Successful ECMO treatment in patients with cerebral hemorrhage and PROC gene mutation associated with VTE: a case report

In this report, we report a case of a middle-aged male, admitted to the ICU with cerebral hemorrhage resulting from a severe high-altitude fall. The patient encountered significant challenges in oxygenation index correction, attributed to extensive embolism in both the primary and branch pulmonary arteries. Consequently, the patient underwent an immediate initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy, persisting for 20 days. During this treatment period, a mutation in the protein C (PROC) gene was identified. The medical team meticulously navigated the delicate balance between anticoagulation and bleeding risks. Eventually, the patient was successfully weaned off VA-ECMO and subsequently discharged. This report aims to delve into the etiology and therapeutic approaches of this uncommon case, with the intention of offering insightful reference for managing similar clinical scenarios in the future.

Systemic Immune-Inflammation Index as a Potential Biomarker for Predicting Acute Pulmonary Embolism: A Systematic Review

BACKGROUND

Acute pulmonary embolism (APE) is a life-threatening condition with a high mortality rate. The pathophysiology involves various complex processes. The systemic immune-inflammatory index (SII) is a well-known biomarker that reflects the intricate balance between pro-inflammatory and anti-inflammatory immune components. In this systematic review, we aim to determine the significance of SII as a potential biomarker for APE.

METHOD

We utilized PubMed, ProQuest, EBSCOHost, and Google Scholar to search for articles. We assessed bias risk using the Newcastle Ottawa Scale (NOS). The outcomes we examined included in-hospital and long-term mortality, the severity of APE, and the sensitivity and specificity of the SII in predicting APE.

RESULTS

Four studies, involving 2,038 patients, were included for analysis. These studies discuss the use of SII in predicting APE severity, APE mortality, high-risk APE, and the occurrence of APE. SII demonstrates significant results in predicting each of these variables. Furthermore, each study establishes different SII cut-off values. Specifically, a cut-off of 1161 predicts massive APE events with a sensitivity of 91% and a specificity of 90%. A cut-off of >1235.35 differentiates high-risk APE with a sensitivity of 87.32% and a specificity of 68.85%. A cut-off of >1111x109 predicts overall mortality with a sensitivity of 72% and a specificity of 51%. Finally, a cut-off at 1839.91 predicts APE events with a sensitivity of 75.8% and a specificity of 61.9%.

CONCLUSION

The SII can be employed as a potential new biomarker to predict outcomes in APE patients, particularly the occurrence, severity, and mortality of APE.

Extra-corporal Membrane Oxygenation (ECMO) in Massive Pulmonary Embolism

BACKGROUND

Massive pulmonary embolism (MPE) carries significant 30-day mortality, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE.

METHODS

A literature review was performed from 1982 to 2022 search for the terms Pulmonary embolism and ECMO and refined by examining those publications that covered MPE RESULTS: In the patient with MPE, veno-arterial-ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes.

CONCLUSIONS

The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.

The effect of off-label use of reduced-dose direct oral anticoagulants therapy in the treatment of pulmonary embolism comparable to standard-dose therapy

Direct oral anticoagulants (DOACs) have been shown to be effective and safe in preventing pulmonary embolism recurrence. In this single-center retrospective observational study, we aimed to evaluate the efficacy and safety of reduced-dose DOACs in 86 consecutive patients with acute pulmonary embolism. Patients were divided into standard-dose and reduced-dose DOACs groups. Initial clot volume did not significantly differ between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 18.8 [Q1-Q3 7.3-30.8] mL vs. 10.0 [Q1-Q3 3.2-27.9] mL, p = 0.1). Follow-up computed tomography (CT) within 30 days showed a higher rate of clot volume reduction or disappearance in the standard-dose group compared to the reduced-dose group (standard-dose DOACs vs. reduced-dose DOACs, 81.6% vs. 53.9%, p = 0.02). However, at the final follow-up CT, there was no significant difference in clot volume change between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 91.5% vs. 82.0%, p = 0.19). Major bleeding occurred in two patients in the standard-dose group (4.3%) and three patients in the reduced-dose DOACs group (7.7%) (p = 0.5). In conclusion, while standard-dose DOACs demonstrated superior efficacy in early clot reduction, reduced doses of apixaban and edoxaban showed comparable efficacy and safety profiles in long-term treatment of acute pulmonary embolism in certain patients.

An overview of systematic reviews on imaging tests for diagnosis of pulmonary embolism applying different network meta-analytic methods

PURPOSE

This study aimed to apply different methods of diagnostic test accuracy network meta-analysis (DTA-NMA) for studies reporting results of five imaging tests for the diagnosis of suspected pulmonary embolism (PE): pulmonary angiography (PA), computed tomography angiography (CTPA), magnetic resonance angiography (MRA), planar ventilation/perfusion (V/Q) scintigraphy and single-photon emission computed tomography ventilation/perfusion (SPECT V/Q).

METHODS

We searched four databases (MEDLINE [via PubMed], Cochrane CENTRAL, Scopus, and Epistemonikos) from inception until June 2, 2022 to identify systematic reviews (SRs) describing diagnostic accuracy of PA, CTPA, MRA, V/Q scan and SPECT V/Q for suspected PE. Study-level data were extracted and pooled using a hierarchical summary receiver operating characteristic (HSROC) meta-regression approach and two DTA-NMA models to compare accuracy estimates of different imaging tests. Risk of bias was assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool and certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

RESULTS

We identified 13 SRs, synthesizing data from 33 primary studies and for four imaging tests (PA, CTPA, MRA and V/Q scan). The HSROC meta-regression model using PA as the reference standard showed that MRA had the best overall diagnostic performance with sensitivity of 0.93 (95% confidence interval [CI]: 0.76, 1.00) and specificity of 0.94 (95% CI: 0.84, 0.99). However, DTA-NMA models indicated that V/Q scan had the highest sensitivity, while CTPA was most specific.

CONCLUSION

Selecting a different DTA-NMA method to assess multiple diagnostic tests can affect estimates of diagnostic accuracy. There is no established method, but the choice depends on the data and familiarity with Bayesian statistics.

Characterization of direct oral anticoagulants use in adult hematopoietic stem cell transplant recipients

Direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) treatment are of interest in oncology due to ease of administration and lack of need for therapeutic monitoring compared to other anticoagulants. Data supporting their use in patients with hematologic malignancies post-hematopoietic stem cell transplant (HCT) are limited. The purpose of the study is to characterize DOAC use in HCT patients. This multicenter, retrospective cohort analysis included allogeneic and autologous HCT recipients. The primary outcome was major bleeding. Secondary outcomes included clinically relevant non-major bleeding (CRNMB)/minor bleeding and VTE recurrence. Of 126 patients, 91 (72.2%) patients received an autologous HCT, and 35 (27.8%) patients received an allo-HCT. No major bleeding occurred in either transplant recipient groups. In autologous HCT recipients, CRNMB/minor bleeding occurred in four (4.4%) patients and VTE recurrence occurred in one (1.1%) patient. For allogeneic HCT recipients, CRNMB/minor bleeding occurred in five (14.3%) patients and VTE recurrence occurred in two (5.7%) patients. For patients that experienced a CRNMB, five (100%) of the allogeneic HCT and two (50%) of the autologous HCT recipients were thrombocytopenic at the time of bleeding. Only 38.5% of patients who experienced a drug-drug interaction requiring DOAC dose adjustment received the appropriate dose adjustment. DOACs were associated with low rates of recurrent VTE and no major bleeding events, similar to published data on DOAC use in the general cancer patient population. This suggests that DOACs may be safe therapeutic options with proactive management of drug interactions and careful monitoring for bleeding events, especially in the allogeneic HCT population where minor bleeding rates were slightly higher.

Symptom-related screening programme for early detection of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the SYSPPE study

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). We aimed to evaluate the impact of a symptom screening programme to detect CTEPH in PE survivors.

METHODS

This was a multicentre cohort study of patients diagnosed with acute symptomatic PE between January 2017 and December 2018 in 16 centres in Spain. Patients were contacted by phone 2 years after the index PE diagnosis. Those with dyspnoea corresponding to a New York Heart Association (NYHA)/WHO scale≥II, visited the outpatient clinic for echocardiography and further diagnostic tests including right heart catheterisation (RHC). The primary outcome was the new diagnosis of CTEPH confirmed by RHC.

RESULTS

Out of 1077 patients with acute PE, 646 were included in the symptom screening. At 2 years, 21.8% (n=141) reported dyspnoea NYHA/WHO scale≥II. Before symptom screening protocol, five patients were diagnosed with CTEPH following routine care. In patients with NYHA/WHO scale≥II, after symptom screening protocol, the echocardiographic probability of pulmonary hypertension (PH) was low, intermediate and high in 76.6% (n=95), 21.8% (n=27) and 1.6% (n=2), respectively. After performing additional diagnostic test in the latter 2 groups, 12 additional CTEPH cases were confirmed.

CONCLUSIONS

The implementation of this simple strategy based on symptom evaluation by phone diagnosed more than doubled the number of CTEPH cases. Dedicated follow-up algorithms for PE survivors help diagnosing CTEPH earlier.

TRIAL REGISTRATION NUMBER

NCT03953560.

Prevention of symptomatic pulmonary embolism for gynecologic malignancies with preoperative asymptomatic venous thromboembolism: GOTIC-VTE trial

OBJECTIVE

In Japan, perioperative prophylaxis of pulmonary embolism (PE) in gynecologic cancer patients with preoperative asymptomatic venous thromboembolism (VTE) has not been well established yet. The GOTIC-VTE trial was a prospective, multi-center, single-arm clinical trial to investigate the prevention of postoperative symptomatic PE onset by seamless anticoagulant therapy from the preoperative period to 4 weeks after surgery instead of using intermittent pneumatic compression.

METHODS

Anticoagulant therapy was started immediately after asymptomatic VTE diagnosis and stopped preoperatively according to the rules of each institution. Unfractionated heparin administration was resumed within 12 hours postoperatively, and this was followed by the switch to low-molecular-weight heparin and subsequently, edoxaban; this cycle was continued for 28 days. Primary outcome was the occurrence of symptomatic PE in 28 days postoperatively. Secondary outcomes were the incidence of VTE-related events in 28 days and 6 months postoperatively and protocol-related adverse events.

RESULTS

Between February 2018 and September 2020, 99 patients were enrolled; of these, 82 patients were assessed as the full analysis set, including 58 for ovarian cancer, fallopian tube, or peritoneal cancer; 21 for endometrial cancer; and 3 for cervical cancer. No symptomatic PE was observed within 28 days postoperatively; two patients had bleeding events (major bleeding and clinically relevant nonmajor bleeding) and three had grade 3 adverse events (increased alanine transaminase, aspartate aminotransferase, or gamma-glutamyl transferase).

CONCLUSION

The multifaceted perioperative management for gynecologic malignancies with asymptomatic VTE effectively prevented postoperative symptomatic PE.

TRIAL REGISTRATION

JRCT Identifier: jRCTs031180124.

Case series and updated literature review

BACKGROUND

Intraoperative pulmonary embolism (PE) with cardiac arrest (CA) represents a critical and potentially fatal condition. Available treatments include systemic thrombolysis, catheter-based thrombus fragmentation or aspiration, and surgical embolectomy. However, limited studies are focused on the optimal treatment choice for this critical condition. We present a case series and an updated review of the management of intraoperative CA secondary to PE.

METHODS

A retrospective review of patients who developed high-risk intraoperative PE was performed between June 2012 and June 2022. For the updated review, a literature search on PubMed and Scopus was conducted which resulted in the inclusion of a total of 46 articles.

RESULTS

A total of 196 174 major non-cardiac surgeries were performed between 2012 and 2022. Eight cases of intraoperative CA secondary to high-risk PE were identified. We found a mortality rate of 75%. Anticoagulation therapy was administered to one patient (12.5%), while two patients (25%) underwent thrombolysis, and one case (12.5%) underwent mechanical thrombectomy combined with thrombus aspiration. Based on the literature review and our 10-year experience, we propose an algorithm for the management of intraoperative CA caused by PE.

CONCLUSION

The essential components for adequate management of intraoperative PE with CA include hemodynamic support, cardiopulmonary resuscitation, and the implementation of a primary perfusion intervention. The prompt identification of the criteria for each specific treatment modality, guided by the individual patient's characteristics, is necessary for an optimal approach.

[Treatment of cardiogenic shock due to right ventricular involvement]

The right ventricle is susceptible to changes in preload, afterload, and contractility. The answer is its dilation with dysfunction/acute failure; filling is limited to the left ventricle and cardiac output. Systemic venous congestion is retrograde to the right heart, it is involved in the genesis of cardiogenic shock due to right ventricle involvement. This form of shock is less well known than that which occurs due to left ventricular failure, therefore, treatment may differ. Once the primary treatment has been carried out, since no response is obtained, supportive treatment aimed at ventricular pathophysiology will be the next option. It is suggested to evaluate the preload for the reasoned indication of liquids, diuretics or even ultrafiltration. Restore or maintain heart rate and sinus rhythm, treat symptomatic bradycardia, arrhythmias that make patients unstable, use of temporary pacing or cardioversion procedures. Improving contractility and vasomotility, using vasopressors and inotropes, alone or in combination, the objective will be to improve right coronary perfusion pressure. Balance the effect of drugs and maneuvers on preload and/or afterload, such as mechanical ventilation, atrial septostomy and pulmonary vasodilators. And the increasing utility of mechanical support of the circulation that has become a useful tool to preserve/restore right heart function.

Venous thromboembolic disease in admitted blunt trauma patients: what matters?

BACKGROUND

Venous thromboembolic events (VTE) are a significant cause of morbidity and mortality following traumatic injury. We examined demographic characteristics, chemoprophylaxis, and outcomes of VTE patients with blunt trauma requiring hospitalization.

METHODS

A retrospective review of adult blunt trauma hospitalizations with and without VTE between 2012 and 2019 was conducted. Deaths in the emergency department were excluded. Univariate and multivariable analyses, including machine learning classification algorithms for VTE, were performed.

RESULTS

Of 10,926 admitted adult blunt trauma patients, 177 had VTE events. VTE events occurred at a median of 6 [IQR 3-11] days, with 7.3% occurring within 1 day of admission. VTE patients were more often male, and more often underwent surgery. They had higher injury severity as well as longer intensive care unit and hospital lengths of stay. While VTE occurred throughout the spectrum of injury severity, 27.7% had low injury severity (ISS < = 9). In multivariable analyses, both heparin and enoxaparin had reduced adjusted odds ratios for VTE.

CONCLUSION

Approximately 7.3% of VTE events occurred within one day of admission. A substantial proportion of VTE events occurred in patients with low injury severity (ISS < = 9). Subcutaneous unfractionated heparin and enoxaparin chemoprophylaxis were both inversely associated with VTE. These findings underscore the need for vigilance for VTE identification in blunt trauma patients throughout their hospitalization and VTE prevention efforts.

An analysis of the ELSO database

AIM

Extracorporeal membrane oxygenation (ECMO) may be beneficial in treatment of massive pulmonary embolus (PE), however the current evidence to guide its use is limited. We aimed to compare the incidence, characteristics, treatments, and outcomes of patients with massive PE by mode of ECMO from a large international registry.

METHODS

Retrospective observational study of the Extracorporeal Life Support Organization (ELSO) database.

RESULTS

A total of 821 patients underwent 833 ECMO episodes for PE. Mean age was 49 (±15) years, 408 (50.1%) were female, and 450 (54.7%) had a cardiac arrest prior to ECMO initiation. Venoarterial (VA) ECMO was the most common mode in 489 (58.7%), followed by extracorporeal cardiopulmonary resuscitation (ECPR) in 229 (27.4%) and venovenous (VV) ECMO in 85 (10.2%). The number of episodes per year increased over the study period, predominantly driven by an increase in ECPR. In-hospital mortality was the highest for ECPR 156/229 (68.1%), followed by VA ECMO 209/498 (42.7%) and VV ECMO 24/85 (28.2%) P < 0.001. After controlling for univariate and clinically significant variables at the time of ECMO initiation, increasing age (OR 1.02 (1.00-1.03), lower pH (OR 0.18 (0.03-0.44), lower diastolic blood pressure (OR 0.99 (0.97-1.00) and ECPR mode (OR 3.67 (1.46-9.230) were independently associated with in-hospital mortality.

CONCLUSION

ECMO use for massive PE is increasing globally, and overall mortality rates compare favorably with other indications of ECMO. The use of ECPR and worsening metabolic status at initiation were associated with higher in-hospital mortality, suggesting delays in initiating ECMO should be avoided.

[Anatomy-physiology considerations for cardiogenic shock with right ventricular involvement]

Since the discovery of right ventricular infarction, interest in the characteristics of the right ventricle has been increasing. Right ventricular function is now known to be a predictor of mortality in different settings. The right ventricle is a low-pressure, high-compliance, high-volume chamber. To carry out its normal function, it is coupled to the pulmonary circulation and the left ventricle. In the face of acute changes in pressure, volume overload and ischemia, it dilates to adapt to its new load. Its manifestation may be ventricular dysfunction and/or failure that will progress to cardiogenic shock due to right ventricular involvement. Various entities may be the cause of acute dysfunction: right ventricular infarction (alterations in contractility due to ischemia) and high-risk pulmonary thromboembolism (increased afterload). Both share a similar ventricular pathophysiology and high mortality without treatment. Understanding anatomy and physiology, dysfunction and acute ventricular failure are important to define a convenient diagnosis and treatment oriented towards pathophysiology. In this first part, the anatomy and physiology, acute right ventricular dysfunction/failure and cardiogenic shock are taken into consideration, from the perspective of these two entities. In another paper, treatment aimed at cardiogenic shock due to right ventricular involvement will be reviewed.

Half-Dose tPA for Massive Pulmonary Thromboembolism After Liposuction

Background

The most aggressive preventive strategies may fail to prevent pulmonary embolism (PE) after liposuction. PE can cause serious life-threatening consequences and death. If hemodynamic detoriation occurs, treatment is systemic or catheter-directed fibrinolytic therapy and, if failed, surgical embolectomy. A latent risk exists for catastrophic hemorrhage when thrombolytic is administered after surgery. Thus, the use of tissue plasminogen activator (tPA) has never been studied in postoperative patients, and the safety of this medicine is unknown. In this case study, a 31-year-old obese woman was evaluated for complaints of shortness of breath, palpitations, and hypotension in the first postoperative day after liposuction.

Conclusions

Successful management of massive PE with a half-dose regimen of tPA (alteplase 50 mg over 2 hours) is reported.

PECSS: Pulmonary Embolism Comprehensive Screening Score to safely rule out pulmonary embolism among suspected patients presenting to emergency department

BACKGROUND

Pulmonary embolism is a severe cardiovascular disease and can be life-threatening if left untreated. However, the detection rate of pulmonary embolism using existing pretest probability scores remained relatively low and clinical rule out often relied on excessive use of computed tomographic pulmonary angiography.

METHODS

We retrospectively collected data from pulmonary embolism suspected patients in Zhongshan Hospital from July 2018 to October 2022. Pulmonary embolism diagnosis and severity grades were confirmed by computed tomographic pulmonary angiography. Patients were randomly divided into derivation and validation set. To construct the Pulmonary Embolism Comprehensive Screening Score (PECSS), we first screened for candidate clinical predictors using univariate logistic regression models. These predictors were then included in a searching algorithm with indicators of Wells score, where a series of points were assigned to each predictor. Optimal D-Dimer cutoff values were investigated and incorporated with PECSS to rule out pulmonary embolism.

RESULTS

In addition to Wells score, PECSS identified seven clinical predictors (anhelation, abnormal blood pressure, in critical condition when admitted, age > 65 years and high levels of pro-BNP, CRP and UA,) strongly associated with pulmonary embolism. Patients can be safely ruled out of pulmonary embolism if PECSS ≤ 4, or if 4 < PECSS ≤ 6 and D-Dimer ≤ 2.5 mg/L. Comparing with Wells approach, PECSS achieved lower failure rates across all pulmonary embolism severity grades. These findings were validated in the held-out validation set.

CONCLUSIONS

Compared to Wells score, PECSS approaches achieved lower failure rates and better compromise between sensitivity and specificity. Calculation of PECSS is easy and all predictors are readily available upon emergency department admission, making it widely applicable in clinical settings.

TRAIL REGISTRATION

The study was retrospectively registered (No. CJ0647) and approved by Human Genetic Resources in China in April 2022. Ethical approval was received from the Medical Ethics Committee of Zhongshan Hospital (NO.B2021-839R).

Denali Inferior Vena Cava Filter Retrieval: Complications and Success Rates

PURPOSE

The present study was to evaluate the outcomes of Denali filter retrieval.

MATERIALS AND METHODS

We retrospectively reviewed 143 patients who received Denali filter insertion from September 2015 to April 2020. Ninety-seven patients who required removal of the filters were include in this study. Filters were retrieved with either standard or advanced techniques. Venography before and after retrieval was obtained to evaluate technical success, complications and duration of filter insertion.

RESULTS

All 97 filters were retrieved successfully without complications. Ninety-two (94.8%) were retrieved with standard technique and 5 filters (5.2%) required the advanced technique. There were two cases with a filter angle greater than 15 degrees. Inferior vena cava penetration was shown in 17 patients (17.5%) on venography but was not associated with contrast media extravasation after filter removal.

CONCLUSION

The Denali filter showed a high rate of successful retrieval without complications. This study adds value to previous studies and trials showing that the Denali filter is a reliable and safe filter that can potentially improve retrieval rates, with increasing use of this device.

[Ultrasound-accelerated thrombolysis. Initial experience in patients with contraindications to systemic thrombolysis]

Background

acute pulmonary embolism (APE) is a complex and potentially deadly entity, with a variable clinical course, considered the third cardiovascular cause of death. Its management varies according to the stratified risk from anticoagulation to reperfusion therapy, suggesting systemic thrombolysis as a first-choice strategy; however, in a large group of patients their use will be contraindicated, discouraged or will have failed, thus recommending as options in such cases endovascular therapies or surgical embolectomy. With the presentation of 3 clinical cases and a review of the literature, we seek to communicate our initial experience in the use of ultrasound-accelerated thrombolysis with the EKOS system and to investigate key elements for its understanding and application.

Clinical cases

the cases of 3 patients with APE of high and intermediate risk with contraindications for systemic thrombolysis taken to accelerated thrombolysis therapy by ultrasound are discussed. They presented adequate clinical and hemodynamic evolution in the short term, achieving a rapid decrease in thrombolysis, systolic and mean pulmonary arterial pressure, improvement of right ventricular function and reduction of thrombotic burden.

Conclusion

Ultrasound-accelerated thrombolysis is a novel pharmaco-mechanical therapy that combines the emission of ultrasonic waves with the infusion of a local thrombolytic agent, a strategy that, according to different trials and clinical registries, has a high success rate and a good safety profile.

Signs and symptoms of acute pulmonary embolism and their predictive value for all-cause hospital death in respect of severity of the disease, age, sex and body mass index: retrospective analysis of the Regional PE Registry (REPER)

BACKGROUND

The incidence of the signs and symptoms of acute pulmonary embolism (PE) according to mortality risk, age and sex has been partly explored.

PATIENTS AND METHODS

A total of 1242 patients diagnosed with acute PE and included in the Regional Pulmonary Embolism Registry were enrolled in the study. Patients were classified as low risk, intermediate risk or high risk according to the European Society of Cardiology mortality risk model. The incidence of the signs and symptoms of acute PE at presentation with respect to sex, age, and PE severity was investigated.

RESULTS

The incidence of haemoptysis was higher in younger men with intermediate-risk (11.7% vs 7.5% vs 5.9% vs 2.3%; p=0.01) and high-risk PE (13.8% vs 2.5% vs 0.0% vs 3.1%; p=0.031) than in older men and women. The frequency of symptomatic deep vein thrombosis was not significantly different between subgroups. Older women with low-risk PE presented with chest pain less commonly (35.8% vs 55.8% vs 48.8% vs 51.9%, respectively; p=0.023) than men and younger women. However, younger women had a higher incidence of chest pain in the lower-risk PE group than in the intermediate-risk and high-risk PE subgroups (51.9%, 31.4% and 27.8%, respectively; p=0.001). The incidence of dyspnoea (except in older men), syncope and tachycardia increased with the risk of PE in all subgroups (p<0.01). In the low-risk PE group, syncope was present more often in older men and women than in younger patients (15.5% vs 11.3% vs 4.5% vs 4.5%; p=0.009). The incidence of pneumonia was higher in younger men with low-risk PE (31.8% vs<16% in the other subgroups, p<0.001).

CONCLUSION

Haemoptysis and pneumonia are prominent features of acute PE in younger men, whereas older patients more frequently have syncope with low-risk PE. Dyspnoea, syncope and tachycardia are symptoms of high-risk PE irrespective of sex and age.

Using Non-Invasive Respiratory Monitoring for COVID-19 Pulmonary Embolism Diagnosis

With the high incidence rate of pulmonary embolism (PE) and pneumonia reported in hospitalized patients with COVID-19, the ability to determine the dominant etiology for severe respiratory distress quickly and accurately is crucial to a patient's well-being. Traditionally, D-dimer blood tests and diagnostic imaging studies would be utilized to determine the presence of a PE or a venous thromboembolism. However, COVID-19 places patients in a prothrombotic state and performing diagnostic imaging studies on all patients with COVID-19 would be impractical, making the need for a simple and reliable method to determine the likelihood of PE or venous thromboembolism a priority for emergency departments. The authors believe the use of non-invasive respiratory monitoring technology to assess lung function in hospitalized patients with COVID-19 can aid in discerning the dominant hypoxia etiology and tailoring of their treatment. Here, the authors outline a case and method of using non-invasive respiratory monitoring of lung function in the successful diagnosis of a PE in a 62-year-old patient with COVID-19.

[Ethiology, risk factors and Whole blood viscosity index in thromboembolic venous disease]

Backround

Venous thromboembolic disease (VTED) is a frequent cause of hospitalization and mortality. Whole blood viscosity (WBV) participates in the pathogenesis of thrombosis.

Objective

To identify the most frequent etiologies and their association with WBV index (WBVI) in hospitalized patients with VTED.

Material and methods

Observational, cross-sectional, retrospective, analytical study, Group 1: cases (patients diagnosed with VTED) and Group 2: controls without thrombosis. Risk factors for VTED were described and WBVI was calculated from total proteins and hematocrit. Descriptive and inferential statistics were used with Chi-squared test, Fisher's exact test, Mann Whitney U test, bivariate and multivariate logistic regression analysis.

Results

We included 146 patients and 148 controls, age 46.3 ±17.7 vs. 58 ± 18.2 years, of both sexes (female, 65.1%). The most frequent etiology was neoplastic (23.3%), followed by diseases with cardiovascular risk (17.8%). Independent risk factors for VTED were age, chronic kidney disease, presence of liver disease or solid neoplasia. WBVI was similar in patients with VTED as in those without thrombosis. We found an association of the presence of deep vein thrombosis and diseases with cardiovascular risk (p = 0.040).

Conclusions

The presence of chronic kidney disease, liver disease, and solid neoplasia are independent risk factors for VTED. The WBVI is a simple and rapid diagnostic tool in the evaluation of patients with VTED.

Impact of COVID-19 Infection on the Clinical Outcomes of Pulmonary Embolism Hospitalizations : A Nationwide Analysis

BACKGROUND

There is an increased risk of venous thromboembolism among patients with COVID-19 infection, with the risk being higher among those needing intensive level of care. Existing data is, however limited regarding the outcomes of patients admitted with concurrent COVID-19 infection and pulmonary embolism (PE).

METHODS

All acute PE admissions were identified from the National Inpatient Sample database during 2020 using ICD-10 codes. Patients were subsequently classified into those with and without COVID-19 infection. The primary outcome of interest was in-hospital mortality. Using multivariate logistic regression, the predictors of mortality were assessed for patients with concurrent acute PE and COVID-19.

RESULTS

The database query generated 278,840 adult patients with a primary diagnosis of PE. Of these, 4580 patients had concurrent PE and COVID-19 infection. The concurrent PE and COVID-19 infection group had a higher proportion of Black-American and Hispanic patients, and those living in the zip codes associated with lowest annualized income compared to the PE alone group. Furthermore, patients in the concurrent PE and COVID-19 infection group had an increased risk of in-hospital mortality (adjusted odds ratio [aOR]:1.62; 95% CI: 1.17 - 2.24; p = 0.004), septic shock (aOR: 1.66; 95% CI 1.10-2.52; p = 0.016), respiratory failure (aOR: 1.78; 95% CI 1.53-2.06; p = 0.001), and a longer hospital stay [5.5 days vs 4.59 days; p = 0.001).

CONCLUSION

Concurrent COVID-19 and PE admissions is associated with an increased in-hospital mortality, risk of septic shock and respiratory failure, and a longer length of hospital stay.

Pulmonary artery compliance in different forms of pulmonary hypertension

OBJECTIVE

Pulmonary artery compliance (PAC), estimated as stroke volume (SV) divided by pulmonary artery pulse pressure (PP), may be a predictor of survival in pulmonary arterial hypertension (PAH). Resistance-compliance (RC) time, the product of PAC and pulmonary vascular resistance, is reported to be a physiological constant. We investigated if differences in PAC and RC time exist between pulmonary hypertension (PH) subgroups and examined whether PAC is an independent predictor of transplant-free survival in PAH.

METHODS

This was a retrospective analysis of adult PAH (n=532) and chronic thromboembolic PH (CTEPH, n=84) patients enrolled in the US Pulmonary Hypertension Association Registry from 2015 to 2019. PAC and RC time were compared between PH subgroups (connective tissue disease-PAH (CTD-PAH), idiopathic/heritable-PAH (i/h-PAH), drug/toxin-PAH (d/t-PAH)). Cox proportional hazards models were constructed for transplant-free survival, adjusting for REVEAL 2.0 risk score.

RESULTS

There were no differences in estimated PAC between PAH subgroups, nor between PAH and CTEPH. RC time was shorter in CTEPH compared with PAH (median 0.55 (IQR 0.45-0.64) vs 0.62 (0.52-0.73) s, p<0.0001). RC time was shortest in CTD-PAH when compared with i/h-PAH and d/t-PAH ((0.59±0.18) vs (0.65±0.20) vs (0.73±0.25) s, p=0.0001). PAC was associated with transplant-free survival (HR 0.72, 95% CI 0.55 to 0.94, p=0.02) but was not an independent predictor of outcome after adjustment for REVEAL 2.0 score.

CONCLUSION

PAC was similar between PH groups and was not an independent predictor of transplant-free survival in PAH. RC time was different between PH subgroups, challenging RC time constancy.

TRIAL REGISTRATION NUMBER

NCT04071327.

The Effect of Perioperative Fluid Management and Operative Modifications on Mortality and Morbidity in Patients Undergoing Pulmonary Endarterectomy

INTRODUCTION

Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe disease treated with pulmonary endarterectomy. Our study aims to reveal the differences in liquid modalities and operation modifications, which can affect the patients' mortality and morbidity.

METHODS

One hundred twenty-five patients who were diagnosed with CTEPH and underwent pulmonary thromboendarterectomy (PTE) at our center between February 2011 and September 2013 were included in this retrospective study with prospective observation. They were in New York Heart Association functional class II, III, or IV, and mean pulmonary artery pressure was > 40 mmHg. There were two groups, the crystalloid (Group 1) and colloid (Group 2) liquid groups, depending on the treatment fluids. P-value < 0.05 was considered statistically significant.

RESULTS

Although the two different fluid types did not show a significant difference in mortality between groups, fluid balance sheets significantly affected the intragroup mortality rate. Negative fluid balance significantly decreased mortality in Group 1 (P<0.01). There was no difference in mortality in positive or negative fluid balance in Group 2 (P>0.05). Mean duration of stay in the intensive care unit (ICU) for Group 1 was 6.2 days and for Group 2 was 5.4 days (P>0.05). Readmission rate to the ICU for respiratory or non-respiratory reasons was 8.3% (n=4) in Group 1 and 11.7% (n=9) in Group 2 (P>0.05).

CONCLUSION

Changes in fluid management have an etiological significance on possible complications in patient follow-up. We believe that as new approaches are reported, the number of comorbid events will decrease.

Surgical Management of Massive Pulmonary Embolism Presenting with Cardiopulmonary Arrest: How Far Is Too Far?

The incidence of diagnosed massive pulmonary embolism presenting to the Emergency Department is between 3% and 4.5% and it is associated with high mortality if not intervened timely. Cardiopulmonary arrest in this subset of patients carries a very poor prognosis, and various treating pathways have been applied with modest rate of success. Systemic thrombolysis is an established first line of treatment, but surgeons are often involved in the decision-making because of the improving surgical pulmonary embolectomy outcomes.

Complexities and complications of extreme obesity

Obesity is a common chronic disorder and has detrimental long-term consequences if left untreated. Herein, we report a case of a young lady who suffered from morbid obesity and many of its consequences, and we present a literature review of these complications. While the cause of obesity is multifactorial, the genetic component is particularly important in the pathophysiology of marked obesity. Resistance to Leptin is considered one of the main causes of obesity. There is a unique relationship between polycystic ovary syndrome and obesity, as observed in our case. Obesity is associated with cardiovascular and lung diseases such as heart failure, thromboembolic disease, sleep apnea, and pulmonary hypertension. Our patient had cardiomegaly (730 gm) with eccentric hypertrophy of left and right ventricles. The coronary arteries and aorta were free of atherosclerosis, which is a surprising finding that relates to the mysterious phenomenon of obesity paradox. The terminal event in our young woman was multiple segmental and subsegmental pulmonary arterial thrombi/thromboemboli superimposed on chronic cardiopulmonary stress due to massive obesity.

An Ambulatory Pathway for the Investigation of Patients with Suspected Pulmonary Embolism

Aims The aim of this project was to provide an ambulatory pathway for diagnosis and management of patients with suspected Pulmonary Embolism (PE) with "low-risk" features. Methods A structured algorithm for the management of suspected PE was designed and implemented in April 2021. This involved the development of local guidelines to identify those "low-risk" patients with suspected PE, through the use of modified sPESI and Hestia criteria. This pathway was audited monthly to establish effect on admission and hospital length of stay. Results 51 CT PAs were performed by the Emergency Department in April 2021. Total number of CT confirmed PEs in April was 7(11%). 12 "low-risk" patients with suspected PE were identified and placed on the "Ambulatory Suspected Pulmonary Embolism Pathway". One (8.3%) patient on this pathway had a confirmed PE. Patients placed on this pathway spent significantly less time in the Emergency Department and in hospital with greater satisfaction by physicians using this pathway. Conclusion This pathway has succeeded in significantly decreasing length of stay both in the ED and in hospital for patients with suspected and confirmed PE.

Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022

No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.

Fatal pulmonary embolism in patients on antipsychotics: case series, systematic review and meta-analysis

Since the 1950 s, several studies have reported that patients using first generation and/or second-generation antipsychotics had increased risk of venous thromboembolism events. These events include deep vein thrombosis and/or pulmonary embolism (PE). However, data about fatal PE in patients on antipsychotics (APs) remain scarce. Thus, the current study aimed to investigate sociodemographic, clinical and pharmacological characteristics related to psychiatric patients on APs and who died from a fatal PE. We reported a case-series, then conducted a literature review of relevant studies and performed a meta-analysis of studies with usable data. The main outcome of the study suggested a significantly high risk of fatal PE in patients using APs compared to nonusers (Odds Ratio=6.68, with 95% confidence interval 1.43-31.11). Clozapine was the most incriminated drug. Low potency first generation APs were the second most exhibited medication. Studies about the topic remain scarce with a high heterogeneity and a high probability of bias. Further studies are needed to ascertain this risk and to establish target preventive measures in this particularly vulnerable population.

Contemporary Practice Patterns and Outcomes of Systemic Thrombolysis in Acute Pulmonary Embolism

OBJECTIVE

While systemic thrombolysis (ST) is standard of care in treatment of high-risk pulmonary embolism, large variation in real world usage exists, including use in intermediate-risk pulmonary embolism. There is a paucity of data defining the outcomes, practice patterns of ST dose, duration, and treatment in presumed or imaging confirmed pulmonary embolism.

METHODS

We performed a multicenter retrospective study evaluating real world practice patterns of systemic thrombolysis use in the setting of acute pulmonary embolism (presumed versus imaging confirmed intermediate- and high-risk). Patients who received tissue plasminogen activator for pulmonary embolism between 2017 and 2019 were included. We compared baseline clinical characteristics, tissue plasminogen activator practice patterns, and outcomes in those with confirmed versus presumed pulmonary embolism.

RESULTS

104 patients received systemic thrombolysis for pulmonary embolism; 52 patients had confirmed pulmonary embolism and 52 patients had presumed pulmonary embolism. Significantly more patients treated for presumed pulmonary embolism experienced cardiac arrest (n=47, 90%) than those with confirmed pulmonary embolism (n=23, 44%, p<0.01). Survival to hospital discharge was 65% in patients with confirmed pulmonary embolism versus 6% for those with presumed pulmonary embolism (p<0.01). Systemic thrombolysis was contraindicated in 56% of patients with confirmed pulmonary embolism, with major bleeding in 26% but no intracranial hemorrhage.

CONCLUSIONS

The in-hospital mortality of confirmed acute pulmonary embolism remains high (35%) in contemporary practice in those treated with systemic thrombolysis. A large proportion of these patients had contraindications to systemic thrombolysis and major bleeding rates were significant. Confirmed pulmonary embolism had higher survival rate compared to presumed, including those with cardiac arrest. This observation suggests a limited role of empiric thrombolysis in cardiac arrest situations.

Assembling the Puzzle: Taking into Account Clinical Presentation and Predictive Scores

Syncope is a common cause of emergency department visits. Physicians must scrutinize for life-threatening causes to avoid patient morbidity and mortality. Clinical decision rules are used to stratify risks and guide the course of action, including the need for further testing. This is the case of a 83-year-old man was brought to the emergency department after a 5-minute episode of sudden loss of consciousness. Vital signs showed hypotension and physical examination was unremarkable. Despite Wells score of 0, clinical suspicion for pulmonary embolism persisted, for which further testing was pursued. D-dimer was elevated at 13.77 mcg/mL and a chest computed tomography with angiography showed an extensive bilateral pulmonary embolism involving the distal right and left main pulmonary arteries. He was started on full-dose anticoagulation. This case exemplifies the need of high clinical suspicion along with the importance of applying predictive scores for diagnosing unusual causes of syncope.

Incidence of Venous Thromboembolism: The 3rd Korean Nationwide Study

BACKGROUND

The incidence of venous thromboembolism (VTE) has gradually increased in the Korean population. This study aimed to evaluate the annual age- and sex-adjusted incidence rates (ASR) of VTE and anticoagulation trends between 2014 and 2018.

METHODS

Using the Korean Health Insurance Review and Assessment Service database, we retrospectively identified VTE patients between 2014 and 2018 using both diagnostic and medication anticoagulant codes assigned within 6 months of the initial index event. Anticoagulant patterns were classified as follows: direct oral anticoagulants (DOAC), parenteral anticoagulants, warfarin, and mixed anticoagulation regimens.

RESULTS

We identified 95,205 patients with VTE (female, 56.8%). The ASR for VTE per 100,000 person-years increased from 32.8 in 2014 to 53.7 cases in 2018 (relative risk of 1.63; 95% confidence interval, 1.6-1.67). The VTE incidence rates were 25 times higher in the ≥ 80 group than in the 30s group. VTE occurred 1.29 times more often in women than in men. The proportion of DOAC prescriptions increased from 40.5% to 72.8%, whereas warfarin prescriptions decreased from 27% to 5.6% in 2014 and 2018.

CONCLUSION

In Korea, the ASRs of VTE continued to increase since 2014, but the rate of increase slowed in 2018. The VTE occurred more often in the elderly and in women. Five years after the introduction of DOACs in 2013, they accounted for 73% of all anticoagulants used to treat VTE.

D-dimer: an analyte with increasing application in Covid-19 infection

INTRODUCTION

: D- Dimer levels from peripheral blood are increasingly used to assess various pathological conditions. Initially an area for haematologists, now this analyte is evaluated more extensively from many specialities of medicine. Covid-19 infection has not only added a new dimension to D-Dimer level assessment in this disease but has also shed newer lights to the underlying pathophysiological mechanisms for its elevation in this disease.

AREAS COVERED

Innate variability in measuring D- Dimer levels, Impact of various techniques in measuring D- Dimer, non availability of uniform controls and standards, molecular heterogeneity of the product, how it is produced. Reasons for raised D- Dimer in covid-19 infection. D- Dimer in other pathological states. Articles with relevant key words from 1990 searched in PubMed were utilized for review.

EXPERT OPINION

: D-Dimer has important application in diagnosis, prognosis, management and understanding various conditions. Its level can rise with increased coagulability of blood, sepsis, cytokine storm and snake bite etc. Renal function, age influences its reference ranges. Units of measurement, its expression varies in different reports needing international standardization. In Covid-19 infection its levels correlate with stage of the disease, pathology and complications.

CT Angiography for the Detection of Pulmonary Embolism: Role of Tube Voltage and Contrast Injection Rate on Diagnostic Confidence

RATIONALE AND OBJECTIVES

Pulmonary CTA is the current standard method to assess for suspected pulmonary embolism. In some instances, the test results in low confidence interpretations. Our purpose was to compare the diagnostic confidence for three different scan protocols.

MATERIALS AND METHODS

Pulmonary CTA images from 401 patients were retrospectively analyzed. 202 studies used a tube voltage of 120 kVp and a contrast injection rate of 4 cc/s, 99 studies 120 kVp and 5 cc/s, and 100 studies 100 kVp and 4 cc/s. The level of diagnostic confidence was extracted from the final clinical reports. For each study, attenuation of the pulmonary artery, image noise, signal-to-noise ratio (SNR), and radiation dose were compared.

RESULTS

The 120 kVp, 5 cc/s protocol resulted in high diagnostic confidence in 84% of cases, more than with the 120 kVp, 4cc/s (65%) and the 100 kVp protocol (65%, p < 0.004). The 100 kVp protocol had a lower radiation dose, higher image noise, lower SNR, but equal and higher attenuation values of the pulmonary artery.

CONCLUSION

The reduction of tube voltage to 100 kVp at 4 cc/s maintains diagnostic confidence with lower radiation exposure, but does not equal the higher confidence achieved with 120 kVp at 5cc/s.

Semiautomatic Identification of Pulmonary Embolism in Electronic Health Records Through Sentence Labeling

In this study, we tested the quality of the information extraction algorithm proposed by our group to detect pulmonary embolism (PE) in medical cases through sentence labeling. Having shown a comparable result (F1 = 0.921) to the best machine learning method (random forest, F1 = 0.937), our approach proved not to miss the information of interest. Scoping the number of texts under review down to distinct sentences and introducing labeling rules contributes to the efficiency and quality of information extraction by experts and makes the challenging tasks of labeling large textual datasets solvable.

Association between myocardial fibrosis, as assessed with cardiac magnetic resonance T1 mapping, and persistent dyspnea after pulmonary embolism

Background

Persistent dyspnea is a common symptom after pulmonary embolism (PE). However, the pathophysiology of persistent dyspnea is not fully clarified. This study aimed to explore possible associations between diffuse myocardial fibrosis, as assessed by cardiac magnetic resonance (CMR) T1 mapping, and persistent dyspnea in patients with a history of PE.

Methods

CMR with T1 mapping and extracellular volume fraction (ECV) calculations were performed after PE in 51 patients with persistent dyspnea and in 50 non-dyspneic patients. Patients with known pulmonary disease, heart disease and CTEPH were excluded.

Results

Native T1 was higher in the interventricular septum in dyspneic patients compared to non-dyspneic patients; difference 13 ms (95% CI: 2–23 ms). ECV was also significantly higher in patients with dyspnea; difference 0.9 percent points (95% CI: 0.04–1.8 pp). There was no difference in native T1 or ECV in the left ventricular lateral wall. Native T1 in the interventricular septum had an adjusted Odds Ratio of 1.18 per 10 ms increase (95% CI: 0.99–1.42) in predicting dyspnea, and an adjusted Odds Ratio of 1.47 per 10 ms increase (95% CI: 1.10–1.96) in predicting Incremental Shuttle Walk Test (ISWT) score < 1020 m.

Conclusion

Septal native T1 and ECV values were higher in patients with dyspnea after PE compared with those who were fully recovered suggesting a possible pathological role of myocardial fibrosis in the development of dyspnea after PE. Further studies are needed to validate our findings and to explore their pathophysiological role and clinical significance.

Risk Stratification of Pulmonary Thromboembolism using Brain Natriuretic Peptide and Troponin I; a Brief Report

INTRODUCTION

Pulmonary thromboembolism (PTE) is one of the most prevalent medical disorders, with a notable annual fatality rate. This study aimed to evaluated the accuracy of serum pro-BNP and troponin I levels in PTE diagnosis.

METHODS

This cross-sectional study was implemented on 267 patients with suspected PTE (sudden chest pain or sudden dyspnea) in Imam Reza Hospital in Mashhad, Iran. All patients underwent pulmonary computed tomography (CT) angiography (as the gold standard test) and their serum levels of troponin I and pro-BNP were measured. The screening performance characteristics of pro-BNP in detection of PTE cases were measured and reported using receiver operating characteristic (ROC) curve analysis.

RESULTS

Two-hundred-sixty-seven patients with a mean age of 67.7 ±11.5 years were evaluated (60.1% male). PTE was confirmed via CT angiography in 121 patients. The area under the ROC curve of troponin I and pro-BNP in detection of PTE was 0.501 ng/mL and 0.972 pg/mL, respectively. The sensitivity and specificity of proBNP at the best cut-off point (100 pg/ml) were 85.4% and 80.2%, respectively. The sensitivity and specificity of troponin I at the best cut-off point (0.005 ng/ml) were 65.5% and 42%, respectively.

CONCLUSION

Due to the comparatively good sensitivity and specificity of proBNP in diagnosis of pulmonary thromboembolism, it can be employed as a diagnostic determinant in patients with suspected pulmonary thromboembolism along with other laboratory tests.

An efficient and fast multi-band focused bioimpedance solution with EIT-based reconstruction for pulmonary embolism assessment: a simulation study from massive to segmental blockage

OBJECTIVE

Pulmonary embolism (PE) is an acute condition that blocks the perfusion to the lungs and is a common complication of Covid-19. However, PE is often not diagnosed in time, especially in the pandemic time due to complicated diagnosis protocol. In this study, a non-invasive, fast and efficient bioimpedance method with the EIT-based reconstruction approach is proposed to assess the lung perfusion reliably.

APPROACH

Some proposals are presented to improve the sensitivity and accuracy for the bioimpedance method: (1) a new electrode configuration and focused pattern to help study deep changes caused by PE within each lung field separately, (2) a measurement strategy to compensate the effect of different boundary shapes and varied respiratory conditions on the perfusion signals and (3) an estimator to predict the lung perfusion capacity, from which the severity of PE can be assessed. The proposals were tested on the first-time simulation of PE events at different locations and degrees from segmental blockages to massive blockages. Different object boundary shapes and varied respiratory conditions were included in the simulation to represent for different populations in real measurements.

RESULTS

The correlation between the estimator and the perfusion was very promising (R = 0.91, errors < 6%). The measurement strategy with the proposed configuration and pattern has helped stabilize the estimator to non-perfusion factors such as the boundary shapes and varied respiration conditions (3-5% errors).

SIGNIFICANCE

This promising preliminary result has demonstrated the proposed bioimpedance method's capability and feasibility, and might start a new direction for this application.

Added Value of Dual-Energy CT in COVID-19 Pneumopathy

Teaching point: The use of dual-energy instead of conventional single-energy computed tomography pulmonary angiogram can provide additional value concerning the diagnosis of COVID-19 and its complications, especially in the detection of small pulmonary embolism.

An Untapped Resource: Characteristics of Thrombus Recovered from Intermediate or High Risk Pulmonary Embolus Patients

INTRODUCTION

Response to anticoagulation varies during management of acute hospitalized pulmonary embolism. We aimed to study thrombus histology in pulmonary embolism samples removed during acute surgical embolectomy to evaluate whether thrombus morphology was similar between patients and whether there was an association with duration of symptoms and/or resolution on follow up imaging.

METHODS

This was a retrospective observational single center study at the University of Rochester Medical Center. We evaluated patients that underwent acute surgical embolectomy and followed up in our clinic 2-4 months after the event with Ventilation/Perfusion (V/Q) scan obtained for all regardless of symptoms. Thromboemboli were formalin fixed and processed for light microscopy in the hospital histopathology laboratory. Four-micron thick sections were stained with hematoxylin and eosin, Masson trichrome, and Verhoeff elastic tissue stains. Immunohistochemistry was performed using anti-CD31 and anti-CD68. Slides were independently evaluated for time-dependent microscopic changes using Irniger's classification by two blinded pathologists.

RESULTS

Sixteen patients underwent embolectomy with fifteen having V/Q imaging at follow up. The majority of patients were female. Samples showed a generally similar overall architecture that included a central core composed primarily of red blood cells and fibrin and an outer layer of platelets and monocytes. Two samples had evidence of fibrosis and recanalization.

CONCLUSIONS

We found heterogeneous histopathology in samples obtained during acute embolectomy. Further prospective studies should systematically characterize clot morphology and evaluate treatment response and outcomes. Careful thrombus specimen measurement and consistent sampling for sections will be required to draw firm conclusions.

Right Atrial Thrombus in a Patient of Rheumatic Heart Disease with Severe Mitral Regurgitation: A Rare Association

BACKGROUND

Right atrial thrombus is a rare phenomenon, and its incidence is not well-defined. It usually occurs in the presence of predisposing factors like tricuspid stenosis or following central venous catheterization. Isolated right atrial thrombus without any predisposing factors occurs rarely.

CASE PRESENTATION

We herein report a 30-year-old male patient, a known case of rheumatic heart disease with mitral regurgitation, presented with severe breathlessness and orthopnea. He was diagnosed with acute pulmonary oedema with biventricular dysfunction and congestive symptoms. On transthoracic 2D echocardiography, he was found to have severe mitral and severe tricuspid regurgitation. All cardiac chambers were dilated, and an incidental finding of right atrial thrombus was noted. The patient was managed conservatively, but he succumbed to his worsening heart failure.

CONCLUSION

Treating physicians should be aware of the possibility of right atrial thrombus in rheumatic mitral valve disease because of its clinical implications, like life-threatening pulmonary embolization and need of surgical management.

The Impact of Pop-Up Clinical Electronic Health Record Decision Tools on Ordering Pulmonary Embolism Studies in the Emergency Department

BACKGROUND

Emergency physicians make time-sensitive care decisions for life threatening diagnoses and utilize evidence-based decision rules and testing with high sensitivity to ensure that critical diagnoses are not missed. Current literature suggests that there is over testing for pulmonary embolism in the emergency department.

OBJECTIVES

This study aimed to determine whether the addition of a pop-up notification of the Modified Wells Criteria into the workflow would impact the number of total orders for computed tomography pulmonary angiography (CTPA) or the diagnostic yield of those studies.

METHODS

This study was a retrospective observational study comparing CTPA utilization rates and diagnostic yield among physicians at a single academic emergency department in the 1 year prior and 1 year post implementation of an active electronic health recored (EHR) pop-up of Modified Well's scoring when ordering a CTPA.

RESULTS

CTPA utilization rates were statistically equivalent, p <0.0001 within a 0.5% equivalence margin, during the pre and post intervention years. The observed difference was 0.1% (95% CI -0.02%, 0.21%). Despite proving equivalence in the rates of CTPA studies ordered, the diagnostic yield, however, was significantly different (p = 0.001), 32.35% in the pre-intervention year compared to 41.60% in the post-intervention year.

CONCLUSION

There are many barriers to the implementation of successful EHR alerts. These findings support and validate previous studies that have shown a higher diagnostic yield of CT angiography for pulmonary embolism after implementation of active alerts integrated into the EHR with ordering studies. These tools are effective quality improvement initiatives, and their use should be encouraged.

[Prophylaxis of Venous Thromboembolism in Psychiatric Inpatients]

N/a.

Seeking an Optimal Approach for Computer-Aided Pulmonary Embolism Detection

Pulmonary embolism (PE) represents a thrombus ("blood clot"), usually originating from a lower extremity vein, that travels to the blood vessels in the lung, causing vascular obstruction and in some patients, death. This disorder is commonly diagnosed using CT pulmonary angiography (CTPA). Deep learning holds great promise for the computer-aided CTPA diagnosis (CAD) of PE. However, numerous competing methods for a given task in the deep learning literature exist, causing great confusion regarding the development of a CAD PE system. To address this confusion, we present a comprehensive analysis of competing deep learning methods applicable to PE diagnosis using CTPA at the both image and exam levels. At the image level, we compare convolutional neural networks (CNNs) with vision transformers, and contrast self-supervised learning (SSL) with supervised learning, followed by an evaluation of transfer learning compared with training from scratch. At the exam level, we focus on comparing conventional classification (CC) with multiple instance learning (MIL). Our extensive experiments consistently show: (1) transfer learning consistently boosts performance despite differences between natural images and CT scans, (2) transfer learning with SSL surpasses its supervised counterparts; (3) CNNs outperform vision transformers, which otherwise show satisfactory performance; and (4) CC is, surprisingly, superior to MIL. Compared with the state of the art, our optimal approach provides an AUC gain of 0.2% and 1.05% for image-level and exam-level, respectively.