1
|
Montisci R, Licciardi M, Cecchi R, Kondo T, Gerosa G, Casula R, Cecchetto G, Montisci M. Malpratice claims in cardiology and cardiac surgery: A medico-legal issue. Leg Med (Tokyo) 2023; 65:102319. [PMID: 37696211 DOI: 10.1016/j.legalmed.2023.102319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/25/2023] [Accepted: 08/21/2023] [Indexed: 09/13/2023]
Abstract
Medical liability has become a challenge in every physician's modern practice with the consequent loss of the physician's autonomy and an increase in "defensive medicine". From this perspective, the role of Legal Medicine in assessing medical liability has become increasingly specific and a homogenization of the methods of ascertainment is increasingly necessary, since such a process can contribute to strengthening the guarantees in professional liability procedures. Focusing on malpractice claims in the field of cardiology, the complexity of the management of cardiac pathologies and the frequency of severe adverse events implies the importance of a multi-disciplinary approach, together with the application of a shared ascertainment methodology. In particular, it is essential for the forensic pathologist to collaborate with experts in cardio-pathology, cardiology and/or cardiac surgery in cases of alleged medical liability in the cardiologic field and to follow the guidelines which have been produced to assist the expert dealing with deaths reflecting cardiac disease, in order to prevent criticism of case analysis in medico-legal environments and to promote the standardization of the structure of the juridical-legislative medical malpractice lawsuits.
Collapse
Affiliation(s)
- R Montisci
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - M Licciardi
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - R Cecchi
- Institute of Legal Medicine, Department of Medicine and Surgery, University of Parma, Italy.
| | - T Kondo
- Institute of Legal Medicine, Wakayama Medical University School of Medicine Graduate School of Medicine, Japan
| | - G Gerosa
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - R Casula
- Clinical Cardiology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - G Cecchetto
- Legal Medicine and Toxicology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - M Montisci
- Legal Medicine and Toxicology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| |
Collapse
|
2
|
Ostberg NP, Zafar MA, Mukherjee SK, Ziganshin BA, Elefteriades JA. A machine learning approach for predicting complications in descending and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2023; 166:1011-1020.e3. [PMID: 35120761 DOI: 10.1016/j.jtcvs.2021.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/30/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To use machine learning to predict rupture, dissection, and all-cause mortality for patients with descending and thoracoabdominal aortic aneurysms in an effort to improve on diameter-based surgical intervention criteria. METHODS Retrospective data from 1083 patients with descending aortic diameters 3.0 cm or greater were collected, with a mean follow-up time of 3.52 years and an average descending diameter of 4.13 cm. Six machine learning classifiers were trained using 44 variables to predict the occurrence of dissection, rupture, or all-cause mortality within 1, 2, or 5 years of initial patient encounter for a total of 54 (6 × 3 × 3) separate classifiers. Classifier performance was measured using area under the receiver operator curve. RESULTS Machine learning models achieved area under the receiver operator curves of 0.842 to 0.872 when predicting type B dissection, 0.847 to 0.856 when predicting type B dissection or rupture, and 0.820 to 0.845 when predicting type B dissection, rupture, or all-cause mortality. All models consistently outperformed descending aortic diameter across all end points (area under the receiver operator curve = 0.713-0.733). Feature importance inspection showed that other features beyond aortic diameter, such as a history of myocardial infarction, hypertension, and patient sex, play an important role in improving risk prediction. CONCLUSIONS This study provides surgeons with a more accurate, machine learning-based, risk-stratification metric to predict complications for patients with descending aortic aneurysms.
Collapse
Affiliation(s)
- Nicolai P Ostberg
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Sandip K Mukherjee
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
| |
Collapse
|
3
|
Gurevitz M, Weinberger A, Miller D. Aortic Root Aneurysm in an Extreme Athlete. Cureus 2022; 14:e26661. [PMID: 35949787 PMCID: PMC9357427 DOI: 10.7759/cureus.26661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 11/05/2022] Open
Abstract
Aortic root aneurysms require close clinical monitoring due to the risk of dissection or rupture. While patients usually remain asymptomatic, it can occasionally be detected on physical examination as a diastolic murmur, which can be further confirmed with diagnostic imaging. The vast majority of aneurysms are found in patients with congenital or acquired conditions that compromise vascular integrity. Here, we present a case of an athletic, healthy appearing 54-year-old who was incidentally found to have a severely enlarged aneurysm requiring urgent surgical intervention.
Collapse
|
4
|
Yacoub B, Kabakus IM, Schoepf UJ, Giovagnoli VM, Fischer AM, Wichmann JL, Martinez JD, Sharma P, Rapaka S, Sahbaee P, Hoelzer P, Burt JR, Varga-Szemes A, Emrich T. Performance of an Artificial Intelligence-Based Platform Against Clinical Radiology Reports for the Evaluation of Noncontrast Chest CT. Acad Radiol 2022; 29 Suppl 2:S108-S117. [PMID: 33714665 DOI: 10.1016/j.acra.2021.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/01/2021] [Accepted: 02/11/2021] [Indexed: 12/20/2022]
Abstract
RATIONALE AND OBJECTIVES Research on implementation of artificial intelligence (AI) in radiology workflows and its impact on reports remains scarce. In this study, we aim to assess if an AI platform would perform better than clinical radiology reports in evaluating noncontrast chest computed tomography (CT) scans. MATERIALS AND METHODS Consecutive patients who had undergone noncontrast chest CT were retrospectively identified. The radiology reports were reviewed in a binary fashion for reporting of pulmonary lesions, pulmonary emphysema, aortic dilatation, coronary artery calcifications (CAC), and vertebral compression fractures (VCF). CT scans were then processed using an AI platform. The reports' findings and the AI results were subsequently compared to a consensus read by two board-certificated radiologists as reference. RESULTS A total of 100 patients (mean age: 64.2 ± 14.8 years; 57% males) were included in this study. Aortic segmentation and calcium quantification failed to be processed by AI in 2 and 3 cases, respectively. AI showed superior diagnostic performance in identifying aortic dilatation (AI: sensitivity: 96.3%, specificity: 81.4%, AUC: 0.89) vs (Reports: sensitivity: 25.9%, specificity: 100%, AUC: 0.63), p <0.001; and CAC (AI: sensitivity: 89.8%, specificity: 100, AUC: 0.95) vs (Reports: sensitivity: 75.4%, specificity: 94.9%, AUC: 0.85), p = 0.005. Reports had better performance than AI in identifying pulmonary lesions (Reports: sensitivity: 97.6%, specificity: 100%, AUC: 0.99) vs (AI: sensitivity: 92.8%, specificity: 82.4%, AUC: 0.88), p = 0.024; and VCF (Reports: sensitivity:100%, specificity: 100%, AUC: 1.0) vs (AI: sensitivity: 100%, specificity: 63.7%, AUC: 0.82), p <0.001. A comparable diagnostic performance was noted in identifying pulmonary emphysema on AI (sensitivity: 80.6%, specificity: 66.7%. AUC: 0.74) and reports (sensitivity: 74.2%, specificity: 97.1%, AUC: 0.86), p = 0.064. CONCLUSION Our results demonstrate that incorporating AI support platforms into radiology workflows can provide significant added value to clinical radiology reporting.
Collapse
Affiliation(s)
- Basel Yacoub
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - Ismail M Kabakus
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina.
| | - Vincent M Giovagnoli
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - Andreas M Fischer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina; University Hospital Basel, University of Basel, Department of Radiology, Basel, Switzerland
| | - Julian L Wichmann
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany; Siemens Healthineers, Erlangen, Germany
| | - John D Martinez
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | | | | | | | | | - Jeremy R Burt
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - Tilman Emrich
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina; University Medical Center Mainz, Department of Diagnostic and Interventional Radiology, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner-Site Rhine-Main, Mainz, Germany
| |
Collapse
|
5
|
Elefteriades JA, Ziganshin BA, Rizzo JA. Reply to the Positive Predictive Value of the Thumb-Palm Test for General Population Screening of Ascending Aortic Aneurysm. Am J Cardiol 2021; 161:117-118. [PMID: 34794610 DOI: 10.1016/j.amjcard.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 10/19/2022]
|
6
|
Aldalati A, Bellamkonda VR, Moore GP, Finch AS. Three Cases of Emergency Department Medical Malpractice Involving "Consultations": How Is Liability Legally Determined? Clin Pract Cases Emerg Med 2021; 5:283-288. [PMID: 34437032 PMCID: PMC8373181 DOI: 10.5811/cpcem.2021.7.52680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/02/2021] [Indexed: 11/18/2022] Open
Abstract
This article presents three successfully litigated medical malpractice cases involving emergency physicians and consultants. We discuss the respective case medical diagnoses, as well as established legal principles that determine in a court proceeding which provider will be liable. Specifically, we explain the legal principles of “patient physician relationship” and “affirmative act.”
Collapse
Affiliation(s)
- Alaa Aldalati
- Mayo Clinic College of Medicine and Science, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota
| | - Venkatesh R Bellamkonda
- Mayo Clinic College of Medicine and Science, Department of Emergency Medicine, Rochester, Minnesota
| | - Gregory P Moore
- Mayo Clinic College of Medicine and Science, Department of Emergency Medicine, Rochester, Minnesota
| | - Alexander S Finch
- Mayo Clinic College of Medicine and Science, Department of Emergency Medicine, Rochester, Minnesota
| |
Collapse
|
7
|
Dietenbeck T, Houriez-Gombaud-Saintonge S, Charpentier E, Gencer U, Giron A, Gallo A, Boussouar S, Pasi N, Soulat G, Mousseaux E, Redheuil A, Kachenoura N. Quantitative magnetic resonance imaging measures of three-dimensional aortic morphology in healthy aging and hypertension. J Magn Reson Imaging 2021; 53:1471-1483. [PMID: 33426700 DOI: 10.1002/jmri.27502] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 01/16/2023] Open
Abstract
Automated segmentation of three-dimensional (3D) aortic magnetic resonance imaging (MRI) renders a possible retrospective selection of any location to perform quantification of aortic caliber perpendicular to its centerline and provides regional and global 3D biomarkers such as length, diameter, or volume. However, normative age-related values of such measures are still lacking. The aim of this study was to provide normal values for 3D aortic morphological measures and investigate their changes in aging and hypertension. This was a retrospective study, in which 119 healthy controls (HC: 48 ± 14 years, 61 men) and 82 hypertensive patients (HT: 60 ± 14 years, 43 men) were enrolled. 1.5 and 3 T/3D steady state free precession or spoiled gradient echo were used. Automated 3D aortic segmentation provided aortic length, diameter, volume for the ascending (AAo), and descending aorta (DAo), along with cross-sectional diameters at three aortic landmarks. Age, sex, body surface area (BSA), smoking, and blood pressures were recorded. Both groups were divided into two subgroups (≤50 years, >50 years). Statistical tests performed were linear regression for age-related normal values and confidence intervals, Wilcoxon rank sum test for differences between groups (HC or HT), and multivariate analysis to identify main determinants of aortic morphological changes. In HC, linear regression revealed an increase in the AAo (respectively DAo) length by 2.84 mm (7.78 mm), maximal diameter by 1.36 mm (1.29 mm), and volume by 4.28 ml (8.71 ml) per decade. AAo morphological measures were higher in HT patients than in HC both ≤50 years but did not reach statistical significance (length: +2 mm, p = 0.531; diameter: +1.4 mm, p = 0.2936; volume:+6.8 ml, p = 0.1857). However, length (+6 mm, p = 0.003), maximal diameter (+4 mm, p < 0.001) and volume (+12 ml, p < 0.001) were significantly higher in HT patients than in HC, both >50 years. In a multivariate analysis, age, sex, and BSA were the major determinants of aortic morphology, irrespective of the presence of hypertension. Global and segmental aortic length, volume, and diameters at specific landmarks were automatically measured from 3D MRI to serve as normative measures of 3D aortic morphology. Such indices increased significantly with age and hypertension among the elderly subjects. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 3.
Collapse
Affiliation(s)
- Thomas Dietenbeck
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France.,Institute of Cardiometabolism and Nutrition (ICAN), Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France
| | - Sophia Houriez-Gombaud-Saintonge
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France.,Institute of Cardiometabolism and Nutrition (ICAN), Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France.,ESME Sudria Research Lab, Paris, France
| | - Etienne Charpentier
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France.,Institute of Cardiometabolism and Nutrition (ICAN), Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France
| | - Umit Gencer
- PARCC, Université de Paris, INSERM, Paris, France.,Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Alain Giron
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France
| | - Antonio Gallo
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France.,Institute of Cardiometabolism and Nutrition (ICAN), Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France
| | - Samia Boussouar
- Département d'Imagerie Cardiovasculaire DICVRIT, Institut de Cardiologie, Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France
| | - Nicoletta Pasi
- Département d'Imagerie Cardiovasculaire DICVRIT, Institut de Cardiologie, Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France
| | - Gilles Soulat
- PARCC, Université de Paris, INSERM, Paris, France.,Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Elie Mousseaux
- PARCC, Université de Paris, INSERM, Paris, France.,Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Alban Redheuil
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France.,Institute of Cardiometabolism and Nutrition (ICAN), Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France.,Département d'Imagerie Cardiovasculaire DICVRIT, Institut de Cardiologie, Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France
| | - Nadjia Kachenoura
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France.,Institute of Cardiometabolism and Nutrition (ICAN), Groupe Hospitalier Pitié Salpêtrière APHP, Paris, France
| |
Collapse
|
8
|
Medical malpractice litigations involving aortic dissection. J Thorac Cardiovasc Surg 2020; 164:600-608. [DOI: 10.1016/j.jtcvs.2020.10.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/28/2020] [Accepted: 10/08/2020] [Indexed: 01/16/2023]
|
9
|
Bautz B, Schneider JI. High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update). Emerg Med Clin North Am 2020; 38:453-498. [PMID: 32336336 DOI: 10.1016/j.emc.2020.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.
Collapse
Affiliation(s)
- Benjamin Bautz
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA.
| |
Collapse
|
10
|
Diaz-Zuccarini V, Bonfanti M, Franzetti G, Balabani S. Virtual TEVAR: Overcoming the Roadblocks of In-Silico Tools for Aortic Dissection Treatment. Theranostics 2019; 8:6384-6385. [PMID: 30613306 PMCID: PMC6299687 DOI: 10.7150/thno.30753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/30/2018] [Indexed: 11/29/2022] Open
Abstract
The use of in silico tools for the interventional planning of complex vascular conditions, such as Aortic Dissections has been often limited by high computational cost, involving long timescales for accurate results to be produced and low numbers of patients, precluding the use of statistical analyses to inform individual-level models. In the paper [Theranostics 2018; 8(20):5758-5771. doi:10.7150/thno.28944], Chen et al. proposed a novel algorithm to compute patient-specific 'virtual TEVAR' that will help clinicians to approach individual treatment and decision-making based on objective and quantifiable metrics and validated on a cohort of 66 patients in real time. This research will significantly impact the field and has the potential to transform the way clinical interventions will be approached in the future.
Collapse
|
11
|
Rose M, Newton C, Boualam B, Bogne N, Ketchum A, Shah U, Mitchell J, Tanveer S, Lurie T, Robinson W, Duncan R, Thom S, Tran QK. Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection. World J Emerg Med 2019; 10:94-100. [PMID: 30687445 DOI: 10.5847/wjem.j.1920-8642.2019.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute aortic dissection (AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) is crucial. The study assessed emergency providers (EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients. METHODS This retrospective study examined adult patients transferred directly from a referring emergency department (ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care (ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance (ADoEMTALA). RESULTS There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five (36.6%) patients had ADoCC while 166 (57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA (IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association (AHA) ED Departure SBP guideline (OR 1.8, 95% CI 1.03-3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care (IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA. CONCLUSION Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.
Collapse
Affiliation(s)
- Mark Rose
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA
| | - Carina Newton
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA
| | | | - Nancy Bogne
- University of Maryland at College Park, College Park, USA
| | - Adam Ketchum
- University of Maryland at College Park, College Park, USA
| | - Umang Shah
- University of Maryland at College Park, College Park, USA
| | | | - Safura Tanveer
- University of Maryland at College Park, College Park, USA
| | - Tucker Lurie
- University of Maryland, School of Medicine, Baltimore, USA
| | - Walesia Robinson
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA
| | - Rebecca Duncan
- Program of Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, USA
| | - Stephen Thom
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA
| | - Quincy Khoi Tran
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA.,Program of Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, USA
| |
Collapse
|
12
|
Bonfanti M, Balabani S, Greenwood JP, Puppala S, Homer-Vanniasinkam S, Díaz-Zuccarini V. Computational tools for clinical support: a multi-scale compliant model for haemodynamic simulations in an aortic dissection based on multi-modal imaging data. J R Soc Interface 2018; 14:rsif.2017.0632. [PMID: 29118115 PMCID: PMC5721167 DOI: 10.1098/rsif.2017.0632] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 10/13/2017] [Indexed: 11/12/2022] Open
Abstract
Aortic dissection (AD) is a vascular condition with high morbidity and mortality rates. Computational fluid dynamics (CFD) can provide insight into the progression of AD and aid clinical decisions; however, oversimplified modelling assumptions and high computational cost compromise the accuracy of the information and impede clinical translation. To overcome these limitations, a patient-specific CFD multi-scale approach coupled to Windkessel boundary conditions and accounting for wall compliance was developed and used to study a patient with AD. A new moving boundary algorithm was implemented to capture wall displacement and a rich in vivo clinical dataset was used to tune model parameters and for validation. Comparisons between in silico and in vivo data showed that this approach successfully captures flow and pressure waves for the patient-specific AD and is able to predict the pressure in the false lumen (FL), a critical variable for the clinical management of the condition. Results showed regions of low and oscillatory wall shear stress which, together with higher diastolic pressures predicted in the FL, may indicate risk of expansion. This study, at the interface of engineering and medicine, demonstrates a relatively simple and computationally efficient approach to account for arterial deformation and wave propagation phenomena in a three-dimensional model of AD, representing a step forward in the use of CFD as a potential tool for AD management and clinical support.
Collapse
Affiliation(s)
- Mirko Bonfanti
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK
| | - Stavroula Balabani
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK.,Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
| | - Sapna Puppala
- Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
| | - Shervanthi Homer-Vanniasinkam
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK.,Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK.,University of Warwick Medical School & University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
| | - Vanessa Díaz-Zuccarini
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK
| |
Collapse
|
13
|
Gryaznov AA, Ziganshin BA, Elefteriades JA. Time to Move to Earlier Intervention for Thoracic Aortic Aneurysm? STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2017. [DOI: 10.1080/24748706.2017.1404664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Anton A. Gryaznov
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
14
|
Thoracic aortic aneurysm: unlocking the “silent killer” secrets. Gen Thorac Cardiovasc Surg 2017; 67:1-11. [DOI: 10.1007/s11748-017-0874-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/21/2017] [Indexed: 12/25/2022]
|
15
|
Chenkin J. Diagnosis of Aortic Dissection Presenting as ST-Elevation Myocardial Infarction using Point-Of-Care Ultrasound. J Emerg Med 2017; 53:880-884. [PMID: 29066079 DOI: 10.1016/j.jemermed.2017.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/07/2017] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Aortic dissections can present with a broad spectrum of signs and symptoms, making them difficult to diagnose in the emergency department (ED). Aortic dissections can cause occlusion of the coronary arteries, mimicking an acute ST-elevation myocardial infarction (STEMI). Emergency point-of-care ultrasound (POCUS) may be a useful diagnostic tool to help differentiate aortic dissection from a primary myocardial infarction. CASE REPORT A 69-year-old man with no medical history presented to our ED complaining of chest pain. His electrocardiogram revealed new and dynamic ST-segment elevations consistent with a septal myocardial infarction. While the patient was being prepared for the cardiac catheterization laboratory, the treating emergency physician performed a POCUS study. The scan revealed an echogenic flap in the ascending aorta, significant aortic regurgitation, and intimal flaps in the carotid artery and abdominal aorta. The diagnosis of a type A aortic dissection was confirmed with computed tomography angiography. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Differentiating an acute STEMI from an aortic dissection can be extremely difficult in the ED. It is important not to delay reperfusion therapy for patients with a true STEMI; however, the same treatment can be lethal for patients with aortic dissection. Emergency POCUS is a fast and accessible test that has been shown to have high specificity for the diagnosis of aortic dissection in the ED. POCUS may be a useful tool to help emergency physicians diagnose aortic dissection presenting with STEMI.
Collapse
Affiliation(s)
- Jordan Chenkin
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, and the University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
16
|
Abstract
Aortic dissection (AD) is a lethal, treatable disruption of the aortic vessel wall. It often presents without classic features, mimicking symptoms of other conditions, and diagnosis is often delayed. Established high-risk markers of AD should be sought and indicate advanced aortic imaging with CT, MRI, or TEE. Treatment is immediate surgical evaluation, aggressive symptom relief, and reduction of the force of blood against the aortic wall by control of heart rate, followed by blood pressure.
Collapse
Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Maimonides Medical Center, 4821 Fort Hamilton Parkway, Brooklyn, NY 11219, USA.
| |
Collapse
|
17
|
Long B, Koyfman A. Vascular Causes of Syncope: An Emergency Medicine Review. J Emerg Med 2017; 53:322-332. [PMID: 28662832 DOI: 10.1016/j.jemermed.2017.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 05/05/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Syncope is a common emergency department (ED) complaint, accounting for 2% of visits annually. A wide variety of etiologies can result in syncope, and vascular causes may be deadly. OBJECTIVE This review evaluates vascular causes of syncope and their evaluation and management in the ED. DISCUSSION Syncope is defined by a brief loss of consciousness with loss of postural tone and complete, spontaneous recovery without medical intervention. Causes include cardiac, vasovagal, orthostatic, neurologic, medication-related, and idiopathic, and most cases of syncope will not receive a specific diagnosis pertaining to the cause. Emergency physicians are most concerned with life-threatening causes such as dysrhythmia and obstruction, and electrocardiogram is a primary means of evaluation. However, vascular etiologies can result in patient morbidity and mortality. These conditions include pulmonary embolism, subclavian steal, aortic dissection, cerebrovascular disease, intracerebral hemorrhage, carotid/vertebral dissection, and abdominal aortic aneurysm. A focused history and physical examination can assist emergency physicians in determining the need for further testing and management. CONCLUSIONS Syncope is common and may be the result of a deadly condition. The emergency physician, through history and physical examination, can determine the need for further evaluation and resuscitation of these patients, with consideration of vascular etiologies of syncope.
Collapse
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
18
|
Nienaber CA, Clough RE. Management of Acute Aortic Syndromes. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
19
|
|
20
|
Andersen ND, Benrashid E, Ross AK, Pickett LC, Smith PK, Daneshmand MA, Schroder JN, Gaca JG, Hughes GC. The utility of the aortic dissection team: outcomes and insights after a decade of experience. Ann Cardiothorac Surg 2016; 5:194-201. [PMID: 27386406 DOI: 10.21037/acs.2016.05.12] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mortality rates following acute type A aortic dissection (ATAAD) repair are reduced when operations are performed by a high-volume acute aortic dissection (AAD) team, leading to efforts to centralize ATAAD care. Here, we describe our experience with ATAAD repair by our AAD team over the last 10 years, with a focus on patient selection, transfer protocols, operative approach, and volume trends over time. METHODS An AAD team was implemented at our institution in 2005, with dedicated high-volume AAD surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Further process improvements were made in 2013 to facilitate the rapid transfer of ATAAD patients to our institution using stream-lined triage, diagnostic, and transfer protocols for patients with suspected ATAAD (RACE-AD protocol). Volume trends and outcomes were assessed longitudinally over this period. RESULTS Institutional ATAAD repair volume remained constant at 12±2 cases per year from 2005-2013, but increased nearly two-fold to 22±6 cases per year (P=0.004) from 2013-2015 following implementation of the RACE-AD protocol. To accommodate this increased volume, two additional surgeons were added to the AAD team. Surgeon ATAAD repair volume was unchanged over the 10-year interval (7.9±3.9 cases per year from 2005-2013 versus 5.5±1.5 cases per year from 2013-2015; P=0.36), and all AAD team surgeons consistently met or exceeded the high-volume surgeon threshold of 5 ATAAD repairs per year. Thirty-day/in-hospital mortality rates of less than 10% were maintained over the study period. CONCLUSIONS Centralization of ATAAD care has begun to occur at our center, with maintenance of low mortality rates for ATAAD repair. These data confirm a net positive impact on regional ATAAD outcomes through transfer of patients to a high-volume center with dedicated AAD surgeons.
Collapse
Affiliation(s)
- Nicholas D Andersen
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Adia K Ross
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lisa C Pickett
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Peter K Smith
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mani A Daneshmand
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jacob N Schroder
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey G Gaca
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
21
|
Iakoubova OA, Tong CH, Catanese J, Rowland CM, Luke MM, Tranquilli M, Elefteriades JA. KIF6 719Arg Genetic Variant and Risk for Thoracic Aortic Dissection. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2016; 4:83-90. [PMID: 28097184 DOI: 10.12945/j.aorta.2016.16.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 05/06/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Carriers of the 719Arg variant in KIF6, compared with noncarriers, have been reported to be at greater risk for coronary heart disease (CHD) in six prospective studies. Because CHD, thoracic aortic dissection, and nondissection thoracic aortic aneurysm share some risk factors and aspects of pathophysiology, we investigated whether carriers of the 719Arg variant also have greater odds of thoracic aortic dissection or nondissected thoracic aortic aneurysm than noncarriers. METHODS We genotyped 140 thoracic aortic dissection cases, 497 nondissection thoracic aortic aneurysm cases, and 275 disease-free controls collected in the United States, Hungary, and Greece and investigated the association between KIF6 719Arg carrier status and thoracic aortic dissection, and between KIF6 719Arg carrier status and nondissection thoracic aortic aneurysm, using logistic regression models adjusted for age, sex, hypertension, smoking, and country. RESULTS The odds of aortic dissection were two-fold greater in KIF6 719Arg carriers compared with noncarriers (odds ratio (OR) 2.14, 95% confidence interval (CI) 1.18-3.9). To account for the potential of concomitant CHD to confound the association between the KIF6 719Arg and thoracic aortic dissection, we repeated the analysis after removing subjects with concomitant CHD; the estimates for association of KIF6 719Arg carrier status remained essentially the same (OR 2.04, 95% CI 1.11-3.77). In contrast, KIF6 719Arg carrier status was not associated with risk for nondissection thoracic aortic aneurysm. CONCLUSIONS We observed an association of the KIF6 719Arg genetic variant with thoracic aortic dissection in this multicenter case-control study. This association may enhance our management of patients with thoracic aortic disease.
Collapse
Affiliation(s)
- Olga A Iakoubova
- Quest Diagnostics Research and Development, San Juan Capistrano, California, USA
| | - Carmen H Tong
- Quest Diagnostics Research and Development, San Juan Capistrano, California, USA
| | - Joseph Catanese
- Quest Diagnostics Research and Development, San Juan Capistrano, California, USA
| | - Charles M Rowland
- Quest Diagnostics Research and Development, San Juan Capistrano, California, USA
| | - May M Luke
- Quest Diagnostics Research and Development, San Juan Capistrano, California, USA
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
22
|
Gu G, Wan F, Xue Y, Cheng W, Zheng H, Zhao Y, Fan F, Han YI, Tong C, Yao C. Lumican as a novel potential clinical indicator for acute aortic dissection: A comparative study, based on multi-slice computed tomography angiography. Exp Ther Med 2016; 11:923-928. [PMID: 26998013 DOI: 10.3892/etm.2016.3020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 09/18/2015] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to investigate the association between serum lumican levels and acute aortic dissection (AAD) severity. A total of 82 patients with chest or back pain and 30 healthy volunteers were recruited. Among the patients, there were 70 cases of AAD and 12 cases of intramural hematoma (IMH). AAD severity was determined using multi-slice computed tomography angiography (MSCTA). Serum was collected from the patients upon admission, and lumican levels were detected using an enzyme-linked immunosorbent assay. In addition, correlation analyses were conducted between lumican levels and AAD severity by designing a 'SCORE X, RANGE Y' system to measure the number of affected vital arteries and vertical range of false lumen, based on the MSCTA. Lumican levels differed significantly among the AAD patients (2.32±4.29 ng/ml), IMH patients (0.72±0.32 ng/ml) and healthy volunteers (0.85±0.53 ng/ml; P=0.003). In the AAD patients presenting within 12-72 h of symptom onset, the Spearman's rho correlation coefficient between lumican and SCORE or RANGE was 0.373 (P=0.046) and 0.468 (P=0.010), respectively. The present results suggest that lumican may be a potential marker for aiding the diagnosis and screening for AAD, and may be used to predict the severity of AAD.
Collapse
Affiliation(s)
- Guorong Gu
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Fang Wan
- Shanghai Medical Imaging Institute, Shanghai 200032, P.R. China; Department of Sports Medicine and Arthroscopy Surgery, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China
| | - Yuan Xue
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Weizhong Cheng
- Shanghai Medical Imaging Institute, Shanghai 200032, P.R. China
| | - Haiyin Zheng
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Yun Zhao
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Fan Fan
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Y I Han
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Chaoyang Tong
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Chenling Yao
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| |
Collapse
|
23
|
Pare JR, Liu R, Moore CL, Sherban T, Kelleher MS, Thomas S, Taylor RA. Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection. Am J Emerg Med 2015; 34:486-92. [PMID: 26782795 DOI: 10.1016/j.ajem.2015.12.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 11/17/2015] [Accepted: 12/08/2015] [Indexed: 12/22/2022] Open
Abstract
STUDY OBJECTIVE Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis with a nonspecific presentation. Ascending aortic dissection is associated with aortic dilation, which can be determined by emergency physician focused cardiac ultrasound (EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time to diagnosis for AAD. METHODS We performed a retrospective review of patients treated at 1 of 3 affiliated emergency departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD. All autopsies were reviewed for missed cases. Primary outcome measure was time to diagnosis. Secondary outcomes were time to disposition, misdiagnosis rate, and mortality. RESULTS Of 386547 ED visits, targeted review of 123 medical records and 194 autopsy reports identified 32 patients for inclusion. Sixteen patients received EP FOCUS and 16 did not. Median time to diagnosis in the EP FOCUS group was 80 (interquartile range [IQR], 46-157) minutes vs 226 (IQR, 109-1449) minutes in the non-EP FOCUS group (P = .023). Misdiagnosis was 0% (0/16) in the EP FOCUS group vs 43.8% (7/16) in the non-EP FOCUS group (P = .028). Mortality, adjusted for do-not-resuscitate status, for EP FOCUS vs non-EP FOCUS was 15.4% vs 37.5% (P = .24). Median rooming time to disposition was 134 (IQR, 101-195) minutes for EP FOCUS vs 205 (IQR, 114-342) minutes for non-EP FOCUS (P = .27). CONCLUSIONS Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.
Collapse
Affiliation(s)
- Joseph R Pare
- Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT.
| | - Rachel Liu
- Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT
| | - Christopher L Moore
- Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT
| | - Tyler Sherban
- Frank H. Netter, MD School of Medicine, North Haven, CT
| | | | - Sheeja Thomas
- Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT
| | - R Andrew Taylor
- Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT
| |
Collapse
|
24
|
He F, Li L, Bynum J, Meng X, Yan P, Li L, Liu L. Medical Malpractice in Wuhan, China: A 10-Year Autopsy-Based Single-Center Study. Medicine (Baltimore) 2015; 94:e2026. [PMID: 26559306 PMCID: PMC4912300 DOI: 10.1097/md.0000000000002026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Medical disputes in China are historically poorly documented. In particular, autopsy-based evaluation and its impact on medical malpractice claims remain largely unstudied. This study aims to document autopsy findings and medical malpractice in one of the largest cities of China, Wuhan, located in Hubei Province. A total of 519 autopsies were performed by the Department of Forensic Medicine, Wuhan University School of Medicine, Wuhan, China, over a 10-year period between 2004 and 2013. Of these cases, 190 (36.6%) were associated with medical malpractice claims. Joint evaluation by forensic pathologists and clinicians confirmed that 97 (51.1%) of the 190 claims were approved medical malpractice cases. The percentage of approved malpractice cases increased with patient age and varied according to medical setting, physician specialty, and organ system. The clinico-pathological diagnostic discrepancy was significantly different among various physician specialties (P = 0.031) and organ systems (P = 0.000). Of those cases involved in malpractice claims, aortic dissection, coronary heart disease, and acute respiratory infection were most common. Association between incorrect diagnosis and malpractice was significant (P = 0.001). This is the first report on China's medical malpractice and findings at autopsy which reflects the current state of health care services in one of the biggest cities in China.
Collapse
Affiliation(s)
- Fanggang He
- From the Department of Forensic Medicine (FH, XM, PY, LL), Wuhan University School of Medicine, Wuhan; Department of Forensic Medicine (LL), School of Basic Medical Sciences, Fudan University, Shanghai, PR China; Division of Forensic Pathology (FH, LL, LL), University of Maryland School of Medicine; Department of Pathology (JB), Johns Hopkins University Hospital, Baltimore, Maryland; and Department of Forensic Medicine (LL), TongjiMedical College, Huazhong University of Science and Technology, Wuhan, PR China
| | | | | | | | | | | | | |
Collapse
|
25
|
Alter SM, Eskin B, Allegra JR. Diagnosis of Aortic Dissection in Emergency Department Patients is Rare. West J Emerg Med 2015; 16:629-31. [PMID: 26587083 PMCID: PMC4644027 DOI: 10.5811/westjem.2015.6.25752] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/09/2015] [Accepted: 06/08/2015] [Indexed: 11/11/2022] Open
Abstract
Introduction Aortic dissection is a rare event. While the most frequent symptom is chest pain, that is a common emergency department (ED) chief complaint and other diseases causing chest pain occur much more often. Furthermore, 20% of dissections are without chest pain and 6% are painless. For these reasons, diagnosing dissections may be challenging. Our goal was to determine the number of total ED and atraumatic chest pain patients for every aortic dissection diagnosed by emergency physicians. Methods Design: Retrospective cohort. Setting: 33 suburban and urban New York and New Jersey EDs with annual visits between 8,000 and 80,000. Participants: Consecutive patients seen by emergency physicians from 1-1-1996 through 12-31-2010. Observations: We identified aortic dissection and atraumatic chest pain patients using the International Classification of Diseases 9th Revision and Clinical Modification codes. We then calculated the number of total ED and atraumatic chest pain patients for every aortic dissection, along with 95% confidence intervals (CIs). Results From a database of 9.5 million ED visits, we identified 782 aortic dissections or one for every 12,200 (95% CI [11,400–13,100]) visits. The mean age of dissection patients was 66±16 years and 38% were female. There were 763,000 (8%) with atraumatic chest pain diagnoses. Thus, there is one dissection for every 980 (95% CI [910–1,050]) atraumatic chest pain patients. Conclusion The diagnosis of aortic dissections by emergency physicians is rare and challenging. An emergency physician seeing 3,000 to 4,000 patients a year would diagnose an aortic dissection approximately every three to four years.
Collapse
Affiliation(s)
- Scott M Alter
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
| | - Barnet Eskin
- Morristown Medical Center, Department of Emergency Medicine, Morristown, New Jersey
| | - John R Allegra
- Morristown Medical Center, Department of Emergency Medicine, Morristown, New Jersey
| |
Collapse
|
26
|
Ziganshin BA, Elefteriades JA. Treatment of Thoracic Aortic Aneurysm: Role of Earlier Intervention. Semin Thorac Cardiovasc Surg 2015; 27:135-43. [DOI: 10.1053/j.semtcvs.2015.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 12/12/2022]
|
27
|
Albini P, Barshes NR, Russell L, Wu D, Coselli JS, Shen YH, Allison PM, LeMaire SA. D-dimer levels remain elevated in acute aortic dissection after 24 h. J Surg Res 2014; 191:58-63. [DOI: 10.1016/j.jss.2014.03.074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/20/2014] [Accepted: 03/25/2014] [Indexed: 11/17/2022]
|
28
|
Lee JJ, D'Ancona G, Amaducci A, Follis F, Pilato M, Pasta S. Role of Computational Modeling in Thoracic Aortic Pathology:
A Review. J Card Surg 2014; 29:653-62. [DOI: 10.1111/jocs.12413] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jake J. Lee
- School of Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Giuseppe D'Ancona
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Andrea Amaducci
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Fabrizio Follis
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Michele Pilato
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | | |
Collapse
|
29
|
Lanigan MJ, Chaney MA, Gologorsky E, Chavanon O, Augoustides JG. CASE 2—2014. J Cardiothorac Vasc Anesth 2014; 28:398-407. [DOI: 10.1053/j.jvca.2013.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Indexed: 01/16/2023]
|
30
|
Martufi G, Gasser TC, Appoo JJ, Di Martino ES. Mechano-biology in the thoracic aortic aneurysm: a review and case study. Biomech Model Mechanobiol 2014; 13:917-28. [DOI: 10.1007/s10237-014-0557-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 01/27/2014] [Indexed: 01/22/2023]
|
31
|
Friedman T, Mani A, Elefteriades JA. Bicuspid aortic valve: clinical approach and scientific review of a common clinical entity. Expert Rev Cardiovasc Ther 2014; 6:235-48. [DOI: 10.1586/14779072.6.2.235] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
32
|
Andersen ND, Ganapathi AM, Hanna JM, Williams JB, Gaca JG, Hughes GC. Outcomes of acute type a dissection repair before and after implementation of a multidisciplinary thoracic aortic surgery program. J Am Coll Cardiol 2014; 63:1796-803. [PMID: 24412454 DOI: 10.1016/j.jacc.2013.10.085] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/29/2013] [Accepted: 10/08/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the results of acute type A aortic dissection (ATAAD) repair before and after implementation of a multidisciplinary thoracic aortic surgery program (TASP) at our institution, with dedicated high-volume thoracic aortic surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. BACKGROUND Outcomes of ATAAD repair may be improved when operations are performed at specialized high-volume thoracic aortic surgical centers. METHODS Between 1999 and 2011, 128 patients underwent ATAAD repair at our institution. Records of patients who underwent ATAAD repair 6 years before (n = 56) and 6 years after (n = 72) implementation of the TASP were retrospectively compared. Expected operative mortality rates were calculated using the International Registry of Acute Aortic Dissection pre-operative prediction model. RESULTS Baseline risk profiles and expected operative mortality rates were comparable between patients who underwent surgery before and after implementation of the TASP. Operative mortality before TASP implementation was 33.9% and was statistically equivalent to the expected operative mortality rate of 26.0% (observed-to-expected mortality ratio 1.30; p = 0.54). Operative mortality after TASP implementation fell to 2.8% and was statistically improved compared with the expected operative mortality rate of 18.2% (observed-to-expected mortality ratio 0.15; p = 0.005). Differences in survival persisted over long-term follow-up, with 5-year survival rates of 85% observed for TASP patients compared with 55% for pre-TASP patients (p = 0.002). CONCLUSIONS ATAAD repair can be performed with results approximating those of elective proximal aortic surgery when operations are performed by a high-volume multidisciplinary thoracic aortic surgery team. Efforts to standardize or centralize care of patients undergoing ATAAD are warranted.
Collapse
Affiliation(s)
- Nicholas D Andersen
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Asvin M Ganapathi
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer M Hanna
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Judson B Williams
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - G Chad Hughes
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
| |
Collapse
|
33
|
Taylor RA, Iyer NS. A decision analysis to determine a testing threshold for computed tomographic angiography and d-dimer in the evaluation of aortic dissection. Am J Emerg Med 2013; 31:1047-55. [DOI: 10.1016/j.ajem.2013.03.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 03/19/2013] [Accepted: 03/23/2013] [Indexed: 12/12/2022] Open
|
34
|
Strayer RJ, Shearer PL, Hermann LK. Screening, evaluation, and early management of acute aortic dissection in the ED. Curr Cardiol Rev 2013; 8:152-7. [PMID: 22708909 PMCID: PMC3406274 DOI: 10.2174/157340312801784970] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 05/10/2011] [Accepted: 08/01/2011] [Indexed: 11/26/2022] Open
Abstract
Acute aortic dissection (AAD) is a rare and lethal disease with presenting signs and symptoms that can often be seen with other high risk conditions; diagnosis is therefore often delayed or missed. Pain is present in up to 90% of cases and is typically severe at onset. Many patients present with acute on chronic hypertension, but hypotension is an ominous sign, often reflecting hemorrhage or cardiac tamponade. The chest x-ray can be normal in 10-20% of patients with AAD, and though transthoracic echocardiography is useful if suggestive findings are seen, and should be used to identify pericardial effusion, TTE cannot be used to exclude AAD. Transesophageal echocardiography, however, reliably confirms or excludes the diagnosis, where such equipment and expertise is available. CT scan with IV contrast is the most common imaging modality used to diagnose and classify AAD, and MRI can be used in patients in whom the use of CT or IV contrast is undesirable. Recent specialty guidelines have helped define high-risk features and a diagnostic pathway that can be used the emergency department setting. Initial management of diagnosed or highly suspected acute aortic dissection focuses on pain control, heart rate and then blood pressure management, and immediate surgical consultation.
Collapse
Affiliation(s)
- Reuben J Strayer
- Mount Sinai School of Medicine, One Gustave L Levy Place Box 1149, New York, NY 10029, USA.
| | | | | |
Collapse
|
35
|
Suzuki T, Bossone E, Sawaki D, Jánosi RA, Erbel R, Eagle K, Nagai R. Biomarkers of aortic diseases. Am Heart J 2013; 165:15-25. [PMID: 23237129 DOI: 10.1016/j.ahj.2012.10.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 10/05/2012] [Indexed: 12/27/2022]
Abstract
The development of diagnostic biomarkers of acute cardiovascular disease remains an important topic of interest given potential use to aid in early diagnosis. Cardiac biomarkers of ischemia and heart failure have already proven to be clinically useful. Biomarkers of aortic diseases are also needed, especially for life-threatening conditions such as aortic dissection. In this review, we discuss the present status of the development of biomarkers of aortic diseases. Although aortic dissection has been most vigorously pursued, there has also been notable recent progress in biomarkers of aneurysms and inflammatory aortic disease.
Collapse
|
36
|
Kuzmik GA, Sang AX, Elefteriades JA. Natural history of thoracic aortic aneurysms. J Vasc Surg 2012; 56:565-71. [DOI: 10.1016/j.jvs.2012.04.053] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 04/11/2012] [Accepted: 04/13/2012] [Indexed: 12/21/2022]
|
37
|
Quantitative proteomics analysis by isobaric tags for relative and absolute quantitation identified Lumican as a potential marker for acute aortic dissection. J Biomed Biotechnol 2011; 2011:920763. [PMID: 22228989 PMCID: PMC3250623 DOI: 10.1155/2011/920763] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 10/27/2011] [Accepted: 10/27/2011] [Indexed: 11/18/2022] Open
Abstract
Acute aortic dissection (AAD) is a serious vascular disease. Currently the diagnosis relies on clinical and radiological means whereas serum biomarkers are lacking. The purpose of this study was to identify potential serum biomarkers for AAD using isobaric tags for relative and absolute quantitation (iTRAQ) approach. A total of 120 serum samples were collected from three groups: AAD patients (n = 60), patients with acute myocardial infarction (AMI, n = 30), and healthy volunteers (n = 30), whereas the first 10 samples from each group were used for iTRAQ analysis. Using iTRAQ approach, a total of 174 proteins were identified as significantly different between AAD patients and healthy subjects. Among them, forty-six proteins increased more than twofold, full-scale analysis using serum sample for the entire 120 subjects demonstrated that Lumican level was significantly increased relative to control and AMI samples. Further, Lumican level correlated with time from onset to admission in AAD but not AMI samples. Using iTRAQ approach, our study showed that Lumican may be a potential AAD-related serum marker that may assist the diagnosis of AAD.
Collapse
|
38
|
|
39
|
Abstract
This article reviews the elements of medical malpractice, informed consent, and affirmative defense; and discusses the legal risks associated with the diagnosis and therapy of cardiovascular disease.
Collapse
Affiliation(s)
- S Y Tan
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA.
| |
Collapse
|
40
|
Suzuki T, Distante A, Eagle K. Biomarker-assisted diagnosis of acute aortic dissection: how far we have come and what to expect. Curr Opin Cardiol 2010; 25:541-5. [PMID: 20717014 DOI: 10.1097/hco.0b013e32833e6e13] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Acute aortic dissection is a disease that is often a challenge to diagnose. Early and immediate diagnosis is important for initiation of treatment and improved survival. Despite recent advances in imaging methods to diagnose the disease, biochemical methods are not available. RECENT FINDINGS Biomarkers that might be useful for the biochemical detection of acute aortic dissection have been recently described, such as assays for the circulating proteins, smooth muscle myosin heavy chain, creatine kinase BB-isozyme, calponin (smooth muscle troponin) and elastin. C-reactive protein and D-dimer have also been shown to be useful. SUMMARY Biomarker-assisted diagnosis of acute aortic dissection would be helpful in detecting this acute catastrophic aortic disease, which still remains a challenge to diagnose. Although recent progress in development of biomarkers has been made, there is no widely accepted strategy. Available biomarkers such as D-dimer may play an assistive role in the meantime.
Collapse
Affiliation(s)
- Toru Suzuki
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan.
| | | | | |
Collapse
|
41
|
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55:e27-e129. [PMID: 20359588 DOI: 10.1016/j.jacc.2010.02.015] [Citation(s) in RCA: 998] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
42
|
Elefteriades JA. Physicians Should Be Legally Liable for Missing an Atypical Aortic Dissection: CON. Cardiol Clin 2010; 28:245-52. [DOI: 10.1016/j.ccl.2010.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
43
|
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266-369. [PMID: 20233780 DOI: 10.1161/cir.0b013e3181d4739e] [Citation(s) in RCA: 1175] [Impact Index Per Article: 83.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
44
|
|
45
|
Woo KMC, Schneider JI. High-risk chief complaints I: chest pain--the big three. Emerg Med Clin North Am 2010; 27:685-712, x. [PMID: 19932401 DOI: 10.1016/j.emc.2009.07.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. Although many (if not most) emergency department patients with chest pain do not have an immediately life-threatening condition, correct diagnoses can be difficult to make, incorrect diagnoses may lead to catastrophic therapies, and failure to make a timely diagnosis may contribute to significant morbidity and mortality. Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.
Collapse
Affiliation(s)
- Kar-mun C Woo
- Department of Emergency Medicine, Boston Medical Center, Dowling 1 South, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | | |
Collapse
|
46
|
|
47
|
Parsa CJ, Hughes GC. Surgical Options to Contend with Thoracic Aortic Pathology. Semin Roentgenol 2009; 44:29-51. [PMID: 19064070 DOI: 10.1053/j.ro.2008.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
48
|
Aortic dissection—in pursuit of a serum marker. Am J Emerg Med 2008; 26:942-5. [DOI: 10.1016/j.ajem.2007.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 12/14/2007] [Accepted: 12/15/2007] [Indexed: 11/18/2022] Open
|