Comparison of the Wells score with the revised Geneva score for assessing suspected pulmonary embolism: a systematic review and meta-analysis

Clinical Presentation and Risk Stratification of Pulmonary Embolism

Pulmonary embolism (PE) presents with a spectrum of symptoms, ranging from asymptomatic cases to life-threatening events. Common symptoms include sudden dyspnea, chest pain, limb swelling, syncope, and hemoptysis. Clinical presentation varies based on thrombus burden, demographics, and time to presentation. Diagnostic evaluation involves assessing symptoms, physical examination findings, and utilizing laboratory tests, including D-dimer. Risk stratification using tools like Wells score, Pulmonary Embolism Severity Index, and Hestia criteria aids in determining the severity of PE. PE is categorized based on hemodynamic status, temporal patterns, and anatomic locations of emboli to guide in making treatment decisions. Risk stratification plays a crucial role in directing management strategies, with elderly and comorbid individuals at higher risk. Early identification and appropriate risk stratification are essential for effective management of PE. As we delve into this review article, we aim to enhance the knowledge base surrounding PE, contributing to improved patient outcomes through informed decision-making in clinical practice.

Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners

Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.

Prognostic Value of Neutrophil/Lymphocyte Ratio for Pulmonary Embolism: A Meta-Analysis and External Validation

BACKGROUND

Prognostic value of neutrophil/lymphocyte ratio (NLR) for pulmonary embolism (PE) has been reported in several retrospective studies. The purpose of this investigation was to perform a pooled analysis and external validation of predictive value of NLR.

METHODS

PubMed, Embase, and Cochrane databases were searched from inception to November 5, 2022. A random effects model was used. Grade was used to evaluate the certainty of evidence. External validation was conducted in clinical cohorts before and after a propensity scoring matching (PSM). Covariates include basic clinical characteristics, such as age, gender, etc. The value of NLR in prediction model was also evaluated.

RESULTS

A total of 15 studies comprising 5,874 patients were included. Pooled risk ratio of NLR was 2.33 (95% confidence interval [CI]: 1.97-2.75), with an area under the curve of 0.78 (95% CI: 0.74-0.81), a sensitivity of 0.75 (95% CI: 0.71-0.79), a specificity of 0.67 (95% CI: 0.61-0.73), and a median cut-off value of 5.7. Grade of Recommendations Assessment Development and Evaluation (GRADE) certainty analysis showed the quality of the evidence was moderate. Before (n = 336) and after (n = 152) propensity scoring matching, risk ratio of NLR was 2.69 (95% CI: 1.04-6.97) and 6.58 (95% CI: 1.99-17.75). A prediction model consisting of NLR, age, D-dimer, and simplified PE severity index had an area under the curve of 0.809 (95% CI: 0.738-0.88), a sensitivity of 0.638 (95% CI: 0.511-0.745), and a specificity of 0.851 (95% CI: 0.709-0.917). Net reclassification index (12%, P = 0.035) and integrated discrimination improvement (17%, P = 0.022) indicated an improvement caused by NLR.

CONCLUSIONS

Prognostic value of NLR for PE was confirmed by meta-analysis and validated in an independent cohort, deserving further clinical application.

Establishment of machine learning-based tool for early detection of pulmonary embolism

BACKGROUND AND OBJECTIVES

Pulmonary embolism (PE) is a complex disease with high mortality and morbidity rate, leading to increasing society burden. However, current diagnosis is solely based on symptoms and laboratory data despite its complex pathology, which easily leads to misdiagnosis and missed diagnosis by inexperienced doctors. Especially, CT pulmonary angiography, the gold standard method, is not widely available. In this study, we aim to establish a rapid and accurate screening model for pulmonary embolism using machine learning technology. Importantly, data required for disease prediction are easily accessed, including routine laboratory data and medical record information of patients.

METHODS

We extracted features from patients' routine laboratory results and medical records, including blood routine, biochemical group, blood coagulation routine and other test results, as well as symptoms and medical history information. Samples with a feature loss rate greater than 0.8 were deleted from the original database. Data from 4723 cases were retained, 231 of which were positive for pulmonary embolism. 50 features were retained through the positive and negative statistical hypothesis testing which was used to build the predictive model. In order to avoid identification as majority-class samples caused by the imbalance of sample proportion, we used the method of Synthetic Minority Oversampling Technique (SMOTE) to increase the amount of information on minority samples. Five typical machine learning algorithms were used to model the screening of pulmonary embolism, including Support Vector Machines, Logistic Regression, Random Forest, XGBoost, and Back Propagation Neural Networks. To evaluate model performance, sensitivity, specificity and AUC curve were analyzed as the main evaluation indicators. Furthermore, a baseline model was established using the characteristics of the pulmonary embolism guidelines as a comparison model.

RESULTS

We found that XGBoost showed better performance compared to other models, with the highest sensitivity and specificity (0.99 and 0.99, respectively). Moreover, it showed significant improvement in performance compared to the baseline model (sensitivity and specificity were 0.76 and 0.76 respectively). More important, our model showed low missed diagnosis rate (0.46) and high AUC value (0.992). Finally, the calculation time of our model is only about 0.05 s to obtain the possibility of pulmonary embolism.

CONCLUSIONS

In this study, five machine learning classification models were established to assess the likelihood of patients suffering from pulmonary embolism, and the XGBoost model most significantly improved the precision, sensitivity, and AUC for pulmonary embolism screening. Collectively, we have established an AI-based model to accurately predict pulmonary embolism at early stage.

Low Risk Meets High Stakes: Unraveling the Mystery of Low D-dimer Pulmonary Embolism

Pulmonary embolisms (PEs) are potentially life-threatening emergencies that carry significant morbidity and mortality. Advances in treatment options and the safety of existing procedures have effectively reduced the long-term and short-term effects of the condition. Therefore, it is important to make an early diagnosis so that treatment options can be thoroughly explored. The D-dimer is an important tool in the early diagnosis of PEs. It is especially useful in ruling out the diagnosis in patients with a low to moderate suspicion of the disease. We present a case of a 22-year-old male who presented with exertional dyspnea, congestion, and rhinorrhea for one day and was noted to have persistent hypoxia and tachycardia. The influenza test was positive, and he was started on oseltamivir. Due to persistent hypoxia, a CT pulmonary angiogram was ordered and revealed filling defects in the left lower lobe segmental vessels suggestive of PE, as well as multifocal multilobar bilateral ground-glass opacities. He was initially treated with a heparin drip and subsequently switched to eliquis. After a significant improvement in his hypoxia, he was discharged home for outpatient follow-up, including a hypercoagulable workup. This case demonstrates that despite the usefulness of the D-dimer as a diagnostic tool for PEs, it cannot solely or fully replace the full gamut of screening tools used to determine the risk of PE. Although rare, false-negative scores do occur; therefore, the tool should always be used in conjunction with other scoring systems, physician gestalt, and within the specific clinical context.

Diagnostic Yield, Radiation Exposure, and the Role of Clinical Decision Rules to Limit Computed Tomographic Pulmonary Angiography-Associated Complications

OBJECTIVES

Computed tomographic pulmonary angiography (CT-PA) is associated with significant cost, contrast, and radiation exposure. Clinical decision rules (CDRs) reduce the need for diagnostic imaging; however, their utility in the medical intensive care unit (MICU) remains unknown. We explored the diagnostic yield and complications associated with CT-PA (radiation exposure and contrast-induced acute kidney injury [AKI]) while investigating the efficacy of CDRs to reduce unnecessary testing.

METHODS

All CT-PAs performed in an academic MICU for 4 years were retrospectively reviewed. The Wells and revised Geneva scores (CDRs) and radiation dose per CT-PA were calculated, and the incidence of post-CT-PA AKI was recorded.

RESULTS

A total of 439 studies were analyzed; the diagnostic yield was 11% (48 PEs). Positive CT-PAs were associated with a higher Wells score (5.8 versus 3.2, P < 0.001), but similar revised Geneva scores (6.4 versus 6.0, P = 0.32). A Wells score of ≥4 had a positive likelihood ratio of 2.1 with a negative predictive value of 98.2. More than half (88.9%) of patients with a Wells score of ≤4 developed an AKI, with 55.6% of those having recovery of renal function.

CONCLUSIONS

There is overutilization of CT-PA in the MICU. The Wells score retains its negative predictive value in critically ill adult patients and may aid to limit radiation exposure and contrast-induced AKI in MICU.

Assessment of the Utilization of Validated Diagnostic Predictive Tools and D-Dimer in the Evaluation of Pulmonary Embolism: A Single-Center Retrospective Cohort Study from a Public Hospital in New York City

INTRODUCTION

A significant increase in the use of computed tomography with pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE) has been observed in the past twenty years. We aimed to investigate whether the validated diagnostic predictive tools and D-dimers were adequately utilized in a large public hospital in New York City.

METHODS

We conducted a retrospective review of patients who underwent CTPA for the specific indication of ruling out PE over a period of one year. Two independent reviewers, blinded to each other and to the CTPA and D-dimer results, estimated the clinical probability (CP) of PE using Well's score, the YEARS algorithm, and the revised Geneva score. Patients were classified based on the presence or absence of PE in the CTPA.

RESULTS

A total of 917 patients were included in the analysis (median age: 57 years, female: 59%). The clinical probability of PE was considered low by both independent reviewers in 563 (61.4%), 487 (55%), and 184 (20.1%) patients based on Well's score, the YEARS algorithm, and the revised Geneva score, respectively. D-dimer testing was conducted in less than half of the patients who were deemed to have low CP for PE by both independent reviewers. Using a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off in patients with a low CP of PE would have missed only a small number of mainly subsegmental PE. All three tools, when combined with D-dimer < 500 ng/mL or <age-adjusted cut-off, yielded a NPV of > 95%.

CONCLUSION

All three validated diagnostic predictive tools were found to have significant diagnostic value in ruling out PE when combined with a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off. Excessive use of CTPA was likely secondary to suboptimal use of diagnostic predictive tools.

Comparison of VTE risk scores in guidelines for VTE diagnosis in nonsurgical hospitalized patients with suspected VTE

BACKGROUND

The assessment of VTE likelihood with VTE risk scores is essential prior to imaging examinations during VTE diagnostic procedure. Little is known with respect to the disparity of predictive power for VTE diagnosis among VTE risk scores in guidelines for nonsurgical hospitalized patients with clinically suspected VTE.

METHODS

A retrospective study was performed to compare the predictive power for VTE diagnosis among the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores in the leading authoritative guidelines in nonsurgical hospitalized patients with suspected VTE.

RESULTS

Among 3168 nonsurgical hospitalized patients with suspected VTE, VTE was finally excluded in 2733(86.3%) ones, whereas confirmed in 435(13.7%) ones. The sensitivity and specificity resulted from the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores were (90.3%, 49.8%), (88.7%, 53.6%), (73.8%, 50.2%), (97.7%,16.9%), (80.9%, 44.0%), and (78.2%, 47.0%), respectively. The YI were 0.401, 0.423, 0.240, 0.146, 0.249, and 0.252 for the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores, respectively. The C-index were 0.694(0.626-0.762), 0.697(0.623-0.772), 0.602(0.535-0.669), 0.569(0.486-0.652), 0.607(0.533-0.681), and 0.609(0.538-0.680) for the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores, respectively. Consistency was significant in the pairwise comparison of Wells vs Geneva(Kappa 0.753, P = 0.565), YEARS vs Padua(Kappa 0.816, P = 0.565), YEARS vs IMPROVE(Kappa 0.771, P = 0.645), and Padua vs IMPROVE(Kappa 0.789, P = 0.812), whereas it did not present in the other pairs. The YI was improved to 0.304, 0.272, and 0.264 for the PERC(AUC 0.631[0.547-0.714], P = 0.006), Padua(AUC 0.613[0.527-0.700], P = 0.017), and IMPROVE(AUC 0.614[0.530-0.698], P = 0.016), with a revised cutoff of 5 or less, 6 or more, and 4 or more denoting the VTE-likely, respectively.

CONCLUSIONS

For nonsurgical hospitalized patients with suspected VTE, the Geneva and Wells scores perform best, the PERC scores performs worst despite its significantly high sensitivity, whereas the others perform intermediately, albeit the absolute predictive power of all isolated scores are mediocre. The predictive power of the PERC, Padua, and IMPROVE scores are improved with revised cutoffs.

Predictive Model for Pulmonary Embolism in Pregnant and Postpartum Women: A 10-Year Retrospective Study

Background: Pulmonary embolism (PE) in pregnant and postpartum women is fatal, and risk assessment is crucial for effective and safe management, the aim of this retrospective study was to establish a nomogram for predicting the risk of PE in pregnant and postpartum women. Methods: Totally 343 subjects suspected of PE at the Obstetrics Department of Affiliated Dongyang Hospital of Wenzhou Medical University from January 2012 to December 2021 were retrospective analyzed in our study. Pregnant women suspected of PE and who underwent computed tomographic pulmonary angiography examination were included in the study. The least absolute shrinkage and selection operator regression technique was used to select the best prediction features, and multivariate logistic regression is used to build the prediction model. Bootstrap resampling 1000 times was used to validate the model visualized by nomogram. Evaluate the performance of the model from three aspects: identification, calibration and clinical utility. Results: Our predictive model indicated that chest tightness, anhelation, lactate, and D-dimer were associated with PE. The area under the receiver operating characteristic curve of the model was 0.836 (95% CI: [0.770-0.902]), indicating that our model had a good differential diagnostic performance. Good consistency between prediction and real observation was presented as the calibration curve. Decision curve analysis indicated that our model had a good net clinical benefit. Conclusions: We developed a novel numerical model for selecting risk factors for PE in pregnant and postpartum women. Our results may help obstetricians and gynaecologists to develop individualized treatment plans and PE prevention strategies.

Diagnostic accuracy of multiorgan point-of-care ultrasound compared with pulmonary computed tomographic angiogram in critically ill patients with suspected pulmonary embolism

BACKGROUND

Critically ill patients have a higher incidence of pulmonary embolism (PE) than non-critically ill patients, yet no diagnostic algorithm has been validated in this population, leading to the overuse of pulmonary artery computed tomographic angiogram (CTA). This study aimed to comparatively evaluate the diagnostic accuracy of point-of-care ultrasound (POCUS) combined with laboratory data versus CTA in predicting PE in critically ill patients.

METHODS

A prospective diagnostic accuracy study. Critically ill patients with suspected acute PE undergoing CTA were prospectively enrolled. Demographic and clinical data were collected from electronic medical records. Blood samples were collected, and the Wells and revised Geneva scores were calculated. Standardized multiorgan POCUS and CTA were performed. The discriminatory power of multiorgan POCUS combined with biochemical markers was tested using ROC curves, and multivariate analysis was performed.

RESULTS

A total of 88 patients were included, and 37 (42%) had PE. Multivariate analysis showed a relative risk (RR) of PE of 2.79 (95% CI, 1.61-4.84) for the presence of right ventricular (RV) dysfunction, of 2.54 (95% CI, 0.89-7.20) for D-dimer levels >1000 ng/mL, and of 1.69 (95% CI, 1.12-2.63) for the absence of an alternative diagnosis to PE on lung POCUS or chest radiograph. The combination with the highest diagnostic accuracy for PE included the following variables: 1- POCUS transthoracic echocardiography with evidence of RV dysfunction; 2- lung POCUS or chest radiograph without an alternative diagnosis to PE; and 3- plasma D-dimer levels >1000 ng/mL. Combining these three findings resulted in an area under the curve of 0.85 (95% CI, 0.77-0.94), with 50% sensitivity and 96% specificity.

CONCLUSIONS

Multiorgan POCUS combined with laboratory data has acceptable diagnostic accuracy for PE compared with CTA. The combined use of these methods might reduce CTA overuse in critically ill patients.

Diagnostic Accuracy of Multiple D-Dimer Cutoff Thresholds and Other Clinically Applicable Biomarkers for the Detection and Radiographic Evaluation of Pulmonary Embolism

Background: Diagnostic work-up of pulmonary embolism (PE) remains a challenge. Methods: We retrospectively studied all patients referred for computed tomography pulmonary angiography (CTPA) with suspicion of PE during a 12-month period (2018). The diagnostic accuracy of different D-dimer (Dd) cutoff thresholds for ruling out PE was evaluated. Furthermore, the association of Dd and red cell distribution width (RDW) with embolus location, CTPA findings, and patient outcome was recorded. Results: One thousand seventeen (n = 1017) patients were finally analyzed (mean age: 64.6 years (SD = 11.8), males: 549 (54%)). PE incidence was 18.7%. Central and bilateral embolism was present in 44.7% and 59.5%, respectively. Sensitivity and specificity for conventional and age-adjusted Dd cutoff was 98.2%, 7.9%, and 98.2%, 13.1%, respectively. A cutoff threshold (2.1 mg/L) with the best (64.4%) specificity was identified based on Receiver Operating Characteristics analysis. Moreover, a novel proposed Dd cutoff (0.74 mg/L) emerged with increased specificity (20.5%) and equal sensitivity (97%) compared to 0.5 mg/L, characterized by concurrent reduction (17.2%) in the number of performed CTPAs. Consolidation/atelectasis and unilateral pleural effusion were significantly associated with PE (p < 0.05, respectively). Patients with consolidation/atelectasis or intrapulmonary nodule(s)/mass on CTPA exhibited significantly greater median Dd values compared to patients without the aforementioned findings (2.34, (IQR 1.29−4.22) vs. 1.59, (IQR 0.81−2.96), and 2.39, (IQR 1.45−4.45) vs. 1.66, (IQR 0.84−3.12), p < 0.001, respectively). RDW was significantly greater in patients who died during hospitalization (p = 0.012). Conclusions: Age-adjusted Dd increased diagnostic accuracy of Dd testing without significantly decreasing the need for imaging. The proposed Dd value (0.74 mg/L) showed promise towards reducing considerably the need of CTPA. Multiple radiographic findings have been associated with increased Dd values in our study.

A Novel Clinical Score for Differential Diagnosis Between Acute Myocarditis and Acute Coronary Syndrome - The SAlzburg MYocarditis (SAMY) Score

Background

Acute myocarditis and acute coronary syndrome (ACS) are important differential diagnoses in patients with new-onset chest pain. To date, no clinical score exists to support the differentiation between these two diseases. The aim of this study was to develop such a score to aid the physician in scenarios where discrimination between myocarditis and ACS appears difficult.

Materials and Methods

Patients with ACS (n = 233) and acute myocarditis (n = 123) were retrospectively enrolled. Least absolute shrinkage and selection operator (LASSO) regression was conducted to identify parameters associated with the highest or least probability for acute myocarditis. Logistic regression was conducted using the identified parameters and score points for each level of the predictors were calculated. Cutoffs for the prediction of myocarditis were calculated. Validation was conducted in a separate cohort of 90 patients.

Results

A score for prediction of acute myocarditis was calculated using six parameters [age, previous infection, hyperlipidemia, hypertension, C-reactive protein (CRP), and leukocyte count]. Logistic regression analysis showed a significant association between total score points and the presence of myocarditis (B = 0.9078, p < 0.0001). Cutoff #1 for the prediction of myocarditis was calculated at ≥ 4 (Sens.: 90.3%, Spec.: 93.1%; 46.3% predicted probability for acute myocarditis), cutoff #2 was calculated at ≥ 7 (Sens.: 73.1%, Spec.: > 99.9%; 92.9% pred. prob.). Validation showed good discrimination [area under the curve (AUC) = 0.935] and calibration of the score.

Conclusion

Our clinical score showed good discrimination and calibration for differentiating patients with acute myocarditis and ACS. Thus, it could support the differential diagnosis between these two disease entities and could facilitate clinical decisions in affected patients.

Hospitalizations for pulmonary embolism in Brazil (2008-2019): an ecological and time series study

Objective

To assess the temporal trends of hospitalizations for pulmonary embolism (PE) in Brazil, its regions, and states between 2008 and 2019.

Methods

An ecological and time series study was conducted. Data were obtained from the Hospital Information System (SIH) of the Brazilian Ministry of Health. The inflection point regression model was applied for temporal trend analyses. Trends were classified as increasing, decreasing, or stationary according to the slope of the regression line. The Annual Percent Charge (APC) and the Average Annual Percent Change (AAPC) were calculated considering a confidence interval of 95% and p-value <0.05. Furthermore, spatial distribution maps of epidemiological indicators related to PE in Brazil were elaborated.

Results

There was an increasing trend in the hospitalization rate for PE in Brazil, ranging from 2.57 in 2008 to 4.44/100,000 in 2019 (AAPC=5.6%; p<0.001). Total and average hospitalizations costs also showed increasing trend in the country (AAPC=9.2% and 3.0%, respectively). Still, there was a decrease in the in-hospital mortality rate (from 21.21% to 17.11%; AAPC=-1.9%; p<0.001). Similar trends were observed in most regions. The average hospitalization time in Brazil showed a stationary trend. The hospitalization rate has also increased in 18 states (66.67%). Seven states showed a decrease in the mortality rate (25.93%), except for Roraima, which showed an increasing trend.

Conclusion

Hospitalizations for PE represent a serious public health problem in Brazil and the temporal patterns observed herein demonstrate an increasing trend in all regions and states of the country.

Evaluation of the modified Wells score in predicting venous thromboembolic disease in patients with tuberculosis or HIV in a South African setting

Background

There is paucity of data on the modified Wells score (MWS) utility on patients with venous thromboembolism (VTE) in a South African setting where there is a high burden of HIV and tuberculosis (TB). This study analyses the performance of this score in HIV/TB-infected patients compared with non-infected patients.

Objectives

To assess the performance of the MWS as an additional risk factor for VTE in hospitalised patients with a high burden of HIV/TB infections.

Method

This study was a retrospective cross-sectional cohort analysis of the utility of the MWS in 156 HIV/TB-infected and non-infected adult patients diagnosed with VTE on compression ultrasonography (CUS) or computed tomography pulmonary angiography (CTPA) in a medical inpatient setting over six months. Patients with HIV and/or TB were assessed as having an additional risk factor (1 point for each), and this was compared with the MWS. A McNeymar’s paired sample chi-squared test was used to compare the sensitivity of this score against the MWS.

Results

Of the 156 patients with VTE who were enrolled, HIV was the commonest risk factor (42.31%) with TB accounting for 10.90% of cases. When the MWS adjusted for HIV/TB was used, the sensitivity increased from 25% to 100% for the HIV–/TB+ category, it increased from 77.36% to 98.11% in the HIV+/TB– category and it increased from 84.62% to 92.95% in the HIV+/TB+ category. These differences were statistically significant at P < 0.05 in all categories.

Conclusion

The MWS performs better when the infectivity of HIV/TB is included as an additional risk factor in the score.

Predictive scores failing at identifying psychiatric disabilities following childhood bacterial meningitis calls for revision of current follow-up guidelines

BACKGROUNDS

Psychiatric disabilities affect one in three survivors of bacterial meningitis. Since current guidelines do not recommend psychiatric follow-up in all children, disabilities are often detected late. Identifying children with elevated risk of psychiatric disabilities using predictive scores could be one strategy for detecting psychiatric disabilities without having to conduct psychiatric evaluations in all children. Therefore, we searched for existing predictive scores and later tested five predictive scores' ability to predict psychiatric disabilities following childhood bacterial meningitis.

METHODS

From an existing dataset, we selected 73 children with bacterial meningitis of whom 22 later developed psychiatric disease and 15 experienced concentration or learning difficulties. Using these, we tested each predictive score's sensitivity at their cut-off level for predicting psychiatric disease and concentration or learning difficulties using a chi-square test. Furthermore, we performed a receiver operating characteristic curve (ROC) analysis to assert the area under the curve (AUC) as a measure of overall predictive performance.

RESULTS

The sensitivity of each predictive score' ranged from 6 to 38% for psychiatric disease and from 8 to 57% for concentration or learning difficulties. In the ROC-analysis, the AUC was 0.59-0.73 and 0.53-0.72, respectively.

CONCLUSIONS

All predictive score failed at identifying children later developing psychiatric disabilities, excluding this as a feasible strategy for detecting psychiatric disabilities. Hence, current guidelines for bacterial meningitis need to be revised to recommend psychiatric evaluations in all children.KEY NOTESCurrent guidelines not recommending psychiatric evaluations in all children following bacterial meningitis may result in late detection of psychiatric disabilities.We tested predictive scores' ability to identify children later developing psychiatric disabilities following bacterial meningitis.All predictive score failed at identifying children later developing psychiatric disabilities, excluding this as a feasible strategy. Hence, current guidelines for bacterial meningitis need to be revised to recommend psychiatric evaluations in all children.

Predicting pulmonary embolism among hospitalized patients with machine learning algorithms

Background

Objective

Materials and Methods

Results

Conclusions

Elderly Population with COVID-19 and the Accuracy of Clinical Scales and D-Dimer for Pulmonary Embolism: The OCTA-COVID Study

BACKGROUND

Elderly COVID-19 patients have a high risk of pulmonary embolism (PE), but factors that predict PE are unknown in this population. This study assessed the Wells and revised Geneva scoring systems as predictors of PE and their relationships with D-dimer (DD) in this population.

METHODS

This was a longitudinal, observational study that included patients ≥75 years old with COVID-19 and suspected PE. The performances of the Wells score, revised Geneva score and DD levels were assessed. The combinations of the DD level and the clinical scales were evaluated using positive rules for higher specificity.

RESULTS

Among 305 patients included in the OCTA-COVID study cohort, 50 had suspected PE based on computed tomography pulmonary arteriography (CTPA), and the prevalence was 5.6%. The frequencies of PE in the low-, intermediate- and high-probability categories were 5.9%, 88.2% and 5.9% for the Geneva model and 35.3%, 58.8% and 5.9% for the Wells model, respectively. The DD median was higher in the PE group (4.33 mg/L; interquartile range (IQR) 2.40-7.17) than in the no PE group (1.39 mg/L; IQR 1.01-2.75) (p < 0.001). The area under the curve (AUC) for DD was 0.789 (0.652-0.927). After changing the cutoff point for DD to 4.33 mg/L, the specificity increased from 42.5% to 93.9%.

CONCLUSIONS

The cutoff point DD > 4.33 mg/L has an increased specificity, which can discriminate false positives. The addition of the DD and the clinical probability scales increases the specificity and negative predictive value, which helps to avoid unnecessary invasive tests in this population.

[Acute Chest Pain: A Stepwise Approach to Management]

Acute chest pain is one of the most important cardinal symptoms in medicine. There are several important differential diagnoses for chest pain. Therefore, a thorough history and physical examination, as well as the 12-lead ECG and laboratory tests are crucial. In clinical practice, it is useful to distinguish between cardiac chest pain and other forms of chest pain in order to treat patients appropriately and to exclude potentially life-threatening conditions.

Incremental value of compression ultrasound sonography in the emergency department

The quick evaluation of venous thromboembolism is a key point of modern medicine since the delayed diagnosis is associated with a worse prognosis. Venous ultrasound (VU) is a sensitive and rapidly performed test in cases of suspected deep venous thrombosis. Various protocols have been proposed for its execution, such as the study of the whole deep venous circulation of the lower limb or the analysis of the femoral-popliteal area. The aim is to detect a vessel thrombus and the most sensitive element is the non-compressibility with the probe. Initially, the thrombus is hypoechogenic and adherent to the vessel; later, it tends to organize and recanalize. Usually, in the early stages, the risk of embolism is higher. The role of studying the iliac axis and calf veins is still uncertain. VU is not useful for assessing response to anticoagulation therapy and it is unclear whether the persistence of thrombotic abnormalities can guide on a possible prolongation of therapy.

Which adults with sickle cell disease need an evaluation for pulmonary embolism?

Individuals living with sickle cell disease (SCD) are at an increased risk of venous thrombo-embolism (VTE) including pulmonary embolisms (PEs). There is a high mortality associated with PE in individuals with SCD. It can be difficult to diagnose PE since presenting symptoms of PE often mimic those of other forms of vaso-occlusive crisis in SCD. Currently, there are no validated models for predicting PEs in patients with sickle cell disease, which often leads to frequent CT scans and exposure to harmful radiation and intravenous contrast. The aim of this study was to evaluate different host variables and potential clinical biomarkers of patients with SCD including those used in the Wells score to assess predictability for PE in order to create a more accurate diagnostic algorithm to predict PE. A retrospective chart review was performed on 349 patients with SCD who underwent testing for a PE with a CT scan of the chest. Forward and backward stepwise model selection was performed to obtain a parsimonious model of the predictors of PEs. The incidence of PE in this population was 9·7%. Of the factors evaluated for this study, the Wells score was the only one with clinical significance. A Wells score greater than 4 had a sensitivity and specificity of 72·5% and 70·1%, respectively, and a score greater than 6 had a sensitivity and specificity of 50% and 87%, respectively. The Wells score is an acceptable clinical tool which may prove useful in individuals with SCD to predict who is most likely to have a PE and therefore should undergo a CT scan. A prospective study is needed to further confirm these findings.

YEARS Algorithm Versus Wells' Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography

OBJECTIVES

This study retrospectively applied Wells' score and YEARS algorithm to the same sample of patients to evaluate the predictive performance of each when compared with the gold standard CT pulmonary angiography.

DESIGN

Retrospective analytical study.

SETTING

A tertiary University Hospital in Ireland.

PATIENTS

Data from 794 patients who underwent CT pulmonary angiography to rule out pulmonary embolism.

INTERVENTIONS

Patients were analyzed using retrospective application of both Wells' score and YEARS algorithm. Sensitivity, specificity, and diagnostic odds ratio were calculated and compared.

MEASUREMENTS AND MAIN RESULTS

Of 794 scans, 78 (9.8%) were positive for pulmonary embolism. The YEARS algorithm was more sensitive than the Wells' score (97.44% vs 74.36%) but was less specific (13.97% vs 33.94%). Furthermore, the diagnostic odds ratio of YEARS was higher than Wells' score (6.27 vs 1.48). YEARS provides better negative predictive value (98% vs 92.4%), and both scores have poor positive predictive value (10.9%).

CONCLUSIONS

Both scores successfully exclude pulmonary embolism, although YEARS has a better negative predictive value. Both exhibit poor positive predictive value.

Development of the "OS-SEV90 Score" to Predict Severe Postoperative Complications at 90 Days Following Bariatric Surgery

BACKGROUND

Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated.

OBJECTIVES

This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors.

METHODS

We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction ("OS-SEV90 score") was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high.

RESULTS

Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78-5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12-4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26-3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. "the OS-SEV90 score" based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3-4), and high (≥5). According to "the OS-SEV90 score," SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group.

CONCLUSIONS

A predictive model of SPC within 90 days "the OS-SEV90 score" has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

Pulmonary embolism secondary to deep venous thrombosis: A retrospective and observational study for clinical characteristics and risk stratification

OBJECTIVE

To investigate the risk factors, predilection sites in pulmonary embolism (PE) patients caused by deep venous thrombosis (DVT) and explore the value of scoring systems in assessing the risk of PE in DVT patients.

METHODS

A total of 692 DVT patients were enrolled, and divided into no pulmonary embolism (NPE, 226, 32.66%), silent pulmonary embolism (SPE, 330, 47.67%) and featuring pulmonary embolism (FPE, 136, 19.65%) groups. For each group, the differences of clinical data and PE locations were compared, and the risk factors of PE secondary to DVT were analyzed. The predictive value of the scoring system for the diagnosis of PE and FPE was evaluated.

RESULTS

PE presented more in the bilateral pulmonary arteries (PAs) (249, 53.43%) and has no significant difference in PESI scores in different locations. Gender, DVT locations, and previous surgery were the independent risk factors of PE. DVT locations, previous history of COPD, and previous surgical interventions were the independent risk factors of FPE. The results for areas under the ROC curves were: AUC_(Wells) = 0.675, AUC _{(Revised Geneva)} = 0.601, AUC_(D-dimer) = 0.595 in the PE group; AUC_(Wells) = 0.722, AUC _{(Revised Geneva)} = 0.643, AUC_(D-dimer) = 0.557 in the FPE group.

CONCLUSIONS

PE secondary to DVT mostly occurs in the bilateral PAs. Male gender, DVT locations, and previous surgery increased the risk of PE. The Wells scoring system was more advantageous for evaluating the diagnosis of PE in patients with DVT.

Effectiveness of Clinical Decision Tools in Predicting Pulmonary Embolism

Objective

The Wells criteria and revised Geneva score are two commonly used clinical decision tools (CDTs) developed to assist physicians in determining when computed tomographic angiograms (CTAs) should be performed to evaluate the high index of suspicion for pulmonary embolism (PE). Studies have shown varied accuracy in these CDTs in identifying PE, and we sought to determine their accuracy within our patient population.

Methods

Patients admitted to the Emergency Department (ED) who received a CTA for suspected PE from 2019 Jun 1 to 2019 Aug 31 were identified. Two CDTSs, the Wells criteria and revised Geneva score, were calculated based on data available prior to CTA and using the common D-Dimer cutoff of >500 μg/L. We determined the association between confirmed PE and CDT values and determined the association between the D-Dimer result and PE.

Results

392 CTAs were identified with 48 (12.1%) positive PE cases. The Wells criteria and revised Geneva score were significantly associated with PE but failed to identify 12.5% and 70.4% of positive PE cases, respectively. Within our cohort, a D-Dimer cutoff of >300 μg/L was significantly associated with PE and captured 95.2% of PE cases.

Conclusions

Both CDTs were significantly associated with PE but failed to identify PE in a significant number of cases, particularly the revised Geneva score. Alternative D-Dimer cutoffs may provide better accuracy in identifying PE cases.

Suspected Acute Pulmonary Embolism: Gestalt, Scoring Systems, and Artificial Intelligence

Pulmonary embolism (PE) remains a diagnostic challenge in 2021. As the pathology is potentially fatal and signs and symptoms are nonspecific, further investigations are classically required. Based on the Bayesian approach, clinical probability became the keystone of the diagnostic strategy to rule out PE in the case of a negative testing. Several clinical probability assessment methods are validated: gestalt, the Wells score, or the revised Geneva score. While the debate persists as to the best way to assess clinical probability, its assessment allows for the good interpretation of the investigation results and therefore directs the correct diagnostic strategy. The wide availability of computed tomography pulmonary angiography (CTPA) resulted in a major increase in investigations with a moderate increase in diagnosis, without any notable improvement in patient outcomes. This leads to a new challenge for PE diagnosis which is the limitation of the number of testing for suspected PE. We review different strategies recently developed to achieve this goal. The last challenge concerns the implementation in clinical practice. Two approaches are developed: simplification of the strategies versus the use of digital support tools allowing more sophisticated strategies. Artificial intelligence with machine-learning algorithms will probably be a future tool to guide the physician in this complex approach concerning acute PE suspicion.

Diagnostic management of inpatients with a positive D-dimer test: developing a new clinical decision-making rule for pulmonary embolism

Background

A positive D-dimer test has high sensitivity but relatively poor specificity for the diagnosis of pulmonary embolism, causing difficulty for clinicians unskilled in pulmonary embolism diagnosis in determining whether a patient with a positive D-dimer test needs to undergo computed tomographic pulmonary angiography.

Objectives

We sought to develop a new clinical decision-making rule based on a positive D-dimer result to predict the probability of pulmonary embolism and to guide clinicians in making decisions regarding the need for computed tomographic pulmonary angiography.

Methods

We conducted a prospective, multicenter study in three hospitals in China. A total of 3014 inpatients with positive D-dimer results were included. In the derivation group, we built a multivariate logistic regression model and deduced a regression equation from which our score was derived. Finally, we validated the score in an independent cohort.

Results

Our score included nine variables (points): chest pain (1.4), chest tightness (2.3), shortness of breath (3.6), hemoptysis (3.4), heart rate ≥100 beats/min (3.6), blood gas analysis (2.9), electrocardiogram presenting a typical S1Q3T3 pattern (4.1), electrocardiogram findings (2.4), and ultrasonic cardiogram findings (3.7). The sensitivities and specificities were 100% and 86.94%, respectively, in the derivation group and 100% and 90.82%, respectively, in the validation group. Additionally, the observed and predicted proportions of patients who underwent computed tomographic pulmonary angiography were 16.82% and 10.76%, respectively, in the derivation group and 18.72% and 11.40%, respectively, in the validation group.

Conclusions

The new score can categorize inpatients with a positive D-dimer test as pulmonary embolism-likely or pulmonary embolism-unlikely, thus reducing unnecessary computed tomographic pulmonary angiography examinations.

Clinical and laboratory characteristics of patients with novel coronavirus disease-2019 infection and deep venous thrombosis

OBJECTIVE

Early reports suggest that patients with novel coronavirus disease-2019 (COVID-19) infection carry a significant risk of altered coagulation with an increased risk for venous thromboembolic events. This report investigates the relationship of significant COVID-19 infection and deep venous thrombosis (DVT) as reflected in the patient clinical and laboratory characteristics.

METHODS

We reviewed the demographics, clinical presentation, laboratory and radiologic evaluations, results of venous duplex imaging and mortality of COVID-19-positive patients (18-89 years) admitted to the Indiana University Academic Health Center. Using oxygen saturation, radiologic findings, and need for advanced respiratory therapies, patients were classified into mild, moderate, or severe categories of COVID-19 infection. A descriptive analysis was performed using univariate and bivariate Fisher's exact and Wilcoxon rank-sum tests to examine the distribution of patient characteristics and compare the DVT outcomes. A multivariable logistic regression model was used to estimate the adjusted odds ratio of experiencing DVT and a receiver operating curve analysis to identify the optimal cutoff for d-dimer to predict DVT in this COVID-19 cohort. Time to the diagnosis of DVT from admission was analyzed using log-rank test and Kaplan-Meier plots.

RESULTS

Our study included 71 unique COVID-19-positive patients (mean age, 61 years) categorized as having 3% mild, 14% moderate, and 83% severe infection and evaluated with 107 venous duplex studies. DVT was identified in 47.8% of patients (37% of examinations) at an average of 5.9 days after admission. Patients with DVT were predominantly male (67%; P = .032) with proximal venous involvement (29% upper and 39% in the lower extremities with 55% of the latter demonstrating bilateral involvement). Patients with DVT had a significantly higher mean d-dimer of 5447 ± 7032 ng/mL (P = .0101), and alkaline phosphatase of 110 IU/L (P = .0095) than those without DVT. On multivariable analysis, elevated d-dimer (P = .038) and alkaline phosphatase (P = .021) were associated with risk for DVT, whereas age, sex, elevated C-reactive protein, and ferritin levels were not. A receiver operating curve analysis suggests an optimal d-dimer value of 2450 ng/mL cutoff with 70% sensitivity, 59.5% specificity, and 61% positive predictive value, and 68.8% negative predictive value.

CONCLUSIONS

This study suggests that males with severe COVID-19 infection requiring hospitalization are at highest risk for developing DVT. Elevated d-dimers and alkaline phosphatase along with our multivariable model can alert the clinician to the increased risk of DVT requiring early evaluation and aggressive treatment.

Diagnostic and prognostic value of the D-dimer test in emergency department patients: secondary analysis of an observational study

Background D-dimer measurement improves the rule-out of thromboembolic disease. However, little is known about the risk of false positive results for the diagnosis of thromboembolic disease and its prognostic value. Herein, we investigated factors influencing the accuracy of D-dimer and its prognostic value in a large cohort of emergency department (ED) patients. Methods This is a secondary analysis of a prospective observational single center, cohort study. Consecutive patients, for whom a D-dimer test was requested by the treating physician, were included. Associations of clinical parameters on admission with false positive D-dimer results for the diagnosis of thromboembolic disease were investigated with logistic regression analysis. Results A total of 3301 patients were included, of which 203 (6.1%) had confirmed thromboembolic disease. The negative and positive predictive values of the D-dimer test at the 0.5 mg/L cut-off were 99.9% and 11.4%, respectively. Several factors were associated with positive D-dimer results potentially falsely indicating thromboembolic disease in multivariate analysis including advanced age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.04-1.05, p < 0.001), congestive heart failure (CHF) (OR 2.79, 95% CI 1.77-4.4, p < 0.01), renal failure (OR 2.00, 95% CI 1.23-3.24, p = 0.005), history of malignancy (OR 2.6, 95% CI 1.57-4.31, p < 0.001), C-reactive protein (CRP) (OR 1.02, 95% CI 1.01-1.02, p < 0.001) and glomerular filtration rate (GFR) (OR 0.99, 95% CI 0.99-1.00, p = 0.003). Regarding its prognostic value, D-dimer was associated with a 30-day mortality (adjusted OR 1.05, 95% CI 1.02-1.09, p = 0.003) with an area under the curve (AUC) of 0.79. Conclusions While D-dimer allows an accurate rule-out of thromboembolic disease, its positive predictive value in routine ED patients is limited and largely influenced by age, comorbidities and acute disease factors. The strong prognostic value of D-dimer in this population warrants further investigation.

Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over age 65

TITLE

Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over 65 years of age.

INTRODUCTION

The incidence and mortality of pulmonary embolism (PE) is high in the elderly. The Wells score (SW) and the revised Geneva score (RGS) have been validated in patient populations with a large age range. The aim of this study was to compare the predictive accuracy of these two scores in diagnosis of PE in patients over 65 years of age.

METHOD

A prospective multicentre study (nine French and three Belgian centres) was conducted at the same time as the PERCEPIC study. A total of 1757 patients admitted with suspected PE were included and divided into two groups according to age (≥65 years or <65 years). The pre-test probability of PE was assessed prospectively for the RGS. The SW was calculated retrospectively. The predictive accuracy of the two scores was compared by the area under the curve (AUC) of the ROC curves.

RESULTS

The overall prevalence of PE was 11.3%. The prevalence among patients aged ≥65 in the low, moderate and high pre-test probability groups, evaluated using the WS and was respectively 13.5% (CI 95%: CI 9.9-17.3), 28.2% (CI 22.1-34.3), 50% (CI 26-74) and 8.1% (CI 3.2-12.9), 22.3% (CI 18.2-26.3), 43.7% (CI 25.6-61.9) using the RGS. The AUC for the WS and RGS for patients aged ≥65 was 0.632 (CI 0.574-0.691) and 0.610 (CI 0.555-0.666). The difference between the AUCs was not statistically significant (p = .441).

CONCLUSION

In the population for this study, the WS and RGS have the same PE diagnostic accuracy in patients over age 65. This result should be validated in a prospective study that directly compares these scores.

MeningiSSS: A New Predictive Score to Support Decision on Invasive Procedures to Monitor or Manage the Intracerebral Pressure in Children with Bacterial Meningitis

BACKGROUND

Knowing the individual child's risk is highly useful when deciding on treatment strategies, especially when deciding on invasive procedures. In this study, we aimed to develop a new predictive score for children with bacterial meningitis and compare this with existing predictive scores and individual risk factors.

METHODS

We developed the Meningitis Swedish Survival Score (MeningiSSS) based on a previous systematic review of risk factors. From this, we selected risk factors identified in moderate-to-high-quality studies that could be assessed at admission to the hospital. Using data acquired from medical records of 101 children with bacterial meningitis, we tested the overall capabilities of the MeningiSSS compared with four existing predictive scores using a receiver operating characteristic curve (ROC) analysis to assert the area under the curve (AUC). Finally, we tested all predictive scores at their cut-off levels using a Chi-square test. As outcome, we used a small number of predefined outcomes; in-hospital mortality, 30-day mortality, occurrence of neurological disabilities at discharge defined as Pediatric Cerebral Performance Category Scale category two to five, any type of complications occurring during the hospital stay, use of intensive care, and use of invasive procedures to monitor or manage the intracerebral pressure.

RESULTS

For identifying children later undergoing invasive procedures to monitor or manage the intracerebral pressure, the MeningiSSS excelled in the ROC-analysis (AUC = 0.90) and also was the only predictive score able to identify all cases at its cut-off level (25 vs 0%, p < 0.01). For intensive care, the MeningiSSS (AUC = 0.79) and the Simple Luanda Scale (AUC = 0.75) had the best results in the ROC-analysis, whereas others performed less well (AUC ≤ 0.65). Finally, while none of the scores' results were significantly associated with complications, an elevated score on the MeningiSSS (AUC = 0.70), Niklasson Scale (AUC = 0.72), and the Herson-Todd Scale (AUC = 0.79) was all associated with death.

CONCLUSIONS

The MeningiSSS outperformed existing predictive scores at identifying children later having to undergo invasive procedures to monitor or manage the intracerebral pressure in children with bacterial meningitis. Our results need further external validation before use in clinical practice. Thus, the MeningiSSS could potentially be helpful when making difficult decisions concerning intracerebral pressure management.

Comparison of international societal guidelines for the diagnosis of suspected pulmonary embolism during pregnancy

Pregnancy-associated pulmonary embolism is one of the leading causes of maternal mortality. Diagnosis of pulmonary embolism in pregnancy is challenging, with symptoms of pulmonary embolism mimicking those of pregnancy. Several key components such as clinical prediction tools, risk stratification, laboratory tests, and imaging widely used for diagnosis of pulmonary embolism in the non-pregnant population show limitations for diagnosis in pregnancy. Further, because of the difficulty of studying pregnant patients, high-quality research evaluating the performance of these diagnostic components in pregnancy is scarce. Seven international medical society guidelines present clinical diagnostic pathways for evaluation of pulmonary embolism in pregnancy that show conflicting recommendations on the use of these diagnostic components. This Review assesses all key components of diagnostic clinical pathways recommended by guidelines for evaluation of pulmonary embolism in pregnancy, reviews current evidence, compares the guideline recommendations with respect to each key component, and provides our preferred diagnostic pathway. It provides the guidelines and available data needed for informed decision making to diagnose pulmonary embolism in pregnancy.

Predictive Model for Pulmonary Embolism in Patients with Deep Vein Thrombosis

BACKGROUND

To develop and verify a risk predictive model/scoring system for pulmonary embolism (PE) among hospitalized patients with deep venous thrombosis of the lower extremities (LDVT).

METHODS

776 patients with LDVT were enrolled in a case-control study between January 2016 and June 2017 from the Vascular Surgery Department of Shanxi Dayi Hospital, China. They were randomly divided into development (543 patients, 70%) and validation (233 patients, 30%) databases. Based on the results of pulmonary computed tomography arteriography, patients were divided into 2 categories; those with PE were designated as the case group, whereas those without comprised the controls. A logistic regression model and scoring system for PE in patients with LDVT was established in the development database and verified in the validation database. Scoring system (Shanxi Dayi Hospital score [SDH score]) was tabulated as follows: right lower extremity or bilateral lower extremities, 1; surgery or immobilization, 1; malignant tumor, 1; history of venous thromboembolism (VTE), 2; D-dimer >1,000 ng/mL, 2; and unprovoked, 2. Calibration and discrimination of the model were assessed by the Hosmer-Lemeshow goodness of fit test and the area under the receiver operating characteristic curve (AUC). Wells score, the Revised Geneva score, and the SDH score for predictive value of PE by AUC in the validation database were compared.

RESULTS

776 patients with LDVT were divided into 2 risk categories based on the scores from the risk model as follows: PE unlikely (score <3) and PE likely (score ≥3). Sensitivity, specificity, and crude agreement of the SDH score in the development database were 76.39%, 55.89%, and 61.33%, respectively. In the validation database, the logistic regression model showed good calibration and discriminative power. The Hosmer-Lemeshow goodness of fit test P value was >0.05, and the AUC was 0.705 (95% CI: 0.634-0.776, P < 0.001). The SDH score also showed good discriminative power, and the AUC was 0.702 (95% CI: 0.631-0.774, P < 0.001). Sensitivity, specificity, and crude agreement of the SDH score in the validation database were 67.61%, 61.73%, and 63.52%, respectively. AUC for the Wells score and the Revised Geneva score was 0.611 (95% CI: 0.533-0.688, P = 0.007) and 0.585 (95% CI: 0.503-0.666, P = 0.040), respectively. Difference of the AUC was not statistically significant between the Wells score and the SDH score (0.611 vs. 0.702, P = 0.059) but was so between the Revised Geneva score and the SDH score (0.585 vs. 0.702, P = 0.016). Sensitivity of the Wells score, Revised Geneva score, and the SDH score (64.79%, 67.61% vs. 67.61%) was not statistically significant. However, the specificity of the Wells score and Revised Geneva score was significantly lower than that of the SDH score (48.77%, 39.51% vs. 61.73%).

CONCLUSIONS

Our logistic regression model and the SDH score based on 7 risk factors as right lower extremity, bilateral lower extremities, unprovoked, surgery or immobilization, malignant tumor, history of VTE, and D-dimer>1,000 ng/mL showed good calibration and discriminative power for the assessment of PE risk in patients with LDVT. The SDH score is more specific for PE prediction in the Chinese population, compared with the Wells score and the Revised Geneva score.

New evidence in diagnosis of pulmonary embolism during pregnancy

Diagnosis of pulmonary embolism (PE) in pregnancy is notoriously difficult and lacking high quality evidence. Three studies (DiPEP, ARTEMIS and CT-PE-Pregnancy) evaluating a systematic approach to PE diagnosis have recently been published. DiPEP is a retrospective case-control study that found a poor utility of clinical decision rules or D-dimer testing for PE diagnosis in pregnancy. ARTEMIS and CT-PE-Pregnancy are well conducted prospective management studies that proposed two algorithms with different clinical decision rules and D-dimer criteria for the diagnosis of PE in pregnancy. They included few events in high risk patients, which makes difficult the assessment of both algorithm's safety in women with a high probability of PE. Considering this new evidence, D-dimer testing might be useful to avoid radiation imaging in pregnant women considered at low risk for PE. In contrast, a negative D-dimer cannot be considered sufficiently safe to rule out PE when clinicians estimate that PE is the most likely diagnosis.

Is Bedside End-Tidal CO2 Measurement a Screening Tool to Exclude Pulmonary Embolism in Emergency Department?

Background

Pulmonary embolism (PE) is among the most difficult conditions to diagnose in emergency department. The majority of patients thought to have PE are tested positive for D-dimer and subsequently tested with advanced diagnostic modalities. Novel noninvasive tests capable of excluding PE may obviate the need for advanced imaging tests. We studied the role of combined clinical probability assessment and end-tidal carbon dioxide (ETCO₂) measurement for diagnosis of possible PE in emergency department.

Methods

We included 100 consecutive subjects suspected to have PE and a positive D-dimer test to study clinical probability of PE and ETCO₂ levels. ETCO₂ > 34 mm Hg was found to be the best cut-off point for diagnosing PE. PE was ultimately eliminated or diagnosed by spiral computed tomography (CT).

Results

Diagnostic performances of tests were as follows: ETCO₂ and D-dimer had a sensitivity of 100% and a negative predictive value (NPV) of 100% at the cut-off levels of 34 mm Hg and 500 ng/mL, respectively; Wells score had a sensitivity of 80% and NPV of 69.7% at a score of 4.

Conclusions

ETCO₂ alone cannot reliably exclude PE. Combining it with clinical probability, however, reliably and correctly eliminates or diagnoses PE and prevents further testing to be done.

Wells’ Score in Diagnosis of Pulmonary Embolism in Patient with Thrombocytopenia: A Case Report

Current diagnostic workup of patients with suspected acute pulmonary embolism (PE) usually starts with the assessment of clinical pretest probability, using clinical prediction rules and plasma D-dimer measurement. Although an accurate diagnosis of acute pulmonary embolism (PE) in patients is thus of crucial importance, the diagnostic management of suspected PE is still challenging.

A 60-year-old man with chest pain and expectoration of blood was admitted to the Department of Cardiology, General Hospital in Cuprija, Serbia. After physical examination and laboratory analyses, the diagnosis of Right side pleuropne monia and acute pulmonary embolism was established. Clinically, patient was hemodynamically stable, auscultative slightly weaker respiratory sound right basal, without pretibial edema. Laboratory: C-reactive protein (CRP) 132.9 mg/L, Leukocytes (Le) 18.9x109/L, Erythrocytes (Er) 3.23x1012/L, Haemoglobin (Hgb) 113 g/L, Platelets (Plt) 79x109/L, D-dimer 35.2. On the third day after admission, D-dimer was increased and platelet count was decreased (Plt up to 62x109/L). According to Wells’ rules, score was 2.5 (without symptoms on admission), a normal clinical finding with clinical manifestation of hemoptysis and chest pain, which represents the intermediate level of clinical probability of PE. After the recidive of PE, Wells’ score was 6.5. In summary, this study suggests that Wells’ score, based on a patient’s risk for pulmonary embolism, is a valuable guidance for decision-making in combination with knowledge and experience of clinicians. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being consiered.

Wells and Geneva Scores Are Not Reliable Predictors of Pulmonary Embolism in Critically Ill Patients: A Retrospective Study

BACKGROUND

Critically ill patients are at high risk for pulmonary embolism (PE). Specific PE prediction rules have not been validated in this population. The present study assessed the Wells and revised Geneva scoring systems as predictors of PE in critically ill patients.

METHODS

Pulmonary computed tomographic angiograms (CTAs) performed for suspected PE in critically ill adult patients were retrospectively identified. Wells and revised Geneva scores were calculated based on information from medical records. The reliability of both scores as predictors of PE was determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

Of 138 patients, 42 (30.4%) were positive for PE based on pulmonary CTA. Mean Wells score was 4.3 (3.5) in patients with PE versus 2.7 (1.9) in patients without PE (P < .001). Revised Geneva score was 5.8 (3.3) versus 5.1 (2.5) in patients with versus without PE (P = .194). According to the Wells and revised Geneva scores, 56 (40.6%) patients and 49 (35.5%) patients, respectively, were considered as low probability for PE. Of those considered as low risk by the Wells score, 15 (26.8%) had filling defects on CTA, including 2 patients with main pulmonary artery embolism. The area under the ROC curve was 0.634 for the Wells score and 0.546 for the revised Geneva score. Wells score >4 had a sensitivity of 40%, specificity of 87%, positive predictive value of 59%, and negative predictive value of 77% to predict risk of PE.

CONCLUSIONS

In this population of critically ill patients, Wells and revised Geneva scores were not reliable predictors of PE.

Negative D-dimer testing excludes pulmonary embolism in non-high risk patients in the emergency department

PURPOSE

The purpose of this study was to assess the ability of d-dimer testing to obviate the need for cross-sectional imaging for patients at "non-high risk" for pulmonary embolism (PE).

METHODS

This is a retrospective study of emergency department patients at an academic medical center who underwent cross-sectional imaging (MRA or CTA) to evaluate for PE from 2008 to 2013. The primary outcome was the NPV of d-dimer testing when used in conjunction with clinical decision instruments (CDIs = Wells', Revised Geneva, and Simplified Revised Geneva Scores). The reference standard for PE status included image test results and a 6-month chart review follow-up for venous thromboembolism as a proxy for false negative imaging. Secondary analyses included ROC curves for each CDI and calculation of PE prevalence in each risk stratum.

RESULTS

Of 459 patients, 41 (8.9%) had PE. None of the 76 patients (16.6%) with negative d-dimer results had PE. Thus, d-dimer testing had 100% sensitivity and NPV, and there were no differences in CDI performance. Similarly, when evaluated independently of d-dimer results, no CDI outperformed the others (areas under the ROC curves ranged 0.53-0.55). There was a significantly higher PE prevalence in the high versus "non-high risk" groups when stratified by the Wells' Score (p = 0.03).

CONCLUSIONS

Negative d-dimer testing excluded PE in our retrospective cohort. Each CDI had similar NPVs, whether analyzed in conjunction with or independently of d-dimer results. Our results confirm that PE can be safely excluded in patients with "non-high risk" CDI scores and a negative d-dimer.

Diagnostic Performance of Wells Score Combined With Point-of-care Lung and Venous Ultrasound in Suspected Pulmonary Embolism

OBJECTIVE

Lung and venous ultrasound are bedside diagnostic tools increasingly used in the early diagnostic approach of suspected pulmonary embolism (PE). However, the possibility of improving the conventional prediction rule for PE by integrating ultrasound has never been investigated.

METHODS

We performed lung and venous ultrasound in consecutive patients suspected of PE in four emergency departments. Conventional Wells score (Ws) was adjudicated by the attending physician, and ultrasound was performed by one of 20 investigators. Signs of deep venous thrombosis (DVT) at venous ultrasound and signs of pulmonary infarcts or alternative diagnoses at lung ultrasound were considered to recalculate two items of the Ws: signs and symptoms of DVT and alternative diagnosis less likely than PE. The diagnostic performances of the ultrasound-enhanced Ws (USWs) and Ws were then compared after confirmation of the final diagnosis.

RESULTS

A total of 446 patients were studied. PE was confirmed in 125 patients (28%). USWs performed significantly better than Ws, with a sensitivity of 69.6% versus 57.6% and a specificity of 88.2% versus 68.2%. In combination with D-dimer, USWs showed an optimal failure rate (0.8%) and a significantly superior efficiency than Ws (32.3% vs. 27.2%). A strategy based on lung and venous ultrasound combined with D-dimer would allow to avoid CT pulmonary angiography in 50.5% of patients with suspected PE, compared to 27.2% when the rule without ultrasound is applied.

CONCLUSIONS

A pretest risk stratification enhanced by ultrasound of lung and venous performs better than Ws in the early diagnostic process of PE.

Elevated d-dimer cut-off values for computed tomography pulmonary angiography-d-dimer correlates with location of embolism

BACKGROUND

Acute pulmonary embolism (APE) is a potentially fatal condition, and making a timely diagnosis can be challenging. Computed tomography pulmonary angiography (CTPA) has become the modality of choice, and this contributes to the increasing load on emergency room CT scanners. Our purpose was to investigate whether an elevated d-dimer cut-off could reduce the demand for CTPA while maintaining a high sensitivity and negative predictive value (NPV).

METHODS

We retrospectively reviewed all patients referred for CTPA with suspicion of APE in 2012, and collected d-dimer values and CTPA results. We investigated the diagnostic performance of d-dimer using a 0.5 mg/L cut-off and an age adjusted cut-off. We also evaluated a new and elevated cut-off. Cases were categorized according to their CTPA result into: no embolism, peripheral embolism, lobar embolism and central embolism. Finally we investigated a possible correlation between d-dimer values and location of embolism.

RESULTS

We included 1,051 CTPAs, from which 216 (21%) showed pulmonary embolism. There were concomitant d-dimer analyses in 822 CTPA examinations. The current 0.5 mg/L cut-off achieved a sensitivity and NPV of 99%. The age-adjusted cut-off achieved a sensitivity and NPV of 98%, and our suggested cut-off of 0.9 mg/L achieved a sensitivity and NPV of 97%.

CONCLUSIONS

We conclude that the elevated d-dimer cut-off of 0.9 mg/L achieved a high sensitivity and NPV, while reducing the number of CTPA by 27%. The correlation between d-dimer values and location of embolisms supports the suggestion of an elevated d-dimer value.