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Wells rule for pulmonary embolism

Sam Schulman
During the past 7 years, results from phase III trials comparing nonvitamin antagonist K oral anticoagulants (NOACs) with vitamin K antagonists (VKAs) or with placebo, including 34,900 patients, have been published. Recent guidelines have been updated and now suggest treatment with NOACs rather than with VKA. Other updates in the guidelines concern the initial thrombolytic treatment for selected patients with deep vein thrombosis or pulmonary embolism as well as the possibility of withholding anticoagulation for minimal venous thromboembolism...
October 20, 2016: Seminars in Thrombosis and Hemostasis
Pierre Tannous, Zubin Mukadam, Chetan Kammari, Harsha Banavasi, Ayman O Soubani
OBJECTIVE/BACKGROUND: The use of computed tomography pulmonary angiography (CTPA) in the emergency department (ED) for patients suspected to have pulmonary embolism (PE) has been steadily rising in the last 2decades. However, there are limited studies that specifically address the use of CTPA in the ED for cancer patients suspected to have PE. The objective of this study is to assess the rate of positive PE by CTPA in the ED in cancer patients and the variables that are associated with positive results...
September 2, 2016: Hematology/oncology and Stem Cell Therapy
Kara E Hennelly, Marc N Baskin, Michael C Monuteuax, Joel Hudgins, Eugene Kua, Ashlee Commeree, Rotem Kimia, Edward Y Lee, Amir Kimia, Mark I Neuman
OBJECTIVE: To evaluate 2 commonly used adult-based pulmonary embolism (PE) algorithms in pediatric patients and to derive a pediatric-specific clinical decision rule to evaluate children at risk for PE, given the paucity of data to guide diagnostic imaging in children for whom PE is suspected. STUDY DESIGN: We performed a single-center retrospective study among 561 children <22 years of age undergoing either D-dimer testing or radiologic evaluation (computed tomography or ventilation-perfusion scan) in the emergency department setting for concern of PE...
August 24, 2016: Journal of Pediatrics
Thanawat Vongchaiudomchoke, Thananya Boonyasirinant
BACKGROUND: Acute pulmonary embolism (PE) is associated with a variety of non-specific clinical manifestations. Using diagnostic algorithms that are based on internationally recognized guidelines, pulmonary computed tomography angiography (CTA) serves as the gold standard diagnostic imaging tool in PE. However; inappropriate use of pulmonary CTA may lead to unnecessary radiation exposure, contrast exposure, and cost. Based on our review of the literature, there is no existing data regarding prevalence and appropriate use of pulmonary CTA in suspected acute PE in Thailand...
January 2016: Journal of the Medical Association of Thailand, Chotmaihet Thangphaet
Motoharu Tokimitsu, Masako Murata, Yuichi Toriyama, Takao Hirano, Yasuhiro Iesato, Toshinori Murata
BACKGROUND: Fat embolism in the deep retinal capillary plexus is one of the reported mechanisms underlying central/paracentral scotoma in patients with Purtscher's retinopathy. Here we report the clear delineation of capillary dropout in the deep capillary plexus using optical coherence tomography angiography (OCTA) in a chronic case of unexplained scotoma that developed after femoral fracture. The patient exhibited normal fluorescein angiography (FA) findings and a normal retinal appearance...
2016: BMC Ophthalmology
Wojciech S Pietrzyk
BACKGROUND: Long air travel is a risk factor for deep venous thrombosis (DVT). The aim of the study was to report the occurrence of symptomatic DVT cases in cruise ship passengers after long haul flights and to discuss applied diagnostic methods. MATERIALS AND METHODS: A retrospective analysis of medical records of adult patients diagnosed with DVT in medical facility of the passenger ship was performed. On the basis of clinical examinations, B-mode ultrasound scans of the lower extremity venous systems, international normalised ratio (INR) tests, working diagnoses of DVT were established...
2016: International Maritime Health
M Das, J E Wildberger
Pulmonary embolism is an acute and potentially life-threatening condition requiring a differentiated diagnostic algorithm. Assessment of the risk and clinical probability are of utmost importance in order to initiate early treatment or to reliably exclude a pulmonary embolism. Computed tomography of the pulmonary arteries (CTPA) has become the non-invasive gold standard for the diagnostic approach. Alternatively, scintigraphy can also be used. A negative CTPA excludes a pulmonary embolism with a high degree of probability...
June 2016: Der Radiologe
Janneke M T Hendriksen, Wim A M Lucassen, Petra M G Erkens, Henri E J H Stoffers, Henk C P M van Weert, Harry R Büller, Arno W Hoes, Karel G M Moons, Geert-Jan Geersing
PURPOSE: Diagnostic prediction models such as the Wells rule can be used for safely ruling out pulmonary embolism (PE) when it is suspected. A physician's own probability estimate ("gestalt"), however, is commonly used instead. We evaluated the diagnostic performance of both approaches in primary care. METHODS: Family physicians estimated the probability of PE on a scale of 0% to 100% (gestalt) and calculated the Wells rule score in 598 patients with suspected PE who were thereafter referred to secondary care for definitive testing...
May 2016: Annals of Family Medicine
Nick van Es, Tom van der Hulle, Josien van Es, Paul L den Exter, Renée A Douma, Robbert J Goekoop, Inge C M Mos, Javier Galipienzo, Pieter W Kamphuisen, Menno V Huisman, Frederikus A Klok, Harry R Büller, Patrick M Bossuyt
BACKGROUND: The performance of different diagnostic strategies for pulmonary embolism (PE) in patient subgroups is unclear. PURPOSE: To evaluate and compare the efficiency and safety of the Wells rule with fixed or age-adjusted d-dimer testing overall and in inpatients and persons with cancer, chronic obstructive pulmonary disease, previous venous thromboembolism, delayed presentation, and age 75 years or older. DATA SOURCES: MEDLINE and EMBASE from 1 January 1988 to 13 February 2016...
August 16, 2016: Annals of Internal Medicine
Glenn K Geeting, Michael Beck, Michael A Bruno, Rickhesvar P Mahraj, Gregory Caputo, Christopher DeFlitch, Christopher S Hollenbeak
OBJECTIVE: The objective of our study was to determine the impact of embedding a pretest probability rule that is required during the computerized physician order-entry (CPOE) process on the appropriateness of CT angiography (CTA) of the pulmonary arteries for the diagnosis of pulmonary embolism (PE) in the emergency department (ED). MATERIALS AND METHODS: Data were obtained from the electronic medical records of all adults who visited the ED from October 17, 2010, through October 17, 2012 (n = 96,507)...
August 2016: AJR. American Journal of Roentgenology
Y P Woo, F Thien
BACKGROUND: A study conducted at an Australian hospital between 2007 and 2009 led to the implementation of a clinical prediction algorithm for pulmonary embolism (PE) consisting of the Wells criteria and D-dimer testing. Since then, studies conducted in other countries have recommended new D-dimer cut-offs to the algorithm. AIMS: To appraise the implemented algorithm and see if its ability to stratify patient risk has been maintained and to test retrospectively new D-dimer thresholds...
July 2016: Internal Medicine Journal
Paul L den Exter, Wendy Zondag, Frederikus A Klok, Rolf E Brouwer, Janneke Dolsma, Michiel Eijsvogel, Laura M Faber, Marijke van Gerwen, Marco J Grootenboers, Roxane Heller-Baan, Marcel M Hovens, Gé J P M Jonkers, Klaas W van Kralingen, Christian F Melissant, Henny Peltenburg, Judith P Post, Marcel A van de Ree, Tom Vlasveld, Mariëlle J de Vreede, Menno V Huisman
RATIONALE: Outpatient treatment of pulmonary embolism (PE) may lead to improved patient satisfaction and reduced health care costs. However, trials to assess its safety and the optimal method for patient selection are scarce. OBJECTIVES: To validate the utility and safety of selecting PE patients for outpatient treatment by the Hestia criteria , and to compare the safety of the Hestia criteria alone with the Hestia criteria combined with NT-proBNP testing. METHODS: We performed a randomized non-inferiority trial in 17 Dutch hospitals...
March 31, 2016: American Journal of Respiratory and Critical Care Medicine
Matteo Giorgi-Pierfranceschi, Chiara Cattabiani, Nicola Mumoli, Francesco Dentali
It is well known that a number of patients affected by hemodynamic stable pulmonary embolism are admitted to the emergency department presenting chest pain without further symptoms of pulmonary embolism, such as dyspnea, cough, hemoptysis, syncope, and tachycardia, but in a few cases, the presenting symptoms are even more unusual. The gold standard for pulmonary embolism diagnosis is computed tomography pulmonary angiogram resulting in significant exposure to ionizing radiation and contrast, but recently bedside ultrasound has shown to be useful in diagnosing pulmonary embolism in the emergency department...
February 25, 2016: Blood Coagulation & Fibrinolysis: An International Journal in Haemostasis and Thrombosis
Michael B Streiff, Giancarlo Agnelli, Jean M Connors, Mark Crowther, Sabine Eichinger, Renato Lopes, Robert D McBane, Stephan Moll, Jack Ansell
This guidance document focuses on the diagnosis and treatment of venous thromboembolism (VTE). Efficient, cost effective diagnosis of VTE is facilitated by combining medical history and physical examination with pre-test probability models, D dimer testing and selective use of confirmatory imaging. Clinical prediction rules, biomarkers and imaging can be used to tailor therapy to disease severity. Anticoagulation options for acute VTE include unfractionated heparin, low molecular weight heparin, fondaparinux and the direct oral anticoagulants (DOACs)...
January 2016: Journal of Thrombosis and Thrombolysis
Ralph C Wang, Stephen Bent, Ellen Weber, Jersey Neilson, Rebecca Smith-Bindman, Jahan Fahimi
STUDY OBJECTIVE: Validation studies have confirmed the accuracy of clinical decision rules for the evaluation of pretest probability of pulmonary embolism. It has been assumed that clinical decision rules will also decrease testing in actual practice, but the evidence for this is unclear. We perform a systematic review of impact analyses on clinical decision rules for pulmonary embolism. METHODS: MEDLINE, EMBASE, and the Cochrane Library were searched without language restriction for studies assessing the effect of clinical decision rules on efficiency (computed tomography [CT] angiography use and yield) and safety (missed pulmonary embolism) through October 2014...
June 2016: Annals of Emergency Medicine
Xin Xi, Jinghua Yang, Zengzhi Wang, Chenxi Zhu, Jie Li, Shuang Liu
OBJECTIVE: To evaluate the potential utility of a renal function adjusted D-dimer cut-off value for improving the exclusion of pulmonary embolism. METHODS: Retrospective analyses were performed for 1 784 inpatients and outpatients with low and moderate probability of pulmonary embolism at Anzhen Hospital from January 2011 to June 2013. The Well's score was used. The diagnoses of pulmonary embolism were confirmed by computed tomography pulmonary angiogram and ventilation-perfusion scan...
August 11, 2015: Zhonghua Yi Xue za Zhi [Chinese medical journal]
Helia Robert-Ebadi, Grégoire Le Gal, Marc Righini
Modern non invasive diagnostic strategies for pulmonary embolism (PE) rely on the sequential use of clinical probability assessment, D-dimer measurement and thoracic imaging tests. Planar ventilation/perfusion (V/Q) scintigraphy was the cornerstone for more than two decades and has now been replaced by computed tomography pulmonary angiography (CTPA). Diagnostic strategies using CTPA are very safe to rule out PE and have been well validated in large prospective management outcome studies. With the widespread use of CTPA, concerns regarding radiation and overdiagnosis of PE have paved the way for investigating new diagnostic modalities...
2016: Expert Review of Cardiovascular Therapy
Udo Hoffmann, Scott R Akers, Richard K J Brown, Kristopher W Cummings, Ricardo C Cury, S Bruce Greenberg, Vincent B Ho, Joe Y Hsu, James K Min, Kalpesh K Panchal, Arthur E Stillman, Pamela K Woodard, Jill E Jacobs
Primary imaging options in patients at low risk for coronary artery disease (CAD) who present with undifferentiated chest pain and without signs of ischemia are functional testing with exercise or pharmacologic stress-based electrocardiography, echocardiography, or myocardial perfusion imaging to exclude myocardial ischemia after rule-out of myocardial infarction and early cardiac CT because of its high negative predictive value to exclude CAD. Although possible, is not conclusive whether triple-rule-out CT (CAD, pulmonary embolism, and aortic dissection) might improve the efficiency of patient management...
December 2015: Journal of the American College of Radiology: JACR
Maria J Yepes-Temiño, Pablo Monedero, José Ramón Pérez-Valdivieso
BACKGROUND: Patients undergoing lung surgery are at risk of postoperative pulmonary complications (PPCs). Identifying those patients is important to optimise individual perioperative management. The Clinical Prediction Rule for Pulmonary Complications (CPRPCs) after thoracic surgery, developed by the Memorial Sloan-Kettering Cancer Center, might be an ideal predictor. The hypothesis was that CPRPC performs well for the prediction of PPCs. OBJECTIVE: The aim of our study was to provide the external validation of the CPRPC after lung resection for primary tumours, before universal acceptance...
May 2016: European Journal of Anaesthesiology
Bernd Winkler, Claus-Martin Muth, Tim Piepho
The diving accident (decompression incident, DCI) occurs in the decompression phase of dives. The DCI can either be caused by an arterial gas embolism (AGE) subsequent to a pulmonary barotrauma or by the formation of inert gas bubbles subsequent to a reduction of ambient pressure during the ascent from depth. In contrast to the traditional assumption that decompression incidents only occur if decompression rules are neglected, recent data indicate that a vast amount of diving accidents occur even though divers adhered to the rules...
October 2015: Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie: AINS
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