Prediction of significant coronary artery disease in acute chest pain without infarction in emergency department: MAPAC Cardio-PreTest model.

Acute nontraumatic chest pain is a frequent reaso n for consultation in emergency departments and represents a diagnostic challenge. The objective is to estimate the risk of significant coronary artery disease (CAD) in patients with cardiogenic acute chest pain for whom the diagnosis of infarction was ruled out in the emergency department with a nondiagnostic ECG and negative high-sensitivity troponins. We prospectively recruited 1625 patients from emergency departments of seven Spanish hospitals. The outcome was presence of significant CAD determined by presence of ischaemia in functional tests or more than 70% stenosis in imaging tests. In this study, we developed a predictive model and evaluated its performance and clinical utility. The prevalence of significant CAD was 14% [227/1625; 95% confidence interval (CI), 12-16]. MAPAC Cardio-PreTest model included seven predictors: age, sex, smoking, history of hypertension, family history of CAD, history of hyperuricaemia, and type of chest pain. The optimism-adjusted model discrimination was C-statistic 0.654 (95% CI, 0.618-0.693). Calibration plot showed good agreement between the predicted and observed risks, and calibration slope was 0.880 (95% CI, 0.731-1.108) and calibration-in-the-large -0.001 (95% CI, -0.141 to 0.132). The model increased net benefit and improved risk classification over the recommended approach by the European Society of Cardiology [Net Reclassification Index (NRI) of events = 5.3%, NRI of nonevents = 7.0%]. MAPAC Cardio-PreTest model is an online prediction tool to estimate the individualised probability of significant CAD in patients with acute chest pain without a diagnosis of infarction in emergency department. The model was more useful than the current alternatives in helping patients and clinicians make individually tailored choices about the intensity of monitoring or additional coronary tests.

Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department.

BACKGROUND: Nontraumatic headache is a frequent complaint in the emergency department (ED). Cranial computed tomography (CT) is a widely available test for the diagnostic work-up, despite the risk of exposure to ionizing radiation. OBJECTIVES: We sought to develop and evaluate a cranial CT request computerized decision support system (CDSS) for adults with their first presentation of unusual severe nontraumatic headache in the ED. METHODS: Electronic database searches identified clinical decision and prediction rules and studies delineating risk factors in nontraumatic headache. A long list of risk factors extracted from these articles was reduced by a 30-member multidisciplinary expert panel (radiologists, emergency physicians, methodologists), using a 90% agreement threshold. This shortlist was used to develop the algorithm for the cranial CT request CDSS, which was implemented in March 2016. Impact evaluation compared CT scan frequency and diagnostic yield of pathologic findings before (March-August 2015) and after (March-August 2016) implementation. RESULTS: From the 10 selected studies, 10 risk factors were shortlisted to activate a request for cranial CT. Before implementation, 377 cranial CTs were ordered (15.3% of 2469 CT scans) compared with 244 after (9.5% of 2561 CT scans; pre-post difference 5.74%; 95% confidence interval [CI] 3.92-7.56%; p < 0.001), corresponding to a 37.6% relative reduction in the test ordering rate (95% CI 25.7-49.5%; p < 0.001). Despite the reduction in cranial CT scans, we did not observe an increase in pathological findings after introducing the decision support system (70 cases before [18.5%] vs. 35 cases after [14.3%]; pre-post difference -4.0% [95% CI -10.0 to 1.6%]; p = 0.170). CONCLUSION: In nontraumatic headache among adults seen in the ED, CDSS decreased the cranial CT request rate but the diagnostic yield did not improve.

The Salt-Stress Response of the Transgenic Plum Line J8-1 and Its Interaction with the Salicylic Acid Biosynthetic Pathway from Mandelonitrile.

Salinity is considered as one of the most important abiotic challenges that affect crop productivity. Plant hormones, including salicylic acid (SA), are key factors in the defence signalling output triggered during plant responses against environmental stresses. We have previously reported in peach a new SA biosynthetic pathway from mandelonitrile (MD), the molecule at the hub of the cyanogenic glucoside turnover in Prunus sp. In this work, we have studied whether this new SA biosynthetic pathway is also present in plum and the possible role this pathway plays in plant plasticity under salinity, focusing on the transgenic plum line J8-1, which displays stress tolerance via an enhanced antioxidant capacity. The SA biosynthesis from MD in non-transgenic and J8-1 micropropagated plum shoots was studied by metabolomics. Then the response of J8-1 to salt stress in presence of MD or Phe (MD precursor) was assayed by measuring: chlorophyll content and fluorescence parameters, stress related hormones, levels of non-enzymatic antioxidants, the expression of two genes coding redox-related proteins, and the content of soluble nutrients. The results from in vitro assays suggest that the SA synthesis from the MD pathway demonstrated in peach is not clearly present in plum, at least under the tested conditions. Nevertheless, in J8-1 NaCl-stressed seedlings, an increase in SA was recorded as a result of the MD treatment, suggesting that MD could be involved in the SA biosynthesis under NaCl stress conditions in plum plants. We have also shown that the plum line J8-1 was tolerant to NaCl under greenhouse conditions, and this response was quite similar in MD-treated plants. Nevertheless, the MD treatment produced an increase in SA, jasmonic acid (JA) and reduced ascorbate (ASC) contents, as well as in the coefficient of non-photochemical quenching (qN) and the gene expression of Non-Expressor of Pathogenesis-Related 1 (NPR1) and thioredoxin H (TrxH) under salinity conditions. This response suggested a crosstalk between different signalling pathways (NPR1/Trx and SA/JA) leading to salinity tolerance in the transgenic plum line J8-1.

Nitrate- and nitric oxide-induced plant growth in pea seedlings is linked to antioxidative metabolism and the ABA/GA balance.

This study looks at the effects of potassium nitrate (KNO3) and sodium nitroprusside (SNP), a nitric oxide (NO)-donor, on the development, antioxidant defences and on the abscisic acid (ABA) and gibberellin (GA) levels in pea seedlings. Results show that 10 mM KNO3 and 50 µM SNP stimulate seedling fresh weight (FW), although this effect is not reverted by the action of 2-4-carboxyphenyl-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide (cPTIO), a NO-scavenger. The KNO3 treatment increased peroxidase (POX) and ascorbate oxidase (AOX) activities. SNP, on the other hand, reduced monodehydroascorbate reductase (MDHAR) activity and produced a significant increase in superoxide dismutase (SOD), POX and AOX activities. The "KNO3 plus cPTIO" treatment increased ascorbate peroxidase (APX), MDHAR, glutathione reductase (GR) and SOD activities, but POX activity decreased in relation to the KNO3 treatment. The "SNP plus cPTIO" treatment increased APX and MDHAR activities, whereas a huge decrease in POX activity occurred. Both the KNO3 and the SNP treatments increased reduced ascorbate (ASC) concentrations, which reached control values in the presence of cPTIO. All treatments increased the dehydroascorbate (DHA) level in pea seedlings, leading to a decrease in the redox state of ascorbate. In the "KNO3 plus cPTIO" treatment, an increase in the redox state of ascorbate was observed. Glutathione contents, however, were higher in the presence of SNP than in the presence of KNO3. In addition, KNO3 produced an accumulation of oxidised glutathione (GSSG), especially in the presence of cPTIO, leading to a decrease in the redox state of glutathione. The effect of SNP on reduced glutathione (GSH) levels was reverted by cPTIO, suggesting that NO has a direct effect on GSH biosynthesis or turnover. Both the KNO3 and SNP treatments produced an increase in GA4 and a decrease in ABA concentrations, and this effect was reverted in the presence of the NO-scavenger. Globally, the results suggest a relationship between antioxidant metabolism and the ABA/GA balance during early seedling growth in pea. The results also suggest a role for KNO3 and NO in the modulation of GA4 and ABA levels and antioxidant metabolism in pea seedlings. Furthermore, this effect correlated with an increase in the biomass of the pea seedlings.

Small RNA-Seq to Characterize Viruses Responsible of Lettuce Big Vein Disease in Spain.

The emerging lettuce big-vein disease (LBVD) is causing losses in lettuce production ranging from 30 to 70% worldwide. Several studies have associated this disease with Mirafiori lettuce big-vein virus (MiLBVV) alone or in mixed infection with lettuce big-vein associated virus (LBVaV). We used Illumina small RNA sequencing (sRNA-seq) to identify viruses present in symptomatic lettuce plants from commercial fields in Southern Spain. Data analysis using the VirusDetect tool showed the consistent presence of MiLBVV and LBVaV in diseased plants. Populations of MiLBVV and LBVaV viral small RNAs (sRNAs) were characterized, showing features essentially similar to those of other viruses, with the peculiarity of an uneven asymmetric distribution of MiLBVV virus-derived small RNAs (vsRNAs) for the different polarities of genomic RNA4 vs. RNAs1 to 3. Sanger sequencing of coat protein genes was used to study MiLBVV and LBVaV phylogenetic relationships and population genetics. The Spanish MiLBVV population was composed of isolates from three well-differentiated lineages and reflected almost all of the diversity reported for the MiLBVV species, whereas the LBVaV population showed very little genetic differentiation at the regional scale but lineage differentiation at a global geographical scale. Universal primers were used to detect and quantify the accumulation of MiLBVV and LBVaV in field samples; both symptomatic and asymptomatic plants from affected fields carried equal viral loads, with LBVaV accumulating at higher levels than MiLBVV.

Metabolomics and Biochemical Approaches Link Salicylic Acid Biosynthesis to Cyanogenesis in Peach Plants.

Despite the long-established importance of salicylic acid (SA) in plant stress responses and other biological processes, its biosynthetic pathways have not been fully characterized. The proposed synthesis of SA originates from chorismate by two distinct pathways: the isochorismate and phenylalanine (Phe) ammonia-lyase (PAL) pathways. Cyanogenesis is the process related to the release of hydrogen cyanide from endogenous cyanogenic glycosides (CNglcs), and it has been linked to plant plasticity improvement. To date, however, no relationship has been suggested between the two pathways. In this work, by metabolomics and biochemical approaches (including the use of [13C]-labeled compounds), we provide strong evidences showing that CNglcs turnover is involved, at least in part, in SA biosynthesis in peach plants under control and stress conditions. The main CNglcs in peach are prunasin and amygdalin, with mandelonitrile (MD), synthesized from phenylalanine, controlling their turnover. In peach plants MD is the intermediary molecule of the suggested new SA biosynthetic pathway and CNglcs turnover, regulating the biosynthesis of both amygdalin and SA. MD-treated peach plants displayed increased SA levels via benzoic acid (one of the SA precursors within the PAL pathway). MD also provided partial protection against Plum pox virus infection in peach seedlings. Thus, we propose a third pathway, an alternative to the PAL pathway, for SA synthesis in peach plants.

Salt-tolerance mechanisms induced in Stevia rebaudiana Bertoni: Effects on mineral nutrition, antioxidative metabolism and steviol glycoside content.

In order to cope with challenges linked to climate change such as salinity, plants must develop a wide spectrum of physiological and molecular mechanisms to rapidly adapt. Stevia rebaudiana Bertoni plants are a case in point. According to our findings, salt stress has no significant effect on plant growth in these plants, which accumulate sodium (Na+) in their roots, thus avoiding excessive Na+ accumulation in leaves. Furthermore, salt stress (NaCl stress) increases the potassium (K+), calcium (Ca2+), chloride ion (Cl-) and proline concentrations in Stevia leaves, which could contribute to osmotic adjustment. We also found that long-term NaCl stress does not produce changes in chlorophyll concentrations in Stevia leaves, reflecting a mechanism to protect the photosynthesis process. Interestingly, an increase in chlorophyll b (Chlb) content occured in the oldest plants studied. In addition, we found that NaCl induced reactive oxygen species (ROS) accumulation in Stevia leaves and that this accumulation was more evident in the presence of 5 g/L NaCl, the highest concentration used in the study. Nevertheless, Stevia plants are able to induce (16 d) or maintain (25 d) antioxidant enzymes to cope with NaCl-induced oxidative stress. Low salt levels did not affect steviolbioside and rebaudioside A contents. Our results suggest that Stevia plants induce tolerance mechanisms in order to minimize the deleterious effects of salt stress. We can thus conclude that saline waters can be used to grow Stevia plants and for Steviol glycosides (SGs) production.

Alberta Stroke Program Early CT Score applied to CT angiography source images is a strong predictor of futile recanalization in acute ischemic stroke.

INTRODUCTION: Reliable predictors of poor clinical outcome despite successful revascularization might help select patients with acute ischemic stroke for thrombectomy. We sought to determine whether baseline Alberta Stroke Program Early CT Score (ASPECTS) applied to CT angiography source images (CTA-SI) is useful in predicting futile recanalization. METHODS: Data are from the FUN-TPA study registry (ClinicalTrials.gov; NCT02164357) including patients with acute ischemic stroke due to proximal arterial occlusion in anterior circulation, undergoing reperfusion therapies. Baseline non-contrast CT and CTA-SI-ASPECTS, time-lapse to image acquisition, occurrence, and timing of recanalization were recorded. Outcome measures were NIHSS at 24 h, symptomatic intracranial hemorrhage, modified Rankin scale score, and mortality at 90 days. Futile recanalization was defined when successful recanalization was associated with poor functional outcome (death or disability). RESULTS: Included were 110 patients, baseline NIHSS 17 (IQR 12; 20), treated with intravenous thrombolysis (IVT; 45 %), primary mechanical thrombectomy (MT; 16 %), or combined IVT + MT (39 %). Recanalization rate was 71 %, median delay of 287 min (225; 357). Recanalization was futile in 28 % of cases. In an adjusted model, baseline CTA-SI-ASPECTS was inversely related to the odds of futile recanalization (OR 0.5; 95 % CI 0.3-0.7), whereas NCCT-ASPECTS was not (OR 0.8; 95 % CI 0.5-1.2). A score ≤5 in CTA-SI-ASPECTS was the best cut-off to predict futile recanalization (sensitivity 35 %; specificity 97 %; positive predictive value 86 %; negative predictive value 77 %). CONCLUSIONS: CTA-SI-ASPECTS strongly predicts futile recanalization and could be a valuable tool for treatment decisions regarding the indication of revascularization therapies.

Good Clinical and Radiological Correlation from Standard Perfusion Computed Tomography Accurately Identifies Salvageable Tissue in Ischemic Stroke.

INTRODUCTION: It has been debated whether the penumbral pattern, as identified using multimodal imaging, is a specific marker of tissue viability in ischemic stroke. We assessed whether perfusion computed tomography (PCT) accurately identifies salvageable tissue and helps predict postreperfusion outcomes. METHODS: A retrospective study of patients with anterior circulation stroke undergoing reperfusion therapies who had a PCT before treatment and an assessment of vessel recanalization post treatment was conducted. Tissue at risk was considered as that with reduced cerebral blood flow, whereas the infarct core was the region of reduced cerebral blood volume, the mismatch region being salvageable tissue. The volume of hypodensity in slices corresponding to perfusion acquisition cage in 24-hour computed tomography (partial lesion volume [PLV]) was measured. Outcome variables were the amount of preserved tissue, that is, the difference between volumes of tissue at risk and PLV expressed as a percentage, and the modified Rankin Scale (mRS) score at 3 months. RESULTS: Patients (n = 34) meeting the inclusion criteria were included. Vessel recanalization was associated with a larger amount of tissue at risk preserved from definite lesion (89% [interquartile range {IQR}: 76-94] versus 46% [IQR: 23-86], P < .005). The amount of preserved tissue correlated with clinical outcome at 24 hours: for each 10% of preserved tissue, the National Institutes of Health Stroke Scale score improved by 3 points (95% confidence interval [CI]: -4.9 to -.8, P = .007) and was the only predictor of independency (mRS score 0-2) following adjustment for covariates (odds ratio 1.15, 95% CI: 1.04-1.28, P = .005). CONCLUSIONS: PCT provides accurate markers of viability of tissue in acute ischemic stroke and could help predict the degree of improvement following reperfusion.

Computerised clinical decision support for suspected PE.

This study aimed to determine the effect of an evidence-based clinical decision support (CDS) algorithm on the use and yield of CT pulmonary angiography (CTPA) and on outcomes of patients evaluated in the emergency department (ED) for suspected PE. The study included 1363 consecutive patients evaluated for suspected PE in an ED during 12 months before and 12 months after initiation of CDS use. Introduction of CDS was associated with decreased CTPA use (55% vs 49%; absolute difference (AD), 6.3%; 95% CI 1.0% to 11.6%; p=0.02). The use of CDS was associated with fewer symptomatic venous thromboembolic events during follow-up in patients with an initial negative diagnostic evaluation for PE (0.7% vs 3.2%; AD 2.5%; 95% CI 0.9% to 4.6%; p<0.01).

Trichoderma harzianum T-78 supplementation of compost stimulates the antioxidant defence system in melon plants.

BACKGROUND: Compost is emerging as an alternative plant growing medium in efforts to achieve more sustainable agriculture. The addition of specific microorganisms such as Trichoderma harzianum to plant growth substrates increases yields and reduces plant diseases, but the mechanisms of such biostimulants and the biocontrol effects are not yet fully understood. In this work we investigated how the addition of citrus and vineyard composts, either alone or in combination with T. harzianum T-78, affects the antioxidant defence system in melon plants under nursery conditions. RESULTS: Compost application and/or Trichoderma inoculation modulated the antioxidant defence system in melon plants. The combination of citrus compost and Trichoderma showed a biostimulant effect that correlated with an increase in ascorbate recycling enzymes (monodehydroascorbate reductase, dehydroascorbate reductase) and peroxidase. Moreover, the inoculation of both composts with Trichoderma increased the activity of antioxidant enzymes, especially those involved in ascorbate recycling. CONCLUSION: Based on the long-established relationship between ascorbic acid and plant defence responses as well as plant growth and development, it can be suggested that ascorbate recycling activities play a major role in the protection provided by Trichoderma and its biostimulant effect and that these outcomes are linked to increases in antioxidant enzymes. We can conclude that the combination of citrus compost and T. harzianum T-78 constitutes a viable, environmentally friendly strategy for improving melon plant production.

Tuberculosis oral asociada al HIV: presentación de un caso clínico / HIV-related oral tuberculosis: report of a clinical case

La tuberculosis (TBC) es una enfermedad infecciosa causada principalmente por una bacteria, el Micobacterium tuberculosis. La estrecha vinculación entre TBC y VIH oermite hablar de una coepidemia dual. La localización oral de la TBC extrapulmon es rara, tanto en pacientes inmunocompetentes como VIH+. Las manifestaciones clínicas son inespecíficas, pudiendo presentarse como úlceras, fisuras, nódulos, granulomas o tumores. La falta de especificidad de las lesiones dificulta el diagnóstico. En este artículo se presenta un caso clínico de un paciente con TBC extrapulomonar en la cavidad oral asociado a HIV, atendido en el Servicio de Odontología del H.I.G.A. Gral. San Martín de la ciudad de La Plata.

Tuberculosis oral asociada al HIV: presentación de un caso clínico / HIV-related oral tuberculosis: report of a clinical case

La tuberculosis (TBC) es una enfermedad infecciosa causada principalmente por una bacteria, el Micobacterium tuberculosis. La estrecha vinculación entre TBC y VIH oermite hablar de una coepidemia dual. La localización oral de la TBC extrapulmon es rara, tanto en pacientes inmunocompetentes como VIH+. Las manifestaciones clínicas son inespecíficas, pudiendo presentarse como úlceras, fisuras, nódulos, granulomas o tumores. La falta de especificidad de las lesiones dificulta el diagnóstico. En este artículo se presenta un caso clínico de un paciente con TBC extrapulomonar en la cavidad oral asociado a HIV, atendido en el Servicio de Odontología del H.I.G.A. Gral. San Martín de la ciudad de La Plata.(AU)

Implementing a guideline for the request of chest and abdominal x-rays in nontrauma pathologic conditions in an ED.

OBJECTIVE: The purpose of this study is to evaluate the impact of implementing a guideline for the request of chest and abdominal x-ray to reduce unnecessary examinations in nontraumatic pathologic conditions. METHODS: We selected most common chief complaints in nontrauma pathologic conditions at emergency department (ED) and reviewed the available literature to determine the effectiveness of chest and abdominal x-rays for each one. We developed a guideline for the request of x-rays according to the chief complaints, including modulating factors derived from initial clinical evaluation. Guideline implementation was achieved through a multifaceted educational intervention. To evaluate its impact, both in the absolute number and in the adequateness of x-ray requests, we compared data obtained from patients coming to the ED at 2 different time points, October 2004 (preimplementation) and October 2005 (postimplementation). RESULTS: In the preimplementation period, 52.7% of the patients underwent chest x-rays and 28.0% abdominal x-rays, whereas in the postimplementation period, the proportions decreased to 41.8% and 13.5%, respectively (P<.001 in both cases). The adequateness of x-ray requests improved, as shown by a reduction in the number of inappropriate x-ray examinations (absolute error reduction of 9.2%; 95% confidence interval, 7.7-10.8, and relative error reduction of 59.8%; 95% confidence interval, 49.7-69.8). CONCLUSIONS: In our ED, implementing a specifically designed guideline for the request of chest and abdominal x-ray examinations in nontraumatic pathologic conditions reduced the absolute number of requests and the rate of inappropriate requests.

[Thromboembolic events in patients after a negative computed tomography pulmonary angiogram: A retrospective study of 165 patients]. / Aparición de episodios tromboembólicos en pacientes con angiotomografía axial computarizada simple negativa. Estudio retrospectivo de 165 pacientes.

OBJECTIVE: To determine the value of computed tomography (CT) angiography of the chest as a diagnostic test to exclude pulmonary embolism and to assess compliance with diagnostic protocols for thromboembolic disease. PATIENTS AND METHODS: We retrospectively studied patients who underwent CT angiography of the chest because of suspected pulmonary embolism in 2004. All the patients were followed for 3 months. The percentage of patients diagnosed with a thromboembolic event based on an objective test during the follow-up period was determined. We analyzed the percentage of patients with a negative CT angiogram on whom additional diagnostic tests (ultrasound of the lower limbs and/or ventilation-perfusion lung scintigraphy) were performed. RESULTS: One hundred sixty-five patients underwent CT angiography of the chest because of suspected pulmonary embolism in 2004. Four of the patients were excluded from the study because they were on chronic anticoagulation therapy and a further 2 were excluded because they had a life expectancy of under 3 months. Of the remaining 159 patients, 60 had CT angiograms that were interpreted as high probability for pulmonary embolism (prevalence of 38%). Thirty-nine of the 99 patients with a negative CT angiogram experienced an objectively confirmed thromboembolic event (63% sensitivity; 95% confidence interval, 53%-73%). Other diagnostic tests were not performed in 46% of the cases. CONCLUSIONS: In our setting, a negative single-detector helical CT angiogram was not sensitive enough to exclude the diagnosis of pulmonary embolism. Furthermore, compliance with internationally accepted diagnostic protocols was far from optimal.

Aparición de episodios tromboembólicos en pacientes con angiotomografía axial computarizada simple negativa. Estudio retrospectivo de 165 pacientes / Thromboembolic events in patients after a negative computed tomography pulmonary angiogram: a retrospective study of 165 patients

Objetivo: Determinar el rendimiento de la angiotomografía axial computarizada (angio-TAC) de tórax en el diagnóstico de exclusión de la tromboembolia pulmonar (TEP) y comprobar la observancia de los protocolos diagnósticos de enfermedad tromboembólica. Pacientes y métodos: Realizamos un estudio retrospectivo de los pacientes a quienes se realizó una angio-TAC de tórax por sospecha de TEP durante el año 2004. Se realizó un seguimiento de 3 meses en todos ellos. Se determinó el porcentaje de pacientes diagnosticados de un episodio tromboembólico por un método objetivo durante el período de seguimiento. Se analizó el porcentaje de pacientes con angio-TAC negativa a quienes se realizó alguna prueba diagnóstica adicional (ecografía de miembros inferiores y/o gammagrafía de ventilación-perfusión pulmonar). Resultados: Durante el año 2004 se realizaron 165 angio-TAC de tórax por sospecha de TEP. Se excluyó a 4 pacientes con indicación de anticoagulación crónica y a otros 2 con pronóstico de vida inferior a 3 meses. De los 159 pacientes restantes, en 60 la angio-TAC se interpretó como de alta probabilidad para TEP (prevalencia del 38%). Entre los 99 pacientes con angio-TAC negativa, se produjo un episodio tromboembólico objetivamente confirmado en 35 de ellos (sensibilidad del 63%; intervalo de confianza del 95%, 53-73%). En el 46% de los pacientes no se realizó ninguna prueba diagnóstica adicional. Conclusiones: En nuestro medio la angio-TAC helicoidal no multidetectora negativa es insuficiente para el diagnóstico de exclusión de la TEP. La observancia de los protocolos diagnósticos internacionalmente aceptados dista de ser óptima

Objective: To determine the value of computed tomography (CT) angiography of the chest as a diagnostic test to exclude pulmonary embolism and to assess compliance with diagnostic protocols for thromboembolic disease. Patients and methods: We retrospectively studied patients who underwent CT angiography of the chest because of suspected pulmonary embolism in 2004. All the patients were followed for 3 months. The percentage of patients diagnosed with a thromboembolic event based on an objective test during the follow-up period was determined. We analyzed the percentage of patients with a negative CT angiogram on whom additional diagnostic tests (ultrasound of the lower limbs and/or ventilation-perfusion lung scintigraphy) were performed. Results: One hundred sixty-five patients underwent CT angiography of the chest because of suspected pulmonary embolism in 2004. Four of the patients were excluded from the study because they were on chronic anticoagulation therapy and a further 2 were excluded because they had a life expectancy of under 3 months. Of the remaining 159 patients, 60 had CT angiograms that were interpreted as high probability for pulmonary embolism (prevalence of 38%). Thirty-nine of the 99 patients with a negative CT angiogram experienced an objectively confirmed thromboembolic event (63% sensitivity; 95% confidence interval, 53%-73%). Other diagnostic tests were not performed in 46% of the cases. Conclusions: In our setting, a negative single-detector helical CT angiogram was not sensitive enough to exclude the diagnosis of pulmonary embolism. Furthermore, compliance with internationally accepted diagnostic protocols was far from optimal

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