Prevalence Of Pulmonary Embolism Research Articles

Screening pulmonary angiogram and the effect on anticoagulation strategies in severe respiratory failure patients on venovenous extracorporeal membrane oxygenation

BackgroundVenovenous extracorporeal membrane oxygenation in the treatment of severe respiratory failure in adults continues to increase with survival improving; however, it remains associated with serious complications. ObjectiveThe aim of this study was to evaluate the prevalence of pulmonary embolism (PE) in patients with severe respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV ECMO) and in those managed with conventional mechanical ventilation. MethodsA single‐center, observational cohort, retrospective study was undertaken of patients with severe respiratory failure managed with conventional ventilation or requiring ECMO in a tertiary referral university teaching hospital. ResultsWe identified 343 patients with severe respiratory failure between January 2014 and December 2017. VV ECMO was used to support 290 patients and 53 were managed by conventional mechanical ventilation. The prevalence of PE was 9.6% (33/343), of which those supported with VV ECMO was 10% (29/290) and conventional ventilation 7.5% (4/53). There was no difference in survival rates between cohorts with PE versus no PE (ECMO survival to discharge P = .56; conventional ventilation survival to discharge P = .21). ConclusionsThe prevalence of pulmonary embolism in severe respiratory failure has important clinical implications for both short and long‐term anticoagulation strategies. Routine screening pulmonary angiogram is warranted in this cohort.

Epidemio-Clinical, Therapeutic and Evolutive Aspects of Pulmonary Embolism in Young Subject in the Cardiology Department in Point “G” Hospital University Center Bamako

Objective: The purpose of this work was to determine the epidemiological, clinical and evolutionary aspects of the pulmonary embolism of the young person in the cardiology department of the University Hospital Center (CHU) Point G in Bamako-Mali. Methodology: This was an analytical study from January 01, 2018 to December 31, 2018 in the CHU Point G cardiology department, including all patients hospitalized during this period. Results: Of 1379 hospitalized patients, 19 patients were concerned by pulmonary embolism of the young person. The prevalence of pulmonary embolism of the young person was 1.37%. The most affected age group was 21 - 30 (47.4%) of patients. The predominance was female (89.47%) with a gender ratio of 0.11 in favour of women. The average age in the series was 29.79 years with extremes of 16 years and 40 years. Factors predisposing to pulmonary embolism were dominated by peri partum, cardiomyopathy and obesity with 47.3%, 31.57% and 21.1%, respectively. The dominant signs were chest pain and dyspnea in 94.7% and 89.5% of cases respectively. Pulmonary embolism was unlikely in 60.52% according to the Geneva and Wells score simplified. At the thoracic angioscanner, the embolism was bilateral in 52.6% of cases and distal in 36.8% of patients; in 10 patients who performed cardiac ultrasound, pulmonary arterial hypertension (70%), dilation of the right ventricle (20%) and left ventricular dilation (40%). Hyper leucocytosis (47.4%), anemia and low prothrombin rate (TP) (22.2%) were the most found biological abnormalities. More than 2/3 (68.5%) our patients had an intermediate mortality risk according to the PESI (Pulmonary Embolism Severity Index) score. The average hospital stay was 10 days. Hospital mortality was 10.5%. Conclusion: The pulmonary embolism of the young person is a frequent, serious and multifactorial pathology and the female sex is most affected especially during peri partum periods, hence the need for preventive measures. Clinical signs are not specific and based on the assessment of clinical probability. Pulmonary angioscanner remains the confirmation review in our context.

A meta-analysis to estimate the incidence of thromboembolism in hospitalized COVID-19 patients

Coronavirus disease 2019 (COVID-19) is associated with an increased risk of venous and arterial thrombosis in patients. Numerous studies have been conducted on COVID-19 and its association with thromboembolism is well known. We conducted a meta-analysis to find out the incidence of thromboembolism in hospitalised patients with COVID-19 to provide more generalized results. A systematic literature search was conducted in PubMed and SCOPUS to find observational studies reporting outcomes of interest. Amongst the studied thromboembolic events, the meta-analysis showed the prevalence of pulmonary embolism (PP: 12.4% [7.2%, 18.6%]; I2 = 97.23%) to be the highest. It was followed by deep vein thrombosis (PP: 8.6% [4.2%, 14.3%]; I2 = 97.52%), myocardial infarction (PP: 2.3% [0.2%, 11.2%]; I2 = 99.3%), and stroke (PP: 1.2% [0.8%, 1.6%]; I2 = 65.09%). The results of this analysis further warrant the timely and appropriate use of pharmacological thromboprophylaxis and identification of risk factors in hospitalized COVID-19 patients.

Prevalence of pulmonary embolism in emergency department patients with isolated syncope: a prospective cohort study.

Paramount to guide the diagnostic strategy, the prevalence of pulmonary embolism in patients with syncope and no other symptoms is uncertain. We aimed to assess the pulmonary embolism prevalence in patients that present to the emergency department (ED) with syncope and no chest pain nor dyspnea. Multicenter prospective cohort study in seven EDs in France. Adult patients who presented to the ED with syncope (transient loss of consciousness) were included. Patients with chest pain or dyspnea were excluded. Included patients underwent formal work-up for pulmonary embolism, including D-dimer testing and further imaging if positive. Cases of pulmonary embolism were adjudicated by two independent expert radiologists with the review of imaging studies. Secondary objectives included the pulmonary embolism prevalence in the subgroup of patients with cancer, in patients with negative Pulmonary Embolism Rule Out criteria (PERC) score, and according to the clinical probability assessed either by Wells or revised Geneva score. We analyzed 411 patients, in whom 128 (31%) underwent a computed tomographic pulmonary angiogram and 9 (2%) a ventilation-perfusion scan. A pulmonary embolism was confirmed in nine patients (prevalence of 2.2%, 95% confidence interval, 1.1-4.3%), including one subsegmental pulmonary embolism. This prevalence was of 18% (3-52%) in patients with cancer and 0.7% (0.1-4%) in PERC negative patients. In our sample of patients with isolated syncope, the prevalence of pulmonary embolism was 2.2%. This value is not sufficiently low to negate the requirement for a formal work up in the ED, even in the absence of chest pain or dyspnea. However, the large confidence interval precludes any strong conclusion.

The DiPEP Study: An Observational Study of the Diagnostic Accuracy of Clinical Assessment, D-dimer and Chest X-ray for Suspected Pulmonary Embolism in Pregnancy and Postpartum

(BJOG. 2019;126(3):383–392) Pulmonary embolism (PE) is a leading cause of maternal mortality during pregnancy and postpartum, therefore symptomatic at-risk women are commonly seen in emergency departments and maternity units to rule out PE. Recommendations regarding diagnosis of PE vary among various professional societies. Recent reviews have not found sufficient evidence to suggest that D-dimer is an effective tool in detecting PE, mainly due to the low prevalence of PE in study subjects. The aim of this study was to determine whether clinical features or D-dimer could be used during pregnancy and postpartum to select women for diagnostic imaging.

Another Assessment of Pulmonary Embolism Prevalence in Syncope Patients

Recent literature suggests conflicting estimates of the prevalence of pulmonary embolism (PE) in patients who present with syncope. Based on these

Pulmonary embolism during pregnancy: a 17-year single-center retrospective MDCT pulmonary angiography study

ObjectivesTo determine the prevalence of pulmonary embolism (PE) and alternative diagnoses detected by computed tomography pulmonary angiography (CTPA) in pregnant women; and to assess changes over time regarding radiation dose, technical quality, and examination frequency.Materials and methodsThis retrospective study included all pregnant women referred for CTPA due to clinically suspected PE over 17 years. Two blinded radiologists reviewed the CTPAs in consensus with regard to PE, alternative diagnoses, and technical quality. We retrieved patient data regarding radiation dose metrics and associated clinical and laboratory parameters. Subgroup comparisons were performed (Wilcoxon and Kruskal-Wallis tests).ResultsOf the 237 identified patients, 8 (3.3%) were excluded due to inadequate technical CTPA quality, and 229 patients were analyzed (mean age, 31.7 years; mean gestational age, 28 ± 7 weeks). The four different CT systems used over the study period had similar technical quality (p = 0.28). Of 229 patients 16 (7%) patients had PE, 144 (62.9%) had no abnormal findings, and 69 (30.1%) had an alternative diagnosis (consolidation, other pulmonary opacities, pleural effusion, and basal atelectasis). Gestational age, symptoms, and D-dimer levels were not significantly different between patients with or without PE (p > 0.05). Over time, radiation dose exposure decreased by 30% (p < 0.001), while the number of annual examinations increased by > 4-folds.ConclusionsIn pregnant women, CTPA rarely indicates PE and more often shows alternative diagnoses. Over 17 years, the use of CTPA in pregnancy has notably increased, while the radiation dose exposure has decreased by one third.Key Points• The use of CTPA in pregnancy has steadily risen over the last 17 years• In pregnant women, CTPA rarely reveals PE and more often shows alternative diagnoses• Recent technical improvements have substantially decreased the radiation dose exposure inherent in CTPA without reducing diagnostic image quality

The Role of Medical Comorbidities and Socioeconomic Factors in the Prevalence of Venous Thromboembolism Among Different Ethnic/Racial Groups in a Hospitalized Population

Background: The prevalence of venous thromboembolism (VTE) varies by race/ethnicity, with African-Americans displaying a significantly higher rate compared to Caucasians, and with Asian/Pacific Islanders and Hispanics experiencing the lowest rates. Genetic polymorphisms associated with thrombosis and molecular mutations in clotting factors do not explain the differential risk. There is a paucity of data to explain the reasons that underlie disparities in VTE prevalence among race/ethnic subgroups. The MEGA study established that major illness is associated with increased risk of VTE. Socioeconomic factors such as income and healthcare access may also contribute to VTE prevalence. In this study, we examined whether medical or socioeconomic factors experienced by hospitalized patients contributed to the variation in VTE prevalence across race/ethnic subgroups. Such an analysis explores the extent to which race itself is a risk factor versus race serving as a surrogate for differential comorbidity or socioeconomic profiles that affect VTE prevalence. Methods We conducted a serial cross-sectional study using 2002-2014 data from the National Inpatient Sample, the largest all-payer inpatient database in the US, to examine the prevalence of VTE (both deep vein thrombosis (DVT) and pulmonary embolism (PE)) among non-pregnant, adult (18+ years) African Americans, Caucasians, Hispanics and non-Hispanic others (primarily Asian Americans). Patients hospitalized with a principal diagnosis of lower extremity DVT and/or PE, as determined by ICD-9-CM codes, were included in the cohort. Codes for superficial venous thrombi and upper extremity DVT were not included. We used the Elixhauser comorbidity algorithm to assess the contribution of comorbid conditions. Socioeconomic factors investigated included zip code-level household income quartile and insurance type. VTE prevalence was defined as the number of cases per 1000 hospitalized patients. Prevalence of comorbid illness is reported as a percentage of total cases affected. To compare the role of comorbid conditions contributing to VTE with other thrombotic complications, we performed the same analysis in patients admitted with principal diagnosis of acute myocardial infarction (AMI). Results VTE prevalence was higher in patients aged 40 to 79 than those in the youngest (18-39) or oldest (80+) age groups (Figure 1). The prevalence of VTE was highest among African Americans, followed by Caucasians. Hispanics exhibited the lowest prevalence of VTE. Age did not affect this race/ethnic pattern. Diagnosis of chronic anemia, hypertension, renal failure, heart failure and obesity were more frequent in the African American population (Table 1). Subjects with a diagnosis of AMI also had a majority of African Americans with these diagnoses yet the prevalence of AMI was higher in Caucasians and non-Hispanics (Figure 2), suggesting this chronic illness milieu is not the underlying driver for the increase in VTE. Neither type of insurance (private, Medicare, Medicaid or underinsured) nor community-level household income level explain the differential prevalence of VTE across race/ethnic groups, suggesting that lack of resources does not skew the prevalence of VTE among hospitalized patients with regards to race. Conclusions Our nationally-representative study of hospitalized patients in the US confirms previously reported findings that African Americans exhibit a higher prevalence of VTE. In our study cohort, Hispanics displayed lowest prevalence. Number of comorbidities and type of comorbid conditions did not shed any light on the differences in VTE observed among different ethnic groups. Hemoglobinopathy status is thought to influence VTE risk particularly in the African American population. We excluded patients who had diagnoses of sickle cell disease and did not observe any differences in the reported prevalence pattern. We were unable to explore the contribution of sickle cell trait as this condition is rarely reported as a contributing admission diagnosis. Insurance status and income level did not influence the likelihood of being admitted with VTE diagnosis. Our findings do not suggest that race is acting as a surrogate for chronic illness or socioeconomic factors; however, this study is observational and largely descriptive in nature. To fully exclude this possibility, more sophisticated, inferential analyses are needed. Disclosures No relevant conflicts of interest to declare.

P4. Abstract Title: Prevalence of Pulmonary Embolism in Patients Accessing the Emergency Department, Reported by Country of Study: A Systematic Review and Meta-Analysis

<h3>Introduction</h3> Pulmonary embolism (PE) has an incidence of 0.75-2.69 cases per 1,000 individuals in Western Europe and North America (NA), with no significant differences between these two regions. In the United States, there is evidence of PE overdiagnosis, with increased incidence of PE over time and minimal changes in the mortality rate. It is possible that this tendency towards overdiagnosis (and over-testing) is different in NA and Europe. Greater tendency toward overtesting would imply a lower prevalence of PE among suspects and a lower diagnostic yield of imaging techniques. <h3>Aim</h3> The aim of the study was to determine whether the prevalence of PE among patients tested for PE in European and North American emergency department (EDs) differed. The secondary objectives were to determine if the rates of diagnostic imaging use and the diagnostic yield from imaging differed between the two continents. <h3>Methods</h3> The protocol was registered in the PROSPERO database. We searched MEDLINE and EMBASE from inception to September 3, 2017 for all studies which reported on consecutive ED patients tested for PE, without language restrictions. We screened titles and abstracts and then the full texts. Risk of bias was assessed using a modified version "Tool to Assess Risk of Bias in Longitudinal Symptom Research Studies Aimed at the General Population", form the CLARITY group, McMaster University. These steps and data extraction were performed independently by at least two authors. Conflicts were solved through discussion or with the intervention of a third author. For each outcome (PE prevalence, rate of diagnostic imaging, diagnostic yield of CTPA and ventilation-perfusion [VQ] scan), we conducted a meta-analysis of proportions specifying a random-effects model. We reported the pooled estimates as percentages with their 95% confidence intervals (CIs). A multiple meta-regression was conducted to evaluate if the effect of the region on PE prevalence and diagnostic yield of CTPA was independent of the year of execution of the studies. A sensitivity analysis was conducted only including studies at low risk of bias. <h3>Results</h3> The search identified 3109 records (2562 after duplicates removal). After screening the full text of 107 articles, 44 studies were included in the systematic review. Twenty-three of the 44 included studies were at low risk of bias. The overall prevalence of PE was 20% (95% CI 18%, 22%). The prevalence of PE in NA was 8% (95% CI 6%, 9%), while the prevalence of PE in Europe was 23% (95% CI 21%, 26%). After adjusting for the year of execution of the studies, the OR for PE prevalence in studies conducted in Europe versus NA was 1.16 (95%CI 1.11, 1.22). The overall frequency of use of CTPA was 53% (95% CI 45%, 62%). The frequency of CTPA use was 38% (95% CI 24%, 51%) in NA and 59% (95% CI 51%, 68%) in Europe, respectively. After adjusting for the year of study, the OR for the use of CTPA for studies conducted in Europe versus NA was 1.25 (95%CI 1.06, 1.48). The overall frequency of use of V/Q scan was 35% (95% CI 20%, 51%). The adjusted OR for the use of CTPA for studies conducted in Europe versus NA was 1.17 (95%CI 0.88, 1.52). The overall diagnostic yield was 25% (95% CI 20%, 29%). The diagnostic yield in NA was 13% (95% CI 9%, 17%), while the diagnostic yield in Europe was 29% (95% CI 26%, 32%). The adjusted OR for studies conducted in Europe versus NA was 1.16 (95%CI 1.09, 1.24). The overall diagnostic yield for VQ scan was 13% (95% CI 10%, 16%). The adjusted OR for studies conducted in Europe versus NA was 1.03 (95%CI 0.94, 1.14). The sensitivity analyses conducted including only studies at low risk of bias showed results consistent with the main analyses. We did not detect publication bias. <h3>Conclusion</h3> We found that studies reporting on ED patients tested for PE in NA had a lower prevalence of PE diagnosis compared to those conducted in Europe. There was a lower rate of CTPA use and a lower diagnostic yield from CTPA in NA compared to Europe. Our results support the hypothesis that those tested for PE in North American EDs have a lower risk of PE compared to Europe.

P5019Derivation and validation of a new probability score in pulmonary embolism suspicion allowing safely reduction of imaging testing: PEPS (Pulmonary Embolism Probability Score)

Abstract Background In pulmonary embolism (PE) suspicion, several strategies based on clinical criteria and D-dimer (Dd) measurement have been developed in order to reduce resource utilization. However, they used different clinical probability (CP) assessment methods limiting their combination. Purpose To develop and validate a unique probability score integrating most of previous proposals to allow safely reduction of imaging testing. Methods 4 CP levels were previously defined in order to obtain a false negative rate &lt;1.9%: 1) without Dd test: very low CP (PE prevalence &lt;1.9%), 2) with Dd &lt;1000 μg/L: low CP (&lt;15%), 3) with Dd &lt;500 or age x10μg/L: moderate CP (&lt;60%) and 4) precluding PE exclusion on Dd: high CP. We used individual data from 4 prospective cohorts of suspected PE patients in Europe and America (n=11 066) for derivation and internal validation. The variables significantly associated with PE in univariate analysis were included in a multivariate logistic regression model. Points were assigned according to the regression coefficients. The score was validated in two external independent cohorts (n=1554, n=1669). Results PEPS comprised 13 variables: age &lt;50 years (−2), age 50–64 years (−1), heart rate &lt;80 beats/min (−1), chronic lung disease (−1), chest pain and recent dyspnea (+1), syncope (+1), male sex (+1), previous venous thromboembolism (+2), medical or orthopaedic immobilization (+2), estrogenic treatment (+2), oxygen saturation &lt;95% (+3), unilateral lower limb pain (+3) and PE is the most likely diagnosis (+ 5). The rates of false negative and avoidable imaging tests if the PEPS strategy would have been applied were 0.6% [95% CI: 0.3–1.1] and 22.7% [20.2–25.3] in the first external validation cohort, and 0.85 [0.5–1.45] and 26.6% [23.5–29.9] in the second one. Applied retrospectively, PEPS strategy compared favourably with other strategies and combinations. Derivation Int. validation Ext. validation 1 Ext. validation 2 nPE/N % [95% CI] nPE/N % [95% CI] nPE/N % [95% CI] nPE/N % [95% CI] TOTAL 615/5588: 11.0% [10.2–11.9] 432/3726: 11.6% [10.6–12.7] 327/1546: 21.2% [19.2–23.2] 196/1669: 11.7% [10.3–13.4] Very low CP PEPS&lt;0 16/1445: 1.1% [0.7–1.8] 16/946: 1.7% [1.0–2.7] 3/118: 2.5% [0.7–6.8] 5/347: 1.4% [0.6–3.3] Low CP 0≤PEPS&lt;5 127/2620: 4.9% [4.1–5.7] 106/1805: 5.9% [4.9–7.1] 49/611: 8.0% [6.1–10.4] 61/647: 7.2% [5.7–9.1] Moderate CP 5≤PEPS&lt;12 347/1334: 26.0% [23.7–28.4] 243/867: 28.0% [25.1–31.1] 206/715: 28.8% [25.6–32.2] 107/430: 24.9% [21.0–29.2] High CP 12≤PEPS 125/179:69.8% [62.8–76.1] 67/108: 62.0% [52.6–70.6] 69/102: 67.7% [58.1–76.2] 23/45: 51.1% [37.0–65.0] AUC 0.84 [0.83–0.86] 0.82 [0.80–0.84] 0.79 [0.76–0.82] 0.77 [0.74–0.80] CP: Clinical probability; PEPS: Pulmonary Embolism Probability Score. Conclusions A strategy based on the proposed score may lead to a safely substantial reduction of imaging testing. It should now be tested in an outcome interventional study.

Prevalence of venous thromboembolism in admissions and readmissions with and without syncope: a nationwide cohort study.

The Pulmonary Embolism in Syncope Italian Trial reported 17.3% prevalence of pulmonary embolism (PE) in patients admitted with syncope. We investigated the prevalence of venous thromboembolism [VTE, including PE and deep vein thrombosis (DVT)] in syncope vs. non-syncope admissions and readmissions, and if syncope is an independent predictor of VTE. We conducted an observational study of index admissions of the 2013-14 Nationwide Readmission Database. We excluded patients <18 years, December discharges, died during hospitalization, hospital transfers, and missing length of stay. Encounters were stratified by the presence or absence of DVT/PE and syncope diagnoses. Multivariable logistic regression analysis was used to evaluate the association between syncope and VTE. There were 38 655 570 admissions, of whom 285 511 had syncope. In the overall cohort, syncope occurred in 1.6% of VTE and 1.8% in non-VTE admissions. In a multivariable model, syncope was associated with a lower prevalence of VTE [odds ratio (OR) 0.76, 95% confidence interval (CI) 0.75-0.78; P < 0.001]. In index syncope vs. non-syncope admissions, the prevalence of DVT, PE, and VTE were 0.4 ± 0.06% vs. 1.3 ± 0.12%, 0.2 ± 0.04% vs. 1.2 ± 0.11%, and 0.5 ± 0.07% vs. 2.1 ± 0.14% (all P < 0.001), respectively. At 30 days, the prevalence of DVT, PE, and VTE in syncope vs. non-syncope were 2.2 ± 0.14% vs. 2.1 ± 0.14% (P = 0.38), 1.4 ± 0.12% vs. 1.2 ± 0.11% (P = 0.01), and 2.6 ± 0.17% vs. 3.0 ± 0.17% (P = 0.99), respectively. Syncope admissions were associated with a lower prevalence of VTE as compared to non-syncope admissions. Syncope should not trigger an automatic PE workup, rather, should be put into context of patient presentation.

Prevalence and Predictor of Pulmonary Embolism in a Cohort of Chinese Patients with Acute Proximal Deep Vein Thrombosis

The aim of this study is to investigate the incidence of pulmonary embolism (PE) in a cohort of Chinese patients with acute (<14days) proximal (above-knee) deep vein thrombosis (DVT) in the lower limbs, and to evaluate whether the location of thrombosis is associated with the existence of PE. A retrospective review of patients diagnosed with acute proximal DVT from January 2014 to June 2018 at a single center was performed. Helical computed tomography angiography was performed to screen PE within 48hr after admission. Multiple factors associated with PE were compared between the PE group and the non-PE group. A total of 100 patients with acute proximal DVT were screened for PE. The mean age was 56.9±18.1 (range 21-88) years, and 55% were male. The most common risk factors of DVT were immobilization (38%), malignancy (27%), and trauma or surgery (21%). Majority of the patients' thrombosis was located at the left leg (66%) and 8 patients had bilateral lower limb DVT. Femoral vein was involved in 52 patients (52%), while iliofemoral thrombosis was identified in 48 patients (48%). PE was identified in 58 patients (58%), including 3 massive and 55 nonmassive PE. There was no statistical difference between the PE group and the non-PE group in terms of age, sex, and risk factors. The D-dimer level was associated with the existence of PE (P=0.038). Patients with iliofemoral thrombosis had a similar incidence of PE compared with those with femoral thrombosis alone (P=1.000). PE occurred in more than half of patients with acute proximal DVT, despite the fact that most of them were asymptomatic. In this study, existence of PE did not correlate with pelvic thrombosis. Increasing D-dimer level was statistically associated with the presence of PE.

Incidental pulmonary embolism in pancreatic ductal adenocarcinoma: Impact of tumor and AJCC stages at initial staging CT

Background/objectivesTo determine the prevalence of incidental pulmonary embolism (PE) detected during initial staging CT among patients with newly diagnosed pancreatic ductal adenocarcinoma (PDAC) and assess their association with underlying tumor burden. Materials and methodsThis retrospective cohort study evaluated staging chest CT scans (2013–2017) to identify PE among patients with treatment naïve, biopsy-proven PDAC. Data included age, sex, T stage, AJCC stage, presence/absence of metastases and their location at diagnosis. The association of PE with tumor (T1-T4) and AJCC stage were assessed using Pearson Chi-square and Fischer's exact test. A threshold p-value of <0.05 indicated statistical significance. ResultsA total of 174 patients (90 female, mean age, 68 years; range: 34–93) were identified, of which 10 patients harbored incidental PE (prevalence, 5.7%). In the PE group, two patients presented with distant metastasis (liver, 20%), while eight patients had T4 tumors (80%). No statistical association was detected between PE and age, sex, and the presence/absence or location of distant metastasis (p = 0.065, p = 0.59, p = 0.687 and p = 0.933, respectively). Patients with T4 tumors and higher AJCC stages (stage III/IV) were significantly more likely to present with PE than those with lower T stage (p = 0.045) and AJCC stage (stage I/II; p = 0.017). ConclusionThe prevalence of incidental PE among PDAC patients undergoing initial CT staging is 5.7%. Patients with T4 and AJCC stages III/IV are at higher risk of PE. Caution should be exercised during radiographic interpretation of initial staging chest CTs, as incidental PE may be lurking and require treatment.

Comparison of mortality and complications between bilateral simultaneous and staged total hip arthroplasty: A systematic review and meta-analysis.

Total hip arthroplasty (THA) relieves pain and restores function in patients with severe rheumatoid arthritis and osteoarthritis. Over the past few decades, several authors have attempted to assess the efficacy and safety of simultaneous bilateral THA compared with staged bilateral THA. The purpose of this meta-analysis is to compare the mortalities and complications between simultaneous bilateral THA and staged bilateral THA. A literature search to identify eligible studies was undertaken to identify all relevant articles published until August 2018. We included studies that compared simultaneous bilateral THA and staged bilateral THA and their effects on mortality and complications. The outcomes included mortality, the occurrence of deep venous thrombosis (DVT), the occurrence of pulmonary embolism (PE), respiratory complications, cardiovascular complications, digestive system complications and the occurrence of dislocation. Stata 12.0 was used for the meta-analysis. Nineteen studies involving 59,257 patients were identified; among them, 16,758 patients were selected for treatment with simultaneous bilateral THA, and 42,499 patients were chosen for the purpose of staged bilateral THA. The meta-analysis results demonstrated that there was no significant difference between simultaneous bilateral THA and staged bilateral THA in terms of mortality (risk ratio [RR] = 1.15, 95% CI = 0.76, 1.74; P = .520). Compared with staged bilateral THA, simultaneous bilateral THA was associated with a reduction in the occurrence of DVT, PE and respiratory complications (P < .05). There were no significant differences in the cardiovascular complications, digestive system complications or the occurrence of dislocation and infection (P = .057). We observed that the prevalence of DVT, PE and respiratory complications was considerably lower with the use of simultaneous bilateral THA than with the use of staged bilateral THA. Thus, simultaneous bilateral THA is a considerably safer procedure than staged bilateral THA in selected THA patients.

Is the Oral Chemical Prophylaxis Necessary for the Prevention of Venous Thromboembolism after Joint Arthroplasty in a Korean Population?

PurposeVenous thromboembolism (VTE) is a serious complication that may occur after a major orthopedic surgery. The aim of the present study was to determine the necessity of a chemical thromboprophylactic agent (rivaroxaban [RXB]) by analyzing the prevalence of VTE in Korean arthroplasty patients who received RXB for prophylaxis compared with those who did not receive RXB.Materials and MethodsA total of 2,603 patients who underwent knee or hip arthroplasty between 1996 and 2017 were prospectively evaluated. Of these, 1,608 patients underwent surgery before January 2010 and were not administered any type of prophylaxis after surgery; the remaining 995 underwent surgery after 2010 and received oral RXB once daily for 5–13 days from the day after hemovac drain removal to postoperative day 14.ResultsThe primary study outcome was the prevalence of VTE, pulmonary embolism or death during follow up. The overall incidence of VTE was 1.69% (n=44); of these, 12 occurred in the RXB group and 32 in the non-prophylactic group. The odds ratio of VTE in the RXB group was 0.61. However, the statistical power of the study was 0.313 due to the low incidence of VTE.ConclusionTreatment with oral chemical prophylaxis decreased the incidence of VTE after knee or hip arthroplasty in a Korean population. Furthermore, no serious complications occurred after administering oral RXB, which, coupled with its convenience, suggests oral RXB offers an attractive alternative to other agents. However, we recommend that further studies, including a multicenter study, be conducted to achieve adequate statistical power.

Prevalence and Predictors of Pulmonary Embolism in Hospitalized Patients with Syncope.

Approximately one in six patients hospitalized with syncope have pulmonary embolism (PE), according to the PE in Syncope Italian Trial study. Subsequent studies using administrative data have reported a PE prevalence of <3%. The aim of the study was to determine the prevalence and predictors of PE in hospitalized patients with syncope. We retrospectively reviewed the records of patients who were hospitalized in the MedStar Washington Hospital Center between May 1, 2015 and June 30, 2017 with deep venous thrombosis, PE, and syncope. Only patients who presented to the emergency department with syncope were included in the final analysis. PE was diagnosed by either positive computed tomographic angiography or a high-probability ventilation-perfusion scan. Univariate and multivariate logistic regressions were used to assess the associations between clinical variables and the diagnosis of PE in patients with syncope. Of the 408 patients hospitalized with syncope (mean age, 67.5 years; 51% men [N = 208]), 25 (6%) had a diagnosis of PE. Elevated troponin levels (odds ratio 6.6, 95% confidence interval 1.9-22.9) and a dilated right ventricle on echocardiogram (odds ratio 6.9, 95% confidence interval 2.0-23.6) were independently associated with the diagnosis of PE. Age, active cancer, and history of deep venous thrombosis were not associated with the diagnosis of PE. The prevalence of PE in this study is approximately one-third of the reported prevalence in the PE in Syncope Italian Trial study and almost three times the value reported in administrative data-based studies. PE should be suspected in patients with syncope and elevated troponin levels or a dilated right ventricle on echocardiogram.

Prevalence of Pulmonary Embolism in Patients With Syncope

BackgroundThe prevalence of pulmonary embolism (PE) in patients presenting with syncope to the emergency department (ED) is largely unknown. This information, however, is necessary to balance the potential medical benefit or harm of systematic PE screening in patients presenting with syncope to the ED. ObjectivesThis study sought to determine the prevalence of PE in patients with syncope. MethodsUnselected patients presenting with syncope to the ED were prospectively enrolled in a diagnostic multicenter study. Pre-test clinical probability for PE was assessed using the 2-level Wells score and the results of D-dimer testing using age-adapted cutoffs. Presence of PE was evaluated by imaging modalities, when ordered as part of the clinical assessment by the treating ED physician or by long-term follow-up data. ResultsLong-term follow-up was complete in 1,380 patients (99%) at 360 days and 1,156 patients (83%) at 720 days. Among 1,397 patients presenting with syncope to the ED, PE was detected at presentation in 19 patients (1.4%; 95% confidence interval [CI]: 0.87% to 2.11%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.5% to 1.5%). In the subgroup of patients hospitalized (47%), PE was detected at presentation in 15 patients (2.3%; 95% CI: 1.4% to 3.7%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.4% to 2.0%). ConclusionsPE seems to be a rather uncommon cause of syncope among patients presenting to the ED. Therefore, systematic PE-screening in all patients with syncope does not seem warranted. (BAsel Syncope EvaLuation Study [BASEL IX]; NCT01548352)

Could the YEARS algorithm be used to exclude pulmonary embolism during pregnancy? Data from the CT‐PE‐pregnancy study

IntroductionThe recently proposed YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce the use of computed tomography pulmonary angiography (CTPA) among pregnant women with suspected PE. Our aim was to externally validate this finding. MethodsWe performed a post hoc analysis of a prospective management outcome study for PE diagnosis in pregnant women. PE was diagnosed with an algorithm that combined the revised Geneva score, D‐dimer testing, bilateral lower‐limb compression ultrasonography, and CTPA. All women had a 3‐month follow‐up. All of the items necessary to use the YEARS algorithm were prospectively collected at the time of the study. ResultsOf the 395 women included in the original study, 371 were available for the present analysis. The PE prevalence was 6.5%. Ninety‐one women had no YEARS items, and 280 had one or more items. When the YEARS items were combined with D‐dimer levels (<1000 ng/mL in women with no items, and <500 ng/mL in women with one or more items), 77 women (21%) met the criteria for PE exclusion and would not have undergone CTPA as per the YEARS algorithm. None of these 77 women had PE diagnosed during the initial work‐up or 3‐month follow‐up. Therefore, the failure rate of the YEARS algorithm in our pregnant women population was 0/77 (95% confidence interval 0.0‐3.9). ConclusionIn our study, application of the YEARS algorithm would have resulted in safe exclusion of PE in one of five pregnant women without the need for radiation exposure, further supporting the use of the algorithm in this population.

The Risk of Pulmonary Embolism in Patients With Pemphigus: A Population-Based Large-Scale Longitudinal Study.

Growing evidence suggests that inflammation may pose an atypical risk factor for pulmonary embolism (PE), as it drives venous thrombosis via several pathways. The increased risk of PE in several autoimmune diseases has lent weight to this concept. However, the relative risk of PE among patients with pemphigus has not yet been established. We aimed to examine the risk of PE in patients with pemphigus. A large-scale population-based longitudinal cohort study was conducted to evaluate the relative risk (RR) of PE among 1,985 patients with pemphigus relative to 9,874 age-, sex-, and ethnicity-matched control subjects. A multivariate Cox regression model was utilized. The incidence of PE was 3.0 (95% CI, 2.2–4.0) and 1.2 (95% CI, 1.0–1.5) per 1,000 person-years among patients with pemphigus and controls, respectively. The period prevalence of PE corresponding to the study period was 2.2% (95% CI, 1.6–2.9%) among cases and 0.9% (95% CI, 0.7–1.1%) among controls. Patients with pemphigus were twice as likely to develop PE as compared to control subjects (adjusted RR, 1.98; 95% confidence interval [CI], 1.29–3.04). The highest PE risk was observed during the 1st year following the diagnosis of pemphigus (adjusted RR, 3.55; 95% CI, 1.78–7.09) and decreased over time. The increased risk was robust to a sensitivity analysis that included only cases managed by pemphigus-related systemic medications (adjusted RR, 1.82; 95% CI, 1.11–2.98). In conclusion, pemphigus is associated with an increased risk of PE, particularly during the 1st year of the disease. An awareness of this risk should be increased, additional precipitating factors for PE should be avoided, and thromboprophylaxis may be evaluated in high-risk patients. Further research is required to establish this risk.

Yearly trend of acute venous thromboembolism in patients admitted with heart failure in the United States

ABSTRACTIntroduction: Heart failure (HF) patients are at risk for venous thromboembolism (VTE) during the hospital stay. We aim to study the recent trend of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE in heart failure patients from years 2000–2013.Methods: We utilized the National (Nationwide) Inpatient Sample database and selected non-pregnant patients over the age of 18 years for this purpose. We selected HF, DVT, PE, and VTE based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We used STATA for analysis.Results: We noted an increase in prevalence of DVT, PE and composite VTE among HF hospitalizations from 0.55%, 0.17% and 0.76% in 2000 to 0.96%, 0.4% and 1.46%, respectively, in 2013 and a decrease in trend of mortality among HF hospitalizations associated with DVT, PE and VTE from 8.95%, 16.36% and 10.80% in 2000 to 6.78%, 7.92% and 7.20%, respectively, in 2013.Conclusion: Increasing prevalence of VTE is concerning and suggests that we still need to work on delivering prophylaxis to all HF inpatients.