The importance of clinical prediction models in non-fatal pulmonary embolism: an analysis of the best known clinical scores

The clinical evaluation in pulmonary embolism (PE) is the first instrument used by practitioners in the management of this potentially fatal pathology. The necessity of develop- ing certain valid and especially affordable practical instruments has led to the emergence of various clinical prediction models. The purpose of this paper is to analyze the main clinical scores, as a diagnostic or a prognostic tool, with their strengths and weaknesses. The PESI score, while relatively recent, remains the most investigated and validated prognostic score for the identification of the mortality risk and major adverse events, with economic implications of health services reduction costs through the accurate identification of patients with a low risk who are candidates of early hospital discharge. The simplified Geneva score (with a similar accuracy as the Geneva one) identifies a high or low PE probability, especially in combination with D-dimers, with a prognosis value as well. The Wells and simplified Wells scores identify the high or low probability, being improved by the level of D-dimers, having similar results with the Geneva score. The LR-PED score, conceived as an identification score for low risk, uses biochemical and electrocardiographic markers, but is less validated. The Vienna Prediction Model is another system for the evaluation of the recurrence in which the level of D-dimers is the main prediction factor. Other scores were evaluated with a statistically low significance. The Geneva and the PESI scores remain the most valuable instruments of diagnosis and clinical prognostic, respectively.

Massive pericardial effusion associated with hypothyroidism

The diagnosis of hypothyroidism is difficult because hypothyroidism in adults and especially the elderly, classic, has an insidious onset with a range of nonspecific symptoms which may delay diagnosis for months or even years. Old age seems to represent trigger factor for autoimmune diseases, including hypothyroidism. Clinical features in hypothyroidism, such as weight gain, fatigue, cold intolerance, constipation, dry skin, edema and muscle weakness, and decreased osteo-tendinous reflexes are usually subtle and can be overlooked. Thyroid dysfunction may be associated with a negative impact on the cardiovascular system. Pericardial, pleural and peritoneal effusions are common findings in hypothyroidism. This case report represents a typical primary hypothyroidism (autoimmune) and shows the clinical features of this disease. Basically we talked about a severe myxedema with the involvement of internal organs in an elderly woman and the euthyroidism restoration, under thyroid replacement therapy, was correlated with the clinical improvement and cardiovascular and neurological status, with radiographic remission and regression to extinction of pericardial effusion at repeated echocardiographic evaluations.

Thyroid dysfunction and ischemic heart disease--clinical correlations, progressive implications and impact on the prognosis

Thyroid dysfunctions are associated with systolic and diastolic heart dysfunction, hypertension, rhythm disorders, etc. Clinically significant hyperthyroidism and hypothyroidism may have an impact on the patients with ischemic heart disease.

OBJECTIVES

Investigation of the risk of developing ischemic heart disease, of the evolution and prognosis in relation to the entire spectrum of thyroid dysfunctions.

MATERIALS AND METHODS

All participants included in the study were selected from among subjects with heart disorders who were controlled with concern to the thyroid hormonal condition and who hadn't been treated previously for thyroid functional disorders. Based on these criteria we defined a study group made out of 791 subjects, divided into five lots based on the level of thyroid hormones. Once the group was formed, we conducted evaluations of the cardiovascular and thyroid status at 6 and 12 months, respectively.

RESULTS

In the witness lot, during monitoring 49% of the patients showed an ischemic heart disease. The main risk factors were: heart frequency of over 80 beats/min (RR = 1.83), age over 60 (RR = 1.47), female sex (RR = 1.21) and values of triglycerides over 160 mg/dl (RR = 1.23). In the group of patients with overt clinic hyperthyroidism, during monitoring 46.1% showed ischemic heart disease. The main risk factors were: heart frequency over 80 beats/min (RR = 2.41), age over 60 (RR = 1.67), high level of LDL-cholesterol (RR = 1.53) and female sex (RR = 1.31). Among the patients with overt clinical hyperthyroidism, during monitoring 53.3% showed ischemic heart disease. The main risk factors identified were: heart frequency over 80 beats/min (RR = 2.01), age over 60 (RR = 1.42), high levels of triglycerides (RR = 1.42) and LDL-cholesterol (RR = 1.32), as well as the presence of hypertension in the health records (RR = 1.31).

CONCLUSIONS

Thyroid dysfunction is a common clinical condition with a key role in the regulation of the cardiovascular system and may contribute to the evolution of the ischemic heart disease and which should be taken into consideration when patients with heart disease are treated. In this light, thyroid function needs to be evaluated for all patients with a risk for ischemic heart disease.

Risk assessment in the development of atrial fibrillation at patients with associate thyroid dysfunctions

Thyroid hormones are an important regulator of cardiac function and vascular system. Atrial fibrillation is a common cardiac arrhythmia and an important risk factor for the ischemic cerebral vascular accident and heart failure.

OBJECTIVES

The examination of the risk to develop atrial fibrillation in relation to the whole spectrum of thyroid dysfunctions.

MATERIAL AND METHODS

All participants to our study were selected from among subjects with cardiovascular disorders whose hormonal thyroid status had been controlled previously and who hadn't been treated for thyroid functional disorders. Based on these criteria we defined a study lot made up of 791 subjects, 700 women and 91 men, aged between 22 to 86, with a mean age of approximately 60 years old, divided into five groups, based on the level of thyroid hormones. Once the lot was constituted, evaluations were made of the cardiovascular and thyroid condition at 6 and 12 months.

RESULTS

During monitoring, most patients who developed atrial fibrillation were registered in the groups with manifest clinical hyperthyroidism, 34,62% and respectively with subclinical hypothyroidism, 38,6%. The main risk factors at the patients with manifest clinical hyperthyroidism were: female gender (RR=1.97) and age above 60 (RR=1.33), as well as the presence of coronary disease in the personal pathological record (RR=3.31), HBP (RR=1.46) and cardiac frequency in excess of 80 beats/min (RR=1.38). The main risk factors that led to atrial fibrillation among the patients with subclinical hypothyroidism, were: obesity (RR=2.21), the presence in the personal record of heart disease (RR=2,0), age over 60 (RR=1.90) and female sex (RR=1.30). At the patients who had been administered beta blockers prior to admission (RR=0.99), ACEI (RR=0.85) and/or antiarrythmic drugs (RR=0.54), the medication represented a protective factor against developing atrial fibrillation.

CONCLUSIONS

Thyroid dysfunctions are associated with an increased risk to develop atrial fibrillation, both in the case of clinically manifest and the subclinical manifest forms. These results support long term screening for thyroid dysfunctions for patients with atrial fibrillation.

[Treatment with statins and angiotensin-converting enzyme inhibitors in degenerative aortic stenosis--an up-date]

Degenerative aortic stenosis (AoS) is the most common valvular disease in adults; that's why, the aortic valve replacement is one of the most frequent cardiac surgical procedures. The etiology of degenerative AoS is actually well known, the primary lesion being aortic sclerosis. Aortic sclerosis shares many pathological features and risk factors with atherosclerosis and, because atherosclerosis may be prevented and/or reversed by cholesterol lowering, there has been postulated that cholesterol lowering therapy using statin drugs could modify the course of aortic sclerosis/stenosis. Some studies also demonstrated the implication of renin-angiotensin-aldosterone system in the degenerative aortic disease, and the use of angiotensin-converting enzyme inhibitors could also be used to delayed or even reverse the evolution of Ao sclerosis/stenosis. The paper reviews the latest literature date about the definition and prevalence of aortic sclerosis and stenosis as well as medical treatment of degenerative AoS.

CONCLUSIONS

Treatment with statins has not proved effective in preventing the progression of lesions valves but have an important role in patients with associated coronary artery disease. Angiotensin converting enzyme inhibitors does not influence the progression of lesions valves, but may play a role in cardiac remodeling.

[Assessment of left atrial remodeling in atrial fibrillation]

Left atrial size, most frequently assessed for practical reasons by echocardiography, is important in clinical decision-making. Left atrium volume measurements allow an accurate assessment of asymmetric remodeling and reverse remodeling in atrial fibrillation (AF) patients.

AIM

To assess a new method (CTEL2) derived from CT scan by ellipsoid formula (CTEL1) to measure LA volume, we compared the conventional echocardiography-ellipsoid method (EEL), as a reference, with CTEL1 and with the new method-CTEL2.

MATERIAL AND METHOD

Left atrium volume was measured by EEL and CTEL2 in 40 consecutive pts (group 1, 56 +/- 12 years, 80% men) and by EEL and CTEL1, in another 46 consecutive patients (group 2, 58 +/- 11 years, 80% men) with AF. For measurements by CTEL2 we used the same formula as the ellipsoid method but as optimal view for the orthogonal dimensions were taken every time the last axial section just under the superior veins (atrialized in dilated left atrium). Usual, the dimensions are taken on the largest axial left atrium area. The correlation coefficients were compared by Z test with Fisher inverse tank transformation.

RESULTS

Mean left atrium volume irrespective of methods was > 50 mL. We found a good and significant correlation between CTEL1 and EEL (r1 = 0.769; p < 0.001) but a much better between CTEL2 and EEL (r1 = 0.915; p < 0.001). Both r1 and r2 coefficients were significantly stronger for the correlation with CTEL2 and with CTEL1 (p = 0.016).

CONCLUSIONS

This new technique evaluation for left atrium volume is adequacy and could avoid an overestimation or underestimation of LA remodelation assessment, as standard ellipsoid method, in specific situations as cardioversion or AF ablation.

[Cardio-thoracic index: marker of the clinical course of alcoholic dilated cardiomyopathy]

Alcoholic cardiomyopathy (ACM), a principal form of secondary dilated cardiomyopathy, can ensue from heavy consumption of alcohol over a long period of time. In harmful consumption, alcohol and its metabolites has a toxic effect on heart muscle cells. The clinical features include dilatation of the left ventricle, poor myocardial contractility and symptoms of heart failure. The heart and lung X-ray examination is required in all disease stages. The information gathered from this cheap and noninvasive investigation method, are very important in the diagnosis algorithm. In the ACM stages beginning, before the installation of the heart failure symptoms, it is possible to found normal dimensions of the heart, which is compatible with the alcoholic cardiomyopathy diagnosis. Specific for dilated alcoholic cardiomyopathy is the reversible character of cardiomegaly, objectified through the reduction of the cardio-thoracic index in conditions of alcohol abstinence and adequate treatment of the heart failure.

[The implications of thromboembolism in chronic heart failure]

The goal of investigation was to determine whether long-term anticoagulant therapy influences the mortality rate in CHF. The method consisted in the calculation of the annual death rate of the patients with CHF class III-IV NYHA: group A (controls)--who did not receive anticoagulant or antiplatelet therapy; group B--treated with Acenocumarol or Aspirin. The results show in group A, which included 150 patients, during the 5-year interval under study 30 deaths, representing an annual death rate of 4%. In group B, which included 325 patients of which 75 treated with Acenocumarol and 250 patients with aspirin, 20 deaths were recorded during the same 5-year interval, representing an annual death rate of 1.2%. Thus, the mortality risk proved to be 70% lower in group B than in the control group. It came out that the main mechanism of death in CHF is thrombembolism and in this circumstance anticoagulant or antiplatelet therapy would be essential.

[Nebivolol treatment in essential arterial hypertension]

Nebivolol is a lipophilic beta 1-blocker. It is devoid of intrinsic sympathomimetic or membrane stabilising activity but appears to have nitric oxide-mediated vasodilatory effects. Nebivolol 5 mg once daily is well tolerated in patients with hypertension. Adverse events are infrequent, transient and mild to moderate. Those reported most often include headache, fatigue, paraesthesias and dizziness. Several studies reported no signs of orthostatic hypotension with Nebivolol.

[Hemorrhagic risk factors during beta-lactam antibiotics therapy]

Any type hemorrhagic manifestation may occur 12 hours to 5 weeks after the administration of beta-lactam antibiotics. The mechanisms of blood losses proved to be by: 1) immunologic thrombocytopenia (penicillins); 2) alteration of platelet functions (semisynthetic penicillins); 3) hypoprothrombinemia (cephalosporins). The risk factors for the occurrence of hemorrhage under beta-lactam antibiotics therapy are: concomitant administration of cytostatics for a neoplastic malignancy; b) acute or chronic renal failure; c) concomitant treatment for duodenal and gastric ulcer; d) malnutrition; e) dosage and duration of antibiotic administration. The frequency of bleeding under beta-lactams is not determined as yet. A severe case diagnosed at the IIIrd Medical Clinic of Iasi presenting spontaneous daily nasal bleedings that occurred 24 hours after the initiation of the treatment with cephalosporins (Kefurox) is presented. In this patient the risk factor was chronic renal failure.

[The evolutionary characteristics of the hypereosinophilic syndrome]

The case here described is a young male aged 21 years who met all diagnostic criteria for HES: (1) persistent eosinophilia of over 1500/cubic millimeter (19.904-26.070/cubic millimeter) for longer than 6 month (12 month in our patient); (2) lack of evidence of other known causes of secondary hypereosinophilia (SH); (3) multiple organ involvement. The peculiar aspects found in our case are related to organ involvement: occurrence 2 months after HES onset of chronic myocardial infarction in four locations (apical, anteroseptal and posteroseptal, inferior, left ventricular) demonstrated by electrocardiographic and scintigraphic studies; early global cardiac insufficiency (6 months after the onset); acute renal failure (since HES onset) followed by chronic renal failure. The multiple and severe involvement of the nervous system (up to coma) were not a life threat. It is suggested that a possible explanation for the multiple organ involvement could be the chronic disseminated intravascular coagulation.

[Neurological manifestations on collagenoses]

Collagen diseases are precipitated by very different etiologic factors, but have a common pathogenic mechanism--autoimmune, which evolves chronically and progressively involving new territories. The initial and main pathologic lesions are vascular arterial ischemic (and, according to the prevalently involved territory, the type of disease results: PAN--medium-sized and small arterioles; scleroderma--small arterioles and capillaries), and the secondary ones are the result of ischemia with plurivisceral involvement. Neurological dysfunctions were detected in about 50% of collagen diseases diagnosed during a 25 year interval in the IIIrd Medical Clinic of Iaşi. The neurological manifestations were inaugural in 10% (in SLE) to 46.4% (in PAN) of the cases, the remainder occurring during the course of collagenosis, more commonly at 3-5 years and before death. Peripheral nervous system involvement (mainly polyneuritis) has prevailed, the central nervous system involvement being more rare and often fatal. Long-term corticosteroid therapy was followed by full or partial remission of peripheral nervous dysfunctions, but had transient effects or was ineffective on the central nervous ones.

[Therapeutic means and methods in recurrent pleurisy]

During a 10-year interval (1981-1991), at the IIIrd Medical Clinic of Iaşi 960 cases with pleural effusion, of which 768 (80%) non-recurrent and 192 (20%) recurrent, were diagnosed. The etiology in the latter cases was malignant (40%) and non-malignant (60%). Proper treatment methods for limiting or suppressing the recurrent pleurisies proved to be imperative. Thoracocenteses cause protein and electrolyte depletion which aggravate the general state and hasten the unfavourable evolution of the etiological affection. This is the reason why besides the general etiopathogenic treatment, a local pathogenic treatment (cytostatic, anti-inflammatory) and especially pleurodesis are compulsory. The intrapleural administration of cortisone is efficient in the case of recurrent autoimmune pleural effusions but is worthless in the malignant ones. In the latter situation, the intrapleural cytostatic treatment should be first attempted and, in case of failure, the development of pleural symphysis by external radiotherapy or injecting talc into the pleural space should be made. In the terminal stage of cardiac insufficiency or liver cirrhosis with recurrent pleural effusion, the pleurosymphysation is not indicated; a sever edematous-ascitic attack may occur or become aggravated by the pleural irritative process due to this method.

[Chronic reactive inflammations in the etiopathogenesis of malignant hematologic proliferations]

The malignant proliferations are induced by a multitude of etiological factors and possible pathogenic mechanisms. Three new clinical cases and other four previously reported cases of haematological malignant proliferations occurring during the evolution of some chronic reactive inflammatory processes due to various forms of immune deficit are discussed. A review of the literature and of the opinions regarding the pathogenic mechanism responsible for the occurrence and growth of malignant proliferations, especially in the cases with inborn or acquired immunodeficiency, are also included. The authors' pathogenic hypothesis for the cases with various acquired immune deficits and with secondary infectious or allergic reactions is that altered immune responses made possible a lasting antigenic stimulation of certain cell clones of the reactive inflammatory process. By this excessive demand, and instability of the genes has occurred and during their rearrangement a mutation with the depression of an oncogene, responsible for malignant growth, has resulted.

Diagnosis difficulties in multiple myeloma

Some difficulties in the diagnosis of multiple myeloma are presented. The atypical onset (pseudorheumatismal, anaemic, renal or neurological one) as well as the presence of a biological syndrome during some other diseases which may generate the confusion with the multiple myeloma are discussed with reference to the personal casuistry (30 cases of multiple myeloma in a lapse of 12 years). Some peculiar cases of the two categories of difficulties are presented in detail. A careful clinical and biological examination should be performed in every case, as both situations may involve, affect, the prognosis quo ad vitam of the patient.

[The fundus oculi in chronic anemias]

The investigation was carried out in 168 cases thus selected as chronic anaemia to be the only affection. In 49 patients (20%) the following changes, single or associated, were found: retinal pallor in 15% of the cases, superficial retinal bleedings in 6%, deep bleedings in 3.5%, retinal exudates in 4.7%, retinal edema in 3%, papillary edema in 1.7%. In all the 49 cases Hb levels were under 6 g%, anaemia was present for more than 2 years, and the etiological type of anemia were studied. The lower the Hb level, the more pronounced and in larger number of cases the retinal alteration. Therefore, the decisive effector of the injuries was the anemic hypoxia. Pleading for this is the disappearance of all retinal alterations after the antianemic treatment.

[The experience of the 3rd Medical Clinic with lymph node pathology]

In the last 8 years, 511 patients (267 men and 244 women) were investigated. It was found that 44 cases (8.6%) were false adenopathies (various types of tumoral masses) but placed in the nodes areas (localized, generalized or deep). There were 467 cases of true lymphadenopathies, 58 new cases yearly (2.32% of all admitted patients and 6.9% of those with blood diseases). Out of these 467 cases, 330 (70.6%) were malignant neoplastic diseases: malignant lymphomas--206 cases (62.4% of all malignancies), leukemias--99 cases (30%), carcinomatous metastases--25 cases (7.6%). Nonmalignant lymphadenopathies were found in 137 cases (29.4%): specific infections (tuberculosis) and nonspecific ones in 87 cases (63.5%), nonimmune diseases (SLE, PAN, sarcoidosis) in 50 cases. Generalized adenopathies were recorded in 47% of the cases, the involvement of a single node group in 21.8% of the cases, other types of distribution being rare. The general symptoms were absent in 20.5% of the cases, being present in the remainder of 79.5%, especially in the malignant lymphomas, leukemias, nonimmune diseases. The main complications occurring against the background of the etiological affections of lymphadenopathies were: infections (respiratory, urinary, tegumental) in 19.7% of the cases and cardiovascular disturbances (myocardiopathies, rythm and conduction disturbances) in 9.6% of the cases.

[Pseudoadenopathies]

The results of a study concerned with the etiology of some lymph node enlargement in 511 cases aged between 16-80 years, admitted to the III-rd Medical Clinic of Iaşi during the last 7 years are presented. A thorough investigation, by histopathological, cytological, haematological, biochemical, immunological, lymphographic, echographic, radiological examinations, has been done. In 44 cases, the results of the above mentioned investigations indicated that there was no lymph node enlargement, but some other masses sharing the same sites with the lymph nodes, which generated the misdiagnosis in outpatient practice. It is important to note that in 28 cases (63% of the 44 cases) the pseudoadenopathies were localized in the cervical area. The pseudoadenopathies, which are the clinical expression of some tumoral diseases, could be classified as follows: a.--single peripheral; b.--generalized, peripheral; c.--deep. The symptoms which permit the differential diagnosis between the true and pseudoadenopathies are analysed.

[Systolic dynamics in chronic anemias]

The study of the systolic time intervals in 168 cases with chronic anemia revealed three categories of anemic persons with the following systolic dynamics: cardiac hyperkinesia, cardiac insufficiency and normal systolic dynamics. The dynamic systolic type is especially determined by the degree and age of anemia. In case anemia was severe (Hb less than 4 g per cent) but of less than 2 years, a cardiac hyperkinesia was present. If anemia was severe and older than 2.6 years, then a prolonged cardiac hyperkinesia lead to clinically manifest or latent cardiac insufficiency. In anemias with Hb over 3 g per cent, under 1.6 years, 80 per cent of cases had a normal systolic dynamics, a state never encountered in the severe cases.