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Martens ESL, Huisman MV, van Mens TE, Klok FA. The History of Diagnosing Venous Thromboembolism. Semin Thromb Hemost 2024; 50:739-750. [PMID: 38373722 DOI: 10.1055/s-0044-1779484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
An accurate and prompt diagnosis of deep vein thrombosis and/or pulmonary embolism is important to prevent serious complications and mortality. Because the clinical presentation of venous thromboembolism (VTE) is often nonspecific, objective testing by means of radiological imaging is required to confirm the diagnosis. Historically, a diagnosis of VTE involved invasive imaging techniques like contrast venography or conventional pulmonary angiography. Technological developments toward more accurate and less invasive diagnostics have driven the implementation of a variety of newer technologies over the past decades, as well as the derivation and validation of clinical decision rules (CDRs) that can be used to rule out VTE in combination with D-dimer blood tests. In this narrative review, we provide a historical overview of the most notable developments in the imaging techniques and CDRs for VTE diagnosis.
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Affiliation(s)
- Emily S L Martens
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Thijs E van Mens
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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2
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Hepburn-Brown M, Darvall J, Hammerschlag G. Acute pulmonary embolism: a concise review of diagnosis and management. Intern Med J 2019; 49:15-27. [PMID: 30324770 DOI: 10.1111/imj.14145] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 12/14/2022]
Abstract
An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation-perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50-75 per 100 000 in Australia and New Zealand, with 30-day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision-making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation-perfusion scans) is still necessary for objective diagnosis. Anti-coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti-coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti-coagulation and review. However, treatment should be case dependent with full consideration of the patient's clinical state. Direct oral anti-coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti-coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6-12 months.
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Affiliation(s)
- Morgan Hepburn-Brown
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jai Darvall
- Department of Intensive Care and Anaesthesia/Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Girardi AM, Bettiol RS, Garcia TS, Ribeiro GLH, Rodrigues ÉM, Gazzana MB, Rech TH. Wells and Geneva Scores Are Not Reliable Predictors of Pulmonary Embolism in Critically Ill Patients: A Retrospective Study. J Intensive Care Med 2018; 35:1112-1117. [PMID: 30556446 DOI: 10.1177/0885066618816280] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Critically ill patients are at high risk for pulmonary embolism (PE). Specific PE prediction rules have not been validated in this population. The present study assessed the Wells and revised Geneva scoring systems as predictors of PE in critically ill patients. METHODS Pulmonary computed tomographic angiograms (CTAs) performed for suspected PE in critically ill adult patients were retrospectively identified. Wells and revised Geneva scores were calculated based on information from medical records. The reliability of both scores as predictors of PE was determined using receiver operating characteristic (ROC) curve analysis. RESULTS Of 138 patients, 42 (30.4%) were positive for PE based on pulmonary CTA. Mean Wells score was 4.3 (3.5) in patients with PE versus 2.7 (1.9) in patients without PE (P < .001). Revised Geneva score was 5.8 (3.3) versus 5.1 (2.5) in patients with versus without PE (P = .194). According to the Wells and revised Geneva scores, 56 (40.6%) patients and 49 (35.5%) patients, respectively, were considered as low probability for PE. Of those considered as low risk by the Wells score, 15 (26.8%) had filling defects on CTA, including 2 patients with main pulmonary artery embolism. The area under the ROC curve was 0.634 for the Wells score and 0.546 for the revised Geneva score. Wells score >4 had a sensitivity of 40%, specificity of 87%, positive predictive value of 59%, and negative predictive value of 77% to predict risk of PE. CONCLUSIONS In this population of critically ill patients, Wells and revised Geneva scores were not reliable predictors of PE.
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Affiliation(s)
- Adriana M Girardi
- Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Renata S Bettiol
- Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Tiago S Garcia
- Radiology Division, Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Graduate Program in Respiratory Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gustavo L H Ribeiro
- Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Édison Moraes Rodrigues
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Marcelo B Gazzana
- Graduate Program in Respiratory Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Pulmonary Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Tatiana H Rech
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.,Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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4
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Zhou HT, Yan WY, Zhao DL, Liang HW, Wang GK, Ling ZS, Zhang JL. CT pulmonary angiogram for assessing the treatment outcome of acute pulmonary embolism. Echocardiography 2018; 35:396-400. [PMID: 29226460 DOI: 10.1111/echo.13766] [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: 11/27/2022] Open
Abstract
OBJECTIVE To discuss the value of CT pulmonary angiogram (CTPA) for assessing the treatment outcome of acute pulmonary embolism (APE). MATERIALS AND METHODS CT pulmonary angiogram data and other clinical data were collected for 28 cases diagnosed as APE and analyzed retrospectively. The number and positions of emboli in the pulmonary artery, pulmonary artery obstruction index, right ventricular/left ventricular diameter ratio, main pulmonary artery/ascending aorta diameter ratio and blood oxygen saturation, and pulmonary arterial pressure were compared before and after treatment. RESULTS Of 28 cases, emboli in the pulmonary artery completely or partially disappeared in 16 and 12 cases, respectively. CPTA indicated that the pulmonary arterial pressure decreased dramatically and the blood oxygen saturation increased after treatment in 26 cases. There were significant differences in the number and positions of pulmonary emboli and in pulmonary artery obstruction index before and after treatment in 28 cases (P < .05). However, no significant differences were found in the right ventricular/left ventricular diameter ratio or main pulmonary artery/ascending aorta diameter ratio (P > .05). CONCLUSION CT pulmonary angiogram proved reliable for assessing the treatment efficacy of APE, providing more clinical information on the patients' status.
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Affiliation(s)
- Hai-Ting Zhou
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wen-Ying Yan
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - De-Li Zhao
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong-Wei Liang
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guo-Kun Wang
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zai-Sheng Ling
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jin-Ling Zhang
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
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5
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Evaluation of pulmonary complaints in the emergency department. Time to go back to the basics. Ann Am Thorac Soc 2016; 12:625-6. [PMID: 25965537 DOI: 10.1513/annalsats.201412-584ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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6
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2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol 2016; 13:e1-e29. [PMID: 26810814 DOI: 10.1016/j.jacr.2015.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 01/02/2023]
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7
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Rybicki FJ, Udelson JE, Peacock WF, Goldhaber SZ, Isselbacher EM, Kazerooni E, Kontos MC, Litt H, Woodard PK. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016; 67:853-79. [PMID: 26809772 DOI: 10.1016/j.jacc.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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8
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Koch C, Schramm R, Roller F, Hecker A, Henrich M, Schneck E, Krombach G, Weigand M, Lichtenstern C. Impact of unsuspected subsegmental pulmonary embolism in ICU patients. Anaesthesist 2015; 65:122-8. [DOI: 10.1007/s00101-015-0118-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/07/2015] [Accepted: 09/08/2015] [Indexed: 10/22/2022]
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9
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Zhou M, Hu Y, Long X, Liu D, Liu L, Dong C, Wang J, Kong X. Diagnostic performance of magnetic resonance imaging for acute pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost 2015; 13:1623-34. [PMID: 26179627 DOI: 10.1111/jth.13054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 07/07/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND With ongoing technical developments, magnetic resonance imaging (MRI) has notably evolved for the assessment of the pulmonary vasculature. However, uncertainty persists about the performance of MRI for the diagnosis of acute pulmonary embolism (APE). OBJECTIVES To clarify the comprehensive role of MRI in diagnosing APE. METHODS Studies were identified through a search of Pubmed and Ovid databases, and the QUADAS-2 tool was applied for quality assessment of the included studies. RESULTS Fifteen studies based on patients and nine based on vessels were retrieved. The patient-based analysis yielded an overall sensitivity of 0.75 (95% confidence interval, 0.70-0.79) and 0.84 (0.80-0.87) for all patients and patients with technically adequate images, respectively, with an overall specificity of 0.80 (0.77-0.83) and 0.97 (0.96-0.98) and a pooled diagnostic odds ratio (DOR) of 51.07 (18.36-142.05) and 155.22 (86.83-277.47). On average, MRI was technically inadequate in 18.89% of patients (range, 2.10%-27.70%). A direct comparison of different MRI modalities showed that the combined MRI test had the highest pooled DOR and the lowest proportion of inconclusive images. Of note, heterogeneity and moderate quality were observed. On a vessel basis, the MRI had high sensitivity and specificity in larger-order vessels, but a significantly lower sensitivity of 0.55 (0.50-0.60) for subsegmental APE. CONCLUSIONS On a patient-based level, MRI yields high diagnostic accuracy for the detection of APE, especially in technically adequate images, and the inconclusive MRI examinations mainly result from motion artifact and poor arterial opacification. The combined MRI test appears to be a more promising diagnostic tool with greater power of discrimination than single techniques. From a vessel-based perspective, MRI exhibits a high diagnostic capability with proximal arteries, but lacks sensitivity for peripheral embolism.
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Affiliation(s)
- M Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Y Hu
- Tumor Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - X Long
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - D Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - L Liu
- Tumor Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - C Dong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - J Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - X Kong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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10
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Wolberg AS, Rosendaal FR, Weitz JI, Jaffer IH, Agnelli G, Baglin T, Mackman N. Venous thrombosis. Nat Rev Dis Primers 2015; 1:15006. [PMID: 27189130 DOI: 10.1038/nrdp.2015.6] [Citation(s) in RCA: 190] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism (VTE) encompasses deep-vein thrombosis (DVT) and pulmonary embolism. VTE is the leading cause of lost disability-adjusted life years and the third leading cause of cardiovascular death in the world. DVT leads to post-thrombotic syndrome, whereas pulmonary embolism can cause chronic pulmonary hypertension, both of which reduce quality of life. Genetic and acquired risk factors for thrombosis include non-O blood groups, factor V Leiden mutation, oral contraceptive use, hormone replacement therapy, advanced age, surgery, hospitalization and long-haul travel. A combination of blood stasis, plasma hypercoagulability and endothelial dysfunction is thought to trigger thrombosis, which starts most often in the valve pockets of large veins. Animal studies have revealed pathogenic roles for leukocytes, platelets, tissue factor-positive microvesicles, neutrophil extracellular traps and factors XI and XII. Diagnosis of VTE requires testing and exclusion of other pathologies, and typically involves laboratory measures (such as D-dimer) and diagnostic imaging. VTE is treated with anticoagulants and occasionally with thrombolytics to prevent thrombus extension and to reduce thrombus size. Anticoagulants are also used to reduce recurrence. New therapies with improved safety profiles are needed to prevent and treat venous thrombosis. For an illustrated summary of this Primer, visit: http://go.nature.com/8ZyCuY.
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Affiliation(s)
- Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, 819 Brinkhous-Bullitt Building, Chapel Hill, North Carolina 27599-7525, USA.,McAllister Heart Institute, University of North Carolina at Chapel Hill, USA
| | - Frits R Rosendaal
- Department of Clinical Epidemiology and Department of Thrombosis and Hemostasis, Leiden University Medical Center, The Netherlands.,K.G. Jensen Thrombosis Research and Expertise Center, University of Tromsø, Norway
| | - Jeffrey I Weitz
- Department of Medicine and Department of Biochemistry and Biomedical Sciences, McMaster University, and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Iqbal H Jaffer
- Department of Medicine and Department of Biochemistry and Biomedical Sciences, McMaster University, and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Giancarlo Agnelli
- Division of Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Italy
| | - Trevor Baglin
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Nigel Mackman
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, 819 Brinkhous-Bullitt Building, Chapel Hill, North Carolina 27599-7525, USA.,McAllister Heart Institute, University of North Carolina at Chapel Hill, USA.,K.G. Jensen Thrombosis Research and Expertise Center, University of Tromsø, Norway.,Department of Medicine, University of North Carolina at Chapel Hill, USA
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11
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Angriman F, Ferreyro BL, Posadas-Martinez ML, Giunta D, Vazquez FJ, Vollmer WM. Wells Score and Poor Outcomes Among Adult Patients With Subsegmental Pulmonary Embolism. Clin Appl Thromb Hemost 2014; 21:539-45. [DOI: 10.1177/1076029614559772] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Since the introduction of computed tomography pulmonary angiography, isolated subsegmental pulmonary embolism has become a commonly recognized clinical problem, but its clinical relevance remains unclear. The objective of the present study was to evaluate the extent to which the simplified Wells score discriminates between patients with varying levels of risk of complications after presenting with subsegmental pulmonary embolism. Materials and Methods: Retrospective cohort study. Patients included had subsegmental pulmonary embolism (1 or multiple emboli limited to subsegmental arteries). Primary explanatory variable was the simplified Wells score, categorized as high (>4) or low (≤4). The primary outcome was time to death or new venous thromboembolism. Kaplan-Meier techniques and Cox regression analysis were used to compare the survival experience of patients with high versus low Wells score with and without adjustment for active malignancy, age, Charlson score, previous venous thromboembolism, and previous major surgery in the last 30 days. Main Results: Seventy-nine patients with subsegmental pulmonary embolism were included. Patients with a high Wells score had a 4-fold increased risk of the composite outcome (hazard ratio = 4.2, 95% confidence interval [CI] = 2.0-8.9, P < .001). Other covariates significantly associated with increased risk in univariate analyses included active malignancy, a low serum albumin, and an increased Charlson score. In multivariate Cox regression analyses adjusting for these other factors, a high Wells score remained significant (hazard ratio 5.5, 95% CI 2.4-12.6, P < .001). Conclusion: High Wells score is associated with death or new venous thromboembolism during follow-up among patients with subsegmental pulmonary embolism. Clinical trial registration: ClinicalTrials.gov number, NCT01372514.
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Affiliation(s)
- Federico Angriman
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires University, Buenos Aires, Argentina
| | - Bruno L. Ferreyro
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires University, Buenos Aires, Argentina
| | | | - Diego Giunta
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fernando J. Vazquez
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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12
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Kuijpers CCHJ, Fronczek J, van de Goot FRW, Niessen HWM, van Diest PJ, Jiwa M. The value of autopsies in the era of high-tech medicine: discrepant findings persist. J Clin Pathol 2014; 67:512-9. [PMID: 24596140 DOI: 10.1136/jclinpath-2013-202122] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS Although the autopsy is still the gold standard for quality assessment of clinical diagnoses, autopsy rates have been declining over the last decades to <10%. The aim of this study was to investigate the value of autopsies in the high-tech medicine era by determining the frequency of discrepancies between clinical and autopsy diagnoses. METHODS We classified all adult autopsy cases (n=460), performed at Symbiant, Pathology Expert Centre, in 2007 and 2012/2013, as having major, or minor discrepancy or total concordance. The roles of possible contributory factors were analysed. Finally, we assessed the role of microscopic examination in identifying cause of death. RESULTS Major and minor discrepancies were found in 23.5% and 32.6% of the classifiable autopsies, respectively. Most commonly observed major discrepancies were myocardial infarction, pulmonary embolism and pneumonia. Improper imaging and discontinuation of active treatment were significantly associated with a higher and a lower frequency of major discrepancies, respectively. Comparing 2007 and 2012/2013, the frequency of minor discrepancies significantly increased from 26.8% to 39.3%. Final admission length of >2 days was significantly associated with a lower frequency of class III minor discrepancies. Microscopic examination contributed to establishing cause of death in 19.6% of the cases. CONCLUSIONS Discrepant findings persist at autopsy, even in the era of high-tech medicine. Therefore, autopsies still should serve as a very important part of quality control in clinical diagnosis and treatment. Learning from individual and system-related diagnostic errors can aid in improving patient safety.
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Affiliation(s)
| | - Judith Fronczek
- Symbiant Pathology Expert Centre, Alkmaar, The Netherlands Department of Pathology, VU Medical Centre, Amsterdam, The Netherlands
| | | | - Hans W M Niessen
- Department of Pathology, VU Medical Centre, Amsterdam, The Netherlands Department of Cardiac Surgery, VU Medical Centre, Amsterdam, The Netherlands ICaR-VU, VU Medical Centre, Amsterdam, the Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mehdi Jiwa
- Symbiant Pathology Expert Centre, Alkmaar, The Netherlands
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13
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Risk profile and clinical outcome of symptomatic subsegmental acute pulmonary embolism. Blood 2013; 122:1144-9; quiz 1329. [PMID: 23736701 DOI: 10.1182/blood-2013-04-497545] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The clinical significance of subsegmental pulmonary embolism (SSPE) remains to be determined. This study aimed to investigate whether SSPE forms a distinct subset of thromboembolic disease compared with more proximally located pulmonary embolism (PE). We analyzed 3728 consecutive patients with clinically suspected PE. SSPE patients were contrasted to patients with more proximal PE and to patients in whom suspected PE was ruled out, in regards of the prevalence of thromboembolic risk factors and the 3-month risks of recurrent venous thromboembolism (VTE) and mortality. PE was confirmed in 748 patients, of whom 116 (16%) had SSPE; PE was ruled out in 2980 patients. No differences were seen in the prevalence of VTE risk factors, the 3-month risk of recurrent VTE (3.6% vs 2.5%; P = .42), and mortality (10.7% vs 6.5%; P = .17) between patients with SSPE and those with more proximal PE. When compared with patients without PE, aged >60 years, recent surgery, estrogen use, and male gender were found to be independent predictors for SSPE, and patients with SSPE were at an increased risk of VTE during follow-up (hazard ratio: 3.8; 95% CI: 1.3-11.1). This study indicates that patients with SSPE mimic those with more proximally located PE in regards to their risk profile and clinical outcome.
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14
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Chen GW, Song B, Li ZL, Yuan Y. Ectopic blood supply of hepatocellular carcinoma as depicted by angiography with computed tomography: associations with morphological features and therapeutic history. PLoS One 2013; 8:e71942. [PMID: 23967266 PMCID: PMC3744506 DOI: 10.1371/journal.pone.0071942] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 07/07/2013] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To investigate the associations of ectopic blood supply of hepatocellular carcinoma (HCC) with its morphological features and therapeutic history. METHODS Three hundred and six patients with 373 HCC lesions were enrolled in this study, and underwent biphasic contrast-enhanced scans on a 64-section MDCT. The anatomy of ectopic blood supply, morphological characteristics of HCC including the size, location and pseudocapsule, and history of transcatheter arterial chemoembolization (TACE) therapy were quantitively assessed and statistically analyzed. RESULTS Ectopic blood supply was found in 30.8% (115/373) lesions. The ectopic arteries were predominantly composed of inferior phrenic artery (86/115) followed by left and right gastric artery (25/115). Tumor size, location, status of pseudocapsule, and history of TACE therapy could impact the origination of ectopic arteries (all p<0.05). CONCLUSION The ectopic feeding arteries of HCC predominantly composed of the perihepatic arteries are associated with the morphological features of the tumor and therapeutic history.
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Affiliation(s)
- Guang-wen Chen
- Department of Radiology, Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Bin Song
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- * E-mail:
| | - Zhen-lin Li
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yuan Yuan
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Golpe R, de Llano LAP, Castro-Añón O, Vázquez-Caruncho M, González-Juanatey C, Fariñas MC. Long-term outcome of patients with persistent vascular obstruction on computed tomography pulmonary angiography 6 months after acute pulmonary embolism. Acta Radiol 2012; 53:728-31. [PMID: 22850574 DOI: 10.1258/ar.2012.110697] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The incidence and clinical significance of pulmonary residual thrombosis 6 months after an acute pulmonary embolism (PE) are still not well-known. PURPOSE To evaluate the association between residual vascular obstruction and the risk of venous thromboembolism (VTE) recurrence or death. MATERIAL AND METHODS Computed tomography pulmonary angiography (CTPA) was repeated in 97 consecutive patients 6 months after an acute episode of hemodynamically stable pulmonary embolism. We assessed the long-term consequences of residual thrombosis on vital status and incidence of recurrent VTE. RESULTS Six patients were lost for follow-up. The remaining 91 patients were classified according to the presence (Group 1: 18 cases) or absence (Group 2: 73 cases) of residual pulmonary vascular obstruction. After a mean ± SD of 2.91 ± 0.99 years, there were eight (8.8%) deaths and 11 (12.1%) VTE recurrences. Groups 1 and 2 did not differ in the incidence of death or VTE recurrence. CONCLUSION Persistent pulmonary vascular obstruction on 6-month CTPA did not predict long-term adverse outcome events.
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Affiliation(s)
| | | | | | | | | | - María Carmen Fariñas
- Internal Medicine Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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Banse H, Holbrook TC, Gilliam L, Raynor K. Right ventricular and saphenous vein thrombi associated with sepsis in a Quarter Horse foal. J Vet Intern Med 2011; 26:178-82. [PMID: 22168232 DOI: 10.1111/j.1939-1676.2011.00849.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/12/2011] [Accepted: 11/03/2011] [Indexed: 11/30/2022] Open
Affiliation(s)
- H Banse
- Department of Veterinary Clinical Sciences, Oklahoma State University, Stillwater, OK, USA.
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