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Hajsadeghi S, Shamsedini A, Bahadoran P, Amouei E, Mirshafiee S. Comparison of Qanadli score with conventional risk stratifiers in non-massive pulmonary emboli. J Int Med Res 2024; 52:3000605241276481. [PMID: 39301817 PMCID: PMC11418528 DOI: 10.1177/03000605241276481] [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: 03/14/2024] [Accepted: 07/03/2024] [Indexed: 09/22/2024] Open
Abstract
OBJECTIVE The management and risk stratification of non-massive pulmonary embolism (PE) remain unclear. However, early assessment of PE severity can aid physicians in establishing better treatment milestones. There has been no direct comparison of mortality rates in patients with non-massive PE, and existing data are sometimes contradictory. Therefore, we examined the relationship between the Qanadli index and conventional risk stratifiers in PE. METHODS We retrospectively analyzed 200 consecutively selected patients diagnosed with PE. The assessment included computed tomography pulmonary angiography, electrocardiography, echocardiography findings, outcomes, and a comparison with the Simplified Pulmonary Embolism Severity Index (SPESI) score. Descriptive, regression, and receiver operating characteristic analyses were performed. RESULTS The mean Qanadli score was 13.5 ± 1.15. Pearson correlation analysis revealed significant associations between the total Qanadli score and several variables: right ventricular enlargement, follow-up ejection fraction, and SPESI score. Although the Qanadli score did not significantly predict mortality, the risk of death increased by 58.8% for each 1-unit increase in the SPESI score. CONCLUSIONS Although the Qanadli index is valuable in assessing PE and guiding treatment strategies, its standalone predictive value for mortality may be insufficient. Therefore, incorporating scoring systems such as the SPESI and echocardiographic findings is recommended for more accurate mortality prediction.
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Affiliation(s)
- Shokoufeh Hajsadeghi
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Shamsedini
- Department of Cardiology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Pooriya Bahadoran
- Department of Cardiology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Erfan Amouei
- Department of Internal Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shayan Mirshafiee
- Department of Cardiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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2
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Feng Y, He LQ. Soluble ST2: A Novel Biomarker for Diagnosis and Prognosis of Cardiovascular Disease. Curr Med Sci 2024; 44:669-679. [PMID: 39096477 DOI: 10.1007/s11596-024-2907-x] [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: 12/14/2023] [Accepted: 05/30/2024] [Indexed: 08/05/2024]
Abstract
The increasing incidence of cardiovascular disease (CVD) is a significant global health concern, affecting millions of individuals each year. Accurate diagnosis of acute CVD poses a formidable challenge, as misdiagnosis can significantly decrease patient survival rates. Traditional biomarkers have played a vital role in the diagnosis and prognosis of CVDs, but they can be influenced by various factors, such as age, sex, and renal function. Soluble ST2 (sST2) is a novel biomarker that is closely associated with different CVDs. Its low reference change value makes it suitable for continuous measurement, unaffected by age, kidney function, and other confounding factors, facilitating risk stratification of CVDs. Furthermore, the combination of sST2 with other biomarkers can enhance diagnostic accuracy and prognostic value. This review aims to provide a comprehensive overview of sST2, focusing on its diagnostic and prognostic value as a myocardial marker for different types of CVDs and discussing the current limitations of sST2.
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Affiliation(s)
- Yin Feng
- Department of Cardiology, Traditional Chinese and Western Medicine Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Li-Qun He
- Department of Cardiology, Traditional Chinese and Western Medicine Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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3
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Teissandier D, Roussel M, Bannelier H, Freund Y, Catoire P. Contemporary approaches to pulmonary embolism diagnosis: a clinical review. Clin Exp Emerg Med 2024; 11:127-135. [PMID: 38368878 PMCID: PMC11237265 DOI: 10.15441/ceem.23.157] [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: 11/07/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/20/2024] Open
Abstract
The optimal diagnosis strategy for pulmonary embolism (PE) in the emergency department (ED) remains complex. This review summarizes PE diagnosis with clinical presentation, decision rules and investigations for acute PE. This review was performed using studies published between January 1, 2010, and September 1, 2023. PE should be considered in ED in patients with chest pain, shortness of breath, syncope or signs of deep veinous thrombosis. Definitive diagnosis of PE relies on thoracic imaging, with the use of chest tomographic pulmonary angiogram or ventilation-perfusion lung scintigraphy. To limit the continuous increased use of chest imaging, the clinical probability should be the first step for PE workup. The pulmonary embolism rule-out criteria (PERC) can rule out PE at this stage. If not, for low or intermediate probability, several clinical decision rules have been validated, either by ruling out PE on clinical signs, or by raising D-dimer thresholds (YEARS or PEGeD [Pulmonary Embolism Graduated D-Dimer] criteria) or by combination of these different rules. It is recommended that patients with a high clinical probability of PE should undergo chest imaging without the need for D-dimer testing. The PE diagnostic approach can be tailored in specific populations such as pregnant, younger, COVID-19, or cancer patients. PE diagnosis workup illustrates the complexity of modern probabilistic-based approaches of decision-making in medicine. It is recommended to use a Bayesian approach with the evaluation of clinical probability, then order D-dimer if the PERC rule is positive, then adapt the D-dimer threshold for ordering chest imaging using clinical decision rules.
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Affiliation(s)
- Dorian Teissandier
- Department of Emergency, Pitié-Salpêtrière University Hospital, Paris, France
| | - Mélanie Roussel
- Department of Emergency, Centre Hospitalier Universitaire de Rouen, University of Rouen Normandy, Rouen, France
| | - Héloise Bannelier
- Department of Emergency, Pitié-Salpêtrière University Hospital, Paris, France
- UMRS 1166, IHU ICAN, Sorbonne University, Paris, France
| | - Yonathan Freund
- Department of Emergency, Pitié-Salpêtrière University Hospital, Paris, France
- UMRS 1166, IHU ICAN, Sorbonne University, Paris, France
| | - Pierre Catoire
- Department of Emergency, Pitié-Salpêtrière University Hospital, Paris, France
- UMRS 1166, IHU ICAN, Sorbonne University, Paris, France
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4
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Glazier MM, Glazier JJ. Diagnostic Strategies in Pulmonary Embolism. Int J Angiol 2024; 33:89-94. [PMID: 38846998 PMCID: PMC11152624 DOI: 10.1055/s-0044-1779661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Key to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.
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Affiliation(s)
| | - James J. Glazier
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan
- Department of Cardiology, Oakland University William Beaumont School of Medicine, Rochester, Michigan
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5
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Naimi S, Ødegaard KJ, Jenssen KK, Lauritzen PM. Quality of referrals for lower extremity ultrasonography and computed tomography pulmonary angiography and associations with positive findings of venous thromboembolism. Radiography (Lond) 2024; 30:799-805. [PMID: 38493553 DOI: 10.1016/j.radi.2024.03.002] [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: 12/01/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION The referral is the basis for radiologists' assessment of modality, protocol and urgency, and insufficient information may threaten patient safety. The aim of this study was to assess the completeness of referrals for lower extremity venous duplex ultrasonography (LEVDUS) and computed tomography pulmonary angiography (CTPA), and to investigate associations between the provided clinical information including risk factors, symptoms and lab results in the referrals and positive findings of deep vein thrombosis (DVT) and pulmonary embolism (PE), respectively. METHODS Referrals for LEVDUS (801) and CTPA (800) performed from 2016 to 2019 were obtained. Three categories of clinical information from the referrals were recorded: symptoms, risk factors and laboratory results, as well as positive imaging findings of venous thromboembolism (VTE). Referral completeness was rated from zero to three according to how many categories of clinical information the referral provided. RESULTS Information from all three clinical information categories was provided in 15% and 25% of referrals for LEVDUS and CTPA, respectively, while 2% and 10% of referrals did not contain any clinical information. Symptoms were provided most often (85% for LEVDUS and 94% for CTPA). Provided information about risk factors was significantly associated with positive findings for LEVDUS, (p = 0.02) and CTPA (p < 0.001). CONCLUSION A great majority of referrals failed to provide one or more categories of clinical information. Risk factors were associated with a positive finding of VTE on LEVDUS and CTPA. IMPLICATIONS FOR PRACTICE Improving clinical information in referrals may improve justification, patient safety and quality of radiology services.
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Affiliation(s)
- S Naimi
- Department of Life Sciences and Health, Oslo Metropolitan University, P.O. Box 4 St. Olavs Plass, NO-0130 Oslo, Norway.
| | - K J Ødegaard
- Department of Radiology, Lovisenberg Diaconal Hospital, Postboks 4970 Nydalen, NO-0440 Oslo, Norway.
| | - K K Jenssen
- Department of Orthopedic Surgery, Lovisenberg Diaconal Hospital, Postboks 4970 Nydalen, NO-0440 Oslo, Norway.
| | - P M Lauritzen
- Department of Life Sciences and Health, Oslo Metropolitan University, P.O. Box 4 St. Olavs Plass, NO-0130 Oslo, Norway; Division of Radiology and Nuclear Medicine, Oslo University Hospital, Postboks 4956 Nydalen, NO-0424 Oslo, Norway.
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6
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Koehler D, Ozga AK, Molwitz I, Shenas F, Keller S, Adam G, Yamamura J. Influencing factors on the time to CT in suspected pulmonary embolism: an explorative investigation. Sci Rep 2024; 14:8741. [PMID: 38627583 PMCID: PMC11021441 DOI: 10.1038/s41598-024-59428-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 04/10/2024] [Indexed: 04/19/2024] Open
Abstract
Pulmonary embolism is a potentially fatal condition with increased mortality if anticoagulation is delayed. This study aimed to find influencing factors on the duration from requesting a computed tomography (CT) pulmonary angiography (CTPA) to performing a CTPA in suspected acute pulmonary embolism. In 1849 cases, automatically generated time data were extracted from the radiological information system. The impact of the distance to the scanner, case-related features (sector of patient care, triage), and workload (demand for CTs, performed CTs, available staff, hospital occupancy) were investigated retrospectively using multiple regression. The time to CTPA was shorter in cases from the emergency room (ER) than in inpatients and outpatients at distances below 160 m and 240 m, respectively. While requests from the ER were also performed faster than cases from regular wards (< 180 m), no difference was found between the ER and intensive care units. Compared to "not urgent" cases, the workflow was shorter in "urgent" (- 17%) and "life-threatening" (- 67%) situations. The process was prolonged with increasing demand (+ 5%/10 CTs). The presented analysis identified relevant in-hospital influences on the CTPA workflow, including the distance to the CT together with the sector of patient care, the case triage, and the demand for imaging.
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Affiliation(s)
- Daniel Koehler
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Isabel Molwitz
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Farzad Shenas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Sarah Keller
- Department of Radiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jin Yamamura
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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7
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Opitz CF, Meyer FJ. Pulmonary Embolism: An Update Based on the Revised AWMF-S2k Guideline. Hamostaseologie 2024; 44:111-118. [PMID: 38688269 DOI: 10.1055/s-0044-1779011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Pulmonary embolism (PE) is the third most common acute cardiovascular disease. The risk of PE increases with age and mortality is high. Patients are stratified into hemodynamically stable versus unstable patients, as this has important implications for diagnosis and therapy. Since clinical signs and symptoms of acute PE are nonspecific, the clinical likelihood of PE is estimated to guide diagnostic pathways. D-dimer testing is performed in hemodynamically stable patients with low or intermediate probability of PE and the visualization of thromboembolism and its sequelae is commonly achieved with computed tomography pulmonary angiography (CTPA), supplemented by ultrasound techniques. With confirmed PE, another risk stratification estimates disease severity and defines intensity and setting of the ensuing treatment. The therapeutic spectrum ranges from outpatient treatment with initial oral anticoagulation to thrombolytic or interventional treatment in the intensive care unit or catheterization laboratory. In single cases, even acute surgical thrombectomy is attempted.
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Affiliation(s)
| | - F Joachim Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, Sanatoriumsplatz 2, München, Germany
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8
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Gotta J, Koch V, Geyer T, Martin SS, Booz C, Mahmoudi S, Eichler K, Reschke P, D'Angelo T, Klimek K, Vogl TJ, Gruenewald LD. Imaging-based risk stratification of patients with pulmonary embolism based on dual-energy CT-derived radiomics. Eur J Clin Invest 2024; 54:e14139. [PMID: 38063028 DOI: 10.1111/eci.14139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 03/13/2024]
Abstract
BACKGROUND Technological progress in the acquisition of medical images and the extraction of underlying quantitative imaging data has introduced exciting prospects for the diagnostic assessment of a wide range of conditions. This study aims to investigate the diagnostic utility of a machine learning classifier based on dual-energy computed tomography (DECT) radiomics for classifying pulmonary embolism (PE) severity and assessing the risk for early death. METHODS Patients who underwent CT pulmonary angiogram (CTPA) between January 2015 and March 2022 were considered for inclusion in this study. Based on DECT imaging, 107 radiomic features were extracted for each patient using standardized image processing. After dividing the dataset into training and test sets, stepwise feature reduction based on reproducibility, variable importance and correlation analyses were performed to select the most relevant features; these were used to train and validate the gradient-boosted tree models. RESULTS The trained machine learning classifier achieved a classification accuracy of .90 for identifying high-risk PE patients with an area under the receiver operating characteristic curve of .59. This CT-based radiomics signature showed good diagnostic accuracy for risk stratification in individuals presenting with central PE, particularly within higher risk groups. CONCLUSION Models utilizing DECT-derived radiomics features can accurately stratify patients with pulmonary embolism into established clinical risk scores. This approach holds the potential to enhance patient management and optimize patient flow by assisting in the clinical decision-making process. It also offers the advantage of saving time and resources by leveraging existing imaging to eliminate the necessity for manual clinical scoring.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Geyer
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Konrad Klimek
- Goethe University Frankfurt, University Hospital, Clinic for Nuclear Medicine, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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9
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Fan BE, Lippi G, Favaloro EJ. D-dimer Levels for the exclusion of pulmonary embolism: making sense of international guideline recommendations. J Thromb Haemost 2024; 22:604-608. [PMID: 38135252 DOI: 10.1016/j.jtha.2023.12.015] [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: 10/28/2023] [Revised: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023]
Abstract
Several international guidelines provide recommendations around the use of D-dimer testing for exclusion of pulmonary embolism, including the appropriate D-dimer threshold (or cutoff), but there is no consensus among them. We briefly discuss guideline variation, performance characteristics, and limitations of commercially available D-dimer assays in this setting, referencing the Clinical and Laboratory Standards Institute guidelines that recommend immunoassays with high sensitivity (≥97%) and negative predictive value (≥98%). While age-adjusted D-dimer and pretest-adjusted D-dimer are considered a safe strategy across predefined patient subgroups, clinicians need to recognize the different performance characteristics of D-dimer assays to enable safe clinical decisions for their patients. Importantly, D-dimer values must be correlated not only to clinical findings but also interpreted within the context of the accuracy and precision of the specific testing modality, adhering to manufacturer specifications that are approved by regulatory authorities.
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Affiliation(s)
- Bingwen Eugene Fan
- Department of Haematology, Tan Tock Seng Hospital, Singapore; Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore; Lee Kong Chian School of Medicine, Singapore; Yong Loo Lin School of Medicine, Singapore.
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research, Sydney Centres for Thrombosis and Haemostasis, New South Wales Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia; School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, Australia; School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia.
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10
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Pagkalidou E, Doundoulakis I, Apostolidou-Kiouti F, Bougioukas KI, Papadopoulos K, Tsapas A, Farmakis IT, Antonopoulos AS, Giannakoulas G, Haidich AB. An overview of systematic reviews on imaging tests for diagnosis of pulmonary embolism applying different network meta-analytic methods. Hellenic J Cardiol 2024; 76:88-98. [PMID: 37271191 DOI: 10.1016/j.hjc.2023.05.006] [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: 03/29/2023] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023] Open
Abstract
PURPOSE This study aimed to apply different methods of diagnostic test accuracy network meta-analysis (DTA-NMA) for studies reporting results of five imaging tests for the diagnosis of suspected pulmonary embolism (PE): pulmonary angiography (PA), computed tomography angiography (CTPA), magnetic resonance angiography (MRA), planar ventilation/perfusion (V/Q) scintigraphy and single-photon emission computed tomography ventilation/perfusion (SPECT V/Q). METHODS We searched four databases (MEDLINE [via PubMed], Cochrane CENTRAL, Scopus, and Epistemonikos) from inception until June 2, 2022 to identify systematic reviews (SRs) describing diagnostic accuracy of PA, CTPA, MRA, V/Q scan and SPECT V/Q for suspected PE. Study-level data were extracted and pooled using a hierarchical summary receiver operating characteristic (HSROC) meta-regression approach and two DTA-NMA models to compare accuracy estimates of different imaging tests. Risk of bias was assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool and certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. RESULTS We identified 13 SRs, synthesizing data from 33 primary studies and for four imaging tests (PA, CTPA, MRA and V/Q scan). The HSROC meta-regression model using PA as the reference standard showed that MRA had the best overall diagnostic performance with sensitivity of 0.93 (95% confidence interval [CI]: 0.76, 1.00) and specificity of 0.94 (95% CI: 0.84, 0.99). However, DTA-NMA models indicated that V/Q scan had the highest sensitivity, while CTPA was most specific. CONCLUSION Selecting a different DTA-NMA method to assess multiple diagnostic tests can affect estimates of diagnostic accuracy. There is no established method, but the choice depends on the data and familiarity with Bayesian statistics.
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Affiliation(s)
- Eirini Pagkalidou
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Ioannis Doundoulakis
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University, Athens, Greece
| | - Fani Apostolidou-Kiouti
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Konstantinos I Bougioukas
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | | | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece; Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece; Harris Manchester College, University of Oxford, Oxford, United Kingdom
| | - Ioannis T Farmakis
- Centre for Thrombosis and Haemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexios S Antonopoulos
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University, Athens, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece.
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11
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Puchades R, Tung-Chen Y, Salgueiro G, Lorenzo A, Sancho T, Fernández Capitán C. Artificial intelligence for predicting pulmonary embolism: A review of machine learning approaches and performance evaluation. Thromb Res 2024; 234:9-11. [PMID: 38113607 DOI: 10.1016/j.thromres.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Ramón Puchades
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain.
| | - Yale Tung-Chen
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
| | - Giorgina Salgueiro
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
| | - Alicia Lorenzo
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
| | - Teresa Sancho
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
| | - Carmen Fernández Capitán
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
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12
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Chen R, Petrazzini BO, Malick W, Rosenson R, Do R. Prediction of Venous Thromboembolism in Diverse Populations Using Machine Learning and Structured Electronic Health Records. Arterioscler Thromb Vasc Biol 2024; 44:491-504. [PMID: 38095106 PMCID: PMC10872966 DOI: 10.1161/atvbaha.123.320331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major cause of morbidity and mortality worldwide. Current risk assessment tools, such as the Caprini and Padua scores and Wells criteria, have limitations in their applicability and accuracy. This study aimed to develop machine learning models using structured electronic health record data to predict diagnosis and 1-year risk of VTE. METHODS We trained and validated models on data from 159 001 participants in the Mount Sinai Data Warehouse. We then externally tested them on 401 723 participants in the UK Biobank and 123 039 participants in All of Us. All data sets contain populations of diverse ancestries and clinical histories. We used these data sets to develop small, medium, and large models with increasing features on a range of optimizing portability to maximizing performance. We make trained models publicly available in click-and-run format at https://doi.org/10.17632/tkwzysr4y6.6. RESULTS In the holdout and external test sets, respectively, models achieved areas under the receiver operating characteristic curve of 0.80 to 0.83 and 0.72 to 0.82 for VTE diagnosis prediction and 0.76 to 0.78 and 0.64 to 0.69 for 1-year risk prediction, significantly outperforming the Padua score. Models also demonstrated robust performance across different VTE types and patient subsets, including ethnicity, age, and surgical and hospitalization status. Models identified both established and novel clinical features contributing to VTE risk, offering valuable insights into its underlying pathophysiology. CONCLUSIONS Machine learning models using structured electronic health record data can significantly improve VTE diagnosis and 1-year risk prediction in diverse populations. Model probability scores exist on a continuum, affecting mortality risk in both healthy individuals and VTE cases. Integrating these models into electronic health record systems to generate real-time predictions may enhance VTE risk assessment, early detection, and preventative measures, ultimately reducing the morbidity and mortality associated with VTE.
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Affiliation(s)
- Robert Chen
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Medical Scientist Training Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ben Omega Petrazzini
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Genomic Data Analytics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Waqas Malick
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Rosenson
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ron Do
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Genomic Data Analytics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Thompson R, Cassidy R, Hill J, Bryce L, Napier R, Beverland D. Are Patients With Morbid Obesity at Increased Risk of Pulmonary Embolism or Proximal Deep Vein Thrombosis After Lower Limb Arthroplasty? A Large-database Study. Clin Orthop Relat Res 2024; 482:115-124. [PMID: 37404124 PMCID: PMC10723888 DOI: 10.1097/corr.0000000000002742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/24/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Whether increased BMI is associated with an increased risk of venous thromboembolism (VTE) is controversial. Despite this, BMI > 40 kg/m 2 remains a common cutoff for lower limb arthroplasty eligibility. Current United Kingdom national guidelines list obesity as a risk factor for VTE, but these are based on evidence that has largely failed to differentiate between potentially minor (distal deep vein thrombosis [DVT]), and more harmful (pulmonary embolism [PE] and proximal DVT) diagnoses. Determining the association between BMI and the risk of clinically important VTE is needed to improve the utility of national risk stratification tools. QUESTIONS/PURPOSES (1) In patients undergoing lower limb arthroplasty, is BMI 40 kg/m 2 or higher (morbid obesity) associated with an increased risk of PE or proximal DVT within 90 days of surgery, compared with patients with BMI less than 40 kg/m 2 ? (2) What proportion of investigations ordered for PE and proximal DVT were positive in patients with morbid obesity who underwent lower limb arthroplasty compared with those with BMI less than 40 kg/m 2 ? METHODS Data were collected retrospectively from the Northern Ireland Electronic Care Record, a national database recording patient demographics, diagnoses, encounters, and clinical correspondence. Between January 2016 and December 2020, 10,217 primary joint arthroplasties were performed. Of those, 21% (2184 joints) were excluded; 2183 were in patients with multiple arthroplasties and one had no recorded BMI. All 8033 remaining joints were eligible for inclusion, 52% of which (4184) were THAs, 44% (3494) were TKAs, and 4% (355) were unicompartmental knee arthroplasties; all patients had 90 days of follow-up. The Wells score was used to guide the investigations. Indications for CT pulmonary angiography for suspected PE included pleuritic chest pain, reduced oxygen saturations, dyspnea, or hemoptysis. Indications for ultrasound scans for suspected proximal DVT included leg swelling, pain, warmth, or erythema. Distal DVTs were recorded as negative scans because we do not treat them with modified anticoagulation. The division of categories was set at BMI 40 kg/m 2 , a common clinical cutoff used in surgical eligibility algorithms. Patients were grouped according to WHO BMI categories to assess for the following confounding variables: sex, age, American Society of Anesthesiologists grade, joint replaced, VTE prophylaxis, grade of operative surgeon, and implant cement status. RESULTS We found no increase in the odds of PE or proximal DVT in any WHO BMI category. When comparing patients with BMI less than 40 kg/m 2 with those with a BMI of 40 kg/m 2 or higher, there was no difference in the odds of PE (0.8% [58 of 7506] versus 0.8% [four of 527]; OR 1.0 [95% CI 0.4 to 2.8]; p > 0.99) or proximal DVT (0.4% [33 of 7506] versus 0.2% [one of 527]; OR 2.3 [95% CI 0.3 to 17.0]; p = 0.72). Of those who received diagnostic imaging, 21% (59 of 276) of CT pulmonary angiograms and 4% (34 of 718) of ultrasounds were positive for patients with BMI less than 40 kg/m 2 compared with 14% (four of 29; OR 1.6 [95% CI 0.6 to 4.5]; p = 0.47) and 2% (one of 57; OR 2.7 [95% CI 0.4 to 18.6]; p = 0.51) for patients with BMI 40 kg/m 2 or higher. There was no difference in the percentage of CT pulmonary angiograms ordered (4% [276 of 7506] versus 5% [29 of 527]; OR 0.7 [95% CI 0.5 to 1.0]; p = 0.07) or ultrasounds ordered (10% [718 of 7506] versus 11% [57 of 527]; OR 0.9 [95% CI 0.7 to 1.2]; p = 0.49) for BMI less than 40 kg/m 2 and BMI 40 kg/m 2 or higher. CONCLUSION Increased BMI should not preclude individuals from lower limb arthroplasty based on suspected risk of clinically important VTE. National VTE risk stratification tools should be based on evidence assessing clinically relevant VTE (specifically, proximal DVT, PE, or death of thromboembolism) only. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | | | - Janet Hill
- Musgrave Park Hospital, Belfast, Northern Ireland, UK
| | - Leeann Bryce
- Musgrave Park Hospital, Belfast, Northern Ireland, UK
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Amin MS, Ershad R, Kadam N, Khan Z. ECG Features of Pulmonary Embolism in a Patient With Normal D-Dimer and Hypoxia. Cureus 2023; 15:e49433. [PMID: 38149149 PMCID: PMC10750804 DOI: 10.7759/cureus.49433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/28/2023] Open
Abstract
Pulmonary embolism is a life-threatening condition that requires urgent treatment. We present the case of a 76-year-old male referred to our medical team with dyspnoea, shortness of breath on exertion, and chest pain. Upon further questioning, the patient reported a two-week history of right-sided parasternal pleuritic chest pain without radiation. He denied any history of haemoptysis, calf swelling or pain, recent surgery, and reduced mobility. The patient had a medical history of bilateral cataracts, glaucoma, and hypertension. Clinical examination was unremarkable except for requiring 2L/minute supplemental oxygen to maintain an oxygen saturation of 94%, and blood tests were unremarkable, including a normal D-dimer. Chest radiography revealed no obvious pathological findings. However, the electrocardiogram showed a right bundle branch, sinus tachycardia, and an S1Q3T3 pattern. A computed tomography pulmonary angiogram confirmed pulmonary emboli within the right lower lobe segmental artery, extending into the bilateral basal segmental branch and posterior basal segmental branch. The patient was commenced on low molecular weight heparin initially followed by rivaroxaban 20 mg once daily. This case highlights the importance of having a high degree of suspicion for pulmonary embolism, and D-dimer is an important screening test that can be normal.
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Affiliation(s)
- Mehul S Amin
- Internal Medicine, Southend University Hospital, London, GBR
| | - Rifat Ershad
- General Medicine, Basildon Hospital, London, GBR
| | - Nikhil Kadam
- Internal Medicine, Mid and South Essex NHS Foundation Trust, Southend on Sea, GBR
| | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend on Sea, GBR
- Cardiology, Bart's Heart Centre, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
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15
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Osmani N, Marinaro J, Guliani S. Life-threatening pulmonary embolism: overview and management. Int Anesthesiol Clin 2023; 61:35-42. [PMID: 37622318 DOI: 10.1097/aia.0000000000000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Nizar Osmani
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Jonathan Marinaro
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico
| | - Sundeep Guliani
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico
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16
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Akhoundi N, Sedghian S, Siami A, Yazdani nia I, Naseri Z, Ghadiri Asli SM, Hazara R. Does Adding the Pulmonary Infarction and Right Ventricle to Left Ventricle Diameter Ratio to the Qanadli Index (A Combined Qanadli Index) More Accurately, Predict Short-Term Mortality in Patients with Pulmonary Embolism? Indian J Radiol Imaging 2023; 33:478-483. [PMID: 37811186 PMCID: PMC10556326 DOI: 10.1055/s-0043-1769590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Background The Qanadli index can be used to assess the severity of pulmonary arterial involvement in patients with acute pulmonary embolism. However, it seems that considering pulmonary infarction and right ventricle/left ventricle (RV/LV) ratio along with this index (called the combined Qanadli index) can provide a more accurate view of changes in cardiovascular parameters in these patients and help predict mortality in a better manner. In this regard, we evaluated the ability of the combined Qanadli index versus the Qanadli index in predicting short-term mortality in patients with pulmonary embolism. Methods This retrospective study enrolled 234 patients with acute pulmonary embolism. Patients were divided into two groups: those who expired in 30 days and who survived. Then they were evaluated by computed tomography angiography of pulmonary arteries. The RV/LV diameter ratio and also pulmonary artery obstruction index (PAOI) were calculated. The patient's computed tomography scans were reviewed for pulmonary infarction. By adding the RV/LV ratio and pulmonary infarction to PAOI, a new index called the modified Qanadli score was made. Univariable and multivariable logistic regression was done for finding predictors of mortality. Results Nine cases (40%) of patients in the mortality group and 42 (20%) of survivors had ischemic heart disease and the difference was significantly meaningful. The mean Qanadli index in the mortality group was 16.8 ± 8.45 and in survivors was 8.3 ± 4.2. By adding the pulmonary infarction score and PAOI score to RV/LV ratio score, the odds ratio (OR) for predicting mortality increased significantly to 13 and 16, respectively, which were significantly meaningful. Based on our findings, the highest OR for predicting short-term mortality was obtained through a combined Qanadli index (PAOI score + pulmonary infarction score + RV/LV score) that was 17 in univariable and 18 in multivariable logistic regression analysis ( p -value = 0.015). Conclusion The new combined Qanadli index has more ability than the Qanadli index and RV/LV ratio for predicting changes in cardiovascular parameters and short-term mortality in patients with pulmonary embolism.
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Affiliation(s)
- Neda Akhoundi
- Radiology Department, University of California San Diego, Hillcrest Hospital, San Diego, California, United States
| | - Sonia Sedghian
- Radiology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Siami
- Department of Statistics, Biostatistical Analyzer, Amirkabir University of Technology, Tehran, Iran
| | - Iman Yazdani nia
- Radiology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zahra Naseri
- Radiology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Reza Hazara
- Department of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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17
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Wu W, Zhang R, Zhou Y, Wang S, Shen Y, Li N, Tan J, Zheng W, Jia Q, Meng Z. Impacts of different reconstruction methods on the image quality of cadmium-zinc-telluride-based single photon emission computed tomography/computed tomography pulmonary perfusion imaging. Nucl Med Commun 2023; 44:673-681. [PMID: 37233601 DOI: 10.1097/mnm.0000000000001710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE The objective was to evaluate the impacts of different reconstruction methods [filtered back projection (FBP) and ordered subset expectation maximization (OSEM)] and different filters (Butterworth filter and Gaussian filter) on the image quality in cadmium-zinc-telluride (CZT)-based single photon emission computed tomography (SPECT)/computed tomography (CT) pulmonary perfusion imaging. METHODS A combinations including FBP with Butterworth filter, OSEM with Butterworth filter (OSEM + Butterworth filter ), and OSEM with Gaussian filter (OSEM + Gaussian filter) were used during SPECT image reconstruction. Visual and quantitative parameters [root mean square (RMS) noise, contrast and contrast-to-noise ratio (CNR)] were used to evaluate image quality. RESULTS The OSEM + Gaussian filter had better RMS noise and CNR than those of the FBP + Butterworth filter or OSEM + Butterworth filter, while the OSEM + Butterworth filter had the best contrast. The highest visual scores were obtained by OSEM + Gaussian filter ( P < 0.0001). In the lesion size <2 cm group, the contrast ( P < 0.01) and visual scores ( P < 0.001) of OSEM + Butterworth filter were better than those of the other two groups. In the lesion size ≥2 cm group, the RMS noise and visual scores of OSEM + Gaussian filter were better than those of the other two groups. CONCLUSION In CZT SPECT/CT pulmonary perfusion imaging, this study recommended the clinical use of the OSEM + Gaussian filter combination for reconstruction in both conventional and larger lesions, the OSEM + Butterworth filter image postprocessing method might be advantageous in small lesions.
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Affiliation(s)
- Weiming Wu
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
| | - Ruyi Zhang
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
| | - Yaqian Zhou
- Department of Nuclear Medicine, Renji Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shen Wang
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
| | - Yiming Shen
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
| | - Ning Li
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
| | - Jian Tan
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
| | - Wei Zheng
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
| | - Qiang Jia
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
| | - Zhaowei Meng
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin
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Roussel M, Bloom B, Taalba M, Choquet C, Douillet D, Fémy F, Marouk A, Gorlicki J, Gerlier C, Macrez R, Arnaud E, Bompard R, Montassier E, Hugli O, Czopik C, Eyer X, Benhamed A, Peyrony O, Chouihed T, Penaloza A, Marra A, Laribi S, Reuter PG, Behringer W, Douplat M, Guenezan J, Javaud N, Lucidarme O, Cachanado M, Aparicio-Monforte A, Freund Y. Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department : A Retrospective Analysis. Ann Intern Med 2023. [PMID: 37216659 DOI: 10.7326/m22-3116] [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] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). OBJECTIVE To measure any resulting change in CTPA use for suspected PE. DESIGN Retrospective analysis. SETTING 26 European EDs in 6 countries. PATIENTS Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019. MEASUREMENTS The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models. RESULTS 8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, -8.9% [CI, -17.1% to -0.3%]) were observed. LIMITATION Data were limited to 7 days every 2 months. CONCLUSION Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed. PRIMARY FUNDING SOURCE None specific for this study.
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Affiliation(s)
- Melanie Roussel
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.R., Y.F.)
| | - Ben Bloom
- Emergency Department, Royal London Hospital, London, United Kingdom (B.B.)
| | - Mehdi Taalba
- Emergency Department, Rouen University Hospital, Rouen, France (M.T.)
| | - Christophe Choquet
- Emergency Department, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (C. Choquet)
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Angers; and UNIV Angers, UMR MitoVasc CNRS 6215 INSERM 1083, Angers, France (D.D.)
| | - Florent Fémy
- Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cite, Paris; and Toxicology and Chemical Risks Department, French Armed Forces Biomedical Institute, Brétigny-sur-Orge, France (F.F.)
| | - Alexis Marouk
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (A. Marouk)
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny, France (J. Golicki)
| | - Camille Gerlier
- Emergency Department, Hôpital Saint-Joseph, Paris, France (C.G.)
| | - Richard Macrez
- Emergency Department, CHU Caen Côte de Nacre, Normandie Université UNICAEN, INSERM PhIND Institut Blood and Brain, Caen, France (R.M.)
| | - Emilien Arnaud
- Department of Emergency Medicine, Amiens-Picardy University Hospital, Amiens, France (E.A.)
| | - Rudy Bompard
- Emergency Department, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France (R.B.)
| | | | - Olivier Hugli
- Emergency Department, Lausanne University Hospital Emergency Care Service, Lausanne, Switzerland (O.H.)
| | - Charlotte Czopik
- Emergency Department, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (C. Czopik)
| | - Xavier Eyer
- Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France (X.E.)
| | - Axel Benhamed
- Emergency Department, Hospices Civils de Lyon, Lyon, France (A.B., M.D.)
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France (O.P.)
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, Nancy, France (T.C.)
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (A.P.)
| | - Alessio Marra
- Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy (A. Marra)
| | - Said Laribi
- Tours University, Emergency Medicine Department, Tours University Hospital, Tours, France (S.L.)
| | - Paul-Georges Reuter
- Emergency Department, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne; and Université Versailles-Saint Quentin en Yvelines, Boulogne, France (P.-G.R.)
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna General Hospital, Vienna, Austria (W.B.)
| | - Marion Douplat
- Emergency Department, Hospices Civils de Lyon, Lyon, France (A.B., M.D.)
| | - Jeremy Guenezan
- Emergency Department, University Hospital of Poitiers, Poitiers, France (J. Guenezen)
| | - Nicolas Javaud
- Emergency Department, Hôpital Louis-Mourier, Assistance Publique-Hôpitaux de Paris, Colombes; and Reference Center for Bradykinin Angiodema (CReAk), Université Paris Cite, Colombes, France (N.J.)
| | - Olivier Lucidarme
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; and Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale LIB, Paris, France (O.L.)
| | - Marine Cachanado
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (M.C., A.A.)
| | - Ainhoa Aparicio-Monforte
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (M.C., A.A.)
| | - Yonathan Freund
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.R., Y.F.)
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Callejas MF, Lin HM, Howard T, Aitken M, Napoleone M, Jimenez-Juan L, Moreland R, Mathur S, Deva DP, Colak E. Augmentation of the RSNA Pulmonary Embolism CT Dataset with Bounding Box Annotations and Anatomic Localization of Pulmonary Emboli. Radiol Artif Intell 2023; 5:e230001. [PMID: 37293344 PMCID: PMC10245177 DOI: 10.1148/ryai.230001] [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: 01/04/2023] [Revised: 03/15/2023] [Accepted: 04/13/2023] [Indexed: 06/10/2023]
Abstract
Supplemental material is available for this article. Keywords: CT, Pulmonary Arteries, Embolism/Thrombosis, Feature Detection © RSNA, 2023.
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20
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Shargall Y, Wiercioch W, Brunelli A, Murthy S, Hofstetter W, Lin J, Li H, Linkins LA, Crowther M, Davis R, Rocco G, Morgano GP, Schünemann F, Muti-Schünemann G, Douketis J, Schünemann HJ, Litle VR. Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery. J Thorac Cardiovasc Surg 2023; 165:794-824.e6. [PMID: 36895083 DOI: 10.1016/j.jtcvs.2022.05.041] [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: 09/10/2021] [Revised: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice. OBJECTIVE These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer. METHODS The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment. RESULTS The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer. CONCLUSIONS The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis.
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Affiliation(s)
- Yaron Shargall
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Hui Li
- Department of Thoracic Surgery, Capital Medical University, Beijing, China
| | - Lori-Ann Linkins
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Roger Davis
- Patient Representative, Burlington, Ontario, Canada
| | - Gaetano Rocco
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Finn Schünemann
- Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - Giovanna Muti-Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginia R Litle
- Department of Surgery, Boston University School of Medicine, Boston, Mass
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Diagnostic test accuracy of imaging modalities for adults with acute pulmonary embolism: A systematic review and meta-analysis. J Med Imaging Radiat Sci 2023; 54:178-194. [PMID: 36456459 DOI: 10.1016/j.jmir.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/26/2022] [Accepted: 11/07/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This systematic review and meta-analysis aimed to evaluate the current literature on diagnostic test accuracy (DTA) of imaging modalities for adults with acute pulmonary embolism (APE). BACKGROUND Medical imaging plays an integral role in evaluating and managing those with APE. Guidance for imaging modality use for APE diagnosis varies due to a lack of clinical standardisation. Despite this, CTPA remains the first-line imaging modality used by clinicians. METHODS A literature search of PubMed, EMBASE, Trove and Mednar databases (2012-2020; English language) was performed. Studies assessing the DTA of imaging modalities for APE diagnosis were included. DTA studies methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2 tool). Results of eligible studies were pooled using random or fixed effects modelling the calculate the pooled DTA of explored imaging modalities for APE. The Higgins I2 test were performed to assess between study heterogeneity. RESULTS 10 Studies, involving 998 participants, were enrolled and pooled using the random effects model. Of the explored modalities, magnetic resonance imaging (MRI), specifically pulmonary MRI and magnetic resonance pulmonary angiography (MRPA) exhibited the highest pooled DTA. Sensitivity, specificity, negative likelihood ratio, positive likelihood ratio and diagnostic odds ratio for MRPA were 0.952 (95% CI, 0.881 to 0.987), 0.857 (95% CI, 0.637 to 0.97), 5.631 (95% CI, 2.163 to 14.659), 0.06 (95% CI, 0.007 to 0.537) and 80.310 (95% CI, 15.607 to 413.25) respectively. Based on the QUADAS-2 criteria, most studies presented low to moderate risk of bias and concern regarding applicability. CONCLUSION The explored ultrasound and MRI protocols which exhibit a lower radiation burden when compared to the current gold standard computed tomography pulmonary angiography (CTPA), have acceptable diagnostic accuracy for APE and can be useful in certain situations.
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22
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Milos RI, Bartha C, Röhrich S, Heidinger BH, Prayer F, Beer L, Wassipaul C, Kifjak D, Watzenboeck ML, Pochepnia S, Prosch H. Imaging in patients with acute dyspnea when cardiac or pulmonary origin is suspected. BJR Open 2023; 5:20220026. [PMID: 37035768 PMCID: PMC10077421 DOI: 10.1259/bjro.20220026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/23/2022] [Accepted: 12/02/2022] [Indexed: 01/13/2023] Open
Abstract
A wide spectrum of conditions, from life-threatening to non-urgent, can manifest with acute dyspnea, thus presenting major challenges for the treating physician when establishing the diagnosis and severity of the underlying disease. Imaging plays a decisive role in the assessment of acute dyspnea of cardiac and/or pulmonary origin. This article presents an overview of the current imaging modalities used to narrow the differential diagnosis in the assessment of acute dyspnea of cardiac or pulmonary origin. The current indications, findings, accuracy, and limits of each imaging modality are reported. Chest radiography is usually the primary imaging modality applied. There is a low radiation dose associated with this method, and it can assess the presence of fluid in the lung or pleura, consolidations, hyperinflation, pneumothorax, as well as heart enlargement. However, its low sensitivity limits the ability of the chest radiograph to accurately identify the causes of acute dyspnea. CT provides more detailed imaging of the cardiorespiratory system, and therefore, better sensitivity and specificity results, but it is accompanied by higher radiation exposure. Ultrasonography has the advantage of using no radiation, and is fast and feasible as a bedside test and appropriate for the assessment of unstable patients. However, patient-specific factors, such as body habitus, may limit its image quality and interpretability. Advances in knowledge This review provides guidance to the appropriate choice of imaging modalities in the diagnosis of patients with dyspnea of cardiac or pulmonary origin.
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Affiliation(s)
- Ruxandra-Iulia Milos
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Sebastian Röhrich
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Benedikt H. Heidinger
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Florian Prayer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Lucian Beer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christian Wassipaul
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Martin L Watzenboeck
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Svitlana Pochepnia
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
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23
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Tan TH, Ismail R. Utility of Lung Perfusion SPECT/CT in Detection of Pulmonary Thromboembolic Disease: Outcome Analysis. Nucl Med Mol Imaging 2023; 57:1-8. [PMID: 35013684 PMCID: PMC8731677 DOI: 10.1007/s13139-021-00726-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/20/2021] [Accepted: 11/26/2021] [Indexed: 01/13/2023] Open
Abstract
Purpose To evaluate the clinical outcome of Q-SPECT/CT in pulmonary thromboembolic disease. Methods From Jan 2020 to Jan 2021, 30 consecutive patients (M:F = 8:22; median age = 52 year (21-89)) suspected of having acute pulmonary embolism (PE) or chronic thromboembolic pulmonary hypertension (CTEPH) were referred for non-contrasted Q-SPECT/CT. All patients were COVID-19 PCR negative. MSKCC Q-SPECT/CT and/or PISAPED criteria were used to determine the presence of thromboembolic disease in Q-SPECT/CT. Final diagnosis was made based on composite reference standards that included at least 2-month clinical cardiorespiratory assessment and follow-up imaging. Results Q-SPECT/CT was positive in 19 patients: indeterminate in 1 and 10 were negative. Three false positive cases were observed during follow-up. Of the remaining 16 true positives, all patients' cardiorespiratory symptom were improved or stabilised after treatment with anticoagulants. The overall sensitivity, specificity, PPV, NPV and accuracy of Q-SPECT/CT were 100% (95% CI, 79.41-100%), 78.57% (95% CI, 49.20-95.34%), 84.21% (95% CI, 66.41-93.57%), 100% and 90.00% (95% CI, 73.47-97.89%) respectively. Conclusions In the current COVID-19 pandemic, Q-SPECT/CT can be an alternative modality to detect pulmonary thromboembolic disease. Normal Q-SPECT/CT excludes pulmonary thromboembolic disease with high degree of certainty. However, false positive has been observed.
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Affiliation(s)
- Teik Hin Tan
- Nuclear Medicine, Sunway Medical Centre, 5, Jalan Lagoon Selatan, Bandar Sunway, 47500 Petaling Jaya, Selangor Malaysia
| | - Rosmadi Ismail
- Internal Medicine, Sunway Medical Centre, 5, Jalan Lagoon Selatan, Bandar Sunway, 47500 Petaling Jaya, Selangor Malaysia
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24
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Reed MH. Challenges with need to improve the reference standard in diagnosis: paper 3: response to mustafa and schunemann. J Clin Epidemiol 2023; 154:216-217. [PMID: 36455854 DOI: 10.1016/j.jclinepi.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Martin H Reed
- Department of Radiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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25
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Mustafa RA, Schünemann H. Challenges with need to improve the reference standard in diagnosis: paper 2: real-world case examples from GRADE for when a reference standard is not clearly defined/ easily replicable or when it is infeasible/ unethical to perform the reference standard. J Clin Epidemiol 2023; 154:206-207. [PMID: 36455853 DOI: 10.1016/j.jclinepi.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Reem A Mustafa
- University of Kansas Medical Center, 3901 Rainbow Blvd, MS3002, Kansas City, KS 66160, USA.
| | - Holger Schünemann
- University of Kansas Medical Center, 3901 Rainbow Blvd, MS3002, Kansas City, KS 66160, USA
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26
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Seliverstov E, Lobastov K, Ilyukhin E, Apkhanova T, Akhmetzyanov R, Akhtyamov I, Barinov V, Bakhmetiev A, Belov M, Bobrov S, Bozhkova S, Bredikhin R, Bulatov V, Vavilova T, Vardanyan A, Vorobiev N, Gavrilov E, Gavrilov S, Golovina V, Gorin A, Dzhenina O, Dianov S, Efremova O, Zhukovets V, Zamyatin M, Ignatiev I, Kalinin R, Kamaev A, Kaplunov O, Karimova G, Karpenko A, Kasimova A, Katelnitskaya O, Katelnitsky I, Katorkin S, Knyazev R, Konchugova T, Kopenkin S, Koshevoy A, Kravtsov P, Krylov A, Kulchitskaya D, Laberko L, Lebedev I, Malanin D, Matyushkin A, Mzhavanadze N, Moiseev S, Mushtin N, Nikolaeva M, Pelevin A, Petrikov A, Piradov M, Pikhanova Z, Poddubnaya I, Porembskaya O, Potapov M, Pyregov A, Rachin A, Rogachevsky O, Ryabinkina Y, Sapelkin S, Sonkin I, Soroka V, Sushkov S, Schastlivtsev I, Tikhilov R, Tryakin A, Fokin A, Khoronenko V, Khruslov M, Tsaturyan A, Tsed A, Cherkashin M, Chechulova A, Chuiko S, Shimanko A, Shmakov R, Yavelov I, Yashkin M, Kirienko A, Zolotukhin I, Stoyko Y, Suchkov I. Prevention, Diagnostics and Treatment of Deep Vein Thrombosis. Russian Experts Consensus. FLEBOLOGIIA 2023; 17:152. [DOI: 10.17116/flebo202317031152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2024]
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Kristic S, Begic A, Zubovic SV, Basic A, Kuric H. The Correlation Between the D-Dimer Values and Anatomical Distribution of Pulmonary Embolism. Med Arch 2023; 77:354-357. [PMID: 38299089 PMCID: PMC10825744 DOI: 10.5455/medarh.2023.77.354-357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 02/02/2024] Open
Abstract
Background Pulmonary Embolism (PE) represents a life-threatening medical emergency that, given the serious complications, requires urgent application of anticoagulant therapy. In addition to other factors that are taken into account when choosing a therapy for treatment of PE, the anatomical distribution of thrombi is also considered-whether it is a central, lobar, segmental or subsegmental PE. D-dimer is an intermediate product of degradation of fibrin molecules and its values in the plasma are increased in the case of PE, but also in other diseases. Objective To determine whether there is a difference in D-dimer values in subjects with different anatomical distribution of PE. Methods The study included 100 subjects with diagnosed PE by using MSCT and/or V/P SPECT and with measured values of D-dimer. Results Out of 100 subjects, PE was not diagnosed in 37 subjects, while 63 subjects PE was diagnosed. All subjects with diagnosed PE were divided into 3 groups regarding the anatomical localization of thrombus: lobar, segmental or subsegmental. Average D-dimer values were calculated for all 3 groups. Statistical analysis showed that there was no significant difference in D-dimer values between subjects with different anatomical distribution of PE. Conclusion There is no significant difference in D-dimer values between subjects with different anatomical distribution od PE-lobar, segmental and subsegmental PE.
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Affiliation(s)
- Spomenka Kristic
- Clinic of Radiology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amela Begic
- Clinic of Nuclear Medicine and Endocrinology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Sandra Vegar Zubovic
- Clinic of Radiology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amila Basic
- Clinic of Nuclear Medicine and Endocrinology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Haris Kuric
- Clinic of Radiology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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28
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Lasanudin JEF, Laksono S, Kusharsamita H. Current Diagnosis and Management of Acute Pulmonary Embolism: A Strategy for General Practitioners in Emergency Department. ACTA MEDICA (HRADEC KRALOVE) 2023; 66:138-145. [PMID: 38588391 DOI: 10.14712/18059694.2024.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Pulmonary embolism (PE) is a disease with a relatively good prognosis when diagnosed and treated properly. This review aims to analyse available data and combine them into algorithms that physicians can use in the emergency department for quick decision-making in diagnosing and treating PE. The available data show that PE can be excluded through highly sensitive clinical decision rules, i.e. Pulmonary Embolism Rule-Out Criteria (PERC), Wells criteria, and Revised Geneva criteria, combined with D-dimer assessment. In cases where PE could not be excluded through the mentioned strategies, imaging modalities, such as compression ultrasonography (CUS), computed tomographic pulmonary angiography (CTPA), and planar ventilation/perfusion (V/Q) scan, are indicated for a definite diagnosis. Once a diagnosis has been made, treatment of PE depends on its mortality risk as patients are divided into low-, intermediate-, and high-risk cases. High-risk cases are treated for their hemodynamic instability, given parenteral or oral anticoagulant therapy, and are indicated for reperfusion therapy. Intermediate-risk PE is only given parenteral or oral anticoagulants and reperfusion is indicated when anticoagulants fail. Low-risk cases are given oral anticoagulants and based on the Hestia criteria, patients may be discharged and treated as outpatients.
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Affiliation(s)
| | - Sidhi Laksono
- Department of Cardiology and Vascular Medicine, Central Pertamina Hospital, Jakarta, Indonesia.
- Faculty of Medicine, Universitas Muhammadiyah Prof Dr Hamka, Tangerang, Indonesia.
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29
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Shargall Y, Wiercioch W, Brunelli A, Murthy S, Hofstetter W, Lin J, Li H, Linkins LA, Crowther M, Davis R, Rocco G, Morgano GP, Schünemann F, Muti-Schünemann G, Douketis J, Schünemann HJ, Litle VR. Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6889652. [PMID: 36519935 DOI: 10.1093/ejcts/ezac488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice. OBJECTIVE These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer. METHODS The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment. RESULTS The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer. CONCLUSIONS The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis. (J Thorac Cardiovasc Surg 2022;▪:1-31).
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Affiliation(s)
- Yaron Shargall
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hui Li
- Department of Thoracic Surgery, Capital Medical University, Beijing, China
| | - Lori-Ann Linkins
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Roger Davis
- Patient Representative, Burlington, Ontario, Canada
| | - Gaetano Rocco
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Finn Schünemann
- Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - Giovanna Muti-Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginia R Litle
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
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Yanagisawa Y, Ibrahim WH, Kumar N, Cooper J. A 60-Year-Old Woman with a 6-Week History of Shortness of Breath and Intermittent Chest Pain Due to Chronic Thromboembolic Pulmonary Disease Undetected by Computed Tomography Pulmonary Angiography (CTPA) and Diagnosed by Ventilation-Perfusion Imaging. AMERICAN JOURNAL OF CASE REPORTS 2022; 23:e938041. [PMID: 36395074 PMCID: PMC9679983 DOI: 10.12659/ajcr.938041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary disease (CTEPD) is the persistent occlusion of pulmonary arteries resulting from 1 or more thrombo-emboli. Its presentation is often non-specific, with exertional dyspnea and fatigue, yet if left undiagnosed risks of chronic thromboembolic pulmonary hypertension and right-sided cardiac failure can ensue. Computed tomography pulmonary angiography (CTPA) and ventilation/perfusion (V/Q) imaging are most commonly utilized for investigating CTEPD. This report is of a 60-year-old woman with a 6-week history of breathlessness and intermittent chest pain due to CTEPD, undetected by CTPA and diagnosed by V/Q imaging. CASE REPORT A 60-year-old woman presented with a 6-week history of breathlessness, intermittent chest pain, and reduced mobility. Her past medical history included chronic obstructive pulmonary disease, pulmonary sarcoidosis, and obesity. Screening tests for infective and ischemic cardiac etiologies were unremarkable. A calculated Wells score was 6, making CTEPD the main differential diagnosis, and she was commenced on therapeutic dose anticoagulation. A CTPA performed on day 2 of admission showed no evidence of acute thromboembolic pulmonary disease or CTEPD. Instead, V/Q scintigraphy on day 6 revealed a perfusion mismatch in the right lung apex, consistent with CTEPD. The patient improved clinically and was discharged on long-term apixaban. CONCLUSIONS A negative CTPA does not necessarily exclude CTEPD. The sensitivity of CTPA for CTEPD is lower than that of V/Q imaging, and can hence lead to false-negative results, as this case highlights. When there is a high clinical suspicion for CTEPD but a negative CTPA study, V/Q imaging should always be undertaken.
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Affiliation(s)
- Yuuki Yanagisawa
- Department of Internal Medicine, Bedfordshire Hospitals NHS Trusts, Bedford Hospital, Bedford, UK,Corresponding Author: Yuuki Yanagisawa, e-mail:
| | - Wissam Hassan Ibrahim
- Department of Internal Medicine, Bedfordshire Hospitals NHS Trusts, Bedford Hospital, Bedford, UK
| | - Narendra Kumar
- Department of Cardiology, Bedfordshire Hospitals NHS Trusts, Bedford Hospital, Bedford, UK
| | - John Cooper
- Department of Cardiology, Bedfordshire Hospitals NHS Trusts, Bedford Hospital, Bedford, UK
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Scheurer F, Halvachizadeh S, Berk T, Pape HC, Pfeifer R. Chest CT Findings and SARS-CoV-2 Infection in Trauma Patients-Is There a Prediction towards Higher Complication Rates? J Clin Med 2022; 11:6401. [PMID: 36362629 PMCID: PMC9656498 DOI: 10.3390/jcm11216401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/22/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Polytrauma patients with SARS-CoV-2 infections may be associated with an increased complication rate. The main goal of this study was to analyze the clinical course of trauma patients with COVID infection and a positive CT finding. Methods: This was a retrospective in-hospital study. Polytrauma patients diagnosed with SARS-CoV-2 infections were included in our analysis. The outcome parameters were pulmonary complication during admission, pulmonary embolism, pleural effusion, pneumonia, mortality, length of stay and readmission < 30 days. Results: 48 patients were included in the study. Trauma patients in the age-adjusted matched-pair analysis with typical changes in SARS-CoV-2 infection in CT findings showed significantly more pulmonary complications in general and significantly more cases of pneumonia (complications: 56% vs. 11%, p = 0.046; pneumonia 44% vs. 0%, p = 0.023). In addition, the clinical course of polytrauma patients with SARS-CoV-2 infection showed a high rate of pulmonary complications in the inpatient course (53%). Conclusion: The results of our study show that the changes in the CT findings of trauma patients with SARS-CoV-2 infection are a good indicator of further inpatient outcomes. Similarly, polytrauma patients with a SARS-CoV-2 infection and positive CT findings are shown to have increased risk for pulmonary complications.
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Affiliation(s)
- Fabrice Scheurer
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
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Gollamudi J, Sartain SE, Navaei AH, Aneja S, Kaur Dhawan P, Tran D, Joshi J, Gidudu J, Gollamudi J, Chiappini E, Varricchio F, Law B, Munoz FM. Thrombosis and thromboembolism: Brighton collaboration case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2022; 40:6431-6444. [PMID: 36150973 DOI: 10.1016/j.vaccine.2022.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/01/2022] [Indexed: 01/27/2023]
Abstract
This is a Brighton Collaboration case definition of thrombosis and thromboembolism to be used in the evaluation of adverse events following immunization, and for epidemiologic studies for the assessment of background incidence or hypothesis testing. The case definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of SARS-CoV-2 vaccines. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected expert reviewers prior to submission.
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Affiliation(s)
- Jahnavi Gollamudi
- Department of Medicine, Section of Hematology, Baylor College of Medicine, Houston, TX, USA
| | - Sarah E Sartain
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Amir Hassan Navaei
- Pediatric Critical Care, Transfusion Medicine & Coagulation, Pediatrics and Pathology & Immunology Departments, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite WB110, Houston 77021, TX, USA
| | - Satinder Aneja
- Department of Pediatrics, School of Medical Sciences & Research, Sharda University, Gr Noida, India
| | | | - Dat Tran
- Oregon Health Authority, Public Health Division, Acute and Communicable Disease Prevention Section, Portland, OR, USA
| | - Jyoti Joshi
- International Centre for Antimicrobial Resistance Solutions (ICARS), Orestads Boulevard 5, 2300 Copenhagen, Denmark
| | - Jane Gidudu
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Elena Chiappini
- Meyer University Hospital, Department of Health Science, University of Florence, Florence, Italy
| | | | - Barbara Law
- SPEAC, Brighton Collaboration, Independent Consultant, Vancouver, BC, Canada
| | - Flor M Munoz
- Department of Pediatrics, Section of Infectious Diseases, and Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA.
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Girardi AM, Turra EE, Loreto M, Albuquerque R, Garcia TS, Rech TH, Gazzana MB. Diagnostic accuracy of multiorgan point-of-care ultrasound compared with pulmonary computed tomographic angiogram in critically ill patients with suspected pulmonary embolism. PLoS One 2022; 17:e0276202. [PMID: 36256666 PMCID: PMC9578587 DOI: 10.1371/journal.pone.0276202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/30/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Critically ill patients have a higher incidence of pulmonary embolism (PE) than non-critically ill patients, yet no diagnostic algorithm has been validated in this population, leading to the overuse of pulmonary artery computed tomographic angiogram (CTA). This study aimed to comparatively evaluate the diagnostic accuracy of point-of-care ultrasound (POCUS) combined with laboratory data versus CTA in predicting PE in critically ill patients. METHODS A prospective diagnostic accuracy study. Critically ill patients with suspected acute PE undergoing CTA were prospectively enrolled. Demographic and clinical data were collected from electronic medical records. Blood samples were collected, and the Wells and revised Geneva scores were calculated. Standardized multiorgan POCUS and CTA were performed. The discriminatory power of multiorgan POCUS combined with biochemical markers was tested using ROC curves, and multivariate analysis was performed. RESULTS A total of 88 patients were included, and 37 (42%) had PE. Multivariate analysis showed a relative risk (RR) of PE of 2.79 (95% CI, 1.61-4.84) for the presence of right ventricular (RV) dysfunction, of 2.54 (95% CI, 0.89-7.20) for D-dimer levels >1000 ng/mL, and of 1.69 (95% CI, 1.12-2.63) for the absence of an alternative diagnosis to PE on lung POCUS or chest radiograph. The combination with the highest diagnostic accuracy for PE included the following variables: 1- POCUS transthoracic echocardiography with evidence of RV dysfunction; 2- lung POCUS or chest radiograph without an alternative diagnosis to PE; and 3- plasma D-dimer levels >1000 ng/mL. Combining these three findings resulted in an area under the curve of 0.85 (95% CI, 0.77-0.94), with 50% sensitivity and 96% specificity. CONCLUSIONS Multiorgan POCUS combined with laboratory data has acceptable diagnostic accuracy for PE compared with CTA. The combined use of these methods might reduce CTA overuse in critically ill patients.
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Affiliation(s)
- Adriana M. Girardi
- Postgraduate Program in Pneumological Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- * E-mail:
| | - Eduardo E. Turra
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Melina Loreto
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Regis Albuquerque
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Tiago S. Garcia
- Radiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Tatiana H. Rech
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo B. Gazzana
- Postgraduate Program in Pneumological Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Pulmonary Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
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Abstract
IMPORTANCE Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US. OBSERVATIONS PE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age <50 years, heart rate <100/min, an oxygen saturation level of > 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, >40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%). CONCLUSIONS AND RELEVANCE In the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg.
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Affiliation(s)
- Yonathan Freund
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Fleur Cohen-Aubart
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Internal Medicine Department 2, French National Referral Center for Rare Systemic Diseases and Histiocytoses, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Ben Bloom
- Emergency Department, Barts Health NHS Trust, London, United Kingdom
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35
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Isbister GK, Noutsos T, Jenkins S, Isoardi KZ, Soderstrom J, Buckley NA. D‐dimer testing for early detection of venom‐induced consumption coagulopathy after snakebite in Australia (
ASP
‐29). Med J Aust 2022; 217:203-207. [PMID: 35670073 PMCID: PMC9541317 DOI: 10.5694/mja2.51589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/04/2022] [Accepted: 03/16/2022] [Indexed: 12/03/2022]
Abstract
Objective To assess the accuracy and marginal value of quantitative D‐dimer testing for diagnosing venom‐induced consumption coagulopathy (VICC) in people bitten by Australian snakes. Design, setting Analysis of data for suspected and confirmed cases of snakebite collected prospectively by the Australian Snakebite Project, 2005–2019, from 200 hospitals across Australia. Participants 1363 patients for whom D‐dimer was quantitatively assessed within 24 hours of suspected or confirmed snakebite. Main outcome measures Diagnostic performance of quantitative D‐dimer testing for detecting systemic envenoming with VICC (area under the receiver operating characteristic curve, AUC); optimal D‐dimer cut‐off value (maximum sum of sensitivity and specificity). Results D‐dimer values exceeded 2.5 mg/L within three hours of the bite for 95% of patients who developed VICC, and were lower than 2.5 mg/L for 95% of non‐envenomed patients up to six hours after snakebite. The AUC for diagnosing envenoming with VICC on the basis of quantitative D‐dimer testing within six hours of snakebite was 0.97 (95% CI, 0.96–0.98; 944 patients). Diagnostic performance increased during the first three hours after snakebite; for quantitative D‐dimer testing at 2–6 hours, the AUC was 0.99 (95% CI, 0.99–1.0); with a cut‐off of 2.5 mg/L, sensitivity was 97.1% (95% CI, 95.0–98.3%) and specificity 99.0% (95% CI, 97.6–99.6%) for VICC. For 36 patients with normal international normalised ratio (INR) and activated partial thromboplastin time (aPTT) values 2–6 hours after snakebite, the AUC was 0.97 (95% CI, 0.93–1.0); with a cut‐off of 1.4 mg/L, sensitivity was 94% (95% CI, 82–99%) and specificity 96% (95% CI, 94–97%). In all but one of 84 patients who developed VICC‐related acute kidney injury, D‐dimer values exceeded 4 mg/L within 24 hours of the bite. Conclusion D‐dimer concentrations assessed 2–6 hours after snakebite, with a cut‐off value of 2.5 mg/L, could be useful for diagnosing envenoming with VICC.
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Affiliation(s)
- Geoffrey K Isbister
- The University of Newcastle Newcastle NSW
- Calvary Mater Newcastle Newcastle NSW
| | | | | | - Katherine Z Isoardi
- Princess Alexandra Hospital Brisbane QLD
- Queensland Poisons Information Centre Queensland Children’s Hospital Brisbane QLD
| | - Jessamine Soderstrom
- Royal Perth Hospital Perth WA
- Western Australia Poisons Information Centre Sir Charles Gairdner Hospital Perth WA
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36
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Janigro D, Mondello S, Posti JP, Unden J. GFAP and S100B: What You Always Wanted to Know and Never Dared to Ask. Front Neurol 2022; 13:835597. [PMID: 35386417 PMCID: PMC8977512 DOI: 10.3389/fneur.2022.835597] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/03/2022] [Indexed: 12/19/2022] Open
Abstract
Traumatic brain injury (TBI) is a major global health issue, with outcomes spanning from intracranial bleeding, debilitating sequelae, and invalidity with consequences for individuals, families, and healthcare systems. Early diagnosis of TBI by testing peripheral fluids such as blood or saliva has been the focus of many research efforts, leading to FDA approval for a bench-top assay for blood GFAP and UCH-L1 and a plasma point-of-care test for GFAP. The biomarker S100B has been included in clinical guidelines for mTBI (mTBI) in Europe. Despite these successes, several unresolved issues have been recognized, including the robustness of prior data, the presence of biomarkers in tissues beyond the central nervous system, and the time course of biomarkers in peripheral body fluids. In this review article, we present some of these issues and provide a viewpoint derived from an analysis of existing literature. We focus on two astrocytic proteins, S100B and GFAP, the most commonly employed biomarkers used in mTBI. We also offer recommendations that may translate into a broader acceptance of these clinical tools.
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Affiliation(s)
- Damir Janigro
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, OH, United States.,FloTBI, Cleveland, OH, United States
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Jussi P Posti
- Department of Neurosurgery, Neurocenter, Turku Brain Injury Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Johan Unden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Lund University, Lund, Sweden
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Debnath J, Sharma V. Diagnosing pulmonary thromboembolism: Concerns and controversies. Med J Armed Forces India 2022; 78:17-23. [PMID: 35035039 PMCID: PMC8737094 DOI: 10.1016/j.mjafi.2021.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/24/2021] [Indexed: 01/03/2023] Open
Abstract
Pulmonary thromboembolism (PTE) is an important cause of mortality/morbidity even today despite advancement in clinical understanding as well as diagnostic facilities. Clinical diagnosis of PTE is often challenging because of nonspecific sign/symptoms. Adherence to clinical decision-making protocols and appropriate use of diagnostic modalities like computed tomography pulmonary angiography can resolve the diagnostic dilemma in most cases and help in the overall management of PTE. This article deals with various concerns as well as controversies surrounding accurate diagnosis of PTE as on date.
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Affiliation(s)
- Jyotindu Debnath
- Consultant, Professor & Head (Radiodiagnosis), Army Hospital (R&R), Delhi Cantt, India,Corresponding author.
| | - Vivek Sharma
- Professor (Radiodiagnosis), Bharati Vidyapeeth Medical College, Pune, India
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38
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Aubrey Hampton and Benjamin Castleman: Hampton's Hump. J Emerg Med 2021; 61:592-595. [PMID: 34503883 DOI: 10.1016/j.jemermed.2021.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 07/07/2021] [Accepted: 07/13/2021] [Indexed: 11/23/2022]
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39
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Roy PM, Douillet D, Penaloza A. Contemporary management of acute pulmonary embolism. Trends Cardiovasc Med 2021; 32:259-268. [PMID: 34214598 DOI: 10.1016/j.tcm.2021.06.002] [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: 04/01/2021] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 12/14/2022]
Abstract
This review examines the recent progress in the initial management of pulmonary embolism (PE). Diagnostic strategies allowing the safe decrease of imaging testing have been proposed. New modalities of catheter-based interventions have emerged for hemodynamically unstable PE patients. For normotensive PE patients, direct oral anticoagulant treatment has become the new norm and a large proportion of patients are eligible for home treatment.
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Affiliation(s)
- Pierre-Marie Roy
- Angers University Hospital, Emergency Department; UNIV Angers, Health Faculty, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CarMe; F-CRIN INNOVTE; Angers, France.
| | - Delphine Douillet
- Angers University Hospital, Emergency Department; UNIV Angers, Health Faculty, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CarMe; F-CRIN INNOVTE; Angers, France
| | - Andrea Penaloza
- Cliniques Universitaires Saint Luc, Emrgency Department; UCLouvain; F-CRIN INNOVTE; Brussels, Belgium.
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40
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Systematic review and meta-analysis of outcomes in patients with suspected pulmonary embolism. Blood Adv 2021; 5:2237-2244. [PMID: 33900385 DOI: 10.1182/bloodadvances.2020002398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 03/08/2021] [Indexed: 01/14/2023] Open
Abstract
Prompt evaluation and therapeutic intervention of suspected pulmonary embolism (PE) are of paramount importance for improvement in outcomes. We systematically reviewed outcomes in patients with suspected PE, including mortality, incidence of recurrent PE, major bleeding, intracranial hemorrhage, and postthrombotic sequelae. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. We included 22 studies with 15 865 patients. Among patients who were diagnosed with PE and discharged with anticoagulation, 3-month follow-up revealed that all-cause mortality was 5.69% (91/1599; 95% confidence interval [CI], 4.56-6.83), mortality from PE was 1.19% (19/1597; 95% CI, 0.66-1.72), recurrent venous thromboembolism (VTE) occurred in 1.38% (22/1597; 95% CI: 0.81-1.95), and major bleeding occurred in 0.90% (2/221%; 95% CI, 0-2.15). In patients with a low pretest probability (PTP) and negative D-dimer, 3-month follow-up revealed mortality from PE was 0% (0/808) and incidence of VTE was 0.37% (4/1094; 95% CI: 0.007-0.72). In patients with intermediate PTP and negative D-dimer, 3-month follow-up revealed that mortality from PE was 0% (0/2747) and incidence of VTE was 0.46% (14/3015; 95% CI: 0.22-0.71). In patients with high PTP and negative computed tomography (CT) scan, 3-month follow-up revealed mortality from PE was 0% (0/651) and incidence of VTE was 0.84% (11/1302; 95% CI: 0.35-1.34). We further summarize outcomes evaluated by various diagnostic tests and diagnostic pathways (ie, D-dimer followed by CT scan).
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41
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Bayes' rule in diagnosis. J Clin Epidemiol 2021; 131:158-160. [PMID: 33741123 DOI: 10.1016/j.jclinepi.2020.12.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/07/2020] [Accepted: 12/15/2020] [Indexed: 11/21/2022]
Abstract
Establishing an accurate diagnosis is crucial in everyday clinical practice. It forms the starting point for clinical decision-making, for instance regarding treatment options or further testing. In this context, clinicians have to deal with probabilities (instead of certainties) that are often hard to quantify. During the diagnostic process, clinicians move from the probability of disease before testing (prior or pretest probability) to the probability of disease after testing (posterior or posttest probability) based on the results of one or more diagnostic tests. This reasoning in probabilities is reflected by a statistical theorem that has an important application in diagnosis: Bayes' rule. A basic understanding of the use of Bayes' rule in diagnosis is pivotal for clinicians. This rule shows how both the prior probability (also called prevalence) and the measurement properties of diagnostic tests (sensitivity and specificity) are crucial determinants of the posterior probability of disease (predictive value), on the basis of which clinical decisions are made. This article provides a simple explanation of the interpretation and use of Bayes' rule in diagnosis.
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