Retrospective analysis of the diagnostic accuracy of lung ultrasound for pulmonary embolism in patients with and without pleuritic chest pain.

BACKGROUND: Lung ultrasound (LUS) has a role in the diagnosis of pulmonary embolism (PE) mainly based on the visualization of pulmonary infarctions. However, examining the whole chest to detect small peripheral infarctions by LUS may be challenging. Pleuritic pain, a frequent presenting symptom in patients with PE, is usually localized in a restricted chest area identified by the patient itself. Our hypothesis is that sensitivity of LUS for PE in patients with pleuritic chest pain may be higher due to the possibility of focusing the examination in the painful area. We combined data from three prospective studies on LUS in patients suspected of PE and extracted data regarding patients with and without pleuritic pain at presentation to compare the performances of LUS. RESULTS: Out of 872 patients suspected of PE, 217 (24.9%) presented with pleuritic pain and 279 patients (32%) were diagnosed with PE. Pooled sensitivity of LUS for PE in patients with and without pleuritic chest pain was 81.5% (95% CI 70-90.1%) and 49.5% (95% CI 42.7-56.4%) (p < 0.001), respectively. Specificity of LUS was similar in the two groups, respectively 95.4% (95% CI 90.7-98.1%) and 94.8% (95% CI 92.3-97.7%) (p = 0.86). In patients with pleuritic pain, a diagnostic strategy combining Wells score with LUS performed better both in terms of sensitivity (93%, 95% CI 80.9-98.5% vs 90.7%, 95% CI 77.9-97.4%) and negative predictive value (96.2%, 95% CI 89.6-98.7% vs 93.3%, 95% CI 84.4-97.3%). Efficiency of Wells score + LUS outperformed the conventional strategy based on Wells score + d-dimer (56.7%, 95% CI 48.5-65% vs 42.5%, 95% CI 34.3-51.2%, p = 0.02). CONCLUSIONS: In a population of patients suspected of PE, LUS showed better sensitivity for the diagnosis of PE when applied to the subgroup with pleuritic chest pain. In these patients, a diagnostic strategy based on Wells score and LUS performed better to exclude PE than the conventional strategy combining Wells score and d-dimer.

Diagnostic Accuracy of Point-of-Care Ultrasound Integrated into Clinical Examination for Acute Diverticulitis: A Prospective Multicenter Study.

PURPOSE: Diverticulitis is a common cause of abdominal pain and CT scan is commonly used for its diagnosis in the emergency department (ED). The diagnostic performance of point-of-care ultrasound (POCUS) integrated into a clinical exam for diverticulitis is still not established. We evaluate the accuracy of clinical-sonographic assessment for the diagnosis of diverticulitis and whether POCUS could improve the selection of patients needing CT scan for complicated diverticulitis. MATERIALS AND METHODS: This is a multicentric observational study involving adult patients suspected of having diverticulitis presenting at 4 EDs. 21 sonographer physicians were asked to diagnose diverticulitis and complicated diverticulitis based on clinical-sonographic assessment. The final diagnosis was established by two reviewers, blinded to POCUS, based on data collected during the one-month follow-up comprehensive CT scan. RESULTS: Among 393 enrolled patients, 218 (55.5 %) were diagnosed with diverticulitis and 33 (8 %) had complicated diverticulitis. The time to diagnosis by the sonographer physicians was shorter compared to standard care (97 ±â€Š102 vs. 330 ±â€Š319 minutes, p < 0.001). Clinical-sonographic assessment showed optimal sensitivity (92.7 %) and specificity (90.9 %) for diverticulitis. However, the sensitivity (50 %) for complicated diverticulitis was low. The sonographer physician would have proceeded to CT scan in 194 (49.4 %) patients and the CT scan request compared to the final diagnosis of complicated diverticulitis demonstrated 94 % sensitivity. CONCLUSION: Clinical-sonographic assessment is rapid and accurate for the diagnosis of diverticulitis. Even if POCUS has low sensitivity for complicated diverticulitis, it can be used to safely select patients needing CT.

Prediction of Mortality With the Use of Noninvasive Ventilation for Acute Respiratory Failure.

BACKGROUND: In actuality, it is difficult to obtain an early prognostic stratification for patients with acute respiratory failure treated with noninvasive ventilation (NIV). We tested whether an early evaluation through a predictive scoring system could identify subjects at risk of in-hospital mortality or NIV failure. METHODS: This was a retrospective study, which included all the subjects with acute respiratory failure who required NIV admitted to an emergency department-high-dependence observation unit between January 2014 and December 2017. The HACOR (heart rate, acidosis [by using pH], consciousness [by using the Glasgow coma scale], oxygenation [by using [Formula: see text]/[Formula: see text]], respiratory rate) score was calculated before the NIV initiation (T0) and after 1 h (T1) and 24 h (T24) of treatment. The primary outcomes were in-hospital mortality and NIV failure, defined as the need for invasive ventilation. RESULTS: The study population included 644 subjects, 463 with hypercapnic respiratory failure and an overall in-hospital mortality of 23%. Thirty-six percent of all the subjects had NIV as the "ceiling" treatment. At all the evaluations, nonsurvivors had a higher mean ± SD HACOR score than did the survivors (T0, 8.2 ± 4.9 vs 6.1 ± 4.0; T1, 6.6 ± 4.8 vs 3.8 ± 3.4; T24, 5.3 ± 4.5 vs 2.0 ± 2.3 [all P < .001]). These data were confirmed after the exclusion of the subjects who underwent NIV as the ceiling treatment (T0, 8.2 ± 4.9 vs 6.1 ± 4.0 [P = .002]; T1, 6.6 ± 4.8 vs 3.8 ± 3.4; T24, 5.3 ± 4.5 vs 2.0 ± 3.2 [all P < .001]). At T24, an HACOR score > 5 (Relative Risk [RR] 2.39, 95% CI 1.60-3.56) was associated with an increased mortality rate, independent of age and the Sequential Organ Failure Assessment score. CONCLUSIONS: Among the subjects treated with NIV for acute respiratory failure, the HACOR score seemed to be a useful tool to identify those at risk of in-hospital mortality.

Diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism.

Evaluating the diagnostic performance of focused cardiac ultrasound (US) alone and combination with venous US in patients with shock and suspected pulmonary embolism (PE). Consecutive adult patients with shock and suspected PE, presenting to two Italian emergency departments, were included. Patients underwent cardiac and venous US at presentation with the aim of detecting right ventricular (RV) dilatation and proximal deep venous thrombosis (DVT). Final diagnosis of PE was based on a second level diagnostic test or autopsy. Among the 105 patients included in the study, 43 (40.9%) had a final diagnosis of PE. Forty-seven (44.8%) patients showed RV dilatation and 27 (25.7%) DVT. Sensitivity and specificity of cardiac US were 91% (95% CI 80-97%) and 87% (95% CI 80-91%), respectively. Venous US showed a lower sensitivity (56%, 95% CI 45-60%) but higher specificity (95%, 95% CI 88-99%) than cardiac US (both p < 0.05). When cardiac and venous US were both positive (22 out of 105 patients, 21%) the specificity increased to 100% (p < 0.01 vs cardiac US), whereas when at least one was positive (54 out of 105 patients, 51%) the sensitivity increased to 95% (p = 0.06 vs cardiac US). Focused cardiac US showed good but not optimal sensitivity and specificity for the diagnosis of PE in patients presenting with shock. Venous US significantly increased specificity of cardiac US, and the diagnosis of PE can be certain when both tests are positive or reasonably excluded when negative.

Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED.

BACKGROUND: Acute dyspnea is a common symptom in the ED. The standard approach to dyspnea often relies on radiologic and laboratory results, causing excessive delay before adequate therapy is started. Use of an integrated point-of-care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis, while maintaining an acceptable safety profile. METHODS: Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient; a sonographer performed an ultrasound evaluation of the lung, heart, and inferior vena cava, while the treating physician requested traditional tests as needed. Time needed to formulate the ultrasound and the ED diagnoses was recorded and compared. Accuracy and concordance of the ultrasound and the ED diagnoses were calculated. RESULTS: A total of 2,683 patients were enrolled. The average time needed to formulate the ultrasound diagnosis was significantly lower than that required for ED diagnosis (24 ± 10 min vs 186 ± 72 min; P = .025). The ultrasound and the ED diagnoses showed good overall concordance (κ = 0.71). There were no statistically significant differences in the accuracy of PoCUS and the standard ED evaluation for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax, and dyspnea from other causes. PoCUS was significantly more sensitive for the diagnosis of heart failure, whereas a standard ED evaluation performed better in the diagnosis of COPD/asthma and pulmonary embolism. CONCLUSIONS: PoCUS represents a feasible and reliable diagnostic approach to the patient with dyspnea, allowing a reduction in time to diagnosis. This protocol could help to stratify patients who should undergo a more detailed evaluation.

Diagnostic Performance of Wells Score Combined With Point-of-care Lung and Venous Ultrasound in Suspected Pulmonary Embolism.

OBJECTIVE: Lung and venous ultrasound are bedside diagnostic tools increasingly used in the early diagnostic approach of suspected pulmonary embolism (PE). However, the possibility of improving the conventional prediction rule for PE by integrating ultrasound has never been investigated. METHODS: We performed lung and venous ultrasound in consecutive patients suspected of PE in four emergency departments. Conventional Wells score (Ws) was adjudicated by the attending physician, and ultrasound was performed by one of 20 investigators. Signs of deep venous thrombosis (DVT) at venous ultrasound and signs of pulmonary infarcts or alternative diagnoses at lung ultrasound were considered to recalculate two items of the Ws: signs and symptoms of DVT and alternative diagnosis less likely than PE. The diagnostic performances of the ultrasound-enhanced Ws (USWs) and Ws were then compared after confirmation of the final diagnosis. RESULTS: A total of 446 patients were studied. PE was confirmed in 125 patients (28%). USWs performed significantly better than Ws, with a sensitivity of 69.6% versus 57.6% and a specificity of 88.2% versus 68.2%. In combination with D-dimer, USWs showed an optimal failure rate (0.8%) and a significantly superior efficiency than Ws (32.3% vs. 27.2%). A strategy based on lung and venous ultrasound combined with D-dimer would allow to avoid CT pulmonary angiography in 50.5% of patients with suspected PE, compared to 27.2% when the rule without ultrasound is applied. CONCLUSIONS: A pretest risk stratification enhanced by ultrasound of lung and venous performs better than Ws in the early diagnostic process of PE.

Diagnostic accuracy of lung ultrasonography combined with procalcitonin for the diagnosis of pneumonia: a pilot study.

BACKGROUND: The diagnostic value of lung ultrasonography (LUS) and procalcitonin (PCT) in the diagnosis of lung infections is known. No studies evaluated the combination of LUS and PCT for the diagnosis of pneumonia in the emergency department (ED). We evaluated the diagnostic accuracy of the combination of LUS and PCT in the diagnosis of pneumonia. METHODS: Patients with respiratory symptoms of unexplained origin who underwent a chest CT in ED were included in the study if PCT assay was available. LUS was performed before CT and was targeted to the detection of lung consolidations with the morphologic features of pneumonia. A PCT assay was performed at presentation, and cut-off of 0.25 and of 0.5 ng/ml were used to rule-out and rule-in pneumonia. The final diagnosis of pneumonia was established by independent clinicians, on the basis of clinical chart review including CT results. RESULTS: We enrolled 128 patients and pneumonia was the final diagnosis in 61 (47.7%). In 38 patients (29.7%) LUS and PCT were negative (PCT < 0.25 ng/ml). The overall accuracy, sensitivity and negative predictive value of LUS/PCT were 88.8, 96.7 and 94.7% respectively. Sensitivity of the LUS/PCT test was significantly superior to LUS alone (85.2%) and PCT alone (73.8%) (p < 0.05 for both). Specificity and positive predictive value of the combination of positivity of LUS/PCT (PCT > 0.5 ng/ml) were 94% and 83.3% respectively. Specificity of LUS/PCT was not significantly different to LUS alone (88.1%) (p = 0.125). CONCLUSIONS: The sensitivity of the combination of LUS with PCT for the diagnosis of pneumonia was significantly superior when compared with the sensitivity of LUS and PCT alone.

Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography.

OBJECTIVES: Despite emerging evidences on the clinical usefulness of lung ultrasound (LUS), international guidelines still do not recommend the use of sonography for the diagnosis of pneumonia. Our study assesses the accuracy of LUS for the diagnosis of lung consolidations when compared to chest computed tomography (CT). METHODS: This was a prospective study on an emergency department population complaining of respiratory symptoms of unexplained origin. All patients who had a chest CT scan performed for clinical reasons were consecutively recruited. LUS was targeted to evaluate lung consolidations with the morphologic characteristics of pneumonia, and then compared to CT. RESULTS: We analyzed 285 patients. CT was positive for at least one consolidation in 87 patients. LUS was feasible in all patients and in 81 showed at least one consolidation, with a good inter-observer agreement (k = 0.83), sensitivity 82.8% (95% CI 73.2%-90%) and specificity 95.5% (95% CI 91.5%-97.9%). Sensitivity raised to 91.7% (95% CI 61.5%-98.6%) and specificity to 97.4% (95% CI 86.5%-99.6%) in patients complaining of pleuritic chest pain. In a subgroup of 190 patients who underwent also chest radiography (CXR), the sensitivity of LUS (81.4%, 95% CI 70.7%-89.7%) was significantly superior to CXR (64.3%, 95% CI 51.9%-75.4%) (P<.05), whereas specificity remained similar (94.2%, 95% CI 88.4%-97.6% vs. 90%, 95% CI 83.2%-94.7%). CONCLUSIONS: LUS represents a reliable diagnostic tool, alternative to CXR, for the bedside diagnosis of lung consolidations in patients with respiratory complains.

Role of masked coronary heart disease in patients with recent-onset atrial fibrillation and troponin elevations.

BACKGROUND: Patients with recent-onset atrial fibrillation (AF) and cardiac troponin I (cTnI) elevations show poor outcomes. Coronary heart disease might be a cause, consequence, or an innocent bystander. OBJECTIVE: The aim of this study was to recognize and treat coronary heart disease to avoid adverse events. METHODS: Patients with recent-onset AF participated in the study. The exclusion criteria were acute coronary syndrome and severe comorbidities. Patients managed with standard care (group 1, n=1086, years 2010-2011) were compared with patients managed with tailored care inclusive of echocardiography and stress testing when required (group 2, n=1055, years 2012-2013). ENDPOINT: The endpoint was a composite of ischemic vascular events including stroke, acute coronary syndrome, revascularization and cardiovascular death at 6 months of follow-up. RESULTS: Of 4008 patients considered, 2141 were enrolled; 183 showed cTnI elevations, 92 in group 1 and 91 in group 2. cTnI elevations, known ischemic heart disease and age were predictors of the endpoint on multivariate analysis. Overall, two versus seven patients (P=0.033) in groups 1 and 2, respectively, underwent revascularization. Eventually, 16 patients in group 1 versus five patients in group 2 reached the endpoint (P=0.019). Patients of group 2 were managed as follow: 35 were admitted, 15 with positive stress testing and 20 with high cTnI values (mean values: 0.64±1.01 ng/ml). Fifty-six patients were discharged with negative stress testing results (n=13) or very low cTnI values (n=43, mean values 0.29±0.30 ng/ml). CONCLUSION: In patients with AF and cTnI elevations, tailored care inclusive of echocardiography and stress testing succeeded in recognizing and treating masked 'critical' coronary heart disease, avoiding adverse events.

Combined use of aortic dissection detection risk score and D-dimer in the diagnostic workup of suspected acute aortic dissection.

BACKGROUND: Acute aortic dissection (AD) represents a diagnostic conundrum. Validated algorithms are particularly needed to identify patients where AD could be ruled out without aortic imaging. We evaluated the diagnostic accuracy of a strategy combining the aortic dissection detection (ADD) risk score with D-dimer, a sensitive biomarker of AD. METHODS: Patients from two clinical centers with suspected AD were prospectively enrolled in a registry, from January 2008 to March 2013. The ADD risk score was calculated by retrospective blinded chart review. For D-dimer, a cutoff of 500 ng/ml was applied. RESULTS: AD was diagnosed in 233 of 1035 (22.5%) patients. The ADD risk score was 0 in 322 (31.1%), 1 in 508 (49.1%) and >1 in 205 (19.8%) patients. The sensitivity and the failure rate of D-dimer were 100% and 0% in patients with ADD score 0, versus 97.5% (95% CI 91.4-99.6%) and 4.2% (95% CI 0.7-12.5%) in patients with ADD risk score >1. In patients with ADD risk score ≤ 1, the sensitivity and the failure rate of D-dimer were 98.7% (95% CI 95.3-99.8%) and 0.8% (95% CI 0.1-2.6%). The diagnostic efficiency of D-dimer in patients with ADD risk score 0 and ≤ 1 was 8.9% (95% CI 7.2-10.7%) and 23.6% (95% CI 21.1-26.2%) respectively. CONCLUSIONS: In a large cohort of patients with suspected AD, the presence of ADD risk score 0 or ≤ 1 combined with a negative D-dimer accurately and efficiently ruled out AD.

Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism.

BACKGROUND: Presenting signs and symptoms of pulmonary embolism (PE) are nonspecific, favoring a large use of second-line diagnostic tests such as multidetector CT pulmonary angiography (MCTPA), thus exposing patients to high-dose radiation and to potential serious complications. We investigated the diagnostic performance of multiorgan ultrasonography (lung, heart, and leg vein ultrasonography) and whether multiorgan ultrasonography combined to Wells score and D-dimer could safely reduce MCTPA tests. METHODS: Consecutive adult patients suspected of PE and with a Wells score > 4 or a positive D-dimer result were prospectively enrolled in three EDs. Final diagnosis was obtained with MCTPA. Multiorgan ultrasonography was performed before MCTPA and considered diagnostic for PE if one or more subpleural infarcts, right ventricular dilatation, or DVT was detected. If multiorgan ultrasonography was negative for PE, an alternative ultrasonography diagnosis was sought. Accuracies of each single-organ and multiorgan ultrasonography were calculated. RESULTS: PE was diagnosed in 110 of 357 enrolled patients (30.8%). Multiorgan ultrasonography yielded a sensitivity of 90% and a specificity of 86.2%, lung ultrasonography 60.9% and 95.9%, heart ultrasonography 32.7% and 90.9%, and vein ultrasonography 52.7% and 97.6%, respectively. Among the 132 patients (37%) with multiorgan ultrasonography negative for PE plus an alternative ultrasonographic diagnosis or plus a negative D-dimer result, no patients received PE as a final diagnosis. CONCLUSIONS: Multiorgan ultrasonography is more sensitive than single-organ ultrasonography, increases the accuracy of clinical pretest probability estimation in patients with suspected PE, and may safely reduce the MCTPA burden. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01635257; URL: www.clinicaltrials.gov.

Causes of diplopia in the emergency department: diagnostic accuracy of clinical assessment and of head computed tomography.

BACKGROUND: Studies on frequency and underlying diseases causing binocular diplopia in patients presenting to the emergency department (ED) are lacking. OBJECTIVE: To evaluate the prevalence of different diseases causing diplopia and the role of medical history, clinical examination, and unenhanced head computed tomography (UHCT) in the identification of secondary diplopia. METHODS: Diplopic patients presenting to the ED were enrolled prospectively. Cardiovascular risk factors and associated neurological signs and symptoms were reported. UHCT was performed in the ED. RESULTS: Secondary diplopia was diagnosed in 93 of 260 (35.8%) diplopic patients. Among patients with secondary diplopia, the most frequent diagnoses were stroke (45.2%), multiple sclerosis (18.3%), brain tumors (11.8%), and cerebral aneurysms (7.5%). The prevalence of cardiovascular risk factors was similar in primary and secondary diplopia. Among the 118 (45.4%) patients without associated neurological signs or symptoms (isolated diplopia), secondary diplopia was diagnosed in 13 (11%); UHCT was negative in all 13 cases, with a derived null sensitivity. Eighty of 142 (56.3%) patients with associated signs or symptoms had secondary diplopia. The presence of signs or symptoms associated with diplopia showed a sensitivity of 87% [95% confidence interval (CI): 80-92%] and a specificity of 63% (95% CI: 59-66%) for the diagnosis of secondary diplopia. In this group, UHCT identified 30 of 80 (37.5%) cases, increasing the specificity to 98% (95% CI: 96-99%). CONCLUSION: One-third of diplopic patients had secondary diplopia. In patients with isolated diplopia, UHCT does not increase diagnostic sensitivity. In patients with associated neurological signs or symptoms, the prevalence of secondary diplopia was high and UHCT showed incremental diagnostic value.