Delay and misdiagnosis in sub-massive and non-massive acute pulmonary embolism

A new nomogram prediction model for pulmonary embolism in older hospitalized patients

Purpose

Diagnosing pulmonary embolism (PE) in older adults is relatively difficult because of the atypical clinical symptoms of PE in older adults accompanied by multiple complications. This study aimed to establish a nomogram model to better predict the occurrence of PE in older adults.

Methods

Data were collected from older patients (≥65 years old) with suspected PE who were hospitalized between January 2012 and July 2021 and received confirmatory tests (computed tomographic pulmonary angiography or ventilation/perfusion scanning). The PE group and non-PE (control) group were compared using univariable and multivariable analyses to identify independent risk factors. A nomogram prediction model was constructed with independent risk factors and verified internally. The effectiveness of the nomogram model, Wells score, and revised Geneva score was assessed using the area under the receiver operating characteristic curve (AUC).

Results

In total, 447 eligible older patients (290 PE patients and 157 non-PE patients) were enrolled. Logistic regression analysis revealed nine independent risk factors: smoking, inflammation, dyspnea, syncope, mean corpuscular hemoglobin concentration, indirect bilirubin, uric acid, left atrial diameter, and internal diameter of the pulmonary artery. The AUC, sensitivity, and specificity of the nomogram prediction model were 0.763 (95 % confidence interval, 0.721-0.802), 74.48 %, and 67.52 %, respectively. The nomogram showed superior AUC compared to the Wells score (0.763 vs. 0.539, P < 0.0001) and the revised Geneva score (0.763 vs. 0.605, P < 0.0001).

Conclusions

This novel nomogram may be a useful tool to better recognize PE in hospitalized older adults.

Impact of an enhanced focused cardiac ultrasound on treatment changes in a population of internal medicine patients

BACKGROUND

Hospitalized patients with acute shortness of breath (SOB) could benefit from an enhanced focused cardiac ultrasound (eFoCUS) with Doppler measurements to reassess treatment and diagnosis.

METHODS

This was a retrospective observational study performed in a medical ward. Included patients were those hospitalized for acute SOB. The objectives were to assess therapeutic and diagnosis changes associated with eFoCUS. The primary endpoint of the analysis was a composite of introduction or discontinuation of diuretics, antibiotics or anticoagulation following eFoCUS.

RESULTS

Between January 2018 and July 2021, 119 patients were included, 67 women and 52 men, mean age 84 ± 11 years old. The eFoCUS was performed within a median time of 55 h (1st-3rd IQ: 21-107) following hospital admission. Overall, eFoCUS was associated with a change in diagnostic in 40 patients (34% [CI 95%: 25%-43%], p < 10-4 ) and a change in treatment in 53 patients (45% [CI 95%: 35%-54%], p < 10-4 ). Diuretics were prescribed in 94 patients before eFoCUS and in 56 after (p = 10-4 ), antibiotics in 34 before and 27 after and anticoagulation in 30 before and 40 after.

CONCLUSION

eFoCUS was associated with both therapeutic and diagnostic changes in patients with SOB. Such results should be confirmed in multicentric prospective studies.

Self-supervised pre-training with contrastive and masked autoencoder methods for dealing with small datasets in deep learning for medical imaging

Deep learning in medical imaging has the potential to minimize the risk of diagnostic errors, reduce radiologist workload, and accelerate diagnosis. Training such deep learning models requires large and accurate datasets, with annotations for all training samples. However, in the medical imaging domain, annotated datasets for specific tasks are often small due to the high complexity of annotations, limited access, or the rarity of diseases. To address this challenge, deep learning models can be pre-trained on large image datasets without annotations using methods from the field of self-supervised learning. After pre-training, small annotated datasets are sufficient to fine-tune the models for a specific task. The most popular self-supervised pre-training approaches in medical imaging are based on contrastive learning. However, recent studies in natural image processing indicate a strong potential for masked autoencoder approaches. Our work compares state-of-the-art contrastive learning methods with the recently introduced masked autoencoder approach "SparK" for convolutional neural networks (CNNs) on medical images. Therefore, we pre-train on a large unannotated CT image dataset and fine-tune on several CT classification tasks. Due to the challenge of obtaining sufficient annotated training data in medical imaging, it is of particular interest to evaluate how the self-supervised pre-training methods perform when fine-tuning on small datasets. By experimenting with gradually reducing the training dataset size for fine-tuning, we find that the reduction has different effects depending on the type of pre-training chosen. The SparK pre-training method is more robust to the training dataset size than the contrastive methods. Based on our results, we propose the SparK pre-training for medical imaging tasks with only small annotated datasets.

Serum metabolic signatures for acute pulmonary embolism identified by untargeted metabolomics

Background and aims

The important metabolic features of acute pulmonary embolism (APE) risk stratification and their underlying biological basis remain elusive. Our study aims to develop early diagnostic models and classification models by analyzing the plasma metabolic profile of patients with APE.

Materials and methods

Serum samples were collected from 68 subjects, including 19 patients with confirmed APE, 35 patients with confirmed NSTEMI, and 14 healthy individuals. A comprehensive metabolic assessment was performed using ultra-performance liquid chromatography-mass spectrometry based on an untargeted metabolomics approach. In addition, an integrated machine learning strategy based on LASSO and logistic regression was used for feature selection and model building.

Results

The metabolic profiles of patients with acute pulmonary embolism and NSTEMI is significantly altered relative to that of healthy individuals. KEGG pathway enrichment analysis revealed differential metabolites between acute pulmonary embolism and healthy individuals mainly involving glycerophosphate shuttle, riboflavin metabolism, and glycerolipid metabolism. A panel of biomarkers was defined to distinguish acute pulmonary embolism, NSTEMI, and healthy individuals with an area under the receiver operating characteristic curve exceeding 0.9 and higher than that of D-dimers.

Conclusion

This study contributes to a better understanding of the pathogenesis of APE and facilitates the discovery of new therapeutic targets. The metabolite panel can be used as a potential non-invasive diagnostic and risk stratification tool for APE.

Self-supervised learning for medical image classification: a systematic review and implementation guidelines

Advancements in deep learning and computer vision provide promising solutions for medical image analysis, potentially improving healthcare and patient outcomes. However, the prevailing paradigm of training deep learning models requires large quantities of labeled training data, which is both time-consuming and cost-prohibitive to curate for medical images. Self-supervised learning has the potential to make significant contributions to the development of robust medical imaging models through its ability to learn useful insights from copious medical datasets without labels. In this review, we provide consistent descriptions of different self-supervised learning strategies and compose a systematic review of papers published between 2012 and 2022 on PubMed, Scopus, and ArXiv that applied self-supervised learning to medical imaging classification. We screened a total of 412 relevant studies and included 79 papers for data extraction and analysis. With this comprehensive effort, we synthesize the collective knowledge of prior work and provide implementation guidelines for future researchers interested in applying self-supervised learning to their development of medical imaging classification models.

Discussion on operation: To compare the curative effect of PMT and CDT in the treatment of middle and high risk stratified APE and the clinical application value of serum BNP, TnI and plasma DFR levelse

Objective

To compare the efficacy of Percutaneous mechanical thrombectomy (PMT) and Catheter directed thrombolysis (CDT) in the treatment of patients with moderate and high-risk ape and explore the clinical application value of biomarkers in the treatment of moderate and high-risk ape.

Method

A total of 84 patients with ape were selected from the Department of vascular surgery of the Second Affiliated Hospital of Shandong First Medical University and the Department of vascular surgery of Shanghai Ninth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine. According to the relevant guidelines, they were divided into high-risk and medium-risk groups, including PMT groups (35 cases) and CDT groups (49 cases). To detect the changes of serum B-type brain natriuretic peptide (BNP),Troponin I (TnI) and plasma D-dimer/fibrinogen ratio (DFR) levels in different risk stratification before and after PMT and CDT, the correlation and diagnostic value of each index, and compare the thrombus clearance rate, pulmonary artery pressure, average dosage of urokinase, effective thrombolytic time, average hospitalization time and complications of PMT and CDT.

Result

Under different treatment methods and risk stratification, there was no statistically significant difference in the clinical data of patients at general baseline;The preoperative BNP, TnI and DFR levels of PMT and CDT in the middle and high risk stratification were significantly lower than those in the other groups (P < 0.005),Compared with the CDT group, PMT has significantly better therapeutic effect on ape than the CDT group in terms of thrombus clearance rate, pulmonary artery pressure, average dosage of urokinase, effective thrombolytic time and average hospitalization time (P < 0.05),meanwhile,there was no significant difference in postoperative complications between the two groups (P < 0.05). After half a year of follow-up, the levels of BNP, TnI and DFR in the cured group were significantly lower than those in the effective group and the ineffective group. The areas under the curve of serum BNP, TnI and plasma DFR were 0.91, 0.87 and 0.93 and the area under the curve DFR has higher diagnostic efficiency than BNP and TnI, while the sensitivity and specificity of TnI are significantly higher than BNP and DFR.

Conclusion

Serum BNP, TnI and plasma DFR levels can reflect the risk stratification and better clinical diagnostic value of ape,PMT and CDT are used to treat high-risk ape. For hospitals with medical conditions, PMT is more worthy of clinical recommendation.

Automatic detection of pulmonary embolism in computed tomography pulmonary angiography using Scaled-YOLOv4

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.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure

Premature closure is often described as a significant contributor to diagnostic error. Therefore, developing strategies to mitigate premature closure could reduce diagnostic errors and improve patient care. Here we propose the novel concept of pursuit of an "endpoint diagnosis" as a cognitive forcing strategy (CFS) for avoiding premature diagnostic closure. We define an "endpoint diagnosis" as an underlying causative explanation for a patient's signs, symptoms, and laboratory and radiographic data that exhausts additional relevant diagnostic evaluation. We have observed four contexts in which the error of not pursuing an endpoint diagnosis most often occurs: (1) diagnoses that appear to result in the same treatment regardless of etiology, (2) cases that are particularly complex, (3) clinical scenarios that are vulnerable to systems errors, and (4) situations in which patients' problems are attributed to uncontrolled underlying risk factors or an exacerbation of a known condition. Additionally, we address why we believe endpoint diagnoses are not universally pursued, delineate when this approach might be particularly useful, attempt to reconcile the potential conflict between accepting diagnostic ambiguity in certain instances and pursuing endpoint diagnoses, and outline possible concerns that might arise with using this CFS, including the possibility of lengthy evaluations resulting in overdiagnosis and overtreatment. Our overarching goal is for this CFS to help clinicians in their daily clinical practice as they seek to optimize their diagnostic skill and patient care.

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application

Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.

Multimodal Diagnosis for Pulmonary Embolism from EHR Data and CT Images

Pulmonary Embolism (PE) is a severe medical condition that can pose a significant risk to life. Traditional deep learning methods for PE diagnosis are based on Computed Tomography (CT) images and do not consider the patient's clinical context. To make full use of patient's clinical information, this article presents a multimodal fusion model ingesting Electronic Health Record (EHR) data and CT images for PE diagnosis. The proposed model is based on multilayer perception and convolutional neural networks. To remove the invalid information in the EHR data, the multidimensional scaling algorithm is performed for feature dimension reduction. The EHR data and CT images of 600 patients are used for experiments. The experiment results show that the proposed models outperform existing methods and the multimodal fusion model shows better performance than the single-input model.

Pulmonary embolism initially misdiagnosed as perimyocarditis in a young patıent

Pulmonary embolism is a common cardiovascular emergency. In case of delayed diagnosis and treatment morbidity and mortality is high. In this report, we presented a case of pulmonary embolism without apparent risk factors, which was initially misdiagnosed as peri/myocarditis.

Diagnostic Delay of Pulmonary Embolism in COVID-19 Patients

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

Multimodal fusion with deep neural networks for leveraging CT imaging and electronic health record: a case-study in pulmonary embolism detection

Recent advancements in deep learning have led to a resurgence of medical imaging and Electronic Medical Record (EMR) models for a variety of applications, including clinical decision support, automated workflow triage, clinical prediction and more. However, very few models have been developed to integrate both clinical and imaging data, despite that in routine practice clinicians rely on EMR to provide context in medical imaging interpretation. In this study, we developed and compared different multimodal fusion model architectures that are capable of utilizing both pixel data from volumetric Computed Tomography Pulmonary Angiography scans and clinical patient data from the EMR to automatically classify Pulmonary Embolism (PE) cases. The best performing multimodality model is a late fusion model that achieves an AUROC of 0.947 [95% CI: 0.946–0.948] on the entire held-out test set, outperforming imaging-only and EMR-only single modality models.

Clinical Reasoning and Diagnostic Error: A Call to Merge Two Worlds to Improve Patient Care

Numerous and substantial challenges exist in the provision of safe, cost-effective, and efficient health care. The prevalence and consequences of diagnostic error, one of these challenges, have been established by the literature; however, these errors persist, and the pace of improvement has been slow. One potential reason for the lack of needed progress is that addressing delayed and wrong diagnoses will require contributions from 2 currently distinct worlds: clinical reasoning and diagnostic error. In this Invited Commentary, the authors argue for merging the diagnostic error and clinical reasoning fields as the perspectives, frameworks, and methodologies of these 2 fields could be leveraged to yield a more aligned approach to understanding and subsequently to mitigating diagnostic error. The authors focus on the problem of diagnostic labeling (a categorization task where one has to choose the correct label or diagnosis). The authors elaborate on why this alignment could help guide health care improvement efforts, using the vexing problem of context specificity that leads to unwanted variance in health care as an example.

Delayed Diagnosis in Pulmonary Embolism: Frequency, Patient Characteristics, and Outcome

BACKGROUND

The incidence and the outcomes of pulmonary embolism (PE) missed during emergency department (ED) workup are largely unknown.

OBJECTIVES

To describe the frequency, demographics, and outcomes of patients with delayed diagnosis of PE.

METHODS

We retrospectively compared patients diagnosed with PE during ED workup (early diagnosis) with patients diagnosed with PE thereafter (delayed diagnosis). Electronic health records (EHR) of 123,560 consecutive patients who attended a tertiary hospital ED were screened. Data were matched with radiology and pathology results from the EHR.

RESULTS

Of 1,119 patients presenting to the ED with early workup for PE, PE was diagnosed in 182 patients (80.5%) as early diagnosis. Delayed diagnosis was established in 44 cases (19.5%) using radiology and/or autopsy data. Median age of patients with early diagnosis was significantly lower as compared to delayed diagnosis (67 vs. 77.5 years). Main symptoms were dyspnea (109 patients [59.9%] in early, 20 patients [45.5%] in delayed diagnosis), chest pain (90 patients [49.5%] in early, 8 patients [18.2%] in delayed diagnosis), and nonspecific complaints (16 patients [8.8%] in early, 13 patients [29.5%] in delayed diagnosis). In-hospital mortality was 1.6% in early diagnosis and 43.2% in delayed diagnosis.

CONCLUSIONS

Delayed diagnosis of PE carries a worse prognosis than early diagnosis. This discrepancy may arise from either delayed therapy, confounding variables (e.g., older age), or both. Possible reasons for delayed diagnoses are nonspecific presentations and symptoms overlapping with preexisting conditions.

The use of clinical decision rules for pulmonary embolism in the emergency department: a retrospective study

BACKGROUND

Pulmonary embolism (PE) is a common and life-threatening medical condition with non-specific clinical presentation. Computed tomography pulmonary angiography (CT-PA) has been the diagnostic modality of choice, but its use is not without risks. Clinical decision rules have been established for the use of diagnostic modalities for patients with suspected PE. This study aims to assess the adherence of physicians to the diagnostic algorithms and rules.

METHODS

A retrospective observational study examining the utilization of CT-PA in the Emergency Department of King Fahd Hospital of Imam Abdulrahman Bin Faisal University for patients with suspected PE from May 2016 to December 2019. The electronic health records were used to collect the data, including background demographic data, clinical presentation, triage vital signs, D-dimer level (if ordered), risk factors for PE, and the CT-PA findings. The Wells score and pulmonary embolism rule-out (PERC) criteria were calculated retrospectively without knowledge of the results of D-dimer and the CT-PA.

RESULTS

The study involved a total of 353 patients (125 men and 228 women) with a mean age of 46.7 ± 18.4 years. Overall, 200 patients (56.7%) were classified into the "PE unlikely" group and 153 patients (43.3%) in the "PE likely" group as per Wells criteria. Out of all the CT-PA, 119 CT-PA (33.7%) were requested without D-dimer assay (n = 114) or with normal D-dimer level (n = 5) despite being in the "PE unlikely" group. Only 49 patients had negative PERC criteria, of which three patients had PE.

CONCLUSIONS

The study revealed that approximately one-third of all CT-PA requests were not adhering to the clinical decision rules with a significant underutilization of D-dimer assay in such patients. To reduce overutilization of imaging, planned interventions to promote the adherence to the current guidelines seem imperative.

The problem of under-diagnosis and over-diagnosis of pulmonary embolism

Pulmonary embolism (PE) is an increasingly recognised condition which is associated with significant morbidity and mortality. Despite the better awareness of this serious condition, the diagnosis is still overlooked in many cases with sometimes fatal consequences. Under-diagnosis may be due to several reasons including reliance on non-specific 'classic' symptoms, belief that bedside measurements will likely be abnormal in the setting of acute PE, and confounding factors like co-existent cardiorespiratory diseases or being in an intensive care unit, where the diagnosis may not be considered. At the same time, incidental diagnosis of PE is occurring more often due to frequent use of imaging investigations alongside advancements in CT technology, and dilemma exists as to whether the chance finding of PE requires anticoagulation, especially when identified only at the subsegmental level. This article reviews these two issues of under-diagnosis and over-diagnosis of PE in the current era.

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

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

The sensitivities and prognostic values of the Wells and revised Geneva scores in diagnosis of pulmonary embolism in the Japanese population

OBJECTIVE

To assess the sensitivities of the Wells score (WS) and the revised Geneva score (RGS) and their prognostic values in the diagnosis of pulmonary embolism (PE) in the Japanese population.

METHODS

We conducted a retrospective chart review of patients with PE aged 16 years or older who were assessed between December 2008 and August 2014. Patients were divided into the PE unlikely and PE likely groups according to the WS and PE unlikely and PE likely groups according to the RGS. We also described the characteristics and three-month mortality of the patients. Univariate predictors with p < 0.05 were included in the multiple regression model. Fisher׳s exact test and Student׳s t-test were used for categorical and continuous variables, respectively.

RESULTS

PE was confirmed in 53 patients, and seven (13%) patients died within 3 months. The mean age was 66.0 ± 14.4 years. There were 32 female patients (60.4%). The RGS had a higher sensitivity than the WS (20.8% vs. 15.1%, P <0.01), although both scores had low yields. Mortality rate was significantly higher in patients with syncope than in those without (33.3% vs. 7.3%, respectively; P = 0.039). After age and sex adjustments, the presence of syncope showed a statistically significant association with mortality. The mortality rate did not significantly differ between the two groups categorized according to the WS (17.4% vs. 0%; P = 0.58) and RGS (21.7% vs. 14.3%; P = 1.00).

CONCLUSION

WS and RGS had low sensitivity in the diagnosis of PE and had limited prognostic values in a Japanese community hospital setting. Promoting awareness about the risk of mortality in patients with PE, especially those with syncope, is necessary.

Different manifestations of pulmonary embolism in younger compared to older patients: Clinical presentation, prediction rules and long-term outcomes

PURPOSE

Data concerning specific manifestations of pulmonary embolism (PE) among younger patients are scarce. We aimed to evaluate differences in clinical presentation, PE prediction rules, thrombolytic treatment use and PE outcomes in younger (<50 years of age) compared to older patients.

MATERIAL/METHODS

We studied 238 consecutive patients with proven PE who were retrospectively categorized into three PE probability subgroups according to the revised Geneva score (RGS) and Wells score (WS). Duration of follow-up was up to 115 months.

RESULTS

Younger patients accounted for 19.7% of the study cohort. Obesity and smoking were significantly more common, while comorbidities were less common (P<0.05) in the younger patients. According to RGS and WS, younger patients were more often categorized into the low PE probability subgroup and rarely into the high probability subgroup (P<0.05). We found no differences in clinical signs, symptoms, and treatment between the two groups. In-hospital (2% vs. 13%) and long-term (12% vs. 36%) mortality rates were significantly lower in younger patients (P=0.003).

CONCLUSIONS

In younger PE patients, despite differences in predisposing factors and PE probability grading as assessed by RGS and WS, clinical features at admission and treatment were similar compared to the older group. Our findings confirmed lower mortality among younger compared to older patients.

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

OBJECTIVES

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

DESIGN

Retrospective observational study.

SETTING

6 primary care practices across the Netherlands.

PARTICIPANTS

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Factors associated with a delayed diagnosis of pulmonary embolism

BACKGROUND

Acute pulmonary embolism (PE) is frequently a fatal disease. The clinical presentation of PE is variable and frequently nonspecific, and there is commonly a diagnostic delay. We aimed to investigate factors associated with the delay in the diagnosis of PE.

METHODS

Data from patients with PE were collected from January 2011 to December 2013 in an acute care teaching hospital. Time-to-diagnosis, evaluated by obtaining a diagnostic computed tomography scan, was then analyzed by the Cox proportional hazard model for examining factors associated with time to the diagnosis of PE. Independent variables included age, gender, activities of daily living, means of transport to the hospital, body temperature, hypoxemia, typical symptoms for PE, serum C-reactive protein (CRP) concentrations, infiltration on chest radiograph, Wells score, classification of patients with PE based on early mortality risk, patients referred from other specialties, daytime versus nighttime arrival, diagnosed by an emergency physician, and diagnosed by a medical resident.

RESULTS

Sixty patients were included. The time to diagnosis was significantly delayed in low-risk patients (hazard ratio [HR], 2.2; 95% CI, 1.2-4.1) and in patients who did not use an ambulance (HR, 1.9; 95% CI, 1.0-3.7). In an analysis of the latter subgroup, higher serum CRP concentrations were associated with a delayed diagnosis (HR, 1.1; 95% CI, 1.0-1.2).

CONCLUSION

The time to the diagnosis of PE was delayed in low-risk patients and in patients who attended the hospital by means other than an ambulance. In such patients, a delayed diagnosis was associated with higher serum CRP concentrations.

Postoperative Acute Pulmonary Embolism Following Pulmonary Resections

Postoperative acute pulmonary embolism after pulmonary resections is highly fatal complication. Many literatures have documented cancer to be the highest risk factor for acute pulmonary embolism after pulmonary resections. Early diagnosis of acute pulmonary embolism is highly recommended and computed tomographic pulmonary angiography is the gold standard in diagnosis of acute pulmonary embolism. Anticoagulants and thrombolytic therapy have shown a great success in treatment of acute pulmonary embolism. Surgical therapies (embolectomy and inferior vena cava filter replacement) proved to be lifesaving but many literatures favored medical therapy as the first choice. Prophylaxis pre and post operation is highly recommended, because there were statistical significant results in different studies which supported the use of prophylaxis in prevention of acute pulmonary embolism. Having reviewed satisfactory number of literatures, it is suggested that thoroughly preoperative assessment of patient conditions, determining their risk factors complicating to pulmonary embolism and the use of appropriate prophylaxis measures are the key options to the successful minimization or eradication of acute pulmonary embolism after lung resections.

Correlates of syncope in patients with acute pulmonary thromboembolism

Identification of pulmonary thromboembolism (PTE), as a cause of syncope, is important and may be life saving. We prospectively analyzed data on 335 patients with acute PTE. Relationships between syncope secondary to acute PTE and clinical findings, risk factors, and imaging modalities were analyzed. Of the 335 patients, 36 (10.7%) had syncope at presentation. Compared to patients without syncope, those with syncope had a higher frequency of right ventricular (RV) dysfunction (94.3% vs 72.1%, respectively; P value = .004) and saddle embolism (24.2% vs 10.9%, respectively; P value = .044). Frequency of RV dysfunction was similar between patients with and without saddle embolism. Although not significant, more patients with syncope had a history of previous PTE (P value = .086). By multivariable analysis, RV dysfunction and saddle embolism were independent correlates of syncope in patients with PTE. In-hospital mortality was not significantly different between the groups. In conclusion, among patients with PTE, RV dysfunction and saddle embolism were the independent correlates of syncope.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Motion analysis of right ventricular dysfunction under mild or moderate pressure overload caused by acute pulmonary embolism

Acute pulmonary embolism (APE) is the third most common cause of death in the United States. Appearing as a sudden blockage in a major pulmonary artery, APE may cause mild, moderate or severe right ventricular (RV) overload. Although severe RV overload produces diagnostically obvious RV mechanical failure, little progress has been made in gaining a clinical and biophysical understanding of moderate and mild acute RV overload and its impact on RV functionality. In the research described here, we conducted a pilot study in pigs using echocardiography and observed the following abnormalities in RV functionality under acute mild or moderate RV overload: (i) occurrence of paradoxical septal motion with "waving" dynamics; (ii) decrease in local curvature of the septum (p < 0.01); (iii) lower positive correlation between movement of the RV free wall and movement of the septum (p < 0.05); (iv) slower rate of RV fractional area change (p < 0.05); and (v) decrease in movement stability, particularly in the middle of the septum (p < 0.05).

Clinical features of patients inappropriately undiagnosed of pulmonary embolism

PURPOSES

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

BASIC PROCEDURES

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

MAIN FINDINGS

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

PRINCIPAL CONCLUSIONS

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

Sudden death risk in syncope: the role of the implantable cardioverter defibrillator

Syncope is generally benign but when it is due to an underlying cardiovascular condition, the prognosis can be guarded. Patients with syncope may be at risk of dying suddenly from a ventricular arrhythmia especially if the collapse is caused by a poorly-tolerated, self-terminating, ventricular tachycardia (VT). If a similar VT recurs, and persists, it could initiate cardiac arrest, leading to sudden cardiac death. However, distinguishing which patient with syncope may benefit most from implantable cardioverter defibrillator (ICD) therapy, which can stop life-threatening and poorly tolerated VT, thereby preventing sudden cardiac death, remains an ongoing challenge. Careful assessment of the patient's underlying cardiovascular conditions, scrupulous attention to historical detail to assess potential causes for syncope, and risk stratification based upon clinical characteristics and short and long-term risks can help. This review focuses on the sudden death risk in patients with syncope and explores the role of the ICD to treat ventricular arrhythmias, prevent symptoms, and prevent death.

Residual pulmonary thromboemboli after acute pulmonary embolism

BACKGROUND

After an acute pulmonary embolism (PE), the complete resolution of thromboemboli may not be routinely achieved. The rate of persistence may depend on the time and the diagnostic technique used for evaluation.

PATIENTS AND METHODS

Patients were diagnosed with acute PE by means of computed tomography angiography (CTA). While they were receiving anticoagulant therapy, a second CTA was used to explore the rate of persistence of residual thromboemboli. During the initial episode, the plasma levels of Troponin I and natriuretic peptide, patient demographics, and hemodynamic and gas exchange data were evaluated as risk factors for persistence of pulmonary thromboemboli.

RESULTS

In this study 166 patients were diagnosed. A second CTA was not made in 46 (28%) patients for different reasons. In 120 (72%) patients a second CTA was made 4.5 [SD2.34] months after the initial episode (range 2-12 months). Complete clearance of thrombi occurred in 89 (74%, 95% CI 65-81) patients. Residual thrombi remained in 31 (26%, 95% CI 18-34) patients. In 6%, 13% and 81% of the patients the size of the residual thrombi was greater, similar to and smaller than initially diagnosed, respectively. The risk factors for residual thrombi included the thrombotic burden (OR 1.95), the alveolar to arterial difference of oxygen (OR 1.64), and the clinical antecedents of venous thromboembolic disease (OR 0.65).

CONCLUSIONS

After 4.5 months of anticoagulant therapy, residual pulmonary thromboemboli persisted in 26% of the patients. The risk factors for residual thromboemboli include a greater initial thrombotic burden, a deeper gas exchange disturbation and a history of previous venous thromboembolism.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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