Excluding pregnancy-associated deep vein thrombosis with whole-leg ultrasound

Background

Deep vein thrombosis (DVT) is common in pregnancy, yet data are limited on the best diagnostic strategies in pregnant patients suspected of DVT.

Objectives

We conducted a prospective cohort study to evaluate the rate of symptomatic DVT in the 90 days after a negative whole-leg compression ultrasound (CUS) in pregnant women presenting with DVT symptoms.

Methods

In this prospective cohort study, we enrolled pregnant patients suspected of DVT between 2011 and 2019 who were referred to the vascular imaging laboratory at a tertiary care center and had anticoagulation held after a negative whole-leg CUS. Primary outcome was objectively confirmed DVT or pulmonary embolism or death due to venous thromboembolism (VTE).

Results

Whole-leg CUS yielded normal results in 186 patients (97.9%) and identified DVT in 4 (2.1%). The mean age was 30 and 164 were White. Among the 186 patients with a negative, initial whole-leg CUS who did not receive anticoagulation, there were 2 DVT events identified over the 90-day follow-up period, for an overall rate of 1.1% (95% CI: 0.2-3.4%). The study was terminated before full planned accrual for administrative reasons.

Conclusion

The rate of symptomatic DVT is low in pregnant patients who have a single, negative whole-leg CUS and did not receive anticoagulation. Adequately powered studies should prospectively assess whole-leg CUS in a larger population alone and in combination with pre-test probability scores and/or D-dimer to determine its role in the evaluation of suspected DVT in pregnancy.

Prospectively Assessed Long-Term Outcomes of Patients with E-Cigarette- or Vaping-associated Lung Injury

Rationale: E-cigarette- or vaping-associated lung injury (EVALI) was first identified in 2019. The long-term respiratory, cognitive, mood disorder, and vaping behavior outcomes of patients with EVALI remain unknown. Objectives: To determine the long-term respiratory, cognitive, mood disorder, and vaping behavior outcomes of patients with EVALI. Methods: We prospectively enrolled patients with EVALI from two health systems. We assessed outcomes at 1 year after onset of EVALI using validated instruments measuring cognitive function, depression, anxiety, post-traumatic stress, respiratory disability, coronavirus disease (COVID-19) infection, pulmonary function, and vaping behaviors. We used multivariable regression to identify risk factors of post-EVALI vaping behaviors and to identify whether admission to the intensive care unit (ICU) was associated with cognitive, respiratory, or mood symptoms. Results: Seventy-three patients completed 12-month follow-up. Most patients were male (66.7%), young (mean age, 31 ± 11 yr), and White (85%) and did not need admission to the ICU (59%). At 12 months, 39% (25 of 64) had cognitive impairment, whereas 48% (30 of 62) reported respiratory limitations. Mood disorders were common, with 59% (38 of 64) reporting anxiety and/or depression and 62% (39 of 63) having post-traumatic stress. Four (6.4%) of 64 reported a history of COVID-19 infection. Despite the history of EVALI, many people continued to vape. Only 38% (24 of 64) reported quitting all vaping and smoking behaviors. Younger age was associated with reduced vaping behavior after EVALI (odds ratio, 0.93; P = 0.02). ICU admission was not associated with cognitive impairment, dyspnea, or mood symptoms. Conclusions: Patients with EVALI, despite their youth, commonly have significant long-term respiratory disability; cognitive impairment; symptoms of depression, anxiety, post-traumatic stress; and persistent vaping.

Natural Language Processing Performance for the Identification of Venous Thromboembolism in an Integrated Healthcare System

Real-time identification of venous thromboembolism (VTE), defined as deep vein thrombosis (DVT) and pulmonary embolism (PE), can inform a healthcare organization's understanding of these events and be used to improve care. In a former publication, we reported the performance of an electronic medical record (EMR) interrogation tool that employs natural language processing (NLP) of imaging studies for the diagnosis of venous thromboembolism. Because we transitioned from the legacy electronic medical record to the Cerner product, iCentra, we now report the operating characteristics of the NLP EMR interrogation tool in the new EMR environment. Two hundred randomly selected patient encounters for which the imaging report assessed by NLP that revealed VTE was present were reviewed. These included one hundred imaging studies for which PE was identified. These included computed tomography pulmonary angiography-CTPA, ventilation perfusion-V/Q scan, and CT angiography of the chest/ abdomen/pelvis. One hundred randomly selected comprehensive ultrasound (CUS) that identified DVT were also obtained. For comparison, one hundred patient encounters in which PE was suspected and imaging was negative for PE (CTPA or V/Q) and 100 cases of suspected DVT with negative CUS as reported by NLP were also selected. Manual chart review of the 400 charts was performed and we report the sensitivity, specificity, positive and negative predictive values of NLP compared with manual chart review. NLP and manual review agreed on the presence of PE in 99 of 100 cases, the presence of DVT in 96 of 100 cases, the absence of PE in 99 of 100 cases and the absence of DVT in all 100 cases. When compared with manual chart review, NLP interrogation of CUS, CTPA, CT angiography of the chest, and V/Q scan yielded a sensitivity = 93.3%, specificity = 99.6%, positive predictive value = 97.1%, and negative predictive value = 99%.

Recovery: what mental health nurses and service users say about the concept of recovery

This study presents a thematic analysis of focus group talk to examine what recovery in mental health means to service users and nurses. Data were collected from two focus groups, one group of service users and one group of nurses. The service user group (n=6) were adults with previous or recent experience of inpatient mental health services. The nursing group were registered nurses (n=5) of various grades and experience currently working in inpatient mental health services in one region of the U.K. Thematic analysis using Krueger and Casey's framework led to four themes being developed. These were 'understandings of recovery', 'semantics', 'therapeutics' and 'a journey'. While the recovery concept was not new to either group, understandings of recovery were vague and contradictory.

Molecular markers in dysplasia of the larynx: expression of cyclin-dependent kinase inhibitors p21, p27 and p53 tumour suppressor gene in predicting cancer risk

Premalignant conditions affect the larynx. Dysplasia can progress in severity resulting in cancer depending on many clinical, pathological and molecular factors. The purpose of this study was to examine the expression of the p21 and p27 cyclin-dependent kinase inhibitors and p53 tumour suppressor gene in dysplasia of the larynx. A total of 114 cases of untreated dysplasia were selected from the archives of the University of Newcastle. p21, p27 and p53 immunohistochemistry was performed and the cases followed up. Twenty-eight dysplasias (24%) subsequently developed into cancers. Expression of the molecular factors studied was not associated with cancer progression. p53 expression was associated with smoking (P = 0.005). In contrast, grade of dysplasia was significantly associated with cancer risk (odds ratio 6.7; P = 0.0001). The majority (75%) of cancers were detected within 12 months of dysplasia being diagnosed.

Community management of peripherally inserted central catheters

Peripherally inserted central catheters (PICCs) are increasingly being used in the UK to allow patients requiring medium-to-long term venous access for a range of therapies, including ambulatory chemotherapy, to receive their treatment at home, away from the hospital setting. This article provides information for community nurses on the background of PICC lines in the UK, and practical advice on how to clinically maintain and manage these lines. Complications relating to PICCs are discussed, including how to recognize and deal with these complications in the community, and when to refer back to the specialist centre. The author leads at a nurse-managed PICC insertion service at a major cancer centre in Wales. The ongoing success of this service relies heavily on the skill and expertise of the community nurses who support the service.

Expression of MUC1 and MUC2 glycoproteins in laryngeal cancer

The aim of this study was to examine the expression of MUC1 and MUC2 glycoproteins in laryngeal cancer and to determine if mucin expression is related to prognosis. The study included laryngeal specimens from 57 patients comprising of 36 laryngeal carcinomas and 21 normal controls. High MUC1 expression was found in both carcinomas and normal control groups (P = 0.689, Fisher's exact test). High levels of MUC2 expression were only detected in carcinomas versus controls (P = 0.009, Fisher's exact test). Using multivariate analysis neither MUC1 nor MUC2 expression significantly related to survival. MUC1 expression however, did correlate with T stage. Advanced T stage was associated with prognosis (P = 0.001).

An education programme for patients with cancer

This article describes an educational programme set up to help patients and their families come to terms with a diagnosis of cancer. The programme, based on a US project, was piloted with a group of 16 patients and their carers. An evaluation using questionnaires has shown that patients can find a structured cancer education programme beneficial.