Primary cardiac pleomorphic sarcoma presenting as back pain in an 18-year-old man.

Soft-tissue sarcoma is the most prevalent primary malignant cardiac tumor. This sarcoma usually presents with cardiac manifestations secondary to local obstruction or arrhythmias; very rarely does it present with initial symptoms of distant metastasis. We discuss the unusual case of an 18-year-old man who emergently presented with acute-on-chronic back pain. Imaging revealed a lesion on the 12th thoracic vertebra and a large mass arising from the left atrium. The cardiac mass was resected, and immunohistochemical analysis revealed it to be a pleomorphic sarcoma that had metastasized to the spine. The patient died 2 years later of diffuse metastases. In addition to the patient's case, we discuss the nature and treatment of cardiac sarcoma.

Factores que influyen en la realización de una valoración psiquiátrica en pacientes que consultan por intoxicación por cocaína / Factors predicting the decision to perform a psychiatric evaluation in patients with cocaine intoxication

Objetivo: Los consumidores de cocaína presentan frecuentemente alteraciones psiquiátricas. El objetivo de este trabajo es determinar qué factores influyen en la decisión de solicitar una valoración psiquiátrica urgente ante una intoxicación por cocaína. Método: Registro de dos años de las intoxicaciones por cocaína asistidas en urgencias. Se dividieron en dos grupos en función de si se realizó una valoración psiquiátrica. Se recogió edad, sexo, constantes vitales, escala de Glasgow, asociación de alcohol u otras sustancias de abuso, número de drogas consumidas, tiempo transcurrido desde el consumo, turno de asistencia, antecedentes psiquiátricos y de intoxicaciones previas, sintomatología y destino. El análisis estadístico incluyó una regresión logística para determinar factores independientes asociados a la realización de valoración psiquiátrica. Resultados: Se recogieron 327 casos. Se realizó una valoración psiquiátrica en 69(21,1%). Los pacientes valorados por psiquiatría eran de mayor edad (p = 0,007), habían asociado benzodiacepinas más frecuentemente (p = 0,002), tenían mayor porcentaje de antecedentes psiquiátricos (p < 0,001) y agitación psicomotriz (p = 0,001) y tenían sintomatología neurológica con menor frecuencia (p = 0,001). La regresión logística mostró que la asociación de benzodiacepinas (OR = 2,58; IC 95%: 1,18-5,64;p = 0,018), los antecedentes psiquiátricos (OR = 7,40; IC 95%: 3,51-15,64; p < 0,001)y la ausencia de sintomatología neurológica (OR = 2,74; IC 95%: 1,36-5,50; p = 0,005) eran factores independientes para realizar una valoración psiquiátrica. Conclusiones: La valoración psiquiátrica urgente se realiza en pocas ocasiones. El consumo conjunto de benzodiacepinas, los antecedentes psiquiátricos y la ausencia de sintomatología neurológica se asocian a la solicitud de valoración psiquiátrica (AU)

Background and objective: Cocaine users often present in an altered mental state. This study aimed to determine factors that influence the decision to request emergency psychiatric evaluation in cases of cocaine intoxication. Methods: Cases of cocaine intoxication attended in the emergency department were registered over 2 years. Patients were classified in 2 groups according to whether a psychiatric evaluation was performed or not. We recorded age, sex, vital signs, Glasgow score, combined abuse of alcohol or other substances, number of drugs used, time elapsed since drug use, emergency department work shift, mental health history, prior intoxications, symptoms,. Logistic regression analysis was performed to identify factors that were independently associated with performance of a psychiatric evaluation. Results: A total of 327 cases were registered. A psychiatric evaluation was performed in 69 (21.10%). The group of patients receiving such an evaluation were older (P=.007), had a higher rate of benzodiazepine use (P=.002), had higher rates of history of mental illness (P<.001) and psychomotor agitation (P=.001), and a lower rate of neurologic symptoms(P=.001). Logistic regression showed that factors that were independently related to performance of a psychiatric evaluation were benzodiazepine use (OR, 2.58; 95% confidence interval [CI], 1.18-5.64; P=.018), history of mental illness (OR, 7.40; 95% CI, 3.51-15.64; P<.001), and absence of neurologic signs (OR, 2.74; 95% CI, 1.36-5.50; P=.005).Conclusions: Psychiatric evaluation is not often performed in emergency situations. Associated use of benzodiazepines, a history of mental illness, and an absence of neurologic symptoms are associated with a decision to request psychiatric evaluation (AU)

Evaluación del efecto de la información en la satisfacción de los pacientes atendidos en los servicios de urgencias hospitalarios / Evaluation of patient satisfaction with the emergency department: the effect of information

Fundamento: La calidad percibida por los pacientes en los servicios de urgencias está condicionada por varios factores entre los que la información suministrada en relación con su proceso asistencial y la entregada en forma de instrucciones al alta es uno de los elementos más apreciados por los pacientes. Se plantea como objetivo del estudio la valoración del efecto en la calidad percibida por el usuario de una intervención consistente en la entrega de instrucciones estructuradas en el momento del alta. Material y método: Se realiza un estudio multicéntrico en 33 centros, en pacientes con afección traumática menor atendidos en servicios de urgencias hospitalarios. Se establecen dos fases: en la primera se mantiene la pauta asistencial ordinaria utilizada como control, y en la segunda, se aporta información mediante la entrega de instrucciones estructuradas al alta. Se realiza una encuesta telefónica a los 3 días y se valora mediante escala numérica del 0 al 10 la calidad percibida por los pacientes. Resultados: En la valoración basal la puntuación media fue de 8,1 frente a 8,3 en la segunda fase con diferencia estadística (p < 0,05). En la primera fase el 47% valora mejor la atención que el general de la serie, mientras que en la segunda lo hizo el 53%, diferencia estadística significativa (p < 0,05). Los pacientes que, en el momento de ser encuestados, no tenían dolor o éste era leve valoraron mejor la intervención que los que tenían dolor moderado o intenso. Conclusiones: La entrega de instrucciones al alta y su explicación mejora la satisfacción del usuario, más en aquellos cuyo resultado asistencial ha sido favorable

Background: Patient satisfaction with the emergency unit is multifactorial. One of the elements most highly valued by patients is information, not only about the treatment they receive inside the unit but also instructions on how to proceed once discharged. The aim of this study was to evaluate the effect of providing discharge instructions on patient satisfaction. Material and method: A multicenter study of 33 emergency departments was carried out in minor trauma patients who had received medical assistance. Two groups were established: in the first group normal procedure was maintained and used as the control figure; in the second group instructions were given to patients on discharge. A telephone survey was carried out 72 hours post-discharge and a numerical scale (0-10) was used to evaluate patient satisfaction. Results: In the first group the overall evaluation was 8.1 versus 8.3 in the second group (p < 0.05). In the first group, 47% of the patients were satisfied with the care received compared with 53% in the second group (p < 0.05). Quality of care was ranked more highly by patients who were not in pain or only suffering slight pain when completing the questionnaire than by those who were still suffering moderate or severe pain. Conclusions: Explaining and giving instructions at discharge has a positive effect on patient satisfaction, especially in patients with a favorable course before and after discharge

Catheter-tip embolectomy in the management of acute massive pulmonary embolism.

Three catheter interventional techniques are currently available for removing or fragmenting pulmonary emboli: aspiration thrombectomy, fragmentation, and rheolytic thrombectomy. The investigators systematically reviewed all available published research related to the use of catheter-tip devices in patients with pulmonary emboli. Pooled data showed that clinical success with the Greenfield catheter occurred in 72 of 89 patients (81%) when used alone and in 19 of 19 patients (100%) when used in combination with thrombolytic agents. Fragmentation with standard catheters used alone (without thrombolytic agents) was reported in only 3 patients. Clinical success with standard angiographic catheters occurred in 15 of 21 patients (71%) when used in combination with systemic thrombolytic agents and in 115 of 121 patients (95%) when used with local infusions of thrombolytic agents. Data for the Amplatz catheter, the rheolytic Angiojet catheter, and the Hydrolyser catheter when used alone were sparse or absent. Clinical success when used in combination with thrombolytic agents occurred in 6 of 6 patients (100%) with the Amplatz catheter, in 20 of 23 patients (87%) with the Angiojet catheter, and in 19 of 20 patients (95%) with the Hydrolyser catheter. Minor bleeding at the insertion site among all patients, with and without thrombolytic agents, occurred in 29 of 348 patients (8%), and major bleeding at the insertion site occurred in 8 of 348 patients (2%). One patient experienced perforation of the right ventricle with the Greenfield catheter. None reported perforation of a pulmonary artery. In conclusion, all the devices analyzed in this study appear to be useful in the management of acute massive pulmonary emboli.

Pulmonary embolism as a cause of death in adults who died with heart failure.

Although heart failure (HF) is a known risk factor for pulmonary embolism (PE), little is known about the frequency of death from PE in patients who die with HF. This investigation was undertaken to determine the frequency of PE as the cause of death in patients who died with HF on the basis of data from death certificates, as listed by the United States Census Bureau. Among adults with HF who died over the 19-year period of study, PE was the listed cause of death in 20,387 of 755,807 (2.7%). Assuming that the accuracy of death certificates was only 26.7%, the rate of death from PE in these patients may have been as high as 10.1%. The frequency of death from PE in patients who died with HF decreased from 1980 to 1998. In conclusion, the estimated death rate from PE in patients who died with HF is 3% to 10%. A decrease over 2 decades in the proportion of deaths from PE in such patients is compatible with the increasing and effective use of antithrombotic prophylaxis.

Risk of venous thromboembolism in patients hospitalized with heart failure.

Because of uncertainty about the prevalence of pulmonary embolism (PE) and deep venous thrombosis (DVT) in hospitalized patients with congestive heart failure (CHF), data from the National Hospital Discharge Survey were investigated. Among hospitalized patients with CHF, PE was diagnosed in 0.73% and DVT in 1.03%. The relative risk for PE in patients with CHF compared with patients with no CHF was 2.15; for DVT, it was 1.21. The relative risk for PE in patients with CHF was greatest in patients <40 years of age (relative risk 11.72), and the relative risk for DVT was 5.46. In conclusion, a high relative risk for PE, DVT, and venous thromboembolism was shown in patients with CHF who were <60 years of age.

Deep venous thrombosis and pulmonary embolism in hospitalized patients with sickle cell disease.

BACKGROUND: As would be expected with a hypercoagulable state, pulmonary embolism (PE) occurs in sickle cell disease (SCD). Its frequency, however, is undetermined, largely because of difficulties in distinguishing it from thrombosis in situ. The prevalence of deep venous thrombosis (DVT) is also undetermined in patients with SCD. Knowing the prevalence of DVT would be an important step in the overall assessment of the risk of PE in these patients. METHODS: Data from the National Hospital Discharge Survey were assessed. RESULTS: In patients

Fatal pulmonary embolism and stroke.

Death from pulmonary embolism (PE) in patients with ischemic stroke was determined from the United States Census Bureau's Compressed Mortality File, which is based on all death certificates throughout the United States. Among patients with ischemic stroke who died over a 19-year study period, PE was the listed cause of death in 11,101 of 2,000,963 individuals (0.55%). On the basis of an assumed sensitivity of death certificates for fatal PE of 26.7% to 37.2%, the corrected rate of fatal PE was 1.5% to 2.1%. Death rates from PE in patients with ischemic stroke decreased from 1980 to 1998. A decrease over 2 decades in the rate of deaths from PE in patients with ischemic stroke is compatible with the increasing and effective use of antithrombotic prophylaxis.

Multidetector computed tomography for the diagnosis of coronary artery disease: a systematic review.

PURPOSE: The study's purpose was to determine the sensitivity and specificity of contrast-enhanced multidetector computed tomography (CT) for the detection of coronary artery disease. SUBJECTS AND METHODS: A search of the literature in all languages was performed incorporating both electronic and manual components. Manual reference checks of recent reviews and all original investigations supplemented the electronic searches. RESULTS: Average sensitivity for patient-based detection of significant (>50% or > or =50%) stenosis was 61 of 64 (95%) with 4-slice CT, 276 of 292 (95%) with 16-slice CT, and 47 of 47 (100%) with 64-slice CT. Average specificity was 84% for 4-slice CT, 84% for 16-slice CT, and 100% for 64-slice CT. The sensitivity for a significant stenosis in evaluable segments was 307 of 372 (83%) with 4-slice CT, 1023 of 1160 (88%) with 16-slice CT, and 165 of 176 (94%) with 64-slice CT. Average specificity was 93% or greater with all multidetector CT. Seventy-eight percent of segments were evaluable with 4-slice CT, 91% with 16-slice CT, and 100% with 64-slice CT. Stenoses in proximal and mid-segments were shown with a higher sensitivity than distal segments. Left main stenosis was identified with high sensitivity with all multidetector CT, but sensitivity in other vessels increased with an increasing number of detectors. CONCLUSION: Multidetector CT has the potential to be used as a screening test in appropriate patients. Contrast-enhanced 16-slice CT seems to be reasonably sensitive and specific for the detection of significant coronary artery disease but has shortcomings. Preliminary data with 64-slice CT suggest that it is more sensitive and specific.

Pulmonary embolism as a cause of death in patients who died with cancer.

Little is known about the frequency of death from pulmonary embolism in patients who die with cancer. We investigated this on the basis of data from death certificates, as listed by the United States Bureau of the Census in the period 1980-1998. Among patients with cancer who died over the 19-year period of study, pulmonary embolism was the listed cause of death in 0.21% (95% confidence interval, [CI] 0.21-0.22%). The frequency of death from pulmonary embolism in patients who died with cancer decreased from 0.39% in 1980 to 0.15% in 1998. Adjustment of the data for the frailty of the diagnosis of fatal pulmonary embolism based on death certificates indicated a likely range of 0.60% to 1.05% for the frequency of death from pulmonary embolism among patients who died with cancer in the period 1980-1998. In conclusion, with modern diagnostic, prophylactic, and therapeutic methods, death from pulmonary embolism in patients who died with cancer was 1% or less.

Incidence of venous thromboembolism in patients hospitalized with cancer.

BACKGROUND: There are sparse data on the frequency of venous thromboembolism in patients with various types of cancer. We sought to determine the incidence and relative risk of venous thromboembolism, pulmonary embolism, and deep venous thrombosis in patients with malignancies. SUBJECTS AND METHODS: The number of patients discharged with a diagnostic code for 19 types of malignancies, pulmonary embolism or deep venous thrombosis from 1979 through 1999 was obtained from the National Hospital Discharge Survey. Patients studied were men and women of all ages and races. RESULTS: In patients with any of the 19 malignancies studied, 827,000 of 40,787,000 (2.0%) had venous thromboembolism, which was twice the incidence in patients without these malignancies, 6,854,000 of 662,309,000 (1.0 %). The highest incidence of venous thromboembolism was in patients with carcinoma of the pancreas, 51,000 of 1,176,000 (4.3%), and the lowest incidences were in patients with carcinoma of the bladder and carcinoma of the lip, oral cavity or pharynx. The overall incidences of pulmonary embolism and deep venous thrombosis were also twice the rates in noncancer patients. Incidences with cancer were not age dependent. The incidence of venous thromboembolism in patients with cancer began to increase in the late 1980s. CONCLUSION: Patients with cancer had twice the incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis as patients without cancer. The incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis associated with cancer differed according to the type of cancer, was comparable in elderly and younger patients, and increased in the late 1980s and 1990s.

Usefulness of 4-, 8-, and 16-slice computed tomography for detection of graft occlusion or patency after coronary artery bypass grafting.

The sensitivity and specificity of computed tomographic angiography for the evaluation of coronary artery bypass grafts (CABGs) was reviewed. A search of published studies in all languages was performed, incorporating electronic and manual components. A total of 985 patients with 2,200 CABGs participated in investigations with single-detector computed tomography (CT), 441 patients (1,246 CABGs) with 4-slice CT, none with 8-slice CT, and 144 patients (416 grafts) with 16-slice CT. Pooled data showed a sensitivity for the detection of complete occlusion with single-slice CT of 81% (402 of 494 patients), with 4-slice CT of 93% (293 of 315 patients), and with 16-slice CT of 99% (75 of 76 patients). The specificity, based on pooled data, using single-slice CT was 89% (1,507 of 1,697 patients), with 4-slice CT was 96% (878 of 915 patients), and with 16-slice CT was 98% (301 of 306 patients). The detection of complete occlusion and the detection of patency in saphenous vein bypass grafts and arterial bypass grafts were similar with multislice CT. Limited data were available on the detection of significant stenosis, exclusive of complete occlusion. With 4-slice CT, the sensitivity was 74% (23 of 31 patients) and was 88% (21 of 24 patients) with 16-slice CT. In conclusion, single-detector CT was able to detect graft patency, but it was not sensitive for graft occlusion. The data suggest that 4- and 16-slice CT can be used for the detection of complete graft occlusion or graft patency of CABGs. Significant stenosis was better assessed with 16-slice CT than with 4-slice CT.

Venous thromboembolism in patients with ischemic and hemorrhagic stroke.

The rates of pulmonary embolism (PE), deep venous thrombosis (DVT), and their combination, venous thromboembolism (VTE), in hospitalized patients with stroke from 1979 to 2003 were determined from the National Hospital Discharge Survey. Of 14,109,000 patients hospitalized with ischemic stroke, PE occurred in 72,000 (0.51%), DVT in 104,000 (0.74%), and VTE in 165,000 (1.17%). Of 1,606,000 patients hospitalized with hemorrhagic stroke, rates were higher: PE occurred in 11,000 (0.68%), DVT in 22,000 (1.37%), and VTE in 31,000 (1.93%). The rates of VTE with ischemic stroke and with hemorrhagic stroke did not change over the 25-year period of observation.

Mortality from acute pulmonary embolism according to season.

BACKGROUND: Varying observations have been made on seasonal differences of mortality from acute pulmonary embolism (PE). METHODS: The number of deaths each year from PE, from 1980 through 1998, based on death certificates, was obtained from the US National Center for Health Statistics Multiple Cause-of-Death Files. RESULTS: Acute PE as the cause of death ranged from 0.91 to 1.03 PE deaths per quarter per 100,000 population. Small differences were statistically significant due to the large number of patients evaluated. Quarterly mortality rates from PE in the northeast, south, midwest, and west, where seasonal weather varies widely, showed no meaningful seasonal differences. CONCLUSION: Mortality rates from PE do not vary to a meaningful extent according to season.

Outcome and complications of retrievable inferior vena cava filters.

The results and risks of retrievable inferior vena cava filters were reviewed. Systematic review identified 6 prospective case series with broad ranges of indications for filters. In these case series, 4 different types of retrievable filters were inserted in 284 patients. The longest reported duration of insertion was 134 days. Among patients in whom percutaneous removal of the filter was attempted, the filter was successfully removed in 144 of 159 (91%). Surgery was necessary to remove the filter from 1 patient (1%), and filters could not be removed because of large trapped thrombi in 14 patients (9%).