.1016/j.crad.2011.11.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 11/06/2011] [Accepted: 11/08/2011] [Indexed: 10/28/2022]
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Abstract
Unlike in adults, pulmonary embolism (PE) is an infrequent event in children. It has a marked bimodal distribution during the paediatric years, occurring predominantly in neonates and adolescents. The most important predisposing factors to PE in children are the presence of a central venous line (CVL), infection, and congenital heart disease. Clinical signs of PE are non-specific in children or can be masked by underlying conditions. Diagnostic testing is necessary in children, especially with the lack of clinical prediction rules. Recommendations for tests are derived from adult studies with ventilation/perfusion (V/Q) scintigraphy being well established. There exists an increasing role for computerised tomography pulmonary angiography (CTPA) and magnetic resonance pulmonary angiography (MRPA). Thrombotic events in children are initially treated with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). For the extended anticoagulant therapy LMWH or vitamin K antagonists can be used with duration of treatment recommendations extrapolated from adult data. Mortality rates for PE in children are reported to be around 10%, with death usually related to the underlying disease processes. Exact data about recurrence risk in children is unknown. Because of the difference in aetiology, presentation, diagnostic methods and treatment between adults and children further research is necessary to assess the validity of recommendations for children.
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Affiliation(s)
- F Nicole Dijk
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia
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22
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Abstract
Pulmonary embolism (PE) remains one of the most challenging medical diseases in the emergency department. PE is a potentially life threatening diagnosis that is seen in patients with chest pain and/or dyspnea but can span the clinical spectrum of medical presentations. In addition, it does not have any particular clinical feature, laboratory test, or diagnostic modality that can independently and confidently exclude its possibility. This article offers a review of PE in the emergency department. It emphasizes the appropriate determination of pretest probability, the approach to diagnosis and management, and special considerations related to pregnancy and radiation exposure.
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Affiliation(s)
- David W Ouellette
- Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
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Lee JY, Lee SY, Shin I, Park C, Lee BS, Kim MS. Fatal pulmonary embolism and coincidental cerebral infarction after spinal anesthesia -A case report-. Korean J Anesthesiol 2012; 61:515-8. [PMID: 22220231 PMCID: PMC3249576 DOI: 10.4097/kjae.2011.61.6.515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 04/02/2011] [Accepted: 04/26/2011] [Indexed: 11/23/2022] Open
Abstract
A pulmonary embolism and cerebral infarction are the second and third most common acute cardiovascular diseases after a myocardial infarction. Early diagnosis and appropriate management are important clinical challenges. In this case, a fatal pulmonary embolism and extensive cerebral infarction caused cardiac arrest during spinal anesthesia for total hip replacement surgery. Transesophageal echocardiography indicated a pulmonary embolism and brain CT showed large area of acute infarction at right middle cerebral artery territory. Pulmonary CT angiogram revealed massive pulmonary embolism findings. This paper reviews this case and suggests other preventive modalities.
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Affiliation(s)
- Jong-Yeon Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, CHA University, Pocheon, Korea
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Zanobetti M, Bigiarini S, Coppa A, Conti A, Innocenti F, Pini R. Usefulness of chest ultrasonography in detecting pulmonary embolism in patient with chronic obstructive pulmonary disease and chronic renal failure: a case report. Am J Emerg Med 2011; 30:1665.e1-3. [PMID: 22154162 DOI: 10.1016/j.ajem.2011.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 09/19/2011] [Indexed: 01/08/2023] Open
Abstract
We describe the case of a 75-year-old man affected by a chronic obstructive pulmonary disease and chronic renal failure admitted to our emergency department for dyspnea and interscapular stabbing pain. Chest radiography showed diffuse parenchymal consolidation in the lower right lung with bronchiectasis, but the treatment for infection disease did not improve the clinical conditions of the patient. According to Wells score indicating an intermediate risk for pulmonary embolism, we performed a chest ultrasonography that showed ultrasonographic patterns of thromboembolism. Because the presence of chronic renal failure limited the execution of a helical computed tomographic pulmonary angiography, a pulmonary scintigraphy was performed confirming the diagnosis of pulmonary embolism. Our case suggested that chest ultrasonography can be a valuable tool for early detection of pulmonary embolism and to establish immediately an appropriate therapy.
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Affiliation(s)
- Maurizio Zanobetti
- Department of Critical Care Medicine and Surgery, University of Florence, Florence, Italy.
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Stein PD, Matta F. Epidemiology and Incidence: The Scope of the Problem and Risk Factors for Development of Venous Thromboembolism. Crit Care Clin 2011; 27:907-32, vii. [DOI: 10.1016/j.ccc.2011.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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26
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The Optional VenaTech™ Convertible™ Vena Cava Filter: Experimental Study in Sheep. Cardiovasc Intervent Radiol 2011; 35:1181-7. [DOI: 10.1007/s00270-011-0273-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 08/29/2011] [Indexed: 01/08/2023]
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Cronin P, Kelly AM. Influence of population prevalences on numbers of false positives: an overlooked entity. Acad Radiol 2011; 18:1087-93. [PMID: 21703881 DOI: 10.1016/j.acra.2011.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 04/26/2011] [Accepted: 04/29/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Disease prevalence alters the number of true positives (TP), true negatives (TN), false negatives (FN), and false positives (FP), even if the sensitivity and specificity of a test stays the same. METHODS AND MATERIALS We illustrate this using data for the detection of suspected acute pulmonary embolism (PE) from the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II). We chose PE because of the clinical significance of the disease, the low prevalence of PE in the patient population being tested with CTPA with the widespread adoption of CTPA, and the serious clinical consequences of anticoagulation therapy in FP patients. RESULTS Based on PIOPED II data (sensitivity 83%, specificity 96%), at a disease prevalence of approximately 5%, the number of FP patients is greater than the number of TP patients. Scaled to the US population, at a disease prevalence of 5%, there would be 139,800 FPs and 3,356,200 TNs. Assuming a mortality rate of 0.5% and a 3.0% rate of major bleeding secondary to anticoagulation therapy for well-controlled patients, if all FP patients received anticoagulation, there would be 699 deaths and 4194 major bleeding complications. CONCLUSIONS At a prevalence of approximately 5% for PE, the number of FPs approaches or is greater than the number of TPs for CTPA for the detection of suspected acute PE. Patients with FP results may receive unnecessary, potentially harmful treatment with anticoagulation therapy. Population prevalence of disease needs to be taken into account along with the diagnostic accuracy of a test, because this may significantly affect downstream patient outcomes.
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Stein PD, Matta F, Dalen JE. Is the Campaign to Prevent VTE in Hospitalized Patients Working? Chest 2011; 139:1317-1321. [DOI: 10.1378/chest.10-1622] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Xiong L, Trout AT, Bailey JE, Brown RK, Kelly AM. Comparison of Discrepancy Rates in Resident and Faculty Interpretations of On-Call PE CT and V/Q Scans: Is One Study More Reliable During Off Hours? J Am Coll Radiol 2011; 8:415-21. [DOI: 10.1016/j.jacr.2010.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 12/10/2010] [Indexed: 11/27/2022]
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Liang J, Gotway MB, Terzopoulos D, Sostman HD. Interobserver agreement in the diagnosis of acute pulmonary embolism from computed tomography pulmonary angiography and on the effectiveness of computer-aided diagnosis. Am J Emerg Med 2011; 29:465-7. [DOI: 10.1016/j.ajem.2010.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 12/20/2010] [Indexed: 11/17/2022] Open
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Lin X, Liang XX, Tang JJ, Chen JS, Qiu PX, Yan GM. The effect of the fibrinolytic enzyme FIIa from Agkistrodon acutus venom on acute pulmonary thromboembolism. Acta Pharmacol Sin 2011; 32:239-44. [PMID: 21293476 PMCID: PMC4009945 DOI: 10.1038/aps.2010.193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 10/12/2010] [Indexed: 11/08/2022] Open
Abstract
AIM To evaluate the effects of the fibrinolytic enzyme FII(a) from Agkistrodon acutus venom on acute pulmonary thromboembolism (APT) in animal models. METHODS Both rabbit and dog APT models were used. For the rabbit APT model, the thrombi weight before and after administration was measured. Central venous pressure (CVP) and mean arterial pressure (MAP) were measured before and 15, 30, 60, and 120 min after the injection of the blood clot. Partial thromboplastin time (APTT), prothrombin time (PT), platelet count, and fibrinogen concentration were measured using auto analyzers. Plasminogen activity was measured based on chromogenic substrates. In the dog APT model, pulmonary blood flow was recorded using pulmonary angiography. RESULTS Intravenous administration of FIIa (0.1-5.0 mg/kg) improved the APT-induced hemodynamic derangements and reduced thrombi weight. The angiography evidence also showed that the pulmonary emboli had almost disappeared after FII(a) infusion. FII(a) (0.1, 0.5, or 1.0 mg/kg) did not impair the coagulation pathways, although very high doses of FII(a) (5.0 mg/kg) could stimulate the production of plasminogen and result in impairment of the pathways. CONCLUSION FII(a) could effectively protect against APT via degradation of thrombi with less activation of plasminogen, and may provide a novel fibrinolytic enzyme for targeting the main pathological processes of the disease.
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Affiliation(s)
- Xi Lin
- Department of Pharmacology, Medical College, Ji-nan University, Guangzhou 510632, China
| | - Xiu-xia Liang
- Department of Pharmacology, Zhongshan Medical College, Sun Yat-sen University, Guangzhou 510080, China
| | - Jian-jun Tang
- Department of Physiology, Medical College, Ji-nan University, Guangzhou 510632, China
| | - Jia-shu Chen
- Department of Pharmacology, Zhongshan Medical College, Sun Yat-sen University, Guangzhou 510080, China
| | - Peng-xin Qiu
- Department of Pharmacology, Zhongshan Medical College, Sun Yat-sen University, Guangzhou 510080, China
| | - Guang-mei Yan
- Department of Pharmacology, Zhongshan Medical College, Sun Yat-sen University, Guangzhou 510080, China
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Epidemiology and Incidence: The Scope of the Problem and Risk Factors for Development of Venous Thromboembolism. Clin Chest Med 2010; 31:611-28. [DOI: 10.1016/j.ccm.2010.07.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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