Final Diagnosis Of Pulmonary Embolism Research Articles

КЛИНИКО-ЛАБОРАТОРНЫЕ ОСОБЕННОСТИ ТРОМБОЭМБОЛИИ ЛЁГОЧНОЙ АРТЕРИИ У ПАЦИЕНТОВ С КОРОНАВИРУСНОЙ ИНФЕКЦИЕЙ SARS-COV-2 И АБДОМИНАЛЬНЫМ ОЖИРЕНИЕМ

Background. At the present time more than 185 million people are infected with the new coronavirus infection (CVI) SARS-CoV-2, which caused COVID-19 pandemic according to WHO. The issue of increased risk of pulmonary embolism (PE) and associated severe course of the disease in persons with abdominal obesity (AO) is actively discussed in national and foreign publications. Objective of the study. To determine the clinical and laboratory features of PE in patients with abdominal obesity infected with SARS-CoV-2 Material and Methods. An analysis of 11.056 medical records of inpatients treated in the infectious disease departments for patients with COVID-19 of the 4th City Clinical Hospital named after N.E. Savchenko of Minsk during the period from April 1, 2020 to May 31, 2021 was performed. AO in subjects included in the retrospective analysis was determined according to WHO criteria as a body mass index greater than or equal to 30 kg/m2, waist circumference greater than 94 cm in men and 80 cm in women, respectively. To determine clinical and laboratory features of PE, as well as the effect of AO on the severity of this complication, inclusion/exclusion/exclusion criteria were developed and a sample of medical records of patients with COVID-19 (n=33), whose diagnosis of PE was verified by computed tomographic angiography of the chest (CTA chest) was formed. Clinical and instrumental parameters and laboratory characteristics were analyzed in the studied groups at the moment of admission to the hospital and at the time of PE development. Results. According to the results of a retrospective analysis of 11 056 medical records, the proportion of patients in whom the final diagnosis of PE was present was 3.68% (n=407), among whom AO was observed in 22.11% (n=90) of patients. The prevalence of subjects with impaired lipid metabolism among those included in the analysis was 11.38% (n=1259). PE developed in 90 patients with CVI and AO (0.81%) and in 317 patients without AO (2.87%). The prevalence of patients with PE (n=90) in the CVI and AO group (n=1259) was 7.15%; among those with CVI without AO (n=9797) - 3.24% (n=317). In the formed group with AO, C-reactive protein (CRP) and fibrinogen levels at hospitalization were higher than in the group of patients without AO: 116.64 (80.38-134.08) mg/L versus 30.21 (15.11-57.21) mg/L (U=36.04; p<0.01) and 6.97 (6.11 to 8.03) g/L versus 4.71 (4.02 to 5.59) g/L (U=12.0, p<0.01) respectively. On the day of suspected PE, CRP levels were higher in the group of patients with AO and COVID-19 than in the group of patients without AO: 71.01 (50.59-105.06) mg/L versus 34.01 (18.85-60.81) mg/L (U=49.00; p<0.05). In patients with CVI and PE, there was a moderate positive relationship between the presence of AO and the severe course of COVID-19 (r=0.41; p<0.05), AO and elevated fibrinogen levels on admission to the hospital (r=0.58 p <0.05), a strong positive relationship between the presence of AO and increased serum CRP level at the time of hospitalization (r = 0.76; p < 0.01), a moderate positive relationship between AO and CRP level determined at the time of development of PE (r = 0.51; p < 0.01). Conclusion. Among the patients with COVID-19 and AO complicated by the development of PE in comparison with patients without AR was determined a higher prevalence of individuals with a severe course of CVI (χ2=5,18; p<0.05), lower oxygen saturation values at admission and at the time of PE development (U =46.5; p<0.05) and (U=49.5; p<0.05), respectively, higher fibrinogen and CRP levels at the time of hospitalization (U=12.0; p<0.01) and (U=36.04; p<0.01), respectively, higher CRP values at the manifestation of PE (U=49.00; p<0.05). The obtained data indicates in favor of the fact that AO can be considered as a risk factor for the severe course of COVID-19. The pathophysiological basis of the development, course and prognosis of thromboembolic complications in patients with COVID-19 and AO requires further clarification during prospective follow-up of this category of patients.

Thrombolysis During Resuscitation for Out-of-Hospital Cardiac Arrest Caused by Pulmonary Embolism Increases 30-Day Survival: Findings From the French National Cardiac Arrest Registry

Pulmonary embolism (PE) represents 2%to 5%of all causes of out-of-hospital cardiac arrest (OHCA) and is associated with extremely unfavorable prognosis. In PE-related OHCA, inconsistent data showed that thrombolysis during cardiopulmonary resuscitation may favor survival. This was a retrospective, observational, multicenter study from July 2011 to March 2018. All adults with OHCA, treated by a mobile ICU and with a diagnosis of PE confirmed on hospital admission, were included. The primary end point was 30-day survival in a weighted population. Of the 14,253 patients admitted to hospitals, 328 had a final diagnosis of PE and 246 were included in the analysis. In the group that received thrombolysis during resuscitation (n= 58), 14 (24%) received alteplase, 43 (74%) received tenecteplase, and one (2%) received streptokinase. Thirty-day survival was higher in the thrombolysis group than in the control group (16%vs6%; P= .005; adjusted log-rank test) but the good neurologic outcome was not significantly different (10%vs5%; adjusted relative risk, 1.97; 95%CI, 0.70-5.56). Median duration of stay in the ICU was 1 (0-5) day for the thrombolysis group and 1 (0-3) day for the control group (P= .23). In patients with OHCA with confirmed PE and admitted with recuperation of spontaneous circulation in the hospital, there was significantly higher 30-day survival in those who received thrombolysis during cardiopulmonary resuscitation compared with patients who did not receive thrombolysis.

Évaluation de la prise en charge des embolies pulmonaires à bas risque diagnostiquée aux urgences. Étude HoPE (Home Treatment of Pulmonary Embolism)

IntroductionRisk stratification allows outpatient management of low-risk pulmonary embolism (PE). Here, we carry out an evaluation of the professional practices on the emergency management of low-risk PE, after selection with the sPESI score. Material and methodAll patients admitted to the emergency department of Chambéry hospital, with a final diagnosis of PE are analyzed. The PE of score sPESI at 0 are included, in the absence of contraindications. Ninety-day follow-up is done. The objective is to evaluate the proportion of ambulatory care for low-risk patients. ResultsEighty PE were diagnosed in 2016, 28 with sPESI score at 0 and 3 patients excluded. Of the 25 inclusions, 6 patients had signs of right ventricular dysfunction and were therefore hospitalized. The remaining 19 were eligible for outpatient care but only 8 of them stayed less than 24hours in the hospital. DiscussionThe sPESI score is a decision support tool for outpatient management but should not be used alone. The search for right ventricular dysfunction seems important here.

Prevalence and main determinants of early post-traumatic thromboembolism in patients requiring ICU admission

Post-traumatic thromboembolism (PE) is now a common challenging particularly in critically ill patients referred to emergency wards. We aimed to identify main factors associated with PE within 72h of admission after trauma among patients referred to emergency ward. In this retrospective study, the database records of 240 patients, with the primary diagnosis of trauma requiring ICU admission and with a final diagnosis of pulmonary embolism, were reviewed. The patients were categorized as the subjects with early pulmonary embolism (≤3days) and those with late pulmonary embolism (>3days). According to our analysis, 48.5% of the patients suffered PE faced this event within 72h of trauma events. The patients in early PE group were older than those who suffered late PE. The prevalence rate of long bone fractures in lower extremities was significantly higher in those with early PE compared with the other patients. The group with early PE had more severe injury when compared to those with later PE. The severe and very severe injuries were indicated in 49.5 and 15.4% in early PE group, and 14.0 and 6.9% in late PE group, respectively. Using the multivariable logistic regression model, older age, presence of long bone fractures, and more severe injury could predict occurrence of early PE in trauma patients referred to emergency ward. Occurring early PE is predicted in majority of traumatic patients requiring ICU admission especially in older ones, patients with long bone fractures and those with more severe injury.

Diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism.

Evaluating the diagnostic performance of focused cardiac ultrasound (US) alone and combination with venous US in patients with shock and suspected pulmonary embolism (PE). Consecutive adult patients with shock and suspected PE, presenting to two Italian emergency departments, were included. Patients underwent cardiac and venous US at presentation with the aim of detecting right ventricular (RV) dilatation and proximal deep venous thrombosis (DVT). Final diagnosis of PE was based on a second level diagnostic test or autopsy. Among the 105 patients included in the study, 43 (40.9%) had a final diagnosis of PE. Forty-seven (44.8%) patients showed RV dilatation and 27 (25.7%) DVT. Sensitivity and specificity of cardiac US were 91% (95% CI 80-97%) and 87% (95% CI 80-91%), respectively. Venous US showed a lower sensitivity (56%, 95% CI 45-60%) but higher specificity (95%, 95% CI 88-99%) than cardiac US (both p<0.05). When cardiac and venous US were both positive (22 out of 105 patients, 21%) the specificity increased to 100% (p<0.01 vs cardiac US), whereas when at least one was positive (54 out of 105 patients, 51%) the sensitivity increased to 95% (p=0.06 vs cardiac US). Focused cardiac US showed good but not optimal sensitivity and specificity for the diagnosis of PE in patients presenting with shock. Venous US significantly increased specificity of cardiac US, and the diagnosis of PE can be certain when both tests are positive or reasonably excluded when negative.

The Utility of Hybrid SPECT/CT Lung Perfusion Scintigraphy in Pulmonary Embolism Diagnosis

Background: Pulmonary embolism (PE) is diagnosed either by ventilation/perfusion (V/Q) scintigraphy or pulmonary CT angiography. One of the imaging methods used in nuclear medicine is hybrid SPECT/CT scintigraphy. Objectives: The aim of this study was to evaluate the utility of SPECT/CT(Q) scintigraphy in the diagnosis of PE and to compare SPECT/CT(Q) with planar(Q) and SPECT(Q) methods. Methods: The study group consisted of 109 consecutive patients suspected of having PE referred for performing lung scintigraphy. The inclusion criteria were: performance of perfusion planar, SPECT and SPECT/CT scans; availability of clinical data covering a 6-month follow-up period, and D-dimer level testing. The number of eligible patients was 84. PE was reported in patients with at least 1 segmental or 2 subsegmental perfusion defects without parenchymal abnormalities on CT scans. PE was excluded when there was a normal perfusion pattern or perfusion defects were caused by lung parenchymal abnormalities or were not arranged in accordance with the pulmonary vasculature. Results: Twenty-six patients (31%) had a final diagnosis of PE. The sensitivity and specificity values of each method were as follows: planar(Q) 73 and 43%, SPECT(Q) 88 and 47% and SPECT/CT(Q) 100 and 83%. SPECT/CT(Q) yielded a significantly higher diagnostic accuracy than planar(Q) (p < 0.001) and SPECT(Q) (p < 0.001) scans. Conclusions: We conclude that hybrid SPECT/CT(Q) imaging has a high diagnostic efficacy in the diagnosis of PE. Lung perfusion scintigraphy performed with a hybrid SPECT/CT device has a significantly higher sensitivity and specificity than scanning performed with the planar or SPECT technique.

Noncontrast Perfusion Single-Photon Emission CT/CT Scanning: A New Test for the Expedited, High-Accuracy Diagnosis of Acute Pulmonary Embolism

Standard ventilation and perfusion (V˙/Q˙) scintigraphy uses planar images for the diagnosis of pulmonary embolism (PE). To evaluate whether tomographic imaging improves the diagnostic accuracy of the procedure, we compared noncontrast perfusion single-photon emission CT (Q˙-SPECT)/CT scans with planar V˙/Q˙scans in patients at high risk for PE. Between 2006 and 2010, most patients referred for diagnosis of PE underwent both Q˙-SPECT/CT scan and planar V˙/Q˙scintigraphy. All scans were reviewed retrospectively by four observers; planar scans were read with modified Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II and Prospective Investigative Study of Pulmonary Embolism Diagnosis (PISA-PED) criteria. On Q˙-SPECT/CT scan, any wedge-shaped peripheral perfusion defect occupying &gt; 50% of a segment without corresponding pulmonary parenchymal or pleural disease was considered to show PE. The final diagnosis was established with a composite reference standard that included ECG, ultrasound of lower-extremity veins, D-dimer levels, CT pulmonary angiography (when available), and clinical follow-up for at least 3 months. One hundred six patients with cancer and mean Wells score of 4.4 had sufficient follow-up; 22 patients were given a final diagnosis of PE, and 84 patients were given a final diagnosis of no PE. According to PIOPED II, 13 studies were graded as intermediate probability. Sensitivity and specificity for PE were 50% and 98%, respectively, based on PIOPED II criteria; 86% and 93%, respectively, based on PISA-PED criteria; and 91% and 94%, respectively, based on Q˙-SPECT/CT scan. Seventy-six patients had additional relevant findings on the CT image of the Q˙-SPECT/CT scan. Noncontrast Q˙-SPECT/CT imaging has a higher accuracy than planar V˙/Q˙imaging based on PIOPED II criteria in patients with cancer and a high risk for PE.

Lung scintigraphy in the diagnosis of pulmonary embolism: current methods and interpretation criteria in clinical practice.

BackgroundIn current clinical practice lung scintigraphy is mainly used to exclude pulmonary embolism (PE). Modified diagnostic criteria for planar lung scintigraphy are considered, as newer scitigraphic methods, especially single photon emission computed tomography (SPECT) are becoming more popular.Patients and methods.Data of 98 outpatients who underwent planar ventilation/perfusion (V/Q) scintigraphy and 49 outpatients who underwent V/Q SPECT from the emergency department (ED) were retrospectively collected. Planar V/Q images were interpreted according to 0.5 segment mismatch criteria and revised PIOPED II criteria and perfusion scans according to PISA-PED criteria. V/Q SPECT images were interpreted according to the criteria suggested in EANM guidelines. Final diagnosis of PE was based on the clinical decision of an attending physician and evaluation of a 12 months follow-up period.ResultsUsing 0.5 segment mismatch criteria and revised PIOPED II, planar V/Q scans were diagnostic in 93% and 84% of cases, respectively. Among the diagnostic planar scans readings specificity for 0.5 segment mismatch criteria was 98%, and 99% for revised PIOPED II criteria. V/Q SPECT showed a sensitivity of 100% and a specificity of 98%, without any non-diagnostic cases. In patients with low pretest probability for PE, planar V/Q scans assessed by 0.5 segment mismatch criteria were diagnostic in 92%, and in 85% using revised PIOPED II criteria, while perfusion scintigraphy without ventilation scans was diagnostic in 80%.ConclusionsLung scintigraphy yielded diagnostically definitive results and is reliable in ruling out PE in patients from ED. V/Q SPECT has excellent specificity and sensitivity without any non-diagnostic results. Percentage of non-diagnostic results in planar lung scintigraphy is considerably smaller when 0.5 segment mismatch criteria instead of revised PIOPED II criteria are used. Diagnostic value of perfusion scintigraphy according to PISA-PED criteria is inferior to combined V/Q scintigraphy; the difference is evident especially in patients with low pretest probability for PE.

Pulmonary embolism associated with carbamazepime medication: An interesting clinical case

The aim of the study was to present the case of a 65 year old woman with a final diagnosis of pulmonary embolism in relation to carbamazepime consumption. A 65 year old woman is admitted at the Emergency Room for mild progressive dyspnoea and very light right side thoracic pain, with a final diagnosis of pulmonary embolism that was possibly explained as a side effect of carbamazepime consumption as a treatment for trigeminal neuralgia. The absence of major risk factors and the tacit symptoms can leave this condition go undiagnosed, thus compromising the patients’ lives.

Clinical probability and risk analysis of patients with suspected pulmonary embolism.

Pulmonary embolism (PE) is one of the most frequent diseases that could be missed in overcrowded emergency departments as in Turkey. Early and accurate diagnosis could decrease the mortality rate and this standard algorithm should be defined. This study is to find the accurate, fast, non-invasive, cost-effective, easy-to-access diagnostic tests, clinical scoring systems and the patients who should be tested for clinical diagnosis of PE in emergency department. One hundred and forty patients admitted to the emergency department with the final diagnosis of PE regarding to anamnesis, physical examination and risk factors, were included in this prospective, cross-sectional study. The patients with a diagnosis of pulmonary embolism, acute coronary syndrome or infection and chronic obstructive pulmonary disease (COPD) were excluded from the study. The demographics, risk factors, radiological findings, vital signs, symptoms, physical-laboratory findings, diagnostic tests and clinical scoring systems of patients (Wells and Geneva) were noted. The diagnostic criteria for pulmonary emboli were: filling defect in the pulmonary artery lumen on spiral computed tomographic angiography and perfusion defect on perfusion scintigraphy. Totally, 90 (64%) of the patients had PE. Age, hypotension, having deep vein thrombosis were the risk factors, and oxygen saturation, shock index, BNP, troponin and fibrinogen levels as for the biochemical parameters were significantly different between the PE (+) and PE (-) groups (P<0.05). The Wells scoring system was more successful than the other scoring systems. Biochemical parameters, clinical findings, and scoring systems, when used altogether, can contribute to the diagnosis of PE.

Détection de l’embolie pulmonaire aiguë : apport du scanner X faible dose à la tomoscintigraphie pulmonaire de ventilation et de perfusion

Ventilation and perfusion (V/Q) lung SPECT, performed according to the new recommendations of European Association of Nuclear Medicine (EANM), is a first-line examination for the detection of acute pulmonary embolism. Since low-dose CT scan acquisitions may be recorded during the same examination on hybrid cameras, the corresponding additional information should be assessed. The aim of this study is to compare the diagnostic information provided by lung V/Q SPECT, alone and combined with a low-dose CT scan. Each analysis is performed by two readers; one is more experienced (assistant, A) and one less (interne, I). ResultsThe addition of low-dose CT Scan to lung V/Q SPECT: (1) seldom changes the main diagnostic answer in example the presence or absence of pulmonary embolism (2% for A and 6% for I); (2) frequently gives more minor additional informations, 69% for A and 79% for I (localisation of the involved segments, non embolic pleuroparenchymal abnormalities…) and (3) is associated with a concordance of 87% between the two readers with regard to the final diagnosis of pulmonary embolism (84% for SPECT without CT scan). Seventy-nine percent of these discordances were associated with a low quality of ventilation images. ConclusionWhen added to V/Q lung SPECT, low-dose CT scan commonly provides an additional diagnostic information, without affecting interobserver reproducibility, but this information is generally minor without impact on the diagnosis of pulmonary embolism.

Performance of the Pulmonary Embolism Rule-out Criteria (the PERC rule) combined with low clinical probability in high prevalence population

IntroductionPERC rule was created to rule out pulmonary embolism (PE) without further exams, with residual PE risk<2%. Its safety is currently not confirmed in high PE prevalence populations even when combined with low clinical probability assessed by revised Geneva score (RGS). As PERC rule and RGS are 2 similar explicit rules with many redundant criteria, we hypothesized that the combination of PERC rule with gestalt clinical probability could resolve this limitation. MethodsWe collected prospectively documented clinical gestalt assessments and retrospectively calculated PERC rules and RGS from a prospective study of PE suspected patients. We analyzed performance of combinations of negative PERC with low clinical probability assessed by both methods in high overall PE prevalence population. ResultsAmong the final study population (n=959), the overall PE prevalence was 29.8%. Seventy-four patients (7.7%) were classified as PERC negative and among them, 4 patients (5.4%) had final diagnosis of PE. When negative PERC was combined with low pretest probability assessed by RGS or gestalt assessment, PE prevalence was respectively 6.2% and 0%. This last combination reaches threshold target of 2% and unnecessary exams could easily have been avoided in this subgroup (6%). However, it confidence interval was still wide (0%; CI 0–5). ConclusionsPERC rule combined with low gestalt probability seems to identify a group of patients for whom PE could easily be ruled out without additional test.A larger study is needed to confirm this result and to ensure safety.

Delayed diagnosis of pulmonary embolism

Pulmonary embolism is a common and potentially life threatening condition. Delays in pulmonary embolism diagnosis represent an important problem. It is crucial to have early diagnosis of pulmonary embolism if one wishes to reduce its complication. We retrospectively reviewed our patients who visited our emergency department with a final diagnosis of pulmonary embolism. We found that delayed diagnosis of pulmonary embolism usually happened when patients did not present with the classical symptoms and signs leading to other medical diagnosis at first. Clinical signs and symptoms for pulmonary embolism are mostly non-specific; therefore, patients suspected of having pulmonary embolism—because of unexplained chest pain, shortness of breath or tachycardia with or without the risk factors for pulmonary embolism—must undergo diagnostic tests including D-dimer or CT pulmonary angiography if indicated until the diagnosis is ruled out.

Comparison of 4- and 64-slice CT scanning in the diagnosis of pulmonary embolism

With the introduction of multi-detector row CT (MDCT), sensitivity to diagnose pulmonary embolism (PE) has greatly improved. The use of newer generation CT-scans may lead to a higher prevalence and a different distribution of PE. We compared 64-slice with 4-slice MDCT regarding prevalence and distribution of PE, the number of inconclusive test results and inter-reader variability. CT-scans from a random sample of 110 consecutive patients who underwent 4-slice CT-scanning were compared with 64-slice CT-scans from 107 patients from a second cohort. Three radiologists independently reassessed all CT-scans. Consensus was reached in case of disagreement between the readers. Final diagnosis of PE was categorised as central, segmental or subsegmental by the thrombus' most proximal end. The prevalence of PE was 24% (26/110, 95% confidence interval [CI] 17-32%) and 22% (24/107, 16-31%) for the 4-slice and 64-slice cohort, respectively. The prevalence of isolated subsegmental emboli was 2/26 (7.7%; 2.1-24%) and 5/24 (21%; 9.2-41%), respectively (p=0.424). The number of inconclusive scans was 10% in both cohorts, mostly due to movement artefacts and suboptimal intravascular contrast, respectively. The inter-reader agreement between the three readers was 0.70 for the 4-slice scans and 0.68 for the 64-slice scans. Although absolute prevalence of PE was equal in both cohorts, there was a trend towards more subsegmental PE with 64-slice CT. In a multi-reader setting, the number of inconclusive examinations was higher than quoted for clinical management studies, indicating that the diagnosis of PE with MDCT could be less straightforward than assumed.

12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism

Acute pulmonary embolism can produce abnormalities on ECG that reflect severity of pulmonary hypertension. Early recognition of these findings may alter the estimated pretest probability of pulmonary embolism and prompt more aggressive treatment before hemodynamic instability ensues, but it is first important to test whether these findings are specific to patients with pulmonary embolism. We hypothesize that ECG findings consistent with pulmonary hypertension would be observed more frequently in patients with pulmonary embolism. Secondary analysis of a prospective, observational cohort of emergency department patients who were tested for pulmonary embolism. ECGs were ordered at clinician's discretion and interpreted at presentation. Six thousand forty-nine patients had an ECG, 354 (5.9%) of whom were diagnosed with pulmonary embolism. The frequency, positive likelihood ratio (LR+) and 95% confidence interval (CI) of each predictor were as follows: S1Q3T3 8.5% with pulmonary embolism versus 3.3% without pulmonary embolism (LR+ 3.7; 95% CI 2.5 to 5.4); nonsinus rhythm, 23.5% versus 16.6% (LR+ 1.4; 95% CI 1.2 to 1.7); inverted T waves in V1 to V2, 14.4% versus 8.1% (LR+ 1.8; 95% CI 1.3 to 2.3); inversion in V1 to V3, 10.5% versus 4.0% (LR+ 2.6; 95% CI 1.9 to 3.6); inversion in V1 to V4, 7.3% versus 2.0% (LR+ 3.7; 95% CI 2.4 to 5.5); incomplete right bundle branch block, 4.8% versus 2.8% (LR+ 1.7; 95% CI 1.0 to 2.7); tachycardia (pulse rate >100 beats/min), 28.8% versus 15.7% (LR+ 1.8; 95% CI 1.5 to 2.2). Likelihood ratios and specificities were similar when patients with previous cardiopulmonary disease were excluded from analysis. Findings of acute pulmonary hypertension were infrequent overall but were observed more frequently in patients with the final diagnosis of pulmonary embolism compared with patients who do not have pulmonary embolism.

THO-WS-8 Evaluation de la valeur diagnostique en TDM des anomalies pleuroparenchymateuses dans l’embolie pulmonaire algue

Purpose: To describe the pleuroparenchymal abnormalities in patients with and patients without acute pulmonary embolism (PE) at enhanced-spiral computed tomography (CT), with a focus on a particular entity that we have called “framed-mesh opacity”. Materials and methods: Enhanced-spiral CT scans obtained in 453 patients clinically suspected of acute PE were retrospectively reviewed. A validated diagnostic strategy was used to establish the PE diagnosis. The retrospective analysis of vascular and pleuroparenchymal CT abnormalities was carried out independently by 2 different radiologists with, in case of litigation, fi nal consensus given by a vascular or parenchymal referent radiologist. Results: Final diagnosis of PE was established in 136 patients (prevalence of 30%). Among all pleuroparenchymal abnormalities, two had a signifi cant statistical association with PE (p<0.05): the wedge-shaped opacity and the “framed-mesh opacity”. However, with a positive predictive value of 90%, a specifi city of 99.4%, and a likelihood ratio of 21, the “framed-mesh opacity” was much more discriminant. Conclusion: In our retrospective study, the “framed-mesh opacity” appears as a particular CT entity more discriminant than the other pleuroparenchymal abnormalities for the diagnosis of PE in patients suspected with this pathology.

Pulmorary embolism: a difficult diagnostic problem

The mortality of untreated pulmonary embolism (PE) is estimated at approximately 30% of patients, whereas treatment decreases it to 2-8%. A specific combination of symptoms present in PE may suggest other cardiac or lung disorder. To evaluate frequencies of clinical symptoms and changes in diagnostic investigations misleading to the recognition of acute coronary syndrome (ACS) or lung diseases (Ld) in PE patients. Retrospective analysis of 154 records of individuals with recognized PE allowed to divide patients into groups suggestive of ACS (min. 2 of: chest pain, ischemic changes on electrocardiogram (ECG) and elevated cardiac troponin T level [cTnT >0.01 ng/ml]) or suggestive of the Ld (min. 2 of: dyspnea, cough, fever, lung consolidations on chest radiograph). Fifty-five (36%) patients were classified to the ACS group and 54 (35%) to Ld group, while 69 (45%) patients were not included to either group. Twenty-four (16%) patients fulfilled criteria of both groups. There were no significant differences in the frequency of coronary heart disease, heart failure, atrial fibrillation and chronic obstructive pulmonary disease between groups. Elevated troponin level was observed in 68% of patients with chest pain and changes on ECG, and in 26% of patients without coexistence of these symptoms (p < 0.05). In most patients with final diagnosis of PE, symptoms and initial investigation results can mislead to the diagnosis of ACS or lung disease. The chest pain and ischemic changes on ECG are frequently associated with the myocardial injury resulting in increased troponin levels in PE patients.

Initial symptoms in pulmonary embolism differ from those in pneumonia: a retrospective study during seven years

To compare initial symptoms in pulmonary embolism with community-acquired pneumonia and relate to C-reactive protein and pulmonary infiltrates in order to improve the clinical assessment at the emergency department. A retrospective review of patients with pulmonary embolism diagnosed in the clinic for infectious diseases (CID), (n=25), and a randomized sample of patients with pulmonary embolism diagnosed in the department of medicine (n=64), and a randomized sample of patients with community-acquired pneumonia (n=54) diagnosed in the clinic for infectious diseases. Initial symptoms in pulmonary embolism, dominated by dyspnoea and/or pleuritic chest pain were significantly different from those in community-acquired pneumonia, dominated by fever, chills and/or cough (P<0.001). On admission, C-reactive protein and body temperature were significantly higher and pulmonary infiltrates were more common in pneumonia compared with randomized pulmonary embolism patients. Twenty-five patients with a final diagnosis of pulmonary embolism were erroneously suspected of having lung infection, owing to increased C-reactive protein, presence of pulmonary infiltrates and/or high fever. However, they had classical symptoms of pulmonary embolism. Pulmonary infiltrates, high fever and a high level of C-reactive protein can deceive the physician to suspect pneumonia instead of pulmonary embolism. Classical initial symptoms ought to direct the physician in diagnosing pulmonary embolism. We emphasize a detailed patient history of initial symptoms.

Gadolinium-enhanced pulmonary magnetic resonance angiography in the diagnosis of acute pulmonary embolism: a prospective study on 48 patients

Gadolinium-enhanced pulmonary magnetic resonance angiography (MRA) can be an option in patients with a history of previous adverse reaction to iodinated contrast material and renal insufficiency. Radiation is also avoided. The aim of this study is to prospectively compare the diagnostic value of MRA with that of a diagnostic strategy, taking into account catheter angiography, computed tomography angiography (CTA), and lung scintigraphy [ventilation-perfusion (VQ)]. Magnetic resonance angiography was done in 48 patients with clinically suspected pulmonary embolism (PE) using fast gradient echo coronal acquisition with gadolinium. Interpretation was done with native coronal images and multiplanar maximum intensity projection reconstructions. Results were compared to catheter angiography (n=15), CTA (n=34), VQ (n=45), as well as 6-12 months clinical follow-ups, according to a sequenced reference tree. The final diagnosis of PE was retained in 11 patients (23%). There were two false negatives and no false positive results with MRA. Computed tomography angiography resulted in no false negatives or false positives. Magnetic resonance angiography had a sensitivity of 82% and a specificity of 100%. In our study, pulmonary MRA had a sensitivity of 82% and a specificity of 100% for the diagnosis of PE, with slightly less sensitivity than CTA. In the diagnostic algorithm of PE, pulmonary MRA should be considered as an alternative to CTA when iodine contrast injection or radiation is a significant matter.

Exclusion of venous thromboembolism: evaluation of D-Dimer PLUS for the quantitative determination of D-dimer

The objective of this study was to evaluate if D-Dimer PLUS (Dade Behring, USA), a rapid fully automated assay, could be used as an initial screening test in the diagnosis of venous thromboembolism (VTE). Samples from 274 consecutive symptomatic patients with suspected pulmonary embolism ( n=229; 79% outpatients, 21% inpatients), deep venous thrombosis ( n=37; 84% outpatients, 16% inpatients) or suspected for both complications ( n=8) were tested with this D-dimer assay with a Sysmex CA-1500 Coagulation Analyzer. Clinical probability for pulmonary embolism (PE) or deep venous thrombosis (DVT) was staged according to a pretest risk score proposed by Wells. Final diagnosis of PE and/or DVT was established by spiral-computed tomography of the pulmonary arteries or compression ultrasonography, respectively. PE was diagnosed in 13.5% of the patients, whereas DVT was confirmed in 17.7% of the patients. The optimal cut-off value for exclusion of venous thromboembolism was 130 μg/l, and sensitivity, specificity and negative predictive value (NPV) were 95.0% (95% CI: 92.4−97.6), 30.4% (95% CI: 25.0−35.8) and 97.2% (95% CI: 95.2−99.2), respectively. In fact, two patient with PE were missed using D-Dimer PLUS; both cases were outpatients. In conclusion, this assay appears to be safe when implemented in an algorithm based on clinical assessment, D-dimer concentration, and radiological diagnostic techniques to stratify the risk for PE or DVT. However, higher sensitivities and negative predictive values were claimed in the scarce published reports for the D-Dimer PLUS assay than found in this study.