Transdiaphragmatic intercostal hernia induced by sternutation: A case report.

INTRODUCTION AND IMPORTANCE: Sternutation is, by definition, a situation that increases abdominal pressure. However, it has not been clearly linked to protrusion of abdominal content through weaknesses in the abdominal boundaries. CASE PRESENTATION: Here we present a case report in which the only trigger factor found for an abdominal content protrusion was a sternutation episode. The patient arrived in our institution with the diagnosis of a transdiaphragmatic intercostal hernia, proven in CT-scan. He was, then, submitted to emergent surgery, where through thoracotomy and subcostal laparotomy, hernia content was reduced. The patient had a favorable evolution. CLINICAL DISCUSSION: TDIH is a rare entity, for which there are still no consensus regarding its management. This makes clinical practice more challenging, leaving to the surgeon the therapeutic decision tailored to each patient. CONCLUSION: This entity should be further studied, and consensus reached regarding its management.

Comparison of the accuracy of four diagnostic prediction rules for pulmonary embolism in patients admitted to the emergency department.

INTRODUCTION AND OBJECTIVES: Ruling out pulmonary embolism (PE) through a combination of clinical assessment and D-dimer level can potentially avoid excessive use of computed tomography pulmonary angiography (CTPA). We aimed to compare the diagnostic accuracy of the standard approach based on the Wells and Geneva scores combined with a standard D-dimer cut-off (500 ng/ml), with three alternative strategies (age-adjusted and the YEARS and PEGeD algorithms) in patients admitted to the emergency department (ED) with suspected PE. METHODS: Consecutive outpatients admitted to the ED who underwent CTPA due to suspected PE were retrospectively assessed. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and diagnostic odds ratios were calculated and compared between the different diagnostic prediction rules. RESULTS: We included 1402 patients (mean age 69±18 years, 54% female), and PE was confirmed in 25%. Compared to the standard approach (p<0.001), an age-adjusted strategy increased specificity with a non-significant decrease in sensitivity only in patients older than 70 years. Compared to the standard and age-adjusted approaches, the YEARS and PEGeD algorithms had the highest specificity across all ages, but were associated with a significant decrease in sensitivity (p<0.001), particularly in patients aged under 60 years (sensitivity of 81% in patients aged between 51 and 60 years). CONCLUSION: Compared to the standard approach, all algorithms were associated with increased specificity. The age-adjusted strategy was the only one not associated with a significant decrease in sensitivity compared to the standard approach, enabling CTPA requests to be reduced safely.

Comparison of 5 acute pulmonary embolism mortality risk scores in patients with COVID-19.

OBJECTIVE: Pulmonary embolism (PE) is a common complication of SARS-CoV-2 infection. We aimed to explore the short-term outcomes among patients with acute PE and COVID-19 and to further determine and compare the performance of the different prognostic scores (PESI, sPESI, BOVA, FAST and ESC scores) for risk-stratification in this scenario. METHODS: Retrospective single-centre study of 85 patients with SARS-CoV-2 infection and PE admitted to the Emergency Department (ED). The diagnostic accuracy of each above-mentioned prognostic score was calculated post hoc, and their discriminative power was evaluated through an AUC curve. RESULTS: Among the 85 patients, all-cause death occurred within 7 days for 6 patients (7.1%) and within 30 days for 14 patients (16.5%). Despite being older and having a higher percentage of altered mental status on presentation, non-survivors patients did not differ from survivors regarding comorbidities, traditional risk factors for venous thromboembolism and signs and symptoms at the ED presentation.Each risk stratification tool had modest discriminative power for 7-day mortality (AUC range, 0.601-0.730) with slightly lower discrimination for 30-day mortality (AUC range, 0.543-0.638). The pair-wise comparison of ROC curves showed that PESI had better predictive value for short-term mortality than ESC score (z test = 3.92, p = 0.001) and sPESI (z test = 2.43, p = 0.015); there is no significant difference between PESI and BOVA score (z test = 1.05, p = 0.295) and FAST score (z test = 0.986, p = 0.324). CONCLUSION: The most common risk-stratification tools for PE had modest discriminative power to predict short-term mortality in patients with acute PE and COVID-19.

Prognostic Accuracy of the Modified CHA2DS2-VASc Score in COVID-19 Patients Admitted to the Emergency Department Due to Clinical Worsening.

INTRODUCTION: Risk factors comprising the CHA2DS2VASc score are recognized as risk factors for venous thromboembolism and mortality in COVID-19 patients. A modified CHA2DS2VASc score (M-CHA2D2VASc), developed by changing gender criteria from female to male, has been proposed to predict in-hospital mortality in COVID-19 patients. The aim of this study was to evaluate the prognostic accuracy of M-CHA2D2VASc for adverse clinical outcomes and short-term mortality in COVID-19 patients admitted to the Emergency Department. MATERIAL AND METHODS: Retrospective study of patients admitted to the ED who underwent computed tomography pulmonary angiography due to suspected pulmonary embolism or clinical worsening. Patients were stratified into three M-CHA2DS2-VASc risk-categories: low (0 - 1 points), intermediate (2 - 3 points) and high-risk (≥ 4 points). RESULTS: We included 300 patients (median age 71 years, 59% male). The overall mortality was 27%. The M-CHA2DS2-VASc score was higher in non-survivors compared to survivors [4 (IQR:3 - 5) vs 2 (IQR: 1 - 4), respectively, p < 0.001). The M-CHA2DS2-VASc score was identified as an independent predictor of mortality in a multivariable logistic regression model (OR 1.406, p = 0.007). The Kaplan-Meier survival curves showed that the M-CHA2DS2-VASc score was associated with short-term mortality (log-rank test < 0.001), regardless of hospitalization (log-rank test p < 0.001 and p = 0.007, respectively). The survival proportion was 92%, 80% and 63% in the lower, intermediate, and higher risk-groups. As for the risk-categories, no difference was found in pulmonary embolism, Intensive Care Unit admission, and invasive mechanical ventilation. DISCUSSION: This is the first study to validate M-CHA2DS2-VASc score as a predictor of short-term mortality in patients admitted to the Emergency Department. CONCLUSION: The M-CHA2DS2-VASC score might be useful for prompt risk-stratification in COVID-19 patients during admission to the Emergency Department.

Introdução: O score CHA2DS2VASc engloba variáveis reconhecidas como fatores de risco para tromboembolismo venoso e mortalidade nos doentes com COVID-19. O score CHA2DS2VASc modificado (M-CHA2DS2-VASc), criado pela alteração do critério de género de feminino para masculino, foi proposto como preditor da mortalidade intra-hospitalar nestes doentes. O objetivo deste trabalho foi avaliar o valor prognóstico do M-CHA2DS2-VASc como preditor de eventos adversos e mortalidade a curto-prazo nos doentes com COVID-19 admitidos no Serviço de Urgência. Material e Métodos: Análise retrospetiva de doentes admitidos no Serviço de Urgência que realizaram tomografia computorizada pulmonar com administração de contraste por agravamento clínico e/ou suspeita de embolia pulmonar. Definiram-se três categorias de risco M-CHA2DS2-VASc: baixo, intermédio e alto (0 - 1; 2 - 3 e ≥ 4 pontos, respectivamente). Resultados: Incluíram-se 300 doentes (idade mediana: 71 anos, 59% homens). A mortalidade global foi 27%. O M-CHA2DS2-VASc foi maior em não sobreviventes [4 (IQR: 3 - 5) vs 2 (IQR: 1 - 4), p < 0,001) e constituiu um preditor independente de mortalidade numa análise multiparamétrica (OR: 1.406, p = 0,007). As curvas de sobrevivência demonstraram a associação do M-CHA2DS2-VASc com a mortalidade a curto-prazo (log-rank test < 0,001), independentemente dos doentes serem hospitalizados ou não (log-rank test p < 0,001 e p = 0,007, respetivamente). A taxa de sobrevida foi de 92%, 80% e 63% nos grupos de baixo, intermédio e alto risco. De acordo com as categorias de risco, não foram encontradas diferenças na incidência de embolia pulmonar, admissão em Cuidados Intensivos e ventilação mecânica invasiva. Discussão: Este é o primeiro estudo a validar o M-CHA2DS2-VASc como preditor de mortalidade a curto prazo na admissão no Serviço de Urgência. Conclusão: O M-CHA2DS2-VASc pode ser útil para estratificação de risco nos doentes com COVID-19 admitidos no Serviço de Urgência.

Pulmonary embolism and COVID-19: A comparative analysis of different diagnostic models performance.

OBJECTIVE: Pulmonary embolism (PE) is a common complication of SARS-CoV-2 infection. Several diagnostic prediction rules based on pretest probability and D-dimer have been validated in non-COVID patients, but it remains unclear if they can be safely applied in COVID-19 patients. We aimed to compare the diagnostic accuracy of the standard approach based on Wells and Geneva scores combined with a standard D-dimer cut-off of 500 ng/mL with three alternative strategies (age-adjusted, YEARS and PEGeD algorithms) in COVID-19 patients. METHODS: This retrospective study included all COVID-19 patients admitted to the Emergency Department (ED) who underwent computed tomography pulmonary angiography (CTPA) due to PE suspicion. The diagnostic prediction rules for PE were compared between patients with and without PE. RESULTS: We included 300 patients and PE was confirmed in 15%. No differences were found regarding comorbidities, traditional risk factors for PE and signs and symptoms between patients with and without PE. Wells and Geneva scores showed no predictive value for PE occurrence, whether a standard or an age-adjusted cut-off was considered. YEARS and PEGeD algorithms were associated with increased specificity (19% CTPA reduction) but raising non-diagnosed PE. Despite elevated in all patients, those with PE had higher D-dimer levels. However, incrementing thresholds to select patients for CTPA was also associated with a substantial decrease in sensitivity. CONCLUSION: None of the diagnostic prediction rules are reliable predictors of PE in COVID-19. Our data favour the use of a D-dimer threshold of 500 ng/mL, considering that higher thresholds increase specificity but limits this strategy as a screening test.