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Krmpotic K, Ramsay L, McMullen S, Chan AKC, Plint AC, Moorehead P. Pediatric pulmonary thromboembolism: a 3-year Canadian Pediatric Surveillance Program study. J Thromb Haemost 2024; 22:1366-1371. [PMID: 38266677 DOI: 10.1016/j.jtha.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Pediatric pulmonary embolism (PE) is a rare event associated with significant morbidity and mortality. Awareness of clinical presentation and practices unique to children may aid clinicians in prompt identification and treatment. OBJECTIVES To describe the incidence, risk factors, clinical presentation, diagnostic and therapeutic practices, and short-term outcomes of pediatric PE. METHODS We conducted a 3-year national surveillance study through the Canadian Pediatric Surveillance Program. Over 2800 pediatric specialists and subspecialists were contacted monthly from 2020 to 2022 and requested to report all new cases of PE in patients up to 18 years of age. Case-specific data were obtained through voluntary completion of a detailed questionnaire. RESULTS Fifty-eight cases (78% female, n = 45) were reported (2.4 cases per million children), with rates highest in adolescents 15 to 18 years (6.6 cases per million). Detailed information, available for 31 (53%) cases, documented at least 1 risk factor in 28 (90%) cases; 24 (77%) patients presented with 2 or more symptoms. Computed tomography pulmonary angiography was used for diagnostic confirmation in 25 (81%) cases. Anticoagulation was initiated in 24 (77%) of 31 cases; fewer than 5 patients underwent thrombolysis or surgical interventions. Of 28 patients who received therapeutic interventions, 8 (29%) experienced treatment-related complications. Fewer than 5 mortalities were reported. CONCLUSION Pediatric PE is a rare event, with female adolescents at the highest risk. Although the presentation is often nonspecific, clinicians should maintain a high index of suspicion, particularly in patients with risk factors and when other diagnoses that may explain symptoms have been excluded.
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Affiliation(s)
- Kristina Krmpotic
- Department of Pediatric Critical Care, IWK Health, Halifax, Nova Scotia, Canada; Department of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Lily Ramsay
- Department of Pediatric Critical Care, IWK Health, Halifax, Nova Scotia, Canada
| | - Sarah McMullen
- Department of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Critical Care, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Moorehead
- Discipline of Pediatrics, Memorial University, St. John's, Newfoundland and Labrador, Canada
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2
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Tiratrakoonseree T, Charoenpichitnun S, Natesirinilkul R, Songthawee N, Komvilaisak P, Pongphitcha P, Vaewpanich J, Sirachainan N. Clinical prediction tool to identify children at risk of pulmonary embolism. Thromb Res 2024; 234:151-157. [PMID: 38241765 DOI: 10.1016/j.thromres.2024.01.006] [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: 09/25/2023] [Revised: 11/26/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
INTRODUCTION The diagnosis of pediatric pulmonary embolism (PE) is often delayed due to non-specific symptoms, and clinical prediction tools designed for adults are unsuitable for children. This study aimed to create a PE predictive model and to evaluate the reported tools in the Thai pediatric population. MATERIALS AND METHODS A multi-center retrospective study from 4 university hospitals included children ≤18 years of age undergoing computed tomography pulmonary angiogram from 2000 to 2020 with the suspicion of PE. Patients' clinical presentations and risk factors of venous thromboembolism (VTE) were compared between the PE-positive and PE-negative groups. Significant risk factors from univariate and multivariate logistic regression were included to create a clinical prediction tool. The performance of the model was demonstrated by sensitivity, specificity, area under the curve (AUC), Hosmer Lemeshow test, ratio of observed and expected outcomes and bootstrapping. RESULTS Of the 104 patients included, 43 (41.3 %) were grouped as PE-positive and 61 (58.7 %) as PE-negative. Five parameters, including congenital heart disease/pulmonary surgery, known thrombophilia, previous VTE, nephrotic syndrome and chest pain showed significant differences between the two groups. Score ≥ 2 yielded a 74.4 % sensitivity and a 75.4 % specificity with an AUC of the model of 0.809. The model performance and validation results were within satisfactory ranges. CONCLUSION The study created a clinical prediction tool indicating the likelihood of PE among Thai children. A score ≥2 was suggestive of PE.
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Affiliation(s)
| | - Suwanat Charoenpichitnun
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, Bangkok, Thailand
| | | | - Natsaruth Songthawee
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Patcharee Komvilaisak
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pongpak Pongphitcha
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jarin Vaewpanich
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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3
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Başaran AE, Başaran A, Durmuş SY, Kazlı T, Keven A, Bingöl A. Analysis of predictive factors in children with high suspicion of pulmonary embolism. Pediatr Pulmonol 2024; 59:274-280. [PMID: 37933763 DOI: 10.1002/ppul.26742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/17/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND AND AIM Since there is a limited number of predictive models designed for pediatric patients with pulmonary embolism (PE), healthcare providers have resorted to utilizing the Wells criteria and PE Rule-out Criteria (PERC) that have been validated for use in adults. The objective of the study is to identify the predictive factors for PE and assess the effectiveness of the PERC, Wells, and pediatric-specific PE (PPE) criteria. METHODS The study included individuals between the ages of 0-18 years who underwent pulmonary CT angiography and/or ventilation-perfusion scintigraphy with suspicion of PE. Demographic characteristics, symptoms, physical examination findings, risk factors, and laboratory and imaging results were retrospectively analyzed, and PERC, Wells, and PPE criteria were applied to the study population. RESULTS Of the 110 patients included in the study, 27 (24.5%) had PE. Saturation, albumin, cough, calf swelling, central catheter, and malignancy were found to significantly contribute to the model. The total weighted risk score, which represents the sum of all predictive scores, ranged from 0 to 16 with a mean of 5.41 ± 4.02. When the cut-off >6.5, the model had good discrimination power for positive PE (AUC 0.79, 77% sensitivity, and 70% specificity). In our study, the Wells criteria showed a sensitivity of 96% and a specificity of 24%. The PERC exhibited a sensitivity of 96% and a specificity of 21%, while the PPE demonstrated a sensitivity of 74% and a specificity of 30%. CONCLUSION While the sensitivity of Wells, PERC, and PPE models was higher than our developed model, their specificities were considerably lower than our model.
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Affiliation(s)
- Abdurrahman Erdem Başaran
- Department of Pediatrics, Division of Pulmonology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Ayşen Başaran
- Department of Pediatrics, Division of Pulmonology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Suzan Yılmaz Durmuş
- Department of Pediatrics, Division of Pulmonology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Tuba Kazlı
- Department of Pediatrics, Division of Pulmonology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Ayşe Keven
- Department of Radiology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Ayşen Bingöl
- Department of Pediatrics, Division of Pulmonology, Akdeniz University Faculty of Medicine, Antalya, Turkey
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4
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Ciliberti P, Santangelo TP, Ottavianelli A, Porcaro F, Secinaro A. Cardiothoracic Imaging Guidelines Update: Pulmonary Embolism in Pediatrics. J Thorac Imaging 2024; 39:47-48. [PMID: 37884355 PMCID: PMC10712995 DOI: 10.1097/rti.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Affiliation(s)
| | | | | | - Federica Porcaro
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Aurelio Secinaro
- Advanced Cardiovascular Imaging Unit, Bambino Gesù Children’s Hospital
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Abstract
Dual-energy CT has expanded the potential of thoracic imaging in both children and adults. Data processing allows material- and energy-specific reconstructions, which improve material differentiation and tissue characterization compared with single-energy CT. Material-specific reconstructions include iodine, virtual unenhanced, perfusion blood volume, and lung vessel images, which can improve assessment of vascular, mediastinal, and parenchymal abnormalities. The energy-specific reconstruction algorithm allows virtual monoenergetic reconstructions, including low-energy images to increase iodine conspicuity and high-energy images to reduce beam-hardening and metal artifacts. This review highlights dual-energy CT principles, hardware, and postprocessing algorithms; the clinical applications of dual-energy CT; and the potential benefits of photon counting (the most recently introduced iteration of spectral imaging) in pediatric thoracic imaging.
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Affiliation(s)
- Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Marilyn J Siegel
- Edward Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St. Louis, MO 63110
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6
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Du X, Wu Z. The Neglected Fact: Pediatric Pulmonary Embolism. Pediatr Emerg Care 2022; 38:e1574-e1575. [PMID: 35608545 DOI: 10.1097/pec.0000000000002765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Xiaojiong Du
- From the Department of Vascular Surgery, West China Hospital, Chengdu, China
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7
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Kaditis AG, Alexopoulos EI. Pediatric pulmonary embolism: Not as rare as we think. Pediatr Pulmonol 2021; 56:3089-3092. [PMID: 34407317 DOI: 10.1002/ppul.25609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Athanasios G Kaditis
- Division of Pediatric Pulmonology and Sleep, Department of Child Health, University of Missouri School of Medicine and Women's and Children's Hospital, Columbia, Missouri, USA
| | - Emmanouel I Alexopoulos
- Department of Pediatrics, University of Thessaly School of Medicine and Larissa University Hospital, Larissa, Greece
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Zhu H, Qi J, Schoepf J, Savage RH, Tang C, Lu M, Zhou C, Lu G, Wang D, Zhang L. Prevalence and Associated Risk Factors of Pulmonary Embolism in Children and Young Adults With Nephrotic Syndrome: A Chinese Large Cohort Study. J Thorac Imaging 2021; 36:326-332. [PMID: 34269751 DOI: 10.1097/rti.0000000000000603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE Nephrotic syndrome (NS) is highly associated with an increased risk of pulmonary embolism (PE) in children and young adults. However, few studies have specified the risk factors of PE in children and young adults with NS. We sought to determine the prevalence and associated factors of PE confirmed with computed tomography pulmonary angiography in Chinese children and young adults with NS. METHODS Data from 444 children and young adults with NS who had computed tomography pulmonary angiography from December 2010 to October 2018 were retrospectively analyzed. The prevalence of PE was estimated for different age, sex, and histopathologic types of NS. Multivariable logistic regression was used to identify independent risk factors of PE in children and young adults with NS. Models incorporating the independent risk factors were evaluated using receiver operation characteristic curves. Area under the curve was used to determine the best-performing prognosticators for predicting PE. RESULTS There were 444 patients in the study cohort (310 male patients, 134 female patients; mean age 19±3 y; range: 6 to 25 y). PE was present in 24.8% of the participants (110 of 444, 18.2% female). Children and young adult NS patients with PE tend to be older, male, to have a previous thromboembolism history and smoking, and have a higher level of proteinuria, D-dimer, and serum albumin (P<0.05 for all). Children and young adults with membranous nephropathy are likely to have a higher incidence of PE than those with other types of nephropathy. Membranous nephropathy and proteinuria were significant predictors of PE in children and young adults with NS (P<0.05 for all). The area under the curves of each model for the presence of PE in children and young adults with NS based on biochemical parameters and clinical information (model 1), adjusted for proteinuria (model 2), and adjusted for membranous nephropathy (model 3) were 0.578, 0.657, and 0.709, respectively. Compared with model 1, model 2, and model 3 showed statistically significant differences (model 1 vs. model 2, P=0.0336; model 1 vs. model 3, P=0.0268). There was no statistically significant difference between model 2 and model 3 (P=0.2947). CONCLUSION This study identified membranous nephropathy and proteinuria as independent associated factors of PE in children and young adults with NS, which can be noted as a risk factor to guide clinician management in this population.
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Affiliation(s)
- Haitao Zhu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Jianchen Qi
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Joseph Schoepf
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC
| | - Rock H Savage
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC
| | - Chunxiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Mengjie Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Changsheng Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Guangming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Dongqing Wang
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Longjiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
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9
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Avila L, Amiri N, Pullenayegum E, Sealey VA, De R, Williams S, Vincelli J, Brandão LR. Diagnostic value of D-dimers for limb deep vein thrombosis in children: A prospective study. Am J Hematol 2021; 96:954-960. [PMID: 33930198 DOI: 10.1002/ajh.26212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/24/2021] [Accepted: 04/28/2021] [Indexed: 01/01/2023]
Abstract
The present study sought to evaluate the discriminative and predictive ability of D-dimer for pediatric limb DVT. Children aged 28 days-18 years requiring imaging to rule out limb DVT, as per the treating clinical team, were enrolled in the study. The outcome was ultrasound proven DVT. The D-dimer levels were obtained around the time of imaging. Receiver operating characteristic (ROC) curves and logistic regression models were used for data analyses. In total, 296 patients were enrolled between 2017-2020; 204 patients were diagnosed with DVT (DVT[+]). Median D-dimer levels were 2.3 μg/ml FEU (25th-75th percentile 0.9-3.9) among DVT(+) and 1.9 μg/ml FEU (25th-75th percentile 0.8-4.0) among DVT(-) patients (p = 0.60). The area under the ROC curve (AUC) was 0.52 (95% confidence interval [CI] 0.45-0.59). The odds ratio for D-dimer levels was 1.00 (95% CI 0.99-1.01), holding confounders constant. In a sub-group exploratory analysis including 23 patients with no underlying conditions or co-morbidities, the AUC curve was 0.90 (95% CI 0.76-1.00). In conclusion, in this prospective cohort study of consecutive children with suspected limb DVT, D-dimer levels had poor discriminative and predictive ability for DVT. However, D-dimer levels showed better discriminative and predictive ability for DVT in an exploratory sample of patients with no underlying conditions or co-morbidities at the time of diagnosis.
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Affiliation(s)
- Laura Avila
- The Hospital for Sick Children Toronto Ontario Canada
| | - Nour Amiri
- The Hospital for Sick Children Toronto Ontario Canada
| | | | | | - Riddhita De
- The Hospital for Sick Children Toronto Ontario Canada
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10
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Lopes de Bragança R, Gorito V, Cibele DG, Ricca Gonçalves L, Ribeiro A, Baptista MJ, Azevedo I. Pulmonary embolism in pediatric age: A retrospective study from a tertiary center. Pediatr Pulmonol 2021; 56:2751-2760. [PMID: 34133850 DOI: 10.1002/ppul.25527] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Pediatric pulmonary embolism (PE) is rare but associated with adverse outcomes. We aimed to characterize PE cases admitted in a tertiary hospital and to evaluate sensitivity of selected PE diagnostic prediction tools. METHODS Retrospective, descriptive study of PE cases admitted from 2008 to 2020 using data collected from hospital records. Patients were grouped according to PE severity and setting (outpatients vs. inpatients). Links and correlation with demographic characteristics, risk factors, clinical presentation, management, and outcomes were analyzed. PE diagnostic prediction tools were applied. RESULTS Twenty-nine PE episodes occurred in 27 patients, 62.9% female, mean age 14.1 years. Most PE were central and split between massive or submassive. One was diagnosed in autopsy. Twenty outpatients, all adolescents, were admitted for classic PE symptoms; in half of them the diagnosis had been previously missed. Risk factors included contraceptives (65%), thrombophilia (35%), obesity (20%) and auto-immunity (20%). Eight inpatients, diagnosed during cardiorespiratory deterioration (n = 5), or through incidental radiological findings (n = 3), were younger and had immobilization (87.5%), complex chronic diseases (75%), infections (75%) and central venous catheter (62.5%) as risk factors. Retrospectively, d -dimer testing and adult scores performed better than pediatric scores (sensitivity 92.9%-96% vs. 85.7%-92.9%). Both pediatric scores missed a case with a positive family history. DISCUSSION Pediatric PE diagnosis is often delayed or missed. Development of pediatric prediction tools from validated adult scores merits being explored. We argue clinical presentation and risk factors may be different in inpatients and outpatients and propose broader reliance on family history.
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Affiliation(s)
- Raquel Lopes de Bragança
- Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Vanessa Gorito
- Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.,EpiUnit Division, Institute of Public Health, University of Porto, Porto, Portugal
| | - Diana Gonçalves Cibele
- Department of Immuno-hemotherapy, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Luciana Ricca Gonçalves
- Department of Immuno-hemotherapy, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Augusto Ribeiro
- Department of Pediatric Intensive Care, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Maria João Baptista
- Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Pediatric Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Inês Azevedo
- Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.,EpiUnit Division, Institute of Public Health, University of Porto, Porto, Portugal.,Pediatric Pneumology Unit, Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal
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11
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Shoya K, Maeda J, Nagamine H, Shimotakahara A, Yoshimura Y, Saito O. Pulmonary Embolism in a Critically Ill Infant with Univentricular Parallel Circulation. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1733873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractA 3-month-old infant patient with hypoplastic left heart syndrome diagnosed in the prenatal period required long-term intensive care for refractory chylothorax and chylous ascites after undergoing bilateral pulmonary artery banding at age 6 days. Weaning from mechanical ventilation was difficult due to massive edema, and a central venous catheter was required because enteral feeding was hampered by the refractory chyle leakage, for which surgery was ineffective. On the evening after central venous catheter replacement was performed, his respiratory condition suddenly deteriorated; cardiac ultrasound revealed that the left pulmonary arterial blood flow had decreased, and enhanced computed tomography demonstrated a left pulmonary embolism (PE), which was identified as the cause of a sudden decrease in the pulmonary blood flow. The patient died due to refractory septic shock at age 5 months. PEs in children, especially patients with cyanotic congenital heart disease, are difficult to diagnose because of their atypical presentation. Current diagnostic criteria are based on adult guidelines, and a few factors in the criteria, such as tachycardia and hypoxia, are difficult to apply for pediatric cyanotic patients with intracardiac or extracardiac right-to-left shunt. In fact, those criteria have lower specificities in children. In conclusion, the present case suggested that a sudden decrease in the pulmonary blood flow can aid the physicians in diagnosing PE in patients with cyanotic congenital heart disease. We need more pediatric cases and evidence of PE in children to make a PE guideline, which is specific to pediatric patients including cyanotic congenital heart disease.
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Affiliation(s)
- Kazuhiro Shoya
- Department of Critical Care and Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Jun Maeda
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroki Nagamine
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | | | - Yukihiro Yoshimura
- Department of Cardiovascular Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Saito
- Department of Critical Care and Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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12
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White M, Betensky M, Lawson SL, Goldenberg NA. Community-Onset Venous Thromboembolism in Children: Pediatric Emergency Medicine Perspectives. Semin Thromb Hemost 2021; 47:623-630. [PMID: 33971683 DOI: 10.1055/s-0041-1725117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pediatric venous thromboembolism (VTE) is a condition increasingly encountered by emergency medicine physicians. Unfortunately, despite increased incidence, the diagnosis of pediatric VTE relies on a high index of suspicion from clinicians. Delays in diagnosis and initiation of treatment can lead to poor outcomes in children, including an increased risk of mortality from pulmonary embolism, increased risk of VTE recurrence, and the development of the post-thrombotic syndrome. The majority of pediatric VTE events are associated with the presence of at least one underlying prothrombotic risk. Timely recognition of these risk factors in the emergency department (ED) setting is paramount for a prompt diagnosis and treatment initiation. Compared with children with hospital-acquired VTE, children presenting to the ED with new onset VTE tend to be older (>11 years of age), have a lower incidence of co-morbidities, and present more frequently with a deep venous thrombosis of the lower extremity. Currently, there are no validated pediatric-specific VTE clinical pretest probability tools that reliably assist with the accurate and timely diagnosis of pediatric VTE. Compression ultrasound with Doppler is the most common imaging modality used for VTE diagnosis, and low molecular weight heparins are the most common anticoagulants initiated in children presenting with VTE in the ED. Special consideration should be given to patients who present to the ED already on anticoagulation therapy who may require acute management for clinically-significant bleeding or change in antithrombotic therapy approach for progression/recurrence of VTE.
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Affiliation(s)
- Melissa White
- Division of General Pediatrics and Adolescent Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Institute of Clinical and Translation Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Simone L Lawson
- Departments of Pediatrics and Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Neil A Goldenberg
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Institute of Clinical and Translation Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Barrera CA, Otero HJ, Fenlon EP, Francavilla ML, Ellison AM, Kaplan SL. CTA utilization for evaluation of suspected pulmonary embolism in a tertiary pediatric emergency department. Clin Imaging 2021; 75:105-110. [PMID: 33524937 DOI: 10.1016/j.clinimag.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/01/2020] [Accepted: 12/26/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate changes in the utilization of computed tomography angiography (CTA) for evaluating suspected pulmonary embolism (PE) and the positive rate of ancillary for those studies negative for PE in the last 13 years. MATERIALS AND METHODS A retrospective review of patient ≤ 20 years of age who underwent a chest CT angiography to rule out PE was performed in a 13-year-period. CT angiographies were grouped into three categories: Positive for PE, negative for PE and positive for ancillary findings, and negative for any pathology. From the exams with ancillary findings, we examined how many of these had a chest radiograph perform within 24 h prior to the CTA and how many of them had an impression stating the same conclusion as the CTA. RESULTS 307 chest CT angiographies for suspected PE were included. 50 (16%) were reported as positive for PE and 91 (30%) were negative for PE but positive for ancillary findings. The most frequent ancillary findings were pneumonia (n = 26) and pleural effusion (n = 11). Out of 91, 73 patients had a previous chest radiograph and 28 of them reported a similar diagnosis than the CTA. The number of CT angiographies indicated for PE increased by 3.2 studies per year. The rate of CT angiographies positive for ancillary findings (slope = 1.5) and positive for PE (slope = 0.3) remained similar throughout the same period. CONCLUSIONS CTA orders for PE have been increasing without any increased detection of PE or ancillary findings in children.
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Affiliation(s)
- Christian A Barrera
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America.
| | - Hansel J Otero
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
| | - Edward P Fenlon
- Department of Radiology, Columbia University Medical Center, 630 W 168th St, MC 28, New York, NY 10032, United States of America
| | - Michael L Francavilla
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
| | - Angela M Ellison
- Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Summer L Kaplan
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
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Winant AJ, Blumfield E, Liszewski MC, Kurian J, Foust AM, Lee EY. Thoracic Imaging Findings of Multisystem Inflammatory Syndrome in Children Associated with COVID-19: What Radiologists Need to Know Now. Radiol Cardiothorac Imaging 2020; 2:e200346. [PMID: 33778614 PMCID: PMC7397565 DOI: 10.1148/ryct.2020200346] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023]
Abstract
The coronavirus disease 2019 (COVID-19) global pandemic is an ongoing public health emergency, with over 4 million confirmed cases worldwide. Due to the novel nature of this coronavirus and our evolving understanding of its pathophysiology, there is continued uncertainty surrounding diagnosis and management of COVID-19, especially in pediatric patients. In addition, a new febrile hyperinflammatory Kawasaki-like syndrome (also known as multisystem inflammatory syndrome in children, or MIS-C) has emerged in pediatric patients with temporal association to COVID-19 infection. This review article aims to provide an up-to-date review of the clinical and imaging findings of pediatric MIS-C associated with COVID-19, compared with typical acute pediatric COVID-19 infection, with an emphasis on thoracic imaging findings. Supplemental material is available for this article. © RSNA, 2020.
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Affiliation(s)
- Abbey J. Winant
- From the Department of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (A.J.W., A.M.F., E.Y.L.); and Department of Radiology and Pediatrics, The Children’s Hospital at Montefiore and Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, 10467 (E.B., M.C.L., J.K.)
| | - Einat Blumfield
- From the Department of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (A.J.W., A.M.F., E.Y.L.); and Department of Radiology and Pediatrics, The Children’s Hospital at Montefiore and Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, 10467 (E.B., M.C.L., J.K.)
| | - Mark C. Liszewski
- From the Department of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (A.J.W., A.M.F., E.Y.L.); and Department of Radiology and Pediatrics, The Children’s Hospital at Montefiore and Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, 10467 (E.B., M.C.L., J.K.)
| | - Jessica Kurian
- From the Department of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (A.J.W., A.M.F., E.Y.L.); and Department of Radiology and Pediatrics, The Children’s Hospital at Montefiore and Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, 10467 (E.B., M.C.L., J.K.)
| | - Alexandra M. Foust
- From the Department of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (A.J.W., A.M.F., E.Y.L.); and Department of Radiology and Pediatrics, The Children’s Hospital at Montefiore and Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, 10467 (E.B., M.C.L., J.K.)
| | - Edward Y. Lee
- From the Department of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (A.J.W., A.M.F., E.Y.L.); and Department of Radiology and Pediatrics, The Children’s Hospital at Montefiore and Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, 10467 (E.B., M.C.L., J.K.)
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15
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Applications of Pediatric Body CT Angiography: What Radiologists Need to Know. AJR Am J Roentgenol 2020; 214:1019-1030. [DOI: 10.2214/ajr.19.22274] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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Artunduaga M, Rao D, Friedman J, Kwon JK, Pfeifer CM, Dettori A, Winant AJ, Lee EY. Pediatric Chest Radiographic and CT Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI). Radiology 2020; 295:430-438. [PMID: 32125258 DOI: 10.1148/radiol.2020192778] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Electronic cigarette or vaping product use-associated lung injury (EVALI) is a serious public health concern with substantial morbidity and mortality, particularly in young individuals. Purpose To evaluate chest radiographic and chest CT findings of EVALI in the pediatric population. Materials and Methods This was a retrospective study of children who presented to a tertiary pediatric hospital from December 2018 to December 2019. Patients fulfilled the Centers for Disease Control and Prevention criteria for EVALI and had chest radiographs and CT images available at initial presentation. Two pediatric radiologists independently reviewed imaging for pattern, distribution, and extent of pulmonary abnormalities, as well as for extrapulmonary abnormalities. Clinical information, management, and outcomes were reviewed. Interobserver agreement was measured with Cohen κ coefficient. Results Seven male patients (50%) and seven female patients (50%) (mean age, 16 years; range, 13-18 years) were evaluated. All patients underwent chest radiography and CT within 4 days of presentation (range, 0-4 days). Chest radiographic findings included ground-glass opacity in 14 of 14 (100%) and consolidation in eight of 14 (57%). CT findings included ground-glass opacity in 14 of 14 (100%), consolidation in nine of 14 (64%), and interlobular septal thickening in two of 14 (14%). At CT, subpleural sparing was seen in 11 of 14 (79%) and a reversed halo sign was seen in five of 14 (36%). Chest radiographic and CT abnormalities were predominately bilateral in 14 of 14 (100%) and symmetric in 13 of 14 (93%), with lower lobe predominance in seven of 14 (50%). Extent of abnormality was predominately diffuse at both chest radiography and CT. There was almost perfect interobserver agreement between two reviewers for detecting abnormalities on chest radiographs (κ = 0.99; 95% confidence interval: 0.97, 1.00) and CT (κ = 0.99; 95% confidence interval: 0.98, 1.00). Conclusion In pediatric patients, electronic cigarette or vaping product use-associated lung injury is characterized by bilateral symmetric ground-glass opacities, consolidation, and a lower lobe predominance at CT. © RSNA, 2020.
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Affiliation(s)
- Maddy Artunduaga
- From the Pediatric Radiology Division, Department of Radiology (M.A., J.F., J.K.K., C.M.P.) and the Pediatric Respiratory Medicine Division, Department of Pediatrics (D.R., A.D.), UT Southwestern Medical Center and Children's Medical Center, 5323 Harry Hines Blvd, CMC F1.02, Dallas, TX 75390; and Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass (A.J.W., E.Y.L.)
| | - Devika Rao
- From the Pediatric Radiology Division, Department of Radiology (M.A., J.F., J.K.K., C.M.P.) and the Pediatric Respiratory Medicine Division, Department of Pediatrics (D.R., A.D.), UT Southwestern Medical Center and Children's Medical Center, 5323 Harry Hines Blvd, CMC F1.02, Dallas, TX 75390; and Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass (A.J.W., E.Y.L.)
| | - Jonathan Friedman
- From the Pediatric Radiology Division, Department of Radiology (M.A., J.F., J.K.K., C.M.P.) and the Pediatric Respiratory Medicine Division, Department of Pediatrics (D.R., A.D.), UT Southwestern Medical Center and Children's Medical Center, 5323 Harry Hines Blvd, CMC F1.02, Dallas, TX 75390; and Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass (A.J.W., E.Y.L.)
| | - Jeannie K Kwon
- From the Pediatric Radiology Division, Department of Radiology (M.A., J.F., J.K.K., C.M.P.) and the Pediatric Respiratory Medicine Division, Department of Pediatrics (D.R., A.D.), UT Southwestern Medical Center and Children's Medical Center, 5323 Harry Hines Blvd, CMC F1.02, Dallas, TX 75390; and Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass (A.J.W., E.Y.L.)
| | - Cory M Pfeifer
- From the Pediatric Radiology Division, Department of Radiology (M.A., J.F., J.K.K., C.M.P.) and the Pediatric Respiratory Medicine Division, Department of Pediatrics (D.R., A.D.), UT Southwestern Medical Center and Children's Medical Center, 5323 Harry Hines Blvd, CMC F1.02, Dallas, TX 75390; and Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass (A.J.W., E.Y.L.)
| | - Amy Dettori
- From the Pediatric Radiology Division, Department of Radiology (M.A., J.F., J.K.K., C.M.P.) and the Pediatric Respiratory Medicine Division, Department of Pediatrics (D.R., A.D.), UT Southwestern Medical Center and Children's Medical Center, 5323 Harry Hines Blvd, CMC F1.02, Dallas, TX 75390; and Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass (A.J.W., E.Y.L.)
| | - Abbey J Winant
- From the Pediatric Radiology Division, Department of Radiology (M.A., J.F., J.K.K., C.M.P.) and the Pediatric Respiratory Medicine Division, Department of Pediatrics (D.R., A.D.), UT Southwestern Medical Center and Children's Medical Center, 5323 Harry Hines Blvd, CMC F1.02, Dallas, TX 75390; and Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass (A.J.W., E.Y.L.)
| | - Edward Y Lee
- From the Pediatric Radiology Division, Department of Radiology (M.A., J.F., J.K.K., C.M.P.) and the Pediatric Respiratory Medicine Division, Department of Pediatrics (D.R., A.D.), UT Southwestern Medical Center and Children's Medical Center, 5323 Harry Hines Blvd, CMC F1.02, Dallas, TX 75390; and Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass (A.J.W., E.Y.L.)
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17
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George AP, Kent P. The Impact of Multiple Risk Factors for Venous Thromboembolism and Its Implications for Management. Glob Pediatr Health 2019; 6:2333794X19859161. [PMID: 31259213 PMCID: PMC6589984 DOI: 10.1177/2333794x19859161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism (VTE) is a rare multifactorial disorder in childhood with an annual incidence of about 0.07 to 0.14 per 10 000 children. A 15-year-old female with a body mass index of 48 kg/m2 who endorsed oral contraceptive use presented with clinical findings consistent with deep venous thrombosis along with the presence of a pulmonary embolism. Further workup revealed that the patient was heterozygous for factor V Leiden and homozygous for prothrombin G20210A mutations. There are no current pediatric guidelines for the antithrombotic management of patients with multiple risk factors for VTE. Two such risk factors, obesity and the use of estrogen-containing hormone contraceptives, have been implicated in adult VTE cases but have not been clearly delineated in pediatric patients. The need for guidance regarding the VTE management of these patients has become more apparent given the increasing incidence of childhood obesity and the number of adolescents using oral contraceptives. Additionally, thrombophilia testing remains controversial though testing may be indicated in asymptomatic first-degree relatives and in families with antithrombin, protein C, or protein S deficiencies. Given the increased incidence of multiple risk factors for VTE, there is also a need to develop a comprehensive risk assessment tool for pediatric patients at high risk of VTE.
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Affiliation(s)
- Anil P George
- University of Illinois, Department of Pediatrics, Division of Hematology/Oncology, Chicago, IL, USA
| | - Paul Kent
- Rush University Medical Center, Department of Pediatrics, Division of Hematology/Oncology, Chicago, IL, USA
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18
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Abstract
Pulmonary embolism is an uncommon but potentially life-threatening event in children. There has been increasing awareness of pulmonary embolism in children with improved survival in children with systemic disease and advancements in diagnostic modalities. However, literature regarding pulmonary embolism in children is sparse, and thus current guidelines for management of pulmonary embolism in children are extrapolated from adult literature and remain controversial. This article reviews the background and pathophysiology of venous thromboembolism, as well as current diagnostic approach and recommended management of pulmonary embolism in children.
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19
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Hauck A, Camarda J. Rare Cardiac Emergencies: Aortic Dissection, Pulmonary Hypertensive Crisis, and Pulmonary Embolism. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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20
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Sharaf N, Sharaf VB, Mace SE, Nowacki AS, Stoller JK, Carl JC. D-dimer in Adolescent Pulmonary Embolism. Acad Emerg Med 2018; 25:1235-1241. [PMID: 30010232 DOI: 10.1111/acem.13517] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/11/2018] [Accepted: 06/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND D-dimer is used to aid in diagnosing adult pulmonary embolism (PE). D-dimer has not been validated in adolescents. Clinicians must balance the risk of overtesting with that of a missed PE. D-dimer may be useful in this context. This study evaluates D-dimer in PE-positive and PE-negative adolescents. METHODS PE-positive patients < 22 years were diagnosed with PE by computed tomography (CT) or high-probability ventilation/perfusion, seen at emergency departments (EDs)/hospitals within a 16-hospital system across two states, January 1998 through December 2016. Of the 189 PE-positive patients, 88 (46.5%) had a D-dimer and were matched 1:1 by age, sex, and race to patients suspected of PE but confirmed negative by CT angiogram. RESULTS Ages of PE-positive patients ranged from 13 to 21 years, 64 (73%) were female, and 52 (60%) were Caucasian. Mean D-dimer was significantly higher (3,256 ng/mL, 95% confidence interval [CI] = 2,505-4,006 ng/mL) in PE-positive versus PE-negative patients (1,244 ng/mL, 95% CI = 493-1,995 ng/mL; p < 0.001). Mean D-dimer was higher in patients with massive or submassive PE (8,742 ng/mL, 95% CI = 5,994-11,491 ng/mL), followed by PE in central (4,795 ng/mL [95% CI = 3,465-6,125 ng/mL), lobar (3,758 ng/mL [95% CI = 1,841-5,676), and distal (2,327 ng/mL [95% CI = 1,273-3,381 ng/mL]) arteries. When comparing thresholds of positive D-dimer (≥500, ≥750, and ≥1,000 ng/mL), D-dimer had sensitivities of 90, 82, and 67% and specificities of 16, 53, and 67%, respectively. Negative predictive values were 61, 75, and 71% while positive likelihood ratios were 1.1, 1.8, and 2.2, respectively. CONCLUSIONS This study represents the largest available cohort of adolescent patients examining the diagnostic value of D-dimer for PE. Our results indicate that depending on the threshold selected, D-dimer can be a sensitive test for PE in adolescents and that discriminative value is higher for a cutoff of 750 ng/mL than that for 500 ng/mL. Prospective studies investigating the diagnostic value of D-dimer and a clinical decision rule for PE in pediatrics are needed.
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Affiliation(s)
- Nematullah Sharaf
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland OH
| | - Victoria B. Sharaf
- Case Western Reserve University School of Medicine Cleveland Clinic Cleveland OH
| | - Sharon E. Mace
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland OH
- Cleveland Clinic Emergency Services Institute Cleveland Clinic Cleveland OH
| | - Amy S. Nowacki
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland OH
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | - James K. Stoller
- Education and Respiratory Institutes Cleveland Clinic Cleveland OH
| | - John C. Carl
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland OH
- Children's Hospital Cleveland OH
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21
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Kanis J, Pike J, Hall CL, Kline JA. Clinical characteristics of children evaluated for suspected pulmonary embolism with D-dimer testing. Arch Dis Child 2018; 103:835-840. [PMID: 29117964 DOI: 10.1136/archdischild-2017-313317] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/25/2017] [Accepted: 10/30/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND We sought to determine clinical variables in children tested for suspected pulmonary embolism (PE) that predict PE+ outcome for the development of paediatric PE prediction rule. METHODS Data were collected by query of a laboratory database for D-dimer from January 2004 to December 2014 for a large multicentre hospital system and the radiology database for pulmonary vascular imaging in children aged 5-17. Using explicit, predefined methods, trained abstractors, determined if D-dimer was sent in the evaluation of PE and then recorded predictor data which was tested for association with PE+ outcome using univariate techniques. RESULTS D-dimer was ordered in 526 children for clinical suspicion of PE. Thirty-four of 526 were PE+ (6.4%, 95% CI 4.3% to 8.7%). The radiology database identified 17 additional patients with PE (n=51 PE+ total). Children evaluated for PE were primarily in the ED setting (80%), teenagers (88%) and 2:1 female:male. Children with PE had higher mean heart and higher respiratory rate and a lower pulse oximetry and haemoglobin concentration. On univariate analysis, five conditions were more frequent in PE+ compared with no PE: surgery, central line, limb immobility, prior PE or deep vein thrombosis and cancer. CONCLUSIONS The rate of PE diagnosis in children with D-dimer was 6.4%, similar to that seen in adults; most children with PE are over 13 years and had clinical predictors known to increase probability of PE in symptomatic adults. Future studies should use these criteria to develop a clinical decision rule for PE in children.
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Affiliation(s)
- Jessica Kanis
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan Pike
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cassandra L Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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22
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Kanis J, Hall CL, Pike J, Kline JA. Diagnostic accuracy of the D-dimer in children. Arch Dis Child 2018; 103:832-834. [PMID: 29117965 DOI: 10.1136/archdischild-2017-313315] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/26/2017] [Accepted: 09/29/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND We sought to measure the diagnostic accuracy of D-dimer in children with suspected pulmonary embolism (PE). METHODS We queried our electronic medical record for quantitative D-dimer values obtained in all children ages 5-17 over 10 years in our 10-hospital system. Patients who had a D-dimer obtained in the evaluation of PE underwent supervised chart review to extract baseline demographics (age, sex, ethnicity), medical history, laboratory data and imaging results. PE was confirmed by imaging positive for deep vein thrombosis (DVT) or PE and excluded by imaging or no DVT or PE diagnosis within 90 days. RESULTS Over a 10-year period, we identified 13 792 orders for D-dimer testing in 2554 unique patients. Chart review indicated that 526 (20.6%) unique patients had D-dimer testing performed in the evaluation of PE (Cohen's kappa=0.95, 95% CI 0.85 to 1.0). Most D-dimers (465/526, 88%) were ordered in children aged >12 years. Of these 526 children, 34 (6.4%, 95% CI) had a criterion standard positive for new or recurrent PE. The mean D-dimer value was 2104±1394 ng/mL in the 34/34 PE+ children and 586±962 ng/mL in PE- children with a sensitivity of 34/34 (100%, 89% to 100%) and a specificity of 290/492 (58%, 54% to 63%). The area under the receiver operating characteristic curve was 0.90 ((0.9)87-0.94). CONCLUSIONS D-dimer is currently ordered in children for suspected PE in the emergency care setting, mostly in teenagers. The observed lower limit 95% CIs of 89% and 54% for diagnostic sensitivity and the specificity, respectively, suggest if used in patients with low-clinical probability, a normal D-dimer can safely exclude PE in children.
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Affiliation(s)
- Jessica Kanis
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cassandra L Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan Pike
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Biss TT. Pulmonary embolism in childhood: how can we be sure not to miss it? Arch Dis Child 2018; 103:814-816. [PMID: 29550763 DOI: 10.1136/archdischild-2017-314428] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/02/2018] [Accepted: 03/03/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Tina T Biss
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
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24
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Abstract
Pulmonary embolism (PE) in children is a rare condition with potential for high mortality. PE incidence is increasing owing to increased survival of children with predisposing conditions, increased use of central venous catheters, and improved awareness and recognition. Although pediatric PE is distinct from adult PE, management guidelines in children are extrapolated from the adult data. Treatment includes thrombolysis or thrombectomy, and pharmacologic anticoagulation. Ongoing clinical trials are evaluating the use of direct oral anticoagulants in children. Further research is required to develop pediatric-specific evidence-based guidelines for diagnosis and management of PE.
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Affiliation(s)
- Sarah Ramiz
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA
| | - Madhvi Rajpurkar
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA.
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25
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Biss TT, Rajpurkar M, Williams S, van Ommen CH, Chan AKC, Goldenberg NA. Recommendations for future research in relation to pediatric pulmonary embolism: communication from the SSC of the ISTH. J Thromb Haemost 2018; 16:405-408. [PMID: 29197153 DOI: 10.1111/jth.13902] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Indexed: 12/01/2022]
Affiliation(s)
- T T Biss
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M Rajpurkar
- Carman and Ann Adams Department of Pediatrics, Division of Hematology Oncology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, USA
| | - S Williams
- Division of Pediatric Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - C H van Ommen
- Department of Pediatric Hematology, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, the Netherlands
| | - A K C Chan
- McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - N A Goldenberg
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Medicine Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
- Johns Hopkins Children's Center, Baltimore, MD, USA
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26
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Rajpurkar M, Biss TT, Amankwah EK, Martinez D, Williams S, van Ommen CH, Goldenberg NA. Pulmonary embolism and in situ pulmonary artery thrombosis in paediatrics. Thromb Haemost 2017; 117:1199-1207. [DOI: 10.1160/th16-07-0529] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/01/2017] [Indexed: 11/05/2022]
Abstract
SummaryData on paediatric pulmonary embolism (PE) are scarce. We sought to systematically review the current literature on childhood PE and conducted a search on paediatric PE via PubMed (1946–2013) and Embase (1980–2013). There was significant heterogeneity in reported data. Two patterns were noted: classic thromboembolic PE (TE-PE) and in situ pulmonary artery thrombosis (ISPAT). Mean age of presentation for TE-PE was 14.86 years, and 51% of cases were males. The commonest method for diagnosis of TE-PE was contrast CT with angiography (74% of patients). The diagnosis of TE-PE was often delayed. Although 85% of children with TE-PE had an elevated D-dimer at presentation, it was non-discriminatory for the diagnosis. In paediatric TE-PE, the prevalence of central venous catheters was 23%, immobilisation 38%, systemic infection 31% and obesity 13%, elevated Factor VIII or von Willebrand factor levels 27%, Protein C deficiency 17%, Factor V Leiden 14% and Protein S deficiency 7%. In patients with TE-PE, pharmacologic thrombolysis was used in 29%; unfractionated heparin was the most common initial anticoagulant treatment in 64% and low-molecular-weight heparins the most common follow-up treatment in 83%. Duration of anticoagulant therapy was variable and death was reported in 26% of TE-PE patients. In contrast to TE-PE, patients with ISPAT were not investigated systematically for presence of thrombophilia, had more surgical interventions as the initial management and were often treated with anti-platelet medications. This review summarises important data and identifies gaps in the knowledge of paediatric PE, which may help to design future studies.
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Cox M, Epelman M, Chandra T, Meyers AB, Johnson CM, Podberesky DJ. Non–Catheter-related Venous Thromboembolism in Children: Imaging Review from Head to Toe. Radiographics 2017; 37:1753-1774. [DOI: 10.1148/rg.2017170036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Mougnyan Cox
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Monica Epelman
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Tushar Chandra
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Arthur B. Meyers
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Craig M. Johnson
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Daniel J. Podberesky
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
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Shah AY, Jamison M, Otero HJ, Jung L, Frank LH, Guerrera MF, Kirkorian AY. A 17-Year-Old With Chest Pain. Pediatrics 2017; 139:peds.2016-0794. [PMID: 28159870 DOI: 10.1542/peds.2016-0794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2016] [Indexed: 11/24/2022] Open
Abstract
A 17-year-old male subject with a history of deep venous thrombosis presented with acute unilateral severe chest pain. His examination was nonspecific, and vital signs were normal. His initial laboratory evaluation revealed mild thrombocytopenia, elevated troponin levels, and critically elevated activated partial thromboplastin time. A computed tomography angiogram of the chest revealed a pulmonary embolus, and anticoagulation therapy was initiated. His course was complicated by the development of multiple thrombi and respiratory failure. Extensive evaluation revealed a rare, underlying diagnosis in time for life-saving treatment to be initiated.
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Affiliation(s)
- Ankoor Y Shah
- Children's National Health System, Washington, District of Columbia; and
| | - Megan Jamison
- Department of Dermatology, Georgetown University-Washington Hospital Center, Washington, District of Columbia
| | - Hansel J Otero
- Children's National Health System, Washington, District of Columbia; and
| | - Lawrence Jung
- Children's National Health System, Washington, District of Columbia; and
| | - Lowell H Frank
- Children's National Health System, Washington, District of Columbia; and
| | - Michael F Guerrera
- Children's National Health System, Washington, District of Columbia; and
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Comparison of Mechanical Versus Hand Administration of IV Contrast Agents for Pediatric Pulmonary CT Angiography. AJR Am J Roentgenol 2017; 208:632-636. [DOI: 10.2214/ajr.16.16768] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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30
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Lilje C, Chauhan A, Turner JP, Carson TH, Velez MC, Arcement C, Caspi J. Pediatric Pulmonary Embolism: Diagnostic and Management Challenges. World J Pediatr Congenit Heart Surg 2016; 9:110-113. [PMID: 27619327 DOI: 10.1177/2150135116663698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A rare case of massive pulmonary embolism is presented in an oligosymptomatic teenager with predisposing factors. Computed tomography pulmonary angiography supported by three-dimensional reconstruction was diagnostic. The embolus qualified as massive by conventional anatomical guidelines, but as low risk by more recent functional criteria. Functional assessment has complemented morphologic assessment for risk stratification in adult patients. Such evidence is scarce in pediatrics. The patient underwent surgical embolectomy, followed by prophylactic anticoagulation, without further events. Diagnostic and management challenges are discussed.
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Affiliation(s)
- Christian Lilje
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Aman Chauhan
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Jason P Turner
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Thomas H Carson
- 2 Department of Pathology, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Maria C Velez
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Christopher Arcement
- 3 Department of Radiology, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Joseph Caspi
- 4 Department of Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
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31
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Thacker PG, Lee EY. Advances in Multidetector CT Diagnosis of Pediatric Pulmonary Thromboembolism. Korean J Radiol 2016; 17:198-208. [PMID: 26957904 PMCID: PMC4781758 DOI: 10.3348/kjr.2016.17.2.198] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 12/18/2015] [Indexed: 11/19/2022] Open
Abstract
Although pediatric pulmonary thromboembolism is historically believed to be rare with relatively little information available in the medical literature regarding its imaging evaluation, it is more common than previously thought. Thus, it is imperative for radiologists to be aware of the most recent advances in its imaging information, particularly multidetector computed tomography (MDCT), the imaging modality of choice in the pediatric population. The overarching goal of this article is to review the most recent updates on MDCT diagnosis of pediatric pulmonary thromboembolism.
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Affiliation(s)
- Paul G Thacker
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Edward Y Lee
- Division of Thoracic Imaging, Department of Radiology and Medicine, Pulmonary Division Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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32
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Risk factors and clinical features of acute pulmonary embolism in children from the community. Thromb Res 2016; 138:86-90. [DOI: 10.1016/j.thromres.2015.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 11/24/2015] [Accepted: 12/09/2015] [Indexed: 11/23/2022]
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Abman SH, Hansmann G, Archer SL, Ivy DD, Adatia I, Chung WK, Hanna BD, Rosenzweig EB, Raj JU, Cornfield D, Stenmark KR, Steinhorn R, Thébaud B, Fineman JR, Kuehne T, Feinstein JA, Friedberg MK, Earing M, Barst RJ, Keller RL, Kinsella JP, Mullen M, Deterding R, Kulik T, Mallory G, Humpl T, Wessel DL. Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Circulation 2015; 132:2037-99. [PMID: 26534956 DOI: 10.1161/cir.0000000000000329] [Citation(s) in RCA: 702] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension.
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MESH Headings
- Cardiovascular Agents/therapeutic use
- Child
- Child, Preschool
- Combined Modality Therapy
- Diagnostic Imaging/methods
- Disease Management
- Extracorporeal Membrane Oxygenation
- Genetic Counseling
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/therapy
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/therapy
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/therapy
- Infant
- Infant, Newborn
- Lung/embryology
- Lung Transplantation
- Nitric Oxide/administration & dosage
- Nitric Oxide/therapeutic use
- Oxygen Inhalation Therapy
- Persistent Fetal Circulation Syndrome/diagnosis
- Persistent Fetal Circulation Syndrome/therapy
- Postoperative Complications/therapy
- Respiration, Artificial/adverse effects
- Respiration, Artificial/methods
- Ventilator-Induced Lung Injury/prevention & control
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34
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Tang CX, Schoepf UJ, Chowdhury SM, Fox MA, Zhang LJ, Lu GM. Multidetector computed tomography pulmonary angiography in childhood acute pulmonary embolism. Pediatr Radiol 2015; 45:1431-9. [PMID: 25846076 PMCID: PMC4553120 DOI: 10.1007/s00247-015-3336-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 02/03/2015] [Accepted: 03/02/2015] [Indexed: 12/29/2022]
Abstract
Pulmonary embolism is a life-threatening condition affecting people of all ages. Multidetector row CT pulmonary angiography has improved the imaging of pulmonary embolism in both adults and children and is now regarded as the routine modality for detection of pulmonary embolism. Advanced CT pulmonary angiography techniques developed in recent years, such as dual-energy CT, have been applied as a one-stop modality for pulmonary embolism diagnosis in children, as they can simultaneously provide anatomical and functional information. We discuss CT pulmonary angiography techniques, common and uncommon findings of pulmonary embolism in both conventional and dual-energy CT pulmonary angiography, and radiation dose considerations.
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Affiliation(s)
- Chun Xiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - U. Joseph Schoepf
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China. Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA. Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | | | - Mary A. Fox
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
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35
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Radulescu VC. Management of venous thrombosis in the pediatric patient. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2015; 6:111-119. [PMID: 29388593 PMCID: PMC5683259 DOI: 10.2147/phmt.s65697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The incidence of venous thromboembolism in children has increased significantly over the past decade. The evaluation and management of the child with venous thromboembolism, while based on the adult experience, has its own particularities dictated by the differences in the hemostatic system of the newborn and child. The current review addresses the evaluation of pediatric patient with thrombosis as well as the established and emerging treatment interventions.
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Affiliation(s)
- Vlad C Radulescu
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
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Development of a pediatric-specific clinical probability tool for diagnosis of venous thromboembolism: a feasibility study. Pediatr Res 2015; 77:463-71. [PMID: 25518012 PMCID: PMC4346381 DOI: 10.1038/pr.2014.198] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 09/10/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pediatric venous thromboembolism (VTE) is an increasingly common, difficult to diagnose problem. Clinical probability tools (CPT) for adults estimate VTE likelihood, but are not available for children. We hypothesized that a pediatric-specific CPT is feasible. METHODS Radiology reports were utilized to identify children imaged for suspected VTE. Relevant signs, symptoms, and comorbidity variables, identified from published literature, were extracted from corresponding medical records. Variables associated with pediatric VTE were incorporated into a multivariate logistic regression to create a pilot CPT which was confirmed on a separate cohort. RESULTS A total of 389 subjects meeting inclusion criteria were identified: 91 with VTE and 298 without. Univariate analysis revealed male gender (odds ratio (OR) = 2.96; P < 0.001), asymmetric extremity (OR = 1.76; P = 0.033), central venous catheter utilization and/or dysfunction (OR = 2.51; P < 0.001), and cancer (OR = 2.35; P = 0.014) as VTE predictive variables. Documentation of an alternate diagnosis was inversely related to VTE (OR = 0.42; P = 0.004). Receiver operating characteristic analysis of the derived CPT demonstrated reasonable ability to discriminate VTE probability in the training cohort (area under the curve (AUC) = 0.73; P < 0.001) and moderate discrimination in a separate validation cohort of 149 children (AUC = 0.64; P = 0.011). CONCLUSION A pediatric-specific VTE CPT is feasible, would facilitate early diagnosis, and could lead to improved outcomes.
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Evaluation of Contrast Injection Site Effectiveness: Thoracic CT Angiography in Children With Hand Injection of IV Contrast Material. AJR Am J Roentgenol 2015; 204:423-7. [DOI: 10.2214/ajr.14.12810] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Zhang LJ, Zhang Z, Li SJ, Meinel FG, Nance JW, Zhou CS, Zhao YE, Schoepf UJ, Lu GM. Pulmonary embolism and renal vein thrombosis in patients with nephrotic syndrome: prospective evaluation of prevalence and risk factors with CT. Radiology 2014; 273:897-906. [PMID: 25072187 DOI: 10.1148/radiol.14140121] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To prospectively determine the prevalence of pulmonary embolism ( PE pulmonary embolism ) and renal vein thrombosis ( RVT renal vein thrombosis ) with computed tomography (CT) and to identify markers predictive of PE pulmonary embolism and/or RVT renal vein thrombosis in a large consecutive cohort of patients with nephrotic syndrome. MATERIALS AND METHODS This study was approved by the local institutional review board, and all patients or their guardians provided written informed consent. Consecutive patients with nephrotic syndrome (24-hour urine protein > 3.5 g) underwent combined CT pulmonary angiography for PE pulmonary embolism and renal CT venography for RVT renal vein thrombosis . Prevalence of PE pulmonary embolism and/or RVT renal vein thrombosis was estimated for different ages, sexes, and histopathologic types of nephrotic syndrome. Multivariate analysis was used to determine independent predictors for PE pulmonary embolism and/or RVT renal vein thrombosis in patients with nephrotic syndrome. RESULTS There were 512 patients in the study cohort (331 male patients, 181 female patients; mean age, 37 years ± 17 [standard deviation]; range, 9-81 years), including 80 children. One hundred eighty (35%) of 512 patients had PE pulmonary embolism and/or RVT renal vein thrombosis , with PE pulmonary embolism the more common condition (85% [153 of 180]). PE pulmonary embolism was associated with RVT renal vein thrombosis in 85 (56%) of 153 patients and was isolated in 68 patients (44%). Most patients with PE pulmonary embolism (84% [128 of 153]) were asymptomatic. One hundred twelve (22%) of 505 patients had RVT renal vein thrombosis . PE pulmonary embolism and/or RVT renal vein thrombosis was found in 15 (19%) of 80 children with nephrotic syndrome, while 165 (38%) of 432 adult patients with nephrotic syndrome had PE pulmonary embolism and/or RVT renal vein thrombosis (P = .001). Membranous nephropathy was the most common histopathologic type associated with PE pulmonary embolism and/or RVT renal vein thrombosis (48% [88 of 183]). Membranous nephropathy, age greater than 60 years, high hemoglobin level, long prothrombin time, and high creatinine level were independent predictors of PE pulmonary embolism and/or RVT renal vein thrombosis (P < .05 for all). CONCLUSION PE pulmonary embolism and RVT renal vein thrombosis are common in patients with nephrotic syndrome. PE pulmonary embolism is more common than RVT renal vein thrombosis , is most often asymptomatic, and is most frequently found in patients with membranous nephropathy. A high index of suspicion and a low threshold for diagnostic work-up is warranted in these patients.
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Affiliation(s)
- Long Jiang Zhang
- From the Department of Medical Imaging (L.J.Z., Z.Z., C.S.Z., Y.E.Z., U.J.S., G.M.L.) and Research Institute of Nephrology (S.J.L.), Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province, China 200012; and Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (F.G.M., J.W.N., U.J.S.)
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40
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Remy-Jardin M, Pontana F, Faivre JB, Molinari F, Pagniez J, Khung S, Remy J. New Insights in Thromboembolic Disease. Radiol Clin North Am 2014; 52:183-93. [DOI: 10.1016/j.rcl.2013.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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41
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Tang CX, Zhang LJ, Han ZH, Zhou CS, Krazinski AW, Silverman JR, Schoepf UJ, Lu GM. Dual-energy CT based vascular iodine analysis improves sensitivity for peripheral pulmonary artery thrombus detection: an experimental study in canines. Eur J Radiol 2013; 82:2270-8. [PMID: 23891532 DOI: 10.1016/j.ejrad.2013.06.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 06/24/2013] [Accepted: 06/25/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the performance of dual-energy CT (DECT) based vascular iodine analysis for the detection of acute peripheral pulmonary thrombus (PE) in a canine model with histopathological findings as the reference standard. MATERIALS AND METHODS The study protocol was approved by our institutional animal committee. Thrombi (n = 12) or saline (n = 4) were intravenously injected via right femoral vein in sixteen dogs, respectively. CT pulmonary angiography (CTPA) in DECT mode was performed and conventional CTPA images and DECT based vascular iodine studies using Lung Vessels application were reconstructed. Two radiologists visually evaluated the number and location of PEs using conventional CTPA and DECT series on a per-animal and a per-clot basis. Detailed histopathological examination of lung specimens and catheter angiography served as reference standard. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of DECT and CTPA were calculated on a segmental and subsegmental or more distal pulmonary artery basis. Weighted κ values were computed to evaluate inter-modality and inter-reader agreement. RESULTS Thirteen dogs were enrolled for final image analysis (experimental group = 9, control group = 4). Histopathological results revealed 237 emboli in 45 lung lobes in 9 experimental dogs, 11 emboli in segmental pulmonary arteries, 49 in subsegmental pulmonary arteries, 177 in fifth-order or more distal pulmonary arteries. Overall sensitivity, specificity, accuracy, PPV, and NPV for CTPA plus DECT were 93.1%, 76.9%, 87.8%, 89.4%, and 84.2% for the detection of pulmonary emboli. With CTPA versus DECT, sensitivities, specificities, accuracies, PPVs, and NPVs are all 100% for the detection of pulmonary emboli on a segmental pulmonary artery basis, 88.9%, 100%, 96.0%, 100%, and 94.1% for CTPA and 90.4%, 93.0%, 92.0%, 88.7%, and 94.1% for DECT on a subsegmental pulmonary artery basis; 23.8%, 96.4%, 50.4%, 93.5%, and 36.7% for CTPA and 95.9%, 75.5%, 88.2%, 86.5%, and 91.9% on a sub-subsegmental and more distal pulmonary artery basis, respectively. Good inter-modality (κ = 0.65, P<0.001) and inter-reader (κ = 0.70, P<0.001) agreement were observed. CONCLUSION With histopathological findings as the reference standard, DECT based vascular iodine analysis improves the sensitivity for detecting peripheral PE compared with CTPA, albeit at the price of decreased specificity and PPV.
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Affiliation(s)
- Chun Xiang Tang
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu 210002, China
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Image Quality of Thoracic 64-MDCT Angiography: Imaging of Infants and Young Children With or Without General Anesthesia. AJR Am J Roentgenol 2013; 200:171-6. [DOI: 10.2214/ajr.12.8758] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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43
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Lee EY, Neuman MI, Lee NJ, Johnson VM, Zurakowski D, Tracy DA, Boiselle PM. Pulmonary Embolism Detected by Pulmonary MDCT Angiography in Older Children and Young Adults: Risk Factor Assessment. AJR Am J Roentgenol 2012; 198:1431-1437. [DOI: 10.2214/ajr.11.8005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Edward Y. Lee
- Department of Radiology and Department of Medicine, Pulmonary Division, Children’s Hospital Boston and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115
| | - Mark I. Neuman
- Department of Emergency Medicine, Children’s Hospital Boston and Harvard Medical School, Boston, MA
| | - Nam Ju Lee
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Victor M. Johnson
- Department of Anesthesiology, Children’s Hospital Boston and Harvard Medical School, Boston, MA
| | - David Zurakowski
- Department of Anesthesiology, Children’s Hospital Boston and Harvard Medical School, Boston, MA
| | - Donald A. Tracy
- Department of Radiology and Department of Medicine, Pulmonary Division, Children’s Hospital Boston and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115
| | - Phillip M. Boiselle
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Kalava A, Kalstein A, Koyfman S, Mardakh S, Yarmush JM, SchianodiCola J. Pulseless electrical activity during electroconvulsive therapy: a case report. BMC Anesthesiol 2012; 12:8. [PMID: 22650157 PMCID: PMC3403950 DOI: 10.1186/1471-2253-12-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 05/31/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Arrhythmias resulting in cardiac arrest during electroconvulsive therapy have been reported. Most reported cases of cardiac arrest had asystole as the initial rhythm. Pulseless electrical activity as an initial rhythm of cardiac arrest during electroconvulsive therapy has never been reported. Also, thromboembolism after inflation of pneumatic tourniquet during lower limb surgery has been reported but never following tourniquet inflation during an electroconvulsive therapy. CASE PRESENTATION We report a case involving an 81- year- old female who presented to us for an electroconvulsive therapy for severe depression and developed pulseless electrical activity immediately after electroconvulsive therapy. She was successfully resuscitated and was later found to have bilateral pulmonary emboli with a complete occlusion of the right lower lobe pulmonary artery. The source of embolus was from her left lower extremity deep venous thrombus, which we believe, got dislodged intraoperatively after inflation of pneumatic tourniquet. Our patient not only survived the massive pulmonary embolus, but also showed significant improvement in her mental status compared to her pre-admission level at the time of discharge to a sub-acute rehabilitation centre. CONCLUSION We recommend that patients who are elderly and at high risk of thromboembolism should selectively undergo a preoperative doppler ultrasound for deep venous thrombosis. Also, selective application of tourniquet in the upper limb, to monitor for seizure activity, would reduce the incidence of pulmonary thrombo-embolism as embolic events are significantly less from deep venous thromboses of upper extremities when compared to lower extremities.
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Affiliation(s)
- Arun Kalava
- Department of Anesthesiology, New York Methodist Hospital, 506, 6th street, Brooklyn, NY, 11215, USA
| | - Allison Kalstein
- Department of Anesthesiology, New York Methodist Hospital, 506, 6th street, Brooklyn, NY, 11215, USA
| | - Sander Koyfman
- Department of Psychiatry, New York Methodist Hospital, 506, 6th street, Brooklyn, NY, 11215, USA
| | - Simon Mardakh
- Department of Anesthesiology, New York Methodist Hospital, 506, 6th street, Brooklyn, NY, 11215, USA
| | - Joel M Yarmush
- Department of Anesthesiology, New York Methodist Hospital, 506, 6th street, Brooklyn, NY, 11215, USA
| | - Joseph SchianodiCola
- Department of Anesthesiology, New York Methodist Hospital, 506, 6th street, Brooklyn, NY, 11215, USA
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