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Crane HM, Nance RM, Ruderman SA, Haidar L, Tenforde MW, Heckbert SR, Budoff MJ, Hahn AW, Drumright LN, Ma J, Mixson LS, Lober WB, Barnes GS, McReynolds J, Attia EF, Peter I, Moges T, Bamford L, Cachay E, Mathews WC, Christopolous K, Hunt PW, Napravnik S, Keruly J, Moore RD, Burkholder G, Willig AL, Lindstrom S, Whitney BM, Saag MS, Kitahata MM, Crothers KA, Delaney JAC. Venous Thromboembolism Among People With HIV: Design, Implementation, and Findings of a Centralized Adjudication System in Clinical Care Sites Across the United States. J Acquir Immune Defic Syndr 2024; 95:207-214. [PMID: 37988634 PMCID: PMC11151789 DOI: 10.1097/qai.0000000000003339] [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: 02/09/2023] [Accepted: 08/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND People with HIV (PWH) are at increased risk for venous thromboembolism (VTE). We conducted this study to characterize VTE including provoking factors among PWH in the current treatment era. METHODS We included PWH with VTE between 2010 and 2020 at 6 sites in the CFAR Network of Integrated Clinical Systems cohort. We ascertained for possible VTE using diagnosis, VTE-related imaging, and VTE-related procedure codes, followed by centralized adjudication of primary data by expert physician reviewers. We evaluated sensitivity and positive predictive value of VTE ascertainment approaches. VTEs were classified by type and anatomic location. Reviewers identified provoking factors such as hospitalizations, infections, and other potential predisposing factors such as smoking. RESULTS We identified 557 PWH with adjudicated VTE: 239 (43%) had pulmonary embolism with or without deep venous thrombosis, and 318 (57%) had deep venous thrombosis alone. Ascertainment with clinical diagnoses alone missed 6% of VTEs identified with multiple ascertainment approaches. DVTs not associated with intravenous lines were most often in the proximal lower extremities. Among PWH with VTE, common provoking factors included recent hospitalization (n = 134, 42%), infection (n = 133, 42%), and immobilization/bed rest (n = 78, 25%). Only 57 (10%) PWH had no provoking factor identified. Smoking (46%), HIV viremia (27%), and injection drug use (22%) were also common. CONCLUSIONS We conducted a robust adjudication process that demonstrated the benefits of multiple ascertainment approaches followed by adjudication. Provoked VTEs were more common than unprovoked events. Nontraditional and modifiable potential predisposing factors such as viremia and smoking were common.
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Affiliation(s)
- Heidi M Crane
- Department of Medicine, University of Washington, Seattle, WA
| | - Robin M Nance
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Lara Haidar
- Department of Pharmacy, University of Manitoba, Manitoba, CA
| | - Mark W Tenforde
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance, CA
| | - Andrew W Hahn
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Jimmy Ma
- Department of Medicine, University of Washington, Seattle, WA
| | - L S Mixson
- Department of Medicine, University of Washington, Seattle, WA
| | - William B Lober
- Department of Medicine and Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Gregory S Barnes
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Justin McReynolds
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Engi F Attia
- Department of Medicine, University of Washington, Seattle, WA
| | - Inga Peter
- Department of Genetics, Mount Sinai University, New York NY
| | - Tesfaye Moges
- Department of Medicine, University of California, San Diego, CA
| | - Laura Bamford
- Department of Medicine, University of California, San Diego, CA
| | - Edward Cachay
- Department of Medicine, University of California, San Diego, CA
| | | | | | - Peter W Hunt
- Department of Medicine, University of California, San Francisco, CA
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jeanne Keruly
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Greer Burkholder
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Amanda L Willig
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Sara Lindstrom
- Department of Genetics, University of Washington, Seattle, WA; and
| | | | - Michael S Saag
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Joseph A C Delaney
- Department of Medicine, University of Washington, Seattle, WA
- Department of Medicine, University of Manitoba, Manitoba, CA
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Davies-van Es SA, Pennel TC, Brink J, Symons GJ, Calligaro GL. Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension in Cape Town, South Africa. Afr J Thorac Crit Care Med 2023; 29:10.7196/AJTCCM.2023.v29i3.294. [PMID: 37970576 PMCID: PMC10642406 DOI: 10.7196/ajtccm.2023.v29i3.294] [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: 10/31/2022] [Accepted: 05/28/2023] [Indexed: 11/17/2023] Open
Abstract
Background Pulmonary endarterectomy (PEA) is the only definitive and potentially curative therapy for chronic thromboembolic pulmonary hypertension (CTEPH), associated with impressive improvements in symptoms and haemodynamics. However, it is only offered at a few centres in South Africa. The characteristics and outcomes of patients undergoing PEA in Cape Town have not been reported previously. Objectives To assess the difference in World Health Organization functional class (WHO-FC) before and at least 6 weeks after surgery. Methods We interrogated the adult cardiothoracic surgery database at the University of Cape Town between December 2005 and April 2021 for patients undergoing PEA at Groote Schuur Hospital and a private hospital. Results A total of 32 patients underwent PEA, of whom 8 were excluded from the final analysis owing to incomplete data or a histological diagnosis other than CTEPH. The work-up of these patients for surgery was variable: all had a computed tomography pulmonary angiogram, 7 (29%) had a ventilation/perfusion scan, 5 (21%) underwent right heart catheterisation, and none had a pulmonary angiogram. The perioperative mortality was 4/24 (17%): 1 patient (4%) had a cardiac arrest on induction of anaesthesia, 2 patients (8%) died of postoperative pulmonary haemorrhage, and 1 patient (4%) died of septic complications in the intensive care unit. Among the survivors, the median (interquartile range) improvement in WHO-FC was 2 (1 - 3) classes (p=0.0004); 10/16 patients (63%) returned to a normal baseline (WHO-FC I). Conclusion Even in a low-volume centre, PEA is associated with significant improvements in WHO-FC and a return to a normal baseline in survivors. Study synopsis What the study adds. South African patients undergoing pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have a marked improvement in functional status, with many returning to a normal functional baseline. However, the small number of patients included in this study indicates that PEA is probably underutilised. Pre- and postoperative assessment is inconsistent, despite availability of established guidelines.Implications of the findings. More patients should be referred to specialist centres for assessment for this potentially curative procedure. Use of guidelines to standardise investigations and monitoring of patients with CTEPH may improve patient selection for surgery.
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Affiliation(s)
- S A Davies-van Es
- Division of Acute General Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town,
South Africa
| | - T C Pennel
- Chris Barnard Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa
| | - J Brink
- Chris Barnard Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa
| | - G J Symons
- Division of Acute General Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town,
South Africa
- Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - G L Calligaro
- Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
- Division of Pulmonology, Department of Medicine, Groote Schuur Hospital and University of Cape Town Lung Institute, Cape Town, South Africa
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Abate LG, Bayable SD, Fetene MB. Evidence-based perioperative diagnosis and management of pulmonary embolism: A systematic review. Ann Med Surg (Lond) 2022; 77:103684. [PMID: 35638051 PMCID: PMC9142630 DOI: 10.1016/j.amsu.2022.103684] [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: 03/14/2022] [Revised: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The diagnosis and treatment of pulmonary embolism have multi-modal approach based on specificity, sensitivity, availability of the machine, and associated risks of imaging modalities. Aim This review aimed to provide shreds of evidence that improve perioperative diagnosis and management of suspected pulmonary embolism. Methods The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline 2020. After a clear criteria has been established an electronic searching database was conducted using PubMed, Google Scholar, Cochrane library, and Cumulative Index of Nursing and Allied Health Literature (CINAHL), with Key search terms included:(‘pulmonary embolism’ AND′ anesthesia management ‘, ‘anticoagulation’ AND ‘pulmonary embolism’, ‘thrombolysis ‘AND ‘pulmonary embolism’, ‘surgery’ AND′ pulmonary embolism’), were used to draw the evidence. The quality of literatures were categorized based on WHO 2011 level of evidence and degree of recommendation, in addition, the study is registered with research registry unique identifying number (UIN) of reviewregistry1318.” and has high quality based on AMSTAR2 assessment criteria. Results A totally of 27 articles were included [guidelines (n = 3), Cochrane (=5), systemic reviews (n = 7), meta-analyses (=2), RCT (n = 4), cohort studies (n = 3), and cross-sectional study (n = 3) and illegible articles identified from searches of the electronic databases were imported into the ENDNOTE software version X7.1 and duplicates were removed. Discussion Currently divergent and contradictory approaches are implemented in diagnosis and management for patients suspected of pulmonary embolism. Conclusion All perioperative patients, especially trauma victims, prostate or orthopedic surgery, malignancy, immobility, and obesity; smokers; and oral contraceptive users, antipsychotic medications are at increased risk of venous thromboembolism and need special caution during surgery and anesthesia. Currently divergent and contradictory approaches are implemented in diagnosis and management for patients suspected of pulmonary embolism. This study improves perioperative diagnosis and management of suspected pulmonary embolism patients. Patients having trauma, orthopedic surgery, malignancy, immobility; and being smoker; are at risk of VTE and need special caution during surgery.
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Wiese D, Rajkumar L, Lucas S, Clopton D, Benfield J, DeBerry J. CT pulmonary angiography findings in HIV-infected patients referred for suspected pulmonary thrombo-embolic disease. SA J Radiol 2022; 26:2273. [PMID: 35169500 PMCID: PMC8832071 DOI: 10.4102/sajr.v26i1.2273] [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: 08/16/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Abstract
Background South Africa bares a significant burden of HIV and imaging is commonly performed as part of the workup for respiratory distress. Objectives The aim of this study was to document the prevalence of pulmonary thrombo-embolic disease (PTED) and other findings in HIV-infected patients referred for CT pulmonary angiography (CTPA) for suspected PTED. Method Forty CTPA studies of documented HIV-infected individuals investigated for suspected PTED during a 1-year period were retrieved, anonymised and interpreted by three consultant radiologists. Inter-reader reliability was calculated using Free Marginal multi-rater Kappa. Results Fourteen of the forty cases (35%) were positive for PTED. In the pulmonary embolism (PE)-positive group, 57.14% had peripheral disease and 42.86% had both peripheral and central disease. Associated findings in the PE-positive cases were pulmonary infarcts (17.5%), mosaic attenuation (17.5%) and linear atelectasis (7.5%). The most common incidental findings were solid pulmonary nodules (52.5%), non-wedge-shaped consolidation (45%), cardiomegaly (52.5%) and enlarged intra-thoracic lymph nodes (52.5%). Thirty per cent of the study population had findings related directly to the presence of PTED, whilst most cases in the study (77.5%) had pulmonary findings unrelated to PTED. In the PE-negative cases, 55% reported emergent findings that warranted immediate or urgent medical attention. Conclusion Computed tomography pulmonary angiography imaging is critical for diagnosing PE. However, further investigation into the judicious application of CTPA in HIV-infected patients with suspected PTED is required, as CTPA findings in most of the cases in this study were unrelated to PE.
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Affiliation(s)
- Diane Wiese
- Department of Radiology, Faculty of Medicine, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Leisha Rajkumar
- Department of Radiology, Faculty of Medicine, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Lucas
- Department of Radiology, Faculty of Medicine, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - David Clopton
- Department of Radiology, Faculty of Medicine, James H. Quillien VA Healthcare System, East Tennessee State University, Johnson City, Tennessee, United States of America
| | - Jacob Benfield
- Department of Radiology, Faculty of Medicine, James H. Quillien VA Healthcare System, East Tennessee State University, Johnson City, Tennessee, United States of America
| | - Jason DeBerry
- Department of Radiology, Faculty of Medicine, Elizabeth and Claire LaPlante Foundation, West Virginia University, Morgantown, West Virginia, United States of America
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5
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Danwang C, Bigna JJ, Awana AP, Nzalie RNT, Robert A. Global epidemiology of venous thromboembolism in people with active tuberculosis: a systematic review and meta-analysis. J Thromb Thrombolysis 2020; 51:502-512. [PMID: 32627124 DOI: 10.1007/s11239-020-02211-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Despite the wide range of studies supporting an association between exposure to active tuberculosis and risk of venous thromboembolism (VTE), the current systematic review and meta-analysis is the first study assessing the global epidemiology of VTE in patients having active tuberculosis. In this systematic review and meta-analysis, EMBASE, Medline, and Web of Science were searched to identify observational studies, published until December 15, 2019, and reporting on venous thromboembolism in patients with active tuberculosis. No language restriction was applied. Studies were synthetized using a random-effect model. This review is registered with PROSPERO, CRD42019130347. We included 9 studies with an overall total of 16,190 patients with active tuberculosis. The prevalence of VTE was 3.5% (95% CI 2.2-5.2) in patients with active tuberculosis. Furthermore, we found a prevalence of pulmonary embolism (PE) at 5.8% (95% CI 2.2-10.7) and for deep vein thrombosis (DVT) at 1.3% (95% CI 0.8-2.0) in patients with active tuberculosis. Patients with active tuberculosis had a higher risk for VTE (OR 2.90; 95% CI 2.30-3.67), DVT (OR 1.56; 95% CI 1.14-2.14), and PE (OR 3.58; 95% CI 2.54-5.05). This study suggests that VTE is not rare among patients with active TB. Cost-effective preventive strategies and interventions to curb this dreadful burden of VTE among people with active TB are needed.
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Affiliation(s)
- Celestin Danwang
- Epidemiology and Biostatistics Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium. .,Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.
| | - Jean Joel Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, Yaoundé, Cameroon.,School of Public Health, Faculty of Medicine, University of Paris Sud XI, Le Kremlin-Bicêtre, France
| | - Armel Philippe Awana
- Department of Radiology, Jamot Hospital, Yaoundé, Cameroon.,Department of Biomedical Sciences, University of Ngaoundere, Ngaoundere, Cameroon
| | | | - Annie Robert
- Epidemiology and Biostatistics Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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Huson MAM, Kaminstein D, Kahn D, Belard S, Ganesh P, Kandoole-Kabwere V, Wallrauch C, Phiri S, Kreuels B, Heller T. Cardiac ultrasound in resource-limited settings (CURLS): towards a wider use of basic echo applications in Africa. Ultrasound J 2019; 11:34. [PMID: 31883027 PMCID: PMC6934640 DOI: 10.1186/s13089-019-0149-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 12/16/2019] [Indexed: 01/15/2023] Open
Abstract
Background Point-of-care ultrasound is increasingly being used as a diagnostic tool in resource-limited settings. The majority of existing ultrasound protocols have been developed and implemented in high-resource settings. In sub-Saharan Africa (SSA), patients with heart failure of various etiologies commonly present late in the disease process, with a similar syndrome of dyspnea, edema and cardiomegaly on chest X-ray. The causes of heart failure in SSA differ from those in high-resource settings. Point-of-care ultrasound has the potential to identify the underlying etiology of heart failure, and lead to targeted therapy. Based on a literature review and weighted score of disease prevalence, diagnostic impact and difficulty in performing the ultrasound, we propose a context-specific cardiac ultrasound protocol to help differentiate patients presenting with heart failure in SSA. Results Pericardial effusion, dilated cardiomyopathy, cor pulmonale, mitral valve disease, and left ventricular hypertrophy were identified as target conditions for a focused ultrasound protocol in patients with cardiac failure and cardiomegaly in SSA. By utilizing a simplified 5-question approach with all images obtained from the subxiphoid view, the protocol is suitable for use by health care professionals with limited ultrasound experience. Conclusions The “Cardiac ultrasound for resource-limited settings (CURLS)” protocol is a context-specific algorithm designed to aid the clinician in diagnosing the five most clinically relevant etiologies of heart failure and cardiomegaly in SSA. The protocol has the potential to influence treatment decisions in patients who present with clinical signs of heart failure in resource-limited settings outside of the traditional referral institutions.
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Affiliation(s)
- Michaëla A M Huson
- Department of Microbiology and Infectious Diseases, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Dan Kaminstein
- Department of Emergency Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Daniel Kahn
- Department of Internal Medicine, University of California, Los Angeles, CA, USA
| | - Sabine Belard
- Department of Paediatric Pulmonology, Immunology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Prakash Ganesh
- Lighthouse Clinic, Kamuzu Central Hospital, Lilongwe, Malawi.,International Training and Education Centre for Health, University of Washington, Seattle, WA, USA
| | | | - Claudia Wallrauch
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU, Munich, Germany
| | - Sam Phiri
- Lighthouse Clinic, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Global Health, University of Washington, Seattle, USA.,Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Lilongwe, Malawi
| | - Benno Kreuels
- Department of Internal Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tom Heller
- Lighthouse Clinic, Kamuzu Central Hospital, Lilongwe, Malawi.
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