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Embolism
Kinds of Embolism Selected AbstractsABDOMINAL AND FLANK PAIN AS AN UNUSUAL PRESENTATION OF PULMONARY EMBOLISM: A CASE REPORTJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2005Benedetta Boari MD No abstract is available for this article. [source] Emergency Medicine Practitioner Knowledge and Use of Decision Rules for the Evaluation of Patients with Suspected Pulmonary Embolism: Variations by Practice Setting and Training LevelACADEMIC EMERGENCY MEDICINE, Issue 1 2007Michael S. Runyon MD Abstract Background Several clinical decision rules (CDRs) have been validated for pretest probability assessment of pulmonary embolism (PE), but the authors are unaware of any data quantifying and characterizing their use in emergency departments. Objectives To characterize clinicians' knowledge of and attitudes toward two commonly used CDRs for PE. Methods By using a modified Delphi approach, the authors developed a two-page paper survey including 15 multiple-choice questions. The questions were designed to determine the respondents' familiarity, frequency of use, and comprehension of the Canadian and Charlotte rules. The survey also queried the frequency of use of unstructured (gestalt) pretest probability assessment and reasons why physicians choose not to use decision rules. The surveys were sent to physicians, physician assistants, and medical students at 32 academic and community hospitals in the United States and the United Kingdom. Results Respondents included 555 clinicians; 443 (80%) work in academic practice, and 112 (20%) are community based. Significantly more academic practitioners (73%) than community practitioners (49%) indicated familiarity with at least one of the two decision rules. Among all respondents familiar with a rule, 50% reported using it in more than half of applicable cases. A significant number of these respondents could not correctly identify a key component of the rule (23% for the Charlotte rule and 43% for the Canadian rule). Fifty-seven percent of all respondents indicated use of gestalt rather than a decision rule in more than half of cases. Conclusions Academic clinicians were more likely to report familiarity with either of these two specific decision rules. Only one half of all clinicians reporting familiarity with the rules use them in more than 50% of applicable cases. Spontaneous recall of the specific elements of the rules was low to moderate. Future work should consider clinical gestalt in the evaluation of patients with possible PE. [source] Massive Cerebral Embolism Originated from Ruptured Infective Mitral Annular Calcification in a Chronic Hemodialysis PatientECHOCARDIOGRAPHY, Issue 1 2009Junichi Nishida M.D. Infective endocarditis of mitral annular calcification (MAC) has been reported, however, little attention has been given to the possibility of cerebral-embolism based infective endocarditis of MAC. We report a chronic hemodialysis patient of massive cerebral embolism originated from ruptured infective MAC. [source] Triage Patients with Suspected Pulmonary Embolism in the Emergency Department Using a Portable Ultrasound DeviceECHOCARDIOGRAPHY, Issue 5 2008Nicolas Mansencal M.D. The diagnosis of pulmonary embolism (PE) is difficult, despite validated diagnostic models. We sought to determine the value of a portable ultrasound device for triage of patients with suspected PE referred to the emergency department, using simplified echo criteria. We prospectively studied 103 consecutive patients with suspected PE, referred to our emergency department. After D-dimer screening, 76 patients were prospectively enrolled in this ultrasound study and underwent helical chest tomography, transthoracic echocardiography, and venous ultrasonography. Among patients with PE (n = 31), a right ventricular dilation was detected in 17 patients (55%), a direct visualization of clot in the lower limbs was present in 18 patients (58%), and 8 patients (26%) had both right ventricular dilation and deep venous thrombosis. The sensitivity and specificity of a combined ultrasound strategy using echocardiography and venous ultrasonography were respectively 87% (95% confidence interval 74% to 96%), and 69% (95% confidence interval 53% to 82%). The sensitivity of this combined strategy was significantly improved as compared to venous ultrasonography alone (P = 0.01) or echocardiography alone (P = 0.005). In patients with dyspnea or with high clinical probability of PE, this combined strategy was particularly relevant with high sensitivities (respectively 94% and 100%). Echocardiography combined with venous ultrasonography using a portable ultrasound device is a reliable method for screening patients with suspected PE referred to an emergency department, especially in patients with dyspnea or with high clinical probability. [source] Possible Paradoxical Embolism as a Rare Cause for an Acute Myocardial InfarctionECHOCARDIOGRAPHY, Issue 5 2006Aleksandr Rovner M.D. Paradoxical embolus is a rare entity and it has been incriminated as a cause of both cryptogenic strokes and myocardial infarctions (MI). Herein, we present a case of a patient diagnosed with a pulmonary embolism 1 week prior who now presented with an acute MI. Subsequent evaluation revealed a patent foramen ovale and a large thrombus in the right pulmonary artery. It was presumed that the etiology of her infarct was due to paradoxical embolus. The management of the patient is discussed and the literature is reviewed. [source] Echocardiographic Diagnosis of Air Embolism Associated with Central Venous Catheter Placement: Case Report and Review of the LiteratureECHOCARDIOGRAPHY, Issue 4 2006Prasad Maddukuri M.D. Transthoracic echocardiography (TTE) is a valuable tool in the evaluation of patients with suspected air embolism. This report describes the presentation and evaluation of a critically ill woman with spontaneous air embolism occurring during a central venous catheter replacement. Bedside TTE established the diagnosis of air embolism, allowing prompt initiation of appropriate therapy. This case report highlights this uncommon but potentially life-threatening complication of central line placement and the utility of echocardiography in its evaluation. [source] Primary Pulmonary Artery Sarcoma: Surgical Management and Differential Diagnosis with Pulmonary Embolism and Pulmonary Valve StenosisJOURNAL OF CARDIAC SURGERY, Issue 6 2009Xiao-Peng Hu M.D. We present six cases of primary pulmonary artery sarcomas and discuss clinical features, differential diagnosis, surgical treatment, and outcome of the tumors. Methods: Between January 1994 and July 2008, six patients were identified with the disease during operation. Three patients were initially diagnosed with pulmonary valve stenosis, and two patients had a presumptive diagnosis of chronic pulmonary embolism. Two patients had simple or partial tumor resection. Four patients had radical tumor resection and homograft reconstruction of the pulmonary arteries. Results: Histological examinations showed five malignant mesenchymomas and one fibrosarcoma. One patient died of refractory pulmonary hypertension during operation. Two patients died 4 months postoperatively because of brain metastases. Two patients were alive for 3 and 9 months, respectively after the operation with recurrent tumor. One patient is alive even 2 years after resection with no signs of recurrence or metastasis. Conclusions: Because of similar clinical features, pulmonary artery sarcomas are often confused with other pulmonary vascular obstructive diseases. Computed tomography scanning and gadolinium-enhanced magnetic resonance imaging could be useful methods for differential diagnosis. The prognosis is very poor. The survival time after resection varies from several months to several years depending on the presence of recurrence or metastasis. Early diagnosis and radical surgical resection presents the only opportunity for a potential cure. [source] The Surgical Option in the Management of Acute Pulmonary EmbolismJOURNAL OF CARDIAC SURGERY, Issue 6 2008Justo Rafael Sádaba F.R.C.S. (C/Th) Traditionally this condition has been treated with thrombolysis or anticoagulation and support measures. Surgical embolectomy is carried out in situations of hemodynamic instability or contraindication for thrombolysis. We present our results of surgical embolectomy in patients with massive and submassive PE. Methods: Over a three-year period, we have carried out 20 surgical embolectomies for acute PE. The mean age was 66 years, and there were 11 males. In all cases, the diagnosis had been made by a computerized tomography (CT) pulmonary artery angiography. Nine patients (45%) arrived to the operating theater on inotropes, and two of them (10%) with ventilatory support. All patients underwent a median sternotomy, bicaval cannulation for institution of cardiopulmonary bypass (CPB), and main pulmonary arteriotomy for the removal of the thrombus. Results: The mean bypass time was 45 minutes. Two patients (12%) died after being unable to wean off CPB due to right heart failure. Among the 15 survivors, the median ventilation time in the intensive care unit was 24 hours. Twelve patients (60%) required inotropic support postoperatively for right heart failure. All but one survivor (94%) underwent an insertion of a permanent inferior vena cava filter and were anticoagulated with coumarin. The mean follow-up is 9.8 months and is 100% complete, with a survival of 94.5%. All patients were in the World Health Organization (WHO) functional class I, with no re-admissions for respiratory failure. Conclusion: In patients with acute massive or submassive PE, surgical embolectomy offers a valid therapeutic strategy. A right-sided heart failure is the main complication of this condition. [source] Paradoxical Cerebral Embolism and Right Atrial MyxomaJOURNAL OF CARDIAC SURGERY, Issue 6 2008Georges Fayad M.D. No abstract is available for this article. [source] Transcatheter Closure of Patent Foramen Ovale in Patients with Paradoxical Embolism.JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2008Follow-up Results after Implantation of the Starflex® Occluder Device with Conjunctive Intensified Anticoagulation Regimen, Procedural Background:Prevalence of patent foramen ovale (PFO) is higher in patients with paradoxical embolism and associated with increased risk for recurrent thromboembolic events. By percutaneous closure of PFO, surgical closure or permanent oral anticoagulation can be avoided. So far, published series included different occluder systems and various indications and regimens of postprocedural anticoagulation. The aim of the present study was to evaluate the short- and long-term results after implantation of the Starflex® occluder in patients with PFO using an intensified anticoagulation regimen. Methods and Results:154 patients with PFO (94 men; age: 44 ± 13 years) and >1 thromboembolic event were included. Other causes for embolism were excluded. PFO closure was successful in 147 patients (95.5%). All patients were treated with phenprocoumon (INR 2.5) and aspirin (100 mg/die) for 6 months. Transesophageal echocardiography (TEE) was repeated at 6 months. Mean clinical follow-up period was 26 ± 18 months. After 6 months, five patients had a significant residual shunt, and five patients had suspected thrombus formation on the occluder. In three of these five patients, the occluder was surgically removed and foreign body reaction was noted. During follow-up, nine patients suffered from neurological events (two strokes, seven transient ischemic attacks [TIA]), though complete closure of the PFO was documented by TEE. Two patients died during follow-up; three patients had bleeding complications. Conclusion:Percutaneous closure of PFO in symptomatic patients by Starflex® occluder represents an effective therapy with a low incidence of periinterventional complications and recurrent thromboembolism. However, thrombus formation at the occluder system may occur in some patients despite an aggressive anticoagulation regimen. [source] Interventional Treatment of Septic Coronary Embolism: Sailing into Uncharted and Dangerous Waters.JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 4 2002JAMES J. GLAZIER M.D. [source] Cerebral Embolism of Iodized Oil (Lipiodol) after Transcatheter Arterial Chemoembolization for Hepatocellular CarcinomaJOURNAL OF NEUROIMAGING, Issue 4 2009Joon-Tae Kim MD ABSTRACT Cerebral lipiodol embolism is a rare complication of transcatheter arterial chemoembolization (TACE). Its pathological mechanism remains ambiguous despite several investigations. In Case 1, a 67-year-old man with hepatocellular carcinoma (HCC) experienced neurological deficits soon after undergoing a fourth session of TACE. Computed tomography (CT) scan showed multiple hyperdense lesions along the gyrus of frontal lobes and in the subcortical white matter. Transcranial Doppler (TCD) and transesophageal echocardiogram performed during the intravenous injection of agitated saline documented the presence of a right-to-left shunt (RLS) by demonstrating microbubbles in the left middle cerebral artery and left atrium. In Case 2, a 63-year-old woman underwent a third TACE due to a large HCC. After the procedure, her mental status deteriorated. Brain CT showed multiple hyperdense lesions on the cerebral and cerebellar cortex. TCD with agitated saline showed multiple microembolic signals shortly after the injection of agitated saline. The risk of cerebral lipiodol embolism may increase with recurrence and progression of HCC in patients who have a pre-existing RLS in the heart or lung. A test for the detection of an RLS may be necessary to identify patients with a heightened risk of cerebral embolism when multiple TACE procedures are required. TACE for HCC can cause pulmonary embolism or infarction.1,2 However, cerebral lipiodol embolism is rare after TACE. There have been several reports of cerebral embolism after TACE, but their exact mechanism has not yet been fully elucidated. We report herein 2 patients who developed cerebral lipiodol embolism after undergoing multiple TACE procedures for remnant HCC through a pre-existing RLS. [source] Involvement of Jugular Valve Insufficiency in Cerebral Venous Air EmbolismJOURNAL OF NEUROIMAGING, Issue 3 2007Max Nedelmann MD ABSTRACT Background. Cerebral venous air entrapment is a rare finding on cranial computed tomography (CT) scan. Peripheral air embolism is discussed as a potential cause. However, the mechanism of retrograde passage through internal jugular valves and veins is unclear. Case Report. The case of a patient is reported, who had air entrapment in the left cavernous sinus. Prior to CT scanning, a peripheral intravenous line had been placed. Ultrasound revealed excessive insufficiency of the left internal jugular valve. To further study the mechanism of embolism, an echo contrast agent was injected into the cubital vein. A Valsalva maneuver resulted in retrograde transition of microbubbles across the insufficient valve. Valvular function on the unaffected right side was intact. Conclusions. This case report gives insight into the mechanism of cerebral venous air embolism. This is the firstcase describing jugular valve insufficiency as the missing link between peripheral air embolism and cerebral venous air entrapment. [source] Echocardiographic Findings of Patients With Retinal Ischemia or EmbolismJOURNAL OF NEUROIMAGING, Issue 3 2002Mikael Mouradian MD ABSTRACT Background and Purpose. A potential source of emboli is not detected in more than 50% of patients with retinal arterial occlusive events. Echocardiographic studies are not always included in the diagnostic workup of these patients. The authors studied the diagnostic yield of transthoracic (TTE) and/or transesophageal (TEE) echocardiography in identifying potential sources of emboli in patients with retinal ischemia or embolism. Methods. In a prospective study, 73 consecutive patients with clinically diagnosed retinal ischemia or embolism received a standardized diagnostic workup including retinal photography, echocardiography, and imaging studies of the internal carotid arteries. TTE was performed in 83.6% of patients, TEE was performed in 5.5% of patients, and both TTE and TEE were per-formed in 11.0% of patients. Ophthalmological diagnoses consisted of amaurosis fugax (n= 28), asymptomatic cholesterol embolism to the retina (n= 34), and branch or central retinal artery occlusion (n= 11). Results. Echocardiography identified a potential cardiac or proximal aortic source for embolism in 16 of 73 (21.9%) patients, including 8 who also had either atrial fibrillation or internal carotid artery stenosis of more than 50% on the side of interest. Thus, 8 of 73 (11.0%) patients had lesions detected only by echocardiography. The most commonly identified lesions were proximal aortic plaque of more than 4 mm thickness (n= 7, 9.6%) and left ventricular ejection fraction of less than 30% (n= 6, 8.2%). TEE was particularly helpful in identifying prominent aortic plaques. Conclusion. Echocardiography frequently identifies lesions of the heart or aortic arch that can act as potential sources for retinal ischemia or embolism. Further studies are needed to evaluate the prognostic and therapeutic relevance of these findings. [source] Evaluating Patients with Acute Ischemic Stroke with Special Reference to Newly Developed Atrial Fibrillation in Cerebral EmbolismPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2007MINORU TAGAWA M.D. Background:Cardioembolic strokes are extensive and have a poor prognosis. To identify the cardiovascular risk factors of cardioembolic stroke, we evaluated the cardiovascular status with special reference to persistent atrial fibrillation (AF) and paroxysmal atrial fibrillation (PAF) combined with the type of acute ischemic stroke. Methods:We divided 315 consecutive patients admitted to our Department of Neurosurgery with an acute ischemic stroke into four types of brain infarction using clinical history, onset pattern of stroke, and brain imaging: cardioembolic (group E, n = 105), lacunar (group L, n = 92), atherothrombotic (group T, n = 111), and unclassified (n = 7). All patients underwent standard electrocardiography (ECG), a 24-hour ECG recording (Holter ECG) and transthoracic echocardiography (UCG). Results:Persistent AF or PAF was detected in 97 patients (31.5%) using Holter ECG: more frequently in group E (67.6%) than in groups L (15.2%) or T (9.2%). Persistent AF or PAF was first diagnosed on admission using a standard ECG in 16 patients (5.2%) with no previous history and 14 of these patients belonged to group E (13.3%). PAF was newly detected on Holter ECG in another 26 patients (8.4%) and 13 of these patients (12.4%) belonged to group E. Concerning UCG, left atrial enlargement and mitral regurgitation were more frequent in group E than in group L or T. Conclusion:Holter ECG in addition to ECG on admission is important for detecting persistent AF or PAF in patients with ischemic stroke, especially with cardioembolism as diagnosed by neuroimaging. [source] Bedside Transthoracic Sonography in Suspected Pulmonary Embolism: A New Tool for Emergency PhysiciansACADEMIC EMERGENCY MEDICINE, Issue 9 2010Beatrice Hoffmann MD First page of article [source] Maternal Death Following Cardiopulmonary Collapse After Delivery: Amniotic Fluid Embolism or Septic Shock Due to Intrauterine Infection?AMERICAN JOURNAL OF REPRODUCTIVE IMMUNOLOGY, Issue 2 2010Roberto Romero Citation Romero R, Kadar N, Vaisbuch E, Hassan SS. Maternal death following cardiopulmonary collapse after delivery: amniotic fluid embolism or septic shock due to intrauterine infection? Am J Reprod Immunol 2010; 64: 113,125 Problem, The amniotic fluid embolism (AFE) syndrome is a catastrophic complication of pregnancy frequently associated with maternal death. The causes and mechanisms of disease responsible for this syndrome remain elusive. Method of study, We report two cases of maternal deaths attributed to AFE: (1) one woman presented with spontaneous labor at term, developed intrapartum fever, and after delivery had sudden cardiovascular collapse and disseminated intravascular coagulation (DIC), leading to death; (2) another woman presented with preterm labor and foul-smelling amniotic fluid, underwent a Cesarean section for fetal distress, and also had postpartum cardiovascular collapse and DIC, leading to death. Results, Of major importance is that in both cases, the maternal plasma concentration of tumor necrosis factor-, at the time of admission to the hospital and when patients had no clinical evidence of infection was in the lethal range (a lethal range is considered to be above 0.1 ng/mL). Conclusion, We propose that subclinical intraamniotic infection may be a cause of postpartum cardiovascular collapse and DIC and resemble AFE. Thus, some patients with the clinical diagnosis of AFE may have infection/systemic inflammation as a mechanism of disease. These observations have implications for the understanding of the mechanisms of disease of patients who develop cardiovascular collapse and DIC, frequently attributed to AFE. It may be possible to identify a subset of patients who have biochemical and immunological evidence of systemic inflammation at the time of admission, and before a catastrophic event occurs. [source] New England medical center posterior circulation registryANNALS OF NEUROLOGY, Issue 3 2004Louis R. Caplan MD Among 407 New England Medical Center Posterior Circulation registry patients, 59% had strokes without transient ischemic attacks (TIAs), 24% had TIAs then strokes, and 16% had only TIAs. Embolism was the commonest stroke mechanism (40% of patients including 24% cardiac origin, 14% intraarterial, 2% cardiac and arterial sources). In 32% large artery occlusive lesions caused hemodynamic brain ischemia. Infarcts most often included the distal posterior circulation territory (rostral brainstem, superior cerebellum and occipital and temporal lobes); the proximal (medulla and posterior inferior cerebellum) and middle (pons and anterior inferior cerebellum) territories were equally involved. Severe occlusive lesions (>50% stenosis) involved more than one large artery in 148 patients; 134 had one artery site involved unilaterally or bilaterally. The commonest occlusive sites were: extracranial vertebral artery (52 patients, 15 bilateral) intracranial vertebral artery (40 patients, 12 bilateral), basilar artery (46 patients). Intraarterial embolism was the commonest mechanism of brain infarction in patients with vertebral artery occlusive disease. Thirty-day mortality was 3.6%. Embolic mechanism, distal territory location, and basilar artery occlusive disease carried the poorest prognosis. The best outcome was in patients who had multiple arterial occlusive sites; they had position-sensitive TIAs during months to years. Ann Neurol 2004;56:389,398 [source] Electrocardiographic Differentiation between Acute Pulmonary Embolism and Non-ST Elevation Acute Coronary Syndromes at the BedsideANNALS OF NONINVASIVE ELECTROCARDIOLOGY, Issue 2 2010Krzysztof Jankowski M.D., Ph.D. Background: Clinical picture of acute pulmonary embolism (APE), with wide range of electrocardiographic (ECG) abnormalities can mimic acute coronary syndromes. Objectives: Assessment of standard 12-lead ECG usefulness in differentiation at the bedside between APE and non-ST elevation acute coronary syndrome (NSTE-ACS). Methods: Retrospective analysis of 143 patients: 98 consecutive patients (mean age 63.4 ± 19.4 year, 45 M) with APE and 45 consecutive patients (mean age 72.8 ± 10.8 year, 44 M) with NSTE-ACS. Standard ECGs recorded on admission were compared in separated groups. Results: Right bundle branch block (RBBB) and S1S2S3 or S1Q3T3 pattern were found in similar frequency in both groups (10 [11%] APE patients vs 6 [14%] NSTE-ACS patients, 27 [28%] patients vs 7 [16%] patients, respectively, NS). Negative T waves in leads V1-3 together with negative T waves in inferior wall leads II, III, aVF (OR 1.3 [1.14,1.68]) significantly indicated APE with a positive predictive value of 85% and specificity of 87%. However, counterclockwise axis rotation (OR 4.57 [2.74,7.61]), ventricular premature beats (OR 2.60 [1.60,4.19]), ST depression in leads V1-3 (OR 2.25 [1.43,3.56]), and negative T waves in leads V5-6 (OR 2.08 [1.31,3.29]) significantly predicted NSTE-ACS. Conclusions: RBBB, S1S2S3, or S1Q3T3 pattern described as characteristic for APE were not helpful in the differentiation between APE and NSTE-ACS in studied group. Coexistence of negative T waves in precordial leads V1-3 and inferior wall leads may suggest APE diagnosis. Ann Noninvasive Electrocardiol 2010;15(2):145,150 [source] CT31 HYPERBARIC OXYGEN IN POST-CARDIAC SURGERY STROKE PATIENTS , THE CHRISTCHURCH EXPERIENCEANZ JOURNAL OF SURGERY, Issue 2007A. J. Gibson Introduction Post-operative strokes occur in a small percentage of adult cardiac surgical patients and have devastating consequences for these patients. There is evidence to suggest that Cerebral Arterial Gas Embolism (CAGE) is an important aetiological factor in most of these cases. Hyperbaric Oxygen therapy (HBOT) is the administration of 100% oxygen at greater than atmospheric pressure. It is accepted as the definitive treatment for CAGE related to SCUBA diving accidents. The similarities between this and the pathophysiology of post cardiac-surgical strokes due to iatrogenic CAGE suggest that beneficial effects from HBOT may accrue to these patients. Purpose The purpose of this study is to review the experience of treating post cardiac-surgical stroke patients in our local hyperbaric oxygen facility, including their presentation, delay before treatment and outcomes. The current evidence base is reviewed. Method A retrospective case series analysis was conducted. Results Over a 10 year period, patients with post cardiac-surgical strokes and who presented within the first 48 hours were referred for HBOT, of whom 12 were treated. The neurological outcomes were excellent in all but one case who died. A review of the literature provides a rational basis for the potential benefits of HBOT in this scenario, but at present there is only limited clinical data to support its use. Conclusion The postulated mechanisms for the development of post cardiac-surgical strokes provide a sound theoretical basis for the suggestion that the use of HBOT is associated with improved outcomes. However there is no prospective data to support such a claim. Such a trial would be problematic and until more evidence is available, HBOT should be considered on a case by case basis. [source] Potential Impact of Adjusting the Threshold of the Quantitative D-dimer Based on Pretest Probability of Acute Pulmonary EmbolismACADEMIC EMERGENCY MEDICINE, Issue 4 2009Christopher Kabrhel MD Abstract Objectives:, The utility of D-dimer testing for suspected pulmonary embolism (PE) can be limited by test specificity. The authors tested if the threshold of the quantitative D-dimer can be varied according to pretest probability (PTP) of PE to increase specificity while maintaining a negative predictive value (NPV) of >99%. Methods:, This was a prospective, observational multicenter study of emergency department (ED) patients in the United States. Eligible patients had a diagnostic study ordered to evaluate possible PE. PTP was determined by the clinician's unstructured estimate and the Wells score. Five different D-dimer assays were used. D-dimer test performance was measured using 1) standard thresholds and 2) variable threshold values: twice (for low PTP patients), equal (intermediate PTP patients), or half (high PTP patients) of standard threshold. Venous thromboembolism (VTE) within 45 days required positive imaging plus decision to treat. Results:, The authors enrolled 7,940 patients tested for PE, and clinicians ordered a quantitative D-dimer for 4,357 (55%) patients who had PTPs distributed as follows: low (74%), moderate (21%), or high (4%). At standard cutoffs, across all PTP strata, quantitative D-dimer testing had a test sensitivity of 94% (95% confidence interval [CI] = 91% to 97%), specificity of 58% (95% CI = 56% to 60%), and NPV of 99.5% (95% CI = 99.1% to 99.7%). If variable cutoffs had been used the overall sensitivity would have been 88% (95% CI = 83% to 92%), specificity 75% (95% CI = 74% to 76%), and NPV 99.1% (95% CI = 98.7% to 99.4%). Conclusions:, This large multicenter observational sample demonstrates that emergency medicine clinicians currently order a D-dimer in the majority of patients tested for PE, including a large proportion with intermediate PTP and high PTP. Varying the D-dimer's cutoff according to PTP can increase specificity with no measurable decrease in NPV. [source] Sildenafil Improves the Beneficial Haemodynamic Effects of Intravenous Nitrite Infusion during Acute Pulmonary EmbolismBASIC AND CLINICAL PHARMACOLOGY & TOXICOLOGY, Issue 4 2008Carlos A. Dias-Junior While previous studies have shown that sildenafil (an inhibitor of cGMP-specific phosphodiesterase type 5) or nitrite (a storage molecule for nitric oxide) produces beneficial effects during acute pulmonary embolism, no previous study has examined whether the combination of these drugs can produce additive effects. Here, we expand previous findings and examine whether sildenafil enhances the beneficial haemodynamic effects produced by a low-dose infusion of nitrite in a dog model of acute pulmonary embolism. Haemodynamic and arterial blood gas evaluations were performed in non-embolized dogs treated with saline (n = 4), and in embolized dogs (intravenous injections of microspheres) that received nitrite (6.75 µmol/kg intravenously over 15 min. followed by 0.28 µmol/kg/min.) and sildenafil (0.25 mg/kg over 30 min.; n = 8), or nitrite followed by saline (n = 8), or saline followed by sildenafil (n = 7), or only saline (n = 8). Plasma thiobarbituric acid-reactive substances (TBARS) concentrations were determined using a fluorometric method. Acute pulmonary embolism increased pulmonary artery pressure by ,24 mmHg. While the infusion of nitrite or sildenafil infusions reversed this increase by ,42% (both P < 0.05), the combined infusion of both drugs reversed this increase by ,58% (P < 0.05). Similar effects were seen on the pulmonary vascular resistance index. Nitrite or sildenafil alone produced no significant hypotension. However, the combined infusion of both drugs caused transient hypotension (P < 0.05). Both dugs, either alone or combined, blunted the increase in TBARS concentrations caused by acute pulmonary embolism (all P < 0.05). These results suggest that sildenafil improves the beneficial haemodynamic effects of nitrite during acute pulmonary embolism. [source] Direct Comparison of the Diagnostic Accuracy of Fifty Protein Biological Markers of Pulmonary Embolism for Use in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 9 2008Kristen E. Nordenholz MD Abstract Objectives:, Pulmonary embolism (PE) is associated with abnormal concentrations of many proteins involved in inflammation, hemostasis, and vascular injury. The authors quantified the diagnostic accuracy of a battery of protein biological markers for the detection of PE in emergency department (ED) patients. Methods:, A random and a consecutive sample of ED patients evaluated for PE were prospectively enrolled at two academic EDs between August 2005 and April 2006. A plasma sample was obtained at enrollment, and all patients were followed by telephone and medical record review at 90 days for the development of venous thromboembolism (VTE) defined as PE or deep venous thrombosis (DVT), requiring the consensus of two of three blinded physician reviewers. Measurements of potential biological markers were performed by technicians blinded to the study objectives. The diagnostic accuracy of each biological marker was determined by the area under the receiver operating characteristic (ROC) curve. Results:, Fifty potential biological markers were measured in 304 ED patients, including 22 patients (7%, 95% confidence interval [CI] = 4% to 10%) with VTE. Fourteen biological markers demonstrated an area under the curve (AUC) with the lower limit of the 95% CI , 0.5. Of these, three demonstrated an AUC , 0.7: D-dimer (0.90), C-reactive protein (CRP; 0.78), and myeloperoxidase (MPO; 0.78). Conclusions:, From 50 candidate biological markers, only D-dimer, CRP, and MPO demonstrated sufficient diagnostic accuracy to suggest potential utility as biological marker of PE. [source] Tandem Measurement of D-dimer and Myeloperoxidase or C-reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 9 2008Alice M. Mitchell MD Abstract Objectives:, The hypothesis was that the tandem measurement of D-dimer and myeloperoxidase (MPO) or C-reactive protein (CRP) could significantly decrease unnecessary pulmonary vascular imaging in emergency department (ED) patients evaluated for pulmonary embolism (PE) compared to D-dimer alone. Methods:, The authors measured the sequential combinations of D-dimer and MPO and D-dimer and CRP in a prospective sample of ED patients evaluated for PE at two centers. Patients were followed for 90 days for venous thromboembolism (VTE, either PE or deep venous thrombosis [DVT]), which required the consensus of two of three blinded physician reviewers. Results:, The authors enrolled 304 patients, 22 with VTE (7%; 95% confidence interval [CI] = 5% to 10%). The sensitivity and specificity of a D-dimer alone (cutoff , 500 ng/mL) were 100% (95% CI = 85% to 100%) and 59% (95% CI = 53% to 65%), respectively, and was followed by pulmonary vascular imaging negative for PE in 38% (115/304; 95% CI = 32% to 44%). The combination of either a negative D-dimer, or MPO < 22 mg/dL, had a sensitivity of 100% and specificity of 73% (95% CI = 67% to 78%). Thus, tandem measurement of D-dimer and MPO would have decreased the frequency of subsequent negative pulmonary vascular imaging from 38% to 25% (95% CI of the difference of ,13% = ,5% to ,20%). The combination of CRP and D-dimer would not have significantly improved the rate of negative imaging. Conclusions:, The tandem measurement of D-dimer and MPO would have significantly decreased negative pulmonary vascular imaging compared with D-dimer alone and should be validated prospectively. [source] Emergency Department Diagnosis of Submassive Pulmonary Embolism Using Bedside UltrasonographyACADEMIC EMERGENCY MEDICINE, Issue 7 2010David C. Riley MD No abstract is available for this article. [source] Factors Associated With Positive D-dimer Results in Patients Evaluated for Pulmonary EmbolismACADEMIC EMERGENCY MEDICINE, Issue 6 2010Christopher Kabrhel MD Abstract Objectives:, Available D-dimer assays have low specificity and may increase radiographic testing for pulmonary embolism (PE). To help clinicians better target testing, this study sought to quantify the effect of risk factors for a positive quantitative D-dimer in patients evaluated for PE. Methods:, This was a prospective, multicenter, observational study. Emergency department (ED) patients evaluated for PE with a quantitative D-dimer were eligible for inclusion. The main outcome of interest was a positive D-dimer. Odds ratio (ORs) and 95% confidence intervals (CIs) were determined by multivariable logistic regression. Adjusted estimates of relative risk were also calculated. Results:, A total of 4,346 patients had D-dimer testing, of whom 2,930 (67%) were women. A total of 2,500 (57%) were white, 1,474 (34%) were black or African American, 238 (6%) were Hispanic, and 144 (3%) were of other race or ethnicity. The mean (±SD) age was 48 (±17) years. Overall, 1,903 (44%) D-dimers were positive. Model fit was adequate (c-statistic = 0.739, Hosmer and Lemeshow p-value = 0.13). Significant positive predictors of D-dimer positive included female sex; increasing age; black (vs. white) race; cocaine use; general, limb, or neurologic immobility; hemoptysis; hemodialysis; active malignancy; rheumatoid arthritis; lupus; sickle cell disease; prior venous thromboembolism (VTE; not under treatment); pregnancy and postpartum state; and abdominal, chest, orthopedic, or other surgery. Warfarin use was protective. In contrast, several variables known to be associated with PE were not associated with positive D-dimer results: body mass index (BMI), estrogen use, family history of PE, (inactive) malignancy, thrombophilia, trauma within 4 weeks, travel, and prior VTE (under treatment). Conclusions:, Many factors are associated with a positive D-dimer test. The effect of these factors on the usefulness of the test should be considered prior to ordering a D-dimer. ACADEMIC EMERGENCY MEDICINE 2010; 17:589,597 © 2010 by the Society for Academic Emergency Medicine [source] Prospective Study of the Clinical Features and Outcomes of Emergency Department Patients with Delayed Diagnosis of Pulmonary EmbolismACADEMIC EMERGENCY MEDICINE, Issue 7 2007Jeffrey A. Kline MD Objectives:The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED. Methods:For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock). Results:Among 161 patients with PE, 141 (88%) were ED diagnosed and 20 (12%) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [±15] vs. 51 [±17] years; p < 0.001), had a longer median time to heparin administration (33 vs. 8 hours; p < 0.001), and had a higher frequency of altered mental status (30% vs. 8%; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25% vs. 23%). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60% vs. 58%; abnormal troponin I level, 55% vs. 24%); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and >50% vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9% vs. 30%; p = 0.01). Conclusions:In this single-center study, the diagnosis of PE was frequently delayed and outcomes of patients with delayed diagnosis were worse than those of patients with PE diagnosed in the ED. [source] Increased Cerebral Blood Flow And Cardiac Output Following Cerebral Arterial Air Embolism In SheepCLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY, Issue 11 2001David J Williams SUMMARY 1. The effects of cerebral arterial gas embolism on cerebral blood flow and systemic cardiovascular parameters were assessed in anaesthetized sheep. 2. Six sheep received a 2.5 mL injection of air simultaneously into each common carotid artery over 5 s. Mean arterial blood pressure, heart rate, end-tidal carbon dioxide and an ultrasonic Doppler index of cerebral blood flow were monitored continuously. Cardiac output was determined by periodic thermodilution. 3. Intracarotid injection of air produced an immediate drop in mean cerebral blood flow. This drop was transient and mean cerebral blood flow subsequently increased to 151% before declining slowly to baseline. Coincident with the increased cerebral blood flow was a sustained increase in mean cardiac output to 161% of baseline. Mean arterial blood pressure, heart rate and end-tidal carbon dioxide were not significantly altered by the intracarotid injection of air. 4. The increased cardiac output is a pathological response to impact of arterial air bubbles on the brain, possibly the brainstem. The increased cerebral blood flow is probably the result of the increased cardiac output and dilation of cerebral resistance vessels caused by the passage of air bubbles. [source] Emergency Medicine Practitioner Knowledge and Use of Decision Rules for the Evaluation of Patients with Suspected Pulmonary Embolism: Variations by Practice Setting and Training LevelACADEMIC EMERGENCY MEDICINE, Issue 1 2007Michael S. Runyon MD Abstract Background Several clinical decision rules (CDRs) have been validated for pretest probability assessment of pulmonary embolism (PE), but the authors are unaware of any data quantifying and characterizing their use in emergency departments. Objectives To characterize clinicians' knowledge of and attitudes toward two commonly used CDRs for PE. Methods By using a modified Delphi approach, the authors developed a two-page paper survey including 15 multiple-choice questions. The questions were designed to determine the respondents' familiarity, frequency of use, and comprehension of the Canadian and Charlotte rules. The survey also queried the frequency of use of unstructured (gestalt) pretest probability assessment and reasons why physicians choose not to use decision rules. The surveys were sent to physicians, physician assistants, and medical students at 32 academic and community hospitals in the United States and the United Kingdom. Results Respondents included 555 clinicians; 443 (80%) work in academic practice, and 112 (20%) are community based. Significantly more academic practitioners (73%) than community practitioners (49%) indicated familiarity with at least one of the two decision rules. Among all respondents familiar with a rule, 50% reported using it in more than half of applicable cases. A significant number of these respondents could not correctly identify a key component of the rule (23% for the Charlotte rule and 43% for the Canadian rule). Fifty-seven percent of all respondents indicated use of gestalt rather than a decision rule in more than half of cases. Conclusions Academic clinicians were more likely to report familiarity with either of these two specific decision rules. Only one half of all clinicians reporting familiarity with the rules use them in more than 50% of applicable cases. Spontaneous recall of the specific elements of the rules was low to moderate. Future work should consider clinical gestalt in the evaluation of patients with possible PE. [source] Transcatheter versus Surgical Closure of Secundum Atrial Septal Defect in Adults: Impact of Age at Intervention.CONGENITAL HEART DISEASE, Issue 3 2007A Concurrent Matched Comparative Study Abstract Objectives., To compare the short- and mid-term outcomes of surgical (SUR) vs. transcatheter closure of secundum atrial septal defect (ASD) using Amplatzer septal occluder (ASO) in adults with a very similar spectrum of the disease; and to identify predictors for the primary end point. Design., Single-center, concurrent comparative study. Surgically treated patients were randomly matched (2:1) by age, sex, date of procedure, ASD size, and hemodynamic profile. Setting., Tertiary referral center. Patients., One hundred sixty-two concurrent patients with ASD submitted to ASO (n = 54) or SUR closure (n = 108) according with their preferences. Main Outcome Measures., Primary end point was a composite index of major events including failure of the procedure, important bleeding, critical arrhythmias, serious infections, embolism, or any major cardiovascular intervention-related complication. Predictors of these major events were investigated. Results., Atrial septal defects were successfully closed in all patients, and there was no mortality. The primary event rate was 13.2% in ASO vs. 25.0% in SUR (P = .001). Multivariate analysis showed that higher rate of events was significantly associated with age >40 years; systemic/pulmonary output ratio <2.1; and systolic pulmonary arterial pressure >50 mm Hg; while in the ASO group the event rate was only associated with the ASD size (>15 cm2/m2; relative risk = 1.75, 95% confidence interval 1.01,8.8). There were no differences in the event-free survival curves in adults with ages <40 years. Conclusions., The efficacy for closure ASD was similar in both groups. The higher morbidity observed in SUR group was observed only in the patients submitted to the procedure with age >40 years. The length of hospital stay was shorter in the ASO group. Surgical closure is a safe and effective treatment, especially in young adults. There is certainly nothing wrong with continuing to do surgery in countries where the resources are limited. [source] | |||||||||||||||||||||||||||||||||||||||||||