Onset Of Pulmonary Embolism Research Articles

The use of a low dose hydrocortisone to prevent pulmonary embolism in patients with multiple trauma

Venous thromboembolism events are common in trauma patients. Immediate acute inflammation following injury triggers coagulation cascade and may increase the risk of pulmonary embolism (PE) in this population. We aimed to evaluate whether early low-dose steroids prevent symptomatic PE onset in multiple trauma patients. The medical surgical intensive care unit of Habib Bourguiba University Hospital (Sfax--Tunisia). Comparative study of two cohorts: a retrospective cohort of patients who didn't receive early low-dose steroids (steroid (-) group) and a prospective cohort of patients who received hydrocortisone with a dose of 100 mg/8 h for a scheduled period of 7 days (steroid (+) group). All adult patients admitted in our intensive care unit (ICU) for multiple trauma with predicted duration of mechanical ventilation over 48 h were included. Evaluation of the impact of low-dose steroids on the incidence of symptomatic PE. We included 175 patients: 92 in the steroids (-) group and 83 in the steroids (+) group. PE was diagnosed in 15 patients (8.5 %). The incidence of PE was significantly lower in steroid (+) group (3.6 vs 13 %; p = 0.013). In multivariate analysis, independent factors predicting PE onset were meningeal hemorrhage [OR = 14.7; 95 % CI (2.2-96.3); p = 0.013] and pelvic ring trauma [OR = 8; 95 % CI (1.8-36.4); p = 0.007] whereas low-dose steroids were significantly associated with a protective effect [OR = 0.2; 95 % CI (0.05-0.77); p = 0.019]. There was no significant difference between steroids (+) and steroids (-) groups neither in terms of mean ICU length of stay (LOS) (respectively 11 ± 9.7 and 12.3 ± 10.7 days; p = 0.372) nor in terms of ICU mortality (respectively 29.3 and 24.1 %; p = 0.434). Steroids are effective in reducing the incidence of PE in multiple trauma patients. However, no significant benefice was found on ICU mortality.

Dual energy CT pulmonary blood volume assessment in acute pulmonary embolism – correlation with D-dimer level, right heart strain and clinical outcome

To investigate the role of perfusion defect (PD) size on dual energy CT pulmonary blood volume assessment as predictor of right heart strain and patient outcome and its correlation with d-dimer levels in acute pulmonary embolism (PE). 53 patients with acute PE who underwent DECT pulmonary angiography were retrospectively analyzed. Pulmonary PD size caused by PE was measured on DE iodine maps and quantified absolutely (VolPD) and relatively to the total lung volume (RelPD). Signs of right heart strain (RHS) on CT were determined. Information on d-dimer levels and readmission for recurrent onset of PE and death was collected. D-dimer level was mildly (r = 0.43-0.47) correlated with PD size. Patients with RHS had significantly higher VolPD (215 vs. 73 ml) and RelPD (9.9 vs. 2.9%) than patients without RHS (p < 0.003). There were 2 deaths and 1 readmission due of PE in 18 patients with >5% RelPD, while no such events were found for patients with <5% RelPD. Pulmonary blood volume on DECT in acute PE correlates with RHS and appears to be a predictor of patient outcome in this pilot study.

Perfusion defects after pulmonary embolism: risk factors and clinical significance.

Little is known about residual abnormalities after pulmonary embolism (PE). To assess risk factors and the clinical significance of perfusion defects in patients with PE. Consecutive patients receiving at least 3 months of anticoagulant for an acute PE were included in a prospective cohort study. Ventilation/perfusion lung scan, echocardiography, 6-min walk test, thrombophilia and hemostatic variables were performed 6-12 months after PE. Perfusion defect was defined as a perfusion defect in at least two segments. Seventy-three out of 254 patients (29%) had perfusion defects during follow-up (median 12 months) and were more likely to have dyspnea, had a higher systolic pulmonary arterial pressure [39 mmHg (SD) (12) vs. 31 mmHg (8); P < 0.001] and walked a shorter distance during the 6-min walk test [374 m (122) vs. 427 m (99); P = 0.004]. Age [odds ratio (OR) 1.35; 95% confidence interval (CI), 1.11-1.63], the time interval between symptom onset and diagnosis (OR, 1.17; 95% CI, 1.04-1.31), pulmonary vascular obstruction at the onset of PE (OR, 1.34; 95% CI, 1.16-1.55) and previous venous thromboembolism (OR 2.06; 95% CI, 1.03-4.11) were independent predictors of perfusion defect after treatment of acute PE. Total tissue factor pathway inhibitor concentration was associated with perfusion defects. Perfusion defects are associated with an increase in pulmonary artery pressure (PAP) and functional limitation. Age, longer times between symptom onset and diagnosis, initial pulmonary vascular obstruction and previous venous thromboembolism were associated with perfusion defects.

Impact of Thrombophilic Genetic Factors on Pulmonary Embolism: Early Onset and Recurrent Incidences

The importance of genetic thrombophilic factors in the development of venous thromboembolism has been increasingly recognized. Factor V Leiden (FVL), prothrombin gene mutation G20210A (FII G20210), genetic variant C677T of the methylentetrahydrofolate reductase (MTHFR), as well as the polymorphism A2 (PlA2) in platelet glycoprotein IIb/IIIa were recently discussed. We analyzed the contribution of genetic thrombophilic factors to the pathogenesis of pulmonary embolism (PE) and their association with the early onset and recurrence of PE using DNA analysis methods. In this case control trial we found thrombophilic genetic variants in 58.8% of 51 patients with PE. FVL was found in 23.5% of the patients versus 7.1% of the 98 controls (p=0.01), PlA2 IIb/IIIa was found in 35.3% vs. 14.3% (p=0.03), and FII G20210A was found in 5.9% vs. 2.0% (NS). Patients with recurrent PE had a very high prevalence of genetic factors, 70.4%. High prevalence of FVL was found in patients under 45 years of age: 39.3% (OR=14.23, 95% CI=1.58-330.03, p=0.01) as well as in patients with recurrent incidence (37%, OR=7.647, 95% CI=2.27-26.44, p=0.001). FVL was also significantly higher in the subgroup of patients with PE combined with deep venous thrombosis (OR=6.500, 95% CI=1.81-23.76, p=0.002) in comparison with patients with isolated PE (OR=2.261, 95% CI=0.50-9.69). The carriers of FVL are at higher risk for early and recurrent PE events. High prevalence of PlA2 in PE patients evidently shows the impact of this polymorphism in PE development. A different treatment should be considered in carriers of thrombophilic defects.

Impact of earthquakes on risk for pulmonary embolism

Physical and psychological stress induced by catastrophic events such as earthquakes can lead to sudden death, acute coronary syndrome, stroke, and other cardiovascular diseases. We investigated the impact of the earthquake that occurred in Niigata, Japan, on pulmonary embolism. Pulmonary embolism increased to 9 cases in the 4 weeks after the earthquake, compared to 1 case in the 4 weeks before the earthquake, 2 cases in the corresponding 8 weeks in 2003, and 1 case in 2002. The first case occurred two days after the initial earthquake and new cases were reported for 27 days thereafter. Six of 9 patients (67%) took refuge in their automobiles before the onset of pulmonary embolism. Sudden death also increased after the earthquake and 7 of 22 cases (32%) spend night(s) in automobile. In conclusion, pulmonary embolism should be attended after disasters and prolonged immobilization in automobiles may increase risk of pulmonary embolism and sudden death.

Complex regional pain syndrome in upper and lower limbs that showed an alleviating trend after thoracotomy: a case report

AbstractWe experienced a case with complex regional pain syndrome that showed a tendency toward alleviation of the symptoms after thoracotomy. The patient was a 27-year-old woman. Following surgery for cubital tunnel syndrome, complex regional pain syndrome occurred in the upper limb. Subsequently, she suffered from ankle fracture. Despite surgery, complex regional pain syndrome occurred also in the right lower limb. Five months after surgery, she had onset of pulmonary embolism, and was therefore subjected to thoracic thrombectomy. Post-surgically, the dose of analgesics required decreased, probably due to alleviation of symptoms. It has been reported that stress and pain occasionally contribute to increase in thalamic blood flow. Given the fact that she showed decreased blood flow in the contralateral thalamus before onset of pulmonary embolism, it is postulated that an extreme stress, like thoracotomy, might be responsible for reversing the pre-existing limited blood flow to increased levels, resulting...

Pulmonary fat embolism induced by exposure to high ambient temperature in rats with a fatty liver

The aim of this study was to investigate whether a fatty liver contributes to pulmonary embolism under a high ambient temperature. As an experimental model, we exposed fatty liver rats to a high temperature (45 degrees C) and then looked for fat emboli in the alveolar capillaries using the fat-staining method. Fat emboli were detected in the alveolar capillaries of the fatty liver rats, but not in those of the normal liver rats. Moreover, the degree of pulmonary fat embolism tended to become more severe in proportion to the severity of the fatty liver. In addition, fat emboli did not appear at a core body temperature of 40 degrees C, but were detected at a core body temperature of 44 degrees C. From these results, we conclude that a fatty liver may contribute to the formation of pulmonary fat embolism and that high temperatures act as a trigger for the onset of pulmonary embolism. Moreover, it is possible that fatty liver affects the development of heat stroke induced by exposure to a high ambient temperature and that pulmonary fat embolism is a significant finding which helps to enable a diagnosis of heat stroke in autopsy cases.

Risk factors for pulmonary embolism in an Irish patient cohort.

The prevention of pulmonary embolism (PE) is an important component of medical care. To examine the risk factors for venous thromboembolism in an Irish patient cohort with acute PE, and identify cases that may have been preventable. Retrospective review of 60 consecutive cases of computed tomography (CT)-confirmed acute PE. The primary thromboembolic risk factors were elective surgery (27%), medical illness (20%), primary immobility (13%) and isolated distal lower limb fracture (7%). A significant proportion (43%) had been hospitalised within the six weeks prior to PE onset. Some patients had undergone 'low risk' procedures, without prophylaxis, but had other significant thromboembolic risk factors that indicated a requirement for prophylaxis. Hospital- and ward-based thromboprophylaxis guidelines, based on certain categories of patient or procedure, need to be routinely supplemented by an individual risk factor assessment for each patient, to determine those at particularly high risk for venous thromboembolism.

Seasonal variation in onset of pulmonary embolism is independent of patients' underlying risk comorbid conditions.

As for many cardiovascular events, pulmonary embolism (PE) is not randomly distributed over time, but shows rhythmic patterns. The purpose of this study was to investigate whether such temporal pattern of occurrence varied in subgroups of patients according to different risk comorbid conditions. All cases of PE observed at the Hospital of Ferrara, Italy, from 1998 to 2001, were considered. After determination of the day of onset, the population was grouped by gender and the most common underlying risk comorbid conditions, e.g., deep vein thrombosis (DVT), neoplasms, cardiomyopathies, traumas/surgical operations, diabetes mellitus, pulmonary diseases, hypertension, cerebrovascular diseases, heart failure, hematologic diseases. For statistical analysis, chi-square test for goodness of fit and partial Fourier series were used. A total of 784 cases (mean age 71 +/- 14 years) were included. Frequency of onset was higher in winter for total population (p = 0.002), men (p = 0.004), DVT (p = 0.001), pulmonary disease (p = 0.008), cardiomyopathies (p = 0.011), and major traumas/surgical operations (p = 0.049). Chronobiologic analysis identified a winter peak for total population (p = 0.008), men (p < 0.001), DVT (p = 0.006), pulmonary diseases (p = 0.017), and hypertension (p = 0.026). This study confirms the winter peak of PE and provides evidence that it is not influenced by the underlying clinical conditions, but probably by endogenous variations.

Differences in the Clinical Course of Acute Massive and Submassive Pulmonary Embolism-In-Hospital Onset vs Out-of-Hospital Onset-

Acute massive or submassive pulmonary embolism (PE) has high mortality, but the clinical course according to the location of onset (ie, in-hospital or out-of-hospital) is unknown. In the present study 56 consecutive patients with acute massive or submassive PE were studied retrospectively and a comparison made of the clinical characteristics, and outcomes between in-hospital onset (Group A) and out-of-hospital onset (Group B). Patients in Group A (n=28) had more frequent comorbidities with hemodynamic instability (54% vs 4%, p<0.0001) and temporary risk factors (93% vs 11%, p<0.0001), whereas patients in Group B (n=28) had a longer duration of symptoms (median: 5.5 days vs 0.5 day; p<0.0001), and had higher systolic pulmonary artery pressure (63+/-17 mmHg vs 46+/-12 mmHg, p=0.0006). Although in-hospital mortality did not differ between the 2 groups, the recurrence rate was higher in Group B (23% vs 0%, p=0.03). Patients who had in-hospital onset of PE had mostly temporary risk factors, unstable hemodynamics and a lower recurrence rate compared with the cases of out-of-hospital onset. In cases of in-hospital onset, prompt diagnosis and suitable treatment is needed to prevent fatalities and cases of out-of-hospital onset should be followed carefully for recurrence.

Management of venous thrombosis and pulmonary embolism after gynecological surgery.

We experienced 23 cases of venous thrombosis after gynecological surgery for the past 12 years at Tokyo Women's Medical University Hospital, representing 0.345 % of all patients. Eighteen of the 23 cases had deep venous thrombosis (DVT) including five cases followed by pulmonary embolism (PE), and five cases had PE without any symptoms of DVT. The main risk factors for thrombosis in these 23 patients were (1) obesity, DM, hyperlipidemia; (2) huge abdominal tumor, severe adhesion; and (3) hemoconcentration, post-treatment of severe anemia. The onset of PE varied from 1 to 3 postoperative days, when the patients started to walk. Five cases had dyspnea, chest pain, and decreased PaO2 levels without leg pain, while five cases showed only calf pain and tenderness with decreased PaO2 levels. PE was confirmed by immediate diagnostic images such as RI venography with ventilation and perfusion lung scan, pulmonary arterial CT, or pulmonary arteriography. Two patients died and eight patients recovered. The best way of managing venous thrombosis might be as follows: (1) identify the risk factors of thrombosis before surgery; (2) perform prophylactic leg exercises in bed and/or active anticoagulant therapy depending on the degree of risk factors; (3) rapid diagnosis with the images; and (4) proper treatment.

Hemostatic abnormalities in patients with pulmonary embolism compared with that in deep vein thrombosis

We investigated hemostatic abnormalities in 37 patients with deep vein thrombosis (DVT) and pulmonary embolism (PE) (PE patients) and in 40 patients with DVT without PE (DVT patients). Plasma fibrinogen, thrombin-antithrombin complex (TAT), plasmin-plasmin inhibitor complex, fibrin-D-dimer, activated protein C (APC)-protein C inhibitor (PCI) complex, von Willebrand factor (vWf), tissue plasminogen activator (t-PA), PA inhibitor-I (PAI-1), and thrombomodulin levels in both PE and DVT patients were significantly increased compared with normal volunteers. Plasma APC-PCI complex, PAI-1, and vWf levels in PE patients were significantly higher than those in DVT patients without PE. These findings indicate that PE patients are more hypercoagulable and hypofibrinolytic than DVT patients. Plasma TAT, APC-PCI complex, PAI-1, and vWf levels were the most sensitive indicators for PE. In these patients, increases in TAT and APC-PCI complex suggest DVT and increased PAI-1 and vWf suggest the risk of onset of PE.

Dressler-like Syndrome After Pulmonary Embolism and Infarction

Among 195 patients with pulmonary embolism admitted to our hospital, three men and three women, 16 to 65 years old, developed a pericardial syndrome five to 15 days after the onset of pulmonary embolism and infarction. Other known causes of pericarditis were ruled out by clinical history and ancillary methods. The six patients had a pericardial rub, fever, anemia, leukocytosis, and increasing sedimentation rate; four had a pericardial effusion; two had a pleural effusion. One patient, with coexisting heart disease, died after another episode of pulmonary embolism; in the other five, oral corticosteroids induced complete remission of the pericardial syndrome. This type of pericarditis deserves wider recognition.