[Epidemiology of patients presenting to the emergency room for dyspnea in Belgium]. / Epidémiologie des patients se présentant aux urgences pour dyspnée en Belgique.

Studies about patients' profile presenting to the emergency department for dyspnea are scarce in Europe, and even more in Belgium. We analyze here a cohort of patients with acute dyspnea in three Belgian centers, as to the epidemiology of this dyspnea, the tests carried out, the diagnoses retained, the treatments administered, the hospitalization and survival rates. The secondary objective is to compare this Belgian cohort with a European population resulting from a large multicenter study. The analysis of 131 patients showed that acute dyspnea in the emergency department corresponds to four main diagnoses (exacerbation of chronic obstructive pulmonary disease, infections of the lower respiratory tract, acute cardiac decompensation and asthma). The age of patients is over 80 years in a quarter of them, the hospitalization rate is 57 % and the mortality is 5 %. Our analysis also reveals that the check of vital parameters may be insufficiently realized, as may the use of non-invasive ventilation. Etiological diagnoses made in the emergency department are confirmed at the end of hospitalization in 75 % of cases. The Belgian population is younger than the European population (62 against 69 years), presents fewer infection of the lower respiratory tract (20 % against 31 %), and is comparable to the European population for the other parameters studied. The article ends with 10 key messages that will enlighten clinicians about the reality of acute dyspnea in emergency rooms in Belgium.

Le profil des patients se présentant au service des urgences pour dyspnée est peu étudié en Europe, et encore moins en Belgique. Nous analysons ici une cohorte de patients présentant une dyspnée aiguë dans trois centres belges, quant à l'épidémiologie de cette dyspnée, les examens complémentaires réalisés, les diagnostics retenus, les traitements administrés, les taux d'hospitalisations et de survie. L'objectif secondaire est de comparer cette cohorte belge à une population européenne issue d'une vaste étude multicentrique. L'analyse de 131 patients révèle que la dyspnée aiguë au service des urgences correspond à quatre principaux diagnostics : l'exacerbation de bronchopneumopathie chronique obstructive, les infections des voies respiratoires inférieures, la décompensation cardiaque aiguë et l'asthme. L'âge des patients est supérieur à 80 ans chez un quart d'entre eux, le taux d'hospitalisation est de 57 % et la mortalité de 5 %. Notre analyse révèle également que la prise des paramètres vitaux peut être insuffisamment réalisée, tout comme le recours à la ventilation non invasive. Les diagnostics étiologiques posés dans le service des urgences sont confirmés en fin d'hospitalisation dans 75 % des cas. La population belge est plus jeune que la population européenne (62 versus 69 ans), présente moins souvent un diagnostic d'infection des voies respiratoires inférieures (20 % versus 31 %), et est comparable à la population européenne pour les autres paramètres étudiés. L'article évoque 10 messages-clés qui aideront les cliniciens à mieux percevoir la réalité de la dyspnée aiguë aux urgences en Belgique.

Assessing clinical probability of pulmonary embolism: prospective validation of the simplified Geneva score.

Essentials The simplified Geneva score allows easier pretest probability assessment of pulmonary embolism (PE). We prospectively validated this score in the ADJUST-PE management outcome study. The study shows that it is safe to manage patients with suspected PE according to this score. The simplified Geneva score is now ready for use in routine clinical practice. SUMMARY: Background Pretest probability assessment by a clinical prediction rule (CPR) is an important step in the management of patients with suspected pulmonary embolism (PE). A limitation to the use of CPRs is that their constitutive variables and corresponding number of points are difficult to memorize. A simplified version of the Geneva score (i.e. attributing one point to each variable) has been proposed but never been prospectively validated. Aims Prospective validation of the simplified Geneva score (SGS) and comparison with the previous version of the Geneva score (GS). Methods In the ADJUST-PE study, which had the primary aim of validating the age-adjusted D-dimer cut-off, the SGS was prospectively used to determine the pretest probability in a subsample of 1621 study patients. Results Overall, PE was confirmed in 294 (18.1%) patients. Using the SGS, 608 (37.5%), 980 (60.5%) and 33 (2%) were classified as having a low, intermediate and high clinical probability. Corresponding prevalences of PE were 9.7%, 22.4% and 45.5%; 490 (30.1%) patients with low or intermediate probability had a D-dimer level below 500 µg L-1 and 653 (41.1%) had a negative D-dimer test according to the age-adjusted cut-off. Using the GS, the figures were 491(30.9%) and 650 (40.9%). None of the patients considered as not having PE based on a low or intermediate SGS and negative D-dimer had a recurrent thromboembolic event during the 3-month follow-up. Conclusions The use of SGS has similar efficiency and safety to the GS in excluding PE in association with the D-dimer test.

Fourteen years of experience in uncontrolled organ donation after cardio-circulatory death.

BACKGROUND: Since 1999, a protocol for uncontrolled donation after cardio-circulatory death (DCD) has been carried out in our institution. We aimed at evaluating those 14 years of local experience. METHODS: We reviewed the charts of uncontrolled donors from 1999 till 2013. Potential donors with a no-flow period less than 30 minutes were considered. Kidneys were perfused by the use of a double balloon triple lumen catheter after at least a 2-minute period of no touch. We analyzed grafts outcome and warm and cold ischemia times. RESULTS: Thirty-nine procedures were initiated: 19 were aborted because of family refusal (n = 7), medical reasons (n = 7), or canulation failures (n = 5) and 20 harvesting procedures were completed. Transplantation was considered for 35 kidneys (cold storage [n = 5] and hypothermic preservation system [n = 30]). The causes of withdrawal from transplantation were mostly macroscopic lesions (poor perfusion, macroscopic parenchyma or vascular lesions, or infectious risk). We transplanted 22 kidneys locally and 3 were shipped to another Eurotransplant center. Mean donor age was 40 ± 13 years. Among the 20 donors, 13 came from the emergency unit and 7 from the intensive care unit. Mean no-flow time for out-hospital management was 8.7 ± 3.6 minutes. Mean time of cardiopulmonary resuscitation was 71 ± 46 minutes. Mean cold ischemia time was 19 ± 5 hours. Primary nonfunction and delayed graft function occurred in 1 and 12 cases (4.5% and 54%), respectively. Graft survival was 86% at 1 year. Causes of graft loss during the entire follow-up were graft rejection (n = 3), ischemically damaged kidney (n = 2), and recurrence of focal segmental glomerulosclerosis (n = 1). CONCLUSION: In our experience, uncontrolled donors represent a valuable source of kidney grafts, with a prognosis of graft function and survival similar to the literature. To increase the number of available DCD organs, new techniques, such as the use of Normothermic ExtraCorporeal Membrane Oxygenation (NECMO), as well as improvement of recruitment of out of hospital potential donors have to be considered.

Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism.

BACKGROUND: Age-adjusted D-dimer cut-off has recently been proposed to increase D-dimer usefulness in older patients suspected of pulmonary embolism (PE). OBJECTIVE: We externally validated this age-adjusted D-dimer cut-off using different D-dimer assays in a multicenter sample of emergency department patients. METHODS: Secondary analysis of three prospectively collected databases (two European, one American) of patients suspected of having PE. D-dimer performance for ruling out PE was assessed by calculating negative likelihood ratio (nLR) for D-dimer with age-adjusted D-dimer cut-off (< age × 10 in patients over 50 years) and with conventional cut-off (< 500 µg dL(-1)). Test efficiency was assessed by the number needed to test (NNT) to rule out PE in one patient. RESULTS: Among 4537 patients included, overall PE prevalence was 10.1%. In the overall population, nLR was 0.06 (95% confidence interval, 0.03-0.09) with conventional cut-off and 0.08 (0.05-0.12) with age-adjusted cut-off. Using age-adjusted cut-off, nLR was 0.08, 0.09 and 0.06 for Vidas(®) , Liatest(®) and MDA(®) assays, respectively. Use of age-adjusted cut-off produced a favorable effect on NNT in the elderly; the greatest decrease was observed in patients > 75 years: NTT halved from 8.1 to 3.6. The proportion of patients over 75 years with normal D-dimer was doubled (27.9% vs. 12.3%). CONCLUSIONS: Our study shows that age-adjusted D-dimer had low nLR, allowing its use as a rule-out PE strategy in non-high pretest clinical probability patients, as well as using Vidas(®), Liatest(®) or MDA(®) assays. This age-adjusted cut-off increased clinical usefulness of D-dimer in older patients. A large prospective study is required to confirm these results.

Is atrial fibrillation associated with pulmonary embolism?

BACKGROUND: A pulmonary embolism (PE) is thought to be associated with atrial fibrillation (AF). Nevertheless, this association is based on weak data. OBJECTIVES: To assess whether the presence of AF influences the clinical probability of PE in a cohort of patients with suspected PE and to confirm the association between PE and AF. PATIENTS/METHODS: We retrospectively analyzed the data from two trials that included 2449 consecutive patients admitted for a clinically suspected PE. An electrocardiography (ECG) was systematically performed and a PE was diagnosed by computer tomography (CT). The prevalence of AF among patients with or without a PE was compared in a multivariate logistic regression model. RESULTS: The prevalence of PE was 22.8% (519/2272) in patients without AF and 18.8% (25/133) in patients with AF (P = 0.28). After adjustment for confounding factors, AF did not significantly modify the probability of PE (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.42-1.11). However, when PE suspicion was based on new-onset dyspnea, AF significantly decreased the probability of PE (OR 0.47, 95% CI 0.26-0.84). If isolated chest pain without dyspnea was the presenting complaint, AF tended to increase the probability of PE (OR 2.42, 95% CI 0.97-6.07). CONCLUSIONS: Overall, the presence of AF does not increase the probability of PE when this diagnosis is suspected. Nevertheless, when PE suspicion is based on new-onset dyspnea, AF significantly decreases the probability of PE, as AF may mimic its clinical presentation. However, in patients with chest pain alone, AF tends to increase PE probability.

European and American suspected and confirmed pulmonary embolism populations: comparison and analysis.

BACKGROUND: If the prevalence of pulmonary embolism (PE) differs significantly between the US and Europe, this observation could reduce the generalizability of diagnostic protocols for PE derived in either location. OBJECTIVE: To determine possible causes and potential clinical consequences of these PE prevalence differences. METHODS: Secondary analysis of three prospectively collected multicenter samples (two French and one from the US) including 3174 European and 7940 American PE-suspected patients in Emergency departments (ED) (117 for Europe and 12 for US). Comparison of clinical features, resource use and outcomes of European- and US-suspected PE populations in ED. RESULTS: European patients evaluated for PE were significantly older and had a higher clinical pretest probability (CPP) for PE. The final PE prevalence was significantly higher in Europe, in the overall sample (26.5% vs. 7.6%) and in each level of CPP. Suspected European patients categorized as low CPP had a higher posttest probability than US low CPP patients. Suspected US patients categorized as high CPP had a much lower posttest probability of PE than in Europe. The mean number of tests performed for one PE diagnosis was lower in Europe (7.4 vs. 21.6). Among patients diagnosed with PE, European patients had a higher mean severity of illness score and a higher PE-mortality rate (3.4% vs. 0.7%). CONCLUSIONS: Among patients suspected of a PE and those ultimately diagnosed with a PE, European patients had higher acuity, a higher pretest probability and worse outcome than US patients. The present study underscores the importance of disease prevalence for pretest probability scoring approaches and for significance interpretation of imaging tests.

Prognostic value of the Geneva prediction rule in patients in whom pulmonary embolism is ruled out.

OBJECTIVES: The prognosis of patients in whom pulmonary embolism (PE) is suspected but ruled out is poorly understood. We evaluated whether the initial assessment of clinical probability of PE could help to predict the prognosis for these patients. DESIGN: Retrospective analysis of data obtained during a prospective multicentre management study. SETTING: Six general and teaching hospitals in Belgium, France and Switzerland. SUBJECTS: In 1334 patients in whom PE was ruled out, 3-month mortality data were available (hospital readmission status was unknown for three patients) and clinical probability was evaluated with the revised Geneva score (RGS). MAIN OUTCOME MEASURES: Three-month mortality and readmission rates. RESULTS: Three-month mortality and readmissions rates were 3% and 19%, respectively and differed significantly depending on the RGS-determined PE probability group (P<0.001). When compared with patients presenting with a low probability, the risk of death after 3 months was higher in cases of intermediate or high RGS-based probability {odds ratio: 8.7 [95% confidence interval (CI): 2.7-28.5] and 22.6 (95%CI: 2.1-241.2), respectively}. The readmission risk increased with PE probability group (P<0.001). The main causes of death were cancer, respiratory failure and cardiovascular failure. In total, 86% of patients with low RGS-based probability were alive and had not been readmitted to hospital, whereas other patients had a twofold increased risk of death or readmission during the 3-month follow-up. The simplified Geneva score, calculated a posteriori, gave similar results. CONCLUSIONS: Initial assessment of clinical probability may help to stratify prognosis of patients in whom PE has been ruled out. Patients with a low probability of PE have a good prognosis. Whether patients with higher probability might benefit from more vigilant care should be evaluated.

The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism.

BACKGROUND: The Pulmonary Embolism Rule-out Criteria (PERC) rule is a clinical diagnostic rule designed to exclude pulmonary embolism (PE) without further testing. We sought to externally validate the diagnostic performance of the PERC rule alone and combined with clinical probability assessment based on the revised Geneva score. METHODS: The PERC rule was applied retrospectively to consecutive patients who presented with a clinical suspicion of PE to six emergency departments, and who were enrolled in a randomized trial of PE diagnosis. Patients who met all eight PERC criteria [PERC((-))] were considered to be at a very low risk for PE. We calculated the prevalence of PE among PERC((-)) patients according to their clinical pretest probability of PE. We estimated the negative likelihood ratio of the PERC rule to predict PE. RESULTS: Among 1675 patients, the prevalence of PE was 21.3%. Overall, 13.2% of patients were PERC((-)). The prevalence of PE was 5.4% [95% confidence interval (CI): 3.1-9.3%] among PERC((-)) patients overall and 6.4% (95% CI: 3.7-10.8%) among those PERC((-)) patients with a low clinical pretest probability of PE. The PERC rule had a negative likelihood ratio of 0.21 (95% CI: 0.12-0.38) [corrected] for predicting PE overall, and 0.63 (95% CI: 0.38-1.06) in low-risk patients. CONCLUSIONS: Our results suggest that the PERC rule alone or even when combined with the revised Geneva score cannot safely identify very low risk patients in whom PE can be ruled out without additional testing, at least in populations with a relatively high prevalence of PE.

Volumetric or time-based capnography for excluding pulmonary embolism in outpatients?

BACKGROUND: Volumetric capnography is technically more demanding but theoretically better than the time-based alveolar deadspace fraction (P(a)CO(2) - EtCO(2))/P(a)CO(2) as a bedside diagnostic tool for excluding pulmonary embolism (PE) in outpatients. OBJECTIVE: We compared both diagnostic accuracy in patients with a suspected PE and positive D-dimer enzyme-linked immunosorbent assay results. PATIENTS AND METHODS: In this clinical multicenter trial with prospective inclusion and 3-month follow-up, alveolar deadspace fraction was compared by receiver operating characteristic (ROC) analysis with other parameters derived from volumetric capnography. RESULTS: Capnography was performed in 239 patients, and 205 tests (86%) were conclusive. The incidence of PE was 33%. The alveolar deadspace fraction accuracy expressed with ROC curve analysis was 0.73 +/- 0.04. The diagnostic performances of parameters from volumetric capnography were not significantly better. Sixteen per cent [95% confidence interval (CI) 12-21%] of patients presented a (P(a)CO(2) - EtCO(2))/P(a)CO(2) ratio under the cut-off value of 0.15, with a low clinical probability. This combination excluded PE, with a sensitivity of 96% (95% CI 89-99%) and a negative likelihood ratio of 0.17 (95% CI 0.09-0.33%). CONCLUSION: Volumetric capnography failed to show superiority to alveolar deadspace fraction measurements [(P(a)CO(2) - EtCO(2))/P(a)CO(2)] for exclusion of PE in outpatients with positive D-dimer test results. Future studies should clarify the safety of excluding PE in patients combining low clinical probability with positive D-dimer results and (P(a)CO(2) - EtCO(2))/P(a)CO(2) ratios below the cut-off value of 0.15.

Complete venous ultrasound in outpatients with suspected pulmonary embolism.

BACKGROUND: Compression ultrasonography (US) confined to the proximal veins is usually performed to detect deep vein thrombosis (DVT) in patients with suspected pulmonary embolism (PE). Recent studies suggested a limited yield of proximal US when multislice computed tomography (MSCT) was used. OBJECTIVES: To assess whether performing an additional distal vein US would increase the diagnostic yield of the test. PATIENTS AND METHODS: Data of 855 consecutive outpatients included in a multicenter randomized controlled trial were analyzed. Patients were investigated by a sequential diagnostic strategy including clinical probability assessment, D-dimer measurement, proximal US and MSCT. Proximal US was completed by an examination of the distal veins, the result of which was not disclosed to the physician in charge of the patient. RESULTS: US was positive in 21% of patients, of whom 10% (53/541) had proximal DVT and 11% (59/541) isolated distal DVT. Of the 59 patients with distal DVT, 21 (36%) had no PE on MSCT. Twenty of those 21 patients were not given anticoagulant therapy and had an uneventful follow-up. The diagnostic performance of distal US for the diagnosis of PE was as follows: sensitivity 22% [95% confidence interval (CI) 17-29]; specificity 94% (95% CI 91-96); positive likelihood ratio 3.9 (95% CI 2.4-6.4). CONCLUSIONS: In patients with suspected PE, distal US has limited diagnostic performance, and its additional use only modestly increases the yield of US. Moreover, it carries a high false-positive rate, impeding the use of distal US as a confirmatory test for PE.

Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multicenter prospective study.

BACKGROUND: Troponins (cTnI and cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP), myoglobin, heart-type fatty acid-binding protein (H-FABP) and fibrin D-Dimer are emergent candidates for risk stratification in pulmonary embolism (PE). OBJECTIVE: To compare the respective prognostic values of biomarker with non-massive PE to predict an adverse outcome at 3 months. PATIENTS/METHODS: One hundred and forty-six consecutive patients with non-massive PE were included in this multicenter prospective study. The combined outcome consisted of intensive care monitoring on admission, death or hospitalization attributable to either a PE-related complication [defined by PE/deep vein thrombosis (DVT) relapse or major bleeding under anticoagulation] or to dyspnoea with or without chest pain during follow-up. RESULTS: The outcome was met in 12% of patients. In univariate analysis, a NT-proBNP level above 300 pg/ml was the strongest predictor of unfavorable outcome with an odds ratio (OR) of 15.8 [95% confidence interval (CI): 2.05-122). ORs for the other variables were: 8.0 for D-dimer >2000 ng/ml (95% CI: 1.1-64), 4.7 for H-FABP >6 ng/ml (95% CI:1.5-14.8), 3.5 for cTnI >0.09 ng/ml (95% CI:1.2-9.7), 3.4 for myoglobin >70 ng/ml (95% CI:0.9-12.2). Receiver operating curve (ROC) analysis indicated that NT-proBNP was the best predictor [area under the curve (AUC) 0.84; 95%CI: 0.76-0.92; P < 0.0001] with a negative predictive value of 100% (95% CI: 91-100) at 300 pg/ml. At that cut-off, the true negative rate for NT-proBNP was 40%. In multivariate analysis, NT-proBNP was the only significant independent predictors. CONCLUSIONS: NT-proBNP appears to be a good risk stratification marker in identifying low-risk patients with non-massive PE who could be treated in an outpatient setting.

Non-heart-beating donor, 10-year experience in a Belgian transplant center.

All over the world, transplant teams are looking for ways to increase and improve the donor pool. Non-heart-beating donation may increase the number of donors, even if some technical, logistical, and emotional problems are still encountered. The results obtained by our team should stimulate other centers to implement this kind of donation in their hospitals. Herein we have described our experience with non-heart-beating donation.

[Traumatic perforation of the sigmoid colon: role of computed tomography]. / Perforation sigmoïdienne traumatique: intérêt du bilan tomodensitométrique.

The authors report a case of a delayed traumatic perforation of the sigmoid colon, presenting three days after a motor vehicle accident. A review of the literature is presented.

Non-heart-beating donor, renewal of an old procedure: a Belgian experience.

The shortage of donated organs has become a problem in transplantation throughout the world. Transplant teams are looking for other ways to increase and improve the donor pool. Non-heart-beating donation may be a source to increase the number of donors, even if some technical, logistical, and emotional problems are encountered. The results obtained by our team should stimulate other centers to implement this kind of donation in their hospitals. We describe our experience in the policy of non-heart-beating donation and encourage transplant centers to develop such a program.

PaCO(2)/ETCO(2) gradient: early indicator of thrombolysis efficacy in a massive pulmonary embolism.

End tidal CO(2) measurement may be helpful in detecting the efficacy of thrombolysis after a massive pulmonary embolism. We report the case of a 76-year-old man with a massive pulmonary embolism, who required early intubation and mechanical ventilation. Thrombolysis with rtpA (total dosage: 60 mg) was initiated. During this procedure, clinical data, arterial blood gases and end-tidal CO(2) with a capnograph were recorded. Before thrombolysis the P(a-ET)CO(2) gradient was raised to 25 mmHg. During thrombolysis, the clinical data improved and the P(a-ET) gradient fell to 14 mmHg. We postulate that the P(a-ET)CO(2) gradient seems to be a reasonable indicator of efficacy of thrombolysis in this setting. However, the gradient did not return to normal values (4-5 mmHg). The possible reasons for this may be that during mechanical ventilation there was a large ventilation-perfusion ratio and the cardiac output may have still reduced. With these limitations, we conclude that the P(a-ET)CO(2) gradient should be evaluated as an indicator of pulmonary reperfusion in massive pulmonary embolism.

Poststreptococcal reactive arthritis: a form of acute rheumatic fever in adulthood.

We report the case of a middle-aged woman suffering from a relapsing sterile inflammatory arthritis preceded by a streptococcal infection. This observation suggests that streptococcal infection may need to be included in the list of infections known to precipitate reactive arthritis. The clinical presentation of poststreptococcal arthritis in adulthood and its relationship to acute rheumatic fever is discussed.

Fast Fourier imaging.

A new NMR imaging technique, aiming at a reduction of the data acquisition time, is described in detail. The method is applicable in all multidimensional imaging situations where at least one spatial coordinate is resolved. Discussed at some length are the point-spread function, the required bandwidth of the NMR spectrometer, and the sampling strategy used to diminish the loss in signal-to-noise ratio. Experiments reveal that a reduction of the data acquisition time by at least a factor of four is attainable in practice.