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1.
Rev. clín. esp. (Ed. impr.) ; 220(2): 126-134, mar. 2020. ilus, graf
Artículo en Español | IBECS | ID: ibc-186426

RESUMEN

La ecografía clínica se ha desarrollado exponencialmente en la última década en distintos ámbitos de la medicina. De igual manera que ha ocurrido en otros campos de actuación de la medicina interna, su uso se ha implantado en la enfermedad tromboembólica venosa, tanto en la trombosis venosa profunda como en la embolia pulmonar. En esta revisión se repasan las técnicas para el diagnóstico, tanto de la trombosis venosa profunda a través de la ultrasonografía por compresión, como de la ecografía multiórgano que incluye la ultrasonografía por compresión, la ecografía pulmonar en busca de infartos pulmonares y la ecocardioscopia para la detección de dilatación y/o disfunción del ventrículo derecho, para el diagnóstico de la embolia pulmonar. Además, se plantean los escenarios clínicos más frecuentes en los que puede ser de ayuda la ecografía clínica en la vida real, así como sus limitaciones y la evidencia existente


The use of clinical ultrasonography has grown exponentially in the past decade in various medical settings. As with other areas of activity in the field of internal medicine, clinical ultrasonography has been implemented in venous thromboembolism disease, both in deep vein thrombosis and pulmonary embolism. In this review, we cover the diagnostic techniques, both for deep vein thrombosis through compression ultrasonography and for multiorgan ultrasonography, which include compression ultrasonography, pulmonary ultrasonography in the search for pulmonary infarctions and echocardiography for detecting dilation and right ventricular dysfunction for the diagnosis of pulmonary embolism. We also establish the most common clinical scenarios in which clinical ultrasonography can be of assistance in actual clinical practice, as well as its limitations and current evidence


Asunto(s)
Humanos , Ultrasonografía/métodos , Tromboembolia Venosa/diagnóstico por imagen , Trombosis de la Vena/diagnóstico por imagen , Embolia Pulmonar/diagnóstico por imagen , Endosonografía/métodos , Tratamiento de Urgencia/métodos , Sensibilidad y Especificidad , Ultrasonografía Doppler en Color/métodos
2.
Am Surg ; 86(2): 104-109, 2020 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-32167051

RESUMEN

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study-after adjusting for covariates related to patient demographics, injury, and procedures-there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVT after adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.


Asunto(s)
Enfermedades Asintomáticas , Embolia Pulmonar/diagnóstico por imagen , Tromboembolia Venosa/diagnóstico por imagen , Trombosis de la Vena/diagnóstico por imagen , Heridas y Traumatismos/complicaciones , Femenino , Humanos , Tiempo de Internación , Modelos Logísticos , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/diagnóstico por imagen , Masculino , Oportunidad Relativa , Embolia Pulmonar/complicaciones , Embolia Pulmonar/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Ultrasonografía Doppler Dúplex/estadística & datos numéricos , Tromboembolia Venosa/complicaciones , Trombosis de la Vena/complicaciones
5.
Br J Radiol ; 93(1108): 20190635, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-31944831

RESUMEN

The clinical diagnosis of pulmonary embolism is often difficult, as symptoms range from syncope and chest pain to shock and sudden death. Adding complexity to this picture, some patients with non-diagnosed pulmonary embolism may undergo unenhanced imaging examinations for a number of reasons, including the prevention of contrast medium-related nephrotoxicity, anaphylactic/anaphylactoid reactions and nephrogenic systemic fibrosis, as well as due to patients' refusal or lack of venous access. In this context, radiologists' awareness and recognition of indirect signs are cornerstones in the diagnosis of pulmonary embolism. This article describes the indirect signs of pulmonary embolism on chest X-ray, unenhanced CT, and MRI.


Asunto(s)
Imagen por Resonancia Magnética/métodos , Imagen Multimodal/métodos , Embolia Pulmonar/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Diagnóstico Diferencial , Humanos , Hallazgos Incidentales , Enfermedades Pulmonares/diagnóstico por imagen , Arteria Pulmonar/diagnóstico por imagen , Infarto Pulmonar/diagnóstico por imagen , Trombosis/diagnóstico por imagen
6.
Radiol Med ; 125(2): 137-144, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31659676

RESUMEN

OBJECTIVES: To retrospectively compare semi-qualitative and quantitative CT pulmonary angiography (CTPAs) image metrics testing diagnostic performance between protocols performed by 20 or 40 ml of contrast medium (CM) in patients with suspected pulmonary embolism (PE). METHODS: A total of 102 CTPAs performed by 20 ml (ultra-low volume: ULV) and 74 CTPAs performed by 40 ml (low volume: LV) protocol for the diagnosis of clinically suspected PE performed between October 2012 and September 2013 were retrieved. High-concentration CM (Iomeprol 400 mgI/ml) was injected at 3 ml/s (iodine delivery rate 1.2 mgI/s). Two radiologists (blinded and independent) semi-qualitatively scored vascular enhancement and image noise according to a five-point visual scoring system. Quantitative analysis was performed by regions of interest quantifying densitometric parameters, such as central and peripheral pulmonary arteries vascular contrast enhancement (CE, threshold for diagnostic CE ≥ 250 HU), and metrics for image noise. Continuous variables were compared by the Student's t test between groups if normally distributed while categorical variables were analyzed with the Chi-squared test. Interobserver agreement was calculated by the weighted kappa test; correlation coefficients were calculated using Pearson's correlation tests. RESULTS: The semi-qualitative scores for central and peripheral pulmonary arteries vascular CE were sufficient by ULV, yet inferior than LV (p < 0.001). Semi-qualitative image noise was comparable between ULV and LV, and the interobserver agreement was only fair for quality of peripheral vessels. Agreement on nondiagnostic semi-qualitative parameters was seen in 9/102 (8.8%) ULV CTPAs, in particular associated with massive PE (2/9), pleuro-pulmonary abnormalities (5/9) or without major abnormalities (2/9). Quantitative analysis showed that mean CE was lower in ULV group (p < 0.001), though greater than the diagnostic threshold of 250 HU in both groups. CONCLUSIONS: Diagnostic vascular CE (> 250 HU) was obtained in both 20 ml and 40 ml CTPAs. CTPA by 20 ml of CM rendered diagnostic CE for the assessment of pulmonary arteries in patients with clinical suspicion of acute PE. Decreased image quality was mostly associated with massive PE or concomitant pleuro-parenchymal abnormalities.


Asunto(s)
Protocolos Clínicos , Angiografía por Tomografía Computarizada/métodos , Medios de Contraste/administración & dosificación , Servicio de Urgencia en Hospital , Yopamidol/análogos & derivados , Embolia Pulmonar/diagnóstico por imagen , Anciano , Femenino , Humanos , Yopamidol/administración & dosificación , Masculino , Estudios Retrospectivos
7.
Vasc Endovascular Surg ; 54(2): 135-140, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31769352

RESUMEN

PURPOSE: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis (USAT) appears to provide promising results for the management of acute submassive pulmonary embolisms (ASMPEs) at tertiary care centers. This study assessed outcome measures at a community-based hospital systems and compared results to known studies. MATERIALS AND METHODS: This is a single-center, retrospective study assessing clinical outcomes of the EkoSonic Endovascular System intervention for ASMPEs performed by three surgical 3 subspecialties (interventional radiology, interventional cardiology, and vascular surgery) part of a pulmonary embolism response team (PERT). We reviewed 146 PERT activations from June 2013 to December 2017. Eighty-three patients with ASMPEs underwent USAT. RESULTS: Our study showed greater differences (P = .01) between baseline and follow-up pulmonary artery systolic pressures (20.9 ± 9.8 mm Hg [n = 14]) compared to the ULTIMA study (12.3 ± 10 mm Hg [n = 30]). Our length-of-stay measures were shorter (6.1 ± 5.1 [n = 83]; P = .0001) compared to the SEATTLE II study (8.8 ± 5.0 [n = 150]). Preprocedure transthoracic echocardiograms (TTEs) were performed for 54 (65%) of 83 patients. Postprocedure TTEs at 48 hours was performed for 52 (62%) of 83 patients. Use of TTEs before and after intervention did not change outcomes. Intracranial hemorrhage was not observed in our patient population. There was no difference in outcomes between the three subspecialties in our study. CONCLUSIONS: Use of USAT in a community-based hospital PERT has similar outcomes to tertiary care centers. Furthermore, similar outcomes were observed between the three subspecialties suggesting development of a comprehensive care team for management of ASMPEs.


Asunto(s)
Cateterismo Periférico , Fibrinolíticos/administración & dosificación , Hospitales Comunitarios , Embolia Pulmonar/terapia , Terapia Trombolítica/métodos , Terapia por Ultrasonido , Enfermedad Aguda , Adulto , Anciano , Cardiólogos , Cateterismo Periférico/efectos adversos , Femenino , Fibrinolíticos/efectos adversos , Humanos , Infusiones Intraarteriales , Masculino , Michigan , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/fisiopatología , Radiólogos , Estudios Retrospectivos , Especialización , Cirujanos , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Terapia por Ultrasonido/efectos adversos
8.
Clin Nucl Med ; 45(1): 90-91, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31789915

RESUMEN

A 64-year-old woman with a history of cirrhosis and progressive difficulty breathing underwent pulmonary ventilation/perfusion SPECT to evaluate possible pulmonary embolism. The images demonstrated multiple mismatched ventilation/perfusion defects in both lungs, suggesting pulmonary embolism. However, there was also Tc-MAA radioactivity in the brain and bilateral kidney, with a right-to-left shunting rate of 8.8%. In addition, CT pulmonary angiography did not demonstrate embolus. The findings indicated that perfusion defects were caused by hepatopulmonary syndrome.


Asunto(s)
Síndrome Hepatopulmonar/diagnóstico por imagen , Embolia Pulmonar/diagnóstico por imagen , Tomografía Computarizada por Tomografía Computarizada de Emisión de Fotón Único , Angiografía , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana Edad , Radiofármacos , Compuestos de Sulfhidrilo , Agregado de Albúmina Marcado con Tecnecio Tc 99m
9.
Vasc Endovascular Surg ; 54(1): 58-64, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31500542

RESUMEN

A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Their presentation, hospital courses, complications, and follow-up are reviewed. All 5 patients were diagnosed using chest computed tomography (CT) demonstrating a clot in the pulmonary vasculature and right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV) ratio. Patients with severe right heart dysfunction (RV/LV ratio ≥1.4) were protocolized to receive CDT via EkoSonic catheters (EKOS Corporation). Postoperatively, patients were admitted to the ICU with continuous alteplase at 1 mg/h. Echocardiography was then performed after 24 hours of therapy to assess right ventricle function and removal of EkoSonic catheters. Patients with reversal of right heart dysfunction and symptomatic improvement received bedside removal of catheters. The mean patient age was 50.6 years and body mass index was 33.6. Mean RV/LV ratio on admission via CT imaging was 1.56, with a mean troponin of 0.44. Interval mean RV/LV ratio on echocardiography after thrombolysis therapy was 0.91. There was a 0% incidence of periprocedural complications. One (20%) patient out of 5 had an emergency department visit 10 days postdischarge for acute shortness of breath, with workup revealing no evidence of recurrent PE. No patient required hospital readmission within 30 days. At the 6-week follow-up, all patients had continued normal right ventricular function noted on echocardiography. This case series demonstrates that for a select population of patients with severe submassive PE, the use of CDT and echocardiography monitoring can facilitate same-day discharge from the ICU.


Asunto(s)
Fibrinolíticos/administración & dosificación , Unidades de Cuidados Intensivos , Tiempo de Internación , Alta del Paciente , Embolia Pulmonar/tratamiento farmacológico , Terapia Trombolítica/métodos , Adulto , Ecocardiografía , Femenino , Fibrinolíticos/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Sistema de Registros , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/instrumentación , Factores de Tiempo , Resultado del Tratamiento , Dispositivos de Acceso Vascular
10.
Radiol Clin North Am ; 58(1): 93-103, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31731905

RESUMEN

This article describes an approach to analyzing the distribution of intravenous contrast on chest computed tomography and illustrates the various pathologies and pitfalls that may be encountered by the imager, especially in the hospitalized patient. Understanding normal and abnormal distribution of intravenous contrast can be used as a clue to detect alterations in physiology and flow.


Asunto(s)
Medios de Contraste , Cardiopatías/diagnóstico por imagen , Pacientes Internos , Embolia Pulmonar/diagnóstico por imagen , Intensificación de Imagen Radiográfica , Tomografía Computarizada por Rayos X/métodos , Corazón/diagnóstico por imagen , Hospitalización , Humanos , Pulmón/diagnóstico por imagen , Radiografía Torácica/métodos
11.
Braz J Cardiovasc Surg ; 34(6): 783-787, 2020 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-31793258

RESUMEN

Pulmonary endarterectomy is a curative procedure for chronic thromboembolic Pulmonary Hypertension. As usual, cardiopulmonary bypass circuit is required. However, there are several complications attributed to extracorporeal circulation. Hemodilution, systemic inflammatory response syndrome and leukocyte sequestration are circulation related complications. The severe forms include Acute Respiratory Distress Syndrome, Acute Lung Injury, myocardial stunning, dysfunction of the right ventricle, coagulopathy, postoperative stroke or renal dysfunction. In this case report, we aimed to give information about perioperative anesthesia and surgical management of pulmonary endarterectomy which was successfully managed without Cardiopulmonary Bypass.


Asunto(s)
Anestesia/métodos , Endarterectomía , Embolia Pulmonar/cirugía , Humanos , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/fisiopatología , Tomografía Computarizada por Rayos X
12.
Radiol Med ; 125(3): 265-271, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31863358

RESUMEN

PURPOSE: To investigate whether the increased obstruction of the pulmonary arteries was associated with reduced pulmonary vein areas in acute pulmonary embolism (APE). METHOD: We retrospectively analyzed a consecutive series of computed tomography pulmonary angiography studies of 107 patients with APE and 101 controls without APE between November 2010 and January 2019. The control and patient groups were compared with each other for differences between the mean cross-sectional areas of pulmonary veins. Further analysis was conducted by dividing the patient group into high-risk patients (≥ 20%) and low-risk patients (< 20%) according to the pulmonary arterial obstruction index. The mean cross-sectional area of the pulmonary veins in these two groups was compared. RESULTS: The mean cross-sectional areas of the 4 pulmonary veins at the ostium level (CSAPV) were significantly lower for the patient group (mean: 102.6 mm2) compared with the control group (111.8 mm2) (p < 0.001). CSAPV cutoff value for determining the diagnosis of APE that maximized the accuracy was 109.12 mm2 (AUC = 0.721; 95% CI 0.649-0.794); its sensitivity and specificity were 78.2% and 69.2%, respectively. CSAPV cutoff value for differentiating high-risk APE that maximized the accuracy was 102.6 mm2 (AUC = 0.634; 95% CI 0.525-0.743); its sensitivity and specificity were 61.9% and 53.8%, respectively. CONCLUSIONS: There is a negative correlation between the CSAPV and thrombotic material burden in the pulmonary arteries of patients with APE. Hence, the CSAPV can be used as a diagnostic tool in the evaluation of the presence and severity of pulmonary embolism.


Asunto(s)
Arteria Pulmonar/diagnóstico por imagen , Embolia Pulmonar/diagnóstico por imagen , Venas Pulmonares/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Angiografía por Tomografía Computarizada/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Curva ROC , Estudios Retrospectivos , Sensibilidad y Especificidad , Adulto Joven
13.
Clín. investig. ginecol. obstet. (Ed. impr.) ; 46(4): 159-162, oct.-dic. 2019. ilus
Artículo en Español | IBECS | ID: ibc-184304

RESUMEN

La hipertensión pulmonar es una enfermedad compleja, grave y de baja incidencia. Es un estado hemodinámicamente patológico con una presión de arteria pulmonar que supera los 25 mmHg. La presencia de hipertensión pulmonar en el puerperio es poco frecuente y conlleva un alto riesgo para la madre. Se presenta el caso de una mujer de 31 años en puerperio mediato patológico post parto eutócico con datos de bajo gasto cardiaco. El ecocardiograma demostró la presión de la arteria pulmonar que iguala a la sistémica. La angiotomografía helicoidal de tórax descarta tromboembolismo pulmonar, y se realiza diagnóstico de hipertensión de la arteria pulmonar de etiología desconocida


Pulmonary hypertension is a complex, serious and low incidence disease. It is a haemodynamically pathological state with a pulmonary artery pressure that exceeds 25 mmHg. The presence of pulmonary hypertension in the puerperium is rare, and carries a high risk to the mother. The case is presented of a 31 year-old female in the subacute postpartum period of a normal delivery with data of low cardiac output. The echocardiogram showed that the pressure of the pulmonary artery was equal to the systemic. A thoracic helical angio-tomography ruled out pulmonary thromboembolism, making a diagnosis of pulmonary artery hypertension of unknown aetiology


Asunto(s)
Humanos , Femenino , Adulto , Hipertensión Pulmonar/etiología , Periodo Posparto , Embolia Pulmonar/diagnóstico por imagen , Hipertensión/etiología , Embolia Pulmonar/complicaciones , Radiografía Torácica/métodos , Gasto Cardíaco
14.
Medicine (Baltimore) ; 98(48): e17953, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31770203

RESUMEN

Chronic thromboembolic pulmonary hypertension (CTEPH), a late complication of pulmonary embolism (PE), is associated with high mortality. However, whether the right ventricular (RV) echocardiographic parameters can predict - in the short- and long-term - the development of CTEPH and mortality after PE remains unknown. Herein, we aim to investigate the incidence of CTEPH after acute PE and to evaluate the risk factors of CTEPH. In this retrospective cohort, patients with PE were followed for 10 years for the onset of CTEPH. The screening was initially conducted through echocardiography and confirmed by right heart catheterization. Also, transient and permanent risk factors were identified. Among 358 patients with PE, 8 patients (4%) were subsequently diagnosed with CTEPH at a median time of 36 months and 47 died during the follow-up period. Notably, both short- and long-term RV dilatation, hypertrophy, and increased pulmonary pressure increased the incidence of CTEPH. However, RV echocardiographic parameters failed to differentiate survivors from non-survivors. Instead, malignancy, respiratory, or chronic heart failure was strongly associated with post PE mortality in the multivariable analysis. According to our findings, post PE screening of CTEPH may facilitate early diagnosis and intervention for patients at high risk of developing CTEPH. Also, RV echocardiographic parameters are associated with subsequent CTEPH, but mortality is mainly dependent on underlying comorbidities.


Asunto(s)
Ecocardiografía/estadística & datos numéricos , Hipertensión Pulmonar/diagnóstico por imagen , Embolia Pulmonar/mortalidad , Disfunción Ventricular Derecha/diagnóstico por imagen , Anciano , Enfermedad Crónica , Femenino , Humanos , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/mortalidad , Incidencia , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico por imagen , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Disfunción Ventricular Derecha/complicaciones , Disfunción Ventricular Derecha/mortalidad
15.
J Cardiothorac Surg ; 14(1): 196, 2019 Nov 12.
Artículo en Inglés | MEDLINE | ID: mdl-31718656

RESUMEN

BACKGROUND: Primary thrombosis of the pulmonary vasculatures without extra-pulmonary sources of embolism are uncommon. Here, we report 2 cases of thrombosis of the stump of the remnant pulmonary vasculatures after lung resection complicated by embolic events with review of the literature. CASE PRESENTATION: A 75-year-old female was consulted to evaluate cardiac source of embolism for acute cerebral infarction. The patient underwent left upper lobectomy because of lung cancer 2 years ago. Cardiovascular imaging revealed about 1.6 cm × 1.4 cm sized thrombus within the remnant stump of the left superior pulmonary vein. The patient was treated by anticoagulation with warfarin, because the patients refused surgical removal of thrombus. A 57-year-old female who had a history of right pneumonectomy 10 years ago presented with dyspnea. Cardiovascular imaging revealed 1.7 × 1.5 cm sized thrombus in the right pulmonary artery stump and small pulmonary embolism in the left lower segmental pulmonary artery. The patient was treated by long-term anticoagulation with warfarin, and the thrombus and pulmonary embolism were resolved. CONCLUSION: The present cases demonstrated that very late thrombosis of the remnant pulmonary vascular structures and subsequent fatal embolic complications can develope even several years later after lung resection. Therefore, the dead space of the remnant vascular structures should be minimized during lung resection surgery, and the developement of delayed thromboembolic complications associated with vascular stump thrombosis should be carefully monitored.


Asunto(s)
Neoplasias Pulmonares/cirugía , Neumonectomía/efectos adversos , Embolia Pulmonar/etiología , Venas Pulmonares/diagnóstico por imagen , Trombosis de la Vena/etiología , Anciano , Infarto Encefálico/etiología , Disnea/etiología , Femenino , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/cirugía , Embolia Pulmonar/diagnóstico por imagen , Venas Pulmonares/cirugía , Tomografía Computarizada por Rayos X , Trombosis de la Vena/diagnóstico por imagen
16.
N Engl J Med ; 381(22): 2125-2134, 2019 11 28.
Artículo en Inglés | MEDLINE | ID: mdl-31774957

RESUMEN

BACKGROUND: Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP. METHODS: We performed a prospective study in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for 3 months to detect venous thromboembolism. RESULTS: A total of 2017 patients were enrolled and evaluated, of whom 7.4% had pulmonary embolism on initial diagnostic testing. Of the 1325 patients who had a low C-PTP (1285 patients) or moderate C-PTP (40 patients) and a negative d-dimer test (i.e., <1000 or <500 ng per milliliter, respectively), none had venous thromboembolism during follow-up (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%). Of all 1863 patients who did not receive a diagnosis of pulmonary embolism initially and did not receive anticoagulant therapy, 1 patient (0.05%; 95% CI, 0.01 to 0.30) had venous thromboembolism. Our diagnostic strategy resulted in the use of chest imaging in 34.3% of patients, whereas a strategy in which pulmonary embolism is considered to be ruled out with a low C-PTP and a d-dimer level of less than 500 ng per milliliter would result in the use of chest imaging in 51.9% (difference, -17.6 percentage points; 95% CI, -19.2 to -15.9). CONCLUSIONS: A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up. (Funded by the Canadian Institutes of Health Research and others; PEGeD ClinicalTrials.gov number, NCT02483442.).


Asunto(s)
Angiografía por Tomografía Computarizada , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Embolia Pulmonar/sangre , Embolia Pulmonar/diagnóstico , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Probabilidad , Estudios Prospectivos , Embolia Pulmonar/diagnóstico por imagen
17.
Medicine (Baltimore) ; 98(38): e17219, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31567979

RESUMEN

RATIONALE: Retained placenta accreta is an increasing obstetric problem in recent years, and pulmonary embolism (PE) during pregnancy and the postpartum period is a vital condition, but lack of standard therapy guidelines. This report describes a case of postpartum PE combined with retained placenta accreta. PATIENT CONCERNS: A 27-year-old woman presenting with fever and dyspnea after delivery was admitted to our hospital with retained placenta accreta. DIAGNOSES: The patient was diagnosed with the infection, postpartum PE, and residual placenta. INTERVENTIONS: The antibiotics and low molecular weight heparin were initially started to cure the infection and control PE. Mifepristone was then used to promote the necrosis of residual placenta while long-term use of warfarin was served as continuous anticoagulant therapy. Hysteroscopic resection of retained placenta was not performed until thrombi had been almost disappeared after more than 2 months of anticoagulation therapy. OUTCOMES: The patient's menstruation returned to normal within several weeks after hysteroscopic resection and she completely recovered from PE after 3 months of anticoagulant therapy. LESSONS: Treatment of retained placenta accreta can be postponed when encountering complicated cases, such as postpartum PE. PE in perinatal stage can be managed referring to nonmaternal PE.


Asunto(s)
Placenta Accreta/terapia , Retención de la Placenta/terapia , Periodo Posparto , Embolia Pulmonar/terapia , Adulto , Femenino , Humanos , Placenta Accreta/diagnóstico , Retención de la Placenta/diagnóstico , Embarazo , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/etiología , Tomografía Computarizada por Rayos X
18.
Zhonghua Jie He He Hu Xi Za Zhi ; 42(10): 755-759, 2019 Oct 12.
Artículo en Chino | MEDLINE | ID: mdl-31594109

RESUMEN

Objective: To analyze the clinical characteristics of pulmonary embolism patients from different altitudes in plateau areas. Methods: A retrospective cross-sectional study was used to analyze the patients with acute pulmonary embolism diagnosed definitely by pulmonary angiography or pulmonary artery CT angiography admitted to Tibet Autonomous Region People's Hospital from August 2014 to December 2018. The subjects were divided into 3 groups according to the altitude of long-term residence before onset, i.e. low-altitude group (group 1, 2 700 m ≤ altitude ≤3 700 m, n=44), medium-altitude group (group 2, 3 700 m

Asunto(s)
Altitud , Arteria Pulmonar/diagnóstico por imagen , Embolia Pulmonar/diagnóstico por imagen , Dolor en el Pecho/epidemiología , China/epidemiología , Angiografía por Tomografía Computarizada , Estudios Transversales , Disnea/epidemiología , Humanos , Hipoxia , Incidencia , Embolia Pulmonar/epidemiología , Estudios Retrospectivos
19.
Br J Radiol ; 92(1104): 20190526, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31595778

RESUMEN

OBJECTIVE: Unsuspected pulmonary embolism (UPE) has been increasingly diagnosed as an incidental finding on CT scans for routine staging in cancer patients. Previous studies suggest that obesity is an independent risk factor for venous thromboembolism in patients with malignant tumors. In this study, we aimed to investigate the association between abdominal adipose tissue, especially visceral adipose tissue (VAT) and the occurrence of UPE in hospitalized patients with gastrointestinal cancer. METHODS: Routine contrast-enhanced chest and abdominal CT scans of 1974 patients were retrospectively assessed for the presence of UPE, of which 58 patients were identified with UPE and 108 non-UPE patients were selected as the non-UPE control group based on several matching criteria. Abdominal adipose tissue was measured by volumes of VAT and subcutaneous adipose tissue (SAT) at the navel level. RESULTS: VAT, SAT, indwelling venous catheters, surgery, chemotherapy, and bed rest or immobilization were associated with the occurrence of UPE. Higher VAT volumes were associated with increased risk of UPE (odds ratio: 1.96; 95% confidence interval: 1.25, 3.06; p = 0.003) adjusting body mass index (BMI), bed rest or immobilization, surgery, chemotherapy and smoking, while SAT was not associated with UPE adjusting the same confounders (p = 0.117). No statistical association was found between BMI and UPE (p = 0.102). CONCLUSION: Higher VAT rather than SAT is associated with an increased risk of unsuspected pulmonary embolism on routine CT scans in hospitalized gastrointestinal cancer patients. ADVANCES IN KNOWLEDGE: Our findings indicate that VAT is a stronger risk factor for unsuspected pulmonary embolism than BMI and SAT in hospitalized patients with gastrointestinal cancer.


Asunto(s)
Embolia Grasa/etiología , Grasa Intraabdominal/diagnóstico por imagen , Embolia Pulmonar/etiología , Grasa Subcutánea Abdominal/diagnóstico por imagen , Anciano , Reposo en Cama/efectos adversos , Índice de Masa Corporal , Estudios de Casos y Controles , Catéteres de Permanencia/efectos adversos , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/complicaciones , Embolia Grasa/diagnóstico por imagen , Femenino , Neoplasias Gastrointestinales , Humanos , Inmovilización/efectos adversos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Embolia Pulmonar/diagnóstico por imagen , Estudios Retrospectivos , Factores de Riesgo
20.
Trans Am Clin Climatol Assoc ; 130: 60-70, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31516165

RESUMEN

The main focus of this study is bridging the "evidence gap" between frontline decision-making in health care and the actual evidence, with the hope of reducing unnecessary diagnostic testing and treatments. From our work in pulmonary embolism (PE) and over ordering of computed tomography pulmonary angiography, we integrated the highly validated Wells' criteria into the electronic health record at two of our major academic tertiary hospitals. The Wells' clinical decision support tool triggered for patients being evaluated for PE and therefore determined a patients' pretest probability for having a PE. There were 12,759 patient visits representing 11,836 patients, 51% had no D-dimer, 41% had a negative D-dimer, and 9% had a positive D-dimer. Our study gave us an opportunity to determine which patients were very low probabilities for PE, with no need for further testing.


Asunto(s)
Sistemas de Apoyo a Decisiones Clínicas , Medicina Basada en la Evidencia , Costos de la Atención en Salud , Pautas de la Práctica en Medicina , Brechas de la Práctica Profesional , Embolia Pulmonar/diagnóstico , Centros Médicos Académicos , Angiografía por Tomografía Computarizada/economía , Angiografía por Tomografía Computarizada/métodos , Servicio de Urgencia en Hospital , Productos de Degradación de Fibrina-Fibrinógeno/metabolismo , Humanos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/metabolismo , Estudios Retrospectivos
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