Dual-energy and photon-counting computed tomography in critical care.

Chronic Thromboembolism Phenotypes after Acute Pulmonary Embolism: Identification with the SEARCH Algorithm.

ABSTRACT Background: Plasma lactate >2 mmol/L has been associated with increased mortality in acute pulmonary embolism (PE), even among hemodynamically stable patients. Despite strong evidence, lactate remains underutilized in risk stratification tools such as the simplified PE Severity Index (sPESI). To assess the incremental prognostic value of plasma lactate when integrated into a Bayesian probability model for Pulmonary Embolism. Methods: Pretest probabilities were defined by SI and sPESI. Sensitivity and specificity for plasma lactate >2 mmol/L were derived from prior meta-analyses and validated multicenter datasets. Likelihood ratios were applied within a Bayesian nomogram to estimate posttest probabilities. Diagnostic efficiency was evaluated using Bayesian Diagnostic Gain (BDG) and Bayesian Number Needed to Diagnose (BNND). Results: Thirty-day mortality for SI >1 was 24.1% versus 10.7% for low-risk SI and 10.7% versus 1.5% for sPESI. Lactate >2 mmol/L yielded 82.4% sensitivity (95% confidence interval [CI]: 56.8–95.3) and 73.5% specificity (95% CI: 71.8–74.4). Integrating lactate into the SI model produced an Absolute Diagnostic Gain (ADG) of 25.9% (BNND = 4), outperforming the sPESI model (ADG: 16.3%, BNND = 6). Conclusions: Bayesian integration of plasma lactate with the SI enhances prognostic accuracy and produces superior diagnostic gains compared with sPESI-based models. This supports a probabilistic, physiology-driven approach to PE risk stratification.

Myeloproliferative neoplasms (MPNs) are clonal hematopoietic disorders characterized by elevated thrombotic and bleeding risk, and optimal risk stratification and management remain challenging. This review summarizes current evidence on the thrombotic complications in MPNs, including venous events (i.e., deep vein thrombosis, pulmonary embolism, and unusual site thrombosis), and arterial events (ischemic stroke, myocardial infarction, and peripheral arterial thrombosis), and the increased bleeding risk in these diseases. Mechanistically, JAK2-driven clonal hematopoiesis, elevated hematocrit, leukocytosis, platelet activation, endothelial dysfunction, and chronic inflammation interact to promote a pro-thrombotic state; conversely, extreme thrombocytosis, acquired von Willebrand syndrome, and anticoagulant/antiplatelet therapy contribute to bleeding risk. Clinically, thrombosis may precede MPN diagnosis, especially in unusual sites, and treatment should balance the risk of recurrent thrombosis against the risk of hemorrhagic complications. Antithrombotic strategies include low-dose aspirin, vitamin K antagonists, and direct oral anticoagulants, while cytoreductive therapy (hydroxyurea, anagrelide, interferon, and JAK inhibitors) is central for disease control as well as vascular risk reduction. Despite therapy, recurrence of thrombotic events and major bleeding persists, highlighting the need for optimized risk models and alternative therapeutic targets. Future research may focus on integrating molecular biomarkers, inflammation metrics, and vascular-specific endpoints to direct personalized preventive strategies.

Incidence, risk factors, characteristics and shoulder joint function status of heterotopic ossification following surgical treatment of clavicle fracture or acromioclavicular joint dislocation.

This study aims to perform a systematic literature review (SLR) concerning the safety of synthetic and biological disease-modifying antirheumatic drugs (DMARDs) for the 2025 update of European Alliance of Associations for Rheumatology (EULAR) recommendations for the management of rheumatoid arthritis (RA). Medline, Embase, Cochrane CENTRAL, and Web of Science were searched for observational and randomised controlled trials with a primary endpoint of DMARD safety on the conventional synthetic (cs-), biological (b-), and targeted synthetic-DMARDs, as well as glucocorticoids, published between January 14, 2022, and January 22, 2025. Separate searches on DMARD monitoring were conducted from database inception to January 22, 2025. A comparator group was required for inclusion. All safety outcomes were included. A total of 3837 articles were identified, with 321 selected for full-text review; 71 articles were included. Across the evidence base, infections were the most frequently assessed outcome: 13 studies examined serious or hospitalised infections, usually as composite endpoints of bacterial, opportunistic, and herpes zoster infection, while 1 addressed nonserious infections. Serious infections were more common with bDMARDs than csDMARDs. Janus kinase inhibitors (JAKis) showed a higher herpes zoster risk than bDMARDs. Tuberculosis risk was not increased with JAKis compared with bDMARDs, but was higher with infliximab and adalimumab compared with etanercept. Fifteen studies evaluated malignancy, split evenly between analyses of any malignancy and those excluding nonmelanoma skin cancer (NMSC); 2 focused on melanoma and 2 on NMSC. Increased NMSC was noted in patients with RA using DMARDs compared with the general population, with no link to a specific DMARD. Cardiovascular and thromboembolic events were reported in 20 studies. No consistent evidence of increased major adverse cardiovascular events risk with JAKis compared with bDMARDs was identified. Venous thromboembolism risk appeared elevated with JAKis compared with bDMARDs, driven mainly by pulmonary embolism. Fourteen studies reported retention and adverse event-related withdrawals, and 8 assessed other specific adverse events. Gastrointestinal perforation and demyelinating disease were each reported in 3 studies. No eligible articles were identified in searches on DMARD monitoring. There has been a notable increase in studies evaluating safety outcomes, with the majority of these being observational studies focusing primarily on malignancy, thromboembolic, and cardiovascular events, with most studies pertaining to JAKi safety. A substantial proportion of studies in this SLR relied on claims databases to evaluate safety outcomes, a practice that carries important methodological limitations for safety research. Surprisingly, not many studies looked into glucocorticoid safety outcomes over the past 3 years. This SLR, along with the SLR on efficacy of DMARDs, informed the 2025 update of the EULAR recommendations for management of RA with synthetic and biological DMARDs.

Thrombotic diseases such as ischemic stroke, myocardial infarction, and pulmonary thromboembolism pose significant health risks worldwide. Thrombolytic agents such as urokinase are commonly used to dissolve clots, but their systemic administration can cause bleeding complications due to rapid clearance and a lack of target specificity. We developed a novel drug delivery system using ultrasound-responsive liposomes decorated with PEGylated cyclic RGD peptides. This system was designed to enhance the targeted delivery of urokinase to thrombi to improve the thrombolytic efficacy while minimizing side effects. Ammonium bicarbonate, encapsulated in the liposomes, generated microbubbles under ultrasound exposure that enabled controlled drug release and improved clot disruption through cavitation. The release mechanism of ammonium bicarbonate-induced drug release was investigated using multiple kinetic fitting models. The targeting capability of the liposomes, mediated by the cRGD unit, was demonstrated by flow cytometry and fluorescence microscopy, and supported by molecular docking simulations. Hemolytic and cytotoxicity profiles were evaluated using mouse red blood cells and Human Umbilical Vein Endothelial Cells. Studies using an in vivo ferric chloride-induced carotid artery thrombosis model demonstrated that the ultrasound-responsive immunoliposomes significantly enhanced thrombolysis and reduced the bleeding risk compared to free urokinase. This study highlights the potential of ultrasound-responsive immunoliposomes as an effective means of improving the therapeutic outcomes of thrombolytic therapy, offering a promising approach to thrombosis treatment.

As the demand for total shoulder arthroplasty (TSA) increases, it is imperative to optimize preoperative risk factors. While glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are used for glycemic control or weight management in patients with obesity or diabetes, the impact of preoperative use on postoperative TSA outcomes in non-obese patients is unknown. We sought to answer the question: Does preoperative use of GLP-1 RAs lead to increased risk of medical or surgical complications after TSA? We conducted a retrospective cohort study using data from the TriNetX Network to analyze non-obese patients (BMI <30 kg/m2) who underwent anatomic or reverse shoulder arthroplasty between 2013 (the inception of the network) and January 2024 and had at least 1 year of follow up. Patients were categorized by preoperative GLP-1 RA use and matched 1:1 using propensity scores to balance the cohorts based on demographic variables and comorbidities. Outcomes assessed at 90 days and 1 year included revision surgery, emergency department visits, readmission, venous thromboembolism, pulmonary embolism, acute kidney injury, prosthetic joint stiffness, postoperative rotator cuff tear, dislocation, periprosthetic fracture or joint infection, surgical site infection, aspiration, cardiac arrest, and blood transfusion. Among 108 352 non-obese patients, 845 used GLP-1 RAs preoperatively. After propensity score matching, 845 patients remained in each cohort with no significant baseline differences. In the 90 day postoperative period, there were no significant differences in any medical complications between the GLP-1 RA and control groups. Similarly, at 1 year, there were no significant differences in any medical or surgical complications between groups. This retrospective cohort study found that preoperative GLP-1 RA use in non-obese TSA patients was not associated with an increased rate of major postoperative medical or surgical complications. Level III: retrospective cohort study.

COPD exacerbations, often triggered by viral infections like COVID-19, are associated with increased cardiovascular risk. We hypothesized that COVID-19-related exacerbations carry higher short-term cardiovascular and mortality risks than non-COVID-19-related exacerbations. To compare 28-day risk of stroke, pulmonary embolism (PE), acute myocardial infarction (AMI), major adverse cardiovascular events (MACE) and all-cause mortality following COVID-19-related vs. non-COVID-19-related COPD exacerbations and assess variation across the pandemic. Using Swedish national registers, we identified COPD with moderate (treated with oral corticosteroids with/without antibiotics) or severe (hospitalized) exacerbations from March 2020 to June 2023. Exacerbations with infection, hospitalization or intensive care admission for COVID-19 were defined as COVID-19-related. A target trial was emulated and adjusted hazard ratios (aHRs) with 95% confidence intervals (CI) estimated for each outcome, stratified by exacerbation severity and COVID-19 variants. Among 266,273 exacerbations (87.2% moderate, 12.8% severe), 5,425 (2%) were COVID-19-related. COVID-19-related vs. non-COVID-19-related moderate exacerbations were associated with risk of PE (aHR 2.26, 95%CI 1.49-3.42), overall cardiovascular (1.94, 1.47-2.56), MACE (1.88, 1.28-2.76), and mortality (4.58, 4.06-5.17), but not significantly with AMI and stroke. Severe COVID-19-related exacerbations were only associated with higher mortality (1.46, 1.28-1.66). Cardiovascular risks were highest during pre-Alpha and Delta for moderate exacerbations. Mortality remained elevated for both moderate and severe exacerbations, particularly during the same periods. COVID-19-related exacerbations increased MACE, short-term cardiovascular and mortality risks, mainly for moderate exacerbations, with attenuation during Alpha and Omicron, highlighting the need for proactive cardiovascular care during respiratory outbreaks.

Background: While previous studies indicate an association between chest pain and favorable clinical outcomes in patients with pulmonary embolism (PE), the extent and underlying mechanisms of this effect remain inadequately defined. Methods: We investigated the prognostic value of chest pain with regard to in-hospital adverse outcomes and the association of chest pain with age and sex in consecutive patients with confirmed PE enrolled in a single-center registry between 2008 and 2019. Results: Of 858 patients (52% female) included in this study, 435 (51%) had chest pain at presentation. Chest pain was more prevalent in younger individuals aged 18-34 years (74%) compared to patients >34 years (46%). The prevalence of coronary artery disease (CAD) was similar in patients with and without chest pain (17.0% vs. 16.1%). Chest pain patients less frequently presented with elevated troponin levels (p < 0.001) or signs of right heart strain (RHS; p = 0.007) but more frequently exhibited imaging signs of pulmonary infarction (p = 0.001). Chest pain was associated with lower risk of adverse outcome (OR 0.35 [95% CI: 0.19-0.65]) and in-hospital mortality (OR 0.31 [95% CI: 0.13-0.74]). Multivariable models confirmed a prognostic effect independent of sex, comorbidities and results of risk stratification algorithms. Conclusions: In acute PE, chest pain is a favorable prognostic marker irrespective of sex. Chest pain patients are less likely to suffer from myocardial ischemia or show signs of RHS but more frequently show imaging signs of pulmonary infarction, suggesting pleuritic irritation rather than myocardial ischemia as the likely cause of pain.

BackgroundInterstitial lung diseases (ILDs) are a heterogeneous group of often progressive, unpredictable diseases. They frequently result in hospitalisations secondary to respiratory decompensation, termed ILD-related admissions. A proportion are due to an acute exacerbation of ILD (AEILD). All are associated with high mortality but are poorly characterised in real-world populations.AimTo evaluate mortality outcomes and associated risk factors following ILD-related hospital admissions, including AEILD.MethodsWe conducted a multicentre retrospective cohort study of primary International Classification of Diseases Version 10 coded admissions for ILD between 1 January 2017 and 31 December 2019 across 11 NHS hospitals in the North West of England. AEILD events were classified using clinical criteria: <30-day respiratory deterioration not secondary to cardiac failure, pulmonary embolism or pneumothorax. The AEILD subgroup was divided into those with CT confirmation (definite AEILD) and without CT confirmation (suspected AEILD). Primary outcome was time from admission to death. Statistical analyses included Kaplan-Meier and multivariate proportional hazards modelling.ResultsOf 938 ILD-related admissions, 54.5% met study AEILD criteria. Overall, cumulative all-cause mortality to 90-days post-discharge was 40.2%. For the AEILD cohort, cumulative all-cause mortality to 90-days post-discharge was 47.6%. Median survival of the AEILD cohort was 107 days (95% CI 87.0 to 141.0 days) and the other ILD-related admission cohort 241.0 days (95% CI 208.0 to 308.0 days), with a statistically significant difference in survival (p<0.0001). 37.6% (192/511) of AEILD events had CT confirmation. Within the AEILD subgroup, median survival was higher in the CT group (144 days vs 100 days, p=0.027). AEILD was independently associated with mortality in a multivariate model. Preadmission oxygen, age and neutrophilia were associated with mortality in both ILD-admission and AEILD 90-day all-cause mortality models. 13.9% of admissions had documented palliative care input.ConclusionsMortality associated with ILD-related admissions is high, with AEILD events independently associated with mortality. Findings highlight the need for improved education, access to palliative care and targeted AEILD research.

Outcomes of Operative versus Minimally Invasive Management in Hemodynamically Stable Adult Patients With Moderate to Severe Pancreatic Trauma per Mechanism and Grade of Injury: A National Analysis.

Optimal timing of initiation of pharmacologic venous thromboembolism (VTE) prophylaxis following intracerebral hemorrhage is controversial. This study aims to assess the association between the timing of pharmacologic VTE prophylaxis initiation and the risk of VTE and hemorrhagic complications. This was a multicenter, retrospective cohort study completed at 7 community hospitals. This study included patients with nontraumatic intracerebral hemorrhage admitted from August 1, 2023, to July 31, 2024. A total of 111 patients were assessed and categorized based on the administration of early (≤48h) versus delayed (>48h) initiation of VTE prophylaxis. Findings showed no statistically significant difference in the primary outcome of the incidence of VTE with early versus delayed initiation of VTE prophylaxis (5% vs. 8%, P=0.713). Secondary outcomes included incidence of deep vein thrombosis (5% vs. 8%, P=0.713), pulmonary embolism (0% vs. 0%), hematoma enlargement (16% vs. 15%, P=0.623), median intensive care unit (ICU) length of stay (3 vs. 3.5d, P=0.670), hospital length of stay (7 vs. 8d, P=0.724), inpatient all-cause mortality (8% vs. 7%, P=1.000), and discharge disposition. Early pharmacologic VTE prophylaxis (≤48h from ICH onset) was not found to be statistically significant in lowering the incidence of VTE. This occurred with no statistically significant differences in hematoma enlargement, increased inpatient mortality, or increased length of ICU/hospital stay. Additional adequately powered studies are needed to determine if early pharmacologic VTE prophylaxis is associated with a lower incidence of VTE.

Patient: Male, 62-year-oldFinal Diagnosis: Methicillin-susceptibleStaphylococcus aureus (MSSA) tricuspid valve endocarditis • psoas abscess • MSSA bacteremia • septic pulmonary embolismSymptoms: Dyspnea • anorexia • back pain • fatigue • fever • hypotension • tachycardiaClinical Procedure: —Specialty: Infectious DiseasesObjective: Unusual clinical courseBackgroundAcupuncture can pose a risk for both local and metastatic infections, particularly when performed under poor sterilization conditions. To date, a few cases of acupuncture-associated infective endocarditis (IE) have been reported, with most involving left-sided prosthetic or rheumatic cardiac valves. Right-sided endocarditis (RIE) induced by acupuncture is exceptionally rare. Here, we present a case of tricuspid valve IE and septic pulmonary embolism caused by acupuncture without traditional risk factors.Case ReportWe describe a 62-year-old immunocompetent man with a 3-day history of fever, anorexia, and fatigue following long-needle acupuncture treatment. Initial antibiotic treatment with cefazolin successfully treated methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia and resolved septic shock. However, on hospital day 10, new-onset tricuspid valve IE caused recurrent fever, dyspnea, hypotension, and sinus tachycardia. Disseminated abscesses involved in the bilateral psoas, iliopsoas, and erector spinae muscles, along with destruction of the L3/L4 vertebrae, indicated a clinical failure of cefazolin monotherapy. After switching to daptomycin for 6 days, emerging septic pulmonary embolism highlighted the limitation of daptomycin distribution in the lung. A sequential 5-day combination therapy of cefazolin and daptomycin was administered to address these complications. Cefazolin monotherapy was continued for 6 weeks, until the infection resolved.ConclusionsAcupuncture can lead to severe infections, including RIE, in individuals without traditional risk factors. Due to the failure of monotherapy with initial cefazolin and later daptomycin, this case report highlights the importance of diagnosis and antibiotic options in MSSA RIE complicated by persistent bacteremia in non-IV drug users with a native valve.

Postoperative pulmonary embolism (PE) is a severe complication of major cancer surgery. We investigated patients who underwent major cancer surgery at Sichuan Cancer Hospital (2016 to May 2022). Postoperative PE was divided into early and late phases according to whether PE was diagnosed within or after 3 days after surgery, respectively. Patients with early and late PE were compared to patients without postoperative PE in a 1:2 ratio and matched for age (± 3 years), type of cancer, and cancer site. Logistic regression analysis and least absolute shrinkage and selection operator (LASSO) regression analysis were used to identify the risk factors for early and late PE, respectively. The early and late PE groups included 36 and 46 patients, respectively. LASSO logistic regression showed that early postoperative PE was significantly associated with body mass index (BMI), intraoperative hypotension time, and postoperative D-dimer levels (P < 0.05). Postoperative D-dimer levels and severe infection were independent risk factors for late PE (P < 0.05). BMI and intraoperative hypotension time are risk factors for early PE, whereas severe infection is a risk factor for late PE. In addition, high postoperative D-dimer levels were strongly associated with both early and late PE.

Application of a serious-game-based blended learning approach for acute pulmonary embolism training among thoracic surgery nurses: A quasi-experimental study.

Nonthrombotic pulmonary artery embolism (NTPE) involves occlusion of pulmonary arteries by nonthrombotic material, such as septic emboli, tumor cells, fat, air, or foreign substances. NTPE is less common than thrombotic pulmonary embolism (PE) and may be misdiagnosed as PE. Although the clinical manifestation mimics that of PE, NTPE has distinct pathophysiologic mechanisms that necessitate different management. Diagnosis requires a high index of clinical suspicion and knowledge of imaging findings. The authors provide an overview of the various causes of NTPE, including infectious, neoplastic, iatrogenic or exogenous, and miscellaneous entities, and highlight their key imaging findings. Early and accurate diagnosis is essential for appropriate management. ©RSNA, 2026.

Application of murine hindlimb deep vein thrombosis model to assess temporal evolution and hemodynamic sequelae of pulmonary embolism.

ObjectiveGastric cancer is associated with an increased risk of pulmonary thromboembolism. Although the ABO blood group system is a known thrombotic risk factor, its role in gastric cancer-associated pulmonary thromboembolism remains unclear.MethodsThis retrospective study analyzed 1488 gastric cancer patients to assess the association between ABO blood type and pulmonary thromboembolism. Cox proportional hazards models were used to identify independent predictors, and Kaplan-Meier analysis was used to compare cumulative incidence.ResultsPulmonary thromboembolism incidence was highest in the AB group (5.49%), while that in non-AB groups was 1.81% (p < 0.01). Multivariate analysis confirmed AB blood type (hazard ratio: 2.42, 95% confidence interval: 1.09-5.39, p = 0.03), age >65 years (hazard ratio: 2.75, 95% confidence interval: 1.30-5.82, p = 0.01), and metastasis (hazard ratio: 4.03, 95% confidence interval: 1.69-9.62, p < 0.01) as significant independent predictors. Kaplan-Meier analysis confirmed a higher cumulative pulmonary thromboembolism incidence in the AB group (log-rank test, p < 0.01). However, the O versus non-O group showed no significant differences in Kaplan-Meier analysis (log-rank test, p = 0.35).ConclusionsAB blood type is an independent risk factor for pulmonary thromboembolism in gastric cancer patients. This finding, distinct from the traditional non-O group risk model, suggests that identifying AB blood type can improve risk stratification.

Introduction: Classical clinical prediction rules (Wells and Geneva) are widely used to assess the risk of Pulmonary Embolism (PE). Still, their performance in Coronavirus Disease 2019 (COVID-19) is uncertain, given frequent D-Dimer (DD) elevations unrelated to thrombosis. Aim: To compare the diagnostic performance of an optimised DD cut-off against Wells and Geneva scores in Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) confirmed COVID-19 patients with suspected PE. Materials and Methods: A retrospective, single-centre cohort study was conducted at Department of Internal Medicine, Consorci Sanitari de Terrassa, Barcelona, Spain, from Consorci Sanitari de Terrassa (Barcelona, Spain) from January 2021 to June 2021. Adult COVID-19 patients undergoing Computed Tomography Pulmonary Angiography (CTPA) for suspected PE were analysed. Receiver Operating Characteristic (ROC) analysis was used to assess DD, Wells, and Geneva; the optimal DD threshold was identified by Youden’s index. Group comparisons used t-test or Mann-Whitney U for continuous variables and Chi-square or Fisher’s-exact test for categorical variables; p-value &lt;0.05 was considered significant. Results: CTPA was performed in 586 patients, of whom 148 had confirmed COVID-19 infection. PE was diagnosed in 13.5% (20/148) of cases. Patients with PE had significantly higher DD levels than those without PE (p-value &lt;0.05). A DD threshold of 3126 ng/mL yielded 80% sensitivity and 68.5% specificity, potentially avoiding 87 CTPAs while missing 4 PE diagnoses. In comparison, the Wells score showed poor performance {Area Under Curve (AUC) 0.60, 95% Confidence Interval (CI) 0.48-0.72; sensitivity 55%, specificity 56%}, whereas the revised Geneva score was even less accurate (AUC 0.41, 95% CI 0.26-0.55; sensitivity 45%, specificity 55%). Conclusion: In the present cohort of COVID-19 patients with suspected PE, an optimised DD cut-off demonstrated superior discriminatory performance compared to conventional clinical prediction rules. Therefore, in COVID-19 settings with suspected PE, a DD threshold of approximately 3,126 ng/mL may help reduce unnecessary Computed Tomography (CT) pulmonary angiographies when interpreted in conjunction with clinical probability and physician judgment.