Assessment of using ultrasonography to teach abdominal and cervical anatomy in French medical curricula.

PURPOSE: The objective of this work was to assess, in a quantitative and qualitative way, the teaching of cervical and abdominal anatomy via ultrasound for medical students. METHODS: For several years, tutorials on the study of anatomy through use of ultrasound on the living organism have been given at the Medical School of Brest. These sessions have focused on cervical anatomy and abdominal anatomy. Students were invited to quantitatively assess these lessons by taking two tests containing questions on both cervical and abdominal anatomy and ultrasound technique: a pre-test administered at the beginning of the year and a post-test at the end of the year. In addition, a qualitative assessment was carried out at the end of the year. Ten statements were presented, and students were asked to indicate their agreement or disagreement to a four-point Likert scale. RESULTS: One hundred and twelve students answered all the questions on the pre-test with an average of 13.4 correct answers out of 20. Forty-eight students answered all the questions on the post-test with an average of 14.6/20. Twenty-six students who benefited from the courses gave positive feedback about the workshops on the qualitative assessment at the end of the year (median scores > = 3/4). CONCLUSION: The results of this work suggest that the use of ultrasound makes a positive contribution to the teaching of anatomy. The students interviewed think this type of tutorial should be an integral part of the anatomy curriculum at our university. In addition, this type of instruction can serve to introduce the use of ultrasound itself in a practical learning setting.

Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms.

IMPORTANCE: The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain. OBJECTIVE: To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms. DESIGN, SETTING, AND PARTICIPANTS: Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017. EXPOSURES: Acutely worsening respiratory symptoms in patients with COPD. MAIN OUTCOMES AND MEASURES: The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not. RESULTS: Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441). CONCLUSIONS AND RELEVANCE: Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.

Pulmonary perfusion by iodine subtraction maps CT angiography in acute pulmonary embolism: comparison with pulmonary perfusion SPECT (PASEP trial).

OBJECTIVE: To assess the diagnostic accuracy of iodine map computed tomography pulmonary angiography (CTPA), for segment-based evaluation of lung perfusion in patients with acute pulmonary embolism (PE), using perfusion single-photon emission CT (SPECT) imaging as a reference standard. METHODS: Thirty participants who have been diagnosed with acute pulmonary embolism on CTPA underwent perfusion SPECT/CT within 24 h. Perfusion SPECT and iodine map were independently interpreted by 2 nuclear medicine physicians and 2 radiologists. For both modalities, each segment was classified as normoperfused or hypoperfused, as defined by a perfusion defect of more than 25% of a segment. The primary end point was the diagnostic accuracy (sensitivity and specificity) of iodine map for segment-based evaluation of lung perfusion, using perfusion SPECT imaging as a reference standard. Following blinded interpretation, a retrospective explanatory analysis was performed to determine potential causes of misinterpretation. RESULTS: The median time between CTPA with iodine maps and perfusion SPECT was 14 h (range 2-23 h). A total of 597 segments were analyzed. Sensitivity and specificity of iodine maps with CTPA for the detection of segmental perfusion defects were 231/284 = 81.3% (95% CI 76.4 to 85.4%) and 247/313 = 78.9% (95% CI 74.1 to 83.1%), respectively. In retrospect, false results were explained in 48.7%. CONCLUSION: Iodine map CTPA showed promising results for the assessment of pulmonary perfusion in patients with acute PE, with sensitivity of 81.3% and specificity of 78.9%, respectively. Recognition of typical pitfalls such as atelectasis, fissures, or beam-hardening artifacts may further improve the accuracy of the test. KEY POINTS: • Sensitivity and specificity of iodine subtraction maps for the detection of segmental perfusion defects were 81.3% (95% CI 76.4 to 85.4%) and 78.9% (95% CI 74.1 to 83.1%), respectively. • Recognition of typical pitfalls such as atelectasis, fissures, or beam-hardening artifacts may further improve the diagnostic accuracy of the test.

A "one-stop-shop" 4D CTA protocol using 320-row CT for advanced imaging in acute ischemic stroke: a technical note.

This technical note describes a novel CT scan protocol that includes a non-enhanced CT, dynamic CTA, and perfusion of the whole brain and CTA of the carotid arteries using a 320-row area detector CT scanner, with a unique contrast injection and acceptable radiation exposure dose in patients presenting with acute ischemic stroke. The acquisition parameters and reconstruction parameters will be discussed including the use of model-based iterative reconstruction (MBIR), time summing (tMIP), and subtraction techniques to optimize the results of this protocol.Key Points• Scanning on a 320-row area detector CT can achieve both brain perfusion with dynamic angiography and reconstructed arterial and venous CTA, and supra aortic trunk angiography, in a single acquisition. • It provides, in a single exam, a full diagnostic workup, i.e., all the acquisitions that are needed to make a quick decision, with reasonable exposure to ionizing radiation and reduced amount of medium contrast, in case of acute ischemic stroke presentation.

Thoracic Stent-Graft Migration: The Role of the Geometric Modifications of the Stent-Graft at 3 years.

BACKGROUND: To date, clinical and experimental studies on stent graft (SG) migration have focused on aortic morphology and blood flow. However, thoracic endovascular aortic repair (TEVAR) is not an instant fixation of the SG in the aortic lumen but rather a continuous process of deformation and three-dimensional change in the configuration and the geometry of the SG. The aim of this study was to analyze the geometric evolution of the aortic SG in the proximal attachment zone at midterm follow-up and its impact on the SG migration. METHODS: Sixty-two patients underwent TEVAR for thoracic aortic aneurysm from 2007 till 2013. Thirty patients were treated and had a complete clinical and morphological follow-up at 1 month and 3 years. We calculated the SG radius of curvature (RC) change at the proximal attachment zone "P" on the postoperative computed tomography scan at 1 month and 3 years. RESULTS: There were 19 atheromatous aneurysms, 8 postdissection aneurysms, and 3 posttraumatic aneurysms. Two patients were treated at zone 1, seven at zone 2, and twenty-one at zone 3. The median decrease of the RC at "P" was 11 mm (interquartile range, 6.5 mm; range, 1-29 mm. A greater decrease in RC was identified in patients with hostile proximal neck having a large diameter (P = 0.006), short neck length (P = 0.04), and neck thrombus grade II and III (P = 0.02). In the migration group, the RC of "P" decreased significantly at 3 years (27.5 mm vs 18.25 mm; P = 0.03). Three patients had type I endoleak and showed a decrease of the RC at "P" (42 vs 13 mm; 28 vs 15 mm; 24 vs 9 mm). CONCLUSIONS: The SG seems to have geometric changes in the proximal attachment zone over time. The increase of SG curvature might be a predictor for SG migration and may prompt prophylactic reintervention.

Risk factors for recurrent venous thromboembolism after unprovoked pulmonary embolism: the PADIS-PE randomised trial.

We aimed to identify risk factors for recurrent venous thromboembolism (VTE) after unprovoked pulmonary embolism.Analyses were based on the double-blind randomised PADIS-PE trial, which included 371 patients with a first unprovoked pulmonary embolism initially treated during 6 months who were randomised to receive an additional 18 months of warfarin or placebo and followed up for 2 years after study treatment discontinuation. All patients had ventilation/perfusion lung scan at inclusion (i.e. at 6 months of anticoagulation).During a median follow-up of 41 months, recurrent VTE occurred in 67 out of 371 patients (6.8 events per 100 person-years). In main multivariate analysis, the hazard ratio for recurrence was 3.65 (95% CI 1.33-9.99) for age 50-65 years, 4.70 (95% CI 1.78-12.40) for age >65 years, 2.06 (95% CI 1.14-3.72) for patients with pulmonary vascular obstruction index (PVOI) ≥5% at 6 months and 2.38 (95% CI 1.15-4.89) for patients with antiphospholipid antibodies. When considering that PVOI at 6 months would not be available in practice, PVOI ≥40% at pulmonary embolism diagnosis (present in 40% of patients) was also associated with a 2-fold increased risk of recurrence.After a first unprovoked pulmonary embolism, age, PVOI at pulmonary embolism diagnosis or after 6 months of anticoagulation and antiphospholipid antibodies were found to be independent predictors for recurrence.

Normal sonoanatomy of small joints in healthy children: changes in cartilage and vascularisation according to age and gender.

OBJECTIVES: The metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints may be involved in juvenile idiopathic arthritis. Our goal was to describe their normal sonoanatomy in healthy children, according to age and gender. METHODS: We studied 41 consecutive healthy children (20 girls, 21 boys; age 2-15 years) divided into four age groups: 2-4 years (n=9), 5-7 years (n=11), 8-12 years (n=12), and 13-15 years (n=9). Longitudinal ultrasound axis of the MCP and MTP joints were obtained. The evolution of the cartilage thickness and vascularisation of these joints were studied according to age and gender. The MCP or MTP joints were the statistical unit. RESULTS: At all sites, on B-mode images, cartilage thickness was associated with age (p<0.0001). Cartilage thickness at different sites was significantly greater in boys than in girls (p≤0.05). Blood vessels were seen within the cartilage, with differences across age groups. CONCLUSIONS: This study provides children's age- and gender-specific sonoanatomy data of MCP and MTP and confirms the importance of using colour Doppler or Power Doppler to study cartilage vascularisation.

A new time-resolved 3D angiographic technique (4D DSA): Description, and assessment of its reliability in Spetzler-Martin grading of cerebral arteriovenous malformations.

BACKGROUND AND PURPOSE: The Spetzler and Martin (SM) cerebral arteriovenous malformation (AVM) classification is a widely used 5-tier classification. This common language allows specialists to exchange about AVMs and must be reliably characterized by the imaging methods. We presented an agreement study on a new method of digital subtracted 3D rotational angiography resolved in time (four-dimensional DSA: 4D DSA) compared to the gold standard (two-dimensional DSA: 2D DSA) in AVM grading using the SM classification. METHODS: Ten patients with AVMs were included during one year, they had an angiographic exploration with both 4D DSA and 2D DSA. Three readers assessed the SM classification. One reader conducted a second reading. The inter-, intra-observer and intermodality agreements were calculated by Kappas. Dose to patient was reported. RESULTS: Considering the SM grade, the inter-observer agreement between 4D DSA and 2D DSA was equivalent (κ=0.45 and 0.46), and calculated as substantial κ=0.76 between the 2 methods. The agreement between 4D DSA and 2D DSA was calculated as moderate κ=0.46 assessing the size of the nidus, slight κ=0.18 analyzing the drainage and almost perfect κ=0.95 depicting the localization. 4D DSA performed during a standard initial angiographic assessment of AVM represented approximately 6% of the total dose. CONCLUSION: The addition of this new technique 4D DSA could be performed regularly in addition to the 2D DSA if available, to assess SM grading, with an acceptable exposure to ionizing radiation.

Six Months vs Extended Oral Anticoagulation After a First Episode of Pulmonary Embolism: The PADIS-PE Randomized Clinical Trial.

IMPORTANCE: The optimal duration of anticoagulation after a first episode of unprovoked pulmonary embolism is uncertain. OBJECTIVES: To determine the benefits and harms of an additional 18-month treatment with warfarin vs placebo, after an initial 6-month nonrandomized treatment period on a vitamin K antagonist. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind trial (treatment period, 18 months; median follow-up, 24 months); 371 adult patients who had experienced a first episode of symptomatic unprovoked pulmonary embolism (ie, with no major risk factor for thrombosis) and had been treated initially for 6 uninterrupted months with a vitamin K antagonist were randomized and followed up between July 2007 and September 2014 in 14 French centers. INTERVENTIONS: Warfarin or placebo for 18 months. MAIN OUTCOMES AND MEASURES: The primary outcome was the composite of recurrent venous thromboembolism or major bleeding at 18 months after randomization. Secondary outcomes were the composite at 42 months (treatment period plus 24-month follow-up), as well as each component of the composite, and death unrelated to pulmonary embolism or major bleeding, at 18 and 42 months. RESULTS: After randomization, 4 patients were lost to follow-up, all after month 18, and 1 withdrew due to an adverse event. During the 18-month treatment period, the primary outcome occurred in 6 of 184 patients (3.3%) in the warfarin group and in 25 of 187 (13.5%) in the placebo group (hazard ratio [HR], 0.22; 95% CI, 0.09-0.55; P = .001). Recurrent venous thromboembolism occurred in 3 patients in the warfarin group and 25 patients in the placebo group (HR, 0.15; 95% CI, 0.05-0.43); major bleeding occurred in 4 patients in the warfarin group and in 1 patient in the placebo group (HR, 3.96; 95% CI, 0.44 to 35.89). During the 42-month entire study period (including the study treatment and follow-up periods), the composite outcome occurred in 33 patients (20.8%) in the warfarin group and in 42 (24.0%) in the placebo group (HR, 0.75; 95% CI, 0.47-1.18). Rates of recurrent venous thromboembolism, major bleeding, and unrelated death did not differ between groups. CONCLUSIONS AND RELEVANCE: Among patients with a first episode of unprovoked pulmonary embolism who received 6 months of anticoagulant treatment, an additional 18 months of treatment with warfarin reduced the composite outcome of recurrent venous thrombosis and major bleeding compared with placebo. However, benefit was not maintained after discontinuation of anticoagulation therapy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00740883.

Pulmonary embolism diagnostic strategies in patients with COPD exacerbation: Post-hoc analysis of the PEP trial.

BACKGROUND: The prevalence of pulmonary embolism (PE) is approximately 11-17 % in patients with an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The optimal diagnostic strategy for PE in these patients remains undetermined. AIMS: To evaluate the safety and efficacy of standard (revised Geneva and Wells PE scores combined with fixed D-dimer cut-off) and computed tomography pulmonary angiogram (CTPA)-sparing diagnostic strategies (ADJUST-PE, YEARS, PEGeD, 4PEPS) in patients with AE-COPD. METHOD: Post-hoc analyses of data from the multicenter prospective PEP study were performed. The primary outcome was the diagnostic failure rate of venous thromboembolism (VTE) during the entire study period. Secondary outcomes included diagnostic failure rate of PE and deep venous thrombosis (DVT), respectively, during the entire study period and the number of CTPA needed per diagnostic strategy. RESULTS: 740 patients were included. The revised Geneva and Wells PE scores combined with fixed D-dimer cut-off had a diagnostic failure rate of VTE of 0.7 % (95%CI 0.3 %-1.7 %), but >70.0 % of the patients needed imaging. All CTPA-sparing diagnostic algorithms reduced the need for CTPAs (-10.1 % to -32.4 %, depending on the algorithm), at the cost of an increased VTE diagnosis failure rate of up to 2.1 % (95%CI 1.2 %-3.4 %). CONCLUSION: Revised Geneva and Wells PE scores combined with fixed D-dimer cut-off were safe, but a high number of CTPA remained needed. CTPA-sparing algorithms would reduce imaging, at the cost of an increased VTE diagnosis failure rate that exceeds the safety threshold. Further studies are needed to improve diagnostic management in this population.

Safety and Efficacy of Cangrelor Among Three Antiplatelet Regimens During Stent-Assisted Endovascular Treatment of Unruptured Intracranial Aneurysm: A Single-Center Retrospective Study.

Introduction: Thromboembolic events represent the most frequent complications of endovascular treatment of unruptured intracranial aneurysm using stent-assisted coilling or flow diverter stents. Dual antiplatelet therapy has become the standard to prevent these but remains unstandardized. We present here a single center experience of 3 standardized antiplatelet regimens during brain aneurysm treatment, while emphasizing the use of the Cangrelor. Method: We retrospectively reviewed data from patients treated using stent-assisted coilling or flow diverter stents from 2016 to 2021. We collected and compared safety and efficacy data within 6 months of three groups of patients corresponding to three antiplatelet standardized regimens: group T with Ticagrelor, with preprocedural preparation; group E with Eptifibatide, injected during procedure; group C with Cangrelor, injected during procedure. Results: Data of 112 patients were analyzed and 76 belonged to group T, 21 to group E, and 15 to group C. Eleven events over the 14 recorded were adjudicated to be related to antiplatelets, their repartition did not differ between the 3 groups (p = 0.43). All symptomatic events (N = 8) were not distributed significantly differently between the 3 groups (p = 0.11) and asymptomatic events were also balanced (p = 1.00). Of these, 6 subjects had a change in the mRS score at 3-6 months. Thrombo-embolic events represented the most encountered events in the sample: 2 acute ischemic strokes were recorded in group E and 1 in group T; 1 transient ischemic stroke was noted in group E; 4 silent infarcts were found on control MRI (2 belonged to group T, 1 to group E and 1 to group C). Among 3 intracranial bleeding events, 1 was symptomatic in group C, 2 were asymptomatic in group T. On the control evaluation performed at 6 months, there was no significant difference on aneurysmal occlusion (p = 0.67). Conclusion: This single-center retrospective study compared 3 antiplatelet regimens, finding no significant difference in the safety and efficacy in the context of endovascular treatments of unruptured aneurysm using stent or flow diverters. This study adds data for the Cangrelor use and suggests its usefulness in the field of neuro-endovascular intervention. Randomized controlled studies are warranted to confirm these results.

Three-dimensional dispersion entropy for uterine fibroid texture quantification and post-embolization evaluation.

BACKGROUND AND OBJECTIVE: Uterine fibroids are benign tumors that could lead to symptoms complicating a patient's daily life. Those fibroids can be treated using uterine fibroid embolization (UFE), an effective non-surgical procedure. However, objectively quantifying the benefits of such a procedure, and the patient's quality of life, is rather challenging. METHODS: With a novel multiscale three-dimensional (3D) entropy-based texture analysis, the multiscale 3D dispersion entropy (MDispEn3D), this work aims to objectively quantify the evolution -  after UFE  -  of patients' health in terms of quality of life, symptoms severity, and sexual function. For this purpose, clinical data and magnetic resonance imaging (MRI) scans of fibroids are analyzed before UFE (D0), ten days after (D10), and six months after (M6). RESULTS: An inverse correlation is observed between MDispEn3D entropy values and both size and volume of fibroids. An inverse correlation is also observed between MDispEn3D at M6 and the scores of symptoms severity. Moreover, the patient age is found to be related to the relative difference of DispEn3D and MDispEn3D values, between D0 and M6, translating into an increasing entropy value. Furthermore, we show that history of fibroma plays a role in determining the obtained DispEn3D values at D0. Finally, we observe that the lower MDispEn3D values at D0, the larger the size of the fibroid at M6. CONCLUSIONS: The proposed MDispEn3D method - by quantifying fibroid texture - could assist the medical doctors in the prognosis of uterine fibroids and the patients' quality of life assessment post-UFE. It could therefore favor the choice of this treatment compared to other more invasive surgical treatments.

Frequency and predictors for chronic thromboembolic pulmonary hypertension after a first unprovoked pulmonary embolism: Results from PADIS studies.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication of a pulmonary embolism (PE) whose incidence and predictors are not precisely determined. OBJECTIVE: To determine the frequency and predictors for CTEPH after a first unprovoked PE. PATIENTS/METHODS: In a randomized trial comparing an additional 18-month warfarin versus placebo in patients after a first unprovoked PE initially treated with vitamin K antagonist for 6 months, we applied recommended CTEPH screening strategies through an 8-year follow-up to determine cumulative incidence of CTEPH. CTEPH predictors were estimated using Cox models. Pulmonary vascular obstruction (PVO) and systolic pulmonary arterial pressure (sPAP) at PE diagnosis and 6 months were studied by receiver operating curves analysis. All CTEPH cases and whether they were incident or prevalent were adjudicated. RESULTS: During a median follow-up of 8.7 years, nine CTEPH cases were diagnosed among 371 patients, with a cumulative incidence of 2.8% (95% confidence interval [CI] 0.95-4.64), and of 1.31% (95% CI 0.01-2.60) after exclusion of five cases adjudicated as prevalent. At PE diagnosis, PVO > 45% and sPAP > 56 mmHg were associated with CTEPH with a hazard ratio (HR) of 33.00 (95% CI 1.64-667.00, p = .02) and 12.50 (95% CI 2.10-74.80, p < .01), respectively. Age > 65 years, lupus anticoagulant antibodies and non-O blood groups were also predictive of CTEPH. PVO > 14% and sPAP > 34 mmHg at 6 months were associated with CTEPH (HR 63.90 [95% CI 3.11-1310.00, p < .01]and HR 17.2 [95% CI 2.75-108, p < .01]). CONCLUSION: After a first unprovoked PE, CTEPH cumulative incidence was 2.8% during an 8-year follow-up. PVO and sPAP at PE diagnosis and at 6 months were the main predictors for CTEPH diagnosis.

The Impact of Pulmonary Vascular Obstruction on the Risk of Recurrence of Pulmonary Embolism: A French Prospective Cohort.

BACKGROUND: We aimed to assess whether high pulmonary vascular obstruction index (PVOI) measured at the time of pulmonary embolism (PE) diagnosis is associated with an increased risk of recurrent venous thromboembolism (VTE). STUDY DESIGN AND METHODS: French prospective cohort of patients with a symptomatic episode of PE diagnosed with spiral computerized tomography pulmonary angiography (CTPA) or ventilation-perfusion (V/Q) lung scan and a follow-up of at least 6 months after anticoagulation discontinuation. PVOI was assessed based on the available diagnostic exam (V/Q lung scan or CTPA). All patients had standardized follow-up and independent clinicians adjudicated all deaths and recurrent VTE events. Main outcome was recurrent VTE after stopping anticoagulation. RESULTS: A total of 418 patients with PE were included. During a median follow-up period of 3.6 (1.2-6.0) years, 109 recurrences occurred. In multivariate analysis, PVOI ≥ 40% was an independent risk factor for recurrence (hazard ratio 1.77, 95% confidence interval 1.20-2.62, p < 0.01), whether PE was provoked by a major transient risk factor or not. A threshold at 41% was identified as the best value associated with the risk of recurrence 6 months after stopping anticoagulation (area under curve = 0.64). CONCLUSION: PVOI ≥ 40% at PE diagnosis was an independent risk factor for recurrence VTE. Further prospective validation studies are needed.

Long-term recurrence risk after a first venous thromboembolism in men and women under 50 years old: A French prospective cohort.

BACKGROUND: Data on long-term venous thromboembolism (VTE) recurrence risk according to gender are conflicting. OBJECTIVE: To evaluate long-term VTE recurrence risk after a first VTE in men and women under 50 years old. METHODS: Since May 2000, 875 consecutive patients (315 men, 560 women) with a first symptomatic VTE under 50 years old were enrolled in a French prospective multicentre cohort study and were followed up as long as possible. The primary outcome was symptomatic recurrent VTE during follow-up. RESULTS: At baseline, men were older and had more comorbidities than women. First VTE was mainly unprovoked in men (80.6%) and hormone-related in women (84.3%). During a median follow-up of 7.0 years (inter-quartile range, 5.0-11.0), recurrent VTE occurred in 97 men (30.8%) and in 72 women (12.9%) (annual incidence rates of recurrent VTE of 4.8% versus 1.8%-person-years, P<0.001). However, there was no difference according to gender in subgroups of patients with a first unprovoked VTE (5.8% versus 3.8%-person-years, P = 0.09). In women, duration of hormonal treatment before first VTE did not influence recurrence risk. In multivariable analysis, unprovoked VTE and family history of VTE were independently associated with recurrence (hazard ratio of 2.50 (95% confidence interval, 1.61 to 3.85) and 1.52 (1.11 to 2.09) respectively). LIMITATIONS: Number of women with unprovoked VTE was low. CONCLUSIONS: In patients with a first VTE under 50 years old, a first unprovoked episode and a family history of VTE, but not gender, were associated with a high risk of long-term recurrence.

Volume variation may be a relevant metric in the study of aneurysm pulsatility: a study using ECG-gated 4D-CTA (PULSAN).

​BACKGROUND AND PURPOSE: Intracranial aneurysms are a frequently occurring disease, with an estimated prevalence of 2-5% in the general population. They usually remain silent until rupture occurs, with a mortality rate of 35-50% and a high rate of morbidity, including long-term disability. However, preventative treatments have their own risk of complications and morbi-mortality rates, including stroke and hemorrhage. ECG-gated four-dimensional CT angiography (4D-CTA) allows the acquisition of time-resolved three-dimensional reconstructions. The aim of our study was to evaluate different intracranial aneurysm metrics over the cardiac cycle using ECG-gated 4D-CTA. ​MATERIALS AND METHODS: ECG-gated 4D-CTA datasets were acquired in patients presenting with intracranial aneurysms. Seven aneurysm metrics, including aneurysm height, aneurysm length, ostium width, aspect ratio, ostium area, volume, and volume-to-ostium ratio, were analysed over different cardiac phases. Intra-reader agreement, inter-reader agreement, and inter-cycle agreement were calculated through the intraclass correlation coefficient. ​RESULTS: Twenty-one aneurysms from 11 patients were considered for inclusion. Post-processing failed for three aneurysms, and 18 aneurysms were finally analysed. There was good intra-reader agreement for each metric (ICC >0.9). Agreements among three consecutive cardiac cycles were calculated for six aneurysms and were especially good for the volume metric (ICC >0.9). Volume variation appears to be the most relevant metric and seems especially perceptible for aneurysms larger than 5 mm. ​CONCLUSIONS: Quantification of aneurysm volume changes during the cardiac cycle seems quantitatively possible and reproducible, especially for aneurysms larger than 5 mm. Further studies need to be conducted to validate this parameter for intracranial aneurysm assessment.

Predictors of residual pulmonary vascular obstruction after pulmonary embolism: Results from a prospective cohort study.

BACKGROUND: We aimed to determine the prevalence of residual pulmonary vascular obstruction (RPVO) after symptomatic pulmonary embolism (PE) and to identify risk factors for RPVO. METHODS: On the basis of a prospective cohort of patients with a documented symptomatic venous thromboembolism, we included patients who had an acute PE and underwent a ventilation/perfusion lung scan at 3 to 24 months during the follow-up after PE. RPVO score was assessed for each patient. Initial pulmonary vascular obstruction at PE diagnosis was also assessed when available. Univariable and multivariable analyses were performed with preselected data to identify predictors for persistent defect defined as RPVO ≥ 5%. RESULTS: Among the 537 included patients, 278 (51.8%) had RPVO ≥ 5%, and 191 (35.6%) had RPVO ≥ 10%. In primary multivariate analysis on overall population, age ≥ 65 years (odds ratio [OR] 2.25, 95% CI, 1.45-3.52) and chronic respiratory failure (OR 3.19, 95% CI, 1.22-10.04) were independent predictors of RPVO ≥ 5%. In secondary multivariate analysis restricted to 256 patients with available initial pulmonary vascular obstruction score at index PE (IPVO), age ≥ 65 years (OR 2.78, 95% CI, 1.41-5.53), unprovoked PE (OR 2.11, 95% CI, 1.11-4.07) and IPVO ≥ 20% (OR 2.94, 95% CI, 1.68-5.20) were found to be independent risk factors for RVPO ≥5%. CONCLUSION: In this selected population of patients with an acute PE, age ≥ 65 years, unprovoked PE and IPVO ≥ 20% at PE diagnosis appeared to be risk factors for residual pulmonary vascular obstruction measured at three to 24 months.

Evaluation of Venous Thromboembolism Recurrence Scores in an Unprovoked Pulmonary Embolism Population: A Post-hoc Analysis of the PADIS-PE trial.

BACKGROUND: We aimed to validate the Men Continue and HERDOO2 (HERDOO2), D-dimer, age, sex, hormonal therapy (DASH), and updated Vienna recurrent venous thromboembolism prediction models in a population composed entirely of first unprovoked pulmonary embolism, and to analyze the impact of the addition of the pulmonary vascular obstruction index (PVOI) on score accuracy. METHODS: Analyses were based on the double-blind, randomized PADIS-PE trial, which included 371 unprovoked pulmonary embolism patients initially treated for 6 months, successively randomized to receive an additional 18 months of warfarin or placebo, and subsequently followed-up for 2 years. RESULTS: The HERDOO2, DASH, and updated Vienna scores displayed C-statistics of 0.61 (95% CI 0.54-0.68), 0.60 (95% CI 0.53-0.66), and 0.58 (95% CI 0.51-0.66), respectively. Only the HERDOO2 score identified low recurrence risk patients (<3%/year) after anticoagulation was stopped. When added to either of the prediction models, PVOI measured at pulmonary embolism diagnosis, after 6 months of anticoagulation, or both, improved scores' C-statistics between +0.06 and +0.11 points and consistently led to identifying at least 50% of patients who experienced recurrence but in whom the scores would have indicated against extended anticoagulation. CONCLUSIONS: In patients with a first unprovoked pulmonary embolism, the HERDOO2 score is able to identify patients with a low recurrence risk after treatment discontinuation. Addition of PVOI improves accuracy of all scores. CLINICAL TRIALS REGISTRATION: URL: http://www.controlled-trials.com. Unique identifier: NCT00740883.

Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial.

BACKGROUND: Multislice CT (MSCT) combined with D-dimer measurement can safely exclude pulmonary embolism in patients with a low or intermediate clinical probability of this disease. We compared this combination with a strategy in which both a negative venous ultrasonography of the leg and MSCT were needed to exclude pulmonary embolism. METHODS: We included 1819 consecutive outpatients with clinically suspected pulmonary embolism in a multicentre non-inferiority randomised controlled trial comparing two strategies: clinical probability assessment and either D-dimer measurement and MSCT (DD-CT strategy [n=903]) or D-dimer measurement, venous compression ultrasonography of the leg, and MSCT (DD-US-CT strategy [n=916]). Randomisation was by computer-generated blocks with stratification according to centre. Patients with a high clinical probability according to the revised Geneva score and a negative work-up for pulmonary embolism were further investigated in both groups. The primary outcome was the 3-month thromboembolic risk in patients who were left untreated on the basis of the exclusion of pulmonary embolism by diagnostic strategy. Clinicians assessing outcome were blinded to group assignment. Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00117169. FINDINGS: The prevalence of pulmonary embolism was 20.6% in both groups (189 cases in DD-US-CT group and 186 in DD-CT group). We analysed 855 patients in the DD-US-CT group and 838 in the DD-CT group per protocol. The 3-month thromboembolic risk was 0.3% (95% CI 0.1-1.1) in the DD-US-CT group and 0.3% (0.1-1.2) in the DD-CT group (difference 0.0% [-0.9 to 0.8]). In the DD-US-CT group, ultrasonography showed a deep-venous thrombosis in 53 (9% [7-12]) of 574 patients, and thus MSCT was not undertaken. INTERPRETATION: The strategy combining D-dimer and MSCT is as safe as the strategy using D-dimer followed by venous compression ultrasonography of the leg and MSCT for exclusion of pulmonary embolism. An ultrasound could be of use in patients with a contraindication to CT.

Predictors for Residual Pulmonary Vascular Obstruction after Unprovoked Pulmonary Embolism: Implications for Clinical Practice-The PADIS-PE Trial.

BACKGROUND: We aimed to identify risk factors for residual pulmonary vascular obstruction after a first unprovoked pulmonary embolism (PE). METHODS: Analyses were based on data from the double-blind randomized "PADIS-PE" trial that included 371 patients with a first unprovoked PE initially treated during 6 uninterrupted months; all patients underwent baseline ventilation-perfusion lung scanning at inclusion (i.e., after 6 months of anticoagulation). Each patient's pulmonary vascular obstruction indexes (PVOIs) at PE diagnosis and at inclusion were centrally assessed. RESULTS: Among the 371 included patients, residual PVOI was available in 356 patients, and 150 (42.1%) patients had PVOI ≥ 5%. At multivariable analysis, age > 65 years (odds ratio [OR], 2.81, 95% confidence interval [CI], 1.58-5.00), PVOI ≥ 25% at PE diagnosis (OR, 3.53, 95% CI, 1.94-6.41), elevated factor VIII (OR, 3.89, 95% CI, 1.41-10.8), and chronic respiratory disease (OR, 2.18, 95% CI, 1.11-4.26) were independent predictors for residual PVOI ≥ 5%. Patients with ≥ 1 of these factors represented 94.5% (123 patients) of all patients with residual PVOI ≥ 5%. CONCLUSION: Six months after a first unprovoked PE, age > 65 years, PVOI ≥ 25% at PE diagnosis, elevated factor VIII, or chronic respiratory disease were found to be independent predictors for residual pulmonary vascular obstruction. CLINICAL TRIALS REGISTRATION: URL: http://www.controlled-trials.com. Unique identifier: NCT00740883.