Prognostic significance of tricuspid annular displacement in normotensive patients with acute symptomatic pulmonary embolism.

BACKGROUND: Tricuspid annular plane systolic excursion (TAPSE) is an emerging prognostic indicator in patients with acute symptomatic pulmonary embolism (PE). METHODS AND RESULTS: We prospectively examined 782 normotensive patients with PE who underwent echocardiography in a multicenter study. As compared with patients with a TAPSE of > 1.6 cm, those with a TAPSE of ≤ 1.6 cm had increased systolic pulmonary artery pressure (53.7 ± 16.7 mmHg vs. 40.0 ± 15.5 mmHg, P < 0.001), right ventricle (RV) end-diastolic diameter (3.5 ± 0.8 cm vs. 3.0 ± 0.6 cm, P < 0.001), and RV to left ventricle end-diastolic diameter ratio (1.0 ± 0.3 vs. 0.8 ± 0.2, P < 0.001), and a higher prevalence of RV free wall hypokinesis (68% vs. 11%, P < 0.001). Patients with a TAPSE of ≤ 1.6 cm at the time of PE diagnosis were significantly more likely to die from any cause (hazard ratio [HR] 2.3; 95% confidence interval [CI] 1.2-4.7; P = 0.02) and from PE (HR 4.4; 95% CI 1.3-15.3; P = 0.02) during follow-up. In an external validation cohort of 1326 patients with acute PE enrolled in the international multicenter Registro Informatizado de la Enfermedad TromboEmbólica, a TAPSE of ≤ 1.6 cm remained a significant predictor of all-cause mortality (HR 2.1; 95% CI 1.3-3.2; P = 0.001) and PE-specific mortality (HR 2.5; 95% CI 1.2-5.2; P = 0.01). CONCLUSIONS: In normotensive patients with PE, TAPSE reflects right ventricular function. For these patients, TAPSE is independently predictive of survival.

Influence of recent immobilization and recent surgery on mortality in patients with pulmonary embolism.

BACKGROUND: The influence of recent immobilization or surgery on mortality in patients with pulmonary embolism (PE) is not well known. METHODS: We used the Registro Informatizado de Enfermedad TromboEmbólica (RIETE) data to compare the 3-month mortality rate in patients with PE, with patients categorized according to the presence of recent immobilization, recent surgery, or neither. RESULTS: Of 18,028 patients with PE, 4169 (23%) had recent immobilization, 2212 (12%) had recent surgery, and 11,647 (65%) had neither. The all-cause mortality was 10.0% (95% confidence interval [CI] 9.5-10.4), and the PE-related mortality was 2.6% (95% CI 2.4-2.9). One in every two patients who died from PE had recent immobilization (43%) or recent surgery (6.7%). Only 25% of patients with immobilization had received prophylaxis, as compared with 65% of the surgical patients. Fatal PE was more common in patients with recent immobilization (4.9%; 95% CI 4.3-5.6) than in those with surgery (1.4%; 95% CI 1.0-2.0) or those with neither (2.1%; 95% CI 1.8-2.3). On multivariate analysis, patients with immobilization were at increased risk for fatal PE (odds ratio 2.2; 95% CI 1.8-2.7), with no differences being seen between patients immobilized in hospital or in the community. CONCLUSIONS: Forty-three per cent of patients dying from PE had recent immobilization for ≥4 days. Many of these deaths could have been prevented.

Thrombolytic therapy and outcome of patients with an acute symptomatic pulmonary embolism.

BACKGROUND: While the primary therapy for most patients with a pulmonary embolism (PE) consists of anticoagulation, the efficacy of thrombolysis relative to standard therapy remains unclear. METHODS: In this retrospective cohort study of 15,944 patients with an objectively confirmed symptomatic acute PE, identified from the multicenter, international, prospective, Registro Informatizado de la Enfermedad TromboEmbólica (RIETE registry), we aimed to assess the association between thrombolytic therapy and all-cause mortality during the first 3 months after the diagnosis of a PE. After creating two subgroups, stratified by systolic blood pressure (SBP) (< 100 mm Hg vs. other), we used propensity score-matching for a comparison of patients who received thrombolysis to those who did not in each subgroup. RESULTS: Patients who received thrombolysis were younger, had fewer comorbid diseases and more signs of clinical severity compared with those who did not receive it. In the subgroup with systolic hypotension, analysis of propensity score-matched pairs (n = 94 pairs) showed a non-statistically significant but clinically relevant lower risk of death for thrombolysis compared with no thrombolysis (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.36-1.46; P = 0.37). In the normotensive subgroup, analysis of propensity score-matched pairs (n = 217 pairs) showed a statistically significant and clinically meaningful increased risk of death for thrombolysis compared with no thrombolysis (OR 2.32; 95% CI, 1.15-4.68; P = 0.018). When we imputed data for missing values for echocardiography and troponin tests in the group of normotensive patients, we no longer detected the increased risk of death associated with thrombolytic therapy. CONCLUSIONS: In normotensive patients with acute symptomatic PE, thrombolytic therapy is associated with a higher risk of death than no thrombolytic therapy. In hemodynamically unstable patients, thrombolytic therapy is possibly associated with a lower risk of death than no thrombolytic therapy. However, study design limitations do not imply a causal relationship between thrombolytics and outcome.

Noninvasive positive pressure home ventilation in restrictive disorders: outcome and impact on health-related quality of life.

Noninvasive positive-pressure home ventilation (NIPPHV) improves arterial blood gases, dyspnea and health-related quality of life (HRQL) in patients with restrictive thoracic diseases. Whether these changes persist during the follow-up remains unclear. The aim of this study was to investigate the long-term effects of NIPPHV upon dyspnea, HRQL, lung function and hospitalization rate in 35 patients with kyphoscoliosis and 27 individuals with several neuromuscular disorders. So, we measured dyspnea, HRQL, lung function and nocturnal oxygen saturation (SaO2) before and after 3, 6, 9, 12 and 18 months after NIPPHV. Dyspnea was assessed with the Borg scale and HRQL was measured using the Spanish validated version of the SF-36 questionnaire. The kyphoscoliosis group showed significant improvement of PaCO2 and SaO2 at 3 months and minor dyspnea changes at 6 months after NIPPHV had been started. These patients also showed improved health status in the following categories: "physical role" and "emotional role" at 3 months and in the categories "social functioning", "vitality" and "mental health" at 6 months after NIPPHV; some of these changes persisted at 9, 12 and 18 months. In the neuromuscular group, a significant improvement of SaO2 was observed at 3 months and this persisted for 18 months. Changes of HRQL in this group included a significant improvement in "physical role" at 3 months, "emotional role" and "social functioning" at 6 months and "physical functioning" at 9 months. The hospitalization rate decreased significantly in all patients from a mean annual admission rate of 1.1 (1.4) before NIPPHV to 0.6 (1.1) after 12 months of ventilatory support (P<0.005). We conclude that: (a) NIPPHV had a higher impact on arterial blood gases, dyspnea and health-related quality of life in patients with kyphoscoliosis than in those with neuromuscular disorders; (b) most clinical and functional changes persisted at long term and (c) a significant decrease in the hospitalization rate after NIPPHV occurred in both groups.

[Clinical manifestations and prevalence of hypercoagulable states in patients with venous thromboembolic disease]. / Características clínicas y prevalencia de los estados de hipercoagulabilidad en pacientes con enfermedad tromboembólica venosa.

BACKGROUND: Blood flow stasis, an alteration in the coagulation process or endothelium injury the most common mechanisms involved in venous thromboembolic diseases (TED) and constitute the so-called hypercoagulable states (HS). The HS have been classified into two groups: primary and secondary and several of them can be measured. Our purpose was to investigate the prevalence in Spain of measurable HS in patients with venous TED and to know the clinical picture of pulmonary embolism in these patients. PATIENTS AND METHOD: Sixty of 175 consecutive patients diagnosed with deep venous thrombosis and pulmonary embolism fulfilled criteria to study a HS. The study was performed 1 month after anticoagulant therapy was finished. RESULTS: Seventeen (28%) of the 60 patients had one HS that was a primary disorder in 14 and a secondary one in 3. The increase of PAI-1 level was the most common; recurrence of thrombotic events and familial history were frequent in these selected patients. CONCLUSIONS: The prevalence of hypercoagulable states in venous thromboembolic disease was high in this series. The clinical picture was similar to those to be expected and PAI-1 was the most frequent marker of hypercoagulable states.

Use of venous thromboembolism prophylaxis for surgical patients: a multicentre analysis of practice in Spain.

OBJECTIVE: To assess the use of venous thromboembolism prophylaxis in surgical patients. DESIGN: Retrospective multicentre study. SETTING: Eight acute-care teaching hospitals with more than 400 beds, Spain. PATIENTS: Medical records of all consecutive patients undergoing operations in the general surgical and trauma and orthopaedic services during the month of April, 1997, were randomly selected. INTERVENTION: The sample size for each type of operation (general, trauma-orthopaedic) was calculated from the number of operations done at each hospital (with an absolute precision of 5%, and an alpha error of 5%) and the prevalence of the use of venous thromboembolism prophylaxis obtained from a random sample of 50 records (25 from patients in general surgery and 25 from patients in orthopaedic surgery) from each centre. MAIN OUTCOME MEASURES: Appropriate and inappropriate pharmacological prophylaxis defined according to a combination of risk categories for venous thromboembolism, doses of antithrombotic agents given, time of starting prophylaxis, and its duration. RESULTS: A total of 1848 medical records (general surgery, n = 1025; trauma-orthopaedic surgery, n = 823) were included. Physical methods (elastic stockings, intermittent pneumatic compression) were used in only 0.3% of patients. Pharmacological prophylaxis consisted of low molecular weight heparin in 99% of cases. The percentage given heparin-based prophylaxis was 54%. Overall, appropriate prophylaxis was given in 1175 patients (64%). Use of thromboprophylaxis ranged from 27% to 70% among the participating hospitals. Prophylaxis was more likely to be appropriate in orthopaedic patients (577, 70%) than in general surgical patients (598, 58%) in both the high and moderate risk categories. CONCLUSIONS: Given the large variability between the participating hospitals, more specific protocols and recommendations about prophylaxis of thromboembolism in surgical patients are needed.

Prognostic factors in restoration of pulmonary flow after submassive pulmonary embolism: a multiple regression analysis.

Defects as evaluated by lung perfusion scans may persist even 6 months after pulmonary embolism (PE), when treatment is withdrawn. The aim of this study was to evaluate the effect of several potential factors on the resolution of lung perfusion defects, both during the first days and at 6 months, when patients were discharged. In a retrospective follow-up cohort study we included 102 patients with PE, diagnosed lung from a ventilation/perfusion (V'/Q') scan, following Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) criteria, together with a phlebographic study of lower extremities or angiography. Lung perfusion scan was performed at diagnosis, and in two follow-up evaluations, at 7-10 days and at 6 months. Potential factors studied were: age; sex; presence of underlying cardiac or pulmonary disease; venous insufficiency; alveolar-arterial pressure difference for oxygen; delay in diagnosis; abnormalities in electrocardiogram or chest radiograph; and the size of defects as shown in lung perfusion scans. All factors were studied with regards to the size of the defects at the two follow-up evaluations, through a univariate statistical analysis and two multiple stepwise regression analysis. Multivariate statistical analysis selected four factors: size of defects at diagnosis; prior cardiopulmonary disease; delay in diagnosis; and sex, as synergistic variables to predict defect size at 7-10 days. On the other hand, the defect size at 7-10 days was the only variable selected as a predictor of the size of defects at 6 months. Resolution of pulmonary defects during the first days after diagnosis of pulmonary embolism is influenced by the initial defect size, prior cardiopulmonary diseases and sex. The size of residual defects at 6 months depends mainly on the size of defects at 7-10 days.

Disseminated pulmonary granulomas after intravesical bacillus Calmette-Guérin immunotherapy.

Intravesical instillation of bacillus Calmette-Guérin (BCG) vaccine has been shown to be an effective treatment of superficial bladder cancer. However, it is not free of side-effects and complications. We present the case of a 62-year-old man who developed disseminated pulmonary granulomas after local BCG immunotherapy for recurrent papillary bladder cancer.

Influence of cardiopulmonary disease on resolution of pulmonary embolism. A mathematical model to predict remaining defects at six months.

Recovery of lung perfusion after pulmonary embolism (PE) is conditioned by several factors. The aim of this study was to analyze the differences of reperfusion after PE between patients with and without preexisting cardiopulmonary disease, and to develop a mathematical model to predict, at diagnosis, the size of defects in lung perfusion scan at 6 months after treatment. We included 83 patients with diagnosis of PE in a non-concurrent cohort study (cohort I: 26 with preexisting cardiopulmonary disease, and cohort II: 57 without previous cardiopulmonary disease). Lung perfusion scan was performed at diagnosis, 7-10 days after treatment and at 6 months. The defect size was quantified following a numerical score. The recovery of perfusion after 7-10 days was 33% in cohort I and 45% in cohort II, and 50% and 72%, respectively, at the last control at 6 months. A multiple-regression analysis was performed using the final size of defects at 6 months (y) as the dependent variable, and the defect size at diagnosis (x) and the presence of preexisting cardiopulmonary disease (z) as independent variables. The regression equation was y = 1.29 + 0.15x + 2.98z. We conclude that: (1) in patients with cardiopulmonary diseases, the remaining defects at 6 months were larger; (2) at diagnosis, using a mathematical model, it is possible to predict the size of the defects in lung perfusion scan at 6 months in patients with or without previous cardiopulmonary disease.

[Right ventricular thrombosis and pulmonary thrombosis associated with venous-peritoneal diversion (Le Veen). Diagnosis with transesophageal echocardiography]. / Trombosis ventricular derecha y embolismo pulmonar asociados a derivación peritoneo-venosa (Le Veen). Diagnóstico por ecocardiografía transesofágica.

Central venous thrombosis (CVT) and pulmonary embolism (PE) are complications that have been reported in association with the use of venous-peritoneal shunts (Le Veen). CVT usually develops around the proximal end of the catheter; the clinical course is varied and usually requires venous imaging to confirm the diagnosis. We present a case of CVT associated with PE, in which the thrombus was located in the right ventricular cavity (distal to the catheter tip). Two-dimensional transesophageal echocardiography was used for diagnosis and follow-up.

Aetiology of community acquired pneumonia in Valencia, Spain: a multicentre prospective study.

A year long multicentre prospective study was carried out in the Valencia region of Spain, to determine the cause of community acquired pneumonia. The study was based on 510 of 833 patients with pneumonia. Of these, 462 were admitted to hospital, where 31 patients died. A cause was established in only 281 cases--208 of bacterial, 60 of viral, and 13 of mixed infection. The most common microorganisms were Streptococcus pneumoniae (14.5%), Legionella sp (14%), Influenza virus (8%), and Mycoplasma pneumoniae (4%). There was a higher incidence of Legionella sp than in other studies.

[Community viral pneumonia in the adult population: a prospective multicenter study of 62 cases. The Pneumonia Study Group of the Community of Valencia]. / Neumonía comunitaria por virus en la población adulta: estudio prospectivo multicéntrico de 62 casos. Grupo de estudio de neumonías de la Comunidad Valenciana.

The present work prospectively analyzes, in a multicentric study, viral pneumonias acquired in the community during one year. Were studied 510 patients diagnosed of pneumonia in hospital, or whom 62 (12.1%) had a viral origin. Influenza virus A and B were the most common causative agents (47.6% and 20.6% respectively). Smoking habit was present in 44% of patients, previous OCFA in 45% and other previous pathology in 64.4%. The greatest number of registered cases was during December. The most frequent radiologic finding was alveolar pattern. Evolution in general, was favourable with a low mortality rate (one case).

Effect of thoracentesis on pulmonary gas exchange.

The effect of thoracentesis on pulmonary gas exchange was studied in 33 patients with unilateral pleural effusions of various causes. Arterial blood gases were measured before thoracentesis and at 20 minutes, two hours, and 24 hours after the procedure. In 13 patients alveolar arterial oxygen gradient (PA-ao2), physiological dead space:tidal volume ratio (VD/VT), physiological shunt, and "anatomical" shunt were also determined before and two hours after thoracentesis. The Pao2 showed a significant increase at each time, reaching a maximum at 24 hours (mean (SD) increase 1.1 (0.74) kPa; 8.17 (5.57) mm Hg). A concurrent significant decrease of PA-ao2 was observed (mean (SD) 1.72 (0.77) kPa; 12.92 (5.78) mm Hg). This was accompanied by a small but significant decrease of "anatomical" shunt (2.4% (1.5%] and a greater decrease of the physiological shunt (6.5% (4.3%], while VD/VT did not change. The results are probably due to improved ventilation perfusion relationships with, in particular, an increase in the ventilation of parts of the lung previously poorly ventilated but well perfused.