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Glazier CR, Baciewicz FA. Epidemiology, Etiology, and Pathophysiology of Pulmonary Embolism. Int J Angiol 2024; 33:76-81. [PMID: 38846994 PMCID: PMC11152621 DOI: 10.1055/s-0044-1785487] [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
Over the last 20 years, there has been a progressive increase in the incidence of pulmonary embolism (PE) diagnosis in the United States, Europe, and Australia. Increased use of computed tomography pulmonary angiography has likely contributed in part to this rising incidence. However, it is pertinent to note that the burden of comorbidities associated with PE, such as malignancy, obesity, and advanced age, has also increased over the past 20 years. Time-trend analysis in North American, European, and Asian populations suggests that mortality rates associated with PE have been declining. The reported improved survival rates in PE over the past 20 years are likely, at least in part, to be the result of better adherence to guidelines, improved risk stratification, and enhanced treatment. Factors contributing to the development of venous thromboembolism (VTE) include stasis of blood, hypercoagulability, endothelial injury, and inflammation. In 70 to 80% of cases of PE, the thrombi embolizes from the proximal deep veins of the lower extremities and pelvis. Strong risk factors for VTE include lower extremity fractures and surgeries, major trauma, and hospitalization within the previous 3 months for acute myocardial infarction or heart failure with atrial fibrillation. Acute PE causes several pathophysiological responses including hypoxemia and right ventricle (RV) failure. The latter is a result of pulmonary artery occlusion and associated vasoconstriction. Hemodynamic compromise from RV failure is the principal cause of poor outcome in patients with acute PE.
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Affiliation(s)
| | - Frank A. Baciewicz
- Division of Cardiothoracic Surgery, Wayne State University School of Medicine, Detroit, Michigan
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Saini SK, Khan ZS, Do V, Keijzers G. Computed tomography pulmonary angiogram ordering, adherence to decision rules and yield in the emergency department: An observational study. Emerg Med Australas 2024. [PMID: 38698536 DOI: 10.1111/1742-6723.14428] [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: 01/19/2024] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE Pulmonary embolism (PE) frequently requires diagnosis through CT pulmonary angiogram (CTPA). Appropriate application of evidence-based clinical decision tools can reduce unnecessary CTPAs. This study assessed adherence to and the efficacy of various aspects of the Queensland Health suspected PE diagnostic pathway, including Wells score, PE rule out criteria (PERC) and age-adjusted D-dimer interpretation. METHODS Retrospective study of CTPAs ordered from 1 January to 30 April 2023 in a tertiary and urban ED in Southeast Queensland. Data on clinical variables, D-dimer and CTPA results were collected through medical record and radiology database review. Descriptive analyses were used to determine adherence to Queensland guidelines and performance of D-dimer interpretation tools (including comparison of age-adjusted PE with a new pre-test probability [PTP]-based model using D-dimer cut-off <1000 ng/mL for Wells score ≤4 and 500 ng/mL for Wells score 4.5-6). RESULTS A total of 573 CTPAs were available for analysis with a 12.4% (95% confidence interval 10.0-15.4) diagnostic yield. Stratification by Wells score showed yields of 4.0%, 18.5% and 41% for low-, moderate- and high-risk patients, respectively. Twenty-five patients with low-PTP who received CTPA could have been excluded with the PERC rule. Age-adjusted D-dimer interpretation may have prevented 26 CTPAs with no false negatives, whereas PTP approach may have prevented 128 CTPAs with four false negatives. CONCLUSION Guideline adherence can be improved, and adherence to existing clinical decision tools may reduce unnecessary CTPA ordering and increase diagnostic yield. The use of the age-adjusted D-dimer had good sensitivity, whereas the new PTP approach will require further prospective research.
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Affiliation(s)
- Saransh Kumar Saini
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Zain Saleem Khan
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Victor Do
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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3
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Okoli ML, Rao P, Kavuma S, Bulusu RV, Hanna-Moussa S, Vahdat K. POCUS for Thrombus: Emphasizing the Importance of Initial Point-of-Care Ultrasound in the Management of Pulmonary Thromboembolism. Cureus 2024; 16:e58272. [PMID: 38752077 PMCID: PMC11094530 DOI: 10.7759/cureus.58272] [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: 04/02/2024] [Indexed: 05/18/2024] Open
Abstract
Pulmonary embolism (PE) constitutes a substantial health burden among individuals in the United States. It ranks as the third most common cause of cardiovascular death aside from stroke and myocardial infarction. Diagnostic errors are common with PE as patients can present with non-specific symptoms or could be completely asymptomatic with PE being an incidental finding. Diagnostic errors can result in missed or late diagnosis of PE, which, in turn, increases health care costs, morbidity, and mortality rates. Hence, early diagnosis is crucial. Computed tomography pulmonary angiography (CTPA) remains the gold standard in PE diagnosis, despite exposure to high doses of radiation. Point-of-care ultrasound (POCUS) is an underutilized, non-invasive technique that aids in the early diagnosis of PE and can safely reduce the radiation from CTPA in cases where contraindication exists. POCUS has been shown to have a high sensitivity and specificity for early diagnosis of PE.
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Affiliation(s)
| | - Poonam Rao
- Internal Medicine, CHRISTUS Health/Texas A&M College of Medicine, Longview, USA
| | - Siima Kavuma
- Internal Medicine, CHRISTUS Health/Texas A&M College of Medicine, Longview, USA
| | - Ravi Vijay Bulusu
- Internal Medicine, CHRISTUS Health/Texas A&M College of Medicine, Longview, USA
| | | | - Khashayar Vahdat
- Cardiology, CHRISTUS Health/Texas A&M College of Medicine, Longview, USA
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Gianni F, Bonzi M, Jachetti A, Solbiati M, Dreon G, Colombo G, Colombo G, Russo A, Furlan L, Casazza G, Costantino G. How to recognize pulmonary embolism in syncope patients: A simple rule. Eur J Intern Med 2024; 121:121-126. [PMID: 37945410 DOI: 10.1016/j.ejim.2023.10.036] [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: 08/04/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Syncope can be the presenting symptom of Pulmonary Embolism (PE). It is not known wether using a standardized algorithm to rule-out PE in all patients with syncope admitted to the Emergency Departments (ED) is of value or can lead to overdiagnosis and overtreatment. METHODS We tested if simple anamnestic and clinical parameters could be used as a rule to identify patients with syncope and PE in a multicenter observational study. The rule's sensitivity was tested on a cohort of patients that presented to the ED for syncopal episodes caused by PE. The clinical impact of the rule was assessed on a population of consecutive patients admitted for syncope in the ED. RESULTS Patients were considered rule-positive in the presence of any of the following: hypotension, tachycardia, peripheral oxygen saturation ≤ 93 % (SpO2), chest pain, dyspnea, recent history of prolonged bed rest, clinical signs of deep vein thrombosis, history of previous venous thrombo-embolism and active neoplastic disease. The sensitivity of the rule was 90.3 % (95 % CI: 74.3 % to 98.0 %). The application of the rule to a population of 217 patients with syncope would have led to a 70 % reduction in the number of subjects needing additional diagnostic tests to exclude PE. CONCLUSIONS Most patients with syncope due to PE present with anamnestic and clinical features indicative of PE diagnosis. A clinical decision rule can be used to identify patients who would benefit from further diagnostic tests to exclude PE, while reducing unnecessary exams that could lead to over-testing and over-diagnosis.
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Affiliation(s)
- Francesca Gianni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy; Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Mattia Bonzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy
| | - Alessandro Jachetti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy
| | - Monica Solbiati
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy; Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Giulia Dreon
- Scuola di Specializzazione in Medicina di Emergenza-Urgenza, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy
| | - Giulia Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy
| | - Antonio Russo
- Epidemiology Unit, Agency for Health Protection of Milan, Italy
| | - Ludovico Furlan
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy; Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Costantino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy; Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy.
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Madsen SF, Christensen DM, Strange JE, Nouhravesh N, Kümler T, Gislason G, Lamberts M, Sindet‐Pedersen C. Short- and Long-Term Mortality for Patients With and Without a Cancer Diagnosis Following Pulmonary Embolism in Denmark, 2000 to 2020: A Nationwide Study. J Am Heart Assoc 2023; 12:e030191. [PMID: 38014671 PMCID: PMC10727333 DOI: 10.1161/jaha.123.030191] [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: 07/23/2023] [Accepted: 10/19/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND New treatment regimens have been introduced in the past 20 years, which may influence the short- and long-term prognosis for patients with and without a cancer diagnosis following pulmonary embolism. However, newer studies investigating these trends are lacking. Therefore, we aimed to investigate the 30- and 31- to 365-day mortality following pulmonary embolism. METHODS AND RESULTS Using the Danish nationwide registries, patients with a diagnosis of pulmonary embolism between 2000 and 2020 were included. Age- and sex-standardized 30- and 31- to 365-day mortality was calculated and stratified by cancer status. In total, 60 614 patients (29.6% with recent cancer; mean age, 68.2 years) were included. The 30-day mortality for patients with no recent cancer decreased from 19.1% (95% CI, 17.9%-20.4%) in 2000 to 7.3% (95% CI, 6.7%-8.0%) in 2018 to 2020 (hazard ratio [HR], 0.36 [95% CI, 0.32-0.40]; P<0.001). The 30-day mortality for patients with recent cancer decreased from 32.2% (95% CI, 28.8%-36.6%) to 14.1% (95% CI, 12.7%-15.5%) (HR, 0.38 [95% CI, 0.33-0.44]; P<0.001). The 31- to 365-day mortality for patients with no recent cancer decreased from 12.5% (95% CI, 11.4%-13.6%) to 9.4% (95% CI, 8.6%-10.2%) (HR, 0.73 [95% CI, 0.64-0.83]; P<0.001).The 31- to 365-day mortality for patients with recent cancer remained stable: 39.4% (95% CI, 35.1%-43.7%) to 38.3% (95% CI, 35.9%-40.6%) (HR, 0.97 [95% CI, 0.84-1.12]; P=0.69). CONCLUSIONS From 2000 to 2020, improvements were observed in 30-day mortality following pulmonary embolism regardless of cancer status. For patients with recent cancer, 31- to 365-day mortality did not improve, whereas a minor improvement was observed for patients without recent cancer.
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Affiliation(s)
- Sophie Fredslund Madsen
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
| | | | - Jarl Emanuel Strange
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Nina Nouhravesh
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Thomas Kümler
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
- Danish Heart FoundationCopenhagenDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Morten Lamberts
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Caroline Sindet‐Pedersen
- Danish Heart FoundationCopenhagenDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
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Roy PM, Moumneh T, Bizouard T, Duval D, Douillet D. How to Combat Over-Testing for Patients Suspected of Pulmonary Embolism: A Narrative Review. Diagnostics (Basel) 2023; 13:1326. [PMID: 37046544 PMCID: PMC10093278 DOI: 10.3390/diagnostics13071326] [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: 02/28/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
The diagnosis of PE remains difficult in 2023 because the signs and symptoms are not sensible nor specific. The consequences of potential diagnostic errors can be dramatic, whether by default or by excess. Furthermore, the achievement of a simple diagnostic strategy, based on clinical probability assessment, D-dimer measurement and computed tomography pulmonary angiography (CTPA) leads to a new challenge for PE diagnosis: over-testing. Indeed, since the 2000s, the wide availability of CTPA resulted in a major increase in investigations with a mod I confirm erate increase in PE diagnosis, without any notable improvement in patient outcomes. Quite the contrary, the complications of anticoagulation for PE increased significantly, and the long-term consequences of imaging diagnostic radiation is an important concern, especially the risk of breast cancer for young women. As a result, several strategies have been proposed to fight over-testing. They are mostly based on defining a subgroup of patients for whom no specific exam should be required to rule-out PE and adjusting the D-dimer cutoff to allow the exclusion of PE without performing CTPA. This narrative review presents the advantages and limitations of these different strategies as well as the perspective in PE diagnosis.
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Affiliation(s)
- Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
- UMR MitoVasc CNRS 6215 INSERM 1083, University Angers, 49100 Angers, France
- FCRIN, INNOVTE, 42023 Saint-Étienne, France
| | - Thomas Moumneh
- Department of Emergency Medicine, University Hospital of Tours, Avenue of the Republic, 37044 Tours, France
| | - Thomas Bizouard
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
| | - Damien Duval
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
- UMR MitoVasc CNRS 6215 INSERM 1083, University Angers, 49100 Angers, France
- FCRIN, INNOVTE, 42023 Saint-Étienne, France
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Freund Y, Roussel M, Bloom B. YEARS and Adjust-Unlikely Diagnostic Strategies. Ann Emerg Med 2023; 81:516. [PMID: 36948691 DOI: 10.1016/j.annemergmed.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 03/24/2023]
Affiliation(s)
- Yonathan Freund
- Emergency department, Hopital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Mélanie Roussel
- Emergency department, Centre Hospitalier Universitaire de Rouen, Université de Normandie UNIROUEN, Rouen, France
| | - Ben Bloom
- Emergency department, Royal London Hospital, Barts Health NHS trust, London, United Kingdom
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Topff L, Ranschaert ER, Bartels-Rutten A, Negoita A, Menezes R, Beets-Tan RGH, Visser JJ. Artificial Intelligence Tool for Detection and Worklist Prioritization Reduces Time to Diagnosis of Incidental Pulmonary Embolism at CT. Radiol Cardiothorac Imaging 2023; 5:e220163. [PMID: 37124638 PMCID: PMC10141443 DOI: 10.1148/ryct.220163] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 05/02/2023]
Abstract
Purpose To evaluate the diagnostic efficacy of artificial intelligence (AI) software in detecting incidental pulmonary embolism (IPE) at CT and shorten the time to diagnosis with use of radiologist reading worklist prioritization. Materials and Methods In this study with historical controls and prospective evaluation, regulatory-cleared AI software was evaluated to prioritize IPE on routine chest CT scans with intravenous contrast agent in adult oncology patients. Diagnostic accuracy metrics were calculated, and temporal end points, including detection and notification times (DNTs), were assessed during three time periods (April 2019 to September 2020): routine workflow without AI, human triage without AI, and worklist prioritization with AI. Results In total, 11 736 CT scans in 6447 oncology patients (mean age, 63 years ± 12 [SD]; 3367 men) were included. Prevalence of IPE was 1.3% (51 of 3837 scans), 1.4% (54 of 3920 scans), and 1.0% (38 of 3979 scans) for the respective time periods. The AI software detected 131 true-positive, 12 false-negative, 31 false-positive, and 11 559 true-negative results, achieving 91.6% sensitivity, 99.7% specificity, 99.9% negative predictive value, and 80.9% positive predictive value. During prospective evaluation, AI-based worklist prioritization reduced the median DNT for IPE-positive examinations to 87 minutes (vs routine workflow of 7714 minutes and human triage of 4973 minutes). Radiologists' missed rate of IPE was significantly reduced from 44.8% (47 of 105 scans) without AI to 2.6% (one of 38 scans) when assisted by the AI tool (P < .001). Conclusion AI-assisted workflow prioritization of IPE on routine CT scans in oncology patients showed high diagnostic accuracy and significantly shortened the time to diagnosis in a setting with a backlog of examinations.Keywords: CT, Computer Applications, Detection, Diagnosis, Embolism, Thorax, ThrombosisSupplemental material is available for this article.© RSNA, 2023See also the commentary by Elicker in this issue.
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Banks C, Gangathimmaiah V, Emeto TI, Jones L, Furyk J. Raising the D-dimer threshold for ruling out pulmonary embolism: A single-site, observational study with a historical comparison. Emerg Med Australas 2023; 35:200-204. [PMID: 36117393 DOI: 10.1111/1742-6723.14089] [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: 07/19/2022] [Revised: 08/22/2022] [Accepted: 08/28/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study was to assess the impact of introduction of a new pulmonary embolism (PE) diagnostic guideline with a raised D-dimer threshold. METHODS This is a single-site, observational, cohort study with a historical comparison. The new guideline raised the D-dimer threshold to 1000 ng/mL for most patients with a Wells' score of 4 or less. Patients investigated for PE with a D-dimer level and/or definitive imaging in 6-month periods before and after the introduction of the guideline were eligible. Patients with D-dimers of 500-1000 ng/mL were prospectively followed up at 3 months for missed PE. RESULTS During the pre-intervention period, 688 patients were investigated for PE, 366 (53.2%) received definitive imaging and 39 PE were diagnosed (5.7% overall, 10.7% of those imaged). For the 121 patients with D-dimers ≥500 and <1000 ng/mL, 87 (71.9%) were imaged with 7 (5.8%) having a PE diagnosed. Post intervention there were 930 patients, of which 426 (45.8%) received definitive chest imaging and there were 50 patients with PE diagnosed (5.4% overall, 11.7% of those imaged). For the 185 patients with D-dimers ≥500 and <1000 ng/mL, 60 (32.4%) were imaged with 5 (2.7%) having PE diagnosed. No cases of missed PE were identified at 3 months. CONCLUSION The introduction of the new guideline was associated with a reduction in overall imaging rates without evidence of missed PE. Further evaluation in other settings is recommended.
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Affiliation(s)
- Colin Banks
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Theophilus I Emeto
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
- World Health Organization Collaborating Centre for Vector-borne and Neglected Tropical Diseases, James Cook University, Townsville, Queensland, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Leonie Jones
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Jeremy Furyk
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Emergency Department, University Hospital Geelong, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
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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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Le Roux PY, Schafer WM, Blanc-Beguin F, Tulchinsky M. Ventilation Scintigraphy With Radiolabeled Carbon Nanoparticulate Aerosol (Technegas): State-of-the-Art Review and Diagnostic Applications to Pulmonary Embolism During COVID-19 Pandemic. Clin Nucl Med 2023; 48:8-17. [PMID: 36288606 PMCID: PMC9762616 DOI: 10.1097/rlu.0000000000004426] [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: 06/06/2022] [Revised: 07/01/2022] [Indexed: 12/14/2022]
Abstract
ABSTRACT Invented and first approved for clinical use in Australia 36 years ago, Technegas is the technology that enabled ventilation scintigraphy with 99m Tc-labeled carbon nanoparticles ( 99m Tc-CNP). The US Food and Drug Administration (FDA) has considered this technology for more than 30 years but only now is getting close to approving it. Meanwhile, more than 4.4 million patients benefited from this technology in 64 countries worldwide. The primary application of 99m Tc-CNP ventilation imaging is the diagnostic evaluation for suspicion of pulmonary embolism using ventilation-perfusion quotient (V/Q) imaging. Because of 99m Tc-CNP's long pulmonary residence, tomographic imaging emerged as the preferred V/Q methodology. The FDA-approved ventilation imaging agents are primarily suitable for planar imaging, which is less sensitive. After the FDA approval of Technegas, the US practice will likely shift to tomographic V/Q. The 99m Tc-CNP use is of particular interest in the COVID-19 pandemic because it offers an option of a dry radioaerosol that takes approximately only 3 to 5 tidal breaths, allowing the shortest exposure to and contact with possibly infected patients. Indeed, countries where 99m Tc-CNP was approved for clinical use continued using it throughout the COVID-19 pandemic without known negative viral transmission consequences. Conversely, the ventilation imaging was halted in most US facilities from the beginning of the pandemic. This review is intended to familiarize the US clinical nuclear medicine community with the basic science of 99m Tc-CNP ventilation imaging and its clinical applications, including common artifacts and interpretation criteria for tomographic V/Q imaging for pulmonary embolism.
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Affiliation(s)
- Pierre-Yves Le Roux
- From the INSERM (National Institute of Health and Medical Research) and Department of Nuclear Medicine, University Hospital of Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Wolfgang M. Schafer
- Nuclear Medicine Clinic, Maria Hilf Hospital Inc, Academic Teaching Hospital of RWTH Aachen University, Moenchengladbach, Germany
| | - Frédérique Blanc-Beguin
- From the INSERM (National Institute of Health and Medical Research) and Department of Nuclear Medicine, University Hospital of Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Mark Tulchinsky
- Section of Nuclear Medicine, Department of Radiology, Penn State University Hospital, Hershey, PA
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Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13010141. [PMID: 36611433 PMCID: PMC9818351 DOI: 10.3390/diagnostics13010141] [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: 12/11/2022] [Revised: 12/29/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure.
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13
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Roy PM, Moumneh T, Penaloza A, Schmidt J, Charpentier S, Joly LM, Riou J, Douillet D. Diagnostic Strategy for Suspected Pulmonary Embolism in Emergency Departments Based on the 4-Level Pulmonary Embolism Clinical Probability Score: Study Protocol of SPEED&PEPS Trial. Diagnostics (Basel) 2022; 12:3101. [PMID: 36553108 PMCID: PMC9777430 DOI: 10.3390/diagnostics12123101] [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: 10/29/2022] [Revised: 11/17/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction: Several strategies have been devised to safely limit the use of thoracic imaging in patients suspected of pulmonary embolism (PE). However, they are based on different rules for clinical probability (CP) assessment, rendering their combination difficult. The four-level pulmonary embolism probability score (4PEPS) allows the combination of all other strategies using a single CP assessment. Methods and analysis: Pragmatic cluster-randomized trial in 20 EDs. Patients with suspected PE will be included and followed for 90 days (number of patients to be included: 2560, 1280 in each arm). Ten centers will be allocated to the control group where physicians will be free to do as they see fit but they will be given the recommendation to apply a validated strategy. Ten centers will be allocated to the interventional group where the physicians will be given the recommendation to apply the 4PEPS strategy. The primary objective will be to demonstrate that the application of the 4PEPS strategy by the emergency physicians, in comparison to current practices, (i) does not increase the risk of serious events related to diagnostic strategies and (ii) significantly reduces the use of thoracic imaging. Ethics and dissemination: The study will be submitted for approval to an institutional ethics review board for all participating centers. If successful, the SPEED&PEPS trial will have an important impact for patients suspected of PE limiting their irradiation and for public health in substantial savings in terms of the direct cost of diagnostic investigations and the indirect cost of hospitalizations due to waiting times or delayed harmful effects. Funding: This work is funded by a French Public Health grant (PREPS-N 2019). The funding source plays no role in the study design, data collection, analysis, interpretation or the writing of the manuscript. Trial registration: ongoing. Trial status: not started.
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Affiliation(s)
- Pierre-Marie Roy
- Angers University Hospital, Emergency Department, Univ Angers, MitoVasc UMR CNRS 6015—INSERM 1083, FCRIN, INNOVTE, 49000 Angers, France
| | - Thomas Moumneh
- Angers University Hospital, Emergency Department, Univ Angers, MitoVasc UMR CNRS 6015—INSERM 1083, FCRIN, INNOVTE, 49000 Angers, France
| | - Andrea Penaloza
- Cliniques Universitaires St-Luc, Emergency Department, Université Catholique de Louvain, 1200 Bruxelles, Belgium
| | - Jeannot Schmidt
- Clermont-Ferrand University Hospital—Gabriel Montpied, Emergency Department, FCRIN, INNOVTE, 63000 Clermont-Ferrand, France
| | | | - Luc-Marie Joly
- Rouen University Hospital, Emergency Department, 76031 Rouen, France
| | - Jérémie Riou
- Angers University Hospital, Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Univ Angers, MINT UMR INSERM 1066—CNRS 6021, 49000 Angers, France
| | - Delphine Douillet
- Angers University Hospital, Emergency Department, Univ Angers, MitoVasc UMR CNRS 6015—INSERM 1083, FCRIN, INNOVTE, 49000 Angers, France
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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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15
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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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16
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Farag A, Fielding J, Catanzano T. Role of Dual-energy Computed Tomography in Diagnosis of Acute Pulmonary Emboli, a Review. Semin Ultrasound CT MR 2022; 43:333-343. [PMID: 35738818 DOI: 10.1053/j.sult.2022.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Prompt diagnosis of pulmonary embolism is essential to avert morbidity and mortality. There are a number of diagnostic options for identification of a pulmonary embolism, including laboratory and imaging investigations. While computed tomography pulmonary angiography (CTPA) has largely supplanted nuclear medicine ventilation/perfusion studies, there remain significant limitations in the optimal performance of CTPA. Dual-energy computed tomography has the ability to overcome many of the limitations of standard of care CTPA, including rescue of poor contrast boluses and the ability to evaluate pulmonary perfusion defects.
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Affiliation(s)
- Ahmed Farag
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA
| | - Jordan Fielding
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA
| | - Tara Catanzano
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA.
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17
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Thurlow LE, Van Dam PJ, Prior SJ, Tran V. Use of Computed Tomography Pulmonary Angiography in Emergency Departments: A Literature Review. Healthcare (Basel) 2022; 10:healthcare10050753. [PMID: 35627890 PMCID: PMC9140691 DOI: 10.3390/healthcare10050753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/12/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023] Open
Abstract
Computed tomography pulmonary angiography (CTPA) has become the most widely used technique for diagnosis or exclusion of a pulmonary embolism (PE). It has been suggested that overuse of this imaging type may be prevalent, especially in emergency departments (EDs). The purpose of this literature review was to explore the use of CTPAs in EDs worldwide. A review following PRISMA guidelines was completed, with research published between September 2010 and August 2020 included. Five key topics emerged: use of CTPAs; explanations for overuse; use of D-dimer; variability in ordering practices between clinicians; and strategies to reduce overuse. This review found that CTPAs continue to be overused in EDs, leading to superfluous risks to patients. Published studies identify that while clinical practice guidelines (CPGs) have a strong effect on reducing unnecessary CTPAs with no significantly increased risk of missed diagnosis, the adoption of these tools by ED clinicians has remained low. This literature review highlights the need for further research into why CTPAs continue to be overused within EDs and why clinicians are hesitant to use CPGs in the clinical setting. Moreover, investigations into other potential strategies that may combat the overuse of this diagnostic tool are essential to reduce potential harm.
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Affiliation(s)
- Lauren E. Thurlow
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia;
- Correspondence:
| | - Pieter J. Van Dam
- School of Nursing, College of Health and Medicine, University of Tasmania, Burnie, TAS 7320, Australia;
| | - Sarah J. Prior
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Burnie, TAS 7320, Australia;
| | - Viet Tran
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia;
- Emergency Department, Royal Hobart Hospital, Hobart, TAS 7000, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia
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18
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Castañer E, Gonzalez A, Andreu M, Lozano C, Gallardo X. Influence of using recommended radiological criteria on MDCT-angiography diagnosis of single isolated subsegmental pulmonary embolism. Eur Radiol 2022; 32:4284-4291. [PMID: 35032211 DOI: 10.1007/s00330-021-08480-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/18/2021] [Accepted: 11/23/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the rate of false-positive diagnoses of MDCT-pulmonary angiography (MDCT-A) in patients with single isolated subsegmental pulmonary embolism (SISSPE). METHODS All patients who underwent MDCT-A between 2006 and 2017 for ruling out acute pulmonary embolism (PE) and received an initial diagnosis of SISSPE were included. The MDCT-A of these patients were reviewed retrospectively by four experienced thoracic radiologists, who applied radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines (ACCP 2016) for the diagnosis of SISSPE. Data extracted from medical records were history of venous thromboembolism (VTE), alternative diagnoses, other diagnostic studies for VTE, anticoagulation, bleeding complications, and VTE over the following 3 months. RESULTS Of 3839 patients undergoing MDCT-A, PE was found in 1021 (26.6%) and SISSPE in 59 (1.5% overall and 5.8% of all patients with PE). An alternative diagnosis to PE was made on the basis of CT in 33 (55.9%) patients. Forty-one (69.5%) patients received anticoagulants, and major life-threatening bleeding complications occurred in 2, with one death. Recurrent PE was not documented in any patient with SISSPE. In the retrospective assessment of the 59 cases of SISSPE, 21 were negative for PE, with a false-positive rate of 35.6% (21/59); so the percentage of SISSPE cases after the revision was 3.7% of all patients with PE; 11 of these 21 patients received anticoagulation. CONCLUSIONS Radiologists should be aware of the high rate of false-positives when making the diagnosis of SISSPE on MDCT-A without using strict diagnostic criteria. Misdiagnosis exposes patients to unnecessary anticoagulation. KEY POINTS • Radiologist should be aware of the high rate of false-positive diagnoses of single isolated subsegmental pulmonary embolism (SISSPE) in MDCT-pulmonary angiography (MDCT-A) performed for ruling out pulmonary embolism. • Misdiagnosis of SISSPE in MDCT-A can be reduced by using strict diagnostic radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines. • Unnecessary anticoagulation therapy with potential severe bleeding complications may result from misdiagnosis of SISSPE.
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Affiliation(s)
- Eva Castañer
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain.
| | - Amàlia Gonzalez
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Marta Andreu
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Carme Lozano
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Xavier Gallardo
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
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19
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The Effect of Limiting the Scan Range of Computed Tomography Pulmonary Angiography (to Reduce Radiation Exposure) on the Detection of Pulmonary Embolism: A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11122179. [PMID: 34943416 PMCID: PMC8700432 DOI: 10.3390/diagnostics11122179] [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] [Received: 10/25/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Computed tomography pulmonary angiography (CTPA) is the standard imaging test for the evaluation of acute pulmonary embolism (PE), but it is associated with patients' exposure to radiation. Studies have suggested that radiation exposure can be reduced without compromising PE detection by limiting the scan range (the z-axis, going from up to down); (2) Methods: A literature search was conducted in MEDLINE and EMBASE on 17 July 2021. Studies were included if they enrolled patients who had undergone a CTPA and described the yield of PE diagnoses, number of missed filling defects and/or other diagnoses using a reduced z-axis in comparison to a full-length scan. To assess risk of bias, we modified an existing risk of bias tools for observational studies, the Newcastle-Ottawa Scale. Results were synthesized in a narrative review. Primary outcomes were the number of missed PE diagnoses (based on at least one filling defect) and filling defects; the secondary outcome was the number of other missed findings; (3) Results: Eleven cohort studies and one case-control study were included reporting on a total of 3955 scans including 1025 scans with a diagnosis of PE. Six different reduced scan ranges were assessed; the most studied was from the top of the aortic arch to below the heart, in which no PEs were missed (seven studies). One sub-segmental PE was missed when the scan coverage was 10 cm starting from the bottom of the aortic arch and 14.7 cm starting from the top of the arch. Five studies that reported on other findings all found that other diagnoses were missed with a reduced z-axis. Most of the included studies had a high risk of bias; (4) Conclusions: CTPA scan coverage reduction from the top of aortic arch to below the heart reduced radiation exposure without affecting PE diagnoses, but studies were generally at high risk of bias.
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20
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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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21
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Roy PM, Friou E, Germeau B, Douillet D, Kline JA, Righini M, Le Gal G, Moumneh T, Penaloza A. Derivation and Validation of a 4-Level Clinical Pretest Probability Score for Suspected Pulmonary Embolism to Safely Decrease Imaging Testing. JAMA Cardiol 2021; 6:669-677. [PMID: 33656522 PMCID: PMC7931139 DOI: 10.1001/jamacardio.2021.0064] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance In patients with suspected pulmonary embolism (PE), overuse of diagnostic imaging is an important point of concern. Objective To derive and validate a 4-level pretest probability rule (4-Level Pulmonary Embolism Clinical Probability Score [4PEPS]) that makes it possible to rule out PE solely on clinical criteria and optimized D-dimer measurement to safely decrease imaging testing for suspected PE. Design, Setting, and Participants This study included consecutive outpatients suspected of having PE from US and European emergency departments. Individual data from 3 merged management studies (n = 11 114; overall prevalence of PE, 11%) were used for the derivation cohort and internal validation cohort. The external validation cohorts were taken from 2 independent studies, the first with a high PE prevalence (n = 1548; prevalence, 21.5%) and the second with a moderate PE prevalence (n = 1669; prevalence, 11.7%). A prior definition of pretest probability target values to achieve a posttest probability less than 2% was used on the basis of the negative likelihood ratios of D-dimer. Data were collected from January 2003 to April 2016, and data were analyzed from June 2018 to August 2019. Main Outcomes and Measures The rate of PE diagnosed during the initial workup or during follow-up and the rate of imaging testing. Results Of the 5588 patients in the derivation cohort, 3441 (61.8%) were female, and the mean (SD) age was 52 (18.5) years. The 4PEPS comprises 13 clinical variables scored from -2 to 5. It results in the following strategy: (1) very low probability of PE if 4PEPS is less than 0: PE ruled out without testing; (2) low probability of PE if 4PEPS is 0 to 5: PE ruled out if D-dimer level is less than 1.0 μg/mL; (3) moderate probability of PE if 4PEPS is 6 to 12: PE ruled out if D-dimer level is less than the age-adjusted cutoff value; (4) high probability of PE if 4PEPS is greater than 12: PE ruled out by imaging without preceding D-dimer test. In the first and the second external validation cohorts, the area under the receiver operator characteristic curves were 0.79 (95% CI, 0.76 to 0.82) and 0.78 (95% CI, 0.74 to 0.81), respectively. The false-negative testing rates if the 4PEPS strategy had been applied were 0.71% (95% CI, 0.37 to 1.23) and 0.89% (95% CI, 0.53 to 1.49), respectively. The absolute reductions in imaging testing were -22% (95% CI, -26 to -19) and -19% (95% CI, -22 to -16) in the first and second external validation cohorts, respectively. The 4PEPS strategy compared favorably with all recent strategies in terms of imaging testing. Conclusions and Relevance The 4PEPS strategy may lead to a substantial and safe reduction in imaging testing for patients with suspected PE. It should now be tested in a formal outcome study.
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Affiliation(s)
- Pierre-Marie Roy
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Emilie Friou
- Emergency Department, CHU Angers, Angers, France
| | - Boris Germeau
- Emergency Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Delphine Douillet
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Jeffrey Allen Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Internal Medicine, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Grégoire Le Gal
- Ottawa Hospital Research Institute, The Ottawa Hospital, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas Moumneh
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, F-CRIN INNOVTE, Brussels, Belgium
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22
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Douillet D, Roy PM, Penaloza A. Suspected Acute Pulmonary Embolism: Gestalt, Scoring Systems, and Artificial Intelligence. Semin Respir Crit Care Med 2021; 42:176-182. [PMID: 33592653 DOI: 10.1055/s-0041-1723936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pulmonary embolism (PE) remains a diagnostic challenge in 2021. As the pathology is potentially fatal and signs and symptoms are nonspecific, further investigations are classically required. Based on the Bayesian approach, clinical probability became the keystone of the diagnostic strategy to rule out PE in the case of a negative testing. Several clinical probability assessment methods are validated: gestalt, the Wells score, or the revised Geneva score. While the debate persists as to the best way to assess clinical probability, its assessment allows for the good interpretation of the investigation results and therefore directs the correct diagnostic strategy. The wide availability of computed tomography pulmonary angiography (CTPA) resulted in a major increase in investigations with a moderate increase in diagnosis, without any notable improvement in patient outcomes. This leads to a new challenge for PE diagnosis which is the limitation of the number of testing for suspected PE. We review different strategies recently developed to achieve this goal. The last challenge concerns the implementation in clinical practice. Two approaches are developed: simplification of the strategies versus the use of digital support tools allowing more sophisticated strategies. Artificial intelligence with machine-learning algorithms will probably be a future tool to guide the physician in this complex approach concerning acute PE suspicion.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, UCLouvain, F-CRIN INNOVTE, Brussels, Belgium
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23
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Jarman AF, Mumma BE, Singh KS, Nowadly CD, Maughan BC. Crucial considerations: Sex differences in the epidemiology, diagnosis, treatment, and outcomes of acute pulmonary embolism in non-pregnant adult patients. J Am Coll Emerg Physicians Open 2021; 2:e12378. [PMID: 33532761 PMCID: PMC7839235 DOI: 10.1002/emp2.12378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
Acute pulmonary embolism (PE) affects over 600,000 Americans per year and is a common diagnostic consideration among emergency department patients. Although there are well-documented differences in the diagnosis, treatment, and outcomes of cardiovascular conditions, such as ischemic heart disease and stroke, the influence of sex and gender on PE remains poorly understood. The overall age-adjusted incidence of PE is similar in women and men, but women have higher relative rates of PE during early and mid-adulthood (ages 20-40 years); whereas, men have higher rates of PE after age 60 years. Women are tested for PE at far higher rates than men, yet women who undergo computed tomography pulmonary angiography are ultimately diagnosed with PE 35%-55% less often than men. Among those diagnosed with PE, women are more likely to have severe clinical features, such as hypotension and signs of right ventricular dysfunction. When controlled for PE severity, women are less likely to receive reperfusion therapies, such as thrombolysis. Finally, women have more bleeding complications for all types of anticoagulation. Further investigation of possible sex-specific diagnostic and treatment algorithms is necessary in order to more accurately detect and treat acute PE in non-pregnant adults.
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Affiliation(s)
- Angela F. Jarman
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Bryn E. Mumma
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Kajol S. Singh
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Craig D. Nowadly
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Brandon C. Maughan
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOregonUSA
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24
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Hansrivijit P, Trongtorsak A, Gadhiya KP, Lnu K, Dimech CT, Thongprayoon C, Cheungpasitporn W, Lecker SH. Incidence and risk factors of venous thromboembolism in ANCA-associated vasculitis: a metaanalysis and metaregression. Clin Rheumatol 2021; 40:2843-2853. [PMID: 33452661 DOI: 10.1007/s10067-021-05589-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 12/17/2022]
Abstract
The incidence of venous thromboembolism (VTE) in ANCA-associated vasculitis patients varies in different populations. Moreover, the risk factors for VTE in these patients are poorly described due to the small number of events. Ovid MEDLINE, EMBASE, and the Cochrane Library were searched for eligible articles. The inclusion criteria included observational studies that enrolled patients age ≥ 18 years diagnosed with ANCA-associated vasculitis. The incidence of VTE is the outcome of interest. Of 1362 citations, a total of 21 studies (n = 4422) dated from 2006 to 2019 were included in the systematic review. The mean age was 54.2 ± 4.0 years. Most were male (52.0%) and Caucasian (80.9%). With a mean follow-up duration of 5.2 ± 2.8 years, the pooled incidence of VTE in ANCA-associated vasculitis patients was 12.4% (95% CI, 8.8-17.2). Of these, 63.4% (95% CI, 57.3-69.1) had deep vein thrombosis and 26.3% (95% CI, 17.6-37.4) had pulmonary embolism. Recurrent VTE occurred in 10.0% (95% CI, 5.2-18.6). From the metaregression adjusted for age, sex, and ethnicity; positive MPO-ANCA, increasing Birmingham Vasculitis Activity Score at time of vasculitis diagnosis, and presence of renal involvement were positively associated with increased VTE events. Positive PR3-ANCA profile was inversely associated with increased VTE events. Increasing follow-up duration was not associated with increased VTE events. VTE in ANCA-associated vasculitis is common. Positive MPO-ANCA, increasing vasculitis activity, and presence of renal involvement were significant risk factors for VTE while positive PR3-ANCA was inversely associated with increased VTE. Key Points • Venous thromboembolism (VTE) is common in ANCA-associated vasculitis with a pooled incidence of 12.4% • Deep vein thrombosis accounts for two-third of total VTE cases • Positive MPO-ANCA profile, higher disease activity at ANCA-associated vasculitis diagnosis, and renal involvement are risk factors for VTE • Positive PR3-ANCA profile is protective factor for VTE.
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Affiliation(s)
- Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA.
| | - Angkawipa Trongtorsak
- Department of Internal Medicine, Amita Health Saint Francis Hospital, Evaston, IL, 60202, USA
| | - Kinjal P Gadhiya
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Kriti Lnu
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Christina T Dimech
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Stewart H Lecker
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
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25
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Dalager-Pedersen M, Lund LC, Mariager T, Winther R, Hellfritzsch M, Larsen TB, Thomsen RW, Johansen NB, Søgaard OS, Nielsen SL, Omland L, Lundbo LF, Israelsen SB, Harboe ZB, Pottegård A, Nielsen H, Bodilsen J. Venous thromboembolism and major bleeding in patients with COVID-19: A nationwide population-based cohort study. Clin Infect Dis 2021; 73:2283-2293. [PMID: 33400771 PMCID: PMC7929126 DOI: 10.1093/cid/ciab003] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Indexed: 12/21/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a potentially fatal complication of SARS-CoV-2 infection and thromboprophylaxis should be balanced against risk of bleeding. This study aimed to examine risks of VTE and major bleeding in hospitalized and community-managed SARS-CoV-2 patients compared with control populations. Methods Using nationwide population-based registries, 30-day risks of VTE and major bleeding in SARS-CoV-2 positive patients were compared with those of SARS-CoV-2 test-negative patients and with an external cohort of influenza patients. Medical records of all COVID-19 patients at six departments of infectious diseases in Denmark were reviewed in detail. Results The overall 30-day risk of VTE was 0.4% (40/9,460) among SARS-CoV-2 patients (16% hospitalized), 0.3% (649/226,510) among SARS-CoV-2 negative subjects (12% hospitalized), and 1.0% (158/16,281) among influenza patients (59% hospitalized). VTE risks were higher and comparable in hospitalized SARS-CoV-2 positive (1.5%), SARS-CoV-2 negative (1.8%), and influenza patients (1.5%). Diagnosis of major bleeding was registered in 0.5% (47/9,460) of all SARS-CoV-2 positive individuals and in 2.3% of those hospitalized. Medical record review of 582 hospitalized SARS-CoV-2 patients observed VTE in 4% (19/450) and major bleeding in 0.4% (2/450) of ward patients, of whom 31% received thromboprophylaxis. Among intensive care patients (100% received thromboprophylaxis), risks were 7% (9/132) for VTE and 11% (15/132) for major bleeding. Conclusions Among people with SARS-CoV-2 infection in a population-based setting, VTE risks were low to moderate and were not substantially increased compared with SARS-CoV-2 test-negative and influenza patients. Risk of severe bleeding was low for ward patients, but mirrored VTE risk in the intensive care setting.
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Affiliation(s)
- Michael Dalager-Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Søndre Skovvej, Aalborg, Denmark
| | - Lars Christian Lund
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, J B Winsløws Vej, Odense C, Denmark
| | - Theis Mariager
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej, Aalborg, Denmark
| | - Rannva Winther
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej, Aalborg, Denmark
| | - Maja Hellfritzsch
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, J B Winsløws Vej, Odense C, Denmark.,Department of Clinical Pharmacology, Aarhus University Hospital, Vennelyst Boulevard, Aarhus C, Denmark
| | - Torben Bjerregaard Larsen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Søndre Skovvej, Aalborg, Denmark
| | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Alle, Aarhus N, Denmark
| | - Nanna Borup Johansen
- Department of Clinical Evaluation and Biostatistics, Danish Medicines Agency, Copenhagen, Denmark
| | - Ole Schmeltz Søgaard
- Department of Infectious Diseases, Aarhus University Hospital, Palle-Juul Jensens Boulevard, Aarhus N, Denmark
| | - Stig Lønberg Nielsen
- Department of Infectious Diseases, Odense University Hospital, J. B. Winsløws Vej, Odense C, Denmark.,Research Unit for Infectious Diseases, Odense University Hospital, Odense, Denmark; University of Southern Denmark, Odense, Denmark
| | - Lars Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lene Fogt Lundbo
- Center of Research & Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospitals, Amager and Hvidovre, Hvidovre, Denmark
| | - Simone Bastrup Israelsen
- Center of Research & Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospitals, Amager and Hvidovre, Hvidovre, Denmark
| | - Zitta Barrella Harboe
- Department of Pulmonary Medicine and Infectious Diseases, Copenhagen University Hospital North Zealand, Dyrehavevej, Hillerød, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, J B Winsløws Vej, Odense C, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Søndre Skovvej, Aalborg, Denmark
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej, Aalborg, Denmark
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26
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Barrera CA, Otero HJ, Fenlon EP, Francavilla ML, Ellison AM, Kaplan SL. CTA utilization for evaluation of suspected pulmonary embolism in a tertiary pediatric emergency department. Clin Imaging 2021; 75:105-110. [PMID: 33524937 DOI: 10.1016/j.clinimag.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/01/2020] [Accepted: 12/26/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate changes in the utilization of computed tomography angiography (CTA) for evaluating suspected pulmonary embolism (PE) and the positive rate of ancillary for those studies negative for PE in the last 13 years. MATERIALS AND METHODS A retrospective review of patient ≤ 20 years of age who underwent a chest CT angiography to rule out PE was performed in a 13-year-period. CT angiographies were grouped into three categories: Positive for PE, negative for PE and positive for ancillary findings, and negative for any pathology. From the exams with ancillary findings, we examined how many of these had a chest radiograph perform within 24 h prior to the CTA and how many of them had an impression stating the same conclusion as the CTA. RESULTS 307 chest CT angiographies for suspected PE were included. 50 (16%) were reported as positive for PE and 91 (30%) were negative for PE but positive for ancillary findings. The most frequent ancillary findings were pneumonia (n = 26) and pleural effusion (n = 11). Out of 91, 73 patients had a previous chest radiograph and 28 of them reported a similar diagnosis than the CTA. The number of CT angiographies indicated for PE increased by 3.2 studies per year. The rate of CT angiographies positive for ancillary findings (slope = 1.5) and positive for PE (slope = 0.3) remained similar throughout the same period. CONCLUSIONS CTA orders for PE have been increasing without any increased detection of PE or ancillary findings in children.
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Affiliation(s)
- Christian A Barrera
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America.
| | - Hansel J Otero
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
| | - Edward P Fenlon
- Department of Radiology, Columbia University Medical Center, 630 W 168th St, MC 28, New York, NY 10032, United States of America
| | - Michael L Francavilla
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
| | - Angela M Ellison
- Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Summer L Kaplan
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
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27
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Prichard JG, Azimov MB, Oregel KZ. Coccidioidomycosis and Pulmonary Emboli: A Report of 5 Cases. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e924179. [PMID: 32623438 PMCID: PMC7360357 DOI: 10.12659/ajcr.924179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Case series Patient: Male, 35-year-old Final Diagnosis: Coccidioidomycosis infection Symptoms: Dyspena Medication: — Clinical Procedure: — Specialty: Infectious Diseases
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Affiliation(s)
- John G Prichard
- Department of Hematology and Immunology, Ventura County Medical Center, Ventura, CA, USA
| | - Michelle B Azimov
- Department of Hematology Oncology, Ventura County Medical Center, Ventura, CA, USA.,Department of Graduate Medical Education, Community Memorial Health System, Ventura, CA, USA
| | - Karlos Z Oregel
- Department of Hematology Oncology, Ventura County Medical Center, Ventura, CA, USA
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28
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Yoo HHB, Nunes‐Nogueira VS, Fortes Villas Boas PJ. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database Syst Rev 2020; 2:CD010222. [PMID: 32030721 PMCID: PMC7004894 DOI: 10.1002/14651858.cd010222.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke. The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardiopulmonary reserve, classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncology patients). Traditionally, all PEs are anticoagulated in a similar manner independent of their location, or number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by a possible unnecessary use of anticoagulants. Patients with isolated SSPE, or incidental PE, may have a more benign clinical presentation compared to those with proximal PEs. However, the clinical significance in patients, and their prognosis, needs to be studied to evaluate whether anticoagulation therapy is required. This is the second update of the Cochrane systematic review published in 2014. OBJECTIVES To assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 November 2019. We also undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials of anticoagulation therapy versus control in patients with SSPE or incidental SSPE. DATA COLLECTION AND ANALYSIS Two review authors inspected all citations identified to ensure reliable assessment. If relevant studies were identified, we planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We did not identify any studies that met the inclusion criteria. AUTHORS' CONCLUSIONS There is no evidence from randomised controlled trials to assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. Well-conducted research is required before informed practice decisions can be made.
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Affiliation(s)
- Hugo HB Yoo
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Vania Santos Nunes‐Nogueira
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Paulo J Fortes Villas Boas
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
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29
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Faggioni L, Gabelloni M, Neri E, Caramella D. Evidence-based Clinical Decision Support Systems for Suspected Pulmonary Embolism: Are We Ready to Go? Acad Radiol 2019; 26:1084-1086. [PMID: 31126810 DOI: 10.1016/j.acra.2019.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 04/18/2019] [Accepted: 04/18/2019] [Indexed: 02/04/2023]
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30
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Dobler CC, Glasziou PP. Overdiagnosis in respiratory medicine. Respirology 2019; 24:939-941. [PMID: 31209975 DOI: 10.1111/resp.13623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Claudia C Dobler
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Paul P Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
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31
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Dobler CC. Too much or too little medicine? Overdiagnosis, underdiagnosis, overtreatment and undertreatment in respiratory diseases. Breathe (Sheff) 2019; 15:2-3. [PMID: 30838052 PMCID: PMC6395983 DOI: 10.1183/20734735.0006-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
At a time when technical possibilities for medical investigations are plentiful and ever expanding, there is growing awareness that more is not always better and that “too much medicine” may be harmful. In recent years, the global Choosing Wisely educational campaign has aimed to bring attention to unnecessary healthcare. Unnecessary healthcare includes overtesting, overdiagnosis and overtreatment [1]. The March issue of Breathe aims to challenge us to rethink our clinical practice, to reflect on the evidence, and to identify potential cognitive biases that might influence us to provide “too much” or “too little” medicine [2]. The March issue of Breathe focuses on overdiagnosis, underdiagnosis, overtreatment and undertreatment in respiratory diseaseshttp://ow.ly/63OW30ntCeu
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Affiliation(s)
- Claudia C Dobler
- Dept of Respiratory Medicine, Liverpool Hospital, and University of New South Wales, Sydney, Australia
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