Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project

CONTEXT

There are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU).

OBJECTIVE

To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria.

METHODS

In a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to "do not resuscitate" (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs.

RESULTS

In 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR-adjusted odds ratio (AOR) = 7.5; 95% CI 5.6-9.9) and hospice referrals-(AOR = 7.6; 95% CI 5.0-11.7). They had slightly lower 30-day readmissions-(AOR = 0.7; 95% CI 0.5-1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation-by Day 4 of admission-was associated with reductions in LOS (1.7 days [95% CI -3.1, -1.2]) and average direct variable costs (-$1815 [95% CI -$3322, -$803]) compared to those who received no PCC.

CONCLUSION

Receiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered.

Reconstructed 4-chamber views compared with axial imaging for assessment of right ventricular enlargement on CT pulmonary angiograms

PURPOSE

To test the hypothesis that right enlargement assessed from right ventricular/left ventricular (RV/LV) dimension ratios of computed tomographic (CT) angiograms are equivalent irrespective of whether measured on axial views or reconstructed 4-chamber views.

METHODS

RV/LV dimension ratios were calculated from measurements on axial views, manually reconstructed 4-chamber views and computer generated reconstructed 4-chamber views of CT angiograms in 152 patients with PE.

RESULTS

Paired readings of the axial view and manually reconstructed 4-chamber view showed agreement with RV/LV > or =1 or RV/LV <1 in 114 of 127 (89.8%). Paired readings also showed agreement in 119 of 127 (93.7%) with axial views and computer generated reconstructed 4-chamber views. The McNemar test showed no statistically significant difference between assessments of RV enlargement (RV/LV > or = 1) with any method.

CONCLUSION

Right ventricular enlargement can be determined from axial views on CT angiograms, which are readily and immediately available, without obtaining 4-chamber reconstructed views.

Enlarged right ventricle without shock in acute pulmonary embolism: prognosis

OBJECTIVE

An unsettled issue is the use of thrombolytic agents in patients with acute pulmonary embolism (PE) who are hemodynamically stable but have right ventricular (RV) enlargement. We assessed the in-hospital mortality of hemodynamically stable patients with PE and RV enlargement.

METHODS

Patients were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis II. Exclusions included shock, critical illness, ventilatory support, or myocardial infarction within 1 month, and ventricular tachycardia or ventricular fibrillation within 24 hours. We evaluated the ratio of the RV minor axis to the left ventricular minor axis measured on transverse images during computed tomographic angiography.

RESULTS

Among 76 patients with RV enlargement treated with anticoagulants and/or inferior vena cava filters, in-hospital deaths from PE were 0 of 76 (0%) and all-cause mortality was 2 of 76 (2.6%). No septal motion abnormality was observed in 49 patients (64%), septal flattening was observed in 25 patients (33%), and septal deviation was observed in 2 patients (3%). No patients required ventilatory support, vasopressor therapy, rescue thrombolytic therapy, or catheter embolectomy. There were no in-hospital deaths caused by PE. There was no difference in all-cause mortality between patients with and without RV enlargement (relative risk=1.04).

CONCLUSION

In-hospital prognosis is good in patients with PE and RV enlargement if they are not in shock, acutely ill, or on ventilatory support, or had a recent myocardial infarction or life-threatening arrhythmia. RV enlargement alone in patients with PE, therefore, does not seem to indicate a poor prognosis or the need for thrombolytic therapy.

Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II

BACKGROUND

Selection of patients for diagnostic tests for acute pulmonary embolism requires recognition of the possibility of pulmonary embolism on the basis of the clinical characteristics. Patients in the Prospective Investigation of Pulmonary Embolism Diagnosis II had a broad spectrum of severity, which permits an evaluation of the subtle characteristics of mild pulmonary embolism and the characteristics of severe pulmonary embolism.

METHODS

Data are from the national collaborative study, Prospective Investigation of Pulmonary Embolism Diagnosis II.

RESULTS

There may be dyspnea only on exertion. The onset of dyspnea is usually, but not always, rapid. Orthopnea may occur. In patients with pulmonary embolism in the main or lobar pulmonary arteries, dyspnea or tachypnea occurred in 92%, but the largest pulmonary embolism was in the segmental pulmonary arteries in only 65%. In general, signs and symptoms were similar in elderly and younger patients, but dyspnea or tachypnea was less frequent in elderly patients with no previous cardiopulmonary disease. Dyspnea may be absent even in patients with circulatory collapse. Patients with a low-probability objective clinical assessment sometimes had pulmonary embolism, even in proximal vessels.

CONCLUSION

Symptoms may be mild, and generally recognized symptoms may be absent, particularly in patients with pulmonary embolism only in the segmental pulmonary branches, but they may be absent even with severe pulmonary embolism. A high or intermediate-probability objective clinical assessment suggests the need for diagnostic studies, but a low-probability objective clinical assessment does not exclude the diagnosis. Maintenance of a high level of suspicion is critical.

Very Low Probability Interpretation of V/Q Lung Scans in Combination with Low Probability Objective Clinical Assessment Reliably Excludes Pulmonary Embolism: Data from PIOPED II

Use of a very low probability interpretation of ventilation/perfusion (V/Q) lung scans, if verified by prospective evaluation to have a low positive predictive value (PPV), will reduce the number of nondiagnostic interpretations of V/Q scans and may be particularly useful in patients with a relative contraindication to CT. The purpose of this investigation was to test the hypothesis that a very low probability interpretation of the V/Q scan has a PPV of <10%.

METHODS

Data are from PIOPED II (Prospective Investigation of Pulmonary Embolism Diagnosis II). Very low probability criteria are (a) nonsegmental perfusion abnormalities, (b) perfusion defect smaller than corresponding radiographic lesion, (c) > or =2 matched V/Q defects with regionally normal chest radiograph, (d) 1-3 small segmental perfusion defects (<25% of a segment), (e) solitary triple matched defect in middle or upper lung zones, (f) stripe sign around the perfusion defect(s), and (g) perfusion defect from pleural effusion equal to one third or more of the pleural cavity with no other perfusion defect.

RESULTS

A very low probability consensus interpretation of the V/Q scan was made in 56% of patients. The PPV of a very low probability interpretation of the V/Q scans was 36 of 440 patients (8.2%). Among patients with suspected pulmonary embolism who had a low clinical probability objective clinical assessment and a very low probability V/Q scan, the PPV was 8 of 259 patients (3.1%). Among women < or =40 y, the PPV of the very low probability V/Q with a low objective clinical assessment was 1 of 50 (2%).

CONCLUSION

The very low probability V/Q scan together with a low probability clinical assessment reliably excludes pulmonary embolism.

CT Venography for Deep Venous Thrombosis: Continuous Images Versus Reformatted Discontinuous Images Using PIOPED II Data

OBJECTIVE

This study was designed to determine whether discontinuous CT of the lower extremities for the detection of deep venous thrombosis (DVT) yields results similar to those of complete helical imaging using cases from the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II).

MATERIALS AND METHODS

In PIOPED II, CT venography followed CT angiography (CTA) to detect pulmonary embolus, using 7.5-mm continuous helical imaging from the iliac crest to the tibial plateau. DVT was detected in 105 of 737 patients (14.2%). We randomly chose 54 positive cases and 96 negative cases for our study. The continuous helical images were reformatted as 7.5-mm images and two of every three images were deleted. These images (7.5 mm; skip = 15 mm) were then sent--without identifying information--to the original reviewers. From 1 to 3.5 years had elapsed since the original interpretations. The results of the new interpretations were compared with the original CT venography consensus interpretations of PIOPED II.

RESULTS

There was agreement for the presence of DVT in at least one leg (same leg) or for the absence of DVT in both legs in 133 of the 150 study patients (89%). The kappa statistic showed substantial agreement between the consensus interpretations and the test interpretations (kappa = 0.75; 95% CI = 0.64-0.86) per patient.

CONCLUSION

There was good--but not perfect--agreement between continuous helical and discontinuous axial imaging for the detection of DVT. Given the vagaries of interobserver and intraobserver variation, there appears to be little difference between the two approaches. Adopting discontinuous imaging and other dose-reduction strategies can reduce pelvic radiation by more than 75%.

Usefulness of multidetector spiral computed tomography according to age and gender for diagnosis of acute pulmonary embolism

Data from the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) were evaluated to test the hypothesis that the performance of multidetector computed tomographic (CT) pulmonary angiography and CT venography is independent of a patient's age and gender. In 773 patients with adequate CT pulmonary angiography and 737 patients with adequate CT pulmonary angiography and CT venography, the sensitivity and specificity for pulmonary embolism for groups of patients aged 18 to 59, 60 to 79, and 80 to 99 years did not differ to a statistically significant extent, nor were there significant differences according to gender. Overall, however, the specificity of CT pulmonary angiography was somewhat greater in women, but in men and women, it was > or =93%. In conclusion, the results indicate that multidetector CT pulmonary angiography and CT pulmonary angiography and CT venography may be used with various diagnostic strategies in adults of all ages and both genders.

Pulmonary embolism and deep venous thrombosis in hospitalized adults with chronic obstructive pulmonary disease

BACKGROUND

Hospitalized patients with exacerbations of chronic obstructive pulmonary disease (COPD), when routinely evaluated for pulmonary embolism (PE), show PE in 25-29% of cases. We assessed the rate of diagnosis of PE and deep venous thrombosis (DVT) in hospitalized patients with COPD and the influence of age on relative risk compared with hospitalized patients who do not have COPD.

METHODS

A retrospective evaluation of data in hospitalized adults with and without COPD from the National Hospital Discharge Survey.

RESULTS

From 1979 to 2003, 58,392,000 adults 20 years of age and older, were hospitalized with COPD in the United States. Among these patients, PE was diagnosed in 381,000 (0.65%) and DVT in 632,000 (1.08%). The relative risk of PE in adults hospitalized with COPD was 1.92 and for DVT it was 1.30. Relative risks were age dependent. Among those aged 20-39 years with COPD, the relative risk of PE was 5.34. Among patients aged 40-59 years, the relative risk of PE decreased to 2.02, and among patients aged 60-79 years the relative risk of PE was 1.23.

CONCLUSION

These data, when compared with the rate of diagnosis of PE in hospitalized patients with exacerbations of COPD, all of whom were evaluated for PE, indicate that PE in patients with COPD is generally underdiagnosed. In young adults, other risk factors in combination with COPD are uncommon, so the contribution of COPD to the risk of PE becomes more apparent than in older patients.

Catheter-tip embolectomy in the management of acute massive pulmonary embolism

Three catheter interventional techniques are currently available for removing or fragmenting pulmonary emboli: aspiration thrombectomy, fragmentation, and rheolytic thrombectomy. The investigators systematically reviewed all available published research related to the use of catheter-tip devices in patients with pulmonary emboli. Pooled data showed that clinical success with the Greenfield catheter occurred in 72 of 89 patients (81%) when used alone and in 19 of 19 patients (100%) when used in combination with thrombolytic agents. Fragmentation with standard catheters used alone (without thrombolytic agents) was reported in only 3 patients. Clinical success with standard angiographic catheters occurred in 15 of 21 patients (71%) when used in combination with systemic thrombolytic agents and in 115 of 121 patients (95%) when used with local infusions of thrombolytic agents. Data for the Amplatz catheter, the rheolytic Angiojet catheter, and the Hydrolyser catheter when used alone were sparse or absent. Clinical success when used in combination with thrombolytic agents occurred in 6 of 6 patients (100%) with the Amplatz catheter, in 20 of 23 patients (87%) with the Angiojet catheter, and in 19 of 20 patients (95%) with the Hydrolyser catheter. Minor bleeding at the insertion site among all patients, with and without thrombolytic agents, occurred in 29 of 348 patients (8%), and major bleeding at the insertion site occurred in 8 of 348 patients (2%). One patient experienced perforation of the right ventricle with the Greenfield catheter. None reported perforation of a pulmonary artery. In conclusion, all the devices analyzed in this study appear to be useful in the management of acute massive pulmonary emboli.

Outcome of pulmonary embolectomy

In view of the importance of pulmonary embolectomy as a possible treatment option in highly compromised patients with acute pulmonary embolism, a systematic review of immediate surgical outcomes was performed. Pooled data from 46 reported case series of patients operated from 1961 to 2006 showed an average mortality of 389 of 1,300 patients (30%). In patients operated on before 1985, the average mortality was 32%, compared with 20% in patients operated from 1985 to 2005. In patients who experienced cardiac arrest before pulmonary embolectomy, the operative mortality was 59% compared with 29% in patients who did not have preoperative cardiac arrest. In conclusion, despite generally high mortality in patients who undergo pulmonary embolectomy, it may have life-saving potential in some instances.

Pulmonary embolism as a cause of death in adults who died with heart failure

Although heart failure (HF) is a known risk factor for pulmonary embolism (PE), little is known about the frequency of death from PE in patients who die with HF. This investigation was undertaken to determine the frequency of PE as the cause of death in patients who died with HF on the basis of data from death certificates, as listed by the United States Census Bureau. Among adults with HF who died over the 19-year period of study, PE was the listed cause of death in 20,387 of 755,807 (2.7%). Assuming that the accuracy of death certificates was only 26.7%, the rate of death from PE in these patients may have been as high as 10.1%. The frequency of death from PE in patients who died with HF decreased from 1980 to 1998. In conclusion, the estimated death rate from PE in patients who died with HF is 3% to 10%. A decrease over 2 decades in the proportion of deaths from PE in such patients is compatible with the increasing and effective use of antithrombotic prophylaxis.

Noninvasive imaging of the coronary arteries

A reliable noninvasive imaging method for significant coronary artery stenosis would have enormous implications related to cost of diagnosis and enhanced patient safety. Cardiac motion and calcified plaques, in the past, rendered a substantial number of computed tomographic (CT) images of the coronary arteries uninterpretation. The accuracy of multidetector CT for the detection of coronary stenosis appears to have progressively improved as the imaging equipment increased from 4-slice and 16-slice to 64-slice CT. With 64-slice CT, scanning of the entire coronary artery tree is possible in 10 to 13 s. Pooled data of results of a few investigations with 64-slice CT showed that the proportion of unevaluable segments is only 4%. The sensitivity of 64-slice CT for the detection of significant (>50% or = or >50%) coronary stenosis in a patient, based on pooled data, was 97% and specificity was 91%. Regarding detection of significant stenosis in any segment, the sensitivity, based on pooled data, was 91% with 64-slice CT and specificity was 96%. In a limited number of patients, sensitivity for detection of significant stenoses in proximal segments was 100%, in mid segments it was 94%, and in distal segments sensitivity it was 80%. Multi-detector CT provides the opportunity to quantify non-calcified coronary artery plaques, which may potentially be a strong predictor of cardiac events. It was also shown to be useful for the detection of stenosis in coronary artery bypass grafts.

Deep venous thrombosis and pulmonary embolism in hospitalized patients with sickle cell disease

BACKGROUND

As would be expected with a hypercoagulable state, pulmonary embolism (PE) occurs in sickle cell disease (SCD). Its frequency, however, is undetermined, largely because of difficulties in distinguishing it from thrombosis in situ. The prevalence of deep venous thrombosis (DVT) is also undetermined in patients with SCD. Knowing the prevalence of DVT would be an important step in the overall assessment of the risk of PE in these patients.

METHODS

Data from the National Hospital Discharge Survey were assessed.

RESULTS

In patients <age 40 years, 7000 of 1,581,000 (0.44%) with SCD had a discharge diagnosis of PE compared with 59,000 of 48,611,000 (0.12%) of African Americans without SCD. The prevalence of DVT was similar in patients < age 40 with SCD, 7000 of 1,581,000 (0.44%) and in African Americans who did not have SCD, 193,000 of 48,611,000 (0.40%).

CONCLUSION

The high prevalence of apparent PE in patients with SCD, compared with non-SCD African-American patients of the same age and the comparable prevalence of DVT in both groups are compatible with the concept that thrombosis in situ might be present in many. On the other hand, the data suggest that PE is not rare in patients with SCD. This suggests that PE might be an etiologic factor in patients with SCD who develop respiratory symptoms. In such patients, an imaging procedure might be appropriate.

Risk of venous thromboembolism in patients hospitalized with heart failure

Because of uncertainty about the prevalence of pulmonary embolism (PE) and deep venous thrombosis (DVT) in hospitalized patients with congestive heart failure (CHF), data from the National Hospital Discharge Survey were investigated. Among hospitalized patients with CHF, PE was diagnosed in 0.73% and DVT in 1.03%. The relative risk for PE in patients with CHF compared with patients with no CHF was 2.15; for DVT, it was 1.21. The relative risk for PE in patients with CHF was greatest in patients <40 years of age (relative risk 11.72), and the relative risk for DVT was 5.46. In conclusion, a high relative risk for PE, DVT, and venous thromboembolism was shown in patients with CHF who were <60 years of age.

Fatal pulmonary embolism and stroke

Death from pulmonary embolism (PE) in patients with ischemic stroke was determined from the United States Census Bureau's Compressed Mortality File, which is based on all death certificates throughout the United States. Among patients with ischemic stroke who died over a 19-year study period, PE was the listed cause of death in 11,101 of 2,000,963 individuals (0.55%). On the basis of an assumed sensitivity of death certificates for fatal PE of 26.7% to 37.2%, the corrected rate of fatal PE was 1.5% to 2.1%. Death rates from PE in patients with ischemic stroke decreased from 1980 to 1998. A decrease over 2 decades in the rate of deaths from PE in patients with ischemic stroke is compatible with the increasing and effective use of antithrombotic prophylaxis.

Multidetector computed tomography for the diagnosis of coronary artery disease: a systematic review

PURPOSE

The study's purpose was to determine the sensitivity and specificity of contrast-enhanced multidetector computed tomography (CT) for the detection of coronary artery disease.

SUBJECTS AND METHODS

A search of the literature in all languages was performed incorporating both electronic and manual components. Manual reference checks of recent reviews and all original investigations supplemented the electronic searches.

RESULTS

Average sensitivity for patient-based detection of significant (>50% or > or =50%) stenosis was 61 of 64 (95%) with 4-slice CT, 276 of 292 (95%) with 16-slice CT, and 47 of 47 (100%) with 64-slice CT. Average specificity was 84% for 4-slice CT, 84% for 16-slice CT, and 100% for 64-slice CT. The sensitivity for a significant stenosis in evaluable segments was 307 of 372 (83%) with 4-slice CT, 1023 of 1160 (88%) with 16-slice CT, and 165 of 176 (94%) with 64-slice CT. Average specificity was 93% or greater with all multidetector CT. Seventy-eight percent of segments were evaluable with 4-slice CT, 91% with 16-slice CT, and 100% with 64-slice CT. Stenoses in proximal and mid-segments were shown with a higher sensitivity than distal segments. Left main stenosis was identified with high sensitivity with all multidetector CT, but sensitivity in other vessels increased with an increasing number of detectors.

CONCLUSION

Multidetector CT has the potential to be used as a screening test in appropriate patients. Contrast-enhanced 16-slice CT seems to be reasonably sensitive and specific for the detection of significant coronary artery disease but has shortcomings. Preliminary data with 64-slice CT suggest that it is more sensitive and specific.

Pulmonary embolism as a cause of death in patients who died with cancer

Little is known about the frequency of death from pulmonary embolism in patients who die with cancer. We investigated this on the basis of data from death certificates, as listed by the United States Bureau of the Census in the period 1980-1998. Among patients with cancer who died over the 19-year period of study, pulmonary embolism was the listed cause of death in 0.21% (95% confidence interval, [CI] 0.21-0.22%). The frequency of death from pulmonary embolism in patients who died with cancer decreased from 0.39% in 1980 to 0.15% in 1998. Adjustment of the data for the frailty of the diagnosis of fatal pulmonary embolism based on death certificates indicated a likely range of 0.60% to 1.05% for the frequency of death from pulmonary embolism among patients who died with cancer in the period 1980-1998. In conclusion, with modern diagnostic, prophylactic, and therapeutic methods, death from pulmonary embolism in patients who died with cancer was 1% or less.

Incidence of venous thromboembolism in patients hospitalized with cancer

BACKGROUND

There are sparse data on the frequency of venous thromboembolism in patients with various types of cancer. We sought to determine the incidence and relative risk of venous thromboembolism, pulmonary embolism, and deep venous thrombosis in patients with malignancies.

SUBJECTS AND METHODS

The number of patients discharged with a diagnostic code for 19 types of malignancies, pulmonary embolism or deep venous thrombosis from 1979 through 1999 was obtained from the National Hospital Discharge Survey. Patients studied were men and women of all ages and races.

RESULTS

In patients with any of the 19 malignancies studied, 827,000 of 40,787,000 (2.0%) had venous thromboembolism, which was twice the incidence in patients without these malignancies, 6,854,000 of 662,309,000 (1.0 %). The highest incidence of venous thromboembolism was in patients with carcinoma of the pancreas, 51,000 of 1,176,000 (4.3%), and the lowest incidences were in patients with carcinoma of the bladder and carcinoma of the lip, oral cavity or pharynx. The overall incidences of pulmonary embolism and deep venous thrombosis were also twice the rates in noncancer patients. Incidences with cancer were not age dependent. The incidence of venous thromboembolism in patients with cancer began to increase in the late 1980s.

CONCLUSION

Patients with cancer had twice the incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis as patients without cancer. The incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis associated with cancer differed according to the type of cancer, was comparable in elderly and younger patients, and increased in the late 1980s and 1990s.

Mortality from acute pulmonary embolism according to season

BACKGROUND

Varying observations have been made on seasonal differences of mortality from acute pulmonary embolism (PE).

METHODS

The number of deaths each year from PE, from 1980 through 1998, based on death certificates, was obtained from the US National Center for Health Statistics Multiple Cause-of-Death Files.

RESULTS

Acute PE as the cause of death ranged from 0.91 to 1.03 PE deaths per quarter per 100,000 population. Small differences were statistically significant due to the large number of patients evaluated. Quarterly mortality rates from PE in the northeast, south, midwest, and west, where seasonal weather varies widely, showed no meaningful seasonal differences.

CONCLUSION

Mortality rates from PE do not vary to a meaningful extent according to season.

Venous thromboembolism in patients with ischemic and hemorrhagic stroke

The rates of pulmonary embolism (PE), deep venous thrombosis (DVT), and their combination, venous thromboembolism (VTE), in hospitalized patients with stroke from 1979 to 2003 were determined from the National Hospital Discharge Survey. Of 14,109,000 patients hospitalized with ischemic stroke, PE occurred in 72,000 (0.51%), DVT in 104,000 (0.74%), and VTE in 165,000 (1.17%). Of 1,606,000 patients hospitalized with hemorrhagic stroke, rates were higher: PE occurred in 11,000 (0.68%), DVT in 22,000 (1.37%), and VTE in 31,000 (1.93%). The rates of VTE with ischemic stroke and with hemorrhagic stroke did not change over the 25-year period of observation.

Usefulness of 4-, 8-, and 16-slice computed tomography for detection of graft occlusion or patency after coronary artery bypass grafting

The sensitivity and specificity of computed tomographic angiography for the evaluation of coronary artery bypass grafts (CABGs) was reviewed. A search of published studies in all languages was performed, incorporating electronic and manual components. A total of 985 patients with 2,200 CABGs participated in investigations with single-detector computed tomography (CT), 441 patients (1,246 CABGs) with 4-slice CT, none with 8-slice CT, and 144 patients (416 grafts) with 16-slice CT. Pooled data showed a sensitivity for the detection of complete occlusion with single-slice CT of 81% (402 of 494 patients), with 4-slice CT of 93% (293 of 315 patients), and with 16-slice CT of 99% (75 of 76 patients). The specificity, based on pooled data, using single-slice CT was 89% (1,507 of 1,697 patients), with 4-slice CT was 96% (878 of 915 patients), and with 16-slice CT was 98% (301 of 306 patients). The detection of complete occlusion and the detection of patency in saphenous vein bypass grafts and arterial bypass grafts were similar with multislice CT. Limited data were available on the detection of significant stenosis, exclusive of complete occlusion. With 4-slice CT, the sensitivity was 74% (23 of 31 patients) and was 88% (21 of 24 patients) with 16-slice CT. In conclusion, single-detector CT was able to detect graft patency, but it was not sensitive for graft occlusion. The data suggest that 4- and 16-slice CT can be used for the detection of complete graft occlusion or graft patency of CABGs. Significant stenosis was better assessed with 16-slice CT than with 4-slice CT.

Obesity as a risk factor in venous thromboembolism

PURPOSE

Whether obesity is an independent risk factor for pulmonary embolism or deep venous thrombosis has not been fully determined.

METHODS

We used the database of the National Hospital Discharge Survey to further investigate the potential risk of obesity in venous thromboembolic disease.

RESULTS

The relative risk of deep venous thrombosis, comparing obese patients with non-obese patients, was 2.50 (95% confidence interval [CI] = 2.49-2.51). The relative risk of pulmonary embolism was 2.21 (95% CI = 2.20-2.23). Obese females had a greater relative risk for deep venous thrombosis than obese males, 2.75 (95% CI = 2.74-2.76) versus 2.02 (95% CI = 2.01-2.04). Obesity had the greatest impact on both men and women aged less than 40 years.

CONCLUSION

The data indicate that obesity is a risk factor for venous thromboembolic disease in men as well as women.

Trends in the incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients

Trends in the incidences of pulmonary embolism (PE), deep venous thrombosis (DVT), and venous thromboembolism (VTE) (PE or DVT, or both) in hospitalized adults (aged > or =20 years) were evaluated using data from the National Hospital Discharge Survey. From 1979 to 1999, the incidence of DVT in hospitalized patients increased from 0.8% of admissions to 1.3% of admissions. The incidence of PE was 0.4% of admissions and did not change over the 21-year period. Trends and incidences were similar or the same among men and women and whites and blacks.