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Query: UMLS:C0034065 (pulmonary embolism)
 14,979 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Nowadays, computed tomography along with pulmonary angiography (CTPA) is a recognized method of assumed pulmonary embolism (PE) diagnostics; however, even in experienced centers, CTPA sensitivity varies between 58 and 95%. Computed tomography with contrast venography and femoral scanning aimed at the diagnostics of profound venous thromboembolism, is a useful addition to CTPA. Besides these methods, some other well-known diagnostic techniques may be used in complex PE diagnostics: ventilation-perfusion pulmonary scanning, the evaluation of PE probability by clinical manifestations (P. Wells method), and digital subtraction angiography.
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PMID:[Contemporary diagnostics of pulmonary arterial embolism]. 1675 57

In primary care, the physician has to decide which patients with a suspicion of deep vein thrombosis (DVT) have to be referred for further diagnostic work-up. Accurate referral is of utmost importance because unrecognized and therefore untreated DVT may cause pulmonary embolism. The classic clinical findings are not sufficiently accurate for the diagnosis of DVT. The majority of the referred patients, 70 to 80%, do not have DVT and this puts a burden on both patients and health care budgets. Diagnosis in primary care is different from that in secondary care caused by the referral mechanism or spectrum difference. Diagnostic tests derived in secondary care, therefore, cannot simply be generalized to primary-care patients. The well-known diagnostic rule for DVT, the Wells rule, does not adequately rule out DVT in primary-care patients. A proper diagnostic rule for use in primary care is lacking; therefore, we investigated the data of 1,295 patients in primary care suspected of having DVT. We developed and validated a simple diagnostic decision rule to exclude the presence of DVT safely in primary care. Independent diagnostic indicators of the presence of DVT were male gender, oral contraceptive use, presence of malignancy, recent surgery, absence of leg trauma, vein distension, calf circumference difference, and D-dimer test result. Application of this rule could reduce the number of referrals by at least 23%, whereas only 0.7% of the patients with a DVT would not be referred. A diagnosis strategy is given, together with a practical flow diagram.
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PMID:The value of clinical findings and D-dimer tests in diagnosing deep vein thrombosis in primary care. 1702 94

The requirement for a safe diagnostic strategy should be based on an overall posttest incidence of venous thromboembolism (VTE) of less than 1%, with a negative predictive value of more than 99 to 100% during 3-month follow-up. Compression ultrasonography (CUS) and spiral computed tomography (CT) currently are the methods of choice to confirm or rule out deep venous thrombosis (DVT) and pulmonary embolism (PE), respectively. CUS has a negative predictive value (NPV) of 97 to 98%, indicating the need to improve the diagnostic work-up of patients with suspected DVT by clinical score assessment and D-dimer testing. Spiral CT as a stand-alone method detects all clinically relevant PEs and a large number of alternative diagnoses. It rules out PE with a NPV of 98 to 99%. Spiral CT is expensive, emphasizing the need to improve the diagnostic work-up of patients with suspected PE by the use of clinical score assessment and D-dimer testing. Clinical score assessment for DVT and PE has not safely ruled out VTE in multicenter studies and in routine daily practices. Modification of the Wells clinical score assessment for DVT by elimination of the "minus 2 points" for alternative diagnosis will improve the reproducibility of the clinical score assessment. The combination of a first negative CUS and a negative SimpliRed or an enzyme-linked immunosorbent assay (ELISA) VIDAS D-dimer of < 1,000 ng/mL safely exclude DVT (NPV > 99%) irrespective of clinical score assessment and without the need to repeat CUS in approximately 60 to 70% of patients. The rapid quantitative and qualitative agglutination D-dimer assays for the exclusion of VTE are not sensitive enough as stand-alone tests and should be used in combination with clinical score assessment. A normal rapid ELISA VIDAS D-dimer test as a stand-alone test safely excludes DVT and PE, with a NPV of 99 to 100%, irrespective of clinical score, without the need of CUS or spiral CT. The combined strategy of a rapid ELISA VIDAS D-dimer followed by objective testing with CUS for DVT and by spiral CT for PE will reduce the need for noninvasive imaging techniques by 40 to 50%.
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PMID:Different accuracies of rapid enzyme-linked immunosorbent, turbidimetric, and agglutination D-dimer assays for thrombosis exclusion: impact on diagnostic work-ups of outpatients with suspected deep vein thrombosis and pulmonary embolism. 1702 95

A safe and effective management strategy is pivotal in excluding pulmonary embolism (PE). The combination of Wells' simplified dichotomous clinical decision rule and D-dimer test is non-invasive and could be highly efficient, though its safety has not been widely studied. We evaluated safety and efficiency of this combination in excluding PE. Wells clinical decision rule was performed in 941 consecutive patients with suspected PE and, if patients had a score <or=4.0 points, a VIDAS D-dimer test followed. Patients with a normal D-dimer concentration had no further tests, PE was considered excluded, and patients did not receive anticoagulant treatment. Patients, in whom PE was excluded, were followed up for three months. Four hundred fifty patients (51.2%) had a clinical decision score =4.0 points and a normal D-dimer concentration. In 45 of these patients, during the initial diagnostic period additional objective testing, although not indicated, was performed, and PE was established in two patients. During three months of follow up no venous thromboembolic events (VTE) occurred. Therefore, the overall VTE failure rate was two of 450 (0.4% [95%CI 0-1.1]); the overall prevalence of PE was 12.3%. The diagnostic protocol could be completed and allowed a decision to be made in 90% of the study patients. This study has prospectively established the safety of a combination of a dichotomized clinical decision rule and D-dimer test in ruling out PE. The strategy proved highly efficient, since more than 50% of patients could be managed without the need for more invasive and expensive tests.
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PMID:Simple and safe exclusion of pulmonary embolism in outpatients using quantitative D-dimer and Wells' simplified decision rule. 1720 Jul 82

Pulmonary embolism (PE) is a major health problem associated with a significant morbidity and mortality. Immediate recognition of submassive and massive cases is extremely important in order to commencement of early and appropriate therapy that could be life saving. The aim of this study was to assess the ability of two scoring systems, electrocardiography (ECG) and simplified Wells (sWells) clinical scorings in predicting anatomic severity of PE. Hence, ECG and sWells scorings were combined in order to test the hypothesis if this new scoring does enhance the prediction of severity. Fifty six patients with proven PE with high (50 patients) and moderate (six patients)-probability of ventilation/perfusion (V/Q) scan were retrospectively studied. Baseline ECGs were analysed by two independent observers in order to constitute ECG scorings. Baseline sWells scores were also calculated. Anatomic severity of PE was calculated by scintigraphically and categorized into mild (<50% perfusion defect) (group 1), and severe (50% perfusion defect) (group 2) diseases. The mean of ECG scores, sWells scores and the combined scores were 5.23+/-3.42 and 5.85+/-3.82; 6.60+/-1.88 and 7.03+/-2.40; and 10.73+/-3.60 and 11.60+/-4.32 in groups 1 and 2, respectively (p>0.05). An ECG score of 6.5 predicted severe disease (perfusion defect 50%) with a sensitivity of 41.7% and a specificity of 82%). sWells and combined scores did not provide better sensitivity or specificity values based on ROC curve analysis. Our results indicated that ECG scoring could be valuable test in predicting anatomic severity of PE, adding sWells scoring to ECG scoring did not provide any beneficial effect.
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PMID:Electrocardiography and Wells scoring in predicting the anatomic severity of pulmonary embolism. 1722 26

It was the objective of this study to determine the proportion of patients who undergo an appropriate diagnostic work-up following a D-dimer test performed to evaluate suspected pulmonary embolism (PE) or deep vein thrombosis (DVT). We performed a retrospective cohort study at a tertiary care hospital. We included patients if they underwent D-dimer testing between 2002 and 2005, if the D-dimer was performed for evaluation of VTE, and if the D-dimer test was successful. We classified: the patients' clinical probability of DVT or PE according to the Wells models, the imaging results, and the appropriateness of the testing algorithm. Of 1,000 randomly selected patients, 863 met our study criteria. Seven hundred nineteen patients (83%) had testing during an emergency department visit, while 144 were tested as inpatients (17%). Physicians performed the D-dimer test to evaluate DVT and PE in 238 (28%) and 625 (72%) patients, respectively. Overall, the testing strategy was appropriate in 69% (95% confidence interval [CI]: 66%-72%) of cases. The testing strategy was more likely to be appropriate for emergency department versus inpatients (75% vs. 39%, p < 0.05) and for DVT versus PE patients (84% vs. 63%, p < 0.05). Of all in-appropriately tested patients, under-utilization of diagnostic imaging was more common than over-utilization (90% vs. 10%, p < 0.05). VTE was confirmed in 37 of 138 'DVT patients' and 35 of 625 'PE patients' (16% [95% CI: 11%-21%] and 6% [95% CI: 4%-8%], respectively). In conclusion, physicians often fail to use diagnostic testing strategies for VTE correctly following a D-dimer test.
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PMID:Appropriateness of diagnostic strategies for evaluating suspected venous thromboembolism. 1726 47

Pulmonary embolism (PE) is difficult to diagnose. We investigated the relationship between computed tomography pulmonary angiography (CTPA) with clinical assessments and thrombus localization. 56 patients with the suspicion of PE; 27 male, 29 female were included. They were evaluated by empirical and Wells clinical assessments, tested with D-Dimer. According to the combination of both CTPA was performed where necessary (if one of the clinical assessments was high or intermediate or those with low clinical probability and high D-Dimer) in the algorithm we used. CTPA was regarded as gold standard. Dyspnea, chest pain, tachypnea, crackles were the most common symptoms and signs in patients having PE. Recent surgery within the risk factors was significantly higher in the PE present group. PE was diagnosed in 31 (55.4%) patients with CTPA. According to the empirical assessment 20 (64.5%) of the patients had high, 10 (32.3%) had intermediate and 1 (3.2%) had low clinical probability within 31 PE present group, while with Wells scoring 8 (25.8%) had high, 17 (54.8%) had intermediate and 6 (19.4%) had low clinical probability. Sensitivity of the empirical assessment and Wells scoring was 97%, 80% while the specificity was 16%, 68% respectively. Positive and negative predictive values of empirical assessment were 59%, 80% and these values of Wells scoring were 76%, 73% respectively. Thrombus was localized in main pulmonary arteries in 45.8% of patients with high clinical probability according to the empirical assessment. With Wells scoring in 45.5% of the high probability patients and only in 4.3% of the low probability patients thrombus was there. PE can be diagnosed noninvasively. Since PE can easily be underdiagnosed, empirical assessment which is more sensitive will be appropriate. There is a significant correlation between clinical assessments and presence of PE in CTPA. As the severity of clinical assessment increases, thrombus settles more proximal.
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PMID:[Comparison of clinical assessments with computerized tomography pulmonary angiography results in the diagnosis of pulmonary embolism]. 1760 46

Deep venous thrombosis and pulmonary embolism are potentially life-threatening problems that present diagnostic challenges. To employ objective diagnostic tests in an efficient, safe, and cost-effective manner, the clinical probability of these disorders should be estimated before testing. A number of clinical prediction rules are available for suspected deep venous thrombosis, while there are three major prediction rules available for estimating the probability of pulmonary embolism. Recent modifications of the Wells score for deep venous thrombosis simplify its use. Although the Wells score for pulmonary embolism is commonly used, two other rules are useful for this disorder as well. This review summarizes the clinical prediction rules and gives recommendations about their application.
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PMID:Determining the clinical probability of deep venous thrombosis and pulmonary embolism. 1794 48

Pulmonary embolism (PE) could not be diagnosed correctly in 2/3 of patients saving of that pathology, and unfortunately mortality in them could be as high as 30%. In the present study, we aimed to investigate the gender differences in clinical, electrocardiography (ECG) and laboratory findings of PE patients diagnosed with contrast-enhanced helical computerized tomography of thorax. 31 patients (18 females, 58% and 13 males, 42%) were included into the study. Symptoms, risk factors, ECG and arterial blood gases were evaluated, and then Wells, Geneva and ECG scores were obtained in each subject. Alveolo-arterial (A-a) oxygen gradient was calculated as P(A-a)O2= 150-(PCO2/0.8)-PO2. Mean pulmonary artery pressure (PAP) was measured by echocardiography. In female and male patients, Wells score (4.8 +/- 1.9 and 3.2 +/- 2.2, p= 0.017); ECG score (5.9 +/- 3.6 and 3.1 +/- 1.8, p= 0.036) and mean PAP (33.5 +/- 12.3 mmHg and 23.2 +/- 10.0 mmHg, p= 0.017) were significantly different. However, between female and male patients Geneva score (4.8 +/- 1.7 and 5.0 +/- 1.6), A-a gradient (35.2 +/- 17.3 and 42.9 +/- 12.3) and PaCO2 (33.5 +/- 15.1 and 29.8 +/- 5.4) did not differ significantly (p> 0.05). Immobilization and surgical interventions as risk factors for PE were established significantly higher in females than males (50%-30.8%, p= 0.02 and 50%-23.1%, p= 0.01). In female patients with PE, Wells and ECG scores, immobilization, surgical interventions and mean PAP are significantly higher than male patients. So, in the clinical practice, these parameters may help to diagnose acute PE especially in females.
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PMID:[Differences between men and women in the clinical and laboratory findings of patients diagnosed with pulmonary embolism]. 1797 21

The Wells rule is a widely applied clinical decision rule in the diagnostic work-up of patients with suspected pulmonary embolism (PE). The objective of this study was to replicate, validate and possibly simplify this rule. We used data collected in 3,306 consecutive patients with clinically suspected PE to recalculate the odds ratios for the variables in the rule, to calculate the proportion of patients with PE in the probability categories, the area under the ROC curve and the incidence of venous thromboembolism during follow-up. We compared these measures with those for a modified and a simplified version of the decision rule. In the replication, the odds ratios in the logistic regression model were found to be lower for each of the seven individual variables (p = 0.02) but the proportion of patients with PE in the probability categories in our study group were comparable to those in the original derivation and validation groups. The area under the ROC of the original, modified and simplified decision rule was similar: 0.74 (p = 0.99; p = 0.07). The venous thromboembolism incidence at three months in the group of patients with a Wells score < or = 4 and a normal D-dimer was 0.5%, versus 0.3% with a modified rule and 0.5% with a simplified rule. The proportion of patients safely excluded for PE was 32%, versus 31% and 30%, respectively. This study further validates the diagnostic utility of the Wells rule and indicates that the scoring system can be simplified to one point for each variable.
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PMID:Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. 1852 26


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