Validation of helical computed tomography for suspected pulmonary embolism: a near miss?

Division of General Internal Medicine, Department of Internal Medicine, Geneva Faculty of Medicine and Geneva University Hospital, Geneva, Switerland.
Journal of Thrombosis and Haemostasis (Impact Factor: 5.72). 02/2005; 3(1):14-6. DOI: 10.1111/j.1538-7836.2004.01073.x
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Available from: Henri Bounameaux, Oct 07, 2014
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    ABSTRACT: A prospective outcome study designed to evaluate a simple strategy for the management of outpatients with suspected pulmonary embolism (PE), based on clinical probability, D-dimer, and multi-slice computed tomography (MSCT). A cohort of 432 consecutive patients admitted to the emergency department with suspected PE was managed by sequential non-invasive testing. Patients in whom PE was ruled out were not given anticoagulants, but were followed-up for 3 months. Normal D-dimer and low-intermediate clinical probability ruled out PE in 103 patients [24% (95% CI 20-28)]. Seventeen patients had normal D-dimer, but high clinical probability and proceeded to MSCT. All patients proved negative for PE. A total of 329 (76%) patients underwent MSCT examination. Pulmonary embolism was diagnosed in 93 patients [21.5% (95% CI 18-26)] and was ruled out by negative MSCT in 221 patients [51% (95% CI 46-56)]. MSCT scans were determined as inconclusive in 15 (4.5%) patients. No patient developed objectively verified venous thromboembolism (VTE) during the 3-month follow-up period. However, the cause of death was adjudicated as possibly related to PE in two patients, resulting in an overall 3-month VTE risk of 0.6% (95% CI 0-2.2%). The diagnostic algorithm yielded a definite diagnosis in 96.5% of the patients. This simple and non-invasive strategy combining clinical probability, D-dimer, and MSCT for the management of outpatients with suspected PE appears to be safe and effective.
    Journal of Thrombosis and Haemostasis 10/2005; 3(9):1926-32. DOI:10.1111/j.1538-7836.2005.01544.x · 5.72 Impact Factor
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    ABSTRACT: Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism. To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism. Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women. Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months. Symptomatic or fatal venous thromboembolism (VTE) during 3-month follow-up. Pulmonary embolism was classified as unlikely in 2206 patients (66.7%). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients (32.0%), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients (0.5% [95% confidence interval {CI}, 0.2%-1.1%]). Computed tomography showed pulmonary embolism in 674 patients (20.4%). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3-month incidence of VTE was 1.3% (95% CI, 0.7%-2.0%). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan (0.5% [95% CI, 0.2%-1.0%]). The algorithm was completed and allowed a management decision in 97.9% of patients. A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE.
    JAMA The Journal of the American Medical Association 02/2006; 295(2):172-9. DOI:10.1001/jama.295.2.172 · 35.29 Impact Factor
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    ABSTRACT: Thromboembolic events are an increasingly commonly recognized secondary complications in children treated for serious, life-threatening primary diseases. Nevertheless the incidence of venous thromboembolic disease remains 100 times less frequent in hospitalized children than hospitalized adults, as recent data suggest an incidence of 5,3/10.000 pediatric patients compared to an incidence of 2,5-5/100 in adult patients. Diseases usually associated with thromboembolic events in children are neoplasia, autoimmune or cardiac malformative disease. Contrarily to what is observed in the adult, the majority of deep vein thrombosis events occur at the upper limbs veins, usually at the place where devices for venous access like port-a-cath or central venous lines are inserted. Because of the relatively low incidence of venous thromboembolic events in children, the diagnostic approach used are largely extrapolated from guidelines obtained from adult studies. However, the diagnostic performances of some diagnostic tools like Doppler-Ultrasound are probably diminished in children. Moreover, the concept of developmental hemostasis, which stresses the point that the hemostatic system in children is quite different from the adult one, is widely accepted and clearly suggests that the diagnostic and therapeutic approach in pediatric patients may not be simply extrapolated from data obtained in adult studies.From a more practical point of view, the fact that the hemostatic system in children is a dynamic and evolving system, renders the therapeutic approach quite complex. In particular, doses of anticoagulants vary markedly across the pediatric age. The absence of adapted formulations of commonly used anticoagulants, for example the absence of liquid formulations of anti-vitamin K drugs, further complicates the administration and the correct monitoring of anticoagulation in children, and may diminish observance in adolescent patients. Even though the concept that “children are not little adults” is nowadays widely accepted, there is an urgent need for prospective studies to better assess the modalities of diagnosis and treatment of venous thromboembolic disease in this particular population. (J Mal Vasc 2006; 31: 135-142)
    Journal des Maladies Vasculaires 07/2006; 31(3):135-142. DOI:10.1016/S0398-0499(06)76532-5 · 0.24 Impact Factor
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