Probability Of Pulmonary Embolism Research Articles

A unilateral popliteal vein aneurysm in an adult cadaver: A case report

The incidence of venous aneurysm is less than the arterial aneurysms. The knowledge of Popliteal vein aneurysm (PVA) is important as it could be a source of pulmonary embolism, deep vein thrombosis and so could be fatal. PVA could be an incidental finding during the investigations for pulmonary embolism or chronic venous insufficiency. We report a case of left popliteal vein aneurysm in the popliteal fossa in a 65-year-old female cadaver observed during routine dissection. A large saccular dilatation was noted in the left popliteal vein in the distal part of the popliteal fossa. The right popliteal vein was normal.An early diagnosis of PVA with doppler ultrasound examination is important to prevent the occurrence of any thromboembolic events or other major complications.

Validation of the Swedish National Inpatient Register for the diagnosis of pulmonary embolism in 2005.

The Swedish National Inpatient Register (NPR) has near‐complete coverage of in‐hospital admissions and ICD codes in Sweden. Acute pulmonary embolism (PE) is a serious condition presenting challenges regarding diagnosis, treatment, and follow‐up. Here we aimed to validate the accuracy of acute PE diagnosis in the NPR, investigational findings, antithrombotic treatment, and follow‐up of PE patients in Sweden. From a nation‐wide cohort of all patients with in‐hospital diagnoses of acute PE (ICD‐10‐SE codes I26.0–I26.9) in 2005 (n = 5793), we selected those from two Swedish regions for thorough manual review of hospital records. We identified 599 patients with PE diagnoses according to the ICD‐10 coding system. We excluded 58 patients with admissions related to previous PE (47; 8%) or incorrect ICD codes (11; 2%), leaving 501 patients with probable PE diagnoses. We confirmed the diagnosis in 441 (79%) cases, which was based on imaging (435 patients; 73%) or autopsy (6; 1%). In the remaining 60 (11%) cases, the PE diagnosis was based on clinical findings and can therefore not be confirmed. Of the surviving patients with PE, 231 (47%) were offered follow‐up within 6 months after the acute event. At follow‐up, 67 patients (29%) had symptoms requiring clinical attention (dyspnoea or reduced general condition). The Swedish NPR showed acceptable accuracy for PE diagnosis, and could be reliably used for register‐based research regarding acute PE.

Cardiac manifestation of corona virus disease 2019: a preliminary report.

Corona virus disease 2019 (COVID-19) is a multi-systemic illness that can present with cardiac complications. This report describes the preliminary findings of cardiac manifestations seen in patients managed in three centres in Lagos, Nigeria. Ten patients, part of an ongoing study of patients admitted in three centres in Lagos, Nigeria, with COVID-19 diagnosed with reverse transcriptase polymerase chain reaction (RT-PCR) or serology were retrospectively studied for cardiac manifestations. The mean (SD) age was 52.5 ± 18.79 years (with a minimum of 17 years and maximum of 79 years). Six patients were female and four were male. Hypertension was seen in 70%, diabetes in 50% and obesity in 60% of patients. All had elevated inflammatory markers. Only four patients had bilateral pneumonia. The rest had only cardiac manifestations. Six patients presented with de novo heart failure and one had decompensated heart failure. A set of three patients had individually fulminant myocarditis, probable pulmonary embolism and stress cardiomyopathy, respectively. This study shows that co-morbidities are common in patients with COVID-19 and cardiac complications. The array of cardiac complications is large, with the commonest being heart failure.

TO ASSESS SAFETY OF WITHHOLDING ANTITHROMBOTIC THERAPY IN PATIENTS WITH LOW OR INTERMEDIATE PROBABILITY OF PULMONARY EMBOLISM

Background & Method: The study was carried out in the Department of Radio diagnosis, Index Medical College, Hospital & Research Centre, Indore, M.P. including 100 chronic bedridden patients with an aim to assess safety of withholding antithrombotic therapy in patients with low or intermediate probability of pulmonary embolism.
 Result: Males represented about 62% of the entire sample. Majority of male patients were in age group 50 and above. Majority (29%) of female patients were of age group of 20 to 40 yrs. On the basis of B-mode sonography and colour Doppler 20% patients were diagnosed to have acute deep vein thrombosis and 12 % patients were diagnosed to have chronic deep vein thrombosis. Out of 100 chronic bedridden patients in the study, 40% were suspected to have deep vein thrombosis on the basis of clinical signs,45% had a positive d-dimer test, 28% were positive on impedence plethysmography. 30% patients were diagnosed to have deep vein thrombosis by B mode sonography and 32% were diagnosed to have deep vein thrombosis by colour Doppler.
 Conclusion: Only 32 patients were positive for deep vein thrombosis out of 100 patients so it is safe to withhold unnecessary anticoagulation therapy in all chronic bed ridden patients because even after 3 month follow up only 1% patients were positive. Impedence plethysmography is less sensitive than ultrasonography and D-dimer test is more sensitive but it lacks specificity so ultrasound and colour Doppler is more sensitive in clinically suspected DVT patients. Ultrasonography and colour Doppler is better predictor of DVT because it is more sensitive and specific, non-invasive, painless, widely available, easy to use, less expensive, no ionizing radiation.
 Keywords: antithrombotic, pulmonary &embolism.

Development and validation of a novel risk assessment model to estimate the probability of pulmonary embolism in postoperative patients

Pulmonary embolism (PE) is a leading cause of mortality in postoperative patients. Numerous PE prevention clinical practice guidelines are available but not consistently implemented. This study aimed to develop and validate a novel risk assessment model to assess the risk of PE in postoperative patients. Patients who underwent Grade IV surgery between September 2012 and January 2020 (n = 26,536) at the Affiliated Dongyang Hospital of Wenzhou Medical University were enrolled in our study. PE was confirmed by an identified filling defect in the pulmonary artery system in CT pulmonary angiography. The PE incidence was evaluated before discharge. All preoperative data containing clinical and laboratory variables were extracted for each participant. A novel risk assessment model (RAM) for PE was developed with multivariate regression analysis. The discrimination ability of the RAM was evaluated by the area under the receiver operating characteristic curve, and model calibration was assessed by the Hosmer–Lemeshow statistic. We included 53 clinical and laboratory variables in this study. Among them, 296 postoperative patients developed PE before discharge, and the incidence rate was 1.04%. The distribution of variables between the training group and the validation group was balanced. After using multivariate stepwise regression, only variable age (OR 1.070 [1.054–1.087], P < 0.001), drinking (OR 0.477 [0.304–0.749], P = 0.001), malignant tumor (OR 2.552 [1.745–3.731], P < 0.001), anticoagulant (OR 3.719 [2.281–6.062], P < 0.001), lymphocyte percentage (OR 2.773 [2.342–3.285], P < 0.001), neutrophil percentage (OR 10.703 [8.337–13.739], P < 0.001), red blood cell (OR 1.872 [1.384–2.532], P < 0.001), total bilirubin (OR 1.038 [1.012–1.064], P < 0.001), direct bilirubin (OR 0.850 [0.779–0.928], P < 0.001), prothrombin time (OR 0.768 [0.636–0.926], P < 0.001) and fibrinogen (OR 0.772 [0.651–0.915], P < 0.001) were selected and significantly associated with PE. The final model included four variables: neutrophil percentage, age, malignant tumor and lymphocyte percentage. The AUC of the model was 0.949 (95% CI 0.932–0.966). The risk prediction model still showed good calibration, with reasonable agreement between the observed and predicted PE outcomes in the validation set (AUC 0.958). The information on sensitivity, specificity and predictive values according to cutoff points of the score in the training set suggested a threshold of 0.012 as the optimal cutoff value to define high-risk individuals. We developed a new approach to select hazard factors for PE in postoperative patients. This tool provided a consistent, accurate, and effective method for risk assessment. This finding may help decision-makers weigh the risk of PE and appropriately select PE prevention strategies.

Pulmonary Embolism: Epidemiological, Clinical, Therapeutic and Evolution Aspects in the Medicine Department of Hospital of Mali Bamako

Background: Pulmonary embolism (PE) is a severe form of venous thromboembolic disease. In Africa, prevalence of PE in hospitalized medical patients varies among studies. Objective: Aim of this work was to study the epidemiological, clinical, therapeutic and evolution aspects of PE in the medicine department of Mali’s Hospital Bamako-Mali. Methodology: This was a retrospective cross-sectional study carried out from January 01, 2017 to December 31, 2020 in the medicine department of Mali’s hospital Bamako, including all inpatients admitted for PE during the study period. Results: Of 1814 hospitalized patients, 54 patients had pulmonary embolism. Hospital frequency of pulmonary embolism was 2.97%. Predominance was female and sex-ratio M/F was 0.38. Mean age in our series was 54.24 ±1.19 years. Predisposing factors to pulmonary embolism were dominated by obesity 37%, high blood pressure 35.2% and history of cardiovascular disease 20.4%. Dominant signs were dyspnoea and chest pain in 83.3% and 70.4% of cases respectively. Probability of pulmonary embolism was high in 40.7% according to Wells score. Patients with right heart failure were 22.2%. EKG showed sinus tachycardia70.4% and S1Q3 aspect 7.4%. Heart right chambers were dilated at transthoracic echography 42.6%. Obstruction was bilateral at chest angio CT for 51.9% and proximal for 42.6%. Deep venous thrombosis was associated at EP in 16.6%. Treatment was low weight molecular heparin followed by vitamin K antagonist or direct oral anticoagulant. One patient was successfully treated by thrombolysis. Hospital mortality was 16.7%. Conclusion: PE is a serious disease probably underdiagnosed. It is responsible of important mortality.

Antithrombotic Treatment of Pulmonary Embolism

The present article addresses clinical challenges associated with the choice of the anticoagulant agent, the definition of the duration of anticoagulant treatment and the assessment of the risk-to-benefit ratio of prolonged anticoagulation for patients with pulmonary embolism (PE).Anticoagulation is performed with unfractionated heparin (UFH) in hemodynamically unstable patients and with low molecular weight heparins (LWMH) or fondaparinux in normotensive patients. In patients with high or intermediate clinical probability of pulmonary embolism, anticoagulation should be initiated without delay while awaiting the results of diagnostic tests. LMWH and fondaparinux are preferred over UFH in the initial anticoagulation of PE since they are associated with a lower risk of bleeding.All patients with PE require therapeutic anticoagulation for at least three months. The current 2019 guidelines of the European Society of Cardiology (ESC) recommend that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant (NOAC) in preference to a vitamin K antagonist (VKA). In patients with active cancer, Apixaban, Edoxaban and Rivaroxaban are effective alternatives to treatment with LMWH.The decision on the duration of anticoagulation should consider both, the individual risk of PE recurrence and the individual risk of bleeding. The risk for recurrent PE after discontinuation of treatment is related to the features of the index PE event. While patients with a strong transient risk factor have a low risk of recurrence and anticoagulation can be discontinued after three months, patients with strong persistent risk factor (such as active cancer) have a high risk of recurrence and thus should receive anticoagulant treatment of indefinite duration. Given the favourable safety profile of NOACs (especially if a reduced dosage of Apixaban or Rivaroxaban is initiated after at least six months of therapeutic anticoagulation), extended oral anticoagulation of indefinite duration should be considered for all patients with intermediate risk of recurrence.

Investigation of pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study.

Chest pain is a common main complaint in the emergency department. Among its associated differential diagnoses, pulmonary embolism remains a key concern for the clinician. There are no clear recommendations on which patients should have a formal workup for pulmonary embolism diagnosis. The objective of this study was to determine the proportion of patients with chest pain who were investigated for pulmonary embolism diagnosis and to determine the clinical profile of these patients. This was a retrospective multicenter study conducted in three French Emergency Departments. We included all patients who presented to these centers for chest pain during a 2-month period. The primary outcome was the initiation of pulmonary embolism workup. We also aimed to find factors associated with this outcome. We included 881 patients with a main complaint of chest pain. Mean age was 50 years and 481 (56%) were men. A total of 263 patients (30%, 95% confidence interval 27-33%) had a formal pulmonary embolism workup, and pulmonary embolism was ultimately diagnosed in 7 cases (prevalence of 2.6%, 95% confidence interval 1.1-5.3%). Five factors were identified as independently associated with a workup for pulmonary embolism diagnosis: female sex, young age, no ischemic heart disease, recent flight and associated dyspnea. Among patients presenting to emergency department with chest pain, 30% had a workup for pulmonary embolism. We report five clinical variables independently associated with a higher probability of pulmonary embolism workup in our sample.

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.

Pulmonary Embolism

Pulmonary embolism is caused by a blood clot that travels from the deep veins through the heart and then lodges in the pulmonary vasculature. Common symptoms include pleuritic chest pain, dyspnea, or palpitations. Clinical scores such as the Wells score and Revised Geneva score can be used to assess the pretest probability of pulmonary embolism (PE) and guide work-up such as deciding to order D-dimer testing or imaging. However, clinical gestalt can also accurately assess the pretest probability of PE. The Pulmonary Embolism Rule-out Criteria is a decision rule that can be used to rule out PE without further testing. Imaging modalities include computed tomography pulmonary angiogram or ventilation/perfusion scanning. Novel or new oral anticoagulants are becoming the mainstay of treatment for the hemodynamically stable patient with pulmonary embolism. For the patient who is hemodynamically unstable, treatment modalities include intravenous alteplase, catheter-directed thrombolysis, surgical embolectomy, and catheter-directed embolectomy. A subset of patients with PE can be treated as outpatients. This review contains 1 figure, 4 tables, and 55 references. Key Words: anticoagulants, antithrombins, D-dimer, low-molecular-weight heparin, mechanical thrombolysis, multidetector computed tomography, radionuclide imaging, unfractionated heparin, pulmonary embolism, tissue plasminogen activator, warfarin

Underuse of Risk Assessment Scores and Overuse of Computed Tomography Pulmonary Angiography (CTPA) in the Investigation for Pulmonary Embolism in an Emergency Department (ED) in Victoria

Underuse of Risk Assessment Scores and Overuse of Computed Tomography Pulmonary Angiography (CTPA) in the Investigation for Pulmonary Embolism in an Emergency Department (ED) in Victoria

The use of 80 kV versus 100 kV in pulmonary CT angiography: An evaluation of the impact on radiation dose and image quality on two CT scanners

IntroductionUse of CT in the investigation of pulmonary embolism in radiosensitive patients such as pregnant and young female patients entails the need for protocol optimization. The aim of this study was to analyze the dose reduction and image quality achieved by using 80 kV instead of 100 kV in CT pulmonary angiography protocols. Methods80 examinations of non-obese patients were analyzed (40 consecutive patients for each protocol, equally distributed on two CT scanners). Objective image quality was assessed by measurements of HU values (average and standard deviation) in five ROIs in pulmonary arteries and calculations of signal-to-noise (SNR) and contrast-to-noise ratios (CNR). Subjective image quality was independently evaluated by two radiologists in terms of perceived noise, sharp reproduction of pulmonary arteries and overall diagnostic quality. Radiation dose parameters (CTDIvol, DLP, SSDE and effective dose) and effective risk were compared. Differences in radiation dose and objective measures of image quality for the two protocols were assessed using the independent t test; comparison of subjective grading of image quality was performed with the Mann–Whitney U test. ResultsUse of 80 kV significantly increased both arterial contrast enhancement and image noise. Differences in SNR and CNR between protocols were not statistically significant. Achieved dose reduction by using 80 kV was significant on both scanners (SSDE reduction 35% and 46%, p < 0.001; effective dose reduction 40% and 53%, p < 0.001). ConclusionUse of 80 kV protocols for CT examinations of pulmonary arteries in non-obese patients with bodyweight below 80 kg results in significant reduction of radiation doses without compromising image quality.

The Use of Empiric Parenteral Anticoagulation for Acute Pulmonary Embolisms: A Cohort Study

SESSION TITLE: Venous Thromboembolism SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Timely anticoagulation for patients diagnosed with acute pulmonary embolism (PE) is paramount in reducing morbidity and mortality. In fact, guidelines recommend the administration of empiric anticoagulation when the pretest probability for PE is high, or for moderate risk, when diagnostic testing will be delayed greater than 4 hours. However, the risk-benefit ratio must be carefully considered as empiric anticoagulation increases risk for bleeding. We hypothesize that empiric anticoagulation is inadequately administered in moderate to high-risk probability PE patients. METHODS: We conducted a retrospective cohort study of adult patients, between October-December 2016, who were suspected of having a PE. All patients who underwent a CT chest with PE protocol or ventilation-perfusion (V/Q) scan were enrolled. PE was defined as a positive CT chest or a high probability V/Q scan. Data collected included baseline demographics, risk stratification scores for PE (PERC, Geneva, and Wells), and use of full strength anticoagulants prior to diagnostic testing. Risk stratification scores were dichotomized to those with low vs moderate-high pretest probability for PE. The primary outcome measure was the use of empiric anticoagulation based on risk stratification scoring. Fisher’s exact test and student’s t-test was used when appropriate. A p-value of <0.05 was considered significant with a two-tailed approach. RESULTS: The cohort consisted of 104 patients (mean age: 64.1+/-15.5, male: 51%) with a PE diagnostic rate of 10.6%. In patients diagnosed with PE, 27.3% received empiric anticoagulation compared to 1.1% without a PE diagnosis (p-value: <0.0001). When using PERC, 2.9% of low risk patients received empiric anticoagulation compared to 12.9% in the moderate-high risk group (p-value: 0.108). For Well’s criteria, empiric anticoagulation was lower in the low risk group (1.9% vs 17.6%, p-value: 0.006). Finally, 13.0% of low risk patients for the Geneva score received empiric anticoagulation versus 8.6% of moderate-high risk scores (p-value: 0.527). CONCLUSIONS: Only 12.9-17.6% of patients with a moderate-high pretest probability for PE were given empiric anticoagulation. In contrast, 1.9-13.0% of patients determined to be low risk for PE received anticoagulation. Thus, we are not aggressive enough in providing empiric anticoagulation in moderate-high risk patients, but may be too aggressive in those who are low risk. CLINICAL IMPLICATIONS: The use of empiric anticoagulation must be thoughtfully administered in those suspected of PE. The risk-benefit ratio must be carefully weighed and should be adjusted based on the pretest probability for PE. A protocolized approach that couples the use of risk stratification tools with administration of empiric anticoagulation may decrease the risks for significant morbidity and mortality associated with acute PE, while minimizing the risks of bleeding in those where clinical suspicion is low. DISCLOSURE: The following authors have nothing to disclose: Kimberley Doucette, Bilal ElChaarani, Tanuj Sharma, Chee Chan No Product/Research Disclosure Information

Progressive respiratory distress in a 42-year-old HIV-positive woman with systemic lupus erythematosus

BackgroundIdentifying and treating the cause of pulmonary symptoms in HIV patients with underlying systemic lupus erythematosus (SLE) can be very challenging. Delays in diagnosing active SLE in HIV patients can lead to significant morbidity and even mortality. We report the case of an HIV-positive woman with SLE who presented with severe respiratory distress.Case presentationA 42-year-old HIV-positive woman presented with a 7-month history of anorexia, progressive dyspnoea, and a productive cough. She had been put on treatment for pulmonary tuberculosis and pneumocystis jiroveci pneumonia for several months by the referring hospital without any significant improvement in her symptoms. Her initial laboratory investigations showed highly elevated d-dimer test results but confirmatory investigations for pulmonary embolism proved otherwise. An autoimmune screen revealed highly positive antinuclear antibody and anti-double-stranded DNA tests, and she responded very well to SLE treatment.ConclusionsOur case represents a situation where two diseases with antagonizing pathways of disease pathogenesis occur concurrently in the same patient. SLE is usually not among the differential diagnoses in HIV patients with respiratory distress. Management of patients with both SLE and HIV is also very challenging because improvement in one condition can lead to worsening of the other. Despite opportunistic infections being the likely cause of pulmonary symptoms in HIV patients, clinicians are encouraged to have a high index of suspicion for autoimmune interstitial lung disease in these patients.

Approach to Suspected Acute Pulmonary Embolism: Should We Use Scoring Systems?

Modern diagnostic strategies for pulmonary embolism diagnosis almost all rely on an initial assessment of the pretest probability. Clinical prediction rules are decision-making tools using combinations of easily available clinical predictors to define the probability of a disease. The assessment of the clinical probability of pulmonary embolism has an important impact on the diagnostic strategy and on therapeutic management. Clinical prediction rules provide accurate and reproducible estimates of clinical probability. They should be derived and validated following strict methodological standards. The use of clinical prediction rules should be encouraged, since their implementation in local guidelines for pulmonary embolism diagnosis has been shown to improve patients' outcomes.

NEW METHODS OF ASSESSING THE LEVEL OF D-DIMER IN THE DIAGNOSIS OF PULMONARY E

BACKGROUND. Pulmonary embolism (PE) is a pathological condition complicating the course of many diseases, which often remains unrecognized. An important role for its diagnosis is given to D-dimer concentration in blood. This marker has a low specificity and a high predictive value of a negative result. The normal level of D-dimer with low clinical probability of pulmonary embolism allows to exclude this diagnosis with an accuracy of 97%. According to the European Society of Cardiologists, the specificity of D-dimer may be improved by the correction of the upper reference values in patients of different age groups. The aim of the study was to calculate the correction coefficient of the normal D-dimer upper limit depending on age in order to improve the diagnosis of pulmonary embolism in patients with chronic heart failure (CHF). MATERIAL AND METHOD. We surveyed 160 patients over 50 years with suspected pulmonary embolism on the background of CHF of III-IV functional class according to NYHA classification. All patients underwent clinical and biochemical blood tests, d-dimer, echocardiography, Doppler ultrasound, angiography of pulmonary arteries. Based on the results of examination, the diagnosis of pulmonary embolism was set in 102 patients with heart failure of III-IV functional class according to NYHA classification. The level of the proximal occlusion was distributed as follows: main pulmonary artery — 41%, lobar artery — 31%, segmental artery — 28% of patients. All patients had not a high risk of death from pulmonary embolism. In 58 patients with CHF of III–IV functional class and D-dimer above reference values, PE was excluded. RESULTS AND CONCLUSION. In patients with CHF of III–IV functional class (NYHA) over 50 years, the correction of upper limit of D-dimer reference with a coefficient of 0.012 allows to increase the specificity of this marker in the diagnosis of pulmonary embolism by 40%.

Pulmonary Embolism As a Consequence of Ultrasonographic Examination of Extremities for Suspected Venous Thrombosis: A Systematic Review.

Ultrasonographic examination for deep vein thrombosis (DVT) appears to be a safe diagnostic method, but a theoretical concern has been raised for dislodgment of thrombi during examination. We conducted a systematic review of the literature to identify reports of possible or confirmed pulmonary embolism (PE) as a consequence of ultrasonographic assessment of extremities in patients with suspected DVT. We searched PubMed for studies published in English from January 1, 1960, to April 10, 2015. We included all cohort studies, case series, and case reports that described PE as a consequence of ultrasonographic assessment of extremities. We excluded studies that reported assessment of areas other than extremities. We screened 3,626 articles, 15 of which reported the issue of clot dislodgement and embolization following ultrasonographic examination of the extremities, including 8 original case reports (7 men and 1 woman). DVTs were in the lower extremities in all eight cases: five in right and three in left lower extremity. In six cases, the femoral veins were involved, and a free-floating thrombus was reported in two cases. Compression ultrasonography was used in all cases, with or without adjunct techniques. Overall, there were seven confirmed and one probable PE cases, two of which had fatal outcomes. Clot embolization is a rare but potential complication of ultrasonic examination for DVT that can lead into PE. Radiologists and clinicians should be aware of this potentially serious phenomenon and avoid excessive pressure when performing ultrasonographic studies of the extremities.

Potential utility of a renal function adjusted D-dimer cut-off value for improving the exclusion of pulmonary embolism

To evaluate the potential utility of a renal function adjusted D-dimer cut-off value for improving the exclusion of pulmonary embolism. Retrospective analyses were performed for 1 784 inpatients and outpatients with low and moderate probability of pulmonary embolism at Anzhen Hospital from January 2011 to June 2013. The Well's score was used. The diagnoses of pulmonary embolism were confirmed by computed tomography pulmonary angiogram and ventilation-perfusion scan. Based upon estimated glomerular filtration rate (GFR), they were divided into three subgroups of normal renal function, mild renal impairment and moderate renal impairment. Negative D-dimer was defined as a level of age-standardized D-dimer value<500 µg/L. The proportions of patients with negative D-dimer and the utility of D-dimer for ruling out pulmonary embolism were compared between three subgroups. A new D-dimer cut-off point in patients with renal impairment was developed by receiver operating characteristics (ROC) curves and the effect of diagnostic efficiency of ruling out pulmonary embolism with renal function adjusted D-dimer cut-off was assessed. The medians of D-dimer of three subgroups with normal renal function, mild renal impairment and moderate renal impairment were 291.5, 995.5 and 1 901.5 µg/L (P<0.001) respectively. The sensitivity of negative D-dimer for ruling out pulmonary embolism was 99%-100% and the specificity 70%, 42% and 23% in three subgroups. The number of patients needed to test (NNT) for one negative test of D-dimer in three subgroups of different renal function was 3.32, 3.58 and 3.95 respectively. The new D-dimer cut-off value increased to 1.2 and 1.75 times of old one in patients with mild and moderate renal impairments and the proportion of patients with a negative D-dimer level rose from 48.7% to 53.0% as compared with old D-dimer cut-off value. The sensitivity and specificity of negative D-dimer for ruling out pulmonary embolism was 98% and 62% with the new cut-off value versus 99% and 57% with the old cut-off value and the NNT of D-dimer for ruling out pulmonary embolism declined from 3.52 to 3.34. The renal function adjusted D-dimer cut-off point can improve the diagnostic efficiency of D-dimer test for ruling out pulmonary embolism.

Diagnosis of Crohnʼs Disease in a Patient with Pulmonary Embolism: A ‘Clotʼ to Think About

Background: The risk of venous thromboembolism (VTE) amongst patients with inflammatory bowel disease (IBD) is increased by a 2-4 time fold compared to non-IBD patients. This case describes a patient who incidentally was diagnosed with Crohn's disease while investigated for a pulmonary embolism. History: A 66-year old woman was admitted to our hospital after a witnessed episode of loss of consciousness. She had recently been on a 2-hour aeroplane flight. She had lost weight recently but her medical history was otherwise non-contributory and was not on any regular medications. She was an ex-smoker. On physical examination a systolic heart murmur was diagnosed. She was pyrexial. The rest of the examination was unremarkable. Laboratory assessment revealed elevated inflammatory markers and a raised d-dimer. Her head CT was normal and echocardiogram showed severe aortic stenosis. A chest radiograph was normal but CT pulmonary angiogram confirmed a pulmonary embolism (PE). Gastroscopy was normal and cross sectional imaging of the thorax, abdomen and pelvis were showed terminal ileal thickening consistent with Crohn's disease. Ileo-colonoscopy with biopsies confirmed mild to moderately active ileitis but no colonic disease. With the possible exception of weight loss she had no other symptoms attributable to IBD. Her son was diagnosed some years ago with ulcerative colitis from which he as asymptomatic after investigations for pulmonary embolism. Management: She has been anticoagulated with warfarin and awaits surgery for aortic valve replacement. She is currently being managed with aminosalicylates despite limited evidence for 5-ASA's in Crohn's disease given the relatively short segment of otherwise asymptomatic disease with a plan to reassess disease after aortic valve replacement. Discussion: Venous thromboembolism (VTE) is a well-recognised complication of IBD with an overall mortality as high as 25% per episode. Despite emerging evidence that Inflammation and coagulation are interdependent processes that perpetuate and intensify each other, this important complication may not be appreciated as well as it should and a high index of suspicion and prompt treatment are necessary for optimal outcomes. Up to 75% of IBD patients may have no identifiable provoking factors but as many as a third of these will have recurrent VTE within 5 years. Between 55-80% have active IBD at diagnosis of VTE. There remains paucity of clinical data driving evidence- based decisions and although anticoagulation is the cornerstone of therapy, randomised trials testing catheter directed thrombolysis or anticoagulation are much needed.

Scores und Stadien in der Pneumologie

Useful scales and classifications for patients with pulmonary diseases are discussed. The modified Medical Research Council breathlessness scale (mMRC) is a measure of disability in lung patients. The GOLD classifications, the COPD-Assessment Test (CAT) and the BODE Index are important to classify the severity of COPD and to measure the disability of these patients. The Geneva score is a clinical prediction rule used in determining the pre-test probability of pulmonary embolism. The Pulmonary Embolism Severity Index (PESI) is a scoring system used to predict 30 day mortality in patients with pulmonary embolism. The Epworth Sleepiness Scale is intended to measure daytime sleepiness in patients with sleep apnea syndrome. The Asthma Controll Test (ACT) determines if asthma symptoms are well controlled.